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A HANDBOOK OF 
 
 MEDICAL DIAGNOSIS 
 
 IN FOUR PARTS 
 
 I. MEDICAL DIAGNOSIS IN GENERAL III. SYMPTOMS AND SIGNS 
 
 II. THE METHODS AND THEIR IMME- IV. THE CLINICAL APPLICATIONS 
 
 DIATE RESULTS 
 
 FOR THE USE OF PRACTITIONERS 
 AND STUDENTS 
 
 BY 
 
 J. C. WILSON, A.M., M.D. 
 
 Professor of the Practice of Medicine and Clinical Medicine in the Jefferson Medical College, and Physician 
 
 to its Hospital ; Physician to the Pennsylvania Hospital ; Physician in Chief 
 
 to the German Hospital, Philadelphia. 
 
 408 TEXT ILLUSTRATIONS AND 14 FULL PAGE PLATES 
 
 *'T/ie whole Art of Medicine is in Observation.'" 
 
 PHILADELPHIA l^ LONDON 
 
 J. B. LIPPINCOTT COMPANY 
 

 Copyright, 1909 
 By J. B. LippiNCOTT Company 
 
 ELECTROTYPED AND PRINTED BY J. B. l,lPPINCOTT COMPANY 
 THE WASHINGTON SQUARE PRESS, PHILADELPHIA, U.S.A. 
 
To 
 
 THE MEMORY OF MY 
 FATHER 
 
 ELLWOOD WILSON, A.M., M.D. 
 
PREFACE 
 
 This volume has been written partly in response to the wishes of some 
 of my professional colleagues, partly to meet the urgent demands of many 
 successive classes of pupils, but chiefly in the hope that at this time a con- 
 venient and practical presentation of the subject of Medical Diagnosis will 
 prove useful to the profession at large. 
 
 The treatment of the subject-matter under four main headings has 
 been adopted with the view of simplifying the arrangement of the topics 
 in a department of medicine which has attained large scope and insistent 
 importance. It is the confident expectation of the author that this plan 
 will fulfil the twofold requirement, that, within the compass of a single 
 book, clinical phenomena, on the one hand, and, on the other, those com- 
 plexes of clinical phenomena which constitute diseases, are brought into 
 correlation in such a manner that the practitioner who seeks information 
 upon an obscure case may at once turn to the discussion of the methods 
 available to clear it up, and the student may find the definite clinical appli- 
 cations of the same methods and their results in descriptive medicine. 
 
 Practical rather than theoretical considerations have been held con- 
 stantly in view alike in the treatment of the clinical and the laboratory 
 subjects. To attain this end a degree of positiveness of assertion not 
 warranted under other circumstances and the avoidance of the discussion 
 of moot and unsettled questions have seemed proper. 
 
 The Medical Diagnosis of J. M. Da Costa was pubhshed in 1864. That 
 brilliant contribution to the literature marked an epoch in the progress 
 of internal medicine. From the time of its appearance the traditional 
 conception of diagnosis by intuition — a gift of the favored few — ceased to 
 occupy the thoughts of medical men, and the subject ranged itself among 
 the arts based upon scientific facts. It maintained in successive editions 
 during the life of its distinguished author its position in the forefront of 
 the progress of applied medicine during a period of extraordinary advance- 
 ment in the collateral sciences upon which the practice of medicirie rests. 
 The continuing rapid development of knowledge relating to the facts of 
 
vi PREFACE. 
 
 medicine in the last decade has rendered necessary fresh presentations of 
 the subject, and from time to time excellent works have appeared. These 
 differ greatly among themselves, according to the views of their several 
 authors, in method and detail. To add to this honorable list demands the 
 justification of something different in method, new arrangement of detail, and 
 the presentation of the whole subject in accordance with the requirements 
 of contemporary medicine. It is hoped that in the present volume these 
 demands are fulfilled. It is the outcome of many years devoted to work 
 in the wards, with the controlling side-lights upon bedside diagnosis afforded 
 by the clinical laboratory, revelations at the hands of surgical colleagues 
 in the operating theatre and confreres in pathology in the post-mortem 
 room, the frequent opportunity of seeing unusual and grave cases in con- 
 sultation, and long experience as a teacher. Such a career arouses enthu- 
 siasm but begets caution. It does not encourage in any way the belief 
 that diagnosis in medicine is an easy matter, but forces the conclusion that 
 it is often difficult and in rare instances impossible. For this reason and 
 because we are always eager to extend the boundaries of our knowledge, 
 this art is as absorbing as it is useful. 
 
 In the making of a handbook of this kind it is necessary to draw at 
 every step upon the great fund of acquired information which has become 
 the common property of the profession. To those whose contributions 
 have formed that fund and to those who are daily adding to it I tender 
 grateful acknowledgment for its use. I have mentioned by name those 
 to whose work I have especially referred, but, as a general rule, it has been 
 impracticable for want of space to append systematic references to the 
 literature. 
 
 The illustrations are in large part drawn from personal observations. 
 They have been selected solely with the view to elucidate the subject in 
 hand. Diagrams have been employed when this method of presentation 
 has appeared desirable, and the free use of clinical charts constitutes an 
 important feature of the work. 
 
 To the friends and fellow-workers who have rendered — some small, 
 some larger, but all generous and willing — assistance, I desire to express 
 my thanks. The list includes many colleagues in the hospitals with which 
 I am connected, some who were and others who still are resident physi- 
 cians. It includes also Mr. Wilbert and Drs. Bachman, Manges, Rosen- 
 
PREFACE. vii 
 
 berger, Rowntree, Royer, White, W. R. Wilson, and J. Leslie Davis. To 
 Drs. de Schweinitz, Welch and Schamberg, T. M. Rotch, Packard, JPiersol, 
 Young, Emerson, Dudley Fulton, and many others, together with their 
 publishers, I am indebted for permission to use illustrations. The 
 pages on the diagnosis of diseases of the eye were written by Dr. 
 Sweet; those on the stomach and intestines mainly by Dr. Gwyn; 
 those on the nervous system by Drs. James Hendrie Lloyd and the late 
 William Pickett; those on X-ray diagnosis by Dr. Moore, and those on 
 the examination of the blood, urine, sputum, and other fluids by Dr. J. 
 F. Kaltej^er. The excellent drawings, plates, and other illustrations made 
 by Messrs. Schmidt and Faber add much to the usefulness of the book. 
 I am under special and lasting obligation to Dr. Kalteyer for his most 
 able and untiring aid while the work was in press, and to the publishers for 
 their generous cooperation at every stage in its making. 
 
 J. C. Wilson. 
 
 Philadelphia, September, 1909. 
 
CONTENTS. 
 
 PART I. 
 
 OF MEDICAL DIAGNOSIS IN GENERAL. 
 
 I. General Considerations 1 
 
 II. Medical Topography , 8 
 
 III. The Examination of the Patient, and Case-taking 39 
 
 PART II. 
 OF THE METHODS AND THEIR IMMEDIATE RESULTS. 
 
 I. Medical Thermometry 53 
 
 ^11. Physical Diagnosis. General Considerations; Inspection; Palpation; 
 
 Mensuration; Percussion; Auscultation 61 
 
 III. The Examination op the Stomach and Intestines 194 
 
 IV. The Examination of the Upper Air-passages and the Ear. Rhinoscopy; 
 
 Laryngoscopy; Otoscopy 221 
 
 V. The Examination of the Blood 229 
 
 VI. The Examination of the Urine 264 
 
 VII The Examination of the Sputum 296 
 
 VIII. The Examination of Transudates, Exudates, and the Contents of Cysts 300 
 IX. The Examination of the Nervous System. Preliminary Considerations; 
 Motor Symptoms; Sensory Symptoms; Regional Diagnosis of Cere- 
 bral Disease; Aphasia and Other Defects of Speech; Spinal Local- 
 ization; Combined Degenerations; the Reflexes; Electrodiagnosis; 
 Trophic Disturbances; Pain and Temperature; the Muscular Sense; 
 
 ' the Stigmata of Degeneration 306 
 
 X. The Examination of the Eye 351 
 
 XI. The Examination by X-rays 377 
 
 PART III. 
 OF SYMPTOMS AND SIGNS. 
 
 I. General Considerations 339 
 
 II. Appearance; Temperament and Diathesis; Facies; Weight, Form and 
 
 Nutrition 390 
 
 III. Bones; Joints; Musculature; Posture, Attitude and Gait; Posture 
 
 and Movements of Infants 402 
 
 IV. Temperature; Heat Mechanism; Fever; Hypothermia; Significance 
 
 OF Abnormal Temperatures 419 
 
 V. Respiration; Modified Respiratory Movements; Cough and Allied 
 Phenomena; Significance of Cough in Diagnosis; Expectoration or 
 
 Sputum 436 
 
 VI. Circulation; Pulsation; Radial Pulse; Anomalies of the Pulse; Venous 
 
 Pulse; Pulsation of the Liver; Centripetal Venous Pulse 460 
 
 VII. The Digestive System. The Mouth; Lips; Teeth; Gums; Tongue 477 
 
 VIII. The Digestive System, continued. The Palate; Tonsils; Pharynx 490 
 
 ix 
 
X CONTENTS. 
 
 IX. The Digestive System, continued. The QCsophagus 495 
 
 X. The Digestive System, continued. General Symptoms. Appetite; 
 
 Thirst; Eructations; Regurgitation; Nausea; Vomiting; The Vom- 
 iTUs; Defecation; Constipation; Diarrhcea; Tenesmus; Painful 
 
 Defecation; Fecal Incontinence; Character of the Discharges 500 
 XI. The Skin. Physiological AjStd Pathological Changes and Their Sig- 
 nificance; CEdema; Dropsy; Superficial Vascular Changes; Skin; 
 
 Nails; Hair 524 
 
 XII. Genito-ueinaey System. Micturition; Urinary Changes; the Repro- 
 ductive Organs 54S 
 
 XIII. General Symptomatic Disorders of the Nervous System. Pain; Ten- 
 
 derness; Par.esthesia . . 558 
 
 XIV. General Symptomatic Disorders of the Nervous System, contin- 
 
 ued. Vertigo; Convulsions; Tremor; Fibrillary Twitchings 586 
 
 XV. Psychical Conditions; Emotional States; Derangements of Con- 
 sciousness; Insomnia and Other Disorders of Sleep 593 
 
 PART IV. 
 OF THE CLINICAL APPLICATIONS. 
 
 I. 
 
 THE DIAGNOSIS OF THE SPECIFIC INFECTIONS. 
 
 I. Enteric or Typhoid Fever 605 
 
 II. Typhus Fever 641 
 
 III. Relapsing Fever 644 
 
 IV. The Variolous Diseases 647 
 
 A. Variola vera; Smallpox 651 
 
 (a) V. DISCRETA 651 
 
 (b) V. CONFLUENS 653 
 
 (c) V. H,EMORRHAGICA 656 
 
 B. Variola modificata; Varioloid 657 
 
 C. Vaccinia — Vaccination 663 
 
 V. Varicella 668 
 
 VI. Scarlet Fever 670 
 
 VII. Measles 681 
 
 VIII. Rubella 687 
 
 The Fourth Disease 689 
 
 IX. Whooping-cough 689 
 
 X. Mumps 694 
 
 XL Inlfuenza 697 
 
 XII. Dengue 702 
 
 XIII. Diphtheria 705 
 
 XIV. Vincent's Angina 713 
 
 XV. Croupous Pneumonia 714 
 
 XVI. Cerebrospinal Fever 730 
 
 XVII. Erysipelas 737 
 
 XVIII. Sepsis 742 
 
 Toxemia 744 
 
 Septicemia 744 
 
 Cryptogenetic Septicemia 744 
 
 Septicopyemia 744 
 
 Terminal Infections 744 
 
 XIX. Rheumatic Fever 746 
 
CONTENTS. xi 
 
 XX. Yellow Fever 750 
 
 XXI. Cholera 752 
 
 XXII. Bacillary Dysentery 756 
 
 XXIII. The Plague '.• 757 
 
 XXIV. Malta Fever 759 
 
 XXV. Beri-beri 761 
 
 XXVI. Tetanus 763 
 
 XXVII. Hydrophobia 767 
 
 XXVIII. Glanders 771 
 
 XXIX. Actinomycosis 773 
 
 XXX. Anthrax 776 
 
 XXXI. Leprosy 780 
 
 XXXII. Tuberculosis 784 
 
 (A) Acute Miliary Tuberculosis 788 
 
 (B) Tuberculosis of the Lymph-nodes 792 
 
 (C) Tuberculosis of Serous Membranes 794 
 
 (D) Tuberculosis of the Alimentary Canal 797 
 
 (E) Tuberculosis of the Brain and Spinal Cord 800 
 
 (F) Tuberculosis of the Genito-urinary Organs 800 
 
 (G) Tuberculosis of the Lungs 802 
 
 (a) Acute Pneumonic Phthisis 803 
 
 (b) Chronic Ulcerative Phthisis 805 
 
 (c) Fibroid Phthisis 819 
 
 XXXIII. Syphilis 821 
 
 XXXIV. Gonorrhcea 831 
 
 XXXV. Ephemeral Fever 833 
 
 XXXVI. Rocky Mountain Spotted Fever; Tick Fever 834 
 
 XXXVII. Icterus Infectiosus; Weil's Disease 836 
 
 XXXVIII. Glandular Fever 837 
 
 XXXIX. Miliary Fever 838 
 
 XL.'Foot-and-Mouth Disease 839 
 
 XLI. Erysipeloid of Rosenbach 840 
 
 XLII. Erythema Infectiosum 841 
 
 II. 
 
 THE DIAGNOSIS OF DISEASES CAUSED BY ANIMAL PARASITES. 
 
 A. Diseases due to Protozoa 842 
 
 i. Psorospermiasis 842 
 
 ii. Amcebic Dysentery 842 
 
 iii. Trypanosomiasis 844 
 
 iv. Dum-dum Fever 845 
 
 V. The Malarial Fevers 846 
 
 (a) Regularly Intermitting Fever of Tertian or Quar- 
 
 tan Type 850 
 
 (b) Irregular, Remittent, Continued, and Pernicious 
 
 Fevers 852 
 
 (c) Malarial Cachexia 854 
 
 B. Diseases due to Flukes: Distomiasis 855 
 
 C. Diseases due to Cestodes 858 
 
 i. Intestinal Cestodes: Tapeworms 858 
 
 (a) T^NiA Solium 859 
 
 (b) TiENiA Saginata 860 
 
 (c) T^NiA Cucumerium 860 
 
xii CONTENTS. 
 
 (d) T.ENIA Nana , 860 
 
 (e) T^NiA Flavopunctata 861 
 
 (f) T^NiA Lata: Bothriocephalus Latus 861 
 
 ii. Visceral Cestodes 862 
 
 (a) Cysticercus Cellulose 862 
 
 (b) EcHiNococcus Disease 862 
 
 D. Diseases due to Nematodes 866 
 
 i. AscARiAsis 866 
 
 ii. Trichiniasis 867 
 
 iii. Uncinariasis 870 
 
 iv. FiLARiAsis 872 
 
 V. Dracontiasis 875 
 
 III. 
 
 THE DIAGNOSIS OF THE CHRONIC INTOXICATIONS. 
 
 I. Alcoholic Intoxication; Alcoholism 876 
 
 II. Opium Poisoning; Morphinism 879 
 
 III. Cocaine Poisoning; Cocainism 881 
 
 IV. Lead Poisoning; Plumbism 881 
 
 V. Poisoning by Arsenic 884 
 
 VI. Poisoning by Mercury 887 
 
 VII. Poisoning by Phosphorus 889 
 
 VIII. Poisoning by Illuminating Gas 890 
 
 IV. 
 THE DIAGNOSIS OF FOOD POISONING. 
 
 I. Fish Poisoning; Ichthyismus 893 
 
 II. Meat Poisoning; Botulismus 894 
 
 III. Poisoning by Milk and Milk Products 894 
 
 IV. Grain and Vegetable Poisoning 895 
 
 V. 
 
 THE DIAGNOSIS OF AUTOINTOXICATIONS. 
 
 I. The Gastro-intestinal Autointoxications 896 
 
 II. The Retention Autointoxications 898 
 
 III. Autointoxication from Extensive Abolition of the Function of the 
 
 Skin 898 
 
 IV. Acidosis 898 
 
 V. Gout 898 
 
 VI. Glycosuria and Diabetes 898 
 
 VI. 
 
 the diagnosis of heat-stroke and electric stroke. 
 
 Heat-stroke 899 
 
 Electric Stroke 900 
 
 VII. 
 
 THE DIAGNOSIS OF PREGNANCY. 
 
 The Diagnosis of Pregnancy 901 
 
CONTENTS. xiii 
 VIII. 
 
 THE DIAGNOSIS OF CONSTITUTIONAL DISEASES. 
 
 I. Gout 904 
 
 II. Arthritis Deformans 908 
 
 III. The Rheumatoid Affections 910 
 
 A. Chronic Rheumatism 911 
 
 B. Myalgia: Muscular Rheumatism 911 
 
 iv. Diabetes 912 
 
 A. Diabetes Mellitus 913 
 
 B. Diabetes Insipidus 921 
 
 V. Nutritional Diseases ■ 922 
 
 A. Scurvy 922 
 
 B. Infantile Scurvy 925 
 
 C. Rickets 927 
 
 D. Obesity 930 
 
 Adiposis Tuberosa Simplex 931 
 
 Adiposis Dolorosa 932 
 
 VI. Amyloid Disease 932 
 
 IX. 
 
 THE DIAGNOSIS OF DISEASES OF THE DIGESTIVE SYSTEM. 
 
 (Diseases of the Mouth, Tongue, Gums, Sahvary Glands, Pharynx, Tonsils, and (Esophagus 
 are considered in Part III.) 
 
 I. Diseases of the Stomach 935 
 
 i. Acute Gastritis 935 
 
 1. Toxic Gastritis 935 
 
 2. Phlegmonous Gastritis 936 
 
 3. Diphtheritic Gastritis 936 
 
 4. Parasitic Gastritis 936 
 
 5. Dietetic Gastritis 937 
 
 ii. Chronic Gastritis — Chronic Gastric Catarrh 938 
 
 iii. Dilatation of the Stomach — Gastrectasis 939 
 
 iv. Gastric Ulcer 942 
 
 V. Cancer of the Stomach — Carcinoma Ventriculi 944 
 
 vi. Hypertrophic Stenosis of the Pylorus 945 
 
 vii. Tuberculous Ulceration of the Stomach 946 
 
 viii. The Gastric Neuroses 946 
 
 ix. G ASTROPTOSIS 950 
 
 II. Diseases of the Intestines 952 
 
 i. Enteritis 952 
 
 Catarrhal Enteritis 952 
 
 Phlegmonous Enteritis 953 
 
 Diphtheritic Enteritis 953 
 
 ii. DiARRHCEAL DISORDERS OF CHILDREN 954 
 
 iii. Ulceration of the Intestines 956 
 
 iv. Intestinal Stenosis and Obstruction 958 
 
 V. Dilatation of the Intestines — Idiopathic Dilatation of the Colon 963 
 
 vi. Appendicitis 964 
 
 vii. Enteroptosis 972 
 
 viii. Intestinal Indigestion 973 
 
 ix. Intestinal Neuroses 974 
 
 X. Intestinal Neoplasms 975 
 
xiv CONTEXTS. 
 
 III. Diseases of the Liver 977 
 
 i. A^^ATOIIICAL AxOlL^UxLES OF THE LiVER 977 
 
 ii. Movable Liver 978 
 
 iii. Jaundice : Icterus , 979 
 
 iv. Icterus Xeoxatorum 981 
 
 V. Acute Yellow Atrophy 982 
 
 vi. Diseases of the Bile P.^sages and Gall-bladder 983 
 
 Catarrhal. Jauxdice 983 
 
 Chronic Angiocholitis 985 
 
 Various Lesions of the Bile Passages 986 
 
 Inflammation of the Gall-bladder: Cholecystitis 987 
 
 Caxcee of the Bile-ducts and Gaxl-bladder 989 
 
 Cholelithiasis: Gall-stone Disease 989 
 
 vii. Affections of the Blood-vessels of the Liver 997 
 
 Anemia 997 
 
 hyper.emia 997 
 
 DiSE.IlSES of THE PoRTAL VeIN 998 
 
 Diseases of the Hepatic Artery and Veins 999 
 
 viii. Abscess of the Liver: Suppurative Hepatitis 999 
 
 ix. Fatty Liver 1003 
 
 X. CHRON^c Interstitial Hepatitis: Cirrhosis of the Liver 1005 
 
 xi. New Growths in the Li\t:r 1009 
 
 rV. Diseases of the Pancreas 1013 
 
 i. Hemorrhage into the Pancreas 1013 
 
 ii. Acute Pancreatitis 1013 
 
 iii. Chronic P.\ncreatitis 1017 
 
 iv. P.4^^CREATIC Calculi 1018 
 
 V. P.\NCREATic Cysts 1018 
 
 vi. Tumors of the P.\ncreas 1020 
 
 V. Diseases of the Peritoneum 1021 
 
 i. Ascites — Abdomin.^x Dropsy — Hydroperitoneum 1021 
 
 ii. Acute General, Peritonitis 1024 
 
 iii. Acute Circumscribed Peritonitis 1029 
 
 iv. Chronic Peritonitis 1031 
 
 V. Tuberculous Peritonitis — Tuberculosis of the Peritoneum 1032 
 
 vi. Xew Growths in the Peritoneum 1032 
 
 vii. Retroperitoneal Sarcoma 10.34 
 
 X. 
 
 THE DIAGNOSIS OF DISEASES OF THE RESPIRATORY SYSTEM. 
 
 I. DiSE.iSES OF THE XOSE 1035 
 
 i. Acute Xasal Catarrh 1035 
 
 ii. Chronic Xas.u. Catarrh 1036 
 
 iii. Autumnal Cat.\rrh — Hay Fever 1037 
 
 iv. Epistaxis 1039 
 
 II. Diseases of the Lary^cx 1040 
 
 i. Acute Cat.^rrhal Laryngitis 1040 
 
 ii. Acute Laryngitis of Children — Spasmodic Croup 1041 
 
 iii. Subacute L.aryngitis 1042 
 
 iv. Chronic Laryngitis 1042 
 
 V. GEdematous Laryngitis — Acute Laryngeal (Edema 1043 
 
 vi. Pseudomembranous Laryngitis 1044 
 
 \'ii. Tuberculous L.\ryngitis 1045 
 
CONTENTS. XV 
 
 viii. Syphilitic L.^eyngitis 1046 
 
 ix. Laryngismus Stridulus 1047 
 
 X. Chronic Infantile Stridor 1048 
 
 xi. Paraly'Sis of the Laryngeal Muscles 1048 
 
 III. Diseases of the Bronchi 1051 
 
 i. Bronchitis 1051 
 
 (a) Acute Bronchitis 1051 
 
 (b) Chronic Bronchitis 1053 
 
 (1) Dry Bronchitis 1053 
 
 (2; Bronchorrhcea 1054 
 
 (3) Putrid Bronchitis 1054 
 
 (c) Fibrinous Bronchitis 1054 
 
 ii. Bronchiectasis 1055 
 
 iii. Tracheobronchial Stenosis 1057 
 
 iv. Bronchial Asthma 1058 
 
 IV. Diseases of the Pulmonary Tissue 1061 
 
 i. Circulatory Derangements 1061 
 
 (a) Pulmonary Congestion 1061 
 
 (b) Pulmonary Oedema 1062 
 
 (c) Pulmonary Hemorrhage 1063 
 
 ii. Diseases Characterized by Changes in the Vesicular Structure 
 
 of the Lungs 1066 
 
 (a) Pulmonary Emphysema 1066 
 
 Vesicular Emphy'Sema: Substantive Emphysema: Pseudo- 
 hypertrophic EMPHYSEM.-V 1066 
 
 Acute Vesiculak Emphy'Sema 1069 
 
 Compensatory Emphysema: Vicarious Emphysema 1069 
 
 Atrophic Emphy'Sema 1069 
 
 Interstitial Emphysema 1069 
 
 (b) Pulmonary Atelectasis: Collapse of the Lung 1070 
 
 Congenital Atelectasis 1070 
 
 Acquired Atelectasis 1070 
 
 (c) Bronchopneumonia: Lobular Pneumonia: Catarrhal Pneu- 
 
 monia: So-called Capillary Bronchitis 1071 
 
 iii. Diseases of the Lungs Ch.-uracterized by Interstiti.al Inflammation 1075 
 
 (a) Chronic Interstitial Pneumonia: Cirrhosis of the Lung ... . 1075 
 
 (b) Pneumonoconiosis 107S 
 
 iv. Diseases of the Lungs due to Suppuration and Necrosis 1079 
 
 (a) Pulmonary Abscess 1079 
 
 (b) Pulmonary Gangrene 1080 
 
 V. New Growths in the Lungs 1082 
 
 V. Diseases of the Mediastinum 1083 
 
 VI. Diseases of the Pleura 1088 
 
 i. Pleurisy 1088 
 
 (a) Fibrinous or Plastic Pleurisy: Pleuritis Sicca lOSS 
 
 (b) Pleurisy with Effusion: Pleuritis Exudativa 1091 
 
 Serofibrinous Pleurisy 1091 
 
 Purulent Pleurisy: Empyema 1096 
 
 Hemorrhagic Pleurisy 1097 
 
 Chyliform Pleural Effusions: Hydrops Adiposis 1098 
 
 ii. Morbid vStates Characterized by the Transudation of Serum or 
 Chyle, or the Eruption of Pus, Blood, or Air into the 
 
 Pleural Sac 1102 
 
xvi CONTENTS. 
 
 (a) Hydrothorax 1102 
 
 (b) Chylous Pleural Effusion: Hydrops Chylosus 1103 
 
 (c) Pyothorax 1103 
 
 (d) Hemothorax 1104 
 
 (e) Pneumothorax: Hydropneumothorax: Pyopneumothorax. . . 1104 
 
 XI. 
 
 THE DIAGNOSIS OF DISEASES OF THE KIDNEYS. 
 
 I. Anatomical Anomalies of the Kidneys 1107 
 
 II. Movable Kidney 1108 
 
 III. Circulatory Derangements. 1110 
 
 (a) Aneivha 1110 
 
 (b) Congestion 1110 
 
 (c) Hemorrhagic Infarct 1110 
 
 IV. Uremia : HH 
 
 V. Inflammation of the Kidneys 1114 
 
 (a) Acute Nephritis 1114 
 
 (b) Chronic Nephritis; Chronic Bright 's Disease 1117 
 
 1. Chronic Parenchymatous Nephritis 1117 
 
 2. Chronic Interstitial Nephritis 1118 
 
 VI. Pyelitis 1121 
 
 VII. Perinephric Abscess 1123 
 
 VIII. Nephrolithiasis 1 124 
 
 (a) Renal Infarct 1124 
 
 (b) Renal Calculus 1124 
 
 IX. Hydronephrosis 1127 
 
 X. Cysts of the Kidney 1 129 
 
 XI. Tumors of the Kidney 1131 
 
 XII. 
 
 THE DIAGNOSIS OF DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 
 DISEASES OF THE BLOOD. 
 
 I. Anemia 1 133 
 
 i. General Considerations 1133 
 
 ii. Primary Anemia 1134 
 
 (a) Chlorosis 1134 
 
 (b) Pernicious Anemia 1137 
 
 (c) Splenic Anemia 1141 
 
 iii. Secondary or Symptomatic Anemia 1141 
 
 II. Leukemia 1143 
 
 i. Myelogenous Leukemia 1144 
 
 ii. Lymphatic Leukemia 1146 
 
 III. Hodgkin's Disease 1149 
 
 IV. Diseases Characterized by Hemorrhage 1153 
 
 (a) Purpura 1153 
 
 Purpura Simplex 1154 
 
 Purpura Hemorrhagica 1154 
 
 Purpura Rheumatica 1155 
 
 Henoch's Purpura 1156 
 
 Symptomatic Purpura 1157 
 
CONTENTS. xvu 
 
 (b) HEMOPHILIA 1158 
 
 (c) Hemorrhagic Diseases of the New-born 1160 
 
 Acute Fatty Degeneration 1160 
 
 Infectious Hemoglobinuria 1160 
 
 Morbus Maculosus Neonatorum 1161 
 
 DISEASES OF THE DUCTLESS GLANDS. 
 
 I. Diseases of the Spleen 1161 
 
 i. Anatomical Anomalies 1161 
 
 ii. Movable Spleen 1162 
 
 iii. Acute Splenic Tumor 1162 
 
 iv. Chronic Splenic Tumor 1163 
 
 V. Splenic Tumor with Anemia 1165 
 
 vi. Splenic Tumor with Polycythemia and Cyanosis 1165 
 
 vii. Splenic Capsulitis 1166 
 
 viii. Hemorrhagic Infarct of the Spleen 1166 
 
 ix. Abscess of the Spleen 1166 
 
 X. Rupture of the Spleen 1167 
 
 II. Diseases of the Thymus Gland 1167 
 
 III. Status Lymphaticus: Lymphatism 1168 
 
 IV. Diseases of the Thyroid Gland 1169 
 
 i. Acute Thyroiditis 1169 
 
 ii. Goitre: Bronchocele 1170 
 
 iii. Exophthalmic Goitre 1171 
 
 iv. Myxcedema 1174 
 
 1. Cretinism 1175 
 
 2. Myxoedema of Adults 1176 
 
 3. Post-operative Myxcedema: Cachexia Strumipriva 1177 
 
 4. Hypoparathyreosis: Status Parathyreoprivus 1177 
 
 V. Diseases of the Adrenal Bodies 1178 
 
 i. General Considerations 1178 
 
 ii. Addison's Disease 1178 
 
 VI. Acromegaly 1181 
 
 XIII. 
 
 THE DIAGNOSIS OF DISEASES OF THE CIRCULATORY SYSTEM. 
 
 DISEASES OF THE HEART. 
 
 I. Abnormal Positions of the Heart 1183 
 
 II. Diseases of the Myocardium 1183 
 
 i. Acute Myocarditis 1183 
 
 ii. Chronic Myocarditis 1185 
 
 iii. Hypertrophy and Dilatation 1190 
 
 (a) Hypertrophy of the Heart 1190 
 
 (b) Dilatation of the Heart 1 192 
 
 iv. Fatty Heart 1193 
 
 v. Various Degenerations, New Growths, and Parasites of the Heart 1195 
 
 vi. Wounds and Foreign Bodies 1195 
 
 vii. Rupture of the Heart 1195 
 
 viii. Aneurism of the Heart 1196 
 
 ix. Atrophy of the Heart 1 197 
 
xviii CONTENTS. 
 
 III. Diseases of the Pericakdium 1197 
 
 i. Pericarditis 1197 
 
 (a) Fibrinous, Plastic, or Dry Pericarditis 1198 
 
 (b) Pericarditis with Effusion 1200 
 
 ii. Adherent Pericardium 1205 
 
 iii. Hydropericardium 1206 
 
 iv. H^MOPERICARDIUM 1207 
 
 V. Pneumopericardium 1207 
 
 vi. Calcification of the Pericardium 1207 
 
 IV. Diseases of the Endocardium 1207 
 
 i. Endocarditis 1207 
 
 (a) Acute Endocarditis 1208 
 
 (b) Chronic Endocarditis 1212 
 
 V. Chronic Valvular Disease 1214 
 
 i. Aortic Insufficiency • 1214 
 
 ii. Aortic Stenosis 1217 
 
 iii. Mitral Insufficiency 1220 
 
 iv. Mitral Stenosis 1224 
 
 V. Pulmonary Insufficiency and Stenosis 1226 
 
 vi. Tricuspid Insufficiency and Stenosis 1227 
 
 vii. Physical Signs of Uncombined Valvular Lesions of the Left 
 
 Heart, Compensation being Maintained 1228 
 
 viii. Combined Valvular Lesions 1229 
 
 VI. Congenital Lesions of the Heart 1230 
 
 VII. Heart Block: The Stokes-Adams Syndrome 1231 
 
 VIII. Angina Pectoris 1233 
 
 IX. Functional Affections of the Heart: The Cardiac Neuroses 1235 
 
 DISEASES OF THE ARTERIES. 
 
 I. Arteriosclerosis 1239 
 
 II. Aneurism ' 1244 
 
 i. Aneurism of the Aorta 1244 
 
 (a) Aneurism of the Thoracic Aorta 1246 
 
 (b) Aneurism of the Abdominal Aorta 1257 
 
 ii. Aneurism of the Cceliac Axis and its Branches 1258 
 
 iii. Arteriovenous Aneurism 1259 
 
 iv. Periarteritis Nodosa: Congenital Aneurism 1259 
 
 XIV. 
 
 THE DIAGNOSIS OF DISEASES OF THE NERVOUS SYSTEM. 
 DISEASES OF THE BRAIN. 
 
 I. Meningitis '■'^^ 
 
 II. Acute Hemorrhagic Encephalitis 1261 
 
 III. Purulent Meningo-encephalitis and Brain Abscess 1262 
 
 IV. Sinus Thrombosis 1265 
 
 V. Cerebral Hemorrhage 1267 
 
 VI. Cerebral Softening 1271 
 
 VII. The Cerebral Palsies of Children 12/3 
 
 VIII. Hydrocephalus ^277 
 
 IX. Intracranial Aneurisms 1278 
 
 X. Tumors of the Brain 12'9 
 
CONTENTS. xix 
 
 XI. Parasites in the Brain 1283 
 
 XII. Syphilis of the Brain 1284 
 
 XIII. General Paresis 1285 
 
 XIV. Senile Degeneration 1287 
 
 XV. Acute Delirium 1288 
 
 XVI. Multiple Sclerosis 1289 
 
 XVII. Diseases of the Mid-brain 1290 
 
 XVIII. Nuclear Ophthalmoplegia 1291 
 
 XIX. Diseases of the Cerebellum 1295 
 
 XX. Diseases of the Pons 1296 
 
 XXI. Bulbar Palsy 1298 
 
 XXII. Pseudobulbar Palsy 1300 
 
 DISEASES OF THE CRANIAL NERVES. 
 
 I. First Nerve 1303 
 
 II. Second Nerve 1304 
 
 III. Third, Fourth, and Sixth Nerves — Motor Nerves of the Eye 1306 
 
 IV. Fifth Nerve 1307 
 
 V. Seventh Nerve 1310 
 
 VI. Eighth Nerve 1312 
 
 VII. Ninth Nerve 1314 
 
 YIII. Tenth Nerve 1315 
 
 IX. Eleventh Nerve 1316 
 
 X. Twelfth Nerve 1317 
 
 DISEASES OF THE SPINAL CORD. 
 
 I. Spinal Meningitis 1318 
 
 II. Myelitis 1319 
 
 III. Anterior Poliomyelitis 1322 
 
 IV. Acute Ascending Paralysis (Landry) 1324 
 
 V. Progressive Muscular Atrophy 1325 
 
 VI. Amyotrophic Lateral Sclerosis 1327 
 
 VII. Primary Lateral Sclerosis 1328 
 
 VIII. Locomotor Ataxia 1328 
 
 IX. Ataxic Paraplegia 1333 
 
 X. Hereditary Ataxia (Friedreich) 1334 
 
 XI. Syringomyelia 1335 
 
 XII. Syphilis of the Spinal Cord 1337 
 
 XIII. Tumors of the Spinal Cord 1339 
 
 XIV. Injuries of the Spinal Cord 1341 
 
 XV. Hemorrhage in the Spinal Cord 1343 
 
 XVI. Softening of the Spinal Cord 1345 
 
 XVII. The Caisson Disease 1346 
 
 XVIII. Diseases of the Cauda Equina 1347 
 
 XIX. Spina Bifida 1349 
 
 DISE.\SES OF THE SPINAL NERVES. 
 
 I. Multiple Neuritis 1349 
 
 II. The Cervical Plexus 1353 
 
 III. The Phrenic Nerve 1354 
 
 IV . The Brachial Plexus 1355 
 
XX CONTENTS. 
 
 V. The Anterior Thoracic Nerves 1356 
 
 VI. The Posterior Thoracic Nerve 1356 
 
 VII. The Circumflex Nerve 1357 
 
 VIII. The Musculospiral Nerve 1358 
 
 IX. The Median Nerve 1359 
 
 X. The Ulnar Nerve 1360 
 
 XI. The Intercostal Nerves 1361 
 
 XII. The Lumbar Plexus 1362 
 
 XIII. The Anterior Crural Nerve 1363 
 
 XIV. The Obturator Nerve 1364 
 
 XV. The Sacral Plexus ■ 1364 
 
 XVI. The Sciatic Nerves • 1365 
 
 XVII. The Internal Popliteal Nerve 1367 
 
 XVIII. The Peroneal Nerve 1368 
 
 GENERAL NERVOUS DISEASES. 
 
 I. Chorea 1369 
 
 Choreiform Affections ■ ■ ■ • 1372 
 
 II. Epilepsy 1374 
 
 III. Hysteria 1380 
 
 IV. Hypnotism 1385 
 
 V. Neurasthenia 1386 
 
 VI. Occupation Neuroses 1388 
 
 VII. Migraine 1390 
 
 VIII. Paralysis Agitans 1393 
 
 IX. Tetany 1395 
 
 X. The Tics 1396 
 
 VASOMOTOR AND TROPHIC DISEASES. 
 
 I. Raynaud 's Disease 1397 
 
 II. Erythromelalgia 1399 
 
 III. Angioneurotic (Edema 1400 
 
 IV. Hemifacial Atrophy 1401 
 
 V. Osteitis Deformans 1402 
 
 VI. Achondroplasia 1405 
 
 XV. 
 
 THE DIAGNOSIS OF DISEASES OF THE MUSCLES. 
 
 I. Myositis 1406 
 
 II. The Myopathies 1407 
 
 III. Thomsen's Disease: Myotonia 1409 
 
 IV. Paramyoclonus Multiplex 1410 
 
 V. Myasthenia Gravis 1410 
 
 Index 1413 
 
LIST OF PLATES 
 
 PLATE 
 
 I, General Anatomical Outlines and Relations of the Thoracic and 
 
 Abdominal Organs 12 
 
 II. General Anatomical Outlines and Relations of the Thoracic and 
 
 Abdominal Organs 14 
 
 III. Positions of the Vocal Cords 226 
 
 IV. Blood Corpuscles 258 
 
 V. 1. Neutrophile Leukocytosis. 2. Eosinophilia. 3. L'I'mphocytosis. 
 
 4. Myel^mia 262 
 
 VI. Tubercle Bacilli in Sputum 298 
 
 VII. Connection between Sympathetic Nerves Supplying Viscera and 
 
 Spinal Nerves Supplying Muscles of Abdominal Walls 331 
 
 VIII. Varieties in the Normal Fundus 352 
 
 IX. Changes in Arteriosclerosis 376 
 
 X. Changes in Retinal Vessels 376 
 
 XI. Inflammation in the Retina 376 
 
 XII. Typical Vaccination 664 
 
 XIII. Tertian and Quartan Malarial Parasites 847 
 
 XIV. iEsTivo-AUTUMNAL Malarial Parasites 849 
 
A HANDBOOK 
 
 of 
 
 MEDICAL DIAGNOSIS 
 
 PART I. 
 
 OF MEDICAL DIAGNOSIS IN GENERAL. 
 
 I. 
 
 GENERAL CONSIDERATIONS. 
 
 Diagnosis in medicine is the art or process of distinguishing between 
 different diseases. It occupies a position related on the one hand to eti- 
 ology — that science which has for its object the study of the causes of 
 disease — and on the other to therapeutics — the art of healing. To recog- 
 nize a disease involves the consideration of its causes, and if they can be 
 corrected or removed, points the way to a cure — causa suhlata tollitur 
 effectus. Even when the causes are beyond our control or the lesions 
 which they have produced are permanent, a knowledge of the true nature 
 of the malady may enable us to select judiciously the therapeutic meas- 
 ures by which are brought about those adjustments which relieve suffer- 
 ing and prolong life. There is truth in the ancient maxim, '^ qui bene 
 diagnoscit bene curat." Finally, a correct diagnosis is essential to a rea- 
 sonable prognosis, since by this means only can we foretell the probable 
 course of a disease, whether it tends to recovery, to continuing disability, 
 or to death. 
 
 Diagnosis is of fundamental importance in scientific medicine. The 
 prevention of disease and the healing of the sick constitute the goal of 
 medicine, but diagnosis is the course by which that goal is to be reached. 
 Empirical systems ignore alike the causal and the pathological basis of 
 disease and content themselves with the stud}^ and treatment of symptoms, 
 and all practice tends to degenerate into charlatanism in proportion as 
 it allows itself to be betrayed into this delusion. Rational medicine, on 
 the other hand, regards symptoms primarily as clues to a diagnosis, only 
 secondarily as indications for treatment; and treatment itself as efficient 
 
 r 
 
2 MEDICAL DIAGNOSIS. 
 
 when it is causal or radical, and as a makeshift when it is simply pallia- 
 tive or symptomatic. When pain is present we seek by the methods of 
 diagnosis to find the cause of it and to relieve it by the removal of the 
 cause, and are not content simply to relieve the pain without regard to 
 the underlying condition which produced it. 
 
 The art of diagnosis is important not only because of its practical 
 utility, but also because it deals with the facts of nature. Hypotheses 
 and theories in regard to disease come and go, nosological arrangements 
 change and shift like the colors in the kaleidoscope, therapeutic fashions 
 rise and fall, but the facts gained by close and constant observation belong 
 to science and are changeless, and these are the facts with which diagnosis 
 is concerned. It has been said that the whole art of medicine is in obser- 
 vation. It is certainly true that the art of diagnosis is in observation. 
 Errors occur far more commonly from incomplete observation than from 
 want of knowledge. A systematic, patient, painstaking study of the facts 
 is essential to success. 
 
 The requirements of this branch of medicine are most varied and 
 exacting. A knowledge of anatomy, and especially of visceral and regional 
 anatomy, is essential. The variations in the size and position of the organs 
 within the Hmits of health must be known. The structure and relation 
 of the parts entering into the formation of the nervous system must be 
 mastered. The physiological functions of the complex human organism 
 are to be familiar knowledge. The causes of disease, both those belonging 
 to the outside world and those developed within the body itself, and the 
 susceptibilities which vary at different periods of hfe and under different 
 circumstances, must be thoroughly understood. Changes produced by 
 pathogenic factors must be clearly known. In truth, the facts of pathology 
 and semeiology and the natural history of the diseases constitute the 
 basis of diagnosis. 
 
 Hence, in the arrangement of medical studies, diagnosis is properly 
 taken up after the student has made advanced progress in the funda- 
 mental branches, and the success of the practitioner in this field of medicine 
 is dependent upon close habits of observation, accurate knowledge, and 
 large experience. A judicial temperament and the ability to weigh evi- 
 dence and assign due relative value to the factors in clinical problerris 
 are essential. Not less important are patience and a systematic pro- 
 cedure in all cases. Equally essential are correct habits of reasoning, 
 since without these a faulty conclusion may follow accurately observed 
 facts. The diagnostician in the broad field of clinical medicine must 
 frequently turn for assistance to his professional colleague, who is familiar 
 with the facts of the more restricted specialties and has mastered their 
 technic, and he is becoming with advancing knowledge more and more 
 dependent for accurate results ujjon instruments of precision and the 
 clinical laboratory. Finally, the diagnostician shoulcl not be without 
 imagination. Making use of his knowledge of anatomy and morbid anatomy 
 he should cultivate the habit of picturing to himself the changes in the 
 organs of the body by which clinical phenomena are brought about, such 
 as the consolidated lung in pneumonia, the fibrinous exudate or effusion 
 in pleurisy, the impacted gall-stone in bihary fever, the thrombus in phle- 
 
GENERAL CONSIDERATIONS. 3 
 
 bitis, the clot and its location in cerebral apoplexy; and in order that this 
 habit of forming at the bedside, by a process of projective imagination, 
 mental pictures of structural conditions hidden from the eye may be 
 developed to the greatest extent, he should avail himself of every oppor- 
 tunity of witnessing operations involving the cranium, thorax, and abdo- 
 men, and of being present at post-mortem examinations. 
 
 The object of diagnosis is not merely to find a name for a morbid 
 condition or symptom-complex. This it does, it is true, but in doing so 
 it determines the condition of the patient as an individual, the intensity 
 of the pathological process, the importance of prominent symptoms, the 
 presence or absence of complications or intercurrent diseases, and in acute 
 maladies the ability of the organism to withstand the attack. A correct 
 diagnosis enables us to determine whether the condition of the patient 
 is due to causes still operative or the result of influences that have ceased 
 to act; whether or not his malady is self-limited, and, by collating the facts 
 of any given case with the general knowledge of the profession, to form an 
 opinion as to the probable duration of the sickness and its ultimate out- 
 come. It informs us whether the prominent symptoms are the direct 
 manifestation of an independent morbid process, as in gonorrhceal arthritis, 
 the expression of a constitutional susceptibility, as in rheumatic fever, or 
 an acute outbreak of a persistent condition, as in podagra. It enables us 
 to recognize primary and secondary morbid processes and to distinguish 
 between them, as in appendicitis and peritonitis, and to perceive the rela- 
 tion between associated visceral lesions due to the same cause, or to an 
 extension to the neighboring organs, as in the case of left-sided pleurisy 
 with pericarditis. It takes into consideration the hereditary tendencies 
 of the patient, his age, surroundings, occupation, mode of life and habits. 
 Diagnosis is clearly the only basis for rational therapeutics and reasonable 
 prognosis. The medical sciences deal with diseases, the art of diagnosis 
 with individuals. Disease is not an entity, but the sum of the phenomena 
 of the reaction of the organism to pathogenic influences. 
 
 There are various methods of diagnosis, all of which may be included 
 under the two general groups of direct and indirect diagnosis. 
 
 Direct Diagnosis. 
 
 A direct diagnosis is made when the history of the case and the clin- 
 ical phenomena are sufficient to warrant a positive conclusion. The his- 
 tory of a violent prolonged chill, followed by high fever and pain in the 
 chest, with cough, rusty sputum containing pneumococci, dulness upon 
 percussion in the affected area, crepitant rales, and bronchial breathing, 
 justify a direct diagnosis of croupous pneumonia. The previous history 
 of the attack is not always necessary, the foregoing associated symptoms 
 and signs being sufficient for the diagnosis of pneumonia even when the 
 patient is delirious or too ill to give an account of himself. 
 
 The direct method is sometimes described as the semeiological method. 
 The diagnosis is based upon the clinical phenomena of the disease and is 
 reached by analysis and induction. When the data are adequate it is 
 altogether the most scientific and satisfactory method. 
 
MEDICAL DIAGNOSIS. 
 
 Indirect Diagnosis. 
 
 The indirect method must be employed when the cHnical phenomena are 
 obscure or insufficient for a direct diagnosis. The results are not always 
 conclusive and the diagnosis may remain for a time one of probability. 
 This method includes differential diagnosis and diagnosis by exclusion. 
 
 The differential method is based upon the recognition of the 
 essential phenomena by which one disease may be discriminated from 
 others of a group presenting similar manifestations. A young person 
 may present himself complaining of the following symptoms: Loss of 
 flesh and strength, occasional irregular chills, followed by fever and sweat- 
 ing, shortness of breath upon exertion, cough and pain in the chest with 
 scanty expectoration. Upon inspection the respiratory movement of the 
 right side is diminished. The right thorax is found to be enlarged and 
 altered in contour. There is faint cyanotic discoloration with oedema in 
 the infra-axillary region. The heart is displaced to the left and the lower 
 border of the liver downward. Vocal fremitus is enfeebled. There is 
 marked dulness upon 'percussion over the lower part of the chest, con- 
 tinuous with the liver dulness, while the percussion note over the upper 
 portion has a sHghtly tympanitic quality. Upon auscultation the ves- 
 icular murmur is faint and distant. Neither rales nor friction sounds are 
 heard. The greater number of these symptoms and physical signs may be 
 encountered in (a) abscess of the right lobe of the liver, (b) mahgnant 
 disease of the pleura, (c) serofibrinous pleurisy, (d) empyema. 
 
 (a) Abscess of the right lobe of the liver is compai-atively rare. There 
 is frequently a history of dysentery or other disease of the abdominal 
 viscera. The pus collection is rarely sufficiently large to displace the heart. 
 
 (b) Mahgnant disease of the pleura is Hkewise a rare affection. It 
 usually develops insidiously without pain. It is not attended by chills 
 or fever and does not displace the heart or Hver until the growth has 
 attained unusual proportions. It produces a profound cachexia and 
 usually involves rather than compresses the lung, so that tympany in the 
 upper part of the lung is absent and irregular patchy dulness is elicited 
 over the seat of the growth. 
 
 (c) Serofibrinous pleurisy does not usually give rise to fever or, even 
 when massive, to disturbance of the circulation of the wall of the chest or 
 oedema. 
 
 (d) The essential phenomena by which, when present, empyema may 
 be discriminated from the foregoing affections, in addition to the signs of 
 compression of the lung and displacement of adjacent organs, are chills, 
 fever, sweating, and cyanosis and csdema of the chest wall. 
 
 Diagnosis by exclusion differs from differential diagnosis only in 
 its scope. It seeks to estabhsh the nature of the disease by the negative 
 process of showing what it is not. The various diseases presenting similar 
 cHnical phenomena are compared in turn with the case under consideration, 
 and one after another excluded, the diagnosis of that disease being finally 
 made to which the malady most closely conforms. In the above example 
 we should first set aside abscess of the liver, then mahgnant disease of the 
 pleura, then serofibrinous pleurisy, and by exclusion arrive at the diagnosis 
 
GENERAL CONSIDERATIONS. 5 
 
 of empyema. Diagnosis by exclusion is a tedious and inconvenient method, 
 not, however, without value in difficult and obscure cases. It may be 
 employed with advantage in clinical teaching. Other methods are: 
 
 Causal or Etiological Diagnosis. — The nature of an obscure 
 malarial disease with or without fever may be determined by the dis- 
 covery of the sestivo-autumnal parasite in the blood, or the tuberculous 
 basis of impaired health with cough and obscure physical signs may be 
 revealed by an examination of the sputum. When such a diagnosis con- 
 cerns germ diseases it is spoken of as Bacteriological Diagnosis. 
 
 H-*:matological Diagnosis. — This may depend upon (a) the specific 
 agglutinating properties of the serum, as in enteric fever or dysentery; (b) 
 the morphology, as in pernicious anaemia or leukaemia; (c) the presence of 
 parasites, as in malaria or trypanosomiasis; or (d) the result of cultures, as 
 in enteric fever or septic conditions. 
 
 A PROVISIONAL DIAGNOSIS is that which best accords with the sum of 
 the probabilities when the data are insufficient, or pending a further inves- 
 tigation of the facts. Such a diagnosis may serve as a working hypothesis 
 for therapeutic purposes and the general management of the patient. 
 It can be revised or confirmed. 
 
 A SURGICAL DIAGNOSIS is made from the stand-point of the surgeon, 
 and may in proper cases be confirmed or set aside during the life of tlie 
 patient by an exploratory operation. 
 
 Functional diagnosis is the determination of the degree of the 
 impairment of the functions of organs caused by local affections or the 
 extent of the interference with physiological processes resulting from 
 general disease, and the bearing of such impairment or interference upon 
 the future of the individual as regards health and prolongation of life. 
 Functional diagnosis is closely allied to prognosis. 
 
 A THERAPEUTIC DIAGNOSIS is that procedure by which in obscure 
 cases the nature of the disease is determined by the results of treatment. 
 This method is of very limited application. A provisional diagnosis of 
 malaria having been reached by the process of exclusion, the patient may 
 be put at rest and quinine administered in proper doses. ' Should the 
 symptoms promptly disappear, the diagnosis of malaria becomes probable. 
 A similar diagnosis of syphilis having been reached by analogous methods, 
 the subsidence of symptoms upon the administration of mercurials or the 
 iodides may in some cases confo-m the diagnosis. In almost all such cases 
 there are other and better methods of diagnosis which may be employed 
 concurrently with the treatment. In grave or urgent cases it is, however, 
 better to give the patient at once the benefit of the doubt. 
 
 Clinical diagnosis is the diagnosis made at the bedside. 
 
 Anatomical diagnosis is the diagnosis made by the pathologist in 
 the post-mortem room. 
 
 It is not in all cases possible to make a positive diagnosis at once. 
 Time may be required for a more thorough investigation of the history of 
 the case, a closer study of the patient's surroundings, repeated observation, 
 or for the report of examinations conducted in the clinical laboratory. 
 Information bearing upon the previous history of the patient or the be- 
 ginning of his illness cannot always be obtained. He may be delirious, 
 
6 MEDICAL DIAGNOSIS. 
 
 unconscious, or may have lost the power of speech. The history com- 
 municated by his friends is often uncertain and misleading. Persons of 
 the lower classes are very commonly indifferent to symptoms which are 
 not painful or disabling and lack the ability to describe their sensations. 
 Many persons, on the other hand, often intentionally, sometimes uncon- 
 sciously, make false statements in regard to their past life and present 
 symptoms. Some parts of the narrative are exaggerated, others suppressed. 
 Symptoms may be imitated and superficial lesions artificially produced. 
 Hence a group of feigned diseases, against which the physician must be 
 upon his guard. 
 
 Malingering. — The term malingerer is used to describe one who in- 
 tentionally simulates a disease. Malingering occurs in every grade of life 
 and under various circumstances. It is to be suspected when a simulated 
 disease lacks essential symptoms or its picture is overdrawn, and when 
 there is lack of correspondence between the alleged symptoms and the 
 actual signs or the obvious general health; it is to be detected by close 
 study of the case under various conditions, by the use of instruments of 
 precision, and in some cases by the application of powerful faradic currents 
 or an examination under anaesthesia. The over-indulged child, to avoid 
 his lessons or escape punishment, may feign an illness; an older person, 
 to excite compassion or from mere love of deception. It is common among 
 beggars, sailors and soldiers, those improperly seeking pensions, and claim- 
 ants against corporations for accidental damages. The simulation of 
 disease is, however, not always intentional. Hysterical and neurasthenic 
 individuals sometimes exaggerate symptoms or imitate the manifestations 
 of disease without purpose or intention — the unconscious mimicry of 
 disease. There are those, on the other hand, who from motives of delicacy 
 or shame, or in consequence of natural reserve, or from fear of having 
 their apprehensions confirmed, refuse to consult the physician, or when 
 forced to do so give a garbled and incomplete history of their sickness. 
 This may occur among those suffering from venereal diseases or chronic 
 diseases popularly regarded as incurable, as tuberculosis and cancer. 
 
 The diagnosis of an obscure case occasionally demands an investiga- 
 tion of the surroundings of the patient at the time of the development 
 of the illness. Time may be required to ascertain etiological conditions 
 relating to his food, drink, occupation, endemic influences, or exposure to 
 transmissible diseases locally epidemic. Questions of this kind frequently 
 arise at a period like the present, when facilities for commercial intercourse 
 are increasing and when military operations and the exigencies of trade 
 have greatly extended travel to all parts of the world. 
 
 Repeated examinations may be necessary in order to obtain accurate 
 impressions when the physical signs are obscure or ill defined. Excessive 
 subcutaneous fat, local oedema, or general anasarca may interfere with the 
 physical exploration; or local tenderness, intense pain, great restlessness, 
 or an unwilhngness on the part of the patient to submit to an examination 
 may give rise to delay. In other cases the unusual character of the symp- 
 toms or an association of clinical phenomena not previously encountered 
 may render repeated examinations necessary. During the stage of invasion 
 in the acute febrile infections a positive diagnosis is often impossible. 
 
GENERAL CONSIDERATIONS. 7 
 
 The advances of modern medicine have enormously increased our 
 knowledge of diseases and the precision of diagnosis. In all departments 
 of clinical medicine, scientific accuracy has taken the place of probability. 
 The every-day routine examinations of the clinical laboratory cannot be 
 made off-hand. The more elaborate investigations involved in obscure 
 cases demand technical skill and a reasonable time. The reports are 
 necessary to a final diagnosis. An immediate diagnosis is not only not 
 necessary, it is very often not possible. Haste involves the risk of error. 
 Conclusions cannot be reached until the premises are established. A 
 provisional diagnosis may serve to meet the immediate requirements of 
 the situation. Treatment may be instituted in response to urgent indica- 
 tions. When in the period of invasion of an acute illness there is reason to 
 suspect a transmissible disease, such as scarlatina or variola, the same 
 measures of prophylaxis should be instituted pending the evolution of the 
 process that would be employed if the suspected disease were actually 
 present. 
 
 There are cases in which diagnosis in a broad sense is impossible. 
 A name may be given to some prominent symptom or group of symptoms, 
 "but the essential pathological process may remain obscure until its nature 
 is revealed upon the post-mortem table. 
 
 When possible a positive diagnosis should be made at once; in all 
 cases as soon as practicable. The student is, however, warned against 
 making any but a provisional diagnosis upon insufficient data. To ask 
 for delay is by no means a confession of ignorance; on the contrary, it is 
 the course dictated by knowledge and experience. Intelligent people, 
 who seek the best professional advice, fully understand this. It is only 
 the ignorant who are satisfied with a phrase for diagnosis, a prescription 
 dashed off at sight and no directions whatever, who insist upon being 
 told what is the matter at once. 
 
II. 
 
 MEDICAL TOPOGRAPHY. 
 
 Medical topography is that branch of diagnosis which has for its 
 object the consideration of the boundaries and relations of the external 
 parts and internal organs of the bod}^ Various points, Hnes, and regions 
 or areas, some artificial, others natural, serve the purposes of this method 
 of clinical investigation. 
 
 THE HEAD. 
 
 The head is divided by anatomists into two parts, the cranium and 
 the face. 
 
 The Cranium. 
 
 The skull encloses and protects the brain. It is divided into regions 
 corresponding with the superficial bones which enter into the formation 
 of the skull, — namely, occipital, parietal, frontal, and temporal. These 
 regions are separated by the cranial sutures. Opposite the angles of the 
 parietal bones are spaces called fontanelles,— /ons, a fountain, — which 
 remain unossified after the bony growth of the skull is elsewhere completed. 
 Of these, two in the median hue, the anterior and posterior fontanelles, 
 are important. 
 
 The regions of the skull serve for the locahzation of subjective sensa- 
 tions, as pain or headache, and superficial lesions, as craniotabes, nodes, 
 ngevi, injury, or suppuration. The mastoid process of the temporal bone is 
 an important landmark, as indicating the extension of middle-ear disease. 
 The greatest convexity in the frontal region on either side is known as the 
 frontal eminence. It is separated by a sHght depression below from the 
 superciliary ridge, at the level of which in the median line is the nasal 
 eminence or glabella. About the inner third of the orbital arch is the 
 supra-orbital notch or foramen, a point of tenderness in supra-orbital 
 neuralgia. 
 
 Sutures. — Failure on the part of the cranial bones to unite, with 
 persistent wide sutures, may be due to hydrocephalus, cretinism, or in 
 very rare instances to antenatal rickets. 
 
 Fontanelles. — Variations in Prominence. — Bulging of the fonta- 
 nelles is a common symptom in infants and young children. It is much 
 more marked in the anterior fontanelle. When persistent it indicates 
 organic diseases of the brain, as hydrocephalus, meningitis, or intracranial 
 hemorrhage, which is in infants far more commonly meningeal than cere- 
 bral. When transient it is usually pulsating and associated with high 
 temperature and other symptoms of an acute febrile infection. 
 
 Retraction of the fontanelles occurs in chronic wasting diseases, as 
 tuberculosis, infantile atrophy or marasmus, and colitis, and in acute 
 diarrhoeal affections, as enterocolitis and cholera infantum. 
 
MEDICAL TOPOGRAPHY. 9 
 
 Variations in Size. — The posterior fontanelle is normally obliterated 
 about the sixth week. The anterior remains patulous as at birth or even 
 shghtly increases in size up to about the ninth month, and closes before 
 the end of the second year. Delay in closing beyond this period is com- 
 monly associated with wide and ununited sutures and occurs in rickets 
 and hydrocephalus. The diameter of the anterior fontanelle at the end 
 of the first year is normally about 2.5 centimetres. A greater width occurs 
 in rickets and some cases of congenital syphilis. A very wide fontanelle 
 is characteristic of hydrocephalus. 
 
 The Face. 
 
 The regions of the face are the orbital, nasal, buccal, and oral. They 
 contain the muscles of expression and are of great importance in the diag- 
 nosis of local and constitutional disease, as well as in the recognition of 
 mental and emotional conditions. The facies in various conditions will 
 be described in a later chapter. Changes caused by nervous and ocular 
 disorders will be considered under their appropriate headings. 
 
 DEFORMITIES OF THE HEAD IN THE NEWBORN. 
 
 Caput Succedaneum. — A swelling of the scalp caused by pressure 
 during parturition. The lesion consists of passive congestion with extrav- 
 asation of blood and oedema of the tissues of the scalp at the area of 
 absence of pressure, namely, the part of pres- 
 entation. The tumor is irregularly circum- 
 scribed and does not fluctuate. It disappears 
 without treatment in the course of a few days. 
 This condition is to be distinguished from — 
 
 Cephalhaematoma. — A tumor formed 
 during labor by hemorrhage into the space 
 between (a) the occipitofrontalis aponeu- 
 rosis and the periosteum, or between the 
 periosteum and the skull — external cephal- 
 
 hgematoma — or (b), between the skull and ^ ' ,^ 
 
 the dura mater — internal cephalhaematoma. 
 
 / \ T71 r^ rr-M FiG. 1.— Caput succedaneum. Male, 2 
 
 (a) External Cephalhematoma. — The hours old.— Rotch. 
 most common variety is subperiosteal. It 
 
 occurs in the form of an irregular, circular, flat tumor over one or. in 
 rare instances, both parietal bones. There is distinct fluctuation, but the 
 overlying skin is not discolored. Slight elevation of the bone at the 
 border of the swelling may be felt in a few days, with obscure crepitus. 
 The condition is to be distinguished from caput succedaneum by its 
 location, fluctuation upon palpation, and the examination of fluid with- 
 drawn by aspiration. The bony rim is diagnostic at a later period. It 
 is not to be confounded with a depressed fracture, which is irregular in 
 outline and lacks the distinct tumor formation with fluctuation and the 
 rim-like bony circumference characteristic of hsematoma. 
 
 (b) Internal Cephalhaematoma. — A very rare condition which ends 
 in the death of the child. There are pressure symptoms. It is sometimes 
 associated with the external form. It has occurred in breech presentations. 
 
10 
 
 MEDICAL DIAGNOSIS. 
 
 Fluctuating tumors arising from the course of the cranial sutures are 
 usually situated in the occipital region or at the glabella. Three varieties 
 are described. 
 
 Meningocele.— This term is used to designate a hernial protrusion of 
 the meninges through an opening in the bony cranium resulting from 
 defective ossification or failure in suture formation. It may result from 
 
 intra-uterine hydrocephalus. The tu- 
 mors usually contain cerebrospinal fluid, 
 and are translucent, with large veins 
 upon the surface. In some instances 
 an impulse may be felt upon crying 
 and the tumor can be reduced by gentle 
 pressure. 
 
 Encephalocele. — This form of cere- 
 bral hernia is more common. The 
 tumor contains brain substance in addi- 
 tion to the membranes. 
 
 l1ydro=encephalocele. — The her- 
 nial contents consist of the membranes, 
 brain tissue surrounding one of the ventricles, and a portion of the 
 ventricle itself distended with cerebrospinal fluid. These tumors vary 
 in size from a walnut to a large orange and tend to increase in size. 
 They are usually pedunculated. The prognosis is unfavorable, though 
 remarkable recoveries have occurred after operation. 
 
 Anencephalia. — This developmental defect is rarely complete. Par- 
 tial anencephalia is the usual form. In accordance with a recognized 
 pathological law, the deficiency of contents causes microcephalic deformity 
 of the skull. 
 
 Hydrocephalus. — Congenital internal hydrocephalus is a common 
 cause of deformity of the skull in the newborn. The head is markedly 
 enlarged; the cranial bones are thinned and displaced outwards; the 
 
 Fig. 2.— Hydro-encephalocele. — Rotch. 
 
 Fig. 3.— Congenital internal hydrocephalus. Male, 7 months old. — Rotch. 
 
 sutures widely separated and the fontanelles prominent and fluctuating. 
 In marked cases the temporal and parietal bones flare outward so that the 
 cranium is more or less pear-shaped, the greatest diameter being in the 
 upper part. The face is usually normal in size, but it looks abnormally 
 small, being dwarfed by the great size of the head. 
 
MEDICAL TOPOGRAPHY. 11 
 
 THE NECK. 
 Length and Thickness. 
 
 In early infancy the neck appears short on account of the large size 
 of the head and its tendency to fall forward, and the relatively high posi- 
 tion of the sternum and clavicles. The neck appears to be broad in com- 
 parison with its length also by reason of the large amount of sub- 
 cutaneous fat. In fact at all periods of life the thick neck of obese persons 
 appears short, an appearance heightened by the accumulation of fat 
 known as the double chin. 
 
 A short thick neck and stout plethoric body constitute the chief 
 structural factors in the so-called habitus apoplecticus. On the other 
 hand, a long slender neck with a prominent larynx, and narrow fiat chest 
 with projecting scapulae, are characteristic of the habitus phthisicus. But 
 both these designations are misleading, since apoplexy is dependent upon 
 a condition of the arteries and frequently occurs in spare persons with 
 long thin necks, and pulmonary tuberculosis is the result of infection and 
 not rarely selects its victims among those who have well-formed chests 
 and necks, and occasionally among those who are stout, with short thick 
 necks. 
 
 Contour. 
 
 Larynx. — In lean persons the larynx is prominent and forms the 
 projection anteriorly in the median line known as the Adam's apple. In 
 fat persons this organ is much less noticeable. Descent of the larynx upon 
 inspiration occurs in all forms of severe dyspnoea, and especially in the 
 spasmodic respiration which often precedes death in respiratory diseases 
 attended with stenosis of the larynx or oedema, collapse or extensive con- 
 sohdation of the lungs. Pressure displacements of the larynx and trachea 
 sometimes result from the presence of aneurismal or other tumors of the 
 neck. They are usually lateral. Some degree of lateral displacement may 
 also result from pleural adhesions and the traction of a contracting lung 
 in neglected pleurisy or fibroid phthisis. Moderate bilateral prominence 
 and enlargement of the neck without spastic contraction occur in the 
 habitual dyspnoea of severe chronic bronchitis, emphysema, bronchial 
 asthma, cardiac disease and certain cases of chronic uraemia — so-called 
 renal asthma. Rigidity of the neck is sometimes due to myalgia of the 
 cervical muscles, spondylitis deformans involving the cervical vertebrae, 
 or caries. It may be caused by painful inflammatory processes, as acute 
 adenitis, parotid bubo, mumps, boils, or carbuncles. 
 
 Thyroid Body. — This gland is situated in the lower part of the neck 
 and embraces the trachea in its upper part, reaching up to the larynx on 
 each side. It consists of two lateral lobes united by an isthmus. The right 
 lobe is usually slightly longer and wider than the left. Both the larynx 
 and the thyroid body which is in relation with it rise with the act of swallow- 
 ing. Enlargement of the thyroid body usually affects the isthmus and 
 both lobes, but one— very often the right— to a greater extent than the 
 other. The enlargement may be vascular, parenchymatous, fibroid, 
 
12 
 
 MEDICAL DIAGNOSIS. 
 
 cystic, or due to adenoma, carcinoma, tuberculosis, or gumma. Vascular 
 enlargement of the thyroid body may be physiological, occurring during 
 menstruation or pregnancy and subsiding at the termination of these 
 events, or pathological, as in exophthalmic goitre, when it is often variable 
 in size and attended with marked pulsation, thrill, and murmur. Venous 
 hyperaemia may be due to the pressure of an aneurism or mediastinal 
 tumor. Parenchymatous enlargement or simple goitre may be of moderate 
 
 size, but in some instances attains 
 enormous dimensions, protruding 
 beyond the chin and hanging over 
 the sternum. Cystic goitre when 
 multiple may be recognized by the 
 smooth, hemispherical, close set, 
 elastic nodules upon the surface; 
 when single and larger, by fluctua- 
 tion. Thyroid abscess is rare and 
 usually accompanied by local inflam- 
 matory oedema and grave constitu- 
 tional symptoms. Cancer, tubercu- 
 losis, and gumma rarely involve the 
 thyroid and may be recognized 
 by their local characters and the 
 associated constitutional phenomena. 
 An underlying aneurism or medias- 
 tinal growth may displace the thy- 
 roid upwards and forwards or to 
 either side. In aneurism of the 
 innominate, the displacement is to- 
 wards the left. An aneurism some- 
 times imparts its movements to the 
 overlying thyroid. Atrophy of the 
 thyroid may give rise to flattening of the surface. More commonly it can 
 be recognized only upon palpation. It is usually accompanied by the 
 symptoms of cretinism or myxoedema. 
 
 Muscles. — One or both sternomastoid muscles may be hypertrophied 
 and prominent. In torticolHs or wry-neck the contraction is usually 
 unilateral, and the neck is rotated so that the mastoid is drawn towards 
 the inner end of the clavicle, the chin raised and the face turned towards 
 the unaffected side. In rare cases wry-neck is bilateral, — retrocollic spasm, 
 — the head retracted and the face turned upward. The spasm in both 
 forms of torticollis may be tonic or clonic. The disease is sometimes 
 congenital. 
 
 The Clavicles. — The position of these bones has much to do with the 
 appearance of the neck as regards length. They are high in deep-chested 
 persons with large lungs and in emphysema; low in flat-chested indi- 
 viduals with small lungs and in phthisis and pulmonary fibrosis from any 
 cause. These bones are deformed after fracture and sometimes present 
 nodes and irregularities of the surface caused by syphilitic periostitis. 
 Prominence in the retroclavicular space sometimes occurs in emphysema 
 
 Fig. 4. — Cystic goitre. 
 
PLATE I. 
 
 x^'^ X^.>.. 
 
 %^ 
 
 u. 
 
 V I 1 
 
 General anatomical outlines and relations of the thoracic and abdominal organs. 
 
MEDICAL TOPOGRAPHY. 13 
 
 of high grade, but as a rule the clavicles in this condition are prominent 
 and both the retro- and infraclavicular spaces are retracted. The sub- 
 cutaneous fat pads of myxoedema are frequently seen above the clavicles 
 and sometimes at the root of the neck posteriorly. The neck is occasionally 
 the seat of extensive inflammatory oedema with violaceous discoloration — 
 collar of brawn — especially in scarlet fever, erysipelas, and infected wounds, 
 and sometimes much distorted by subcutaneous emphysema, such as 
 follows rupture of the pleura or wounds or operations involving the upper 
 air-passages. 
 
 THE THORAX. 
 
 The thorax is of conical shape with convex walls. Its truncated upper 
 end is narrow and bounded by the first dorsal vertebra, the first pair of 
 ribs, and the manubrium of the sternum. Its expanded base is filled in 
 by the vault of the diaphragm. The anterior border of the base curves 
 downwards and backwards on each side from the xyphoid cartilage to the 
 twelfth rib. Its transverse diameter greatly exceeds its anteroposterior 
 diameter, which is further shortened in the middle line by the projection 
 of the spinal vertebrae forwards into the cavity of the thorax. This space 
 contains the heart and great vessels together with the pericardium, the 
 lungs and pleurae, the trachea, the greater part of the cesophagus, and the 
 thymus gland or its remnant. 
 
 Anatomical Landmarks of the Thorax. 
 
 ANTERIOR SURFACE. 
 
 The Chest. — The clavicles, sternum, ribs, and interspaces constitute 
 natural surface conformations to which, for purposes of study and de- 
 scription, clinical phenomena may be referred. 
 
 The Clavicles. — The part immediately above these bones on either 
 side is known as the supra- or retroclavicular space; that immediately 
 below them as the infraclavicular space. Into the supraclavicular spaces 
 the apex of the lung enters to a slight extent, usually a little further on the 
 right than on the left side. In well-developed lungs these spaces are not 
 retracted, but in ill-developed lungs and in pathological states character- 
 ized by contraction of lung tissue they are more or less strongly depressed. 
 
 The Sternum. — The upper border of this bone is marked by a large 
 incurvation known as the episternal notch, which limits the root of the 
 neck anteriorly and in which can be felt at times the pulsating aorta — 
 dilatation, dynamic pulsation, aneurism of the transverse arch. At the 
 line of juncture of the manubrium and gladiolus or body is a more or less 
 prominent transverse line or prominence, better developed in the male — 
 the angle of Ludovicius. At the lower end is the xyphoid or ensiform 
 appendix, variable in size and shape and sometimes having its tip everted 
 in such a manner as to form an infrasternal depression or fossa. 
 
 The Ribs and Intercostal Spaces. — The Ribs. — In spare persons the 
 ribs may be counted with ease. When, however, there is much subcu- 
 taneous fat, the recognition of any particular rib is sometimes difficult. 
 The first rib may be known by the articulation of its cartilage with the 
 
14 MEDICAL DIAGNOSIS. 
 
 sternum at a point immediately below the articulation of the clavicle. 
 The articulation of the second costal cartilage is directly opposite the 
 junction of the first and second pieces of the sternum — angulus Ludovici. 
 The ribs slope downwards from their spinal articulations in such a manner 
 that their chondrosternal articulations lie at a much lower level, the artic- 
 ulation of the first rib anteriorly being in quiet breathing on the horizontal 
 plane of the fourth rib at the back and so on to the seventh rib. In the 
 expiratorj^ type of chest this oblique position of the ribs is somewhat 
 increased; in the inspiratory type it is much diminished. 
 
 The Intercostal Spaces. — These spaces correspond to the ribs and 
 cartilages immediately above them — that is, the first space lies immediately 
 below the first rib. They are wider in front than behind. In expiration 
 the upper spaces are increased in width and the lower narrowed, while in 
 inspiration these conditions are relatively reversed. It is in accordance 
 with this fact that the upper spaces are wider and the lower narrower in 
 the expiratory, while the upper are narrower and the lower wider in the 
 inspiratory form of chest. In fat persons the intercostal spaces cannot 
 be made out, but in those who are lean they appear as shallow, parallel, 
 oblique furrows symmetrically arranged upon each side of the chest. 
 They are deeper upon inspiration than on expiration or quiet breathing, 
 and conspicuously so in obstructive dyspnoea. These furrows are oblit- 
 erated in massive pneumonia and in pleural effusions and the spaces may 
 actually bulge in old cases of large empyema. Local protrusion of the 
 chest wall such as occurs in large hypertrophy of the heart in early life 
 causes widening of the overlying intercostal spaces. The unilateral flatten- 
 ing of the chest which accompanies fibroid phthisis or follows a neglected 
 pleural effusion, crowds the ribs together, even in some instances to over- 
 lapping, and in this manner obliterates the spaces in whole or in part. 
 
 Normal Cardiac Pulsation. — The apex beat is seen in the fifth inter- 
 costal space to the left of the parasternal line, while undulatory pulsation in 
 several spaces occurs in dilatation of the heart, and heaving pulsation over 
 a large area in marked h3^pertrophy of that organ. In rare instances inter- 
 costal pulsation is due to a neglected empyema. The pulsation is almost 
 always in the anterolateral aspect of the chest upon the left side. In mitral 
 and aortic stenosis, aortic insufficiency, cases of congenital malformation 
 of the heart, and aneurism of the aorta, thrills may be felt upon palpation. 
 
 The Nipple. — This organ is not without value as a topographical 
 landmark in children and spare males, but in women and obese persons of 
 both sexes its position is extremely variable. When there is httle fat and 
 the mammae are undeveloped the nipple is situated about the fourth inter- 
 costal space, sometimes over the fourth, sometimes over the fifth rib, and 
 in a vertical line intersecting the middle of the clavicle — the mammillary 
 line. It is obvious that the nipple — mammilla — is not a satisfactory 
 anatomical landmark. The midclavicular line is much more useful. 
 
 POSTERIOR SURFACE.— THE BACK. 
 
 The Spine. — In children and lean persons the spinous processes are 
 prominent. In muscular adults and fat people they are situated in the 
 middle of a shallow longitudinal groove formed by the prominence of the 
 
PLATE 11. 
 
 . 
 
 J 
 
 General anatomical outlines and relations of the thoracic and abdominal organs. 
 
MEDICAL TOPOGRAPHY. 
 
 15 
 
 erector spinse muscles on either side. They become more prominent 
 when the patient bends strongly forward. Owing to the denseness of 
 the overlying musculotendinous tissues, the spines of the upper five 
 cervical vertebrae cannot as a rule be recognized upon palpation. The 
 sixth may be felt and seen in many persons, and the seventh — vertebra 
 prominens — is usually con- 
 spicuous and forms a point 
 of departure from which the 
 thoracic and lumbar spines 
 may be counted. The eighth 
 and ninth thoracic spines 
 are normally somewhat more 
 prominent than the others. 
 Marked prominence of one or 
 more vertebral spines, with 
 tenderness upon pressure and 
 pain upon rotary movements 
 of the spine or jarring, is sig- 
 nificant of spinal caries, usu- 
 ally tuberculous, rarely syph- 
 ilitic. There is frequently 
 angular curvature. 
 
 Kyphosis. — The curvature 
 is in the sagittal plane with 
 the concavity anterior. It 
 is chiefly thoracic, sometimes 
 cer^dcothoracic, and may con- 
 stitute nothing more than one 
 of the skeletal changes due to 
 old age. It occurs also in 
 those who habitually carry 
 heavy burdens on the head and shoulders, in emphysema, rickets, osteitis 
 deformans, and acromegaly. This rounded curvature is to be distinguished 
 from the sharper, often angular curvature of vertebral caries or mollities 
 ossium. 
 
 Scoliosis. — A rotary-lateral curvature usually involving the upper 
 thoracic spine with compensating curvature in the lower thoracic and 
 lumbar regions. Less commonly it affects the cervical or lumbar regions. 
 Scoliosis is very common in school-girls in consequence of poor muscular 
 development and faulty desk attitudes. It may result from the habitual 
 carrying of heavy weights on the same arm, inequalit}^ in the length of 
 the legs, deformity of a foot, tilting of the pelvis, old sciatica, the arrested 
 gi'owth of a limb following infantile palsy, hemiplegia, and mollities ossium. 
 The deformity of the chest following long-neglected pleural effusion, sero- 
 fibrinous or purulent, includes dorsal scoliosis, the concavity looking towards 
 the affected side. 
 
 Lordosis. — An exaggeration of the normal lumbar curve occurs in ad- 
 vanced pregnancy, large abdominal tumors and ascites, progressive mus- 
 cular atrophy, and pseudohypertrophic muscular paralysis. The attitude 
 
 Fig. 5. — Spinal caries. Lumbar region. — Young 
 
16 
 
 MEDICAL DIAGNOSIS. 
 
 in the last condition is characteristic. The legs are separated, the head is 
 thrown back, the spine strongly curved, and the abdomen thrust forward. 
 Spina Bifida. — This is a developmental fault consisting of failure on 
 the part of the laminae of the vertebrae to unite. The usual site is in the 
 lumbar or lumbosacral region. The protruding tumor is in the middle 
 line, sometimes covered with normal skin, sometimes with a thin, trans- 
 lucent membrane. There are two varieties: 
 
 
 
 Fig. 6. — Kyphosis. 
 
 Fig. 7. — Senile kyphosis. 
 
 Spina bifida occulta, in which the sac is walled off from all 
 connection with the spinal canal, and — 
 
 Spina bifida vera, in which the cyst is filled with cerebrospinal 
 fluid and increases in size during violent crying, and can be diminished 
 by gentle pressure. 
 
 Three subvarieties are recognized: 
 
 Spinal Meningocele. — The protruding membranes contain onl}^ cere- 
 brospinal fluid. 
 
 Meningomyelocele. — The sac contains not only fluid but also sub- 
 stance of the cord. This is the most common form. 
 
Fig. 8. — Primary left dorsal scoliosis. — ^Young. 
 
 Fig. 10 — Spina liilida (.f liiiiiliar region 
 Male, 5 years uld. — Rulch. 
 
 Fig. 9. — Extreme lordo.'si.'; in progressive 
 muscular atrophy. — Young. 
 
MEDICAL TOPOGRAPHY. 17 
 
 Syringomyelocele . — The sac is formed of the membranes and a pro- 
 truding portion of the cord, the central canal being dilated to form the 
 cavity of the tumor. 
 
 This group of deformities is commonly associated with other develop- 
 mental defects. Exceptionally spina bifida occurs in children otherwise 
 healthy and well developed. 
 
 The Scapulae. — These flat, triangular, trowel-like bones are placed 
 symmetrically upon the upper and back part of the thorax and extend, 
 when the arms hang by the sides in the erect posture, from the second to 
 the seventh ribs. They are attached to the skeleton by the clavicle and 
 the humerus and are therefore freely movable. When the arms are folded 
 and the body is bowed forward, the interscapular space is much increased, 
 an important fact in physical diagnosis. The inner borders of the scapulae 
 project in consequence of muscular weakness, palsy, and changes in the 
 contour of the chest. Combinations of these causative conditions may 
 occur in the same case. Both inner borders project in the alar or ptery- 
 goid chest and in the progressive muscular dystrophies affecting the shoulder 
 girdle. The abnormal mobility of the shoulder-blades arising from loss of 
 muscular tone permits the inner borders to project like budding wings. 
 The inner border stands out upon the affected side in contraction of the 
 chest from pulmonary fibrosis; in associated serratus and trapezius paraly- 
 sis, especially when the arms are held out in front in the horizontal plane; 
 in scoliosis due to various causes, and sometimes upon the left side in 
 large aneurism of the descending portion of the arch of the aorta. 
 
 Immobility of the Spine.— Flexion, extension, and lateral and rotary 
 movements may be restricted or wholly prevented by various patho- 
 logical conditions, as (1) those giving rise to pain in movement, among 
 which the more common are traumatism, myalgia — lumbago — abscess, 
 carbuncle, meningeal hemorrhage; (2) those involving spasm, as cerebro- 
 spinal fever and the spastic form of myalgia; (3) those affecting the joints 
 and bones, most of which terminate in ankylosis, as traumatic, gonor- 
 rhoeal, or tuberculous disease and spondylitis deformans; and (4) certain- 
 neuroses, as many of the cases of so-called typhoid spine, railway spine, 
 hysterical spine, irritable spine, and so on. 
 
 LATERAL SURFACES. 
 
 The landmarks are the axilla — armpit — above, the anterior and poste- 
 rior axillary folds, the ribs and interspaces and the upper border of hepatic, 
 on the right, and of splenic dulness on the left side, below. Enlarged lymph- 
 nodes, which frequently undergo suppuration or may be tuberculous, carci- 
 nomatous, leuksemic or pseudoleukaemic, are common in the axillary space. 
 
 Artificial Lines and Spaces of the Thorax. 
 
 The following conventional imaginary lines and spaces serve a useful 
 purpose in the examination and description of thoracic lesions. For 
 convenience of demonstration the lines may be marked upon the surface 
 with a dermatographic pencil. The subject is in the erect posture with 
 his arms symmetrically disposed. 
 2 
 
18 
 
 MEDICAL DIAGNOSIS. 
 
 A. Vertical Parallel Lines. — With the exception of the first 
 and last they are double — bilateral. 
 
 (a) The mesial or mid sternal Hne. 
 
 (b) The line of the sternal border. 
 
 (c) The parasternal line, midway between the line of the ster- 
 
 nal border, and — 
 
 (d) The midclavicular linC; sometimes spoken of as the mammil- 
 
 lary line because in individuals with undeveloped mammae 
 it passes through or near the nipple. 
 
 Fig. 11. — Lines of reference : Anterior. — m, middle line; 
 s, s', right and left lines of the sternal border; ps, ps', para- 
 sternal lines; c, c', midclavicular or mammillary lines. 
 
 Fig. 12. — Lines of reference : Lat- 
 eral. — aa, anterior axillary line; ma, mid- 
 axillary iine; pa, posterior axillary line. 
 
 B. 
 
 (e) The line of the anterior axillary fold. 
 
 (f) The midaxillary line. 
 
 (g) The line of the posterior axillary fold. 
 
 (h) The scapular line, passing vertically through the inferior angle 
 of the scapula — a very movable and uncertain landmark, 
 (i) The posterior mesial line, corresponding to the line of the 
 spinous processes. 
 Horizontal Parallel Lines. — These are anteriorly: 
 
 (a) A line touching the lower border of the cricoid cartilage. 
 
 (b) A line passing through the clavicles. 
 
 (c) A line passing through the third chondrosternal articulation. 
 
 (d) A line passing through the sixth chondrosternal articulation. 
 
MEDICAL TOPOGRAPHY. 19 
 
 And posteriorly: 
 
 (a) A line touching the upper border of the scapulae, 
 
 (b) A line passing through the spines of the scapulae. 
 
 (c) A line passing through the inferior angles of the scapulae. 
 
 (d) A line touching the upper border of the spine of the twelfth 
 
 dorsal vertebra. 
 
 Regional Divisions of the Thorax. 
 
 By the intersection of certain of the above-described lines the follow- 
 ing arbitrary regions are formed: 
 
 (a) The Suprasternal Region. — This region overlies the thyroid 
 body, the trachea, and more deeply the oesophagus. The transverse aorta, 
 when dilated, extends into it and may be felt pulsating above the level 
 of the sternal incisura. 
 
 (b) The Upper Sternal Region.- — Beneath the breastbone lie the 
 remnants of the thymus, the mesial borders of the upper lobes of the lungs, 
 and more deeply the transverse arch of the aorta. 
 
 (c) The Lower Sternal Region. — Within the limits of this space 
 lie the mesial border of the right lung, the termination of the fissure form- 
 ing the upper boundary of the middle lobe, and that part of the right heart 
 which constitutes the area of superficial dulness. 
 
 On each side: 
 
 (d) The Supraclavicular Region. — This space lies above the upper 
 edge of the collar-bone and contains the apex of the corresponding lung. 
 
 (e) The Clavicular Region. — A space of no great moment in diag- 
 nosis. It corresponds to the boundaries of the inner half of the bone. 
 The clavicle may be used as a pleximeter in direct percussion. 
 
 (f) The Infraclavicular Region. — A most important area of the 
 chest. It is bordered above by the line of the clavicles, internally by the 
 line of the sternal border, externally by the line of the anterior axillar}'- 
 fold projected upward to the acromion process, and below by the hori- 
 zontal line passing through the third chondrosternal articulation. It 
 contains on either side that part of the upper lobe of the lung in which 
 tuberculous bronchopneumonia is as a rule first recognizable. 
 
 (g) The Mammary Region. — From the lower border of the preceding 
 to the line passing through the sixth chondrosternal articulation. This 
 space contains on the right side a part of the upper and middle lobes and 
 the fissure separating them, together with the right auricle near the sternal 
 border, and more deeply in the vault of the diaphragm the convexity of 
 the right lobe of the liver. It overlies on the left side the extrasternal 
 area of superficial dulness, the apex of the right and of the left ventricle, 
 and the mesial border of the left lung with the lingula. Into the mammary 
 region on each side extend the interlobar fissures of the lungs. 
 
 (h) The Inframammary Region. — This area, which extends from a 
 horizontal line through the sixth chondrosternal articulation downwards, 
 overlies the liver on the right side, and upon the left a portion of the left 
 lobe of the liver, the fundus of the stomach, the transverse colon, and the 
 spleen. On the left is Traube's semilunar space. 
 
20 
 
 MEDICAL DIAGNOSIS. 
 
 fi) The Axillary Regiox. — This space is bounded by the lines of 
 the axillary folds and the armpit above. It is a diagnostic territory of 
 some importance. 
 
 (j) The Infra-axillary Region. — The upper boundary is the line 
 which passes through the sixth chondrosternal articulation; its lower is 
 the base of the chest. In this region, upon the left, the upper border of 
 splenic dulness may be demonstrated upon percussion. The interlobar 
 fissure traverses the axillary and infra-axillary spaces. 
 
 (k) The Suprascapular Region. — An area of importance on ac- 
 count of the early manifestations of phthisis. 
 
 
 Fig. 13. — Regional divisions of the thorax: Fig. 14. — Regional divisions of t"he chest: Pos- 
 
 Anterior. — a, suprasternal region; 6, upper sternal; terior. — a,a\ .supraclavicular regions; 6,6', supraspi- 
 
 c, lower sternal; d,d', right and left supraclavicular; nous; c,c', infraspinous; d,d', infrascapular; e.e', 
 
 e,e', right and left infraclavicular; /,/', mammarj- interscapular regions. 
 ff.fl'i inframammary. 
 
 (1) The Supraspinous Region. — That space lying between the upper 
 border of the scapula and the spine of the scapula, and occupied by the 
 thick supraspinous muscle. , 
 
 (m) The Infraspinous Region. — From the spine of the scapula 
 to the level of the inferior angle. The infraspinous and infrascapular 
 regions are traversed by the interlobar fissures. This fact is of importance 
 in the recognition of the signs of the extension of a tuberculous infiltra- 
 tion to the apex of the lower lobe. 
 
 (n) The Infrascapular Region. — From the angle of the scapula, 
 namely, about the level of the seventh rib, to the base of the chest. 
 
 (o) The Interscapular Region. — The space lying between the 
 inner borders of the two scapulae. It extends across the spinal column 
 and is much widened when the arms are folded and the body bent forward. 
 
MEDICAL TOPOGRAPHY. 21 
 
 THE ABDOMEN. 
 
 The abdomen is the great cavity of the body extending from the 
 diaphragm above to the levator muscles of the anus below. It is sub- 
 divided by an oblique plane at the brim of the pelvis into two portions, 
 the abdomen proper and the pelvis. For the purpose of exact reference 
 to the position and condition of the organs contained in the cavity of 
 the abdomen in health and disease, certain lines, as in the case of the 
 thorax, are recognized upon the surface. These dividing lines are natural, 
 and artificial or conventional. 
 
 The Natural Lines of the Abdomen. 
 
 (a) The linea alba in the middle line from the ensiform cartilage to 
 the symphysis pubis. 
 
 (b) The line^ semilunares, one upon either side, passing from 
 the ninth costal cartilage to the pubic bone and following the outer border 
 of the rectus abdominis muscle. 
 
 (c) The line^ transversa, of which there are three, the upper 
 being at the level of the tip of the ensiform cartilage, the middle at a 
 level midway between the first and the navel, and the third at the level 
 of the navel. 
 
 (d) In fat persons a deep transverse sulcus or furrow crosses the 
 abdomen a short distance above the pubic arch and a second similar but 
 less marked groove is sometimes seen about the level of the umbihcus. 
 These grooves vary in depth according to the amount of fat in the belly 
 wall and are deeper in the erect than in the recumbent posture. 
 
 The Imaginary or Conventional Lines. 
 
 (a) The mesial line, passing through the tip of the ensiform car- 
 tilage, the umbilicus, and the symphysis pubis, and corresponding to the 
 linea alba. 
 
 (b) The prolongation downward of the midclavicular line, which 
 passes through the eighth costal cartilage to the middle of Poupart's 
 ligament upon each side. 
 
 (c) The infracostal line, passing around the body in the horizon- 
 tal plane of the tenth costal cartilages. 
 
 (d) The bi-iliac line, which corresponds to the plane of the most 
 prominent part of the iliac crests. 
 
 These two lines (c) and (d) divide the abdominal surface into three 
 zones: an upper or epigastric, a middle or umbilical, and a lower or hypo- 
 gastric. The two vertical lines dropped from the middle of the clavicle 
 to the middle of Poupart's ligament again divide each of those zones into 
 three regions, as follows: 
 
 (a) An Epigastric Region or Upper Central Region. — This over- 
 lies a portion of the right and left lobes of the liver and a large part of the 
 anterior wall of the stomach, with the pylorus, the aorta, the coeliac axis, 
 the semilunar ganglia, and at a greater depth the pancreas. 
 
22 
 
 MEDICAL DIAGNOSIS. 
 
 (b) A Right and Left Hypochondriac Region. — The right hypo- 
 chondriac region overlies the right lobe of the liver and the gall-bladder, 
 the duodenum, the hepatic flexure of the colon, and the upper part of 
 the right kidney; the left the greater curvature of the stomach, the spleen, 
 the tail of the pancreas, the splenic flexure of the colon, and the upper part 
 of the left kidney. 
 
 (c) An Umbilical or Middle Central Region. — In this space lie 
 the greater curvature of the stomach, the mesentery, the great omentum, 
 coils of the small intestine, and the transverse colon. 
 
 Fig. 15. — Regional divisions of the abdomen: Fig. 16. — Quadrants of the abdomen. 
 
 a, epigastric or upper central region; 6,6', right 
 and left hypochondrium; c, umbilical or middle 
 central region; d,d', right and left lumbar regions; 
 e, hypogastric or middle lower region. 
 
 (d) A Right and Left Lumbar Region. — The right contains the 
 lower part of the right kidney, the ascending colon, and coils of small 
 intestine; the left the lower part of the left kidney, descending colon, 
 and small intestine. 
 
 (e) A Hypogastric, Suprapubic, or Middle Lower Region. — 
 This space overlies coils of the small bowel, at its lower portion the fundus 
 of the urinary bladder when distended, and the gravid womb. 
 
 (f) A Right and Left Iliac or Inguinal Region. — The right 
 contains the caecum and the base of the appendix or frequently the whole 
 of it, the ileocsecal valve and the right ureter; the left the descending colon 
 and left ureter. 
 
MEDICAL TOPOGRAPHY. 23 
 
 The Quadrants of the Abdomen. 
 
 A simpler division of the surface of the abdomen into regions may 
 be made by a vertical and a transverse line intersecting at the umbilicus. 
 The four spaces thus defined are known respectively as the right and 
 
 LEFT UPPER and LOWER QUADRANTS. 
 
 The Visceral Regions. 
 
 Certain important viscera give their names to the surface areas cor- 
 responding to the situation in which they are normally found. Thus 
 we speak of: — 
 
 (a) The Precordial Area; the Precordia. — That part of the chest 
 wall which overlies the heart, including the areas of superficial and deep 
 dulness and increasing in extent in cardiac dilatation and hypertrophy. 
 
 (b) The Region of the Apex. — A more circumscribed space imme- 
 diately above and around the normal apex and shifting as the apex shifts 
 in enlargement and displacement of the heart. 
 
 (c) The gastric area, which corresponds to the normal situation 
 of the stomach. The limits of this region are not strictly defined, since the 
 organ varies in size when empty or distended with food or gas, and has 
 some degree of mobility. 
 
 (d) The Hepatic Area. — The lower border of this region is usually 
 sharply defined both in normal and pathological conditions. Its upper 
 border rounds away from the chest wall from which the upper surface of 
 the liver is separated by the edge of the lung, and its left border is obscured 
 by the tympany of the stomach and colon. 
 
 (e) The Region of the Gall-bladder. — The notch for the gall- 
 bladder lies in the under border of the liver, slightly internal to the 
 ninth right costal cartilage and near the outer border of the right 
 rectus muscles. The fundus of the organ when distended and enlarged 
 occupies a considerable area on both sides of this point as well as 
 below it. 
 
 (f) The Ileocecal Area. — The part of the abdominal surface lying 
 in the right lower quadrant of the abdomen and the seat of the local 
 manifestations in appendicitis. Here lies the spot of focal tenderness 
 described as McBurney's point. 
 
 (g) The Splenic Area. — The region which occupies the left hypo- 
 chondrium extending towards the infra-axillary region. An enlarged 
 spleen frequently transcends the normal borders of the splenic area, 
 and a dislocated spleen occupies an entirely different position, in such 
 a manner that the normal dulness in the splenic area is replaced by 
 tympany, 
 
 (h) The Sigmoid Area. — The left inguinal region and the parts 
 bordering upon it toward the median line, which are so designated 
 because new growths and other pathological conditions involving the 
 sigmoid flexure of the colon give rise to tumors or other clinical mani- 
 festations in this portion of the abdomen. It corresponds with the left 
 lower quadrant. 
 
24 MEDICAL DIAGNOSIS. 
 
 (i) The Pelvic Area. — The designation sometimes employed to de- 
 scribe the suprapubic area because it is the region of the abdomen in which 
 enlargements and new growths of the pelvic viscera are frequently manifest. 
 
 The extent of the various regions of this group is neither constant 
 nor well defined. Their borders are often shifting and overlapping. Nev- 
 ertheless they serve a useful purpose in the diagnosis of diseases of the 
 abdominal organs. 
 
 Large accumulations of fat in the belly wall or within the peritoneal 
 cavity, pregnancy, meteorism, dropsy and ascites, visceral displacements 
 and enlargements, new growths and extra- and intraperitoneal cysts and 
 abscesses distend the abdomen, modify its contour, and disarrange, often 
 to an extreme degree, the relations between the above-described areas and 
 the internal organs. 
 
 The foregoing anatomical and conventional lines and areas enable us 
 definitely to fix the position of clinical phenomena for purposes of descrip- 
 tion and record. 
 
 The signs or symptoms of a lesion may be referred to a given region, 
 as episternal pulsation, infraclavicular dulness, or precordial pain. More 
 exactly the location of a given phenomenon may be indicated by the rib 
 or interspace in which it is found and the distance from the midsternal 
 line or its relation to one of the other vertical lines described, as, for example, 
 the signs of a small cavity in the second interspace, a measured distance 
 to the right — or left — of the median line; a presystolic thrill in the fifth 
 interspace, to the left of the left parasternal line; an undulatory impulse 
 in the fourth, fifth, and sixth interspaces, extending to a point midway 
 between the left midclavicular line and the line of the anterior axillary fold. 
 
 A tumor or painful spot in the abdomen may be located in one of the 
 nine regions described as the epigastric, right iliac, hypogastric, and so on, 
 or in one of the quadrants of the abdomen. 
 
 If greater accuracy is desired, the position of a lesion, physical sign, 
 or tender spot may be stated to be a measured distance to the right or 
 left, as the case may be, of the middle line at the level of the umbilicus, 
 or a measured distance above or below the level of the umbilicus. Or, 
 again, the anterior superior spine of the ilium may be taken as the point 
 of departure for similar measurements. 
 
 In the back the spinous processes may be taken as points of departure 
 for the measurements. Thus a lesion may be a measured distance from 
 the middle line on a level with the eighth dorsal spine or over a numbered 
 interspace or rib. 
 
 The unit of measurement may be the centimetre, or the inch, if pre- 
 ferred, or the finger's breadth which equals about 2 centimetres or % inch, 
 or the hand's breadth, which varies from about 9 to 11 centimetres or 
 3^ to 4:h inches. 
 
 It is customary to indicate the extent of a lesion or the size of a tumor 
 by less accurate but significant anatomical measurements; thus we say 
 of a splenic tumor that it extends to the crest of the iUum or to the sym- 
 physis pubis or beyond the median line, or of a distended bladder or en- 
 larged uterus that it reaches halfway from the pubis to the umbilicus or 
 to the level of that anatomical landmark. 
 
MEDICAL TOPOGRAPHY. 25 
 
 THE TOPOGRAPHICAL ANATOMY OF THE 
 THORACIC ORGANS. 
 
 The Thymus Gland and its Remnants. 
 
 This temporary organ attains its maximum development about the 
 end of the second year. It then undergoes a gradual involution process 
 until it is reduced to a mere vestige. When fully developed it appears 
 as a narrow elongated body lying in the anterior mediastinal space imme- 
 diately behind the manubrium sterni and extending into the episternal 
 region of the neck. Its size varies according to the degree of development. 
 At birth it is about 6 centimetres in length, 2.5 centimetres in width, and 
 .75 centimetre in thickness. The thymus is occasionally persistent and 
 may then undergo hypertrophy. In this case and when enlarged as the 
 result of tuberculous, syphilitic, or cancerous disease, or hemorrhagic or 
 purulent infiltration, pressure symptoms, namely, paroxysmal dyspnoea — 
 so-called thymic asthma — persistent dyspnoea, spasm of the glottis, or 
 venous hyperaemia and local cfidema arise. 
 
 The Trachea or Windpipe. 
 
 This tubular organ extends in the median line from the larynx to a 
 point opposite the third dorsal vertebra, where it is crossed in front by the 
 arch of the aorta, and there or immediately below this level it bifurcates into 
 the right and left bronchi. Its length is variable, being in the adult about 
 9 to 11 centimetres, its width from 2 to 2.5 centimetres. It is both wider 
 and longer in the male than in the female. The trachea is movable and 
 may be displaced as well as compressed by an aneurism or a new growth. 
 Its posterior membranous part is in relation with the oesophagus behind, 
 and the recurrent laryngeal nerves ascend in the groove between these 
 two organs. The manubrium sterni overlies the trachea, which traverses 
 the posterior mediastinum. 
 
 The Primary Bronchi. 
 
 The right and left bronchi arise at the bifurcation of the trachea and 
 diverge to the corresponding lung upon each side, which they respectively 
 enter at the root to form by successive subdivisions the ramifications of 
 the bronchial tree. The right bronchus — the wider and shorter of the two — 
 passes obhquely downwards and outwards to the lung at the level of the 
 fourth dorsal vertebra, and behind the aorta; the left, smaller in diameter 
 but much greater in length, runs obhquely downwards and outwards 
 below the arch of the aorta to the root of the left lung, into which it passes 
 at the level of the body of the fifth dorsal vertebra. The length of the 
 right bronchus is about 2.5, that of the left nearly 5 centimetres. 
 
 Irregular stenosis of the trachea or a main bronchus, from an aneu- 
 rismai or neoplastic tumor or from a tenacious and adherent exudate, causes 
 tracheal stridor and the accumulation of an abundant liquid exudate, as 
 in some forms of bronchitis, and the pulmonary oedema that precedes 
 death gives rise to coarse tracheal rales. 
 
26 MEDICAL DIAGNOSIS. 
 
 Elasticity of the Tracheobronchial Structures. — That these organs 
 have a high degree of phabihty, analogous to that of the vesicular structure 
 of the lung, is shown by the manner in which they accommodate them- 
 selves to the displacing and distorting pressure of effusions, aneurism, and 
 new growths of various kinds without great impairment of their function. 
 That they possess equally remarkable capacity of elongation and contrac- 
 tion has been recently demonstrated by X-ray examination and the 
 bronchoscope of Chevalier Jackson. 
 
 The CEsophagus: Gullet. 
 
 This tubular organ extends from the pharynx at the lower border of 
 the fifth cervical vertebra — the level of the cricoid cartilage — along the 
 anterior surface of the borders of the vertebrae, to pass through the dia- 
 phragm about the level of the ninth dorsal vertebra and end in the cardiac 
 orifice of the stomach. Its length is about 23 centimetres. In the thorax 
 it lies posterior to the lower part of the trachea, the upper part of the left 
 bronchus, and the posterior surface of the pericardium. The oesophagus 
 may be the seat of simple or syphilitic cicatricial stricture; stenosis from 
 cancerous growth involving its wall or pressing upon it from without or 
 from the external pressure of an aneurism. Spasmodic stricture occurs in 
 neurotic and hysterical persons, and the impaction of a foreign body, as an 
 artificial denture, a. large piece of meat, or a bone, may cause mechanical 
 obstruction, an accident that occasionally occurs among the insane. It is 
 sometimes the seat of a diverticulum. The oesophagus is accessible to exam- 
 ination by the sound, the oesophagoscope, and X-rays. The time occupied in 
 swallowing and the nature of the accompanying sounds may be studied by 
 auscultation. 
 
 The Lungs and Pleurae. 
 
 The lungs occupy the greater part of the cavity of the chest, enclosing 
 between their concave inner surfaces the heart and great vessels. Each 
 lung is attached to the inner wall of the thorax in the region of the bodies 
 of the fourth and fifth dorsal vertebrae by a comparatively small pedicle 
 called the root, and a narrow membranous fold continued downwards 
 from it. Elsewhere the surface of the lung is free and covered by a serous 
 membrane, the pleura, which is also reflected upon the inner wall of the 
 chest. The root of each lung is composed of the respective main bronchus 
 together with large blood-vessels, lymphatic vessels, chains of lymphatic 
 glands, held together by connective tissue and enclosed in the pleura. 
 
 THE PLEURA. 
 
 Each pleura is a closed serous sac, lining the lateral cavity of the 
 thorax to which it belongs, enclosing the lung and its root and forming 
 by the aid of its fellow of the opposite side the mediastinum. That part 
 of the pleura which encloses and covers the lung and its root is called 
 the visceral or pulmonary pleura; that which is reflected upon the ribs 
 and intercostal spaces, covers the upper convex surface of the diaphragm, 
 and passes to the sides of the pericardium, thus forming the mediastinum, 
 
Fio. 17. — Semidiagiuinmalic reconstruction, showing relations of pleural sacs (blue) and lungs (led) to 
 
 thoracic wall; anterior aspect. 
 
 Fig. 18. — Semidiagrammatic reconstruction, showing relations of pleural sacs (blue) and lungs (red) to 
 
 body-wall: posterior aspect. 
 
Fig. ]9. — Semidiagrammatic reconstruction, showing relations of right pleural sac (blue) and lung (red 
 
 to thoracic wall; lateral aspect. 
 
 Fig. 20. — Semidiagrammatic reconstruction, showing reliitions of left pleural sac (blue) and lung (red) to 
 
 thoracic wall; lateral aspect. 
 
MEDICAL TOPOGRAPHY. 27 
 
 is called the parietal pleura, or — as to its different parts — the costal, 
 diaphragmatic, and mediastinal pleura; and these two parts — namely, 
 the visceral and the parietal pleura — are continuous with each other at 
 the root of the lung. 
 
 The upper part of the pleura on each side passes upward beyond the 
 clavicle into the neck, and contains the apex of the lung, which reaches 
 from 2.5 to 4 centimetres above the margin of the first rib, usually a little 
 higher upon one side than upon the other, but not constantly higher upon 
 the right side as is often stated. Beneath the sternum the pleural sacs of 
 the two sides come nearly or quite into contact in the upper part, but in 
 the lower part the right pleura passes to or even beyond the middle line 
 and the left pleura recedes from it to a variable distance beyond the sternal 
 border. At the base of the chest the pleurae do not reach to the attachments 
 of the diaphragm, but they are reflected from the inner wall of the chest to 
 the rising vault of the diaphragm in such a manner that, on quiet respira- 
 tion or on full expiration, the parietal and visceral pleurae are not in apposi- 
 tion,' but the costal and diaphragmatic surfaces of the parietal pleura are 
 opposed. The higher position of the right diaphragmatic vault, due to the 
 high position of the right lobe of the liver, renders the right pleura somewhat 
 shorter than the left, while the smaller portion of the heart upon the right 
 side of the median line renders the right pleura somewhat wider than the left. 
 
 THE LUNGS. 
 
 Each lung is cone-shaped — with its blunt apex extending into the 
 root of the neck, its anterior surface flattened, its lateral and posterior 
 convex surfaces strongly convex, and its inner and inferior surfaces 
 concave. The contour resulting from this conformation gives rise to 
 sharp, well-defined anterior margins, the horizontal sections of which are 
 acutely angular, and to a similar, sharply angular, circumferential border 
 at the base, which fits into the corresponding re-entrant angle between the 
 thoracic wall and the diaphragm — a fact of no little importance in physical 
 diagnosis. Each lung is divided by a long, deep fissure, beginning about 
 the level of the spine of the scapula and proceeding obliquely downward 
 and outward to the sixth rib in the midaxillary line, into an upper and 
 a lower lobe. The right lung is further divided by a second, shorter fis- 
 sure, which passes inward and upward through the anterior margin, thus 
 forming a third or middle lobe. Upon the inner anterior border of the 
 left lobe is situated a deep notch into which the heart, enveloped in its 
 pericardium, is received, and at the inferior part of this border of the 
 lung is situated a tongue-hke projection which passes in front of the apex 
 of the heart — lingula. 
 
 The lungs completely fill the chest, and the surfaces of the visceral 
 and parietal pleurae are accurately in contact except along the ante- 
 rior and inferior margins of the lungs. In these situations the sharp 
 wedge-like borders of the lung advance between the reflected layers of 
 the parietal pleura during inspiration and recede during expiration, as 
 above stated. 
 
28 MEDICAL DIAGNOSIS. 
 
 The Mediastinum. 
 
 This space lies between the layers of an anteroposterior septum 
 formed by the inner or mesial portions of the right and left plem^ae which 
 pass upon the surface of the pericardium from the anterior and posterior 
 walls of the chest to the root of the lung upon either side. It is subdivided 
 into an anterior, middle and posterior mediastinum. 
 
 The anterior is narrow and of little depth, lying directly behind the 
 inner surface of the sternum. At its upper part it contains the atrophied 
 thymus. Behind the gladiolus the right and left pleurae are in contact, 
 and the anterior mediastinum consists merely of the connective-tissue 
 layer by which they are joined. Lower down, while still shallow, it is 
 widened, by the departure of the left pleura from the midsternal line, into 
 a triangular space which lies between the anterior portion of the right 
 ventricle and the wall of the thorax — the area of superficial cardiac dulness. 
 
 The middle mediastinum is the large space between the mesial layers 
 of the two pleurae which contains the pericardium and its contents. 
 
 The posterior mediastinum lies in front of the vertebral bodies and 
 contains the trachea, the oesophagus, the thoracic duct, the descending 
 aorta, the azygos vein, lymphatic vessels and the pneumogastric nerves. 
 
 THE PERICARDIUM. 
 
 This membranous sac, which occupies the middle mediastinum and 
 contains the heart and the roots of the great blood-vessels, is conical 
 in shape, its base resting upon the diaphragm and its apex extending 
 upwards upon the walls of the blood-vessels as far as their first sub- 
 divisions. It consists of two layers, an external fibrous layer, which 
 is attached below to the central tendon of the diaphragm, and above 
 to the surface of the large blood-vessels which it embraces; and an inner 
 serous layer, which lines the fibrous sac in which the heart is contained and 
 is reflected upon the surface of that viscus in such a manner as to form a 
 parietal and a visceral portion. The latter is sometimes described as the 
 epicardium. The fibrous pericardium is furthermore firmly attached to the 
 structures by which it is surrounded, namely, the sternum in front, the 
 mediastinal pleurae laterally, and the trachea, oesophagus, and main bronchi 
 behind. 
 
 The Heart and Great Vessels. 
 
 THE HEART. 
 
 This central organ of the circulation is situated in the cavity of the 
 thorax in the middle mediastinum. It lies unattached within the peri- 
 cardium except by the great vessels which spring from its cavities at the 
 base, and it rests upon the convexity of the diaphragm. Its base is directed 
 upward, backward, and toward the right, and extends from the level of the 
 fourth to that of the eighth dorsal vertebra, while its apex points down- 
 ward, forward, and toward the left, coming into relation with the chest wall 
 in the fifth intercostal space a little to the left of the parasternal line. It 
 projects farther to the left of the median line than to the right in the 
 average ratio of nearlv 2 to 1. 
 
MEDICAL TOPOGRAPHY. 
 
 29 
 
 Orthodiagraphic measurements have shown that the average oblique 
 diameter of the heart from the true apex to the angle at the upper right 
 border of the auricle and the great vessels is between 13 and 14 centimetres; 
 the horizontal distance from the midsternal line to the most distant point 
 of the border of the heart on the right; 3.5 to 4.5 centimetres; to the most 
 distant point on the left, 7.5 to 8.5 centimetres. 
 
 The Relation of the Heart to the Anterior Wall of the Chest. — In 
 general the normal heart in the adult may be said to extend from the level 
 of the second intercostal space on the right side to the fifth interspace on 
 the left. Investigations conducted to 
 ascertain the exact relations of the 
 viscus to the chest wall by thrusting 
 long needles through it immediately 
 after death, by means of sections of 
 frozen bodies, and by the X-rays have 
 not yielded constant nor concurrent 
 results. The discrepancies are doubt- 
 less due to differences existing natu- 
 rally among individuals and to variable 
 conditions, in themselves equally in- 
 capable of exact determination: for ex- 
 ample, the position of the diaphragm, 
 the amount of residual air in the 
 lungs, the quantity of gas in the stom- 
 ach and intestines, and the volume of 
 blood in the chambers of the heart at 
 the time of examination. For clinical 
 purposes it is possible to be over- 
 exact in variable matters of this kind. 
 
 The greater part of the anterior 
 surface of the heart is not directly in 
 relation with the inner chest wall, but 
 separated from it by the wedge-like 
 anterior borders of the lungs. The 
 superior border of the heart closely 
 corresponds to a transverse line drawn 
 about the level of the upper edges of 
 the third costal cartilages and extending from a point two centimetres from 
 the right border of the sternum to the third left costochondral articula- 
 tion. This line constitutes the chnical base of the heart and subdivides 
 the precordia into the cardiac area and the area of the great vessels. 
 
 The inferior border is indicated by a line drawn from a point on 
 the upper border of the sixth rib, directly below the outer limit of the 
 impulse, obliquely upward and to the right, across the base of the ensi- 
 form cartilage, and terminating at the middle of the fifth right interspace 
 near its junction with the sternum. 
 
 The right border nearly coincides with a hne drawn from the point 
 at which the superior border terminates on the right, convex to the right, 
 to the middle of the fifth interspace as above, namely, about 2 centimetres 
 to the right of the right sternal border. 
 
 Fig. 21. — Outline of heart and lines indi- 
 cating the auriculoventricuJar groove and the 
 anterior interventricular groove. 
 
30 MEDICAL DIAGNOSIS. 
 
 The left border is marked by a line joining the apex and the articula- 
 tion of the third left rib with its cartilage. 
 
 A line joining the third left chondrosternal articulation and the seventh 
 right chondrosternal articulation corresponds fairly well with the hne of 
 the auriculoventricular septum. 
 
 A line joining the apex and the third left costochondral articulation 
 corresponds closely with the interventricular septum. 
 
 The gi-eater part of the anterior surface of the heart is formed by the 
 right ventricle and constitutes a triangle included between the above hues 
 and the inferior border of the heart. The apex of this triangle is occupied 
 by the conus arteriosus and the tip of the left auricular appendix. 
 
 The upper third of the right auricle lies behind the sternum, while 
 its two lower thirds extend to the right of the sternal edge and are bounded 
 by the curved right border of the heart. 
 
 The left auricle is deeply seated and is completely covered by the 
 body of the heart and the left lung. 
 
 The left ventricle is likewise deeply seated and wholly retired from 
 the surface of the chest with the exception of a narrow longitudinal strip 
 which forms the left border of the heart and presents anteriorly, and of 
 which the lower end constitutes the true or anatomical apex of the heart, 
 and is separated from the chest-wall by the Hngula, the clinical apex to 
 which the impulse is due being the apex of the right ventricle. 
 
 That portion of the anterior surface of the heart which, uncovered 
 by the borders of the lungs, comes into relation with the wall of the chest, 
 constitutes the area of superficial cardiac dulness and may be more or less 
 accurately defined by percussion; that which recedes by its rounded sur- 
 faces from the chest wall and is covered by a rapidly thickening volume 
 of lung tissue is described as forming the area of deep cardiac dulness and 
 cannot be defined with the nicety which some assume by the ordinary 
 methods of physical diagnosis, though the shadow of its borders may be seen 
 expanding and contracting with the revolutions of the heart upon X-ray 
 examination. 
 
 THE GREAT VESSELS. 
 
 The ascending arm of the arch of the aorta arises at the base of the 
 left ventricle of the heart behind the pulmonary artery. Its course is at 
 first upward and to the right and slightly forward as it passes behind the 
 sternum. At the level of the second right costal or aortic cartilage, the 
 vessel passes upward, backward, and to the left, forming the transverse por- 
 tion of the arch, then backward and downward to form the descending arm 
 of the arch which terminates in the descending portion of the thoracic aorta. 
 
 The pulmonary artery passes a little more than a centimetre beyond 
 the left border of the sternum in a hne about the level of the middle of 
 the left third interspace upward to the second costal cartilage, behind which 
 it divides into its right and left main branches. 
 
 The descending vena cava extends from the second interspace on the 
 right side of the sternum to the base of the heart, which it enters at the 
 level of the middle of the third interspace. Its course is slightly curved, 
 the convexity being toward the right. 
 
MEDICAL TOPOGRAPHY. 
 
 31 
 
 These vessels are situated at varying depths behind the manubrium 
 sterni and in an area extending beyond the right and left sternal borders. 
 This region is sometimes designated the area of the great vessels. 
 
 The Relation of the Valves of the Heart to One Another and to the 
 Surface of the Chest. — The hues of attachment of the bases of the mitral 
 and tricuspid valves correspond to the auriculoventricular sulcus. The 
 semilunar cusps of the aortic and pulmonary valve systems are situated 
 respectively at the origin of each of those vessels from the ventricles. 
 The four sets of valves lie in close proximity to one another and to some 
 extent overlap. The pulmo- 
 nary is most superficial; the 
 mitral most deeply situated; 
 the aortic centrally placed and 
 in parts of its extent covered 
 by the pulmonary; and the 
 tricuspid lowest in position. 
 
 Their relations to the sur- 
 face of the chest are as follows: 
 
 The pulmonary valve lies 
 horizontally immediately to the 
 left of the sternal border at 
 the level of the upper edges of 
 the third left costal cartilage. 
 
 The aortic valve is at a level 
 slightly lower than the pulmo- 
 nary and situated behind the 
 sternum at the level of the third 
 left intercostal space and to 
 the left of the median line. 
 It is nearly horizontally placed. 
 
 The mitral valve — left 
 auriculoventricula r — 1 i e s 
 obliquely behind the sternum 
 to the left of the median line 
 extending from the level of the 
 fourth to that of the upper bor- 
 der of the fifth costal cartilage. 
 
 The tricuspid valve — right auriculoventricular — lies still more obliquely 
 behind the sternum in a line drawn from a point in the midsternal line 
 on the level of the third interspace to the sixth chondrosternal articulation. 
 
 These four valve systems are so close to one another that the sounds 
 produced by each cannot be studied by auscultation directly over the seat 
 of the valve,, but at that point in the precordia at which the blood stream 
 at the moment directly affecting the particular valve mechanism approaches 
 the surface of the chest most closely. 
 
 Puncta Maxima. — These areas, of which there are four, corresponding 
 to the separate valve systems, are: 
 
 1. The pulmonary area — at the inner end of the second left intercostal 
 space. 
 
 Fig. 22. — Position of heart and valves in relation to 
 anterior thoracic wall. A, aortic valve; P, valve of pul- 
 monary aorta; T, tricuspid valve; M, mitral valve; and 
 puncta maxima indicated by red circles. 
 
32 MEDICAL DIAGNOSIS. 
 
 2. The aortic area — at the second right costal cartilage. 
 
 3. The mitral area — at and just above the position of the apex-beat. 
 
 4. The tricuspid area — at the right border of the lower end of the sternum. 
 
 THE TOPOGRAPHICAL ANATOMY OF THE 
 ABDOMINAL VISCERA. 
 
 The Stomach. 
 
 The stomach is that dilated portion of the alimentary canal which 
 lies between the cardiac end of the oesophagus and the pyloric end of the 
 duodenum. It is irregularly gourd-shaped, the larger left end being called 
 the fundus or splenic extremity; the smaller right end the pyloric extremity. 
 The orifice by which the CBSophagus enters is called the cardia or cardiac 
 orifice, that passing to the duodenum the pylorus. The former is imme- 
 diately below the central part of the diaphragm and lies between the greater 
 and lesser curvatures. The latter lies lower down, more toward the anterior 
 abdominal wall, and to the right. The shorter inner curvature of the 
 gourd is known as the lesser, the longer outer curvature is the greater 
 curvature of the stomach. This hollow viscus hes chiefly in the epigastric 
 and left hypochondriac regions, the greater part of its extent being, when 
 distended, in about the proportion of 1 to 5, to the left of the median line. 
 During physiological rest the healthy stomach contains only a little mucus 
 and a small accumulation of air or gas which occupies its fundus, and 
 forms a narrow wrinkled pouch, the long diameter of which is obhque from 
 the cardia downward and to the right and approaches much more nearly 
 to the vertical than to the transverse axis of the body. Its superior border 
 is fixed at the cardia at the point at which the oesophagus pierces the dia- 
 phragm and is attached to the overlying Hver and diaphragm by the 
 gastrohepatic omentum and the gastrophrenic ligament. The gastrocolic 
 omentum is attached to the lower, the gastrosplenic omentum to the left 
 border. The anterior surface is in relation with the diaphragm and under 
 surface of the liver above and the wall of the abdomen lower down; the 
 posterior surface is in relation with the great vessels and pancreas above 
 and the transverse mesocolon lower down. Both these surfaces are free, 
 smooth, and invested with peritoneum. When the stomach is distended, 
 it rotates upon its cardiopyloric axis in such a manner that the anterior 
 surface tends to look upward and the posterior surface downward. The 
 dimensions of the stomach vary according to the degree of distention caused 
 by food, fluid, or gas. When moderately filled, its longest diameter is about 
 25 centimetres, its diameter between the greater and lesser curvature from 
 9.5 to 12 centimetres, and the diameter between its anterior and posterior 
 walls about 9 centimetres. When much distended, a normal stomach may 
 reach to the level of the umbilicus. 
 
 The cardia is situated in a direct line posterior to the left seventh 
 chondrosternal articulation at a distance of about 10 to 12 centimetres 
 from the anterior abdominal wall. The pylorus, which has considerable 
 freedom of motion, lies about the level of the tip of the ensiform cartilage 
 and near the outer border of the right rectus muscle. It is in relation with 
 
MEDICAL TOPOGRAPHY. 33 
 
 the concave surface of the Hver and may extend to the neck of the gall- 
 bladder. When the stomach is distended the pylorus assumes a position 
 further to the right and lower in the abdomen. The fundus rises into the 
 vault of the diaphragm to the level of the fifth interspace in the midaxillary 
 line and is higher than the cardia, just as the lateral vault of the diaphragm 
 is higher than its central aponeurosis. Its upper part lies behind the anterior 
 diaphragmatic border of the left lung and the tips of the seventh, eighth, 
 and ninth left ribs and their cartilages. The convex curve of Traube's 
 semilunar space in this region corresponds with the curvature of the fundus 
 of the stomach. 
 
 The Intestines. 
 
 A. The small intestine begins at the pylorus and terminates at the 
 ileocaecal valve, at which point it joins the large bowel. It has an average 
 length in the adult of about six metres. Its convolutions occupy the middle 
 parts of the abdomen and are surrounded by the large intestine. They are 
 attached to the back wall of the abdominal cavity by the mesentery. 
 The small intestine is divided into (1) an upper portion, or duodenum, 
 about 25 to 30 centimetres in length, into which in its middle third the 
 common bile duct and pancreatic duct discharge their contents; (2) a 
 middle portion, or jejunum; and (3) a lower portion, or ileum. In the last 
 are situated Peyer's patches. The duodenum is the widest and least mov- 
 able of the three portions of the intestines. The coils of the jejunum and 
 ileum are freely movable within the abdomen and among themselves and 
 bear no constant relation to the regions of the surface. 
 
 B. The large intestine extends from the termination of the small 
 intestine at the ileocaecal valve to the anus. Its average length is between 
 1.5 and 2 metres. Its diameter varies at different parts and ranges from 
 3.5 to 6 centimetres. There is a pouch-like dilatation of the rectum im- 
 mediately above its lower end. It is divided into three parts. 
 
 (1) The Caecum ; Intestinum Caecum ; Caput Caecum Coli. — The shortest 
 and widest part of the large intestine. It measures in length and width 
 each about 6 centimetres. As a rule, there is no mesocsecum, and this 
 part of the intestine is attached to the fascia covering the right iliacus 
 muscle. The caecum is situated in the right iliac fossa and is comparatively 
 fixed. Its position determines that of the ileocaecal valve which lies between 
 6 and 7 centimetres mesial to the right anterior superior spinous process. 
 
 (2) The appendix vermiformis arises from the inner and posterior 
 aspect of the caecum near the ileocaecal valve. It lies in the right iliac region 
 and its base is opposite McBurney's point. Its dimensions are extremely 
 variable, its width being that of a large quill and its length from 6.5 to 9 cen- 
 timetres. From its comparatively fixed base, the appendix, being free, may 
 extend in any direction. As a rule it lies downward or inward. It may, 
 however, extend backward, in which case the symptoms of appendicitis may 
 suggest renal colic; or upward, and, if inflamed, suggest gall-bladder disease. 
 
 (3) The CoIon„ — This part of the large intestine constitutes its great- 
 est length. It occupies the peripheral parts of the abdominal cavity, and, 
 owing to the lack of a mesocolon in its ascending and a portion of its 
 descending course, maintains a comparatively fixed position. In some 
 
 3 
 
34 MEDICAL DIAGNOSIS. 
 
 instances there is a short mesocolon in these portions. It is divided, 
 according to its course and direction, into four parts, namely, an ascend- 
 ing, a transverse, a descending portion, and the rectum. 
 
 (a) The ascending colon, commencing at the ceecum, passes upward 
 in a vertical direction to the under surface of the Hver near the gall-bladder, 
 where it turns forward and sharply to the left, forming the hepatic flexure. 
 It is as a rule fixed in its whole course and overlaid by some coils of the 
 ileum. It is contained in the right lumbar and hypochondriac regions. 
 
 (b) The transverse colon passes across the umbilical region from the 
 right to the left hypochondrium. It is deeply situated at its right and left 
 extremities, but in its intermediate course it bends forward and approaches 
 the anterior wall of the abdomen— arch of the colon. It rises shghtly at its 
 left extremity to pass behind the costal margin in relation with the fundus 
 of the stomach and turns abruptly downward to form the splenic flexure. 
 
 (c) The descending colon is continuous with the transverse colon at 
 the splenic flexure. It descends nearly directly downward through the left 
 hypochondrium and lumbar region to the left iliac region, where it curves 
 inward and then downward to form the sigmoid flexure. The descending 
 colon is covered only in front and at its sides by peritoneum, but the sig- 
 moid flexure has a distinct mesocolon and is freely movable. The latter lies 
 well toward the front of the cavity of the abdomen in the left ihac region. 
 
 (d) The rectum, notwithstanding its name, is not straight in man, 
 but curved from its beginning at the brim of the pelvis in front of the left 
 sacro-ihac articulation obliquely downward from left to right to the middle 
 line of the sacrum, then forward in the hollow of the sacrum to the level 
 of the prostate in the male or the vagina in the female, where it again turns 
 and proceeds downward and obHquely backward to the anus. This part 
 of the large intestine lies entirely within the pelvis, but is accessible to 
 examination by the finger, the rectal bougie, and the proctoscope. 
 
 The Liver. 
 
 The Hver is the largest gland in the body and occupies a large space 
 in the abdominal cavity. It measures from 22 to 24 centimetres in its 
 transverse, about 15 centimetres in its maximum anteroposterior, and 
 14 to 16 centimetres in its maximum vertical diameter. It is large and 
 rounded in its right extremity; narrow and wedge-shaped toward the left; 
 convex and smooth upon its upper surface; concave, uneven, traversed 
 by various fissures, and showing the gall-bladder and extrahepatic bile pas- 
 sages upon its lower surface. The rounded, thick posterior part is the most 
 fixed; the thin, sharp anterior margin the most movable part of the organ. 
 
 The liver occupies the right hypochondriac and extends across the 
 epigastrium into the left hypochondriac region. It is closely adapted to 
 the vault of the diaphragm and is in relation with the anterior wall of the 
 abdomen on the right side as far down as the margin of the ribs. The right 
 lobe reaches higher than the left — a fact in accord with the shorter vertical 
 diameter of the right thorax as compared with the left. At its highest 
 point the convex upper surface of the right lobe of the liver correspondi? 
 to the fourth intercostal space in the midclavicular line. The upper 
 
MEDICAL TOPOGRAPHY, 
 
 35 
 
 boundary gradually declines to the base of the ensiform cartilage in the 
 direction toward the left and continues on the right and to the back almost 
 upon the same level, crossing the midaxillary line at the level of the seventh 
 intercostal space and the line of the angle of the scapula about the level of 
 the ninth rib. Owing to the dome-like shape of the upper surface of the 
 right lobe of the liver and the concavity of the base of the lung into which 
 it is adapted, the diaphragm being interposed, there is a considerable 
 difference in the level of the actual upper border of the organ and that of 
 the portion which lies in contact with the wall of the thorax. The latter 
 
 Fig. 23. — Aieas of deep and superficial hepatic 
 dulness. 
 
 Fig. 24. — Areas of deep aud superficial 
 hepatic dulness. 
 
 in the midclavicular line corresponds with the sixth rib; in the mid- 
 axillary line with the eighth rib, and posteriorly with the tenth rib. Upon 
 percussion that portion of the liver which lies in relation with the wall of 
 the chest yields well-marked dulness; that which is covered by the inter- 
 posed border of the lung modified dulness. The former is spoken of as the 
 area of superficial hepatic dulness, the latter as the area of deep hepatic 
 dulness, and these two areas together constitute the area of hepatic dulness. 
 The lower anterior margin corresponds in the midclavicular line with 
 the margin of the ribs; in the median line it lies slightly above a horizontal 
 line midway between the base of the ensiform cartilage and the umbilicus; 
 about the left parasternal line at the lower border of the sixth rib; in the 
 right midaxillary line at the tenth interspace; and at the spine about the 
 level of the eleventh intercostal space. 
 
36 
 
 MEDICAL DIAGNOSIS. 
 
 The interlobar notch hes nearly in the median line. The thin edge 
 of the left lobe reaches closely to the midclavicular line. To the right of 
 the right midclavicular line the lower border corresponds approximately 
 to the costal margin. In aged persons the liver occupies a slightly higher 
 level; in children it is large in proportion to the size of the body and extends 
 higher, displacing the apex beat of the heart to a point behind the fifth 
 rib or in the fourth interspace, and causing the lower border to fall below 
 the line above indicated bv 1 or 2 centimetres. 
 
 The Qall= Bladder and Extrahepatic Bile Passages. 
 
 THE GALL=BLADDER. 
 
 This membranous sac is situated in a fossa in the base of the liver. 
 It is pear-shaped, measuring in its long diameter from 7 to 10 centimetres 
 and in its greatest transverse diameter about 4 centimetres. It hes ob- 
 liquely, with its fundus, which projects beyond the anterior margin of the 
 
 gland, looking downward, forward, 
 and to the right. There is often a 
 slight notch in the margin of the liver 
 at this point, which corresponds to 
 the outer border of the right rectus 
 muscle at the level of the inner edge 
 of the ninth costal cartilage. 
 
 THE EXTRAHEPATIC BILE 
 PASSAGES. 
 
 The Cystic Duct. — The neck of 
 the gall-bladder, which grows gradu- 
 ally narrower, forms a double curve 
 like the letter S, and then becoming 
 much constricted it turns abruptly 
 downward to form the cystic duct, 
 which runs downward and to the left 
 and unites with the hepatic duct to 
 form the common duct. 
 
 The Hepatic Duct. — This duct 
 is formed by the union of a right and 
 a left branch, which issue from the 
 transverse fissure and unite at an 
 obtuse angle. Its diameter is 3 or 4 
 millimetres and its length about 4 
 centimetres. It unites with the cystic 
 duct to form the common duct. 
 The Common Bile Duct; Ductus Communis Choledochus. — This 
 is the largest of the bile passages, being 5 or 6 millimetres in width and 6 
 centimetres or more in length. It runs downward and backward to the 
 inner and posterior wall of the duodenum, where, uniting with the pancre- 
 atic duct to form a dilatation, known as the ampulla of Vater, it penetrates 
 the wall of the duodenum very obliquely in the course of its middle third. 
 
 Fig. 25. — Position of fundus of gall-bladder. 
 
MEDICAL TOPOGRAPHY. 
 
 37 
 
 Pathological conditions involving the ducts, such as cholangitis and 
 gall-stone disease, do not directly give rise to physical signs, but they cause 
 serious symptoms and, indirectly, marked physical signs, and a knowledge 
 of the position and size of these ducts and their relations to each other is 
 of prime importance in the diagnosis of the diseases to which they are liable. 
 
 The weight of the liver and its direct relationship with the diaphragm 
 render it to a high degree subject to the influence of gravity in different 
 postures of the body, as, for example,, the erect position as compared with the 
 dorsal decubitus, and to the influence of the respiratory movements. Due 
 allowance for these changes in the position of the organ is to be made in its 
 physical examination. 
 
 The Pancreas. 
 
 This elongated, flattened gland is situated deeply in the abdominal 
 cavity directly behind the stomach and at the level of the first lumbar 
 vertebra. The larger right extremity is called the head and is embraced 
 by the curvature of the duodenum. Its smaller left 
 extremity, the tail, is situated in a slightly higher level 
 than the head and reaches to the spleen, with which it 
 is in contact. This organ varies considerably in size, 
 being between 15 and 20 centimetres in length, about 
 4 centimetres in average breadth, and about 2.5 centi- 
 metres in thickness. It extends across the epigastric 
 region and into the right and left hypochondrium. Its 
 principal duct traverses the entire length of the gland 
 and in association with the common bile duct enters 
 the duodenum by an oblique passage through its wall. 
 Its great depth in the body renders it as a rule inac- 
 cessible to direct physical examination. The close 
 relations of the head of the pancreas with the portal 
 vein, the inferior vena cava, and the ductus communis 
 choledochus are of clinical importance, since malig- 
 nant or other disease attended by enlargement of that 
 part of the gland constitutes a not infrequent cause 
 of oedema, ascites, or persistent jaundice. 
 
 The Spleen. 
 
 This soft, vascular organ is situated in the left 
 hypochondrium, opposite the ninth, tenth; and eleventh 
 ribs, and in the posterolateral portion of the upper 
 part of the abdominal cavity. It undergoes consid- 
 erable variation in size in health and may be enor- 
 mously enlarged in disease. It is irregularly oval in 
 shape, its upper and posterior borders being rounded and thick, its lower 
 and anterior borders sharp and the latter indented by two or more notches. 
 Its convex outer surface is in relation with the inner surface of the left 
 side of the diaphragm. Its concave inner surface presents a vertical fis- 
 sure called the hilus, and is in relation at its posterior portion with the 
 
 Fig. 26.— Position of 
 spleen. 
 
38 MEDICAL DIAGNOSIS. 
 
 suprarenal capsule and the upper part of the left kidney, and at its ante- 
 rior portion with the stomach, the splenic flexure of the colon, and coils of 
 the small intestine. Its average long diameter under normal conditions 
 is between 8 and 10 centimetres and it cannot be felt upon palpation. 
 Supernumerary spleens are not uncommon. 
 
 The Kidneys. 
 
 The right and left kidneys are deeply seated in the lumbar region in 
 the back part of the cavity of the abdomen and behind the peritoneum, 
 opposite the last dorsal and the first, second, and sometimes the third 
 lumbar vertebrae. The position of the right kidney is slightly lower than 
 that of the left. Each kidney is about 9 centimetres long, 6.5 centimetres 
 in width, and 3 centimetres in thickness, the left being usually longer and 
 thinner than the right. Their oblong, rounded concavo-convex shape is 
 characteristic. The convexity of each is directed outward and backward; 
 the concavity inward and shghtly forward. Near the middle of the con- 
 cave surface is a longitudinal fissure or hilus at which the vessels and 
 nerves enter or emerge and the ureter arises. This excretory duct expands 
 within the hilus into the pelvis of the kidney, from which arise three or 
 sometimes two funnel-shaped spaces which subdivide into a number of 
 smaller tubes called calices or infundibula, similarly funnel-shaped but 
 into which the papillae of the kidney project. The kidnej^s are supported 
 by the vessels and the perirenal fat. The right kidney is in relation with 
 the duodenum and colon in front and the liver above; the left with the 
 spleen above and colon anteriorly. Both He against the corresponding 
 pillar of the diaphragm, the anterior layer of the lumbar fascia, and the 
 psoas muscle. The deep situation of the kidneys and the thick layers of 
 muscles against which they rest, embedded in a layer of fat behind, render 
 them under normal circumstances inaccessible to the ordinary methods 
 of physical examination. When they are displaced or enlarged they present 
 characteristic physical signs. The suprarenal bodies are also beyond the 
 reach of the usual procedures of physical diagnosis. The ureters descend 
 from the hilus of each kidney to enter the bladder at its base. When 
 dilated — hydronephrosis — they form characteristic abdominal tumors. 
 
 The Bladder. 
 
 When empty this organ lies below the symphysis pubis; when dis- 
 tended it gives rise to a globular area of dulness in the hypogastrium. 
 In some neglected cases of urethral stricture or enlarged prostate an over- 
 distended bladder forms a large fluctuating tumor, reaching as high as the 
 umbilicus and inclining somewhat more to one side of the median line 
 than to the other. 
 
III. 
 
 THE EXAMINATION OF THE PATIENT AND CASE-TAKING. 
 
 Case=Taking. 
 
 An accurate knowledge of the facts in the case constitutes the first 
 requisite to a diagnosis. Those relating to the medical life of the patient 
 and his illness up to the time of his coming under observation are known 
 as the HISTORY of the case, or the anamnesis; those relating to his 
 immediate circumstances, alike subjective or objective, are described 
 under the heading present condition, or status pr^esens. 
 
 The examination to ascertain the necessary facts should be conducted 
 in an orderly and systematic manner. Time is thus saved, a general sur- 
 vey of the clinical phenomena made, and those of chief importance brought 
 into contrast and proper relation with those of subordinate value. Data 
 not otherwise obvious are brought to light and the chances of oversight 
 minimized. Vague and pointless inquiries are omitted. The interrogation 
 is precise and explicit. Above all, leading questions are to be avoided. 
 Running comments in the presence of the patient produce an especially 
 unfavorable effect. Tact and patience are necessary. An examination 
 thus conducted has a favorable influence upon the patient, especially in 
 chronic and difficult cases, and always inspires confidence. The investiga- 
 tion should not be unduly extended or minute. The examination of an 
 experienced and thoroughly trained clinician stands in striking contrast 
 to the vague and unsystematic questions of the beginner. On the other 
 hand, the inquiry may be too concise and brief. The former method has 
 been spoken of as the extensive, the latter as the intensive. The middle 
 course is the best. 
 
 There are two principal modes of case-taking, the synthetic and the 
 analytic. 
 
 THE SYNTHETIC METHOD. 
 
 In the synthetic, sometimes spoken of as the historical method, the 
 inquiry begins with the history of the patient, rather than with his present 
 condition. His place of birth, age, social state, occupation, previous dis- 
 eases, habits, hereditary and constitutional tendencies are first ascertained, 
 then follows an investigation into the beginning and progress of the present 
 illness. All this constitutes the anamnesis. The status praesens is then 
 considered. The condition of the several physiological systems, the diges- 
 tive, the circulatory, the respiratory, the genito-urinary, the nervous, and 
 so on, being carefully inquired into in regular order. Finally, the symp- 
 toms and signs referable to the organs or structures especially affected 
 are carefully studied. The next step in the process is the diagnosis, upon 
 which the prognosis, treatment and general management of the case depend. 
 Case-taking by this method follows the natural order. It is scientific and 
 
 39 
 
40 MEDICAL DIAGNOSIS. 
 
 useful in obscure cases. The chief objections to it are the time it consumes 
 and the fact that in the progress of the inquiry unnecessary attention must 
 be given to facts which are found later to have little or no bearing upon 
 the patient's present condition. 
 
 THE ANALYTICAL METHOD. 
 
 In the analytical method the order of procedure is reversed. The 
 principal symptoms are taken as the point of departure for the investiga- 
 tion. The organ or region to which these symptoms are referred is exam- 
 ined by the proper diagnostic measures. The general condition of the 
 patient, his facies, the state of nutrition of his body, his posture, his move- 
 ments, are carefully observed; meanwhile he is questioned as to the dura- 
 tion and progress of the present illness and an inquiry is made into such ■ 
 facts in his previous history and antecedents as may bear upon the case. 
 The chnical study is then extended, the condition of the other organs inves- 
 tigated, the history of the case more systematically reviewed, an opinion 
 formed as to whether the malady is general or local and a diagnosis reached. 
 This is the plan commonly pursued in ordinary professional work where the 
 data are sufficient for a diagnosis by the direct method, and is available 
 in all cases except those where the symptoms are obscure and ill defined. 
 
 QUESTIONS. 
 
 Great care is necessary in formulating questions. It is not sufficient 
 to ask the patient if the present illness began with a chill and be content 
 with an affirmative answer. Many patients regard the transient shivering 
 which so often marks the onset of an acute febrile disease as a chill, whei-eas 
 it is a very different matter from the prolonged and intense rigor that 
 attends the onset of pneumonia or the malarial paroxysm. The physician 
 must be on his guard also in regard to statements made by patients or their 
 friends concerning their previous illnesses. Very often such diagnoses are 
 popular rather than professional, and questions must be so framed as to 
 determine their accuracy. Accounts of influenza, malaria, catarrh of the 
 stomach, rheumatism, and the like cannot be accepted without close inves- 
 tigation into the symptoms, course and duration of the illnesses referred to. 
 The ''stomach cough" and "malaria" of the consumptive are familiar to 
 all practitioners. In the matter of hereditary and family tendencies to 
 disease the examination must be conducted with great care. It is no 
 uncommon thing for patients, even those who are well informed and intel- 
 ligent, to deny the existence of malignant disease, chronic nephritis, a 
 tendency to tuberculosis, and the like, when careful inquiry or the inde- 
 pendent statements of their friends render the occurrence of these diseases 
 in the family in the highest degree probable. A patient will affirm that 
 no case of consumption has ever occurred in his family, and upon cautious 
 questioning admit that his father or mother or other near relative suffered 
 from chronic cough, abundant expectoration, blood-spitting, and progressive 
 emaciation. An epileptic will deny the occurrence of nervous diseases, 
 and subsequently admit that near relations have presented the symptoms 
 
EXAMINATION OF PATIENT AND CASE-TAKING. 41 
 
 of hysteria or neurasthenia or been insane. Patients very often withhold 
 in the presence of a nurse or other attendant important facts that they 
 wilhngly communicate to the physician alone. 
 
 RECORDS. 
 
 Records should be kept m private as well as in hospital and dispensary 
 practice. How full these should be will depend upon the physician's 
 estimate of the importance of the individual case. Their preparation 
 demands close attention, concise statements, and accuracy. They consti- 
 tute a permanent store of professional experience for future reference and 
 study. They are of great value in the review of the history of patients 
 previously seen, as an aid in comparing one's personal observations with 
 those of the profession at large, in the preparation of articles for pubhca- 
 tion, and not infrequently as bearing upon medico-legal cases. They should 
 be preserved in accordance with a uniform plan in books prepared for the 
 purpose, or preferably upon cards of convenient dimensions arranged in 
 cabinets, in the same manner as the index catalogues used in hbraries. 
 Uniformity is important. It prevents the oversight of significant facts 
 and facihtates the comparison of cases. The following scheme is suggestive; 
 it may be modified in accordance with individual views: 
 
 SCHEME FOR CASE RECORDS. 
 
 Case record number Diagnosis Revise Result 
 
 Admitted Discharged (In hospital patients). 
 
 Date of examination 
 
 Name. Age Sex Race Place of birth.. Present 
 
 abode Former occupation Present occupation Social state 
 
 Married, single, widowed. 
 
 Anamnesis. 
 
 1. Family History: Hereditary tendencies; health of parents, brothers and sisters; 
 deaths in family — cause, age. 
 
 2. Personal History: (a) Diseases of childhood; (b) menstruation; (c) preg- 
 nancies, miscarriages, date of last confinement; (d) previous illnesses or injuries; (e) habits 
 — regularity of meals, kind of food, method of eating; bowels; sleep; habitual or 
 occasional physical or mental overexertion; tobacco; alcohol; narcotics. 
 
 3. Present Illness: (a) Date of onset; supposed exciting cause; exposure to con- 
 tagion; prodromes; initial symptoms; course of the attack; previous treatment, (b) 
 Antecedent derangements of health not amounting to positive disease, appetite, pain, 
 cough, disturbances of sleep, headache, etc. 
 
 Status Pr^esens. 
 
 A. General Appearance: Expression, height and weight, musculature, bony 
 structure, panniculus adiposus; posture in bed; movements, gait and station out of bed; 
 temperature; pulse; respiration; color and condition of the skin; perspiration; cedema; 
 eruptions; psychical condition; sensations and complaints; delirium; convulsions; 
 stupor; coma. 
 
 B. Particular Phenomena: Symptoms and signs relating to special structures, 
 organs and functions. 
 
 1. The Digestive Apparatus: Inspection of the mouth, tongue and gums; tonsils 
 and pharynx; palpation of the abdomen, its form and contour, visible peristalsis, tender- 
 ness upon pressure, resistance, tumors; percussion and palpation of the stomach and 
 intestines, liver, gall-bladder, spleen; inspection of vomited matters and faeces. 
 
 2. The Circulatory Apparatus: Inspection and palpation of the cardiac area; visible 
 and palpable pulsation; thrill; precordial prominence; position of the apex; percussion 
 and auscultation of the heart; the pulse-frequency, rhythm, fulness, tension; condition 
 
42 MEDICAL DIAGNOSIS. 
 
 of walls of arteries; venous pulsation; capillary pulse; liver pulsation; auscultation of the 
 arteries and veins; arterial pressure, positive and negative; examination of the blood, etc. 
 
 3. The Respiratory Apparatus: Nose, mouth, and larynx; cough and expectora- 
 tion; chest and lungs — character of the respiration, dyspnoea, stridor, Cheyne-Stokes 
 respiration; contour of the thorax; local, lateral or bilateral retraction or expansion; 
 respiratory excursus; fremitus; local and general physical signs obtained by percussion, 
 auscultation, and mensuration; the cyrtometer. 
 
 4. The Genito-Urinary Apparatus: Palpation of the kidneys and bladder; percussion 
 of the bladder; retention of urine; suppression; frequency of micturition; pain; quantity 
 of urine; total amount for twenty-four hours; disturbance at night; chemical and micro- 
 scopic examination of the urine; sexual organs. 
 
 5. The Xerv'ous System: InteUigence; mental state; subjective sensations; sleep, 
 gait, station, reflexes, tremor, convulsions, spastic conditions, paralysis; aphasia and other 
 disorders of speech; derangements of sensation; the organs of special sense. 
 
 6. The Osseous System — Bones and Joints: General and local changes in the skeleton; 
 cranium, spine, thorax, pehis, long bones, extremities; striking deformities; the joints; 
 size and shape, color, pain, degree of impairment of function, fixation, disintegration. 
 
 7. The Tegumentary System: Itchmg, burning, tension, pain, inflammatory phe- 
 nomena; presence and character of eruptions, macular, papular, vesicular, pustular; 
 uniformity; polymorphism; hypertrophy and atrophy; cicatrices; pigmentary changes; 
 animal and vegetable parasites; subcutaneous structures; enlargement or atrophy of thy- 
 roid body; Ijrniph nodes; constitutional disturbances. 
 
 Diagnosis; Prognosis; Treatment; Subsequent obser\'ations. 
 
 The results of special clinical and laboratory examinations are to be in- 
 corporated under the appropriate headings. Among these are rhinoscopic 
 and laryngoscopic, ophthalmoscopic and otoscopic examinations; hsemato- 
 logic investigations; the chemical and microscopic examination of the gas- 
 tric contents, vomited material, and the stools; of expectorated matters; 
 bacteriologic examinations of the blood, sputum, secretions, exudates, etc., 
 by the methods of staining, culture, and inoculation; examination of the 
 rectum by the finger, the speculum, and by inflation; cystoscopy; special 
 examination of the genital organs in both sexes, examination of the fluids 
 obtained by exploratory puncture, and examination by the X-rays. 
 
 In febrile cases temperature charts should be preserved with the 
 records, and superficial deformities, as swelling or retraction, as well as 
 changes in the viscera revealed by the various methods of diagnosis, may 
 be indicated upon outline clinical diagrams and incorporated in the notes. 
 Changes of contour, glandular enlargements and topographical lesions, 
 such as local consolidations and cavity formation in the lungs, cardiac 
 dilatation or hypertrophy, pleural and pericardial effusions and the result- 
 ing displacement of adjacent viscera, enlargement of the liver and spleen, 
 dilatation of the stomach and displacement of the abdominal organs may 
 in this manner be more or less accurately delineated. The location of 
 tumors and circumscribed exudates may also be indicated, and in the case 
 of the nervous system the extent and distribution of areas of disturbance 
 of sensation and other phenomena. 
 
 Some further explanation of the bearing of the facts noted in the 
 anamnesis upon the mental processes b}' which a diagnosis is reached may 
 be of service to the student. 
 
 Age The age is important. Each period of life has its pecuhar 
 
 susceptibility to morbid influences. In the new-born, congenital defects, 
 the results of the accidents of parturition, diseases arising from faulty 
 management of the cord, those directly transmitted from the mother, 
 and those produced by improper diet and unhygienic surroundings are 
 
EXAMINATION OF PATIENT AND CASE-TAKING. 
 
 43 
 
 common. In childhood, anatomical peculiarities of the growing organism 
 and the sensitiveness of physiological processes to external impressions 
 give rise to special predispositions to disease. Thus, the ready prolifera- 
 tion of the lymph tissues explains the frequent occurrence of respiratory 
 obstruction in the nasopharynx from adenoid hypertrophy, while the 
 narrowness of the larynx accounts for the gravit}^ of catarrhal and infective 
 processes involving that organ, and the great vascularity and rapid over- 
 growth of the epithelium of the bronchi when irritated explain the peculiar 
 liability of children to bronchitis and 
 bronchopneumonia. In the instability „.-<^^^^^\^ 
 
 
 Fig. 27. — Clinical diagram. 
 
 Fig. 28. — Clinical diagram. 
 
 of the nervous system in children we find a ready explanation of their 
 liability to fever, its high range and rapid fluctuations, and to various 
 reflex disturbances, and in the absence of acquired immunity, an explana- 
 tion of the wide prevalence among them of the transmissible infections, as 
 the exanthemata, which are spoken of as the diseases of childhood. In 
 adolescence, hereditary predispositions begin to show themselves, as in 
 the occurrence of tuberculosis and of epilepsy or other nervous affections. 
 The late sequels of infantile diseases, as chronic valvular trouble following 
 rheumatic endocarditis, or chronic nephritis subsequent to scarlatina, 
 often now appear. Changes in the environment of the individual subject 
 him to special pathogenic influences, and pleurisy with or without effusion. 
 
44 MEDICAL DIAGNOSIS. 
 
 pneumonia, and enteric fever are common. The middle period of life is 
 especially prone to diseases that result from occupation, examples of which 
 are lead intoxication, caisson disease, and scrivener's palsy, to those which 
 result from the habitual use of narcotics, as gastric catarrh, hepatic cir- 
 rhosis, and alcoholic neuritis, to those resulting from the stress of life and 
 anxiety, among which may be named cardiac hypertrophy, the neuras- 
 thenias and other nervous diseases and insanity. It is in this period that 
 hereditary and acquired tendencies to sclerotic changes in the vessels 
 and in the nervous system begin to develop and that diabetes and the 
 paroxysms of gout commonly first show themselves. Later in life the 
 indications of progressive degenerations become more marked. The 
 wrinkled skin, the failing sight and hearing, the feeble heart, winter cough, 
 and renal inadequacy are the indications of sclerotic . and nutritive 
 changes which are more apparent in the rigid, tortuous, or atheromatous 
 superficial arteries. This is especially the period of apoplexy, chronic 
 bronchitis, diabetes, cystitis from hypertrophiecl prostate, Parkinson's 
 disease and the special infections^ erysipelas and pneumonia, which are 
 frequently terminal events. In general terms the evolution of life is 
 the period of infections, the involution the period of degenerations; 
 but in pathology age cannot be measured by years, and the signifi- 
 cant sajang that "a man is as old as his arteries" has become a modern 
 medical aphorism. 
 
 Physiological Epochs. — The epochs of life are also marked by special 
 liability to disease. Thus at the first dentition nutritional diseases and 
 gastro-intestinal troubles are common; at puberty, chlorosis and hysteria; 
 at the menopause, hysteria, obesity, and arthritis deformans. It is to be 
 noted, however, that the maladies of these physiological epochs are not 
 the direct result of functional changes, but are the outcome of previous 
 morbid conditions or tendencies. 
 
 Sex. — Sex is likewise important. In early and advanced life the 
 sexes are equally liable to disease. Women between the age of puberty 
 and the menopause are exposed to the danger of many accidents and 
 diseases peculiar to the anatomical and physiological development con- 
 nected with the sexual life and child-bearing. Consideration of these 
 matters properly belongs to gynaecology and midwifery. Sedentary living, 
 the monotony of the household, and depressing moral influences also act 
 as causes of disease in women. Hysteria, neurasthenia, and special forms 
 of insanity occur. These peculiarities do not, however, carry with them 
 an exemption from other pathogenic influences, and among the peasantry 
 of those countries where the women largely engage in the same occupations 
 as the men they suffer, in addition to their own peculiar disorders, from 
 the maladies of the other sex and practically to the same extent. In more 
 enlightened districts and among the upper classes of society women escape 
 many risks of disease to which men are exposed. In the male sex occupa- 
 tion, exposure, the strenuous life, and self-indulgence are common causes 
 of disease, hence the more frequent occurrence of plumbism, farcy, pneu- 
 monia, chronic arthritis, gout, tabes, and alcoholism. As a consequence, 
 arteriosclerosis and atheroma are more marked in men than in women 
 at advanced age. 
 
EXAMINATION OF PATIENT AND CASE-TAKING. 45 
 
 Race and Nationality. — These points demand consideration in the 
 anamnesis. The pecuhar hability of the Hebrew to diabetes and neuras- 
 thenia; of the negro and mulatto to tuberculosis, and the relative immunity 
 of the former to malaria and yellow fever; the prevalence of beriberi 
 among the oriental races, of leprosy in Scandinavia, the Sandwich Islands, 
 and the West Indies; and the frightful ravages of tuberculosis, syphilis, 
 and alcoholism among the Indians of North America are well-known facts. 
 
 Nativity. — The place of birth and residence frequently shed light 
 upon an obscure case, as in ill-defined malaria, the malarial cachexia, 
 goitre, cretinism, and leprosy. A knowledge of the district or locality of 
 the patient's present residence, the situation of his home, its sanitary 
 conditions and surroundings, the source of the water supply, and the 
 disposition of the sewage may shed light upon the diagnosis. 
 
 Occupation. — The occupation of the patient demands careful investi- 
 gation. The habitual over-use of certain muscles, and exposure to particular 
 irritants or poisons or an atmosphere laden with minute mineral or metallic 
 particles or chemicals, or to infections peculiar to certain crafts, cause defi- 
 nite diseases. Examples of such affections are writer's cramp, anthracosis 
 or miner's consumption, chronic phosphorus poisoning among workmen 
 engaged in the manufacture of matches, malignant pustule or wool- 
 sorter's disease, and glanders. It is necessary to inquire carefully into 
 former occupations as well as the present; thus chronic bronchitis with 
 bronchiectasis may have had its origin in the inhalation of the dust caused 
 by stone-cutting — an occupation long abandoned by the patient. In those 
 occupied in professional or literary work functional derangements of the 
 stomach, constipation, and insomnia are common. Even amusements 
 may be the cause of disease, as in the golfer's back and the heart-strain of 
 the athlete. 
 
 Heredity. — The family history has a very important bearing upon 
 the diagnosis, especially in chronic diseases. It is difficult to frame a 
 satisfactory definition for heredity, but we know that traits and lineaments 
 are transmitted from parents to children through the generations, and 
 we occasionally observe in a son who has his mother's features some trick 
 of expression that makes his resemblance to his father for the moment 
 almost starthng. So too are transmitted from one generation to another 
 tissue peculiarities and constitutional tendencies to disease. The inquiry 
 into the family history must be, as has been pointed out in a previous 
 paragraph, conducted with tact and caution. Blunt inquiries in regard 
 to "consumption," "cancer," " Bright's disease," or "insanity" irritate 
 the patient and usually elicit vague replies or absolute denials. A patient 
 should be asked if his parents are living and in good health; if not in good 
 health, the symptoms and duration of the illness; if dead, the cause of 
 death and the age at which it occurred. He should be questioned as to 
 the number of his brothers and sisters, their health, and the cause of any 
 deaths that may have occurred among them. It is very important to learn 
 whether or not deaths in the family have been the result of acute or chronic 
 disease. The inquiry may be extended to the preceding generation and 
 collateral branches of the family. Diseases, it is true, are conveyed by 
 hereditary transmission, but their number is comparatively few. Hsemo- 
 
46 MEDICAL DIAGNOSIS. 
 
 philia is a striking example. Syphilis is very commonly thus transmitted. 
 When the mother has contracted an acute infection, as measles or enteric 
 fever, the child may be born during the period of incubation or with the 
 symptoms of the disease already manifest. A number of nervous diseases 
 are clearly hereditary. As examples may be mentioned progressive mus- 
 cular atrophy, hereditary chorea, Friedreich's ataxia, and migraine. The 
 definite symptoms may not show themselves for some years after birth, 
 in some cases not until adult life. Much more commonly it is the pre- 
 disposition that is transmitted. This is especially the case in tuberculosis. 
 The peculiar exposure of the young infant to infection from a tuberculous 
 mother and the length of time that the tuberculous lesions in many in- 
 stances remain localized render it in the highest degree probable that the 
 predisposition to tuberculosis rather than the disease itself is hereditary. 
 This view is confirmed by the results of pathological and bacteriological 
 investigations. The direct transmission of tuberculosis from the mother 
 to the foetus in the human being is of uncommon occurrence. The doc- 
 trine of the direct hereditary transmission of tuberculosis, so long enter- 
 tained but now fortunately abandoned, was a stumbling block in the way 
 of the recognition of the infectious character of this disease. That the 
 predisposition rather than the disease is hereditary is also true of cancer. 
 The occasional occurrence of chronic Bright's disease in nearly every 
 member of a family in two or three generations, usually first showing itself 
 in adolescence or early adult life, must be attributed to hereditary defects 
 of the renal and vascular tissues, while faults of metabolism, the constitu- 
 tional tendency to which is transmitted from father to son, bear a direct 
 etiological relation to gout and its associated cardiovascular and renal 
 changes. The development of forms of insanity in successive generations 
 of a family, usually at the physiological epochs of life, often not until late 
 middle age, must likewise be attributed to hereditary defects of nervous 
 and mental organization. 
 
 A further peculiarity in regard to the hereditary transmission of 
 disease is to be found in its diverse manifestations among various members 
 of a family. The radical defect or susceptibihty may find expression in 
 pathological conditions which are allied but which have wholly different 
 symptoms. Thus the tendency to deranged metabolism and arteriosclerosis 
 may in one show itself in contracted kidney and hypertrophied heart; 
 in another in disease of the aorta or angina pectoris; in a third in gout^ 
 renal calculus and gravel, or yet again in early cerebral hemorrhage or 
 thrombosis. The neuropathic constitution may manifest itself in one 
 member of a family in forms of neuralgia, neurasthenia, or hysteria; in 
 another in the development of epilepsy, and in a third in the guise of 
 hypochondriasis or insanity. The family susceptibility to certain infec- 
 tions may reveal itself in different individuals in recurrent attacks of 
 tonsillitis or rheumatism, chorea or chronic valvular disease; or the sus- 
 ceptibility to tuberculosis, on the one hand in pulmonary consumption, 
 on the other in tuberculosis of the bones and joints or glandular disease, 
 or finally in the implication of the meninges, pleura, or peritoneum. 
 
 Immunity may be transmitted by inheritance as well as the pre- 
 disposition to disease. There are families and individuals who possess a 
 
EXAMINATION OF PATIENT AND CASE-TAKING. 47 
 
 remarkable natural immunity against the exanthemata. This is espe- 
 cially true in regard to scarlet fever. When we consider the wide 
 prevalence of pulmonary tuberculosis an'd the diffusion of its cause in the 
 centres of population and certain districts and houses, and the fact that so 
 large a proportion of individuals and famihes constantly exposed to the 
 inhalation of an atmosphere containing the tubercle bacilh escape the 
 •disease,, the common existence of a natural immunity which is frequently 
 transmitted by inheritance becomes evident. The predisposition to tuber- 
 culosis is far less general than that to scarlatina and measles. The occur- 
 rence of personal peculiarities and morbid tendencies in an individual 
 which were not manifested in his parents but existed in their ancestors is 
 known as atavism. In rare instances, and especially in cases of nervous 
 disease and insanity, this condition is important in the anamnesis. Curi- 
 ous facts in regard to the duration of life are occasionally observed. 
 There are families in which , in successive generations few members survive 
 the early middle period of life. In such instances death is very often 
 due to an acute disease not always the same. On the other hand, all the 
 members of certain families reach an advanced age, the exceptions being 
 where death is due to accident or violence. 
 
 Medical History. — The personal history is essential to a diagnosis 
 in the broad sense. A knowledge of the significant facts in the past hfe 
 of the patient may clear up a doubtful case. The present disease may be 
 a late sequel of some previous illness, as bronchitis or emphysema after 
 whooping-cough, or an obscure manifestation of one of the exanthemata 
 which the patient escaped in childhood, as scarlatina in the adult with 
 fever of moderate intensity and an irregular patchy eruption, or it may 
 be the expression of a peculiar constitutional susceptibility, as tonsillitis, 
 rheumatic fever, or chorea, from which the patient has suffered on previous 
 occasions. In this connection it is to be borne in mind that many of 
 the acute infectious diseases, and especially the exanthemata, result in 
 an acquired immunity which usually lasts throughout life, hence second 
 attacks are exceedingly infrequent, while the immunity conferred by other 
 infections, for example rheumatic fever, erysipelas, -croupous pneumonia, 
 and diphtheria, is incomplete and of limited duration, so that many individ- 
 uals suffer from repeated attacks of these diseases. In acute febrile attacks 
 and in the presence of epidemics careful inquiry as to exposure to the 
 contagion must be made. The period of incubation and the occurrence of 
 prodromal symptoms are to be taken into consideration. In women 
 abnormal menstruation, the accidents and diseases of pregnancy, the occur- 
 rence of miscarriages, too frequent child-bearing and prolonged lactation 
 may be the cause of serious impairment of health or of actual disease. 
 These matters must be carefully inquired into. In exceptional cases, 
 especially in aggravated and intractable functional nervous diseases, it 
 becomes necessary to inquire more closely into the sexual life of the patient. 
 The investigation must be conducted with great delicacy and discretion. 
 The part played by vicious practices arid excesses in the production of such 
 diseases must be ascertained. It is necessary also to learn whether or not 
 the patient has suffered from venereal infection, the date of its occurrence, 
 the nature, character, and duration of the primary symptoms, the presence 
 
48 MEDICAL DIAGNOSIS. 
 
 or absence of secondary lesions, and the treatment. Gonorrhoea is not 
 always merely a local affection. The frequency with which it is followed 
 by stricture is well known, but the symptoms of the latter condition may 
 first show themselves after the lapse of years. Local abscess formation, 
 acute and chronic cystitis and pyelitis also occur. The immediate 
 recognition of the specific nature of gonorrhoeal ophthalmia, whether in 
 the new-born or in the adult, is a matter of overwhelming importance. The 
 diagnosis of many a case of disabling and stubborn arthritis is made 
 clear by a knowledge of gonorrhoeal infection. Nor is the fact to be 
 overlooked that endocarditis, both in its benign and malignant forms, may 
 be a secondary process. In women the history of primary gonorrhoea is 
 very often obscure. Tubal disease and other pelvic inflammations, only 
 to be relieved by the knife of the gynaecologist, are common results of the 
 extension of the infection. A dissolute life on the part of the patient is 
 presumptive evidence of the nature of the process. There is also gonor- 
 rhoea insontium; a virtuous wife may suffer. The protean manifestations 
 of syphilis are to be borne in mind. The symmetrical arrangement and 
 sequence of the early cutaneous lesions, their later polymorphism and 
 irregular distribution, the buccal and anal mucous patches, the ade- 
 nopathy, the obscurity of the visceral and nervous phenomena, their 
 irregularity and chronicity, are all to be considered in the diagnosis of an 
 obscure case. The presence of the specific organism — spirochseta pallida — 
 is conclusive. Where syphilis is suspected in a family, we must inform 
 ourselves as to whether or not a mother has aborted, especially in her 
 early pregnancies, or has had later a series of abortions or still-born children, 
 and as to snuffles and cutaneous eruptions, especially on the buttocks, 
 in her new-born children, and corneal opacities, interstitial keratitis, Hut- 
 chinson's teeth, and arrested development or nervous diseases in those who . 
 have survived. Nor must the physician overlook the fact that many 
 innocent persons contract syphilis. Not only the blameless wife but also 
 the unsuspecting girl, from the kiss of her betrothed, may become the 
 victim to this disease, while the methods of accidental inoculation are 
 innumerable. Familiar examples are to be found in the chancre upon the 
 hand of the surgeon or accoucheur, or upon the hp or tongue of the 
 incautious borrower of a pipe from an infected friend. When matters 
 of this kind concern members of a family, the physician cannot be too 
 guarded in respect to the way in which his questions are framed or in 
 his statements to a husband or wife. Suggestive questioning or injudicious 
 statements may seriously aggravate existing troubles. If definite communi- 
 cations become necessary, his knowledge of the circumstances will enable 
 him to decide whether it is best personally to assume the whole responsi- 
 bility or to invite a colleague of high reputation to share it with him. 
 
 The history of a surgical operation and the conditions which led up 
 to it, as well as its results, are important. The patient's present condition 
 may be due to a recurrence of the original trouble, or, as in the case of an 
 abdominal operation, to the development of adhesions or constricting bands. 
 
 Personal Habits. — The habits must be closely studied. Important 
 information bearing upon the diagnosis may often be obtained by direct- 
 ing the patient while continuing his ordinary method of living to keep a 
 
EXAMINATION OF PATIENT AND CASE-TAKING. 49 
 
 record of the hours at which his meals are taken, the kind and quantity 
 of food and drink, the action of his bowels, the hours and character of 
 sleep, and his various occupations and amusements, which may be sub- 
 mitted at a subsequent consultation. The causal relation of improper 
 clothing to bronchopulmonary affections, of badly regulated work and 
 sleep to neurasthenic conditions, of injudicious or irregular eating to gastro- 
 intestinal troubles, of the abuse of alcohol to nervous diseases and cirrhosis 
 of the liver, of excess in tobacco to irritable heart and amblyopia, will 
 guide us in the inquiry. Late hours and dissipation, in fact all matters 
 which enter into consideration from the stand-point of the moral hazard 
 of the insurance companies, have a most important bearing upon diagnosis. 
 
 Present Illness. — The history of the present illness must be system- 
 atically investigated and its symptoms recorded in chronological order 
 from the onset to the tim6 of the patient's coming under observation. 
 It is important to learn if possible the effect of treatment. The disap- 
 pearance of a rash after mercurials or the subsidence of headache after 
 continued large doses of the iodides constitutes presumptive evidence in 
 favor of syphihs. The failure of quinine to prevent the recurrence of chills 
 renders the diagnosis of malaria improbable, or of the proper administra- 
 tion of suitable preparations of iron in full doses to correct the pallor, 
 breathlessness upon exertion, and headache of a highly anaemic young 
 woman militates against the diagnosis of chlorosis. Much allowance must 
 be made for the statements of patients both as regards the symptoms of 
 the illness and their reports of previous treatment and the opinions of 
 physicians whom they may have consulted. In many cases the unravelling 
 of a diffuse and inconsequent story can only be accomplished by the exer- 
 cise of skill and patience. On the other hand, the history communicated 
 by intelhgent persons is often curiously succinct and clear. Frequently 
 by reason of the patient's mental condition no account of the illness can 
 be obtained. In some cases it often happens that very little information 
 can be gleaned from the bystanders. In hospital practice the admission 
 of ambulance cases gravely ill, of whose previous condition nothing 
 whatever can be learned, is a matter of daily occurrence. 
 
 Duration. — Of first importance is a knowledge of the duration of 
 the illness, since it enables us at once to form an opinion as to whether the 
 disease should be referred to one or the other of the two general groups 
 of acute or chronic maladies. The fact is, however, not to be overlooked 
 that acute symptoms may be the manifestation of an unsuspected chronic 
 affection, as sudden loss of vision or convulsions in nephritis, angina pectoris 
 in disease of the heart and aorta, or perforation phenomena and peritonitis 
 in peptic ulcer of the stomach and duodenum. The mode of onset next 
 demands our attention. In chronic cases we seek information as to whether 
 the present illness developed insidiously or abruptly upon a condition of 
 previous good health, or followed an acute illness, and whether its course 
 has been gradual and progressive or interrupted by periods of improve- 
 ment; in acute cases whether the attack developed insidiously, as in the 
 case of enteric fever, or abruptly, as in influenza or typical croupous pneu- 
 monia, and whether or not prodromes occurred. It is next in order to 
 ascertain the prominent symptoms of the disease, the region or organ 
 
 4 
 
50 MEDICAL DIAGNOSIS. 
 
 to which they have been referred, whether they have been continuous, 
 intermittent, or paroxysmal, and any changes in the patient's appearance 
 or condition, of which he may or may not be aware, that have attracted 
 the attention of his friends. Finall)^, important information is often reached 
 by due consideration of the views of the patient or others relating to the 
 cause of his illness. 
 
 Status Prsesens. — The investigation of the present condition of the 
 patient must also be conducted in an orderly and systematic manner. 
 The subjective sensations are carefully considered. No complaint of the 
 patient, however trifling, is to be wholly disregarded. The objective 
 symptoms must be studied with equal care. Every fact is to receive proper 
 consideration. Due regard must be paid to the feelings of the patient. 
 Abruptness and all appearance of haste or harshness are to be avoided. 
 The interview must not seem too business-like. The clothing, whether 
 in the consulting room or at the bedside, must be so arranged as to facilitate 
 the examination. No physical exploration of the thoracic or abdominal 
 organs can be made without proper access to the regions to be studied; 
 mistakes from a disregard of this rule are of daily occurrence. In diseases 
 of the heart, lungs, or great vessels it is necessary to inspect the uncovered 
 chest; palpation must also be performed upon the bare surface; per- 
 cussion and auscultation upon the bare skin or more conveniently in most 
 cases through a towel or the single layer of a smooth under-vest. In order 
 that the influence of gravity upon the abdominal viscera may be learned 
 or to study the station and gait, the patient must rise from bed. If there 
 are symptoms referable to the spine, the clothing must be removed and 
 the patient examined in the erect, sitting, or recumbent posture, in the last 
 instance not in bed but upon the firm, smooth surface of a suitable table; 
 the effect of various movements is studied and the condition of the muscles 
 and joints. Accurate measurements of parts, preferably in centimetres,, 
 are essential where there is a departure from normal standards or asym- 
 metry. We measure and note the circumference of the head in hydro- 
 cephalus, the chest on quiet breathing, on full held inspiration and on 
 forced expiration, its lateral circumferences for comparison, its contour 
 by means of the cyrtometer, and we may measure diameters of the head 
 and chest by means of calipers. It frequently, especially in the case of 
 ascites and tumors, is desirable to take the circumference of the abdomen. 
 The muscles in relaxation and contraction are studied by the hand and 
 one side is compared with the other. Where necessary the circumference 
 of the limbs is measured at the same point upon the two sides. Where 
 symptoms relating to the brain or spinal cord dominate the clinical picture, 
 the examination must be made with especial attention to the details bear- 
 ing upon the localization of the lesions. Specimens of the urine must be 
 obtained for examination as a matter of routine in all cases. The diagnosis 
 of obscure conditions, the symptoms of which are referred to the nervous 
 system, digestive organs, or general condition of the patient, frequently 
 depends upon the result. The discovery of chronic disease of the kidneys 
 or the presence of sugar in the urine as the outcome of investigations made 
 upon application for life insurance is a matter of very common occurrence 
 in middle-aged men who regard themselves as in excellent health. 
 
EXAMINATION OF PATIENT AND CASE-TAKING. 51 
 
 In general the examination should be methodically conducted in accord- 
 ance with the foregoing scheme, prominence being given in the record of 
 the case to the symptom-complex which bears directly upon the diagnosis. 
 
 Abbreviations. — Time and space may be saved in case-taking by the 
 use of abbreviations. Thus: 
 
 / & m I & w — father and mother living and well. 
 
 6 3; 2 din infancy; 1 I & w — three brothers; two dead in infancy; 
 
 one living and well, 
 s 2; 1 d at 7 sc fever; 1 at 10 acute nephritis, 
 w & s till 18 then ent fever; I crural phlebitis; elas stk still — well 
 
 and strong till 18, then enteric fever; followed by left crural 
 
 phlebitis; still wears elastic stocking. 
 Epigast pain p c; occas v; blood 12 mos & 1 mo ago — Epigastric 
 
 pain after food; occasional vomiting; haematamesis one 
 
 year and again one month ago. 
 D r u a; def expn; br-vesic resp; crep roles — Dulness right side 
 
 upper lobe, anteriorly; deficient expansion; broncho- 
 vesicular respiration; crepitant rales. 
 Tend r I q; aire D; Sd d of attack; n & v; T. 101° — Tenderness 
 
 in right lower quadrant; circumscribed dulness; third day 
 
 of attack; nausea and vomiting. 
 
 Many similar abbreviations, at once familiar to the writer and intel- 
 ligible to any trained clinician, will suggest themselves. 
 
 Murmurs maj^ be shown on the clinical diagrams (Figs. 27 and 28) 
 by stippling or washes, the point of maximum intensit}' being most 
 deeply colored and the direction of propagation shown by an arrow: 
 
 or more simply by a many-pointed star to indicate the point of maximum 
 intensity and an arrow the direction; thus 
 
 These signs should be drawn in a different color from that of the 
 ground plan, red if the latter is black, or vice versa. 
 
 Dulness may be indicated by cross hatching; its degree by closeness 
 of the mesh; thus 
 
 Relative dulness. -Marked dulness 
 
 Flatness by solid color; thus 
 
52 MEDICAL DIAGNOSIS. 
 
 Rales by dots, their size and abundance corresponding to the phys- 
 ical signs; thus 
 
 /!^^j'; '••:, ', 
 
 
 Crepitant. Subcrepitant. Small mucous. Large mucous. 
 
 Cavities by irregularly outlined spaces; thus 
 
 Friction sounds by zigzags, the extent and coarseness of which 
 indicate the distribution and intensity of the rub; thus 
 
 -# 4 ifiii^ 
 
PART II. 
 
 OF THE METHODS AND THEIR IMMEDIATE RESULTS. 
 
 MEDICAL THERMOMETRY. 
 
 The art of taking and recording the temperature of the body is called 
 medical thermometry. The instruments used are known as clinical 
 thermometers. They are marked off in degrees upon the glass, and each 
 degree is subdivided into fifths, so that the readings may conveniently 
 be recorded in fractions of the decimal system. The thermometers com- 
 monly used in the United States and Great Britain are marked in degrees 
 of Fahrenheit's scale; those used in Europe are graduated according to the 
 Centigrade scale. The scale of Reaumur is rapidly going out of use, but is 
 still employed in some parts of Europe. On the scale of Fahrenheit the 
 distance through which the mercury rises from zero to the boiling-point of 
 water is divided into two hundred and twelve degrees, of which the thirty- 
 second marks the melting-point of ice. Between the melting-point of ice 
 and the boiling-point of water there are one hundred and eighty degrees 
 (32° + 180° = 212° F.). The melting-point of ice is taken as zero in the 
 Centigrade scale and in that of Reaumur, but in the Centigrade the boiling- 
 point of water is at one hundred (100° C), while in Reaumur's it is at 
 eighty (80° R.). The relation of the three scales to each other is, therefore, — 
 
 R. 
 
 4 
 
 To convert recordings of the Fahrenheit scale into Centigrade degrees, — 
 Subtract 32, multiply by 5, and divide by 9; thus: 98.6 — 32 = 66.6x5 
 
 = 333.0 - 9 = 37. That is, 98.6° F. = 37° C. 
 
 To convert Centigrade degrees into Fahrenheit degrees, — 
 
 Multiply by 9, divide by 5, and add 32; thus 37X9 = 333-5 = 66.6 + 
 
 32 = 98.6. That is, 37° C. = 98.6° F. 
 
 The Centigrade scale is more convenient than that of Fahrenheit, 
 
 and many physicians in this country prefer to use it. The following table 
 
 of approximate equivalents may prove of use: 
 
 96.0° F. 
 
 = 35.5° C. 
 
 101.3° F. 
 
 = 38.5° C. 
 
 106.7° F. 
 
 =41.5° C. 
 
 96.8° F. 
 
 = 36.0° C. 
 
 102.0° F. 
 
 = 38.9° C. 
 
 107.0° F. 
 
 = 41.6° C. 
 
 97.8° F. 
 
 = 36.0° C. 
 
 102.2° F. 
 
 = 39.0° C. 
 
 107.6° F. 
 
 = 42.0° C. 
 
 98.0° F. 
 
 = 36.6° C. 
 
 103.0° F. 
 
 = 39.4° C. 
 
 108.0° F. 
 
 = 42.2° C. 
 
 98.6° F. 
 
 = 37.0° C. 
 
 103.1° F. 
 
 = 39.5° C. 
 
 108.5° F. 
 
 = 42.5° C. 
 
 99.0° F. 
 
 = 37.2° C. 
 
 104.0° F. 
 
 = 40.0° C. 
 
 109.0° F. 
 
 = 42.8° C. 
 
 99.5° F. 
 
 = 37.5° C. 
 
 104.9° F. 
 
 = 40.5° C. 
 
 109.4° F. 
 
 = 4.3.0° C. 
 
 100.0° F. 
 
 = 37.8° C. 
 
 105.0° F. 
 
 = 40.5° C. 
 
 110.0° F. 
 
 = 43..3° C. 
 
 100.4° F. 
 
 = 38.0° C. 
 
 105.8° F. 
 
 = 41.0° C. 
 
 111.2° F. 
 
 = 44.0° C. 
 
 101.0° F. 
 
 = :3S.3° C. 
 
 106.0° F. 
 
 = 41.1° C. 
 
 
 
 53 
 
54 MEDICAL DIAGNOSIS 
 
 Seasoning. — As thermometers are liable after a time to give readings 
 that are slightly too high, in consequence of the gradual contraction of the 
 glass of which they are formed, it is necessary at long intervals carefully to 
 compare them with a standard instrument. This is done as a matter of 
 business at the public observatories, to which any instrument-maker will 
 send them. This contraction of the glass is called "seasoning," and goes 
 on very slowly. After two or three years it practically comes to an end, 
 and the thermometer is then seasoned. 
 
 Description of Thermometers. — Clinical thermometers as at present 
 made are of the kind known as maximum, or self-registering; that is, a 
 small portion of the mercury is separated from the main bulk of it, or 
 separates itself from it as it contracts, by reason of a device in the twist of 
 the tube, in such a way that it remains in position in the tube when the 
 temperature falls, until shaken down, and thus indicates the highest tem- 
 perature reached during the observation. The separated portion of the 
 mercury is known as the "index." The reading is taken from the upper 
 end of the index, which is then shaken down bv a quick motion of the wrist, 
 such as is made in cracking a whip, the thermometer being held by its 
 upper end. Before taking the temperature the index should be below 
 95°. The best clinical thermometers are now made with a curved surface, 
 which, acting as a lens, magnifies the width of the mercury; and with a 
 flattened back, which lessens the danger of breakage from rolling. 
 
 Technic. — The object being to measure the internal temperature, 
 the thermometer must be placed in such a position that the tissues of 
 the body completely surround its bulb. The positions available are the 
 armpit, or axilla, the mouth, the vagina, and the rectum. The fold of 
 the groin, when the thigh is bent up or flexed over the abdomen, is in 
 infants also occasionally used; but this locality is less satisfactory than 
 any of the others. 
 
 The axilla is usually selected. If very moist, it should be dried with 
 a towel before the instrument is introduced; or, if dry and harsh, it must 
 be bathed with warm water and then dried. There is no difference in the 
 temperature of the two armpits under ordinary circumstances. The bulb 
 of the instrument must be placed deeply in the hollow and the arm brought 
 well across the chest. Care must be taken that no fold of clothing inter- 
 fere with the contact of the instrument with the skin. Some thermometers 
 are more sensitive than others; that is, they act more quickly. The mer- 
 cury rises rapidly at first, then more slowly. Thick thermometers require 
 five minutes to record the maximum temperature, but the best instruments 
 now made reach the highest point in about two ininutes. In the rectum or 
 vagina less time is required. 
 
 When the temperature is taken in the mouth the bulb must be placed 
 under the tongue and the lips closed about the stem, the patient breathing 
 through his nose. It is an excellent plan to dip the instrument in water 
 and wipe it with a clean napkin in the presence of the patient both before 
 and after using it in the mouth. It is not safe to take the temperature in 
 the mouth either in young children or in conditions of delirium. When the 
 patient is in an insensible state, or when doubts arise as to the correctness 
 of an axillary observation, the rectum or the vagina may be used for apply- 
 
MEDICAL THERMOMETRY. 55 
 
 ing the thermometer, and with self-registering instruments this plan 
 involves no exposure of the person. In European countries the common 
 custom is to take the temperature in the rectum. In restless children 
 care must be taken to prevent the instruments being broken, and in all 
 cases to prevent a short thermometer from slipping entirely into the bowel, 
 from which it might be difficult to extract it. The temperature may be 
 rapidly taken in unmanageable children by means of an old-fashioned 
 thermometer which is not self-registering, by cautiously warming it until 
 the mercury reaches a very high point, say 108°, and then quickly placing 
 it in the armpit. The mercury falls rapidly to the temperature of the 
 patient's body and then stops. 
 
 Frequency. — It is desirable to take the temperature at least twice 
 daily, the best times being between seven and eight in the morning and 
 about eight in the evening. The observations must be repeated at the same 
 hours each day. In cases characterized by great or sudden variations of 
 temperature, by very high temperature, or when the influence of treat- 
 ment upon the fever is being closel}^ watched, observations must be made 
 at shorter intervals of time, and it may become necessary to take the 
 temperature as often as every hour. 
 
 Abnormal Temperatures. 
 
 The temperature in disease may range below or above the normal. 
 Sudden falls of temperature in fever are very significant; just as are 
 abrupt rises from the temperature of health. The following terms are 
 used to indicate the general condition of the patient in abnormal 
 ranges of temperature: 
 
 Below the Normal. F. C. 
 
 a. Temperature of collapse Below 96.5° 35.8° 
 
 h. Subnormal temperature 96.5°— 98° 35.8°— 36.7° 
 
 c. Normal temperature 98° — 99.5° 36.7°— 37.5° 
 
 Above the Normal. 
 
 d. Subfebrile temperature 99.5°— 100.5° 37.5°— 38.1° 
 
 e. Moderate febrile temperature f 100.5°— 102° a.m. 38.1°— 38.9° 
 
 (Mild pyrexia) \ 102.2°— 103° p.m. 39° —39.5° 
 
 /. High febrile temperature i 102° —104° a.m. 38.9° — 10° 
 
 (Severe pyrexia) \ 104° —105.8° p.m. 40° —41° 
 
 g. Intense febrile temperature 1 jQr qo 1 1 qo 410 40 00 
 
 (Hyperpyrexia) j 
 
 The range of deviation from the normal within the limits of which 
 life can be maintained for brief periods is comprised between 92° F. 
 and 110° F. A temperature of 95° F. on the one hand or of 106° F. 
 on the other, already indicates great danger, especially if it be prolonged, 
 and beyond these limits in both directions the danger to life speedily 
 becomes extreme. 
 
 (a) Temperature of Collapse or Shock. — A considerable and rapid 
 fall of temperature attends the collapse which sometimes occurs during or 
 towards the close of some of the essential fevers. In enteric fever this 
 condition may be produced by hemorrhage, or by sudden peritonitis due 
 to perforation, or in consequence of sudden failure of the heart. The last 
 
56 MEDICAL DIAGNOSIS. 
 
 of these accidents is liable to occur in any very grave case of fever, 
 and occasionally follows the critical fall of temperature which occurs in 
 pneumonia, relapsing fever, and more rarely in other febrile diseases. 
 
 Very low axillary temperatures are met with in the stage of collapse 
 in the algid or cold stage of cholera, the internal temperature as indicated 
 by the vagina or rectum remaining high. Great depression of the general 
 temperature occurs in the collapse produced by various poisons, and espe- 
 cially by large quantities of alcohol. The temperature is apt to fall 
 considerably below the normal in ordinary deep alcoholic intoxication, 
 especially if the patients have been exposed to cold and wet. 
 
 (b) Subnormal Temperature. — This condition attends considerable 
 losses of blood; starvation from any cause; the wasting of certain of the 
 chronic diseases, such as cancer of various organs; some diseases of the 
 brain and spinal cord and the later stages of chronic diseases of the lungs 
 and heart, especially when accompanied by dropsy. 
 
 The temperature is very apt to reach subnormal ranges in the 
 morning for a few days at the termination of febrile disorders. 
 
 (c) Normal Temperature. — If in the course of a continued fever, as 
 enteric, the temperature, which has been elevated two or three degrees or 
 more, suddenly falls to normal or near it, though not below, this in itself 
 is significant of something wrong, and may even acquire the importance 
 of the "temperature of collapse," as indicating internal hemorrhage, 
 perforation, or failure of the heart. 
 
 (d) Subfebrile Temperature. — Slight elevations of temperature often 
 accompany trifhng and transient disturbances of the general health, 
 especially in children. They are also observed at the beginning of 
 gradually developing fevers, as enteric, and at the close of slowly subsid- 
 ing febrile conditions. In obscure chronic cases they are of importance 
 as indicating the existence of actual disease which may not manifest its 
 ordinary symptoms. 
 
 (e) Moderate Febrile Temperature. — When the morning temperature 
 reaches 101°-102° F. and the evening shows a further increase of one or 
 two degrees, we have to do with actual fever. So long, however, as the 
 temperature does not exceed these limits, there is no serious danger from 
 the fever process itself. 
 
 (f) High Febrile Temperature. — When the temperature in the morning 
 is above 102°-104° F. and in the evening reaches or ranges higher than 
 104.5°, the case becomes serious from the intensity of the fever alone, 
 and active treatment becomes imperative. High fever is unattended by 
 immediate danger to life if it be transient, but when prolonged it is ominous. 
 A temperature of 105° or even 107° in the hot stage of an ague, when the 
 whole attack lasts but a few hours, is much less dangerous than the same 
 temperature occurring, even for a short time, in the course of one of the 
 continued fevers, when the patient's powers of resistance are called upon 
 to withstand some degree of fever for several days or weeks. 
 
 (g) Hyperpyrexia, or Intense Febrile Temperature. — The temper- 
 ature reaches 105.8° and continues to rise, or at all events does not fall. 
 The condition is one of extreme and imminent danger to life. The resources 
 of the art of medicine are put to their severest test. Hyperpyrexia often 
 
MEDICAL THERMOMETRY. 57 
 
 supervenes with great suddenness. Not a moment is to be lost. The most 
 prompt and radical measures to reduce the temperature of the body too 
 often fail to avert the fatal result. This condition has been encountered 
 after injuries to the brain and to the upper part of the spinal cord; in lock- 
 jaw; in sunstroke, and very often in the infectious diseases, especially 
 scarlet fever and pneumonia. It sometimes occurs in rheumatic fever, 
 especially after the intensity of the symptoms has begun to subside, or 
 even when the patient is apparently almost well. Hyperpyrexia is often 
 one of the indications of approaching death. Hence, in certain cases the 
 futility of treatment. In such cases a temperature of 110° to 112° is some- 
 times seen. The temperature sometimes continues to rise slowly for an 
 hour or two after death. 
 
 The thermometer may be made to indicate a temperature much higher 
 than that of the patient's body, by friction, or by being slipped against a 
 poultice or hot-water bag, or into a cup of tea, when the attention of 
 the nurse is given to other duties. These tricks are sometimes played by 
 hysterical girls. They are readily detected by repeated observations under 
 the eye of the attendant. A number of cases have been recorded in the 
 medical journals in which excessively high temperatures — 120°, 150°, 
 even 170° F. — have been noted and apparently verified by repeated and 
 most careful observations. Many of the patients have subsequently been 
 found to be very clever pretenders and tricksters, but the method by 
 which the high temperatures have been recorded has not been explained. 
 In such cases the temperature should be taken in several different regions, 
 axilla, mouth, rectum, etc., at the same time, and the temperature of the 
 urine when voided. 
 
 Transitory Variations. — The temperature of a fever patient may be 
 somewhat affected by excitement, fatigue, or exposure. Hence hospital 
 patients often show for a few hours after admission a temperature higher 
 than subsequently, or, if they have been exposed to cold, lower than really 
 corresponds to their condition. 
 
 It is a peculiarity of the state of convalescence from the acute fevers 
 that the temperature, though normal, is disturbed by trifling causes, and 
 may be made to rise two or three degrees by the first visit of a friend, the 
 first solid food, or even by sitting up. Such rises are usually very brief, 
 the temperature quickly falling again to normal. They occasion uneasiness 
 lest they be the beginning of a relapse. On the other hand it occasionally 
 happens that, though all the other symptoms have disappeared and the 
 patient is almost well, the temperature remains subfebrile, and the patient 
 is for that reason alone kept in bed. In such cases all traces of fever vanish 
 upon cautiously allowing the patient to sit up an hour or so each day. 
 
 Surface Thermometry. 
 
 This method is of inferior value for diagnostic purposes. The 
 bulb consists of a fine coil at right angles to the tube and forming an 
 expanded base for it. Observations may be taken at the same time 
 in corresponding positions on both sides of the body. The general 
 temperature must be noted. 
 
58 MEDICAL DIAGNOSIS. 
 
 Normal surface temperature (Kunkel). Temperature of room 68° F. — 20° C. 
 
 F. C. 
 
 Forehead 93.38-93.92° 34.1-34.4° 
 
 Cheek under the zygoma 93.92° 34.4° 
 
 Tip of ear "; 83.84° 28.8° 
 
 Back of hand 90.5 -91.76° 32.5-33.2° 
 
 Hollow of the hand (closed) 94.64-95.18° 34.8-35.1° 
 
 Hollow of the hand (open) 93.92-94.64° 34.4-34.8° 
 
 Forearm 92.66° 33.7° 
 
 Forearm (higher) 93.74° 34.3° 
 
 Sternum 93.92° 34.4° 
 
 Pectorales 94.46° 34.7° 
 
 Right iliac fossa 93.92° 34.4° 
 
 Left ihac fossa 94.28° 34.6° 
 
 Os sacrum 93.56° 34.2° 
 
 Eleventh rib (back) 94.1° 34.5° 
 
 Tuberosity of ischium 89.6° 32.0° 
 
 Upper part of thigh 93.56° 34.2° 
 
 Calf 92.48° 33.6° 
 
 The temperature of the skin is slightly higher over an artery than at 
 some distance from it. over muscle than over sinew, over an organ in activity 
 than when at rest, in the frontal than in the parietal region of the head, 
 and on the left side of the head than on the right. 
 
 Local elevation above the general temperature has been noted on the 
 surface of the head in cases of mania and meningitis. Local elevation of 
 the temperature has also been observed in cerebral tumor and abscess. 
 A local rise of temperature also occurs over the painful points in some 
 cases of neuralgia and in areas of superficial inflammation. The surface 
 temperature is increased in the region corresponding to the exudate in 
 croupous pneumonia. Irregularly distributed areas of elevated surface 
 temperature sometimes occur in hysterical persons. 
 
 Subnormal temperature may be observed in a limb from which the 
 blood supply is cut off by the tourniquet or obstruction of the main artery, 
 in an oedematous or cj^anosed part, and in gangrenous areas. Weir Mitchell 
 called attention to the effect of posture upon local temperature. He found 
 the surface of the dorsum and sole of the foot 0.4° C. to 1° C. cooler in the 
 erect than in the recumbent posture. 
 
 Charts. — The temperature must be recorded at once. At the same 
 time a record of the pulse-beats and movements of respiration per minute 
 is to be made. They are to be carefully counted while the thermometer 
 is in position. 
 
 Ruled sheets, called "temperature charts," or "clinical charts." 
 are sold in the shops for this purpose. The form here shown will be found 
 very convenient. It may be so kept with little trouble as to preserve in a 
 compact form all the important facts of an acute case, and is equally useful 
 in hospital and in private practice. The ruled space is arranged for twenty- 
 one days by vertical lines, the weeks being divided by heavy lines. The 
 space for each day is again subdivided for the morning and evening record, 
 as indicated by the M and E. At the left margin the purposes of the spaces 
 formed by the transverse rulings are indicated. At the top the number 
 of movements of the bowels; immediately below the quantity of urine 
 passed, which may be recorded in fluidounces or cubic centimetres; then 
 the scale of Fahrenheit, with the equivalent Centigrade opposite on the right 
 
MEDICAL THERMOMETRY. 
 
 59 
 
 margin. The coarse horizontal Une at 98.4° F. indicates approximately 
 the normal. At the bottom are, first, spaces for each day of the disease, 
 then similar spaces cUvided by a diagonal line for morning (upper, left 
 triangle) and for the evening (lower, right) pulse-rate; below these again 
 corresponding spaces for the respiration-rate, and at the bottom of the 
 chart spaces for the date or day of the month. 
 
 Important clinical facts, as "hemorrhage," "convulsions," "sup- 
 pression of urine," etc., may be noted at the time of their occurrence 
 between the vertical lines on the right or upper side of the chart in the 
 position indicated by the arrows, under the words "clinical memoranda." 
 
 
 
 
 
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 Copyryjht. USB, fry Jnmn C. WiU<m. M.D. FuUv^'d fcv J- B L<ppinrc^ r.--r.T^.^, }'hU.^dilpK>a. /•* 
 
 
 Fig. 29. — Clinical chart. Actual size 28x21 cm. 
 
 While changes in treatment, and in particular such temporary changes as 
 are made necessary by accidents, like hemorrhage, convulsions, or sup- 
 pression of urine, may be noted at the left or lower side under the words 
 "details of treatment," as shown by the arrows. 
 
 The previous history and the condition of the patient when first seen 
 may be written on the back of the chart. 
 
 The spaces corresponding to a degree of the Fahrenheit scale are divided 
 into fifths. The temperature, as observed, is designated by a dot in the 
 appropriate position. These dots joined by ruled lines form a zigzag line, 
 called the temperature curve. It is usual to form the general curve of the 
 case by means of the regular morning and evening temperatures, and to 
 indicate the result of observations made at other hours by dots in the 
 appropriate positions, with figures and letters showing the hour at which 
 they were made; thus, 12 noon, 3 p.m., or 6 a.m. 
 
60 MEDICAL DIAGNOSIS. 
 
 It is customary to join the general curve or range by lines drawn with 
 black ink; the hourly or three-hour observations by lines drawn with 
 red ink. If the fever be prolonged beyond three weeks two or more charts 
 may be pasted together. These charts thus kept are not only of value for 
 preservation: they are also of immediate use as showing at a glance and 
 with precision the facts of the case at every period from its coming under 
 observation, the course it is running by a comparison of the symptoms 
 day by day, and in a general way the effects of treatment, the changes of 
 which are fully presented. Especially are they valuable in fevers in ena- 
 bling us to watch the course of the temperature, which is a conspicuous 
 part of the natural history of the disease and conforms in most of the acute 
 infections to a type not only in its daily fluctuations but also in its duration. 
 
11. 
 
 PHYSICAL DIAGNOSIS. 
 
 General Considerations. — Physical diagnosis is the method of discrim- 
 inating diseases by the direct aid of the special senses, namely the eye, 
 the ear, the touch. The diagnostic criteria thus obtained are known as 
 physical signs. They depend upon the physical nature and structure of 
 the organs or parts examined and vary with the changes caused by disease. 
 Hence they are divided into tw^o groups — normal or healthy, and abnormal 
 or morbid physical signs. As they bear a direct relation to the anatomical 
 condition of structures, their form, contour, density, elasticity, and so forth, 
 and similar physical conditions may be present in different diseases, and as 
 morbid processes may arise in the absence of perceptible alterations in 
 parts, it is evident that physical signs taken singly are not diagnostic of 
 particular diseases. They reveal the anatomical condition but not the 
 morbid process causing that condition, and attain their full value in diag- 
 nosis only when considered in relation to other signs and symptoms and 
 the clinical history of the case. 
 
 Pathognomonic signs are those supposed to be diagnostic of particular 
 diseases. In view of the facts just mentioned, the use of the term pathog- 
 nomonic in this sense is erroneous in theory and misleading in practice. 
 A physical sign is the manifestation of a normal or morbid physical condi- 
 tion, not of health or disease. It is most important for the student to bear 
 this fact clearly in mind. Signs at one time regarded as pathognomonic, 
 as for example the crepitant rale in pneumonia, are now known to occur in 
 other conditions, as oedema of the lungs and partial atelectasis. 
 
 Physical diagnosis is constantly employed in the study of general mala- 
 dies and in local diseases of all parts of the body, but it is of special service 
 in the investigation of diseases of the respiratory and circulatory organs. 
 
 Methods. — The methods of physical diagnosis are inspection, palp.\- 
 
 TION, MENSURATION, PERCUSSION, — including RESPIRATORY PERCUSSION, 
 PALPATORY PERCUSSION, and AUSCULTATORY PERCUSSION, — and AUSCULTA- 
 TION. In the examination of patients these methods are used systemati- 
 cally and in succession, the signs elicited by one serving to confirm, extend, 
 or control the knowledge obtained by the others. 
 
 Technic. — The physical examination must under all circumstances be 
 conducted in a routine manner. More errors in physical diagnosis arise from 
 want of system than from want of knowledge. When the patient is in bed. 
 the bared chest, abdomen, and back must be in turn examined by the several 
 methods. Under some circumstances a towel or a single thickness of rai- 
 ment may be used as a covering, especially in percussion and immediate 
 auscultation. For inspection and jDalpation the surface should be bared. 
 
 The same rules apply to the examination of ambulatory patients. 
 In all cases the outer clothing should be removed. Physical signs cannot 
 be elicited through heavy clothing, starched linen, or the corset; while 
 
 61 
 
62 MEDICAL DIAGNOSIS. 
 
 silk, stiff shirt fronts, and the braces cause upon deep respiratory move- 
 ments crackling and friction sounds that have nothing to do with the 
 organs within the chest. In all cases the examination must be conducted 
 with tact, judgment, and due regard for the sensibilities of the patient. 
 The recognition of abnormal physical signs involves a familiar knowl- 
 edge of those which are normal and their variations within the bounds of 
 health and of the anatomy and physiology of the organs or parts examined. 
 Equally necessary is a ready knowledge of the pathological changes upon 
 which abnormal signs depend. The skilled diagnostician cultivates the 
 habit of seeing with his mind's eye the changes in structure caused by 
 disease. A long apprenticeship in the post-mortem room is an essential 
 preparatory course for good work at the side of the bed. 
 
 INSPECTION. 
 
 This method of physical diagnosis is of the widest apphcation in the 
 study of disease. In many cases a provisional, in some a positive diagnosis 
 may be made upon a careful study of the external clinical phenomena by 
 inspection alone. The facies hepatica, emaciated neck and limbs, and 
 enormously distended abdomen in cirrhosis of the liver, the enlarged parot- 
 ids, disfigured countenance, and projecting lobule of the ear in mumps, 
 the unilateral flushing and jerky dyspnoea in croupous pneumonia, and 
 the rash in the eruptive diseases, tell their own tale. In a narrower and 
 more technical sense inspection is especially of value in the diagnosis 
 of diseases of the thoracic and abdominal organs. 
 
 The clothing must be removed. The light must be good. The skilled 
 diagnostician makes use now of direct light, by which extensive surfaces 
 are fully illumined; now of oblique light, by which local elevations and 
 depressions are accentuated and pulsations are marked by moving shadows. 
 
 By inspection we obtain information in regard to the size, form, or 
 contour, the appearance of the surface, and the movements of the thorax 
 and abdomen. 
 
 Inspection of the Thorax. 
 
 The Size. — The size of the chest is determined by the volume of its 
 contents. Within the limits of health there are wide variations. A seden- 
 tary life tends to shallow breathing and small lungs. The chest then con- 
 forms to the inspiratory type. The anteroposterior diameter is short, 
 the upper intercostal spaces wide, the lower narrow, the costal angle acute. 
 We speak of such a chest as shallow. Active, out-door occupations favor 
 habitual deep breathing and increase in the size of the lungs. The chest 
 now conforms to the expiratory type. The anteroposterior diameter is 
 relatively long, the upper intercostal spaces narrow, the lower wide; the 
 costal angle is obtuse. Such persons are deep chested. Diseases which 
 diminish the size of the lungs, as chronic tuberculosis and fibroid phthisis, 
 correspondingly reduce the size of the thorax, while so-called pseudo- 
 hypertrophic emphysema greatly increases its size. But these changes 
 are accompanied by definite changes in form. Excessive subcutaneous 
 fat sometimes gives rise to an apparent increase in the size of the chest. 
 
PHYSICAL DIAGNOSIS: INSPECTION. 
 
 63 
 
 The Form. — The form of the chest varies with its size. In infancy 
 and early childhood it is somewhat cylindrical, — that is, its anteroposterior 
 diameter and its transverse diameter are nearly the same, — and the 
 respiration is chiefly diaphragmatic. In adults the cross section of the 
 trunk is oval and symmetrical. Upon deep inspiration the anteroposterior 
 diameter of the chest is increased; on forced expiration it is diminished. 
 
 Deformities. — The general 
 deformities in childhood are com- 
 monly due to respiratory obstruction 
 in the upper air-passages, as from 
 adenoid growths in the nasopharynx, 
 enlargement of the tonsils; or in the 
 lungs, as in bronchopneumonia or 
 phthisis. Rickets plays an impor- 
 tant part. In adult life they are 
 commonly caused by fibroid changes 
 in the lungs, pulmonary tuberculosis 
 and emphysema. Unilateral and 
 local deformities are caused by pleu- 
 ral effusions, the retraction which 
 follows the resorption or removal of 
 such effusions, hypertrophy of the 
 heart, and aneurismal or other intra- 
 thoracic tumors. These abnormal 
 modifications in form are more 
 marked when they occur early in 
 life. The following deviations in 
 form are to be considered: 
 
 (a) The Alar or Pterygoid Chest. 
 — The chest is unnaturally small and 
 narrow. The inner borders of the 
 scapulae project like budding wings, 
 the ribs are extremely oblique, the 
 shoulders droop, the neck and chest 
 appear preternaturally elongated, 
 the head is carried unduly forward, 
 and the costal angle is acute. This 
 form of chest is sometiones described 
 as the "paralytic chest." Persons suffering from pulmonary tuberculosis 
 frequently present this form of chest, but it may also occur in poorly 
 nourished individuals who are not phthisical. 
 
 (b) The Rhachitic Chest. — The sternum may project, giving rise to 
 the deformity known as pigeon breast. The sides of the chest are flattened 
 and curve forward to the prominent sternum, as the sides of a boat to the 
 keel — pectus carinatum. From the base of the ensiform cartilage a broad 
 shallow depression or groove passes downward and outward to the infra- 
 axillary region — Harrison's furrow. In some instances the cartilages 
 of the ribs lose their curve and become straight, causing the chest to be 
 quite flat in front instead of being rounded. In others there is a shallow 
 
 Fig. 
 
 30. — Alar deformity of chest. — German 
 Hospital. 
 
64 
 
 MEDICAL DIAGNOSIS. 
 
 longitudinal groove on each side of the front of the chest, a little external 
 to the sternum and nearly parallel to it. The remarkable deformity known 
 as FUNNEL BREAST sometimes but by no means always is due to rickets. 
 It consists in a deep and rather abrupt crater-like depression in the region 
 of the base of the ensiform cartilage. Not rarely there may be felt and 
 sometimes seen a line of nodular thickenings along the chondrocostal 
 articulations on each side, known by the fanciful name of the rhachitic rosary. 
 
 (c) The Barrel Chest.— The 
 deformity characteristic of emphy- 
 sema is very striking. The antero- 
 posterior diameter is greatly 
 increased. The thorax is in a state 
 
 Fig. 31.- — Paralji;ic chest. 
 
 Fig. 32. — Funnel-shaped deformity of chest. 
 — JeSerson Hospital. 
 
 of distention greater than that produced in health by the deepest inspira- 
 tion. It is arched before and behind. The manubrium and body of the 
 sternum are sometimes bent at an angle — angulus Ludovici. The shoulders 
 are high, the neck short, and the costal angle very obtuse. Dorsal kyphosis 
 due to the carrying of burdens upon the shoulders, to advancing years, or 
 to vertebral caries may simulate the barrel-shaped chest of emphysema, 
 (d) Deformities of the Spine. — Curvatures and twisting are very 
 common. The slighter forms are often overlooked. They may be recog- 
 nized upon careful inspection of the bare back, the spinous processes being 
 marked by a dermatographic pencil. Marked curvatures in which rotary 
 displacements are prominent derange the relations of the thoracic viscera 
 to the bonv landmarks and render the physical examination of the chest 
 
PHYSICAL DIAGNOSIS: INSPECTION. 
 
 65 
 
 difficult and the signs uncertain. The cardiac impulse may be displaced 
 upward or to the left; abnormal bulging may simulate aneurismal or other 
 intrathoracic tumor and areas of atelectasis with compensatory emphy- 
 sema occur. Abnormal rigidity of the spine may be due to spastic contrac- 
 tion of the muscles in Pott's disease or to spondylitis deformans. When 
 ankylosis has developed the spine is persistently rigid. These signs may be 
 recognized upon attempts to bend 
 forward or backward or to rotate the 
 shoulders while the pelvis is held 
 fixed. An examination of the verte- 
 bral column forms part of every 
 routine examination of the chest. 
 
 Unilateral changes in the shape 
 of the chest consist in diminution 
 and enlargement. 
 
 Unilateral Diminution. — Flatten- 
 ing of one side of the chest is a sign 
 of chronic pulmonary tuberculosis 
 of the corresponding lung, fibrosis 
 of one lung, or a pleural effusion 
 which has undergone resorption 
 or been cured by operation. The 
 circumference and anteroposterior 
 diameter are diminished; the bilat- 
 eral diameter is increased; the side 
 is angular and flattened before and 
 behind; the upper intercostal spaces 
 are widened, the lower narrowed; 
 the shoulder is lowered and there 
 is lateral curvature of the spine, the 
 convexity being towards the oppo- 
 site side. The vicarious enlargenient 
 of the sound lung gives rise to 
 marked differences in the circum- 
 ference of the two sides. When the 
 
 deformity is due to tuberculous disease of the upper lobe, the flattening is 
 more marked in the upper region of the chest; when to old pleurisy it is 
 more marked at the base. Unilateral flattening of the chest is attended 
 by pleural adhesions. If obstruction of the main bronchus occurs in child- 
 hood, the resulting collapse of the lung may cause an acute unilateral 
 flattening of the chest. Lateral spinal curvature may simulate diminution 
 of the chest from pulmonary disease. 
 
 Unilateral Enlargement. — This deformity of the chest is a sign of 
 vicarious enlargement of one lung as a result of chronic disease of its fellow, 
 pleural effusion, large hsemothorax, pneumothorax, and rarely of rapidly 
 growing malignant disease. Pseudohypertrophic emphysema may in 
 rare instances involve one lung when the other has undergone fibroid changes 
 in consequence of previous di.sease. The enlarged side is rounder than the 
 other; its anteroposterior diameter longer; the intercostal spaces wide; 
 
 Fig. 33. — Emphysematous type of chest. — German 
 Hospital. 
 
66 
 
 MEDICAL DIAGNOSIS. 
 
 the shoulder raised and the spine curved laterally, the dorsal convexity 
 being towards the enlarged side. 
 
 The foregoing alterations in the form of the chest are very obvious 
 when the physician stands behind the seated patient and looks obliquely 
 over his shoulders and the front of his chest. 
 
 Intercostal Spaces. — In large pleural effusions and in pneumothorax 
 the normal depression of the intercostal spaces is obliterated and the 
 surface smooth as contrasted with the opposite side. Bulging of the inter- 
 costal spaces is rare. It may be seen at the base of the chest in large em- 
 pyema of long standing. 
 
 Fig. 34. — Deformity following the resorption of a pleural effusion. — German Hospital. 
 
 Local Changes. — Local changes in shape consist in (a) circumscribed 
 retraction or (b) prominence. 
 
 Local retraction is a sign of the following conditions: 
 
 Tuberculous Consolidation of a Portion of the Lung. — This is usual at the 
 apex and most obvious in the supra- and infraclavicular regions. It is 
 attended by pleural adhesions. 
 
 A Superficial Cavity. — Circumscribed depressions due to this cause 
 are often seen on the anterior surface of the chest near the sternal border 
 and extending over one or two intercostal spaces. Flattening in the postero- 
 lateral aspect of the chest opposite the spine of the scapula and below its 
 level is sometimes seen in pulmonary abscess. 
 
 Old Pleurisy. — A broad, shallow depression in the anterolateral region 
 at the base of the chest is common after pleural effusions. The funnel 
 breast sometimes follows unilateral pleurisy. This deformity in shoe- 
 makers has been attributed to the pressure of the last against the breastbone. 
 
PHYSICAL DIAGNOSIS: INSPECTION. 67 
 
 Local retraction in children may follow croup, bronchopneumonia, and 
 rickets. The deformities caused by these agencies are symmetrical and 
 have already been considered. 
 
 Local prominence is a sign of circumscribed pleural effusion, large 
 vomicae when distended with fluid, diaphragmatic hernia when congenital, 
 tumor of the lung or of the chest wall, mediastinal tumor, abscess of the 
 chest wall, and empyema necessitatis. In a considerable proportion of 
 healthy persons that region of the chest wall which overlies the heart ^ — 
 the precordial space — is slightly prominent. In children and occasionally 
 in adults prominence of the precordial space results from cardiac hyper- 
 trophy or pericardial effusion. The bulging occupies the space between 
 the third and seventh costal cartilages on the left side and the left mid- 
 clavicular line and the sternum. It may extend to the right nipple. Aneu- 
 rism of the arch of the aorta causes local bulging of the chest wall and in 
 rare instances aneurism of the de- 
 scending aorta may erode the ribs 
 and give rise to a circumscribed 
 tumor of the dorsal region to the 
 left of the spine. Inspection of the 
 back frequently reveals local prom- 
 inences of importance in diagnosis. 
 A sharp projection of the spinal 
 processes occurs in vertebral caries. 
 The inner borders of the scapulae 
 stand out prominently in the ptery- 
 goid chest. A congenital rounded 
 tumor in the middle line, translu- 
 
 r>on<- onrl T-iQrtNT- rorlnpihlo ic fViA FiG. 35.— Aueurism of the descending thoracicaorta; 
 cent; ana^ paruy reaUCipie, is tne perforation of chest wall.—Penna. Hospital. 
 
 sign of spina bifida. This defect of 
 
 development is frequently associated with other deformities, as hydro- 
 cephalus or club-foot. A dusky-red, brawny swelling, commonly in the 
 cervical region, discharging pus from several sinuses, is a carbuncle. It 
 occurs frequently in diabetes mellitus, and in all cases the urine should be 
 examined for sugar. Rounded or lobulated elastic tumors, painless and 
 usually movable, are fatty. They sometimes so closely resemble abscesses 
 as to require aspiration for the differential diagnosis. Abscesses appear 
 as fluctuating swellings as the result of caries of the vertebrae, usually 
 tuberculous, and may burrow in various directions. I have seen a large, 
 oblong tumor to the left of the dorsal spine formed by an aneurism of the 
 descending aorta, and a similar tumor in the left lumbar region which ]nil- 
 sated and was connected with a left-sided empyema. In disseminated 
 sarcoma of the skin the lesions are common on the back, appearing as 
 circumscribed nodular masses varying in size from a small shot to a walnut, 
 dark in color and mostly movable. 
 
 Surface. — The appearance of the surface of the chest only excep- 
 tionally yields, upon inspection, physical signs of importance. We note 
 emaciation or an abundant panniculus adiposus, jaundice, cyanosis and 
 pigmentation, the eruptions and scars of the exanthemata or of syphilis 
 or other chronic disease, enlargement of the superficial lymph-nodes at 
 
68 MEDICAL DIAGNOSIS. 
 
 the root of the neck and in the armpits, patches and lines of dilated 
 venules and dilated and tortuous venous trunks. The appearance of 
 linear patches of herpes in shingles — zona, herpes zoster — in the course 
 of the intercostal and lumbar nerves, often clears up the diagnosis 
 where there has been severe burning pain upon one side of the chest 
 or abdomen. 
 
 The Movements of the Chest. — Normal and abnormal types of 
 respiration will be considered in a subsequent section. Anomalous move- 
 ments that affect both sides of the chest occur in dyspnoea, inspiratory 
 dyspnoea, expiratory dyspnoea, Cheyne-Stokes respiration, exaggerated 
 thoracic, exaggerated abdominal breathing, and so on. 
 
 Abnormalh^ deep respiration in the absence of any apparent difficulty 
 either in inspiration or expiration is seen in diabetic coma. 
 
 In the emphysema of the aged and in earlier life in some cases of 
 hereditary syphilis and pulmonary tuberculosis, calcification of the costal 
 cartilages and associated changes in the ribs cause the walls of the chest to 
 move through a limited space as a whole — en cuirasse. 
 
 Unilateral modifications of the respiratory movements may consist of 
 (a) diminished expansion of one side or (b) increased expansion of one side. 
 
 (a) Diminished expansion of one side may involve the entire side, 
 as in large pleural effusion, pneumothorax, pneumonia involving the whole 
 of one lung, tuberculous consolidation of a lung, or tumor of the lung or 
 pleura. The afi^ected side is not only immobile but it is also distended and 
 altered in contour. In tuberculosis it is, however, usually contracted in 
 consequence of pleural adhesions and sclerotic changes in the lung. In 
 massive pneumonia it is almost immobile but not enlarged. Contraction 
 also occurs in the occlusion of a large bronchus from the presence of an 
 aneurism or other tumor. 
 
 In tuberculosis confined to the apex of one or both lungs there is failure 
 of expansion in the corresponding region of the chest. 
 
 Diminished unilateral expansion may be a sign of infradiaphragmatic 
 disease — on the right side, of an enlarged liver or hepatic tumor; on the 
 left, of an enlarged spleen or tumor in the splenic region. 
 
 In rare instances a hemiplegia or paralysis of one side of the diaphragm 
 or a diaphragmatic hernia may be the cause of diminished expansion of 
 one side of the chest. 
 
 Non-expansive inspiration is attended with retraction of the inter- 
 spaces. This sign is especially noticeable in the inframammary, the infra- 
 axillary, and the infraclavicular regions in partial atelectasis or collapse of 
 the lungs, in obstruction of the glottis as in pseudomembranous laryngitis, 
 oedema of the glottis, or pseudomembranous bronchitis such as occurs in 
 infralaryngeal diphtheria or in the diffuse atelectasis of bronchopneumonia. 
 Under those conditions both sides are involved. When a main bronchus 
 is occluded the sucking in of the intercostal spaces upon inspiration is 
 limited to the affected side. This phenomenon is caused b}^ intrathoracic 
 negative pressure during inspiration, in consequence of which the soft 
 parts of the thoracic wall yield to the external pressure of the atmosphere. 
 
 (b) Increased expansion of one side of the chest is usually com- 
 pensatory. It occurs when the respiratory movement of the opposite side 
 
PHYSICAL DIAGNOSIS: INSPECTION. 69 
 
 is interfered with by pathological conditions of the lung, as tuberculosis, 
 pneumonia, fibrosis and atelectasis from other causes, or by pleural effu- 
 sion, pneumothorax, or tumor, and thus becomes a sign of tho.se conditions. 
 
 The Diaphragm Phenomenon — Litten's Sign. — The diaphragm ap- 
 proaches the wall of the thorax in expiration and comes into contact with 
 it at the end of the act. It is separated or peeled off from it in inspiration. 
 These movements are rendered visible by the procedure suggested by 
 Litten in 1892. The patient is placed upon his back with his chest bared 
 and his feet toward a window. Cross lights are excluded. If the examina- 
 tion is made at night, a strong light held at the foot of the bed .serves' the 
 purpose. The observer stands at a little distance and views the surface 
 of the lower part of the chest obliquely. Upon deep inspiration a short, 
 narrow, horizontal shadow is seen to move from the sixth intercostal space 
 downward over two or more interspaces upon both sides. During expira- 
 tion this shadow moves up again to the line from which it started but is 
 less distinct. It may in some cases be seen in the epiga.strium. This phe- 
 nomenon is practically present in all healthy persons, the only exceptions 
 being due to abnormal thickness of the chest walls and inability on the 
 part of the patient to make full, deep respiratory movements. It is best 
 observed in young, lean, muscular persons. The extent of the movement 
 of the shadow in normal chests is about two and a half inches; upon forced 
 breathing slightly more than this. 
 
 The descending shadow is due to the undulation of the chest wall 
 caused by the separation of the diaphragm from its contact with the lower 
 part of the thorax and the descent of the border of the lung into the wedge- 
 shaped space between them during inspiration, and the reverse shadow 
 by the retraction of the lung and the coming together of the diaphragm 
 and chest wall during expiration. 
 
 The shadow is absent upon the affected side in pneumonia of the 
 lower lobe, pleural effusion, extensive pleural adhesions, intrathoracic 
 tumors, and marked emphysema. In these conditions the diaphragm 
 does not approach and recede from the chest wall and the undulations 
 which cause the shadow do not occur. The extent of the movement is 
 lessened in conditions of debility, slight emphysema, and upon the affected 
 side in phthisis. In the latter condition there are probably two factors in 
 restricting the movement, diminished pulmonary expansion and limited 
 pleural adhesions. 
 
 Litten's sign is present in hepatic and splenic enlargements and in 
 subphrenic abscess and may be of service in the differential diagnosis 
 between those conditions and pleural effusion. In very large ascites it 
 may be absent. 
 
 The Movements of the Heart. — Inspection yields important phys- 
 ical signs in regard to the heart and great vessels in health and disease. 
 These signs relate to (a) the cardiac impulse; (b) other movements of 
 the surface having the cardiac rhythm: (1) pulsations at the root of 
 the neck, (2) aneurism. (3) tumors in contact with large arterial trunks, 
 (4) pulsating empyema. 
 
 (a) The Cardiac Impulse. — With the systole of the heart tiiere is 
 seen in most norma! chests an outward movement or pulsation in a limited 
 
70 MEDICAL DIAGNOSIS. 
 
 area in the fifth left intercostal space just beyond the parasternal line — 
 the visible impulse or so-called apex-beat of the heart. In infants and young 
 children, owing to the proportionately greater size of the liver, the impulse 
 is often visible as high as the fourth interspace, while in aged persons it 
 may normally be as low as the sixth interspace. It is occasionally absent 
 in healthy persons, especially those having deep chests and capacious 
 lungs. It invariably takes place at the time of the contraction of the 
 ventricles. The most important factor in the production of the impulse 
 is the change in the direction of the long axis of the ventricles against the 
 resistance of the chest wall. It is a mistake to speak of it as a "blow" 
 or "impact " against the wall of the chest, since that part of the heart which 
 causes it, namely, the apex of the right ventricle, is already in contact with 
 the wall in diastole and simply becomes more tense and prominent during 
 systole. Around the point where the soft parts are protruded by the impulse 
 they are very slightly retracted at the time of its occurrence — the "negative 
 impulse." This is clue to the lessening size of the contracting ventricles, 
 which, being air-tight within the cavity of the chest, must be followed 
 down under the pressure of the atmosphere by the elastic and yielding 
 lungs and the somewhat yielding intercostal tissues. A clear conception 
 of this fact renders intelligible the systolic recession of the chest wall 
 occasionally seen in emaciated persons in the third, fourth, or even the fifth 
 intercostal space, close to the left border of the sternum. 
 
 Since the normal impulse is caused by the apex of the right ventricle 
 and not by that of the left, which extends further dow^nward and is sepa- 
 rated from the wall of the chest by a tongue-like projection of the lower 
 lobe of the left lung, the apex of the right ventricle is sometimes spoken 
 of as the "clinical apex" and that of the left ventricle as the "anatomical 
 apex" of the heart. 
 
 The normal impulse is usually limited in extent, often not exceeding 
 an inch square. Its position varies somewhat with the posture. When 
 the patient lies upon the left side, it may shift an inch or more towards 
 the axillary line, and a similar displacement to the right, but less in extent, 
 takes place when he lies upon the right side. The impulse is less marked 
 and less extensive in the recumbent than in the erect posture. These 
 changes in the position of the heart are caused by corresponding altera- 
 tions in the position of the apex under the influence of gra\dty. The posi- 
 tion of the impulse is little influenced by cpiet breathing, but as the dia- 
 phragm sinks and the lower ribs are elevated in inspiration a change in 
 the relation of the apex-beat to the chest wall, in some instances amounting 
 to an interspace, may be observed upon forced breathing. 
 
 The impulse becomes forcible and extended when the normal heart is 
 acting rapidly and with force under physical or mental stress and in thin, 
 nervous persons, and it is often extended in young children even at rest. 
 
 The character of the impulse and its extent are best studied by palpa- 
 tion, but inspection alone enables us in many cases to determine that the 
 Impulse is extended, heaving, tapping, or undulatory. 
 
 Displacements of the Impulse of the Heart. — Disflacements due 
 to Changes in the Heart Itself. — The impulse is displaced downward and 
 toward the left in hypertrophy and dilatation of the heart, and the combi- 
 
PHYSICAL DIAGNOSIS: INSPECTION. 71 
 
 nation of these conditions is the most common cause. Enlargement of 
 the left ventricle tends to displace the visible impulse downward, enlarge- 
 ment of the right ventricle tends to displace the impulse to the left, and 
 both of these conditions tend to increase its extent. 
 
 Pressure Displacements are next in Order of Frequency. — The heart is 
 dislocated upward in pressure from below the diaphragm, as in excessive 
 tympany, ascites, massive tumors, large cysts, and pregnancy. In any of 
 these conditions the impulse may be seen in the fourth interspace and to 
 the left of the midclavicular line. The heart in pleural effusion, pneumo- 
 thorax, or rapidly growing malignant tumors of the pleura, is displaced 
 towards the opposite side. When these conditions are left-sided the 
 impulse may disappear behind the sternum or become visible at its right 
 border, or in extreme cases in the right nipple line. In large right-sided 
 ■effusions, on the contrary, the impulse may be displaced as far left as the 
 line of the anterior axillary fold. Cysts and abscess in the right lobe of 
 the liver may displace the heart somewhat to the left and shift the impulse 
 to a corresponding extent. 
 
 The heart may be displaced downward by an aneurism of the arch of 
 the aorta or a mediastinal tumor. Under those circumstances the impulse 
 is not only lower than normal but it is also somewhat further to the left. 
 
 Traction displacements of the heart occur in pulmonary cirrhosis and 
 long-standing disease of the pleura. The displacement is toward the affected 
 side. Pleuropericardial adhesions and negative pressure constitute the 
 mechanical factors by which this group of displacements is brought about. 
 A cardiac impulse may be seen to the right of the sternum, or to the left 
 of the left midclavicular line, or if there be great retraction of the upper 
 lobe on either side there may be visible cardiac pulsation at the corre- 
 sponding border of the manubrium. Spinal curvatures and rotations may 
 produce such displacement of the heart as to cause a wholly abnormal 
 position of the visible cardiac impulse or its absence altogether. Dextro- 
 cardia may be the cause of a right-sided impulse, an anomaly also present 
 in complete transposition of the viscera. 
 
 Systolic Retraction. — I have already spoken of the negative 
 impulse present under normal conditions in the immediate proximit)'' of 
 the apex-beat and the more extended systolic recession of the interspaces 
 occasionally seen along the lower sternal border. These are distinctly 
 accentuated when a hypertrophied and somewhat dilated heart is acting 
 forcibly. As these forms of systolic recession are due to atmospheric pres- 
 sure, they may be spoken of as pulsion recessions in contradistinction to 
 those due to the drawing in of the surface in consequence of adhesions, 
 which may be called traction recessions. 
 
 The latter are seen in adherent pericardium with chronic mediastinitis. 
 The impulse is undulatory and in the region of the apex there is marked sys- 
 tolic retraction. Owing to the enlargement of the heart the precordial region 
 is prominent and the chest asymmetrical. The impulse is greatly extended. 
 
 Broadbent's Sign. — When the heart is extensively adherent to the 
 diaphragm, there occurs with each pulsation a systolic tug. This may be 
 communicated through the diaphragm to the j)oints of its insertion in the 
 wall of the chest and well seen in the eighth and ninth intercostal spaces in 
 
72 MEDICAL DIAGNOSIS. 
 
 the parasternal line; but Broadbent has pointed out the fact that it 
 is often also seen on the left side behind, between the eleventh and 
 twelfth ribs. Careful inspection in this region will frequently reveal a 
 systolic retraction of the chest wall, which becomes more evident upon 
 deep inspiration. 
 
 Visible Pulsations of the Heart in Regions other than the 
 Apex. — These are mostly due to retraction of the lungs. In debilitated 
 and bed-ridden persons and especially in the graver forms of anaemia, the 
 breathing is shallow and the lungs are not fully expanded. Their borders 
 are therefore more or less withdrawn from the space which they normally 
 occupy between the heart and the chest wall. The pulsations of the conus 
 arteriosus and right ventricle thus frequently become visible in the second, 
 third, and fourth left interspaces near the sternal border. In some instances 
 these pulsations may also be observed to the right of the sternum. Such 
 pulsations are also seen when the borders of the lungs are retracted as the 
 result of fibroid phthisis. 
 
 (b) Other Movements of the Surface of the Chest having the Cardiac 
 Rhythm. 
 
 1. Pulsations at the root of the neck will be described and 
 their significance as physical signs pointed out in a subsequent section. 
 They are venous and arterial. 
 
 Prominence of the veins of the neck is observed in emaciated and 
 elderly persons otherwise in health. These veins are more or less distended 
 upon expiration, particularly when cough occurs or dyspnoea is present. 
 Transient engorgement results from efforts at lifting or from straining. 
 Pathological conditions that give rise to engorgement of the jugulars are 
 aneurism, mediastinal tumor, adhesive mediastinitis, and obstruction to 
 the pulmonary circulation from any cause. Respiratory engorgement 
 and collapse of the jugulars are especially marked in the dyspnoea of 
 asthma and emphysema. 
 
 Collapse of the jugular upon one side, not disappearing when pressure 
 is made upon it immediately above the clavicle, is a sign of thrombosis of 
 the lateral sinus. 
 
 Pulsating Jugulars. — The pulsations are best studied on the right 
 side of the neck and during quiet breathing. Pulsation communicated 
 from the underlying carotid may be recognized by emptying the vein by 
 stripping it upward gently with the finger-nail or the blunt edge of the 
 tongue spatula. It does not refill from below. 
 
 The visible pulsations in the carotids often seen in thin, nervous persons 
 without disease of the heart are without clinical importance. Violent 
 throbbing of the carotids is common in aortic regurgitation and frequently 
 occurs in simple hypertrophy of the heart without valvular lesions. 
 
 2. Aneurism. — Careful inspection of the anterior surface of the chest 
 must be made in all cases of suspected aneurism. Direct and oblique 
 illumination must be in turn employed, and the examination must be so 
 conducted that profile views are made from above, the patient being in 
 the sitting po.sture, and from the side, the patient being recumbent. In 
 this way slight pulsations and pulsating prominences may be discovered. 
 The pulsation of aortic aneurism is commonly present in the first and second 
 
PHYSICAL DIAGNOSIS: INSPECTION. 
 
 73 
 
 right interspaces near the sternal border and is sometimes accompanied 
 by slight systolic elevation of the inner end of the clavicle. When the 
 innominate is involved the pulsation may be seen at the root of the neck 
 upon the right side or at the notch of the sternum. Aneurismal pulsations 
 sometimes occur to the left of the manubrium sterni and elsewhere in the 
 chest and are to be sought for in every doubtful case. Aneurisms that 
 have perforated the chest wall appear as circumscribed globular or irregular 
 pulsating tumors, the overlying skin being thinned and adherent and 
 ultimately ulcerated, so that there is 
 superficial clot formation and more 
 or less continuous oozing of blood. 
 The tumor may be soft and fluctu- 
 ating; more commonly in conse- 
 quence of the deposition of stratified 
 fibrin layers within the sac it is dense 
 and resistant. In the former case 
 the pulsation is expansile; while in 
 the latter case it is apt to be non- 
 expansile, but forcible and heaving. 
 
 3. Tumors in Contact with 
 Large Arterial Trunks. — En- 
 larged lymph-nodes, especially 
 when single, and neoplasms in the 
 neck overlying the carotid artery 
 sometimes move synchronously 
 with the pulsations of the vessel and 
 present superficial resemblances to 
 aneurisms. The tumor is dense, 
 the pulsation not expansile, and 
 other signs of aneurism are lacking. 
 
 4. Pulsating Pleurisy. — In 
 neglected purulent effusions a pul- 
 sating movement synchronous with 
 the cardiac rhythm is sometimes 
 observed. The cases are not numer- 
 ous. The phenomenon is almost 
 always associated with left-sided 
 effusions and occupies an extensive 
 area of the lower anterolateral sur- 
 face of the left chest. In cases where it is circumscribed and confined 
 to the precordial region the differential diagnosis relates to aneurism 
 and is attended with difficulty. A limited number of cases have been 
 right-sided and in one or two of the reported instances the effusion has 
 been serofibrinous. Pulsating empyemata may be intrapleural or the 
 pulsations may occur in the extrapleural empye7na necessitatis. None of 
 the explanations of the mechanism by which the cardiac impulse in these 
 cases is transmitted through the pus collection to the surface of the chest 
 is satisfactory. An important factor is superficial ulceration of the costal 
 pleura with loss of tone in the intercostal muscles. 
 
 Fig. 3{). — Aneurism of the thoracic aorta.- 
 Hospital. 
 
 -German 
 
74 MEDICAL DIAGNOSIS. 
 
 Inspection of the Abdomen. 
 
 In the examination of this portion of the body the patient should be 
 in the recumbent position and preferably in bed. The abdomen in exposed 
 from the arch of the ribs to the suprapubic region. The patient should 
 lie straight and fiat. The head should be at first low and the lower limbs 
 extended; later the head should be raised upon pillows and the thighs and 
 knees strongly flexed, the heels being drawn up towards the buttocks, 
 in order to relax the abdominal wall; finally it is often necessary to have 
 the patient assume the standing posture, in which case the clothing or a 
 sheet is supported about the hips by the patient or an assistant. The light 
 must be good and the examination made from above, from the sides and 
 obliquely. Physical signs of importance, such as asymmetry in contour 
 or movement or slight local elevation or depression of the surface, may 
 often be detected when otherwise not very obvious, if the observer stands 
 ■Sit the patient's head and views the abdomen obliquely from above down- 
 wards. Combined inspection, palpation, and percussion are necessary. 
 Auscultation is of inferior value in the examination of this region. 
 
 (a) The Normal Abdomen. — In infants and young children the 
 abdomen is relatively larger as compared with the size of the chest than in 
 adults. It is also more protuberant than in well -formed adults. It is 
 larger in women than in men and is enlarged and protuberant in obese 
 and elderly persons. In thin women who have borne many children it is 
 relaxed, coarsely wrinkled, and pendulous. Tight corsets cause bulging 
 of its lower segment. Transient prominence of the upper segment may 
 sometimes be observed after a hearty meal. 
 
 The size of the abdomen in health varies greatly in different individuals 
 according to the amount of subcutaneous and omental fat and the size of 
 the intestines, which are apt to be distended in persons who habitually 
 eat large quantities of coarse food. The physiological enlargement of the 
 abdomen in pregnancy is frequently enormous. 
 
 The normal abdomen is symmetrical in contour, slightly arched from 
 above downward and from side to side, the curves being more prominent, 
 especially in the lower part, in the erect than in the recumbent posture. 
 The navel is shallow and marked by irregularly spiral folds of skin in thin 
 persons and deep and funnel-shaped in those who are fat. 
 
 The skin of the abdomen in healthy persons is opaque and the super- 
 ficial veins are not conspicuous. In brunettes regularly distributed areas 
 of increased normal pigmentation are present in the median line and 
 above the flexures of the thighs. This coloration is deepened and con- 
 spicuous in pregnancy — chloasma uterinum. The respiratory movements 
 of the diaphragm are communicated to the upper portion of the abdomen, 
 the ensiform cartilage and the arch of the ribs being elevated and becom- 
 ing more prominent with inspiration. In persons with very thin and 
 relaxed abdominal walls the peristaltic movements of the stomach and 
 intestines may be occasionally seen. 
 
 (b) Inspection of the Abdomen in Disease. — We study the size of 
 the belly as manifest in genei'al or local retraction or distention, alteration 
 in form and contour, the appearance of the surface and abnormal move- 
 
PHYSICAL DIAGNOSIS: INSPECTION. 75 
 
 merits. In this connection the general rule that the size of a hollow ana- 
 tomical structure or viscus varies with the contents must be borne in mind. 
 
 General Retraction of the Abdomen. — When the longitudinal and 
 transverse curves of the surface are reversed and become concave instead 
 of convex, the abdomen is described as scaphoid or boat-shaped. Two 
 factors may cause this condition and they are frequently combined, namely, 
 extreme wasting and irritative tonic spasm of the abdominal walls. The 
 former occurs in actual starvation; inanition from any cause, especially 
 malignant disease of the larynx or oesophagus, stricture of the latter from 
 other causes, stricture of the pylorus without marked gastric dilatation, 
 diabetes, phthisis, cerebrospinal fever, cholera, chronic diarrhoea, anorexia 
 nervosa, and the pernicious vomiting of pregnancy; the latter, in meningitis, 
 cerebral tumor, and lead colic, and, especially when combined with muscular 
 rigidity and marked tenderness, is a most important sign of early peritonitis. 
 
 Extreme retraction of the abdomen occurs in wasting of the subcu- 
 taneous and omental fat and atrophy of the abdominal organs. 
 
 Fig. 37. — Scaphoid abdomen caused by starvation in a case of cesophageal carcinoma. — Jefferson Hospital. 
 
 Local retractions of the abdomen are not of importance as physical 
 signs. They are seen around the base of large hernias, especially in the 
 lateral regions of the abdomen, in large ventral hernias, and in the upper 
 regions in diaphragmatic hernias. These areas of depression disappear 
 when the hernias which cause them are reduced. 
 
 In moderately large peritoneal effusions of some standing, when the 
 patient assumes the lateral decubitus the side of the abdomen which is 
 uppermost shows a concave retraction while the anterior and dependent 
 portions bulge more prominently. 
 
 General Distention of the Abdomen. — This condition may be caused 
 by subcutaneous and intra-abdominal fat, the excessive accumulation of 
 gas in the stomach or intestines, fluid in the abdominal wall or peritoneal 
 ■cavity or both combined, or a large intra-abdominal tumor. 
 
 Subcutaneous and intra-abdominal fat accumulations in the obese 
 frequently cause enormous distention of the belly. In such cases there is 
 excessive and often irregular development of the panniculus adiposus else- 
 where; while in ascites and tumor the general nutrition is usually impaired. 
 In cases where there is reason to suspect pregnancy or the presence of an 
 abdominal tumor a large deposit of fat may render the diagnosis diffi- 
 cult. Large accumulations of fat in the omentum, such as sometimes 
 occur in persons of middle age, may simulate pregnancy or a tumor. 
 Fat in the belly walls interferes greatly with the examination by means 
 of the X-rays. 
 
76 MEDICAL DIAGNOSIS. 
 
 The Excessive Accumulation of Gas — Meteorism, Tympanites. — The 
 distention is symmetrical and may be extreme. There is tympanitic 
 percussion resonance and absence of fluctuation. The association of these 
 physical signs renders the diagnosis easy. When extreme the condition 
 causes restriction of respiratory movement, the disappearance of the 
 respiratory excursus in the epigastric zone, and displacement of the 
 cardiac impulse upward ag high as the fourth interspace and to the 
 left of its normal position. 
 
 Moderate distention may result from injudicious eating, acute and 
 chronic gastro-intestinal disorders, especially in neurotic persons, and the 
 slight paresis of the intestines which occurs in acute febrile diseases, as 
 enteric fever or pneumonia. Nervous women are apt to "bloat." as it 
 is popularly called, after eating. Excessive tympany occurs in grave 
 eases of the infectious diseases, as enteric fever with deep ulceration, 
 septic conditions, acute general peritonitis, intestinal obstruction, after 
 the release of a constricted loop of intestine after operation, as in 
 strangulated hernia, and in some cases of hysteria. 
 
 Fig. 38. — Ascites, caused by cirrhosis of the liver. — Jefferson Hospital. 
 
 Free gas in the peritoneal cavity occurs as the result of the perforation 
 of an air-containing viscus into that space. The abdomen is greatly and 
 uniformly distended, its surface tense and smooth, the outlines of intestinal 
 convolutions and vermicular movements are not visible, and the respira- 
 tory movement of the upper part of the abdomen ceases. The most common 
 causal conditions are peptic ulcer of the stomach or duodenum, a perforat- 
 ing typhoid ulcer, and ulcerative or necrotic appendicitis. As the air occu- 
 pies the highest region of the cavity, it causes a disappearance of the normal 
 percussion dulness of the liver and spleen, which is replaced by a tympanitic 
 note in these areas, of the same character as that over the abdomen else- 
 where. The mere disappearance of the hepatic dulness does not, however, 
 justify the diagnosis of pneumoperitoneum, since the intestines and espe- 
 cially the transverse colon may occupy the space between the liver and 
 the wall of the thorax and separate them completely. Moreover, the liver 
 dulness may be greatly diminished in pulmonary emphysema of high grade, 
 atrophic cirrhosis of the liver and acute yellow atrophy. The diagnosis of 
 free air in the peritoneum may, however, be determined by careful per- 
 cussion in the axillary line according to the following procedure: In the 
 dorsal posture there is dulness alike in the condition under consideration 
 and when the liver is separated from the wall of the thorax anteriorly by 
 the distended intestine. When, however, the patient is turned upon his 
 
PHYSICAL DIAGNOSIS: INSPECTION. 
 
 77 
 
 left side there always remains a limited area of dulness in the axillary 
 line high up in the case of meteorism, while the dulness wholly disap- 
 pears in the case of pneumoperitoneum. The same method of exam- 
 ination is appHcable to the spleen, although the small size of this organ 
 renders its recognition alike in large 
 meteorism and in pneumoperitoneum a 
 matter of much greater difficulty than 
 in the case of the liyer. 
 
 Fluid in the Abdominal Wall or 
 Peritoneal Cavity. — An excessiye dropsy 
 of the wall in some cases of anasarca 
 may cause distention of the abdomen. 
 This condition is encountered in acute 
 nephritis and in the later stages of 
 cardioyascular disease. The abdomen is 
 tense, doughy, and pits upon pressure; 
 the more dependent parts of the bodj^, 
 feet, ankles, legs, thighs, and pudenda, are 
 highly oedematous, and the condition is 
 usually associated with effusion into the 
 peritoneum and sometimes also into the 
 other serous cavities. The pallid and puffy 
 facies in acute nephritis is characteristic. 
 
 Ascites or free fluid in the cavity of the 
 'peritoneum }nelds characteristic physical 
 signs. The enlargement of the abdomen 
 is general and symmetrical. Its degree 
 and outline depend upon the amount of 
 the fluid and the fact that under the 
 influence of gravity it changes its position with changes in the posture 
 of the patient. In moderate effusions, in the dorsal decubitus the middle 
 of the abdomen is more or less flattened while the lateral regions bulge 
 outward, in the lateral decubitus the lower lateral and anterior walls of the 
 
 Fig. 39. — Ascites. — German Hospital. 
 
 Fig. 40. — Pregnancy — ninth month. 
 
 belly protrude while that which is uppermost is slightly incurved, in the 
 knee-elbow posture the weight of the fluid causes the abdomen to sag 
 down in an unusual manner, and in the erect posture the lower segment of 
 the abdomen is especially prominent. In all these positions there is dul- 
 ness upon percussion over the dependent areas and tympanitic resonance 
 
78 
 
 MEDICAL DIAGNOSIS. 
 
 over the upper, since the fluid gravitates toward the dependent regions of 
 the ca\aty and the air-containing intestines float upon it in the upper 
 spaces. Ascites in a belly pre\^ously relaxed or pendulous causes in the 
 erect posture a prominent and somewhat conical symmetrical protrusion 
 of the lower parts. Massive ascites gives rise to uniform symmetrical 
 
 enlargement of the abdomen, but Kttle influ- 
 
 ^^■^ enced by change of posture. 
 
 • iPfl^^^ Ascites results from pathological processes 
 
 » lii^P directly implicating the peritoneum, as ordinary 
 
 * "Ir infections or tuberculous inflammation or can- 
 
 cer, or the portal vessels, as the pressure of new- 
 growths, gall-stones, cancerous invasion, extreme 
 sclerosis or pylephlebitis due to other causes, or 
 disease of the liver. Cirrhosis of the liver is a, 
 common cause of ascites. Tumors of the abdo- 
 men and especially large solid tumors of the 
 ovary are frequently attended by ascites. The 
 foregoing have been spoken of as local causes. 
 The general causes of ascites are those which 
 give rise to anasarca and effusion into the other 
 serous sacs. Peritoneal effusion resulting from 
 local causes is not usually at first associated 
 with oedema of the low^er extremities. As the 
 fluid accumulates it exerts pressure upon the 
 large abdominal veins, especially the iliacs and 
 ascending vena cava, giving rise to dropsy. 
 
 Tumor as a Cause of General Ahdoviinal 
 Enlargement. — The pregnant uterus, ovarian, 
 pancreatic, and hydatid cysts, and large new 
 growths cause distention which may simulate 
 that due to the causes just considered. The 
 enlargement caused by these conditions differs 
 from that caused by fat, tympany, or fluid in 
 being usually more prominent in the anteropos- 
 terior than in the bilateral diameter, not so sj^m- 
 metrical, and not yielding uniform signs upon 
 palpation and percussion. Other causes of gen- 
 eral enlargement of the abdomen are fecal accu- 
 mulation, cancer of the bowel, disseminated cancer of the peritoneum, and 
 large peritoneal or retroperitoneal sarcomata and lipomata. To this list must 
 be added hydronephrosis and enormous dilatation of the stomach or colon. 
 Local Prominence of the Abdomen. — Circumscribed swellings or tume- 
 faction may be caused by abnormal conditions of the belly wall or of 
 the contents of the cavity. These changes in contour should be carefully 
 sought for in all cases presenting symptoms referable to the abdominal 
 viscera. The methods of especial value are inspection, palpation, and per- 
 cussion. In thin persons radioscopy yields important results. 
 
 The recognition of the nature of local bulgings in the abdominal wall 
 is as a rule not attended by great difficulty, but the diagnosis of visceral 
 
 Fig. 41. — Dilatation of colon 
 Male, 12 years old. — Rot eh. 
 
PHYSICAL DIAGNOSIS: INSPECTION. 
 
 79 
 
 tumors is frequently obscure and in many cases can only be positively 
 determined by an exploratory operation. 
 
 Local Prominences due to Changes in the Wall of the Ab- 
 domen. — These comprise abnormal conditions of the muscles, irregular 
 collections of subcutaneous fat, hernia, abscess, enlarged lymph-glands,, 
 and neoplasms, particularly sarcomata. 
 
 A spastnodically contracted rectus muscle may simulate a tumor. The 
 diagnostician must be on his guard against the appearance and sensation 
 imparted to the touch by a contracted right rectus in the pyloric region. 
 
 Phantom Tumor. — The condition known as phantom tumor, due to 
 persistent gaseous distention of a knuckle of gut with spasmodic contrac- 
 tion of the overlying muscle, causes a tumor-like swelling. Such swellings 
 
 Fig. 42. — a, paraumbilical hernia; b, hernia reduced. 
 
 appear and disappear, with alterations in contour and position; sometimes 
 subside under gentle friction with the warmed hand and always under 
 anaesthesia. They occur in hysterical persons. Fitz has suggested that 
 in some of the cases phantom tumors are symptomatic of congenital or 
 acquired dilatation of the colon. 
 
 Fat. — In very obese persons remarkable rolls and masses of sub- 
 cutaneous fat collect in the abdominal wall. These are usually but not 
 always symmetrical in arrangement, and may simulate tumors, from which 
 they may be differentiated by their continuity with the panniculus adi- 
 posus, their consistency and want of tenderness, and the general condition 
 of the patient. Circumscribed fatty tumors — lipomata — are common. 
 They are hemispherical or egg-shaped, elastic, painless, somewhat mov- 
 able, and more common in the lateral and posterior aspects of the trunk 
 than in the abdominal wall. They frequently occur in spare persons. 
 
 Hernia. — No examination of the abdomen is complete that does not 
 include the sites of hernia. This is especially important in cases attended 
 
80 MEDICAL DIAGNOSIS. 
 
 by intestinal obstruction and vomiting, or persistent pain in the inguinal 
 region. The inguinal and femoral regions should be examined by palpation 
 under the cover of the sheet or clothing and if necessary by inspection as 
 well. Ventral and umbilical hernias and scar-hernias after operation may 
 be readily recognized. The tumor varies in consistency according as it 
 consists wholly of gut or partly of omentum. It is usually soft, without 
 pain upon manipulation, and reducible. It varies in size from a mere nodule 
 to a sac containing a large portion of the abdominal contents. It very 
 often disappears spontaneously when the patient assumes the recumbent 
 posture, or is then readily reduced. Strangulated hernia does not, as a rule, 
 yield to taxis. 
 
 Abscess. — Purulent collections in the abdominal wall may be recog- 
 nized by the signs of inflammation, swelling, redness, heat, and pain, by 
 their contour, and especially by fluctuation. Pus may form in any part 
 of the wall or find its way to any point upon the surface. Appendiceal 
 abscess usually forms a circumscribed, fluctuating tumor in the right 
 lower quadrant of the abdomen. 
 
 Lymph-nodes. — The superficial lymphatic glands of the groin do not 
 form visible tumors unless distinctly enlarged. They are frequently pal- 
 pable as small nodular bodies in adults who are in good health. They may 
 become enlarged and tender in injuries of the leg or foot, in venereal disease, 
 and in common with the superficial lymph nodules in other parts of the 
 body in some of the acute infectious diseases and in particular in the bubonic 
 plague. Slight enlargement of the inguinal lymphatics is common in gener- 
 alized malignant diseases — carcinomatosis, sarcomatosis. Massive enlarge- 
 ment of these structures takes place in Hodgkin's disease. The enlarged 
 inguinal glands in venereal disease and the plague frequently form sup- 
 purating buboes. 
 
 Neoplasms of various kinds may develop in the abdominal wall. The 
 most common variety is sarcoma. In sarcomatosis cutis many small 
 subcutaneous nodules appear scattered over the abdomen. In a recent 
 case a sarcoma developed at the umbilicus and was followed, after opera- 
 tion, in about a year by a small nodule in the immediate neighborhood 
 and many others in different parts of the body. 
 
 Local Prominences due to Abnormal Conditions within the 
 Abdominal Cavity. — These conditions comprise: 
 
 Temporary Dilatation of the Stomach from Excesses at Table, 
 
 Gastrectasis, 
 
 Local Gaseous Distention of the Bowel, 
 
 Fecal Accumulations, 
 
 Ectopic or Floating Viscera, 
 
 Visceral Hypertrophies and Enlargements, 
 
 Intra- and Perivisceral Abscess, 
 
 Abscess from Caries of the Spine, 
 
 Cysts, 
 
 Extra-uterine Pregnancy, 
 
 Abdominal Aneurism, 
 
 Glandular Enlargements, and 
 
 Malignant and other New Growths. 
 
PHYSICAL DIAGNOSIS: INSPECTION. 
 
 81 
 
 Any of these can exist without being the occasion of prominence 
 recognizable upon inspection; but under favorable conditions this method 
 of physical examination yields suggestive — even positive — physical signs. 
 It is usually a question of the degree of their development respectively. 
 
 Excessive fat and muscular rigidity mask the signs of these conditions, 
 and in the case of great abdominal tenderness a satisfactory examination 
 is impossible. The plain recognition of an abdominal tumor does not in 
 all instances justify a further diagnosis of its cause or nature. 
 
 Gastrectasis. — Temporary dilatation of the stomach from excesses in 
 eating causes in persons who are not obese a visible prominence in the 
 epigastric region. Substantive gastrectasis from any cause shows a bulg- 
 ing of the abdominal wall in the region of the umbilicus 
 or above it. This bulging has downwards and to the 
 left the outline of the greater curvature; if the stomach, 
 as is very commonly the case, is displaced downward 
 and its longitudinal axis more vertical than normal, 
 the outline of the lesser curvature may also be visible 
 below the ensiform cartilage. 
 
 Intestinal Obstruction. — The entire abdomen may be 
 distended or only parts of it. If the colon be distended 
 by hard fecal masses the course of the bowel is marked 
 by an elongated eminence, the contours of which cor- 
 respond to those of the gut. If the intestinal stenosis 
 be acute a local area of gaseous distention without peri- 
 stalsis occurs above the obstruction. The obstruction 
 may be caused by fecal accumulations, large gall-stones, 
 enteroliths, or the pressure of a tumor. Any of these 
 may give rise to a distinct, localized, asymmetrical 
 prominence of the abdominal wall. 
 
 Intussusception is most common in childhood and 
 shows itself as an elongated sausage-shaped tumor usu- 
 ally in the region of the caecum or at the sigmoid flexure 
 
 Ectopic or Floating Viscera. — General splanchnop- 
 tosis — Glenard's disease — causes a prominence or pro- 
 trusion of the lower segment of the abdomen and is 
 common in women, being favored by tight corsets, the 
 method of supporting the skirts, and the relaxation due to childbearing. 
 Enteroptosis causes a similar deformity more or less marked; gastroptosis 
 is usually associated with dilatation of the stomach. A vertical position 
 of the stomach may be congenital or acquired as the result of tight lacing. 
 The pylorus then occupies a position in the median line or to the left of 
 it, and the greater curvature lies below the level of the umbilicus. In thin 
 persons these displacements of the organ may sometimes be demonstrated 
 by the methods of physical diagnosis, especially if it be inflated with gas 
 followed by the introduction of water through the tube so that the greater 
 curvature may be determined by dulness on percussion in sharp contrast 
 with the tympanitic resonance of the colon. 
 
 Floating kidney sometimes gives rise to an oval prominence plainly 
 visible upon inspection, which may be made to shift its position or dis- 
 6 
 
 Fir,. 43. — ^'i.■<ce^op- 
 tosis. — I'eimsylvania 
 Hospital. 
 
82 MEDICAL DIAGNOSIS. 
 
 appear upon manipulation or upon changes in the posture of the patient, 
 ^he swelHng caused by a displaced kidney is usually upon its own side, 
 but when very movable it may sometimes be forced beyond the median 
 line to the opposite side. It may occupy a position anywhere between the 
 ribs and the pelvis and is freely movable with deep respiration. Ren 
 mobilis is much more common in women and upon the right side. 
 
 Floating Spleen. — The normal spleen which, in consequence of elonga- 
 tion of the gastrosplenic ligament and the splenic artery and veins, has 
 become dislocated — lien mobilis — does not cause a visible abdominal 
 swelling. When, however, the displaced organ is also enlarged, as is fre- 
 quently the case, there may sometimes be seen a rounded swelling upon the 
 left side in any position from the hypochondrium to the pelvis. This 
 swelling, like that caused by the dislocated left kidney, with which float- 
 ing spleen is often associated, is freely movable upon manipulation and 
 change of posture. 
 
 Floating liver is among the rarest of clinical or anatomical findings. 
 The dislocation of the organ is usually slight. There is general enlarge- 
 ment of the right lateral region and a large mass of characteristic outline 
 which descends when the patient assumes the erect posture. Tympany in 
 the upper part of the right hypochondrium — normal area of liver dulness — 
 disappearing when the organ is replaced, and the well-defined lower border of 
 the liver upon palpation, render the diagnosis a matter of comparative ease. 
 
 Enlargement of the Gall-bladder. — This condition may properly be 
 considered at this point, since the position of the enlarged bladder is very 
 different from that of the normal gall-bladder. The enlargement is the 
 result of cholecystitis, frequently associated with cholelithiasis, or carcinoma. 
 
 The gall-bladder is distended by a serous fluid which gradually accumu- 
 lates in consequence of the inflammatory changes in its walls, — dropsy of 
 the gall-bladder, — the bile no longer entering, because of obstruction of 
 the cystic duct by a calculus, a plug of tenacious mucus, adhesive cholan- 
 gitis, or a carcinomatous nodule. In comparatively rare instances infection 
 by pyogenic organisms causes suppurative cholecystitis — empyema of 
 the gall-bladder. If the gall-bladder be sufficiently distended and the 
 abdominal wall thin, there may be seen an elongated, smooth prominence 
 in the region of the notch of the liver, projecting below the liver margin 
 and rising and falling with the respiratory movements. The gall-bladder 
 may be greatly distended, reaching in some instances the size of the 
 fist or more. It is then sometimes pear-shaped, the fundus being freely 
 movable from side to side upon manipulation and change of posture. 
 
 In some instances when the cholecystitis is associated with cholelith- 
 iasis the gall-bladder is distended by an enormous accumulation of calculi; 
 in others the tumor may be due to primary or secondary carcinoma ol the 
 gall-bladder. 
 
 Visceral Enlargements. — The so-called corset fiver may give rise to a 
 visible prominence in the right lateral region, reaching as low as the crest 
 of the ilium and moving with respiration. In cases in which the pressure 
 constriction is marked the portion of the liver below it is movable and 
 may simulate, especially when a loop of intestine occupies the groove, 
 a displaced kidney or new growth in the ascending colon. 
 
PHYSICAL DIAGNOSIS: INSPECTION. 
 
 83 
 
 Enlargement of the liver, causing marked prominence in the right h3'po- 
 chondrium, in some cases of the entire abdomen, may be due to hypertrophic 
 cirrhosis, carcinoma, amyloid disease, conditions causing obstructive jaun- 
 dice, leukaemia, syphilis, hypersemia due to cardiac disease, and fatty liver. 
 
 Enlargement of the spleen may attain a considerable degree before it 
 gives rise to signs upon inspection. Massive enlargement may occur in 
 chronic malaria— ague cake, leukaemia and pseudoleuksemia. The organ 
 may reach to the pelvis and even 
 to the right of the median line. 
 
 Enlargement of the Kidneys. — 
 Renal tumors develop from behind 
 forward, tending to displace the 
 movable organs of the abdomen, 
 especially the intestines, aside. 
 
 The anatomical relations of the 
 ascending and descending colon are 
 such that these portions of the intes- 
 tines, being attached to the kidneys 
 by connective tissue, are retained in 
 front of the growing renal tumor and 
 tend to obscure its dulness upon 
 percussion. The development of the 
 tumor from the upper portion of the 
 kidney causes a prominence of the 
 hypochondrium on the correspond- 
 ing side, which extends as the growth 
 develops to the iliac region; the 
 development of the tumor from the 
 lower portion of the kidney causes 
 prominence first in the iliac region. 
 Two solid new growths of the kidney 
 only are of clinical importance from 
 the stand-point of diagnosis, namely, 
 carcinoma and sarcoma. The for- 
 mer is more common in advanced 
 life, the latter in childhood; the for- 
 mer is apt to cause early cachexia, 
 while in the latter the general nutri- 
 tion may be maintained; finally, sarcomatosis of the skin in connection 
 with tumor of the kidney is highly suggestive as to the nature of the 
 renal affection. Renal adenoma cannot be differentiated from carcinoma 
 during the life of the patient. Much more rare is hypernephroma. 
 
 In the rare cases in which both kidneys are involved the abdominal 
 enlargement is of course bilateral. 
 
 The very rare primary malignant disease of the suprarenal capsules 
 may give rise to a tumor in the hypochondrium of the corresponding side, 
 which differs in no respect from the similar manifestation caused by a tumor 
 of the upper half of the kidney. Renal tumors move only slightly or not 
 at all with respiration. 
 
 Fig. 44. — Massive enlargement of spleen in a case of 
 splenomedullaryleukfemia. — Jefferson Hospital. 
 
84 MEDICAL DIAGNOSIS. 
 
 Enlargement of the pancreas is caused by chronic pancreatitis and car- 
 cinoma. It very rarely reaches such a size as to occasion visible prominence 
 in the epigastrium. 
 
 Abscess. — Local bulgings of the surface may be caused by suppurative 
 inflammation in and around the abdominal viscera. 
 
 Abscess of the Liver. — Multiple ab«eess does not usually reveal itself 
 by changes in the contour of the surface. Tropical abscess commonly 
 causes the liver to enlarge upward, especially upon the right side. The 
 respiratory excursus is diminished or absent and the lower intercostal 
 spaces obliterated. There is often local oedema. 
 
 Subphrenic abscess occasions marked downward displacement of the 
 liver and a smooth, soft tumor in the epigastrium. If, as is commonly 
 the case, there is air as well as pus in the subphrenic space, the diagnosis is 
 not attended with difficulty. 
 
 Abscess of the spleen, when of sufficient size, sometimes reveals itself 
 by a splenic tumor, upon the surface of which a fluctuating area or areas 
 may be obscurely felt through a thin-walled abdomen. 
 
 Renal abscess may cause a circumscribed tumor in the hypochondrium 
 or iliac region of the affected side, with obscure fluctuation, but without 
 cedematous swelling of the neighboring tissues. 
 
 Perinephritic Abscess. — The swelling occupies the lumbar region and 
 there is oedema of overlying and adjacent parts. There is frequently 
 burrowing of the pus in a downward direction, so that a second fluctuating 
 tumor may be present at a more dependent point. 
 
 Abscess in Appendicitis. — The common situation of the large, circum- 
 scribed intraperitoneal abscess is in the iliac region between the navel and 
 the anterior superior spine. The abscess may form in the retroperitoneal 
 space and burrow beneath the iliac fascia, showing itself at Poupart's 
 ligament, or it ma}^ accumulate in the retroperitoneal tissue in the flank, 
 forming a large paranephritic abscess, with the usual cedematous condition 
 of the surrounding parts. 
 
 Abscess from caries may follow enteric fever and show itself as a small 
 fluctuating tumor overlying a rib or costal cartilage. Vertebral caries may 
 cause an abscess in the lumbar region, or the pus may follow the sheath 
 of the psoas muscle and point below Poupart's ligament — psoas abscess. 
 
 Ovarian or tubal abscess may give rise to distention in the iliac region 
 of either side. When upon the right side these conditions may simulate 
 appendiceal abscess, with which they are also occasionally associated. 
 
 Cysts.- — Local as well as general prominence may be caused by cysts 
 of various kinds. If large the distention is general, if small it is local and 
 circumscribed. From a pathologico-anatomical beginning wholly without 
 symptoms and unrecognizable, certain cysts frequently attain enormous 
 dimensions. Among these are especially to be mentioned cysts of the 
 pancreas, hydronephrosis, and ovarian cysts, which are often of such size 
 as to simulate ascites. The smaller cysts do not present physical signs 
 which differentiate them from abscesses in the same localities. It is only 
 by a general knowledge of the pathological processes which give rise to 
 cyst- and abscess-formation respectively and a careful consideration of 
 the anamnesis and associated symptoms that the differential diagnosis 
 
PHYSICAL DIAGNOSIS: INSPECTION. 85 
 
 can in some instances be made out, as in dropsy and empyema of the 
 gall-bladder, echinococcus and abscess of the spleen, or hydro- and pyo- 
 nephrosis. Cysts springing from the liver, dropsy of the gall-bladder, 
 echinococcus and pancreatic cysts have their early manifestations in the 
 upper regions of the abdomen — epigastric zone — to the right and left of 
 the median line respectively; those springing from the kidney — hydrone- 
 phrosis, echinococcus — first appear in the lateral regions, while those from 
 the pelvic organs, ovarian cysts, hydramnion, arise from the pelvis — hypo- 
 gastrium. Mesenteric cysts are usually situated to the right of the umbil- 
 icus and below its level. Cysts connected with the liver and spleen are 
 influenced by the respiratory movements; those connected with the pan- 
 creas only slightly or not at all, and those developing from the kidneys, 
 ureters, and pelvic organs remain wholly unaffected by the respiratory 
 movements of the diaphragm. 
 
 Aneurism. — Aneurism of the abdominal aorta may cause a distinct, 
 pulsating tumor commonly in the epigastrium but occasionally to the 
 left of the median line in front or in the lumbar region. This tumor is almost 
 always immovable, but in rare instances has been influenced by manipula- 
 tion and change of posture, but not by respiration. It presents the signs 
 of aneunsm, and is to be differentiated from tumors overlying the aorta 
 and from the so-called "dynamic pulsation" of the aorta which occurs 
 in neurotic individuals. The distended urinary bladder in urethral stric- 
 ture, impacted calculus, etc., gives rise to a distinct rounded oval tumor of 
 the hypogastrium, which reaches in extreme cases well up towards the 
 umbilicus. To a less extent the retention of the low fevers and comatose 
 conditions gives rise to a similar prominence. In the latter case, the incon- 
 tinence of retention — stillicidium urin(V — prevents extreme distention. 
 The anamnesis, the oval outline of the tumor, its central and symmetrical 
 situation, fluctuation, and its immediate disappearance upon catheterization 
 render the diagnosis clear. 
 
 Extra-uterine Pregnancy. — There is a history of morning nausea, 
 paroxysmal colicky pain with faintness, enlargement and hardness of the 
 breasts, and chloasma uterinum, together with the presence of a prominence 
 to the right or left of the median line above the brim of the pelvis. "S'ery 
 often rupture of the sac takes place before it has attained sufficient enlarge- 
 ment to be recognized by the methods of physical diagnosis. This accident 
 is attended by collapse symptoms, and upon vaginal examination the uterus 
 is found to be somewhat enlarged and displaced downward and to the 
 opposite side. 
 
 Glandular Erdargements. — Enlargement of the retroperitoneal glands, 
 usually sarcomatous — Lobstein's cancer — may cause a visible tumor in 
 the epigastric or umbilical region, usually tense, immovable, and nodular; 
 sometimes slightly movable and obscurely fluctuating and crossed by 
 the colon, which may be recognized upon palpation or by its tympanitic 
 resonance, to secure which artificial inflation may be necessary. Tuber- 
 culous mesenteric glands — tabes mesenterica — cause, especially in children, 
 marked protrusion of the abdomen with tympany. The enlarged lymphatic 
 glands may cause irregular local prominence in the region of the navel or 
 in the right iliac fossa and may be recognized upon palpation. 
 
86 
 
 MEDICAL DIAGNOSIS. 
 
 Malignant and Other New Growths. — Malignant diseases of abdominal 
 organs — carcinoma, sarcoma — are of chief, while benign affections, fibroma, 
 lipoma, myxoma, adenoma, and gumma, are of subordinate interest from the 
 stand-point of diagnosis. This difference is to be ascribed not only to the 
 greater frequency of the former and their disastrous effects upon the health 
 and ultimately upon the life of the patient, but also to the fact that at 
 some time in their course the diagnosis becomes both practicable and ob- 
 vious, while in the latter with less significant symptoms the diagnosis cannot 
 be made out and the condition often remains unsuspected during the whole 
 ^ . course of the patient's life and only 
 
 assumes pathologico-anatomical 
 interest when the case, death hav- 
 ing resulted from an entirely dif- 
 ferent disease, at length comes to 
 autopsy. It is of diagnostic impor- 
 tance that in visceral as well as in 
 external cancer, secondary implica- 
 tion of adjacent and distant organs 
 takes place with characteristic signs 
 and that ultimately in many cases 
 the superficial lymphatic glands 
 become enlarged, nodules appear in 
 the skin and elsewhere— general car- 
 cinomatosis, general sarcomatosis. 
 Cancer of the Stomach. — The 
 tumor can be seen in some cases, 
 but is usually only to be recognized 
 upon palpation. It most com- 
 monly occupies the region of the 
 pylorus and may be slightly mov- 
 able with respiration and freely so 
 upon manipulation. A visible 
 tumor occupying the greater part of 
 the epigastrium and even extending 
 beyond its borders, irregular, nod- 
 ular, well defined at its margin, 
 immovable and very distinct through the emaciated wall of the belly, is 
 sometimes present in advanced cases of carcinoma extensively involving 
 the anterior wall of the stomach. 
 
 Cancer of the Liver. — The volume of the organ is usuall}^ greatly in- 
 creased. The increase is rapid and may assume enormous dimensions. 
 It may affect the entire liver or the right or left lobe to a preponderating 
 extent. When the right lobe is chiefly involved, there is a flaring out of 
 the lower ribs and costal cartilages; when the left, the appearance of the 
 tumor may suggest a new growth involving the greater curvature of the 
 stomach, a cyst of the pancreas, or an enlarged spleen, but these doubts are 
 immediately set at rest by palpation and percussion. The surface is usually 
 uneven and the border irregular, and these signs may in some cases be 
 clearly made out upon inspection. In the absence of adhesions the respira- 
 
 FiG. 45. — Sarcomatosis cutis, — primary tumor 
 springing from a pigmented mole on the foreliead; 
 metastatic growths appeared in a few months after 
 primary growth. — Jefferson Hospital. 
 
PHYSICAL DIAGNOSIS: INSPECTION. 87 
 
 tory excursus of the liver may be seen, and in one remarkable case in my 
 service at the Philadelphia Hospital, when upon autopsy the entire right 
 lung was found to be solidified by secondary carcinomatous infiltration, 
 the respiratory movement of the liver, plainly seen through the abdominal 
 wall, was from left to right upon inspiration. When, as is often the case, 
 extensive adhesions are present, respiratory movement of the enlarged 
 liver does not take place Multilocular echinococcus and gumma of the 
 liver present great difficulties in diagnosis. Splenic enlargement in the 
 former and a history of lues in the latter are significant. An individual 
 who has syphilis may also be the subject of echinococcus disease. 
 
 Cancer of the Gall-bladder. — The position of the tumor and its respira- 
 tory movement are important. It is apt to be mistaken for cancer of the 
 pylorus or duodenum. In the latter affections, when the cancer is primary, 
 free hydrochloric acid may be wanting in the gastric contents, secondary 
 dilatation of the stomach shortly appears, and the tumor may be made out 
 to be connected with the stomach or bowel by dilating the stomach, with 
 simultaneous percussion and palpation, while the seat of the tumor in the 
 gall-bladder becomes at the same time more obvious by its shape and 
 relatively superficial situation. 
 
 A tumor formed by cancer of the head of the 'pancreas cannot often be 
 positively differentiated from cancer of the pylorus, duodenum, transverse 
 colon, or porta hepatis. At best in a majority of cases the diagnosis must 
 be made by exclusion. 
 
 Inspection of the Surface of the Abdomen. Abnormal Signs. — 
 Moderate ascites and large tumors may be present without changes in the 
 integument; but excessive distention causes nutritive changes and the 
 skin loses its natural appearance, becoming tense, glistening, and thinned. 
 White lines or strise — linece albicantes — irregularly parallel and slightly 
 depressed below the adjacent surface are produced by extreme or prolonged 
 distention, as in pregnancy, obesity, and ascites. They are seen upon the 
 abdomen, flanks, and thighs, and persist after the condition which caused 
 them has passed away. Jaundice is often more conspicuous here than on 
 surfaces exposed to the air. Striking deposits of pigment occur in the 
 linea alba in pregnancy, especially in brunettes, and pigmentation due to 
 abdominal growths and diseases of the peritoneum, Addison's disease, 
 melanotic cancer, exophthalmic goitre, scleroderma, arteriosclerosis, and 
 chronic heart disease is often conspicuous upon the abdomen, especially 
 in the lower quadrants and about the flexures of the thighs. The pigmen- 
 tation of vagabondage due to lice and filth is usually characterized by the 
 parallel linear superficial lesions of scratching. The haemochromatosis of 
 hypertrophic cirrhosis and diabetes and in rare instances scleroderma are 
 attended by conspicuous pigmentation. The prolonged administration 
 of arsenic frequently causes marked discoloration of the skin. The general 
 discoloration of argyria is less pronounced upon the surface of the trunk 
 than upon the face and extremities. The specific eruptions of the exan- 
 themata, especially the initial rashes of variola, and the rose spots of enteric 
 fever are to be sought for upon the abdomen. Tache bleuatres. tinea 
 versicolor, and the symmetrical diffuse macular eruption of secondary 
 syphilis are to be seen. The scars of surgical operations, especially those 
 
MEDICAL DIAGNOSIS. 
 
 performed for the relief of appendicitis, gastric and gall-bladder disease, 
 and various diseases of the pelvic organs are common nowadays and may 
 shed light upon many abdominal disorders — adhesions and the like — post- 
 operative neurasthenia and other obscure maladies.. Enlarged inguinal 
 
 glands and retracted cicatrices 
 in the groins may be significant 
 of venereal infection. 
 
 Vascular Changes. — Signs relat- 
 ing to circulatory derangements are 
 enlarged superficial epigastric 
 arteries and enlarged superficial 
 veins. The former are exceed- 
 ingly rare and indicate obstruction 
 of the aorta or iliac arteries; the 
 latter very common and constitute 
 the evidence of collateral venous 
 circulation in obstruction of the 
 portal system or the inferior or 
 superior vena cava. Among the 
 common causes of such obstruction 
 are, in the portal circulation, cir- 
 rhosis of the liver and tumor; in 
 the general circulation, abdominal 
 and mediastinal tumor, dilatation 
 of the stomach of high grade, and 
 ascites of long standing. 
 
 Caput medusae is a varicose 
 arrangement of the dermal veins 
 around the umbilicus with radiat- 
 ing branches. It is made up by the 
 dilated branches of the epigastric 
 veins at their juncture with a large 
 single vein which passes from the 
 hilum of the liver and follows the 
 course of the round ligament — 
 para-umbilical vein of Sappey. 
 Much more commonly the enlarged 
 collateral veins are distributed 
 irregularly over the surface of the 
 abdomen and indicate one of the 
 courses towards the right heart 
 taken by the blood in pressure 
 upon the inferior vena cava. There is engorgement of the blood from 
 the lower extremities in the inferior epigastric and internal mammary 
 veins, with dilatation of the superficial abdominal veins. In obstruc- 
 tion of the portal system and inferior vena cava the course of the 
 blood in the dilated superficial veins is upward; when the superior cava 
 is obstructed the course of the blood in the superficial veins of the chest 
 and abdomen is downward, the blood seeking its way to the right heart 
 
 Fig. 46. — Sarcoma of spine, showing venous stasis and 
 metastatic growtli in orbit. — Young. 
 
PHYSICAL DIAGNOSIS: INSPECTION. 89 
 
 by means of the right ai^ygos which communicates with various tributaries 
 of the inferior vena cava. Pressure upon the innominate vein of the right 
 or left side may give rise among other signs to great cUlatation of the 
 superficial veins of the thorax and abdominal wall. 
 
 The Umbilicus. — The navel normally shows transverse or slightly 
 spiral folds of the skin and is moderately retracted. It is deeply so and 
 funnel-shaped in obese persons and level with the surrounding surface or 
 protruding in large ascites and pregnancy. It may be the seat of caput 
 medusae or hernia, inflammation or eczema, carcinoma secondary to gastric 
 carcinoma or tuberculous infiltration secondary to tuberculous peritonitis. 
 A mole in the region of the umbilicus may undergo sarcomatous changes. 
 
 Movements of the Abdomen in Disease. — Inspiratory retraction 
 of the epigastrium is present in stenosis of the upper air-passages and 
 imperfect action of the diaphragm. Diminished respiratory movement 
 of the abdomen may be caused by upward pressure upon the diaphragm, 
 as in tympany, ascites, and abdominal tumors on the one hand, or by mas- 
 sive pleural or pericardial effusions on the other. In the early stages of 
 peritonitis abdominal respiratory movement is greatly impaired or wholly 
 absent, on account of the pain and tonic contraction of the muscles of the 
 wall; in the later stages on account of the tympany and upward pressure 
 upon the diaphragm. 
 
 Visible Peristalsis. — In thin persons the normal peristaltic movements 
 may sometimes be seen. They appear as wave-like, rounded elevations of 
 the surface which may be attended by borborygmi and may be intensified 
 by gentle irritation of the skin by the application of cold, brisk tapping or 
 faradism. In some instances the peristaltic movements of the stomach 
 from left to right are in sharp contrast to those of the transverse colon from 
 right to left. In the wide separation of the recti occasionally seen in women 
 who have borne many children these vermicular movements are very 
 conspicuous. 
 
 The most important diagnostic significance of visible peristalsis relates 
 to intestinal obstruction. The presence of peristalsis must be determined 
 and whether or not it is always in the same direction and ceases at a certain 
 spot. If the obstruction is at or above the ileocsecal valve the distended 
 and mobile coils of small intestine occupy a position in the central portion 
 of the abdomen, but if the obstruction involves the lower part of the large 
 intestine — sigmoid flexure — the distention and movements of the bowel 
 may be manifest in the region occupied by the ascending and transverse 
 colon. The inflated fixed intestinal coil of acute stenosis of the gut, ileus — 
 strangulated hernia — shows no peristaltic movement. Prior to immobility 
 there is peristalsis. In chronic obstruction, after the muscularis of the 
 gut has become hypertrophied, there is active peristalsis, with marked 
 recurrent tumor subsiding with coarse borborygmi, just in advance of the 
 stenosis. As the gas in the tumor is under tension, it does not yield tym- 
 panitic resonance but dulness upon percussion. Visible peristalsis in the 
 left hypochondrium, with the vermicular contractions from left to right, 
 has been observed in extreme gastrectasis. 
 
 Pulsation Synchronous with the Cardiac Systole. — Dynamic pulsation 
 occurs in neurotic persons. It is seen in the median line and is often violent 
 
90 
 
 MEDICAL DIAGNOSIS. 
 
 but neither diffuse nor expansile. The pulsation of abdominal aneurism 
 usually has both these characters and very often in addition systolic 
 thrill and bruit. It is mostly situated in the median line, but may 
 
 be seen in the left lateral region 
 of the abdomen. 
 
 An Aid to Inspection in Cir=. 
 cumscribed Movements not Well 
 Defined. — I have found the fol- 
 loT\dng suggestion of K. H. Beall 
 of much service: 
 
 "Over the area under inspec- 
 tion there is drawn with a skin 
 pencil a square plaid figure, the 
 squares of which are from 1.5 to 
 2.5 cm. in diameter and from 12 
 to 50 in number, according to the 
 size of the area being studied. 
 Any slight movement of the skin 
 at any point in such a marked area 
 causes a change in the direction of 
 some of the lines and a distortion 
 of the figure, and so renders visible movements of the internal organs 
 which are not to be detected otherwise. " 
 
 Fig. 47. — Beall's aid to inspection. 
 
 PALPATION. 
 
 The method of physical diagnosis in which the sense of touch is em- 
 ployed is known as palpation. It consists in the systematic examination 
 of the surface of the chest and abdomen by the la^ang on of the hand. 
 The physical signs elicited depend upon the condition and movements of 
 the parts and the underlying structures. As in inspection, we study the 
 form, size, condition of the surface, and movements. The method is appli- 
 cable and essential to the examination of the thorax and abdomen. 
 
 Palpation in the Examination of the Thorax. 
 
 The chest should be bared, the attitude easy, the arms symmetrically 
 disposed, the muscles relaxed. The examining hand should be warm and 
 laid gently upon the surface. The amount of pressure employed must be 
 determined in individual cases. Ticklishness, tenderness, and excessive 
 fat constitute obstacles. The first may be overcome by care and diverting 
 the attention of the patient; the others often amount to insuperable diffi- 
 culties in the application of this method of diagnosis. The palmar surface 
 of the whole hand is employed for a general survey, as in locating the posi- 
 tion of the cardiac impulse or a thrill; the more sensitive finger tips for the 
 study of the particular characters of such phenomena, for example the force 
 and extent of the impulse or the coarseness or fineness and extent of a thrill. 
 
 By palpation we confirm and amplify the signs obtained by inspec- 
 tion, especially those dependent upon the form and contour of the chest, 
 
PHYSICAL DIAGNOSIS: PALPATION. 91 
 
 the width of the interspaces, the presence of local swellings and deformi- 
 ties, and the respiratory and cardiac movements. These it is not necessary 
 at this point to repeat. But there are other physical signs, not always 
 recognizable upon inspection, which we investigate by palpation. These 
 comprise the condition of the wall of the chest as regards 
 
 Muscular Tension, 
 
 OEdema, 
 
 Width of the Interspaces, 
 
 Fluctuation, 
 
 Nodes, Gummata, and Periosteal Thickening, 
 
 Location and Character of the Heart's Impulse. 
 
 Extracardial Pulsation and Diastolic Shock, and in particular the 
 
 following physical signs which are exclusively within the scope 
 
 of this method: 
 The Crepitation of Subcutaneous Emphysema, 
 Thrills, Cardiac and Vascular, 
 Fremitus, Vocal, Friction, and Rhonchal, 
 Tracheal Tugging. 
 
 Tension. — The tension of the muscular wall of the chest in the inter- 
 costal spaces and about the ensiform cartilage is not a sign of great value, 
 yet it is to be studied in doubtful cases. The inspiratory retraction of the 
 base of the chest is a sign of obstruction to the entrance of air, which may 
 be at the larynx, as in oedema of the glottis, or in the smallest bronchial 
 tubes, as in bronchopneumonia. The slight normal furrow of the lower 
 intercostal spaces may be obliterated by pleural or pericardial effusion or 
 a rapidly growing new growth. In old empyemata there is great relaxa- 
 tion and bulging and the cardiac pulsations may even be transmitted to 
 the surface — pulsating empyema. Epigastric rigidity and tenderness are 
 conspicuous in tetanus, and these phenomena are early symptoms in 
 peritonitis beginning in the upper part of the abdomen. 
 
 (Edema. — Local oedema may indicate intrathoracic suppuration as 
 in empyema or hepatic abscess, inflammation of the wall of the chest as 
 in carbuncle, or obstruction to the venous circulation as in mediastinal 
 tumor or aneurism. The puffiness involves the head and neck on both 
 sides when the pressure involves the precava and is unilateral when it 
 affects the right or left innominate only. 
 
 Spaces. — The width of the intercostal spaces may be felt when not 
 seen upon inspection, and should be carefully investigated in cases of pleu- 
 ral effusion, since they are wide when the chest is distended and become 
 narrow as the fluid undergoes resorption. 
 
 Fluctuation. — Elasticity or fluctuation in any prominence or tumor 
 upon the surface of the chest is an important sign. It may be due to abscess 
 of the wall itself, empyema necessitatis, cyst formation, or sarcoma. The 
 differential diagnosis rests upon the associated clinical phenomena. In 
 abscess of the wall the volume of the tumor is not affected by the respira- 
 tory movements; in empyema necessitatis the tumor diminishes upon 
 inspiration anrl increases with expiration and the physical signs of intra- 
 
92 MEDICAL DIAGNOSIS. 
 
 pleural effusion are present; a cyst is usually sharply circumscribed, 
 distinctly globular, tense, sometimes translucent, and commonly movable 
 within a limited range. 
 
 Nodes. — Nodes upon the ribs, cartilages, or sternum or thickening 
 at the chondrocostal or sternoclavicular articulations and periosteal thick- 
 ening are important signs of disease. They may sometimes be felt when 
 not obvious upon inspection, and their size and consistence can be recog- 
 nized upon palpation. Among the earliest of the skeletal lesions of rickets 
 is a nodular enlargement of the ribs at the juncture of the bone with the 
 cartilage. These nodules are present upon the ribs of both sides and are 
 symmetrical in their arrangement — the so-called rosary of rickets. Gum- 
 mata are common upon the sternum and roughening and enlargement of 
 the clavicles may be a m'anifestation of late syphilis. The clavicles are 
 enlarged and the sternum deformed in acromegaly. Acute painful enlarge- 
 ment of the sternoclavicular articulation is not rare in gonorrhoeal arthri- 
 tis. A soft, elastic, slightly fluctuating tumor upon the upper part of the 
 sternum may be a tuberculous abscess. Tender points are found upon 
 palpation. They are not physical signs, but may be mentioned in this 
 connection as symptoms of great value. They are found in intercostal 
 neuralgia and correspond to the points of emergence of the intercostal 
 nerves ; in neurasthenia tender points are also found along the dorsal spine 
 and the tenderness is very often present upon light and absent upon firm 
 pressure; in necrosis of a rib; in fibrinous pleurisy and especially in 
 that form of pleurisy which occurs in pulmonary tuberculosis, where the 
 tenderness is most common and most marked in the infraclavicular region. 
 
 Apex=beat. — The precise location and character of the impulse of 
 the heart. The palm of the hand should be first laid over the precordia 
 below the left nipple. The signs elicited by inspection are thus confirmed 
 and amplified. We determine whether the rhythm of the heart is regular 
 or irregular and, if irregular, whether the arrhythmia is in time or in force 
 or both, that is, whether there are differences in the intervals between 
 the ventricular contractions, or in the power with which the heart con- 
 tracts or these are combined. We observe also in this way the general 
 character of the heart's action, that is, feeble or strong; heaving power- 
 fully so as to move the whole chest, as in great hypertrophy or the over- 
 action of mental or physical excitement — palpitation; that it has the 
 diffuse slap often encountered in dilatation of the right ventricle, the sharp 
 tap of mitral stenosis or the slow, heaving, forcible impulse sometimes 
 met with in aortic stenosis. 
 
 The more sensitive tips of the fingers are next brought into service. 
 They are placed over the point of maximum impulse and moved in vari- 
 ous directions. The apex of the heart as determined by finger-tip palpa- 
 tion and by percussion is usually two or three centimetres below and to 
 the left of the point of maximum or visible impulse. It frequently happens 
 that the impulse not recognized upon inspection may be felt and rarely 
 that a visible impulse cannot be appreciated by the trained touch. These 
 two methods must be used in all cases. 
 
 Inspection and palpation yield the most satisfactory results in the 
 study of the size of the heart. The base of the organ is fixed and is as a 
 
PHYSICAL DIAGNOSIS: PALPATION. 93 
 
 rule not greatly displaced even by the pressure of an aneurism or new- 
 growth. To fix the position of the apex is to determine the long axis of 
 the heart and gain a fairly correct idea of its size. The data obtained by 
 percussion are much less definite, partly because of inherent difficulties 
 in recognizing the limits of dulness in the rounded body of the heart sur- 
 rounded by resonant lung and partly because of the modifying effects of 
 pleural adhesions or effusion, gastric dilatation or abdominal tympany. 
 When the impulse cannot be located by inspection or palpation, we employ 
 auscultation and consider the clinical impulse to be near the point at which 
 the first sound is most distinctly heard. 
 
 The changes in the relation of the apex to the wall of the chest caused 
 by changes in the posture of the patient have already been considered. 
 
 Extracardiac Pulsation. — Pulsation beyond the limits of the 
 heart is frequently seen, but its precise location, extent, and character 
 are best studied by the sense of touch. A heaving impulse at the root 
 of the neck occurs in hypertrophy, especially that form associated with 
 aortic insufficiency and in overaction from nervous causes. It occurs 
 also in anaemia and large hemorrhages, in apoplexy, and rarely in the 
 stage of onset of intense infections, as variola. It is a conspicuous phenom- 
 enon in exophthalmic goitre. In neurotic persons the pulsating dilated 
 transverse aorta may in rare instances be felt in the sternal notch — 
 dynamic pulsation. Aneurism of the innominate artery or of the trans- 
 verse portion of the aortic arch may give rise to similar pulsation. Anom- 
 alies in the distribution of the subclavian or thyroid arteries may also give 
 rise to pulsation in this region. In old pleural adhesions at the apex and 
 in pulmonary tuberculosis subclavian pulsation is often marked and 
 extended. Pulsation commonly to the right of the manubrium, some- 
 times to the left of it, occurs in aneurism of the thoracic aorta and may 
 often be felt when it is not seen. The force and extent of the impulse in 
 pulsating empyema are best estimated by palpation. 
 
 Epigastric Pulsation. — This phenomenon is generally regarded as 
 the sign of hypertrophy of the right ventricle and this view is unquestion- 
 ably in some cases correct. The hypertrophied and overacting right 
 heart communicates its movements to the tissues at the tip of and below 
 the ensiform cartilage. The retraction corresponds to time with the ven- 
 tricular systole and is due to the negative pressure caused by the altera- 
 tion in size and diminution in the volume of the ventricles at this moment 
 of the heart's revolution. Epigastric pulsation has been observed in cases 
 in which no hypertrophy of the right ventricle has been found post mor- 
 tem. Liver pulsation is much more frequently palpable than visible, and 
 the distinction between this condition and a liver jogged by an overacting 
 heart may often be made by bimanual palpation, since a pulsating liver 
 expands and contracts, a jogged liver merely moves. Bimanual palpation, 
 one hand upon the upper dorsal spine and the other upon the manubrium, 
 may detect the expansile pulsation of a deep-seated aortic aneurism which 
 presents no external signs. Diastolic shock is an important physical sign 
 of aneurism. The tips of the fingers upon the sac in case erosion of the 
 chest wall has taken place, or upon the surface directly overlying the sac, 
 may often detect a diastolic shock, sometimes of considerable force. 
 
94 MEDICAL DIAGNOSIS. 
 
 Crepitation. — In wounds and operations upon the neck and chest 
 air may find its way into the subcutaneous tissues and give rise to crepi- 
 tation upon palpation. In rare cases this condition may result from the 
 rupture of dilated peripheral pulmonary vesicles in emphysema. 
 
 Succussion. — When both fluid and air are present in a large space with 
 rigid walls, as in pneumohydrothorax or pneumopyothorax, a distinct vibra- 
 tion or impulse may be felt upon shaking the patient or causing him to 
 suddenly twist his body. This phenomenon, which is accompanied by a 
 splashing sound, constitutes the sign known as Hippocratic succussion. 
 
 The arterial pulse is studied by palpation. This subject will be fully 
 considered in a later section. 
 
 Thrills. — The palpable vibrations of the surface transmitted from 
 the interior of the heart or arteries are known as thrills. They are usually 
 confined to limited areas and may be easily overlooked unless the surface 
 is first searched with the palmar surface of the open hand. They may 
 then be studied with the finger-tips. They can frequently be felt only 
 upon the lightest pressure, wholly disappearing if the pressure be increased. 
 The sensation has been compared to that communicated to the hand by 
 the purring cat — jremissement cataire. Thrills are usually felt during a 
 portion of the cardiac revolution only — presystolic, systolic, post-sj^stolic. 
 They may disappear when the heart is acting feebly and become manifest 
 again when, with general improvement in the condition of the patient, 
 the heart contracts with greater power. They usually correspond in the 
 time of the cardiac cycle with audible murmurs or bruits and are signifi- 
 cant of the same lesions and produced by the same mechanism, namely, 
 fluid veins, the vibrations of which transmitted through tissues to the sur- 
 face are realized by the ear as murmurs, by the touch as thrills. In other 
 words the thrill is the sensory equivalent of the murmur. The fact that 
 very coarse thrills, especially the presystolic thrill, sometimes occur when no 
 murmur can be heard, does not militate against the foregoing statement, 
 since regular vibrations may be palpable though not frequent enough 
 to produce sound. It is in accordance with these statements that thrills 
 vary in the rapidity of their vibrations — fineness, coarseness — and that 
 the finer thrills correspond to the higher pitched murmurs and the reverse. 
 A thrill at the base of the heart of maximum intensity in the aortic 
 area is common in aortic stenosis. 
 
 A thrill of coarse quality, limited in extent, presystolic in time, more 
 marked during expiration, and most distinctly felt in the fourth or fifth 
 intercostal space inside the midclavicular line — mitral area — is the sign 
 of mitral stenosis. 
 
 A systolic thrill in the same area is sometimes present in mitral 
 incompetence and in rare instances in aortic stenosis. 
 
 A thrill often accompanies the presystolic murmur of aortic incompe- 
 tency — Flint's murmur. 
 
 A thrill diastolic in time is occasionally felt in aortic incompetency^ 
 but is not very common. 
 
 Thrills are common in congenital defects of the heart. 
 A thrill systolic in time at the second left costal cartilage and inter- 
 space — pulmonary area — is occasionally observed in exophthalmic goitre; 
 
PHYSICAL DIAGNOSIS: PALPATION. 95 
 
 very rarely it is a sign of pulmonary stenosis. A diastolic thrill in this 
 area may be the sign of a rare condition, pulmonary incompetency. 
 
 A thrill over the lower portion of the sternum and at its right border — 
 tricuspid area — sometimes occurs in dilatation of the right ventricle and 
 tricuspid incompetence. 
 
 Systolic thrills when beyond the limits of the precordial space are 
 more likely to be indicative of thoracic aneurism than of valvular disease. 
 They are oftenest felt to the right of the sternal border and above the 
 fourth rib, but may be present in the left side in a corresponding region. 
 They are more common in aortic dilatation than in sacculated aneurism. 
 
 It is important to recognize the difference between a thrill and the 
 slight shuddering tremor which may be felt in the merely overacting 
 heart, as in palpitation from any cause. 
 
 Fremitus. — Fremere, to roar or murmur as a crowd or mob; techni- 
 cally, palpable vibration. The difference between a thrill and fremitus 
 is much more readily recognized than described. It is, however, an essen- 
 tial difference and depends upon the difference in the mechanism by which 
 they are respectively produced. Fremitus is usually much coarser than 
 thrills, the vibrations are irregular and variable, the extent is far wider, 
 and fremitus, even when produced by the movement of the heart as in the 
 friction fremitus of pericarditis, does not constantly conform to definite 
 movements in the cardiac cycle. Fremitus is a tactile phenomenon com- 
 municated to the surface of the chest by the act of phonation — vocal 
 fremitus; by the friction of roughened surfaces against each other — fric- 
 tion fremitus; or by the respiratory movement of exudates of varying 
 consistency within the bronchial tubes — rhonchal fremitus. 
 
 Vocal Fremitus. — This physical sign is of great value in the diagnosis 
 of diseases of the respiratory organs. It is frec[uently spoken of as tactile 
 fremitus, but erroneously so, since all fremitus is tactile. The hand is laid 
 upon the bared chest while the patient counts "one, two, three,'' or repeats 
 some words, as "twenty-one" or "ninety-nine." Under normal circum- 
 stances the fremitus is more intense in men than in women, in adults than 
 in children, and in persons whose voices are powerful and low-pitched than 
 in those whose voices are feeble and shrill. The patient should be asked 
 to repeat the same phrase as the examining hand passes from one part 
 of his chest to another, and to let his speaking be loud, low, and slow, always 
 as nearly as possible in the same tone. This method of physical diagnosis 
 is without value in persons suffering from aphonia or in those so feeble 
 that they can only use the whispering voice. It is practicable in young 
 infants who cry during the examination. 
 
 Vocal Fremitus in Health. — The vibrations of the vocal cords 
 in phonation are transmitted along the walls of the trachea and bronchi 
 and the column of air which they contain to the surface of the chest, which 
 is thus set into vibration from within. These vibrations vary in different 
 regions normally, and are most distinct where the large bronchial tubes 
 approach the chest wall, less distinct where the mass of intervening vesicu- 
 lar tissue is greatest, and feeble or absent where the lung tissue does not • 
 come into contact with the wall, as in the precordial space. Pathological 
 conditions which increase the capacity of the lung to conduct vibrations. 
 
96 MEDICAL DIAGNOSIS. 
 
 as consolidation, intensify the vocal fremitus; those which separate the 
 lung from the wall, as pleural effusions, diminish or abolish it, as the case 
 may be. There is normally considerable difference in the intensity of the 
 vocal fremitus in the two sides, especially in the upper regions. This 
 inequality is to be constantly borne in mind. The vibrations are more 
 intense on the right than on the left side, in the upper (subclavicular) 
 region than in the lower (inframammary), and in front than behind. It is 
 feeble over the scapulae, and usually absent or very feeble in that portion 
 of the precordial space which corresponds to the area of superficial cardiac 
 dulness. A thick layer of subcutaneous fat impairs the value of this physi- 
 cal sign, while a thin, elastic chest wall and deep voice render it very useful. 
 Vocal Fremitus in Disease of the Respiratory Organs. — The 
 vibrations are intensified by conditions which cause consolidation of the 
 lung, as tuberculous infiltration, croupous and bronchopneumonia, hypo- 
 static congestion and atelectasis; they are enfeebled or absent altogether 
 in pathological conditions which separate the periphery of the lung from 
 contact with the chest wall, such as pleural effusion, pneumothorax, and 
 cysts or tumors in the pleural cavity. Pleural thickening is usually attended 
 with enfeeblement of the vocal fremitus proportionate to its degree, and, 
 as a much thickened pleura gives rise to impairment of resonance, the 
 differential diagnosis between a moderate effusion and pleural thickening 
 may be attended with difficulty. 
 
 Temporary disappearance of vocal fremitus in pneumonia in an area 
 corresponding to a lobe or part of a lobe may be caused by the plugging 
 of a large bronchus with a mass of tenacious mucus. In the same manner 
 a foreign body may cause localized absence of this sign. In infants and 
 less frequently in adults distinct vocal fremitus is occasionally encountered 
 upon the affected side in large effusions — a very puzzling phenomenon. 
 The most probable explanation of this anomaly in children is that the 
 intense fremitus caused by violent crying is transmitted along the elastic 
 chest walls from the sound to the affected side of the chest; in adults, that 
 tensely stretched strands or bands, the result of partial adhesions caused 
 by a former attack of fibrinous pleurisy, conduct the vibrations from the 
 compressed lung to the wall of the chest. In a moderate effusion under 
 favorable circumstances the following variations may be recognized: 
 normal vocal fremitus over the apex, enfeebled fremitus in the mammary 
 region, and the complete absence of this sign at the base. 
 
 If the limitations of its usefulness be borne in mind, vocal fremitus 
 is a sign of very great value, but it may mislead the unwary. In massive 
 pericardial effusion it is of great service in the differential diagnosis 
 between that condition and large left-sided pleural effusion. 
 
 Friction Fremitus. — In health the smooth and moist pleural and peri- 
 cardial surfaces move upon each other without appreciable sound. When 
 these surfaces are the seat of a fibrinous exudate they cause friction sounds 
 which vary with the arrangement and density of the exudate and the 
 energy of the respiratory or cardiac movements as the case may be. The 
 vibrations which cause the sounds are transmitted to the surface and con- 
 stitute the tactile sign known as friction fremitus. The sensation com- 
 municated to the examining finger is that of grating or rubbing and varies 
 
PHYSICAL DIAGNOSIS: PALPATION. 97 
 
 from the finest grazing to a coarse attrition. It corresponds in location 
 and extent with the friction sound which is its auditory equivalent. 
 
 Pleural fremitus is common in the infra-axillary region or below 
 the nipple and is not transmitted beyond a limited area. 
 
 Pericardial fremitus, which is the sign of fibrinous or dry peri- 
 carditis, is felt in the precordial space over the right ventricle. It does 
 not usually correspond in time accurately with the systole or diastole, 
 gives the impression of being very superficial and is limited to a circum- 
 scribed area. It differs from the thrills felt over the heart in the tactile 
 qualities referred to in a preceding paragraph. 
 
 Pleural fremitus and pericardial friction fremitus disappear as 
 effusion takes place, separating the roughened surfaces, and as adhesions 
 develop, by which the surfaces are united. 
 
 Rhonchal Fremitus. — Coarse bronchial rales, both dry and moist, 
 sometimes communicate irregular vibrations to the surface of the chest 
 readily recognized upon palpation. This form of fremitus is common in 
 young children and may occur in thin-chested adults. It differs from fric- 
 tion fremitus in being coarse and more irregular and varying in intensity 
 and quality with the rales that cause it. The sign is of little diagnostic value. 
 
 Tracheal tugging, a sign first described by Oliver, is of great value 
 in the diagnosis of deep-seated thoracic aneurism. "Place the patient in 
 the erect position and direct him to close his mouth and elevate his chin 
 to almost the full extent; then grasp the cricoid cartilage between the 
 finger and thumb and use steady and gentle upward pressure on it, when, 
 if dilatation or aneurism exists, the pulsation of the aorta will be distinctly 
 felt transmitted through the trachea to the hand." A better method con- 
 sists in the application of the index and middle fingers of the same hand 
 on the sides of the cricoid cartilage, or the physician may stand behind 
 the patient, who is seated, and place the forefingers upon the sides of the 
 cricoid, with gentle upward pressure. The downward tug may be readily 
 recognized. The tug is due to the fact that the arch of the aorta passes 
 over the left primary bronchus in such a manner that when the aorta is 
 dilated it impinges upon the bronchus with each pulsation. The tension 
 of the bronchus is communicated through the trachea to the larynx. A 
 downward tug felt only upon inspiration is frequently present in health 
 and has no diagnostic value. Pulsation transmitted from the vessels of 
 the neck to the cricoid must not be confounded with tracheal tugging. 
 The movement of the former is forward and backward; of the latter a 
 distinct downward pull with release. 
 
 Palpation in the Examination of the Abdomen. 
 
 This is the most valuable of the methods of physical diagnosis in 
 diseases of the organs below the midriff. The patient should be in bed 
 and the belly should be bared as for inspection. The hand of the physi- 
 cian should be warmed and applied to the surface -with gentle pressure. 
 One or both hands may be necessary. Bimanual palpation may be from 
 side to side, the wall of the abdomen being deeply folded between the 
 hands, or any accessible organ or tumor being thus investigated, or the 
 
 7 
 
98 MEDICAL DIAGNOSIS. 
 
 bimanual method may be used in the study of the lateral regions of the 
 abdomen, one hand being placed in the lumbar region, the other in front. 
 In this manner the border of the liver may be raised up against the 
 anterior wall or a floating kidney thrust forward for examination, or 
 deep fluctuation elicited in paranephritic or appendiceal abscess, or a 
 hydronephrosis studied, or the contour of an enlarged spleen or carcinoma 
 of the sigmoid flexure made out. When the object of the examination is 
 to localize and determine the degree of tenderness it is better to study the 
 face of the patient than to depend upon his statements or exclamations. It 
 is also important to distinguish between superficial tenderness, as in cutane- 
 ous hyperaesthesia and the deep tenderness of an inflamed or tumid organ. 
 It will frequently be found that here as elsewhere, in neurotic persons, 
 more vivid expressions of pain are called forth by a light touch than by 
 firmer pressure — a fact in itself of great diagnostic importance. 
 
 Excessive abdominal fat, muscular tension, and ticklishness are obsta- 
 cles. The first often nullifies the results of palpation; the others may 
 be overcome. Muscular tension due to apprehension, the excitement of 
 the occasion, or other nervous causes may be overcome by elevating the 
 head upon pillows and causing the patient to flex his thighs and knees; 
 continuous deep or rapid breathing is also useful. Tact and address on 
 the part of the physician and suggestion are also to be employed. It is 
 frequently necessary to examine the patient under general anaesthesia 
 before expressing a final opinion as to the nature of the case, and finally, 
 there are serious cases of abdominal disease in which it may become neces- 
 sary to perform an exploratory operation to arrive at a positive diagnosis. 
 Ticklishness is an obstacle of minor importance, but it may call for the 
 exercise of much patience on the part of both the doctor and the patient. 
 
 It often becomes necessary to turn the patient from side to side or 
 to examine him in the knee-elbow posture, or standing. A digital exami- 
 nation by the rectum or vagina with or without bimanual manipulation 
 is frequently required in lesions of the lower portions of the abdomen. 
 
 The regions of the abdomen must be in turn systematically explored, 
 the natural rings and accidental sites of hernia examined, and the general 
 outline, contour, and condition of the belly, particularly as to its symmetry 
 and elasticity, carefully determined. Large knowledge of the changes 
 caused by abdominal disease and wide experience are required in this 
 field of diagnosis. Here also a delicate and well-trained touch — tactus 
 eruditus — is especially serviceable. 
 
 The signs obtained by inspection are confirmed by palpation. i\Iuch 
 knowledge is' obtained by the latter method. This comprises the follow- 
 ing subjects: 
 
 The Condition of the Abdominal Walls, 
 
 General and Local Fluctuation, 
 
 Pulsation, Thrill and Fremitus, 
 
 The Respiratory, Postural, and Manipulative Movements of Organs 
 or Tumors, 
 
 Peristaltic and Fetal Movements, 
 
 The Outline and Relations of Palpable Tumors, 
 
 Their Density and Elasticity, 
 
 The Nature of the Surface of Tumors. 
 
PHYSICAL DIAGNOSIS: PALPATION. 99 
 
 The Abdominal Walls.— In healthy young persons the belly walls 
 are soft and elastic but neither tense nor relaxed, and the curvature of 
 the abdomen as determined by inspection and palpation is symmetrical 
 and uniform. 
 
 Abnormal firmness and relaxation are attended by a loss of healthy 
 elasticity. Local firmness may be caused by inflammatory or carcinoma- 
 tous infiltration, and general hardness by the massive enlargement of the 
 liver, spleen, uterus, an ovary, or other organ, or diffuse malignant deposits 
 in the intestines or peritoneum. Muscular rigidity is characteristic of the 
 early stage of peritonitis. It may be localized, as in the right lower quad- 
 rant in appendicitis or enteric fever, or general. Local rigidity of the 
 bellies of the recti is sometimes observed in neurotic persons and ma}' be 
 mistaken for a tumor, as a thickened or carcinomatous pylorus. Local 
 rigidity with meteorism constitutes phantom tumor. A generalized inelas- 
 tic doughy sensation upon palpation is often observed in tuberculous 
 peritonitis. The general distention of ascites is associated with dulness 
 save in the upper portions, where there is tympany, and with fluctuation; 
 that of meteorism is associated with tympany everywhere, including the 
 dependent parts, and a balloon-like elasticity quite different from that of 
 the normal abdomen. The anasarcous abdominal wall is doughy, inelastic, 
 and pits upon pressure; dropsical accumulations are seen in the flank 
 and elsewhere in the more dependent parts. 
 
 Relaxation follows the resorption of large amounts of fat and repeated 
 childbearing. In such cases the belly wall is often pendulous and remark- 
 ably puckered and thrown into folds when the patient lies upon her back. 
 Relaxation also follows ascites of long standing and the removal of large 
 tumors and is usually present in old age and the advanced stages of wast- 
 ing diseases. In women who have borne many children wide separation 
 of the recti is occasionally seen, the connective tissue of the linea alba 
 being enormously stretched and thinned and the gastric and intestinal 
 peristalsis plainly seen and felt over a large area in the middle of the 
 abdomen. In such cases very large ventral hernia and downward displace- 
 ment of the abdominal viscera — Glenard's disease — are commonly present. 
 
 Local tumors of the abdominal walls are abscess, attended by local 
 induration and central softening; cysts, oval or circular in outline, tense, 
 elastic and fluctuating; enlarged lymph-nodes in the inguinal region; 
 subcutaneous carcinomatous and sarcomatous tumors, which may be mov- 
 able or immovable, and arranged in irregular masses as is common in the 
 former, or scattered singly over a wide area as in sarcoma; and hernia. 
 The last appears in definite locations, as the inguinal and crural rings, the 
 umbilicus, in the linea alba — ventral hernia — and in the sites of scars after 
 surgical operations. Upon palpation the hernial tumor is usually soft, 
 elastic and reducible; omental hernias are doughy and irregular in outline. 
 The hernia which cannot be returned to the abdomen by manipulation 
 is irreducible, that which is tightly constricted and is therefore likely to 
 become or has already become sphacelated is strangulated. 
 
 The umbilicus that pouts in ascites or pregnancy is smooth, stretched, 
 and somewhat translucent. In umbilical hernia the ring is usually dis- 
 tinctly felt; when omental the tumor at the navel is often large, firm, 
 
100 MEDICAL DIAGNOSIS. 
 
 irregular in its surface and irreducible and may suggest a malignant growth. 
 The umbilicus, normally somewhat movable, when the seat of secondary 
 carcinoma, usually by extension from the liver, becomes fixed and is indu- 
 rated and nodular. Tuberculous infiltration of the tissues around the 
 navel has been observed in tuberculosis of the peritoneum. A deeply 
 seated, painful swelling of the navel is usually an abscess. 
 
 Fluctuation. ^This sign is elicited b}" combined bimanual percussion 
 and palpation, those methods being employed at the limits of the area 
 examined, as for example at the right and left lateral regions of the abdo- 
 men in suspected ascites and at the opposite borders of circumscribed 
 collections of fluid as in pancreatic or other cysts. To elicit general fluc- 
 tuation the palpating left hand or finger-tips are lightly laid upon the sur- 
 face of the right side of the patient's abdomen, while with the fingers of 
 his right hand the examiner percusses or taps somewhat sharply upon 
 the left side of the abdomen. If there be ascites a transmitted wave cor- 
 responding to each tap is felt upon the opposite side. This wave is also 
 in many cases visible. Very light percussion may bring out this physical 
 sign when the wall of the abdomen is thin. The thin ulnar border of the 
 hand of an assistant must be rather firmly pressed against the abdomen 
 in the middle line to arrest the undulatory transverse movement of the 
 wall, which very often simulates the fluctuation of peritoneal effusion. 
 This sign does not arise unless the fluid is freely movable and sufficient 
 in amount to rise above the pelvis — two or more litres. 
 
 The method of determining fluctuation in circumscribed collections 
 of fluid, as pancreatic or other cysts within the abdomen, circumscribed 
 effusions, dropsy or empyema of the gall-bladder, etc., is somewhat differ- 
 ent in technic and available only in patients w'hose belly walls are com- 
 paratively thin. The tips of the palpating fingers are lightly placed in 
 contact with the surface at one border of the area under examination while 
 the opposite border is sharply but lightly flicked with the nail — dorsal 
 surface of the tip of the middle or ring finger suddenly disengaged from 
 contact with the palmar surface of the thumb, as one flicks a crumb. By 
 this method not only can fluctuation of limited extent be determined but 
 also the limits of the area in which it is present defined. 
 
 Pulsation, Thrill and Fremitus. — Pulsation. — In thin persons the 
 normal pulsation of the aorta may be felt upon deep palpation in the middle 
 line about the level of the umbilicus. Abnormal pulsation of the abdomi- 
 nal aorta is of two kinds, the so-called dynamic pulsation seen in neurotic 
 persons, not expansile and not associated with tumor or other signs of 
 dilatation of the vessel, and the expansile pulsation of abdominal aneurism, 
 in which a tumor that can be grasped between the hands and is the seat 
 of distinct expansile pulsation may be present together with other signs 
 of aneurism. The differential diagnosis between these two forms of pul- 
 sation should not be a matter of doubt. Pulsation is sometimes trans- 
 mitted from the aorta to a tumor overlying it in such a manner as to 
 simulate aneurism, especially as the pressure of the tumor may cause 
 both bruit and thrill. The fact that the pulsation is not expansile and the 
 palpation of the tumor in the knee-elbow posture, when the movement of 
 the aorta is no longer communicated to it, serve to render the differential 
 
PHYSICAL DIAGNOSIS: PALPATION. 101 
 
 diagnosis between such a tumor and aneurism a matter of comparative 
 ease. Dynamic pulsation of the aorta is felt in the course of the vessel 
 in the middle line and slightly to the left of it; that of aneurism is usually 
 more extended transversely and may be felt some distance to the left, 
 even reaching almost as far as the iliac crest, as I saw in a case verified 
 by autopsy. 
 
 The liver pulsation due to tricuspid incompetency — hepatic venous 
 pulse — may freciuently be recognized upon palpation, especially bimanual 
 palpation, when it is not visible upon inspection, and by the former method 
 the difference between the expansive movement of a pulsating liver and 
 the jogging due to the communicated movement of the heart may be 
 appreciated. 
 
 Thrill. — This sign is sometimes met with in abdominal aneurism and 
 tumors pressing upon the aorta. It has little diagnostic significance. 
 
 Fremitus is the sign of echinococcus cysts — hydatid fremitus or thrill. 
 The tumor is soft, elastic, fluctuating, and in the majority of cases the seat 
 of a peculiar vibration or fremitus, which may be felt by palpation with 
 two or three fingers of the same hand or by placing three finger-tips widely 
 separated upon the surface and lightly percussing the middle finger. Gall- 
 stone fremitus is sometimes elicited upon palpation of the gall-bladder 
 distended with a large number of calculi. It is a comparatively rare but 
 very important sign. 
 
 Movements of Abdominal Organs or Tumors. — The movements of 
 intra-abdominal organs and tumors constitute physical signs of great 
 value in diagnosis. They may be observed in some instances upon 
 inspection but very often can be felt when they cannot be seen. They are 
 respiratory, postural, and manipulative. 
 
 Respiratory movements are communicated to the organs in close 
 relation to the diaphragm, especially the liver, spleen, and to a less extent 
 the kidneys. Tumors of the stomach, owing to its being a hollow viscus, 
 are usually but little if at all influenced by the movements of the dia- 
 phragm. When adhesions have taken place with the diaphragm itself 
 or the liver or spleen, tumors of the stomach share with these organs in 
 the respiratory movements. Conditions which hinder the respiratory 
 movements of the diaphragm, such as pleurisy, emphysema, massive 
 enlargement of the liver or spleen, advanced pregnancy, meteorism and 
 ascites, restrict or wholly arrest the respiratory movements of abdominal 
 viscera. The anatomical relations of the pancreas and retroperitoneal 
 glands are such that they are not influenced by the movements of res- 
 piration. Very large cysts of the pancreas may show slight movement 
 on deep breathing. 
 
 Intra-abdominal new growths which are influenced by respiratory 
 movements originate in the upper portion of the cavity; those which 
 manifest no respiratory movement upon careful palpation commonly 
 but not always develop from the pelvic organs or from structures directly 
 connected with the spinal column behind the peritoneum — pancreas, 
 retroperitoneal lymphatic glands, aneurism. It is evident that the ante- 
 rior portion of a tumor originating behind the peritoneum, sufficiently 
 large and not too rigid, may be somewhat influenced by deep respiration. 
 
102 MEDICAL DIAGNOSIS. 
 
 In determining such movements the fingers grasp the tumor or the ulnar 
 edge of the hand is pressed against its upper border during full inspiration; 
 upon expiration it is felt to slip upwards. 
 
 Postural Movements. — Free fluid in the cavity tends to gravitate 
 to the most dependent space while the air-containing intestines float upon 
 the surface of the fluid. The importance of this general fact has been 
 dwelt upon in a previous section. Small effusions may cause dulness in 
 the umbilical region when the patient assumes the knee-elbow position. 
 Floating viscera, kidneys, sj^leen, and in very rare instances the liver, are 
 recognized upon palpation by their size, shape, and general relationships. 
 The Uver when dislocated has but little range of movement, but the kid- 
 ney and spleen may be found in distant regions of the abdominal cavity, 
 even at the brim of the pelvis. 
 
 The Technic of Palpation of the Kidney. — The recognition of 
 a displaced kidney is not attended with difficulty. Palpation should be 
 bimanual, one hand pressing upward from the lumbar region while the 
 other is gently moved over the anterior surface of the abdomen, which 
 should be as relaxed as possible. The tumor is oval, smooth, firm, and has 
 the oblong shape of the kidney. It is sometimes possible to recognize the 
 hilum and to feel the pulsating renal artery. The tumor is usually sensi- 
 tive to firm pressure and freely movable. In the knee-elbow posture it 
 advances towards the wall of the abdomen, while it sinks backward and 
 may be pressed into its normal position when the patient assumes the 
 dorsal decubitus. In the lateral and erect postures, it sinks to the lowest 
 point of its range of movement. Except in the case of a much elongated 
 mesonephron, it moves also with the movements of respiration. Wan- 
 dering kidney is more common in women, in multipara, upon the right 
 than the left side and is occasionally bilateral. 
 
 The Technic of Palpation of the Spleen. — The patient should 
 be placed in a position midway between right lateral and dorsal, with 
 his left hand upon his head. The thighs should be flexed in order to relax 
 as far as possible the abdominal wall. The head should be slightly 
 retracted and the patient directed to breathe deeply and slowly. The 
 physician, standing at the patient's right, exerts with his left hand firm 
 pressure upon the infra-axillary region downwards and forwards while, with 
 his right hand, he presses the soft belly wall below the arch of the ribs 
 upwards and inwards to determine whether or not the lower border of the 
 spleen can be felt and in particular at the end of deep inspiration. The 
 physiological variations in the size of the organ should be borne in mind. 
 It requires some skill to recognize slight increase in volume and abnormal 
 consistency and anomalies in shape. Too much force must not be employed 
 lest a, greatly softened spleen, as in enteric fever, might be ruptured. The 
 data yieldecl by percussion in the examination of the spleen are rendered 
 uncertain by, gastrectasis, meteroism, pleural effusion, and fecal accu- 
 mulations in the colon and new growths in the splenic region. The 
 results of palpation in moderate enlargement are much more satisfactory 
 and reliable. : ■'■.. . . 
 
 The diagjip^is ;Qf massive enUr,gement of the spleen is usually a matter 
 of .ea?e.and certainty. The contour of the tumor, upon which may bedis- 
 
PHYSICAL DIAGNOSIS: PALPATION. 103 
 
 tinctly felt a sharply rounded inner border, often notched opposite the 
 hilum, its firmness, its slight movement upon deep breathing, and the 
 smoothness of the surface are of diagnostic importance. 
 
 Wandering spleen is not often difficult of recognition. The displaced 
 organ is readily palpable below the left hypochondrium, less often in the 
 umbilical or left iliac region and very rarely at the brim of the pelvis, as 
 a smooth oval tumor of the outline of the spleen, notched and freely mov- 
 able upon change of posture and by manipulation. If the gastrosplenic 
 ligament and the splenic vessels are much elongated, namely, if the organ 
 occupies a position to which the movements of the diaphragm do not 
 extend, it does not move even upon the deepest respiration. 
 
 In some cases a tumor of the pylorus is extremely movable and may 
 show a lateral range of several inches as the patient turns from side to 
 side. Mesenteric cysts are usually situated below and to the right of 
 the umbilicus and are often freely movable in all directions. The same is 
 true of omental tumors. 
 
 Movements upon Manipulation.- — All abnormal organs and tumors 
 that change their position in response to changes in posture are movable 
 upon manipulation or palpation. The list comprises floating liver, spleen, 
 and kidney; in the absence of adhesions, tumors of the pylorus and less 
 frequently of other parts of the stomach, as the greater curvature, new 
 growths in the intestines, excepting the ascending and descending colon; 
 fecal accumulations, gall-stones and enteroliths; mesenteric and omental 
 tumors. The range of movement is limited in tumors of the gall-bladder 
 and pancreatic cyst, in the upper regions of the abdomen; very limited 
 in tumors of the ascending and descending colon laterally and enlarge- 
 ments of the uterus and ovaries in the lower segment. All malignant and 
 some benign tumors tend to contract adhesions which interfere with move- 
 ment. The following are immovable, small tumors of the pancreas, retro- 
 peritoneal growths, peri-appendiceal infiltration, adhesions and abscess, 
 abdominal aneurism and abscesses. 
 
 Peristaltic and Fetal Movements. — The peristaltic movements 
 may sometimes be felt, as they may be seen, in thin individuals in health 
 and when in obstruction of the bowel they become excessive. In chronic, 
 slowly developing stenosis of the gut the musculature of the intestines 
 undergoes hypertrophy and the peristalsis becomes proportionately more 
 powerful. Antiperistaltic or reverse waves may sometimes be felt. Pal- 
 pable coarse intestinal movements with the formation of knots accom- 
 panied by borborygmi may be present in colic and in hysteria. The gastric 
 and intestinal movements are very plainly felt and seen in cases of wide 
 separation of the recti in women who have borne man}^ children. 
 
 The movements of the foetus may be often plainly felt upon palpation, 
 and in advanced pregnancy the position of the foetus may be recognized 
 by this method of examination. All these movements may be rendered 
 more active by manipulation and the sudden application of cold. 
 
 Tumors of the stomach and intestines when not fixed by adhesions fre- 
 quently undergo slight changes in position with the peristaltic movements. 
 
 Outline. — The outline and relations of tumors as determined by 
 palpation constitute most important diagnositic criteria. We thusirtieter- 
 
104 MEDICAL DIAGNOSIS. 
 
 mine whether an intra-abdominal mass is round, oval, or irregular in out- 
 line ; whether it is rough, nodular, or smooth ; whether it resembles a viscus 
 as the kidney or spleen in shape and has characteristic anatomical features, 
 as the hilum or a pulsating artery. We ascertain its apparent point of 
 origin, as in the epigastrium, the lateral regions of the abdomen, or the 
 pelvis, and whether or not it has direct attachments or relations with 
 another organ, such as msLy be made out between an enlarged gall-bladder 
 and the liver, carcinoma of the pylorus and the stomach, or a large cyst 
 in the left hypochondrium and the pancreas. 
 
 Density and Elasticity. — The signs relating to the consistency of an 
 intra-abdominal mass can be ascertained by palpation alone. We thus 
 determine whether it is fluctuating as in abscess or cyst; soft as in rapidly 
 developing new growths and aneurism; moderately firm as in organs the 
 seat of congestion and hypertrophy, or dense and strong as in slowly 
 developing carcinoma or interstitial overgrowths — hepatic cirrhosis. We 
 note also that in fecal accumulations the tumor is sometimes hard and 
 firm and sometimes soft and doughy and can be indented by the finger. 
 
 Surface. — Palpation enables us to determine the smoothness or 
 unevenness of the surfaces of organs and tumors. The smooth surface 
 of an amyloid or fatty liver, the coarse granular surface of the liver in 
 atrophic cirrhosis, the nodular liver with its rounded isolated eminences 
 at the summit of which slight depressions may be felt — Farre's tubercles — 
 in cancer, are examples of surface changes of diagnostic importance. The 
 smooth surface of the distended gall-bladder stands in strong contrast 
 with the irregular outline of carcinoma of the pylorus; the irregular multi- 
 locular echinococcus of the liver can hardly be differentiated from hepatic 
 cancer, but is wholly unlike the smooth, elastic, and vibrating single hydatid 
 cyst. The smooth, elastic, and fluctuating cyst in hydronephrosis differs 
 altogether from the firm, nodular and irregularly shaped mass in carcinoma 
 of the kidney; and the smooth, ovoid, nearly centrally placed tumor of 
 early pregnancy is wholly unlike the tumor formed by irregular, coarsely 
 nodular subperitoneal uterine myomata. 
 
 Thayer of Galveston has suggested a method of palpating the abdom- 
 inal organs which is of practical value. The patient should sit up in 
 bed, or, if a walking patient, upon a table, with the knees widely separated 
 and the soles of the feet together, and the hands resting upon the calves 
 or the knees. The body from the waist up is then supported upon a tripod, 
 composed of the spine and the arms. The elbows should be nearly or quite 
 extended, but ready to be flexed or held entirely straight, as the physician 
 asks for more or less space. Under ordinary quiet breathing this posture 
 permits the viscera to come forward into the field of examination to the 
 full extent permitted by their normal attachments, the liver, stomach, 
 and spleen coming down, and the flanks and their contents coming for- 
 ward, and the relaxed integuments approaching the mid-line, in such a 
 manner that everything accessible in this examination tends to approach 
 the anterior abdominal wall, instead of receding from it. 
 
 The examiner sits behind the patient, his outer foot on the floor, his 
 inner leg flexed at the knee, with the foot on his other knee or beneath it. 
 This flexed knee is applied to the lower lumbar region, or the sacrum, of 
 
PHYSICAL DIAGNOSIS: MENSURATION. 105 
 
 the patient, and, since the pressure of the tibial tuberosity causes discom- 
 fort, he should save the patient this by putting a pillow between his knee 
 and the subject's back. 
 
 The abdominal wall is relaxed and the abdominal contents tend to 
 fall forward against the wall and may be readily palpated b}^ the hands 
 of the examiner, which are passed around the sides of the patient under 
 his arms. The organs, tumors, exudates are examined in a position cor- 
 responding to that of the body of the examiner. If the patient is too ill 
 to sit up he may be moved to the edge of the bed with his back toward the 
 examiner and his lower limbs strongly flexed, and palpation performed in the 
 same manner. 
 
 MENSURATION. 
 
 The use of instruments of precision is of great importance in physical 
 diagnosis. Such appliances vary from a simple graduated tape to the 
 most intricate and delicate hae mo dynamo meter or polygraph. The writer 
 holds the opinion that simplicity both of method and of instruments 
 yields the most satisfactory results at the bedside, and that intricate and 
 costly mechanical devices which require great technical skill and con- 
 sume much time are better suited to scientific research than to every-day 
 clinical work. 
 
 Measurements of the chest — thoracometry — may be conveniently 
 made by a steel tape graduated upon one side in centimetres, on the other 
 in inches; the diameters are taken by calipers made for the purpose. 
 
 The circumference and semicircumferences are taken at the level 
 of the nipples or the fourth costosternal articulation in quiet breathing, in 
 full held inspiration and on full expiration. Care must be taken that the 
 tape is horizontal. The normal chest is nearly but not quite symmetrical, 
 the right semicircumference being in the majority of individuals slightly 
 larger than the left — an average difference of about half an inch. It is 
 well to make a mark with a dermatographic pencil in the median line in 
 front and over a vertebral spine at the same level and measure the semi-- 
 circumference from point to point on each side for comparison. Two tapes 
 attached to a little wooden saddle which fits over a vertebra are useful to 
 determine the semicircumference on quiet breathing and the differences 
 on forced respiration. The average circumference in men is 34.3 inches 
 (87 cm.); in women 29.5 inches — (75 cm.). The difference in forced 
 expiration and full held inspiration varies in normal individuals between 
 1.5 (4 cm.) and 5 inches (12.5 cm.). 
 
 The main diameters of the chest at the same level as taken by compass 
 calipers with curved arms or slide calipers are : anteroposterior (the depth 
 of the chest) average in repose in men 7.5 inches (19 cm.); in women 
 6.9 inches (17 cm.); bilateral or transverse (the breadth of the chest), 
 average in men 9.9 inches (25 cm.). 
 
 Spirometry.— Mensuration may be employed not only to ascertain 
 the size of the chest and its movements but also to learn the volume of 
 the tidal air. The instrument used for this purpose is the spirometer. 
 Various forms are in use but the results are far from satisfactory. The 
 instruments are cumbersome and require a certain amount of training to 
 
106 MEDICAL DIAGNOSIS. 
 
 obtain constant results. The sex, age, weight and height must be taken 
 into account. Thus for every inch above five feet, eight cubic inches are 
 to be added to the normal standard, which for five feet is 174 cubic inches. 
 The estimated average lung capacity for height in males between sixteen 
 and forty years of age is, according to Otis, twenty-three cubic centimetres 
 for every centimetre of height; in females at nineteen years of age, it is 
 fifteen cubic centimetres for each centimetre of height. 
 
 Waldenburg's pneumatometer is an apparatus designed to measure the 
 respiratory energy. Normally the power exerted in expiration is greater 
 than in inspiration by from twenty to thirty millimetres of mercury. 
 In emphysema and asthma the expiratory pressure is greatly diminished, 
 while in certain forms of phthisis the inspiratory power is much lessened. 
 
 Cyrtometry. — The determination of the outline of a cross-section of 
 the chest may be made with an instrument called a cyrtometer — measure 
 of the curve. This procedure is of no great use in ordinary clinical work 
 but very suggestive and important in teaching. Elaborate and costly 
 instruments are not necessary for this purpose. The best device consists 
 in a little metal saddle made to fit the spine, to each side of which is hinged 
 a strip of leaden ribbon half an inch in width and thick enough to be easily 
 bent so as to conform to the surface of the chest, yet retain its form when 
 removed. The saddle is set upon the spine at the level selected, the leaden 
 band is carefully adjusted to the surface on each side and made to meet 
 at the median line in front. It is then released, opened at the hinges, 
 removed from the chest and then laid upon a sheet of paper, the ends 
 being brought together at the point of meeting in the median line. The 
 outline is controlled by the fixation of the main diameters by means of 
 the calipers. A soft pencil is then used to make the tracing on the inside 
 of the cyrtometer. The various deformities of the chest described under 
 inspection may be thus depicted. 
 
 Circumferential measurements of the abdomen at the level of the 
 umbilicus and vertical measurements from the ensiform cartilage are 
 useful, especially for purposes of comparison in ascites and enlargements 
 from tumor or other conditions. They are best made with the ordinary 
 graduated tape. Measurements from various fixed points upon the surface 
 of the thorax or abdomen are necessary for purposes of record. 
 
 The Sphygmograph. — This is an instrument for the graphic registra- 
 tion of the pulse. There are various forms. Vierordt's, 1855, was the earli- 
 est. Marey's, 1860, was more practical and as modified by Mahomed and 
 others is still much used. The instruments of Sommerbrodt, Jaquet and 
 Frey are more recent. That of Dudgeon has many advantages and is in 
 general use. Dudgeon makes the following claims for his instrument:. 
 
 That it magnifies the movements of the artery in a uniform degree, 
 namely, fifty times; that the pressure of the spring can be regulated from 
 1 to 5 ounces; that it requires no wrist rest and can be used with equal 
 facility whether the patient be standing, sitting, or recumbent: that a 
 tracing can be made with it almost as quickly as the pulse can be felt with 
 the finger; that owing to its great sensitiveness it records the slightest 
 deviation in the form or character of every beat; its construction is so 
 simple th'c.t any watchmaker can repair it if broken; that it is so small, 
 
PHYSICAL DIAGNOSIS: MENSURATION. 
 
 107 
 
 CYRTOMETRIC TRACINGS. 
 
 Fig. 48. — Outline of normal chest. 
 
 Fig. 49. — Outline of emphysematous chest. 
 
 Fig. 50. — Outline of chest showing "funnel-shaped" Fig. 51. — Outline of phthisical chest, 
 
 deformity. 
 
 Fig. 52. — Outline of the chest in spinal curvature. 
 
 Fig. 53. — Outline of the chest in rickets. 
 
108 
 
 MEDICAL DIAGNOSIS. 
 
 2§ X 2 inches, and so light, 4 ounces, that it msiy be carried in the pocket; 
 that it is much less expensive than other forms of the instrument. 
 
 The sphygmograph is of great value in clinical work but it is rarely 
 essential to a diagnosis. That which it adds to the information obtained 
 by the well-trained finger relates to minutia3 many of which are still the 
 subject of dispute. 
 
 It is chiefly useful in making permanent records for future compari- 
 son, in the graphic representation of details for purposes of discussion and 
 the teaching of students, and in leading to close habits of observation. It 
 corroborates facts in regard to the pulse previously obtained by palpation. 
 There is no instrument of precision employed in clinical medicine 
 the results of which are so greatly influenced by the personal equation. 
 A series of sphygmograms taken in succession in the same case by differ- 
 ent observers may show variations 
 that are remarkable and inex- 
 plicable. The regulation of the 
 pressure is uncertain and the diffi- 
 culties in the way of securing a uni- 
 form pressure at different times 
 and in different cases are in the 
 present state of development of 
 the instrument insurmountable. 
 The time consumed in the appli- 
 cation of the instrument is in 
 ordinary clinical work out of pro- 
 portion to the results. Neverthe- 
 less the sphygmograph has its 
 place and is regarded by those 
 who have by practice acquired 
 the ability to take rapid and accu- 
 rate tracings as a valuable aid to 
 systematic clinical work. 
 Directions for the application of Dudgeon's sphygmograph: 
 
 (a) Mark the exact position of the artery with a line drawn by ink or 
 a dermatographic pencil and prolonged to the ball of the thumb. 
 
 (b) Wind up the clockwork used to drive the smoked paper along 
 by means of the milled button at the back of the clockwork box. 
 
 (c) Insert the smoked paper between the rollers and under the writ- 
 ing needle. 
 
 (d) Place the patient in a comfortable position with the hand selected 
 pointing towards you, the wrist exposed, the fingers gently flexed and 
 the muscles relaxed, and request him to hold the hand and arm per- 
 fectly still. 
 
 (e) Slip the band, the free end of which has been drawn through the 
 retaining clamp, over the patient's hand. The metal box should be placed 
 toward the elbow. 
 
 (f) Adjust the instrument by placing the bulging button of the spring 
 directly over the radial artery as shown by the line previously drawn, and 
 close behind the prominence of the os trapezium. 
 
 Fig. 54. — Dudgeon's sphygmograph. 
 
PHYSICAL DIAGNOSIS : MENSURATION. 109 
 
 (g) Retain the instrument accurately in its place with the left hand 
 and draw the band through the clamp with the right until the writing 
 needle plays freely over the middle of the smoked paper; then fasten the 
 band by screwing up the clamp with the left hand. If the band is not 
 used, place the patient's hand and wrist on some proper support and 
 hold the instrument with one hand; or the band may be passed around 
 the wrist and held from underneath without clamping. 
 
 (h) Regulate the pressure by means of the milled head of the thumb 
 screw until the needle attains its greatest amplitude of movement. The 
 pressure is graduated in ounces but the reading is never reliable. 
 
 (i) Set the smoked paper in motion by pushing toward the right the 
 small lever at the top of the box, and either stop the mechanism by revers- 
 ing this lever just before the slip runs out or catch the slip in the free 
 hand. Two tracings may be taken at varying pressure or the clockwork 
 may be stopped about the middle 
 of the slip, the pressure increased 
 to the maximum and the tracing 
 resumed. The effect of medium 
 and maximum pressures is thus 
 obtained. Strips of paper of proper 
 texture and accurate size can be 
 obtained from the instrument- 
 makers. They are prepared for use 
 by passing them through the smoke 
 of burning gum camphor. For this 
 
 purpose a suitable holder is made Fig.55.— Diagram of normal pulse tracing. a,b, 
 
 frnm q atrir-. r>f iin +nrr>orl r^^Tor up-stroke, percussion stroke; ascending or anacrotic 
 
 ironi a strip OI tin turneu over jimb. 6, e, descending or catacroticlimb. a, 6, c, per- 
 
 cit fVio onrlo Tl- ia i i-nnnr-l-Q nf +Viq+ cussion wave; c, rf, e, predicrotic or tidal wave; e,f,g, 
 
 at tne enaS. it is important tnat dicrotic or recoil wave; 6, c,d, pretidal notch; d,e,f, 
 
 they be smoked as evenly as POS- the aortic notch; hi, base line The period indi- 
 
 . "^ . . ^ , cated between a and e corresponds to the ventncu- 
 
 Slble. After the tracing is made it lar systole; the period between e and g to the aortic 
 
 may be labelled with the name, date, 
 
 diagnosis, etc., upon the smoked surface with a coarse needle, or these facts 
 may be written with ink on the unsmoked end of the slip. The smoke 
 upon the surface of the paper is then set by passing the slip through a 
 quick drying varnish, such as photographer's negative varnish or a solu- 
 tion of benzoin in alcohol in the proportion of 1 ounce to 6. If the tracing 
 is to be much handled a second coat should be applied. 
 
 The Sphygmogram under Normal Conditions. — The percussion stroke 
 or ascending limb is caused by the wave-like transmission of the impulse 
 communicated to the blood in the arterial system by the ventricular sj's- 
 tole. The elastic walls of the suddenly distended artery contract slightly, 
 causing the aortic or pretidal notch, and again expand as indicated by the 
 tidal wave, after which the pressure again diminishes until the closure 
 of the aortic valves, by which a base of support is presented to the blood 
 column with a resultant recoil which is manifested in the dicrotic wave. 
 Insignificant undulatory curves in the lower part of the descending or 
 catacrotic limb, scarcely shown in ordinary tracings, are caused by minor 
 oscillations of the arterial walls. The intrinsic movements of an extremely 
 delicately adjusted and sensitive writing needle are to be taken into account 
 
110 
 
 MEDICAL DIAGNOSIS. 
 
 but cannot be determined. It is evident that the excursion of the needle 
 will be exaggerated when the pulse is quick and of large volume and that 
 under these circumstances the tracing represents the qualities of the pulse 
 plus certain qualities of the instrument not shown in tracings of other pulses, 
 particularly those of small volume, high tension, and tardy development. 
 
 The Diagnostic Significance of Sphygmograms. — In the normal sphyg- 
 mogram the up-stroke is straight, almost vertical, of moderate amplitude 
 as compared with the tracings of low and high tension pulses, the apex 
 acute rather than obtuse, the descent gradual, interrupted by a small tidal 
 and well-marked dicrotic wave. Sphygmograms are read from left to right. 
 
 Minor departures from the normal in any of these particulars cannot 
 be regarded as of diagnostic value. The tracings are much modified by cer- 
 tain pathological conditions and the following points deserve consideration: 
 
 Fig. 56. — Aortic regurgitation. 
 
 Amplitude. — The length of the percussion stroke varies considera- 
 bly under normal conditions. It is dependent primarily upon the quick- 
 ness of the pulse, secondarily upon the relaxation of the peripheral vessels. 
 A long up-stroke indicates a pulse of low tension and large volume. The 
 up-stroke is elongated in pyrexia. A striking character of the tracing of 
 aortic regurgitation is the long up-stroke. On the contrarj^ the percus- 
 sion stroke is short when the pulse is of small volume or of high tension, 
 as is seen in tracings from cases of arteriosclerosis, aortic stenosis, mitral 
 stenosis and regurgitation and aneurism. 
 
 Fig. 57. — Mitral stenosis. 
 
 Direction. — The direction of the percussion stroke is dependent upon 
 the quickness of the pulse. It is vertical or nearly so in tracings from 
 cases in which the ventricular systole is sharp, especially in cases of dilated 
 hypertrophy. The up-stroke is vertical in the tracing of pulses of low ten- 
 sion and both vertical and elongated in aortic incompetency. It is oblique 
 or sloping in fat persons, the force of the percussion impulse being taken 
 up by the thick tissue overlying the artery. Tracings of this kind are 
 characteristic of cases in which there is a relatively slow discharge of blood 
 from the ventricle into the arterial system, whether in consequence of 
 lesions of the vessels or lesions of the heart itself. A sloping anacrotic 
 
PHYSICAL DIAGNOSIS: MENSURATION. 
 
 HI 
 
 limb occurs in tracings in arteriosclerosis, high tension from any cause, 
 and aneurism. It is seen also where the left ventricle is weak, or where 
 the mass of blood in the ventricle is divided, as in mitral incompetence, 
 or where there is mechanical obstruction of the flow of the blood through 
 the heart, as in mitral and aortic stenosis. 
 
 Apex or Summit. — The apex is sharp or pointed in the great majority 
 of tracings, both normal and pathological. Tracings in which the apices 
 
 Fig. 58. — Arteriosclerosis. 
 
 are blunt or broad are frequently the result of improper adjustment of 
 the sphygmograph or too great pressure. Tracings of this kind are some- 
 times obtained in high tension pulses, arteriosclerosis, aortic stenosis, 
 and especially in aneurism. 
 
 Line of Descent. — This in a normal pulse tracing is gradual and 
 undulatory, showing in succession the pretidal notch, the tidal wave, 
 the aortic notch, and the dicrotic wave. Under normal circumstances the 
 blood takes some time to flow from the arterial system into the capillaries 
 and the subsidence of the pulse wave is gradual and the line of descent 
 sloping. The line of descent is relatively abrupt when the outflow from 
 the arterial system into the capillaries is rapid, as in tracings from cases 
 of great relaxation of the peripheral circulation and in aortic regurgita- 
 tion in which the arteries suddenly collapse in consequence of the defect 
 in the aortic valves; it is more gradual than normal when the outflow is 
 retarded, as is the case in arteriosclerosis, during a chill and in the early 
 stages of peritonitis. Great irregularity in the line of descent is frequently 
 seen in tracings of mitral disease, especially during impairment or rupture 
 of compensation. All forms of intermittence and irregularity of the pulse 
 are graphically represented in properly taken sphygmograms. 
 
 Fig. 59. — Pulsus bisferiens. 
 
 Tidal Wave.— The prominence of this curve indicates increase of 
 the arterial tension during the ventricular systole. It occurs in some cases 
 of arteriosclerosis and in aortic stenosis. This wave is sometimes per- 
 ceptible to the finger — pulsus hisferiens. It is small or absent when the 
 heart is very weak, or when with moderate systolic force there is free per- 
 
112 MEDICAL DIAGNOSIS. 
 
 ipheral circulation. It is absent in mitral and aortic incompetency of high 
 grade. It occasionally happens that the tidal or predicrotic wave is pres- 
 ent in some pulse curves of a tracing and absent in others — a condition 
 arising from variations in the am.ount of blood discharged into the arte- 
 rial system during the ventricular systole. Tracings showing a marked 
 predicrotic w^ave upon alternate beats or at other intervals indicate 
 derangement of the nervous mechanism of the heart. 
 
 Dicrotic Wave. — This w^ave is usually present in the normal pulse 
 tracing. It corresponds to that period of the cardiac revolution immedi- 
 ately following the closure of the aortic valves. When the vasomotor tone 
 is good and the arterial tension high the dicrotic wave is feebly marked 
 or absent. It is absent or faintly indicated in free aortic regurgitation. 
 In some cases of arteriosclerosis when well marked, it may be recognized 
 by the palpating finger, and the pulse is spoken of as dicrotic. Different 
 degrees of dicrotism are shown in tracings. When the dicrotic wave is 
 well marked but the aortic notch is above the respiratory or base line, 
 the pulse is called dicrotic. When the aortic notch falls to the level 
 of the base line the pulse is said to be fully dicrotic. When the aortic 
 
 Fig. 60. — Dicrotic pulse. 
 
 notch falls below the level of this line the pulse is called hyperdicrotic. 
 If the hyperdicrotic pulse is very rapid the second beat is altogether 
 lost and the pulse is said to be monocrotic. 
 
 Respiratory or Base Line. — In the normal sphygmogram the 
 lowest points of the percussion strokes of successive pulse waves are on 
 the same horizontal plane, and a line drawn through these points is called 
 the base or respiratory line. The term respiratory is used to designate 
 this line because the inspiration and expiration to some extent in health, 
 but much more in disease, exert a marked influence upon it. Full and sud- 
 den inspirations reduce the arterial tension and lower the base line. Forced 
 expiration on the contrary increases arterial tension and raises the base 
 line. In cases of severe dyspnoea from any cause the base line is undulatory, 
 falling with inspiration and rising with expiration. 
 
 Mackenzie's Clinical Polygraph. — By means of this instrument, for a 
 description of which the student is referred to ''The Study of the Pulse," 
 London, 1902, graphic tracings of the venous pulsations in the neck or 
 liver are made in connection with sphygmographic tracings of the radial 
 pulse. The simultaneous tracings upon the same strip of paper afford an 
 opportunity for accurate timing of the radial and the venous pulses for 
 clinical purposes by the familiar method of laboratory research. This 
 method may be made use of in hospital work and under certain circum- 
 stances in the consultation room, and, by a modification of the instru- 
 ment, the portable ink-writing polygraph may be used in private practice 
 at the bedside. 
 
PHYSICAL DIAGNOSIS: MENSURATION. 
 
 113 
 
 The following tracings were made by Bach man by means of an in- 
 strument supplied with Marey's tambours. A rubber tube four feet in 
 length connects the receiver with the tambour. The records were made 
 upon smoked paper with an ordinary laboratory kymograph. 
 
 Fig. 61. — Normal carotid tracing. 
 
 Fig. 62. — Mitral insufficiency. 
 
 t 
 1 - J "'"■■•- ; 
 
 
 I 
 
 \ t 
 
 
 
 S 
 
 'i 
 
 ! \ 
 
 1 
 -J 
 
 
 Curol.ui 
 
 ^m 
 
 
 Cd'/dioclp^'V "■'" 
 
 
 
 llA-SJlAflJuJl-.-lJ. 
 
 
 .1 Jl A f. ^ .'U \ 
 
 
 Tiwf '/yo" 
 
 
 
 
 
 
 
 Fig. 63. — Mitral stenosis. 
 
 M 'Iv 
 
 
 i 
 
 1 A 
 
 IV 
 
 M 
 
 
 
 '1/ 
 
 /V 
 
 ' vv , V' 
 
 \ 
 
 ; lA 
 
 ; A 
 
 v\ 
 
 
 
 i lA^ 
 
 1 'vA 
 
 -—' ^-J 
 
 ^X. 
 
 -^ 
 
 "^■-J ^ 
 
 / \^- 
 
 ■v_ 
 
 > 
 
 
 -J 
 
 Carotid 
 
 
 
 
 
 
 
 
 
 f] 
 
 
 
 / 
 
 
 
 
 
 
 M 
 
 
 /U 
 
 if\ 
 
 r^, 
 
 
 
 
 ,^/^ 
 
 
 
 ^-^ v^ 
 
 J \ 
 
 
 \ 
 
 1.^ 
 
 -^\ 
 
 Cardiac Apex. V 
 
 _^ 
 
 
 v 
 
 
 
 / 
 
 / 
 
 
 ^■^- 
 
 ——— -^^-^-^—^-^-^^ - - 1 
 
 Fig. 64. — Pulsus bisferieas — aortic regurgitation and stenosis; mitral regurgitation. 
 
114 
 
 MEDICAL DIAGNOSIS. 
 
 ^. / \ 
 
 Cardiao Apex 
 
 Fig. 65. — Aortic regurgitation. 
 
 Fig. 66. — Aortic stenosis — anacrotic pulse 
 
 Fig. 67. — Pulsus trigeminus. 
 
 i r^-^j^ /'^^-^ N-_/^^ 
 
 ■ Tv 
 
 /V.^ ;V. 
 
 /\ 
 
 1 — ■ -^ ^"^^ 
 
 ' Carotid * 
 
 V ' 
 
 ~^''~"' .:^^ 
 
 
 i^"'V^-^V.,y\^^\f-^^\, 
 
 ,,,^ 
 
 Ia^'^'^ V^-^~^\ 
 
 ^--y\/^^-' 
 
 Cardirio Apex. 
 
 
 
 
 ' — ' ' — '~ 
 
 1 — 1 
 
 -1 , , , , r— 
 
 -. — . — , — .- 
 
 Fig. 68. — Mitral regurgitation and stenosis. 
 
PHYSICAL DIAGNOSIS: MENSURATION. 115 
 
 A A, \f\ y. I 
 
 Carotid 
 
 \r 
 
 Cardiac Apex 
 Time ijlo" 
 
 Fig. 69. — Mitral and aortic regurgitation. 
 
 The Sphygmomanometer. — Instruments for measuring the blood- 
 pressure in the arteries have come into general use. They not only 
 render it possible to determine the blood-pressure with a reasonable ap- 
 proximation to accuracy, due allowance being made for variations inherent 
 to the instrument employed, but they also reveal changes in pressure not 
 recognizable by palpation in the ordinary way. The mechanical principle 
 involved in the instruments thus far devised for clinical use consists in 
 the transference of the blood-pressure within limits nearly constant as 
 regards the apparatus to a properly graduated mercurial manometer. 
 The essential parts comprise a compressing armlet having a breadth of 
 not less than 8 cm., connections of tubing which is practically non- 
 distensible, an inflating apparatus, and the manometer. For practical pur- 
 poses such an instrument must be capable of measuring both systolic 
 and diastolic pressures; its application must be simple and the results 
 obtainable within a period not exceeding three minutes; it must be not 
 too delicate for ordinary clinical use and sufficiently compact to be readily 
 transported by hand. 
 
 Two instruments meet these requirements — Stanton's and Janeway's. 
 The method in use consists in the close application of the armlet to the 
 arm at the level of the heart, the patient being either in the sitting or the 
 recumbent posture; the application of the finger to the radial pulse, the 
 patient's arm being completely relaxed and the pressure being steadily 
 raised by the other hand by means of the inflating apparatus. When the 
 pulse can no longer be felt, the pressure is gradually released until it 
 is again perceptible. This manoeuvre is repeated as a control observa- 
 tion. The height of the mercury at which the pulse is again felt indicates 
 the systolic blood-pressure. As the pressure is gradually released the 
 lowest point at which the maximum oscillation of the mercury occurs 
 indicates the diastolic pressure. 
 
 Technic. — The following practical suggestions of Dr. Stanton will 
 be found useful: "It is wise to form a method by which all pressures are 
 taken. This diminishes the time required and eliminates error. The 
 muscles of the arm should always be relaxed: hence, if the patient is in a 
 
116 
 
 MEDICAL DIAGNOSIS. 
 
 sitting posture, the elbow and forearm should be supported, as muscular 
 contractions show themselves on the mercury column. Preferably, the 
 pressures should be taken with the patient recumbent. For most observers 
 it is easier to take the pressure from the left arm, as the necessary manipu- 
 lations of the manometer are more easily done with the right hand. In 
 nearly all cases the first estimation will be found 10 to 20 millimetres higher 
 than subsequent estimations. This is probably due to excitement arising 
 from fear that the examination will cause pain. Several estimations should 
 be made until the level normal to the individual is obtained. In cases 
 with a very rapid pulse-rate the diastolic pressure is hard to determine 
 
 Fig. 70. — Dr. Stanton's sphygmomanometer. 
 
 because of the inertia of the mercury. Repeated observations may be 
 necessary. With a very slow, strong pulse the oscillations may be so large 
 that it is hard to distinguish the largest ones. In these cases, by leaving 
 the valve A open, some of the oscillation is absorbed by the elastic rubber 
 bulb, and the reading becomes easier. In cases showing threatened circu- 
 latory failure, especially in cases of high pressure, it will be found almost 
 impossible to get a clear-cut high or low pressure. That is, in spite of 
 repeated estimations, the high pressures will vary from 5 to 15 millimetres. 
 These cases may, at times, show a condition in which an occasional beat 
 comes through at a much higher level than that at which all the beats can 
 be detected. Often this is due to the action of respiration. This should be 
 noted in the estimation thus: High pressure, occasional beat at 170; all 
 other beats at 155. Diastolic level with increasing pressure: Where the 
 diastolic level is hard to obtain, it is of help to get the greatest oscillation 
 
PHYSICAL DIAGNOSIS: MENSURATION. 
 
 117 
 
 with increasing pressure as well as with decreasing pressure. With the 
 valve A at right angles (shut off from the syringe) blow up the syringe 
 until a good pressure is established in the second bulb. Now open A very 
 slowly and the air can be made to enter at any desired rate of speed. As 
 the mercury column rises the oscillations begin, grad- 
 ually increase in size until the maximum, and then 
 diminish. By shutting off A completely, the behavior 
 of the oscillations under diminishing 
 pressure can be noted. Point of 
 disappearance and reappearance of 
 pulse: Where it is desirable to com- 
 pare the point at which the pulse 
 disappears with the point at which 
 it reappears, this can readily be 
 accomplished as follows: Blow up 
 the apparatus until the pulse is 
 nearly gone; then, dropping the syr- 
 inge portion, gently compress the 
 second bulb until the pulse com- 
 pletely disappears; a relaxation of 
 the bulb allows it to reappear." 
 
 The modification of the Riva- 
 Rocca sphygmomanometer by Beall 
 and Mason is portable and compact. 
 The accompanying illustrations 
 show the instrument ready for use 
 and closed for transporting. The 
 manometer tube is in two sections, 
 connected by a rubber cuff, and the 
 scale is hinged, the break occurring 
 at the 195 mm. 
 
 The elaborate studies of 
 Theodore Janeway ^ show 
 the upper limit of noi 
 blood-pressure in 
 young adults is 
 about 145 mm. and 
 the lower limit 
 about 80 mm. In 
 the great major- 
 ity of young males 
 the upper limit is 
 100 mm. to 130 
 mm. In females it 
 
 is about 10 mm, lower. In infants the pressures are lower. After fifty 
 they are higher. Blood-pressures above 160 mm. or 180 mm. are almost 
 always associated with disease. Janeway places the normal diastolic pres- 
 sure at 25 to 40 mm. below the systolic pressure in the same individual, 
 
 1 The Clinical Study of Blood-pressure. New York, 1904. 
 
 1= 
 
 y 
 
 
 = 
 
 j^ 
 
 
 = 
 
 335 
 
 
 
 
 
 
 
 
 =. 
 
 J20 
 
 
 3 
 
 310 
 
 
 =• 
 
 JOS 
 
 
 S- 
 
 ISi 
 
 
 = 
 
 7B1 
 
 
 
 
 
 
 
 
 =. 
 
 275 
 
 
 
 
 
 
 
 
 = 
 
 
 
 = 
 
 JbU 
 
 
 =- 
 
 255 
 
 
 
 
 
 =3. 
 
 m 
 
 
 
 
 
 
 
 
 
 111 
 
 
 
 nn 
 
 
 
 
 
 =• 
 
 m 
 
 
 =■ 
 
 fe 
 
 
 S 
 
 1~ 
 
 
 = 
 
 
 
 
 
 
 = 
 
 195 
 
 
 
 
 
 ^ 
 
 IBS 
 
 
 
 lEU 
 
 
 = 
 
 
 
 
 
 
 
 
 
 
 ifi 
 
 
 
 
 
 1. 
 
 
 
 % 
 
 105 
 
 
 - 
 
 135 
 HO 
 
 
 - 
 
 l?S 
 
 
 
 
 
 
 ll>i 
 
 
 _ 
 
 
 
 
 lOD 
 
 
 
 
 
 _ 
 
 bU 
 
 
 = 
 
 
 
 — 
 
 
 
 
 75 
 
 
 = 
 
 70 
 
 
 _ 
 
 fiS 
 
 
 2 
 
 BO 
 SB 
 
 I 
 
 —-3 S 
 
 No.l 
 
 Portable blood-pressure apparatus. — Beall and Mason. 
 
118 MEDICAL DIAGNOSIS. 
 
 that is to say, between 65 and 110 mm. In the aged a difference of 
 50 mm. is common. A difference of less than 20 mm. between the 
 systoUc and diastolic pressure indicates an abnormally small pulse; a 
 difference of more tlian 50 mm. an abnormally large pulse. 
 
 The readings are much influenced by the breadth of the armlet and 
 by exertion, attitude and other physical conditions and by psychical states. 
 
 The Blood=pressure in Disease. — High BIood=pressure — Hypertension. 
 — The highest recorded arterial pressures have occurred in acute compres- 
 sion of the brain, such as is caused by intracranial hemorrhage or fracture 
 of the base of the skull. A permanently high blood-pressure accompanies 
 persistence in the peripheral resistance with hypertrophy of the left 
 ventricle, in arteriosclerosis and renal disease. 
 
 Low Blood=pressure — Hypotension. — This condition is present in wast- 
 ing diseases and cachectic states, various infections and toxaemias, espe- 
 cially when severe, profuse hemorrhage, collapse and shock, and terminal 
 states — agonal hypotension. 
 
 Nephritis.- — Permanent high pressure is a conspicuous phenomenon 
 in chronic interstitial nephritis. Systolic pressures of 200 mm. and more 
 are common. Diastolic pressures are usually 60 to SO mm. lower. The 
 facts have great value in diagnosis. There are cases of interstitial nephritis 
 in which high arterial pressure as shown by the sphygmomanometer does 
 not occur. They are those with associated severe wasting diseases, those 
 in which there is late cardiac insufficiency, and those tliat have reached 
 the terminal stages of the disease. 
 
 In chronic parenchymatous nephritis high tension also occurs, but 
 is by no means so constant as in the interstitial form. In amyloid dis- 
 ease blood-pressure is inconstant, sometimes high, sometimes subnormal. 
 
 Uraemia. ^The s3'mptoms of this condition, especially in its chronic 
 form, are associated with increased blood-pressure and become more marked 
 as the tension rises, less marked as it falls. Persistent lower tension has 
 followed improvement under treatment. A gradual fall has preceded death. 
 
 Arteriosclerosis.^ — When the larger superficial arteries onh' are 
 involved the blood-pressure is not markedly affected. Arteriosclerotic 
 processes generally involving the smaller vessels are accompanied by 
 increased blood-pressure, the systolic pressure being increased much more 
 than the diastolic. 
 
 Apoplexy.- — As a general rale patients who become hemiplegic either 
 in consequence of thrombosis or hemorrhage have previously, if examined, 
 manifested sclerosis of the peripheral vessels with elevation of blood- 
 pressure. 
 
 Diseases of the Heart.— In primary, uncomplicated cardiac insuf- 
 ficiency from myocardial changes high normal pressures appear to be the 
 rule. When the cardiac insufficiency is due to failing compensatory hyper- 
 trophy in arteriosclerosis and renal disease, the blood-pressure is high. 
 As the myocardium becomes feebler the arterial tension falls. 
 
 Valvular Disease. — In aortic insufficienc}' the sphygmomanom- 
 eter, to use the words of Janeway, "gives a numerical value to the well- 
 known pulsus celer. which expresses perfectly the mechanical effect of 
 the lesion in the systemic arterial circulation." The systolic pressures are 
 
PHYSICAL DIAGNOSIS: MENSURATION. 119 
 
 high, the diastolic pressures low. In combined aortic insufficiency and 
 stenosis the blood-pressure determination is of value in indicating the 
 preponderating lesion, a high degree of stenosis being accompanied by a 
 proportionately lower systolic pressure. In associated aortic and mitral 
 insufficiency the degree of the latter defect may be estimated by the sys- 
 tolic as compared with the diastolic blood-pressure. In disease of the 
 aortic valves the systolic pressure is frequently variable in the absence of 
 obvious cause, while the diastolic pressure is more constant. Sphygmoma- 
 nometric measurements are of less value in other forms of valvular disease. 
 
 Angina Pectoris. — Hypertension is an important condition in this 
 syndrome. It is not, however, constant. 
 
 The Acute Infectious Febrile Diseases. — The type of this group, 
 namely, enteric fever, shows with great constancy low pressure. System- 
 atic observations at regular and frequent intervals have shown that hypo- 
 tension is first apparent toward the end of the first or early in the second 
 week and increases as the attack goes on. The daily oscillations are not 
 significant. Crile's statistics, quoted by Janeway, are ver}^ suggestive. 
 The mean pressure by weeks in all cases was, first week, 115 mm.; second 
 week, 106 mm.; third week, 102 mm.; fourth week, 96 mm.; and fifth 
 week, 98 mm. Other observers have confirmed these results. A grad- 
 ually progressive fall indicates increasing failure of vasomotor tonus; 
 a sudden fall actual collapse or hemorrhage. A sharp rise in pressure 
 attends the occurrence of perforation. If the observations hitherto recorded 
 should be confirmed by further clinical studies the sphygmomanometer 
 will prove of great value in the differential diagnosis between collapse from 
 hemorrhage or other cause in enteric fever and intestinal perforation. The 
 importance of continuous records in this connection is obvious. In the 
 terminal stage of the consecutive peritonitis hypotension becomes extreme 
 — agonal fall of pressure. Pneumonia stands alone among the complica- 
 tions of enteric fever in causing hypertension. The favorable influence of 
 treatment by systematic cold bathing is manifest in a rise of pressure. 
 
 Pneumonia. — Uniform tendencies in blood-pressure have not been 
 observed in this disease. The reports are at variance. Subnormal pres- 
 sures are common; in severe cases the rule. A rapid fall may precede 
 collapse or the fatal issue. 
 
 Chronic Diseases — Tuberculosis pulmonum in its advanced stages 
 gives low pressures. In the early stages of syphilis when there is fever 
 and the condition is analogous to an acute infectious process, there is 
 hypotension. Diabetes is apparently without direct influence upon the 
 blood-pressure. When associated with arteriosclerosis or chronic renal 
 disease it may show hypertension, and in advanced cases hypotension is 
 common in consequence of emaciation and cardiac insufficiency. The 
 secondary anaemias are attended by low blood-pressures. The derange- 
 ment of pressure in chlorosis is neither marked nor characteristic. Chronic 
 bronchitis, emphysema and asthma are frequently attended with high 
 arterial tension. Pleural effusions are attended by hypertension which 
 falls upon aspiration. 
 
 Diseases of the Nervous System. — In locomotor ataxia the light- 
 ning pains are attended by a fall in blood-pressure; in the gastric crises 
 
120 MEDICAL DIAGNOSIS. 
 
 the pressure is greatly increased. Arteriosclerosis of the cerebral vessels 
 may exist without similar changes in the general vascular system Blood- 
 pressure estimations are therefore without value as indicating the exist- 
 ence of intracranial vascular lesions. When there is reason to suspect 
 their presence, increased arterial pressure due to cardiac, vascular, or renal 
 causes affords important data for prognosis and treatment. With high 
 pressure there is danger of hemorrhage, with low pressure danger of throm- 
 bosis. Cerebral hemorrhage is attended by marked hypertension which 
 continues to rise as the hemorrhage increases, and remains stationary or 
 falls when the hemorrhage ceases. In uraemic coma the pressure is also 
 greatly increased. 
 
 In epilepsy, owing to the difficulty of making observations during the 
 attack, there is some uncertainty. During the attack there is said to be 
 a sudden rise in the blood-pressure, followed by a rapid fall to normal as 
 the paroxysm ceases. In coma following an attack of general convulsions 
 the fact that in epilepsy the blood-pressure falls while in urssmia it remains 
 high is of diagnostic importance. In tic douloureux there is a rise of pres- 
 sure during the pain proportionate to the intensity of the attack. Insom- 
 nia may be associated with increased tension on the one hand or norma) 
 or diminished tension on the other. In the former condition the pressure 
 falls during sleep. In hysteria and neurasthenia the pressures are variable. 
 Some observers have observed high pressures in neurotic and excitable 
 persons, but this condition is not constant. 
 
 Mental Diseases. — In melancholia the pressure is abnormally high 
 and shows rises and falls corresponding to the intensity of the mental symp- 
 toms. In mania, on the other hand, the pressure tends to subnormal levels. 
 
 PERCUSSION. 
 
 Percussion in ph^'sical diagnosis is the art of striking or tapping upon 
 the surface of the body in such a manner as to call forth sounds, from the 
 nature of which conclusions are drawn as to the structure of the underly- 
 ing parts. 
 
 This art was first described and systematically employed in the latter 
 part of the eighteenth century by Auenbrugger, a physician of Gratz, who 
 published his observations in a little book entitled Inventum Novum. 
 The subject was widely brought to the attention of the profession by 
 Corvisart in the beginning of the following century. 
 
 The practice of this method demands nice training both of the hands 
 and ear in order to secure its best results. Careless and inexact methods 
 yield not only unsatisfactory but also positively misleading results. It is 
 especially true of percussion that they find it most useful who most 
 clearly realize its limitations as an art in diagnosis. Unfortunately too 
 many practitioners, otherwise well trained, fail to acquire proficiency in 
 percussion and equally fail to appreciate its limitations. 
 
 Neither percussion nor auscultation requires the possession of much 
 technical knowledge of acoustics nor a cultivated musical ear. It is, how- 
 ever, necessary to be able to discriminate differences in the character, 
 intensity, and pitch of sounds. 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 121 
 
 The Theory of Percussion.— Reduced to its simplest terms the theor}^ 
 of percussion depends upon the differences in the vibrations produced by 
 blows delivered upon structures which do not and those which do contain air, 
 and in the latter case upon cUfferences in the mechanical arrangement under 
 which the air is present. There is nothing a priori in the matter. Our 
 whole knowledge in regard to the signs elicited is the result of observation 
 and experience. It has been found that direct percussion, that is, percus- 
 sion without the intervention of a finger or other form of pleximeter, prac- 
 tised upon the thigh, which does not contain air, produces a minimum of 
 sound which has a peculiar quality, technically described as dull. The 
 interposition of a pleximeter increases the intensity of the sound and 
 slightly alters its other acoustic properties. From this we infer that in 
 percussion the vibrations of the pleximeter itself constitute a certain factor 
 in the general result. It has further been found that percussion over the 
 liver and spleen, organs which do not contain air, produces a similar dull 
 sound, but that the quality of dulness is modified according to the force 
 with which the act is performed. Upon light percussion over the spleen 
 or centrally over the liver the dulness is much hke that of the thigh, but 
 upon powerful percussion over these organs the dull sound is modified, 
 the quality of resonance being added. This fact in connection with others 
 presently to be mentioned leads us to infer that by light percussion 
 a limited region of the wall of the body is set into vibration, but that the 
 area is extended by forcible percussion, so that the sound produced partakes 
 of qualities due to the sound-producing mechanism of adjacent organs or 
 structures, and that if we desire to obtain the percussion phenomena pecu- 
 liar to an organ we must content ourselves with well-defined but light 
 percussion of the surface overlying the viscus immediately in question.. 
 Experience amply confirms this inference. It has been further established 
 that percussion over the distended bladder or a cyst, or any considerable 
 collection of fluid, as a serofibrinous or purulent pleural effusion, produces 
 a dull sound, and that there are degrees in the dulness just as we find 
 differences upon light and heavy percussion over the spleen and liver, 
 the sign having a certain quality of resonance at some parts of the border 
 or edge of the effusion and wholly lacking resonance over the mass or 
 base of the effusion. The recognition of these differences led to the very 
 proper employment of such terms as relatively dull, dull, and absolutely 
 dull or fat. To return to the liver and the flatness upon light percus- 
 sion and the development of some degree of resonance upon forcible 
 percussion especially near the borders of the dull area, we have attrib- 
 uted the latter to the vibrations of adjacent organs. Pursuing our 
 investigations we find that as we proceed in lines upwards the sign 
 changes somewhat abruptly from dull to a distinctly resonant sound, hav- 
 ing qualities hereafter to be pointed out, which, with modifications of 
 intensity and so on, but not of quality, is everywhere present over the 
 chest where the surface or periphery of the lung comes into contact with 
 the wall. For this reason the percussion sound elicited over the chest, and 
 having the peculiar resonant quality spoken of, is known as pulmonary 
 resonance, or briefly and technically as clear. Again, when we extend our 
 percussion in lines proceeding downwards from the liver, we pass, under 
 
122 MEDICAL DIAGNOSIS, 
 
 normal circumstances, quite abruptly, about the margin of the ribs, to a 
 region which yields upon percussion a note of high resonance having 
 likewise peculiar qualities of its own, which, because of its being produced 
 by a mechanism remotely analogous to that of a drum, is called tympanitic. 
 A very important fact in connection with these three fundamental 
 qualities of the signs elicited upon percussion, namely, dulness, clearness, 
 and tympany, is this, that they are constantly related to and dependent 
 upon the absence or presence of air in the examined structures and upon 
 the mode of arrangement of the air when it is present. The constant 
 correspondence between the clinical and post-mortem percussion signs and 
 the post-mortem conditions justifies us in formulating the following dicta: 
 Upon percussion: 
 
 1. Airless viscera and hollow viscera distended with fluid yield dulness, 
 flatness. 
 
 2. The normal lungs contained in the chest under conditions of norynal 
 tension yield a clear note. 
 
 3. Air contained in hollow viscera, as the intestines, the walls of which 
 are not tense, yield tympanitic resonance. 
 
 These physical signs — namely, clearness, dulness, and tympany — are 
 normal. The percussion sound clearness as such is always normal. It 
 cannot be elicited anywhere save over the chest, and there is no condition 
 of structures other than the lungs by which the physical arrangement 
 essential to its production can be brought about. With dulness and tym- 
 pany the case is different. The modifications or absence of clear or pul- 
 monary resonance in regions normally occupied by the lungs constitute 
 morbid physical signs. Dulness in regions normalh^ clear or tj^mpanitic 
 and the extension of dulness beyond the limits of airless viscera constitute 
 morbid physical signs, and this statement is also true of the presence of 
 tympany in regions in which the physical conditions essential to its 
 production do not normally exist. 
 
 The foregoing facts also warrant the following statements: 
 Upon percussion: 
 
 1. There is no difference in the physical signs by which a distinction can 
 be made between an airless viscus and a collection of fluid. 
 
 2. The signs do not enable us to determine the line of contact between 
 two airless viscera or an airless viscus and a collection of fluid, or betiveen 
 collections of fluid separated by a membrane. 
 
 Percussion is the application of an every-day art to diagnosis in medi- 
 cine. The woodsman taps with his axe upon the trunk of a tree to learn 
 whether or not it is hollow, the ganger upon the cask with his mallet to 
 find the level of the wine, and the carpenter with his hammer upon the 
 plastered wall to fix the position of a stud into which he can drive his nail. 
 
 The Technic of Percussion. — The patient may be examined in the 
 recumbent, sitting, or erect posture. The outer clothing should be removed. 
 The air contained in thick garments or in several layers of clothing seri- 
 ously modifies the results of percussion. A single under-garment or a 
 towel is preferable to the bare skin. The limbs should be symmetri- 
 cally disposed and the muscles relaxed. Errors may arise from forcible 
 percussion when the patient is resting upon a feather bed or very elastic 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 123 
 
 mattress. In general terms much display of energy on the part of the 
 physician is to be avoided. It not only yields misleading results but it 
 also alarms and may even hurt the patient. 
 
 Two methods are employed, immediate or direct, and mediate or 
 indirect percussion. 
 
 Immediate or Direct Percussion. — The blow is struck directly upon the 
 surface with the palm of the slightly flexed hand, or upon the clavicles or 
 sternum with the tip of the second or third finger, or upon the abdomen 
 with the dorsal surface — nail — of the second finger flicked off from the 
 thumb as one flicks a crumb. The first two of these methods were 
 originally employed. The last is a modern refinement. 
 
 With the Palm of the Hand. — The whole hand slightly flexed or the 
 palmar surface of the fingers held closely together may be employed. The 
 blow is delivered chiefly from the wrist, very slightly from the elbow, care 
 being taken to avoid too much force and the over-production of noise. 
 This method is available for a rapid preliminary survey and class demon- 
 stration of gross differences between the sides of the chest, or the upper 
 and lower part of one side, especially posteriorly. It cannot often be 
 employed satisfactorily in the examination of the abdomen. The objec- 
 tions to it are that it demands too much force and that the vibrations 
 caused are too extensive. It lacks the nicety of good clinical work. 
 
 Direct finger percussion over the clavicles and sternum is often prac- 
 tised, but is here mentioned only to condemn it as mostly inexact, often 
 misleading, and at best yielding results obtained much more satisfactorily 
 by other methods. The results are unsatisfactory because of the elasticity 
 and extensive vibrations of long and flat bones. The resonance produced is 
 that of an elongated or very large pleximeter — so-called bone or osteal reso- 
 nance, well illustrated upon percussion, in the same manner, of the head with 
 the finger-tip. As there is no intracranial air, it is evident that the reso- 
 nance is due to the vibrations communicated by the bone to the external air. 
 
 Direct Percussion or Finger- flicking. — In this procedure the skin 
 should be bared. Very exact and satisfactory results may be obtained, 
 especially in the examination of circumscribed regions in a thin-walled 
 abdomen. It is by far the most satisfactory method of mapping out the 
 limits of the splenic dulness. 
 
 Mediate or Indirect Percussion — Pleximetry. — The blow is delivered 
 not directly upon the surface of the body but upon an interposed plate or 
 disk of ivory or hard rubber — a pleximeter, literally, measurer of the blow. 
 This instrument should be quite flat with rounded edges, about an inch 
 and three-quarters in length and five-eighths of an inch in width, so that it 
 may be closely applied to the surface in the intercostal spaces. There 
 should be at each end a little flange or ear by which it is held in position. 
 The percussing instrument or hammer is called a plexor, and consists of a 
 suitable head of soft rubber, or metal tij^ped with soft rubber, and a light, 
 stiff handle. The plexor of Wintrich has a handle or shaft nearly corre- 
 sponding in length to a human hand from the wrist-joint to the first pha- 
 langeal joint and a head corresponding in length from the last named joint 
 to the tips of the fingers. Instrumental pleximetry is much used among 
 European physicians. 
 
124 MEDICAL DIAGNOSIS. 
 
 Finger Pleximetry — Finger Percussion. — This method is almost 
 exclusively used by American physicians. A finger of the left hand is used 
 as the pleximeter and the right hand as the plexor, the fingers being flexed 
 as nearly as possible at a right angle at the first phalangeal joint to form 
 the head of the hammer, and the hand from this joint to the wrist forming 
 its handle or shaft. The blow is delivered from the wrist and not from the 
 elbow, and the head of the plexor, made up of the last two phalanges, must 
 fall at a right angle upon the dorsum of the middle or terminal phalanx of 
 the finger used as the pleximeter, the palmar surface of which is closely 
 applied to the part examined. It is scarcely necessary to add that in left- 
 handed persons the fingers of the right hand are used as pleximeters and 
 the left hand becomes the plexor. 
 
 The advantages of finger percussion are (a) that the soft palmar under- 
 surface of the pleximeter can be closely applied to the part to be examined 
 and the danger of a thin layer of air between them wholly avoided; (b) 
 that the finger used as a pleximeter is also a palpating finger and receives 
 sensory impressions concerning the firmness or elasticity of the underlying 
 part which supplement the auditory impressions caused by the vibrations 
 occasioned by the blow; (c) that the pleximeter is composed of tissues 
 corresponding in physical composition with the wall of the body, which it 
 protects from the blow without the interposition of an instrument of wholly 
 different composition, and (d) that the instruments are always at hand. 
 
 Flicking percussion may also be intermediate, a finger of the left 
 hand being used as the pleximeter. 
 
 Superficial and Deep Percussion. — These terms indicate in general 
 the degree of force employed. In superficial percussion the blow is light 
 and the vibrations are limited in extent and depth. This method is essen- 
 tial in the study of conditions in which the percussion signs involve limited 
 areas, as in the heart and spleen, or in which we have to deal with thin 
 wedges of tissues yielding different signs which overlie each other, as the 
 lung surrounding the cardiac ventricles, or dipping down between the wall 
 of the chest and the liver or the wedge-shaped anterior lower border of the 
 liver occasionally seen. Superficial percussion enables us to determine 
 the nature of the structure immediately beneath the surface, and is 
 necessary where, by reason of the thinness and elasticity of the walls, 
 wide areas of tissue are set into vibration by the blow, as in children 
 and emaciated persons, and in elderly persons whose costal cartilages 
 have undergone calcification. Only superficial percussion should be 
 employed in the examination of the chest after recent hemorrhage. 
 
 Deep percussion excites vibrations in wide areas and to a considerable 
 depth. It is employed where the chest walls are very muscular or fat and 
 to ascertain the dulness or resonance of the deeper structures, as the actual 
 limits of cardiac dulness, the upper border of liver dulness, pneumonic 
 consolidation not reaching to the periphery of the lung, or a deep-seated 
 aneurism. In the case of a wedge-shaped anterior lower border of the 
 liver superficial percussion enables us to demonstrate the actual limits 
 of dulness, while deep percussion, by acting upon the underlying intestine 
 through the thin wedge of liver, yields a most misleading tympanitic 
 resonance. 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 125 
 
 The following directions must be carefully observed: 
 
 1. Apply the second or ring finger of the left hand accurately and 
 firmly but without undue pressure to the surface to be examined. 
 
 2. Raise the other fingers and palm from the surface to avoid muffling 
 the vibrations. The finger used as the pleximeter only should at the 
 moment be in contact with the surface. 
 
 3. Deliver a quick, rebounding blow, with the tip of the percussing 
 finger or fingers perpendicularly upon the finger used as a pleximeter, 
 upon the middle phalanx or the terminal phalanx above the nail. The 
 quicker the rebound of the plexor the better and more significant the result. 
 
 4. Let the blow be delivered from the wrist held perfectly loose and 
 not from the elbow. The force must be moderate and equal at correspond- 
 ing points upon the two sides of the chest; lighter where the chest wall is 
 thin, as in lean persons and in the infraclavicular and axillary and infra- 
 axillary regions, and more forcible in the examination of the back of a very 
 muscular man or the mammary regions of one who is fat. 
 
 5. The attitude of the patient is important. It must be easy and 
 unconstrained. Rigid and fixed positions are to be avoided. Muscular 
 tension modifies percussion resonance. The arms must be symmetrically 
 arranged. In the examination of the anterior surface of the body let them 
 lie loosely at the sides in the recumbent posture or hang relaxed if the 
 patient is erect; in the examination of the back the patient should bend 
 forward and gently fold his arms. I do not like the hands to be placed 
 each upon the opposite shoulder, since it involves an undesirable degree 
 of muscular tension; while in the examination of the lateral regions of the 
 chest the hands should be placed together upon the top of the head with 
 the fingers lightly interlocked. 
 
 6. The patient must breathe gently and regularly. If changes in the 
 percussion signs upon full held inspiration and forced expiration are to 
 be studied — respiratory percussion — give the necessary directions. 
 
 7. Perform percussion systematically and in a routine manner, exam- 
 ining corresponding parts upon the two sides of the chest above and 
 below, anteriorly, laterally, and posteriorly, comparing and noting the 
 signs at each step in the proceeding. Comparison and contrast are essential 
 alike in percussion and auscultation. It is often useful to apply two or 
 more fingers widely separated to the surface and lightly percuss one after 
 the other. In this way the border-line between dulness and clearness or 
 tympany can be defined and demonstrated with great exactness. 
 
 8. Deliver two or three percussion strokes and then examine the cor- 
 responding point upon the opposite side in the same manner. This ma- 
 noeuvre may be repeated as often as is necessary. Dexterity and close 
 attention to the sounds render a wearisome prolongation of the exami- 
 nation unnecessary. 
 
 9. To determine the borders of areas of dulness, clearness, or tympany 
 percuss in parallel or radiating lines and note the points in such lines at 
 which the quality of the percussion signs changes. Repeated light per- 
 cussion is often necessary. These points may be fixed by touches with the 
 dermatographic pencil, which when joined by a line indicate the borders 
 of the areas studied. 
 
126 MEDICAL DIAGNOSIS. 
 
 Practitioners gradually develop modifications of percussion methods 
 to suit themselves. There are many different methods, but not every one 
 of them is right. • Those not based upon a knowledge of the principles upon 
 which this method of physical diagnosis rests and those which are slovenly 
 or careless are positively wrong. It is like playing a musical instrument. 
 Knowledge, aptitude, and training are essential, and there are good per- 
 formers, poor performers, and those who cannot play at all. 
 
 Sources of error especially to be avoided are: 
 
 1. Failure to apply the pleximeter accurately to the surface. A thin 
 stratum of air modifies the result and may render it wholly misleading. 
 
 2. Applying the other fingers or the palm of the hand to the surface 
 in such a manner as to dampen the vibrations and muffle the sound. 
 
 3. Awkwardness, slowness, and the use of too much force in deliver- 
 ing the blow. These may all be readily avoided if the percussion stroke 
 is from the wrist as a centre of movement rather than the elbow. 
 
 4. A false attitude on the part of the patient. Many persons on being 
 examined assume rigid and fixed postures with the muscles in tension and 
 the arms in constrained positions. 
 
 5. Too much clothing, and setting the air contained in the pillow, bed, 
 or mattress into vibration by powerful percussion. 
 
 6. A want of system in conducting the examination. More errors 
 arise from carelessness than from ignorance. 
 
 THE SIGNS ELICITED UPON PERCUSSION. 
 
 The sounds differ among themselves, as already seen, as follows: 
 
 A. Quality: (1) Clear, (2) dull, and (3) tympanitic. 
 
 A structure containing no air yields upon percussion a minimum of 
 sound due to vibrations in the surrounding air and is said to be completely 
 dull or flat. 
 
 Changes in such a structure by which it becomes air-containing or the 
 contiguity of air-containing structures modify the percussion sign, which 
 acquires resonance, and the dulness is no longer flat or complete, but marked, 
 and, as it is a question of degree, moderate or merely slight or relative. 
 
 The physical signs by which these modifications of flatness are brought 
 to pass are (a) in the direction of the conditions which underlie tympany, 
 namely, collections of air contained in spaces the walls of which are not 
 too tense, as, for example, the intestines; and (b) in the direction of the 
 arrangement of the air in the lung under normal conditions which involve 
 a certain tension as to the vesicles and as to the whole lung within the 
 thorax — clearness. 
 
 The terms used to designate (a) modifications of dulness in the direc- 
 tion of tympany are slight tympany, dull tympany, moderate tj^mpany, and 
 tympany. 
 
 Special modifications of tympany are cracked-pot resonance and 
 amphoric resonance. 
 
 Cracked-pot Resonance: the Cracked-metal Sound. — This per- 
 cussion sign requires for its development a rather forcible abrupt stroke 
 while the mouth of the patient is open. The physical condition is an air- 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 127 
 
 containing cavity communicating freely with a bronchus and sufficiently 
 near the surface of the chest to be compressed by the sudden blow. It 
 may also be elicited, in the absence of cavity formation, in conditions in 
 which by reason of yielding chest walls a certain amount of air contained 
 in the lungs or in the pleural cavity is suddenly forced by strong percussion 
 into the large bronchi. We may encounter the cracked-pot sound therefore 
 in infants not suffering from disease of the lungs, especially when percus- 
 sion is performed at the time of the full inspiration of crying, in pleurisy, 
 above the level of an effusion, over lung relaxed by the pressure of a large 
 pericardial effusion, sometimes in emphysema and in certain cases of pneu- 
 mothorax. This modification of tympanitic resonance may be imitated 
 by sharply percussing the cheek while the mouth is open or by striking 
 the two hands held together against the knee in such a way as to cause a 
 sound like that produced when coins are rattled in the hands. For this 
 reason the cracked-pot sound is sometimes called the money-jingle sound. 
 This sound is in many cases only to be heard when at the moment of per- 
 cussion the patient's open mouth is turned directly toward the ear of the 
 physician or when the patient holds the bell piece of a double stethoscope 
 just in front of his open mouth. As sudden compression of the cavity is 
 essential the blow must be of some force and as the walls of such a cavit}^ 
 are not always highly resilient the peculiar phenomenon in question is often 
 produced only upon the first two or three strokes of percussion and suf- 
 ficient time must elapse for the full redistention of the cavity before 
 the cracked-pot sound can again be heard. 
 
 Amphoric or Metallic Resonance. — This sign has the quality 
 characteristic of the sound produced by percussing a large vessel with a 
 wide mouth — amphora, a jar. It is a ringing tympanitic sound and denotes 
 a cavity of considerable size with firm elastic walls which do not vibrate 
 in unison. The pitch varies with the shape and size of the cavity and the 
 degree of tension of its walls. A closed cavity distended with air or gas 
 under pressure so that its walls vibrate in unison yields dulness on percus- 
 sion. Amphoric resonance frequently occurs without the cracked-pot 
 quality, but the cracked-pot sound is usually also amphoric. 
 
 (b) Modifications of dulness in the direction of clearness are slight 
 or relative dulness, impaired resonance, clearness. 
 
 But, leaving dulness altogether out of the question, we find that changes 
 in the physical condition in the lung by which the normal or vital tension 
 is relaxed frequently occur. This takes place, for example, in congestion, 
 in oedema and atelectasis from compression, in both of which the residual 
 air is diminished, and the normal, clear or vesicular resonance acquires the 
 tympanitic quality to a varying degree — vesiculot^^mpanitic resonance — 
 and as the lesions upon which vesiculotympanitic resonance depend-s 
 undergo resolution this sign is gradually replaced by the normal or clear 
 resonance again. These changes can occur only in regions in which we 
 normally find the clear or vesicular percussion resonance, namely, over 
 the lungs. It has been demonstrated experimentally that the extreme 
 distention of a hollow viscus, as a bladder, with air so that its opposite 
 walls upon percussion do not vibrate independently, but as a whole, does 
 away with the tympanitic sound, and causes it to be replaced by dulness. 
 
128 MEDICAL DIAGNOSIS. 
 
 B. Volume or Intensity. — This acoustic property is of minor impor- 
 tance in percussion. It depends upon the volume of air contained in the 
 structures examined, the elasticity of the enclosing walls and energy of 
 their vibrations, and the force of the blow. This term has reference to the 
 loudness or degree of sonority of percussion sounds, which may be on the 
 one hand so great as to obscure their value or on the other so faint as to 
 be without any significance whatever. The duration of percussion sounds 
 usually corresponds to their volume or intensity. 
 
 C. Pitch. — The distinction between sounds and musical tones must 
 be borne in mind. In percussion we have to do with the former. Never- 
 theless the pitch of percussion sounds is of great importance. Pitch indi- 
 cates in music the relative position of notes upon the scale and depends 
 upon the frequency of the vibrations by which tones are produced. In 
 physical diagnosis we find that large air-containing spaces with slight or 
 moderate tension yield percussion resonance of low pitch, while small 
 spaces with high tension yield resonance of higher pitch, and that the vibra- 
 tions of the pleximeter upon the thigh or over an airless viscus yield a 
 sound of slight intensity and high pitch. 
 
 Percussion over the abdomen reveals great variations in the pitch 
 of sounds having the quality of tympany, as over the stomach and large 
 and small intestines. These variations are of some value, but cannot be 
 relied upon in mapping out the positions of those viscera. They serve a 
 purpose in indicating the border-line between contiguous organs, as the 
 stomach and transverse colon and coils of intestines under different degrees 
 of tension. 
 
 The quality of a sound is that property which enables us to recognize 
 it whenever heard without seeing the mechanism by which it is produced, 
 as the sound of a bell, a drum, and so on; the volume or intensity of a 
 sound relates to the energy and the mass of the material by which it is 
 produced, as, for example, in great and little bells, the sound of which has 
 the same quality and may have the same pitch while differing greatly in 
 intensity or volume; the pitch depends upon the rapidity of the vibrations 
 by which sound is produced, as in the long strings of the piano which pro- 
 duce low notes, and the short strings which send forth the high notes. 
 
 The Lung Reflex (Abrams). — It has been observed that local 
 irritation of the skin of the chest as by cold or the application of mustard 
 has been followed by the evidences of a temporary circumscribed emphy- 
 sema of the underlying lung. These signs of dilatation of the air-vesicles 
 have in some instances been confirmed by X-ray examination. Cabot 
 has referred to this observation in explanation of the fact, well known to 
 teachers of physical diagnosis, that the repeated demonstration of an area 
 of moderate dulness, as, for example, in incipient tuberculosis, is followed 
 by a modification of the percussion sign, which graduall}' becomes more 
 resonant. The repeated percussion apparently acts as a local irritant. 
 If the consolidation is dense and extensive this change cannot occur. 
 
 Respiratory Percussion. — Differences in the sound are noted upon 
 quiet breathing and full held inspiration. The contrast between the two 
 sides of the chest in slight consolidation, as in beginning phthisis or pleural 
 thickening, is thus accentuated, the dulness upon the affected side remain- 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 129 
 
 ing the same, while the resonance upon the sound side is increased. This 
 method is serviceable in determining the presence or absence of slight 
 degrees of relative dulness, especially in the infraclavicular regions in 
 incipient pulmonary tuberculosis. 
 
 Palpatory Percussion. — As has been pointed out in the general con- 
 sideration of percussion, palpation is an essential though subordinate 
 factor in finger percussion, which is gradually taking the place of other 
 methods. Palpatory percussion is a method in which the attention is 
 especially directed to the resistance and elasticity of the tissues over which 
 the percussion is performed. It consists in the combined use of palpation 
 and percussion in a modified form, and is applicable (a) to the determina- 
 tion of the outlines and boundaries of the solid viscera under various con- 
 ditions, but especially to the study of the deep dulness of the heart both 
 when the lungs are normal and when they are emphysematous; (b) to 
 the examinations of solid organs of limited size surrounded by air-contain- 
 ing and resonant structures, as the spleen, and particularly when there is 
 tympanitic distention of the abdomen; and (c) to the recognition of the 
 extent and the horizontal levels of fluid exudates in the abdominal and tho- 
 racic cavities in different postures. The physical signs depend to a greater 
 extent upon the sensation of resistance imparted to the percussion finger 
 than upon the character of the sounds perceived, though both have value. 
 Various methods have been described. Delicacy of touch, a light stroke, 
 and a lingering rather than a momentary contact with the surface under 
 examination are essential to success in all of them. 
 
 The direct methods of palpatory percussion are: 
 
 1. That of the Writer. — This consists in flicking the surface 
 with the nail of the middle finger in the manner described under the 
 caption direct or immediate percussion. This method is painless to the 
 patient and yields very accurate results. The nail should strike the surface 
 percussed flatly and linger for an instant. 
 
 2. Maguire's Method. — The palmar cushion of the tip of one finger 
 is employed as the plexor. The stroke is not short and quick but prolonged 
 and combined with a certain movement of pressure or palpation. 
 
 3. Method of Hein. — The first and middle fingers are employed, 
 the tip of one resting upon the surface while the other, used as a plexor, 
 delivers a light tap upon the adjacent surface, palpation and percussion 
 being literally performed at the same time. The fingers are alternately 
 used and the whole surface is gradually examined. Very accurate results 
 may be obtained by this method. 
 
 The Indirect Methods Are: 1. The finger used as a pleximeter is 
 struck lightly with the fingers of the other hand, which are slightly flexed 
 in such a manner that the blow is delivered by the pulps rather than the 
 extreme tips. The stroke is not sharp and rebounding, but prolonged 
 and pushing, the so-called palpating stroke, and the percussing fingers 
 remain a moment upon the plexor finger before the blow is repeated. 
 
 2. That of Ebstein. A glass pleximeter 4 centimetres in length and 
 1.3 centimetres in width, with a projecting bar 1.5 centimetres in height 
 is used. This is held firmly in place while the finger held as in ordinary 
 finger percussion delivers a gentle but pushing or pressing percussion stroke 
 
 9 
 
130 MEDICAL DIAGNOSIS. 
 
 upon the flat upper surface of the bar. The pleximeter devised by Sansom 
 consists of a slender rod of square section having at one end attached at 
 right angles a thin plate and at the other end a similar plate parallel to 
 the first. The measurements are about the same as those of the glass 
 pleximeter of Ebstein, but all the parts are made of hard rubber. In use 
 the larger plate is applied to the surface of the chest and held in position 
 by the tips of two fingers, one on each side of the rod. Percussiou is then 
 made upon the upper plate, the finger of the other hand being employed 
 as a plexor. Greater attention is paid to the vibrations perceived by the 
 fingers than to the sound. This special pleximeter enables the observer 
 who has acquired skill in its use to recognize slight modifications of the 
 vibrations produced by percussion and to map out more closely than by 
 other methods, but not absolutely, the limits of the deep dulness of the 
 heart and the great vessels. 
 
 Auscultatory Percussion. — The chest piece of a binaural stetho- 
 scope is applied to the surface over the body of an organ, as the heart, 
 liver, stomach, etc., and held in place by an assistant or the patient him- 
 self. Using finger pleximetry with very light strokes, percussion is per- 
 formed in radiating lines towards or away from the stethoscope as a centre. 
 Direct percussion with the finger-tips may be employed especially in case 
 the observer himself for any reason is obliged to use one hand to hold the 
 stethoscope in place, or a light stroking touch or scratching of the skin 
 will serve the purpose. A stiff brush may be used for this purpose. The 
 sounds are greatly intensified and changes in their quality, volume, and 
 pitch are readily appreciated. Of especial importance are the abrupt 
 changes that take place as the line of percussion passes over the border 
 of the organ over which the stethoscope is placed. The points at which 
 the change occurs being marked and these points being joined by lines, 
 an approximate outline of the organ is obtained. The observation must 
 be controlled and errors eliminated by percussing in segments of widening 
 circles and by the employment of the ordinary methods of percussion. 
 This method is much more useful in the examination of the abdominal 
 than of the thoracic viscera. It should be acquired by every student. 
 
 Percussion Signs in the Chest. 
 
 THE EXAMINATION OF THE NORMAL CHEST BY PERCUSSION. 
 
 Pulmonary Resonance. — The sounds elicited vary in different regions. 
 The anterior and lateral surfaces are more resonant than the posterior 
 by reason of the greater thickness of the walls of the last. The resonance 
 in the former is known as normal, pulmonary, or vesicular. The portion of 
 the apex of the lung above the clavicle yields a sound which acquires the 
 tympanitic quality — vesiculotympanitic — as the trachea is approached. 
 Some difficulty in the application of the finger or pleximeter renders 
 percussion less satisfactory in this region than in other parts of the chest. 
 Over the clavicle the sound has the peculiar quality known as osteal reso- 
 nance; is dull towards the scapular extremity and acquires a distinctly 
 tympanitic quality with heightened pitch at its sternal end of the bone. 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 131 
 
 In the infraclavicular region, that is, as far downward as the fourth 
 rib, the pulmonary or vesicular resonance is characteristic. There is usually, 
 however, a slight disparity in the two sides, the sound of the right being 
 somewhat less resonant, shorter in duration, and of higher pitch than the 
 left. The recognition of this fact is of cardinal importance. From the 
 fourth rib downwards on the right side the resonance upon strong per- 
 cussion is slightly diminished, owing to the presence of the dome of 
 the right lobe of the liver. About the sixth rib the pulmonary reso- 
 nance ceases. During full inspiration the liver is pushed downwards 
 to the extent of an inch or more and the line of dulness is depressed 
 to a corresponding degree. 
 
 On the left side the vesicular resonance is impaired by the presence 
 of the heart between the fourth and sixth ribs and to the left as far as the 
 mamillary or midclavicular line. The extent of this area is diminished 
 under any conditions in which a larger wedge of the border of the lung is 
 interposed between the wall of the chest and the heart, as upon deep 
 inspiration and in those who have deep chests and voluminous lungs. At 
 the base anteriorly the clear resonance passes into the tympanitic reso- 
 nance of the fundus of the stomach — Traube's semilunar space; laterally 
 into the dulness of the spleen. 
 
 In the lateral regions, axillary and infra-axillary, percussion yields 
 vesicular resonance modified in the direction of higher pitch and dimin- 
 ished intensity towards the base of the chest by the presence of the liver 
 on the right and the spleen on the left side. 
 
 Posteriorly the sound varies markedly according to the region per- 
 cussed. The greater thickness of the muscles and the presence of the scap- 
 ulae are to be considered. The resonance is everywhere diminished as 
 compared with the anterior and lateral regions. It has the quality of 
 clearness but is muffled and merges into dulness over the scapulae. The 
 percussion sound is clear over the apices but usually slightly less so on 
 the right side than on the left; and in the interscapular regions, which are 
 widened when the patient bends forward and folds his arms. It is also 
 clear from the angle of the scapula on each side to the base of the chest, 
 namely, about the level of the tenth rib, where on the right side the liver 
 dulness begins. On the left side the clear percussion sound may be found 
 a little lower than upon the right; while the resonance upon deep percus- 
 sion is somewhat diminished on the right by the convexity of the liver 
 and on the left to a less extent by the spleen. 
 
 In children and emaciated persons the resonance in the back is often 
 very good and percussion yields results scarcely less satisfactory than in 
 the front of the chest. 
 
 Normal Tympanitic Areas in the Chest. — These are at the sternal 
 ends of the clavicles, over the manubrium sterni and at the left base anteri- 
 orly. The first and second of these regions owe their tympanitic resonance 
 to the proximity of the trachea and main bronchi and their osteal quality 
 to the large proportion of bone entering into the wall of the chest. In 
 elderly persons with calcification of the costal cartilages this osteal quality 
 is widely present and when combined with tympany as is often the case 
 greatly impairs the value of the percussion signs. 
 
132 
 
 MEDICAL DIAGNOSIS. 
 
 Percussion directly over the trachea at the episternal notch and that 
 over the larynx, ^.e., over the plates of the thyroid cartilage, yields amphoric 
 resonance. The normal tympany at the left base anteriorly is due to 
 the presence of the fundus of the stomach when distended with air and 
 the adjacent transverse colon. The curved upper border of this space, the 
 convexity of which corresponds with the convexity of the diaphragm, is of 
 special diagnostic A^alue. The degree of distention of the stomach increases 
 
 this curve, which is flattened 
 or may even become concave 
 in large left-sided pleural effu- 
 sions. Traube's semilunar 
 space is bounded to the right 
 by the left lobe of the liver 
 — dull; above by the lung — 
 clear ; to the left by the spleen 
 — -dull upon light percussion 
 and is itself tympanitic, the 
 tympany being continuous 
 with that of the stomach and 
 transverse colon. It often 
 requires nice work in percus- 
 sion to map out the border- 
 line between the clear vesic- 
 ular resonance which forms 
 the upward limit of this space 
 and the tympanitic resonance 
 of the space itself. 
 
 Dull Areas in the Nor- 
 mal Chest. — These are found 
 to correspond to the scapulse 
 with their large muscular 
 masses in the chest wall, the 
 liver and spleen reaching up 
 into the chest in the vault of 
 the diaphragm and the heart within the chest itself. The scapular dul- 
 ness has already been described. The hver dulness extends in the right 
 midclavicular Hne from about the sixth rib to the border of the ribs and 
 shifts downwards an inch or more on full inspiration; the dulness of the 
 left lobe is continuous vertically with the cardiac dulness, from which it 
 cannot be distinguished by ordinary percussion, although the border-line 
 between them is sufficiently indicated for clinical purposes by the upper 
 border of liver dulness on the right side and the position of the cardiac 
 impulse on the left. In doubtful cases auscultatory percussion may be 
 employed. The heart rests upon the central tendon of the diaphragm and 
 the upper curvature of the liver fits into the vault of the diaphragm. 
 
 The area of the splenic dulness extends from the upper border of the 
 ninth to the lower border of the eleventh rib and from a point slightly 
 anterior to the midaxillary line backward towards the spine. It varies 
 normally with the physiological changes in the size of the organ. 
 
 Fig. 
 
 -Normal tympany. 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 133 
 
 Cardiac Dulness. — The cardiac dulness is divided into the superficial 
 and the deep. 
 
 Superficial. — The superficial cardiac dulness corresponds to that 
 part of the organ constituted by the anterior surface of the right ventricle, 
 which uncovered by lung lies in relation with the chest wall. It begins 
 above about the level of the fourth costal cartilage and extends to the apex, 
 being bounded below by the dulness of the left lobe of the liver and on the 
 right by the resonance of the anterior border of the right lung at the middle 
 line. This irregularly quadrilateral area varies in size according to the 
 expansion of the borders of the lungs, especially the left. It is smaller 
 upon inspiration than upon expiration and in active individuals with volu- 
 minous lungs than in sedentary persons with small and narrow chests. It 
 yields upon superficial percussion a flat and upon deep percussion a dull note. 
 
 Deep. — The deep cardiac dulness corresponds to the borders of the 
 heart itself beneath the overlapping margins of the lung and extends beyond 
 the area of superficial dulness. Upon deep percussion over this area the 
 note is dull, but the rounded receding surface of the heart renders a liter- 
 ally exact determination of its limits impracticable. Even the most skilful 
 percussion yields only approximate results. The difficulties in determin- 
 ing the upper and right border of the heart by percussion are increased 
 by the fact that the organ is covered in those regions not only by the 
 borders of the lung but also by the sternum, which modifies to a high degree 
 the percussion sound of the structures underlying it. 
 
 Enlargement of the heart gives rise to increase in the diameters of 
 both these areas, the deep area of cardiac dulness being increased by the 
 enlargement of the heart itself; the superficial area by the pushing aside 
 of the margins of the lungs. The determination of the superficial area of 
 cardiac dulness is a relatively easy matter, but the knowledge thus obtained 
 relates rather to the position of the margins of the lungs than to the size 
 of the heart ; the determination of the deep area in so far as it is practica- 
 ble would indicate the actual size of the heart, but the difficulties in reach- 
 ing exact data are in many cases insuperable. For these reasons we cannot 
 regard percussion as the best method of ascertaining the size of the heart. 
 It has a value as a control method, but the position of the apex-beat, as 
 determined by inspection, palpation, or auscultation, and the extent of the 
 impulse, with associated clinical phenomena, constitute diagnostic criteria 
 at once more convenient of application and far more precise. 
 
 The resonance of the normal chest is modified within narrow limits 
 by a variety of conditions, among the more important of which are the 
 following: 
 
 1. Change of Posture. — In the lateral decubitus the resonance of the 
 lower lung is slightly less than that of the upper by reason of the greater 
 amount of air in the latter. On exchanging the recumbent for the erect 
 posture the pitch of the percussion sound is raised (Da Costa). If the 
 patient turns upon the left side, the heart, under the influence of gravity, 
 swings outwards towards the left axilla, with a corresponding change in 
 the position of the apex and the cardiac dulness. 
 
 2. Respiration. — The general resonance of the chest is greater upon 
 full held inspiration than on quiet breathing simply because of the increase 
 
134 MEDICAL DIAGNOSIS. 
 
 of ait within its cavity. This increase of resonance may be noted on quiet 
 respiration after great muscular exertion, which is accompanied by a 
 temporary physiological distention of the vesicular structure of the lungs. 
 
 The increase in the volume of the lungs upon full inspiration not only 
 augments the resonance but also extends its borders in certain directions, 
 especially over the heart so that the superficial area of cardiac dulness is 
 diminished, and at the base of the chest so that the liver and spleen are 
 carried downwards with the descending diaphragm, and areas at the base, 
 dull on expiration or quiet breathing, yield a clear note. This respiratory 
 excursus of the lower margin of the lungs is observed posteriorly as well 
 as anteriorly, but not to the same extent. It varies in different individuals 
 in health just as the inspiratory expansion varies and is diminished by the 
 presence of pleural adhesions. 
 
 3. Gaseous Distention of tlie Stomach and Colon. — This condition may 
 displace the upper crescentic convexity of Traube's half-moon-shaped 
 space and cause tympanitic resonance in the lower part of the left chest 
 or impart a tympanitic quality to the vesicular resonance — vesiculo- 
 tympanitic resonance. It may also to some extent displace the diaphragm 
 upwards, thus causing the lower margins of the lungs to assume a position 
 slightly higher than normal with a corresponding upward displacement 
 of the limit of pulmonary resonance. 
 
 Age. — In children the lungs are relatively small and the dull areas 
 of the heart and liver correspondingly greater. In old age the borders of 
 the lungs are usually emphysematous, even in persons otherwise in normal 
 condition. Hence the area of superficial cardiac dulness is encroached 
 upon and the upper border of liver dulness is slightly lower than at earlier 
 periods of life. Under this circumstance the vesicular resonance acquires 
 a faintly tympanitic quality. 
 
 The Condition of the Chest Wall. — The obvious part in this respect 
 played by great muscular development and obesity has already been 
 spoken of. There are persons in whom percussion on account of these 
 obstacles yields negative results, ffidema of the chest wall is also an 
 important obstacle. Highly developed mammae likewise interfere with the 
 application of this method of examination; so also do the tenderness of 
 inflammation of the chest wall and hypersesthesia. 
 
 PERCUSSION IN DISEASE OF THE THORACIC ORGANS. 
 
 Percussion in the different regions of the normal thorax yields (1) 
 vesicular resonance, the sign of normal lung tissue under normal intra- 
 thoracic tension; (2) diminished resonance or dulness over the scapulae 
 and the area of deep cardiac dulness; (3) absence of resonance or flatness 
 over the lower ribs on the right side anteriorly; (4) vesiculotympanitic 
 resonance towards the base of the chest anteriorly on the left; (5) tym- 
 panitic resonance over Traube's semi-space and over the manubrium and 
 the sternal ends of the clavicles; (6) amphoric resonance over the trachea 
 and cracked-pot resonance sometimes in the crying infant. While these 
 sounds are normal when obtained in the particular regions of the chest 
 above indicated, they become abnormal or morbid signs in other positions. 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 135 
 
 Thus vesicular resonance in the area of superficial cardiac dulness may 
 indicate dextrocardia or some other form of malposition of the heart; 
 diminished resonance or dulness in the infraclavicular or mammary regions 
 may be significant of tuberculous infiltration or at the bases of broncho- 
 pneumonia; absence of resonance or flatness over a large area on either 
 side which is normally clear denotes pleural effusion, a tumor, or some other 
 airless condition; vesiculotympanitic resonance is the sign of a moderate 
 degree of atelectasis due to compression of the lung and of emphysema; 
 when of high degree it constitutes the percussion sign known as skodaic 
 resonance; tympanitic resonance elsewhere than normal is the sign of a 
 cavity, pneumothorax, or pneumopericardium; and amphoric resonance 
 save over the trachea and the cracked-pot sound except in crying children 
 must in all instances be looked upon as pathological conditions. 
 
 The changes which modify the normal resonance affect (a) the borders 
 of the lungs; (b) the structure and tension of the lungs, and (c) adjacent 
 organs. They may be general, unilateral, or local. 
 
 Changes in the Relation of the Borders of the Lung to the Wall 
 of the Thorax. 
 
 The Apices. — The lungs normally reach about an inch and a half to 
 two inches above the clavicles, the right apex being usually somewhat 
 higher than the left. Normal pulmonary resonance is obtained therefore 
 in both retroclavicular spaces. If absent in one or both and especially 
 when replaced by dulness there is consolidation and retraction of the apex 
 or apices. This sign is significant of tuberculous disease, fibroid phthisis, or 
 local adhesive pleurisy. It is often stated that bulging of the retroclavicular 
 space with tympanitic resonance occurs in emphysema. This is not always 
 true. Owing to the skeletal changes in the thorax in emphysema of high 
 grade there is usually retraction of the spaces immediately above and below 
 the clavicles. Transient prominence with vesiculotympanitic resonance 
 occurs in the acute emphysema of asthma and pertussis. 
 
 The Anterior Borders. — The resonance is marked by the osteal quality 
 of the percussion sound oyer the sternum and the signs are uncertain. 
 Below the level of the fourth costal cartilage the border of the left lung 
 sweeps downward and to the left, and is readily made out by percussion, 
 forming the upper and left lateral boundary of the area of superficial cardiac 
 dulness. Below the clinical apex of the heart and between the anatomical 
 apex and the chest wall a tongue-like projection of the anterior border of 
 the lower lobe called the lingula gives rise to a clear percussion sound over 
 a limited wedge-shaped space. The anterior border of the left lung is 
 pushed aside by an hypertrophied heart or large pericardial effusion so 
 that the area of superficial cardiac dulness is increased. An increase in 
 diameter is, however, much more frequently due to diminution in the 
 volume of the lung as in tuberculous or fibroid disease and consequent 
 retraction of its borders. In substantive chronic emphysema and the acute 
 emphysema of asthma and whooping-cough the left border of the lung is 
 advanced and in extreme cases to such an extent as to obliterate the area 
 of superficial cardiac dulness. 
 
 The Lower Borders. — Due allowance must be made for the changes 
 caused by posture, exertion, age, etc. (p. 133). The borders are lowered 
 
136 MEDICAL DIAGNOSIS. 
 
 in pathological conditions in which the volume of the lungs is increased 
 and they occupy a position higher than normal when it is diminished. 
 
 In advanced cases of emphysema the lower border of the lung as 
 marked by the transition to liver dulness on the right side and to tympany 
 on the left, may reach the ninth rib and a corresponding level in the lateral 
 and posterior regions. The respiratory excursus of the border is very 
 limited in this disease. It is likewise much restricted by old pleural 
 adhesions. Permanent upward displacement with restricted respiratory 
 movement is a sign of tuberculous or fibroid shrinking, chronic broncho- 
 pneumonia, or pulmonary collapse. The lung border ma}' be pushed up 
 by a distended abdomen, or drawn up by its own elasticit}^ in paralysis of 
 the diaphragm. It is also displaced upward and rendered immovable by 
 fluid or air in the pleural cavity — hydro-pyo-hsemo-pneumothorax. 
 
 Impaired Resonance; Dulness; Flatness. — The resonance is dimin- 
 ished in proportion as the amount of air is decreased in the part percussed. 
 It is modified according to the changes in the physical structure of the 
 spaces containing the air caused by the lesions of disease. Consolidation of 
 the lung from exudate within its substance, compression, infarct, collapse, 
 renders the percussion sound over the affected area less resonant in pro- 
 portion to the extent of the lesion. In disseminated lesions, as those of the 
 common forms of ordinary or tuberculous bronchopneumonia, there is usu- 
 ally a local compensatory emphj^sema which modifies the dulness. The 
 association of heightened pitch and diminished volume with diminished pul- 
 monary resonance must always be borne in mind. In many instances the 
 well-trained ear will recognize a change in the pitch of the percussion sign 
 before alteration in its quality. The sensation of increased resistance — 
 loss of elasticity — which is experienced by the pleximeter finger in fluid 
 exudates and dense consolidations is also to be remembered. 
 
 Impaired resonance is a sign of beginning or disseminated tubercle, 
 bronchopneumonia, early croupous pneumonia, small effusions, thickened 
 pleura, gangrene of limited extent, and small abscesses or tumors. Dulness is 
 present when the lesions of the above conditions are close set or extended. 
 
 Flatness when no Air is Present. — The percussion sound is dull over 
 the complete consolidation of croupous pneumonia involving a lobe or an 
 entire lung because some air yet remains in the large and middle-sized 
 bronchial tubes; it is flat over a large effusion because the lung with its 
 compressed vesicles and w-ith it the air-containing bronchi are pushed 
 wholly away! The presence of circumscribed consolidations, especiallj' 
 when not directly beneath the chest wall, cannot be recognized by percus- 
 sion. Their only sign may be a slight elevation of the pitch. Hence central 
 pneumonias and deep-seated aneurisms are frequently overlooked. An 
 effusion into the pleura of serum, pus, or blood which does not reach 500 
 to 750 cubic centimetres in volume does not often yield definite physical 
 signs upon percussion, and a pericardial effusion of half this amount may 
 escape detection. In pneumothorax when the bronchopulmonary fistula 
 has closed and the air is present under a high degree of tension, the per- 
 cussion note over the greater part of the affected side may be dull. 
 
 Impaired resonance over the apex or upper lobe of one lung with 
 normal resonance elsewhere is commonly significant of tuberculosis. It 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 
 
 137 
 
 may, however, be caused by an apex pneumonia or gangrene. Dense 
 pleural thickening is also a cause of dulness in this region. Slight impair- 
 ment of resonance in this region which passes away upon repeated deep 
 inspiration or prolonged percussion may simply indicate habitual deficient 
 respiratory expansion of the lungs. 
 
 Dulness at the base of the chest, always more pronounced and signifi 
 cant posteriorly, may be the sign of pneumonia, oedema, hypostatic con- 
 gestion, atelectasis, or pleural effusion or thickening. Less commonly it 
 stands for infarct, abscess, gangrene, tuberculosis, or tumor. 
 
 Fig. 73. — Pleural effusion, left side, showing degree of displacement of heart and of obliteration of 
 
 Traube's semilunar space. 
 
 Fig. 74. — Pneumohydrothorax — erect posture. 
 
 Fig. 75. — Pneumohydrothorax — dorsal decubitus. 
 
 Flattening of the convexity of Traube's semilunar space is a sign 
 of moderate pleural effusion ; marked depression, with a concave upper 
 line, occurs in massive effusion. 
 
 Vesiculotympanitic resonance of woodeny quality is significant of 
 extensive fibroid changes in the lung. 
 
 Dulness at one or the other base, the upper line shifting quickly upon 
 change in posture, is characteristic of pneumohydrothorax. The upper 
 line of small pleural effusions shifts much more slowly and that of large 
 effusions scarcely at all save in prolonged and decided change of posture. 
 It is to be remembered that a pleural effusion which develops insidiously 
 while the patient is up and about occupies the lower part of the chest and 
 causes dulness at the base anteriorly, while one that accumulates in a bed- 
 
138 MEDICAL DIAGNOSIS. 
 
 ridden patient may cause extensive dulness posteriorly and reveal itself 
 anteriorly merely by skodaic resonance. The significance of dulness in the 
 interscapular region is often obscure. It may be a sign of pulmonary 
 collapse or great enlargement of the bronchial glands. In the latter case 
 there is also dulness instead of osteal tympany over the lower cervical 
 vertebrae. Dulness or flatness in the left suprascapular or particularly 
 in the left interscapular space may be caused by the presence of an aneurism 
 of the descending aorta. 
 
 Increased Resonance — Hyperresonance — Vesiculotympanitic Reso= 
 nance — Tympany. — Solidification of lung tissue changes its percussion 
 note to dulness. An increase in the amount of air causes an increase of 
 resonance, but does not necessarily change the quality of the note, which 
 retains its clearness alike in shallow-chested and in deep-chested individ- 
 uals and in forced expiration and in full held inspiration. In truth 
 the change from the clear to the tympanitic percussion note very fre- 
 quently accompanies a reduction in the amount of air contained in the 
 portion of the lung under examination. The resonance has a tympanitic 
 quality in extreme dilatation of the air-cells, as emphj^sema, in deep con- 
 gestion, oedema, the pressure atelectasis overlying an effusion or adjacent 
 to a tumor, and that part of the lung which is the seat of collateral fluxion 
 in pneumonia; it may be exquisitely tympanitic in any of these conditions. 
 
 Clearness is replaced by tympany over portions of the lung which have 
 broken down with the formation of cavities, provided that the cavities 
 contain air; when they are filled with fluid the percussion sound is dull. 
 
 The note is tympanitic in pneumothorax and in the rare instances of 
 pneumopericardium that occur. But when the cavity in pneumothorax 
 is closed and the air is present under high tension the note becomes dull. 
 
 The tympanitic percussion sound may be due to extrapulmonary 
 conditions. We have seen that percussion of the parts immediately over 
 the trachea and main bronchi yields resonance having this quality. In the 
 same manner inexpert percussion over a consolidated lung may yield a 
 tympanitic sound due to the air in the trachea and large bronchi on the 
 one hand or to the air in the stomach and intestines on the other. 
 
 Finally, the bases of the chest posteriorly in crying infants in health 
 often yield a tympanitic sound, and that sound, as has been pointed out, 
 sometimes has the cracked-pot quahty. 
 
 When we come to review the physical conditions present under the 
 foregoing circumstances, we are impressed with the fact that, whether 
 directly or by conduction, the vibrations produced by percussion act upon 
 air-containing structures which do not fulfil the requirements of the clear 
 percussion sound, namely, air contained in elastic vesicles under physio- 
 logical tension within the chest. On the contrary, they present, completely 
 or in a modified manner, the very conditions necessary to the tympanitic 
 percussion sound, namely, air in spaces, the walls of which are not under 
 any great degree of tension. 
 
 In emphysema we recognize as an essential lesion that nutritive change 
 in the alveolar walls which interferes with expiratory contraction; even 
 in local or compensatory emphysema there is some degree of impairment 
 of contractility from vesicular overdistention. In congestion and oedema 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 139 
 
 the volume of air in the chest is decreased as the quantity of blood is 
 increased or serum is present and the normal tension diminished to a corre- 
 sponding degree. In compression of the lung the air is squeezed out of the 
 atelectic portion as the water out of a sponge and the vesicular tension 
 is done away with altogether. In collateral fluxion the condition is the 
 same as in congestion from other causes. In the foregoing conditions the 
 percussion sound varies from vesiculotympanitic resonance — mere hyper- 
 resonance — to an exquisite tympany. In air-containing cavities within 
 the lungs or in the pleural space and in the case of the tracheobronchial 
 or gastro-intestinal tympanitic sound we have to do with the conditions 
 essential to this phenomenon and the quality is unmixed and constant. 
 
 The pitch of the tympanitic sound varies with the degree of tension 
 of the air within the cavity, becoming higher — dull tympany — as the 
 tension increases, and with the relative width of the opening with which 
 the cavity communicates with the air, the wider the opening the higher 
 the pitch. The student may demonstrate these facts by percussing his 
 distended cheeks under progressive degrees of tension with his mouth 
 closed and with his mouth opened progressively to the full extent. 
 
 1. Vesiculotympanitic resonance on both sides of the chest is signifi- 
 'cant of emphysema, which may be acute as in asthma or pertussis, or chronic 
 as in pseudohypertrophic emphysema. The degree of tympany varies with 
 the grade of the disease. In extreme cases the percussion sound becomes 
 high in pitch, small in volume, and short in duration — dull tympany. 
 
 2. The percussion note is hyperresonant and has the tympanitic 
 quality over the sound side in the vicarious respiration such as occurs in 
 extensive disease of the lung, massive pleural effusion, or large tumor of 
 the opposite side. 
 
 3. An exquisite tympanitic sound, often partaking of the amphoric 
 quality, is present over the affected side in pneumothorax. With extreme 
 intrapleural tension the sound becomes less resonant — dull tympany or 
 flat tympany — or may become quite dull. 
 
 4. Local tympanitic percussion resonance is a constant sign of pressure 
 atelectasis. It is present at the level of pleural effusions, above towards 
 the axilla and at the base posteriorly on the left side in massive pericardial 
 effusions, and surrounds the dulness caused by pleural and pulmonary 
 tumors. In old cases, as the atelectasis becomes complete, the tympanitic 
 resonance is replaced by dulness. 
 
 5. Tympanitic resonance in one or both infraclavicular spaces asso- 
 ciated with dulness at the base of the chest may be a sign of pleural effusion, 
 pneumonia of the lower lobe, infarct, abscess, gangrene, or, if bilateral, 
 of oedema. 
 
 6. Tympanitic resonance at the sternoclavicular articulation and 
 below it with dulness at the apex is usually conducted tracheobronchial 
 resonance. It is encountered in tuberculosis and apex-pneumonia. 
 
 7. Circumscribed tympanitic percussion resonance is the sign of a 
 cavity which may be tuberculous, bronchiectatic, or the result of abscess 
 or gangrene. The nearer the cavity lies to the surface the better defined 
 the tympany. Consolidation of the intervening lung tissue acts in the same 
 way. In tuberculosis a cluster of small communicating cavities is often 
 
140 MEDICAL DIAGNOSIS. 
 
 present at the apex. Single small cavities even when they are superficial, 
 and deeply seated cavities even when of moderate size, do not yield a 
 tympanitic percussion sound. 
 
 8. Subdiaphragmatic tympanitic resonance when the distention is 
 extreme may be elicited by percussion in the anterior axillary line on the 
 left side as high as the third interspace. 
 
 Amphoric Resonance. — This is the sign of a cavity of large size or, 
 when very extensive, of pneumothorax. The cracked-pot sound is usually 
 the sign of a cavity of some size with compressible walls and communicat- 
 ing freely with a bronchus. The essential physical requirement is that the 
 walls should be freely compressible so that there may be a free outrush of 
 air at the moment of the percussion stroke. 
 
 The following percussion phenomena described in the text-books are 
 of greater clinical interest than practical value. They are very rarely 
 brought out in a manner that amounts to a demonstration. 
 
 1. Wintrich's Sign. — The tympanitic percussion sound is higher 
 in pitch upon opening the mouth and lower when it is closed. The patient 
 should open his mouth, protrude his tongue, and breathe quietly. This 
 phenomenon is occasionally, but by no means in the majority of instances, 
 observed in large cavities of the lung or pneumothorax with wide com- 
 munication with a bronchus. 
 
 2. Interrupted Wintrich's Sign. — If the foregoing sign is exclu- 
 sively present in the sitting posture, it is evidence of a cavity containing 
 fluid which in one posture occludes and in the other leaves open the com- 
 munication with the bronchus. Under these circumstances gurgling or 
 the rale of cavities is usually present. 
 
 3. Gerhardt's Sign. — The pitch changes with change of posture, 
 usually becoming higher in the erect posture but scarcely ever becoming 
 higher in the recumbent position. The alterations in pitch are attributed 
 to the changes in the shape of the cavity caused by the gravitation of the 
 fluid to its lowest part. 
 
 4. Friedreich's Sign. — The tympanitic resonance over a cavity 
 communicating with a bronchus is higher in pitch upon inspiration than 
 upon expiration. The change in pitch is always slight and often too slight 
 to be of value in diagnosis. The inspiratory rise is attributed to the widely 
 open glottis and the increased tension of the air in the cavity. 
 
 5. Biermer's Sign. — In pneumohydrothorax the tympanitic per- 
 cussion note is lower in the recumbent than the erect posture, the change 
 being due to alterations in the shape and relative diameters of the air 
 space caused by the gravitation of the fluid. The underlying principle in 
 Gerhardt's sign and Biermer's sign is the same. 
 
 Coin Percussion— Coin Test— Anvil Test. — Auscultation is performed upon 
 the chest while an assistant percusses at a point diametrically opposite 
 upon the front or back as the case may be, using a coin laid flat upon 
 the surface as a pleximeter and another as the plexor, striking with its 
 edge. The coins should be of some weight, as fifty-cent pieces or silver 
 dollars. If pneumothorax be present the peculiar auscultatory sign consists 
 of a clear metallic, ringing, bell-like note. Control observations may be 
 made upon the opposite side and over the compressed lung. This sign 
 does not occur over very large cavities — voiyiicce. 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 141 
 
 PERCUSSION IN DISEASE OF THE HEART. 
 
 The normal superficial and deep cardiac dulness and the method of 
 determining them have been discussed in a foregoing section. By this 
 method of physical diagnosis we ascertain approximateh^ the size, shape, 
 and position of the heart, the relation of the anterior borders of the lungs, 
 especially upon the left side, to it, and the presence of pericardial effusion 
 when it is of sufficient amount. The area of superficial cardiac dulness is 
 ascertained by light percussion in the parasternal line from above down- 
 wards until dulness with a distinct sense of resistance is reached, usually 
 about the level of the fourth rib or its lower border. This point is in a 
 transverse or oblique line extending downward and outward from mid- 
 sternum. Next percuss over the lung upon the right side about the level 
 of the fifth rib and in a transverse line across the sternum to the left. About 
 or just beyond the ixiiddle line the sound again becomes dull and the resist- 
 ance increased. This marks the limit of the anterior border of the right 
 lung. Continuing to percuss in the same line and lightly as before, we reach 
 a point at which the sound again becomes clear and which corresponds to 
 the anterior border of the left lung at the level named. This determines 
 the transverse diameter of the superficial area of cardiac dulness. The 
 left lower angle corresponds to the apex and can be determined by palpa- 
 tion. The lower border is bounded by a line prolonged from the upper 
 border of liver dulness to the apex of the heart. 
 
 The area of deep cardiac dulness may be roughly estimated by per- 
 cussion in corresponding parallel lines from the parasternal line on the right 
 side across the chest to the left and from above downward upon the left 
 side along the sternal border, the parasternal line and the mamillary line. 
 The base line is the same in both areas. The first modification of clear 
 pulmonary resonance as we approach the heart may be accepted as a sign 
 indicating the outline of that organ. 
 
 SIGNIFICANCE OF VARIATIONS IN THE CARDIAC DULNESS. 
 
 Alterations in the size of the superficial area, as has been heretofore 
 stated, are usually signs of pulmonary rather than of cardiac disease. They 
 correspond to increase as in emphysema, or decrease as in phthisis in the 
 volume of the lung. This area together with the deep area undergoes 
 changes, however, with changes in the volume of the heart. 
 
 Increase of Cardiac Dulness. — When the enlargement, as determined 
 by percussion and other methods, extends chiefiy to the left and downward, 
 the longest diameter being oblique from above downward and to the left, 
 it is the sign of hypertrophy and dilatation of the left ventricle. When 
 the enlargement is to the right, with an extension of the dulness in the third 
 and fourth intercostal spaces at the right border of the sternum and a 
 rounded blunt apex, the longest diameter being transverse, it is a sign of 
 hypertrophy and dilatation of the right ventricle and auricle. Enlarge- 
 ment both to left and right indicates hypertrophy and dilatation of both 
 ventricles, the dilatation under these circumstances being almost always 
 in excess of the hypertrophy. 
 
142 MEDICAL DIAGNOSIS. 
 
 Enlargement of the boundaries of precordial dulness to the lett. right, 
 and upwards may indicate the presence of a pericardial effusion. The 
 dulness is marked and its outline is pyramidal or pear-shaped, the smaller 
 end being directed upward. The increase in dulness ma}' be first observed 
 in the angle formed by the right border of the cardiac and the upper border 
 of the liver dulness, which becomes at first rounded and then obliterated. 
 The dulness may extend to the second interspace or higher and is sharply 
 defined at its borders. In pericardial effusions of considerable size the 
 compressed left lung yields a vesiculotympanitic or tympanitic resonance 
 — dull tAmipany; skodaic resonance. The apex-beat may be felt or located 
 by the intensity of the first sound within the borders of dulness. Percus- 
 sion alone will not always enable us to make a differential diagnosis between 
 a moderate pericardial effusion and extreme dilatation of the heart. 
 
 Under normal conditions the impairment of resonance due to the 
 presence of the aorta and pulmonary artery does not extend beyond the 
 manubrium on either side. When it can be made out upon the right side 
 in the first and second interspaces, or in the notch of the sternum, it is 
 usually a sign of dilatation of the aorta or of aneurism of the ascending or 
 transverse portion of the arch. Sometimes it indicates the presence of a 
 mediastinal tumor. 
 
 Decrease in the area of cardiac dulness is mosth' caused by pul- 
 monar}' emphysema, by which the heart is covered more completely by 
 the lung and displaced towards the middle of the thorax. The heart like 
 other muscle masses undergoes atrophic changes in acute and chronic 
 wasting diseases, as enteric fever and consumption, with a corresponding 
 diminution in the area of cardiac dulness. This area is diminished in extent, 
 altered in outline, and in extreme cases rendered wholly unrecognizable 
 by percussion in left pneumothorax, pneumopericardium, and emphysema 
 of the mediastinum, such as follows trauma and occasionally occurs in fatal 
 cases of pertussis or after tracheotomy. Extreme meteorism and great 
 distention of the stomach by gas may cause like effects. Under these 
 conditions the modified pulmonary resonance of the deep area and the 
 dulness of the superficial area are replaced by a tympanitic note. 
 
 Dislocation of the Cardiac Dulness. — The heart is a very movable 
 organ. The shifting which the apex undergoes upon changes of the posture 
 of the body has already been described. The heart is displaced upwards 
 by great meteorism. ascites, a massive abdominal tumor, or pregnancy; 
 to the left by pleural effusion, pneumothorax, or tumor on the right side; 
 to the right by similar conditions upon the left side. Great enlargement 
 of the right lobe of the liver likewise displaces the heart to the left. Con- 
 traction of the lung with adherent pleurisy displaces the heart by traction 
 toward the affected side, as in old pleural effusions that have undergone 
 resorption or been relieved by operation, and in cirrhosis of the lung. 
 Aneurismal or cancerous tumors and diaphragmatic hernia are among the 
 rarer causes of displacement of the heart. Practically speaking, displace- 
 ments of the heart are the result of diseases of the pleura or lungs. 
 The greater part of the heart and its apex may lie to the right of the median 
 line with or without general transposition of the viscera. Under all these 
 conditions except the last, there are such modifications of the percussion 
 
PHYSICAL DIAGNOSIS: PERCUSSION. 143 
 
 signs relating to the heart as to render that method of physical diagnosis 
 still more unsatisfactory and frequently wholly useless in determining the 
 boundaries of the cardiac dulness, valuable as it remains in the diagnosis 
 of the primary disease. The position of the apex as located by palpation 
 and auscultation constitutes the most reliable evidence of the region occu- 
 pied by the displaced heart. The diagnosis of congenital displacement of 
 the heart should in no instance be made until all other causes capable of 
 producing such displacement have been shown to be absent. 
 
 Percussion in the Examination of the Abdomen. 
 
 This method is far less valuable than palpation in the diagnosis of 
 abdominal diseases. It has, however, much usefulness for direct examina- 
 tion and is particularly important in controlling the results obtained by 
 the other methods of physical examination. 
 
 The Technic. — The general directions are the same as in the technic 
 of palpation. Direct percussion except flicking percussion cannot be 
 employed, owing to the sensitiveness of the surface and the elasticity of 
 the walls of the abdomen. As in palpation the patient must be examined 
 in various postures, and it is frequently necessary to distend the stomach 
 or colon with air or water. Auscultatory percussion is of service in deter- 
 mining the boundary lines between contiguous viscera, whether they be 
 solid or air containing. 
 
 PERCUSSION OF THE ABDOMEN IN HEALTH. 
 
 The upper limits of hepatic and splenic dulness are determined by 
 vesicular resonance. With this exception the signs relate to dulness and 
 tympanitic resonance and their modifications. 
 
 The normal dull areas in the abdomen are: 
 
 (a) Hepatic- -The upper border of dulness begins about the level of 
 the sixth rib in the midclavicular line. Its lower border nearly corre- 
 sponds with the arch of the ribs. This area of dulness shifts with the 
 respiratory movements about two fingers' breadth on quiet and slightly 
 more upon deep breathing. The dulness extends upon corresponding 
 lines in the epigastric zone and its respiratory excursus is less at the 
 back than in front. The dulness of the left lobe extends to the left of 
 the median line and is continuous vertically with that of the heart. 
 
 (b) Splenic. — The dull area of the spleen occupies the space between 
 the ninth and eleventh ribs, its anterior border being slightly in advance 
 of the midaxillary line. Its respiratory excursus is slightly less than that 
 of the liver. The observation must in all cases be confirmed by palpation. 
 
 The above are constant in health. 
 
 Dull areas that are not constant also occur under physiological 
 conditions. These are: 
 
 (c) The Distended Bladder.— The dull area is situated in the supra- 
 pubic region in the median line. It may extend half-way to the umbilicus. 
 It is oval and symmetrical in outline and disappears upon micturition or 
 catheterization. 
 
144 MEDICAL DIAGNOSIS. 
 
 (d) A Distended Stomach. — A hearty meal or the large ingestion of 
 fluid will cause an area of dulness in the epigastrium which disappears 
 in the course of digestion. The sharp contrast between the lower border 
 of the dulness and the tympanitic resonance of the transverse colon 
 indicates the position of the greater curvature of the stomach. 
 
 (e) Fecal Masses in the Colon. — In persons of sedentary habits it 
 is not uncommon to find areas of dulness corresponding to the course of 
 the colon, and especially to the left end of its transverse portion, which 
 disappear upon brisk and repeated purgation. 
 
 (f) Pregnancy. — The oval area of dulness gradually developing 
 upward from the pelvis, always central, at first symmetrical, later deflected 
 somewhat laterally, is suggestive. The diagnosis of this physiological 
 condition under ambiguous circumstances or in a doubtful case must be 
 a guarded one. 
 
 With the above exceptions the percussion resonance of the abdomen 
 is tympanitic. Its pitch varies with the dimensions of the particular space 
 and the tension of the contained air, being relatively high as the space is 
 small and the tension great. The stomach and colon yield therefore a 
 percussion note of lower pitch than the small intestines. The structure 
 and functions of these organs are, however, such as to cause great varia- 
 tions in the size, tension, and relation of their various parts, and lessen the 
 value of the signs obtained by this method of examination. The percussion 
 signs are furthermore greatly modified by the thickness of the abdominal 
 walls and their general state as to tension and relaxation. 
 
 PERCUSSION IN DISEASE OF THE ABDOMINAL ORGANS. 
 
 Under ordinary circumstances except as above stated the abdomen 
 in health is everywhere tympanitic beyond the borders of the liver and 
 spleen. Persistent dulness is significant of morbid conditions. It may be 
 general or local, continuous with the dulness of the liver or spleen or 
 separated from them, fixed or shifting. 
 
 General Dulness of the Abdomen. — The retracted abdomen seen 
 in the wasting diseases and in resophageal and pyloric carcinoma, cholera, 
 and the pernicious vomiting of pregnancy is usually dull upon percussion. 
 The areas of tympanitic resonance are limited in extent and of irregular 
 distribution. This is especially true of the scaphoid abdomen so often 
 observed in meningitis, tumor of the brain, and lead colic. The bowels 
 are empty of air and collapsed. 
 
 The general distention due to fat in the walls and intra-abdominal 
 fat, fluid within the peritoneal cavity, or abdominal tumor yields dulness 
 upon percussion. The bowels contain air but under conditions which 
 modify the results of percussion. In the case of an excess of fat in the 
 walls the force of the blow is not transmitted to the underlying gut; in 
 excessive omental fat the same is true. Fluid accumulates in the depend- 
 ent parts, displacing the coils of intestine, which float upon the surface, 
 and yields dulness upon percussion at the lower levels with tympany above 
 shifting with change of posture, the line between them tending to maintain 
 its correspondence with the plane of the horizon. Thus, in the recumbent 
 
PHYSICAL DIAGNOSIS : PERCUSSION. 
 
 145 
 
 posture there is general dulness save in a limited oval region around the 
 umbilicus, over which there is tympanitic resonance; in the erect posture 
 the resonance of this region is replaced by dulness while there may be 
 demonstrated a broad line of tympanitic resonance in the epigastric zone, 
 previously dull ; in the lateral postures the area of resonance seeks the upper 
 spaces and shifts alternately as the patient turns from side to side. The 
 fluid commonly gravitates slowly from region to region and a few moments 
 must be permitted to elapse before the change of note can be demonstrated. 
 Large monocystS; as of the pancreas or ovary, also yield fluctuation and 
 general dulness, but the intestines do not float at the highest level, being, 
 
 Fig. 76.- 
 
 -Free fluid in abdominal cavity — dorsal decubitus — flatness in flanks and tympany over 
 supernatant coils of intestines. 
 
 Fig. 77. — Free fluid in peritoneal cavity — lat- 
 eral decubitus — flatness in dependent side and 
 tympany above. 
 
 Fig. 78. — Abdominal tumor — increase in antero- 
 posterior diameter — flatness centrally and tympany 
 in flanks. 
 
 on the contrary, pushed aside, and causing resonance in the flanks, which 
 does not change to any great extent with change of position and does not 
 present the oval area of tympanitic resonance in the umbilical region which 
 is characteristic of ascites. The presence of peritoneal adhesions and a great 
 quantity of fluid sometimes renders fluctuation obscure and the results of 
 percussion uncertain by interfering with the free movement of the superna- 
 tant intestines. Tumors of sufficient size to give rise to marked distention 
 and general dulness or flatness usually increase the anteroposterior diameter 
 of the abdomen to a greater extent than the bilateral as compared with 
 ascites and meteorism. The enlargement caused by tumor is not usually 
 symmetrical. The intestines are pushed aside and tympanitic resonance is 
 10 
 
146 
 
 MEDICAL DIAGNOSIS. 
 
 elicited upon percussion in the flanks and especially upon the opposite 
 part of the abdomen to that from which the growth has developed — on 
 the left side in case of tumor of the liver, on the right in case of tumor of 
 the spleen, above in tumors springing from the pelvic organs, below in 
 those springing from organs in the epigastric zone, and so forth, while over 
 the tumor there is dulness. The list of tumors which attain dimensions 
 sufficiently great to cause general distention of the abdomen comprises 
 cancer, syphilitic and amyloid disease, and hydatid cysts of the liver; 
 malignant disease and multiple cysts of the kidney; cancer of the intestines 
 and peritoneum; ovarian cysts and uterine fibromata and retroperitoneal 
 
 sarcoma. Very marked distention 
 may be present in pancreatic cyst, 
 hydronephrosis and tuberculosis of 
 the mesenteric glands, and Hodgkin's 
 disease. All these conditions yield 
 dulness upon percussion. An impor- 
 tant sign in the diagnosis of large neo- 
 plasms of the retroperitoneal glands 
 arises from the fact that, while the 
 intestines are in general pushed aside 
 by the tumor, the ascending or 
 descending colon, according to the 
 side upon which the growth develops, 
 passes obliquely across it and yields 
 tympanitic resonance, at both borders 
 of which dulness begins. 
 
 Gaseous distention of the abdo- 
 men — meteorism, tympany — yields 
 tympanitic resonance at all points 
 and increases the vertical diameter 
 of the abdomen by pushing the dia- 
 phragm upwards and interfering with 
 its descent. In extreme distention the note becomes higher in pitch, 
 shorter in duration, and diminished in intensity until it finally may be dull. 
 This condition is commonly due to paresis of the intestinal wall and 
 occurs in peritonitis, the advanced stages of the infectious fevers, and 
 hysteria. To a less degree it is present in cretinism, rickets, and pseudo- 
 hypertrophic paralysis. Great dilatation of the stomach and congenital 
 dilatation of the colon are attended with general abdominal enlargement 
 over which the note is tympanitic. 
 
 Free gas in the peritoneal cavity may be the outcome of a perforating 
 ulcer of the stomach or duodenum — peptic ulcer — or of the ileum in enteric 
 fever or of the appendix. The accident which leads to the escape of gas 
 is usually attended with severe abdominal pain, collapse, and meteorism. 
 Rapid obliteration of liver dulness in an abdomen not previously much 
 distended is an important sign. Mere disappearance of the anterior liver 
 dulness at the margin of the ribs or in the nipple line may be a sign of ordi- 
 nary meteorism. If, however, liver dulness is present in the infra-axillary 
 line while the patient is in the dorsal decubitus and is replaced by tym- 
 
 FlG. 79. — Tumor of left side of abdomen — 
 dulness with strip of tympany corresponding 
 to colon. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 147 
 
 panitic resonance when he is turned upon the left side, it may be inferred 
 that there is free air in the peritoneal cavity. 
 
 Local Areas of Dulness. — Spasmodic local contractions of the abdom- 
 inal muscles and phantom tumors may yield dulness upon percussion. 
 In obscure cases a somewhat deeply seated tumor may be examined by 
 percussion, if the walls are relaxed, by pressing with the pleximeter hand 
 gently but firmly for a time until the bowel is pushed aside, and the mass 
 may be recognized by palpation and its percussion signs ascertained. 
 Any local tumor or new growth gives rise to percussion dulness in that 
 area of the abdominal wall which overlies it. The variety of such morbid 
 conditions is very great. The nature and point of origin of the most 
 important of them have been indicated under the heading Palpation 
 in Diseases of the Abdominal Organs. 
 
 AUSCULTATION. 
 
 Auscultation as a method of physical diagnosis is the art by which 
 we recognize and interpret the sounds produced within the body in health 
 and disease. 
 
 This is the most important of the methods of physical diagnosis. It 
 is essential to the diagnosis of diseases of the organs of respiration and 
 circulation and of limited service in the diagnosis of diseases of the diges- 
 tive organs. 
 
 The Methods. — Auscultation is of two kinds, — immediate or direct, in 
 which the ear is applied directly to the surface to be examined, and mediate 
 or indirect, in which a stethoscope is employed. The latter was practised by 
 Laennec, the discoverer of auscultation; the former has since come into use. 
 
 Each of these methods has its peculiar advantages in diagnosis. Direct 
 auscultation is useful for a general survey of the chest, including both its 
 respiratory and circulatory phenomena, the study of broad areas and the 
 determination of the presence or absence of abnormal signs. It also enables 
 us to detect the signs of deep-seated lesions, as central consolidation o'f the 
 lung, which are not audible by the stethoscope. Indirect auscultation, on 
 the other hand, is preferable for the nice study of the signs heard in limited 
 areas, the point of maximum intensity of a murmur or the limits of a fric- 
 tion sound. Just as in palpation we use the palm of the hand to find and 
 estimate the extent of the impulse of the heart and then study its force and 
 characters with the smaller and more sensitive finger-tips, so the experi- 
 enced diagnostician uses the two methods of auscultation. Like the other 
 methods of physical diagnosis they are not independent and sufficient of 
 themselves, but interdependent and complementary. There is no question 
 as to which should be employed, since both are necessary: the one for one 
 kind of observation, the other for a different kind; the one for clinical 
 research, the other to control its results. 
 
 Many experienced auscultators use the direct method in the exam- 
 ination of the back of the chest and the stethoscope for the examination 
 of the anterior surface, the reason for this being found in the difficulty 
 in reaching the supraclavicular and axillary regions by the direct method, 
 the closer study necessary in the examination of cardiac and pericardial 
 
148 
 
 MEDICAL DIAGNOSIS. 
 
 conditions, and certain personal considerations which appeal to the user of 
 the stethoscope. 
 
 Stethoscopes. — These instruments are made of various materials and 
 shapes. The young auscultator of a mechanical turn of mind is very apt 
 to turn his attention to the stethoscope and there are many inventions. 
 Few only deserve serious consideration. The underlying principle is the 
 conduction of the sound. There are two kinds of stethoscopes, the single 
 and the double or binaural. 
 
 The single stethoscope was used by Laennec. The best form is the 
 gun-metal instrument with detachable hard-rubber ear-piece devised by 
 Hawksley of London. 
 
 The double stethoscope of Cammann of New York consisted of a chest- 
 piece connected with two tubes fitted with ear-pieces. Many modifications 
 of this instrument have since been made and the double stethoscope has 
 come into general use. The chest-pieces as now made 
 consist of interchangeable bell-like expansions of hard or 
 soft rubber, or a shallow metal cup with a hard-rubber 
 diaphragm held in place by a metal ring, seven-eighths 
 of an inch in diameter so as to be applied to the costal 
 interspaces, or larger; the tubes are long and flexible 
 to. enable the examiner to move the chest-pieces freely 
 without changing his position, while the ear-pieces are 
 in some instances attached to metal arms held together 
 by a spring or hinged and held in position by a rubber 
 band. In other forms the soft-rubber tubes are con- 
 nected directly with the chest-piece and ear-piece, the 
 latter retaining its place in the meatus by its appropri- 
 ate shape and size. 
 
 In selecting a stethoscope attention should be given 
 to the kind. It should be an excellent conductor of 
 sound as tested by comparing several different instru- 
 ments under similar conditions, and simple in construc- 
 tion, durable, and convenient to carry. Attention must also be given to 
 the particular instrument to see that the ear-pieces fit comfortably, that 
 the pressure is right, and that extraneous sounds are excluded. 
 
 With a good instrument, even with the unaided ear, and a fair amount 
 of training the sounds which constitute auscultatory signs may be heard. 
 The problem in diagnosis is their proper interpretation. 
 
 The phonendoscope of Bianchi consists of a shallow metallic circular 
 chest -piece with vibrating hard-rubber disks and soft-rubber tubing con- 
 ductors to the ear-pieces. It is readily applied, and, while it intensifies the 
 sounds, does not produce exaggerated sounds. It is especially useful in 
 auscultatory percussion. 
 
 In the Bowles stethoscope the chest-piece is constructed wdth a 
 vibrating hard-rubber diaphragm with the attachment for the conducting 
 tubes at a right angle to its central axis. Multiple attachments are made 
 for class demonstration. The sounds are intensified and the claim has 
 been made that cardiac murmurs otherwise inaudible may be distinctly 
 heard. The flat chest-piece is especially serviceable in the examination 
 
 Fig. 80. — Hawksley's 
 single stethoscope. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 
 
 149 
 
 of the back of the chest in persons too ill to be moved, since it may, by push- 
 ing the bedclothes down, be slipped under the patient's back at different 
 points without changing his position. Combinationformsin which the Bowles 
 attachment is fitted into the chest-piece of an ordinary stethoscope are sold. 
 
 The differential stethoscope of Alison has two chest- 
 pieces with separate conducting tubes. This instrument 
 enables the examiner to compare the sounds heard at 
 different parts of the chest and to study differences in 
 their acoustic properties as well as in the time of their 
 occurrence. Notwithstanding its value it has not come 
 into general use. 
 
 The Technic of Auscultation. — The following gen- 
 eral rules are to be observed: 
 
 1. The patient's attitude should in so far as possible 
 be comfortable and unconstrained. 
 
 2. Let the chest be bared or covered only with a 
 towel or single layer of undergarment. When the steth- 
 oscope is used it is better to have the chest bare. 
 When direct auscultation is practiced it is convenient 
 and fitting, though not essential, to have a layer of thin 
 stuff between the ear of the examiner and the skin of 
 the patient. Auscultation cannot be properly performed 
 through the patient's ordinary clothing. The superim- 
 posed layers of several' garments, silk fabrics, and the 
 suspenders or corsets not only mask the sounds within 
 the chest but also give forth sounds of their own upon 
 respiratory movements. 
 
 3. In indirect auscultation apply the chest-piece 
 of the stethoscope closely to the surface, steadying it 
 by grasping it between the thumb and index finger. 
 
 4. If the single stethoscope is used, it must be 
 applied perpendicularly to the surface. If it is tilted, 
 external sounds are not excluded. ' 
 
 5. The stethoscope must be applied very lightly in 
 auscultation of blood-vessels. The rim of the instru- 
 ment may cause a murmur in the vessels at the root of 
 the neck or in the abdominal aorta by causing the 
 physical condition to which such murmurs are due, 
 namely, sudden narrowing of the lumen — stenosis. 
 
 6. Examine the chest in a routine manner first at 
 one apex, then at the other, and at corresponding points 
 upon the two sides from above downwards, in front, 
 behind, and at the sides. Comparison and contrast are essential to auscul- 
 tation. Equally important are the differences in the sounds upon ordinary 
 quiet breathing, full respiration, and coughing. The respiratory signs are 
 to be considered also in connection with the signs upon auscultation of 
 the voice. In very serious cases, where the patient cannot be disturbed 
 or where the condition can be at once recognized, a complete systematic 
 examination may be omitted. 
 
 Fig 
 
 81. — Bowles bin- 
 aural stethoscope. 
 
150 MEDICAL DIAGNOSIS. 
 
 7. Examine the heart in the same systematic manner, placing the 
 stethoscope over the puncta maxima in turn and noting the direction in 
 which sounds or murmurs are propagated together with the presence or 
 absence of friction sounds, etc. 
 
 8. Consider the patient. Do not fatigue him unnecessarily" either in 
 mind or body. Do not cause distress by undue pressure of the stethoscope 
 or by insisting upon the rejDetition of deep breathing or cough when they 
 give rise to pain. Conduct the examination with method, dispatch, and 
 regard for his feelings and do not repeat it with unnecessary frequency. 
 
 9. Consider yourself. Assume a position which enables you to place 
 your ear or the stethoscope in accurate relation to the surface to be ex- 
 amined. Use such patience with skill as will render the examination 
 satisfactory to you. If, despite your efforts, the results do not justify 
 a diagnosis, defer expressing an opinion until you have an opportunity 
 of repeating the examination under more favorable circumstances. In 
 dispensary and hospital practice be on your guard against vermin. 
 
 In children auscultation is even more valuable in the diagnosis of 
 diseases of the chest than in adults. Owing to the great elasticity of the 
 walls of the chest and the corresponding increase of resonance, percussion 
 is of much less general applicability. Dulness. even when the physical 
 conditions which cause it are present, is not usually so marked nor its 
 limits so easily recognized, nor do we derive the same advantage from 
 comparing and contrasting the two sides, since the acute pulmonary 
 affections of early life are much more frequently double than those after 
 the second dentition. 
 
 In children the back of the lungs should be first listened to. The 
 diagnosis may often be made at once upon a careful and systematic exami- 
 nation of the back alone, after taking the history of the illness and noting 
 the symptoms. This is especially true in acute and chronic bronchitis, 
 croupous and bronchopneumonia, and pleural effusion. Crying is of great 
 assistance. The deep inspirations develop the signs characteristic of the 
 lesions which are present, and we also obtain the signs which arise from the 
 character and modifications of the vocal resonance. 
 
 The position in which the child is examined by auscultation should 
 vary with its age. Very young infants may be examined in either a lying 
 or sitting posture on the lap of the nurse or upon a pillow; or they may 
 be held in the arms of an attendant who presents one part of the chest 
 after another to the ear of the physician. The physician himself may 
 hold the baby seated upon his left hand and supported by his right hand 
 applied to the front of its chest and listen to its back with his right ear. 
 Older children may be held seated upon the forearm of the mother or 
 nurse with the head resting upon her shoulder while the physician listens 
 to the back. 
 
 The difficulty with beginners in auscultation is that they hear too 
 much. They cannot at first discriminate between sounds that are signifi- 
 cant and those which are irrelevant. The power to do this comes, however, 
 with practice. 
 
 The most important of the sounds which, by a process of selective 
 attention, the young auscultator must learn to disregard are the following: 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 151 
 
 1. Outside Noises. — A quiet room and silence are desirable but cannot 
 always be secured. We must train ourselves not to hear extraneous sounds 
 while engaged in listening to those which are the object of our immediate 
 attention. Properly fitting ear-pieces and accurate adjustment of the chest- 
 piece of the stethoscope are of help in excluding the sounds which we do 
 not want to hear. 
 
 2. Accidental noises produced by the stethoscope. These comprise 
 friction rubs of the instrument upon the skin, especially when it is dry and 
 harsh or covered with coarse hair; friction rubs of the auscultator's fingers, 
 or his sleeves, or the like, upon the stethoscope; friction or fine snapping 
 sounds caused by the movement of one part upon another of an adjustable 
 stethoscope of several pieces; sounds made by the breath of the examiner 
 upon the rubber cross-piece or steel spring of the stethoscope, and finally 
 the humming or buzzing sound — tinnitus — made by the ear-pieces. Most of 
 these sounds are easily recognized and avoided. The last is to be dimin- 
 ished by very careful adjustment of the ear-pieces and overcome by usage. 
 
 3. Adventitious sounds conducted by the stethoscope but not properly 
 constituting auscultatory signs. The sounds made by the friction of the 
 clothing and coarse hairs are very confusing. The first are easily obviated; 
 the second by practice, by applying the chest-piece beyond the borders 
 of the hairy patch, or by the use of oil. Sounds produced by the contraction 
 of muscular masses may often be heard, especially upon deep breathing, 
 in various parts of the chest and in particular over the pectorals and tra- 
 pezii. These sounds are faint and variable in kind but often quite distinct. 
 They can be produced upon the forcible contraction of any muscle. The 
 thenar mass, for example, when contracted with the stethoscope applied 
 over it, affords a good illustration of such sounds. Cabot has suggested 
 that auscultatory sounds described as ''crumpling," "obscure," "distant," 
 and "indeterminate" rales are in reality due to muscular contractions. 
 The fact that such sounds are very often associated with distinct or easily 
 recognized rales and other evidences of pulmonary disease and occur in 
 individuals with atrophic chest muscles, should put us on our guard against 
 hasty conclusions. 
 
 Auscultation as Applied to the Diagnosis of Diseases 
 of the Organs of Respiration. 
 
 It is of practical importance that the movement of the tidal air on 
 quiet breathing is in many persons not sufficient to cause auscultatory 
 phenomena of significance. It becomes necessary then to listen to the 
 chest during deep or forced respiration. If the patient is stupid or awk- 
 ward, difficulties arise. He holds his breath, or pants, or makes strange 
 noises, or does not appear able to take a deep breath. You show him how 
 to breathe for the examination or you ask him to cough, listening to the 
 respiratory signs during the deep inspiration which follows or precedes, 
 or you ask him to count as long as he can with a single breath. The full 
 breath which follows enables us to ascertain the presence or absence of 
 abnormal signs. These difficulties are usually encountered in subacute 
 and doubtful cases. In acute cases and in chronic cases with advanced 
 lesions the signs are commonly distinctive upon ordinary breathing. 
 
152 MEDICAL DIAGNOSIS. 
 
 THE SIGNS IN HEALTH. 
 
 Auscultation of the normal chest discovers two respiratory sounds 
 which are tj^pical: 
 
 1. Tracheal, bronchial, or tubular breathing, 
 
 2. Vesicular breathing, and combinations of these types in varying 
 degree, namely, 
 
 3. Bronchovesicular breathing. 
 
 1. Tracheal, bronchial, or tubular breathing is heard when the 
 stethoscope is placed over the thyroid cartilage, over the trachea in the 
 episternal notch, and in the upper part of the interscapular space upon the 
 right side — normal bronchial respiration. Sometimes nearly pure bronchial 
 breathing can be heard in health over the manubrium sterni or the three 
 lower cervical vertebrae. 
 
 It has its origin in the larynx, and is sometimes for that reason spoken 
 of as laryngeal, and, from the situations at which it is heard in health, 
 tracheal or bronchial. Since it is conducted along the column of air in the 
 bronchial system and probably also along its elastic walls and resembles 
 the sound produced by breathing through a tube, it is called tubular. 
 
 This type of breath sound is heard with inspiration and expiration, 
 these two elements of the sound being separated by a brief interval of silence 
 at the end of inspiration. Its quality is bronchial, tubular, or blowing; 
 its pitch relatively high as compared with vesicular breathing. The expira- 
 tory element is slightly more intense, usually of higher pitch, and slightly 
 more prolonged than the inspiratory part. It may be imitated by slowly 
 breathing through the hollow of the hand, closed by flexing the fingers 
 till their tips touch thenar and hypothenar eminences, or through the 
 lips and teeth held in the position to sound the German ch. 
 
 It is produced at the chink of the glottis where the air upon inspira- 
 tion and expiration is thrown into eddies or swirls — fluid veins. For the 
 reason that a similar mechanism is involved in the production of vesicular 
 breathing and cardiac and vascular murmurs, it may properly be considered 
 at this point. 
 
 The Theory of Fluid Veins. — Chauveau pointed out the fact that 
 when a fluid is forced under pressure from a narrow into a wider tube or 
 channel, or through a narrow opening into a large cavity or space, it is 
 thrown into swirls or eddies, the vibrations of which, transmitted to the 
 enclosing substance and to the surrounding air, are recognized as auditory 
 phenomena. These swirls have been called fluid veins. They are currents 
 within currents, and their vibrations are not only transmitted laterally 
 but also longitudinally in the stream in which they exist, so that the sounds 
 are heard over the point at which they are produced and at a distance in 
 the direction of the flow. The extent and force of these swirls and the 
 consequent loudness of the sound by which they are represented depend 
 to some extent upon the composition and density of the fluid but mainly 
 upon the force of the current. The student will realize the nature of fluid 
 veins and the part they play in the production of the bronchial respiration 
 and the vesicular murmur, — for the air acts in the same way as other 
 fluids, — and especially their part in the production of endocardial and vas- 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 153 
 
 cular murmurs, if he considers the course of a rivulet which flows at one 
 time down a steep and rapid course, and at another along a nearly level 
 bed with even sides and a smooth bottom, and now as a gentle stream and 
 again with considerable force. The quiet current flowing in even banks 
 is smooth and noiseless, while the little torrent in its rocky bed has its 
 surface thrown into countless screw-like swirls, and murmurs or roars, 
 according to the force and volume of the water. The stream is an open 
 channel; the respiratory and vascular spaces are closed tubes; but the 
 mechanism by which the sounds are produced is the same in each. It is 
 evident that the intensity of the bronchial respiration will vary with the 
 quantity of the tidal air, the force with which it passes through the 
 glottis, the distance at which it is heard, and the conducting properties 
 of the media through which it is transmitted. Variations in pitch depend 
 upon the size and shape of the spaces — pharynx, buccal cavity, trachea, 
 etc. — which constitute resonating chambers in relation with the larynx. 
 We are thus prepared to find wide differences in intensity and pitch in the 
 breath sounds which have the characteristic tubular or bronchial quality. 
 
 2. Vesicular Breathing. — Respiration of this type is heard when the 
 stethoscope is placed elsewhere over the chest where the lungs are in 
 contact with the chest wall, namely, in the front of the thorax with the 
 exception of the area of superficial cardiac and hepatic dulness, in the 
 infrascapular regions and in the axillary and the upper part of the infra- 
 axillary regions. In the right interscapular region the breathing in health 
 is usually broncho vesicular, the vesicular element predominating. 
 
 This sound has its origin in the parenchyma of the lung, and is due to 
 the transmission of the vibrations, caused by fluid veins or swirls in the 
 air passing into and out of the infundibula and alveoli, to the surface of 
 the chest. The hypothesis that the vesicular respiration is merely a modi- 
 fication of the bronchial appears to me to rest upon insufficient facts. This 
 type of breathing is heard throughout the whole act of inspiration, and is 
 immediately followed, without an interval of silence, by a short but incon- 
 stant expiratory sound. The inspiratory portion is low in pitch as com- 
 pared with bronchial respiration, of variable intensity, and has the char- 
 acteristic quality described as vesicular, which is to be learned only by 
 experience. It is sometimes called the vesicular murmur, and it may be 
 of service to the student to note that it possesses the distinguishing pecuUar- 
 ity of murmurs, namely, that they are sounds made up of a multitude of 
 small sounds, all having about the same acoustic properties, as we speak 
 of the murmur of a crowd, of the leaves of the forest, of the sea, and so on. 
 The expiratory part is still lower in pitch than the inspiratory, much less 
 intense, frequently absent altogether, and does not exceed one-third the 
 length of the latter. 
 
 The vesicular murmur is not equally intense in all parts of the chest. 
 It is loudest in the infraclavicular, axillary, and infrascapular regions, and 
 fainter at the bases in front and behind. That is to say, it is loudest over 
 large masses of lung tissue and faintest over the thin wedge-shaped borders. 
 But it is also less distinctly heard in the mammary and scapular regions. 
 We conclude therefore that it is not well conducted through thick layers 
 of muscle, bone, and fat. Wherever heard, whether loud or faint, it retains 
 
154 MEDICAL DIAGNOSIS. 
 
 its characteristic breezy quality and low pitch, and the relative duration, 
 intensity, and pitch of the inspiratory and expiratory elements are preserved. 
 
 The vesicular murmur is feeble and distant on shallow breathing and 
 intense upon deep breathing, especially after prolonged deep breathing as 
 after exertion. It is intense over the unaffected lung in cases in which the 
 opposite lung has been thrown out of service by disease, and in healthy chil- 
 dren, hence it is spoken of, when thus intensified, as "puerile" or "exagger- 
 ated' ' respiration. Intense vesicular respiration somewhat modified is spoken 
 of as "rough"; just as broncho vesicular respiration is often called "harsh." 
 
 3. Bronchovesicular Breathing. — This form of respiration, as the 
 name indicates, has the characteristics of both bronchial and vesicular 
 breathing and consists in fact of a breath sound in which both are present. 
 It is heard in the normal chest very often, but not invariably directly below 
 the right clavicle, and quite constantly at the sternal borders opposite the 
 lower part of the manubrium and in the upper portions of the interscapular 
 spaces, namely, in situations in which both sounds are within range of 
 hearing. Many of the difficulties regarding bronchovesicular respiration 
 are solved when we recognize the fact that it is made up of the two forms 
 in varying degrees of combination, so that it sometimes presents the traits 
 of bronchial breathing slightly modified by the admixture of faint vesicular 
 breathing and sometimes those of vesicular breathing slightly modified 
 by bronchial, and between these two we encounter every grade of admixture. 
 This gradation by which the breath sound passes from bronchial to the 
 vesicular respiration may be heard in the normal chest by moving the 
 stethoscope from point to point, starting at that part of the manubrium 
 over which bronchial breathing is heard and advancing towards the nipple 
 where the vesicular murmur alone can be recognized. The inspiration 
 becomes, as we proceed, lower in pitch, less intense, and longer in duration, 
 and the expiration also lower in pitch and less intense, but shorter in 
 duration. The interval of silence which is characteristic of bronchial 
 respiration is filled by the vesicular element in bronchovesicular respiration. 
 This interval of silence is present in bronchial breathing because the swirls 
 — fluid veins — by which the vibrations causing the sound are produced, 
 arise at a single point, the glottis, and there is at that point an interval of 
 equilibrium between the flood tide of inspiratory and the ebb tide of expira- 
 tory air. The vesicular murmur, on the other hand, is produced at a 
 multitude of different points, and the moment of silence is as variable as the 
 individual httle sounds which cover the whole time of the inspiratory 
 act, since vesicles at the distant periphery of the lung are still expanding 
 when those nearer the inlet have ceased to dilate. 
 
 The conditions which modify the bronchial respiration as a physical 
 sign and those which modify the vesicular murmur also modify the broncho- 
 vesicular breathing. It therefore presents differences in intensity, dura- 
 tion, and pitch, corresponding to variations in the quantity and force of 
 movement of the tidal air, to the size and shape of the resonating chambers 
 formed by the upper air spaces and the tracheobronchial system and the 
 physical condition of the intervening tissues through which the sounds are 
 conducted to the ear. The qualities of the two component types of breath- 
 ing, though they vary in proportion, are not changed. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 155 
 
 It is essential for the student to become familiar with these three 
 forms of normal breath sounds and the localities in which they may be 
 heard in the normal chest. Familiarity with normal physical signs is the 
 first step towards the recognition of those w^hich are abnormal. 
 
 Bronchial breathing is heard in the front of the neck and over the 
 upper part of the manubrium, vesicular breathing over the greater 
 part of the chest, as above, because the mechanism by which they are 
 respectively produced is situated in the regions indicated. Broncho- 
 vesicular respiration is heard normally over the lower part of the manu- 
 brium and laterally to it and in the interscapular spaces because both its 
 factors are within the range of hearing. Bronchial respiration is heard in 
 the right interscapular space and bronchovesicular respiration is more 
 prominent (bronchial) over the upper part of the right lung by reason of 
 the larger size and higher origin of the large bronchus on the sight side. 
 
 Bronchial or tubular breathing is conducted in the column of air in 
 the bronchial tree to its remote twigs. It is not conducted to the surface 
 of the chest because the vibrations are on the one hand lost in the mass 
 of cushiony, elastic vesicular tissue which constitutes the lung parenchyma, 
 and on the other hand the bronchial sound is drowned in the vesicular 
 murmur. When this tissue becomes soUdified by compression — atelectasis 
 — or by an exudate — pneumonia, tuberculosis — the vesicular murmur is 
 done away with and the vibrations conducted by the bronchial tubes are 
 freely transmitted to the surface. 
 
 THE SIGNS IN DISEASE. 
 
 The auscultatory phenomena which constitute abnormal or morbid 
 physical signs are (a) variations in the intensity and rhythm of the breath 
 sounds, (b) normal physical signs heard in abnormal situations, and (c) 
 purely adventitious sounds. 
 
 (a) Variations in Intensity and Rhythm. — Bronchial Respiration. — 
 It has been explained that bronchial respiration heard beyond the limits 
 of certain regions of the chest in which it is normally present is usually 
 due to the consolidation of lung tissue — atelectasis; presence of an exudate, 
 as in pneumonia, tuberculosis, etc. It may, however, arise in connection 
 with cavities in the lungs or pneumothorax. Under these circumstances 
 there are layers and masses of compressed or consolidated lung tissue 
 present and the peculiar modification of the bronchial respiration is prob- 
 ably due to the fact that the cavity acts as a resonating space. Bronchial 
 respiration varies greatly in pitch. This variation is the outcome of com- 
 plex conditions not fully understood, but has been attributed to the rela- 
 tive size of the tubes or cavities from which the sound is directly conducted 
 through consolidated tissue to the ear. The pitch is usually high and the 
 sounds whiffing or snoring in pneumonia of the lower lobes, especially in 
 children, and low and the sound soft and sighing or metallic over cavities. 
 
 The following varieties of bronchial respiration are to be especially 
 considered: 
 
 1. Feeble and distant bronchial respiration is often heard in central 
 pneumonia and pulmonary infarct and over a pleural effusion In the 
 
156 MEDICAL DIAGNOSIS. 
 
 former case the bronchial breathing may be only heard upon deep inspira- 
 tion and is therefore inconstant; in the latter it is frequently so faint as 
 to be overlooked. The sound is conducted by the chest wall or by tense 
 adhesions, the result of former attacks of pleurisy. 
 
 2. Intense bronchial breathmg usually conveys the sensation of being 
 close to the ear, that is, well conducted. It accompanies dense consolida- 
 tion of the lung in which vicarious or supplemental respiration is well 
 established. 
 
 3. Absence of bronchial respiration or its sudden disappearance under 
 conditions in which the mechanism for its conduction exists may be due 
 to the plugging of a large bronchus with a mass of tenacious exudate. 
 The disappearance of cavernous or amphoric respiration often results from 
 the accumulation of fluid within the walls of the cavity. Under these cir- 
 cumstances the bronchial respiration returns after cough and expectoration. 
 
 4. Cavernous respiratioti is a variety of bronchial breathing sometimes 
 heard over a cavity. It is low in pitch, soft in quality, and the expiratory 
 element is prolonged. 
 
 5. Amphoric respiration is a variety which has the peculiar quality 
 heard when one produces a sound by blowing across the mouth of an empty 
 jar or bottle. The pitch is variable, usually low, and the sound is hollow, 
 metallic, and musical. Amphoric respiration is never heard over the normal 
 chest, and indicates a superficial cavity vdih. rigid walls — or pneumothorax 
 — having free communication with a large bronchus. The sound may be 
 imitated by whispering "who" with some force and the lips held rigid. 
 
 Vesicular Respiration — The normal vesicular murmur undergoes 
 modifications in intensity and rhythm which are of diagnostic significance. 
 
 1. Feeble vesicular respiration primarily indicates diminution in the 
 quantity and energy of the movement of the tidal air. Hence it is present 
 in varying degrees in quiet breathing in aged and bed-ridden persons, 
 in paretic conditions of the respirator}^ muscles, including the diaphragm, 
 when the movement of the diaphragm is impeded by meteorism, ascites, 
 abdominal tumor, or pregnancy. The vesicular murmur is often feebly 
 heard because it is poorly conducted, as in very thick chest walls. In 
 pleural adhesions the expansion of the periphery of the lung may be em- 
 barrassed, and with thickening conduction is also impaired. A thin layer 
 of effusion or a tumor acts in the same waj'. In pneumothorax the lung 
 is compressed and removed from contact with the chest wall, and the 
 vesicular murmur, if heard at all, is faint and distant. In acute bronchitis 
 the swelling of the mucosa and the presence of the exudate interfere with 
 the access of air to the vesicles and proportionately enfeeble the vesicular 
 murmur, especially over the lower lobes. In chronic bronchitis enfeeble- 
 ment is brought about by the accompanying emphysema and restricted 
 movements of the chest. 
 
 In congestion and oedema of the lungs the murmur is enfeebled. 
 
 Emphysema by impairing the elasticity of the lungs and restricting 
 the respiratory excursus increases the residual and diminishes the tidal air, 
 thus rendering the vesicular murmur faint and in rare cases almost 
 wholly abolishing it. Pain, as in pleurisy, restricts the respiratory 
 movement and renders the vesicular sound faint. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 157 
 
 Occlusion of the upper air-passages, as by spasm, oedema of the glottis, 
 the presence of an exudate, as in diphtheria, quinsy, or retropharyngeal 
 abscess, renders the murmur feeble in proportion to the extent of the 
 obstruction. Pressure upon the trachea or a primary bronchus by aneurism, 
 tumor, or enlarged lymph-gland acts in the same way. A foreign body 
 or a plug of tenacious mucus in a bronchus enfeebles the respiratory murmur 
 in the corresponding region to a degree proportionate to the stenosis. In 
 such conditions the occurrence of rales obscures the enfeeblement of the 
 respiratory sounds and the latter will be overlooked unless made the 
 subject of especial attention. 
 
 2. Absence of the vesicular murmur may be noted over an area of the 
 chest more or less extensive when the obstruction to a bronchus in any of 
 the foregoing conditions is complete. Marked obstruction of the upper air- 
 passages is at once followed by the signs of asphyxia. The murmur is 
 absent over the greater part of the chest in rare cases of advanced emphy- 
 sema, and no respiratory sound is heard over a pneumothorax not com- 
 municating with a bronchus, a large pleural effusion and locally over limited 
 areas in some cases of cirrhosis of the lung and at the apex in rare instances 
 in beginning tuberculosis. 
 
 3. Intensified or exaggerated vesicular breathing — puerile, vicarious, or 
 compensatory respiration — is normal in childhood and gradually decreases 
 until some time before puberty the intensity of the sound becomes that 
 of adult life. It occurs in health after exertion and in dyspnoea from 
 almost any cause in which there is no obstruction to the entrance of air. 
 It occurs over one lung when the other is put out of service, as in pneu- 
 monia, large effusion, tumor, etc., and in some instances over a portion 
 of one lung under similar conditions, hence the adjectives vicarious and 
 compensatory. 
 
 4. Derangements of rhythm occur in emphysema, in which the loss of 
 elasticity relatively prolongs the expiratory act and the expiratory sound; 
 in asthma, in which the dyspnoea is expiratory, in the ordinary dyspnoea 
 or panting of great exertion, in which the inspiratory and the expiratory 
 breath sounds are nearly equal, and in various forms of inspiratory dyspnoea 
 which are attended by diminution of the intensity and prolongation of 
 the inspiratory element of the vesicular murmur. 
 
 5. Interrupted or cogwheel inspiration is characterized by a series of two, 
 three, or four inspiratory sounds instead of the normal continuous murmur. 
 It indicates in some instances a fault in the muscular function and occurs 
 during periods of excitement or during a chill; more commonly it is a sign 
 of early pulmonary tuberculosis, the air entering adjacent lobules in turn 
 as the force of inspiration increases. It is usuall}^ heard in limited areas. 
 When restricted to the precordial space it is significant of pressure of the 
 heart upon the borders of the lung — cardiopulmonary murmur. In some 
 instances the respiratory sound is not actually broken, but wavy or jerky, 
 and is then described under these terms. It is not rarely present in tuber- 
 culosis before the disease has shown itself by other signs, and individuals 
 who present it should be carefully watched. In other cases it is wholly 
 without diagnostic significance, which it acquires only in conjunction with 
 other physical signs or the symptoms of pulmonary disease. 
 
158 MEDICAL DIAGNOSIS. 
 
 (b) Normal Physical Signs in Abnormal Situations. — Normal Sounds 
 Heard in Abnormal Situations. — Note the relative duration of the inspir- 
 atory and expiratory sounds and determine the presence or absence of an 
 interval of silence between them and the quality of the sound, whether soft 
 and breezy — vesicular murmur; blowing and tubular — bronchial breathing; 
 or whether these qualities are both present — bronchovesicular. The most 
 important facts for the beginner in the recognition of bronchovesicular respi- 
 ration are the prolongation and relatively high pitch of the expiratorj^ sound. 
 
 Perfectly normal vesicular respiration is rarely heard in other than its 
 extensive normal domain in the chest. The rare cases of dextrocardia are 
 attended with dislocation of the precordial space, and fibroid contraction 
 of one lung frequently displaces the border of the opposite lung towards 
 the affected side so that it occupies the area of superficial cardiac dulness 
 in whole or in part. The modified respiration of emphysema, faint and 
 prolonged, is sometimes heard in the precordia and over the upper normal 
 area of the liver dulness. 
 
 Bronchovesicular and bronchial respiration are on the contrary com- 
 mon and significant signs of disease in the chest. The lesions are commonly 
 progressive, and bronchovesicular usually, both in acute and chronic affec- 
 tions, precedes and progressively develops into bronchial respiration. 
 Pulmonary consolidation either from compression or infiltration is the 
 underlying physical condition and reaches its extreme development whether 
 rapidly or slowly by progressive advance. 
 
 These signs are heard over the compressed lung in the following 
 conditions: pleural effusion, the area in which they are present becom- 
 ing more limited and the respiration more characteristically bronchial 
 as the effusion augments; pericardial effusion; pneumothorax, in which 
 more or less complete compression of the lung, unless prevented by old 
 partial adhesions,, takes place rapidly; tumor of the lung or pleura; massive 
 enlargement of the heart, and large aortic aneurism. They are heard over 
 the lung undergoing solidification or already solidified from infiltration in 
 tuberculosis, bronchopneumonia, croupous pneumonia, pulmonary infarct. 
 As already pointed out, distant bronchial breathing may frequently be heard 
 over an effusion. It remains to point out the more important fact that 
 loud, distinct, and well-conducted bronchial respiration is by no means 
 uncommon over pleural effusions of large amount in thin-walled individuals 
 and especially in children. This sign is conducted from the compressed 
 lung by way of the wall of the chest and probably in some cases also along 
 bands of old adhesions tightly stretched between the compressed lung and 
 the chest wall by the force of the accumulating fluid. In pneumothorax 
 the variety of bronchial breathing known as amphoric is heard when there 
 is free communication between the pleural cavity and a bronchus. 
 
 Cavernous or amphoric respiration may be heard over cavities, 
 whether due to the breaking down of lung tissue (tuberculosis, abscess, 
 gangrene) or to dilatation of bronchi (bronchiectasis). Deep-seated cavi- 
 ties due to any of these causes may be attended with distinct bronchial 
 respiration yet be difficult to locate with precision. 
 
 Bronchovesicular respiration must be distinguished on the one hand 
 from puerile or exaggerated vesicular respiration and on the other from 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 159 
 
 bronchial respiration. The breezj^ quality, low pitch, short expiratory 
 element, and absence of a period of silence between inspiration and expira- 
 tion are characteristic of the former, however intense. The tubular quality, 
 relatively high pitch, longer expiratory sound, and an interval of silence 
 are distinctive of the latter, and between the two are all degrees of transi- 
 tional sounds. Normal in the right infraclavicular region, at the upper 
 sternal borders, and in the neighborhood of the upper dorsal vertebrae, 
 bronchovesicular respiration elsewhere in the chest becomes a sign of 
 disease, and denotes partial consolidation of the lung, patches of collapse 
 or infiltrated lung or consolidation with intervening normal vesicular 
 tissue. This sign is present in early pulmonary tuberculosis, at the borders 
 of the exudate in croupous pneumonia, in bronchopneumonia, and in 
 incomplete atelectasis from any cause. 
 
 (c) Adventitious Sounds. — Purely adventitious respiratory signs 
 are of two kinds: (1) Rales, which are produced by abnormal conditions 
 within the lungs, and (2) friction sounds which originate in the pleura. 
 
 1. Rales. — Literally a rale is a "rattle" and may be defined as an 
 abnormal respiratory sound heard on auscultation. Rales are grouped as 
 dry or moist according to the impression conveyed to the mind as to the 
 presence or absence of fluid in the mechanism by which they are produced. 
 They are laryngeal, tracheal, bronchial, vesicular, and cavernous, according 
 to the situations in which they occur. 
 
 In general rales or rhonchi are generated in the air-passages by the 
 ebb and flow of the air when their lumen is contracted or when they con- 
 tain fluid — dry and moist bronchial rales. Certain rales originate in the 
 bronchioles and vesicular structure of the lung (vesicular rales), others 
 in cavities (gurgling), and finally the succussion sound and the sign known 
 as gutta cadens or metallic tinkling have their origin in hydropneumothorax. 
 Rales may be heard upon inspiration or expiration or during both acts. 
 They may obscure the normal breath sounds or entirely replace them. 
 
 Dry rales are produced by stenosis of the bronchial tubes. This 
 narrowing may be present at one point only as in laryngeal diphtheria or 
 oedema of the glottis, or a tumor pressing upon the trachea, but is usually 
 present at the same time at many points and in many bronchial tubes of 
 varying diameter. It is brought about by a variety of pathological con- 
 ditions, as a mass of tenacious mucus adherent to the surface of the tube, 
 swelling of the mucosa or submucosa, spasmodic contraction of the bronchial 
 musculature, and the external pressure of enlarged glands or a tumor. 
 When this narrowing involves the smaller bronchial tubes the rales which 
 result are high pitched — sibilant; when it affects the larger tubes the 
 rales are low pitched — sonorous. They resemble the cooing of doves, the 
 hissing of geese, and have very often a musical quality. Sometimes they 
 are groaning or squeaking. In asthma they are often heard in great variety 
 of size, pitch, intensity, and quality, both upon inspiration and expiration, 
 and appear and disappear with the most remarkable modifications and 
 great rapidity. 
 
 Moist rales are caused by the passage of air through the bronchi 
 when they contain fluid — mucus, pus, blood. The mechanism consists in 
 the presence of bubbles or diaphragms before the incoming and outgoing air 
 
160 MEDICAL DIAGNOSIS. 
 
 which continuously burst and reform. When this process takes place in 
 the larger tubes, the bubbles are large and the rales coarse or large bubbling; 
 when in the smaller tubes, they are finer, small bubbling or subcrepitant 
 rales. Large moist rales are usually low in pitch; small moist rales higher, 
 and in this respect moist and dry rales correspond. The tracheal rale or 
 death-rattle is an example of a very coarse rale; the small moist or sub- 
 crepitant rale heard in bronchopneumonia in both respiratory acts is an 
 example of a fine moist rale. 
 
 Both dry and moist rales vary in intensity and locality. The extent 
 of the area over which they are heard depends upon that of the process 
 by which they are caused; their acoustic characters upon the physical 
 changes produced by that process. In bronchitis rales are very often best 
 heard at the bases of the lungs posteriorly; in tuberculous disease of an 
 apex, in the subclavicular region. Rales are very often influenced by the 
 act of coughing and expectoration. Dry rales produced by pressure steno- 
 sis, tenacious exudate which cannot be dislodged, or bronchial spasm, do 
 not disappear upon coughing. 
 
 Vesicular or crepitant rales originate in the finest bronchioles and 
 air-cells. Notwithstanding the differences of view in regard to the mechan- 
 ism by which they are produced, the weight of evidence is still in favor of 
 the theory that it is by the inspiratory separation of the walls of terminal 
 structures — bronchioles, alevoli — previously collapsed or held together by 
 a thin layer of sticky exudate or serum. In support of this theory the 
 following facts may be adduced: This rale, at one time held to be pathog- 
 nomonic of croupous pneumonia, is now known to occur also in other 
 pathological conditions in which an exudate or blood is present in the 
 lung parenchyma, as pulmonary cedema, hemorrhagic infarct, and acute 
 pneumonic phthisis. It is common in partial atelectasis — atelectatic 
 crepitation of Abrams. Crepitant rales sometimes associated with sub- 
 crepitant rales are frequently heard during deep inspiration at the bases 
 of the chest posteriorly and laterally in persons whose respiration is habitu- 
 ally shallow. This is not only the case in bed-ridden individuals but also 
 in many healthy persons, especially after middle age. The crepitant rale 
 is heard only upon inspiration. The subcrepitant rale with which it is 
 often associated is usually coarser and slightly moist. 
 
 The crepitant rale is usually heard towards the end of inspiration; 
 the individual rales are of the same size and intensity and they often 
 occur in "showers," a large number of single sounds having the same 
 acoustic properties following each other in rapid and irregular succession. 
 
 The crepitant rale occurs in croupous pneumonia at the beginning of 
 the process,— crepitus indux, — disappears when the exudate undergoes 
 coagulation, and reappears together with subcrepitant rales when the 
 exudate undergoes liquefaction and resorption,— cre/^iY us redux. This 
 auscultatory sign may be imitated by placing a little mucilage between 
 the finger and thumb and making repeated contact and separation. With 
 contact there is no sound, but upon separating the thumb and finger a 
 string of tenacious mucilage is drawn out which finally snaps with a sharp 
 sound not unlike the rale. It may also be imitated by the crackling of 
 fine salt thrown upon the fire, the creaking of a silk garment, or lightly 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 161 
 
 rubbing a few strands of hair between the thumb and finger. If the stetho- 
 scope is applied over the thick growth of coarse hair found upon the chest 
 of many men, a sound closely resembling crepitation will be heard. Crack- 
 ling is the term used technically to designate a rale coarser than crepitus 
 but having in other respects similar acoustic properties. This rale consists 
 of a limited number of well-defined sharp crackling sounds often heard in 
 beginning pulmonary tuberculosis or at the borders of an advancing tuber- 
 culous lesion and for this reason is of considerable diagnostic importance. 
 The distinction between crepitus and crackling is not always unattended 
 with difficulty. Crepitus consists of a number of fine sounds, heard only 
 upon inspiration and often over a considerable area at the base of the 
 lung; crackling of a few sharp, well-defined, rather coarser sounds heard also 
 in inspiration but over a limited area and commonly at the apex. It is 
 probable that the mechanism is the same in both, but that crackling occurs 
 in limited lesions, hence only a few individual sounds are heard; in wider 
 spaces, terminal bronchi, hence the sounds are coarser; and at a point 
 surrounded by densely consolidated tissue, hence they are better conducted 
 to the ear. Moist crackling and clicking are varieties of crackling which 
 are regarded as indicative of softening tubercle. In certain cases of dry 
 or plastic pleurisy fine, dry friction sounds are to be heard which can 
 scarcely be distinguished from subcrepitant rales. If they occur only upon 
 inspiration they may be mistaken for crepitus. 
 
 Gurgling or the rale of cavities is caused by the entrance and exit 
 of air in a cavity containing fluid. Coarse churning sounds are heard resem- 
 bling those produced by pouring fluid rapidly from a bottle. These very 
 coarse, well-defined rales are known also as cavernous, and sometimes 
 have the metallic or amphoric quality. 
 
 Metallic Tinkling — Gutta Cadens. — All rales heard in pneumothorax 
 acquire the amphoric or metallic quality. In some instances single rales 
 having an exquisite metallic or bell-like musical quality may follow deep 
 inspiration or the act of coughing. This sound, which resembles that made 
 by single fine shot dropped into a metal bowl or basin, was at one time 
 thought to be caused by a drop of exudate or pus collecting at the vault 
 of the cavity and falling upon the surface of the fluid collected at its base. 
 It is now known that it may occur in the absence of any such collection 
 of fluid and that it may be due to the bursting of a bubble formed at the 
 pleural orifice of a bronchopulmonary fistula. 
 
 Hippocratic Succussion. — This phenomenon, although it is not a rale 
 in the narrow sense, may be^best described at this point. It is character- 
 istic of hydro- (pyo-haemo-) pneumothorax and consists of a distinct loud 
 splashing which may be heard and felt when the thorax is suddenly shaken. 
 It is due to the swash of the free fluid against the wall of the chest, just as a 
 similar sound is produced by the sudden movement of a partially filled cask. 
 
 The Bronchopulmonary Fistula Rale. — In hydro- or pyopneumo- 
 thorax, when the accumulating fluid rises above the pleural opening of the 
 fistula there may be sometimes heard in connection with paroxysmal 
 cough bubbling sounds due to inspired air being forced from the lung and 
 up through the fluid. Under such circumstances violent spells of cough 
 are apt to be followed by copious expectoration. 
 11 
 
162 MEDICAL DIAGNOSIS. 
 
 Rales may be conveniently grouped as follows: 
 
 f Low pitched — ^Sonorous. 
 Bronchial Rales I ^''^' °^ Vibrating J High pitched— Sibilant. 
 1 Moist or Bubbling I Large bubbling — Mucous. 
 
 [ Small bubbling — Subcrepitant. 
 
 Vesicular Rales j S^'^PJ^r^- .<^,. ,. , 
 (.Crackling (Clicking). 
 
 The Rale of Cavities | i^'^''^' hoarse Bubbling-Gurgling. 
 i. Cavernous and Amphoric Rales. 
 
 ( Metallic Tinkling — Gutta Cadens. 
 Rales in Pneumothorax and similar conditions. < The Bronchopulmonarj^ Fistula Rale. 
 (Hydro-pyo-heemo-pneumothorax) (, The Hippocratic Succussion. 
 
 2. Friction Sounds. — The surfaces of the normal pleura, being moist 
 and smooth, glide noiselessly over one another with the movements of respi- 
 ration. When, however, the serous membrane is roughened by the presence 
 of a fibrinous exudate, as in pleurisj^, the movement of the opposed surfaces 
 gives rise to sounds known as "pleural friction sounds" or "friction rubs. " 
 As the lesions of pleurisy vary from a mere dryness of the surface in the 
 beginning to every grade of exudate in amount, texture, and arrangement, 
 including the fibrinoserous forms, so the friction sounds present great 
 diversity in their acoustic properties, not only in different cases but also 
 in the same case during its course. 
 
 The general and almost constant character of pleural friction is, how- 
 ever, that of the sounds produced by the rubbing together of dry or slightly 
 moistened surfaces, and is properly characterized as grazing, rubbing, 
 creaking, leathery, grating, rasping, and the like. Friction sounds are 
 usually jerky and irregularly interrupted, and change in character not 
 only in the course of time but even in the course of a single respiratory 
 act. They are superficial and give the impression of being produced very 
 near the ear. They vary in intensity from a mere graze, scarcely audible^ 
 to a coarse, loud, and prolonged creaking like that of new leather and 
 audible to the patient himself or the bystanders. They are described as 
 fine, medium, or coarse. They are as a rule best heard and often only heard 
 in the infra-axillary or inframammarj^ region where the respiratory excursus 
 is widest and the pleura investing the thin wedge of lung is in contact 
 upon one side with the costal and upon the other with the diaphragmatic 
 pleura. Not being well conducted, they are heard where they are produced, 
 so that in cases of diaphragmatic pleurisy the friction sounds may be heard 
 below the level of the lung, in croupous pneumonia opposite the seat of 
 the exudate, and in the earliest days of phthisis at the apex. They may 
 sometimes be heard over the entire lung from the apex to the base. In 
 children and spare persons the intensity of these sounds may be increased 
 by firm pressure upon the chest, and they are often attended by a palpable 
 sign — friction fremitus. They occur most commonly during inspiration and 
 especially toward the end of the act, and are frequently heard also during 
 expiration. Less often they are present during expiration alone. 
 
 Friction sounds are sometimes inconstant, ceasing after several deep 
 inspiratory acts and being again heard after a period of quiet breathing. 
 They are not modified, however, to the same extent as rales, nor do they 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 163 
 
 disappear upon coughing and the expectoration of mucus. Various pos- 
 tural methods of bringing out friction sounds in suspected cases have been 
 described, as raising the arm upon the affected side or having the patient 
 quickly rise from the recumbent to the sitting posture during held expira- 
 tion and then take a ver}' deep inspiration. 
 
 Deep breathing, coughing, pressure upon the affected side, not only 
 increase the intensity of the sounds, but are also attended with pain. In 
 exceptional cases friction sounds are unattended by pain during these acts. 
 When a plastic pleurisy is followed by a serofibrinous exudate the friction 
 sounds disappear, but recur upon the resorption or removal of the fluid. 
 They are usually present upon one side of the chest only, but may some- 
 times, especially in disseminated tuberculosis, be heard in circumscribed 
 areas on both sides. 
 
 Crumpling friction sounds are the signs of acute inflammation of the 
 pleura. When the process subsides the surfaces become fused, the fibri- 
 nous exudate organized. The condition is that of adherent pleura and, 
 unless dense and extensive, does not give rise to physical signs. In old 
 pleurisy at the' apex and especially when cavities exist, curious, low- 
 pitched, soft, creaking sounds are sometimes heard. This sound resembles 
 that produced by squeezing soft thick paper together in the hand in 
 irregular folds and is described as crumpling. It is present upon inspira- 
 tion and expiration and is not affected by cough, nor has it the characters 
 by which we recognize rales. 
 
 In some cases of pleural effusion a considerable period elapses between 
 the resorption of the fluid and the formation of adhesions. During this 
 time friction sounds may be heard and the patient may experience annoying 
 grating or rubbing sensations, especially upon deep breathing or coughing. 
 
 Sounds closely simulating friction sounds may be produced by rubbing 
 the thumb and finger together near the ear or by holding the hollow of the 
 hand over the ear and rubbing or stroking the back of it with the fingers 
 of the other hand. There is a fine friction sound which cannot be dis- 
 tinguished from crepitus. Both occur in showers at the end of inspiration, 
 both are close to the ear and have the same acoustic qualities, both are 
 accompanied by an expiratory element which may be in one case a fric- 
 tion sound and in the other a subcrepitant rale. By the sound itself the 
 differentiation is impossible, but when concomitant phenomena are taken 
 into account we find the friction sound is usually more limited in extent, 
 attended more commonly by expiratory sounds, is less uniform in charac- 
 ter, and disappears when the movement of the chest wall is restricted by 
 compression, while crepitus persists. The distinction between fine friction 
 of this form and the crepitant rale or crackling is rather of theoretical than 
 practical importance when we reflect that in pneumonia, when, as is com- 
 monly the case, the exudate extends to the periphery of the lung, the 
 pleura overlying it is the seat of an inflammatory exuclate, and in tuber- 
 culosis of the apex the early lesions which give rise to creaking are accom- 
 panied by a circumscribed pleurisy. In point of fact when we hear one of 
 these signs the other usually is also present. 
 
 The friction sound which closely resembles crepitus or crackling is 
 very rarely, if ever, heard in simple, uncomplicated pleurisy. 
 
164 MEDICAL DIAGNOSIS. 
 
 Friction sounds heard over the chest are significant of pleurisy. Those 
 over the precordial space, having the cardiac rhythm, are usually but not 
 invariably signs of pericarditis. The subject of pericardial and pleuro- 
 pericardial friction will engage our attention in a subsequent section. 
 Friction sounds heard in the epigastric zone constitute in rare instances 
 the signs of a peritonitis. The effusion in hydrothorax is not preceded 
 by a friction sound. Pleurisy is frequently primary; often secondary to 
 intrapulmonary disease, pneumonia, tuberculosis, cirrhosis of the lung, 
 abscess, gangrene, or cancer; and sometimes, especially upon the right 
 side, secondary to subdiaphragmatic disease, as abscess, cancer or hyda- 
 tids of the liver, or subphrenic abscess. Friction sounds may therefore be 
 significant of any of these affections. 
 
 Riesman has described under the term subpleural friction a fine soft 
 rubbing or crepitation which occurs in the absence of pain or the signs of 
 consolidation in miliary tuberculosis. The difficulty in distinguishing fine 
 pleural friction from crepitus has already been discussed. 
 
 AUSCULTATION DURING PHONATION. 
 
 Auscultation of the Voice in Health and Disease. — The sounds heard 
 upon auscultation of the chest of a person who is speaking when the face 
 of the patient is turned away or the opposite ear of the examiner closed, 
 or when the binaural stethoscope is employed, constitute the set of physi- 
 cal signs comprised under the general term vocal resonance, and have 
 diagnostic value. The ordinary spoken and the whispered voice are studied. 
 Obstacles to the employment of this method of physical diagnosis consist 
 in want of cooperation, as in children and extremely ill persons, in inability 
 to use the voice, as in mutes, those suffering from aphonia from any cause, 
 and in extremely feeble patients and great obesity. 
 
 TheTechnic. — The patient is instructed to turn his face away and 
 count "one, two, three"; or repeat "twenty-one" or "ninety-nine" in 
 the loud voice or in a stage whisper. The sound is conducted through 
 the bronchi and along their walls in the same manner as in a speaking 
 tube and greatly dispersed and damped in the cushiony vesicular tissue. 
 Changes in the physical condition of the lung parenchyma favor or still 
 further impede the transmission of the voice in such a manner that increase, 
 diminution, or absence of vocal resonance correspond to these changes and 
 thus become signs of disease. The modifications of vocal resonance corre- 
 spond in general to those of vocal fremitus and have the same significance. 
 
 Normal Vocal Resonance. — The voice is heard as a confused inarticu- 
 late hum, most distinct in adults possessed of deep voices and tremulous 
 in aged persons. This sound is more intense upon the right than upon the 
 left side and at the apices than at the base. As the stethoscope is carried 
 to a position nearer the main bronchi the resonance becomes louder and 
 more distinct until finally, when it is placed over the bronchi or trachea 
 in the position in which normal bronchial breathing is heard, the audible 
 words may be recognized — bronchophony. 
 
 Increased Vocal Resonance. — This sign when heard over the lung — 
 with rare exceptions, presently to be mentioned — denotes an increase in 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 165 
 
 the power of the lung to conduct sound-producing vibrations, — namely, 
 consolidation. It has, therefore, the same significance as bronchial respi- 
 ration. Fully developed it constitutes bronchophony, and indicates con- 
 solidation of lung tissue in the neighborhood of large or medium-sized 
 bronchial tubes. In addition to this simple form of bronchophony there 
 are the following varieties: 
 
 Pectoriloquy. — Laennec used this term to indicate the complete trans- 
 mission of articulate words. The voice appears to be directly spoken into 
 the observer's ear. This sign occurs in dense consolidation extending from 
 a large bronchus to the wall of the chest, over a cavity communicating 
 freely with a bronchus of some size, in a pneumothorax communicating 
 with a bronchus, and in some instances over the atelectatic lung over- 
 lying a large pleural effusion. When pectoriloquy is very distinct and 
 circumscribed it constitutes the distinct physical sign of a cavity, and, 
 as Da Costa well said, deserves the name of cavernous voice. 
 
 Amphoric Vocal Resonance. — Over large cavities and in pneumo- 
 thorax communicating with a bronchus the voice is peculiarly ringing and 
 metallic. The amphoric character is due to the same physical conditions 
 which we find to underlie the amphoric quality in the breath sounds and rales. 
 
 Whispering Pectoriloquy. — As a rule the whispered voice is heard as a 
 faint, distant, expiratory whiff or puff over the trachea and primary bronchi 
 in front and behind while elsewhere it is almost or quite inaudible. When, 
 however, the physical conditions which cause bronchophony are present, 
 the whispered voice is heard with curious nearness and distinctness. Whis- 
 pering pectoriloquy is a very important physical sign, indicating, when 
 distinct and circumscribed, a cavity, and in varying degrees of intensity 
 consolidation of lung tissue. It is therefore of practical value in the diag- 
 nosis of limited areas of consolidation and in determining the boundaries 
 of large ones. The more dense the consolidation the more distinct the 
 whispered voice. Whispering pectoriloquy may be present over the 
 atelectatic lung in pleural effusion and occasionally over the effusion itself. 
 
 Diminished Vocal Resonance. — This sign indicates impaired con- 
 duction in the lung and is present in emphysema and the occlusion of a 
 bronchus. It also denotes the interposition of substances between the 
 lung and the chest wall, which leads to the diffusion and weakening of 
 vibrations passing from one medium to another, and occurs in pleural 
 effusion, pleural thickening, and tumors. The more massive the effusion, 
 the greater the thickening, or the larger the tumor, the more marked the 
 diminution in the transmitted voice resonance. It may be completely 
 absent in closed pneumothorax. Absent vocal resonance is most common 
 in large pleural effusion. 
 
 /Egophony. — Literally, the bleating of a goat. A peculiar quavering 
 quality of the voice with a distinctly nasal tone is heard when the patient' 
 speaks in a natural voice. This sign is best brought out by using repeated 
 rather than single syllables, as "twenty-one " or " ninety-nine. " It may be 
 heard at or just below the upper limit of moderate-sized pleural effusions 
 in the region of the angle of the scapula; less frequently in the front of the 
 chest. It is in rare instances heard over consolidated lung tissue. It is 
 not an important physical sign. 
 
166 MEDICAL DIAGNOSIS. 
 
 Bacelli's Sign. — Upon direct auscultation in the anterolateral region 
 of the affected side the whispered voice is said to be distinctly transmitted 
 through a serous but not through a purulent effusion, the difference being 
 attributed to variations in the density of serofibrinous and purulent effu- 
 sions. This sign is not constant, since in large effusions there is commonly 
 absence of vocal resonance in both kinds of fluid. 
 
 Auscultation as Applied to the Diagnosis of Diseases 
 of the Circulatory Organs. 
 
 The Technic. — This method is of cardinal importance in the examina- 
 tion of the heart. Upon it in most instances the diagnosis depends. 
 Inspection, palpation, and percussion may be used to amplify and control 
 the signs obtained by auscultation, but in a considerable proportion of 
 the cases they contribute no essential facts. Before we apply the stetho- 
 scope, we inquire into the history of the case and place the patient as far 
 as possible at his ease. The examination is best conducted when the patient 
 is in a comfortable position, leaning back in a chair or propped up with 
 pillows in bed. We note the facial expression, the appearance of the 
 eyes, the state of the capillary circulation, the presence or absence of 
 dropsical swellings, whether or not there is cough, the character of the 
 respiration and any abnormal impulse or movement that may be present 
 at the root of the neck or in the chest. The signs elicited upon inspec- 
 tion, palpation, and percussion are then ascertained. Finally we employ 
 auscultation. 
 
 In women the breast is drawn aside and held by the patient herself 
 or her nurse. In young children inspection and palpation should precede 
 auscultation. Percussion is useless. Very often the auscultatory signs 
 must be caught in the intervals of crjdng and struggling. Many difficulties 
 may be overcome by tact and gentleness. 
 
 The increase in the frequency of the heart's action and the accom- 
 panying change in the character of the first sound that occur in nervous 
 persons under examination {le coeur medicale) must be borne in mind. A 
 few minutes' chat upon indifferent subjects will usually cause the excited 
 action to subside. If on the other hand the action of the heart is weak 
 and the sounds too faint to be well studied, or there is a doubt as to the 
 presence of a murmur, the patient should be asked, unless his general con- 
 dition forbids, to take a series of very deep breaths, or quickly stoop and 
 rise several times, or take a few brisk turns up and down the room. The 
 increase in the force of the heart's action will often render the sounds 
 distinct and dispel any doubt as to the presence of a murmur. In cases 
 of acute disease or profound general or cardiac asthenia such diagnostic 
 measures are strictly contraindicated. 
 
 Faint and distant sounds and obscure murmurs may become more 
 audible if the patient leans slightly forward and to his left, thus 
 bringing the heart under the influence of gravity into closer relation 
 with the wall of the chest. It is important also to request the patient 
 to stop breathing for a moment now and again during the course of the 
 examination, since the breath sounds may mask the normal and abnormal 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 
 
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168 MEDICAL DIAGNOSIS. 
 
 sounds of a feeble heart. The heart sounds should also be studied with 
 full held inspiration and forced expiration. 
 
 Auscultation has for its object the determination of the character, 
 intensity, and rhythm of the normal heart sounds, and their modifications 
 within the range of health, the recognition of modifications which tran- 
 scend those limits, and the detection of abnormal or adventitious sounds. 
 
 THE SIGNS IN HEALTH. 
 
 The Normal Heart Sounds. — When the stethoscojDe is placed over 
 the heart two sounds are heard. Of these one is found to correspond 
 in time with the cardiac impulse, and the other to follow it after a short 
 interval of silence. After a longer, but still short interval, these sounds 
 are repeated in the same order. For this reason they are spoken of re- 
 spectively as the first and second sound of the heart. 
 
 The Characters of the Sounds. — The first sound is not only compara- 
 tively long, but it is also low in pitch and muffled. The second sound, 
 on the contrary, is comparatively short and is high pitched and clear. The 
 two sounds are therefore in sharp contrast in regard to their duration, 
 pitch, and quality. The respective characters of the two sounds may be 
 roughly imitated by the repetition of the syllables " ubb dup. " 
 
 Causes of the First Sound. — The first sound is due to vibrations 
 caused by the simultaneous tension of the mitral and tricuspid valves 
 in closure, the muscular contraction of the ventricles and the vibration 
 of the blood contained within the ventricles at the moment of systole. 
 
 The Cause of the Second Sound. — The second sound is due to the vibra- 
 tions caused by the simultaneous closure of the semilunar valves of the 
 pulmonary artery and the aorta at the beginning of the ventricular diastole. 
 
 A Third Sound of the Heart. — Gibson has recently described a wave 
 in the jugular pulse in healthy young adults occurring after the clos- 
 ure of the semilunar valves and before the auricular contraction, and 
 accompanied by a low-pitched, clear sound at the apex, more distinctly 
 audible in the cardiac revolutions which occur in the intervals between 
 expiration and inspiration than at any other stages of respiration. This 
 sound is not easily appi^eciated and is only audible in a certain propor- 
 tion of the diastolic periods. It corresponds in time to the first element 
 of the reduplicated second sound heard only at the apex, long familiar 
 to clinicians. The explanations of this sound are at present purely 
 hypothetical. 
 
 The Cardiac Cycle or Revolution. — Each revolution of the heart 
 consists of an auricular systole, the instantly succeeding ventricular systole, 
 and a period of repose of the whole heart. The relative time occupied 
 with these events varies with the frequency of the action of the heart. 
 With a pulse-rate of 74, that is, a cardiac revolution of about 0.8 second, 
 the cardiac revolution comprises an auricular systole of 0.1 second, a 
 ventricular systole of 0.3 second, and a period of repose of the whole heart 
 of 0.4 second. With increased pulse-frequency the diastole of the ven- 
 tricles is shortened much more than the systole; it is also, with slowing 
 of the pulse-rate, lengthened to a greater extent. The statements which 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 169 
 
 assign regular proportions to the duration of the sounds and silences of 
 the heart are misleading, since these vary in length, not relatively with 
 varying heart frequency, but absolutely, the second silence being very 
 fluctuating, since it corresponds to the fluctuating ventricular diastole, 
 while the first sound and the short first silence together, which nearly 
 correspond to the ventricular systole, are much more constant. 
 
 The Valve Areas or Puncta Maxima. — With the stethoscope applied 
 over the apex of the heart the first sound is heard much more distinctly 
 than the second sound and has a booming character which is in sharp 
 contrast with the short and "valvular" quality of the latter. The temp- 
 tation to rely upon the rhythm of the sounds for the recognition of the 
 systolic sound or the first and second sounds is to be avoided. The aus- 
 cultatory sign must be verified by inspection or palpation. This is espe- 
 cially important in the rapidly acting heart and in all morbid conditions. 
 The systolic or first sound corresponds to the impulse as determined by 
 sight or touch, or in default of these by the pulsation of the carotid. The 
 radial pulse cannot be depended upon as a guide. The recognition of 
 the first and second sounds is of especial importance in the diagnosis of 
 valvular diseases. 
 
 When the stethoscope is carried to the base of the heart, either to the 
 right or the left border of the sternum, the first sound becomes less distinct 
 than at the apex while retaining its acoustic properties, and the second sound 
 more distinct and prominent with an intensification of its snapping or 
 valvular quality. 
 
 The sounds may be further analyzed by placing the stethoscope at 
 the following principal points or areas: 
 
 1. The Mitral Area. — At or above the apex in the fifth intercostal 
 space and upon the parasternal line. At this point that factor of the first 
 sound made up by the closure of the mitral valve and the contraction of 
 the left ventricle is best heard. 
 
 2. The Tricuspid Area. — At the juncture of the ensiform cartilage with 
 the sternum and at the right border of the base of the sternum. In this 
 region that factor of the first sound caused by the closure of the tricuspid 
 valve and the contraction of the right ventricle is most distinctly heard. 
 
 3. The Aortic Area. — In the second right intercostal space near the 
 sternum or directly over the second right costal cartilage at its sternal 
 articulation — the aortic cartilage. At this point the aortic element of 
 the second sound is best heard. 
 
 4. The Pulmonary Area.^ — In the second left intercostal space near 
 the sternal border. At this point the pulmonary element of the second 
 sound is best appreciated. 
 
 These areas do not correspond to the position of the respective valve 
 systems, but they do correspond to the anatomical relationship to the 
 wall of the chest of the structure in which the mechanism producing 
 the sound exists, or in which the sound is conducted. That is to say, the 
 anatomical apex of the heart formed by the left ventricle comes nearest 
 to the chest at the apex; the tricuspid valve system at the right border 
 and base of the sternum; the aorta just above its origin at the second 
 right interspace, and the pulmonary artery above its valves at the second 
 left interspace. 
 
170 MEDICAL DIAGNOSIS. 
 
 At the apex the first sound and its modifications in health and disease 
 are best studied; at the base the second sound. In the former position 
 this first sound is louder and more distinct; in the latter the rhythm is 
 changed and the stress falls upon the second sound. The rhythm is the 
 same in the mitral and the tricuspid areas and the quality of the first 
 sound is similar, though in health the first sound is usually less intense 
 in the tricuspid area. The rhythm is likewise the same in the aortic and 
 the pulmonary areas, and the quality of the second sound is similar upon the 
 right and left sides. 
 
 Modifications in the Normal Heart Sounds. — Variations in character, 
 intensity, and rhythm are to be considered. There are marked differences 
 in the sounds in different individuals and in the same individual at differ- 
 ent periods of life and under varying conditions of activity and emotion. 
 
 Character. — The heart in children is less covered by the lungs than in 
 later life and the chest wall is far thinner and more elastic. It follows 
 that the sounds though feeble are more distinctly heard. As the muscle 
 is smaller and thinner the valvular element of the first sound is more in 
 e^'idence, and as the frequency is greater the long pause is shortened so 
 that the rhythm, which at birth has the characteristic tic-tac of the fetal 
 heart, like the ticking of a watch, only gradually changes to that above 
 described as occurring in later life. 
 
 Embryocardia is a common condition in which the rhythm suggests 
 that of the fetal heart, the long pause being shortened and the first and 
 second sound presenting nearly the same acoustic properties. This modifi- 
 cation of the cardiac rhythm occurs in tachycardia, the cardiac asthenia 
 of the later periods of exhausting diseases and in extreme dilatation. 
 
 The first sound at the apex is not only somewhat louder in powerful 
 persons wdth well-developed muscles but it is also more prolonged than in 
 feeble persons who lead sedentary lives — a difference due to an increase 
 of the muscular factor entering into the production of the sound. 
 
 A similar increase in the duration and intensity of the first sound 
 occurs under conditions of bodily exercise and mental excitement. Under 
 these circumstances the sound is occasionally attended by curious metallic 
 reverberations, the cliquetis vietallique of the French. 
 
 Intensity. — In young persons with thin, elastic chest walls the sounds 
 of the heart are louder and more distinct than in older persons, in w^hom the 
 walls are thicker and the costal cartilages more rigid. Thick layers of sub- 
 cutaneous fat may render the sounds faint and distant. The interposition 
 of the thick edge of a voluminous lung may have the same effect. There 
 are marked differences in the intensity of the sounds in repose and activity. 
 
 The First Sound at the Apex. — The first sound is louder and more 
 distinct in the mitral area than in the tricuspid, but in young persons 
 under conditions of excitement or after great muscular effort it may be 
 heard with equal clearness and intensity over the whole front of the chest. 
 
 The Second Sound at the Base. — The peculiarity of the second 
 sound is its valvular quality. Its intensity varies in health with the energy 
 of the heart's action. It has been assumed that the intensity of the aortic 
 sound under normal conditions is greater than that of the pulmonary 
 second sound. Vierordt, however, in 1885 first called attention to the fact 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 171 
 
 that the relative intensity of these two components of the second sound 
 varies at different periods of life, an observation that has been confirmed 
 by other recent clinicians and especially by the investigations of Creigh- 
 ton in 1899. This observer found that in 90 per cent, of healthy children 
 under ten years of age the pulmonic second sound is more intense than the 
 aortic; in 66 per cent, between the tenth and twentieth years the pul- 
 monic sound is more distinct; in about half in the following decade, and 
 after the thirtieth year the proportion gradually declines until after sixty, 
 when the aortic second sound is more intense — accentuated — in almost 
 every case. It thus appears that the relative intensity of the two elements 
 of the second sound depends upon the age of the individual, the sound in 
 the pulmonary area being more intense in early, and that in the aortic 
 area more intense in later life, while in middle life their intensity is much 
 the same. Cabot suggests that "it is therefore far from true to suppose 
 that we can obtain evidence of a pathological increase in the intensity of 
 either of the sounds at the base of the heart simply by comparing it with 
 the other." The difficulty lies in the failure on the part of the auscultator 
 to recognize the difference between mere loudness or intensity which may 
 be normal, and accentuation, which is a morbid physical sign. 
 
 In elderly persons the second sounds are frequently heard more 
 distinctly in the third or fourth interspace than in the second. 
 
 Rhythm. — The derangements of rhythm which may occur in health are: 
 
 1. Gallop Rhythm in which the Diastolic Pause is Shortened with the 
 Addition of an Extra Sound of the Heart. — The rhythm suggests the 
 cadence of the footfall of a cantering horse. It is expressed by the 
 repetition of the syllables "rat-ta-ta." The mechanism of its produc- 
 tion is not clear. 
 
 G. Canby Robinson has summarized the results of recent studies of 
 gallop rhythm as follows: " Gallop rhythm of the heart is a fairly frequent 
 clinical phenomenon, and consists in the presence of a group of three 
 cardiac tones, none of which are murmurs. It occurs under variable 
 clinical conditions. That form of gallop rhythm which is best heard at 
 the apex or over the central part of the precordium may be divided 
 into the presystolic, protodiastolic, and mesodiastolic types, depending 
 on whether the extra tone falls at the end, at the beginning, or in the 
 middle of diastole. Each form is associated with a characteristic 
 cardiogram. There are a number of factors which probably combine 
 in various ways to produce the various forms of gallop rhythm. 
 
 "Presystolic gallop rhythm is heard in two classes of cases. It is 
 heard in strongly acting hearts in which a muscle sound produced by a 
 strongly acting, hypertrophied auricle is probably the cause of the extra 
 tone; and it is also heard in weak, rapidly acting hearts at the height of 
 acute febrile diseases, at which time there is possibly a delay in the con- 
 duction of the heart-beat from the auricles to the ventricles. Under these 
 circumstances the sound produced during the contraction of the auricles 
 becomes distinguishable from that produced during the contraction of the 
 ventricles. In both classes of cases, the extra tone seems to be produced 
 in the auricle rather than in the ventricle. Protodiastolic and mesodiastolic 
 gallop rhythm are caused by the production of an extra tone in the ven- 
 
172 MEDICAL DIAGNOSIS. 
 
 tricles. The factors that probably combine to produce this extra tone are 
 an increase in the amount and velocity of the flow of blood from the auricles 
 into the empty ventricles and a loss of tone of the heart muscle of the 
 ventricles. The longer silent period in cases of gallop rhythm does not 
 as a rule occur during diastole, but is usually a systolic silence." 
 
 This derangement of the cardiac rhythm may sometimes be observed 
 in the normal heart when rapidly acting under conditions of great exertion 
 or excitement. 
 
 2. Reduplication of the Second Sound at the Base of the Heart. — Splitting 
 of the second sound may be heard at the base of the heart at the end of 
 full inspiration, especially if the breath be held or after active muscular 
 exertion. Its mechanism probably consists in the asynchronous closure 
 of the aortic and pulmonary valve systems as the result of heightened 
 pressure in the pulmonary circuit. 
 
 3. Reduplication of the First Sound at the Apex. — An impure first 
 sound may occasionally be heard at the apex, especially at the end of 
 expiration under normal circumstances. This modification varies from a 
 mere blur or prolongation of the sound to a distinct repetition, consti- 
 tuting a form of the gallop rhythm. It may be represented by the syllables 
 "trupp" or "turrupp." In health it is not constant in the same indi- 
 vidual. It has been attributed to conditions temporarily giving rise to an 
 increase in the vis-a-fronte of one or the other ventricle. 
 
 MODIFICATIONS OF THE HEART SOUNDS IN DISEASE. 
 
 Variations in the character, intensity, and rhythm which transcend 
 the borders of health, together with wholly abnormal or adventitious 
 sounds, are to be considered. 
 
 Character. — The acoustic properties of the heart sounds are modi- 
 fied not only by changes in the heart itself and in the arteries but also by 
 pathological conditions in the adjacent parts and the state of the chest 
 walls as regards elasticity and thickness. Finally the character of the heart 
 sounds is modified by constitutional conditions. Changes in character are 
 commonly associated with changes in intensity, but it is well for the 
 student to train himself to appreciate modifications of character and of 
 intensity as constituting distinct groups of physical signs. 
 
 1. The Heart.— The first sound is prolonged and dull in hypertrophy; 
 when the associated dilatation is marked it is sometimes very clear and 
 sharp. A metallic clinking— tintement metallique—is occasionally heard 
 to the right of the apex-beat. The second sound is loud and distinct, often 
 ringing in character and doubled. When valvular lesions are present the 
 sounds are greatly modified and replaced or accompanied by murmurs. 
 
 In hypertrophy of the right ventricle the first sound at the lower part 
 of the sternum is louder and fuller than normal; but with much associated 
 dilatation it is clearer and sharper. Accentuation of the pulmonary 
 second sound is frequently present. 
 
 In dilatation the first sound is shorter and sharper, in other words, 
 more valvular in character than normal. The muscular element is dimin- 
 ished. With progressive thinning of the walls these changes become more 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 173 
 
 marked. The second sound when heard in aortic insufficiency ma}^ be 
 distinct, or faint and obscure; wlien tliere is dilatation of tlie aortic arch it 
 may be ringing and prolonged. 
 
 The second sound is rarely heard in the aortic area in aortic stenosis for 
 the reason that the deformity of the cusps is such as to prevent their free play. 
 
 Accentuation of the pulmonary second sound is an important sign in 
 mitral insufficiency. 
 
 The first sound is unusually sharp and clear in mitral stenosis, while 
 the second sound in the second left interspace is strongly accentuated and 
 sometimes reduplicated. 
 
 2. The Arteries. — Accentuation of the aortic second sound occurs 
 in arteriosclerosis, — especially that form which accompanies chronic 
 nephritis, — in atheroma and dilatation of the aortic arch, and in aortic 
 aneurism. It is the sign of increased arterial tension and is associated 
 with hypertrophy of the left ventricle. 
 
 3. Diseases of Neighboring Organs. — In pericardial effusion the heart 
 sounds are not only indistinct but they also have a peculiar muffled and 
 distant quality, due to diffusion. Accentuation of the pulmonary second 
 sound is frequently an early and persistent sign. 
 
 In some cases of pneumothorax the heart sounds acquire a metallic 
 quality; in pneumopericardium they are feeble, distant, and muffled. 
 
 They are distant and muffled in pulmonary emphysema, well trans- 
 mitted in consolidation of the lung and in chronic interstitial pneumonia 
 and pulmonary phthisis, and sharp and ringing during cardiac overaction, 
 especially in young persons and in the periods of excitement and palpita- 
 tion which occur in exophthalmic goitre, chlorosis, and anaemic states. 
 
 4. Different Conditions of the Walls of the Chest. — As in health so in 
 disease, remarkable differences in the heart sounds occur as the result 
 of differences in the chest wall. Through the thin and elastic tissues of 
 the young the sounds are conducted with great distinctness; they are 
 faint and diffuse when the chest walls are thick and fat, and when the car- 
 tilages are calcified, the sternum thickened, or when deformities of the chest 
 derange the normal relation of the heart to the wall, or finally when a new 
 growth is interposed. 
 
 5. Constitutional Conditions. — The first sound is shortened as well 
 as faint in conditions of general asthenia such as result from actual star- 
 vation and wasting diseases. In enteric fever the first sound becomes 
 progressively shorter, more indistinct and valvular in quality — a change 
 due to the progressive wasting of the myocardium. 
 
 Intensity. — The significance of increase or decrease in the intensity 
 of the heart sounds as morbid physical signs has already to some extent 
 been indicated. It is important to note that as a rule increase in the 
 intensity of the first sound is associated with its prolongation, while de- 
 crease in intensity is attended with decrease in duration. The loud first 
 sound is in strong contrast with the short second sound; the faint first 
 sound resembles it. As the feeble heart is commonly also a rapid heart, 
 in which the long pause is shortened, it may become difficult to tell which 
 is the first and which the second sound. The first sound corresponds to 
 the impulse at the apex or to the carotid pulse. 
 
174 MEDICAL DIAGNOSIS. 
 
 Accentuation. — It is important at this point to emphasize the dis- 
 tinction between "loudness" and "accentuation" — a matter not always 
 made clear in the books. Loudness or sound intensity has to do with the 
 volume of a given sound; accentuation is that acoustic property which 
 indicates suddenness in the application of the energy by which the sound 
 is produced. The first sound of the heart is often loud, even booming, 
 but never, according to my belief, accentuated. It may have a slapping 
 equality as in mitral stenosis, but that is something altogether different 
 from accentuation. The second sound of the heart at the base may be loud 
 and distinct without being accentuated. It may become accentuated with- 
 out becoming louder. Accentuation is then something quite different from. 
 loudness. The word conveys the idea of suddenness, sharpness, a certain 
 vibrating quality due to quick and sharp tension. Loudness is a matter 
 of degree; accentuation a matter of quality. From this point of view 
 accentuation becomes a physical sign of great importance. 
 
 The first sound is increased in intensity in conditions which cause 
 the heart to act with unusual energy. In intense emotional states the first 
 sound is greatly increased and may sometimes be heard all over the chest. 
 Such overaction may be pathological, as in mania and acute febrile states. 
 The first sound is louder than normal in hypertrophy of the left ventricle, 
 but less constantly so than has been assumed; even with a considerable 
 degree of associated dilatation the sound may still be quite intense. 
 
 The first sound is enfeebled in conditions of general asthenia such as 
 result from starvation, long-continued fevers, wasting diseases, hemorrhage, 
 shock, and profound exhaustion from over-exertion; in dilatation of the 
 ventricles, myocarditis, fatty heart, and rupture of the compensation in 
 chronic valvular disease; in chlorosis and ansemia and in all conditions 
 that interfere with its transmission to the ear of the auscultator, such as fat 
 in the chest walls, emphysema, pleural and pericardial effusions, and certain 
 mediastinal tumors. In conditions in which direct pressure is exerted upon 
 the wall of the heart by effusion or tumor, its action is impeded and its 
 sound enfeebled. 
 
 The second sound is increased in intensity in nervous overaction of 
 the heart and in all conditions in which the lungs are retracted so as to 
 bring the aortic arch and the conus arteriosus into more extended relation 
 with the wall of the thorax. An apparent increase in the loudness of one 
 or the other elements of the second sound is produced by the retraction of 
 the anterior border of the lung upon the corresponding side. The second 
 sound is diminished in intensity by those conditions, both general and 
 cardiac, which weaken the action of the heart and diminish the intensity 
 of the first sound. 
 
 The significance of changes in the intensity of the aortic and pul- 
 monary elements in the second sound demands consideration. 
 
 It has already been pointed out that in normal individuals after middle 
 life the aortic second sound is more intense than the pulmonary. A mere 
 increase in the volume of the sound may be the result of increased cardiac 
 action. An increase associated with that change of quality designated by 
 the term accentuation constitutes a morbid physical sign and becomes 
 more significant in proportion as the accentuation becomes more marked. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 175 
 
 Accentuation of the aortic second sound occurs in all conditions in 
 which the arterial blood-pressure — vis-a-fronte — is increased, nameh', 
 arteriosclerosis, chronic nephritis,, and in aortic aneurism and dilatation 
 of the aortic arch. In conditions characterized by habitual increase in 
 arterial tension there is usually cardiac hypertrophy. 
 
 Diminution in the intensity of the aortic second sound occurs in 
 conditions in which the blood thrown into the aorta by the ventricular 
 systole is reduced in amount as in aortic and mitral stenosis and to some 
 degree also in mitral insufficiency. Under these circumstances the aortic 
 second sound may be so diminished as to be no longer heard at the apex. 
 Weakening of the wall of the heart, as in fibrous and interstitial myocarditis, 
 fatty degeneration, and extreme dilatation, likewise gives rise to enfeeble- 
 ment of the aortic second sound. Relaxation of the peripheral arteries 
 produces the same effect. The aortic second sound is extremely faint in 
 collapse from any cause. 
 
 The pulmonic second sound is louder than the aortic in children and in 
 young adults. A pathological increase in the loudness of this sound has the 
 same significance in regard to the pulmonary circulation that an increase 
 in the aortic second sound has in regard to the general circulation, namely, 
 an augmentation in the resistance to the flow of the blood. This occurs 
 in chronic valvular disease of the heart, especiall}' in mitral stenosis and 
 insufficiency, and in various pulmonary diseases, particularly emphysema, 
 chronic bronchitis, phthisis, interstitial pneumonia, and compression 
 atelectasis. These conditions are associated with hypertrophy of the 
 right ventricle, compensatory in nature; when the compensation fails, 
 the pulmonary second sound becomes faint and indistinct. Under all 
 these conditions the more intense pulmonary second sound is also 
 accentuated. 
 
 Weakening of the pulmonary second sound is the sign of a weakened 
 right ventricle or tricuspid insufficiency. This sign is of great value in 
 pneumonia as indicating failure of the right ventricle. The pulmonic second 
 sound should therefore be systematically studied, since it affords at once 
 indications for treatment and data for prognosis. 
 
 Rhythm. — The derangements of the rhythm of the heart which may 
 be heard under certain circumstances in health, namely, the gallop rhythm, 
 reduplication of the second sound at the base of the heart and reduplica- 
 tion of the first sound at the apex, have alread}^ been described. The forms 
 of arrhythmia which occur in health are transitory, like the conditions 
 which cause them. When the causes are persistent they likewise persist 
 and constitute morbid physical signs. 
 
 Allorrhythmia is the general term used to designate deviations from 
 the normal rhythm of the heart. 
 
 Intermission occurs when one or more beats of the heart are dropped. 
 The dropping of the beat sometimes occurs at regular intervals; more 
 frequently without any definite sequence. This fault of rhythm is encoun- 
 tered in neurotic persons and sometimes in the aged, and is usually the 
 sign of defective innervation rather than of organic disease. When the 
 patient is conscious of it, as is frequently the case, it constitutes a source 
 of great annoyance and distress. 
 
176 MEDICAL DIAGNOSIS. 
 
 Irregularity is the condition in which the beats are unequal in volume 
 and force or follow one another at unequal intervals. 
 The following forms of arrhythmia are recognized : 
 
 1. Intermission. — There is an occasional intermission or dropping 
 of a beat of a heart otherwise acting regularly. The absence of the heart 
 sounds proves that the systole does not occur. The systole may be too 
 weak to cause a pulse wave yet a faint first sound may be heard. Inter- 
 mittent pulse may occur without complete cardiac intermission. 
 
 2. Reduplication. — (a) Reduplication or doubling of the second sound 
 at the base. Any pathological condition which increases the tension in the 
 general arterial system on the one hand, or in the pulmonary circulation on 
 the other, and thus deranges the synchronism of the aortic and pulmonary 
 elements of the second sound, may cause this form of arrhythmia. 
 
 (b) Reduplication or doubling of the first sound at the apex occurs in 
 many pathological conditions causing an increase in the work of one or the 
 other side of the heart. It occurs also in myocarditis. 
 
 3. Cardiac Alternation. — Strong and feeble systolic contractions occur 
 in regular alternation, with a corresponding alternate pulse rhythm. 
 
 4. Series of Cardiac Revolutions in Rapid Succession, each group being 
 separated from the following one by a longer interval. This form of arrhyth- 
 mia corresponds to the pulsus bigeminus or pulsus trigeminus. The first 
 beat of the series is commonly stronger than the succeeding pulsations, 
 and in some cases the last may be so feeble that the pulse wave is not 
 transmitted to the wrist; in the bigeminal variety only one radial pulse 
 is felt for two contractions of the heart. This form of arrhythmia is not 
 usually continuous but occurs at intervals in a heart otherwise regular. 
 
 5. Delirium Cordis. — The loss of rhythm is complete. The heart's 
 action is wholly irregular in time and force and characterized by weakness 
 and rapidity. 
 
 6. The Pendulum Rhythm. — The pause between the systolic and dias- 
 tolic sounds is prolonged and tends to become equal with the long pause. 
 This variety of arrhythmia has been observed in conditions of high 
 arterial tension, as chronic nephritis, and is due to a prolongation of the 
 ventricular systole. 
 
 7. Embryocardia. — The rhythm of the fetal heart. (See p. 170.) 
 
 8. The Gallop Rhythm. — This variety has already been described. 
 When permanent it is usually a sign of great weakness of the heart muscle. 
 
 The significance of arrhythmia is not always apparent. It may be 
 due to emotional or other psychical causes, to central or cerebral conditions, 
 as hemorrhage or concussion, to reflex influences, especially those of 
 gastric origin, or to toxic agencies. Among the last, excesses in tea, 
 coffee, and tobacco are prominent, and certain narcotic drugs, as digitalis, 
 belladonna, and aconite, are to be named. 
 
 Changes in the heart itself are potent factors in the causation of 
 derangements of rhythm. These may involve the ganglia, which may be 
 fatty, pigmented, or sclerotic, or the walls of the heart, which may show 
 simple dilatation, fatty degeneration, or sclerosis, or the coronary arteries 
 and their branches, which are frequently sclerotic. Yet there are cases 
 in which these conditions are present without arrhythmia, and again cases 
 
PHYSICAL DIAGNOSIS: AUSCULTATION. 177 
 
 of marked and persistent arrhythmia in which the health appears to be 
 in no other respect impaired. Nor do valvular lesions necessarily give 
 rise to faults of rhythm so long as compensation is maintained. With 
 failure of compensation arrhythmia is often present, especially in mitral 
 disease, and it is interesting to note that while the other symptoms of 
 this condition disappear under rest and treatment some degree of irregu- 
 larity of the heart usually persists. The bigeminal and trigeminal rhythm 
 occur most commonly in mitral disease; delirium cordis in rupture of 
 compensation, particularly toward the end; the pendulum rhythm in 
 conditions of high arterial tension; embryocardia in dilated heart. 
 
 ABNORMAL OR ADVENTITIOUS SOUNDS. 
 
 Upon auscultation over the heart and great vessels and in some cases 
 over wide areas of the surface of the chest both anteriorly and posteriorly, 
 sounds are heard in pathological conditions which differ from the normal 
 heart sounds and constitute abnormal or morbid physical signs. These 
 sounds bear a definite relation to the cardiac cycle and are dependent 
 upon the action of the heart. They may be arranged in two groups 
 according as they have been found, upon comparison of clinical with 
 post-mortem findings, to originate from (A) abnormal conditions within 
 the heart, or (B) outside of it. 
 
 Those which have their origin within the heart are spoken of as 
 endocardial; those which arise outside of the heart as exocardial. 
 
 A. Endocardial adventitious sounds are called murmurs. They are: 
 
 Organic ; 
 
 Functional, Accidental or Hsemic. 
 
 B. Exocardial adventitious sounds, sometimes called paracardial 
 
 murmurs, include: 
 
 Pericardial Friction; 
 
 Pleuropericardial Friction; 
 
 Cardiopulmonary Murmurs; 
 
 The Precordial Rales of Emphysema; 
 
 Pericardial Splashing; 
 
 The Murmurs of Aneurism. 
 
 A. Endocardial Murmurs. — Much confusion has arisen from the 
 attempts of writers and teachers to explain auscultatory phenomena in 
 muscial terms. Neither the sounds of the heart — sometimes erroneously 
 called "tones" — nor cardiac murmurs, with exceptions presently to be 
 mentioned, are musical phenomena. They both arise from irregular 
 sound-producing vibrations which lack, as a rule, the rapidity necessary 
 to the production of musical tones, though exceptionally murmurs acquire 
 a distinct musical quality. A "sound" of the heart is produced by a 
 single sudden derangement of the equipoise of sound-producing structures, 
 which are thrown into vibration; a murmur by the continuous action of 
 forces which maintain such vibrations. The sound presently ceases; the 
 murmur continues so long as the force which causes the vibrations con- 
 
 12 
 
178 MEDICAL DIAGNOSIS. 
 
 tinues to act. The sound corresponds in a way to a single blow upon a drum; 
 the murmur to the continuous, rapidly repeated, but less intense sounds 
 known as the roll of the drum; or the sound to the picking of the violin 
 string, the murmur to the continuous note made by the drawing of the 
 bow. But both these comparisons have the fault of Ukening musical phe- 
 nomena to those which usually lack the musical quality. Furthermore the 
 mechanism by which sounds and murmurs are produced is different. 
 
 The Mechanism of Endocardial Murmurs. — The heart sounds arise from 
 the contraction of the heart muscle, the vibration of the blood mass, and 
 the sudden tension of the auriculoventricular and semilunar valve sys- 
 tems. When murmurs arise a new set of physical conditions comes into 
 play, namely, fluid veins (see p. 152). These swirls, or currents within 
 currents of the blood, are attended with vibrations, which, first com- 
 municated to the wall of the heart or vessels and thence by way of the 
 intervening tissues to the surface of the chest, are recognized by the 
 auscultator as auditory phenomena^murmurs. 
 
 The Mechanism of Organic Murmurs — Lesions. — In by far the greater 
 number of instances the fluid veins are due to actual lesions of the heart, 
 and for this reason the murmurs are known as organic. The lesions mostly 
 involve the valves, a fact which is indicated by the descriptive adjective 
 valvular. They are on the one hand inflammatory and proliferative or 
 adhesive, on the other sclerotic. Those that occur in early life are usu- 
 ally inflammatory; those which develop later are mostly sclerotic; but 
 the inflammatory lesions of the valves undergo sclerotic changes, and old 
 sclerotic valves are frequently the seat of recurrent inflammatory proc- 
 esses — recurrent endocarditis. As the result of each of these processes 
 involving the valves, deformities arise. Inflammation causes vegetations, 
 thickening, adhesions, and in extreme cases necrosis; sclerosis gives rise 
 to thickening, retraction, crumpling; both result in loss of elasticity and 
 freedom of movement. In cases of long standing hme salts are deposited 
 and the rigidity and deformity are correspondingly increased. 
 
 Stenosis and Insufficiency. — The impairment of function is two- 
 fold. That function of the valves by which they yield before the blood 
 stream and permit it to pass unhindered from auricle to ventricle or 
 from ventricle to artery may be deranged. The condition is known as 
 stenosis or narrowing, and the fluid veins are developed in the normal 
 direction of the blood stream. Or that function by virtue of which the 
 valves close their respective orifices is at fault, and there is valvular 
 insufficiency or incompetency, the fluid veins developing in the reverse 
 direction. Very often both these functions are impaired, and the condi- 
 tion is that of combined stenosis and insufficiency, with double murmurs. 
 
 Relative Insufficiency. — Again, the orifice guarded by a valve 
 system may be enlarged in consequence of the dilatation of the heart, so 
 that the edges of the valves may be unable to meet and close it. This con- 
 dition is known as relative insufficiency or incompetence, and is dependent 
 not upon lesions of the valves, but upon nutritive or degenerative lesions 
 of the heart muscle. Acute relative insufficiency such as sometimes accom- 
 panies the heart failure of violent exertion is due to relaxation of the wall 
 of the heart and papillary muscles. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 179 
 
 Roughening of the surfaces of the valves or of the parts immediately 
 adjacent to them and sudden dilatation of the artery just beyond the valve 
 system may lead to the production of a murmur. 
 
 The deformity which gives rise to an endocardial murmur may be of all 
 degrees, from such as only slightly impair the function of the valve system 
 to a stenosis which leaves a tiny orifice or mere chink for the passage of 
 the blood or an incompetence that is almost complete and transfers the 
 pressure of the blood column to the wall of the chamber of the heart which 
 is immediately behind the defective valve, namely, the left ventricle in 
 aortic insufficiency and the left auricle in mitral insufficiency. A projecting 
 firm vegetation or rigid spicule or the inelastic edge of a sclerotic valve 
 may be the cause of a systolic murmur, where there is practically no 
 actual narrowing of the orifice. One of the first lessons for the student 
 of heart murmurs to learn is that by no means every systolic murmur 
 having its point of maximum intensity in the aortic area is the sign of 
 aortic stenosis. 
 
 Stenosis or Narrowing of an Orifice Guarded by a Valve 
 System. — There is impairment of the function by which the valves open 
 at the physiological moment. The flow of the blood is obstructed and 
 under ordinary circumstances a murmur is produced, which is spoken of 
 as an obstructive murmur. If the heart be very feeble, marked obstruc- 
 tion may exist without producing a murmur that can be recognized. If the 
 left auriculoventricular orifice is involved, the condition is known as mitral 
 stenosis or obstruction; if the aortic, as aortic stenosis or obstruction. 
 
 Incompetence or Insufficiency. — The function of the valves by 
 which they close the orifice is impaired and a portion of the blood which 
 has just passed through the orifice escapes from the main stream and flows 
 back into the chamber of the heart whence it came. This pathological 
 event is known as regurgitation, and the murmur which attends it is called 
 a regurgitant murmur. We then have mitral and aortic incompetence, 
 insufficiency or regurgitation as one or the other of these valve systems is 
 affected. 
 
 Valvular lesions of the right side of the heart are of infrequent occur- 
 rence. They are sometimes the result of developmental defects or prenatal 
 endocarditis. However produced they cause similar impairment of the 
 valve functions, manifest by murmurs — tricuspid and pulmo^iary stenosis 
 and incompetence. Stenosis is always due to deformity of the segments 
 of a valve system. Incompetence is mostly due to the same cause, but 
 not always. The deformity which prevents a valve from fully opening 
 also generally prevents it from fully closing. 
 
 Combined stenosis and incompetence arises under the conditions 
 just indicated. The lesion is a "double" one and manifests itself by a 
 "double" or "to-and-fro" murmur. 
 
 Incompetence may, however, arise in the absence of stenosis as the 
 result of (a) a lesion by which a valve segment has been destroyed by 
 ulcerative endocarditis or has contracted adhesions to the wall of the 
 heart, or (b) of relaxation of the cardiac muscle, as in relative insufficiency. 
 
 Stenosis without incompetence is comparatively infrequent; incom- 
 petence without stenosis is not very uncommon. 
 
180 MEDICAL DIAGNOSIS. 
 
 Valvular lesions exert their effect (a) upon the blood stream within 
 the heart, (b) upon the walls of the heart, (c) upon the viscera, and finally 
 (d) upon the peripheral circulation. 
 
 (a) The Effect of the Valvular Lesions which Produce Endo- 
 cardial Murmurs upon the Blood Stream within the Heart. — The 
 beginning of evil in stenosis and incompetence is the same. It consists 
 in a reduction of the quantity of blood which eventually passes the 
 diseased valve system with each revolution of the heart. In stenosis a 
 portion of the stream corresponding to the extent of the pathological 
 barrier is held back; in incompetence a portion corresponding to the 
 degree of the pathological defect returns into the chamber whence it 
 came — regurgitates. The result is a tendency to retardation of the flow, 
 diminution in the volume of blood entering the arteries, and increase in 
 the volume retained in the veins, with progressive transference of blood- 
 pressure from the arterial to the venous side of the circulation. Were this 
 tendency unchecked every case of valvular disease would in a short time 
 terminate in death, the venous pressure rising and the arterial falling until 
 the circulation becomes no longer possible. This result, which is the usual 
 cause of death in valvular disease, is postponed for an indefinite period by 
 compensatory changes in the muscle of the heart itself. It is true these 
 changes are consecutive to the lesion, but as the latter is progressive, the 
 former are correspondingly progressive. When the one advances at the 
 same rate as the other a physiological balance is again established, the 
 stability of which depends upon the tardiness of the valvular disease on the 
 one hand, and the ability of the hypertrophied heart muscle to maintain 
 its nutrition on the other. When extensive valvular defects develop sud- 
 denly or are rapidly progressive, compensation is not established and 
 death occurs in a short time. 
 
 (b) The Effects upon the Walls of the Heart. — The immediate 
 effects of the separation of the blood stream into a major part circulating 
 under physiological conditions and a minor part held back under patho- 
 logical influences are exerted upon the walls of the chamber behind the 
 affected valve system. They are first dilatation, then hypertrophy. These 
 changes may affect the whole organ, the heart acting as a single muscle 
 and undergoing a general enlargement in response to the increased work 
 required of it; more commonly they affect one or more of the chambers 
 and in particular that chamber immediately subjected by the valvular 
 lesion to increase in its blood contents in diastole and to a necessary 
 increase in its energy in systole in order to overcome the obstacle in stenosis 
 or propel an augmented volume of blood in incompetence. In mitral 
 stenosis the left auricle cannot empty itself and receives blood from the 
 pulmonary circuit; in mitral incompetence it receives blood at the same 
 moment from the pulmonary circuit and the left ventricle; in combined 
 mitral lesions some blood is retained and some regurgitates, while the 
 physiological supply enters by the pulmonary veins. Consequently the 
 left auricle is first dilated and then hypertrophied. In aortic stenosis the 
 left ventricle cannot empty itself and in diastole the blood received from 
 the left auricle is augmented by that retained at the time of the previous 
 systole; in aortic incompetence blood enters the left ventricle in diastole 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 181 
 
 at the same moment from two sources, the left auricle and the aorta; 
 in combined aortic disease the blood coming from the left auricle is 
 augmented by that retained at the previous systole and that returning 
 from the aorta. Under these circumstances the left ventricle is first dilated 
 and then hypertrophied. It is important to bear in mind the cardinal 
 fact that all these changes, like the lesion itself, are slight at first and 
 gradually progress, and that in the early stages neither the dilatation 
 nor the hypertrophy can be recognized by the ordinary methods of physical 
 diagnosis. Even at this period the murmurs indicative of the respective 
 lesions are commonly quite audible, often loud or harsh, and months 
 may elapse before the signs of enlargement of the heart or venous stasis 
 can be determined. The diagnosis rests upon the presence and characters 
 of the murmur. Nevertheless it is an error to speak of this stage as pre- 
 ceding compensation. There are, however, cases of rapidly developing 
 lesions in which complete compensation is only gradually attained; some 
 in which it is never reached. If the quantity of blood held back in stenosis 
 or regurgitated in incompetence be represented by x, it is evident that 
 there must be an increased capacity of the affected chamber, represented 
 by the same symbol, and that the chamber must be dilated to that 
 extent. While if the resulting hypertrophy of the wall of the chamber be 
 such as to enable it to propel the normal quantity of blood plus x, it is 
 evident that a condition is established in respect to the volume of blood 
 maintained in circulation, which is practically normal despite the valvular 
 lesion, and this condition is known as compensation. This condition exists, 
 however, by virtue of an abnormal increase in the nutrition and work of 
 the heart muscle and at the expense of the normal reserve power of the 
 heart, and is therefore unstable. It consists in a degree of dilatation and 
 hypertrophy combined and in ratio to the valvular defect, but demands 
 for its maintenance a hypertrophy slightly in excess of the dilatation. The 
 nutrition of the overgrown and overworked muscle ultimately fails and 
 dilatation develops in excess of hypertrophy. The compensation under 
 these circumstances is said to be at first "deranged" or "failing," later 
 "broken " or "ruptured." It is a question of degree. In a small proportion 
 of the cases failure of compensation occurs in the absence of marked 
 increase in the size of the affected chamber or chambers of the heart 
 and has been ascribed to derangement of the innervation of the heart. 
 
 (c) Effects upon the Viscera. — Compensation, while adequate to 
 the maintenance of a fair degree of health for an indefinite period, is never 
 complete. There is always increased resistance to the onward flew of the 
 arterial blood and a corresponding increase in the blood-pressure upon the 
 venous side of the circulation. This results in increased fulness of the 
 pulmonary circuit, manifest by accentuation of the pulmonary second 
 sound, hypertrophy of the right ventricle and a tendency to passive hyper- 
 semia of the viscera in general; hence, accentuation of the aortic second 
 sound, dyspnoea upon exertion, a peculiar liability to bronchial catarrh 
 and the occasional occurrence of blood-streaked sputum or slight haemop- 
 tysis — phenomena which are common in mitral disease even while the 
 compensation remains fairly good. Upon failure of compensation there is 
 marked venous engorgement of the viscera, with grave derangement of 
 
182 MEDICAL DIAGNOSIS. 
 
 function, shown on the part of the lungs by marked dyspnoea or orthop- 
 nea, cyanosis, cough, and the occasional expectoration of frothy blood; 
 of the liver and gastro-intestinal organs by loss of appetite, deficient diges- 
 tion, nausea, slight jaundice and constipation; on the part of the kidneys 
 by scanty urine and albuminuria. Dulness, stupor, somnolence with ina- 
 bility to sleep are symptoms of the derangement of the cerebral circulation. 
 
 (d) Effects upon the Peripheral Circulation. — While compen- 
 sation is maintained, dropsy, as the result of valvular lesions, does not 
 occur. There is sometimes to be found slight pretibial cedema, especially 
 after fatiguing exertion or long standing. When compensation fails, how- 
 ever, the diminished arterial pressure and the increased venous pressure 
 interfere with the circulation of the blood in the capillary zone and give 
 rise to oedema. Under these circumstances, there is an accumulation of 
 extravascular serum about the capillaries and a retardation of the lymph- 
 flow. Hence the visceral derangements are not only hypersemic, they are 
 also oedematous. The action of gravity renders this accumulation of extra- 
 vascular fluid early manifest in the dependent parts, namely, the legs and 
 feet. As it increases, the thighs, genitalia, and loins become involved, and 
 finally there is general oedema with effusion into the serous sacs. The 
 dropsy of heart disease is often irregularly distributed, but its presence 
 in particular localities may usually be explained by the relatively loose 
 arrangement of the subcutaneous or other tissues involved, postural 
 influences, and the action of gravity. 
 
 Compensation in mitral disease commonly fails by degrees, with 
 periods of improvement following rest and treatment, and the ultimate 
 catastrophe usually occurs after impaired health of prolonged duration. 
 
 Compensation in aortic disease is chiefly maintained by the left ven- 
 tricle, which often becomes enormously hypertrophied, — cor bovinum. 
 There is some increase in the venous pressure, since the ventricle receives 
 its blood in diastole not only from the auricle but also from the aorta, 
 but so long as the mitral valve remains competent, the visceral engorge- 
 ment and general oedema which characterize the dyscrasia of the stadium 
 ultimum of mitral disease do not occur. Precordial pain, angina pectoris, 
 and momentary faintness upon rising or at stool are common, and in many 
 cases the rupture of compensation is immediate and instantly fatal, death 
 occurring with the heart in asystole. 
 
 The Mechanism of Functional, Accidental, or Hsemic Murmurs. — The 
 murmurs designated by these terms are not signs of disease of the valves 
 or orifices of the heart. The frequency of their occurrence enables us 
 to determine with precision that they do not correspond to anatomical 
 changes in the organ found upon examination after death. The mechanism 
 by which they are produced has been the subject of much controversy, 
 but none of the explanations advanced has been generally accepted. 
 Functional murmurs are almost exclusively systolic and are heard over a 
 limited space in the pulmonary area. They have been ascribed to dila- 
 tation of the conus arteriosus, to the fact that in ansemia and similar 
 conditions there is lowered tonicity of the arterial walls which undergo an 
 abnormal dilatation at the time of the systole, and to the lowered blood- 
 pressure of ansemia in the aorta and pulmonary artery, which, in connec- 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 183 
 
 tion with the relatively high intraventricular pressure at the beginning of 
 systole, prevents the closure of the semilunar valves and the systolic 
 tension of the vessels, with the result that a systolic murmur arises 
 upon the passage of the blood into the large vessels at the moment of 
 physiological stenosis — contraction of the cardiac sphincters. 
 
 Diastolic functional murmurs, which are so rare that they scarcely 
 demand consideration for diagnostic purposes, are probably venous mur- 
 murs transmitted to the innominata or vena cava and heard at the base 
 of the heart. 
 
 The Significance of Endocardial Murmurs. — In order to determine the 
 diagnostic meaning of a murmur heard upon auscultation of the precordial 
 area, we must first answer the following questions: Is it endocardial 
 or exocardial? (See page 177.) If endocardial, is it organic or functional? 
 (See page 188.) Having found it to be an endocardial murmur of organic 
 origin we must then ascertain (1) its time in the cardiac cycle; (2) its 
 point of maximum intensity; (3) the direction in which it is propagated 
 and the area over which it can be heard; (4) its relation to the normal 
 sounds of the heart; (5) its acoustic properties, and (6) the effects of 
 exercise, respiration, and posture upon it. 
 
 (1) The Time of Murmurs in the Cardiac Cycle. — The determina- 
 tion of this point is of primary importance. For diagnostic purposes the 
 systole may be regarded as lasting from the beginning of the first sound of 
 the heart until the second sound; the diastole from the beginning of the 
 second sound until the beginning of the first sound in the next revolution of 
 the heart. A murmur heard at the time of the first sound or replacing the 
 first sound or extending into or developing in the period between the first 
 and the second sounds is systolic. Murmurs which develop in the latter 
 period are designated late systolic. 
 
 A murmur which occurs at the time of the second sound or replaces it 
 is diastolic. Murmurs which occur during the last portion of the diastole 
 and run up to the first sound are known as presystolic. 
 
 When the heart is acting moderately there is no difficulty in recognizing 
 the first and second sounds by their respective characters, and the long and 
 short silences by their relative duration. But when the heart is rapid the 
 different acoustic characters of the two sounds cannot always be made out 
 and the rhythm is so deranged that the difference between the long and 
 the short silence is less marked. Under these circumstances the systole 
 may be determined by palpation with the finger over the apex or the 
 carotid artery during auscultation, or by inspection if the double stetho- 
 scope is used. The interval between the time of the cardiac impulse and 
 the radial pulse renders the latter a misleading guide for this purpose. 
 
 (2) The Point of Maximum Intensity of Murmurs. — The area in 
 which a murmur is best heard is likewise of cardinal importance in diag- 
 nosis. The murmur is loudest at the point of its production and is best 
 transmitted in the direction of the blood stream in which the fluid veins 
 which produce it are developed. It is in accordance with these laws that a 
 murmur having its point of greatest intensity in the mitral area has its 
 origin at the mitral valve. It is necessary in this connection to bear in 
 mind the fact that the mitral area is not constant in the normal position 
 
184 MEDICAL DIAGNOSIS. 
 
 but that it shifts with displacement of the heart. In a limited proportion 
 of cases of mitral disease this murmur is best heard to the right of the 
 normal position of the impulse, and in rare instances at the left border of 
 the sternum higher up, even as high as the punctum maximum of the 
 pulmonary second sound. 
 
 It is also in accordance with the above laws that murmurs heard in 
 the pulmonary area, namely, the second left intercostal space, have their 
 origin in the conus arteriosus or at the pulmonary orifice; that murmurs 
 having their maximum intensity at the right lower border of the sternum, 
 at the level of the fourth and fifth intercostal spaces, or at the base of the 
 ensiform cartilage are produced at the tricuspid orifice, and that murmurs 
 whose maximum intensity is in or near the aortic area have their origin 
 at the aortic orifice. Murmurs arising at this point very often, however, 
 are best heard over the upper part of the body of the sternum near its 
 left border or, less frequently, at the apex or over the lower part of the 
 sternum — aortic insufficiency. 
 
 (3) The Propagation of Murmurs and the Extent of the Area 
 IN WHICH THEY CAN BE Heard. — Murmurs are very often heard over 
 limited areas and transmitted in definite directions. This is especially but 
 not exclusively true of the murmurs produced by lesions of single valve 
 systems. Thus the murmur of mitral stenosis — the presystolic murmur — 
 is heard over a circumscribed area just above the apex and is not propa- 
 gated, while the systolic murmur of mitral incompetence is heard over a 
 considerable area to the right of the apex and upward and is transmitted 
 distinctly in the direction of the left axilla and to the back. On the other 
 hand the systolic murmur of aortic stenosis is usually prolonged and loud, 
 heard over an extended area and transmitted into the carotid and sub- 
 clavian artery; it is in some instances heard at a distance from the chest. 
 The diastolic murmur of aortic incompetence may also be heard over an 
 extensive area of the chest both in front and behind. A murmur distinctly 
 heard over two or more valve areas may be due to one or to several valve 
 lesions. If it is systolic in time, it may be the sign of mitral insufficiency 
 or of aortic stenosis, or the murmur may be a compound of two murmurs, 
 each representing one of these lesions. The difficulties are greatly increased 
 when there are to-and-fro murmurs representing double lesions — stenosis 
 and incompetence — of the respective valves. A correct diagnosis rests 
 upon the application, in the study of individual cases, of the knowledge, 
 obtained by clinical experience and post-mortem examination, that the 
 murmur produced by each valvular lesion has its characteristic point of 
 maximum intensity and definite line of propagation along which its inten- 
 sity gradually diminishes as the stethoscope is moved away from that 
 point. A murmur which fulfils these requirements in regard to a particular 
 valve area and line of propagation and is unaccompanied by any other 
 murmur may be regarded as the sign of a lesion of that valve. When, 
 however, two or more murmurs are heard which differ in their acoustic 
 characters, as pitch, quality, and duration, and present each its point of 
 maximum intensity, and are propagated respectively in different direc- 
 tions, a correct diagnosis can only be reached by the separate study of 
 each as though it alone were present, the others being for the time being 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 185 
 
 disregarded. In this analytical study too much importance cannot be 
 placed upon the differences in pitch and quality and the evidences of the 
 influence of the lesions which cause the murmurs, upon the size of the heart, 
 the viscera and the pulmonary and peripheral circulation. In compli- 
 cated cases of cardiac disease the diagnosis cannot be made by an analysis 
 of the murmurs alone. A systematic study of the associated physical signs 
 is essential to success. 
 
 When several murmurs are present, it is best not to attempt an over- 
 refined diagnosis in regard to the lesions which underlie all of them. We 
 may be content when we have determined with accuracy the two which 
 are most important, and we may be reconciled to our inability to satis- 
 factorily do more than this by the knowledge that greater nicet}^ of diag- 
 nosis, though it might gratify our technical ambition, is not demanded 
 by the requirements of therapeutics and prognosis, and has been dis- 
 credited by the experience of the post-mortem room. 
 
 In this connection it is important to call the attention of the student 
 to the fact that the intensity of a murmur does not necessarily gradually 
 and progressively diminish in its line of propagation, but may be modified 
 by the presence of a viscus or the interposition of a new growth. Thus an 
 aortic murmur may be distinctly heard in the aortic area and near the apex 
 and only faintly in the intervening space. This phenomenon has been 
 attributed to the interposition of the right ventricle, while the transmission 
 of a mitral regurgitant in the direction of the left axilla may be abruptly 
 interrupted by a pleural effusion or neoplasm. 
 
 (4) The Relation of Murmurs to the Sounds of the Heart. — A 
 murmur may accompany the sounds of the heart or may replace them. 
 The systolic apex murmur of mitral incompetence wholly or in part 
 replaces the first sound. The systolic basic murmur of aortic stenosis 
 accompanies the first sound, but when compensation fails the first sound 
 is greatly weakened, and with enfeeblement and dilatation of the ventricle 
 or upon the supervention of relative mitral incompetence it may no longer 
 be heard. In aortic stenosis the second sound is not often heard at the 
 aortic cartilage, because the deformity of the valve usually prevents its 
 closure. In aortic incompetence, the second sound may be well heard or it 
 may be replaced by the murmur. In some cases it may be absent in the 
 aortic area but heard over the carotid artery. 
 
 A murmur which accompanies a sound also follows it, since the time 
 of the murmur is longer than that of the sound. A murmur may run up 
 to a sound, as the presystolic murmur of mitral stenosis. In rare cases 
 murmurs occur between the sounds. The persistence of the sound along 
 with the murmur may be of favorable prognostic significance, as, for 
 example, in aortic incompetence, where it indicates partial closure of the 
 damaged valve cusps with corresponding preservation of function. 
 
 (5) The Acoustic Properties of Murmurs. — Under this caption the 
 (a) intensity, (b) quality, (c) pitch, and (d) duration of murmurs are to be 
 considered. 
 
 (a) Intensity. — The intensity of cardiac murmurs is extremely variable. 
 A murmur may be so loud that it may be heard at a distance of some 
 feet, or so low as to be scarcely audible when the patient holds his breath. 
 
186 MEDICAL DIAGNOSIS. 
 
 Not infrequently a loud murmur is heard by the patient himself. Such very 
 loud murmurs are rare. The intensity of a murmur is by no means pro- 
 portionate to the gravity of the lesion by which it is produced. On the 
 contrary, since its intensity depends upon the energy with which the blood 
 is propelled through the affected orifice, that is, upon the compensation, a 
 loud murmur is, other things being equal, more favorable than a faint one. 
 As compensation fails, the murmur becomes fainter and it not infrequently 
 happens that in patients coming under observation with greatly impaired 
 compensation no murmur can be recognized upon careful auscultation, 
 but after rest and suitable treatment have brought about inprovement in 
 the general condition and in compensation a murmur appears which 
 becomes more intense as the patient grows better. This is especially 
 the case in mitral disease. There are, however, cases of acute rheumatic 
 endocarditis, especially in children, and of malignant endocarditis in 
 which the changes in the valvular lesions develop rapidly while the power 
 of the myocardium is still maintained, in which increasing loudness of the 
 murmur constitutes a most unfavorable sign. The intensity of an organic, 
 endocardial murmur is important less from its degree at any one time than 
 from its decrease or increase during the progress of the case. 
 
 A murmur is not usually of the same intensity during its brief course. 
 In general it is louder at the beginning than at the end. Presystolic mur- 
 murs are, however, usually louder at the close. The cause of the increase 
 in intensity is here due to the fact that the blood flows gently through the 
 auriculoventricular orifice at the beginning of the ventricular diastole, 
 but with increased force under the stress of the auricular contraction later. 
 
 (b) Quality. — Endocardial murmurs vary in quality from a soft blow- 
 ing sound — bellows murmur souffle — of little intensity, to a coarse, 
 harsh, rasping sound of considerable loudness. In rare instances they 
 are musical. The musical quality is usually manifest during a part of 
 the murmur only, the remainder having the ordinary blowing or rasping 
 character. The musical quality indicates an organic lesion, but does not 
 enable us to define its nature and is without significance in prognosis 
 •except that it indicates a certain degree of power in the heart muscle. The 
 presystolic murmurs which are produced by mitral and tricuspid stenosis 
 and the "Flint murmur" of aortic insufficiency have a peculiar "rum- 
 bling" or "blubbering" quality not heard under other conditions. These 
 murmurs have been compared to a short roll of the drum, but they are 
 much less regular. 
 
 (c) Pitch.— This attribute of murmurs is also variable. Blowing 
 murmurs of soft quality are commonly low pitched, while the coarser 
 murmurs are often high in pitch: to this general statement the excep- 
 tion that the very coarse, blubbering presystolic murmurs are usually 
 of low pitch. It is the high-pitched murmur that tends to assume the 
 musical quality. 
 
 (d) Duration. — A murmur may occupy the whole period of the systole 
 or the diastole or any part of either of these periods. The systolic murmur 
 of mitral incompetence is sometimes prolonged, the diastolic murmur of 
 aortic incompetence almost always so. Presystolic murmurs are of shorter 
 duration. The length of murmurs is not of itself of prognostic significance. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 187 
 
 (e) Variation in Murmurs. — Rapid changes in the acoustic properties of 
 murmurs, even their disappearance and reappearance, may occur in acute 
 endocarditis when vegetations are forming upon the valve segments, and 
 especially in the malignant form, in which the vegetations grow with rapidity 
 upon the valves and adjacent walls and ulcerative lesions occur. Similar 
 changes may occur in 'the course of acute endocarditis as the result of 
 rupture of chordae tendinese or the formation of adhesions between valve 
 segments or between a segment and the wall of the heart. 
 
 (6) Effects of Exercise, Respiration, and Posture upon Endo- 
 cardial Murmurs. — Faint murmurs usually become more distinct upon 
 moderate exercise, as walking rapidly two or three times across a room, or 
 stooping and rising several times in succession, and these movements are 
 sometimes necessary in the examination of doubtful cases. When, how- 
 ever, a murmur has grown indistinct or disappeared as the result of rupture 
 of compensation, movement simply increases the cardiac dyscrasia. 
 
 Organic murmurs are usually more distinctly audible upon quiet 
 breathing, or while respiration is momentarily suspended, and at the close of 
 expiration, when a larger area of the heart is uncovered. In this respect 
 they differ from functional murmurs, which are frequently best heard upon 
 inspiration. 
 
 Posture exerts an important influence upon the intensity of certain 
 murmurs. Systolic murmurs not heard in the upright position may be 
 distinctly audible in recumbency; on the other hand, murmurs not heard 
 in the recumbent posture may be recognized when, by the patient 
 leaning forward, the heart is brought into closer relation with the wall 
 of the thorax. Presystolic murmurs are sometimes much better heard in 
 the erect than in the recumbent posture. 
 
 The Significance of Functional, Accidental, or Hsemic Murmurs. — A large 
 proportion of endocardial murmurs, much larger than was formerly 
 supposed, are not associated with anatomical cardiac lesions. Certainly 
 murmurs are not rarely heard intra vitam in cases in which no corresponding 
 valvular lesions are found post mortem. Systolic murmurs arising in condi- 
 tions of cardiac asthenia from relaxation of the cardiac sphincter — rela- 
 tive incompetence — and having all the characters of incompetence from 
 actual lesions at the mitral orifice, though often transient are not usually 
 described as "functional." Short, whiffing, systolic murmurs, sometimes 
 heard in the mitral area directly after violent or prolonged physical effort, 
 are probably due to relative insufficiency resulting from acute dilatation. 
 They disappear in the course of a little time. 
 
 Functional murmurs are almost always systolic in time. By far the 
 greater number of them have their point of maximum intensity in the 
 pulmonic area; occasionally only are they most distinctly heard in the 
 aortic or mitral areas. They are commonly well heard to a little distance 
 from the point of maximum intensity in all directions rapidly diminishing 
 in loudness, and are not distinctly transmitted in a definite line, as is usual 
 with organic murmurs. They are as a rule soft and blowing in character. 
 A loud coarse murmur, whatever its other points of resemblance to func- 
 tional murmurs, is likely to prove to be organic, especially when persistent. 
 Functional murmurs are usually most distinct at the close of inspiration. 
 
188 MEDICAL DIAGNOSIS. 
 
 They are commonly transient and disappear when the condition with 
 which they are associated improves. They are not associated with the 
 signs of enlargement of the heart or with accentuation of the pulmonary 
 second sound. 
 
 Functional murmurs are significant of the various forms of anaemia. 
 For this reason they are spoken of as ''hsemic murmurs." They occur in 
 secondary anaemias, chlorosis, pernicious anaemia, leukeemia and Hodgkin's 
 disease. A distinct, prolonged systolic murmur in the pulmonary area is 
 common in chlorosis, and, in consequence of the retraction of the bor- 
 ders of the lungs, is frequently associated with a loud pulmonary second 
 sound. In the stadium ultimum of pernicious anaemia the haemic 
 murmurs often disappear. 
 
 The differential diagnosis between organic and functional endocardial 
 murmurs rests upon the following facts: 
 
 Organic murmurs occur at any period in the revolution of the heart; 
 functional murmurs are practically always systolic. It becomes necessary, 
 therefore, to contrast the characters of organic systolic murmurs with those 
 of functional murmurs. 
 
 Systolic organic murmurs are usually well propagated in the case of 
 mitral insufficiency toward the left axilla and to the back; in aortic 
 stenosis, to the carotids and the subclavians, especially upon the right side. 
 They are often soft and blowing, not rarely coarse and loud, sometimes 
 musical. The point of maximum intensity corresponds to the respective 
 mitral and aortic areas as above described (see page 169), and only in excep- 
 tional cases is to be located in the neighborhood of the pulmonary area. 
 Organic murmurs, except in the case of relative insufficiency, are persist- 
 ent, diminishing in intensity and ultimately disappearing only when the 
 compensation fails and is finally ruptured. They are sooner or later asso- 
 ciated with the signs of enlargement of the heart and increase of the blood- 
 pressure in the veins, as accentuation of the pulmonic second sound, visceral 
 engorgement and anasarca. The anamnesis commonly points to an acute 
 infection, rheumatic fever, hard work and worry as causal factors. 
 
 Functional murmurs, on the other hand, are not propagated in definite 
 directions; practically always soft and blowing, very exceptionally loud or 
 coarse; never musical. Their point of maximum intensity is almost invari- 
 ably in the pulmonic area. They are transient and not associated with 
 the signs produced by the effects of valvular lesions, as manifest in retard- 
 ation of a part of the blood stream; accentuation of the pulmonic second 
 sound, enlargement or distention of the walls of the heart; visceral derange- 
 ments — venous engorgement; or disorders of the peripheral circulation 
 — dropsy. Anaemia is almost always present. 
 
 The rare diastolic functional murmur, so rare as to be unimportant 
 in diagnosis, has been observed only in anaemia of very high grade and in 
 association with a venous hum. 
 
 B. Exocardial Adventitious Sounds. — Morbid physical signs not hav- 
 ing their origin within the heart are frequently heard upon auscultation 
 in the precordial region. Important in themselves, the}'' acquire addi- 
 tional diagnostic importance by reason of their occasional close resemblance 
 to endocardial murmurs. Of these the following are the more important. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 189 
 
 (a) Pericardial Friction. — The friction rub of dry or fibrinous peri- 
 carditis is heard upon auscultation as a grazing, creaking, or rasping sound 
 occupying some part of the time of the cardiac revolution. It is sometimes 
 systolic, sometimes diastoHc, often to-and-fro, but rarely corresponds to 
 the systole or diastole as endocardial murmurs do. It occurs irregularly 
 and with momentary interruptions, commonly changes in character and 
 time from one examination to another, and may appear, disappear, and 
 appear again in the course of a few hours. Pericardial friction is usually 
 best heard in the area of superficial cardiac dulness, but may be heard at 
 any part of the precordial region and sometimes over the greater part 
 of it. In some instances it is confined to the base of the heart. It is always, 
 however, distinctly circumscribed and never propagated in any direction 
 beyond the borders of the heart. It conveys the impression of being pro- 
 duced close to the ear and is intensified by the pressure of the stethoscope, 
 which also increases the pain which is present. It is apt also to be increased 
 when the patient inclines his body forward. It is little influenced by the 
 respiratory movements, except that in some instances its area is slightly 
 extended in expiration. Pericardial friction is frequently associated with 
 endocardial murmurs, the signs occurring as the manifestations of an 
 endopericarditis or the pericarditis developing in an individual already 
 the subject of chronic valvular disease. Under these circumstances the 
 friction sound is usually more conspicuous than the endocardial murmur 
 and at times may mask it altogether. 
 
 The differential diagnosis between an endocardial murmur and a 
 pericardial friction rests upon a critical analysis of the signs in the light 
 of the history of the case. 
 
 (b) Pleuropericardial Friction. — Cases occasionally occur in which fibri- 
 noid exudate upon that part of the pleura which is in relation with the 
 pericardium gives rise to a friction sound having the cardiac rhythm, the 
 roughened pleural surfaces being moved in apposition to each other by the 
 movement of the heart. The differential diagnosis between pericardial 
 and pleuropericardial friction rests upon the following facts: 
 
 The pleuropericardial friction is commonly heard in connection with 
 a friction sound having also the respiratory rhythm — pleural friction. 
 It is apt to be increased by forced respiratory movements and to be more 
 distinct upon inspiration, whereas pericardial friction is best heard at the 
 close of expiration. A positive diagnosis cannot always be made. 
 
 (c) Cardiopulmonary Murmurs. — Murmurs, hitherto known as cardio- 
 respiratory, having the cardiac rhythm, are occasionally produced in 
 the borders of the lung in relation with the heart by the traction or 
 pulsion of the heart upon the lung tissue in systole or diastole. The mur- 
 murs are pulmonary but not respiratory, and are due to the sudden dis- 
 placement of a certain volume of air from a mass of lung tissue confined 
 by adhesions. They are most commonly heard near the apex of the heart 
 and over the projection of the left lung which overlaps it, known as the 
 lingula; less often under the left clavicle or about the angle of the left 
 scapula. These murmurs are mostly systolic— traction murmurs; very 
 rarely diastolic — pulsion murmurs — and are heard over circumscribed 
 areas. They are much influenced by active respiration and cough. They 
 
190 MEDICAL DIAGNOSIS. 
 
 occur during inspiration and are scarcely, if at all, audible during expira- 
 tion, a fact which is of importance in distinguishing them from endocardial 
 murmurs, which are usually better heard when the breath is held in expira- 
 tion and a larger cardiac surface left uncovered by the retracted lung. 
 Cardiopulmonary murmurs have the soft, breezy quality of the vesicular 
 murmur and suggest an inspiratory act broken by successive movements 
 of the heart, which in point of fact they are. In rare instances these mur- 
 murs are accompanied by crepitant or subcrepitant rales. Their importance 
 from the standpoint of the diagnostician consists in their superficial resem- 
 blance to endocardial murmurs, from which they may be differentiated 
 without difficulty. 
 
 (d) The Precordial Rales of Emphysema. — In rare cases of emphysema, 
 in consequence of the rupture of the walls of vesicles, air finds its way 
 along the interstitial tissue to the root of the lung and thence to the 
 connective tissue of the anterior mediastinum. The superficial cardiac 
 dulness, if not previously obliterated by the borders of the emphysematous 
 lung, disappears with weakening of the heart sounds and the occurrence of 
 high-pitched metallic or crepitant rales which have the rhythm of the 
 heart. These signs are to be differentiated by their acoustic properties 
 from the tricuspid regurgitant murmurs, due to the dilatation of the right 
 ventricle, so frequently heard in emphysema. They are also to be differ- 
 entiated from the rales having the cardiac rhythm, which are heard in rare 
 cases of infiltration of the lungs or cavity formation in the neighborhood of 
 the heart, by the persistence in the latter of superficial cardiac dulness and 
 the heart sounds, the character of the associated respiratory sounds, and by 
 the fact of their occurrence in pulmonary emphysema. 
 
 (e) Pericardial Splashing. — In pneumohydro- or pneumopyo-pericar- 
 dium there may be heard peculiar splashing sounds of metallic character 
 similar to the succussion sounds of pneumohydrothorax, but having the 
 cardiac rhythm. The heart sounds under these circumstances are usually 
 feeble and distant. The cardiac dulness is in the recumbent posture 
 replaced by an area of tympany, the borders of which shift with changes in 
 the posture of the patient. These splashing sounds can under no circum- 
 stances be mistaken for murmurs, but they may closely resemble the splash- 
 ing of the gastric contents sometimes produced by the movements of the 
 heart, or that of pneumothorax or of a large vomica, from which they may, 
 however, be distinguished by the gravity of the symptoms, the concomi- 
 tant signs of pericardial perforation or inflammation, the examination of 
 the patient when the stomach is empty, or a systematic routine examina- 
 tion of the lungs. 
 
 (f) The Murmurs of Aneurisms. — Aneurism of the thoracic aorta more 
 commonly involves the ascending portion of the arch. On auscultation 
 at the base of the heart or sometimes in a wide area there may be heard a 
 systolic murmur, transmitted like the murmur of aortic stenosis in the 
 direction of the aorta itself and the vessels of the neck. A diastolic mur- 
 mur is sometimes also present. The latter is due to the reflux of blood into 
 the sac, and may easily be mistaken for the murmur of aortic insufficiency 
 with which it is not infrequently associated, as the manifestation of relative 
 incompetence in consequence of the dilatation of the aorta or of valvular 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 191 
 
 deformities resulting from sclerotic changes. The differential diagnosis 
 rests upon the presence or absence of the signs of aneurism, as deter- 
 mined by systematic inspection, palpation, percussion, and the anamnesis. 
 
 SOUNDS HEARD OVER THE PERIPHERAL VESSELS. 
 
 Auscultation of the Arteries. Normal Conditions. — When the steth- 
 oscope is lightly placed over the larger arteries where they run superficially, 
 sounds may be heard which correspond to the sounds of the heart. These 
 sounds are produced (a) in the heart and (b) in the arteries themselves. 
 
 The carotid may be studied at the angle of the jaw or at the inner 
 border of the sternocleidomastoid muscle; the subclavian directly above 
 the clavicle and external to the sternocleido muscle or directly below it, 
 in the arm between the pectoralis major and the deltoid; the brachial 
 at the inner border of the biceps or at the bend of the elbow, the arm being 
 slightly flexed; the radial just above the wrist, and the femoral immediately 
 below Poupart's ligament. 
 
 (a) The normal heart sounds are transmitted to some distance along 
 the course of the main arteries at the root of the neck and may be heard 
 in adults over the carotids and subclavians, more distinctly upon the right 
 than upon the left side. In infancy and childhood only the second sound 
 is thus transmitted, the first being very indistinct or wholly inaudible. 
 
 (b) A systolic sound, due to the sudden tension of the arterial walls, 
 may in some cases be heard over the abdominal aorta and the femorals. 
 In the majority of cases no sound is heard over these vessels nor over the 
 smaller superficial arteries so long as the stethoscope is applied without 
 pressure. When, however, some degree of pressure is exerted upon the 
 wall of the artery by the rim of the stethoscope, a systolic murmur is pro- 
 duced, often intense and high-pitched, the so-called compression murmur. 
 This murmur is due to sudden narrowing of the lumen of the vessel at the 
 point of pressure with the production of fluid veins. If the pressure is 
 increased to such a degree as to obliterate the lumen of the artery a sys- 
 tolic sound is produced by the increased force of the tension of the arterial 
 wall — pressure sound. These phenomena are physiological and without 
 other clinical significance than that which attends the risk of attaching 
 erroneous importance to them. 
 
 (c) Intracranial Murmurs. — In children up to the sixth year there 
 is sometimes to be heard upon auscultation over the cranium, and especially 
 over the anterior fontanelle and in the parietal regions, a distinct systolic 
 murmur, which apparently originates in the internal carotids from some 
 unknown cause and is without diagnostic significance. 
 
 (d) The Uterine Souffle. — A soft blowing systolic murmur is heard 
 over the pregnant uterus. It is first heard about the end of the sixteenth 
 week and increases in frequency until the eighth month, after which it 
 remains stationary. This murmur is subject to great variation as regards 
 quality, intensity, rhythm, and point of maximum intensity. It is usually 
 most distinct low down and upon one or the other side of the uterus, some- 
 times at the fundus, but very rarely over the entire uterine body. It is 
 attributed to the circulation of the blood in the arteries of the uterine 
 
192 MEDICAL DIAGNOSIS. 
 
 wall. The diagnostic importance of this sign is impaired by the fact that 
 a similar murmur is occasionally heard in chronic metritis, uterine myomata, 
 and ovarian cysts. 
 
 Single or double murmurs corresponding in time to the fetal heart- 
 beats are sometimes recognized in auscultation in pregnancy. They have 
 in some instances been found to be associated with defects of development 
 or endocardial lesions of the fetal heart — cardiac souffle. In other cases 
 murmurs have originated in the umbilical cord — funic murmurs. 
 
 Auscultation of the Arteries. Pathological Conditions. — (a) It is 
 obvious that abnormal sounds — murmurs — heard in the aorta will be 
 transmitted into the carotids and subclavians. The systolic and less 
 intensely the diastolic murmurs of lesions of the aortic valve system 
 are transmitted along the course of these vessels. 
 
 (b) In any condition in which the pulse is quick — pulsus celer — the 
 arteries may yield upon auscultation a systolic sound. This sign is some- 
 times present in fever and is common in aortic insufficiency, and may be 
 heard over the radials as well as over arteries of larger calibre. In aortic 
 insufficiency of high grade a double sound is sometimes heard over the 
 femorals, the systolic dilatation and the diastolic contraction of the artery 
 being alike attended with an audible sound. Systolic and diastolic sounds 
 in the femoral artery have also been observed in pregnancy and in chronic 
 lead poisoning, 
 
 (c) Double Murmurs in the Arteries. Diiroziez's Murmurs.— In well- 
 marked cases of expansile pulse in which the blood wave rises rapidly 
 and rapidly recedes there may frequently be detected over the femoral 
 or brachial artery at a certain point in the gradually increased pressure of 
 the stethoscope a double — namely, systolic and diastolic — murmur. Some 
 care is necessary to exert the degree of pressure under which this sign is 
 best heard. It may be observed in aortic insufficiency, chlorosis, and 
 other conditions in which there is well-marked pulsus celer. 
 
 (d) Subclavian Murmurs. — Systolic murmurs occurring independently 
 of pressure by the stethoscope are common. Heard upon one side only 
 when the attitude of the patient is unconstrained and the arms hanging 
 at the sides, such a murmur is very suggestive of apex disease of the lung 
 with pleural adhesions implicating the artery in its course. They are 
 commonly louder upon inspiration, exceptionally upon expiration. Such 
 murmurs are occasionally to be heard upon one or both sides in normal 
 individuals, and there are those who are able to produce them at will 
 by assuming certain attitudes, with fixation of the arms and the muscles 
 of the upper part of the chest. 
 
 (e) Thyroid Murmurs. — Systolic murmurs are very common over the 
 enlarged and tortuous arteries in goitre and especially in Graves's disease. 
 
 (f) Murmurs in Local Arteriosclerosis in Superficial Arteries. — Sys- 
 tolic murmurs due to this cause are occasionally observed. They are 
 audible in some cases without pressure by the stethoscope; in others upon 
 a minimum pressure. They are most common in the carotids. 
 
 Auscultation of the Veins. Normal Conditions. — In healthy individ- 
 uals the blood flows in the veins without sound or murmur. In rare instances 
 the occurrence of a venous hum constitutes an exception to this rule. 
 
PHYSICAL DIAGNOSIS : AUSCULTATION. 193 
 
 Auscultation of the Veins. Pathological Conditions. — (a) The venous 
 pulse in tricuspid insufficiency may by sudden tension of the valves and 
 walls of the jugular, and in particular the valves of the bulb, give rise to 
 a systolic sound which is scarcely to be distinguished from the almost 
 synchronous systolic carotid sound, except by the fact that it slightly 
 precedes it. 
 
 (b) Venous Hum — Nun's Murmur. — This is the single venous murmur 
 of practical diagnostic importance. Since the return flow of the venous 
 blood is to all intents uninterrupted, venous murmurs are continuous. 
 
 The patient should assume the upright posture with the head straight. 
 The stethoscope should be placed over the space between the sternal and 
 clavicular portions of the sternocleidomastoid muscle without pressure. 
 The murmur in question when present is heard as a pecuUar, sometimes 
 blowing, sometimes coarse and humming or again musical continuous 
 sound, with rhythmical systolic, diastolic, and inspiratory intensifications. 
 It is best heard upon the right side and diminishes in loudness or entirely 
 disappears when the patient assumes the recumbent posture. Rotation 
 of the face toward the opposite side increases the intensity of the sound. 
 Pressure with the stethoscope at first increases then enfeebles the murmur 
 until it wholly ceases and the systolic sound of the carotid is heard. In 
 some cases a feeble murmur loses its continuous character and is perceived 
 only at the moment of systole, diastole, or during inspiration. Under 
 these circumstances the murmur becomes continuous upon light pressure 
 with the stethoscope or if the head is rotated toward the opposite side — 
 manoeuvres which enable the diagnostician to distinguish the murmur 
 from arterial and inspiratory murmurs. In other cases the diastolic por- 
 tion of the murmur may be transmitted to the base of the heart and heard 
 there as a diastolic murmur apparently of endocardial origin. The differ- 
 ential diagnosis may be attended with difficulty unless auscultation is 
 practised from point to point from the heart along the course of the jugular, 
 when it will become clearly apparent that the diastolic murmur heard over 
 the base of the heart is in point of fact the transmitted venous hum. The 
 venous hum occurs in anaemic and chlorotic persons and occasionally in 
 healthy individuals with normal blood. In the last it has been assumed 
 that the phenomenon is due to some anatomical peculiarity, as, for instance, 
 sudden and unusual widening of the jugular at the bulb. 
 
 In general terms the causes of the venous hum are the more rapid 
 flow of the blood current by reason of its lowered specific gravity and defi- 
 cient haemoglobin, and the sudden widening of the jugular at the bulb. 
 The fact that this murmur is louder in the erect posture is rightly ascribed 
 to the influence of gravity in hastening the flow; the increased intensity 
 upon inspiration to the aspiration exerted by the chest movement at that 
 time, and the greater loudness upon the right side to the more direct and 
 unrestrained flow of the blood arising from differences in the anatomical 
 arrangement of the veins of the two sides. 
 
 13 
 
194 MEDICAL DIAGNOSIS. 
 
 III. 
 
 THE EXAMINATION OF THE STOMACH AND INTESTINES. 
 
 General Considerations. — Diseases of these organs are (a) primary or 
 organic and (b) secondary or symptomatic, and in each of these groups 
 there are cases in which recognizable anatomical lesions are present and 
 cases in which there is merely derangement of function. Thus, carcinoma 
 and ulcer are examples of organic disease with characteristic lesions, and 
 hyperchlorhydria and pyloric spasm are functional affections; while loss 
 of appetite, eructations, and vomiting occur as symptoms of phthisis, 
 often without actual lesions of the stomach, and erosion and ulcer are 
 not infrequent in chlorosis. It is of cardinal importance that the differ- 
 ential diagnosis between organic and functional disease of the stomach 
 and intestines should in all cases be made, particular^ as the former 
 only require direct local treatment and the latter are frequentlj^ made 
 worse by such treatment. 
 
 The Anamnesis. — It is very common for patients to attribute to 
 ''stomach trouble" or "bowel trouble" symptoms due to diseases of other 
 organs or to constitutional disease. A careful and systematic anamnesis 
 is therefore necessary in all cases. 
 
 Status Praesens. — The actual condition is ascertained by, (a) physical 
 examination, with special modifications, as inflation, transillumination, 
 the Rontgen rays; (b) chemical and (c) microscopic examination of the 
 gastric contents and alvine discharges. Differences in the methods, the 
 substances to be examined, and the results render it convenient to 
 consider the stomach and intestines separatel5^ 
 
 EXAMINATION OF THE STOMACH. 
 
 (a) Physical Examination. — Inspection. — The recumbent posture 
 and exposure of the w^hole abdomen as well as the thorax and neck are 
 necessary. In the neck may sometimes be seen the enlarged left supra- 
 clavicular lymph-node in cases of carcinoma of the subdiaphragmatic 
 viscera; the general conformation of the thorax and abdomen may be 
 studied and in some cases the flaring of the left costal arch from the pres- 
 sure of a distended high-placed stomach. When the abdominal wall is 
 thin and relaxed the outline of the distended stomach, the slow, large 
 movements of gastric peristalsis from left or right, far more rarely reverse 
 peristalsis, the presence of tumor masses in the gastric wall or at the 
 pylorus, or of metastatic growths about the umbilicus, in the Hver, or 
 elsewhere, may be observed. 
 
 Palpation. — This method is useful in determining localized or general 
 tenderness, the presence of a tumor, enlargement and displacement of the 
 stomach, and "splashing. " The stomach should be palpated systematically 
 with both hands and for several minutes. By this means peristalsis may 
 be aroused and a tumor which is not otherwise recognizable brought 
 
THE STOMACH AND INTESTINES. 
 
 195 
 
 within reach. In stenosis of the pylorus and gastroptosis the wall of the 
 stomach may sometimes be felt to become tense, with the sensation of the 
 passage of fluid in the region of the pylorus, and in persons with thin- 
 walled abdomens the tip of a bougie may be recognized as it is cautiously 
 moved along the greater curvature. Succussion or ''splashing" may be 
 recognized both by the palpating hand and by the ear. It occurs in motor 
 insufficiency and is of diagnoctic value when elicited after a fasting period 
 of seven hours. The patient should be in the dorsal posture with the 
 head and shoulders slightly elevated and at the moment the examination 
 is made the stomach should be depressed by deep-held inspiration. The 
 examiner exerts pressure upon the epigastrium at the level of the xyphoid 
 appendix and with the finger-tips of the other hand makes quick pressing 
 movements immediately followed by relaxation. This method may be 
 used in the determination of the lower border of the stomach after the 
 
 Fig. 82. — Palpating the abdomen. — Cohnheim. 
 
 administration of half a litre of water. The outspread fingers of the 
 palpating hand are used with the short pushing stroke of palpatory per- 
 cussion, beginning below the level of the umbilicus and proceeding upward 
 until the splash is felt. 
 
 Percussion. — This method is of little value by itself. The stomach 
 and adjacent coils of intestines yield tympanitic resonance or, when they 
 contain fluid or solid matter, dulness, and their boundary lines cannot 
 be defined by ordinary percussion. Auscultatory percussion, especially 
 when the stomach is inflated, is of use. The percussion should be per- 
 formed in lines radiating from a centre over the stomach and the points of 
 change in the auscultatory phenomena marked upon each line in turn. 
 Those points are then connected. Control observations may be made by 
 changing the centre and repeating the observation. 
 
 Auscultation has only a limited application in the examination of the 
 stomach. It is employed in the study of deglutition phenomena, "splash- 
 ing, " the Spritzgerausch of pyloric stenosis and hour-glass contraction 
 of the stomach. In the last, if the narrowing be of high degree, there 
 
196 MEDICAL DIAGNOSIS. 
 
 may be an audible sound produced by the passage of water from the 
 cardiac to the pyloric loculus, especially if pressure be used. 
 
 The Swallowing Test. — This test is used to determine the patency 
 of the cardiac orifice and is performed in the following manner: The ear 
 or the bell of a stethoscope is placed at the left of the tip of the ensiform 
 cartilage or, better, at the left of the seventh thoracic vertebra of the 
 patient, standing, who is directed to take a mouthful of water and swallow. 
 There is at once heard the rumble of the contracting oesophageal and 
 cervical muscles brought into play and in about seven seconds the trickling 
 of the fluid entering the stomach through the cardiac orifice. Delay or 
 absence of the latter sound suggests more or less complete stenosis in the 
 course of the cesophagus or at the cardia. 
 
 Inflation. — The stomach may be distended by means of a stomach- 
 tube and an ordinary rubber bulb syringe or by carbon dioxide evolved 
 within the organ itself. To this end 3 to 5 grammes of tartaric acid dis- 
 solved in half a glass of water are swallowed and this is followed bj^ an 
 equal amount of sodium bicarbonate dissolved in the same quantity of 
 water. The stomach first distends at its least resisting part and in the 
 case of moderate enlargement and thin abdominal walls its greater curva- 
 ture and inferior border may be made out by inspection or auscultatory 
 percussion. The gas may be expelled as it is formed either at the cardia 
 or at the pylorus, and in large stomachs the introduction of a sufficient 
 quantity of air may cause much discomfort or even pain, or the gas evolved 
 may be insufficient. The chief value of this method Ues in the determina- 
 tion of the size, outline, and position of the stomach. It is of importance 
 in the differentiation between tumors of the anterior wall and those sit- 
 uated in the posterior wall or behind the stomach. It is evident that 
 upon inflation the former will become more prominent, the latter less 
 obvious. Inflation is of some value also in bringing into prominence 
 obscure tumors of the pylorus. 
 
 Position of Fluids Ingested under Observation. — The position 
 of the lower border of the stomach is ascertained as closely as possible, 
 the patient standing. He is then directed to swallow a glass of water and 
 the resulting dulness is determined by percussion. This manoeuvre being 
 repeated two or three times at short intervals, changes in the level of the 
 dulness may occur, which are indicative of the position of the lower border 
 of the stomach. In normal stomachs of good musculature the increased 
 amount of fluid enlarges the area of dulness in an upward direction; in 
 relaxed and dilated stomachs the dulness sinks with the increasing weight. 
 The method is of no great value except in dilated stomachs and 
 gastroptosis in individuals with thinned abdominal walls. 
 
 Transillumination. — The gastrodiaphane of Einhorn consists of a 
 flexible tube carrying at its tip a small electric light. The patient drinks 
 two or more glasses of water; the tube is introduced and the circuit com- 
 pleted. The light shows through the abdominal wall in the normal stomach 
 as a triangular area having its apex and focus of intensity somewhat to 
 the left of the median line and above the umbilicus; in gastroptosis or 
 dilatation the point of illumination is lower and the light more diffused. 
 Changes follow movements of the bulb. This procedure shows the lowest 
 
THE STOMACH AND INTESTINES. 197 
 
 limit of the stomach at one point. There is no certainty that the lamp 
 does not push the greater curvature into positions it would not otherwise 
 occupy, or that the position of the illuminated area affords positive data 
 in regard to the size and shape of the organ. 
 
 Direct Gastroscopy. — Direct inspection of the mucous membrane 
 of the stomach through a rigid metal tube requires the patient recum- 
 bent, with his head extended in such a manner that the trachea and 
 oesophagus approach nearly a direct course. General anaesthesia is recom- 
 mended for the best results. The tube used is fitted with a small electric 
 light, mirror, and obturators, and in general resembles those employed in 
 the diagnosis of rectal and sigmoid disor.ders, being, however, longer and 
 slightly thinner. Many conditions of the stomach are readily recognized 
 by direct inspection. An empty or even well washed stomach is preferable 
 at the time of examination. Ulcerations and local thickenings can be 
 readily located. Inflammation, catarrh, or atrophy of the mucous mem- 
 brane can be determined. Some care is necessary to ensure inspection of 
 the whole interior, particularly if the stomach is enlarged. The cardia 
 is first inspected. Inflation aids in bringing other parts into view. 
 By some manipulation of the upper end of the gastroscope and simul- 
 taneous palpation and manipulation on the part of an assistant the whole 
 stomach can be gone over and outlined. The readiness with which the 
 end of the tube can be felt through the abdominal wall is of some 
 service. The use of the oesophagoscope and gastroscope demands consider- 
 able technical skill. 
 
 The Rontgen Rays. — Thickenings, the puckerings caused by dense 
 cicatricial masses and tumors at the pylorus or elsewhere cast shadows 
 which often afford confirmatory evidence of great importance in diag- 
 nosis. By the aid of the bismuth meal — two ounces of bismuth subnitrate 
 mixed in six ounces of rice pudding or suspended in eight ounces of kefir — 
 the outline of the greater curvature, hour-glass contraction, the position 
 of the pylorus, and the motor power of the stomach can be determined. 
 The tracing of such a meal through the alimentary canal by serial obser- 
 vations during the course of several hours frequently jdelds diagnostic 
 data of great value in diseases of the small and large intestines, while 
 important facts are sometimes to be acquired in disorders of the lower 
 bowel by X-ray studies made after the injection of bismuth suspension 
 per rectum. Recent improvements in apparatus and technic, which 
 render possible instantaneous radiograms, have led to more accurate 
 knowledge in regard to gastric and intestinal peristalsis under normal 
 and pathological conditions, much of which may become available for 
 diagnostic purposes. 
 
 The Stomach-tube. — Various styles are in use. The simplest is the 
 best. They are made of soft red rubber with a lumen of about .50 to .75 
 cm., walls not too thick, and about 70 to 90 cm. in length; near the gastric 
 end one or two large lateral openings. Whether there should be an open- 
 ing at the end is a matter of opinion. The upper end is fitted to a glass 
 funnel of a capacity of 500 c.c. At the middle there may be a bulb which 
 serves for inflation or suction and permits free siphonage. As the distance 
 from the incisor teeth to the cardia is on the average 40 cm., or slightly 
 
198 MEDICAL DIAGNOSIS. 
 
 less than 16 inches, there should be an encircling mark at this point. It 
 is important to note that many of the tubes supplied at the shops are 
 marked at a point 51-60 cm. from the tip, about the distance to the lowest 
 point of the greater curvature. For infants a soft catheter may be used. 
 Introducing the Tube. — The sitting position is easiest. It is best not to 
 elevate the chin, since stretching the neck seems to occlude the upper 
 oesophagus. Plates and false teeth should be removed. Soaking the 
 last several inches of the tube in hot water makes the first contact of the 
 tube with the pharynx less irritating. Holding the tube in the hand, as 
 one would a pen, with five or six inches projecting, the examiner instructs 
 the patient to open his mouth moderately wide, with the tongue touch- 
 ing and against the teeth. The tube is then passed straight back to the 
 middle of the posterior pharyngeal wall and directed downward. If the 
 patient can swallow at this moment the tube is usually engaged at once 
 
 Fig. 83. — Stomach-tube. — Cohnheim. 
 
 in the upper oesophagus and can be rapidly pushed in, reaching the stomach 
 in several seconds, and is securely in place before the first expulsive 
 coughing efforts begin. By ordering the patient to breathe deeply several 
 times one usually succeeds in quieting most of the discomfort and can 
 proceed with the examination. To avoid the doubling up of the tube or 
 the unpleasantness of the coughing or vomiting which often ensues, many 
 prefer to introduce the forefinger of one hand along the side of the mouth 
 as a guide and to pass the tube along this guiding finger. Many attempts 
 are often necessary to overcome the spasmodic expulsive efforts of the 
 pharynx. At times the distress is such that it is necessary to forego the 
 attempt. Cocainization of the pharynx has been recommended; it does 
 not, however, seem to have been very successful in difficult cases. 
 
 The great value of the stomach-tube in gastric diagnosis lies in the 
 ease with which the stomach may be inflated and its contents removed. 
 Much time will be saved by having the patient take one or other of the 
 various test-meals whenever the tube is to be passed. After removal of the 
 meal the patient's clothes are loosened and he is directed to lie down with 
 the tube still in position. Inflation can now be performed and in conjunction 
 
THE STOMACH AND INTESTINES. 
 
 199 
 
 with some of the various methods already mentioned will be found to be the 
 most satisfactory way of estimating the size and position of the stomach. 
 
 The stomach is inflated until the patient indicates the beginning of 
 discomfort. The examiner then clamps the tube or can ask the patient to 
 hold it firmly in his teeth, thus giving the examiner the free use of both 
 hands. During the inflation the examiner should carefully watch for the 
 area where the stomach first manifests its presence. In a normal stomach 
 this will be just below the left costal margin and in the epigastrium 
 between the ensiform and navel. The stomach will stretch easily and its 
 greater curvature can be followed to the umbilicus before overdistention 
 is complained of. The lesser 
 ■curvature must be outlined as 
 well, either by inspection, per- 
 cussion, or auscultatory percus- 
 sion, and marked in pencil. Its 
 position should be under the cos- 
 tal arch as high as the sixth and 
 seventh ribs, and just below the 
 ensiform cartilage in the mid- 
 line. The fundus may distend 
 high up toward the axilla. A 
 distinct stomach-shaped outline 
 can usually be obtained. It is 
 only by outlining both lesser and 
 greater curvatures that the differ- 
 ence between displaced and di- 
 lated stomachs is determined. 
 
 The great advantage of the 
 use of the stomach-tube in 
 inflating is that the process can 
 be repeated as often as may be 
 desired without undue discom- 
 fort or delay, since after the first 
 few minutes the patient experi- 
 ences little or no uneasiness. 
 
 In addition to the estimation of the size, shape, and position of the 
 stomach, the stomach-tube is used to determine conditions of hyper- 
 secretion and retention. To test for hypersecretion the stomach-tube is 
 passed in the morning before any fluid or food has been ingested, or the 
 stomach may be washed out and the tube again passed after several hours' 
 fasting. The recovery of more than 10 to 20 c.c. suggests disturbance of 
 the gastric functions. In testing for retention the examiner washes the 
 stomach clean, administers certain solid articles of diet, and passes the 
 tube to obtain samples of the stomach contents, seven or eight hours 
 later, or, according as marked conditions are suspected, twelve, twenty- 
 four, or even forty-eight hours after the taking of the meal. 
 
 Contraindications for the Use of the Stomach-tube. — Those who for 
 repeated diagnostic or therapeutic purposes have become accustomed to 
 the tube take it without difficulty and many learn to introduce it them- 
 
 FiG. 84.- 
 
 -Method of introducing the stomach-tube. - 
 Cohnheim. 
 
200 MEDICAL DIAGNOSIS. 
 
 selves. Its first introduction is often attended witli great gagging, strain- 
 ing, and congestion, and is not wholly without danger in elderly persons 
 with arteriosclerosis, myocarditis, and emphysema of high degree. It is 
 also hazardous and unjustifiable in hemorrhagic cases, especially haemop- 
 tysis, hsematemesis, or cases of marked anaemia with tarry stools, and in 
 aneurism of the aorta, in great debility from acute or chronic illness, and 
 in pregnancy. Even in the absence of any of the foregoing conditions the 
 retching, gagging, and distress of the patient may be so great that the 
 attempt to pass the tube must be temporarily abandoned. 
 
 (b) The Chemical Examination. — The further examination of the 
 stomach consists in the administration of certain test-meals or substances, 
 their removal by means of the stomach-tube after a given period of time, 
 and the application of various chemical tests for the digestive agents of 
 the gastric juice. 
 
 Previous to the giving of a test-meal the stomach should be perfectly 
 free from food remains; hence in cases of suspected dilatation or retention 
 lavage must first be employed. Whatever the form of test-meal some 
 difficulty may be met with in removing it. Frequently the tube is not in 
 the stomach, either not reaching beyond the cardia, or doubled up in the 
 oesophagus or pharynx. In other cases the tube may have reached the 
 greater curvature and turned upward upon itself until the openings are 
 above the level of the stomach contents. Not infrequently plugs of mucus 
 will close the eyes of the tube. In marked displacement and dilatation 
 the end of the tube may not reach the ingested test-meal unless introduced 
 many inches beyond the average distance. Forcing in a little air, partly 
 withdrawing and advancing the tube, will usually clear the opening and 
 enable one to find the proper distance and the point at which the material 
 best flows out or comes out by suction. Some little information is gained 
 by the way in which the material comes away. In atonic conditions of 
 the gastric muscles suction must often be used, even w^hen large amounts 
 of fluid material are present. With a musculature of fair or active tone the 
 gushing forth of the stomach contents is not uncommon. 
 
 Test=MeaIs. — Several standard test-meals are in use. 
 
 The Ewald Test-breakfast. — This consists of 35 grammes of stale 
 bread or toast without butter and 200-400 c.c. of weak tea or water. Two 
 small sUces of toast without butter and one cup of weak tea without 
 cream or sugar represent these amounts fairly well. This meal is to be 
 removed at the end of one hour, or not later than an hour and a quarter, 
 since in the normal stomach the height of acidity is reached by this time 
 and the stomach has already begun to empty itself. Not infrequently the 
 stomach is found empty at this time and one must repeat the meal and 
 remove it earlier. Attention to the details of managing the tube will 
 usually enable one to obtain some part of the gastric contents. With this 
 meal after one hour's time 40 to 60 c.c. of stomach contents should be 
 obtained, brown or white according as toast or bread has been used, of 
 the consistency of thin porridge, or if the absorption of fluid has been rapid 
 much thicker, the bread or toast finely minced by the stomach's activity 
 and without an odor. The glairy saliva produced in excess by the tube's 
 presence in the mouth and the whiter plugs of mucus from the posterior 
 
THE STOMACH AXD INTESTINES. 201 
 
 nares, are often mixed with the contents and can be readily distinguished 
 and at once removed. As the contents settle mucus from the stomach 
 will gather together and remain upon the top. Little or none should be 
 present, nor should there be a layer of froth. On standing, if in sufficient 
 amount, the removed test-meal and gastric juice show two layers: the 
 upper fluid, gray, milky, or light green in color; the lower brown or white, 
 composed of the remains of the bread or toast. The tea or water is 
 usually quickly absorbed, and the overlying fluid consists largely of 
 gastric juice. 
 
 Objections to the Ewald test-meal are, first, that even stomachs 
 whose motive power is failing can get rid of most of the fluid of the meal 
 within the stated time, and hence relaxed conditions in their early stages 
 may be overlooked; secondly, that the mild character of the meal does not 
 bring out certain conditions of hyperactivity of the gastric mucosa as a 
 more stimulating one would tend to do. 
 
 Riegel's test-meal — 200 c.c. mutton broth, 150-200 grammes beef- 
 steak, potato puree 50 grammes, one roll 35-50 grammes — has been pro- 
 posed in order to overcome these difficulties. The gastric contents are 
 removed at the end of four hours for the various tests of gastric secretion, 
 or at the end of seven hours to test for gastric motility or retention, it 
 being usual for the normal stomach to have emptied itself by that time. 
 The general readings of the chemical tests in Riegel's meals after four 
 hours are found to correspond more or less with those of the Ewald meal 
 after one hour. As a matter of experience it might be said that careful 
 physical examination will overcome the first objection, and that only 
 occasionally, when the symptoms do not correspond with results of the 
 Ewald test-meal, will the Riegel meal be necessary. 
 
 Many other test-meals have been proposed, but thej^ do not seem to 
 yield any better results than the two mentioned.^ 
 
 After consideration of such points as the amount removed, the manner 
 of its expulsion or withdrawal, and preferably after a preliminar}^ setthng, 
 the upper liquid layer or the whole contents are filtered and the filtrate 
 submitted to chemical examination. 
 
 Starch. — The effect of the salivary enzjmies can be first and most 
 simply ascertained. The conversion of starch to achroodextrin and mal- 
 tose goes on in the stomach until the free acids of gastric secretion reach 
 a certain point. The well-known iodine reaction, coloring starch violet, 
 coloring erythrodextrin, the first product, mahogany brown, and having 
 no characteristic color effect in the final stages, achroodextrin and maltose, 
 allows us to estimate quickly and qualitatively the extent of salivary 
 digestion. Both the filtrate and residue contain reacting substances, 
 soluble and insoluble starch. Excess of unaltered starch gives at once 
 with iodine solutions (Lugol's solution .1 Gm. 'iodine, .2 Gm. potass, iodide, 
 200 c.c. water) a deep violet color; achroodextrin and maltose show no 
 color reaction, though the latter is readily detected by Fehling's solution. 
 Iodine, however, must be added in excess, since achroodextrin has a 
 greater affinity for it than has starch, and the violet starch reaction may 
 
 iFor a full discussion of this subject consult Clinical Diagnosis: Emerson; second edition. 
 J. B. Lippincott Co., 1908. 
 
202 MEDICAL DIAGNOSIS. 
 
 only appear after all the achrooclextrin has been satisfied. The same 
 color effects can be readily seen under the low power of the microscope. 
 
 The main relationship which starch tests, i.e., saUvarj^ digestion, 
 bear to stomach digestion is that hyperacid conditions of the stomach 
 interfere with its progress, and that hj^po-acid conditions may favor it. 
 
 The more important tests in ordinary clinical work are those for (1) 
 acidity; (2) presence of free acids; (3) presence of free HCl, lactic, and 
 butyric acids; (4) presence of HCl in combination (combined HCl). Tests 
 for proteid digestion, pepsin and peptone reaction, are usually considered 
 to be unnecessary when normal or increased free HCl is found. Milk- 
 curdling ferment is rarely tested for. A fat-splitting ferment in small 
 amounts has been occasionally demonstrated, but is not regarded as of 
 great practical importance. The qualitative tests in common use can be 
 first considered. 
 
 Qualitative Tests. — 1. Test for Acidity. — The products and agents 
 of gastric digestion are normally acid, this reaction being due to free acids 
 — HCl, lactic acid, butyric acid, and their combinations. Blue litmus 
 paper is reddened by their presence. 
 
 2. Tests for the Presence of Free Acids. — Congo red paper or 
 solution is turned deep blue by free HCl. A less intense reaction is given 
 by the organic acids. 
 
 3. Tests for the Presence of Free HCl, Lactic Acid, etc. — HCl. 
 — (a) Methyl Violet Reaction. — To a pale violet solution of methyl violet 
 (one drop concentrated aqueous or alcoholic solution in a test-tube of 
 water) add a few drops of the filtrate. A distinct blue change takes place 
 if free HCl is present. A control tube should be on hand for comparison. 
 
 (b) TrojDCEolin 00 Reaction. — Two or more drops of fresh concen- 
 trated alcoholic solution of tropseolin (a deep orange-colored solution) 
 are spread on a porcelain plate or dish. The same amount of filtrate is 
 added to this surface and the porcelain gently heated. A distinct violet 
 reaction turning to blue takes place. 
 
 (c) Phloroglucin-vanillin {Gilnzburg's) Reaction. — Two or three drops 
 of the solution (phloroglucin 2 Gm., vanillin 1 Gm.. alcohol 30 c.c.) are 
 used with the same amount or more of the filtrate as in the tropjeolin 
 test and dried by gentle heat. The brown color of the phloroglucin-vanilhn 
 is changed to a distinct carmine red if free HCl is present. 
 
 (d) Dimethylamidoazohenzol Reaction. — A drop of a .5 per cent, 
 alcoholic solution of this substance (a light red-brown solution) added to 
 the filtrate or to the residue, quickly gives a bright red color if free HCl 
 is present. In cases where but a few drops of gastric contents have been 
 secured this test can be readily applied without waiting to filter. 
 
 The last two tests are by far the most reliable and are generally con- 
 sidered as absolute tests for the presence of free HCl. Lactic acid in excess 
 may give suggestive results in the methyl violet and tropseolin reactions. 
 
 Lactic Acid. — Uff'elman's Test. — One drop of a 10 per cent, solution 
 of ferric chloride is added to 20 c.c. of a 1 per cent, solution of carbolic 
 acid. The resulting deep blue mixture is diluted until it appears as a light 
 amethyst. On the addition of a gastric filtrate containing lactic acid the 
 amethyst changes to distinct yellow. Excess of free HCl, sugars, or peptones 
 
THE STOMACH AND INTESTINES. 
 
 203 
 
 may decolorize the amethyst, and the yellow tint of many filtrates if added 
 in excess gives suggestive but uncertain results. A comparison with a 
 test solution of lactic acid is always useful for a beginner. Far better 
 results are obtained by shaking a portion of the filtrate with ether, which 
 extracts the lactic acid, and applying the test to the evaporated residue, 
 which may be preferably diluted with 2 or 3 c.c. of water. Strauss' modi- 
 fication of this test is also serviceable. One may dispense with the sep- 
 arator if it is not obtainable. Five c.c. of gastric juice are placed in a test- 
 tube; 20 c.c. of ether are then added, the tube corked, thoroughly shaken 
 for a few minutes, and allowed to settle. The overlying ether and extract 
 can now be carefully removed with a pipette and mixed with 5 c.c. of 
 distilled water. To this mixture two drops of a 1 in 9 
 watery solution of ferric chloride are added and the mixture 
 is again shaken. The watery layer, as it settles below, is of 
 an intense greenish-yellow color if lactic acid be present. 
 
 Butyric Acid. — This acid is usually only tested for by 
 its odor. This and others of the volatile fatty acids, acetic 
 and valerianic, are only looked for in marked conditions 
 of stagnation of the gastric contents. Very minute quanti- 
 ties of them all, however, occur in various food-stuffs. 
 
 Combined HCl. — A qualitative test for the proteid com- 
 binations of HCl is not in general use. The quantitative 
 tests will be considered below. 
 
 . Proteid Digestive Power. — For the qualitative tests 
 of the power of the gastric juice to digest proteid, one or 
 two simple devices have been used. Fibrin and coagulated 
 albumin (egg albumin) are the common proteids used: the 
 fibrin, well washed, hardened in alcohol and stained by 
 neutral carmine, will digest in gastric juice containing 
 free HCl and pepsin, imparting a red color to the liquid 
 mixture as the carmine is set free by the digestion. 
 
 Small pieces, or disks 2 mm. in diameter, 1 mm. in 
 thickness, of not too firmly coagulated egg albumin are 
 placed in a few c.c. of gastric contents. According to the 
 amount of pepsin and free HCl present digestion begins 
 more or less rapidly, and softening of the edges of the 
 seen in one to two hours. Many hours are required for the complete gran- 
 ulation of either fibrin or albumin. Gastric juices deficient in free HCl 
 have less and less effect upon the proteids employed. Some slight diges- 
 tion goes on even with complete absence of free HCl. 
 
 Neither of the proteid digestive tests is very instructive, and one 
 must remember that the pepsin present in the gastric filtrate has been 
 already partly used in the proteid digestion of the test-meal. Sahli's des- 
 moid-proteid digestive test will be considered under the absorption tests. 
 
 Tests for Rennin and Rennin Zymogen. — To 10 or 15 c.c. of neutral 
 milk add 5 c.c. of gastric filtrate, and place the mixture in a thermostat or 
 in any warm place. In 10 to 15 minutes coagulation begins. This is 
 merely the familiar ''junket making." Free HCl is not necessary for its 
 performance. 
 
 Fig. 85.— Sepa- 
 rating apparatus 
 suitable for test- 
 ing for lactic acid. 
 — Strauss. 
 
 disks 
 
 can 
 
 be 
 
204 MEDICAL DIAGNOSIS. 
 
 Quantitative Tests. — For the differentiation of many of the dis- 
 orders of gastric secretion an estimation of the amount of acids and acid 
 combinations is often necessary. Free HCl is the only free acid regularly 
 estimated. The estimation of the total acidity of the gastric contents, 
 which is made up of free HCl, traces perhaps of other acids (lactic acid), 
 and combinations of HCl and lactic acid (if present) with the proteids of 
 the administered meal, is the next important step. Estirr.ations of these 
 combined products are also made. 
 
 Quantitative Estimation of the Amount of Free HCl. — The 
 amount not used in the process of digestion at the time of the test-meal's 
 removal. The general principle of all the tests for total acidity and free 
 acids is the same, namely, to add to the filtrate a standard alkaline solu- 
 tion until the acid contents are neutralized. To aid in determining neutral- 
 ization various coloring agents, some of which have been alreadj^ described 
 in the qualitative tests, are added to the gastric filtrate. These coloring 
 agents all have the peculiarity of losing or even changing their color when 
 the filtrate becomes neutral or faintly alkaline in reaction from the added 
 alkaH. The solution in general use is the ''one-tenth normal" sodium 
 hydrate. This one-tenth normal solution, written f-^ NaOH, is preferred on 
 account of its dilution, which, when dealing with such small amounts and 
 percentages as are found in the stomach contents, is very necessary. One 
 c.c. of this ^ NaOH corresponds to or exactly neutrahzes .00365 gramme 
 of free HCl. 
 
 In making the quantitative estimation, 10 c.c. of the gastric filtrate 
 are taken in a beaker. By means of a graduated burette the ^ NaOH is 
 allowed to drop into the beaker until the so-called indicators or coloring 
 agents show their characteristic changes, indicating complete neutraliza- 
 tion. The number of c.c. of ^ NaOH used, multiplied by the free HCl 
 equivalent of 1 c.c. -^ NaOH (.00365 gramme), gives the amount of HCl 
 in the 10 c.c. of gastric filtrate, and one readily calculates the percentage 
 amount therefrom, normally about .1825 gramme per 100 c.c. 
 
 At present it is more common to express the results in direct figures 
 or per cent., indicating merely how many c.c. of ^ NaOH are necessary 
 to neutralize 100 c.c. of the gastric filtrate {i.e., its contained free HCl), as, 
 for instance, if 10 c.c. of gastric filtrate (containing free HCl) are neutral- 
 ized by 5 c.c. of ^ NaOH, the percentage of free HCl is said to be 50. 
 
 The most convenient indicator for free HCl is dimethylamidoazo- 
 benzol. In contact with free HCl in the filtrate a bright red color is shown. 
 Neutralization by ^ NaOH turns the red color to a turbid yellow. The 
 beaker containing the filtrate and indicator should be well stirred or shaken 
 while adding the alkaline solution from the burette. 
 
 Equally satisfactory for quantitative estimation is the phloroglucin- 
 vanillin test. Ten c.c. of the filtrate are placed in a beaker, the ^ NaOH 
 is added slowly, and after every 10 to 15 drops one takes a drop of the 
 filtrate and tests it for free HCl on a porcelain plate with the phloroglucin- 
 vanillin. The non-appearance finally of any trace of the carmine-red 
 color indicates the complete neutralization of the free HCl in the filtrate. 
 
 Estimation of Total Acidity. — The same methods are used with 
 merely different indicators: either phenolphthalein or rosolic acid. Two 
 
THE STOMACH AND INTESTINES. 205 
 
 or three drops of a 1 per cent, alcoholic solution of the former give to the 
 gastric filtrate a turbid appearance. Upon the gradual addition of the 
 ^ NaOH there appears a red-purple color where the drop strikes, quickly- 
 disappearing at first but becoming more and more persistent until shaking 
 the filtrate no longer causes the color to disappear. A good rule to follow 
 in this test is to consider the reaction complete when the color will remain 
 for 40 or 60 seconds. 
 
 Upon the addition of 2 or 3 drops of a concentrated solution of rosolic 
 acid to 10 c.c. of the filtrate the color is changed to light brown. Neu- 
 tralization is shown by the appearance of a rosy red color. 
 
 Since the estimation of the total acidity requires the greater amount 
 of alkaline solution, it is possible to make both tests in one beaker con- 
 taining 10 c.c. of filtrate. Using dimethylamidoazobenzol as an indicator 
 one can find first the amount of -^ NaOH necessary to neutralize the free 
 HCl present. By adding phenolphthalein or rosolic acid to the now light 
 yellow mixture the determination of the total acidity can be made; the 
 amount of ^ NaOH dropped in after using the last indicator being merely 
 added to the amount recorded in the estimation of the free HCl. 
 
 Frequently it is of interest to estimate how much of the secreted HCl 
 has combined with the proteid of the meal forming the so-called combined 
 HCl. Many cases showing no free HCl on tests will show that there has 
 been free HCl secreted in the stomach as evidenced by the existence of 
 its combined products. 
 
 The simplest tests require the finding of the total acidity in the 
 beginning. 
 
 The total acidity represents free acid, acid combined with proteids, 
 and acid salts (acid phosphate). 
 
 Alizarin as an indicator reacts acid to free acid and acid salts, but 
 not to combinations of acids and proteids; hence the difference between 
 two tests, the amount of -^ NaOH used in one with phenolphthalein as 
 an indicator, the other with alizarin, must represent the acids in combina- 
 tion. The reaction is complete when the yellow of the indicator turns to 
 a distinct violet. 
 
 To summarize these tests with an example, the following normal 
 figures may be used. 
 
 1. 10 c.c. of gastric filtrate with phenolphthalein as an indicator for 
 neutralization require 4 c.c. -^ NaOH: 100 c.c. would require 40 c.c. 
 Free acids, acids in combination, acid salts = total acidity 40. 
 
 2. 10 c.c. of gastric filtrate with alizarin as indicator (free acids, acid 
 salts) requires 3 c.c. -^NaOH: for neutrahzation 100 c.c. would require 
 30 c.c. Total acidity 40-30 = 10. Combined acids 10. 
 
 3. 10 c.c. of gastric juice with dimethylamidoazobenzol as indicator 
 (free hydrochloric acid only) require 2.5 c.c. fjy NaOH for neutralization. 
 Free HCl therefore = 25, in terms of 100. 
 
 A much more reliable method of estimating combined HCl is that of 
 Cohnheim and Krieger. Calcium phosphotungstate separates HCl from 
 its combination with albumin and albumoses, the calcium uniting with the 
 HCl forming neutral calcium chloride. In the process a reduction of the 
 total acidity takes place, corresponding to the amount of combined HCl, 
 
206 MEDICAL DIAGNOSIS. 
 
 which has been changed to the neutral calcium chloride. The difference 
 between titrations before and after the calcium phosphotungstate reaction 
 must represent the amount of acid in proteid combination. The detail is 
 more troublesome than the simple alizarin process, but gives far more 
 accurate results than can be expected where two separate color changes are 
 required. 
 
 Four per cent, phosphotungstic acid is neutralized by gently boihng 
 with calcium carbonate. Calcium phosphotungstate is formed; the solu- 
 tion is filtered, tested for neutrality, and can be kept for any length of 
 time. 30 c.c. of this calcium phosphotungstate is added to 10 c.c. of gastric 
 juice. A heavy precipitate of proteid phosphotungstate results while the 
 newly formed neutral calcium chloride remains in solution. This mixture 
 is now filtered, the precipitate remaining on the filter paper being well 
 washed by pouring on it distilled water (two or three separate additions of 
 5 or 10 c.c.) and adding the wash water to the original filtrate. 
 
 Using rosolic acid as an indicator the total acidity of 10 c.c. of gastric 
 juice is first estimated, then the same test is repeated with the material 
 obtained after the phosphotungstate reaction, usually about 50 c.c. of 
 clear fluid. As an illustration: 
 
 1. Total acidity of 10 c.c. gastric juice, rosolic acid as indicator = 50. 
 
 2. Total acidity of mixture (10 c.c. gastric juice + 30 c.c. calcium 
 phosphotungstate + wash water), rosolic acid as indicator = 35. 50—35 = 15, 
 difference due to conversion of HCl combined with proteids into neutral 
 calcium chloride. Combined HCl therefore = 15. 
 
 Gastric juices in which the free HCl is absent are often examined 
 for free HCl deficiency. This is necessary if the calcium phosphotung- 
 state method of estimating combined acids is used. The process is simple 
 and similar to the above tests. To 10 c.c. of filtrate, dimethylamidoazo- 
 benzol is added. With absence of HCl there is of course no reaction. 
 ^ HCl is now added until a reaction for free HCl takes place. If for 
 instance 1 c.c. y^ HCl must be added, the equation is 10 c.c. gastric filtrate, 
 with dimethylamidoazobenzol as indicator, required 1 c.c. -^ HCl to pro- 
 duce a reaction of HCL In terms of 100, HCl deficit=10. 
 
 Quantitative tests for lactic acid are not necessary. The chlorides 
 as a general rule are not tested. Since, however, their increase in gastric 
 carcinoma has been claimed, a quantitative estimation is at times called 
 for. The procedure is lengthy, and for its methods the reader is referred 
 to works on chemistry. 
 
 Test of Gastric Absorption. — The absorptive power of the stomach 
 may be estimated by the administration, when the organ is empty, of a 
 gelatin capsule containing 0.2 Gm. of potassium iodide. The saliva and 
 urine are tested at intervals of several minutes by the addition of a small 
 quantity of starch meal or a bit of starch paper and HCl. A positive re- 
 action is shown by the familiar blue color which normally should appear 
 in the saliva in six to fifteen minutes and in the urine in about fifteen 
 minutes. This test is of no great value. 
 
 Sahli's Desmoid Test. — More as a test of peptic activity than of 
 gastric absorption, this deserves mention and description. Recognizing 
 that peptic digestion as shown in the test-tube represents by no means the 
 
THE STOMACH AND INTESTINES. 207 
 
 conditions inside the stomach, many investigators have endeavored to 
 invent some capsule which would open and give out its absorbable con- 
 tents as a result of gastric digestion alone. Great trouble was experienced 
 for two reasons. First, osmosis between the contents of the capsule and 
 gastric juice took place through the animal membranes (proteid sub- 
 stances), and, secondly, many of the substances used were disintegrated 
 by the muscular action of the stomach. Sahli's invention consisted in 
 enclosing absorbable substances (iodoform and methylene blue) in a small 
 piece of rubber dam, tying them in with a strand of raw catgut. Osmosis 
 cannot take place through the rubber; raw catgut can only be dissolved 
 by the gastric contents resisting absolutely the pancreatic ferments. The 
 appearance of iodine in the saliva and methjdene blue in the urine is held 
 to indicate that the raw catgut has been digested by the gastric juice and 
 set the contents of the ''pill" free; hence the main value of the test is the 
 proof of the digestion of proteid and peptic activity. The details of the 
 desmoid test are as follows: 
 
 Iodoform .1 gramme and methylene blue .05 gramme are enclosed in 
 a square of rubber dam 2X2 cm. The rubber is stretched tightly to make 
 a small pill and its loose ends tied with catgut which has been previously 
 softened in water. All free hanging edges of rubber are trimmed off. 
 The pill properly formed should sink in water and should show no diffu- 
 sion of methylene blue when placed therein. Well made and tested in 
 this way a pill given during a full general meal, preferably at mid-day, 
 should sink to the bottom of the stomach and will not be carried off until 
 the end of digestion. In from 5 to 7 hours the first blue tingeing of the 
 urine from methylene blue takes place. Iodine can be determined in the 
 saliva or urine by shaking a small quantity of the respective fluid with a 
 few c.c. of chloroform and adding pure colorless nitric acid, a reddening 
 of the chloroform being the indicator of the presence of iodine. 
 
 Tests of the Motor Power of the Stomach. — Lavage. — The most 
 satisfactory test for gastric motility consists in the administration of a 
 Riegel test-meal and the washing out of the stomach at the end of seven 
 hours, when under normal conditions the organ will be found to have 
 emptied itself. After an Ewald test-meal traces of food should have dis- 
 appeared at the end of two hours. No remnants of an ordinary supper 
 should be found upon washing out the stomach the following morning 
 after rising at the usual hour. In atonic conditions and dilatation 
 remnants of partially digested food may be washed out not only at the end 
 of these periods but in extreme cases even at the end of two or three days. 
 
 The Salol Test. — Less reliable is the administration of one gramme 
 of salol in gelatin capsules directly after an ordinary meal. The urine is 
 voided at subsequent intervals of half an hour, one, two, three, and twenty- 
 seven hours, and the respective discharges preserved for examination in 
 separate vials. Each portion is then separately tested for the presence 
 of salicyluric acid by the addition of a small quantity of a solution of ferric 
 chloride, which develops in the presence of the acid a violet color. The 
 presence of salicyluric acid in the urine is the sign of the decomposition 
 of the salol into phenol and salicylic acid, and, as this takes place onh"- in 
 an alkaline medium, it is the indication that the salol has passed from the 
 
208 
 
 MEDICAL DIAGNOSIS. 
 
 stomach into the intestine, which with normal gastric motility takes place 
 in about one hour. A retarded reaction indicates impairment of motility, 
 a delay of twenty-four hours is suggestive of pyloric obstruction. This test 
 is not accurate, as it is impossible to determine in different individuals the 
 relative time consumed by the chemical changes in the intestine and the 
 elimination by the kidneys. Moreover, the salol may go out of the stomach 
 not with the first portion of the food but with the last. Normally all of 
 the salicyluric acid should have been eliminated within twenty-seven hours, 
 (c) Microscopical Examination of Gastric Contents. — With the 
 ordinary Ewald test-meal little is to be learned by microscopical exami- 
 nation. Starch granules, a few epithelial cells, and bacteria are usually 
 seen. If there has been much trouble in passing the tube a few blood-cells 
 may be found. With a mixed meal or in vomited material starch, potato 
 
 Fig. 86. — K, free nuclei; Sp, spirals; Sch, 
 mucus; H, yeast-cells; E, epithelium; AE, alveolar 
 epi thelium . — Cohnheim . 
 
 Fig. 87. — E, epithelium; L, leucocytes; 
 RB, red blood-cells; F, fat-cells. — Cohnheim. 
 
 starch, fat droplets, and meat fibres are readily recognized. Many and larger 
 bacteria are seen, a few leucocytes are commonly met with, and in sedi- 
 ments deposited after standing, many large granular mononuclear cells. 
 In cases of acute gastritis considerable blood and pus may be found among 
 the stringy, transparent strands of mucus. In gastric ulcer, blood in the 
 test-meal or vomitus is common. It may be recognizable if the hemorrhage 
 has been recent. The hyperacid condition of the gastric juice in these 
 cases, however, destroys the blood-cells rapidly and chemical tests for the 
 blood are necessary. Tissue cells from the ulcerating area are often found. 
 In gastric cancer with lessened acidity blood-cells are less quickly destroyed, 
 but as a general rule the digestive juices rapidly alter the separate cells. 
 Small clots which have partially resisted the gastric juice form the sediment 
 in the characteristic "coffee-ground" vomitus of cancer of the stomach. 
 Occasionally small masses showing distinct adenocarcinomatous arrange- 
 ment may be found and are conclusive proof of the existence of cancer. 
 Small masses of tumor visible macroscopically are occasionally seen in 
 the vomit or washings from a caicinomatous stomach. 
 
THE STOMACH AND INTESTINES. 
 
 209 
 
 Of the bacilli present a majority are small, more or less motile, prob- 
 ably introduced with food. A few extra large organisms of the hay bacillus 
 group are always to be found. One should be careful not to consider these 
 large regular organisms as the form described by Oppler and Boas. The 
 latter are large, irregular club-shaped and vacuolated bacilli, possibly the 
 degenerate forms of the so-called gas bacillus, or of a special lactic acid 
 forming bacillus. They are most commonly found when lactic acid is pres- 
 ent, and under this condition have been considered as suggestive of cancer. 
 
 Einhorn's Bead-test of Digestive Activity. — Six small glass 
 beads are connected with a silk thread; to each bead is tied some par- 
 ticular sort of food. Raw catgut and a soft long-bone of a pickled herring 
 are the two substances used to test gastric digestion; raw meat, raw 
 thymus gland, mutton fat, and a cube of cooked potato test the intestinal 
 digestive power. The beads and thread can be placed together in a gela- 
 
 FiG. 88. — .S'^ starch-cells ; H, yeast- 
 cells; Sa, sarcinae; M, muscle-fibres; F, fat- 
 balls and droplets; K, potato-starch cells. — 
 Cohnheim. 
 
 Fig. 89. — H, yeast-cells ; M, muscle-fibres; 
 L, leucocytes with shrunken nuclei; B, Oppler-Boa.s 
 bacilli; St, starch-cells; F, fat; E, epithelium; A', 
 potato-starch cells with yeast-cells. — Cohnheim. 
 
 tin capsule and swallowed. Normally the beads should appear in the stool 
 in one or two days; their elimination earlier than this indicates accelerated 
 motility of the intestine; their appearance in the stool later than two 
 days after administration is held to indicate retardation of the fecal excre- 
 tion. All the beads should be empty, though traces of fat, thymus, and 
 fish-bone may be left undigested. Excretion of the catgut and fish-bone 
 undigested would indicate impaired gastric digestion. Excretion of undi- 
 gested meat, thymus, or fat indicates deficient intestinal digestion. The 
 silk thread is of course merely to facilitate the finding of the beads. 
 
 EXAMINATION OF THE INTESTINES AND F/ECES. 
 
 Only the lower bowel is accessible for direct examination of its inte- 
 rior. Inspection with the aid of proctoscopes, digital examination of the 
 rectum, and inflation of the colonic area enable us to investigate at least a 
 part of the large bowel directly. The remainder as well as the small intes- 
 tine can only be reckoned with through the abdominal wall by inspection, 
 14 
 
210 
 
 MEDICAL DIAGNOSIS. 
 
 palpation, percussion, auscultation, and radioscopy. On the other hand, a 
 careful examination of the faeces will tell us much as to function of the 
 intestines and as to the presence of abnormal conditions. 
 
 Inspection as apphed to the examination of the intestines ma}^ be,^ 
 as we have said, direct when we are dealing with the large bowel; the 
 proctoscope and the rectal tubes ahowing inspection of the mucous mem- 
 brane practically to the splenic flexure of the colon. The tubes or specula 
 come in varying sizes, usually four in a set, ranging from -i to 14 inches 
 (14 to 35 cm.) in length and from 1 inch diameter in the short speculum 
 to i inch diameter in the longer. They are provided with obturators. 
 Their use is associated with considerable pain, though with persistence 
 and gentleness most patients can go through the performance without 
 an ansesthetic. Warming and oiling the instruments thoroughly will 
 overcome some of the cUfficulties. After the sphincter muscle of the anus- 
 has been stretched and dilated the discomfort lessens. Either the knee- 
 chest or the recumbent posture with the knees elevated may be used. 
 Too much elevation of the lower part of the body will naturally by gravity 
 
 send the bowel away 
 from the examiner. The 
 electric headlight with 
 reflector facilitates ex- 
 amination. Very little 
 trouble is experienced in. 
 straightening out the 
 sigmoid flexure, nor dO' 
 the valves of the rectum 
 interfere with the prog- 
 ress of the speculum. 
 It is common to find that the bowel dilates perceptibly with air when 
 the speculum is in place, thus materially aiding the examination. 
 
 In the more modern rectoscopes and sigmoidoscopes the distal end is 
 so arranged that air can be forced into the bowel in front of the advancing 
 tube. A glass shield near the distal end allows the observer to look into 
 the bowel and at the same time keeps in the injected air which balloons 
 the bowel for several inches. A small electric hght arranged in front of the 
 tube gives a clear view of the mucous membrane. 
 
 Inspection with the proctoscope or rectoscope may show us first 
 the presence of scybala, beyond reach of the palpating finger, revealing 
 themselves often as hard, adherent, though detachable, masses of vary- 
 ing size, dark in color, or gray if covered by mucus, and usually easily 
 indented or broken away with a probe, and readily differentiated from 
 polypoid and other growths; second, ulcerating and bleeding points, 
 dilated venules, fistulous communications, thickening and reddening of 
 the mucous membrane of the bowel; general reddening of the whole sur- 
 face in colitis, showing mucus, glairy or dense and white if the condition 
 of mucous colitis is present, and often in large amounts; third, polypoid 
 growths, malignant growths in the form of local thickening, strictures, 
 foreign bodies, ulcerating tumor masses; fourth, obstructions outside the 
 bowel, tumors of uterus, ovary, etc., preventing insertion of the examining 
 
 Fig. 90. — Rectoscope. 
 
THE STOMACH AND INTESTINES. 211 
 
 tubes. It is usually considered permissible and advisable to remove 
 small particles of suspicious growths for microscopical examination. 
 
 Examination of the bowel by means of bougies may at times help in 
 diagnosing a stricture, particularly if the feeling of distinct resistance and 
 the sensation of passing an obstruction can be appreciated repeatedly at 
 the same point both during the introduction and withdrawal of the sound. 
 
 Palpation as a means of examination in regard to the intestine has 
 but limited direct application, namely, the examination of the rectum 
 by the finger, or if the sphincter can be dilated by two fingers or the whole 
 hand. Examination is always facilitated by a previous good clearing out 
 of the lower bowel. The forefinger of either hand may be used and various 
 positions employed. The examiner, however, reaches a higher point in 
 the bowel if the patient lies on his side with his knees drawn up to a mod- 
 erate extent. In this posture more freedom is given the introduced finger, 
 and the rotation of the hand and finger in examining the sides and front 
 of the rectum much aided. The knee-chest position is also convenient. 
 
 To avoid the unpleasant fecal odor it is advised to fill the space be- 
 tween one's nail and finger with a little moist soap and to follow this by a 
 free greasing of the finger with oil or vaseline. A finger cot can be used. 
 
 After inspecting the anus and neighborhood for fissures, fistulas, 
 hemorrhoids, exuding blood or pus, etc., the finger is gently inserted, 
 overcoming gradually the spasm of the sphincter which always occurs 
 and which must not be taken for a stricture. The tight grip of the muscle 
 on the finger relaxes during the examination and gives considerably more 
 freedom of movement. Examining as a routine the prostate and bladder, 
 or the uterus, one may at once exclude or determine conditions affecting 
 those organs; then, sweeping around to either side one feels for points of 
 tenderness, irregularities on the smooth wall of the bowel, dilated veins, 
 fistulous communications, polypi, etc. The finger is then turned toward 
 the back of the rectum. The position and condition of the coccyx should 
 always be determined during any rectal examination. Various obstetrical, 
 genito-urinary, and gynaecological examinations may be made by w^ay of 
 the rectum. The fact that impacted ureteral calculi can at times be per- 
 ceived by the examining finger if caught in the bladder wall or in the 
 neighborhood of the pelvic brim must be mentioned. Too little considera- 
 tion is given to a rectal examination in appendicitis and appendicular 
 complications. An appendix abscess extending downward, though often 
 painless, is frequently associated with an extreme tenderness when touched 
 by the examining finger. This tenderness is usually too localized to be 
 confused with any general abdominal distress, and its high position to the 
 right is of diagnostic significance. 
 
 The examining finger has first l-L^' inches of contracted sphincter 
 area to overcome. A slow inserting movement dilates the muscles with- 
 out pain, and allows the examiner and patient to appreciate localized 
 tender areas, such as are occasioned by fistulae, or ulcerations of hemor- 
 rhoidal veins. A forcible dilatation would readily, by the pain occasioned, 
 prevent the disclosure of many of these minor conditions. Beyond the 
 sphincters the finger has free play and at times one fails to touch any 
 part of the bowel, the rectum being ballooned by flatus; by crooking the 
 
212 MEDICAL DIAGNOSIS. 
 
 finger one touches readily the rectal wall. It is at times possible to dis- 
 tinguish emptied fallen coils of small intestines in the pelvis by rectal 
 examination; such a condition may take place when a complete stricture 
 has occurred high up in the small intestine, the empty tract below col- 
 lapsing and descending. 
 
 Indirectly both the small and large bowel can be examined through 
 the abdominal wall by inspection and palpation. Auscultation has but a 
 doubtful bearing on abdominal conditions; even marked intestinal dis- 
 orders may yield nothing to the most experienced. On the other hand, 
 correct interpretations of simple existing phenomena may give most 
 important results. Inspection is always preferably performed with the 
 patient lying on his back, with his knees either flexed or extended. (See 
 Methods of Physical Diagnosis.) 
 
 Examination of the large intestine and the csecal region is helped by 
 the easily applied method of inflation. Before this procedure a thorough 
 purging is always advisable. The soft rubber rectal tubes, i to i inch in 
 diameter, with two or more lateral openings, and connected with a David- 
 son syringe or a double or single atomizer bulb, can be inserted to any 
 distance desired. A slow twisting insertion will quickly put the openings 
 above the anus and sphincters. Since the sigmoid flexure is the most 
 commonly dilated part of the bowel, inflation should begin while the tube 
 is entering the flexure, and the first examination directed to this part. 
 Unless previously distended by gas or continued fecal accumulations the 
 sigmoid flexure should not rise easily out of the pelvis during inflation. 
 Usually when a point half way between the groin and the umbilicus is 
 reached distinct discomfort is felt unless relieved by passage of the air 
 upward. In many instances it will be found that the inflating air passes 
 readily beyond the sigmoid and shows its presence in the descending and 
 transverse colon. It is now generally conceded that the ileocsecal valve 
 allows air to pass during the process of inflation and its passage can at 
 times be heard with the stethoscope applied in the right iliac fossa. 
 
 To further inflate the colon the rectal tube may be passed upward 
 its whole length; we cannot be sure, however, that it will pass beyond 
 the splenic flexure nor could further passage be expected. Inflation of 
 the transverse and ascending colon and of the caecum take place quite 
 readily with the tube in this locahty. The pain of extreme distention will 
 always warn the operator when to temporarily moderate the air-pressure, 
 which, however, is usually reheved at this stage by the passage of air 
 upward through the ileocsecal valve. Detaching the rectal tube from the 
 inflating apparatus aflows the bowel to return to its normal state, by 
 expelling the contained air. 
 
 Carefully applied inflation in connection with inspection and palpa- 
 tion may give important results. Idiopathic dilatation of the sigm.oid 
 flexure can be readily differentiated from abdominal distention due to 
 other causes, the sigmoid clearly outlining itself as it rises from and descends 
 again into the left iliac fossa, often overlying the rest of the abdominal 
 contents in its sweep upward and to the right. Tumors, malignant or 
 other strictures of the bowel, fecal accumulations may be brought up from 
 the pelvis into sight and touch. The position of the colon and caecum can 
 
THE STOMACH AND INTESTINES. 213 
 
 be readily outlined, visibly in thin subjects, by percussion and palpation 
 in those stouter and more muscular, although the examiner can always see 
 that inflation is going on by the puffing up of the various regions. One 
 must know that at both the splenic and hepatic flexure the bowel will be 
 less prominent than elsewhere. The same pathological conditions men- 
 tioned in connection with the sigmoid flexure may be shown in the colon. 
 One would naturally expect that complete strictures from any cause 
 would prevent passage of air upward or downward. In such cases the 
 distention and condition (muscular hypertrophy, visible peristalsis) above 
 the stricture may tell us as much or more than inflation from below; and 
 further, in such conditions the diagnosis is rarely in doubt. Incomplete 
 or partial strictures, whose symptoms may be very obscure, are at times 
 clearly brought out by the rapid inflation from below, as a sudden nar- 
 rowing above the dilated lower part. 
 
 Easily recognized is the displacement of the colon, particularly the 
 transverse colon in enteroptosis. The transverse colon may lie below 
 the umbilicus, or even in the pelvis, the common appearance on inflation 
 being a shallow V-shaped protuberance, the arms of the V running up to 
 the liver and spleen. The relation of the bowel to retroperitoneal and 
 other tumors is more easily determined by inflation than by any other 
 means. Inflation of the bowel above the ileocsecal valve doubtless may be 
 of value. Its application has given but uncertain results. Inflation of 
 the bowel as a test for perforation is now universally condemned. Many 
 cases of flatulence supposedly due to gastric distention can be found to be 
 due to distention of the colon. Inflation is a valuable aid in the differ- 
 ential diagnosis of these conditions. 
 
 RoNTGEN-RAY EXAMINATION OF THE INTESTINES. — Large and Small 
 solid tumors, thickening and muscular hypertrophy can at times be 
 made out by the fluoroscope or in skiagrams. The data obtained by this 
 method are, however, usually confirmative of facts elicited by the anam- 
 nesis and the above described methods. Scybalous masses present no 
 different shadow from that of organic disease. Lining the intestine by 
 continuous doses of bismuth allows the coils to be readily photographed, 
 and under this condition peristalsis can be readily observed by the fluoro- 
 scope and the rate of progress of fecal matter observed. More feasible 
 and of distinct value in recognizing displacements of the colon is the 
 injection of suspensions of bismuth in large quantities. Very serviceable 
 photographs can be secured by this method. Localization of small metallic 
 or other solid foreign bodies in the intestines is remarkably facilitated by 
 the X-rays. 
 
 So-called "test lavage" is used at times to bring away secretion or 
 material from the large bowel: mucus, blood, ulcerating fragments of new 
 growths. The examination of the sediment of such washings at times 
 gives distinct help. It can only be satisfactorily performed when the large 
 bowel has been previously completely emptied. 
 
 It has been suggested that dilatation of the duodenum, with stricture 
 beyond, can be diagnosed by filling the stomach and duodenum with water 
 through a stomach-tube. Dulness and distention toward or in the right 
 hypochondrium and the fact that the fluid may return as does the fluid 
 
214 MEDICAL DIAGNOSIS. 
 
 from an hour-glass stoniacli, part at once and the rest a few minutes later, 
 is . considered suggestive. An inflation that outlines the stbmach and 
 produces an extra prominenc'e in the right hypochondrium would be 
 equally suggestive. 
 
 Fffices. — The accurate determination of many points with regard to the,-* 
 faeces is difficult, owipg to xhe wide A'ariations in their composition and to 
 the fact that the establishment of a normal or standard bowel movement 
 requires the continued administration of certain standard diets for several 
 successive days.^ 
 
 I^arious standard diets are recommended, the simplest being milk, 
 since it contains fat, proteids, and carbohydrates. 
 
 1. Milk, '8 oz. every two hours from 8 a.m. to 10 p.m., amounting to 
 4 pints in the twenty-four hours. 
 
 2. That of Schmidt is more complicated, but approaches more nearly 
 a general diet: 
 
 7.30 A.M. Milk, 17 J oz., and 6 biscuits. 
 
 9.00 A.M. Gruel, l| oz. oatmeal, 1 egg, 2 biscuits, | oz. butter, 7 oz. milk, 10^ oz. 
 
 water. 
 1.00 P.M. ]Minced beef, 4J oz. raw weight, lightly fried in J oz. butter, leaving the 
 , interior raw, and potato puree — 7 oz. mashed potatoes, 7 oz. milk, 
 J oz. butter. 
 4.30 P.M. Milk, 17^ oz. 
 7.30 P.M. Same as at 9 a.m. 
 
 3. A "mixed diet" is more liberal and better borne, but the neces- 
 sary cooking makes the eventual microscopical examination much less 
 satisfactory than either of the preceding: 
 
 8.00 A.M. 10 oz. hot water. 
 
 9.00 a.m. 3 oz. fresh fish, 4 biscuits, J oz. butter, 10 oz. tea, 2 oz. milk. 
 12.00 M. 10 oz. hot water. 
 
 1.00 P.M. 3 oz. mutton, 3 oz. cabbage, 4 biscuits, J oz. butter, rice pudding (h oz. 
 rice in 10 oz. milk). 
 
 4.30 P.M. 10 oz. tea, 2 oz. milk, 2 biscuits. 
 
 6.00 P.M. 10 oz. hot water. 
 
 7.00 P.M. 3 oz. fresh fish, 3 oz. chicken, 3 oz. spinach, rice pudding (as before), 2 
 
 biscuits, ^ oz. butter. 
 10.00 P.M. 10 oz. milk. 
 
 4. A meat diet: I lb. finely minced beef every three hours and 10 ounces 
 hot water one hour before meal-time. It contains no carbohydrates. 
 
 The first dejecta usuahy appear in from twenty-four to forty hours 
 after the standard meal has been given. Radioscopic examination of the 
 intestine and the passage of its contents shows that in about seven hours 
 the ileocsecal valve has been reached by part of the residue, which may 
 now remain four hours in the colon, three hours in the sigmoid flexure and 
 rectum before being expelled. 
 
 Attempts to describe bowel movements resulting from standard diets 
 have been made. 
 
 1. F^CES Resulting from Milk Diet. 
 
 Amount. — 
 
 Quantity of milk in 24 hrs. Faces excreted, average weight in Gm. 
 
 4 pints 135.2 Gm. 
 
 5 pints 151 Gm. 
 
 6 pints 198 Gm. 
 
THE STOMACH AND INTESTINES. 215 
 
 Color. — Yellow-white, or white tinged with orange. 
 
 Consistency. — Not well formed, tending to Be lumpy; rolls of fecal 
 matter not homogeneous but composed of lumps welded together, or firm 
 sausage-shaped masses plus soft paste. * . . 
 
 Odor. — Not offensive; more hke stale cheese than faeces. 
 
 If constipation exists, a tendency to isolated scybala of pale color is 
 seen, often firm, hard, and dry enough to rattle in tlie vessel, and to break 
 up like dry clay, with an earthy odor. 
 
 With diarrhoea a milk diet gives faeces resembling Devonshire cream — 
 sticky, but capable of being poured from one vessel to another. Gas bubbles 
 and froth are seen on shaking, and the odor is that of decomposed cheese 
 or putrid proteid. 
 
 Caseous fiocculi, the evidences of disturbed digestion, are readily 
 recognized as bright white, small, fibrillary-looking, friable masses. 
 
 2. F^CES Resulting prom the Schmidt Diet. 
 
 Amount. — Smaller "than that from the milk diet. Average 90 Gm. 
 
 Color.— Light brownish-yellow, darker on the outside than inside. 
 
 Consistency. — Well formed rolls or sausage-shaped masses, as a rule. 
 These readily break up on drying. 
 
 Odor. — Distinctly fecal. 
 
 In constipation on a Schmidt diet lumps of fecal matter are massed 
 together, or isolated scybala are seen. 
 
 In diarrhoea on this diet the fgeces resemble closely those of a patient 
 on a milk diet. 
 
 3. F^CES Resulting from a Mixed Diet. 
 Amount. — Average 102 Gm. 
 
 Color. — Nut-brown, olive-green (chlorophyll of vegetables), varies 
 much from day to day. 
 
 Consistency and Form. — Usually large, firm, roll or sausage-like motions. 
 On drying break up easily. 
 
 Odor. — Fecal. 
 
 In constipation the feeces of a mixed diet are usually dark brown or 
 black scybala with pressure facets and mucus in the crevices. They may 
 be of stony hardness and not offensive. 
 
 In diarrhoea the motions are dark brown or nearly black, of thick 
 sticky or pasty consistence with small scybala. Soft movements in general 
 from a mixed diet have most offensive odors. An increase of the quantity 
 of milk in mixed diets makes the stools paler and less firm. 
 
 4. Meat Diet. 
 Amount. — Average 54 Gm. 
 Color. — Dark brown to black. 
 
 Consistency and Form. — Firm rolls, 2 to 3 inches in length. 
 
 Odor. — Fecal but very offensive. 
 
 Variations in consistency and form, in odor, and in color naturally 
 depend on local conditions and the time the fecal material is retained in 
 the large bowel. The amount is important, but several days are required 
 to get the proper average. The formation of scybala, according to these 
 results, may take place in a very few days. 
 
216 MEDICAL DIAGNOSIS. 
 
 The faeces are composed of: 
 
 1. Food remains. 
 
 (a) Indigestible remnants. 
 
 (b) Digestible but not absorbed remains. 
 
 2. The remains of the digestive secretion. 
 
 3. Products resulting from the digestion of food in the intestinal canal. 
 
 4. Formed and unformed products of the intestinal mucosa. 
 
 5. Bacteria. 
 
 6. Various substances introduced accidentally from without; various 
 concrements, gall-stones, intestinal stones, parasites, cotton, wool, or linen 
 fibres. 
 
 The faeces are collected in a bed-pan or any large clean vessel. 
 
 In the study of any question of absorption or excretion the rule is 
 to place the patient on one of the standard diets for at least four days 
 before beginning any estimation. The administration of some coloring 
 matter such as charcoal or carmine with the first meals of the standard 
 diet will render easy the recognition of their first dejecta. 
 
 The faeces are to be examined macroscopically, microscopically, and 
 chemically. 
 
 Fermentation. — Normal firm bowel movements will usually dry with- 
 out appreciable gas formation, and even semisolid or pultaceous stools ordi- 
 narily produce only a small amount. A stool which on standing shows 
 evidence of fermentation by the production of gas bubbles or a distinct 
 frothy layer, or gas bubbles in such abundance as to give a pale appearance 
 to a more or less soKd stool, should be considered pathological and examined 
 for fermentable products — carbohydrates. 
 
 Excess of neutral fat in the stools can be readily noted. The normal 
 bowel movement leaves no greasy mark upon a vessel containing it. Neu- 
 tral fat will show itself in the gross examination either as a very pale, white, 
 distinctly greasy bowel movement, or if the stool be Hquid the fat may 
 rise to the top, forming the characteristic appearance of melted fat, and on 
 cooling may partially or completely solidify. The soaps in ordinarj^ amounts 
 and the fatty acids are not macroscopically recognizable. 
 
 Excess of proteids in the faeces, when in the form of meat, can often 
 be recognized by the appearance of numerous reddish points throughout 
 the bowel movement. One must be certain that other coloring or colored 
 matters have not been ingested. Casein shows itself as the familiar white 
 floccuh, easily disintegrated, much denser white than mucus. Undissolved 
 connective tissue has the appearance of fine cotton-wool fibres and can be 
 removed for further examination. Other substances to be considered in 
 the gross examination are mucus, blood, pus, foreign bodies, and parasites. 
 Small amounts of mucus are always present, but require search to demon- 
 strate their presence. A constipated stool often shows flakes of dense 
 white mucus in the interstices of the firm masses, or mucus may follow the 
 movement. 
 
 Brownish, gelatinous-look-ing mucus, colored by the bile pigments, 
 usually comes from the small intestine; colorless mucus and that appear- 
 ing as denser, whiter masses and flakes, from the colon. Tubular masses 
 from the large intestine, sometimes many centimetres in length, are seen 
 
THE STOMACH AND INTESTINES. 217 
 
 in membranous colitis. Floating or softening these masses or strands 
 in water will usually determine their character. Unformed mucus, par- 
 ticularly in liquid stools, sometimes on standing accumulates in masses 
 as large as a hen's egg. 
 
 Fresh blood can be easily recognized. Unless quickly voided, blood 
 in the intestines becomes black and small amounts do not show in the 
 stools. Large amounts appear as 'Harry stools" — large black masses, 
 clots too large to be broken up or absorbed. 
 
 Pus is usually quickly disintegrated. Fresh pus which retains its 
 appearance is practically always from the sigmoid or rectum. 
 
 Parasites are described in another section. Many food remains are 
 detected at a glance: fruit stones and seeds, skin of fruit, vegetables, food 
 pulp of oranges, grape fruit, lemons, large masses of connective tissue,, 
 bones, etc. 
 
 For the more careful examination various simple plans are recom- 
 mended. In examining the whole quantity of faeces an ordinary fine sieve 
 on which running water can play enables one to collect the larger foreign 
 bodies and soHd material; or the faeces are placed in a large vessel with 
 water and thoroughly broken up. Mucus, woody fibres, smaller seeds, and 
 bacteria float and can be removed by pouring off after settling. By repeat- 
 ing the process several times a residue of solid matter, deodorized and 
 decolorized, is obtained. Gall-stones, pancreatic calculi, muscle fibres, 
 connective tissue, casein, parasites, are easily looked for in this way. 
 
 Spreading the faeces on a glass plate with a dark background facilitates 
 the examination. Pieces of connective tissue, muscle fibres, casein, foreign 
 bodies, or anything differing from the homogeneous fecal matter may be 
 readily found in this way. 
 
 Microscopical Examination. — Mixed Diet. — A small piece of fecal 
 matter can be taken from the stool after it has been mixed in a mortar or 
 a vessel, or several loopsful of a liquid stool can be smeared on a slide. 
 A cover-glass is preferable if high power is used. For a low-power exami- 
 nation a glass 3 or 4 inches square on which a comparatively large amount 
 of fasces has been thinly spread, can be placed on the stage of the microscope. 
 A large area can be quickly gone over in this way. 
 
 Masses of mucus, blood, or pus, meat fibres, etc., should be picked off 
 for separate examination before mixing the fecal material. Schmidt 
 recommends taking three separate specimens of softened faeces. No. 1 is 
 examined direct. In it we can note much fibre, colorless soaps, neutral 
 fat if present, small and large yellow salts of calcium. No. 2 is stirred 
 with a small drop of 30 per cent, acetic acid heated for a moment until 
 it begins to boil, then covered with a cover-glass. After cooling, small 
 flakes of fatty acids appear. The soap flakes and calcium salts will have 
 disappeared. No. 3 is rubbed up with a drop of Lugol's solution. Under 
 the microscope unaltered starch will assume a violet color. 
 
 Since 85 per cent, or more of the food is digested and absorbed, and 
 since of the remainder a portion is in the shape of products — albumoses, 
 fatty acid, soaps, dextrin, etc., little unaltered food is present in the speci- 
 men. Easily recognized are the bacteria which make up practically one- 
 third of the dry substance of the stool. Acid-fast bacilli may be tubercle 
 
218 MEDICAL DIAGNOSIS. 
 
 or smegma bacilli. Leptothrix threads are easily recognized. Epithelial 
 cells in considerable numbers are always present. They are usually of the 
 smaller round type, and show evidences of digestion or disintegration. 
 No deduction can be drawn from their number or form as to conditions in 
 the bowel. Squamous epithelia from the mouth or from the food are 
 occasionally seen. Structureless or faintly striated mucus in small amounts, 
 bile-stained if from parts high up, pale if from lower down, may, by the 
 number of leucocytes or epithelial cells entangled in it, give evidence of 
 catarrhal conditions of the bowels. Mucus is less dense, less sharp in outline 
 than connective tissue; acetic acid causes it to show faint striations. A 
 few leucocytes are always present. 
 
 Food Remains. — Undigestible remnants of any kind may appear. 
 Many of them are recognizable macroscopically. The framework of vege- 
 tables gives most varied pictures. Many of the structures suggest parasites 
 and have frequently been mistaken for them. Remnants of undigested 
 starch may be suspected by their pallid color and their cellular envelope. 
 It is well to stain suspicious specimens with iodine and look for the blue 
 stained masses; to judge whether starch is being excreted in excess is not 
 easy with the microscope; the fermentation test is the more accurate 
 method. 
 
 Two or three small meat fibres in a field, showing very dim or no stria- 
 tion, and with no remnants of nuclei, may be considered normal in patients 
 on a mixed diet. Retention of the striation, persistence of the nuclei in 
 good condition, and presence of meat fibres in numbers suggest disturbance 
 of intestinal digestion, particularly that part related to the pancreas. It 
 is not likely that anacidity of the gastric juice will show the same condition. 
 Specimens from fsBces of patients with pancreatic derangements may show 
 meat fibres in such numbers that counting them in one field may be difficult 
 or impossible. Some cases show excess of meat fibres in the stools if over 
 60 grammes of meat are taken per day. 
 
 Schmidt's Nucleus Test for Pancreatic Disease or Impairment of Pan- 
 creatic Function. — The disintegration or non-disintegration of the meat 
 fibre nuclei in the centre of small balls of meat of standard size — | to * inch 
 in diameter — kept together by non-digestible netting and given in the food, 
 cannot be said to be positive enough for any certain deductions to be made. 
 We can only say that if all the nuclei, even those on the outside of the balls, 
 are found unaffected by digestion, pancreatic insufficiency is suggested. 
 Connective tissue and elastic tissue are constantly present on a mixed diet, 
 though in very small amounts. They are readily recognized by their dense 
 and fibrillated appearance. Gastric juice readily digests connective tissue, 
 and its persistent presence in large quantity must be taken as pointing to 
 impaired gastric digestion. A few fat drops may be found on a mixed or 
 meat diet, but more than eight to ten fat drops in a single field should 
 attract attention. This neutral fat is easily seen as yellowish, oily looking 
 drops of varying size and shape. Constant presence of the flakes of the 
 ■'higher melting point" fat, and the flaky needle-Hke crystals of the fatty 
 acids, or of the flake or disk crystals of the soaps, is to be considered as 
 abnormal. Gentle heating of the slide will dissolve the crystals and flakes 
 of the fatty acid and soap. Triple phosphate crystals, colorless and of 
 
THE STOMACH AND INTESTINES. 219 
 
 characteristic shape, neutral phosphate of Hme crystals, colorless, or the 
 yellow calcium salts (sometimes bile stained) are commonly found. Oxal- 
 ate of hme crystals are usual in a mixed diet. Their presence in the fseces 
 when no vegetables are being eaten is said to indicate some intestinal 
 disorder. Cholesterin crystals, Charcot-Leyden crystals, especially if much 
 mucin is present, are both found in the fseces. Very frequently present are 
 the so-called ''yellow bodies": large lumps of bright j^ellow material, 
 structureless, often surrounded by mucus, and recognized macroscopically. 
 They give a proteid reaction. They are considered to be albumin, bile 
 stained, and, when in great amount together with much mucus, indicate 
 some disturbance of proteid digestion. 
 
 Casein flocculi are seen microscopically as almost structureless 
 masses, finely fibrillated and enclosing fat droplets in their meshes. 
 
 Hairs, cotton and linen fibres, are common in the stools, being 
 taken in with the food in large numbers. 
 
 Chemical Examination.— In health 
 the fseces have a neutral or faintly alka- 
 line reaction. On standing this becomes 
 faintly acid. Stools with excess of car- 
 bohydrates ferment and give a strong 
 acid reaction. Excess of fat, fatty acid, 
 gives faintly acid stools. Decomposition 
 of excess of proteid matter produces an 
 alkaline reaction. A mixed diet in health 
 causes neutral faeces; a pure proteid diet 
 produces alkaline fseces; a pure carbo- 
 hydrate diet produces acid fseces; a diet 
 of fats produces acid fseces. Only freshly 
 
 1 r 1 1 • i J • A Fig. 91. — Charcot-Leyden crystals from the 
 
 passed fseces can be used m testing. A stools, x 4oo.— Emerson, 
 
 markedly acid reaction in fresh fseces 
 
 suggests fermentative changes from undigested carbohydrates. " Acid 
 diarrhoeas," so-called, may be associated with hyperacidity of the stomach 
 and insufficiency of the biliary and pancreatic secretion. 
 
 The test for hydrobihrubin or the bile products is important, since they 
 may be present in colorless stools. The fseces are stirred up with a concen- 
 trated solution of mercuric chloride; normal fseces are colored red; fseces 
 containing unchanged bilirubin become green. The pale stool of the leuco- 
 hydrobilirubin gives the red reaction. Absence of the red or green coloring 
 is seen in fatty stools with complete acholia. 
 
 Composition. — From 74 to 84 per cent, of the fseces is water; 16-26 
 per cent, is dry substance. Of the dry substance 10-20 per cent, can be 
 extracted with ether, i.e., are fats. Over 90 per cent, of fats taken in are 
 absorbed. 
 
 Fats. — Qualitative tests only can be considered. The fats are readily 
 detected macroscopically and microscopically. They are excreted as 
 neutral fats, soaps, and fatty acids. These have been described. Crystals 
 and flakes melt readily. Extracting a small mass of fseces with ether and 
 pouring the ether through a piece of filter paper will, if fats are in excess, 
 give the characteristic appearance of oil on the paper. 
 
 • ■•-, ', 
 
 \ ■-' - 
 
 - \ , ^ 
 
 f, 
 
 
 
 / 
 
 -/ . 1 - ■ 
 
 
 \ 
 
 '•" ^\~'~*- 
 
 ■ ^^-. \ 
 
 
 ijC/::: ■( :, 
 
220 MEDICAL DIAGNOSIS. 
 
 From 2 to 6 per cent, of the dry substance is carbohydrate, usually 
 dextrin. Tincture of iodine or Lugol's solution will stain unaltered starch 
 blue; dextrin remains red. There is no reaction for sugar. Fermentation 
 is the simplest test for excess of carbohydrate or carbohydrate residue. 
 Schmidt's fermentation tube may be employed or one may note carefully 
 the presence of gas formation in the freshly passed stool. 
 
 Proteids. — More than 85 per cent, of proteids taken into the body are 
 absorbed. The proteid residue in health is partly from the food, partly 
 from the disintegration of proteids of the body — leucin, tyrosin, indol, 
 skatol, mucin, nuclein. Albumin and globuHns, and their transformative 
 products, albumoses, peptones, are not found normally. Their presence in 
 the stools means either insufficient proteid digestion and absorption, or that 
 the '^ postdigestive putrefaction" in the large intestine has not had time to 
 take place. The simple tests for albumin and albumose can be applied after 
 dissolving, mixing a small amount of fecal material in water, and filtering. 
 Any inflammatory condition of the lower bowel will jdeld albumin in the 
 faeces. Serous exudation higher up may undergo the natural digestive proc- 
 esses. Persistent intense diarrhoea, choleraic diarrhoea, can hurry materials 
 through before digestion of albumin or albumoses has progressed, and faeces 
 from these conditions may give albumin reactions from food taken or from 
 serous exudation into the bowel as in typhoid fever, cholera, or dysentery. 
 
 "Total nitrogen" estimations are necessary to determine the relation 
 of proteid output and intake. As of the fats and carbohydrates one can 
 say of the proteids — for clinical purposes macro- and microscopical exami- 
 nations jrield more useful information. 
 
 Digestive ferments are not found. The pigmentary remains of the bile 
 have been spoken of. Mention has been made of the various salts and crys- 
 tals, phosphates, oxalates, cholesterin, etc., visible microscopically, remains 
 of food digested, or of digestive procedure. Chemical tests show presence of 
 bile salts, bile acids, leucin, tyrosin, xanthin, carnin, and proteid derivatives. 
 
 The most important chemical test for practical purposes is the test 
 for blood. Teichman's acid-haemin test may be used, but others are simpler 
 and more certain. They all depend upon altered haemoglobin reactions. 
 No examination of faeces can be considered complete unless a blood test 
 has been made; since occult bleeding may go on indefinitely with no gross 
 signs of blood in the faeces and no blood-corpuscles to be seen microscopi- 
 cally. All bleeding from the nose, gums, pharynx, lungs, and vagina must 
 be excluded. No meat can be taken during the days on which the faeces 
 are tested. It is best to wait for forty-eight hours or to mark a food period 
 by giving charcoal, lycopodium, or carmine. 
 
 To perform the test we must first remove gross fat by shaking with 
 ether; otherwise the final ether extract may be clouded. This is poured 
 away and the residue is used. 10 c.c. of fluid faeces or 5 c.c. of soHd faeces, 
 broken up in 5 c.c. water, are treated with 3 c.c. glacial acetic acid, thor- 
 oughly mixed and shaken. This dissolves red blood-cells and sets free 
 haemoglobin or makes acid haematin. After standing a few minutes excess 
 of ether, 20-30 c.c, is added and the mixture vigorously shaken and then 
 allowed to separate. The overlying ether is poured off and the tests made 
 with it as follows: 
 
UPPER AIR-PASSAGES AND EAR. 221 
 
 Turpentine-Guaiac Test. — To a few cubic centimetres of the above 
 ethereal extract previously treated with a httle alcohol are added 10 drops 
 of freshly made guaiac tincture and 30 drops of turpentine. In the 
 presence of blood pigment a distinctly blue color occurs. Sources of error 
 are the recent eating of potatoes or other starchy food, iron as a medicine, 
 or the presence of bile, sahva, milk, pus in considerable quantities, and 
 urobihn. The reaction may fail in the presence of minute traces of blood. 
 
 Aloin Test. Klinge and Shaer. — This test is extremely deHcate. Foods 
 containing haemoglobin and all vegetables and drugs must be avoided for 
 several days. The diet period must be determined by charcoal or lycopo- 
 dium, not carmine. From 1 to 1.5 c.c. of turpentine are superimposed and 
 then 0.5 c.c. of freshly made 3 per cent, aloin solution. The reaction con- 
 sists in the rapid development at the hne of contact of a bright rose-red 
 color. ■ In a doubtful case both these tests may be used and repeated 
 several times. 
 
 In ulcerating carcinoma ventriculi, occult blood is continually present 
 in the stools; in ulcus ventriculi there are intervals in which no occult 
 blood can be detected; in intestinal tuberculosis it is absent; in enteric 
 fever it may occur in the absence of gross hemorrhage or may antedate 
 the latter by twenty-four or forty-eight hours. 
 
 IV. 
 
 THE EXAMINATION OF THE UPPER AIR-PASSAGES AND 
 
 THE EAR. 
 
 RHINOSCOPY. LARYNGOSCOPY. OTOSCOPY. 
 
 General Considerations. — Local affections of the nose, throat, or ears 
 may give rise either to local or constitutional symptoms, while constitu- 
 tional diseases frequently produce local manifestations. For this reason 
 a fair degree of dexterity in the use of the mechanical means by which we 
 are enabled to distinguish between the manifestations of local and con- 
 stitutional diseases, as observed in these organs, is of no less importance 
 to the general clinician than to the specialist. 
 
 The instruments ordinarily employed in a simple examination of the 
 nose, throat, larynx, or ear are a head mirror for reflection of light, tongue 
 depressor, laryngeal mirror, and nasal and aural specula. They require 
 no special description. They are of varied designs, but any instrument to 
 which the physician has become accustomed will usually meet the require- 
 ments of ordinary cases and most of them are amply efficient in the hands 
 of the skilled examiner. 
 
 Of far greater importance than the kind of instrument to be employed is 
 its careful manipulation. Every instrument must be carefully cleansed both 
 before and after using, alike for the actual necessity of cleanliness and the 
 
222 MEDICAL DIAGNOSIS. 
 
 reassurance it gives the patient. The speculum should be slightly warmed 
 over a spirit flame or gas burner before introduction into the nose or ear. 
 Either natural or artificial light, if sufficiently strong, can be con- 
 densed and reflected by the mirror to the point or area to be examined,, 
 and the source of the light may be either to the right or left of the patient.. 
 
 The Examination of the Nose. 
 
 Anterior Rhinoscopy. — Externally around the margin of the nares 
 may be noted excoriations, usually produced by acrid secretions, exces- 
 sively acid or alkaline, which occur in the course of the various infectious 
 diseases, colds, nasal hydrorrhoea, syphilis, etc. True rhinoscopy has to 
 do with the examination of the interior of the nose, for which purpose it 
 is necessary to dilate the nostrils, one at a time, with a bivalve speculum, 
 using care to avoid injury to the mucous membrane with the points of 
 the instrument, or unnecessarily annoy the patient by overdistention. 
 
 Structures Observed. — Under normal conditions, the patient sitting 
 erect before the operator, with the head tilted slightly backward, the 
 distended alee should present clearly to view the lower turbinates, the 
 middle and lower -meati on the outer walls, the area opposite to these on the 
 septum, and the floor. This constitutes about the lower third or respir- 
 atory portion of the nares. The area just within the nares on the lower 
 anterior margin of the septum should be especially examined as the most 
 frequent location of the source of hemorrhage, four-fifths of the cases of 
 spontaneous epistaxis originating in this area. 
 
 Tilting the patient's head backward brings into view the upper or 
 olfactory portion of the nostrils, the middle turbinate and superior meatus, 
 rarely a small portion of the superior turbinate, the close proximity of the 
 septum and outer wall preventing an exposed view of the ethmoid and 
 sphenoid area, superior turbinate and points of entrance to the frontal 
 sinus. It is this space that we frequently find bathed in pus in the case 
 of purulent sinusitis, ethmoiditis, or antrum disease. As a rule, an accumu- 
 lation of pus above the middle turbinate is an indication of disease of the 
 ethmoid or frontal sinus, while if pus collects beneath the middle turbinate 
 its source is probably from the antrum of Highmore. In case the whole 
 naris is bathed in the purulent secretion, first cleanse the nostril, then 
 have the patient lean forward or turn the head well toward the side 
 involved in order to favor the discharge of fresh pus and determine its origin 
 more clearly. Nasal polypi are also most frequently found originating 
 in this part of the nares, arising from the marginal mucosa of a turbinate 
 which has undergone mucoid degeneration, from necrotic tissue in the 
 ethmoid cells; or less frequently from the sphenoid sinus, which lies slightly 
 below and posterior to the ethmoid cells. Beneath the middle turbinate 
 is the only natural opening into the antrum of Highmore — the ostium 
 maxillare — which, however, in many cases is so obscure as to be found 
 with difficulty even by experienced rhinologists. There are occasionally 
 two or more openings and they may enter the antrum at variable points, 
 even as high as the floor of the orbit. The inferior meatus is important 
 for two reasons: first, it is beneath the lower turbinate that we find the 
 
UPPER AIR-PASSAGES AND EAR. 
 
 223 
 
 nasal opening of the lachrymal duct, which may become occluded from 
 either an acute or chronic enlargement of the turbinate; second, because 
 of the thinness of the bony wall dividing the nares from the antrum of 
 Highmore, through which a cannula may be easily introduced for diag- 
 nostic purposes in suspected purulent infection of the sinus. 
 
 If on first looking into the nose the view is obstructed by an intumes- 
 cent condition of the membrane, which is found in nearly every local con- 
 gestion, whether active or passive, th2 difficulty of obtaining a satisfactory 
 view will be greatly obviated by the introduction of a small pledget of 
 cotton dipped into a solution of cocaine and camphor, each two grains to 
 the ounce of liquid albolene. The objection to 'the adrenalin preparations 
 in examination is threefold: first, it frequently acts as an irritant, throw- 
 ing the patient into a violent state of sneezing; second, by the intense 
 
 Rear of 
 Choana pharynx 
 
 Septum Choana 
 
 Upper turbinate bone 
 Promontory of tube 
 
 Rosenmiiller's fossa 
 
 Middle turbinate bone 
 
 Opening of Eustachian 
 
 tube 
 
 Lower turbinate bone 
 
 Upper turbinate bone 
 
 Promontory of tube 
 
 Rosenmiiller's fossa 
 Middle turbinate bone 
 
 Opening of Eustachian 
 
 tube 
 
 Lower turbinate bone 
 
 Soft palate 
 
 Uvula 
 Fig. 92. — Normal posterior nares, view obtained by repeated change of the mirror. 
 
 bleaching of the membrane; and, thirdly, because of the aggravated con- 
 gestion which follows its use. All the accessory cavities herein referred 
 to are in direct communication with the nares; each sinus or cell is lined 
 by mucous membrane, somewhat modified in character from that in the 
 nasal chambers, and any inflammatory process in one cavity may cause 
 more or less irritation in one or all of the others. 
 
 Posterior Rhinoscopy. — To examine the nasopharynx there are needed 
 a head mirror, tongue depressor, and rhinoscopic mirror. Some persons 
 are able to depress their tongues by voluntary muscular efTort, in which 
 case the depressor is not needed. There is also a great difference in the 
 ability of individuals to relax the soft palate at will, thus allowing an 
 unobstructed vision in the mirror of the vault of the pharynx and the 
 posterior nares. The process of such examinations will often require great 
 patience if the pharynx be hypersensitive, since the slightest touch with 
 the mirror may produce gagging. 
 
 Let the patient sit comfortably in the chair and assure him that there 
 will be nothing connected with the examination to cause either pain or 
 
224 MEDICAL DIAGNOSIS. 
 
 discomfort. There is a general tendency to hold the breath and strain on 
 the pharyngeal muscles. To obviate these difficulties explain that it is 
 important to allow the mouth to open widely and easil}^, without the 
 slightest tension of the jaw, leaving the tongue at rest in its natural posi- 
 tion, and to breathe quietly and freely through the mouth. The prob- 
 abiHty is that after this reassurance the soft palate will relax to its normal 
 position. A common difhculty consists in the involuntary retraction of 
 the soft palate tightly against the pharyngeal wall as soon as the mirror 
 approaches the mouth, and its retention in that position until the mirror 
 is withdrawn. This frequently can be obviated by having the patient close 
 his eyes. Should this fail, the most satisfactory recourse left is cocainiza- 
 tion to a degree sufficient to relieve the hypersensitiveness, when with a 
 long applicator, bent at right angles, making a hook about three-fourths 
 of an inch long on the end, the soft palate may be gently drawn for- 
 ward, and the rhinoscope placed in position to reflect the image desired. 
 It is always better to twist a small piece of cotton on the retractor, 
 which being dipped into a bland oil will prevent injury to the mucous 
 membrane. 
 
 Structures Observed. — With the rhinoscope just below and posterior 
 to the margin of the soft palate, and with a strong light, the angle of 
 reflection in the mirror may be so directed by manipulation as to show suc- 
 cessively all the structures in the nasopharynx, viz., the Eustachian orifices 
 on the extreme outer margins, and just above and slightly posterior to 
 these the fossse of Rosenmiiller, which are occasionally obstructed b}^ 
 adhesive bands; in each naris are seen the middle and lower turbinates, 
 the latter being indistinct except over its upper half; and directly pos- 
 terior and below the posterior margin of the septum on the pharygneal 
 wall is the usual position of the pharyngeal tonsil or adenoids. Since this 
 lymphoid structure under normal conditions undergoes atrophy about 
 the age of puberty, when observed in adults, or when sufficiently large 
 in children to interfere with nasal respiration, it should be regarded as 
 pathologic. Polypoid growths in the nasopharynx originate usually from 
 mucoid degeneration of the posterior margins of the middle or superior 
 turbinates or from the posterior ethmoid cells; fibromata, sufficiently 
 large to ffil the entire vault, suspended by a small pedicle and hanging 
 low enough in the oropharj^nx for the lower margin to be seen by direct 
 vision, are not infrequent!}^ observed. Posterior rhinoscopy is seldom 
 accomplished in children with any degree of satisfaction, in which case 
 ocular inspection must be supplanted by digital examination. 
 
 Laryngoscopy. 
 
 For the examination of the laryngopharynx, larynx, and trachea 
 the same instruments are required as those used for posterior rhinoscopy, 
 and the same precautions toward preventing nervousness on the part of 
 the patient during examination are of even greater importance. The 
 tongue depressor will not be needed in all cases, since in some a better 
 view can be obtained by grasping the tip of the tongue with a towel or 
 handkerchief and drawing it well out and downward, using care not to 
 
UPPER AIR-PASSAGES AND EAR. 225 
 
 cause pain underneath the tongue by too forceful traction over the lower 
 teeth. In still others the patient may be able voluntarily to depress 
 the tongue. 
 
 The oropharynx is examined by direct inspection. The appearance 
 and color of the mucous membrane of the posterior pharyngeal wall vary 
 greatly according to the condition of the gastro-intestinal tract. The 
 redness frequently observed along the anterior borders of the faucial 
 tonsillar pillars in gouty or lithajmic individuals is a sign of diagnostic 
 importance. This may vary in color from a dark pink blush to a purplish 
 crimson, and may be regular in outline or occasionally present the appear- 
 ance of petechial spots, particularly on the uvula. Another phenomenon 
 often observed is indicative of either acute or chronic inflammatory Eus- 
 tachian or middle-ear involvement. It consists of a prominence or bulging 
 of the postpharyngeal wall, evidently an inflammatory infiltrate, just back 
 of the posterior faucial pillar on the same side as that of the affected ear. 
 
 In the examination of the laryngopharynx the laryngoscope is used. 
 Observe the base of the tongue carefully to detect the presence of an 
 enlarged lingual tonsil, which gives rise to various annoying symptoms, 
 most prominent of which is the constant accumulation of mucus about 
 the glottis and the resulting pharyngeal tenesmus. Occasionally this 
 mass of tonsillar tissue is sufficient to press the epiglottis downward and 
 thus interfere with the examination of the larynx proper. 
 
 Foreign Bodies. — The most frequent locations of foreign bodies, 
 such as broken bits of toothpicks or match-sticks, fish-bones, tooth-brush 
 bristles, etc., in the laryngopharynx are the glosso-epiglottidean pouches 
 at the base of the tongue, or else in the sinus pyriformis which lies partially 
 posterior to and on either side of the glottis. The patient's sensation of 
 locality of a foreign body in such a position is frequently misleading; for 
 instance, a fish-bone or bristle sticking in the base of the tongue may 
 give the sensation of being farther down in the larynx, or perhaps even 
 in the nasopharynx. 
 
 Examination.— A strong, well focussed light is essential, and whether 
 the patient be in the sitting or recumbent position, the head must be well 
 extended and free breathing through the mouth insisted upon. The auto- 
 scope, an instrument devised some years ago for the purpose of making 
 direct inspection of the larynx, is not generally employed at the present 
 time. Proceeding with the usual method, the patient's tongue is depressed, 
 or drawn outward, the laryngoscope is carefully introduced into the upper 
 laryngopharynx in a manner that will push the uvula backward out of 
 range of the reflected laryngeal image. The best angle of reflection can 
 be determined according to the case in hand, the epiglottis, owing to its 
 variability both in point of shape and position in different individuals, 
 being the principal obstacle to a clear view of the underlying structures. 
 This difficulty, however, can best be obviated by the influence which the 
 effort on the part of the patient to produce certain vocal tones has upon 
 the position of the larynx. Two vocal sounds are utilized; first, the classic 
 "ah," during the intonation of which the larynx is in the most natiu'al 
 relation to the surrounding structures at rest, except for the fact that the 
 cords are approximated or in the position of phonation. With the parts 
 
 15 
 
226 MEDICAL DIAGNOSIS. 
 
 in this position there will be reflected in the laryngoscope the edge of the 
 epiglottis and a narrow margin of its underlying surface, the arytenoids,. 
 and the posterior half of each vocal cord, which appears in the mirror as 
 the inferior half. 
 
 The same relation will still be preserved if the patient now be 
 instructed simply to breathe, allowing the arytenoids and hence the cords 
 to swing freely open. But to obtain an image of the junction of the cords 
 at the anterior ends, appearing superiorly in the mirror, the effort to pro- 
 duce the vowel tone "e" must be made. "This will so elevate the larynx 
 and change its position in relation to the epiglottis and other structures 
 as to expose the whole length of the cords and the whole inferior surface 
 of the epiglottis in one view, and in most cases, after holding the tone for 
 a few seconds, the patient may breathe freely without the tongue falling 
 back to its original position, A good plan is to have the patient hold the 
 note for a moment, followed by free respiration, and repeat the process as 
 often as required till a satisfactory view is obtained of all the intralaryn- 
 geal structures. During respiration the anterior wall of the trachea also 
 may be seen, in some cases as far down as the bifurcation, though to be 
 satisfactory an examination of the lower part of the trachea and bronchial 
 tubes should be made with a bronchoscope. This instrument has been 
 perfected in recent years to such an extent as to be of great value in the 
 hands of a skilful operator for the removal of foreign bodies or for the 
 inspection of any diseased condition of the lining membrane. If during 
 the examination the patient has an inclination to gag, free and rapid 
 respiration may overcome it; should the tendency persist, however, with- 
 draw the mirror and allow the throat to be at rest for a short time; under 
 no condition will anything be gained by forcing or attempting to prolong 
 an examination when the patient coughs, gags, or the muscles of the throat 
 become fatigued. 
 
 The larynx is subject to the same inflammatory changes which may take 
 place in any other mucous membrane, and likewise to any local infection. 
 The histologic structure of the submucous tissue seems to favor rapid and 
 extensive oedema from local inflammations, due to traumata, scalds, and the 
 inhalation of irritant vapors; from infectious processes involving adjacent 
 structures, as diphtheria, foUicular tonsilhtis, and tuberculosis; and from 
 circulatory disturbances such as may arise from cardiac or renal lesions. 
 
 Chronic hoarseness not amenable to treatment, particularly in indi- 
 viduals past forty years of age, must be regarded as suspiciously indica- 
 tive of malignancy and be kept constantly under observation in order 
 that should such a condition exist it may be detected at the earliest stage 
 possible. Sluggishness in the movement of the vocal cord, or even an 
 apparent paralysis of the cord on the affected side, has been observed 
 not infrequently in laryngeal carcinoma long before any actual tumor 
 was visible. 
 
 Otoscopy. 
 
 For convenience in description the organ of hearing is usually divided 
 into the external, middle, and internal ear. The last embraces that part 
 of the petrous portion of the temporal bone in which the terminal fila- 
 
DESCRIPTION OF PLATE III. 
 
 1. Laryngeal image during respiration. 
 
 2. Laryngeal image during phonation. 
 
 3. Laryngoscopic picture in a case of paralysis of the right recurrent laryngeal nerve. 
 
 4. Laryngoscopic picture in a case of bilateral paralysis of the recurrent laryngeal nerves. 
 
 5. Laryngoscopic picture in a case of paralysis of the interarytenoid muscle. 
 
 6. Position of the vocal cords in unilateral adductor paralysis. 
 
 7. Position of the vocal cords in bilateral adductor paralysis— during efforts at deep inspiration. 
 
 8. Position of the vocal cords in paralysis of the right internal tensor. 
 
PLATE III. 
 
UPPER AIR-PASSAGES AND EAR. 227 
 
 ments of the auditory nerve are distributed, and therefore is also desig- 
 nated as the sound-perceiving apparatus. The external and middle ear, 
 since they serve the purpose of transmitting sound impressions to the 
 nerve, are called the sound-conducting apparatus. 
 
 It is of importance to distinguish between diseased conditions of the 
 sound-perceiving and the sound-conducting apparatus, or between disturb- 
 ance of hearing caused by nerve lesions and that dependent upon diseased 
 structures of the ear itself. For example, in any case of deafness the first 
 thing to be ascertained is what part of the ear, if any, is at fault. Deaf- 
 ness, either partial or complete, may be caused by obstructions in the 
 external auditory canal, such as foreign bodies, impacted cerumen, con- 
 genital atresia, exostosis, furunculosis, etc., and also by hemorrhage into 
 the semicircular canals, or as the effect of certain drugs. The condition 
 of the external canal and the tympanic membrane can easily be determined 
 by direct ocular inspection, a strong, well focussed light being directed 
 into the canal through a suitable speculum. If the canal be found 
 clear, then the difficulty must lie either in the middle or the internal ear. 
 To distinguish between these the tuning-fork test, devised by Weber, is 
 usually employed. 
 
 External Auditory Canal. — The external auditory canal varies greatly 
 in size and somewhat in direction in different individuals. The cartilagi- 
 nous portion of the canal is usually directed more or less downward and 
 forward, so that in order to bring this part of the canal and the bony meatus 
 into the same axis for inspection of the walls of the canal and the drum 
 membrane it is necessary to draw the auricle gently upward and backward. 
 By holding the auricle in this position with one hand and manipulating 
 the speculum with the other — a metallic conical speculum is the most 
 desirable — every part of the canal wall and drum membrane may be clearly 
 seen. Note the size of the canal and any acute inflammatory swelling or 
 chronic induration. The cartilaginous portion of the canal comprises a 
 little over one-third of the whole length of the meatus. Its junction with 
 the bony meatus is the most frequent site of furunculosis. In young chil- 
 dren the cartilaginous meatus comprises about two-thirds of the whole 
 extent of the canal. When a furuncle is of deep origin pus may burrow 
 beneath the periosteum inward toward the tympanic cavity, occluding 
 the osseous meatus entirely and giving rise to most excruciating pain. The 
 pain within the ear and swelling extending even back of the auricle may 
 be confused with acute mastoiditis. In furunculosis the most acute pain 
 is apt to be elicited by pressing upon the tragus, or, if there be postauricular 
 tenderness, it will likely be superficial; in mastoiditis, however, the pain 
 may be slight superficially and intensified by deep pressure over the mas- 
 toid, and pain is not apt to be elicited on pressure over the tragus. 
 
 When the cartilaginous portion of the canal is occluded by swelling, 
 gently insert a tightly rolled pledget of cotton dipped in a solution com- 
 posed of camphor and carbolic acid, equal parts, and allow it to remain a 
 few minutes. The swelling is thus sufficiently reduced to alloAV the intro- 
 duction of a small speculum for the examination of the deeper canal and 
 tympanic membrane. This solution also produces partial anaesthesia of 
 the membrane, thus allowing a more thorough examination. 
 
228 MEDICAL DIAGNOSIS. 
 
 The tympanic membrane separating the external canal from the 
 tympanum, irregularly oval in shape and slightly concave in its normal 
 state, is affected to some degree by every inflammatory disease of the mid- 
 dle ear, both acute and chronic, and should therefore receive most careful 
 attention in every aural examination. A strong, well focussed light is a 
 necessity and the largest speculum which the canal will admit should be 
 used. The external layer of the drum membrane is modified skin, clear 
 and almost translucent in its normal condition, and through it can be seen 
 the impression of the malleus with which it lies in direct contact. Acute 
 inflammations of the middle ear produce a pink or reddish hue along the 
 margins of the malleus and in some cases over the entire membrane. 
 
 Exudates, serous or purulent, in the tympanic cavity, even though 
 small in quantity, produce bulging of the membrane and frequently ter- 
 minate in spontaneous rupture into the external canal. In acute and 
 chronic inflammations causing occlusion of the Eustachian tube the tym- 
 panic membrane will be found retracted. Retraction may also be brought 
 about by adhesions within the tympanic cavity following marked inflam- 
 matory involvement. In a case of retracted membrane we can ascertain 
 whether the tube is patulous by one of the usual methods of inflation, 
 Valsalva's consists of a vigorous expiratory effort while the nose and 
 mouth are kept closed. Politzer inflates the tympanum through one nos- 
 tril by compression of a rubber air-bag while the patient is in the act of 
 swallowing. The opposite nostril and the mouth are closed. Eustachian 
 catheterization is the most satisfactory method in difficult cases. With 
 Siegel's otoscope the air within the external auditory canal can be 
 exhausted and adhesions involving the tympanic membrane observed. 
 Aural polypi originate most frequently within the middle ear from gran- 
 ular or necrotic tissue and protrude into the external canal through per- 
 forations in the tympanic membrane, though they occasionally may be 
 found in any part of the canal, particularly at the cartilaginous and osseous 
 junction. Exostoses occur in any portion of the osseous canal, particularly 
 from the posterior wall and from the osseous and cartilaginous junction. 
 In chronic non-suppurative processes involving the middle ear, the drum 
 membrane becomes opaque and thickened, and usually distorted in shape. 
 In cases of otosclerosis white chalky spots are observed in the membrane 
 which may otherwise appear normal. A sign of diagnostic importance 
 in mastoiditis complicating chronic suppurations of the middle ear is an 
 infiltration of the membrane covering the superior posterior osseous wall 
 of the external auditory canal, presenting the appearance of a circum- 
 scribed drooping or bulging. 
 
 Pharynx and Eustachian Tube. — No examination of the ear can be 
 considered complete without a careful inspection of the nasopharynx at 
 the entrance of the Eustachian tube slightly below and anterior to the fossa 
 of Rosenmiiller. The technic of this procedure is described under posterior 
 rhinoscopy. Catheterization of the tube for diagnostic purposes can be 
 accomplished either through the nose or by way of the oropharynx. 
 
EXAMINATION OF THE BLOOD. 229 
 
 V. 
 THE EXAMINATION OF THE BLOOD. 
 
 General Considerations. — Information derived from blood exami- 
 nations, while not essential in the establishment of a diagnosis in most 
 instances, is frequently a useful aid. Negative blood reports are often 
 important in diagnosis, as in the exclusion of malaria from a group of dis- 
 eases which have similar clinical features, such as malignant endocarditis, 
 septicaemia, and certain types of tuberculosis. Diseases associated with 
 marked splenic or glandular enlargement present so close a resemblance 
 to leukaemia that only a study of the blood can exclude the latter 
 condition. Many blood examinations elicit results which assist in arriv- 
 ing at or completing a diagnosis. Evidence of a pathognomonic char- 
 acter gained from haematological studies is available in only a limited 
 number of diseases, notably in myelogenous leukaemia, malaria, relapsing 
 fever, trypanosomiasis, and filariasis. The condition of the blood as to 
 haemoglobin value, the number of erythrocytes and leucocytes, may serve 
 as an index of body nutrition. Blood counts often yield information 
 which bears upon prognosis, — e.g., in chlorosis a steady haemoglobin 
 rise is an evidence of favorable progress of the patient, while an erythro- 
 cytic gain in progressive pernicious anaemia or leucocytic decrease in 
 leukaemia likewise points to improvement. Counts of the white corpuscles 
 also aid in establishing the leucocytic standard of the patient. The opsonic 
 index and the agglutination phenomenon are recognized adjuncts in the 
 field of diagnosis. 
 
 Methods of Blood Examination. 
 
 Obtaining Blood. — For most clinical examinations a few drops of 
 blood, obtained from a puncture in the lobe of the ear or the finger-tip, 
 will suffice. The lobe of the ear is sometimes selected for making the 
 puncture on account of its lessened sensibility and because the operation 
 can be performed without the patient seeing it, but the finger-tip is generally 
 chosen as this site is more convenient for the examiner. The puncture 
 should be made with a lancet-shaped or triangular surgical needle, an 
 instrument especially devised for this purpose, or a steel pen with one of 
 the nibs broken off. The part selected should be cleansed with alcohol or 
 with soap and water followed by alcohol, and dried with a towel or hand- 
 kerchief. If not warm, the skin is warmed by gentle friction, but forcible 
 rubbing should be avoided, since it excites active hyperemia. If the 
 individual is a bleeder, the precaution of making a superficial puncture 
 and of having measures at hand to control hemorrhage should be observed. 
 It is obvious that areas of cedema and of inflammation must be avoided. 
 If the former be present about the hands or ear, an area free or nearly so 
 of cedema is chosen. The puncture is made with a quick thrust of the 
 instrument, which has previously been cleansed with alcohol or passed 
 through a flame. The first drop or two of blood should be wiped away. 
 
230 MEDICAL DIAGNOSIS. 
 
 Forcible squeezing of the tissues in the immediate vicinity of the wound 
 must be avoided, as this may alter the composition of the blood by the 
 addition of lymph fluids. As the blood flows from the wound, its gross 
 appearance as to color and fluidity is noted. 
 
 Preparation of Fresh Blood for Immediate Examination. — A 
 cover-glass is applied to a droplet of blood and then placed upon a clean 
 slide. The blood usually spreads into a thin layer. Warming the slide 
 by friction with a piece of gauze, a handkerchief, or tissue paper before 
 applying the cover-glass facilitates spreading. In a well-prepared prep- 
 aration the corpuscles are arranged in a single layer separated from each 
 other over an area sufficiently large for the desired study. If it be necessary 
 to delay the examination, drying of the specimen can be prevented by 
 ringing the margins of the cover-glass with vaseline or cedar oil. 
 
 Preparation of Blood for Staining. — Cover-glasses which have clean 
 polished surfaces are placed upon a sheet of paper, or preferably upon 
 a folded towel, from which they can be picked up easily. A cover-glass, 
 held with the fingers, or with forceps, is applied to the summit of the 
 droplet of blood, being careful to avoid touching the skin, and allowed to 
 fall upon another cover. As soon as the blood has ceased spreading, 
 the covers are slid apart. In performing this operation, care should be 
 exercised not to lift the glasses apart: the shding motion must be performed 
 rapidly, avoiding a jerky uneven stroke. The smear may be made upon 
 a slide by placing a drop of blood upon it and spreading with another 
 slide or with a glass rod especially designed for this purpose. 
 
 Methods of Fixation. — Heat Fixation. — The covers are placed in 
 an oven, the ordinary dry-heat sterilizer being convenient for this purpose, 
 and heated gradually until the temperature reaches to 120° C, or up to 
 155"^ C. and subjected to this temperature for from ten to twenty minutes. 
 A convenient plan for fixing the specimens with heat consists in placing 
 the spreads upon a heated copper plate. The plate, about 20 centimetres 
 in length, 8 centimetres in width, and from ^ to 1 centimetre in thickness, 
 supported by a suitable stand, is heated at one end with the flame from a 
 Bunsen burner or an alcohol lamp. When the plate is thoroughly heated, 
 the covers are placed upon it at a point where the temperature is sufficient 
 to boil water (which is previously determined by dropping water upon 
 its surface, beginning at the end farthest away from the flame) and exposed 
 to this heat for about 30 minutes. A method less suitable than the ones 
 mentioned consists in passing the film rapidly thi'ough a Bunsen flame 
 forty or fifty times. 
 
 Fixation by Wet Methods. — Fixation may be obtained by sub- 
 merging films in a mixture of equal parts of absolute alcohol and ether 
 for 20 or 30 minutes, or in absolute alcohol for five minutes. The 
 Futcher-Lazaer method subjects the films to .25 per cent, formalin in 
 95 per cent, alcohol for one minute; they are then rinsed in water and 
 dried with filter-paper. 
 
 Blood Staining. — Many methods for staining blood are available. 
 To Ehrlich belongs the credit of devising a mixture by which all known 
 varieties of blood-cells except those which contain basophilic granules 
 are completely colored. At the present time certain panoptic fluids 
 
EXAMINATION OF THE BLOOD. 231 
 
 containing eosin-methylene-blue compounds are employed extensively 
 in routine work, having largely supplanted Ehrlich's triple stain. 
 
 Ehrlich's triple stain is prepared by mixing saturated aqueous solu- 
 tions of acid fuchsin of orange G. and of methyl green 00 with glycerin, ethyl 
 alcohol, and water. The following formula is recommended b}"- Emerson: 
 
 Acid fuchsin solution 6- 7 c.c. 
 
 Orange G. solution 13-14 c.c. 
 
 Distilled water 15 c.c. 
 
 Absolute alcohol 15 c.c. 
 
 Add drop by drop, shaking after each addition: 
 
 Methyl green 00 solution 12.5 c.c. 
 
 Then add: 
 
 Absolute alcohol 10 c.c. 
 
 Glycerin 10 c.c. 
 
 Allow the mixture to stand for twenty-four hours, and if, as is some- 
 times the case, a precipitate is present, care should be exercised not to 
 disturb it when removing some of the stain. The combination of dyes 
 in this mixture contains a neutral staining ingredient in addition to its 
 acid and basic principles. 
 
 Staining Technic. — The stain is applied to the blood-film previously 
 fixed by heat, for five minutes, after which the excess of stain is drained 
 off and the cover washed with water, dried, and mounted in xylol balsam 
 or cedar oil. Normal erythrocytes are colored orange, eosinophilic granules 
 dull red, neutrophilic granules violet or lilac, nuclear structures various 
 shades of green, blue, or black, malarial parasites and bacteria green or 
 blue, W'hile basophilic granules are unstained. 
 
 Jenner's stain is prepared as follows: Mix equal parts of a 1 per 
 cent, aqueous methylene-blue solution with a 1.25 per cent, aqueous eosin 
 (water soluble) solution. After shaking thoroughly, the solution is allowed 
 to stand for twenty-four hours and then filtered. The precipitate is dried. 
 One part of precipitate is dissolved in two hundred parts of methyl alcohol. 
 Films are treated with this solution without previous fixation for from 
 three to five minutes, washed with water, dried, and mounted in xylol 
 balsam or cedar oil. The following tinctorial reaction is secured: Normal 
 er^'throcytes stain terra-cotta; nuclei, various shades of blue or green; 
 basophilic granules, dark blue; neutrophilic granules, pink; eosinophilic 
 granules, bright red; the cytoplasm of lymphocytes and malarial para- 
 sites, a deep blue. A deposit of dark granules upon the film which is 
 often observed is an objectionable feature and interferes with the useful- 
 ness of this method. 
 
 Leishman's stain, an improvement on Jenner's, is based on the 
 Romanowsky method. It is prepared as follows: (1) A one per cent, 
 aqueous solution of methylene blue (Gruber's medicinal), containing 5 
 per cent, of sodium carbonate, is heated at 65° C. for twelve hours and then 
 allowed to stand for ten days. (2) An equal volume of a 1 per cent, solution 
 of eosin in distilled water is added to the methylene-blue solution in an 
 
232 MEDICAL DIAGNOSIS. 
 
 open vessel and the mixture stirred from time to time. After twelve hours 
 the resultant sediment is collected on filter-paper and washed with water 
 until the washings are almost colorless. One and a half parts of dried 
 powdered precipitate are added to one hundred parts of pure methyl 
 alcohol. Previous fixation is not required with Leishman's reagent, since 
 it possesses the double property of fixing and of staining. Three or four 
 drops of this stain are placed upon the blood-film and allowed to act for 
 thirty seconds, when double the amount of water (six or eight drops) is 
 poured upon the cover and mixed with the stain. After five minutes the 
 spread is washed gently with water and a few drops allowed to remain 
 upon the specimen for about a minute. The smear is now dried, first be- 
 tween filter-paper and then in the air, and mounted in balsam or cedar 
 oil. The nuclei of leucocytes and of erythroblasts, and blood-platelets are 
 stained various shades of purple, the protoplasm of lymphocytes and certain 
 polychromatophilic erythrocytes various tints of blue, basophilic granules 
 dark violet or royal purple, normal erythrocytes and eosinophile granules 
 pink, and neutrophile granules a dull red. Malarial parasites and try- 
 panosomes are distinctly stained by this method. Wright's stain, which 
 is also a modification of the Romanowsky method, contains an eosin-meth- 
 ylene-blue combination held in solution by methyl alcohol. Wright's 
 method is extensively employed in this country. Hasting's mixture, 
 another eosin-methylene-blue stain, is much used by some workers. For 
 general routine work Leishman's stain can be highly recommended. 
 
 Double Staining. — The films, after suitable fixation obtained by 
 immersion in absolute alcohol, alcohol and ether, or by heating as pre- 
 viously described, are treated first with an acid stain followed by a basic 
 dye, rinsed in water, dried, and mounted. A staining fluid containing 
 acid and basic coloring principles may be employed for this purpose. 
 Most of the methods of double staining are not suitable for differentiating 
 all forms of blood-cells, as certain histological elements remain unstained. 
 Neutrophilic granules are as a rule not colored, and therefore neutrophilic 
 myelocytes cannot be distinguished from large mononuclear leucocytes. 
 If only the nuclear structures are to be studied, double staining is of service, 
 but is nevertheless inferior to Leishman's stain and similar methods. 
 
 Plehn's stain has the following formula: 
 
 Saturated aqueous solution of methylene blue 60 c.c. 
 
 One-half per cent, eosin solution (in 75 per cent, alcohol) 20 c.c. 
 
 Distilled water 40 c.c. 
 
 Twenty per cent, solution of caustic potash 5-1 c.c. 
 
 Specimens are fixed in absolute alcohol for from three to five minutes, 
 stained with Plehn's solution, washed in water, dried, and mounted. This 
 mixture stains malarial parasites blue and eosinophilic granules red. 
 
 Eosin and Methylene Blue. — A convenient plan consists in treating 
 the fixed smear with a solution consisting of eosin ,5 part in 70 per cent, 
 alcohol 100 parts, for a minute or two; wash the cover in water, and then 
 counterstain with a half-saturated solution of methylene blue or Delafield's 
 hsematoxylin solution for a half to one minute. The specimen is then 
 rinsed in water, dried between bibulous paper or in the air, and mounted. 
 
EXAMINATION OF THE BLOOD. 233 
 
 Chenzinsky recommends a stain composed of 40 cubic centimetres 
 of satm-ated methylene blue, 20 cubic centimetres of a .5 per cent, eosin 
 solution in 70 per cent, alcohol and 40 cubic centimetres of distilled water. 
 Films fixed in absolute alcohol are subjected to Chenzinsky's solution for 
 from three to six hours, the staining being done at 37° C. in an incubator. 
 Ehrlich suggested a mixture consisting of hematoxylin 2 grammes, eosin 
 0.5 gramme, absolute alcohol 100 grammes, distilled water 100 grammes, 
 glycerin 100 grammes, acetic acid 10 grammes, and an excess of alum. The 
 stain is not ready for use until several weeks have elapsed, since this time is 
 required for the ripening of the stain. 
 
 Basophilic granules may be demonstrated by a stain recommended 
 by Ehrlich which has the following formula: 
 
 Saturated alcoholic solution of dahlia 50 c.c. 
 
 Acetic acid 10-20 c.c. 
 
 Distilled water 100 c.c. 
 
 Differential Counting. — This method consists of determining the 
 relative number of the different forms of blood-cells, generally expressed 
 in percentage figures and sonretimes as the number per cubic milhmetre. 
 The leucocyte differential estimation is important in the diagnosis of a 
 number of conditions. An approximate differential count can be made by 
 an examination of fresh, unstained blood by the experienced worker, 
 but for accurate determinations stained films are essential. A mechanical 
 stage is necessary for this method of counting. 
 
 Technic. — The specimen is brought into focus, and the shde is shifted 
 with the mechanical stage so as to bring successive fields into view, being 
 careful not to pass over any portion more than once. The different forms 
 of leucocytes are noted and their number recorded until at least five hun- 
 dred cells have been studied. From these figures the relative percentages 
 are calculated. When nucleated erythrocytes are encountered, their num- 
 ber should also be noted, and the total number of these cells per cubic 
 millimetre can be determined by the following formula: 
 
 Number of leucocytes per cu. mm. X number of nucleated 
 
 red cells counted in the stained film Number of nucleated erythro- 
 
 Number of leucocytes counted in the stained film ^ytes per cubic millimetre. 
 
 It is sometimes important to estimate separately the different varieties 
 of abnormal red cells, especially the varieties of nucleated cells. 
 
 Enumeration of the Erythrocytes, Leucocytes, and BIood=pIatelets. 
 
 — For clinical purposes, the red cells are counted in a small amount of 
 blood of known quantity, from which an estimate of the number per cubic 
 millimetre is made, this figure being the standard upon which the variations 
 in health and disease are based. A number of methods are available for 
 this purpose. The one recommended by Thoma is generally selected, as 
 it gives fairly accurate results. 
 
 The Thoma=Zeiss Haemocytometer. — This apparatus consists of two 
 graduated pipettes (the i-ed and white counters) for measuring, diluting, and 
 mixing the blood, and a glass chamber in which the corpuscles are counted. 
 
234 
 
 MEDICAL DIAGNOSIS. 
 
 The erythrocytometer consists of a graduated capillary tube, upon which 
 the figures .5 and 1 appear. The tube expands into a bulb, above 
 which the figure 101 is inscribed. A rubber tube with a mouth-piece 
 
 attached is fastened to the short end of the 
 pipette. Filling the pipette with blood to the 
 point marked .5 and then drawing a diluting 
 solution into it until the fluid reaches to the 
 point marked 101, insures a blood dilution of 
 1 :200, while a dilution of 1 : 100 is obtained when 
 the pipette is filled to the point marked 1, and 
 then with a diluent to the mark 101. The white 
 pipette, or leucocytometer, is similar in con- 
 
 ^,y;.l,.jirr.T;::7.S tSA. ,„ 
 
 
 3^ 
 
 c '6 
 
 lOOmm. 
 
 I 
 400 qmm. 
 
 Fig. 93. — I, leucocy- 
 tometer ; II, erythrocy- 
 tometer of Thoma - Zeiss 
 haemocytometer. 
 
 B 
 
 Fig. 94.- — Counting chamber of the Thoma-Zeiss 
 haemocytometer. A, profile view; B, face view; a, 
 wall of cell ; 6, central disk ; c, groove about disk ; 
 d, ruled surface. 
 
 struction to the red pipette, but differs in that the capillary bore is larger 
 and the bulb smaller so that dilutions of 1 : 20 and 1 : 10 may be secured. 
 
 A B 
 
 Fig. 95. — A, Zappert ruling ; B, Turk's ruling. — Emerson. 
 
 The counting chamber consists of a heavy glass slide upon which 
 is cemented a glass plate having a circular opening; a disk is cemented 
 to the slide so that it occupies a central position in the circular open- 
 
EXAMINATION OF THE BLOOD. 235 
 
 ing of the plate. The disk is shghtly thinner (by one-tenth of a mm.) 
 than the plate which surrounds it. When the cover-glass, a part of 
 this instrument, is placed upon the plate, the distance between the disk and 
 the cover is one-tenth mm. The surface of the disk is ruled by vertical and 
 horizontal lines one-twentieth of a mm. apart. These lines form four hun- 
 dred squares, the dimensions of each being one-twentieth by one-twentieth 
 mm. Groups of 16 squares are indicated by a double ruling. The space 
 overlying each square between the surface of the disk and the cover-glass 
 measures twit cu. mm. (-gV mm. X 2V mm. X r(5" = Tir(ro" cubic millimetre). 
 Zappert's modified ruling of the Thoma-Zeiss counting chamber divides 
 the surface into eight large squares, immediately surrounding the 400 
 small squares; each large square is equal to the surface ruling of the 400 
 central squares. The total ruling represents an area of 3600 small squares. 
 Technic of Counting the Erythrocytes. — Special fluids are 
 employed for diluting the blood. Toisson's solution stains nuclei a pale 
 blue, therefore rendering differentiation between non-nucleated erythro- 
 cytes and white corpuscles easy. Its composition is as follows: 
 
 Methyl violet, 5B 0.025 part 
 
 Sodium chloride 1.0 part 
 
 Sodium sulphate 8.0 parts 
 
 Neutral glycerin 30.0 parts 
 
 Distilled water 160.0 parts 
 
 Hay em's solution: 
 
 Mercuric chloride 0.25 part 
 
 Sodium chloride 0.5 part 
 
 Sodium sulphate 2.5 parts 
 
 Distilled water 100.0 parts 
 
 Other diluting fluids recommended for clinical work are a 2.5 per 
 cent, aqueous solution of potassium bichromate, a .5 per cent, aqueous 
 solution of sodium sulphate, and a .7 per cent, aqueous solution of sodium 
 chloride. These solutions should be filtered before using. 
 
 The blood obtained in the usual manner is drawn into the erythro- 
 cytometer to the point .5, unless decided oligocythemia is suspected, 
 when it is desirable to fill to the mark 1. after which the tip of the pipette 
 is wiped. Toisson's or some other diluting solution is drawn into the 
 pipette until the fluid reaches to the point 101. The pipette should be 
 rotated gently, as the diluting fluid enters the bulb, in order to secure a 
 mixture. After filhng the pipette, the thumb and finger are immediately 
 placed over its ends and the instrument shaken for about a half minute, 
 in order to obtain a thorough mixture. The unmixed fluid in the capil- 
 lary portion is then blown out. The counting chamber is now placed upon 
 a perfectly level surface and a droplet of the mixture is deposited in the 
 central portion of the ruled disk. The pipette should be shaken just before 
 adjusting the diluted blood, and the fluid in the capillary portion should 
 always be expelled after mixing in this manner, since corpuscles in the 
 capillary tube may gravitate on standing, thus creating an uneven mixture. 
 The cover-glass is then quickly adjusted in its position. If the fluid flows 
 into the depression surrounding the disk, the operation must be repeated. 
 After the corpuscles have settled, the counting chamber is placed upon 
 
236 
 
 MEDICAL DIAGNOSIS. 
 
 the stage of the microscope and a field of 16 squares is brought into focus. 
 In general routine work, the calculation of determining the number of 
 erythrocytes per cubic millimetre is usually based on the number of cells 
 found within 64 squares, provided a uniform distribution of the cells 
 exists. The following plan may be adopted in counting the corpuscles: 
 The cells within the upper left-hand corner square of a group of 16 squares 
 
 are first counted, then the cells in 
 each of the remaining three squares 
 in that Hne, going from left to 
 right, after which the corpuscles 
 in the next row of squares are 
 enumerated, proceeding from right 
 to left, next those in the third 
 row and finally in the last line of 
 squares, as shown in the diagram 
 (Fig. 96). The counting chamber 
 is now moved, so as to bring into 
 focus another area of 16 squares, 
 and the number of cells in this 
 group is estimated. This process is 
 repeated until the desired number 
 of squares (not less than 64) has 
 been covered. In order to avoid 
 confusion in counting, the cor- 
 puscles which touch the right and 
 lower lines are included in the count of the square in question. The 
 formula for calculating the number per cubic millimetre is as follows: 
 
 
 
 
 
 
 
 
 
 A 
 
 
 
 B 
 
 c 
 
 
 
 J 
 
 ^ 
 
 
 
 ^ 
 
 -^ 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 Fig. 96. — Scheme for counting cells overlying ruled 
 surface. 
 
 : Number of cells per cubic mm. 
 
 Number of cells counted X 4000 X number of dilutions 
 Number of squares 
 
 The greater the number of cells counted, especially with low dilu- 
 tions, assuming that the mixture is thorough, the more accurate will be 
 the results. 
 
 Technic of Counting the Leucocytes. — In determining the number 
 of leucocytes, the red pipette may be used, but more accurate results 
 are obtained with the white pipette, as lower dilutions are secured. A 
 \ ov \ per cent, aqueous solution of acetic acid is employed when using 
 the white counter in order to dissolve the red cells. Except in the case of 
 leukagmic blood, a dilution of 1 : 20 or 1 : 10 is most convenient for the majority 
 of leucocytic counts. When the number of white cells is estimated with the 
 red counter, with a 1:100 or 1:200 dilution, Toisson's solution is very 
 useful, since with it the leucocytes are tinted blue and therefore readily 
 distinguished from erythrocytes, which have a yellowish or greenish color. 
 With Zappert's modified ruling the cells overlying a larger area can be 
 counted. The formula for estimating the leucocytes per cubic millimetre 
 is the same as that used for determining the number of erj'throcytes. 
 In routine clinical work the corpuscles overlying the entire ruled area of 
 at least 400 squares should be counted when employing dilutions of one 
 in ten or twenty. 
 
EXAMINATION OF THE BLOOD. 237 
 
 Cleansing the Instrument. — After removing the fluid from the pipette, 
 it is rinsed with water, then with alcohol, and finally with ether, and dried 
 thoroughly. An atomizer bulb is useful for expelhng the fluid from the 
 tube and for drying, A simple method of removing the fluid from the 
 pipette consists in pressing the end of the rubber tube between the fingers 
 so as to occlude its lumen, and then by twisting the tube the fluid is ex- 
 pelled from the pipette. The counting chamber should be cleaned with 
 water and dried with a soft handkerchief or tissue paper. Alcohol, ether, 
 and xylol should not be used for cleaning the counting chamber, since 
 these substances may dissolve the cement which holds the parts together. 
 
 Qowers's Haemocytometer. — The principle of determining the number 
 of corpuscles with this instrument is similar to that of the Thoma-Zeiss 
 method. A mixing jar is used instead of a mixing pipette. The instru- 
 ment consists of a capillary tube for measuring 5 cubic millimetres of 
 blood, a pipette having a capacity of 995 cubic millimetres for measuring 
 the diluting fluid, a mixing jar, a glass stirring rod, and a ruled counting 
 chamber. The counting chamber is so constructed that the space over- 
 lying each square represents -g-ToT of ^ cubic millimetre. 
 
 Oliver's Haemocytometer. — With this method the number of corpuscles 
 is approximately estimated by an optical effect and not by actually 
 counting the cells in a known area. As the number of leucocytes cannot 
 be determined with this method, it is not suitable for the majority of blood 
 examinations and therefore has not been adopted for routine clinical work. 
 
 Enumeration of Blood-platelets. — The blood-platelets are rarely 
 seen in fresh unstained specimens, as they disappear almost immediately 
 after the blood is exposed to the air. They are colorless, spherical, oval, 
 or irregular, varying considerably in size, usually from one to three microns. 
 In fresh blood, platelets are demonstrated by placing a cover-glass upon 
 a slide and bringing their edges in contact with the blood as it flows from 
 the puncture. Their number may be approximately estimated by Deter- 
 man's method as follows: Place a di^op of a 9 per cent, aqueous solution 
 of sodium chloride upon the skin and make the puncture through the 
 drop of fluid. As the blood flows from the wound, it is mixed with the 
 reagent by stirring with a cover-glass or slide, and then a part of this 
 mixture is placed upon the Thoma-Zeiss counting chamber and the cover- 
 glass adjusted. The ratio of blood-platelets to erythrocytes is next de- 
 termined in a given area. The number of red corpuscles per cubic millime- 
 tre is found by the Thoma-Zeiss method, and from this figure the actual 
 number of blood-platelets per cubic millimetre can be calculated by the 
 ratio the red cells bear to platelets. 
 
 Hsemoglobin Estimation. — The principle involved in the estimation 
 of hsemoglobin with most of the instruments used in clinical work is based 
 upon a comparison of the color of undiluted or diluted blood with a standard 
 color scale. 
 
 Dare's Method. — The principle of this method is based on matching 
 the tint of a film of undiluted blood of definite thickness with a graduated 
 color scale. The essential parts of this ha3moglobinometer are a wedge- 
 shaped semicircle of glass stained with Cassius's "golden purple" so that 
 the various dej^ths of the color displayed by the scale represent liiemoglobin 
 
238 
 
 MEDICAL DIAGNOSIS. 
 
 values ranging from 10 per cent, to 120 per cent, (this wedge is contained 
 within a hard-rubber case so that it can be revolved by operating a thumb- 
 screw) ; a telescoping camera tube supplied with a magnifying lens through 
 which the color of the blood and that of a part of the wedge is viewed; a 
 pipette composed of two plates of glass, one being transparent and the 
 other opaque (white glass); a part of the surface of the latter is slightly 
 bevelled, so that a thin compartment is formed between the plates when 
 their surfaces are opposed; and a candle holder. 
 
 Technic. — The pipette is brought in contact with a large drop of 
 blood. It fills by capillarity. The pipette is then placed in its compart- 
 ment on the side of the case. The light of a candle is used in making 
 
 the color comparison, the instru- 
 ment being held in a position so as 
 to avoid direct sunlight. The rapid- 
 ity with which an accurate haemo- 
 globin estimation can be made is the 
 greatest advantage of this method. 
 The matching of the colors should 
 be done immediately after filling the 
 pipette, since coagulation may begin 
 within three or four minutes. The 
 tint of the colored wedge of Dare's 
 hsemoglobinometer does not in every 
 instance correspond exactly with the 
 color curve of certain anaemic bloods. 
 
 TaLLQ VIST's H.EMOGLOBINOM- 
 
 ETER. — With this method the color 
 of a drop of blood soaked into filter- 
 paper is compared with a color scale 
 lithographed upon paper. The 
 apparatus consists of a book con- 
 taining sheets of white filter-paper 
 and a lithographed color scale of 
 ten tints representing haemoglobin 
 values between 10 and 100 per cent. 
 Technic. — A piece of the white filter-paper is applied to the drop of 
 blood, and, as soon as the moist gloss has disappeared from the surface of 
 the blood-soaked paper, its color is compared with the scale. Accurate 
 results are not claimed for this simple method. An error of at least ten 
 per cent, is unavoidable. 
 
 Von Fleischl H^emometer. — This instrument is composed of the 
 following parts: A metallic stage having a circular opening in its centre, 
 supported by a stand. To the frame of this stand is attached a plaster- 
 of-Paris reflector. A glass wedge, tinted with Cassius's "golden purple," 
 fixed within a metal frame. The depths of the color of the wedge corre- 
 spond to a scale of haemoglobin percentages stamped upon the frame, which 
 range from 1 to 120. A cylindrical metalhc mixing cell, divided into equal 
 parts by a vertical partition, and provided with a glass bottom. A capil- 
 lary measuring pipette attached to a metal handle. As the capacity of the 
 
 Fig. 97. — 1. Dare's hsemoglobinometer. A, 
 telescope ; B, pipette in place ; C, case enclosing 
 color-prism ; D, milled head moving prism ; E, 
 candle ; F, window admitting light to color-prism. 
 2. Pipette. A, the white glass; B, clear glass 
 disk. — ^Emerson. 
 
EXAMINATION OF THE BLOOD. 
 
 239 
 
 pipettes varies in different instruments, a figure is stamped upon the handle 
 of the pipette and a similar marking on the stage of the instrument for which 
 it is suited. A finely pointed glass dropper, for fiUing the metalhc cell. 
 
 Technic. — When one end of the pipette is brought in contact with 
 the blood, secured in the usual manner, it fdls automatically by capil- 
 larity. Blood adhering to the external surface of the pipette must be 
 wiped away before emptying its contents. After partially filling one 
 of the compartments of the cell with water, the blood is washed out 
 of the pipette with water. The blood and the water are then thoroughly 
 mixed by stirring with the handle of the pipette. The fluid adhering 
 to the handle must then be washed off with water, which is allowed to 
 drain into the mixing compartment. The other division of the cell is 
 filled with water. Avoid moistening the top of the vertical septum, as 
 this may cause the fluids of the compartments to commingle. The filled 
 cell is now adjusted in its proper position on the stage, and a comparison 
 of the color of the diluted blood with that of the scale is made in a dark- 
 ened room, or with a light-proof box. A candle flame placed about 15 
 or 20 centimetres in front of the plaster-of-Paris reflector is used for illu- 
 mination. The operator, standing to one side of the instrument, matches 
 the colors by turning the thumb-screw. The glass wedge should be moved 
 quickly. Never view the colors for more than a few seconds, since the 
 eye is easily fatigued by prolonged inspection. After two readings have 
 been made, the mean of these is taken as the result. An attempt should 
 always be made to compare only the median portion of the color fields^ 
 which may be readily accomplished 3 
 
 by placing under the glass bottom of 
 the cell a diaphragm of thin metal 
 or paper, having a narrow slit about 
 4 millimetres in width, the long 
 axis of which is at right angles 
 to the partition of the mixing cell. 
 
 When the haemoglobin percent- 
 age is low (below 30), two or three 
 pipettes full of blood should be used, 
 and the result divided by the 
 number of pipettes employed. 
 Degree of error with the von Fleischl 
 instrument is between 5 and 10 
 per cent. 
 
 The Meischer's H^moglo- 
 BiNOMETER. — This modification of 
 the von Fleischl instrument pos- 
 sesses certain advantages over the 
 latter whereby the degree of error is 
 considerably lessened. The prin- 
 ciple of Meischer's method is the 
 same as that of von Fleischl. A 
 mixing pipette is employed with which accurate dilutions of 1 : 200, 1 : 300, or 
 1 :400 can be secured. For normal blood or nearly so, dilutions of 1 :400 are 
 
 Fig. 98. — 1. Meischer's modification of Fleischl's 
 haemoglobinometer. 4. stage ; /i, color-prism rack ; 
 C, milled head ; D, cell ; E, cover-glass ; /'', cap ; G, 
 cell seen from above. 2. Mixing pipette. 3. Color- 
 prism. — Emerson. 
 
240 MEDICAL DIAGNOSIS. 
 
 most convenient, but with low haemoglobin values dilutions of 1 : 200 or 1 : 300 
 are more serviceable. Two metallic chambers are employed, each of which 
 is divided by a vertical partition and supplied with a glass bottom. One 
 compartment receives the diluted blood, the other water. One chamber 
 is shallower than the other. The partition dividing the cells is slightly 
 raised so that the glass cover, provided with a groove, may be slid over 
 the top of the cylinder, thereby preventing the fluids from commingling, 
 A lid having a narrow oblong opening is used to cover the chamber so 
 that the width of the field exposed when making the color comparison 
 does not correspond to more than three degrees of the percentage scale. 
 The tinted wedge of this instrument is more accurate than that of the 
 von Fleischl. After securing the desired dilution and mixture in the 
 pipette, one of the compartments in each of the cells is filled with the 
 blood solution, the other compartment with water; the glass cover is 
 then slid into position and the metal top adjusted. The reading of each 
 cell is then made with artificial illumination, using the same technic as 
 with the original von Fleischl method. The result of the reading of the 
 shallower cell is multiplied by f ; this figure should correspond closely with 
 the reading of the other chamber, one result controlling the other. The 
 mean of the two readings represents the hsemoglobin percentage. 
 
 Oliver's H.emoglobinometer. — With this method the color of a 
 definite quantity of diluted blood is compared \\ath a standard color scale, 
 consisting of a series of tinted glass plates. The instrument is composed 
 of the following parts: A standard blood scale composed of 12 colored 
 disks, mounted upon a perfectly white surface in two metal frames. Their 
 tints correspond with the color of various dilutions of blood. These primary 
 disks correspond to haemoglobin percentages ranging from 10 to 120; 
 two pieces of tinted glass, called riders, are supplied with the instrument 
 for ordinary clinical purposes. When a rider is superimposed upon a pri- 
 mary color, its shade deepens and therefore determines intermediate 
 percentages between those indicated by the disks. An error of 2| per 
 cent, is unavoidable. A capillary tube having a capacity of 5 cubic 
 millimetres for measuring blood. A standard mixing cell provided with a 
 glass lid. A camera tube through which the colors are viewed, and a 
 pipette for washing the blood out of the measuring pipette. 
 
 Technic. — The blood measured in the pipette is washed into the 
 mixing cell with water and mixed with the handle of the pipette. The fluid 
 which adheres to the handle is rinsed with the water and the cell filled. 
 The glass lid of the mixing cell is then adjusted in a manner so that a 
 small air bubble is present under the cover. The color of the diluted blood 
 is matched with one of the disks of the color scale in a darkened room, 
 illuminated with the light of a small wax candle placed about 10 centi- 
 metres in front of the mixing cell and the color disk. One or both riders 
 may be required to intensify the tint of the primary disk. 
 
 GowERs's HiEMOGLOBiNOMETER. — With tliis method a definite quan- 
 tity of blood is diluted, until the color of the mixture corresponds with 
 a standard color contained in a tube. This instrument consists of: A 
 standard color tube which contains glycerin jelly colored with picrocar- 
 mine, so that its tint corresponds with that of a solution containing one 
 
EXAMINATION OF THE BLOOD. 
 
 241 
 
 part of normal blood in a hundred parts of water; a mixing test-tube 
 having a graduated scale ranging from 5 to 120; a pipette for measuring 
 20 cubic millimetres of blood. 
 
 Technic. — The measuring pipette, to which is attached a small rubber 
 tube, is filled by suction up to the point marked 20. A few drops of 
 water are placed into the mixing tube, then the blood in the pipette is 
 blown into the tube. Water is added in small amounts, shaking after 
 each addition in order to secure a mixture, until the color of the solution 
 corresponds with that of the standard tube. The height of the fluid 
 reached indicates the haemoglobin percentage. The color comparison is 
 made with daylight by holding the tube against a white background. 
 
 Sahli's H^mometer. — The principle of this method is based on 
 comparing the tint of a standard fluid 
 composed of a definite amount of normal 
 blood and of a decinormal solution of 
 hydrochloi'ic acid with the tint of a solu- 
 tion of blood to be tested treated with a 
 decinormal hydrochloric acid solution and 
 water in sufficient quantity to exactly 
 match the colors. The height of the 
 column of fluid in the mixing tube indi- 
 cates the haemoglobin percentage. Sahli 
 claims that with this method the color 
 of the standard solutions and that of the 
 blood properly diluted corresponds quite 
 accurately, thereby insuring uniform 
 results. The apparatus is similar in con- 
 struction to Gowers's haemometer. It 
 consists of a sealed tube containing the 
 standard color solution of decinormal 
 hydrochloric acid holding one per cent, of 
 blood; a graduated test-tube for mixing 
 
 the blood with a decinormal hydrochloric acid solution and water; a 
 pipette for measuring 20 cubic millimetres of blood; a perforated stand 
 with a white glass back for holding the tubes; a bottle for carrying the 
 acid solution; and a finely pointed pipette. The standard color fluid 
 has a brownish-yellow color, due to haematin hydrochlorate held in sus- 
 pension. Since precipitation of this substance will occur on standing, 
 the sealed tube is provided with a glass ball which serves to mix the parti- 
 cles when the tube is agitated. 
 
 Technic. — The graduated tube is filled with decinormal hydrochloric 
 acid to the mark 10. Twenty c.mm. of blood measured in the pipette 
 are then blown into the acid solution and mixed. The measuring pipette 
 is then filled with water and discharged into the mixing tube. The 
 graduated tube is now placed in its compartment in the stand alongside 
 of the standard tube and water is added in small amounts to the blood 
 solution, mixing after each addition, until the color matches the standard 
 tint. The height of the column of fluid in the tube, as indicated by the 
 16 
 
 Fig. 99. — a, Sahli's haemometer; h, pipette. 
 
242 MEDICAL DIAGNOSIS. 
 
 graduated scale, represents the haemoglobin percentage. The test is con- 
 ducted with natural or artificial light. More accurate readings are possible 
 when the test is made with artificial light in a darkened room. 
 
 Color (ndex. — The terms color index, blood decimal, or blood quotient 
 are used to express the average haemoglobin richness of the erythrocytes. 
 This factor is determined by dividing the haemoglobin percentage by the 
 percentage of colored corpuscles per cubic millimetre. The normal color 
 index is expressed by the figure 1, i.e., 100 per cent, of haemoglobin divided 
 by 100 per cent, of red cells. In anaemic states the same result is ob- 
 tained when the haemoglobin and red cells are proportionately reduced. 
 In chlorosis the color index is generally decidedly diminished, while in 
 most symptomatic anaemias it is slightly and in some cases markedly low- 
 ered. In pernicious anaemia, except during periods of improvement, it 
 is generally increased. 
 
 Estimation of the Relative Volume of Plasma and of Corpuscles. — 
 This determination is made by applying centrifugal force to blood con- 
 tained in a tube, which separates the corpuscles from the plasma. By 
 estimating the volume of corpuscles, an approximate idea may be formed 
 of the number of cells per cubic millimetre. 
 
 Daland's Hematocrit. — This instrument consists of a set of gears 
 operating a metal frame into which are fastened two capillary tubes. 
 A hand lever is connected with the gears. The tubes for measuring the 
 blood, graduated into 100 equal divisions, are 50 millimetres in length, 
 with a lumen of ^ millimetre diameter. 
 
 Technic. — A piece of rubber tubing with a mouth-piece is attached 
 to one end of the graduated tube. Blood is sucked into the pipette 
 until completely filled. After removing the rubber tubing, the pipettes 
 containing blood are fastened into the metal frame and immediately the 
 handle of the instrument is turned for 3 minutes, at the rate of about 
 77 revolutions per minute, which produces the speed desired. The 
 centrifugal force separates the blood into three layers; the one most 
 distant, of dark red color, is composed of erythrocytes, the middle one, 
 of milky color, is formed of leucocytes, while the inner clear layer con- 
 sists of plasma. With normal blood the column of erythrocytes reaches 
 to the graduation marked 50 or 51; each division of the scale approx- 
 imately represents 100,000 corpuscles per cubic millimetre. Accurate 
 estimations of the number of cells per cubic millimetre is impossible, since 
 the size of the erythrocytes varies in pathological conditions and because 
 a uniform speed is almost impossible to obtain. Variations in the cen- 
 trifugal force will produce differences in the degree of compactness of the 
 cells. The number of leucocytes can only be roughly estimated when 
 there is a marked increase, as in leukaemia, but under normal conditions 
 or pathological states with slight or moderate variations the leucocytic 
 layer is too indistinct to warrant an opinion as to their number. The 
 pipettes of this instrument should be cleaned immediately after using by 
 passing a fine wire through the lumen, then washing with water, followed 
 by alcohol and ether. 
 
 Volume Index. — Volume index, the term applied to represent the 
 average volume of the erythrocyte, is determined by dividing the per- 
 
EXAMINATION OF THE BLOOD. 243 
 
 centage volume, as estimated with the haematocrit, by the percentage of 
 the erythrocytes per cubic millimetre, obtained with the haemocytometer. 
 
 Estimation of Specific Gravity. — An accurate estimation of the 
 specific gravity of the blood can be obtained by Schmaltz's method, which 
 consists of weighing a dry pipette upon a sensitive balance. The pipette 
 is then filled with water and the weight determined. After cleaning and 
 drying, the pipette is filled with blood and again weighed. From these 
 figures the specific gravity is calculated. 
 
 Hammerschlag's Method. — Hammerschlag's modification of Roy's 
 method is based upon the principle of suspending a drop of blood in a 
 liquid having the same specific gravity. The specific gravity of the sus- 
 pension fluid is then determined with a hydrometer, which corresponds 
 to that of the blood. 
 
 Technic. — Pour benzol and chloroform into an hydrometer jar, in 
 such proportions as to secure a mixture having a specific gravitj^ of 
 about 1.060. Partially fill a pipette, or rnedicine dropper, with blood 
 and insert it into the benzol-chloroform solution; expel a droplet into 
 the fluid. If the blood is lighter than the mixture, it will rise to the 
 top. Benzol should then be added and the fluid carefully stirred with a 
 glass rod until the blood is suspended in the mixture. The specific grav- 
 ity of the benzol-chloroform solution is next determined, which corre- 
 sponds to that of the blood. If the specific gravity of the blood is greater 
 than that of the benzol-chloroform mixture, causing the blood to sink, 
 the addition of chloroform is necessary to cause suspension. This method 
 of determining the specific gravity is seldom employed in clinical M^ork, 
 as it is tedious and as errors of technic are readily made. The specific 
 gravity ranges of the blood correspond quite closely to definite haemoglobin 
 percentages; notable exceptions to this rule are found in progressive per- 
 nicious anaemia, where the haemoglobin percentage is slightly higher than 
 the specific gravity indicates, while in leukaemia the reverse is observed. 
 Hammerschlag's scale of specific gravity ranges with equivalent haemoglobin 
 percentages is as follows: 
 
 Spec. Gravity. Hamoglobin. 
 
 1.033-1.035 25-.30 per cent. 
 
 1.035-1.038 30-35 per cent. 
 
 1.038-1.040 35-40 per cent. 
 
 1.040-1.045 40-45 per cent. 
 
 1.045-1.048 45-55 per cent. 
 
 1.048-1.050 55-65 per cent. 
 
 1.050-1.053 65-70 per cent. 
 
 1.053-1.055 70-75 per cent. 
 
 1 .055-1 .057 75-85 per cent. 
 
 1.057-1.060 85-95 per cent. 
 
 Estimation of the Time of Coagulation. — As a number of condi- 
 tions influence the rapidity with which coagulation of the blood occurs 
 after it is withdrawn from the blood-vessels, such as the amount of blood 
 and the temperature, the results obtained by different methods of deter- 
 mining the clotting time are not available for comparative studies. In 
 this connection it should also be borne in mind that the factors which 
 control intra- and extravascular coagulation are in all likelihood dissimilar. 
 
244 
 
 MEDICAL DIAGNOSIS. 
 
 Method of Russell and Brodie. — The coagulation time is deter- 
 mined by microscopical study of the blood. The apparatus needed for 
 this method is provided with a moist chamber having a glass bottom. A 
 removable glass cone (the lower surface of which is 4 mm. in diameter) 
 forms the upper portion of the chamber. A current of air is introduced 
 into the chamber by means of a small tube one end of which projects into 
 the cell, while to the other end is attached a rubber tube supplied with a 
 bulb. Boggs's coagulometer, a modification of the instrument just de- 
 scribed, is equipped with an improved glass cone and a metal tube. 
 
 Technic. — A drop of blood is placed upon the lower surface of the 
 cone which is then immediately fitted into the chamber. The instrument 
 is then put upon the stage of the microscope and with a low-power objec- 
 tive the blood is brought into focus. At successive intervals the blood is 
 agitated by means of the current of air sent into the cell from the bulb. 
 It will be noted that at first the stream of air causes the corpuscles to 
 
 Fig. 101.- 
 
 Diagram to illustrate the movement of the 
 cells during coagulation. — Emerson. 
 
 Fig. 100. — Coagulometer of Russell and 
 Brodie as modified by Boggs. A, moist cham- 
 ber ; B, cone of glass, the lower surface of which 
 holds the drop of blood ; C, side tube ; D and 
 E, cover-glass ; at £, a pinhole. — Emerson. 
 
 move freely. A little later clumps 
 form in the peripheral zone of 
 the blood and these can be ad- 
 vanced by the air current. Then 
 as clotting progresses masses of 
 blood-cells cease to move freely, the drop alters its shape, and the cor- 
 puscles exhibit a concentric motion. Lastly, a radial movement appears, 
 clumps of cells being displaced by the air current towards the centre and 
 these quickly return to their original position. Clotting is now considered 
 complete. The normal coagulation time as determined by this method varies 
 from three to eight minutes, the average time being about five minutes. 
 
 Wright's Method. — The coagulometer devised by Wright consists 
 of a cylindrical tin vessel provided with a perforated partition^ the open- 
 ings of which are so arranged as to support twelve graduated tubes and 
 a thermometer. The tubes are graduated for 5 c.c. of blood, and are num- 
 bered from one to twelve. 
 
 Technic. — Water having a temperature of 18.5° C. is poured into 
 the metal container. The blunt end of six or eight of the tubes 
 is then covered with a rubber cap. The tubes are then placed, closed 
 end downward, into the water. After having acquired the tempera- 
 ture of the water, they are removed separately at once or one-half 
 minute intervals, the cap taken off, filled with 5 c.c. of blood and imme- 
 diately replaced into the water without reapplying the caps. Attempts 
 
EXAMINATION OF THE BLOOD. 245 
 
 at short intervals are made to dislodge the blood from the tubes by blow- 
 ing. When the blood cannot be removed from one of the tubes, coagula- 
 tion may be considered complete. The clotting time is the difference of 
 time between the filling the tube and the unsuccessful attempt to expel 
 its contents. With this instrument the coagulation time of normal blood 
 in most instances is from three to six minutes, although the period may 
 be as long as fifteen minutes. 
 
 Bacteriological Examination. — This field of investigation is of diag- 
 nostic value in a considerable group of diseases. There are two methods 
 of demonstrating bacteria in the blood, — one by an immediate micro- 
 scopical examination of stained films, the other by blood culturing. The 
 former plan has given unsatisfactory results in the hands of most workers. 
 R. C. Rosenberger claims that tubercle bacilli can be detected in the 
 blood of tuberculous patients, and recommends the following simple 
 method for their detection: About 5 c.c. of blood, withdrawn from a vein 
 in the arm, are mixed with an equal quantity of a 2 per cent, solution of 
 citrate of sodium in normal salt solution. The mixture is shaken and 
 placed in a refrigerator for twenty-four hours. A small quantity of the 
 sediment is spread rather thickly upon a new clean glass slide, dried upon 
 a copper plate with moderate heat, and then placed in distilled water until 
 complete laking of the blood results. A delicate film remains upon the 
 slide. This is dried and fixed through a Bunsen flame and then stained 
 for tubercle bacilli, employing the usual technic. The blood for cultural 
 methods is taken as a rule from a superficial vein at the bend of the elbow. 
 
 Technic. — The skin of the flexor surface of the elbow is cleansed 
 as for a surgical operation, by scrubbing thoroughly with soap and 
 water, washing with sterilized water, alcohol, and ether, after which an 
 antiseptic dressing is applied and allowed to remain for six or eight 
 hours. The operator, having prepared his hands, should, after removing 
 the antiseptic dressing, wash the skin with sterilized water. A syringe 
 (of moderate size like the instrument used for exploratory puncture) 
 or a special "blood aspirator" is required to remove the blood from 
 the vein. A most useful instrument employed by many workers con- 
 sists of a graduated glass tube having a capacity of about 10 cubic 
 centimetres, one end of which is fitted to a No. 42 hypodermic needle, 
 and into the other end a small plug of cotton is inserted. In order 
 to sterilize the instrument, it is placed in a large glass tube, the ends of 
 which are then plugged wdth cotton. After sterilization a piece of rubber 
 tubing is fastened to the end of the aspirator containing the cotton. A 
 bandage is wound around the arm of the patient so as to obstruct the 
 venous circulation, and when the superficial veins at the elbow become 
 distended, the needle of the syringe or blood aspirator is inserted into 
 the most prominent vessel. When employing the syringe, the piston is 
 withdrawn slowly until the desired quantity of blood is obtained. As a 
 rule, the blood flows freely into the aspirator previously described, but, 
 should this not be the case, a sufficient amount can be secured by 
 making suction through the rubber tube. The bandage about the arm 
 is then removed, the needle withdrawn, and a sterilized dressing applied 
 to the wound. 
 
246 
 
 MEDICAL DIAGNOSIS. 
 
 The blood is placed in a suitable culture medium. Fluid media such as 
 bouillon and litmus milk are generally selected for the primary inocula- 
 tions when certain types of bacteria are suspected, while agar may be 
 chosen when the medium is to be plated. One or two cubic centimetres 
 of blood are added to 50 or 100 c.c. of fluid medium so that dilutions of 
 one in fifty or one in one hundred are secured. For details of 
 bacteriological technic, which do not fall within the scope of this 
 work, special treatises on bacteriology should be consulted. 
 
 Agglutination Reaction. — The blood in certain stages of 
 typhoid fever, and often after the attack, possesses the prop- 
 erty of checking the motility of typhoid bacilli and causing 
 these organisms to form into clumps. This agglutination 
 phenomenon is so pronounced that high dilutions of blood, 
 as one in fifty or one hundred, or even higher, give positive 
 results. The blood in similar dilutions in other diseases and 
 in health does not act in this manner with typhoid bacilli. 
 With low dilutions, however, a positive agglutination reaction 
 is often present with normal or abnormal blood. In a number 
 of diseases — as pneumococcal and streptococcal infections, 
 paratyphoid fever;, Malta fever, tuberculosis, cholera, plague, 
 relapsing fever, glanders, and others — specific agglutination 
 reactions have been obtained. The agglutination test is 
 chiefly employed in the diagnosis of typhoid and paratyphoid 
 fevers and is generally spoken of as the Widal, Gruber-Widal, 
 or Pfeiffer- Widal reaction. For this test two methods are 
 available, (1) the microscopic and (2) the macroscopic. In 
 typhoid fever the agglutination reaction is positive in about 
 97 per cent, of the cases during the course of the disease, 
 manifesting itself in a majority of them about the end of the 
 first or during the second week, in a few instances as early 
 as the third or fourth day, while in others it is not obtained 
 until the attack is far advanced, and it often persists long 
 after convalescence. The intensity of the reaction varies in 
 different cases. Positive reactions are obtained with dilu- 
 tions as high as 1 : 200. In some instances the reactions occur 
 almost instantly, while in others the stoppage of motility 
 and clumping take place slowly. 
 
 1. Microscopical Serum Test. — This test may be per- 
 formed with fluid blood, blood-serum, or dried blood. 
 
 Technic. — Preparing Cultures. — From a slant agar growth 
 of typhoid bacilli, preferably not older than one month, sub- 
 cultures are made in sterile bouillon and incubated at blood 
 heat for 8 to 12 hours, when they are ready for use. The stock culture 
 should be kept in a cool place. Some workers prefer a suspension of 
 typhoid bacilli in salt solution made by placing a loopful of a twenty-four 
 hour agar growth in saline solution. The tube containing the fluid is 
 agitated until a uniform suspension of the germs is obtained. 
 
 Collecting and Diluting Serum. — A capillary pipette, suitable for 
 measuring the blood, is made from a piece of glass tubing about 30 cm. 
 
 Fig. 102.— 
 Capillary- 
 pipette. 
 
x_' 
 
 EXAMINATION OF THE BLOOD. 247 
 
 in length and 5 or 6 mm. in diameter. The middle portion of this tube 
 is heated in the Bunsen flame; rotating continuously in its long axis until 
 the glass is thoroughly softened over 3 to 6 centimetres of its length; 
 remove from the flame and draw the two ends apart M'ith a steady uniform 
 pull so that the heated portion tapers into a long capillary tube. By 
 melting the middle of the capillary tube in the flame, two pipettes 
 with the capillary end sealed off are made. A AVright's blood capsule, 
 shown in Fig. 103, will be found convenient for collecting the blood. 
 Preparing the Serum. — The patient's finger-tip is cleansed and 
 rubbed briskly so as to produce hyperemia. A puncture is then made 
 of sufficient size so as to insure a good flow of blood. The sealed tips 
 of a Wright's capsule are broken off, and the end of the short curved 
 portion of the capsule is placed into the blood as it issues from the 
 small wound, the body of the tube slanting downward so as to allow 
 the blood to enter by gravity. The capsule is partly filled {h or fj 
 full). The tip of the longer arm is sealed off by heating in a flame. 
 When properly cooled, the blood is shaken down. The other end 
 may then be closed to prevent evaporation, if the test is not made 
 immediately. The capsule is now booked upon the rim of 
 a centrifuge tube and centrifugalized until clear serum sepa- 
 rates. Slight turbidity of the serum does not interfere with 
 the test. The capsule containing the centrifugalized blood is 
 opened by filing a groove into the glass tube above the level fig. io3.— 
 of the serum and breaking off the end. The fine end of a work.-Emlrso^ 
 capillary pipette (having previously been broken off the sealed 
 tip) is inserted into the capsule and the serum drawn into the tube. The 
 blood -serum may be diluted and mixed with the culture in watch crystals 
 or in a porcelain plate having a number of cup-shaped depressions as shown 
 in Fig. 104. One drop of serum is now placed into one of the depressions 
 of the porcelain plate. Dilutions of the serum with sterilized normal 
 salt solution are then made. The capillary tube, having been cleaned 
 with salt solution or water, is partly filled with saline fluid. Into the 
 
 depressions containing a drop of 
 serum, 24 drops of salt solution are 
 allowed to fall from the pipette and 
 mixed, thus making a dilution of 
 1-25, since the drops from the 
 pipette are practically of the same 
 size. Into a second depression are 
 ^^" '"''■l^^^^^lJtJZ-XA^:'''^' '''' placed 5 drops of salt solution 
 
 and 5 drops of the diluted serum 
 of 1-25, securing a 1-50 dilution. More accurate results are obtained 
 by measuring and diluting the serum in a Thoma-Zeiss hsemocytometer 
 pipette. Two hanging drop preparations are prepared — one from each 
 dilution — by mixing upon a cover-glass a platinum loopful of bouillon 
 culture of typhoid bacilli with a loopful of diluted serum. Since each 
 dilution of serum is again diluted to h, the proportions now stand 
 1-50 and 1-100. The cover-glasses are adjusted upon the slides and the 
 edges of the slips surrounded by petrolatum to prevent evaporation. The 
 
248 MEDICAL DIAGNOSIS. 
 
 preparations are allowed to stand at room temperature for exactly one 
 hour. In order to secure correct results, it is essential that the motility 
 of the bacilli should be active, and the density of the culture be uniform 
 and not show clump-like gatherings. 
 
 Recording Results. — i\.t the end of one hour, the hanging drop slides 
 are examined microscopically. When motion of the bacilli is found absent 
 and clumping good in both slides, the reaction is termed ''positive," but 
 when the free motion without clumping of bacteria is noted, the test is 
 negative. Variations between these two extremes may be recorded ac- 
 cording to the judgment of the examiner. Thus, if 1-50 shows no motion 
 and good clumping, but 1-100 exhibits slight motion and only fair clump- 
 ing, the reaction may be called "very suggestive;" or, again, if 1-50 
 shows slight motion and poor clumping, while 1-100 free motion and no 
 
 =^^^' 
 
 %- 
 
 
 
 w 
 
 ™^ * 
 
 Fig. 105. — Widal test. Field of motile organ- Fig. 106. — Widal test. Field of agglutinated 
 isms. — Emerson. organisms. — Emerson. 
 
 clumping, the reaction may be called "slightly suggestive." It is best 
 to indicate definitely the results of each dilution, as for example: 
 
 1-50 Good clumping. No motion. 
 
 1-100 Fair clumping. Slight motion. 
 
 This allows the diagnostician to form his own conclusions and does 
 away with dogmatic assertions, such as "Widal positive" or "Widal 
 negative," which are so often a matter of personal equation upon the 
 part of the laboratory worker. 
 
 The liquid serum method, unfortunately, cannot always be employed 
 by physicians in active practice. The microscopical test may be carried 
 out with blood collected upon a piece of paper, or upon a slide and allowed 
 to dry, after which the test may be made at any time. The blood secured 
 in this manner is moistened and dissolved in sterilized water, and then diluted 
 and mixed v/ith the culture in the desired proportions. It is obvious that 
 accurate dilutions are impossible, an objection to this method. 
 
 2. Macroscopical Serum Test. — By aspirating a vein, a sufficient 
 amount of blood is collected in a sterile test-tube and allowed to clot, 
 so as to separate the serum, or the blood may be centrifugated. The 
 
EXAMINATION OF THE BLOOD. 249 
 
 serum is mixed with salt solution and bacterial culture in the desired pro- 
 portions (1-50 or 1-100). In the case of a positive reaction a flaky precipi- 
 tate will separate with a clear supernatant fluid, while a negative reaction 
 shows uniform turbidity of the fluid. The macroscopical test may also 
 be performed by mixing bouillon and serum in proper dilutions and inocu- 
 lating the mixture with a loopful of a broth culture. The presence of a pre- 
 cipitate in the tube at the end of twenty-four hours' incubation signifies 
 a positive result. The chief objection to the macroscopic method is the 
 relatively large amount of blood required. The microscopic test is gen- 
 erally employed in clinical work. The macroscopical test may also be 
 performed with dead cultures of the bacilli. The principle of the Ficker 
 "Typhus Diagnosticum" is based on mixing a dead culture with diluted 
 blood-serum. Bacilli in liquid media killed with carbolic acid or formalin 
 are also employed for this test. 
 
 Opsonic Index of the Blood and Its Determination. — Leishman 
 in 1902 devised a method for estimating the phagocytic activity of the 
 leucocytes. Extensive researches upon this subject have recently been 
 made by Wright and Douglas, and many other investigators. Opsonins 
 are substances within the blood which prepare bacteria for ingestion by 
 the white cells. The power of the leucocytes alone to ingest bacteria, the 
 so-called "spontaneous" phagocytosis, has been shown to be very slight, 
 and the role played by them in fighting diseases is merely as scavenger, 
 collecting bacteria acted upon by the opsonins. Opsonins do not stim- 
 ulate or otherwise affect the leucocytes. These substances are destroyed 
 by a temperature of 65° C. for ten minutes. 
 
 Technic. - — The special technic used for the determination of the 
 opsonic power of the blood may be briefiy set forth as follows: There 
 must be on hand for the test (1) an emulsion of the bacteria in salt solution, 
 (2) washed white blood-cells, taken from any source, (3) serum from the 
 patient's blood, and (4) serum of normal blood or from a mixture of healthy 
 bloods taken as a standard control. 
 
 Preparing the Bacterial Emulsion.- — The micro-organisms for the test 
 are inoculated upon culture medium. For some forms of bacteria, as the 
 Staphylococcus aureus, an agar medium is selected. After twenty-four 
 hours of incubation at 37° C. a fair-sized colony, found on the culture 
 medium, is removed and mixed with a sterile .85 per cent, salt solution. 
 The resulting bacterial emulsion is drawn up and down in a small pipette 
 by means of rubber teat. The emulsion is set aside for a few minutes so 
 as to allow the bacterial clumps to settle. The supernatant liquid is then 
 removed and diluted to the desired density. Centrifugalizing may be neces- 
 sary to separate bacterial clumps. With bacteria not readily emulsified, 
 such as tubercle bacilli, grincUng between glass plates or in an agate mortar 
 is required to disintegrate the masses. The emulsion in case of tubercle 
 bacilli may be made from fresh cultures or from dry, dead germs, such as 
 are obtained in the production of tuberculin. Tubercle bacilli are best 
 emulsified with a 1.5 per cent, salt solution. The proper density is one 
 which on mixture with a normal serum and with the leucocytes in equal 
 proportions will show that after incubation an average of 5 or 6 germs 
 have been phagocytozed by each leucocyte. The density of the standard 
 
250 MEDICAL DIAGNOSIS. 
 
 bacterial mixture may be fixed by McFarland's nephelometer, or by count- 
 ing the bacteria in a given amount of emulsion in a Thoma-Zeiss count- 
 ing chamber. 
 
 Obtaining the Washed Leucocytes. — A test-tube is filled two-thirds full 
 with an aqueous solution containing 1.5 per cent, sodium citrate and .85 per 
 cent, sodium chloride. The finger is pricked and S to 12 drops of blood 
 are allowed to fall into the tube. The solution is shaken and then the 
 tube is i^laced in an electric centrifuge and centrifugalized for 5 minutes 
 at a speed of 1500 to 2000 revolutions per minute. The citrate defibrin- 
 ates the blood and prevents clotting, while the sodium chloride solution 
 washes the cells free of serum. Upon removal from the centrifuge, the 
 tube is found to contain a compact sediment of blood-cells with a clear 
 or very slightly cloudy supernatant fluid which consists of serum and 
 salt solution. Overlying the surface of the red sediment will be found 
 a white coating termed the "creamy layer," which is formed principally 
 of white cells. The clear supernatant fluid is now drawn off with a capil- 
 lary pipette by means of a rubber bulb. The layer of leucocytes, which 
 contains some red cells, is now carefullj^ removed from the compact la^^er 
 of erythrocytes with the capillary pipette and placed in a small glass 
 tube having a sealed end. The leucocytes may be washed with saline 
 solution several times in order to remove the sodium citrate. This is 
 accomplished by placing the leucocytes in a centrifuge tube or small test- 
 tube and partly filhng it with .85 per cent, salt solution. The tube is 
 then centrifugalized, after which the supernatant fluid is removed with a 
 pipette. This operation may be repeated. 
 
 Obtaining the Serum. — A Wright's capsule is filled two-thirds full of 
 blood, obtained from the patient, and centrifugalized until the serum is 
 clear. Serum must also be obtained from normal blood. Having on hand 
 the bacterial emulsion, washed corpuscles, and serum, the main part of 
 the test may be carried out. By means of a capillary pipette, equal 
 amounts of bacterial emulsion, white blood-cells, and serum are measured, 
 and the fluid mixed on a slide or watch crystal by drawing the material 
 up and forcing it down the capillary pipette. The fluids are measured 
 in the following manner: The rubber teat attached to the pipette is 
 compressed, and, by gently relaxing the pressure, white cells, bacterial 
 emulsion, and serum, in the order named, are drawn into the capillary 
 bore up to the mark indicated by the pencil mark, each column being 
 separated, by a small air bubble. Two pipettes are necessary for one test, 
 one for the patient's serum, the other for the control serum. A special 
 pipette, supplied with a rubber teat, is often used to measure and mix 
 the bacterial emulsion serum and washed leucocytes, and is constructed in 
 such a manner as to allow the worker a means of controlling accurately 
 the amount of fluids drawn up in the long arm of the pipette and of 
 mixing the contents afterwards. The sealed tip of a capillary pipette 
 having been broken off squarely, a pencil mark is made 2 or 3 cm. above 
 its extremit3^ After the ingredients are thoroughly mixed, the fluid is 
 drawn into the pipette and its end sealed in the flame. The tube is then 
 placed in the incubator at 37° C. for 15 minutes. In a like manner, the 
 control test is prepared with equal amounts of white corpuscles, bacterial 
 
EXAMINATION OF THE BLOOD. 251 
 
 emulsion, and normal serum, which are also incubated. After incubation 
 the end of the pipette is broken off and the contents are run up and down 
 so as to mix thoroughly. Smear preparations are made of the material 
 from each pipette upon slides or cover-glasses. After fixation the smears 
 are treated with any reliable stain, such as Leishman's, which brings out 
 distinctly the leucocytes and bacteria. For tubercle bacilli, carbol fuchsin 
 and Gabbett's or Pappenheim's stain may be employed. The specimens 
 are now examined with an oil-immersion lens. The number of bacteria 
 in 100 typical polymorphonuclear neutrophiles is determined in both 
 specimens. The average number of bacteria per leucocyte is then cal- 
 culated for each specimen, which constitutes the phagocytic index. The 
 phagocytic index of the patient's serum divided by the phagocytic index 
 of the normal or control serum gives the opsonic index. The test can 
 only be carried out properly in a well-equipped laboratory by one who has 
 mastered opsonic technic. The strength of the bacterial emulsion, the 
 length of incubation, the age of the ingredients employed, and the personal 
 equation are some of the factors which influence the results. Opsonic 
 index is employed in the diagnosis and prognosis of certain infectious 
 diseases and in gauging the dose and the frequency of administration 
 of bacterial vaccines. After the injection of therapeutic doses of bacterial 
 vaccines, the index is seen primarily to fall and soon afterwards to rise 
 above the normal. The initial fall constitutes the ''negative phase" and 
 the rise the "positive phase." The vaccine should not be repeated until 
 the negative phase has passed into the positive, and this can only be 
 gauged by repeated observations of the index. The value of the opsonic 
 index for therapeutic or diagnostic purposes has not been definitely settled. 
 
 Test for the Detection of Diabetes Mellitus. — Two clinical blood- 
 tests have been devised for this purpose, both of which are based upon 
 similar principles. 
 
 Williamson's Test. — Twenty cubic millimetres of blood measured 
 with the pipette of a Gowers's hsemocytometer are mixed with 40 cubic 
 millimetres of distilled water in a test-tube. One cubic centimetre of a 
 solution of methylene blue, of a strength of 1:6000, and 40 cubic centi- 
 metres of a 6 per cent, aqueous solution of potassium hydrate are then 
 added to the diluted blood. A control test with normal blood should 
 always be made. The test-tubes are then placed in boiling water for about 
 five minutes, after which the solution containing the diabetic blood will 
 have a yellowish color, while the color of the control mixture remains 
 unaltered. This reaction may be positive in cases of diabetes mellitus 
 after sugar disappears from the urine. 
 
 Bremer's Test. — Cover-glass films of the suspected blood and of 
 normal blood to be used as a control test are made, which are fixed by 
 heat at a temperature of 135° C. The smears are treated with a freshly 
 prepared aqueous solution of Congo-red. The stain is washed off with 
 water, and the preparations dried. The diabetic blood-film is colored 
 a greenish-yellow, while the control film is stained red. Other aniline 
 dyes, as methylene blue, methyl green, may be employed for this test. 
 This test is at times positive with the blood of individuals suffering from 
 -other diseases, as leukaemia, Hodgkin's disease, and Graves's disease. 
 
252 MEDICAL DIAGNOSIS. 
 
 General Results of Blood Examinations. 
 
 Volume. — The blood, which forms from 4 per cent, to 7 per cent, 
 of the total body weight, is a highly specialized tissue, consisting of eryth- 
 rocytes, leucocytes, blood-plaques, and hsemokonia, suspended in a liquid 
 matrix, the plasma. In health the total volume of blood varies within 
 narrow limits. The view formerly entertained that an increase in the 
 total amount is constantly present in some individuals — plethora — is not 
 sustained by recent researches. Oligcemia, or a decrease in the total quan- 
 tity,— e.g., due to a copious hemorrhage, — persists only for a short time 
 after the bleeding, as the volume is rapidly brought up to its normal 
 standard by the absorption of fluid from other tissues, which dilutes the 
 remaining blood, producing a condition termed hydrmmia or serous pleth- 
 ora. Rapid abstraction of watery elements from the blood by sweating, 
 diarrhoea, or vomiting causes a transitory increase in its density, known 
 as anhydrcemia. 
 
 Color. — The color of the arterial blood is bright red, due to the presence 
 of a large amount of oxyha?moglobin, while that of venous blood, which 
 contains less oxyhsemoglobin and much carbon dioxide, is dark red or 
 purple. In some pathological states, as in diabetes mellitus and in leu- 
 kaemia, the blood often has a milky tint; a peculiar chocolate color is some- 
 times imparted to the blood by poisoning with potassium chlorate, nitro- 
 benzol, and hydrocyanic acid. Imperfect aeration, encountered in some 
 diseases of the respiratory organs and heart and in chronic polycythsemia 
 with splenic enlargement (Osier's disease), causes dark red blood similar to 
 the color of venous blood. In carbon monoxide poisoning it is bright scarlet. 
 
 Reaction. — The reaction of normal blood is alkaline. The degree of 
 alkalescence varies considerably both in health and in disease. None of 
 the methods of determining the intensity of this reaction has been gen- 
 erally adopted for routine cHm'cal purposes, and, as the results of various 
 methods are not uniform, comparative studies by different observers are 
 in the main inaccurate. The adoption of some standard technic may 
 establish definite results, but up to the present time the data bearing 
 upon this subject are insufficient to warrant positive opinions. Statistics 
 indicate that the alkalinity is lowered in many pathological conditions, 
 notably in diabetic coma, in many of the infectious diseases, especially 
 in Asiatic cholera, in organic hepatic disease, in uraemia, in cachectic states, 
 in a considerable group of skin affections, in poisoning by mineral acids, and 
 in a number of other conditions. In chlorosis and rheumatic fever it has 
 been found increased. 
 
 Specific Gravity. — The specific gravity of normal blood is about 
 1.060. It fluctuates sHghtly in health, while in disease there are wide 
 oscillations. The specific gravity range is decidedly influenced by the 
 amount of haemoglobin, and so close is the relation between the two that 
 an approximate haemoglobin estimation can be made by determining 
 its specific gravity. Exceptions to this rule are found in the case of leu- 
 kaemia, in which the range of specific gravity would indicate a higher 
 haemoglobin value than actually exists, while in pernicious anaemia the 
 reverse is true. 
 
EXAMINATION OF THE BLOOD. 253 
 
 Coagulation of the Blood. — Within a short time after blood has 
 been withdrawn from the circulation of a healthy individual, it under- 
 goes coagulation, a process which determines the formation of fibrin and 
 the separation of a clear, straw-colored fluid, the blood-serum. In a num- 
 ber of diseases considerable importance is attached to the determination 
 of the time required for clotting. Delayed coagulation is encountered 
 in persons suffering from obstructive jaundice, purpura, scurvy, and hfiemo- 
 philia. In pernicious anaemia, in some cases of leukaemia, and at times 
 in Hodgkin's disease, the rate of coagulation is prolonged. In some of 
 the infectious fevers, and in acute inflammation attended with abscess 
 formation, clotting is retarded, while in chlorosis, pneumonia, and scarlet 
 fever it is rapid. 
 
 The Plasma. — The plasma, a complex albuminous body, which holds 
 in suspension the solid elements and in solution many organic and inor- 
 ganic compounds, is the vehicle through which substances are transported 
 to the tissues and waste products carried to the excretory organs. The 
 plasma also holds certain bodies possessing antitoxic, bactericidal, ag- 
 glutinative, and opsonic properties. Agglutinins are of importance in 
 the diagnosis of many infectious diseases, as in enteric fever, paratyphoid 
 infections, Malta fever, cholera, relapsing fever, and dysentery. Some 
 observers have noted this reaction in tuberculosis, pneumococcus and 
 streptococcus infections, plague, and leprosy. 
 
 Erythrocytes. — The red blood-corpuscles in a preparation of fresh 
 blood, taken from the peripheral circulation of a healthy person, appear 
 as pale yellowish-green, non-nucleated, flattened, biconcave cells of a 
 circular outline. They are pliable, somewhat elastic, non-amoeboid, trans- 
 parent, and show a tendency to form into groups or rolls when withdrawn 
 from the circulation, and consist of a fine stroma which holds an albu- 
 minous iron compound, the haemoglobin. Structural alterations of these 
 cells occur when blood is removed from the circulation. They occasion- 
 ally exhibit amoeboid activity and may undergo disintegration, fragmen- 
 tation, vacuolation, and crenation. A crenated corpuscle is a shrunken 
 cell from which knob-Hke processes project. Structural alterations similar 
 to those caused by withdrawing the blood from the vessels occur within 
 the circulation as a result of pathological factors. 
 
 Staining Reaction of the Erythrocyte. — The normal red blood-cell, 
 when properly fixed, has a monochromatophilic reaction, showing 
 a selective affinity for acid dyes, while the Hving cell does not absorb 
 stains (achromatophilic). On account of its biconcavity, the central 
 part of the cell stains less intensely than the peripheral zone. The long 
 diameter of the majority of the healthy cells measures about 7.5 microns, 
 while its variations are between 6 and 9 microns. 
 
 Haemogenesis and Haemolysis. — It appears to be definitely established 
 that in the adult the red bone-marrow is the chief, if not the only seat 
 of erythrocytic formation. The colored cells develop from nucleated 
 elements, erythroblasts, situated along the walls of capillary spaces of 
 the marrow. Some authorities contend that erythroblasts and certain 
 forms of immature leucocytes are derived from a common ancestral cell. 
 The spleen and lymphatic glands are regarded by some as sources of 
 
254 MEDICAL DIAGNOSIS. 
 
 erythrocytic formation, a view which is not entertained by man}^ writers. 
 The fairly uniform number maintained in the circulating blood of the 
 healthy individual depends upon the existence of a parallelism between 
 the rate of formation and the rate of destruction. Pathological erythro- 
 cytic destruction, unless excessive or prolonged, excites augmentation 
 in the activity of erythroblastic multiplication and is followed by an 
 increase in the output of red cells from the marrow. Most authorities 
 maintain that the liver and in a less degree the spleen and the gastro- 
 intestinal capillary area are concerned in destroying weakened, degener- 
 ated, or necrotic cells, while some hold that the bone-marrow also has a 
 hsemolytic function. The coloring material derived from the disintegrated 
 cells is in part transformed, in the liver, into bile pigment and eliminated 
 through the biliary channels, in part discharged by the kidneys, and prob- 
 ably, to a considerable extent, stored up in many of the tissues where it- 
 is available for future needs of the body. 
 
 Number of Red Blood=ceIls. — The normal number of erythrocytes^ 
 which is 5,000,000 per cubic millimetre for an adult male and 4,500,000' 
 for an adult female, is subject to slight variations under certain phys- 
 iological conditions and to pronounced alterations in many morbid states.. 
 A decrease in the number is termed oligocythcemia, while an increase 
 is designated folycythamia. High counts are at times an indication of a 
 decrease in the volume of plasma causing a relative polycythsemia. After 
 blood transfusion, and after active blood regeneration, a temporary rise 
 may be noted. Polycythsemia is encountered in the new-born, where it 
 exists for some days after birth — probably not exceeding ten — in indi- 
 viduals residing in high altitudes, and in robust and well-developed per- 
 sons. Massage, electricity, and cold bathing may also induce an increase 
 in the erythrocytes in the peripheral blood. A slight reduction in the 
 erythrocytes is brought about by pregnancy, menstruation, and lactation; 
 it is also met with in poorly nourished individuals, in those who are 
 fatigued, and during the period of digestion. Oligocythaemia, due tc^ 
 physiological causes, may sometimes be accounted for by temporary dilu- 
 tion of the blood, while in other instances an absolute decrease in the 
 number of cells offers the best explanation. 
 
 In pathological states a relative transitory increase arises when the 
 output of fluid from the body is decidedly in excess of the intake, and 
 is therefore conspicuous in diseases associated with marked polyuria, as 
 diabetes, with copious sweating, as from night sweats of pulmonary tuber- 
 culosis, with frequent vomiting, with profuse diarrhoea, as in Asiatic cholera,, 
 and after the withdrawal of a large quantity of fluid from a serous cavity, 
 which rapidly reaccumulates, thereby draining the blood of much fluid. 
 The pathological factors responsible for oligocythaemia are numerous, 
 and in the vast majority of diseases associated with lowered counts the 
 reduction depends upon increased blood destruction, in some it may be 
 due to defective blood formation, or to a combination of both of these 
 factors, while in others a slight transitory decrease is brought about by 
 blood dilution — whenever the amount of fluid taken into the body is 
 above the output of liquid. Lowered erythrocytic standards are noted 
 in the primary anaemias, notablj'' pernicious anaemia, in which the figure 
 
EXAMINATION OF THE BLOOD. 255 
 
 often falls as low as one million, and in occasional instances below half 
 a million. Secondary anaemias arise from a great variety of causes, as 
 from infections due to bacteria and animal parasites, metallic poisoning, 
 organic visceral disease, hemorrhage, and many others. 
 
 The Haemoglobin. — Haemoglobin, a complex albuminous compound 
 containing iron which is a component of the red cells, normally exists 
 in two chemical states, in combination with oxygen (oxj^hsemoglobin) 
 and as reduced or plain haemoglobin. Normal blood contains about 14 
 per cent, of haemoglobin. A reduction of hasmoglobin, termed oligochromce- 
 mia, is generally associated with a fall in the number of erj'throcytes. 
 This deficiency of corpuscles, as a rule, is not so marlced as the haemo- 
 globin loss, although sometimes the number of colored elements remains 
 normal; rarely there is a proportionate reduction of the coloring matter 
 and of the number of cells, or the latter may even show a greater percent- 
 age reduction than the haemoglobin. An insufficient amount of haemo- 
 globin in the corpuscles is brought about by an elfort on the part of the 
 bone-marrow to rapidly regenerate cells at the expense of perfect forma- 
 tion (i.e., after or during rapid haemolysis). A high color index occurs in 
 pernicious anaemia. Investigations, both experimental and clinical, have 
 demonstrated that the haemoglobin rises in certain anaemic states by the 
 administration of iron compounds. 
 
 Hcemoglohincemia, the term which implies the presence of haemo- 
 globin in solution in the plasma, is due to a number of causes, and is at 
 times followed by the excretion of haemoglobin by the kidneys (haemo- 
 globinuria). The disease known as paroxysmal haemoglobinuria is a 
 striking example of the latter condition. Among the conditions capable 
 of producing haemoglobinaemia are poisoning by sulphuric acid, nitro- 
 benzol, phenacetin, acetanilid, phenol, hydrochloric acid, potassium chlorate, 
 mushrooms, and snake venoms. Haemoglobinaemia is excited by some of 
 the infectious diseases, as malarial fever, enteric fever, j^ellow fever, typhus 
 fever, variola, septicaemia, diphtheria, and syphilis; also by malignant 
 jaundice, scurvy, sunstroke, burns, and from exposure to intense cold. 
 
 M ethcemoglohin , another combination of oxygen and hiemoglobin, 
 is a component of some pathological bloods and is present in poisoning 
 with such substances as potassium chlorate, aniline, amyl nitrite, potas- 
 sium permanganate, antifebrin, nitro-benzol, hydrochinone, potassium ferro- 
 cyanide, and snake venom. Carbon monoxide haemoglobine, which occurs 
 in coal-gas poisoning, gives the blood a bright scarlet appearance. 
 
 Abnormal Erythrocytes. — Cells exhibiting abnormal variations in 
 size are common in anaemic states, particularly small erythrocytes known 
 as microcytes, which have a diameter of less than 6 microns, and when 
 these forms predominate in the blood the condition is termed microcytosis 
 or microcyihcemia. This change is conspicuous in chlorosis and in some 
 secondary anaemias of the chlorotic type. Minute erythrocytes, spherical 
 in form, with a deeply colored protoplasm, are often described as Eich- 
 horst's corpuscles. Cells measuring more than 9 microns are designated 
 macrocytes, and when these abnormally large forms outnumber other 
 colored elements macrocytosis or macrocythdmia exists. Typical cases 
 of pernicious anaemia show an average increase in the size of the red cells. 
 
256 MEDICAL DIAGNOSIS. 
 
 Kapid or defective blood formation has been advanced as the factor 
 responsible for microcytosis, although structural alteration in the cells 
 after they have entered the circulation, such as fragmentation and loss 
 of haemoglobin, maj^ account for some of these dwarfed elements. Macro- 
 cytosis appears to depend upon the development of large cells in the mar- 
 row, or perhaps it is due to swelling of the protoplasm of the erythrocytes 
 while in the general circulation. 
 
 Poikilocytes are cells having an irregular or distorted outline and 
 often appear as pear-shaped, elongated, oval, and "hour-glass" forms. 
 These pathological cells show wide variations in size and in staining pecu- 
 liarities. The degree of cell deformity and the extent of the variation in 
 size are generally proportionate to the severity of the aneemia. Per- 
 nicious anaemia and grave secondary anaemias reveal poikilocytosis in 
 its most typical form. Cells so deficient in haemoglobin that a mere color- 
 less shell remains are termed phantom or shadow corpuscles or achroma- 
 cytes. Erythrocytes which react indifferently and irregularly to acid and 
 basic dyes, staining diffusely with both, — termed polychroinatophUic cells, — ■ 
 are observed in profound anaemias, particularly in progressive pernicious 
 anaemia. The}^ appear in specimens stained with eosin-methylene-blue 
 mixtures, as purple, brownish, or bluish cells, their color, as a rule, being 
 unevenly distributed, and in some instances only a part of the protoplasm 
 exhibits this altered tinctorial reaction. The cj^toplasm of nucleated 
 red cells, especially of the megaloblast, often shows this change. Some 
 authorities maintain that this abnormal staining quality is an indication 
 of immature cell development, while others regard it as a sign of stroma 
 degeneration. Oval or "ring-like" bodies reacting to basic dyes are occa- 
 sionally observed in the red cells which some students assert are the remains 
 of a nuclear structure. Red cells which contain granular areas having 
 a basic stain affinity scattered through the cytoplasm, appearing in some 
 corpuscles as a fine stippling and in others as coarse irregular granules, are 
 described as cells showing granular basophilia. This condition is observed 
 in severe anaemias, especially of the pernicious type, in leukaemia, and 
 constantly in chronic lead poisoning. Some investigators regard it as an 
 indication of degeneration of the cells, while others are inclined to view 
 this feature as an evidence of nuclear fragmentation. 
 
 Nucleated Red Blood-cells. — Nucleated red blood-corpuscles 
 are normally found in the blood during the early months of fetal life and 
 in the blood-marrow of all individuals. Two principal types are found, 
 normoblasts and megaloblasts. 
 
 Normoblasts. — This cellular element, a normal constituent of the 
 bone-marrow of the healthy adult, is about the size of the normal erythro- 
 cyte, and consists of a single oval or round nucleus (rarely two or three), 
 which reacts intensely to basic stains, while the cytoplasm has an acido- 
 philic affinity like a normal erythrocyte. At times this cell contains an 
 irregularly shaped nucleus or several may be noted in a single cell. The 
 nucleus is often eccentrically placed, and sometimes extrudes from the 
 cell or may be found free in the plasma. The occurrence of normoblasts 
 in the circulation of the adult is generally regarded as a sign of rapid blood 
 regeneration, well illustrated after a profuse traumatic hemorrhage, where 
 
EXAMINATION OF THE BLOOD. 257 
 
 large numbers of these cells often are present in the blood, a condition 
 which Von Noorden has termed "blood crisis." Cells having the diameter 
 ranging from 4 to 6 microns, with a round or oval nucleus reacting sharply 
 to basic dyes, and a shrunken irregular protoplasm, called microblasts, 
 probably represent normoblasts having a degenerated cytoplasm. Megal- 
 ohlasts "^ry in size between 1 1 and 20 microns in diameter, and consist 
 of a large nucleus of loose texture staining feebly, surrounded by a com- 
 paratively small amount of cytoplasm. A clear hyaline space or ring 
 sometimes separates the nucleus from the protoplasm, which not infre- 
 quently has a polychromatophilic reaction. Fetal bone-marrow normally 
 contains megaloblasts. Most writers regard the presence of megaloblasts in 
 the circulating blood of the adult an indication of a reversion of the marrow 
 activity to an earlier type similar to that found in the foetus. These cells 
 are found in grave forms of anaemia, as typified in pernicious ana?mia. 
 
 Blood=plateIets. — Blood-platelets, or blood-plaques, are small, spher- 
 ical, oval, or irregular bodies, having a pale yellowish color, and measure 
 from 1 to 4 microns in diameter. They are not endowed with amoeboid 
 activity, and stain with both acid and basic dyes. Blood-plaques disap- 
 pear rapidly after the blood is exposed to the air. Some writers con- 
 sider these elements as being derived from fragmented red blood-cells. 
 The investigations of J. H. Wright indicate that they represent broken- 
 off pieces of processes of giant marrow cells. Hayem's hypothesis that 
 the blood-plates develop into erythrocytes is rejected by most authorities. 
 Counts in the neighborhood of 30,800 per cubic milHmetre are consid- 
 ered normal. Variations under physiological and pathological influences 
 are common. In many severe secondary anaemias, in leukaemia, in chloro- 
 sis, and in rheumatoid arthritis an increase is encountered, while in per- 
 nicious anaemia their number is generally reduced. In some of the specific 
 infectious diseases, particularly in pneumonia, in tuberculosis, and in 
 bubonic plague, an increase is found, while in others, notably in erysip- 
 elaS; in malaria, and in typhus fever, there is a decrease. A marked reduc- 
 tion is frequently seen in purpura and haemophilia. 
 
 Haemokonia. — In fresh unstained blood there are found, in the plasma, 
 ;small, transparent, highly refractile bodies, not exceeding one micron in 
 diameter, of spherical, oval, or dumb-bell shape, possessing active molec- 
 ular motion, which are termed haemokonia, or blood dust. These bodies 
 are insoluble in ether or alcohol and do not stain with osmic acid. Their 
 significance is as yet unknown ; it has been suggested that they represent frag- 
 ments of cells or free cell granules, as eosinophilic or neutrophilic granules. 
 
 Leucocytes. — The leucocytes, or white blood-corpuscles, in a wet prepa- 
 ration of fresh blood taken from a normal individual, appear as pale, color- 
 less, nucleated cells, the greater number of which are granular and endowed 
 with amoeboid activity. Ehrlich's classification is generally adopted for 
 clinical work. The following table includes the main varieties of leucocytes 
 with their relative percentages present in the blood of the normal adult: 
 
 Polynuclear neutrophiles 60-70 per cent. 
 
 Eosinophiles 5- 4 per cent. 
 
 Basophiles or mast-cells 025- .5 per cent. 
 
 Small lymphocytes 20-30 per cent. 
 
 Large lymphocytes, hyaline cells, and transitional forms. . 4- 8 per cent. 
 17 
 
258 MEDICAL DIAGNOSIS. 
 
 In infancy the percentage of lymphocytes is greater than in adult 
 life, while eosinophiles may reach as high as 14 per cent, in childhood. 
 
 Polynuclear Neutrophiles. — These cells, the diameter of which ranges 
 between 7h and 11 microns, have an irregular nucleus, appearing in various 
 shapes, as in the form of the letters U, Z, S, and a finely granular pro- 
 toplasm. The irregularly shaped nucleus, which is composed of enlarge- 
 ments or lobes connected by bands, reacts to basic dyes with marked 
 affinity. The granules are fine, of an irregular outline, and absorb acid 
 dyes (finely granular oxyphile cells). According to Ehrlich, the granules 
 have a neutral staining property. The polynuclear neutrophiles possess 
 amoeboid and phagocytic properties. 
 
 Eosinophiles or polynuclear eosinophiles (coarsely granular oxyphiles) 
 are about the size of or slightly larger than the normal erythrocyte, 
 their diameter ranging from 7 to 10 microns. They possess a nucleus 
 similar in structure and tinctorial qualities to that of the polynuclear 
 neutrophile; their protoplasm contains coarse, highly refractile, oval or 
 spherical granules, staining deeply with acid dyes. They are endowed 
 with active amoeboid qualities. 
 
 Basophiles or Mast=cens. — Under this term are classified leucocytes 
 which have a lobed or twisted nucleus like that of the neutrophiles and a 
 cytoplasm beset with very irregularly shaped basophilic granules of varying 
 size. The granules are not colored with Ehrlich's triple stain, but may be 
 plainly seen when treated with Leishman's or Ehrlich's dahlia mixture. 
 
 Small Lymphocytes. — These are essentially non-granular cells, the 
 majority being about the size of the normal erythrocyte. They consist 
 of a large circular or oval nucleus, which has a decided basic property 
 and a relatively small amount of protoplasm, reacting feebly to basic 
 and occasionally to acid stains. With Ehrlich's triple stain, the cytoplasm 
 is colored a pale pink or gray, while with Leishman's eosin-methylene- 
 blue mixture, a fight blue, showing less basic affinity than the nucleus. 
 Lymphocytes treated with I^eishman's stain occasionally show a few 
 fine pink granules in their cytoplasm. These cells are neither amoeboid 
 nor phagocytic. 
 
 Large Lymphocytes. — Several varieties of leucocytes are embraced 
 under this heading — lymphocytes proper of large size, generally regarded 
 as the product of lymphatic tissue, and large mononuclear or hyaline cells, 
 probably of bone-marrow origin. A distinction cannot always be made 
 between large lymphocytes and hyaline cells, since they resemble each 
 other as to structure and tinctorial reactions. The nucleus of the latter 
 cell Is round or oval. The protoplasm of the lymphocyte has a sHghtly 
 stronger basic affinity than that of the large mononuclear. From a clinical 
 standpoint this differentiation does not appear important. The large 
 lymphocytes have a relatively smaller nucleus than the small forms, and 
 stain less intensely. Transitional forms closely resemble large lympho- 
 cytes and hyaline cells in size and staining quafities, but differ from 
 these leucocytes in having an indented or distorted nucleus, resembling 
 the form of the nucleus of some of the polynuclear neutrophiles. 
 
 Hyaline cells are said to possess active phagocytic and amoeboid 
 properties. 
 
DESCRIPTION OF PLATE IV. 
 
 1. Neutrophile myelocyte. 
 
 2. Neutrophile myelocyte showing indentation of its nucleus. 
 3, 4. Neutrophile myelocytes. 
 
 5, 6, 7, 8, 9, 10. Polynuclear neutrophiles. 
 11, 12. Eosinophlle myelocytes. 
 13, 14, 15, 16. Polynuclear eosinophiles. 
 17. Basophile myelocyte. 
 18, 19. Polynuclear basophiles. 
 
 20. Blood platelets. 
 
 21. Large mononuclear form. 
 22, 23. Transitional forms. 
 
 24, 25. Large lymphocytes. 
 
 26. Lymphocyte showing acidophilic granules in its protoplasm. 
 27, 28, 29. Small lymphocytes. 
 30, 31, 32. Normal erythrocytes. 
 33, 34. Mlcrocytes. 
 35. Macrocyte. 
 36, 37, 38, 39, 40, 41. Poikilocytes. 
 
 42, 43, 44, 45. Erythrocytes containing basophilic granules. 
 
 46. Erythrocyte exhibiting polychromatophilia and granular basophilia. 
 
 47. Megaloblast. 
 48, 49, 50. Normoblasts. 
 
 51, 52, 53. Erythrocytes with polychromatophilic protoplasm. 
 
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 28 
 
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EXAMINATION OF THE BLOOD. 259 
 
 Myelocytes. — These cells, which are normal constituents of the bone- 
 marrow and only present in the blood in pathological states, are in the 
 main large cells supplied with a large circular, oval, or slightly indented 
 nucleus, staining feebly with basic principles, and surrounded by a granular 
 protoplasm. 
 
 These cells are classified into three groups, depending on the 
 microchemical reaction of the cell-granules, namely into neutrophilic, 
 eosinophilic, and basophilic varieties. The neutrophilic myelocyte is the 
 commonest form. Neutrophilic granules of myelocytes do not stain as 
 distinctly as those found in the polynuclear cells. Types intermediate 
 between typical polynuclear neutrophiles and typical neutrophilic myelo- 
 cytes are observed in some pathological conditions, especially myelogenous 
 leukaemia and not infrequently in leucocytosis. Myelocytes often show 
 indistinct granulations embedded in a feebly basic protoplasm; these 
 forms are considered by some to be closely related to cells farther back 
 in their ancestral development. 
 
 There are a number of special varieties of leucocytes described by 
 different authors which are occasionally detected in blood-films and 
 probably represent atypical forms. Because of their uncommon occur- 
 rence and difficulty of recognition, these cells will merely be mentioned. 
 
 Atypical lymphocytes are not infrequently encountered in severe 
 anaemias, particularly in lymphatic leukaemia. Some of these cells are 
 almost devoid of protoplasm, while others contain a distorted nucleus. 
 The term neutrophilic pseudolymphocyte has been suggested for those 
 cells which have a round nucleus, rich in chromatin, surrounded by a 
 narrow rim of protoplasm, filled with neutrophilic granules. These 
 leucocytes may represent small myelocytes, as their color character- 
 istics, excluding the strong basic nucleus, suggest neutrophile myelo- 
 cytes. Tiirk employs the name "stimulation form" for moderately 
 large leucocytes having a single round weakly basophilic nucleus, and 
 a non-granular cytoplasm, which stains a brown color with the triple 
 mixture. 
 
 Development of Leucocytes. — Most authorities regard the bone-mar- 
 row and the lymphatic tissues as the seats of leucocyte formation, the 
 former being concerned in the development of polynuclear neutrophiles, 
 eosinophiles, basophilic and hyaline cells, while the latter appear respon- 
 sible for the production of lymphocytes. In the bone-marrow are found 
 groups of cells, " leucoblastic areas," consisting of myelocytes surrounded 
 by polynuclear elements, while erythroblastic zones are present princi- 
 pally along the margins of vascular spaces. It is conceded by most author- 
 ities that the polynuclear neutrophile is developed from the neutrophile 
 myelocyte, the polynuclear eosinophile from the eosinophile myelocyte, 
 and a basophilic cell from its parent marrow cell. In the transformation 
 of the myelocyte into the polynuclear leucocyte, the nucleus undergoes 
 condensation and lobulation, the size of the cell decreases, and the stain- 
 ing reaction of the nucleus and of the granules intensifies. The large 
 mononuclear or h3^aline and transitional leucocytes are probably formed in 
 the marrow. The lymphocytes are derived from lymphatic tissue, the 
 small form being the progeny of the large cell. 
 
260 MEDICAL DIAGNOSIS. 
 
 Number of Leucocytes. — Many circumstances affect the number 
 of leucocytes in the circulation. The colorless corpuscles range between 
 6000 and 8000 per cubic millimetre in a healthy person; this standard 
 is, however, subject to slight variations, beyond these limits, in certain 
 physiological, and often to pronounced alterations in pathological states. 
 The number is influenced by the condition of body nutrition, e.g., in pro- 
 longed starvation low counts are conspicuous, by unequal distribution 
 of the cells, by blood dilution and by blood inspissation. The most ac- 
 ceptable theory, advanced to explain the occurrence of an increase in the 
 number of colorless elements (leucocytosis) in disease, points out that 
 irritants acting in the tissues produce chemical substances which attract 
 certain leucocytes towards the seat of mischief, and cause the leucocyte 
 forming organs to pour out an increased number of cells. This attraction 
 force has been termed "'positive chemotaxis," in contradistinction to a 
 repelling action set up by some irritants called '^negative chemotaxis." 
 The degree of leucocytosis depends mainly upon the intensity of the chemo- 
 tactic force and the responding powers of the individual. 
 
 Leucocytosis. — The term leucocytosis or hyperleucocytosis designates 
 an increase in the number of leucocytes in the peripheral blood over the 
 normal standard. This increase, as a rule, involves a marked percentage 
 gain in the polynuclear neutrophile elements with a fall in the percentage 
 of other forms, but sometimes comprises a proportionate rise in all the 
 varieties, or a percentage gain in the lymphocytes, eosinophiles, or baso- 
 phils. Leucocytosis is classified into special forms, depending on physi- 
 ological or pathological disturbances; these types being further subdivided 
 into special varieties, dependent upon certain etiological factors,— e.g-., 
 digestive, inflammatory, toxic, malignant, and post-hemorrhagic leucocy- 
 tosis. A rise in the number of polynuclear neutrophile cells is called polynu- 
 clear neutrophile leucocytosis; an augmentation in lymphocytes is termed 
 lymphocytosis; an increase of eosinophiles is known as eosinophilia; the 
 latter forms also being sub-grouped into (a) an absolute and (b) a relative 
 increase; e.g., absolute lymphocytosis is shown by a gain in the total count 
 with a rise in the percentage of lymphocytes, while relative lymphocytosis 
 implies a percentage gain without an increase in the total number of these 
 cells. The terms absolute and relative as applied to leucocytosis are often 
 misleading to the student. 
 
 Physiological Leucocytosis. — The leucocytosis which depends upon phys- 
 iological factors is, in the main, slight, of short duration, and commonly 
 involves a proportionate increase in all of the forms of leucocytes, less often 
 an absolute and a relative gain in the polynuclear neutrophile elements. 
 Leucocytosis of Digestion. • — In nearly all healthy individuals, 
 during the period of digestion, from one to four hours after taking food, 
 a slight rise in the number of leucocytes is present, which generally consists 
 of an absolute increase. Some claim that the gain principally involves 
 the neutrophiles, while others assert the lymphocytes are responsible. 
 In the new-born, leucocytosis of digestion is pronounced. In starvation 
 and frequently in the morbid states associated with faulty nutrition, the 
 number of white corpuscles decreases. The rapidity with which digestion 
 leucocytosis manifests itself after taking food is regarded by some writers 
 
EXAMINATION OF THE BLOOD. 261 
 
 as bearing a direct relation to the activity of the digestive function. In 
 persons suffering from gastric ulcer, leucocytosis sometimes comes on very 
 soon after taking food, pointing to rapid digestion; while in gastric cancer, 
 it may be delayed or absent. This rule is not constant and httle importance 
 should be attached to digestion leucocytosis in diagnosis. 
 
 Leucocytosis Occureing during Pregnancy and after Parturi- 
 tion. — A moderate rise in the number of leucocytes occurs during the later 
 months of pregnancy,* and persists for about two weeks after parturition. 
 
 Leucocytosis of the New-born. — The high counts observed for 
 about ten days after birth are attributed to blood inspissation and to the 
 establishment of digestion leucocytosis. Higher counts are present in 
 early childhood than in the advanced periods of life. Leucocytic oscilla- 
 tions of a very moderate character occur after exercise, massage, after 
 cold or hot bathing, and after the use of electricity. 
 
 Pathological Leucocytosis. — Inflammatory and Infectious Leuco- 
 cytosis. — The presence or the absence of a leucocytosis in many of the 
 infectious and inflammatory diseases is a sign of considerable importance 
 in diagnosis. Its clinical value is comparable in a measure with other 
 signs, such as temperature range and pulse, certain physical signs, etc. 
 This pathological increase, which is essentially a polynuclear neutrophile 
 leucocytosis, is as a general rule encountered in acute local inflamma- 
 tions, as in furuncles, cellulitis, abscesses, in general sepsis, and in nearly 
 all of the specific infectious diseases, except in uncomplicated cases of 
 enteric fever, paratyphoid infections, tuberculosis, malaria, measles, 
 German measles, influenza, leprosy, and Malta fever. High leucocytic 
 ranges are often attributable to suppurative inflammation. Duration 
 and height of fever have no direct relation to the leucocyte curve. Counts 
 between 15,000 and 20,000 are common, while ranges above 30,000 are 
 uncommon and above 50,000 very rare. 
 
 Preagonistic or Terminal Leucocytosis. — The exact nature of 
 the leucocytosis which so often precedes death is still a mooted question; 
 many investigators attribute this rise to terminal infections. 
 
 Malignant Leucocytosis. — Different opinions have been advanced 
 to explain the gain of colorless elements so frequently noted in individuals 
 suffering from carcinoma and sarcoma. Some writers contend that asso- 
 ciated_ inflammatory disturbance about the growth or septic absorption 
 from the tumor induces the leucocytic gain, while others hold that the 
 direct effect of the tumor is the responsible factor. In rapidly spreading 
 malignant growths, especially when metastasis has occurred, counts are 
 generally high and much above those noted in slowly growing tumors; 
 in sarcomata the gain is usually more pronounced than in carcinomata. 
 The cellular rise in the majority involves mainly the neutrophiles, although 
 lymphocytosis, especially in sarcomata, has been recorded. In cases of 
 carcinoma of the stomach, leucocytosis is often absent. 
 
 Post-hemorrhagic Leucocytosis. — The gain in the white corpus- 
 cles which follows and persists for some days after a profuse hemorrhage 
 is generally accounted for Iiy an increased production and output of poly- 
 nuclear neutrophiles. Some observers hold that the lymph (rich in cells) 
 which passes into the blood after blood loss is the responsible factor. 
 
262 MEDICAL DIAGNOSIS. 
 
 A leucopenia, lasting for a few hours, precedes the leucocytosis due to 
 hemorrhage. Leucocytosis is present in many cases of secondary anaemia. 
 
 Leucocytosis due to Toxic and Therapeutic Agents. — Among 
 the substances capable of producing a rise in the leucocytic standard may 
 be mentioned quininO; ether, chloroform, potassium chlorate, illuminat- 
 ing gas, salicylates, uric acid, and various organic extracts. 
 
 Lymphocytosis. — This condition, an increase of lymphocytes, is 
 normal in infants and in young children. A relative lymphocytosis 
 due to diminution of the polynuclear elements has been recorded in the 
 following conditions: chlorosis, pernicious ansemia, severe secondary 
 angemia, and in some of the infectious diseases, as tuberculosis, enteric 
 fever, malaria, and influenza. A lymphocytosis is sometimes observed 
 in Hodgkin's disease, and often in children suffering from syphilis, ansemia, 
 pseudoleukaemia infantum, rickets, whooping-cough, and gastro-intestinal 
 diseases. Diseases of the lymphatic glands and spleen are sometimes 
 attended by an increase in these cells. Lymphocytosis in most instances 
 is a relative condition. Absolute lymphocytosis of high grade is a constant 
 feature of lymphatic leukaemia. In myelogenous leukaemia the percentage 
 of lymphocytes is reduced, although the total number is increased. 
 
 EosiNOPHiLiA. — An increase in the number of eosinophiles has been 
 observed in the blood of normal infants, in anaemia pseudoleukaemia 
 infantum, in splenomedullary leukaemia, in bronchial asthma, after hemor- 
 rhage, in diseases of the sldn, as urticaria, lupus, eczema, leprosy, and 
 pemphigus, after coitus, during convalescence from many of the acute 
 infectious diseases, in bone diseases and in morbid states caused by 
 intestinal worms, particularly in trichiniasis. Definite conclusions regard- 
 ing the clinical significance of fluctuations in these cells in morbid states 
 cannot be drawn from our present knowledge, although some diagnostic 
 importance should be attached to the almost constant eosinophilia in 
 trichiniasis, in ankylostomiasis, and in bilharzial infection. 
 
 Basophilia. — This term is used to express an increase in the number 
 of basophiles in the circulating blood, which is frequently noted in spleno- 
 medullary leukaemia. Some writers have reported basophilia in splenic 
 anaemia, in certain skin diseases, in acute bone inflammation, and in 
 gonorrhoea. The clinical significance of basophilia remains unsettled. 
 
 Leucopenia. — A decrease in the number of leucocytes is termed leuco- 
 penia, or hypoleucocytosis, and may be brought about by physiological 
 and pathological factors. A deficiency in the number of colorless cells 
 is seen in starvation and in malnutrition, and almost constantly in the 
 infectious diseases not associated with leucocytosis, as tuberculosis, malaria, 
 measles, influenza, enteric fever, Malta fever, and German measles. Low 
 leucocyte counts are common in pernicious ansemia, in chlorosis, in splenic 
 anaemia, and in profound symptomatic anaemias. 
 
 Myelsemia. — The appearance of myelocytes in the blood, spoken of 
 as myelaemia, points to rapid leucocyte proliferation in the bone-marrow. 
 Myelocytes are often found in the circulation when leucocytosis is present. 
 In splenomedullary leukaemia this condition is most striking, in pernicious 
 ansemia, cholorsis, lymphatic leukaemia, Hodgkin's disease, and in profound 
 secondary anaemias, a small number of myelocytes is not infrequent. 
 
€ 
 
 'MtiL ^^- 
 
 ^ 
 
 #M1 
 
 % 
 
 0. 
 
 ■^^■ 
 
 u 
 
 
 vj 
 
 
 
 IT 
 
 • 
 
 
 «5J" 
 
 ^#i 
 
 1. NEUTR0PH1LE LEUCOCYTOSIS. 
 3. LYMPHOCYTOSIS. 
 
 2. EOSINOPHILIA. 
 4. MYEL/EMIA. 
 
 /,. Schmidt. 
 
 AHOBniroBsltrrttore 
 
EXAMINATION OF THE BLOOD. 263 
 
 Parasites — Bacteraemia. — Bacteria frequently gain access to the cir- 
 culation, either from an infected area within the body or from without. 
 Bacteria are seldom found by a microscopical examination of the fresh 
 unstained blood; culturing methods being required to reveal their pres- 
 ence. From a clinical view-point the demonstration of bacteria in the 
 circulation may be regarded as evidence of disease. The detection of 
 micro-organisms in the blood is often essential in establishing a diagnosis 
 of septicaemia, malignant endocarditis, puerperal sepsis, and pyaemia. In 
 some of the specific infectious diseases the exciting principle has been 
 isolated from the blood. In over 80 per cent, of the cases of enteric fever, 
 Eberth's bacillus can be recovered from the blood by culturing methods. 
 The specific micro-organisms of paratyphoid fever, croupous pneumonia, 
 anthrax, glanders, leprosy, influenza, plague, tuberculosis, and Malta fever 
 have been isolated from the blood. In septicaemia or septicopyaemia staph- 
 ylococci, streptococci, and gonococci have been separated from the blood. 
 
 Recently R. C. Rosenberger discovered tubercle bacilli in the blood of 
 fifty cases of tuberculosis. In some of the blood spreads examined only a 
 few bacilli were seen, while in other instances large numbers, generally 
 arranged in clumps of 30 or more, were present, especially in the cases of 
 acute miliary tuberculosis. 
 
 Animal Parasites. — From our present knowledge it is impossible to 
 fix a sharp dividing line separating some of the lower vegetable and animal 
 parasites. Investigators seem to favor placing the Treponema pallidum 
 and the spirochaeta of relapsing fever among the animal parasites. For 
 a description of the animal parasites found in the blood, the reader is 
 referred to the section which deals with diseases caused by animal parasites. 
 
 Method of Examination for Malarial Parasites. — Fresh, unstained blood 
 is more suitable for study than stained blood, because it enables the 
 examiner to observe the activity of the parasites. The most desirable 
 time for conducting the examination is during the period when pigmented 
 forms are present. The intracellular pigmented bodies are usually most 
 abundant about 6 or 8 hours before a paroxysm. Considerable experience 
 is necessary before the various types can be differentiated; especially is 
 this true of hyaline unpigmented forms. The skilled microscopist must 
 often make a prolonged search before parasites are detected in malarial 
 •blood. The fresh blood is prepared in the usual manner, between a cover- 
 glass and slide, and the examination is made with an oil-immersion lens 
 with moderate illumination. 
 
264 MEDICAL DIAGNOSIS. 
 
 VI. 
 THE EXAMINATION OF THE URINE. 
 
 The essential diagnostic principles of urinalysis, coupled with certain 
 methods of examination required for general clinical work, are detailed 
 in the following section. Tests suitable for the general practitioner must 
 in the main be simple and easily applied. The importance of the findings 
 obtained by careful and systematic studies of the urine, w^hen correctly 
 interpreted and given their proper place in a symptom-complex, can scarcely 
 be overestimated in diagnosis. In a considerable group of morbid states 
 the urinary picture is absolutely necessary in establishing a final diagnosis, 
 while in a large number of cases the results of the examination form a link 
 in the chain of symptoms completing the diagnosis. Negative reports in 
 some instances are essential for the solution of certain clinical problems. 
 For an exhaustive account of the urine, which does not fall within the scope 
 of this book, the reader is referred to special treatises on this subject. 
 
 PHYSICAL EXAMINATION. 
 
 Amount. — The daily standard for a healthy adult, as estimated by 
 different authorities, varies between 900 and 2000 c.c. Most observers 
 fix the amount between 1000 and 1500 c.c, although temporary oscilla- 
 tions beyond these limits, of slight, moderate, or even of an excessive degree, 
 are often physiological. The urinary secretion is greater during the day 
 than through the night, more abundant in cold than in hot weather, and 
 relatively more active in children and infants than in adults. Polyuria 
 depends in the main on, (a) increased ingestion of water, (b) heightened 
 blood-pressure, and (c) on increased activity of the renal epithehum, while 
 oliguria results from (a) lessened consumption of water, (b) lowered blood- 
 pressure, and (c) impaired function of kidney epithehum. 
 
 Specific Gravity. — In health the specific gravity ranges between 1.015 
 and 1.025 while the daily output of urine is within normal limits. In 
 general terms the specific gravity is a fair index of the bulk of solids elimi- 
 nated. An approximate estimate of the weight of urinary sohds expressed 
 in grammes for a thousand cubic centimetres of urine may be determined 
 by multiplying the second and third decimal figures of the specific gravity 
 by two. Pathologically, wide variations, as low as 1.002 and as high as 
 1.040, are frequent. Ranges above 1.050 are extremely uncommon. The 
 volume of urine and the specific gravity in the main fluctuate in an inverse 
 manner; therefore, without a knowledge of the daily output the density 
 has practically no cHnical significance. A correct specific gravity determi- 
 nation can only be made from a mixed twenty-four hours' sample. In dis- 
 eases associated with polyuria lowered ranges are the rule. A notable ex- 
 ception is found in the case of diabetes mellitus, in which the increased 
 density is caused by the presence of glucose. A diminished volume of 
 urine of low specific gravity is seen in a number of chronic diseases, and 
 
EXAMINATION OF THE URINE. 265 
 
 often in cases of oedema. Large urinometers are preferable to small instru- 
 ments for measuring the specific gravity, since the divisions of the scale 
 can be read with greater accuracy. The large amount of urine necessary 
 to float these hydrometers is, however, an objectionable feature. This 
 may be overcome by estimating the density with a set of two or three 
 pycnometers of moderate size, each of which represents a portion of the 
 scale. In measuring the specific gravity the following precautions are 
 essential for accurate results: The hydrometer should be placed into cool 
 urine, the surface of which is free from foam; the instrument should 
 not touch the sides of the hydrometer jar. 
 
 Color. — Normal urine owes its color to urochrome and urobilin, chiefly 
 to the former, while the tints of many pathological urines depend upon 
 such substances as biliary pigment, ha3moglobin, methsemoglobin, hsematin, 
 hsematoporphyrin, melanin, indican and alkaptone. After the ingestion of 
 iodine, phenol, salol, senna, santonin, and methylene blue, the urine often 
 has an abnormal hue. The shade of the color depends chiefly upon the 
 amount of urinary water, so that concentrated specimens are usually dark, 
 while those of low specific gravity are generally pale. An exception to this 
 rule is noted in diabetic urine, which is light yellow or pale greenish-yellow, 
 of increased density and of excessive quantity. In acute febrile diseases 
 and pernicious anaemia the urine is high colored, while in chlorosis, dia- 
 betes insipidus, and contracted kidney it is pale. Bile pigment is respon- 
 sible for dark yellow, yellowish-green, dark brown, and rarely, black urine, 
 which on shaking develops a yellowish foam; blood pigment stains the 
 urine bright red, dark red, reddish-brown, or rarely, black. Melanotic 
 pigment imparts a brown or black appearance which generally develops 
 some time after the urine is voided, but occasionally is noted in the fresh 
 specimen. A similar color occurs in alkaptonuria, which condition can be 
 differentiated from melanuria by testing with Fehling's solution; the alkap- 
 tone bodies reduce the copper salt, while the latter gives a negative reac- 
 tion. The ingestion of phenol and its allied compounds may cause a green- 
 ish-black discoloration, of methylene blue a green or blue urine, of santonin 
 a yellow, and of rhubarb an orange-colored urine. A milky appearance is 
 noted in chyluria and at times in phosphaturia and pyuria. The presence 
 of hgematoporphyrin may impart a dark red color. 
 
 Transparency. — Normal urine immediately after being voided is 
 generally clear; on cooling it occasionally becomes turbid, due to pre- 
 cipitation of urates or phosphates. Turbidity, associated with a sediment, 
 is one of the characteristic features of many abnormal urines, and may 
 depend upon an excess of urates or phosphates, or on the presence of 
 epithelial elements, pus-cells, red blood-corpuscles, chyle, or bacteria. 
 
 Odor.— This property of the urine, although of little clinical signifi- 
 cance, except in a few instances, occasionally attracts the attention of the 
 patient who suspects that an abnormal state of the kidneys exists. The 
 odor of normal urine is sufficiently familiar to require no special description. 
 Urine decomposed by bacterial growth within the bladder, or after it has 
 been voided, emits an ammoniacal stench. Acetone, when present in large 
 amount, may give the urine a sweetish, fruit-like odor. The ingestion of 
 turpentine, terebene, asparagus, and onions imparts peculiar odors. 
 
266 MEDICAL DIAGNOSIS. 
 
 Reaction. — A normal, mixed twenty-four hour sample in nearly every 
 instance is acid, while individual specimens passed during the day vary 
 considerably in reaction. For clinical purposes the reaction may be deter- 
 mined with litmus paper. An alkaline reaction after a heavy meal is 
 attributed to the increased alkalinity of the blood during gastric digestion. 
 The ingestion of food rich in vegetables, or the administration of tartaric, 
 citric, or acetic acid lessens acidity, or produces alkalinity, while a diet 
 rich in meat or the taking of mineral acids intensifies the acidity. The 
 reaction of normal urine is held to be due to diacid phosphate; Folin, 
 however, contends that free organic acids are in part responsible. The 
 total acidity of a twenty-four hour collection of healthy urine is equal to 
 from 1.5 to 2.3 grammes of hydrochloric acid. Alkalinity is caused by 
 the presence of alkalies in excess of acids. An amphoteric reaction depends 
 on a balance existing between the acid and basic equivalent of the urinary 
 salts. Urine that has been exposed to the air for some time becomes alka- 
 line from ammoniacal decomposition. Alkaline urine is frequently seen in 
 cystitis, but in a number of cases of bladder inflammation, both acute and 
 chronic, the urine is acid. A strongly acid urine occurs in gout, diabetes, 
 rheumatic fever, in some varieties of nephrolithiasis, in leukaemia, in intes- 
 tinal and stomach diseases associated with diminished or abolished gastric 
 secretion, in scurvy, in chronic nephritis, and often in febrile states. Low- 
 ered acidity, and occasionally alkalinity, is seen in ansemia, notably per- 
 nicious anaemia and chlorosis, following the crisis of pneumonia, after 
 blood transfusion with saline solution, in haematuria, and when transudates 
 are rapidly absorbed. 
 
 Sediments. — Occasionally deposits of uric acid, amorphous urates, 
 carbonates and phosphates, and invariably those consisting of pus, epi- 
 thelial and red blood-cells, are significant of morbid states. The presence 
 of a sediment of uric acid crystals, amorphous urates, or phosphates need 
 not, and as a rule does not, imply an increased output of these salts, but 
 may depend on changes in the reaction of the urine. 
 
 MICROSCOPICAL EXAMINATION. 
 
 Microscopical examination of sediments is of cardinal importance in 
 urinalysis. A sediment best suited for this method of study should be 
 secured from a fresh specimen of urine by centrifugalization. When the ex- 
 amination cannot be made immediately after the urine is voided, it is advis- 
 able to add an antiseptic to it, such as a little powdered camphor, a few drops 
 of formaldehyde solution, or thymol, in order to prevent decomposition. 
 
 Crystalline and Amorphous Substances Present in Acid Urine. — 
 Calcium Oxalate. — Crystals of calcium oxalate are found in many sedi- 
 ments and appear in various sizes, mostly in the form of colorless octahedra, 
 generally designated "envelope crystals," sometimes as dumb-bell figures 
 and rarely as oval disks. These crystals are soluble in hydrochloric acid, 
 but not in acetic acid or sodium hydrate. Normal urine may contain these 
 crystals, after the eating of tomatoes, asparagus, garlic, rhubarb, or oranges. 
 After the ingestion of bicarbonate of soda, in certain forms of gastro- 
 intestinal neuroses, in jaundice, in phthisis, and in diabetes meUitus, oxa- 
 
EXAMINATION OF THE URINE. 
 
 267 
 
 late crystals are sometimes noted. Renal calculi composed of this substance 
 are not uncommon. Oxaluria can only be regarded as pathological when 
 a chemical examination shows an increased quantity of oxalic acid, provided 
 the factors responsible for its occurrence in health can be excluded. 
 
 Uric Acid. — This substance, as a rule, crystallizes in the form of whet- 
 stone shaped crystals, arranged singly or in clusters, and occasionally in 
 the form of dumb-bell figures, or as rhombic plates. These crystals vary 
 considerably in size, and their color ranges from a pale yellow to a dark 
 brown. Uric acid crystals dissolve in a sodium hydrate solution, and when 
 this test is followed by the addition of hydrochloric acid to the alkaline 
 solution, rhombic plates appear. Uric acid crystals are frequently seen in 
 the urine when the uric acid output is normal or even decreased, since this 
 substance is more readily soluble in warm than in cold solution. Urinary 
 inspissation is another factor which determines precipitation. In leukaemia; 
 
 Fig. 107. — Calcium oxalate crystals. 
 
 Fig. 108. — Uric acid crystals. 
 
 and during or immediately following acute gout, the urine contains an 
 excess of uric acid, and may reveal an abundant precipitate of these crys- 
 tals (brick-dust sediment). Calculi formed of uric acid are among the most 
 common renal concretions. When amorphous granules of sodium and 
 potassium urate occur in the urine in abundance, they impart a turbidity 
 to it, which is often associated with a light yellow or pink sediment. This 
 precipitate disappears upon heating the urine to a temperature of 50° C; 
 on the addition of hydrochloric acid to the urine, amorphous urates are 
 converted into uric acid crystals. Amorphous sediments of urates are 
 frequently present in scanty, concentrated urines, such as occur in fevers. 
 Calcium sulphate is seen in the form of long, transparent colorless 
 needles, or elongated platelets, arranged singly or in crystalline masses. 
 They are insoluble in ammonia, acetic acid, and alcohol. Von Jaksch found 
 these crystals in association with triple phosphates and calcium carbonate 
 in the urine of a patient who showed a tendency to calculus formation. 
 No special clinical significance has as yet been attached to the presence 
 of these crystals. 
 
268 
 
 MEDICAL DIAGNOSIS. 
 
 HiPPURic ACID occurs as rhombic prisms or slender needles arranged 
 separately or in clusters. These crystals are soluble in ammonia and 
 insoluble in hydrochloric acid. They have been noted, though very infre- 
 quently, in febrile diseases, in diabetes, and after the ingestion of benzoic 
 acid, salicylic acid, cranberries, mulberries, blueberries, and prunes. 
 
 BiLiRUBix is found as fine needles arranged in clusters or rhombic 
 plates having a yellow or ruby color, or as an amorphous substance. This 
 sediment is soluble in sodium hydrate and chloroform; on treating the 
 crystals with nitric acid a green color appears about them. Von Jaksch 
 contends that the presence of crj^stals of bilirubin in the urine, as a rule, 
 points to antecedent hemorrhage into the urinary tract or to the rupture 
 of an abscess. Their presence, either free or imbedded in cells or tube- 
 casts, has been recorded in acute nephritis, chronic interstitial nephritis, 
 amyloid kidney, jaundice, acute j'ellow atrophy of the liver, hepatic cir- 
 
 FiG. 109. — Leucin spheres and tjTOsin crystals. 
 
 Fig. 110. — Cystin crystals. 
 
 rhosis, phosphorous poisoning, carcinoma of the bladder, and after the 
 rupture of a suppurating hydatid cj^st into the urinary tract. 
 
 Leucin and Tyrosix. — These substances are never found in normal 
 urine. They are generally held in solution unless present in considerable 
 quantities, when they separate in a crystalline form. Their precipitation 
 can be brought about by treating the urine with an excess of basic plumbic 
 acetate; then filtering; and to filtrate hydrogen sulphide is added to remove 
 the excess of lead acetate. The filtrate is then evaporated to a small volume. 
 Absolute alcohol is used to remove traces of urea. The insoluble residue 
 is finally extracted with alcohol containing a little ammonia. Leucin and 
 tyrosin will precipitate in this concentrated solution. Leucin presents the 
 appearance of spheres of varying sizes, sometimes termed ''leucin balls." 
 These spheres have a brown color and show delicate lines radiating from 
 their centre to the periphery. Leucin spheres are insoluble in ether. 
 Tyrosin crystals are noted in the form of slender needles, frequently 
 grouped in bundles. They dissolve in ammonia and hydrochloric acid, 
 but are insoluble in acetic acid. Leucin and tyrosin occurring mostly 
 
EXAMINATION OF THE URINE. 
 
 269 
 
 together have been observed almost constantly in acute yellow atrophy 
 of the liver, phosphorous poisoning, and Weil's disease, occasionally 
 in catarrhal jaundice, cholelithiasis, cirrhosis and cancer of the liver, 
 enteric fever, gout, and diabetes, and rarely in a limited number of 
 other conditions. 
 
 Xanthin is found in the form of colorless crystals resembling those of 
 uric acid in outline. The}' are soluble in ammonia. These crystals are 
 rare ingredients of urinaiy sediments; calculi consisting of xanthin have 
 been found by some investigators. 
 
 Cystix crv'stals are six-sided colorless plates, which are soluble in 
 ammonia and insoluble in acetic acid and water. Von Jaksch recommends 
 the following microchemic^l test for their detection: A drop of hydrochloric 
 acid is added to the urinary sediment. When the acid comes in contact 
 with cystin, there develop prismatic crj'stals (hydrochlorate of cystin) 
 
 Fig. 111. — Triple phosphate crystals 
 
 Fig. 112. — Neutral calcium phosphate crystals. 
 
 which are grouped in masses suggesting a rosette form. Cystinuria is a 
 rare condition. In some cases it is unattended mth symptoms, while in 
 others it is responsible for calculus formation. 
 
 Soaps of lime and magnesia consist of needles arranged in bundles or 
 sheaves, sometimes radiating from a central point forming a sphere. They 
 resemble tyrosin crystals in form and arrangement. These crA'stals are 
 rarely found. They have been noted in septicaemia. 
 
 Fat globules can be recognized by their highly refractive appearance ' 
 and solubihty in ether. Among the conditions in which lipuria is seen, 
 may be mentioned, acute and chronic parenchymatous nephritis, diabetes 
 mellitus, bone disease and injury, chyluria, phosphorus poisoning, and 
 certain diseases of the liver and pancreas. 
 
 Crystalline and Amorphous Substances found in Alkaline Urine. — 
 Ammoxiomagxesium phosphate or triple phosphate crystals are color- 
 less and vary considerabh^ in size and appearance. In their most char- 
 acteristic form they occur as the so-called "coffin-lid" crystals; others 
 resemble fern leaves in outline, while some are arranged in the shape of 
 
270 
 
 MEDICAL DIAGNOSIS. 
 
 the letter ''X." Triple phosphate crystals are found in association with 
 amorphous deposits of phosphates, carbonates, and at times with ammo- 
 nium urate. 
 
 Neutral calcium phosphate occurs in alkaline, faintly acid, or 
 amphoteric urine in the form of sheets or needle-like crystals, the latter 
 being arranged singly or in masses forming dumb-bell or star-shaped 
 figures. These bodies are soluble in acetic acid. 
 
 Neutral magnesium phosphate crystals are colorless, refractile, elon- 
 gated plates with irregular or bevelled edges; they are soluble in acetic acid. 
 
 Calcium carbonate crystals are found in alkaline urine associated 
 with amorphous carbonates. They are dumb-bell shaped bodies which 
 dissolve in acetic acid with the liberation of gas. 
 
 Amorphous phosphates of calcium and magnesium and amorphous 
 CARBONATES are of common occurrence in alkaline urine. The addition 
 
 Fig. 113. — Ammonium urate crystals. 
 
 Fig. 114. — Cholesterin crystals. 
 
 of a fixed alkali to urine will precipitate amorphous phosphates and car- 
 bonates. On heating urine having a low acid or alkaline reaction, a white 
 cloud simiij.r to that produced by albumin appears which consists of 
 phosphates or carbonates. On the addition of acetic acid, phosphates 
 and carbonates are dissolved. The solution of the latter is attended with 
 the evolution of gas. Amorphous phosphates or carbonates are often 
 responsible for a turbid urine with a heavy sediment. Microscopically, 
 these bodies appear as colorless, coarse granules, which are soluble in acetic 
 acid. Phosphatic sediments are occasionally symptomatic of certain 
 types of dyspepsia, of neurasthenia, of diseases associated with marked 
 gastric acidity, and of some cases of cystitis. A deposit of phosphates 
 does not of itself indicate an increased output of phosphoric acid; this can 
 only be determined by quantitative analysis. 
 
 Ammonium biurate appears as dark brown spheroidal bodies from the 
 surface of which spicules project, the so-called ''thorn-apple" or "hedge- 
 hog " crystals, and in the form of coarse yellow needles grouped in clusters. 
 Ammonia biurate may be associated with triple and amorphous phosphates. 
 
EXAMINATION OF THE URINE. 271 
 
 Acetic acid will cause solution of these crystals with the formation of uric 
 acid. Ammoniacal fermentation of the urine, occurring in the bladder or 
 after it has been voided, is responsible for the precipitation of ammonium 
 biurate. 
 
 Cholesterin crystals occur as colorless thin plates. They are rare 
 constituents of urinary sediment and have been observed in hydatid cystic 
 kidney, pyonephrosis, hydronephrosis, and cystitis. 
 
 Indigo, a rare ingredient of the urinary sediments, is found in the 
 form of a blue crystalline body consisting of needles grouped in a stellate 
 manner or as rhombic plates, and also as bluish amorphous granules. 
 The amorphous material is not infrequently present in decomposing urine. 
 Indigo is a rare constituent of urinary calculi. 
 
 Cellular Deposits. — Epithelial Cells. — Epithehal cells in small 
 numbers, not sufficient to impart a sediment or cloudiness to the urine, 
 can be found in every speci- 
 men. In many instances " _,.-; ^ ^ , u "j.lil|Tli 
 
 their number is so large as a iMFWIP^ ''■'' ' • '' ' 
 
 to justify a diagnosis of an W^ ^ ^ — <-< | 
 
 inflammatory, atrophic, or .-^^^ §1^1 
 
 degenerative lesion involv- '- _ ^ * f ^^'^^ ^ '^'' • v- 
 
 ing the genito-urinary tract. , ' ^^ ,^., ,<<?%, ^^ '■ 
 
 The predominance of one or , /.; "/ ■ •' 'i^'* ^^ 
 
 several of the types of epi- >•• '/ - '- . , ';ivi> 
 
 thelial elements, unless cor- .,/ ■,'^ , ^ ' ^^^ /.^^ 
 
 related with other clinical "'v , - "^^^ I 
 
 data, has little significance. ' '" c' ' " ■.<;■ z^':^''^^. \ 
 
 It is impossible to locate | ' ' (^ ' ^ I 
 definitely a lesion of the } ' . 
 
 genito-urinary tract from the j r | 
 
 morphological characters of [^ - ' j 
 
 epithelium alone. This diffi- Fig. 115.— Epithelial cells, a, flattened cells; 6, conical cells 
 
 CUlty is apparent when we digeneS'cellsI°"^^*'°°'' '=- ™^"d and polygonal cells; d, 
 
 consider, (1) similarity of 
 
 many of the cells of different parts of the tract, notably those derived 
 from the pelvis of the kidney, ureters, and bladder, (2) alterations in the 
 shape of these delicate formations due to the action of the urine, and (3) 
 the influence exerted on these cells by morbific factors, such as necrosis, 
 pressure, etc. Therefore, little importance should be attached to their 
 histological structure. Round cells, having a relatively large nucleus, are 
 derived from the tubular structures of the kidney and the deeper layers 
 of the renal pelvis. When casts are beset with round cells it points to a 
 renal origin of this epithelium. An abundance of round cells in the absence 
 of casts, especially when pus-cells and subjective symptoms pointing to 
 pyelitis are present, is suggestive of origin from the renal pelvis. This 
 opinion is strengthened by the presence of polygonal and conical cells, 
 some of which have a tail-like elongation of their protoplasm; these cells 
 are often arranged in a stratified manner. Round cells are also derived 
 from the male urethra, while small conical and polygonal cells originate 
 in the superficial layers of the pelvis of the Kidney. Cylindrical cells with 
 
272 MEDICAL DIAGNOSIS. 
 
 bluntly pointed ends are found in the superficial layers of the male urethra. 
 Flattened, oval or circular, or polygonal cells line the superficial layers of 
 the ureter, bladder, prepuce, fossa navicularis, and vagina. Large squa- 
 mous cells are generally derived from the vagina or prepuce. Protoplasmic 
 degeneration of the epithelial cells is extremely common. A final diagnosis 
 should never depend on the characters of the epithelia in the absence of 
 clinical findings. 
 
 Leucocytes. — A careful search in every normal or morbid specimen 
 of urine will reveal a few leucocytes. The action of the urine upon these 
 cells causes alterations in their structure. In acid urine they have a distinct 
 nucleus, while in alkaline urine their protoplasm is swollen and cloudy, 
 obscuring the nucleus. By treating a specimen of urine having a weakly 
 acid or alkaline reaction with acetic acid, the nuclear outline becomes sharply 
 marked. The leucocytes stain a mahogany brown with a solution of iodo- 
 
 potassic iodide (glycogen reaction), 
 V >». _^ while epithelial cells are tinted a 
 
 (' ' '' ;\ light yellow with this reagent. Pus- 
 
 cells in considerable or large numbers 
 frequently indicate inflammatory 
 disease of some part of the genito- 
 urinary tract. They occur in renal 
 hyperaemia, nephritis, abscess and 
 ) / tuberculosis of the kidney, pyelitis, 
 
 urethritis, cystitis, prostatitis, epi- 
 didymitis, and orchitis. A leucor- 
 rhoeal discharge is a common cause of 
 pyuria. Urine containing many pus- 
 corpuscles generally gives a positive 
 reaction for albumin. Renal and ex- 
 L J trarenal albuminuria may coexist. 
 
 Fig. 116.— Red blood-cells and leucocytes. ReD BlOOD-CELLS. Hsematuria, 
 
 or the presence of red corpuscles in 
 the urine, is always pathological except during menstruation. In cer- 
 tain uterine diseases attended with bloody discharge some of the eryth- 
 rocytes may be washed into the urine. A microscopic inspection serves 
 to recognize red blood-cells in almost every instance, so that chemical 
 tests for their detection are rarely required. In some urines the red cells 
 are unaltered, while in others changes in their structure are found, such as 
 decided shrinkage of the cell, or crenation, or they may be partially or 
 completely decolorized, and appear as pale yellow disks or as faintly out- 
 lined rings (phantom corpuscles). The quantity of blood may be sufficient 
 to tinge the urine pale or dark red, but in many cases the amount is so 
 small that the microscopic test is essential in the diagnosis of hfematuria. 
 When the erythrocytes are intimately mixed with the urine, this suggests 
 a hemorrhage in the kidneys, renal pelvis, or ureters. The presence of 
 •dehsemoglobinized corpuscles is noted in kidney lesions, such as congestion 
 and inflammation. Unaltered blood or blood-tinged urine passed at the 
 beginning of micturition is of urethral origin; on the other hand, when 
 .blood appears at the end of urination, its source is generally the neck of 
 
EXAMINATION OF THE URINE. 273 
 
 the bladder. Bleeding may cause coagula of certain shapes; cyhndrical 
 clots of large size suggest urethral hemorrhage, those of small diameter 
 may indicate ureteral hemorrhage, while irregular clots often form in the 
 bladder. Neither the morphological characters of red blood-cells nor the 
 size and outline of clot can be rehed upon to definitely determine the 
 site of a hemorrhage, unless these findings are supported by other chnical 
 data. The use of the cystoscope, urethral and ureteral catherization, and 
 examination with X-rays, especially for renal calculus, afford valuable 
 adjuncts in the diagnosis of hsematuria. An albumin reaction is invariably 
 obtained when red blood-cells are abundant in the urine, but when only 
 small numbers exist, a negative test is the rule. The quantity of albumin 
 is proportionate to the amount of blood. 
 
 Tube=casts. — These are cyhndrical bodies moulded in the uriniferous 
 tubules. Their structure is variable, and may consist of a hyaline or waxy 
 material, of cellular bodies, of granular elements, of fat globules, and in 
 rare instances of bacteria or of amorphous substances. 
 
 Hyaline Casts. — These, by far the most common, are slightly refrac- 
 tile, transparent, of regular outhne, with rounded ends. They are invisible 
 in a brightly illuminated field on the microscope, so that it is necessary 
 to cut off much of the reflected light with the iris diaphragm in order to 
 bring out their outline. Epithelial cells, leucocytes, red blood-corpuscles, 
 and granules frequently beset these casts, and, indeed, it is not uncommon 
 to find adherent cells or granules so numerous that the hyaline material 
 is obscured. Casts covered with granules are termed hyalogranular. This 
 appearance may make it impossible to distinguish hyaline casts from those 
 composed principally of granules. Clinically, however, the significance of 
 hyaline casts coated with granules and those composed wholly or mostly of 
 granules is identical. It should be remembered that a sharp distinction can- 
 not be drawn between these forms. Hyaline casts are soluble in acetic acid. 
 
 Waxy casts appear as highly refractile, sharply defined, colorless 
 or yellowish cylinders, showing a tendency to transverse fragmentation. 
 Like hyaline casts they may be studded with cells or granules. They 
 may exhibit an amyloid reaction, but this is no criterion that lardaceous 
 renal disease exists, but, on the contrary, amyloid disease of the kidney is, 
 as a rule, not associated with casts giving this reaction. Not infrequently, 
 casts are observed that cannot be definitely classified as belonging to the 
 waxy or hyaline varieties. 
 
 Granular casts are composed of fine or coarse granules. Cells form- 
 ing leucocytic or epithelial casts may show a decided granular protoplasm, 
 so that it becomes difficult to distinguish their outline; these types consti- 
 tute border line varieties between cellular and granular casts. Clinicallj^, 
 this is of little moment, since the granular or fatty casts represent products 
 of degenerated cells. Acetic acid dissolves granular casts. 
 
 Fatty casts consist of fat globules derived from degenerated cells. 
 Ether dissolves fatty casts. 
 
 Epithelial casts are made up of renal epithelial cells, many of which 
 present degenerative changes. These casts may have tubular form. 
 
 Leucocytic casts consist of white blood-cells. They are generally 
 recognized at a glance, but should uncertainty arise as to the character of 
 
 18 
 
274 MEDICAL DIAGNOSIS. 
 
 the cells forming these cylinders, this doubt can be settled by treating the 
 specimen with a droplet of acetic acid, which clarifies the protoplasm of 
 the leucocytes and causes the nucleus to become distinct. 
 
 f^i 
 
 3 
 
 10 
 
 6 
 5 
 
 II '^ 
 
 14- 
 
 15 
 
 12 16 
 
 '[ Id 
 
 Fig. 117. — Tube-casts 1, 2, 3, 5, hyaline casts; 4, 6, hyaline casts beset with epithelial cells; 
 7, hyaline cast — one end of which is coated with fine granules ; 8, hyaline cast beset with leucocytes ; 
 9, finely granular cast; 10, coarsely granular cast; 11, 12, 13, waxy casts; 14, fatty cast; 15, 16, 
 epithelial casts ; 17, blood-cast ; 18, leucocytic cast. 
 
 Blood-casts consist of erythrocytes, many of which may be alteifed 
 by crenation or dehamoglobinization. Pus- and blood-casts are rarely 
 encountered. Casts formed of haemoglobin, of bacteria, or of urates are rare. 
 
 Cylindeoids are of two forms; one variety appears as long twisted 
 or curved ribbon-like structures, composed of mucus, and therefore insolu- 
 ble in acetic acid. This cyUndroid is readily distinguished from true hya- 
 
EXAMINATION OF THE URINE. 275 
 
 line casts, because of its length and flattened appearance. A second group 
 consists of elongated cylindrical bodies. They show considerable varia- 
 tion in their short diameter, and are composed of a hyaline material. This 
 cylindroid often tapers into a long thread-like tail. Some of the latter 
 variety closely resemble hyaline casts, but can generally be distinguished 
 from glassy casts by their irregular diameter. The material composing 
 the latter type is soluble in acetic acid. Some authorities contend that 
 this form of cylindroid has the same clinical significance as the hyaline 
 cast. The mucous cylindroids are in the main formed in the bladder. 
 Clinical Significance of Tube=casts. — Tube-casts, especially of the 
 hyaline variety, are often _^ 
 
 found in the urine of I 
 
 morbid states and occa- ' ■ 
 
 sionally of apparently ^'v 
 
 healthy persons. Some '. / 
 
 observers maintain that 
 
 their presence in the , 
 
 urine of so-called healthy 
 
 persons can be explained ; 
 
 by temporary circula- 2 ' j 
 
 tory disturbances, such j \ 
 
 as result from violent i 
 
 physical exercise or from 
 overstimulation, as with 
 alcohol. These circula- .' ! 
 
 tory derangements, al- 
 though of a temporarj^ 
 nature, cannot be re- 
 garded as strictly physi- 
 ological; therefore, the 3 
 presence of casts under 
 
 such circumstances re- ! 
 
 fleets an abnormality of , 2 
 
 the renal function. The 
 
 finding of casts over a Fig. IIS.— Cyllndroids. l, Cyllndroids resembling hyaline tube- 
 
 Inrirt- T^oTirirl n-onofQlKr casts; 2, cylindroids stippled with granules; 3, ribbon-iike mucous 
 long peilOa geneiauy cylindroids; 4, spiral form of cylindroid.— Modified from Emerson. 
 
 warrants a diagnosis of 
 
 structural changes in the kidneys. The number of casts present in a speci- 
 men of urine is sometimes an index of the extent or severity of renal involve- 
 ment. In acute diffuse nephritis their number is generally large, in chronic 
 parenchymatous nephritis they are usually fairly abundant, while in the 
 interstitial form only a small number is noted. In passive renal conges- 
 tion, amyloid disease, and in the degenerations attending febrile diseases, 
 casts are generally few in number, but occasionally plentiful. The size of 
 casts varies considerably. Large cyUnders at times exceed 1 mm. in length. 
 The size of tube-casts has no special diagnostic significance. The predomi- 
 nance of one or several varieties of casts may be of value in deciding 
 the character of a renal lesion. Hyaline casts do not signify any special 
 morbid change, as they occur under a variety of circumstances. Often 
 
276 MEDICAL DIAGNOSIS. 
 
 they appear when there is only a slight functional derangement of the 
 kidneys, but they are invariably present in organic renal disease. Waxy, 
 granular, epithelial, and fatty casts point to degeneration of the renal 
 parenchyma, while pus-casts may indicate purulent kidney disease. 
 Blood-casts signify hemorrhage. 
 
 Spermatozoa and Testicular Casts. — Spermatozoa are found in 
 the urine after coitus, pollution, and rarely after convulsions. The urine 
 which contains spermatozoa occasionally reveals testicular casts. These 
 casts closely resemble renal casts. Thej^ can, however, be distinguished 
 from the latter, since they occur only in the first part of the urine voided 
 while renal casts are present in the entire specimen. Their recognition 
 depends mainly upon the finding of spermatozoa with these casts in the 
 first urine of a two-glass test, and an absence of both of these elements in 
 the second specimen of urine. 
 
 Irregular shreds and ribbon-like threads (tripperfaden) are seen 
 without magnification in the urine after acute gonorrhoea and in chronic 
 urethritis. They consist of shreds of coagulated mucus, to which are 
 generally adherent leucocytes and epithelial cells. 
 
 Bacteria ; Animal Parasites. — Bacteria. — The presence of bacteria in 
 abnormal urine depends upon, (1) contamination of urine after it is voided, 
 (2) existence of infectious lesions of the genito-urinary tract or communi- 
 cating with it, and (3) elimination of bacteria from the blood by the kidneys. 
 In large numbers bacteria impart turbidity to the urine, which does not clear 
 up completely by centrifugating or by passing the urine through filter-paper. 
 
 The Micrococcus ureee is considered responsible for ammoniacal 
 fermentation. The colon bacillus, tubercle bacillus, typhoid and paraty- 
 phoid bacillus, plague bacillus, ray fungus, sarcina? and moulds are the com- 
 moner micro-organisms found in pathological urine. The typhoid bacillus, 
 which is eliminated by the kidney in every case of enteric fever, is occasion- 
 ally the exciting factor of inflammatory disease of the bladder and renal 
 pelvis. Tubercle bacilli in the urine may indicate a tuberculous focus in 
 the urinary tract. Their elimination by the kidneys from the blood in the 
 absence of genito-urinary tuberculosis has been suggested. The smegma 
 bacillus, which exists in the secretions of the external genitals, is at times 
 washed into the urine. This contamination can be avoided by carefully 
 cleansing the external genitals, or by securing the urine with a catheter. 
 Pappenheim's stain is highly recommended as means of differentiating the 
 tubercle from the smegma bacillus. Yeast cells are often found in diabetic 
 urine and may give rise to pneumaturia. 
 
 Animal Parasites. — The Trichomonas vaginalis is rarely noted and 
 its presence is probably dependent upon contamination of the urine with 
 a vulvovaginal discharge containing this parasite. Ova of the Distoma 
 haematobium are sometimes seen in the urine when the adult worm resides 
 in the mucous membrane of the renal passages. Distomiasis is essentially 
 a tropical disease which is occasionally responsible for hsematuria. Filarial 
 embryos have been found in certain cases of tropical hsematuria. Echino- 
 coccus booklets or fragments of cysts may be present in cases of hydatid 
 disease of the urinary system. There are a few instances on record in 
 which the Eustrongylus gigas was noted in the urine. 
 
EXAMINATION OF THE URINE. 277 
 
 Calculi. — Urinary calculi of renal and vesical origin vary as to si^ 
 and outline. Stones small enough to pass through the urinary passages 
 are more common than the large calculi found in the renal pelvis or 
 bladder. 
 
 Uric acid stones vary in size from that of a grain of sand to concre- 
 tions large enough to fill up the renal pelvis. These calculi are reddish- 
 brown or dark gray, very dense, have a smooth or slightly roughened sur- 
 face, dissolve in alkalies, and, when treated with sodium hydrate, generate 
 ammonia. They give murexide test. Sometimes calcium oxalate is present 
 in uric acid concretions. Ammonium urate stones have a waxy consist- 
 ence, give the murexide test and liberate ammonia when treated with 
 sodium hydrate. These calculi are rare. At times they are found in 
 adults, and are occasionally discovered in the new-born. Calcium oxalate 
 stones are responsible for severe attacks of renal colic and heematuria. 
 These calculi are very hard, their surface is generally irregular, often 
 showing sharp projections, and their color is dark gray or black. Hydro- 
 chloric acid dissolves them, and acetic acid will also cause solution when 
 added to the powdered stone. Phosphate stones have a soft texture, are 
 white or pale yellow, and have a rough surface. They are soluble in acetic 
 acid without gas formation. They are formed in the bladder much more 
 frequently than in the renal pelvis. Cystin stones have a wax-like consist- 
 ency, are white or yellowish in color, dissolve in ammonia, and give the 
 reaction for cystin. They are of rare occurrence. Xanthin stones are 
 hard, of a white or yellowish-brown color, and dissolve in ammonia. Indigo 
 stones have a blue or bluish-gray color. Xanthin and indigo calcuH are 
 extremely rare. Calcium carbonate stones are white, have a chalk-like 
 consistency, and are soluble in acetic acid with gas formation. Stones con- 
 sisting of fatty acids and cholesterin have been recorded in a few instances. 
 
 Tumor fragments from carcinoma or sarcoma of the urinary tract 
 are rarely present in the urine. Fecal matter has been found in the urine 
 in cases of enterovesical fistula. 
 
 CHEMICAL EXAMINATION. 
 
 Nitrogenous Bodies. — The normal amount of nitrogen eliminated by 
 the kidneys per day varies between 10 and 16 grammes. It may be 
 reduced to 5 or 6 grammes on a vegetable diet. Nitrogen, the best index 
 of proteid metabolism, is principally eliminated in the form of urea, and 
 to some extent as ammonia, uric acid, and extractives. Hammarsten's 
 estimation of the percentage of nitrogen excreted in the principal nitroge- 
 nous bodies is as follows: 
 
 Adults, per cent. 
 
 Infants, per cent. 
 
 Urea 84 to 91 
 
 NH3 2 to 5 
 
 Uric acid 1 to 3 
 
 Extractives 7 to 12 
 
 73 to 76 
 7.8 to 9.6 
 3 to 8.5 
 7.3 to 14.7 
 
278 
 
 MEDICAL DIAGNOSIS. 
 
 Nitrogen is increased by a rich proteid diet, active exercise, in fevers, 
 in cachexia, in diabetes, in poisoning by arsenic, antimony, phosphorus, 
 and certain organic poisons, after hemorrhage, in dyspepsia, during the 
 resolution stage of pneumonia, and from the absorption of exudates and 
 transudates. It is lowered from lack of exercise, by a vegetable diet or 
 one containing much carbohydrate, during the convalescence of fevers, in 
 persons gaining weight rapidly, during pregnancy, during the formation 
 of exudates and transudates, and in nephritis. 
 
 Urea. — Quantitative Estimation; Hypobromite Method. — This 
 quantitative test is based upon the principle that an alkaline solution of 
 
 hypobromite of soda will decompose urea into 
 nitrogen, and carbon dioxide, which is absorbed in 
 the excess of alkah. The amount of urea is esti- 
 mated by the volume of nitrogen set free. Hiifner 
 has shown that one cubic centimetre of nitrogen 
 (at 0° C. and 760 mm. pressure) represents .00268 
 gramme of urea. A convenient method (Rice) of 
 preparing the hypobromite reagent is as follows: 
 (1) A solution is made by dissolving 100 grammes 
 of NaOH in 250 c.c. of water; (2) a solution of 
 bromine one part, potassium bromide one part, and 
 water eight parts. These solutions are mixed in 
 equal amounts. Special forms of apparatus have 
 been devised for collecting the nitrogen and meas- 
 uring its volume. The Heintz modification of the 
 Doremus apparatus can be highly recommended 
 because it is easy to operate and is sufficiently 
 accurate for clinical purposes. With this apparatus 
 the test is conducted as follows: The large tube is 
 filled with hypobromite reagent and the small tube 
 with urine up to the point indicated by the mark 1. 
 By opening the stop-cock, one cubic centimetre of 
 urine is allowed to flow very slowly into the large 
 tube. The reaction occurs immediately and nitro- 
 gen gas is set free and collects in the upper part 
 of the tube by displacing the fluid. The apparatus 
 is then set aside for fifteen minutes, when the reading is taken. The amount 
 of urea for one cubic centimetre of urine is indicated by a graduated scale 
 at the upper level of the fluid. Albumin should always be removed before 
 making this test. A considerable error will occur when the urine is rich in 
 ammonia. There are other methods for estimating urea which give more 
 accurate results, but they are objectionable because they are tedious and 
 entirely" too compHcated for the general practitioner. 
 
 On an ordinary diet the daily amount of urea varies between 20 
 and 40 grammes, on a rich diet it may reach 100 grammes, while on a 
 restricted diet it is sometimes reduced to 15 grammes. As a rule the 
 quantity of urea and the total nitrogen output are parallel, so that for 
 cHnical purposes the amount of urea is generally determined instead of 
 the total nitrogen. Urea may show a reduction with a rise in the am- 
 
 FiG. 119. — Heintz modifica- 
 tion of Hiifner apparatus for 
 urea determination. A, bulb; 
 B, graduated tube to collect 
 and measure the nitrogen; C, 
 tube for urine; D, stop-cock. 
 
EXAMINATION OF THE URINE. 279 
 
 monia elimination. This is observed in certain forms of liver disorders, 
 although in many cases of hepatic disease the urea output is unaltered. 
 
 Uric Acid. — Folin's Modification of Hopkins's Test. — Three 
 hundred cubic centimetres of urine are treated with 75 c.c. of a reagent 
 prepared as follows: 500 grammes of ammonium sulphate and 5 grammes 
 of uranium acetate are dissolved in 650 c.c. of water, to which are added 
 60 c.c. of a 10 per cent, acetic acid solution, and water enough to bring 
 the amount up to 1 litre. After standing for about five minutes the urine 
 so treated is filtered through two thicknesses of filter-paper. Into each of 
 two beakers 125 c.c. of filtrate are poured, treated with 5 c.c. of concen- 
 trated ammonia, and set aside for twenty-four hours. The ammonium 
 urate precipitate is next washed with a small quantity of a 10 per cent, 
 solution of ammonium sulphate. The precipitate of ammonium urate 
 collected on filter-paper is washed with 100 c.c. of water into a beaker, 
 after perforating the filter-paper. The solution is finally treated with 
 15 c.c. of concentrated sulphuric acid and then immediately titrated with 
 a 1/20 normal solution of potassium permanganate, until a faint red color 
 tints the entire solution. This color disappears rapidly. Each cubic centi- 
 metre of a 1/20 normal permanganate solution represents .00375 gramme 
 of uric acid. 
 
 Uric acid is an oxidation product of the xanthin bases. Its origin 
 depends upon the nucleins derived from the food (exogenous uric acid) and 
 from the body tissues (endogenous uric acid). The normal daily amount 
 of uric acid found in the urine varies between .2 and 1.25 grammes, 
 which represents from 1 to 2 per cent, of the total nitrogen output. 
 Uric acid is increased by a diet rich in nuclear proteids, active muscular 
 exercise, in fevers, in anaemia, in leukaemia, in pneumonia during the stage 
 of resolution, in cirrhosis of the liver, and in diabetes mellitus. In gout the 
 amount of uric acid is generally decreased between the acute attacks, and 
 rises during and immediately after the paroxysm. In gout an increase of 
 uric acid is found in the blood (uratsemia) . The circumstances which bring 
 about the separation of uric acid crystals in and about the joints and in 
 other tissues are not definitely known. The mere existence of urataemia 
 does not justify the conclusion that it is the principal or primary factor 
 of this disease; on the contrary it would appear that an increase of urates 
 which occurs in a number of conditions, as anaemia, leukaemia, and during 
 the resolution stage of pneumonia, does not in itself favor precipitation 
 of biurate of sodium. It has been suggested that an excess of sodium 
 salts in the blood, lymph, and especially in synovial fluid, determines the 
 precipitation of urates. Solutions of uric acid have been shown to possess 
 only slightly toxic or harmless properties when injected into the tissues of 
 animals. 
 
 The quantity of uric acid in the urine is decreased on a restricted diet, 
 especially one poor in substances containing nucleins, after the adminis- 
 tration of large doses of quinine, in nephritis, and in certain chronic diseases. 
 At the present time a final opinion as to the role played by uric acid in the 
 so-called uric acid diathesis cannot be given. 
 
 Xanthin Bases. — Under this heading is included a group of substances 
 found in the urine in very small amounts and regarded as being formed 
 from nucleins. In this group may be included xanthin, hypoxanthin. 
 
280 MEDICAL DIAGNOSIS. 
 
 heteroxanthin, paraxanthin, guanin and adenin. In the main it may be 
 said that the amounts of uric acid and the xanthin bases fluctuate in a paral- 
 lel manner. The xanthin bases are increased in the urine in leukaemia, after 
 a diet rich in nucleins, and in pneumonia. Rarely, calculi consist of xanthin. 
 
 Ammonia. — The normal daily output of ammonia is about 0.7 gramme, 
 wliich represents slightly over four per cent, of the total nitrogen elimina- 
 tion. It exists in combination with some of the urinary acids. Its presence 
 in the urine is accounted for by a small amount of ammonia which is not 
 transformed into urea in the liver. Ammonia is increased in conditions 
 associated with deficient oxidation, as cardiac dyspncea, in certain diseases 
 of the parenchyma of the liver, such as acute j^ellow atrophy and phos- 
 phorous poisoning, in diabetes mellitus, and, notablj^, in pernicious vomit- 
 ing of pregnancy. 
 
 Chlorides. — Quantitative Determination. — Ten cubic centimetres 
 of urine are diluted with 90 c.c. of water, to which are then added a few 
 drops of a strong potassium chromate solution. A standard silver solution 
 (1 c.c. of which represents .0035 gramme of chlorine, or .0058 gramme of 
 NaCl) is then slowly added from a graduated burette. The development of a 
 permanent orange color indicates that all the chlorine has been precipitated. 
 
 The excretion of chlorides, which varies from 10 to 15 grammes per day, 
 depends almost exclusively upon the quantity of chlorides ingested. A 
 decreased elimination is present on a diet poor in chlorides, in the acute 
 fevers (probably due to a deficiency of chlorides in the fever diet), before 
 the crisis in pneumonia, in acute and chronic nephritis, in many chronic 
 diseases, in gastric disorders associated with vomiting, in diseases attended 
 with diarrhoea, and during the formation of transudates and exudates. 
 An augmented ehmination is observed after a diet rich in chlorides, after 
 the acute fevers, especially during the stage of resolution of pneumonia, 
 in diabetes insipidus, and from rapid resorption of transudates and exudates. 
 
 Phosphates. — Phosphoric acid of the urine is combined T\ith sodium, 
 potassium, ammonium, calcium, and magnesium. The daily amount of 
 phosphoric acid excreted by the kidneys varies between two and three 
 grammes. A cUminished excretion has been noted in some febrile diseases, 
 in cases of arthritis, between the paroxysms of gout, in pregnancy, in. acute 
 yellow atrophy of the liver, in nephritis, in Addison's disease, and in chronic 
 lead poisoning. An increased ehmination has been noted on a diet rich 
 in meat, during the attack of gout, in diabetes melhtus, in neurasthenia, 
 in hysteria, in leukaemia, and after active muscular exercise. The existence 
 of a phosphatic deposit in the urine is not necessarily a sign of increased 
 elimination, and is frequently due to alkalinity of the urine. A quantita- 
 tive estimation of phosphoric acid is necessary to estabUsh an increased 
 output. Xeubauer's method consists in titrating the urine with a uranium 
 nitrate solution, using cochineal as an indicator. For the details of this 
 method special works on urinary chemistry should be consulted. 
 
 Sulphates.— Sulphuric acid exists in the urine as mineral, preformed 
 or neutral sulphates, and as conjugate or ethereal sulphates. The total 
 daily output of sulphuric acid varies between 2 and 3 grammes, nine-tenths 
 of which is eliminated as mineral sulphates and the remainder as ethereal 
 sulphates. Ethereal sulphates occur in combination with certain aromatic 
 
EXAMINATION OF THE URINE. 281 
 
 bodies, the most important of these being phenol, indoxyl, skatoxyl, and 
 cresol. The sulphate ehmination is controlled principally by proteid metab- 
 olism, so that the amount is increased after a diet rich in meat, by muscular 
 exercise, in the acute febrile diseases, in acute inflammator}^ diseases of 
 the brain and spinal cord, and by certain poisons which augment proteid 
 destruction. The output of sulphates is reduced by a vegetable diet or 
 one poor in proteids, during the period of convalescence from the acute 
 fevers, and in many chronic diseases. The quantity of ethereal sulphates 
 depends mainly upon putrefactive changes occurring in the intestinal tract, 
 and sometimes in other parts of the body. The normal proportion of 
 ethereal sulphate to neutral sulphate varies considerably. The conjuoate 
 sulphates are diminished by starvation, by the administration of calomel 
 and hydrochloric acid, and are increased by the ingestion of alkalies and 
 carbolic acid, in intestinal diseases associated with increased putrefaction, 
 as in constipation, enteric fever, and tuberculous enteritis. 
 
 Indican. — Obermayer's Test. — The reagent for this method is made 
 by dissolving two parts of ferric chloride in 1000 parts of concentrated 
 hydrochloric acid. A small amount of urine is treated with an equal part 
 of Obermayer's reagent and the mixture shaken with 2 or 3 cubic centi- 
 metres of chloroform, which extracts indican. It is light blue or colorless 
 when a normal amount is present, while an increased quantity is shown 
 by a dark blue color. 
 
 Jaffe's Test Modified by Stokvis. — Equal volumes of hydrochloric 
 acid and urine are mixed. The Hquid is treated with a droplet of a con- 
 centrated solution of sodium or calcium hypochlorite and then shaken with 
 a few c.c. of chloroform. A blue color is imparted to the chloroform by the 
 indigo. An approximate estimate of the amount may be formed by the 
 depth of this color. Iodine in the urine tints the chloroform pink. Bile 
 pigment should always be removed with lead subacetate before testing 
 for indican. Indol is formed in the intestines as a result of putrefactive 
 processes; in the blood it is oxidized and combines with sulphuric acid, 
 being eliminated as sodium or potassium indoxyl sulphate or indican. As 
 putrefaction is essential for the formation of indican, only small traces of 
 this substance occur in the urine of healthy persons, since intestinal decom- 
 position is slight under normal conditions. The quantity of indican is 
 influenced by the character of food, being smaller upon a milk than on a 
 full mixed diet. Jaffe found that 6.6 mg. was the average normal amount 
 for 1000 c.c. of urine. 
 
 Pathological indicanuria occurs in carcinoma of the stomach, in cer- 
 tain forms of gastritis, and in conditions associated with inhibited intes- 
 tinal peristalsis, as constipation, intestinal obstruction, and peritonitis. 
 The amount of indican is augmented in putrid bronchitis, in empyema, and 
 in gangrene and abscess of the lungs. 
 
 Urinary Pigments. — The color of normal urine depends chiefly upon 
 urochrome. The following pigments are responsible for the color of many 
 abnormal urines: pathological urobilin, uroerythrin, haemoglobin, methaem- 
 oglobin, urohsematin, uroroseinogen, biliary pigment, and melanin. After 
 the ingestion of senna, santonin, iodine, phenol, and creosote abnormal 
 pigmentation of the urine often occurs. 
 
282 MEDICAL DIAGNOSIS. 
 
 Biliary Pigments. — Rosenbach's Modification of Gmelin's Method. 
 — The urine is filtered through thick filter-paper. A drop of concentrated 
 nitric acid is then placed upon the urine-soaked filter-paper. A play of 
 colors, consisting of red, yellow, green, blue, and violet, in which the green 
 predominates, will develop in the presence of biliary pigment. 
 
 Smith's Test. — A small amount of tincture of iodine diluted with 10 
 parts of alcohol is added to 5 or 10 c.c. of urine, so that the iodine solution 
 forms a layer above the urine. An emerald color forms at the zone of 
 contact of two fluids when bilirubin is present. Biliary acids are associated 
 with bilirubin so that their clinical significance is practically the same. 
 The tests for biliary acids are attended with considerable difficulty. 
 
 The biliary pigments are bilirubin, biliverdin, bilifuscin, and biliprasin. 
 Bilirubin is found in freshly voided urine only, while the other pigments 
 may appear after the urine has stood for a time. Biliary pigment occurs 
 in the urine in both toxsemic and obstructive jaundice. 
 
 Phenol. — Salkow^ski's Test. — About 10 c.c. of urine are treated with 
 a few c.c. of nitric acid and boiled. On cooling, bromine water is added. 
 An increased amount of phenol is shown by the development of a decided 
 cloudiness or precipitate. 
 
 The amount of phenol eliminated is very small (.03 gramme daily 
 under normal conditions). This substance is increased whenever putrefac- 
 tive processes occur in the body, as in gangrene, putrid bronchitis, em- 
 pyema, and, rarely, from intestinal decomposition. It has also been 
 •demonstrated in tuberculosis, meningitis, peritonitis, erysipelas, scarlet 
 fever, and from poisoning with phenol or some of its derivatives, such 
 as salicylic acid, pyrocatechin and hydroquinone. The urine containing 
 phenol may become dark brown or black on standing. 
 
 Pathological Urobilin. — Braunstein's Test. — About 20 c.c. of urine 
 are mixed with 5 c.c. of a reagent which consists of 100 parts of a con- 
 centrated solution of cupric sulphate, 6 parts of hydrochloric acid, and 3 
 parts of ferric chloride. A small amount of chloroform is added to the 
 mixture. On shaking, the chloroform becomes rose colored. 
 
 This pigment is closely related to urochrome and can be differentiated 
 from the latter by the spectroscope. Urobilin and its chromogen are solu- 
 b)le in chloroform and precipitated with ammonium sulphate. Patho- 
 logical urobilin is sometimes encountered in the urine in febrile diseases, 
 cirrhosis of the liver, pernicious anaemia, cancer, cerebral hemorrhage, 
 scurvy, Addison's disease, haemophilia, and syphilis. 
 
 Melanin and Melanogen. — These substances are occasionally found in 
 the urine of persons suffering from melanotic tumors, chronic malaria, and 
 certain wasting diseases. The urine containing melanin and melanogen 
 may have a normal yellow color when voided, but becomes darker when 
 exposed to the air. 
 
 Albumins. — The proteids found in the urine are serum albumin, 
 serum globulin, nucleo-albumin, albumose, Bence-Jones's albumin, haemo- 
 globin, fibrin and histon. The most important of these from a clinical 
 standpoint is serum albumin. 
 
 Serum Albumin. — The most useful tests for the detection of albumin 
 are the boiling and acidulation tests and Heller's test, because they afford 
 
EXAMINATION OF THE URINE. 283 
 
 uniformly satisfactory results, are simple and easily applied. It is claimed 
 that these tests are less sensitive than many others, such as Speigler's and 
 Tanret's. Before testing for albumin the urine should be clear, and, if 
 cloudy, must be filtered through several layers of filter-paper. Bacteria 
 cannot be completely removed by filtration through ordinary filter-paper. 
 It is desirable to have a fresh specimen for testing. In certain cases several 
 samples should be secured, i.e., the first urine passed in the morning on 
 arising, and that voided late in the afternoon. Albumin reactions are 
 sometimes less distinct in concentrated specimens than in those of low 
 specific gravity, and it is, therefore, advisable to dilute an inspissated 
 urine before applying albumin tests. 
 
 Boiling and Acidulation Test. — Clear urine is boiled in a test-tube. 
 When a precipitate forms this is generally due to either phosphates or 
 albumin (serum albumin in conjunction with serum globulin). The tur- 
 bidity caused by phosphates clears on the addition of a few drops of color- 
 less nitric acid, while the cloud due to albumin remains or even is intensi- 
 fied after acidulation. A precipitate of carbonates, developing on heating, 
 will disappear upon the addition of nitric acid with the liberation of gas 
 (CO2). If on boiling the urine remains clear but subsequently on cooling 
 a cloud develops, this is due to albumose. This turbidity will again 
 disappear on heating. Certain resinous bodies, as copaiba, benzoin, 
 cubebs, and turpentine, also produce a precipitate on heating. This cloud 
 can be distinguished from that produced by albumin by the fact that 
 alcohol dissolves the turbidity produced by these substances. When 
 employing acetic acid., it is best to add a few drops before boiling, care 
 being taken to avoid an excess, since albumin may not precipitate on 
 boiling. If a cloud forms after the urine is treated with acetic acid, 
 this is caused by nucleo-albumin and should be removed by filtration before 
 testing for serum albumin. The most accurate results are obtained with 
 this method when a dilute acetic acid solution is employed (25 per cent.). 
 
 Heller's Test. — Colorless nitric acid is allowed to flow slowdy from 
 a pipette into a test-tube or a conical glass vessel containing a small quan- 
 tity of urine, so that the urine forms a distinct layer above the acid. In 
 order to prevent mixing the acid and urine, the test-tube or conical vessel 
 should be inclined while adding the nitric acid. When serum albumin is 
 present a white disk appears at the zone of contact between the urine and 
 acid. When a small amount of albumin exists the precipitate does not 
 form immediately but in the course of several minutes. An approximate 
 quantitative estimate of albumin can be formed from the thickness of the 
 coagulated layer. A pale red or reddish-violet disk, at or above the plane 
 of contact, is noted in many normal and abnormal urines. A white pre- 
 cipitate is also caused by serum globulin and albumose. The latter dis- 
 appears on heating and reappears on cooling. Nucleo-albumin in large 
 amounts may give a positive reaction, but this is so uncommon that it 
 can be disregarded for practical purposes. Certain resinous bodies, indi- 
 cated in the discussion of the boihng and acidulation test, produce a 
 white cloud which disappears when treated with alcohol. 
 
 Acetic Acid and Potassium Ferrocyanide Test. — A few drops 
 of 10 per cent, solution of potassium ferrocyanide or platinocyanide are 
 
284 
 
 MEDICAL DIAGNOSIS. 
 
 added to a small amount of urine previously acidified with acetic acid. 
 A precipitate indicates albumin or albumose. If, on heating, the turbid- 
 ity disappears completely, the presence of the latter substance is indi- 
 cated, or, if the cloud partly clears on warming, the presence of both 
 substances may be inferred. When a precipitate, due to nucleo-albumin, 
 forms on addition of acetic acid, the urine should be filtered and the 
 test repeated. 
 
 Spiegler's Test. — The test solution as modified by Jolles consists 
 of mercuric chloride 10 grammes, succinic acid 20 grammes, sodium chlo- 
 ride 20 grammes, and distilled water 500 c.c. The reagent is added slowly 
 by means of a pipette to a small amount of urine contained in a test-tube, 
 so that the urine forms a layer above the test solution. A white cloud 
 at the junction of the fluids indicates albumin, nucleo-albumin 
 \ ] or albumose. When the urine contains iodine, a precipitate of 
 mercuric iodide forms, which is soluble in alcohol. This test 
 is very sensitive. 
 
 Many other methods for the detection of albumin are recom- 
 mended by different authorities, as tests with picric acid, meta- 
 phosphoric acid, phosphotungstic acid, and trichloracetic acid. 
 Quantitative Determination of Albumin. Esbach's 
 Method. — The test solution is prepared by dissolving 10 
 grammes of picric acid and 20 grammes of citric acid in 1000 
 c.c. of distilled water. A special graduated test-tube devised 
 by Esbach and known as an albuminometer is required for this 
 method. The urine should have an acid reaction. It is poured 
 into the albuminometer to the mark ''U "; the reagent is then 
 added until the fluid reaches to the mark "R. " The fluids 
 are then mixed and the test-tube set aside for twenty-four 
 hours, when the reading is taken. The height of the column 
 of coagulated albumin, as measured by the scale on the tube, 
 represents the amount pro mille. Esbach's reagent precipi- 
 tates serum albumin, serum globulin, albumose, uric acid, and 
 creatinin. When the specific gravity exceeds 1.008, or when a 
 large amount of albumin exists, the urine should be diluted 
 with one or several volumes of water before applying the test. 
 The reading is multiplied by the number of dilutions. Esbach's 
 method, although not so accurate as the gravimetric determination, is quite 
 satisfactory for general clinical purposes. 
 
 Boiling Test. — An approximate estimate of the quantity of albumin 
 can be formed by boiling acidified urine in a test-tube and allowing the 
 precipitate to settle for twenty-four hours. The error with this method 
 may be considerable, because albumin sometimes separates in large and 
 at other times in small flakes. 
 
 Gravimetric Method. — One hundred cubic centimetres of urine are 
 sufficiently acidulated with acetic acid to insure separation of all the 
 albumin. It is then boiled and passed through a filter of known weight. 
 The precipitate collected on the filter is washed with hot water until the 
 washings cease to give a reaction for chlorides. The precipitate is next 
 washed successively with alcohol and ether to remove fat. The filter 
 
 -u 
 
 Fig. 120.— 
 Esbach's albu- 
 minometer. — 
 Eraerson. 
 
EXAMINATION OF THE URINE. 285 
 
 containing the precipitate is now dried at a temperature of 120° to 130° 
 and then carefully weighed. The weight of the albumin is obtained by 
 subtracting the weight of the filter-paper from the combined weight of the 
 filter-paper and dried precipitate. 
 
 Albuminuria. — The term albuminuria implies the presence in the 
 urine of coagulable albumin, and refers particularly to serum albumin. 
 One or more albuminous bodies are almost invariably associated with 
 serum albumin. Albuminuria is symptomatic of a large number of morbid 
 states, from minor disturbances in health to malignant diseases. 
 
 1. Renal Albuminuria. — When albumin is eliminated by the kid- 
 neys the condition is termed renal albuminuria. 
 
 (a) So-called 'physiological albuminuria is occasionally noted in healthy 
 individuals after violent exercise or severe nervous stress. Whether albu- 
 minuria is ever physiological is still a mooted question. Albuminuria 
 often occurs in pregnancy, esiDecially in the later stages. The so-called 
 albuminuria of adolescents is probably pathological. 
 
 (b) Albuminuria of Organic Kidney Disease. — In this variety the 
 presence of albumin in the urine depends directly on structural changes 
 in the renal tissues, and in nephritis, and amyloid, tuberculous, malignant 
 and cystic disease of the kidney. In acute and chronic parenchymatous 
 nephritis the amount is generally large, while in amyloid disease it is moder- 
 ate or small, and in contracted kidney it is small. The mere presence of 
 albumin in_th^jirine^,ne.VJ£C_JSJ^arxan±s^^~dia^nosis.. of organic renal, disease; 
 on the other hand mere traces occur in granular kidney, and, indeed, albumin 
 may be absent for a time in this disease. Large quantities of albumin 
 usually justify a diagnosis of organic kidney disease. 
 
 (c) Febrile Albuminuria. — A discharge of albumin of slight or moderate 
 degree in fevers and inflammatory diseases is suggestive of a simple paren- 
 chymatous degeneration of the kidney and of vascular derangements, 
 incident to the febrile or inflammatory process, while a high grade of al- 
 buminuria, noted in a limited number of these cases, points to marked renal 
 degeneration, often associated with decided congestion. The difference 
 between albuminuria of febrile and inflammatory disorders and that of 
 acute Bright's disease is essentially one of degree, so that a sharp distinc- 
 tion cannot be made between these forms. Albuminuria is symptomatic 
 of many of the infectious diseases, especially enteric fever, typhus fever, 
 pneumonia, cerebrospinal fever, yellow fever, plague, cholera, malignant 
 endocarditis, diphtheria, erysipelas, and variola. 
 
 (d) Toxic Albuminuria. — Under this heading is included the albu- 
 minuria produced by drugs, such as salicylic acid, potassium iodide, salol, 
 urotropine, phenol, alcohol, ether, chloroform, lead, mercury, phosphorus, 
 and a number of other toxic substances. 
 
 (e) Albuminuria occurring in blood disorders is seen in severe second- 
 a.ry anaemias, pernicious anaemia, chlorosis, and leukaemia. 
 
 (f) Alimentary Albuminuria. — The ingestion of very large amounts of 
 albumin, such as raw eggs, may excite albuminuria, but a moderate quan- 
 tity of albuminous food will never produce albuminuria in a healthy person. 
 An antecedent chronic albuminuria may be intensified by a moderate 
 consumption of albumin. 
 
286 MEDICAL DIAGNOSIS. 
 
 (g) Albuminuria dependent upon circulatory disturbances of the kid- 
 neys is seen in cardiac disease, especially during the stage of ruptured 
 compensation, in pulmonary disease with venous stasis, from pressure on 
 the renal veins by a tumor, cyst or peritoneal effusion, and by a thrombus in 
 these vessels. In floating kidney albuminuria sometimes depends on kink- 
 ing of the renal veins so that it may be present only while the individual 
 is in the erect posture, disappearing when in the recumbent position (ortho- 
 static albuminuria). 
 
 (h) Albuminuria in nervous diseases is common when organic lesions 
 of the nervous system exist, such as apoplexy, brain tumor, and spinal 
 sclerosis, but it is infrequent in functional disorders, such as neurasthenia 
 and migraine. 
 
 (i) Albuminuria caused by obstruction in the urinary passages occurs 
 in nephrolithiasis, when the stone blocks up the ureter for a time, and also 
 when the ureter is compressed by a tumor or is twisted. The urine which 
 has been impeded in its passage shows albumin in many instances. 
 
 2. Accidental Albuminuria. — When the urine contains albumin 
 derived from the renal passages or genital organs it is designated accidental 
 or extrarenal albuminuria. The presence of pus, blood, leucorrhoeal 
 discharge, and chyle in the urine, as a rule, causes a slight, and rarely, a 
 moderate albumin reaction. This type occurs in pyehtis, ureteritis, cystitis, 
 prostatitis, vesicuhtis, epididymitis, urethritis, vulvovaginitis, and during 
 menstruation. A vaginal discharge is often washed into the urine. The 
 diagnosis of accidental albuminuria is generally unattended with difficulty, 
 provided the results of microscopic examination and the clinical investi- 
 gation are carefully considered. In general terms it may be said that the 
 intensity of the albumin reaction is directly proportionate to the amount 
 of cellular deposit. The differentiation between renal and extrarenal 
 albuminuria rests on the data obtained by a careful urinalysis with other 
 clinical findings. Both conditions often coexist. The presence of tube- 
 casts and many pus-cells with an albumin reaction greater than the number 
 of leucocytes would indicate, argues in favor of a coexistent renal and 
 accidental albuminuria. 
 
 Serum Globulin. — Kauder's Test. — The urine is treated with a sufii- 
 cient quantity of ammonia to separate the phosphates, which are removed 
 by filtration. An equal bulk of a saturated solution of ammonium sulphate 
 and filtrate are mixed. A precipitate represents serum globulin. 
 
 Serum globuHn and serum albumin are almost invariably associated,, 
 so that their cHnical significance is similar. As a rule serum albumin is 
 found in excess of serum globulin, although exceptions to this rule are 
 recorded in amyloid disease, diabetes, and severe nephritis. 
 
 Nucleo=.albumin. — This body is precipitated by strong acetic acid. 
 Concentrated urines should always be diluted with two or three volumes 
 of water before applying this test. Urine containing much serum albumin 
 and serum globulin should be boiled and filtered in order to remove these 
 substances before testing for nucleo-albumin. 
 
 Ott's Method. — Add to the urine an equal volume of saturated solu- 
 tion of sodium chloride, and treat the mixture with Almen's tannin solution. 
 The presence of nucleo-albumin is shown by the formation of an abundant 
 
EXAMINATION OF THE URINE. 287 
 
 precipitate. Almen's solution consists of 5 grammes of tannic acid, 10 c.c. of 
 a 25 per cent, solution of acetic acid, and 240 c.c. of 50 per cent, ethyl alcohol. 
 Nucleo-albumin can be removed from the urine with neutral lead acetate. 
 
 With certain delicate tests nucleo-albumin can be demonstrated in 
 many normal and abnormal specimens, so that its presence in small amount 
 may be regarded as physiological. When nucleo-albumin can be de- 
 tected by tests generally employed in routine clinical work, it is probably 
 pathological. Nucleo-albuminuria occurs in inflammatory diseases, espe- 
 cially of a catarrhal nature, of the urinary tract, as cystitis and pyelitis. In 
 febrile diseases associated with albuminuria, in leukaemia, in jaundice, and in 
 acute nephritis, nucleo-albuminuria is not uncommon. In the last named dis- 
 ease nucleo-albuminuria sometimes precedes and follows serum albuminuria. 
 
 Albumose. — To the urine strongly acidulated with acetic acid, is added 
 an equal amount of a saturated solution of sodium chloride. The presence 
 of a precipitate, which disappears on boiling and returns on cooling the 
 urine, consists of albumose. When serum albumin coexists with albumose^ 
 this must be removed by boiling and filtering before applying the test. 
 
 Albumosuria is referred to by some writers as peptonuria, a term which. 
 Kiihne restricts to the presence of true peptone. According to Kiihne, 
 peptonuria has been found in pneumonia, phthisis, and gastric ulcer. The 
 chief clinical significance of albumose in the urine relates to morbid lesions, 
 characterized by a destruction of leucocytes, with the absorption of the 
 disintegrated products. In many diseases showing these pathological 
 features, ^especially in purulent collections, the occurrence of albumosuria 
 may be a useful sign in diagnosis. In this connection it must be pointed 
 out that, since the group of conditions in which it occurs is a vast one, its 
 significance is of less value in diagnosis than any other urinary findings. 
 Albumosuria has been noted in pneumonia during the period of resolution, 
 in suppurative meningitis, in liver abscess, in septicaemia, in leukaemia, 
 in endocarditis, in myxoedema, in diphtheria, in measles, in rheumatic 
 fever, in scarlet fever, in acute yellow atrophy of the liver, in scurvy, in 
 dermatitis, and in intestinal diseases characterized by ulceration, as enteric 
 fever, tuberculosis, and carcinoma. Albumosuria may be associated with, 
 or occur independently of, serum albuminuria. 
 
 Bence= Jones's Albumose. — The recognition of this proteid depends upon 
 the fact that its precipitation occurs at a temperature of 59° to 60° C. 
 Upon boiling, the cloud entirely or partially disappears, to return again on 
 cooling. With Heller's nitric acid test Bence-Jones's albumin gives a reac- 
 tion like that of serum albumin. 
 
 This proteid, first described by Bence-Jones, occurs with considerable 
 frequency in myeloma of the bones. It is generally designated as albumose, 
 but probably incorrectly. The researches of Simon and Magnus Levy 
 indicate that it is a true albumin. 
 
 Haemoglobin. — The spectroscopic examination, as a rule, shows absorp- 
 tion bands of methaemogiobin, sometimes of oxyhaemoglobin. 
 
 Donogany's Test. — If, on the addition of 1 c.c. of ammonium sulphide 
 solution and an equal quantity of pyridine to 10 c.c. of urine, an orange color 
 develops, the presence of blood may be inferred. When the result is 
 doubtful, a spectroscopic examination should be made of the mixture. 
 
288 MEDICAL DIAGNOSIS. 
 
 The physiological destruction of red corpuscles is not followed by 
 hsemoglobinuria, because the coloring matter set free from the disintegrated 
 erythrocytes is converted wholly, or in part, in the liver into bile, and, per- 
 haps, a fraction of the amount is redeposited in the tissues and stored 
 there for the future demands of the system. The explanation generally 
 offered to elucidate hemoglobinuria is based upon an erythrocytolysis so 
 excessive that a part of the hasmoglobin liberated into the plasma (hamo- 
 globinsemia) is secreted by the kidneys. Hemoglobinuria occurs in some 
 cases of malarial fever (black water fever) . It has been observed in yellow 
 fever, variola, icterus gravis, scarlet fever, enteric fever, syphilis, Raynaud's 
 disease, and from the toxic action of phenol, potassium chlorate, snake 
 venom, hydrogen sulphide, carbon monoxide, and after exposure to the 
 cold. The etiological factor responsible for paroxysmal hsemoglobinuria 
 has not been definitely determined. Some writers claim that exposure to 
 cold is the exciting cause, while others hold that it is of nervous origin. 
 Hsematuria is much more common than hsemoglobinuria. 
 
 Fibrin. — The suspected fibrin clots are separated from the .urine by 
 filtration, then thoroughly washed with water and dissolved by boiling in 
 a 5 per cent, solution of hydrochloric acid. ' The solution thus secured 
 gives the test for serum albumin when the coagulum consists of fibrin. 
 
 Fibrinuria has been noted in hsematuria, chyluria, and in pseudomem- 
 branous inflammation of the urinary tract. 
 
 An acetosoluble albumin referred to by Simon as Patein's albumin 
 has been reported in cystic kidney and nephritis. 
 
 Glucose. — Fresh urine is desirable for quantitative examinations for 
 sugar. When albumin is present, this should be removed from the urine 
 before testing for glucose. 
 
 Trommer's Test. — To a small amount of urine rendered strongly 
 alkaline with a solution of sodium hydrate, is added drop bj^ drop a 10 per 
 cent, solution of cupric sulphate, until the cupric oxide which forms ceases 
 to be dissolved. On heating the urine, treated in this manner, a yellow or 
 red precipitate develops when sugar is present. Small traces of sugar 
 often give negative results unless the urine is boiled. Cupric oxide is often 
 reduced by other substances. This may occur after the ingestion of benzoic 
 acid, chloral, salicylic acid, sulphonal, chloroform, and from the presence 
 in the urine of uric acid, creatinin, creatin, bile pigment, and hydroquinone. 
 Glucose causes precipitation of cupric oxide at a temperature below the 
 boiling point, which affords a means of distinguishing it from other reducing 
 sub.stances. 
 
 Fehling's Test. — This method is a modification of Trommer's test. 
 Two solutions are required, an alkaline and a copper solution, which should 
 be mixed just before applying the test. Fehling's reagent deteriorates in 
 a few days to such an extent that it is unsuited for testing; therefore, it is 
 necessary to keep the alkaline and copper solutions in separate bottles sup- 
 plied with well-fitting rubber corks. The alkaline solution consists of potas- 
 sium and sodium tartrate 173 grammes, potassium hydrate 60 grammes, 
 and 500 c.c. of distilled water. The copper solution consists of cupric 
 sulphate 34.64 grammes, dissolved in 500 c.c. of distilled water. Equal 
 volumes of these solutions are poured into a test-tube and shaken; the 
 
EXAMINATION OF THE URINE. 289 
 
 mixture is then diluted with four parts of water and boiled. After remov- 
 ing the test-tube from the flame the urine is added in small amounts, and 
 after each addition the mixture heated but not boiled. When sugar 
 is present a yellow or red precipitate of cupric suboxide separates. A 
 change of the blue color of Fehling's solution to green, with a slight 
 turbidity of the liquid after the addition of the urine, is very often seen, 
 and may not be caused by glucose. Nearly every reduci&g substance 
 except sugar requires boiling to produce precipitation of cupric suboxide. 
 
 Phenylhydrazine Test. — About .5 gramme of phenylhydrazine hydro- 
 chloride and 1 gramme of sodium acetate are added to about 8 c.c. of urine 
 contained in a test-tube. If the salts do not dissolve on warming the urine, 
 water is added to effect solution. The tube is now placed in boiling water 
 for 20 or 30 minutes, then removed, and rapidly cooled by placing the test- 
 tube in cold water. The formation of a bright yellow precipitate indicates 
 the presence of sugar. Mere traces of glucose cause a small amount of 
 precipitate which should be examined microscopically for phenylglucosa- 
 zone crystals. These consist of yellow needles arranged singly or in clus- 
 ters. Their melting point is 205° C. In experienced hands this test is 
 generally considered the most sensitive. 
 
 Nylander's Modification of Boettger's Test. — Almen's reagent, 
 required for this method, consists of 4 grammes of potassium and sodium 
 tartrate, 2 grammes of bismuth subnitrate, and 10 grammes of sodium 
 hydrate dissolved in 90 c.c. of water. This solution is then boiled and, after 
 cooling, it is filtered. A small quantity of Almen's reagent is added to the 
 urine, approximately in the proportion of 1 to 11, and the resultant mix- 
 ture is boiled. In the presence of sugar a dark gray or black precipitate of 
 metallic bismuth separates. A positive reaction may be given by albumin, 
 melanin, melanogen, and other reducing substances found in the urine 
 after the ingestion of salol, benzol, sulphonal, trional, turpentine, quinine, 
 rhubarb, and senna. 
 
 Fermentation Test. — The principle of this method is based on the 
 fact that glucose is decomposed by yeast into alcohol and carbon dioxide. 
 Special fermentation tubes, as designed by Einhorn, are convenient in 
 conducting this test. The method is carried out by mixing a bit of a cake 
 of compressed yeast with urine in a test-tube. Einhorn's fermentation 
 tube is filled with this mixture, care being taken to exclude air bubbles 
 from the top of the tube. The saccharometer is kept at a temperature of 
 from 25° to 38° for twenty-four hours, during which time the CO2 collects 
 in the upper part of the tube, A temperature of 34° C. gives the most 
 satisfactory results. A control test should always be made with normal 
 urine, since slight fermentation occurs in every specimen. With Einhorn's 
 tube, an approximate estimate of the quantity of sugar can be formed, 
 but for accurate quantitative analysis Robert's differential method is to 
 be preferred. The fermentation test serves to differentiate fermentable 
 sugar from other reducing substances. 
 
 Quantitative Estimation of Sugar. Fehling's Titration 
 Method. — 10 c.c. of Fehling's solution diluted with 40 c.c. of water are 
 boiled. At this temperature saccharine urine is added drop by drop from 
 a graduated burette, until the blue color of the test solution disappears, 
 
 19 
 
290 MEDICAL DIAGNOSIS. 
 
 which indicates complete reduction of cupric oxide. The presence of 
 reduced copper held in suspension obscures the color of the solution, so 
 that it is necessary to allow the cuprous oxide granules to settle from time 
 to time in order to detect the tint of the fluid. The cupric oxide contained 
 in 10 c.c. of Fehling's solution is reduced by .05 gramme of glucose. 
 
 Robert's Differential Density Method. • — For general clinical 
 work, Robert's method is most satisfactory. The principle of this method 
 rests on determining the specific gravity before and after fermentation; 
 each .001 degree of difference in the specific gravity represents .23 per 
 cent, of sugar. The test is carried out by noting the specific gravity of 
 200 c.c. of urine taken from a mixed 24-hour specimen. A portion of a 
 cake of compressed yeast is mixed with the urine, which is then set aside 
 for 24 or 48 hours. The glucose generally disappears in 24 hours, but, in 
 order to ascertain whether all the sugar has been decomposed, the urine 
 is tested by Fehling's method. After all the sugar has been decomposed, 
 the specific gravity of the fermented urine is taken and the difference 
 between the two readings determined. The small urinometers employed 
 in clinical work are not suited for exact determination, therefore it is 
 convenient to use larger instruments. Accurate estimations can be taken 
 with a set of four or five hydrometers, each of which represents a part of 
 the specific gravity range ordinarily encountered in diabetic urine. For 
 example, hydrometer number 1 indicates the scale from 1.000 to 1.010; 
 number 2 ranges from 1.010 to 1.020; number 3 ranges from 1.020 to 
 1.030; number 4 ranges from 1.030 to 1.040, number 5 ranges from 
 1.040 to 1.050. The specific gravity observations should be taken at, 
 or nearly, the same temperature. Evaporation of the urine should be 
 reduced to a minimum during fermentation. The first specific gravity 
 determination is taken before the yeast is added to the urine, and the 
 second reading is made after the fermented urine has been filtered. 
 
 The quantitative determination for sugar by the polariscope is rec- 
 ommended highly by many workers, A polariscope designed for this 
 estimation is an expensive instrument. The rapidity with which a deter- 
 mination can be made is one of its chief advantages over other methods. 
 
 Physiological Glycosuria. — The presence of traces (.5 pro mille) of glu- 
 cose in the urine of healthy persons is conceded by most authorities. This 
 quantity cannot, however, be detected by the tests employed in routine work. 
 
 Pathological Glycosuria. — This condition may be said to exist when 
 glucose can be recognized by the tests generally in vogue in clinical work. 
 Glycosuria may be transitory, intermittent, or constant. The latter variety 
 is one of the cardinal symptoms of diabetes melhtus. 
 
 Glycosuria depends directly on an excess of sugar (above .2 per cent.) 
 in the blood. A possible exception to this rule relates to the glycosuria fol- 
 lowing the administration of phloridzin. It is thought that this substance 
 produces such alterations in the renal epithehum as to permit of increased 
 glucose ehmination. A renal form of diabetes has been suggested. The 
 sugar of the blood is derived principally from the carbohydrates of 
 the food, and in all likehhood some glucose is produced from the 
 albumins of the food. In certain cases of diabetes, characterized by rapid 
 emaciation, body proteids are concerned in its formation. Although many 
 
EXAMINATION OF THE URINE. 291 
 
 factors involved in the physiology of glucose metabohsni remain unex- 
 plained, much clinical and experimental evidence supports the view, (1) 
 that sugar metabolism is to a great extent regulated by the nervous system, 
 (2) that the liver is chiefly concerned in converting sugar into glycogen, 
 and also in forming glucose, and (3) that the pancreas secretes a sugar- 
 destroying ferment. A hypothetical conception of pathological glycosuria 
 based on this theory may be said to depend on a failure on the part of the 
 liver to form and store up glycogen, a disturbance which might result from 
 a loss of nervous control or from disease of the hepatic cells; or on an in- 
 abihty on the part of the system to consume sugar, which is ascribed to a 
 disturbance in the function of the pancreas inhibiting or suppressing the 
 secretion of the glycolytic substance. Clinically, glycosuria occurs under 
 a variety of circumstances: Disorders of the nervous system. Tempo- 
 rary or permanent glycosuria is observed in brain tumors, meningitis, 
 injuries to the nervous system, neurasthenia, exophthalmic goitre, and 
 may follow worry, fright, or mental overwork. Diseases of the pancreas. 
 Permanent glycosuria is often associated with sclerosis, and sometimes 
 with atrophy or tumors of the pancreas, while temporary glycosuria is at 
 times symptomatic of acute inflammation of this organ. Hepatic disease, 
 abscess and cirrhosis of the liver may be attended with the temporary or 
 constant presence of sugar in the urine. Toxic agents. The occasional 
 occurrence of glucose in the urine is noted in the infectious diseases, as 
 syphilis, influenza, enteric fever, diphtheria, rheumatic fever, and malaria, 
 and from poisoning by chloral, alcohol, and morphine. The explanation 
 of glycosuria occurring under these circumstances might be found in the 
 development of a disorder of the function of the liver, the pancreas, or the 
 nervous system, produced by these toxic agents. This variety is mainly 
 observed as a transitory form, although occasionally diabetes develops 
 after an acute infectious disease, which suggests permanent morbid proc- 
 esses of the hepatic or pancreatic tissues excited during the acute stage 
 of the disease. 
 
 The power possessed by the system to consume sugar varies in health 
 and in disease. Carbohydrate tolerance can be determined by the admin- 
 istration of glucose by the mouth. The urine of healthy persons generally 
 does not show glucose unless the amount ingested exceeds 250 grammes. 
 When glycosuria follows the taking of 100 grammes, an abnormal sugar 
 metabolism probably exists (pathological alimentary glycosuria). Car- 
 bohydrate tolerance is lessened by age, and is often reduced in obesity 
 and gout. 
 
 Lactose. — The presence of milk sugar in the urine is indicated by a 
 positive reaction with Trommer's and Nylander's tests after prolonged 
 boiling, when negative results are obtained with the phenylhydrazine and 
 fermentation tests. Lactose is found in the urine during the last weeks of 
 pregnancy and in nursing women. Glycosuria and lactosuria are occa- 
 vsionally associated. The ingestion of more than 120 grammes of lactose 
 often causes a lactosuria. 
 
 Levulose. — The presence of fruit sugar may be inferred when the urine 
 gives sugar reactions with Trommer's, Fehling's, the fermentation and 
 phenylhydrazine tests, and does not rotate polarized light to the right. 
 
292 
 
 MEDICAL DIAGNOSIS. 
 
 Levulose at times rotates polarised light to the left. Levulose occurs in 
 the urine in some cases of diabetes and, at times, in the urine of healthy- 
 persons after the ingestion of levulose. 
 
 Pentose. — Pentose can be recognized by the fact that it does not 
 undergo fermentation with yeast, but gives a positive reaction with 
 Fehling's, Nylander's, and the phenylhydrazine tests. Pentose has been 
 discovered in the urine after eating plums, pears, apples, cherries, and 
 huckleberries, from the ingestion of 50 grammes or more of pentose, and 
 occasionally in diabetes. A family tendency has been recorded. 
 
 Dextrin. — This substance reduces Fehling's solution, the copper separat- 
 ing first as a green, then changing to a yellow precipitate, and sometimes as a 
 dark brown sediment. Dextrin has been found in the urine in the absence of 
 glucose. Some authorities regard the presence of traces of dextrin as normal. 
 Acetone. — Legal's Test. — A few drops of freshly prepared concen- 
 trated solution of sodium nitroprusside are added to a small amount of uri- 
 nary distillate, and the mixture treated with sodium or potassium hydrate. 
 
 When a ruby color develops, rapidly changing to 
 yellow, it signifies the presence of acetone. This test 
 is usually negative with mere traces of acetone. 
 
 Lieben's Test. — A few drops of potassium 
 hydrate solution and a small quantity of iodopo- 
 tassic iodide are added to the urinary distillate, 
 and the mixture warmed. Acetone is indicated 
 by the formation of iodoform, which appears as 
 hexagonal or stellate crystals, and can be recog- 
 nized by its characteristic odor. 
 
 Dunning's Test. — Tincture of iodine, or 
 Lugol's solution, is added to the urinary distillate, 
 and the mixture treated wdth ammonia until a black 
 precipitate develops, which slowly disappears, leav- 
 ing a 3^ellow deposit of iodoform crystals. 
 Acetone occurs in normal urine in small quantities, not exceeding 
 10 mg. in twenty-four hours. It is increased by restricting or withholding 
 carbohydrates from the diet, especially when large amounts of proteids 
 are consumed. It is also augmented in febrile diseases, in certain cachexias, 
 in gastric ulcer, and follows the administration of phloridzin, and chloro- 
 form narcosis, and in severe forms of diabetes mellitus, notably before 
 and during diabetic coma. 
 
 Diacetic or Aceto=acetic Acid. — Gerhardt's Test. — 10 or 15 c.c. of 
 urine are subjected to the action of a solution of ferric chloride. When a 
 precipitate forms on the addition of the ferric chloride, it is removed by 
 filtration, and to filtrate is again added the test solution. Diacetic acid 
 may be inferred when a Bordeaux red color develops, which maj^ com- 
 pletely disappear in from 24 to 48 hours. Sahcylic acid, salol, aspirin, 
 diuretin, sodium acetate, and antipyrin may give a similar reaction. 
 Prolonged boiling of the urine containing diacetic acid will cause a com- 
 plete or partial disappearance of this substance. 
 
 Diacetic acid is rarely found in normal urine. It occurs in conjunction 
 with large amounts of acetone, and the clinical significance of aceto-acetic 
 
 Fig. 121. — Iodoform crystals 
 formed from the distillate of 
 the urine of a case of diabetes. 
 — Emerson. 
 
EXAMINATION OF THE URINE. 293 
 
 acid is similar to that of acetone. Oxybutyric acid may also be associated 
 with diacetic acid. Diaceturia is of special importance in diabetics, since 
 it is a trustworthy sign of acidosis, and is always a forerunner of diabetic 
 coma. Aceto-acetic acid has been noted in the urine in febrile diseases, in 
 gastro-intestinal disturbances, especially those attended with starvation, 
 and occasionally in individuals who have consumed a rich proteid diet for 
 a number of days. 
 
 ^-Oxybutyric Acid. — The urine is evaporated to the consistency of a 
 syrup, and an equal volume of concentrated sulphuric acid is added. By 
 distillation crotonic acid is obtained. Crystals of crotonic acid separate 
 on cooling the distillate. If crystallization does not occur readily, an 
 ethereal extract is obtained, evaporated, and the residue dissolved in water 
 and allowed to crystalHze. The presence of /?-oxybutyric acid may be 
 inferred by these crystals. If fermented diabetic urine containing oxy- 
 butyric acid be subjected to polariscopic examination, polarized light is 
 rotated to the left. 
 
 /J-oxybutyric acid is the mother substance of diacetic acid, while ace- 
 tone is derived from the latter substance. Its presence may be suspected 
 when diacetic acid exists in the urine in large amounts. /9-oxybutyric acid 
 occurs less frequently than diacetic acid and acetone, and in general terms 
 paay be said to arise under conditions similar to those causing acetonuria. 
 It is found in the urine in severe infectious fevers, during starvation, and 
 in grave forms of diabetes. /9-oxybutyric acid is generally regarded as the 
 cause of diabetic coma. Some attribute the symptoms of this condition 
 to a lowering of the alkalinity of the blood (alkali starvation), others con- 
 tend that its toxic action is responsible. 
 
 Alkaptone Bodies. — The urine containing alkaptone bodies reduces 
 Fehling's reagent, causing this test solution to blacken. This reaction 
 serves to differentiate it from glucose. Nylander's, the phenylhydrazine 
 and the fermentation tests are negative with urine containing alkaptone 
 bodies. 
 
 Urine of alkaptonuric individuals appears normal when voided, but 
 on standing its color changes to a reddish-brown or black. This peculiar 
 characteristic of the urine is thought to be due to homogentisinic acid and 
 uroleucinic acid. The cause of this condition is not known. The condition 
 is compatible with good health, and is often peculiar to several members 
 of a family, but inheritance does not seem to be an important factor in its 
 production. 
 
 Ehrlich's Diazo Reaction. — This test, introduced by Ehrlich, depends , 
 on certain diazo bodies, which probably combine with aromatic compounds, 
 giving a color reaction. The test is conducted as follows: A solution con- 
 sisting of 5 parts of sulphaniUc acid, 50 parts of hydrochloric acid, and 1000 
 parts of water, is mixed with a .5 per cent, solution of sodium nitrite in the 
 proportion of 50 of the former to 1 of the latter. An equal volume of urine 
 is added to this mixture and shaken. Upon the addition of a few drops 
 of ammonia, a cherry-red color develops at the zone of contact, indicating 
 a positive diazo reaction. On shaking, the entire fluid becomes red. A 
 brown or salmon color constitutes a negative reaction. The chief clinical 
 significance of this reaction relates to its almost constant presence in 
 
294 MEDICAL DIAGNOSIS. 
 
 enteric fever, but is without value as a differential sign, since it occurs in 
 a number of diseases. It is frequently present in measles, and occasionally 
 in pneumonia, scarlet fever, diphtheria, phthisis, rheumatic fever, menin- 
 gitis, and at times in non-febrile diseases, such as chronic nephritis, car- 
 cinoma of the stomach, and leukaemia. The administration of salol, phenol, 
 and betanaphthol may interfere with this reaction. 
 
 Fat. — Normal urine does not contain fat, but it is present in small 
 amounts, rarely in large quantities in chronic parenchymatous nephritis, 
 occasionally when fat occurs in excessive amounts in the blood, and after 
 the administration of large doses of cod-liver oil. It has been observed 
 in bone diseases in which there is a destruction of the bone-marrow, in 
 diabetes mellitus, leukaemia, pancreatic diseases, chronic tuberculosis of 
 the lungs, and obesity. In chyluria or galacturia the milky appearance 
 of the urine is due to fat globules. Chylous or chyhform urine, in addition 
 to fat, may also contain leucocytes, red blood-cells, fibrin, albumin, and 
 occasionally leucin, tyrosin, and cholesterin. 
 
 Cryoscopy of the Urine. — The determination of the freezing point of 
 the urine permits one to measure its molecular concentration. The appa- 
 ratus devised by Beckmann is generally employed in ascertaining the freez- 
 ing point. The average freezing point in normal individuals, as determined 
 by Koranyi, is —1.7° C, although wide variations are noted. Cryoscopy of 
 the urine is rarely employed in routine clinical work, since the results have 
 not been satisfactory. 
 
 Cam midge's Test. — A test for the detection of pancreatic disease has 
 been suggested by Cammidge. He holds that this reaction is due to the 
 presence in the urine of a peculiar body, probably pentose. 
 
 The following is the technic as described by Cammidge : " A specimen 
 of the twenty-four hours' urine, or of the mixed morning and evening 
 secretions, is filtered several times through the same filter-paper and 
 examined for albumin, sugar, bile, urobilin, and inclican. A quantitative 
 estimation of the chlorides, phosphates, and urea is also made, and the 
 cent rifugali zed deposit from the urine examined microscopically for calcium 
 oxalate crystals. If the urine is found to be free from sugar and albumin, 
 and of an acid reaction, 1 cm. of strong hydrochloric acid (specific gravity 
 1.16) is mixed with 20 c.c. of the clear filtrate, and the mixture gently 
 boiled on the sand-bath in a small flask having a long-stemmed funnel in 
 the neck to act as a condenser. After ten minutes' boiling the flask is well 
 cooled in a stream of water, and the contents made up to 20 c.c. with cold 
 distilled water. The excess of acid present is neutralized by slowly adding 
 4 grammes of lead carbonate. After standing for a few minutes to allow 
 of the completion of reaction, the flask is again cooled in running water 
 and the contents filtered through a well-moistened, close-grained filter- 
 paper until a perfectly clear filtrate is secured. The filtrate is then well 
 shaken with 4 grammes of powdered tribasic lead acetate and the result- 
 ing precipitate removed by filtration, an absolutely clear filtrate being 
 obtained by repeating the filtration several times if necessary. Since the 
 large amount of lead now in solution would interfere with the subsequent 
 steps of the experiment, it is removed either by treatment with a stream 
 of sulphuretted hydrogen or, what I have found to be equally satisfactory 
 
EXAMINATION OF THE URINE. 295 
 
 and less disagreeable, by precipitating the lead as a sulphate. For this 
 purpose the clear filtrate is well shaken with 2 grammes of finely powdered 
 sodium sulphate, the mixture heated to the boiling point, then cooled to 
 as low a temperature as possible in a stream of cold water, and the white 
 precipitate removed by careful filtration; 10 c.c. of the perfectly clear 
 transparent filtrate is made up to .18 c.c. with distilled water and added 
 to 0.8 gramme of phenylhydrazine hydrochloride, 2 grammes of powdered 
 sodium acetate and 1 c.c. of 50 per cent, acetic acid contained in a small 
 flask fitted with a funnel condenser. The mixture is boiled on a sand-bath 
 for ten minutes, and then filtered hot through a filter-paper moistened with 
 hot water into a test-tube provided with a 15 c.c. mark. Should the 
 filtrate fail to reach the mark, it is made up to 15 c.c. with hot distilled 
 water. In well-marked cases of pancreatic inflammation a light yellow, 
 flocculent precipitate should form in a few hours; but it may be necessary 
 to leave the preparation to stand overnight before a deposit occurs. Under 
 the microscope the precipitate is seen to consist of long, light yellow, flexi- 
 ble, hair-like crystals, arranged in sheaves which, when irrigated with 33 
 per cent, sulphuric acid, melt away and disappear in ten to fifteen seconds 
 after the acid first touches them. The precipitate should always be exam- 
 ined microscopically, as it may be difficult to determine the characters of 
 a small deposit with the naked eye, and so cases giving only a slight reac- 
 tion may be overlooked. To exclude traces of sugar, undetected by the 
 preliminary reduction tests, a control experiment is carried out by treating 
 20 c.c. of the urine in the same way as in the test described, excepting for 
 the addition of the hydrochloric acid. 
 
 " The urine employed for the experiment should be fresh, and not have 
 unc^rgone fermentative changes. If alkaline in reaction, it should be made 
 acid with hydrochloric acid before the test is commenced; any glucose 
 that may be present should be removed by fermentation after the urine 
 has been boiled with the acid, and the excess neutralized." 
 
296 MEDICAL DIAGNOSIS. 
 
 VII. 
 THE EXAMINATION OF THE SPUTUM. 
 
 Systematic examination of the sputum furnishes important chnical 
 data in a considerable group of diseases. 
 
 MICROSCOPICAL EXAMINATION. 
 
 Leucocytes. — The mere presence of leucocj^tes has no special signifi- 
 cance, since they occur in every specimen. A sputum containing an 
 abundance of white blood-corpuscles generally indicates a pathological 
 disturbance of some part of the respiratory tract, as chronic bronchitis, 
 bronchiectasis, pulmonary abscess, tuberculosis with cavity formation, or 
 may be due to a rupture of an extrapulmonary purulent collection into 
 the lungs. The polynuclear neutrophile leucocytes are most often found in 
 sputum, although in a limited number of diseases, particularly bronchial 
 asthma, eosinophiles are noted. The sputum in asthma is usually loaded 
 with eosinophiles, some of which have the characteristic morphology and 
 staining reaction of the hsemic eosinophiles, while others are supplied with 
 a circular nucleus. In certain cases of bronchitis, tuberculosis, and after 
 haemoptysis, eosinophiles are present in the expectoration. 
 
 Epithelial Cells. — Every specimen of sputum contains epithelial cells. 
 Pavement epithelium may be derived from the mouth, the pharynx, and 
 the upper half of the larynx, while cylindrical cells may come from the 
 nose, the lower part of the larynx, trachea, and bronchi. Catarrhal inflam- 
 mation, especially in its early stages, generally determines the presence of 
 large numbers of epithelial elements. Ciliated cells are occasionally found 
 in asthma and acute bronchitis, provided the specimen be examined im- 
 mediately after expectoration. Alveolar epithelial cells which occur in 
 the sputum in almost every pulmonary disease, as well as in the "so-called" 
 normal expectoration, are large, of an oval, round, or polygonal shape, 
 supplied with one or several relatively small vesicular nuclei, imbedded in 
 protoplasm which often contains albuminous granules, myelin droplets, 
 fat globules, particles derived from hsemoglobin, or coal pigment. These 
 cells occur in abundance in acute inflammatory pulmonary disease and 
 tuberculosis. Myelin granules have an irregular outline, often present a 
 concentric arrangement, and are found either intra- or extracellularly. 
 Myelin probably consists mainly of protagon and of small amounts of 
 lecithin and of cholesterin. These droplets dissolve in alcohol, stain hght 
 yellow with iodine, poorly with aniline dyes, and are not blackened with 
 osmic acid. Alveolar epithelium, containing granules of altered blood 
 pigment, is seen in the sputum of congestion of the lungs, notably in 
 that form due to heart disease, hence the term "heart disease cells" is 
 applied to them. 
 
 Red blood=cells occurring in small numbers are commonly observed 
 in the sputum of many diseases of the respiratory tract and, therefore, have 
 
EXAMINATION OF THE SPUTUM. 
 
 297 
 
 
 r^^s^,,^f^^*.:,' ■•>' 
 
 
 ^V 
 
 ■ "■■ \^. ; ■, ': 
 
 
 v!v 
 
 '■' ■ : k--"'^- ■ 
 
 
 *x - 
 
 , 
 
 
 ■ ■ '"' 'v,;.'^-, iJ-':-^ . 
 
 ' : 
 
 -Elastic tissue from luni 
 ment. X 50. — J 
 
 ' allowing alveolar arriinge- 
 L,nierson. 
 
 no special importance, but when present in considerable or large numbers 
 indicate a morbid lesion. Expectoration of blood (haemoptysis) is due to a 
 variety of causes (see page 458). Erythrocytes in the sputum, as a rule, ex- 
 hibit alteration of structure, so that crenated, dehsemoglobinized, and frac- 
 tured cells are common. 
 Elastic tissue, in 
 considerable amounts, 
 can be readily demon- 
 strated by the following 
 method: A thin layer of 
 sputum, obtained by 
 pressing it between two 
 glass plates, is examined 
 with the aid of a hand 
 lens. When elastic tissue ^'°' ^""" 
 cannot be recognized by 
 
 this method, the microscope should be employed; a suspected particle^ 
 which generally has a gray or yellow color, is placed upon a slide and 
 studied by low magnification. Elastic tissue may also be demonstrated 
 by treating the sputum with an equal quantity of a 10 per cent, solu- 
 tion of potassium or sodium hydroxide and boiling the mixture until 
 it becomes homogeneous. The solution is shaken with four or five parts 
 of water and the mixture centrifugated. The sediment is then examined 
 microscopically. Elastic tissue is found as long slender threads, generally 
 having a waxy appearance, and at times these fibres conform to the 
 outline of alveoli. The presence of elastic fibres indicates disintegration 
 
 of bronchial or pulmonary tissue, the latter 
 being positively affirmed when the fibres 
 have an alveolar arrangement. Elastic 
 tissue is noted in bronchiectasis, pulmon- 
 ary abscess, gangrene, tuberculosis, and 
 tumors of the lungs. 
 
 Curschmann's spirals are noted in 
 the sputum in cases of bronchial asthma, 
 occasionally in tuberculosis, croupous 
 pneumonia, and bronchitis. Upon micro- 
 scopic examination, they consist of delicate 
 twisted threads, often wound around a 
 central core. Many of these spirals are coated with mucus in which 
 epithelial cells, eosinophiles, neutrophile leucocytes, and Charcot-Leyden 
 crystals are imbedded. Curschmann's spirals consist chiefly of mucus, 
 while the central core is held to be fibrin in some instances. Many author- 
 ities claim that these bodies are formed in the bronchioles. 
 
 Crystals. — With the exception of Charcot-Leyden crystals, very little 
 importance can as yet be attached to the presence of crystalline bodies. 
 Charcot-Leyden crystals are colorless and have the shape of two elongated, 
 sharply pointed, hexagonal, pyramidal figures with bases opposed. They 
 stain with eosin. It was formerly thought that they were the exciting 
 factor of bronchial asthma. This view is no longer entertained, since these 
 
 
 'F 
 
 a-" 
 
 r - 
 \ 
 
 
 5# 
 
 m 
 
 |):~ 
 
 
 
 i>>i' 
 
 
 
 
 
 V, 
 
 ^ \ 
 
 ^ " 
 
 
 
 
 
 :x„ 
 
 ^'" 
 
 
 
 
 H'&,\ 
 
 Fig. 123. — Curschmann's spiral, from 
 the sputum of a case of asthma. X 200. — 
 Emerson. 
 
298 MEDICAL DIAGNOSIS. 
 
 crystals are occasionally found in other diseases, such a bronchitis and 
 tuberculosis. They are probably formed from eosinophile cells. Crystals 
 of fattj^ acids are noted in the sputum of tuberculosis, gangrene, bron- 
 cliiectasis, and fetid bronchitis. 
 
 Cholesterin plates, which are rarely seen in the sputum, have been 
 found in conjunction with fatty acid crystals in abscess of the lung, and 
 phthisis. 
 
 H.EMATOiDiN CRYSTALS occur in the putrid sputum of certain lung 
 diseases, and in empyema and hepatic abscess with a bronchial outlet, and 
 occasionally after haemoptysis. Leucin and tyrosin crj^stals are at times 
 present in purulent sputum, while calcium oxalate and triple phosphate 
 crystals are rare ingredients of sputum. 
 
 Animal Parasites. — The Trichomonas pulmonalis has been reported 
 in a few instances in the sputum in lung gangrene, tuberculosis, abscess, 
 and putrid bronchitis, while circomonads have been recorded in pulmonary 
 gangrene. The sputum in cases of Hver abscess perforating into the lung 
 may show the Amoeba coli. 
 
 T^NiA EcHiNOCOCCUS. — Hydatid disease may cause pulmonary ab- 
 scess or gangrene and is sometimes responsible for copious haemoptysis. 
 The sputum in this condition may contain shreds of cyst membrane, 
 daughter cysts, scohces and hooklets of the worm. 
 
 DiSTOMA Pulmonale. — This parasite is responsible for a form of 
 chronic pulmonary disease, characterized by haemoptysis, seen in Japan, 
 China, and Korea. This fluke and its ova are found in the sputum. 
 
 Vegetable Parasites. — A large number of micro-organisms have been 
 found in the sputum. Among these may be mentioned: the tubercle 
 bacillus, Diplococcus pneumoniae, staphylococci, streptococci, sarcinae, 
 streptothrix, actinemyces, Micrococcus catarrhalis, and the influenza, 
 smegma, typhoid, plague, diphtheria, and Friedlander's bacillus. 
 
 In the case of tubercle bacilli, their staining reaction, outline, and 
 size, in the absence of biological tests, generally afford sufficient evidence 
 to establish the diagnosis of this organism. With most bacteria occur- 
 ring in the sputum this is not the case, so that their identity can only 
 be determined provisionally but not finalty b}' their tinctorial and mor- 
 phological characteristics. This tentative opinion is, however, often 
 strengthened by the correlation of the chnical data of the underlying 
 pathological process. Cultural studies are as a rule essential, and inocula- 
 tion experiments often required for a bacteriological diagnosis. Works on 
 bacteriology should be consulted for bacteriological investigations. 
 
 Tubercle Bacillus. — The finding of tubercle bacilli in the sputum 
 is a valuable sign in establishing the diagnosis of tuberculosis of the lungs, 
 although the absence of these organisms in the expectoration of an individ- 
 ual presenting pulmonary symptoms does not necessarily negative the 
 diagnosis. The failure to find bacilli on a number of examinations in a 
 suspected case, particularly of a chronic nature, is strong evidence against 
 the existence of phthisis. In acute tuberculosis, especially in the early 
 stages, they are frequently wanting in the sputum. There is no single 
 characteristic presented by macroscopic examination of the sputum by 
 which its tuberculous nature can be recognized. Rosenberger holds the 
 
PLATE YI. 
 
 %^ 
 
 
 » 
 
 ^,^ ''// 
 
 \^ 
 
 1? 
 
 t:;^., "^^ 
 
 ^. 
 
 V 
 
 A-^5s 
 
 \jc 
 
 •i': \ 
 
 Tubercle bacilli in sputum stained with carbol fuchsin and Pap^enheim's reagent. 
 
EXAMINATION OF THE SPUTUM. 299 
 
 view based on repeated observations that tubercle bacilli are present 
 in the fgeces of persons suffering from active pulmonary tuberculosis, even 
 in the acute miliary form. The technic of the examination for tubercle 
 bacilli is as follows: Preferably a caseous mass or a bit of purulent or 
 hemorrhagic sputum is placed upon a slide or cover-slip. As it is often im- 
 possible to find cheesy particles, the sputum is selected from different 
 parts of the specimen. A thin smear is then made, carefully dried and 
 fixed by rapidly passing the slide or cover-glass through a flame several 
 times. The tubercle bacillus belongs to the group of organisms, generally 
 designated acid-fast bacteria, which, after staining, resist to a marked 
 degree decolorization with solutions of mineral acids. 
 
 If it be desired to concentrate the bacteria in the specimen of the 
 sputum, the method of Miilhauser-Czaplewski will be found most service- 
 able. From four to eight volumes of a .25 per cent, solution of sodium 
 hydrate are added to the sputum, placed in a bottle, and shaken until the 
 fluid has a uniform mucilaginous appearance. A few drops of phenol- 
 phthalein solution are added and the liquid is boiled. A 2 per cent, solution 
 of acetic acid is now added drop by drop until the pink color of the liquid 
 just disappears. The material can now be centrifugated and the sediment 
 examined. 
 
 Ziehl-N eelsen Method. — The stain for this method consists of 10 c.c. 
 of a concentrated alcoholic solution of fuchsin, dissolved in 90 cubic centi- 
 metres of a 5 per cent, solution of carbolic acid. The film of sputum upon 
 the cover or slide is covered with the stain. The cover or slide is then 
 held over a flame until the solution is brought to the boiling point; or the 
 specimen may be stained in cold carbol fuchsin for 24 hours. After a half 
 minute, the excess of hot stain is poured off and the specimen washed with 
 water. The stained preparation- is next placed in a 25 per cent, solution 
 of nitric acid for several seconds until the bright red color disappears, 
 then washed in water and dried. The specimen may be counterstained 
 with a watery solution of Bismarck brown or methylene blue for a minute 
 or two. The cover-glass film is mounted on a slide in balsam or cedar oil. 
 The specimen spread and stained upon a slide, the most convenient method, 
 may be examined without a cover-glass. 
 
 Gahbett's Method. — The sputum properly spread and fixed upon a slide 
 or cover-glass is covered with a reagent consisting of fuchsin 1 gramme, 
 alcohol 10 cubic centimetres, and a 5 per cent, solution of carbolic acid 100 
 cubic centimetres, and held over a flame until the stain boils. After drain- 
 ing off the carbol fuchsin from the slide, the specimen is treated for two 
 minutes with Gabbett's reagent, composed of methylene blue, 2 parts, dis- 
 solved in 100 parts of a 25 per cent, solution of sulphuric acid; then washed 
 with water, thoroughly dried, and examined microscopically. 
 
 Pappenheim' s Method. — Competent bacteriologists consider this 
 method the most reliable, since it is claimed that it offers the means of 
 distinguishing tubercle bacilli from other acid-fast organisms. Pappen- 
 heim's stain is prepared by dissolving 1 part of corallin in 100 parts of 
 absolute alcohol. This solution is then saturated with methylene blue, 
 after which 20 parts of glycerin are added. After staining the specimen 
 with a heated carbol fuchsin solution in the manner previously described, 
 
300 MEDICAL DIAGNOSIS. 
 
 the excess of stain is drained from the slide and immediately Pappenheim's 
 solution is placed upon it and aUowed to act for a few minutes. Fresh 
 solutions may be added several times if the spread is tinged red in any 
 part. The sUde is next washed in water, dried, and examined. 
 
 With these methods, tubercle bacilli appear as straight or shghtly 
 bent red rods, varying from 1.5 to 4 microns in length and from .1 to .2 
 micron in thickness. Occasionally ihej are tinted more deeply in certain 
 parts, having the appearance of a streptococcus (beaded forms). Branch- 
 ing forms are rarely found. The older varieties of bacilli are thought to 
 stain more intensely than the younger forms. As a rule a number of organ- 
 isms can be found in preparations, many of which are frequently arranged 
 in groups containing several or more organisms. It is most uncommon ta 
 find but a single bacillus in a specimen and, when this occurs, the possi- 
 bility of contamination of the sputum from dust should be remembered. 
 The number of germs in chronic cases often is an index to the extent of 
 the ulceration in the lung, although, in acute cases, the degree of the tuber- 
 cle involvement bears no relation to the abundance of bacilli. A lessening 
 in the number of bacilli ofttimes is associated with a steady improvement 
 in the patient, and a disappearance of the micro-organisms frequently 
 points to quiescent or healed lesions. 
 
 DiPLOcoccus Pneumoniae. — The finding of pneumococci in the sputum,, 
 in the absence of other clinical data, is without diagnostic significance, 
 since these organisms exist in the saliva of a considerable proportion of 
 healthy individuals, as well as in the expectorated material in several 
 diseases. Their presence in the sputum of a case exhibiting pulmonary- 
 symptoms often establishes an etiological diagnosis. Pneumococci are 
 found in large numbers in the sputum of croupous pneumonia and occa- 
 sionally^ in bronchopneumonia. This organism reacts positively to solutions 
 of basic dyes. Stained specimens frequently show a colorless capsule 
 about the diplococci. 
 
 VIII. 
 
 THE EXAMINATION OF TRANSUDATES, EXUDATES, AND THE 
 
 CONTENTS OF CYSTS. 
 
 The results of the examination of transudates, exudates, and the 
 contents of cysts bj" physical, chemical, microscopical, and bacteriologi- 
 cal methods are diagnostic auxiliaries. 
 
 Exploratory Puncture. — An exploratory syringe, equipped with a 
 large stout needle, is generally used for this purpose, but for some explora- 
 tions the aspirator needle alone is employed, since the positive internal 
 pressure of certain effusions expels the fluid. The operation of explora- 
 tory puncture must be performed under strict antiseptic precautions; 
 the skin should be sterihzed by thoroughly scrubbing with soap and hot 
 sterihzed water, followed by washing with hot sterilized water and then 
 
TRANSUDATES, EXUDATES, AND CYST CONTENTS. 301 
 
 with an antiseptic solution. When possible an antiseptic dressing should 
 be applied for some hours prior to performing the operation. The hands 
 of the operator should be surgically clean and the instrument should be 
 sterile. The technic of peritoneal, pleural, pericardial, and lumbar punc- 
 ture is discussed in Part IV. 
 
 The differentiation between exudates and transudates is not, as a rule, 
 difficult, since the internist is guided by associated clinical phenomena in 
 determining the origin of the fluid. There are, however, cases in which 
 the character (whether it be inflammatory or non-inflammatory) of the 
 material cannot be ascertained by the symptoms or the history of the case, 
 and the final distinction must rest with the laboratory, although in a few 
 instances the various methods of laboratory research fail to solve the 
 problem. 
 
 Transudates are generally light yellow or pale yellowish-green, at times 
 reddish, due to blood staining, milky as noted in chylous effusions, and 
 dark yellow when deeply tinged with biliary pigment. 
 
 The composition of transudates of the peritoneal, pleural, and peri- 
 cardial sacs is nearly the same. They consist of water (95-96 per cent.), 
 solids, proteids, extractives, inorganic salts, and uric acid. Allantoin, 
 dextrose, fructose, urobilin, and biliary pigment have also been demon- 
 strated in transudates. Their specific gravity is generally below 1.018, in 
 many cases as low or even below 1.010, and occasionally above 1.020. Hy- 
 drsemic transudates are of lighter specific gravity than those due to stasis. 
 The specific gravity is influenced mainly by the proteids contained in the 
 fluid, so that exudates, which are generally richer in albuminous bodies 
 than dropsical fluids, are as a rule of higher gravity than transudates. 
 The estimation of the total proteids content is therefore of value in dif- 
 ferentiating between transudates and exudates. The percentage of pro- 
 teids in stasis transudates generally ranges from 1 to 3, while in hydrsemic 
 effusion it is much lower, usually not above .5. Transudates either contain 
 no fibrin or it exists only in minute amounts. A few endothelial cells and 
 leucocytes, at times erythrocytes and cholesterin crystals, are found. 
 In hydroperitoneum occurring in leukaemia, Charcot-Leyden crystals, 
 mast cells, and eosinophiles have been recorded. In the main the chlorides 
 exist in greater concentration in transudates than in exudates, and as a 
 rule the degree of alkalinity of dropsical fluids is about that of the blood of 
 the individual in question, while in an exudate it is lowered. 
 
 Exudates. — The chief varieties of exudates are serous, hemorrhagic, 
 purulent, and putrid, and between these types there are gradations and 
 combinations. The recognition by macroscopic inspection of purulent 
 collections is generally a simple matter, although serous exudates, which 
 contain a large number of fine fibrin flakes and chylous fluids, are of similar 
 appearance. The uniform turbidity of purulent effusions serves to dis- 
 tinguish them from serofibrinous effusions, while the presence of fine 
 granules of fat is characteristic of chylous fluids. In many inflammatory 
 collections a coagulum forms immediately after the fluid is withdrawn 
 from the body. Their specific gravity is generally above 1.018, the proteid 
 content is usually above 4 per cent, and at times as high as 6 per cent. 
 Serum albumin and globulin in considerable amounts, traces of fibrinogen 
 
302 MEDICAL DIAGNOSIS. 
 
 and serosamucin are present in exudates; nucleo-albumin. albumoses, 
 leucin, and tyrosin have also been noted. 
 
 Rivalta's Test. — The principle of this test is based on the precipita- 
 tion in many exudates of a peculiar body, the character of which has not 
 been definitely determined, although regarded by some authorities as mucin 
 and denominated serosamucin, while others hold that it is a globuhn. 
 This test is carried out by allowing a drop of the fluid to fall into a weak 
 acetic acid solution (two drops of glacial acetic acid in 100 c.c. of distilled 
 water). When the drop sinks and leaves a turbidity it indicates the pres- 
 ence of tliis substance, while the failure to produce cloudiness denotes the 
 absence of this body (serosamucin). The intensity- of the cloudiness and 
 the rapidity with which it forms are an index to the amount present. This 
 test is of importance in differentiating exudates from transudates. 
 
 Animal parasites, bacteria, many cellular elements, lymphocytes, poly- 
 nuclear cells, endothelial cells, erythrocytes, and deti'itus occur in exudates. 
 
 Bacteriological Examination. — Bacteria rarely exist in transu- 
 dates, but their presence in exudates, which is frequent, furnishes a most 
 useful field for diagnosis and prognosis. The fluid for bacteriological 
 examination is collected in a sterile flask, the neck of which is then immedi- 
 ately plugged with sterile cotton. (For technic consult works on bacteriol- 
 ogy.) A diagnosis of tubercle bacilli can often be made by staining methods. 
 
 Collecting Sediment. — Fluids removed by puncture often coagulate 
 spontaneously. Since the coagulum entangles some of the cellular bodies 
 and bacteria, the elements which I'emain in the fluid portion do not form 
 an accurate basis for calculating the number or the percentages of the dif- 
 ferent varieties of cells. In order to prevent coagulation one-third or 
 fourth volume of a 2 per cent, sodium citrate salt solution is added to the 
 specimen. After centrifugalization or sedimentation the supernatant fluid 
 is removed and the tube is filled with saline solution, then gently agitated 
 and recentrifugated. Much of the albumin is removed from the fluid by 
 this procedure, which insures better results in staining. 
 
 Inoscopy, the method introduced by Jousset, was designed to aid in 
 the diagnosis of tuberculosis. The exudate is allowed to coagulate spon- 
 taneously, but should this not occur the addition of horse serum will bring 
 about clotting. The coagulum which holds many of the tubercle bacilli 
 is then removed, broken up, and digested by means of a fluid consisting of 
 NaF 3 grammes, pepsin 1 or 2 grammes, glycerin 10 c.c, HCl 40 per cent. 
 15 c.c, water 1000 c.c The resulting liquid is then centrifugated and the 
 sediment examined in the usual manner for tubercle bacilli. 
 
 Cytological Examination. — After securing the sediment of the 
 citrated material, or the digested coagulum, it should be properly fixed. 
 Treating the sediment with a | or 1 per cent, formaldeh^'de solution for 
 several minutes is highly recommended by some workers. The sediment 
 is spread into a thin film upon a slide or cover-glass, dried, and if not pre- 
 viously fixed is now subjected to such fixatives as methyl alcohol, or alcohol 
 and ether, heat, or formalin solutions. The selection of the stain depends 
 upon the structures desired to be demonstrated and upon the choice of 
 the worker. Most of the Romanowsky modifications or double stains, as 
 eosin and hsmatoxylon or methylene blue, give satisfactory results. The 
 
TRANSUDATES, EXUDATES, AND CYST CONTENTS. 303 
 
 principle which involves the determination of the percentages of the vari- 
 ous types of cells is the same as for differential leucocyte counting. Im- 
 mediate citration of fresh specimens, followed by centrifugating, probably 
 offers the best means of studying cellular elements and bacteria. 
 
 Cytodiagnosis.— The cytological formula does not diagnose a disease, 
 but rather suggests the acuteness or chronicity of a pathological condi- 
 tion, the stage and intensity of a morbid process, or the absence of inflam- 
 mation. A rare exception relates to effusions which contain tumor frag- 
 ments, the histology of which may be diagnostic. 
 
 The most important cellular elements entering into cytological studies 
 are lymphocytes, polynuclear cells, endothehal cells, eosinophile cells, mast 
 cells, erythrocytes, and tumor cells. 
 
 Endothelial Cells. — An increase of endothehal cells in a fluid is generally 
 associated with non-inflammatory effusions of the serous cavities. Drop- 
 sical effusion due to passive congestion and hydremic transudates shows 
 endotheliocytosis. In the early stages of a tuberculous effusion a high 
 percentage of endothehal elements is sometimes noted. 
 
 Lymphocytes. — An irritant of mild intensity is responsible for a 
 lymphocyte predominance in an effusion. Such a reaction is essentially 
 local and does not provoke a general stimulus. An irritation of low grade, 
 especially when protracted over a long period, calls forth these cells. Lym- 
 phocytosis is the rule in tuberculosis, although a polynucleosis may precede 
 a lymphocytic phase or in some instances it may follow. These variations 
 are attributed to increased virulence of bacteria and to secondary or mixed 
 infections. A lymphocyte preponderance preceded by a polynucleosis is 
 regarded as having a favorable prognostic significance. The development 
 of a polynucleosis taking the place of a lymphocytosis is suggestive of a 
 complication. In the late stages of acute inflammations or when these tend 
 to become chronic, a high lymphocyte percentage is often noted. Lym- 
 phocytosis is noted almost constantly in effusions of tuberculous origin and 
 sometimes in those due to syphilis, ursemia, malignant tumors, and paresis. 
 
 Polynuclear Cells. — The exudates in acute inflammation or infections 
 of serous sacs, such as are produced by staphylococci, pneumococci, strep- 
 tococci, meningococci, colon bacilli, and typhoid bacilli, contain a high per- 
 centage of polynuclear leucocytes. In the early stage of tuberculosis a 
 polynucleosis is sometimes noted, and frequently in tuberculosis pericardial 
 effusions. As an acute inflammation subsides polynuclear preponderance 
 becomes less marked, and this is often followed by a rise in the number of 
 the lymphocytes, which may outnumber the multinuclear elements. 
 
 Eosinophilic cell increase has been recorded in effusion occurring in 
 the course of rheumatic fever, tuberculosis, nephritis, syphilis, carcinoma, 
 and following trauma. 
 
 Mast cells have been noted occasionally in effusions, especially those 
 of long standing. 
 
 Erythrocytes. — Contamination of the fluid with blood from the wound 
 made by puncture is unavoidable in many instances, but aside from this 
 source red corpuscles in an effusion are at times the expression of malig- 
 nant, renal, or tuberculous disease. They are also seen in effusion due to 
 acute infections. The possibility of a hemorrhage, as in cerebral apoplexy 
 
304 
 
 MEDICAL DIAGNOSIS. 
 
 with effusion into the ventricles of the brain, or a small leak of an aneurism 
 into a serous sac, should always be borne in mind. 
 
 Cells derived from carcinoynata and sarcomata when found singly in 
 effusions of serous cavities are believed by some writers to possess certain 
 features which may be of diagnostic value. These cells may show mitotic 
 figures. The results of an histological examination of a tumor fragment 
 may warrant a final diagnosis. 
 
 The recognition of some of the varieties of cells just described may not 
 be so simple a matter. A cell having a single nucleus undergoing degenera- 
 tion and fragmentation may resemble a multinuclear element. Polynuclear 
 cells may be difficult to detect when the cell body undergoes shrinkage 
 and becomes disintegrated. 
 
 Chylous fluids owe their turbidity to fine particles of fat. The amount 
 of fat varies; it is often under 1 per cent., but in a case reported by Hammer- 
 fahr it reached 2.95 per cent. Other constituents of this variety of effu- 
 sion are water (90 per cent. +), albumin, fibrin, globulin, cholesterin, 
 lecithin, salts, soaps, fatty acids, and other substances. The fat is soluble 
 in ether and gives the tests for this substance. 
 
 There are certain effusions designated chyloid or pseudochylous which 
 closely resemble chylous fluids in their gross appearance but differ from 
 them since the free, fine, fat particles are absent. The opalescence of these 
 fluids probably depends on a variety of causes, while in some instances 
 the milky appearance cannot be explained. The presence of endothelial 
 or epithelioid cells with a fatty degenerated protoplasm is the explanation 
 suggested by Quincke in some of these cases. Other observers hold that 
 bacteria, globulins, lecithin, mucin, and certain proteids (other than 
 
 globulin) are responsible for the turbidity 
 which may in some instances suggest a puru- 
 lent character rather than a milky appearance. 
 Chylous collections are not uncommonly 
 noted, especially in the peritoneal cavity and 
 pleural sacs, rarely in the pericardium. These 
 effusions arise in a number of diseases in which 
 pressure is exerted on the thoracic duct or the 
 lymphatic vessels. 
 
 Cerebrospinal Fluid. — In health the cere- 
 brospinal fluid obtained by lumbar puncture 
 is colorless, clear, of alkaline reaction, has a 
 low specific gravity, ranging from 1.003 to 
 1.007 due to the presence of from 1 to 1.5 per 
 cent, of solids and cellular elements (endothelial 
 cells and leucocytes), not exceeding 5 per c. 
 mm. The amount under normal conditions 
 has been set as varying between 5 and 10 c.c. 
 although these figures are only approximate. The dural pressure as deter- 
 mined with an ordinary water manometer in the dorsal position ranges 
 from 60 to 100 mm. in health, while in disease, as in meningitis and cere- 
 bral tumor, it may reach from 200 to 800 mm. Serious symptoms may 
 arise on withdrawing the fluid when the pressure falls below 60 mm. 
 
 Fig. 124. — Smear of the spinal 
 fluid of a case of epidemic cerebro- 
 spinal meningitis. — Emerson. 
 
TRANSUDATES, EXUDATES, AND CYST CONTENTS. 305 
 
 Urea, globulin, protalbumose, nucleoproteid, and a reducing substance 
 probably similar to pyrocatechin, and sodium chloride and other inorganic 
 salts are present. Serum albumin is said never to exist in the normal 
 fluid. There is some doubt as to the presence of glucose; some author- 
 ities claim that it is a normal constituent (.4 to .5 per cent.), which dis- 
 appears when meningitis develops (Lannois and Boulard), while others 
 hold that it does not exist in health. 
 
 In pathological conditions the cerebrospinal fluid is often altered. 
 
 In disease the quantity varies from a few c.c. to more than 100 c.c. 
 The amount is increased in acute hydrocephalus, in general paresis, dementia 
 prsecox, in some of the infectious diseases, in brain tumors, and in menin- 
 gitis. It should be borne in mind that interference with the circulation of 
 the cerebrospinal fluid from increased intracranial pressure, as in brain 
 tumor, which cuts off the communication between the subarachnoid 
 basilar spaces of the brain and those of the cord, may result in an absence 
 or diminished amount. 
 
 The fluid is often pale yellow, cloudy, or creamy in appearance in acute 
 meningitis, while in tuberculous meningitis, hydrocephalus, and brain 
 tumors it is generally clear and colorless. In hemorrhage into the ven- 
 tricles fluid blood may be obtained by puncture, while in icterus the fluid is 
 yellowish. As a rule a turbid fluid points to an acute meningitis. Albumin 
 may be present and the specific gravity is raised when acute inflammation 
 of the meninges exists. Cholin, a substance which is derived from the 
 destruction of nerve tissue, is present in the spinal fluid in cases of organic 
 disease of the nervous system, notably in paresis, tabes dorsalis, syphilitic 
 epilepsy, dementia paralytica, cerebral abscess, brain syphilis, myelitis, 
 and spina bifida. 
 
 Bacteriological studies of the spinal fluid are most essential in diag- 
 nosis. The following are the more important bacteria which have been 
 found by lumbar puncture: meningococcus, pneumococcus, staphylo- 
 coccus, streptococcus, B. tuberculosis, B. coli communis, B. influenzae, B. 
 mallei, B. pyogenes foetidus. 
 
 Trypanosomes are present in the spinal fluid in African sleeping 
 sickness. 
 
 Cytological Examination. — The results of cytological studies of the 
 cerebrospinal fluid fall in line with those previously mentioned. In tuber- 
 culosis a high lymphocyte count is the rule. Lymphocyte preponderance 
 has also been noted in paresis, tabes, cerebrospinal syphilis, syringomyelia, 
 cerebral tumors, pressure myelitis, in chronic and in later stages of cere- 
 brospinal meningitis, in epilepsy, and in sleeping sickness. In acute 
 meningitis, such as is determined by the meningococcus, staphylococcus, 
 streptococcus, pneumococcus, B. typhosus, B. coli communis, a multi- 
 nuclear cellular predominance exists. 
 
 Contents of Cysts. — Pancreatic Cysts. — The evidence that the fluid 
 from an abdominal cyst has the property of digesting albumin in an 
 alkaline medium suggests a pancreatic origin. A negative result does not 
 rule out the possibility of pancreatic cyst, since trypsin disappears in collec- 
 tions of long standing. 
 
 Ovarian Cyst. — Fluid of ovarian cysts is often pale yellow, sometimes 
 20 
 
306 MEDICAL DIAGNOSIS. 
 
 reddish or dark brown; the specific gravit}' shows wide fluctuation between 
 1.010 to 1.038; the consistency varies from a watery fluid to dense, viscid, 
 ''jelly-like" material. 
 
 Cystic collections of low specific gravity contain little albumin (serum 
 albumin and globulin), while those of high specific gravity have large 
 amounts of albumin. Puramucin is present in colloid cysts. Pseudo- 
 mucin or metalbumin also exists in these cysts. 
 
 Ciliated cylindrical epithelial cells, squamous epithelium, erythrocytes, 
 fat, fatty acid crystals, cholesterin plates, and hsematoidin are also noted 
 in the cysts. 
 
 Hydatid Cysts. — They may be recognized by the presence of cyst 
 membrane, scolices, and booklets. The fluid of these cysts is almost color- 
 less, of very low specific gravity, contains little or no albumin, shows a 
 considerable amount of sodium chloride, has a neutral or faintly acid reac- 
 tion, and traces of sugar and succinic acid may be present. Granular and 
 fatty detritus, calcareous fragments, hsematoidin, cholesterin crystals, and 
 granular cells are frequently found. In the event of suppuration leuco- 
 cytes appear in the fluid. 
 
 Hydronephrosis. — The fluid of hydronephrosis does not always pre- 
 sent features which are diagnostic. This applies especially to chronic 
 hydronephrosis with complete occlusion of the ureter. In acute cases 
 or those associated with partial occlusion of the ureter so that the kidney 
 still functionates, the presence of a high urea content and uric acid, 
 and especially when renal tube-casts and cells are found, renders the 
 diagnosis a comparatively simple matter. 
 
 IX. 
 THE EXAMINATION OF THE NERVOUS SYSTEM. 
 
 PRELIMINARY CONSIDERATIONS. 
 
 The diagnosis of disease of the nervous system demands an accurate 
 knowledge of the anatomy and physiology of the structures involved and 
 of the pathological processes to which they are liable. It is essential 
 to determine not only the location but also when possible the nature 
 of the lesion. 
 
 The nervous system, by which the organism is brought into relation 
 with its environment and by which its functions are made manifest and 
 controlled, is essentially composed of morphological units having a similar 
 structure — the neurons — and held together and supported by a special 
 tissue — the neuroglia. 
 
 The Neuron. — Each neuron consists of (a) a nucleated proto- 
 plasmic mass — the cell-body — which presides over the nutrition of the neu- 
 ron and is the seat of origin of nervous impulse, and (b) processes which 
 form outgrowths from the cell-body and constitute the elements along which 
 impulses are conveyed. These processes are of two kinds, (a) branched 
 
EXAMINATION OF THE NERVOUS SYSTEM. 307 
 
 protoplasmic outgrowths, dendrites, which may be multiple and form 
 arborescent interlacing ramifications with similar processes from other 
 neurons, and (b) the single elongated process, axon, commonly prolonged 
 to form the axis-cylinder process. 
 
 The dendrites, uneven in contour and relatively thick as they arise 
 from the cell-body, rapidly become more slender in consequence of their 
 repeated branching until they terminate in dehcate end branches with 
 terminal bead-like thickenings. 
 
 The axons are slender thread-like extensions of uniform diameter 
 and variable length, sometimes reaching only to adjacent neurons, some- 
 times extending to distant neurons within the cerebrospinal axis, as from 
 the cerebral cortex to the lower part of the spinal cord, sometimes beyond 
 as from the lower part of the cord to the muscles of the foot. The axons, 
 like the dendrites, finally terminate in end arborizations — telodendria. 
 Most of them, shortly after leaving the cell-body, give off processes termed 
 collaterals which after a variable course terminate in end arborizations 
 which interlace with the processes of other and sometimes distant neurons. 
 Less frequently short axons arise which are not continued as axis-cylinders 
 but at once terminate in complex branching end brushes within the sub- 
 stance of the gray matter. 
 
 Histologists are not of accord as to whether the relation between 
 the neurons is that of continuity or simple contiguity. The weight of 
 opinion is at present in favor of the view that the neurons are separate 
 and distinct morphological units, their processes interlaced to form paths 
 of conduction but probably never actually continuous in the anatomical 
 sense. The axis-cyhnders, usually supplied with a medullary sheath, are 
 described as nerve-fibres. Collected into bundles they form the nerve- 
 trunks which ramify to the various muscles and other organs. 
 
 Divisions of the Nervous System. — Central Portion. — In verte- 
 brates there is an axial accumulation of the cell-bodies in the cerebrospinal 
 axis from and to which the processes pass. This includes the brain and 
 spinal cord and contains the principal axial collections of neurons. 
 
 Peripheral Portion. — This division embraces the nerve-cells of the 
 sensory gangha and is chiefly made up of the nerve-fibres which pass to 
 and from the end organs. 
 
 Sympathetic Nervous System. — This division is intimately correlated 
 with the peripheral nervous system, but possesses a certain degree of 
 physiological independence and supplies the unstriped muscular and the 
 glandular tissues of the body and the muscle of the heart. 
 
 Nerve Terminations. — The terminal end arborizations of the pe- 
 ripheral nerves constitute the mechanism by which the various structures 
 of the body are combined in consistent and harmonious relation with the 
 nervous system. Certain of these terminations transmit impulses which 
 give rise to muscular contraction; others originate impulses which cause 
 various sensations of pain, temperature, pressure, or the special senses. 
 The nerve terminations may therefore be divided according to their func- 
 tion into motor and sensory. 
 
 Motor Nerve Endings. — These include three groups: (a) The terminal 
 arborization of the axons of neurons in the motor nuclei of the spinal cord 
 
308 
 
 MEDICAL DIAGNOSIS. 
 
 and brain stem that pass to voluntary muscle; (b) those of sympathetic 
 neurons that pass to involuntary muscle; (c) the muscle of the heart. 
 Sensory Nerve Endings. — These are the peripheral terminal arboriza- 
 tions of the neurons, the cell-bodies of which are in the spinal and other 
 sensory ganglia. They therefore constitute the point of departure of the 
 paths which conduct sensory stimuli to the central nervous system. 
 
 The function of the neuron is to conduct nervous impulses. In its 
 simplest form the nervous system consists of (a) the sensory neuron, 
 which receives the external stimulus acting upon the integument and 
 other sensory surfaces and by means of its process conducts it from the 
 periphery to the cell-body which commonly lies in the cerebrospinal axis. 
 Such a process constitutes functionally a centripetal or afferent fibre. 
 The stimulus thus received is transmitted from the cell-body of the sensory 
 
 neuron by means of its dendrites which inter- 
 lace with those of the associated cell-body of 
 (b) a motor neuron to the latter, in which a 
 responsive impulse originates and is conveyed 
 along its axis-cylinder process — nerve-fibre — 
 to the muscle-cell and causes contraction. 
 The latter process is therefore known as a 
 centrifugal or efferent fibre. This elementary 
 conception of the relation and functions of 
 the sensory and motor neurons is greatly 
 modified by the fact that the centripetal 
 impulses are conveyed to the cell-bodies of 
 other neurons not only in the immediate 
 neighborhood but also at different and even 
 distant levels. Neurons of the same function 
 are usually grouped together, aggregations of 
 cell-bodies forming nuclei, and collections of the fibres forming bundles, 
 tracts, or systems. The former are situated in the gray matter of the 
 brain and spinal cord, the latter run in the white substance of the brain 
 and spinal cord and in the peripheral nerves. By this means the various 
 parts of the central nervous system are connected with each other and 
 with the muscles and viscera. 
 
 Many of the tracts are highly complicated and obscure both as to their 
 course and formation. Others are simpler and, as the result of studies of 
 the degenerations caused by injury or disease, have been traced in their 
 course through the cerebrospinal axis. Chief among the latter group is 
 the pyramidal tract which transmits motor impulses from the cortex to 
 the periphery. 
 
 The Motor System. — A muscular movement depends upon the com- 
 bined functional activity of many associated neurons. It follows that the 
 movements of the various parts of the body are represented in the central 
 nervous system by localized aggregations of correlated neurons, or centres. 
 Muscular movements are not only localized in the motor areas of the 
 cerebral cortex but they are also localized in the different levels of the 
 ventral horns of the spinal cord and the motor nuclei of the cerebral 
 nerves. Voluntary motor impulses originating in the cortex of the brain 
 
 Fig. 125. — Diagram showing fun- 
 damental units of nervous system. A, 
 sensory neuron, conducting afferent 
 impulses by its process (o) from pe- 
 riphery (S); B, motor neuron sending 
 eiferent impulses by its process (e) to 
 muscle. — Piersol. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 309 
 
 pass through at least two neurons before they reach the muscles. For 
 "this reason the motor tract is divided into an upper and a lower segment. 
 
 The Upper Motor Seg- i e G 
 
 ME NT. — Clinical researches ~ 
 
 (Hughlings Jackson), experi- 
 mental studies (Hitzig, Ferrier, 
 Horsley and others), and the 
 studies of tract myelination at 
 progressive periods in the devel- 
 o p m e n t of the cerebrum by 
 Flechsig, have thrown much 
 light upon the functions of 
 many of the cortical regions of 
 the brain and the sensory and 
 motor tracts. The cell-bodies 
 ■of the upper motor neurons 
 are arranged in functionally 
 allied groups in the cerebral 
 cortex over the ascending fron- 
 tal convolution and extending 
 deeply into the fissure of Ro- 
 lando. In this region the move- 
 ments of the body are definitely 
 represented. It has been dem- 
 onstrated that motor impulses are excited by stimu" 
 lation over these areas in a definite order from above 
 downward, as follows: leg, trunk, arm, neck, face; 
 the areas for the leg, trunk, and arm covering the 
 upper half, including the Rolandic surface of the 
 convolution, and those for the head and face, together 
 with those for the jaws, lips, tongue, and larynx, the 
 lower half, likewise the surface extending into the 
 fissure. The centre for motor speech lies in the left 
 "fcliird frontal, Broca's, convolution. 
 
 The axis-cylinder processes of the upper motor 
 neurons pass from the gray matter of the motor 
 cortex into the white matter of the brain and form 
 part of the extensive converging tract known as the 
 corona radiata. Collected into 
 a compact bundle — the pyram- 
 idal tract — they pass between 
 the basal ganglia in the internal 
 capsule occupying the knee and 
 the anterior two-thirds of the 
 posterior limb. The move- 
 ments of the opposite side of the 
 body are represented at this 
 level from before backward in the following order: eyes, head, tongue, 
 mouth; shoulder, elbow, wrist, fingers, thumb; trunk; hip, ankle, knee, toes. 
 
 Fig. 126. — Diagram of motor path from right cortex. 
 Upper segment black; lower red. A destructive lesion at 1 
 causes upper segment paralysis of the arm of the opposite 
 side; at 2 upper segment paralysis of the opposite side — 
 hemiplegia; at 3 upper segment paralysis of the face, arm, 
 and leg of the opposite side and lower segment paralysis of 
 the eye muscles of the same side— crossed paralysis; at 4 
 upper segment paralysis of arm and leg of the opposite side 
 and lower segment paralysis of the face and external rectus 
 of the same side— crossed paralysis; at 5 uppersegment paral- 
 ysis of all muscles below lesion and lower segment paralysis of 
 muscles represented at level of lesion — spinal paraplegia; at 
 6 lower segment paralysis of muscles represented at level 
 of lesion — anterior poliomyelitis. — VanGehuchten modified. 
 
310 
 
 MEDICAL DIAGNOSIS. 
 
 Emerging from the internal capsule the fibres of the pyramidal (cor- 
 ticospinal) tract pass into the crus. At this point some of them leave the 
 
 Fig. 127. — Diagram of cortical centres. 
 
 tract and crossing the middle line end in arborizations among the ganglion 
 cells in the nucleus of the third nerve upon the opposite side, and at succes- 
 sive levels fibres are given off which 
 terminate in the nuclei of all the motor 
 cerebral nerves of the opposite side, 
 while a limited number of fibres are 
 distributed to the corresponding nuclei 
 of the same side. From the crus the 
 pyramidal tract enters the pons and 
 passes to the medulla oblongata form- 
 ing its anterior area — the pyramid. 
 At the lower limit of the medulla, 
 after the fibres to the nuclei of the 
 cerebral nerves have been given off, 
 five to seven coarse strands pass 
 obliquely across the anterior median 
 fissure, interlacing with similar strands 
 from the opposite side and thus 
 constituting the decussation of the 
 pyramids. In consequence of this 
 arrangement the greater number of 
 the fibres of the important motor 
 paths pass to the opposite sides to reach the lateral columns of the cord in 
 which they descend as the lateral or crossed pyramidal tracts. The fibres 
 that remain upon the same side as the pyramid from which they emerge 
 
 
 Fig. 128.- 
 
 -Diagram of internal capsule showing 
 motor and sensory paths. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 311 
 
 are collected in its lateral portion and descend in the ventral columns as 
 the direct pyramidal tracts or Tiirck's columns. At every level of the 
 spinal cord axis-cylinder processes emerge from the crossed pyramidal 
 tract to enter the ventral horns and end in arborizations about the cell- 
 bodies of the lower motor neurons. In consequence of this arrangement 
 the tract diminishes in size as it descends in the cord. In a somewhat 
 similar manner the fibres of the direct pyramidal tract cross at different 
 levels in the ventral white commissure and end in arborizations about cell- 
 bodies in the ventral horns on the opposite side. The direct pyramidal 
 tract also diminishes in size as it descends and commonly ends about the 
 middle of the thoracic portion of the cord. 
 
 Motor impulses originating in the right 
 cerebral cortex cause muscular contractions 
 upon the left side of the body, while those 
 starting from the left side of the brain 
 cause contraction of the muscles upon the 
 right side of the body. As a rule, to which 
 there are few exceptions, the motor paths 
 are crossed chiefly at the decussation of the 
 pyramids and to a less extent at different 
 levels of the cord by fibres given oE from 
 the direct pyramidal tracts t9 the cell- 
 bodies of the opposite side. This crossing in 
 either case is in the upper motor segment. 
 
 The Lower Motor Segment. — The 
 cell-bodies and processes of the neurons of 
 the lower motor segment lie in the nuclei 
 of the cerebral motor nerves and in the 
 various levels of the ventral horns of the 
 spinal cord. The axis-cylinder processes 
 of the neurons of this segment leave the 
 spinal cord in the ventral roots and pass 
 in the peripheral "nerves to the muscles of 
 the body, in which they end in brush-like 
 arborizations in the motor end plates. 
 These neurons, in contradistinction from 
 the neurons of the upper motor segment, which are crossed, are direct, 
 that is, the cell-bodies, their protoplasmic processes, and the muscles to 
 which their axis-cylinders are distributed are upon the same side of the body. 
 
 The Segments of the Spinal Cord. — The spinal nerves are con- 
 nected with the lateral surfaces of the cord by fan-shaped bundles of an- 
 terior and posterior roots which are collected into compact strands as they 
 are assembled to form a common trunk. That portion of the cord to which 
 the root fibres of a spinal nerve are attached constitutes its cord segment, 
 the limits of which correspond to the interval which separates the extreme 
 fibres of the nerve and those of the adjacent nerves. The spinal cord is 
 thus seen to consist of a series of segments, each of which gives origin to 
 the anterior or motor and receives the posterior or sensory root fibres of 
 one pair of spinal nerves. These nerves, commonly numbering thirty-one 
 
 Fig. 129. — Diagram of motor path, 
 showing the crossing of tlie path in the 
 upper segment. 
 
312 
 
 MEDICAL DIAGNOSIS. 
 
 First cervical nrui ■ 
 
 vertebra i^ r 'j^'^f 
 
 First thoracic 
 vertebra 
 
 First thoracic 
 spine 
 
 First lumbar 
 spine 
 
 Sacrum 
 
 First sacral 
 vertebra 
 
 Coccyx • 
 
 Fig. 130. — Diagram .showing relations of bodies 
 and spines of vertebise to levels at which spinal nerves 
 escape from vertebral canal. — Piersol. 
 
 pairs, are eight cervical, twelve 
 thoracic, five lumbar, five sacral, 
 and one coccygeal. In the cervi- 
 cal region all the nerve-roots but 
 the eighth emerge above the ver- 
 tebra, while throughout the 
 thoracic, lumbar, and sacral re- 
 gions the roots for each segment 
 of the cord leave the spinal canal 
 below the vertebra of correspond- 
 ing number. Owing to the fact 
 that the vertebral column in- 
 creases in length to a greater 
 extent than the cord, there is 
 a progressive disparity from 
 above downwards between the 
 cord segments and their respec- 
 tive vertebrae. In point of fact 
 the segment corresponds to the 
 nerve which is connected with 
 it, and not to the level of the 
 vertebra opposite to it. The 
 position of a lesion involving a 
 particular spinal segment is 
 therefore, except in the upper 
 cervical region, some distance 
 above the vertebra of corre- 
 sponding number. Ziehen has 
 formulated the following rule 
 to determine the levels of origin 
 of the cervical and thoracic 
 nerve-roots: For the cervical 
 nerves subtract one from the 
 number of the nerve, and the 
 remainder will indicate the corre- 
 sponding spinous process; for the 
 upper thoracic nerves (I-V) sub- 
 tract two; for the lower thoracic 
 nerves (V-XII) subtract three. 
 Axis-cylinder processes from more 
 than one segment of the cord 
 may enter into the formation of 
 a peripheral nerve and the greater 
 number of the long striped mus- 
 cles are supplied with nerve-fibres 
 from more than one segment. 
 
 The cutaneous distribution 
 of the peripheral nerves has 
 been accurately worked out and 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 313 
 
 is of diagnostic value in lesions of the main trunks and their ramifi- 
 cations. The segmental areas which correspond to the dorsal roots, 
 though less definitely determined, are suflaciently known to be of great 
 service in the segmental locaHzation of lesions of the dorsal roots and 
 the cord. These skin-fields or dermatomes have been mapped out as 
 
 The Localization of the Functions in the Segments of the Spinal Cord. 
 Based upon the studies of Starr, Edinger, Wuhmanu, and others. 
 
 Segment. 
 
 Muscles. 
 
 Reflex. 
 
 I, II, and III 
 
 Cervical 
 
 IV Cervical . . 
 
 V Cervical . . . 
 
 VI Cervical . . 
 
 VII Cervical.. 
 
 VIU Cervical 
 
 I Thoracic . . . 
 
 II to XII Tho- 
 racic 
 
 I Lumbar 
 
 II Lumbar . . . 
 
 III Lumbar . . 
 
 IV Lumbar . . 
 
 V Lumbar . . . 
 
 I to II Sacral . 
 Ill to V Sacral 
 
 Diaphragmatic. 
 
 Dilatation of the pupil (0. 
 IV- VII J. 
 
 Scapular (C. V-T. I), supi- 
 nator longus (C. V), and 
 biceps (C. V-Vl). 
 
 Triceps and posterior wrist 
 (C.VI-VIII). 
 
 Splenius capitis, trapezius, hyoid muscles, diaphragm (C. III- 
 V), sternomastoid, levator "scapulae (C. III-V) 
 
 Trapezius, scaleni (C. IV-T. I), rhomboid, diaphragm, teres 
 minor, levator scapulae, supraspinatus 
 
 Diaphragm, rhomboid, biceps, supinator brevis (C. V-VII), 
 teres minor, subscapularis, brachialis anticus, pectoralis 
 (clavicularpart), supra- and infraspinatus (C. V-Vl}, deltoid, 
 supinator longus (C. V-VII), serratus magnus j 
 
 Teres minor and major, biceps, supinator brevis, coraeo-brach- 
 ialis, extensors of wrist (C. VI-VIII), infraspinatus, b achialis 
 anticus, pectoralis 'clavicularpart), pronator teres, deltoid, 
 supinator longus, serratus magnus (C. V-VIII), triceps (outer 
 and long heads) 
 
 Teres major, pectoralis major (costal part), pronators of wrist, 
 flexors of wrist, subscapularis, pectoralis minor, triceps, latis- 
 simus dorsi (C. Vl-VIII), deltoid (posterior part), serratus 
 magnus, extensors of wrist and Augers 
 
 Pectoralis major (costal part), latissimus, pronator quadratus, 
 radial lumbricales and interossei, flexors of wrist and fingers 
 
 Lumbricales and interossei, thenar and hj'pothenar eminences 
 (C. VII-T. I) 
 
 Muscles of back and abdomen, rectus abdominis (T. V-T. XII), 
 transversalis (T. Vll-L. I), erectores spinse (T. I-L. V), ex- 
 ternal oblique (T. V-XII), intercostals (T. I-T. XII), internal 
 oblique (T. VII-L. I) 
 
 Lower part of external and internal oblique and transversalis, j Cremasteric (L. I-III). 
 psoas major and minor (?), quadratus lumborum (L. l-II), 
 cremaster 
 
 Psoas major and minor, sartorius (lower part), iliacus, flexors 
 of knee ( Remak) , pectineus, adductor longus and brevis 
 
 Scapulohumeral and ante- 
 rior wrist (C. VIl-VIlI). 
 
 Palmar(C. VII-T. I). 
 
 Epigastric (T. IV-VIT), ab- 
 dominal (T. VII-XII). 
 
 Sartorixis (lower part), inner rotators of thigh, adductors of 
 thigh, abductors of thigh, quadriceps femoris (L. Il-L. IV) 
 
 Flexors of knee (Ferrier), abductors of thigh, quadriceps 
 femoris, extensors of ankle (tibialis anticus), adductors of 
 thigh, glutei (medius and minor) 
 
 Flexors of knee (hamstring muscles) (L. IV-S. II), flexors 
 of ankle (gastrocnemius and soleus) (L. IV-S. II), outward 
 rotatois of thigh, extensors of toes (L. IV-S. I), glutei, 
 peroiisei 
 
 Flexors of ankle (L. V-S. II), intrinsic muscles of foot, long 
 flexor of toes (L. V-S. II), perona^i 
 
 Perineal muscles, levator and sphincter ani (S. I-III) 
 
 PateUar tendon (L. H-IV). 
 Gluteal (L. IV-V). 
 
 Foot reflex (S. I-II), plantar 
 (S. II-IIl). 
 
 Vesical (L. IV-V) and anal 
 (S. I-III). 
 
 the result of observations by Henry Head in the distribution of the 
 cutaneous lesions of herpes zoster and the areas of referred pain and tender- 
 ness corresponding to certain visceral lesions, and in cases of gross lesions 
 of the cord by Starr, Kocher and others; as the result of studies of anaes- 
 thesia under similar conditions; and of morphological investigations, ana- 
 tomical dissections, and experimental physiological researches. The skin 
 areas upon the trunk form irregularly parallel zones, somewhat horizontal 
 in the erect posture, and even more irregularly distributed elongated tracts 
 
314 
 
 MEDICAL DIAGNOSIS. 
 
 
 Ce' 
 
 .Or 
 
 Ct 
 
 Ct 
 
 Ti, 
 
 Li 
 
 iGm 
 
 upon the extremities. The technic consists in the use of a blunt instru- 
 ment, as the head of an ordinary toilet pin, in determining the presence of 
 areas of abnormal sensation and defining their boundaries. 
 
 The Sensory System. — The 
 path for sensor}* conduction is 
 much more complicated than 
 that for motor conduction and 
 is composed of three or more 
 associated neurons, one above 
 the other. The cell-bodies of 
 the lowest neurons are situated 
 in the ganglia of the sensory 
 cerebral nerves and the gangha 
 of the dorsal roots of the spinal 
 nerves. The latter gangha cells 
 have a single process which, after 
 leaving the cell-body, undergoes 
 a T-shaped division, one portion 
 being the peripherally directed 
 process or dendrite (sensory 
 nerve) which conducts impulses 
 from the integument, mu- 
 cous membranes, muscles, 
 tendons, and joints of 
 parts of the body with 
 which it may be related; 
 the other the axon or axis- 
 cylinder process which 
 enters the spinal cord by way of the 
 posterior root fibre and conveys the 
 various impulses to the central nervous 
 system to be transformed into sensations 
 of temperature, touch, muscle-sense, and 
 pain. The larger number of the sen- 
 sory neurons lie outside of the spinal 
 cord. The portions of those neurons 
 within the cord constitute the paf'S of 
 sensory conduction, which become more 
 intricate as the various tracts approach 
 the brain. Upon entering the cord the 
 axons of the sensory neurons of the first 
 order divide into an ascending and a 
 descending branch which run in the 
 dorsal fasciculi. The short descending 
 branch, after giving off a number of 
 collaterals, terminates in the gray matter of the cord. The ascending branch 
 is of variable length. It may soon terminate in the gray matter or may reach 
 to the nuclei of the medulla. The lower sensory neuron does not cross the 
 middle fine. The cell-bodies about which the axis-cylinders of the neurons 
 
 'Sffl' 
 
 Set 
 
 Lm 
 
 'Lh/ 
 
 bi 
 
 .Le 
 
 LttN 
 
 5ii 
 
 6i 
 
 /Si/ 
 
 Fig. 131. — Anterior and posterior segmental 
 skin-fields. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 315 
 
 of the first order and their collaterals end are the sensory neurons of the 
 second order. The axis-cylinder processes of many of those cells cross to 
 the opposite side of the cord and run in the ventrolateral ascending column 
 of Gowers and the ground bundles. The lemniscus is probably the principal 
 sensory tract in the medulla, pons, and cerebral peduncles. The fibres are 
 not, however, continued directly to the cefebral cortex but terminate about 
 cells in the ventrolateral portion of the optic thalamus, from which point 
 the path of sensory conduction is continued by a higher order of neurons, 
 the processes of which terminate in the postcentral and parietal convolu- 
 tions of the cortex. Other but less direct sensory paths lie in series ol 
 neurons in the gray matter of the cord and in the direct cerebellar tract 
 and the tract of Gowers, and pass onward through the cerebellum. Some 
 of the axis-cylinder processes of the sensory neurons of the first order ana 
 their collaterals terminate in arborizations about the cell-bodies of the 
 lower motor neurons and thus complete the path for reflexes. 
 
 It is probable that the conduction paths for cutaneous sensory 
 impulses reach the opposite side soon after entering the cord, and 
 that the paths for muscular sense lie upon the same side of the cord 
 in the tracts of Goll, crossing by way of the axons of the second order 
 in the medulla. 
 
 Fibre Tracts of the White Matter of the Cord. — Of these there are 
 three sets: (1) Those which enter the cord from the periphery, viscera, 
 and other parts of the body; (2) those which enter it from the brain; (3) 
 those which have their origin in the cell-bodies of the neurons which lie 
 within the cord. The fibres which arise from the same group of nerve- 
 cells or nucleus have the same function and a similar destination and 
 proceed together in the same course, thus constituting a tract, column, 
 or fasciculus. Some of these fibres are the pathways for the transmission 
 of impulses from lower to higher levels, and the strands which these form 
 constitute ascending tracts, while others which convey impulses from above 
 downward enter into the formation of descending tracts. These tracts are 
 not sharply defined, nor do their boundaries and areas, since they are sub- 
 ject to increase and diminution by the continual accession or departure 
 of nerve-fibres, remain the same at different levels of the cord. In fact 
 the borders of those tracts often overlap. Their anatomical differentiation 
 has been accomplished partly by the study of degenerative processes caused 
 by experimental methods — Wallerian degeneration — and partly by re- 
 searches in myelination at progressive periods of development — embryo- 
 logical method. Pathologically they are differentiated in a corresponding 
 manner by the degenerations which follow traumatism of the cord and the 
 definite and constant reaction of certain tracts to pathogenic influences 
 as in tabes and other diseases. 
 
 Relation of Diseases of the Cord to Lesions of the Fibre Tracts.— In 
 tabes and Friedreich's ataxia the posterior columns are principally in- 
 volved; in combined sclerosis the posterior columns and lateral pyramidal 
 tracts; in lateral sclerosis the lateral pyramidal tracts; in amyotrophic 
 lateral sclerosis the lateral pyramidal tracts and the anterior horns, 
 and in anterior poliomyelitis and progressive muscular atrophy the 
 anterior horns. 
 
316 
 
 MEDICAL DIAGNOSIS. 
 
 Sensory Areas of the Cerebral Cortex. — The cortical representation 
 of sensory stimuli is less definite than that of motion. It lies posterior to 
 the fissure of Rolando and is extensively distributed over the post-central 
 and parietal convolutions. 
 
 Fig. 132. — Diagram of spinal cord, showing the relation of the piincipal tracts. 
 
 I. Goll's or postero-internal column — fasciculus graciius. Terniinoiion. — Fibres end around neurons 
 of gray matter of cord or in nuclei of medulla. Function — Sensory impulses from muscles, tendons and 
 joints of same side. Deneneration followed by ataxia and loss of muscle sense. 
 
 II. Burdach's or posterolateral column — fasciculus cuneatus. Tenninntion. — Nucleus cuneatus in 
 the medulla; Clark's column. Collaterals to neurons of posterior horn. The root fibres passing to Clark's 
 column traverse the middle and median part of this tract. Function. — Tactile impulses from opposite 
 side. Various afferent impressions of muscle sense, heat, cold and pain. Degeneration causes pain, anes- 
 thesia, ataxia, and loss of reflexes. 
 
 III. lissauer's tract or marginal zone. This fasciculus is situated immediately dorsal to the inner 
 side of the posterior horn. Composed of some of the more external root fibres which do not enter Burdach's 
 column. Fibres of small size and short course. They penetrate the substantia Rolandi and end in arbori- 
 zations about its cells and those of the caput cornu. 
 
 IV. Direct cerebellar tract — fasciculus cerebellospinalis. Terminatioyi. — Ascending path of the second 
 order conveying impulses from Clark's cells to the cerebellum. Function. — Impulses from %iscera, which 
 prolDably influence maintenance of equihbrium. 
 
 V. Gowers's tract — fasciculus anterolateralis superficialis. Termination. — Sensory pathway of second 
 order connecting cord with cerebellum and probably with cerebrum. Fibres are chiefly axons of neurons 
 in the posterior horn, partly upon the same and partly upon the opposite side. Boundaries not well defined. 
 Function. — The conveyance of sensory impulses — tactile pain and temperature — from opposite side by 
 ■way of the anterior commissure. 
 
 VI. Lateral or crossed pyramidal tract — fasciculus cerebrospinalis lateralis. Termination. -^Fihrea 
 are axons of cortical motor neurons. They extend from superficial gray matter of cerebrum to various 
 levels of cord, undergoing decussation at lower part of medulla. Function. — Conveyance of motor impulses 
 of brain. 
 
 VII. Lateral ground bundle — fasciculus lateralis proprius. Terminations. — Composition very com- 
 plex. Long descending paths; one long ascending strand and many short strands both ascending and 
 descending. Functions. — Both motor and sensory. Connects, by means of its intersegmental association 
 fibres, different levels of the cord and forms a direct sensory link between cord and higher centres — meduUa 
 and cerebrum. 
 
 VIII. Anterior ground bundle — fasciculus anterior proprius. Constitutes with lateral ground bundle, 
 with which it is continuous, a single anterolateral tract or fundamental column. Its composition and func- 
 tions are the same as those of the lateral ground bundle. 
 
 IX. .interior or direct pyramidal tract — fasciculus cerebrospinalis anterior. Termination. — Composed 
 of pyramidal filDres which do not undergo decussation in medulla oblongata. Made up of 15 to 20 per cent, 
 of pyramidal fibres. Almost all fibres cross in anterior white commissure at successive levels to terminate in 
 arborizations about root cells of anterior horn of opposite side. Function. — Motor tract from cerebral cortex. 
 
 X. Gray matter of the cord, a, a', anterior horns; emergences of anterior motor root fibres; b, b', 
 posterior horns; entrance of po.aiterior root fibres; c, posterior commissure; d, anterior commissure. Function. 
 — Anterior horns motor; posterior sensory. Cells of anterior horns trophic; those in angle of posterior com- 
 missure probably influence automatic movements while those near by are trophic vasomotor, and secretory. 
 
 Of the foregoing, I, II, and III comprise the fibre tracts of the posterior column; IV, V, VI, and VII the 
 fibre tracts of the lateral column, and VIII and IX the fibre tracts of the anterior column of the cord. 
 
 The Cortical Areas for the Special Senses. — The individual sensory 
 paths terminate in circumscribed regions which are as a rule widely removed 
 from one another. As mapped out by myelination these areas correspond 
 to regions of the cortex which pathological lesions have shown to be related 
 
EXAMINATION OF THE NERVOUS SYSTEM. 317 
 
 to the various special forms of sensation. According to Flechsig olfactory 
 fibres end mainly in the uncinate gyrus; visual fibres have been traced to 
 the occipital lobe in the region of the calcarine fissure, while auditory fibres 
 run to the temporal lobe. 
 
 It is in accordance with these observations that the cuneus and cal- 
 carine fissure together constitute the primary or lower cortical visual 
 centre in which are represented the opposite visual half fields, while the 
 outer surface of the occipital lobe contains centres for higher visual proc- 
 esses in which the vision of the eye of the opposite side is represented. 
 Mind blindness results from a destructive lesion of the lateral lobe in the 
 left hemisphere if both occipital lobes are involved. A lesion of the cuneo- 
 calcarine cortex results in lateral homonymous hemianopsia. The centre 
 for memory of the meaning of printed words, letters, figures, and objects 
 seen is probably in the left angular gyrus. A destructive lesion in this 
 area is attended by inability to read or comprehend written language 
 although ordinary vision is not impaired. This area is*known as the visual 
 speech centre. The auditory centre is in the upper temporal convolution 
 and transverse temporal gyri and it is in this region upon the left side that 
 the memories of the meaning of heard words and sounds are stored. A 
 special centre for musical memories lies anterior to the auditory centre. 
 It is probable that the centre of each side is connected with both auditory 
 nerves. The olfactory centre probably comprises a portion of the base 
 of the frontal lobe and the uncinate gyrus. The gustatory centre has 
 been thought to be in the anterior portion of the gyrus fornicatus near 
 the centre for smell. Our knowledge in regard to these two centres is 
 not definite. 
 
 The centres for the " higher psychical functions" are generally assumed 
 to lie in the prefrontal lobes, particularly upon the left side. Extensive 
 unilateral lesions of the anterior portion of the frontal lobe may be present 
 without causing marked symptoms of any kind. Atrophy of this portion 
 of the brain is often marked in various forms of dementia. 
 
 Symptoms due to derangements of the motor tracts constitute the 
 most important group of localizing phenomena. They are objective on 
 the one hand and are upon the other caused by lesions of conduction paths 
 that are comparatively well understood. Lesions involving the motor 
 path are irritative or destructive. The greater number of the lesions of 
 the motor cortex are at the same time destructive and irritative. They 
 destroy the nerve-cells and their processes in a particular centre and by 
 their presence and advance stimulate those of adjacent centres into morbid 
 or disordered activity. The clinical manifestation of a destructive lesion 
 of a motor centre is loss of function— paralysis; that of an irritative lesion 
 abnormal muscular contraction. Important differences in the paralysis 
 or abnormal contraction are dependent upon the position of the lesion as 
 regards the motor segments. These differences are due first to anatomical 
 relations and second to secondary degenerations. 
 
 The cortical motor centres are more or less widely separated from one 
 another, and a circumscribed destructive lesion of the motor area may 
 therefore give rise to a limited paralysis involving a limb oi- a group of 
 muscles in a limb — cerebral monoplegia. As the axis-cylinder processes 
 
318 MEDICAL DIAGNOSIS. 
 
 converge to form the pyramidal tract in the internal capsule, a lesion of 
 limited extent causes paralysis of most of the muscles upon the opposite 
 side of the body — hemiplegia. A lesion in the pyramidal tract as it 
 descends, giving off fibres to the motor nuclei at various levels, causes 
 paralysis of the muscles having their spinal centres below the seat of the 
 lesion. It follows from the decussation of the pyramids that when the 
 lesion is above the crossing the paralysis is upon the opposite side of the 
 body, and when it is below it, upon the same side. 
 
 The cell-body and particularly its nucleus maintain the nutrition of 
 all parts of the neuron. If the cell-body be destroyed its processes undergo 
 degeneration, or if any process be separated from its cell-body it likewise 
 undergoes degenerative changes throughout its whole extent — secondary 
 degeneration. Degeneration of the axons of the upper motor segment 
 ceases, however, at the lower motor segment. The muscles are paralyzed 
 but do not undergo degenerative atrophy; they are spastic; their reflexes 
 are exaggerated arid they do not show qualitative changes in their 
 electrical reactions. 
 
 In complete transverse lesion of the cord — complete spinal para- 
 plegia — the muscles upon both sides are paralyzed below the lesion, but 
 they are flaccid; the deep reflexes are abolished; the muscles undergo 
 rapid atrophy with loss of faradic excitability. 
 
 Irritative lesions of the upper motor segment involving the motor 
 cortex give rise to the convulsive phenomena known as cortical or Jack- 
 sonian epilepsy. 
 
 Destructive lesions of the lower motor segment cause degeneration 
 alike of the axis-cylinder processes in the peripheral nerves and of the 
 muscle-fibres with which they are connected. The anatomical distribution 
 of the cell-bodies of the segment gives rise to special peculiarities in the 
 distribution of the paralysis which are strongly in contrast to that result- 
 ing from lesions of the upper motor segment and which have important 
 bearings upon the localization of the lesion. These cell-bodies are col- 
 lected in groups or nuclei from the peduncles of the brain throughout 
 the entire extent of the spinal cord and send axis-cylinder processes to all 
 the muscles of the body. Certain groups of the neurons which make up 
 the lower segment are therefore widely separated, and a circumscribed 
 lesion may result in paralysis of a limited number of muscles or a group 
 of muscles instead of one-half of the body as in upper segment paralysis — 
 hemiplegia. A lesion causing lower segment paralysis may be situated 
 either in the cord or in the peripheral nerve. If in the cord or its nerve- 
 roots the paralyzed muscles are not supplied by a single nerve but are 
 represented in adjacent cord segments and the accompanying sensory 
 derangements involve the skin fields related to those segments; if on the 
 contrary the lesion is in the nerve, the paralyzed muscles and the anaes- 
 thetic area are those supplied by that particular nerve and its branches. 
 The neurons of the lower motor segment maintain not only the nutrition 
 of their axis-cylinder processes which make up the peripheral nerves but 
 also that of the muscle-fibres in which their processes terminate. The 
 degeneration which results from injury of the cell-bodies or their processes 
 involves the muscles to which they are distributed. In lower motor segment 
 
EXAMINATION OF THE NERVOUS SYSTEM. 319 
 
 paralysis the affected muscles are the seat of degenerative atrophy, 
 manifest in diminished tension, aboHtion of their refiexes and reaction of 
 degeneration — flaccid paralysis. 
 
 Irritative lesions of the lower motor segment cause fibrillary con- 
 tractions which may be due to stimulation either of the cell-bodies or of 
 their axis-cylinder process in the peripheral nerves; or they may give rise 
 to spasmodic contractions when the lesion affects the motor nerve-roots 
 as they emerge from the cord. 
 
 Symptoms due to derangements of sensory paths are of far less local- 
 izing value than motor symptoms. This is partly due to the greater com- 
 plexity of the sensory tracts, partly to less exact knowledge concerning 
 them. If sensory symptoms are limited to the distribution of a peripheral 
 nerve it is evident that the lesion is in the nerve-trunk or its branches; 
 if restricted to the fields corresponding to one or more spinal segments 
 the cord is at fault; if they chiefly affect one side of the body, the brain. 
 The nature of the sensory phenomena has little value. Intense pain, for 
 example, may be symptomatic of peripheral nerve disease as in some 
 forms of neuritis, or of a degenerative process within the cerebrospinal 
 axis as in tabes. 
 
 Irritative lesions cause disordered subjective sensations of heat, cold, 
 formication, and the like — the paraesthesias — and pain of every variety as 
 to kind and degree. 
 
 Destructive lesions, if they completely interrupt the sensory path, 
 wholly abolish sensation in the parts of the body involved. A lesion of a 
 peripheral sensory neuron in the course of the nerve gives rise to anaes- 
 thesia in the area of distribution of the nerve; a complete transverse lesion 
 of the spinal cord gives rise to total loss of sensation of all parts below its 
 level. Destructive lesions of the central nervous system do not however 
 usually interrupt all the sensory conduction paths, and sensation may not 
 be wholly abolished even in extensive disease. Sensation may be diminished 
 or lost in all its phases as in complete transverse lesions of the cord, or there 
 may be dissociation sensory paralysis as in certain diseases of the cord in 
 which pain-sense and temperature-sense are abolished while tactile sensa- 
 tion remains unimpaired, or in some lesions of the cerebral cortex in which 
 there may be a loss of the muscular sense and astereognosis — the loss of 
 the ability to recognize an object placed in the hand — while other phases 
 of sensation are fully preserved. 
 
 EXAMINATION OF THE PATIENT. 
 
 The Anamnesis. — An accurate history of the case is of the highest 
 importance in disease of the nervous system. This must include in 
 many cases the facts relating to the antecedents of the patient, which 
 bear upon hereditary predisposition, as the occurrence of nervous or 
 mental disease in the parents, children, or collateral members of his fam- 
 ily. Peculiarities, idiosyncrasies, and psychoses are especially to be 
 ascertained, often a matter of no little difficulty. A histoi-y of gout, 
 alcoholism, or syphilis in a parent, when it can be obtained, may give 
 the key to the situation. 
 
320 MEDICAL DIAGNOSIS. 
 
 The investigation of the personal history must bear upon any pre- 
 vious serious illness and its nature, whether nervous or not, and especially 
 whether or not such an illness was of a similar nature to that from which 
 the patient is suffering. 
 
 It may be necessary to follow in our investigation a chronological 
 order, ascertaining whether or not nervous symptoms have occurred in 
 infancy and childhood, such as convulsions, enuresis, night terrors. The 
 period of school life is to be studied in obscure cases. The neurasthenic 
 may have been bright and successful at school, but shy, retiring, and not 
 disposed to make friends; the sufferer from petit mat, sometimes confused 
 and forgetful; the hysterical girl, especially at puberty, nervous and emo- 
 tional. The occupation is next to be considered. Is it one that involves 
 continuous monotony, mental strain, extreme responsibility? Have there 
 been prolonged or cumulative depressing emotions, disappointment, fear, 
 sorrow, or grief? Wounds and injuries, alcoholism, and abnormal sexual 
 matters, especially syphilis, are of etiological importance in many neuro- 
 logical cases. Severe infectious processes, particularly enteric fever, may 
 have been the point of departure for visceral and vascular changes which 
 after a time manifest themselves in the guise of nervous disease. Of special 
 importance are such maladies in their relation to postinfective psychoses 
 and neurasthenia. The part played by obscure toxaemias due to chronic 
 gastro-intestinal or other visceral diseases in the etiology of certain spinal 
 cord degenerations is not to be disregarded. Notwithstanding the number 
 of points to be considered the value of the history cannot be measured by 
 its length. On the contrary it is most important to briefly record only the 
 facts which are pertinent and significant. 
 
 Status Praesens. — While investigation on every side is necessary for 
 a full understanding of many nervous cases, yet there are certain special 
 paths of approach which experience has taught us lead most directly to a 
 diagnosis in the average case; in. other words certain distinctly neuro- 
 logical methods of investigation. These methods may be grouped according 
 to the character of the symptoms and signs that each brings into view, 
 the most important being, (1) motor and (2) sensory symptoms; (3) cere- 
 bral symptoms, of which, on account of comprehensive and special char- 
 acters, (4) asphasia requires separate consideration; (5) spinal symptoms 
 in so far as they connect segments of the cord with particular regions of 
 the body; (6) the reflexes; (7) electrical phenomena; (8) trophic disturb- 
 ances; (9) pain and temperature; (10) muscular sense. 
 
 1. Motor Symptoms. 
 
 Paralysis. — Motor paralysis signifies impairment of some portion of 
 the motor pathway. When partial it is to be distinguished from akinesia, 
 common in states of mental stupor, and from incoordination, often mis- 
 taken by the patient and his friends for true weakness. The practical 
 tests for muscular weakness consist, for the hand and forearm, in estimat- 
 ing the patient's " grip" as he squeezes the hand of the examiner, especially 
 in comparing the grip of an affected hand with the other, which may be 
 normal or less affected. Of mechanical devices the dynamometer of Math- 
 
EXAMINATION OF THE NERVOUS SYSTEM. 321 
 
 ieu is most commonly used. The power of arms and legs is tested by having 
 the patient make various movements while the examiner, grasping the 
 part, offers resistance. 
 
 A general surmise as to the location of the lesion (cerebral or spinal) 
 causing the impairment of the motor path is made by observing whether 
 the affected part is flaccid or spastic. Flaccidity nearly always denotes 
 a lesion of lower motor neurons (ganglion cells of ventral gray horns, 
 peripheral nerves with their terminals) as seen in poliomyelitis and neu- 
 ritis, while spasticity signifies a lesion of central or upper motor neurons 
 (cell-bodies of motor cortex, fibre tracts through subcortex, internal cap- 
 sule, pons, medulla, ventral and lateral pyramidal tracts of spinal cord), as 
 in old brain hemorrhage. 
 
 A notable exception to this broad rule is that in lesion of the spinal 
 cord, complete or nearly complete transversely, especially one high up in 
 the cord, the effect is as if all motor neurons below it were destroyed, 
 i.e., there is total flaccid paralysis below the level of the lesion. The expla- 
 nations of this phenomenon are numerous but unsatisfactory. Another 
 exception to this rule is readily correlated with it by bearing in mind 
 that the superior motor neurons of the pyramidal tract are not wholly 
 cerebral but have a spinal portion which is mostly contained in the 
 lateral tract; hence it follows that a spinal palsy is spastic if the lateral 
 tracts are involved. 
 
 To decide whether a member be flaccid or spastic, all the patient's 
 active movements, including gait, are to be studied, as well as various 
 passive motions which may suggest themselves to the examiner. His 
 opinion will be rather one of judgment than of definite methods. 
 
 Monoplegia is a paralysis restricted to one member, whether this be 
 disabled entirely or only in one group of muscles. Hemiplegia, or paraly- 
 sis of one side of the body, is nearly always due to a brain lesion, and, 
 when so, the upper face will be found unaffected or slightly affected, 
 except in recent cases where the paralysis in the upper distribution of the 
 facial nerve may be very distinct for a time. The slight implication of 
 the upper face is characteristic of a long-standing cerebral hemiplegia. 
 Diplegia — double hemiplegia — occurs particularly in childhood. Para- 
 plegia is a symmetrical paralysis involving the upper or lower limbs, but 
 when the term is used without qualification it refers to paralysis of the 
 lower limbs. The term brachial paraplegia is employed to denote paralysis 
 of the upper hmbs; crural paraplegia that of the lower. It is generally 
 a spinal palsy. 
 
 Contracture. — In paralysis of long duration contractures appear 
 which are generally characteristic. Those which arise in spastic paralyses 
 depend upon shortening of the paralyzed muscles, the stronger muscles 
 contracting more than the weaker, and produce such postures of the limbs 
 as are seen in hemiplegia''(flexion of elbow, wrist and fingers, adduction of 
 arm to chest, extension of the leg on the thigh, adduction of the knees, 
 extension of the foot and inversion with plantar flexion of toes). According 
 to some investigators the contractures of cerebral hemiplegia are the result 
 of the greater paralysis in certain groups of muscles. The contractures 
 in flaccid paralyses depend upon the unbalanced action of the opposing 
 
 21 
 
322 MEDICAL DIAGNOSIS. 
 
 sound muscles, as seen in the accentuated wrist-drop and foot-drop of old 
 peripheral neuritis, or depend upon the contraction of the paralyzed 
 muscles themselves. 
 
 Convulsions and spasm (see Part III, p. 588). 
 
 Jacksonian epilepsy (see p. 589). 
 
 Athetosis or mobile spasm consists of irregular writhing movements, 
 especially of the fingers but also of the arms and other parts. It is almost 
 pathognomonic of the cerebral palsies of childhood, in which affections the 
 symptom may mislead by being more prominent than the hemiplegia or 
 diplegia which underlies it. Occurring in adult hemiplegics these movements 
 are sometimes called posthemiplegic chorea, but are less prominent than the 
 weakness and rigidity of the limb. Athetosis is usually aggravated by volun- 
 tary movements, as when the patient attempts to pick up a small object. 
 
 Tremor (see p. 592). 
 
 Fibrillary tremor or fibrillary twitching (see p. 593). 
 
 Tics. — Twitching simultaneous over a large area, inducing a purposive 
 movement at intervals and habitually, is called a "tic." It is not a sign 
 of any known lesion but is functional (a neurosis). 
 
 Ataxia. — In the course of investigation of motor signs the examiner may 
 observe irregularity and uncertainty in various acts which require a degree 
 of precision. Ataxia results from inharmonious action of muscle-groups 
 even when disorder of motility, either excess or deficiency, is not present. 
 
 The defect is largely in the muscular sense, which is discussed in its 
 relation to astereognosis. Yet the practical tests for the symptom are 
 motor. In the arm ataxia is discovered by directing the patient to close 
 his ej^es and then with his index finger to touch the tip of his nose, or to 
 meet the tip of the other index finger in sweeping the arms around hori- 
 zontally in front; in the leg, by having him attempt to touch one knee 
 with the heel of the other foot. If there be considerable ataxia the patient 
 touches wide of the mark. Ataxia of the legs is better revealed in the 
 patient's manner of walking, which is considered in connection with other 
 disorders of gait. 
 
 2. Sensory Symptoms. 
 
 Studies of sensation involve a subjective element which makes them 
 at best uncertain. Scientific methods aim to diminish this uncertainty 
 by magnifying the objective element through the use of technical pro- 
 cedures which render the examiner less dependent upon the patient's 
 statements. In children, and in stuporous and demented patients, the 
 objective element alone is considered — a start, a vocal sound, or the with- 
 drawal of a member when the patient is touched, pricked, etc. 
 
 Paraesthesia, — " Numbness and tingling," " pins and needles," ''crawl- 
 ing sensations" — formication — and burning sensations are symptoms of 
 sensory irritation. They are prominent in neuritis, and in spinal diseases 
 which implicate the posterior nerve-roots (see also p. 582). 
 
 Delayed Sensation. — Recognition of any artificial sensation is, for 
 the purposes of the clinician, instantaneous; if an interval occurs between 
 the application of a stimulus and the patient's response to it, we speak of 
 "delayed sensation," which is common especially in tabes dorsalis. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 323 
 
 Pain. — Pain is a prominent symptom of many nervous diseases. 
 
 The objective study of sensation comprises the testing of the senses of 
 touch — common sensibihty — of pain, and of temperature. The muscular 
 sense is of interest cHnically in relation to astereognosis, and also in relation 
 to ataxia of movement, which may arise from defect of the muscular sense. 
 
 In testing the sense of touch it is well to blindfold the patient, to take 
 care that the surface examined shall not be chilled by exposure, and to 
 touch the part with light pressure and without causing pain. The instru- 
 ment most commonly used for this purpose is Carroll's sesthesiometer, 
 but a tooth-pick or a feather will serve. The patient is directed to say 
 "now" when the touch is felt; or to count successive touches a short 
 distance apart, ''one, two, three," etc., and the failure to note one or more 
 touches will mark the boundary of an area of anaesthesia. Sensibility to 
 touch is more acute on the back than on the front of the body. Loss of 
 tactile sensibility, either total — ancesthesia — or partial — hypcesthesia — may 
 be functional and a sign of hysteria, in which case it commonly affects 
 half the body — hysterical hemianaesthesia — or a segment of one limb, or 
 all of one extremity up to a certain level — " glove-anaesthesia" and "stock- 
 ing-anaesthesia;" or anaesthesia and hypaesthesia may constitute a sign of 
 organic nervous disease which is destructive in character or is at an ad- 
 vanced stage. In the case of hemihypaesthesia or hemianaesthesia, the 
 hemorrhage or other destructive lesion may be in the posterior part of the 
 internal capsule — where according to some anatomists sensory fibres are 
 collected into a bundle (carrefoure sensitif) — in the tegmentum of the 
 pons, or in the spinal cord, provided one lateral half of the pons or cord 
 be severed. In any of the cases mentioned the lesion is situated on the 
 side opposite to that of the anaesthesia. 
 
 In testing the pain sense, a needle-point or one of the sharp points 
 of the sesthesiometer is employed, and the skin is "pricked," not scored, 
 with the instrument. Remind the patient that actual pain, not the mere 
 sense of being touched, is to call forth his response; or instruct him to say 
 "touch," or "pain," according as the one or the other sensation is excited 
 by the sharp point. 
 
 The temperature sense is well studied by the use of two test-tubes of 
 water, one heated to about 100° F. or above, the other cooled to 60° F. or 
 lower, the tubes being applied alternately, and each being held in contact 
 with the skin-surface for several moments, since recognition of heat or of 
 cold is commonly less prompt than that of touch and of pain. The heat 
 of the one tube should not be sufficient to burn, as that would introduce 
 the factor of pain; yet practically this distinction is of little consequence, 
 because the thermic sense and the pain sense, being conducted in adjacent 
 tracts of the coi-d, are commonl}' abolished together. Ordinarily when 
 tactile anaesthesia has been demonstrated in a certain area, we may expect 
 to find thermo-anaesthesia and analgesia associated with it. But the con- 
 verse of this does not always hold true; for over surfaces which betray no 
 tactile anaesthesia, or at most only hypaesthesia, we may find areas of anal- 
 gesia and thermo-anaesthesia. This is that dissociated sensory loss which 
 is most common in syringomyelia, though other lesions of the central 
 part of the gray matter of the cord may cause the phenomenon. 
 
324 MEDICAL DIAGNOSIS. 
 
 3. Regional Diagnosis of Cerebral Disease. 
 
 General Symptoms. — The general symptoms of intracranial disease — 
 vomiting, headache, and optic neuritis — have little value in cerebral locali- 
 zation. Headache is more likely to be frontal in lesions of the fore-brain 
 and occipital in those in or about the cerebellum, but this is not constant. 
 Dense tumors of some size, well above the base of the skull, may yield a 
 shadow on the X-ray plate. 
 
 Predominant mental symptoms are suggestive of lesion of the pre- 
 frontal lobes, particularly the left; but it must be remembered that after 
 head injuries delirium, confusion, or stupor may ensue from shock, with- 
 out reference to severity or site of the trauma, and moreover that demon- 
 strable brain lesions are comparatively rare causes of insanity. 
 
 Paralysis. — Of motor signs indicating lesion of the precentral con- 
 volution, anterior to the fissure of Rolando, paralysis has the greatest 
 localizing value. Paralyses in the distribution of cranial nerves, especially 
 of several, commonly indicate lesion at the base of the brain. If a single 
 cranial nerve is implicated, the lesion is probably outside of the central 
 nervous system; if one arm or leg is paralyzed, a cortical lesion should be 
 suspected, and this is rendered probable if the paralyzed part is the seat 
 of clonic spasm. Paralj^sis of the face indicates lesion in the lower third of 
 the Rolandic cortex; paralysis of an arm or leg, lesion of the middle or 
 upper third respectively. 
 
 Astereognosis. — Pure motor phenomena point to a lesion anterior to 
 the fissure of Rolando; if the lesion be posterior to this fissure (postcentral) 
 the motor signs are likely to be associated with the phenomenon called 
 astereognosis, which becomes more prominent as the pai^ietal lobe is en- 
 croached upon. By study of the '' stereognostic sense" which is the physio- 
 logic process by which solid objects are recognized by contact, neurologic 
 diagnosis has made a distinct advance. Astereognosis, or want of this 
 sense, may be diagnostic of lesion of the superior parietal lobule. To test 
 for this phenomenon it is well to study separately the several processes by 
 which normally the hand recognizes the shape and size of objects, especially 
 the ''spacing sense," the sense of position, and the pressure sense, the 
 last two of which are the chief components of the muscular sense. 
 
 The "spacing sense" is tested by touching the skin at two points 
 simultaneously, as with the two arms of the sesthesiometer, and observing 
 how near together they may be while still recognized as two points. The 
 examiner compares his results with those obtained in a normal subject. 
 
 The sense of position is studied by asking the patient (blindfolded) to 
 tell where his hand or foot is, after the examiner has quietly placed it in 
 a particular attitude, or to imitate with one limb an attitude given to the 
 other by the examiner. 
 
 The pressure sense is tested by bhndfolding the patient, placing his 
 hand supine upon a table, and laying in his palm, one after another, 
 small objects identical save in their Weight, which is graded in a series. 
 For this purpose cartridges filled with layers of cotton and regulated 
 numbers of buckshot may be used. The main test, which reveals 
 astereognosis directly if it be at all pronounced, consists in handing 
 
EXAMINATION OF THE NERVOUS SYSTEM. 325 
 
 the patient various common objects, — watch, spool, block of wood, pen- 
 knife, — each of which he essays to name or to describe. 
 
 Deafness, in the absence of disease of the external, middle or internal 
 ear, may be due to lesion of the first or second temporal convolution, 
 particularly that of the left side. 
 
 Blindness without demonstrable cause in the eye may be due to lesion 
 anywhere in the course of the optic nerves, tracts or "radiations" as far 
 as the cunei lobes, which face one another across the great longitudinal 
 fissure in the occipital lobe. Unilateral blindness of both eyes and in the 
 same side of each eye (lateral homonymous hemianopsia) indicates that 
 the lesion is unilateral, that it is back of the optic chiasm and is on the 
 side opposite to that on which the patient's vision has failed — that is, on 
 the same side as the blind half-retina. To determine how far back of the 
 chiasm such a lesion is we must rely on signs and symptoms arising from 
 involvement of contiguous structures, especially (in lesions at the base of 
 the brain) the cranial nerves, which are spared in lesion of the optic radia- 
 tions, or of the cuneus — subcortical or cortical lesions. A theoretically 
 positive means of distinguishing basal from cortical lesions causing hemi- 
 anopsia is Wernicke's pupillary-inaction sign, which consists in the 
 absence of the light reflex of the iris when only the blind half of the retina 
 is illuminated. The finding of this condition points to a basal lesion, 
 i.e., at or below the optic thalamus and external geniculate body, for con- 
 traction of the iris is a function of the third nerve, and no part of this 
 nerve extends above the ''primary optic centres," which are at the base 
 of the brain. 
 
 Partial loss of vision, not accounted for by eye disease, may be due 
 to lesion of the angular gyrus, visual acuity — macular vision — being im- 
 paired; or it may be due to lesion in front of the optic chiasm, in the 
 angle between the optic nerves, where by interfering with the internal 
 fibres of each nerve it causes blindness of each inner (nasal) half-retina, a 
 condition called (from the blind half-fields) temporal hemianopsia, which 
 is pathognomonic of lesion in the situation described. 
 
 Symptoms of Cerebellar Disease. — The cerebellum is to the clinician 
 chiefly an organ of coordination, and this function resides mainly in the 
 middle lobe. The cardinal signs of cerebellar disease are nystagmus and 
 a peculiar ataxia which gives a staggering character, or tituhation, to the 
 patient's gait. This ataxia disappears when the patient lies down, and 
 the knee-jerks are often preserved. Neoplasms beneath the middle lobe 
 of the cerebellum are likely to cause this form of ataxia together with 
 external ocular palsies from pressure upon the nuclei of the third and fourth 
 nerves beneath the quadrigeminal bodies. A tumor arising from these 
 bodies can hardly be distinguished from cerebellar tumor implicating 
 the vermis. 
 
 The Internal Capsule. — Of the great interior structures of the l^rain 
 only the posterior limb of the internal capsule has functions so definite that 
 certain symptoms may be referred to it. Sudden hemiplegia, with hemi- 
 anaesthesia and hemianopsia, is generally indicative of lesion in the internal 
 capsule, since this complex of symptoms from cortical or even subcortical 
 lesion could be induced only by uncommonly extensive damage. The 
 
326 MEDICAL DIAGNOSIS. 
 
 symptoms referable to single minute destructive foci in the posterior limb 
 of the capsule, from the "knee" backwards, are, so far as is known, (1) 
 paralysis of the face from above downwards, (2) of the arm and (3) of the 
 leg, also from above downwards, (4) anaesthesia of varying extent up to 
 hemiansesthesia, which probably indicates destruction of the posterior 
 third of the posterior hmb, (5) hemianopsia. 
 
 Cerebral Ganglia. — Of the great cerebral ganglia none has an independ- 
 ent symptomatology. Lesions affecting the corpus striatum cause pre- 
 dominant motor signs because of pressure upon the motor bundles of the 
 capsule, while affections of the optic thalamus commonly cause hemi- 
 ansesthesia from pressure upon the posterior fibres of the capsule — 
 carrefour sensitif — or destruction of sensory fibres within the thalamus 
 and often hemianopsia from involvement of the optic radiations, which are 
 collected into a bundle posterior to the capsule and enter the optic thala- 
 mus. Mobile spasm or athetosis, associated with these paralyses, is in 
 favor of thalamic lesion. Weakness of the articulatory muscles resembling 
 bulbar paralysis, but not due to lesion of the medulla oblongata, is called 
 pseudobulbar paralysis. It is most often due to multiple hemorrhages or 
 softening in the outer part of the lenticula. 
 
 Lesions of the corpus callosum are revealed by disturbance of the 
 functions of surrounding parts, notably of the motor zone, — as shown by 
 early epileptic seizures, by paralyses, and symptoms referable to the pre- 
 frontal region. From the latter arise the pseudoparetic mental states 
 which are characteristic of callosal lesion. 
 
 4. Aphasia and Other Defects of Speech. 
 
 Though endowed with a normal brain, the individual born deaf and 
 blind becomes an imbecile by deprivation of the sense-impressions out of 
 which knowledge grows, unless he be trained like Laura Bridgman through 
 the touch-sense. The cochlea, the retina, etc., begin the transformation, 
 from mere contact with the external world, into the higher special sense- 
 impressions. These, carried by their separate paths to the cortex, are 
 elaborated in the special-sense centres into perceptions of things. Roughly 
 speaking, each cortical centre is opposite the organ of that sense. Taldng 
 one sense, vision, rays of light from an object, for example a cow, received 
 by the retina are carried through the visual system to the cuneus as sensa- 
 tions of form, color, etc. Thence passing still higher, in the angular gyrus 
 is formed a visual image of a cow — object-seeing — and this is associated 
 with an image of the word cow written or printed — word-seeing. Lesion 
 of angular gyrus then does not cause ordinary blindness — as lesion of the 
 cuneus does in one half-field — but loss of these visual images, so that the 
 patient seeing a cow can hardly tell it from a horse — object mind-blind- 
 ness; and seeing the word cow fails to get the meaning from it, as if it were 
 a foreign word — word-blindness. In like manner, close to the auditory 
 centre is a higher centre for the formation of auditory images, by which a 
 peculiar sound is identified, for example, as the lowing of a cow — object- 
 hearing — and by which the spoken word cow is recognized as the name of 
 that animal — word-hearing. With a lesion then in the first temporal 
 
EXAMINATION OF THE NERVOUS SYSTEM. 327 
 
 convolution, sparing the main auditory centre, so that the patient is still 
 capable of hearing noises, there may be loss of these auditory images with 
 consequent object-deafness and word-deafness; sounds and words heard 
 are meaningless. 
 
 To speak of a cow it is necessary to recall the word cow. Many persons 
 are likely to recall a word as it sounds; some as it appears written; but 
 most revive it in both ways, so that impairment of either the auditory or 
 the visual word-image interfering with the recollection of words causes 
 aphasia, in the one case, from lesion of the angular gyrus — visual or optic 
 aphasia; in the other, from lesion of the first temporal convolution — audi- 
 tory aphasia. In either case due to a lesion of a sensory centre it is spoken 
 of as sensory aphasia; and because the essential defect is inability to recol- 
 lect words (verbal amnesia) both are included under the term amnesic 
 aphasia. The act of speaking involves several groups of muscles, and is 
 interfered with, therefore, in various forms of paralysis. In bulbar paraly- 
 sis, the hps, tongue, etc., becoming atrophied and paretic, there is defect 
 of articulation, incidentally; and in the similar paralysis from cerebral 
 lesion (pseudobulbar paralysis) the patient may be inarticulate. In hke 
 manner lesion in the cortical centres for the lips, tongue, etc., at the foot 
 of the motor zone, cripples the speech just as lesion in the leg centre causes 
 limping; so here on the emissive side of the speech-process there is set 
 apart a higher centre for the fine adjustment of movements in uttering 
 words, and for the memory of these movements. This is Broca's centre, 
 in the posterior part of the third frontal convolution. By lesion here, the 
 muscles of articulation still intact, the patient loses his motor memories 
 and his power to utter words. This is motor aphasia — or aphemia. 
 
 Parallel to these defects of articulation are defects in the act of writing 
 which has its higher centre in the second frontal convolution, related to 
 the arm centre as Broca's is to the centres for the tongue, lips, etc. Lesion 
 in the writing centre causes motor agraphia, even though the arm be still 
 useful otherwise. In lesion of the angular gyrus, as the appearance of words 
 is forgotten, writing is imperfect; there is sensory agraphia. In reading 
 aloud, the image of the printed word must be conducted from the angular 
 gyrus to Broca's centre, there to be matched with the motor image used in 
 uttering the word; and the utterance must be guided, too, by the auditory 
 image conducted from its centre. For this purpose Broca's centre is con- 
 nected with the others by tracts of fibres which being damaged, particu- 
 larly in the insula — island of Reil, there is interference with the conduction 
 referred to, and hence, with reading aloud and with similar uses of speech, 
 conduction-aphasia. For perfect speech all the centres must act in unison 
 through conduction-paths connecting each centre with the rest, and con- 
 sidering such multiple connections it is evident that aphasia of some kind 
 may result from lesion at any point within a wide area. This '' zone of 
 language" is nearly coextensive with the distribution of the middle cere- 
 bral artery, and aphasia is generally a consequence of apoplexy from this 
 vessel, commonly in association with hemiplegia. This same region, acting 
 as a unit, forms a complete image not alone of the word but of the object 
 also, as it looks, sounds, feels, smells, tastes — in short, a concept of the 
 object; so that this is a concept area (Mills). 
 
328 MEDICAL DIAGNOSIS. 
 
 Aphasia being a curtailment of the power to comprehend as well as 
 of the power to emit language, spoken, written or by signs — pantomime — 
 care and system in testing for it are very important. ''Impediments" of 
 speech, mechanical imperfections of the vocal organs, are first to be elimi- 
 nated by examination of the mouth, throat, and nasal cavities. In cleft 
 palate, hypertrophic rhinitis, and in tongue-tie, the difficulty is mainly in 
 the enunciation of consonants, such as m, n, b, etc. 
 
 Dysarthrias, from paralysis or defective innervation of the muscles 
 of articulation, are to be recognized partly by finding additional signs of 
 cerebral paralysis or other organic nervous disease, and partly by special 
 characters of the speech in certain affections. Somewhat suggesting 
 mechanical impediment is the speech of bulbar paralysis, marked as it is 
 by labored pronunciation of consonant-sounds. 
 
 Elision of syllables by running words together, may be observed in 
 hereditary ataxia, in which disease speech is at the same time monotonous. 
 These two characters belong also to the speech of general paresis, forming 
 with the difficulty of enunciating the r's and I's, as in " artillery," and with 
 its tremulous, measured drawl, the peculiar "paretic speech" which is 
 one of the cardinal signs of this disease. The measured character of such 
 speech exists in purer form — scanning — in disseminated sclerosis. 
 
 Ordinary stuttering is a pure neurosis. It manifests itself by spas- 
 modic halting in attempts to utter certain words, usually those beginning 
 with consonants. 
 
 In differentiating aphasia from other speech defects the greatest 
 difficulty arises in the case of actual mental loss — dementia — which indeed 
 may coincide with aphasia, as in hemiplegia and senility, or may have 
 aphasia for an episodic manifestation, as in paresis. 
 
 The stubborn speechlessness frequently met with in paranoia and 
 melancholia is nearly always accompanied by other signs of negativism, 
 as refusal of food and resistance to the attentions of the nurse. Hysterical 
 aphasia is intermittent and its victim exhibits the stigmata of the neurosis. 
 
 In testing an apparent aphasic it is well to begin on the sensory side, as- 
 certaining whether the centres for word-hearing and word-seeing are impaired. 
 A number of common objects may be placed before the patient who endeav- 
 ors to pick out those named in turn by the examiner and then to select from 
 a list of names on paper, that of the object selected by the examiner. 
 
 As the purpose is to determine the clearness of word-images, these 
 simple tests are essential; but the examiner may progress to words and 
 sentences of any complexity. Rarely being complete, aphasia is often 
 betrayed by persistent, helpless misapplication of words, the patient say- 
 ing or writing for instance ''dog" when a hat is showed to him and its 
 uses demonstrated by him. Paraphasia and paragraphia are forms of 
 aphasia rather characteristic of sensory aphasia. 
 
 To test a patient's emissive power of language, that is, to discover 
 motor aphasia and agraphia, objects are shown to him, and he endeavors 
 to utter and write their names. Simple acts performed in the patient's 
 presence are described by him both orally and in writing. In motor aphasia 
 "recurring utterances" are common, a patient repeating "any one any" 
 or other meaningless phrase on all occasions when attempting to talk. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 329 
 
 Even after demonstrating that a patient hears, reads, utters, and 
 writes words correctly, and thus that the widely separated cortical speech- 
 areas in the first and second left temporal convolutions, the angular gyrus, 
 the third frontal and the second frontal convolutions are probably intact, 
 together with the subcortical region corresponding to each centre, we may 
 still find that the patient is much crippled in the use of language. In such 
 a case we conclude that some of the fibres connecting these cortical centres 
 with one another are cut off, and that we are dealing with a case of " con- 
 duction aphasia" or "transcortical aphasia." The prominent features of 
 this form are paraphasia, paralexia, etc., so extreme that the jumbHng of 
 words and syllables is spoken of as '^ jargon-speech." 
 
 So entangled in these " association-systems" are all the cortical centres 
 that speech-defect from cortical lesion always betrays some features of 
 conduction aphasia. If our tests reveal uncompHcated word-deafness or 
 word-blindness, or simple loss of the power of utterance, we recognize 
 that the lesion is deep in the brain, beneath the level of association- 
 systems, where the fibres radiating to or from the particular centre 
 are bundled together. This is called "subcortical" or "pure" aphasia, 
 and yet some evidence exists that this form of aphasia may result from 
 cortical lesions. 
 
 As an auxihary test for this form, the study of pantomime is of value. 
 In pure motor aphasia, for instance, the patient though speechless as 
 regards utterance, may when asked how old he is, open and shut his hand 
 the proper number of times. In ordinary motor aphasia this is impossible. 
 
 5. Spinal Localization. 
 
 One of the consequences of modern clinico-pathological study is the 
 tendency to interpret nervous symptoms and signs in relation to anatomical 
 structure, rather than in relation to empirical disease forms. This tend- 
 ency in the field of brain disease has created cerebral localization; and it 
 has affected our conceptions of spinal disease to the extent that we speak 
 less of "locomotor ataxia," of "spastic paraplegia" or of "progressive 
 muscular atrophy" as disease entities than as dominant symptoms of 
 various lesions affecting certain structures of the spinal cord. Assuming 
 in this connection that the symptoms in a given case are of spinal origin, 
 we infer from "ataxia" of a limb that the dorsal column of the cord is 
 affected; from spasticity with increased reflexes, the pyramidal tract; 
 from atrophy, the ventral horns of the gray matter; from anaesthesia, the 
 dorsolateral column again; from loss of pain- and temperature-sense with- 
 out anaesthesia — dissociation of sensation — the central part of the gray 
 matter; from pain, the dorsal roots. Then we endeavor to determine the 
 lesion which has caused the particular symptom-complex which confronts 
 us by bringing to bear our knowledge of the natural history of nervous 
 disease and by collating the spinal symptoms with any cerebral mani- 
 festations which may be present. By this method we may find that our 
 "locomotor ataxia" case is really one of combined degeneration of the 
 cord or one of paresis, and that "progressive muscular atrophy" is symp- 
 tomatic of syringomyelia or of tumor. 
 
330 MEDICAL DIAGNOSIS. 
 
 Spinal localization in the ordinary sense, however, relates to diagnosis 
 of the level of a lesion in the cord. It is based upon our accumulated 
 knowledge of the motor sensory reflex and sympathetic control exercised by 
 each segment of the spinal cord over a corresponding segment of the body. 
 
 Injury to the spinal cord at any point involving the motor tracts — 
 unless it be completely severed — causes paralysis, with increase of reflexes, 
 below that point; but at the level of the lesion we are likely to find the 
 reflexes abolished. We commonly find also anaesthesia covering the body 
 below this level if the lesion is grave, and the upper limit of anaesthesia, 
 with the zone of absent reflexes coinciding, is the best index to the level 
 of the spinal lesion. If the lesion affects one lateral half of the cord the 
 above principles still apply, but the disturbance of sensation, except of 
 the sense of position, is found on the side opposite to that of the lesion 
 and to that of the motor symptoms — Brown-Sequard's paralysis, although 
 even in this form tactile sensation is often preserved. 
 
 The level thus ascertained marks the relative position of the lesion, 
 but its actual position in the spinal column will be found above this, gener- 
 ally a distance of about three spinal segments. A narrow zone of anaesthesia 
 is usually present in Brown-Sequard's paralysis on the side of the lesion, 
 and at its level and above this may be a narrow zone of hyperaesthesia. 
 Such an anaesthetic zone occurring independently points to a lesion outside 
 the cord substance and involving spinal roots of at least two segments. 
 Sensory loss from injury to the cord proper or the posterior roots is dis- 
 tributed in horizontal bands about the trunk and longitudinal bands in the 
 limbs, irrespective of the distribution of the nerves — segmental anaesthesia. 
 
 The clinician should be able to conclude off-hand from atrophy of the 
 shoulder, or loss of reflexes in that region, that the upper cervical region is 
 affected when the symptoms are of spinal origin; from such symptoms 
 affecting the forearm and hand, that the lesion is lower down in the cervical 
 swelling; from loss of knee-jerk, that it is in the lumbar, and from loss of 
 control of sphincters, in the sacral region; but for finer deductions it is 
 well to record the findings in a particular case, and then interpret them 
 by reference to the tables and diagrams upon pp. 312, 313,. and 314. 
 
 Combined Degenerations. — " Typical cases" are as narrow summits 
 in the great ranges of disease. From each summit the symptomatology 
 and pathology form a downward slope, by which that disease merges with 
 one or more of its neighbors. Of lateral sclerosis very few absolutely pure 
 cases have been reported. On the one hand, in cases that seem like pure 
 lateral sclerosis, there is nearly always insidious degeneration in the ventral 
 gray horns — chronic poliomyelitis; or the latter disease after a course of 
 years may take on spastic symptoms because the pyramidal tracts are 
 invaded, that is, degeneration beginning in either motor neuron tends 
 to progress to the other. 
 
 In some cases the affection of superior and inferior motor neurons 
 is simultaneous, progressive muscular atrophy and spastic paraplegia 
 developing pari passu. Such cases constitute amyotrophic lateral sclerosis. 
 In them the bulbar part is prominent and degeneration may extend even 
 to the cortex, mapping out the motor zone, for amyotrophic lateral sclerosis 
 is a disease of the whole motor system. 
 
PLATE VII. 
 
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 SOLAR PLEXU5 
 
 SUPPLIES ALL 
 ABDOtllnAL VISCERA . 
 
 SUP'nESEnTERIC 
 
 PLEXUS SUPPLIES PANCREAS. 
 -\ SMALL iriTESTinE. ILIO- 
 
 COLon.ASCEnoino s 
 
 I TRAnSVERSE COLOM. 
 
 5 LUHBAR riERVE:5 
 SUPPLY QUADRATUS 
 
 6 PSOAS. 
 
 44 5" SACRAL n: 
 
 LEVATOR Ani 
 SPHIMCTER AMI 
 
 COCCYGEAL PLEXUS 
 
 ILIO -IMGUIMALn.su 
 ILIO -HYPOGASTRIC N. 
 CEMITO -CRURAL t^m.ti CREHASTER. 
 
 COCCYGEAL MERVES supply 
 LEVATOR AMI 4 5PHIMCTER AMI 
 
 PLEXUS on THE SUPr 
 
 HEHORRHOIDAL 
 
 VESSELS SUPPLIES 
 RECTUM i Anus. 
 
 'IRECTAL ^VESICAL 
 
 ■< PLEXUSES SUPPLY 
 VRECTUn t BLADDEn . 
 
 Connection between sympathetic nerves supplying viscera and spinal nerves supplying muscles of 
 
 abdominal walls. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 331 
 
 On the other hand degeneration in the lateral columns may be accom- 
 panied by dorsal degeneration. Such implication of superior motor neurons 
 with inferior sensory neurons in combined degeneration suggests a local, 
 extraneous cause, acting upon the lateral and posterior columns simul- 
 taneously. The mechanism for this could be the marginal system of 
 arteries carrying some toxin into these portions of the white matter, and 
 the lesion might be expected to spread around the arterioles from the 
 very margin of the cord. These conditions are clearly present in some cases 
 of ergotism, pernicious anaemia, etc. An acute diffuse dorsolateral degen- 
 eration may be found at autopsy, though commonly no symptoms have 
 been observed in life. In various undetermined toxaemias (Putnam and 
 E. W. Taylor) a subacute degeneration is established, partly diffuse, but also 
 partly systematic, as in time it enters the course of ascending and descend- 
 ing tracts. This subacute combined degeneration is clinically distinct 
 from the other types (Russell, Batten and Collier). Possibly similar in 
 origin but appearing as a pure combined system disease (Striimpell) , the 
 chronic form, posterolateral sclerosis, has been recognized longer. It is 
 manifested clinically by paraplegia from the pyramidal tract lesion, with 
 ataxia from the lesion in the dorsal columns — ataxic paraplegia of Gowers 
 — but without lightning pains or other sensory phenomena and without eye- 
 symptoms, because the sensory root-zones and roots — including the optic 
 nerves — are spared. For this last reason, too, the reflexes are preserved 
 in posterolateral sclerosis; by the degeneration of the pyramidal tracts 
 they are usually increased and the legs made spastic. At a late stage the 
 root-zones may be invaded and reflexes impaired until the case appears like 
 one of simple tabes dorsalis, only an autopsy revealing the combined lesion. 
 
 A combined sclerosis is the commonest spinal lesion of paresis. 
 
 6. The Reflexes. 
 
 Every segment of the spinal cord contains not only centres for certain 
 groups of muscles but also for reflex movements. The reflex starts in an 
 impulse arising from the stimulation of a sensory nerve. It is transmitted 
 to a centre in the cord and passes by way of the processes of the sensory 
 cell-bodies to the neurons of the corresponding motor centre, in which it 
 originates a motor impulse which in turn passes by way of the motor nerve 
 to the muscle-fibres supplied by the nerve. This complete path, made up 
 of centripetal or sensory fibres with their cell-bodies and correlated cell- 
 bodies with their centrifugal or motor fibres, is called a reflex arc. The 
 sensory impulse may be transmitted to centres at higher or lower levels 
 and excite several motor impulses, thus producing a complicated reflex arc. 
 The cord segments are connected with fibres from the cerebrum having 
 the function of inhibiting the reflex. If these fibres are irritated the reflexes 
 are impaired from abnormal inhibition; if they are destroyed the reflexes 
 are exaggerated. If the arc is interrupted either in its afferent or efferent 
 limb or in the centre the reflex is lost. 
 
 Involuntary contraction of muscles aroused by a sensory impression 
 upon related parts is a reflex in the ordinary sense. For fine deductions 
 the muscles themselves must be observed. The quadriceps cruris, for 
 
332 MEDICAL DIAGNOSIS. 
 
 example, may be seen to contract on tapping the patellar tendon, even 
 when no motion of the leg occurs, and^nder such circumstances the " knee- 
 jerk" cannot be said to be abolished; but ordinarily we recognize reflex 
 response in muscles by a characteristic motion imparted to a member, as 
 the kicking movement of the leg which is regarded as a measure of the 
 knee-reflex. 
 
 Absence of the usual motor response, of the knee-jerk for example, 
 or its diminution or exaggeration, are the matters to be attended to in the 
 study of most reflexes, particularly the "tendon-reflexes." This is true 
 also of most of the superficial — skin — reflexes, though in certain of them 
 the character of the motion elicited is significant; thus with the plantar 
 reflex, flexion of the toes is normal, while extension — Babinski reflex — 
 indicates lesion of the pyramidal tract of the corresponding side, extension 
 of the toes being equivalent to exaggeration of other reflexes. In a third 
 group, the so-called periosteal reflexes, any motion of the member estab- 
 lishes the presence of the reflex, as in the case of the scapulohumeral, 
 the motion of which maj^ be external or internal rotation, and ad- or ab- 
 duction of the upi^er arm, according as to which of the muscles attached 
 to the scapula are most actively excited when this bone is jarred by 
 tapping at a spot where it is bare save of periosteum and skin. 
 
 A reflex must be fairly constant and discernible in the normal subject 
 to give much significance to its alterations, particularly to its absence. 
 Many reflexes are of minor clinical importance because they are present 
 in only a small percentage of normal subjects and then are not pronounced, 
 the ulnar for instance. Reflexes of the lower extremity are on the whole 
 more important than those of the upper, and the knee-jerk is preeminent 
 in this respect. 
 
 The reflexes of the upper extremity being inconstant, absence of any 
 one of them signifies little; exaggeration of one has a certain value; and 
 even the marked presence of a number of them in a patient has something 
 of the import of exaggeration of other reflexes. 
 
 Knee=jerk or Patellar Tendon Reflex. — To elicit the knee-jerk the 
 leg is rendered passive by crossing the knee over its fellow, or by 
 supporting it on the examiner's forearm passed under the patient's knee 
 and braced by the hand placed upon the other knee, or by having 
 the patient while recumbent draw up his knee into an easj^ position 
 with all muscular tension on his part withdrawn; the patellar tendon well 
 below the knee-cap is then struck a firm, quick blow with the ulnar edge 
 of the hand or with a percussion hammer. 
 
 The knee-jerk should never be declared absent until Jendrassik's 
 method of reinforcement has confirmed the result. This is applied by 
 directing the patient to hook his hands together and to keep them so while 
 tugging at them as if to pull them apart. It is customary for the examiner 
 to count "one, two, three" after instructing the patient to "pull hard" 
 at "three," the tap on the tendon being made at about "four." 
 
 The signs + for increased and — for diminished knee-jerks are com- 
 monly employed; and, in writing, " kj " for the reflex itself is allowable. 
 
 The knee-jerk being due to contraction of the quadriceps cruris 
 muscle, the essential phenomenon may be induced by tapping the 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 333 
 
 muscle itself just above the patella, especially if the latter is pressed 
 downward by a finger laid along the upper edge of the bone and this 
 finger is then tapped with the hammer. 
 
 Fig. 133. — Method of testing patellar reflex. 
 
 Fig. 134. — Achilles tendon reflex. 
 
 Babinski Reflex. — In testing for the Babinski reflex the examiner 
 supports the patient's ankle with his left hand and strokes the sole of the 
 
 Fig. 13.5. — Plantar flexion. 
 
 foot with any object which makes a distinct sensory impression — a some- 
 what sharp point being necessary when the skin is thick — at the same time 
 noting the movement of the toes, which in all normal persons past the age 
 
334 MEDICAL DIAGNOSIS. 
 
 of infancy is plantar flexion. Extension (dorsifiexion) of the toes, partic- 
 ularly of the big toe, elicited in this way constitutes the Babinski reflex, 
 which is a most impoitant sign of involvement of the pyramidal tracts. 
 
 i-iG. 130. — BabiiisKi reliex (dorsiflexion of the toes). 
 
 Ankle Clonus. — This phenomenon usually accompanies a considera- 
 bly increased knee-jerk, and has a similar significance. To test for it. the 
 v.-hole leg should be relaxed — best by having the patient supine. The 
 
 Fig (37. — Biceps reflex. 
 
 examiner's left hand supports the leg, and his right, clasping the 
 patient's foot, presses it upward, when, if clonus is present, the foot is 
 pushed back against the hand in a series of jerks which are due to clonic 
 spasm of the (soleus) muscle. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 335 
 
 Achilles Jerk. — A single reflex-contraction of the calf muscle may be 
 induced by tapping the tendon, which the examiner has rendered tense by 
 pressing the foot upward. This reflex is called the Achilles jerk and is an 
 index of the condition of the sciatic nerve and corresponding segments 
 of the spinal cord. It is best obtained by having the patient kneel upon a 
 chair while the examiner taps the Achilles tendon. 
 
 The Abdominal Reflex. — This reflex, quite a constant one, is elicited 
 by stroking the side of the abdomen. The ensuing contraction is wide- 
 spread over tliis region. 
 
 The Cremasteric or Inguinal Reflex consists in a drawing-up of the 
 scrotum and testicle on stroking the inside of the thigh. 
 
 The Epigastric Reflex. — On stroking along the costal margin the 
 muscles over the pit of the stomach contract. 
 
 Fig. 138. — Triceps reflex. 
 
 Among the i-eflexes of the upper extremity, the Radial — ^a periosteal 
 reflex — is elicited by tapping above the styloid process of the radius, and 
 consists mainly in flexion at the elbow-joint. The nearly identical motion 
 of the Biceps Reflex arises when the tendon of this muscle is tapped at the 
 bend of the elbow. In testing the last two reflexes the examiner places 
 his forearm under that of the patient, in order to relax the latter. 
 
 To elicit the Triceps Reflex the patient's upper arm is given a fixed 
 support on the examiner's wrist or on a chair-back, when tapping above the 
 olecranon causes an outward jerk of the forearm. 
 
 Plantar Reflex. — Produced by tickling the sole of the foot. It consists, 
 when fully developed, of sudden withdrawal of the foot by flexion at the 
 hip and knee, dorsal flexion of the ankle and plantar flexion of the toes. 
 The movement in undeveloped cases may consist of sudden plantar flexion 
 of the toes. It occurs in normal conditions, but in varying degrees. There 
 are those who have the power to voluntarily prevent it. This reflex is 
 exaggerated in neurasthenia, hysteria and other functional diseases of the 
 nervous system, and may be associated in extreme cases with general 
 
336 MEDICAL DIAGNOSIS. 
 
 convulsive movements or may be crossed, — that is, it may occur not only 
 on the side tickled but also upon the opposite side. It is also increased, 
 but usually to a moderate extent only, in organic disease of the central 
 nervous system. It is as a rule abolished in the affected side in hemiplegia 
 and invariably absent in destructive lesions involving the sensory nerves 
 of the legs. 
 
 Other reflexes of minor clinical importance are: 
 
 The Supra=orbital Reflex. — Produced by a sharp tap upon the trunk 
 of the supra-orbital nerve, it consists of slight, momentary contractions of 
 the orbicularis palpebrarum, especially in its external half. It is absent in 
 destructive lesions of the supra-orbital nerve and in peripheral facial palsy. 
 
 The Malar Reflex. — Not usually present in normal conditions, but 
 caused in recent facial paralysis of peripheral origin by percussion over 
 the malar bone. It consists of contraction of the elevator of the angle of 
 •the mouth and movements of the ala nasi. 
 
 Fig. 139. — Paradoxical reflex. 
 
 The Chin Reflex. — This phenomenon is ehcited by tapping upon a 
 small flat object, as an ivory paper cutter or a tongue depressor, laid upon 
 the lower front teeth, or the finger laid upon the protuberance of the chin 
 when the mouth is open and the jaw relaxed and drooping. The response 
 consists in a sharp upward movement of the jaw. It may be present in 
 nervous conditions, as hysteria, and in cachectic states. 
 
 The Femoral Reflex. — This phenomenon does not occur in health. 
 It is produced in transverse lesions of the spinal cord above the level of the 
 eighth dorsal segment by irritation of the anterior surface of the upper 
 part of the thigh, and consists in plantar flexion of the toes and extension 
 of the foot. 
 
 Sinkler's Toe Reflex. — This reflex is produced by sudden forcible 
 flexion of the great toe. It consists in forcible flexion of the knee and hip 
 and is met with in spastic conditions arising in spinal disease, as spastic 
 paraplegia. 
 
 Qowers's Front Tap. — The leg being slightly flexed, a blow is struck 
 upon the tibiahs anticus muscle. Plantar flexion of the toes occurs in a 
 considerable proportion of normal persons, many neurasthenic and hysteri- 
 cal individuals, and not at all in tabes. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 337 
 
 Paradoxical Reflex. — This phenomenon is caused by sudden short- 
 ening of the tendon. It is elicited by deep pressure upon the calf muscles 
 and consists in extension — dorsifiexion — of the toes, especially the great 
 toe. It is regarded as a sign of irritation or early organic affection of the 
 motor pathway. 
 
 Oppenheimer's Reflex. — Dorsifiexion of the toes and foot upon 
 forcibly stroking the skin along the inner border of the tibia. 
 
 Pfliiger's Laws. — 1. The reflex occurs upon the same side of the body 
 as that to which the irritant is applied and in muscles whose motor nerves 
 arise from the same segments of the cord. 
 
 2. If the reflex occurs on the opposite side, only the corresponding 
 muscles contract. 
 
 3. If the reflexes are unequal on the two sides, the stronger are on the 
 side upon which the irritation has been applied. 
 
 Fic;. 140.— Oppenheimer's reflex. 
 
 4. When the reflex extends to other segments the direction of the 
 extension is toward the medulla. 
 
 5. All the muscles of the body may yield reflexes. 
 
 7. Electrodiagnosis. 
 
 For diagnostic purposes the galvanic battery is more important than 
 the faradic; but each gives considerable information as to the cause and 
 character of motor paralysis or the variety of muscular atrophy present, 
 and the prognosis in paralysis and atrophy of certain kinds. 
 
 The electrodes, covered with absorbent cotton and wetted, are placed 
 upon the patient's bare skin, one at some "indifferent" point, as the back 
 of the neck, the other upon the part to be examined — motor point of the 
 muscles or the nerve-trunks. With a faradic current thus appUed, on 
 opening the circuit a quick contraction of the muscles ensues in the region 
 of the distal electrode, whether this be positive (the anode) or negative 
 (the cathode) ; but if the interruptions are rapidly repeated the muscle is 
 thrown into a tetanic state. If these muscles be the seat of paralysis from 
 lesion of the inferior motor neuron — poliomyelitis, neuritis, etc. — or if 
 they be atrophied, their response to the faradic current is diminished in a 
 degree which, after some experience; can be estimated by the examiner. 
 22 
 
338 
 
 MEDICAL DIAGNOSIS. 
 
 Fig. 141. — Motor points. 1, frontalis; 2, corrugator pupercilli; 3 
 nasal muscles; 5, levator labii superioris; 6, zygornaticus major 
 
 orbicularis palpebrarum; 4, 
 
 ,uo ...c., aris oris; 8, lower branch of 
 
 ferioris; 11, depressor anguli oris; 12 platysnja; 
 
 facial; 9, depressor labii inferioris; 10, levator labii infenons; 11, depress9r anguii o"^' i^/^J^'X 18 
 13, sternohyoid; 14, omohyoid; 15, sternothyroid; 16, temporalis; 17. .^"^1 "f ve "pper ^Dra"^.' if' 
 facial nerve, middle branch; 19, facial nerve, lower branch; 20, occipitalis; 21, retrahens aurem, 22, 
 facial trunk; 23, posterior auricular nerve; 24, masseter; 25. spinal accessory "f^ve, ,^t). sp'enms, //, 
 hypoglossal nerve; 28, sternocleidomastoid; 29, trapezius; 30, phrenic nerve; 31, Erb=. point (dertoia 
 
 hypoglossal nerve; zs, s^ernocleluuIIla^Lulu, -c, uii^jjc^iuo, ^^•, h"'— -;"—•-'.--■-.... -oo ^irnumflpx 
 biceps, brachialis anticus, supinator longus); 32, anterior thoracic nerve (pectoralis major) 33 circumHex 
 
 nerve.'Cdeltoid); 34, long thoracic "-- ^f '-f.^- --^-g^.-)-, ^itis^muf do^ ^'^-^a ">^<'-- ^hdZinil 
 (nervi intercostales abdominales); 37, .serratus magnus, .i>s, latissimus uorsi, 
 externus (nervi intercosta es abdominales); 40, transversus abdominis. 
 
 39, obliquus abdominis 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 339 
 
 This diminution of faradic contractility serves as an early index of the 
 extent of paralysis and atrophy which is likely to appear in acute anterior 
 
 
 \ y~ 
 
 31 
 
 — 32 
 
 Fig. 142. — Motor points 1, musculocutaneus; 2, caput interims m. tricipitis; 3, n. musculocu- 
 taneus; 4, biceps; 5, medianus; C, brachialis internus; 7, n. ulnaris; 8, rami n. median! pro m. pronatore 
 radii terete; 9, paimaris longus; 10, radialis internus; 11, ulnaris internus; 12, flexor digitorum pro- 
 fundus; 13, flexor digitorum sublimis; 14, flexor digitorum sublimis (digitt. 11 et III); 15, n. ulnaris; 
 16, flexor digitorum sublimis (digitt. indicis et minim.); 17, flexor pollicis longus; 18, medianus; 19, 
 abductor pollicis brevis; 20, rami volar, prof, nervi ulnaris; 21, paimaris brevis; 22, abductor digiti 
 minimi; 23, flexor digiti minimi; 24, opponens digiti minimi; 25, lumbricales II, HI et IV; 26, opponens 
 pollicis; 27, flexor pollicis brevis; 28, adductor pollicis; 29, lumbricalis I; 30, caput externus m. tncipitis; 
 31, n. radialis; 32, brachialis internus; 33, supinator longus; 34, radialis externus longus; 35, radialis 
 externus brevis; 36, extensor digitorum communis; 37, ulnaris internus; 38, extensor digiti minimi 
 proprius; 39, extensor indicis proprius; 40, extensor indicis prop, et abductor pollicis longus- 41, abduc- 
 tor pollicis longus; 42, extensor pollicis brevis; 43, extensor pollicis longus; 44, flexor pollicis longus; 
 45, interosseus dorsalis I; 46, abductor digiti minimi; 47, interosseus dorsalis IV; 48, mterosseus 
 dorsalis III; 49, interosseus dorsalis II. 
 
 poliomyelitis, in Bell's palsy, or other disease inducing rapid degeneration 
 of muscles; but at the end of two weeks from the onset in these affections 
 there is commonly no response whatever to faradism. 
 
340 
 
 MEDICAL DIAGNOSIS. 
 
 On the other hand, if the galvanic current be applied as described 
 above over paralyzed or atrophied muscles the contractility is found to be 
 at first increased; that is, galvanic hyperexcitability is a sign of muscle 
 
 34 
 
 19_ 
 
 37 
 
 Fig. 143. — Motor points. 1, anterior crural nerve; 2, tensor fasciae latee; 3, sartorius; 4, obturator 
 nerve; 5, pectineus; 6, quadriceps (comnaon point); 7, rectus femoris; 8, adductor longus; 9, adductor 
 magnus; 10, gracilis; 11, crureus; 12, vastus externus; 13, vastus internus; 14, external popliteal 
 nerve; 1.5, peroneus longus; 16, extensor longus digitorum; 17, tibialis anticus; 18, peroneus brevis; 
 19, extensor hallucis longus; 20, extensor brevis digitorum; 21, dorsal interossei; 22, gluteus maximus; 
 23, adductor magnus; 24, sciatic nerve; 25, semitendinosus; 26, gracilis; 27, biceps (long head); 28, 
 semimembranosus; 29, biceps (short head); 30, internal popliteal nerve; 31, external popliteal nerve; 
 32, gastrocnemius (outer head); 33, gastrocnemius (inner head); 34, soleus; 35, flexor longus digitorum; 
 36, flexor longus hallucis; 37, posterior tibial nerve. 
 
 degeneration. Later it diminishes. Contraction of the muscles under the 
 galvanic current is only momentary, appearing both on closing and on 
 opening the circuit. The various responses of the normal muscle are as 
 follows: To the negative pole, or cathode, the first or most active response 
 is on closing the jircuit, which is expressed thus, C.C.C. On opening the 
 
EXAMINATION OF THE NERVOUS SYSTEM. 341 
 
 circuit there is no response, C.O.C. To the positive pole, or anode, a 
 response not so active as to the cathode is obtained on closing the circuit, 
 A.C.C., and occasionally a response is also obtained on opening the circuit, 
 especially if the pole is held on the trunk of a motor nerve, A.O.C. These 
 two responses to the anode may be about equal, but usually the response 
 at closure is greater than at opening, and neither is as active as the response 
 to the closure of the cathode. Thus the normal formula stands as follows: 
 
 C.C.C. > A.C.C. > or = A.O.C. > C.O.C. 
 
 This formula represents what we find practically at the bedside. 
 There are some distinctions between the responses to nerve-tissue on the 
 one hand and muscle-tissue on the other, as observed in laboratory experi- 
 ments on animals; but these need not detain and confuse us here. 
 
 Reaction of Degeneration — R.Q. — When a muscle is degenerating — 
 for instance, when it is cut off from its nerve supply either by injury or 
 disease (nerve injuries, neuritis, acute anterior poliomyelitis) — the reactions 
 to galvanism are altered. The anodal closure contraction becomes greater 
 than the cathodal closure contraction, A.C.C. > C.C.C, although both are 
 diminished as compared with those of the normal muscle. At the same time 
 the anodal opening contraction (never very conspicuous) disappears, and very 
 rarely the cathodal opening contraction is seen. Thus the typical reaction 
 of degeneration is as follows: A.C.C. > C.C.C. (C.O.C. sometimes seen, A. 
 O.C. disappearing). The response of degenerating muscle is sluggish, not 
 quick and active, 
 
 8. Trophic Disturbances. 
 
 In a broad sense all disease is nutritional disorder; but there are some 
 diseases which directly attack the nervous structures presiding over nutri- 
 tion of related parts of the body, and these are properly "trophic diseases." 
 The nutritional disorder may be the principal manifestation of the disease, 
 as is indeed recognized in the very name of the group of muscular atrophies. 
 Whether or not there be separate trophic nerve-fibres, we know that for 
 the muscles the trophic impulses traverse the motor nerves chiefly. If 
 motor palsy is accompanied by rapid wasting, the lesion is probably in the 
 gray matter (of the cord, oblongata, etc.) or in the peripheral nerves, 
 since they, comprising the lower motor neurons, preside over nutrition 
 most directly. But slow wasting may affect parts paralyzed by cerebral 
 disease (upper motor neurons), the affected side in old hemiplegia being 
 commonly much atrophied. This is ascribed to involvement of trophic 
 centres in the cortex. While the spastic spinal palsies arise from disease 
 of superior motor neurons — pyramidal tracts — they often manifest 
 atrophy which may be similar in all respects to that of chronic poliomye- 
 Htis — ordinary progressive muscular atrophy. In such cases there is no 
 physiological paradox: the atrophy is referable to implication of the gray 
 matter of the cord. Primary lateral sclerosis is practically always accom- 
 panied by atrophy, distributed as in poliomyelitis, which implies that the 
 two motor neurons— superior and inferior — are perhaps independently, 
 though simultaneously, involved, and bulbar palsy is frequently included 
 in the clinical picture. It is well, therefore, to conceive of chronic polio- 
 
342 MEDICAL DIAGNOSIS. 
 
 myelitis, lateral sclerosis, amyotrophic lateral sclerosis and bulbar palsy 
 as constituting one disease, of which a particular symptom — atrophy, 
 etc. — is dominant in each of the types named. 
 
 The distribution of muscular atrophy has considerable significance, 
 especially the region of the body in which it first appears. Atrophy begin- 
 ning in the small muscles of the hand, or in the shoulder, is generally pro- 
 gressive — spinal — muscular atrophy. 
 
 In the "family type" of spinal atrophy appearing in infancy, the 
 muscles of the legs and back are the first to show wasting. The myopathies 
 or muscular dystrophies are likely to appear first in the pelvic girdle (leg 
 type), in the shoulder girdle (arm type), or in the face (face type). When 
 atrophy occurs in the foot and outer lower leg — peroneal muscles — the 
 so-called primary neuritic atrophy is to be considered. 
 
 The cardinal tests of spinal, as distinguished from idiomuscular, atro- 
 phies are the electrical reaction of degeneration and fibrillary twitching, 
 both present in the former, and absent in the latter or myopathies. 
 
 Fig. 144. — l^ed-.^ore-J. — German Hospital. 
 
 The muscles above or below a diseased joint often waste. This is 
 called " arthritic atrophy," and is explained as a reflex phenomenon set 
 up by irritation of sensory nerves supplying the joint. 
 
 The clinician must discriminate between the atrophy from disuse or 
 from joint disease, and that which is the essential manifestation of 
 certain grave nervous diseases; and he does so mainly by considering 
 the correlated symptoms and signs. 
 
 Certain diseases are presumably, though not manifestly, trophic in 
 origin; as arthritis deformans. Others, such as acromegaly, myxoedema, 
 and adiposis dolorosa, result from disease of ductless glands — pituitary 
 body, thyroid — through the medium of the trophic nervous apparatus, 
 which is affected by the absence or derangement of the secretions of these 
 glands. These diseases — characterized respectively by gross enlargement 
 of hands, feet, and face; by thickened, doughy skin; by great masses of 
 painful fat — illustrate trophic excess, hypertrophy, and hyperplasia. 
 
 Still another group of affections, pathologically obscure and clinically 
 indefinite, illustrate trophic disease arising through the medium of vaso- 
 motor derangement. These comprise angioneurotic oedema, acroparaes- 
 thesia, Raynaud's disease, erythromelalgia, and perhaps other diseases. 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 343 
 
 A variety of local affections occur however as incidents, more or less 
 important, in the course of organic nervous diseases, and constitute trophic 
 manifestations of these diseases, just as paralysis and anaesthesia constitute 
 
 Fig. 145. — Ataxic elbow-joint. — Young 
 
 their motor and sensory manifestations. These trophic disturbances some- 
 times resemble independent affections and the nervous diseases underlying 
 them may thus be overlooked, for instance, bed-sores in emaciation or 
 sprains in Charcot joints. A joint affection, especially if it be subacute or 
 
 Fig. 14f). — Pprforatinp: ulcers of the foot. — German Hospital. 
 
 chronic and confined to one oi- two joints, is often of nervous origin. In 
 acute myehtis inflammatory arthropathies; resembling rheumatism, may 
 arise. In old hemiplegia — on the paralyzed side — and in various chronic 
 cord-diseases, an osteo-arthritis is not uncommon. The classic form is 
 the Charcot joint, which occurs most frequently early in the course of 
 
344 MEDICAL DIAGNOSIS. 
 
 tabes dorsalis. The arthropathy of syringomyelia often affects the spine, 
 inducing scohosis. Painless whitlows of fingers or toes call for study of 
 sensation in these parts, for if they betray loss of temperature and pain 
 sensibility, we are dealing with "Morvan's disease," a trophic manifesta- 
 tion of syringomyelia. Painless perforating ulcer of an extremity, often 
 on the ball of the foot or great toe, belongs commonly to tabes dorsalis or 
 to syringomyelia. Bed-sores form usually at spots injured, especially over 
 the sacrum from pressure of the bed, but the extent of the ulceration is 
 ordinarily out of proportion to the apparent cause. Moreover, sloughs do 
 form without external cause, from purely trophic defect. The skin shows 
 changes in various nervous diseases, as do the nails, hair and other 
 structures histologically allied to the skin. '' Glossy skin," — shiny, thin, 
 dry epidermis on the extremities, — results from neuritis of somewhat long 
 duration. The vesicles of herpes zoster are a trophic manifestation of 
 neuritis, most frequently intercostal. 
 
 9. Pain and Temperature. 
 
 In ordinary anaesthesia, as that of neuritis or of tabes dorsalis, loss of 
 sensibility to pain, and to heat and cold, is associated with the loss of 
 touch sense. The nerves and dorsal roots, the seat of these diseases, con- 
 tain the fibres for all forms of sensation. 
 
 There is a remarkable condition, however, in which a patient, though 
 feeling himself touched by an object — touch sensation preserved — cannot 
 tell whether it is hot or cold — temperature sense lost — or whether it is 
 sharp or dull — pain sense lost. This separate sensory loss is called disso- 
 ciated ancesthesia. It is in the root-zone that the pain and temperature 
 fibres part company with all others to enter the gray matter and sweep 
 across by way of the commissure to the opposite margin of the cord. 
 
 In the neighborhood of the central canal — central gray matter — the 
 pain and temperature fibres from one side decussate with those from 
 the opposite side in a narrow space, and a small lesion at this point, 
 sparing the dorsal columns, may cause dissociate anaesthesia. The lesion 
 that most often occoirs here is a peculiar tumor that forms by prolifera- 
 tion of neuroglia just back of the central canal. 
 
 When proliferated rapidly neuroglia forms a soft mass. In the brain 
 where its commonest seat is deep in the cerebellum, it meets equal pres- 
 sure on all sides and so becomes globular — glioma; but in the cord the 
 line of least resistance is up and down, and the gliomatous tissue forms a 
 rod along the centre of the cord. Neuroglia tumors tend to break down 
 centrally. Glioma of the brain is thus commonly cystic, and gliosis of the 
 cord when advanced is characterized by cavity formation within it, by 
 which the cord is finally converted into a tube. From this circumstance 
 the entire disease-process gets its name syringomyelia. 
 
 Dissociated anaesthesia may result from tumor, hemorrhage in the cen- 
 tral gray matter, but it is so" early and so constant in gliomatosis that it 
 is commonly spoken of as syringomyelic dissociation. 
 
 As the neuroglia mass spreads it causes various symptoms, most com- 
 monly those of progressive muscular atrophy because the ventral gray 
 
EXAMINATION OF THE NERVOUS SYSTEM. 345 
 
 horns are slowly invaded. In chronic poliomyelitis it is usually the hands 
 and arms that are atrophied, the cervical and upper thoracic part of 
 the cord being the commonest seat of the gliosis. The pain and tem- 
 perature fibres from each root-zone, having reached the opposite margin 
 of the cord, turn upward to form the column of Gowers. This column 
 is bounded in front by the motor root-zone, behind by an imaginary 
 line passing transversely through the central canal. A lesion such as 
 tumor severing the column of Gowers will cause dissociated anaesthesia 
 below it on the opposite side of the body. Lateral trauma of the spine 
 is likely to sever this column, with a similar result; but practically 
 such a trauma always implicates also the crossed pyramidal tract, causing 
 motor paralysis on the side of the lesion. The combination of motor paral- 
 ysis on one side of the body and sensory paralysis on the opposite side, 
 " Brown-Sequard's paralysis," is pathognomonic of unilateral cord lesion. 
 In Brown-Sequard's paralysis touch sense is usually preserved on both 
 sides of the body, the dorsal columns of the cord escaping. 
 
 10. Muscular Sense. 
 
 Normal coordination depends upon several factors, any one of which 
 being defective, incoordination or ataxia may result. In walking, under 
 normal circumstances, the sensations imparted by the surface control to 
 some extent the movements, and the absence of this control, as in the 
 anaesthesia of tabes, constitutes an element of ataxia. Subconscious sensa- 
 tions from the joints, muscles, skin, fasciae, together with appreciations 
 of weight and balance, enter into the special kind of perception designated 
 the muscular sense — ''sixth sense" of Sir Charles Bell — and defect of this 
 sense is an important factor in most forms of ataxia. It is suppressed 
 at its very source when the nerve-termini in joints and muscles are impli- 
 cated in a peripheral neuritis, and this causes so marked an ataxia that 
 such cases have been designated peripheral pseudotabes. A part of the 
 ataxia in such cases of peripheral neuritis may be due to anaesthesia of 
 the skin. The ataxia of true tabes has, to some extent, this same periph- 
 eral origin, since neuritis is a part of the disease, but it has a more 
 important spinal origin. In the cord many muscular-sense axons pass 
 up the dorsal columns in company with the touch-sense axons, and here 
 they are implicated in tabetic degeneration. Ataxia, by loss of muscular 
 sense and by anaesthesia combined, is a constant symptom of lesion of 
 the dorsal columns. 
 
 Muscular sense is represented in the cerebral cortex posterior to the 
 motor area, being associated with touch sense here as in the cord. These 
 two senses are involved when the hand, unaided, recognizes an object held 
 in it (stereognosis) ; they are especially combined for this purpose in the 
 superior parietal lobule, and loss of this perceptive power — astereognosis — 
 is most commonly due to lesion in that area. 
 
 Muscular sense guides the cerebellum in its chief function, the mainte- 
 nance of equilibrium. Fibres delegated to this function from the root- 
 zone enter the base of the dorsal gray horn and connect with the cell- 
 bodies of Clarke and Stilling which are found in that situation throughout 
 
346 MEDICAL DIAGNOSIS. 
 
 the cord (Gordinier). These cell-bodies are the beginning of superior 
 muscular-sense neurons; their axons sweep outward to the margin of the 
 cord and turn upward in the direct cerebellar tract, the terminus of 
 which is the middle lobe — vermis — of the cerebellum, which it reaches 
 by way of the inferior cerebellar peduncle — restiform body. Lesion of 
 this neuron-system, in the cord or in the cerebellum (Barker), causes the 
 defect of equilibration called cerebellar ataxia. 
 
 Assistance in coordination is derived from all the senses, consciously, 
 as when the tabetic watches the ground in walking, and unconsciously, 
 through impulses collected in the cerebellum from the eye, cutaneous sen- 
 sations, the joint and muscle surfaces and the internal ear. Disturbance 
 in one of these sensory organs may cause vertigo. 
 
 The internal ear is virtually two organs, having distinct functions, 
 and the eighth nerve is double accordingly. The semicircular canals of the 
 vestibule are water-levels telling the position of the head, as muscular 
 sense does that of the limbs, and the part of the eighth nerve arising thence 
 called the vestibular nerve is concerned not with hearing but with equili- 
 bration. It connects with its superior neurons in the dorsomesal nucleus 
 to pass to the cerebellum. 
 
 Lesion of any part of the vestibular tract from the internal ear to the 
 cerebellum may cause vertigo, as in Meniere's disease. 
 
 The eighth nerve's division into two js clear as it enters the pons, the 
 two parts being separated by the inferior cerebellar peduncle. The outer or 
 cochlear division is the true nerve of hearing. It enters the ventrolateral 
 nucleus to be continued by fibres that cross the middle line of the pons, 
 forming the trapezoid body, — acoustic decussation (M. Allen Starr), — then 
 pass upward in the lateral fillet, and by way of the postgeminum and post- 
 geniculum reach the auditory centre in the first temporal convolution. 
 
 The Stigmata of Degeneration. 
 
 Degeneration, degeneracy, deviation are terms used to denote in 
 individuals a decline from the average normal condition in physical or 
 moral quahties. This decline varies in degree from deviations from the 
 normal scarcely to be recognized upon the most careful study, to the pos- 
 session of physical and moral defects which render the subject unfit for 
 the ordinary duties and responsibilities of life, and are obvious to the casual 
 observer. It is accompanied by physical, physiological and neuropsychic 
 anomalies known as the ''stigmata of degeneration." An undue impor- 
 tance has doubtless been ascribed to these anomalies and their combina- 
 tions, especially to those of minor degree, by Lombroso and his followers; 
 nevertheless their consideration is of practical value in the study of diseases 
 of the nervous system and has an important bearing upon the diagnosis 
 and prognosis of individual cases of this group of affections. Every sign 
 of deviation from the average normal is not necessarily a stigma of degen- 
 eration, and Walton has suggested that it is desirable " to name the phe- 
 nomena signs of deviation, and call their possessors deviates or a deviate 
 as the case may be, limiting the term degeneration only to such deviations 
 as obviously imply deterioration." 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 347 
 
 Etiological Classification. — Walton has grouped the causes of the 
 so-called stigmata of degeneration, including the signs of deviation only, 
 as follows: 
 
 I. The potential variations from the average normal contained in the 
 parent germ, including the results (a) of atavism, (b) of parental similarity, 
 and (c) of selective tendency on the part of the ancestry. 
 
 II. Intra-uterine infection. 
 
 III. Mechanical injury during intra-uterine life. 
 
 IV. The absence or peculiarity in the germ of certain elements, or 
 their disappearance or anomalous development, without traceable inherited 
 tendency or other known explanation. 
 
 V. Mechanical influence exerted during infancy. 
 
 VI. Deleterious influences and habits in the ancestry, productive of 
 enfeeblement, undersize, and lessened resistance in the progeny but not alter- 
 ing the essential potential characteristics transmitted by the parent germ. 
 
 VII. Absence or hypertrophy of certain glands, pituitary, thyroid, 
 which have a nutritional influence. 
 
 VIII. Arrest of development, such as is seen in harelip and similar 
 defects. 
 
 List of Stigmata. — The following list, compiled from Dana, Church 
 and Peterson, Walton, and others, includes the more important deviations 
 and stigmata. Those which are of minor significance, either alone or in 
 association with others, as indicating actual degeneracy, are placed in 
 middle single columns; those generally recognized as stigmata of degen- 
 eration, in double columns at the sides. 
 
 Anatomical Stigmata. 
 
 Anomalies of the Cranium. 
 
 Cranial asymmetry. 
 
 
 Macrocephalus. 
 
 Microcephalus. 
 
 
 Platycephalus. 
 
 Leptocephalus. 
 
 
 Oxycephalus. 
 
 Plagiocephalus. 
 
 
 Scaphocephalus. 
 
 Trigonocephalus. 
 
 
 Short parietal arc. 
 
 Short frontal arc. 
 
 
 High prominent forehead. 
 
 Anomalies of the Face. 
 
 Heavy jaws. 
 Lemurian hypophysis. 
 Orthognathism. 
 
 
 Prognathism. 
 
 Opisthognathism or retrognar- 
 thism. 
 
 Large frontal sinuses, small 
 
 
 Crania progenia (lower teeth 
 
 orbit. 
 Great or unequal prominence 
 of malar bones. 
 
 
 projecting beyond upper, 
 and inferior maxillary angle 
 obtuse). 
 
 Anomalies of the Eye. 
 
 Narrow palpebral fissure. 
 
 Flecks on the iris. 
 Chromatic asymmetry of the 
 
 Microphthalmus. 
 
 Albinism. 
 
 iris. 
 
 Congenital cataracts. 
 
 Pigmentary retinitis. 
 
 
 Muscular insufficiency, stra- 
 
 
 Hypermetropia. 
 
 bismus. 
 
 Myopia. 
 
 
 Astigmatism. 
 
348 
 
 MEDICAL DIAGNOSIS. 
 
 Deformities of the Palate. 
 
 High and narrow. 
 Torus palatinus. 
 Dome-shaped. 
 Hip-roofed. 
 
 Horseshoe. 
 Gothic arch. 
 Flat-roofed. 
 Asymmetrical. 
 
 Dental Anomalies. 
 
 Badly set and 
 
 badly 
 
 nour- 
 
 
 Small or peg-shaped lateral 
 
 ished. 
 
 
 
 Double rows. 
 Adventitious teeth. 
 Double crown. 
 Macrodontism. 
 
 incisors. 
 
 Microdontism. 
 
 
 
 
 Projecting teeth. 
 
 Badly placed c 
 
 3r misplaced 
 
 
 Striated transversely. 
 
 teeth. 
 
 
 
 
 
 Hutchinson's teeth. 
 
 
 
 
 Anomalies of the Nose. 
 
 Defective development of 
 cartilage and tissue of alse. 
 
 Deviation of nose. 
 
 Absent cartilages. 
 Atresia of nasal fossa. 
 Defective osseous develop- 
 ment. 
 
 Anomalies of the Tongue and Lips. 
 
 Macroglossus. 
 Microglossus. 
 Bifidity of point. 
 Harelip. 
 Cleft palate. 
 
 Anomalies of the Ear. 
 
 
 Excessively long. 
 
 
 
 Excessively prominent. 
 
 
 
 Set too close to the head. 
 
 
 Set too far back. 
 
 
 Set too low. 
 
 Absence of helix, antihelix, or 
 
 
 Obliteration of markings. 
 
 lobule. 
 
 
 
 Absence of fissura intertrag- 
 
 
 Too conchoidal (antihelix, 
 
 ica. 
 
 Excessively large (absolutely 
 
 crura, etc. , too little marked 
 
 
 or relatively). 
 
 and helix like rim of funnel) . 
 
 Too small. 
 
 
 Lack of uniformity in width. 
 
 Asymmetry of the two ears, 
 
 
 
 general anomaly of left 
 
 
 
 (Blainville ear). 
 
 Prominence of antihelix. 
 Adherent lobules. 
 
 
 Anomalies of the Limbs. 
 
 Symphysodactyly or achisto- 
 dactylus (joining of fin- 
 gers). 
 
 Ectrodactyly (fingers want- 
 ing). 
 
 Left arm and leg longer than 
 
 right. 
 Excessive length of arms. 
 Long fingers. 
 Polydactyly. 
 
 Syndactyly (web fingers). 
 
 Amelus or ecromelus (limb 
 wanting). 
 
EXAMINATION OF THE NERVOUS SYSTEM. 
 
 Anomalies of the Limbs. 
 
 349 
 
 Phocomelus (segment of limb 
 wanting) . 
 
 Oligomelus (excessive gracil- 
 
 ity). 
 
 Megalomelus. 
 Megalodactyly, 
 
 Oligodactyly. 
 
 Anomalies of the Trunk and General Structure. 
 
 Hernias, when congenital. 
 
 
 Malformation of breasts and 
 thorax. 
 
 Dwarfism. 
 
 
 Gigantism. 
 
 Infantilism. 
 
 
 
 Masculinism in women. 
 
 Spina bifida. 
 
 Femininism in men. 
 
 Feebleness of construction. 
 
 
 Lordosis. 
 
 Scoliosis. 
 
 
 Kyphosis (Fere). 
 
 Malformed coccyx. 
 
 
 Thoracic asymmetry. 
 
 Mammary development in 
 
 
 Mammary absence or redu- 
 
 males. 
 
 
 plication in females (poly- 
 mastia) . 
 
 Anomalies of the Genital Organs. 
 
 Small or deformed genitalia. 
 
 
 Hermaphrodism. 
 
 Cryptorchismus. 
 
 
 Hypospadias. 
 
 Epispadias. 
 
 
 Defect, or great volume of 
 prepuce. 
 
 Torsion of prepuce. 
 
 
 Imperforate meatus. 
 
 Labia too large or too small. 
 
 
 Clitoris large. 
 
 Labia minora hypertrophied. 
 
 Folds between labia majora 
 and minora. 
 
 Labia minora pigmented, par- 
 ticularly in brunettes. 
 
 
 Imperforate vulva. 
 
 
 Atresia of vagina. 
 
 Double vagina. 
 
 
 Uterus bicornis. 
 
 Atrophic uterus. 
 
 
 
 Muscular Anomalies. 
 
 Dystrophies. 
 
 Depression above glabella due 
 to overaction of corrugators. 
 
 Unequal innervation of facial 
 muscles on the two sides. 
 
 Anomalies of the Skin. 
 
 
 Polysarcia. 
 
 
 
 Hypertrichosis (superfluous 
 
 
 
 hair) . 
 
 
 
 Premature grayness. 
 
 
 
 Precocious and abnormal 
 
 
 
 hairy development. 
 
 
 
 Rudimentary tail. 
 
 
 Glabrous chin (no beard). 
 
 
 Vitiligo. 
 
 Absence of nails or fetal state 
 
 
 Melanism of skin. 
 
 of nails. 
 
 Pigmented or vascular na'vi. 
 
 
 Molluscum. 
 
 Pigmented spots. 
 
 Ichthyosis. 
 
350 
 
 MEDICAL DIAGNOSIS. 
 
 Physiological Stigmata. 
 
 Anomalies of Motor Function. 
 
 Lefthandedness. 
 Retardation of learning to 
 
 walk and talk. 
 Nystagmus (congenital) . 
 
 Tremors. 
 Epilepsy. 
 
 Tics. — Facial spasm, habit 
 chorea, tic convulsif. 
 
 Anomalies of Sensory Function. 
 
 Deaf -mutism. 
 
 Neuralgia. 
 
 Migraine. 
 
 Constitutional headaches. 
 
 
 Hyperaesthesia. 
 
 
 Angesthesia. 
 
 Bhndness. 
 
 Daltonism (color-blindness, 
 
 achromatopsia). 
 Hemeralopia (night-blind- 
 
 
 Nyctalopia (day-blindness) . 
 
 ness) . 
 
 Concentric limitation of visual 
 field. 
 
 Anomalies of Speech. 
 
 Mutism. 
 
 Stammering. 
 Stuttering. 
 
 Defective speech. 
 
 Anomalies of Genito-urinary Function. 
 
 Sexual irritability. 
 
 Sterility. 
 Amenorrhoea. 
 
 Impotence. 
 
 Urinary incontinence. 
 
 Anomalies of Instinct or Appetite. 
 
 Gluttony. 
 Rumination. 
 
 Merycism. 
 
 Uncontrollable appetites (nar- 
 cotics) . 
 
 Retardation of Puberty. 
 
 Deficient Vital Activity of Organic Functions. 
 
 Weak heart. 
 
 Low arterial tension. 
 
 Coldness of extremities. 
 
 Flushing of extremities. 
 
 General chills and flushes. 
 
 Weak digestion. 
 
 Constipation. 
 
 Psychic and Psychoneurotic Stigmata. 
 
 Dementia praecox. 
 Mania depressive. 
 Hysteria. 
 Phobia. 
 Invalid habit. 
 Feeble-mindedness . 
 
 Moral delinquency. 
 Precocity. 
 
 Paranoia. 
 
 Eccentricity. 
 
 Compulsive insanity. 
 Melancholia. 
 Hypochondria. 
 Psychopathic endowment. 
 Idiocy. 
 
 Sexual perversion. 
 Over-development of certain 
 
 aptitudes. 
 Ideo-obsessive constitution. 
 
EXAMINATION OF THE EYE. 
 
 351 
 
 X. 
 
 THE EXAMINATION OF THE EYE. 
 
 General Considerations. 
 
 The close relationship existing between the eye and the nervous 
 system, the opportunities furnished by the fundus of the eye to study 
 changes in the general circulatory system, and the knowledge that disturb- 
 ances of ocular function are not infrequently the underlying cause of 
 systemic affections, render a study of the ocular apparatus of extreme 
 importance in the diagnosis of general disease. 
 
 It must be remembered that, while the eye is the organ of sight, with 
 its own special function, it is also a part of the general organism, is influ- 
 enced by the status of the whole body, is disturbed with the disturbance 
 of other structures, and exhibits in a marked degree affections of other 
 organs by which its function is interfered with. 
 
 The importance of the thorough analysis of the ocular comphcations in 
 all diseases, particularly in affections of the brain and spinal cord, is well rec- 
 ognized. An examination of this character, to be effective, must be systema- 
 tized in order to determine the actual conditions underlying an affection of 
 which the eyes furnish the chief manifestation; in what respect, if any, the 
 ocular functions are abnormal; and finally, the true inference to be drawn 
 from these disturbed functions in the diagnosis of systemic affections. 
 
 1. Inspection: The position of the eyeballs in relation to the orbital 
 bones is observed to determine any undue prominence or recession of one 
 or of both eyes; any abnormality of the eyelids as evidenced by tumors, 
 general swelling, drooping, inability to close the lids, inverted margins, 
 size of the commissure, and the presence of crusts or secretions on the 
 margins; congestion of the blood-vessels, or granulations or new growths 
 on the conjunctiva; the size, response to light stimuli, and equality or 
 inequality of the pupils, and variations in the color of the irides; deviation 
 of the visual axes, or involuntary 
 movement of the eyeballs; the sensi- 
 bility of the cornea or its loss of 
 transparency; and the depth of the 
 anterior chamber and any turbidity 
 of its fluid contents. 
 
 The anterior segment of the 
 eyeball is most satisfactorily studied 
 by oblique illu7nination. The patient 
 is placed about two feet from the 
 source of illumination. The exam- 
 iner focusses the light upon the 
 cornea with a convex lens of 2-inch or 3-inch focus held between the thumb 
 and forefinger of the right hand, and studies the illuminated area through 
 another lens of similar strength held between the thumb and forefinger of the 
 
 Fig. 147 
 
 -Ob'ique or focal illumination. - 
 Hausell and Sweet. 
 
 -From 
 
352 
 
 MEDICAL DIAGNOSIS. 
 
 left hand, the second finger raises the upper hd, and the little finger resting 
 upon the forehead steadies the hand. The distance of the second lens from 
 the eye is varied slightly to bring into focus the cornea, iris, and crystalline 
 lens. Opacities of the cornea or lens, as seen by oblique illumination, 
 appear as gray or white spots upon the black background of the pupil. 
 
 2. Vision: Decrease in the normal acuteness of vision of each eye 
 as measured by test letters for near and far is to be noted; the history of 
 the decline, and its association with pain or inflammation of the external 
 structures; any departure from the normal field of vision must be recorded; 
 contraction of the peripheral limits for form and color, areas of deficient or 
 lost perception, and reversal in the order of the color fields. 
 
 3. Ophthalmoscopic Examination: Two methods are employed in 
 the examination of the deeper structures of the eye by the ophthalmo- 
 scope — the Direct Method, which gives an upright image of the eyeground, 
 
 and the Indirect, in which the image 
 is inverted. In both the patient is 
 seated in a darkened room with his 
 back to the source of illumination, 
 and the observer is to the side to 
 be examined. B}" the direct method 
 the examiner approaches close to the 
 side of the patient's head, using his 
 eye corresponding to the eye under 
 examination, and reflects the light 
 by means of the ophthalmoscopic 
 mirror into the eye. The rays from 
 the fundus are reflected back, and, 
 passing through the opening in the 
 mirror enter the observer's eye, giv- 
 ing an upright image of the eyeground. The optic nerve is best seen 
 when the patient looks at a distant object to the side and beyond the 
 observer's head. The fovea! region is brought into view when the patient's 
 gaze is directed into the aperture of the mirror. By the indirect method 
 the observer, about 15 to 20 inches in front and to the side of the patient, 
 reflects the light through a convex lens of about 2-inch focus held at 
 its focal length from the eye, and secures an aerial image focussed by 
 the strong glass. In case the details of the fundus are not at first plainly 
 seen the object lens is slightly advanced or withdrawn from the eye. 
 Strain on the examiner's accommodation is reheved by a +4 D. lens 
 rotated before the sight-hole of the ophthalmoscope. 
 
 The normal eye presents many variations from the typically pictured 
 fundus, and extended experience is necessary to distinguish the variations in 
 health from the changes wrought by disease. The color of the fundus reflex is 
 a bright pink or red, due to the reflected light from the choroidal vessels and 
 the pigment of the retina and choroid. In the negTO the reflex is grayish, be- 
 cause of the absorption of the light rays by the abundant pigment. The optic 
 disk, or nerve head, lies to the nasal side of the posterior pole, and is round or 
 oval, with clear cut edges, often fringed with choroidal pigment. The nerve 
 is often cupped in the centre, at which point the central artery and vein 
 
 Pig. 148. — Ophthalmoscopic examination by direct 
 method. — From Hansell and Sweet. 
 
PLATE VIII. 
 
 [Varieties of the Normal Fundus.— After Wurdemann in Posey and Spiller. 
 A, alblnotic fundus; albino and light blonde (after Greef, modified by Wiirdemann) . B, the 
 tessellated fundus; brunette (after Greef, modified by Wurdemann). C, the negroid fundus ; negro 
 (Wiirdemann). D, the yellow fundus ; Chinese (after Oeller, modified by Wurdemann.— DJ . 
 
EXAMINATION OF THE EYE. 
 
 353 
 
 pass. The artery and vein divide into two main branches, and these sub- 
 divide into the numerous smaller vessels. The fovea, with its central 
 yellow spot, is the most sensitive part of the retina. It is about 3 mm. 
 to the temporal side of the nerve, and is darker than the rest -of the retina. 
 In this region no blood-vessels are to be seen by the ophthalmoscope. 
 
 4. Pain: The character of the pain should be known, its situation, its 
 dependence on the use of the eyes, and its association with tenderness in 
 the region of the orbit, particularly at the points of exit of the supra-orbital 
 or infra-orbital nerves. 
 
 5. Headache is one of the most prominent symptoms of eyestrain. It 
 is dull and heavy, usually bilateral, increased by application to close work, 
 riding in cars and shopping, and sometimes accompanied by pain in the eye- 
 balls. It is to be distinguished from the sharp periodic attacks of pain 
 characteristic of neuralgia of the first and second divisions of the 5th nerve. 
 
 Affections of the nasal tissues, as deflections of the septum and 
 purulent collections in the frontal sinus, cause headache which resem- 
 bles that of eyestrain. The diag- 
 nosis of nasal and sinus headache 
 is made by its longer duration, its 
 association with manifest symptoms 
 of nasal trouble, and its independ 
 ence of use of the eyes. 
 
 Asthenopia from general 
 muscle weakness is present during 
 convalescence from acute fevers or 
 prolonged illnesses, and attempts at 
 reading are often followed by head- 
 ache, blurring of sight, and pain in 
 
 the eyes and head. DeSchweinitz refers to a peculiar form of asthenopia seen 
 after the presbyopic age, most frequently in women, which is not relieved 
 by glasses or treatment of muscular anomalies. These patients present 
 the ordinary symptoms of neurasthenia, doubtless the outcome of begin- 
 ning arteriosclerosis, and proper tests usually show high arterial tension, 
 which, if reduced by appropriate dietetic and medicinal measures, will 
 cause a disappearance of the asthenopia. 
 
 6. Photophobia is a symptom of affections of the cornea and iris, 
 of a few diseases of the retina, and in many cases of uncorrected refractive 
 errors and muscular anomalies. As an isolated symptom it possesses 
 little importance in arriving at a differential diagnosis of ocular affections. 
 
 7. Epiphora: Increase in the flow of tears is seen in exophthalmic 
 goitre, in certain affections of the central nervous system (locomotor 
 ataxia), and in obstruction of the lachrymal duct. 
 
 Fig. 149. — Ophthalmoscopic examination by indirect 
 method. — From Hansell and Sweet. 
 
 The Eyeball and Orbit. 
 
 Protrusion of the eyeball — exophthalmos, proptosis — may be caused 
 by tumors, aneurisms, hemorrhage, exostoses, and growths or inflamma- 
 tions originating in or extending to the orbit from the adjacent sinuses; 
 by orbital cellulitis and paralysis of the ocular muscles. 
 23 
 
354 MEDICAL DIAGNOSIS. 
 
 Bilateral exophthalmos, varying from a slight prominence of the 
 eyeballs to a protrusion that prevents the closure of the eyelids, is found 
 in exophthalmic goitre. Widening of the palpebral fissure from nervous 
 affections, with undue exposure of the sclera, will give the impression 
 of exophthalmos. 
 
 Proptosis associated with deep-seated pain upon attempts to move 
 the eyeball, hmited or complete immobility of the globe, and swelling 
 and oedema of the eyelids, which may be so great as to prevent opening 
 of the Uds, is found in orbital celluhtis, facial erysipelas, meningitis, in 
 general septicaemia, or, in less degree, after scarlatina, typhoid fever, and 
 influenza. Purulent inflammation of the adjacent sinuses may lead to 
 the same symptoms. 
 
 Sudden exophthalmos in infants, with the eyeballs turned down, 
 points to the possibility of the existence of scurvy. The protrusion may 
 be moderate at first and increase during 24 hours and be associated at its 
 height with thickening and ecchymosis of the upper lid. The subperi- 
 osteal hemorrhage to which the affection is due may affect both orbits, 
 but unequally. The eyeball is freely movable. 
 
 Pulsating exophthalmos, usually unilateral, most frequently follows 
 traumatism, and is found in arteriovenous aneurism of the internal carotid 
 and cavernous sinus or aneurism of the ophthalmic artery. 
 
 Abscess of the frontal sinus may cause displacement of the eyeball 
 downwards and outwards, with diplopia. In purulent disease of the frontal 
 and ethmoidal sinuses a small fluctuating swelhng may appear at the 
 upper and inner angle of the orbit, which breaks and discharges pus. 
 Gradual displacement of the eyeball forward may be the result of an orbital 
 tumor within the cone of muscles. 
 
 Exophthalmic Goitre. — One of the earlier signs is lagging of the upper 
 lid when the eyes are slowly rotated downwards (Graefe's sign). There is 
 also imperfect power of winking (Stellwag's sign); retraction of the upper 
 lid and widening of the palpebral fissure (Dalrymple's sign), and imperfect 
 power of convergence of the eyes. 
 
 Involuntary resistance to eversion of the upper eyelids is believed 
 by Gifford to be one of the earhest symptoms of Graves's disease. It tends 
 to disappear with the development of the disease, and is explained by 
 hyperexcitability of Miiller's muscle through the sympathetic. Gifford 
 also attaches importance to swelling of the tissues between the eyebrow 
 and eyelid as an early diagnostic sign of the disease. 
 
 Retraction of Eyeball. — Enophthalmus, or sinking of the eye into 
 the orbit, occurs in some instances in extreme emaciation from absorption 
 of orbital fat, in paralysis of the sympathetic, in facial hemiatrophy, and 
 from traumatism. Since the amount of exposed sclera determines the 
 apparent recession of the globe, the examiner may be misled into mistak- 
 ing the widened commissure of tabes or other nerve disease for enophthal- 
 mus. Traumatism in the vicinity of the orbit is sometimes followed by 
 an actual enophthalmus, which may be immediate, or be delayed for several 
 weeks or months. 
 
 Nystagmus is a series of involuntary, regular, and rapid oscillations 
 of the eyes. These movements may be horizontal, vertical, or rotary, or 
 
EXAMINATION OF THE EYE. 355 
 
 a combination of all three. Unilateral nystagmus is rare. The lateral 
 oscillation is the most common. Congenital nystagmus i.-^ found in children 
 with congenital cataract, dense central corneal opacity, or imperfectly 
 developed eyeballs, and in albinism. Miner's nystagmus is an acquired 
 form, which is probably due to the prolonged upward inclination of the 
 eyes in semi-darkness. Nystagmus may be a symptom of irritation or 
 diseases of the inner ear, of tumors of the cerebellum, multiple sclerosis, 
 hereditary ataxia, and of syringomyelia. 
 
 In multiple sclerosis and in hereditary ataxia the nystagmus occurs 
 only when the eyes are turned in the direction of a moving object, and 
 particularly as the eyes reach the limit of their rotation in the lateral 
 plane. A slight nystagmus is occasionally found in hysteria. 
 
 Tension." — In the normal eyeball the tension of the globe, as measured 
 by the pressure of the two index fingers upon the sclera through the closed 
 lid, presents a uniform resistance. Increase in the intra-ocular tension 
 occurs in acute glaucoma, in some forms of iridocyclitis, and occasionally 
 after traumatism. Lowered tension may result from degeneration of the 
 ciliary body and choroid, in rupture of the globe, detachment of the retina 
 and after operations. 
 
 The Eyelids. 
 
 Marginal Inflammation. — Red, moderately swollen lid margins, asso- 
 ciated with heat, burning and photophobia, are seen in persons exposed to 
 cold winds and dust, in children affected with nasopharyngeal inflammation 
 following measles, and as a result of the strain of uncorrected refractive 
 errors. In severe types of the disease the lid margins are covered with 
 hardened, yellowish crusts which, upon removal, expose ulcers extending 
 deep into the lid border. 
 
 Redness and itching of the lid margins in children may be due to 
 the presence of the pediculus pubis in the eyelashes. Close examination 
 will show the eggs upon the cilia, and the parasite partly buried in the 
 hair follicle. 
 
 Inversion of the lashes or of the lid border is most commonly caused 
 by chronic inflammation of the bulbar conjunctiva. The irritation of the 
 misplaced cilia ultimately leads to inflammation and haziness of the 
 cornea. Eversion of the lid may follow burns or wounds, with subse- 
 quent cicatricial contraction of the skin; appears as a senile condition, 
 from loss of muscle power; or accompanies facial palsy. The lower lid 
 is most frequently affected. 
 
 CEdema of the lids accompanies severe inflammation of the conjunc- 
 tiva, purulent disease of the eyeball, orbit or frontal or ethmoidal sinuses, 
 and general affections like nephritis and gout. 
 
 Localized swelling of the eyelids and conjunctiva, with or without 
 vascular changes of the eyeball, is seen in neurotic oedema, urticaria, and 
 disease of the antrum, or may be due to errors of diet. The swelling may 
 be sufficient to completely close the eye, and is accompanied by itching 
 and burning. In a few days the parts return to the normal. 
 
 A locahzed painful swelling of the fid and discoloration of the skin 
 may be either a st3'-e {hordeolum) or an abscess of the fid (phlegmon). The 
 
356 MEDICAL DIAGNOSIS. 
 
 pain is severe and is frequently accompanied by swelling of the entire lid 
 and oedema of the conjunctiva. Styes are situated in the connective tissue 
 near the lid margin and are apt to recur in persons with deranged bodily 
 functions, and in those who suffer from uncorrected refractive errors. 
 
 Swelling of the lid, appearing suddenly after injury, and increasing 
 upon blowing the nose, the soft mass crackhng on pressure, is caused by 
 the presence of air which has escaped into the cellular tissue through a 
 fracture of the orbital wall (emphysema). 
 
 Inflammation of the tarsus (tarsitis), usually monocular, may be 
 syphilitic, gouty or tubercular. The Hd is swollen and drooping and can- 
 not be raised by the levator palpebrarum muscle. 
 
 Sebaceous cysts occur both on the eyelids and in the eyebrow. An 
 accumulation of secretion in the sebaceous glands of the lids appears as 
 small yellowish elevations which develop about the age of puberty, and are 
 due to improper care of the skin or to gastro-intestinal disorders. Mol- 
 luscum contagiosum is a disease of the sebaceous glands which occurs 
 among ill-nourished children. It is characterized by waxy-colored, rounded 
 papules, the size of a pea. 
 
 Erysipelas attacks the lids by extension from the adjoining skin of 
 the face. The typical shiny, dusky swelling, with the subsequent develop- 
 ment of small vesicles, serves to distinguish it from other affections. Severe 
 attacks may affect the orbital tissues and cause optic nerve atrophy and 
 fatal meningitis. 
 
 Syphilis may appear either as a primary sore, or as a secondary disease, 
 and is usually located at the Hd border. The ulceration and induration 
 present the typical features of a chancre. It may be mistaken for an 
 epithelioma, but the improvement under antisyphilitic treatment clears 
 up the diagnosis. 
 
 Herpes Zoster. — Violent paroxysmal pain, associated with a vesicular 
 eruption on the skin of the Hd, forehead and occasionally the side of the 
 nose, is indicative of herpes zoster ophthalmicus. The vesicles vary in size, 
 have an inflamed base, and are situated over the region supplied by the 
 first and second division of the fifth nerve. Corneal ulcers and iritis show 
 ocular involvement. Depressed nutrition is a common cause. 
 
 Xanthelasma. — YeUowish irregular shaped patches of connective 
 tissue, located in the upper eyeHds near the internal canthus, are termed 
 xanthelasma. Rarely they form on the lower Hds. The growth causes 
 no trouble, and is probably due to local iU nutrition. 
 
 Chalazion. — A smaU round elevation of either the upper or lower Hd, 
 of slow growth, with the skin freely movable over the hardened tumor, 
 and a purplish discoloration of the surface of the conjunctiva immediately 
 beneath, is termed a chalazion. It is due to inflammation of a Meibomian 
 gland, with retention of the secretion. Inflammation of the Hd margins 
 and the strain of ametropia may be causative factors. 
 
 Inflammation of the Lachrymal Sac. — A small tumor near the inner 
 surface of the lower Hd over the lachrymal sac, which disappears upon pres- 
 sure, with the escape of a viscid mucus through the puncta, is due to 
 catarrhal inflammation of the sac. The secretion may become purulent, 
 with severe pain, and intense swelling and redness of the skin somewhat 
 
EXAMINATION OF THE EYE. 357 
 
 resembling erysipelas. In both the chronic and acute forms the tears 
 flow over the cheek. A swelling at the upper and inner angle of orbit, 
 due to sinus disease, has been mistaken for lachrymal abscess. 
 
 Ptosis. — Drooping of the eyelid, partially or completely covering the 
 cornea, may be either congenital, or due to injury to the levator muscle, to 
 thickening of the tissues of the lid, or to paralysis of the third nerve. A form 
 of hysterical ptosis due to spasm of the orbicularis muscle has been described. 
 
 Lagophthalmos, or inability to close the eyelid, may be congenital, 
 but is usually an accompaniment of paralysis of the facial nerve. Marked 
 protrusion of the eyeball, mechanically preventing closure of the lid, is 
 seen in orbital tumors, exophthalmic goitre, and in corneal staphyloma. 
 
 Blepharospasm, or an involuntary contraction of the eyelids, may 
 vary in degree from a slight twitching of a few of the fibres of the orbicu- 
 laris to a tonic spasm. In its simplest form it is due to uncorrected refrac- 
 tive errors, inflammation of the lid borders, and corneal and conjunctival 
 irritation. Obstinate cases of cramp of the orbicularis arise from reflex 
 irritation of the fifth nerve, through some remote cause that it is often 
 difficult to determine. It is occasionally a hysterical manifestation. 
 
 Conjunctiva and Sclera. 
 
 The white of the conjunctiva changes to a dull yellow in so-called bilious- 
 ness, and to a pronounced brownish-yellow color in icterus. In anaemia, 
 tuberculosis, and nephritis the conjunctiva may become pearly white. 
 
 Inflammation. — The normal conjunctiva is coursed by a few small 
 blood-vessels which arise from the deep furrow where the membrane is 
 reflected to the under surface of the lids. Redness is the result of a marked 
 increase in the number of blood-vessels from inflammation of the conjunc- 
 tiva, or, as this membrane covering the eyeball is transparent, to con- 
 gestion of the deep sclera beneath. 
 
 Hyperemia of the conjunctiva is seen in measles, scarlet fever, hay 
 fever, influenza, nasal catarrh, the strain of uncorrected refractive errors 
 and from exposure to wind, dust, and bright light and heat. The con- 
 junctiva is often inflamed in facial paralysis, owing to the inability of the 
 lids to protect the globe from external irritants. The presence of a foreign 
 bod}^ on the conjunctiva or cornea causes many of the characteristic symp- 
 toms of an acute catarrhal conjunctivitis. 
 
 The ordinary conjunctival inflammations are unattended with severe 
 pain, but are accompanied with a mucous or mucopurulent discharge. 
 In inflammation of the sclera, the affected area is seen to be beneath the 
 loose conjunctiva, while in disease of the iris, ciliary body or cornea, a 
 ring of fine straight vessels surrounds the corneal border. In these latter 
 affections, pain is often quite severe. Since the conjunctiva may be also 
 inflamed in disease of these deeper structures, a diagnosis cannot be made 
 by the appearance of congestion only. 
 
 A type of contagious conjunctivitis (acute contagious conjunctivitis) 
 is due to the Koch-Weeks bacillus or to the pneumococcus. A subacute 
 form of conjunctival inflammation, which may occur in epidemic form, is 
 caused by the diplobacillus of Morax and Axenfeld. Severe inflamma- 
 
358 MEDICAL DIAGNOSIS. 
 
 tion, with swelling of lids, infiltration of the conjunctiva, and a purulent 
 discharge, occurs from the entrance of infection, usually the gonococci, 
 into the eyes of the child from the birth canal (ophthalmia neonatorum). 
 A similar form of inflammation follows the entrance of gonorrhoea! pus 
 into the conjunctival sac of the adult (gonorrhoeal conjunctivitis). 
 
 Diphtheria of the conjunctiva is rare. A membrane forms on the 
 surface of the conjunctiva, presenting the same characteristics as that 
 found in the throat. A pseudomembranous conjunctivitis may be due 
 to the pneumococcus or to streptococcus infection, and to some of the 
 other micro-organisms found in the ordinary types of inflammation. 
 
 Roughness or elevation of the conjunctiva of the hds may indicate 
 trachoma or vernal catarrh. Distended and tortuous vessels in the con- 
 junctiva may be due to constipation, auto-intoxication, chronic alcoholism 
 or lithsemia. 
 
 Single or multiple blebs appear on the conjunctiva in badly nourished 
 children, often after measles. Eczema of the nares and disease of the 
 nasopharynx are usually coexistent. 
 
 Hemorrhage beneath the conjunctiva appears in injuries of the head, 
 and also in severe compression of the abdomen. It is not uncommon in 
 whooping-cough, after severe vomiting, and in obstinate constipation, 
 the straining causing a rupture of one of the conjunctival vessels. Spon- 
 taneous hemorrhage in the aged, especially if recurrent, should direct 
 attention to the possibility of disease of the blood-vessels and to nephritis. 
 
 Uric acid deposits are frequently found in the conjunctiva of the 
 lids of gouty individuals. 
 
 Tumors and cysts of various kinds may appear in the conjunctiva of 
 the eyeball. Small, yellowish elevations are found near the cornea, usually 
 at the inner portion, but are of little significance. A fleshy fan-shaped 
 growth is often seen in persons past 40 years whose eyes have been sub- 
 jected to long exposure to wind, dust or sand. The usual situation is over 
 the internal rectus muscle, the apex often extending upon the cornea. Most 
 of the malignant growths appear at the junction of the sclera and cornea. 
 
 Inflammation of the sclera is found in association with the rheu- 
 matic and gouty diathesis, in scrofula, intestinal disorders and in syphilis. 
 In the superficial form of inflammation (episcleritis) there is usually a 
 circumscribed area of purpHsh discoloration beneath the conjunctiva, 
 most frequently in the region of the external rectus muscle, and slightly 
 raised above the healthy sclera. In disease of the true sclera (scleritis) 
 the inflammation may affect the entire anterior portion, and extend to the 
 cornea, iris, and ciliary body. Affections of sclera are distinguished from 
 conjunctivitis by the engorgement of the deeper vessels, the purplish color, 
 the severe pain, the absence of discharge, and the frequent relapses. 
 
 Cornea. 
 
 Keratitis. — The cornea is subject to both ulcerative and non-ulcera- 
 tive affections. 
 
 Ulcerative Keratitis. — Loss of sensibility of the cornea, with 
 subsequent ulceration and destruction, is found in affections of the trunk 
 
EXAMINATION OF THE EYE. 359 
 
 of the fifth nerve or of its ganghon, or after removal of the latter for 
 trifacial neuralgia. The corneal affection is due to a trophic change in 
 the membrane and to the irritation of foreign substances, which are not 
 recognized by the insensitive cornea. 
 
 A severe type of corneal ulceration, which may progress to perforation, 
 is found in association with herpes of the region about the eyes, particularly 
 of the lachrymal branch of the trifacial. The disease is preceded by severe 
 burning and neuralgic pain, in isolated spots, upon which are developed 
 the characteristic vesicles. 
 
 Chronic malarial keratitis attacks the superficial layers of the cornea, 
 is characterized by anaesthesia of the cornea and tenderness over the supra- 
 corneal notch. The ulcer is narrow, with offshoots resembling the veins 
 of a leaf (dendritic keratitis). The disease is rare, however, even in 
 malarious districts. 
 
 Small blebs, which later break down into ulcers, are located either on 
 the cornea or at the junction of the cornea and the sclera in strumous 
 children, and are associated with inflammatory diseases of the nasal pas- 
 sages, often following the exanthematous fevers. Eczema about the 
 nares is usually coexistent. Abscess and ulceration may occur during 
 convalescence from measles, smallpox, scarlet fever and other toxic diseases. 
 Exophthalmic goitre may give rise to extensive ulceration owing to con- 
 stant exposure of the cornea through inability to close the lids over the 
 globe. An extensive ulceration of the centre of the cornea may follow the 
 exhaustion of a prolonged diarrhoea or dysentery or similar debilitating 
 illness in the aged. 
 
 Interstitial Keratitis. — Inflammation of the deeper layers of the 
 cornea, without ulceration, is frequently seen in children, between 5 and 
 15 years of age, who have inherited syphilis, and also in tubercular, scrofu- 
 lous, and other poorly nourished individuals. In its earliest stage the con- 
 gestion surrounding the cornea is of the deep vessels, there is dread of 
 light, and close examination shows a fine dot-like infiltration of the inter- 
 stitial layers of the cornea, which later coalesce into the typical bluish 
 white haziness. The affection is bilateral, although months may elapse 
 before the second eye is affected. 
 
 Arcus Senilis. — A circle of fatty degeneration close to the cornea, 
 but with a clear ring separating it from the junction of the cornea and 
 sclera is present in the eyes of persons of advanced years. It possesses 
 no significance. A senile atrophy of the margin of the cornea has been 
 described in association with arcus senilis. 
 
 Partial insensibility of the cornea is seen in exophthalmic goitre, and 
 its presence probably explains a number of the other eye symptoms. 
 
 The Iris and Pupil. 
 
 Pigmentation. — Slight variation in the pigmentation of the irides is 
 not uncommon in health, but difference in color is rare, except in disease. 
 A yellow green color of one iris, while the other is blue or brown, is an early 
 evidence of inflammation of the iris and ciliary body. Retained metallic 
 foreign bodies often cause the iris to assume the brownish hue to which 
 
360 MEDICAL DIAGNOSIS. 
 
 the term siderosis is given. Inflammation of the iris occurs in syphilis, 
 rheumatism, gout, tuberculosis, diabetes, and from injuries, primarily in 
 one eye, or in the fellow eye from sympathy. Inflammation is accompanied 
 by irregularity and contraction of the pupil, injection of the pericorneal ves- 
 sels, and frontal pains, usually worse at night. SweUing in the stroma of the 
 iris is a sign of tertiary syphilis. Sarcoma, as a primary disease, is rare. 
 
 The Pupil. — Variations in the size of the pupil occur under the influ- 
 ence of light, and in convergence and accommodation. The average size 
 of the pupils, in diffuse daylight, with the eyes fixed on a distant point, 
 is 4 mm. Careful tests of changes in the pupils are of importance in the 
 diagnosis of general affections, particularly of the nervous system. 
 
 The normal reactions are as follows: 
 
 1. Direct Reaction. — If one eye is excluded, and the patient directed 
 to fix a distant object, the pupil of the exposed eye, when covered by the 
 hand or card, will dilate. Upon removal of the cover it will contract to 
 its previous size. 
 
 2. Indirect Reaction (Consensual Reflex).— If one eye is shaded, 
 the other pupil will dilate equally with the shaded pupil, to again contract 
 when the shade is removed. Normally the two pupils should be of equal 
 size, whether one or both is covered or uncovered. 
 
 3. Associated Reaction (Reflex to Accommodation and Con- 
 vergence). — The patient is directed to look into the distance and then 
 converge the eyes on a point, such as a pencil, held about 5 inches from the 
 eye. The pupils contract under the influence of the convergence and 
 accommodation. 
 
 4. Sensory Reaction (Skin Reflex). — Stimulation of the sensory 
 nerves of the skin, by pinching the skin of the neck, or by the passage of 
 a faradic brush along the spine, causes slight dilatation of the pupils. 
 
 5. Orbicularis Pupillary Reaction (Lid-closure Reflex). — 
 Contraction of the pupils occurs upon forcible efforts to close -the lids. 
 
 6. Drug Reaction. — Dilatation of the pupil (mydriasis) follows the 
 instillation of mydriatic drugs, and contraction of the pupil (myosis) the 
 instillation of myotics. 
 
 7. Cerebral Cortex Pupillary Reflex. — Haab describes a reflex 
 to which this term has been given. He found that if a patient seated in 
 a dark room, with the eyes fixed at the black wall, and a light placed to 
 shine laterally into the eyes, is requested to direct his attention to the light, 
 without changing the position of the eyes, the pupils will contract. Since 
 the accommodation remains suspended, and the light entering the eye is 
 unchanged, the contraction of the pupil is in some manner connected with 
 the power of attention, and Haab, therefore, believes the test should be 
 made in every case of .nervous disorder. 
 
 Myotic Pupillary Tract. — Stimulation of the centre for the third 
 nerve, by the action of light passing along the optic nerve and optic 
 tracts, causes an impulse to pass to the lenticular ganglion, and thence 
 by the short ciliary nerves to the sphincter of the pupil, which contracts, 
 lessening the size of the pupil. 
 
 Mydriatic Pupillary Tract. — The dilator muscle of the iris is 
 innervated by the sympathetic. The impulse passes from the medulla 
 
EXAMINATION OF THE EYE, 361 
 
 into the cord, thence through the first three dorsal nerves to the superior 
 cervical ganglion, to the plexus around the internal carotid, and through 
 the long ciliary nerves to the ciliary muscle and iris. Stimulation of the 
 centres of this tract causes dilatation of the pupil. 
 
 Abnormal Pupillary Reactions. — Failure of the pupil to react, either 
 wholly or in part, is due to a lesion in the iris, in some part of the 
 third nerve, in the centres of the brain, or in the light-conducting paths. 
 Lesions in the iris may be swelling or atrophy, or old or recent attach- 
 ments from inflammation. Immobility to light stimulus, with preser- 
 vation of the reflex to accommodation, is one of the important abnormal 
 pupillary changes. 
 
 Reflex Immobile Pupil (Argyll-Robertson Pupil). — Loss of 
 reaction of the pupil to direct light, with preservation of the contraction 
 of the iris in accommodation and convergence, comprises the well-known 
 Argyll-Robertson pupil, and is an early symptom of tabes. Although of 
 great diagnostic value when present, — and in the majority of cases it 
 exists in the incipient stages of the disease, — there are rare instances in 
 which it has not been found, even when all other symptoms of the disease 
 have existed for years. Associated with lost light reflex is frequently noticed 
 alteration in the shape of the pupil. The pupil may be of normal size, but 
 more often myosis is found, from implication of the cervical portions of 
 the cord controlling the dilating centres. The Argyll-Robertson pupil- 
 lary phenomenon is also seen in paretic dementia. The loss of the light 
 reflex in aortic disease is due to the general syphilitic infection. 
 
 Dilatation of the Pupil. — The pupil is dilated in glaucoma, in optic 
 atrophy, in diseases of the orbit, in irritation of the cervical sympathetic, 
 in acute mania, m cerebral softening, in extensive disease or injury of the 
 cerebral centres, in complete paralysis of the third nerve, in paralysis of 
 the sphincter of the iris by a blow upon the eyeball, in strong emotion, 
 and when mydriatics have been used. In neurasthenia and hysteria, 
 mydriasis is often present. 
 
 Dilatation of the pupil may be caused by an irritation of the dilator 
 pupillary centre or tract (irritative mydriasis), or by a paralysis of the 
 pupil-contracting centre or fibres (paralytic mydriasis). 
 
 Unilateral mydriasis, in which the pupil fails to react to direct light 
 but contracts consensually with its fellow, is seen in complete optic atrophy, 
 in which the conductivity of the one optic nerve is lost. The failure of one 
 pupil to react to separate stimulation of either eye, but contracting upon 
 convergence, while the other pupil reacts to light stimulus of either eye, 
 is seen in tabes and in syphilis. Sudden unilateral mydriasis in which the 
 instillation of a drug can be excluded is worthy of a careful study as a 
 possible early symptom of latent sclerosis of the cord. 
 
 Corte claims that in any serious diphtheritic attack failure of the 
 pupils to react to light indicates a fatal termination. 
 
 Complete blindness will cause bilateral mydriasis with failure of the 
 pupils to react to light stimulus. A slight contraction of the pupils has 
 been observed in the blind, who are entirely devoid of light perception, 
 after the eyes have been exposed to bright daylight for several minutes. 
 
 In mydriasis from drugs, the accommodation is temporarily suspended. 
 
382 MEDICAL DIAGNOSIS. 
 
 Contraction of the Pupil. — Abnormal contraction of the pupils is 
 due either to irritation of the pupil-contracting centre or fibres, or to 
 paralysis of the sympathetic. 
 
 In disease of the central nervous system, the myosis may be due to 
 irritation of the sphincter nucleus; but should mydriasis follow the myosis, 
 it is an indication of the spread of the affection and destruction of the 
 sphincter centre. 
 
 In irritative myosis the pupil rarely dilates under cover or in a bright 
 light, but acts normally when a mydriatic or myotic drug is instilled. 
 In the paralytic myosis the reaction to light and in convergence is pre- 
 served, but the pupils dilate imperfectly when shaded. Mydriatics act 
 Imperfectly, but the pupils contract further to myotics. 
 
 In old age the pupils are usually smaller than in middle life, although 
 perfectly normal in reaction. Inflammations of the iris are always asso- 
 ciated with small pupils, and the iris is likely to become attached to the 
 lens capsule. 
 
 Myosis is seen in the early stages of inflammation of the brain and 
 meninges, apoplexy, abscess, and in other affections which indicate irrita- 
 tion of the part; also in hysteria, toxaemia, and in epilepsy. Paralytic 
 myosis occurs in tabes, general paralysis, spinal meningitis, and destructive 
 lesions of the cord. 
 
 Unequal pupils (anisocoria) may point to purely functional affec- 
 tions, such as hysteria and the psychoses, or to grave organic disease, as 
 paresis, tabes, etc. The pupillary phenomena must be studied in connec- 
 tion with other symptoms to arrive at a correct diagnosis. Inequality of 
 the pupils, although the reaction to light remains, is present in many cases 
 of exophthalmic goitre. Bichelonne believes that unilateral mydriasis is 
 an important sign in the early diagnosis of pulmonary tuberculosis. 
 
 Alternating mydriasis, in which the dilatation changes from one 
 eye to the other, is occasionally present in general paralysis and in tabes, 
 and has been described as a premonitory symptom of insanity. 
 
 Hippus. — An alternate contraction and dilatation of the pupil, occur- 
 ring under a uniform stimulus of Hght, is a normal phenomenon, but may 
 be excessive in hysteria, epilepsy, advanced paralysis, early stages of 
 meningitis and mania, and in phthisis. 
 
 Hemiopic Pupillary Inaction. — The Wernicke pupil is described 
 under hemianopsia. 
 
 Iritis. — Inflammation of the iris may accompany disease of or trauma- 
 tism to other ocular structures, or be due to constitutional disorders. The 
 principal signs are changes in the color of the iris, injection of the peri- 
 corneal vessels, myosis, and attachments of the iris to the lens capsule. The 
 symptoms are severe brow pain, worse at night, and slowly faihng vision. 
 
 Syphilis is the most common cause of iritis. In the secondary stage 
 the iritis is plastic, and in the tertiary stage, plastic and gummatous. 
 
 The iritis of rheumatism is usually unilateral, although the second eye 
 may later become affected. In chronic rheumatic subjects the iritis is of a 
 severe and destructive type. The attacks usually recur during a relapse of 
 the rheumatism, or they may be the only evidence of the rheumatic poison. 
 The so-called idiopathic iritis, in which syphihs, gonorrhoea, and traumatism 
 
EXAMINATION OF THE EYE. 363 
 
 can be positively excluded, is probably due to the so-called gouty or rheu- 
 matic diathesis. In these cases the pain is usually of greater severity, the 
 disease more slowly amenable to treatment, and the relapses frequent. 
 
 In severe inflammations of the iris, the ciliary body is involved, and 
 the disease is referred to as iridocyclitis. Uveitis, or inflammation of 
 the iris, ciliary body, and choroid, occurs in rheumatism and gout, dia- 
 betes, influenza, anaemia, syphilis, tuberculosis, and the specific fevers. 
 The disease, which is probably the manifestation of some toxic process, is 
 characterized by moderately deep anterior chamber, hazy cornea and aque- 
 ous, pupil not contracted, occasionally a slight increase in the tension of 
 the eyeball, and the deposit in triangular form of small dots on the pos- 
 terior surface of the cornea. 
 
 Iritis is often seen during the late stages of gonorrhoea, usually affects 
 both eyes, and recurs with relapses of gonorrhoea and with the appearance 
 of the gleety discharge. 
 
 Although tubercle, particularly in the miliary form, is occasionally 
 found in the iris and choroid, it is of little value in general diagnosis, since 
 the deposits in the choroid are seen at a time when the disease has shown 
 itself in other regions so plainly that the diagnosis is easy. 
 
 Ocular Muscles. 
 
 Mobility of the Eyes. — Under normal conditions, the eyeballs move 
 in perfect accord in all directions, with no manifest lagging movement in 
 either eye in any of the several rotations. In equilibrium of the 
 ocular muscles, every movement of one eye is accompanied by simultaneous 
 and equal movement of the other, the image of the object upon which 
 the eyes are fixed is formed on the fovea of each eye, and the effort required 
 on the part of any one muscle or group of muscles in sustaining binocular 
 single vision is equal in the two eyes. 
 
 Disturbance of equilibrium may be arranged in two groups: 
 
 1. Organic anomalies, in which there is double vision in attempts to 
 rotate the eyes in the direction of the affected or paralyzed muscle or 
 group of muscles. 
 
 2. Functional anomalies, in which there are: 
 
 (a) An actual deviation of the visual line of one eye from that of the 
 other, persisting in all movements of the two eyes. 
 
 (b) A tendency to deviation, which is overcome by increased or de- 
 creased innervation to the muscle or group of muscles affected. 
 
 Organic Anomalies (Ocular Palsies). — Since binocular single vision 
 can only be maintained if the image of the object falls upon the macula 
 of each eye or upon corresponding points of each retina, any disturbance 
 of the motor apparatus by palsy of one or more of the ocular muscles results 
 in an impression of the object upon non-corresponding points of each retina. 
 Two images are, therefore, transmitted to the brain, and double vision, or 
 diplopia, results. The symptoms of ocular palsies are: (1) diplopia; 
 (2) limitation of movement of one or both eyes in the direction of the 
 paralyzed muscle; (8) actual deviation; (4) false projection; (5) vertigo; 
 and (6) abnormal position of the head. 
 
364 MEDICAL DIAGNOSIS. 
 
 Diagnosis of Ocular Palsies. — Paralysis of an ocular muscle is 
 to be suspected if the patient complains of seeing double or tilts the head 
 to prevent diplopia, and complains of vertigo in attempts to fix an object 
 in that portion of the field in which double vision exists. If the paralysis 
 is complete, the eye with the affected muscle fails to rotate past the median 
 line when the object fixed passes to the side to which the affected muscle 
 ordinarily rotates the eye, and in fixation with the affected eye, the devia- 
 tion of the sound eye (secondary deviation) is greater than is the deviation 
 of the squinting eye when the sound eye fixes (primary deviation). 
 
 Diplopia. — In partial paralysis the limitation of rotation may be so 
 slight as to escape observation. It becomes manifest, however, even in 
 slight degrees, upon the tests for diplopia. The patient, seated in a dark- 
 ened room, with the head fixed in one position, is directed to follow with 
 the eyes a lighted candle held at a distance of about 10 feet, and moved 
 in all portions within the field of vision. If a piece of colored glass is held 
 before one eye, the images of the two eyes are in this way differentiated. 
 By this test the behavior of the two images in their relative height and 
 distance from each other, and their separation and approximation, as the 
 light is carried up and down, to the right and to the left of the patient, 
 determines which of the muscles is palsied. Special skill and training 
 are essential in the diagnosis of the more complex forms of palsies, and it 
 is unnecessary in this connection to enter fully into details, but the fol- 
 lowing points will serve to indicate roughly the character of the affection: 
 
 1. Double images are seen only when the eyes are turned in the direc- 
 tion in which the paralyzed muscle or muscles normally rotate the eye; in 
 all other directions there is single vision. 
 
 2. The image of the eye with the paralyzed muscle (false image) 
 separates from the image of the sound eye (true image) as the object is 
 carried into the field governed by the muscle affected; that is, the distance 
 between the double images increases as the object fixed upon is moved 
 in the direction toward which the paralyzed muscle should rotate the eye. 
 
 If the false image is on the same side as the affected eye the diplopia 
 is homonymous; if the false image is projected to the side of the sound 
 eye the diplopia is crossed, or heteronymous. 
 
 Homonymous diplopia, with images in the same horizontal plane, indi- 
 cates paralysis of an external rectus, right externus if the images separate 
 as the object fixed is carried to the right, and left externus if they separate 
 as the object fixed is carried to the left. 
 
 Crossed diplopia in the horizontal plane indicates paralysis of an 
 internus, right internus if the double images separate in looking to the left, 
 and the left internus if they separate in looking to the right. 
 
 Vertical diplopia in upper field (that is, one image higher than the 
 other) indicates a paralysis of the superior rectus or inferior oblique: if 
 diplopia increases in looking up and to the right, and image of right eye is 
 higher, paralysis of right superior rectus; if lower, left inferior oblique. 
 Increase in diplopia in looking up and to the left, with image of right eye 
 higher, paralysis of right inferior oblique; if lower, left superior rectus. 
 
 Vertical diplopia in lower field shows a paralysis of the inferior rectus 
 or superior oblique. Increase in the diplopia in looking down and to the 
 
EXAMINATION OF THE EYE. 365 
 
 right, with image of right eye lower, indicates paralysis of right inferior 
 rectus; if higher, left superior oblique. Diplopia increasing down and to 
 the left, with image of right eye higher, shows paralysis of right superior 
 oblique, if lower, left inferior rectus. 
 
 Special Palsies. — Paralysis of the Sixth Nerve. — The long course 
 of the sixth nerve at the base of the brain renders it particularly liable 
 to pressure from inflammatory exudation, hemorrhage, and fracture. It 
 is the most frequent of the ocular palsies, and it is indicated by conver- 
 gence of the affected eye, homonymous diplopia, and inability of the eye to 
 rotate outwards past the median line. 
 
 Paralysis of the third nerve is shown by ptosis, the pupil moder- 
 ately dilated and unresponsive, the power of accommodation abohshed, 
 and crossed diplopia, with the eyeball turned outward and slightly down- 
 ward from the action of the external rectus and superior oblique. In cyclo- 
 plegia only that portion of the nerve controlling the ciliary muscle is 
 affected. There may or may not be associated paralysis of the sphincter 
 of the pupil (iridoplegia). 
 
 Paralysis of the fourth nerve, which controls the superior oblique, 
 is less frequent. There is vertical diplopia in the lower field, the image 
 of the affected eye is the lower, and the distance between the images 
 increases as the eye is rotated downwards and inwards. 
 
 Ophthalmoplegia externa is the term employed to designate paraly- 
 sis of all the external ocular muscles. The affected eye is incapable of move- 
 ment, and the lid droops and cannot be voluntarily raised. Paralysis of 
 the iris and ciliary muscle is known as ophthalmoplegia interna. 
 
 Conjugate Palsy. — In this rare affection the individual muscles of 
 each eye possess their normal power to turn the globe in any desired posi- 
 tion, but there is inability to rotate the two eyes in associated action. 
 It may affect convergence, so that the eyeballs cannot be converged, 
 although individually capable of internal rotation; or it is shown in loss 
 of associated lateral or vertical movements. In all cases the lesion is 
 central, and involves the centres for conjugate movement, although spas- 
 modic conjugate deviation is seen in hysteria. 
 
 Causes of Ocular Palsies, — The seat of the lesion in paralysis of 
 the ocular muscles may be intracranial, orbital, or peripheral: it may include 
 meningitis, tumors, hemorrhage, gumma, or vascular changes in the brain; 
 orbital cellulitis, traumatism, and inflammation of the nerve in the muscle. 
 The constitutional causes are syphilis, tuberculosis, diabetes, nephritis, 
 influenza, tabes, rheumatism, and general paralysis of the insane, and 
 toxic agents. 
 
 At least one-half of the ocular palsies are considered to be due directly 
 to syphihtic gummatous deposits, syphilitic periostitis in the orbit or 
 along the base, or to degeneration in or close to the nuclei of the nerves. 
 These are exclusive of the indirect syphilitic affections, as manifested in 
 tabes, general paresis, and diseases of the blood-vessels. Nuclear and periph- 
 eral palsies may be caused by rheumatism, diabetes, tonsillitis, influenza, 
 ptomaine poisoning, and by lead, alcohol, tobacco, and other toxic 
 agents. In that variety of ptomaine poisoning known as botulismus, 
 nuclear palsies are frequent. Basal palsies are seen in hemorrhage, menin- 
 
366 MEDICAL DIAGNOSIS. 
 
 gitis, especially tubercular, abscess, and cavernous sinus disease. The 
 paralyses associated with diabetes occur only in diabetes mellitus, develop 
 suddenly, but usually are of short duration and most frequently affect 
 the sixth nerve. Neuralgia of the region about the eye is often associated 
 with the paralysis, so that pain in this situation in saccharine diabetes 
 should direct attention to a possible disturbance of the motor apparatus 
 on the same side. 
 
 Ophthalmoplegia interna, or paralysis of the ciliary muscle and 
 the sphincter of the pupil, is more frequently unilateral than bilateral, 
 and is seen in syphilis, tabes, and intracranial disease. Either the sphincter 
 or the ciliary muscle may be first affected, and later the external ocular 
 muscles become implicated. It is also found after diphtheria. The lesion 
 is probably nuclear. 
 
 Paralysis op the accommodation, destroying the power of reading, 
 is seen in about 5 per cent, of cases of diphtheria, usually affects both eyes, 
 and only rarely is associated with palsy of the iris. Occasionally paraly- 
 sis of the external rectus is associated with the loss of accommodation. 
 The same palsies are also seen in severe cases of influenza, in multiple 
 sclerosis, and in ptomaine poisoning. 
 
 Intermittent palsy of one or more muscles is frequently one of the 
 early symptoms of tabes. One eye is generally affected, and the paralysis 
 disappears in a few weeks to again recur. The same is found in syphilis, 
 but the paralysis affects more than one muscle. The external rectus is 
 probably the most frequently involved, and next the muscles supplied by 
 the third nerve, either as a group or individually, while the parts supplied 
 by the fourth nerve are rarely affected. 
 
 Palsies of some of the ocular muscles, most frequently those 
 supplied by the third nerve, are present in "ophthalmoplegic migraine" 
 and follow the subsidence of pain. The attacks are usually recurrent, 
 the palsy occurring on the same side as the pain. The disease is rare, 
 and should be differentiated from brain tumor. 
 
 Functional Anomalies. — Both of the functional defects, the tendency to 
 deviation (heterophoria) and the actual turning of one visual line from that 
 of its fellow (heterotropia, or functional squint), are due in many instances to 
 errors of refraction, and to disturbance of the relation between convergence 
 and accommodation. There is no paralysis and no double vision. 
 
 Latent Deviations (Heterophoria, Insufficiency of the Ocular 
 Muscles).- — If there is a lack of equilibrium in the action of the muscles of 
 the two eyes in binocular vision, so that fixation of the eyes is only main- 
 tained through an excessive amount of nerve force expended in helping 
 the weak muscle or set of muscles, there follows a train of symptoms 
 which is usually included under the term muscular asthenopia. There is 
 more or less constant dull headache, which may be general or localized 
 in the frontal or occipital region, blurred vision, inability to use the eyes at 
 near work, and photophobia. Sometimes there may be vertigo and nausea, 
 confusion of ideas, insomnia, and a feeling of physical exhaustion while 
 in a moving crowd, in attendance at the theatre, or after riding in the cars. 
 Heterophoria is a most active causative factor in many of the reflex nervous 
 disorders. Pelief in many cases has undoubtedly followed the correction of 
 
EXAMINATION OF THE EYE. 367 
 
 the defects, but does not justify the extravagant claims made that epilepsy, 
 chorea, melancholia, dyspepsia, and other affections are not only primarily 
 due to heterophoria, but are cured after correction of the muscle anomaly. 
 
 Forms of Deviation. — The tendency of the visual lines to deviate 
 from the normal parallehsm is divided into esophoria, a tendency of the 
 visual lines to turn inward; exophoria, a tendency of the visual lines to 
 turn outward; and hyperphoria, a tendency of one visual line to deviate 
 above that of its fellow. The inward tendency of the visual lines is of 
 relatively less importance as a cause of reflex symptoms than is hyper- 
 phoria or exophoria. 
 
 To determine the existence of the muscle anomaly, the latent defect 
 is made manifest by means of a prism of sufficient strength to cause di- 
 plopia, or by the use of a piece of cobalt glass or a rod of glass held before 
 the eye. The line of light made by the rod is so dissimilar from the image of 
 the other eye that the fusion impulse is abolished, and the eyes take the 
 position of greatest rest. The prism that fuses the double images made by 
 the prism or brings the line of light into the flame seen by the other eye is 
 the measure of the defect. Correction of the refraction is essential to a cure. 
 
 Manifest Deviations (Concomitant Squint, Heterotropia). — In 
 this affection there is an actual deviation of one visual hne from that of 
 the other, but the squinting eye is able to follow the movements of the 
 fixing eye in all directions; there is no acknowledged diplopia, and the 
 deviation is transferred from one eye to the other, and remains of the same 
 degree upon alternately covering one eye and then the other. The absence 
 of double vision, and the fact that the power of rotation of the eye is not 
 limited, serve to distinguish the functional from the paralytic squint. 
 
 Functional squint may be either convergent, divergent, or vertical. 
 The three principal causes of the strabismus are a disturbance in the normal 
 relation between convergence and accommodation, brought into existence 
 by errors of refraction; a weakness of opposing muscles, either through 
 structural changes or disturbed innervation; and unequal vision of the two 
 eyes, so that the normal desire for fusion is abolished. The strabismus 
 may be monolateral, when one eye always fixes and the other always squints; 
 or alternating, when either eye may be used for fixation, since the visual 
 acuity is about the same in each. Squint is an affection of early child- 
 hood, often disappearing if proper treatment is instituted at this time. 
 
 Vision. 
 
 AFFECTIONS OF VISION. 
 
 Imperfect vision is due to errors of refraction; to opacities of the 
 cornea, crystalHne lens, or vitreous; to disease of the retina, choroid, optic 
 nerve, or central nervous system; or to functional neuroses. 
 
 Central vision is tested by means of letters corresponding in size to 
 a fixed standard. The patient, seated 20 feet from the test card, and one 
 eye covered, is asked to read the smallest line of letters that can be de- 
 ciphered. If the vision thus estimated does not conform to the standard, 
 the various errors of refraction should be excluded before concluding that 
 the reduced vision is the result of disease. The effect of faulty vision upon 
 
368 
 
 MEDICAL DIAGNOSIS. 
 
 the health of patients is oftentimes overlooked. In a person given to any 
 manner of indoor vocation, whose nervous system is at all delicately 
 balanced, an uncorrected eye-strain may give rise to headache, drowsiness, 
 transient vertigo, and sometimes to nausea, irritability of temper, and 
 insomnia. These symptoms are probably more often found when vision is 
 in excess of the normal standard, hence the state of the refraction must be 
 learned in order to determine the extent to which the accommodative 
 strain is responsible for the reflex manifestation. 
 
 Peripheral Vision. — In testing the perception of the outlying por- 
 tions of the visual field, the examination is made of each eye separately, 
 the oculist employing an instrument known as a perimeter, which consists 
 of an arc of a circle, of about 12 inches radius. The eye to be examined is 
 at the centre of the circle, and fixed steadfastly upon a white spot upon 
 
 Fig. 150. — Diagram of perimetric charts of visual fields for white (form field). 
 
 the arc. A white object 5 to 10 mm. in size is slowly moved along the arc, 
 from its extremity towards the fixed spot, until it comes within the patient's 
 range of vision, and the point recorded at which the object is first seen. 
 The arc is moved to another position and this is continued until the whole 
 circle has been tested. The record of the usual points so taken is recorded, 
 as in Fig. 150. As will be seen, the outlines of the visual field are far from 
 symmetrical. Its greatest extent is on the temporal side, usually about 
 90°, on the nasal side 55°, above 50°, below 65°. The perimeter is not 
 absolutely necessary to make out gross lesions such as hemianopsia or 
 extensive contraction of the field, since the finger carried from point to 
 point, as the patient gazes into the examiner's eye, will indicate marked 
 departure from the normal limits. Accurate examination requires the 
 services of the ophthalmologist. 
 
 Gradual failure of vision apart from refractive errors is seen in disease 
 of the cornea, in cataract, non-inflammatory glaucoma, atrophy of the optic 
 nerve, and various forms of intra-ocular disease. Rapid loss of sight occurs 
 
EXAMINATION OF THE EYE. 
 
 369 
 
 in acute glaucoma, retinal hemorrhages, embolism or thrombus of the 
 central retinal vessels, oedema of the retina, cerebral effusions, metastatic 
 disease of the eye, ptomaine poisoning, and after quinine, wood alcohol, 
 and other toxic agents. In every instance of decrease in the normal acuity 
 of vision, the oculist should be immediately consulted. 
 
 Cataract affects vision in proportion to the degree and situation of 
 the opacity. It appears as a congenital or senile condition, in connection 
 with disease of the eyes, in diabetes, in traumatism, and with many con- 
 stitutional disorders that influence the nourishment of the lens through the 
 nutrient vessels of the choroid and ciliary body. Cataract has been mistaken 
 for non-inflammatory glaucoma, owing to the greenish reflex of the lens in 
 the latter disease. The diagnosis is readily made with the ophthalmoscope. 
 
 Second Sight. — The ability of persons past middle life to lay aside 
 their usual convex reading glasses and read the finest print (so-called second 
 sight) indicates swelling of the lens, and is one of the first signs of cataract. 
 Glycosuria is a frequent cause of cataract, and acquired myopia after 40 
 years of age, even with clear crystalline lens, should direct attention to 
 the possible existence of diabetes. 
 
 Acute Glaucoma. — Recurring attacks of blurred vision, the obscura- 
 tion lasting from a few minutes to an hour or more^ when associated with 
 halos about the light (iridescent vision), should direct attention in persons 
 past middle life to the possibility of an oncoming attack of acute glaucoma. 
 The "glaucomatous attack" usually occurs at night, is characterized by 
 severe pain in the head, nausea and vomiting, and rapid loss of sight. 
 The eyeball is intensely congested, the pupil dilated, the cornea anaesthetic 
 and steamy, and the globe of stony hardness. The affection should not be 
 mistaken for a '' cold in the 
 eye," iritis, or neuralgia. The 
 rheumatic and gouty diathesis 
 is a possible causative factor. 
 
 Alterations in the Visual 
 Field. — Changes in the visual 
 field, as evidenced by irregular 
 or concentric narrowing of the 
 normal limits for form and 
 color, the presence of central 
 or peripheral areas of lost per- 
 ception (scotoma), or transpo- 
 sitions of the order of colors, 
 is seen in disease of the retina, 
 optic nerve, and central ner- 
 vous system, or may be present 
 in purely functional neuroses. 
 
 Amblyopia and amaurosis 
 designate defective vision due 
 either to functional disturbance 
 
 or to actual disease of the visual apparatus, without gross ophthalmoscopic 
 changes, although the latter restriction is not always adhered to. The 
 affection of the sight may be limited to central vision, include the whole 
 
 24 
 
 GREEN 
 
 Rtn 
 
 BLUl 
 
 Fig. 151. — Diagram of form and co'or fields of right eye. 
 
370 MEDICAL DIAGNOSIS. 
 
 or only part of the visual field, or be only for form or for color. A number 
 of congenital forms of amblyopia are recognized — for form, as in the poor 
 vision of squint, or for color, as in color-blindness. Partial or complete loss 
 of sight may be due to irritations affecting the fifth nerve, severe injuries of 
 the head, autointoxication, the nephritis of the eruptive fevers, diabetes, ma- 
 laria, rheumatism, action of certain drugs, and to hysterical manifestations. 
 
 Sudden transient failure of vision may mean merely the tempo- 
 rary giving out of eyes already weakened by general affections or too 
 persistent use. 
 
 In the so-called "visual aura" of migraine, there is a decided blurring 
 of the visual field, which has been designated as amblyopia, but is transi- 
 tory, and is to be distinguished from the permanent functional impairment 
 of sight included in the term. 
 
 Dercum regards a slight degree of amblyopia, with or without a dimi- 
 nution of the color sense, as an early and invaluable symptom of paresis, 
 which may even antedate distinct and demonstrable anomalies of the 
 pupils or changes in the eye-grounds. 
 
 Transient blindness, persisting for a few minutes to several hours or 
 days, may be due to spasm of the retinal arteries. The diminution in the 
 calibre of the vessels has been observed in epilepsy, migraine, cold stage 
 of malarial fever, and in some toxic conditions. 
 
 In ursemia, particularly in the nephritis of scarlet fever and of preg- 
 nancy, the sudden loss of sight may be associated with convulsions, coma, 
 and other cerebral symptoms. Although the blindness may be complete^ 
 the reactions of the pupils are usually preserved. 
 
 Amblyopia from Loss of Blood.- — Amblyopia, with subsequent 
 complete atrophy of the optic nerve, may follow profuse spontaneous 
 hemorrhages from the stomach, intestines, uterus, or nasal cavity. The 
 loss. of sight may not appear for a week or more after the bleeding, being 
 due, as shown by Holden, to degeneration of the ganglionic cells of the 
 retina from impaired nutrition. 
 
 Methyl-alcohol Amblyopia. — Rapid loss of sight may follow the 
 drinking of wood alcohol in its crude or purified state, or when employed 
 as an adulterant in the manufacture of Jamaica ginger, impure whiskey, 
 cheap essences, bay rum, and other alcoholic beverages. The eye symptoms 
 are often associated with vomiting and purging, severe headache, and intense 
 weakness. The vision may improve for a few hours or days to again relapse, 
 often ending in complete blindness. 
 
 Quinine Amblyopia. — Total blindness may follow the taking of 
 quinine in large quantities, the amount of the drug required varying in 
 different individuals. The pupils are dilated and unresponsive, the optic 
 disks pale, and the retinal circulation seriously restricted. Central vision 
 is usually restored but the peripheral limits of the field remain contracted. 
 
 Central Amblyopia (Retrobulbar Neuritis). — The orbital portion 
 of the optic nerve is subject to interstitial inflammation in either an acute 
 or chronic form. In both, the disease affects those portions of the nerve 
 that supply the macular region. The early symptoms are dimness of vision, 
 without marked ophthalmoscopic changes, and a weakness or loss of color 
 perception in the central visual field. 
 
EXAMINATION OF THE EYE. 371 
 
 In retrobulbar inflammations, as pointed out by Gowers, the visual 
 acuity is less in very bright light, and exposure to excessive hght may 
 lead to deterioration of vision that may last for some time. This is due 
 to the slowness with which the ill-nourished axis-cylinders are regenerated. 
 The same author also shows the close relationship between retrobulbar 
 disease and affections of the seventh nerve, since paralysis of the facial 
 nerve may precede the optic-nerve inflammation. 
 
 In acute retrobulbar neuritis there is rapid failure of vision with central 
 or paracentral scotoma, which is usually followed by recovery of vision, 
 although the optic disk still shows pallor. The affection may, however, 
 rapidly progress until the entire nerve is implicated, and vision is nearly 
 if not completely lost. The disease may arise during the course of rheu- 
 matism, gout, diabetes, smallpox, and other general affections, in which 
 the blood carries the toxsemic substance; or may follow orbital or sinus 
 disease, menstrual suppression, alcohol or lead intoxication; and occasion- 
 ally is found in insular sclerosis and myelitis. 
 
 In chronic retrobulbar neuritis there exists with dimness of vision a 
 small central color scotoma, particularly for red and green, the horizontal 
 oval area in the visual field extending from the fixing point to the blind 
 spot. The affection is found principally in persons using large quantities 
 of tobacco, especially when combined with the use of alcohol. It is most 
 frequently noted between 40 and 50 years of age, and has also been found 
 in alcoholics who are not users of tobacco, and from the toxaemia of lead, 
 cannabis indica, stramonium, chloral, carbon bisulphide, iodoform, etc. 
 The disturbance of vision is greater for near objects, and is more marked 
 in bright light. 
 
 A form of retrobulbar neuritis similar to that of toxic origin appears 
 as an hereditary affection, and is referred to as hereditary optic neuritis. 
 It affects several members of a family, especially the males, and has been 
 traced through several generations. The exciting cause is exposure to 
 cold, syphilis, excessive venery, and the heavy consumption of tobacco. 
 
 Hemianopsia (hemianopia) is a loss of one-half of the visual field 
 of one or both eyes, due to a lesion in the optic chiasm, along the optic 
 tracts, or in the visual centres in the occipital lobe. It does not include 
 defects in the field caused by disease within the eyeball. The line divid- 
 ing the seeing from the blind field is horizontal or vertical, or nearly so, 
 and may cut exactly through the fixing point, or circumscribe this point 
 by a small zone of preserved vision. 
 
 The dividing line may have an oblique direction, but this is extremely 
 rare, or only a sector, commonly a quadrant, of the field may be wanting. 
 
 Hemianopsia is classified according to the relative position of the 
 blind portions of the two fields. It is homonymous if there is loss in the 
 corresponding halves of each field; bitemporal if both temporal fields are 
 blind, and binasal when the nasal halves are lost. When the dividing line 
 between the lost and preserved field is vertical, the defect is known as 
 vertical hemianopsia, and when the dividing line is horizontal, the hemi- 
 anopsia is horizontal or altitudinal. 
 
 Homonymous hemianopsia is the commonest form, and reveals itself 
 as a defect in the right or left half of each visual field. For instance, in 
 
372 
 
 MEDICAL DIAGNOSIS. 
 
 Fig. 152 the left half of each field is wanting, showing loss of function in the 
 right half of each retina. If the right half of each field is lost the condition 
 is right lateral hemianopsia; in loss of the left half of each field, left lateral 
 hemianopsia. The seat of the lesion in homonymous lateral hemianopsia 
 is in any part of the visual tract between the chiasm and the occipital lobe. 
 BiTEMPOEAL HEMIANOPSIA is a Comparatively rare phenomenon, but 
 one of great diagnostic moment when found. It manifests itself as a 
 blindness of the outer, or temporal, halves of the visual fields, indicat- 
 ing suspended function of the nasal portions of each retina. It is caused 
 by a lesion which destroys the function of the crossed fibres without 
 affecting the uncrossed fascicuh. This may be a tumor, fracture, exos- 
 tosis, aneurism, or disease of the blood-vessels. Loss of the two temporal 
 
 Fig. 152. — Diagram of perimetric charts of right lateral hemianopsia. The dark areas show loss 
 of the nasal half of left and temporal half of right fields, with contraction of the preserved fields. The 
 dividing line passes aroiind fixing point. 
 
 fields is seen in acromegaly, although it is not a constant symptom, since 
 the type of hemianopsia will depend upon the direction the pressure is 
 exerted upon the chiasm and tracts. 
 
 BiNASAL HEMIANOPSIA, in which both the nasal fields are lost, is rare. 
 If it is true that the crossed and uncrossed fibres of the optic nerve are 
 mingled at the outer half of the chiasm, then a lesion of this structure 
 cannot cause binasal hemianopsia. Shoemaker believes that this defect 
 in the fields is due to an inflammation of the optic nerves. 
 
 Both upper or both lower fields may be wanting. In this condition, the 
 lesion is, as a rule, at the chiasm, encroaching on it from above or below. 
 
 If the blind halves of the field have lost not only perception of form 
 and light, but also of color, the defect is absolute; if only recognition of 
 color is lost, the hemianopsia is relative. 
 
 Hemianopsia as a Diagnostic Symptom. — In lateral hemianopsia 
 the intracranial lesion is on the opposite side from the dark fields. If 
 unassociated with motor or sensory symptoms, the lesion is confined to 
 
EXAMINATION OF THE EYE. 373 
 
 the cuneus, or the immediately surrounding gray matter; a lesion in one 
 nerve tract, or in the primary optic centres, with symptoms of basal disease, 
 would cause changes in the pupil, and possibly some affection of the nerve 
 head could be recognized. Hemiplegia and hemianaesthesia are often present 
 with lateral hemianopsia, indicating organic disease of the brain, the lesion 
 being situated in the internal capsule. If right hemiplegia and aphasia 
 are associated with lateral hemianopsia, an extensive lesion probably 
 exists of the area supphed by the middle cerebral artery. A lesion of the 
 posterior gray matter of the optic thalamus could produce lateral hemi- 
 anopsia, with hemianaesthesia and ataxia of one side of body. A cortical 
 lesion is usually associated with concentric contraction of the preserved 
 fields, or is found in cases in which the light sense is preserved, but the 
 color or form sense is abolished. 
 
 Hemianopic Pupillary-inaction Sign. — This is an important local- 
 izing sign in hemianopsia, and consists in carefully noting if the pupil reacts 
 to a beam of light thrown upon the non-functionating half of the retina. 
 It is an extremely delicate test to make, owing to the difficulty of restrict- 
 ing the beam of light so that it shall illuminate the non-acting half of the 
 retina without allowing any light to fall upon the seeing half. If the pupil 
 reacts when the light is thrown upon either the blind or the seeing half of 
 the retina, the lesion is back of the primary optic centres; but if there is 
 no reaction when the light falls upon the blind side, but the pupil reacts 
 when the light falls upon the functionating side, the lesion is in front of 
 the primary optic centres, and in that position has affected the motor arc 
 of the pupil. The test should always be made in a well-darkened room, 
 with barely sufficient light to conduct the examination, and should be 
 confirmed by a second observer before basing a diagnosis on its apparent 
 presence. When present it is a valuable sign, but its absence is not decisive, 
 owing to the difficulty of making the test. 
 
 Hysterical Amaurosis. — The diagnosis of visual defects due to 
 hysteria is sometimes difficult, although healthy eye-grounds and pupils 
 normally reacting to light would point strongly to hysteria. Cases of 
 hysteric blindness have been reported, however, in which light failed to 
 have any action on the pupil. 
 
 If unilateral blindness arises suddenly, following fright, emotional 
 excitement, slight injury, or menstrual pain, hysteria may be suspected. 
 While the defect may be bilateral, it is more often unilateral. It is not 
 uncommon to find, associated with the ocular symptoms, other disturbances 
 of sensation, such as hemianaesthesia of the skin, cornea, or conjunctiva. 
 If the amaurosis is restricted to one eye, under some conditions it may be 
 transferred to the other temporarily; and, again, the unilateral character 
 of the affection may entirely disappear in binocular fixation, as proved 
 by the diplopia if a prism of sufficient strength to prevent normal fusion 
 is placed before one eye. 
 
 Not only may the vision be reduced in hysteria, but changes in the 
 peripheral field are common. The contraction in the field is usually equal 
 in the different meridians, and is often of the tubular type, in which the 
 limits of contraction remain the same, no matter what distance the test 
 object is removed from the eye. The field for colors likewise shows con- 
 
374 MEDICAL DIAGNOSIS. 
 
 centric contraction, or the limits of one color may overlap that of another, 
 or there may be a complete reversal of the colors. 
 
 Optic Neuritis. — Inflammation may affect the optic nerves at their 
 intra-ocular portions (papillitis) or in their course in the orbit (retro- 
 bulbar neuritis). Under the term hypercemia of the nerve head is included 
 a type of optic-nerve irritation in which the disks become of dull red color, 
 the surface and margins veiled, and the lymph sheaths of the vessels 
 prominent. It is seen in refractive error, particularly hyperopia and hyper- 
 opic astigmatism, after long-continued exposure to intense light or heat, 
 in some types of inflammation of the uveal tract, in orbital and sinus disease, 
 in chronic insanity, and from toxic agents. 
 
 Papillitis. — Optic neuritis may be manifest as a true inflammation 
 of the nerve tissue, a swelling of the intra-ocular ending of the optic nerve, 
 or as a descending neuritis. The changes in the optic-nerve head may 
 range from a decided redness, moderate swelling, and blurring of the margins, 
 to an intense rounded protrusion of the disk from inflammatory exudation, 
 reddish gray in color and sloping down into the surrounding retina, the 
 retinal arteries shrunken, and the veins full and tortuous and covered in 
 by infiltration or ending in numerous hemorrhages. Upon subsidence of 
 the inflammation the nerve head becomes grayish white in color, the oedema 
 subsides, and the extent to which the pressure has affected the nerve- 
 fibres is shown by the degree of optic atrophy that follows. 
 
 A moderate degree of papillitis, associated with hemorrhages through- 
 out the retina, few changes in the vessels, and spots of fatty degeneration 
 of the retinal elements, is described as neuroretinitis, and is the type most 
 frequently found in association with renal disease. The intense swelling of 
 the papilla, with exudation and tortuosity of the veins, is termed choked disk 
 or papillcedema, and is the usual type found in certain forms of brain tumor. 
 
 The neuritis may be due to affections of the orbit, such as fracture, 
 orbital tumors, purulent cellulitis, and sinus disease. Intracranial causes 
 are tumors, meningitis, gumma, abscesses, and aneurisms. The situation 
 of the intracranial portion of the optic nerve tracts at the base of the 
 brain renders them particularly liable to implication in inflammations of 
 the basal portion of the meninges and to the pressure of tumors, abscesses, 
 or aneurisms. In children, tubercular meningitis is usually accompanied 
 by swelling of the optic disk. The absence of affections of the optic nerve 
 does not preclude the presence of a new growth in the brain, although when 
 the base, and particularly the cerebellum, is the seat of a neoplasm, swelling 
 of the optic disk is almost always present. Double optic neuritis of high 
 degree, rapidly progressive, and accompanied by marked exudation in 
 the nerve and surrounding retina, usually indicates a tumor of the cere- 
 bellum, while one of slower growth, less intense, and either unilateral or 
 considerably greater on one side than on the other, is seen in neoplasms of 
 the cerebrum. The "stellate figure" in the macula, which is seen in a large 
 proportion of the cases of renal retinitis, is not uncommon in the intense 
 papillitis of brain tumor. Tumors or abscesses of the frontal region rarely 
 cause optic neuritis, although swelling of the optic disk may occur. 
 
 Apart from the intracranial causes, papillitis may occur from general 
 infections. These are in the nature of a toxin, occurring in such diseases 
 
EXAMINATION OF THE EYE. 375 
 
 as influenza, syphilis, malaria, rheumatism, erysipelas, and many of 
 the exanthematous and continued fevers. Lead and alcohol may also 
 cause inflammation of the optic nerve, and the same process is seen in 
 anaemia, loss of blood, sunstroke, and after violent exertion. Syphilis 
 may cause a primary neuritis or act secondarily through gumma of the 
 brain or meninges. 
 
 Unilateral optic neuritis may be due to orbital or sinus disease, and in 
 rare instances to cerebral tumor, in which the neuritis occurs on the side 
 of the neoplasm. The inflammation of the retina and optic nerve of nephri- 
 tis and certain constitutional disorders is often unilateral, but with the 
 progress of the systemic disease the inflammation attacks the other eye. 
 
 Perfect central vision is usually unimpaired even in intense papillitis 
 during the acute stage, and if defects in vision occur they partake of the 
 nature of sector-like defects in the visual field. 
 
 Retrobulbar neuritis has been considered under Amblyopia. 
 
 Optic-nerve Atrophy. — Degeneration and atrophy of the optic nerves 
 may be primary, when there has been no previous inflammation or 
 swelling of the papilla, or secondary, if preceded by previous optic neuritis. 
 In both forms there are changes in the color of the disk, varying from a 
 gray to grayish white, with the edges usually clear and distinct in the 
 primary forms, but veiled in the secondary. 
 
 Primary atrophy is more frequently associated with spinal disease, 
 particularly locomotor ataxia, in which it usually appears before the ataxic 
 symptoms. It is also found in insular sclerosis, paralysis of the insane, 
 and occasionally in lateral sclerosis. It may occur as a result of excessive 
 hemorrhage from the stomach, uterus, or intestines, in the toxaemia of 
 fevers, alcohol or lead poisoning, in chronic malaria, syphihs, and dia- 
 betes, in fractures of the base, and in deformities of the skull. Hered- 
 itary optic-nerve atrophy is not uncommon, the atrophy appearing in 
 early adult life. 
 
 Secondary or Consecutive Atrophy. — The contracted retinal arteries, 
 the dilated and tortuous veins, and the veiling of the surface and edges 
 of the optic nerve point to a previous papillitis. Extensive retinal and 
 choroidal disease also results in atrophy of the nerve, as will pressure 
 upon the nerve-fibres by an aneurism, tumor, or exostosis. 
 
 Retinitis. — The retina is implicated in disease affecting the intra- 
 ocular end of the optic nerve, and also from extension of disease from the 
 ciliary body and choroid. The inflammation is associated with oedema 
 and exudation, hemorrhages either in the fibre layer or deeper, small- 
 cell infiltration, and tortuosity of the retinal vessels, with changes in 
 their calibre. 
 
 Retinal Hemorrhage. — Extravasation of blood into the retina may 
 occur independently of any inflammation of the retina. It is usually 
 the evidence of extensive vascular disease, organic heart affections, or 
 suppressed menstruation. It may occur in scurvy, purpura, marked anaemia, 
 diabetes, and particularly in the type of neuroretinitis associated with 
 nephritis. Retinitis with hemorrhages resembling those seen in renal 
 disease are often present in simple anaemia and chlorosis. The position 
 and extent of the hemorrhage determines the effect on vision. 
 
376 MEDICAL DIAGNOSIS. 
 
 Arteriosclerosis. — A study of the changes in the retinal blood- 
 vessels is of extreme importance as bearing on the early diagnosis of vari- 
 ous phases of general arteriosclerosis. The early alterations in the retinal 
 circulation which should direct attention to general symptoms indicative 
 of beginning sclerotic changes are tortuosity of one or more of the smaller 
 arteries, the evidence of undue pressure of an artery at its point of crossing 
 of a retinal vein, and an increase of the light reflex of the arteries. At first 
 the vein is simply displaced in the direction of the arterial circulation, and 
 its flow slightly obstructed; later the venous current is markedly impeded, 
 and the vein greatly narrowed where the arterial pressure is exerted, and 
 is distended on the peripheral side. These changes are rarely accompanied 
 by sufficient fibrous thickening to cause white lines of perivascular inflam- 
 mation along the vessel. As the vessel walls lose their elasticity, the im- 
 pediment to the flow of blood results in tortuous vessels, the escape of 
 fluid into the surrounding tissues, and retinal oedema. These conditions 
 are not due to old age only, but to actual sclerosis of the vessels from disease. 
 
 The importance of early recognition of these ocular changes lies in 
 their association with similar disease of the brain and kidney. There is no 
 difficulty in determining by the ophthalmoscope the evidence in the eye- 
 ground of well-advanced types of arteriosclerosis^ but it is important that 
 recognition of these signs should be made before the disease has reached a 
 point where treatment is ineffectual. De Schweinitz called especial atten- 
 tion to the value of early recognition of the signs, even though they be 
 only suggestive, of angiosclerosis of the retinal vessels in persons who have 
 reached the age at which vessel degeneration may begin to appear, and 
 who consult the ophthalmologist for a change of reading glasses. These 
 signs are " a corkscrew appearance of individual vessels, a slight thicken- 
 ing of the perivascular lymph sheaths, a beginning brick-dust appearance 
 of the optic nerve-head, and a flattening of a vein against an artery or a 
 bending in a curve of the vein overlying the artery." With these retinal 
 conditions present the physician should carefully examine the cardio- 
 vascular system, and accurately test the arterial tension by approved 
 means, and, should the tests confirm the retinal findings, institute appro- 
 priate treatment, which may save not only lesions of the eyes but of other 
 structures, notably the brain, which, if they occur, may prove fatal. 
 
 Obstruction of the Retinal Vessels. — An embolism may lodge in the 
 central retinal artery or in one of its branches. Sudden blindness 
 follows complete obstruction of the central vessel, whereas in plugging of 
 one of the smaller vessels the blind area will correspond to the section of 
 the retina supphed by the vessel affected. The fundus picture in embohsm 
 of the central artery shows a palhd disk, a grayish white cedema of the 
 retina, and the appearance of a central red spot in the fovea. The affection 
 presents the same general symptoms and changes in the eye-ground as in 
 thrombus. Both occur in endarteritis, heart disease, and changes in the 
 composition of the blood. 
 
PLATE IX. 
 
 V 
 
 [Changes in Arteriosclerosis.— After De Schweinitz. 
 
 A, Normal fundus. B to F, successive changes occurring in arteriosclerosis, including pallid arteries 
 (B), later assuming a silver-wire appearance (C); indented veins (B, C), afterward showing ampullifonn 
 enlargements (D, E) ; corkscrew capillaries (C, D) ; corkscrew arteries and veins (D, E) ; perivasculitis 
 (C, D); sclerosis of vessels (F); oedema of disk (B, C, D, E), hemorrhages(C, F).— D.] 
 
PLATE X. 
 
 [Changes in Retinal Vessels.— After \Yurdemann in Posey and t^pille^. 
 A, Embolism central artery; partial, affecting only inferior branch (Haab). B, Embolism central 
 artery total within nerve; a cilio-retinal vessel supplies a small area of retina m which function is 
 preserved (Wiirdemann). C, Thrombosis of central vessels from mumps (^^urdemann). D, bame case 
 six months later, showing sclerosis and atrophy (Wiirdemann). E, Hemorrhages trom retmal vessels 
 (Magnus). F, Perivasculitis luetica (Magnus).— D.] 
 
PLATE XL 
 
 [Inflammations of the Retina.— After Wiirdemann in Posey and Spiller. 
 
 A, CEdema in pernicious ansemia (Oliver). B, Leiuwmic retinitis (Oliver). C, Albuminuric ret- 
 initis and neuritis of pregnancy (Wiirdemann). D, Albuminuric retinitis in the negro (\\ virdemnnn). 
 E, Syphilitic retinitis (Haab). F, Atrophy of retina, chorioid, and nerve following chorio-retnutis 
 luetica) (Oeller.— D.] 
 
EXAMINATION BY X-RAYS. 377 
 
 XI. 
 THE EXAMINATION BY X-RAYS. 
 
 The Rontgen ray with present-day technic, in the hands of one 
 skilled in its employment, brings to the general practitioner an agent of 
 very positive worth. 
 
 In surgery its employment for diagnostic purposes is well recognized. 
 To the ophthalmologist its service in localizing foreign bodies in the eye 
 marks one of the distinct advances in that specialty. With an efficient 
 equipment, and one skilled in the use of it, the Rontgen rays play a very 
 important part in the diagnosis of general medicine. Not that they alone 
 should be expected to declare what the obscure disease of head, chest, or 
 abdomen is, but, in conjunction with the history of the case, its physical 
 signs and symptoms, and such other technic as is in current use, the 
 X-rays prove a very useful adjunct in corroborating, modifying, or 
 controlling knowledge gained in the more usual ways. 
 
 Apparatus and Technic. — In the development of the Rontgen rays 
 the chief things necessary are a source of electricity, an apparatus for 
 transforming the electric current, an X-ray tube, a fluoroscope, and radio- 
 graphic plates. 
 
 Source of Electricity. — The electric current may be that of the 
 street, of the storage battery, or of the static machine. The street current 
 (of 100 or more volts) is, perhaps, the most satisfactory supply for those 
 who can obtain it. The static machine is subject to changes of weather 
 and is costly, but it is often the only means of delivering an electric current 
 sufficient to produce the Rontgen rays. With the static machine a coil is 
 not necessary. The storage battery is also costly, heavy, requires frequent 
 recharging, and is employed principally because of its portability. 
 
 Tube. — The tube consists of a glass bulb, from 4 to 8 inches in diam- 
 eter, and so exhausted of air as to make it nearly a vacuum. Within this 
 bulb and near its centre is a platinum plate, known as the anode, and at 
 a fixed distance and angle another aluminum plate, known as the cathode. 
 The poles are connected outside the bulb with the terminals, and the cur- 
 rent passes within the tube from the cathode to the anode, and in doing so 
 generates the Rontgen rays. Attached externally to the best tubes now 
 in use is a smaller glass bulb, which serves as a "safety valve" to the larger 
 bulb. It contains certain chemicals, which, acted upon by the current, 
 reduce the vacuum of the larger bulb, and so preserve it from puncture 
 and fit it for use. The glass of the bulb should be of the clearest quality, 
 free from lead, and as thin as can be emploj^ed with safety. The tubes 
 highly exhausted are known as "high" or hard tubes, and are the tubes 
 required where the greatest penetration is necessary. The tubes of lesser 
 vacuum are known as "soft" tubes, and are commonly used for purposes 
 of treatment. Age and usage vary the vacuum and make the life of a 
 tube an uncertainty. Tubes are easily broken, punctured, and softened, 
 so that they are always an item of expense to the skiagrapher. 
 
378 MEDICAL DIAGNOSIS. 
 
 Coil. — The coil consists of three principal parts: 1. The interrupter 
 which makes and breaks the current, and so increases the electromotive 
 force of the current. 2. The condenser, designed to eliminate self-induced 
 currents. 3. The coil itself. The coil consists of the primary, through 
 which the interrupted current passes, and the secondary, which delivers 
 the induced current through the terminals to the tube. In the use of the 
 street current and the current from the storage battery the coil is essential 
 for the production of the X-rays. 
 
 The Fluoroscope. — The fluoroscope consists of a screen, upon which 
 are deposited crystals of calcium tungstate or barium platinocyanide. 
 The screen is surrounded on one side by a hood. 
 
 Fluoroscopic examinations can be quickly made, they are inexpensive, 
 moving organs can be watched, and, for certain parts of the body, they 
 give the most satisfactory information. But constant use of the fluoroscope 
 has been found dangerous, and there is less detail than in the skiagraphic 
 plate. Furthermore, no record remains of what was studied except in the 
 observer's mind. 
 
 Plates. — The plates prepared by different manufacturers are similar 
 to those employed by the photographer, in fact, for some forms of X-ray 
 work, ordinary photographers' plates may be used. The plate shows more 
 detail than the fluoroscope, furnishes a permanent record, and can be 
 studied and compared with plates made subsequently. 
 
 The Rontgen rays can be developed regardless of daylight or dark- 
 ness, but a darkened room gives the operator the best opportunity of 
 controlling his apparatus and for the use of the fluoroscope. When a 
 tube is giving satisfactory results it emits a peculiar greenish fluorescence, 
 so that when the hand is held between it and the fluoroscope its bony 
 structures are clearly seen and outlined. In making radiographic pictures 
 the tube is placed at a definite distance from the part, with the plate on 
 the opposite side. The current is turned on to produce the rays, and after 
 a proper exposure the structures of the part are pictured upon the sensitive 
 plate. Every operator learns to know his current, coil, and tubes, and 
 how they are best used, and the length of time required to make a picture. 
 The rays, too frequently used or employed for too great a length of time, 
 are likely to excite a dermatitis, deep burns that require months to heal, 
 destruction of hair, withering of fingers and nails, possible injury to the 
 sexual functions, and interference with the process of metabolism. The 
 tube should be enclosed in a heavy glass shield, and the operator protected 
 behind a leaden screen. The fluoroscope must he einployed loith great caution. 
 The handle should be protected with a leaden cover, and the observations 
 made as rapidly as possible. The well-being of both the patient and the 
 operator is to be kept constantly in mind. 
 
 The Head. — Perhaps the most difficult field of all in the use of the 
 X-rays is that of the head. The tissues of the head offer much resistance 
 to the transmission of the rays, and cause shadows of varying intensities, 
 since the bony walls are irregular, interrupted by numerous sutures, fur- 
 rowed by grooves and sinuses, containing air spaces, and because the brain 
 structures are convoluted and freely bathed with blood. "When a good 
 picture is obtained, the shadows of the normal structures make the outline 
 
EXAMINATION BY X-RAYS. 379 
 
 of any pathological condition difficult to procure and difficult to interpret. 
 It requires the best of technic to produce a satisfactory picture, and a 
 wide experience to interpret a good picture. It is possible, especially 
 when the skull is thin, to derive definite information as to the size and posi- 
 tion of dense, sharply outlined, coarse lesions, as sarcomata, fibromata, 
 cysts, abscesses, tuberculous nodules, and rarely of blood-clots. The find- 
 ings here are not as certain as elsewhere, but the diagnostician, who wishes 
 to exhaust every means, will certainly not reject the information brought 
 to him by this agency. In the hands of expert operators positive infor- 
 mation is often added to that obtained by other means of diagnosis, and 
 not infrequently negative findings are of great value. To know, for in- 
 stance, that a good skiagraph shows no shadow in a region where the physi- 
 cal signs suggest a tumor, would probably make the average physician 
 hesitate to employ surgical intervention; while, in an equally good picture, 
 a clearly outlined growth in some region producing few physical signs 
 might, if known at an early period, be the means of saving life. 
 
 The Neck. — The presence of an aneurism, or a tumor, and its extent 
 can often be determined. Expansile pulsation would suggest an aneurism 
 with thin walls, and a dense, dark shadow having a heaving impulse 
 synchronous with the cardiac beat would be suggestive of a tumor attached 
 to one of the larger vessels. 
 
 The Thorax. — The chest is the region in which the X-rays are of 
 great use to the internist, and the fluoroscope often yields data of diagnostic 
 value. The lung tissue offers little resistance to the passage of the rays, 
 and, consequently, the shadows of the sternum, ribs, clavicle, scapulse, and 
 spinal column are clearly seen, and the position of the heart, the arch of 
 the aorta and diaphragm recognized without difficulty. A further advan- 
 tage of the fluoroscope is that these organs can be observed in motion, 
 in both the state of health and disease. 
 
 Upon the screen of the fluoroscope, the normal lung appears trans- 
 lucent, the bony parts dark, and the heart and diaphragm exhibit charac- 
 teristic movements. It is, therefore, evident with these conditions that 
 positive information can be gained with the fluoroscope. Through this 
 instrument the diaphragm in health is seen as a dome-shaped shadow at 
 the level of the fourth rib on the right side, and of the fourth interspace 
 on the left, which in health makes an excursion between 1.5 and 1.7 cm., 
 and in full inspiration between 6.8 and 7.1 cm. The average excursus in 
 quiet breathing is estimated at 1.25 cm. In tall subjects it is greater, and 
 in small, deep-chested persons somewhat less. This knowledge of the 
 action of the diaphragm is of great moment, for in nearly every morbid 
 condition of lung or pleural cavity there is an attending change in the 
 action of the diaphragm. Consequently, every operator should familiarize 
 himself with the appearance of the normal chest, the position and move- 
 ment of the normal heart, and particularly the position and excursions of 
 the normal diaphragm. 
 
 Phthisis. — In general it may be said that a darkening of the fluoro- 
 scopic pictures of the apices suggests phthisis. Sometimes there may be 
 only a diminution of the clearness of the lung, and the outline of clavicle 
 and ribs is less distinct than on the sound side. The movements of the 
 
380 
 
 MEDICAL DIAGNOSIS. 
 
 diaphragm may be restricted on the affected side, and occasionally the 
 heart is drawn towards it. The limits of the excursion of the diaphragm 
 should be traced upon the skin with pencil, and the difference, if any, 
 noted in this way. The extent of the darkened area and its outline should 
 
 Fig. 153. — Case of acute miliary tuberculosis in girl of twelve years. (A. W. George, M.D.) — Rotch. 
 
 Fig. 154. — Enlarged bronchial glands in a girl of twelve years. Notice dark shadows situated along 
 right border of heart extending up into apex. Seen in all normal chests, but to less extent than these. 
 Lungs and pleurae otherwise normal. (A. W. George, M.D.) — Rotch. 
 
 be likewise indicated upon the chest wall, or tracing paper, so that it may 
 be compared with the condition later. An X-ray plate made in this state 
 often shows a "mottling" of the part, or it ma}^ indicate general apical 
 consolidation. If there be enlarged bronchial glands they also may cause 
 circumscribed shadows. In the early stages, with an irregular rise of 
 
EXAMINATION BY X-RAYS. 
 
 381 
 
 Fig. 155. — Case of plastic pleurisy in girl six years of age. Shadow extending over entire left chest except- 
 ing in central part. Shadow not changed with position. (A. W. George, M.D.; — Rotch. 
 
 Fig. 156. — Left-sided pleural effusion with displacement of heart to the right. (Mange.s.) — Jefferson 
 
 Hospital. 
 
382 MEDICAL DIAGNOSIS. 
 
 evening temperature, with slight digestive symptoms, with or rarely with- 
 out cough, before the sputum gives a positive report, and when indefinite 
 physical signs exist, the Rontgen rays may afford diagnostic criteria as 
 to the nature of the disorder. The progress of the pathological process 
 can also be studied. Cavity formation presents a clear space in the picture 
 of the affected lung. If there are thickened walls, they frequently cast a 
 dark shadow, and fluid, offering resistance to the rays, can be seen and 
 outlined in the broken-down area. Comparative studies of skiagraphs 
 made on repeated examinations afford valuable information in some cases. 
 The report of the Rontgen rays should never be considered apart from the 
 knowledge gained by other clinical investigations and the history of the 
 case, but, combined with these, it rounds out and completes the case 
 record, and gives the practitioner an opportunity to see with his own eyes 
 what is transpiring before him. In emphysema the lung is brighter than 
 normal, as seen through the screen. This obtains throughout the whole 
 structure involved. Thickening of the pleura may present shadows, and, 
 not infrequently, pleural fibrosis is responsible for displacement of organs, 
 and shows a picture which indicates these changes. 
 
 Pneumonia. — Usually the physical signs of pneumonia, with its his- 
 tory, are so characteristic that an appeal to the X-rays is not necessary. 
 The fluoroscope may be of aid in the diagnosis of central pneumonia, and 
 the picture will localize the darkened, restricted area in the central part 
 of. the lung with a clear space above and below it. In certain obscure 
 cases where the physical signs are less marked than usual, and in the aged, 
 the rays may be of great service. 
 
 Pleurisy with Effusion. — Referring alwaj^s to the history and physi- 
 cal signs, the rays in this disease may give much additional information. 
 In a pleural effusion of any extent the movements of the diaphragm are 
 restricted or arrested. The lung above is more dense than on the sound 
 side. The heart is displaced. The line of the ribs is distorted, and the 
 dark shadow of the effusion joins that of the diaphragm. If the pleurisy is 
 attended by phthisis, the apex will show an area reduced in clearness. 
 In old pleurisy with adhesions, the heart is often displaced toward the 
 affected side, the ribs are drawn nearer together, and the excursion of the 
 diaphragm is markedly restricted. Empyema. — In empyema the outline of 
 the involved area is seen as a very dense shadow. The very heavy shadows 
 of the thickened walls can occasionally be distinguished from the opacity 
 caused by the fluid. The movements of the diaphragm are interfered with, 
 and the adjacent viscera are dislocated. In chronic empyema adhesions may 
 displace surrounding organs towards the diseased side. In pneumopyothorax 
 and pneumohydrothorax there is a clear space between the fluid and the 
 lung above. The dark shadow of the fluid shifts with the change of the 
 patient's position. It sometimes can be seen to pulsate with the heart. 
 
 Emphysema. — In this condition, wdth more air in the lung tissue than 
 normally, it is evident that the extent of the lung will be increased. The 
 picture is clearer than that of the normal lung. The diaphragm is lower, 
 and its excursion restricted. If the left side is involved, the outline of the 
 heart is sharper than normal, lower down in the chest, and more vertical 
 than in health. 
 
EXAMINATION BY X-RAYS. 
 
 383 
 
 Fig. 157. — Tack in the right bronchus. Operation, recovery (case of Dr. Gibbon). (Manges.) — Jefferson 
 
 Hospital. 
 
 Fig. 158. — Aneurism involving the arch of the aorta. (Manges.) — Jefferson Hospital. 
 
384 MEDICAL DIAGNOSIS. 
 
 Bronchitis. — In the average case of bronchitis the fluoroscopic 
 and radiographic examinations are unnecessary. The action of the dia- 
 phragm may be restricted when the bronchial tubes contain much secretion, 
 and after coughing, when the bronchi have been freed from mucus, the 
 movements of the diaphragm approach the normal. Occasionally the 
 outline of the ribs appears less distinct than in health. The symptoms of a 
 rapidly developing bronchitis or pneumonia, especially in young children 
 in whom a history cannot be obtained, may depend upon a foreign body 
 lodged in the trachea or in the bronchial tubes, and in such case the ad- 
 vantage of the X-ray examination is obvious. Negative findings in some 
 cases of severe bronchitis may be of diagnostic importance. 
 
 The Heart. — By means of the fluoroscope the position, size, and 
 action of the heart are readily seen because this organ casts a very dark 
 shadow upon the screen, and if the heart is hypertrophied or dilated, its 
 extent beyond the normal boundaries is seen at a glance. Irregularity and 
 extent of contraction of the ventricles has been observed. If there are 
 pleuritic or diaphragmatic adhesions, the displacement of the heart and its 
 tugging upon these structures may be observed. Displacement from new 
 growths or pleural effusion is likewise recognized. The radiograph is of 
 much less value than the fluoroscope in the study of this particular organ. 
 
 The Aorta, and Aneurisms. — The course of the aorta can be seen 
 arising in the normal chest, slightly to the right and above the heart, and 
 then running to the left of the spinal column and downward until it is lost 
 in the shadow of the heart. A small aneurism in the ascending arch wiU 
 be seen as a shadow extending to the right of the sternum, while a smaU 
 aneurism of the transverse or descending portion of the arch casts a shadow 
 greater than the normal shadow on the left side of the sternum. A large 
 Aneurism produces a shadow both to the right and to the left of the sternum, 
 and shows distinct pulsation. Here, as everywhere, the findings of the X-rays 
 must be taken in conjunction with the history and signs and symptoms. 
 
 New Growths. — A new growth of considerable size is almost certain 
 to be seen and localized by the aid of the fluoroscope and sensitive plate. 
 In an afebrile case with the signs of pulmonary solidification, with cough 
 and blood-tinged expectoration, a dark area in the picture of the lung 
 structure is almost certain to be a new growth. Changes in its position 
 and growth, and its relation to the surrounding viscera, can be noted from 
 week to week, and a prognosis indicated. In doubtful cases the value of a 
 negative fluoroscopic examination is self-evident. In diseases of the chest 
 the X-ray examination is an agent that brings positive service to those 
 who employ it intelligently. 
 
 The Abdomen. — The CEsophagus. — The course and condition of the 
 oesophagus can be ascertained by means of the Rontgen rays. The shadow 
 caused by a rubber-coated wire when inserted into the oesophagus will 
 indicate the direction of the organ. The X-rays can localize a stricture 
 when a bulbar bougie is inserted to the level of the obstruction, and 
 diverticula can be outlined by lowering a thin rubber tube filled with shot 
 or mercury into it, or by having the patient swallow a suspension of bis- 
 muth subnitrate. New growths in the oesophagus are difficult to see, 
 because of the density of the shadows cast by the sternum and spinal column. 
 
EXAMINATION BY X-RAYS. 
 
 385 
 
 The Stomach. — By distending the stomach with air or gas, the light- 
 ened space gives a fair idea of the position and size of this organ. Bismuth 
 suhnitrate in the amount of an ounce or more, taken in a bowl of milk, 
 will cast a dark shadow upon the plate, which more distinctly shows the 
 outline of the viscus. If there is a stricture at the pylorus, celluloid cap- 
 sules of bismuth will lie in the stomach for a period of time, and then be 
 expelled by vomiting. A large carcinomatous mass involving the stomach 
 
 Vir,. 
 
 l.jO. — "Hour-glass" deformity of the stomach; diagnosis confirmed at operation (case of Dr. Gibbon). 
 (MangesJ — Jeffer.;on Hospital. 
 
 wall will usually make its impress upon the sensitive plate and confirm 
 the other means of diagnosis. A change in the shape and size of the stomach, 
 as in the ''hour-glass stomach," has been likewise studied with bismuth. 
 Stomach peristalsis can also be studied with the X-rays. 
 
 The Intestinal Tract. — Because of the lack of contrast in the 
 density of the shadows, the amount of information gained b}^ the X-ray 
 examination of these structures is often disappointing. New growths may 
 cast shadows here as they do everywhere, but their actual relation to the 
 section of the bowel from which they spring can only, as a rule, be roughly 
 25 
 
386 MEDICAL DIAGNOSIS. 
 
 estimated. Injection of bismuth subnitrate into the colon serves to out- 
 Hne that part of the canal. It is well to remember that acute abdominal 
 symptoms may be excited by a foreign body, which has been swallowed^ 
 and in such cases the X-ray picture may clear up the diagnosis. 
 
 The Liver. — In children and in thin subjects the left lobe of the liver 
 can usually be outlined. Marked displacement or enlargement of the liver 
 often shows in a satisfactory radiograph. A distended gall-bladder, espe- 
 cially if it be filled with gall-stones, is likely to give a picture of some real 
 worth. Carcinomatous masses cause characteristic irregular, dense shadows. 
 
 The Spleen. — If the stomach is distended by air or gas, so as to 
 increase the contrast, the shadow of the spleen can quite commonly be seen 
 with the fluoroscope, and its size, position, and movement on deep inspi- 
 ration observed. If it should be a wandering spleen, the absence of this 
 shadow in the normal position would be a confirming figure in that diagnosis. 
 
 The Kidneys. — With good technic it is at times possible to get an 
 outline of these structures, to know if they are in their normal positions 
 (particularly on the left side), to know if they are swollen, or if the shadow 
 is enlarged by perinephritic abscess, and particularly if it is possible to 
 determine v/hether there be a stone in the organ. Stone in the bladder and 
 stone in the ureters concern the surgeon more, as a rule, than the general 
 practitioner; and yet, with an obscure history and physical signs, the 
 general practitioner is the first one called in to make a diagnosis, and he 
 fails to do himself justice if he neglects to procure a good radiograph plate. 
 
 The Extremities. — Hardened arteries, when palpable, are readily 
 recognized, but in the deeper structures this is impossible, and a good 
 X-ray plate will often exhibit this condition in the femoral, the popliteal, 
 and the dorsalis pedis, as it will in the bronchial arteries. The shape and 
 density of the bones and the size of calcareous deposits in muscles and 
 tendons as their coverings are determined satisfactorily in a limited group 
 of diseases. 
 
 The Joints. — In swollen and stiffened joints it is often important, 
 both in determining the treatment and the prognosis,- to know whether 
 injury to the bony structures exists, or whether there be exostosis, or 
 simply an inflammatory condition of the soft parts. A good view with the 
 fluoroscope, or, better yet, a satisfactory radiograph picture, will deter- 
 mine this question. Calcified joints or deposits of any density will give a 
 dark shadow. 
 
 New Growths. — The position, shape, and size of tumors such as 
 sarcomata and fibromata can be pictured, and, not infrequently, the 
 differential diagnosis between these and an aneurism made. 
 
 Orthodiagraphy. — Moritz has devised a method of X-ray examina- 
 tion of the heart, which eliminates certain errors of the ordinary exami- 
 nation by a device which makes use only of the central rays from the 
 ordinary Crookes' tubes, that is, those which fall perpendicularly upon the 
 plate or fluoroscopic screen. By an orderly progressive movement of the 
 special tube along the periphery of the heart's shadow, and marking upon 
 the screen or the chest of the patient successive points at its border, and 
 joining these points by lines, a fairly accurate outline of the heart may 
 be obtained. The results of this method, as worked out by several 
 
r 
 
 EXAMINATION BY X-RAYS 
 
 387 
 
 • 
 
 Fig. 160. — Intestinal obstruction due to peritoneal adhesions. Diaainosis confirmed at operation (case 
 of Dr. Loux). (Manges.) — Jefferson Hospital. 
 
 Fig. 161. — Calculus in the left renal pelvis. (Manges.) — Jefferson Hospital 
 
388 MEDICAL DIAGNOSIS. 
 
 observers, confirm certain facts that have been determined by the methods 
 of physical diagnosis, and have long been known. Among these the 
 following are important: 
 
 (a) In the adult under normal circumstances the liver and diaphragm, 
 upon change from the recumbent to the erect posture, assume a lower 
 level, and corresponding with this change the heart assumes a somewhat 
 more vertical position, its apex being lower and its transverse diameter 
 decreased. 
 
 (b) In the aged the diaphragm likewise occupies a lower position, but, 
 owing to the relaxation of the ligamentous attachments of the great vessels, 
 the heart sinks as a whole so that its position remains more transverse. 
 
 (c) In females the average position of the heart is about an interspace 
 higher than in males. 
 
 (d) In acute and chronic pulmonary emphysema the position of the 
 diaphragm, and consequently that of the heart, is much lower than under 
 normal circumstances,, and for that reason the upper border of cardiac 
 dulness is, notwithstanding the increase in size of the right ventricle, 
 considerably lowered. 
 
 (e) Under pathological conditions the cardiac impulse does not, in 
 all cases, correctly indicate either the extreme left border of the heart 
 or its lower border. The apex may be covered by the border of the lung 
 on the one hand, and the movement of the chest wall may, on the other, 
 extend beyond the actual border of the heart. As shown by the X-ray 
 shadow the lower border may, in some cases, extend below the region of 
 the impulse. 
 
 Stereoskiagraphy. — The application of the principles of stereoscopy 
 to skiagraphy, first employed by Elihu Thompson, is of service in the 
 locaHzation of foreign bodies, tumors, and various lesions of the skeleton. 
 Several special instruments for making skiagraphs and different methods for 
 viewing stereoskiagrams (Wheatstone, Brewster) have been devised. "In 
 the study of normal and morbid conditions I invariably resort to the em- 
 ployment of stereoskiagraphy at the Philadelphia Hospital" (Kassabian). 
 
PART III. 
 
 OF SYMPTOMS AND SIGNS. 
 
 I. 
 
 GENERAL CONSIDERATIONS. 
 
 Symptoms and Signs. — The clinical phenomena of disease are divided 
 into two general groups: (a) subjective, those obtained by inquiry, and 
 (b) objective, those learned by observation. The former are known as 
 SYMPTOMS, the latter as signs. These may be general, as fever, debility, 
 or emaciation, or local, as pain, dyspnoea, or dulness upon percussion. 
 The dividing line between symptoms and signs is not well defined. Pain 
 and nausea are symptoms of which nothing can be learned by observa- 
 tion alone; an endocardial murmur or pleural friction rub, signs concern- 
 ing which the patient can give no personal account; while retching, cough, 
 and palpitation partake at once of the nature of both signs and symptoms 
 and may be referred to the one or other group of clinical phenomena accord- 
 ing to the point of view from which they are regarded. Symptomatology 
 is .that department of medical science which has for its object the consider- 
 ation of the symptoms of disease; semeiology {(rri/isiov, a sign), that 
 which has for its object the consideration of the signs of disease. Just as 
 symptoms and signs are not always to be closely distinguished, so the 
 scope and subject matter of these sub-sciences of medicine largely overlap, 
 and symptomatology and semeiology are frequently used interchangeably. 
 Pure symptoms are limited in number as compared with signs, and, since 
 they are wholly subjective and our knowledge of them is based upon the 
 statements of the patient, who may, according to his temperament or for 
 purposes of his own, either unintentionally or wilfully misrepresent them, 
 they are of far less value in diagnosis than signs. Symptoms, which have 
 their origin in the deranged sensations of the patient, stand in contrast to 
 signs, which are dependent upon changes in organs or tissues. For this 
 reason qualifying adjectives are sometimes employed, and we speak of 
 rational symptoms and physical signs. It is customary, however, to 
 apply the word symptom to many of the objective phenomena of disease. 
 
 Syndrome is a term used to designate a set of concomitant symptoms, 
 especially the concurrence of a group of symptoms not indicating a disease 
 with well-determined anatomical lesions, as for example fever, seasickness, 
 and astasia-abasia; a symptom-complex; a symptom-group. 
 
 Diseases upon one basis of classification are divided into constitutional 
 or general, namely, those in which the organism as a whole reacts to the 
 pathogenic influence; and local or organic, in which the lesions involve 
 primarily or chiefly a viscus or an anatomical tract. General symptoms 
 
 3S9 
 
390 MEDICAL DIAGNOSIS. 
 
 fire often the expression of a local disease and local symptoms the expression 
 of a general disease; thus emaciation, pallor, and a profound cachexia 
 attend the progress of carcinoma of the stomach, while tenderness in the 
 right iliac fossa, diarrhoea, and tympany are symptoms of enteric fever. 
 
 II. 
 
 APPEARANCE; TEMPERAMENT AND DIATHESIS; FACIES; 
 
 FORM AND NUTRITION. 
 
 APPEARANCE. 
 
 The general appearance of the patient when first seen forms the ground- 
 work for the study of his present condition — the status prcesens. Whatever 
 knowledge may be subsequently obtained of the facts in the case, the 
 general appearance constitutes the point of departure for the direct diag- 
 nosis. In the successful clinician the habit of observing and noting its 
 various details with great rapidity is cultivated in a high degree. The 
 facial expression, state of nutrition, movements and attitude, mode of 
 speech, and mental condition are at once observed. An opinion is formed 
 as to what manner of man the patient is. Information as to his social 
 position, occupation, and habits may be learned from his dress: Is he neat 
 or slovenly? Are his clothes buttoned awry? Is his collar loose to make 
 room for swollen glands or a goitre? Do his trousers show the white stains 
 of diabetic urine? Has he the tabetic or steppage gait or the festination 
 of paralysis agitans? Has he the flushed face with dilated venules and the 
 trembling tongue of the alcoholic, or the enlarged girth and the waistband 
 lengthened with a loop of string, of hepatic cirrhosis with ascites? The 
 hands tell a story of their own. We note at a glance that they are white 
 and soft and the finger-nails are clean, as occurs mostly, but not always, 
 with men of leisure and professional men; that they are large and callous, 
 as in those who follow the sea; coarse, sunburnt, and freckled, as in the 
 farmer; or that they bear the oil and grime of the mechanic who has hurried 
 from his work. The trembling hand of alcoholism, the pill-rolling move- 
 ments of paralysis agitans, the nodules and tophi of gout, the deformities 
 and relaxed ligaments of arthritis deformans, and the spade-like hands of 
 myxoedema tell their own tale. 
 
 The diagnosis may sometimes be made at a glance. The flushed face, 
 hurried breathing, unilateral movement of the chest, and rusty sputum of 
 pneumonia scarcely demand the additional data of chill, crepitant rale, 
 and percussion dulness; nor the intense headache, opisthotonos, vomiting, 
 herpes, and petechise the history of sudden onset or the epidemic prevalence 
 of cerebrospinal fever; while the paroxysm of whooping-cough is in itself 
 diagnostic. The diagnosis thus made cannot, however, be called intuitive. 
 In truth there is no such thing as an intuitive diagnosis. Before a conclu- 
 sion is reached, however brief the time, the clinician, usually without being 
 aware of his mental processes, has been weighing and sifting the symptoms 
 
SYMPTOMS AND SIGNS: TEMPERAMENT— DIATHESIS. 391 
 
 and assigning to each its proper value and importance. Such a diagnosis 
 must in all cases be personally regarded as provisional and not announced, 
 however tempting the circumstances, until sufficient facts for its full sup- 
 port have been obtained. There are pitfalls in the way of him who makes 
 "what in the language of the ward classes is called a "snap diagnosis." 
 It is never complete; the pneumonia may be complicated with pericarditis. 
 Such a diagnosis is sometimes altogether false; there are cases of enteric 
 fever in neurotic individuals in early life that closely simulate the symp- 
 tom-complex of meningitis — the so-called cerebrospinal form of enteric 
 fever — and a child long convalescent from whooping-cough may under 
 emotional excitement or when suffering from an attack of subacute 
 laryngitis have paroxysms of cough with whooping. 
 
 TEMPERAMENT AND DIATHESIS. 
 
 Under the teaching of the French school great importance was at one 
 time attached to temperament or diathesis as a condition of the hereditary 
 constitution manifested in the general appearance of the patient. Less 
 attention is paid to this subject now than formerly, but no very close 
 observation is required to establish the fact that many individuals have in 
 common peculiarities of physical and mental organization very different 
 from those of others and that corresponding differences in general health 
 and tendency to disease occur. Disregarding misleading refinements and 
 combinations the following principal forms may be described: 
 
 The sanguine, sometimes called the Arthritic or Gouty Tempera- 
 ment. -^The characteristics of this condition are well-developed bones and 
 muscles, a fine skin, good hair, fair complexion, good nutrition, a general 
 appearance of health and energy. The physiological processes are active, 
 the digestion excellent, the bowels regular, the respiratory excursus large, 
 the action of the heart regular, the pulse full and strong. In disposition 
 persons of this temperament are cheerful and hopeful, hence the adjective 
 "sanguine" often applied to them. Mentally they are active but of delib- 
 erate judgment and they do a large part of the world's work. They are 
 especially liable to bronchitis and other catarrhal affections and to arterio- 
 sclerosis, and in advancing life prone to sclerotic changes in the valves of 
 the heart, aneurism, angina pectoris, or apoplexy. 
 
 The nervous diathesis shows itself commonly in slender or under- 
 sized individuals who are often poor and irregular eaters, not well nourished. 
 Such persons are alert and active but often incapable of sustained effort. 
 The physiological processes are not always well performed. They often 
 possess high intellectual ability and are subject to intense emotions. They 
 are predisposed to derangements of the digestive apparatus and to head- 
 ache from slight causes. They take things to heart, as the phrase goes, 
 and are liable to break down under stress of work and worry. Neuras- 
 thenia, hysteria, migraine, and other functional diseases of the nervous 
 isystem and insanity are common. 
 
 The Bilious Diathesis. — The complexion is dark, the hair dark 
 brown or black, often coarse and oily, the skin shows a tendency to local 
 pigmentation which varies in intensity, especially about the eyes and brow. 
 
392 MEDICAL DIAGNOSIS. 
 
 The appetite is irregular, often poor, fats and sugars are digested with 
 difficulty, and the bowels are sluggish. The nutrition is not good, though 
 women of this temperament often grow stout in middle life. They are 
 subject to attacks of that form of gastrohepatic catarrh popularly 
 described as biliousness and are often at such times faintly jaundiced. 
 Nausea and headache are common. Such persons often lack energy. 
 
 The Lymphatic Diathesis. — The muscles are soft and flabby, there 
 is very often a slight excess of subcutaneous fat. The skin is pallid, the 
 physiological processes are sluggishly performed. Mentally such persons are 
 dull and unresponsive. They are subject to enlargements of the subcuta- 
 neous lymph-nodes and are liable to chlorosis and other forms of ansemia. 
 
 The Strumous Diathesis. — The word struma, meaning scrofula or 
 glandular tuberculosis, though still applied in another sense to goitrous 
 swellings, has lost its significance in medicine and has almost disappeared 
 from the modern literature. The term strumous diathesis has, however, 
 a very definite significance and is applied to a bodily constitution unfor- 
 tunately too common. The bony framework departs widely from the 
 normal type. The chest is small and flat, the shafts of the long bones 
 slender, their epiphyses enlarged and thickened. The musculature is 
 undeveloped and soft. The appearance is characteristic, the head is large, 
 the cranial bosses prominent, the forehead broad and protuberant, the 
 lips full, the nose short and broad, its alse thickened, the lower jaw small, 
 the teeth carious, the complexion commonly fair, the hair fine and the eye- 
 lashes long. The nutrition is poor and the general appearance of such 
 individuals delicate and frail. The cervical lymphatics are often enlarged. 
 Such persons are subject to tuberculosis of the glands, bones, and lungs 
 and miliary tuberculosis, and usually die at an early age. They are fre- 
 quently the offspring of tuberculous parents. Whether the constitutional 
 peculiarities which go to make up the so-called strumous diathesis are to 
 be ascribed to profound derangements of nutrition, transmitted from 
 tuberculous parents, or to a latent tuberculosis acquired in the earliest 
 period of life cannot always be determined. 
 
 Cachexia is a term used to describe the ravages of certain chronic 
 wasting diseases, especially untreated malaria, the graver forms of syphilis, 
 and carcinoma, particularly when it involves the digestive organs. The 
 cachexisB present a combination of profound ansemia, extreme emaciation 
 and debility, and a diffuse, faint, muddy pigmentation of the skin. 
 
 Dyscrasia is a depraved state of the system, especially of the blood, 
 due to constitutional disease. In the words of Bristowe it is a general 
 deterioration of health and functional disturbance caused by the deflec- 
 tion of nutrition. We speak of a tuberculous, malarial, syphilitic, or 
 cancerous dyscrasia. 
 
 FACIES. 
 
 The appearance of the face is often of diagnostic importance. It 
 frequently indicates the subjective sensations and not rarely the psychical 
 condition. To say that a patient's expression is that of suffering, acute 
 pain, anxiety, overwhelming illness, or that it is excited, dull or, stupid, is 
 intelligible without further comment. The face is an index of the physio- 
 
SYMPTOMS AND SIGNS: FACIES. 
 
 393 
 
 logical age of the patient. The gray hair, wrinkled brow, arcus senilis, and 
 hanging folds of skin about the neck are very suggestive. They enable the 
 clinician to compare the apparent age of the patient with his actual age as 
 measured by years. The facies of fever patients is often characteristic. 
 In the stage of excitement there is an intensification, in that of depression 
 a blurring of expression, accompanied by a peculiar moist appearance of 
 the eye, a feverish flush and often a very slight turgescence of the skin 
 of which I shall speak more fully in a later paragraph. Equally character- 
 istic is the facies of dyspnoea. Here also puffing or turgescence is present, 
 sometimes marked, and there is cyanosis, and with these symptoms dilated 
 nostrils, an open mouth, and hurried breathing. The flushed face and 
 bright eyes that follow too much wine, and the bloated countenance with 
 its blurred lines, dilated venules, thickened nose, acne, and trembling tongue 
 of some forms of chronic alcoholism are sadly familiar. The characteristic 
 change of the countenance seen in those about to die, especially in patients 
 
 suffering from ileus, peritonitis, ^ ......„„.,...„„„.., : 
 
 cholera, and similar diseases, is ;««"•'=•'>■ 
 described as the facies Hip- 
 pocRATiCA. The changes are 
 largely due to a diminution in 
 the contents of the blood- and 
 lymph- vessels and muscular re- 
 laxation. The skin falls back 
 upon the bones, the lines of 
 expression are more sharply de- 
 fined than normally, the nose 
 is sharp and pinched, the eyes 
 sunken, the temples hollow. 
 With the pallor there is some de- 
 gree of cyanosis which gives the 
 skin a leaden or faintly livid hue. The surface is cool and bathed with sweat. 
 
 The appearance of the face in the following conditions is suggestive 
 if not always characteristic: 
 
 Enteric Fever. — In well-developed cases the face is dull, expression- 
 less, pallid, with a faint, dusky flush over the cheek bones, often slightly 
 drawn. The eyelids are half closed, the lips pallid and separated, in neg- 
 lected cases sordes may be seen upon the teeth. Such also is the facies of 
 patients profoundly septic. It occurs in the so-called "typhoid state" 
 and is seen in puerperal septicaemia, malignant endocarditis, infection after 
 surgical operations, and the like. 
 
 Acute Peritonitis. — The expression is one of intense suffering, 
 the face is pale and drawn, sometimes the upper lip is contracted so as to 
 show the teeth. 
 
 Pneumonia. — A circumscribed flush of one or both cheeks may be 
 seen; it may be bright or dusky. When one cheek only is flushed it is usu- 
 ally that upon the side of the pulmonary lesion. With this appearance in. 
 grave cases are associated the facial changes peculiar to dyspnoea. A 
 similar appearance accompanies the symptomatic fever of phthisis — hectic 
 fever. The flushing is, however, brighter and not so distinctly circumscribed. 
 
 Fig. 162. — Cerebrospinal fever, fourth day of attack. 
 Fever facies; patch of herpes; retraction of head. — Munic- 
 ipal Hospital, Royer. 
 
394 
 
 MEDICAL DIAGNOSIS. 
 
 It is in strong contrast with the pallor of the brow and neck. The strik- 
 ing appearance of such patients is intensified by expanding nostrils, hurried 
 - - breathing, bright moist eyes, and an 
 
 intense, often eager, expression. 
 
 Tetanus. — The facial peculiarity 
 is startling. Under the action of the 
 toxin of the disease all the muscles 
 of expression are thrown into tonic 
 spasm more or less intense at the 
 same time, whereas under ordinary 
 circumstances the varying moods 
 are expressed by the contraction 
 now of one set of muscles, now of 
 another. The lips are parted and 
 the corners of the mouth drawn up 
 as in laughter or grinning, while other 
 parts of the face and especially the 
 brow are contracted and throwa 
 into folds as though in grief or 
 anger — risus sardoxicus of the 
 older writers. 
 
 The Exanthemata — The appear- 
 ance of the face in the eruptive infec- 
 tious diseases is usually diagnostic. 
 The diffuse uniform rash, often in 
 strong contrast with the white border 
 around the mouth, and the slightly tumid skin of scarlet fever, the turgid 
 skin, coarse measly rash with its crescentiform arrangement and coryza in 
 measles, the pock in different stages 
 of development T\dth its umbilicated 
 vesicles or hideous pustules and 
 crusts and swollen and disfigured fea- 
 tures in the variolous diseases, and 
 the pellucid hemispherical vesicles 
 or crusts without areolae, scattered 
 singly or in groups about the brow or 
 mouth in varicella, are characteristic. 
 Mumps.— The deformity, alike 
 when it involves one or both sides, 
 is characteristic. The swelling is at 
 first limited to the region of the 
 parotid gland, behind the jaw and 
 below the ear, but the surrounding 
 oedema sometimes assumes remark- 
 able proportions. The lobule of 
 the ear stands out at right angles 
 to the side of the head. When 
 the swelling advances upon the cheeks, the corners of the mouth are 
 slightly drawn up. The parotid bubo which occurs in some cases of enteric 
 
 Fig. 163. — Parotid bubo complicating enteric fever. 
 — Jefferson Hospital. 
 
 Fk; 
 
 1C4. — Oedema in acute nephritis 
 Hospital. 
 
 -Jefferson 
 
SYMPTOMS AND SIGNS: FACIES. 
 
 395 
 
 Fig. 165. — Facies in a case of adenoid vegetations 
 of the nasopharynx. — Merrick. 
 
 fever, pneumonia, septicaemia, and other grave infections superadds 
 to the facies of those conditions a deformity somewhat like that of 
 mumps. The overlying skin is usually of a dusky red color. 
 
 Renal Disease. — The striking 
 appearance of the patient in some 
 forms of acute nephritis and very 
 commonly in chronic parenchyma- 
 tous nephritis is of diagnostic impor- 
 tance. It is characterized by intense 
 waxy pallor, marked oedema of the 
 35^elids, and general puffiness of the 
 face by which the lines of expression 
 are to some extent impaired. 
 
 Hepatic Disease. — In chronic 
 diseases of the liver and especially 
 in cirrhosis and gall-stone disease the 
 facies is peculiar. The features are 
 as a rule sharp, the face thin, con- 
 junctivae muddy, venules dilated, 
 lips red, and skin slightly jaundiced 
 or subicteroid — facies hepatica of 
 the older writers. 
 
 Malaria. — The pallor, sallow- 
 ness, and muddy conjunctivae which 
 
 are so commonly seen in intensely malarious districts are not without 
 
 considerable value in the diagnosis of the cachexia of this disease. 
 
 Syphilis. — The face may show characteristic eruptions at different 
 
 stages of the disease. The coppery fiat papule or papulosquamous syphilide 
 
 upon the temples and forehead — 
 CORONA VENERIS — is commou. The 
 face of the patient under treatment 
 may show not the eruption of the 
 disease but the drug exanthem 
 produced by the iodides. Babies 
 suffering from inherited syphilis are 
 usually pale, weazened, and wrin- 
 kled. They look curiously like 
 miniature old men. They have 
 snuffles and superficial excoriations 
 about the angles of the nose and 
 corners of the mouth. 
 
 Rickets. — The frontal and pari- 
 etal eminences are exaggerated 
 and the top of the skull flattened, 
 so that the head assumes an appear- 
 ance of squareness and is some- 
 times spoken of as box-shaped. 
 Hydrocephalus. — The head is characterized by its spherical shape, 
 great size, and protruding eyeballs, the result of depression of the orbital 
 
 -Exophtlialmic goitre. — Jefferson 
 Hospital. 
 
396 
 
 MEDICAL DIAGNOSIS. 
 
 Fig. 167. — Leprosy. 
 
 plate of the frontal bone. The exophthalmus is sometimes so marked 
 that the eyelids cannot be closed. The size of the head is often enormous, 
 
 its diameter may reach 20 to 25 cm. 
 in a child a few years old. The face 
 on the contrary appears very small, 
 its expression vacant and fatuous. 
 The cranial bones are separated 
 and exceedingly thin. The hair is 
 scanty and the veins may be seen 
 beneath the skin. 
 
 Hypertrophy of the Tonsils 
 and of the Adenoid Tissue of the 
 Pharnyx. — As a result of habitual 
 mouth-breathing the expression of 
 the countenance gradually under- 
 goes characteristic changes, the face 
 becomes apathetic and vacant, the 
 nostrils are narrow, the lips thick, 
 and there is projection of the upper 
 jaw and lip. 
 
 Myxoedema. — The face is 
 "moon-shaped," swollen and flattened, the nose broad, the mouth 
 coarse and large, the lines of expression obliterated. The skin is yellow, 
 waxy, dry, and scaly, the hair thin and scanty, the cheeks and nose flushed. 
 
 Cretinism.- — The face is large, 
 the lips thick, the tongue large and 
 protruded, the mouth open and drool- 
 ing, the nose flattened, the skin pallid 
 and waxy, the expression idiotic. 
 
 Acromegaly. — The bony hyper- 
 trophy is especially manifested in 
 the supra-orbital arches, the malar 
 bones, and in the projecting lower 
 jaw. The forehead is receding, the 
 nose is increased in size, its alas dis- 
 tended, the eyelids enlarged and 
 thickened. The cartilages of the ear 
 are also enlarged so that very often 
 the ears stand out conspicuously 
 from the head. 
 
 Exophthalmic Goitre. — The 
 protrusion of the eyeballs, some- 
 times so marked that the patient 
 can no longer close his eyes, pro- 
 duces a remarkable change in the 
 expression. In its lighter grades 
 
 the air is that of surprise, but when the exophthalmus is marked the 
 patient has a frightened or astonished look which is intensified by the 
 characteristic tremor. The enlargement of the thyroid body as well 
 
 
 \ / 
 
 j 
 i 
 
 1__ 
 
 
 
 Fig. 168. — Facial paralysis following cerebrospinal 
 fever. — Jefferson Hospital. 
 
SYMPTOMS AND SIGNS: FACIES. 
 
 397 
 
 Hemiatrophia facialis. — After Hirt. 
 
 as the visible pulsation and venous distention add to the peculiar 
 expression of the countenance in this disease. 
 
 Leprosy. — The development of leprous nodules upon the face and 
 the thickening of the skin give rise to remarkable deformities. The chin, 
 lips, nose, eyelids, and ears undergo 
 peculiar and characteristic changes, 
 in consequence of which the face 
 assumes the appearance of a hideous 
 expressionless mask. Baldness, loss 
 of the eyebrows, lashes, and beard, 
 and ulceration also occur. The dis- 
 figurement suggests the conventional 
 face of the satyr or the lion and is 
 often spoken of as leonine — facies 
 
 LEONIXA. 
 
 Nervous and Mental Disease. — 
 
 In functional nervous diseases there 
 are frequently changes in the coun- 
 tenance more easily recognized than 
 described. The pallid, slightly drawn 
 face of the neurasthenic with its habitual air of depression is faixdliar 
 to the practitioner. These traits, somewhat intensified, are common in 
 women broken down by frequent child-bearing and in those who suffer 
 from disease of the pelvic organs — facies uterina. In hysteria the face 
 
 usually remains free from the motor 
 disturbances so common elsewhere, par- 
 ticularly in the lower extremities. There 
 is neither spasm, paralysis, nor other con- 
 stant characteristic save that it reflects, 
 often intensely, the varying uncontrolled 
 emotions of the patient. Equally without 
 cause laughter succeeds tears or vivacity 
 is followed by an air of sullen and dogged 
 indifference. Central or peripheral dis- 
 ease of the nervous system may manifest 
 itself in spasmodic twitching of the facial 
 muscles. ]\Iimetic spasm or convulsive 
 tic consists of clonic contractions of the 
 muscles supplied by the facial nerve. 
 They are usually limited to the region 
 about the eye or above the corner of the 
 mouth. Sometimes they involve the 
 greater part of one or both sides of the 
 face. Similar contractions of the mus- 
 cles of expression occur in children and 
 are known as habit spasm. In peripheral facial palsy the affected side is 
 smooth and motionless, the wrinkles of the forehead and the labionasal 
 fold disappear, the corner of the mouth is lowered and frequently drools, 
 and the mouth itself is slightly drawn toward the sound side. The eyelids 
 
 Pig. 170. — Paranoia, homicidal type. — Chase. 
 
398 MEDICAL DIAGNOSIS. 
 
 are motionless and can only be partly closed. The tears fall over the 
 cheeks. The contrast mth the opposite side is intensified upon efforts to 
 sniile or close the eye. When the paralj^sis is due to central causes the 
 lower segment of the face is chiefly involved. In old cases, after contract- 
 ure has taken place the mouth is drawn toward the affected side. 
 
 In organic disease tremor and paralysis are significant. Tremor of 
 the lips and tongue occurs in chronic alcoholism. Fibrillary tremor is fre- 
 quently associated with progressive palsy. In bulbar paralysis the lips 
 are thin, compressed, and tremulous, the tongue is wasted and protruded 
 with difficulty, and there is dribbling of saliva. In paralysis agitans the 
 appearance of the countenance is very strikingly changed. The face has 
 a curious stiff, expressionless immobility which has given rise to the name 
 Parkinson's mask. There is often druling from the partially closed mouth 
 and the lips and tongue frequently share in the general tremor. In general 
 paresis local twitchings of the face, irregularity of the pupils, and slight 
 tremulousness of the lips are suggestive. The rare disease facial hemi- 
 atrophy is a trophic neurosis affecting one side of the face, commonly the 
 left. The soft tissues and bones are alike involved in the atrophic process, 
 wliich is sharply limited at the mesial line. The eye is sunken and the 
 corresponding half of the tongue and soft palate may be implicated. 
 
 The facies in disease of the mind is often characteristic. The depres- 
 sion of melancholia, the agitation and eagerness of acute mania, the alert 
 slyness of chronic mania, the irregular contractions of the facial muscles in 
 paresis, the fixed expression in paranoia with homicidal tendencies, the 
 fatuous face of the imbecile, are well known to every student of psychiatry. 
 
 FORM AND NUTRITION OF THE BODY. 
 
 These are important factors in the problem of diagnosis. The normal 
 of different individuals varies within wide limits. It is scarcely necessary 
 to say that persons may be tall or short, stout or slight, fat or lean, mthout 
 manifesting, even in wide ranges of difference in these respects, either the 
 predisposition to or the sj^mptoms of disease. Health consists in the ability 
 of the individual organism to maintain its normal activities in the environ- 
 ment in which it happens to be placed. The somewhat pallid, hollow- 
 chested and slender book-keeper often has good health and length of daj's 
 while the clear-eyed, bright-skinned, deep-chested, well-developed athlete 
 not infrequently breaks down' in early middle life. Variations in these 
 respects give rise to predisposition or constitute the indications of disease 
 when they become excessive. We say that a man has a splendid or powerful 
 physical development when the measurements of his body transcend the 
 average, but the health of another who does not reach the average may 
 be equally good. Not only anatomical structure but also physiological 
 function are to be considered. Subtle hereditary tendencies, the value of 
 which we cannot always estimate, and the shifting balance between the 
 powers of the organism and the work which it is called upon to do engage 
 our attention. To say that the physical organization is feeble, dehcate, 
 slender, robust, or muscular needs no further explanation. The condition 
 of nutrition shows itself furthermore in the development and tonicity of 
 
SYMPTOMS AND SIGNS: FORM AND NUTRITION. 399 
 
 the muscles and especially in their relation to the amount of subcutaneous 
 fat — panniculus adiposus. On the one hand a moderate amount of sub- 
 cutaneous fat is not incompatible with excellent health, an excess is alike 
 inconvenient and dangerous, and obesity constitutes a positive disease. 
 On the other hand a spare man may be equally healthy, while rapid loss 
 of fat is a suspicious symptom and emaciation an alarming sign of disease. 
 In estimating the value of these conditions the hereditary tendencies, the 
 occupation, the age, and the sex of the patient must receive due consideration. 
 In young infants the panniculus is well developed. In infancy it often 
 dmndles, only to increase again as puberty approaches. At this period it 
 not infrequently again becomes excessive. In advanced life the fat com- 
 monly diminishes and the aged as a rule are spare. The panniculus is usually 
 greater in women than in men and very often increases after the menopause. 
 In most chronic diseases the nutrition is impaired because either sufficient 
 nourishment is not taken on account of loss of appetite, or that which is 
 taken is not assimilated. A high degree of emaciation attends diseases of 
 the digestive organs and chronic febrile diseases, for example, carcinoma, 
 especially carcinoma of the oesophagus or pylorus, enterocolitis with exces- 
 sive diarrhoea, some forms of diabetes mellitus, phthisis, and enteric fever 
 with repeated relapses. Wasting of fat is accompanied by wasting of muscle. 
 
 Weight. — The weight of the body and the amount of subcutaneous 
 fat may be approximately estimated by inspection, but this method is 
 uncertain and practically valueless in determining the progress of gain or 
 loss. Accurate data can only be obtained by the use of scales at regular 
 intervals and the preservation of the records for comparison. Small plat- 
 form scales provided \\dth a device for ascertaining the height of the patient 
 are indispensable in the consulting room of the medical clinician engaged 
 in the treatment of chronic cases. The autoinatic weighing machines found 
 in public places in the cities are unreliable. Allowance must be made for 
 the clothing and its variations in the different seasons, and when practica- 
 ble the weight should be obtained shortly after the voidance of urine and 
 an action of the bowels, and before a meal. Errors of two or three pounds 
 may thus be eliminated, though for practical purposes in the long run slight 
 fluctuations in the weight may be disregarded in the course of chronic 
 disease. Many healthy individuals show an annual oscillation of several 
 pounds in net weight, allowance being made for clothing, the minimum 
 being reached in the spring or early summer, the maximum in the autumn 
 or beginning of the winter. The body weight should be taken according to 
 the requirements of individual cases at regular intervals of a week or 
 longer. Daily observations are unnecessary. 
 
 The relation of the average body weight to the age and height of 
 healthy individuals is set forth in the following tables: 
 
 Average Weight of Healthy Adult Males. — Hutchinson. 
 
 4 ft. 6 in. to 5 ft. in 92.26 lbs. 
 
 5 ft. in. to 5 ft. 1 in 115.52 lbs. 
 
 5 ft. 2 in. to 5 ft. .3 in 127.86 lbs. 
 
 5 ft. 4 in. to 5 ft. 5 in 1.39.17 lbs. 
 
 5 ft. 6 in. to 5 ft. 7 in 144.29 lbs. 
 
 5 ft. 8 in. to 5 ft. 9 in 157.76 lbs. 
 
 5 ft. 10 in. to 5 ft. 11 in 170.86 lbs. 
 
 5 ft. 11 in. to 6 ft. in 177.25 lbs. 
 
400 MEDICAL DIAGNOSIS. 
 
 Infants, whether nursed or artificially fed, should be weighed at regular 
 intervals of some days or a week. Important information is thus obtained 
 not only as to the appropriateness of the food in kind and quantity but 
 also as to the presence of assimilative disorders. The average normal 
 weight of the newborn is, according to Uffelmann, in girls 3000 grammes, 
 in boys 3500. During the first three or four days of life there is a decrease 
 of from 220 to 300 grammes. After this there is in healthy children a 
 progressive increase. 
 
 Average Daily Increase in Weight During the First Year of Life. — Gerhardt. 
 
 1st month 25 grammes. 
 
 2nd month 23 grammes. 
 
 3rd month 22 grammes. 
 
 4th month 20 grammes. 
 
 5th month 18 grammes. 
 
 6th month 17 grammes. 
 
 7th month 15 grammes. 
 
 8th month 13 grammes. 
 
 9th month 12 grammes. 
 
 10th month 10 grammes. 
 
 11th month 8 grammes. 
 
 12th month 6 grammes. 
 
 The weight index is the ratio of the weight of a given infant to the 
 weight of the average normal infant of the same age. 
 
 Useful figures to remember are that the initial weight is doubled at 
 5 months and trebled at 15 months; also that the weight at one year is 
 doubled at 7 years and that this weight is again doubled at 14 years (Rotch). 
 
 In infants and young children misleading inferences may be drawn 
 from a consideration of the weight alone. There are some who are fat and 
 flabby and not healthy. Such children are pallid, they lose and gain weight 
 rapidly and have but little resisting power to disease. Then there are many 
 who are bright and rosy, whose flesh is firm and solid, whose nutrition is 
 good, who gain in weight normally and are not liable to the wasting diseases. 
 
 In the following table the comparative average weight of the sexes 
 is shown. It will be observed that from birth until the sixth year the 
 average weight in the two sexes is nearly the same. From this period for 
 some years the weight of the female is considerably less than that of the 
 male. About the age of puberty the difference becomes less marked, though 
 the weight of the female is decidedly below that of the male. 
 
 Average Normal Weight in the Two Sexes at Different Periods of Life — Quetelet. 
 
 Males. Females. 
 
 New-born 3.1 kgs. 6.82 lbs. 3.0 kgs. 6.60 lbs. 
 
 1st year 9.6 kgs. 19.80 lbs. 8.6 kgs. 18.92 lbs. 
 
 2nd year 11.0 kgs. 24.20 lbs. 11.0 kgs. 24.20 lbs. 
 
 3rd year 12.5 kgs. 27.50 lbs. 12.4 kgs. 27.28 lbs. 
 
 4th year 14.0 kgs. 30.80 lbs. 13.9 kgs. 30.58 lbs. 
 
 5th year 15.4 kgs. 33.88 lbs. 15.3 kgs. 33.66 lbs. 
 
 6th year 17.8 kgs. 39.16 lbs. 16.7 kgs. 36.74 lbs. 
 
 7th year 19.7 kgs. 43.34 lbs. 17.8 kgs. 39.16 lbs. 
 
 8th year 21.6 kgs. 47.52 lbs. 19.0 kgs. 41.80 lbs. 
 
 9th year 23.5 kgs. 51.70 lbs. 21.0 kgs. 46.20 lbs. 
 
 10th year 25.2 kgs. 55.44 lbs. 23.1 kgs. 50.82 lbs. 
 
 11th year 27.0 kgs. 59.40 lbs. 25.5 kgs. 56.10 lbs. 
 
 13th year 33.1 kgs. 72.82 lbs. 32.5 kgs. 71.50 lbs. 
 
SYMPTOMS AND SIGNS: FORM AND NUTRITION. 401 
 
 Males. Females. 
 
 15th year 41.2 kgs. 90.64 lbs. 40.0 kgs. 88.00 lbs. 
 
 17th year 49.7 kgs. 109.34 lbs. 46.8 kgs. 102.96 lbs. 
 
 19th year 57.6 kgs. 126.72 lbs. 52.1 kgs. 114.62 lbs. 
 
 20th year 59.5 kgs. 130.90 lbs. 53.2 kgs. 117.04 lbs. 
 
 25th year 66.2 kgs. 145.64 lbs. 54.8 kgs. 120.56 lbs. 
 
 30th year 66.1 kgs. 145.42 lbs. 55.3 kgs. 121.66 lbs. 
 
 60th year 61.9 kgs. 136.18 lbs. 54.3 kgs. 119.46 lbs. 
 
 70th year 59.5 kgs. 130.90 lbs. 51.5 kgs. 113.30 lbs. 
 
 In cases of tardy or interrupted convalescence from an acute disease 
 systematic observations of the weight of the patient at intervals of a week 
 are of great use. A sudden arrest or decrease in weight may mark the 
 development of a tuberculous process. Loss of weight is of great impor- 
 tance in the diagnosis of early phthisis. An arrest of the loss, still more 
 a gain in body weight, must in most cases of this disease be regarded as 
 favorable. There are, however, exceptional cases in which after a consider- 
 able steady gain in weight the tuberculous process suddenly makes grave 
 or even fatal progress. 
 
 The weight is not in all cases merely an indication of the general 
 nutrition and amount of fat. It is sometimes made up in considerable part 
 of dropsical effusions, as in advanced disease of the mitral valve with rup- 
 ture of compensation, of accumulations in the serous sacs, as in massive 
 serofibrinous pleurisy or the ascites of cirrhosis of the liver, of the contents 
 of cysts, as in enormous monolocular disease of the ovary, or of new growths 
 of large size, as in the splenic tumor in leukaemia or sarcoma of the kidney 
 in young children. In a dropsical patient the successful use of salines or 
 diuretics may be followed coincidently with the subsidence of the ana- 
 sarca by a reduction in weight amounting to many pounds in a few days. 
 The tendency to accumulate excessive fat at middle life, especially in women 
 after the menopause, must be regarded as pathological, and obesity, as 
 has been said, constitutes a positive disease. The gain in weight occurs 
 at the time of beginning decrease of muscular power, at the period of physio- 
 logical involution. The individual must carry about a growing mass of 
 inert fat with lessening ability on the part of the skeletal muscles to bear 
 it and of the heart to carry on the circulation, and the disproportion 
 between the burden and the ability to bear it increases with advancing 
 years. Visceral fat accumulations occur, also fatty changes in the myo- 
 cardium and vessels. Obese persons in early middle life bear the acute 
 infections and especially enteric fever badly. Very often the fat accumu- 
 lations are largely local, as in the mammae, abdomen, and hips in women, 
 or in the abdomen, abdominal walls, and omentum in men of sedentary 
 life and given to the pleasures of the table. 
 
 26 
 
402 
 
 MEDICAL DIAGNOSIS. 
 
 III. 
 
 BONES; JOINTS; MUSCULATURE; POSTURE, ATTITUDE, AND 
 GAIT; POSTURE AND MOVEMENTS OF INFANTS. 
 
 BONES. 
 
 The skeleton determines the stature and frame of the individual. As 
 has been already pointed out the normal limits of variation in the meas- 
 urements of the bony framework are very wide. Excess in either direc- 
 tion, as in gigantism or dwarfism, is pathological and has been ascribed to 
 derangements of the functions of the pituitary body. 
 
 Average Height in Males and Females at Different Periods of Life. — Quetelet. 
 
 New-born 50.0 
 
 1st year 69.8 
 
 2nd year 79.1 
 
 3rd year 86.4 
 
 4th year 92.7 
 
 5th vear 98.7 
 
 6th year 104.6 
 
 7th year 110.4 
 
 8th year 116.2 
 
 9th year 121.8 
 
 10th year 127.3 
 
 15th year 151.3 
 
 20th year 167.0 
 
 25th year 168.2 
 
 30th year 168.6 
 
 40th year 168.6 
 
 60th year 167.6 
 
 70th year 166.0 
 
 There is a constant relationship in healthy persons between the mus- 
 cular development and the size and strength of the bones. In puny individ- 
 uals with small and flabby muscles the skeleton is usually more or less 
 under-developed. In this nutritional relationship between the muscles 
 and the bones the muscles constitute the controlling factor. In a similar 
 manner the bony walls of the cranium and thorax undergo changes corre- 
 sponding to changes in the viscera which they contain. 
 
 Thorax. — In bed-ridden individuals and those suffering from wasting, 
 diseases the involution of the lungs from diminished functional activity or 
 their diminution in size from pathological changes causes alterations in 
 the shape and contour of the thorax, which tends to assume permanently 
 the EXPIRATORY FORM; while an active life in the open air by increasing 
 the volume of the lungs modifies the chest, which under these circumstances 
 tends to assume permanently the inspir.-vtory form. Analogous changes 
 in the chest result from lesions which increase the volume of the thoracic 
 viscera, as in pulmonary emphysema and great cardiac enlargement. 
 The point for the student to bear in mind is that many general and local 
 changes in the form of the chest are primarily due to visceral disease and 
 not to disease of the bones. Some of these are more marked when the 
 
 Males. 
 
 
 
 Females. 
 
 
 cm. 
 
 20.00 
 
 in. 
 
 49.4 
 
 cm. 
 
 19.76 
 
 in 
 
 cm. 
 
 27.92 
 
 m. 
 
 69.0 
 
 cm. 
 
 27.60 
 
 in 
 
 cm. 
 
 31.64 
 
 m. 
 
 78.1 
 
 cm. 
 
 31.24 
 
 in 
 
 cm. 
 
 34.56 
 
 in. 
 
 85.4 
 
 cm. 
 
 34.16 
 
 in 
 
 cm. 
 
 37.08 
 
 in. 
 
 91.5 
 
 cm. 
 
 36.60 
 
 in 
 
 cm. 
 
 39.48 
 
 m. 
 
 97.4 
 
 cm. 
 
 38.96 
 
 m 
 
 cm. 
 
 41.84 
 
 in. 
 
 103.1 
 
 cm. 
 
 41.24 
 
 m 
 
 cm. 
 
 44.16 
 
 m. 
 
 108.7 
 
 cm. 
 
 43.48 
 
 in 
 
 cm. 
 
 46.48 
 
 m. 
 
 114.2 
 
 cm. 
 
 45.68 
 
 in 
 
 cm. 
 
 48.72 
 
 m. 
 
 119.6 
 
 cm. 
 
 47.84 
 
 m 
 
 cm. 
 
 50.92 
 
 m. 
 
 124.9 
 
 cm. 
 
 49.96 
 
 in 
 
 cm. 
 
 60.52 
 
 in. 
 
 148.8 
 
 cm. 
 
 59.52 
 
 m 
 
 cm. 
 
 66.80 
 
 m. 
 
 157.8 
 
 cm. 
 
 63.12 
 
 m 
 
 cm. 
 
 67.28 
 
 m. 
 
 157.4 
 
 cm. 
 
 62.96 
 
 m 
 
 cm. 
 
 67.44 
 
 in. 
 
 158.0 
 
 cm. 
 
 63.20 
 
 m 
 
 cm. 
 
 67.44 
 
 m. 
 
 158.0 
 
 cm. 
 
 63.20 
 
 m 
 
 cm. 
 
 67.04 
 
 m. 
 
 157.1 
 
 cm. 
 
 62.84 
 
 m 
 
 cm. 
 
 66.40 
 
 m. 
 
 155.6 
 
 cm. 
 
 62.24 
 
 in 
 
SYMPTOMS AND SIGNS: JOINTS. 403 
 
 visceral disease takes place early in life, as in precordial prominence and the 
 development of Harrison's furrows, others late in life, as in fibroid phthisis 
 and emphysema. There are, however, exceptions to this general state- 
 ment, an example of which is to be found in the changes of the shape of the 
 chest which result from disease of the spine, as kyphosis. 
 
 Cranium. — The skull may be abnormal in size and shape either as 
 the result of arrest of development of the brain with or without malfor- 
 mation, or as the result of pathological increase in the size of the brain. 
 The short diameters and peculiar shape of the head of the microcephalic 
 idiot and the globe-like cranium of chronic hydrocephalus developing at 
 birth or in early infancy with its wide sutures, open fontanelles, and card- 
 like thinness of the bones, are examples of the influence exerted by changes 
 in the soft parts upon the bony walls containing them. 
 
 Skeletal Changes. — The bones themselves undergo pathological 
 changes. These changes may be general or local. In acromegaly there 
 is hypertrophy of the bones of the hands, feet, and face, especially the 
 inferior maxilla. The clavicles, sternum, and in some instances the long 
 bones of the extremities also participate in the over-growth. In ostitis 
 DEFORMANS Or Paget's DISEASE there is thickening of the bones of the 
 skull and changes in those, of the face, the outline of which becomes tri- 
 angular with the apex at the chin; the long bones are involved and become 
 deformed. In rickets, a disease of childhood, the head is large and square, 
 the forehead prominent, the anterior fontanelle open, the epiphyses of 
 the long bones are enlarged, nodules develop at the junction of the ribs 
 with their cartilages. Changes in the shape of the chest and protrusion 
 of the sternum cause the deformity known as chicken or pigeon breast. 
 The spine is curved, the clavicle bent, the pelvis deformed, and the long 
 bones of the lower extremities show deformity. Rachitic children are often 
 bow-legged; those who reach maturity are under-sized. Osteomalacia is 
 characterized by resorption of the lime salts. The bending of the softened 
 bones under the action of gravity and muscular tension gives rise to 
 extraordinary deformities. These affect the spine, thorax, pelvis, and long 
 bones. In some instances the superficial bones crepitate upon pressure 
 and can be indented by the finger. They are readily fractured and this 
 accident may follow a trifling fall or blow or, in the case of the femur or 
 humerus, result from the muscular force exerted in turning in bed. Pul- 
 monary osteo-arthropathy — osteo-arthropathie hypertrophiante 
 pneumonique of Marie — a condition encountered in certain chronic dis- 
 eases of the lungs and pleura, is characterized by bulbous enlargement of 
 the terminal phalanges of the fingers and toes and of the distal epiphyses 
 of the bones of the upper and lower extremities. The finger-nails are 
 hypertrophied and strongly incurved. The bones of the head and face are 
 not affected. 
 
 JOINTS. 
 
 There are affections of the joints which lie on the border line between 
 surgery and medicine. To the former belong traumatic and operative 
 conditions; to the latter lesions arising in consequence of various consti- 
 tmional affections. Commonly the question of diagnosis first rests with 
 
404 MEDICAL DIAGNOSIS. 
 
 the medical clinician. Those joint affections which properly come within 
 the scope of internal medicine may be comprehensively described as the 
 MEDICAL ARTHROPATHIES. The large and small joints may be affected. 
 The chief symptoms are pain, especially upon movement, impairment of 
 function, and the signs of inflammation or disorganization, namely, changes 
 in color, size, and shape. The requisites to the proper examination of a 
 diseased joint are a knowledge of the local anatomy and pathology and of 
 the constitutional diseases in which joint affections occur. 
 
 Pain. — Pain is an important symptom. It may be spontaneous. More 
 commonly it is caused by movement. Pain upon pressure occurs in acute 
 forms of arthritis and is often intense. Pain is commonly referred to the 
 affected joint, sometimes to a distant part, as the pain in the knee in hip- 
 joint disease. In con3equence of the freer movement permitted by mus- 
 cular relaxation during sleep the pain is worse at night. There may be 
 insomnia, or sleep may from time to time be broken by sudden agonizing 
 pain. This is especially the case in tuberculous joint-disease. The patient 
 very often awakes with a sharp cry of pain. The pain in myalgia and 
 various forms of neuritis is frequently attributed to diseases of the joint; 
 upon movement the pain is found not to involve the joint, but other struct- 
 ures, and the joint is neither tender nor swollen. In chronic joint affections 
 movement is sometimes attended by a sensation of grating or crepitus, or 
 there may be a catching sensation attended with crackling sometimes 
 audible at a distance. 
 
 Color. — The color of the joint in acute inflammation is pinkish or red; 
 when intense it is cyanotic or dusky. When there is marked periarticular 
 oedema the overlying skin is pale. 
 
 Changes in Size. — In acute inflammation the joints are usually 
 enlarged. This enlargement is attended with alteration in the contour. 
 These changes are due to effusion, which may be articular or periarticular. 
 The former may be serous, purulent, or hemorrhagic. The latter may 
 be oedematous or exudative. These conditions are often combined. In 
 chronic arthritis there is infiltration of the tissues entering into the for- 
 mation of the joint. Enlargement due to effusion within the joint may 
 be recognized by palpation, especially in large joints. In the knee the 
 patefla floats. Rounded local swellings fluctuating upon palpation may 
 indicate the distention of the synovial sac. Enlargement may be due 
 to changes in the ends of the bones. 
 
 Irregular diminution in the size may occur in chronic disease of the 
 joints, as rheumatoid arthritis or other diseases characterized by resorp- 
 tion or retrogressive processes. Not only the tissues of the joint but the 
 periarticular structures undergo atrophy and subluxations occur, or there 
 may be diminution in the soft parts with thickening of the bones. All 
 these processes are associated with changes in contour. 
 
 The posture is of importance. In forms of acute arthritis, flexion or 
 semi-flexion and immobility are present — the attitude of least tension and 
 therefore of least pain. The mobility of the joint is determined by passive 
 movement. Fixation may be voluntary because it relieves pain. It may 
 result from muscular spasm or large effusion. Sudden locking of a joint, 
 especially the knee, may be due to floating cartilages or "joint mice" 
 
SYMPTOMS AND SIGNS: JOINTS. 
 
 405 
 
 becoming arrested between the anterior surface of the bones and the cap- 
 sular Hgament. In late cases the immobility is due to ankylosis, which may 
 be adhesive, fibrous, or bony. Movement may be limited or prevented by 
 the development of osteophytes in the region of the joints. Crepitus may 
 be detected upon palpation. 
 
 Any of the joints may be involved in general diseases. The knee, 
 hip, and shoulder are especially important, because of the frequency with 
 which they are implicated, the disabling results, and the tendency to 
 disorganization and ankylosis. 
 
 The medical arthropathies are inflammatory or infective, degenera- 
 tive, and neuropathic. 
 
 Primary Arthritis. — Simple acute synovitis with effusion is very 
 common especially in adolescents and young adults. It most frequently 
 
 Fig. 171. — Tophaceous deposits in gout. 
 
 involves the knee-joint. Traumatism and sudden chilling are causes. Some 
 of the cases appear to be monarticular rheumatism with trifling fever. 
 There is marked tendency to recurrence and chronicity. 
 
 Rheumatic Fever. — The affected joints are swollen, hot, usually 
 slightly reddened, and painful upon motion. The amount of swelling is 
 variable. The intra-articular effusion is usually slight or moderate, the 
 periarticular oedema being commonly marked. When the wrists and 
 ankles are implicated there is marked swelling of the hands and feet. The 
 joint effusion of rheumatic fever is fugacious. The tendency to rapidly sub- 
 side in one joint and develop in others is characteristic. The process is 
 rarely limited to a single joint. Any joints may be affected, but the knees, 
 ankles, and wrists are especially liable to the rheumatic inflammation. 
 
 Chronic Rheumatism. — This term is applied to a chronic condition 
 in which the joints are painful, stiff, moderately swollen, and but slightly 
 deformed. It is common in individuals who have been much exposed to 
 the vicissitudes of the weather or have lived in damp places. Its etiological 
 affinity to rheumatic fever may well be questioned. Some of the cases 
 described under this term are undoubtedly subacute forms of rheumatoid. 
 
406 MEDICAL DIAGNOSIS. 
 
 arthritis. In others the process is gouty. Cases of adhesive chronic ar- 
 thritis have been described under the term chronic rheumatism. Very 
 fat persons with small bones at or beyond middle life often suffer from 
 painful knees. There is nothing to indicate gouty or rheumatic disease 
 and no sign of actual inflammation. The pain is brought on by standing 
 or walking and is often intense^ There may be tenderness. The condition 
 is mechanical, the bearing surface being inadequate to the weight of the 
 body. Other articulations are not involved. 
 
 Qout. — This form of arthritis is due to the precipitation of salts of 
 uric acid in the joint structures. The metatarsophalangeal joint of the 
 great toe is first and most commonly affected, but other joints and espe- 
 cially the knee and ankle are occasionally involved. There is rapid swell- 
 ing with heat, tension, and a bluish-red glistening skin. 
 
 Arthritis Deformans. — Implication of the joints is usually symmetri- 
 cal though monarticular forms occur. First one or two joints only are 
 involved. Gradually others are implicated and cases occur in which 
 
 Fig. 172. — Heberden's nodes (page 909). 
 
 all the joints suffer. Attacks of acute inflammation are succeeded by 
 periods of quiescence, but after each attack the evidences of disintegra- 
 tion are more pronounced. The ligaments of the small joints, especially 
 of the hands, are relaxed and the bones of the phalanges under the action, 
 of gravity very often form an obtuse angle with the metacarpal bones 
 toward the ulnar side. Atrophic changes in the muscles and other 
 structures relating to the affected joints occur in extreme cases. 
 All the articulations may become ankylosed and the patient bed- 
 ridden and almost completely helpless. There are partial or mon- 
 articular forms which occur in old persons. The spine may be 
 involved — spondylitis deformans — with pain, anaesthesia, and muscular 
 atrophy. In other cases the spine is involved together with the shoul- 
 der- and hip-joints and nervous symptoms are less prominent. Kyphosis 
 and fixation occur. 
 
 Infective Arthritis. — Inflammatory joint affections frequently 
 develop during convalescence from the acute infectious diseases. One 
 or more joints, show signs of inflammation. This form of arthritis 
 is frequent after scarlet fever and sometimes occurs in cerebrospinal 
 meningitis, the variolous diseases, dengue, and enteric fever. An 
 
SYMPTOMS AND SIGNS: JOINTS. 
 
 407 
 
 Fig. 173. — Arthritis deformans. — Jefferson Hospital. 
 
 acute arthritis going on to suppuration with disorganization of the joint 
 occurs in septic conditions. The joint affection which accompanies 
 •osteomyehtis is attended with high 
 fever and constitutional disturbances. 
 Gonorrhoea! Arthritis. — Fre- 
 quently one joint only is involved, 
 sometimes several. The knee, wrist, 
 and ankle frequently suffer. Teno- 
 synovitis may occur. Fever is 
 moderate or absent, or there is 
 great pain on movement, and the 
 joint affection is frequently per- 
 sistent and disabling. 
 
 Arthritis in Hemorrhagic Dis= 
 eases. — Acute arthritis, more or less 
 intense and suggestive of the joint 
 affection of rheumatic fever, occurs 
 in forms of purpura and in haemo- 
 philia. It is the larger joints that 
 are chiefly affected. Intra-articular hemorrhage may occur. Arthritis 
 is an occasional complication of scurvy. 
 
 Tuberculous Arthritis. — Tuber- 
 culous joint disease is common. It 
 is often secondary to tuberculosis of 
 the bones. It was formerly known 
 as white swelling — tumor albus. The 
 process is comj)aratively subacute 
 but tends to permanent disorgani- 
 zation. Tuberculous joints are 
 usually swollen. In the course of 
 the disease chronic inflammatory 
 infiltration takes place into the cap- 
 sule, ligaments, and periarticular 
 connective tissue. Caseation and 
 softening result in abscess formation 
 and burrowing along the lines of 
 least resistance. Tortuous fistulous 
 passages occur. The hip, elbow, 
 knee, and wrist are frequently 
 affected. There may be evidences 
 of tuberculosis in the lungs or else- 
 where. More commonly the process 
 is limited to the affected joint and 
 adjacent structures. 
 
 Syphilis. — The acute joint affec- 
 tion of new-born infants sometimes 
 regarded as rheumatic is mostly syphilitic. It is a form of primary exuda- 
 tive arthritis with fibrous thickening of the capsule. Gummatous inflam- 
 mation in the neighboring tissues may involve a joint by extension. In 
 
 Fig. 174. — Arthritis deformans with extreme ulnar 
 deformity. — Jefferson Hospital. 
 
408 
 
 MEDICAL DIAGNOSIS. 
 
 acquired syphilis subacute synovitis occasionally occurs during the period 
 of eruption. The sternoclavicular joint shows a peculiar liability. In 
 late syphilis, forms of chronic arthritis, the result of gummatous infiltration 
 
 of the tissues forming the joint, occur. 
 Actinomycosis. — The joints are 
 sometimes involved by metastasis. 
 In other cases they are invaded by 
 extension, as when the disease reaches 
 the articulations of the cervical verte- 
 brae or when prevertebral actino- 
 mycosis attacks the spine or the 
 disease extends from the thorax to 
 the sternoclavicular joints or from 
 the abdomen to the hip-joints. 
 
 Neuropathic Joint Affections. — 
 Hysteria especially may simulate dis- 
 ease of the joints. The impairment 
 of function is caused by contracture 
 of muscles. Pain is more diffuse and 
 spontaneous than in actual arthritis. 
 The patient avoids movement and 
 does not cooperate in the examination. 
 The signs of effusion, inflammation, 
 and erosion are lacking. These are the cases in which spontaneous cures 
 sometimes occur under profound mental suggestion. In some instances, 
 from prolonged disuse, infiltration, and thickening of the periarticular 
 tissues, false ankylosis and atrophy of the associated muscles occur. It 
 is important to bear in mind that hysterical symptoms may be superadded 
 to those of actual joint disease. The differential diagnosis between 
 traumatic joint disease and a hysterical joint in traumatic hysteria is 
 occasionally attended with difficulty. Vasomotor changes with swelling, 
 
 Fig. 175. — Gonorrhceal arthriti 
 Hospital. 
 
 -Pennsylvania 
 
 Fig. 176. — Ataxic knee-joint. — Young. 
 
 tension, and redness sometimes occur and the surface temperature may 
 be two or three degrees higher than that in the axilla. These symp- 
 toms are not associated with fever or the evidences of constitutional 
 disturbance and are commonly transitory and recurrent. 
 
SYMPTOMS AND SIGNS: MUSCULATURE. 409-. 
 
 More important are the changes that take place in connection with 
 certain diseases of the nervous system — Charcot's joints, tabetic 
 JOINTS — particularly locomotor ataxia, syringomyelia, less frequently in 
 anterior poliomyelitis and other diseases of the spinal cord. The joint 
 affection in tabes is much more common in the joints of the lower extrem- 
 ities, especially the knee, less frequent in the hip and ankle; that of 
 syringomyelia is by far more common in the upper extremities. The 
 derangements are primarily trophoneurotic. The process is frequently 
 monarticular. The pathological and clinical changes correspond to those 
 of the milder and graver forms of rheumatoid arthritis. In the more 
 severe forms they differ in suddenness of onset, intra-articular effusion,, 
 and a rapid, disintegrating course without pain. Subluxations and 
 luxations take place. When the tarsal articulations are implicated 
 flat-foot occurs with characteristic deformities — the tabetic foot. 
 
 MUSCULATURE. 
 
 Diagnostic criteria of importance are obtained by an examination of 
 the condition of the muscles. Wide variations in the bulk and tonicity 
 of the general musculature is encountered within the limits of health. 
 These variations depend largely upon the hereditary constitution, occu- 
 pation, and bodily activities of the individual and are not of diag- 
 nostic significance. Trophic derangements result in hypertrophy and 
 atrophy. 
 
 Hypertrophy. — True hypertrophy, that is to say, increased volume 
 with increase of power, is exceedingly rare. It occurs in Thomsen's disease. 
 Congenital hypertrophia musculorum vera has been described. Patho- 
 logical increase in the muscles is almost always a pseudohypertrophy. 
 The abnormal volume is not due to an increase in the contractile tissue 
 but to a proliferation of the connective tissue and fat. This muscular 
 dystrophy occurs in its most pronounced form in the so-called pseudo- 
 hypertrophic muscular paralysis of childhood, and very rarely in some 
 of the affected muscles in certain cases of chronic progressive muscular 
 atrophy. 
 
 Atrophy. — Atrophy of the muscles may be simple or inactivity atrophy 
 — the atrophy of disuse. The affected muscles are diminished in size, soft, 
 and flaccid; there is loss of the contractile substance; the interstitial con- 
 nective tissue is not increased. This form of atrophy occurs in certain 
 forms of paralysis, and supervenes upon mechanical fixation of a limb or 
 the prolonged immobility resulting from joint pain or ankylosis. Com- 
 plete loss of movement usually gives rise to a high grade of simple atrophy. 
 Atrophy from disuse rarely attains the degree often seen in the degenera- 
 tive atrophies. In simple atrophy there is general diminution in the volume 
 of the affected limb, while in the degenerative atrophies single muscles or 
 groups of muscles are exclusively or chiefly involved. The electrical re- 
 actions in simple atrophy are quantitatively and not qualitatively changed. 
 The nutritional muscular atrophy which occurs in starvation, in the course 
 of acute infections, and in the chronic wasting diseases must be regarded 
 as a diffuse form of simple atrophy. 
 
410 
 
 MEDICAL DIAGNOSIS. 
 
 Myoidema. — This phenomenon consists in a sudden contraction of 
 muscular fibres when smartly tapped with the finger or hammer, with 
 transitory humping at the point of impact. It is manifested in muscles 
 that are undergoing rapid wasting, especially in phthisis, and is as a rule 
 best developed in the muscles of the chest. 
 
 Degenerative Atrophy. — The degenerative muscular atrophies, which 
 are characterized not only by loss of contractile substance but also 
 
 Fig. 177. — Pseudohypertrophic muscular paralysis. Brothers, eight and ten years old. 
 lordosis ; b, showing atrophy of back and enlarged calves. — Rotch. 
 
 a, showing the 
 
 by an overgrowth of the interstitial connective tissue, may be referred to 
 two groups: (a) the progressive muscular atrophies, and (b) the atrophic 
 paralyses. 
 
 The progressive muscular atrophies may be divided into myopathic, 
 peripheral, and central or nuclear according to the seat of the essential 
 pathological process, which may primarily involve the muscles, or result 
 from an acute or chronic peripheral neuritis, or from degenerative changes 
 in the ganglion cells of the anterior horns of the cord, or the motor 
 nuclei of the brain. There is progressive atrophy of individual muscles 
 and muscle groups; diffuse atrophy of an entire limb occurs only in 
 advanced stages; the strength of the muscles is diminished in proportion 
 to the diminution of their volume. In this respect the progressive muscular 
 
SYMPTOMS AND SIGNS: MUSCULATURE. 
 
 411 
 
 atrophies are in contrast with the secondary degenerative atrophies which 
 follow the atrophic paralyses. In the latter the paralysis comes first, the 
 atrophy afterwards. The discrimination between myopathic, neural, and 
 nuclear muscular atrophies rests upon the fact that in the different forms 
 particular groups of muscles are affected. In the myopathic forms of 
 degenerative atrophy— the muscular dystrophies— the following principal 
 types occur: 1. Pseudohypertrophic muscular atrophy of childhood — 
 
 Fig. 178.- 
 
 -a, infantile atrophy from improper feeding (female ten miontlis old); 6, recovery after three 
 months. — Rotch. 
 
 the so-called pseudohypertrophic muscular paralysis. 2. The juvenile 
 type of Erb — dystrophia musculorum progressiva; the atrophy begins in 
 the shoulder girdle and is not preceded by pseudohypertrophy. 3. The 
 juvenile type of Leyden-Mobius; the atrophy begins in the lower extrem- 
 ities. This form is closely allied to the progressive pseudohypertrophy of 
 childhood. 4. The infantile type of Duchenne — the facio-scapulo-humeral 
 
 Fig. 179. — General atrophy of the muscles in a case of cerebrospinal fever; fifty-fifth day of illness. — Royer. 
 
 type of Landouzy-Dejerine. This form begins j.n the face. The loss of 
 power in the muscles of expression gives rise to the characteristic facies 
 MYOPATHICA. The eyes can no longer be completely closed, the cheeks are 
 sunken, the lips thickened and everted, speech is impaired, and the ordinaiy 
 changes in the countenance in laughter and crying are not seen. The 
 myopathic atrophies are commonly hereditary and almost always show 
 themselves in early life. Neural atrophy begins commonly in the under 
 extremities in the distribution of the peroneal nerve — the peroneal type 
 of Charcot and Marie — and may lead to the development of club-foot, 
 usually pes equinus or pes equinovarus. It differs from other forms of 
 
412 MEDICAL DIAGNOSIS. 
 
 myopathic atrophy in the frequent occurrence of derangements of sensation^ 
 pain, and fibrillary contractions and in the occasional presence of the reaction 
 of degeneration. In many cases of peripheral neuritis the affected muscles 
 undergo degenerative atrophy. Spinal or nuclear atrophy usually first 
 shows itself in the intrinsic muscles of the hand and by extension early 
 involves the tongue, lips, palate, pharynx, and larynx, giving rise to the 
 picture of bulbar paralysis. Fibrillary contractions of the muscles are 
 common and reactions of degeneration occur. The disease develops almost 
 exclusively in adult life and is not hereditary. 
 
 The Atrophic Paralyses. — The muscles undergo secondary degenera- 
 tive atrophy. The lesion which interferes with the transmission of motor 
 impulses at the same time interrupts trophic influences to the muscle. 
 The paralysis shows itself first and is followed by atrophy, which in the 
 course of some weeks becomes marked and often reaches a very high grade. 
 The reactions are those of degeneration. In this form of degenerative 
 atrophy fibrillary contractions are frequently present. 
 
 THE POSTURE, ATTITUDE, AND GAIT. 
 
 Posture. 
 
 Patients who are very ill of an acute disease or in the advanced stages 
 of chronic disease are usually seen in bed; those suffering from trifling 
 affections or in whom the symptoms of grave disease are not yet urgent 
 or disabling continue to be about, but this is not always the case. Whether, 
 on the one hand, a patient remains up and about, endeavoring to attend 
 to his ordinary duties while suffering from serious symptoms or, on the 
 other hand, betakes himself to bed upon the occurrence of trifling symp- 
 toms is often a matter of temperament. It is not uncommon for a patient 
 suffering from enteric fever to come to the consultation room or dispensary 
 in the second week of the attack with a temperature of 104° F. (40° C.) and 
 a well-developed rose rash — walking typhoid. Patients who realize their 
 condition very often feel compefled by circumstances to continue the 
 discharge of a daily duty or are buoyed up by the hope of speedy improve- 
 ment, and again there are acute diseases which run a favorable course which 
 begin with urgent and distressing symptoms. The physician usually 
 finds those patients in bed who have high fever, prostration, or a general 
 sense of serious illness, and those who suffer from dyspnoea, pain, vertigo, 
 and other symptoms intensified by movement or exertion. In meningitis, 
 peritonitis, rheumatic fever, pericarditis, typical croupous pneumonia, and 
 in well-developed cases of the acute exanthemata it is impossible for the 
 patient to be out of bed. It is to be noted, however, that upon the appear- 
 ance of the eruption in the variolous diseases the symptoms of onset often 
 undergo such an amelioration that the patient regards himself as conva- 
 lescent and insists upon getting out of bed. 
 
 Decubitus is the posture of the patient in bed. It is of diagnostic 
 importance. It is in moderate illness, as in health, easy and unconstrained. 
 The patient arranges the bed-clothes, changes his position when it has 
 become uncomfortable, lies naturally upon his back— active dorsai^ 
 
SYMPTOMS AND SIGNS: POSTURE. 413 
 
 DECUBITUS — or turns upon the side — active lateral decubitus. The 
 posture of weak, helpless, or unconscious individuals in bed is wholly dif- 
 ferent. The muscles play little part in maintaining the position. 
 The relaxed body yields to the law of gravity and sinks toward the 
 foot of the bed, where it remains. The patient, even when his breathing 
 is hindered and his position is uncomfortable, is unable to change it. The 
 attendants must again and again lift him upon the pillows. The condition 
 is wholly passive — passive dorsal decubitus. In rare instances the 
 patient in this state lies upon the side — passive lateral decubitus. 
 
 Forced or imperative attitudes are very characteristic of certain 
 diseases. The following are the most important: 
 
 The Dorsal Posture. — In acute peritonitis, whether general or local, 
 the patient lies upon the back with the thighs flexed upon the abdomen 
 and the legs upon the thighs. Movement is avoided and the patient shrinks 
 from pressure upon the abdomen. 
 
 The Reclining Dorsal or the Sitting Posture. — In diseases attended 
 with difficult respiration, especially certain diseases of the respiratory 
 and circulatory organs and the kidneys, the patients are forced to assume 
 a semi-upright posture on the bed-rest or propped up with pillows, or to 
 sit upright. Attempts to lie flat in bed increase the difficulty of respiration. 
 The sitting position relieves it by favoring the action of the accessory 
 respiratory muscles, especially when the arms are used to elevate and fix 
 the shoulders. In the case of peritoneal effusions the respiratory move- 
 ment of the diaphragm is less interfered with in the sitting posture unless 
 the effusion be very large, in which case the abdomen is somewhat com- 
 pressed by the thighs. This attitude, furthermore, favors the return of the 
 venous blood from the brain. For this reason high grades of dyspnoea 
 are described under the term orthopncea. When the difficulty of respira- 
 tion is extreme the patients can no longer remain in bed but are obliged to 
 sit upright, fixing the shoulders by placing the hands upon the side of the 
 chair or its arms in order to facilitate the use of the accessory muscles and 
 to relieve the abdomen from the pressure of the thighs. The distress is 
 also to some extent relieved by the gravitation of venous blood and the 
 fluid of general dropsical effusions to the lower extremities. Orthopncea 
 is present during the paroxysms of asthma, in extreme cases of valvular 
 ■disease of the heart with ruptured compensation, in large pleural and peri- 
 'Cardial effusions, in massive peritoneal effusions, and in general anasarca, 
 which may be cardiac or renal but is very often cardiorenal. It occurs 
 also in advanced pulmonary emphysema and in obstructive diseases of 
 the larynx, as croup and diphtheria. Except in extreme cases it is usually 
 paroxysmal, the attack being brought on by movement, coughing, conver- 
 sation, or other exertion. 
 
 Lateral Postures. — Patients suffering with unilateral disease of the 
 thoracic organs very often lie upon the affected side. This is especially 
 the case in large pneumonic exudates, pleural and pericardial effusions, and 
 other conditions which greatly diminish the respiratory surface of the 
 affected lung. In this posture the respiratory excursus of the sound side 
 is not hampered by the weight of the diseased organs. In painful condi- 
 tions, however, the patients sometimes lie upon the sound side. In acute 
 
414 MEDICAL DIAGNOSIS. 
 
 fibrinous pleurisy the pain of which is greatly intensified by breathing^ 
 the lateral decubitus upon the affected side is assumed by preference because 
 the weight of the body somewhat diminishes the respiratory excursus of 
 that side of the chest. Patients suffering from heart disease and many 
 individuals in good health lie more comfortably upon one side than upon 
 the other; sometimes the right side is preferred, sometimes the left. In 
 cardiac hypertrophy the patients usually lie more comfortably upon the 
 left side, and in large aneurisms of the aorta, upon the affected side. Pa- 
 tients suffering from harassing cough in the dorsal position are sometimes 
 relieved by turning upon one side. This happens in certain cases of uni- 
 lateral pulmonary cavity and the relief is obtained by turning upon the 
 affected side. The explanation of this phenomenon is purely physical; 
 while the patient lies upon his back or upon the sound side the secretion 
 formed in the cavity escapes into the bronchus little by little, causing 
 irritation which manifests itself by cough, while, on the other hand, if he 
 continues to lie upon the affected side it collects without producing reflex 
 cough until the cavity overflows. The lateral decubitus with the thighs, 
 and legs flexed upon the abdomen and the spine and neck strongly arched 
 forward is usually assumed during the pains of parturition and is common 
 in hepatic and intestinal colic. In acute cerebrospinal meningitis the 
 patient frequently lies upon the side with the thighs and legs strongly 
 flexed and the spine extended in the position of opisthotonos. In some 
 cases the lower extremities are extended — complete opisthotonos. 
 
 The ventral posture is sometimes assumed in cases of abdominal pain,, 
 as colic, gastralgia, or enteralgia. The patient lies prone upon the bed 
 with his face buried in the pillow. Tenderness upon abdominal pressure, 
 as in peritonitis, renders this attitude impossible. It sometimes affords 
 relief to the pain of abdominal aneurism and in certain cases of caries of 
 the spine. In most cases of gastric ulcer this posture -is avoided on account 
 of the epigastric tenderness upon pressure. In some cases of this disease, 
 however, the pain is relieved by the ventral decubitus, probably because 
 the ulcer is so situated as to escape in this position the pressure of the 
 contents of the stomach. Patients suffering from headache very often 
 assume this posture. 
 
 Restlessness in bed is a very common symptom. The patient is unable 
 to maintain the same position for any length of time; he tosses about, 
 turns from side to side, fusses at the bed-clothes, and his hands and feet 
 are in constant motion. Restlessness may be the manifestation of nervous 
 irritability or of pain. It is common in affections attended with burning 
 and itching of the skin, as scarlet fever and urticaria. It occurs also in 
 some cases of shock and accompanies profuse hemorrhage, in which case 
 it is attended with pallor, urgent thirst, and rapid, small pulse. In truth 
 the association of restlessness with these symptoms, occurring suddenly 
 without visible bleeding, warrants a provisional diagnosis of internal 
 hemorrhage. The term jactitation is used to designate a high degree of 
 restlessness. The patient tosses about violently; the constant efforts of 
 the attendants are necessary to keep him in bed. Jactitation occurs in 
 maniacal delirium, in cases of violent chorea, in which it is accompanied 
 by constant twitching of the muscles, as a temporary manifestation in 
 
SYMPTOMS AND SIGNS: ATTITUDE. 
 
 415 
 
 some forms of hysteria, and in a high degree during the stage of clonic 
 convulsions in epilepsy. 
 
 Opisthotonos, predominating tonic contraction of the spinal muscles, 
 so that the body rests upon the head and heels; emprosthotonos, or 
 bending forward of the trunk; pleurothotonos, arched lateral posture; 
 
 --^ 
 
 r 
 
 ^ > ili W li rm . ft ite. 
 
 Fig. 180. — Opisthotonos in a case of epidemic cerebrospinal meningitis. — Royer. 
 
 Fig. 181. — Pleurotliotonos in a case of epidemic cerebrospinal meningitis. — lloyer. 
 
 and ORTHOTONOS; in which the trunk and neck are rigidly extended in a 
 straight line, are all symptoms that occur in tetanus and in some cases of 
 meningitis and strychnine poisoning. 
 
 Attitude. 
 
 The attitude and movements of patients who are able to be about 
 frequently convey important information in regard to their condition. 
 The young and the strong carry themselves erect and walk briskly and 
 firmly; the aged and feeble and those mentally depressed are bowed and 
 move slowly and with effort. The convalescent from a prostrating disease 
 is at first weak and shaky; he can scarcely stand; an hour in the arm-chair 
 fatigues him. In a little time he makes the journey around his room with 
 
416 MEDICAL' DIAGNOSIS. 
 
 slow and uncertain gait, and is soon obliged to rest. With returning 
 strength comes the erect carriage and firmer step. Modifications of atti- 
 tude and gait constitute characteristic symptoms in many diseases. In 
 general they are due to skeletal defects, as in caries of the spine, hip-joint 
 disease, or ankylosis of the knee; derangements of the muscular power or 
 function, as in pseudohypertrophic muscular paralysis, chorea, and the 
 shaking palsies; derangements of the balance between antagonistic muscle 
 groups, as in forms of spinal curvature and club-foot; derangements of 
 coordination, as in cerebellar disease and tabes; forms of paralysis, as in 
 hemiplegia, anterior poliomyelitis; and contractures, as in the cross-legged 
 progression of children suffering from spastic paraplegia. 
 
 Station is technically the ability to maintain the erect position while 
 standing. It depends largely upon muscular and visual coordination. 
 Within limits it is better the wider the base of support, hence the test should 
 be made with the feet parallel and the heels and toes touching, first with the 
 eyes open, later with them closed. Hinsdale found in normal individuals 
 of both sexes the average oscillation in the above position, as determined 
 by an instrument devised for the purpose, to be about an inch in a forward 
 and backward line and three-quarters of an inch laterally. The oscilla- 
 tion in children is greater than that in adults. Upon closing the eyes it is 
 increased about 50 per cent. In diseases characterized by impairment of 
 the power of coordination, as tabes and lesions of the cerebellum, station 
 is greatly impaired and the patient may be wholly unable, under the condi- 
 tions of the test and with closed eyes, to keep his balance — Romberg's 
 SYMPTOM. During paroxysms of Meniere's disease — aural vertigo — the 
 power of standing in the erect posture is wholly lost. Astasia is a term 
 employed to designate inability to stand, abasia the inability to walk, in 
 the absence of paralysis. Astasia-abasia is a syndrome of hysteria in 
 which the patient is unable to stand or walk but can usually creep about 
 like a child, upon the hands and knees. 
 
 The following peculiarities of attitude are to be noted: 
 In HEMIPLEGIA and paralysis of one leg the patient supports himself 
 almost entirely upon the sound leg. In chronic sciatica the patient spares 
 the affected limb both in walking and standing by fixation of the hip-joint, 
 and in doing so develops a scoliosis, the spinal column showing a double 
 curvature, the lower convex, the upper, which is compensatory, concave 
 toward the affected side, the general inclination of the body being 
 toward the sound side. In paralysis agitans the attitude is characteris- 
 tic. The head and upper part of the body are inclined forward, the elbows 
 and knees being slightly flexed. The striking appearance of the patient is 
 heightened by the expressionless countenance, the tremor, and the move- 
 ments of the fingers and hands. In pseudohypertrophic paralysis the 
 patient stands with his feet separated, the belly protruding, and the 
 shoulders thrown back as the result of marked lordosis. In the sitting 
 posture the curvature of the spine is corrected. 
 
SYMPTOMS AND SIGNS: GAIT. 417 
 
 Gait. 
 
 In a number of diseases, especially those affecting the nervous system, 
 the gait is much modified and its peculiarities often justify conclusions 
 regarding both functional derangements and anatomical lesions. The 
 following symptomatic gaits are frequently observed: 
 
 The Paraplegic Gait.— In paresis of the lower extremities the gait 
 is feeble and uncertain. Both feet are slowly advanced and dragged 
 upon the floor. The patient stumbles over trifling inequalities and eleva- 
 tions of the surface. The loss of power is frequently more marked on one 
 side than on the other. Crutches become necessary and at length the loss 
 of power is complete. This gait is seen in chronic myelitis. 
 
 The Hemiplegic Gait. — When the hemiplegic has sufficiently recov- 
 ered to walk, the gait is characteristic. The sound limb is advanced, 
 the paralyzed limb dragged after it. In other cases the step of the para- 
 lyzed limb is accomplished by lifting the pelvis and a movement of cir- 
 cumduction. When contractures have taken place the affected arm is 
 rigid, strongly flexed at the elbow and wrist and carried across the body, 
 and the fingers and thumb are flexed upon the palm. 
 
 The Spastic Gait. — In spastic paresis of the lower extremities 
 such as occurs in forms of spinal paralysis there is peculiar stiffness of the 
 legs, which are scarcely bent at the hip- and knee-joints, while the thighs 
 interfere with each other by reason of the contraction of the adductors. 
 The contraction of the gastrocnemii produces pes equinus. The patient 
 walks with two canes and in stepping leans upon one, lifting the pelvis of 
 the opposite side as he steps, and dragging the foot in circumduction. 
 In some cases the contact of the foot with the floor produces ankle clonus 
 which adds to the peculiarity of the gait. A modification of the spastic 
 gait, sometimes seen in children, is known as cross-legged progression. 
 In consequence of the contraction of the adductors and calf muscles there 
 is close circumduction of the knees, and in stepping the legs are crossed 
 and the advancing foot brought down not only in front of but to the out- 
 side of its fellow. 
 
 The Steppage Gait. — In some cases of peripheral neuritis the 
 paralysis of the extensors of the feet causes a peculiar modification in 
 progression. In stepping forward the knee is strongly flexed and the foot 
 sharply advanced in order that the dragging toes may be lifted from the 
 ground; the heel is brought down first and the appearance is that of a 
 person stepping over obstructions. 
 
 The waddling gait occurs in pseudohypertrophic muscular paralysis 
 and is not less characteristic than the attitude in this disease. In con- 
 sequence of the lordosis the shoulders are thrust back and the belly 
 forward, the legs are separated, the feet raised slowly with the toes drop- 
 ping, the centre of gravity being alternately shifted over the foot upon 
 which the patient throws his weight. The manner in which the child, after 
 lying down upon the floor, gets up is especially characteristic. He rolls 
 over upon the abdomen, gets upon all fours, and first extends the arms, 
 then the legs. The hands are next drawn toward the legs until he can 
 grasp one knee with the corresponding hand. He pushes himself up until 
 27 
 
418 MEDICAL DIAGNOSIS. 
 
 the other knee can be grasped and assumes the erect posture by gradually- 
 raising the point of support of the hand upon the thigh. Late in the disease, 
 when the atrophy involves the muscles of the upper extremities, it becomes 
 impossible to rise. 
 
 The ataxic gait is that of incoordination of the lower extremities. 
 It is observed in its most typical form in tabes dorsalis. In stepping the 
 foot is raised higher than usual with a jerk and rapidly advanced with 
 an awkward and irregular movement, the toes slightly drooping. It is 
 then brought down with an abrupt stamp upon the heel or the entire sole. 
 Progression is irregular and it is impossible for the patient to walk with, 
 one foot before the other, as in following a crack upon the floor or a chalked 
 line. He walks with a swaying motion. The legs are separated in order to 
 increase the base of support, which is further enlarged as the disease makes 
 progress by the use first of one cane, later of two. In advanced cases walk- 
 ing becomes impossible without the aid of one or even two attendants. 
 Finally, the power of locomotion is entirely lost. These symptoms of im- 
 paired coordination are greatly increased upon closing the eyes. Patients 
 who can go about fairly well in daylight cannot walk at all in the dark. 
 
 The gait of sciatica derives its characteristics from muscular fixation 
 of the hip-joint voluntarily brought about to diminish pain. 
 
 The Gait in Chorea. — In severe chorea the irregular muscular con- 
 tractions interfere greatly with ordinary movements. The gait of the 
 patient is often hopping or sliding, sometimes it resembles the movements 
 of skating. In the worst cases walking becomes impossible. 
 
 The reeling or staggering gait is a form of the ataxic gait. It 
 occurs in conditions attended with marked disturbance of coordination,, 
 such as drunkenness, cerebellar disease, lesions of the labyrinth, and some 
 forms of paralysis of the muscles of the eye. 
 
 The Festinating Gait. — This modification of walking occurs in. 
 paralysis agitans and is not less characteristic than the attitude in that 
 disease. The patient bends forward, the elbows are slightly abducted 
 and flexed, the knees are also flexed, and the patient walks with the appear- 
 ance of haste, as though to overtake his advancing centre of gravity. 
 He cannot halt at once. The peculiarity of the gait is largely due to stiff- 
 ness and weakness of the muscles. The gait is sometimes described as 
 propulsive. A similar gait and inability to stop immediately sometime® 
 shows itself in exhausted pedestrians. Retropulsion may occur. 
 
 Posture and Movements of Infants. 
 
 The position and movements of infants are of diagnostic impor- 
 tance. The healthy baby uses its muscles and joints. Its postures are 
 active, its movements constant, and a source of evident pleasure. It 
 loves to be fondled and played with. How different the baby who is really 
 ill! Its postures are passive. Its head drops and rolls from side to side 
 with the motion of the pillow upon which it rests. Its limbs dangle help- 
 lessly, and voluntary movements are slight and infrequent. In many 
 febrile diseases there is cerebral irritation, shown by the drawn face and 
 head pressure deep into the pillow. In severe rickets there is tenderness 
 
SYMPTOMS AND SIGNS: TEMPERATURE. 419 
 
 of the muscles and bones, motion is painful and therefore avoided; in 
 infantile scurvy a similar condition exists, and in well-developed cases the 
 attitude is almost diagnostic, the child lying upon its back with the thighs 
 and legs strongly flexed, shunning all movements and screaming with 
 fear if it is approached. In cerebrospinal fever and other forms of menin- 
 gitis there is painful retraction of the muscles of the back of the neck — 
 opisthotonos. 
 
 IV. 
 
 TEMPERATURE; FEVER; HYPOTHERMIA; SIGNIFICANCE OF 
 
 ABNORMAL TEMPERATURES. 
 
 TEMPERATURE. 
 
 Variations in the temperature of the body constitute symptoms of 
 great importance both in acute and in chronic disease. From the earliest 
 times practitioners estimated the heat of the body by the hand and thus 
 sought to determine the presence or absence of fever. The introduction 
 of the clinical thermometer into medical practice marked an important 
 advance in modern medicine. (See Part II, Clinical Thermometry.) 
 
 Heat Mechanism. — The temperature of homothermous or warm- 
 blooded animals is constant within narrow limits and is not materially 
 influenced by changes in the temperature of the medium in which the 
 organism lives. In the human being the amount of heat produced and 
 dissipated at different parts of the body varies. The equilibrium of tem- 
 perature is maintained in part by direct conduction but chiefly by the 
 circulating blood and lymph. The internal parts of the body have never- 
 theless a higher temperature than the external and some internal organs 
 are warmer than others. The heat production is greater in organs when 
 they are active than when they are at rest, and the temperature varies in 
 different regions of the surface of the body. The heat mechanism is made 
 up of two factors: (a) heat production or thermogenesis, and (b) heat dis- 
 sipation or thermolysis. Under normal conditions these two functions so 
 nearly balance that the mean bodily temperature is maintained within 
 very narrow limits. The regulating mechanism is expressed by the term 
 thermotaxis. It is obvious that thermotaxis may be deranged by altera- 
 tions in either thermogenesis or thermolysis. 
 
 Thermogenesis accompanies oxidation. Hence almost every struc- 
 ture of the body may be regarded as the source of heat. In this respect 
 the skeletal muscles and the glands play the chief part. The general ther- 
 mogenic centres have been shown to be in the spinal cord. Thermogenic 
 centres probably exist in the caudate nuclei, pons, and medulla oblongata; 
 excitation of these regions is followed by a rise in heat production — punc- 
 ture pyrexia. They are therefore known as thermo-accelerator centres. Irri- 
 tation of the region of the sulcus cruciatus and at the junction of the supra- 
 Sylvian and post-Sylvian fissures in the dog is followed by a decrease in heat 
 production. These centres are therefore known as thermo-inhibitory. 
 
420 MEDICAL DIAGNOSIS. 
 
 Thekmolysis or heat dissipation is the result of radiation and conduc- 
 tion from the surface, of the evaporation of water from the lungs and skin, 
 and of the warming of the food, drink, and inspired air. 
 
 Thekmotaxis or heat regulation is brought about by reciprocal 
 changes in heat production and heat dissipation through the action of 
 cutaneous impulses and of variations in the temperature of the blood upon 
 the thermogenic and thermolytic centres. Thus in an animal exposed to 
 moderate cold, heat dissipation is increased, but cutaneous impulses are 
 generated which excite the thermogenic centres and heat production also 
 is increased, whereas an increase of the temperature of the blood increases 
 the activity of the thermolytic process. In either case the temperature of 
 the body is maintained. Under abnormal conditions this reciprocal influ- 
 ence is deranged. 
 
 Abnormal thermotaxis is a term used to designate the regulation of 
 the heat mechanism under pathological conditions in which the body 
 temperature is maintained at a range higher or lower than that of health. 
 
 Under ordinary circumstances the presence or absence of hyperther- 
 mia may be determined by the hand, but this mode of observation yields 
 no accurate data either for comparison or record. An impression as to 
 the surface temperature is thus obtained but this does not always corre- 
 spond with the internal temperature of the body. During a chill the tem- 
 perature of the skin, in consequence of the contraction of the arterioles, is 
 in most instances greatly reduced, while the internal temperature, as deter- 
 mined by the thermometer, is high. On the other hand, when the skin is 
 active and perspiring and evaporation is prevented by the bed-clothing, the 
 surface may feel hot to the hand while the internal temperature remains 
 normal. The normal axillary temperature ranges about 98.6° F. — 37° C. 
 It undergoes diurnal oscillations of a degree to a degree and a half, falling 
 to 97.5°-98° F. in the early hours of the morning and rising to 99°-99.3° F. 
 toward evening. It is very probable that this physiological oscillation 
 is dependent upon the alternations of sleep and waking. Observations 
 upon men who have habitually slept during the day and watched during 
 the night have shown an inversion of the curve. A slight physiological 
 rise takes place during gastric digestion. Violent physical exercise is fre- 
 quently followed by a temporary rise of two or three degrees; this fact 
 may, in part at least, explain the elevation of temperature sometimes 
 observed after a violent general convulsion and w^hich is very common in 
 the status epilepticus. In children and adolescents the range is somewhat 
 higher than in adults and also less stable, that is to say, the diurnal phys- 
 iological oscillations are slightly greater and the sensitiveness of the tem- 
 perature to pathogenic influences more marked. 
 
 Kieffer states that careful observation has shown that permanent 
 increase of external heat in the tropics is followed by a rise of bodily 
 temperature of .05° F. for every degree of external heat above the 
 mean annual norm and that as a direct consequence the respiratory 
 function is diminished, the pulse-frequency shghtly decreased, the diges- 
 tion, appetite, and assimilation unfavorably affected, the functional activ- 
 ity of the skin greatly increased, and the nervous system distinctly 
 depressed. 
 
SYMPTOMS AND SIGNS: FEVER. 421 
 
 In aged persons the diurnal temperature range in health is slightly 
 lower. and may fall to 97° F. (36.1° C). In very aged persons, on the other 
 hand, the range may be as high as in children. 
 
 The action of prolonged or intense heat and cold upon the temperature 
 must be regarded as pathological. 
 
 Abnormal Temperature. — Variations in the body temperature may be 
 plus to progressively higher ranges, designated subfebrile and febrile, the 
 latter comprising (a) slight fever, (b) moderate fever, (c) high fever, (d) 
 hyperpyrexia; or minus — subnormal temperature and the temperature of 
 collapse. 
 
 The term pyrexia is used to designate conditions characterized by 
 elevation of temperature; hyperpyrexia, those marked by excessively high 
 temperature; and apyrexia, the absence of fever. Hypothermia is the 
 term applied to conditions in which the temperature is subnormal. 
 
 FEVER. 
 
 Elevation of temperature alone does not constitute fever. Extreme 
 transient rises of 104° F. (40° C.) have been observed after violent, pro- 
 longed gymnastic exercises, and much higher temperatures in hysteria, 
 in neither case associated with the other symptoms which enter into the 
 modern conception of fever. These symptoms are, in addition to eleva- 
 tion of temperature, subjective sensations of illness, cerebral phenomena, 
 weakness, loss of appetite, thirst, increased frequency of pulse and respi- 
 ration, altered urine, and derangements in nutrition which cause wasting 
 of the body. It is furthermore essential to our conception of fever and 
 necessary to the complete manifestation of the symptom-complex that 
 the process should occupy a certain time. There are, however, febrile 
 periods of minimal duration, as for example in the course of the ague 
 paroxysm, in which most of the objective symptoms occur or in which, if 
 the paroxysm is repeated for some time at quotidian or tertian intervals, 
 all of them, including wasting of the body, are manifest. On the other hand, 
 the acute febrile infectious diseases usually run a self-limited course, meas- 
 ured by days or weeks; again, in certain of the chronic infections, as forms 
 of tuberculosis, there may be fever every day for months. Nor are these 
 symptoms altogether dependent upon or caused by the elevation of tem- 
 perature, as is shown by the fact that artificial over-heating of the body 
 produces certain of them but not all, that in different diseases their in- 
 tensity by no means corresponds to the degree of the temperature, and 
 that marked falls of temperature can occur either spontaneously or as the 
 result of antipyretic treatment without a corresponding amelioration in 
 other respects. Elevation of temperature is nevertheless a constant and 
 essential element in the condition known as fever and in certain cases 
 dominates the clinical picture. In a majority of instances, however, the 
 associated conditions constitute a much more important measure of the 
 gravity of the case than the range of temperature. 
 
 Causes of Fever. — It is evident that the causes of fever act through 
 the nervous system and thus produce derangements of the heat-regulating 
 function. At the same time they also produce derangements of the normal 
 
422 MEDICAL DIAGNOSIS. 
 
 tissue changes with increased oxidation and heat production. They con- 
 sist of soluble toxic substances circulating in the blood and are, (a) the 
 result of infection by micro-organisms, which may be general or local, or 
 (b) the result of intoxication, which may arise within the body itself from 
 faulty metabolism or be introduced from without, as in food poisoning. 
 In cases of infection with profound nutritive disturbances toxins derived 
 from both these sources are present. In either event, whether the fever- 
 producing agent be a toxin produced by the growth and development of 
 micro-organisms or an albumose, ferment, or ptomaine produced by faulty 
 cell metamorphosis within the organs or tissues themselves, the condition 
 constitutes a toxaemia, 
 
 Sapreemia is an infection of the blood by putrefactive products. 
 
 It is probable that in the rare cases of fever attributed to intense 
 emotion, as fright, or to violent pain or peripheral irritation, the rise of 
 temperature is caused by the sudden derangement of physiological processes, 
 with the production of toxins, rather than by direct action upon the heat- 
 regulating processes, and that in many, though not all, of the cases of cere- 
 bral disease accompanied by fever, as thrombosis, hemorrhage, and tumor, 
 the elevation of temperature is due to local infection rather than to imphca- 
 tion of the heat centres, while the symptom-complex and the condition of 
 the blood in sunstroke render it highly probable that the elevation of tem- 
 perature is due not so much to the direct effect of heat upon the nervous 
 system as to toxic substances generated by the action of heat upon the 
 tissues of the body and especially upon the muscles. It is thus seen that 
 many different pathogenic principles developed within the body or intro- 
 duced from without are directly or indirectly capable of producing the 
 reaction which we designate by the term fever. 
 
 Symptoms of Fever. — These substances not only cause elevation of 
 temperature and more or less marked disturbances of nutrition but they 
 also produce subjective sensations of illness and cerebral symptoms, such 
 as headache, somnolence, stupor, and, in grave cases, coma and delirium, 
 which may be mild and wandering or active and maniacal. Among the 
 effects produced upon the nervous system must be included the profound 
 sensation of weakness often present in the early stages of febrile diseases 
 and which bears no direct relation to the inability to take food or to the 
 wasting of the tissues of the body which occurs later. They produce de- 
 rangements of the normal secretions, which are manifested on the part of 
 the skin by dryness and heat or, in some cases, and especially at the time of 
 defervescence, by profuse, even colliquative sweating, on the part of the 
 gastro-intestinal tract by thirst, loss of appetite, dry, furred tongue, im- 
 paired digestion, and constipation, and on the part of the urinary appa- 
 ratus by scanty, high-colored urine of increased specific gravit3^ 
 
 Pulse in Fever. — Derangement of the pulse-frequency is a constant 
 phenomenon of fever. To what extent it is due to elevation of the tem- 
 perature and to what extent to the action of fever-producing toxins upon 
 the nervous systejn cannot be determined. In almost all cases of fever 
 there is an acceleration of the pulse-rate, the frequency of which usually 
 corresponds to the intensity of the fever. Liebermeister found that for 
 ever}^ degree centigrade (1.8° F.) of elevation of temperature above the 
 
SYMPTOMS AND SIGNS: FEVER. 423 
 
 normal there is an increase of eight beats of the pulse. This parallelism 
 between the temperature and pulse may be regarded as relatively favor- 
 able, whereas a greatly increased pulse-frequency indicates serious cardiac 
 or vasomotor disturbance and is of unfavorable prognostic significance. 
 A pulse-rate of 140-160 in the adult while resting quietly in bed is in itself 
 a very serious symptom. The pulse-frequency in children suffering from 
 febrile diseases is relatively high. In phthisis with moderate fever or even 
 in the absence of fever there is commonly a quickened pulse. There are 
 cases in which, notwithstanding marked elevation of temperature, the pulse- 
 rate remains low. This departure from the ordinary parallelism is of 
 diagnostic importance. High temperatures with slow pulse are observed 
 in cases of cerebral disease in which there is pressure at the base, as tuber- 
 culous meningitis, in yellow fever, and in febrile diseases in individuals 
 suffering from cardiac lesions attended by diminished pulse-frequency, as 
 sclerosis of the coronary arteries and myocarditis. It is to some extent 
 characteristic of enteric fever that the pulse-frequency is moderate as 
 compared with the elevation of temperature, and this want of correspond- 
 ence is of importance in the differential diagnosis between enteric fever 
 and acute miliary tuberculosis or septicaemia, in both of which the pulse- 
 rate is high. 
 
 Respiration in Fever. — Increased frequency of respiration occurs in 
 almost all cases of fever. That this phenomenon is in part due to the 
 stimulating effect of the heated blood upon the respiratory centre has been 
 shown experimentally; exposure to artificial heat increases the frequency 
 of breathing. That it is also in part due to the direct action of the fever- 
 producing toxins upon the respiratory centre is rendered probable by the 
 fact that the acceleration of breathing bears no direct ratio to the elevation 
 of temperature but varies greatly at the same temperature in different dis- 
 eases. It is a matter of experience that cases of febrile disease in which, in 
 the absence of complications on the part of the respiratory organs, the res- 
 piration frequency is greatly increased are almost always of grave import. 
 
 Emaciation. — Wasting accompanies fever. Even in febrile attacks of 
 moderate duration the loss of flesh may be marked; in prolonged fevers 
 emaciation may be extreme. The blood undergoes analogous changes, 
 the patient becomes anaemic, and the loss of flesh at the close of a prolonged 
 fever is not more striking than the pallor, A decrease in the number of the 
 erythrocytes accompanies all cases of pyrexia, but requires some time to 
 become manifest. There is progressive loss of the albumins of the plasma. 
 
 Pyrexia a Symptom. — The clinical significance of fever would be much 
 less important were it not for the fact that the febrile movement, in its 
 mode of onset, intensity, course, and decline, bears a relation to the partic- 
 ular morbid condition in which it occurs, frequently definite and always 
 suggestive. 
 
 Until recently much stress was laid upon the distinction between symp- 
 tomatic fever and essential or idiopathic fever. The former was regarded 
 as a manifestation of some local malady, the latter as constituting the 
 actual disease. The stimulus given to the study of causes by the science 
 of bacteriology has shown that this distinction is more apparent than real 
 and that in the light of modern pathology pyrexia is always a symptom. 
 
424 MEDICAL DIAGNOSIS. 
 
 Idiopathic Fever. — Nevertheless there is a group of acute infectious 
 diseases in which fever is not only constantly present but also the most 
 conspicuous symptom, and in which the morbid process is literally coex- 
 tensive with the febrile movement, which is self-limited, the illness begin- 
 ning with the rise of temperature and the convalescence setting in with 
 defervescence. This group constitutes the idiopathic fevers or, more 
 sim.ply, the fevers. 
 
 Varieties. — Subdivisions, arranged according to the course of the 
 febrile movement, are (a) the continued fevers, as influenza and enteric 
 fever, and (b) the periodical (malarial) fevers, as intermittent, remittent, 
 and pernicious fever. In some of the continued fevers other symptoms, 
 as eruptions, are no less constant or characteristic than the course of the 
 fever, — a fact which led to the establishment of a further subdivision 
 upon an entirely different basis of classification, which comprises the 
 EXANTHEMATA OR THE ERUPTIVE FEVERS. Furthermore, in certain of the 
 diseases which are regarded as continued fevers, a characteristic periodicity 
 occurs, or the course of the disease is interrupted by periods of apyrexia of 
 considerable duration, an example of which is relapsing fever, whereas in 
 the periodical fevers, strictly so-called, namely, the malarial infections, 
 there are certain cases in which the febrile movement lacks distinct peri- 
 odicity—continued malarial fever — or is absent altogether — malarial 
 infection without fever. On the other hand there is a large group of diseases 
 that has nothing to do with malaria in which the occurrence of febrile 
 paroxysms, separated by very definite periods of apyrexia, in other words, 
 distinct periodicity, is characteristic — for example, the hectic fever of 
 pulmonary tuberculosis, hepatic fever, urethral fever, and the fever in some 
 cases of mahgnant endocarditis. Finally, there are local and general in- 
 fections in which the symptom fever is inconstant and irregular. For these 
 and other reasons, the principal of which is that fever is always sympto- 
 matic and never of itself an actual disease, the distinction between symp- 
 tomatic fever and essential or idiopathic fever has been abandoned — a long 
 step in the direction of a scientific or etiological basis for the classification 
 of diseases. Terms and phrases that have long lost their original significance 
 remain to encumber the literature and embarrass the study of medicine 
 and the period is remote when we shall cease to speak of scarlet fever or 
 yellow fever. 
 
 Type in Fever. — Type is a term loosely used to indicate the intensity 
 of fever. Thus we speak of fever of mild type or fever of grave type. It is 
 applied more accurately to the course or range of the temperature as de- 
 picted upon cHnical charts. There are three principal types of fever: (a) 
 the CONTINUED, in which the limits of the diurnal range do not usually 
 exceed 1.8° F. (1° C), the fall occurring in the morning, the rise in the 
 evening. This is about the measure of the diurnal oscillation in health. 
 There is, therefore, a parallelism between the temperature of health and 
 fever of the continued type, the latter being elevated two or more degrees 
 above the former and fluctuating in harmony with it. Since the tempera- 
 ture range upon the chart is represented not by a straight but by a curved 
 line showing the diurnal oscillations it is better to describe this as the 
 SUBCONTINUOUS type. Fever of this type is characteristic of the fastigium 
 
SYMPTOMS AND SIGNS; FEVER. 
 
 425 
 
 of uncomplicated enteric fever, (b) The remittent type, characterized by- 
 falls of several degrees in the temperature, which does not, however, reach 
 the normal. The remissions may take place at any hour of the day and are 
 often accompanied by free sweating. They are followed in the course of a 
 few hours by exacerbations of greater or less extent. There is no parallelism 
 between fever of this type and the normal temperature range. This is the 
 type seen in some forms of estivo-autumnal malaria and in septic condi- 
 tions, (c) The INTERMITTENT type, characterized by a fall of temperature 
 
 
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 Dayq/Dis 
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 Fig. 182. — Fever of remittent type: lysis in enteric Fig. 183. — Intermittent malar 
 fever. single tertian infection. Man 
 
 al fever, tertian tjrpe; 
 , aged thirty-three. 
 
 from febrile ranges to the normal or below it, a period of apyrexia of vari- 
 able duration, and the recurrence of fever. The febrile paroxysms are of 
 short duration as compared with the intermission and commonly liegin 
 with a chill and terminate in profuse sweating. During the intermission 
 the patient usually feels fairly comfortable or quite well. Fever of this 
 type occurs in malaria. The repetition of the paroxysms may extend 
 over a considerable time. Intermittent fever in which the paroxysm recurs 
 daily is known as quotidian; when the paroxysm recurs upon the third 
 day, including the day of onset, it is tertian; when it recurs upon the fourth 
 day, quartan. The paroxysms may occur at any period of the day and 
 usually at the same hour. In malaria they ordinarily recur in the fore- 
 noon, in hectic fever in the afternoon, (d) The inverse type. The tern- 
 
426 
 
 MEDICAL DIAGNOSIS. 
 
 perature in fever of the continued type and in many cases of the remit- 
 tent type undergoes diurnal oscillations of wider excursus than those of 
 health but corresponding to them in time. That is, the remission occurs 
 in the early morning hours, the exacerbation toward evening. In excep- 
 tional cases the remission takes place in the evening and the exacerbation 
 in the morning — inverse type. Fever of this type occasionally occurs in 
 tuberculosis and in rare instances in enteric fever. 
 
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 Date. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 Fig. 184. — Intermittent malarial fever, quotidian type; 
 double tertian infection. Man, aged twenty-nine. 
 
 Fig. 185. — Temperature of inverse type. 
 
 Atypical Fever. — In many febrile diseases the temperature range is 
 altogether irregular. This is especially the case in diseases in which the 
 symptoms in general are irregular or atypical, as diphtheria and the va- 
 rious septic infections. 
 
 The Type of Fever in Particular Diseases. — Many of the febrile infec- 
 tions have a characteristic temperature range. The febrile movement in 
 uncompHcated cases on the one hand is self-limited and on the other under- 
 goes definite modifications at different stages in the course of the affection 
 and upon the occurrence of special manifestations, as the appearance of an 
 eruption. In a more narrow sense the temperature range in such diseases 
 is said to be typical or to conform to type. It is to be borne in mind, 
 however, that marked departures from type may occur in consequence of 
 variations in the intensity of the infection, pecuHarities on the part of the 
 
SYMPTOMS AND SIGNS: FEVER. 
 
 427 
 
 individual, the occurrence of complications, and from the action of drugs. 
 The type of fever, both as regards the daily range and the temperature 
 curve throughout the course of the attack, constitutes a valuable aid to diag- 
 nosis, and is always to be taken into consideration. It is rarely possible, 
 however, to make a diagnosis from the temperature alone, nor is it desirable. 
 In connection with the temperature we must consider the other symptoms 
 and signs, the surrounding circumstances, and the previous treatment. 
 
 In well-developed cases, unmodified by 
 complication or treatment, the temperature 
 curve may be said to be characteristic in 
 the following diseases: tertian and quartan 
 malaria, enteric fever, typhus fever, relaps- 
 ing fever, and croupous pneumonia. It con- 
 forms in a general way to type, but less 
 closely, in scarlatina, measles, erysipelas, and 
 the variolous diseases. It is variable and 
 atypical in cerebrospinal fever, rheumatic 
 fever, endocarditis, and the septic infections. 
 
 Stages. — The course of the attack may 
 be divided into (a) the stage of prodromes, 
 (b) the onset or stage of invasion, (c) the 
 fastigium, and (d) the defervescence or stage 
 of decline. In typical cases of the different 
 febrile diseases each of these periods has a 
 definite duration and a characteristic curve 
 upon the temperature chart. 
 
 (a) The Stage of Prodromes. — This pe- 
 riod is usually marked by vague feelings of 
 discomfort, lassitude, pain in the back, un- 
 sound sleep, and feverishness, the tempera- 
 ture reaching subfebrile or even mild febrile 
 elevations in the later part of the day. These 
 symptoms are often absent. Prodromes usu- 
 ally occur in diseases of gradual develop- 
 ment. They are common in enteric fever. 
 
 (b) The Onset or Stage of Invasion. — The rise of temperature may be 
 gradual or abrupt. When gradual the evening exacerbations exceed the 
 morning remissions in such a way that the temperature rises progressively 
 to the fastigium or acme. Under these circumstances the stage of invasion 
 may occupy a period of several days, as in enteric fever. When abrupt the 
 acme is reached at once or in the course of a few hours, as in scarlet fever, 
 influenza, or croupous pneumonia. The onset is very often attended by 
 chilliness or a chill. This symptom may vary in intensity from transient 
 sensations of cold, with shivering, pallor, and slight cyanosis of the lips and 
 finger-tips, to a severe and prolonged chill or rigor, with violent shaking or 
 tremor of the whole body, chattering teeth, cold extremities, and marked 
 cyanosis. The temperature of the surface of the body is much reduced and 
 the patient experiences a sensation of extreme cold, whereas the internal 
 temperature, taken in the rectum, is high, 104°-107° F. (40°-42° C). The 
 
 
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 Fig. 186. — Fever of irregular pe- 
 riodicity. 
 
428 
 
 MEDICAL DIAGNOSIS. 
 
 violence of the chill commonly corresponds with the abruptness of the onset. 
 The insidious and gradual invasion of enteric fever is not often attended by 
 chills. The abrupt onset of croupous pneumonia very frequently manifests 
 itself by a prolonged chill of great severity, occurring without warning in 
 a condition of apparent health. The chill which ushers in the febrile par- 
 oxysm or ague fit of malaria is intense and prolonged, and the congestive 
 chill of the algid variety of pernicious estivo-autumnal malaria may termi- 
 nate in death. Chills occurring later in the attack may mark the develop- 
 ment of an intercurrent disease, as croupous pneumonia in the course of 
 enteric fever. The chills of malignant endocarditis cannot be distinguished 
 from the ague paroxysm, the resemblance to which is frequently heightened 
 by a regular periodicity. Ague-like chills occur in some cases of phthisis 
 and are common in local suppurations with pent-up pus, cholelithiasis, and 
 septic and other conditions attended by fever of intermittent type. 
 
 
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 Fig. 187. — ^Temperature curve in enteric fever, with recrudescence and relapse. 
 
 The perturbation of the nervous system, which is manifested in the 
 adult as a chill, may show itself in the child as a convulsion, sudden stupor, 
 or very rarely as an outbreak of delirium. In the adult the onset of an 
 acute febrile infection may be marked by sudden maniacal delirium and 
 patients developing pneumonia or enteric fever have in some instances 
 been regarded as insane and committed to an asylum. 
 
 The chill which attends the general or local infections and which is of 
 varying intensity must be distinguished from the so-called nervous chill 
 which sometimes occurs in persons of neurotic constitution under condi- 
 tions of excitement, intense pain, moderate shock, or great fatigue. Under 
 such circumstances there may be trembling and agitation, but the pulse 
 remains good, the normal color is preserved, and the thermometer does not 
 show a rise in temperature. 
 
 (c) The Fastigium or Acme. — Fastigium is literally the summit or 
 ridge of a building. The temperature range in the continued fevers shows 
 diurnal remissions and exacerbations corresponding to those of health, but 
 somewhat greater. The elevation above the normal differs in different 
 
SYMPTOMS AND SIGNS: FEVER. 
 
 429 
 
 diseases and in different cases of the same disease. In croupous pneumonia 
 and in typhus and relapsing fevers the elevation is high. In many cases of 
 enteric fever it is moderate. A parallelism with the temperature of health 
 is to some extent maintained in the continued fevers. This parallelism 
 may, however, be interrupted by accidents, as hemorrhage or perforation 
 in enteric fever, complications, as empyema in pneumonia, the occurrence 
 of pseudocrises, the action of antipyretic drugs, or the external applica- 
 tion of cold by means of baths or otherwise. In the periodical fevers the 
 
 
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 Fig. 188. — Croupous pneumonia in a child three Fig. 189. — Pneumonia. Early defervescence; inter- 
 years old. Defervescence by crisis on the evening rupted crisis. 
 of the sixth day. 
 
 diurnal range is much greater than in health. The term acme is used to 
 indicate the summit of the range when the febrile movement is transient, 
 as in influenza or the ague paroxysm. 
 
 An abundant hemorrhage from any surface, especially intestinal hem- 
 orrhage in enteric fever, causes an abrupt fall of the temperature to normal 
 or below it. The shock of perforation is likewise accompanied by a fall of 
 several degrees. 
 
 A normal temperature in the course of fever may thus assume the 
 significance of an abnormal temperature. 
 
 In abortive cases of enteric fever, especially in children, the defer- 
 vescence is often critical. Intercurrent diseases and complications may 
 cause a rise above the range of the fastigium. 
 
430 
 
 MEDICAL DIAGNOSIS. 
 
 c. 
 
 1-42 = 
 
 (d) The Defervescence or Stage of Decline. — The fall of temperature 
 may be abrupt, or gradual. The former is known as crisis or critical defer- 
 vescence, the latter as lysis. The abrupt fall in crisis amounts to several 
 degrees in the course of a few hours. The temperature usually reaches 
 subnormal ranges from which it reacts gradually. The fall may be broken 
 by a slight rise — interru-pted crisis. It is often attended by critical dis- 
 charges, such as copious perspiration, passage of a large quantity of urine, 
 or large liquid stools. Not infrequently it occurs during, or is followed by, 
 a deep and prolonged sleep from which the patient awakes refreshed but 
 
 weak and exhausted. There is a corre- 
 sponding fall in the pulse and respiration 
 frequency. The gradual fall in lysis takes 
 place by progressive increase in the morn- 
 ing remissions and decrease in the evening 
 exacerbations until normal or subnormal 
 ranges are attained. This process fre- 
 quently extends over several days, as in 
 enteric fever. The term rapid lysis is ap- 
 plied to a gradual defervescence of shorter 
 duration. Febrile diseases of sudden onset, 
 such as croupous pneumonia, for instance, 
 not infrequently terminate by crisis, while 
 those of gradual invasion commonly ter- 
 minate in lysis. 
 
 Persistence of fever beyond the normal 
 period in a self-limited disease is due usu- 
 ally to a complication; sometimes to re- 
 lapse. The febrile course of measles is fre- 
 quently prolonged by bronchopneumonia; 
 of scarlet fever by middle-ear disease, 
 endo- or pericarditis, pleurisy, or nephritis; 
 of enteric fever by phlebitis, abscess forma- 
 tion, cholecystitis, necrosis of cartilage or 
 bone, some form of secondary infection, or 
 by relapse. Cases of enteric fever extend- 
 ing to the fifth week or longer, in which 
 no complication can be discovered, are 
 mostly instances of intercurrent relapse. 
 
 The Temperature during Convalescence. — In the early days of con- 
 valescence from acute febrile disease the temperature range is frequently 
 subnormal. It is also labile, that is to say, very readily disturbed by 
 trifling influences, such as constipation, the return to sohd food, mental 
 excitement, or over-exertion. A transient rise of temperature produced by 
 any of these causes is known as a recrudescence. 
 
 Relapse. — A recurrence of fever, together with the characteristic 
 symptoms of the primary attack, due to reinfection. Instances of two or 
 more relapses — midtiple relapse — are of occasional occurrence. That form 
 of relapse which begins before the defervescence from the primary attack 
 is completed is known as intercurrent relapse. 
 
 
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 Fig. 190. — Scarlet fever: deferves- 
 cence by lysis. Boy, aged twelve. 
 
SYMPTOMS AND SIGNS: FEVER. 
 
 431 
 
 Bed Fever. — Patients who have passed through febrile diseases some- 
 times develop during convalescence a moderate febrile movement, the 
 evening exacerbations ranging as high as 100° or 101° F. This fever tends 
 to run on indefinitely but may quickly disappear if the patient is allowed 
 to sit up. A diagnosis of bed fever should never be made until other fever- 
 producing conditions are excluded. 
 
 Paroxysmal Fever. — The fever recurs at intervals. The temperature 
 is high and the accompanying symptoms usually severe. The febrile move- 
 ment is of short duration and commonly preceded by a chill and followed 
 by profuse sweating. 
 
 
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 Fig. 191. — Interrupted lysis. 
 
 Periodical Fever. — The periodicity may be regular or irregular. 
 Intermittent and remittent fevers are periodical. Tertian and quartan 
 malaria constitute the very type of the regularly recurring periodical 
 fevers. The periodicity of the estivo-autumnal fevers is not so well de- 
 fined; the type is blurred and in some cases wholl}^ obliterated. We 
 observe forms of continued malarial fever due to estivo-autumnal infection. 
 
 Other febrile diseases are characterized by periodicity — a matter of 
 great practical importance in diagnosis. 
 
 Paroxysmal fever, often of regular periodicity, may occur in the 
 following conditions: (a) Abscess formation and other suppurative proc- 
 esses, as empyema. In cerebral abscess the temperature may be continu- 
 ously normal or subnormal. Evacuation of pus and free drainage is fol- 
 
432 
 
 MEDICAL DIAGNOSIS. 
 
 lowed by disappearance of fever, (b) Pyaemia and septicaemia, (c) Malig- 
 nant endocarditis, (d) Suppurative and' infectious processes in the liver 
 and bile-passages — hepatic fever. Under this heading are abscess of the 
 hver, diffuse cholangitis, cholecystitis, inflammation of the hepatic, cystic, 
 and common ducts, gall-stone disease, especially impacted gall-stones, and 
 hypertrophic cirrhosis, (e) Infections of the genito-urinary tract, as cysti- 
 tis and pyelitis, prostatic abscess, and after the passage of the catheter or 
 sound — catheter fever, urinary fever, (f) Tuberculosis. Paroxysmal fever 
 is present in the acute mihary form, the early stages of many cases and 
 
 
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 Fig. 192. — Urethral fever. Man, aged sixty-four. 
 
 Fig. 193. — Cerebral hemorrhage. Hyperpyrexia. 
 Pre-agonistic rise of temperature. 
 
 the later stages — after cavity formation — of almost all cases of pulmonary 
 phthisis, and very often in acute tuberculous processes involving the bones, 
 joints, and glands. Sometimes in the last few days of consumption the 
 fever wholly ceases, (g) Hodgkin's disease and leukaemia. Periods of 
 fever may be separated by prolonged periods of apyrexia. (h) Syphilis. 
 The initial fever may come on within four or six weeks after infection and 
 persist for several weeks. Paroxysmal "fever in some instances accom- 
 panies the development of gummata and other lesions of the tertiary 
 period, (i) Rapidly growing malignant neoplasms, (j) Very rarely in 
 morphinism, the febrile paroxysm being preceded by a chill and followed 
 by copious sweating. If the minimal temperatures fall to or below the 
 normal the fever is intermittent in type; if they fail to reach the normal 
 
SYMPTOMS AND SIGNS: HYPOTHERMIA. 433 
 
 it is of remittent type. In the course of any of the foregoing diseases the 
 fever may change from one to the other of these types and frequently 
 it becomes irregular and wholly atypical. In the course of defervescence by 
 lysis as the fever gradually falls to normal it passes from the subcontinu- 
 ous type of the fastigium first to the remittent type, then to intermittent. 
 
 The febrile paroxysms, in some cases of pyaemia, malignant endo- 
 carditis, and tuberculosis, and of disease of the liver and bile-passages, are 
 ushered in by rigor and terminate by sweating, and recur with such regu- 
 larity that they closely resemble the ague paroxysms of malaria. Errors 
 of diagnosis are common, but readily avoide4 by close observation, exam- 
 ination of the blood, and the therapeutic test of quinine. 
 
 Hyperpyrexia. — Excessively high temperatures are occasionally ob- 
 served. The thermometer may register 105.8° F. (41° C.) and higher in 
 injuries involving the cervical portion of the spinal cord, and in tetanus, 
 rheumatic fever, scarlet fever, enteric fever, yellow fever, and sunstroke. 
 Very high temperatures occur in croupous pneumonia, the paroxysms of 
 malarial fever, relapsing fever, and erysipelas. A marked rise may occur 
 in the acute infections just before death — pre-agonistic rise. Excessive 
 temperature when transient is not necessarily of grave prognostic import; 
 if continued for some hours it is apt to be followed by death. Da Costa 
 has recorded a temperature of 110° F. (43.3° C.) in a case of cerebral rheu- 
 matism, Jacobi has seen in scarlet fever 107.6° F. (42° C), Sahli 113° F. 
 (45° C.) in enteric fever, Richet 107° F. (41.7° C.) in sunstroke, with re- 
 covery. The literature contains many instances of recovery after such 
 temperatures. There are well authenticated cases of even higher temper- 
 atures with recovery. The most remarkable is that of Teale, reported to 
 the London Clinical Society in 1875. A lady fell from her horse and sus- 
 tained serious spinal injuries. For sixty days she had frequent rises of 
 temperature to 111.2° F. (44° C.) and higher but eventually recovered. 
 Bryant, Guy's Hospital Reports, 1894, has recorded the facts of one hun- 
 dred cases of hyperpyrexia, several of which, however, are not above 
 suspicion. Many of the cases of excessively high temperature have oc- 
 curred in hysterical persons and several of the most remarkable instances 
 on record are obviously the result of deception. 
 
 HYPOTHERMIA. 
 
 Subnormal Temperature. — Hypothermia may be present under the 
 following conditions: 
 
 (a) The intense action of external cold. A transient body tempera- 
 ture of 86° F. (30° C.) may occur, yet recovery take place. 
 
 (b) After a pronounced crisis at the close of an acute infectious dis- 
 ease, as pneumonia. Postcritical falls to 95° F. (35° C.) or even to 93.2° F. 
 (34° C.) have been observed. 
 
 (c) In shock and collapse. The fall of temperature is associated with 
 signs of failure of- the circulation, frequent, small, or imperceptible pulse, 
 colliquative sweating, great relaxation, and extreme pallor. The mind, 
 except in the presence of cerebral lesions, usually remains clear. The con- 
 dition may be transient or it may be the immediate forerunner of death. 
 
 28 
 
434 
 
 MEDICAL DIAGNOSIS. 
 
 Subnormal temperature may be the result of internal or external hemor- 
 rhage, traumatism, surgical operation, prolonged anaesthesia, the apoplectic 
 insult in cerebral hemorrhage, embolism or thrombosis, the sudden rupture 
 of a hollow viscus with the discharge of its contents into the peritoneum, 
 or finally the action of intense pain or a sudden, overwhelming, depressing; 
 emotion in a neurotic individual. When reaction takes place the tempera- 
 ture rises very often to febrile ranges, either as the result of infection or, in the 
 case of cerebral or spinal lesions, from irritation of the tissues which constitute 
 
 
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 Fig. 194. — Pneumonia. Death in collapse after 
 
 crisis. 
 
 Fig. 195. 
 
 —Enteric fever; subnormal temperature 
 due to repeated hemorrhage. 
 
 the heat centres. In lesions of the cerebrospinal axis the reactive fever is 
 frequently due to inflammatory reaction in the neighborhood of the lesion, 
 
 (d) In various conditions attended by greatly diminished tissue 
 change or profound disturbance of the heat mechanism, as in the coma 
 attending acute poisoning from alcohol, illuminating gas, carbohc acid, and 
 other toxic agents, starvation, carcinoma of the oesophagus, other internal 
 cancers, abscess of the brain, myxoedema, sclerema neonatorum, and in some 
 forms of mental disease, as melancholia. Subnormal temperature ranges 
 are also occasionally observed in profound anaemia, the terminal stages of 
 tuberculous processes, especially tuberculous peritonitis, and in diabetes. 
 
 The Action of Drugs upon the Temperature.— Antipyretic drugs^ 
 most of which are synthetic products of coal-tar, while capable of produc- 
 
SYMPTOMS AND SIGNS: ABNORMAL TEMPERATURES. 435 
 
 ing marked effects upon febrile temperatures, have little influence upon the 
 body temperature in health. Their free use in fever is followed by a tend- 
 ency to collapse, and the resulting fall of temperature is of short duration. 
 External Antipyretics. — Cold baths or gradually cooled baths, spong- 
 ing, packs, ice-bags, circulating coils for the application of iced water, and 
 cold enemata reduce the febrile temperature not only without the pertur- 
 bating effects of drugs but, if rightly employed, with a favorable influence 
 upon the general condition of the patient. • 
 
 Trifling rises of temperature follow the administration of full doses 
 of atropine, cocaine, strychnine, caffeine, and certain other drugs, while 
 correspondingly sHght faljs occur after morphine, quinine, alcohol, and the 
 general anaesthetics. 
 
 THE SIGNIFICANCE OF ABNORMAL 
 TEMPERATURES. 
 
 To recapitulate: A rise of temperature, if moderate, may be physio- 
 logical—digestion, violent muscular effort. Such rises are commonly tran- 
 sient. If the rise be accompanied by other 
 symptoms of fever it may indicate (a) an 
 infection, either general or local; (b) an in- 
 toxication, which may arise within the body 
 from faulty metabolism or be introduced 
 from outside the body, as in the case of food 
 or drink; (c) a lesion involving the heat- 
 regulating mechanism of the nervous system. 
 
 As a rule there are associated symp- 
 toms which render practicable the differen- 
 tial diagnosis of these conditions. 
 
 A fall of temperature may indicate 
 blood loss, which may be internal and con- 
 cealed, as in a small rupture of the wall of 
 the heart not presently fatal; a similar leak- 
 age from an aneurism; collapse, as in apo- 
 plexy; excessive radiation, as in exposure; 
 diminished metabolism, as in convalescence, 
 starvation, forms of poisoning, and certain 
 nutritional and nervous diseases. The fall 
 may be transient or sustained. 
 
 Whether the temperature be higher or 
 lower than the normal it serves to exclude 
 maUngering and, as a rule, hysteria. It is 
 important to bear in mind that remarkable 
 departures from the normal temperature are 
 observed in some cases of hysteria, and that 
 the clever malingerer often plays tricks with 
 the thermometer that are as difficult of detection as they are puzzling. 
 
 The Prognostic Significance of Abnormal Temperature. — The height 
 of the temperature is important, since the danger increases with the inten- 
 
 
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 Fig. 19G. — Ischiorectal abscess. 
 Fever immediately relieved by in- 
 cision and drainage. 
 
436 MEDICAL DIAGNOSIS. 
 
 sity of the fever. A rise of 7.2° F. (4° C.) or 9° F. (5° C.) is of itself ominous. 
 If sustained for some hours death almost always follows, though remark- 
 able exceptions to this rule have been observed. Abrupt rises from the 
 range of health, such as are seen in malaria or relapsing fever, are less 
 dangerous than sudden rises above the fastigium in the course of enteric 
 or other continued fever. 
 
 Variations from type in the temperature curve modify the prognosis 
 unfavorably. The irregular pneumonias of moderate temperature, 102° F. 
 (38.8° C.) are attended by greater danger to life than the typical forms 
 with intense fever, 104° F. (40° C.) or higher. 
 
 The temperature in childhood is less stable than in adult life. It is 
 elevated by slight causes, and reacts more readily to antipyretic treatment. 
 Forms of ephemeral fever are more common than in later life. High tem- 
 peratures are less dangerous. 
 
 V. 
 
 RESPIRATION; MODIFIED RESPIRATORY MOVEMENTS; COUGH 
 
 AND ALLIED PHENOMENA; SIGNIFICANCE OF COUGH IN 
 
 DIAGNOSIS; EXPECTORATION. 
 
 RESPIRATION. 
 
 The normal respiration-frequency in the adult is from 16 to 24 in the 
 minute. The average pulse-frequency varies between 64 and 96. The 
 normal pulse-respiration frequency is therefore 1 to 4-4.5. In early life 
 the respiration is more rapid, the average being in the new-born 44; in the 
 fifth year 26. Posture exerts a marked influence. In normal adults the 
 average frequency while recumbent is 14, while sitting 20, and in the erect 
 posture 22. These differences are exaggerated in those who are enfeebled 
 by disease. The respiration is shghtly less frequent in the morning than at 
 night, and about one-fourth less during sleep. It is more rapid after eating 
 and especially after a hearty meal, a fact which finds its explanation in 
 the more limited excursus of the diaphragm when the stomach is full. 
 The rate is very httle influenced by the external temperature. It is modi- 
 fied by the internal temperature and much increased in fever. It increases 
 with muscular activity. The respiration frequency may be modified within 
 Hmits by an effort of the will and is profoundly affected by the emotions. 
 CHnically the rate is often quickened by the knowledge on the part of the 
 patient that his breaths are being counted. It is therefore important, if 
 possible, to count without his being aware of it, for instance, when you 
 appear to be counting the pulse. Failures of observation may be controlled 
 by counting for one or more entire minutes. The rate and depth of the 
 respirations bear an inverse relation to each other: the greater the fre- 
 quency the less the depth, or the slower they are, the deeper. General 
 abnormal conditions and local diseases, especially those which involve the 
 organs of respiration, modify both the frequency and extent of the respira- 
 tory movements. 
 
SYMPTOMS AND SIGNS: RESPIRATION. 437 
 
 Tidal Air. — This term is used to designate the inflow and outflow of 
 air during quiet respiration. It amounts to about 500 cubic centimetres — 
 30 cubic inches. Complemental air is the volume that can be inspired 
 after the completion of an ordinary inspiration; reserve or supplemental 
 AIR, the volume that can be expelled after an ordinary expiration; resid- 
 ual air, the volume remaining in the lungs after the most forcible expira- 
 tion; stationary air, the volume remaining in the lungs after an ordinary 
 expiration and equal to the reserve air plus the residual air. Vital ca- 
 pacity is the volume of air that can be expired after the fullest inspiration. 
 The average is about 3400 cubic centimetres for men and 2500 cubic centi- 
 metres for women. Lung capacity is the total quantity of air in the lungs 
 after full inspiration, and is equal to the vital capacity plus the residual air. 
 
 Vital Capacity. — The measurement of the vital capacity is determined 
 by various modifications of the spirometer devised by Hutchinson. It is 
 affected by age, sex, stature, posture, occupation, and disease. It increases 
 with age, the maximum being attained at about the thirty-fifth year. It 
 is greater in men than in women of the same height in the ratio of 10 to 
 7.5. It increases in proportion to the stature up to the twenty-fifth year, 
 and Arnold found that, in the adult, for each centimetre of increase or 
 decrease of height beyond a mean standard there is a corresponding rise or 
 fall in the vital capacity of 60 cubic centimetres for men and 40 for women. 
 The ratio as modified by posture, is 0,96 in the prone, 1.11 in the sitting 
 or erect, and 1.13 in the standing position. The vital capacity is greater in 
 those leading an active than in those who lead a sedentary life. It is 
 obvious that improper clothing and tight lacing and all pathological condi- 
 tions which interfere with the full and free expansion of the chest, whether 
 general, as in wasting diseases of every kind, or local, as in thoracic or 
 abdominal diseases, must diminish the vital capacity; nor is it to be over- 
 looked that pregnancy or a sedentary life not in itself incompatible with 
 excellent health may exert a similar influence. The spirometer, partly for 
 these reasons, partly by reason of its inconvenience of application and un- 
 certainty as an instrument of precision, and, finally, because there are other 
 methods far more available and accurate, has fallen wholly into disuse in 
 ordinary clinical work. 
 
 Peculiarities in the respiratory phenomena are expressed by the fol- 
 lowing terms: 
 
 Eupncea is a condition of normal respiration observed during bodily 
 and mental quiet. Apncea is a temporary suspension of the respiratory 
 movements. Hyperpncea is a term used to designate increased respiratory 
 activity. Heat-dyspncea and polypncea are forms of hyperpncea due to 
 direct excitation of the respiratory centres, as the result of an increase in 
 the temperature of the blood or of reflex excitation of the cutaneous nerves 
 by external heat. Dyspncea is difficult or labored breathing; the respir- 
 atory frequency is often less than normal but may be increased. As- 
 phyxia or suffocation is the term used to express the condition caused 
 by deprivation of air. The respirations are at first increased in frequency 
 and depth, then a period of increasing dyspnoea follows, with violent spas- 
 modic expirations and convulsions. The final condition is that of collapse, 
 which is ushered in by progressive slowness and shallowness of the respi- 
 
438 MEDICAL DIAGNOSIS. 
 
 rations, dilatation of the pupils, disappearance of the motor reflexes, loss of 
 consciousness, convulsive twitching, and relaxation of the sphincters. The 
 heart commonly continues to beat for some minutes after the cessation of 
 breathing, so that by means of artificial respiration the patient may be 
 restored to life. After death the blood is dark, the veins and lungs 
 engorged, and the arteries empty. 
 
 Type in Respiration. — The filling of the lungs with air is brought to pass 
 in part by the outward and upward movement of the ribs and sternum and 
 in part by the contraction of the diaphragm. Either of these factors may 
 predominate; hence a costal type of respiration and a diaphragmatic or 
 abdominal type. In women the costal type is more pronounced; in men the 
 abdominal. In the new-born the type is abdominal, in older children costal. 
 
 The type undergoes modifications in consequence of various patho- 
 logical conditions which affect the costal or abdominal respiration. 
 
 Limitation of costal respiratory movements is caused by intratho- 
 racic disease or by changes in the wall of the thorax. Dense pleural thick- 
 ening, pulmonary consolidation, loss of pulmonary elasticity, effusions, 
 large aneurisms, and tumors of every kind limit the respiratory excursus 
 in the region involved. If one-sided, as is mostly the case, the unaffected 
 lung takes upon itself additional work, — vicarious respiration, — and the 
 increased respiratory movement of the sound side is in strong contrast to 
 the restricted movement of the affected side. Calcification of the costal 
 cartilages and the ankylosis of the costosternal articulations, which takes 
 place in arthritis deformans and emphysema, interfere with the move- 
 ments of the ribs and may convert the costal type of respiration in the 
 female or the costo-abdominal in the male into the purely abdominal type. 
 
 Limitation of abdominal respiration may arise as the result of mechan- 
 ical interference with movements of the diaphragm, paralysis of the dia- 
 phragm itself through flattening of its vault by the presence of pleural 
 effusions, or in emphysema, and instinctively to avoid pain. The costal 
 type may therefore be intensified and the diaphragmatic diminished in 
 the following conditions: mechanically in all forms of marked distention 
 of the ^.'r-r'omen, as advanced pregnancy, tympany, tumors, and ascites; 
 acute inflammations of the serous membranes in relation with the dia- 
 phragm, as pleurisy, pericarditis, and peritonitis — the limitation of move- 
 ment being in part the result of pain, in part the result of paresis of the 
 musculature of the diaphragm; paralytic states involving the diaphragm, 
 as multiple neuritis or progressive muscular atrophy. 
 
 MODIFIED RESPIRATORY MOVEMENTS. 
 
 Derangements of the Frequency and Rhythm of the Respiration. — 
 (a) Diminution in the Respiration Frequency — Oligopnoea. — This symptom 
 is common in stuporous conditions and in coma. It occurs in severe 
 brain disorders, as hemorrhage, tumors, meningitis, in uraemia, diabetic 
 coma, intense infections, and many forms of narcotic poisoning. As disso- 
 lution approaches the respiration dechnes in frequency. In all of these 
 conditions the rhythm of the respiration may be deranged. The changes 
 are due to altered function of the respiratory centre. 
 
SYMPTOMS AND SIGNS: RESPIRATORY MOVEMENTS. 439 
 
 (b) Increased Frequency — Polypnoea. — This results from increased de- 
 mands upon the respiratory function and constitutes an important element 
 in the symptom-complex dyspnoea. It occurs also as a nervous symptom 
 in hysteria and certain forms of cerebral disease. 
 
 (c) Characteristic Derangements. — 1. Meningeal Respiration. — This 
 form of breathing, as its name indicates, is common in meningitis, but may 
 occur in other affections of the brain and in severe general infections and 
 toxic conditions. It is characterized by pauses in breathing, which last 
 from a few seconds to half a minute or longer and recur at regular or irreg- 
 ular periods. It is of unfavorable prognostic import. 
 
 2. Cheyne-Stokes Respiration. — There are similar pauses in this 
 form of breathing. They do not, however, occur as mere interruptions of 
 respiration but are preceded by a gradual diminution in the depth and 
 frequency of the respiratory acts until breathing wholly ceases. After a 
 pause of several or many seconds the breathing is re-established. It is at 
 first shallow and slow, but progressively increases and becomes by degrees 
 more rapid, deeper, and sometimes "urgent, until a maximum is attained. 
 
 Fig. 197. — Cheyne-Stokes respiration — pneumatography. 
 
 Then follows another gradual decrease, to be again followed in time by 
 total arrest of respiratory movement. Cheyne-Stokes respiration is char- 
 acterized by an exquisite periodicity. It is encountered in grave general 
 conditions due to affections of the brain, heart, or respiratory organs, espe- 
 cially in individuals who have marked arteriosclerosis. It occurs also 
 in uraemia and usually but by no means invariably in unconsciousness. 
 This form of breathing may arise while consciousness is retained, and espe- 
 cially is this the case in chronic affections of the circulatory and respiratory 
 organs. Under some circumstances consciousness is partially or wholly 
 lost during the respiratory pauses and regained in the intervals of breath- 
 ing. During the pauses there is sometimes a marked slowing of the pulse, 
 with altered tension, and contraction of the pupils, but these phenomena 
 bear no constant relation to the respiratory changes. During the accel- 
 eration in breathing which follows the pause the patients in some instances 
 experience a desire for air and in other instances the sensation of having 
 been roused from sleep. Cyanosis may occur during the pause. In certain 
 cases Cheyne-Stokes respiration occurs only in sleep. Full doses of mor- 
 phine are followed by an intensification of the phenomena, and Cheyne- 
 Stokes respiration may first appear in the sleej) which follows the admin- 
 
440 MEDICAL DIAGNOSIS. 
 
 istration of this drug. The prognosis of the underlying condition is always 
 grave, and this form of respiration is seen in profound illness from which, 
 exceptionally, the patient rallies in a short time or, and this is the general 
 rule, presently dies. In some cases of cardiac or renal disease, however, 
 Cheyne-Stokes respiration recurs from time to time for months. 
 
 3. Jerking Respiration. — The act may be spasmodic. Usually it is 
 the inspiration that is jerking, less commonly the expiration, rarely both. 
 Jerking inspiration is seen in sobbing, hysteria, hydrophobia, sometimes, 
 in asthma; jerking expiration, in acutely painful respiration, such as 
 occurs in pleurisy, especially diaphragmatic, in pleurodynia, or in the case 
 of a broken rib. Jerking respiration is more apt to occur when the breath- 
 ing is of the costal type than when it is abdominal. 
 
 Dyspnoea. — This term includes a variety of respiratory derangements 
 which, much as they may differ among themselves in detail, have one 
 thing in common, namely, difficulty in breathing. The clinical conception, 
 whatever the cause or whatever the derangement, rests upon inadequate 
 oxygenation of the blood. Dyspnoea may arise from a deficiency of oxygen 
 or from an excess of carbon dioxide in the blood. Cardiac and hemorrhagic 
 dyspnoeas are due chiefly to a deficient supply of oxygen. In cardiac dys- 
 pnoea the poor supply of blood to the tissues results from the enfeebled action 
 of the heart. In hemorrhagic dyspnoea there is enfeebled action of the 
 heart on the one hand and a diminished quantity of blood on the other. 
 All conditions which lessen the force of the circulation or the quantity of 
 haemoglobin tend to cause dyspnoea; hence individuals who suffer from car- 
 diac lesions or forms of anaemia, or who are enfeebled by disease, experience 
 difficulty in respiration after slight exertion. Conditions which interfere 
 with the interchange of oxygen and carbon dioxide in the lungs, such as 
 bronchitis of the smaller tubes, forms of pneumonia, emphysema, extensive 
 pulmonary tuberculosis, laryngeal obstruction, abdominal tumors, and 
 large ascites, tend to the production of dyspnoea, especially upon exertion. 
 
 The respiration may be more or less frequent than normal. Two prin- 
 cipal forms may be distinguished, namely, that in which the breathing is 
 rapid and shallow and that in which it is slow and deep. In the former the 
 ratio between inspiration and expiration is not usually much deranged; 
 difficulty in breathing attends both acts and the condition is spoken of as. 
 mixed dyspnoea. In the latter the ratio is disordered, sometimes the inspi- 
 ration, sometimes the expiration being more prolonged. To the one is 
 applied the term inspiratory dyspnoea; to the other expiratory dyspnoea. 
 The first is characterized by inspiratory, the second by expiratory stridor. 
 In all forms of dyspnoea certain muscles which ordinarily are little or not 
 at all used in respiration and have other functions are brought into play.. 
 They are the auxiliary muscles of respiration. Among them are the 
 scaleni, trapezii, levatores scapulae, the sternocleidomastoid, sterno- and 
 thyrohyoid muscles, and the pectorales. The action of these muscles is 
 more powerfully exerted in the 6rect or sitting posture — orthopnoea — the 
 position usually assumed in inspiratory dyspnoea. In expiratory dyspnoea 
 the abdominal muscles are used as auxiliary muscles. 
 
 In dyspnoea of high grade the muscles of facial expression are also 
 brought into play, with the effect of dilating the nostrils and separating 
 
SYMPTOMS AND SIGNS: RESPIRATORY MOVEMENTS. 441 
 
 the lips and jaws. The action of these muscles gives to the facies a very 
 characteristic and distressed appearance. Very striking is the play of the 
 nostrils in young children suffering with pneumonia. The entrance of air 
 is to some extent favored by the action of these muscles, but the ex- 
 planation of their participation in the dyspnoeal movements is to be sought 
 in the implication of associated muscle groups in the intense innervation 
 supplied to the essential muscles of respiration. 
 
 The term dyspnoea is sometimes used to designate the sensation of 
 breathlessness which attends difficult breathing. Hence subjective and 
 objective dyspnoea. These two forms are usually associated, but to this 
 statement there are exceptions. Cases occur in which, with persistent 
 obstruction of the respiration and well-marked objective dyspnoea, there 
 is no sense of breathlessness or oppression. Cyanosis may even be present 
 without subjective dyspnoea. As death approaches and objective dyspnoea 
 becomes urgent carbon-dioxide narcosis develops and subjective dyspnoea 
 disappears. There are cases, however, in which objective dyspnoea is 
 slight or absent altogether, yet the patient complains of distressing sub- 
 jective dyspnoea. To this category must be referred the precordial distress 
 of melancholia and the frequent desire of nervous patients to take a series 
 of deep inspirations. Pure subjective dyspnoea is rare. 
 
 Cyanosis attends every obstruction to respiration of high grade, what- 
 ever the cause. The blood becomes progressively richer in carbon dioxide 
 and poorer in oxygen. In chronic conditions attended with dyspnoea the 
 organism may gradually become adjusted to subnormal oxygenation of 
 the blood, so that the other functions are fairly well performed and the 
 patient, although manifestly dyspnceic, especially upon exertion, and con- 
 stantly cyanosed, has little subjective dyspnoea. On the other hand a 
 similar degree of obstruction to respiration, if rapidly established, is at- 
 tended with the most urgent and distressing dyspnoea. 
 
 Pneumothorax affords a striking example of the adjustment of the 
 organism to respiratory disturbances of high grade. The sudden inter- 
 ference with respiration causes intense objective and subjective d3^spnoea, 
 which gradually subsides and in many cases wholly disappears so long as 
 the patient is at rest. 
 
 Dyspnoea is of much less unfavorable prognosis when the cyanosis is 
 slight than when it is deep and persistent. 
 
 Forms of Dyspnoea. — Dyspnoea as the result of pain occurs in 
 pleurisy and especially in diaphragmatic pleurisy, peritonitis, inflamma- 
 tion of the diaphragm, and in affections of the intercostal muscles, as 
 myalgia and trichinosis. Deep breathing is impossible; the respirations 
 are shallow and hurried. The difficulty is not mechanical but functional. 
 
 Dyspnoea from Diminution of the Respiratory Surface or Lim- 
 itation OF THE Respiratory Excursus. — These conditions are commonly 
 associated. They are present in diseases involving the parenchyma of the 
 lungs, such as croupous and bronchopneumonia, large infarcts, congestion, 
 and the like; also in those affections in which the capacity of the thorax is 
 decreased, as pleural and pericardial effusion, pneumothorax, tumors, 
 massive hypertrophy of the heart, and kyphoscoliosis; and finally when- 
 ever the movements of the chest are hindered, as in emphysema, severe 
 
442 MEDICAL DIAGNOSIS. 
 
 chest-pain, or spasm or palsy of the respiratory muscles. Under these 
 circumstances the tidal air is diminished and the number of respiratory 
 acts is correspondingly increased. In proportion as the requirements of the 
 organism are thus satisfied the associated symptoms, — subjective dysp- 
 noea and cyanosis, — are slight or absent. Bodily effort increases the diffi- 
 culty. The deficiency of oxygen asserts itself and these symptoms become 
 manifest upon moderate exertion. If the condition be unilateral, as in 
 pleural effusion, vicarious respiration is established. 
 
 Dyspxcea in Circulatory Derangements. — Valvular lesions cause 
 dyspnoea when the compensation fails. Myocardial changes act in the 
 same way. There is a transference of blood-pressure from the arterial to 
 the venous side of the circulation. The organs receive less arterial and 
 retain more venous blood than normal. The circulatory derangement 
 affects the respirator}" centre, with the result that the breathing is increased 
 both in frequency and depth. Lesions of the left side of the heart cause 
 overfilling not only of the veins of the general circulation but also of those 
 of the pulmonary circuit. The overfilling of the pulmonary capillaries, 
 which ultimately gives rise to brown induration, is an additional cause of 
 dyspnoDa, not so much because of the space occupied bj^ the blood as by 
 reason of the impairment of elasticity in the congested tissue of the lung. 
 The alveolar distention remains near the inspiration point and the respir- 
 atory excursus is correspondingly diminished. The loss of elasticity acts 
 as a direct hindrance to breathing. The paroxysmal attacks of dyspnoea 
 in such cases constitute so-called cardiac asthma. This term is frequently 
 used to describe any shortness of breath occurring in disease of the heart. 
 It is preferable to restrict it to the attacks which bear a close resemblance 
 to true bronchial asthma. Such attacks often come on at night after the 
 first sleep. In both conditions the form of dyspnoea is the same. There is 
 a tendency to prolongation of the respiratory act with difficult and pro- 
 longed expiration attended by stridor. To the habitual overfilling of the 
 pulmonary capillaries in mitral disease must be ascribed the dyspnoea 
 upon exertion which is so common in this condition in the absence of 
 impaired compensation. A further cause of dyspnoea in circulatory dis- 
 turbances is the bronchial catarrh which is present to some degree in most 
 of the cases. 
 
 Dyspncea in Obstruction of the Upper Air-passages. — The stress 
 upon the inspiratory muscles is proportionate to the degree of obstruction. 
 The respiration tends to become prolonged and deep. In many cases, how- 
 ever, it is increased in frequency and correspondingly superficial. This form 
 of dyspnoea is present in the marked stenosis of the pharynx which occurs 
 as the result of hypertrophy of the tonsils or retropharyngeal abscess, in 
 spasmodic and membranous laryngitis, in oedema or spasm of the glottis, 
 in paresis of the abductor muscles of the larynx (posterior crico-arytenoids) 
 and in narrowing of the pharynx and trachea by tumors, foreign bodies, and 
 compression from outside, as in the case of aneurism or mediastinal tumor. 
 
 As the obstruction reaches a high grade the volume of air in the lungs 
 is progressively diminished and the less rigid portions of the thorax yield 
 to the pressure of the external atmosphere. The depressions are especially 
 marked in the epigastrium and the suprasternal and postclavicular regions. 
 
SYMPTOMS AND SIGNS: RESPIRATORY MOVEMENTS. 443 
 
 In young chikh-en, in consequence of repeated attacks of laryngitis or 
 bronchitis the cartilaginous portions of the wall of the thorax yield and 
 more or less persistent deformities of the chest arise. Among these are the 
 wide, shallow, oblique depressions at the base of the chest known as Harri- 
 son's furrows, and the prominence of the sternum, known as chicken-breast. 
 
 The stridor in this form of dyspnoea is characteristic. It is commonly 
 loud, prolonged, and hissing or whistling in character and usually much more 
 marked upon inspiration than upon expiration, — a fact that finds explana- 
 tion in the lateral drawing together of the tissues below the seat of obstruc- 
 tion in consequence of the tendency to vacuum caused by the powerful 
 inspiratory effort and the greater force of the inspiration as compared with 
 the expiration. In fact stridor may be wholly absent during the expiration. 
 When, however, patients suffering from stenosis of the upper air-passages in 
 increasing obstruction become obliged to use the abdominal muscles in 
 active expiration, expiratory stridor becomes marked or predominant. 
 
 Dyspnoea in Bronchitis. — Dyspnoea arises, as a rule, only in those 
 cases in which the catarrhal inflammation involves the finer tubes. The 
 lumen is narrowed by swelling of the mucosa and the presence of secretion 
 or exudate. If the narrowing involves a limited number of bronchial 
 tubes the difficulty in breathing is not urgent and compensation takes 
 place by increase in the respiration frequency. When the obstruction in- 
 volves a great number of bronchial tubes differences in type of the dyspnoea 
 arise which depend upon the degree of obstruction. In so-called capillary 
 bronchitis the respiratory surface is diminished to an extent correspond- 
 ing with the number and distribution of the lobules involved; dyspnoea 
 with hurried respiration then results. In the dry bronchitis of the middle- 
 sized tubes it is yet possible for a sufficient quantity of air to be drawn 
 into the lungs. This can generally be accomplished best by respiration of 
 diminished frequency and abnormal depth, just as in stenosis of the larynx. 
 
 Dyspnoea in Bronchial Asthma. — The breathing is slow, the ex- 
 piration usually prolonged and accompanied with stridor — expiratory 
 dyspncea. The rales can be heard at a considerable distance from the 
 patient. The difficulty is not to get the air into the lungs but to get it 
 out. Acute emphysema occurs and the respiratory excursus is greatly 
 diminished; hence the ''air hunger." 
 
 Dyspnoea in Emphysema. — The chest tends to assume permanently 
 the inspiratory form. The elasticity of the lung parenchyma is impaired. 
 The respiratory excursus is correspondingly diminished. The alveolar 
 septa are in many places destroyed, together with the intra-alveolar blood- 
 vessels. The breathing is shallow and frequent. The patient is distressed 
 for breath, especially upon the slightest exertion. The dyspnoea is increased 
 by the bronchitis which is so common in emphysema. Modifications arise in 
 consequence of the frequent occurrence of bronchial asthma in emphysema. 
 
 So-called Ur^emic Dyspnoea. — This form may occur as a true urse- 
 mic bronchial asthma. There is slowing of the respiration with prolonged 
 expiration and expiratory stridor. The condition is not common. The 
 dyspnoea in the majority of the cases is not actually uraemic but rather a 
 manifestation of cardiac derangement, bronchial catarrh, or beginning 
 pulmonary oedema. 
 
444 MEDICAL DIAGNOSIS. 
 
 The Dyspnoea of Fever. — Rise of temperature is usually associated 
 with increase in respiration frequency. Artificial elevation of temperature 
 also causes hurried breathing. The dyspnoea is doubtless due to the action 
 of heated blood upon the respiratory centre. As it bears no constant rela- 
 tion to the height to which the temperature rises, it is probably due, in 
 part at least, to the action of the fever-producing toxins. Experience has 
 shown that febrile diseases in which the respiration frequenc}", in the 
 absence of lung complications, is very high, are as a rule of serious import. 
 
 The Dyspncea of An.^mia. — When the hsemogiobin is diminished, 
 the oxygen requirement of the organism demands the most complete per- ■ 
 formance of the respiratory function. There is no hindrance to respiration 
 and the breathing is quickened and increased in depth. This form of 
 dyspnoea is characteristic of high grades of secondary anaemia such as 
 occur in hemorrhage, in advanced pernicious anaemia, and in chlorosis, 
 following exertion. It is a symptom of internal hemorrhage and occa- 
 sionally of hemorrhagic pancreatitis. 
 
 COUGH AND ALLIED PHENOMENA. 
 
 The normal rhj'thmical expansions and contractions of the thorax 
 serve the physiological purposes of respiration. Certain other move- 
 ments which are respiratory in character serve other purposes. Of these 
 some are voluntary, others involuntary, some purposeful, others spasmodic. 
 Among such movements are the following: 
 
 Cough.— A more or less deep inspiration is followed by an expira- 
 tory act which is interrupted bj' repeated partial closure of the glottis and 
 the production of a series of characteristic sounds. The air is expelled 
 through the narrowed glottis with some force so that foreign bodies, such 
 as a crumb, mucus in the respiratory passages, and the like, are swept from 
 the upper air-passages into the mouth. In the great majority of cases 
 cough, whether in consequence of lesions of the respiratory organs or dis- 
 ease or irritation in distant organs, is reflex and spasmodic. It may be 
 voluntarily produced. 
 
 Hawking is a voluntary act, the result of irritation in the pharynx. It 
 resembles cough except that the glottis is open and the expiration continuous. 
 
 Sneezing consists in a deep inspiration followed by a forcible expira- 
 tory^ blast through the nose; the glottis is open and the mouth usually 
 but not always closed. Sneezing is excited by irritation of the terminal 
 fibres of the nasal branches of the fifth pair of cranial nerves and is often 
 preceded by peculiar sensations in the nose. 
 
 Laughing is an emotional act characterized by deep inspiration suc- 
 ceeded by repeatedly interrupted expiration with an open glottis and 
 vibrating vocal cords. The mouth is wide open, the expiration is much less 
 forcible than in coughing, and the muscles of expression give a character- 
 istic appearance to the face. Laughing may be voluntary or involuntary. 
 When very violent and repeated it may be spasmodic and accompanied 
 by tears. 
 
 ■ Crying closely resembles laughing. It cannot in fact always be dis- 
 tinguished from laughing and the one may readily alternate with the other 
 
SYMPTOMS AND SIGNS: COUGH. 445 
 
 in young children or patients suffering from hysteria. The rhythm and 
 the facies are different. Crying is involuntary and accompanied by tears. 
 
 Sobbing follows long spells of crying or is the expression of deep 
 grief. It is characterized by interrupted inspirations with a partially 
 closed glottis, followed by a prolonged quiet expiration, and is usually 
 involuntary. i 
 
 Sighing consists in a prolonged inspiration attended by a character- 
 istic soft sound. The mouth is closed or the lips but slightly parted; it 
 is largely voluntary. 
 
 Yawning consists in a prolonged deep inspiration through the widely 
 opened mouth accompanied by a peculiar sound. The glottis is open and 
 the expiration short. The arms are thrown out and the shoulders back. 
 It may be either voluntary or involuntary but is not spasmodic. 
 
 Snoring occurs during sleep. The mouth is open and the relaxed 
 palate is thrown into vibration by the in- and outflowing air. The sound 
 is louder during inspiration. It is much more liable to occur when the 
 sleeper is on his back. 
 
 Stertor or stertorous breathing resembles snoring. It occurs in 
 apoplectic and other comatose states, as cerebral concussion, fracture of 
 the skull, epilepsy, deep anaesthesia, alcoholic stupor, poisoning by opium, 
 illuminating gas, and other narcotics, pulmonary cedema, and all conditions 
 in which excessive amounts of mucus or fluid are accumulated in the 
 bronchi, and frequently in the death-agony. Among the varieties of ster- 
 tor are buccal, characterized by vibrations of the lips and puffing of the 
 relaxed cheeks during expiration; palatine, in which the soft palate vibrates 
 with the in-going and out-going air; pharyngeal, caused by the sinking 
 tack of the base of the relaxed tongue into near relation with the posterior 
 wall of thig pharynx; mucous, the coarse snoring sound produced by the 
 churning of the respiratory air through fluid, such as mucus or blood in the 
 trachea or larger bronchial tubes. 
 
 Stridor or stridulous breathing is that noisy form of breathing caused 
 by obstruction in the larynx or trachea. This symptom may be present in 
 croup and diphtheria, oedema of the glottis, laryngeal tumors, mediastinal 
 new growths, and aortic aneurism. Stridor due to laryngeal obstruction is 
 ■commonly accompanied by aphonia. It varies greatly in character, being 
 harsh, musical, or crowing. 
 
 Hiccough is caused by a sudden spasmodic contraction of the dia- 
 phragm accompanied by closure of the glottis. There is a peculiar abrupt 
 sound and a distressing sensation of jerking in the epigastrium. It is due 
 to irritation of the terminal filaments of the phrenic nerve, which may be 
 direct or reflex. It may occur as the result of gastric or peritoneal irrita- 
 tion or may be the manifestation of a derangement of the nervous system. 
 Hiccough is occasionally observed after excessive or injudicious eating or 
 drinking, in gastric disorders, peritonitis, the so-called typhoid state, and 
 ursemia. It occurs also in hysteria and may constitute a pure neurosis. 
 The hiccough of cerebral disease, as hydrocephalus or meningitis, is doubt- 
 less the result of irritation of the central origin of the phrenic nerve. The 
 writer knows a gentleman in whom certain kinds of tobacco invariably 
 produce distressing hiccough, while others can be smoked with impunity. 
 
446 MEDICAL DIAGNOSIS. 
 
 Persistent and intractable hiccough occasionally attends the closing days of 
 fatal illness and in rare instances, occurring as a neurosis, has caused death 
 by exhaustion. 
 
 Of all the special or modified respiratory movements cough has the 
 most important bearing upon diagnosis and therefore requires more ex- 
 tended consideration. 
 
 SIGNIFICANCE OF COUGH IN DIAGNOSIS. 
 
 Etiological Considerations. — Reflex Cough. — Cough in the vast ma- 
 jority of instances is the result of reflex irritation of the terminal nerve fila- 
 ments of the vagus distributed to the respiratory tract. Irritation of the 
 mucous membrane of the larynx above the vocal cords does not produce 
 cough but causes gagging, while irritation below the cords gives rise to 
 cough. Especially sensitive areas are the interarytenoid space and the 
 region of the bifurcation, while the general mucous membrane of the 
 trachea and bronchi shows a scarcely inferior irritability. Lesions of the 
 lung parenchyma probably do not cause cough, though they are usually 
 connected with pathological conditions of the bronchi. Pleural irritation 
 is commonly attended by this symptom. The aspiration of a pleural 
 exudate is frequently followed by prolonged and violent cough. 
 
 Irritation of the nasal mucosa, which is supplied with sensory nerve- 
 twigs from the trigeminus, may in neurotic individuals produce coughing 
 with lachrymation, as in rose cold, haj^ fever, and similar conditions. In 
 such persons the slightest touch of the probe in the sensitive areas may 
 provoke violent attacks of coughing. Less common is cough as a symp- 
 tom of hypertrophic, atrophic, or vasomotor rhinitis or of polypi or devia- 
 tions of the septum. The inhalation of dust or smoke, irritating chemical 
 fumes, as those of ammonia, bromine, or pungent substances, as pepper, 
 produces cough in a normal respiratory mucous membrane. Violent 
 paroxysmal cough is excited by the insufflation of a foreign body, as a 
 crumb or a drop of liquid, into the larynx or through the glottis. The 
 common source of irritation is to be found in a morbid condition of the 
 mucous membrane of the larynx, trachea, or bronchi. There may be 
 merely inflammation and hypersesthesia with altered or deficient secretion; 
 an exudate of varying consistence, from the thin fluid of bronchorrhoea to 
 the tough masses of tenacious mucus in the early stages of acute bron- 
 chitis; or the solid bronchial casts of the terminal tubules in croupous 
 pneumonia or fibrinous bronchitis; or, finally, the material in the bronchi 
 may be derived from adjacent structures and consist of blood, as in broncho- 
 pulmonary hemorrhage or an aneurism, or pus from an empyema, a sub- 
 phrenic abscess, or an abscess of the liver. 
 
 Cough Occurs as a Symptom in All Forms of Respiratory Catarrh. — 
 In acute or subacute rhinitis it is often associated with sneezing; in laryn- 
 gitis with hoarseness or aphonia; in tracheitis or tracheobronchitis with 
 substernal pain; in bronchitis of the larger tubes with tickling sensations 
 in the early stages and a mucopurulent expectoration later; in bronchitis 
 of the smaller tubes with dyspnoea and a tendency to cyanosis; in pneu- 
 monia with fever and other indications of acute illness; in pleurisy with a 
 
SYMPTOMS AND SIGNS: COUGH IN DIAGNOSIS. 447 
 
 stitch in the side. Cough is a prominent symptom in bronchiectasis and 
 in all diseases, both acute and chronic, in which the respiratory mucous 
 membrane is primarily in a morbid condition or is irritated b}' the presence 
 of exudates or discharges from the alveolar tissues or other sources. The 
 irritation is always mechanical, often also chemical. Cough is therefore a 
 constant and suggestive symptom in pulmonary tuberculosis in all its 
 forms and at all stages of its progress. Cough is at once the reflex response 
 to the irritation and the effort to remove the cause of the irritation, and 
 ceases when the effort is successful. The offending substance ejected is 
 known as expectoration, phlegm, or sputum, or, in the plural, sputa. 
 
 Exceptionally there are cases in which, with the most pronounced 
 symptoms and signs of disease of the lungs, cough is wholly absent. This 
 may occur in the low fevers, the pneumonia of drunkards, the cachectic, 
 or the aged, in cerebral disease, and shortly before death. The reflexes are 
 obtunded and bronchial secretion or an exudate, the presence of which is 
 manifested by rales, fails to excite cough. The sudden cessation of cough 
 in grave cases of pneumonia or advanced phthisis is an ominous sign. 
 Cough is sometimes absent because the bronchial secretion is swept on- 
 ward by the ciliated epithelium to the larynx and removed by hawking. 
 If it is then swallowed, as is a frequent occurrence, not only is cough absent 
 but also expectoration. 
 
 Much less common is cough due to extrarespiratory irritation. The 
 sufferers are usually neuropathic. 
 
 Pharyngeal Cough. — Tickling of the wall of the pharynx or the base of 
 the tongue, which in most persons is resented by gagging, in some is fol- 
 lowed by cough. Lymphoid growths in the nasopharynx and collections 
 of thick mucus, or the presence of inflammatory exudates, may be the 
 cause of cough. Elongation of the uvula and paresis of the palate may 
 excite cough by producing irritation of the posterior wall of the pharynx, 
 especially during recumbency. 
 
 Ear Cough. — Not infrequently paroxysmal cough is produced by the 
 presence of a foreign body in the external auditory meatus or by disease 
 of that passage. The mere introduction of the speculum may cause cough 
 so violent as to make the examination most difficult. The afferent nerve 
 is the auricular branch of the pneumogastric or. according to others, the 
 auriculotemporal branch of the fifth nerve. 
 
 Stomach Cough. — The popular explanation of certain forms of cough 
 as a manifestation of disorders of the stomach is sustained neither b}^ 
 pathological nor experimental investigation. The morning cough of the 
 drunkard is to be accounted for by the pharyngeal catarrh which accom- 
 panies chronic alcoholic gastritis; of the consumptive, by lesions of the 
 lungs or larynx, with which secondary gastric disorders are commonly 
 associated. The cough occasionally observed in subacute catarrhal gas- 
 tritis and which disappears as the gastritis improves is due to the asso- 
 ciated pharyngitis. Bronchitis is very common in chronic alcoholism and 
 other forms of ill health with derangement of the gastro-intestinal tract, 
 and a careful investigation of the cases of so-called stomach cough will 
 almost always demonstrate, with the gastric condition, associated lesions 
 of the respiratory tract which account for this symptom. 
 
448 MEDICAL DIAGNOSIS. 
 
 Liver Cough. — This symptom is doubtless due to irritation of the 
 •diaphragmatic pleura. It is met with in certain cases of hypertrophy of the 
 liver, perihepatitis, hydatids, and hepatic and subphrenic abscess. 
 
 Disease or enlargement of the spleen may also in rare cases be the 
 cause of cough. 
 
 Cough may exceptionally be provoked by pressure in the region of the 
 liver or spleen. 
 
 For some years the writer had under observation a case of ventral 
 hernia midway between the tip of the ensiform cartilage and the umbilicus 
 in the median line, in which violent paroxysmal cough attended the pres- 
 ence of the tumor and immediately subsided upon its reduction. 
 
 Dentition. — Cough is not uncommon during the first dentition, with- 
 out manifestations of disease of the respiratory tract. It appears before 
 the eruption of the successive groups of teeth and disappears with the 
 completion of the process. 
 
 Mediastinal Cough. — Mediastinal tumor or abscess, thoracic aneurism, 
 enlarged bronchial glands, and caries of the dorsal vertebrae are occasional 
 causes of persistent and troublesome cough. Massive hypertrophy or great 
 dilatation of the heart is also in some instances accompanied by cough. 
 
 Nervous Cough. — The diagnosis of nervous cough is only to be made 
 when, in default of direct signs or symptoms or by exclusion, the absence 
 of disease of the respiratory organs or other lesions recognized as the cause 
 of this symptom can be established. Not rarely cough is the only direct 
 manifestation of a bronchitis or pulmonary tuberculous process in which, 
 for the time being, the ordinary physical signs are lacking. It often hap- 
 pens that the diagnosis of nervous cough is made when the intensity and 
 persistence of the cough is altogether out of proportion to its actual physical 
 ■cause, as is common in neurotic individuals. Nevertheless in some cases 
 cough must be recognized as a purely nervous phenomenon. There are 
 persons who cough whenever their feet are chilled or a cold air blows 
 upon an exposed part of the body. Paroxysmal cough of purely nervous 
 nature is not uncommon in both sexes at puberty. Cough is one 
 of the multitudinous sym.ptoms of hysteria. Under certain conditions 
 cough may occur in neurotic individuals in consequence of disease or irri- 
 tation of the mammae or of the genital organs in either sex. It has been 
 shown that cough may be excited by irritation of the floor of the fourth 
 ventricle above the centre for respiration. Whether, under pathological 
 conditions, a true "centric cough" occurs is open to question. Irritation 
 of a ''cough centre" has been invoked to explain hysterical and other 
 coughs of purely nervous origin. 
 
 Clinical Varieties of Cough. — The character of the cough is of impor- 
 tance in diagnosis. It is modified according to the seat of the irritation, 
 whether respiratory or extrarespiratory; by the anatomical structure 
 involved, as the larynx, bronchi, pleura; by the amount and consistence 
 ■of the irritating substance; and by the constitutional peculiarities of the 
 patient. The following forms demand especial consideration: 
 
 Dry Cough. — Patients themselves recognize the distinction between 
 dry and moist cough. Cough due to irritation of the respiratory mucous 
 membrane is dry when it occurs in the absence of secretion or if the secre- 
 
SYMPTOMS AND SIGNS: COUGH IN DIAGNOSIS. 449 
 
 tion is tough, tenacious, and not readily dislodged. Extrarespiratory 
 cough — so-called " reflex cough" — is dry. The sound is hacking, barking, or 
 ringing and is not accompanied by expectoration. Dry cough is frequently 
 spoken of as "unproductive." It occurs in the early stage of acute bron- 
 chitis, broncliial asthma, influenza, pneumonia, and pleurisy, in affections 
 of the upper air-passages, phthisis, and pertussis. This is the cough which 
 is excited by the inhalation of foreign bodies, irritating fumes, or dust, and 
 by extrarespiratory causes. It results from pleural irritation and is 
 encountered in pleurisy with fibrinous exudate and upon the withdrawal 
 of an effusion. 
 
 Loose or Moist Cough. — This cough is associated with sounds indi- 
 cating the part played by fluid in the mechanism of its production. It 
 differs from dry cough not only in its acoustic characters but also in the 
 occurrence of expectoration. It is "productive." Loose cough occurs in 
 the later stages of acute bronchitis, influenza, and pneumonia; toward the 
 close of the paroxysms of whooping-cough and asthma; in chronic bron- 
 chitis, bronchiectasis, and pulmonary gangrene; in advanced phthisis; 
 and in all conditions attended by moderate or abundant bronchial secretion. 
 
 Constant and Recurrent Cough. — Adjectives such as constant, per- 
 sistent, recurrent, designate peculiarities of the cough dependent upon 
 the persistence or recurrence of its cause. So-called nervous cough is 
 usually persistent; also the cough which attends diseases of the upper air- 
 passages and acute bronchitis and that of bronchorrhoea. On the other 
 hand, in chronic bronchitis, especially when there is bronchial dilatation, 
 the cough is apt to occur paroxysmaliy at varying intervals. The expec- 
 toration of a large amount of matter is followed by relief. After a time 
 the secretion reaccumulates, a mere overflow into the bronchi on change 
 of posture excites cough, and the process is repeated. This form of cough 
 attends the later stages of phthisis with large vomicae and occurs in some 
 cases of empyema with bronchopulmonary fistula. Recurrent cough is 
 very common in chronic bronchitis and phthisis; it constitutes the "morn- 
 ing cough" of these conditions. The secretion accumulates slowly during 
 sleep without exciting irritation. On waking, the patient moves, the 
 accumulated material shifts its position a little, the bronchial reflex is 
 brought into play, cough results and continues until the offending mass is 
 expelled. 
 
 Paroxysmal Cough. — Recurrent cough is not necessarily paroxysmal, 
 and paroxysmal cough for the time may be constant. The word paroxj^sm 
 conveys the idea of suddenness and intensity. Such is the cough of acute 
 inflammatory conditions; that caused by foreign bodies in the air-passages, 
 the insufflation of saliva, and the like; by the periodical flooding of the 
 bronchi with the abundant contents of the cavities in phthisis, bronchial 
 dilatation, pulmonary abscess, or gangrene; and finally that of pertussis. 
 The paroxysm recurs at intervals varying from an hour or less to once a 
 day or longer. In the case of cavities or a bronchial fistula in empyema 
 the interval is determined by the accumulation; in pertussis by the inten- 
 sity of the neurosis. In the latter condition the cough is characteristic. 
 Into its production two factors enter: an abundant tenacious mucus and 
 a pathological nervous excitabihty. After a long inspiration, the expira- 
 29 
 
450 MEDICAL DIAGNOSIS. 
 
 tory cough-efforts succeed each other with such rapidity that inspiration 
 is partial or absent until at last a prolonged inspiration takes place which, 
 by reason of the spasmodic contraction of the glottis, is attended by a 
 harsh, crowing sound or whoop; hence the common term whooping-cough. 
 A somewhat similar inspiratory whoop sometimes attends the paroxysmal 
 cough of other diseases, but so infrequently that in the vast majority of 
 cases the phenomenon justifies the diagnosis of whooping-cough. The 
 differential diagnosis involves consideration of the age of the patient, the 
 presence or absence of an epidemic, history of exposure, the duration and 
 course of the attack, and the presence or absence of lesions capable of 
 causing violent paroxysmal cough other than that of pertussis. The cough 
 which attends enlargement of the bronchial glands, mediastinal tumor, 
 caries of the dorsal vertebrae, enlargement of the heart, and pericardial 
 effusion is paroxysmal and dry. Quite often it has the laryngeal character. 
 Very violent paroxysms of cough frequently result in retching and vomit- 
 ing and, as a result of the venous congestion from intrathoracic pressure,, 
 in hemorrhage from mucous surfaces or into the skin. 
 
 Croupy Cough. — A dry cough, described as metallic, ringing, or croupy^ 
 is characteristic of laryngeal irritation. The voice is usually hoarse or 
 aphonic, though it may be unimpaired. The laryngeal cough occurs in 
 simple or exudative laryngitis, spasm of the larynx, from the inhalation of 
 smoke or dust, as the result of the irritation produced by foreign bodies 
 in the larynx, and in tuberculous, syphilitic, or cancerous ulceration. 
 The cough of hysteria is usually laryngeal in character, though upon laryn- 
 goscopical examination neither swelling nor paralysis may be present. 
 It is described by such adjectives as barking or croaking and resembles 
 other hysterical manifestations by the readiness with which it may be 
 voluntarily produced. A barking laryngeal cough, in the absence of swell- 
 ing of the laryngeal mucosa or paralysis of the vocal cords or of lesions 
 directly or indirectly involving the recurrent laryngeal nerves, is commonly 
 hysterical. 
 
 Suppressed Cough. — Voluntary efforts to suppress cough are made 
 under circumstances in which the sound of the cough is likely to annoy 
 others and when the act is attended by pain, as in pleurisy, acute perito- 
 nitis, and some forms of acute bronchitis. The suppressed cough is usually 
 lacldng in tone, and is explosive and persistent. 
 
 Undeveloped Cough. — Incomplete efforts at cough, unattended by 
 the characteristic sound, are observed in cases of destructive ulceration 
 or paralysis of the vocal cords or of partial paralysis of the expiratory 
 muscles. This form of cough is encountered in laryngeal phthisis, in pa- 
 tients suffering from bulbar paralysis, in enormous ascites or abdominal 
 tumors, and in conditions attended with extreme debility, especially the 
 later stages of croupous and bronchopneumonia, chronic bronchitis, 
 pulmonary oedema, and consumption. 
 
 In the majority of instances the diagnostic significance of the symp- 
 tom cough is direct and obvious. It is the indication of disease affecting 
 the respiratory organs, manifested more or less fully by concurrent signs 
 and symptoms; in a far smaller proportion of cases its significance is 
 remote and obscure and only to be learned by close and systematic study 
 
SYMPTOMS AND SIGNS: EXPECTORATION. 451 
 
 of the various organs or parts to derangements of which it may be clue. 
 Important among these derangements are diseases of the intrathoracic 
 circulatory organs, mediastinum, ears, teeth, and nose, some nervous affec- 
 tions, and the neurotic constitution. To this list must be added malinger- 
 ing, since cough may be a voluntary act. 
 
 THE EXPECTORATION OR SPUTUM. 
 
 These terms are applied to material voided by coughing or hacking. 
 The expectorated substance is usually a secretion or exudate derived from 
 the mucous membrane of the nose, pharynx, larynx, or bronchial tubes, or 
 from the alveoli. It may consist of pus, which finds its way into the air- 
 passages from an abscess or an empyema, or of blood from the pulmonary 
 vessels or an aneurism. With these substances are frequently admixtures 
 of food, drink, and the secretions of the mouth. Macroscopic and micro- 
 scopic foreign bodies which have found their way into the respiratory 
 passages are usually voided in the sputa. 
 
 Any of these substances may be present and not expectorated. In- 
 fants and young children almost always swallow the sputa and older 
 persons frequently do so as a habit or from inability to expectorate or in 
 abnormal mental states. 
 
 The naked-eye examination of the expectorated matter is frequently 
 of great use in diagnosis; the microscopic examination is often essential. 
 For the ordinary bed-side examination a considerable quantity of the 
 sputum should be collected, preferably in a transparent glass spit-cup. 
 
 The quantity of the sputum varies according to the nature of the path- 
 ological process. Persistent and distressing cough may yield only an 
 occasional small tough mass of tenacious material, as in dry bronchitis or 
 beginning phthisis. In other patients an occasional spell of coughing 
 may bring up enormous quantities of material, as in some forms of chronic 
 bronchitis, bronchiectasis, advanced phthisis, pulmonary oedema, and 
 haemoptysis. The amount of pus expectorated in empyema with broncho- 
 pulmonary fistula may exceed 1000 c.c. in twenty-four hours. 
 
 The consistence bears some relation to the amount. An abundant 
 expectoration is usually more fluid than a scanty one. Sputum composed 
 of blood, pus, or a serous fluid is always thin; that consisting of mucus or 
 mucopus usually thick and frequently tough and tenacious. 
 
 The reaction of fresh sputum is commonly alkaline. After standing 
 for some hours in the cup, the sputum yields an acid reaction — a change 
 due to decomposition processes caused by bacteria. 
 
 The color and translucency vary with the nature of the disease. 
 Mucous expectoration may be transparent and thin, resembling saliva in 
 consistency, or much thicker and still transparent. In proportion as 
 cellular elements are present the sputum becomes thick and opaque, 
 assuming the yellowish or greenish-yellow hue of pus. The gradations are 
 expressed by the terms mucous, mucoid, mucopurulent, and purulent ex- 
 pectoration. Serous expectoration is usually clear and transparent, some- 
 times slightly tinged with blood. It is thin, frothy, and abundant, and 
 occurs in oedema of the lungs and in the rare cases of perforation of a 
 
452 MEDICAL DIAGNOSIS. 
 
 serous pleural exudate. The albuminous expectoration which exception- 
 ally follows the aspiration of a pleural exudate is also thin, colorless, and 
 abundant. The color is red when the sputum is admixed with blood. 
 The proportion varies from pure blood to a mere trace sufficient to impart 
 a faint pink tinge. Hemorrhagic sputum occurs in traumatism of the 
 lungs, in the blood-spitting of tuberculosis, in pulmonary infarct, and in 
 croupous pneumonia. It is also present in cases of gangrene of the lung, 
 tumor of the lung, and intense pulmonarj' congestion. The "rusty 
 sputum'' of pneumonia owes its varying shades of color to derivatives of 
 the blood-coloring matter. In rare instances the sputum of pneumonia 
 is lemon-yellow or grass-green. These variations suggest the changes in 
 color that take place in the subcutaneous blood extravasations following 
 a bruise. In the adynamic and septic forms of croupous pneumonia and, 
 more rarely, in gangrene of the lungs the expectoration is fluid and dark 
 colored. This form of sputum is described as "prune-juice" expectoration. 
 The sputum in malignant disease of the lungs is often viscid, tenacious, 
 and of a bright red color. This is the "currant-jelly"' sputum of authors. 
 A stiU more objectionable term is "anchovy-sauce" sputum — a term 
 applied to brownish-red sputum such as is seen in rupture of a liver abscess 
 through the lungs, the peculiar appearance of which is due to the mixture 
 of altered blood, pus, and bile. 
 
 Blood-streaked sputum may occur in the following conditions: 
 violent cough, acute bronchitis, or disease of the mitral valves. It may 
 result from the admixture of blood from the mouth, as in the case of 
 scurvy and other forms of inflammation of the gums with bleeding, or 
 of ulceration of the tonsils or pharj^nx, or from the oozing of blood from 
 an aortic aneurism into a bronchus. It occurs also in acute broncho- 
 pneumonia and plastic bronchitis. It is very often observed a day or two 
 after an attack of haemoptysis. Under these circumstances the streaks or 
 masses of blood are clotted and dark. Blood-streaked sputum is not 
 uncommon during the course of pulmonary phthisis. 
 
 Yellow^ or green sputa can only be regarded as deriving their 
 color from altered bile pigment when icterus or at least yellowness of the 
 conjunctiva and biliary pigment in the urine are actually present. Icteric 
 sputum may occiu' not only in pneumonia complicated with jaundice but 
 also in any form of lung disease in a patient suffering from jaundice. A 
 peculiar brownish tint is sometimes seen in the sputum in cases of chronic 
 valvular disease. It is due to the presence of amorphous pigment in the 
 epithelial cells. The brownish sputum sometimes seen in pulmonar}' abscess 
 and other destructive processes involving the lung owes its color to the 
 presence of hsematoidin crystals, which are also the source of the coloring 
 matter in the ochre-yellow purulent sputum of liver abscess with perfor- 
 ation into the lung. Greenish sputum is sometimes encountered in sarcoma 
 of the lungs and very rarely in carcinoma. Remarkable coloration follows 
 the habitual inhalation of certain dust-particles. Black sputum is common 
 in those who breathe an atmosphere laden with coal-dust or soot. The 
 pigment particles are only to a Hmited extent free in the sputum; much 
 more commonly they are enclosed in round or oval cells which are in part 
 epithelial, in part leucoc}i;es. 
 
SYMPTOMS AND SIGNS: EXPECTORATION. 453 
 
 The color of the sputum varies in different forms of pneumonoconiosis. 
 In anthracosis it is often of an intense black; in the siderosis of mirror 
 polishers it may be ochre-red; workers in lapis lazuli may have a blue 
 sputum, and so on. The dust particles which are expectorated are those 
 recently inhaled which have not yet penetrated to the lung parenchyma, 
 as is shown by the fact that the color disappears from the sputum in the 
 course of a short time after the workman has abandoned his occupation. 
 If however the color persists or returns after a time, it is the sign of a 
 destructive process, usually tuberculous. Various colors may be imparted 
 to the sputum by articles of food or drink, as milk, wine, coffee, or medi- 
 cines. Finally after the sputum has been ejected it may undergo color 
 changes in consequence of the growth of chromatogenous bacteria and 
 thus become blue, green, yellow, or red. The Bacillus pyocyaneus may 
 be the cause of a blue discoloration of the sputum. 
 
 Air. — Air in the sputum is shown by the presence of minute bubbles. 
 The quantity depends upon circumstances. It is greater in sputum from 
 the finer than in that from the larger tubes, in sputum of thin than in that 
 of thick and tenacious consistency, and in the sputum which is largely 
 composed of mucus than in that which is chiefly pus. A little water in 
 the spit-cup enables us to estimate the relative amount of air, as it affects 
 the specific gravity; sputa which float contain air; those which sink do not. 
 The sputa of phthisis and bronchitis often present the appearance of flat 
 circular or coin-shaped masses — the so-called "nummular sputa" — or the 
 masses may be globular; they are commonly grayish-white and sink in water; 
 sometimes they are buoyed up by the small bubbles of air which they contain. 
 
 Stratification, — Layer formation takes place in the collected sputa 
 of chronic bronchitis with abundant expectoration — bronchorrhoea — of 
 bronchiectasis, putrid bronchitis, and gangrene of the lungs. The material 
 is of thin consistence and abundant. As a rule it collects in three well- 
 defined layers which can be studied by the use of a glass spit-cup. The 
 upper stratum contains air and is often frothy, the middle is fluid and 
 consists of mucus or pus-serum, and the lower is sedimentary and made up 
 of pus corpuscles, m.olecular lung detritus, and shreds of necrotic tissue. 
 
 Odor. — The odor of fresh sputum has, under ordinary circumstances, 
 nothing characteristic. Speedy decomposition renders it offensive. The 
 sputum of putrid bronchitis, bronchiectasis, gangrene of the lung, and 
 perforating empyema is always heavy and fetid; frequently horribly, 
 offensive. In abscess of the lung and in many cases of advanced phthisis 
 also it is offensive. The foulness is imparted to the expired air, which 
 not infrequently is even more obnoxious than the sputum. It is probable 
 that in the cases of pulmonary consumption in which the sputum and 
 breath are foul there is already cavity formation, though too small in some 
 instances to be recognized by the methods of physical diagnosis, in which 
 the secretion collects and undergoes decomposition. Very often the odor is 
 imparted to the breath by offensive material in the crypts of the tonsils or 
 by decaying teeth or other necrotic material in the mouth — a fact that 
 cannot in all cases be established by the use of deodorizing mouth washes, 
 since they act only upon the surfaces with which they come in contact 
 and cannot reach deeply-seated tissues from which the odor may proceed. 
 
454 MEDICAL DIAGNOSIS. 
 
 Other Macroscopical Characters of the Sputum. — Very often the 
 expectorated material presents a homogeneous appearance, as is the case 
 with mucus, pus, blood, etc. Occasionally, on the other hand, the matter 
 expectorated at different times varies in appearance and not infrequently 
 a single mass consists partly of mucus and partly of pus, or of these sub- 
 stances with masses of blood. The purulent expectoration of an empyema 
 or a pulmonary abscess is sometimes flaky or thready, best shown when 
 the sputum is suspended in water. The naked-eye characters of the sputum 
 may be conveniently studied by pouring a small quantity upon a plate or 
 slab of wliich half is black, the other half white, or placing a specimen 
 between two glass plates and examining it over a white and black back- 
 ground alternately. A hand lens may be used and particular objects 
 removed for microscopical examination. Minute, dirty gray masses of 
 necrotic lung tissue containing elastic fibres may be detected in the spec- 
 imen in gangrene and abscess of the lung and in the later stages of phthisis; 
 fragments of necrotic cartilage in destructive processes involving the 
 bronchi, the trachea, or the larynx, and in rare cases shreds of tissue from 
 tumors of the bronchi or lungs. Minute, dirty white or yellowish masses, 
 in some instances constituting casts of the smaller bronchial tubes, are 
 seen in fetid bronchitis and gangrene of the lungs. These masses consist 
 of aggregations of bacteria and crystals of the fatty acids. They have an 
 intensel}^ disagreeable odor. Similar masses may be expectorated in lacu- 
 nar tonsillitis and are sometimes present in the crypts of the tonsils in 
 the absence of inflammation. Curschmann's spirals are visible to the naked 
 eye and may be studied with the lens. They consist of twisted masses 
 which may reach 1 or even 2 cm. in length and have a diameter of about 1 
 mm. These masses are made up of a highly refractive central undulating 
 core or thread around which are coiled spiral filaments which are sometimes 
 branching. The central core was at one time thought to be fibrinous, but 
 has more recently been shown to consist of a substance analogous to mucin. 
 These spirals are formed in the finest bronchial tubes as the product of an 
 exudative bronchiolitis, and as this pathological process is frequently 
 associated with bronchial asthma the spirals are very often found in that 
 disease and in well-marked cases are sometimes present in great numbers. 
 The association, however, is by no means constant; cases of asthma are 
 occasionally encountered in which no spirals can be found in the sputum, 
 and the spirals are sometimes present in the expectoration of cases of 
 bronchitis unattended by asthmatic symptoms. Curschmann's spirals 
 occasionally appear also in the sputum of croupous pneumonia and are 
 then seen to be in strong contrast with the fibrinous casts of the bronchioles 
 which occur in that disease. They have also been encountered in the 
 sputum of pulmonary phthisis. Microscopically, leucocytes, notably 
 eosinophiles, epithelial cells, and Charcot-Leyden crystals are found en- 
 tangled in the spirals. 
 
 Fibrinous coagula, recognizable by their white or grayish-white color, 
 tough consistence, and characteristic form, are found in the sputum under 
 varying pathological conditions. They are usually coughed up in masses 
 surrounded with mucus and, when of great size, with difficulty. In diph- 
 theria fibrinous pseudomembrane is expectorated, sometimes in irregu- 
 
SYMPTOMS AND SIGNS: EXPECTORATION. 455 
 
 lar masses, sometimes as a fibrinous mould, more or less incomplete, of the 
 larynx or trachea. When the diphtheritic exudate extends to the bronchi, 
 branching casts are sometimes coughed up. These casts may be easily 
 recognized in the sputum and are of great importance both in diagnosis 
 and prognosis. Fibrinous casts are common in croupous pneumonia, in 
 the sputum of which they are frequently present in great numbers. They 
 can be readily seen when the sputum is shaken with water in a test-tube, 
 or when the masses of mucus in which they are embedded are shaken out 
 in water with a forceps. In pneumonic sputum the fibrinous casts are 
 small. Similar casts consisting chiefly of mucus are characteristic of 
 so-called fibrinous or croupous bronchitis and provoke the intense paroxys- 
 mal cough of that disease. 
 
 Foreign bodies that have found their way into the air-passages by 
 aspiration are usually expectorated promptly. They may, however, 
 remain in a bronchus for a long time and give rise to symptoms of vary- 
 ing intensity. Instances are recorded in which a tooth, cherry-pits and other 
 seeds, a beard of wheat, etc., have been expectorated after periods of 
 months or years. Bronchial concretions, consisting in the main of lime 
 salts and sometimes of considerable size, are in rare instances found in 
 the sputum. They occur only in chronic conditions and are formed in 
 the cavities of phthisis and bronchiectasis, or consist of fragments of 
 bronchial glands that have undergone calcareous degeneration and found 
 their way into the bronchial system. Even more rare is the presence in 
 the sputum of echinococcus daughter cysts, membranes, or booklets, 
 which have found their way from the lung, pleura, or the liver into the 
 bronchi. 
 
 The Sputum in Different Diseases. 
 
 Bronchitis. — The sputum is usually mucoid and mucopurulent. As a 
 rule, at the beginning of an acute bronchial catarrh the bronchial secretion 
 is diminished and the sputum scanty. In the course of some days, as the 
 symptoms ameliorate, the expectoration becomes more abundant, less 
 tenacious, and distinctly purulent. As the general symptoms improve 
 there is a gradual diminution in the quantity of the sputum. In chronic 
 bronchitis the expectoration varies greatly; sometimes it is more, some- 
 times less purulent. The subjective sensations of the patient are usually 
 better when the sputum is of moderate amount, worse when the expec- 
 toration is suppressed or greatly increased in quantity (see bronchitis). 
 
 Fibrinous or Croupous Bronchitis. — The sputum differs from that of 
 ordinary bronchitis in that from time to time it contains fibrinous casts 
 associated with blood. Charcot-Leyden crystals are also present. The 
 expectoration of the larger casts very often takes place after distressing 
 cough, recurring in paroxysms which are separated by periods of urgent 
 dyspnoea. 
 
 Pulmonary Tuberculosis. — The sputum of tuberculosis presents to 
 the naked eye nothing characteristic. All varieties of sputum that occur 
 in ordinary bronchitis, from mucous to purulent, occur in phthisis. In 
 advanced ulcerative phthisis purulent expectoration is often constant and 
 abundant. For the provisional . diagnosis the presence of the minute 
 
456 MEDICAL DIAGNOSIS. 
 
 grayish masses which frequently contain colonies of tubercle bacilli is 
 important. Very often the sputum has an offensive odor; this is espe- 
 cially the case when there are cavities, the contents of which undergo 
 stagnation and decomposition. A positive diagnosis rests upon the pres- 
 ence of tubercle bacilli and, in the absence of other destructive pulmonary 
 lesions, the presence of elastic fibres. It is important for the student to 
 bear in mind that there is no constant relation between the abundance of 
 these morphological elements and the intensity of the process, therefore 
 the gravity of the prognosis. There are cases of pulmonary tuberculosis 
 of the gravest character in which neither tubercle bacilli nor elastic fibres 
 are found. Very often these are cases of phthisis florida or of disseminated 
 miliary tuhercidosis in which the constitutional symptoms develop in ad- 
 vance of the local manifestations. The abundant catarrhal secretion, so 
 common in unfavorable cases, proportionately diminishes the number of 
 tubercle bacilli present in single specimens. On the other hand tubercle 
 bacilli and elastic fibres are frequently found in the early stages at a period 
 when the physical examination of the lung yields vague and uncertain signs. 
 The diminution or temporary disappearance of tubercle bacilli and elastic 
 fibres from the sputum cannot be regarded as indicating a favorable prog- 
 ress of the case in the absence of the general clinical indications of an arrest 
 of the process, such as diminished cough, improved appetite, gain in weight, 
 and disappearance of fever. In a suspected case the presence of tubercle 
 bacilli in the sputum justifies a positive diagnosis. Their absence cannot 
 be regarded as conclusive until repeated examinations have been made. 
 
 Acute Miliary Tuberculosis. — The sputum is that of ordinary 
 catarrhal bronchitis and does not contain tubercle bacilli except when 
 there is an associated ulcerative phthisis. In a large proportion of the 
 cases there is no expectoration. 
 
 Croupous Pneumonia. — Hemorrhagic sputum is characteristic. Blood- 
 spitting may be the initial symptom. At first the sputum is commonly 
 mucoid, transparent and homogeneous; after twenty-four hours it is 
 blood-tinged and viscid so that it adheres to the bottom of the spit-cup 
 when turned upside down, and sometimes has to be wiped from the lips 
 or face of the patient. At first red from unchanged blood-coloring matter 
 it gradually becomes rusty or orange-yellow in color. Occasionally the 
 sputa are variable; sometimes mucoid, sometimes blood-streaked, at 
 other times pure blood. When jaundice is present the sputum may be 
 green or yellow from the presence of bile pigment. Very commonly the 
 sputum contains fibrinous casts of the smaller tubes. If there is an asso- 
 ciated bronchitis of the smaller tubes the typical pneumonic sputum may 
 be modified by the presence of mucus or mucopus. Fluid sputum of a 
 dark brown color — the so-called "prune-juice" expectoration — is an 
 unfavorable sign since it may indicate a beginning oedema of the lungs. 
 In some instances a diminished consistency of the sputum marks the 
 beginning of resolution. The amount of sputum in croupous pneumonia 
 is very variable. In children and the aged, and in adynamic cases, there 
 may be none, and exceptionally it may be scanty in classical cases in adults. 
 A quantity amounting to 200-500 c.c. in twenty-four hours is not uncom- 
 mon. The amount after the crisis, abundant at first, gradually diminishes. 
 
SYMPTOMS AND SIGNS: EXPECTORATION. 457 
 
 In some cases there is at this period little or no expectoration. Under 
 the microscope are seen leucocytes, erythrocytes, mucous corpuscles, epi- 
 thelial cells, and occasionally hsematoidin crystals. The pneumococcus of 
 Weichselbaum and Frankel is present in the vast majority of cases, and 
 sometimes Friedlander's bacillus. Fibrinous casts of the bronchioles and 
 moulds of the alveoli are not uncommon. Chemically the expectoration is 
 particularly rich in sodium chloride. 
 
 Bronchopneumonia, Including Aspiration Pneumonia and Hypo= 
 static Pneumonia. — The sputum usually presents the appearance of the 
 ordinaxy forms of bronchitis; exceptionally that of croupous pneumonia. 
 The latter is intelligible, since not only in the clinical phenomena but also 
 in the histological findings there are cases of bronchopneumonia which 
 are difficult to distinguish from croupous pneumonia. In these cases the 
 sputum is hemorrhagic and contains fibrinous exudate. Bacteriologically 
 a mixed infection is the rule. The pneumococcus and Friedlander's bacillus 
 are found in association with the ordinary pus-producing and other organ- 
 isms. The Klebs-LofRer bacillus is present when the lesions are secondary 
 to diphtheria. In the lobular forms the streptococcus is the common 
 organism; in the lobar forms, the pneumococcus. 
 
 Gangrene of the Lungs. — The intensely offensive odor, abundance, 
 fluidity, and dark, dirty, greenish-brown color are characteristic. Upon 
 standing the sputum separates into three strata — an upper frothy layer, 
 which may contain necrotic particles of lung tissue which float by reason 
 of entangled air, a middle thin layer, and a greenish-brown sediment which 
 consists in part of leucocytes, in part of gangrenous detritus. Shreddy 
 fragments of lung tissue of considerable size and frequently showing the 
 alveolar arrangement may be picked out if the sediment is spread upon a 
 glass. Under the microscope are seen elastic fibres, pigment granules, 
 crystals of the fatty acids, cholesterin, leucine and tyrosine crystals, 
 bacteria, and leptothrix. Altered blood-corpuscles are also present. When 
 the fluid is retained in the gangrenous cavity for some time, the elastic 
 fibres may undergo solution owing to the action of a peptonizing ferment. 
 The odor is the more intense in proportion as the communication between 
 the gangrenous areas and the bronchi is more free. Cases occur in which, 
 in the absence of odor during life, circumscribed areas of gangrenous lung 
 have been found upon post-mortem examination. 
 
 Abscess of the Lung. — The sputum is essentially purulent. It is 
 offensive, but less intensely so than that of gangrene. When placed in 
 water it has a thready or granular appearance. When the perforation is 
 small there is an accompanying catarrhal bronchitis and the sputa are 
 mucopurulent. When, however, the abscess discharges abruptly, a large 
 amount of pus commingled with masses of necrotic lung tissue and con- 
 taining elastic fibres in abundance is discharged. Microscopically the spu- 
 tum contains hsematoidin, cholesterin and fat crystals and various bacteria. 
 
 Perforating Empyema. — The sputum resembles that of pulmonary 
 abscess. It may be at first free from odor but in the course of a little time 
 becomes offensive. It is voided in considerable quantities at varying 
 intervals. Elastic fibres are wholly absent or are present in small numbers. 
 Haematoidin and other crystals and pyogenic bacteria are present. 
 
458 MEDICAL DIAGNOSIS. 
 
 Putrid Bronchitis. — The expectoration presents characteristics simi- 
 lar to that of perforating empyema. It is purulent and foul-smelling, but 
 does not contain elastic fibres. It is voided from time to time in moder- 
 ate amounts; not in large bulk at intervals of some hours as is the case in 
 empyema with bronchopulmonary fistula and bronchiectasis. 
 
 Bronchiectasis. — In saccular bronchiectasis the sputum is sometimes 
 mucopurulent, sometimes purulent. It is brought up from time to time 
 in severe paroxysms and in large quantities — mouthfuls. These paroxysms 
 may follow change of posture, the cough reflex being excited by the shift- 
 ing of accumulated secretion from the dilatation to the normal bronchial 
 tube. A paroxysm usually occurs in the morning. The color of the expec- 
 torated matter may be gray or grayish-brown. It is usually fluid, acid- 
 smelling, sometimes extremely fetid. Upon standing it separates into 
 three layers, an upper consisting of brownish froth, a middle thin watery 
 layer, and a lower, thick and granular. Microscopically the sputum con- 
 sists of pus corpuscles, epithelial cells, erythrocytes, and large numbers of 
 crystals of the fatty acids. Haematoidin crystals are sometimes seen. In 
 the absence of bronchial ulceration, elastic fibres are not found, nor are 
 tubercle bacilli present. Nummular sputa are uncommon. In many cases 
 the sputum cannot be distinguished from that of a putrid bronchitis. 
 Hemorrhage occasionally occurs. 
 
 (Edema of the Lungs. — The sputum is usually thin, frothy, colorless 
 or slightly blood-tinged, and abundant. Upon standing it deposits a 
 sediment consisting in part of red blood-corpuscles and in part of ele- 
 ments characteristic of the antecedent condition, as bronchitis or pneu- 
 monia. It is largely made up of blood-serum and is therefore rich in 
 albumin. In the rare cases in which perforation of the lung occurs in 
 serofibrinous pleurisy the expectorated matter resembles that of pulmonary 
 oedema but is richer in albumin. A very abundant sputum, similar in 
 character, is sometimes expectorated after paracentesis thoracis, begin- 
 ning toward the close of the operation — the expectoration alhumineuse of 
 the French. This serous sputum is the result of an acute pulmonary 
 oedema following the dilatation of the compressed lung. 
 
 Bronchopulmonary Hemorrhage — Haemoptysis. — In the blood-spit- 
 ting which follows traumatism, the rupture of an aneurism, the lesions 
 of tuberculosis, or new growths involving the lungs the sputum consists 
 of more or less abundant, bright red, frothy blood. The distinction be- 
 tween venous and arterial blood cannot be made, since the dark blood of 
 the pulmonary arteries becomes oxygenized and frothy during its course 
 through the bronchial tubes. The differential diagnosis between haemop- 
 tysis and haematemesis rests upon the following facts: In bronchopul- 
 monary hemorrhage the blood is coughed up. In gastric and oesopha- 
 geal hemorrhage it is vomited, but the account of the patient or his friends 
 is not always satisfactory; in the excitement and alarm the distinction 
 may not be made. Moreover violent paroxj^smal cough may on the one 
 hand be followed by gagging and vomiting, while on the other hand some 
 portion of vomited blood may be drawn into the larynx by aspiration 
 and thus excite coughing. The examination of the blood itself is impor- 
 tant. Bright red, frothy blood may usually be referred to a lesion of the 
 
SYMPTOMS AND SIGNS: EXPECTORATION. 459 
 
 respiratory tract; blood that is dark, clotted, and free from air-bubbles, 
 to the digestive tract. But there are exceptions to this rule. In profuse 
 hemorrhage from the stomach the blood is sometimes vomited so rapidly 
 that it is bright red and fluid, while in abundant pulmonary hemorrhage, 
 resulting from erosions of a large branch of the pulmonary artery, the 
 expectorated blood may be dark in color and contain but little air. 
 
 The reaction of the blood in haemoptysis is alkaline. In haematemesis 
 which occurs during digestion, when the stomach contains a large amount 
 of acid fluid, the reaction may be acid. Too great importance cannot be 
 ascribed to the reaction of the blood in doubtful cases, since vomited 
 blood is frequently alkaline. The presence of particles of food in the blood 
 is of importance in diagnosis. 
 
 There are, however, cases in which the distinction between haemoptysis 
 and haematemesis cannot be immediately made. 
 
 The condition of the patient prior and subsequent to the bleeding is 
 in doubtful cases of greater importance than the appearance of the blood. 
 A history of gastric symptoms before the blood loss or the occurrence of 
 such symptoms subsequently is common in bleeding from the stomach. 
 The presence of altered blood in the stools after the hemorrhage points to 
 bleeding from the stomach rather than from the lungs. On the other 
 hand the mere fact that the patient has suffered for some time from cough 
 and expectoration is suggestive of pulmonary hemorrhage, which is apt 
 to be followed for some days by the occasional expectoration of small 
 blood-clots or of sputum mixed with blood. When due consideration is 
 given to these facts errors of diagnosis are not likely to occur. 
 
 Hemorrhagic sputum is occasionally encountered in acute bronchitis. 
 This sputum is to be distinguished from pneumonic sputum by the fact 
 that the blood is present in streaks rather than as a homogeneous mixture. 
 Profuse haemoptysis rarely has its seat of origin in the larynx or trachea, 
 since the blood-vessels of these organs are of relatively small size. On 
 the other hand, blood-streaked sputa are not uncommon in acute catarrhal 
 inflammation of the trachea, larynx, or pharynx. There are forms of 
 hemorrhagic bronchitis characterized by blood-tinged sputum which con- 
 tinue for some days or weeks. Such cases are not uncommon during 
 epidemics of influenza. It sometimes happens, especially during sleep, 
 that the blood in epistaxis trickles into the pharynx and is swallowed. If 
 vomited, such blood may be regarded as due to gastric ulcer. If the blood 
 in the pharynx under these circumstances excites cough and is ejected 
 mingled with mucus, it may be erroneously regarded as coming from the 
 lungs. If the trickhng blood be seen upon the wall of the pharynx the 
 diagnosis is at once established and the precise site from which it comes 
 may be determined by means of the rhinoscope. 
 
 Infarcts. — The sputum in hemorrhagic infarct is commonly dark in color 
 and resembles pure blood, from which it differs in its somewhat tenacious 
 consistence, suggestive of pneumonic sputum. In point of fact the sputa 
 in cases of pulmonary infarct may vary according to the amount of bron- 
 chial secretion present from pure blood to a tenacious blood-tinged mucus. 
 
 Chronic Valvular Disease. — Hemorrhagic sputum occurs in certain 
 cases of valvular disease of the heart, particularly in mitral stenosis. 
 
460 MEDICAL DIAGNOSIS. 
 
 VI. 
 
 CIRCULATION; PULSATION; RADIAL PULSE; ANOMALIES OF 
 THE PULSE; CAPILLARY PULSE; VENOUS PULSE. 
 
 CIRCULATION. 
 
 The term arterial pulse is used to designate the rhythmical fluctua- 
 tions of the arterial pressure which correspond to the contractions of 
 the ventricles of the heart. These rhythmic fluctuations depend upon 
 the intermittent injection of blood from the ventricles to the aorta, 
 upon the resistance to the arterial flow produced by friction, and upon 
 the elasticity of the walls of the arteries. After the blood enters the capil- 
 laries the pressure is no lon^^er intermittent, but is continuous, and pulsa- 
 tion under normal conditions disappears. The pulse may be affected 
 by changes either in the force of the ventricular contractions, in the 
 elasticity of the arteries, or in the peripheral resistance, and by vary- 
 ing combinations of these modifications. The examination of the arterial 
 pulse is therefore obviously of great diagnostic importance. By this 
 means conclusions may be reached in regard to a wide range of clinical 
 facts, including the innervation of the heart, the power of the heart muscle, 
 the blood-pressure, the blood loss in hemorrhage and anaemia due to other 
 causes, the condition of the peripheral arteries, the action of fever-pro- 
 ducing toxins upon the heart and blood-vessels, and finally, under certain 
 conditions, in regard to the presence and nature of valvular lesions. 
 
 PULSATION. 
 
 Arterial pulsation may be studied in any of the superficial arteries. 
 The methods employed in ordinary clinical work are palpation and inspec- 
 tion. Auscultation is of more limited apphcation in the study of the blood- 
 vessels. The results obtained by the use of the sphygmograph are of 
 more value in clinical research and for purposes of record and comparison 
 than for diagnosis. 
 
 The increase in the contents of the arterial system which causes the 
 pulsation is accompanied not only by an increase in the diameter of the 
 artery at any given point but also by an increase in the length of the vessel. 
 This increase in length results in a more or less marked lateral undulation 
 and exaggeration of the curves of the vessel, normally not sufficient to 
 attract attention, but conspicuous in the temporal arteries of emaciated 
 persons and at various points in the course of the superficial arteries in 
 conditions, such as aortic insufficiency, which are attended with cardiac 
 hypertrophy and relaxation of the arterial walls. The arterial pulse, 
 corresponding to a contraction of the ventricles, is not perceptible at 
 the same moment at all parts of the body, an appreciable interval sepa- 
 rating the cardiac impulse, the radial pulse, and that of the dorsal artery 
 of the foot. 
 
SYMPTOMS AND SIGNS: PULSATION. 461 
 
 The Aorta and Its Branches. — Pulsation in the notch of the ster- 
 num is occasionally seen in aged persons in the absence of disease. It 
 occurs in dilatation of the aorta and is a sign of aneurism of the trans- 
 verse portion of the arch. In rare cases it is due to an anomalous distri- 
 bution of the branches of the aorta in this region. 
 
 Pulsation at the root of the neck is common in cardiac hyper- 
 trophy and dilatation, in aortic insufficiency, and in neurotic and anaemic 
 conditions, especially during periods of physical or mental excitement. 
 It is a prominent symptom of exophthalmic goitre. Under these circum- 
 stances pulsation of the aorta is associated with a heaving impulse in the 
 innominate and carotids, communicated to the overlying tissues, so that 
 throbbing in this region becomes a sign of importance. It is often accom- 
 panied with distention of the veins and flushing of the face. 
 
 The differential diagnosis between dynamic dilatation of the arch of 
 the aorta and aneurism cannot in all cases be made during life. Not rarely 
 when the signs of dilatation of the arch and enlargement of the innominate 
 and right carotid have been well marked clinically, the vessels have been 
 found post mortem to be of normal measurement. 
 
 Pulsation of the subclavians occurs in the general pulsation at 
 the root of the neck, above spoken of. It is usually less marked than that 
 of the innominate and carotids. Visible pulsation of the subclavians 
 is sometimes present in consolidation and retraction of the lung in 
 phthisis. 
 
 Pulsation of the abdominal aorta is very common. It may often 
 be made out in quite thin persons under normal conditions both by inspec- 
 tion and palpation. Under these circumstances it is of very slight inten- 
 sity. More vigorous pulsation in the line of the abdominal aorta, namely, 
 in the median line or slightly to the left of it, and in the epigastric zone 
 is an important sign of disease. Objectively the pulsation varies in degree. 
 It is frequently violent and throbbing and may be demonstrated by the 
 motion communicated to the stethoscope lightly pressed upon the surface. 
 Subjectively the sensation of throbbing is annoying and frequently dis- 
 tressing. It often prevents sleep. Epigastric pulsation is not in all in- 
 stances due to the movements of the aorta. It may be directly due to the 
 heart. A faint pulsation in the region of the ensiform cartilage occurs in 
 physiological over-action of the heart, in hypertrophy and dilatation of 
 the right ventricle, and in displacement of the heart towards the right in 
 consequence of left-sided pleural effusion or of emphysema. In the last 
 named condition the epigastric pulsation is often marked, since the heart 
 is displaced toward the median line and the right ventricle is hypertro- 
 phied. The pulsation is transmitted to the left lobe of the liver. It is 
 more marked in the neighborhood of the ensiform appendix and costal 
 cartilages than toward the umbilicus, and nice observation will show 
 that it corresponds in time to the cardiac systole, whereas aortic pulsation 
 is slightly postsystolic. 
 
 The most common causes of pulsation of the abdominal aorta are 
 referable to the nervous system — simple dynamic pulsation. The throb- 
 bing may be a direct manifestation of neurasthenia or hysteria, or it may 
 be a reflex manifestation of disorders of the gastro-intestinal tract. It is 
 
462 MEDICAL DIAGNOSIS. 
 
 much more common in females and in early life. It occurs also as the 
 result of diminution of the amount of blood and thus becomes one of the 
 signs of anaemia due to hemorrhage or other cause. Marked epigastric 
 pulsation frequently occurs as a sign of enlarged lymphatic glands, carci- 
 noma of the stomach or pancreas, or other form of tumor overlying the 
 aorta. In rare instances fecal accumulations in the colon transmit the 
 aortic impulse to the surface. Thorough evacuation of the bowels is an 
 imperative preliminary measure in the diagnosis of doubtful cases. Finally 
 it may be due to an aneurism. 
 
 The diagnostic significance of this sign varies greatly and in some 
 cases is only to be determined by careful study of the associated clinical 
 phenomena. In simple dynamic pulsation the aorta may in thin persons 
 frequently be felt to be somewhat dilated, especially during the paroxysm, 
 but no distinct tumor formation can be recognized. The symptoms of 
 neurasthenia or the stigmata of hysteria are present and these are often 
 associated with gastro-intestinal symptoms. The throbbing is intense and 
 distressmg, sometimes diffused but never distinctly expansible. It can 
 be felt when the patient is in the knee-elbow posture. The throbbing of 
 anaemia is much less marked. Pulsation transmitted from the aorta through 
 an overlying tumor communicates a lifting sensation to the hand upon 
 palpation, is usually circumscribed, not expansile, and disappears when 
 the patient is examined in the knee-elbow position, the mass falling away 
 from the aorta under the action of gravity. The clinical phenomena of 
 the primary condition are usually more or less well defined. Errors of 
 diagnosis not infrequently occur under these circumstances, the tumor 
 being mistaken for an aneurism. When well defined the pulsation of 
 an abdominal aneurism is characteristic. If the aneurism be of large size 
 there is dulness continuous with that of the left lobe of the liver. In thin 
 persons a distinct tumor may be felt, the pulsation is expansile and 
 forcible, and persistent rather than paroxysmal. A systolic murmur is 
 very commonly heard in the absence of pressure of the stethoscope or the 
 murmur may' be audible in the back. In some cases a low-pitched soft 
 diastolic murmur is heard. In many cases there is a distinct systolic thrill. 
 Both the murmur and thrill may occur in other conditions which cause an 
 abrupt narrowing in the lumen of the aorta, and may be produced by the 
 pressure of the stethoscope. These signs are occasionally encountered 
 in the epigastric pulsation of nervous diseases and in tumors of various 
 kinds developing in relation with the abdominal aorta. The diagnosis of 
 aneurism must therefore be made with extreme caution. It is justified 
 in cases in which there is a distinct tumor with expansile pulsation per- 
 sisting in the knee-elbow posture and when radiating pain, vomiting, and 
 retardation of the femoral pulse are present. The pulsation of an abdom- 
 inal aneurism may be manifest in the left hypochondrium or lumbar 
 region. The X-rays furnish an important aid to diagnosis in doubtful 
 cases. Epigastric pulsation must not be confounded with the purely 
 subjective sensation of fluttering in the left hypochondrium of which 
 hysterical women frequently complain. These two phenomena are en- 
 tirely distinct, though they are frequently present in the same case. 
 
SYMPTOMS AND SIGNS: RADIAL PULSE. 463 
 
 RADIAL PULSE. 
 
 The pulse may be studied in any superficial artery. For this purpose 
 the radial, because of its accessibility and convenience, is usually selected. 
 This artery is palpated over the flat portion of the radius between the 
 styloid process and the tendon of the radialis internus. In an anomalous 
 distribution of the artery the radial pulse must be sought for elsewhere. 
 It is a good plan to compare the pulse in the radials of both sides. It 
 occasionally occurs that a small arterial twig occupies the usual position 
 of the radial while the main branch has an anomalous course. In the 
 absence of comparison with the other side an erroneous conclusion as to 
 the volume and force of the pulse would be formed. In any case of doubt 
 the pulse in the bend of the elbows or in the brachial or axillary arteries 
 upon the two sides may be compared. Pathological differences in volume, 
 force, and time, that is to say, retardation upon one side, are due to the 
 interference with the flow of blood in the artery caused by endarteritis 
 and aneurism, or the pressure of a tumor upon the wall of the vessel. Com- 
 plete obliteration results from embolism or thrombosis. In traumatism 
 from extensive crushing or laceration it is a sign of destruction of the 
 artery. Retardation of the femoral pulse upon both sides may occur in 
 aneurism of the thoracic or abdominal aorta. On one side it is commonly 
 the sign of aneurism of the common iliac artery. Under certain circum- 
 stances it is convenient to study the pulse in the temporals, carotids, or 
 even in the posterior tibials. 
 
 The best method of feeling the pulse consists in the application of 
 the tips of three adjacent fingers, that of the index finger being, according 
 to an old rule, nearest the heart of the patient. Under changing pressure 
 the distention of the artery which constitutes the pulse is recognized and 
 studied. The value of the pulse in diagnosis depends largely upon the 
 experience and judgment of the physician. In the study of the pulse the 
 following points require especial consideration; (a) condition of the arterial 
 wall; (b) frequency; (c) rhythm; (d) volume; (e) celerity; (f) tension; (g) 
 dicrotism. 
 
 The condition of tlie arterial wall enables us to form conclusions as 
 to the presence or absence of general arteriosclerosis, and to recognize 
 the modifications of the pulse-wave caused by changes in the elasticity of 
 the artery. It is of much greater diagnostic importance than the pulse- 
 rate. Empty the artery by pressure and roll it to and fro upon the under- 
 lying bone. In healthy individuals in early life the artery is felt as a strand 
 of soft elastic tissue. In arteriosclerosis and in those conditions in which 
 the blood-pressure is habitually high, such as chronic nephritis, gout, and 
 lead poisoning, the increased resistance of the artery may be readily recog- 
 nized. It feels like a whip-cord, under the fingers. In advanced arterio- 
 sclerosis calcareous deposits in the wall of the artery — atheroma — can be 
 distinctly felt , and in some cases these deposits are so coarse and irregular 
 as to warrant their comparison with a string of wampum. Such arteries 
 are often tortuous. These changes can be best recognized by passing the 
 palpating finger gently along the course of the artery. Important as is 
 the study of the condition of the walls of the peripheral arteries for the 
 
464 MEDICAL DIAGNOSIS. 
 
 diagnosis of arteriosclerosis, it is nevertheless necessary to call attention 
 to the fact that there are cases of very advanced sclerosis of the aorta and 
 even of the coronaries, and indeed of other deeply situated vessels, in 
 which the superficial arteries upon palpation yield no indication of changes 
 in their walls. To arteriosclerosis, which is often unequally distributed, 
 the radial shows no special liability. It is therefore necessary in suspected 
 cases to examine carefully the superficial arteries in various parts of the 
 body. Increased arterial tension and an accentuated aortic second sound 
 are important signs of arteriosclerosis. 
 
 Frequency of the Pulse. — By this term is indicated the number of 
 beats in a minute. It is convenient to count the radial pulse for 15 seconds 
 and multiply the result by 4. If the pulse is irregular or extremely rapid if 
 becomes necessary to count for an entire minute and to repeat the counting 
 in order to avoid error. If after repeated observation wide variations in 
 the frequency are found, the extremes may be recorded. Various devices 
 have been suggested for the counting of very rapid pulses. If regular, 
 every second or third beat may be counted and the result multiplied re- 
 spectively by 2 or 3; or a dot for each beat may be made with a pencil 
 upon a sheet of paper. These methods are liable to error, and variations 
 in the pulse-frequency uncountable by ordinary methods, that is, exceeding 
 200, are without clinical importance. 
 
 The pulse-frequency is modified by a great variety of physiological 
 influences. The pulse should therefore be counted regularly under simi- 
 lar conditions. When this is impracticable any circumstance liable to 
 influence the frequency should be noted. 
 
 Mental excitement in nervous individuals exerts a marked influence 
 upon the frequency of the pulse. The approach of the physician to the 
 bedside or the entrance of the patient to the consulting room is often 
 followed immediately by a rapid increase. It is therefore wise to post- 
 pone the taking of the pulse until after some general conversation suffi- 
 ciently prolonged to enable the patient to regain his equanimity. 
 
 The effect of muscular effort in increasing the pulse-frequency is well 
 known. Athletic sports, running, boxing, stair-chmbing, and similar 
 effort may be followed by a very rapid pulse-rate which is nevertheless 
 physiological. During convalescence from disease and in feeble and deli- 
 cate persons slight movements of the body increase the pulse-frequency, 
 which falls again after a period of rest. If, however, the effort be pro- 
 longed the return to the normal frequency is delayed. 
 
 The pulse-rate is modified by the posture of the body. It rises imme- 
 diately upon change from the recumbent to the sitting and again from the 
 sitting to the standing position. The frequency attained immediately after 
 these changes falls again in a little time but not to the normal of the previous 
 posture. The pulse-rate for the same individual is relatively higher while 
 each of these positions is maintained. The figures in healthy individuals, in 
 the absence of other modifying conditions, are approximately in the recum- 
 bent posture 66, in the sitting 70, in the standing 80 beats per minute. 
 
 The pulse-frequency is increased during the digestion of food. Hearty 
 meals and alcoholic beverages render the increase more marked. The 
 diurnal modifications of the pulse bear a definite relation to the periods 
 
SYMPTOMS AND SIGNS : RADIAL PULSE. 465 
 
 of taking food. They occur, however, in those who are fasting and bear 
 some relation to the diurnal variations of the temperature. The pulse's 
 frequency is to some extent modified by respiration, being sKghtly in- 
 creased upon inspiration and diminished upon expiration. It is higher 
 after paroxysms of cough. It varies greatly at different periods of life. 
 
 Pulse-frequency at Different Ages.— Rollet. 
 
 At birth 144-133 per minute 
 
 To end of 1st year 143-123 per minute 
 
 10th to 15th year 91- 76 per minute 
 
 20th to 60th year 73- 69 per minute 
 
 Pulse-frequency in Childhood. — Vierordt. 
 
 0- 1 year 134 per minute 
 
 1- 2 years 110. 6 per minute 
 
 2- 3 years 108 per minute 
 
 3- 4 years 108 per minute 
 
 4- 5 years 103 per minute 
 
 5- 6 years 98 per minute 
 
 6- 7 years 92 . 1 per minute 
 
 7- 8 years 94 . 9 per minute 
 
 8- 9 years 88. 8 per minute 
 
 9-10 years 91.8 per minute 
 
 10-11 years 87 . 9 per minute 
 
 11-12 years 89. 7 per minute 
 
 12-13 years 87. 9 per minute 
 
 13-14 years 86.8 per minute 
 
 In general terms the frequency declines with advancing years. The 
 pulse in women is about 7 beats per minute more rapid than in men of 
 corresponding age. In large individuals it is shghtly slower under similar 
 conditions than in those of smaller size. 
 
 Cases are occasionally observed in which the radial pulse is less fre- 
 quent than the impulse of the heart. This discrepancy arises in conse- 
 quence of the feebleness of certain contractions of the heart, the pulse- 
 wave not reaching the radials. Under these circumstances the pulse 
 is commonly but not always irregular. In every case of irregularity of 
 the pulse it is desirable to count the contractions of the heart as mani- 
 fested in the precordial impulse. 
 
 In general, departures from the normal pulse-rate, either in the direc- 
 tion of increased or diminished frequency, arise in consequence of derange- 
 ment of the nervous mechanism of the circulation. Increase may be due 
 to paresis of the pneumogastric or irritation of the sympathetic nerves 
 or the intracardiac ganglia; decrease to irritation of the pneumogastric or 
 paresis of the cardiac sympathetic nerves and ganglia. Much less com- 
 monly derangements of the pulse-rate arise in consequence of causes affect- 
 ing the heart itself. 
 
 Increased Frequency— Rapid Heart.^ — Perhaps the most common cause 
 of an increase in the pulse-rate is the action of the fever-producing 
 toxins. We find it therefore in the febrile infections, the increase in the 
 pulse-frequency bearing a general relation to the elevation of the tem- 
 perature. The prognosis in severe febrile disease is more favorable where 
 this parallelism is maintained than in those cases in which the pulse-rate 
 is increased out of proportion to the rise of temperature; the very rapid 
 
 30 
 
466 MEDICAL DIAGNOSIS. 
 
 pulse being the sign of special implication of the heart or vasomotor sys- 
 tem. In the acute febrile diseases a pulse-rate of 140-160 in the adult, 
 if maintained for any length of time, is of itself ominous. In children 
 even higher pulse-rates are not uncommon in cases that run a favorable 
 course. The effect of the specific toxins upon the mechanism of the 
 circulation is by no means constant. A knowledge of the variations is of 
 diagnostic importance in doubtful cases. In scarlet fever the pulse-rate is 
 high — 120-160 — throughout the whole course of the attack; in diseases 
 to which it bears some resemblance, such as angina tonsillaris, diphtheria, 
 rubella, and measles, the pulse-rate of the period of invasion is slower. The 
 pulse-rate in acute miliary tuberculosis and in septicopysemic conditions 
 is high, out of proportion to the temperature. In malignant endocarditis 
 the pulse is rapid both during the febrile paroxysms and in their intervals. 
 In puerperal sepsis a high pulse-rate is more constant than elevation of 
 temperature. Increased pulse-frequency is common in the early stages of 
 phthisis and usually persists throughout the whole course of the disease,, 
 alike in afebrile periods and when the temperature is moderate or excessive. 
 
 On the other hand the pulse-frequency of enteric fever is low in pro- 
 portion to the temperature. In cases of average severity it frequently 
 does not exceed 100-110 with a temperature range during the fastigium 
 of 102° F. (38.9° C.) A.M. to 104° F. (40° C.) p.m. This fact is not without 
 importance in the differential diagnosis between enteric fever and septic 
 infections, the so-called typhoid form of malignant endocarditis and acute 
 miliary tuberculosis. A very rapid pulse in enteric fever is usually the 
 sign of an inflammatory complication or secondary infection. 
 
 A frequent pulse occurs in acute affections of the heart, endocarditis,, 
 pericarditis, and myocarditis, and in chronic valvular disease in the stage 
 of failure of compensation. Increased pulse-frequency after slight exer- 
 tion occurs in most forms of chronic myocarditis, in general muscular 
 asthenia, in anaemia, during convalescence from acute diseases, and in con- 
 ditions of the neighboring organs which subject the heart to abnormal 
 pressure, as pleural effusion, thoracic aneurism, massive enlargement of 
 the liver and spleen, tympany, and ascites. The frequency of the pulse is 
 increased in cardiac palpitation from any cause. 
 
 The pulse-frequency is greatly increased in many nervous diseases. 
 A rapid pulse with subnormal temperature is characteristic of shock and 
 collapse. Acceleration of the pulse is a constant symptom of exophthal- 
 mic goitre; during the paroxysms of palpitation the pulse is often un- 
 countable. In neurasthenia, Addison's disease, the primary and secondary 
 anaemias, arthritis deformans, and locomotor ataxia the pulse-frequency is 
 likewise habitually increased. In these conditions the rapidity of the pulse 
 may be continuous or show itself only after moderate exertion. In general 
 terms it is proportionate to the severity of the disease. Pain often causes 
 increase in the pulse-rate. Exceptionally slowness of the pulse occurs in 
 connection with very intense pain. In either case the derangement is reflex. 
 
 Excesses in alcohol, tobacco, coffee and tea, disorders of digestion, 
 lack of sleep, other exhausting influences, and lowered blood-pressure 
 .not rarely produce abnormal pulse-frequency. Certain drugs, as atro- 
 pine, have the same effect. 
 
SYMPTOMS AND SIGNS : RADIAL PULSE. 467 
 
 Tachycardia — Pycnocardia — Heart Hurry. — The extreme rapidity which 
 follows violent exercise or fright may persist for days or weeks; the 
 rate may reach 160-220, The condition may occur as a pure neurosis. 
 Palpitation and dyspnoea are not always present. The patient is often 
 able to attend to his ordinary duties. Tachycardia is one of the symp- 
 toms of the neurasthenic at the menopause and has been attributed to 
 reflex irritation from ovarian or uterine disease. Thite symptom may be 
 due to lesions such as a tumor or clot in or about the medulla or pressure 
 upon the pneumogastrics. 
 
 Paroxysmal tachycardia is a neurosis characterized by attacks of 
 greatly increased action of the heart occurring at irregular intervals and 
 without obvious cause. The attacks usually begin abruptly and are of 
 varying duration, frequently not exceeding an hour or two. The pulse- 
 rate exceeds 200 and is sometimes uncountable. Subjective symptoms 
 may be absent. In many of the cases there is much distress and oppression. 
 
 Diminished Frequency — Slow Heart. — In many cases the normal pulse- 
 rate does not exceed 60. In some individuals the pulse may be slow 
 under conditions in which in others it is rapid. This is often the case 
 during the period of convalescence from pneumonia, enteric fever,' rheu- 
 matic fever, and diphtheria. The pulse is slow while the patient is at rest 
 but is accelerated by slight exertion. It is the slow pulse of exhaustion 
 and occurs in young persons and at the close of uncomplicated cases. Tran- 
 sient slowing of the pulse is a postcritical symptom in certain febrile 
 diseases, as pneumonia. If the pulse-frequency remains high during an 
 abrupt fall of temperature in the course of croupous pneumonia, pseudo- 
 crisis is to be thought of. Slow pulse is encountered in chronic gastritis 
 and ulcer and cancer of the stomach. It occurs in emphysema but is not 
 common in other affections of the respiratory system. It is not rare in 
 aortic stenosis but is infrequent in other valvular diseases of the heart. 
 It is an occasional but by no means constant symptom in chronic myocar- 
 ditis. Toxic agents, as lead, alcohol, tobacco, coffee, digitalis, and opium, 
 produce slowing of the pulse, and it occurs in some cases of primary and 
 secondary anaemia, diabetes, and myxoedema, especially while the patient 
 is at rest. 
 
 Bradycardia — Brachycardia. — The pulse-rate falls as low as 40 and 
 may be persistently slow. It is important to see that the arterial pulse 
 corresponds in frequency with the cardiac contractions. Bradycardia 
 may be physiological or pathological. In rare instances it is a peculiarity 
 of normal individuals. During labor, whether premature or at term, the 
 pulse may fall to 40 or below it. Slow pulse is one of the symptoms of 
 hunger and exhaustion. Cachectic individuals have usually not only 
 subnormal temperature but also low pulse-rate. Slowing of the pulse occurs 
 in gall-stone colic, in renal and hepatic colic, and in lead colic. It is asso- 
 ciated with acute but not necessarily with chronic jaundice. Either the 
 circulatory mechanism becomes habituated to the bile intoxication or 
 the bile salts are diminished in amount. Bradycardia occasionally occurs 
 in disease of the genito-urinary tract, especially in nephritis and in uraemia. 
 It is of special diagnostic importance in acute cerebral disease associated 
 with intracranial pressure. It occurs in various forms of meningitis, 
 
468 MEDICAL DIAGNOSIS. 
 
 especially tubercular meningitis, in which considerable elevation of tem- 
 perature is sometimes associated with a slow pulse. Chronic cerebral 
 compression, such as results from tumor or hydrocephalus, is not attended 
 with bradycardia except during acute exacerbations. Apoplexy, the 
 postepileptic state, disease of the medulla and diseases and injuries of the 
 cervical cord may be associated with a very slow pulse. Bradycardia 
 occurs in general paresis, mania, and melancholia. It constitutes the 
 essential sign of heart block. A very slow pulse is occasionally associated 
 with shock and may follow the rapid evacuation of large peritoneal or 
 pleuritic effusion. Certain drugs, as opium and digitalis, cause slow pulse. 
 
 Rhythm. — Under normal conditions the pulse is regular or rhythmic, 
 that is to say, the individual pulse-waves are of like volume and follow 
 one another at equal intervals of time. Physiological derangements of 
 rhythm are slight and transient and occur under those physiological con- 
 ditions which are attended by changes in the pulse-frequency. Marked 
 disturbances of rhythm — arrhythmia — are always pathological and have 
 their source either in functional derangements of the heart or demon- 
 strable lesions of that organ. 
 
 The causes of the various disturbances of rhythm are, (a) psychic or 
 emotional, (b) central organic disease, as endarteritis, hemorrhage, con- 
 cussion, or compression, (c) reflex, such as produce the cardiac irregularity 
 in gastro-intestinal derangements and diseases of the liver, kidneys, or 
 genito-urinary organs, (d) toxic, the common agents being tea, coffee, 
 tobacco, and alcohol, and finally (e) changes in the heart itself, either in 
 the ganglia, in which fatty, pigmentary, and sclerotic changes have been 
 described, or in the heart muscle, derangements in the rhythm of the pulse 
 being very common in acute and chronic dilatation and the forms of de- 
 generative myocarditis which result from sclerosis involving the coronary 
 arteries and their branches. 
 
 There are in general two forms of arrhythmia: first, intermission, in 
 which heart-beats are dropped at regular or irregular intervals; second, 
 irregularity, in which the heart beats are unequal in volume and force or 
 follow each other at irregular intervals. Inequality in volume and force 
 and inequality in interval are usually associated. The irregular pulse is 
 at the same time an unequal pulse. 
 
 Intermission. — There is dropping of a pulse-beat. A series of normal 
 pulsations is interrupted by a pause corresponding to the time occupied 
 by one or more beats. The dropping may be constant or occasional and 
 recur at regular or irregular intervals; sometimes every third, fourth, or 
 fifth beat is dropped, sometimes only one or two in a minute. Heart 
 dropping occurs in neurasthenic persons and is very often unsuspected by 
 the patient. In some instances it is attended by a sensation in the pre- 
 cordia which the patients describe as though the heart had stumbled 
 or turned over. This subjective sensation or even the knowledge that 
 there is intermission of the pulse greatly aggravates the sufferings and 
 distress of the neurasthenic patient, from whom it is therefore desirable to 
 withhold the information discovered upon an examination of the pulse. 
 This condition occasionally occurs in individuals apparentl}^ in excellent 
 health. On the other hand, it is sometimes a sign of myocarditis and of 
 
SYMPTOMS AND SIGNS : RADIAL PULSE. 469 
 
 fatty heart. It may be a manifestation of the effects of over-indulgence 
 in tea, coffee, or tobacco upon the innervation of the heart. 
 
 Irregularity. — Several varieties of this form of arrhythmia are de- 
 scribed, among which the following are the more important: 
 
 Pulsus Paradoxus — Kussmaid. — ^The beats during inspiration are 
 more frequent but less full than during expiration. This pulse may be 
 sometimes detected in healthy children during sleep. It occurs also in 
 forms of cardiac asthenia, large pericardial effusion, and chronic medias- 
 tinitis. It is not diagnostic of any particular disease, but is occasionally 
 associated with feeble peripheral circulation. 
 
 Pulsus Alternans. — Strong and weak ventricular contractions alter- 
 nate regularly and are manifested in the peripheral arteries by alternate 
 full and feeble pulse-beats. 
 
 Pulsus Bigeminus and Pulsus Trigeminus. — There are periodical 
 irregularities. In the former two pulse-beats, in the latter three, are asso- 
 ciated in groups and are separated by a more or less distinct pause. This 
 condition occurs in mitral disease but cannot be regarded of diagnostic 
 importance. 
 
 Pulsus irregularis, the manifestation of a heart's action wholly irreg- 
 ular both in time and in volume. When very rapid it indicates the condi- 
 tion graphically described under the term delirium cordis. This irregular 
 pulse occurs in valvular disease with ruptured compensation, especially in 
 disease of the mitral valves. It occurs also in the acute myocarditis of the 
 infectious diseases, in exophthalmic goitre, and in some cerebral affections. 
 
 Hirschfelder, as a result of recent studies of the irregular pulses, 
 divides them into four groups: 
 
 L Those of neurogenic origin. This form of arrhythmia is observed 
 in certain phases of respiration, in children, in some cases of meningitis, 
 and sometimes in the convalescence from the acute febrile infections. It 
 is not a primary manifestation of cardiac disturbance. 
 
 2. Those due to diminished contractility of the heart. The essential 
 modification of rhythm consists in the pulsus alternans, in which with 
 regularity in time there is irregularity in volume, each alternate beat 
 being small. This form is observed in very rapid action of the heart and 
 in some cases of angina pectoris. It is the sign of insufficient strength and 
 too rapid action of the heart. 
 
 3. Those associated with heart block, whether organic, as in the 
 Adams-Stokes syndrome, or due to myocardial weakness and stimulation 
 of the vagus, such as occurs in conditions following influenza or diphtheria 
 or in connection with tumor pressure upon the vagus. 
 
 4. Those due to abnormal impulses, extrasystoles. The extrasystoles 
 which arise in the auricles are of two kinds, those resulting from impulses 
 arising abnormally and those resulting from the effort of an hyperti'ophied 
 auricle to overcome an obstruction as in mitral stenosis. Those arising in 
 the ventricles are often due to the inability of the heart to empty itself. 
 
 Volume. — The volume is the measure of the lateral excursus of the 
 arterial wall under the influence of the pulse-wave. If the expansion is 
 marked the volume is correspondingly great and the pulse is said to be 
 large or full — pulsus magnus. If the expansion is slight the pulse is said 
 
470 MEDICAL DIAGNOSIS. 
 
 to be small — pulsus parvus. The large pulse is commonly a pulse of low 
 tension. It is encountered in the early stage of the acute febrile diseases 
 and in conditions of hypertrophy of the left ventricle, especially when asso- 
 ciated with relaxation of the peripheral vessels, as in aortic insufficiency. 
 The small pulse Ataxies in tension. If low it is the sign of feeble action of 
 the heart or diminished amount of blood. It occurs therefore in cardiac 
 or general asthenia, in the later stages of acute exhaustive diseases, in the 
 cachexias, and in terminal conditions. The pulse is small and of low ten- 
 sion in valvular disease of the heart with ruptured compensation, and 
 small and usually of good tension in aortic and mitral stenosis. The pulse 
 is small and tense in unyielding arteries, whether the condition be tem- 
 porary and due to vasomotor stimulation, as occurs during a chill or in 
 a^ute peritonitis, or whether it be persistent in consequence of fibroid 
 changes in the artery itself, as in arteriosclerosis. 
 
 Failure of the Radial Pulse when the Arms are Elevated. — Sewell 
 has recently called attention to the fact that in a considerable proportion 
 of persons one or both radial pulses fail at the wrist when the arms are 
 raised passively above the head. This phenomenon is intimately connected 
 with phases of the respiration, and a pulse which has disappeared during 
 quiet breathing may reappear upon vigorous respiration. Sewell regards 
 it as a sign of vasomotor activity and as belonging to the series of physio- 
 logic compensations. It is not of diagnostic importance. 
 
 Celerity.— There is an important distinction between the frequency 
 and slowness of the pulse, by which we understand the number of beats 
 in a minute, and the quickness and tardiness of the pulse, by which is 
 understood the mode in which the pulse-wave develops under the finger. 
 The pulse is said to be quick — pulsus celer — when it is characterized by a 
 wave of rapid ascent and equally rapid recedence. The quick pulse is a 
 pulse of low tension. It is encountered when the peripheral vessels are 
 relaxed, as in the fevers and in various forms of anaemia. Celerity is char- 
 acteristic of the water-hammer pulse of aortic insufficiency. This pulse 
 occurs also in consequence of the extreme relaxation of the peripheral 
 arteries in many cases of neurasthenia. In these conditions there is often 
 a visible pulsation in the superficial arteries associated with capillary and, 
 in some instances, with venous pulsation. 
 
 The tardy pulse — pulsus tardus — is characterized by the gradual rise 
 and equally gradual descent of the pulse-wave. It is a pulse of high tension 
 and is encountered in arteriosclerosis, advanced age, chronic interstitial 
 nephritis, and in some instances during the attacks of angina pectoris. 
 The pulse in aortic stenosis and in arteries peripheral to an aneurism is 
 commonly tardy. 
 
 Tension. — This term includes those qualities of the pulse which indi- 
 cate the arterial blood-pressure. On the one hand the adjectives hard and 
 tense are sometimes used interchangeably in regard to the pulse, — pulsus 
 durus, — while on the other hand the adjective soft is used synonymously 
 with relaxed — pulsus mollis. The clinician must, however, be constantly 
 on his guard against confounding rigidity of the arterial wall with intra- 
 arterial tension or blood-pressure. It is important also to distinguish 
 between the tension corresponding to the ventricular systole and that 
 
SYMPTOMS AND SIGNS : RADIAL PULSE. 471 
 
 corresponding to the ventricular diastole. In chronic nephritis the tension 
 of the pulse is commonly increased both in systole and diastole. This 
 is also true of the pulse in aortic stenosis. In these conditions the artery 
 remains well filled in the interval between the pulse-waves. In acute 
 pyrexia the s3^stolic blood-pressure commonly is high, the diastolic low; 
 that is to say, the arterial contents are diminished and the walls relaxed 
 in the interval between the pulse-waves. In arteriosclerosis both the 
 systolic and diastolic tension are high. In valvular disease with ruptured 
 compensation the systolic and the diastolic tension are low. 
 
 High tension occurs in chronic interstitial nephritis, gout, lead poison- 
 ing, and in the diabetes of advanced age. The pulse is small and tense in 
 the early stages of acute peritonitis. The pulse tension is increased in 
 pregnancy and in some forms of anaemia. 
 
 The pulse of low tension is soft and compressible. It is a sign of 
 cardiac and general asthenia and occurs in all forms of depression and 
 exhaustion. It is common in the later stages of the acute febrile infections 
 and is characteristic of enteric fever throughout the greater part of its 
 course. The pulse of obese persons is very often of low tension. Temporary 
 diminution of arterial tension may follow hot drinks, alcoholic beverages, 
 the hot bath, and accompany the period of reaction following great physical 
 exertion or mental excitement. The degree of pulse tension is often an 
 individual peculiarity. In some families persistent high arterial tension is 
 common, in others the tension is low, and these peculiarities may be trans- 
 mitted by heredity. The statement is very often made that arterial ten- 
 sion increases with age. In this connection the clinician will do well to 
 recognize the distinction between histological changes in the arterial walls 
 and increase of intra-arterial pressure. When the diastolic pressure is 
 relatively high and the artery remains well filled between the beats, the 
 pulse is said to be full — pulsus plenus. When the pulse-wave is very full 
 and quick and the vessels are soft and compressible, the pulse is sometimes 
 spoken of as gaseous. When the artery is collapsed between the beats, 
 the pulse is said to be empty — pulsus vacuus, vet inanis. When the pulse- 
 wave is very small and the artery relaxed, the pulse is described as thready, 
 running, or undulatory. 
 
 The blood-pressure — arterial tension — may be estimated by the 
 fingers; but this method is inexact and subject to many fallacies. More 
 exact and definite measurements are made by various forms of sphygmo- 
 manometers. 
 
 Dicrotism. — The occurrence of a secondary pulse-wave in each arterial 
 beat is commonly shown in normal sphygmographic tracings. It is recog- 
 nized by the finger only when fairly well marked. The conditions which 
 favor dicrotism are diminished arterial tension, relaxed capillaries, — both 
 of which are due to diminished vasomotor tonicity, — a sudden forcible 
 ventricular systole, and relaxation of the arterial walls. Dicrotism may be 
 occasionally recognized by the finger in persons apparently in good health. 
 Such individuals usually manifest a high degree of vasomotor instability, 
 are easily fatigued and bear acute illness badly. The clinical condition 
 in which dicrotism is most marked is fever. It is usually well developed in 
 enteric fever from the beginning of the second week. 
 
472 MEDICAL DIAGNOSIS. 
 
 ANOMALIES OF THE PULSE. 
 
 The pulse should be examined not only in both radials but, under 
 certain circumstances, in the superficial arteries elsewhere. Retardation, 
 smallness, feebleness, or obliteration of the pulse on one side of the body 
 or locally may be caused by deviations from normal anatomical standards 
 or by traumatism, embolism, thrombosis, tumor pressure, and aneurism. 
 
 If the pulse be relatively feeble or small, or if it be absent in the right 
 radial, it may indicate an aneurism of the ascending aorta or innominate; 
 in the left radial, an aneurism of the transverse or descending portion of 
 the arch; in a radial of either side it may indicate the presence on the 
 same side of embolism, thrombosis, aneurism of the subclavian, axillary, 
 or brachial arteries, cervical or axillary tumors exerting pressure upon the 
 vessel, and if slight in degree may be suggestive of pneumothorax or large 
 pleural effusion; in one femoral, popliteal, or posterior tibial artery the inter- 
 ference of the circulation may be due to aneurism, tumor pressure, embo- 
 lism, or thrombosis; in these vessels on both sides, to abdominal aneurism 
 or congenital obliteration of the aorta. Osier has called attention to entire 
 absence of pulse in the femorals as an occasional sign of aneurism of the 
 abdominal aorta. 
 
 The Pulse in Different Conditions of the Heart and BIood= vessels. — 
 Myocarditis. — In the various forms of arteriosclerosis the pulse is usu- 
 ally feeble. It is sometimes, but not invariably, irregular. It is com- 
 monly slow, and not infrequently bradycardia is present, the pulse falling 
 as low as 30 or 40 per minute. In fatty heart the pulse may show the 
 same characters. Extreme fatty changes occur, however, without modi- 
 fication of the pulse, which may remain regular and of moderate strength. 
 
 Mitral Stenosis. — In the early stages the frequency of the pulse is 
 not increased. In fact the pulse is sometimes slower than normal. It is 
 small and rather tardy, the artery not well filled, the successive beats 
 irregular in time and volume. 
 
 Mitral Incompetence. — The modifications depend upon the extent 
 of the lesion and the condition of the left ventricle. The frequency is in- 
 creased, the volume and tension are diminished, the rhythm usually, but 
 by no means constantly, irregular. 
 
 Aortic Stenosis. — In uncomplicated cases the pulse is slow, its vol- 
 ume diminished, its tension maintained, the artery being well filled during 
 the ventricular diastole. The pulse of aortic stenosis is usually regular. 
 
 Aortic Incompetence.- — The large mass of blood propelled into the 
 aorta by the dilated and hypertrophied left ventricle causes sudden dis- 
 tention of the arterial system, which is followed by an equally sudden 
 collapse resulting from the failure of the base of support to the column of 
 blood normally supplied by the aortic valves; characteristic and striking 
 changes in the arterial pulse result, and are manifested in all the super- 
 ficial arteries. The pulse is increased in frequency and usually regular. 
 The artery is suddenly distended, the pulse being quick, jerking, visible, 
 and abruptly receding. The pulse is locomotor, that is to say, the visible 
 arteries are elongated and their curves accentuated. The jerking, visible, 
 and collapsible character of the pulse, as observed in the arm and wrist, is 
 
SYMPTOMS AND SIGNS : CAPILLARY PULSE. 473 
 
 intensified by elevating the member above the head. Very often there is 
 pulsation at the root of the neck, and in well-developed cases there is dis- 
 tinct pulsation of the tissues of the hands and feet — capillary pulse — which 
 may be felt by gently grasping the hand or foot, placing the thumb upon 
 the palmar or plantar surface and the fingers upon the dorsal surface. 
 With the ophthalmoscope pulsation of the retinal arteries may be seen. 
 Capillary and the so-called penetrating venous pulsation also occur. 
 
 The pulse of aortic incompetence is frequently called the Corrigan 
 pulse, after Sir Dominic Corrigan who first systematically studied and 
 described its peculiarities. 
 
 Arteriosclerosis. — Modifications of the pulse in arteriosclerosis 
 depend upon the peripheral resistance and the force of the ventricular 
 systole. Sclerosis and high tension are usually associated. The pulse- 
 wave is tardy, sustained, and subsides slowly, the vessel remaining full 
 between the beats — diastolic tension. Pressure of the finger does not 
 readily obliterate the pulse. The anastomotic or recurrent pulse may be 
 present, but disappears upon pressure on the ulnar artery. An effort must 
 be made to discriminate between the firmness due to intra-arterial tension 
 and that due to thickening of the arterial wall. If, when the pulse-wave is 
 arrested by the pressure of the finger, the artery can be felt beyond the 
 point of compression, its walls are thickened. 
 
 Aneurism.^ — In symmetrical arteries a difference in the time of the 
 maximum impulse or a difference of volume of the pulse-wave is more 
 significant than the character of the pulse-wave in a single artery. If an 
 aneurism lies in the course of an artery the pulse-wave is retarded and its 
 curves flattened. In the case of an aortic aneurism involving the arch 
 below the origin of the innominate the pulse-wave on the two sides is 
 alike. When the aneurism involves the transverse portion of the arch 
 between the innominate and left subclavian, the right radial pulse may be 
 normal, the left modified. When the aneurism involves the innominate, 
 the right subclavian, or the right axillary, the right radial pulse may show 
 the aneurismal modifications, the left remaining normal. If the aneurism 
 involves the left subclavian or left axillary the right radial pulse remains 
 normal and the left will be modified. 
 
 CAPILLARY PULSE. 
 
 Normally the pulse-waves penetrate to the smallest arteries but are 
 lost in the capillaries. Under certain circumstances, however, the pulse 
 is manifest in the capillaries and shows itself upon inspection as a pulsatile 
 flushing and fading of the surface. The capillary pulse may on the one 
 hand be due to any of the causes that favor the transmission of the 
 pulse-wave into the capillaries, and on the other to those which 
 interfere with the flow of the blood from the capillaries into the veins. 
 Conditions which especially favor the development of the capillary 
 pulse are relaxation of the peripheral circulation and rapid discharge 
 of a large amount of blood from the ventricle into the arterial system — 
 pulsus celer. Capillary pulse is occasionally seen in areas of local hyper- 
 semia and inflammation, as in whitlow, and patients often recognize this 
 
474 MEDICAL DIAGNOSIS. 
 
 increased pulsation in the throbbing character of the pain. Of greater 
 interest is the capillary pulse of aortic incompetence. It is seen in the 
 pulsatile changing in the color intensity of the nail-bed — subungual pulse 
 — a phenomenon which becomes more marked when the nail is slightly 
 pressed near its edge so that the underlying tissue is momentarily pale. 
 The border line between the pink and white advances and recedes with 
 each cardiac revolution. The capillary pulse can be distinguished in the 
 ear, lips, cheek, and especially distinctly upon the forehead at a point 
 where it is reddened by light rubbing. The capillary pulse shows clearly 
 through a piece of glass pressed upon the mucous surface of the everted 
 lip. It is, however, not confined to aortic regurgitation, but occurs also in 
 pyrexia, chlorosis, and other forms of anaemia, neurasthenia, and exoph- 
 thalmic goitre. The capillary pulse of aortic incompetency is more marked 
 in stages in which the compensation is good and disappears upon the 
 failure of compensation. 
 
 VENOUS PULSE. 
 
 Movements in the veins caused by respiration must be first con- 
 sidered. The modifications of intrathoracic pressure caused by respiration 
 are of importance in connection with the venous circulation. Inspira- 
 tion hastens, expiration retards the flow of blood in the veins. These 
 modifications are not seen upon ordinary quiet breathing. On the other 
 hand in forced respiration and dyspnoea there is expiratory venous dis- 
 tention and inspiratory venous collapse, best seen in the veins of the 
 neck, especially when they have been enlarged by previous congestion 
 and are therefore more distinctly visible. Even more marked is the influ- 
 ence of the variations of intrathoracic pressure by violent cough and 
 prolonged muscular effort. In individuals in which these paroxysms of 
 intravenous pressure recur through long periods, as in those who suffer 
 from chronic paroxysmal cough, the veins, especially the jugular, become 
 permanently enlarged so that during the paroxysms the patient is not 
 only cj^anosed but manifests a distinct distention of the vessels at the root 
 of the neck. The jugular bulb sometimes appears as a small, sausage-like 
 swelling in the region of the insertions of the sternocleidomastoid muscle. 
 
 More rarely distention of the veins takes place during inspiration; 
 retraction upon expiration. This reversal of the ordinary conditions is 
 the result of mechanical interference by pressure or traction upon the 
 great veins within the thorax, such as occurs in chronic mediastinitis, 
 mediastinal tumors or a large pericardial or pleural effusion, — conditions 
 in which Kussmaul's pulsus paradoxus is frequently observed. 
 
 The Forms of Venous Pulse. — Pulsation in the veins is due to the 
 movements of the heart and has the cardiac rhythm. A pulsation com- 
 municated by the underlying carotids is sometimes seen in the external 
 jugular veins. This is the so-called false venous pulse. The distinction 
 between this and true venous pulsation is usually unattended with diffi- 
 culty. The more extended superficial pulsation due to the greater width 
 of the vein and the peculiar, prolonged, undulatory movement which is 
 characteristic of the low intravenous tension are of importance. Upon 
 
SYMPTOMS AND SIGNS : VENOUS PULSE. 475 
 
 light palpation the pulse is feeble and compressible and in strong contrast 
 to that elicited upon palpation of the underlying artery. Upon compression 
 of the vein the peripheral pulsation continues or may be increased in 
 consequence of the distention; upon compression of the artery at the root 
 of the neck the pulsation wholly disappears. 
 
 True Venous Pulse. — Three forms are encountered: the physiological 
 or negative venous pulse, the regurgitant or positive venous pulse, and the 
 penetrating or positive centripetal venous pulse. 
 
 (a) Negative Venous Pulse. — This form of pulsation in the veins is 
 called normal or physiological because it is constantly seen in the exposed 
 veins of animals and frequently in the jugulars of human beings in health. 
 It is not observed in all persons, simply because the jugular veins in many 
 individuals are difficult or impossible to distinguish. It is very obvious 
 upon inspection in those persons in whom the veins are distended and 
 plainly visible. The physiological venous pulse is readily distinguished 
 from positive or regurgitant venous pulsation by compression of the vein 
 with the finger. The pulsation peripheral to the point of compression 
 ceases, and that central to it likewise disappears or becomes much fainter. 
 The diminution or complete disappearance in the latter case makes it 
 evident that the pulse-waves are not transmitted to the blood in the veins 
 by the cardiac systole. It is thus apparent that the continuous blood 
 stream from the veins is rhythmically restrained and hastened by the 
 action of the heart. The negative venous pulse is observed only in the 
 •external jugulars. It is presystolic in time. The collapse of the vein at 
 the time of the ventricular systole is attributed to the negative intratho- 
 racic pressure caused by the diminution in the size of the heart at that 
 moment in its revolution. During the ventricular diastole the aspiration 
 influence ceases and the blood accumulates in the veins. It may be 
 urged against this statement, however, that the venous pulse, central 
 to the point of compression, though always reduced, does not in all 
 cases wholly disappear; but the external jugular cannot be entirely 
 emptied of blood as there are tributary veins central to the point of 
 compression. In some cases this form of venous pulsation can be still 
 further reduced by simultaneous compression of the subclavian. In 
 order to determine the time of the venous pulse, which is diastolic, 
 — presystolic, — it must be compared with the carotid pulse which is of 
 •course systolic. The negative venous pulse is without diagnostic signifi- 
 cance. A knowledge of it is necessary, however, in order that it may be 
 differentiated from the form about to be described. 
 
 (b) Positive or Regurgitant Venous Pulse. — This form of venous 
 pulsation is observed in tricuspid incompetence. During the ventricular 
 systole the blood regurgitates into the right auricle and the pulse-wave is 
 transmitted to the vein. The pulsation is presystolic-systohc rather 
 than purely systolic, as in the case of the arterial pulse. When the valve 
 in the jugular is competent the pulsation is more marked in the bulb, but 
 it does not always cease at the level of the valve even when competent. 
 The regurgitation is interrupted, but a positive pulse-wave of similar form, 
 though weaker, is induced in the blood which accumulates above the 
 "valve. In some instances the closure of the valve under the influence 
 
476 MEDICAL DIAGNOSIS. 
 
 of the regurgitant blood wave gives rise to a sound distinctly audible upon 
 auscultation. In the majority of instances, as a result of the over-disten- 
 tion of the veins, the valve becomes insufficient so that the positive pulse 
 is equally perceptible over the upper portion of the jugular. The dis- 
 tinction between the positive and negative venous pulse rests upon the 
 correspondence of the former with the carotid pulse and its persistence 
 in the pulsating vein below the point of compression. In fact, for reasons 
 that are obvious, it persists or even becomes more marked between the 
 compressing finger and the heart, while it disappears entirely beyond the 
 point of compression. As a rule, positive venous pulsation is observed only 
 in the jugulars. In very pronounced cases, however, it may be manifest 
 in other superficial veins more distant from the heart. 
 
 This form of pulsation is a sign of tricuspid incompetence. It has, 
 however, been observed in two extremely rare conditions in which the 
 lesions likewise favor the transmission of the systolic pulse-wave to the 
 jugular veins, namelj^, mitral incompetence with persistent foramen ovale 
 and aneurism of the aorta communicating with the descending vena cava. 
 
 The patient should be examined in the recumbent posture and during 
 very quiet breathing. Before making compression in the course of the 
 vein the finger-nail should be placed upon the vein at the root of the neck 
 and lightly drawn upward to empty the vessel. In the absence of regur- 
 gitation the vein refills slowly, but if the tricuspid valves be incompetent 
 the vein quickly refills from below and again pulsates. 
 
 Pulsation of the Liver. — In advanced cases of tricuspid incompetence 
 the liver becomes enlarged and the hepatic veins dilated and engorged. 
 In this condition the organ pulsates, the regurgitant wave being trans- 
 mitted through the inferior vena cava. The pulsation may be recognized 
 upon palpation, one hand being placed over the cartilages of the lower 
 ribs to the right of the ensiform cartilage, and the other upon the side at 
 the costal margin. An expansive pulsation of the entire organ can be felt 
 with each cardiac impulse. In marked instances liver pulsation may be 
 made out upon inspection. Pulsation of the liver must be distinguished 
 from the jogging of the organ by a powerfully acting h3'pertrophied heart. 
 It must also be distinguished from the epigastric pulsation of the abdom- 
 inal aorta — dynamic pulsation — previously described and from aneuris- 
 mal pulsation. In very rare cases of aortic regurgitation, with good com- 
 pensation and no sign of tricuspid incompetence, an arterial liver pulse 
 has been noted, and local pulsation with double murmur has been observed 
 in acute cholangeitis. 
 
 (c) Penetrating or Positive Centripetal Venous Pulse. — This 
 rare phenomenon is due to the fact that under certain conditions the 
 pulserwave is not lost in the capillaries but transmitted through them to 
 the smaller veins. It has the same significance as the capillary pulse and 
 occurs in cases of aortic incompetence or neurasthenia with great vaso- 
 motor relaxation. It has been observed in cases in which the capillary 
 pulse has been faintly perceptible or absent altogether. It is associated 
 with quick arterial pulse of large volume and is manifest not in the jugulars 
 but in the small veins of the extremities, and disappears upon compression 
 in the central, not in the peripheral, portion of the compressed vein. 
 
SYMPTOMS AND SIGNS : LIPS. 477 
 
 In this connection diastolic collapse of the cervical veins, the so-called 
 Friedreich's sign, may be mentioned. This sign occurs in chronic adhesive 
 pericarditis but is of no great diagnostic value. The collapse of the veins 
 is due to diastolic intrathoracic aspiration. The mechanism is the reverse 
 of that in the physiological venous pulse. 
 
 VII. 
 
 THE DIGESTIVE SYSTEM: MOUTH; LIPS; TEETH; GUMS; 
 
 TONGUE. 
 
 THE MOUTH. 
 
 The most important method of examination is inspection. The 
 patient should be placed in a good light. The illumination is more satis- 
 factory by light reflected from a head mirror. The mouth should be opened 
 widely and, according to the part to be examined, the tongue should be 
 protruded, drawn back, or moved from side to side. The soft palate and 
 pharynx are best seen upon depression of the base of the unprotruded 
 tongue with a spatula or the handle of a spoon. These instruments, if 
 introduced too far, cause gagging. The examination of the posterior wall 
 of the pharynx is facilitated when the patient pronounces the broad a, 
 thus elevating the soft palate. In conditions of delirium or unconscious- 
 ness and in insane patients the examination of the mouth is often attended 
 with great difficulty. In some instances holding the nose will cause the 
 patient to open his mouth; in others, if necessary, the patient must be 
 anaesthetized. In the case of children the examination is best conducted 
 when the physician and mother or nurse sit viz-a-viz, the body of the child 
 resting upon the knees of the latter, who holds his hands, the head upon 
 the lap of the former, who opens the mouth and depresses the tongue 
 with the spatula. The pharynx is best seen at the beginning of gagging. 
 Palpation by means of the finger is very useful in detecting the presence 
 and location of foreign bodies, the existence of retropharyngeal abscess, 
 and especially adenoid vegetations in the nasopharynx and other similar 
 conditions. This manoeuvre, which is very annoying to the patient, must be 
 executed rapidly. In the case of unruly patients or children the danger of 
 being bitten is not to be overlooked. Against this accident a guard or 
 shield may be employed, or the physician may, with the thumb and finger 
 of the free hand, press the cheeks of the patient between the separated 
 molars. 
 
 THE LIPS. 
 
 The lips are thick and coarse in habitual mouth-breathers, in cretin- 
 ism, and in myxo^dema. They are parted in conditions of great prostra- 
 tion and habitually in idiots and in some forms of insanity. They are palHd 
 in anaemia and, like the nail-beds, early show cyanosis and the variations 
 in its intensity. The lips are apt to be dry in dyspnoea and in obstruction 
 
478 MEDICAL DIAGNOSIS. 
 
 to the nasal breathing. Dryness of the lips is associated with a diminu- 
 tion or perversion of the oral secretion, as in stomatitis, glossitis, and tonsil- 
 litis. The lips and mouth are dry and the latter open in the soporose con- 
 dition preceding dissolution. There is drooling in dentition, mercurial 
 salivation, diphtheritic paralysis, bulbar palsy, and idiocy. In these condi- 
 tions the lips are apt to be loose and pendulous. Tremor or twitching of 
 the lips occurs under intense emotion or may be a symptom of nervous 
 disease. Convulsive retraction of the upper lip occasionally occurs as a 
 sign of intense abdominal pain. Of great diagnostic importance is the 
 occasional presence upon the lips of aphthous ulceration, mucous patches, 
 sordes, rhagades — linear clefts or ulcerations at the corners of the mouth — 
 or the scars resulting from them. The last, occurring in young children, 
 are suggestive of hereditary syphilis. Herpes labialis is common in certain 
 individuals in feverish colds, and occurs with such frequency in pneumonia, 
 ague, and cerebrospinal fever as to have diagnostic value. It is very 
 rare in enteric fever. This vesicular eruption develops rapidly upon an 
 inflammatory base as a single lesion or in groups, most commonly upon 
 the outer border of the lip, occasionally on other parts of the face, as the 
 nose, the cheeks, or the ear. These positions are indicated by qualifying 
 adjectives, as herpes labialis, facialis, nasalis, and the like. The contents 
 of the vesicles are at first lymphoid, later purulent and scanty. Their 
 efflorescence is attended by annoying burning or itching. They rapidly 
 undergo desiccation with the formation of thick, tightly adherent scabs. 
 The whole process is of short duration. 
 
 In paralysis of the seventh nerve the angle of the mouth on the affected 
 side is lowered. In drinking, the liquid is apt to escape. In smiles or 
 laughter the corner of the mouth is immobile and in attempts to show . 
 the upper teeth it is not raised. The mouth and lips are drawn toward 
 the sound side. The labial sounds may not be fully formed. It is im- 
 portant to note that the displacement of the angle of the mouth may 
 be due to loss of the teeth upon ttie opposite side or to retraction as the 
 result of scar formation. 
 
 The lips are extremely sensitive and abscesses and acute inflammatory 
 processes are attended with great pain. They are sometimes the seat of 
 carbuncles. They undergo extensive necrosis in cancrum oris. The 
 lip may be lacerated in the epileptic convulsion, but this is not common. 
 It may be the seat of angioneurotic oedema or may be greatly swollen 
 in consequence of the bites of insects. The lip is occasionally the seat 
 of the initial lesion of syphilis. It shows more or less extensive super- 
 ficial necrosis extending out upon the chin or cheeks after the taking of 
 corrosive poisons and especially in carbolic acid poisoning. Epithelioma 
 of the lip is common. It shows itself as an irregularly circular or oval 
 ulcer with a swollen, infiltrated base, usually upon the lower lip, de- 
 veloping from a fissure or wart. At the beginning there are alternations 
 of scab formation and open ulceration. After a time the submaxillary 
 lymphatics become involved. 
 
 The differential diagnosis between chancre and epithelioma of the 
 lip is usually unattended with difficulty. The chancre occurs, as a rule, 
 early in life, epithelioma late. In chancre the lymphatics are involved 
 
SYMPTOMS AND SIGNS : TEETH. 479 
 
 early; in epithelioma late. Chancre is commonly circumscribed and 
 densely indurated; epithelioma tends to spread and the induration is less 
 dense. Healing of the chancre is progressive, especially under treatment; 
 in epithelioma there is a tendency to extend, with alternations of scab 
 formation and ulceration. In the former, constitutional symptoms and 
 secondary rashes occur. 
 
 THE TEETH. 
 
 The teeth are of diagnostic interest. The time of their eruption and 
 shedding in children and their state of preservation in adults are to be 
 considered. Dentition and teething are terms used to describe the cutting 
 of the teeth. 
 
 The First Dentition. — The temporary or deciduous teeth — the so- 
 called milk teeth — are twenty in number; in each jaw two central incisors, 
 two lateral incisors, two canines, two first molars and two second molars. 
 They appear with considerable regularity as to order and time. Their 
 eruption usually takes place in groups of four. 
 
 The first group — the lower and upper central incisors, 6 to 9 months. 
 An interval of 1 to 3 months. 
 
 The second group — the upper and lower lateral incisors, 8 to 12 months. 
 An interval of 1 to 3 months. 
 
 The third group — the four anterior molars, 12 to 15 months. An 
 interval to the 18th month. 
 
 The fourth group — the four canines, 18 to 24 months. An interval 
 of 2 to 3 months. 
 
 The fifth group — the four posterior molars, 24 to 30 months. 
 
 Healthy children usually have from four to eight teeth before they are 
 a year old, and cut their first molars between a year and a year and a half, 
 the canines before the end of the second year, and should complete denti- 
 tion by the cutting of the second molars before the middle of the third 
 year. The first teeth are usually the lower central incisors. The upper 
 lateral incisors as a rule appear before the lower; the upper first molars 
 usually precede the lower and not infrequently appear at about the same 
 time with the lower lateral incisors. 
 
 Precocious dentition occasionally occurs. It is of no special signifi- 
 cance. Delayed dentition occurs as the result of malnutrition either from 
 improper feeding or disease. It is especially common in rickets. 
 
 The eruption of the teeth in healthy, well-nourished children com- 
 monly takes place without constitutional disturbance. At most transitory 
 loss of appetite, fretfulness, disturbed sleep, a slight rise of temperature, 
 100-102° F. (37.7-38.8° C), and derangement of the bowels are observed. 
 In feeble and poorly nourished infants, especially in neurotic families, the 
 perturbations caused by dentition may be more severe, the foregoing 
 symptoms being aggravated and the temperature reaching higher levels, 
 103-104° F. (39.4-40° C). The accidental coincidence of gastro-intestinal 
 derangements, tonsillitis, laryngitis, and bronchial catarrh is very com- 
 mon, and the physician must be on his guard not to ascribe to dentition 
 symptoms which are due to other causes. On the other hand there is 
 danger that reflex symptoms due to the irritation of dentition will be 
 
480 MEDICAL DIAGNOSIS. 
 
 erroneously interpreted. For example, annoying spasmodic cough; with- 
 out fever, other constitutional disturbance or rales, and manifestly reflex, 
 frequently accompanies the eruption of each group of teeth. Dentition 
 may be the exciting cause of general convulsions in feeble, badly-nour- 
 ished, rhachitic, or neurotic children. The process rarely causes eclampsia 
 in well-nourished healthy babies. Tension, tumefaction, tenderness of the 
 gums, and the bluish-red hue of deep congestion are indications for the 
 use of the lancet. 
 
 The Second Dentition. — The permanent teeth in each jaw consist of 
 two central and two lateral incisors, two canines, four bicuspids, and six 
 molars. Their eruption takes place in the following order: 
 
 Anterior molars, sixth to seventh year. 
 
 Central incisors, seventh to eighth year. 
 
 Lateral incisors, eighth to ninth year. 
 
 Anterior bicuspids, tenth to eleventh year. 
 
 Posterior bicuspids, tenth to eleventh year. 
 
 Canines, eleventh to twelfth year. 
 
 Second molars, twelfth to fourteenth year. 
 
 Third molars — wisdom teeth, eighteenth to twenty-fifth year. 
 
 The milk teeth are gradually displaced by the permanent teeth and 
 three additional molars appear on the sides of each jaw, so that the twenty 
 milk teeth are replaced by the full set of thirty-two permanent teeth. The 
 second dentition begins with the eruption of the anterior molars some- 
 where between the fifth and seventh years. Following these the milk 
 teeth are gradually shed in the order in which they appeared, each tooth 
 being forthwith or shortly replaced b}^ a permanent tooth. 
 
 Shape and Structure of the Teeth. — Defects in the teeth are numer- 
 ous, the most important being abnormalities of form, and especially the de- 
 ficient development of enamel. In badly-nourished, feeble children the 
 milk teeth are prone to caries. 
 
 The developing teeth are influenced by malnutrition, stomatitis, 
 especially that produced by mercury, and constitutional diseases, as 
 syphilis and rickets. The developmental defects show^ themselves in the 
 permanent teeth. In rickets the teeth may be small and badly formed. 
 As the result of infantile stomatitis the surfaces of the teeth are pitted, 
 owing to deficient formation of enamel; the condition is sometimes im- 
 properly spoken of as erosion. These changes affect the incisors and ca- 
 nines, which are pitted by areas of default of enamel, and are of a bad 
 color, showing a transverse furrow across all the teeth at the same level; 
 the first permanent molars are also involved. These furrows are attrib- 
 uted, probably correctly, to severe illness in early life and are regarded as 
 analogous to furrows on the nails which occur after serious disease. 
 
 Hutchinson Teeth. — In congenital syphilis the teeth are deformed 
 and present appearances regarded by Hutchinson as specific and peculiar. 
 The upper central incisors are affected. They are peg-shaped, short, and 
 narrow, being smaller at the cutting edge than at the root. The enamel is 
 commonly well formed and regularly developed, but the color is more 
 j^ellow than that of the other teeth. At the edge of the teeth there is a 
 single concave notch of varying depth in which the dentin is exposed. 
 They are called Hutchinson, notched, or screw-driver teeth. These defects 
 
SYMPTOMS AND SIGNS : GUMS. 481 
 
 are not constant nor are they pathognomonic of syphilis, as they are some- 
 times found in other conditions, especially rickets. In the presence of other 
 signs of syphilis — rhagades, keratitis, iritis, and nodes — notched teeth ac- 
 quire positive diagnostic importance. 
 
 Caries. — Carious and neglected 
 teeth play a very important part 
 in the causation of derangements of 
 digestion from imperfect mastica- 
 tion, and are themselves not rarely 
 the result of constitutional disturb- 
 ances. Extensive and rapid dental 
 caries may occur after serious acute 
 
 disease and in constitutional dis- Fig. i98-Hatchinson's teeth. 
 
 orders as rickets and diabetes. It 
 
 also occurs in pregnancy. The teeth become loose in forms of stomatitis 
 associated with swollen and ulcerated gums, such as are encountered in 
 mercurial ptyalism, scurvy, purpura, and phosphorus poisoning. Receding 
 gums with exposure of the neck of the teeth and their ultimate loss 
 occur from neglected salivary deposits, pyorrhoea alveolaris, and gouty 
 conditions. 
 
 Sordes — literally filth — is a term applied to collections of dark brown 
 foul matter upon the teeth and lips in low fevers. It consists of food, 
 epithelial material, and altered blood, and contains micro-organisms in 
 great numbers. 
 
 THE GUMS. 
 
 The gingival mucous membrane is pale in all forms of anaemia; it is 
 red and spongy when the teeth are carious or ill-kept. A narrow red line 
 along the margin is seen in some cases of tuberculosis, diabetes, and in 
 cachectic states; also in alveolar disease. The gums are red, spongy, and 
 ulcerated as a result of accumulated tartar and gangrenous and mercurial 
 stomatitis. They are swollen, spongy, and bleeding in scurvy. 
 
 In lead poisoning a narrow bluish-black line is seen, although not 
 invariably, at the margin of the gums. The color is not uniform, but, 
 being due to lead sulphide deposited in the papillae of the gums, is seen 
 with the magnifying glass to be stippled. This line may form rapidly 
 after exposure and disappear in the course of a few weeks under treatment, 
 or it may persist for months. It is usually limited in extent. A similar 
 line, due to the deposition of carbon particles, has been observed in miners. 
 Such lines are to be distinguished from the deposits of black matter upon 
 the teeth at the line of their juncture with the gums in untidy persons and 
 smokers who neglect the mouth. The latter disappears upon the use of the 
 tooth-brush, or the two lines may be differentiated by slipping the corner 
 of a piece of writing-paper under the gum. If the pigment material is in 
 the gum it stands out plainly against the white paper; that on the tooth 
 is not seen. It is under certain circumstances also to be distinguished 
 from cyanosis due to general disturbances of the circulation or local in- 
 flammatory processes. In cyanosis the discoloration is uniform and more 
 intense at the edges of the gums and disappears under pressure. 
 
 31 
 
482 MEDICAL DIAGNOSIS. 
 
 THE TONGUE. 
 
 Great differences of opinion exist in regard to the value in diagnosis 
 of signs presented by the tongue. To the careful observer an exami- 
 nation of the tongue yields information of diagnostic importance. This 
 organ should be studied with reference to its motility, size, condition of 
 the mucous membrane as regards color, papillae, dryness, moisture, coat- 
 ing, and the presence or absence of various lesions. 
 
 (a) Motility. — The manner in which the tongue is protruded upon 
 request is often suggestive. Under ordinary circumstances the movement 
 is commonplace and familiar. In very ill patients the tongue is protruded 
 slowly and incompletely. In the advanced stages of enteric fever the 
 patient protrudes his tongue hesitatingly and does not immediately with- 
 draw it unless requested. In chorea the tongue is thrust out with a pecu- 
 liar jerk and immediately withdrawn. In well-marked cases it is impos- 
 sible for the patient to keep it out for any length of time. Spasm of the 
 muscles of mastication renders it impossible to protrude the tongue. The 
 spasm may be tonic or clonic; in rare instances it occurs as an independent 
 affection. It is usually part of general convulsive disease. In the tonic 
 form the jaws are held forcibly together — lockjaw. The masseter and 
 temporal muscles are tense and hard and the spasm is frequently attended 
 with pain. It is an early and prominent symptom in tetanus and occurs 
 also in tetany. There is tonic spasm of the jaw muscles in trismus neona- 
 torum and strychnia poisoning and sometimes in hysteria and epilepsy. 
 Trismus may follow exposure to cold or occur as the result of reflex irri- 
 tation in diseases of the mouth, teeth or jaw or of irritative lesion in the 
 region of the motor nucleus of the fifth nerve. Clonic spasm of the muscles 
 of the jaw is seen in the chattering of the teeth which occurs after exposure 
 to cold, in some conditions of mental excitement, and during a chill. Its 
 rare occurrence as a substantive affection has been noted. Pain and 
 swelling of the tissues about the angle of the jaw, such as attend disease of 
 the bones, mumps, suppurative tonsilhtis, and trichinosis involving the 
 masticatory muscles, may prevent the opening of the mouth and pro- 
 trusion of the tongue. 
 
 General tremor of the tongue occurs in alcoholism and in conditions 
 of asthenia. Tremor and fibrillary contractions are observed in patients 
 presenting bulbar symptoms with atrophy of the tongue and may be espe- 
 cially pronounced in progressive bulbar atrophy. Fibrillary contrac- 
 tions are occasionally seen in healthy individuals. 
 
 Paralysis of the tongue results from disease of the hypoglossal nerves. 
 When one nerve is involved the base of the tongue is slightly higher upon 
 the paralyzed side, and motion within the mouth toward that side is 
 impaired. When the tongue is protruded it deviates to the paralyzed side, 
 being pushed by the geniohyoglossus on the normal side; there is slight 
 difficulty in chewing and swallowing. When both hypoglossal nerves are 
 involved the tongue cannot be moved within the mouth and cannot be 
 protruded; mastication and articulation are greatly impaired. Palsy of 
 the tongue from nuclear disease is usually associated with a similar condi- 
 tion of the lips, pharynx, and larynx. The power of protruding the tongue 
 
SYMPTOMS AND SIGNS : TONGUE. 483 
 
 is impaired in paresis, diphtheritic palsy, progressive muscular atrophy, 
 and some forms of hemiplegia. Slight deviation toward the paralyzed 
 side may occur in cases of hemiplegia in which the face is affected. 
 When the fibres of the hypoglossal are involved within the medulla after 
 leaving their nuclei, there may be paralysis of the tongue on one side 
 and paralysis of the limbs on the other, and the tongue w^hen protruded 
 deviates toward its sound side. Other causes of nuclear or infranuclear 
 lesions of the hypoglossal are lead poisoning, basal meningitis, and tumors 
 of the base. 
 
 Spasm of the tongue is very rare. It may be unilateral or bilateral 
 — tonic or clonic. It is usually one of the manifestations of some other 
 convulsive disease, as spasm of the facial muscles, tetanus, epilepsy, or 
 chorea. Tonic spasm may occur in hysteria and as the result of reflex 
 irritation of the fifth nerve. The tongue is contracted and rigid. Clonic 
 spasm is much more common. Spasm of the lingual muscles occurs in 
 stuttering. It is an occasional symptom in disseminated sclerosis, general 
 paresis, and melancholia. There are cases of paroxysmal clonic spasm in 
 which the tongue is thrust out and drawn in as often as forty or fifty times 
 a minute. In this affection the spasm is usually bilateral; the attacks 
 may occur during sleep. 
 
 The frsenum of the tongue may be abnormally short — a congenital 
 defect which, by limiting the movements of the tongue, interferes with 
 nursing in the new-born and with articulation later. 
 
 (b) Size of the Tongue. — Variations in the size of the tongue are of 
 diagnostic importance. The tongue is slightly enlarged and flabby in 
 various conditions of ill health and especially in chronic gastritis, forms of 
 anaemia, scurvy, and typhus fever. Under these circumstances the edges 
 are indented by the teeth. 
 
 Enlargement of the tongue, or macroglossia, is usually congenital but 
 may occur in later life. In the congenital form the tongue and very often 
 the lips are greatly enlarged by an increase in all the tissue elements, an 
 increase in the fibrous tissue alone, or from the development of tumor-like 
 masses — true lymphangioma. The organ may become so large that it 
 projects beyond the teeth, in some cases attaining twice its normal size. 
 The surface is dry, fissured, or ulcerated from contact with the teeth, and 
 deformity of the bony structures results from pressure. The lymph-vessels 
 are dilated and in some instances there are actual cysts. 
 
 Great enlargement takes place in acute inflammation of the tongue, 
 such as glossitis, inflamed ranula, erysipelas, angina Ludovici. The tongue 
 is frequently much enlarged in actinomycosis. One side only may be 
 involved in the inflammatory process — hemiglossitis. The tongue is some- 
 what enlarged in acromegaly and myxcedema. Localized swelling may be 
 caused by tumors, as gumma or carcinoma. The tongue in rare instances 
 becomes cyanosed and oedematous from obstruction to the return of the 
 venous blood. 
 
 Diminution in the size of the tongue may be the result of a temporary 
 shrinking or of atrophy. The tongue may be uniformly diminished in 
 size after hemorrhage, during convalescence from enteric fever, or in con- 
 ditions of advanced emaciation. 
 
484 MEDICAL DIAGNOSIS. 
 
 Atrophy of the tongue is the result of disease in the path of the hypo- 
 glossal nerve. If the lesion be supranuclear there is no wasting of the 
 tongue. There may be some degree of paralysis. Ordinarily this condi- 
 tion constitutes an element of hemiplegia. In nuclear or infranuclear 
 paralysis the tongue is atrophied on one or both sides according as the 
 lesion is unilateral or bilateral. The muscular tissue is alone affected, 
 ordinary sensation and taste remaining practically normal. The reaction 
 of degeneration is present in the wasted half of the tongue. 
 
 Facial hemiatrophy is usually associated with hemiatrophy of the 
 tongue on the same side. Local diminution in the size of the tongue may 
 follow the resorption of a gumma or extensive scar formation following a 
 deep ulcer. 
 
 (c) Mucous Membrane. — The color of the organ itself is to be dis- 
 tinguished from the coating. The tongue is pale in anaemia; red in in- 
 flammation, as glossitis and stomatitis, and in the infectious diseases, as 
 measles, scarlatina, and enteric fever; dark red in conditions of prostra- 
 tion; bluish in cyanosis; yellow in jaundice. It is stained various colors 
 by ingested articles — red or purple by fruits or wine, black by iron, bis- 
 muth, or charcoal, yellow by rhubarb, tobacco, or licorice root, brown by 
 chocolate and opium. Ingestion of corrosive substances may give rise to 
 staining with superficial necrosis. Ammonia, corrosive sublimate, sul- 
 phuric, carboKc, and oxalic acids turn the tongue white; hydrochloric, 
 nitric, chromic, and picric acids yellow; the caustic alkalies turn it red. 
 Local discoloration of the tongue is caused by telangiectatic patches, 
 purpura, ecchymoses, and infarcts. Patches of pigmentation may mark 
 the site of healed glossitis or occur as manifestations of Addison's disease. 
 In the latter condition the color is bluish- or grayish-black and the areas of 
 pigmentation are associated with similar areas of pigmentation upon the 
 buccal mucous membrane and the lips. The "black tongue" or nigrities 
 is a rare affection of parasitic origin. It is characterized by irregular 
 areas of blackish-brown or black color, with enlargement of the papillae, 
 which occupy the middle of the dorsum of the tongue. The discoloration 
 begins as a small spot and extends; after a time desquamation occurs 
 which goes on slowly. The condition may become chronic. It is to be 
 distinguished from staining of the tongue caused by iron, bismuth, and 
 the like, and from purposeful discoloration in malingering. 
 
 Moisture. — The normal tongue owes its moisture to the buccal secre- 
 tions and saliva. A physiological increase of these secretions occurs in 
 hunger and is excited by the sight or odor of food. Such an increase is 
 also promoted by sapid and stimulating substances and by mastication. 
 It is called salivation or ptyalism. It occurs during dentition, menstrua- 
 tion in some instances, often during pregnancy — usually in the early 
 months but sometimes throughout the whole period. Jaborandi and its 
 alkaloid pilocarpine, muscarine, tobacco, mercury, gold, copper, and the 
 iodine compounds excite an increased flow of saliva. A pathological in- 
 crease of saliva occurs in forms of glossitis and stomatitis, especially that 
 induced by mercury, sometimes in the fevers, in the epileptic paroxysm, 
 and in some forms of idiocy and nervous disease. It has been observed 
 in disease of the pancreas. 
 
SYMPTOMS AND SIGNS : TONGUE. 485 
 
 Xerostomia — dry mouth — is a condition characterized by arrest of 
 the sahvary and buccal secretions. The condition is rare. It was first 
 described by Jonathan Hutchinson. The tongue is red, dry, and fissured; 
 the buccal mucous membrane is smooth and dry. Movements of the parts 
 involved in articulation, mastication, and deglutition are attended with 
 difficulty. In some cases the dryness extends to the nostrils and eyes and 
 is accompanied by distressing itching. Slight enlargement of the salivary 
 glands has been observed but is not constant; most of the cases occur in 
 women of neurotic constitution. In a case under my observation in a 
 woman aged thirty this condition developed during the convalescence 
 from an attack of epidemic influenza. It has been suggested that the 
 disease is due to involvement of a hypothetical centre controlling the 
 salivai'y and buccal secretions. 
 
 Dryness of the tongue occurs in mouth-breathing, with thirst, after 
 violent exertion, in febrile and septic states, conditions of profound pros- 
 tration, and as the result of loss of fluid in diabetes mellitus and insipidus. 
 It is an important symptom of atropine poisoning, and attends facial 
 paralysis. Dryness of the tongue occurs under other conditions attended 
 with extreme loss of fluid from the body, as in hemorrhage and cholera. 
 
 The papillae of the tongue are often swollen, giving it a warty, granu- 
 lar appearance. This condition is seen in catarrhal and other forms of 
 stomatitis, in some forms of chronic gastritis, and sometimes in the acute 
 febrile infections. The enlarged fungiform papillae of the tongue in scarlet 
 fever have given rise to the unfortunate term "strawberry tongue," which 
 by some teachers is understood to mean a tongue covered with a white 
 fur through which the tip of the papillae show, and by others to mean the 
 rough bright red tongue which follows the separation of the coating. The 
 latter is sometimes called the "raspberry tongue." In conditions of pros- 
 tration, such as attend the later stages of infections or sepsis, and in some 
 constitutional diseases, as diabetes, the tongue sheds its epithelium and 
 the papillae undergo atrophy. This condition is usually attended with 
 dryness and glossing of the surface. The papillae at the border of the 
 tongue are sometimes greatly enlarged in gouty individuals. Patients are 
 occasionally alarmed upon the discovery of the large circumvallate papillae 
 at the root of the tongue and hesitatingly accept the assurance that they 
 are normal. 
 
 Coating of the Tongue. — This subject involves a consideration also 
 of the general condition of the mucous membrane as regards color, dry- 
 ness and moisture, and the condition of the papillae. The presence or 
 absence of coating is determined by local and constitutional conditions. 
 It does not follow, as is very often assumed, that the condition of the 
 tongue is directly dependent upon the condition of the mucous membrane 
 of the stomach. On the contrary the diagnostic significance of coated 
 tongue will be best understood by the clinician who realizes the fact, of 
 which there is abundant clinical demonstration, that the condition of the 
 tongue as regards coating and allied phenomena is largely dependent upon 
 constitutional influences which are likewise exerted upon other mucous 
 surfaces. Coating of the tongue occurs in many morbid conditions, es- 
 pecially dyspeptic states and in fevers, and is usually associated with loss 
 
486 MEDICAL DIAGNOSIS. 
 
 of appetite; yet there are healthy individuals with good appetite whose 
 tongue is constantly furred. A coated tongue is present in acute and 
 chronic gastric catarrh, while on the other hand gastric ulcer is very often 
 accompanied by a clean tongue and good appetite. The coating or fur is 
 composed of accumulated epithelium and food detritus and contains great 
 numbers of micro-organisms. The immediate cause of the extraordinary 
 proliferation and accumulation of epithelial elements is not well understood. 
 That the absence of coating is not merely dependent upon mechanical con- 
 ditions associated with drinking and the ingestion of food is clearly shown 
 by clinical experience. The coating of the tongue like its mucous membrane 
 is very often stained by articles of food and drink or by drugs. 
 
 Coating of the Tongue in Local and General Conditions. — (a) Local- 
 ized COATING of the tongue results from the irritation of a tooth and sur- 
 rounds traumatic and other circumscribed lesions. 
 
 (b) UisnLATERAL COATING of the tougue is sometimes seen in trifacial 
 neuralgia involving the infra-orbital branch. It may occur also in uni- 
 lateral palsy of the tongue. 
 
 (c) A UNIFORM THIN, WHITISH COATING is habitual to many persons 
 in health, especially mouth-breathers, smokers, and those who are troubled 
 by subacute catarrhal processes involving the pharynx and stomach. It 
 occurs also in constitutional disturbances attended by slight fever. 
 
 (d) A THiCKisH, PASTY, YELLOW- WHITE FUR is commou in those ad- 
 dicted to excesses at table or in tobacco or alcohol. It is attended with a 
 disagreeable taste. On rising it usually involves the greater portion of the 
 dorsum of the tongue, but disappears in part or wholly during the day. 
 In many persons this coating remains upon the back part of the tongue 
 continuously. Its disappearance is to some extent due to movements of 
 the tongue, friction against the teeth, the mechanical effects of food and 
 drink, and increased flow of salivary and buccal secretions. A slightly 
 enlarged, flabby, indented tongue covered with fur of this kind very often 
 accompanies chronic gastritis. 
 
 (e) A THICK, UNIFORM, MOIST, WHITISH OR YELLOWISH-WHITE COATING 
 
 with abrupt edges is seen in the early stages of the acute febrile diseases. 
 In consequence of the diminished amount and altered character of the 
 salivary and buccal secretions, this coating presently loses its moisture 
 and becomes dry and darker in color. After a time it separates, leaving 
 the tongue moist and of normal appearance if convalescence has begun, 
 or dry, hard, red or brown, and denuded of epithelium if the fever con- 
 tinues and particularly if the patient falls into the so-called typhoid condi- 
 tion. Under these circumstances the tongue becomes fissured both longi- 
 tudinally and transversely. In some cases a deep median fissure forms, 
 on each side of which there is a thick, rough, dry, brownish fur, the tip and 
 edges of the tongue being red and denuded; or again the tongue may be 
 dry, red, and glazed. It is protruded upon request tremulously and slowly 
 and, owing to the accompanying mental condition, is not immediately 
 withdrawn. The disappearance of the crusty coating, the redevelopment 
 of epithelium, and the return of moisture are favorable signs. The tongue 
 may be dry, brown, and incrusted in the last stages of chronic diseases of 
 the nervous system, and in cancer, nephritis, and pulmonary tuberculosis. 
 
SYMPTOMS AXD SIGNS : TOXGUE. 487 
 
 (f) The thick white fur of the acute febrile diseases is sometimes 
 penetrated by the greatly enlarged filiform j^apillse which appear as scat- 
 tered bright red minute points. This constitutes one of the forms of so- 
 called "strawberry tongue." It occurs with some frequency in scarlet 
 fever, but is not diagnostic of that disease, since it may be present in 
 other acute febrile infections. 
 
 (g) A DENSE, WHITE, FLAKY COATING is sometimes seen upon the 
 tongue of patients who are fed upon an exclusive milk diet. A somewhat 
 similar appearance may be presented by children suffering from thrush — 
 a condition caused by saccharomyces albicans, which begins on the tongue 
 in the form of slightly elevated pearly white spots which, by increase in 
 size and coalescence, may cover the greater part of the dorsum of the 
 tongue. 
 
 (h) General hypertrophy of the papill.e gives rise to a peculiar 
 appearance which suggests coarse plush. This is the shaggy tongue. It is 
 seen in gastro-intestinal and constitutional diseases in advanced life, but is 
 sometimes present in elderly people whose health is good. The shaggy 
 tongue is frequently also fissured, the plush-like surface being divided by 
 conspicuous deep longitudinal and transverse lines of separation. The 
 color is usually deep red. Upon the supervention of acute illness it quickly 
 becomes dry, hard, and full, usually remaining rough. 
 
 A red, dry tongue, denuded of epithelium, glistening and resembling 
 raw beef — the beefy tongue — occurs in dysentery and chronic intestinal 
 catarrh. It is seen also in hepatic abscess. 
 
 Other conditions of the tongue may be of diagnostic importance: 
 fissures, ulcers, mucous patches and plaques, tumors, and cicatrices. 
 
 (a) Fissures of the tongue are often seen in healthy persons in ad- 
 vanced life. They may be the signs of a superficial chronic glossitis caused 
 by habitual use of tobacco or irritating food or drink. The median longi- 
 tudinal fissure is commonly the most marked and readily becomes ulcer- 
 ated. Transverse fissures are common. Sometimes the fissures are forked 
 or curved. Fissures may be deep and inflamed, the result of extending 
 glossitis — dissecting glossitis — or syphilis. Fissures are common in chronic 
 hepatic disease, chronic colitis, and diabetes mellitus. Local fissures or 
 notches at the edge of the tongue may arise from the irritation of a broken 
 or carious tooth or from syphilitic ulceration. 
 
 (b) Ulcers of the Tongue. — Simple excoriations occur as the result of 
 slight traumatism or scalding, or spontaneously in dyspeptic conditions. 
 Aphthous stomatitis is characterized by small, slightly depressed spots 
 with grayish bases and bright red mai-gins. They occur at the edges and 
 tip of the tongue, on the frsenum, and elsewhere about the mucous mem- 
 brane of the lips and mouth. The ulcers are preceded by vesicles and are 
 -attended with great pain. The buccal secretions are increased. The ulcers 
 may appear singly or in series or crops. They occur in transient gastric 
 derangements and in women at the menstrual period. There is an indi- 
 vidual predisposition to them. 
 
 A chronic, recurrent herpetic eruption of the buccal mucous mem- 
 brane, sometimes associated with erythema multiforme, has been observed 
 in neurotic persons. 
 
488 MEDICAL DIAGNOSIS. 
 
 Riga's disease is an affection occurring about the time of the first 
 dentition and characterized by a pearly white pseudomembrane beneath 
 the tongue and upon the frsenum, with induration and ulceration. It is 
 endemic and sometimes epidemic in Southern Italy. 
 
 Superficial ulcers with a red glazed surface occur upon the tongue in 
 various forms of chronic glossitis. They are of irregularly round or oval 
 shape with infiltrated edges and are usually extremely painful. Ulceration 
 of the tongue is commonly attended with salivation. Tuberculosis of the 
 tongue shows itself in the form of circumscribed, indolent, irregularly 
 extending ulceration with a necrotic or caseous base. The edges are usually 
 sHghtly infiltrated but sharply defined. This ulcer is extremely painful 
 upon contact and is sometimes attended by salivation. The lesions may 
 be single or multiple and are usually secondary to tuberculous disease of 
 the lungs. The glands at the angle of the jaw are not usually enlarged. 
 Syphilis is a common cause of ulceration of the tongue. In secondary 
 syphilis superficial and linear ulcers are common at the border of the 
 tongue as the result of the irritation of the teeth. A single ulcer with an 
 indurated base and enlargement of the cervical glands may be the initial 
 lesion of syphilis. A mucous patch may undergo ulceration, and in later 
 syphilis a gumma may become necrotic, forming a deep foul ulcer. In 
 some instances difficulty attends the differential diagnosis of a single 
 ulcer, which may be due to tuberculosis, syphilis, or maHgnant disease. 
 The resemblances upon inspection and palpation may be very close. 
 In the first there are usually evidences of tuberculosis of the larynx or 
 lungs and the presence of tubercle bacilli in the scrapings. In cases not 
 otherwise to be determined inoculation experiments should be performed. 
 In the initial lesion of syphilis the induration is dense and circumscribed. 
 The age and habits of the patient are to be taken into consideration. Great 
 enlargement and tenderness of the lymphatics of the neck constitute im- 
 portant symptoms. The evolution of the process and the development of 
 mucous patches, cutaneous rashes, fever, and the like make the diagnosis 
 clear. In gummatous ulceration the enlarged surface is greater and the 
 infiltration less dense. The therapeutic test is important; the ulcer heals 
 under antisyphilitic treatment. A carefully taken clinical history sheds 
 light upon a doubtful case. In epithehoma of the tongue the diagnosis 
 may be reached by exclusion. The process tends to spread, the sub- 
 lingual lymphatics become involved, the ulcer is foul and indolent, and 
 the patient is almost always past middle age. 
 
 The ulcer frequently observed on the frsnum of the tongue in whoop- 
 ing-cough is traumatic. It results from the violent impact of the under 
 surface of the tongue against the sharp lower incisors during the 
 paroxysm. 
 
 (c) Mucous Patches and Plaques, — The multiple grayish-white 
 superficial lesions of syphilis known as mucous patches occur upon the 
 tongue as well as upon the soft palate, cheeks, and lips. A sHghtly 
 raised, smooth, red, oval-shaped area sometimes seen in the middle of 
 the dorsum of the tongue in pipe smokers is known as the smoker's 
 patch. The surface is smooth and sometimes white or pearly white in 
 appearance. 
 
SYMPTOMS AND SIGNS : TONGUE. 489 
 
 Xanthelasma occasionally appears upon the sides of the tongue in the 
 form of yellowish, soft, slightly raised, oblong patches. It occurs in vari- 
 ous conditions but is noticeably frequent in chronic jaundice and diabetes. 
 
 Leucoplakia is a condition characterized by the development of irreg- 
 ular white or pearly-white smooth patches upon the tongue which show 
 no tendency to ulcerate. They are hard to the touch and gradually 
 extend, sometimes becoming papillomatous. These patches may be the 
 starting-point of epithelioma. The condition is described under various 
 terms, as buccal psoriasis, ichthyosis and keratosis mucosce oris. They 
 present some points of similarity to the lesions of syphilitic glossitis, 
 which is, however, more common at the edge and tip of the tongue than 
 on the dorsum and yields to antisyphilitic medication. 
 
 Eczema of the tongue — geographical tongue. This condition is char- 
 acterized by the formation of irregularly annular patches upon the tongue. 
 There is desquamation of the epithelium. The process is attended with 
 burning and itching. The patches extend at the margins with new forma- 
 tion of epithelium in the centre. The borders are slightly red and well 
 defined but without induration. The condition is more common in infants 
 and children than in adults. The process is recurrent and protracted. 
 
 (d) Tumors of the Tongue. — Solid tumors of the tongue are usually 
 tuberculous or syphilitic. They invade the substance of the organ, usually 
 presenting toward its dorsal surface. Tuberculous nodules break down, 
 promptly giving rise to an indolent ulceration with caseation. Gummata 
 rapidly undergo extensive necrosis but yield to treatment. Retention 
 cysts occur in connection with the tongue. Ranula is the most common; 
 it is due to an obstruction and dilatation of a duct of the sublingual or 
 submaxillary glands. Mucous cysts also occur. Echinococcus cysts, 
 which develop as a rule by preference in highly vascular structures, are rare 
 in the tongue. 
 
 (e) Cicatrices. — Scars upon the tongue tell the tale of former 
 traumatism, as the accidental biting of the tongue, a fall or blow upon 
 the chin when the tongue is between the teeth, or the grinding of the 
 teeth during the clonic convulsions of epilepsy. They may be the indica- 
 tions of former active diseases, especially syphilis. Sclerosis of the tongue 
 with local deformity is a common result of the healing of gummatous 
 ulceration. 
 
 The buccal mucous membrane is commonly implicated in infections 
 involving the other organs of the mouth, especially the various forms of 
 stomatitis. It is very often the starting-point of the progressive gangre- 
 nous affection known as noma or cancrum oris. 
 
490 MEDICAL DIAGNOSIS. 
 
 VIII. 
 
 THE DIGESTIVE SYSTEM (CONTINUED): THE PALATE: 
 TONSILS; PHARYNX. 
 
 The passage from the mouth to the oesophagus by wa}' of the pharynx 
 is called the fauces or isthmus faiicium. It is bounded above by the soft 
 palate, laterally b}^ the palatine arches and tonsils, and below by the base 
 of the tongue. These structures are covered with mucous membrane con- 
 tinuous with that of the mouth and are liable to the same morbid processes. 
 An inspection of these parts yields information of importance in the diag- 
 nosis of local and constitutional disease. Infection may take place di- 
 rectl}^ or by extension from the mouth and nasopharynx. Forms of angina 
 — simplex, follicular, suppurative, and diphtheritic — result. When the 
 tonsils are principally or alone involved the condition is spoken of as 
 tonsillitis. The underlying muscular structures may be involved by 
 extension. The tonsils and adjacent lymph structures are points of inva- 
 sion for the infecting agents in rheumatism and other affections. There are 
 forms of acute tonsillitis that are essentially rheumatic. In children the 
 articular manifestations of rheumatic fever and chorea frequently show a 
 definite relationship to tonsillitis and the latter affection is not rarely 
 followed by endocarditis and chorea. The tonsils ma}- be the port of 
 invasion for tuberculosis or the seat of tuberculous lesions. 
 
 Subacute and chronic pharyngeal inflammation may be secondary 
 to gastric disorders or to the gouty diathesis. The pharynx is sometimes 
 involved in rheumatism. Paralysis of the soft palate and spasm and 
 paralysis of the pharynx occur. Superficial ulceration of the pharjmx 
 is very common in advanced pulmonar}' tuberculosis. 
 
 General redness of the faucial mucous membrane occurs in simple 
 inflammations and in many of the specific febrile affections, as rotheln, 
 the variolous diseases, influenza, and erysipelas. In the exanthemata, 
 especially measles, scarlatina, varicella, and variola, there are efflorescences 
 corresponding to the cutaneous eruptions. In these situations the pocks 
 of varicella and variola, owing to the action of warmth and moisture, 
 lose their roof in the vesicular stage and are converted into small cir- 
 cular or oval superficial ulcerations with purulent or necrotic bases and 
 a more or less marked areola. Redness of the mucous membrane in this 
 region is a symptom of chronic gastritis or the action of certain drugs, as 
 the iodine compounds and belladonna, and of corrosive poisons. 
 
 Hemorrhage occurs into the mucous membrane in the form of petech- 
 ise, infarcts, and extravasations, and there is bleeding from these surfaces 
 in general hemorrhagic states. These tissues are pallid in the anaemias, 
 3'ellow in jaundice, and show a bluish tint in cyanosis. The mucous 
 patches of syphiHs may be seen. 
 
 Pain is a prominent symptom in angina, especially in the acute forms. 
 It may be spontaneous, but is excited by the movements of deglutition 
 and bv contact of articles of food and drink with ulcerated surfaces. Pain 
 
SYMPTOMS AND SIGNS : PALATE. 491 
 
 and tickling referred to the pharynx may be symptomatic of acute rhini- 
 tis. These symptoms are common in hay fever. Sensations of dryness 
 and tickhng accompanied by the inchnation to hawk and clear the throat 
 are constant symptoms of pharyngitis. Annoying hawking is especially 
 excited by disease of the nasopharynx. 
 
 Dysphagia is common. It varies in degree and may be due to pain or 
 to mechanical obstruction. When dysphagia is marked both these causes 
 are commonly operative. In suppurative tonsillitis and retropharyngeal 
 abscess dysphagia may be complete. It is a symptom of the various forms 
 of stomatitis and glossitis as well as of tonsiUitis and pharyngitis. Painful 
 dysphagia referred to the pharynx is a common symptom in cases showing 
 no signs of inflammation of the mucous membrane — rheumatic pharyngitis. 
 The angina which attends diphtheria, scarlet fever, measles, varicella, and 
 variola is accompanied by dysphagia which is often distressing. 
 
 Dyspnoea may become an important symptom in suppurative tonsil- 
 litis, retropharyngeal abscess, and erysipelas extending to the pharynx. 
 
 Chronic interference with respiration accompanied by mouth-breath- 
 ing results from hyperplasia of the tonsils and especially from hyperplasia 
 of the pharyngeal tonsil — adenoid vegetations. In severe acute angina and 
 in certain chronic diseases involving the tonsils and pharynx, as cancer 
 and forms of syphilis, the drainage of the fauces is interfered with and the 
 accumulating secretions and exudates undergo decomposition. The odor 
 of the breath may be intense, fetid, and disgusting. Accumulations of 
 epithelial cells, leucocytes, and bacteria in the tonsillar crypts are very 
 common in chronic lacunar tonsillitis and in individuals presenting no 
 other symptoms of disease of the throat. They appear as small white or 
 yellowish-white concretions which sometimes undergo calcareous changes. 
 They ai-e sometimes expectorated and should be removed by the curette. 
 They impart a disagreeable odor to the breath. 
 
 THE PALATE. 
 
 Developmental deformities do not fall within the scope of this work. 
 A narrow, high, arched palate is regarded as among the stigmata of degen- 
 eration. Circumscribed ulceration of the mucous membrane of the hard 
 palate is frequently met with in the new-born or may be caused in artifi- 
 cially-fed children by the irritation of the rubber nipple. The ulceration 
 thus caused is sometimes described under the term Bednar's aphtha. In 
 young children patches of thrush are not uncommon upon the hard palate. 
 Abscess formation attended with great pain occasionally involves the 
 mucous membrane of the hard palate in connection with alveolar disease. 
 Perforations occur as the result of syphilis. 
 
 The soft palate in health is freely movable and symmetrical. The 
 form of the uvula varies in different persons. As a result of defective 
 development it is sometimes bifid. It may be attached laterally to the 
 soft palate or tonsil or to the posterior wall of the pharjmx in consequence 
 of adhesive inflammation in diphtheria or syphilis. Perforation of the 
 soft palate is almost always the result of syphilis. In very rare instances 
 it has followed scarlet fever. The uvula varies in length normally. It 
 
492 MEDICAL DIAGNOSIS. 
 
 frequently becomes elongated in angina and bronchitis. Under these 
 circumstances it causes irritation of the base of the tongue and excites 
 cough, especially in the recumbent posture; the mechanical violence of 
 intense paroxysmal cough elongates the uvula and thus a vicious circuit 
 is established. It becomes elongated and cedematous in cases of debility, 
 anaemia, and anasarca. When greatly oedematous the uvula becomes 
 globular and may attain the size of a cherry, interfering with swallowing 
 and breathing and producing a constant disposition to hawk. In consti- 
 tutional hemorrhagic states submucous extravasation of blood may occur 
 in the uvula. In very rare instances crops of vesicles resembling herpes 
 show themselves upon the palate. 
 
 Anaesthesia of the hard and soft palate and of the anterior two-thirds 
 of the tongue occurs in lesions of the sensory division of the fifth nerve. 
 The tactile sense is usually lost before the pain. The palate is innervated 
 by the accessory nerve to the vagus. Paralysis of the soft palate occurs in 
 bulbar palsy, basal tumors, and meningitis of the base. By far the most 
 common cause is postdiphtheritic neuritis. Upon inspection while the 
 patient pronounces the long a the palate and uvula are thrown back and 
 elevated. Under normal circumstances the extent of this movement is 
 the same on both sides. In unilateral paralysis movement upon the af- 
 fected side is greatly diminished. In bilateral paralysis the whole palate 
 remains relaxed and motionless, the voice has a nasal character, the pro- 
 nunciation of certain consonants — gutturals — is impaired, and upon attempts 
 to swallow, liquids are returned through the nose. Lesions involving the 
 nerve-supply of one side cause unilateral paralysis. 
 
 THE TONSILS. 
 
 The tonsils, also called amygdalce from their almond shape, lie at the 
 side of the pharynx between the anterior and posterior palatine folds. 
 They are larger in childhood than in adult Hfe and early undergo senile 
 involution. The greater part of their surface is exposed to inspection by 
 ordinary methods. Upon gagging they are rotated forward. In inflamma- 
 tion the mucosa is reddened and swollen and the surface covered with a 
 mucoid or mucopurulent secretion which may be tinged with blood. In 
 follicular or lacunar tonsilHtis this secretion develops in the crypts, pro- 
 ducing whitish-yellow spots. These may by extension and coalescence 
 form patches upon the tonsils presenting a superficial resemblance to diph- 
 theria. The pseudomembrane thus formed is not usually distinctly mar- 
 ginate and corresponds in appearance to the points of exudate seen to 
 occupy adjacent crypts. It is not developed in the mucosa but lies upon it, 
 as may be seen upon removing it by wiping or gentle scraping. A pseudo- 
 membranous exudate frequently forms in the course of various infections, 
 as scarlet fever, measles, pertussis, enteric fever, and variola. In a great 
 majority of these cases the Streptococcus pyogenes is the active organism. 
 As a rule the development of this form of pseudomembrane does not 
 constitute a serious complication of the primary disease. It may, how- 
 ever, give rise to an intense angina with local sloughing and grave con- 
 stitutional disturbance. A general streptococcus infection is by no means 
 
SYMPTOMS AND SIGXS : PHARYXX. 493 
 
 infrequent. A pseudomembranous exudate occurs in its most typical form 
 as a manifestation of diphtheria. It is caused by the Klebs-Loffler bacillus. 
 
 In suppurative tonsillitis or quinsy one or both tonsils may be in- 
 volved. The earliest symptoms are those of an ordinary acute angina — 
 pain, dryness, dysphagia, with fever and other symptoms of constitutional 
 disturbance. The tonsils are enlarged, dusky red, and oedematous. They 
 may even meet, or if one only is involved it may extend some distance 
 beyond the median Hne. In many instances there is salivation. The breath 
 is foul, the glands of the neck enlarged, and the patient opens his mouth 
 only partially and with great difficulty. After suppuration occurs fluctua- 
 tion may be felt. 
 
 Enlargement of the tonsils is common in children. It may be due to 
 repeated attacks of acute tonsillitis or to a chronic inflammatory process 
 leading to a hj'perplasia of the lymphoid elements. The tonsillar crypts 
 are enlarged. In some cases a probe may be introduced to the depth of a 
 centimetre or more. Partial or complete adhesions of the anterior pillars 
 to the tonsils are seen, and these structures are sometimes thin, red, and 
 stretched by the enlargement of the tonsil. In some instances the tonsils 
 are dense and firm, the connective-tissue stroma predominating. Enlarge- 
 ment of the tonsils is very often associated with adenoid vegetations in 
 the pharyngeal vault. Mouth-breathing and its concomitant derange- 
 ments accompany this condition. Ulceration of the tonsils is not very 
 common. In syphilis the primary chancre has occurred upon the tonsils. 
 In secondary syphilis mucous patches are very common in this region, and 
 in the tertiary stage gumma may give rise to enlargement of the tonsil 
 and, upon breaking down, result in deep circular ulceration with a necrotic 
 base and little hypersemia of the surrounding tissue. Tuberculous ulcera- 
 tion of the tonsils is not common. 
 
 THE PHARYNX. 
 
 This organ may be divided into an upper portion — the nasopharynx — 
 and a lower portion — the oropharynx. The former may be examined by 
 palpation with the finger or by the rhinoscopic mirror; the latter by direct 
 inspection in a good light. Small foreign bodies, as fish-bones or a beard 
 of wheat, may be recognized upon inspection; larger foreign bodies, as an 
 artificial denture or fragment of meat or bone, by inspection or palpation. 
 The presence of adenoid vegetations due to hyperplasia of the pharyngeal 
 tonsil may be thus determined. Papillomatous masses sometimes fill the 
 vault of the pharynx, extending into the posterior nares and greatly inter- 
 fering with respiration. By occluding the orifices of the Eustachian tubes 
 they cause deafness and middle-ear disease. 
 
 Cyanosis and Pulsation. — Cyanosis of the pharyngeal mucosa may 
 result from general derangements of the circulation or respiration or from 
 local causes, as obstruction to the return flow of the blood by way of the 
 superior vena cava, from aneurism or from mediastinal tumor. In aortic 
 regurgitation pulsation of the capillary vessels may be seen or unilateral 
 pulsation may be the manifestation of a tortuous internal carotid artery 
 or aneurism of that vessel. In the oozing that takes place from the pharynx 
 
494 MEDICAL DIAGNOSIS. 
 
 in intense congestion or hemorrhagic states the blood may be swallowed 
 and accumulate in the stomach. If vomited the hemorrhage may be 
 attributed to a lesion of the stomach. This error of diagnosis may be 
 avoided by careful inspection of the pharynx. 
 
 Pharyngitis. — In acute inflammation of the oropharynx the mucosa 
 is congested and reddened. The patient complains of tickling and dryness 
 with a constant desire to hawk. The secretions are diminished and al- 
 tered. There is dryness with thin flakes or a whitish exudate, to be seen 
 only upon close examination. The constitutional symptoms are slight. 
 
 Rheumatic angina is characterized by sore throat and dysphagia 
 referred to the pharynx. In the majority of the cases the signs upon in- 
 spection are not distinctive. 
 
 Chronic pharyngitis may develop insidiously or as the result of re- 
 peated acute attacks. The mucosa is at first reddened and shows dis- 
 tended vesicles; later it is relaxed and presents a granular or warty appear- 
 ance — granular pharyngitis, due to hyperplasia of the lymph elements. 
 The secretion is mucoid or purulent and undergoes desiccation, forming 
 dry crusts or scales which very often communicate an offensive odor to the 
 breath. The process extends into the nasopharynx. There is very often 
 a free mucoid or mucopurulent secretion which gives rise to the sensation 
 of dropping or trickling into the throat and causes hawking. In other 
 cases the secretion is slight and the mucous membrane reddish-brown, dry, 
 atrophic, smooth and glistening — 'pharyngitis sicca. The pseudomembra- 
 nous exudate of diphtheria frequently extends into the pharynx; the exudate 
 of pseudodiphtheritic, diphtheroid, or diplococcus inflammation commonly 
 appears upon the tonsils and does not as a rule involve the pharynx. 
 
 Ulceration of the pharyngeal wall is not uncommon. Limited areas of 
 superficial ulceration occur in chronic pharyngitis. Small round or oval 
 ulcers upon the posterior wall are sometimes seen in enteric fever. Irregu- 
 lar superficial patches of ulceration are frequently seen in the later stages 
 of consumption. The bases are necrotic and grayish-yellow. The ulcera- 
 tion may involve the greater part of the posterior pharyngeal wall and 
 cause intensely painful dysphagia. Ulceration of the pharyngeal wall 
 occurs also in syphilis. In the secondary stage it is very often superficial 
 and associated with mucous patches. In the tertiary stage it results from 
 the breaking down of gummata which heal satisfactorily under treatment, 
 leaving white cicatrices. 
 
 Ulceration of the pharynx may occur in connection with the various 
 forms of pseudomembranous inflammation and attends cancer and lupus. 
 The etiological diagnosis of ulceration of the pharynx is frequently attended 
 with difficulty. As in the case of the tongue, tubercle, cancer, and syphilis 
 are to be differentiated. A careful anamnesis is important. The asso- 
 ciated clinical phenomena are very often characteristic. In tuberculosis 
 the presence or absence of tubercle bacilli and the inoculation test are 
 important; in syphilis the therapeutic test. 
 
 Acute phlegmonous inflammation of the pharynx may result from 
 traumatism or foreign bodies in the pharynx. 
 
 Acute infectious phlegmon, a rare condition, characterized by anginal 
 symptoms, dysphagia, rapid abscess formation, swelling of the neck, and 
 
SYMPTOMS AND SIGNS : CESOPHAGUS. 495 
 
 severe constitutional symptoms, may result from direct traumatism, 
 the injury caused by foreign bodies, or arise spontaneously. 
 
 Retropharyngeal abscess manifests itself upon inspection and palpa- 
 tion as a projecting fluctuating tumor upon the posterior wall of the pharynx 
 in the median line. Attendant phenomena are restlessness, dysphagia, and 
 changes in the voice, which becomes nasal or metallic as the result of pres- 
 sure. Retropharyngeal abscess is a rare affection. It has been observed 
 in children previously in apparent good health as a sequel of the infectious 
 diseases, particularly scarlet fever and diphtheria, and in caries of the 
 cervical vertebrae. 
 
 Angina Ludovici : Ludwig's Angina ; Cellulitis of the Neck. — A rap- 
 idly developing phlegmonous inflammation of the tissues about the floor of 
 the mouth is described under these names. It apparently results from 
 trauma or some lesion about the roots of the teeth or from infection of the 
 submaxillary gland. It may occur as the result of secondary infection in 
 the specific fevers, particularly diphtheria and scarlet fever. The inflamma- 
 tion is the result of streptococcus infection. Swelling usually appears first 
 in the submaxillary region of one side and rapidly spreads, with diffuse 
 dull redness and brawny induration of the neck. The tendency is to speedy 
 suppuration and extensive gangrene with general septicaemia. The disease 
 is rare and very fatal. 
 
 The innervation of the pharynx is derived from the pharyngeal plexus, 
 formed by the combination of the glossopharyngeal and branches of the vagus. 
 
 Spasm of the pharynx is a functional disorder. It is common in neuro- 
 pathic individuals. It is the cause of ordinary gagging and occurs in hydro- 
 phobia and as a convulsive manifestation of hysteria — globus hystericus. 
 
 Motor palsy of the pharynx occurs in postdiphtheritic neuritis, acute 
 ascending paralysis, and bulbar paralysis. It may result from lesions at 
 the base of the brain. It is commonly bilateral. There is difficulty in 
 swallowing and food is not properly passed into the oesophagus. Particles 
 of food may pass into the larynx and, when there is associated paralysis 
 of the soft palate, into the posterior nares. Fluids are regurgitated 
 through the nose. In unilateral lesions the power of deglutition remains. 
 
 Anaesthesia of the pharynx is produced by bromidism and the local 
 application of cocaine. 
 
 IX. 
 
 THE DIGESTIVE SYSTEM (CONTINUED): THE CESOPHAGUS. 
 
 The upper limit of this organ is about at the level of the cricoid car- 
 tilage and opposite the sixth cervical vertebra. It terminates in the car- 
 diac orifice of the stomach opposite the upper border of the body of the 
 eleventh thoracic vertebra. It has a short infradiaphragmatic course of 
 about one and a half centimetres. It begins about six inches — fifteen cm. 
 — from the incisor teeth, is about nine and a half inches — twenty-four cm. 
 — in length, and varies from three-fourths to one and a fourth inch — two 
 to three cm. — in diameter, the narrowest parts being at the commence- 
 
496 MEDICAL DIAGNOSIS. 
 
 ment, in the middle, where it is crossed by the left primary bronchus, and 
 at its point of entrance into the stomach. The oesophagus is in relation 
 with the trachea, the left bronchus, the thyroid body, the peribronchial 
 lymph-glands, the pneumogastric and recurrent laryngeal nerves, the 
 aorta, the azygos vein, the thoracic duct, and the pericardium and pleurae. 
 Nearly its whole course is in the posterior mediastinum. 
 
 The principal methods of examination are auscultation, direct inspec- 
 tion of the interior of the oesophagus, the use of the sound, and the Ront- 
 gen rays. Ordinary inspection, palpation, and percussion are of no prac- 
 tical value, although the first two of these methods may reveal a tumor 
 upon the left side of the neck when there is a diverticulum or new growth in 
 the cervical portion. 
 
 Auscultation. — Upon auscultation, the stethoscope being placed to 
 the left of the ensiform cartilage or to the left of the spine opposite the 
 tenth rib, a gurgling sound may be heard six seconds after the act of swal- 
 lowing, as determined by the movement of the larynx. This murmur is 
 due to the propulsion of the liquid or bolus of food into the stomach and 
 is not to be confounded with the sound to be heard over the cervical part 
 of the oesophagus during swallowing. The absence, delay, or prolongation 
 of the first-named sound is evidence of obstruction at the lower end of the 
 oesophagus. 
 
 OEsophagoscopy. — Direct inspection may be practised through a 
 suitable tube or instrument with proper illumination. The mucosa in 
 acute inflammation is reddened, swollen, and lax; in chronic inflammation, 
 grayish-white, covered with a viscid mucus, and shows dilated veins. The 
 instrument may be used as a sound to determine the presence or absence 
 of dilatation or narrowing. Ulceration, new growths, and cicatrices may 
 be recognized, and fragments of ulcerated tissue have been removed through 
 the cesophagoscope for examination. Foreign bodies may be located and 
 have been removed by instruments passed through the tube when their 
 removal by ordinary methods has proved impracticable. 
 
 The (Esophageal Sound. — The ordinary rubber tube used in the 
 examination and treatment of diseases of the stomach may be utilized or 
 oesophageal bougies especially made for the purpose. The latter are of 
 whalebone or narrow blades of metal with rounded edges and provided 
 with adjustable olive-shaped tips made of hard rubber, ivory; or metal and 
 of various sizes. The sound is introduced in the same manner as the 
 stomach tube. It may pass directly into the stomach or be arrested by 
 some obstruction. The location of the stenosis can be readily deter- 
 mined by measuring the distance from the teeth upon withdrawing 
 the instrument. No force is to be used. Feeble and ansemic patients 
 may faint during this examination and neurotic or hysterical indi- 
 viduals may have local spasm or even general convulsions. Under 
 such circumstances the instrument should be immediately withdrawn. 
 Sounding must be performed with due caution, since there is the 
 danger of injury or perforation of the wall of the oesophagus, the rup- 
 ture of an aneurism, or the laceration of the varicose veins of the oesopha- 
 geal plexus in atrophic cirrhosis. By the use of the sound the location of 
 strictures, dilatations, diverticula, ulceration or at least areas of sensi- 
 
SYMPTOMS AND SIGNS: (ESOPHAGUS. 497 
 
 tiveness, and the presence or absence of foreign bodies and their location 
 may be learned. The careful use of this instrument yields information as to 
 whether or not a stricture is dilatable or rigid and unyielding. 
 
 The X=rays. — The presence and position of foreign bodies in the 
 oesophagus may be ascertained by this method of examination, and in 
 appropriate cases information in regard to tumors of, or in relation with, 
 the oesophagus. The possibility that a large atheromatous plate in the 
 aorta may be mistaken for a foreign body in the gullet is to be borne in 
 mind. 
 
 Symptoms of disease of the oesophagus are dysphagia, pain, and the 
 regurgitation of food. 
 
 Dysphagia varies according to the disease and its site and is com- 
 monly greater with solids than with fluids; the pain may be sharply local- 
 ized or diffuse; the regurgitation of food may be partial or complete and 
 take place immediately or not for some time. 
 
 The oesophagus is subject to developmental defects, of which the 
 most important is atresia. Liquids are immediately regurgitated and the 
 sound cannot be passed. Death results from inhalation pneumonia or 
 starvation. 
 
 Alterations in Calibre. — The oesophagus may be narrowed or dilated. 
 Very often these two conditions are combined, the tube being narrowed 
 at one point and dilated at another. 
 
 Narrowing may be intrinsic, due to lesions of the oesophagus itself, 
 as congenital defect, stricture from inflammation, cicatrix or neoplasm, 
 or muscular spasm; or extrinsic, due to pressure from without. The 
 symptoms vary. In the first instance they are chiefly dysphagia, pain, and 
 regurgitation; in the second there are superadded to these the symptoms 
 of the disease causing the compression. Narrowing may be a congenital 
 defect. Its position in this case is usually at the upper or lower extremity. 
 The chief symptom is dysphagia. 
 
 In inflammatory and cicatricial stenosis there is a history of accidental 
 or intentional swallowing of a caustic or corrosive fluid, or the history 
 may point to ulceration as the result of traumatism produced by a foreign 
 body, softened glands, syphilis, or peptic ulcer at the cardia. Ninety 
 per cent, of the cases of stenosis are due to cancer, which acts by infil- 
 trating the walls and causing the development of contracting connective 
 tissue. In stricture arising from cicatrix the dysphagia comes on gradually 
 and is progressive and permanent. It may begin abruptly and at first be 
 caused by solids only; later by fluids. Associated spasm may cause varia- 
 tions in degree, but there are no intervals of complete relief as in spas- 
 modic stricture. The bougie is always arrested at the same distance from 
 the teeth. Food is regurgitated shortly after it is taken and, unless acid 
 in itself, shows an alkaline reaction. Subjectively it seems to stop at or 
 near the manubrium. There is actual progressive starvation and cor- 
 responding emaciation. Signs of pressure upon the recurrent pharyngeal 
 nerves are rare in cicatricial stenosis. 
 
 Malignant stricture of the oesophagus is commonly carcinomatous. 
 A limited number of cases of sarcoma have been reported. Carcinoma is 
 more common in men than in women. It is rare before forty and most 
 32 
 
498 MEDICAL DIAGNOSIS. 
 
 frequent between fifty and sixty. It occurs with about equal frequency 
 in the upper and the lower half of the organ. The symptoms are not 
 very different from those of cicatricial stricture. Pain is more prominent; 
 it is usually referred to the gullet; sometimes to the back between the 
 shoulder-blades. The food is commonly returned shortly after it is taken 
 and is sometimes streaked with blood, or it may contain fragments of 
 necrotic tissue. The obstruction may become complete by the impaction 
 of food in the stricture. Cough is common, and hoarseness, aphonia or 
 complete loss of voice may result from involvement of the recurrent laryn- 
 geal nerves. Hunger, at first urgent, gives place to indifference to food. 
 Thirst is troublesome, the mouth dry, the breath foul, and hiccough fre- 
 quent. The progress of the disease is rapid. 
 
 Spasmodic Stricture. — OEsophagismus occurs in neurotic persons and 
 especially in hysterical women. It has some points of resemblance ta 
 the "globus hystericus." It may be due to mental shock or prolonged 
 depressing emotions, but it is more frequently due to reflex irritation in 
 disorders of the gastro-intestinal or reproductive tract. In rare instances 
 it accompanies disease of the larynx, and it often recurs in diseases of 
 the oesophagus. It occurs in human rabies and in the hysterical counter- 
 feits of that disease, and has been observed in cerebrospinal fever, tetanus, 
 and epilepsy. Dysphagia is paroxysmal and of varying degree. It comes on 
 abruptly and often passes away as rapidly as it came. Food is regurgitated 
 suddenly and with force. There are gulping sounds. The difficulty in 
 swallowing is produced by liquids as well as by solids. The patients often, 
 complain of pain which is constricting and burning in character. Emacia- 
 tion does not usually occur. The bougie is not always arrested at the same 
 level and may usually be passed by firm pressure beyond the point of re- 
 sistance and into the stomach. 
 
 Pressure. ^Narrowing of the oesophagus by pressure from without 
 may be caused by enlargement of the thyroid body, as in goitre, Graves's 
 disease, cystic degeneration, or tumors involving that organ or enlarged 
 lymph-glands. Within the thorax a mediastinal tumor, dislocation back- 
 ward of the sternal end of the clavicle, prevertebral abscesses and tumors, 
 aneurism of the aorta, a distended diverticulum or massive pericardial 
 effusion may compress the oesophagus. The essential symptom is dys- 
 phagia. The sound may usually be passed with persistent gentle pressure. 
 If there is reason to suspect the presence of an aneurism the sound must 
 not be used. The oesophagus adjusts itself to external pressure to a re- 
 markable degree and unless it is extreme the symptoms are slight. 
 
 Obstruction from plugging may result in infants from excessive pro- 
 hferation of the thrush fungus; at any period of life from any foreign body 
 swallowed by accident or design. Common among these are masses of 
 meat, fragments of bone, artificial dentures, jack-stones and other small 
 playthings. Pedunculate polypi and other tumors may obstruct the 
 oesophagus without causing stricture. 
 
 Diverticula or circumscribed lateral dilatations are of two kinds, 
 those caused by internal pressure — pulsion diverticula — and those brought 
 about by the contraction of fibrous tissue outside the organ — traction 
 diverticula. 
 
SYMPTOMS AND SIGNS: (ESOPHAGUS. 499 
 
 Pulsion diverticula first show themselves by discomfort or a sense 
 of obstruction after swallowing food, usually referred to the sternal region 
 and often attended by cough. After a time liquids only can be taken and 
 are sometimes regurgitated and swallowed again and again before reach- 
 ing the stomach. Portions of food may be regurgitated several hours 
 after having been swallowed. Pressure or upward stroking of the left 
 side of the neck may aid in the regurgitation of food. A tumor is not 
 often present. Upon auscultation the sound produced by the passage of 
 food into the stomach is absent. A sound may be introduced into the 
 diverticulum, the blind end of which may be eight inches — twenty cm.^ 
 or more from the teeth; it may pass into the stomach and be freely mov- 
 able in that organ; or one sound may be passed into the diverticulum 
 and while it is still in place another may be passed beyond it into the 
 stomach. The symptoms increase in severity and in many cases there is 
 progressive emaciation. As a rule the progress of the disease is tardy. 
 
 Traction diverticula are usually situated upon the anterior or lateral 
 wall and near the bifurcation of the trachea. They are funnel-shaped 
 and vary in depth from one-half to three-quarters of an inch and are 
 usually single but may be multiple. They commonly give rise to no symp- 
 toms. Particles of food or foreign bodies may, however, be caught in 
 them and cause ulceration and perforation, with bronchopneumonia, 
 pulmonary gangrene, mediastinitis or pericarditis and pleurisy. A posi- 
 tive diagnosis cannot be made. 
 
 Ulceration may cause tenderness, dysphagia; perforation the secondary 
 lesions just mentioned; and rupture, which usually results from the presence 
 of a foreign body, may cause gangrenous mediastinitis and pleurisy. 
 
 (Esophageal hemorrhage may result from ulcer, cancer, the presence 
 of foreign bodies, the rupture of an aneurism or of the dilated veins of the 
 oesophageal plexus in thrombosis of the portal vein or in atrophic cirrhosis 
 of the liver. 
 
 The bleeding may be occasional or constant and vary in quantity from 
 a trifling amount to a copious loss which is quickly fatal. The associated 
 symptoms may render the diagnosis easy, but in the case of varicose veins 
 the differential diagnosis from gastric hemorrhage is often difficult. The 
 presence of other symptoms of portal obstruction and the fact that the 
 blood is regurgitated rather than vomited are to be considered, but the 
 blood may be discharged into the stomach and subsequently vomited. 
 
 Inflammation of the CEsophagus. — OEsophagitis is attended by local- 
 ized or diffuse pain upon swallowing, prostration, and in the severe acute 
 forms by chills and fever. There may be tenderness upon pressure and 
 upon bending the spine; for this reason the head is held rigid. Abscess 
 formation may show itself by a circumscribed swelling upon one side of 
 the neck with pressure upon the larynx and hoarseness and dyspnoea. In 
 the phlegmonous form pus may be expectorated and in the chronic cases 
 a glairy, viscid mucus. 
 
 Tuberculous and syphilitic ulcerations occur as local manifestations in 
 these diseases, and their presence is to be suspected when there is dyspha- 
 gia, persistent substernal pain, or the regurgitation of blood-stained mucus 
 in connection with the general phenomena of these diseases respectively. 
 
500 MEDICAL DIAGNOSIS. 
 
 Paralysis. — The cesophageal muscles are sometimes paralyzed in 
 central or peripheral diseases of the nervous system. Lesions in the neigh- 
 borhood of the origin of the pneumogastric nerves, such as hemorrhage, 
 softening, tumor, or sclerosis, are among the central causes; pressure 
 neuritis of the pneumogastric from enlargement of the lymphatic glands, 
 or disease of the vertebrae and toxic neuritis after diphtheria or in chronic 
 alcoholism or lead poisoning are among the peripheral causes. Difficulty 
 of swallowing, without pain, is a characteristic symptom. It develops 
 gradually or abruptly, according to the cause. The food produces a sense 
 of weight or pressure and a large bolus is more readily swallowed than 
 small morsels. Fluids may be regurgitated. Gurgling sounds attend the 
 act of swallowing, but the normal sound at the cardia is not heard. The 
 bougie passes freely. 
 
 X. 
 
 THE DIGESTIVE SYSTEM (CONTINUED): APPETITE; THIRST; 
 ERUCTATIONS; REGURGITATION; NAUSEA; VOMITING: 
 THE VOMITUS; DEFECATION; CONSTIPATION; DIARRHCEA; 
 TENESMUS; PAINFUL DEFECATION; FECAL INCONTI- 
 NENCE; CHARACTER OF THE DISCHARGES. 
 
 Appetite, thirst, the frequency of defecation and the consistency and 
 other characters of the stools vary within wide limits in health. They are 
 to a considerable extent influenced by habit and the mode of life of the 
 individual. Beyond these limits they, together with certain associated 
 symptoms, acquire clinical significance of importance in disease of the 
 digestive organs and other local and general affections. 
 
 APPETITE. 
 
 Appetite is dependent upon the state of the gustatory nerves, the 
 condition of the stomach, and the requirements of the organism as a whole. 
 
 The appetite for food may be diminished, lost — anorexia; increased — 
 polyphagia or hulijnia; perverted — pica or parorexia; or insatiable — acoria. 
 
 Loss of appetite varies from mere indifference to food to complete 
 anorexia. It is symptomatic of the most varied morbid states, the enu- 
 meration of which would comprise a nosological system. 
 
 The appetite is more or less impaired in: 
 
 (a) The acute infections. The absence of the normal desire for food 
 is due chiefly to the toxaemia, and in part to the subacute gastritis which 
 is usually present. 
 
 (b) The chronic infections, especially in the active stages of syphilis, 
 tuberculosis, and malaria, and in the conditions of malnutrition and cachexia 
 to which these diseases give rise. 
 
 (c) Septic conditions, both acute and chronic, and in all forms of 
 local suppuration. Loss of appetite in the absence of gastric disease or 
 
SYMPTOMS AND SIGNS: APPETITE. 501 
 
 other adequate obvious cause, especially when associated with persistent 
 leucocytosis, may be symptomatic of local suppuration in some part of 
 the body. 
 
 (d) Pyrexia. Fever is attended by loss of appetite as in any of the 
 foregoing conditions, and this symptom is commonly present in the early 
 convalescence from febrile diseases. A notable exception to the latter 
 statement occurs in enteric fever, in which hunger is usually a prominent 
 and urgent symptom after the defervescence. 
 
 (e) All forms of anaemia, chronic wasting diseases, and in many 
 functional and organic diseases of the nervous system. The loss of appe- 
 tite is not only an important symptom in these conditions but it is also 
 an etiological factor. A vicious circuit is established. The inability to 
 take food aggravates the condition that causes it. 
 
 A remarkable suppression of the desire for food is manifest in certain 
 cases of hysteria. There are instances in which the suppression of appe- 
 tite is maintained for long periods, as in "fasting girls." Deception is to 
 be guarded against. To hysteria is to be referred the condition described 
 by Gull as anorexia nervosa, in which there is not only complete loss of 
 appetite but also absolute inability to take food, with the gravest symp- 
 toms of inanition, sometimes ending in death. 
 
 (f) Cachexias and terminal states. The patient is not only unable 
 to take food save in minimum quantities, but life is also often maintained 
 without it for considerable periods — a fact due to the extreme limitation 
 of vital activities. 
 
 (g) Toxic conditions. Complete loss of appetite attends all acute 
 toxic conditions, and there is great impairment in chronic intoxications, 
 as that of lead, arsenic, or mercury. The anorexia is due in part to the 
 general malnutrition; in part to local disorder of the organs of digestion. 
 In chronic alcoholism appetite is irregular and enfeebled and at the close 
 of a debauch is completely lost. Aversion to food is frequently the fore- 
 runner of an attack of delirium tremens. 
 
 (h) Psychic states. Depressing emotional conditions, such as result 
 from worry, anxiety, suspense, and grief, are usually attended with anorexia. 
 The impairment of appetite under these circumstances is largely depend- 
 ent upon the temperament of the individual. 
 
 (i) Functional or organic disease of the stomach. Appetite may 
 persist normally or in some abnormal form in the gastric neuroses, and 
 is maintained in some cases of gastric ulcer. Patients suffering from 
 disease of the stomach frequently have a craving for food which is im- 
 mediately dispelled upon attempts to eat. Loss of appetite not infre- 
 quently results from a monotonous or inadequate dietary. Under these 
 circumstances the appetite frequently returns when the patient is per- 
 mitted to take ordinary food. There is a French proverb to the effect 
 that appetite comes with eating. 
 
 Polyphagia is a term used to indicate excessive or voracious eating. 
 It may be occasional, as in the convalescence from enteric fever or in chil- 
 dren suffering from whooping-cough, the frequent vomiting caused by the 
 paroxysms not permitting the absorption of sufficient food to -meet the 
 needs of the organism; or persistent, as in diabetes. 
 
502 MEDICAL DIAGNOSIS. 
 
 Bulimia and acoria are terms used to designate an insatiable appetite. 
 This is symptomatic of certain insanities and some forms of idiocy and 
 occurs in paroxysms in certain cases of hysteria, neurasthenia, epilepsy, 
 and exophthalmic goitre. In polyphagia the patient eats large quanti- 
 ties of food and is for the time being satisfied. In bulimia the ordinary 
 sense of satiety after eating does not occur. Acoria is the loss of the 
 sensation of satiety. 
 
 Pica or parorexia is a craving for unnatural articles of food — a de- 
 praved appetite. It is seen in some cases of hysteria, chlorosis, and in 
 pregnancy. These terms are also employed to designate a nervous craving 
 for special articles of diet or for articles that are not fit for food. 
 
 THIRST. 
 
 Thirst is in some instances an individual peculiarity. There are 
 persons who rarely experience the sensation of thirst and do not con- 
 sume enough fluid to fully meet the requirements of the body; others 
 who without impairment of health manifest an habitually abnormal 
 desire for fluid. 
 
 Impaired Thirst. — The sensation of thirst is diminished in soporous 
 states, even when the buccal and salivary secretions are diminished and 
 the mouth and tongue are dry, as in enteric fever. 
 
 Increased thirst is symptomatic of many morbid states. It is a con- 
 stant symptom in fevers and occurs in all conditions attended with abun- 
 dant or profuse loss of fluids, and is proportionate to the dehydration of 
 the tissues. It therefore attends profuse sweating both physiological 
 and pathological, abundant diuresis from any cause, persistent vomiting, 
 abundant watery discharges from the bowels, and sudden copious hemor- 
 rhage. It occurs at the time of crisis from acute diseases, as -croupous 
 pneumonia; in the polyuria of hysteria and persistently in diabetes insipi- 
 dus and mellitus; in the copious vomiting of acute irritant poisoning and 
 in some cases of uraemia; after the action of eiaterium and other drugs 
 producing large watery discharges from the bowels; in cholera nostras 
 and Asiatica and after all kinds of abundant hemorrhages both pathologi- 
 cal and traumatic. An unusual desire for water is observed in some cases 
 of chronic gastritis. Persistent excessive thirst is very often the first 
 symptom to attract attention in diabetes. The arrest of the buccal secre- 
 tions in xerostomia or dry mouth gives rise to continued and distressing 
 thirst. Polydipsia is a term used to describe the habitual taking of fluid 
 in excessive amounts. 
 
 ERUCTATIONS, REGURGITATION, NAUSEA, AND 
 
 VOMITING. 
 
 The oesophagus enters the stomach at an angle, forming a valve- 
 like fold which serves to prevent the return of the contents of the 
 stomach. The relation of the central tendon of the diaphragm to the 
 oesophagus is such that it closes the oesophageal opening only at the 
 time of inspiration. 
 
SYMPTOMS AND SIGNS: NAUSEA. 503 
 
 Eructations or Belching. 
 
 The spasmodic forcible discharge of gas or air from the mouth is a 
 common symptom. It may come from the oesophagus; much more com- 
 monly it comes from the stomach. It is sometimes odorless, frequently 
 offensive. It may consist of air swallowed with the food or with the saliva, 
 or of the gaseous products of the chemical decomposition of the food in 
 the stomach. The eructations may be occasional or occur in paroxysms 
 lasting for periods of some hours. Eructations are symptomatic of 
 acute indigestion such as results from over-eating, various forms of 
 gastritis and other organic affections of the stomach, or they may be of 
 nervous origin. Large quantities of odorless gas are sometimes forcibly 
 expelled at intervals during a period of several hours in hysterical and 
 neurasthenic individuals, the stomach at the same time being tensely 
 distended. 
 
 Regurgitation. 
 
 The liquid portions of the food, and in some instances the solids, are re- 
 turned to the mouth without the violence characteristic of vomiting. Regur- 
 gitation from the oesophagus occurs as a symptom of stricture, dilatation or 
 diverticulum, the food being returned immediately or after an interval. Re- 
 gurgitation from the stomach may be due to over-distention with food, or 
 drink and relaxation of the cardiac orifice. The regurgitation of considerable 
 quantities of an opalescent, slightly alkaline fluid is spoken of as water-brash. 
 
 Merycism or rumination is the regurgitation of solid food from the 
 stomach to the mouth, when it is again chewed and swallowed. The food 
 is returned in small portions without nausea. This phenomenon appears 
 at first to be the result of regurgitation, later a habit. 
 
 Pyrosis or heart=>burn is a burning sensation behind the sternum," 
 extending to the pharynx. It is often accompanied by eructation and 
 sometimes by the regurgitation of an acid fluid. It is due to the ejection 
 of the gastric contents into the cesophagus. It occurs in hyperchlorhydria 
 but may appear as a neurosis when the gastric secretion is normal. 
 
 Nausea. 
 
 Nausea or sickness at the stomacli is closely associated with vomiting 
 in its mechanism and clinical significance. It belongs to the group of 
 abnormal sensations referred to the stomach, and occurs in functional 
 and organic affections. Those causes which excite vomiting also excite 
 nausea, though the latter may occur in the absence of the former. The 
 term "nervous nausea" is applied to this symptom when it arises in con- 
 stitutional disorders and diseases of the central nervous system. It is 
 common in neurasthenia and hysteria and is very often the result of reflex 
 irritation in distant organs, for example, the uterus and ovaries. Nausea 
 is very common in the early stages of pregnancy, and, associated with 
 retching and vomiting, constitutes in pregnancy the syndrome known as 
 morning sickness, which in exceptional cases is persistent and intractable 
 and may even cause death. 
 
504 MEDICAL DIAGNOSIS. 
 
 Vomiting. 
 
 Vomiting is the forcible expulsion of the contents of the stomach 
 through the mouth. In exceptional cases the contents of the intestines 
 may also be expelled through the mouth — fecal or stercoraceous vomiting. 
 
 The Muscular Mechanism. — The act of vomiting is a complex reflex 
 movement in which many muscles take part. There is usually a sensation 
 of nausea and a reflex flow of saliva into the mouth, accompanied or fol- 
 lowed by a series of more or less violent retching movements which consist 
 of deep inspirations with closure of the glottis. As a result of these move- 
 ments the stomach is compressed by the diaphragm and the negative pres- 
 sure in the thorax and especially in the oesophagus is decidedly increased. 
 In the course of these retching movements the act of vomiting is brought 
 about by a sudden convulsive contraction of the abdominal muscles which 
 exerts additional pressure upon the stomach. With this the cardiac orifice 
 of the stomach is dilated and the stomach contents are forced through the 
 oesophagus, the glottis being closed by the adductor muscles and the nasal 
 chambers shut ojff from the pharynx by the contraction of the posterior 
 pillars of the fauces upon the palate and uvula. In the vomiting of uncon- 
 sciousness, as in anaesthesia, the laryngeal muscles may relax and vomited 
 matters be insufflated into the trachea, and in violent vomiting the material 
 may in part be forced past the palate and uvula and ejected through the nose. 
 
 It is not uncommon for the contents of the duodenum to be forced 
 by the violence of the contraction of the abdominal muscles through the 
 pylorus, so that the vomitus consists of bile-stained material and some- 
 times of pure bile. 
 
 The muscles concerned in vomiting are respiratory. The act consists 
 essentially in the simultaneous spasmodic contraction of the diaphragm, 
 an inspiratory muscle, and the abdominal or expiratory muscles, contrac- 
 tion of the muscular fibres of the stomach being altogether of subsidiary 
 importance. 
 
 The Nervous Mechanism. — The reflex nature of vomiting is shown 
 by the frequency with which it is produced by the stimulation of sensory 
 nerves and by injuries to various parts of the central nervous system. 
 Disagreeable emotions and derangements of the equilibrium of the body, 
 irritation of the mucous membrane of various parts of the alimentary 
 canal, pathological states of the genito-urinary tract, and lesions or injuries 
 of the brain may all cause vomiting. Vomiting may also be caused by 
 direct action upon the medullary centres, as in the case of drugs — apomor- 
 phine and various narcotics — and by or in the toxaemia of the infections 
 and autointoxications, as uraemia and cholaemia. 
 
 The causes are many, but the most common is irritation of the sensory 
 fibres of the gastric mucous membrane. In this case the afferent path is 
 by way of the sensory fibres of the vagus; the efferent path by way of the 
 motor fibres innervating the muscles concerned in the act of vomiting, 
 namely, the vagi, the phrenics, and the spinal nerves distributed to the 
 abdominal muscles. It is now generally conceded that there is a definite 
 vomiting centre situated in the medulla in close proximity to the respira- 
 tory centre. 
 
SYMPTOMS AND SIGNS: VOMITING. 
 
 505 
 
 The readiness with which children vomit is due in part to the greater 
 reflex excitability of the nervous system in early life; in part to the posi- 
 tion of the stomach, which is more nearly vertical than in adults. The 
 undeveloped state of the fundus and the defective closure of the cardia 
 increase the liability of infants to vomiting, which often occurs without 
 effort as a mere regurgitation of a portion of the food upon change of 
 posture or sKght pressure upon the epigastrium. 
 
 Brain 
 
 Pharynx 
 
 Liver and gall-bladder 
 
 Stomach 
 
 Kidney and ureter 
 
 Intestines 
 
 Uterus 
 
 Bladder 
 
 Vesical nerves 
 
 Vomiting centre 
 in the medulla 
 
 — Spinal cord 
 
 Vagus 
 
 Pulmonary branches 
 
 Splanchnic nerves 
 Gall-duct 
 
 Renal nerves 
 Mesenteric nerves 
 Vesical nerves 
 Uterine nerves 
 
 Fig. 199. — Diagram of afferent nerves which may excite the vomiting centre. 
 Modified from Briinton. 
 
 1. Vomiting from Direct Irritation of tlie Terminal Fibres of the Vagus 
 in tlie Stomacii. — Vomiting from this cause is very common. It may 
 result from anatomical lesions of the stomach itself and from quantitative 
 and qualitative abnormalities of the contents of the organ. Vomiting 
 is a common phenomenon in various forms of gastritis. In acute gastric 
 catarrh there is vomiting of the gastric contents followed by mucus 
 often stained with bile; a sense of relief is then experienced. In chronic 
 gastric catarrh vomiting is common; it occurs at various intervals after 
 the taking of food. Frequently, and especially in the gastric catarrh of 
 alcoholic subjects, there is distressing vomiting of tough mucus on rising — 
 vomitus matutinus potatorum. Vomiting is common in peptic ulcer of the 
 
506 MEDICAL DIAGNOSIS. 
 
 stomach and is frequently provoked by the intake of food, which also 
 causes pain. The pain very often precedes the vomiting and is relieved 
 by it. The vomiting which attends carcinoma ventriculi is a common 
 and distressing symptom. It is not often present until the disease has 
 made considerable progress. It may occur when the stomach is empty, 
 but usually follows the ingestion of food, after varying intervals. When 
 the growth involves the cardia food may be immediately vomited; when 
 the pylorus, after an interval of several hours. Vomiting may be absent 
 in carcinoma of the fundus or lesser curvature. In stenosis of the pylorus 
 from carcinoma or other cause food is retained in the stomach, which grad- 
 ually undergoes dilatation, and is vomited after some hours or a day or 
 two — retention vomiting. The vomiting of large quantities of fluid after 
 considerable intervals of time is characteristic of gastric dilatation. Vom- 
 iting does not occur in gastrectasis of slight degree and in the extreme 
 cases, by reason of the impaired contractility of the wall of the stomach, 
 may wholly cease — an unfavorable symptom. Vomiting is a common 
 symptom of cholera morbus and cholera Asiatica and may be regarded 
 as the direct result of the inflammation of the gastric mucous membrane. 
 It usually occurs after the diarrhoea, sometimes coincidently with it, 
 scarcely ever before it. Vomiting in cholera is usually unattended with 
 effort, is frequently repeated, and ceases or alternates with singultus in 
 the algid stage. The vomitus is liquid and sometimes resembles the rice- 
 water discharges. This symptom occurs in hyperacidity and hypersecre- 
 tion and may be so persistent in cases of gastric hyperesthesia that all 
 food is promptly ejected. External pressure upon the stomach, as in peri- 
 carditis, ascites, or pericardial effusion, may cause vomiting. 
 
 2. Vomiting from Central Irritation of the Vagus. — To this cause must 
 be referred the vomiting which is so common in diseases of the brain 
 and its membranes — anaemia, hypersemia, concussion, sea-sickness, Meni- 
 ere's disease, tumor, abscess, and various forms of meningitis. So-called 
 cerebral vomiting is characterized by the absence of nausea, its sudden- 
 ness, projectile character, and the fact that it occurs independently of the 
 taking of food. Vomiting of gastric origin is mostly followed by a sense 
 of relief, while that dependent upon cerebral causes usually aggravates 
 the symptoms, probably because of the mechanical disturbance produced 
 by the act. Vomiting is an early and important symptom in tuberculous 
 meningitis and cerebrospinal fever. 
 
 3. Reflex Vomiting. — The following forms are to be considered: 
 
 (a) Vomiting produced by irritation — tickling — of the base of the 
 tongue or the fauces. Nausea, gagging, and vomiting are frequently caused 
 by the unskilful use of the tongue-depressor or the laryngoscopic mirror. 
 In the older medicine tickling the throat with a feather often played the 
 part of an emetic. When the mucous membrane is abnormally sensitive, 
 as in neurotic individuals or as the result of acute or chronic catarrh, very 
 slight irritation of the fauces may cause vomiting. The vomiting of acute 
 angina, that caused by efforts to dislodge tough masses of mucus, that 
 attendant upon hypertrophy of the tonsils, and the vomiting which accom- 
 panies the paroxysm of pertussis must be referred to this group. The 
 irritation caused by partially detached diphtheritic membrane sometimes 
 
SYMPTOMS AND SIGNS: VOMITING. 507 
 
 produces efforts at vomiting which may have the favorable effect of wholly- 
 detaching the mass. 
 
 The vomiting of consumption is sometimes an early symptom; it i-s 
 more common and troublesome in the later stages. It is frequently caused 
 by severe paroxysms of coughing. The vomiting of phthisis may be cerebral, 
 as from tuberculous meningitis, of which it is often an early and ominous 
 symptom; due to pressure upon the vagi by caseous glands; the mani- 
 festation of irritation of the peripheral distribution of the vagi; pulmonary, 
 pharyngeal, or gastric or mechanical, as from the succussion of urgent cough. 
 
 (b) The vomiting of peritonitis, which is frequently severe and intract- 
 able and always significant. 
 
 (c) That caused by irritation of the intestinal mucous membrane. In 
 some instances the action of purgatives is preceded by vomiting. This 
 symptom may attend intestinal parasites, colic, enterocolitis, appendicitis, 
 strangulated hernia, intussusception, torsion, and ileus. In any form of 
 obstruction of the bowel retroperistalsis may occur with vomiting, which 
 gradually becomes stercoraceous. 
 
 (d) That attendant upon visceral diseases of various kinds, as biliary 
 and renal colic, acute nephritis, pyelitis, cystitis, Addison's disease, and 
 acute yellow atrophy of the liver. 
 
 (e) That which is symptomatic of disorders of the female sexual organs. 
 Vomiting is common in anomalies of menstruation, uterine displacements, 
 and pelvic exudates and new growths. 
 
 Of especial importance is the vomiting of pregnancy. A little mucus 
 is thrown up with great nausea and effort when the patient rises in the 
 morning. Commonly the vomiting does not recur until the next day; 
 sometimes it is persistent and distressing. Usually it ceases after a few 
 months. The pernicious form has been spoken of above. 
 
 (f) So-called nervous vomiting. The most typical form is that which 
 occurs in hysteria. It depends upon the hyperaesthesia and abnormal 
 motility of the stomach and upon quantitative and qualitative changes 
 in the gastric secretions. The vomitus is often of large amount and con- 
 sists of thin fluid. It is a notable fact that notwithstanding persistent 
 vomiting hysterical patients lose little weight. 
 
 The persistent vomiting of Leyden is a form of nervous vomiting 
 characterized by recurrent attacks coming on without obvious cause or as 
 the result of slight indigestion, fatigue, or worry, and lasting from some 
 hours to several days. The vomiting is copious and continuous; the 
 abdomen retracted and the bowels constipated. There is epigastric pain 
 together with intense headache and intolerance of light and sound. The 
 pulse is frequent but there is no fever. 
 
 The gastric crises which occur in tabes, and less frequently in acute 
 myelitis, disseminated sclerosis and paresis, are to be mentioned in this 
 connection. Together with distressing pain there is vomiting, usually 
 persistent and uncontrollable. Food is at first ejected, then a colorless 
 .stringy fluid and in some cases a blood-stained mucus. There is vertigo 
 and a sense of sinking at the pit of the stomach. The attack lasts from 
 some hours to two or three days. In the intervals there may be no signs 
 of gastric disease. 
 
508 MEDICAL DIAGNOSIS. 
 
 The vomiting of migraine belongs to the category of nervous vomiting. 
 
 (g) Reflex vomiting may accompany diseases of the heart, especially 
 myocarditis, fatty heart and angina pectoris. Vomiting due to cardiac 
 disease is not infrequently associated with hiccough, 
 
 4. Direct Irritation of the Centre for Vomiting. — This form is less 
 frequent. It arises under the following conditions: 
 
 (a) The action of certain emetics of which apomorphine is a type. 
 
 (b) The action of toxic substances in the blood, as for example those 
 present in nephritis both acute and chronic. Vomiting is an early and 
 ominous symptom in many cases of uraemia and not rarely the first indica- 
 tion of contracted kidneys. Ursemic vomiting occurs independently of 
 the taking of food and is often severe and distressing. 
 
 (c) As an early manifestation of the toxaemia of the acute infections, 
 especially in childhood. Vomiting may attend the stage of onset in scarlet 
 fever, croupous pneumonia, diphtheria, and other acute febrile diseases. 
 
 The Gross Characteristics of the Vomitus. 
 
 The general appearance, quantity, odor, and reaction of the ejected 
 material is of importance in diagnosis. These peculiarities depend largely 
 upon the presence or absence of food in the stomach, its character and the 
 time that has elapsed since its ingestion. When vomiting occurs directly 
 after eating, the food shows little or no change. On the other hand, if some 
 hours have elapsed there may be no trace of food. In retention vomiting, 
 however, it is not uncommon to find particles of food taken at a previous 
 meal or upon a preceding day. In sucklings the appearance of the vomited 
 milk is of importance. The presence of curds indicates the presence of 
 the milk-curdling ferment; an uncurdled milk some time after nursing 
 shows the absence of normal gastric secretions and may be the sign of 
 grave changes in the stomach. 
 
 Aside from the presence of food the following peculiarities are of 
 diagnostic importance: 
 
 Watery Fluid and Mucus. — The vomitus may consist of a watery 
 fluid containing little or no mucus. This is common in the morning in 
 chronic gastric catarrh, especially that of alcoholic subjects. If the reac- 
 tion is alkaline, the fluid usually consists of saliva that has been swallowed 
 during the night and the vomitus consists largely of saliva in cases in which 
 prolonged nausea has preceded the act of vomiting. If the reaction be 
 acid the vomitus consists either of gastric fluid in excess — hypersecretion — 
 or of food and mucus that have undergone acid fermentation. More com- 
 monly the vomited matter contains mucus and in some cases of acute and 
 chronic gastric catarrh it is composed of masses of tenacious mucus. The 
 vomiting of hyperacid gastric juice occurs in peptic ulcer of the stomach 
 and in neurotic conditions, as migraine, hysteria, the gastric crises of tabes 
 and exophthalmic goitre. In some cases of cholera the contents of the 
 intestines are forced into the stomach and vomited, presenting the usual 
 characters of the rice-water discharges and containing the comma bacilli 
 of Koch. 
 
SYMPTOMS AND SIGNS: VOMITING. 509 
 
 Bilious Vomiting. — Bile is very commonly present, imparting a green 
 or yellow color. It occurs after repeated or violent vomiting and is of no 
 great diagnostic importance. The early vomiting of considerable amounts 
 of bile occurs in some cases of peritonitis and intestinal obstruction. 
 
 Vomiting of Blood — Haematemesis — Qastrorrliagia. — This symptom 
 occurs in a number of morbid conditions and is of great importance in 
 diagnosis. The differential diagnosis between haematemesis and haemopty- 
 sis has already been considered. The vomited blood may be bright 
 red and fluid — a sign that it has remained in the stomach but a brief 
 period; or it may consist of reddish or reddish-brown clots that have 
 formed during a longer period; or finally it may present the appearance of 
 cofTee grounds, indicating that it has been subjected to the action of the 
 gastric juice for a sufficient time to undergo partial digestion, with altera- 
 tion of the haemoglobin and destruction of the erythrocytes. In some 
 instances a superficial resemblance to recent blood may be due to the pres- 
 ence of red wine or various reddish-colored fruits or the jellies or preserves 
 made from them; in others altered blood — "coffee grounds" — may be 
 suggested by the presence in the vomitus of coffee, cocoa, minute frag- 
 ments of boiled or over-cooked meat, and certain drugs, as the prepara- 
 tions of bismuth and iron. As a rule these uncertainties may be settled 
 by close inspection and an inquiry into the facts, but there are rare cases 
 in which a chemical, microscopic, or spectroscopic examination may be 
 necessary to determine the question. Bright red blood is usually vomited 
 in considerable amounts and in association with small clots, while the 
 altered blood which resembles coffee grounds is mixed with the vomitus 
 in small quantities. 
 
 Not all blood ejected from the stomach is derived from the vessels 
 of that organ. Blood is frequently swallowed and then vomited. In 
 haemoptysis a portion of the blood coughed up is often swallowed. Blood 
 readily finds its way from the nasal chambers or pharynx into the stomach, 
 especially when the patient is in the recumbent posture. The blood oozing 
 from the bitten tongue in the epileptic paroxysm may be swallowed during 
 the postepileptic stupor or the vomited blood may be derived from the 
 vessels of the oesophagus. Blood may be swallowed by malingerers, who 
 sometimes suck it from a wound made for the purpose in the mouth or 
 upon the hand or forearm. In very rare instances infants vomit milk 
 stained with blood derived from a fissured or ulcerated nipple. 
 
 Bleeding from the stomach occurs under various conditions, of which 
 the following are important: 
 
 1. Circulatory Derangements. — Portal obstruction and the re- 
 sulting passive hyperaemia of the gastric mucosa lead to haematemesis. 
 This symptom therefore occurs in cirrhosis of the liver, in malignant and 
 other tumors of the porta, and in adhesive pylophlebitis. Copious haematem- 
 esis, occurring in hepatic cirrhosis and terminating fatally, occasionally 
 arises from rupture of the veins of an enlarged oesophageal plexus. The 
 visceral congestions resulting from cardiac mural and valvular disease 
 tend also to hemorrhage. Haematemesis is occasionally encountered in 
 massive enlargement of the spleen. 
 
510 MEDICAL DIAGNOSIS. 
 
 2. H-EMic Disorders. — Hsematemesis is frequently symptomatic 
 of the grave anaemias. It occurs in pernicious anaemia, leukaemia, haemo- 
 philia, scurvy, and purpura haemorrhagica, in profound jaundice, and after 
 extensive burns. It has been observed in phosphorus poisoning and in 
 acute yellow atrophy of the hver. 
 
 3. The I>rFECTiONS. — Vomiting of blood is of occasional occurrence 
 in epidemic influenza, tj^phus, relapsing fever, and dengue. It is a promi- 
 nent event in some forms of pernicious malarial fever, malignant variola, 
 and yellow fever. In the last the vomiting of altered blood — hlack vomit — 
 is characteristic. 
 
 4. Traumatis:^!. — Contusions of the epigastric region, as from a blow 
 or kick, crushing, and other injuries, are sometimes followed by the vomit- 
 ing of blood. The vomitus is often blood-streaked after prolonged or 
 violent vomiting. Under this caption must be placed the direct injury to 
 the gastric mucosa caused by the corrosive poisons, caustic alkahes, the 
 mineral acids, arsenic, and the like. 
 
 5. Specific Axatomical Lesioxs of the Stomach. — Cancer is a, 
 common cause of gastric hemorrhage. The blood is usually dark and 
 altered and rarely profuse, slight oozing, either continuous or frequently 
 repeated, being the rule. Even more common is gastric ulcer. The blood 
 is usuallj^ abundant, bright red, and fluid. Copious haematemesis is sug- 
 gestive of ulcer. Free and even lethal bleeding may occur in superficial 
 erosions, aifd profuse hemorrhage may come from the erosions of the gas- 
 tric mucous membrane which sometimes occur after operations upon the 
 abdomen and especially in cases in which the omentum has been wounded. 
 In gastric and duodenal ulcer, especially the latter, the blood may not be 
 vomited but is passed in the stools. Miliary aneurism is a rare cause of 
 gastric hemorrhage. It is not common for death to result directly from 
 the bleeding, wliich is often repeated from time to time. Anaemia, fre- 
 quently of high grade, results. Syncope with or without general convul- 
 sions maj' immediately follow profuse hemorrhage. Hemiplegia and 
 amaurosis, which may be followed by optic atrophy, are rare sequelae. 
 
 6. Certain Xervous Affections. — Haematemesis is an occasional 
 event in hysteria,, and cases of gastric bleeding have occurred in apparently 
 healthy individuals in the absence of any local or general condition to 
 account for it, and without a second appearance. This symptom is 
 comparatively infrequent in epilepsy and in general paresis, and Schiff 
 and others have directed attention to it as a rare phenomenon in local 
 cerebral disease. In the newborn it may occur as an isolated symptom 
 or with hemorrhage from other mucous tracts. 
 
 7. Fatal gastric hemorrhage may result from the rupture of 
 an aneurism of the aorta or its branches into the stomach. Under such 
 circumstances death may occur from blood loss without vomiting, the 
 stomach being distended with blood. 
 
 Fecal or Stercoraceous Vomiting. — This is a significant symptom in 
 acute obstruction of the bowel. The anatomical condition may be strangu- 
 lation, intussusception, volvulus, or abnormal contents. The last of these — 
 fecal masses, biliary calculi, and enteroliths — may cause acute obstruction 
 by the sudden shifting of their position. Vomiting comes on early and is 
 
SYMPTOMS AND SIGNS: DEFECATION. 511 
 
 persistent. The vomitus consists at first of the contents of the stomach, then 
 of bile or bile-stained material, and finally of a brownish or blackish fluid of 
 a distinctly fecal odor. In this fluid masses of fecal matter ma}^ be present. 
 Retroperistalsis not rarely occurs in peritonitis and in some eases stercora- 
 ceous vomiting is the result of a gastro-intestinal fistula. Chronic intesti- 
 nal obstruction is not usually attended by this form of vomiting even 
 when of high grade. In the terminal paroxysms, however, it may occur. 
 
 Purulent vomiting is rare and not usually dependent upon primary 
 disease of the stomach; it may, however, occur in phlegmonous gastritis. 
 The more common cause is perforative ulceration of the wall of the stomach 
 in hepatic abscess or empyema. 
 
 Parasites in the Vomit. — The Ascaris lumbricoides occupies the upper 
 part of the small intestine. From this position it finds its way readily 
 into the stomach and is often ejected with the vomit. In rare cases the 
 segments of taenia are present in vomited matter and the booklets and 
 fragments of echinococcus cysts have been observed; so also trichinellae and 
 the larvse of insects. 
 
 The quantity of the vomitus depends upon the volume of the stomach 
 contents and the intensity of the act of vomiting. Very significant is the 
 retention vomiting of pyloric obstruction and the large fluid vomiting in 
 gastrectasis from other causes. 
 
 The Odor. — The vomit is commonly sour-smelling and often intensely 
 acid. It is ammoniacal in ursemia and fecal in acute intestinal obstruction 
 and in some cases of peritonitis. The odor of the vomitus in poisoning is 
 sometimes of great diagnostic importance. Striking examples are carbolic 
 acid, the garlicky smell in phosphorus poisoning, that of bitter almonds 
 in poisoning by hydrocyanic acid and nitrobenzole, the vinegar-like odor 
 in poisoning by acetic acid, and the smell of ammonia; less significant 
 are the odors of alcohol or laudanum. 
 
 The reaction is commonly acid. Where there is an excess of saliva, 
 bile, or blood the reaction is alkaline. In hypersecretion the reaction is 
 intensely acid and patients speak of their teeth being set on edge by the 
 taste. In uraemia the reaction may be alkaline. 
 
 The taste of the vomitus is, according to the patients, commonly sour 
 and when bile is present, bitter. Blood imparts a salty or sweetish taste. 
 
 DEFECATION. 
 
 Significance of Abnormal Defecation. — The indigestible parts of 
 the food, with debris, bacterial masses, and secretions from the intestinal 
 tract, pass slowly through the large intestine and reach the sigmoid flexure, 
 in which they accumulate. As the semisolid or solid material passes into 
 the rectum it stimulates the sensory nerves of that part of the intestine, 
 giving rise to a peculiar sensation and desire to defecate. This material 
 is retained in the rectum by the two sphincter muscles, the internal of 
 which is a band of the circular layer of involuntary muscles of the rectum. 
 Upon the passage of fecal matter into the rectum the internal sphincter 
 passes into a condition of tonic contraction, the relaxation of which marks 
 the beginning of the act of defecation. The internal sphincter is composed 
 
512 MEDICAL DIAGNOSIS. 
 
 of unstriped muscular fibre and receives its innervation from the sympa- 
 thetic system and from the sacrospinal nerves. The external sphincter 
 ani is made up of striated muscular fibres and is to a large extent under the 
 control of the will. Upon intense rectal stimulus the voluntary control 
 is overcome and this sphincter is also relaxed. The act of defecation is 
 therefore in part voluntary and in part involuntary. The voluntary factor 
 is made up of the inhibition of the external sphincter and the simultaneous 
 action of the abdominal muscles, the diaphragm being contracted and the 
 glottis closed. Pressure is thus exerted upon the abdominal and pelvic 
 viscera, with the result that the contents of the descending colon and sig- 
 moid flexure are forced into the rectum. This pressure is augmented by 
 deep inspiration and fixation of the respiratory muscles. The involun- 
 tary factor consists in the contraction of the muscles of the rectum, in 
 particular the circular layer, and the relaxation of the internal sphincter, 
 in part the result of reflex stimulation from the lumbar cord and in 
 part from automatic peristaltic movements. The action of defecation is 
 essentially, however, an involuntary reflex, as is well seen in infants and 
 in soporose states. 
 
 Under normal conditions the bowels move once a day, the act being, 
 like sleep and the taking of food, of diurnal rhythmical recurrence. There 
 are healthy individuals, however, in whom the rhythm is not diurnal, but 
 at intervals of two or three days or exceptionally longer, and in whom efforts 
 to bring about the diurnal movement by means of purgatives are followed 
 by manifest derangements of health. The normal periodical movement of 
 the bowels is maintained by the observation of a fixed hour for this function, 
 and various derangements, especially constipation, result from the neglect 
 of this rule. 
 
 It is important for the physician to inform himself as to the periodicity, 
 frequency, and character of the bowel movements and in certain cases to 
 inspect the stools. Departures from the normal in respect of this function 
 relate to constipation, diarrhoea, tenesmus, painful defecation, fecal incon- 
 tinence, and the character of the discharges. 
 
 CONSTIPATION. 
 
 Constipation — costiveness — infrequent or difficult evacuation of faeces; 
 retention of faeces. This condition is of great and varied diagnostic impor- 
 tance. Its cause may be constitutional or intestinal. Very often several 
 causes are associated. 
 
 The more important constitutional or general causes of constipation are: 
 
 1. Personal peculiarity: Sluggishness of the bowels is frequently an 
 hereditary and family tendency. It is far more common in persons of dark 
 than in those of fair comjDlexion and is especially associated with the traits 
 that constitute the bilious temperament. 
 
 2. Unhygienic habits, as want of proper exercise, the failure to observe 
 regularity in the hour of defecation or to devote to the act sufficient time, 
 irregularity or undue haste in meals and the eating of unwholesome food or 
 of excessive quantities of food. From this point of view constipation is 
 primarily not a condition of the body but a condition of the mind. On the 
 
SYMPTOMS AND SIGNS: CONSTIPATION. 513 
 
 other hand too Httle food or a diet consisting largely of proteid substances 
 or which contains a minimum of undigested residuum tends to constipa- 
 tion. It is obvious that a sufficient bulk of residual material is required to 
 form the fecal mass and excite peristalsis. The insufficient ingestion of 
 fluid tends also to cause constipation. 
 
 3. Dehydration of the tissues by profuse and frequently repeated 
 sweating, diuresis from the action of drugs, the polyuria of diabetes insip- 
 idus and mellitus, or repeated hemorrhages is attended by constipation. 
 
 4. The febrile infections, except those in which diarrhoea is an especial 
 symptomj are characterized by a tendency to constipation. Even in 
 these affections constipation very often gives way in the later course of the 
 attack to diarrhoea, and the latter may assume the guise of a critical dis- 
 charge, as sometimes occurs in croupous pneumonia. 
 
 5. The habitual use of purgative drugs is a fruitful cause of constipation. 
 
 6. Constipation is a very common condition in the anaemias, especially 
 in chlorosis, and is often a troublesome symptom in neurasthenia and 
 hysteria. 
 
 7. General asthenia and cachectic states are very often attended by 
 constipation; so also conditions in which the abdominal muscles are over- 
 distended and their contraction hampered, as obesity, ascites, large ab- 
 dominal tumors, and pregnancy. 
 
 Among local causes of constipation the following are to be considered: 
 
 1. Alterations in the quantity and quality of the intestinal juices and 
 a deficiency of bile or pancreatic secretion. Under these circumstances 
 constipation may be an important symptom of fever, chronic diseases of the 
 gastro-intestinal tract, and diseases of the liver, biliary passages, and the 
 pancreas. It is to be borne in mind that the normal presence of bile in the 
 intestine constitutes a powerful stimulus to peristalsis. 
 
 2. The motor mechanism of the intestine may be at fault. The defect 
 may be nervous, as in organic disease of the nervous system — myelitis, 
 meningitis, and tetanus, or functional, as in hysteria and neurasthenia. 
 Or the defective intestinal innervation may be the manifestation of a general 
 asthenia. The arrest of peristalsis and tympanites in severe enteritis, 
 some cases of appendicitis and in peritonitis and acute pancreatitis are 
 primarily due to derangements of the nerve-supply to the bowel, second- 
 arily to paresis of its muscular wall. Chronic intestinal catarrh and portal 
 congestion from hepatic or cardiac disease are often attended by constipation 
 due to impaired nutrition of the muscular coat of the bowel. Atonj^ of the 
 colon and especially of the muscular wall of the sigmoid flexure is an im- 
 portant local cause of constipation. Dilatation of the colon is attended 
 with constipation. Large collections of scybala may accumulate in the 
 sigmoid flexure and be felt upon palpation of the abdomen. Constipation 
 due to this cause is encountered in neurasthenia and hysterical persons 
 and is common in the insane. It occurs also in bed-ridden and elderly 
 individuals. 
 
 3. Local disease of the rectum or anus or of adjacent organs is a com- 
 mon cause of constipation. When such conditions, as is usuall}- the case, 
 render the act of defecation painful, the patient is apt to postpone it unduly 
 and there is very often reflex spasm of the sphincters which renders it for 
 
 33 
 
514 MEDICAL DIAGNOSIS. 
 
 the time impossible. Under these circumstances fecal material accumu- 
 lates in the rectum and sigmoid flexure of the colon and greatly adds to the 
 discomfort of the patient. Such local disorders are inflamed hemorrhoids, 
 anal fissure, irritable ulcer, prostatic inflammation or abscess, and a tender 
 retroverted uterus or prolapsed ovary. 
 
 4. ConstijDation is observed in malignant disease of the oesophagus, 
 pylorus and bowel and in other chronic conditions in which a minimum of 
 food is ingested or that which is taken cannot pass onward or is persistently 
 vomited. 
 
 5. This symptom may be due to a contracted condition of the bowel — 
 so-called spasmodic constipation. The narrowing of the bowel may be the 
 result of ulcerative colitis or dysentery; a manifestation of hysteria or of 
 the atrophic processes of advanced life. The bowel may be in a condition 
 of permanent contraction or spasm at one part and dilated elsewhere. 
 The stools are small and sausage-shaped or they may be liquid with hard 
 scybalous masses varying in size from a marble to a walnut. Spasmodic 
 constipation occurs in the pelvic disorders of women and in chronic lead 
 poisoning. 
 
 6. Strangulated hernia is attended with acute constipation. Laxatives 
 are without effect. There are vomiting and abdominal distention. Pain is 
 usually present. Similar symptoms attend volvulus and other forms of 
 intra-abdominal strangulation. In intussusception, the sausage-like tumor, 
 tenesmus, bloody mucus, and a relaxed anus are significant. Acute reten- 
 tion of faeces with the signs of obstruction demands very careful and sys- 
 tematic examination of the abdomen, a digital exploration of the rectum, 
 and examination of the hernial rings. 
 
 Chronic intestinal obstruction may be due to foreign bodies, very large 
 gall-stones, tumors within the gut or exerting pressure upon its wall, masses 
 of scybala, and strictures of every kind. The constipation is gradually 
 developed; occasionally interrupted by watery diarrhoea and sometimes 
 by attacks with the symptoms of acute obstruction. Three facts are of 
 great importance: First, that fluid fecal matter may work its way past 
 the obstruction from time to time; second, that the dilated and con- 
 gested bowel below the obstruction may discharge a thin fecal-stained 
 mucus; and, finally, that both these conditions are occasionally mistaken 
 for diarrhoea. 
 
 7. Constipation in infants. Constipation in the new-born may be 
 due to imperforate anus or a congenital stricture. In some cases it results 
 from dilatation of the colon, which may attain enormous dimensions, or it 
 may be due to simple atony of the large bowel. 
 
 Constipation in sucklings and especially in bottle-fed infants is often 
 due to deficiency of the intestinal secretions, the faeces being dry and hard. 
 This condition has been attributed to insufficient water and a deficiency of 
 fat in the food. In older children attention to the hour of defecation and 
 regular habits are as important as in later Hfe. Constipation often results 
 from enterocolitis, from impairment of the contractility of the muscular 
 wall and derangement of the normal secretions. Acute constipation is 
 frequently symptomatic of mechanical obstruction by foreign bodies, hard- 
 ened and impacted faeces, twists, and intussusception. 
 
SYMPTOMS AND SIGNS: DIARRHCEA. 515 
 
 Associated Symptoms. — Sensations of pressure and distention in the 
 abdomen, uneasiness and pain, especially in the course of the transverse 
 colon, loss of appetite, a furred tongue, a disagreeable taste, and uneasy 
 precordial sensations are common. Patients very often attribute these 
 phenomena to derangements of the liver or stomach. An effectual purge 
 is of diagnostic importance. The results very often show that these symp- 
 toms are due to constipation. 
 
 Of especial importance are the morbid phenomena in the distribution 
 of the hemorrhoidal veins that result from constipation. Pain before and 
 after defecation, protrusion of the dilated blood-vessels, bleeding and the 
 discharge of stringy mucus are common. Paroxysmal neuralgic pain 
 referred to the coccyx or the suprapubic region or to the inner aspect of the 
 thigh are less frequent. Gastric catarrh with manifold symptoms and 
 occasional implication of the duodenum and bile passages also occurs. In 
 some instances catarrhal jaundice results and in chronic constipation a 
 slight icteric discoloration of the conjunctiva is often seen. 
 
 Constitutional derangements are not less common. They consist 
 of headache, vertigo, depression of spirits, disinclination for work, and 
 debility. Actual neurasthenia with the most varied and depressing symp- 
 toms may result from obstinate and prolonged constipation. It is on the 
 other hand important to bear in mind that nervous disease is a frequent 
 cause of constipation and that the most troublesome constipation may 
 occur, for example, in hysteria. Under such circumstances a vicious circuit 
 is established, the constipation aggravating and intensifying the symptoms 
 of the disease of which it is itself a symptom. 
 
 The duration of constipation is largely dependent upon its cause. 
 Simple forms resulting from neglect of hygienic laws may last three or four 
 days; more troublesome cases may resist usual treatment for weeks. 
 Stubborn constipation with severe symptoms suggests mechanical obstruc- 
 tion of the bowel. The passage of flatus is a favorable sign. In tran- 
 sient constipation the indican in the urine is not increased; in chronic 
 obstruction it is apt to be increased. 
 
 DIARRHCEA. 
 
 Abnormal frequency and diminished consistence of the stools. This 
 symptom is of the most varied significance. It results from increased 
 peristalsis, particularly when the large intestine is affected, from diminished 
 absorption of the contents of the bowel, from an excess of fluid in the bowel 
 either in consequence of hypersecretion of the substances entering into the 
 formation of the succus entericiis or of transudation of serum, and in rare 
 instances from direct abnormal communication between the stomach or 
 small intestine and the colon. 
 
 Diarrhoea may therefore be symptomatic of deranged innervation of 
 the bowel, mechanical or chemical irritation by its contents, the action of 
 toxic substances, either in the bowel or in the blood-current, as in poisoning, 
 autointoxication or the infections, defective nutrition or circulatory de- 
 rangements of the wall of the bowel, or local disease, as ulceration or new 
 growths in the bowel itself or adjacent organs. 
 
516 MEDICAL DIAGNOSIS. 
 
 Diarrhoea may be primary or secondary or it may be acute or chronic. 
 The number of stools varies from 3 or 4 to 30 or more in the course of 
 twenty-four hours, their consistency from semisohd to watery, and their 
 color, odor, and other physical characters vary within equally wide ranges 
 (see pp. 518, 519). 
 
 The recognition of the following forms of diarrhoea is essential: 
 
 1. Nervous diarrhoea. This symptom may denote mere increase of 
 peristalsis in the absence of any lesion of the intestine, in hysteria, 
 neurasthenia, the intestinal crises of tabes, exophthalmic goitre, Addison's 
 disease, movable kidney, in the first dentition, and in emotional disturb- 
 ances in healthy individuals of neurotic temperament. The character- 
 istic manifestations of the underlying nervous disorder are of diagnostic 
 importance. The stools are of gruel-like consistence and contain noth- 
 ing of pathological importance. The attack begins abruptly and is of 
 short duration. 
 
 2. Irritation of the intestine secondary to constitutional conditions. 
 Diarrhoea may occur in uraemia, hyperpyrexia, extensive burns, sudden 
 chilling of the surface, certain infectious conditions, as malaria and septi- 
 caemia, and as the result of the subcutaneous injection of such purgatives 
 as podophyllin or magnesium sulphate. The urine should be examined 
 in every case. 
 
 3. Increased intestinal fluid. The stools are abnormally frequent 
 and watery after the administration of the hydragogue cathartics and in 
 cholera nostras and Asiatica. 
 
 4. Irritation of the intestine by various ingesta, or pathological 
 bowel contents. Abnormal peristalsis and looseness of the bowels is caused 
 by indigestion, intestinal parasites, local fecal accumulations, poisoning 
 by the salts of mercury, antimony, arsenic, copper and. so forth, the pur- 
 gative drugs, organic acids derived from the food or from its decomposition 
 in the stomach or intestines, mushroom poisoning, unaccustomed or im- 
 proper articles of diet, bulky or indigestible food, large quantities of cold 
 food or drink, or the administration of enemata. In all cases the anamnesis 
 and physical examination are of diagnostic importance. 
 
 5. Abnormal irritability of the bowel. Diarrhoea may be the mani- 
 festation of an idiosyncrasy, and is symptomatic of catarrhal inflammation 
 and of ulcerative processes of all kinds, from superficial erosions from 
 mechanical irritation to the specific ulcerations of enteric fever, dysentery, 
 or tuberculosis. 
 
 6. Impaired absorption. Diarrhoea is not rarely due to extensive 
 ulceration or atrophy of the mucosa, amyloid disease, and portal congestion. 
 The diarrhoea of tabes mesenterica is largely due to failure in fat absorption. 
 
 7. Mucous colitis — membranous enterocolitis. This syndrome is 
 characterized by paroxysmal diarrhoea accompanied by severe hypogastric 
 or left ihac pain and the discharge of masses of mucus or membranous casts 
 of the bowel. The attack occurs at varying intervals, and the disease is 
 observed in neurotic persons, usually women. 
 
 8. Under very unusual circumstances a fistulous communication 
 between the stomach or upper part of the intestine and the colon — 
 usually its transverse part — may be the cause of diarrhoea with stools 
 
SYMPTOMS AND SIGNS: TENESMUS. 517 
 
 containing undigested food and conversely of the eructation of intestinal 
 gas or the vomiting of fecal material. 
 
 9. Lienteric diarrhoea. Normal stools are usually more or less homo- 
 geneous. They frequently, however, contain such indigestible articles as 
 seeds, husks, the capsules of berries, fruit pits, and the like. The diarrhoea 
 caused by excessive quantities of food or the ingestion of food that cannot 
 be digested, or which attends forms of enteritis that interfere with normal 
 digestion is characterized by the presence in the stools of undigested or 
 only partially digested particles of food and is known as lienteric. Frag- 
 ments of food may be recognized in the stools shortly after it has been 
 eaten. This form of diarrhoea may be acute, as after errors in diet or acute 
 enteritis, or chronic, as in chronic intestinal catarrh. 
 
 Associated Symptoms. — Diarrhoea is often unattended by any symp- 
 tom other than the frequent recurrence of the peculiar sensation which 
 invites to the closet. Usually there is uneasiness in the abdomen, which 
 may be associated with local or general pain, often colicky, and tenderness. 
 Severe diarrhoea is attended with thirst, appetite is impaired, and there is 
 debility proportionate to the urgency of the intestinal symptoms. Local 
 or general tympanitic distention of the bowel also occurs. Vomiting is 
 common, especially in the diarrhoeas of infancy. The loss of fluid not only 
 causes thirst, but may give rise to f aintness, collapse, cramps of the muscles, 
 subnormal temperature, diminution of urine even to suppression and albu- 
 minuria. The acidity of the urine is increased and it gives the reaction 
 for indican. 
 
 TENESMUS. 
 
 Rectal tenesmus — painful, ineffectual, and usually long-continued 
 straining at stool. This symptom occurs alone, but it is very often asso- 
 ciated with vesical tenesmus, partly because of the anatomical relationship 
 of the organs, partly because of the common action of some of the causes. 
 It consists of spasm of the musculature concerned in defecation and micturi- 
 tion. The violent spasmodic contractions are repeated at short intervals 
 and are attended with such distress that in extreme cases children fall into 
 general convulsions and adults faint. The discharge consists of small 
 amounts of stringy, sometimes bloody, mucus from the anus or a few drops 
 of urine as the case may be. Rectal tenesmus occurs in the course of irri- 
 tating lesions of the rectum and anus, whether these be primary or second- 
 ary. It is a symptom of intussusception, dysentery, polypus, adenoma and 
 malignant tumors of the rectum and sigmoid flexure, proctitis and peri- 
 proctitis, hydatid cysts of the pelvis, mechanical injuries to the rectum by 
 foreign bodies, or in exceptional cases in highly neurotic persons it may 
 follow digital or instrumental examination. Tenesmus is not a common 
 symptom of hemorrhoids or fissure of the anus. It may be caused by im- 
 pacted faeces, masses of round worms, the presence of foreign bodies, and, in 
 connection with vesical tenesmus, by stone in the bladder. It is also a 
 distressing symptom in acute inflammation and abscess of the prostate 
 gland. Tenesmus is easily recognized. Its cause may be obscure. When 
 it is violent or persistent a digital or proctoscopic examination should be 
 made under local or general anaesthesia. 
 
518 MEDICAL DIAGNOSIS. 
 
 PAINFUL DEFECATION. 
 
 The pain may be such as to cause fecal impaction from voluntary 
 postponement of the act. The passage of a large hard fecal mass is attended 
 with pain under normal conditions. In proctitis, inflamed hemorrhoids, 
 fissure of the anus, prolapsus, irritable ulcer, and malignant disease of the 
 rectum pain upon defecation is a conspicuous symptom. It is usually pres- 
 ent in inflammation of the prostate and is sometimes symptomatic of acute 
 inflammatory affections of the pelvic organs in women. 
 
 FECAL INCONTINENCE. 
 
 This symptom may be due to local causes, as laceration of the peri- 
 neum involving the anal sphincters, surgical over-stretching, and malig- 
 nant or syphilitic disease of the rectum; more commonly it is due to 
 general conditions which profoundly affect the nervous system, as coma 
 from any cause, myelitis and other diseases of the spinal cord, grave chorea, 
 convulsive diseases, as epilepsy, tetanus, and strychnine poisoning, and 
 certain severe infections, as enteric fever, dysentery, cholera Asiatica and 
 nostras and cholera infantum. Involuntary discharges very often precede 
 dissolution. The unclean habits of some forms of insanity cannot be 
 placed in this group of symptoms. 
 
 THE GROSS PHYSICAL CHARACTERS OF THE 
 
 STOOLS. 
 
 The fecal discharges of the healthy adult are of brownish color, cyhn- 
 drical form, soft soHd or semisolid consistency, 150 to 200 grammes in 
 daily quantity, usually neutral or faintly alkaline in reaction when passed, 
 and emit the offensive characteristic odor. 
 
 Abnormal variations in these respects constitute diagnostic criteria 
 of some importance. The macroscopic examination is too often neglected. 
 Laboratory investigation is sometimes necessary (see p. 217). 
 
 1. The color, which is due to the presence of altered bile pigment, 
 principally hydrobilirubin, may be modified by certain articles of diet or by 
 drugs. It may be rendered black by .blueberries or by iron, manganese, 
 or bismuth; yellow by rhubarb, colchicum, senna, or santonin; green 
 by spinach or calomel or by certain chromatogenous bacteria. In 
 suckhngs and others who subsist upon an exclusive diet of milk the fseces 
 are golden yellow or whitish; in those who hve largely on meat they are 
 brownish-black in color, and this is also the case with fecal matter long 
 retained in the bowel as in obstruction. In jaundice due to obstruction 
 they are grayish or putty-colored. When they are increased and 
 thinned by intestinal hypersecretion or transudation their color is usually 
 light brown or yellowish; when very watery, as in cholera, they are of a 
 dirty-gray color — rice-water discharges. The presence of blood colors the 
 stools red or black: red when the blood comes in considerable quantity 
 under active peristalsis from the ileum as in enteric fever, or when it comes 
 from the lower bowel as in dysentery, or from the rectum as in piles; black 
 
SYMPTOMS AND SIGNS: STOOLS. 519 
 
 when it is derived from the upper regions of the gastro-intestinal tract as in 
 peptic ulcer, or when it is thoroughly mixed with the stool. 
 
 2. The form is lost in diarrhoea, the discharge being gruel-like or watery 
 in consistence. The normal C3dindrical or sausage-shaped stool may be 
 modified in various conditions of the lower bowel. In prolapsus ani or 
 stricture of the rectum, more rarely in intussusception, the diameter may 
 be much narrowed — pipe-stem stools; in stricture or cancer of the rectum 
 or the pressure of an enlarged prostate gland or abscess or in large pelvic 
 tumors impinging upon the rectum the stools may be flattened or ribbon- 
 shaped; in constipation from any cause, but especially that which results 
 from atony and distention of the colon, they often assume the form of 
 irregular, round, hard masses like the dung of sheep — scybala. 
 
 3. The consistence is increased in constipation. The fluid is resorbed 
 and the mass tends to become hard and dry. The consistence is diminished 
 in diarrhoea. Serous stools are observed in cholera Asiatica, cholera nostras 
 and cholera infantum; in poisoning by antimony, arsenic, and mushrooms. 
 Small, dribbling, serous stools occur in some cases of intestinal obstruction 
 from cancer and other causes. Serous stools contain little or no fecal 
 matter. 
 
 4. The quantity varies greatly. It is diminished when the diet is 
 concentrated or consists principally of meat; increased when the diet is 
 largely made up of starchy and vegetable foods. The amount voided at 
 one effort depends of course upon the frequency of the act and may attain 
 in cases of constipation as much as 1000 grammes. The quantity in 
 diarrhoea is increased by the hypersecretion of the intestinal glands and 
 the transudation of serum from the blood-vessels. In starvation the total 
 quantity may not exceed 90 grammes a day. 
 
 5. The reaction and odor. The reaction is faintly acid in nursing 
 infants and alkaline in some forms of intestinal fermentation. The acidity 
 is due to carbohydrate fermentation or the presence of fatty acids. The 
 reaction is of no great diagnostic value. Depending upon the amount of 
 proteid decomposition and the putrefactive bacteria present, the odor of 
 the stools is more or less offensive. Diets that allow much proteid resi- 
 due to reach the large bowel usually give foul-smelling movements. A 
 milk diet in health gives an almost odorless stool. Indol and skatol, 
 ■derivatives of proteid decomposition, are mainly responsible for the 
 characteristic fecal odor. 
 
 The odor in healthy infants is sour and unlike the fecal odor of the 
 stools of adults. The so-called " albuminous decomposition" in the faces 
 of infants and the resulting putrid odor are due to the decomposition of 
 the undigested proteid of the milk in the large intestine. In cholera 
 infantum it is sometimes faintly musty, sometimes suggestive of the 
 washings of meat. In the absence of bile the stools have a peculiarly 
 offensive odor. 
 
 The presence of milk curds in the stools of infants indicates an error 
 in the quantity or quality of the food and is one of the earlier symptoms of 
 enterocolitis; the presence of curds in the stools of adults who are taking 
 a milk diet, as in enteric fever, constitutes an indication for the use of 
 alkalies in connection with the milk or a reduction in its quantity. 
 
520 MEDICAL DIAGNOSIS. 
 
 Abnormal Substances in the Stools. — In lienteric diarrhoea the stools 
 contain undigested particles of food. Other abnormal substances are by 
 no means uncommon and may be of great diagnostic importance. Among 
 these are mucus, blood, pus, fat in excess, gall-stones, intestinal sand, con- 
 cretions, intestinal parasites, sloughs, and foreign bodies that have been 
 swallowed. 
 
 Mucus. — Minute particles of mucus may be observed upon the surface 
 of the formed stools in health. Large quantities covering the stools or 
 expelled with them in masses indicate a deranged secretion of the mucous 
 glands of the colon or rectum. Masses of mucus that may be shaken out 
 in water into sheets or tubular casts of the intestine are diagnostic of 
 membranous colitis. Mucus intimately admixed with the fecal matter may 
 come from the small bowel. Mucus in the stools is symptomatic of mechan- 
 ical or pathological irritation of the bowel and is seen in such conditions as 
 impacted faeces, foreign bodies, intestinal parasitism, new growths, intus- 
 susception, and all forms of dysentery, enterocolitis, and proctitis. 
 
 Blood. — A distinction is made between "hemorrhage from the bowel" 
 — the discharge of red blood unmixed with fecal matter — and ''melaena" — 
 blood intimately mixed with the faeces and occurring in the form of " tarry" 
 or pitch-like masses, usually of semisolid consistence and glistening appear- 
 ance. The difference consists chiefly in the time the blood remains in the 
 intestine and therefore in general terms indicates the portion of the gut 
 into which it has been discharged. If, as in the case of peptic ulcer of the 
 stomach or duodenum, the hemorrhage has been high up in the intestinal 
 tract, the blood remains a considerable time in the bowel, and is subjected 
 to mechanical conditions by which it is incorporated with the fecal contents, 
 undergoing at the same time a sort of digestion by which its physical 
 characters are much changed. If, on the other hand, the blood is poured 
 out lower down in the bowel and under the influence of an active peri- 
 stalsis is speedily evacuated, it maintains the characteristic appearance of 
 fresh blood, often bright red and sometimes commingled with recently 
 formed clots. The appearance of the evacuations therefore is of diagnostic 
 importance in this respect. On the other hand, a copious hemorrhage from 
 the ileum, as in enteric fever with active peristaltic movement, usually 
 shows itself in the discharge from the bowel of bright red blood, while a 
 slow oozing from the colon with tardy onward propulsion in the bowel 
 may appear in the stools as ''coffee-ground" or even as "tarry" material. 
 
 Blood is frequently present in the stools in quantities so minute that 
 its presence can onl}^ be detected by chemical examination — occult blood 
 (Part II, p. 220). 
 
 The more important causes of blood in the stools are portal congestion, 
 ulceration of the intestinal mucosa, neoplasmata and in particular malig- 
 nant disease of the gut, intestinal parasites, embolism of the mesenteric 
 arteries, intussusception, and traumatism. 
 
 1. Portal Congestion. — This occurs in cirrhosis of the liver, portal 
 thrombosis, and dilatation of the hemorrhoidal veins — piles. The diagnosis 
 of hemorrhoids rests upon the habitual or occasional discharge of bright 
 red blood wath the stools, the appearance and habits of the patient, and the 
 signs obtained upon inspection or a digital examination. 
 
SYMPTOMS AXD SIGNS: STOOLS. 521 
 
 2. Ulcerative Processes in the Bowel. — Intestinal hemorrhage occur- 
 ring in the course of an attack of enteric fever is of positive diagnostic im- 
 portance. It means the erosion of an arterial twig in an ulcer. If the 
 hemorrhage is profuse it may at once lead to collapse with the associated 
 sj^mptoms of internal hemorrhage; if slight, the stools may be tarry or 
 contain slight amounts of red blood without symptoms. In either case the 
 appearance of blood in the stools is of prognostic importance, since it 
 denotes deep ulceration which may be followed in a day or two by a more 
 abundant blood loss or by pei'foration. Other ulcerative processes that 
 lead to the appearance of blood in the stools are dysentery, syphilis, and 
 tuberculosis. Under these conditions the blood appears in the form of 
 streaks or stripes upon the stools or admixed with mucus or pus. Dysen- 
 teric stools may present the appearance of meat washings or of masses of 
 blood commingled with liquid fecal matter. The mere presence of blood 
 in the stools does not under ordinary circumstances justify a diagnosis. 
 The anamnesis and a systematic investigation of the present condition of 
 the patient are necessary. 
 
 3. Malignant Disease of the Bowel. — Blood in the stools is in many 
 cases the first symptom to attract the attention of the patient to carcinoma. 
 The stools are not, however,^ characteristic, and a systematic examination, 
 which may reveal the presence of an abdominal tumor, is necessary. General 
 failure of health, secondary anaemia, signs of intestinal obstruction, and 
 cachectic phenomena are confirmative. 
 
 4. Intestinal Parasites. — The Ankylostomum duodenale is a common 
 cause of persistent melsena among workers in the soil and miners. Grie- 
 singer first drew attention to this parasite as the cause of Egyptian chlorosis. 
 The worms infest the upper portion of the small intestine and are very 
 abundant in the jejunum. The diagnosis rests upon the prevalence of the 
 condition among workmen in tunnels, brick-yards, excavations., and the 
 like, and the presence of the ova in the stools. 
 
 5. Embolism, of the Mesenteric Arteries — Infarction of the Bowel. — 
 In consequence of valvular lesions of the heart, but with no great frequency, 
 emboHsm of this distribution may occur. It is probable that the occlu- 
 sion of small vessels produces no symptoms of importance and that the cir- 
 culation may be reestablished. If the superior mesenteric artery is occluded, 
 or a large branch, the symptoms are sudden collapse, violent colicky pains, 
 signs of peritonitis, and thin, blood-tinged stools or hemorrhage from 
 the bowel. 
 
 6. Intussusception. — This affection occurs in infancy and childhood. 
 Bloody stools are of diagnostic importance since they occur in at least 
 sixty per cent, of the cases either spontaneously or after the administration 
 of an enema. The blood is commonly mixed with mucus. Associated 
 symptoms are tenesmus and a sausage-shaped tumor in the line of the colon. 
 Vomiting and tympany are less common. 
 
 7. Traumatism. — Injuries of the bowel as a cause of bloody stools 
 commonly involve the rectum, and when they do not penetrate the peri- 
 toneum may be readily overlooked. The abundant venous supply favors 
 free bleeding, and, since the blood is often retained in consequence of 
 spasm of the sphincters, the signs for a time may be simply those of inter- 
 
522 MEDICAL DIAGNOSIS. 
 
 nal hemorrhage and collapse. The anamnesis is of importance and a digi- 
 tal examination reveals the actual condition. The presence of foreign 
 bodies may be thus discovered in children, idiots, and insane persons. 
 
 8. Constitutional Conditions. — Intestinal hemorrhage is occasionally 
 symptomatic of leukaemia, hemophilia, purpura hsemorrhagica, and scurv}'. 
 This symptom is, however, so closely associated with the general phenomena 
 of those diseases that it is of secondary importance in their diagnosis. 
 
 9, Miscellaneous Causes of Intestinal Hemorrhage. — Bloody stools are 
 of infrequent occurrence in consequence of the rupture of an aneurism of 
 the abdominal aorta into the bowel, jaundice, acute yellow atrophy of 
 the Hver, phosphorus poisoning, yellow fever, pernicious malarial fever, 
 and very rarely septicaemia. 
 
 Concealed Hemorrhage. — Concealed intestinal hemorrhage may 
 occur in the foregoing conditions. If small it may give rise to no symp- 
 toms, although prolonged and unsuspected bleeding may be the cause of 
 profound secondary anaemia with its usual symptoms; if large the hemor- 
 rhage, while not for a time appearing at the anus, occasions the symptoms 
 of internal hemorrhage, — namely, collapse, restlessness, air-hunger, pallor, 
 a pinched face, cold extremities, a rapid, weak, even imperceptible pulse, 
 urgent thirst, and a tendency to syncope. 
 
 Pus. — In small quantities pus may be present in the stools in dysen- 
 tery, enteritis, colitis, proctitis, and in ulceration of the colon or rectum 
 due to malignant growths or syphilis. Small amounts of pus may be present 
 in the stools in profuse leucorrhoea or urethritis; but under these cir- 
 cumstances its appearance is without diagnostic importance, since the 
 associated symptoms will fully explain it. In large quantities and usually 
 in single discharges, or in large quantities at irregular intervals, pus may 
 be present in the stools in consequence of the rupture of an abscess, or 
 the establishment of a fistulous communication between a purulent collec- 
 tion and the bowel. Such abscesses are usually periproctic, pelvic, or 
 perinephric; sometimes appendicular; and, less commonly, in the gall- 
 bladder, hepatic or infradiaphragmatic. 
 
 Fatty Stools. — The appearance of the discharges is greasy and glisten- 
 ing. An excess of neutral fat is present in obstructive jaundice and in vari- 
 ous forms of pancreatic disease. Fatty diarrhoea, with icterus and sugar in 
 the urine, has been observed in acute suppurative pancreatitis. Over- 
 feeding and indigestion in infants may be the cause of fatty stools, and 
 Biedert has described a fat diarrhoea in which the percentage of fat is 
 enormously increased. The condition is primary in which the ingestion of 
 fat is excessive and which may be corrected by modification of the food, 
 and secondary which is due to catarrhal inflammation of the intestine or 
 disease of the pancreas. 
 
 Gallstones — Biliary Calculi. — Gall-stones have been found to be 
 present in Europeans in from 5 to 10 per cent. In the East gall-stones are 
 said to be extremely rare. Gall-stones vary in size from a concretion barely 
 perceptible to the naked eye to the size of a walnut or larger. They are 
 spherical, oval, or angular, the surface being smooth, mammillated, or 
 faceted. When large they are commonly single; when small they may 
 number hundreds. In a case of mine the small stones numbered by actual 
 
SYMPTOMS AND SIGNS: STOOLS. 523 
 
 count 300. When extremely small they are described as biliary or 
 intestinal sand. Their color varies from a whitish-gray to dark yellow 
 or brown, sometimes black. Their consistence is usually firm, but they 
 are often friable, being crushed by pressure between the thumb and 
 forefinger, wdth crystalline fracture. In some cases, however, they are 
 extremely hard. 
 
 Intestinal Sand. — Small brown or green calculi, spherical or irregular 
 in shape and of rough surface, and varying in size from grains of sand to 
 small shot, are sometimes present in the stools in considerable quantity. 
 This material may or may not be preceded by attacks of colic. These 
 calculi are of variable composition. They consist in some instances of 
 inorganic salts, as calcium carbonates and phosphates, magnesia and iron, 
 together with organic matter, bacteria and urobilin. Cholesterin is not 
 present. A nucleus may sometimes be demonstrated. It is formed of a 
 grain of quartz sand or a minute particle of the case of a fruit seed. In 
 other very rare cases calcium sulphate has been the chief constituent. 
 This form of intestinal sand occurs in intestinal neuroses of the secre- 
 tory type. 
 
 Pancreatic Calculi. — Kinnicutt has recently studied the subject of the 
 discharge of pancreatic calculi during life. The decisive evidence of pan- 
 creatic lithiasis consists in the presence of the characteristic concretions in 
 the stools. They are composed chiefly of calcium carbonate. They are 
 extremely rare — a fact due in part to the small size of the calculi and 
 their friability, so that they may be voided in fragments or particles not 
 easily recognized. 
 
 Intestinal Concretions — Enteroliths. — Concretions of various kinds 
 occur in the stools. They are comparatively rare. The following forms are 
 encountered: 
 
 1. Hard round fecal masses — scybala. They occur in chronic consti- 
 pation, especially in elderly people, and in cases in which after abdom- 
 inal operation partial obstruction of the bowel occurs as the result of 
 adhesions. 
 
 2. Enteroliths. Earthy concretions are sometimes observed in the 
 stools. They are largely composed of magnesium phosphate, the alkaline 
 carbonates, and organic matter. They are hard, dense, and made up of con- 
 centric layers about a chalky nucleus that very often surrounds a foreign 
 body. They are usually oval and are very rarely, when several are present, 
 faceted, and occur in early and middle life. 
 
 3. Concretions composed of vegetable fibres or of hairs that have 
 been swallowed are light, porous, usually of irregular shape, and frequently 
 show upon section open spaces or cavities in their substance. They are 
 sometimes found in the caecum and may attain the size of an orange. They 
 are sometimes made up of the insufficientl)^ ground husks of oats or the 
 capsules of small fruits. They occur more commonlj' in early life and in 
 females. 
 
 4. Certain drugs and similar substances, as chaik, magnesia, bismuth, 
 and shellac, when taken in undue quantities, form intestinal concretions, 
 which appear in the stools and reveal their true nature only upon chemical 
 examination. 
 
524 MEDICAL DIAGNOSIS. 
 
 Intestinal concretions when of small size occasion no characteristic 
 symptoms. When of larger size they may be arrested at a point of stenosis 
 of the bowel; or upon the occurrence of contraction and oedematous swell- 
 ing, and they may then give rise to the symptoms of intestinal obstruction. 
 Large concretions are usually arrested in the caecum, in the colon, or in the 
 ampullae of the rectum, less frequently above the ileocsecal valve. Obstruc- 
 tion in the upper part of the small intestine may be caused by concretions 
 formed in the stomach or by gall-stones. 
 
 Intestinal Parasites. — The Ascaris lumbricoides — round worm — and 
 its ova are frequently found in the stools of children and young adults. 
 Oxyuris vermicularis — thread-worm, pin-worm — a very common para- 
 site, infests the rectum and colon; intestinal cestodes — tape-worms — 
 of which the common forms are the Tcenia saginata or mediocanellata, 
 the Tcenia solium, and the Bothriocephalus latus, show themselves in the 
 stools in the form of segments or proglottides, and their ova are usually 
 present in great numbers (see p. 858). 
 
 Sloughs. — The invaginated portion of the bowel in intussusception 
 may slough off en masse and be discharged from the bowel. Polypi of the 
 intestine or rectum may also become detached by sloughing and be dis- 
 charged with the faeces. Masses of necrotic tissue may become separated 
 from malignant or other ulcerating growths in the intestine and be dis- 
 charged with the faeces. They are to be distinguished from fragments of 
 undigested meat. The intestinal sloughs in enteric fever may sometimes 
 be recognized in the stools and are often mistaken for milk curds. 
 
 Foreign Bodies. — The most diverse articles may be found in the stools, 
 having been swallowed by accident or design. Small articles of all kinds 
 may be swallowed by children, idiots, and dements; bird-seed and the like 
 by hysterical persons; coins, rings, and gems by professional thieves; 
 nails, glass, fragments of china, etc., by fakirs, and such articles as artificial 
 teeth or even a clinical thermometer by unconscious persons, and all of 
 these things have been voided with the stools. 
 
 XL 
 
 THE SKIN; PHYSIOLOGICAL AND PATHOLOGICAL CHANGES 
 
 AND THEIR SIGNIFICANCE; (EDEMA; SUPERFICIAL 
 
 VASCULAR CHANGES; NAILS; HAIR. 
 
 THE SKIN. 
 
 Changes in the skin not only occur as manifestations of cutaneous affec- 
 tioris but they also constitute important diagnostic signs of diseases of the 
 internal organs. The methods of examination are inspection and palpation. 
 The clothing is to be so arranged as to facilitate the necessary investigation. 
 
 The condition of the skin varies within physiological limits at different 
 periods of life and in the sexes. In infancy and childhood the skin is dis- 
 tensible, elastic, full, of fine texture, and faint rosy color. The capillary 
 
SYMPTOMS AND SIGNS: SKIX. 525 
 
 circulation is active, pressure causes local pallor which quickly disappears. 
 In middle life the skin is finer, softer, and shows more physiological tur- 
 gescence in women than in men. With advancing age the skin loses its 
 elasticity. Partly for this reason, partly on account of the diminished 
 amount of subcutaneous fat; and partly because of the larger development 
 of connective tissue, wrinkles develop. The skin in elderly persons is paler 
 and more abundantly pigmented than in the young. The skin of very fat 
 persons frequently has a disagreeable unctuous feel; it may be firm and 
 tense or loose and flabby. The skin is sometimes flabby and relaxed in 
 fat babies who are not properly fed. In the cachexias of infancy, such 
 as that of congenital syphilis or marasmus, the skin is muddy, loose, 
 inelastic, and sometimes wrinkled like that of old men. 
 
 Color. — The normal tint of the skin, the so-called flesh color, depends 
 upon the blood showing through the upper layers of the integument and 
 the epidermis. The changes in color are quantitative and qualitative, 
 physiological and pathological. Quantitative changes consist in varying 
 degrees of color, from blushing to blanching. They are best observed upon 
 the face. On the other hand qualitative changes in the color of the skin 
 are studied best upon other parts of the body where the flesh color is paler 
 and less variable. The mucous membrane of the conjunctiva, lips, and 
 mouth must always be examined. 
 
 Variations in the flesh color depend upon the amount of blood in the 
 cutaneous vessels, the amount of the blood-coloring matter, that is, the 
 percentage of haemoglobin, and the thickness of the tissues covering the 
 vessels. It is obvious that since any of these factors may vary in degree 
 the quantitative changes in the color of the skin do not always have the 
 same diagnostic significance. 
 
 Pallor. — The skin may be pale by reason of general or local deficiency 
 of blood, that is to say, in consequence of anaemia or of contraction of the 
 capillaries. The various forms of anaemia have in common a diminution 
 in the coloring matter of the blood — oligochromcemia. Pallor, even 
 when persistent, does not in all instances justify a diagnosis of anaemia, 
 since there are many habitually pale persons whose blood shows upon 
 examination a practically normal constitution both as regards the erythro- 
 cytes and the haemoglobin. Many such individuals present no symptoms 
 of constitutional or local disease and regard themselves as in perfect health. 
 The pallor in these cases is due to an abnormality of the skin, either an 
 unusual opaqueness of the superficial layers or a deficiency in the blood 
 supply or a combination of these two conditions. If the conjunctival 
 mucous membrane and that of the lips and mouth present a normal 
 appearance, the pallor is due to the first of these anomalies. In the major- 
 ity of instances, however, marked and persistent pallor is associated with 
 other evidences of more or less decided derangement of health. Even 
 under these circumstances in a certain proportion of the cases the blood 
 shows no abnormal change. Two explanations of the pallor may be ad- 
 vanced: first, a reduction in the total quantity of the blood, which never- 
 theless retains its constituent elements in normal proportion; second, that 
 the skin, particularly of the face, as the result of abnormal conditions of 
 the circulation receives a diminished amount of blood. Since we have no 
 
526 MEDICAL DIAGNOSIS. 
 
 clinical method of determining the total volume of blood in the body, the 
 first of these explanations is purely theoretical and without practical 
 apphcation. The second explanation finds support in the constant presence 
 of other symptoms indicative of circulatory derangements, among which 
 are a small and feeble pulse, general asthenia, over-filling of the super- 
 ficial veins, shght cyanosis, faintness, and dizziness. The part played by 
 enfeeblement of the heart's action on the one hand and by vasomotor 
 derangements on the other cannot in all cases be satisfactorily determined. 
 Lowered blood-pressure does not necessarily induce pallor, since in this 
 condition the lumen of the peripheral vessels is widened and their contents 
 increased; but diminished blood-pressure gives rise to pallor when the chief 
 factor in its production is cardiac weakness and the vasomotor tonus is 
 maintained. Increased vasomotor tonus may be the cause of pallor of 
 high intensity. Among the more important diseases in which pallor occurs 
 as the result of a diminution in the blood supply to the vessels of the face, 
 without marked changes in the composition of the blood, are gastro-intes- 
 tinal affections, both acute and chronic, diseases of the heart, pulmonary 
 consumption and other chronic infections — conditions ultimately leading 
 to anaemia which in many cases is profound. To this group the transient 
 pallor of intense emotion, nausea, vertigo, syncope and collapse, in which 
 vasomotor derangements and cardiac failure are associated in the produc- 
 tion of lowered blood-pressure, bears a close etiological relation. Indoor 
 occupations, dependence upon artificial light, mining and the like cause 
 permanent pallor. 
 
 Clinically the following points are important: (a) Transient pallor is 
 caused by cardiac failure, as in nausea, rigors, syncope, and shock, or by 
 vasomotor spasm, as in the intense emotions of fright, fear, anger, in pain, 
 epilepsy, and other paroxysmal neuroses. Transient pallor is frequently 
 but not always followed by more or less intense flushing. 
 
 (b) Sudden and more persistent pallor accompanies hemorrhage, acute 
 poisoning, and overwhelming infection — the malignant forms. Associated 
 with other symptoms of collapse it is a striking and suggestive sign of 
 internal hemorrhage, such as may occur in a large pulmonary cavitj^; as the 
 result of the rupture of an aortic aneurism into the pericardial, pleural, or 
 peritoneal sac; in consequence of a perforating lesion in peptic ulcer or 
 enteric fever; in rupture of the sac in ectopic gestation, or in concealed 
 uterine hemorrhage before or after parturition. Small hemorrhages do not 
 necessarily cause pallor except when frequently repeated or persistent. 
 
 (c) Gradually developing pallor is a symptom of almost all serious 
 acute and chronic diseases. In the acute infections it usually passes olT with 
 convalescence; in the chronic diseases its intensity is very often a measure 
 of the gravity of the case. It is sometimes seen in altered conditions of 
 living,, as in the case of young immigrant girls who during the process of 
 acclimatization not rarely permanently lose their color without changes in 
 the blood or other signs of ill health. The pallor in persistent slight hemor- 
 rhage, such as occurs in neglected hemorrhoids, is very often intense, as 
 is the pallor of chlorosis, pernicious anaemia, and the secondary anaemias 
 which occur in chronic poisoning, chronic infections, chronic suppurative 
 processes, nephritis, and valvular and mural disease of the heart. 
 
SYMPTOMS AND SIGNS: SKIN. 527 
 
 Redness. — The change in the color of the face is quantitative. 
 It is due to two causes: first, thinness and transparency of the super- 
 ficial layers of the integument; second, increased fulness of the capillaries 
 — hypercemia. An abnormally high haemoglobin percentage cannot of 
 itself be regarded as a cause of the increased redness of the complexion. 
 Whether or not a true plethora occurs is undecided. Physiologically we 
 find the redness of the skin of the face greater in persons who live in the 
 open air and are especially exposed to sunlight and the wind, which increase 
 the cutaneous circulation. An abnormally transparent skin is the evident 
 cause of the blooming redness of the cheeks occasionally seen in chlorotic 
 g\v\&~ chlorosis JJorida. Very characteristic in these cases is the contrast 
 between the color of the skin and the blue-white conjunctivae. Among the 
 physiological causes of intensification of the color of the skin are powerful 
 muscular effort and the action of external heat, as in hot baths, friction of 
 the surface, exposure to fire or heat, radiation from other sources, sunburn 
 and the like. Extreme cold also produces cutaneous hyper aemia of the face. 
 Habitual exposure to heat or cold, especially when associated with moist- 
 ure, causes the chronic purplish hyperaemia of the hands frequently seen 
 in washerwomen and bartenders who are otherwise in good health. 
 
 Transient reddening of the skin dependent upon vasomotor influences 
 occurs under certain psychic influences, especially embarrassment and 
 shame. The reddening of the skin in such cases is not restricted to the face 
 but may spread over the throat and even the upper part of the chest. 
 In these latter situations it may be irregularly distributed in such a way 
 as to give rise to errors in diagnosis as regards actual disease of the skin, as 
 erythema, especially in sensitive persons, and particularly in women when 
 it is necessary to remove the clothing from the upper part of the body for 
 the purposes of examination. One-sided flushing of the face occurs in 
 certain forms of migraine and in affections of the cervical sympathetic. 
 
 In addition to the foregoing facts the flushing incident to pyrexia, 
 certain infections, and the action of drugs deserves attention. 
 
 Fever. — The flushing of the skin in acute febrile conditions is very 
 characteristic. It is often attended with slight turgescence and sometimes 
 with a tendency to sweat. The flush of fever is usually widely distrib- 
 uted over the surface. It is -more marked in young persons of fair com- 
 plexion than in older persons and in brunettes. It has a tendency to 
 localize itself iji the cheeks where it is sometimes circumscribed or unilateral, 
 as in croupous pneumonia. Circumscribed flushing of the cheeks in persons 
 otherwise pallid is a very striking phenomenon in the hectic fever of ad- 
 vanced phthisis. In children the fever flush is sometimes so intense as to 
 suggest the existence of erythema or scarlatina. In rare instances pyrexia! 
 flushing occurs during the first week of enteric fever, especially in young 
 persons of fair skin, and may be so marked as to give rise for a time to 
 uncertainty in diganosis. 
 
 Tache cerebrate is a cutaneous vasomotor phenomenon which occurs 
 especially in young persons in acute febrile affections, as cerebrospinal 
 meningitis, enteric fever, and influenza, in certain functional nervous 
 affections, as hysteria, neurasthenia, and sometimes in organic diseases of 
 the brain and spinal cord. It is called forth by slight irritation of the 
 
528 MEDICAL DIAGNOSIS. 
 
 sldn, such as is produced by tapping with the finger-tip or drawing the 
 finger or a pencil smartly over the surface. A white spot or line appears 
 and is shortly followed by a bright red discoloration which persists for 
 several minutes. 
 
 Dermatographism. — This condition, closely allied to the above, is not 
 uncommon in neurotic persons, particularly in those who suffer from 
 urticaria. Wheals may be produced by drawing the finger or a pencil 
 somewhat firmly over the surface. Letters and other symbols may be 
 brought out in a conspicuous manner and often last for several hours. 
 The itching characteristic of urticaria does not occur. 
 
 Drugs. — The reddening of the face caused by alcohol is of diagnostic 
 importance. The expression "flushed with wine" is significant. The 
 slightly turgid, purplish-red face of chronic alcoholism, with its distended 
 venules, is unfortunately too familiar. The flush produced by the nitrites 
 and especially by the inhalation of amyl nitrite resembles the blushing due 
 to psychic causes. Flushing of the face follows the administration of cer- 
 tain poisons, as belladonna, opium, and hyoscyamus. 
 
 Cyanosis. — This term is used to designate the dusky blue or purplish 
 color of the skin dependent upon the circulation in the capillaries of blood 
 abnormally rich in carbon dioxide and poor in oxygen. Cyanosis may be 
 general or local. 
 
 General cyanosis is dependent upon two factors, first, deficient oxy- 
 genation of the blood in the lungs, as the result of which the arterial blood 
 reaches the capillaries containing less oxygen and darker in color than 
 normal; second, stasis in the venous radicals, resulting in an accumulation 
 of venous blood in the capillaries of the skin, which by the retardation in 
 its flow becomes richer in carbon dioxide and darker in color. Since the 
 conditions are universal it may be assumed that the bluish discoloration 
 exists not only in the skin but in all the tissues of the body. Only in its 
 intense forms does cyanosis show itself in all parts of the surface. When 
 slight it appears in certain parts only and here it is in all instances more 
 intense than elsewhere. These regions are the face and especially the cheeks, 
 the- tip of the nose, the ears, lips and mucous surface of the mouth, which 
 have an especially abundant capillary circulation and translucent integu- 
 ment. Other points in which cyanosis is especially manifest are the hands 
 and feet, particularly the terminal phalanges and the nails, in which blood 
 stasis is favored by their remoteness from the heart. 
 
 The primary derangement may be respiratory or circulatory. The 
 interdependence of the respiration and circulation is such, however, that 
 when cyanosis is marked there is general derangement of both in varying 
 proportion. 
 
 Respiratory. — All conditions which interfere with the respiratory 
 function and thus reduce the aeration of the blood may give rise to cyanosis. 
 They are comprised in four groups: 
 
 (a) All affections which interfere with the access of air to the vesicular 
 structure of the lungs, such as retropharyngeal abscess, stenosis of the larynx 
 caused by pseudomembranous exudate, as in diphtheria, oedema of the 
 glottis, pseudocroup, laryngismus stridulus, pertussis, paralysis of the 
 abductor muscles, tumors of the larynx, foreign bodies in the pharynx. 
 
SYMPTOMS AND SIGNS: SKIN. 529 
 
 larynx, trachea, or bronchi, all forms of stenosis of the trachea, including 
 thyroid enlargement and other deep-seated tumors of the neck, as well 
 as mediastinal and other intrathoracic tumors, strangulation, bronchitis, 
 and bronchial asthma. 
 
 (b) Affections which interfere with the action of the respiratory 
 muscles, including paralysis and atrophy such as occur in bulbar paralysis 
 and peripheral neuritis; spasmodic contraction of these muscles, as that of 
 tetanus or epilepsy; painful affections, such as myalgia, pleurisy, and 
 peritonitis, in which the respiratory movements are instinctively restrained; 
 finally, the action of drugs, such as opium and its preparations, which 
 depress the respiratory centres. 
 
 (c) Affections which diminish the respiratory surface. This group 
 includes all forms of consolidation of the lung, croupous pneumonia, bron- 
 chopneumonia, including tuberculous infiltration and acute miliary tuber- 
 culosis, atelectasis, pressure atelectasis from pleural and pericardial effusion 
 and pneumothorax. In emphysema the respiratory surface is not only 
 greatly restricted but its functional integrity is also impaired. 
 
 (d) Conditions in which respiratory movements are restricted and the 
 respiratory surface is circumscribed by subdiaphragmatic pressure, as in 
 hydramnion, enormous ascites, enlargement of the liver or spleen, or mas- 
 sive abdominal or pelvic tumors. 
 
 Under all these circumstances the aeration of the blood in the lungs is 
 diminished and venous stasis is favored by the reduction in the normal 
 aspiratory function of the lungs which constitutes an important factor in 
 the circulation. The absence of cyanosis, often observed in advanced 
 phthisis with extensive destruction of the lungs and very limited respira- 
 tory movement, is probably due to the great wasting of the body and corre- 
 sponding reduction in the mass of the blood, to the aeration of which the 
 remaining limited vesicular structure is still adequate. Cyanosis is marked 
 in proportion as the interference with respiration is rapid and urgent. In 
 chronic cases the interference may reach a high grade without causing cyan- 
 osis during repose, though this symptom may apjoear upon slight exertion. 
 
 Circulatory. — Primary derangements of circulation which cause cyan- 
 osis may be referred to the following groups: 
 
 (a) Affections of the heart and arteries, including valvular disease with 
 impaired or ruptured compensation, myocarditis, acute dilatation of the 
 heart, the cardiovascular changes which occur in chronic nephritis, other 
 forms of arteriosclerosis, and pericarditis. 
 
 In persistent foramen ovale and other forms of cardiac malformation, 
 such as stenosis of the pulmonar}^ arterj^, there is very often marked and 
 continuous cyanosis. To this condition of congenital cyanosis the term 
 morbus cceruleus has been given. In acquired conditions permitting an 
 admixture of venous blood with arterial within the vessels, as in the very 
 rare cases of aneurism of the aorta communicating with the vena cava, 
 cyanosis is a suggestive symptom. 
 
 (b) Conditions affecting the pulmonary circulation. In disease of the 
 mitral valve, both stenosis and insufficiency, even when compensation is 
 good there may very often be seen, especially upon exertion, a slight degree 
 of cyanosis. This is a manifestation of the changes caused by the habitual 
 
 34 
 
530 MEDICAL DIAGNOSIS. 
 
 increase of tension in the pulmonary circuit and the bronchial catarrh 
 which to some degree is almost constantly present. Though having its 
 primary cause in the circulatory apparatus this form of cyanosis must be 
 looked upon as respiratory. 
 
 Pressure upon the pulmonary artery or veins by massive pericardial 
 effusion, mediastinal tumor or aneurism is a very common cause of cyanosis. 
 The circulation of the pulmonary capillaries is obstructed in many of the 
 conditions involving the respiratory apparatus which give rise to cyanosis. 
 Blueness of the general surface, very often intense, is produced by 
 overdoses of certain of the coal-tar derivatives, especially acetanilid, by 
 nitrobenzole, and by poisoning with illuminating gas. 
 
 Local cyanosis results from venous stasis, from compression of the 
 part or from venous thrombosis. Cyanosis of the head and neck or an upper 
 extremity may result from the pressure of a tumor or aneurism upon the 
 jugular, subclavian, innominate, or descending cava, the distribution of 
 the cyanosis corresponding with the point of pressure. Similar cyanosis of 
 one or both lower extremities may result from pressure involving iliac veins 
 or the ascending vena cava or from venous thrombosis. Local venous 
 thrombosis giving rise to cyanosis of an arm is sometimes seen in cancer 
 of the breast with secondary implication of the axillary glands. 
 
 Cyanosis, often of high grade, results from vasomotor derangements. 
 To this cause must be referred the cyanotic discoloration of the extremities 
 and ears which follows exposure to intense cold, the cyanosis of paralyzed 
 members, and the bluish discoloration of the hands which occurs in hyster- 
 ical and neurasthenic persons. In the latter group of cases the local cyanosis 
 is sometimes associated with oedema — the blue osdema of French authors- 
 Local cyanosis is seen in intense inflammation involving the skin. 
 The conditions which give rise to cyanosis, namely, retarded circula- 
 tion and reduced oxygenation, interfere with the local production of animal 
 heat. In cyanosis the skin and extremities show reduction of surface 
 temperature. 
 
 Jaundice — Icterus. 
 
 These terms are used to designate the peculiar pathological yellow 
 discoloration of the skin, mucous membranes, and fluids of the body caused 
 by the circulation in the blood of bile pigment. The change is qualitative. 
 There are two forms, obstructive and toxsemic. 
 
 Obstructive Jaundice. — This is the more common form. The dis- 
 charge of bile into the intestine is interfered with wholly or in pai't by 
 stenosis or closure of the bile passages. As a result there is resorption of 
 the bile, the pigments of which discolor the tissues in shades varying from 
 light yellow to a dark brownish-yellow or olive-green. The darker shades 
 of jaundice result either from change of the original bile pigments to darker 
 pigmentary bodies or from their excessive accumulation in the skin. The 
 more intense and darker forms of jaundice occur in protracted cases. In 
 permanent obstruction the color may be greenish-black or bronze — the 
 so-called black jaundice. 
 
 Among the more important causes of obstructive jaundice are catarrhal 
 inflammation of the mucous membrane of the duodenum or the common 
 
SYMPTOMS AND SIGNS: SKIN. 531 
 
 duct; gall-stones and parasites, as the round worm, in the ducts; stricture or 
 obliteration of the duct; tumors developing in the duct or exerting pressure 
 upon its orifice; external pressure upon the duct by tumors of the liver, 
 stomach, pancreas, kidney, or omentum, or by enlarged glands in the porta, 
 or in rare instances by aneurism or fecal accumulation. 
 
 The yellow discoloration is observed first and, when slight, only in 
 the conjunctivae and the mucous membrane of the mouth. Its presence 
 may be detected by pressure upon the mucous membrane of the everted 
 lip with a glass slide, thus expressing the blood and permitting the yellow 
 stain of the tissues to become apparent. It is sometimes distinct at certain 
 pale areas of the hard palate. The shghter grades of icterus cannot be 
 recognized in artificial light. Superficial resemblances to jaundice are seen 
 in the dirty yellow or muddy discoloration of the malarial and malignant 
 cachexias. In these conditions the absence of yellowness in the conjunc- 
 tival and oral mucous membranes is conclusive. The collections of yellow 
 subconjunctival fat occasionally seen in elderly persons are only in the 
 most remote way suggestive of jaundice. The yellow discoloration which 
 occurs in picric acid poisoning presents superficial resemblances to jaun- 
 dice. The absence of bile pigment in the urine is important. 
 
 Pruritus is a troublesome symptom. It is usually more marked in the 
 chronic cases. Lesions of the skin, the result of scratching, are not uncom- 
 mon. Sweating is common and may be locaHzed. Urticaria, furuncles, 
 lichen, xanthelasma, and other diseases of the skin occur. In some of the 
 chronic cases circumscribed patches of dilatation of the capillary vessels 
 and minute arteries — telangiectasis — develop in the skin of the face and 
 body and occasionally upon the mucous membranes. In protracted and 
 severe cases there may be hemorrhages into the skin, usually in the form 
 of purpuric spots upon the lower extremities, but sometimes as large 
 ecchymoses, and in some instances spontaneous bleeding from the mucous 
 membranes occurs. The blood in chronic jaundice coagulates very slowly — 
 ten to twelve minutes, instead of about four in the case of normal blood — 
 and troublesome and even fatal hemorrhage, usually in the form of uncon- 
 trollable capillary oozing, may follow operation or injury. The sweat is 
 bile-stained and discolors the clothing. The urine contains bile pigment 
 and may show the color reaction to Gmelin's test before the yellow tint 
 appears in the mucous membranes or the skin. The color varies from light 
 yellow with a greenish tinge to a deeply opaque black-green. In intense or 
 long-standing jaundice the urine commonly contains albumin and tube 
 casts which are bile-stained. Upon agitation the dark urine of jaundice is 
 frothy and is often popularly compared to porter. The sputa are not often 
 bile-stained, except when pneumonia is present. On the other hand the 
 saliva very rarely shows the yellow discoloration, which is likewise absent 
 in the tears and milk. 
 
 As no bile is discharged into the intestine the stools are of a pale drab 
 or clay color. They are usually pasty and very fetid. The absence of bile 
 in the faeces is of importance in the differential diagnosis between obstruc- 
 tive and toxsemic jaundice. Commonly there is constipation; occasionally 
 diarrhoea. The pulse, in obstructive jaundice especially, in recent cases is 
 usually slow and may fall to 30 or lower. The frequency of the respiration 
 
532 MEDICAL DIAGNOSIS. 
 
 is also diminished, in some instances to 10 or 8 per minute. The tem- 
 perature may be subnormal. These symptoms are attributed to the 
 action of the bihary salts, which undergo resorption together with the 
 bile pigment. They are not constant and when present not necessarily 
 unfavorable. 
 
 The patient is usually depressed and irritable. In severe cases melan- 
 cholia may develop. The liability to the occurrence of the condition called 
 cholsemia constitutes a serious danger in persistent jaundice. The patient 
 falls into the so-called typhoid state, with fever, rapid pulse, dry tongue, 
 and muttering dehrium. Convulsions and coma develop and rapidly prove 
 fatal. This group of symptoms resembles uraemia. They have been attrib- 
 uted to poisoning by cholesterin — cholestersemia. The toxic substances 
 have not been determined. 
 
 Toxasmic Jaundice. — The jaundice is associated with the presence of 
 various poisons in the blood which act directly upon the red blood-corpuscles 
 and in some cases upon the liver-cehs. Among these poisons are (a) snake 
 venom, phosphorus, arsenic, chloral hydrate, chloroform, and ether; (b) 
 toxins elaborated within the organism in the course of the specific infec- 
 tious diseases, as yellow fever, relapsing fever, malaria, pneumonia, enteric 
 fever, typhus, and scarlatina; (c) the toxins of septic conditions, pyaemia, 
 malignant endocarditis, acute yellow atrophy of the hver, Weil's disease, 
 and epidemic jaundice. The symptoms are generally less intense than in 
 obstructive jaundice. The discoloration of the skin is usually slight; 
 exceptionally, as in the case of acute yellow atrophy and malignant jaun- 
 dice, it is intense. The stools are colored with bile, sometimes deeply. 
 The urine may be dark from increase in the normal urinary pigments but 
 gives little or no reaction for bile pigment. Toxic jaundice of slight degree 
 frequently appears during the course of febrile affections and under other 
 circumstances and may be without unfavorable prognostic significance. 
 On the other hand in many cases the conditions in which this form of 
 jaundice occurs are attended with profound constitutional disturbance, 
 manifest in intense fever, delirium, suppression of urine, hemorrhages into 
 the skin and from mucous surfaces, convulsions and coma, and verj^ often 
 terminate in death. 
 
 The jaundice due to obstructive changes in the bile passages was 
 formerly spoken of as hepatogenous; toxaemic jaundice as hcematogenous. 
 Concerning the mode of origin of toxaemic jaundice there is much diversity 
 of opinion and the cases differ among themselves. In groups of cases there 
 is probable resorption of bile pigments from the liver as the result of patho- 
 logical processes involving the finer ducts or the hver parenchyma itself. 
 Some pathologists attribute the icterus, so common in pneumonia, to a 
 catarrh of the finer bile passages dependent upon venous stasis, while others 
 attribute it in part at least to the interference with the respiratory move- 
 ment of the diaphragm caused by the consohdation of the lung, and result- 
 ing in an accumulation in the smaller ducts of bile which undergoes resorp- 
 tion. The rapid course and profound disorganization of the liver in acute 
 atrophy and in phosphorus poisoning suggest the possibility that other 
 forms of grave toxaemic jaundice may be due to as yet unknown paren- 
 chymatous changes in the Hver. On the other hand most of the poisons 
 
SYMPTOMS AND SIGNS: SKIN. 533 
 
 which cause icterus exert a destructive influence upon the erythrocytes. 
 It has been shown experimentally, however, that the yellow pigment in 
 poisoning by certain substances, as toluylendiamine, is not formed in the 
 blood but in the liver, the haemoglobin being transformed into biliary 
 pigment in that organ. As a result of this transformation the bile pigments 
 accumulate in the liver in such quantity that they cannot be wholh^ excreted, 
 a certain portion undergoing resorption. In consequence of these facts 
 the term hcematohepatogenous has been suggested for this form of 
 jaundice. In the present state of knowledge the etiological designation 
 toxaemic jaundice is to be preferred. The term toxEemic-obstructive jaun- 
 dice has been suggested by Hunter. 
 
 Normal and Abnormal Pigmentation — Melanoderma. — The physiological 
 pigmentation of the skin shows wide variations not only in different races 
 but in different individuals of the same race. Among the fair-skinned a 
 blonde and a brunette type are recognized. The latter is characterized by a 
 darker color of the hair, skin, and iris. Normally the skin is more deeply pig- 
 mented in the exposed portions of the body to which the light and air have 
 free access than elsewhere; upon extensor than upon flexor surfaces in 
 the region of the joints; and about the nipples, linea alba, and genital or- 
 gans. During pregnancy the pigmentation in these latter situations is 
 greatly increased, especially in brunettes, and upon the face and in other 
 portions of the body there are occasionally seen irregular, abnormally pig- 
 mented areas known as chloasma gravidarum — masque des femmes enceintes. 
 Patchy pigmentation of the skin is a common symptom of uterine disease. 
 In sedentary persons of constipated habit irregular patchy pigmentation 
 of the skin is common, especially about the face and eyes. 
 
 Freckles or ephelides are another physiological pigmentation of the 
 skin without diagnostic importance. The pigmentation appears in cir- 
 cumscribed spots varying from one to several millimetres in diameter, 
 chiefly upon the face, but also in other parts of the body, especially the 
 backs of the hands and arms. They are more common in fair than dark 
 persons and are almost always present in individuals with red hair. The 
 spots are more abundant and the pigmentation deeper in summer than in 
 winter, when they sometimes wholly disappear. 
 
 The pigmentation following measles and showing the characteristic 
 form and arrangement of the eruption is not wholly without interest to the 
 clinician, and the localized pigmentation which follows the application of 
 sinapisms and blisters deserves passing mention. 
 
 The vagabond's skin is a term applied to the diffuse pigmentation 
 resulting from lousiness and dirt and the scratching caused by these condi- 
 tions. The pigmentation sometimes reaches a very high grade. It may 
 be arranged in a very characteristic manner in stripes corresponding to the 
 lines of scratching. This condition has been confounded with the pig- 
 mentation of Addison's disease. 
 
 Melanosarcoma, especially when generahzed, very often produces a 
 deep and widespread cutaneous pigmentation. Under these circumstances 
 in exceptional cases the urine also contains abnormal pigment. 
 
 In advanced pulmonary tuberculosis a striking brownish discol- 
 oration of the face or the whole body is sometimes observed. 
 
534 MEDICAL DIAGNOSIS. 
 
 In ABDOMINAL NEW GROWTHS, especially cancer or lymphoma, diffuse 
 cutaneous pigmentation occasionally occurs. It is not uncommon in tuber- 
 culosis of the peritoneum. 
 
 In HtEmachromatosis, such as occurs in hypertrophic cirrhosis, dia- 
 betes, and other conditions, pigmentation of the skin may be present. 
 
 Exophthalmic goitre maybe associated with abnormal pigmentation. 
 
 Gastric. — In rare instances diffuse pigmentation attends gastric ulcer 
 and dilatation. 
 
 In SCLERODERMA cutaneous pigmentation may be general and of 
 high grade. 
 
 Cardiac. — In chronic disease of the heart and arteriosclerosis diffuse 
 pigmentation may occur. 
 
 Addison's Disease. — The bronze discoloration of this affection is 
 clinically the most important form of abnormal pigmentation of the skin. 
 It usually shows itself first upon exposed surfaces, as the hands and face, 
 and is more intense in those regions in which the skin is normally more 
 deeply colored than elsewhere. It begins as a faint smoke-gray discolora- 
 tion and progressively deepens to an intense bronze or mulatto hue. In 
 the diffuse smoky coloration isolated intense dark brown points may be 
 distinguished. The grayish pigment patches seen upon the mucous mem- 
 brane of the mouth are characteristic of Addison's disease. The palms and 
 soles as well as the nails commonly remain pigment free. The discolora- 
 tion of Addison's disease may suggest intense jaundice, but the general 
 condition, the yellow staining of the conjunctivae and the mucous mem- 
 brane of the mouth, and the presence of bile pigment in the urine are of 
 positive diagnostic importance. 
 
 Hepatic Disease. — The peculiar discoloration of the skin occasion- 
 ally seen in cirrhosis and other diseases of the liver demands consideration. 
 The color is a dirty brownish-gray. It is to be differentiated from icterus 
 by the color itself, the absence of staining of the mucous membranes, and 
 the condition of the urine. This pigmentation is of especial interest in 
 connection with the bronzing of the skin that occurs in certain cases of 
 diabetes — diabete bronze — developing late in hsemachromatosis and asso- 
 ciated with pigmentary cirrhosis of the liver and pancreas. The color 
 suggests Addison's disease, but the presence of grape sugar, the physical 
 signs of hepatic cirrhosis without jaundice, and the absence of the char- 
 acteristic symptoms of Addison's disease are of diagnostic importance. 
 
 Arsenomelanosis. — The pigmentation of the skin produced by the 
 prolonged administration of arsenic in full doses sometimes presents a very 
 close resemblance to Addison's disease. In a majority of the cases it 
 entirely disappears when the drug is withheld; exceptionally it is persistent. 
 It is important to know that in some instances the pigmentation of the skin 
 has followed the use of arsenic in moderate doses. 
 
 Argyria. — The prolonged administration of silver nitrate results in 
 the deposition of particles of metallic silver or its albuminate in the internal 
 organs and in the skin. The resulting discoloration is a peculiar bluish- 
 gray which is more intense upon the face and hands and is not changed by 
 pressure. The discoloration may be observed in the mucous membrane 
 of the mouth. It is persistent and not amenable to treatment. 
 
SYMPTOMS AND SIGNS: SKIN. 535 
 
 Albinism is a term used to designate developmental deficiency of pig- 
 ment. In albinos the skin, hair, and eyes are conspicuous by the absence 
 of pigment. The affection may be partial or universal. It is frequently 
 associated with other developmental defects, especially coloboma. N3^s- 
 tagmus is common. 
 
 Vitiligo is a condition of the skin characterized by deficiency of pig- 
 ment. The patches are usually circumscribed, very often distinctly margi- 
 Tiate, and sometimes surrounded by a zone of pigmentation slightly deeper 
 than normal. It may occur on any part of the body, but is common on the 
 back of the neck and shoulders, the abdomen, and scrotum. There are no 
 subjective symptoms. It occurs in adolescents and young adults. 
 
 Leucoderma or pigment atrophy, usually circumscribed or irregularly 
 distributed, is encountered in exophthalmic goitre, myxoedema, sclero- 
 derma, and other constitutional disturbances. 
 
 Moisture. — There are wide variations in the activity of the sweat- 
 glands within physiological limits. Perspiration is excited by those causes 
 which determine an active blood supply to the skin. It is therefore more 
 abundant in warm weather, after exercise, hot baths, and hot drinks. An 
 outburst of sweating may occur in connection with sudden intense emotion. 
 A pathological increase of perspiration is termed hyperidrosis; its absence 
 anidrosis. These terms are commonly used to designate conditions in which 
 the increase or absence are persistent or habitual. 
 
 Hyperidrosis. — Free perspiration attends certain febrile diseases, 
 especially rheumatic fever, some cases of enteric fever, acute polyneuritis, 
 miliary fever, and septic conditions. A critical decline of fever, whether 
 ■spontaneous or the result of the administration of antipj^retics, is 
 almost always attended by more or less abundant sweating. Perspiration 
 is one of the processes by which, both physiologically and pathologically, 
 the temperature of the body is lowered. Profuse sweating attends the 
 crisis in pneumonia, relapsing fever, and typhus. Sweating is often abund- 
 ant toward the close of enteric fever when the temperature curve assumes 
 a distinctly remittent or intermittent type. The fall of temperature in the 
 ague paroxysm is almost always attended with copious sweating. That 
 'Of the hectic fever of phthisis and other wasting diseases usually occurs 
 during the night or toward morning. It is attended with abundant sweat- 
 ing — Jiight-sweats — and is of unfavorable prognostic significance. Pro- 
 fuse sweating occurs in some cases of phthisis in the absence of fever. 
 Sudden abundant sweats are accompanied by sensations of great weakness 
 and prostration which are in part due to the relaxation of the vessels fol- 
 lowing the sudden withdrawal of fluid. Excessive sweating occurs in the 
 convalescence from some diseases. It occurs in collapse, urgent dyspnoea, 
 and sometimes accompanies severe paroxysms of pain. In rare instances 
 ■of diabetes abundant perspirations have alternated with polyuria. In- 
 creased sweating sometimes attends the suppression of urine that occvu-s 
 in certain forms of nephritis. Under these circumstances crystals of urea 
 may accumulate upon the skin and especially upon the face. 
 
 liocahzed sweating is not uncommon in pathological conditions. 
 Hyperidrosis of the hands and feet occasionally occurs in neurotic inth'vidu- 
 .als and sometimes in persons otherwise healthy. The condition is very 
 
536 MEDICAL DIAGNOSIS. 
 
 annoying. The sweat is usually copious and foul-smelling. Axillary sweat- 
 ing is an annoying constitutional peculiarity. Sweating of the head, 
 especially during sleep, is an important symptom in rickets. Unilateral 
 sweating of the head or face occurs in certain nervous diseases, as migraine 
 and neuralgia, and may result from pressure upon the sympathetic by a 
 thoracic aneurism or mediastinal tumor. Localized sweating depends 
 upon vasomotor derangements. Diaphoresis follows the administration 
 of certain drugs, especially ammonium acetate, pilocarpine, and many of 
 the coal-tar derivatives. 
 
 Anidrosis. — Abnormal dryness of the skin occurs under conditions in 
 which an excess of fluid is withdrawn from the body by way of its internal 
 surfaces, or very little water reaches the blood by way of the gastro-intes- 
 tinal tract — for example, profuse diarrhoea, continuous vomiting, diabetes 
 mellitus and insipidus, chronic nephritis with polyuria, and the deprivation 
 of fluid. The dry skin of myxoedema and general anasarca is largely attrib- 
 utable to the interference with the cutaneous circulation resulting from 
 tension. 
 
 Modifications in the Perspiration. — Perspiration when abundant usually 
 has a peculiar acid odor. That in rheumatic fever is acid and ill- 
 smelling; the sweat of the hands, feet, and axilla is almost always foul; 
 that in certain forms of nephritis has a urinous odor. The sweat may be 
 discolored — chromidrosis — yellow from biliary pigments in jaundice; blue 
 from the action of the Bacillus pyocyaneus. There are instances recorded 
 of the sweating of a blood-stained fluid or blood in hysterical females — 
 hcematidrosis — and there exists a term — menidrosis— to describe vicarious 
 menstruation by way of the skin. These conditions are of no importance 
 in diagnosis. Various colored perspiration-stains upon the linen are not to 
 be mistaken for instances of chromidrosis. It may prevent error to call 
 attention to the fact that some of the aniline dyes undergo more or less 
 marked changes in color under the action of perspiration. 
 
 Fulness of the Skin — Turgor. — The normal appearance of fulness 
 of the sldn is due to the blood and lymph in its vascular and lymph spaces. 
 It varies in different individuals and in different parts of the body, and is 
 more pronounced in females. In connection with an abundant panniculus 
 it has much to do in causing the condition described by the French as 
 emhonj)oint. Increased fulness of the skin is seen in fever and other con- 
 ditions attended by active cutaneous circulation; decreased fulness in all 
 conditions in which the cutaneous circulation is diminished without stasis, 
 particularly in emaciation, the cachexias, and under the deprivation of 
 fluid. Increased fulness is manifested by rounding of the contours, espe- 
 cially those of the face, and usually by a deeper color of the skin, while 
 diminished fulness produces accentuation of the angles and is usually 
 associated with more or less pallor. In the former condition the skin is 
 smooth, soft, and elastic; when pinched up into folds it rapidly reassumes 
 its normal surface. In the latter such folds only slowly disappear. Normal 
 fulness or turgor is to be distinguished from oedema and anasarca by the 
 pathological amount of fluid in the skin in the latter, the loss of the normal 
 cutaneous elasticity, and by the persistence of the pitting made by pressure 
 of the finger. The difference between "looking well" and "looking bad" 
 
SYMPTOMS AND SIGNS: SKIN. 
 
 537 
 
 Fig. 200. — d 
 atous ueplinti 
 
 very often depends upon slight transient variations in the normal fulness 
 of the face,, which is diminished in conditions of exhaustion and depression 
 and increased after repose and in pleasur- 
 able excitement. The turgor of the skin 
 is usually increased in exophthalmic goitre. 
 Greatly diminished fulness of the sldn such 
 as occurs in ileus, peritonitis, cholera, and 
 some cases of shock, and which precedes 
 death, gives rise to the facies Hippocratica 
 seen in these conditions. 
 
 CEdema — Dropsy. — An abnormal accu- 
 mulation of serous fluid collects in the lymph 
 spaces of the skin and the subcutaneous 
 connective tissue as the result of a disturb- 
 ance of the balance between the fluid which transudes from the capillaries and 
 that which is taken up by the lymphatics. This disturbance of balance may 
 
 be due to (a) venous obstruction, 
 (b) altered condition of the blood 
 — hydrcemia, (c) inflammation, 
 and (d) oedema of nervous ori- 
 gin. The diagnostic significance 
 of oedema depends upon its 
 location, extent, and mode of 
 development and its causal rela- 
 tions to local or constitutional 
 diseases. General oedema is de- 
 scribed under the term anasarca. 
 The skin is distended and the. 
 normal surface landmarks oblit- 
 erated. When oedema is marked 
 the surface is tense, pallid, and 
 glistening. In rapidl}-- devel- 
 oping recent oedema it has a 
 translucent appearance. In 
 some surfaces, especially upon 
 the abdomen and thighs, trans- 
 parent parallel stripes appear, 
 similar to those seen on the 
 abdomen in pregnancy. These 
 are due to the collection of the 
 fluid in the lines of separation 
 of the distended tissues or in 
 the enlarged lymphatic spaces. 
 They usually disappear upon 
 the subsidence of the oedema 
 without leaving traces. Occa- 
 sionally they leave permanent irregular linear scars. In oedema of 
 high grade, especially under the influence of irritation or slight trau- 
 matism of the skin, blebs may form upon the epidermis which rupture 
 
 Fig. 201. — Oildema of the legs with cutaneous 
 blebs in a case of subacute parenchymatous nephritis. — 
 Jefferson Hospital. 
 
538 
 
 MEDICAL DIAGNOSIS. 
 
 and are followed by the discharge of serous fluid. Occasionally; espe- 
 cially upon the legs and ankles, transudation of the fluid takes place 
 through minute openings of the skin without bleb formation. Under 
 these circumstances infection may occur, giving rise to erysipelatous 
 or other inflammation. The pale color of the skin in oedema is caused 
 by diminished capillary circulation from compression. The oedem.atous 
 parts are sometimes cyanosed and in inflammatory oedema the skin 
 is reddened. 
 
 The normal elasticity of the skin is impaired by tension and the inhibi- 
 tion of fluid. Pressure upon the oedematous part gives rise to pitting which 
 only slowly disappears. Where the skin is normally distensible and elastic 
 the pitting is more transient. This is especially the case in children. In 
 
 Pig. 202.- 
 
 -QSdema of abdominal wall and thighs in ascites due to atrophic cirrhosis of the liver .- 
 
 Hospital. 
 
 -Jefferson 
 
 moderate oedema of long standing a gradual increase in the subcutaneous 
 ■connective tissue develops and pitting is less marked and more transient. 
 
 (a) Venous Obstruction. — Factors in the production of this form of 
 oedema are diminished general muscular activity, impaired pumping action 
 of the organs of respiration, diminution of the aspiratory force of the heart 
 in* diastole and positive pressure on the veins. Coincidently the return 
 flow of the lymph which is brought about by the same forces that maintain 
 the venous circulation is impeded. This form of dropsy is frequently asso- 
 ciated with effusion into the great serous sacs. The fluid which collects is 
 clear, usually colorless, of low specific gravity, fibrin free, and contains a 
 .slightly smaller amount of proteids than the blood- serum. It is to be 
 distinguished from an inflammatory exudate which is often turbid, some- 
 times bloody, of high specific gravity, and usually contains masses of fibrin. 
 Ohanges in the tissues and particularly in the endothelium of the lymph- 
 spaces also play an important part in oedema-formation — so-called "vital 
 secretory" processes. 
 
 The collection of serous fluid in the pericardium is known as hydroperi- 
 
SYMPTOMS AND SIGNS: SKIN. 
 
 539 
 
 cardiuTTi, in the pleural cavity as hydrothorao:, in the peritoneal cavity as 
 hydroperitoneum or ascites, in the brain as hydrocephalus, in the joints as 
 hydrarthrosis. Any of the affections of the heart and lungs which, by inter- 
 fering with the return of the venous blood, cause cyanosis may also cause 
 CEdema. Cyanosis and oedema are therefore frequentl}^ associated. This 
 form of oedema appears earliest and reaches its fullest development in those 
 regions in which the circulation, by reason of remoteness from the heart 
 and the influence of gravity, is less active, as in the extremities and the 
 lumbar regions and other dependent 
 portions in bedridden patients. The 
 face at first is free and becomes 
 cedematous only when the anasarca 
 reaches a high grade. Gravity plays 
 an important part in the localization 
 of the oedema. CEdema of the legs 
 and feet while the patient is in the 
 upright position may alternate with 
 oedema of the back and thighs when 
 he is in the recumbent posture. The 
 patient who is apparently free from 
 oedema while in bed may show 
 oedema of the feet and ankles when 
 he first rises. In prolonged main- 
 tenance of the lateral decubitus the 
 oedema is more marked upon the de- 
 pendent side. In anasarca of high 
 grade, partly on account of their 
 dependent position and partly on ac- 
 count of the distensibility of the skin, 
 the penis and scrotum and the labia 
 majora become enormously swollen. 
 
 Local oedema may be due to 
 the obstruction of a venous trunk by 
 thrombosis or pressure. CEdema of 
 the arm from the pressure of enlarged 
 axillary lymphatics upon the veins, 
 and the oedema of the leg in throm- 
 bosis of the femoral vein are familiar examples. Obstructive oedema of the 
 lower extremities is frequently secondary to peritoneal effusion, such as 
 results from cirrhosis or portal thrombosis or from chronic peritonitis. 
 The accumailation of the fluid presses upon the inferior vena cava or the 
 common iliac veins. In other cases the oedema of the lower extremities 
 and the peritoneal effusion are due to the same cause. When, upon investi- 
 gation, the signs of peritoneal effusion are found to have preceded the 
 oedema of the limbs, the latter condition is usually secondary. 
 
 (b) Altered Condition of the Blood — Hydraemia. — A watery condition of 
 the blood is a common cause of oedema and other forms of dropsy. To this 
 condition may be referred those forms of oedema which occur in nephritis, 
 chronic wasting diseases, the anaemias, and cachexias. Not infrequently 
 
 Fig. 203. — OSdema of left leg due to a thrombus in 
 the external iliac vein. — German Hospital. 
 
540 MEDICAL DIAGNOSIS. 
 
 associated cardiovascular disorders are present which interfere with the 
 venous circulation, and in such cases the oedema from venous obstruction 
 and the oedema of hydrsemia are combined. This form of oedema differs 
 markedly from the oedema of venous obstruction in its early localization, 
 which is dependent much less upon remoteness from the heart and the action 
 of gravity and much more upon the peculiarities of the lymph structures. 
 It is characteristic of the oedema of certain forms of nephritis that it first 
 appears in the face and especially about the eyelids. With this early oedema 
 of the face pretibial oedema is often associated and is sometimes present 
 in cases of nephritis, especially the chronic interstitial forms in which facial 
 oedema is shght or absent altogether. The oedema of acute nephritis often 
 develops rapidly and reaches a very high grade. Not infrequently it is 
 associated with effusion into the serous sacs. In that form of nephritis 
 characterized by contraction of the kidney oedema is very often slight in 
 amount and a late manifestation, first showing itself when the hyper- 
 trophied heart begins to fail. In the subacute and chronic forms of paren- 
 chymatous nephritis the oedema is usually moderate, showing, however, 
 temporary increases which accompany exacerbations of the disease. In 
 the hydrsemia resulting from large or frequently repeated hemorrhage, 
 oedema is often pronounced. (Edema of the feet and ankles is a very 
 unfavorable symptom in pulmonary consumption. Occurring in the ab- 
 sence of renal disease or especially in the absence of conditions giving rise 
 to venous obstruction it is commonly an indication of approaching death. 
 
 (c) Inflammatory CEdema. — The local oedema in the region of in- 
 flammatory and suppurative processes is of diagnostic importance. It 
 is sometimes known as collateral oedema. The color of the surface 
 varies from a faint blush to a deep, mottled, cyanotic, purplish red. 
 It is due to obstruction of the lymph circulation by the inflammatory 
 exudate. In some instances it appears to be caused by an accumulation 
 of the fluid part of the exudate in the tissues surrounding the inflammatory 
 focus. It occurs in the region behind the ear in mastoid disease; about the 
 angle of the jaw in mumps and parotid bubo; at the base of the thorax in 
 empyema. It is an important sign of hepatic abscess, acute suppurative 
 gall-bladder disease, and is sometimes seen in the right lower quadrant of 
 the abdomen in appendicular abscess. It constitutes the so-called collar 
 of brawn in severe anginose scarlatina. 
 
 (d) (Edema of Nervous Origin. — The rare cases of sudden transitory 
 oedema of the face and neck, sometimes associated with symptoms of oedema 
 of the respiratory or gastro-intestinal mucous membranes, must be ascribed 
 to angioneurotic derangements. The mechanism which causes it remains 
 unknown. The condition known as angioneurotic oedema is characterized 
 by the sudden occurrence of local oedematous swellings of transient duration 
 upon the face, hands, and elsewhere. Forms of localized oedema, described 
 under the term giant urticaria, are of angioneurotic origin. The acute 
 oedema associated with urticaria and gastro-intestinal crises which occurs 
 in severe purpura, and the cases of oedematous swelling and tumefaction of 
 the whole arm upon exertion, are to be referred to this group. The local 
 oedema occurring as a symptom in peripheral multiple neuritis and the 
 oedema of beriberi are probably of nervous origin, as is hysterical oedema. 
 
SYMPTOMS AXD SIGNS: SKIX. 541 
 
 (e) (Edema due to Other Causes. —CEclema neonatorum is a rare condi- 
 tion sometimes confused with sclerema, from which, however, it is patho- 
 logically distinct. It is encountered in feeble infants, especially those born 
 prematurely or exposed to cold after birth. Cases of hereditary oedema 
 have been described. The oedema is congenital and persistent; it involves 
 one or both legs and is dense and inelastic. It shows no disposition to 
 increase and is unattended bj^ special inconvenience. 
 
 The oedema which occurs in trichinosis is of diagnostic importance. 
 It appears in the face and over the affected muscles, and undergoes 
 remarkable fluctuations in degree during the course of the disease. 
 
 General oedema in the absence of nephritis is not infrequently observed 
 in certain of the infectious diseases, as scarlet fever and diphtheria; it may 
 follow the therapeutic injection of the different sera and in some instances 
 the administration of potassium iodide. Slight oedema of the feet and 
 ankles — a mere puffiness — is not uncommon in individuals otherwise 
 healthy, after prolonged standing or walking or after forced marches. 
 
 Lymphcedema. — The transudation of lymph through the walls of the 
 lymphatic vessels, or distention of the lymph spaces from mechanical 
 obstruction, may cause great swelling, which is usually local or confined to 
 a single Hmb. It results from pressure upon, or internal occlusion of, a 
 lymph-vessel and is seen in the lymph scrotum and certain forms of elephan- 
 tiasis caused by the Filaria sanguinis hominis and accompanied by chyluria. 
 Lymphoedema involving a member — 7?iacrom6'/{a— sometimes occurs in 
 lymphadenoma. This form differs from ordinary oedema by its greater 
 firmness and brawniness — a very important point in differential diagnosis. 
 
 It is of diagnostic importance to recognize the distinction between 
 the various forms of oedema and myxoedema — an affection of the thyroid 
 gland characterized by swelling of the skin, eyelids, and other parts of the 
 body, due to the deposition in the skin and subcutaneous tissues of a mucin- 
 ous material. The skin is dry, rough, and swollen, but firm and inelastic, 
 and does not pit on pressure. 
 
 Certain connective-tissue dystrophies present a superficial resemblance 
 to localized oedema. The swellings usualh' involve the outer or posterior 
 aspect of the extremities, but may appear at various parts of the trunk. 
 They are to be differentiated from oedema by their localization, the absence 
 of pitting upon pressure, and by other appearances of the skin characteristic 
 of oedema. 
 
 Scleroderma, a brawny induration of the skin, in some instances 
 suggests chronic oedema. Two forms are recognized, the circumscribed 
 and the diffuse in which large areas are involved. The skin is brawny, 
 hard, and inelastic. When circumscribed the patches are irregularly oval 
 and vary in diameter; they may be as large as the hand. They are preceded 
 by hypersemia of the skin. The disease is more common in women than in 
 men and frequently shows itself about the neck and breasts. The diffuse 
 form involves the extremities and face. The skin is hard and firm with 
 stiffness and tension. It is adherent to the underlying tissues and cannot 
 be pinched up into folds. There is impairment of movement. Very often 
 there are vasomotor disturbances with cyanosis. Pigment alterations are 
 frequent — both melanoderma and leucoderma. 
 
542 MEDICAL DIAGNOSIS. 
 
 Sclerema neonatorum is a rare disease of the new-born in which the 
 skin rapidly assumes the cHnical appearance of scleroderma. It is usually 
 fatal. It presents superficial points of resemblance to oedema neonatorum^ 
 from which it is to be distinguished by the complete absence of the 
 ordinary signs of anasarca. 
 
 Scurvy sclerosis — a deep brawny infiltration of the subcutaneous tissues 
 and muscles, with hemorrhagic discoloration of the overlying skin — fre- 
 quently seen on the calves of the legs, is not to be confounded with oedema,, 
 although it is very often associated with it. 
 
 Subcutaneous Emphysema. — The presence of gas, usually air, in the 
 meshes of the subcutaneous tissue gives rise to swelling and puffiness of 
 the surface which may be either general or local. The appearance is not 
 unlike that of oedema, but upon palpation a peculiar crackling is to be felt 
 and heard, due to the displacement of bubbles of air in the tissues. The 
 surface resistance is lower than normal and pitting from pressure does not 
 occur. Upon percussion the sound is tympanitic. The skin is pale and has. 
 a distended appearance. In very rare cases subcutaneous emphysema is 
 due to the presence of aerogenous bacteria — Bacillus aerogenes capsulatus — 
 and allied organisms. This gaseous and necrotic oedema occurs in serious 
 wound infection and may extensively involve the subcutaneous tissues of 
 the body. The infection may proceed from the uterus, gastro-intestinal 
 canal, or respiratory tract. Analogous to this condition is the subcutaneous 
 emphysema of malignant oedema. It is sometimes associated with tetanus. 
 
 In the greater number of cases the air finds its way under the skin 
 through an external wound or through the ulceration or laceration of some 
 air-containing organ. Subcutaneous emphysema is, therefore, an accident 
 of carcinomatous or other ulceration of the oesophagus, of diseases attended 
 by violent paroxysmal cough by which the alveolar tissue is mechanically 
 torn, or occasionally of the after-treatment of tracheotomy, the air being 
 forced into the subcutaneous tissues by efforts of cough. The air usually 
 accumulates about the root of the neck and over the manubrium. It may 
 invade the tissues underlying the skin very extensively and sometimes in- 
 volves the greater part of the body. As a rule it undergoes rapid resorption. 
 
 Cutaneous hemorrhages appear as spots or streaks of varying size^ 
 at first red, but quickly becoming darker. Small hemorrhages — petechioe — 
 frequently have their origin in the hair follicles. Larger hemorrhages — 
 ecchymoses — are diffuse. Hemorrhages arranged in the skin in the form 
 of lines and streaks are called vibices. The term suggillation is sometimes 
 used to describe the ecchymosis following a bruise. Hceniatoma is a tumor 
 containing effused blood. Cutaneous hemorrhages may occur upon any 
 part of the body, but when due to constitutional disease they are more 
 abundant upon the lower extremities. In consequence of transformations 
 in the haemoglobin the color during resorption undergoes progressive changes 
 to blue, green, and yellow, and gradually fades. The appearance and dis- 
 tribution of petechiae is characteristic of cutaneous hemorrhage. They are 
 not usually elevated above the skin. Occasionally in purpura there are 
 vesicular points distended with blood. In doubtful cases cutaneous hem- 
 orrhages may be distinguished from local hypersemia or erythema by the 
 fact that they do not disappear when the skin is made tense by traction 
 
SYMPTOMS AND SIGNS: SKIN. 543 
 
 upon it of the thumb and finger or by pressure with a glass sHde. In 
 local hyperaeniia the spot of redness disappears; in hemorrhage, owing to 
 the expression of the blood from the surrounding capillaries, it becomes 
 more distinct. Affections characterized by the extravasation of blood into 
 the skin are collectively described under the term purpura. 
 
 Cutaneous hemorrhage is in all cases of diagnostic importance. The 
 more important conditions with which it is associated are traumatism, 
 intense venous stasis, the severe and especially the malignant infections^ 
 sepsis of various kinds, deep jaundice, and cachectic and ansemic states. 
 It is a characteristic phenomenon of the action of certain snake venoms 
 and under exceptional circumstances follows the administration of 
 copaiba, quinine, ergot, iodine, and other drugs. 
 
 Hemorrhage into the skin occasionally occurs in acute myelitis, 
 severe neuralgia, and in tabes. In the last it is very often transient. The 
 bleeding points or stigmata that have attracted so much attention in rare 
 cases of hysteria are of nervous origin. 
 
 It is frequently associated with arthritis. The relationship of these 
 conditions has been regarded without adequate reason as rheumatic. 
 
 Other changes in the skin of diagnostic importance are: striations, 
 desquamation, furunculosis, cicatrices, and glossy skin. 
 
 Striations. — The striae of the skin of the abdomen and those occur- 
 ring in oedema and peritoneal effusion, which resemble the striations of 
 pregnancy, have already been described. They frequently disappear after 
 resorption of the fluid, but may persist for a long time. Similar striations 
 may attend the rapid development and equally rapid resorption of a 
 thick panniculus adiposus. They are encountered in cases of great abdomi- 
 nal distention from rapidly developing tumors or other cause. 
 
 Desquamation. — Shedding of the epidermis is of diagnostic impor- 
 tance. A diffuse desquamation of the trunk and extremities, usually in the 
 form of fine scales, occurs in the cachexia associated with emaciation. A 
 similar fine-scaled desquamation follows measles. A coarser desquamation, 
 sometimes lamellar, is almost constant after scarlet fever. A coarse des- 
 quamation follows erysipelas. The decrustation of the variolous diseases 
 may be mentioned in this connection. 
 
 Furunculosis. — Boils or furuncles are the expression of an acute 
 inflammation of a hair follicle and its sebaceous gland and the connective 
 tissue immediately surrounding them. It is a local process due to an infec- 
 tion through the folhcle by pus-producing organisms, usually the Staphy- 
 lococcus aureus. Furunculosis occurs in conditions of lowered vitality, 
 as during the convalescence from infectious diseases, especially enteric 
 fever. The occurrence of furuncles in crops, or their persistent recurrence, 
 is a common event in diabetes mellitus and should always lead to an 
 examination of the urine for the presence of sugar. 
 
 Cicatrices or Scars. — These, whether recent or old, constitute 
 important diagnostic signs. In doubtful cases special significance attaches 
 to the presence or absence of the scars of vaccination and their characters 
 and to the scars of smallpox. The scars of furuncles and carbuncles, of 
 lupus, of inguinal buboes, and those left by tuberculous glands whicli have 
 healed spontaneously or been removed are very suggestive in doubtful 
 
544 
 
 MEDICAL DIAGNOSIS. 
 
 cases. The scars left by tuberculous disease of the glands or bones are 
 usually retracted and adherent. The presence or absence of scars upon the 
 genitalia following the primary syphilitic infection is of great importance. 
 They are usually difficult to discover in the female and are not always 
 persistent. The serpiginous cicatrices of late syphilis cannot be mistaken. 
 Cicatrices produced by therapeutic measures, such as cupping, venesection, 
 
 leeching, the application of croton oil and 
 tartar emetic ointment, and those left by 
 surgical operations are of importance in 
 the anamnesis. Occasionally scars upon 
 the head or elsewhere constitute sugges- 
 tive diagnostic evidence in obscure nervous 
 diseases. Scars upon the tongue, the result 
 of laceration during the epileptic par- 
 oxj^sm, may serve to clear up any doubt 
 as to the character of convulsive seizures. 
 Glossy Skin. — The appearance is 
 characteristic. The skin is atrophied and 
 attached to the subjacent structures. It is 
 smooth, tense, and hairless and occurs most 
 frequently and is more pronounced in the 
 hands and fingers. It may develop else- 
 where. The condition is the result of the 
 trophic disturbance caused by traumatic or 
 other lesions of the nerves. It is encoun- 
 tered in extremities that have been splinted 
 after fracture, forms of neuritis, in condi- 
 tions giving rise to the claw hand, in long- 
 standing oedema, and in some advanced 
 cases of arthritis deformans. It is not 
 often seen in young persons. 
 
 Collateral Circulation in the Skin. 
 — Dilatation of the superficial vessels fre- 
 quently sheds light on symptoms dependent 
 upon deeper circulatory derangements. In 
 aged persons the overfilled veins of the ex- 
 tremities, showing prominently through the 
 translucent atrophic skin, are an indication 
 of the diminished cardiac power associated 
 with general involution of the muscular 
 system. The veins are darker in color than the blood which they contain 
 — a phenomenon doubtless due to intensification of the color in transmission 
 through the skin. 
 
 In tumors of the mediastinum which compress the great veins of the 
 thorax, especially the venae cavse superior and inferior, the venous collat- 
 erals upon the anterior surface of the chest may be greatly enlarged. The 
 blood is transferred from the compressed vena cava inferior by way of the 
 intercostal veins and the internal mammary vein to the superior vena cava, 
 or the reverse. 
 
 Fig. 204. — Distended veins of the leg 
 and abdomen in a case of mediastinal 
 tumor. — Jefferson Hospital. 
 
SYMPTOMS AND SIGNS: SKIN. 
 
 545 
 
 Thrombosis of the -vena cava ascendens or of both common iliac veins 
 results in the development upon the surface of the abdomen and antero- 
 lateral aspects of the chest of prominent sinuous venous enlargements, 
 sometimes reaching the thickness of a finger, by which the blood from the 
 lower extremities and the kidneys is conveyed to the veins of the thorax. 
 In cirrhosis of the liver and portal thrombosis the compensatory circula- 
 tion is often by way of the superficial veins. Occasionally a greatly enlarged 
 para-umbilical vein passes from the hilus of the liver along the course 
 of the round ligament and joins the 
 epigastric veins at the navel, produc- 
 ing a large varix with wavy radial 
 distribution of the veins known as 
 the caput Medusce. More commonly 
 branches pass in the round and sus- 
 pensory ligaments and unite with the 
 epigastric and mammary systems. 
 The vessels are numerous and of no 
 great size. An important point of 
 difference between the enlargement 
 of the superficial collateral veins in 
 obstruction of the vena cava and 
 portal obstruction is to be found in 
 their distribution. In the former the 
 enlarged collaterals usually occupy 
 the anterolateral aspect of the chest; 
 in the latter the region around the 
 navel and ensiform cartilage. It is 
 important to' determine in which 
 direction the blood in the distended 
 vein flows. This is done by empty- 
 ing the vein by stroking it between 
 two fingers and determining by re- 
 moval of the pressure of the fingers 
 alternately from which direction the 
 blood stream comes. In great disten- 
 tion of the veins the valves become 
 inadequate and this investigation is 
 without result. The small vascular 
 
 dendrites so often seen in irregular arrangement at the base of the thorax in 
 chronic affections of the lungs and pleura indicate local areas in which col- 
 lateral circulation has been established between the lungs and skin. They 
 are especially common in pleural adhesions and are frequently seen upon 
 the upper part of the back in chronic pulmonary tuberculosis with great 
 pleural thickening. In many cases these minute dendritic enlargements at 
 the base of the chest and the borders of the area of superficial cardiac dul- 
 ness are without pathological significance, since they occur in healthy indi- 
 viduals. They have a certain clinical interest, however, since by their 
 distribution they indicate upon inspection the position of the borders of the 
 lung. Enlargement of the veins of the legs may be due to changes in their 
 
 35 
 
 Fig. 205. — Varicose veins. — German Hospital. 
 
546 MEDICAL DIAGNOSIS. 
 
 walls on the one hand or to thrombosis or pressure pn the other. Enlarge- 
 ment of the veins of both legs is caused by the obstruction of the vena cava 
 or both iliacs. Great enlargement of the veins of the legs, with the formation 
 of varices, sometimes occurs after repeated pregnancies, and enormous vari- 
 cosity of one leg, with great dilatation, frequently results from venous 
 thrombosis following pregnancy or the infectious diseases, especially enteric 
 fever. The varicosities which occur in the absence of pressure or throm- 
 bosis are largely due to changes in the walls of the veins themselves. 
 
 THE NAILS. 
 
 The appearance of the nails is to some extent indicative of the state 
 of nutrition and habits. The deformity arising from biting the nails is 
 characteristic and consists in shortening of the nail with projection of the 
 tip of the finger, into which the edge of the nail tends to bury itself. Coarse 
 longitudinal striae associated with brittleness are said to indicate gouty 
 tendencies. Small white flecks — leucopathia unguis — are the result of 
 trifling knocks; the color is due to the presence of air among the cells. 
 Transverse arched bands, dull and opaque, contrasting with the normal 
 glistening surface, are seen after severe acute illness and indicate a period 
 of malnutrition. They appear at the root of the nail and gradually advance. 
 They are often seen after enteric fever and sometimes, in the case of relapse, 
 there is a corresponding secondary band. Pressure upon the nails drives 
 blood from the capillaries of the bed. The blanching is marked and some- 
 what prolonged in anaemic states. The nail is normally of a pink tint. 
 Cyanosis shows itself early in the nails and their blueness is a measure of 
 its intensity. When the capillary pulse is present it may be seen in the 
 nail-beds, especially after slight pressure. The nutrition of the nails is 
 affected in various skin diseases. They become dry, fragile, and malformed 
 in neuritis, syringomyelia, Raynaud's disease, and scleroderma. Destruc- 
 tion of the nails occurs in the neuritis of Morvan's disease and leprosy. 
 In hemiplegia and infantile palsy the growth of the nails upon the paralyzed 
 side is retarded. Oriychia is ulceration of the nail matrix. It may be due 
 to syphilis or tuberculosis. In chronic disease of the chest the nails become 
 hypertrophied and incurvated and the terminal phalanges clubbed — the 
 Hippocratic fingers. These changes are seen most frequently in bronchi- 
 ectasis and empyema, less often in phthisis. The deformity may develop 
 very rapidly. Trifling lesions at the root of the nail — a mere splitting of 
 the fold of epidermis at the side of the finger-nail, may be the point of 
 serious infection. Malignant endocarditis and tetanus have arisen from 
 this cause, and such sores upon the finger of the surgeon are frequently 
 the seat of the initial lesion of syphilis. Congenital absence and deformities 
 of the nails are not common. They may be hereditary and are usually 
 associated with defects in development of the hair and teeth. 
 
 Shedding of the nails sometimes occurs in syphilis, alopecia areata, 
 saccharine diabetes, hysteria, and other neurotic conditions. Extravasa- 
 tion of the blood beneath the nails may occur from injury or very rarely 
 in purpuric affections. The blood-clot brings about a separation of the 
 nail from its bed and its ultimate detachment. 
 
SYMPTOMS AND SIGNS: HAIR. 547 
 
 THE HAIR. 
 
 Wide variations in color, texture, and abundance occur in different 
 individuals. Certain changes are of diagnostic importance. 
 
 Color. — Grayness or canities may begin early in life. It is a sign of 
 old age but there are people who grow old without growing gray. Gray 
 hair in young people is sometimes hereditary. It is often associated with 
 early arteriocapillary sclerosis. In a family in which nearly every member 
 for three generations was the victim of chronic nephritis it was characteristic 
 for the hair to turn gray before thirty. Early grayness, however, is not 
 incompatible with excellent health. In rare instances rapid whitening of 
 the hair has been attributed to extreme terror or anxiety. Circumscribed 
 patches of gray hair are occasionally seen in healthy individuals. Their 
 development sometimes appears to depend upon severe neuralgia involv- 
 ing the distribution of the supra-orbital branch of the fifth nerve. It is 
 easy for the close observer to detect bleached or dyed hair. To the physician 
 the former is suggestive of an undisciplined life, the latter of chronic lead 
 poisoning as the cause of nervous symptoms otherwise obscure. Discolor- 
 ation of the hair occurs in workers in copper, cobalt, indigo, and from local 
 contact with dyes. Change in color may occur after severe illness with 
 temporary loss of hair or after frequently repeated excessive sweating 
 such as follows the hypodermic use of pilocarpine. 
 
 Hypertrichosis. — A growth of hair that is abnormal in quantity or in loca- 
 tion may be congenital or acquired. It is a deformity rather than a disease. 
 Very rare instances have been reported in which a growth of hair has covered 
 the entire body except the palms, soles, terminal phalanges, upper eyelids, 
 borders of the lips, prepuce, and glans penis. Hirsuties is more commonly 
 localized. The causes of this condition are obscure. Among them heredity 
 and irregularities or arrest of the sexual functions are prominent. A luxuri- 
 ant growth of deeply pigmented hair has been observed in Addison's disease. 
 
 Atrophy of the hair occurs as the result of systemic conditions inter- 
 fering with nutrition. The hair becomes dry and lustreless and splits at 
 the end. It may undergo atrophy in local diseases of the scalp and in 
 general conditions, as extreme emaciation and cachexia. Imperfect nutri- 
 tion of the hair is conspicuous in myxcedema and occurs in advanced cases 
 of pulmonary consumption. 
 
 Alopecia may involve the scalp or other hairy parts of the body. It may 
 be congenital and is usually accompanied by defects in the teeth and nails. 
 This form is very often hereditary. The hair does not usually grow in scars 
 upon the scalp. Alopecia senilis accompanies other senile changes. Prema- 
 ture falling of the hair sometimes appears to be an idiopathic condition. It 
 occurs in various local and systemic diseases. Among the latter are acute 
 febrile infections, syphilis, and erysipelas. As a rule the hair grows again. 
 
 Alopecia areata or circumscribed patches of baldness appears in some 
 instances to be a trophoneurosis occurring after shock or injury to the 
 nervous system. In others it appears to be a local parasitic disease. 
 
 Diseases of the skin as such do not fall within the scope of this work. 
 The cutaneous manifestations of the individual constitutional and organic 
 diseases are considered elsewhere (see Part IV). 
 
548 MEDICAL DIAGNOSIS. 
 
 XII. 
 GENITO-URINARY SYSTEM; MICTURITION; THE REPRODUC- 
 TIVE ORGANS. 
 
 The diagnostic significance of the results of examination of the urine 
 by laboratory methods is set forth in a previous chapter. The clinical 
 facts may properly be considered separately. 
 
 MICTURITION— URINATION. 
 
 The urine is secreted continuously and conveyed by the ureters to the 
 bladder, from which it is ejected at intervals through the urethra by the 
 act of micturition. The urine accumulating in the bladder is prevented 
 from escaping by the elasticity of the parts surrounding the internal ure- 
 thral orifice and the contraction of the internal sphincter. When the 
 accumulation reaches a certain point the desire to pass water is aroused. 
 The external sphincter may be controlled by voluntary effort. The act of 
 micturition consists in strong contraction of the bladder with the simul- 
 taneous relaxation of the sphincters and the contraction of the abdominal 
 muscles, especially toward the close of the act. The contraction of these 
 muscles with closure of the glottis and fixation of the diaphragm increases 
 the pressure upon the contents of the abdominal and pelvic cavities and 
 favors the complete emptying of the bladder. The peculiar sensation 
 caused by the accumulation of urine in the bladder is followed by the 
 reflex muscular contractions which constitute the act of micturition. 
 Not only is this act largely under the control of the will, but the ability to 
 void small quantities is also to some extent voluntary. 
 
 The average total daily quantity of urine in healthy men is 1200 to 
 1700 c.c; in women the amount is less by 200-300 c.c. This represents 
 the water excreted by the kidneys, but there is in health as well as in disease 
 a vicarious relationship between the function of those organs and the skin 
 and lungs, so that during increased cutaneous and respiratory activity, as 
 in prolonged exercise or in warm weather, the quantity of urine may be 
 reduced to 400-500 c.c. in twenty-four hours. 
 
 The quantity is diminished in disease in a corresponding manner. 
 Thus, the loss of fluid by pathological sweating, profuse vomiting, colliqua- 
 tive diarrhoea, and hemorrhage is attended by more or less marked reduc- 
 tion in the urine. The quantity is also reduced in acute nephritis, in 
 lowering of the blood-pressure from any cause, in many febrile conditions, 
 and in dropsies and effusions into the serous sacs. Suppression of urine 
 more or less complete is designated anuria — to a less extent oliguria. 
 
 An abnormal and continued increase of the daily quantity of urine, 
 not accounted for by increased ingestion of fluid, constitutes the patho- 
 logical condition designated polyuria. This condition occurs in diabetes 
 insipidus and mellitus, in emotional states, in hysteria, during the epileptic 
 paroxysm, in irritable lesions of the floor of the fourth ventricle, under the 
 
SYMPTOMS AND SIGNS: MICTURITION. 549 
 
 influence of diuretics, in contracted kidneys, in chronic parenchymatous 
 nephritis, in lardaceous renal disease, from increased blood-pressure, and 
 as a result of the resorption of transudates and exudates. 
 
 The daily quantity is voided in several acts of micturition, usually 
 about five, but the number within normal limits is largely determined by 
 the habits and circumstances of the individual. 
 
 The following abnormal conditions are of diagnostic importance: 
 (a) Dysuria. — This term is comprehensively employed to designate 
 difficult, slow, and frequent micturition, and, since these symptoms are 
 mostly though not always attended with distress which is often urgent, 
 it includes painful micturition. 
 
 1. Vesical tenesmus constitutes the most severe form of dysuria. 
 It consists of painful spasm of the bladder and is often associated with 
 rectal tenesmus. The spasm is often so urgent that the patient is unable 
 to remain at rest, but returns at short intervals to the ineffectual and 
 agonizing attempt to pass water, with the result that a few drops at most 
 are voided with violent bearing down and burning pain in the urethra. 
 
 2. Strangury.— Not rarely a few drops of blood or bloody mucus are 
 discharged in the spasmodic efforts at urination, and the condition is de- 
 scribed as strangury. This term is, however, frequently employed inter- 
 changeably with tenesmus. 
 
 ' Very concentrated and acid urine is a cause of dysuria and the ingestion 
 of certain condiments in excess, as mustard, pepper, and horseradish, may 
 produce similar inconvenience. The absorption of cantharides and turpen- 
 tine applied to the surface, or overdoses of these substances, may be 
 followed by strangury. A sudden attack of vesical tenesmus for which no 
 obvious cause is discoverable may be found upon investigation of the 
 facts of the case to be a tabetic crisis. 
 
 Dysuria, especially these more intense forms, is liable to occur in al- 
 most all acute inflammatory diseases of the urinary tract. They are 
 encountered therefore in posterior gonorrhoea and in gonorrhoeal inflam- 
 mation of the neck of the bladder, and in acute cystitis, prostatitis, and pye- 
 litis. Dysuria also accompanies the chronic forms of these affections but 
 is much less urgent and distressing. Tenesmus is also symptomatic of 
 direct irritation of the bladder, as by stone, gravel, foreign bodies, parasites, 
 and local ulceration. Reflex dysuria with tenesmus is sometimes present 
 in renal colic. 
 
 Dysuria is a symptom of incomplete retention. When after the act 
 of micturition there is residual urine, it is evident that the capacity of the 
 organ will be more speedily reached than when it is emptied normally. 
 Urination becomes more frequent and more difficult. This form of dysuria 
 occurs in paresis of the bladder, as in tabes, hypertrophied prostate, tumor 
 involving the neck of the bladder, stricture and phimosis, prostatic abscess, 
 arteriosclerosis of the vesical arteries, spasm of the neck of the bladder, 
 and oedematous swelling of the urethral mucosa in acute gonorrhoea. A 
 chancre of the urethra may act in the same way, and in the variolous dis- 
 eases pocks in the meatus may occasion similar symptoms. 
 
 Dysuria frequently attends general peritonitis, acute inflammatory 
 diseases of the pelvic organs, and may occur in dysmenorrhoea. 
 
550 MEDICAL DIAGNOSIS. 
 
 (b) Frequent Micturition. — This occurs in polyuria. It is obvious 
 that in the absence of dilatation of the bladder an increase in the quantity 
 of urine must be followed by an increase in the frequency with which it is 
 voided. Hence in diabetes insipidus and diabetes mellitus, in contracted 
 Iddneys and in some forms of pyelitis the frequenc}^ of urination is greatly 
 increased. A diabetic who voids 6 litres of urine in twenty-four hours, 
 with an average vesical capacity of about 300 c.c, would be obliged to pass 
 water at least twenty times in the course of the day — a requirement which 
 is slightly diminished by a gradual increase in the size of the bladder. When, 
 on the other hand, the bladder has undergone concentric hypertrophy in 
 consequence of chronic cystitis and its capacity is greatly diminished, the 
 necessity to void urine at short intervals becomes imperative. If the call 
 be not obeyed, as in deep sleep, the urine may be involuntarily discharged. 
 
 Frequent micturition is often due to psychical causes, among them 
 fright and excitement. Soldiers in battle and students awaiting examina- 
 tion constitute oft-quoted examples. The urine is voided at short intervals 
 and in small amounts and often involuntarily. It is also a common symp- 
 tom in hysteria and neurasthenia. 
 
 (c) Slow Micturition. — The act is slow, prolonged, and difficult in all 
 conditions characterized by mechanical obstruction to the outflow and in 
 nervous affections attended by paresis of the vesical wall. Hence the form 
 of dysuria encountered in incomplete urinary retention from any cause is 
 characterized by slow or prolonged micturition. Stillicidium urinoe. or the 
 slow discharge of urine drop b}^ drop has been described under the term 
 "incontinence of retention." It occurs in the low fevers and in soporose 
 and comatose conditions, when, because of the neglect of a routine physical 
 examination and of the use of the catheter, the bladder has been allowed 
 to become overdistended. 
 
 (d) Incontinence of Urine. — This condition is due to mechanical and 
 nervous causes. 
 
 1. Mechanical causes are chiefly operative in women. Laceration of 
 the perineum or injuries to the urethra sustained in parturition, relaxation of 
 the floor of the pelvis, and cystocele are common causes of urinary inconti- 
 nence. The urine may dribble constantly or be discharged in gushes upon 
 any muscular effort which increases the pelvic pressure, as lifting, stooping," 
 or coughing. Violent sudden cough, as in pertussis, may cause incontinence 
 in depressed or asthenic conditions with relaxation of the sphincter muscles. 
 
 2. The nervous causes of incontinence are much more common. 
 They may be cerebral, as in coma and shock, idiocy and dementia, or the 
 stuporous states of the profound infections; spinal, as in traumatism, 
 hemorrhage, and tumors of the cord, transverse myelitis, meningitis, and 
 tabes; or reflex in consequence of the local irritation of ascarides, phimosis, 
 contracted urinary meatus, stone in the bladder, cystitis, or highly con- 
 centrated or acid urine. To the last of these causes miay be referred enuresis 
 nocturna, which occurs in neurotic children and acquires the force of a 
 morbid habit, the urine being voided involuntarily, as a rule during sleep, 
 but frequently during the waking hours under excitement or preoccupation. 
 If the vesical centre in the lumbar cord is destroyed, complete paralysis 
 will ensue, with retention or the dribbling incontinence of retention. 
 
SYMPTOMS AND SIGNS: MICTURITION. 551 
 
 (e) Retention of Urine. — Retention and incontinence are very con- 
 stantly associated, and are due in many instances to the same causes. 
 Thus, retention may occur in coma from any cause, in the soporose states 
 incident to profound toxasmia, as in the graver forms of the infectious 
 diseases and especially in the terminal infections, in peritonitis, in acute 
 pelvic inflammations, and in injuries and diseases of the spinal cord. 
 
 Temporary loss of vesical power sometimes results from overdisten- 
 tion in consequence of prolonged voluntary retention. Mechanical causes 
 of retention are stricture, urethritis, the arrest of a calculus in the urethra, 
 prostatic enlargement, and the pressure of the head in parturition. Remark- 
 able retention of urine is sometimes observed in hysterical persons. 
 
 In infants this condition may occur from phimosis, inflammation of 
 the prepuce, or highly concentrated or acid urine. These causes may act 
 reflexly, by producing spasm of the sphincters, or mechanically. The pas- 
 sage of a renal calculus through the ureter may, by reflex irritation, give 
 rise to frequent micturition on the one hand or to spasm of the sphincters 
 and retention on the other. 
 
 (f ) Suppression of Urine — Anuria. — This condition may be mechani- 
 cal, renal or general, partial or complete. 
 
 1. Mechanical causes of complete anuria are renal calculi blocking 
 both ureters simultaneously or the ureter when only one exists. The symp- 
 toms are those of ura?mia.- The condition is extremely rare. Life may 
 be prolonged several days with complete anuria; in Polk's case in which 
 a solitary kidney was removed, the patient lived eleven days. Partial 
 anuria — oliguria — may be caused by the presence of an abdominal aneurism 
 or tumor upon one or both ureters, or by a kink in the ureter in the case 
 of an ectopic kidney, or by malignant disease of the wall of the bladder 
 involving one or both urethral orifices. In any of these conditions hydrone- 
 phrosis may occur. 
 
 2. Renal lesions leading to suppression of urine are acute congestion, 
 acute nephritis; the acute exacerbations of chronic nephritis, pyelitis, 
 abscess of the kidney, perinephric abscess, and hydro- and pyonephrosis. 
 Among the rare causes of suppression is thrombosis of the inferior vena 
 cava or of the renal vein, 
 
 3. General conditions accompanied by suppression of urine are extreme 
 lowering of the blood-pressure such as occurs in profuse hemorrhage from 
 any cause; collapse or shock from injuries, surgical operations; the per- 
 foration of hollow viscera, as in peptic ulcer, empyema of the gall-bladder, 
 enteric fever, or rupture of the uterus; the stage of collapse in cholera 
 Asiatica, cholera nostras, or yellow fever, the pernicious malarial fevers, 
 and acute peritonitis. Operations upon the urinary tract — even so trifling 
 a procedure as catheterization — may in elderly men be followed by urinary 
 suppression. 
 
 This symptom also occurs in acute poisoning by phosphorus, lead, and 
 turpentine, in acute yellow atrophy of the liver, and in sunstroke. 
 
 Anuria, more or less complete, and prolonged for daj^s, is occasionally 
 observed in hysterical girls. In rare cases there are sj'^mptoms of ursemia, 
 but as a rule there are no associated symptoms other than those due to 
 the hysteria. In such cases, in order to avoid deception, the patient must 
 
552 MEDICAL DIAGNOSIS. 
 
 be isolated and carefully and continuously watched, and the catheter used 
 at unexpected and irregular periods. Anuria may result from reflex irri- 
 tation and functional arrest in a normal kidney, the ureter of the opposite 
 side being blocked by a calculus, or the opposite kidney having been 
 removed by operation. 
 
 Haematuria. — When small amounts of blood are present the color of 
 the urine is smoky. With larger quantities it is bright red or even dark 
 brown and opaque like porter. Erythrocytes are present, usually crenated 
 or as rounded shadowy disks. The haemoglobin is soon dissolved, especially 
 in ammoniacal urines and those of low specific gravity. Blood from the 
 kidneys is intimately mixed with the urine, which is discolored both at 
 the beginning and at the end of the act of micturition. Clots are often 
 present and they may be in the form of casts of the pelvis or ureters. Blood 
 from the bladder may not appear until toward the end of micturition or at 
 its close. Upon washing out the bladder the water returns tinged if the 
 source of the hemorrhage be in the bladder but clear if it be in the kidneys. 
 The differential diagnosis of the source of the bleeding, however, is often 
 attended with difficulty and can be made only by means of the cystoscope 
 or a differentiator by which the urine from each ureter may be obtained 
 separatel}^ 
 
 Hsematuria may be symptomatic of the following conditions: 
 
 1. The hemorrhagic varieties of the acute febrile infections, forms 
 of purpura, haemophilia, very severe cases of scurvy, and leukaemia. A 
 special form of haematuria or haemoglobinuria — black water fever — prevails 
 in certain malarious districts. 
 
 2. Diseases of the Urinary Passages. — Sarcoma or tuberculosis 
 of the kidney, calculus in the ureter, tumor, ulceration or calculus in the 
 bladder, parasites of the bladder — Bilharzia haematobia, psorospermiasis — 
 or rupture of veins in its wall may be the cause of haematuria. In rare- 
 instances this condition is due to disease of the prostate. The arrest of a 
 calculus in the urethra or acute gonorrhoeal urethritis is sometimes attended 
 by the passing of blood. This symptom occurs in strangury and there are 
 cases of persistent haematuria in which no adequate lesion has been found. 
 
 3. Traumatism. — Haematuria follows operations upon the kidney. 
 Gun-shot wounds or stabs involving the kidney, laceration of the organ 
 from blows upon the back, falls or crushing accidents cause profuse bleed- 
 ing. Similar injuries involving the bladder or prostate, falls or kicks 
 resulting in severe contusion of the perineum and laceration of the urethra 
 are also followed by hemorrhage, and this symptom frequently follows 
 the use of the catheter. 
 
 (g) Haemoglobinuria. — The urine is discolored by haemoglobin, chiefly 
 methaemoglobin. Red corpuscles are absent or few in number. The 
 urine is smoky or brownish-red, even black, and upon standing deposits a 
 dense, dirty brown sediment made up of granular pigment, the detritus of 
 blood-corpuscles, epitheliimi, and pigmented urates. 
 
 Three forms are recognized: the toxic, the paroxysmal, and haemo- 
 globinuria of the new-born. 
 
 1. Toxic Haemoglobinuria. — This variety is encountered in poison- 
 ing by those agents which produce rapid destruction of the erythrocytes. 
 
SYMPTOMS AND SIGNS: REPRODUCTIVE ORGANS. 553 
 
 Important among these are potassium chlorate, pyrogalhc acid, carbolic 
 acid, arseniureted hydrogen, carbon monoxide, naphthol, and muscarine. 
 It is also produced by the transfusion of blood from one mammal into 
 another, by exposure to intense cold and violent exertion, and occurs 
 after extensive burns. In malarial subjects it may follow the administra- 
 tion of quinine — black water fever. 
 
 2. Paroxysmal H.emoglobinuria. — An affection characterized by 
 the occasional passage of urine colored by hsemoglobin. It occurs in adults 
 and is more common in males than in females. The paroxysms are excited 
 by cold and exertion and last from a few hours to a day or two. It is thought 
 by some observers to have an essential relationship to Raynaud's disease; 
 by others to malaria. Pain in the lumbar region is common. The attacks 
 may be ushered in by chills followed by fever; more commonly the tem- 
 perature is normal or slightly subnormal. They recur at irregular intervals 
 for an indefinite time. 
 
 3. Epidemic Hemoglobinuria op the New-born. — The disease 
 develops about the fourth day and attacks a large proportion of the infants 
 in the maternity institution where it appears. There is bloody urine with 
 vomiting and purging, jaundice, hurried breathing, and cyanosis. It is 
 rapidly fatal. Post-mortem examination reveals enlargement of the spleen 
 with punctiform hemorrhages upon the surface and in the parenchyma of 
 the viscera. This disease is to be differentiated from icterus neonatorum 
 to which it bears only a superficial resemblance. 
 
 THE REPRODUCTIVE ORGANS. 
 
 In both men and women sexual neurasthenia, hypochondriasis, and 
 perversion frequently occur. Ungratified desire, excessive venery, and 
 unnatural sexual acts are more commonly the alleged than the actual 
 causes of various nervous and mental diseases. The two latter are prob- 
 ably manifestations more often than causes of such forms of disease. 
 Irregular manifestations may be on the one hand psychical, on the other 
 physical; frequently they are both. The field is a large one and the extent 
 to which it is to be investigated in individual cases may be left to the judg- 
 ment of the clinician. 
 
 The history or the actual manifestations of venereal disease in a 
 patient, or in an individual with whom the patient has had sexual relations, 
 are often of great importance in the diagnosis of an otherwise obscure case. 
 A gonorrhoeal discharge may solve the problem of an obscure and intract- 
 able arthritis or indicate the nature of serious tubal or other pelvic disease, 
 and explain an unlooked for ophthalmia in the new-born. Syphilitic lesions 
 or the scar of a chancre in the husband may be the key to the solution of 
 obscure nervous symptoms in the wife, or nutiitional disorders and lesions 
 of the organs of special sense in the child. 
 
 In the male, priapism, impotence, and spermatorrhoea occur as impor- 
 tant manifestations of disease. 
 
 (a) Priapism. — This term is used to designate abnormally frequent 
 and prolonged erection. The condition is not associated with libido scxualis 
 but with distress and pain and constitutes a morbid s3anptom. 
 
554 MEDICAL DIAGNOSIS. 
 
 It is often manifest in a mild degree in young boys. Even at the age 
 of one or two years it may be painful and distressing and often leads to 
 enuresis nocturna. It may be due to phimosis and disappear after circum- 
 cision. In the adult it may result from inflammatory irritation of the ure- 
 thral mucosa. It may follow the passing of a bougie and is very common in 
 gonorrhoea and in the chronic inflammation of the prostatic portion of the 
 urethra in those who have practised masturbation or indulged in sexual 
 excesses or irregularities. The condition may be due to excessive stimula- 
 tion of the centre in the lumbar cord. The latter form comes on during 
 sleep. The patient awakes with intensely painful priapism unattended by 
 the slightest libido sexualis. This presently subsides only to return when, 
 under the influence of deep sleep, the inhibition of the special spinal centre 
 is withdrawn. In severe cases sleep is seriously interrupted and the annoy- 
 ance of the patient is increased by the discharge of a thin mucus from 
 Cowper's glands and painful neuralgia in various parts of the body. This 
 form of priapism is often accompanied by impotence. 
 
 Priapism may be the result of stone in the bladder, inflammation of 
 the prostate, a perineal abscess, proctitis or periproctitis, inflamed hemor- 
 rhoids, or poisoning by cantharides. It is said to be symptomatic of certain 
 forms of neurasthenia and hysteria. It is a common symptom in fractures 
 of the spine, especially when the cervical portion is involved. It may occur 
 in myelitis, spinal meningitis, and in lesions of the pons and cerebellum. 
 It occurs in hydrophobia and tetanus and has frequently been observed 
 in leukaemia. 
 
 (b) Impotence— Impotentia Coeundi — This symptom may be me- 
 chanical, psychical, irritative, or paralytic. 
 
 1. Mechanical impotence arises from congenital or acquired deformi- 
 ties; loss of substance from ulceration, gangrene, or operation; the presence 
 of tumors, as Iwdrocele, enormous hernia, elephantiasis of the scrotum, and 
 the like. To this li^t must be added hypertrophy of the organ, tumior of 
 the glands, preputial or urethral calculi and defect, atrophy or destruction 
 of the testicles. To this group of causes is to be added deviation of the 
 erect penis from abnormally short frsenum and various infiltrations and 
 indurations in its tissues. A rare cause of impotence is deformity due to 
 ossification of the fibrous tissue in the organ. 
 
 2. Psychical. — This form of imi3otence arises from apprehension, 
 shame, or self-distrust. It may occur alike in those who have made too 
 great experience and in those who have made none, and the fear of it fre- 
 quently leads men about to marrj^ to take medical advice. It is sometimes 
 due to indifference, aversion, or dislike towards a particular person and in 
 rare instances to constitutional lack of sexual feeling. 
 
 3. Irritative. — There is premature ejaculation or even ejaculation in 
 the absence of sexual approach. This may occur in healthy individuals after 
 long abstinence. It is very often due to local irritation, to lesions resulting 
 from urethritis, or to excesses. The subjects ai-e usually neurasthenic, 
 the nervous condition being the cause in some cases, in others the effect 
 of the sexual irregularity. 
 
 4. Paralytic. — Under this heading are to be grouped those forms of 
 impotence caused by the loss of power to react to physiological stimuli on 
 
SYMPTOMS AND SIGNS: REPRODUCTIVE ORGANS. 555 
 
 the part of the sexual nerves or their centres. In the atonic cases anaimia 
 and relaxation of the parts are present and the patients are neurasthenic. 
 Sexual irregularities and excesses, immoderate indulgence in alcohol and 
 tobacco are causes. Certain drugs, as opium and its derivatives, nitre, 
 the salicylates and the bromides, taken in large doses or for long periods 
 of time, lead to this form of impotence. 
 
 Diseases of the brain and spinal cord may be the cause of paralytic 
 impotence. Tabes dorsalis and other affections, characterized by im- 
 paired function of the bladder or rectum or by local anaesthesia, are espe- 
 cially to be considered. This condition is also symptomatic of diabetes 
 mellitus, obesity, and cachectic states. 
 
 (c) Spermatorrhoea. — This term is used to designate the patho- 
 logical discharge of seminal fluid which takes place without erection or 
 sexual sensation during the act of micturition or defecation. The emissions 
 which occur at intervals of two or more weeks in continent young men 
 during sleep, and which are accompanied by lascivious dreams, are physio- 
 logical rather than pathological and are not to be considered under this 
 heading. When, however, these emissions recur at short intervals, or 
 every night, they become symptomatic of disease and the border-line 
 between such nocturnal pollution and spermatorrhoea is no longer clearly 
 defined. Gonorrhoea, onanism and sexual excesses are liable to be followed 
 by spermatorrhoea. Constipation, nervous diarrhoea, fissure of the anus, 
 seat-wormS; and proctitis may act as accidental causes. The patients are 
 neurasthenic and depressed, complain of headache, backache, and loss of 
 energy, are much given to the reading of advertisements upon loss of man- 
 hood and are the easy pre 3^ of quacks. A large proportion of those who 
 think they are victims of this disease do not have it, but suffer from chronic 
 gonorrhoea, prostatorrhcea, urethrorrhcea, and forms of phosphaturia. 
 The microscope is essential to the diagnosis, and it is necessary when sper- 
 matozoids are present to ascertain whether or not a sexual act has preceded 
 the emission of the fluid in question. If not, and especially if spermato- 
 zoids are present upon repeated examination, the diagnosis becomes posi- 
 tive. These bodies are present in the urine, which may be acid, of high 
 specific gravity, and contain oxalates, or alkaline with phosphates. 
 
 In the female pruritus vulvae, leucorrhoea, and disorders of menstrua- 
 tion may be symptomatic of various local and general conditions. 
 
 (a) Pruritus Vulvge. — This condition is a common result of inflam- 
 matory affections and displacements of the womb, ovarian disease, and 
 affections of the urethra, bladder, and kidneys. It is, especially in children, 
 a common manifestation of seat-worms and is very often the first symp- 
 tom of the diabetic woman to attract her attention to her condition. This 
 condition on the one hand frequently leads to masturbation; on the other 
 is not rarely the result of it. 
 
 (b) Leucorrhoea. — Vaginal discharge is an important sign of many 
 pelvic diseases. It is associated, very often in connection with pelvic 
 inflammations of mild grade, with the anaemias, especially when intense, 
 with conditions of debility and the later stages of chronic diseases when 
 they occur in early life and in particular with pulmonary tuberculosis. In 
 young children a purulent discharge indicates vulvitis or vaginitis, which 
 
556 MEDICAL DIAGNOSIS. 
 
 may be due to trauma, filth, ascarides, or gonorrhoea. In middle life an offen- 
 sive sanguinolent discharge may be the earliest sign of carcinoma uteri. 
 (c) Menstrual Derangements. — The normal menstrual function may 
 be deranged in various ways. It maj^ be absent for a time or cease alto- 
 gether — amenorrhoea; abnormally profuse — menorrhagia; or attended with 
 much distress and pain— dysmenorrhoea. These derangements are due to 
 local and to constitutional conditions. 
 
 1. Amenorrhoea. — Failure in the function may be a manifestation of 
 arrested development of the ovaries and uterus. The interruption of 
 menstruation may be physiological or pathological. 
 
 Physiological amenorrhoea is a characteristic sign of pregnancy and 
 usually persists during lactation. There are important exceptions to both 
 these rules. In very rare instances there is a shght menstrual discharge 
 during the first two or three months of gestation and many women men- 
 struate regularly during the period of nursing. Amenorrhoea occurs in 
 extra-uterine foetation. 
 
 Pathological amenorrhoea is observed in conditions of malnutrition, 
 as in overworked school-girls, in those suffering from chlorosis, and in 
 wasting diseases, as enteric fever, tuberculosis, diabetes, and exophthalmic 
 goitre. It may be symptomatic of powerful depressing psychical states, 
 as anxiety, worry,, or grief, and of nervous affections, as hysteria, or of 
 melancholia or other forms of insanity, and not infrequently occurs in young 
 immigrants. It is common in morphinism and other drug habits and in 
 cachectic states, whether due to chronic intoxication, as by mercury or 
 lead, or to malaria, cancer, nephritis, leukaemia, or profound anaemia from 
 any cause. The retention of the flow which takes place in cases of imper- 
 forate hymen, atresia vaginae, and analogous conditions cannot be regarded 
 as a form of amenorrhoea. 
 
 Delay in the estabhshment of menstruation is in some girls consti- 
 tutional and often hereditary; its early cessation may in some instances be 
 accounted for upon similar grounds. There are healthy women who cease 
 to menstruate at thirty or thirty-five. Premature menopause may be due 
 to atrophy of the ovaries following disease or their operative removal. 
 
 So-called vicarious menstruation, namely, the monthly discharge of 
 blood from the nose, lungs, stomach, from hemorrhoids, ulcers or wounds, 
 in the absence of the normal flow, is described. There is no physiological 
 basis for such a phenomenon and it is probable that in the- cases described 
 the conditions causing amenorrhoea have also caused hemorrhages, the 
 regular periodicity and duration of which have corresponded to the men- 
 strual period less in fact than in fancy. 
 
 2. Menorrhagia. — Abnormally profuse menstruation may be symp- 
 tomatic of disorders of the pelvic organs or of constitutional disease. It 
 occurs in a great variety of local diseases but especially in chronic endo- 
 metritis, submucous myomata, polypi, and uterine displacements. Menor- 
 rhagia is an occasional symptom in haemophilia, scurvy, purpura haemor- 
 rhagica, and leukaemia. When menstruation takes place in the course of 
 the acute infectious diseases, for example influenza, enteric fever, or variola, 
 it frequently amounts to menorrhagia. Other conditions in which this 
 symptom is occasionally observed are intense jaundice, phosphorus poison- 
 
SYMPTOMS AND SIGNS: REPRODUCTIVE ORGANS. 557 
 
 ing, alcoholism, cirrhosis of the liver, and valvular disease of the heart. 
 The administration of certain drugs, as ergot, gossypium, aloes, and the oil 
 of savine, is sometimes followed by menorrhagia. Irregular menstruation, 
 sometimes profuse, not infrequently precedes the menopause. 
 
 3. Dysmenorrhcea. — This term is used to designate collectively the 
 symptom-complex in difficult menstruation of which pain is the chief 
 element. The morbid conditions in which it occurs may be arranged under 
 two headings, affections of the sexual system and general diseases. 
 
 Under the first heading are to be included those diseases in which there 
 is an obstruction to the outflow of the menstrual fluid, as in contraction of 
 the internal or external os uteri, congenital narrowing of the cervical canal 
 or a narrowing acquired as the result of flexions of the uterus, the presence 
 of tumors or cicatricial contractions following unwise treatment. This 
 form is spoken of as mechanical dysmenorrhcea. Here also are to be con- 
 sidered the dysmenorrhoeas caused by irritable or inflamed conditions of 
 the mucosa secondary to chronic metritis, displacements, tumors and 
 disease of the ovaries. 
 
 Under the second heading we include the dysmenorrhcea of neurotic 
 persons — neuralgic or nervous dysmenorrhcea. This form is common alike 
 in badly-nourished, anaemic, unmarried women and in women who have 
 borne children. Very frequently no adequate lesions of the pelvic viscera 
 can be discovered; more commonly trifling abnormalities such as cause 
 insignificant symptoms in otherwise well-nourished and healthy women. 
 The patients are neurasthenic and frequently hysterical. The symptoms 
 vary greatly. In many cases they amount merely to an intensification of 
 the ordinary discomforts which attend the periodical sickness; in others 
 the patient may writhe with anguish or manifest the most intense reflex 
 phenomena as nausea, vomiting, headache, or convulsions. Usually these 
 symptoms subside upon the establishment of the flow; sometimes they 
 continue with remissions and exacerbations throughout the whole period, 
 and in some cases they cease entirely only to recur toward the close of the 
 process. 
 
 Membranous d^-smenorrhoea — decidua menstrualis — a form of dys- 
 menorrhcea in which, with recurring menstruation, hollow membranous 
 casts of the uterus are expelled with great pain. These casts consist of a 
 thickened menstrual decidua. They vary from membranous fragments to 
 complete triangular casts of the interior of the womb, showing the openings 
 of the tubes and the internal os. They are usually expelled upon the second 
 or third day, sometimes later. The pains are paroxysmal and very intense 
 and cease immediately upon the expulsion of the membranes from the 
 womb. This form of dysmenorrhcea is sometimes encountered in women 
 suffering from chronic metritis or endometritis. It is very chronic, some- 
 times continuing throughout the entire menstrual life of the individual. 
 There is complete relief during the intermenstrual periods. The condition 
 is to be differentiated from early abortion and extra-uterine pregnancy. 
 
 4. Metrorrhagia. — An abnormal uterine hemorrhage is to be distin- 
 guished from an excessive menstrual discharge or menorrhagia, with which 
 it is, however, very commonly associated. It may occur in diseases of the 
 reproductive organs or in certain general affections. Metrorrhagia due to 
 
558 MEDICAL DIAGNOSIS. 
 
 local disease usually indicates disease of the uterus and mostly the presence 
 of new growths, namely, carcinoma, sarcoma, or fibroid tumors. The 
 bleeding in carcinoma at first takes the form of an increased menstrual 
 flow usually more and more prolonged and frequently accompanied by a 
 more or less abundant watery discharge. The bloody discharge after a 
 time persists during the intermenstrual periods and becomes wholly atyp- 
 ical. The occurrence of bleeding in women who have passed the meno- 
 pause is very suggestive and renders an examination per vaginam at once 
 imperative. The metrorrhagia of sarcoma and in particular of sarcoma 
 involving the uterine mucosa presents similar characters. Subserous 
 fibromata do not bleed. Those situated in the substance of the uterus, if 
 near the serous surface, bleed little or not at all. Submucous fibromata 
 bleed more or less freely. Necrotic changes in uterine neoplasm ata are 
 attended by a foul-smelling discharge in which shreds of broken-down 
 tissue are present. The atypical bleedings which attend inflammatory 
 affections are less frequent and less profuse. Those which are caused by 
 mucous polypi are often profuse and continuous. 
 
 Exceptionally metrorrhagia occurs in valvular disease of the heart, 
 especially mitral stenosis, and is said to have been observed in cirrhosis 
 of the liver. This symptom occurs infrequently in the acute infectious 
 febrile diseases, as enteric fever, measles, scarlet fever, variola, cholera, 
 and malaria, and in phosphorus poisoning and scurvy. In the last the 
 blood loss is sometimes copious. Difficulties arise in the differential diag- 
 nosis of the cause of the bleeding when the patient suffering from the 
 foregoing diseases has also local conditions in themselves capable of caus- 
 ing metrorrhagia or when, during the acute illness or shortly before its 
 onset, an abortion or miscarriage has taken place. 
 
 XIII. 
 
 GENERAL SYMPTOMATIC DISORDERS OF THE 
 
 NERVOUS SYSTEM. 
 
 PAIN. 
 
 Pain is a symptomatic sensory neurosis. The pain sense is to be dis- 
 tinguished from the tactile sense, the pressure sense, and the thermal sense. 
 It is, however, so closely associated with the last two that a considerable 
 degree of pressure, unusual heat, or intense cold is accompanied by pain. 
 Pain is in the strictest sense a symptom. It is purely subjective, hence its 
 value in diagnosis is to a large degree dependent upon the individual 
 peculiarities of the sufferer, the nature of the primary lesion or disease, and 
 concomitant phenomena, many of which are objective. Judged by these 
 standards pain is a symptom of the most varied intensity, from a trifling 
 discomfort without direct diagnostic significance to agony so extreme as 
 to cause death. The pain sense is universally distributed throughout the 
 body, the only structures in which it is wholly lacking being the hair and 
 
SYMPTOMS AND SIGNS: PAIN. 559 
 
 nails. Variations in the pain sense in different localities, probably due to 
 modifications in the sensory nerve supply, must be invoked in explanation 
 of the different kinds of pain in the various viscera and other anatomical 
 structures. Etiological factors of the most diverse kind have to do with 
 pain in its relation to time, as shown in its onset, course, and decline. 
 
 Pain is dependent upon consciousness. In profound coma, as that of 
 surgical anaesthesia, consciousness and pain are alike wholly abolished. 
 When consciousness is less completely impaired there are objective mani- 
 festations of painful impressions, though the patient, upon recovering, 
 may have no recollection of pain. Pain may be absent in shock. Individ- 
 uals usually make no complaint of pain during the period of shock follow- 
 ing gun-shot wounds or other severe traumatism. Under these circum- 
 stances pain comes on as shock subsides. 
 
 Etiology. — Pain is functional or organic. The temporary pain in over- 
 worked muscles is functional. The pain in pleurisy and gastric ulcer is 
 organic. Pain occurs as a more or less prominent symptom under the 
 following conditions: 
 
 1. Excessive or unduly prolonged physiological activity, either 
 physical, as in muscular strain or fatigue, or psychical, as in the head- 
 ache which follows undue intellectual effort. The pains of parturition 
 are physiological. 
 
 2. Traumatism of all kinds. 
 
 3. Circulatory disturbances, (a) Passive congestion. An example of 
 pain thus caused is to be found in thrombosis of the crural vein, formerly 
 known as phlegmasia alba dolens. (b) Active hyperemia, for example, the 
 cutaneous pain of local irritants, as heat, cold, mustard and the like. Pain 
 in the region of the spleen after running is an example of visceral pain due 
 to this cause, (c) Ana3mia. Examples of this form of pain are headache 
 upon exertion and the neuralgias. 
 
 4. Inflammation. Pain is a prominent symptom in all forms of 
 inflammation. 
 
 5. Toxsemia. The offending substance or substances in the blood 
 may be the result of (a) infection, as in the acute specific fevers and malaria; 
 (b) incomplete or perverted physiologicochemical processes or the defec- 
 tive elimination of waste, as in the headache of uraemia and diabetes and 
 the pains of gout, rheumatism, and lithsemia; (c) the action of drugs or 
 poisons. Pain due to this cause may be hypersemic, as in the head pain 
 produced by amyl nitrite and quinine; inflammatory, as in the later stages 
 of narcotic poisoning; purely nervous, as an abstinence symptom in mor- 
 phinism and the pains of the chloral habit and lead colic. 
 
 6. Changes in the arteries. Examples of pain due to this cause are 
 found in syphilis, chronic alcoholism, chronic lead poisoning, migraine, 
 and aneurism. To this general topic must also be referred the pain in 
 intermittent claudication and angina pectoris. 
 
 7. All organic painful diseases, abscess, tumor, both benign and 
 malignant, and various diseases of the viscera, whether the pain be due to 
 changes in the organ itself or disturbance of adjacent structures by pres- 
 sure or displacement. 
 
 8. Caries and other diseases of the bones. 
 
560 MEDICAL DIAGNOSIS. 
 
 9. Neuropathic conditions, for example, neurasthenia, hysteria, tabes, 
 dysmenorrhoea, and tetanus. 
 
 10. Reflex irritation, as the supra-orbital pain in indigestion and the 
 various locaHzed head pains of eye-strain, pain in the external auditory 
 meatus in dental irritation, and coccygodynia in uterine disease. Anal- 
 ogous are the pains in the knee which occur in hip-disease and painful 
 sensations due to the irritation of the nerve stump referred to the hand or 
 foot, as the case may be, in an amputated limb. 
 
 The cause of pain is very often simple. In many cases, however, it is 
 complex, two or moi-e of the foregoing factors being operative. 
 
 Mode of Expression of Pain. — Pain must be studied subjectively, 
 as we experience it in our own person, and objectively, as manifested by 
 the movements, attitudes, and verbal descriptions of the sufferer. 
 
 Subjectively we know that certain external impressions give rise to 
 the sensation of pain and that this sensation is accompanied by movements 
 of withdrawal from the object causing the pain, by particular attitudes of 
 the body and contortions of the facial muscles. Under certain circumstances 
 there are inarticulate sounds, cries or groans expressive of pain; these 
 phenomena are varied according to the suddenness and the intensity of the 
 pain and its character. 
 
 Objectively we recognize in these phenomena a manifestation of pain 
 in others. The gestures that are characteristic of different varieties of pain 
 have been described by W. H. Thomson. In pains due to inflammation 
 the patient avoids touching the painful part, or approaches it very cau- 
 tiously. Thus the hand passes over an inflamed joint with a hovering 
 gesture. If the pain be deeper seated the gestures are indicative of its 
 distribution and the character of the inflamed tissue. Thus the substernal 
 pain of bronchitis as indicated by the whole hand laid upon the sternum 
 and passed over the chest. In pleurisy the location of the pain is indicated 
 by the tips of the straightened fingers, the natural gesture expressive of 
 the stabbing or lancinating character of the pain. Precordial pain, if 
 severe, is indicated by the tips of the bent fingers. The gestures by which 
 abdominal pain is indicated are equally significant. In pains associated 
 with lesions of the intestines the open hand is passed over the abdomen 
 with a rotary movement. In the localized pain of appendicitis the open 
 hand is held over the affected area with the fingers lightly flexed. In peri- 
 tonitis the tips of the fingers are used but they touch the surface very gently 
 and cautiously. Local pains resulting from visceral disease or colic are 
 indicated by less guarded gestures; radiating pains by a repeated sweep 
 of the hand in the same direction; distention pains and colic by a firm 
 pressure upon the abdomen; neuralgic pains by repeated firm pressing 
 movements of the hand in the direction of the involved nerve. The light- 
 ning pains of tabes are often indicated by a quick sweep of the tips of the 
 fingers along the limb. 
 
 The shrinking of the whole body or of a member from an object ca- 
 pable of causing or increasing pain is a characteristic gesture; so also is the 
 limping gait in painful conditions of a lower extremity. For diagnostic 
 purposes it is important to bear in mind the fact that limping is frequently 
 due to restricted movement not necessarily accompanied by pain. Very 
 
SYMPTOMS AND SIGNS: Px\IN. 561 
 
 characteristic are the attitudes in certain painful affections: retraction 
 of the head in meningitis, the shallow breathing and flexion of the trunk 
 toward the affected side in plastic pleurisy, the strong bending forward in 
 colic, the rigid trunk and flexed thighs in peritonitis, the semiflexion and 
 immobilization of inflamed joints. 
 
 Sudden immobility of the whole body is diagnostic of angina pectoris. 
 
 The facies of pain constitutes a most important objective manifesta- 
 tion, whether it be the contorted, dusky pale face of sudden agony or the 
 drawn and pallid countenance of prolonged and repeated suffering. Severe 
 pain, especially when paroxysmal, is frequently accompanied by dilatation 
 of the pupils, rapid respiration, flushing or pallor, free sweating, increased 
 arterial tension, and sensations of faintness. Inarticulate sounds and invol- 
 untary exclamations are familiar objective manifestations of sudden and 
 intense pain. 
 
 Some of the objective manifestations of pain are involuntary and 
 cannot be simulated; others may, with or without the conscious intention 
 to deceive, be feigned or exaggerated. By the verbal description we gain 
 information as to the location, character, intensity, and duration of pain, 
 and the patient's opinion as to its cause. The accounts are much modified 
 by the temperament, power of expression, and general experience of the 
 sufferer. 
 
 Not only the ability to express the subjective sensation of pain varies 
 greatly but also the susceptibility. There are on the one hand individuals 
 in whom the pain sense is but slightly developed; on the other those in 
 whom it is present to an abnormal and excessive degree. 
 
 There are racial differences in the susceptibility to pain and the mode 
 of expressing painful sensations. The Latin races manifest a greater sus- 
 ceptibility to pain than the Anglo-Saxons. Oriental apathy is proverbial. 
 On the other hand Hebrews appear to have a peculiar susceptibility to pain. 
 
 The individual susceptibility is much modified by temperament. 
 Phlegmatic persons suffer less and show such sufferings as they experience 
 much less forcibly than those of sanguine or nervous temperament. The 
 neurotic individual suffers in proportion to the instability of his nervous 
 organization. The pains of hypochondria and hysteria are probably of 
 central origin. They are of irregular distribution, inconstant, and occur 
 independently of the recognized causes of pain. They are probably none 
 the less real. They diminish in intensity or disappear when the patient's 
 attention is diverted from them and are aggravated by suggestion. The 
 painful aura of epilepsy is also of central origin. Fright, expectation, and 
 dread intensify painful impressions. 
 
 Somewhat analogous to the influence of temperament is that of the 
 power of expression. The manifestations of pain are sometimes much less 
 marked in the rude and uneducated than those in the higher walks of life. 
 Apathy is a striking mental condition in hospital patients. 
 
 Experience is not less important. Habitual exposure to hardship 
 benumbs the pain sense. On the other hand a life of refinement and luxury 
 exalts it. Prolonged suffering or frequent recurrence of painful sensations 
 augments the sensibility and each recurrence becomes less endurable. 
 There is a popular phrase to the effect that the patient is worn out with pain, 
 
 36 
 
562 MEDICAL DIAGNOSIS. 
 
 The manifestations of painful sensations are much influenced by cir- 
 cumstance and motive. Consciousness of pain is greatly diminished during 
 intense religious or other excitement and upon the field of battle. When 
 the excitement subsides pain asserts itself. The repression of the mani- 
 festations of pain by religious fanatics, the stoicism of captives under tor- 
 ture, and the fortitude with which the brave endure suffering set common 
 experience at naught and emphasize the purely subjective nature of pain 
 as a S3miptom. Not uncommonly patients understate their sufferings 
 either from motives of pride or reserve or in order to avoid operation or 
 treatment. On the other hand patients frequently appear to overstate 
 their sufferings in order to secure sympathy or for other obvious motives. 
 Women are more susceptible to pain than men and according to circum- 
 stances manifest it with greater intensity or endure it with greater fortitude. 
 
 The patient's description of his sufferings, the character of the con- 
 comitant phenomena, and the presence of an obvious cause will enable the 
 physician to form an estimate of the significance of pain. In young chil- 
 dren, in certain forms of insanity, and under other circumstances in which 
 patients are unable to describe their sensations the ol:)jective manifestations 
 of pain are of diagnostic value in determining its seat and intensity. The 
 physician must be on his guard in any particular case against under-esti- 
 mating the importance of pain or being deceived by its unintentional or 
 purposeful exaggeration. 
 
 Varieties of Pain. — Pain in the broadest sense may be considered as 
 parenchymatous or neuralgic. In the former the terminal sensory fila- 
 ments are irritated; in the latter the nerve-trunks, the sensory roots, or the 
 sensory centres. Parenchymatous pain is as a rule less intense than neu- 
 ralgic pain and the spontaneous remissions are less marked. In the former 
 the pain in the whole affected region is increased by pressure, while in the 
 latter, though in some cases the entire region is tender under pressure^ 
 the general rule is that the tenderness is localized to the course of the nerve- 
 trunk, especially when it is superficial or overlies a bone or makes its exit 
 through dense fasciae — so-called tender points. An example of parenchym- 
 atous pain is that which occurs in visceral diseases and the diffuse head- 
 aches; examples of neuralgic pains are the various actual neuralgias which 
 occur as primary affections in persons otherwise in fair health, in the ca- 
 chectic and broken-down, and as secondary affections in gout, syphilis, and 
 diabetes, and the lightning pains of spinal disease, especially tabes. The 
 pains originating from suggestion and autosuggestion and many of the 
 forms of hysterical pain are of central origin and may be regarded as 
 parenchymatous. 
 
 Pain has been described as acute, sharp, lancinating, dull, throbbing, 
 grinding, shooting, burning, chilling, shivering, boring, creepy, griping or 
 colicky, itching and formicating. These descriptive adjectives indicate not 
 so much distinct variations in the quality of pain as the simultaneous 
 recognition of other associated sensations; hence, the descriptions of pain 
 are often complex or picturesque in proportion to the vividness of the 
 patient's imagination and his powers of expression. 
 
 (a) Acute Pain — Sharp, Lancinating, or Stabbino. — These adjec- 
 tives are employed to describe the pain which attends acute inflammations 
 
SYMPTOMS AND SIGNS: PAIN, 563 
 
 of serous membranes, as pleurisy, pericarditis, and peritonitis; the pains 
 of acute arthritis; acute neuralgias; the painful forms of neuritis; acute 
 phlegmonous inflammation, and the pains of thoracic aneurism. The 
 lightning pains of tabes belong to this group and are characterized by 
 their suddenness, brief duration, and intensity. They are sometimes spoken 
 of as shooting pains. 
 
 (b) Dull pain is symptomatic of inflammation of the mucous mem- 
 branes and the viscera. It occurs also in chronic inflammations. 
 
 (c) Throbbing or pulsating pain is encountered in acute superficial 
 phlegmonous inflammations. This is the pain of whitlow — paronychia. 
 
 (d) Grinding, burning, or gnawing are adjectives used to describe 
 the pain which occurs in diseases of the bones and periosteum, in aneurism 
 of the thoracic and abdominal aorta, in carcinoma of the viscera and of 
 the breast. Pain of this kind sometimes occurs in lithsemic conditions and 
 in the later stages of acute gout. The localized neuralgic pain in the head, 
 known as clavus, and the persistent local pains which occur in some forms 
 of tabes are described as boring. 
 
 (e) Aching pains are not unlike the preceding. They are usually 
 persistent and intense and, when severe, throbbing. Aching is a term 
 used to describe pains in the head, those resulting from dental caries 
 and forms of neuritis and myalgia, especially lumbago — hence, cephalalgia, 
 odontalgia, rhachialgia. The pains which occur in the initial period of 
 acute infectious diseases, as, for example, variola, influenza, and dengue, 
 and are referred to the bones and muscles, are of this character. They 
 are frequently associated with painful sensations of chilling or shiver- 
 ing and, since they spread from one part to another, are often described 
 as creeping. 
 
 (f) Burning pain occurs in the superficial cutaneous lesions caused 
 by intense heat or the action of the sun's rays, and caustic applications. 
 It is characteristic of certain forms of neuritis. Circumscribed neuralgias 
 are frequently associated with the sensation of burning pain — causalgia. 
 
 (g) Itching pain occurs in irritable states of the mucous membranes, 
 stich as attend certain forms of conjunctivitis, some acute diseases of the 
 upper air-passages, and hay fever and some forms of inflamed hemorrhoids. 
 Formication is a term used to describe a sensation like that of ants or other 
 insects crawling over the skin. It is occasionally painful. 
 
 (h) Griping or colicky pains are those which attend the overaction 
 of the muscular walls of tubal structures. Flatulent or other distention 
 of the stomach or intestines induces pain of this kind — popularly gripes 
 or belly-ache. The pains upon overaction of the muscular wall of the intes- 
 tines caused by indigestible food, cathartic drugs, irritant poisons, and 
 certain infections, as those of cholera morbus and cholera Asiatica, are 
 colicky. To this group belong also the intense paroxysmal pains which 
 attend the passage of hepatic and renal calculi — biliary colic; renal colic. 
 These pains are frequently spoken of as cramp, a term also applied to 
 painful contraction of the skeletal muscles, as those of the calf, toes, fin- 
 gers, the pains of tetanus and strychnine poisoning and those which occur 
 in habitually over-used muscles in certain occupations — writer's cramp, 
 piano-player's cramp. 
 
564 MEDICAL DIAGNOSIS. 
 
 (i) Tenesmus is the term used to describe the painful bearing-down or 
 straining sensations which accompany expulsive efforts from the outlets 
 of the pelvic organs under certain abnormal conditions, as urination when 
 there is acute inflammation of the bladder, urethra, or prostate gland, or 
 stricture; defecation in proctitis or inflamed piles or hydatid or other 
 tumors compressing the rectum. The bearing-down pains of labor are 
 tenesmic. 
 
 Pain is modified by physical and psychical influences. Among the 
 former are pressure, mechanical irritation, movement, and rest. 
 
 Modifications by Physical Causes. — The pain which is caused by 
 pressure and the increase of pain upon pressure are described as tenderness. 
 This will be discussed later under a separate heading. 
 
 Mechanical irritation causes pain or aggravates it in inflammation 
 and ulceration of mucous membranes, as in aphthous and other forms of 
 stomatitis, angina tonsillaris, peptic ulcer and fissure of the anus, inflamed 
 hemorrhoids, and in various lesions of the tegumentary structures. Even 
 slight mechanical irritation of the normal mucous membrane of the orifices 
 of the body causes pain, as the presence of a minute foreign body under 
 the eyeHd, the introduction of a probe into the nasal chambers, or the 
 passing of an urethral bougie. 
 
 Movement aggravates the pain of wounds, fractures, and inflammations. 
 The pain which attends acute inflammation of serous membranes is espe- 
 cially increased upon movement, as is to be observed upon full inspiration 
 in pleurisy and upon flexion and extension of the thigh in peritonitis. 
 Movement intensifies the pain of arthritis, hence the involuntary immobili- 
 zation of the joints and the rehef afforded by splints. Movement also greatly 
 increases the pains of vertebral disease and neuritis. The pains of myalgia 
 and of all acute inflammations involving the muscles are augmented by 
 movement of the affected part. In many instances the pains of inflamma- 
 tory conditions and of visceral disease are increased by the motion of the 
 body in transportation. 
 
 Rest, upon the contrary, is commonly attended with remission of pain; 
 functional rest, by its temporary disappearance, as in myalgia, the headache 
 of eye-strain, headache from prolonged study, and the pain of gastric ulcer. 
 The foregoing facts indicate the value of attitude, posture, and movement 
 in determining the diagnostic significance of pain. 
 
 Cold and heat modify pain. Hot apphcations are usually soothing; 
 cold apphcations only occasionally afford rehef. The apphcation of heat 
 or cold to the spine may indicate the level of disease by local intensification 
 of pain. Apphcations of heat or cold frequently enable the dentist to 
 locate the offending tooth in diffuse pain involving the distribution of the 
 dental branches of the fifth nerve. 
 
 Seasonal influences modify habitual tendencies to pain. The pains of 
 chronic arthritis, gout, and neuralgia are worse in cold and damp weather, 
 better when it is warm and dry. The influence of climate upon such chronic 
 painful affections is similar; dry, equable, warm, inland chmates being 
 more favorable than those of the opposite characteristics. 
 
 Modifications by Psychical Causes. — Among the psychical influences 
 which modify pain and its manifestations, intense emotion, excitement, 
 pride, and fortitude have already been mentioned. Other influences of 
 
SYMPTOMS AND SIGNS: PAIN. 565 
 
 more importance in diagnosis are diversion, preoccupation, expectant 
 attention, suggestion, and autosuggestion. They may be active under 
 certain circumstances and to some extent in almost any kind of pain; but 
 they are agencies of especial importance in neurotic persons and in those 
 suffering from hysteria, neurasthenia, and hypochondriasis. Not only are 
 the pains for which there are no obvious physical causes augmented or 
 diminished, or made to disappear or shift to other parts, by purely psychical 
 influences, but even those which attend actual injury and manifest disease 
 ma}^ be greatly modified for a brief period of time. In the hypnotic state 
 pre-existing pain may be made to disappear and definite pain aroused 
 with readiness. It is evident that persons of great determination may 
 inhibit the manifestation of pain under the stress of powerful motives. 
 There are also rare individuals who appear to be able to inhibit the 
 sensation of pain. 
 
 Time. — Pain in relation to time may be occasional, constant, persistent, 
 intermittent, recurrent, or paroxysmal. Pain that continues for any length 
 of time shows marked remissions and exacerbations. The remissions are 
 due to functional exhaustion of the pain sense. 
 
 Distribution. — Pain may be (a) diffuse or general, or (b) circum- 
 scribed or local. 
 
 Diffuse pain is symptomatic of the stage of onset in the majority 
 of the acute febrile infections. It varies in intensity from a mere sense of 
 malaise or general soreness, as in enteric fever, to the severe aching of 
 influenza, dengue, or variola. It occurs also in angina tonsillaris, partic- 
 ularly the lacunar form, and in trichiniasis. Diffuse pains attend certain 
 stages of some chronic diseases, as syphilis, lithsemia, and saturnine and 
 mercurial intoxication. They are sometimes described as vague and are 
 often shifting. They are probably peripheral in origin and due to the 
 action upon the nervous system of toxic substances in the blood. 
 
 Circumscribed or local pain occurs as a symptom in the greatest 
 variety of morbid conditions. It is in fact the most common and most 
 important of the subjective manifestations of disease. Its value in diag- 
 nosis depends largely upon the ability of the physician to estimate the ac- 
 curacy of the verbal description, the spontaneity of the accompanying 
 objective phenomena, the anatomical relationships of the pain itself, the 
 underlying pathological process, and the importance of alleged or manifest 
 causes. Pain, and in particular local pain, may be a danger signal, a sign 
 post, a gauge of the progress or extension of disease, a counter check to 
 objective phenomena, or it may be to the unwary or ill-informed physician 
 a delusion and a snare. 
 
 Feigned Pain. — The simulation of pain is common enough in malinger- 
 ing, neurasthenia, and hysteria. The motives of malingering are innumer- 
 able. In neurasthenia and hysteria they usually consist of a morbid crav- 
 ing for sympathy. The detection of simulated pain is in some cases 
 attended with difficulties that are insurmountable. In malingering the 
 simulation of pain is usually overdone. The distribution of the pain does 
 not conform to known anatomical rules. Suggestion is of importance. The 
 objective phenomena commonly associated with intense pain are wanting 
 or incongruous. 
 
566 MEDICAL DIAGNOSIS. 
 
 To properly estimate the value of pain in an obscure case it is some- 
 times desirable to have the patient under the close observation of an experi- 
 enced nurse or attendant or in a hospital for some days. 
 
 Significance of Pain. — In general terms local pain is symptomatic of 
 disease of the part to which it is referred. Organic headache, angina ton- 
 sillaris, the pain in the side in pleurisy, in the abdomen in peritonitis, in 
 the joints in arthritis, and various forms of pain due to traumatism, are 
 examples of the relationship of local pain to local disease. As regards the 
 anatomical structure involved pain may be tegumentary, muscular, osseous, 
 visceral, or neural. Very commonly the pain is also Hmited to the region or 
 organ affected. But there are numerous exceptions to these statements, 
 and we find local pain frequently symptomatic of a pathological process in 
 a distant part, or local disease causing pain in an extended area. The 
 recognition of these facts is of cardinal importance in estimating the value 
 of local pain in diagnosis. 
 
 Referred Pain. — A familiar example is the intense pain over the supra- 
 orbital notch sometimes felt upon eating an ice. The organ affected is 
 probably the stomach, the location of the pain being determined by the 
 association of sensory nerves from that organ with the trifacial. Very 
 curious instances of referred pain have been reported — a case in which 
 rubbing the forearm caused pain in the chest; another in which rubbing 
 or pinching a mole on the leg was attended by sharp pain in the chin. 
 
 Referred pains manifest themselves in: 
 
 1. Symmetrical Areas. — A case is reported by Mitchell in which a 
 shell-wound of the right foot at once gave rise to burning pain in both feet. 
 A shell-wound of the left thigh caused an immediate reference of pain to 
 the same area on both sides, so that the patient supposed he was shot 
 through both thighs. Again, an injury to the median and ulnar nerves was 
 attended by pain in the opposite hand. 
 
 Allochiria is the name given to the phenomenon of pain or other sen- 
 sation referred to a symmetrical area. It has been observed in tabes and 
 in postdiphtheritic neuritis. 
 
 2. Functionally Associated Organs. — Pain in the mammae is 
 common in congestion of the pelvic organs and dysmenorrhoea; pain in 
 the glans penis or testicle in renal colic; diffuse pain in the abdomen in the 
 early stage of appendicitis. 
 
 3. Segmental Areas. — Visceral disease is frequently attended by 
 pain and tenderness referred to areas corresponding to the nerve supply 
 of a given spinal segment. The affected organs receive their sensory nerve- 
 fibres from the same segment of the spinal cord from which arise the fibres 
 of the sensory areas to which the pain is referred. In the words of Head: 
 " As the sensory and localizing power of the surface of the body is enor- 
 mously in excess of that of the surface of the viscera, an error of judgment 
 occurs, the diffusion area being accepted by consciousness and the pain 
 referred to the surface of the body instead of to the organ actually affected." 
 Hence the pain in intestinal colic is referred to the whole abdomen; that of 
 hepatic colic to the epigastric zone, and that of renal colic to the lumbar 
 region. So also pain in the heart, lungs, liver, and stomach may be referred 
 to areas innervated by the cranial nerves and nerves given off from the 
 
SYMPTOMS AND SIGNS: PAIN. 567 
 
 cervical plexus, and the pain in disease of the pelvic organs is very com- 
 monly referred to the back. A striking example of this kind of pain-refer- 
 ence is seen in the pam and exquisite tenderness of the right hypochondrium 
 sometimes encountered in diaphragmatic pleurisy. 
 
 4. Longitudinally Related Areas. — Pain arising in the course of 
 a nerve may be referred to its terminal distribution. The pain in the stump, 
 which appears to be in the amputated foot, is a familiar example. The 
 lightning pains of tabes, the thigh pains in mahgnant disease of the rectum 
 and in psoas abscess, and the pain around the umbilicus in vertebral caries 
 are further illustrations. Sometimes the areas are not so directly related, 
 as in the knee pain in hip-joint disease, the shoulder pain in disease of the 
 liver, and the pain in the distribution of the ulnar nerve in angina pectoris. 
 
 Peripheral pain may be an early and suggestive symptom in organic 
 disease of the brain and spinal cord. In meningitis the pains in the back 
 and limbs may be very severe. The joints are frequently the seat of pain, 
 which may be more or less constant or lancinating and paroxysmal. 
 
 Painful Crises. — Severe and prolonged attacks of pain, associated with 
 functional disturbances and wholly independent of local organic disease, 
 occur in some cases of locomotor ataxia and are known as the tabetic crises. 
 They are (a) cardiac — intense precordial pain accompanied by a feeling of 
 oppression and rapid and irregular pulse; (b) gastric, the most common — 
 sudden severe pain in the epigastrium, with vomiting, rapid and irregular 
 pulse, sometimes symptoms of collapse; there may be vomiting without 
 pain or pain without vomiting; (c) laryngeal, which is comparatively 
 rare — pain in the larynx with paroxysmal cough, inspiratory stridor and 
 sensations of choking; (d) pharyngeal, also rare — painful acts of degluti- 
 tion following one another at short intervals and lasting from some minutes 
 to half an hour. Intestinal, rectal, urinary, and genital crises have also 
 been described. Suddenness of onset, intensity, paroxysmal character, 
 and abrupt termination are characteristic of these attacks. The absence 
 of lesions in the affected viscera either during the attacks or in the intervals 
 between them is of diagnostic importance. Errors in diagnosis are common. 
 
 Localization of Pain. 
 
 Superficial pains are mostly symptomatic of diseases of the under- 
 lying parts, but they may be referred. 
 
 Deep-seated pain attends inflammatory and ulcerative diseases of 
 the viscera, mediastinal tumor, aortic aneurism, visceral cancer, and dis- 
 ease of the bones. 
 
 Pain may be unilateral or bilateral. The former usually attends mor- 
 bid processes confined to the affected side; the latter those involving both 
 sides or of central origin. This rule is far from being absolute. The pain 
 caused by floating kidney is occasionally referred to the opposite side of 
 the abdomen. 
 
 The more important local pains and their diagnostic significance are 
 now to be considered. 
 
 Pain in the Head. — (a) Headache is a term used to designate pain 
 referred to various regions of the head. It may be paroxysmal or con- 
 
568 MEDICAL DIAGNOSIS. 
 
 tinuous. The term cephalalgia was applied by the ancients to slight, 
 limited, or transitory headaches; the term cephala^a to severe, deep-seated, 
 and chronic pains in the head. Headache is in many cases a symptom of 
 such importance and prominence that it overshadows all others and lends 
 to the clinical picture its most characteristic feature, often at first sight its 
 only obvious feature. Headache is a symptom very often significant 
 when other phenomena are obscure. It thus acquires a high degree of 
 diagnostic importance. 
 
 Organic and Functional Headaches. — Headaches due to lesions of 
 the skull or intracranial disease are organic; those due to other causes are 
 functional. In general terms headache is the manifestation of the irrita- 
 tion of sensory nerve-fibres caused by derangement of pressure or tension, 
 inflammation, toxaemia, and reflex disturbances. It is probable that the 
 meninges are chiefly concerned in the causation of headache. The sub- 
 stance of the brain in the lower animals does not respond to direct irrita- 
 tion by the manifestations of pain; and lesions of cerebral tissue not directly 
 or indirectly involving the membranes may exist without causing headache. 
 The meninges and especially the dura, on the other hand, are directly or 
 indirectly implicated in those pathological processes which give rise to 
 headache. The sensory nerve supply of the dura in the anterior three- 
 fourths of its extent, that of the falx and probably that of the tentorium 
 are derived from the trigeminus, while the dura mater of the posterior fossa 
 is supplied with sensory fibres from the vagus. The trigeminus is the nerve 
 of sensation to the scalp as far back as the vertex, while the posterior 
 branches of the upper four cervical nerves supply the muscles and the skin 
 of the back of the neck and the occiput. Sometimes headache is referred 
 to the scalp; usually the pain is deep-seated and intracranial. In rare 
 cases superficial headaches are essentially myalgic, the pathological condi- 
 tion involving the occipitofrontal, temporal, or sternomastoid muscles. 
 
 The following clinical considerations in regard to headache are 
 important: 
 
 Distribution of Headache. — This pain is usually bilateral. It may 
 be frontal, occipital, parietal, and temporal, vertical or diffuse. The area 
 most commonly involved is frontal, next in order of frequency is diffuse 
 headache, then follow in the order named vertical, occipital, and temporal. 
 Headache often shifts from one part of the head to another and is not 
 always confined to regions limited by anatomical boundaries. 
 
 Varieties of Headache. — Headache, according to the character of the 
 pain, may be: 1. Pulsating or throbbing. Headache of this kind is symp- 
 tomatic of circulatory disturbances; it is often diffuse. 2. Dull, heavy. 
 This is the headache due to toxaemia; it is usually frontal, sometimes 
 occipital. 3. Binding or constrictive; the sensation is often described as 
 that of a tight band around the head; the focus of intensity is referred to 
 the parietal regions. This is the headache of hysteria and neurasthenia. 
 4. Burning or sore; forms of headache diagnostic of anaemia, rheumatism, 
 and lithaemia. 5. Boring or sharp. These headaches are symptomatic of 
 hysteria and allied conditions; they are usually localized; one form is 
 known as "clavus" — the sensation as if a nail were being driven into 
 the head. 
 
SYMPTOMS AND SIGNS: PAIN. 569 
 
 Headache may be transient or persistent. In the latter case there may 
 be exacerbations and remissions, or occasional intermissions which may 
 last for days or weeks. There may be slight, continuous headache with 
 exacerbations of yarying intensity. Headache of this kind is symptomatic 
 of forms of reflex irritation, especially those arising from defects of accom- 
 modation. Persistency is characteristic of organic headaches such as occur 
 in cerebral tumor or abscess or pachymeningitis, or those which result from 
 excesses in tobacco or alcohol, syphilis, and uraemia. The headaches which 
 occur after sunstroke are persistent, with brief and irregular periods of 
 remission. 
 
 The headache following cerebral concussion is severe and protracted. 
 It may be circumscribed and limited to a region corresponding to the seat 
 of the injury or to the opposite side of the head. It is commonly associated 
 with tenderness on light percussion. The headache following injury may 
 be, on the other hand, diffuse. It is apt to be associated with vertigo, 
 lassitude, and indisposition to mental effort. 
 
 Significance of Headache. — Congestion. — Headache may result 
 from mechanical interference with the return of venous blood from the 
 head. When produced by improper clothing it is slight and ceases upon 
 removal of the cause; when due to venous obstruction from the pressure of 
 tumors it is not usually severe. The headache caused by violent paroxysmal 
 or frequently repeated cough is congestive. 
 
 Hypercemia. — Headache is symptomatic of active cerebral hyperaemia 
 such as follows excessive and prolonged mental effort, and results from the 
 action of vasodilator drugs, as alcohol and the nitrites. This form of 
 headache occurs in the initial stage of acute meningitis. The headache of 
 cerebral hyperaemia, whether passive or active, is usually frontal or diffuse, 
 often pulsating or throbbing. 
 
 Anmmia. — Headache occurs in the ana?mia due to blood loss or other 
 cause. It is a common symptom in chlorosis. Anaemic headache is com- 
 monly severe, usually frontal or diffuse, often attended by sensations of 
 pressure and not rarely associated with vertigo and tinnitus aurium. The 
 headache of anaemia is intensified by effort. 
 
 Inflammation. — Headache is characteristic of all forms of cerebral 
 meningitis, both acute and chronic. It is usually at first localized, a fact 
 of importance in the diagnosis of meningitis due to mastoid or ethmoid 
 disease or disease or injury of the cranial bones. It, however, rapidly 
 becomes diffuse. Meningeal headache is usually continuous with exacer- 
 bations of great severity. Headache in exceptional cases is absent in 
 the early stages of gradually developing leptomeningitis. Sudden intense 
 headache with painful rigidity of the muscles of the back of the neck and 
 vomiting are early symptoms of epidemic cerebrospinal fever. Intense 
 paroxysmal headache is a symptom of tuberculous meningitis. The head- 
 ache of pachymeningitis is local at first, but later becomes generalized. 
 Severe frontal headache, usually unilateral, is symptomatic of disease of 
 the frontal sinuses. 
 
 Infection. — Headache is a common manifestation of infection. This 
 headache is usually frontal, it may be occipital or general, is often neuralgic 
 or superficial, soon becoming dull, deep-seated, and severe. Headache is 
 
570 MEDICAL DIAGNOSIS. 
 
 an important symptom of the stage of onset of the acute febrile infections. 
 It is early and severe in typhus and associated with pain in the back and 
 limbs. After a time it is followed by stupor. It is a constant symptom in 
 the early stages of enteric fever but subsides spontaneously during the 
 second week of the disease. It occurs at the onset of relapsing fever and 
 persists until the crisis, when it commonly ceases altogether. The head- 
 ache of influenza is diffuse with points of intensity in the region of the 
 frontal sinuses and behind the eyeballs. It may be a troublesome sequel. 
 Intense headache characterizes the period of invasion of smallpox and 
 is usually accompanied by excruciating pains in the back and joints. 
 
 Headache occurs in early syphilis. The headaches of late syphilis are 
 usually symptomatic of arterial changes, gummata, or meningitis. Head- 
 ache is common in hereditary S3^philis. Paroxysmal headache is symp- 
 tomatic of malaria. It occurs in the hot stage of the paroxysm. It is 
 persistent and intense in estivo-autumnal fever. Periodical headache may 
 be the chief symptom in estivo-autumnal infection. 
 
 Toxaemia. — Some intractable headaches are symptomatic of chronic 
 ursemia. They are frontal or temporal, intense, usually continuous, with 
 irregular exacerbations. Headaches of the same general character occur in 
 diabetes and in those suffering from the gouty diathesis. To this group we 
 may refer the headaches of chronic lead poisoning, those occurring in gastro- 
 hepatic derangements, and constipation. These headaches are intensified 
 by alcoholic })everages and relieved by free purgation. Certain drugs cause 
 headache. Full doses of quinine or the salicylates produce headache and 
 tinnitus aurium. Opium causes distressing headache with floating sensa- 
 tions, nausea, and vomiting. All these symptoms are increased when the 
 patient assumes the upright posture. Tense, vertiginous headache follows 
 the administration of the nitrites in full doses. Headache is a significant 
 symptom in chronic poisoning by lead, tobacco, alcohol, opium, and chloral. 
 In the case of lead and of alcohol arterio-capillary sclerosis is cooperative. 
 Opium and chloral headaches are often abstinence symptoms, occurring upon 
 the withdrawal of the drug. Intense headache not unlike that of migraine 
 frequently follows excesses in alcohol — the acute alcoholism of debauch. 
 
 Cerebral Abscess. — Headache is often very severe and persistent in 
 cerebral abscess. It is apt to be associated with vertigo and pronounced 
 mental dulness and irritation. Vomiting is common but not constant. 
 Chronic brain abscess may present no other symptom than headache, vertigo, 
 mental dulness, irritability, and physical depression. The pain is usually 
 related to the region of the lesion; in ear disease it is referred to the parietal 
 or the occipital region of the affected side. In abscess following disease of 
 the nasal or ethmoid bones the pain is referred to the brow. In abscess 
 from traumatism the focus of pain is located in the region of the injury. 
 
 Tumor. — Headache may be said to be a constant symptom of brain 
 tumor. Its frequency and intensity vary according to the location of the 
 new growth, the rapidity of its development, and in some degree to its 
 character. Headache is more persistent and severe in cerebellar than in 
 cerebral tumors; in those of the cerebral hemispheres than in those of the 
 base and in those directly implicating the meninges. It is more prominent 
 in tumors of rapid than in those of slow growth, without regard to the nature 
 
SYMPTOMS AND SIGNS: PAIN. 571 
 
 of the pathological process. In general terms the nature of the tumor 
 formation has no direct relation to the intensity of the headache, the 
 exception to this rule being that gliomata are less painful than other forms 
 of coarse intracranial new growths. Headache in brain tumor is sometimes 
 dull and boring, sometimes lancinating, usually intense, often agonizing. 
 It is commonly continuous with periods of intensification, but sometimes 
 recurs with a regular periodicity suggestive of malaria. The fact that it is 
 commonly worse at night has some diagnostic value. The focus of the 
 headache in cerebral tumor may be in the region involved, in the brow or 
 in the occiput, or the pain may be diffuse. The headache of brain tumor 
 may be localized when of moderate degree, diffuse during periods of inten- 
 sification. Light percussion with the finger-tips may elicit tenderness in 
 a region corresponding to the tumor. The headache of pachymeningitis 
 interna haemorrhagica is usually at first referred to the vertex; later it 
 becomes generalized. 
 
 Aneurism. — Headache, either continuous or paroxysmal, is the most 
 common symptom of intracranial aneurism affecting the larger arteries 
 at the base. The location of the headache has in general no definite 
 relation to the position of the aneurism, though aneurisms of the basilar 
 artery usually occasion occipital headache. Headache occurs in caries 
 of the bones of the skull. 
 
 Neurotic States. — Headache is a very common symptom in neuro- 
 pathic conditions. In neurasthenia it is frontal, occipital, or diffuse; it is 
 apt to be continuous and is aggravated by mental application and physical 
 effort. Its intensity is moderate and it is attended by sensations of pres- 
 sure in the head, aching in the back of the neck, and spinal pains. Head- 
 ache is very common in the interparoxysmal periods of hysteria. It is 
 often referred to the vertex and may be severe and persistent. Headache 
 is common in emotional and precocious children. It is frequently associated 
 with brow pains, pains in the back of the neck, and intolerance of bright 
 light. Headaches of this kind are allied to the headaches of hysteria. 
 Headache frequently enters into the symptom-complex of the epileptic 
 paroxysm. It may precede or follow the convulsive attack. In the latter 
 case it is associated with drowsiness and hebetude. Headache is common 
 in petit mal. In many cases of epilepsy it constitutes an important symp- 
 tom in the interparoxysmal state. 
 
 He/lex Headache. — This form is often troublesome and persistent. 
 This is sometimes the case when the direct s3"mptoms of the local disease 
 are slight or absent. Errors of refraction constitute a common cause of 
 reflex headache. The pain is usually frontal, sometimes temporal, often 
 occipital. The patient is frequently unaware of any defect in visual accom- 
 modation. The headache is usually aggravated by close or prolonged 
 use of the eyes. Reflex headache may occur as a symptom in chronic nasal 
 disease especially in affections of the accessory sinuses. It usually involves 
 the temporal region or the vertex. It is associated with sensitiveness of 
 the nasal wall of the orbit and hyperaesthetic areas on the mucous mem- 
 brane of the middle turbinate bone. Headache is an important symptom 
 of adenoid vegetations in the nasopharynx. It constitutes one of the 
 forms included under such terms as "school headaches," "headaches of 
 
572 MEDICAL DIAGNOSIS. 
 
 the period of growth/' and the like. Associated symptoms are mouth- 
 breathing, mental dulness, and irritabihty. Carious teeth and exposure 
 of the pulp not only cause toothache but occasionally also cause reflex 
 headache. Disease of the auditory apparatus may be the unsuspected 
 cause of persistent headache. 
 
 The headache of acute indigestion and gastro-intestinal catarrh is 
 probably rather toxsemic than reflex. 
 
 The importance of headache as a disease of the sexual organs is prob- 
 ably over-estimated; yet this symptom is very common in those of both 
 sexes who suffer from actual disease of the reproductive apparatus or are 
 the victims of psychical processes concerning such diseases. Very often 
 these headaches are due rather to the attendant neuropathic condition 
 than to reflex irritation. 
 
 Associated Symptoms. — Vertigo, nausea, vomiting, drowsiness, irrita- 
 bility, and hebetude are associated with headache with such frequency as 
 to indicate a common causation. These symptoms are as a rule less con- 
 stant and less severe in symptomatic than in organic headaches. Vertigo 
 is a frequent attendant upon headache due to gastro-intestinal disorder; 
 nausea and vomiting in acute toxaemia; somnolence in malaria, anaemia, 
 and syphilis. In organic headaches the presence of this group of symptoms 
 and their persistence are important and suggestive. 
 
 Headache is essentially a symptom and a careful examination and 
 inquiry will reveal some general or local cause. Headache is to be differen- 
 tiated from migraine — a paroxysmal neurosis. 
 
 Neuralgia differs from headache in the following points: The pain 
 involves the trunk or branches of the nerve rather than its peripheral 
 distribution. It is unilateral, localized, sharp, paroxysmal, and there are 
 present the characteristic tender points of Valleix. Neuralgia affecting 
 the first branch of the fifth nerve is sometimes attended with suffusion of 
 the eye and oedema of the lids. 
 
 Functional and Organic Headaches. — The differential diagnosis 
 between functional and organic headaches is of fundamental importance. 
 Organic headache is commonly persistent, varying from time to time in 
 intensity, som.etimes undergoing violent exacerbations but rarely wholly 
 absent. It often interferes with sleep. It is aggravated by mental or 
 physical effort, by excitement, alcohol, and all conditions that increase 
 intracranial hyperaemia. It yields less readily than functional headache 
 to symptomatic treatment. It tends to progressively increase in severity 
 and is in many cases ultimately replaced by the stupor, drowsiness or coma 
 of the terminal stage of the disease. Associated symptoms, such as vomit- 
 ing, vertigo, hebetude, and irritability, are of diagnostic importance, and 
 double optic neuritis, convulsions, and localizing symptoms, as monospasm, 
 cranial nerve paralysis, cerebellar titubation, forced movement, and hemi- 
 anopsia, render the differential diagnosis between organic headaches and 
 functional headaches in most cases an easy matter. 
 
 (b) Pains in the Scalp. — Myalgic pains have been already spoken of. 
 They are usually frontal or occipital, increased by voluntary movements 
 of the scalp and by pressure. Various affections of the skin are attended 
 by itching and burning pains of moderate degree. Local dermatitis attended 
 
SYMPTOMS AND SIGNS: PAIN. 573 
 
 with pain sometimes results from the injudicious application of hair washes 
 containing excess of cantharides and sometimes from the action of pediculi; 
 also from burns and scalds, from erysipelas, and from traumatism. 
 
 Diffuse wandering pains are often experienced in various parts of the 
 scalp and are associated with tenderness of the skin. These pains are not 
 confined to the ramification of nerve-trunks and cannot be strictly regarded 
 as neuralgic, but they very frequently alternate with true neuralgia. A 
 patient under my observation compared these pains to sheet lightning. 
 
 (c) Pains in the Face. — The most important is trigeminal or facial 
 neuralgia, known also as tic douloureux and pTosopalgia. Neuralgia of the 
 fifth nerve is much more frequent than all other forms of neuralgia. 
 The pain is spontaneous, paroxysmal, and unilateral. Neuralgic pains in^- 
 volving the ophthalmic division usually affect the supra-orbital branch 
 and are known as brow ague or supra-orbital neuralgia. The pain 
 radiates over the front of the head from the supra-orbital notch. It may 
 be felt in the eyelid or the eyeball or at the side of the nose. Tender 
 points are found at or above the supra-orbital notch, in the upper eyehd, 
 and on the side of the nose. 
 
 The neuralgic pain may be referred to the eyeball itself. It may occur 
 spontaneously or as the result of over-use of the eyes. It is attended with 
 dimness of vision and lachrymation and may occur alone or in connection 
 with other neuralgic pain in the region of the fifth. 
 
 Neuralgia of the superior maxillary division of the fifth nerve is referred 
 to the region between the orbit and the mouth and the side of the nose. 
 Areas of special intensity are upon the side of the nose, over the prominent 
 part of the upper jaw and along the gum. Paroxysms are frequently induced 
 by the use of the tooth-brush. When the inferior maxillary division is 
 involved a focus of pain is frequently found just in front of the ear, or in 
 the temple or opposite the point of emergence of the nerve from the fora- 
 men, or in the region of the parietal eminence, and sometimes a point at 
 the side of the tongue. 
 
 In intense paroxysms of trifacial neuralgia the whole side of the face 
 and brow is involved and there is reflex facial spasm — tic convulsif. Supra- 
 orbital neuralgias are occasionally attended with vasomotor disturbance. 
 In other instances a herpetic eruption occurs which is probably the mani- 
 festation of an actual neuritis. Intractable neuralgias of the fifth nerve 
 occurring late in life are known as degenerative neuralgias and are asso- 
 ciated with changes in the ganglion of Gasser. 
 
 Severe pains in the distribution of the fifth nerve accompany cancer of 
 the tongue, lingual ulcer, and caries of the inferior maxilla. Caries of the 
 teeth and exposure of the pulp may give rise to pain referred to the ear. 
 
 (d) Pain in the Eye. — Inflammatory diseases of the eye cause local pain. 
 In acute conjunctivitis there is pain in the eyelids, accompanied by photo- 
 phobia and lachrymation; in iritis pain in the eyeball and intense supra- 
 orbital pain, which may radiate in the distribution of the ophthalmic division. 
 
 The pain of glaucoma involves the distribution of the trigeminus, 
 having its focus of intensity in the eyeball or at the supra-orbital notch. 
 In the acute cases it is agonizing and associated with depression, pallor, 
 nausea, and vomiting. In the chronic form it may be subacute with par- 
 
574 MEDICAL DIAGNOSIS. 
 
 oxysms of great severity. As the disease begins with great frequency on 
 one side there is a misleading resemblance to migraine. Increase of the intra- 
 ocular tension, irregular or dilated pupil, with inactive iris, haziness, anaesthe- 
 sia of the cornea, and various visual derangements are suggestive symptoms. 
 
 (e) Pain in the Ear. — The pain of acute middle-ear disease is intense, 
 throbbing, increased by pressure in front of the tragus and by gentle trac- 
 tion of the ear. It is subject to exacerbations and remissions and often 
 radiates to the side of the face. Upon spontaneous or surgical perforation 
 of the tympanic membrane the distressing feeling of tension is followed by 
 immediate relief. Tinnitus is a common accompaniment. Pain referred 
 to the ear and the side of the head is a prominent symptom in mastoid dis- 
 ease. It is accompanied by tenderness upon pressure and localized oedema. 
 
 (f) Pain Referred to the Mouth. — Pain is a symptom of various forms 
 of stomatitis. It is intense in aphthous stomatitis, a very trifling affection, 
 and often wholly absent in cancrum oris, one of the gravest of diseases. 
 In mucous patches and syphilitic ulceration pain is less conspicuous than 
 in tuberculous ulceration. In carcinomata pain is a persistent and distress- 
 ing symptom. In inflammatory and ulcerative conditions of the pharynx 
 pain is a prominent symptom. It is excited by mechanical irritation and 
 by the contraction of the pharyngeal muscles in deglutition. Pain is not 
 a prominent symptom in epidemic parotitis and parotid bubo. It is excited^ 
 however, by the movements of the parts involved and accompanied by 
 great tenderness upon pressure. 
 
 (g) Sinus Pain. — Pain is a prominent symptom in disease of the acces- 
 sory sinuses of the nose, especially in those cases in which there is an obstruc- 
 tion to the outlet. Under these circumstances the pain may be extremely 
 severe and accompanied by marked systemic disturbance, as fever, chilli- 
 ness, headache, and malaise. The sinuses usually involved are the antrum 
 of Highmore and the frontal sinuses. Free discharge of mucus or pus is 
 usually followed by immediate relief, but there are chronic forms in which 
 the pain is apt to be of a dull character and constant, with exacerbations 
 in damp weather and after exposure to cold. The diagnosis of antrum 
 disease may be confirmed by transillumination with an electric light. 
 
 Pain in the Body. — (a) Pain in the Back — Backache; Rhachialgia. — 
 Pain may occur in any part of the back. It is more common in the 
 lumbar and sacral regions than elsewhere. Pain in the back of the neck 
 extending between the shoulder-blades is a common symptom in neuras- 
 thenia and hysteria. 
 
 Acute pain in the small of the back attends the period of onset of many 
 of the infectious febrile diseases, especially influenza, dengue, variola, and 
 cerebrospinal fever. It occurs also in angina tonsillaris and acute nephritis. 
 Acute pain in the back, much aggravated upon movements of extension, 
 as in rising after lacing one's shoes, is characteristic of lumbago. Unilateral, 
 deep-seated lumbar pain of great severity is symptomatic of renal colic. 
 Persistent pain of this kind attends renal calculus. This pain is aggravated 
 by pressure over the kidney or sudden jarring of the body. Pain in the back 
 is often present in floating kidney. Sacral pains are symptomatic of disease 
 of the pelvic organs, especially uterine flexions and displacements, ovarian 
 disease, disease of the colon and rectum, hemorrhoids, and urethral stric- 
 
SYMPTOMS AND SIGNS: PAIN. 575 
 
 ture. Many of the pains in the lower part of the back are myalgic. Pains 
 of this kind result from occasional or habitual overwork of the muscles or 
 from traumatism in the form of contusion or strain, or finally from expos- 
 ure to cold or damp, especially in lithamic individuals. The pain of myalgia 
 is increased by movement, cold, and pressure; it is relieved by rest in the 
 recumbent posture and by hot applications. 
 
 Pain in the spine occurs in disease of the vertebrae. Traumatism, 
 syphilis, tuberculosis, and caries from pressure, as in aneurism of the aorta, 
 are common causes. The pain is local and corresponds to the segment of 
 the column involved. It is increased by sudden pressure upon the head 
 or shoulders, by jarring, by the application of heat, cold, and faradism, and 
 is relieved by the recumbent posture and in some cases by suspension and 
 a properly applied spinal jacket. Rigidity results from muscular spasm in 
 the earlier stages and from ankylosis in the later. Various deformities 
 occur. Pain is present in that form of arthritis deformans which involves 
 the vertebra? — spondylitis deformans — spondylose rhizomelique. There are 
 associated nerve-root symptoms, as anaesthesia and muscular atrophy. 
 
 Pain attends various diseases of the spinal meninges. It is local and 
 often intense. There are symptoms of irritation in the course of the nerves. 
 The more common causes are hemorrhage into the spinal membranes and 
 meningitis. Muscular spasm and rigidity are present. 
 
 Diseases of the cord are more apt to cause radiating and referred pains 
 than pain in the spine itself. The latter is felt in the lumbar region; the 
 former, as nerve-root irritation, as girdle pains, and in the lightning pains 
 of tabes. 
 
 (b) Pain in the Side. — 1. The pain may be symptomatic of injury 
 or inflammation of the skin, as abrasion, contusion, local dermatitis, or 
 furunculosis. The last is common in the axillary region. In rare instances 
 phlegmon or subcutaneous extravasations of blood may be the cause of 
 severe pain. An inspection of the parts is necessary in all cases. 
 
 2. Myalgic pains are not uncommon. Pleurodynia affects the muscles 
 on one side, usually the intercostals, sometimes the pectorals and the 
 serratus magnus. It is more common on the left than on the right side. 
 It is especially distressing since the muscles are in constant use in respira- 
 tion. The movements are restricted on the affected side, but deep breath- 
 ing, coughing, and forced lateral movements increase the pain. Tenderness 
 is present often in a limited area. This affection may suggest intercostal 
 neuralgia, from which it is to be distinguished by the more circumscribed 
 area involved, the paroxysmal character of neuralgic pain, and the well- 
 defined tender points. It is sometimes mistaken for pleurisy, but the 
 absence of friction sounds is of diagnostic importance. Violent spasmodic 
 flexion to one side is an occasional though rare manifestation of tetanus 
 and is attended with great pain in the affected muscles. Side pains refer- 
 able to the muscles are observed in some cases of trichiniasis, 
 
 3, Pains due to injury or disease of the bones may be referred to the 
 side. Fracture of the ribs, periostitis, osteosarcoma, rickets, and some cases 
 of osteitis deformans are to be considered. The diagnosis demands a care- 
 ful examination of the area involved by inspection, palj^ation, ausculta- 
 tion, and in obscure cases by the Rontgen rays. 
 
576 MEDICAL DIAGNOSIS. 
 
 4. The pain of plastic pleurisy is referred to the inframammary 
 region or the side. It is sharp or stabbing, — the stitch in the side, — 
 increased on deep breathing and accompanied by friction sounds, in some 
 cases friction fremitus and a dry cough. It may occur in previously 
 healthy individuals, or be accompanied by slight fever and presently dis- 
 appear; it is a secondary process in croupous pneumonia and develops 
 during cancer, abscess, and gangrene when the surface of the lung is 
 involved. It is a very common phenomenon in tuberculosis of the lungs 
 and may be basic or apical. 
 
 5. Pain in the side may be due to visceral disease. Sudden tension of 
 the spleen, as often occurs in boys after running, is accompanied by intense 
 pain in the infra-axillary region of the left side. Heavy, dull, dragging 
 pains are symptomatic of the splenic tumor of leukaemia and the malarial 
 cachexia — ague cake. Renal colic is characterized by an extension of the 
 pain from the lumbar region to the affected side and thence downward 
 toward the groin. In biliary colic the pain frequently extends to the right 
 side of the chest. A dull heavy pain in the side sometimes attends up- 
 ward pressure upon the diaphragm such as occurs in an overloaded stom- 
 ach or distended colon, rapidly developing ascites, or an enormous abdom- 
 inal tumor. Pain, paroxysmal in character but not extremely intense, 
 occurs in the early stage of some cases of pyelitis. Intense pain in the 
 lumbar region, aggravated by pressure, is a symptom of perinephritic 
 abscess. It is often referred to the hip-joint or the adjacent region or the 
 inner aspect of the thigh. This pain is attended with fixation of the thigh, 
 which is flexed to relax the psoas muscle, and the patient in walking stoops 
 and throws his weight upon the sound side. The pain of hepatic abscess 
 is usually referred to the back or shoulders; it may be most severe in the 
 right h3^pochondrium. A duller, dragging pain is felt in the right side when 
 the patient turns upon the left. The pain of angina pectoris is occasionally 
 referred to the left side — fifth, sixth and seventh and even eighth and ninth 
 dorsal areas. 
 
 6. Pain in the side is very often the manifestation of disease of the 
 nerves themselves. Neuralgia may be the result of nutritional changes in 
 the sensory nerve-roots, the course of the nerve, or its peripheral distribu- 
 tion. Intercostal neuralgia is very common. Women are more liable than 
 men; adults far more liable than children. The left side is more frequently 
 involved than the right. Neuropathic individuals especially suffer. Inter- 
 costal neuralgia is encountered in ansemic conditions, general malnutrition, 
 gout, lead poisoning, malaria, cachexia, and chronic nephritis. The attack 
 may follow exposure to cold. The pain is paroxysmal and burning or 
 lancinating and there are characteristic "points douloureux. Trophic or 
 vasomotor phenomena may occur, as local cedema or erythema. The 
 Jjosterior branches of the lumbar plexus may be involved with pain in 
 advance of the crest of the ilium extending along the inguinal canal and 
 spermatic cord to the scrotum — irritable testis — or the labium majus. 
 The pain of herpes zoster is intense and often persistent. It corresponds 
 to the distribution of the eruption. The pain in caries of the vertebrae 
 and aneurism of the descending aorta is referred to the distribution of the 
 intercostal nerves. 
 
SYMPTOMS AND SIGNS: PAIN. 577 
 
 (c) Pain in the Chest and Abdomen. — 1. The skin may be the seat 
 of pain in inflammatory diseases, burns, severe eruptions, and herpes zoster. 
 Painful burns sometimes result from the unguarded use of sinapisms or 
 hot-water bags. An inspection of the part is necessary. 
 
 2. Myalgia of the abdominal muscles may result from continuous 
 cough. The epigastric pain in children suffering from measles is due to the 
 cough. Muscular pain attends tetanus and some cases of strychnia poison- 
 ing. Trichiniasis is to be considered. 
 
 3. Periostitis and necrosis of the sternum, costal cartilages, and ribs 
 cause pain in the anterior wall of the thorax. Resorption and ulceration 
 from aneurism, malignant disease, syphilis, and enteric fever are common 
 causes of painful lesions in these structures. Contusions, fractures, and 
 dislocations cause pain. 
 
 4. Many visceral diseases cause pain in the chest and abdomen. It is 
 an important sign of aneurism of the aorta. It is usually dull and persistent 
 with frequent paroxysms in which it is sharp and lancinating. It is fre- 
 quently severe when erosion of the chest wall or vertebrae is taking place. 
 Anginose attacks may occur. Pain may be absent. Broadbent has spoken 
 of aneurism of the ascending arch as the aneurism of physical signs; of the 
 transverse arch as the aneurism of symptoms. Pain is the chief symptom 
 in aneurism of the abdominal aorta. It is epigastric, paroxysmal, and radi- 
 ates to the back and sides. Severe epigastric pain occurs in aneurism of 
 the coeliac axis and the splenic artery. Pain may occur in mediastinal 
 tumor, but it is much less common than in aneurism and does not have the 
 radiating character so common in the latter affection. The pain of 
 mediastinal abscess is substernal, throbbing, and usuall}^ associated with 
 chilliness and profuse sweating. In plastic pericarditis pain may be 
 absent. When present it is variable in intensity, usually mild, exception- 
 ally severe, and frequently intensified by the pressure of the stethoscope. 
 It is felt in the precordia or at the base of the ensiform cartilage. The pain 
 of pericarditis with effusion is sharp and lancinating and intensified by 
 pressure over the ensiform cartilage. It may be dull and dragging. Pain 
 is not a symptom of endocarditis. It occurs in chronic valvular disease, 
 especially aortic insufficiency, in which it is sometimes persistent and 
 distressing. It is usually precordial, dull, and aching; sometimes sharp and 
 radiating to the neck and down the left arm. Pain is much less common in 
 aortic stenosis and is not a prominent symptom in mitral disease so long as 
 compensation is maintained. Angina pectoris is characterized by par- 
 oxysmal, agonizing pain in the region of the heart, radiating into the neck 
 and arms, especially into the ulnar distribution of the left arm, and often 
 attended with the fear of impending death. Chest pain is common and 
 severe in croupous pneumonia, pleurisy, and pulmonary abscess. It may 
 occur in any part of the chest but is most common in the inframammary 
 and mammary regions. In some cases of severe acute bronchitis substernal 
 pain is a distressing symptom. Pain may be absent in diseases of the 
 liver. It occurs in acute infectious cholecystitis and is paroxysmal and 
 severe. It is referred to the region of the liver but may have its focus of 
 intensity as low as the appendix or in the epigastrium. Intense paroxysmal 
 pain is met with in cancer of the bile passages. Biliary colic is of common 
 
 37 
 
578 MEDICAL DIAGNOSIS. 
 
 occurrence in gall-stone disease. There is agonizing pain in the region of 
 the gall-bladder, extending into the lower thoracic, epigastric, and upper 
 abdominal zones and radiating to the right shoulder. Dull dragging 
 pain with intense exacerbations associated with nausea or vomiting is 
 encountered in so-called hj^pertrophic cirrhosis. Pain of a dull, aching 
 character and radiating to the back and right shoulder occurs in hepatic 
 abscess. Pain and uneasiness in the right hypochondrium are present in 
 some cases of cancer of the Hver. In pancreatic disease pain may be a 
 prominent and suggestive symptom. It occurs in hemorrhage, acute 
 pancreatitis, and abscess and is referred to the upper zone of the abdomen. 
 It is intense and persistent with agonizing paroxysms. Painful coHcky 
 attacks with nausea and vomiting have been noted in pancreatic cysts and 
 the passage of calculi has caused pancreatic colic. A dull pain under the 
 sternum is present in inflammation and in spasm of the oesophagus. In 
 cancer it may be persistent or only present upon attempts to swallow food. 
 The pain of gastralgia is usually deeply seated; that of gastritis more 
 superficial. Cardialgia is a term used to designate the uneasy and painful 
 sensations in chronic gastritis, sometimes caused by the taking of food, 
 sometimes present when the stomach is empty. Pain is a distinctive symp- 
 tom of gastric ulcer. It is gnawing, burning, paroxysmal, induced by tak- 
 ing food, and referred to the epigastrium. It is also in some cases felt in the 
 back at the level of the tenth dorsal vertebra. In peptic ulcer of the duo- 
 denum the pain is sometimes located in the right hypochondrium and may 
 come on two or three hours after eating. Pain is an early symptom in 
 cancer of the stomach and occurs at some period in almost all cases. It is 
 usually epigastric but may be felt in the back or loins. It is usually burn- 
 ing or gnawing and rather continuous than paroxysmal, though it is aggra- 
 vated after food. The gastric crises of tabes consist of intense paroxysmal 
 pain in the stomach accompanied with vomiting and an excess of intensely 
 acid gastric fluid. Intestinal diseases are accompanied by pain which may 
 be colicky when the small intestine is involved and bearing-down when the 
 colon is affected — the tormina and tenesmus of the older physicians. 
 Abdominal pain of variable intensity occurs in acute and chronic catarrh, 
 ileocolitis, proctitis, malignant disease of the intestines, obstruction, intus- 
 susception, ileus, and appendicitis. It is the first and most distinctive symp- 
 tom of peritonitis. Inframammary pain upon the left side is a common 
 symptom of fecal accumulations in the sigmoid flexure of the colon in 
 women, and is relieved by free purgation. Renal cohc may extend well into 
 the abdomen upon the affected side. Pyelitis may cause suprapubic pain. 
 Displaced kidney is usually a source of much discomfort; often of distressing 
 pain. The paroxysmal pains known as DietVs crises occur in this condition. 
 5. Lead colic, the referred pain of diaphragmatic pleurisy felt in the 
 right hypochondrium, and the girdle sensations of disease of the spinal 
 cord are abdominal pains of purely nervous origin. The last may be a 
 mere sensation of a cord or belt around the waist or it may constitute an 
 actual pain. It is usually upon the level of the umbilicus or higher but may 
 be lower. The pain is sometimes much less marked upon one side than 
 upon the other and may suggest a unilateral new growth or other form of 
 one-sided abdominal disease. 
 
SYMPTOMS AND SIGNS: PAIN. 579 
 
 Pains in the Extremities. — In general terms the diagnostic significance 
 is the same for the arms and hands and for the legs and feet. The excep- 
 tions are mainly as follows: The pain of angina pectoris extends to the 
 arms and especially to the left arm and involves the ulnar distribution. 
 The pain in writer's spasm and other occupation neuroses involves the 
 forearms and hands. It consists of irregular darting pains in the affected 
 muscles and the usual pains attending the spasm upon effort. The pains 
 of dactylitis, onychia, and paronychia involve the fingers. Gout occa- 
 sionally affects the fingers, but usually the foot and especially the great toe. 
 A group of painful affections are due to improper foot wear — ingrowing toe- 
 nail, corns, bunions and metatarsalgia. The pains of flat-foot, varicose veins 
 and varicose ulcer are to be considered in regard to the habitually erect 
 posture. The especial liability of the knee and ankle to troublesome painful 
 affections and the greater frequency of venous thrombosis in the lower 
 extremity are due to postural conditions and the greater distance of the 
 blood-vessels from the heart. .Referred pains are common in the lower 
 extremities. The pain in hip-joint disease and obturator hernia is often 
 referred to the inner side of the knee; that of ovarian and uterine disease, 
 fecal impaction, aneurism, and other abdominal tumors, to the inner sur- 
 face of the corresponding thigh, and in rare instances that of acute disease 
 of the prostate gland to the sole of the foot. Pains in the hmbs associated 
 with numbness and tingling have occasionally been observed in the pre- 
 hemiplegic stage of cerebral hemorrhage. Pain in the toes, due to periph- 
 eral neuritis, is an occasional affection after enteric fever. The aflfection 
 is not attended by the signs of inflammation and passes away in the course 
 of some days. Painful muscular cramps in the post-dormitium usually 
 involve the lower extremities and in particular the muscles of the calf of 
 the leg. They occur in pregnancy, in gouty subjects, and in persons oth- 
 erwise in good health. Similar painful cramps may attend violent exer- 
 tion and exposure to cold, as in swimmers. 
 
 The painful affections common to the upper and lower extremities,, 
 aside from traumatism and the action of cold, as in frost-bite, involve the 
 muscles, nerves, blood-vessels, articulations, and bones. 
 
 1. Pain is symptomatic of myalgia from unaccustomed or habitual 
 overwork. It shows itself in athletes, dancers, horseback riders, pedestrians 
 and soldiers after forced marches and is without diagnostic significance. 
 Muscular pain occurs in various forms of myositis and especially in trich- 
 iniasis. General muscular pain is a symptom of rickets: It occurs in scurvy 
 and is distinctive of infantile scorbutus, in which it is a prominent symp- 
 tom upon both voluntary and passive movement of the legs. Painful 
 cramp upon muscular effort — intermittent claudication — occurs in throm- 
 bosis and arteriosclerosis of the lower extremities. 
 
 2. Nervous pain is symptomatic of neuralgia — tender points; par- 
 oxysms, pressure aggravation; neuritis either intrinsic or from pressure; 
 peripheral neuritis or neuromata. Diffuse pain below the knees is especially 
 common in alcoholic neuritis. Sciatica, as well as brachial neuritis, which is 
 the same thing in the upper extremity, is in some instances a neuralgia; 
 in others a neuritis of the nerve or its plexus. It is almost always unilateral. 
 Lightning pains occur in spinal disease, especially tabes. They are more 
 
580 MEDICAL DIAGNOSIS. 
 
 common in the legs than in the arms. They are sometimes locahzed. 
 Bilateral neuralgic pains in the arms and legs are due to spinal cord disease 
 as sclerosis, to general toxic conditions as lead or arsenic, to vertebral 
 disease, or in the lower extremities to pressure upon the nerve-roots of the 
 Cauda equina. 
 
 3. Venous thrombosis — milk-leg, phlegmasia alba dolens — is often 
 extremely painful. It occurs in lying-in women and as a sequel to enteric 
 fever and other infectious diseases. A similar condition may occur in 
 consequence of local pressure in the upper extremity. Pain, usually tin- 
 gling or burning in character, occurs in the early stages of local gangrene, 
 in ergotismus, diabetes, and Raynaud's disease. 
 
 4. The joints are especially liable to pain. Exquisite pain is experienced 
 in the joint affection of rheumatic fever. The wrists, elbows, knees, and 
 ankles are especially liable to involvement. Another exquisitely painful 
 joint affection is gout. Arthritis deformans is attended by occasional 
 outbreaks of pain, each of which results in an increase of the previously 
 existing deformity of the joints. Many of the cases described under the 
 term chronic rheumatism belong to this category. The pain in gonorrhoeal 
 arthritis is persistent and rebellious to treatment. That of ordinary syno- 
 vitis is of moderate intensity. Pysemic joints are usually exquisitely painful. 
 Postfebrile arthritis closely resembles the joint affection of rheumatic 
 fever. In spinal arthropathies — Charcot's joints — and in tuberculous joints 
 pain is not always a conspicuous symptom. 
 
 5. All forms of periostitis are accompanied by pain. The subperi- 
 osteal hemorrhages of scurvy are attended with pain, which is also a com- 
 mon symptom in osteomyelitis and a group of cases of osteitis deformans. 
 
 TENDERNESS. 
 
 Tenderness is pain upon pressure. It usually but not invariably accom- 
 panies spontaneous pain. Intestinal colic and some forms of neuralgia are 
 relieved by pressure. Tenderness may be present in the absence of spon- 
 taneous pain. This symptom is often of considerable diagnostic value, 
 but being purely subjective it is liable to the uncertainties which modify 
 the diagnostic significance of spontaneous pain. It is attended by objec- 
 tive manifestations, as wincing, flinching, exclamations of suffering, and the 
 like. As in the case of spontaneous pain the allegations of the patient can- 
 not always be depended upon. In certain cases tenderness may disappear 
 when his attention is directed to other objects, or it may be present under 
 the influence of suggestion or expectant attention, or finally it may be 
 simulated in malingering. 
 
 A distinction is to be made between tenderness, which is pain upon 
 pressure, and hyperesthesia, which is an exaggeration of the sensibility 
 of the skin. Tenderness is (a) superficial, namely, pain upon a very hght 
 touch; or (b) deep, that is, pain excited by pressure sufficiently firm to 
 extend to underlying parts. Superficial tenderness is closely allied to 
 hyperesthesia and is usually coupled with a diminution of the power to 
 recognize the nature of the agent by which the impression is caused — loss 
 of tactile sensibility. 
 
SYMPTOMS AND SIGNS: TENDERNESS. 581 " 
 
 For practical purposes tenderness, like pain, may be best studied in 
 relation to the parts in which it is localized and the anatomical structures 
 involved. 
 
 The Head. — Tenderness of the scalp occurs during and after the 
 attack in migraine, occipital neuralgia, and in hysterical conditions. Light 
 pressure or the use of the comb or brush may excite pain. Local tenderness 
 is present in traumatism, especially contusions, and subcutaneous effusions 
 of blood. Diffuse tenderness may be elicited in myalgia of the occipito- 
 frontalis muscle. Tenderness attends periostitis and caries of the skull. 
 It is present also in gumma. Tenderness with or without local oedema is 
 symptomatic of infection of the mastoid sinuses — suppurative mastoiditis. 
 Localized pain is produced by tapping upon the skull in some cases of 
 meningitis, tumor, and abscess of the brain — a symptom of minor impor- 
 tance. 
 
 The Face. — Tenderness immediately in front of the tragus is pres- 
 ent in acute inflammation of the middle ear. Tenderness over the malar 
 bone is symptomatic of abscess and malignant disease of the antrum 
 of Highmore. The tender points in trifacial neuralgia are found at the 
 emergence of the branches from the bony foramina and their pene- 
 tration of fasciae. There is occasionally also sympathetic tenderness at 
 the occipital protuberance and over the ujsper cervical spines. Exqui- 
 site hj^persesthesia is encountered in some cases of neuralgia of the 
 fifth nerve. 
 
 The Neck. — Localized tenderness is found in acute inflammatoiy 
 conditions, as mumps, cellulitis— angina Ludorici — acute adenitis; in 
 myalgia, the spastic rigidity of meningitis; in caries of the cervical verte- 
 brae and in cervico-occipital and cervicobrachial neuralgia. 
 
 The Thorax. — Tenderness in the course of the spine occurs in men- 
 ingitis, spondylitis, arthritis deformans involving the spine, periostitis, 
 and in some cases of myelitis. It is a symptom of importance in neuras- 
 thenia, hysteria, and spinal irritation, and in lumbago. Pressure upon the 
 tender points produces not only pain but also marked acceleration of the 
 pulse — Mannkopfs symptom. Thoracic aneurism causing erosion of the 
 vertebrae is a cause of tenderness in the dorsal or lumbar spine. Spinal 
 tenderness may frequently be found in lumbar, subphrenic, and perinephric 
 abscess, and has been observed in acute inflammation of the bronchial 
 glands and in some cases of tumor of the mediastinum. In these condi- 
 tions pain may be also called forth by sudden pressure upon the shoulders 
 of the patient or by jarring the body, as by a misstep. 
 
 Tenderness attends periostitis and caries of the clavicles, sternum, 
 ribs, and cartilages. It may be present in these structures in the painful 
 form of osteitis deformans, especially early in the course of the disease. 
 It is found in abscess of the wall of the thorax, perforating empyema, and 
 eroding aneurism. Tender points are present in intercostal nem-algia. 
 Tenderness upon percussion is not uncommon in the infraclavicular regions 
 in phthisis. The mammae sometimes are tender at the menstrual period, 
 in early pregnane}^ in the condition known as irritable breast, which is a 
 syndrome of hysteria, and in adenoma and malignant tumor. Tender- 
 ness is a symptom of pericarditis. 
 
582 MEDICAL DIAGNOSIS. 
 
 Abdominal tenderness is a very common symptom. It may be 
 general, as in peritonitis, or local. The latter is usually present in a limited 
 area, as the epigastric, hypochondriac, umbilical, hypogastric, or iliac 
 regions; or the tenderness may be found in one of the quadrants of the 
 abdomen. Sometimes the tenderness is distinctly focal, as in peptic ulcer, 
 the McBurney point in appendicitis, the region of the gall-bladder, or 
 pyosalpinx. In other cases it is diffused, with or without circumscribed 
 areas of intensit3^ 
 
 Epigastric tenderness is a symptom in acute and some cases of chronic 
 gastritis, pancreatitis, pericarditis, acute yellow atrophy of the liver, and 
 disease of the gall-bladder and bile passages. It may be found in some cases 
 of Addison's disease. One or more tender points are present in peptic 
 ulcer. Tenderness in this region attends the myalgia of persistent cough 
 and may be observed in hysteria and hypochondriasis. 
 
 Tenderness in the right hypochondrium is encountered in various 
 diseases of the liver, as perihepatitis, congestion, acute hepatitis, abscess, 
 cancer, acute yellow atrophy, and in diseases of the gall-bladder and bile- 
 ducts, including cholelithiasis. In the last group of cases the tenderness 
 may be confined to the region of the gall-bladder, or diffused over the 
 hepatic area or even more widely; in the left hypochondrium in acute 
 distention of the spleen, infarct, perisplenitis, pancreatitis, and fecal 
 impaction; in either hypochondrium in diaphragmatic pleurisy; in both 
 in influenza, relapsing fever, and the gastrohepatic form of estivo- 
 autumnal malarial fever. Tenderness in the umbilical region may be 
 ehcited in peritonitis, enteritis> and enteric fever; in the right iliac region 
 in enteric fever, appendicitis, renal calculus, fecal accumulations in the 
 hepatic flexure of the colon, and in cancer; in the left iliac region in can- 
 cer of the sigmoid flexure and in some cases of membranous colitis; in 
 either in pelvic inflammations and diseases of the tubes and ovaries; in 
 both when any of these conditions are bilateral, and in hysteria. Hypo- 
 gastric tenderness may be symptomatic of cystitis, inflammation of the 
 pelvic organs, dysmenorrhoea, and hysteria. 
 
 The Extremities. — Cutaneous hypersesthesia may be due to peripheral 
 neuritis, especially the alcohoHc form, neuritis involving a nerve-trunk 
 in the course of which there are tenderness upon pressure and points dou- 
 loureux, crural thrombosis, varicose veins; to periostitis, osteitis, osteo- 
 sarcoma, arthritis, myalgia, myositis, rickets, scurvy, trichiniasis, or tetanus. 
 Forms of arthritis especially characterized by pain and tenderness are 
 encountered in rheumatic fever, the acute process in arthritis deformans, 
 the gonorrhoeal joint infection, gout, sprain, and tuberculosis. The hyster- 
 ical knee is usually exquisitely painful upon pressure. 
 
 PARiESTHESIA. 
 
 Parsesthesia is a condition of modification of normal sensibility. The 
 phenomena are due to irritation of the sensory nerves in their course or 
 distribution. They depend upon nutritive disturbances of the nervous 
 system or the action of toxic or irritating substances in the blood. The 
 itching of mild morphine intoxication is an example. Similar symptoms 
 
SYMPTOMS AND SIGNS: PAR.ESTHESIA. 583 
 
 occur in gout and lithsemia and are met with in neurasthenia and hysteria. 
 Sensations of numbness, burning, stinging, itching, and formication are 
 common. Coldness, weight, tenesmus, the girdle sensation, precordial 
 constriction, tightness, throbbing, sinking, faintness, and debility also 
 belong to this group of symptoms. The sensations are closely allied to pain 
 and are often described as painful by the patients. They are wholly sub- 
 jective and their value in diagnosis rests entirely upon the ability of the phy- 
 sician to estimate the patient's accuracy of expression and desire to com- 
 municate the truth. There is no objective method of testing his statements. 
 
 These perversions of sensibility are very common and in many instances 
 constitute the principal if not indeed the only symptom of which patients 
 complain. They are much more common in women than in men and in 
 the well-to-do than in the poor. Common associated conditions are defec- 
 tive digestion, constipation, anaemia, and general malnutrition. Impor- 
 tant etiological factors are overwork, worry, irregular or indifferent meals, 
 the stress of life, too frequent child-bearing, prolonged lactation, and enter- 
 optosis. Remarkable forms and combinations are described by women 
 passing through the grand climacteric. Forms of general and local paraes- 
 thesia constitute important epiphenomena of many chronic morbid states. 
 
 Cerebral Parsesthesias. — Sensations of heat, fulness, pressure, and 
 other abnormal sensations in the head — the so-called cerebral parcesthesice — 
 occur in neurotic individuals and over-taxed brain workers. These abnor- 
 mal sensations do not amount to actual pain, though they frequently alter- 
 nate with it. The.y are often distressing and sometimes intense. They 
 occur in adolescence and early adult life and are especially common in women 
 about the time of the grand climacteric. They are, however, more com- 
 mon in men than in women and in those given to intellectual pursuits and 
 of sedentary habits than among the laboring classes. They occur with 
 great frequency in lithsemic and gouty individuals. These sensations are 
 sometimes general, sometimes localized to the vertex, occiput, or forehead. 
 They frequently persist for long periods of time, in some cases preserving 
 the same character, in others varying. They are augmented by mental 
 effort and by disagreeable emotions and intensified by introspection and 
 attempts on the part of the patient to explain them to his physician. 
 They are, on the other hand, minimized by diversion and suggestion. 
 
 Forms of Paraesthesia. — The parsesthesise may be best studied in 
 respect of their character, since almost any of them may be referred to 
 various parts of the body and all parts at different times. They are de- 
 scribed in the most varied combinations, so that numbness and tingling, 
 itching and formication, burning and stinging, coldness and tension, tight- 
 ness and throbbing, and many others occur. 
 
 Numbness. — This is a common symptom in superficial injuries of the 
 skin from cold or heat; the action of corrosive substances, as the mineral 
 acids and carbolic acid; overdoses of certain drugs, as aconite and the 
 bromides; injuries of nerves, neuritis, neuralgia in the stage of access and 
 decline and in the remissions of pain; herpes zoster; peripheral neuritis 
 from any cause and in the endemic form of the tropics, beriberi; hysteria, 
 neurasthenia, tetany, tabes, the early stages of myelitis, and in cerebro- 
 spinal fever. Numbness may be a localizing symptom in coarse lesions of 
 
584 MEDICAL DIAGNOSIS. 
 
 the brain, as tumor or abscess. It may occur as a premonitory symptom 
 in apoplexy and as the aura in epilepsy. The sensation is sometimes de- 
 scribed as like that produced by a very mild faradic current. It is common 
 and distressing in myxoedema and may be a troublesome symptom affect- 
 ing the hands and feet in arthritis deformans. Numbness in the hands and 
 feet constitutes the condition known as acroparcesthesia. Waking numb- 
 ness occurs at or about the menopause. It involves the extremities and 
 usually passes off as the day goes on and ceases when the patient becomes 
 adjusted to the non-menstrual life. Numbness is sometimes associated 
 with or alternates with burning and tingHng. 
 
 Itching or Pruritus. — This form of para3sthesia is frequently asso- 
 ciated with formication and is sometimes so severe as to be described as 
 pain. It is also associated with burning, especially in inflam.mations of 
 the skin such as occur in the exanthemata, as measles and scarlet fever. 
 Itching of the scalp is a symptom of seborrhoea; of the lips and nose a 
 symptom of herpes; of the eyeHds a symptom of beginning conjunctivitis; 
 of the anal region a symptom of hemorrhoids or ascarides; of the external 
 genitaha in both sexes a symptom of saccharine diabetes, in the female of 
 leucorrhoea and neurotic states. Itching of the whole surface is a trouble- 
 some symptom in aged persons, in certain subjects in winter, in others 
 who are lithaemic or gouty, in hysteria, neurasthenia, and many organic 
 diseases of the nervous system. It is a symptom of jaundice, and some- 
 times follows the administration of morphine, copaiba, and other drugs. 
 Pruritus is an occasional symptom in chronic interstitial nephritis and 
 chronic lead poisoning. 
 
 Coldness. — A common form of paraesthesia. It is often general, as 
 in the chill, rigor, or shivering which marks the onset of an acute febrile 
 infection as pneumonia, or constitutes the initial stage of ague. Under 
 these circumstances the internal temperature is elevated. Sensations of 
 coldness with a normal or subnormal temperature occur in myxoedema, 
 profound asthenia from any cause, especially after hemorrhage, hysteria, 
 neurasthenia, and in some forms of spinal cord disease, as tabes, lateral 
 sclerosis, and syringomyelia. Coldness in the back is often experienced 
 by persons who are suffering from pulmonary tuberculosis in the period 
 of incipiency. Subjective sensations of coldness in the extremities are 
 usually associated with actual low temperature and often with some degree 
 of cyanosis. In other cases the sensation of coldness is referred to a cir- 
 cumscribed area, usually in the leg or thigh. The affected region feels as 
 though in contact with a piece of cold metal or even a piece of ice. This 
 symptom occurs in neuropathic persons usually in middle Hfe and com- 
 monly in men. It has been observed in local injury to a nerve-trunk and 
 in spinal diseases. 
 
 Heat. — Heat as a subjective sensation not dependent upon general 
 or local elevation of temperature constitutes a common and distressing 
 paresthesia. When it amounts to pain it is known as causalgia. It is 
 mostly locaHzed. Flushing is accompanied by the sensation of heat. 
 Flushes of heat are common in stout women at middle life, at or about 
 the menopause, and in nervous persons with weak heart. Subjective 
 sensations of heat are sometimes associated with the girdle sensation. 
 
SYMPTOMS AND SIGNS: PARiESTHESIA. 585 
 
 Weight. — This parsesthesia is likewise of common occurrence. It 
 occurs in the chest as a symptom in severe acute bronchitis, asthma, pleural 
 and pericardial effusion, and mediastinal tumor; also in great cardiac hyper- 
 trophy and dilatation and in valvular disease upon rupture of compensa- 
 tion. Substernal weight and oppression may be a symptom of acute indi- 
 gestion or of an overloaded stomach and may precede haematemesis. The 
 sensation may be referred to the epigastrium. Weight upon the chest 
 occurs in hysteria and neurasthenia and constitutes the incubus in night- 
 mare. It is symptomatic of enteroptosis and splanchnoptosis, ascites, and 
 abdominal and pelvic tumors. 
 
 Tenesmus or Bearing Down. — This form is frequently so distress- 
 ing as to amount to actual pain. The milder forms are encountered in 
 over-distention of the bladder, straining at stool, and some varieties of 
 dysmenorrhoea. 
 
 Precordial constriction or stenocardia accompanies the pain of 
 angina pectoris. Similar sensations but much less intense are sometimes ex- 
 perienced in cardiac asthenia^ myocarditis, fatty heart, pericarditis, and when 
 the heart is displaced upward by large ascites or abdominal tympany. 
 It belongs also to the wide group of sensations in hysteria and neurasthenia. 
 
 Throbbing. — Sensations of throbbing are felt in conditions charac- 
 terized by vascular relaxation and nervous excitement. Among these are 
 aortic regurgitation, anaemia, and paroxysmal states in hysteria and nevu'as- 
 thenia. Almost every part of the body may be the seat of these sensations. 
 They affect the head in migraine and other intense headaches; the neck 
 in front and laterally in cardiac hypertrophy and exophthalmic goitre; 
 the precordia in palpitation; the epigastrium in the pulsating aorta of 
 neurasthenia; and constitute a local symptom in phlegmon and aneurism. 
 Throbbing is commonly associated with objective pulsations. Purely 
 subjective sensations of fluttering are described by nervous women. They 
 are often referred to the left inframammary region. 
 
 Faintness. — Faintness is a sensation attendant upon enfeeblement 
 of the heart's action, whether due to physical or emotional causes. Hence 
 it occurs in dilated heart, myocarditis, fatty heart, and all forms of anaemia, 
 especially upon exertion; in hemorrhage, shock, collapse, and upon the too 
 sudden withdrawal of fluid by the trocar or aspiration; and finally in 
 fatigue, excessive heat, and intense pain. Faintness attends sudden depress- 
 ing emotion and mental shock. Weakness and debility are attended by 
 subjective sensations which are characteristic and important, since they 
 are often danger signals in the absence of the objective phenomena of 
 oncoming disease. Sudden sensations of weariness out of all proportion to 
 effort — fatigue symptoms — are suggestive of neurasthenia. 
 
586 MEDICAL DIAGNOSIS. 
 
 XIV. 
 
 GENERAL SYMPTOMATIC DISORDERS OF THE NERVOUS 
 
 SYSTEM (CONTINUED): VERTIGO; CONVULSIONS; 
 
 TREMOR; FIBRILLARY TWITCHINGS. 
 
 VERTIGO. 
 
 Vertigo — literally a turning — is a symptomatic derangement of the 
 nervous system governing the relationship of the body to external objects. 
 It is of two kinds: objective vertigo, characterized by sensations of move- 
 ment on the part of surrounding objects which are really at rest, and 
 subjective vertigo, characterized by sensations of movement on the part of 
 the individual himself. It is popularly known as dizziness or giddiness. 
 This symptom attends organic intracranial disease, but is more common in 
 peripheral or functional disturbance. Vertigo in which no underlying 
 pathological condition is discoverable is known as essential. Vertigo is a 
 common nervous symptom. It is often associated with headache. It may 
 occur (1) in mild cerebral concussion; (2) circulatory disturbances, as 
 cerebral anemia and hyperaemia; (3) local nerve irritation, as mechanical 
 irritation of the external auditory meatus, inflammation of the middle ear, 
 or the application of electrical currents to the head. A special form of 
 vertigo — true auditory vertigo — occurs in labyrinthine disease. (4) Vertigo 
 is a common symptom in toxiemic conditions and is associated with head- 
 ache in the period of onset of the acute infections, in many cases of acute 
 and subacute gastrohepatic derangements, and in lithsemia. It is symp- 
 tomatic of narcotic poisoning, especially that produced by alcohol, tobacco, 
 opium, and the nitrites. It occurs also in aniline poisoning, (5) It is a 
 common S5miptom iv arteriosclerosis and (6) in valvular disease of the 
 heart, especially aortic insufficiency, and in forms of degenerative myo- 
 carditis; (7) in neuropathic conditions, especially neurasthenia and epi- 
 lepsy; (8) in reflex disturbances, such especially as arise from diseases of 
 the visual apparatus or the stomach; (9) in organic disease of the brain, 
 especially in tumor, cerebellar disease, in meningeal irritation and menin- 
 gitis, and in brain syphilis. Finally, (10) vertigo results from mechanical 
 causes, such as swinging, certain unusual postures, rapid rotary move- 
 ments, and sea-sickness. 
 
 Vertigo varies in intensity from a trifling sensation of imperfect 
 equilibrium — mere swimming of the head — to the most active and dis- 
 tressing sensations of rapid or irregular movement or whirling of the body 
 or of surrounding objects. 
 
 The equilibrium of the body is maintained by muscular action. The 
 nicely adjusted and constantly varying motor impulses necessary to equi- 
 hbrium are determined in cerebral centres in response to sensory impres- 
 sions which are as continuous as the motor impulses which respond to them. 
 These sensory impulses are visual, aural, muscular, articular, cutaneous. 
 
SYMPTOMS AND SIGNS: VERTIGO. 587 
 
 and visceral. Anything which suddenly deranges the continuous and 
 systematized though unconscious sensory impulses from these structures 
 causes a derangement of the nervous mechanism by which the body is 
 maintained in its relation to external objects. This derangement mani- 
 fests itself as vertigo. These sensory impressions are not felt in normal 
 consciousness, but when they are interrupted or when the cortical processes 
 by which they are converted into motor impulses are deranged consciousness 
 in regard to them is perverted and vertigo results. For this reason vertigo 
 implies a disturbance, not a loss of consciousness. In true vertigo con- 
 sciousness is always retained. 
 
 Vertigo comes on suddenly and is commonly of short duration. In 
 the objective form the floor or the bed on which the patient is lying appears 
 to rise and sink and objects whirl around, usually in a definite direction. 
 In subjective vertigo the patient himself appears to be whirling around or 
 rising and sinking in space. These sensations are often accompanied by 
 compensatory movements on the part of the patient which may result in 
 a fall. Mental confusion, faintness, a sense of alarm, and nausea or vomit- 
 ing are associated symptoms, which vaiy in intensity but are almost al- 
 ways present. When the vertigo is severe consciousness is impaired but 
 not lost. The attacks continue to recur whilst the causal condition per- 
 sists. The term status veriiginosis has been applied to persistent vertigo. 
 
 The following forms of vertigo demand separate consideration: 
 
 Aural Vertigo. — This symptom frequently arises from the pressure 
 of accumulated cerumen in the external auditory canal or from the pres- 
 sure of air against the tympanic membrane by a blow upon the ear, or the 
 entrance of water in diving or surf bathing, or the too forcible use of the 
 ear syringe. It may also occur, though it is not a common symptom, in 
 cases of middle-ear disease or from the use of the Eustachian catheter. 
 Vertigo occurring under the above circumstances is usually slight and 
 transitory. Labyrinthine vertigo is the chief symptom in Meniere's disease. 
 
 Toxic Vertigo. — Vertigo which attends the onset of the acute infec- 
 tions is of no great importance and usually quickly passes away. That 
 which occurs in gastrohepatic catarrh is commonly annoying on rising in 
 the morning in persons of bilious temperament and sedentary lives, espe- 
 cially if they be addicted to the pleasures of the table. This symptom 
 occurs also in acute indigestion and in lithiemic conditions. Vertigo is 
 a very common drug symptom, which is, however, much influenced by 
 habit and idiosyncrasy. 
 
 Cardiovascular Vertigo. — Vertigo is a symptom of cerebral anaemia. 
 It occurs in sudden blood loss, cardiac asthenia, excitement, or sudden 
 effort during digestion, upon sudden effort in myocarditis, valvular disease, 
 and in particular aortic insufficiency. It occurs also in pernicious and other 
 forms of anaemia, chlorosis, and leukaemia. Associated with tinnitus aurium 
 it is very common in sclerotic changes in the branches of the cerebral 
 arteries. 
 
 Neurotic Vertigo. — Vertigo sometimes occurs in epilepsy as an aura. 
 It is not rare in petit mal. Vertigo is a common and distressing symptom 
 in neurasthenia. The attacks are frequent but not commonly severe or 
 prolonged. They are attended with nausea, though vomiting is not com- 
 
588 MEDICAL DIAGNOSIS. 
 
 mon. It is usually subjective and frequently reflex. Stumbling or para- 
 lyzing vertigo has been observed in exophthalmic goitre and as an endemic 
 condition in certain cantons of Switzerland during the summer. There is 
 a sudden loss of power in the legs with impairment of consciousness. Par- 
 oxysmal vertigo may occur in nervous individuals after excitement or 
 fatigue. It is very distressing, occurring suddenly, accompanied with 
 nausea and vomiting, and lasting sometimes for hours. 
 
 Reflex vertigo may be associated with the brow pains and other forms 
 of headache which are symptomatic of errors in refraction or want of 
 harmonious action in the ocular muscles. 
 
 Mechanical Vertigo. — This symptom attends sudden lowering of 
 the head, whirling around, or swinging in individuals not accustomed to it,. 
 and is a very important part of the symptom-complex in sea-sickness and 
 car-sickness. Mild persistent vertigo has been observed in elevator boys. 
 
 Vertigo op Intracranial Disease. — This is a very common symp- 
 tom in diseases of the brain and its meninges. It is sometimes distressing 
 but as a rule is of secondary importance to the headache, vomiting, and 
 mental dulness with which it is commonly associated. It occurs at some 
 time during the course of meningitis, cerebral abscess, thrombotic soften- 
 ing, tumor of the brain, and cerebellar disease. This form is of considerable 
 importance in the diagnosis of cerebral syphilis. 
 
 Laryngeal vertigo, better called laryngeal epilepsy, usually mani- 
 fests itself in neurotic adults. The paroxysm begins with tickling or irrita- 
 tion in the larynx, cough, partial loss of consciousness, and dyspnoea. Light 
 tonic or clonic movements occur. The patients suffer from laryngitis, 
 bronchitis, asthma, or pulmonary phthisis. The attacks recur as often as 
 once a day or at longer intervals. 
 
 CONVULSIONS. 
 
 The term convulsion is used to designate a paroxysm of involuntary 
 and more or less violent muscular contractions involving the voluntary 
 muscles in general. The word spasm is frequently used in a more limited 
 sense to indicate similar involuntary contractions of the -muscles of partic- 
 ular parts of the body. We speak of general convulsions and local spasms^ 
 This distinction is, however, not always observed. 
 
 General Convulsions. — Convulsions are tonic and clonic. A tonic 
 convulsion is an involuntary muscular contraction which is continuous 
 and intense. It may be of brief duration, as in the beginning of the epileptic 
 paroxysm; or prolonged, as in tetanus. A clonic convulsion is character- 
 ized by the rapid alternation of contraction and relaxation, as in the second 
 stage of the epileptic paroxysm or in infantile eclampsia. The posture in 
 tonic convulsions is forced and immovable; in clonic convulsions it is con- 
 stantly changed. The arms and legs are alternately flexed and extended 
 with more force than in ordinary movements, the body is violently tossed, 
 and the muscles of the face contorted. The chief centre for convulsions is 
 the cerebral cortex. Tonic and clonic convulsions may succeed each other, 
 as in epilepsy, or may alternate, as in hysteria. Consciousness is often pre- 
 served in general convulsions of the tonic type, as strychnine poisoning and 
 
SYMPTOMS AND SIGNS: CONVULSIONS. 589 
 
 tetanus, and usually lost in those of clonic type, as epilepsy and ursemia. 
 A spasm may be confined to a muscle or a group of muscles; or it may ex- 
 tend to an entire limb or the whole of the body. A cramp is a painful 
 tonic spasm affecting a single muscle or group of muscles, as the well- 
 known cramp in the calves of the legs. 
 
 Etiology. — From the standpoint of etiology convulsions are symp- 
 tomatic of (1) local irritation; (2) general cortical irritation, (a) from 
 causes wholly unknown, (b) from the toxaemia of infection, (c) from va- 
 rious intoxications; (3) circulatory derangements; (4) inflammatory and 
 degenerative processes involving the cerebral cortex; (5) convulsions are 
 very often of reflex origin. 
 
 Convulsions are essentially paroxysmal. Even though the cause is 
 persistent, the motor centres become exhausted and there are intermis- 
 sions, as in uraemia. Again the paroxysms occur as storms, the cause 
 exhausting itself in a single paroxysm or series of paroxysms and only 
 again asserting itself after an interval more or less prolonged, as in ordi- 
 nary epilepsy. In infancy, in the children of neurotic parents, and in neuro- 
 pathic individuals convulsions frequently arise from the action of causes not 
 capable of producing them at a later age or in normal individuals. 
 
 1. Local Irritation. — The motor areas may be directly involved 
 in fracture, hemorrhage, cicatrix, or neoplasm, as in focal or Jacksonian 
 epilepsy. The initial symptom may be a local spasm, involving the leg, 
 arm, or face, the convulsion becoming generalized in the course of a few 
 seconds or longer. Again the local irritation may be transmitted from a 
 distance, as in tumor, abscess, or sclerosis. 
 
 2. The irritation may be general, (a) from causes wholly unknown, 
 as in epilepsy. The paroxysm is frequently preceded by an aura; it begins 
 with tonic spasm and loss of consciousness and is characterized by clonic 
 convulsions. So characteristic is the latter stage, that general convulsions 
 due to other causes are described as epileptiform or epileptoid. The par- 
 oxysm is followed by hebetude, drowsiness, or stupor, and may be replaced 
 by a maniacal outbreak or other mental disturbance — the psychical epi- 
 leptic equivalent, (b) The toxaemias of infection. General convulsions very 
 commonly attend the onset of the infectious diseases in childhood. They 
 occur at this period of life as the equivalent of the initial chill in the adult 
 and are frequently seen at the onset of scarlet fever, measles, and pneumonia, 
 and in other not well defined infections. They are frequent in rickets, 
 which is the most important predisposing cause of infantile convulsions. 
 They are early symptoms of that disease, and when convulsions occur in 
 infancy without manifest cause rickets is to be considered. The convul- 
 sions of tetanus, strychnine poisoning, and hydrophobia are to be considered 
 under this heading, (c) General convulsions occur in poisoning from 
 aconite, prussic acid, and veratrum viride, and in chronic alcoholism and 
 lead poisoning. Under this heading are to be included the convulsions of 
 uraemia, puerperal eclampsia, and asphyxia. 
 
 3. Circulatory derangements are sometimes the cause of general 
 convulsions which occur after profuse hemorrhages, and in the cerebral 
 anaemia which immediately precedes dissolution. Violent general convul- 
 sions occasionally occur during the coma following sunstroke. 
 
590 MEDICAL DIAGNOSIS. 
 
 4. Inflammatory and degenerative processes involving the cere- 
 bral cortex give rise to general convulsions. Under this heading are to 
 be considered the convulsions of cerebrospinal fever and other forms of 
 meningitis, cerebral syphilis, general paresis, and pachymeningitis hsemor- 
 rhagica. 
 
 5. Convulsions are very often of reflex origin. Painful affections and 
 excitation in the region of a sensory nerve may produce spasms. Exam- 
 ples of reflex convulsions are those following severe injuries, burns, those 
 associated with renal or intestinal colic, a foreign body in the ear, intestinal 
 strangulation, retention of urine, and phimosis. Dentition and intestinal 
 worms are less common causes of convulsions than is generally supposed. 
 Indigestion is a cause of convulsions in infants and older children. In 
 whooping-cough convulsions" are very common. They result from the 
 asphyxia attendant upon a prolonged paroxysm, cerebral congestion, or 
 hemorrhage resulting from such a paroxysm. In other cases they are to 
 be attributed to the depressed condition of the nervous system caused by 
 the disease itself. General convulsions have been attributed to enlarge- 
 ment of the thymus gland as a result of pressure either upon the pneumo- 
 gastric or upon the trachea. They frequently occur in children in whom no 
 cause can be discovered and may in such cases be regarded as idiopathic. In 
 infants in whom an attack of convulsions has once occurred a predisposition 
 seems to be established, so that similar attacks occur from indifferent or not 
 recognizable causes. In infantile convulsions the attack is commonly pre- 
 ceded by restlessness, fretfulness, grinding of the teeth, and slight twitching. 
 It may occur suddenly without premonitory symptoms. The initial cry so 
 common in epilepsy is usually absent, nor are the successive stages so well 
 defined. The spasm begins in the hands; the eyes are fixed and staring 
 or strongly turned upward; the body rigid, and the face congested. The 
 convulsion is at first tonic, so that respiration is suspended, but presently 
 clonic convulsions set in, the eyes are moved from side to side, there are 
 violent twitchings or alternate flexions and extensions of the limbs, contor- 
 tion of the face, and retraction of the head. There is spastic flexion of the 
 fingers, the thumb being against the palm — clenched fingers. These move- 
 ments gradually cease and the child passes into a condition of stupor. 
 There is usually slight elevation of temperature. Convulsions arising from 
 indigestion and those which usher in an infectious disease are commonly 
 single, but those due to rickets recur in series. In some instances one 
 attack succeeds another until death ensues. 
 
 When the attack occurs in a healthy child, it may be due to acute 
 indigestion or some form of peripheral irritation; when accompanied by 
 high fever and vomiting it may be the forerunner of an acute infection, as 
 scarlet fever, or of infantile hemiplegia; when it occurs in badly nourished 
 or rickety children it is apt to be incomplete and to recur. The convulsions 
 of infancy do not of necessity run on into epilepsy, but general convulsions 
 occurring without apparent cause at irregular intervals in young children 
 otherwise healthy are in a limited proportion of the cases epileptic from the 
 beginning. 
 
 Ursemic convulsions may be preceded by headache and restlessness. 
 Sometimes they come on without warning. The epileptic cry does not 
 
SYMPTOMS AND SIGNS: CONVULSIONS. 591 
 
 occur, but in other respects the attack may resemble true epilepsy. The 
 convulsions are often recurrent and prolonged, the seizures being separated 
 by periods of coma or deep stupor. The temperature is usually subnormal; 
 exceptionally it is elevated. The condition is recognized by the characters 
 of the urine, the presence of oedema, the condition of the heart and arteries, 
 a urinous odor, and the history of the case. 
 
 Puerperal convulsions present the same clinical picture as those which 
 occur in ordinary nephritis. 
 
 Hysterical convulsions are to be distinguished from epilepsy by the 
 emotional state which precedes the attack, the globus hystericus, the diffi- 
 cult respiration, the alternating laughter and tears. Sensations may be 
 described which suggest the epileptic aura, as precordial, abdominal, or 
 pelvic uneasiness or distress. The patient does not fall to the floor in instant 
 and complete unconsciousness as in epilepsy, but gently or by preference 
 upon a sofa or couch in such a way as to do herself no harm. The move- 
 ments are irregular and clonic but usually much less violent than in epi- 
 lepsy. The tongue is not bitten. The attack gradually subsides and the 
 patient becomes conscious and emotional again. At the close of the attack 
 a large amount of light-colored urine of low specific gravity is often voided. 
 The more violent convulsions, manifestations of hystero-epilepsy, include 
 grinding of the teeth, tonic spasm, opisthotonus, and other forced attitudes, 
 clonic spasms, and more or less profound unconsciousness. The attack is 
 more prolonged than in epilepsy and is followed by contortions and cata- 
 leptic poses and in some instances by attitudinizing suggestive of various 
 passionate states. 
 
 In tetanus the earliest symptoms are slight stiffness of the neck and 
 some embarrassment in mastication. These symptoms gradually increase 
 until the condition of trismus or lockjaw develops. The spasm extends 
 and involves the muscles of the body, causing the rigid attitudes known as 
 opisthotonus, orthotonus, pleurotonus, and emprosthotonus. Respiration 
 is interfered with by the muscular spasm and asphyxia may threaten from 
 closure of the glottis. The convulsive paroxysms are excited by the slight- 
 est irritation and are of variable duration. Complete relaxation may not 
 occur during the intervals. There is usually a history of trauma. 
 
 The resemblance of strychnine poisoning to tetanus is close. Trismus 
 is absent as a rule and the relaxation between the convulsive paroxysms 
 is complete. There is a history of the ingestion of the poison. 
 
 Tetany is characterized by the peculiar position of the hands and feet, 
 the involvement of the extremities, less often the face and neck, and the 
 presence of Trousseau's symptom — the reproduction of the paroxysm by 
 compression of the affected part either in the direction of the principal 
 nerve-trunks or over the blood-vessels; or of Chvostek's symptom — an 
 increase in the mechanical irritability of the motor nerves, a slight tap 
 over the nerve-trunk being sufficient to throw the muscles into active spasm. 
 The history of the case is quite different from that of both tetanus and 
 strychnine poisoning. 
 
592 MEDICAL DIAGNOSIS. 
 
 TREMOR. 
 
 Tremor is a rhythmical to-and-fro movement of limited range due to 
 the alternate contraction and relaxation of opposing muscles. The move- 
 ments are involuntary and differ from fibrillation in that they cause loco- 
 motion of the parts involved. It is due to nutritive alterations in the motor 
 neurons both of the cortex and spinal cord. A distinction is made between 
 intention or volitional tremor, which shows itself only upon intentional move- 
 ments, and passive tremor, which occurs when the parts are at rest. The 
 former is sometimes spoken of as paralytic; the latter as spastic tremor. 
 In the examination the patient is to be observed at rest, in intentional 
 movement, and in attitudes which require sustained tonic contraction of 
 the muscles, as horizontal extension of the arms and hands, separation of 
 the fingers, or protrusion of the tongue. 
 
 The following forms of tremor are of diagnostic importance: 
 
 1. The Intention Tremor of Multiple Sclerosis. — This form of 
 tremor does not occur during rest, but shows itself upon intentional move- 
 ment, usually at first slight, then progressively more rapid and with wider 
 oscillations, so that the intended movement is greatly hindered. The 
 movements in some cases are so great and so irregular as to suggest ataxia. 
 The rate of the tremor in disseminated sclerosis is given by Peterson at 
 7.9 to 8.1 per second for the earlier stages and 4.6 to 6.3 for the later stages. 
 
 2. The tremor of paralysis agitans is distinctly slower. It con- 
 tinues during rest, becomes less marked upon movement, and upon deter- 
 mined impulse of the will may disappear for a brief period. The rate is 
 from 3 to 6 per second. This form of tremor disappears during sleep. It 
 usually first appears in the hands and is characterized by rhythmical 
 movements of the index finger against the thumb which suggest pill rolling. 
 The tremor of paralysis agitans very seldom affects the head. 
 
 3. Senile tremor is in its more moderate forms an intention tremor; 
 in well developed forms a tremor of rest. The hands and arms are more 
 commonly involved, but the head is often affected and the under jaw and 
 lips. The rate is from 4 to 6 oscillations per second. 
 
 4. The tremor op exophthalmic goitre is best manifested in the 
 hands when extended and the fingers separated. It sometimes affects the 
 head. The rate is rapid — 8 or more per second — and the excursion limited. 
 Upon intentional movements the tremor is sometimes increased. This 
 form of tremor is common in hysteria, in which, however, every form 
 may be encountered. It is seen also in tuberculous meningitis, in 
 lesions of the corpora quadrigemina, and rarely in disease of the cere- 
 bellum. Similar tremors occur in the acute febrile diseases. The 
 tremor of enteric fever is an example. It occurs even in mild cases and is 
 most noticeable in the tongue when it is protruded for examination. At 
 first fine, it becomes coarser as the exhaustion increases. The lips are 
 affected and in severe cases the hands. It is more marked in persons who 
 are addicted to alcohol. Murchison regarded excessive tremor as one of 
 the signs of deep ulceration of Peyer's patches. 
 
 5. The toxic tremors are usually fine. They are intensified upon 
 intentional movement. The more common causes are alcohol, tobacco, 
 
SYMPTOMS AND SIGNS: FIBRILLATION. 593 
 
 morphine, and mercury. In alcoholic tremor first the hands and then the 
 lips are affected, and it is temporarily intensified upon the withdrawal of 
 alcohol and diminished by its administration in increased doses. 
 
 6. Tremor due to miscellaneous causes, as intense emotion, exces- 
 sive or prolonged muscular effort and extreme cold may occur in healthy 
 persons and is without diagnostic importance. Popular phrases are trem- 
 bling with anger ov fear or cold, and buck fever, in the inexperienced hunter. 
 
 FIBRILLARY TWITCHING OR FIBRILLATION. 
 
 This is an involuntary, brief, sluggish contraction of groups of muscular 
 fibres rather than of an entire muscle. It is manifested as a wave-like 
 movement of feeble intensity just under the skin, not involving the muscle 
 as a whole and producing no movement of the parts to which the muscle 
 is attached. It may occur in a limited number of fibres at long intervals, 
 or in successive groups of fibres in rapid succession. There are cases in 
 which fibrillary contractions do not occur spontaneously but can be excited 
 by tapping the skin overlying the muscle with the finger, and in those cases 
 in which they occur infrequently they may be produced in the intervals by 
 the same manoeuvre. They often occur in healthy persons upon exposure 
 of the surface of the body to cold air. Fibrillation is probably caused by 
 a lesion which at once weakens and irritates the cell-body of the peripheral 
 motor neuron in the anterior horn of the spinal cord (Lloyd). It is, there- 
 fore, symptomatic of progressive degenerative processes involving and gradu- 
 ally destroying the large ganglionic motor cells, and occurs in paretic 
 and atrophic muscles when those changes are of nuclear origin. This phe- 
 nomenon is especially seen in anterior poliomyelitis and in bulbar paralysis. 
 It may be present in traumatic neuroses without paresis or atrophy. 
 
 Other morbid motor phenomena are discussed in the chapter upon 
 the Examination of the Nervous System. 
 
 XV. 
 
 PSYCHICAL CONDITIONS, EMOTIONAL STATES, DERANGE- 
 MENTS OF CONSCIOUSNESS, INSOMNIA AND 
 OTHER DISORDERS OF SLEEP. 
 
 PSYCHICAL CONDITIONS. 
 
 The consideration of abnormal mental phenomena comes properly 
 within the scope of psychiatry. Mental derangements constitute at times, 
 however, important symptoms in almost every department of internal 
 medicine. The degree of intelhgence, defects of memory, emotional 
 states, and irritative and depressive derangements of consciousness are 
 to be considered. Closely allied are insomnia and other disorders of sleep. 
 
 Intelligence. — The age, education, and social surroundings of the 
 patient are to be considered. Derangements of intelligence are frequently 
 38 
 
594 MEDICAL DIAGNOSIS. 
 
 associated with impaired consciousness but may occur independently of it. 
 Both vary greatly in degree. Slight intellectual defects often not recognized 
 in the ordinary demeanor and conversation of the patient become apparent 
 upon further knowledge or upon taking a careful clinical history. The 
 lower grades, designated by such terms as dulness and stupidity, or an 
 extreme degree, as idiocy and demientia, are immediately apparent in the 
 facial expression and behavior of the individual. Not infrequently a fall- 
 ing off in intelligence is manifest in persons suffering from chronic incurable 
 affections, as valvular disease of the heart, nephritis, tuberculosis, and cancer. 
 Not only is the nutrition of the cerebral cortex impaired but the patient's 
 range of thought becomes progressivelj* more circumscribed. His interest 
 in general affairs or the particular objects of his previous intellectual activity 
 diminish in proportion as his interest in his sj^mptoms and in the narrow 
 life of the sick-room increase. Graver derangements amounting to abso- 
 lute indifference, stupidity, or dementia are on the other hand observed 
 in cerebral diseases, especially in tumors of the brain, progressive bulbar 
 paralysis, multiple sclerosis, hemorrhage, thrombosis, embolism, and soften- 
 ing. In other cases stupidity or dementia may be the expression of a 
 developmental anomaly of the brain, as in idiocy and cretinism. Of special 
 interest is the derangement of intelhgence which occurs in myxoedema, 
 both that form which develops spontaneously and in the cachexia struma- 
 priva. In this condition, w^hich is closely allied to cretinism or indeed 
 practically identical with it, the derangements of intelligence vary in degree 
 from moderate apathy and indifference with slowness of thought associated 
 with slowness of speech to a state bordering upon dementia. A transient 
 abnormal exaltation in mental activity with a rapid flow of ideas and un- 
 usual facility of expression may attend hectic fever, the action of alcohol, 
 and excitement due to other causes. A corresponding depression in mental 
 activity is observed in the period of reaction. The patient who has been 
 restless and talkative in the febrile period is depressed and silent during the 
 sweating that attends the defervescence; the exhilaration of alcohol is 
 followed by the depression of a physical if not a moral remorse; fervor of 
 speech and energetic action give place to dulness and abstraction. 
 
 Mental dulness or confusion occurs independently of derangements of 
 consciousness. Confusion of thought attends grave neurasthenia, cerebral 
 tumor, arteriocapillary sclerosis, old age, and profound malnutrition. 
 Slowness of apprehension and unreadiness in expression are usually char- 
 acteristic of defective intelligence, but may indicate lesions of the nervous 
 mechanism by which ideas are received and expressed, as in forms of aphasia. 
 
 Memory. — As age increases the memory becomes less accurate and 
 retentive. In many old people in other respects in good health and intelli- 
 gence failure of memory becomes pronounced. At earlier periods of life 
 the integrity of the memory is dependent upon the same conditions of 
 general good health as that of the intelligence. We find therefore very often 
 impairment or loss of memory in local lesions of the brain such as result 
 from hemorrhage or softening, which are not, however, necessarily asso- 
 ciated with enfeeblement of intelligence. Weakness of memory is very 
 often observed in the traumatic neuroses — a fact demanding attention 
 since frequently this condition is attributed to malingering. Individuals 
 
SYMPTOMS AND SIGNS: EMOTIONAL STATES. 595 
 
 . recovered from severe traumatic neurasthenia very often have but faint 
 recollection of the events associated with and following the injury. Loss 
 of memory occurs in epilepsy, bromidism, and chronic alcoholism, is 
 common in insanity, and often complete in terminal dementia. 
 
 EMOTIONAL STATES. 
 
 Mental depression is very common in chronic and incurable diseases. 
 It is sometimes purely symptomatic. More commonly it arises from pain 
 and suffering or from apprehension in regard to the future. A high grade 
 of depression characterizes hypochondriasis and melancholia. In deep 
 jaundice, especially when chronic, depression is very common. Mental 
 depression frequently attends diseases of the stomach, particularly those 
 in which pain is prominent. Periods of depression occur during the meno- 
 pause and in pronounced neurasthenia, hysteria, and in cerebral disease. 
 
 Emotional exaltation characterizes acute and chronic mania and is 
 an important element in active delirium. During anaesthesia by chloro- 
 form, ether, and nitrous oxide the early derangement of consciousness is 
 manifest by emotional excitement which is often intense. A similar condi- 
 tion is characteristic of alcoholic intoxication. 
 
 Instability of temper, irritability, and sensitiveness are very common 
 in invalids. The testiness and outbursts of anger which occur in gout 
 and the fretfulness and impatience of uterine disease are well known. 
 Emotional instabihty and similar changes in disposition are frequently 
 observed in pregnancy. 
 
 DERANGEMENTS OF CONSCIOUSNESS. 
 
 These may be irritative or depressive. Irritative derangements of 
 consciousness vary in degree from mild emotional excitement to furious 
 homicidal mania; in extent from perversion in a limited region of con- 
 sciousness relating to a single idea or group of ideas to systematized delu- 
 sions influencing the whole life of the patient. Irritative frequently alter- 
 nate with depressive derangements of consciousness. Delusions, illusions, 
 and hallucinations are irritative derangements of consciousness. 
 
 A delusion is an unfounded conviction or belief. It is very often ab- 
 surd or ridiculous. Delusions that are persistent and based upon false 
 ideas having a logical interdependence or sequence are known as organized. 
 An expansive delusion is an insane behef in the individual's own greatness, 
 power, or goodness. No evidence or demonstration is sufficient to convince 
 a person of the falsity of his delusions. Examples of delusions that are 
 common are the belief that individuals, almost always unknown, are con- 
 spiring to do the patient a serious harm, or that the patient is the Christ 
 or Solomon or Queen Victoria. 
 
 An illusion is a false or misinterpreted sensory perception. The phe- 
 nomena upon which it is based actually exist. A patient who mistakes the 
 nurse for an officer of the law, or a bundle of rags for her baby, or ordinary 
 household sounds for the voice of God is the subject of an illusion. Illu- 
 siDns are very often transient or momentary. 
 
596 MEDICAL DIAGNOSIS. 
 
 An hallucination is a sense perception not founded on objective reality. 
 Hallucinations may relate to any of the senses. The patient who sees the 
 figures of bystanders or hears whispering voices, or perceives a disagreeable 
 odor or unpleasant taste, or feels upon his shoulder the pressure of a hand 
 when none of these objects exist, suffers from an hallucination. Hallucina- 
 tions are frequently persistent and distressing. 
 
 The Obsessions. — An obsession is an idea which dominates conscious- 
 ness often to the exclusion of other thoughts and ideas. It comes unbidden 
 and cannot be dismissed by any effort of the will. Nevertheless its nature 
 and unreasonableness are usually fully understood by the subject. 
 
 Obsessions very commonly take the form of definite systematized 
 fears relating to certain objects or conditions. These constitute the 
 so-called phobias, as kenophobia, the dread of large or open spaces; 
 claustrophobia, the fear of closed or narrow spaces; agoraphobia {ayopd, 
 a market place), the fear of a crowd; aichmo phobia, the fear of pointed 
 instruments or weapons or the dread of being touched by anything; 
 metallo phobia, a terror of touching or handling a metallic object; pyrho- 
 phobia, a morbid dread of fire; and many other forms of persistent and 
 dominating fear. 
 
 Doubt constitutes a common form of obsession. The mental uncer- 
 tainty may be restricted to a single subject or set of subjects or embrace 
 almost every affair of life from the simplest to the most important, recur- 
 ring with intolerable insistence and refusing to be allayed by the demon- 
 stration of the actual conditions to which they relate. 
 
 Another group of obsessions consists in a morbid exaggeration of the 
 activities of life. Those who are subject to them are possessed of a demon 
 of unrest and are irresistibly impelled to be continually doing something or 
 going somewhere, usually aimlessly and without fixed purpose, and always 
 ready without adequate motive to change from one occupation to another 
 or from the selected course to a different pne. 
 
 Closely allied to this group of obsessions are those which consist, in an 
 irritable impulse to touch a spot or an object — folie de toucher — or to repeat 
 certain movements, as returning to pass through a door two or three times 
 before departing from it, and the like. 
 
 Fixed ideas are closely allied to obsessions and the terms are often used 
 interchangeably. There are those, however, who distinguish between these 
 two derangements of consciousness, namely, that an obsession is recog- 
 nized by the patient as an abnormal train of ideas without basis in fact, 
 while the subject of a fixed idea is convinced that it is based upon the 
 conditions as they exist and perfectly normal under the circumstances. 
 
 The foregoing derangements of consciousness are permanent symp- 
 toms in insanity. They occur also in hysteria and neurasthenia and con- 
 stitute important elements of delirium. 
 
 Delirium is an irritative derangement of consciousness characterized 
 by restlessness, excitement, and incoherence. Periods of delirium may 
 alternate with somnolence, stupor, or convulsions. There are two forms of 
 delirium. In the active or maniacal the patient is wild and noisy. He 
 sings, screams, shouts, tries to get out of bed, struggles with his attendants, 
 and has to be restrained bv force. His face is congested, his eyes bright, 
 
SYMPTOMS AND SIGNS: DELIRIUM. 597 
 
 his expression alert, excited, even fierce. The second form is low or mutter- 
 ing. The patient Hes quiet, murmuring in a low tone, holding incoherent 
 and often whispered conversation with imaginary persons, or occupied with 
 vague fancies and taking no notice of what goes on around him. If aroused 
 he may give a rational but brief reply to questions, quickly relapsing into 
 his wandering dreams. This form of delirium is sometimes associated with 
 restlessness. The patient moves in bed, may even try to get up, but is 
 easily restrained. Between these two there are transitional forms attended 
 with moderate restlessness and excitement. The patients are irritable, 
 disturbed by trifles, and at times incoherent, though not boisterous. 
 
 Delirium develops very readily in persons of neurotic temperament 
 and in early life. It may occur in any severe illness. It is especially com- 
 mon in fever and usuaHy indicates a grave infection. In febrile diseases 
 children are more Hable to dehrium than adults, just as they are more 
 liable to high temperature. In general terms, there is no constant relation 
 between particular diseases and forms of dehrium. Active dehrium is, 
 however, frequently associated with the acute infectious fevers. The 
 delirium of pneumonia is sometimes violent; in inflammatory diseases of 
 the brain and in acute mania it is often furious. In fevers of ordinary 
 intensity the delirium is of moderate type. It is muttering or wandering m 
 the exhaustion of the low fevers and in the later stages of other acute dis- 
 eases. Delirium may be present in uraemia and in poisoning by belladonna, 
 cannabis indica, hyoscyamus, and opium, and a loud and boisterous delirium 
 quite different from delirium tremens sometimes occurs in acute alcoholism. 
 In enteric fever the headache usually ceases as delirium develops. 
 
 The onset of dehrium may be abrupt or gradual. An outbreak of 
 maniacal delirium has in rare instances been the first manifestation of an 
 acute infectious disease, as enteric fever, typhus, or pneumonia. Cases have 
 occurred in which under these circumstances individuals have been regarded 
 as insane and placed in an asylum. Much more commonly dehrium de- 
 velops gradually, showing itself first in a certain confusion of thought upon 
 awaking from sleep. In some cases delirium is absent during the day, 
 coming on again and increasing as night approaches. Mild nocturnal 
 delirium is sometimes seen during convalescence from pneumonia, enteric 
 fever, and septic conditions. 
 
 The delirium of inanition occurs in wasting diseases and in starvation. 
 It is not very rare in malignant disease of the oesophagus or stomach and 
 occurs in cases characterized by intractable vomiting. The delirium of 
 convalescence is probably a delirium of inanition. In this form of dehrium 
 the outbreak is sudden, usually in the early morning. There is feebleness 
 of pulse and a relaxed and sweating skin with cold hands and feet. It is 
 very often of brief duration, yielding in the course of some hours or a day 
 or two to the proper administration of nourishment and stimulants. Mani- 
 acal delirium not uncommonly follows the epileptic paroxysm — postepileptic 
 mania — or may develop as the psychical equivalent of the paroxysm. 
 
 The delirium of alcohohsm — delirium tremens — is very characteristic. 
 It is almost always associated with hallucinations which take the form of 
 large numbers of small objects, as mice, bugs, serpents., which continually 
 approach the patient and inspire abject and pitiable terror, or there are 
 animals running around his bed or crawling upon the walls. The delirium 
 
598 MEDICAL DIAGNOSIS. 
 
 is busy. The patient is restless, his hands are constantly moving, he tries 
 to get out of bed, but is usually tractable. Associated symptoms of diag- 
 nostic importance are tremor and sleeplessness, which are almost constantly 
 present. A condition not unlike delirium tremens may develop in other 
 drug habits. It has been observed after prolonged excesses in morphine, 
 chloral, and paraldehyde. 
 
 Carphologia, literally a gathering of chaff, the picking at the bed- 
 clothes, seen in the wandering delirium of grave fevers and profound 
 exhaustion, is of unfavorable prognostic significance. The patients lie 
 quiet, wholly oblivious of their surroundings, plucking with feeble hands 
 at the bed-covering or grasping at imaginary objects in the air. These 
 movements are dependent upon hallucinations. 
 
 Delirium is sometimes simulated by malingerers. Feigned delirium 
 is to be recognized by the absence of other signs of illness, the want of the 
 characteristic incoherence, and by the continuing sameness and limited 
 range of the manifestations. 
 
 Depressive derangements of consciousness vary in degree from simple 
 clouding of the ordinary consciousness to complete unconsciousness. They 
 affect the entire field of consciousness. Loss of consciousness may be sud- 
 den or gradual, and is a symptom of great diagnostic importance. 
 
 Somnolence is the term used to describe the mildest degree. The 
 individual is dull, drowsy, and indifferent, but retains an appreciation of 
 his surroundings and can respond more or less intelligently when addressed. 
 Naturally there is no sharp line of demarcation between this and the fol- 
 lowing progressive conditions. 
 
 Sopor, literally a sound or deep sleep, constitutes a more profound 
 impairment of consciousness. The individual lies deeply drowsy and indif- 
 ferent to his surroundings but can be aroused. To questions he rephes in 
 monosyllables and when aroused can move himself about and has a con- 
 fused notion of his surroundings. Left to himself he sinks again into an 
 abnormal drowsiness attended with muttering or snoring. 
 
 Stupor is partial or nearly complete un-consciousness. The patient 
 cannot be aroused except with difficulty and then rephes reluctantly and 
 briefly to questions, relapsing at once into his previous condition. The ex- 
 pression of the face is dull and " stupid. " He is still capable of swallowing. 
 Coma is complete loss of consciousness. The patient cannot be aroused 
 from his insensibility. Perception and vohtion are whohy suspended. 
 The face is expressionless, the respiration stertorous, the mouth open, the 
 tongue dry. Swallowing is impossible, the sphincter ani is relaxed, there 
 is urinary incontinence or retention. The breathing is frequently irregular. 
 It may be irregularly interrupted or show the Cheyne-Stokes modification. 
 Coma vigil is a condition of profound unconsciousness attended by 
 muttering delirium and carphologia. It is characteristic of this condition 
 that the eyes are open and appear to follow the movements of the attend- 
 ants. The prognosis is ominous. 
 
 Syncope — a swoon or fainting — is a sudden loss of consciousness, 
 usually complete and transient, associated with pallor, coolness of the skin, 
 and muscular prostration. It is a manifestation of acute anaemia of the 
 brain resulting from failure of the heart's action. It may be caused in 
 neurotic persons by sudden violent depressing emotions, as fear or horror, 
 
SYMPTOMS AND SIGNS: COMA. 599 
 
 or follow intense or prolonged muscular effort, or accompany hemorrhage 
 or shock. It is important in all cases to make the differential diagnosis 
 between suddenly on-coming coma and syncope. 
 
 Lethargy or trance is a condition of unconsciousness, more or less 
 complete, which occurs in hysteria. It has been observed in rare instances 
 after excessive mental application or exhausting disease and cases have 
 been noted in which it has occurred in individuals otherwise apparently 
 in good health. It differs from coma in resembling a deep and protracted 
 sleep from which the patient in some instances may be partially aroused. 
 The patient is usually pallid, the extremities relaxed, the eyelids closed, 
 the eyes turned upward or to one side. The pupils vary in size but react 
 to light. Respiration and circulation are greatly enfeebled. The tem- 
 perature is subnormal. The attack varies in duration from some hours to 
 several weeks. Cataleptic rigidity, or convulsions, may develop. 
 
 Catalepsy is a condition of impaired consciousness characterized by 
 rigidity affecting the voluntary muscles. A limb or the body of the patient 
 may be maintained continuously for some time in the same posture. The 
 position of the limb may be passively changed with slight resistance, 
 remaining in the posture in which it has been placed. This condition of 
 increased muscular tonus has been termed "waxy flexibility." The attack 
 may last for a few minutes or for several hours. It is attended with com- 
 plete anaesthesia of the skin and deeper tissues. The rhythm of the 
 respiration is disturbed, the circulation feeble, the surface temperature 
 depressed, and the reflexes impaired. The eyes are usually open ; the pupils 
 are dilated but react to light. The attitudes are sometimes bizarre and 
 grotesque. As the attack passes away the power of muscular movement 
 is fully regained. Catalepsy is a rare symptomatic disorder. It is encoun- 
 tered in hysteria, occurs in hypnotic states, and has been observed in cerebral 
 disease, as tumor and meningitis, and in forms of insanity, as melancholia. 
 
 Coma may be easily recognized. Its diagnostic significance is often 
 obscure. It occurs not only in cerebral disease but in the most varied 
 constitutional conditions. It may be symptomatic of the following: 
 
 (a) Organic disease of the brain, either general, as acute encephalitis, 
 cerebral syphilis, multiple sclerosis, and general paresis; focal, as intra- 
 cranial hemorrhage, embolism, thrombosis or softening, tumor, abscess 
 and thrombosis of the cerebral sinuses; disease of the meninges, as inflam- 
 mation, the pressure from exudate, and subdural hemorrhage or tumor; 
 or, finally, it may occur in the course of disease of the cranial bones, (b) 
 Traumatism of the head, producing cerebral commotion or compression, 
 (c) The pre-agonistic state in all diseases terminating fatally, (d) The fully 
 developed febrile infectious diseases. Only exceptionally is coma under 
 these circumstances complete. Early and complete coma occurs in the 
 malignant forms, (e) Uraemia, in which it commonly alternates with con- 
 vulsions, (f) The last stage of diabetes, (g) Forms of auto-intoxication 
 analogous to diabetic coma in which /?-oxybutyric acid or its derivatives arc 
 present in the blood, (h) Rare cases of septicaemia, pyaemia, carcinoma, and 
 acute yellow atrophy of the liver, (i) Narcotic poisoning, especially by alco- 
 hol, morphine, chloral, and various poisonous gases, and the surgical anaes- 
 thesia produced by the administration of ether, chloroform, nitrous oxide, 
 etc. (j) General convulsions, infantile eclampsia, and the epileptic par- 
 
600 MEDICAL DIAGNOSIS. 
 
 oxysm. (k) Drowning and asphyxia from other causes. (1) Sunstroke and 
 similar conditions produced by exposure to excessive heat, (m) Hysteria. 
 
 The Associated Phenomena in Different Morbid States Characterized by 
 Coma. — The diagnosis of the underlying condition is always important, 
 often difficult, sometimes impossible. When the previous history can be 
 obtained from the patient's friends the diagnosis is simplified. A child is 
 seized with convulsions and vomiting and falls presently into coma. The 
 fact that other children in the family suffer from scarlet fever justifies a 
 provisional diagnosis of malignant scarlet fever. A man in middle life 
 complains of headache and becomes comatose, with twitching of the face 
 and general convulsions. Information to the effect that he has had poly- 
 uria with low specific gravity, small amounts of albumin, and casts, war- 
 rants a diagnosis of uraemia. A girl is found unconscious, pallid, with 
 irregular respiration and occasional twitching of the face or extremities. 
 It is of diagnostic importance to learn that she has been a highly nervous 
 person who has just passed through some emotional stress and that the 
 coma was preceded by tears and outbreaks of laughter — phenomena, 
 characteristic of hysteria. 
 
 The anamnesis is not always conclusive. It frequently happens that 
 a patient suffering from chronic nephritis becomes comatose from cerebral 
 hemorrhage and that a man who has been drinking falls into a coma not 
 the manifestation of alcoholic intoxication but of fracture of the skull.. 
 The causal diagnosis of coma is attended with increased difficulty in am- 
 bulance cases and patients concerning whom no history can be obtained^ 
 seen for the first time in a comatose condition. 
 
 Cerebral Disease. — Coma occurring in the course of organic disease 
 of the brain is usually preceded by such general symptoms as headache,, 
 vomiting, delirium, and somnolence, with varied local symptoms which 
 depend upon the position and extent of the lesions and may be either 
 irritative or paralytic. 
 
 Apoplexy — the Apoplectic Insult. — Premonitory symptoms are 
 rare. Headache, ocular derangements, and paraesthesia of the extremi- 
 ties may occur but are not characteristic. The coma usually is sudden 
 and complete and the condition is popularly spoken of as a ''stroke." 
 In other cases the coma develops gradually — ingravescent apoplexy. 
 
 Traumatism of the Head. — The history of an accident or injury is 
 important. A careful examination should be made for contusion, lacera- 
 tion, or depression of the skull. If necessary the head should be shaved. 
 Bleeding from one or both ears may occur in fracture of the base of the skulL 
 
 Infectious Diseases. — The antecedent conditions leading up to the 
 coma are usually known. Coma under these circumstances may be a 
 manifestation of the intensity of the primary infection or of some second- 
 ary process. Occasionally in grave enteric fever, very commonly in severe 
 typhus and cerebrospinal fever, coma develops in the course of the disease 
 and is not necessarily the sign of impending dissolution. Coma may occur 
 under similar circumstances from an intercurrent nephritis with uraemia or 
 from intercurrent cerebral hemorrhage, sinus thrombosis, or in the rheu- 
 matic fever attended with endocarditis from embolism. Coma occurs 
 early in, or may even mark the onset of, the malignant forms of the infec- 
 tious diseases, particularly scarlet, enteric, and cerebrospinal fever and the 
 
SYMPTOMS AND SIGNS: COMA. 601 
 
 pernicious forms of malarial infection. In the last there is the history 
 of exposure in intensely malarial localities and of one or two recent well 
 characterized paroxysms of ague. 
 
 Uremia. — Ursemic coma may occur in acute or chronic nephritis. 
 
 Diabetes. — In saccharine diabetes coma very often attends the ter- 
 minal condition, particularly in the young. Three forms of diabetic coma 
 are recognized: (a) The patient after exertion is seized with sudden weak- 
 ness, syncope, and somnolence which gradually deepens to coma and is 
 followed in a few hours by death, (b) The early symptoms are due to pul- 
 monary or gastric derangement or there may be some local affection, as 
 pharyngitis, phlegmon, or carbuncle. The attack begins with nausea and 
 vomiting. The breath has the peculiar sweetish, fruity odor of acetone. 
 The onset of coma is gradual. Death occurs in the course of one to five days. 
 (c) The patient without special previous symptoms is suddenly seized 
 with violent headache and the sensation of profound illness and rapidly 
 falls into deep and fatal coma. There are cases of diabetes in which the 
 coma is due to some accidental cause, as uraemia, apoplexy, or meningitis. 
 
 Narcotic Poisoning. — In coma from opium and its derivatives the 
 face is pallid, dusky, and slightly cyanotic, respirations and pulse slow^ 
 pupils equal and contracted, skin natural, and temperature normal. 
 
 In alcoholic coma the face is commonly flushed, sometimes pallid,, 
 occasionally cyanotic. The respirations are usually normal in depth and 
 frequency. They are sometimes stertorous. The odor of the breath is 
 characteristic, the pulse is at first frequent and full, later small and feeble. 
 The pupils are equal, sometimes normal, more frequently dilated. The 
 skin is usually cool and moist and the surface temperature lowered, espe- 
 cially under circumstances of exposure to cold or damp, when heat dissipa- 
 tion is favored. Convulsions are not common. 
 
 Poisonous Gases. — Coma develops under circumstances that make 
 the diagnosis clear. It may result from the inhalation of carbon dioxide, 
 as in disused wells, and carbon monoxide — illuminating gas, charcoal fire — 
 a very common cause of accidental death and suicide. There can be no 
 question about the coma of surgical anaesthesia. During this state various 
 accidents may occur. Asphyxia has resulted from the falling back of the 
 base of the tongue and from pulmonary oedema. Progressively deepening 
 coma may terminate in death from failure of the cardiac or respiratory 
 centres, and apoplexy may occur. 
 
 Convulsions. — Coma is very often preceded by general convulsions 
 or alternates with them. It is frequently preceded by convulsions in the 
 malignant forms of the infectious diseases, especially in children, and 
 sometimes in dentition and the digestive disorders in young infants — 
 infantile eclampsia. It follows the general convulsions of epilepsy. Coma 
 and convulsions may alternate in cerebral syphilis, general paresis, and 
 some forms of alcoholism. The alternation of coma and convulsions is 
 characteristic of uraemia. 
 
 The coma of sunstroke is very often preceded by convulsions. The 
 skin is excessively hot and dry, the face flushed, the respiration labored, 
 the pulse frequent and full. The temperature ranges extremely high and 
 may become that of hyperpyrexia. Upon venesection the blood is dark, 
 thick, and flows slowly from the vein. The diagnosis is usually easy. 
 
602 MEDICAL DIAGNOSIS. 
 
 Epilepsy. — The diagnosis of postepileptic coma rests upon the history 
 of the case, the convulsive seizure, the bitten tongue, the foam upon the 
 lips, and the sudden profound loss of consciousness of no very long dura- 
 tion. The congestion of the face, stertorous breathing, urinary incon- 
 tinence, and general muscular relaxation may suggest apoplexy, but the 
 signs of hemiplegia are lacking. 
 
 Hysteria. — The unconsciousness of hysteria is commonly incomplete 
 — lethargy or its intensification, trance. Its duration may extend over 
 several days or weeks. True hysterical coma which is a further intensifica- 
 tion of the foregoing is very rare. A condition of impaired consciousness 
 suggestive of coma not infrequently enters into the symptom-complex in 
 the grand attack of hysteria. It is usually preceded by the ordinary 
 phenomena of the hysterical paroxysm: laughing, crying, convulsions, 
 extravagant muscular movements, and the like. 
 
 For practical purposes the differential diagnosis between the coma 
 resulting from opium, traumatism, alcohol, apoplexy, and uraemia is of 
 imperative importance. Only in a correct diagnosis are to be found the 
 indications for treatment. These are often immediate and urgent. Further- 
 more the diagnosis may have to do with questions of medico-legal interest. 
 Definite diagnostic phenomena are to be systematically sought for. 
 
 Such points in the anamnesis as are available are to be obtained from 
 the patient's friends or the bystanders. The immediate investigation de- 
 mands an examination of the scalp and head for evidences of traumatism; 
 of the eyes with reference to pupillary conditions and reactions, strabismus, 
 and conjugate deviation; the face for blood extravasations, flushing, 
 pallor, cyanosis, oedema, puffing of the cheeks, the presence of foam upon 
 the lips, a bitten tongue, relaxation of the jaw, the odor of the breath, 
 and the presence upon the lips or face of the stains of corrosive or other 
 poisons. The character of the respiration is to be studied, the frequency, 
 volume, and tension of the pulse, the sounds of the heart. The occurrence 
 of fecal or urinary incontinence is to be noted, catheterization should be 
 performed, and the urine examined for the presence of albumin, blood, 
 sugar, acetone, etc. The signs of hemiplegia are to be sought in the posi- 
 tion of the head and eyes — conjugate deviation — in the greater relaxation 
 of the mouth and cheek upon one side and the complete loss of muscular 
 tonus in the arm and leg. The temperature must be taken in the axilla, 
 and if found to be very low, in the rectum also. The signs of antecedent 
 disease, general anasarca, great emaciation, various specific and other 
 eruptions and scars, and the general condition of the viscera as determined 
 by the methods of physical examination, such as the presence of effusions 
 in the serous sacs, great enlargement of the liver or spleen, and the like, are 
 to be in turn rapidly investigated. The stomach pump is often necessary 
 for the diagnosis. If the conditions suggest the possibility of pernicious 
 malarial fever an examination of the blood should be made for Laveran's 
 bodies. 
 
 Not every case demands such comprehensive and elaborate investi- 
 gation. Very often the condition underlying the coma is obvious at a 
 glance. In other cases it is speedily revealed. Once in a while the true 
 condition is not discovered without careful and prolonged study, and there 
 are obscure cases which tax the resources of clinical medicine. 
 
SYMPTOMS AND SIGNS: INSOMNIA. 603 
 
 INSOMNIA AND OTHER DISORDERS OF SLEEP. 
 
 Insomnia — Abnormal Wakefulness. — These terms are used to desig- 
 nate a disturbance of the nervous system characterized by habitual incom- 
 plete sleep or periods of entire absence of normal sleep. Sleep varies with age, 
 sex, and individual peculiarity. In very young babies sleep is practically 
 continuous; a healthy child two years old passes half its time in slumber; 
 the adult requires from seven to eight hours out of twenty-four; and aged 
 persons not more than five or six hours. Women need more sleep than 
 men. Workers in the open air require longer hours of sleep than those of 
 sedentary habits. Insomnia may be functional or symptomatic. Func- 
 tional insomnia occurs in neurotic individuals and over-taxed brain workers. 
 Symptomatic insomnia is an important element in the symptom-complex 
 of a great variety of morbid conditions. It occurs in painful diseases, as 
 cancer, aneurism, and the intractable neuralgias. It is common in acro- 
 megaly. Insomnia is a very troublesome symptom in neurasthenia and 
 various forms of insanity. It is an important element in acute delirium. 
 Advanced disease of the heart is very often attended by sleeplessness due 
 in part to cerebral anaemia, in part to the condition of the blood, but 
 chiefly to the inability of the patient to lie down. As the condition pro- 
 gresses wakefulness gives way to somnolence and stupor. Tea and coffee 
 have in many persons the power of inhibiting sleep. Complete insomnia 
 is a conspicuous phenomenon in delirium tremens and alcoholic mania. 
 Insomnia occurs with some degree of frequency also in the early stage of 
 enteric fever, influenza, and croupous pneumonia. It is met with in cases 
 of malaria and is a troublesome symptom in trichiniasis. It is not un- 
 common during the convalescence from acute disease. Insomnia may 
 take the form of troubled and unrefreshing sleep of short duration or 
 broken by intervals of distressing wakefulness, or sleep may be absent for 
 days together. The patient may fall asleep upon going to bed but awakes 
 in the course of two or three hours and lies absolutely awake or lightly 
 dozes until morning. There is often great and irregular mental activity, 
 especially in neurasthenia, and the cares, anxieties, and worries of the day 
 are rehearsed with torturing iteration. Such insomnia is associated with 
 restlessness, which is also present in the insomnia of insanity. Insomnia 
 is rare in children but when present significant of profound disturbance of 
 the nervous system. The sleeplessness of the aged is usually tranquil and 
 unaccompanied by excitement or irritability. 
 
 Dreams usually have their starting-point in some sensory impression 
 arising from local causes, as an uncomfortable posture, a sound which is 
 perceived but which does not arouse, an over loaded stomach, a distended 
 bladder or rectum, or a condition which interferes with the action of the 
 heart and lungs. Nightmare is a frightful dream accompanied by sensa- 
 tions of oppressive weight upon the chest, intense fear, horror, or anxiety, 
 and inability to move or cry out. The attack ends in a groan and the 
 recovery of consciousness. It is mostly symptomatic of indigestion. 
 
 Night Terrors — Payor Nocturnus. — This condition, which presents 
 points of resemblance to nightmare and somnambulism, is a paroxysmal 
 disturbance of sleep in young children. It differs from nightmare in the 
 
604 MEDICAL DIAGNOSIS. 
 
 gradual subsidence of the attack and the persistence of terror and distress 
 after waking. It differs from somnambulism in the gradual waking, the less 
 complete automatism, and the terror. The child starts up in bed screaming 
 with fear and seeks protection, trembling and sobbing. The dream images 
 are often indefinite, sometimes the creatures of imagination, suggested by 
 the tales of the nursery. Night terrors occur commonly in neurotic and 
 badly nourished children. They are sometimes symptomatic of eye-strain, 
 the cutting of the second teeth, intestinal parasites, or indigestion. 
 
 Sleep drunkenness is a rare condition resembling maniacal delirium 
 which appears upon waking from profound sleep. There are delusions of 
 immediate danger to life or liberty. The sufferer fails to recognize his 
 surroundings. He is excited, incoherent, and boisterous. The attack is 
 usually of short duration. 
 
 Somnambulism — sleep=walking — is a disorder of sleep in which con- 
 sciousness and volition are suspended but the activity of certain nerve- 
 centres is exerted and coordinated movements are automatically per- 
 formed. It occurs in adolescents and young adults of neurotic tempera- 
 ment and is more common in females. It is due to causes which ordinarily 
 give rise to dreams, including indigestion, faulty attitude during sleep, 
 intense excitement, or violent distressing emotion during the period preced- 
 ing sleep. The attacks are frequently recurrent and may become habitual. 
 They are of brief duration but may continue an hour or two, during which 
 time difficult and compHcated actions are performed, apparently with 
 conscious intention. The eyes are closed or, if open, are staring and fixed. 
 There is complete indifference to sound and the expression is blank and 
 impassive. The patient on waking has no recollection of his wanderings. 
 
 Morbid Sleep. — Drowsiness may be symptomatic of cerebral malnutri- 
 tion or toxaemia. It is common in aged persons with feeble heart and dis- 
 eased blood-vessels, in the obese, and in malaria, anaemia, and diabetes. It 
 is caused by the impure air of crowded assemblies. Cases have been 
 reported in which prolonged deep sleep has ceased after the discharge of 
 lumbricoid worms. Morbid sleep is a symptom by no means uncommon in 
 organic cerebral disease, as syphihs, tumor, and arteriosclerosis. It is 
 common in insanity, both in the prodromal period and the developed state. 
 
 Narcolepsy is abnormal deep sleep occurring in spells which may be 
 of short duration or prolonged and continuous. The cause is unknown. In 
 some instances the sleep has progressively advanced to deep and fatal coma. 
 
 Waking numbness — sleep palsy. — This is a form of paraesthesia occur- 
 ring upon waking. There is a sensation of numbness and tingling. The dis- 
 tribution involves one or more extremities, usually the hands and arms. It 
 is commonly of brief duration, disappearing in an hour or two. It resembles 
 the forms of paraesthesia which occur about the grand climacteric. 
 
 Paroxysmal disturbances of the nervous system, both physiological 
 and pathological, are common during sleep. Seminal emissions, the vene- 
 real orgasm, and urinary incontinence are accidents of sleep. Epileptic 
 seizures — nocturnal epilepsy — are not uncommon, and the paroxysms of 
 asthma and migraine frequently come on in sleep. 
 
PART IV. 
 
 OF THE CLINICAL APPLICATIONS. 
 
 I. 
 DIAGNOSIS OF THE SPECIFIC INFECTIONS. 
 
 I. ENTERIC OR TYPHOID FEVER. 
 
 Definition. — An acute general infection caused by the Bacillus 
 typhosus, characterized clinically by fever of prolonged duration, a 
 scanty rose-colored, maculopapular eruption, enlargement of the spleen, 
 abdominal tenderness, diarrhoea and tympanites, profound asthenia, and 
 rapid wasting; anatomically by hyperplasia and ulceration of the lymph 
 follicles of the intestines, enlargement of the mesenteric glands, and diffuse 
 parenchymatous changes in the viscera. 
 
 Etiology. — Predisposing Influences. — Enteric fever is the prevalent 
 febrile infection of the present historical epoch, just as typhus was that of 
 the three hundred years preceding the beginning of the nineteenth century 
 and the plague that of the Middle Ages. It owes its present wide distribution 
 and great prevalence to faulty disposal of sewage and neglect of the simplest 
 sanitary laws. Defective drainage and contaminated water and milk con- 
 stitute the means by which the specific infecting organisms are distributed. 
 Climate. — Enteric fever prevails in all parts of the world but is especially 
 common in temperate climates. Season. — It is most common in the 
 autumn months but occurs at all seasons of the year. Of personal causes: 
 Sex. — Males and females are equally liable to the disease. The mode of 
 life of the individual exposes males to the infection to a greater extent 
 than females. In early childhood the sexes suffer alike; in late childhood 
 and adolescence, boys more than girls. More men than women are admitted 
 to hospitals. The conditions of camp life in military campaigns especially 
 favor the spread of the infection. In the Spanish-American and South 
 African wars enteric fever prevailed most disastrously. Age. — Enteric 
 fever is especially a disease of youth and early adult life. The period of 
 greatest liability is from the fifteenth to the twenty-fifth year. Expos- 
 ure and immunity are to be considered in this connection. Exposure 
 to the infection is probably greater after adolescence and the immu- 
 nity acquired by the attack more general after the twenty-fifth year. 
 Cases occasionally occur after sixty. Occupation and Social State. — 
 These conditions are without predisposing influence. Immunity. — Not all 
 who are exposed contract the disease. An unrecognized or forgotten 
 attack in childhood may have conferred immunity. There are families 
 which show in successive generations an especial susceptibilit3^ The im- 
 munity acquired by the attack is usually life-long. Second attacks have 
 
 605 
 
606 
 
 MEDICAL DIAGNOSIS. 
 
 Fig. 206. — Bacillus typhosus. 
 
 occurred in the course of several months or years and three attacks in 
 the same person have been noted by competent observers. 
 
 The Exciting Cause. — Bacillus Typhosus. — This organism, the ba- 
 cillus of Eberth, is constantly present in enteric fever. It is a short, 
 thick, flagellate, motile bacillus with rounded ends, growing readily on 
 various culture media. It can now be differentiated from certain other 
 bacteria, to which it bears a close morphological resemblance, especially 
 the BL,cillus coli communis, with which it is liable to be confounded. These 
 organisms colonize with preference in the lymphoid tissues. They are 
 
 distributed in recent infection in the 
 solitary follicles and Peyer's patches 
 of the intestines, in the mesenteric 
 glands, spleen, bone-marrow, liver, and 
 in the bile. They have been isolated 
 from foci of suppuration in various 
 parts of the body, from meningeal and 
 pleural exudates and vegetations upon 
 the endocardium. Their presence in 
 the blood and rose spots may be 
 demonstrated. In the course of the 
 second week and afterwards they have 
 been isolated by culture methods from 
 the stools. They are met with in the 
 urine and sputum and have in a few 
 instances been found in the sweat. 
 Outside the body typhoid bacilli retain their vitality in water, snow, 
 ice, the superficial layers of the soil, dust, and in faeces for periods varying 
 according to circumstances from several days to many months. In milk 
 they undergo rapid growth without changing its appearance. They retain 
 their vitality for three months in sour milk and for shorter periods in butter 
 made from infected cream. 
 
 The above facts are of great use in the etiological diagnosis of enteric 
 fever, especially when the disease occurs in local outbreaks. It is most 
 important in this connection that the infecting principle is discharged 
 from the body of the patient in the urine and especially in the faeces. 
 Its conveyance by means of water, milk, or other articles of food contam- 
 inated by such discharges in consequence of faulty sanitation is the 
 source of the sporadic, endemic, and epidemic prevalence of the disease. 
 It may be stated positively that enteric fever is not contagious in the 
 ordinary sense, i.e., transmissible from the sick to others by contact or by 
 the exhalations from the body, when the introduction of bacilli-containing 
 dejecta or secretions does not take place. 
 
 Infected water is the ordinary means of transmission. By means of 
 such water the infection of milk, uncooked vegetables, salads, oysters, and 
 clams occurs. It has recently been shown that lobsters also may become 
 infected when kept in cages in sewage-contaminated water awaiting a 
 market. Natural ice and vegetables grown upon soil fertilized by sewage, 
 eaten raw, may convey the germs. Flies and atmospheric dust play an 
 important part in the dissemination of the disease. The open latrines on 
 
ENTERIC OR TYPHOID FEVER. 607 
 
 the one hand and the unscreened mess table on the other were largely 
 responsible for the terrible epidemics among our recruits in the practice 
 camps at the time of the Spanish-American War. 
 
 When the bacilli find their way into the intestinal tract the evolution 
 of the disease is as follows: Being resistant to dilute acids they are by no 
 means wholly destroyed by the hydrochloric acid of the gastric secretion. 
 If acid be absent or the water or other fluid containing them be ingested 
 when hydrochloric acid is not secreted they pass into the intestine and 
 colonize and multiply in the lymph structures, finding their way into the 
 mesenteric glands and thence by means of the blood to the spleen, liver, 
 kidneys, and bone-marrow. In these locations and elsewhere they form 
 soluble toxins which, circulating in the blood, exert their influence espe- 
 cially upon the nervous system and the nutrition and thus give rise to the 
 fever and other constitutional symptoms. Brieger isolated from cultures 
 a toxin belonging to the ptomaine group to which he gave the name typho- 
 toxin. Later with Fraenkel he isolated a toxalbumin. Of greater impor- 
 tance is the poison derived from the bacilli — protein toxin — by R, Pfeiffer. 
 
 Period of Incubation. — The duration of the time from the entrance 
 of the pathogenic principle until the appearance of the phenomena of the 
 fever varies upon the average between two and three weeks. This period 
 runs its course without symptoms, provided prodromes are not included. 
 
 Stage of Prodromes. — The onset is very rarely abrupt. It is as a 
 rule preceded by a period of impaired health characterized by malaise, 
 feebleness, indisposition to bodily or mental effort, loss of appetite, head- 
 ache, vertigo, and disturbed sleep. Abdominal uneasiness, even pain, 
 and diarrhoea in the absence of laxatives are often present at this time. 
 Slight but transient rises of temperature may occur. Bleeding at the 
 nose is common. 
 
 The course of the attack varies between twenty-one and twenty- 
 eight days. It may be divided into the stage of onset, the fastigium or 
 fully developed disease, and the stage of decline upon which supervenes 
 the convalescence. As, however, there are anatomical changes in the lym- 
 phoid structures of the intestines which run their successive courses in 
 periods of five to seven days and correspond to changes in the symptom- 
 complex of similar duration, it is convenient for purposes of description to 
 divide the course of the attack into four periods of a week each. 
 
 Course of the Disease. — First Week. — The attack of enteric fever 
 begins with a distinct and sustained elevation of temperature. This rise 
 is frequently attended with chilliness, which may be repeated, but rarely 
 by a pronounced chill. The patient now in the majority of instances betakes 
 himself to his bed. During the first four or five days the temperature 
 rises in the evening from one to two degrees higher than upon the previous 
 evening and each morning a degree or more above that of the preceding 
 morning. At the end of this time the temperature has reached its fastig- 
 ium, 103°-105° F. (39.5°-40.5° C), and with slight morning remissions 
 remains, in the absence of complications, at this level until the end of the 
 second week. During this period there are lassitude, headache, anorexia, 
 thirst, a hot, dry skin, diminished urine, and restless sleep. The headache 
 becomes progressively more severe and is attended with tinnitus aurium 
 
608 MEDICAL DIAGNOSIS. 
 
 and delirium, at first mild and present usually upon waking. Epistaxis 
 frequently occurs. It is usually slight but may be free. The tongue is 
 coated and is seen to be of a bright red color at the edges and tip — "red 
 tongue fever." At this time constipation is the rule but laxatives act 
 with unusual energy. Toward the end of the first week spontaneous 
 diarrhoea often occurs. There are cases, however, in which constipation 
 continues throughout the attack. The spleen is found upon palpation to 
 "be enlarged toward the end of this period; there is slight tympanitic 
 distention of the abdomen and tenderness in the ileocaecal region. The 
 gurgling upon pressure, often observed in this region, is wholly without 
 diagnostic value. 
 
 A few scattered, medium-sized, dry rales may usually be heard upon 
 auscultation of the lungs. The pulse is rapid, 90-110, but less so in pro- 
 portion to the rise of temperature than in many other acute diseases. 
 It is full in volume, of low tension, and often dicrotic. 
 
 Second Week. — The fever now assumes the subcontinuous type, the 
 range between the evening rises and morning remissions not greatly exceed- 
 ing those of health. The symptoms become progressively more severe. 
 The pulse is rapid and gradually loses its dicrotism. About the tenth day 
 the headache spontaneously ceases and is replaced by somnolence and 
 stupor, which alternate with delirium usually wandering but sometimes 
 noisy and active. The facies is dull, faintly flushed, sometimes slightly 
 cyanotic. The lips and tongue are dry and there is a tendency for sordes 
 to collect upon the teeth and gums. The abdominal symptoms, diarrhoea 
 and tympanites, are aggravated; there is decided enlargement of the spleen 
 and between the sixth and tenth days the eruption makes its appearance, 
 commonly upon the upper abdominal or lower thoracic regions anteriorly. 
 Traces of albumin are now to be found in many of the cases. The signs of 
 bronchitis are more pronounced. Fine subcrepitant and crepitant rales 
 are heard at the bases posteriorly and slight dulness upon percussion may 
 be found in this region. 
 
 Third Week. — The temperature assumes the remittent type showing 
 morning remissions of increasing length. The pulse becomes more feeble 
 and frequent, 110-140. The first sound of the heart is faint and may be 
 inaudible. There is muscular tremor. Diarrhoea and tympanitic disten- 
 tion of the abdomen may increase or, if previously absent, now appear. 
 There is often retention of urine and sometimes involuntary discharges of 
 urine and faeces. Weakness is most marked and wasting conspicuous. 
 Stupor and delirium continue. The rash, which has continued to appear 
 and fade in successive crops, now as a rule gradually diminishes and does 
 not in most cases again appear. This is especially the period of severe 
 complications, hypostatic pneumonias, bed-sores, parotitis, hemorrhages, 
 and perforation. 
 
 Fourth Week. — The type of the fever is now intermittent, the morning 
 remissions gradually falhng to normal or slightly subnormal ranges and 
 the evening rises progressively diminishing until they no longer transcend 
 the normal. The tongue becomes clean and moist, the diarrhoea ceases, 
 and there is a rapidly increasing and urgent desire for food. The spleen 
 undergoes involution. The tympanites subsides. The pulse becomes 
 
ENTERIC OR TYPHOID FEVER. 
 
 609 
 
 stronger and fuller and the first sound and impulse of the heart more 
 distinct. The convalescence may be postponed by the occurrence of 
 various sequels or by relapse, and in some instances the symptoms of the 
 fourth or even of the fifth week may continue to be the same which were 
 present during the third — progressive asthenia, rapid and feeble pulse, 
 abdominal distention, involuntary discharges, dry tongue, muttering 
 delirium, stupor, and subsultus. 
 
 The foregoing sketch represents a severe attack of enteric fever unmod- 
 ified by treatment and terminating in recovery. But from this typical 
 picture of the disease there are many variations. The problem in diagnosis 
 is to determine not the nature of a well-defined typical case of enteric 
 
 
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 fever — that any tyro in medicine can readily do — but to recognize the 
 atypical cases and to differentiate them from the affections to which they 
 present features of resemblance and to do this successfully at the earliest 
 possible moment, since failure in this respect leads to indifference in regard 
 to the search for the cause of the attack on the one hand and neglect in 
 the proper treatment and disposal of the evacuations on the other. 
 
 Symptoms of Especial Importance in Diagnosis. — Before entering 
 upon the consideration of the varieties of enteric fever it is important to 
 give our attention in greater detail to certain of the principal symptoms 
 the association of which is of cardinal importance in diagnosis. These 
 symptoms relate to (a) the fever, (b) the pulse, (c) the rash, (d) the 
 abdominal organs, and (e) the nervous system. 
 
 (a) Tlie Fever. — 1. Regular, so-called Typical Course, — The 
 temperature rises by regular step-like gradations, with marked evening 
 exacerbations and slight morning remissions, until it reaches a range of 
 
 39 
 
610 MEDICAL DIAGNOSIS. 
 
 103°-105° F. (39.5°-40.5° C.) by the fourth or fifth day. From this period 
 to the end of the second week its range is subcontinuous, the oscillations 
 between the morning minima and the evening maxima but Httle exceed- 
 ing those of health. During this time the temperature is scarcely modified 
 by ordinary antipyretic measures and only gradually yields to systematic 
 cold batliing. Toward the end of the second and throughout the third 
 week the type becomes remittent with diurnal oscillations of gradually 
 increasing length until in the fourth week the type is distinctly inter- 
 mittent, the diurnal oscillations progressively diminishing at the expense 
 of the evening rises until subnormal ranges are reached. The defervescence 
 is by lysis. From this level the temperature again in the course of a few 
 days rises to normal, but it remains for a time unstable and is liable 
 to recrudescences of l°-3° F., extending over a day or two, from the 
 action of sh'ght causes, — physical or mental effort, the visits of friends, 
 constipation, the eating of solid food, — fehris carnis. 
 
 This typical temperature range is much less common than it was 
 formerly thought to be and numerous modifications occur in cases that in 
 other respects must be regarded as typical. 
 
 2. Variatioxs IX THE TEMPERATURE Range. — The fact that most of 
 the cases do not come under observation until some days have elapsed and 
 the temperature has attained its fastigium throws some obscurity upon the 
 frequency of the gradual step-like ascent of the first week. In cases seen 
 from the onset it is often absent and the temperature may reach 104°-105° 
 F. in the course of twenty-four or forty-eight hours. This is especially 
 common in the cases which begin abruptly with chills or in children with 
 convulsions. Not rarely the temperature range is remittent throughout — 
 infantile type, seen sometimes also in the adult. Not very rarely the 
 temperature falls rapidly about the end of the second week, — defervescence 
 by- rapid lysis, or by crisis, — an event more common in the cases which be- 
 gin abruptly than in those of gradual onset. Inverse temperature is 
 observed very rarely in enteric fever and is without diagnostic significance 
 other than that which arises from its occasional occurrence in tuberculosis. 
 
 The course of the temperature is sometimes interrupted by sudden 
 falls. These declines may amount to 8° or 10° F. in the course of a few hours. 
 They occur from hemorrhage from any cause and especially accompany 
 intestinal hemorrhage. As a rule they are followed in the course of several 
 hours, when the bleeding has ceased, by a rise to the former range, but the 
 temperature often remains unstable; exceptionally the temperature stays 
 low and the patient enters upon an early convalescence. Hyperpyrexia is 
 not common in enteric fever. In very rare instances collapse may occur 
 in the absence of hemorrhage or perforation. 
 
 Recrudescences of fever from trifling causes, occurring as a manifesta- 
 tion of the instabilit}^ of the heat-regulating mechanism which follows the 
 infection, are of no great importance. They are, however, to be differen- 
 tiated from the symptomatic fever of an inflammatory complication, as 
 pneumonia or pleurisy or venous thrombosis. In this connection the 
 local phenomena and an increase of the leucocytes are of importance. 
 
 Suhfehrile States in Convalescence. — In children and neurotic individ- 
 uals there may be evening fever, 100.5°-102° F. (.3S°-39° C), for weeks after 
 
ENTERIC OR TYPHOID FEVER. 
 
 611 
 
 1-05° 
 
 Fig. 208. — Collapse in enteric fever, 14th day. No 
 hemorrhage. Ultimate recovery. 
 
 C. 
 
 420 
 
 the symptoms of the disease have disappeared and convalescence is in 
 other respects fully established. I have several times seen this condition 
 in laboring men in hospital wards. It has been described as bed-fever. 
 It disappears when the patient is allowed to sit up. A similar evening rise 
 may be the sign of a latent complication. 
 
 The subnormal temperature of early convalescence is not important. 
 It is especially liable to occur in feeble or greatly emaciated individuals 
 but may be encountered in persons making a good recovery. In the course 
 of a week or ten days the tempera- 
 ture rises to normal and regains its 
 stability. The hypothermia of hem- 
 orrhage and the morning remissions 
 of the later stages have been already 
 described. That of cold bathing 
 and other antipyretic treatment is 
 transient and without diagnostic 
 importance. 
 
 Relapses are characterized by a 
 febrile range like that of the primary 
 attack, except that the respective 
 periods are shorter just as the re- 
 lapse is shorter — ten days to two 
 weeks. The gradual ascent, subcon- 
 tinuous fastigium, and defervescence 
 by lysis with remittent and inter- 
 mittent curves are important from 
 the standpoint of diagnosis. 
 
 Afebrile Typhoid. — Cases have 
 been described in which the general 
 constitutional symptoms and the 
 duration of the case together with 
 the eruption, enlargement of the 
 spleen, dicrotism, and the diazo re- 
 action have been present without 
 fever or at most with only a trifling 
 elevation of the evening tempera- 
 ture to subnormal ranges, and in which the etiology of the disease and the 
 existence of a local epidemic have rendered the diagnosis of enteric fever 
 in the highest degree probable. The diagnosis will become positive in the 
 event of the occurrence of intestinal hemorrhage or upon post-mortem 
 examination resulting in the demonstration of the characteristic intestinal 
 lesions. In the absence of those events the diagnosis may then be made 
 by the finding of the bacilli in the urine and stools or in blood cultures. 
 
 3. Chills. — Chilliness is not uncommon in the period of onset, but rigors 
 are rare in enteric fever. Chills occasionally, however, occur with the initial 
 rise of temperature; at irregular intervals during the course of the attack, 
 followed by profuse sweating; sometimes upon the development of compli • 
 cations; after the administration of internal antipyretics, and in septic con- 
 ditions. Chilliness and shivering are frequent at the end of tub-baths. 
 
 
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612 MEDICAL DIAGNOSIS. 
 
 (b) The Pulse. — The characters and frequency of the pulse in relation 
 to the fever are of diagnostic importance. The pulse is commonly full and 
 of low tension in the beginning of the attack. Dicrotism appears early 
 and is not only more common but also more marked than in any other 
 acute disease. The frequency is increased but not proportionately to the 
 elevation of the temperature. A pulse of 100-120 may within the second 
 week be associated with a temperature of 104°-105° F. (40°-40.5° C). 
 Later the pulse becomes more frequent and feeble and its volume is much 
 diminished. In grave cases with great prostration it may reach 160 and 
 such a degree of enfeeblement as to be scarcely countable. 
 
 (c) The Rash. — The eruption occurs in at least four-fifths of the 
 cases. It consists of lenticular, hypersemic papules, slightly elevated above 
 the surface of the skin, of a pale rose color, one to four mm. in diameter 
 and disappearing upon pressure or when the skin is made tense. These 
 roseolous maculopapules may be felt by the finger. They must not be 
 confounded with the dense papules or small pustules of acne which are 
 common upon the trunk, especially the back, of young persons. They 
 appear in successive crops and vary in number from two or three, found 
 only upon careful search, to a somewhat copious roseola distributed upon 
 the surface of the trunk and extremities. Contrary to the general opinion, 
 I am now of the belief that cases characterized by an abundant rash 
 frequently run a severe course. The eruption first makes its appearance 
 between the end of the first and the middle of the second week and commonly 
 in the epigastric zone upon the anterior surface of the body. It is also fre- 
 quently noted upon the back, between the shoulder-blades. It may in rare 
 instances be seen upon the face, especially in young persons of fair skin. 
 The spots are circular or oval with well-defined borders. They gradually 
 fade in two or three days, leaving an area of pigmentation the degree of which 
 varies according to the complexion of the individual. In the majority of 
 cases no new crops appear after the defervescence begins, but exceptionally 
 the spots continue to appear after the temperature has fallen to normal. 
 
 Other points of value in diagnosis in connection with the skin are the 
 out-cropping of sudamina as the fever begins to decline; the occasional 
 occurrence of purpura; an infrequent erythematous eruption at the outset, 
 resembling that of scarlet fever; a fine branny desquamation in children; the 
 presence of the tache cerebrals, and the great infrequency of herpes labialis 
 in comparison with malaria, croupous pneumonia, and cerebrospinal fever. 
 
 (d) The Symptoms Relating to the Abdominal Organs. — Splenic en- 
 largement may be made out upon palpation, the border of the organ 
 extending below the ribs, especially on deep inspiration. The results of 
 percussion are obscured by the meteorism which is common after the 
 beginning of the second week. A splenic tumor is demonstrable in more 
 than eighty per cent, of the cases. 
 
 Diarrhoea is a variable symptom. It is present at some time in the 
 course of the majority of the cases, often alternating with constipation. 
 There are, however, epidemics in which constipation throughout is the rule. 
 Diarrhoea is more common in the later course of the attack. It is caused 
 by the associated catarrh rather than by the ulcers and is indicative of 
 extensive rather than of deep ulceration. The number of the stools varies 
 
ENTERIC OR TYPHOID FEVER. 
 
 613 
 
 from two or three to eight or ten in twenty-four hours. They are usually 
 large, thin, grayish-yellow in color and of a granular composition. They 
 very often contain one or more soft scybalous masses of the size of a walnut. 
 The reaction is alkaline and the odor foul. On standing, the fluid and 
 solid constituents separate into two layers, the upper containing albumin, 
 salts, and coloring matter, the lower epithelial debris, cellular elements, 
 fat crystals, triple phosphates, and later in the disease sloughs from the 
 necrotic Peyer's patches, and microscopic blood. In many cases the bacilli 
 of Eberth may be found after the middle of the second week. This separa- 
 tion of the stools into layers is 
 not often seen in other forms 
 of diarrhoea, but cannot be 
 regarded as pathognomonic. 
 In truth it cannot be said that 
 the stools of enteric fever are 
 characteristic in any diagnostic 
 sense. The familiar compari- 
 son with pea-soup is inexact 
 and misleading and might well 
 be discarded with a multitude 
 of other unscientific, tradi- 
 tional, false phrases from 
 the language of descriptive 
 medicine. 
 
 Tenderness and Pain. — 
 Tenderness in the ileocsecal re- 
 gion is common in the early 
 course of the attack and im- 
 portant in the differential diag- 
 nosis between enteric fever and 
 appendicitis. The tenderness is 
 in some instances confined to 
 the umbilical region; less often 
 it may be elicited upon pres- 
 sure over almost any part of 
 the abdomen. Tenderness and 
 pain in the abdomen may be 
 symptomatic of an over-distended bladder, pleurisy, crural phlebitis, or 
 other acute affection. In a large proportion of the cases no definite cause 
 for these symptoms can be discovered. Pain and tenderness are occasion- 
 ally associated with intestinal hemorrhage but are present and intense 
 in almost all cases of perforation. 
 
 Intestinal Hemorrhage. — Hemorrhage from the bowel is a serious 
 accident, occurring in from three to ten per cent, of all cases. It varies 
 in amount from a trace of blood in the stools to a profuse and fatal blood 
 loss. Large hemorrhages most commonly occur about the time of the 
 separation of the sloughs, namely, between the close of the second and the 
 beginning of the fourth week. The slighter hemorrhages which take place 
 earlier than this period are due to oozing from the hyperaemic Peyer's 
 
 
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 Fig. 209. — Enteric Fever. Hemorrhage on the 13th day; 
 recovery. Woman, aged 23. 
 
614 
 
 MEDICAL DIAGNOSIS. 
 
 patches; those which occur after it are to be ascribed to the mechanical 
 disturbance of unhealed ulcers by the peristaltic movement of the bowel 
 and the contact of the intestinal contents. Intestinal hemorrhage 
 usually comes on without premonitory symptoms. It may reveal itself 
 at once by the discharge of blood from the anus, with faintness, 
 feeble pulse, pallor, and a rapid fall of temperature to the extent of 
 several degrees, or by collapse symptoms which may terminate in 
 death before the blood appears in the stools — concealed hemorrhage. 
 Intestinal bleeding may be symptomatic of a general hemorrhagic con- 
 dition manifested also by pe- 
 techise and hsematuria or ooz- 
 ing from other mucous surfaces. 
 Perforation. — Intestinal 
 perforation is the gravest acci- 
 dent that occurs in enteric 
 fever. Its frequency is about 
 three per cent, of all cases. It 
 may happen in otherwise ap- 
 parently mild cases but is more 
 common in severe cases in 
 which diarrhcEa and meteorism 
 are marked or in which hemor- 
 rhage has occurred. Nearly 
 fifty per cent, of the cases 
 occur in the third or fourth 
 week. The symptoms are first 
 those caused by the perforation 
 itself and the escape of the con- 
 tents of the bowel into the per- 
 itoneum, and second, those of 
 the resulting peritonitis. Of 
 the first group, sudden, sharp 
 pain in the right lower quad- 
 rant of the abdomen, increasing 
 in severity, attended by general 
 or local tenderness, is the most 
 significant. Next in order of 
 importance is rigidity of the abdominal muscles, which become spastic 
 upon palpation. Irritabihty of the bladder and frequent micturition are 
 not uncommon. Much less frequent are collapse symptoms, fall in temper- 
 ature, increase in pulse-frequency, and coldness of the surface with sweat- 
 ing. In grave toxemia with stupor the symptoms of perforation may 
 be obscured. 
 
 The second group comprises the symptoms of the consecutive peri- 
 tonitis. The local symptoms are of great importance since the life of the 
 patient may depend upon their early recognition. They consist of muscular 
 rigidity with pain upon pressure and deep breathing, limitation of the respir-, 
 atory movements, obliteration of the lower border of the liver and splenic 
 dulness from the presence of free air in the peritoneal cavity, fulness and 
 
 
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 Fig. 210. — Enteric fever. Signs of perforation, 14th day; 
 operation refused; death two days later. 
 
ENTERIC OR TYPHOID FEVER. 615 
 
 tenderness upon digital examination per rectum; absence of the peris- 
 taltic murmur upon auscultation, friction sounds in the upper hepatic 
 area or elsewhere, and in the majority of the cases a rapidly progressive 
 leucocytosis. These phenomena are not all present in every case but the 
 presence of several of them justifies the diagnosis of typhoid peritonitis in 
 its early stage. Their progressive development is soon followed by the 
 occurrence of more ominous signs. The spastic contraction of the muscles 
 of the abdominal wall is replaced by tympanitic distention which pro- 
 gressively increases. Percussion in the flanks reveals flatness in the most 
 dependent region, the sign of an accumulating exudate. The pain is less 
 urgent; the tenderness less acute. Further displacement of the liver and 
 splenic dulness in an upward direction is noted and the impulse of the heart 
 may be found as high as the fourth interspace. In a small number of the 
 cases perforation and peritonitis occur with a flat or even retracted abdomen. 
 
 The general symptoms indicate the gravity of the condition. They 
 consist of pallor, an expression indicative of pain, which develops later into 
 the facies Hippocratica, profuse clammy sweating, a feeble, thready, fre- 
 quent pulse, hiccough, and vomiting. The respiration is shallow, the heart 
 sounds indistinct, the temperature, which may have fallen upon the occur- 
 rence of perforation, rises again, and the kidneys secrete little or no urine. 
 This formidable array of symptoms, the forerunners of the approaching fatal 
 issue, may be masked by those of an antecedent overwhelming toxaemia. 
 
 Perforative peritonitis without the escape of air into the peritoneal 
 sac may arise from the rupture of a pseudo-abscess, softened mesenteric 
 gland, or a splenic or hepatic abscess. A general or local peritonitis may 
 occur in consequence of infection through the thinned base of a deep ulcer 
 without rupture. 
 
 (e) The Nervous System. — There is nothing characteristic in the 
 nervous symptoms of enteric fever; yet their association with the phe- 
 nomena mentioned in the foregoing pages constitutes a symptom-complex 
 that is in the highest degree significant. 
 
 Headache, sleeplessness, and a condition of the nervous system which 
 renders physical and mental effort alike difficult characterize the period 
 of prodromes. The headache may involve any part of the head or be gen- 
 eral. Its most constant peculiarity is that it becomes worse toward 
 night. It usually ceases spontaneously about the middle of the second 
 week and is replaced by somnolence and stupor — a change which is of diag- 
 nostic value. Tinnitus aurium frequently accompanies the headache and 
 deafness develops with the progress of the disease. 
 
 Delirium sometimes begins early and is usually of mild character. 
 The patient can be roused, his attention fixed and his replies become ap- 
 parently rational. The delirium is at first nocturnal. Later it becomes 
 continuous and marked. It may not appear until the second or even the 
 third week. In other cases it is noisy and restless and attended with efforts 
 to get out of bed. In hard drinkers it may be associated with tremor and 
 the hallucinations peculiar to delirium tremens. Abrupt changes in the 
 form of delirium occur. The patient who has been apathetic and wander- 
 ing may without warning develop an active and purposeful delirium with 
 suicidal tendencies. The enteric fever patient who has become delirious 
 
616 MEDICAL DIAGNOSIS. 
 
 must under no circumstances be left alone. Somnolence and hebetude 
 are common and in the severe cases these symptoms deepen into a stupor 
 from which the patient cannot be roused. Coma vigil, tremor, subsultus 
 tendinum, and carphologia are among the most ominous symptoms of 
 the disease. 
 
 Convulsions are rare. They may occur in children at the onset. In 
 the course of the attack and especially in adults they may be hysterical, 
 ursemic or symptomatic of some nervous complication, as encephalitis or 
 thrombosis of cerebral arteries or veins. 
 
 Varieties. — Enteric fever is in the strictest sense a disease of the 
 whole organism. Scarcely an organ escapes; not a function goes on nor- 
 mally. The duration of the attack with profound derangements of nutrition 
 exposes the defenceless tissues to the secondary invasions of pathogenic 
 organisms both local and general. In different cases various organs bear 
 the brunt of the attack according to the personal predisposition of the 
 individual. Variations in the intensity of the infection, — virulence of the 
 bacilli, — the resistance of the individual, — integrity of the tissues, degrees 
 of hereditary or acquired immunity or predisposition, — complications, 
 sequels, relapse, the management of the case and the surroundings likewise 
 modify the severity of the attack. Hence a most diverse and complex 
 symptomatology. A full account of enteric fever in all its relations would 
 constitute an epitome of the Practice of Medicine. It is important to 
 remember that the disease presents the widest variations from a typical 
 course alike in its mode of onset, its intensity, the prominence of certain 
 symptoms, and in its duration. Errors in diagnosis in doubtful cases are 
 to be avoided only by the routine employment of every resource of clinical 
 medicine with due regard to the teachings of the clinical laboratory and 
 the post-mortem room. From the standpoint of the infection the follow- 
 ing varieties may be recognized: 
 
 (a) Ordinary Form with WelUdeveloped Intestinal Lesions. — This group 
 includes the great majority of the cases. The lesions of the lymph 
 structures are well marked and more or less extensive; the mesenteric 
 glands and spleen are enlarged, parenchymatous changes are present 
 in the viscera. The anatomical diagnosis can be made in the absence of 
 a history of the symptoms. 
 
 (b) Cases Characterized by Slight Intestinal Lesions. — The changes 
 in the lymphoid structures of the intestines may be superficial and limited 
 in extent and therefore readily overlooked, or if death has occurred late 
 in the attack the ulceration may have already healed. The symptom- 
 complex may be that of an ordinary attack with or without mild intestinal 
 symptoms, of a general sepsis with high fever and marked nervous symp- 
 toms, — so-called typhoid state — typhoid septicaemia, — or of an affection of 
 one or more viscera with profound constitutional disturbance. The organs 
 especially involved may be the liver, gall-bladder, lungs, pleura, kidneys, 
 endocardium, or meninges. It is in the last group that the cases are found 
 which are described as pneumotyphus, in which the attack sets in with 
 pulmonary symptoms; pleurotyphus, beginning with an acute pleurisy; 
 nephrotyphus, in which the general symptoms and urinary findings of 
 an acute nephritis are present at the onset, and the cerebrospinal form ia 
 
ENTERIC OR TYPHOID FEVER. 617 
 
 which the attack begins suddenly with urgent symptoms of disturbance 
 of the nervous system. In all of these unusual forms the symptoms which 
 dominate the clinical picture at the onset shortly, and mostly in the course 
 of the first week, become subordinate to those characteristic of enteric 
 fever and the attack generally runs its subsequent course in the usual way 
 and time. In many of these cases, however, the intestinal lesions are 
 well developed. To elevate these groups of cases into separate varieties 
 is to increase the difficulties of the student and teacher alike without any 
 compensatory advantages of classification. 
 
 (c) Cases Characterized by the Absence of Intestinal Lesions. — In 
 some of the cases the true nature of the affection has not been demon- 
 strated; in others lesions such as those of tuberculous ulceration, by which 
 the bacilli of Eberth may have found access, were present. There remain, 
 however, a limited number of cases in which the Bacillus typhosus has been 
 demonstrated in the organs, the symptoms have been characteristic, and 
 death has occurred at a time when the lesions of the gut are commonly 
 conspicuous, yet none have been discovered. The possibility that the 
 bacilli have found entrance by way of the intestinal wall without giving 
 rise to demonstrable lesions has been suggested. Infection by way of the 
 respiratory passages has not been demonstrated. Even in the cases of 
 pneumotyphus the absence of intestinal lesions to which the early lung 
 affection may have been consecutive has not been established. 
 
 (d) Mixed or Secondary Infections. — The conditions caused by the 
 Bacillus typhosus impair the powers of resistance. A secondary invasion 
 of colon bacilli, streptococci, staphylococci, or the pneumococci may occur 
 with the development of consecutive local and constitutional phenomena. 
 This true mixed infection may take place in any disease and is to be dis- 
 criminated from other specific infections which occur as complications or 
 intercurrent affections, as infection with Bacillus tuberculosis. Bacillus 
 diphtherise. Streptococcus Fehleisen or, the malarial parasite. 
 
 (e) Cases Presenting the Symptoms of Enteric Fever but due to 
 other Organisms— Paratyphoid. — Researches conducted since 1896 have 
 shown that a symptom-complex not to be distinguished from enteric fever 
 may be caused by organisms other than the Bacillus typhosus, which stand 
 in their cultural and agglutinating properties between B. typhosus and B. 
 coli communis, and that B. coli may perhaps play the same etiologic role. 
 This fact does not, however, impair the universal belief in the specific 
 nature of B. typhosus and enteric fever. 
 
 As regards intensity the following forms may be described: 
 
 (a) The Mild Form — Typhus Levissimus. — The fever is moderate, 
 not exceeding 102°- 103° F. (39°-39.5° C.) in the evening. The symptoms 
 characteristic of the ordinary form are present but are of mild intensity. 
 Headache, weakness, epistaxis, rose spots, and the signs of splenic enlarge- 
 ment are present, but the illness is so slight that it is difficult to make the 
 patient realize its true nature. Diarrhoea is not common. These cases 
 are often regarded as simple continued fever, febricula, or gastric fever. 
 Their duration varies from eight to fourteen days. 
 
 (b) The Abortive Form. — The onset is abrupt and marked by shiver- 
 ing or a chill. The temperature rises abruptly and ma}^ reach 104° F. 
 
618 MEDICAL DIAGNOSIS. 
 
 (40° C). Rose spots appear early, often before the fifth day. At the end 
 of the first week, or early in the second, the temperature falls by rapid 
 lysis or even by crisis with profuse sweating and the patient enters upon 
 convalescence. These cases are sometimes seen in epidemics. The recog- 
 nition of the true nature of the mild and abortive cases is of the utmost 
 importance from the standpoint of prophylaxis. 
 
 (c) The Latent or Ambulatory Form — Walking Typhoid. — The symp- 
 toms are slight and the patient continues to attend to his affairs as 
 usual. There is feverishness and a feehng of illness. Diarrhoea is commonly 
 present but not urgent. The rose spots and enlarged spleen are often found 
 in the routine examination of walking typhoid patients; or sudden dehrium, 
 hemorrhage, or perforation may occur. Cases belonging to this group are 
 more common in men than in women and among laboring men, tramps, and 
 others who habitually give little attention to their subjective symptoms. 
 They are also encountered with some frequency among school-boys. 
 
 (d) The Grave Form. — The symptoms may at first be of moderate 
 intensity. More commonly they are severe from the onset. The infection 
 is intense. The temperature is high, 105°-106° F, (40.5°-41° C), with very 
 trifling remissions, and the duration of the fever may be protracted into 
 the fifth or sixth week. To this category must be assigned the cases of 
 mixed or secondary infection and the cases beginning with severe symptoms 
 referable to the lungs, kidneys, and nervous system. 
 
 Modifications of the course of the attack as determined by anatomical 
 and physiological conditions pecuHar to the individual give rise to the 
 following forms : 
 
 (a) Enteric Fever in Children. — This disease is not common in infancy.- 
 The nature of the food and doubtless the presence of an immuniz- 
 ing substance in the milk of the mother protects sucklings. Cases have, 
 however, been reported in the first week of life and occasionally in the first 
 year. Enteric fever is not at all uncommon after the second year. The 
 onset may be insidious; commonly it is abrupt with high temperature. 
 The type of the fever in a majority of the cases is remittent throughout — 
 infantile remittent of the early writers. Nose-bleeding and diarrhoea are 
 comparatively infrequent but bronchial catarrh begins early and is often 
 moderately severe. There is nothing pecuHar about the rash, which may 
 be sparse or plentiful. Tympanites is commonly sHght and intestinal 
 hemorrhage and perforation much less common than in adults. Nervous 
 symptoms are often prominent. The attack may begin with convulsions. 
 Drowsiness alternating with insomnia, and mild delirium interrupted by 
 sudden outcries and spells of fretfulness are observed. Aphasia, usually 
 transient, and noma are prominent sequels. The mortality is much lower 
 among children than in older persons. The marked differences in the course 
 of the disease in childhood and after puberty, and especially the very 
 common occurrence of fever of remittent course in connection with the 
 symptom-complex just described, warrant the division of the cases of 
 enteric fever into two great groups, those of the Infantile and those of 
 the Adult Type. Those of the infantile type are milder than those of the 
 adult type and the prognosis is more favorable. Cases of the former 
 sometimes occur among adults; of the latter among children. The prog- 
 
ENTERIC OR TYPHOID FEVER. 619 
 
 nosis is less favorable in an attack of adult type in a child; more so when 
 the infantile type occurs in later life. This is in accordance with a long 
 recognized fact, namely, that in the absence of complications the prognosis 
 is more favoral)le in proportion as the morning remissions are longer, i.e., 
 as the temperature curve conforms to the remittent type of fever. It has 
 been found also that treatment which systematically brings about large 
 oscillations between the morning and evening temperatures, as the cold 
 bath treatment, also renders the prognosis more favorable. 
 
 (b) Enteric Fever in the Aged. — The course of the disease is much 
 modified when it occurs in middle life or in elderly persons. The tempera- 
 ture range is irregular and not so high. The rose rash and splenic tumor 
 are often absent. Diarrhoea and tympany are often troublesome and 
 there is a marked tendency to complications, especially those affecting the 
 respiratory tract — pneumonia, bronchitis. 
 
 (c) Enteric Fever in Pregnancy. — The pregnant woman enjoys no 
 immunity against the disease. The fever may develop at any time, but is 
 more commonly met with in the first half of pregnancy. Abortion or pre- 
 mature labor occurs in a large proportion of the cases. The maternal 
 mortality is high — sixteen to twenty per cent. Infection of the foetus 
 does not always follow, but when it occurs the child dies either in utero or 
 shortly after delivery. Recent investigations have shown that the bacilli 
 may pass by way of the placenta to the child and cause a typhoid septi- 
 caemia without intestinal lesions. The positive Widal reaction has been 
 observed with fetal blood. 
 
 Complications and Sequels. — Complications and sequels are more 
 common in enteric fever than in any other acute infectious disease. A 
 recognition of this fact is of great importance in diagnosis, since cases occur 
 in which the prominence of a complication may mask the sj^mptoms of 
 the primary disease. 
 
 The following more important complications are to be considered: 
 
 (a) Complications Involving the Digestive and Abdominal Organs. — 
 Ulcerative stomatitis occasionally occurs. Phlegmonous and pseudo- 
 membranous angina is a rare complication, which may develop in the third 
 week and usually proves fatal. Parotid bubo, usually single, sometimes 
 double, is a grave but not necessarily fatal complication in severe cases. 
 It may be followed by extensive sloughing or by angina Ludovici, venous 
 thrombosis or pyaemia. Hsematemesis is of extremely rare occurrence in 
 enteric fever. It may result from the specific lesions implicating agminate 
 follicles present in the gastric mucous membrane or from a peptic ulcer. 
 
 The enlargement of the spleen may attain such a degree that the 
 capsule may burst. Rupture of this organ is more likely to be the result 
 of abscess formation following infarct. The latter condition owes its occur- 
 rence to embolism or venous thrombosis. 
 
 The liver itself is rarely the seat of changes which attract attention. 
 Jaundice is of very infrequent occurrence. Hepatic abscess is exceedingly 
 rare. Cholecystitis is, on the other hand, conmion. Pain, tenderness, and 
 muscular rigidity in the region of the gall-bladder may be noted in most 
 of the cases. Distention of the viscus — gall-bladder tumoi- — may be recog- 
 nized upon nice palpation and percussion. Perforation may occur with 
 
620 MEDICAL DIAGNOSIS. 
 
 the symptoms of intestinal perforation — extreme pain, tenderness, rigidity^ 
 fall of temperature, collapse symptoms, and the general and local signs of 
 peritonitis. A suppurative cholangitis may occur. More commonly the 
 symptoms gradually subside and recovery follows. There may, however, 
 be remote consequences. The bacilli frequently give rise to chronic chole- 
 cystitis with recurrent paroxysms and to cholelithiasis. 
 
 Persistence of B. typhosus After Recovery. — In by far the 
 greater number of cases inflammation of the bile-ducts and gall-bladder 
 terminates in recovery, but in about 2 per cent, it persists, especially in. 
 the gall-bladder, and the bacillus continues to multiply in the latter 
 for an indefinite period. From this viscus it passes from time to time in 
 considerable quantities into the gut and may be recovered from the faeces. 
 These cases constitute a group of individuals now known as "typhoid 
 carriers" who are a constant source of danger to the public, since they may 
 spread the infection without giving rise to suspicion. Many of the sporadic 
 cases, the origin of which has been involved in obscurity, are now attributed 
 to these "carriers." Many of them are women and the subjects of chole- 
 lithiasis. The presence of Eberth's bacilli in the stools is frequently asso- 
 ciated with a remarkable reduction in the total number of micro-organisms 
 ordinarily present in the faeces. 
 
 Intestinal hemorrhage and perforation have already been considered. 
 These events are so directly due to the specific lesions of enteric fever, 
 they occur with such frequency, and require such a degree of importance 
 in the consideration of the subject that it seems more in accordance with 
 the facts to regard them not as complications, but rather as accidents in 
 the disease. 
 
 (b) Complications Affecting the Respiratory Organs. — Laryngeal ulcera- 
 tion is common in the severe cases. It may consist merely of superficial 
 erosion and run its course without symptoms. It may, on the other 
 hand, give rise to hoarseness, pain and difficulty in deglutition. Finally, 
 it may produce perichondritis, in the course of which oedema of the glottis 
 may occur. Bronchitis is prominent in infancy and often severe in old 
 persons. Hypostatic pneumonia and deglutition pneumonia are almost 
 always present in severe cases after the middle of the second week. Pul- 
 monary oedema is a terminal condition. 
 
 Lobar pneumonia occurs, (1) as an initial condition — pneumotyphus. 
 The onset is abrupt with chill, high temperature, pain in the sides. Cough 
 and bloody sputa occur. After a day or two the signs of consolidation occur 
 and the case presents the complete clinical picture of an ordinary croup- 
 ous pneumonia. Crisis does not occur and by the end of the first or the 
 middle of the second week rose spots appear and the symptoms of enteric 
 .fever are unmistakable. In the absence of rose spots, the uncertainty as 
 to whether the case is one of croupous pneumonia with so-called typhoid 
 symptoms resulting from secondary infection or enteric fever with early 
 pulmonary localization can only be cleared up by a bacteriological diag- 
 nosis — presence or absence of Eberth's bacilli in the sputum, urine, and 
 pus, blood culture, Gruber-Widal test. (2) Croupous pneumonia is a com- 
 mon and serious complication — intercurrent disease — in the second or 
 third week. It usually occurs in cases already otherwise severe. The 
 
ENTERIC OR TYPHOID FEVER. 621 
 
 symptoms are not usually well developed. Cough is slight, rusty sputum 
 may be absent, and the presence of the pulmonary consolidation may only 
 be discovered upon routine examination. Secondary gangrene of the lung 
 may develop. Pulmonary gangrene in enteric fever is more frequently 
 the result of the breaking down of an infarct. Abscess of the lung con- 
 stitutes one of the less common complications. 
 
 Pleurisy is by no means rare. It may be fibrinous, serofibrinous, or 
 purulent. The effusion is often small and circumscribed. It may follow 
 the signs of an infarct — local pain and dulness, increased fever, and hemor- 
 rhagic sputa. Typhoid bacilli have frequently been found in both the 
 serous and purulent pleural exudates. 
 
 Pulmonary tuberculosis is not rarely an associated affection. The 
 patient may be already phthisical, in which case the enteric fever plays 
 the role of an intercurrent disease, or a latent tuberculous process may 
 become active. Haemoptysis may be profuse, even fatal. Pneumothorax 
 has been observed. It may result from the rupture of a peripheral abscess 
 of the lung. 
 
 (c) Complications Affecting the Circulatory Organs. — Pericarditis is 
 exceedingly uncommon. It has been observed in children and in con- 
 nection with pneumonia. Endocarditis is likewise rare. 
 
 Myocardial changes are on the other hand most frequent. They begin 
 early and are often well established by the end of the second week. The 
 heart is soft, flabby, and of a pale yellowish — faded-leaf — color. Upon the 
 table it often flattens into a formless mass. Microscopically the changes 
 are those of parenchymatous degeneration and interstitial myocarditis. 
 There may be fatty degeneration of high grade. Feebleness of the pulse, 
 faint, even inaudible first sound, profound asthenia, fatal collapse may be 
 the manifestations of the changes in the myocardium. Acute dilatation 
 with relative insufficiency, thrombus formation and visceral engorgements 
 likewise arise and are attended with their usual symptoms and signs. 
 There is a direct relationship in patients who recover between the myo- 
 cardial changes of enteric fever and chronic myocarditis, the symptoms of 
 which develop later in life, as can be learned from the anamnesis. 
 
 Vascular occlusions occur both in the veins and arteries. They may 
 result from embolism or thrombosis. Obliteration of the femoral artery 
 may occur with gangrene of the foot and leg. Obliteration of both femorals 
 with extension of the clot into the aorta has been observed. The condition 
 has been ascribed to local arteritis with thrombus formation. 
 
 Venous thrombosis is of comparatively frequent occurrence — two to 
 four per cent, of the cases. It is usually unilateral, sometimes bilateral, 
 the left side being first affected, the right later. In far the greater number 
 of cases the femoral vein is the seat of the occlusion; less frequently the 
 popliteal or the long saphenous. The clot may extend along the vein from 
 the point of formation. The greater liability of the left femoral vein has 
 been attributed to the relative retardation of the blood-flow in the left 
 common iliac vein caused by the pressure of the right iliac artery which 
 crosses it. The occurrence of venous thrombosis is attended by elevation 
 of temperature, pain, tenderness, enlargement, and tense oedema of the leg. 
 It may come on later in the attack or not until after defervescence. Eberth's 
 
622 MEDICAL DIAGNOSIS. 
 
 bacilli have been found in the clot and in the wall of the vein. Suppura- 
 tion and pyaemia may occur. A fragment of the clot swept into the blood 
 stream may cause sudden death by plugging of the pulmonary artery. 
 Gangrene does not result from venous thrombosis. As the collateral 
 circulation is established the enlargement of the leg subsides, but many 
 patients are obliged to wear an elastic stocking for months or even years. 
 
 Thrombosis of the cerebral sinuses is a rare accident. Infarction of 
 the lungs, spleen, or kidneys occurs as the result of arterial occlusion, due 
 more commonly to thrombosis than embolism. 
 
 Gangrene as a sequel of enteric fever most commonly affects the 
 feet and legs. Gangrenous areas occur less frequently upon the face, 
 neck, and trunk. The genitalia, especially in girls, the nose and ears 
 may also be affected. 
 
 The blood undergoes important changes. In the third week the 
 erythrocytes and haemoglobin are reduced. A gradual increase to normal 
 takes place during convalescence, the haemoglobin, which has suffered a 
 relatively greater reduction than the corpuscles, regaining the normal 
 more slowly than the latter. These changes are without diagnostic value. 
 
 Very important, however, is the fact that there is a reduction of the 
 leucocytes during the whole course of the attack — leucopenia. This con- 
 dition is of actual diagnostic value in the differentiation between enteric 
 fever and septic states, and other infectious diseases which resemble it 
 more or less closely. A leucocytosis occurs when in the course of enteric 
 fever a local inflammation arises or pneumonia or some other affection 
 characterized by an increase in the number of the leucocytes occurs as an 
 intercurrent disease. The large mononuclear and transitional forms are 
 increased and the polynuclear neutrophiles are greatly diminished. In 
 contrast to these changes, the polynuclear neutrophiles are increased in 
 inflammatory conditions, as in abscess formation or perforation, a fact of 
 diagnostic value. 
 
 (d) Complications Affecting the Nervous System. — The nervous sys- 
 tem, as has been pointed out above, in all cases manifests to a greater 
 or less degree the effects of the intoxication. These effects are apparent 
 at the onset of the attack and vary in intensity from the headache and 
 indisposition to mental effort seen in the mildest cases to the furious symp- 
 toms of meningitis. The latter cases, which fortunately are extremely 
 rare, are characterized by intense headache, photophobia, painful retrac- 
 tion of the muscles of the back of the neck, muscular twitchings, rigidity, 
 and in some cases convulsions. The onset is abrupt and vomiting may 
 occur. At the end of a week the symptoms become less intense, in a con- 
 siderable proportion of the cases almost as suddenly as they appeared. 
 The headache ceases, rose spots appear, there is palpable enlargement of 
 the spleen, and the case presents the clinical features of an ordinary attack 
 of enteric fever which runs the usual course. These are the cases described 
 as cerebrospinal typhoid. In fatal cases of this group the lesions of menin- 
 gitis are not found. 
 
 Inflammation of the meninges of the brain has been observed. It is 
 an extremely rare complication. Typhoid bacilli have been isolated from 
 the exudate in pure culture. Kernig's sign was present in a case of enteric 
 
ENTERIC OR TYPHOID FEVER. 623 
 
 fever with meningeal symptoms recently observed. Lumbar puncture 
 may be necessary in the differential diagnosis between this form of enteric 
 fever and cerebrospinal fever. 
 
 The rare cases of thrombosis of the cerebral veins and sinuses are 
 characterized by local and general convulsive movements, active delirium, 
 and rapidly developing coma. 
 
 Neuritis is an infrequent complication. It is usually confined to a 
 single nerve; sometimes it is symmetrical. Less frequently there is a 
 general peripheral neuritis. Neuritis affecting a single nerve area may 
 develop during the course of the attack, or, as is more commonly the case, 
 after convalescence has begun. There is severe pain in the affected limb 
 with exquisite tenderness over the trunk of the nerve. There ma}^ be 
 swelling and redness. The extensors are more commonly involved and 
 wrist-drop or foot-drop may occur. 
 
 Tender toes constitute the manifestation of a form of neuritis not very 
 uncommon. This distressing but not very serious condition may occur 
 under any treatment but is said to be more frec[uent in cases treated by 
 systematic cold bathing. The tips of the toes, their pads, and sometimes 
 the pads at their bases are painful and exquisitely sensitive so that it is 
 impossible for the patient to bear the weight of the bedclothes. There is 
 neither redness nor swelling, and the condition — which begins toward the 
 end of the attack — usually disappears in the course of a week or ten days. 
 
 Multiple neuritis, sometimes giving rise to paraplegia, palsies of 
 individual nerve-trunks from neuritis and poliomyelitis, hemiplegia from 
 thrombosis or meningo-encephalitis, and tetany may develop during 
 convalescence. These sequels are of extremely rare occurrence and of 
 secondary importance in the diagnosis. 
 
 Postfebrile insanity is encountered more frequently after enteric 
 fever than any other acute infection. It belongs to the group of confu- 
 sional insanities and is the manifestation of profound nutritional derange- 
 ments in neurotic individuals. It has occurred in my experience in cases 
 in which active delirium has been present during the attack. There are 
 persistent hallucinations, melancholia, and speech derangements. The 
 prognosis is good. A majority of the cases recover in the course of six or 
 eight months. After that period the outlook becomes progressively less 
 favorable, though I have seen a case recover at the end of a year. 
 
 Complications relating to the eye are exceedingly rare.. Of those 
 affecting the ear, otitis media is common. There have been years in my 
 service in the Pennsylvania Hospital in which no cases of this complica- 
 tion have occurred, and years in which it has been extremely frequent. 
 The otitis commonly develops insidiously but it sometimes comes on with 
 a chill and increase of fever. The ears should be examined as a matter of 
 routine. ^lastoid disease may occur. 
 
 (e) Other Complications. — Febrile — toxic — albuminuria is of very 
 frequent occurrence as in the other serious infectious diseases. Hyaline 
 and granulohyaline casts may be found in the centrifugated urine. This 
 condition passes away with convalescence. Eberth's bacilli are demon- 
 strable in the urine in a large proportion of the cases. In some cases they 
 have been found in the urine of persons months, even years, after the attack. 
 
624 
 
 MEDICAL DIAGNOSIS. 
 
 The attack may begin with the symptoms of an acute nephritis — 
 nephro typhus. The toxic albuminuria occasionally leads to the develop- 
 ment of an acute nephritis with scanty urine of high specific gravity, a 
 large amount of albumin, and microscopical blood. This complication may 
 be the cause of a fatal termination of the case. Otherwise it gradually 
 subsides and complete recovery ensues. Polyuria during the course of 
 the attack is an extremely rare complication. Chronic nephritis is a 
 rare sequel. The multiple foci of round-celled infiltration — lymphom- 
 atous infiltration — which may lead to the formation of miliary abscess 
 does not as a rule give rise to symptoms and is rather of pa.thological 
 than of clinical interest. 
 
 Pyelitis is occasionally observed. It may develop in the later 
 stages of the attack or during convalescence. It may involve one or 
 both kidneys. This infection reveals itself by free blood together with 
 
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 .TEMPERATURE. 
 
 Fig. 211. — Polyuria in enteric fever. 
 
 pus and later by a condition in which there is an abundant pyuria. 
 If one kidney only is affected the pyuria may be intermittent, with an 
 almost pus-free urine in the intervals. 
 
 Catarrh of the bladder or an acute cystitis may be the cause of the 
 urinary pus. These conditions are somewhat common in enteric fever, 
 especially after repeated catheterization. The more common pyogenic 
 micro-organisms are B. coli, B. typhosus, and staphylococci. Orchitis 
 occasionally occurs, as a rule in association with a purulent urethritis. 
 In women oedema and gangrene of the vulva and acute mastitis are very 
 rare complications. Menstruation is not likely to occur during the attack. 
 When it does occur it is usually profuse. 
 
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 have seen several. Hemorrhages into the skin are more common than from 
 mucous surfaces. The general symptoms are severe. 
 
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 and necrosis with abscess and sinus formation are complications and 
 sequels often encountered. The bone lesions of enteric fever are notable 
 for their persistence. Typhoid bacilli are present in a majority of the 
 
ENTERIC OR TYPHOID FEVER. 625 
 
 cases. The tibiae, ribs, and costal cartilages are most commonly involved. 
 Arthritis involving the knee and hip is among the infrequent comphca- 
 tions. It is usually septic. 
 
 Typhoid Spine. — Spinal symptoms are sometimes observed in the 
 later course of severe attacks or during convalescence. They consist of 
 pain in the lumbosacral region, aggravated by mx)vement, tenderness upon 
 pressure, stiffness, and inability to execute movements requiring flexion, 
 extension, or rotation of the spine. Nervous symptoms are prominent in 
 some cases. There is no rise of temperature and physical signs are absent. 
 The condition is usually a neurosis — hysterical spine — and terminates in 
 recovery. There may be a spondylitis. I have seen a fatal case of vertebral 
 tuberculosis following enteric fever in a lad of seventeen, which for a 
 period of several months was regarded as an instance of typhoid spine. 
 
 Parenchymatous degeneration of the voluntary muscles, which espe- 
 cially affects the recti abclominalis and the adductors of the thigh, some- 
 times leads to the rupture of the mass of the muscle and may also lead to 
 hemorrhage and abscess formation. 
 
 The Association of other Diseases with Enteric Fever. — The fre- 
 quency of croupous pneumonia as an intercurrent disease has been noted 
 above. Erysipelas occurs in about two per cent, of the cases, more com- 
 monly in the period of convalescence. The exanthemata, especially 
 measles and varicella, may be associated with enteric fever. 
 
 Malarial fever and enteric fever may coexist. There is no such thing 
 as a hybrid, as indicated by the term typhomalarial fever. Such cases 
 are usually enteric fever or estivo-autumnal fever without well-marked 
 paroxysms. 
 
 Tuberculosis as an associated disease has already been mentioned. 
 The various phases of this relation will be fully considered later. 
 
 The Effect of Enteric Fever upon Certain Chronic Diseases. — 
 During the attack of enteric fever the paroxysms of epilepsy frequently cease, 
 the irregular movements of chorea and the allied affections are in abeyance, 
 and sugar frequently wholly disappears from the urine in diabetic subjects. 
 In all these conditions the effect is only temporary and the symptoms 
 of the antecedent disease recur with convalescence or shortly afterwards. 
 
 Relapse. — The frequency of relapse varies, according to different 
 observers, between three and eighteen or twenty per cent. Relapse occurs 
 with greater frequency in cases treated by systematic cold bathing. It is 
 obvious that a therapeutic method which reduces the mortality will increase 
 the number of convalescent cases in which relapse may occur. 
 
 The ordinary form of relapse begins after the defervescence is com- 
 plete and presents the picture of a repetition of the primary attack, usually 
 shortened and moderated in intensity. The onset is somewhat more rapid; 
 sometimes abrupt with a chill. At times, however, the relapse is even 
 more severe than the original disease and occasionally it terminates in 
 death. The interval between the defervescence and the relapse varies 
 from two or three to twenty days. I have seen a case in which it was five 
 weeks. The question as to whether a repetition of the attack after a pro- 
 longed period constitutes a late relapse or an early second attack is purely 
 academic and without practical importance. The relapse is commonly 
 
 40 
 
626 
 
 MEDICAL DIAGNOSIS. 
 
 single; occasionally multiple: two are by no means rare; three are infre- 
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 and other factors in the enteric fever symptom-complex. It is to be dis- 
 tinguished from recrudescence — a transient fever dependent upon the 
 instability of the heat-regulating apparatus during convalescence and due 
 to trifling causes; from so-called bed-fever, — an unimportant clinical 
 manifestation, — and from the symptomatic fever which may be the first 
 
 
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 Pig. 212. — Enteric fever. Relapse beginning in abrupt rise of temperature on the 29th day after 
 the onset of the primary attack and the 14th after complete defervescence. Duration of relapse 13 days» 
 Recovery. Girl, aged 11 years. 
 
 indication of some sequel or fresh infective or inflammatory process, to 
 which the depraved nutrition of the organism singularly disposes it. 
 
 Intercurrent Relapse. — This form of relapse receives its name from the 
 fact that it begins before the primary attack comes to an end. The patient 
 seems to be doing well; the temperature has assumed the remittent, even 
 the intermittent, curve; the tongue begins to clean off; the nervous symp- 
 toms ameliorate, and convalescence appears assured, when the fever again 
 rises and becomes subcontinuous, and with recurrence of the symptoms 
 the attack repeats its previous course. Relapses of this form are often 
 severe. They explain a large proportion of the protracted cases. 
 
 Theory of the Relapse in Enteric Fever. — In a majority of the 
 cases the circumstances under which relapses occur render it practically 
 
ENTERIC OR TYPHOID FEVER. 627 
 
 impossible for the reinfection to have come from outside. Neither the 
 water nor the food, including the milk, can be incriminated. The theory 
 of reinfection from within the organism is the only alternative. Of the 
 actual conditions favoring its occurrence little is known. As a working 
 hypothesis, reinfection from the gall-bladder and bile passages as suggested 
 by Chiari appears to meet the requirements of a majority of the cases. 
 The persistence of the bacilli in the mesenteric glands, the spleen, and the 
 gall-bladder, and their presence in the stools for a long time after deferves- 
 cence favor this view. The immunity conferred by the attack is apparently 
 of slow development. The fact that the greater number of relapses occur 
 within a week or ten days after the fever has subsided, at a time when solid 
 food in increasing amounts is being taken, lends support to this hypothesis. 
 It is at least possible that increased peristalsis may cause the sudden dis- 
 charge of large quantities of bacilli-laden bile into the intestines at a time 
 when immunity is not yet complete. Too much food and unwholesome 
 food may cause recrudescences of fever, but that they can, in the absence 
 of reinfection, cause relapse is a proposition not to be considered. The 
 hypothesis of Durham, that groups of bacilli of similar species but not 
 identical cause the attack, and that the antitoxin formed in the blood 
 does not neutralize all these groups, those remaining active giving rise to 
 single or multiple relapses, is highly ingenious but lacks proof. 
 
 Diagnosis. — (1) The causal or etiological diagnosis; (2) the direct 
 diagnosis; (3) the differential diagnosis; (4) diagnosis by exclusion; and 
 (5) a provisional diagnosis are to be considered. 
 
 The diagnosis is a simple matter in well-characterized cases after the 
 first week. The atypical cases are obscure and the more widely they 
 depart from the type the more uncertain does the diagnosis become. The 
 remarkable variations in the disease itself, the great number of complica- 
 tions and seqiiels, and the irregularity of its course add to the difficulties. 
 The diagnostician must know not only enteric fever but he must also know 
 the many maladies to which in its multiform aspects it bears a close or 
 superficial resemblance. 
 
 1. Causal or Etiological Diagnosis. — In sporadic cases in which the true 
 nature of the attack remains obscure and the association of cardinal 
 symptoms essential to a clinical diagnosis is lacking, it is of importance 
 to ascertain whether or not the patient has visited a district in which enteric 
 fever is endemic or in which the water supply is tainted; whether he has 
 been in a house in which there were one or several cases or he is a newcomer, 
 and to ascertain the length of time since such probable exposure. The 
 question of acquired immunity is to be considered. A clear history of a 
 previous attack is presumptive but not positive evidence against enteric 
 fever in a doubtful case. In a majority of sporadic cases the source of 
 the infection cannot be traced. 
 
 In local epidemics every effort should be made to find the starting- 
 point of the outbreak. Has a case been the source of contamination? 
 Has a sewer burst and discharged its contents into a water reservoir? Do 
 the cases follow the distribution of the milk from a particular dairy? Are 
 they limited to those who have eaten oysters or other shell-fish from beds 
 in sewage-defiled waters ? If in a standing camp is the water to be incrimi- 
 
628 MEDICAL DIAGNOSIS. 
 
 nated, or badly constructed latrines and swarms of house-flies? Upon the 
 answer to questions like these often depend many lives. Diagnosis and 
 prophylaxis, the work of the physician and of the sanitarian, are inseparably 
 bound together. Bacteriologically, the presence of the bacilli in the blood 
 or discharges is of conclusive importance. 
 
 The isolation of B. typhosus from the blood by means of culture 
 methods has become in recent years a practical diagnostic procedure. 
 The quantity of blood necessary is considerable but not so great as to do 
 harm in any case. Its withdrawal from a vein is almost painless. This 
 method yields positive results early in the attack, even before the appear- 
 ance of the eruption. It is especially valuable in septic cases. A recent 
 method is that of Peabody, and consists in the employment of ox-bile as 
 a culture medium for the Bacillus typhosus. The quantity of blood required 
 is small — two cubic centimetres being sufficient. The blood is inoculated 
 into a small quantity of sterile ox-bile which is incubated for twenty-four 
 hours. A portion of this culture is then transferred to Loffler's blood- 
 serum medium and incubated for another twenty-four hours. The isola- 
 tion of a motile bacillus may be regarded as presumptive evidence of the 
 existence of enteric fever, but further cultures are necessary to establish 
 the identity of the organism. 
 
 Blood removed from the rose spots contains the bacilli. The procedure 
 is attended with pain and is useless for diagnostic purposes, since the 
 eruption itself constitutes a cardinal diagnostic criterion. The isolation 
 of the bacilli from the urine is now a practical method of diagnosis. Their 
 demonstration is conclusive as regards the nature of the disease. Their 
 presence has been noted in some cases at an earlier period than a positive 
 agglutination test. 
 
 The isolation of the bacilli from the stools has been rendered practi- 
 cable by the more recent culture methods, but the technical difficulties are 
 considerable and the results uncertain. 
 
 Of the foregoing methods, blood cultures and the examination of the 
 urine are more practical than the others and are in use when the necessary 
 technical skill and the facilities of a clinical laboratory are at hand. 
 The majority of practitioners are not, however, in a position to avail 
 themselves of them. 
 
 The Agglutination Test — Widal Test. — This diagnostic procedure 
 is of very great value. It depends upon the property of the blood-serum 
 of an enteric fever patient, when added to a fresh culture of the bacilli, to 
 cause an arrest of the movement of the latter and their agglutination in 
 clumps. The test requires a definite dilution of the serum and time limit. 
 The microscopical examination is made by means of the hanging drop. 
 A dilution of 1-50 and time limit of an hour are in general use. The result 
 is decisive if loss of motility and clumping occur within this period. The 
 dried serum is convenient but its use does not permit of accurate dilution. 
 Small glass bulbs may be used for the collection of the serum. When the 
 test yields a positive result an equally prompt and energetic response to an 
 increased dilution renders the diagnosis even more certain. 
 
 The results of the Widal test are to be taken into consideration in 
 connection with the following facts: 
 
ENTERIC OR TYPHOID FEVER. 629 
 
 A positive result has been obtained some time in the course of the 
 attack or convalescence in about 97 per cent, of cases in which the clinical 
 or post-mortem data rendered the diagnosis certain. 
 
 A positive result has been obtained in about 93 per cent, of similar 
 cases in which the test was made before the eighth day. 
 
 In a limited number of cases the diagnosis has been negative in the 
 early course of the attack and become positive in the third or fourth 
 week, or not until after the defervescence or upon the occurrence of a 
 relapse. A well-characterized case of enteric fever with enlarged spleen, 
 rose spots, diarrhoea, even intestinal hemorrhage may give a negative 
 result throughout. 
 
 The agglutinating power is retained by the serum for an indefinite 
 time, sometimes months, even years, after the attack. A positive reaction 
 may be therefore misleading, especially in a patient in whom the disease 
 has run its course in an irregular manner or has been of the mildest or of 
 the ambulatory variety — typhus levissimus, typhus ambulans — and does 
 not therefore appear in the anamnesis. 
 
 The blood-serum of healthy persons and of persons suffering from 
 other specific infections, undiluted or in much lower dilution than is used 
 in the Widal test, sometimes causes loss of motility and clumping of the 
 bacilli in cultures, but not with the same promptness and energy, and this 
 property in non-typhoid blood is lost when higher dilutions, 1-50, 1-100, 
 are employed. 
 
 In a limited number of cases presenting the clinical picture of enteric 
 fever but in which the Widal test has remained negative, a positive reaction 
 has been obtained with cultures of paratyphoid bacilli — paratyphoid. 
 
 Caution is therefore necessary, except in the prompt and marked 
 reaction on the one hand and in the cases, on the other hand, in which the 
 reaction does not occur at any time, in drawing either positive or negative 
 conclusions. If, however, due regard be paid to the above mentioned 
 peculiarities in the reaction, the Widal test is of great value in diagnosis. 
 
 The macroscopic method is not in general use. 
 
 The Widal test, important as it is, cannot be made available for the 
 general practitioner because of the difficulty of having constantly on hand 
 fresh cultures of the bacilli. Only in communities in which there are 
 well-eciuipped clinical laboratories can its full usefulness be realized. 
 
 The Ophthalmic Reaction in the Diagnosis of Enteric Fever. — 
 Chantemesse (1907) announced a new characteristic reaction for the 
 diagnosis of enteric fever. The test is performed by instilling into the 
 conjunctival sac a solution prepared from virulent typhoid bacilli by wash- 
 ing, drying and trituration, precipitation with alcohol, and again drying 
 and reducing to powder. The powder thus obtained is dissolved in sterile 
 water in the proportion of 5V ]\Ig. to a drop, which is the quantity 
 employed. A positive reaction consists in the occurrence, in from three to 
 eighteen hours, of congestion, lachrymation, and a serofibrinous exudate. 
 The conjunctivitis attains its maximum in a few hours and subsides in the 
 course of twenty-four to seventy-two hours. In control cases the negative 
 result is manifest in absence of change or at most a slight hj^peraemia which 
 passes off in the course of five or six hours. This diagnostic test has the 
 
630 MEDICAL DIAGNOSIS. 
 
 advantages of simplicity of technic as compared with blood cultures and 
 the Widal test, and being available at an earlier period than the latter. 
 
 The urotoxic coefficient in enteric fever is high and has been found 
 to be increased in cases treated by systematic cold bathing. This fact 
 which is intimately related to the bacteriology of the disease is not used 
 for diagnostic purposes. 
 
 2. The Direct Diagnosis. — The presence of B. typhosus in the blood 
 or excretions or a prompt response to the Widal test renders the diagnosis 
 positive independently of the clinical phenomena. The direct diagnosis 
 then rests upon the bacteriological diagnosis. In the vast majority of cases 
 the diagnosis can be made with precision at the bedside — a fortunate 
 matter, since the elaborate procedures of the bacteriological laboratory 
 are not always available. 
 
 The association of the four following symptoms is of cardinal 
 importance: 
 
 (a) The Gradually Ascending Temperature. — This phenomenon 
 is available only when the observations have been begun early in the 
 attack — second or third day. This happens only in a limited number of the 
 cases; but a temperature of 103°-104° F. (39.5°-40° C.) of subcontinuous 
 type and a history of febrile symptoms of gradually increasing severity 
 and several days' duration are significant. A curve of remittent type in 
 the third week and distinct intermissions with progressively f alHng evening 
 maxima are of great diagnostic value in a case in which other diagnostic 
 criteria have been uncertain. The duration of the febrile movement is 
 important, but it is in the doubtful cases that we find a shorter or, more 
 commonly, a longer course than in those which are typical. 
 
 (b) The pulse-frequency, which is increased, but not in proportion 
 to the temperature. With evening maxima of 104° F. the pulse-frequency 
 may not exceed 90-110 per minute. This derangement of ratio is observed 
 in very few of the acute febrile infections. Yellow fever is conspicuous, 
 but there can scarcely be any question as to the discrimination between 
 that disease and enteric fever. There is nothing characteristic in the pulse 
 itself. Dicrotism occurs under other conditions, but its early appearance 
 is very suggestive. 
 
 (c) Enlargement of the Spleen. — This is a constant phenomenon, 
 but cannot always, on account of the distention of the bowel, be demon- 
 strated. It occurs in the other acute infections. Nevertheless enlarge- 
 ment of the spleen at the end of the first week, associated with the 
 other cardinal symptoms, is of great diagnostic value in the direct 
 diagnosis. 
 
 (d) The Eruption. — The appearance of the rose spots at the close 
 of the first or in the course of the second week is an event of the highest 
 diagnostic significance. A single spot is without great value, and the 
 single spot is usually a "doubtful" spot; but successive crops of papulo- 
 macular, rose-pink spots, distributed over the upper abdominal or lower 
 
 ■ thoracic regions, disappearing upon pressure or when the skin is made 
 tense, each spot fading in the course of three or four days, do not occur in 
 any other febrile infection and may be regarded as rendering a provisional 
 diagnosis positive. 
 
ENTERIC OR TYPHOID FEVER. 631 
 
 Symptoms of minor diagnostic importance are epistaxis, the furred 
 tongue, red at the borders and tip, diarrhoea with thin, ochre-colored stools 
 containing now and then one or two hard masses, and separating on stand- 
 ing into a thin upper and a thicker sedimentary layer, tympanj^, the ner- 
 vous phenomena, and bronchitis. Intestinal hemorrhage or perforation 
 confirms the diagnosis in a doubtful case. The tendency to complications 
 is characteristic of enteric fever, especially in the later course of the attack. 
 Furunculosis, abscess formation, parotitis, bed-sores, septic phenomena 
 -are of merely suggestive importance. A subnormal temperature and eager 
 hunger after defervescence are of very common occurrence. The absence 
 of leucocytosis is of value, but it is precisely in the doubtful cases that 
 inflammatory processes or obscure pus collections impair the value of this 
 method of diagnosis. 
 
 Among the symptoms which militate against the diagnosis but do 
 not negative it entirely are marked coryza, herpes, initial sweating, early 
 arthritis and endo- or pericarditis; the continued absence of abdominal 
 symptoms, as diarrhoea, especially if resistant to laxatives, a retracted 
 abdomen and only slight enlargement of the spleen. The continuing 
 absence of the diazo reaction is not common in enteric fever. 
 
 3. Differential Diagnosis. — The data for a positive diagnosis of enteric 
 fever are rarely present during the first week. A provisional diagnosis 
 only is possible. This is especially the case when the patient is seen for 
 the first time. During the fastigium if the four cardinal symptoms of sub- 
 continuous high temperature, slow pulse in proportion to the temperature, 
 enlarged spleen, and rash are present the nature of the malady is beyond 
 question. But it often happens that one or more, even all of these symp- 
 toms, are wanting. The fever may be irregular, the pulse rapid, the enlarge- 
 ment of the spleen not demonstrable, and eruption absent. In the later 
 course of the attack septic phenomena, various complications, or an inter- 
 current relapse may again render the diagnosis obscure. It is instructive, 
 therefore, to consider under the above heading (a) the diseases which resem- 
 ble enteric fever in the first week, (b) those which resemble it during the 
 fastigium, and (c) those which resemble it at later periods. 
 
 (a) Diseases which Resemble Enteric Fever in the First Week. 
 — We must consider first the diseases which sometimes resemble it in its 
 normal course — influenza, febricula, the exanthemata, febrile enteritis 
 and gastro-enteritis, appendicitis — and those which resemble it in certain 
 of its varieties — cerebrospinal fever, pneumonia, central pneumonia, acute 
 nephritis, and septic conditions. 
 
 Influenza can in some of the cases be excluded only after several days, 
 especially when the attack has begun with a gradual, step-like elevation 
 of temperature, diarrhoea, and enlargement of the spleen. I have many 
 times seen epistaxis at the onset of an attack of epidemic influenza. The 
 initial nervous symptoms are also much alike. In favor of influenza 
 are a more abrupt onset, catarrhal symptoms, especially coryza and con- 
 junctivitis, the intensity of the headache and its localization in the orbital 
 regions, a pulse-rate proportionate to the rise in temperature, and the 
 fact that the attack runs its course and defervescence is complete by 
 the end of a week. 
 
632 MEDICAL DIAGNOSIS. 
 
 Febricula. — Every practitioner sees cases of transient fever with 
 headache, malaise, anorexia, and sometimes barely recognizable enlarge- 
 ment of the spleen. If the symptoms last twenty-four hours and disappear 
 altogether, the attack is known as ephemeral fever; if they continue longer, 
 to six or seven days in the absence of local trouble, it is designated febricula. 
 Many of the cases are examples of the mildest variety of enteric fever as 
 shown by the Wiclal test. The diazo reaction may also be present. In some 
 instances rose spots are seen. If these tests are negative the illness is not due 
 to typhoid infection, but to some other infectious agent, gastro-intestinal 
 catarrh, ptomaine poisoning or overwhelming foul odors, or the fever is symp- 
 tomatic of some unrecognized local infection or inflammatory process. 
 
 Acute Exanthemata. — Scarlet fever, measles, and the variolous diseases 
 may during the period of onset give rise to the suspicion that enteric fever 
 is developing. The character of the temperature range, the coryza in 
 measles, the angina of scarlatina, the intense headache and backache of 
 variola, together with the initial rashes when present and the appearance 
 of the definite eruption in a relatively short time, settle any question as 
 to the essential nature of the infection. A doubt only can arise in regard 
 to the eruption of measles. In several instance* I have seen, especially 
 in children, a typhoid eruption so copious as to suggest the exanthem of 
 measles. In measles the rash shows itself upon the fourth day after a 
 slight fall of temperature, usually first on the face and later over the trunk 
 and limbs, presents a crescentic arrangement, and is preceded by marked 
 catarrhal symptoms. 
 
 Febrile Enteritis and Gastro-enteritis. — As a rule, gastric and intestinal 
 catarrhs run their course without fever. Febrile cases do, however, occur. 
 It is to the infrequent cases of this kind that such terms as gastric fever and 
 mucous fever owe their existence. Most of the cases so designated by 
 practitioners are cases of enteric fever, and these terms are, fortunately, 
 falling into disuse. The prominence of dyspeptic symptoms, colicky pains, 
 the irregular course of the fever, the absence of disparity between the 
 pulse-frequency and the elevation of temperature weigh heavily against 
 the diagnosis of enteric fever, and a negative Widal reaction up to the time 
 of complete defervescence would be conclusively against such a diagnosis. 
 
 Appendicitis. — The gastro-intestinal symptoms and especially the 
 pain and tenderness may if attended by a rise in temperature simulate 
 enteric fever. I have known of several instances in which a patient suffering 
 from the latter disease has been admitted to a hospital at night and at once 
 operated upon, with the recognition upon the following day of the true 
 nature of the disease. This mistake ought not to occur. The sudden onset, 
 the localization of the pain, the high degree of circumscribed tenderness, 
 the absence of fever, or its irregularity when present, and the lack of the 
 cardinal symptoms upon which the diagnosis of enteric fever rests should 
 put the practitioner upon his guard. It is, however, to be borne in mind 
 that after the middle of the second week of enteric fever perforation of the 
 appendix has been observed. 
 
 Right tubo-ovarian disease with fever may also simulate enteric fever. 
 The presence of a tender mass upon the right side with fixation of the uterus 
 and leucocytosis are of positive diagnostic significance. 
 
ENTERIC OR TYPHOID FEVER. 633 
 
 Meningotyphoid — cerebrospinal fever — takes first place among the 
 diseases which simulate enteric fever in its more irregular forms. In fact 
 the resemblance between the cerebrospinal form of enteric fever in the 
 first week and cerebrospinal fever is so great that a differential diagnosis 
 is in a majority of the cases altogether impossible. The onset is sudden 
 with intense headache, photophobia, delirium, painful rigidity of the back 
 of the neck, and sometimes vomiting. Kernig's sign may be present. 
 Examination of the fluid obtained by lumbar puncture may show the 
 meningococcus. The appearance of rose spots and abdominal symptoms 
 at the end of the first week and mitigation of the nervous symptoms are 
 characteristic of enteric fever. Herpes is common in cerebrospinal fever. 
 
 Pneumonia. — Pneumotyphus must be very rare. I have seen a very 
 limited number of cases. The sudden onset with chill, high fever, pain in 
 the side, cough, and the signs of consolidation are very misleading. The later 
 course is that of enteric fever. The difficulties are increased in the irregular 
 cases of enteric fever in aged persons. Such cases have been regarded as 
 pneumonia until at the autopsy the intestinal lesions of enteric fever have 
 been found. The recognition of intercurrent croupous pneumonia at the 
 height of the disease is a comparatively easy matter provided that system- 
 atic routine examination by the methods of physical diagnosis are made. 
 
 There are cases of central pneumonia, occurring independently of 
 enteric fever, which simulate it very closely. These cases run their course 
 for days with no other symptoms than those of fever and perhaps a trifling 
 cough. Pain, rusty sputum, and the signs of consolidation are not present. 
 The diagnosis rests upon the abrupt onset with chill and high temperature, 
 difficulty in breathing, the early appearance of herpes, and a slight degree 
 of jaundice. Leucocytosis is of diagnostic value. It is to be remembered 
 that this sign may be absent in the gravest cases of pneumonia and present 
 in enteric fever complicated by inflamma.tory or purulent processes. The 
 absence of the temperature curve of enteric fever, of relative slowness of 
 the pulse, of considerable enlargement of the spleen, and of rose spots is 
 important. The occurrence of rusty sputum, even when scanty, localized 
 bronchophony, a tympanitic percussion sound, and crepitant rales estab- 
 lish the diagnosis of a central pneumonia, which is fully confirmed when 
 defervescence takes place by crisis and free sweating. 
 
 Nephrotyphus. — The cases which begin with the clinical phenomena 
 of an acute nephritis present great diagnostic difficulties during the first 
 week and the practitioner who brings to the study of his cases in a system- 
 atic manner the ordinary clinical methods — early and thorough examination 
 of the urine, for example — may in this particular group of cases encounter 
 uncertainties that his less careful brother may avoid. There are headache, 
 vertigo, mental dulness, disinclination for effort, loss of appetite, and fever. 
 Epistaxis occurs in both conditions. The illness looks like enteric fever; 
 the urine is that of an acute inflammation of the kidneys. It is scanty, high- 
 colored, of high specific gravity — 1.024 to 1.030 — and contains much albu- 
 min, together with hyalogranular and epithelial tube-casts, cylindroids, and 
 red blood-corpuscles. Rose spots, splenic tumor, a more or less character- 
 istic temperature range, and the duration of the attack render the diag- 
 nosis clear. The nephritis does not tend to become chronic. 
 
634 MEDICAL DIAGNOSIS. 
 
 Sepsis. — I employ this term here to cover the conditions included 
 under septicaemia, pyaemia, and septicopysemia. In general the differential 
 diagnosis between these conditions and enteric fever is not attended with 
 difficulty. Where there is trauma or obvious bone disease or demonstrable 
 suppuration no question arises. There are, however, forms of sepsis, 
 especially those of cryptogenetic origin, having in common with enteric 
 fever high temperature, splenic tumor, and nervous symptoms in which 
 the diagnosis is very uncertain. Among the symptoms which favor the 
 diagnosis of sepsis are the following: irregular fever with marked remis- 
 sions and intermissions early in the illness; chills followed by profuse 
 perspiration; endocarditis of the septic or malignant form; septic arthritis 
 involving a single joint or many; tenderness upon pressure over the bones 
 — sternum, clavicles, tibiae — and retinal hemorrhage. The pulse also is 
 very frequent and arrhythmic. In many of the cases there are marked 
 meningeal symptoms and cutaneous lesions, herpes, urticaria, erythema, 
 and petechias are common. We do not overlook the fact that sepsis 
 frequently occurs in the course of enteric fever and that there is a recog- 
 nized form of typhoid septicaemia — facts which are of importance in the 
 diagnosis of individual cases. 
 
 (b) Diseases which Resemble Enteric Fever in the Fastigium. — 
 Malaria, typhus and relapsing fevers, internal anthrax, miliary and tuber- 
 culous peritonitis, certain forms of sepsis, and malignant endocarditis 
 may be grouped in this category. 
 
 Malarial fever may as a rule be readily differentiated from enteric 
 fever. The regularly intermitting forms present no difficulties. In the 
 estivo-autumnal form the diagnosis may be uncertain for several days. 
 The appearance after a time of the parasite in the blood settles all doubt 
 as to the nature of the disease. Meanwhile the absence of chills, the con- 
 tinued fever with very moderate remissions, together with weakness, diar- 
 rhoea, and a palpable spleen, suggest enteric fever. The malarial and the 
 typhoid infection may be present in the same patient at the same time. 
 With the estivo-autumnal variety this association is not uncommon, as was 
 shown in soldiers returning from Cuba and Porto Rico during the Spanish- 
 American War. With the tertian and quartan parasites the association is rare 
 and these organisms are very seldom present in the blood of individuals 
 suffering from enteric fever. A hybrid disease such as is indicated by the 
 term typhomalarial fever — a separate nosological entity — does not exist. 
 
 Typhus fever may be differentiated from enteric fever by the erup- 
 tion, which in the latter is far and away more sparse and appears several 
 days later in the course of the attack. Cases in which the rash appears 
 early and is so copious as to suggest typhus fever do occur, but they are 
 extremely rare. It does not, save in the rarest cases of hemorrhagic enteric 
 fever, become petechial, as is the rule in typhus. The abrupt rise and 
 critical fall of temperature in typhus are very significant, as is also the 
 high pulse-frequency. Dicrotism is often present in both diseases. The 
 difference in the duration of the two diseases, typhus lasting usually from 
 ten to fourteen days, is to be noted. The Widal reaction is almost invari- 
 ably wholly absent in typhus. Blood cultures may become necessary in 
 a doubtful case. 
 
ENTERIC OR TYPHOID FEVER. 635 
 
 Relapsing fever may be readily differentiated from enteric fever by 
 its abrupt onsejb with chill and very high temperature, jaundice, pain and 
 tenderness in the epigastric zone, critical defervescence, period of complete 
 apyrexia, and relapse. The presence of the spirochseta of Obermeier in the 
 blood is absolutely conclusive. In typhus and relapsing fevers the prev- 
 alence of an epidemic is to be taken into consideration in the differential 
 ■diagnosis. Too great importance must not, however, be attached to 
 epidemic influence. When an epidemic exists it does not necessarily follow 
 that a person taken ill has contracted the prevalent disease. 
 
 Internal anthrax presents the symptoms of a severe infectious disease 
 with intestinal symptoms. Fever, diarrhoea, and splenic enlargement 
 occur. There are symptoms, however, which scarcely belong to enteric 
 fever, as repeated vomiting, colic, bloody diarrhoea, haematuria, dyspnoea, 
 cyanosis, and submucous extravasations of blood in the mouth. An exami- 
 nation of the blood reveals the presence of anthrax bacilli. If B. anthracis 
 is not present, inoculation experiments must be practised. 
 
 Acute miliary tuberculosis is occasionally mistaken for enteric fever. 
 This error in diagnosis arises from the fact that the former disease fre- 
 quently begins rapidly in persons apparently in good health, with fever, en- 
 largement of the spleen, and nervous symptoms, and without demonstrable 
 signs of organic lesions upon physical examination. The presence in rare 
 cases of a scanty eruption of rose-colored maculopapules not to be dis- 
 tinguished from the rash of enteric fever adds greatly to the uncertainties 
 of the diagnosis. Their recurrence in crops is in favor of the latter affection. 
 The Widal test should be tried and, in the case of a negative result, repeated 
 at intervals of some days. In such cases there is usually little sputum and 
 neither that which is expectorated nor the urine contains tubercle bacilli. 
 Careful examination of the chest will often elicit suggestive signs, as vesiculo- 
 tympanitic resonance at an apex and a few scattered small mucous or 
 coarse crepitant rales of high pitch. Cyanosis and dyspnoea are prominent 
 symptoms. The pulse, in the absence of an associated meningitis in which 
 it is often slow, is frequent, feeble, and arrhythmic, showing in particular 
 remarkable variations in frequency in the course of brief intervals of time. 
 The splenic enlargement is less marked than in enteric fever; but there are 
 a few cases of the latter disease in which the spleen is but little enlarged 
 and many in which during the fastigium the enlargement cannot be demon- 
 strated on account of the meteorism. The diazo reaction is sometimes 
 absent in enteric fever and often present in tuberculosis. This last is there- 
 fore of secondary importance in the differential diagnosis between these 
 two diseases. A complicating meningitis may occur in either affection, 
 but is much more common in tuberculosis. If an ophthalmoscopic exami- 
 nation, which should be repeated from time to time, reveals the presence 
 of tubercles in the choroid, the diagnosis is established. The atypical 
 course of the temperature in tuberculosis, especially its extreme irregularity, 
 the occurrence of remissions, and its occasional morning exacerbations 
 and evening remissions — inverse type — are of great diagnostic value. 
 
 Tuberculous peritonitis may, in certain of its forms, present a mis- 
 leading resemblance to enteric fever. The attack begins gradually with 
 abdominal tenderness, meteorism, and diarrhoea. There are moderate fever 
 
636 . MEDICAL DIAGNOSIS. 
 
 of subcontinuous or remittent type and rapid wasting. The diagnostic 
 criteria are those already mentioned under acute miliary tuberculosis. 
 Ascites, a doughy distention of the abdomen, the presence of enlarged 
 mesenteric glands or a sausage-shaped omental tumor are confirmatory 
 data in tuberculous disease. 
 
 Sepsis may present the same difficulties in diagnosis from enteric fever 
 in this period as in the first week. The points of differentiation are the 
 same and have already been set forth in sufficient detail. The long-con-, 
 tinned symptomatic fever of deep-seated suppuration, often obscure, may 
 in the absence of chills and sweating closely simulate enteric fever. This 
 is especially true of the deep abscesses which occasionally occur in visceral 
 and bone tuberculosis. 
 
 Malignant endocarditis is not rarely mistaken for enteric fever. Chang- 
 ing murmurs, embolism, and the presence of leucocytosis are of great 
 diagnostic aid. The Widal reaction and blood cultures when positive as 
 regards B. typhosus dispel any doubts as to the presence of enteric fever. 
 
 (c) Diseases which Resemble Enteric Fever in its Later Course. 
 — Septic conditions, various complications, and intercurrent relapse greatly 
 modify the period of decline. In fact the terminal course of an ordinarily 
 well-characterized, uncomplicated attack of enteric fever is often as typical 
 as the onset. The falling temperature with its remittent and intermittent 
 curve, the cleaning tongue and urgent hunger, the clearing mind and natural 
 sleep, all coming on toward the close of an illness of three or four weeks' 
 duration, would almost justify a diagnosis in the absence of a history of 
 the previous course of the attack. Yet this favorable course is often greatly 
 modified by the above conditions. 
 
 Sejjsis of obscure origin — cryptogenetic — sometimes sepsis due to 
 obvious causes, as purulent effusion, abscess formation, or caries, may so 
 dominate the clinical picture as to raise a doubt in regard to the true nature 
 of the primary attack. In default of a satisfactory anamnesis the methods 
 of the laboratory, especially blood cultures, the examination of the urine 
 for B. 'typhosus, and the Widal test are in many cases essential to a positive 
 diagnosis. Comphcations, as pleurisy with effusion, bronchopneumonia, 
 pulmonary abscess or gangrene, malignant endocarditis, cystitis and pye- 
 litis, and various nervous diseases may assume such a degree of prominence 
 as to dwarf the significance of the early symptom-complex and raise the 
 question as to whether or not the previous symptoms have been those of 
 enteric fever or simply earher manifestations of the present disease. Here 
 also the results of laboratory research render positive assistance. 
 
 Intercurrent relapse frequently prolongs the attack to six or seven weeks. 
 Fresh crops of rose spots, the character of the temperature range, which may 
 after having been strongly remittent again become subcontinuous, the per- 
 sistent enlargement of the spleen, and the other symptoms of a specific 
 rather than a septic infection afford the criteria for a diagnosis. If these 
 symptoms are ill defined or there be secondary infection or marked and 
 grave complications, the diagnosis of intercurrent relapse remains uncertain. 
 
 Urcemia in its chronic forms may suggest enteric fever at the later 
 periods of its course by a rapid and feeble pulse, dry and fissured tongue, 
 stupor, wandering delirium, subsultus, and continued fever of mild type. 
 
ENTERIC OR TYPHOID FEVER. 637 
 
 The urinary findings, the condition of the arteries, a negative Widal reaction, 
 and the previous history are usually sufficient for the differential diagnosis. 
 
 4. Diagnosis by Exclusion. — Enteric fever is by far the most common 
 of the febrile infectious diseases; with the exception of intestinal symptoms, 
 enlargement of the spleen, trifling bronchitis, and a relatively slow pulse, 
 there are no constant evidences of visceral disease; the age at which the 
 disease is most common and the immunity which is established by the 
 attack are facts available in a doubtful case for the diagnosis by exclusion. 
 
 5. A Provisional Diagnosis. — There are cases in which a positive 
 diagnosis cannot be made when the patient is seen for the first time. Delay 
 may be required for the accumulation of the necessary data in the progress 
 of the attack to a point at which characteristic symptoms appear. A 
 provisional diagnosis becomes, under these circumstances, imperative. 
 Pending the decision a due regard of the welfare of the patient and the 
 community demands the exercise of all the measures of treatment and all 
 the precautions against the spread of the disease that we would employ 
 if a positive diagnosis were made. 
 
 The Diagnosis of Intestinal Perforation. — The direct diagnosis 
 of this accident rests upori the association of the symptoms to which it 
 gives rise. There are cases, however, in which several of the more 
 characteristic symptoms are not present, and every clinical phenomenon 
 of intestinal perforation may show itself in the course of enteric fever in 
 perforative lesions of other organs, as the appendix, gall-bladder, or peptic 
 ulcer of the stomach or duodenum; while acute abdominal symptoms with 
 or without collapse, followed by the signs of local or general peritonitis, 
 may be the manifestations of intussusception, volvulus, strangulation of 
 a Meckel's diverticulum, softened splenic infarct, hepatic abscess or pseudo- 
 abscess of the mesenteric glands. Prompt recourse to surgical measures 
 in any of these conditions may be the only means of saving life. In the 
 face of the urgent symptoms of some grave intra-abdominal accident it 
 is better in selected cases not to lose time in the attempt to make a diag- 
 nosis of the lesion by ordinary measures but at once to open the abdomen 
 and ascertain the actual condition and if possible correct it. This diag- 
 nostic procedure is justified by the fact that enteric fever patients bear 
 ansesthesia and operation well. 
 
 Prognosis. — The mortality varies greatly in different outbreaks, 
 the range being from five to seventeen per cent. It is slightly higher in 
 hospital than in private practice. After the first year, the prognosis is in 
 general less favorable as the age of the individual increases. The mortality 
 is greater after puberty; after forty it rises rapidly and in aged persons 
 enteric fever is a very fatal disease. In respect of prognosis the infantile 
 type — high evening temperatures with marked morning remissions through- 
 out — is much more favorable than the adult type of the disease — high or 
 moderate evening exacerbations with very slight morning remissions. 
 Fat persons do not bear enteric fever well. Their powers of resistance to 
 infections in general are less than in the spare and muscular; there is an 
 increased tendency to parenchymatous degenerations of the viscera; the 
 evidences of myocardial changes are early noted, and the nursing and 
 treatment are less satisfactory. Those given to the abuse of alcohol also 
 
638 MEDICAL DIAGNOSIS. 
 
 bear the disease badly. Women in general show a higher mortality than 
 men, and pregnant and lying-in women attacked by enteric fever are in 
 great danger. When the disease develops in persons suffering from chronic 
 disease, especially affections of the heart, chronic bronchitis, emphysema^ 
 goitre, and pulmonary tuberculosis, the prognosis is less favorable than in 
 those in previous good health. When the tuberculous patient survives the 
 attack, the lung trouble usually manifests itself with increased intensity. 
 There are, however, exceptions to this rule. I have seen several cases in 
 which an apparent arrest took place after convalescence. An antecedent 
 chronic nephritis adds to the gravity of the case. Diabetes mellitus is 
 also unfavorable. The temperature is not usually high and sugar disappears 
 from the urine, but the resisting powers of the patient are much impaired. 
 
 The intensity of the infection as shown by high temperature maxima, 
 the limited range of the remissions, prolongation of the fever, and the 
 prominence of nutritional disorders and nervous symptoms is of prog- 
 nostic importance. The outlook is relatively much more favorable in the 
 cases in which the fever is moderate and the associated symptoms of mild 
 degree — typhus levissimus — and in those in which, while the fever is high 
 and the morbid phenomena severe, the course is short — abortive cases. 
 In general an abrupt rise of temperature occurs in the latter group of cases 
 and is therefore not without value as indicating a short attack. Even in 
 these cases a severe complication, a relapse, or the gravest accidents — 
 hemorrhage, perforation — may occur. These events are, however, much 
 more common in cases otherwise severe. 
 
 The maintenance of the power of the heart as indicated by the pulse 
 is very important in prognosis. So long as the frequency remains low as 
 compared with the fever and the volume is fair, the outlook is relatively 
 favorable; but an increased pulse-frequency, associated as it almost invari- 
 ably is in this disease with loss of power, is of grave prognostic significance. 
 This is particularly the case when there are developed at the same time 
 such evidences of circulatory failure as pulmonary hypostasis, faint cyanosis, 
 coolness of the extremities, pulmonary oedema, and symptoms of collapse. 
 The prognosis becomes progressively more ominous as the frequency of 
 the pulse increases. In children and neurotic individuals, especially 
 women, a frequent pulse is less significant, particularly when it again 
 becomes slower. 
 
 As a general rule the gravity of the case is proportionate to the intensity 
 of the nervous symptoms. Continuing delirium, stupor, coma, and partic- 
 ularly coma vigil, are of grave import; so also are meningeal symptoms, 
 apoplectiform seizures, and local and general convulsions. Less alarming 
 are the psychic derangements which occur toward the close of the attack 
 and during convalescence — postfebrile insanit3^ 
 
 The prognosis is rendered unfavorable by the development of compli- 
 cations and sequels. These are, as has been already stated, more numerous 
 than in any other infectious febrile disease and not infrequently determine 
 the outcome of the case. 
 
 Intestinal hemorrhage, when slight and occurring early in the attack, 
 is not necessarily unfavorable. Large bleedings occurring early are dis- 
 tinctly so, for four reasons: they indicate grave local lesions and usually 
 
PARATYPHOID FEVERS. 
 
 639 
 
 also intense infection; they debilitate the patient and lower his powers of 
 resistance; they are often repeated after a longer or shorter interval and 
 in some instances are followed by perforation, and finally they constitute 
 a distinct contraindication to the treatment by systematic cold bathing. 
 
 Intestinal perforation is almost always followed by the fatal issue. 
 The patient succumbs in the course of a few days to the consecutive peri- 
 tonitis. In rare instances a longer period may elapse and a very few cases 
 of spontaneous recovery have been noted. A favorable prognosis cannot 
 be made and the only chance for the patient lies in prompt surgical inter- 
 vention. Peritonitis without perforation constitutes a complication of 
 most gloomy import. It is probable that a proportion of the cases described 
 as perforation with recovery have been instances of this kind. 
 
 Finally the prognosis is much influenced by the general management 
 of the individual case and treatment. Skilful nursing, a careful dietary, 
 the avoidance of drugging, and systematic cold bathing have reduced the 
 death-rate to about seven and one-half per cent. The earlier the treatment 
 is instituted the better the result. 
 
 PARATYPHOID FEVERS. 
 
 Definition.— A group of infectious febrile diseases, caused by organ- 
 isms intermediate between Bacillus typhosus and Bacillus coli and 
 presenting the clinical phenom- 
 ena of enteric fever. 
 
 Etiology. — There are a 
 number of organisms in this 
 intermediate series, including 
 the Bacillus enteritidis, and sev- 
 eral varieties causing diseases 
 in animals. 
 
 Buxton has suggested the 
 following classification: 
 
 " Paracolons. — Those which 
 do not cause typhoidal symp- 
 toms in man. A group con- 
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 "Paratyphoids. — Those 
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 symptoms. 
 
 "(A) A distinct species cul- 
 turally unlike the paracolons. 
 
 " (B) A distinct species 
 culturally resembling the 
 paracolons. " 
 
 Cases of paratyphoid have 
 been reported from all parts of 
 the world in which systematic laboratory work in bacteriology is carried 
 on. It has occurred in series of enteric fever cases, in house epidemics, 
 
 
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 -Jefferson Hospital. 
 
640 
 
 MEDICAL DIAGNOSIS. 
 
 and under circumstances which render it probable that it is sometimes 
 a water-borne disease. 
 
 Symptoms. — The features of the reported cases are very variable. 
 
 1. Many of the cases cannot be distinguished from enteric fever 
 except by the failure of the blood-serum to agglutinate B. typhosus 
 and its power to agglutinate the organisms of this group. Hemorrhage, 
 crural phlebitis, and relapse occur. 
 
 2. Others present the clinical features of septic infections and resemble 
 the so-called typhoid septicaemia or enteric fever with intercurrent or 
 
 terminal sepsis — cases in which 
 the diagnosis is reached by ex- 
 clusion rather than by the pres- 
 ence of the ordinary clinical 
 features of enteric fever. 
 
 3. Finally the organisms 
 have been found in abscesses in 
 cases in which no history of 
 enteric fever has been obtained. 
 The first group of cases, 
 those which are clinically indis- 
 tinguishable from enteric fever, 
 are almost always mild and 
 terminate in recovery. The 
 anatomical lesions are therefore 
 as yet undescribed. The last 
 group is without interest in this 
 respect. Cases of the second 
 group may end fatally. Wells 
 and Scott (1904) studied a 
 fatal case of their own in con- 
 nection with four fatal cases 
 collected from the literature, 
 one of which occurred in my 
 service in the Pennsylvania 
 Hospital and was studied by 
 Longcope. The most constant 
 lesion was enlargement of the 
 spleen. The intestinal conditions were variable. In two of the cases the 
 intestines were normal. Ulcers were present in the others, but they 
 resembled those of dysentery rather than of enteric fever. In all the cases 
 the solitary follicles, the Peyer's patches, and the mesenteric glands were 
 unaffected. The other changes present were those of a septicaemia. 
 
 Diagnosis. — The direct diagnosis of paratyphoid rests upon the 
 failure of the blood-serum to agglutinate B. typhosus and its power to 
 agglutinate B. paratyphosus or B. paracoli. 
 
 It is in the highest degree probable that reported cases of mild enteric 
 fever — typhus levis, typhus levissimus^and cases of the so-called septi- 
 csemic variety have been instances of paratyphoid. Whether or not a 
 separate disease should be recognized merely upon the agglutinating prop- 
 
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 Fig. 214. — Fatal paracolon infection 
 Hospital, 
 
 ■ Pennsylvania 
 
TYPHUS FEVER. 641 
 
 erties of the blood-serum is open to question. The working hypothesis 
 that cUnical conditions not to be differentiated from enteric fever may 
 be caused by a number of alhed pathogenic organisms is supported by 
 the facts reported by Achard and Bensaude (1896), Widal (1897), Gwyn 
 (1898), and many observers since. 
 
 II. TYPHUS FEVER. 
 
 Typhus Exanthematicus; Jail, Camp, or Ship Fever. 
 
 Definition. — An acute, infectious, epidemic disease characterized by 
 sudden onset, intense fever, a peculiar rash, at first macular, later pete- 
 chial, great prostration, marked nervous symptoms, a defervescence usually 
 critical, and an average duration of about fourteen days. There are no 
 characteristic anatomical lesions. 
 
 Typhus — t6<po? smoke — used by Hippocrates to define a confused 
 state of the mind with a tendency to stupor, expresses a prominent con- 
 dition of the disease. Typhus has become a rare disease. Its practical 
 disappearance dates from the early part of the nineteenth century, when 
 enteric fever became more prevalent. Sporadic cases and small local 
 epidemics of typhus occasionally occur in great cities, particularly in 
 Great Britain and Ireland and in Russia. 
 
 Etiology. — Predisposing Influences. — Typhus is a disease of cold 
 and temperate climates. Its prevalence is but little influenced by the 
 season of the year or by meteorological conditions. Overcrowding plays 
 the most important part among predisposing influences to typhus. Do- 
 mestic and personal filthiness, insuflftcient food, and intemperance are also 
 of importance. Typhus is a disease of the poor and under-fed of large 
 cities. Age and sex are without influence. Occupation is without influence 
 except as it involves actual exposure to the contagion, as in the case of 
 hospital attendants, physicians, clergymen, and those who care for the dead. 
 
 The Exciting Cause. — The infecting agent has not yet been 
 demonstrated. 
 
 Typhus fever is readily transmissible from the sick to the well by 
 actual contact, by means of the atmosphere to short distances, and by 
 fomites. The infecting principle is thrown off in the expired air of the 
 patients and in the exhalations from their bodies. It probably finds access 
 by means of the breath or by the saliva which is swallowed. 
 
 The attack confers an immunity which in most instances is permanent. 
 
 Symptoms. — The period of incubation is about twelve days. It may 
 be less. Prodromes, consisting of lassitude, vertigo, headache, loss of 
 appetite, and restlessness at night, occasionally occur. 
 
 Stage of Invasion. — The onset is abrupt and marked by a chill or 
 chilliness, followed by fever. In children the onset may be attended by 
 vomiting or convulsions. The skin is hot, the face flushed, the eyes injected, 
 headache is constant and severe. There is a feeling of dulness and con- 
 fusion, with vertigo and tinnitus aurium. The patient complains of pain 
 in the back and soreness of the limbs and joints. There is early muscular 
 weakness and an extreme sense of prostration. There is confusion of mind 
 
 41 
 
642 
 
 MEDICAL DIAGNOSIS. 
 
 and failure of memory. Delirium occurs early; it may be mild and wander- 
 ing or active and noisy. The tongue is at first large, pale, and coated with 
 a thick fur, but presently becomes brown and dry. Appetite is lost; there 
 is thirst; the secretion of saliva is diminished; taste is perverted and a 
 stale, unpleasant odor loads the breath. There is constipation as a rule 
 but in some instances diarrhoea. The pulse is full but compressible. It 
 soon grows feeble and varies in frequency from 120-130. Dicrotism is 
 uncommon. The temperature rises rapidly. By the third or fourth day 
 it may reach 103°-105° F. (39.5°-40.5° C), and continues at this range 
 with moderate morning remissions until the crisis. Hyperpyrexia, 107°- 
 109° F. (42°-42.7° C), not infrequently precedes death. 
 
 Stage of Eruption. — On the fourth or fifth day, less often at the 
 end of the first week, the eruption appears. It consists of numerous roseola- 
 like spots of irregular outline and from 
 one to three lines across, scattered sin- 
 gly or arranged in close-set groups like 
 the rash of measles. These spots are at 
 first of a dirty rose color, slightly raised 
 above the surface of the surrounding 
 skin, and disappear upon pressure. In 
 the course of a day or two they become 
 darker and are then no longer elevated 
 but appear as faint, dirty brown stains 
 without defined margins. A little later 
 petechise show themselves at the centre 
 of many of these spots. The spots fade 
 during the first half of the second week 
 and disappear with or without desqua- 
 mation toward its close. In many of 
 the cases petechise appear about the 
 time the typical rash begins to fade. 
 A faintly reddish, lightly defined mottling or marbling of the skin between 
 the spots or groups of spots also occurs. This mottling has been described 
 from its appearing to lie beneath the surface as the subcuticular eruption 
 of typhus. The appearance of the rash varies greatly, the differences being 
 determined by the general abundance of the two eruptions, by the relative 
 preponderance of one or the other, and by the extent of the petechise. 
 The spots and mottling together constitute the " mulberry rash" of Jenner. 
 The eruption usually appears first on the sides of the chest or abdomen 
 and spreads in a brief time over the body and limbs. It rarely occurs upon 
 the neck or face. It may first appear upon the back of the hands. The 
 roseola-like rash may be absent altogether, the faint subcuticular mottling 
 alone being present. The entire absence of eruption is very rare. Sudamina 
 are not common. 
 
 The odor surrounding the patient has been regarded as characteristic. 
 
 Stage of Nervous Prostration. — During the second week the 
 
 depression becomes profound. Headache passes into delirium and the 
 
 impairment of the mental powers is extreme. Drowsiness and stupor are 
 
 marked and in severe cases there is a tendency to coma. The delirium 
 
 
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 215. — Typhus fever — fatal on 16th day 
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TYPHUS FEVER. 643 
 
 may be low and wandering or noisy and boisterous. Stupor alternates 
 with sleeplessness. Coma vigil, subsultus tendinum, and picking at the 
 bedclothes may occur. The tongue is dry, fissured, and crusted. Sordes 
 collect upon the teeth and lips. The conjunctivae are deeply injected; 
 the pupils are contracted; deafness is often present. The flushing of the 
 face gives place to a dusky pallor and emaciation progresses. There is 
 cough and rales are heard in all parts of the chest. Hypostatic congestion 
 occurs in severe cases. The heart's action is faint and indistinct; the 
 pulse small, weak, often difficult to count — ranging from 112-140 or more. 
 A systolic murmur in the mitral area is not infrequent. The area of splenic 
 dulness is increased. The state of the bowels varies from constipation to 
 irregular, scanty dejections or moderate diarrhoea. The urine is decreased 
 in amount, high colored, and frequently albuminous. In severe cases the 
 discharges are passed involuntarily or there is retention of urine. Areas 
 of the skin subjected to pressure show a tendency to slough. The surface 
 now becomes cooler and is often moist. 
 
 In malignant cases death occurs in the course of a few days — typhus 
 siderans; more commonly between the tenth and seventeenth days. The 
 mode of death is by coma or by asphyxia in consequence of sudden pul- 
 monary engorgement or by failure of the heart, the pulse becoming 
 imperceptible, the surface cold, livid, and bathed in sweat. In the milder 
 cases and especially in children the rash is slight, petechise are absent, and 
 defervescence takes place at the end of the first or the beginning of the 
 second week. In the average cases defervescence takes place about the 
 fourteenth day by crisis, the temperature falling in a single night or in 
 the course of twenty-four or forty-eight hours to the normal or even 
 below it. The convalescence is rapid. Relapse is extremely rare. 
 
 Complications and Sequels. — Laryngitis, bronchitis, and broncho- 
 pneumonia are common. Gangrene of the lung may occur. Independently 
 of scurvy, which has been a frequent concomitant in typhus epidemics, 
 bleeding from the nose, gums, bowels, urinary passage, and the vagina has 
 been noted, as well as the spitting and vomiting of blood. In certain 
 epidemics gangrene of the extremities, the nose, and the genitalia, and 
 cancrum oris have occurred. Septic parotitis and arthritis occur and 
 extensive subcutaneous abscesses. Various palsies are met with. 
 
 Diagnosis. — The direct diagnosis of typhus during epidemics is 
 usually a simple matter. In early or isolated cases the nature of the disease 
 must remain in doubt until the appearance of the eruption. The abrupt 
 onset, initial chill, and sudden rise of temperature are important. The 
 critical defervescence about the fourteenth day is characteristic. 
 
 Differential Diagnosis.— Enteric fever (see p. 634). Relapsing 
 FEVER in its great epidemics has prevailed in connection with typhus. 
 The stage of complete apyrexia, the clear mind, epigastric pain and tender- 
 ness, absence of eruption, the low death-rate, and the spirochsetai of Ober- 
 meier serve to differentiate this disease from typhus. Cerebrospinal 
 FEVER may at the onset resemble typhus. Associated headache, vomiting, 
 and painful rigidity of the muscles of the back of the neck, Kernig's sign, 
 and in fatal cases characteristic lesions are of diagnostic importance. The 
 presence of the Diplococcus intracellularis meningitidis in the fluid with- 
 
644 MEDICAL DIAGNOSIS. 
 
 drawn by lumbar puncture will determine the question. Plague. — 
 Nausea and vomiting, pallor, and the early appearance of glandular swellings 
 are characteristic. The duration of the plague is much shorter than that 
 of typhus and the mortality greater. Malaria. — The malignant malarial 
 fevers of tropical and subtropical climates occasionally present strong 
 resemblances to typhus. These fevers are, however, endemic, not conta- 
 gious, unattended by specific eruptions, show greater enlargement of the 
 spleen and in the blood the malarial parasite. Measles and typhus in 
 children are attended by a somewhat similar eruption about the fourth 
 day of the attack. In measles catarrhal phenomena are prominent during 
 the stage of invasion; the eruption, which first shows itself upon the face, 
 is brighter in its tints and very rarely petechial. Alcoholism. — Certain 
 forms of alcoholism are attended by trembling delirium like that occasion- 
 ally seen in typhus. Shivering, headache, pains in the limbs, fever, and 
 eruption are absent. 
 
 Prognosis and Mortality. — The mortality ranges from 10 to 20 per 
 cent. It is much influenced by age; not exceeding 4 per cent, under ten 
 years and rising above 50 per cent, after sixty. Among individual peculi- 
 arities unfavorably affecting the prognosis are intemperate habits, disease 
 of the kidneys, gout, obesity, and mental depression. 
 
 III. RELAPSING FEVER. 
 
 Fehris Recurrens; Sjpirillum Fever. 
 
 Definition. — An acute, infectious, epidemic disease caused by the 
 spirochseta of Obermeier, characterized by a febrile paroxysm of five to 
 seven days terminating by crisis, an interval of complete apyrexia of 
 about the same length of time and one oi" more abrupt relapses. There 
 are no characteristic anatomical lesions. 
 
 Relapsing fever has prevailed extensively in Europe and particularly 
 in Ireland, usually in association with typhus fever. It has occurred in 
 India and other tropical countries. Relapsing fever has never taken 
 foothold in America. 
 
 Etiology. — Predisposing Influences. — The conditions favoring the 
 development of relapsing fever are those which predispose to typhus. 
 Destitution, filth, and overcrowding play the most important part. The 
 Irish writers have especially insisted upon the connection between this 
 fever and famine. Parry, on the other hand, found the patients in the out- 
 break in Philadelphia with a single exception well fed and in a position to 
 obtain a plentiful supply of milk, meat, and eggs, or other articles of diet 
 that were ordered. Climate has no direct influence upon the development 
 or propagation of relapsing fever. The season of the year is "without influ- 
 ence. Age, sex, and occupation are likewise without influence except that, 
 as in the case of other directly contagious diseases, attendants upon the 
 sick, including medical men, are exposed to constant danger of con- 
 tracting the disease. In the great Irish outbreaks a large proportion of 
 the cases admitted to the hospitals were wandering musicians, pedlers, 
 beggars, and tramps. 
 
RELAPSING FEVER. 
 
 645 
 
 The Exciting Cause. — Obermeier in 1873 demonstrated in the 
 blood an organism now recognized as the specific cause of relapsing fever. 
 This micro-organism is a slender spirillum or spirochseta varying in length 
 from 16 to 40 ix, twisted spirally in from ten to twenty turns. In fresh 
 blood it is very active. Under a low power it shows itself by the commo- 
 tion among the blood-corpuscles, caused by its rapid movements. Culture 
 experiments have not been satisfactory. Koch, however, observed the 
 formation of tangled masses and an increase in the length of the spirochseta 
 in blood-serum. These micro-organisms are present in the blood only 
 during the febrile paroxysm. About the time of the crisis they disappear 
 and are not found during the apyi-exia. At this period minute, highly 
 refractive bodies are seen in the blood which have been thought by some 
 observers to be spores, by others debris of the organisms, masses of which 
 may still be discovered in the tissues of the spleen. Upon the occurrence 
 of relapse active spirochsetse are again 
 found in the blood. Relapsing fever 
 may be produced in man by inoculation 
 with the blood of a patient, and several 
 instances are recorded where infection 
 has followed wounding of the hands at 
 autopsies. Koch, VanDyke Carter, and 
 others have produced the disease in 
 monkeys by inoculation. Tictin, in 
 Odessa, suspected suctorial insects to be 
 the medium of transmission of the dis- 
 ease and was able to produce an attack 
 in a healthy monkey by inoculation of 
 blood sucked by a bed-bug from an 
 infected monkey. This observation ex- 
 plains many facts relating to the spread 
 of the disease. In monkeys killed ten hours after the crisis the parasites 
 are found in the phagocjrtes in the spleen. They have not been found in 
 the secretions or excretions. In the case of abortion they have been 
 found in the blood of the foetus. 
 
 No immunity from subsequent attacks is experienced by those who 
 have suffered from relapsing fever. Second and third attacks in the 
 same individual within the course of a few months have been observed 
 in many epidemics. 
 
 Symptoms. — The period of incid^ation under ordinary circumstances 
 varies from five to seven days. It may exceptionally be only twenty-four 
 hours, or twelve or fourteen days. 
 
 The Primary Paroxysm. — Prodromes are as a rule absent. The 
 onset is marked by chills or chilliness, rapid rise of temperature, headache, 
 and pain in the back and limbs. Sweating is common. Appetite is lost 
 and nausea and vomiting are common, sometimes persistent. The tongue 
 is usually moist, covered with a thick white or yellowish-white fur. It is 
 apt to continue in this condition throughout the paroxysm. In a small 
 proportion of the cases it becomes dry or shows a dry brownish streak in 
 the middle. The bowels are as a rule constipated. In a considerable pro- 
 
 FiG. 216. — Spirillum of relapsing fever in blood. 
 
646 
 
 MEDICAL DIAGNOSIS. 
 
 portion of the cases jaundice occurs. There is no characteristic eruption. 
 Sudamina appear and facial herpes occasionally occurs. As early as the 
 second day there is distress in the epigastric zone. The liver and spleen 
 are now found to be enlarged, the latter reaching some distance below the 
 ribs. There is marked tenderness in the splenic and hepatic areas. General 
 muscular pain and soreness constitute prominent symptoms of the disease. 
 These pains are especially severe in the calves of the legs. They are present 
 when the body is in repose but are aggravated both by movement and pres- 
 sure. The mind is usually clear; delirium rare. Sleeplessness is a dis- 
 tressing symptom. Epistaxis may occur but is not common. The fever is 
 intense, 104°-107° F. (40°-41.7° C), and subcontinuous in type. The pulse 
 is frequent, 110-130. It is of moderate fulness and tension, often quick, and 
 sometimes dicrotic. About the fifth to the seventh day, sometimes as early 
 as the third, or again as late as the tenth day, crisis occurs. The deferves- 
 cence takes place in the course of a few hours and is frequently attended 
 
 by profuse sweating or diarrhoea. 
 The temperatui'e may fall several 
 degrees below the normal. In rare 
 instances the crisis is attended by 
 transient violent delirium. In fee- 
 ble persons collapse may occur. 
 The urine not infrequently contains 
 albumin. 
 
 • The Intermission. — The crisis 
 nearly always sets in during the 
 night. The patient in the course 
 of a few hours experiences remark- 
 able relief and very often declares 
 himself quite well. The pains, 
 headache, and gastric symptoms 
 There is first a feeling of weakness 
 This period usually lasts about 
 
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 promptly disappear with the fever. 
 
 but strength augments from day to day. 
 
 a week. In some instances it does not exceed four or five days. 
 
 a limited number of cases the relapse does not occur. 
 
 The Relapse. — Between the twelfth and twentieth days from the 
 beginning of the attack, but in by far the greater number of cases on or 
 about the fourteenth day, the patient, with the same suddenness as before, 
 again falls ill. The relapse sets in usually at night. The symptoms are a 
 repetition of those of the primary paroxysm. Usually they are somewhat 
 less severe and the relapse is of shorter duration, being commonly about 
 three days, sometimes not more than twenty-four hours. Occasionally a 
 second relapse, less frequently a third, occurs and in very rare instances 
 a fourth has been noted. 
 
 Convalescence. — At the termination of the disease, especially after 
 repeated relapses, the patient is much prostrated, there is marked ema- 
 ciation, and the convalescence is tardy, weeks often elapsing before the 
 health is restored. 
 
 Complications and Sequels Mild bronchitis is not uncommon. 
 
 Pneumonia has been frequent in some of the epidemics. Chronic valvular 
 
VARIOLOUS DISEASES. 647 
 
 disease and myocarditis render the patient liable to sudden death from 
 syncope. The sudden swelling of the spleen may cause rupture of its 
 capsule. Nephritis is a rare complication. Hsematemesis and hematuria 
 have been noted. Parotid bubo has been a prominent complication in 
 some epidemics. Pregnant women almost invariably abort or miscarry 
 during the course of relapsing fever. This accident exceptionally occurs 
 in the first paroxysm, commonly in the second. The foetus even at the 
 approach of term perishes and the life of the mother is often, though not 
 invariably, lost. Forms of ophthalmia have been common sequels in some 
 of the epidemics. Palsies may occur as the result of peripheral neuritis. 
 
 Diagnosis. — The direct diagnosis rests upon the abrupt onset, high 
 temperature, enlargement of the liver and spleen, the critical defervescence 
 at the end of five to seven days, and the occurrence of relapse. The presence 
 of spirochsetse in the blood renders a doubtful diagnosis positive. Lowen- 
 thal used the serum test upon active spirilli with positive results in 30 out 
 of 39 tests. In 14 cases he was able by this method to make a diagnosis 
 after the disease was past, thus determining the true nature of a previous 
 illness of doubtful character. 
 
 Prognosis. — The prognosis is, as a rule, favorable. The mortality in 
 different epidemics varies between two and four per cent. Death may 
 occur from the intensity of the fever and the consequent exhaustion, 
 usually at the close of the relapse, or by progressive exhaustion after 
 repeated relapses. It may occur from collapse at the time of crisis. 
 
 IV. THE VARIOLOUS DISEASES. 
 Variola — Smallpox. 
 
 Definition. — An acute, infectious, endemic and epidemic disease, 
 highly contagious, characterized by. fever of typical course and a general 
 eruption which passes through the progressive stages of macule, papule, 
 vesicle, pustule, and crust. 
 
 Etiology. — Predisposing Influences. — Smallpox may be regarded 
 as the prototype of contagious diseases. It is endemic and in the absence 
 of vaccination occasionally epidemic in every climate and among all races. 
 Outbreaks are more common in the great centres of population, but when 
 the disease is transported to countries in which it has never or not recently 
 prevailed, as in Iceland or in North America among the aborigines, it has 
 raged as a veritable scourge. The negro races are peculiarly susceptible 
 and suffer more severely than whites. 
 
 Age confers no immunity. The foetus in utero may develop the 
 disease if the pregnant mother has contracted it. Miscarriage as in 
 other grave infections is liable to occur and the foetus may be born with 
 the signs of the disease or the child at term may develop it within the 
 period of incubation. In rare instances the foetus may bear the scars. 
 Sometimes the child in a smallpox hospital is born without signs of the 
 disease, and may, if at once vaccinated, escape. Such children are very 
 delicate. Welch has seen a case at the age of eighty-three. Sex is with- 
 out influence. The menstrual period and pregnancy are supposed to 
 
648 MEDICAL DIAGNOSIS. 
 
 render individuals especially liable to contract the disease. Questions 
 relating to vaccination and revaccination and exposure render generali- 
 zations in regard to these conditions useless. Previous disease has no 
 influence. Neither acute nor chronic affections confer immunity, save in 
 so far as patients suffering from acute infections such as scarlet or enteric 
 fever, measles, or influenza are less exposed to the contagion in limited 
 epidemics than persons going about. 
 
 The Exciting Cause. — Bodies resembling protozoa in the lesions 
 were first described by Guarniere — Cytoryctes variolce. Later Councilman 
 and his associates demonstrated a protozoon with a cytoplasmic stage and 
 a double cycle and small structureless bodies in the lower layer of the 
 epithelial cells. Various observers have confirmed these findings. These 
 organisms bear a definite relation to the lesions and the hypothesis that 
 they are the cause of the disease is tenable. 
 
 The infecting principle is thrown off in the expired air and in the 
 exhalations from the skin, in the secretions and excretions, and in the 
 crusts of the unruptured and ruptured pocks formed during desiccation. 
 The disease is transmissible during the whole course of the attack from 
 the initial stage, before the appearance of the exanthem, until the dried 
 crusts have entirely separated and the person and clothing of the patient 
 have been disinfected. It may be communicated by approach, contact, 
 by a third person himself immune, and by any articles serving as fomites. 
 The dried scales and pus and the discharges from the nose and mouth 
 floating in the air as dust play the chief role in the dissemination of the 
 virus, and it is by this means that transmission through the atmosphere, 
 in the absence of any communication, has taken place at distances of one 
 hundred metres or more. It is inoculable by means of the lymph of the 
 vesicles, pus, crusts, and the blood — the contents of the vesicles being most 
 virulent at the time when turbidity appears, the blood during the early 
 stages of the attack. The corpses of those dead of variola communicate 
 the disease to susceptible persons not only in the performance of autop- 
 sies or dissections but also in their ordinary disposal for burial. The danger 
 is greatest in the immediate proximity of cases, but under certain condi- 
 tions it extends to remote distances. In this connection the part played 
 by flies and other insects is not to be overlooked. The poison is not 
 only virulent, it is also in the highest degree tenacious and persistent. 
 Infected clothing that has been packed away may after several years give 
 rise to the disease and thus become the unsuspected cause of outbreaks 
 in localities long free from the disease. Cases have been traced to baled 
 rags brought from distant countries as an article of commerce. It clings 
 to articles of furniture, carpets, and rooms, and is liable in times of epidemics 
 to infect cabs and other public conveyances. 
 
 The usual mode of access is by way of the inspired air. The suscep- 
 tibility to the disease is in the absence of vaccination almost universal. 
 Natural immunity has, however, been observed, and very rare instances 
 are now encountered in which, vaccination having been unsuccessful, 
 even when repeated, the individual has failed to contract variola upon 
 exposure. Temporary immunity in unvaccinated persons has also in 
 rare cases been observed. An acquired immunity results from the attack. 
 
VARIOLOUS DISEASES. 649 
 
 In most instances it is permanent. Second attacks are exceedingly rare 
 and third attacks almost unknown. Louis XV, of France, who had small- 
 pox at fovu'teen, died of a second attack at the age of sixty-four. The 
 immunity acquired by vaccination is of variable duration, the limit of 
 which varies between five and ten years. 
 
 Variola is transmissible to monkeys by inoculation, and among the 
 domestic animals, the cow and horse, a local reaction takes place. The 
 variolous disease of sheep is analogous to but not identical with smallpox 
 in the human body. 
 
 Symptoms. — Cases of smallpox present wide variations in intensity 
 and clinical manifestations, from a malady trifling in itself to an over- 
 whelming illness terminating in death as early as the third or fourth day. 
 The differences mainly but not exclusively appear at the time of the erup- 
 tion, the symptoms of the stage of invasion being much more constant. 
 For purposes of description the following scheme is convenient: 
 
 A. Variola vera — Smallpox. 
 
 (a) V. discreta — Discrete smallpox. 
 
 (b) V. confluens — Confluent smallpox. 
 
 (c) V. hsemorrhagica — Hemorrhagic smallpox, 
 
 i. Purpura variolosa, 
 ii. V. pustulosa hsemorrhagica. 
 
 B. Variola modificata — Modified smallpox. 
 
 (a) Varioloid. 
 
 (b) Variola sine eruptione. 
 
 The period of incubation varies from five to fifteen days. In the 
 majority of cases it is twelve or thirteen days. The incubation is apt to 
 be shorter in the malignant forms of the disease. At the time when inoc- 
 ulation was practised the local reaction and constitutional symptoms 
 frequently appeared toward the end of the third or during the fourth day. 
 Prodromes are as a rule absent. 
 
 The course of the attack may be divided into the stage of invasion, 
 the stage of eruption, and the stage of desiccation and decrustation. 
 
 L Invasion. — The initial symptoms are acute, usually intense, excep- 
 tionally mild. There is no constant relation between the severity of 
 this stage and the gravity of the subsequent course of the attack. The 
 mildest varioloid may begin with violent symptoms. On the other hand, 
 symptoms of slight intensity at the onset are not often followed by con- 
 fluence or grave hemorrhagic conditions. The attack usually begins 
 with a chill which may be repeated several times during the first twenty- 
 four hours. In young children a general convulsion may take the place 
 of the chill. Severe headache usually frontal, dizziness, pain in the back, 
 and vomiting occur. The temperature rises in the course of some hours to 
 103°-104° F. (39.5°-40° C.) and frequently reaches maxima of 105°- 
 106° F. (40.5°-4Ll° C). Its type during the stage of invasion, namely, 
 until the signs of eruption begin to appear, is subcontinuous, with slight 
 morning remissions. The respiration and pulse are accelerated, the former 
 not infrequently reaching 30-36 per minute, the latter 120-140. The 
 pulse may be full and bounding; in grave and malignant cases it is often 
 
650 MEDICAL DIAGNOSIS. 
 
 feeble and soon becomes irregular and intermittent. The skin is hot 
 and dry, the cheeks reddened, the conjunctiva injected. The tongue is 
 at first slightly swollen, indented by the teeth, and covered with a thick, 
 moist, yellowish-white fur. Pharyngitis appears early and there is pain 
 upon swallowing. The breath is foul. Thirst, loss of appetite, and nausea 
 sometimes leading up to repeated vomiting, accompany the fever. The 
 nervous symptoms of the onset persist throughout this stage. Headache, 
 dizziness, and pains in the back and limbs become even more severe. 
 Insomnia alternates with light slumber and delirium, sometimes wandering, 
 sometimes furious. The lumbosacral pain is excruciating and during an 
 epidemic, when associated with high fever, headache, and vomiting, is of 
 diagnostic importance. In severe cases occasionally there is marked pre- 
 cordial oppression. Physical examination of the heart and lungs yields 
 negative results. Exceptionally a few scattered rales are heard. The 
 area of liver dulness is not increased. The spleen is usually palpable; 
 it may remain normal in cases of varioloid and in hemorrhagic cases. 
 Constipation is the rule. The urine is scanty and high colored. Febrile 
 or toxic albuminuria is common. Hsematuria is a frequent attendant 
 condition in purpura variolosa. The blood shows no characteristic changes. 
 It does not tend to form rouleaux. There is rapid disintegration of red 
 cells ; during the fever they are normal or increased, but upon the occur- 
 rence of defervescence the number of red cells diminishes suddenly. 
 Regeneration takes place slowly. In hemorrhagic cases the anaemia comes 
 on quickly and is proportionate to the amount of blood extravasation. 
 There is no leucocytosis in the mildest cases such as occur in vaccinated 
 persons nor in the initial stages of graver cases. Leucocytosis does not 
 appear in the absence of complications until suppuration takes place, and 
 is due to infection by pus organisms and not to the poison of variola itself. 
 Menstruation is excessive and if the onset of smallpox occurs toward its 
 close the flow is increased and prolonged. 
 
 During this stage the so-called initial or accidental rashes occur. They 
 are more common in some epidemics than others, but are encountered 
 in from ten to fifteen per cent, of all cases. Two varieties may be recog- 
 nized which differ in form, distribution, and in prognostic importance. 
 The more common, roseola variolosa, is macular^ suggesting the eruption 
 of measles, though it does not present the characteristic papules nor their 
 grouping in crescents. This rash usually appears upon the second day and 
 disappears within twenty-four hours, never persisting after the appear- 
 ance of the pocks. It comes out, as a rule, first upon the face, next upon 
 the body, and finally in abundance upon the extremities. It is full)* 
 developed in the couise of some hours and then fades somewhat more slowly. 
 It is more common in mild than in severe cases. The second form, ery- 
 thema variolosa, is much less common. It appears early, usually upon the 
 first da}', and may in some cases antedate the fever and other constitutional 
 phenomena. It consists of a vivid dark crimson efflorescence, throughout 
 which are scattered numerous purpuric spots of varying size, — hemor- 
 rhagic erijthe^na. The distribution of this rash is remarkable. The regions 
 involved constitute the "triangles of Simon," of which the first, the more 
 common, has its base line across the abdomen, its lateral boundaries along 
 
VARIOLOUS DISEASES. 651 
 
 the inner portions of the thighs, and its apex at the knees; the second, 
 of which there are usually two, occupy the lateral thoracic region, the 
 axillae, a portion of the inner surface of the arm, and extend forward upon 
 the chest. This rash lasts until after the true exanthem appears. It grad- 
 ually fades, the purpuric spots more slowly than the surrounding erythema. 
 Within the limits of these triangles the variolous exanthem frequently 
 comes out less abundantly than elsewhere upon the surface of the body. 
 Some observers, as Hebra, noted this form of the initial rash more commonly 
 in females. It is of unfavorable prognostic omen. The duration of the 
 stage of invasion is three days. In rare cases the eruption may first appear 
 toward the end of the second day; more rarely still, not until toward the 
 close of the fourth day. 
 
 2. The Stage of Eruption. — From the time of the appearance of the 
 exanthem the divergence of the clinical varieties begins. The essential 
 difference between variola vera or true smallpox and variola modificata or 
 varioloid consists in the fact that in the former suppuration takes place 
 in the fully developed pocks, with well-marked secondary fever, while in 
 the latter most of the pocks undergo involution from the vesicular stage 
 without further constitutional disturbance. 
 
 A. Variola Vera. 
 
 (a) The Discrete Form. — About the end of the third or the beginning 
 of the fourth day the eruption appears. It shows itself first upon the 
 face and scalp, particularly at the edge of the hair, and in some cases upon 
 the wrists. It spreads downward over the trunk and extremities. By the 
 close of the third day of the eruption and sixth of the attack it is fully 
 developed and the surface is more or less thickly covered with pocks, which 
 are more abundant and advanced upon the face, where they first appeai'ed, 
 than elsewhere. Here and there are to be seen scattered individual pocks 
 that appear later than those which surround them. The exanthem is 
 often conspicuously copious in local areas which are submitted to habitual 
 pressure by the clothing, as the collar, corset, or garters, or recently irri- 
 tated by some application, as iodine or a sinapism. It is usually less abun- 
 dant in the hypogastric region and inner surfaces of the arms and thighs 
 than elsewhere and upon the lower than the upper extremities. 
 
 As the eruption comes out the temperature falls, the constitutional 
 symptoms subside, and the patient feels so much better that he regards 
 himself as convalescent. 
 
 The evolution of the pock is as follows: The macule consists of a 
 red spot, disappearing upon pressure and varying in size from the head 
 ,of an ordinary toilet pin to a split pea. The color and distribution of the 
 rash at this period suggest measles and the differential diagnosis, especially 
 in adults, may be difficult. Within twenty-four hours a distinct hard 
 papule appears which feels like a shot embedded in the skin. This rapidly 
 becomes acuminate and there develops at the summit a minute vesicle 
 with clear contents, which gradually extends to the size of the papule 
 and becomes tense from the increase of contained lymph. The greater 
 number of the fully developed vesicles present a well-marked and highly 
 
652 
 
 MEDICAL DIAGNOSIS. 
 
 characteristic central depression — primary umbilication. At the centre of 
 this depression may be found in many but not in all of the pocks a hair 
 follicle or the duct of a sebaceous gland. Finally the clear, opalescent 
 contents become cloudy, then opaque and yellow, the vesicle is converted 
 into a pustule — stage of 7naturation — and with this change the umbilica- 
 tion disappears and the fully developed pock becomes hemispherical. 
 The pustule is surrounded by a distinct areola several millimetres in width 
 and the skin is slightly swollen. By the third day the pock has reached 
 its full development and enters upon the stage of involution or desiccation. 
 Resorption of the contents rapidly takes place, the roof of the pustule 
 
 
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 Fig. 218. — Discrete smallpox. Moderate fever of suppuration ; recovery. — Royer. 
 
 sinks in, — secondary vvibilication, — hard, yellowish-brown or blackish 
 crusts form, which gradually separate, leaving abruptly defined, shallow 
 scars, with glistening red bases, which in the course of time become white 
 and finally disappear. If the cutis has been implicated permanent scars — 
 pittings — are formed. The resulting disfigurement in ordinary discrete 
 smallpox is commonly slight. 
 
 The time occupied by the successive stages is approximately as fol- 
 lows: macular one day; papular one day; vesicular three days; pustular 
 three days; desiccation five to ten days. Puncture of the vesicles with 
 a fine needle is followed by the escape of a portion only of its lymph, which 
 is enclosed in several spaces limited by septa. Upon the palms and soles 
 the pocks are as a rule scanty and owing to the thickness of the epidermis 
 
VARIOLOUS DISEASES. 
 
 653 
 
 they remain for some time deeply embedded. Early in the second week 
 of the attack with the maturation of the pocks secondary fever and more 
 or less severe constitutional symptoms occur. The skin is swollen, tense, 
 and sore, especially upon the face, the eyelids are tumid, and the counte- 
 nance greatly disfigured. There is marked leucocytosis. The secondary 
 fever rises rapidly to about the range of that of the initial stadium and 
 falls by lysis which in many cases is rapid so that defervescence is complete 
 and the patient enters upon convalescence in thirty-six or forty-eight hours, 
 namely, about the eleventh or twelfth day of the attack. The fever may, 
 however, last several days. Delirium is common in severe cases and sui- 
 cidal tendencies may show themselves. General septicaemia may develop. 
 
 The mucous membranes exposed to the air are involved usually at 
 the same time with the skin; not rarely earlier. The nasal chambers, 
 the buccal and pharyngeal surfaces, 
 the palate, and the larynx and tra- 
 chea are the seat of a more or less 
 abundant eruption. The tongue is 
 less frequently attacked, though now 
 and then pocks may be observed 
 upon the border and its under sur- 
 face. The anal, preputial, and vulvar 
 regions are later affected. The pocks 
 upon mucous membranes are at first 
 analogous to those upon the skin. 
 Under the influence of heat and 
 moisture in the vesicular stage their 
 roofs undergo maceration and dis- 
 crete superficial ulcers are formed. 
 The mucous lesions are associated 
 with catarrhal processes and add 
 greatly to the sufferings of the pa- 
 tient. Among the symptoms to 
 
 which they give rise are, in the mouth, pain and difficulty in swallowing, 
 hoarseness and aphonia, and excessive secretion, and about the meatus 
 urinarius in both sexes, distressing pain in micturition. These symptoms 
 are greatly aggravated in the stage of suppuration. Among persons 
 not protected by vaccination the discrete form has fortunately in all 
 times been the most common. 
 
 (b) The Confluent Form. — The pocks are closely set and run together, 
 especially upon the face, hands, wrists, and feet. This grave form of the 
 disease is encountered among those children and adults alike who have 
 not been protected by vaccination and revaccination. It has not been 
 especially common in particular epidemics nor is it transmitted from 
 person to person. On the other hand the mildest case of varioloid may 
 give rise to an infection resulting in variola confluens, while the latter 
 may cause in a partially protected person variola discreta or varioloid. 
 Personal predisposition must therefore enter largely into its causation. 
 
 The invasion symptoms usually are very severe. The eruption appears 
 some twelve or eighteen hours earlier than is common in the discrete 
 
 Fig. 219. — Discrete smallpox. — Royer. 
 
654 
 
 MEDICAL DIAGNOSIS. 
 
 form — in some cases by the end of the second or the beginning of the 
 third day. The earlier its appearance the greater the danger of confluence. 
 Its efflorescence is rapid so that by the end of the second day, the fourth 
 or fifth of the attack, it has invaded the entire body from the head to the 
 feet. The remarkable remission of fever and amelioration of the general 
 symptoms seen upon the appearance of the eruption in the discrete form 
 seldom occur. As a rule the improvement in this respect is only partial^ 
 fever persisting throughout the attack and becoming intense as suppuration 
 takes place. The skin is swollen and hypersemic; the individual pocks 
 
 
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 Fig. 220. — Confluent smallpox. Incomplete defervescence upon appearance of rash; severe secondary 
 fever; death on the 16th day. — Royer. 
 
 in the papular stage are small and crowded upon the skin; they are rapidly 
 converted into vesicles, which, increasing in size, soon become pustules. 
 During this process confluence takes place and extensive superficial abscesses 
 are formed. The face in severe cases presents the appearance of a thick 
 yellowish mask. Upon the arms and legs the pocks are numerous and 
 limited patches of confluence are sometimes seen, especially upon parts 
 subjected to pressure, as the buttocks, while they remain discrete upon 
 the trunk. The swelling of the hands and feet increases and these parts 
 are the seat of most distressing tension, pain, and tenderness. The eruption 
 is abundant upon the mucous membranes of the nose, mouth, pharynx, 
 and larynx. Confluence may give rise to extensive superficial ulceration. 
 Deep abscess formation may occur in the tonsils or in the retropharyngeal 
 
VARIOLOUS DISEASES. 
 
 655 
 
 tissues and necrosis of the laryngeal cartilages which may be associated 
 with oedema of the glottis. The cervical lymph-glands are enlarged and 
 tender. At this period purulent metastases in distant organs frequently 
 develop. Toward the end of the first or at the beginning of the second 
 week the fever rises to 104° F. (40° C.) or higher, the pulse to 120. De- 
 
 FiG. 221. — Confluent smallpox. — R,oyer. 
 
 lirium, very often maniacal, sets in; the patient is often with difficultv 
 restrained from leaving his bed, and with the signs of a profound toxtemia, 
 progressively feebler and more frequent pulse, subsultus, involuntary 
 discharges, or preagonistic hyperpyrexia, death closes the scene. When 
 recovery occurs, the cutaneous and constitutional symptoms undergo 
 gradual improvement, and irregular 
 fever may even in the absence of 
 complications prolong the convales- 
 cence into the fourth week. 
 
 3. Stage of Desiccation and 
 Decrustation. — The areola fades ; 
 the pustule sinks and becomes flat- 
 tened; its edge is sharply defined 
 against the surrounding skin and 
 separation gradually takes place, the 
 entire process occupying in V. dis- 
 creta two weeks or more and in V. 
 confluens a longer time. As a rule 
 the desiccation begins in the face 
 and scalp, where crusts may be seen, 
 while upon the extremities the exanthem is still in the pustular stage. 
 In some instances the desiccation takes place on all parts of the skin 
 at the same time. Many of the pustules break and the exuding con- 
 tents dry in the form of broad thin crusts. The process of desiccation 
 is attended by intense itching. The pocks upon the palms and soles are 
 limited in number and form hard circumscribed nodules in the thick epi- 
 
 Fir.. 222 —Exfoliation of the palmar epider- 
 mis contamma, embedded pocks occurring in the 
 later stage of severe smallpox. — After Welch and 
 Schamberg. 
 
656 
 
 MEDICAL DIAGNOSIS. 
 
 dermis, which in the course of three or four weeks undergo separation and 
 may be picked out. The hair usually falls out and in some cases the nails 
 are lost. In the confluent form the thick epidermis of the hands and feet 
 is sometimes cast off entire. The crusts upon separation sometimes reform 
 and the ulcerative lesions of the skin heal slowly by granulation. Upon 
 the face the resulting scars are much more disfiguring than the pitting of 
 V. discreta. They are extensive, of irregular outline, and intersected by 
 lines and bands which gradually undergo contraction, causing ectropion 
 of the eyelids and lips and interfering with the muscles of expression. 
 
 The appearance of the patient in the stage of maturation, particu- 
 larly in V. confluens, is horrible. The swollen face, thickly covered with 
 pustules and blebs, some of which are broken and exude a sticky pus, or 
 with a hideous mask of necrotic skin, the tumid and closed eyelids, the 
 distorted nose and lips, the disfigured ears, the foul secretions, and the 
 
 stench which surrounds the 
 wretched being create an impres- 
 sion not to be forgotten and merit 
 the popular adjective loathsome 
 applied to the disease. 
 
 (c) Hemorrhagic Forms. — i. 
 Purpura Variolosa. — This is the 
 most malignant form of variola. 
 It is fortunately comparatively 
 rare and in some epidemics no 
 cases have been observed. It may 
 occur at any period of life, is less 
 common among children than 
 grown persons, and affects as a rule 
 young and vigorous adults. The 
 influence of vaccination and especially of repeated revaccination is of the 
 greatest importance in preventing this clinical manifestation of the variolous 
 infection. The incubation is short — five to eight days. Prodromes, especially 
 lumbosacral pains, are not uncommon. The invasion is attended with pro- 
 found constitutional disturbance. Fever may be moderate, but there is great 
 prostration; the pulse is small and frequent, the respiration accelerated, and 
 the patient experiences a feeling of overwhelming illness. Headache and 
 backache are severe and precordial and epigastric distress are often asso- 
 ciated with vomiting and purging. The mind remains clear. Commonly 
 upon the second day, sometimes earlier, a diffuse, scarlatiniform rash makes 
 its appearance upon the lower part of the body and the extremities and 
 shortly thereafter upon the face. Purpuric spots of varying size rapidly 
 appear. Ecchymoses invade and frequently entirely cover the face. The 
 conjunctivae, eyelids, and loose tissues adjacent are distended with a san- 
 guinolent oedema and in a short time the greater part of the surface of the 
 body is involved in a livid, purplish-red discoloration. Mucous hemor- 
 rhages are common, epistaxis, bleeding from the gums, and haematuria being 
 the usual forms; haemoptysis, haematemesis, and melaena less frequent. 
 Metrorrhagia is common and pregnant women abort. In rare instances 
 death may take place without the occurrence of free hemorrhage. Very 
 
 Fig. 223. — Hemorrhagic smallpox. — Royer. 
 
VARIOLOUS DISEASES. 
 
 657 
 
 often there is no trace of the exanthem. If hfe be prolonged a few scattered 
 blood-tinged papules may be discovered upon the forehead and wrists. 
 This form of variola terminates in death within a week and very often 
 as early as the fourth or fifth day. 
 
 ii. Variola Pustulosa Hasmorrhagica. — This form is much more com- 
 mon than the preceding and usually occurs in feeble and cachectic per- 
 sons and drunkards who are not protected by vaccination. The attack 
 develops as an ordinary severe case of variola, which becomes hemorrhagic 
 in the vesicular or pustular stage. Exceptionally bleeding takes place 
 into some of the pocks while yet in the papular stage. The bleeding is 
 in many instances restricted 
 to the eruption upon the 
 lower part of the body and 
 the lower extremities. 
 Blood extravasation may 
 also involve the skin beyond 
 the pocks and free hemor- 
 rhages from mucous sur- 
 faces may lead up to the 
 fatal issue. The earlier in 
 the course of the attack the 
 hemorrhages appear the 
 graver the outlook. Death 
 commonly results at the end 
 of the first or in the begin- 
 ning of the second week. 
 Recovery may occur in 
 cases in which hemorrhage 
 into the pocks does not take 
 place until the stage of sup- 
 puration. A distinction 
 must be made between this 
 form of variola and cases of 
 V. discreta in which, owing 
 to mechanical violence, 
 pressure, or other accidents, 
 blood is extravasated into 
 a few vesicles or pustules. To the latter group must be referred cases of 
 hemorrhage into the pustules of the legs in patients who have gotten 
 out of bed during their delirium. Osier describes a series of six cases 
 in which hemorrhage into the vesicles was followed by " a rapid abortion 
 of the rash and speedy recovery." 
 
 
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 Fig. 224. — Severe varioloid. — Royer. 
 
 B. Variola Modificata. 
 
 (a) Varioloid. — This term is applied to the modified form of smallpox 
 which occurs in persons who possess a partial immunity as the result of 
 vaccination and revaccination. It is characterized anatomically by the 
 fact that the typical exanthem causes as a rule only superficial lesions 
 
 42 
 
658 MEDICAL DIAGNOSIS. 
 
 upon the skin and therefore rarely leaves permanent scars; clinically by 
 the absence of the stage of suppuration and the secondary fever and a. 
 shorter and more favorable course. The period of incubation is the same. 
 The onset is abrupt and in many cases the initial symptoms are severe. 
 Generally the symptoms of the stage of invasion are relatively mild. Head- 
 ache and backache may, however, be intense. If an initial rash appears it 
 is the macular variety — roseola variolosa. The papules appear toward the 
 close of the third or in the beginning of the fourth day, first upon the face 
 and then elsewhere, spreading from above downward. They vary in num- 
 ber from ten or twelve upon the face and hands to a copious eruption 
 distributed over the entire surface. AYithin forty-eight hours their appear- 
 ance is complete, although during the latter part of this period a few fresh 
 papules may be recognized here and there among those which first ap- 
 peared. The fever ends at once by crisis and the general symptoms rapidly 
 improve. The development of many of the pocks is arrested in the papular 
 stage; others abort early in the vesicular stage and in some few the con- 
 tents of the vesicles may become cloudy and slightly opacpie. Desiccation. 
 sets in early and goes on with rapidity. Convalescence is usually complete. 
 
 (b) Variola sine Eruptione. — During outbreaks of variola cases are 
 sometimes observed in which no trace of eruption can be discovered. The 
 diagnosis rests upon etiological as well as upon clinical grounds. A history 
 of exposure, sudden onset, fever, intense lumbosacral pains, and critical 
 defervescence upon the third day justify a provisional diagnosis of smallpox 
 without eruption. The transmission of the disease to others would render 
 the diagnosis positive. Variola sine eruptione occurs in young persons 
 who have been well vaccinated-and invariably runs a favorable course. 
 
 The modification of variola caused by artificial inoculation is no longer 
 encountered in western countries. About the eighth day local reaction was 
 manifest at the point of inoculation. Fever and constitutional symptoms 
 developed and were followed by a typical exanthem, not usually copious. 
 
 A rare anomaly in the pock is described under the name of horn-pox 
 or wart-pox — V. verrucosa. The eruption appears upon the third or fourth 
 day but instead of developing as usual the papules undergo desiccation 
 upon the fifth or sixth day and are converted into dense warty or horny 
 nodules. This change is more common upon the face than elsewhere. 
 
 Complications and Sequels. — The complications are not numerous 
 and mostly develop during the stage of suppuration. They consist mainly 
 of extensions of the suppurative inflammatory process in the skin or mucous 
 membranes or of metastatic infections. It follows that they are more 
 common and severe in proportion to the extent and intensity of the sup- 
 puration — in V. confluens than in V. discreta, and infrequent in varioloid. 
 Bed-sores and acute gangrene are frequent in severe cases. Erysipelas 
 is not uncommon. Phlegmonous inflammation of the skin may occur. 
 Furunculosis and acne are often troublesome diu-ing convalescence. Super- 
 ficial erosions in the larynx may in healing give rise to adhesions which 
 result in permanent hoarseness; the cartilages may be involved and acute 
 cedema of the larynx may cause sudden death. Lesions of the larynx 
 play an important part in the causation of bronchitis and bronchopneu- 
 monia which is perhaps the most common of the complications. Croupous 
 
VARIOLOUS DISEASES. 
 
 659 
 
 pne\imonia is infrequent; pulmonary abscess may occur. Purulent pleurisy 
 has been common in some epidemics. Cardiac complications are infrequent. 
 Myocardial changes are observed. An apex systoHc murmur may occur. 
 Pericarditis is rare. Simple endocarditis is not common in smallpox. 
 Malignant endocarditis has been in some instances found post mortem. 
 Venous thrombosis may occur during the later course of the attack. In 
 the digestive tract parotitis and inflammatory affections of the other sali- 
 vary glands occasionally occur. Their frequency varies in different epidemics. 
 Pseudomembranous angina is common in severe cases and especially in the 
 hemorrhagic forms. The vomiting of the initial stage is not apt to persist. 
 Diarrhoea is frequent, especially in children. Dysenteric symptoms are 
 
 
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 frequently mentioned by the older authorities but are rare at present. 
 Complications in the urinary tract are infrequent. Toxic albuminuria is 
 common; nephritis rare. Hsematuria is usual in the malignant cases. 
 Inflammation of the ovaries and of the testicles — orchitis variolosa — may 
 occur. ^ Pregnant women usually abort. Pysemic arthritis and acute 
 necrosis of bones or cartilages may, as in the other severe acute infections, 
 develop during the convalescence. Diabetes mellitus is a rare sequel. 
 
 The nervous system is especially prone to react to the variolous infec- 
 tions. In children general convulsions are common at the outset and may 
 be repeated. In adults and especially in alcoholics maniacal dehrium may 
 terminate in coma. Post-febrile insanity sometimes occurs. It is less 
 common than after influenza and enteric fever and commonly ends in 
 recovery. Epilepsy is a very rare sequel. Purulent meningitis and enceph- 
 
660 MEDICAL DIAGNOSIS. 
 
 alitis are likewise rare complications. Hemiplegia has been observed in 
 a few instances. Transient aphasia has been noted. Paraplegia may 
 occur at any time dm*ing the attack. It begins abruptly; is usually sub- 
 acute, and may involve the sphincters. In some instances the symptoms 
 have been those of acute ascending paralysis and the termination rapidly 
 fatal. The palsies of the lower extremities and the monoplegias observed 
 occasionally are manifestations of an infectious neuritis. Ataxic S3/mptoms 
 may occur. Paralysis of the soft palate analogous to that which follows 
 diphtheria sometimes occurs. Paralysis of individual muscles or muscle- 
 groups, as the deltoid, and circumscribed areas of cutaneous anaesthesia 
 have been described. 
 
 Otitis media purulenta is a frequent complication. It results from the 
 extension of the catarrhal inflammation by Way of the Eustachian tube. 
 It usually develops during the stage of suppuration. Exceptionally puru- 
 lent disease of the mastoid arises with necrosis of the bone, or the labyrinth 
 may be involved. Serious affections of the eye with resulting blindness 
 were common in former times. They are relatively infrequent at present 
 because of the greater attention now given to the early ocular lesions. The 
 conjunctivitis incident to the disease may become chronic. Diffuse kera- 
 titis may occur and result in ulceration and perforation with destruction 
 of the eyeball. Iritis and choroiditis are less common. In the purpuric 
 cases retinal hemorrhages may occur. Pocks develop very commonly 
 upon the outer surface of the eyelids and result in scar formation with 
 ectropion and its attendant evils. Much less commonly they involve the 
 palpebral conjunctiva and very rarely the ocular conjunctiva. Synechise 
 !hay result. 
 
 External and internal nasal deformities sometimes result from the 
 ulcerative processes and subsequent scar formation. Necrosis of the carti- 
 laginous sei3tum with perforation, occlusion of a nasal chamber, partial 
 adhesion of the soft palate, and loss of the sense of smell are among the 
 sequels of smallpox. 
 
 Diagnosis. — A correct diagnosis where there is a question of variola 
 is one of the most critical and important of the duties of the physician. 
 A mistake may be the cause of an extended and disastrous epidemic. 
 
 The DIRECT DIAGNOSIS of typical variola is unattended by difficulty 
 after the appearance of the eruption. In the atypical and modified forms 
 the difficulties are frequently insurmountable. During the prevalence of 
 an epidemic every case of sudden illness is suspected. The sudden occur- 
 rence of headache, rigors, intense backache, epigastric pain, nausea and 
 vomiting, and high temperature is important. The initial rashes may be 
 misleading. The measly rash — roseola variolosa — bears in many instances 
 some resemblance to measles, for which the disease may be mistaken. 
 More commonly, however, during an epidemic measles is mistaken for 
 variola. The scarlatinal rash — erythema variolosa. — lacks as a rule the 
 vividness of the eruption of scarlet fever and differs from it in distribution, 
 occupying the abdominocrural or pectoral triangles of Simon. In fact 
 the occurrence of this rash in connection with the foregoing symptoms 
 renders the diagnosis of smallpox almost positive. A history of exposure 
 and the absence of vaccination scars are of diagnostic importance. The 
 
VARIOLOUS DISEASES. 661 
 
 development toward the close of the third or at the beginning of the fourth 
 day of an eruption of red macules upon the face, scalp, and wrists, rapidly 
 becoming papular and feeling like shot embedded in the skin, coincidently 
 with a marked remission in the febrile movement, renders the diagnosis 
 positive. In any doubtful case, especially in the negro, the buccal and 
 faucial mucous membrane should be carefully examined. 
 
 In malignant hemorrhagic smallpox death may occur before the char- 
 acteristic rash develops. If the patient survive to the end of the third or 
 fourth day a few shrunken, shotty papules may be felt about the roots of 
 the hair and upon the wrists. 
 
 Differential Diagnosis. — Smallpox during its initial stage presents 
 some points of superficial resemblance to the following diseases: 1. Scarlet 
 Fever. — There is erythematous sore throat, more or less painful. The rash 
 is brighter and more intense than the erythematous initial rash of small- 
 pox, in which petechise are very commonly present. It appears first upon 
 the chest and throat and is rapidly diffused. 2. Measles. — The stage of 
 invasion is accompanied by marked catarrhal symptoms. The rash appears 
 about the fourth day but is distinctly maculopapular, lacking the shot-like 
 firmness of the variolous papule and showing a crescentic arrangement. 
 There is no remission in the febrile movement upon the development of 
 the rash. 3. Typhus. — The eruption is rare upon the face and when 
 present in this region is comparatively faint. The macules are not hard 
 or elevated. There is no fall of temperature upon the appearance of the 
 eruption. 
 
 During the vesicular and pustular stage smallpox may be mistaken 
 for: 4. Varicella. — Errors in diagnosis between these two diseases 
 are very common. In varicella initial symptoms are usually absent. The 
 eruption is always discrete and appears in successive crops. It is usually 
 not observed until it has reached the vesicular stage. The vesicles are 
 irregularly oval or circular, tensely distended with a transparent fluid. 
 They are clear, bright, and pearly. Primary umbilication does not occur, 
 but in rare cases, as the contents of the vesicles undergo resorption, the 
 roof of the vesicle falls in, giving rise to the condition known as secondary 
 umbilication. 5. Pustular Syphilides. — Individual pustules occasionally 
 bear a close resemblance to the variolous pock. The polymorphous char- 
 acter of syphilitic eruptions, their symmetrical distribution, their persist- 
 ence, the presence of mucous patches, the history of the case, and the 
 nature of the febrile movement when present serve to render the differ- 
 ential diagnosis a relatively easy matter. 6. Pustular glanders is 
 attended with malaise, pyrexia, and pain in the limbs. There is an eruption 
 of indurated red papules upon the summit of which pustules develop. 
 There is a fetid nasal discharge. The invasion symptoms and the course 
 of the disease are totally unlike smallpox. 7. Cerebrospinal Fever. — 
 The sudden onset, intense symptoms, and petechial rash may lead to errors 
 of diagnosis. Painful rigidity of the back of the neck and spastic con- 
 traction of the limbs may be present in both these conditions. Papules 
 should be carefully sought for at the roots of the hair and upon the wrists. 
 Photophobia, pupillary inequalities, strabismus, and very irregular fever 
 suggest meningitis rather than smallpox. Lumbar puncture is important. 
 8. Drug Exanthems. — Iodide of potassium, the bromides, and the local 
 
662 MEDICAL DIAGNOSIS. 
 
 use of croton oil may produce rashes suggesting smallpox, but the resem- 
 blance is extremely superficial and the true nature of these affections 
 becomes apparent upon examination. 
 
 Prognosis and Mortality. — In persons not protected by vaccination 
 smallpox is a very fatal disease. In the older epidemics the mortality 
 ranged from 40 to 60 per cent, and smallpox was dreaded alike from its 
 loathsomeness, its high mortality, and its serious sequels. At the present 
 time the mortality of smallpox is greatly influenced by: 
 
 1. Vaccination and Revaccination. — During the nineteenth cen- 
 tury smallpox epidemics diminished in the most remarkable manner in 
 extent and frequency and showed a correspondingly lowered mortality. 
 Nevertheless among the unvaccinated the gravity of the disease and the 
 death-rate are practically unchanged. MacCombie's statistics show in 3940 
 unvaccinated cases of all ages 1758 deaths — 44.6 per cent. Among 17,756 
 vaccinated cases 1441 deaths, a mortality of 8.1 per cent. Welch, Municipal 
 Hospital, Philadelphia, reported in 2831 cases of variola 1534 deaths^ a 
 mortality of 54.18 per cent., and in 2169 cases of varioloid 28 deaths, a 
 mortality of 1.29 per cent. In Sheffield in the outbreak of 1887-8, of 4703 
 cases 474, or 10 per cent., terminated fatally. Of 552 patients not vacci- 
 nated 274, or 49.6 per cent., died; while of 4151 vaccinated patients 200, 
 or 4.8 per cent., died. 
 
 The character of the vaccination is of great importance as affecting 
 the prognosis. The relative value of multiple or repeated vaccinations is 
 shown by McCombie's analysis of 11,724 cases. This author regards an 
 area of |- to J square inch of well-foveated surface as indicating efficient 
 vaccination. He found the mortality among cases with one good mark to 
 be 6.4 per cent.; among those with one indifferent mark, 16.7 per cent. 
 Among those with two good marks, 3.7 per cent.; among those with two 
 indifferent marks, 11.2 per cent. Among those with three good marks 3.7 
 per cent.; among those with three indifferent marks 7.4 per cent. With 
 four or more good marks 2.7 per cent.; with four or more indifferent marks 
 4.8 per cent., and concludes that the protection against a fatal attack is 
 three or four times greater among patients with efficient than those with 
 indifferently successful vaccination. W. M. Welch analyzed 5000 cases 
 with reference to the character of the cicatrices, whether produced in 
 primary vaccination or in revaccination, with the following result: The 
 mortality among persons having good scars was 8 per cent.; fair scars 14 
 per cent. ; those with poor scars 27 per cent. ; average mortality in persons 
 showing the cicatrices of vaccination 16 per cent.; mortahty among un- 
 vaccinated persons 58 per cent. 
 
 Death from smallpox is rare in persons whose primary vaccination 
 was efficient and in whom revaccination has been successful. These well- 
 established facts are of the greatest practical importance. 
 
 2. The Virulence of the Attack. — Smallpox modified by efficient 
 vaccination and revaccination is a comparatively trifling disease with a 
 death-rate but little exceeding 1 per cent, of all cases. Ordinary discrete 
 smallpox is a grave affection with a greath^ increased mortality. Con- 
 fluent smallpox is even more grave, the majority of the cases terminating 
 in death, and those recovering frequently suffering from serious, often 
 
VARIOLOUS DISEASES. 663 
 
 irremediable, sequels. Finally, the hemorrhagic form — jyurpura variolosa — 
 is invariably fatal. Petechial rashes and hemorrhagic phenomena are 
 especially unfavorable. A rise of temperature directly after the appear- 
 ance of the eruption is a bad sign. Continuing delirium, persistent high 
 temperature, and convulsions are of grave prognostic omen. 
 
 3. The Patient's Surroundings. — Unfavorable hygienic conditions, 
 overcrowding, poverty, and want greatly increase the mortality. 
 
 4. The Occurrence of Complications. — The compHcations of variola 
 affect the prognosis unfavorably. Certain epidemics have been attended 
 with an unusual death-rate in consequence of the frequent occurrence of 
 ordinary grave complications. The laryngeal and pulmonary compli- 
 cations are especially ominous. 
 
 5. Age. — Among the conditions unfavorably affecting the death-rate in 
 individual cases age is of great importance. In young children the disease 
 is peculiarly fatal. Unvaccinated infants in the first year mostly die, and 
 the mortality is high up to the tenth year. From ten to twenty years of 
 age there is a slight decrease in the death-rate, which after the thirtieth 
 year again rises. 
 
 6. Previous Illness. — Previous severe illness and alcoholism render 
 the prognosis unfavorable. 
 
 7. Pregnancy, — Pregnant women are especially liable to the disease 
 in the confluent and hemorrhagic forms. Abortion usually occurs and is 
 apt to be followed by septic infection. To this rule there are fortunately 
 occasional exceptions. The foetus may show a well-developed eruption 
 and quickly die or it may develop the eruption shortly after birth. In cases 
 in which abortion does not occur the child may undergo the disease in utero 
 and be after birth immune alike to vaccination and variola. 
 
 Vaccinia, Cowpox, Kinepox. 
 
 Definition. — An eruptive disease of the cow, communicable only by 
 inoculation and causing, when transmitted to the human being, local 
 reaction in the form of a pock and constitutional disturbances which are 
 followed by a more or less lasting immunity against smallpox. 
 
 Vaccination. 
 
 Definition. — The artificial inoculation of vaccine virus for the pur- 
 pose of producing immunity against smallpox. 
 
 Arm to arm vaccination was formerly very generally practiced in order 
 to perpetuate the lymph and secure its greatest purity. The use of crusts 
 came into vogue at a later period. Bovine vaccine lymph has now come 
 into general use, and has the advantage over the arm to arm method of 
 avoiding the opening of the vesicle and thus affording the opportunity for 
 accidental infection and of wholly eliminating the danger of syphilis and 
 other mfections. When it is necessary to use human lymph it should be 
 taken upon the eighth day from a typical unbroken vesicle in a perfectly 
 healthy child at least three months old. The vesicle must be pricked at 
 several points, care being taken not to draw blood. The lymph may be 
 
664 
 
 MEDICAL DIAGNOSIS. 
 
 in a preserved dry state upon sterilized bone points or slips. When required 
 for use the dry lymph is moistened by a few drops of warm sterilized water. 
 It may also be preserved in capillary glass tubes, each containing the 
 quantity required for one vaccination, sufficiently long to admit of sealing 
 in the flame of a spirit lamp, thin enough to enable them to be instan- 
 taneously sealed, and strong enough to be handled and transported. 
 
 Glycerinated Lymph. — The thorough incorporation of four parts of 
 a sterilized 50 per cent, solution of chemically pure glycerin in water with 
 one part of lymph or vesicle pulp, and the storing of this mixture in sealed 
 capillary glass tubes, protected from light for some weeks, is followed by 
 the destruction not only of the ordinary saprophytic bacteria found in the 
 lymph, but also of tubercle bacilli and the streptococcus of erysipelas. 
 
 Lymph thus treated is fully as effi- 
 cient as ordinary lymph. 
 
 Vaccinia produced by human- 
 ized lymph has a somewhat more 
 rapid evolution than that caused by 
 bovine virus and is attended with 
 milder constitutional symptoms. 
 
 The Technic. — The outer sur- 
 face of the arm near the insertion 
 of the deltoid is usually selected. 
 In infants the left arm is preferable. 
 In females the outside of the leg just 
 below the knee is sometimes chosen. 
 The surface must be washed, dried 
 with a soft towel, and the lymph 
 inserted by puncture, multiple super- 
 ficial crossed incisions, or after the 
 removal of the epidermis by scrap- 
 ing. The spots are to be rendered 
 moist by the exuding serum but care 
 should be taken not to draw blood. For this purpose a thoroughly sterilized 
 old-fashioned thumb lancet or an ordinary flat-headed surgical needle should 
 be employed. The insertion should be performed at two points about an 
 inch apart and the diameter of the abraded or scarified area should be about 
 one centimetre. The clothing should not be replaced until the serum has 
 thoroughly dried. A thin layer of sterilized gauze should be lightly applied 
 and held in place by means of adhesive plaster, not encircling the limb. 
 This should be occasionally renewed. The pock should be kept dry and 
 clean, and may be lightly dusted with starch or toilet powder. The new- 
 born should be vaccinated only during the prevalence of smallpox. Children 
 are commonly vaccinated in the course of the third month. In case of 
 failure the operation must be repeated. Persons exposed to the contagion 
 of smallpox should be immediately revaccinated. The immunity conferred 
 diminishes with time. Revaccination should be performed at the seventh 
 year of age, again at puberty, and from time to time as epidemics occur. 
 Typical Vaccination. — The period of incubation varies from three 
 to five days. At the end of this time local reaction shows itself in the form 
 
 Fig. 226.- 
 
 — Scars from an infantile vaccination. — 
 After Welch and Schamberg. 
 
PLATE XII. 
 
 ^ 
 
 3 
 
 • 
 
 4 
 
 S 
 
 I* 
 
 Typical Vaccination. 
 
 1. Papules. 2. Vesicles with clear contents. 3. Vesicles with opaque contents. 4. Fully developed 
 pocks with erythematous areola. 5. Crusts, i'.. Appearance immediately after sejiaration ot crusts. 
 
VARIOLOUS DISEASES. 
 
 665 
 
 of one or more reddish papules at the point of inoculation. These in the 
 course of five days develop into compound vesicles, the contents of which 
 are at first clear but later become opaque. By the eighth day the vesicle 
 is fully developed and is round or oval with prominent and well-defined 
 edges and a depressed or umbilicated centre. About the tenth day an 
 erythematous areola usually appears and the contents of the pock become 
 purulent. The surrounding skin is swollen, indurated, and tender. Scab- 
 bing now begins at the centre of the pock and rapidly extends toward its 
 borders. The areola fades about the end of the second week, and the pock 
 
 Fig. 227. — Two sisters suffering from .-smallpox. The one on the right was successfully vaccinated ia 
 infancy ; she contracted a mild varioloid and recovered without any scarring. The other, unvaccinated^ 
 developed a severe smallpox, and recovered, though considerably pitted. — After Welch and Schamberg. 
 
 is converted into a thick brownish crust which gradually becomes dry and 
 hard and separates between the twentieth and twenty-fifth days after the 
 vaccination, leaving a scar of a dusky red color which gradually becomes 
 white and pitted or foveated. The corresponding superficial lymphatic 
 glands, namely, the axillary or inguinal, as the case may be, during the 
 evolution of the pock become slightly enlarged and tender. 
 
 The constitutional reaction is commonly slight. It shows itself by 
 moderate fever, restlessness at night, loss of appetite, and irritability. 
 These phenomena usually appear upon the third or fourth day and con- 
 tinue until the early part of the second week. Erythema, roseola, or urti- 
 caria may develop at any time during the course of the vaccine disease. 
 These eruptions are usually transient. Leucocytosis shows itself about 
 the third day coincidently with the appearance of the local eruption, and 
 
666 MEDICAL DIAGNOSIS. 
 
 again about the time the pock reaches maturity. The resulting immunity 
 against vaccinia Hke that against variola varies in duration in different 
 individuals. In rare instances it is permanent, but as a rule successful 
 revaccination may be performed in the course of some years. The pock 
 of revaccination, however, lacks in most instances the typical develop- 
 ment of the primary vaccine lesion. The constitutional reaction in 
 revaccination is sometimes severe. If no characteristic lesion follows 
 the attempt at revaccination, the operation should be repeated once or 
 twice at short intervals. 
 
 Atypical Vaccinia in Man. — 1. Variations in the Number of Pocks. 
 
 (a) Supernumerary pocks occasionally develop in the vicinity of the 
 original vaccine lesion. 
 
 (b) Confluent pocks may in rare instances be formed by the coales- 
 cence of the supernumerary pocks either among themselves or with the 
 original lesions. 
 
 (c) Generalized vaccinia or vaccinal eruptive fever is less common. It 
 consists of a vaccine rash developing in various parts of the body, especially 
 about the wrists or on the back. Secondary pocks usually begin to develop 
 about the eighth or tenth day after vaccination and are often more abun- 
 dant on the vaccinated limb than elsewhere. The pocks appear in succes- 
 sive groups so that they may be seen in all stages of development. The 
 disease sometimes lasts several weeks. 
 
 (d) Vaccinal Eruptions Generalized by Autoinoculation. — Supernumer- 
 ary pocks may be produced by scratching with the nails after they have 
 been in contact with the ruptured vaccine pock. They may occur in any 
 part of the body and vary from one or two to many. The number is some- 
 times very great. They have been observed upon the cheek, lips, tongue, 
 buttocks, breast, and the genital organs. On the mucous surface of the 
 vulva the resulting ulceration may give rise to the suspicion of venereal 
 disease. 
 
 (e) Local vaccinal eruptions may arise at the seat of previously existing 
 cutaneous lesions, as impetigo, eczema, acne, or psoriasis. 
 
 2. Variations in the Size of the Pocks. 
 
 (a) Two or more of the primary vesicles caused by vaccination may 
 coalesce to form one large pock. 
 
 (b) The size of the pock may be increased by coalescence of supernumer- 
 ary pocks in the immediate neighborhood. 
 
 3. Variations in the Contents of the Pock. — In cachectic indi- 
 viduals the contents of the vesicle, instead of being clear and limpid at 
 the end of the first week, may be watery, hemorrhagic, or purulent. 
 
 4. Variations in the Evolution of the Pock. 
 
 (a) Acceleration. — The pock develops more rapidly in summer than in 
 winter. Its evolution is apparently hastened by idiosyncrasies on the part 
 of individuals and by the character of the lymph employed. 
 
 (b) Retardation. — Cases occur in revaccination in which vesicles ap- 
 parently aborted become active a week or more after the original insertion. 
 
 (c) Abortion. — The non-development of the pock is determined by the 
 im.munity of the patient, the quality of the lymph, and the skill of the 
 vaccinator. In revaccination a bright red papillary lesion, " raspberry 
 excrescence," sometimes develops about a week after the insertion of the 
 
VARIOLOUS DISEASES. 667 
 
 lymph. Vesicles do not form and the papules remain hard and dense for 
 several weeks. There is no areola, and healing ultimately takes place 
 without the formation of a scar. 
 
 5. Variations in the Involution of the Pock. — These anomalies 
 are determined by vaccinal injuries. Secondary infection may take place 
 at the time of the operation or subsequently if the pock is injured. It may 
 be due to the use of contaminated lymph or infected instruments or may 
 arise at a later period from other causes. Vaccination is not wholly free 
 from the danger of accident. Severe inflammation, suppuration, deep- 
 seated ulceration, or gangrene may occur in mismanaged cases. Erysipelas 
 is an occasional complication. Cellulitis, abscess formation, and septicaemia 
 may occur. These accidents are, however, not peculiar to vaccination. They 
 may arise in any lesion of the skin in default of proper antiseptic measures. 
 
 6. Variations in Healing and the Formation of Scar. — The 
 lesion of the skin caused by vaccination is usually fully healed by the end 
 of the third week. It may, however, remain open for some weeks. The 
 scar sometimes manifests hypertrophy or puckering or runs into keloid. 
 
 7. Transmission of Chronic Specific Disease by Vaccination. 
 
 A. Vaccination and Syphilis. — Vaccina syphilis. — Syphilis has been 
 transmitted by vaccination, but the number of well-authenticated cases is 
 limited. The general use of bovine lymph has rendered invaccinated 
 syphilis a remote possibility. It may, however, occur in consequence of 
 the use of lymph taken from an individual suffering from syphilis or from 
 contamination of the instrument or wound or it may be due to infection 
 from the vaccinator. The sequence of events is as follows: 
 
 If the subject be susceptible to vaccination the pocks may show no 
 departure from the normal course, but in some instances they abort. If 
 they be irritated, the vaccinal sore may become inflamed, suppuration may 
 occur, and the ulcers may scab over and again break out. Whether the 
 vaccination runs a typical or an atypical course, a chancre with indurated 
 base eventually forms at the point of inoculation, and the signs of general 
 infection at a later period. 
 
 Acland makes the following deductions from a well-known case of 
 autovaccinp,tion with vaccine virus from a syphilitic child; they are in 
 entire accordance with general observation. 
 
 (a) That vaccination can be successfully performed with lymph taken 
 from a source tainted with syphilis without necessarily communicating 
 that disease. 
 
 (b) That if syphilis be communicated in the process of vaccination it 
 does not follow that all the points of insertion will become infected. 
 
 (c) That the evolution of syphilis, as regards the primary and secondary 
 stages, is not necessarily disturbed; that it is neither accelerated nor re- 
 tarded by simultaneous vaccination. 
 
 (d) That no care in the selection of lymph obviates the risk of vaccinat- 
 ing from an obviously tainted source. 
 
 (e) That when syphilis is communicated by vaccination, the first ap- 
 pearance of the disease is at the seat of puncture. 
 
 B. Vaccination and Tubercle. — The communication of pulmonary 
 tuberculosis as a result of vaccination is of exceeding rarity. It may in 
 
668 MEDICAL DIAGNOSIS. 
 
 fact be doubted whether it has ever occurred. In well-regulated vaccine 
 laboratories the animals used are previously submitted to the tuberculin 
 test. It has been suggested that they should, after the collection of the vac- 
 cine material, be slaughtered and submitted to examination for tuberculous 
 lesions. In case of their presence, the vaccine material must be rejected. 
 In some few instances lupus has been observed at the seat of vaccination. 
 
 C. Vaccination and Leprosy. — The alleged cases of transmission of 
 leprosy by vaccination are open to serious doubt. 
 
 D. Vaccination and Cancer.— There are no authentic cases on record 
 in which cancer has resulted from vaccination or developed in the vaccina- 
 tion scar. 
 
 E. Vaccination and Tetanus. — The vaccine lesion, like other wounds 
 of the skin, renders the patient liable, under certain circumstances and the 
 absence of proper precautions, to tetanus infection. A limited number of 
 instances of fatal tetanus after vaccination are reported. 
 
 •Acland has arranged the dates at which various eruptions or complica- 
 tions may be looked for after vaccination, as follows: 
 
 1. During the first three days: erythema; urticaria; vesicular and 
 bullous eruptions; invaccinated erysipelas. 
 
 2. After the third day and until the pock reaches maturity: urticaria; 
 lichen urticatus; erythema multiforme; accidental erysipelas. 
 
 3. About the end of the first week, and generally after the maturation 
 of the pocks: generalized vaccinia — (a) by autoinoculation, (b) by general 
 infection; impetigo; accidental erysipelas; vaccinal ulceration; glandular 
 abscess; septic infections; gangrene. 
 
 4. After the involution of the pocks: invaccinated diseases, for 
 example, syphilis. 
 
 V. VARICELLA. 
 
 Chicken-pox. 
 
 Definition. — An acute infectious, endemic and epidemic disease of 
 childhood characterized by mild constitutional symptoms and a vesicular 
 exanthem which develops in irregular, successive crops. 
 
 Chicken-pox was formerly confused with smallpox and until recently 
 there have been those who regarded it as a greatly modified and very mild 
 variety of smallpox. It is now generally looked upon as an entirely dis- 
 tinct disease. One of these diseases never gives rise to the other; the 
 attack of one does not confer immunity against the other, and it is no rare 
 event for a person who has recently suffered from one to contract the other. 
 Vaccination confers no immunity against varicella, and children who have 
 recently suffered from varicella react to vaccination in the ordinary manner. 
 
 Etiology. — Predisposing Influences. — Varicella is a wide-spread 
 disease, endemic and frequently epidemic in the great centres of popu- 
 lation, usually in the autumn or early spring. As in the case of other 
 readily transmissible infections, sporadic cases occur and frequently 
 become the centre of house epidemics or extended outbreaks. The liabil- 
 ity is general, and scarcely any individual who has not had the disease 
 escapes when it makes its appearance in a school or other public institu- 
 
VARICELLA. 669 
 
 tion. It is a disease of childhood, the majority of cases occurring before 
 the eighth year and few after the tenth. It is comparatively infrequent 
 during the first year and, though rare, occasional cases occur after puberty. 
 Sex is wholly without influence as a predisposing factor. 
 
 The exciting cause is not known. The disease is highly conta- 
 gious and usually communicated in the ordinary intercourse of children in 
 the family, the school, or the playground. Direct contact is not necessary, 
 the infection being communicable at some little distance by the air and to 
 greater distances by persons who pass from the sick to those who are sus- 
 ceptible, and finally by means of fomites. Inoculation experiments have 
 shown that it is present in the contents of the vesicles. Outbreaks of 
 varicella are sometimes associated with measles, whooping-cough, scarlet 
 fever, or variola. 
 
 Symptoms. — The period of incubation is usually thirteen or fourteen 
 days Prodromes as a rule do not occur. In a majority of the cases the erup- 
 tion is the first sign. It first appears usually upon the face and spreads 
 into the hairy scalp and progressively over the trunk and extremities. It 
 sometimes comes out first upon the back and shoulders and very often at 
 the same time upon the wrists and forearms. The pocks are more numerous 
 upon the trunk and upon the upper than the lower portions. The rash 
 consists of small red, scattered flat papules, circular or ovoid in shape, 
 "which rapidly develop into vesicles. They usually come out in irregular 
 crops, fresh spots continuing to appear among the older, so that by the 
 fourth or fifth day they are seen in all stages of evolution and involution. 
 Some few of the papules do not develop into vesicles at all but undergo 
 complete resolution in the course of several hours. Nearly all of them 
 develop into vesicles which are fully formed within twenty-four hours. 
 Not infrequently the papular stage is so brief that the fully developed 
 vesicle appears upon skin that shortly before seemed entirely normal. 
 The vesicles are usually at first hemispherical and appear to be superficially 
 situated in the skin. Their contents are limpid, so that they sometimes 
 present the appearance of a drop of clear or faintly yellowish fluid resting 
 upon the surface. In the course of a few hours they become milky and 
 then seropurulent and in a further brief period desiccation takes place 
 with the formation of flat, yellowish-brown, firmly adherent crusts, which 
 separate in about a week, leaving in the majority of instances no scar. 
 The vesicles are readily ruptured by scratching and other injury. Under 
 these circumstances, and when the lesion approaches more nearly to that 
 of variola and involves the deeper structures of the skin, pitting may 
 result, especially upon the face. It is probable that spontaneous rupture 
 of the vesicles does not occur. The pock in varicella commonly has little 
 or no areola, but in the severer cases marked infiltration and hypersemia 
 of the surrounding skin may be observed. The diameter of the vesicle 
 varies from 1 to 15 or 20 millimetres; their number from ten to hundreds. 
 They are in most cases discrete, but when very numerous confluence may 
 often be discovered upon careful search. Primary umbilication does not 
 occur, but as desiccation takes place a depression in the centre of the crust — 
 secondary umbilication — is sometimes, seen. The eruption occurs upon 
 the mucous membrane of the mouth. It is rare upon the conjunctivae 
 
670 MEDICAL DIAGNOSIS. 
 
 and upon the labia and prepuce. In these situations, under the influence 
 of warmth and moisture the roof of the vesicle is rapidly destroyed and 
 the lesion converted into a circumscribed superficial ulcer. The peripheral 
 lymph-glands are not infrequently slightly swollen and tender. In the 
 lighter forms there is little or no elevation of temperature during the whole 
 course of the disease; in the more severe cases fever, if not previously 
 present, develops with the rash, to the abundance of which it bears, how- 
 ever, no constant relation. It commonly subsides in two or three days 
 and very seldom lasts a week. It does not conform to type. 
 
 The duration of the attack is variable. Three or four weeks may 
 elapse before the separation of the last crusts. Relapses do not occur. 
 The immunity acquired is in most instances permanent. In rare cases 
 subsequent attacks have been observed. 
 
 The anomalies of the disease relate to the rash. In rare instances 
 some of the vesicles contain blood, with ecchymoses and bleeding from the 
 mucous surfaces — Varicella hcemorrhagica; still more rarely they develop 
 into bullae like those of pemphigus or ecthyma — V. bullosa; in cachectic 
 children some of the skin lesions may become extensively ulcerated or 
 even gangrenous, and death occur as the result of exhaustion — V. gangrenosa 
 vel escharotica. 
 
 Diagnosis. — Direct Diagnosis. — Varicella in cases seen from the 
 beginning is easily recognized. The mildness of the initial symptoms, the per- 
 sistence of fever if present upon the appearance of the eruption, the character 
 of the individual pock, which is essentially vesicular, its rapid evolution, 
 the absence of primary umbilication, the appearance of the lesions in irregu- 
 lar crops, so that papules, vesicles, and crusts are seen at the same time in 
 the same region, are of diagnostic importance. Varicella is usually endemic 
 in cities; variola occasionally epidemic. 
 
 Differential Diagnosis. — This important matter principally relates 
 to the discrimination of varicella from smallpox, and the chief points are 
 indicated in the foregoing paragraph. In smallpox the onset is abrupt; 
 the fever high; headache and backache intense. There are cases in which, 
 at the period of desiccation, the differential diagnosis cannot be made. 
 
 The resemblance of urticaria, pemphigus, and other diseases of the 
 skin to varicella is remote. 
 
 Prognosis. — Varicella is a benign affection. Convalescence is in the 
 majority of cases uneventful and complete. In rare instances death has 
 resulted from nephritis, sepsis, or laryngitis. 
 
 VI. SCARLET FEVER. 
 
 Scarlatina. 
 
 Definition. — An acute, infectious disease, occurring sporadically and in 
 circumscribed epidemics, and characterized by erythematous angina, a diffuse 
 uniform exanthem followed by desquamation, and a tendency to nephritis. 
 
 Etiology. — Predisposing Influences. — No region can claim immu- 
 nity from scarlet fever. It occurs in every climate and attacks all races. 
 It may prevail at any season, but, owing to the mode of life and the closer 
 
SCARLET FEVER. 671 
 
 intercourse of school children in autumn and winter, epidemics are more 
 extensive and severe at these seasons of the year. Among personal condi- 
 tions predisposing to this disease age plays an important part. Children 
 at the breast are rarely attacked. More than half the cases occur before 
 the fifth year and 90 per cent, before the tenth. Adults occasionally con- 
 tract the disease. After puberty the liability rapidly diminishes. Sex is 
 without influence. 
 
 Exciting Cause. — The specific pathogenic germ is not yet known. 
 Streptococci have been demonstrated in the skin and the blood during 
 life and in the viscera after death, and the disease has been regarded 
 as a streptococcus infection. These micro-organisms are, however, present 
 under widely different conditions. Mallory found between the epithelial 
 cells of the epidermis a protozoon which assumed rosette forms like the 
 malarial parasite. Inoculation experiments upon human beings have 
 demonstrated the presence of the infecting agent in the blood, the tears, 
 the secretions of the nose, larynx, and bronchi, the urine, the desquamating 
 skin, and in the contents of miliary vesicles. It is probably eliminated in 
 the discharges from the bowels. The disease caused by artificial inocula- 
 tion is usually of severe form. The infecting principle is virulent and 
 tenacious. It is transmitted directly from the sick to the well and indirectly 
 by means of fomites. These may be the clothing of the patient, the bed- 
 ding and furniture of his room, toys, books, letters or other articles with 
 which he has been in contact or which have been exposed to an atmosphere 
 bearing the fine dust made up of his dried secretions or the particles of his 
 desquamating skin. The vessels he has used and remnants of food may 
 also convey the disease. Persons, themselves insusceptible, may be the 
 carriers of the contagion to others at a distance. Physicians and nurses 
 are especially exposed to this risk and the experience of the medical pro- 
 fession in this respect is peculiarly sad. The only way to escape catas- 
 trophe is to reahze its danger. Household pets, as cats, dogs, and birds, 
 may under certain circumstances carry the disease. Several epidemics 
 have been traced to milk supply. It is probable, as shown by Dornbliith, 
 that the milk has been merely the means of conveyance. The cream is 
 especially liable to cause the disease, and the risk is avoided by boiling. 
 The poison is not borne to any great distance in the air. Its virulence is 
 greatly diminished by oxygen, sunlight, and diffusion. On the other hand, 
 it shows under opposite conditions a vital persistence greater than that 
 of any other disease. Articles of clothing folded and packed away have 
 given rise to the disease after months and even after years. The time at 
 which the patient becomes a source of contagion has been the subject of 
 controversy. It is not only probable but it is also safe to assume that 
 transmission may occur at any time, from the beginning of the attack until 
 desquamation is completed, or, in the case of a pathological discharge, as in 
 otitis media, for an indefinite period. The infecting principle gains access by 
 way of the inspired air. Occasionally the attack of scarlet fever is compli- 
 cated by another specific infection, as erysipelas, measles, pertussis, vari- 
 cella, enteric fever, or diphtheria. The Klebs-Loffler bacillus may, how- 
 ever, be absent in throat affections of the most severe character, even 
 those in which pseudomembrane is conspicuous. It is now thought that 
 
672 MEDICAL DIAGNOSIS. 
 
 the febrile and desquamative diseases to which certain of the domestic ani- 
 mals, as the cat, dog, and horse, are subject — forms of " distemper" — are not, 
 as was formerly supposed, identical with scarlet fever in the human being. 
 
 The individual predisposition to scarlet fever is much less general 
 than to measles, variola, and many other contagious diseases. Many persons 
 upon exposure escape. Individuals sometimes escape upon close exposure 
 and contract the disease years later. Certain families show an immunity 
 transmitted from generation to generation; on the other hand many 
 families suffer from a fatal liability. The immunity after puberty is not 
 w^holly due to previous attacks. The attack confers an immunity which 
 •commonly is permanent. Second attacks are very rare. I have seen three 
 attacks separated by intervals of several years in the same person. Certain 
 individuals who possess an immunity acquired by the attack in early life 
 .suffer from slight sore throat when exposed to the infection. 
 
 The disease frequently occurs sporadically under circumstances in 
 which it is impossible to trace its transmission. Any such case may become 
 the focus of an epidemic. General epidemics are made up of series of local 
 or circumscribed outbreaks. They last longer than epidemics of measles, 
 sometimes several months, and show remarkable remissions and exacerba- 
 tions. Epidemics of scarlet fever differ greatly in the severity of the primary 
 disease and in the prominence of severe complications. 
 
 Symptoms. — The period of incubation varies from one to seven days; 
 in the majority of cases the disease develops on the third or fourth day after 
 exposure. A short incubation is commonly followed by a severe attack. 
 
 (a) Stage op Invasion. — The onset is usually abrupt, without pro- 
 dromes. It very often comes on at night. The intensity of the initial 
 symptoms is frequently in direct relation to the severity of the subsequent 
 course of the disease. A chill is rare; convulsions are common, especially in 
 young children. Vomiting may be the first symptom. It is in many cases 
 repeated. The temperature rises in the course of a few hours to 104°-106° F. 
 (40°-41.1° C), and the skin is extremely dry and hot. In very mild cases 
 the temperature may not exceed 101°-102° F. (38.3°-38.9° C). Older 
 children complain of sore throat and upon inspection the mucous membrane 
 of the soft palate, tonsils, and pharynx shows a uniform erythematous 
 blush varying in intensity according to the severity of the case. The hard 
 palate shows a finely stippled punctiform rash. Febrile phenomena are 
 marked — a furred tongue, red at the tip and edges, refusal of food, thirst, 
 scanty, high-colored urine, restlessness, somnolence, and delirium. Cough 
 and other symptoms of impHcation of the respiratory tract are slight or 
 altogether absent. 
 
 (b) Stage of Eruption. — The eruption appears during the latter 
 part of the first or in the course of the second day, coming out first upon 
 the neck, chest, especially in the infra-axillary regions, and spreading over 
 the face and body to the extremities with such swiftness that in the course 
 of from twenty-four to thirty-six hours the entire surface is covered. It 
 consists at first of minute, close-set red points, coarser and more widely 
 separated upon the legs than elsewhere. The intervening skin rapidly 
 becomes reddened and slightly swollen. In severe cases oedema of the 
 hands and fingers is often marked and a Hke condition of the eyelids occurs. 
 
SCARLET FEVER. 
 
 673 
 
 The fully developed rash upon the back, abdomen, and thighs is of an intense 
 scarlet or violet-red color, difficult to describe or reproduce and quite 
 unlike that of any other eruptive disease. It has been compared, but very 
 inappropriately, to the color of the boiled lobster. Its distribution over 
 the surface of the body is, in the great majority of cases, nearly uniform, 
 with the common exception of a ring around the mouth which, remaining 
 free, is in strildng contrast with the rest of the face. Exceptionally the 
 face and neck only are involved, or the body and extremities, and in 
 some instances, especially in adults, the rash is irregularly patchy in 
 areas varying in diameter from 5 to 20 cm., oval or circular, not abruptly 
 
 
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 ■-r'M 
 
 >Z0.. 1 
 
 77? 
 
 
 /f 
 
 fy^ 
 
 ft---; 
 
 
 
 ,.■■■' 
 
 y 
 
 y 
 
 
 ,y 
 
 
 
 
 
 -;.. 
 
 
 
 
 
 
 
 
 
 
 
 
 Fig. 228.— Scarlet fever. 
 
 Fig. 229. — Scarlet fever. 
 
 marginate but shading off into the surrounding skin. The eruption is 
 largely hypera?mic and the white streak produced by drawing the finger 
 over the surface immediately disappears. 
 
 Sudamina may appear and in a group of cases — scarlatina miliaria — 
 the skin is extensively covered with minute yellow vesicles. In the more 
 intense eruptions punctiform hemorrhages may appear and in malignant 
 cases petechiae and extensive subcutaneous hemorrhagic effusions. 
 
 Subjectively sensations of tension, burning, and pricking, together 
 with more or less intense itching, attend the eruption and to these symptoms 
 the restlessness and jactitation in many of the cases are largely due. Swell- 
 ing of the peripheral lymph-nodes, especially in the region about the 
 angles of the jaw, is common and in some instances they are very tender. 
 
 43 
 
674 MEDICAL DIAGNOSIS. 
 
 The rash reaches its height upon the third or fourth day and gradually 
 fades first where it first appeared. By the end of the first week it has in 
 most instances wholly vanished. 
 
 The tongue is at first covered with a thick whitish fur through which 
 project the tips of the swollen red papilla? — an appearance described as 
 the strawberry tongue. In the course of a few days the coating separates, 
 leaving the whole dorsum of the tongue red and rough, the so-called straw- 
 berry or raspberry tongue of writers. These terms are neither exact nor 
 descriptive and ought to be abandoned. The bowels are, as a rule, consti- 
 pated. Diarrhoea may be an early symptom and is sometimes severe. 
 It may occur as the result of a simple catarrhal enteritis or of a dysenteric 
 colitis with tenesmus and bloody stools. In grave cases meteorism may 
 be present. 
 
 In a majority of the cases there is simply an erythematous angina 
 with slight enlargement of the tonsils and palatine arches; in other cases 
 these and the contiguous structures are intensely swollen and infiltrated 
 and foci of suppuration may appear; finally, more or less extensive pseudo- 
 membrane may develop with intense inflammation, cervical adenitis, and 
 inflammatory infiltration and oedema of the tissues of the neck. The 
 ordinary inflammation is due to the scarlatina poison; the graver forms 
 and many of the pseudomembranous inflammations to secondary infection 
 by pus-producing micro-organisms, while true diphtheria occurs as a 
 complication resulting from infection by the Klebs-Loffler bacillus. 
 Membranous laryngitis is rare in scarlet fever and still more rare is the 
 development of a membranous (croupous) exudate in the bronchi. 
 
 The temperature conforms much less closely to type than that of 
 measles or variola. It is much modified by secondary infections. Its 
 rise is abrupt, to 104°-106° F. (40°-41.1° C.) ; it remains with slight morning 
 remissions about this level until the eruption is fully developed, about the 
 third day. From this point in uncomplicated cases the temperature grad- 
 ually falls coincidently with the fading of the rash, until toward the end 
 of the first week the defervescence is complete. In mild cases the maximum 
 temperature may not exceed 102° F. (38.9° C), while in the gravest cases 
 hyperpyrexia may occur— 105.8°-109° F. (41°-42.8° C). The tempera- 
 ture finally reaches subnormal ranges and the morning remissions continue 
 in some cases to be subnormal for two or three weeks. It is important to 
 continue thermometric observations for some time after the acute symp- 
 toms have ceased. 
 
 The pulse is rapid, 120-160; its tension notably increased. In uncom- 
 plicated cases the erythrocytes and haemoglobin are but moderately 
 decreased. Leucocytosis is marked from the onset. In postscarlatinal 
 nephritis profound anaemia rapidly develops. The area of splenic dulness 
 is increased and the lower margin of the organ may be palpable. The 
 area of hver dulness is not enlarged. The urine during the period of invasion 
 and in the early days of the eruption may show a trace of albumin with a 
 few tube-casts — toxic or febrile albuminuria. This disappears with the 
 defervescence. Systematic examination of the urine should be made at 
 intervals of two or three days until desquamation has ceased and convales- 
 cence is fully established. 
 
SCARLET FEVER. 
 
 675 
 
 (c) Stage of Desquamation. — Desquamation follows the disappear- 
 ance of the rash. It may begin at once or not until after several days 
 have elapsed. It first shows itself, as a rule, upon the neck or chest; some- 
 times upon the abdomen above the inguinal folds. It bears some relation 
 to the intensity of the eruption, being in mild cases furfuraceous, in grave 
 cases lamellar or membranous. The thicker layers of the skin upon the 
 hands and feet may come off in extensive patches and children sometimes 
 remove the epidermis of several fin- 
 gers like the rag of a glove. The 
 average duration of the desquama- 
 tion is about two weeks, but the proc- 
 ess is in many cases repeated and 
 may continue for five or six weeks. 
 The palmar and plantar surfaces are 
 the last to cease shedding. Occa- 
 sionally the hair falls out. 
 
 Varieties. — The cases differ 
 greatly in severity and duration 
 and may be arranged in the follow- 
 ing groups: 
 
 1. The Ordinary Form — Scar- 
 latina Simplex. — This variety has 
 been outlined in the foregoing gen- 
 eral description. It presents varying 
 grades of severity, but the symptom- 
 
 • complex is well defined and the acute 
 process in uncomplicated cases comes 
 to an end by the sixth or seventh day. 
 
 2. Larval or Undeveloped 
 Forms. — (a) Scarlatina Afebrilis. — 
 The objective phenomena of illness 
 are absent and the patient does not 
 regard himself as sick. Fever is 
 absent or shght— 100° F. (37.8° C), 
 and lasts only a few hours. The rash 
 also is faint, usually limited to the 
 throat and chest, and transient, (b) 
 Scarlatina sine Eruptione. — There 
 may be sudden fever with sore throat and vomiting but the skin remains 
 free from eruption. At most there is a transient faint erythematous blush 
 such as is often observed in acute indifferent febrile attacks in young 
 persons of blond complexion, (c) Scarlatina sine Angina. — Fever may 
 be present and the eruption may be more or less well defined but the 
 appearance of the throat remains normal ■ throughout the sickness. 
 
 These incompletely developed cases often give rise to great difficulties 
 in diagnosis. They occur with some frequency in certain epidemics and 
 are to be recognized by the epidemic tendency, the severe complications 
 which frequently develop, the occurrence of postscarlatinal nephritis, and 
 the fact that they may become centres of infection. The afebrile forms 
 
 Fig. 230. — Desquamation upon face, neck, and chest 
 after scarlet fever. — After Welch and Schamberg. 
 
676 MEDICAL DIAGNOSIS. 
 
 are especially likely to spread the disease. It not infrequently happens 
 that, in a family of children, one may apparently escape the attack and 
 play about as usual, until, as the others recover, desquamation or sudden 
 pallor, dropsy, and albuminuria make it evident that he also has suffered 
 the infection but without the usual symptoms. 
 
 3. Malignant Forms — Scarlatina Maligna. — (a) Scarlatina Sid- 
 erans. — These cases occur sporadically and during severe epidemics. The 
 child is overwhelmed at once by the intensity of the infection. Blinding 
 headache, vomiting, convulsions, hyperpyrexia, delirium passing rapidly 
 into coma succeed one another in appalling succession. There is suppres- 
 sion of urine; the heart's action is progressively rapid and feeble and 
 dyspnoea occurs. Death ensues within twenty-four or thirty-six hours, 
 (b) Scarlatina HcB7norrhagica. — Petechise appear and develop in a brief 
 time into vibices and extensive suggillations. Epistaxis and haematuria 
 are common. All the evidences of a profound toxaemia occur and death 
 takes place in the course of two or three days. Enfeebled and badly 
 nourished infants and especially the inmates of public institutions are 
 particularly liable to this form of scarlet fever, but it occasionally occurs 
 in well-nourished children living under favorable circumstances. 
 
 4. The Anginose Form — Scarlatina Anginosa. — The throat symp- 
 toms early dominate the clinical picture. Intense inflammation of the 
 tonsils and contiguous structures is attended with pain, dysphagia, and 
 mechanical dyspnoea. Pseudomembrane develops and may extend over 
 the soft palate and uvula into the nasopharynx and nasal chambers or 
 downward to the larynx. The Eustachian tube is involved with infection 
 of the middle ear. Local necrosis takes place and the fetor is almost 
 unbearable. The glands of the neck are enlarged. General sepsis fre- 
 quently results with fatal termination. If life be prolonged the separation 
 of the sloughs may give rise to fatal hemorrhage from the carotid artery. 
 
 5. Protracted Form — Scarlatina Typhosa. — Severe and prolonged 
 cases with delirium, profound prostration, sustained high temperature, 
 and all the evidences of grave general infection. Gastro-intestinal disturb- 
 ances and marked tympany may be present. The fever may continue for 
 two or three weeks and terminate in lysis. This form has been described 
 also as septic or adynamic scarlatina. 
 
 6. Surgical and Puerperal Scarlatina. — Some years ago the 
 subject of scarlet fever after surgical operations and in the lying-in woman 
 attracted much attention. Scarlatiniform rashes may occur under two 
 conditions: First, the patient maj^, at the time of operation or confinement 
 or thereafter, contract scarlet fever and present all the symptoms of the 
 disease; in this case the surgeon or accoucheur must question himself as 
 to his part in conveying the infecting principle; and second, the patient 
 may develop an erythema as the result of sepsis or as a drug exanthem. 
 The angina and peculiar appearance of the tongue are not present. The 
 distribution of the rash is irregular and its course not that of the eruption 
 of scarlet fever. Local erythema may result from carbolic acid or subli- 
 mate solutions of undue strength, and general rashes from certain drugs, 
 as copaiba, oil of santol, and quinine. Desquamation may occur as the result 
 of intense erythema due to any cause. These cases have become infre- 
 quent under the methods of modern surgery. 
 
SCARLET FEVER. 677 
 
 Complications and Sequels. — The complications of scarlet fever are 
 numerous. They are mostly due to secondary streptococcus infection, 
 the primary infection rendering the tissues vulnerable and lowering the 
 powers of resistance of the organism. They are usually severe and have 
 much to do with the gravity of the disease. Some epidemics are character- 
 ized by the prominence of certain complications. Almost any tissue of 
 the body may become the seat of inflammation and abscess formation 
 during an attack. The following are more commonly involved: 
 
 (a) Throat. — Pseudomembranous and necrotic inflammation of the 
 faucial structures occurs in the anginose form. It is described as scarla- 
 tinal diphtheria and may develop during the stage of invasion or upon the 
 appearance of the exanthem. In grave cases there is extensive inflammatory 
 oedema of the neck — "collar of brawn." General septicaemia is apt to 
 supervene and in many epidemics the throat affection is the cause of high 
 mortality. As a rule the throat affection is due to streptococcus infection; 
 much less commonly there is a true complicating diphtheria. 
 
 (b) Kidneys. — Nephritis constitutes the most common and important 
 complication. Toxic or febrile albuminuria occurring at the height of the 
 fever is usually transient and without greater significance than the same 
 condition in other diseases, as pneumonia. Much more important is the 
 albuminuria which comes on with the fading of the rash or during the 
 stage of desquamation. The anatomical condition in the quickly fatal 
 cases is that of a glomerulonephritis of varying intensity. Clinically the 
 following grades may be recognized: 
 
 1. Mild Catarrhal Nephritis. — The urine remains normal in amount. 
 It contains a moderate amount of albumin and a few tube-casts. Cylin- 
 droids are present. There is no blood. Qildema is slight and is confined 
 to the eyelids and the pretibial areas. The process may last a few weeks 
 and terminate in complete recovery or it may be the starting point of a 
 chronic nephritis. Sudden intensification of the symptoms may occur 
 with anuria and fatal uraemia, oedema, or effusion into the serous sacs or 
 the larynx. 
 
 2. Graver cases with increased albumin, casts, and blood. The urine 
 is diminished and there is slight or moderate oedema of the face and lower 
 extremities. Effusion into the serous sacs may occur. The symptoms are" 
 not urgent, but anaemia is pronounced and the nephritis tends to become 
 chronic. Uraemia may suddenly develop. When apparent recovery takes 
 place renal inadequacy is often established, and the albuminuria of 
 adolescence or the nephritis following an acute illness or exposure to cold 
 years afterwards may be traced to this condition. These are the cases 
 that under well-directed treatment frequently end in recovery. 
 
 3. Very severe cases with rapidly developing intense anaemia, general 
 anasarca, anuria, or the passage of small amounts of bloody or porter- 
 colored urine which coagulates upon the application of heat and is loaded 
 with blood and casts. Uraemic accidents, vomiting, facial spasm, convul- 
 sions, and coma promptly occur, and despite treatment a large proportion 
 of the cases die. 
 
 In rare instances cedema may occur without albuminuria. Under 
 these circumstances the dropsy may change its location, coming and going 
 
678 MEDICAL DIAGNOSIS. 
 
 without apparent cause. It may be associated with effusion into the serous 
 sacs, especially ascites, oedema of the glottis or sudden pulmonary oedema. 
 This form of oedema may be the result of angemia or cachexia. 
 
 (c) Joints. — Rarely during the acute attack, more commonly in the 
 second or third week, there may develop inflammation of the joints, syn- 
 ovitis scarlatinosa, so-called scarlatinal rheumatism. The cases may be 
 arranged in two groups: 1. Those in which a serous synovitis of more or 
 less intense character is present, involving most frequently the small joints 
 of the fingers, the wrists and knees, exceptionally the spinal articulations, 
 and terminating in complete resolution in the course of a few days. Several 
 joints are usually affected — polyarthritis — but there is little or no rise of 
 temperature and the joint affection lacks the fugacious character so marked 
 in rheumatic fever. This form has been regarded as due to the scarlatinal 
 poison. 2. Suppurative arthritis, usually implicating a single joint and 
 appearing as a local manifestation of a general septic process. Streptococci 
 have been demonstrated in the intra-articular exudate. 
 
 (d) Heart. — Benign endocarditis may occur alike when joint compli- 
 cations are present and in their absence. Malignant endocarditis is very 
 rare. Pericarditis is much less frequent than endocarditis. If effusion 
 takes place it may be purulent or, in grave cases, hemorrhagic. Myocarditis 
 is not uncommon. Hypertrophy and dilatation are constant accompani- 
 ments of scarlatinal nephritis in children; they are less frequent in adults. 
 It is of importance to perform auscultation of the heart and lungs ad a matter 
 of daily routine in every case of scarlet fever. There is no reason why 
 rheumatic fever may not occur as a complication of scarlatina and account 
 for the joint affection and cardiac lesions in certain cases. 
 
 (e) Respiratory Organs. — Bronchitis and inhalation pneumonia — 
 bronchopneumonia — are present in cases attended with severe lesions of 
 the upper air-passages. Hypostatic congestion is common in the gravest 
 cases. Croupous pneumonia is rare. Pleurisy is relatively common. It 
 may be plastic; more frequently it is serofibrinous or purulent; rarely 
 hemorrhagic. It usually develops about the middle of the second week. 
 
 (f) Auditory Apparatus. — Infection of the middle ear by way of the 
 Eustachian tube is very common. It occurs in almost every case of anginose 
 scarlatina and is attended by serious dangers, both near and remote. In 
 about 85 per cent, of the cases both ears are affected. Suppurative otitis 
 media results with perforation of the tympanic membrane. The inflamma- 
 tion may extend to the labyrinth or to the mastoid cells. Extensive necrosis 
 of parts of the temporal bone vaay result. Paralysis of the facial nerve is a 
 rare sequel. Meningitis, brain abscess, and sinus thrombosis may occur. 
 In the absence of those accidents spontaneous healing may take place in 
 the course of a few weeks. More commonly the otitis becomes chronic 
 and in many cases, despite treatment, gives rise to permanent impairment 
 or loss of hearing. Burkhardt-Merian found among 4309 cases of acquired 
 deaf-mutism 445, or 10.3 per cent., to be due to scarlet fever. 
 
 (g) Lymphatic Glands. — Imphcation of the lymphatic system occurs 
 in all cases. In mild scarlet fever there is commonly some degree of enlarge- 
 ment of the superficial lymph-nodes, especially in the neck. It is, however, 
 slight and undergoes resolution during convalescence. In more serious 
 
SCARLET FEVER. 679 
 
 cases the glands may be enormously swollen with cellulitis of the surround- 
 ing tissues. Phlegmonous inflammation — angina Ludovici — may occur 
 and lead to extensive necrosis with erosion of vessels and fatal hemorrhage. 
 Retropharyngeal abscess is a very rare complication. The enlargement 
 of the cervical glands is occasionally persistent. 
 
 (h) Among the rarer complications and sequels are enterocolitis, 
 local periostitis, noma, perforation of the soft palate, symmetrical gangrene, 
 and various palsies. Protracted angemia may occur and the growth and 
 development of the child may be greatly retarded. Acute psychoses, 
 mania, or melancholia sometimes develop during convalescence. These 
 conditions are commonly of brief duration, coming to an end in the course 
 of some hours or days. Exceptionally they last several weeks. Hereditary 
 predisposition is present in many of the cases. Boys more frequently 
 suffer than girls. The prognosis is uniformly favorable. 
 
 Diagnosis. — The direct diagnosis rests upon the sudden onset with 
 rapid rise of temperature, vomiting, and nervous disturbances, as convul- 
 sions or stupor, the erythematous angina often accompanied with pseudo- 
 membranous exudate, the peculiar tongue, the exanthem, the desquamation, 
 and the swelling of the superficial lymph-nodes. The prevalence of an 
 epidemic or a history of exposure is of importance' in doubtful cases. 
 There are cases in which for a time the diagnosis must remain uncertain. 
 
 Differential Diagnosis. — 1. Measles. — Less abrupt onset, catarrhal 
 symptoms, Koplik's sign, longer period of invasion, a distinctly maculo- 
 papular rash, coarse, measly, and thick-set, with an irregularly crescentic 
 arrangement, the less intense sore throat, the absence of leucocytosis, and 
 the fine desquamation are important criteria. The rash appears upon 
 the third or fourth day or later, and first upon the face. It is duller in hue 
 than that of scarlet fever. In rare cases of measles in which a uniform, 
 vivid red rash covers the face and body, maculopapules will be found 
 about the wrists or ankles. 
 
 2. Rotheln. — The eruption may closely resemble that of scarlet 
 fever. The disease is usually slight; fever and constitutional disturbances 
 are insignificant; angina is absent or trifling; the adenitis involves the 
 postauricular glands to a greater extent than the anterior chains; and 
 the prevalence of an epidemic is of diagnostic importance. 
 
 3. Septicemia. — Not only so-called surgical and puerperal infection 
 but other forms of septicaemia may present rashes almost identical with 
 that of scarlet fever. Certain of these cases show also erythematous sore 
 throat with a tongue thickly furred and red at the edges and tip, and if 
 death does not occur desquamation may take place precisely as in scarlet 
 fever. The diffei^ential diagnosis is difficult and may in any given case 
 be impossible. 
 
 4. Diphtheria. — False membrane may develop early and present 
 the appearance of true diphtheria. Scarlet fever with intense pseudo- 
 membranous angina, diphtheria with an erythematous rash, and the coex- 
 istence of scarlet fever and diphtheria are to be considered. The early 
 membranous sore throat of scarlet fever does not usually show the presence 
 of the Bacillus diphtherise, which is, however, usually present in the later 
 forms. The erythema of diphtheria is comparatively rare and when present 
 
680 MEDICAL DIAGNOSIS. 
 
 lacks the uniform distribution and the intense scarlet color of that of 
 scarlet fever. In every suspected case a bacteriological examination must 
 be forthwith made. 
 
 5. Other Acute Infections. — In rare instances rashes suggestive 
 of scarlet fever occur in influenza, cerebrospinal fever, variola, — the initial 
 rashes, — varicella, and enteric fever. The differential diagnosis must rest 
 upon the symptom-complex in individual cases. As a rule little real diffi- 
 culty arises and even that is dispelled in a brief time. 
 
 6. Acute Exfoliative Dermatitis. — Sudden onset with fever, 
 scarlatiniform eruption rapidly becoming universal and fading after five 
 or six days with membranous desquamation present a problem in diagnosis 
 difficult of solution. The absence of angina and the tongue of scarlet 
 fever, the occurrence of alopecia, the loss of the nails, a tendency to recur 
 periodically, the occurrence in adults, and the sporadic character of this 
 rare disease in which the case never becomes a focus of contagion usually 
 render the diagnosis a simple matter. Cases first seen during the stage 
 of erythema sometimes present great difficulties in diagnosis. 
 
 7. Erythema Simplex. — This dermatosis occurring in young children 
 may suggest scarlet fever. The trifling constitutional disturbance, the 
 transient eruption, the absence of angina, and in most cases absence of 
 desquamation are of diagnostic value. 
 
 8. Drug Exanthems. — Local erythematous rashes may follow the 
 application of mustard, solutions of carboHc acid, corrosive sublimate, or 
 other irritants. Circumscribed or diffuse eruptions may follow the internal 
 administration of belladonna, quinine, the iodides, more rarely chloral, 
 sulphonal, antipyrin, turpentine, and the hypodermic injection of tuberculin. 
 These rashes are not accompanied by fever, a fact which may be rendered 
 unavailable in diagnosis by the presence of fever in the condition for which 
 the drug is administered; nor by angina, save in the cases of belladonna, 
 in which dryness and redness of the throat are conspicuous; and certain 
 of them occasion symptoms which are distinctive — tinnitus in the case of 
 quinine, coryza in iodine, and so forth. The difficulty in diagnosis is 
 usually slight. 
 
 It may be said that the greater the experience of the practitioner in 
 the acute exanthemata, the greater his hesitancy to make a positive diag- 
 nosis in doubtful cases. The only safe rule of practice is to regard every 
 uncertain case as a possible source of infection and treat it accordingly 
 until the diagnosis becomes clear. 
 
 Prognosis. — The mortality varies greatly in different epidemics. It 
 is modified by the severity of the infection and the prevalence of grave 
 comphcations and is lower in private practice than in hospitals. In some 
 outbreaks the disease has been benign, the death-rate not exceeding 5 per 
 cent. ; in others, exceedingly severe, with a maximum mortaUty of 30 or 
 even of 40 per cent. The prognosis in individual cases is influenced by the 
 following conditions: 1. Age. The danger is much greater in infancy and 
 early childhood than later. A large proportion of the deaths occur between 
 the third and sixth years. The absolute mortality among adults is low but 
 my observation leads me to believe that, in proportion to the number of 
 cases, scarlet fever after puberty is very fatal. 2. Sex. It is said that the 
 
MEASLES. 681 
 
 mortality is higher among males than females. 3. The previous health 
 of the patient. Delicate, poorly nourished, and sickly children bear the 
 disease badly. Like the other acute infections scarlet fever is severe and 
 attended with a high death-rate in orphan asylums and similar institutions. 
 
 The danger is great in proportion to the intensity of the primary infec- 
 tion as shown by early high fever, stupor, delirium, restlessness, the evi- 
 dences of general septic infection, and the prominence of local infective 
 processes, such as membranous or suppurative angina, cervical cellulitis, 
 laryngeal obstruction, bronchitis, bronchopneumonia, pleural effusion, 
 heart complications, and nephritis. Hemorrhagic cases are usually fatal. 
 A persistently high pulse-rate is of itself an unfavorable sign. 
 
 The prognosis must in all instances be guarded. Apparently benign 
 cases may develop the gravest symptoms or fatal nephritis may occur 
 during convalescence. No case, however favorable, can be regarded as 
 out of danger until at least four weeks have elapsed from the onset of the 
 attack. 
 
 VII. MEASLES. 
 
 Rubeola; Morhilli. 
 
 Definition. — An acute febrile infection occurring in epidemics, and 
 characterized by initial coryza, bronchial catarrh, and a generalized maculo- 
 papular eruption. 
 
 Etiology. — Predisposing Influences. — The susceptibility to measles 
 appears to be almost universal. The disease prevails in every climate 
 and attacks all races. Negroes suffer more severely than whites and are 
 more liable to develop grave complications and sequels. Season. — Outbreaks 
 take place at all times of the year but are more common in the winter and 
 spring than in the warmer seasons. Age plays an important part. Measles 
 is peculiarly a disease of childhood. Adults not protected by an attack 
 in early life may contract it and frequently manifest the symptoms in an 
 aggravated form. It is more common after puberty than scarlet fever. 
 Congenital cases have been observed; it is rare during the first six months 
 of life. The great majority of cases occur before the tenth year. The 
 sexes are alike liable. 
 
 Exciting Cause. —The specific pathogenic cause has not been demon- 
 strated. Inoculation experiments upon human beings have shown the 
 presence of the infecting principle in the blood, in the tears, in the 
 secretions of the nasal, pharyngeal, and bronchial mucous membrane, and 
 in the contents of vesicles occasionally present. Inoculation with the 
 epithelial scales thrown off at the close of the disease has been unsuccessful. 
 Transmission of the disease under ordinary circumstances takes place by 
 the breath or the nasal or bronchial secretion. It may result directly from 
 close approach or contact with the patient, or remotely through the con- 
 veyance of the poison by a third person or by fomites. Measles is very 
 commonly disseminated in school or upon playgrounds by children who 
 appear to be suffering from ordinary nasal or bronchial catarrh but who 
 are in reality in the pre-eruptive stage. The infecting principle is intensely 
 active but neither tenacious nor persistent as is that of scarlet fever. The 
 
682 MEDICAL DIAGNOSIS. 
 
 disease is communicable during its whole course from the earliest appear- 
 ance of coryza. The individual predisposition to measles is so general 
 that upon exposure very few escape. The adult who suffers has, as a rule, 
 not been exposed to the infection in childhood and is often an only child 
 who has been educated at home. A congenital immunity seems to exist 
 in rare instances. In the majority of cases an acquired immunity 
 results from the attack. Second, or even third, attacks may occur at 
 intervals of some years, but they are infrequent. I cannot agree with those 
 who regard multiple recurrences as common, since my experience coincides 
 with that of Jiirgensen and Eichhorst in Germany, and Holt in this country, 
 who hold that second attacks are rare. Measles in cities is in a certain 
 sense endemic. Sporadic cases occur at intervals and constitute the starting- 
 point of more or less extensive epidemics. When the susceptible individuals 
 in the affected locality have had the disease the epidemic ceases. The 
 poison is- frequently carried to neighboring regions by persons in the period 
 of incubation or in the pre-eruptive stage, who become centres of infection 
 for new local epidemics. Extensive outbreaks occur at intervals of five 
 or six years and at long intervals the disease becomes pandemic. Occasion- 
 ally other epidemic diseases of children, especially whooping-cough and 
 varicella, precede, accompany, or follow outbreaks of measles. Outbreaks 
 are common in time of war among the younger recruits and conscripts, 
 many of whom come from country districts in which the disease has not 
 prevailed for long periods. 
 
 Symptoms. — The period of incubation is from seven to fourteen 
 days, usually about ten. In artificially inoculated cases it is commonly 
 less than ten. Prodromes are common. They consist of loss of appetite, 
 restless sleep, fretfulness, and in many cases feverishness or light fever. 
 
 (a) Stage op Invasion. — The prodromal symptoms are intensified. 
 There is chilliness which may be repeated, sometimes shivering, but con- 
 vulsions and distinct chills are uncommon. The temperature rises, reaching 
 102°-104° F. (38.9°-40° C.) upon the first or second day. It then falls a 
 degree or more to rise again upon the appearance of the exanthem. Nausea, 
 vomiting, and headache are present. The tongue is furred. Coincidently 
 with the appearance of these symptoms coryza develops and is often 
 intense. The phenomena are those of an ordinary severe influenza. Irrita- 
 tion and smarting of the eyelids, lachrymation, photophobia, persistent 
 sneezing, running at the nose, sore throat, discomfort in swallowing, hoarse- 
 ness, and cough, at first of a brassy or croupy character, develop one upon 
 the other in rapid succession and varying intensity. These initial catarrhal 
 symptoms are characteristic and occur in the mildest cases in which chilli- 
 ness, fever, and the associated signs of the reaction of the organism to 
 general infection are not observed. Upon inspection the vessels of the 
 conjunctivae are injected, the eyelids swollen, the nasal mucosa tumid and 
 reddened. The mucous membrane of the mouth and throat is erythema- 
 tous, while upon the soft palate and roof of the mouth, and particularly 
 upon the buccal mucous membrane, are to be seen pin-head or split-pea- 
 sized, circumscribed, round or irregularly shaped reddish blotches slightly 
 or scarcely at all raised above the surrounding surface, usually discrete, 
 sometimes confluent. This eruption also shows itself in the larynx and is 
 
MEASLES. 
 
 683 
 
 doubtless the cause of the laryngobronchial symptoms as it is of the 
 coryza. It has been called the enanthem in contradistinction to the rash 
 upon the skin, the exanthem. In a strong light there may be seen upon 
 some of the spots upon the mucosa of the cheeks and lips minute bright 
 whitish or bluish-white flecks described by Koplik. These flecks appear early 
 and soon disappear, and since they have not been observed in other diseases 
 are of value in the early diagnosis of measles. The duration of the stage of 
 invasion, or, as it is sometimes called, the catarrhal stage, is commonly three 
 or four days; exceptionally it is shorter or it may be as long as a week. 
 
 
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 Fig. 231.— Measles. 
 
 Fig. 232. — Frank uncomplicated measles 
 in a woman aged 52. 
 
 (b) Stage of Eruption. — The fever rises and may reach 104°- 106^ F. 
 (40°-41.1° C), the pulse-rate may be 140 or higher. Delirium or stupor 
 may be present in the severer cases. The patient complains of heat and 
 burning of the skin, sore throat and general discomfort, and is restless 
 and wakeful. Usually upon the second or third day of the eruption great 
 and rapid amelioration of all these symptoms occurs and the fever which 
 has remained high falls by crisis or by rapid lysis to normal or subnormal 
 ranges. The eruption appears as small red or brownish-red soft flat papules 
 which rapidly increase in size and in numbers. When fully developed the 
 individual spots are irregularly circular or oval and differ greatly in size, 
 the average diameter being that of a split pea. They are unevenly dis- 
 tributed but close set and very often confluent, especially upon the face, 
 
684 MEDICAL DIAGNOSIS. 
 
 buttocks, hands and feet, where there is also some tumefaction. They are 
 circumscribed and the intervening skin is normal or slightly hypersemic. 
 Not infrequently a crescentic arrangement may be made out elsewhere. 
 The color momentarily fades upon pressure or upon tension of the skin. 
 The eruption appears first upon the forehead, chin, and cheeks; it invades 
 the hairy scalp and spreads rapidly to the neck, back, hands and arms, 
 anterior surface of the trunk and lower extremities, commonly in the order 
 named, invading the entire surface in the course of twenty-four or thirty- 
 six hours. By the end of the second or during the third day the eruption 
 is fully developed. In severe cases punctiform hemorrhages now appear 
 in some of the papules, especially upon portions of the body exposed to 
 pressure. This condition is not significant and must not be confounded 
 with the true hemorrhagic variety of the disease. From this time the 
 eruption rapidly fades, first where it first appeared, namely, upon the face, 
 and in the course of a further period of two or three days disappears, leaving 
 faint yellowish or dirty-brown areas of pigmentation which in turn gradually 
 pass away. In the beginning of the stage of eruption and in many cases 
 throughout its course the skin is moist and often bathed in free perspira- 
 tion. At the height of the eruption the superficial lymph-nodes of the 
 neck and elsewhere are often slightly swollen and tender. 
 
 (c) Stage of Desquamation. — Following the fading of the rash des- 
 quamation takes place in the form of fine branny scales, so fine that the 
 condition may be easily overlooked. This process begins on the face and 
 involves the entire surface, occupying about a week. The catarrhal symp- 
 toms in uncomplicated cases gradually disappear, so that, by the end of 
 the second week from the initial coryza, convalescence is fully established. 
 Cough frequently persists. In the absence of inflammatory complications 
 leucocytosis does not occur. Epistaxis is common at the height of the 
 attack; diarrhoea is apt to occur at some time during its course. Relapses 
 of measles are extremely rare. 
 
 During epidemics atypical cases occur. They are not common. Varia- 
 tions in the rash may consist: (1) in the development of distinct papules, 
 hard to the touch but not extending deeply into the skin — morbilli papulosi; 
 (2) a vesicular form, m. vesiculari; (3) cases in which the eruption does 
 not appear, although the general symptoms and the coryza are present — 
 m. sine exanthema; (4) cases in which the mucous membranes are not 
 involved — m. sine enanthema. To these must be added variations in the 
 constitutional manifestations. In rare cases there is no rise of tempera- 
 ture — ni. afebriles. In the malignant forms the organism is unable to 
 withstand the intensity of the infection and death takes place in the 
 course of two or three clays after sustained hyperpyrexia, profound 
 adynamia, or hemorrhages into the skin and mucous membranes. The 
 malignant forms are very rare in private practice; they occasionally occur 
 in asylums and in the fierce epidemics of camps, and were common in the 
 first outbreak among the natives of the Fiji Islands, where measles pre- 
 vailed as a veritable scourge. Death may occur before the rash appears, 
 or a few papules may show themselves upon the forehead and wrists. 
 Hemorrhagic or black measles — m. hcemorrhagica — is characterized by 
 convulsions, delirium and coma, petechise, bleeding from mucous surfaces, 
 and profound constitutional depression. 
 
MEASLES. 
 
 685 
 
 Complications and Sequels. — Epidemics differ greatly as regards the 
 frequency and severity of complications. In their absence measles is a 
 comparatively benign malady, but they are sufficiently common to place it 
 among the more serious diseases of childhood. Debilitated and badly nour- 
 ished children living in unhygienic surroundings and those in asylums and 
 institutions are especially liable. The ordinary complications are due to an 
 extension or intensification of the catarijial processes peculiar to the disease. 
 
 Otitis media is not very uncommon. It may result in perforation of 
 the tympanic membrane and permanent impairment of hearing, or lead to 
 sinus thrombosis, meningitis, or abscess of the brain. Purulent conjuncti- 
 vitis may occur and in neglected cases infiltration and ulceration of the 
 cornea. Catarrhal laryngitis is of 
 frequent occurrence; the pseudo- 
 membranous form is rare and very 
 dangerous; oedema of the glottis is 
 very uncommon. Diphtheria is much 
 less frequent in measles than in 
 scarlet fever. 
 
 The catarrhal bronchitis so 
 prominent in the disease is, in itself, 
 without serious significance, and in 
 favorable cases terminates in reso- 
 lution with the convalescence. Its 
 tendency to extend to the finer tubes 
 and give rise to lobular collapse and 
 bronchopneumonia constitutes the 
 gravest danger. If the involvement 
 of the vesicular structure is limited 
 there is increase of fever with accel- 
 eration of the pulse, harassing cough, 
 and disturbance of respiration. The 
 sickness is prolonged but terminates 
 favorably. When the lesions are 
 extensive the symptoms become 
 urgent and a large proportion of the 
 cases die. It is to this compHcation that the high death-rate of measles 
 under unfavorable circumstances is due. Croupous pneumonia is much 
 less common. Pleural effusion is rare. Acute enterocolitis is a frequent 
 and serious complication in some epidemics. Toxic albuminuria occa- 
 sionally occurs as in other febrile infections, and the diazo reaction 
 is present. There is httle tendency to nephritis. Arthritis is very rare. 
 In young and debilitated children gangrenous stomatitis and in girls 
 gangrene of the pudenda occur during convalescence with greater fre- 
 quency than in any other infectious disease. 
 
 Among the common sequels are chronic local inflammations, con- 
 junctivitis, otitis, nasal catarrh, laryngitis, and bronchitis. The intestinal 
 catarrh arising as a complication may lead to chronic colitis. Tuberculo- 
 sis is a very common sequel. The lesions of measles are such as to render 
 the patient peculiarly hable to this infection, but the rapidity with which 
 
 Fig. 233. — Cancrum oris complicating measles.- 
 After Welch and Schamberg. 
 
686 MEDICAL DIAGNOSIS. 
 
 tuberculous bronchopneumonia and acute miliary tuberculosis develop 
 in many instances renders it probable that a latent tuberculous process 
 has been roused into activity during the attack. Pulmonary tuberculosis 
 is a common remote sequel of measles in the adult, and miliary tuberculosis 
 and tuberculous meningitis may frequently be traced to measles in earlier 
 life. In some cases enlarged caseating bronchial glands may be the starting- 
 point of the general infection. Among the rarer sequels are tuberculosis 
 of the cervical lymph-nodes and of the bones and joints. Palsies occur 
 as the result of peripheral neuritis but are much more rare than in diph- 
 theria or scarlet fever. 
 
 Diagnosis. — The direct diagnosis of well-developed measles after the 
 appearance of the eruption is generally unattended with difficulty. 
 During an epidemic coryza persistent sneezing and fever are suspicious. 
 The appearance of the eruption on the second or third day upon the mucous 
 membrane of the mouth and throat, and Koplik's sign are of positive 
 diagnostic value. 
 
 The DIFFERENTIAL DIAGNOSIS concerns: 1. RoTHELN (see p. 689). 2. 
 Variola (seep. 661). 3. Typhus fever (see p. 644). 4. Scarlet fever 
 (see p. 679). 
 
 5. Syphilitic roseola usually occurs in the adult. The eruption 
 if carefully examined is seen to be polymorphous, the enlargement of the 
 superficial lymphatic glands is greater, and the signs of syphilis are to be 
 found in the mouth and throat and upon the genitalia. 
 
 6. Drug Exanthems. — Exceptionally the administration of salicy- 
 lates, antipyrin, quinine, turpentine, or copaiba is followed by a rash sug- 
 gesting rather than resembling that of measles. These rashes are not 
 accompanied by fever or throat symptoms, nor have they the uniform 
 appearance and distribution of the measles exanthem (see p. 683). 
 
 In the negro the difficulties in doubtful cases are increased; but the 
 mode of onset, the coryza and bronchitis, and the peculiarities of the rash 
 upon the mucosa of the mouth are of diagnostic importance. The soft flat 
 papules may be distinguished in the darkest skin. 
 
 The diagnosis in certain cases must for a time remain doubtful, espe- 
 cially when the disease appears sporadically or prevails during epidemics 
 of rotheln, scarlatina, variola, or typhus. 
 
 Prognosis. — The character of the prevailing epidemic and previous 
 condition of the individual greatly modify the prognosis. The death-rate 
 during the first six months of life is relatively low; it reaches its maximum 
 during the second year and rapidly falls after the fifth year. After the 
 twentieth year it rises again. In private practice the mortality is about 
 3 per cent., in some epidemics not more than 1.8 per cent.; in hospital and 
 asylum practice and in camps and barracks it may reach 30 per cent. The 
 vital statistics of measles are misleading, because the people regard the 
 disease as an insignificant malady and among the lower classes only the 
 more serious cases come under medical observation. Uncomplicated 
 measles is, in point of fact, a benign infection, but the tendency to pul- 
 monary complications renders it one of the gravest diseases of childhood. 
 It is estimated that about one-third of the cases in which bronchopneu- 
 monia develops terminate fatally. 
 
RUBELLA. 687 
 
 VIII. RUBELLA. 
 
 Roiheln; German Measles; Epidemic Roseola. 
 
 Definition. — An acute epidemic infectious disease characterized 
 by a diffuse maculopapular eruption and swelling of the superficial 
 lymphatic glands. 
 
 Rubella has some points of resemblance to scarlet fever and to measles 
 and was at one time regarded as a hybrid of the two. It is now known to 
 be an independent substantive affection. 
 
 Etiology. — The infecting principle has not yet been discovered. 
 The disease is readily transmissible and usually prevails in extensive epi- 
 demics. Outbreaks occur in series, followed by long intervals during which 
 the disease does not recur. In the absence of an acquired immunity persons 
 at any age are susceptible. Rubella does not protect against the infection 
 of scarlet fever or of measles, nor do these diseases protect those who have 
 passed through them against rubella. 
 
 Symptoms. — The period of incubation varies from ten to twenty days. 
 Prodromes are usually absent. 
 
 Stage of Invasion. — The symptoms are generally mild. They 
 consist of the ordinary manifestations of the reaction of the organism to an 
 infection of little intensity, and the coryza, laryngitis, and pharyngitis 
 which usually precede the exanthemata. The duration of this stage is 
 not constant, varying from a few hours to two or three days. The symp- 
 toms may be so slight as to be altogether overlooked and the rash may 
 then be the first indication of illness. The elevation of temperature is 
 trifling, usually about 100° F. (37.8° C), and rarely exceeding 102° F. 
 (38.9° C), and transient. In asylums and foundling institutions rubella 
 sometimes prevails as a serious malady. 
 
 Stage of Eruption. — The rash commonly appears upon the first 
 day; it may be as late as the third. It shows itself first upon the face 
 and neck, and spreads in the course of twenty-four hours over the body 
 and extremities. It consists of round or oval reddish spots about the 
 diameter of a split pea, mostly discrete, sometimes confluent, and surrounded 
 by areas of hypersemic skin. In some of the cases extensive tracts of the 
 skin are intensely hyperamic so that the rash resembles that of scarlet 
 fever rather than measles. The crescentic arrangement of the papules, 
 seen in measles, cannot usually be made out. The eruption frequently 
 fades irregularly in patches some hours after it comes out, so that 
 certain areas of the surface are covered and not the entire body at the 
 same time. In the course of two or three days the rash gradually disap- 
 pears with fine furfuraceous desquamation, leaving a faint pigmentation 
 which persists for a short time. Slight itching commonly accompanies 
 the rash. The superficial lymphatic glands, especially those of the neck, 
 are slightly enlarged. They undergo resolution in a short time after 
 the fading of the eruption. The suboccipital and lateral chains are 
 commonly involved to a greater extent than the anterolateral. The 
 enlargement of the lymph-nodes in some instances precedes the appear- 
 ance of the eruption. 
 
688 
 
 MEDICAL DIAGNOSIS. 
 
 Relapses are rare; complications infrequent. Albuminuria, bronchitis, 
 coHtis, and pneumonia have been noted. Herpes may occur. There are 
 no special sequels. The immunity acquired by the attack is not always 
 permanent. Second and third attacks may occur. 
 
 Diagnosis. — The early cases may present great difficulty in diagnosis. 
 When an epidemic is prevalent the recognition of rubella is easy. The direct 
 DIAGNOSIS rests upon the trifling nature of the disease, the short initial period, 
 the character of the eruption, its patchy distribution, the early enlargement 
 of the glands, and the absence of severe throat symptoms and coryza. 
 
 DIFFERENTIAL DIAGNOSIS OF SCARLET FEVER, MEASLES, AND RUBELLA. 
 
 Scarlet Fever. 
 
 Contagion 
 
 Transmissibility 
 
 Period of Incubation 
 Prodromes 
 
 Koplik Spots 
 
 Vomiting 
 
 Temperature 
 
 Catarrhal Symptoms 
 Tongue 
 
 Throat 
 
 Lymph-nodes 
 
 Pulse 
 
 Urine 
 
 Eruption 
 
 Highly contagious 
 
 By direct contact, ap- 
 proach, and fomites 
 
 Average 2 to / days 
 
 Highly contagious Variable in epidemics. 
 
 By direct contact, fo- 
 mites, and through the 
 air 
 
 Average 9 to 14 daj-s . . . . 
 
 Direct contact and fomites; 
 not through the air. 
 
 Absent or very brief — i Commonly 3 to 4 days, 
 onset commonly sudden i Drowsiness and ca- 
 I tarrhal symptoms 
 ! 
 
 Not present Present in about 90 per Not present. 
 
 cent, of cases j 
 
 Common at onset Infrequent j Rare. 
 
 Variable; average 1 to 3 
 weeks. 
 
 Slight and of short duration. 
 
 High— 103°-105°F.— last- ; High, lasting about a 
 ing about a week week, average 102°- 
 
 I 104° F. 
 
 Slight elevation, seldom 
 more than 101°-102° F. — 
 subsides in 1 to 3 days. 
 
 More or less intense ery- 
 thematous angina 
 
 Glands at angle of the jaw 
 enlarged 
 
 Desquamation . 
 Convalescence . 
 
 Commonly absent Prominent throughout ... Slight. 
 
 Whitish fur, enlarged Tongue coated 
 
 papiUse ; later dry and 
 red 
 
 Slightly coated, not charac- 
 teristic. 
 
 Moderate redness of mu- 
 cous membranes 
 
 Punctiform red spots over 
 uvula, palate, and phar- 
 
 Ce rvi cal, postauricular General enlargement, espe- 
 and submaxillary cially of postcervical 
 nodes enlarged chains. 
 
 High f requen cv - 
 140 
 
 •120— ! Corresponding to eleva- ' Varies with fever. 
 I tions in temperature i 
 
 Early toxic albuminuria Albuminuria rare 
 in severe cases. Later 
 signs of nephritis 
 
 First appears on neck and 
 chest, spreads slowly 
 over entire body. Ful- 
 ly developed about the 
 fourth day. Small 
 punctate efflorescence 
 or diffuse blush disap- 
 pearing on pressure, 
 lasts about a week. In- 
 tense scarlet color; usu- 
 ally absent around 
 mouth 
 
 Coarse, bran-like ; la- 
 mellar 
 
 Tardy; complications fre- 
 quent, especially ne- 
 phritis, otitis media, etc 
 
 First appears on face, 
 spreads gradually over 
 entire body. Fully de- 
 veloped by the second 
 or third day. Consists 
 of small papules ar- 
 ranged in crescentic 
 groups; these are con- 
 fluent in places; fades 
 in 4 or 5 days; deep red, 
 dusky or purplish 
 
 Albuminuria very rare and 
 slight. 
 
 First appears on face, 
 spreading to neck and 
 breast, tlien to arms, legs 
 and feet. Fades in parts 
 first involved while 
 spreading to others. Two 
 varieties — morbilliform, 
 small, slightly elevated 
 papules, discrete, some- 
 times confluent; scarlatin- 
 iform. Duration 2 to 4 
 days or less. Color rose 
 red but variable. 
 
 Branny 
 
 Slow; tendency to com- 
 plications as broncho- 
 pneumonia and other 
 infectious diseases, es- 
 pecially tuberculosis 
 
 Fine, branny. 
 
 Rapid 
 tions. 
 
 without complica- 
 
WHOOPING-COUGH. 689 
 
 Differential Diagnosis. — Rubella is most frequently mistaken for 
 mild measles or scarlatina. From measles it is distinguished by the want of 
 prominence of catarrhal phenomena, the slighter fever, the brighter hue 
 of the eruption, the absence of the crescentic grouping of the papules, the 
 fact that the adenitis involves to a greater degree the suboccipital and 
 postauricular glands, and the absence of Koplik's sign; from scarlatina by 
 its gradual onset, benign character, the absence of severe throat symptoms, 
 the peculiarities of the rash, the character of the desquamation, the tongue, 
 and the fact that there is no special tendency to nephritis. 
 
 Prognosis. — Rubella is a benign disease almost invariably terminating 
 in recovery. In foundling hospitals and asylums it has sometimes assumed 
 unusual severity, and fatal cases have occurred commonly as the result of 
 an intercurrent pneumonia, colitis, or nephritis, rather than of the primary 
 disease (see table on opposite page). 
 
 THE FOURTH DISEASE. 
 
 In 1900 Dukes described an infectious disease which he called ''the 
 fourth disease." This communication attracted considerable attention 
 and the subject has been discussed by a number of clinicians. The incuba- 
 tion period is stated to be about the same as that of German measles, ten 
 to twenty-one days. Prodromes were absent in most of the cases but 
 malaise and a mild erythematous angina were occasionally observed at the 
 time of the appearance of the rash. The evolution of the exanthem was 
 rapid, the entire body being covered in the course of a few hours. Whether 
 or not it was present upon the face is not stated. Its color was like that 
 of scarlet fever but brighter. The superficial lymph-nodes were enlarged. 
 The temperature was subfebrile, not often exceeding 101° F. (38.5° C). 
 Upon the subsidence of the eruption there was desquamation. Sequels 
 were not observed and the attack did not confer immunity against scarlet 
 fever or rubella. This affection has not been generally recognized as a 
 clinical entity. 
 
 IX. WHOOPING-COUGH. 
 
 Pertussis; Tussis Convulsiva. 
 
 Definition. — An infectious endemic and epidemic disease character- 
 ized by hypersesthesia and catarrh of the respiratory tract and a peculiar, 
 spasmodic cough occurring in paroxysms which terminate in a prolonged 
 inspiration attended by a shrill crowing sound or whoop. 
 
 Etiology.^PREDisposiNG Influences. — Whooping-cough is a widely 
 prevalent disease. The individual susceptibility, like that to measles, is 
 almost universal. Very few persons unless rendered immune by a previous 
 attack escape upon exposure. Nearly twice as many cases occur during 
 the winter and spring as during the summer and autumn. It is peculiarly 
 a disease of infancy and early childhood. More than one-half the cases 
 occur during the first two years of Hfe; very few cases after the second 
 dentition. That the immunity after the seventh year is acquired rather 
 than congenital is shown by the fact that in individuals not protected by a 
 previous attack the disease may be contracted upon exposure at any period 
 
 44 
 
690 MEDICAL DIAGNOSIS. 
 
 of life. Sucklings are not exempt. Sex is without influence in early life, 
 but among adults women are more liable than men, a fact to be explained 
 in part by- increased exposure, in part by the more common neurotic con- 
 stitution in women. Pregnancy appears to be attended with an especial 
 liability. The previous condition of health is of great importance. Delicate 
 children and those suffering from nasal or bronchial catarrh are especially 
 liable to contract the disease upon slight exposure. 
 
 Exciting Cause. — The specific infecting agent has not yet been dem- 
 onstrated. Afanassiew, 1887, discovered in the secretions a short bacillus, 
 cultures of which injected into the respiratory passages in animals produce 
 catarrhal inflammation. Koplik has more recently found a bacillus resem- 
 bling that of influenza but larger, which he regards as the cause of the 
 disease. Spengler and others have described an organism to which the 
 name Bacillus pertussis has been given. 
 
 Clinical experience makes it clear that the infective material is elim- 
 inated by way of the mucous discharges and perhaps by the expired air. 
 It reaches the organism with the inspired air. Actual contact, close ap- 
 proach, or fomites, especially such articles as the handkerchief or towel, 
 constitute the usual means of transmission from the sick to the well. Under 
 certain circumstances a third person may readily transmit the infective 
 material. The dried sputum circulating as dust in the atmosphere is prob- 
 ably also a source of infection. The disease is transmissible from the 
 earliest appearance of the catarrhal symptoms, and since it cannot be 
 recognized until the spasmodic stage, and since in suitable weather the 
 patients are kept as much as possible in the open air, the patient alike 
 in the nursery and school and out of doors is in constant danger of dis- 
 seminating it. The attack confers an immunity which in most cases is life- 
 long. The occasional occurrence of cases in elderly persons, who have 
 passed through an attack in childhood, living in the house with children 
 suffering from the disease, shows, however, that the protection is not always 
 permanent. 
 
 Whooping-cough is endemic in large cities when it takes the form of 
 extended epidemics at irregular intervals of from two to four years. Its 
 prevalence is sometimes so wide-spread as to merit the descriptive term 
 pandemic. Outbreaks are not infrequently associated with epidemics of 
 measles, scarlet fever, or varicella, and these diseases occasionally run their 
 course coincidently with whooping-cough in the same individual. 
 
 Symptoms. — The period of incubation varies from seven to ten days. 
 If, after exposure, two full weeks elapse without the development of catar- 
 rhal symptoms, the probability becomes very strong that infection has not 
 taken place. 
 
 The Course of the Attack. — (a) The catarrhal stage begins with the 
 symptoms of an ordinary subacute bronchitis, which gradually increase in 
 intensity. In the course of some days the cough tends to become par- 
 oxysmal, the spells being more frequent and severe during the night and 
 after meals. Running at the nose, hoarseness, and a croupy ringing cough, 
 the indications of a nasal and laryngeal catarrh of moderate severity, are 
 associated symptoms. There is very often fever of moderate grade. The 
 duration of this stage is about a week or ten days. Cases vary greatly in 
 
WHOOPING-COUGH. 691 
 
 this respect, however, some children developing the whoop in the course 
 of a day or two from the beginning of the catarrhal symptoms, others not 
 until three or four weeks have elapsed. 
 
 (b) Spasmodic or Paroxysmal Stage. — The fever subsides. The catar- 
 rhal symptoms continue and may be intensified. The cough becomes dis- 
 tinctly paroxysmal and characteristic, the attacks ending in a long-drawn 
 "whoop" from which the disease receives its name. The true nature of 
 the disease is now first apparent. The patient experiences a sensation of 
 tickling in the larynx or under the sternum. Little children run terrified 
 to the nurse or mother and cling to her; older persons grasp some object, 
 as the arms of a cuair, for support. The fully developed paroxysm usually 
 begins with a long-drawn inspiration which is immediately followed by a 
 series of ten or fifteen short explosive coughs of increasing intensity and 
 repeated so rapidly that breathing is ineffectual until at length a prolonged 
 deep inspiration occurs, during which the whoop is produced. One or more 
 new series of coughs terminating in the whoop may forthwith follow and 
 the paroxysms may not come to an end until a mass of tough stringy mucus 
 is raised. This is usually small but in little children it is often very abund- 
 ant and must be removed from the mouth by the finger. It may be ex- 
 pelled in the act of vomiting. An abundance of thick mucus is at the same 
 time discharged from the nose. The signs of mechanical disturbance of 
 the venous circulation are conspicuous. The face and neck become con- 
 gested and cyanotic, the veins of the face and the jugulars stand out prom- 
 inently, there is protrusion of the eyeballs, sometimes marked injection 
 of the conjunctivae, and the lips are swollen and blue. As the attack comes 
 to an end the face or the whole body may break out into a more or less 
 profuse sweat. In severe paroxysms the sphincters may be relaxed. Head- 
 ache and vertigo are common, and at the close of a severe attack the child 
 sinks exhausted upon the mother's lap. The condition is most distressing, 
 but in a little while the child usually recovers himself and goes about 
 his play until another spell occurs. The single paroxysm lasts from 
 fifteen to forty-five seconds, rarely longer; when two or more immediately 
 succeed each other, the whole attack may be prolonged to two or three 
 minutes. They are fortunately not all of the same intensity, frequent 
 milder attacks occurring between those which are more severe. They may 
 be brought on by taking food or drink, especially anything cold, by laughter 
 or vexation, and in some cases by traction of or pressure upon the tongue. 
 They are more frequent in a close room than in the open air and by night 
 than during the day. The number of paroxysms varies from three or four 
 to sixty to one hundred during twenty-foiu- hours. Severe paroxysms 
 after the taking of food almost always cause vomiting and the patients 
 very often become much emaciated and reduced in strength. In many 
 cases, however, as soon as the distressing symptoms are over the child 
 will eat another meal, which should always, under these circumstances, be 
 offered to it. The violence of the cough forces the tongue against the 
 lower incisor teeth and very often causes laceration of the mucous mem- 
 brane of the frsenum, which is followed by superficial ulceration. A marked 
 leucocytosis occurs. In very mild cases the paroxysms are not only less 
 frequent but they are also less violent, and occasional cases occur in which 
 
692 MEDICAL DIAGNOSIS. 
 
 the whoop is absent throughout the attack, the nature of which is apparent 
 from the presence of other cases in the house, the spasmodic spells of cough- 
 ing attended with vomiting and terminating with the expulsion of a mass 
 of tenacious mucus, and the protracted course of the illness. 
 
 The cough is the result of an extended irritation involving the upper 
 air-passages. It is probable that the gradual accumulation of mucus in the 
 region of the bifurcation of the trachea plays an important role in its pro- 
 duction. The mechanism of the whoop consists in the forcible indrawing 
 of air through the spasmodically narrowed glottis. The disease has the 
 characteristics of a neurosis affecting the respiratory tract. 
 
 Laryngoscopic examination frequently shows the mucous membrane 
 of the larynx to be congested and swollen, especially in the interarytenoid 
 space, and sometimes the seat of hemorrhagic patches or superficial ero- 
 sions. Irritation of the mucous membrane between the arytenoids or of 
 the posterior surface of the epiglottis with a sound, always causes the 
 paroxysm. A similar condition of congestion and swelling has been ob- 
 served in the trachea, in which a plug of mucus has been seen just before 
 the paroxysm — Roosbach. The difficulty of such examinations is obvious. 
 
 Physical examination yields unimportant signs. The resonance is 
 impaired during the paroxysm and increased at its close. Auscultation 
 yields commonly an enfeebled vesicular murmur and a few bronchial rales, 
 usually dry — sonorous or sibilant. 
 
 The average duration of the spasmodic stage is about one month. 
 The symptoms progressively increase in intensity for a fortnight or longer, 
 remain stationary for a time, and gradually subside. In mild cases this stage 
 may not exceed a week or ten days, or the whoop may be wholly absent; in 
 severe cases it may be prolonged, especially if the patient must be housed, 
 as in the winter, for three or four months, with remissions and exacerbations. 
 
 (c) Stage of Decline. — The paroxysms diminish in severity and fre- 
 quency; the expectoration becomes more abundant and less tenacious; 
 and finally, as at the beginning, the symptoms are those of an ordinary 
 catarrhal bronchitis, which varies in intensity and continues two or three 
 weeks in favorable and much longer in unfavorable cases, especially dur- 
 ing the winter months when convalescents must be kept housed. 
 
 The duration of the attack varies between two and four months. 
 A majority of the cases in older children can scarcely be regarded as ill. 
 They are out of bed and eat well, and in proper weather can pass some 
 hours in the open air. They, however, lose flesh and become pale. 
 
 A cough habit is often developed during the attack, and for several 
 months after full convalescence has been established, with every cold 
 or nasobronchial catarrh, however trifling, a paroxysmal cough with 
 whooping returns, and this is particularly the case with the children of 
 neurotic parents. Under these circumstances the disease is not commu- 
 nicated. Relapses practically do not occur. Second attacks are by no 
 means uncommon, but as has already been mentioned they usually occur 
 after the lapse of years, and children and their parents or grandparents 
 often suffer at the same time. 
 
 Complications and sequels are numerous and may be arranged in 
 two categories, the mechanical and the infectious. 
 
WHOOPING-COUGH. 693 
 
 (a) The mechanical complications and sequels are caused by increased 
 respiratory pressure during the paroxysm, or circuhitory disturbances. 
 Acute emphysema is common. It is as a rule transient. If it persists 
 pseudohypertrophic emphysema results. Rupture of the tissue of the 
 lung may give rise to interstitial emphysema, or the air may find its way 
 along the peribronchial connective tissue to the anterior mediastinum or 
 upwards and give rise to subcutaneous emphysema of the neck. Pneu- 
 mothorax is less common. Dilatation of the right heart may occur in 
 consequence of the interference with the pulmonary circulation during 
 the paroxysms. It is possible that valvular disease may, in some instances, 
 be due to the heart strain of severe whooping-cough. The pulse after the 
 paroxysm is often feeble and irregular, and progressively so as the attack 
 goes on. The vomiting is largely due to mechanical disturbance caused 
 by cough. Sometimes the jDatient vomits freely during several paroxysms 
 daily for j^eriods of weeks, and as a result is greatly reduced in flesh and 
 strength. Partly as the result of the violent succussion and partly from 
 exhaustion, involuntary discharges of gas or fecal matter are of common 
 occurrence in severe paroxysms. Prolapse of the bowel and hernia are 
 common and must be ascribed to the same causes. Involuntary discharge 
 of urine likewise occurs. Pregnant women frequently abort. Very common 
 are lesions of the blood-vessels during the paroxysms, resulting in hemor- 
 rhages into the skin, particularly about the forehead and eyes, and into the 
 mucous membranes, especially subconjunctival ecchymoses. Much less 
 common are slight hemorrhages — not more than a few drops — from the ear 
 in consequence of superficial lacerations of the tympanitic membrane. 
 Epistaxis is very frequent, haemoptysis rare. Hemorrhage from the bowel 
 is very unusual, and when it occurs is due to the mechanical derangements 
 which cause prolapse. Convulsions are not uncommon, especially in very 
 young children, and have been ascribed to the engorgement of the cerebral 
 vessels. Meningeal and cerebral hemorrhages occur, but these accidents 
 are extremely infrequent. Hemiplegia and aphasia may result. Sudden 
 death has occurred. 
 
 (b) The infectious complications include inflammatory enlargement 
 of the bronchial glands, sufficient in some instances to give rise to dulness 
 over the manubrium; bronchopneumonia, which is very common and 
 the cause of death in the majority of the fatal cases; tuberculosis, which 
 may take the form of a tuberculous bronchopneumonia, miliary tuber- 
 culosis, or an acute caseous consumption; croupous pneumonia, which is 
 infrequent; pleurisy, still more rare; and nephritis, likewise very uncom- 
 mon. Other inflammatory complications are seldom encountered. Tran- 
 sient albuminuria is not infrequent and glycosuria is occasionally observed. 
 Many of the complications are essentially chronic and persist as sequels. 
 The patients not infrequently show an especial predisposition to recur- 
 rences of bronchial catarrh. Emphysema and asthma are common sequels. 
 
 Diagnosis. — The direct diagnosis of whooping-cough during the early 
 part of the catarrhal stage is impracticable. In the course of a week the 
 increasing severity of the symptoms and the tendency of the cough to 
 become paroxysmal and worse at night, to cause vomiting, suffusion of 
 the eyes, and flushing of the face, render the diagnosis during an epidemic, 
 
694 MEDICAL DIAGNOSIS. 
 
 or with a history of exposure, a probable one. A like uncertainty arises 
 in regard to very mild cases. A child may cough for several weeks without 
 having a well-developed paroxysm. ' If there be no fever, only a few rales 
 now and then upon auscultation, and ordinary treatment be without 
 effect, the diagnosis by exclusion may be made. The occurrence of the 
 whoop renders the diagnosis easy and certain. It is to be remembered 
 that pressure upon or traction of the tongue, the act of swallowing, and 
 emotional disturbances may cause a paroxysm — facts which the physician 
 may use for diagnostic purposes. The diagnosis may also be difficult in 
 early infancy, when the cough attending ordinary bronchitis sometimes 
 assumes a paroxysmal character and is attended with a croupy or crowing 
 sound that is suggestive of the whoop. The ulcer upon the frsenum and 
 subconjunctival or other hemorrhages are not apt to occur in mild cases 
 and these only present diagnostic uncertainties. 
 
 Prognosis. — Uncomplicated whooping-cough tends to run a favor- 
 able course. The great tendency to compHcations places it, however, 
 among the most serious of the diseases of childhood. It has been estimated 
 that fully two-thirds of the deaths from this disease occur within the first 
 year. After the fourth year the danger rapidly diminishes. Broncho- 
 pneumonia and enterocolitis are the most common causes of death. Con- 
 vulsions very often occur in fatal cases in early infancy. Dehcate and 
 badly nourished children, those Hving under improper hygienic conditions, 
 those who have rickets or who have been debilitated by a recent attack of 
 measles, influenza, or other serious infection are apt to suffer severely. 
 The aged bear whooping-cough badly. It is peculiarly fatal among negroes. 
 The danger of early or remote tuberculosis lends especial importance to 
 this disease. Death may occur during a paroxysm from intracranial 
 hemorrhage or asphyxia, but such accidents are exceedingly uncommon. 
 The prognosis is to some extent modified by the frequency as well as by 
 the severity of the paroxysms. Cases run a more favorable course in sum- 
 mer than in winter. Reliable general statistical facts relating to the mor- 
 tafity are not available. Many of the milder cases never come under medical 
 observation. In foundling asylums and children's hospitals the death- 
 rate may exceed twenty-five per cent. 
 
 X. MUMPS. 
 
 Epidemic Parotitis. 
 
 Definition. — An acute infectious disease, prevailing in limited epi- 
 demics, and characterized by inflammation and enlargement of the sahvary 
 glands, especially the parotid. 
 
 Etiology. — Predisposing Influences. — Mumps is a wide-spread 
 disease and is usually endemic in large cities. Sporadic cases occur and 
 become foci of circumscribed outbreaks which run a fingering course of 
 months or, in some instances, of a year or more. The infecting principle 
 is much less readily transmitted than that of many of the contagious dis- 
 eases and the congenital immunity much more common. In general 
 practice extensive epidemics are infrequent, but when the disease appears 
 
MUMPS. 
 
 695 
 
 in reformatory institutions and schools a large proportion of the inmates 
 usually contract it. The cases are more numerous in the spring and autumn 
 than at other seasons. Mumps is peculiarly a disease of childhood and 
 adolescence. It is not common in early infancy nor after the twentieth 
 year. More boys than girls suffer in a ratio estimated as high as two to one. 
 
 Exciting Cause. — The specific cause has not been demonstrated. 
 The disease is directly transmitted by personal contact. Rare instances 
 have been observed in which the contagion has been indirectly transmitted 
 by a third person or by fomites, especially clothing. Two views may be 
 entertained as to the mode of infection. The first is the one generally 
 accepted, namely, that the pathogenic principle finds its way from the 
 mouth to the glands along the course of the salivary ducts and, as the 
 parotid is usually involved, through the duct of Stenson; second, that the 
 infection is a general one, to which 
 certain anatomical structures, as the 
 salivary glands and, in particular, the 
 parotid gland, especially react. The 
 occasional occurrence of inflammation 
 of the testes, and of the ovaries and 
 mammae in the female, and the defi- 
 nite incubation and typical course of 
 the disease lend support to this view. 
 
 Symptoms. — The period of incu- 
 bation varies from fourteen to twenty- 
 one days. In rare instances it has 
 appeared to be shorter. Prodromes 
 are commonly absent. In mild cases 
 the swelling and associated local 
 symptoms constitute the earliest 
 manifestations. In severer cases 
 more or less pronounced constitu- 
 tional disturbance, with shivering, vomiting, and moderate fever, 100°- 
 101° F. (37.8°-38.3° C), characterize the invasion, which is abrupt and 
 precedes the local inflammation by about twenty-four hours. In severe 
 cases the temperature may reach 103°-104° F. (39.5°-40° C). A feehng 
 of tension with soreness is felt just below one ear, more commonly 
 the left. Upon examination slight swelling may be observed, which 
 increases until, in the course of forty-eight hours, it reaches its maxi- 
 mum. The parotid is now greatly enlarged and the adjacent tissues 
 of the neck and often of the side of the face tensely osdematous. The 
 skin is glossy, hard to the touch, its folds are obliterated, and, commonly, 
 by reason of interference with the circulation by pressure, white in color. 
 It pits only slightly upon pressure. The swelling occupies the lateral 
 region of the neck between the jaw and the mastoid process, extending 
 upward to the zygoma and downward and forward toward the clavicle 
 and the median line. Its extent varies with the intensity of the attack. 
 The ear is pushed upward, and its lobule, which occupies the centre 
 of the swelling, is sharply pushed outward. In almost all instances the 
 other side is affected in a day or two, sometimes not for several days or 
 
 Fig. 234. — Mumps. — Cotton. 
 
696 MEDICAL DIAGNOSIS. 
 
 until the inflammation upon the side first affected has subsided. Very 
 often the swelling of the second gland is so sHght that it can only be de- 
 tected upon close scrutiny. The disfigurement is marked and when both 
 sides are affected the patient may be scarcely recognizable. In some 
 instances the other salivary glands are involved, and several cases have 
 come under my observation in house epidemics in which the submaxillary 
 glands have been inflamed while the parotids have remained unaffected. 
 The sublingual glands and the lachrymal glands may also be involved. 
 Movements of the jaw, the act of deglutition and, in severe cases, even 
 phonation are attended with difficulty and pain. There is trouble in tak- 
 ing any form of nourishment, even liquids. The fetor is often extreme. 
 Movements of the head are restricted and in order to relieve tension there 
 is flexion of the neck toward the affected side. The salivary secretion is 
 usually diminished, exceptionally increased. Its reaction may be acid. 
 Slight deafness and earache often occur, and in rare instances otitis media. 
 Permanent deafness, usually one-sided and complete, without otitis media, 
 has been observed. This condition develops suddenly during the course 
 of the disease or in convalescence, with nausea and vomiting, vertigo and 
 a staggering gait. It is probably due to a lesion of the labyrinth. After 
 from five to ten days the swelling gradually subsides, the stiffness and 
 impairment of movement disappear, and normal conditions are restored. 
 Local desquamation may occur. The glandular inflammation undergoes 
 resolution without abscess formation. If suppuration occurs it is due to 
 a mixed infection and must be regarded as a complication. The pus may 
 be evacuated externally or may burrow in the tissues of the neck. Secondary 
 pyothorax or pyopericardium may follow with or without general sepsis. 
 
 Orchitis occurs in about one-third of the cases after puberty. In 
 infancy and childhood it is exceedingly rare. It usually affects one testicle 
 onl}^, occasionally both. Weight, swelling, and pain are the symptoms. 
 The testicle may be enormously enlarged. Epididymitis is not common. 
 There may be effusion into the tunica vaginalis, scrotal oedema, and a mild 
 mucopurulent urethral discharge. Atrophy may result and, when both 
 testicles are involved, loss of the procreative function. Even with some 
 atrophy of both testicles functional power may be retained. In adoles- 
 cents and young adults great anxiety upon this question arises during the 
 attack. Mastitis may occur in boys. In females also, usually after the age 
 of puberty, enlargement and tenderness of the breasts, pain and tender- 
 ness in the ovaries, hsematoma of the labia, or a vulvovaginal discharge 
 may occur. These phenomena are very uncommon. Thyroid enlarge- 
 ment is extremely rare. 
 
 Exceptionally the symptoms are very severe. High fever may be 
 accompanied by vomiting, delirium, and sleeplessness. Great exhaustion may 
 result. As a rule the patient is not seriously ill. The constitutional dis- 
 turbance comes to an end within a week; the local symptoms more slowly. 
 
 Relapse is extremely rare. The attack confers an immunity which 
 is practically permanent. 
 
 Complications and Sequels. — The frequent involvement of the gen- 
 erative organs and the fact that it sometimes precedes the parotitis or 
 occurs without it compel the recognition of these local inflammations as 
 
INFLUENZA. 697 
 
 incidental manifestations of the disease rather than comphcations. The 
 frequency of actual complications varies in different epidemics. The 
 fatal cases are frequently associated with meningeal symptoms. Hemi- 
 plegia, coma, and acute mania may occur. Among the rare complications 
 are albuminuria, nephritis with ursemic accidents, polyarthritis, endo- 
 carditis, facial palsy from pressure, peripheral neuritis, and hemiplegia. 
 The common sequels have been already indicated. The inflamed glands 
 may not undergo resolution but remain enlarged and hard. Ptyalism or 
 xerostomia may persist for some time. Parotid bubo is very rare in idio- 
 pathic mumps. Local gangrene may occur. Deafness may be permanent. 
 Optic atrophy is among the rarest of sequels. 
 
 Diagnosis. — The direct diagnosis of mumps is under ordinary circum- 
 stances easy. The location of the swelling in front of the ear and below it, 
 and the abrupt displacement of the lobule outwards, together with the 
 circumscribed outline at first corresponding to that of the parotid, are im- 
 portant anatomical considerations. Mumps is a primary affection and 
 very rarely goes on to suppuration. The relative rapidity with which the 
 swelling develops and subsides is characteristic of mumps. 
 
 Differential Diagnosis. — L Parotid bubo. The glandular inflam- 
 mation is secondary to some acute infection or sepsis and commonly pro- 
 ceeds to multiple or general abscess formation. This condition is very 
 rare in childhood. 2. Acute cervical adenitis. The swelling is below the 
 angle of the jaw. It does not at any time correspond to the outline of the 
 parotid; nor has it the location of the submaxillary glands. It may be 
 tuberculous or secondary to tonsillar or peritonsillar infection. Irregular 
 contour, redness, the absence of involvement of the generative glands in 
 all cases, and the absence of a definite, self-limited course are to be con- 
 sidered. 3. Hodgkin's disease is a chronic affection of the lymphatic 
 glands. The salivary glands are not- involved. 4. Abscess from disease 
 of the jaw in dental caries gives rise to swelling localized in wholly different 
 positions from that of the parotid and is not characterized by definite 
 constitutional phenomena or transmissibility. 5. Gonorrhoeal orchitis 
 has a definite history and upon examination of the discharge the gon- 
 ococcus is found. Doubts can only arise when the inflammation of the 
 testes precedes or occurs coincidently with the parotitis. 
 
 Prognosis. — Mumps, in the vast majority of cases, is a mild disease 
 and terminates in complete recovery in a short time. 
 
 XI. INFLUENZA. 
 
 Epidemic Catarrhal Fever; La Grippe. 
 
 Definition. — An acute, infectious, pandemic disease, caused by the 
 bacillus of Pfeiffer. It is characterized by catarrh of the mucous mem- 
 brane of the respiratory tract, less frequently of the digestive tract, by 
 quickly on-coming debility and nervous symptoms. There is a tendency 
 to complications, especially pneumonia. The general outbreaks are 
 followed for some years by the local epidemic or endemic occurrence 
 of the disease. 
 
698 
 
 MEDICAL DIAGNOSIS. 
 
 Etiology. — Predisposixg Influexces. — When the disease invades 
 a community, a large proportion of the population is attacked without dis- 
 tinction. Previous illness affords no protection. Aged and infirm persons 
 and those of nervous temperament are pecuHarly liable to suffer, but the 
 robust possess no immunity. All races and dwellers in every clime are 
 hable to the disease. Adults are attacked earher than chilclren and in 
 some epidemics the latter have manifested a sHght relative immunity. 
 A limited number of persons appear to be immune and there are those 
 who, ha^dng passed through a series of outbreaks in safety, finally acquire 
 the disease. An attack of influenza confers no exemption from the disease 
 in subsequent outbreaks, and, independently of relapses, which are fre- 
 quent, individuals have been known to experience a second attack during 
 the prevalence of the same epidemic. The disease bears no relation to 
 
 known atmospheric conditions. It may 
 prevail at any season of the year. 
 It follows lines of travel and advances 
 at about the ordinary rate of com- 
 mercial intercourse. The duration of 
 the outbreak in a community is from 
 four to eight weeks, exceptionally a 
 longer time. The epidemic of 1831 was 
 continuously prevalent in Paris for 
 nearly a year. The epidemics rapidly 
 reach their height and usually subside 
 almost as suddenly as they begin. In 
 large cities influenza makes its appear- 
 ance at the same time in several differ- 
 ent localities and spreads from these 
 as foci of infection throughout the 
 community. In the great pandemics of influenza the other acute 
 infectious diseases are less common than usual. 
 
 Exciting Cause. — Pfeiffer — 1892 — isolated from the nasal and bron- 
 chial secretions of patients suffering from influenza a bacillus now recognized 
 as the cause of the disease. It occurs in great numbers in the nasal secre- 
 tions and is frequently seen in the sputum in almost pure culture. It 
 persists in the secretions for some time after the symptoms have subsided. 
 The disease is readily transmissible by direct contact and fomites; 
 also to short distances by the atmosphere. Influenza bacilli are destroj^ed 
 by drying, and rapidly perish in water. They probably enter the body by 
 means of the inspired air. Pfeiffer, from a study of the biological char- 
 acters of the influenza bacillus, concludes that its development outside 
 the human body — that is to say, in the ground or in water — is impossible; 
 that its dissemination when dry can take place only to a limited extent, 
 and that the contagium is, as a rule, transferred b}^ the recent moist secre- 
 tion from the nasal and bronchial mucous surfaces of influenza patients. 
 Symptoms. — Influenza presents the greatest variations as regards 
 intensity, from a trifling indisposition to an illness of the gravest kind. 
 In every epidemic the majority of the sufferers manifest the disease in a 
 mild form, very many in a rudimentary form. The symptom-complex 
 
 Fig. 235. — Bacillus influenzae in sputum. 
 
INFLUENZA. 
 
 699 
 
 is extremely variable and greatly modified by complications and sequels. 
 The period of incubation varies from a few hours to three days. Prodromal 
 symptoms are rare. The onset is abrupt, marked by chilliness or a chill 
 which may be repeated. There is fever, headache (usually intense), with 
 pain back of the eyeballs, severe pain in the back, limbs, and joints, and 
 a general feeling of muscular soreness with tenderness upon pressure. 
 These symptoms are accompanied by mental and physical depression, 
 with malaise and restlessness. The circulation is depressed, the spleen 
 slightly enlarged. In a considerable proportion of the cases catarrhal 
 phenomena do not occur and the attack consists of a fever-storm with its 
 associated phenomena, together with rapidly developing asthenia, more 
 or less profound. The cases may in general be grouped as mild and severe. 
 In mild cases the chill may be slight or absent altogether. Headache 
 and muscle pains are moderate. There is a sense of weariness upon effort, 
 
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 ■disinclination for affairs, some difhculty in fixing the attention. Coryza, 
 erythematous angina, and a tickling cough occur. The fever is usually 
 slight, the temperature not rising above 102° F. (39° C). Many of the 
 patients suffering from influenza in this form are able to continue their 
 ordinary avocations. No great intensification of the symptoms is neces- 
 sary, however, to compel them to betake themselves to bed. 
 
 In the severer cases the chill is more marked or the shivering more 
 prolonged. Fever is rapidly established, the acme being reached within 
 twenty-four or thirty-six hours. The temperature may rise to 104° or 
 105° F. (40°-40.5° C). Sensations of heat alternate with chilliness. There 
 is pain in the orbits and at the root of the nose. Coiyza is severe. Epi- 
 .staxis is occasionally observed. The throat is sore ; there are tickling sen- 
 sations in the upper air-passages, hoarseness, and sometimes dyspnoea. 
 The cough is paroxysmal, distressing, and at first unproductive. Chest 
 pains and stitches in the side also occur. The pulse may be full and com- 
 pressible; more commonly it is feeble, small, and irregular. It is as a rule 
 only moderately increased in frequency. In some cases there is slight 
 
700 MEDICAL DIAGNOSIS. 
 
 blueness of the lips and finger-tips. The patient is distressed by want of 
 sleep. At the end of four or five days the febrile symptoms decline rapidly, 
 less commonly gradually. The defervescence is often accompanied by 
 copious sweat, spontaneous diarrhoea, increased flow of sedimentary urine, 
 and considerable amelioration of the subjective symptoms. The catarrhal 
 symptoms outlast the fever two or three days, but cough and expectora- 
 tion may persist for some time. Cutaneous hyperesthesia is often present 
 and areas of burning pain in the skin occur. Neuralgias may develop 
 during the attack and persist for a long time. 
 
 Symptoms referable to the nervous system may dominate the clin- 
 ical picture. In other cases gastro-intestinal symptoms are conspicuous. 
 The attack may develop abruptly with symptoms like those of cholera 
 morbus. Finally, cases occur in which there is no marked localization of 
 the infectious process. The patient suffers from fever and great depres- 
 sion and simultaneous implication of the respiratory, circulatory, nervous, 
 and gastro-intestinal systems. 
 
 Herpes is common. Urticaria and purpura have been observed. The 
 sense of smell is often lost and that of taste impaired or perverted. The 
 hearing is blunted. Febrile albuminuria is not uncommon in the severe 
 cases. A mild anaemia develops in grippe. Leucocytosis does not occur 
 in uncomplicated cases. 
 
 Attempts have been made to arrange the cases of influenza in different 
 groups, and in theory a thoracic, cardiac, gastro-intestinal, and nervous 
 variety may be recognized. In practice, however, various described types 
 merge into each other, and are so modified by individual peculiarities of the 
 patient and by complications which arise in the course of the attack that 
 there is but little advantage in referring particular cases to theoretical 
 categories. 
 
 The duration of the milder forms of influenza is from one to three or 
 four days. In well-developed cases without complications convalescence 
 sets in between the fourth and seventh days. Severe cases with compli- 
 cations may be protracted for several weeks. Relapses occur in about 
 10 per cent, of the cases. If the fever continues beyond the seventh or 
 eighth day it will usually be found upon careful examination to be due to 
 some complication. The temperature curve of influenza not infrequently 
 merges into that of a complicating bronchitis, bronchopneumonia, or 
 croupous pneumonia. 
 
 Complications and Sequels. — Among the complications, intense bron- 
 chitis, implicating the large and small tubes and giving rise to a prolonged 
 symptomatic fever, may occur. This bronchitis has no special peculiar- 
 ities. The sputum may be abundant and thin, or may be of a greenish- 
 yellow color and nummular. It is sometimes bloody. Bronchopneumonia 
 is not uncommon, especially in children and aged persons. It may be due 
 to the influenza bacillus or to mixed infection. It constitutes a serious 
 complication and is a frequent cause of death. Influenza pneumonia may 
 occur at any time during the course of the attack. Its symptoms are fre- 
 quently obscure and its course irregular. Extensive involvement of the 
 lung may take place Avithout great rise of temperature. Croupous pneu- 
 monia is less common. Abscess or gangrene of the lung may follow the 
 pneumonia of grippe. Pleural effusion is not an uncommon complication 
 
INFLUENZA. 701 
 
 and empyema may occur. Pulmonary tuberculosis may develop after 
 an attack of influenza, or, if already present, it is usually aggravated. En- 
 docarditis and plastic or purulent pericarditis may occur in connection 
 with pneumonia or independently of that complication. 
 
 Among complications relating to the nervous system meningitis, 
 encephalitis, and brain abscess are to be mentioned. Peripheral neuritis 
 not uncommonly develops during the course of the attack. Headache, 
 insomnia, and neuralgia are common sequels. Forms of neurasthenia 
 occur. Hysteria and chorea have been noted, and psychic disorders, as 
 melancholia and the insanities of malnutrition. 
 
 Otitis media constitutes one of the more distressing complications and 
 sequels of influenza. Rapid disorganization of the structures of the mid- 
 dle ear may give rise to permanent deafness. Persistent vertigo may follow 
 influenza. Conjunctivitis is frequent and may be severe. Iritis and optic 
 neuritis are rare sequels. I have seen severe and protracted xerostomia 
 develop after defervescence. Cardiac symptoms are common and dis- 
 tressing. They consist of heart consciousness, precordial pain, breath- 
 lessness and faintness upon effort, and unsatisfactory sleep. The physical 
 signs are those of an enfeebled and irregular heart. Arrhythmia, tachy- 
 cardia, and bradycardia are common. These symptoms are to be ascribed 
 in part to the disturbed nutrition of the heart muscle and in part to the 
 derangements of the cardiac innervation. An attack of influenza has 
 appeared in some instances to be the starting-point of pernicious anaemia. 
 Less common complications and sequels are parotitis, nephritis, phlebitis, 
 venous and arterial thrombosis. 
 
 Diagnosis. — Direct Diagnosis. — During a pandemic it is unattended 
 with difficulty. The progress of the outbreak, the number of individuals 
 attacked nearly at the same time or in quick succession, the profound 
 asthenia, and the prominence of the nervous symptoms serve to distinguish 
 it from other epidemic diseases. Bacteriological diagnosis can be made 
 by an examination of the bronchial sputum. 
 
 Differential Diagnosis. — Non-specific Influenza. — The differential 
 diagnosis between influenza and non-specific catarrhal affections rests upon 
 the pandemic or epidemic prevalence of the former, great prostration, and 
 prominence of the nervous symptoms. The relation of these two diseases 
 is analogous to that between cholera Asiatica and nostras. The diseases 
 designated by the term influenza may be divided into : (1) pandemic influ- 
 enza vera, caused by the bacillus of Pfeiffer; (2) endemic-epidemic influenza 
 vera, recurring from time to time locally after the pandemics, caused by 
 the same infecting agent; (3) endemic influejiza nostras — pseudo-influenza, 
 catarrhal fever — sometimes miscalled grippe — a disease sui generis. The 
 infecting micro-organism is not known. Enteric Fever.— In the gastro- 
 intestinal form the malaise, headache, dulness of hearing, mental depres- 
 sion, fever, epistaxis, a coated tongue, tender belly, and diarrhoea may 
 suggest enteric fever. An attack of influenza in uncomplicated cases runs 
 its course before the time at which splenic tumor and rose spots establish 
 the diagnosis of enteric fever. The occurrence of influenza during the 
 period of incubation of enteric fever ma}' add to the difficulties of diagno- 
 sis. Bacteriological methods and especially the Widal test are necessary 
 
702 MEDICAL DIAGNOSIS. 
 
 in doubtful cases. Cerebrospinal fever has prevailed during some, epidemics 
 of influenza. The occasional occurrence of cases of influenza marked by 
 painful retraction of the muscles of the back of the neck and vomiting 
 renders the differential diagnosis between these two affections difficult. 
 Nor is the fact to be overlooked that meningitis occurs as a complication 
 of influenza. Dengue closely resembles influenza. Each of these diseases 
 occurs in abruptly developing pandemics affecting almost all the inhabi- 
 tants of the regions invaded. They resemble each other in the frequency 
 of relapse, liability to repeated attacks during the same outbreak, the fact 
 that they are not self-protective, in the want of accord between the grav- 
 ity of the symptoms and the low death-rate of uncomplicated cases, the 
 suddenness of the attack, intensity of the pains, and the high degree of 
 mental and physical depression. Influenza lacks, however, the cutaneous 
 manifestations, the remission in the course of the fever, and the tendency 
 to arthritis seen in dengue. It differs also in the liability to serious com- 
 plications and in prevailing in all climates. 
 
 Prognosis. — Death is rare in uncomplicated cases except at the ex- 
 tremes of life. The very young bear influenza badly, the aged bear it 
 worse. Previous disease is unfavorable. Individuals suffering from chronic 
 bronchitis, emphysema, myocarditis, and nephritis offer diminished resist- 
 ance. Exhausting diseases increase the danger of the attack. Cases at- 
 tended by very severe symptoms usually recover unless the patient be very 
 young or very old or the subject of some complicating malady. The prog- 
 nosis in individual cases is greatly modified by the character of the pre- 
 vailing epidemic. In some epidemics the death-rate has been low and the 
 mortality from other diseases only slightly increased. More commonly 
 the death-rate of endemic affections is much increased, and in some of the 
 early epidemics influenza appears to have been attended by a high direct 
 death-rate. 
 
 XII. DENGUE. 
 
 Definition. — A pandemic infectious disease of tropical and subtrop- 
 ical climates, characterized by a febrile paroxysm with recurrence, intense 
 pains in the joints and muscles, and an early erythematous and a late poly- 
 morphous eruption. 
 
 The popular term break-bone fever denotes the atrocious character 
 of the pain. 
 
 Etiology. — Predisposing Influences. — Dengue first excited general 
 attention by its epidemic prevalence in the West India Islands in 1827. 
 Benjamin Rush observed an outbreak in Philadelphia in 1780. Dengue 
 is, in the strictest sense, a pandemic disease. No other disease, with the 
 exception of influenza, prevails so widely and attacks so large a proportion 
 of the population. Equally remarkable is its rapidity of diffusion. In Gal- 
 veston in the epidemic of 1897, 20,000 persons were attacked in the course 
 of two months. Dengue is a disease of warm climates and of warm seasons. 
 When it has occurred in the summer in temperate climates it has dis- 
 appeared upon the appearance of frost. The recent experimental inves- 
 tigations of Ashburn and Craig led them to believe that dengue is not a 
 contagious disease, but that it is infectious in the same manner as yellow 
 
DENGUE. 
 
 703 
 
 fever and malaria and that the mosquito at fault is probably Culex fatigans 
 (Wied). The liability is universal. Neither age, sex, nor occupation confers 
 immunity. The outbreaks chiefly affect cities, less generally the open 
 country. To this statement, however, there have been many exceptions. 
 
 Exciting Cause. — No organism, either bacterium or protozoon, 
 can be demonstrated in either fresh or stained specimens of dengue blood 
 with the microscope (Ashburn and Craig). The pathogenic organism is 
 probably ultramicrosco]3ic. 
 
 Symptoms. — The period of incubation varies from three to five days. 
 At the beginning and at the height of epidemics it has not, in some cases, 
 
 
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 Fig. 239. — Dengue. — Ashburn and Craig. 
 
 exceeded a few hours. The invasion is abrupt. Prodromes are unusual; 
 when present they consist of lassitude, headache, a furred tongue, loss of 
 appetite, muscular soreness, and chilliness. The attack sets in with intense 
 headache, backache, and severe pains in the joints and muscles. The af- 
 fected joints are swollen, and the face and neck flushed and turgid. Move- 
 ments are executed with pain and difficulty. Conjunctivitis, swelling of 
 the eyelids, intolerance of light, and stiffness of the muscles of the eyeballs 
 are common. The tongue is heavily coated, and there is epigastric distress 
 which is followed by nausea and vomiting. Appetite is lost and the bowels 
 are constipated. Thirst is not a prominent symptom. The temperature 
 rises rapidly, often reaching bv the end of the first twenty-four hours 
 106.7° to 107.6° F. (41.5° to 42° C.). The pulse is tense and frequent, 120 to 
 
704 MEDICAL DIAGNOSIS. 
 
 140. The breathing is rapid, the skin hot and dry. Confusion of thought 
 and dehrium occur, and in children the attack may begin with convul- 
 sions. An erythematous rash appears in many of the cases. 
 
 The duration of the first febrile paroxysm is variable, lasting from a 
 few hours to several days, the average being about three days. Defer- 
 vescence is commonly sudden and is often attended with critical discharges, 
 such as profuse sweating, epistaxis, or diarrhoea. The eruption now dis- 
 appears, the skin becomes moist, and there is an amelioration of the pains 
 in the muscles and joints. 
 
 The afebrile period lasts two or three days. In some cases it does not 
 occur, or is so brief as to be overlooked. There are cases in which the tem- 
 perature falls but does not quite reach the normal. Notwithstanding the 
 great relief which the patient experiences, there remain some headache and 
 stiffness of the muscles and joints. At the expiration of several hours, 
 more commonly of two or three days, a second febrile paroxysm sets in. 
 The symptoms are much the same as those of the initial paroxysm but 
 less intense. An eruption of variable character develops at this stage of 
 the disease. It is sometimes macular like the rash of measles, or diffuse 
 and erythematous like that of scarlet fever, or papular. Sometimes it 
 resembles an urticaria, and there are cases in which vesicles occur. Ap- 
 pearing in many instances first upon the hands and feet, this eruption 
 generally invades the greater part of the surface of the body. In other 
 cases it is limited to certain areas. It is attended by distressing itching, 
 and gradually fades after two or three days, being followed by a branny 
 desquamation. The duration of the second paroxysm is from two to three 
 days. Defervescence is gradual; the acute symptoms disappear and the 
 patient enters upon convalescence much enfeebled, the muscular pains 
 and stiffness of the joints often lasting for a considerable time. The small 
 and large joints are alike involved, many being affected at the same time 
 or in rapid succession. The muscles are also stiff and sore, and this, with 
 the swollen condition of the integuments, greatly increases the difficulty and 
 awkwardness of movement, especially in the fingers and hands. In severe 
 cases the mucous membrane of the mouth, throat, and nose is inflamed. 
 The secretion of saliva is sometimes increased and the salivary glands, in 
 particular the parotid, are swollen and tender. The superficial lymphatics 
 about the angle of the jaw and in the groin are in some cases enlarged. 
 
 The Blood. — The white corpuscles are diminished in number and 
 there is a relative increase in the small mononuclear variety. The char- 
 acteristic blood findings are: (1) the absence of a demonstrable protozoon; 
 (2) leucopenia; (3) diminution of polymorphonuclears, and (4) a striking 
 variation in the percentage of other leucocytes at different periods of the 
 attack (Stitt). 
 
 The urine during the access of fever is scanty and of high color. With 
 the crisis the quantity is increased. Albuminuria is not usually present. 
 
 Diagnosis. — The direct diagnosis is not difficult. No other disease 
 spreads with such rapidity through a community and attacks so large a 
 proportion of the inhabitants. 
 
 Differential Diagnosis. — Influenza, see p. 702. From acute 
 articular rheumatism dengue differs in its course and duration as well as 
 
DIPHTHERIA. 705 
 
 in the eruptions which attend it; from scarlet fever and measles, in every- 
 thing except the occurrence of the rashes, which resemble the exanthems 
 of these diseases only in the most superficial way; from relapsing fever 
 in all things except its course, and from yellow fever in many important 
 particulars, among which its extremely low death-rate, the absence of 
 jaundice and black vomit, the infrequency of hemorrhage and albumi- 
 nuria, and the correlation between the pulse-rate and the temperature are 
 of diagnostic importance. Yet upon these very points experts have failed 
 to agree in the differential diagnosis, as in the State of Texas during the 
 epidemic of 1897- The difficulty is increased by the fact that yellow fever 
 and dengue have the same habitat and very often prevail side by side. 
 
 Prognosis. — Dengue is seldom fatal. A few fatal cases have been 
 noted in extensive outbreaks; but in many epidemics in large cities not 
 a single death has occurred. 
 
 XIII. DIPHTHERIA. 
 
 Definition. — A specific mfectious disease, caused by the Klebs-Loffler 
 bacillus and characterized by a fibrinous exudate, usually situated upon 
 and in the mucous membrane of the upper respiratory passages, and by 
 serious constitutional symptoms due to toxins formed in the local lesions. 
 
 Clinically the term diphtheria is applied to cases of pseudomembra- 
 nous inflammation in which the presence of the Klebs-Loffler bacillus 
 can be demonstrated. Cases of pseudomembranous inflammation, which 
 present similar local and constitutional features, but in which Klebs- 
 Loffler bacilli are not present, are designated pseudodiphtheria or diph- 
 theroid angina. 
 
 Etiology. — Predisposing Influences. — Diphtheria is widely distrib- 
 uted but is especially a disease of temperate climates. The general prev- 
 alence is more extensive in winter and it is probable that the frequent 
 occurrence of catarrhal inflammation of the pharyngeal mucous membrane 
 constitutes a definite predisposing factor. Severe epidemics are occa- 
 sionally encountered in summer. Neither altitude nor the constitution, of 
 the soil exerts a special influence. Diphtheria is endemic in cities and towns, 
 where it frequently becomes epidemic, but this is also the case in rural 
 districts, where the population is scattered, and among hamlets and farms 
 it often rages with extreme virulence. The affection spares no class in a 
 community. Rich and poor alike contract it. Crowding, uncleanliness. 
 and neglect of sanitary laws favor the spread of the disease among the 
 poor; therefore epidemics are much more common among the poor than 
 among well-to-do and well-advised persons. These elements of predis- 
 position are fully explained by the fact that diphtheria is a readily trans- 
 missible disease. Infants in the first year of life are rarely affected. The 
 period of greatest liability lies between the second and the fifteenth years. 
 The mortality is especially great between the second and the fifth years. 
 The disease may occur at any age and it not infrequently happens that the 
 nurse or a parent contracts the disease from a child, and many physicians 
 have lost their lives from diphtheria contracted in the discharge of duty. 
 In later childhood and adolescence girls are attacked more fi'equently 
 
 45 
 
706 
 
 MEDICAL DIAGNOSIS. 
 
 than boys. The diminished resistance to pathogenic influences on the 
 part of the local mucous membrane which accompanies chronic naso- 
 pharyngeal catarrh, adenoid vegetations, hypertrophied tonsils, and laryn- 
 gitis constitute an especial predisposition to the disease. Certain acute 
 febrile infections, such as measles and scarlet fever, act in the same way. 
 It is important, however, to bear in mind the fact that the pseudomem- 
 branous inflammation common as a complication of the acute diseases 
 is more frequently diphtheroid and due to streptococcus infection. 
 
 The attack does not confer immunity; on the contrary, certain per- 
 sons manifest a peculiar susceptibility. There are on the other hand per- 
 sons who appear to be possessed of a natural immunity and do not contract 
 the disease upon exposure nor, in some instances, even when the bacilli 
 are present in their throats. 
 
 Exciting Cause. — The Klebs-Loffler bacilli are non-motile; they 
 vary in length from 2.5 to 3 /jl and from 0.5 to 0.8 /j. in breadth, and present 
 different forms, some of which are pointed, others blunt and rounded at 
 the ends, and less frequently forms that are irregular and branching. They 
 are very tenacious of life and have been grown in culture after a non- 
 parasitic existence under varying conditions for periods measured by weeks 
 and months. Attached to clothing, bedding, articles of furniture, even 
 the walls and floor of the room occupied by the patient, they maintain 
 their pathogenic power. Milk serves as a culture media in which they 
 grow rapidly without altering its appearance. The bacilli are found in 
 large numbers in the false membrane of cases of true diphtheria. In this 
 situation they grow and multiply, being rarely found in the blood during 
 life. In the lesions of the bronchopneumonia of laryngeal diphtheria they 
 may be the predominant organism. After death they are occasionally 
 present in the blood and viscera. They vary greatly in virulence. Guinea- 
 pigs, the most susceptible of laboratory animals to the poison, are used 
 
 for determining the intensity of cultures. 
 Non- virulent bacilli are sometimes- 
 spoken of as the pseudobacillus of diph- 
 theria — a misnomer. The pseudodiph- 
 theria bacillus or Bacillus xerosis 
 resembles the Klebs-Loffler bacillus 
 morphologically, but differs from it in 
 certain cultural peculiarities and being 
 non-pathogenic. The biological rela- 
 tionship of this organism to the Klebs- 
 Loffler bacillus has not been determined. 
 The Klebs-Loffler bacilli may be 
 present upon the mucous membrane of 
 cases which show no membranous exu- 
 date and present the clinical picture 
 of a lacunar tonsillitis or a simple 
 erythematous angina. They are very 
 often found in the throat and nose of individuals who have passed 
 through an attack of diphtheria and are fully convalescent. Under these 
 circumstances they may persist for weeks or months, during which time 
 
 Fig. 240. — Bacillus diphtherise from culture 
 on Loffler's blood-serura. 
 
DIPHTHERIA. 707 
 
 the patient may communicate the disease to others or pass through one 
 or more fresh attacks himself. They are frequently isolated from the 
 throats of healthy persons, both the nurses and attendants upon the sick 
 and others living in the same house with the patient or convalescent. 
 The organisms have been found in the hair and clothing of nurses and in 
 the dust of diphtheria wards. The disease may be communicated by means 
 of infected milk. 
 
 The foregoing facts shed considerable light upon the endemic and 
 epidemic prevalence of the disease, as well as the occurrence of sporadic 
 cases. They enable us to understand the persistence of diphtheria in 
 localities, the occurrence of house and neighborhood epidemics, the 
 simultaneous occurrence of scattered cases in a school district, and the 
 development of cases in patients long confined in hospital wards, after 
 visiting days. 
 
 The Toxin. — The general symptoms are caused not by the bacilli but 
 by toxins formed by them. Susceptible animals may be rendered immune 
 by the injection of progressively stronger doses of attenuated cultures of 
 the bacilli or increasing quantities of the toxin. By suitable treatment 
 in this manner large animals, as the horse, may be rendered to a high 
 degree immune. 
 
 Symptoms. — The period of incubation varies from two or three to 
 seven days. The onset is marked by slight chilliness and sometimes in 
 young children by convulsions. The signs of a febrile infection, elevation 
 of temperature,— 102°-103° F. (38.9°-39.5° C.),— malaise, backache, and 
 muscle pains follow. These symptoms vary greatly in intensity. Older 
 children and adults complain of sore throat. An examination of the fauces 
 must be made as a matter of routine in infants who are taken acutely ill. 
 The pseudomembranous exudate rapidly forms upon the mucous surfaces 
 of the tonsils and adjacent parts and shows a marked tendency to spread 
 upwards to the nasopharynx, the nasal chambers and accessory sinuses, 
 the tear duct and the Eustachian tube, or downwards to the epiglottis, 
 larynx, trachea, bronchi. Much less frequently the oesophagus, stomach, 
 and duodenum are invaded. Accidental infection of the vulva and vagina, 
 the ear, conjunctivae, and wounds occurs. The larynx is primarily involved 
 in a large proportion of the cases. 
 
 According to the local lesions the following groups of cases are to be 
 considered : 
 
 1. Faucial Diphtheria. — The mucosa is at first reddened and there 
 is difficulty in swallowing. The membrane usually first appears upon one 
 tonsil and, in the course of a few hours, without bridging across, upon the 
 other. After some hours, or it may be a day or two, it has in neglected cases 
 covered the tonsils and spread to the half-arches, the soft palate and uvula, 
 and to the pharynx — pharyngeal diphtheria. Meanwhile, the tonsils are 
 enlarged and the soft palate and uvula are swollen, reddened, and oedema- 
 tous. The membrane, at first whitish, soon assumes a gray or dirty 
 yellowish-white color. As a rule the patch or patches are distinctly mar- 
 ginate and surrounded by a border of red deeper than that of the general 
 mucosa. The membrane, when forcibly detached, leaves an eroded surface 
 with punctate bleeding, upon which a fresh pellicle soon appears. The 
 
708 MEDICAL DIAGNOSIS. 
 
 lymph-nodes about the angle of the jaw are swollen and tender. Vari- 
 ations in the character of the exudate occur. It may be throughout punc- 
 tiform and restricted to the tonsils, or punctiform at the outset but rapidly 
 becomes membraniform, and extends. Again the exudate may be pul- 
 taceous rather than pseudomembranous. Finally, there are cases with 
 acute erythematous angina and constitutional symptoms in which no 
 membrane is present but virulent Klebs-Loffler bacilli are found in 
 the secretions. The breath of the patient has a fetid, sickening odor, 
 which surrounds his person and permeates the atmosphere of the room. 
 
 2. Nasal Diphtheeia. — The Klebs-Loffler bacilli are frequently 
 found in the nasal secretions when the exudate has invaded the pharynx, 
 although no membrane is present in the nasal chambers. When membra- 
 nous exudate is present two conditions occur. In the first the nares are 
 occupied by a thick, tough membrane, which rarely extends to the adjacent 
 parts and in which Klebs-Loffler bacilli are present, but the constitutional 
 symptoms are very slight or altogether absent. The disease shows very 
 little tendency to affect other children in the family. 
 
 The second and far more common form of nasal diphtheria may be 
 primary, but usually arises in the course of the attack by extension from 
 the pharynx or autoinoculation by way of the nostrils. Exceptionally 
 the symptoms are mild, but in the majority of cases both the local and 
 constitutional symptoms are most intense — a fact attributed to the abun- 
 dant supply of lymph-vessels to the mucous membrane of the nose and 
 consequent free absorption of diphtheria' toxin. 
 
 3. Laryngeal Diphtheria. — The term membranous croup was at 
 one time used without distinction to designate all forms of membranous 
 laryngitis. This misleading and dangerous custom is fortunately passing 
 away. More than four-fifths of such cases in large series of statistics have 
 shown the presence of Klebs-Loffler bacilli. In a considerable proportion 
 of the rest the result, for various reasons, has been doubtful, while 
 in the small remainder other organisms, chiefly streptococci, have been 
 found. While the clinical symptoms are practically the same, the differ- 
 ential diagnosis can readily be made bj^ laboratory methods, and the mem- 
 l)ranous laryngitis associated with the Klebs-Loffler bacillus is called 
 laryngeal diphtheria, while that in which other organisms are exclusively 
 present is known as diphtheroid laryngitis or pseudodiphtheritic laryn- 
 gitis. The latter affection is rarel}'- a primary disease, but usually arises 
 as a complication in the course of some acute disease — scarlet fever, variola. 
 
 The local symptoms of laryngeal diphtheria are at first those of an 
 acute laryngitis, with hoarseness and a rough, so-called "croupy" or laryn- 
 geal cough. In the course of twenty-four or thirty-six hours the patient — 
 usually a child — suddenly becomes worse, with symptoms of laryngeal 
 stenosis — dyspnoea, slight cyanosis, rapid pulse, aphonia, brassy cough, 
 and restlessness. These symptoms, which commonly develop at night, 
 are at first paroxysmal, with intervals of quiet breathing and sleep. In 
 favorable cases, after two or three paroxysms without marked dyspncea 
 or cyanosis, the child falls asleep and awakes in the morning greatly 
 improved. Not rarely the attack recurs upon the succeeding night with 
 more intensity. 
 
DIPHTHERIA. 709 
 
 The respiratory obstruction, which is at first due in part to laryngeal 
 spasm, with the increasing exudate soon ceases to be paroxysmal and be- 
 comes continuous with exacerbations and remissions. Inspiration and to 
 a greater extent expiration are increasingly difficult. The auxiliary re- 
 spiratory muscles are brought into play, the lower intercostal spaces and 
 epigastrium show inspiratory retraction. The voice is reduced to a husky 
 whisper. The cyanosis of the lips and finger-tips becomes more intense. 
 There is urgent air hunger and after a period of extreme restlessness the 
 patient sinks into a semiconscious listlessness, with general relaxation and 
 a freely perspiring skin, only to start up again in the course of a few minutes, 
 tossing about and struggling for air. Occasionally in a severe paroxysm 
 of cough shreds of membrane are coughed up with great temporary or even 
 permanent relief. In other cases, a fold of detached membrane becomes 
 lodged in the glottis and is followed by fatal asphyxia. The fatal issue is, 
 as a rule, preceded by increasing dyspnoea and cyanosis, a period of distress- 
 ing jactitation, coma, and slight, shuddering convulsions. Pharyngeal 
 exudate may be present, the membrane invading the larynx from above — 
 descending croup; the invasion being from the larynx upward — ascending 
 croup. In many of the cases the membraniform exudate is situated wholly 
 within the larynx, where it may be seen upon laryngoscopic examination — 
 a procedure usually attended, however, with great practical difficulties. 
 If the duration of the attack be prolonged, bronchopneumonia occurs. 
 This complication may be due to an extension of the bronchitis, caused 
 by i-etained secretions, to the finer bronchial tubes — secondary infection — 
 or to an infralaryngeal extension of the exudate along the trachea and into 
 the bronchial tubes — a true diphtheritic tracheobronchitis. Thus arises 
 respiratory obstruction at two anatomical levels, namely, at the larynx 
 and in the smaller bronchial tubes, a condition often difficult of recognition 
 because of the diminution of tidal air and consequent fainter vesicular 
 sounds and small mucous rales on the one hand, and the loud laryngeal 
 stridor and coarse tracheal rales* on the other; a fact of great practical 
 importance because a successful intubation or tracheotomy, which wholly 
 relieves the obstruction at the upper level, can have no effect whatever 
 upon that at the lower level. 
 
 4. Other Sites of the Diphtheritic Exudate. — The conjunctiva 
 may be the seat of a primary or secondary diphtheria. In the latter case 
 the extension is by way of the tear duct or by autoinfection. The symp- 
 toms may be those of a catarrhal conjunctivitis, the bacilli being present 
 in the secretions, or they may be very serious. The invasion of the middle 
 ear by way of the Eustachian tube may be the occasion of an otitis causing 
 destruction of the tympanic membrane and erosions of the external meatus 
 covered with a characteristic membrane. Vulvar and vaginal diphtheria 
 is occasionally encountered. Diphtheria of the skin occurs in the ordinary 
 forms of faucial and nasal diphtheria when, as is not rarely the case, fis- 
 sures and abrasions form about the nostrils and corners of the mouth and 
 become infected. The membrane in diphtheria of the anus or genitalia may 
 likewise invade the adjacent cutaneous surfaces. Wounds and ulcerated 
 surfaces in persons suffering with diphtheria are liable to be the seat of an 
 adherent pseudomembrane associated with the Klebs-Loffier bacillus. 
 
710 MEDICAL DIAGNOSIS. 
 
 The organism may be present in inflamed or necrotic lesions with mem- 
 brane and, in rare instances, wound infection may occur in the absence of 
 throat affection or traceable exposure to diphtheria cases or fomites. A 
 large proportion of the cases of pseudomembranous inflammation of wounds 
 are due to streptococcus infection or to mixed infection. Local diphtheritic 
 lesions, when severe, are frequently associated with more or less necrosis 
 and gangrene. 
 
 In favorable cases the process of separation of the membrane and 
 healing may be observed in faucial diphtheria. After some days the ex- 
 tension of the process is arrested and in the slighter cases the membrane 
 becomes thinner, less distinct at the margins, and gradually disappears. 
 In the more severe forms it appears thicker at the margins, which curl 
 outward from the underlying surface, and separates en bloc or by a gradual 
 disintegration. In either case the outlying mucous membrane loses its 
 redness and oedema and shows rapid and marked improvement. Local 
 ulcerations often persist, which, in healing, may give rise to adhesions of the 
 uvula to a tonsil or of the soft palate in part to the wall of the pharynx, 
 and the like. 
 
 Infragiottic membranes separate from the underlying surface in more 
 or less extensive membraniform shreds. Pathologically the conditions 
 differ in the mucous membranes above the glottis, which are provided with 
 a squamous epithelium, and in those below it which have a columnar and 
 ciliated epithelium. In the former the membrane is found not only upon, 
 but also in, the substance of the mucosa, while in the latter it is super- 
 ficial, involving largely the epithelial surfaces and not causing necrosis 
 of the underlying tissues. 
 
 Diphtheritic Toxcemia; the Systemic Infectio?i. — There is, in the major- 
 ity of cases, a general correspondence between the intensity of the local 
 lesions and the severity of the constitutional symptoms. To this rule, 
 however, there are important exceptions. There may be extensive and 
 intense faucial or nasal membranous inflammation with relatively mild 
 general symptoms, or profound toxeemia with limited and apparently su- 
 perficial local lesions. It has been assumed in explanation of this discrep- 
 ancy that certain individuals may be more susceptible to the diphtheria 
 bacillus and others more susceptible to its toxins. It is more in accord- 
 ance with the known facts to explain these differences by assuming that 
 in some instances the bacilli form a larger amount of more virulent toxin 
 than in others and that severe local lesions are in part due to the action 
 of associated organisms — mixed local infections. This explanation finds 
 support in the fact that the graver symptoms are, as a rule, not at first 
 present but arise later when the local disease is at its height. The sever- 
 est form is septic diphtheria, the outcome of the simultaneous action of 
 the diphtheria bacilli, streptococci, and saprophytic bacteria which are 
 present in the necrotic lesions. 
 
 The general symptoms of the attack of diphtheria are those of a mild 
 or intensely severe general infection. The onset is marked by chilliness, 
 a chill, followed by vomiting, fever of atypical course, headache, and anor- 
 exia. The temperature varies not only in different cases but also in the 
 course of the attack in the same case. Often but slightly above normal, 
 
DIPHTHERIA. 711 
 
 it sometimes reaches 104° F. (40° C). In the severest cases the tempera- 
 ture is sometimes subnormal. The pulse in severe cases is small, weak, 
 and irregular, and in some of the gravest cases there is bradycardia. In 
 the septic cases with gangrenous lesions the constitutional depression may 
 be extreme, with frequent thready pulse, high fever, and nervous symp- 
 toms, or there may be ashen pallor, great enlargement of the superficial 
 lymph-glands, and a subnormal temperature. A leucocytosis is present 
 alike in the mild and moderately severe cases. 
 
 The following visceral changes occur: The toxin of diphtheria acts 
 especially upon the heart muscle and the nervous system. The myo- 
 cardium shows fatty degeneration. Endocarditis is rare and the bacilli 
 have been found in the lesions. Pericarditis is extremely rare. Pulmo- 
 nary complications are very common and are often the cause of death, 
 especially in laryngeal diphtheria. The most common condition is bron- 
 chopneumonia. Klebs-Loffler bacilli and streptococci are often present, 
 but the organism in the greater number of cases is the pneumococcus. 
 The liver, spleen, and kidneys show the parenchymatous changes present 
 in the severe infections. 
 
 Complications and Sequels.— T'/ie Heart. — Irregular action is common. 
 A faint, blowing, systolic murmur is heard in a majority of the cases. 
 Rapid action, associated with gallop rhythm and epigastric pain, and brady- 
 cardia are grave symptoms. Acute dilatation due to granular and fatty 
 degeneration may be the cause of sudden death in the course of an other- 
 wise favorable convalescence. Paralysis occurs in from 15 to 20 per cent, 
 of the cases. It is usually incomplete. In rare cases it comes on as early 
 as the seventh day, but commonly not until the second or third week and 
 sometimes later. It is more frequent in adults than in children. Diph- 
 theritic palsy may follow cases in which the local and constitutional symp- 
 toms are mild. The palate is most frequently involved, the symptoms 
 being speech having the nasal quality and the regurgitation of fluids 
 through the nose in swallowing. Upon inspection the soft palate is seen 
 to be relaxed and immobile upon phonation. Sensation is likewise greatly 
 diminished. The constrictors of the pharynx may be affected. The in- 
 trinsic and extrinsic muscles of the eye are also frequently involved. 
 Strabismus, ptosis, and loss of accommodation result. The loss of power 
 may affect a single limb or the arms "or legs together. As a rule it is the 
 result of peripheral neuritis, and the limbs are flaccid, with impairment or 
 abolition of the tendon reflexes. Multiple neuritis is common. The paralysis 
 may affect the extensors of the feet or there may be complete paraplegia. 
 "When the arms are involved the patient is often unable to help himself. 
 In other cases an acute ataxia, resembling tabes but without the lightning- 
 pains and pupillary phenomena, has been observed. This condition may 
 be attributed to the action of the toxin upon the posterior columns and 
 posteiior nerve-roots and is analogous to the derangements of coordination 
 experimentally produced in animals by the injection of Klebs-Loffler 
 bacilli or the diphtheria toxin. 
 
 The occurrence of albuminuria is common and may be noted as early 
 as the first day of the attack. This early change in the urine must be 
 regarded as a " toxic " albuminuria. The albumin in favorable cases dis- 
 
712 MEDICAL DIAGNOSIS. 
 
 appears in the course of some days. In cases of greater severity it persists 
 and red blood-corpuscles and epithelial and hyaline casts appear. The 
 condition is that of an acute nephritis. Anasarca, contrary to the course 
 of the renal affection in scarlet fever, is very rarely encountered and the 
 acute nephritis shows very little tendency to become chronic. 
 
 Hemorrhage from the local lesions occasionally occurs in the severer 
 cases of faucial and nasal diphtheria. Epistaxis may be the first symptom. 
 
 A diffuse erythematous rash occasionally develops early in the course 
 of the disease. Urticaria is by no means infrequent, and petechise and 
 purpuric hemorrhages appear in the later stages of the grave cases. Jaun- 
 dice, as in other septic conditions, is often present in the worst cases. 
 
 Psendodiphtheria. — The diphtheroid affection is rarely transmitted 
 to other patients or the attendants. As a rule the local process is of mod- 
 erate intensity and the constitutional symptoms, if present at all, are mild. 
 There are, however, cases in which the most intense streptococcus infec- 
 tion is associated with non-diphtheritic membranous inflammation of the 
 throat or nose. 
 
 Diagnosis. — Direct Diagnosis. — This rests upon the presence of 
 a false membrane having the characters above described; bacteriologi- 
 cally, upon the presence of the Klebs-Loffler bacillus. There are, however, 
 cases of membranous inflammation in which the Klebs-Loffler bacillus 
 is not present — diphtheroid angina — and the bacillus may be frequently 
 demonstrated in cases presenting the clinical phenomena of an ordinary 
 lamnar tonsillitis or simple tonsillar or pharyngeal catarrh, or in the throats 
 of persons in health. This want of accord between the clinical and bac- 
 teriological diagnosis is apparent rather than real. The same thing is seen 
 in other affections, as, for example, tuberculosis. It is a question of the 
 seed and the soil. The bacillus varies in virulence and the individual in 
 power of resistance. The Klebs-Loffler bacillus is the criterion. Mem- 
 branous inflammations associated with it constitute diphtheria; non-mem- 
 branous inflammations in which it is present are diphtheritic, as tonsillitis, 
 pharyngitis, rhinitis, and the like. The recognition of the diphtheritic char- 
 acter of many of these milder throat affections marks an important recent 
 advance in practical medicine. 
 
 Bacteriological Diagnosis. — For the positive determination of 
 the true character of an acute throat affection a bacteriological examina- 
 tion is often necessary. The material should be taken from the throat 
 as early as possible in the course of the attack and at a time when no anti- 
 septic, and in particular no mercurial preparation, has recently been applied. 
 An immediate diagnosis may sometimes be reached by making a smear 
 preparation. Cultures require about fourteen hours at the body tempera- 
 ture. If the result is negative the examination must be repeated. When 
 the result is positive the examination should be repeated at intervals of 
 ten days or two weeks until the bacilli are no longer found. Pending the 
 result of the examination every acute sore throat in a child must be re- 
 garded as suspicious, and measures of isolation and disinfection instituted 
 without delay. 
 
 Therapeutic Test, — Antitoxin Treatment. — In every suspicious 
 case the physician should at once administer diphtheria antitoxin serum 
 
VINCENT'S ANGINA. 713 
 
 in doses corresponding to the age of the patient and the intensity of the 
 process. As the action of this remedy is specific and without influence 
 upon forms of throat affection due to causes other than the Klebs-Loffier 
 bacillus, its proper administration has an incidental diagnostic value of great 
 importance. The dose for a child varies from 1000 to 3000 units, repeated 
 if necessary at intervals of eight hours; for an adult from 4000 to 6000 
 units. In very grave cases a total dosage of 50,000 or 70,000 may be re- 
 quired. When administered early the serum is followed in the course of 
 a few hours by local and general improvement. The swelling of the faucial 
 mucous membrane subsides, the membrane shrivels and gradually dis- 
 appears, the sickening odor becomes less intense, the temperature falls 
 to normal, and the pulse loses in frequency and gains in force. Even in 
 apparently hopeless cases improvement and eventual recovery frequentl}' 
 occur. Most remarkable results are seen in laryngeal diphtheria, so that 
 intubation and tracheotomy have become far less common than formerl}'. 
 The diphtheria antitoxin serum is wholly without effect in pseudodiph- 
 theritic membranous angina. 
 
 Differential Diagnosis. — Pseudodiphtheritic Angina. — The majority 
 of the cases of diphtheroid throat inflammation are caused by the Strepto- 
 coccus pyogenes. They are almost always secondary to other infections, 
 as scarlet fever, variola, measles, or pertussis. The local process is usuall}^ 
 less extensive and the general symptoms less severe. Exceptionally the 
 local and constitutional infections are intense; palsy has been noted and 
 a fatal result may occur. The bacteriological findings are diagnostic. 
 
 Prognosis. — The mortality in former years ranged between 30 and 
 50 per cent. In local epidemics in rural districts it was even higher. Since 
 the introduction of the antitoxin treatment it has progressively fallen and 
 is now about 10 per cent. Of unfavorable omen in individual cases are 
 extensive or gangrenous exudate, sanious discharge from the nostrils, an 
 intense penetrating sickening stench, a feeble, thready pulse, cold, clammy 
 hands and feet, and petechise. The c mmon causes of death are laryngeal 
 obstruction, bronchopneumonia, sepsis, sudden asystolism, paralysis, and 
 uraemia. 
 
 XIV. VINCENT'S ANGINA. 
 
 Definition. — An acute febrile, pseudomembranous inflammation of 
 the tonsils, associated with Bacillus fusiformis and the spirochseta of 
 Vincent, and characterized by a tendency to destructive ulceration of the 
 tissues involved, enlargement of the lymphatic glands at the angle of the 
 jaw, and an irregular, slow course. 
 
 This affection is comparatively rare and chief!}' affects children and 
 young adults. 
 
 Symptoms. — The onset may be acute or subacute, with the symptoms 
 of an ordinary angina or simple membranous sore throat. The constitu- 
 tional symptoms are often severe. The tonsils are usually at first affected 
 and, in some cases, the local manifestations of the disease are confined to 
 those organs. More commonly the uvula and half-arches are also involved 
 and the ulceration may extend to the pharynx and even to the gums. The 
 exudate is of soft consistency, usually of a greenish or grayish-yellow color, 
 
714 MEDICAL DIAGNOSIS. 
 
 and readily detached, leaving a slightly depressed bleeding ulcer with 
 irregular ragged borders. The process is slowly progressive, not readily 
 yielding to trratment, and may result in extensive destruction of the 
 
 parts involved, especially the uvula 
 and soft palate. 
 
 Diagnosis. — This form of mem- 
 branous angina may be recognized by 
 its tardy progress, the destructive ten- 
 dency of the ulcerative process, and 
 the presence of Bacillus fusiformis and 
 the spirochseta of Vincent. The dif- 
 ferential diagnosis from diphtheria rests 
 upon the above anatomical and clinical 
 characters and the absence of the Bacil- 
 lus diphtherise from the exudate. In fact 
 diphtheria can usually be excluded when 
 the associated fusiform organisms and 
 spirochsetse are present. As a rule, the 
 Fig. 241.— Fusiform bacilli and spirilla in vin- direct dlaguosis depends upon the labo- 
 
 cent s angina. — Rosenberger. f f r' 
 
 ratory findings. Mucous patches may 
 resemble this form of angina or it may develop upon syphilitic lesions. 
 Prognosis. — Recovery occurs as a rule after a duration varying 
 from four or five days to several weeks. In a recent case in the Penn- 
 sylvania Hospital, Vincent's angina was the terminal event in aplastic 
 anaemia in a young adult male. 
 
 XV. CROUPOUS PNEUMONIA. 
 
 Fibrinous Pneumonia; Lung Fever; Lobar Pneumonia; Pleuropneumonia. 
 
 Definition.— An acute infectious disease due to the Diplococcus pneu- 
 monise of Fraenkel and Weichselbaum and characterized by pulmonary 
 inflammation and fever, usually of abrupt onset, high range, and critical 
 termination. 
 
 Etiology. — Predisposing Influences. — Pneumonia prevails alike in 
 hot and cold countries. It is said to be more prevalent in the temperate 
 climates. 
 
 Season plays an important part as a predisposing factor. The inci- 
 dence of the disease is uniformly greater in winter and the early spring. 
 March is the month of greatest liability. This is in accordance with the 
 fact that exposure to cold and especially unusual exposure to cold and wet 
 are very often soon followed by the initial chill. Steady, low temperatures 
 are less dangerous. Personal Factors. — Croupous pneumonia may occur 
 in the new-born and in early infancy. It is common till the sixth year. 
 The liability then diminishes until the fifteenth year. From fifteen to forty- 
 five is a period of special liability. After sixty the disease is very common 
 and often constitutes the terminal event in the aged, both in chronic dis- 
 ease and when the previous health has been well preserved. In infancy 
 and old age the incidence for the sexes is about equal; in the middle period 
 
CROUPOUS PNEUMONIA. 715 
 
 of life, when the mode of living is different, males are more frequently 
 affected than females. There is no special racial predisposition. The 
 negro bears the disease badly. Ptich and poor are alike liable. No occupa- 
 tion is conspicuous as a predisposing factor. Overwork and sudden expo- 
 sure constitute especial risks. Lumbermen and miners frequentl}' suffer. 
 The disease is very common in cities. Pneumonia attacks the robust and 
 hearty and the debilitated and previously ill with impartial energy. The alco- 
 holic is especialh' liable. The last illness of the chronic invalid is very often 
 pneumonia. Pneumonia sometimes follows injuries, especially contusions 
 of the chest. This may occur in the absence of the signs of injury to the 
 lung. The term "contusion pneumonia" is used to describe this variet}'. 
 
 Iminunity . — There is apparently no natural immunity, certainly no 
 permanent acquired immunity. On the contrary, croupous pneumonia is 
 conspicuous among the infections for its liability to recur. Subsequent 
 attacks have been noted in from 15 to 50 per cent, of the cases. I have 
 seen a woman who stated that the attack was the twelfth, and several 
 persons in whom a number of annual attacks occurred. 
 
 A powerful protective serum has been obtained by the repeated inocu- 
 lation of various animals, as the horse, ass, and coav, with dead and living 
 cultures of the pneumococcus. The specific protective substances — 
 opsonins — are formed in the bone-marrow and, circulating in the blood, 
 enter into chemical combination with the iDneumococci which are thus 
 rendered an easier prey to the phagocytes. The formation and gi^adual 
 accumulation of similar substances in the human body dtu-ing the 
 attack serve to explain the crisis. The organisms are rapidly destroyed 
 within the exudate in the lungs and in the circulating blood. The dura- 
 tion of the local and general immunit}' which follows is uncertain. 
 
 Exciting Cause. — Diplo coccus 
 pneumoniEe of Fraenkel and Weich- 
 selbaum, ^Micrococcus lanceolatus, or 
 pneumococcus. This organism is the 
 sole cause of true acute croupous pneu- 
 monia. It is present in the expectoration 
 and pulmonary exudate in enormous 
 numbers. Upon examination of the 
 lungs, when death has occurred in the 
 stage of resolution, it is found only in 
 small numbers or may be wholly' absent 
 — phagocytosis. It may be obtained 
 in blood cultures during the attack by 
 the more recent methods in more than 
 75 per cent, of the cases. The pneu- Fig. 242.— Spread of -sputum showing pneumo- 
 
 • i_^ f cocci in pairs and in chains. 
 
 mococcus occurs m man}^ other dis- ^ 
 
 eases, especially bronchopneumonia, pleurisy, endocarditis and pericarditis, 
 meningitis, peritonitis, in forms of arthritis, and in middle-ear disease. 
 Pneumococcus Septicceynia. — An acute general infection without locali- 
 zation in the lungs or serous membranes is occasionally encountered. This 
 variety of pneumonia is analogous to the primary septicaemia due to 
 general infection by Eberth's bacillus — typhoid septicaemia. 
 
716 MEDICAL DIAGNOSIS. 
 
 In its attenuated forms the pneumocoecus is present in the secretions 
 of the mouth "and bronchi in a large proportion of healthy individuals. 
 Its presence has been demonstrated in the dust of rooms. Various other 
 organisms are associated with the pneumocoecus in croupous pneumonia, 
 as secondary or mixed infections. The most frequently encountered is 
 the Streptococcus pyogenes. Less common are staphylococci, the bacillus 
 of Friedlander, B. typhosus, B. diphtherise, and B. influenzae. These bac- 
 teria are often the cause of bronchopneumonia, which in some instances 
 closely resembles croupous pneumonia. The latter is a distinct, specific dis- 
 ease uniformh' caused by the pneumocoecus, and the recognition of its etio- 
 logical and clinical independence is a matter of great practical importance. 
 
 Pathological Anatomy. — The lesions in the inflamed lung undergo 
 progressive changes, which, since the time of Laennec, have been described 
 as the stage of engorgement, the stage of reel hepatization, and the stage 
 of gray hepatization. Engorgement. — The vesicular tissue is deep red, 
 firmer than normal to the touch, and on section shows abundant blood and 
 serum. It crepitates upon pressure, and excised pieces float upon water. 
 The capillaries are distended and the air-vesicles contain blood-corpuscles 
 and swollen detached alveolar cells. Red Hepatization. — The air-cells 
 and terminal bronchi are occupied by the coagulated exudate, entangled 
 in which are pneumococci, red blood-corpuscles, leucocytes, and alveolar epi- 
 thelium. The affected portion of lung is soUd and airless. It is enlarged and 
 shows the oblique, parallel markings of the ribs. On section the surface is of 
 a reddish-brown color and granular, an appearance produced by the pro- 
 trusion of the fibrinous moulds in the vesicles. The terminal bronchi also 
 contain branching fibrinous casts. The surface yields upon scraping a 
 reddish, viscid serum. The hepatized lung is extremely friable. Gray 
 Hepatization. — The lung tissue is now of a dirty gray color and more friable. 
 The cut surface is more moist, has lost its granular appearance, and yields 
 upon scraping a milky turbid fluid. The air again reaches the alveoli, from 
 which the fibrin and red blood-cells have in great part disappeared, but in 
 which are great numbers of leucocytes. The foregoing stages gradually 
 merge into each other and the process is not equally advanced in all parts 
 of the lesion. The liquefaction of the exudate and resolution are the 
 result of the action of proteolytic enzymes. The part of the lung occupied 
 by the exudate varies from a small patch to the entire lung. Commonly 
 a single lobe is involved. The uninvolved portions are usually congested 
 and oedematous. The pleural surface opposite the exudate is always 
 inflamed when the latter extends to the periphery of the lung. The bron- 
 chial glands are enlarged and sometimes softened. 
 
 The right heart is dilated. Pericarditis is not rare, especialh" in left- 
 sided and double pneumonias. Endocarditis is common both in the simple 
 and in the malignant form. Myocardial changes occur. The spleen shows 
 moderate enlargement and, in the kidneys, parenchymatous swelling and 
 the lesions of interstitial nephritis are frequently present. Meningitis is 
 by no means rare and is often associated with malignant endocarditis. 
 Diphtheroid colitis is rare. The liver is slightly enlarged and deeply 
 congested. The distribution of the lesion is as follows: The right lung 
 alone is involved in about 50 per cent, of the cases; the left alone in about 
 
CROUPOUS PNEUMONIA. 
 
 717 
 
 c. 
 
 -42* 
 
 33 per cent. ; both in less than 20 per cent. In double pneumonia the 
 lower lobes are usually affected, or an entire lung with the lower lobe 
 of the other. Much less frequently the lower lobe of one lung and the 
 upper lobe of the other are involved — crossed pnetnnoriia. Very rarely 
 both upper lobes suffer. 
 
 Croupous pneumonia in the majority of the cases occurs as a sporadic 
 disease. At the seasons of greatest prevalence it is the type of an endemic 
 disease. House epidemics are by no means rare. In a family of five I 
 have seen the mother and two children attacked in rapid succession, two 
 of the cases proving fatal. More 
 extensive local epidemics occasionally 
 occur in schools, prisons, and other 
 institutions. 
 
 Symptoms. — In the well-devel- 
 oped cases of croupous pneumonia 
 the attack runs a typical course and 
 is self-limited. The period of incuba- 
 tion is of unknown duration. It is 
 probably brief. Prodromes are unus- 
 ual. When present they consist of 
 slight catarrhal symptoms. The 
 onset is abrupt, with a chill which is 
 commonly severe and prolonged. 
 The temperature rises rapidly to the 
 fastigium — 104°-105° F. (40°-40.6° 
 C). Headache, general pains, and 
 the sensation of being very ill are fol- 
 lowed in the course of a few hours by 
 a severe stitch-like pain in the side. 
 increased on full breathing, a short 
 dry cough, hurried respiration, and a 
 full bounding pulse. Very significant 
 is a short, expiratory grunt. The 
 pain is often characteristic. The face 
 is slightly cyanotic, with dusky, cir- 
 cumscribed flushing of one or both 
 cheeks; the eyes are bright; the 
 
 expression anxious; the nostrils dilate, and later patches of herpes, usually 
 made up of many small vesicles, some of which contain blood, appear upon 
 the lips and nose. The patient lies upon the affected side or flat upon his 
 back. By the close of the second day there is scanty, viscid, blood-stained 
 expectoration — rusty sputum. The physical signs of consolidation of the 
 affected lung tissue are present — small mucous and crepitant rales followed 
 by dulness and bronchial breathing. At the end of several days deferves- 
 cence by crisis occurs with a remarkable amelioration of all the symptoms. 
 
 The following symptoms require special consideration: Fever. — 
 The temperature rises rapidly, sometimes reaching the fastigium within 
 twelve hours, usually within twenty-four hours. In childhood and old 
 age the rise is more gradual, especially if there is no chill. Its course is 
 
 
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718 
 
 MEDICAL DIAGi^OSIS. 
 
 subcontinuous and remarkably constant, the morning remissions and 
 evening exacerbations in many cases not greatly exceeding the diurnal 
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 at any period but are more common about the fifth or sixth day. They 
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 Fig. 244. — Croupous pneumonia. Recovery. 
 
 The time occupied by the crisis varies from two to several hours. It is 
 accompanied by an abundant sweat and usually occurs during a deep and 
 prolonged sleep, from which the patient awakes weak but refreshed and 
 comfortable. The fall almost always reaches subnormal ranges — 96°-97° 
 F. (35.o°-36° C), and may be followed by a postcritical rise and sub- 
 normal oscillations for a few days. In some instances the crisis is inter- 
 rupted by a rebound — interrupted crisis — or it may extend over twenty-four 
 hours — protracted crisis. In delayed cases and in children the deferves- 
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 ture is much lower. Afebrile cases are encountered. Pain. — The pain 
 
CROUPOUS PNEUMONIA. 
 
 719 
 
 has all the characters of pleurisy. It is stitch-like and lancinating, usually 
 severe, aggravated by deep breathing and cough, and referred to the region 
 of the nipple or the infra-axillary region on the affected side. Occasion- 
 ally it is referred to the epigastrium or the region of the appendix: an 
 important point for the diagnostician. In these cases there is a diaphrag- 
 matic pleurisy. In apex pneumonia pain is less constant and less severe 
 and in central lesions it is absent. Dyspnea. — The respiration rate is 
 increased in almost all cases, the masked pneumonias of drunkards and 
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 Fig. 245. — Croupous pneumonia. 
 Prolonged febrile movement, termi- 
 nating by lysis on 21st day of attack. 
 
 Fig. 246. — Pneumonia ; pseudocrisis, 
 5tii day ; crisis 8th day. 
 
 the exceptions. The pulse-respiration ratio may be 2:1 or even 1.5:1. 
 The respiration-frequency ranges from 30 to 50, and in children as high as 
 80 per minute in cases that recover; in fatal cases it is even more rapid. 
 The breathing is shallow; the ancillary muscles are brought into play; 
 there is, in man}'' cases, respiratory distress associated with air hunger and 
 a characteristic expiratory grunt or snort. Cough. — The early cough is 
 due to pleural irritation and is short, hard, and dry. Later it becomes 
 frequent, somewhat paroxysmal, and productive. It is attended with 
 pain, often severe throughout the attack. About the time of the crisis, it 
 becomes easier and is attended with free expectoration. Terminal pneu- 
 monias and those of the aged and drunkards are often without cough. 
 
720 MEDICAL DIAGNOSIS. 
 
 Absence of cough is also occasionally observed in the pneumonia of infancy. 
 Slight cough after the crisis is often ^vithout significance; but severe 
 paroxysmal cough may be a sign of pleural effusion. Sputum (see 
 Part III, page 456). Pulse. — At the onset the pulse is small, but it soon 
 becomes strong and full. It is seldom dicrotic. Later it becomes feeble 
 and small. The f requeue}^ varies in favorable cases from 80 to 110. A 
 very frequent pulse — 130-140 — is of unfavorable prognostic import, but 
 less so in children than in adults. In feeble and aged persons the pulse 
 is small and frequent from the onset. After the crisis the pulse remains 
 frequent for a time but gradually returns to normal. The peripheral blood- 
 pressure during the earl}' days of the attack shows httle or no change. 
 Later there is often a progressive fall. A sudden drop may be the pre- 
 cursor of death. In the septic cases there is an early fall. Heart Sounds. — 
 They are usually distinct and well-defined. The second pulmonary sound 
 is accentuated. With engorgement of the right heart and incomplete 
 systole of the right ventricle, the pulmonarj' second sound becomes pro- 
 gressively fainter. Great impairment of heart power shows itself in heart 
 sounds of the fetal type. Sudden collapse may occur early in the disease, 
 at the crisis, or during convalescence, and terminate in death. This may 
 happen without warning in previous^ healthy persons with good hearts. 
 Blood. — A decrease of the red corpuscles occurs at the time of the crisis 
 but marked anaemia is not common. A leucocytosis varying from 10,000 
 to 50,000 per c. mm. is present in most cases throughout the attack. It 
 disappears after the crisis. Its persistence may be the sign of a complica- 
 tion. It bears some ratio to the extent of the pulmonar}^ exudate. In 
 the toxic cases leucocj^tosis may be absent, and its absence in any case is 
 an unfavorable sign. The blood-plaques and fibrin elements are increased. 
 The eosinophile cells are decreased. Pneumococci can be isolated in 
 some cases. Digestive System. — There is complete anorexia. The 
 tongue, at first covered with a thick white fur, becomes red and glazed 
 and in the severer cases dry and brown. Vomiting is frequent in children. 
 Constipation is the rule. Meteorism is a troublesome condition in the 
 graver cases. Fibrinous exudates have been observed in the mouth and 
 nose and other mucous surfaces. Skix. — Herpes is very common — 20-60 
 per cent, of the cases. It appears usually upon the lips at the border of 
 the mucosa; less frequently upon the alse nasi, infrequently upon the 
 genitalia or anus, rarely upon the buttocks. Slight cyanosis may occur. 
 Redness of the cheeks, and especially of the cheek upon the affected side, 
 is very common. A general erythema is encountered in rare cases. As 
 in all grave infections petechise may occur. Sweating is not common dur- 
 ing the course of the attack, but is profuse at the crisis. Nervous Sys- 
 tem. — The symptoms referable to the nervous system are not peculiar to 
 pneumonia but are, in certain cases, of great assistance in the diagnosis. 
 In infants and young children convulsions may take the place of the initial 
 chill. Headache is frequent and often severe. Insomnia is a troublesome 
 symptom, often followed by delirium. The latter may be mild and wander- 
 ing, becoming progressively more severe, even increasing after the crisis. 
 In the intervals there is marked mental confusion. In a group of cases in 
 children the symptoms suggest meningitis, and the actual condition is very 
 
CROUPOUS PNEUMONIA. 721 
 
 often overlooked. There are cases in which the onset is marked by furi- 
 bund mania. In alcohoHc cases the nervous phenomena closely simulate 
 delirium tremens. Finally there are cases characterized from the onset 
 by dulness and stupor, with no chill and but little fever, in which pulmo- 
 nary symptoms are nearly or quite absent, but grave depression and wan- 
 dering delirium constitute the only manifestations of profound toxaemia. 
 The true character of such cases can only be determined by a systematic 
 routine examination of the chest. Apex pneumonia is more frequently 
 attended by severe nervous symptoms. The attack may be followed by 
 postfebrile delusional insanity, which as a rule terminates in recovery. 
 Urine. — The secretion has the usual characters of fever-urine. Toxic 
 albuminuria is common. Later the signs of an acute nephritis may be 
 present. Urea and uric acid, diminished during the attack, are greatly 
 increased upon the occurrence of crisis. The chlorides are diminished 
 or absent. 
 
 Physical Examination. — Inspection. — The attitude is variable. In 
 lung lesions of moderate extent the patient lies upon hi? back or upon the 
 affected side; in pneumonia of an entire lung, or double pneumonia, he 
 usually prefers to be supported by pillows. The respiratory movement 
 of the affected side is diminished. In basal pneumonia there may be 
 increased movement over the upper lobe. The increased compensatory 
 excursus on the sound side is often very conspicuous. The frequent breath- 
 ing, the action of the auxiliary muscles of respiration, and the sudden mus- 
 cular relaxation in expiration are to be noted. Orthopnoea may be present 
 in severe cases. The affected side may look larger, but the increase upon 
 actual measurement is trifling. 
 
 The difference in the expansion of the two sides is very evident upon 
 palpation. The vocal fremitus is greatly increased over the lesion. It 
 may be diminished or absent if the exudate extends into the middle-sized 
 bronchi or a plug of tenacious mucus occludes a tube of some size. 
 
 Percussion. — During the stage of engorgement the resonance is of 
 higher pitch and vesiculotympanitic — Skodaic resonance. After hepati- 
 zation has occurred percussion yields dulness, which varies from partial 
 impairment of resonance with the tj^mpanitic quality, to almost complete 
 loss of resonance. Flatness is only present in massive pneumonia when 
 the fibrinous exudate extends some distance into the larger bronchi. Be- 
 yond the borders of the lesion percussion often yields Skodaic resonance. 
 As resolution takes place the dulness becomes less marked; the qualit}' 
 becomes vesiculotympanitic and by degrees the normal pulmonary reso- 
 nance is restored. A certain elevation of pitch and faint tympanitic quality 
 may persist for several weeks. Wintrich's phenomenon is sometimes 
 present in apex pneumonia. In rare cases the percussion sound has an 
 amphoric quality and suggests a cavity. In central pneumonia the symp- 
 toms may be well marked but percussion may fail to indicate the site of 
 the exudate until it reaches the periphery of the lung, sometimes a period 
 of several days. 
 
 Auscultation. — In the stage of engorgement faint respiratory 
 sounds. The tidal air is not only decreased in volume, it also ebbs and 
 flows with diminished force. Then follow crepitant rales, heard only at 
 
 46 
 
722 MEDICAL DIAGNOSIS. 
 
 the end of inspiration — crepitus indux. In the stage of red hepatization, 
 when dulness appears, the respiration becomes bronchial, at first soft 
 and low-pitched, and more distinct upon expiration. Fully developed it 
 is high-pitched, heard alike upon inspiration and expiration, with an 
 interval of silence between the inspiratory and the expiratory sound and 
 often, especially in the young, having a loud, snoring quality. In massive 
 pneumonias in wdiich the exudate fills the bronchi bronchial breathing 
 is absent. Upon resolution small mucous and crepitant rales are again 
 heard — crepitus redux — and are sometimes foUowed by larger bronchial 
 rales which disappear as convalescence advances; more frequently by 
 nearly or quite normal vesicular breathing. In central pneumonias the 
 auscultatory like the percussion signs may be absent for a time. The 
 variety of bronchophony known as aegophony is sometimes present, but it 
 is a sign of trifling importance. 
 
 After the diagnosis is fully established it is not desirable to make 
 frequent examinations of the chest. They are exhausting to the patient, 
 especially as the crisis draws near, and in the absence of some special 
 indication in the symptoms or general condition should not be repeated 
 oftener than once in three or four days. In the necessary movements the 
 patient must be carefully assisted and make as little effort on his own 
 part as possible. 
 
 Complications and Sequels. — These are not many. Pleurisy. — In- 
 flammation of the pleura corresponding to the exudate is always present 
 when the latter extends to the periphery of the lung. It is usually fibri- 
 nous and cannot then be regarded as a complication. When serofibrinous, 
 the effusion usually contains coarse fibrin flakes and there is much soft 
 fibrinous deposit. It is often abundant. Even a moderate effusion coming 
 on during the stage of hepatization may cause urgent pressure symptoms. 
 A rare complication is pleural effusion upon the opposite side. 
 
 Metapneumonic Empyema. — This complication is not altogether 
 infrequent. Cases are sometimes regarded as instances of delayed resolu- 
 tion. The pneumococcus is usually present early; the streptococcus after- 
 wards. The signs of pleural effusion may appear during the attack or after 
 the crisis. In the former case there may be pressure symptoms, as 
 dyspnoea, cardiac embarrassment, and sensations of tightness, together with 
 persistence of the fever. In the latter, the temperature rises and becomes 
 remittent or intermittent and there are irregular profuse sweats, marked 
 anaemia, leucocytosis, and not rarely paroxysmal cough. The diagnosis of 
 small encapsulated and interlobar empyemata may often be made with 
 confidence in cases in which their precise location remains obscure. 
 
 Pericarditis. — This complication is comparatively infrequent — 5 
 per cent. It occurs chiefly in left-sided or double pneumonias. The exu- 
 date is usually fibrinous. Precordial pain may be overlooked in connection 
 with the pleurisy. A friction sound may be obscured by bronchial rales. 
 The effusion may be serofibrinous or purulent. 
 
 Endocarditis. — Primar}^ endocarditis may occur, or a fresh attack 
 supervene in chronic valvular disease. The malignant form is occasion- 
 ally associated with meningitis. The signs are not constant. Of diagnostic 
 importance are murmurs which change their quality or point of maximum 
 
CROUPOUS PNEUMONIA. 
 
 723 
 
 intensity, irregular fever with chills and sweating, and signs of embolism. 
 There are cases discovered post mortem in which no murmur has been 
 recognized during life. 
 
 Thrombosis. — This condition may occur during convalescence. The 
 femoral vein is commonly affected. EmboUsm of the larger arteries is 
 very rare. Aphasia is also rare. It may occur with or without hemiplegia. 
 
 Meningitis is a rare complication occurring during the course of the 
 attack or after the crisis. It has been observed more frequently during 
 epidemics of cerebrospinal fever. It constitutes a most serious compli- 
 cation. The pneumococcus has been found in the exudate. Very rare 
 
 
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 Fig. 247. — Pneumonia followed by empyema. 
 
 indeed are multiple neuritis, myelitis, and an ascending paralysis presenting 
 the characters of Landry's paralysis. Postinfective insanity is rare. In 
 individuals predisposed to neurasthenia an attack of pneumonia may 
 precipitate the outbreak. 
 
 Gastro-intestinal and Other Abdominal Complications. — Crou- 
 pous gastritis and colitis have been described. Appendicitis may occur as 
 an intercurrent affection. Epigastric pain, which is especially common 
 in children, is usually due to diaphragmatic pleurisy. It may simulate 
 peritonitis— a fact of importance in diagnosis, since in rare instances in- 
 flammation of the upper peritoneum by extension from the pleurae has 
 been observed. The abdominal pain, if localized and attended with shock, 
 may suggest acute hemorrhagic pancreatitis. 
 
724 MEDICAL DIAGNOSIS. 
 
 Jaundice. — Mild jaundice is not uncommon. It develops early and has 
 no bearing upon the prognosis. A deep obstructive jaundice may occur. 
 
 Meteorism. — Abdominal distention is a common and troublesome symp- 
 tom in the graver cases. It is the manifestation of the action of toxins upon 
 the nerve supply of the walls of the gut. By mechanically interfering with 
 the action of the diaphragm it adds to the embarrassment of the respiration. 
 
 Other Complications. — Parotid bubo occasionally occurs, especially 
 in connection with endocarditis of malignant type. Middle-ear disease is 
 common in children, and polyarthritis resembling that of rheumatic fever, 
 sometimes clearly septic in character, may occur during the course of the 
 attack or during the convalescence. 
 
 Relapse is a rare event. It is important not to mistake the fever of 
 delayed resolution or of empyema for relapse. An initial chill, high fever, 
 cough, rusty sputum, and critical defervescence would justify the diagnosis 
 of relapse. 
 
 Convalescence is commonly rapid. Resolution does not immediately 
 occur. Impaired resonance with the vesiculotympanitic quaUty and 
 feeble vesiculobronchial respiration may persist for a fortnight or longer. 
 Fever and a leucocytosis after the crisis suggest delayed resolution or 
 empyema. A systematic physical examination and the use of the aspirator 
 needle may become necessary. Persistent dulness is often due to a greatly 
 thickened pleura. 
 
 Anatomically the terminations of croupous pneumonia are: 
 
 1. Resolution. — The exudate undergoes liquefaction and resorp- 
 tion. Only in small part is it expectorated. Complete restoration of the 
 lung gradually occurs — restitutio ad integrum. 
 
 2. Delayed Resolution. — Resolution is more commonly delayed 
 in pneumonias of the aged and in debilitated subjects; it may be delayed 
 also in basal lesions and in previously robust persons. The crisis is followed 
 by an apparent convalescence, but the signs of local consolidation con- 
 tinue. From three to five or six weeks elapse before dulness and bronchial 
 breathing wholly disappear. Complete recovery ultimately follows. In 
 a second group of cases the defervescence is by lysis, with irregular, recur- 
 rent fever, sweating, rapid pulse, slight cough, usually little or no expec- 
 toration, and impaired nutrition. The condition simulates pulmonary 
 tuberculosis. In the course of four or five weeks, sometimes not until 
 two months or more have elapsed, complete resolution takes place and 
 the patient regains his health. 
 
 3. Abscess. — Local infection with pyogenic organisms. The abscess 
 cavities are multiple and small or they may coalesce and form an extensive 
 depot. Cough is paroxysmal and accompanied by an abundant purulent 
 expectoration containing elastic fibres, sometimes cholesterin crystals 
 and hsematoidin crystals. The onset of the condition is commonly attended 
 with increased fever of hectic type and other signs of sepsis. The differ- 
 ential diagnosis between a circumscribed empyema with bronchopulmonary 
 fistula and pulmonarj^ abscess rests largely upon the character of the sputum. 
 
 4. Gangrene. — Infection with saprophitic bacteria. The condition 
 may occur independently of or in connection with abscess. The con- 
 dition occurs mostly in persons debilitated by previous bad health. It 
 
CROUPOUS PNEUMONIA. 725 
 
 manifests itself clinically by septic phenomena and extreme prostration 
 and by a disgusting, penetrating fetor of the sputum and breath. 
 
 5. Fibroid Induration. — Defervescence either by crisis or lysis 
 may occur, but the signs of consolidation — dulness, increased vocal frem- 
 itus, bronchial respiration — continue unchanged. Occasional rales are 
 heard. Cough ma^^ be troublesome, but expectoration is scanty. Reso- 
 lution does not take place gradually as is usual, but the signs become more 
 •marked with contraction of the opposite side and the gradual development 
 of chronic interstitial pneumonia — fibroid phthisis. In other cases the 
 fever returns, the expectoration increases, and the course of the case is 
 that of a rapid pulmonary consumption — phthisis florida. 
 
 Clinical Varieties. — The clinical picture of croupous pneumonia is 
 made up of two essentially different groups of symptoms, namely, those 
 due to the local pulmonary lesion and those clue to the toxsemia. As these 
 vary greatly, it is evident that the individual cases, while conforming to a 
 type, will present differences which are determined among other factors 
 by the relative preponderance of one or the other of these two symptom- 
 groups. Complete consolidation of a lung may, on the one hand, be ac- 
 companied by but trifling evidences of general infection, while, on the other 
 hand, severe, even fatal, toxsemia occasionally occurs in cases in which the 
 pulmonary lesion is limited in extent. The other factors are: 1. Local 
 Variations. — (a) Apex pneumonia is more common in children. It is 
 frequently associated with marked cerebral Symptoms and may simulate 
 meningitis. In the absence of cough and sputum the pulmonary lesion 
 is often overlooked. Pneumonia of the apex in adults may be accompanied 
 by grave constitutional symptoms, (b) Double pneumonia is attended 
 with the additional dangers incident to progressive diminution of the 
 respiratory surface. The second lung is usually involved a day or two 
 after the first and to a less extent. The extension of the process is 
 not attended by a chill, (c) Central Pneumonia. — The exudate may re- 
 main circumscribed about the root of the lung or in the substance of a 
 lobe and not reach the periphery for three or four days, when the physical 
 signs may be for the first time detected. Meanwhile characteristic symp- 
 toms — chill, fever, cough, and rusty sputum — are present, but pain does 
 not occur until the inflammation reaches the pleura, (d) Pneumonia in 
 Emphysematous Persons. — The symptoms are distinctive, but, owing to 
 the diminished vascular supply and the dilatation of the vesicles, there is 
 not a sufficient c^uantity of fibrinous exudate to give rise to the signs of 
 consolidation. Several days may elapse before the site of the lesion can be 
 detected, (e) Masnve Pneumonia. — A rare form in which the fibrinous 
 exudate fills the bronchi. A lobe or the entire lung may be involved. 
 The affected portion is converted into a completel}^ airless mass. The 
 percussion sound is not dull but flat. Upon auscultation neither rales nor 
 bronchial respiration are heard, and vocal fremitus is absent. The signs 
 closely simulate pleural effusion, but adjacent organs are not displaced, 
 (f) Migratory Pneumonia. — The inflammation creeps about, involving in 
 succession one lobe after another, resolution, not always complete, taking 
 place in turn as new areas are afi"ccted. The migrations are not attended 
 by chills; fever continues and the course of the disease is much protracted. 
 
726 MEDICAL DIAGNOSIS. 
 
 2. The Intensity of the Process. — (a) Larval or Rudimentary 
 Pneumonia. — Mild cases occasionally occur. The symptoms consist of 
 slight chill, moderate rise of temperature, and cough. The pulmonary 
 signs are obscure. The expectoration is slight in amount and not usually 
 rusty. Herpes is common. The attack comes to an end in the course of 
 two or three daj^s. Its true nature is often overlooked, (b) Abortive 
 Pneumonia. — The attack begins with a severe chill. The fever is high. 
 Pleural pains, cough, rusty sputum, herpes, and characteristic physical 
 signs enter into a symptom-complex which is complete. In the course of 
 the second or upon the third day the temperature falls by crisis and the 
 patient enters upon convalescence, (c) Intense Pneumonia: Sthenic Pneu- 
 mo7iia. — The adjectives sthenic and asthenic have to a great extent passed 
 out of use, but almost every day one sees in a large hospital service cases 
 of pneumonia of great severity but in strong contrast as regards the char- 
 acter of the symptoms. Those terms serve a useful purpose in this 
 connection. Intense pneumonia occurs in middle life, in individuals 
 previously in good health, usually males, large, deep-chested, hard workers 
 in the open air. The initial chill is severe and prolonged, the temperature 
 high, the pulse bounding, the face flushed, chest pain very intense, the 
 breathing hurried, cough frequent, sputum hemorrhagic, the delirium 
 active, even maniacal, and the signs indicative of an extensive pulmonary 
 inflammation. These cases are attended with especial danger to life, 
 (d) Toxic, Asthenic or So-called Typhoid Pneumonia. — ^This variety, equally 
 severe and even more dangerous, is in the strongest contrast to the variety 
 just described. The ordinary symptoms of pneumonia may be absent and 
 the pulmonary lesions limited. The symptoms are those of profound 
 toxffimia. Early prostration, delirium, jaundice, meteorism, and diarrhoea 
 are present. The hands and lips tremble and stupor alternates with 
 wandering delirium. The condition is one of pneumococcus septicaemia 
 or mixed pneumococcus and streptococcus infection. 
 
 3. Individual Tendencies. — (a) Age. — In the new-born croupous 
 pneumonia is extremely rare. It is common in infants and young children. 
 Convulsions replace the initial chill. The apex is not rarely involved. 
 Cough is slight and suppressed or absent altogether. There is no expec- 
 toration. Excitement, jactitation, boring of the head into the pillows, 
 and high fever followed by stupor and convulsions suggest meningitis. 
 The apex pneumonia is often wholly overlooked. Pneumonia in the aged 
 usually develops insidiously without a distinct chill. There is little cough 
 and expectoration. Fever is moderate and irregular and the physical signs 
 not well defined. Great depression, inability to take nourishment, mild 
 delirium, and a tendency to stupor are present, (b) Sex. — In women at 
 the middle period of life pneumonia tends to assume the toxic form, in 
 men the sthenic form; in infancy and old age the course of the disease is 
 the same in males and females, (c) Pneumonia in Alcoholic Subjects. — Two 
 forms are to be considered — pneumonia in steady drinkers and pneumonia 
 during debauch. In the first the early symptoms do not differ from those 
 of ordinary pneumonia. Delirium with tremor soon develops, vomiting 
 is troublesome, the circulation fails, sleeplessness is uncontrollable, and 
 the signs of nephritis with ursemic phenomena are common. In the second 
 
CROUPOUS PNEUMONIA. 727 
 
 the onset is insidious, the temperature but sHghtly raised, cough, expec- 
 toration, and sputum trifling or wholly absent, and the clinical picture that 
 of delirium tremens. Only by a systematic physical examination can the 
 condition be recognized, (d) Pneumo7iia in Chronic Diseases; Terminal 
 Pneumonia. — The terminal event in many chronic diseases, especially 
 pulmonary tuberculosis, valvular and myocardial disease of the heart, 
 arteriosclerosis, nephritis, diabetes, cancer, and diseases of the spinal cord, 
 is croupous pneumonia. The development of this intercurrent disease is 
 very frequently overlooked, partly because it is very insidious and presents 
 none of its ordinary symptoms, and partly because the patient has reached 
 a point in the progress of the primary affection in which a proper physical 
 examination can no longer be made. The diagnosis is frequently made in 
 the post-mortem room. The intercurrent pneumonias of the acute infec- 
 tions, as enteric fever, diphtheria, and influenza, are not as a rule due to 
 the pneumococcus, but to the specific organism of the primary disease 
 in association with secondary invading bacteria — Streptococcus pyogenes, 
 staphylococcus, or the colon bacillus. 
 
 4. Varieties due to Differences in the Determining Causes. — 
 (a) Contusion Pneumonia. — Contusion of the chest, or violent bodily 
 shock without direct injury to the lung, may be followed in the course of a 
 day or two by the onset of a well-characterized croupous pneumonia, (b) 
 Postoperative Pneumonia. — The cases probably do not all belong to the 
 same group. True croupous pneumonia is much less common than broncho- 
 pneumonia, which may be diffuse or pseuclolobar. Croupous pneumonia 
 may occur after operations of various kinds, irrespective of the anaesthetic 
 employed. Bronchopneumonia is common after operations upon the mouth 
 and throat, (c) Ancesthesia Pneumonia. — This variety is almost always 
 bronchopneumonia. In many instances the lesions are so massed as to 
 constitute a pseudolobar pneumonia. The symptoms develop in the 
 course of the first or second day after the operation, much more commonly 
 when ether has been administered and the mouth, throat, or abdomen has 
 been operated upon. It is probably an aspiration pneumonia. 
 
 Diagnosis. — Direct. — In well-developed cases of primary croupous 
 pneumonia the diagnosis is an easy matter and errors are not often made. 
 The mistakes in diagnosis occur mostly in the aberrant and intercurrent 
 forms in which the disease is latent and the symptoms masked, and are the 
 result of neglect to carefully and systematically examine every patient, 
 and especially chronic cases, upon the appearance of fresh local or con- 
 stitutional symptoms, however trifling they may appear. In certain 
 cases the general symptoms are indeterminate but the local phenomena 
 decisive, in others the physical signs are obscure, but chill, fever, cough, 
 and sputum are characteristic. In either of these conditions the diagnosis 
 is clear; still more clear is it when both symptoms and signs are present 
 and well defined. 
 
 Differential Diagnosis. — 1. Acute Pneumonic Phthisis (see p. 803). 
 2. Hemorrhagic Infarct. — There are circumscribed dulness and bloody 
 sputum. The chill of pneumonia does not occur; there may be complete 
 absence of fever; the blood is less thoroughly admixed with the sputum, 
 and finally a condition capable of giving rise to embolism may be dis- 
 
728 MEDICAL DIAGNOSIS. 
 
 covered. 3. Pulmonary (Edema. — The sputum is bloody, but it is also 
 thin and frothy, a condition only exceptional in pneumonia. Dulness is 
 not common and when present involves both bases posteriorly and is far 
 less strictly dehmited than in pneumonia. Both conditions may be pres- 
 ent. Collateral oedema — fluxion oedema — is common in pneumonia and 
 an inflammatory oedema may develop at the borders of the lesion. 4. 
 Bronchopneumonia. — Massed lesions of considerable extent or involving a 
 lobe — pseudolobar pneumonias — are misleading. Croupous pneumonia 
 generally occurs as an acute process, attacking persons in previous good 
 health, or as an intercurrent specific disease in various chronic affections, 
 whereas bronchopneumonia is mostly an affection secondary to some acute 
 specific fever, as measles or other condition in which the aspiration of 
 infectious matter from the mouth or throat takes place. Croupous pneu- 
 monia is furthermore an acute, short, well-characterized disease, beginning 
 abruptly with a chill and terminating by crisis, while bronchopneumonia 
 comes on gradually or abruptly with temperature rise but without chill, 
 continues indefinitely, and terminates in favorable cases by lysis. In the 
 cases in which the diagnosis is uncertain, sputum is often absent, but, as 
 a rule, to which, however, there are exceptions, when present it is rusty 
 and viscid in croupous pneumonia and mucopurulent in bronchopneumonia. 
 5. Pleural Effusion. — This question of diagnosis is of daily occurrence at 
 the bedside and demands special consideration (see p. 1099). 6. Menin- 
 gitis. — Doubts arise in some cases of apex pneumonia, especially in chil- 
 dren. A knowledge that the pulmonary lesions are often masked will 
 remind the practitioner that in every case in which meningeal symptoms 
 are present the lungs and heart are to be particularly examined. 7. Enteric 
 Fever. — There are two principal sources of error. Patients suffering with 
 toxic pneumonia or the asthenic form of the disease present septic symp- 
 toms identical with those of enteric fever with mixed infection. Clinically, 
 in the absence of a satisfactory anamnesis the diagnosis is often obscure. 
 A positive agglutination with the Widal test is mostly conclusive. Excep- 
 tionally the patient may have passed through enteric fever some. weeks or 
 months before. To this condition the term typhoid pneumonia is frequently 
 applied. This unfortunate term is also used to designate cases of enteric 
 fever in which bronchopneumonia — inhalation pneumonia — has arisen as an 
 intercurrent condition. Much less common are cases of enteric fever which 
 begin with the symptoms and soon develop the signs of pneumonia — pneu- 
 motyphus. The diagnosis cannot be made with precision until the eruption 
 and splenic tumor appear or a positive result follows the agglutination test. 
 Prognosis. — Croupous pneumonia, taking all cases together, is an 
 extremely fatal disease. The statistics are unreliable. When the facts 
 in the natural history of this disease are considered it appears probable 
 that the mortality, according to hospital statistics, is too high; according 
 to the impressions of physicians in private practice, too low. Especially 
 misleading are the figures collected to support the efficacy of certain methods 
 of treatment. It is necessary to be explicit. The clinical varieties are to 
 be considered. Apex pneumonia is more liable to be associated with ner- 
 vous symptoms and grave toxgemia. Double pneumonia is attended with 
 increasing circumscription of the respiratory surface and stress upon the 
 
CROUPOUS PNEUMONIA. 729 
 
 right heart, as well as by a more intense toxemia. In the migratory form 
 there is increased clanger from the prolongation of the active disease. As 
 regards the intensity of the process, the powers of resistance of the indi- 
 vidual play an important part. On the one hand robust and previously 
 healthy persons, free from alcoholism, perish in a few days, while individuals 
 of feeble constitution recover from an apparently hopeless attack. The 
 toxic cases are mostly fatal. Nevertheless the better the previous health, 
 the more favorable the outlook. That wholly unknown influence called 
 by the older writers the epidemic constitution is far from being unim- 
 portant. The mortality varies in different years in the same locality 
 between 5 and 30 per cent., and without discoverable cause there are alter- 
 nating series of favorable and unfavorable cases. The mortality in house 
 epidemics and institutions is high. Negroes in the United States show 
 an increased mortality. The death-rate is distinctly higher in the southern 
 than in the northern states of our country. In high altitudes the prognosis 
 is extremely unfavorable. The question of diagnosis has a distinct bearing 
 upon the statistics. The pneumonias of infancy and old age, secondary 
 pneumonias, and terminal pneumonias are very often not recognized. In 
 infants bronchopneumonia is frequently mistaken for croupous pneumonia 
 or the latter for meningitis. In the aged, pneumonia frequently causes 
 death without characteristic or even suggestive symptoms. Insidiously 
 developing intercurrent pneumonias may be wholly overlooked and the 
 fatal issue ascribed to the primary disease. Certainly this is true of 
 terminal pneumonias — a fact which accounts for the discrepancy in the 
 death-rate from pneumonia as reported from the wards and upon the 
 protocols of the post-mortem room. It is easy to overlook pneumonia 
 in a patient dying in the ward of a chronic disease: impossible to do so 
 upon the autopsy table. 
 
 Statistics, to be of value, especially to be of value in determining the 
 relative efficacy of different plans of treatment, must be based upon large 
 numbers of cases analyzed with reference to all the factors which influence 
 the result of the attack in individual instances. In hospitals the mortality 
 ranges from 20 to 40 per cent. In the Pennsylvania Hospital, of 943 cases 
 entered as pneumonia in seven years, 19S or 21 per cent. died. In the 
 German Hospital, of 407 cases treated during ten years 108 died, a mor- 
 tality of 26.5 per cent. The mortality in private practice varies according 
 to different observers from 3 or 4 to 20 per cent. The series of cases in 
 private practice are usually too small to be of statistical value. 
 
 Among the circumstances which bear upon the prognosis in indi- 
 vidual cases are the following: Under one year the death-rate is much 
 higher than between two and twelve. Adolescents and healthy young 
 adults bear pneumonia well. The death-rate is very low among recruits 
 and young soldiers, picked men living a regular life in well-constructed 
 barracks. After sixty, 75 per cent, die; yet remarkable recoveries occur. 
 I have now under observation a lady aged 99 who has twice had well-char- 
 acterized croupous pneumonia since her eightieth year. Women bear 
 pneumonia comparatively badly. When it occurs during pregnancy there 
 is danger of abortion or premature labor, but the danger is not so great 
 as it was at one time thought to be. In those previously ill with chronic 
 
730 
 
 MEDICAL DIAGNOSIS. 
 
 disease, the obese, and especially in those habitually given to drink, pneu- 
 monia is especially dangerous. In such cases also astonishing recoveries 
 occasionally take place. The outlook is also grave in gouty persons and 
 those suffering from emphysema. Complications add greatly to the grav- 
 ity of the cases. Pneumococcus meningitis may be regarded as a fatal 
 disease; endocarditis is usually of the malignant type; septic phenomena, 
 whether due to the toxaemia of the primary infection or to secondary 
 infection, are ominous. A low leucocyte count is unfavorable. 
 
 Death is commonly caused by the action of the toxins upon the vas- 
 omotor centres with progressive lowering of the blood-pressure. In many 
 cases over-distention of the right heart is at fault. Sudden cedema of the 
 lungs frequently precedes the fatal event. 
 
 XVI. CEREBROSPINAL FEVER. 
 
 Ejpidemic Cerebrospinal Meningitis. 
 
 Definition. — An acute, infectious, epidemic disease caused by the 
 Diplococcus intracellularis meningitidis, characterized clinically by sudden 
 onset, with headache, vomiting, and painful contraction of the muscles 
 of the back of the neck, irregular fever, profound nervous symptoms, 
 rapid course, and high death-rate; anatomically, by inflammation of the 
 meninges of the brain and cord. 
 
 Etiology. — Predisposing Influences. — Climate appears to have 
 little influence as a predisposing factor. Outbreaks are more common and 
 extensive in the winter and spring than in the warm seasons of the j^ear. 
 Densely populated cities and sparsely settled agricultural regions are alike 
 subject to its prevalence. Damp, overcrowded, and unclean habitations 
 favor its spread, and persons li^dng on the ground floor are especially apt 
 
 to suffer. Individuals of all occupa- 
 tions and professions are liable to this 
 disease. Military life involves a spe- 
 cial liability. Among adults the pro- 
 portion of males attacked is greater 
 than that of females. Among chil- 
 dren the number of males and females 
 is about equal. 
 
 Cerebrospinal fever is especially a 
 disease of children and young adults. 
 After 40 it is uncommon, though the 
 diagnosis has been verified post mortem 
 in individuals over 70. 
 
 Exciting Cause. — Diplococcus 
 intracellularis meningitidis ; meningo- 
 coccus. This organism is found in the 
 fluid obtained b}' lumbar puncture and 
 in the meningeal exudate. The cerebrospinal fluid is usually more or 
 less turbid, sometimes very turbid, especially early in the course of the 
 attack. While turbidity of the spinal fluid is of diagnostic importance, 
 
 1% 
 
 'm?^- 
 
 
 
 n^'r 
 
 Fig. 248.— Spread of meningococcal exudate 
 sho'N^'ing intracellular meningococci. 
 
CEREBROSPINAL FEVER. 731 
 
 its limpidity does not constitute a negative sign, and in either case 
 cultures are necessary to the diagnosis. In the tissues the diplococcus is 
 almost constantly confined to the interior of the polynuclear leucocytes. 
 The diplococci are found only in connection with the lesions of the disease. 
 Mixed infections are not uncommon. 
 
 Cerebrospinal fever does not appear to be contagious in the sense in 
 which we use the term in speaking of smallpox, scarlet fever, and typhus. 
 The definite micro-organism which causes it is, in the majority of instances, 
 confined to the meninges of the brain and cord, with little or no opportu- 
 nity of transmission to other individuals. In cases in which there are lesions 
 in the lungs, ears, and nose, however, infection of neighboring objects or 
 persons may readil}'' take place. Councilman has recently made the fol- 
 lowing statement: ''The presence of sporadic cases is of importance in 
 the occurrence of epidemics. The Diplococcus intracellularis is an organ- 
 ism of feeble vitality: it dies out easily on exposure to drying and light 
 and is incapable of a saprophytic existence. In the absence of intervening 
 infections, it would be impossible for the period of epidemics to be bridged 
 over. Not only this, but there is evidence that this organism can produce 
 other infections and may even live as an inhabitant on the normal mucous 
 membrane. " 
 
 Second attacks are exceedingly rare. In most cases lasting immunity 
 is established. 
 
 Symptoms of the Ordinary Forms. — Cerebrospinal fever presents a 
 great diversity of symptoms in different cases. No other acute disease 
 appears in such various guises. Stille has well called it a "chameleon-like 
 disorder. " The period of incubation is unknown. Prodromes are rare. 
 When present they consist of headache, dragging muscular pains, vertigo, 
 and a sense of fatigue. The onset of the attack is usually abrupt. It is 
 marked by a chill, agonizing headache, nausea, and vomiting. In some 
 cases headache is not a conspicuous symptom. The attack begins with 
 vertigo and the patient acts like a drunken man. Dragging pains in the 
 neck spread along the spine and into the extremities and are followed b}" 
 motor symptoms which progressively develop. These consist of tetanoid 
 stiffness of the spinal muscles, great pain on attempting to bend the head 
 forward or to turn it from side to side, and awkwardness and difficulty 
 in movements of the extremities. Strabismus, inequality of the pupils, 
 and palsies of the facial muscles are common. In the course of a little 
 time opisthotonos develops, the head is drawn back, the spine curved, the 
 forearms flexed on the arms and the legs on the thighs. Muscular cramps 
 and spasmodic twitchings occur and in young children general convul- 
 sions. Hemiplegia has been frequently observed. Paraplegia may also 
 occur. Paralysis may develop during the course of the attack and dis- 
 appear shortly or persist for some time. The sensory symptoms consist 
 of headache, which may be sharp, lancinating or boring, and is commonly 
 referred to the back of the head; sometimes it is felt as a constricting 
 band ; pain in the back of the neck and in the lumbar and epigastric regions 
 and general hyperesthesia, most marked in the face and neck. Various 
 disturbances of the special senses, as photophobia, intolerance of sounds, 
 ringing in the ears, and vertigo, occur. The psychical disturbances are 
 
732 
 
 MEDICAL DIAGNOSIS. 
 
 striking. The patient is restless and distressed. His face is seldom flushed, 
 usually pale, and slightly cyanotic. In children there is great irritability. 
 Delirium occurs early and may be active, even maniacal, or of a busy 
 wandering type. After a time it passes into somnolence or stupor, which 
 may be still attended by more or less restlessness and continual movement 
 on the bed. In the worst cases stupor deepens to coma. The tongue is 
 at first slightly covered with a whitish fur. In conditions of great depres- 
 sion it becomes dry and brown and sordes collect. Taste is lost and the 
 patient refuses food; nevertheless the vomiting persists. Constipation is 
 commonly present throughout the sickness. Toward the end of the attack, 
 however, diarrhoea and involuntary discharges may take place. Slight, 
 exceptionally marked, enlargement of the spleen may be made out. The 
 fever is generally moderate, very irregular, and does not observe a typical 
 course. There are frequent remissions. In some instances fever is slight 
 or absent altogether. On the other hand, the temperature may reach 
 105° or 106° F. (40.5°-41.1° C). It may abruptly rise before death. The 
 fever, even when intense, may be of short duration. There is no constant 
 relation between the intensity of the febrile movement and the severity 
 of the other symptoms. Defervescence may take place without improve- 
 ment in other respects, so that there are cases in which severe nervous 
 symptoms persist for weeks after the temperature has fallen to normal or 
 subnormal ranges. Many of the cases show a temperature range of irreg- 
 ularly remittent type. In the milder cases the temperature is sometimes 
 distinctly intermittent. The subfebrile temperatures are sometimes broken 
 by rapid and transient elevations. The pulse is also irregular. There is 
 no constant correspondence between the pulse and temperature. It may 
 be soft and w^eak, even slower than in health, and is often intermittent and 
 
 arrhythmic. Abrupt changes in the 
 ' ' force and frequency of the pulse are 
 
 common. Change in the frequency 
 from 80 to 100 has been observed in 
 the course of a minute. The rhythm 
 of the respiration may be disturbed 
 and Cheyne-Stokes breathing may 
 occur in the graver cases. 
 
 Leucocytosis is present through- 
 out the disease, diminishing toward 
 the end of the attack in cases 
 which recover. 
 
 Lesions of the skin are com- 
 mon. To their prominence is due 
 the old name of spotted fever. They 
 vary greatly in different epidemics. 
 In many cases they are absent alto- 
 gether. They are often polymor- 
 phous. Herpes is far more common 
 than any other eruption. It usually appears on the lips and nose, 
 but may involve other parts of the face or body and may vary from 
 a crop of a few fine vesicles to an abundant eruption of large vesicles. 
 
 Fig. 249. — Petechial eiuption ; epidemic cerebro- 
 spinal meningitis. — Royer. 
 
CEREBROSPINAL FEVER. 733 
 
 A petechial rash is frequently observed, and in some instances extensive 
 hemorrhagic areas develop in the skin. The petechise often resemble 
 flea-bites. They are distributed in varying numbers over the whole 
 surface, but particularly about the knees and elbows. In some cases 
 the rash is abundant and develops with great rapidity. Patches of 
 erythema, dusky mottlings, and rose spots disappearing on pressure, like 
 the rash of enteric fever, have been observed. Among the rarer cutaneous 
 manifestations are urticaria, erythema nodosum, pemphigus, and gangrene. 
 The urine is, as a rule, increased. It may be much increased even with 
 high temperature. The reaction is usually acid. A moderate amount of 
 albumin is frequently present. There is a special form of cerebrospinal 
 fever characterized by symptoms of an acute nephritis and corresponding 
 to the renal form of enteric fever. Glycosuria occasionally occurs, and in 
 malignant cases hsematuria has been observed. Retention of urine is 
 common in the graver cases. Polyuria is frequent in children, and in some 
 cases has persisted for years after convalescence. 
 
 The eye lesions are referable to three causes: First, neuritis, due to 
 the involvement of the nerve in the exudate at the base without extension 
 of the inflammatory process to either the orbit or the eye. This condition 
 may affect the oculomotor and the optic nerve. Second, inflammation 
 from the meninges may extend directly into the eye along the pia-arach- 
 noid of the optic nerve, causing purulent choroido-iritis and in very rare 
 instances suppuration in the orbit. Keratitis may arise in consequence of 
 an extension of the inflammation from the iris and ciliary region. The 
 third cause is neuritis of the fifth nerve, with loss of sensation and keratitis 
 and purulent conjunctivitis. 
 
 Symptoms relating to the auditory apparatus are very common. The 
 auditory nerve is generally swollen and surrounded by the exudate. Ex- 
 tensive degeneration of the nerve-fibres is frequently found, being most 
 marked in the chronic cases. The abortive form of epidemic cerebrospinal 
 meningitis is the cause of many cases of early acquired deafness. Deafness 
 is frequently due to disease of the labyrinth. Otitis media and mastoid 
 disease occur. The diplococci are found in the pus-cells. 
 
 Coryza has been frequently observed in the course of the attack. 
 Weigert first advanced the opinion that in meningitis the nose forms the 
 portal of entry for the infectious organisms. It may be, however, that 
 their presence is due to an extension from the brain and not to primary 
 invasion. Epistaxis also occurs. 
 
 The wasting in severe cases is rapid and extreme. An early, sudden, and 
 great loss of strength is a frequent and prominent condition in this disease. 
 
 The symptoms may be divided into those due to the inflammatory 
 lesions of the cerebrospinal organs and those due to a general infection. 
 In the malignant cases both these groups of symptoms are of overwhelm- 
 ing severity. In the mild cases the nervous symptoms are predominant. 
 The foregoing symptoms indicate the nature and severity of the disease 
 in its ordinary form. 
 
 Anomalous Forms. — 1. Malignant (Meningitis Cerebrospinalis Epi- 
 demica Siderans). — The patient is struck clown without warning and speed- 
 ily falls into a state of collapse. A violent chill is followed by cyanosis, 
 
734 MEDICAL DIAGNOSIS. 
 
 coldness of the surface, profuse perspiration, intense headache which alter- 
 nates with drowsiness, and brief delirium followed by unconsciousness. 
 There may be contraction of the neck. Respiration is slow and labored; 
 the pulse rapid and feeble; the urine scanty and loaded with albumin. 
 Purpuric blotches appear on the surface. Cases of this kind have occurred 
 in many epidemics and with greatest frequency at the beginning of the 
 outbreak. They may occur sporadically.. Death may ensue in the course 
 of a few hours. 
 
 2. Abortive {Meningitis Cerebrospinalis Epidemica Abortiva). — The 
 onset of the attack is severe. In the course of a few days the symptoms 
 subside and convalescence is rapid. 
 
 3. Mild (Meningitis Cerebrospinalis Epidemica Ambulans). — Patients 
 complain of headache, stiffness in the neck and spine, and malaise. Vom- 
 iting occurs. Fever is, as a rule, absent. Cases of this kind can only be 
 recognized in the light of a prevailing epidemic. 
 
 4. Intermittent {Meningitis Cerebrospinalis Epidemica Intermittens). 
 — This form is common. Not only the fever, but other symptoms of the 
 
 Fig. 250. — Cerebrospinal fever ; 53d day of the attack. — Pennsylvania Hospital. 
 
 disease show extraordinary exacerbations and remissions, which may be 
 repeated at intervals of twenty-four or forty-eight hours. These cases 
 may be due to successive involvement of areas of the meninges or to 
 fresh growths of the organisms. They rarely present the well-marked 
 periodicity of the malarious diseases. 
 
 5. Chronic {Meningitis Cerebrospinalis Epidemica Chronica). — Cases 
 of this form occur in all epidemics. The disease lasts, with numerous com- 
 plications, remissions, and exacerbations, for several weeks or in some 
 instances for five or six months. Emaciation is extreme. The symptoms 
 may be due to the persistence of conditions left by the acute attack, such 
 as chronic hydrocephalus or abscess of the brain, or general neuritis. 
 
 Complications and Sequels. — Among the complications and sequels 
 are pleurisy, endocarditis, and pericarditis. Bronchial catarrh and deglu- 
 tition pneumonia are very common. Croupous pneumonia has been com- 
 mon in some of the epidemics. This complication occurs more frequently 
 at the close than at the beginning of an epidemic. It is uncertain whether 
 in some instances the cases of pneumonia reported in connection with epi- 
 demic meningitis have been cases of true croupous pneumonia or cases of 
 meningococcus pneumonia. 
 
CEREBROSPINAL FEVER. 735 
 
 Arthritis, commonly slight, but in rare instances suppurative, has 
 been noted. The wrist-joints are most commonty involved. Swelling of 
 the parotid glands is an occasional accident of the disease. It may be 
 slight or may run on to suppuration — parotid bubo. 
 
 Intestinal catarrh may occur as a complication. Malarial and enteric 
 fever, and measles, scarlet fever, and cholera have been encountered as 
 intercurrent affections. 
 
 The convalescence is irregular and uncertain. After severe cases it is 
 apt to be tardy. Relapses are not uncommon and are often fatal. 
 
 Among the more important sequels are prolonged debility and ema- 
 ciation, palsies and various forms of paralysis, impairment of intelligence 
 in consequence of chronic meningitis and chronic hydrocephalus, espe- 
 cially in children, and more or less complete deafness and loss of vision. 
 General motor weakness and paralysis of individual cranial nerves or of 
 the lower extremities may persist for a long time. They depend on lesions 
 of the brain or spinal cord, or pressure exerted by extensive organized 
 inflammatory exudate, or on peripheral neuritis. 
 
 Diagnosis. — Direct Diagnosis. — The recognition of cerebrospinal 
 fever by ordinary clinical methods is a matter of difficulty in sporadic 
 cases and at the beginning of outbreaks. The diagnosis of any form of 
 meningitis is occasionally obscure. Sudden onset, chill, fever, vomiting, 
 delirium, tremor, and painful rigidity of the back of the neck may occur 
 in pneumonia, the malignant form of variola, typhus, and especially in the 
 cerebrospinal form of enteric fever. Kernig's sign is found to be present 
 in 80 to 90 per cent, of the cases of meningitis and only exceptionally pres- 
 ent in other diseases. This test is often attended by evident pain on the 
 part of the patient. 
 
 If meningitis be present there is usually no great difficulty in recogniz- 
 ing cerebrospinal fever during an epidemic. The ordinary and anomalous 
 forms alike show a symptom-complex that in the course of a little time is 
 distinctive. In all cases when practicable lumbar puncture should be 
 performed. If carried out early in 
 the attack, at the time when the 
 diagnosis is often as important 
 as it is difficult, the result is com- 
 monly conclusive. 
 
 Lumbar Puncture (Quincke). 
 — The operation is devoid of danger 
 and can be performed without gen- 
 eral ansesthesia. Freezing of the 
 skin may be dispensed with, as it 
 is as painful as the puncture and 
 causes unnecessary delay. In chil- 
 dren excitement may be avoided 
 by a few whiffs of chloroform. ^'''- -'''•" ^'^''™;ieni3tis*^?oyer"''' ^'"''^'''■°"p'"^' 
 Surgical antisepsis is to be strictly 
 
 observed. Suitable pointed cannulas are sold in the shops. A small 
 aspirator needle may be used. The instrument is introduced into the 
 subarachnoid space between the fourth and fifth lumbar vertebra?. The 
 
736 MEDICAL DIAGNOSIS. 
 
 point of entrance may be determined by drawing a line connecting the 
 highest points of the crest of the ilium posteriorly. This line passes over 
 the spine of the fourth lumbar vertebra. The point of entrance is about 
 one centimetre below and one centimetre to the right of the intersection 
 of the transverse line and the median line. Some prefer the third lumbar 
 interspace. The patient should lie upon the right side, the spine being 
 strongly bowed, the thighs and knees flexed, and the left shoulder drawn 
 forward. The thumb of the left hand being used as a guide, the needle is 
 thrust with a rotary movement in an upward and inward direction to a 
 depth varying, according to the age of the patient and the thickness of the 
 tissues, from about two and a half centimetres in infants to between four 
 and six centimetres in adults. The fluid runs drop by drop or in a stream, 
 the normal pressure being about 120 mm. of mercury. In meningitis the 
 pressure may reach 250-300 mm. Normal fluid is clear and limpid, but 
 no conclusions can be reached without careful laboratory investigation, 
 including, in doubtful cases, the inoculation of a guinea-pig. 
 
 If the patient has meningitis the fluid withdrawn is, as a rule, but 
 not invariably, more or less cloudy; if cerebrospinal fever, the Diplococcus 
 intracellularis meningitidis — meningococcus — will be found on direct mi- 
 croscopic examination or in cultures. Positive conclusions can only be 
 drawn from positive results. When the result is negative the operation 
 must be repeated. 
 
 Differential Diagnosis. — 1. Pneumococcus Meningitis. — This may 
 occur alone or in connection with croupous pneumonia. The pulmonary 
 lesion may be latent. Symptoms indicating extensive infection of the 
 meninges, of the cord and spinal roots, and extension of the infective proc- 
 ess along the cranial nerves are less marked or absent altogether. Con- 
 traction of the muscles of the neck may be absent, delirium and coma are 
 present and occur early, and this form of meningitis is fatal, while cases 
 of the epidemic form may recover. 
 
 2. Streptococcus Meningitis. — This form is secondary to infection 
 elsewhere. Fracture of the skull, especially fracture of the base, local 
 abscess formation, acute endocarditis, erysipelas of the face and scalp, 
 otitis media with extension to the mastoid or the meninges are forms of 
 primary infection. Opisthotonos is neither common nor well developed. 
 The symptoms develop slowly and are often for a time obscure. The 
 association of painful rigidity, intense headache, and vomiting is not con- 
 spicuous. Eye symptoms are common. 
 
 3. Tuberculous Meningitis. — This, perhaps the most familiar form of 
 meningitis, is to be distinguished from cerebrospinal fever by a protracted 
 period of prodromes, more gradual onset, slower course, slow and irregular 
 pulse, great irregularity of the respiration, and the absence of eruption. 
 Antecedent tuberculous disease, failure of health following measles or 
 influenza, tuberculous glands, or a hereditary predisposition to tuberculous 
 infection are found in the history of the patient. In children or during 
 the prevalence of an epidemic of cerebrospinal fever and in cases in which 
 the tuberculous process involves the spinal meninges (Hirsch), the diag- 
 nosis is far from easy. The result of spinal puncture is conclusive. 
 
 4. The Cerebrospinal Form of Enteric Fever (see p. 633). 
 
ERYSIPELAS. 737 
 
 5. Scarlet Fever. — In some instances the sudden onset, high febrile 
 movement, vomiting, convulsions, and stupor suggest cerebrospinal fever 
 as it occurs in children. The presence of the peculiar redness of the pala- 
 tine half-arches, rapidly followed by general erythematous angina, are im- 
 portant. In the course of twenty-four or thirty-six hours the efflorescence 
 will clear up any uncertainty. 
 
 6. Typhus Fever. — At one time cerebrospinal fever was confounded 
 "with typhus or regarded as a variety of that disease. To Stille is due the 
 credit of having finally settled every question of doubt concerning the 
 identity of these two diseases in this country. They are in strong con- 
 trast in respect of their causes, symptoms, course, lesions, and sequels. 
 
 7. Hysteria. — Cases of cerebrospinal fever, occurring in nervous fe- 
 males at the close of epidemics or sporadically, have presented a deUrium 
 so peculiar and an array of symptoms so little characteristic that they 
 have been looked upon as manifestations of hysteria. This error in diag- 
 nosis is no longer possible. 
 
 Prognosis. — In individual cases the prognosis can never be made 
 with certainty. The abortive and fulminant cases run the most rapid 
 course. Hirsch has emphasized the fact that certain cases, which at the 
 onset present the symptoms of cerebrospinal fever, recover after an illness 
 of a few hours which terminates in free sweating. The malignant cases, 
 on the other hand, prove fatal in a few hours or two or three days. Mod- 
 erately severe cases may last one or two weeks or several months. The 
 first week is the time of greatest danger. Symptoms rendering the prog- 
 nosis unfavorable are intense excitement, early depression, persistent 
 vomiting, irregular respiration, and convulsions alternating with coma. 
 The average mortality is about 40 per cent. It varies in different epidemics 
 from 20 to 75 per cent. 
 
 Relapses are not infrequent and are often fatal. 
 
 XVII. ERYSIPELAS. 
 
 Definition. — An acute, infectious, endemic affection caused by the 
 Streptococcus erysipelatis and characterized by fever, a peculiar circum- 
 scribed inflammation of the skin, and ready transmissibility. 
 
 Etiology. — Predisposing Influences. — Erysipelas is a widely prev- 
 alent disease which occurs in every climate and to which all races are 
 liable. It is endemic at all seasons of the year and may prevail in local 
 epidemics at any time if the conditions are favorable to its spread. Such 
 epidemics are more common and extensive in the spring. Erysipelas be- 
 longs to the group of wound infections and spreads chiefly by accidental 
 inoculation. Neither age nor sex therefore essentially predisposes to the 
 disease. Incidentally certain conditions of the individual and his sur- 
 roundings render him especially liable. The integuments afford less com- 
 plete protection against infection at the extremes of life than at other 
 periods. During the first two weeks, the infant is very liable to erysip- 
 elas, which most commonly starts from the umbilicus, though it may appear 
 at any wound or abrasion. Aged persons frequently suffer from chronic 
 5 diseases of the skin, such as eczema, acne, furunculosis, prurigo, varicose 
 
 47 
 
738 MEDICAL DIAGNOSIS. 
 
 ulcers and fissures where the skin and mucous membranes merge, and are 
 hence especially liable to accidental inoculation. But these lesions may 
 occur at any period of life. Wounds and injuries are more common in 
 males than in females and for this reason the former suffer from erysipelas 
 more frequently than the latter. Those who have recently undergone 
 surgical operations and lying-in women are peculiarly liable to infection. 
 Exhausting diseases, conditions of cachexia, chronic nephritis, and alco- 
 holism are important predisposing factors. Among local conditions filth, 
 overcrowding, defective ventilation, and deficient sunlight are most im- 
 portant. Unsanitary apartments and buildings frequently become the 
 abiding place of the poison. The appearance of a single case of erysipelas 
 in a surgical ward or lying-in hospital is an imperative reason, not only 
 for immediate disinfection, but also for abandoning its use for a period. 
 Notwithstanding these precautions the disease occasionally continues to 
 recur in modern institutions of approved construction. The greatly di- 
 minished death-rate after surgical operations and among puerperal women 
 at the present time is largely due to the infrequency of erysipelas, and this 
 to the scientific cleanliness of a modern technic. A family or hereditary 
 predisposition is sometimes observed. An apparent personal predisposi- 
 tion is not uncommon. Certain individuals contract the disease several 
 times, at intervals varying from some months to a year or more. 
 
 Exciting Cause. — The specific cause of the disease is the Strepto- 
 coccus erysipelatis, or S. pathogenes longus. This organism belongs 
 to the group S. pyogenes. The Streptococcus erysipelatis is thrown off 
 from the inflamed surface throughout the whole course of the disease and 
 during the desquamation. It is capable of an indefinitely prolonged ex- 
 istence. Under ordinary circumstances it is not intensely virulent, but 
 when a number of susceptible persons are crowded together under bad 
 hygienic conditions the results are disastrous. It is extremely tenacious, 
 adhering to the clothing and bedding of the patient and the furniture and 
 walls and floor of the room, occupied during his illness. It clings also to 
 the clothing of individuals who come into contact with the patient, to the 
 hands of operators and attendants, and to surgical instruments. By these 
 means it may be and frequently is, in the absence of proper precautions, 
 communicated to persons at a distance, who in their turn become centres 
 of infection. It gains access to the organism in the vast majority of cases 
 by demonstrable wounds or abrasions of the skin, or, less commonly, of 
 the mucous membranes. The most minute lesion of the integument, 
 readily overlooked or already healed when the erysipelatous flush first 
 appears, or, if not healed, concealed by the blush itself, may serve as the 
 point of entrance. Fissures at the angle of the mouth, nose, or eye, a lesion 
 of the lachrymal duct, a crack in the fold behind the ear, a fissured nipple, 
 an abrasion about the genitalia or at the anus, the prick of a needle, the 
 piercing of the lobule for ear-rings, a scratch, in fact any solution of the 
 continuity of the integument whatever, may be the starting point of the 
 disease. In like manner any lesion of the mucous membrane of the upper 
 respiratory tract or of the oropharynx may become the seat of primary 
 infection. The condition of the mucous membrane of the genital tract 
 in the puerperal woman especially invites infection, which is invariably 
 
ERYSIPELAS. 
 
 739 
 
 followed under these circumstances by serious results. The relationship 
 of certain forms of puerperal infection and erysipelas is obvious. Chronic 
 affections of the nasal or laryngeal mucous membrane, varicose ulcers 
 and diseases of the skin render those suffering from them hable to repeated 
 attacks of erysipelas. Abrasion of the skin for vaccination, or the use of 
 the hypodermic syringe without proper precautions as to disinfection 
 and cleanliness, may open the way for the erysipelatous infection. 
 
 Symptoms. — The incubation varies from a few hours to several days. 
 Its extreme Hmit is not more than a week. The local and constitutional 
 symptoms of erysipelas of the face and head and of other parts of the body 
 are identical. When the 
 face and head are involved 
 it not infrequently happens 
 that the local injury to the 
 skin by which the infection 
 has taken place cannot be 
 discovered. Such cases are 
 sometimes spoken of as 
 idiopathic — E. verum, E. 
 cryptogeneticum. When the 
 cutaneous inflammation 
 affects other parts of the 
 body, a lesion of the skin 
 or mucous membrane can 
 almost always be found. 
 In general terms the sever- 
 ity of the constitutional 
 symptoms is in proportion 
 to the extent and intensity 
 of the local inflammation. 
 
 Prodromes are as a 
 rule absent. The onset is 
 commonly marked by a 
 rigor or shivering, followed 
 by a rapid rise of temper- 
 ature to 103°-105° F. (39.5° 
 -40.5° C). Headache, 
 pains in the back and 
 occur. In the course of 
 
 
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 Fig. 252. — Facial erysipelas. 
 
 hmbs, nausea and vomiting also frequently 
 some hours the signs of local inflammation 
 appear. In many of the milder cases the constitutional symptoms are 
 at first slight and the patient becomes aware of the trouble by 
 burning and pricking sensations in the affected skin. The skin is red- 
 dened, tense, and glossy. It is swollen and oedematous and the borders 
 of the affected area are abruptly marginate. It is hot and firm to the touch 
 and the patient complains of subjective sensations of burning, tension, 
 and stiffness. It is a peculiarity of the erysipelatous inflammation that, 
 involving a limited area at first, it tends to spread broadly in various direc- 
 tions, advancing by a well-defined border slightly raised above the level 
 of the surrounding skin. This advance is usually from an ear across the 
 
740 MEDICAL DIAGNOSIS. 
 
 face to the other ear, or from any point, as the corner of the nose or mouth, 
 or the canthus of an eye, rapidly over the entire face, into the hairy scalp, 
 and downwards to the neck. The general swelling in severe cases is marked 
 and the loose skin of the eyelids and adjacent parts becomes enormously 
 cedematous. The eyelids cannot be opened, the nose is swollen to an 
 extraordinary bulk, the lips hugely distended, the ears cushiony and 
 deformed and the whole countenance strangely disfigured and unrecogniz- 
 able. As the inflammation advances cord-like thickenings of the lymphatic 
 vessels may often be felt upon palpation beyond its border in the area of 
 skin which as yet presents no discoloration or oedema. In some instances 
 the involved lymphatic vessels appear as reddened strands or 'spots, ad- 
 vanced areas of infection which are speedily overtaken by the progressing 
 inflammation. The neighboring superficial lymphatic glands are very 
 often enlarged and tender. In severe cases vesicles form upon the surface 
 of the inflamed skin, especially upon the eyelids, ears, and forehead. In 
 the course of three or four days the inflammation reaches its height and 
 begins to undergo resolution at the point first involved. Here the color 
 becomes paler, the swelling diminishes, and desquamation takes place; 
 meanwhile the peripheral inflammation may for a day or two continue 
 to advance. Careful inspection from day to day reveals the fact that at 
 any given point the inflammation reaches its maximum in the course of 
 three or four days and then rapidly subsides, a matter of importance in 
 estimating the worth of local therapeutical applications. The mucous 
 membrane of the mouth and nose is frequently involved by extension. The 
 mouth and gums are reddened, the pharynx is congested, the tongue 
 swollen, dry, and cracked. The pulse is rapid. The mind is commonly 
 clear. In the course of six or seven days the rash in favorable cases ceases 
 to spread, the redness and swelling subside, the temperature falls by 
 crisis, and the patient enters upon convalescence. There is marked leuco- 
 cytosis. The urine is scanty and high colored. Febrile albuminuria is 
 commonly present. Recrudescences of fever frequently occur. Relapses 
 are not common. 
 
 Anomalies in the clinical course relate to the rash and to the con- 
 stitutional disturbances. That form in which vesiculation is abundant 
 is known as E. vesiculosum; that in which bullae form as E. bullosum. The 
 contents of the vesicles and blebs is usually a slightly turbid serum. Pus 
 may be present — E. pustulosum. These lesions may be ruptured by acci- 
 dental violence or the contents may undergo gradual resorption. Thin, 
 yellowish-brown crusts result, which after a little time separate without 
 scar formation. Deeper abscess formation in the connective tissue is not 
 uncommon — E. phlegmonosum. A very grave form is that in which, in 
 consequence of enfeebled powers of resistance, the swelling and tension result 
 in necrosis and gangrene of the skin — E. gangrcenosum. The inflammation 
 in rare cases shows a remarkable tendency to spread — E. migrans. The 
 inflammation may advance from the face over the neck and chest, sub- 
 siding in one area as it extends to another, until it has traversed the greater 
 part of the body. The duration of the disease may extend over many 
 weeks, and death may occur from exhaustion or from a complicating pneu- 
 monia. Anomalies in the constitutional symptoms consist in the absence 
 
ERYSIPELAS. 
 
 741 
 
 of fever — E. afebrile; in hyperpyrexia which is apt to terminate fatally with 
 progressive cardiac weakness and coma; or in great constitutional depress 
 sion from the outset, a condition to which cachectic and aged persons and 
 those given to excesses in alcohol are especially liable. Erysipelas of the new- 
 born, starting at the navel, shows an abruptly marginate area of redness 
 and induration, which may be superficial but commonly involves the deeper 
 tissues. It extends rapidly and may invade the greater part of the trunk. 
 Suppuration and gangrene sometimes occur. The prognosis is ominous. 
 Complications and Sequels. — The visceral complications are due to 
 general septic infection. Purulent meningitis may occur in erysipelas of 
 
 
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 Fig ^53. — Erysipelas ambulans. Woman aged 50. Recovery. 
 
 the face and head. When the inflammation involves the mucous membrane 
 of the throat or invades the neck, acute oedematous laryngitis may occur 
 and prove rapidly fatal. Croupous pneumonia is sometimes encountered. 
 Bronchopneumonia is a common late complication in fatal cases. Otitis 
 media and acute nephritis are occasional complications. Septic inflamma- 
 tion of one or more joints may occur. Malignant endocarditis, pericarditis, 
 and pleurisy are important complications. Among the sequels are areas 
 of cutaneous hyperesthesia or anassthesia and persistent neuralgias. 
 Repeated attacks of erysipelas have in rare instances been followed by 
 thickening and induration of the skin. The hair falls out after erysipelas 
 of the scalp, sometimes after severe attacks involving distant parts of the 
 body, as in the other acute infections. 
 
742 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — The direct diagnosis of erysipelas rarely presents diflB- 
 culty. It rests upon the sudden onset, the chill or shivering, fever, and 
 other constitutional symptoms, and the peculiar character of the inflamma- 
 tion of the skin, in which rapid advance from an infected centre, elevation 
 above the level of the surrounding skin, distinct margination, and the 
 tendency to resolution in the region first involved while evolution is tak- 
 ing place at the border, are characteristic. 
 
 The DIFFERENTIAL DIAGNOSIS between erysipelas and other forms of 
 dermatitis can be easily made. The main fact is that erysipelas is an acute 
 infectious process attended with fever which begins abruptly and ends 
 by crisis. 
 
 Prognosis. — Previously sound individuals except at the extremes 
 of life usually recover. In the new-born erysipelas is commonly fatal, in 
 the aged very often so. In broken down and cachectic persons and drunk- 
 ards the prognosis is unfavorable. Death is usually the result of intense 
 general infection or grave complications. Er\^sipelas is not only less fre- 
 quent, but it is also much less fatal than formerly. The mortality is about 
 five per cent. It is higher in hospitals than in private practice. 
 
 XVIII. SEPSIS. 
 
 SepHcoemia; Pycemia; Septicopycemia. 
 
 Definition. — A disease produced by the general invasion and growth 
 in the body of pyogenic micro-organisms. 
 
 Pycemia is the term used to designate the condition in which pus col- 
 lections occur in various parts of the body in consequence of the lodgement 
 of infected emboli; sepiiccemia — hactercemia — that condition in which 
 purulent collections are absent, but with or in the absence of a local infec- 
 tion there is invasion of the blood and tissues by bacteria together with 
 the signs of profound disorder of the entire organism, and septicopycemia, 
 the condition in which bactersemia and pyaemia are present at the same 
 time. Saprcemia is the condition caused by the absorption into the blood 
 of septic or putrid products. The general term septic infection or sepsis is 
 more convenient and more in accordance with the facts. Some other 
 definitions are necessary. Infection is the term used to designate the 
 pathological processes caused by the implantation and growth of 
 pathogenic micro-organisms, most of which are specific. Toxcemia is 
 used to denote, (a) the presence of soluble toxic substances or toxins in 
 the blood, mostly elaborated by pathogenic micro-organisms in their 
 growth and multiphcation, and (b) the morbid processes which those 
 poisons produce. 
 
 Septicaemia and toxaemia are sometimes associated, as in enteric 
 fever, in which the pathogenic organism — Bacillus typhosus — may be 
 grown in cultures from the blood, while the symptoms of the disease are 
 those of a continuous intoxication; sometimes separate, as in tetanus and 
 diphtheria, in which the infection is local and the pathogenic organisms 
 develop in circumscribed areas, while their poisonous products produce 
 characteristic constitutional effects. 
 
SEPSIS. 
 
 743 
 
 Etiology. — Predisposing Influences. — The predisposition to sep- 
 tic infection is general. It occurs everywhere, at all periods of life, and 
 under the most varying circumstances. Pathogenic Agents. — The pyo- 
 genic cocci — streptococci and staphylococci — are the most common. Other 
 organisms capable of causing sepsis are Micrococcus lanceolatus (pneu- 
 mococcus), gonococcus, Bacillus coli, Bacillus typhosus, Bacillus proteus. 
 Bacillus pyocyaneus, and Bacillus influenzae. 
 
 Symptomatology. — The symptom-complex is that of a severe consti- 
 tutional disease. In many of the cases the general symptoms are simply 
 those of any intense infective process, without, however, definite signs of 
 visceral or other localization. In another large group of cases to the fore- 
 going symptoms are added those of an inflammatory implication of the en- 
 docardium or pericardium with which the evidences of myocardial changes 
 are shortly associated. Again, the evidences of inflammation of the bones 
 and joints dominate the situation. In a very extensive group of cases 
 
 Fic. 254. — Streptococcus pyogenes. 
 
 Fig. 255. — Staphylococcus pyogenes aureus. 
 
 the tegumentary structures are especially involved in septic inflammatory 
 processes, such as forms of eiythema, scarlatiniform eruptions, malignant 
 erysipelas, and acute septic phlegmon. Subcutaneous hemorrhages are com- 
 mon. Finally, we recognize a great group of cases in which inflammatory 
 and suppurative disease of the various viscera, as for example, the lungs, 
 kidney, liver, stomach, and intestines or spleen, give rise to the chief 
 manifestations of the septic process. 
 
 The onset may be gradual, with chilliness or chills, general malaise, 
 dragging pains in the limbs, and irregular fever. More commonly a decided 
 rigor initiates an active febrile movement. Pallor, faint cyanosis, rapid 
 and feeble pulse, anorexia, constipation alternating with diarrhoea, a ten- 
 dency to profuse sweating, and a mind strikingly clear and alert are 
 symptoms encountered in well-developed sepsis. Soreness of the bones 
 and muscles, tender joints, great irregularity of temperature, with wide 
 oscillations and a profound feeling of lassitude are also common. A leuco- 
 cytosis of varying degree, sometimes high, occurs in the majority of cases. 
 In the graver cases even with abscess formation at various points, an 
 increase of leucocytes may be absent. 
 
744 MEDICAL DIAGNOSIS. 
 
 Toxaemia ^LocAL Infection with the Absorption of Toxins. — 
 Familiar examples of mild and transient forms are the chilliness and fever 
 which attend an attack of angina tonsillaris or a local phlegmonous inflam- 
 mation. Most important are erysipelas, pneumonia, diphtheria, and tet- 
 anus,, diseases in which the pathogenic organisms develop locally, while 
 the constitutional symptoms are caused by the absorption of the poisonous 
 products of their growth. 
 
 Septicemia; Bacteremia — Local Infection with the Invasion 
 OF Micro-organisms. — Streptococcus and staphylococcus infection is com- 
 monly at first local, the toxins undergoing absorption and causing symp- 
 toms — toxasmia. The process may be arrested at this point; if not, the 
 cocci enter the blood stream and are carried to all points of the body with- 
 out causing foci of suppuration. The cause of the infection may frequently 
 be traced, as in puerperal sepsis or injuries of the extremities, along the 
 lymphatic vessels. 
 
 The case now becomes more severe; the symptoms more urgent. 
 Specific infections in which a primary local infection may become gener- 
 alized are gonorrhoea, pneumonia, and puerperal fever. To a slight extent 
 the micro-organisms of diphtheria may also enter the blood stream. In 
 the severer forms of the specific infectious diseases, as scarlet fever, diph- 
 theria, enteric fever, and tuberculosis, secondary or mixed infections fre- 
 quently take place, greatly adding to the gravity of the case and often 
 obscuring the features of the primary disease. The most active agent is the 
 streptococcus. 
 
 Cryptogenetic Septicemia — General Septicemia in the Ab- 
 sence OF Local Infection. — Cryptogenetic septicaemia may develop 
 in the subjects of acute or chronic disease or even in persons in apparently 
 good health. This condition explains a considerable number of obscure 
 febrile cases. Many of the cases are terminal infections. No focus of 
 infection is apparent during life or demonstrable after death. The strep- 
 tococcus is the common infecting organism, but the staphylococcus, pneu- 
 mococcus, B. proteus and B. pyocyaneus may be found. 
 
 Septicopyemia; Pyemia — General Infection with Suppura- 
 tive Foci. — The organisms may colonize in various parts of the body 
 and give rise to abscess formation. These suppurative processes are due 
 to the lodgement of infected emboli. The lesions are known as embolic or 
 metastatic abscesses. In infected wounds, septic phlegmon, and osteo- 
 myelitis they are frequently encountered in the lungs; in suppurative 
 lesions in the intestines, or elsewhere in the parts tributary to the portal 
 system, metastatic abscesses occur in the liver and may be accompanied 
 with suppurative pylephlebitis. Endocarditis is of common occurrence 
 in septicaemia. The most common organisms in septicopysemia are strep- 
 tococci and staphylococci. 
 
 Terminal Infections. — Secondary or terminal infection is the cause 
 of death in many acute and chronic diseases. The infection may be local 
 and take the form of visceral disease. The serous membranes are espe- 
 cially liable to these terminal inflammations, and acute pleurisy, pericarditis, 
 peritonitis, endocarditis, or meningitis are final events in many cases of 
 nephritis, arteriosclerosis, cirrhosis of the liver, and cerebral and spinal 
 
SEPSIS. 745 
 
 disease. Not rarely the terminal process is an acute miliary tuberculosis. 
 The enterocolitis so common toward the end of chronic diseases may be 
 classed with the terminal infections. Less frequently the terminal infection 
 is general. This especially occurs in chronic renal and cardiac disease, 
 tuberculosis, leukaemia, and Hodgkin's disease. 
 
 Diagnosis. — Direct Diagnosis. — It cannot be made in the beginning 
 of the milder cases. When the symptoms are severe or the illness has lasted 
 for some time, the history of an abortion or confinement, an infected 
 wound involving the skin or mucous membrane, an attack of tonsillitis 
 and especially middle-ear disease, and the occurrence of chills, irregular 
 fever, copious sweating, progressive pallor, and asthenia render the diag- 
 nosis probable. Gonorrhoeal infection, the reinfection of old scars, and the 
 previous occurrence of disease of the bones, periosteum, or joints are also 
 of diagnostic significance. The signs of an endocarditis are important, 
 especially if the murmurs undergo changes in the course of a short time 
 or are associated with embolic abscesses. Blood cultures may not show 
 the presence of pathogenic micro-organisms. 
 
 Cryptogenetic sepsis is more difficult of diagnosis-. The symptom- 
 complex is not characteristic. Chills and irregular fever of wide range, 
 with irregular, even prolonged intermissions, copious sweating, profound 
 asthenia, pallor, emaciation, followed after intervals by visceral inflamma- 
 tions, especially affecting the heart, rapid respiration, circumscribed patches 
 of pulmonary consolidation, pleural effusions, enlargement of the liver, 
 localized bone disease or arthritis, and polymorphous cutaneous lesions, 
 especially erythema and hemorrhage, are suggestive. The diagnosis must 
 in many instances be made by exclusion. 
 
 Differential Diagnosis. — Acute Miliary Tuberculosis. — The gen- 
 eral bronchopneumonia affecting the whole of one or both lungs which 
 is characteristic of this disease is not seen in sepsis. If circumscribed 
 tuberculous foci are present, the diagnosis of miliary tuberculosis is prob- 
 able. Implication of the serous membranes, the pleurae, pericardium, 
 meninges, or peritoneum increases the resemblance to sepsis and renders 
 the diagnosis more difficult. Chronic Ulcerative Phthisis. — In the gravest 
 cases and particularly in the stadium ultimum, symptoms occur which are 
 not caused by the Bacillus tuberculosis. These secondary infections are 
 due to streptococci and are mostly terminal. Other organisms are present 
 in the sputum. Influenza. — Severe cases of influenza may give rise to 
 difficulties in diagnosis, especially in those cases in which pneumonia, 
 bronchopneumonia, pleurisy, and local pus formation occur. The epi- 
 demic prevalence of influenza, the sudden onset with characteristic symp- 
 toms, the prominence of catarrhal symptoms in the majority of instances, 
 and the severe neuralgias early in the attack are of diagnostic value. 
 Enteric Fever (see p. 634). Malaria. — Perhaps no more common error in 
 diagnosis occurs. In phthisis, in internal abscess, in suppurative disease 
 of the liver or hepatic fever from impacted calculus, in malignant endo- 
 carditis, the recurrent chills, irregular high temperature, and profuse sweat- 
 ing too often betraj^ the incautious practitioner into a false diagnosis of 
 malaria. The presence of the malarial parasite in the blood and the thera- 
 peutic test, or either of them, are conclusive. 
 
746 MEDICAL DIAGNOSIS. 
 
 Prognosis. — The prognosis is ominous. Very mild cases recover. 
 Many cases make an apparent recovery, only to recur. The fulminant 
 cases are fatal in a short time. Of visceral localizations, septic endo- 
 carditis is the most grave. In the absence of local abscess formation 
 recovery may, in rare instances, take place after very grave constitu- 
 tional symptoms have lasted a long time. Brilliant results sometimes 
 follow the early evacuation of pus and effectual drainage. 
 
 XIX. RHEUMATIC FEVER. 
 
 Acute Rheumatism; Acute Polyarthritis. 
 
 Definition. — An acute febrile disease of undetermined causation, 
 characterized by polyarthritis of fugacious character and a tendency to 
 inflammation of the endocardium and pericardium. 
 
 Etiology. — Predisposing Influences. — Rheumatic fever is a disease 
 of northern and temperate climates. The effect of season is modified 
 by local conditions. Cold and dampness, and especially a combination 
 of these two seasonal conditions, constitute predisposing factors of great 
 importance. Rheumatic fever is rare in the first years of life and after 
 the age of fifty. Adolescents and young adults are especially liable. 
 The two hemidecades of greatest liability are those from 15 to 20 and from 
 20 to 25. First attacks are ver}^ rare after the fortieth year. The liability 
 of the sexes is much modified by age and occupation. If these factors 
 are disregarded males appear to be more liable than females in about the 
 proportion of 2.5 to 1.0. Under twenty the disease is more common in 
 females. The predisposition appears to be hereditary, usually from the 
 maternal side. Those avocations which involve exposure to cold and 
 damp and sudden violent changes of temperature constitute a predispos- 
 ing influence of great importance. We find a great majority of the cases 
 among coachmen, cooks, bakers, housemaids, sailors, gardeners and out- 
 door laborers. It is sometimes possible to trace the attack to sudden or 
 prolonged exposure to cold and damp. 
 
 Exciting Cause. — The specific pathogenic agent has not yet been 
 conclusively demonstrated. The hypothesis that the infection is septic 
 rather than specific is thought to find support in the character of the fever, 
 the joint affection, the tendency to implication of serous membranes, the 
 sweating, anaemia, leucocytosis, and the tendency to relapse. On the other 
 hand, pysemic joints undergo suppuration and pursue a wholly different 
 course, and the pains of sepsis are not influenced by the salicylates. The 
 causal relation of the diplococci of Poynton and Paine, of Wasserman, and 
 of Walker to the disease has not yet been established. The results of 
 streptococcus infection ma}' have no actual relation with, but merely a 
 superficial resemblance to, rheumatic fever. The chemical, metabolic, and 
 nervous hypotheses have merely a historical interest. 
 
 Symptoms. — Prodromes are not common. When present they con- 
 sist of sore throat, slight pains in the joints, and malaise. Not rarely a well- 
 marked attack of angina tonsillaris precedes the joint affection. 
 
RHEUMATIC FEVER. 747 
 
 The onset is usually abrupt. There is very often the chilliness which 
 attends the development of a mild infective process. Fever of moderate 
 intensity— 101°-103° F. (3S°-39.5° C.)— and irregular type follows and in 
 the course of twenty-four or thirty-six hours the nature of the attack is 
 established. One or more, usually several, joints are now swollen, red- 
 dened, and painful. The pulse is frequent, full, and soft. The tongue is 
 covered with a soft, thick, white coating; appetite is lost; there are thirst, 
 constipation, and scanty, high-colored, and very acid urine. There is fre- 
 quently abundant, highly acid, and ill-smelling perspiration. The joints 
 are involved successively but without regular order. The large joints, 
 as the knee, ankle, shoulder, are most frequently affected; the smaller 
 joints of the hands and feet somewhat less so. The wrists and ankles are 
 often enlarged and exquisitely tender and painful from the simultaneous 
 implication of many joints and the sheaths of the tendons. The arthritis 
 is curiously fugacious. As one joint is attacked the inflammation subsides 
 in another previously involved. This constitutes a characteristic clinical 
 feature of the disease. The inflammatory exudate is endo- and peri-articular. 
 Suppuration does not occur and ankylosis is very rare, being not a phe- 
 nomenon of rheumatic fever but a secondary process from want of use and 
 fixation and encountered chiefly in the knee, elbow, or wrist in hysterical 
 girls. Symmetrical bilateral arthropathy is often seen. In severe and 
 protracted cases numbers of joints are implicated and the vertebral artic- 
 ulations do not always escape. 
 
 Pain is a constant and conspicuous symptom. It is spontaneous and 
 usually agonizing upon movement and pressure. Frequently the weight 
 of the sheet cannot be borne. Prostration, inability to sleep, and abject 
 helplessness add to the sufferings of the patient. The temperature range 
 does not often exceed 103° F. (39.5° C.) and rarely, except in hyper- 
 pyrexia, surpasses 104° F. (40° C). It does not conform to type and is 
 extremely irregular, with marked remissions and exacerbations, which corre- 
 spond more closely to the presence or absence of the abundant sweats than 
 to the intensity of the arthritis. The defervescence is by gradual lysis. 
 Recrudescences are common and relapse frequently occurs. Anaemia of 
 high grade develops with great rapidity. A leucocytosis of moderate 
 degree is present. Febrile albuminuria is common. The saliva is some- 
 times acid or neutral in reaction. There are subacute forms with less in- 
 tense symptoms which sometimes tend to become chronic. In children 
 rheumatic fever may be attended with very slight or obscure joint affec- 
 tion but with marked and disabling heart lesions. The attack does not 
 confer immunity against subsequent attacks; on the contrary, like crou- 
 pous pneumonia, diphtheria, and erysipelas, rheumatic fever tends to recur 
 and many persons in the course of time experience several attacks. 
 
 Rheumatic Hyperpyrexia; Cerebral Rheumatism. — In rare cases 
 a day or so after the onset, but usually during the course of the second 
 week, a rapid rise of temperature to 108°-110° F. (42.5°-43.5° C.) occurs. 
 Delirium, stupor, a feeble, frequent, and flickering pulse, and extreme pros- 
 tration accompany the hyperpyrexia. In the course of a few hours the 
 patient usually falls into a comatose state. This form of rheumatic fever 
 is almost always fatal. If the temperature is reduced by cold baths or 
 
748 MEDICAL DIAGNOSIS. 
 
 external cold it rises again. In some instances convulsions precede the 
 coma. Rheumatic hyperpyrexia is extremely rare in this country. 
 
 Heart. — Endocarditis, pericarditis, and associated myocardial changes 
 are so frequent that they must be regarded as pathological processes in- 
 cident to the disease rather than accidental complications. The incidence 
 is variously estimated at 33 to 50 per cent. It is probably higher than these 
 figures indicate. Endocarditis. — This is by far the most common of the 
 heart affections and rheumatic fever is by far the most common cause 
 of chronic valvular disease. The habihty is greatest in the rheumatic 
 fever of childhood and decreases with age. On the other hand it increases 
 with the number of attacks. The mitral valve system is most frequently 
 involved, the aortic next, and both next, the ratio being about 90-25- 
 20. Ulcerative endocarditis is of infrequent occurrence in rheumatic 
 fever. Pericarditis. — Pericardial inflammation may be associated with 
 endocarditis, as is commonly the case, or occur independently. Well- 
 marked pericardial signs may mask an indistinct endocardial murmur, 
 which very often becomes plainly audible as the friction sounds subside. 
 The exudate may be fibrinous, serofibrinous, or purulent. The last occurs 
 more frequentlj^ in childhood. Myocarditis. — Changes in the heart muscles — 
 granular and fatty degeneration — are associated in varying degree with 
 the endocarditis and pericarditis, and manifest themselves clinically by 
 enfeebled action and the signs of dilatation. 
 
 Lungs and Pleura. — Pleurisy may occur and the exudate is often 
 serofibrinous, the effusion not, however, commonly attaining a great volume. 
 Pneumonia is an occasional complication. Acute pulmonary congestion is 
 a grave accident. These conditions are more liable to develop in the 
 cases in which heart lesions are present. 
 
 Nervous System. — Grave nervous symptoms, delirium, stupor, con- 
 vulsions, and coma arise in the cases of hyperpyrexia and are sometimes 
 manifestations of uraemia. Delirium may be due to the salicylates or other 
 drugs and in cases of idiosyncrasy may result from ordinary therapeutic 
 doses. The mental condition in rheumatic fever is as a rule, even in severe 
 cases, remarkably clear. Chorea, while it does not often appear during the 
 attack of rheumatic fever, follows it in about 15 per cent, of the cases. 
 
 Cutaneous Affections. — These occasionallj^ appear, as in the other 
 acute febrile infections. They are not important and comprise sudamina, 
 miliaria, urticaria, forms of erythema and petechise. Subcutaneous nodules 
 occasionally develop upon the tendons and fasciae, about the wrists and 
 hands, and elsewhere. They vary in size up to that of a pea. They grow 
 rapidty and slowly disappear. They are not usually tender to the touchy 
 nor painful. These subcutaneous fibrous nodules are encountered in 
 greater frequency in children than in adults. 
 
 Diagnosis. — Direct. — The direct diagnosis of rheumatic fever is not 
 usually attended with difficulty. It rests upon the association of the fore- 
 going symptoms, especially the rapid onset, the fugacious polyarthritis, 
 irregular fever, abundant acid sweats, rapidly developing anaemia, and 
 tendency to cardiac complications. 
 
 Differential. — 1. Sepsis; Septicopyoemia. — Arthritis, irregular fever, 
 and endocarditis are common to both diseases. But in septic conditions 
 
RHEUMATIC FEVER. 749 
 
 the arthritis is fixed, not fugacious, affects a few joints, not many, and 
 tends to suppuration and disorganization instead of restitutio ad integrum 
 as in rheumatic fever. The fever in sepsis is as a rule more distinctly inter- 
 mittent, with higher maxima, and is interrupted by periodical chills some- 
 times of ague-like regularity. The endocarditis of sepsis is severe, often 
 malignant, with embolic phenomena and retinal hemorrhages. Cases 
 occur in which for a time the differential diagnosis between relatively 
 mild septicopyemia and severe rheumatic fever cannot be positively made. 
 2. Acute Osteomyelitis. — When the lower end of the femur or the tibia is 
 afTected the differential diagnosis may be at first obscure. In the rare 
 cases in which several bones are involved the resemblance to rheumatism 
 is increased. The epiphysis is the seat of the disease rather than the joint, 
 and the local and constitutional symptoms are more severe. 3. Acute 
 Arthritis of Early Infancy. — The knee or the hip is usually affected. The 
 affection is mostly monarticular and goes on to early suppuration. It 
 is commonly pysemic; sometimes gonorrhoeal. 4. Gonorrhoeal Arthritis 
 (see p. 833). 5. Gout. — Many cases of podagra are falsely diagnosticated 
 as rheumatism. An arthritis confined to one or two joints, especially the 
 metatarsophalangeal joint of the great toe, the knee, or the ankle, of ex- 
 tremely acute onset and great intensity, with cyanotic redness of the skin 
 which is tense and glossy, exquisitely painful both at rest and on move- 
 ment, and so tender that the weight of the bedclothes can scarcely be 
 borne, speaks for gout, especially if tophaceous masses are present in the 
 helix of the ear or around the small joints and the patient has reached 
 middle age. 6. Arthritis Deformans. — The acute outbreaks of joint inflam- 
 mation by which certain forms of this disease advance cannot be differen- 
 tiated from rheumatic fever in the early course. There is fever, together 
 with redness, swelling, tenderness and pain, mostly affecting the small 
 joints. When these symptoms pass, however, there remains the evidence 
 of changes in the joints and periarticular thickening. Fresh attacks 
 of more or less intense arthritis occur and after each one the signs 
 of damage to the joints are more pronounced. 7. Meningitis. — When in 
 rheumatic fever the vertebral articulations are involved, there may be 
 severe pain upon movement of the neck, together with painful rigidity of 
 the muscles. As fever is present, the condition, especially in the absence 
 of joint affection of the extremities, may closely simulate meningitis. The 
 absence of severe headache, pupillary derangements, hypersesthesia, 
 Kernig's sign, and negative results upon examination of the fluid obtained 
 by spinal puncture are of diagnostic importance. 8. Peliosis Rheumatica. 
 — The multiple arthritis and fever of Schonlein's disease may suggest rheu- 
 matic fever. The simultaneous appearance of purpura, purpura urticans, 
 and erythema exudativum, especially when associated with hemorrhage 
 from mucous surfaces or the evidence of internal bleeding, is decisive. 
 9. Hysteria. — A hysterical arthritic neurosis, usually involving the knee, 
 elbow, or wrist, does not often closely simulate rheumatic fever. 
 
 Prognosis. — The course of rheumatism varies from two or three to 
 six weeks or longer and is marked by many remissions and exacerbations, 
 both of the fever and other constitutional symptoms and the arthropathy. 
 Rheumatic fever tends to recovery. The mortality does not exceed 2 or 3 
 
750 MEDICAL DIAGNOSIS. 
 
 per cent, and death is the result not of the disease in its ordinary mani- 
 festations but of the heart affection or hyperpyrexia. It acquires, however, 
 a sinister importance on account of the frequency of the implication of 
 the heart, as the result of which arise initial lesions of the valves and myo- 
 cardium, especially progressive, constituting the conditions of deformity 
 and impaired function known as chronic valvular disease, irreparably 
 damaging to function and ultimately the cause of death. 
 
 XX. YELLOW FEVER. 
 
 Definition. — A febrile disease of tropical and subtropical countries 
 due to an unknown infectious principle transmitted by the bite of a variety 
 of mosquito — Stegomyia fasciata — and characterized by jaundice, albu- 
 minuria, slow pulse, and black vomit. 
 
 Etiology. — Predisposing Influences. — Yellow fever has frequently 
 been transported to the seaboard cities of the United States and toward 
 the end of the eighteenth century prevailed in frightfully disastrous epi- 
 demics in Philadelphia and other northern cities. It is a disease of the 
 seaboard and low levels. It rarely shows itself above an altitude of 1000 
 feet. It occurs chiefly in cities and, during outbreaks, is most prevalent 
 in the low, badly drained, and overcrowded districts occupied by the poor, 
 and in the hot season. The epidemics in the United States have always 
 appeared during the summer and autumn and come to an end upon the 
 occurrence of frost. 
 
 The Actual Cause. — The specific germ of yellow fever has not yet 
 been demonstrated. The following are the conclusions of the Yellow 
 Fever Commission of the United States Army: 
 
 1. The mosquito — Stegomyia fasciata — serves as the intermediate 
 host for the parasite of yellow fever. 2. Yellow fever is transmitted to 
 the non-immune individual by means of the bite of the mosquito that has 
 previously fed on the blood of those sick with this disease. 3. An interval 
 of about twelve days or more after contamination appears to be necessary 
 before the mosquito is capable of conveying the infection. 4. The bite 
 of the mosquito at an earlier period after contamination does not appear 
 to confer any immunity against a subsequent attack. 5. Yellow fever can 
 also be experimentally produced by the subcutaneous injection of blood 
 taken from the general circulation during the first and second days of 
 this disease. 6. An attack of yellow fever, produced by the bite of the 
 mosquito, confers immunity against a subsequent attack of the non-ex- 
 perimental form of this disease. 7. The period of incubation in thirteen 
 cases of experimental yellow fever has varied from forty-one hours to five 
 days and seventeen hours. 8. Yellow fever is not conveyed by fomites, 
 and hence disinfection of clothing, bedding, or merchandise, supposedly 
 contaminated by contact with those sick with this disease, is unnecessary. 
 9. A house may be said to be infected with yellow fever only when there 
 are present within its walls contaminated mosquitoes capable of convey- 
 ing the parasite of this disease. 10. The spread of yellow fever can be most 
 effectually controlled by measures directed to the destruction of mosquitoes 
 and the protection of the sick against the bites of these insects. 11. While 
 
YELLOW FEVER. 751 
 
 the mode of propagation of yellow fever has now been definitely deter- 
 mined, the specific cause of this disease remains to be discovered. 
 
 Symptoms. — The period of incubation is three or four days. In 13 
 experimental cases it varied from 41 hours to 5 days and 17 hours. The 
 course of the attack may be divided into a stage of invasion and a stage of 
 collapse. These periods are, however, not always well characterized. 1. 
 Invasion. — The onset is sudden, without prodromes, and commonly in 
 the early morning. It is marked by chilliness, headache, severe pains in the 
 back and limbs, a rapid rise of temperature to 102°-105° F., and pungent 
 heat and dryness of the surface. The tongue is moist and covered vrith a 
 thick white fur. There is usually some soreness of the throat, together with 
 nausea and vomiting, which become more severe upon the second and third 
 day, and constipation. The facies even upon the first day is suggestive, 
 even characteristic. It is flushed and there is slight tumefaction of the 
 eyelids and lips. The conjunctivae are injected and icteroid. Later the 
 intense jaundice from which the disease takes its name rapidly invades 
 the entire surface. The fever having attained its fastigium during the first 
 day maintains its elevation for two or three days and subsides in favorable 
 cases by lysis. In abortive cases the temperature may fall to normal in 
 twenty-four or thirty-six hours. 2. The Remission or Stage of Calm. — 
 This period lasts two or three days. The symptoms ameliorate and the 
 condition of the patient is in every way more satisfactoiy. Convales- 
 cence may now set in with rapid improvement, or there may be febrile 
 reaction lasting from one to three days and terminating in rapid lysis, or 
 the patient may pass into: 3. The Stage of Collapse. — This period is 
 attended with characteristic ''black vomit" and other hemorrhages. The 
 vomiting, in the grave cases, is uncontrollable and copious, being attended 
 with great abdominal pain and exhaustion. The oozing of blood from the 
 mucous surfaces and the occurrence of petechise usually precede death. 
 
 The pulse upon the first day does not usually exceed 110 per minute 
 and, notwithstanding the persistence of a relatively high temperature, 
 becomes during the second or third day progressively slower until it may 
 reach, with a temperature of 102°-103° F., a rate as low as 50, 40, or even 
 30 per minute. This low pulse-rate, with a persistent or even rising febrile 
 movement, is a characteristic and striking feature of the disease. Albu- 
 minuria occurs about the third day of the attack. In the mild cases it is 
 transient, but in the severe cases it is continuous, abundant, and accom- 
 panied by the ordinary signs of acute nephritis. Suppression may occur 
 and the manifestations of uraemia, convulsions and coma, or these in alter- 
 nation, lead to a rapidly fatal issue. Delirium may be present early in the 
 course of severe cases. The mental condition is usually, however, one of 
 remarkable clearness and alertness. 
 
 Varieties. — 1. Mild cases — "walking yellow fever" — present sim- 
 ply a transient fever and slight jaundice and would not be recognized 
 except in the light of the prevalent epidemic. These cases are especially 
 dangerous, since they may be the source of contamination of mosquitoes 
 and the subsequent infection of non-immune persons with the fever in its 
 severer forms. 2. Average cases vnth high fever and the characteristic 
 features of the infection — jaundice, vomiting, fever, slow pulse, albuminuria. 
 
752 MEDICAL DIAGNOSIS. 
 
 black vomit and other hemorrhages, and prostration. 3. Malignant. — 
 The patient is overwhelmed by the infection and death occurs in the course 
 of the second or third day. 
 
 Convalescence in favorable cases is rapid and complete, the albumi- 
 nuria usually passing away in the course of a little time. In severe cases 
 terminating in recovery, the convalescence may be protracted by parotid 
 bubo, suppurative processes elsewhere, or persistent diarrhcea. Second 
 attacks are exceedingly rare. 
 
 Diagnosis. — Direct Diagnosis. — The symptom-complex in weU- 
 developed cases is so characteristic that a positive diagnosis would appear 
 to be a simple matter, especially when a number of causes have occurred 
 in a circumscribed region. Commercial interests and considerations of local 
 policy, have, however, in many instances, interposed insuperable difficulties 
 to the recognition of the early cases — difficulties that have frequently led 
 to wide-spread and disastrous epidemics. In some such instances the 
 disease has been reported as dengue, in others as malarial fever. 
 
 Differential Diagnosis. — Dengue. — The facies, jaundice, albumi- 
 nuria, slow pulse, great severity, and high mortality clearly differentiate 
 yellow fever from dengue. The difficulties relate to the initial cases, which 
 may be mild, and the fact that the two diseases may coexist in the same 
 locality. Everj^ suspect should be at once isolated in a screened hospital. 
 Malaria. — The differential diagnosis concerns the estivo-autumnal variety 
 which especially prevails in the regions and at the season of the year in 
 which outbreaks of yellow fever are liable to occur. The facies, early jaun- 
 dice, early albuminuria, slight enlargement of the spleen, hemorrhages, 
 especially black vomit, and the absence of the blood parasite justify the 
 diagnosis of yellow fever. In estivo-autumnal fever the facies is not char- 
 acteristic, jaundice and albuminuria are later, the splenic tumor is more 
 marked, black vomit and bleeding gums are wholly exceptional. In hem- 
 orrhagic malarial fever, hsematuria, a rare symptom in yellow fever, is 
 most conspicuous. 
 
 Prognosis. — The mortality ranges from 10 to 80 per cent. It varies 
 greatly in different epidemics. Among the working classes and hard 
 drinkers it is especially high. Of favorable prognostic significance are 
 mild fever, slight jaundice, a free secretion of urine, and the absence of 
 black vomit. High fever at the onset is ominous. Black vomit, though 
 serious, is not invariably followed by death. Suppression of urine and 
 uraemic symptoms are rarely followed by recovery. 
 
 XXI. CHOLERA. 
 
 Cholera Asiatica; Cholera Infectiosa. 
 
 Definition. — An infectious disease, endemic and epidemic in certain 
 districts of India, and occasionally epidemic in Europe and America, 
 caused by the comma bacillus of Koch and characterized by violent 
 purging, rice-water discharges, and early collapse. 
 
 Etiology. — Predisposing Influences. — Of great importance is expo- 
 sure in an infected district, but the chief danger lies in the drinking of 
 
CHOLERA. 753 
 
 water contaminated with the fecal discharges of cholera patients. Cholera 
 is endemic upon the delta of the Ganges. Thence it is from time to time 
 transported along the lines of commerce to various parts of the world. 
 Cases on ship-board have reached the New York Quarantine Station on 
 several occasions in the last three decades, but the disease has not gained 
 foothold upon our shores since 1873. It has prevailed extensively in the 
 East in recent years and is still to some extent epidemic in the Philippines. 
 Outbreaks are more common in warm climates — India, Egypt, the Islands 
 of the Malay Archipelago — but the disease has prevailed fiercely in Siberia 
 and Northern Russia and to some extent in Canada. Warm weather 
 favors the spread of cholera, but cold does not arrest it. It is especially 
 a disease of seaport cities and commercial centres, being transported by 
 persons and effects. It journeys in the East with caravans and pilgrims. 
 It is not conveyed by the atmosphere and does not advance at a faster 
 rate than that of ordinary commercial intercourse. In epidemics those 
 who handle the soiled linen of the sick or remove the discharges are espe- 
 cially liable to contract the disease. Physicians and nurses on the contrary 
 are seldom attacked. Students in the study of the germs have contracted 
 "laboratory cholera.'"' The drinking of contaminated water or milk, 
 articles of uncooked food as salads and the like washed with such water, 
 other articles of food accidentally contaminated, are common causes of 
 the disease. The part played by the house-fly in mechanically transporting 
 the pathogenic organism from the stools to articles of food is most impor- 
 tant. Every period of life is liable. 
 
 Exciting Cause. — The "comma bacillus," discovered by Koch in 
 1884, is the cause of the disease. This organism is present in all cases of 
 Asiatic cholera and does not occur in other diseases. It is a spirochseta, 
 morphologically appearing as a slightly curved rod, about half the length 
 of the tubercle bacillus but much thicker than that organism, sometimes 
 presenting an S-shaped appearance, and occasionally assuming spiral 
 curves. As other organisms present 
 similar forms, the characteristic growth 
 in cultures becomes important. Comma 
 bacilli are found in the stools from the 
 onset of symptoms and in the rice- 
 water discharges and contents of the 
 intestine after death in almost pure 
 culture. They are rarely present in the 
 vomited material and then only after 
 violent or protracted retching. They 
 are not present in the circulating blood 
 or in the viscera, but are sometimes 
 found in the intestinal glands and sub- 
 mucosa. They have been demonstrated 
 in water tanks and in other drinking ^ ok« a -n f a • *• i, i 
 
 o Fig. 256. — Spirillum of Asiatic cholera. 
 
 water supplies during epidemics. The 
 
 symptoms are due to a virulent toxin, caused by the bacilli, which acts 
 chiefly upon the vasomotor system. The immunity of certain persons 
 during epidemics, and the fact that virulent cholera bacilli have been 
 
 48 
 
754 MEDICAL DIAGNOSIS. 
 
 isolated from the stools of healthy individuals raises the question as to 
 natural immunity. Artificial immunity can be established in the cases 
 of laboratory animals and human immunity by the methods of Haffkin. 
 General epidemics in a community are caused by contamination of 
 the water supply and usually arise with great rapidity. Circumscribed 
 outbreaks develop more slowly and the source of the infection cannot 
 always be traced. 
 
 Symptoms. — The period of incubation varies from two to five days. 
 The course of the attack may be divided into four stages. Any one of 
 these stages may be absent. 
 
 1. Premonitory Diarrhcea. — Looseness of the bowels may begin 
 abruptly or be preceded by colicky pains and vomiting with or without 
 fever. At the time of an epidemic every case of diarrhoea must be re- 
 garded as a " suspect, " until the true nature of the symptoms is settled 
 by bacteriological examination of the discharges. The stools and any 
 linen that is soiled must be efficiently disinfected. 2. Serous Diarrhcea. — 
 Diarrhoea becomes more urgent, with frequent large liquid stools, which 
 presently assume the rice-water appearance. Or the attack may begin 
 in this way without premonitory symptoms. There are griping pains in 
 the abdomen and much bearing down, with great prostration. The tongue 
 is covered with a thick, whitish fur and there is extreme thirst. In the 
 course of a few hours vomiting occurs. Severe muscular cramps, espe- 
 cially in the legs and feet, add to the sufferings of the patient. Notwith- 
 standing the severity of the symptoms recovery may, in favorable cases, 
 set in at this period. The pains and tenesmus may cease, the rice-water 
 character of the discharges give place to stools that are fecal and bile- 
 stained, the gastric irritability subside, and little by little the ability 
 to retain water and nourishment return. 3. Stage of Collapse. — In 
 other cases collapse symptoms rapidly develop. The appearance of the 
 patient is due to the rapid withdrawal of fluid from the tissues. The skin 
 is ashy gray, shrivelled, wrinkled and inelastic, and covered with a clammy 
 perspiration; the features are shrunken, the eyeballs sunk in the sockets, 
 the nose pinched, the cheeks hollow, and the surface cyanotic and mottled. 
 The external temperature is subnormal but the internal registers 103°- 
 104° F. (39.5°-40° C.) or higher. The pulse is feeble, thready, and un- 
 countable. Diarrhoea frequently ceases and there is merely a continuous 
 oozing of rice-water material from the anus. The voice is husky and whis- 
 pering. The mental condition often remains singularly clear and alert. 
 At the last, coma supervenes. This is the fatal stage of cholera. It lasts 
 from a few hours to a day or two. The thin liquid stools are of a grayish- 
 white color, resembling turbid whey or rice-water. They contain much 
 granular matter and small whitish flakes of mucus. In other cases they 
 are tinged with blood and have the appearance and odor of the washings 
 of meat. They are alkaline in reaction, highly albuminous, and contain 
 sodium chloride in large proportion. Under the microscope epithelial 
 cells and bacteria, often comma bacilli in nearly pure culture, are seen. 
 The urine is greatly diminished or anuria may be present. That which 
 is voided is intensely albuminous. Microscopically it presents the char- 
 acters of an acute parenchymatous nephritis. Saliva is scanty but the 
 
CHOLERA. 755 
 
 function of the sweat-glands is maintained. Cholera Sicca. — In rare in- 
 stances the contents of the bowel are retained and collapse terminates 
 in death without diarrhoea. 4. Reaction. — In the cases which survive 
 the stage of collapse the symptoms characteristic of that condition grad- 
 ually subside. The action of the heart grows stronger, warmth ai^d color 
 return to the skin, which regains its natural turgor, cyanosis disappears 
 and is often replaced by a reddish mottling or erythematous blush, the 
 stomach becomes retentive of water and bland fluids, the colicky pains 
 and violent muscular cramps cease, the stools are much less frequent, and 
 the secretion of urine is re-established. With these signs of improvement 
 the disparity between the external and internal temperatures passes away. 
 The patient now enters upon convalescence which is often protracted, but 
 frequently interrupted by a relapse, which usually proves fatal. 
 
 Cholera-typhoid. — The stage of reaction may pass into a septic con- 
 dition characterized by so-called typhoid symptoms, due to secondary 
 infection. In some instances the predominant features are those of gen- 
 eral sepsis, in others pulmonary, and frequently they are ursemic. Feeble, 
 rapid pulse, dry tongue, muttering delirium, and stupor are followed by 
 coma, which terminates in death. As in other epidemic diseases cases of 
 every degree of severity occur. 
 
 Complications and Sequels. — The attack in the graver cases is so 
 severe and rapid in its course that complications as such are not common. 
 Important sequels are inflammation of the mucous membranes, as diph- 
 theroid colitis, pleurisy, and pneumonia, and abscess formation, especially 
 parotid bubo. Muscle cramps may persist and subacute gastro-intestinal 
 symptoms are often present for a long time. 
 
 Diagnosis. — Direct. — During an epidemic no doubt arises in well- 
 developed cases. The clinical picture is unmistakable. The uncertainty 
 in regard to first cases and suspects is usually quickly dispelled by the 
 course of the attack. Bacteriological examinations are necessary. 
 
 Differential. — Cholera Nostras: Cholera Morbus. — The symptoms 
 and course of severe cases do not differ from those of Asiatic cholera. The 
 cases are sporadic and occur in hot weather in temperate climates. There 
 is often a history of improper food, chilling, or exposure. Vomiting, diar- 
 rhoea with rice-water stools, colic, muscular cramps, suppression of urine, 
 cyanosis, and collapse may terminate fatally in the course of ten or twelve 
 hours. The differential diagnosis can only be made by laboratory methods. 
 Arsenical and Other Poisoning. — Vomiting, diarrhcsa, and collapse are 
 constant symptoms in acute poisoning by the preparations of arsenic, 
 mercury, and the poisonous fungi. The absence of cholera, the sporadic 
 occurrence of poison cases, the anamnesis, the evidences of the poi- 
 sonous substance, or the vial or box in which it was contained, are 
 important. 
 
 Prognosis. — The mildest cases recover; the severe cases almost in- 
 variably die. The mortality ranges in different epidemics between 30 and 
 80 per cent. In any given case alcoholism, old age, or diminished powers 
 of resistance from other causes, marked cyanosis, a temperature much 
 below normal, and early collapse are of ominous prognostic import. 
 
756 
 
 MEDICAL DIAGNOSIS. 
 
 XXII. BACILLARY DYSENTERY. 
 
 Definition. — An intestinal disease, usually acute but sometimes be- 
 coming chronic, occurring sporadically and in local epidemics, due to a 
 specific bacillus and characterized by tormina, tenesmus, and frequent 
 discharges of mucus and blood. 
 
 Etiology. — Predisposing Influences. — Dysentery is a widely spread 
 disease. It occurs in all parts of the world but is especially common in 
 tropical and subtropical countries. While bacillary dysentery is much 
 more prevalent and disastrous in hot climates, it is also common in tem- 
 perate climates both as a sporadic and an epidemic affection. Overcrowd- 
 ing and neglect of sanitary requirements both in military and civil life 
 are predisposing influences of great importance. It follows that dysentery 
 constitutes one of the most serious difficulties in warfare, especially in 
 
 tropical campaigns, and that its epi- 
 demic outbreak in overcrowded insti- 
 tutions not infrequently occurs. 
 
 Exciting Cause. — Bacillus Dysen- 
 terice. — Shiga, in 1898, discovered in the 
 stools of these cases a bacillus, having 
 specific characters, which he regarded 
 as the cause of the disease, and to 
 which he gave this name. This organ- 
 ism has been found in the dysentery 
 of the Philippines, Porto .Rico, in that 
 occurring in various points in the 
 United States and Europe. It has 
 been demonstrated in the summer diar- 
 rhoeas of infancy. 
 
 There are several strains, as deter- 
 mined by the relative agglutinating 
 power of the immune serum upon the bacilli in pure culture and the action 
 of the bacilli upon various sugars, but the lesions produced are the same. 
 Flexner's types are, (1) the Shiga, (2) the Flexner-H arris — the strain prev- 
 alent in the United States, and (3) Bacillus Y. The Bacillus dysenterise 
 has never been isolated except from the stools or lesions in human beings. 
 The mode of infection has not been demonstrated. The lesions comprise 
 intense hyperemia of the mucosa of the large intestine, with scattered 
 points of hemorrhage, superficial necrosis over limited or extended surfaces, 
 and enlargement of the solitary follicles. Deep ulceration is not present 
 in the cases that are early fatal. In the most intense cases great thickening 
 of the mucosa and other coats of the colon occurs, together with extensive 
 necrosis and gangrene. The ileum may be involved. 
 
 Symptoms. — The period of incubation does not exceed forty-eight 
 hours. The onset is sudden, with abdominal pain and frequent discharges 
 consisting at first of fgeces, followed by mucus which soon becomes bloody. 
 There is urgent inclination to go to stool, with twisting abdominal pain 
 and violent rectal tenesmus. The pyrexia, moderate at first, soon rises 
 to 103°-104° F. (39.5°-40° C). Thirst is intense and there is complete 
 
 Fig. 257. — Bacillus dysenterise (Shiga). 
 
PLAGUE. 757 
 
 loss of appetite. The pulse is rapid, small, and feeble. In the very severe 
 cases the patient becomes delirious and death occurs in the course of the 
 third or fourth day. In favorable cases the urgency of the intestinal 
 symptoms gradually declines, the temperature falls, and convalescence may 
 be fully established in three or four weeks. There are other cases in which, 
 with subacute symptoms, the cases run a protracted course. Many of our 
 soldiers return from the island possessions with chronic dysentery. 
 
 Among the important complications and sequels are malarial infec- 
 tion, subacute septic arthritis, pleurisy, pericarditis, endocarditis, and 
 sepsis. Albuminuria, anaemia, oedema of the legs and feet, and various 
 palsies due to neuritis occur in the protracted cases. In contrast to amcebic 
 dysentery, abscess of the liver is extremely rare. 
 
 Diagnosis. — Direct. — Laboratory methods are necessary. In non- 
 amoebic dysentery the B. dysenterise must be sought in the stools. It is 
 isolated most conveniently from the shreds of mucus. In the acute cases 
 the blood-serum agglutinates the bacillus in the Flexner-Harris strain in 
 dilutions of 1-1000 up to 1-1500; the Shiga strain agglutinates less readily. 
 
 Differential. — Bacillary dysentery is to be distinguished from 
 amoebic dysentery only by the methods of the laboratory. 
 
 Prognosis. — The outlook in the sporadic cases in temperate climates 
 is favorable; in local epidemics less so, especially with bad sanitary ar- 
 rangements. In active campaigns and tropical dysentery the death-rate 
 is high. The dysentery of Japan has a mortality of about 25 per cent. 
 After recovery there is very frequently prolonged ill health with gastro- 
 intestinal symptoms and diarrhoea. 
 
 XXIII. THE PLAGUE. 
 
 Bubonic Plague. 
 
 Definition. — An infectious febrile disease of the Orient, caused by 
 Bacillus pestis, and characterized by glandular swellings or buboes, car- 
 buncles, pneumonia, and, in many cases, hemorrhages beneath the skin 
 and from the mucous surfaces. 
 
 Etiology. — Predisposing Influences. — This disease, the great pesti- 
 lence of Europe and Great Britain for eleven hundred years, practically 
 disappeared towards the close of the seventeenth century. It has not 
 appeared as an epidemic in England since the Great Fire in London in 
 1666, the year following the Great Plague. Its cessation is due to modern 
 methods of living. It has been said of Europe that when the shirt came 
 in the plague went out. Always smouldering and frequently flaring up 
 in the East, the plague occasionally slipped over into Lower Italy, Egypt, 
 and other countries bordering on the Mediterranean, but not until the out- 
 break at Hong Kong in 1894 did it again threaten to become a world pest. 
 Since that date it has continued its ravages, especially in India, where 
 during the first six months of 1905 nearly 900,000 persons died of it, the 
 highest mortality for a half year made in the epidemic of eleven years' 
 duration. During the past decade the plague has appeared in Egypt and 
 other parts on the Mediterranean, South Africa, Oporto, Glasgow, New 
 
758 
 
 MEDICAL DIAGNOSIS. 
 
 York, Mexican and South American ports, Australia and New South Wales. 
 Occupation, age, and sex are without influence as predisposing factors. The 
 disease spreads chiefly among the poorer classes. The prevalence is greatest 
 in the hot season, but outbreaks sometimes occur during the coldest weather. 
 Personal and household cleanliness are important. In Bombay few attend- 
 ants upon the sick were attacked, and not a case occurred among the 
 British soldiers engaged in police duty and disinfection. Only an occasional 
 case occurs among Europeans living in infected regions. 
 
 Exciting Cause. — Bacillus pestis was discovered by Kitasato. It 
 appears in the form of short, non-motile rods, with rounded ends, staining 
 readily and more densely at the poles than in the middle, and decolorized 
 by Gram's method. This organism has a characteristic growth in culture. 
 It is present in the blood and lesions of the plague and in the dust of houses 
 
 in which cases have occurred, and in 
 the earth of the floors and a^ljacent 
 parts. Dogs and cats and household 
 vermin, as rats, mice, flies, and fleas, 
 suffer from the infection, transmit it to 
 others and to man, and die infected by 
 its germ. Plague bacilli are present in 
 enormous numbers in the hemorrhagic 
 sputum in the pneumonic form of the 
 disease, and may be found in the ordi- 
 nary bubonic form. 
 
 Mode of Transmission. — The plague 
 is not contagious in the ordinary sense. 
 It is dependent on the disease in the 
 rat, and is transmitted from rat to 
 man by the rat flea. Cases common- 
 ly occur singly in a house. Multiple 
 Rat fleas are carried by personal 
 and other fomites. Insanitary conditions except as to rats have no 
 relation to plague. — Plague Commission, 1908. 
 
 Symptoms. — The period of incubation varies from two to five days. 
 The following forms are described: 1. Rudimentary Form; Pestis 
 Minor. — The patient is not in all cases ill enough to go to bed. There 
 is moderate fever, with enlargement and tenderness of the inguinal glands, 
 which sometimes undergo suppuration. These cases constitute a danger 
 to the community by the presence of the bacilli in the discharges. 2. The 
 Ordinary Form; Bubonic Plague. — The onset is sudden, with a chill 
 which is immediately followed by fever, headache, backache, muscular 
 soreness, great anxiety, and depression of spirits. The temperature pro- 
 gressively rises until the third or fourth day, when there is a more or less 
 marked remission, followed by a further rise coincident with the develop- 
 ment of the buboes, and accompanied by signs of septic infection, dry, 
 brown tongue, delirium, stupor and coUapse symptoms — secondary fever. 
 Death frequently occurs at this stage. The swelling of the superficial 
 lymph-nodes occurs between the third and fifth days, the inguinal nodes 
 being involved in more than half the cases, less frequently' those of the 
 
 Fig. 258. — Bacillus pestis. a, organism from 
 culture ; b, smear preparation from spleen. 
 
 cases are usually simultaneous. 
 
MALTA FEVER. 759 
 
 axilla or neck. The adenitis may undergo resolution, suppuration, or, in 
 rare cases, gangrene, with the formation of deep sloughs. Necrosis of the 
 subcutaneous tissue may give rise to more or less extensive carbuncles. 
 Enlargement of the spleen occurs. Petechi£e are common, and the exten- 
 sive subcutaneous hemorrhages that characterized the disease in certain 
 epidemics gave to it in the Middle Ages the popular name of the Black 
 Death. Haemoptysis and other hemorrhages from the mucous surfaces 
 have been especially noted in some outbreaks. 3. The Septic Form. — 
 The symptoms are from the onset overwhelming, and death occurs in the 
 course of three or four days without the appearance of buboes. Hemor- 
 rhages constitute a prominent feature. Metastatic abscesses are frequentl)'" 
 found in the viscera. 4. The Pneumonic Form. — The disease may appear 
 as a primary specific pneumonia, with the usual characters of infectious 
 inflammation of the lungs. The type is bronchopneumonic, the fever high, 
 the respirations rapid, the sputum hemorrhagic and laden with the bacilli. 
 The attack lasts only a few days and almost invariably terminates in death. 
 
 Diagnosis. — Direct. — Cases imported during the stage of incubation 
 or the first cases in an outbreak may be readily overlooked. In suspected 
 cases all uncertainty can be at once settled by a proper laboratory inves- 
 tigation. The bacteriological examination of the blood, pus from the 
 buboes, the urine, and the sputum yields positive results. If necessary 
 cultures should be made and inoculation experiments upon guinea- 
 pigs. The danger of the importation of the disease at the present time 
 renders an efficient inspection at the quarantine station at every port 
 of entry imperatively necessary, with bacteriological studies in the case 
 of every suspect. 
 
 Prognosis. — Bubonic plague is the most fatal of the acute infectious 
 epidemic diseases. In the larval forms recovery is the rule; in the septic 
 and pneumonic forms death; in the ordinary bubonic form a great major- 
 ity of the cases die. The statistics of the Middle Ages are unreliable, but 
 it is stated that the Black Death of the fourteenth century destroyed one- 
 fourth of the population of Europe. 
 
 XXIV. MALTA FEVER. 
 
 Definition. — An acute general infectious disease, caused by the Mi- 
 crococcus melitensis and characterized by irregular fever of long duration 
 and remittent or intermittent type, with periods of apyrexia, by profuse 
 sweating, rheumatoid pains, arthritis, and enlargement of the spleen. 
 
 Etiology. — Predisposing Influences. — The disease prevails widely 
 upon the littoral and islands of the Mediterranean and is known as 
 Mediterranean fever, rock fever, Neapolitan fever, Danubian fever. It 
 has also been encountered in China and India, Manila and in the West 
 Indies, and imported cases have been studied in this country. It is 
 prevalent in summer as an endemic disease, not occasionally in circum- 
 scribed epidemics. It is not directly transmissible from the sick to the 
 well. Malta fever is especially a disease of young adults. It has been 
 particularly studied by the surgeons of the British Army stationed at 
 Gibraltar and Malta. 
 
760 
 
 MEDICAL DIAGNOSIS. 
 
 Exciting Cause. — The Micrococcus melitensis was first isolated 
 and studied by Brun in 1887. This organism has not been found in the 
 circulating blood, but is present in the spleen during life and after death. 
 It is pathogenic for monkeys, and cases of accidental infection in laboratory 
 
 work have been reported. The serum 
 of the patient after the fifth day causes 
 agglutination of cultures of the organ- 
 ism in dilution of 1 to 10 or 1 to 50. 
 
 The milk supply at Malta is largely 
 derived from goats, and Zammit, in 
 1905, made the important discovery 
 that the goats of the island are infected 
 with Micrococcus melitensis and isolated 
 this organism from the milk and urine 
 of those animals. 
 
 Symptoms. — The period of incu- 
 bation lasts from six to ten days. The 
 onset is preceded by prodromes not 
 unlike those of enteric fever. The 
 course of the disease is characterized by 
 undulations of fever, 102°-104° F. (39°-40° C), of distinctly remittent type, 
 lasting as a rule from one to three weeks, and separated by intervals of 
 incomplete or complete apyrexia of two or more days' duration. In rare 
 cases during the pyrexial period the fever conforms to the intermittent type, 
 without, however, manifesting the regular periodicity of the malarial infec- 
 
 FiG. 259. — Micrococcus melitensis. 
 
 
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 Fig. 260. — Malta or undulant fever. — Jackson. An average case may extend more than twice the duration 
 
 shown on this chart. 
 
 tions. This irregular fever is indefinitely prolonged, lasting from three 
 months, the average time, to six months, and being in some instances 
 prolonged by a series of relapses to two years. Obstinate constipation, 
 progressive anaemia, and debility are common symptoms; the spleen is 
 enlarged and tender; neuralgias, inflammation of the joints, with intra- 
 
BERI-BERI. 761 
 
 articular effusion, painful inflammatory conditions of certain fibrous 
 structures, and orchitis occur as complications. The wave-like range of 
 the temperature has suggested the name " undulant fever. " A malignant 
 type, fatal in the course of a week or ten days, is recognized, and a 
 so-called intermittent type with a daily rise of temperature toward 
 evening has been described. 
 
 Diagnosis. — Direct. — In districts in which Malta fever is endemic 
 the direct diagnosis is not attended with difficulty. It rests upon the char- 
 acter of the fever and its protracted course with intervals of apyrexia, 
 the tendency to relapse, the headache, lassitude, and joint affection. 
 Finally, the agglutination test is conclusive. 
 
 Differential. — The true nature of the disease may not be apparent 
 in imported cases. Malaria reveals itself upon an examination of the 
 blood. The temperature is higher, the periodicity, as a rule, more dis- 
 tinctly defined. Joint pains are not prominent. The judicious use of 
 quinine is curative — therapeutic test. Enteric fever differs from Malta 
 fever in its temperature range and duration. If relapses occur they con- 
 stitute a repetition of the primary attack and like it are attended by sub- 
 continuous temperature, rose spots, and marked intestinal and nervous 
 symptoms. A positive Widal reaction is conclusive. Endemic and epi- 
 demic influences are suggestive. Dengue is a pandemic disease and spreads 
 with great rapidity. The joint affection is among the earliest and most 
 conspicuous phenomena. The initial febrile paroxysm is of short duration 
 and the recurrent paroxysm is characterized by a polymorphous rash. 
 Rheumatic fever bears only a superficial resemblance. 
 
 Prognosis. — The mortality is about 2 per cent. Death is due to 
 the debility resulting from indefinitely prolonged fever, the anaemia, or 
 complications. Convalescence is hastened by change of climate. 
 
 XXV. BERI-BERI. 
 
 Kakke. 
 
 Definition. — An endemic and epidemic multiple neuritis of unde- 
 termined etiology, widely prevalent in tropical and subtropical countries 
 of the East, and characterized by motor and sensory palsies, atrophy of 
 the muscles, and dropsy. 
 
 Etiology. — Predisposing Influences. — This disease is widely prev- 
 alent in China, Japan, the Philippines, and the Malay Archipelago. Local 
 epidemics have been observed in Australia. It is very common in Brazil 
 and occurs in the West Indies. Imported cases are not uncommon in the 
 seaport cities of the United States, especially on the Pacific Coast. In a 
 few instances American fishermen have suffered from it, both upon the 
 Grand Banks and in shore fishing. In its prevalence as determined by 
 season and locality it is not unlike malaria, being most common in the hot 
 and rainy seasons. Absence of sunlight and air, and overcrowding are 
 important favoring conditions, hence beri-beri is frequent in jails and 
 asylums. It is also a common and troublesome disease on shipboard, 
 both in naval and commercial service. It is especially a disease of fisher- 
 
762 
 
 MEDICAL DIAGNOSIS. 
 
 men, a fact attributed to exposure and wet. In districts where the disease 
 is endemic, and even in epidemics, the native races chiefly suffer. The 
 imported cooUes are especially hable to it. Young men from 16 to 30 are 
 most frequently attacked, but no period of life is exempt. Males suffer 
 much more often than females. Beri-beri has long been regarded as a 
 food disease and attributed to rice which has undergone certain unknown 
 changes, or fish eaten raw or improperly cooked. Many striking facts 
 have been adduced in support of these opinions, especially the practical 
 disappearance of the disease in the Japanese Navy after certain changes 
 in the diet, among which was the abolition of fresh fish as an article of food. 
 On the contrary, Hamilton Wright, who has made an especial study of the 
 disease, holds the opinion that ''no food as food either qualitatively or 
 quantitatively is a factor in the production of the disease. " 
 
 Exciting Cause. — ^The Dutch ph3^sicians, who have first-hand knowl- 
 edge of the disease upon an extensive scale, believe that beri-beri is an 
 infectious disep.se. Wright holds that.it is an acute or subacute infectious 
 
 Fig. 261. — Atrophic varietj' of beri-beri showing muscular atrophy and wrist-drop. — •Jm/.-nnl of Tropical 
 
 Medicine) . — I niernational Clinics. 
 
 disease, due to a specific but as j^et undiscovered organism, probably in- 
 gested with the food accidentally contaminated by it. He thinks that 
 the disease may be spread by fecal contamination, and regards this hy- 
 pothesis as of great importance for prophylaxis. 
 
 No specific bacterium has as yet been demonstrated. 
 
 Symptoms. — The period of incubation is unknown. Wright thinks 
 it is short. A dry and wet form were once recognized. The following 
 clinical forms are described but they are not sharply differentiated: 1. Un- 
 developed OR Larval Form. — The onset is marked with catarrhal phe- 
 nomena which are followed by nervous symptoms, such as modifications 
 of sensation, parsesthesias, hyperaisthesia and pain, and loss of power 
 in the limbs, chiefly in the legs and feet. The muscles are not only 
 weak, they are also tender upon pressure. There is in many cases even 
 in this form oedema of the feet and ankles, but it is slight. Cardiac palpi- 
 tation, dyspnoea, and abdominal dis.tress may be present. This symptom- 
 complex is of variable duration. After a week or two, or several months, 
 recovery takes place, but there is a tendency to recurrence. 2. Atrophic 
 Form; so-called Dry Form. — Early symptoms are the same as in the 
 incomplete form. There is, however, more pain, wasting of the muscles 
 
TETANUS. 
 
 763 
 
 sets in and progresses rapidly so that in a short time paralytic phenomena 
 are pronounced and the power of movement is greatly impaired. Cardiac 
 derangements and dropsy are not prominent. 3. Dropsical, or so-called 
 Wet Form. — With similar initial 
 symptoms oedema occurs early and 
 soon becomes general with eiTu- 
 sions into the serous sacs. Muscu- 
 lar and neural symptoms are less 
 pronounced than in the atrophic 
 form and the wasting is not appar- 
 ent until after the anasarca sub- 
 sides. 4. Acute Cardiac, or 
 Pernicious Form. — The symp- 
 toms which characterize the rudi- 
 mentary form are followed by the 
 evidences of acute cardiac asthe- 
 nia, which may persist for several 
 weeks or terminate fatally in the 
 course of a day or two. 
 
 Diagnosis, — Direct. — In 
 countries in which beri-beri is 
 endemic there is little difficulty 
 in the diagnosis. 
 
 Differential. — Only in an 
 isolated imported case could mul- 
 tiple neuritis from other causes, 
 as alcohol, arsenic, etc., occasion 
 difficulty. Here the anamnesis 
 is most important and dropsical 
 symptoms most suggestive. 
 
 Prognosis. — The disease is 
 essentially subacute and chronic 
 and lasts a varying time, meas- 
 ured by days or months. The 
 acute cardiac forms usually be- 
 come chronic after a number of 
 days or weeks. Recurrences are common, especially in the wet season. 
 The mortality varies from 2 or 3 to 50 per cent., and is very high 
 among coolie laborers imported into a beri-beri district. 
 
 Fig. 262. — CEdematous variety of beri-beri. — {Journal 
 of Tropical Medicine.) — International Clinics. 
 
 XXVI. TETANUS. 
 
 Lockjaw. 
 
 Definition. — An infectious disease caused by a bacillus found in 
 garden earth and in the excrement of animals, especially the horse, char- 
 acterized by tonic spasm of the muscles, with paroxysmal exacerbations. 
 
 Etiology.— Predisposing Influences. — Tetanus is essentially a 
 wound infection. The view at one time entertained, that the disease may 
 
764 
 
 MEDICAL DIAGNOSIS. 
 
 be cryptogenic and idiopathic, and due to rheumatism or exposure to coldr 
 is no longer accepted. Many cases arise in consequence of insignificant 
 wounds which are overlooked or entirely healed at the beginning of the 
 attack. Internal injuries involving the mucous membrane, which elude 
 observation, are to be considered in this connection. Tetanus occurs in all 
 latitudes but is much more common in tropical than in temperate climates, 
 and among the colored than the white races. This is especially true of 
 puerperal tetanus and tetanus of the new-born. In tropical America and the 
 West Indian Islands tetanus has prevailed as a veritable public scourge. 
 Since the discovery of the tetanus bacillus and the diffusion of the 
 knowledge of its saprophytic existence the prevalence of the disease has 
 greatly diminished. Tetanus occurs more frequently in the summer and 
 early winter than at other seasons of the year. It has been attributed to 
 exposure to cold and to sleeping upon the damp ground. Aside from the 
 frequency of tetanus among the new-born, age is without influence. The 
 disease is said, however, to be less common after the sixteenth year. Sex 
 is without influence except in so far as occupation renders males more 
 liable than females. Occupation is an important predisposing influence. 
 All those which involve liability to wounds of the extremities, with coin- 
 cident fouling with earth, manure, or the excrement of animals, especially 
 with that of the horse, or with dust or dirt containing such material, pre- 
 dispose to tetanus. Hence stablemen, teamsters, gardeners, and soldiers, 
 especially cavalrymen, are particularly liable to the disease. In some 
 military campaigns tetanus has contributed largely to the mortality. 
 
 The majority of cases occur after lacerated and crushed wounds, 
 especially those involving large nerves. The disease is comparatively 
 infrequent after incised wounds. The extent and severity of the wound 
 has no direct relation to the liability to tetanus. The condition of the 
 wound as regards its tendency to heal is entirely without influence; tetanus 
 
 may occur when a wound has completely 
 healed and a cicatrix has formed. The 
 disease may follow the most trifling 
 traumatism — the extraction of a tooth, 
 the use of cupping glasses, the sting of 
 an insect, the application of a blister. 
 It is far more frequent after injuries of 
 the extremities than in other parts of the 
 body. The disease has been attributed 
 to the use of the hypodermic syringe. At 
 one time tetanus was common in hospi- 
 tals and occasionally became epidemic 
 in maternity institutions, a large pro- 
 portion of the lying-in women and their 
 children dying of this disease. 
 
 Exciting Cause. — The tetanus 
 bacillus has been found in the cultivated surface soil of all countries, 
 but not beyond the depth of 30 cm. It has also been found in the 
 dust of streets and in the woodwork of houses and furniture. It 
 is frequently present in the excrement of animals and man. The 
 
 Fig. 263, — Bacillus tetani and free spores. 
 
TETANUS. 765 
 
 comparative infrequency of tetanus is in strong contrast with the 
 wide distribution of its cause. 
 
 Symptoms. — The period of incubation is extremely variable. In gen- 
 eral the onset occurs between the eighth and fourteenth days, rarely later 
 than the fourth week. Prodromes are infrequent. They consist of nausea, 
 tenderness in the wound or scar, increased suppuration or spontaneous 
 reopening of the wound, accompanied by restlessness and loss of sleep. 
 
 The attack is occasionally marked by shivering or an actual chill. 
 The characteristic symptoms are continuous tension of the voluntary 
 muscles, and the occurrence at irregular intervals of spasms of varying 
 intensity. The tension and the spasms are commonly relaxed during 
 sleep. In inoculated animals, these symptoms usually commence in the 
 region of the wound and extend to other parts of the body. In man they 
 often first involve the muscles of the neck and suggest an ordinary torti- 
 collis from cold. Tension and spasm of the masticatory muscles — trismus 
 — soon occur and may be the earliest manifestations of the true condition. 
 There is inability to open the mouth or protrude the tongue — lock]' mo 
 — and efforts to perform these actions provoke more or less persistent 
 spasm of the facial muscles — risus sardonicus. Presently the abdomen 
 is felt to be hard and board-like, as in the early stage of peritonitis, 
 from contraction of the muscles. A sensation of oppression or pain in the 
 precordia, extending to the spine, is frequently experienced, and has been 
 attributed to spasm of the diaphragm. The pain at this time is not usually 
 severe in proportion to the violence of the spasm; later it becomes more 
 intense. In a short time the spasms extend to the voluntary muscles in all 
 parts of the body and affect them with about equal severity. The dorsal 
 and lumbar muscles may contract more violently than their antag- 
 onists, giving rise to opisthotonos. Forcible contraction of the abdominal 
 muscles, causing emprosthotonos, or of the muscles of one side — pleu- 
 Tothotonos — are far less common and less marked. On the other hand, 
 transient or persistent rigidity of the trunk and limbs — orthotonos — is 
 frequently observed. The fingers are but slightly involved in the general 
 stiffness and spasmodic contraction. The laryngeal muscles may be in- 
 volved, causing noisy respiration, dyspnoea, or fatal asphyxia. The spasms 
 may occur spontaneously and are apt to come on when the patient awakes 
 from sleep. They are caused by trifling external impressions, as efforts 
 to move, the arrangement of the bedclothing, or an examination of the 
 pulse or heart. Attempt to swallow frequently brings on violent general 
 spasm. Viscid saliva accumulates in the mouth and is swallowed with 
 difficulty. Respiration is disturbed; there may be cyanosis; the expres- 
 sion is greatly changed. The spasms are followed by great exhaustion, 
 with periods of quietude, drowsiness, and sleep. The duration of the par- 
 oxysms is variable. The intellect as a rule remains clear throughout the 
 attack. In rare cases delirium has occurred. The pulse is increased in 
 frequency during the paroxysms; in the intervals the pulse and respira- 
 tion are commonly normal. The temperature is frequently normal until 
 toward the close of the attack; in some instances there is fever from the 
 onset, 104°-105° F. (40°-40.5° C). A preagonistic rise is usual and often 
 extreme, 106°-110° F. (41.1°-43.5° C). Abundant perspirations occur 
 
766 MEDICAL DIAGNOSIS. 
 
 during the paroxysms. The urine is decreased in quantity, concentrated, 
 dark, and frequently albuminous. Its toxic coefficient is increased and its 
 injection into animals has caused fatal tetanus. The bowels are consti- 
 pated. The sphincters are contracted. The administration of a clyster 
 may be difficult and catheterization impossible. These procedures are 
 not only hindered by the state of the muscles but they also cause violent 
 general spasms. 
 
 The acute cases usually prove fatal about the third day. The milder 
 cases may continue for two or three weeks or even longer. Recoveries 
 usually take place in the prolonged cases. The disease is most severe and 
 quickly fatal when it develops shortly after the injury. Death occurs 
 in the acute cases, usually during the paroxysm, from asphyxia, oedema of 
 the glottis, or cerebral hemorrhage; less frequently from sudden collapse 
 or coma. In the prolonged cases it may be the result of exhaustion or of 
 inhalation pneumonia. If the patient survives the fourth day the intensity 
 of the symptoms may gradually diminish. Tetanus neonatorum is due to 
 infection at the navel. The disease usually shows itself between the first 
 and fifth days after the separation of the cord. The symptoms are the 
 same as those of ordinary traumatic tetanus. The duration is variable, 
 death commonly occurring about the third or fourth day. Recovery is rare. 
 
 The term puerperal tetanus is applied to those cases which develop 
 in the lying-in woman. It frequently occurs as the result of abortion or 
 from neglect of antiseptic precautions in confinement. Tetanus may occur 
 after operations or injuries of the genitalia in non-pregnant women. Tet- 
 anus bacilli have been found in the uterus and vaginal discharges. 
 
 The Cephalic or Facial Tetanus of Rose originates from a lacerated 
 wound in the region of the facial nerve and is characterized by trismus, diffi- 
 culty in swallowing, and paralysis of the facial muscles upon the same side. 
 
 Diagnosis. — Direct. — This rests upon the occurrence of stiffness in 
 the muscles of the neck, trismus, substernal pain extending to the back, 
 followed by risus sardonicus, general tension of the muscles with paroxysms 
 of spasm, and finally upon the bacteriological examination. The previous 
 occurrence of trauma is most important. Courmont has shown that neither 
 spontaneous nor experimental tetanus develops any agglutinating property 
 in the blood. 
 
 Differential. — 1. Torticollis following exposure to cold — so-called 
 rheumatic torticollis. A history of trauma and the rapid development 
 of the attack speedily settle any doubt. 2. Trismus associated with 
 quinsy. Parotitis and local abscesses of the jaws or teeth may suggest 
 tetanus, but a careful examination and the absence of general symptoms 
 render the diagnosis clear. It is important in this connection to note that 
 the rigidity of the masticatory muscles in tetanus is bilateral. 3. Strychnia 
 Poisoning. — The spasms are very suggestive but trismus is rarely marked, 
 and in the intervals between the paroxysms there is, in stiychnia poisoning, 
 no rigidity. 4. Cerebrospinal Meningitis. — Opisthotonos is a common 
 and prominent symptom and in rare cases general spasms may occur, 
 but the high fever and grave mental derangements stand in contrast to 
 the absence of fever at the beginning and the mental clearness in tetanus. 
 5. Tetany. — Spasm of the extremities, the peculiar position of the wrists 
 
HYDROPHOBIA. 767 
 
 and hands and the feet and toes, the occurrence of the symptom described 
 by Trousseau and that of Chvostek, together with the conditions under 
 which the disease occurs, usually render the diagnosis a simple matter. 
 6. Hydrophobia. — The history of the case, showing the bite of an animal 
 or man, the long period of incubation, the absence of trismus, the influence 
 of attempts to swallow in producing the spasms, and the great rest- 
 lessness and jactitation are of diagnostic importance. 7. Hysteria. — The 
 paroxysms are occasionally attended by convulsions which suggest tetanus. 
 The absence of antecedent trauma, the neurotic temperament, the inter- 
 paroxysmal state, the emotional manifestations, the curious sensory dis- 
 turbances, the existence of hysterogenetic areas render the differential 
 diagnosis between this condition and tetanus easy. 
 
 Prognosis. — The worst days are the first four. The aphorism of Hippoc- 
 rates still holds good: "The patient who survives the fourth day may 
 recover. " Traumatic tetanus is less frequent and less fatal in women than 
 in men. The general mortality is about 80 per cent. The later the disease 
 shows itself after the occurrence of the wound of infection the milder is 
 its course, and the more intense the initial symptoms the greater the danger. 
 The mortality is greater in children than in adults. Restriction of the 
 spasms to the muscles of the neck and jaw, and the absence of fever are 
 favorable. 
 
 XXVII. HYDROPHOBIA. 
 
 Rabies; Lyssa. 
 
 Definition. — An acute infectious disease of warm-blooded animals, 
 caused by an unknown specific virus contained in the saliva, character- 
 ized by convulsive and paralytic symptoms and communicated by 
 inoculation to man. 
 
 The terms ''hydrophobia" and "rabies" denote prominent symptoms. 
 The Greek term "lyssa" is frequently used. The distinction between 
 lyssa humana and lyssa animalis is unnecessary. 
 
 Etiology. — Predisposing Influences. — A distinction was formerly 
 made between the hydrophobia of man and that of animals. Experi- 
 mental medicine has established the fact that the disease in man and 
 animals is the same. Climate is without influence. The disease occurs in 
 all parts of Europe and is common in France, Holland, and England. At 
 one time frequent in Germany, it has in recent years become rare as a 
 result of the strict enforcement of laws regulating the muzzling and care of 
 dogs. It is very common in Russia. In North America it is comparatively 
 infrequent. The greater number of cases develop in the summer months, 
 a fact which finds ready explanation in the out-door life and lighter clothing 
 at this season. Men and children are affected more frequently than women 
 who are less exposed and whose clothing affords some degree of protection. 
 
 Epidemics among animals can often be traced to a single case. The 
 spontaneous occurrence of the disease as the result of cold, heat, thirst, or 
 other such cause has not been established. It is equally contrary to experi- 
 ence that hydrophobia arises spontaneously in man. Inoculation takes 
 place in the vast majority of cases by the bites of animals suffering from 
 
768 MEDICAL DIAGNOSIS. 
 
 the disease. Not every bite of an animal suffering from rabies produces 
 the disease, since the saliva may be wiped off by the clothing. Especially 
 dangerous are bites upon the face, hands, and the uncovered legs and feet. 
 
 Rabies occurs most frequently in the dog, wolf, and cat. Nearly all 
 the domestic animals occasionally suffer as the result of inoculation. Rats 
 and, in this country, the skunk are particularly liable. The disease is com- 
 monly propagated by the dog, which is on the one hand peculiarly suscep- 
 tible and on the other hand liable to infect other animals and human beings, 
 the disposition to bite being an especial manifestation of the attack. Next 
 in importance in disseminating the disease is the cat. The propagation 
 of hydrophobia by other animals is comparatively rare. Recent researches 
 show that rabbits, guinea-pigs, and other warm-blooded animals in which 
 hydrophobia was not formerly observed are susceptible. 
 
 Exciting Cause. — The nature of the poison is unknown. It is most 
 abundant in the central nervous system and especially in the medulla 
 oblongata. It is present also in the peripheral nerves, though in much 
 smaller amounts. 
 
 Symptoms. — The period of incubation in man is irregular. Its aver- 
 age duration is from 20 to 60 days. It may, however, be prolonged to 
 three months and exceptionally to six months. 
 
 The period of incubation is influenced by: (a) the susceptibihty of the 
 patient — it is shorter in children than in adults; (b) the animal communi- 
 cating the infection. The incubation is shortest after the bite of the wolf 
 and increases in the following order — the cat, the dog, and other animals, 
 (c) The amount of the virus introduced — puncture wounds and extensive 
 laceration wounds being followed by shorter periods; and (d) the part of 
 the body upon which the inoculation takes place. Bites upon the face and 
 head are followed by shorter periods of incubation, and next in order are 
 bites upon the hands. 
 
 Stage of Prodromes.' — There is irritation about the scar or the wound, 
 together with pain. In some instances the healed wound reopens. Sensa- 
 tions of numbness may occur. Trembling and fibrillary contraction of the 
 muscles of the affected member have also been observed. Other prodromal 
 symptoms consist of a feeling of depression, aching, and a sensation of 
 pressure in the head. The patient becomes sad, loses interest in his sur- 
 roundings, and prefers to be alone. He is unwilhng to talk about the injury 
 to which his illness is attributed. He is restless, apprehensive, and seeks 
 relief from these symptoms in long solitary excursions. Children become 
 depressed, lose interest in their ordinary play, and have irregular and 
 disturbed sleep. There is increased general sensibility and bright light 
 and noises are extremely distressing. There is laryngeal irritation which 
 may show itself in shght hoarseness and occasional spasmodic cough. 
 There may be difficulty in swallowing. Shivering may occur, which is 
 followed by some elevation of temperature and increased pulse-frequency. 
 Loss of appetite, nausea, and epigastric pain occur. This stage commonly 
 lasts from two to eight days. It maj^ however be much prolonged. In 
 some instances the prodromal symptoms are altogether absent. Stage 
 OF Excitement. — There is an intense sensation of dyspnoea, interrupted 
 by sighing and accompanied by a feehng of oppression and precordial 
 
HYDROPHOBIA. 769 
 
 distress. Difficulty in swallowing becomes more marked and it is commonly 
 on account of these symptoms that the patient consults a physician. The 
 difficulty in swallowing is characteristic. Attempts to drink or even to 
 swallow the saUva produce violent painful reflex spasm of the muscles of 
 the larynx and throat, which passes away to return with renewed intensity 
 upon further attempts. So distressing is this symptom that the patient 
 avoids taking fluid until compelled by the urgency of thirst. As the case 
 progresses any irritation — a sound, a draught of air, the sight of water 
 or the mere suggestion of it — may bring about the spasm. The superficial 
 and deep reflexes are increased. The pupils are usually slightly dilated. 
 This stage is characterized also by great excitabiHty and restlessness. The 
 patient is tormented by occasional hallucinations, his speech is short and 
 broken, his voice hoarse, and during the convulsive attacks inarticulate 
 sounds may be uttered which have been compared to the barking of a dog. 
 In the maniacal excitement the patient sometimes bites himself. Very 
 rarely, however, does he attempt to injure his attendants. The saliva is 
 much increased. It is frothy and discolored and freely expectorated. 
 At the beginning of the attack there is usually free perspiration. The 
 urine is diminished and of high specific gravity. Albumin and casts are 
 sometimes present. Sugar has been observed and in some cases hsemo- 
 globinuria. Trembling of the tongue and hands is common and in some 
 instances there is persistent tremor of the muscles of the face. Priapism 
 occurs. The temperature is commonly elevated and may reach 100° to 
 103° F. (37.8°-39.5° C). In many cases there is a preagonistic rise. The 
 pulse is increased in frequency, irregular and intermittent. The respirations 
 are irregular and shallow in the intervals between the convulsive paroxysms 
 and sometimes assume the Cheyne-Stokes rhythm. The expression is 
 anxious. Hallucinations and sometimes furious maniacal excitement 
 attend the convulsive paroxysms. In the interval the mind is usually 
 clear. Death may occur from asphyxia during the paroxysm. This stage 
 commonly lasts from 2 to 3 days. Paralytic Stage. — The spasms become 
 less frequent and less severe. There gradually develops muscular relax- 
 ation. Difficulty -in breathing disappears and it becomes possible to swal- 
 low. The patient sinks into unconsciousness, the heart's action becomes 
 progressively more feeble, and death occurs in collapse. The paralysis 
 may be limited to certain groups of muscles, as the tongue, the facial 
 muscles, or the muscles of the eye. In other cases hemiplegia or paraplegia 
 may occur. In rats as a rule, and occasionally in rabbits, the stage of 
 excitement does not occur and the onset of the attack is marked by para- 
 lytic symptoms — dumb rabies. The disease occasionally assumes this form 
 in human beings. It is apt to follow multiple and severe wounds inflicted 
 by the rabid animal, and has been attributed to proportionally large doses 
 of the virus — an opinion supported by experimental investigations. 
 
 Diagnosis. — Direct. — There is nothing characteristic about the 
 wound. It may heal promptly by first intention or by suppuration and 
 granulation in the ordinary manner. The diagnosis depends upon the 
 history of the bite of an animal suspected or known to be rabid, the occur- 
 rence of irritation in the wound or scar, the characteristic spasm of the 
 muscles of deglutition and respiration, the intense reflex excitability, the 
 
 49 
 
770 MEDICAL DIAGNOSIS. 
 
 short duration of the disease and the fatal issue. It is important in doubt- 
 ful cases to determine by inoculation the presence or absence of the disease in 
 the suspected animal. A small quantity of the substance of the central 
 nervous system of a rabid animal inoculated subdurally will produce in a 
 rabbit the paralytic form of rabies in the course of fifteen or twenty daj^s. 
 
 Differential. — The following diseases may present superficial resem- 
 blances to hydrophobia in the human being: 1. Hysteria. — The reflex 
 irritability may suggest hydrophobia, but the spasms lack early locali- 
 zation to the muscles of the throat and neck and the intensity of the 
 later general convulsions. The stigmata of hysteria are present and the 
 manifestations are indefinitely prolonged. 2. Lyssophobia. — The points of 
 differential diagnosis are those which are to be considered in hysteria. 
 The symptoms arise in hysterical and neurasthenic persons who have 
 been bitten by dogs or other animals and who fear that they have been 
 infected with hydrophobia. The pseudohydrophobic spasms are the 
 result of autosuggestion. Cases of this kind are doubtless among the 
 reported recoveries from hydrophobia. 3. Tetanus. — The incubation 
 period is shorter; the convulsions are tonic; trismus is an early and per- 
 sistent symptom, and the disease follows indifferent wounds and injuries 
 rather than the bites of rabid animals. 4. Various diseases — epilepsy, 
 poisoning by datura stramonium, sunstroke, cerebral tumor, acute mania — 
 may present symptoms suggestive of hydrophobia and give rise to diffi- 
 culties in diagnosis in cases in which there is the history of the bite of an 
 animal suspected of rabies. The symptom-complex, course, and termina- 
 tion in these affections render the diagnosis as a rule a comparatively 
 easy matter. 5. Landry^s paralysis presents sj^mptoms in some respects 
 suggestive of dumb hydrophobia. The anamnesis is of great importance. 
 Where there is a history of the bite of a rabid animal, or of an animal sup- 
 posed to be rabid, and the patient has been subjected to the Pasteur treat- 
 ment, the differential diagnosis between the attenuated form of paralytic 
 rabies, which occasionally develops subsequently, and Landry's paralysis 
 is extremely difficult. 
 
 Prognosis. — Hydrophobia occurs in only 15 or 20 per cent, of individ- 
 uals bitten by rabid animals. The danger is greatest when the wounds are 
 lacerated or deep and especially when they involve the muscles. It is also 
 greater in bites of the face and head than in those of the extremities. The 
 probability that the patient may escape increases with the lapse of time. 
 From the fourth month after the inoculation the danger rapidly decreases. 
 According to Woodhead the mortality of patients bitten by rabid animals 
 varied from 5 to 50 per cent, prior to the introduction of the Pasteur 
 treatment, and the general mortality of those bitten by rabid animals was 
 16 per cent. Bollinger's statistics indicate that of patients bitten by dogs 
 undoubtedly rabid 47 per cent, suffer and die from hydrophobia. Where 
 the wounds have not been cauterized 83 per cent, of the cases succumb; 
 where they have been cauterized 33 per cent. die. When the symptoms in 
 the human being are well developed the prognosis is absolutely unfavor- 
 able, death taking place in a period varying from 12 hours to 4 days. 
 Laveran, Roux, and others have reported cases in which some symptoms 
 of hydrophobia have appeared in individuals undergoing the Pasteur 
 
GLANDERS. 
 
 771 
 
 treatment who have ultimately recovered. At the Pasteur Institute at 
 Paris, of 27,719 cases of all kinds treated up to January, 1904, 117 died, a 
 mortality of 0.42 per cent. These figures do not include a small number 
 of cases in which the disease appeared during or within fifteen days after 
 the treatments. Recovery occasionally takes place in animals inoculated 
 in the laboratories. 
 
 XXVIII. GLANDERS. 
 
 Farcy. 
 
 Definition. — An infectious disease of the horse caused by the Bacillus 
 mallei and characterized by the development of nodules in the nose which 
 undergo ulceration — glanders; nodules in the skin — farcy — and lymphan- 
 gitis. It occurs occasionally in man as the result of accidental inoculation. 
 
 Etiology. — Predisposing Influences. — Among animals the ass is 
 especially liable to glanders. Mules and horses are less so. Other animals 
 may contract the disease. Wild animals in confinement, as in menageries, 
 frequently develop it. Animals contract the affection usually through 
 direct contact and commonly by the respiratory tract. Glanders in man 
 occurs as a rule from exposure to the disease in horses. Stablemen, team- 
 sters, coachmen, veterinary surgeons, and cavalrymen are especially liable. 
 As a rule the infection is derived from chronic cases in the horse the nature 
 of which for a long time remains obscure. Acute glanders in the horse is 
 generally recognized and its further spread controlled by the destruction^ of 
 the animal. The infection in man usually occurs through some more or less 
 trifling lesion of the skin. Infection by way of the respiratory surfaces is much 
 less frequent. Infection may take place by way of the mucous membranes. 
 The disease in a pregnant animal may be communicated to the foetus. 
 
 Exciting Cause. — The specific germ — Bacillus mallei — morpholog- 
 ically resembles the tubercle bacillus but is shorter and thicker. It is 
 chiefly communicated from the sick to 
 the well by the discharges, including 
 the urine and milk. When the bacilli 
 are present in the circulating blood the 
 course of the disease is very rapid. The 
 patient perishes with acute symptoms. 
 
 Cases of glanders in animals have 
 been reported in which recovery has 
 followed the repeated injection of small 
 but increasing doses of mallein: a sub- 
 stance isolated by Kalning and later by 
 Hellman from cultures of the bacilli. 
 
 Symptoms. — For purposes of de- 
 scription it is convenient to make a 
 distinction between glanders and farcy. 
 They are due to the same cause and 
 are very often associated. Acute and chronic forms occur. The period 
 of incubation of acute glanders varies from three to five days. Pro- 
 dromes are not uncommon, and consist of loss of appetite, nausea, and 
 
 A^ ^ ^^' '^^ J / / 
 
 Fig. 264.— Bacillus mallei. 
 
772 MEDICAL DIAGNOSIS. 
 
 pain in the head and extremities. In acute glanders the stage of invasion 
 is marked by general febrile disturbance. The mucous membrane of the 
 nose is swollen and respiration interfered with. There is a scanty, bloody 
 secretion which rapidly becomes more abundant and purulent. The nose 
 is reddened and swollen. An erj'sipelatous inflammation may extend 
 over the face. The nodules upon the nasal mucous membrane rapidly 
 break down, with the development of extensive ulcers which may go on to 
 necrosis. The lymph-nodes of the neck and the salivary glands a.re com- 
 monly much enlarged. Suppurative lesions of the skin, Ij^mphangitis, 
 and an inflammatory enlargement of the superficial lymph-nodes occur. 
 Stage of Eruption. — The eruption is sometimes abundant, especiall}' on the 
 face and extremities, particularly^ the larger joints. It has been mistaken 
 for variola. Only exceptionallj^ do the pustules show umbilication. In 
 some instances they are confluent. There is troublesome cough with abun- 
 dant sanguinolent or mucopurulent foul-smelling expectoration. Sup- 
 purative arthritis may occur. Hemorrhages into the skin and mucous 
 membranes have been noted. Colliquative sweating, diarrhoea, stupor, 
 convulsions, and coma are followed by death, which usually takes place in 
 the course of the second or third week of the attack. When an acute 
 attack develops in the course of chronic glanders death may occur as early 
 as the second or third day. 
 
 Acute Faecy. — The infection in man usually takes place from inoc- 
 ulation by way of the skin. There is intense inflammatory reaction with 
 phlegmon formation which rapidly breaks down into an ulcer with irregular, 
 abrupt edges, from which extend painful reddened lines marking the course 
 of the lymph vessels. The corresponding lymphatic glands are swollen, 
 tender, and painful. The swollen lymphatics are known among veteri- 
 narians as farcy-pipes; the nodular dilatations in their course as farnj- 
 buds or hnttons. If the lesion be situated upon one of the extremities the 
 limb rapidly becomes oedematous. Phlebitis may occur and abscesses 
 form in the subcutaneous connective tissue. In other cases there are no 
 signs of local inoculation. The sickness begins with the constitutional 
 symptoms characteristic of glanders. In the course of from three to seven 
 days small nodules occur in distant parts of the body which rapidly undergo 
 suppuration with the formation of deep ulcers and areas of gangrene. The 
 joints may be involved and abscesses form in the muscles. The constitu- 
 tional symptoms are those of an acute infection. The attack frequently 
 begins wdth a chill or shivering. The fever is constant and may be intense. 
 It does not conform to type. Remissions and intermissions occur. The 
 mucous membrane of the nose may not be involved and the eruption may 
 be absent. In the acute cases the bacilH have been found in the urine, 
 both in animals and man. The termination is commonly in death in the 
 course of the second week. 
 
 Chronic Forms. — The disease develops insidiously. Fever as a rule 
 is absent. If the infection takes place through a lesion of the skin, similar 
 manifestations to those in acute farcy may occur, developing however 
 more slowly, and only after some time do symptoms of glanders or farcy 
 appear. Symptoms referable to the organs of respiration are prominent. 
 Thev consist of sensations of fulness in the nose, hoarseness, cough, an 
 
ACTINOMYCOSIS. 773 
 
 abundant nasal secretion, and later dark, dry crusts. Upon examination 
 catarrhal inflammation and ulceration are discovered. The condition is 
 often looked upon as a chronic nasal catarrh. The process may last for 
 months. In some cases recovery has taken place. More commonly the 
 acute form of the disease develops or the patient dies of exhaustion. In 
 chronic farcy the patients experience for some weeks pains in the limbs 
 and joints. At the end of this time subcutaneous nodules develop. These 
 undergo suppuration and form more or less extensive abscesses and ulcers. 
 In some instances they show a tendency to heal; in others healing may 
 take place and the scars after a time break down. The lymph-nodes are 
 not often inflamed and the eruption is rare. Chronic farcy may last, with 
 periods of rest and recrudescence, for two or three years and end in recovery. 
 Most of the cases, however, terminate fatally with acute symptoms. 
 
 Diagnosis. — Direct. — The diagnosis of glanders or farcy depends 
 upon the occurrence of the foregoing symptom-complex. With a clear 
 history of the case and a knowledge of the occupation of the patient the 
 diagnosis in acute cases is not difficult. In chronic cases no suspicion of 
 the true nature of the disease may be entertained. A positive diagnosis 
 can be reached by bacteriologic methods. Strauss recommends for diag- 
 nostic purposes the injection of cultures of the secretion into the peri- 
 toneal cavity of a male guinea-pig. After two days, in positive cases, there 
 develop swelling of the testicles and granular inflammation of the tunica 
 vaginalis; later a specific orchitis, which undergoes suppuration. The 
 animal dies in the course of two or three weeks and the visceral lesions of 
 glanders are found. Mallein is frequently used for diagnostic purposes. 
 
 Differential. — In the beginning of the acute cases the symptoms 
 and course of the temperature may suggest enteric fever, and the joint pains 
 rheumatic fever. Later glanders is to be distinguished from erysipelas 
 and pysemia. The urgency of the symptoms, the well-defined local mani- 
 festations, and the course of the attack will usually render the diagnosis 
 a comparatively simple matter. The indolent serpiginous ulcers of chronic 
 farcy may suggest tuberculosis or syphihs. 
 
 Prognosis. — The prognosis is in a high degree unfavorable. Recovery 
 takes place very rarely in the acute cases. Chronic glanders usually ter- 
 minates in death. In chronic farcy, recovery occurs in about 50 per cent, 
 of the cases. 
 
 XXIX. ACTINOMYCOSIS. 
 
 Definition. — A chronic infectious disease caused by the Streptothrix 
 actinomj'^ces or ray fungus, characterized by granulomatous new forma- 
 tions and multiple abscesses, in the pus of which are found peculiar bodies 
 containing the organisms. 
 
 Etiology. — Predisposing Influences. — This disease occurs in all 
 parts of the world. Those cereals armed with stiff or thorny processes may 
 serve as carriers of the fungus. Barley and rye may be especially named. 
 Cattle are most exposed to the danger of infection at the time of the second 
 dentition and in the autumn and winter. Low and damp localities favor 
 the infection. The fungus penetrates the tissues by way of pre-existent 
 lesions of the mucous membranes or through wounds inflicted by the 
 
774 MEDICAL DIAGNOSIS. 
 
 spears of grain or pointed straws. The visual region of infection both in 
 man and animals is the mouth; less commonly the gastro-intestinal canal, 
 the lungs, or the wounded or abraded skin. The infection may be acquired 
 by drinking water contaminated by the discharges from the mouth of an 
 animal suffering from the disease. There is no reason to believe that 
 infection occurs by means of the milk or flesh of diseased animals. 
 Cases have occurred at all ages, from five to seventy years. . Men suffer 
 more frequently than women in the proportion of 5 to 3. Those 
 occupations which involve habitual contact with cattle and their food 
 must be regarded as predisposing causes. 
 
 Exciting Cause. — The parasite has been variously classified. Israel 
 and Bostrom described it as a cladothrix; more recently it has been re- 
 garded as belonging to the sti^eptothrix group. It appears in the pus as 
 minute specks, which are yellowish or brownish by reflected light — sulphur 
 
 granules — and often greenish by trans- 
 mitted light. These granules vary in 
 diameter from one-half to two milli- 
 metres and consist of a central core of 
 filaments among which are cocci in 
 varying numbers surrounded by a mass 
 of radiating filaments, many of which 
 present bulbous or clubbed extremities. 
 The earliest developmental forms con- 
 sist of smaller granules of a gray color 
 and translucent appearance composed 
 of a thick mass of threads either single 
 or branched; closely interwoven at the 
 centre and possessing the ray -like 
 -r, ..^. c . .-u ■ arrangement. The organism is polv- 
 
 FiG. 265. — Streptothrix actmomyces. F' . '^ i i i i 
 
 morphous. In animals the club-shaped: 
 forms are more common; in man the filamentous. Both threads and clubs 
 are present in cases in which the process is active. Ordinary pyogenic 
 bacteria are present in varying numbers. The ray fungus has been grown 
 upon artificial culture media and actinomycosis has been successfully 
 inoculated both directly and by the artificially grown organism. 
 
 Symptoms. — Actinomj^cosis is at first a local disease. Its course is 
 generally chronic, and as distant organs become involved it presents the 
 clinical picture of a chronic pyaemia. In very rare cases rapid dissemination 
 may occur by way of the blood-vessels, and the disease run an acute course. 
 
 Gastro-intestinal Form. — The infection takes place by way of 
 lesions in the mucous membrane of the mouth or throat or through the 
 tonsils. The jaw is very commonly involved in cattle, much less frequently 
 in man. There is swelling of the side of the face, usually involving the 
 lower, rarely the upper jaAV. The appearance may suggest sarcoma or a 
 phlegmon. Sinuses form and the characteristic pus is discharged. Bur- 
 rowing may take place in various directions. Indolent ulcers are common. 
 The duration is variable. Very rarely the fatal issue occurs as the result 
 of secondary infection or embolism in a few weeks. The usual course is 
 chronic and may extend over years. The tongue may be involved either 
 
ACTINOMYCOSIS. 775 
 
 primarily or secondarily. One or more circumscribed nodules form and in 
 the course of a few weeks undergo softening and may be incised. Intes- 
 tinal actinomycosis commonly involves the region about the caecum and 
 the appendix, or the sigmoid flexure and the rectum. Metastases are 
 common. Pericsecal abscesses have been reported. The anus may be 
 involved. Actinomyces have been found in the stools. Peritonitis is a 
 common termination, but the disease may run a very chronic course with 
 septic phenomena and cachexia. 
 
 Respiratory Form. — Actinomycosis of the neck may directly involve 
 the larynx or may give rise to laryngeal cBdema. The lungs may be involved 
 primarily or secondarily. The lesions are less characteristic. In many 
 cases they are merely those of a chronic bronchial catarrh. In others 
 the tissue of the lungs is studded with gray nodules, resembling miliary 
 tubercles and consisting of granulation tissue surrounding masses of the 
 parasitic growth. In other cases the lesions are those of chronic broncho- 
 pneumonia with interstitial changes and a tendency to softening and the 
 formation of cavities. As the process advances it involves the pleura, 
 which may become adherent and greatly thickened or undergo suppura- 
 tive changes leading to circumscribed empyema. Fistulous tracts are 
 formed which open at the inner border of the scapula or elsewhere along 
 the spinal column. Erosion of the vertebrae and necrosis of the ribs and 
 sternum may occur. The clinical phenomena are those of pulmonary 
 tuberculosis or fetid bronchitis. Actinomycotic granules are not alwaj^s 
 present in the sputa. As the disease advances there are septic symptoms 
 with progressive emaciation and night-sweats. In rare instances the con- 
 dition may simulate enteric fever. The duration varies from a few weeks 
 to two or three years. Recovery is rare. 
 
 Cutaneous Form. — Cutaneous actinomycosis is very rare. It appears 
 in the form of circumscribed tumors of a mottled purplish red and yellow 
 color, varying in diameter from 1 to 3 or 4 centimetres, presentmg one or 
 more crater-like ulcerative openings, from which is discharged a clear sticky 
 fluid sometimes containing the characteristic granules. In some instances 
 the ulcerative process, while undergoing cicatrization at the centre, advances 
 at the periphery. The condition is chronic and intractable. 
 
 In some few instances other regions have been primarily involved, 
 especially the reproductive organs in the female, and the orbit. Bollinger 
 reported a case of primary disease of the brain. In the other recorded 
 cases the cerebral lesions have been the result of metastasis. The symp- 
 toms are those of cerebral tumor or abscess. 
 
 Diagnosis. — Direct. — This rests upon the presence of the actino- 
 myces in the pus. Local tumor formation with a tendency to implication 
 of bone and formation of multiple sinuses should arouse suspicion. Vis- 
 ceral actinomycosis dves rise to obscure symptoms. Tumors involving 
 the lower jaw and the neck with multiple fistulae are very suggestive. 
 In the examination of the sputum some forms of degenerate epithelium 
 and the Leptothrix buccalis may present strong points of resemblance to 
 detached threads of the ray fungus. 
 
 Differential. — Actinomycosis of the lungs may resemble forms of 
 chronic bronchitis and tuberculosis. Tuberculosis of the gastro-intestinal 
 
776 MEDICAL DIAGNOSIS. 
 
 tract maj^ give rise to local peritonitis, infiltrations, abscess formations, 
 and fistulse,. which cannot in the absence of the actinomyces be distin- 
 guished from similar conditions due to other causes. Cutaneous acti- 
 nomycosis may resemble lupus and the lesions in the tongue may be 
 mistaken for carcinoma, cysts, or syphilitic gummata. 
 
 Mycetovia or Madura Foot. — This curious disease of hot climates 
 presents points of resemblance to actinomycosis. It is a chronic destruc- 
 tive local inflammation of the foot, or more rarely of the hand, resulting 
 in an excessive proliferation of connective tissue. There are two varieties 
 of the disease: the pale or ochroid form which is characterized by yellow- 
 ish-white or brownish granules in the discharge, and the melanoid form 
 which is characterized by dark brown or black masses of varying size. 
 The disease shows no tendenc}^ to formation of visceral deposits. It was 
 earlv described by Van Dyke Carter as a fungus disease. An organism has 
 been cultivated from the pale variety which has been thought to be closely 
 related but not identical with actinomyces. 
 
 XXX. ANTHRAX. 
 
 Wool-Sorter's Disease; Malignant Pustule. 
 
 Definition. — An acute, infectious, epidemic disease of vertebrate 
 animals, particularly sheep and cattle, caused by the Bacillus anthracis, 
 and occurring sporadically in man as the result of accidental inoculation. 
 
 Etiology. — Predisposixg Influences. — Anthrax is readily communi- 
 cated from the domestic animals to man. Those occupations which involve 
 direct or indirect contact with living or dead animals suffering from the 
 disease constitute the chief predisposing cause. Individuals especially 
 liable may be grouped as folloAvs: 1. Farmers, shepherds, drovers, far- 
 riers, and veterinary surgeons. 2. Slaughterers and butchers. 3. Tanners, 
 skin dressers, rag sorters, and workers in wool, hair, and horn. 4. Those 
 who come in contact with persons following the foregoing occupations or 
 who live in their neighborhood. 5. Anthrax may be transmitted from one 
 person to another, and is under certain circumstances communicable from 
 the human dead bod}^ to those coming into contact with it. 
 
 Anthrax is the most widely spread and destructive of the epizootics. 
 All vertebrate animals are susceptible to anthrax, the herbivora being 
 most liable, the omnivora less so, and carnivora only under unusual 
 circumstances. 
 
 Exciting Cause. — The Bacillus anthracis. This organism usually 
 finds access to animals by way of the gastro-intestinal tract from infected 
 fodder or infected pastures or water. Pasteur held that the earth-worm 
 plays an important part in bringing to the surface and distributing bacilli 
 from the buried carcasses of infected animals. Certain localities thus 
 become permanently infected. The disease is directly inoculable and the 
 infection may take place by the bites or stings of insects. Omnivorous 
 animals, as the hog, dog, cat, and rat, though less susceptible, sometimes 
 contract the disease by feeding upon infected carcasses. The disease 
 does not spread by mere contact or association. The danger of infection 
 
ANTHRAX. 
 
 777 
 
 I/.X -^^^ 
 
 Fig. 266. — Bacillus anthracis 
 
 is greatly diminished if the carcasses of animals dead of the disease are 
 buried unopened. Occasionally local outbreaks of anthrax among cattle, 
 sheep, and other animals, in regions in which the disease does not prevail 
 continuously, have been traced to imported hides, wools, and hair. These, 
 not being thoroughly disinfected, are 
 washed, the water being discharged 
 into streams and sewers. In some 
 instances the refuse from the manu- 
 facture of such articles is utilized for 
 manure, and farms and fields thus 
 become infected. 
 
 Symptoms. — The cases may be 
 grouped, according to the seat of the 
 IDrimary lesion by which the infection 
 takes place, into (a) external or cuta- 
 neous anthrax, and (b) internal or 
 visceral anthrax, of which there are 
 pulmonary and intestinal forms. 
 
 (a) External or Cutaneous Anthrax. 
 — 1. Malignant Pustule or Vesicle. 
 — The term " malignant pustule" is inappropriate and misleading. The 
 condition is in some cases not malignant and the lesion does not sui> 
 purate. Anthrax is literally a burning coal. The general condition is 
 known as anthracamia. The term charbon — coal — is applied by the 
 French to the local lesion of the skin, and fihrre charhonneuse to the 
 
 general disease. The inoculation 
 almost always occurs on some 
 exposed part, as the arm, face, neck, 
 or chest. The period of incubation 
 varies from a few hours to two or 
 three days. The early symptoms 
 are local irritation and itching. A 
 papule forms which rapidly becomes 
 vesicular. There is surrounding 
 redness and considerable brawny 
 swelling. By the third day the 
 vesicle ruptures, leaving a brown 
 base exuding serum. In the course 
 of twenty-four hours a black, dry, 
 depressed eschar forms, around 
 which at a little distance are several 
 small secondary vesicles, sometimes 
 discrete, sometimes confluent. The 
 oedema extends for some distance 
 and is very tense and deep. The related lymph-nodes are swollen 
 and tender. Lesions upon the face or neck cause extraordinary swelling 
 and disfigurement. Implication of the larynx and mediastinal glands 
 gives rise to great difficulty in breathing and swallowing. Pus does not 
 occur in favorable cases until the eschar begins to separate, usually toward 
 
 Fig. 267. — .-Vnthrax pustule; early stage. — Royer. 
 
778 
 
 MEDICAL DIAGNOSIS. 
 
 the end of the second week. The severity of the general symptoms has no 
 constant relation to the amount of local disease. Cases with marked 
 local lesions may show but slight constitutional disturbance. Commonly 
 symptoms of general infection rapidly follow the appearance of the papule, 
 or thejT^ may be deferred for some days. There is a feeling of illness, chilli- 
 ness, thirst, vomiting, and restlessness. In many of the cases the symptoms 
 are those of the internal affection. Death may take place in from' three 
 to five days. In favorable cases the constitutional symptoms are slight, 
 the eschar suppurates, and the wound heals. 2. Malignant Anthrax 
 
 (Edema. — Swelling appears 
 
 in the eyelids or elsewhere on 
 
 , the head, hands, and arms. 
 
 Neither papule nor vesicle 
 develops and there is no 
 characteristic eschar. The 
 oedema may be very exten- 
 sive and occasionally follows 
 the constitutional sj^mptoms. 
 Extensive areas of gangrene 
 may result, with grave con- 
 stitutional symptoms. A 
 remarkable characteristic of 
 the external forms of anthrax 
 is the mental condition of the 
 patient. With the gravest 
 symptoms the mind may be 
 perfectly clear and the patient 
 manifest no indications of 
 anxiety or distress up to the 
 time of death. 
 
 (b) Internal or Visceral 
 Anthrax. — 1. Pulmonary 
 Anthrax (Wool-sorter's Dis- 
 ease ; A nfhraccemia) . — This 
 form of anthrax occasionally 
 develops in those exposed by 
 their occupations to the inhalation of anthrax spores in dust arising 
 from the products of diseased animals. Wool and hair imported from 
 Russia, Asia, Egypt, and South America appear to have been the cause 
 of the disease in a large proportion of the cases. The symptoms are 
 often indefinite until the approach of death. Prodromes are not com- 
 mon. The onset is usually acute. The patient suddenly feels out of sorts, 
 has shivering, chilliness, uneasiness about the chest and stomach, and 
 sensations of great weakness and weariness. In the course of a day or two, 
 without having expressed sensations of being seriously ill, the patient 
 may fall into a condition of collapse which terminates a few hours later 
 in death. The tongue is moist and coated, thirst is moderate, and there 
 may be weight and uneasiness at the stomach with complete loss of appetite. 
 Vomiting and diarrhoea also occur. Symptoms referable to the respira- 
 
 FiG. 268. — Anthrax- 
 
 -fifth day; oedema of neck and thorax. 
 — Royer. 
 
ANTHRAX. 779 
 
 tory system consist of a feeling of oppression, quickened respiration, 
 cough, not commonly severe, with or without expectoration. The pulse 
 is usually weak and rapid, out of proportion to the severity of the other 
 symptoms, and toward the close of the case becomes irregular and 
 uncountable. The heart sounds are greatly enfeebled. Wandering or 
 active delirium, convulsions, and coma have been observed. The skin is 
 moist. The temperature rises to ]02°-103°F. (38.9°-39.5° C.) and may 
 reach 105°-106° F. (40.5°-41.1° C). It is commonly four or five degrees 
 higher in the rectum than in the axilla. The urine is scanty, dark-colored, 
 and of high specific gravity. Albuminuria is common. 2. Intestinal 
 Anthrax {Mycosis Intestinalis). — This form is rare in man. Infection 
 occurs by way of the stomach and intestines in consequence of eating the 
 flesh or drinking the milk of diseased animals. The symptoms are those 
 of intense poisoning, with gastro-intestinal irritation, and consist of nausea, 
 persistent vomiting, abdominal pain, and diarrhoea. There is great weak- 
 ness, restlessness, and difficulty in breathing. The pulse is small and rapid, 
 the surface of the skin cold and moist, the face and extremities are slightly 
 cyanotic. The rectal temperature is but slightly above normal. Hemor- 
 rhage from the mucous surfaces may occur and is sometimes accompanied 
 by petechise and cutaneous abscesses. The spleen is enlarged. The blood 
 is dark and fluid and contains the bacilli. Convulsions and coma are 
 followed by collapse, and death occurs in from two to seven days. 
 Instances have been recorded of local outbreaks in which the symptoms 
 have developed at about the same time in a number of individuals. 
 
 The external form of anthrax may be associated with both the pul- 
 monary and intestinal forms of the disease. Eppinger has shown that 
 rag-picker's disease is a local anthrax of the lung and pleura with general 
 infection, and a consideration of the pathological anatomy justifies the 
 conclusion that the intestinal form also begins as a local process to which 
 the constitutional symptoms are secondary. 
 
 Diagnosis. — Direct. — In both the external and internal forms of 
 anthrax the occupation of the patient is of diagnostic importance. In 
 external anthrax the direct diagnosis rests upon the character of the papule 
 on an uncovered portion of the body, the rapid development of a vesicle, 
 the redness and extensive brawny induration extending along the lym- 
 phatics to the neighboring glands. Microscopical examination of the 
 contents of the vesicle may show the presence of anthrax bacilli. Cult\u-es 
 and inoculation experiments in a guinea-pig or white mouse give conclu- 
 sive results in the course of two days, the animal dying and the internal 
 organs showing anthrax bacilli in enormous numbers. These organisms 
 may not appear in the blood until shortly before death. The appearance 
 of the local lesion upon the third or fourth day is very characteristic. The 
 central depressed eschar, the surrounding vesicles, redness, extensive 
 oedema, with comparatively little pain, are significant. 
 
 Differential. — An ordinary boil or carbuncle. This rests upon the 
 absence of suppuration and of a moist yellow slough. Phlegmonous Ery- 
 sipelas and Cellnlitis. — Anthrax may be distinguished b}' the absence of 
 pain and of marginal secondary vesicles in the case of slough. Chancre. — 
 The differential diagnosis rests principally upon the ra])i(lity of the progress 
 
780 MEDICAL DIAGNOSIS. 
 
 and more serious constitutional symptoms of anthrax. Glanders. — There 
 is an absence of the profuse purulent discharge from the nostrils. The 
 direct diagnosis of pulmonary anthrax in the early stage is impossible. 
 Later the gravity of the illness in connection with the symptoms above 
 described, in an individual exposed to infection in his occupation, is highly 
 suggestive. The direct diagnosis can, however, be made in some instances 
 by microscopical examination of the blood. If this be negative inocula- 
 tion experiments should be performed. The progress of the case in intes- 
 tinal anthrax is so rapid, and the symptoms so closely resemble those of 
 gastro-intestinal poisoning due to other causes, that a positive diagnosis 
 during life is usually impossible. 
 
 Prognosis. — Every case of anthrax may be regarded as a grave ill- 
 ness, but cases of spontaneous recovery are not altogether uncommon. 
 The mild cases are most frequent in children and the intensity of the attack 
 in man is said to correspond to the intensity of the disease in the animal 
 from which the infection is derived. The prognosis is much more favorable 
 in localized external anthrax than in the internal form. Malignant oedema 
 of the face or neck is dangerous to life, partly by its extent and partly 
 through the pressure exerted upon the structures of the neck, especially 
 of the great vessels. The prognosis in anthrax oedema is by far graver 
 than that of malignant pustule. Inhalation anthrax — the rag-picker's 
 disease — gives a mortality of 50 per cent. The graver cases with severe 
 fever, rapid prostration, and the evidences of extensive pulmonary inflam- 
 mation terminate in death. Bell states that " no case demonstrated during 
 life to be intestinal anthrax has ended in recovery." 
 
 XXXI. LEPROSY. 
 
 Lepra; Elcvhatitiasis Grcecorum. 
 
 Definition. — A chronic, infectious, endemic disease caused by the 
 Bacillus leprae, characterized by a disseminated nodular infiltrate in the 
 skin and mucous membranes — tuberculous leprosy— or lesions of the 
 nerves — anaesthetic leprosy. In the complete or generalized disease both 
 sets of lesions are present^the mixed form. 
 
 Etiology. — Predisposing Influences. — No race is exempt. Lep- 
 rosy occurs in all latitudes, in moist and dry climates, alike at the sea 
 level and in mountainous settlements. Congenital leprosy is very rare; 
 in fact its occurrence is doubted. The disease sometimes shows itself 
 in childhood, but the vast majority of the cases develop in early adult 
 life. In some instances it has first appeared in extreme old age. Males 
 are affected in greater proportion than females. The mode of life is 
 not without influence. The poor suffer more frequently than the well- 
 to-do, but the latter do not escape. It has been thought that the 
 habitual or exclusive use of certain articles of diet, as vegetables, salted 
 food, food without salt, fish or pork, predispose to leprosy, either by 
 the ingestion of the bacilli or by rendering the tissues less resistant to 
 their development. Leprosy prevails in mountainous districts, as Kur- 
 distan and Kashmir, where a fish diet is unknown, and among the Brahmins 
 
LEPROSY. 
 
 781 
 
 who never taste fish. Furthermore systematic examinations of fish and 
 preparations of fish in countries in which the disease is endemic have 
 failed to reveal the presence of the Bacillus leprae. 
 
 The Exciting Cause. — The Bacillus lepra constitutes the specific 
 infecting agent. Nothing is known of the distribution of the Bacillus 
 leprae outside of the human body. It has not been found in the tanks in 
 which lepers bathe, nor in the soil about the graves of lepers, although in 
 some few instances it has been discovered in the soil of the paths and 
 banks surrounding asylums. 
 
 It has been asserted that vaccination may be the means of transmitting 
 leprosy. The danger cannot arise where bovine vaccine is used. The 
 majority of lepers have never been vaccinated, and in countries where 
 leprosy is steadily diminishing vaccination is becoming more general. 
 
 Until recently a belief in the hereditai'y transmission of leprosy was 
 generall}^ entertained. The present 
 drift of opinion is against this view. 
 The transmission of the disease takes 
 place under conditions that are not 
 well understood. It has been suggested 
 that the lepra bacillus undergoes some 
 developmental change in an interme- 
 diary host. It is probable that the 
 bacilli find access to the body through 
 the skin and mucous membranes, espe- 
 cially the mucous membrane of the nose. 
 When leprosy is carried by immi- 
 grants into highly civilized countries 
 it rarely spreads. In countries where 
 the disease has been endemic its diffu- 
 sion is largely influenced by the degiee 
 of association of the lepers with the healthy. When the intercourse 
 with lepers is controlled by legal enactments or a general dread of the 
 disease, its prevalence is circumscribed and limited. The transmission 
 of the disease by the conjugal relation is rare. There are, however, 
 many recorded cases indicating that the communication has taken place 
 after marriage. Physicians in charge of hospitals and asylums for lepers 
 rarely contract the disease. From 9 to 10 per cent, of the helpers in 
 the leper settlement at Molokai have developed the malady. Prolonged 
 exemption does not indicate permanent immunity. 
 
 Symptoms. — (a) Tuberculous Leprosy. — The period of incubation 
 varies from a few months to several years. The prodromal symptoms 
 consist of irregular fever, weakness and prostration, loss of appetite, and 
 impaired nutrition. Repeated epistaxis is not uncommon. After a time 
 areas of cutaneous erythema appear. These may be sharply defined and 
 in some instances are anaesthetic. Later they undergo pigmentation. 
 These spots vary in size and some of them may disappear. Aftei a time 
 pea-sized or larger nodules appear which may run together and form large 
 tuberculous masses. These tubercles are at first soft and elastic and 
 slightly tender upon pressure; later they become firmer and are insensi- 
 
 FiG. 269. — Bacillus of leprosy; section of skin. 
 
782 
 
 MEDICAL DIAGNOSIS. 
 
 tive. They may develop upon any portion of the body. The scalp is, 
 however, usually exempt. They are most common upon the face, the 
 dorsal surfaces of the hands and feet, upon the ankles, wrists, and forearms, 
 and the outer aspect of the thighs. 
 
 The lesions progressively involve new areas of skin with the forma- 
 tion of fresh tuberculous masses, and as the older ones undergo ulceration 
 areas of cicatrization form. These changes in the skin undergo their most 
 marked development upon the face, producing the characteristic fades 
 leonina. The superficial lymphatics generally become enlarged early in 
 the course of the disease. The eyelashes and eyebrows fall out and 
 there is atrophy and loss of hair elsewhere upon the body. The hair}^ 
 scalp is usually unaffected. The mucous membrane of the upper air- 
 
 FlG. 270. — Early stage of tuberculous leprosy 
 — German Hospital. 
 
 Fig. 2j 1. — Tube-culous leprosy. 
 
 passages undergoes infiltration, with the formation of tubercles. These 
 speedily break down, giving rise to painful ulceration. Changes in the 
 voice occur. It becomes harsh or nasal, or more or less complete 
 aphonia may develop. 
 
 As cicatrization takes place various deformities result, as stenosis of 
 the mouth or palate, and laryngeal stenosis. The process involves the 
 eyelids and extends to the ocular conjunctiva and the cornea, resulting in 
 ultimate destruction of vision in from 66 to 75 per cent, of the cases. 
 
 The duration of the disease is indefinite. The patient may live 
 for years, becoming more and more deformed and helpless. Death 
 commonly results from exhaustion, colliquative diarrhoea, or inhalation 
 pneumonia; sometimes from stenosis of the larynx or trachea or laryn- 
 geal oedema. 
 
 (b) An.^sthetic Leprosy. — The period of incubation is commonly 
 more prolonged than in the tuberculous form. The onset is insidious and 
 
LEPROSY. 
 
 783 
 
 characterized by subjective cutaneous symptoms, as hypersesthesia, pruritus, 
 and pain. Fever is not common. Persistent and troublesome pains in 
 the limbs are frequent. Hyperidrosis may be an early symptom. Trophic 
 disturbances may give rise to the formation of bulla). Patches of erythema 
 varying in size from one to several centimetres, usually circular or oval in 
 outline, form upon the trunk and limbs. After a time these spots disappear, 
 leaving areas of anaesthesia, but anaesthetic patches may occur without 
 the development of macules. The erythematous spots show a variety of 
 tints, from pinkish-red to a bluish- or brownish-red color, and many of them 
 undergo pigmentation. As the areas become anaesthetic the pigment may 
 gradually disappear, leaving well- 
 defined white or yellowish patches 
 in striking contrast to the surround- 
 ing skin. The superficial nerve- 
 trunks are felt to be enlarged and 
 nodular. The hair of the affected 
 surfaces may become white or fall 
 out, and as the disease develops 
 there is complete suppression of per- 
 spiration. Similar lesions may 
 appear upon the face. They ma}^ 
 remain discrete or become confluent. 
 As the disease advances they are 
 frequently the seat of bullse, some of 
 which undergo involution, with cica- 
 trization, others break down, form- 
 ing more or less superficial ulcers, 
 which on healing leave conspicuous 
 scars, which are at first dark but later 
 become pale, smooth, and shining. 
 
 The modifications of sensibility 
 consist first of exaltations of sensi- 
 bility, such as have been described; 
 second, of perversions of sensation, 
 which consist of dysaesthesias, formi- 
 cation, numbness, and delayed sensa- 
 tion; and third, abolition of sensation, which is more or less complete. 
 The trophic changes involve the conjunctivae and the mucous membranes 
 of the nose, mouth, and throat, which may become dry and red and the 
 seat of areas of superficial ulceration. The ulcers which form in the anaes- 
 thetic patches developing in the hands and feet may be very destructive, 
 giving rise to contracture and necrosis, which produce distressing deformi- 
 ties, the loss of fingers and toes, and the development of perforating ulcers. 
 Spontaneous resorption of bone may take place. 
 
 In favorable cases the disease may last for a long period without 
 the development of marked trophoneurotic changes. The average dura- 
 tion of life in this form of lepros}^ is about twent}^ years. In some 
 instances the progress of the disease is arrested and the patient may 
 reach an advanced age. 
 
 Fig. 272. — Ansesthetic leprosy. 
 
784 MEDICAL DIAGNOSIS. 
 
 (c) Mixed or Complete Leprosy. — The lesions peculiar to the tuber- 
 cular and the anaesthetic forms develop simultaneously, or in succession. While 
 the distinction between the two main forms is in well-marked cases sharply 
 defined, there are many cases which must be referred to the mixed form. 
 
 Diagnosis. — The direct diagnosis of leprosy in the early stage may be 
 difficult. The erythematous macules wath hypersesthesia, pain, and pig- 
 mentation, and the subsequent development of tuberculous nodules are 
 characteristic. In the nervous form the areas of persistent anaesthesia, 
 with bullae, ulceration, deformities, and necrosis of the hands and feet, are 
 important. A history of residence in a country in which leprosy prevails, 
 even without actual association with known lepers, justifies the suspicion 
 of contagion. The bacteriological examination of the nasal discbarge, the 
 serum of a blister, or of an excised nodule may settle a doubtful case. 
 
 The differential diagnosis involves the consideration of a great 
 number of chronic affections which present resemblances to leprosy, among 
 which may be named especially syphiHs, lupus, multiple neuritis, syringo- 
 myelia, and Morvan's disease. 
 
 Prognosis. — The experience of history shows leprosy to be an incurable 
 disease. Abortive cases occur but they are extremely rare. The prognosis 
 as regards recovery or even as regards the arrest of the process is highly 
 unfavorable; that as regards the expectancy of life must be guarded. The 
 miserable life of the leper may be prolonged for twenty years or more. The 
 outlook in the tuberculous form is less favorable than in the anaesthetic form. 
 
 XXXII. TUBERCULOSIS. 
 
 Definition. — An infectious disease caused by the Bacillus tuberculosis, 
 and characterized histologically by the formation of tubercles and infiltra- 
 tions of tuberculous tissue, which undergo caseation and necrosis or sclerotic 
 changes; anatomically, by alteration and destruction of the parts imme- 
 diately affected, and clinically, by local and constitutional symptoms which 
 vary according to the structures involved and the extent of the process. 
 
 Etiology. — Predisposing Influences. — Tuberculosis is a wide-spread 
 disease affecting both human beings and animals. Among the latter the 
 domestic animals and, in particular, the bovines chiefly suffer. Wild 
 animals in captivity are peculiarly liable to tuberculosis. The liability of 
 the hog is much less than that of horned cattle; of the horse and sheep 
 very slight; of the dog and cat even less, though these animals housed as 
 pets with tuberculous persons sometimes contract the disease. Rabbits 
 and guinea-pigs, especially the latter, are peculiarly susceptible to tuber- 
 culous infection, and are for that reason much used for the purposes of 
 laboratory research. Avian tuberculosis constitutes a special variety of 
 the disease. The wide prevalence of tuberculosis among human beings is 
 due to methods of living favorable to the propagation of the infecting 
 principle. It is most prevalent in the centres of population and in densely 
 peopled locaHties in which direct sunHght, fresh air, and cleanliness are 
 little known. About one-seventh of all deaths are caused by tuberculous 
 disease. Climate has little influence as a predisposing cause. Tubercu- 
 losis is more common in proportion to the population in temperate than 
 
TUBERCULOSIS. 785 
 
 in tropical or extreme northern regions. xUtitiide is important. The great 
 plateaus of the United States and Mexico, the settlements of the high 
 regions of the Alps, the Andes, and the Himalayas are remarkably free from 
 tuberculous affections. Soil and Locality. — Tuberculous diseases and 
 especially phthisis have been shown to be more prevalent in wet, badly 
 drained districts than in dry uplands with a porous, sandy soil. The 
 influence of soil in this respect consists in an increased liability to catarrhal 
 affections and hence general increase in susceptibility. Mode of Life. — 
 Tuberculosis is fostered by darkened houses and unventilated sleeping 
 rooms. Habitual life in the open air is unfavorable to it alike in the individ- 
 ual and in the community. Like other readily transmissible infections, 
 it spreads with great rapidity when introduced among aboriginal peoples 
 previously free from it. Race. — The influence of racial susceptibility is 
 much less than that exerted by the mode of life. It is difficult to separate 
 these factors. The American Indian, the negro, and the immigrant peasant 
 fiom Ireland and Southeastern Europe suffer in this country from an 
 especial liability. There is an apparent relative immunity arnong the 
 Jews. Personal Predisposition. — The phthinoid or pterygoid chest is not 
 only seen in phthisical individuals but it is also characteristic of those 
 who manifest a peculiar susceptibility to phthisis. On the other hand a 
 very large proportion of those who contract the disease have well-developed 
 chests and every evidence of perfect health. Now that tuberculosis is 
 known to be an infection to which the liability is wide-spread, less attention 
 than formerly is paid to the so-called diathetic states. Age. — Tuberculous 
 infection may occur at any age. Eai'ly adult life, from twenty to thirty- 
 five, is attended with a peculiar liability. The susceptibility of the various 
 tissues and organs varies with different periods of life. In infancy the 
 intestines, glands, and meninges, in childhood and adolescence the bones 
 and lymph-nodes, and later the lungs, other viscera, and the skin are more 
 commonly affected, but any form of tuberculosis may occur at any period 
 of life. Sex. — Women become tuberculous in slightly higher proportion 
 than men. Occupation. — Those who work in a confined and dust}' atmo- 
 sphere are very liable to contract pulmonary consumption. From this 
 point of view phthisis merits a place among the occupation diseases. 
 Previous Disease. — Catarrhal affections predispose to tuberculosis. It is 
 to this fact that must be ascribed the frequency of pulmonary tuberculosis 
 after the acute diseases in which bronchial catarrh plays a prominent 
 part, as pertussis and measles. The marked predisposition to tuberculosis 
 of the lymph-nodes on the part of young children is due to their liability 
 to catarrhal processes in the upper respiratory passages and bronchi. 
 I am not disposed to think that tuberculous infection is especially favored 
 by entei'ic fever. Influenza and variola are regarded as predisposing influ- 
 ences. In such cases the development of the disease nuiy be either the 
 result of direct infection upon a soil prepared by the antecedent malady or 
 of the lighting up of a latent tuberculous focus. Tabes mesenterica is 
 doubtless in most cases the result of infection by way of the lesions of a 
 catarrhal enterocolitis. Among chronic diseases syphilis and diabetes 
 are very often followed by pulmonary tuberculosis, and the latter affection 
 is a common terminal condition in chronic bronchitis, disease of the heart, 
 50 
 
786 
 
 MEDICAL DIAGNOSIS. 
 
 cirrhosis of the Kver, and chronic nephritis. Cases of tabes and other forms 
 of spinal scleiosis often terminate m pulmonary tuberculosis. In cases of 
 chronic antecedent disease, whether the tuberculous process be frank or 
 latent, the final event is an acute miliary tuberculosis. A blow or injury 
 is very often followed by tuberculous disease of the part. In the case 
 of meningitis, or bone or joint disease, it is necessary to assume an 
 antecedent latent tuberculosis; when pleural or pulmonary tuberculosis 
 follows a contusion of the chest in the absence of fracture of a rib or 
 laceration of the pleura or lung, we may assume that the resistance 
 of the part has been impaired by the injm-y, and infection thus ren- 
 dered possible. Much more commonly, careful inquiry will elicit a 
 history of previous symptoms of tuberculosis. The danger of a surgical 
 operation m local tuberculosis is always to be considered. Latent trouble 
 
 elsewhere may be lighted up, or an 
 acute miliary process develop. 
 
 The Pathogenic Organism. — The 
 demonstration by Koch of the tubercle 
 bacillus and the etiological unity of the 
 tuberculous diseases constitutes one of 
 the most remarkable and beneficent 
 achievements of modern medicine and 
 ranks in importance with .Tenner's 
 great work. 
 
 The bacilli are present in varying 
 abundance in all the lesions of tuber- 
 culosis. They are very numerous in 
 active lesions, but scanty in the sluggish 
 processes of chronic glandular or bone 
 disease. When a tuberculous focus, as 
 a softened lymph-node, discharges its 
 contents into a vein or lymph vessel, the bacilli are swept on with the current 
 to effect new lodgement and produce new tubercles at various points in the 
 body. When not found in the effusions of serous tuberculous inflammation, 
 as pleurisy, or in sections of chronic or obsolescent lesions, the nature of the 
 process may frequently be demonstrated bj' culture or inoculation. Rosen- 
 berger, as the result of the examination of the thoracic ducts in subjects 
 dead of tuberculosis, and the examination of the blood by a special technic 
 (see p. 245) in 120 cases of tuberculosis, including advanced and incipient 
 cases and the miliary variety, has reached the conclusion that tuberculosis 
 in all its forms is a bactersemia. His investigations also lead him to regard 
 termxinal mixed infections as uncommon. The bacilli are thrown off by 
 way of the discharges, the sputum in laryngeal and pulmonary tuber- 
 culosis, the urine, faeces, vaginal discharges and rarely the semen in the 
 genito-urinary forms, and tuberculous sinuses, abscesses, and ulcerated 
 surfaces in various parts of the body. They retain their vitality outside 
 the body for an undetermined period. 
 
 The chief source of infection is the sputum. Beside this all others 
 fall into insignificance. The principal vehicle of transmission as shown 
 by Cornet is the atmospheric dust. 
 
 Fig. 273. — Spread of sputum showing Bacillus 
 tuberculosis. 
 
TUBERCULOSIS. 787 
 
 Modes of Infection. — (a) Heredity. — Clinical and experimental 
 evidence are alike against transmission from the male by means of the 
 spermatozoids. The hypothesis that transmission may occur from the 
 tuberculous mother by way of the ovum has some experimental support. 
 Transmission b}" way of the blood, the bacilli penetrating the placenta, 
 is supported by clinical and laboratory facts. The placenta under such 
 circumstances is usually tuberculous, but in some instances it has been 
 apparently normal. The number of reported cases of congenital tuber- 
 culosis in man is limited. 
 
 The difficulties in determining the part played by heredity in individual 
 cases arise from the uncertainty in regard to the transmission of individual 
 susceptibility from the affected forebears to the offspring, the absence as 
 yet of definite conclusions as to the prolonged latency of tubercle bacilli 
 in the tissues of an apparently healthy child of a tuberculous parent, and 
 the fact that tuberculosis is at the outset a distinctl}'' local process, which 
 may, when acquired by postnatal infection, become circumscribed or 
 obsolescent, and remain latent in the tissues (lymph-nodes, for example) 
 for an indefinite period, to become again active under various circumstances, 
 as traumatism, acute disease, or softening and rupture of a gland-capsule. 
 The mere fact that a parent, grandparent, or collateral relation in a pre- 
 vious generation suffered from tuberculosis no more proves the hereditary 
 nature of the disease than the occurrence of scarlet fever in them would 
 render it hereditar}^ Yet the assumption in regard to the one disease might 
 with the same indifference to scientific accuracy be made of the other. 
 
 (b) Inoculation. — Tuberculosis in man has been in rare instances 
 produced by inoculation. Those who work in the post-mortem room 
 frequently contract local skin tuberculosis, the nature of which has been 
 demonstrated both microscopically and by inoculation in animals — post- 
 mortem warts. These lesions are discrete, small nodules and are almost 
 always situated upon the backs of the hands or fingers. Inoculation may 
 also take place in various accidental ways; among these are circumcision, 
 cuts from the broken spit-cup of a consumptive, and the bite of a tuber- 
 culous person. There is no evidence to support the assertion of the anti- 
 vaccinationist that consumption is transmitted in the vaccine virus, beyond 
 the fact that in a very limited number of cases lupus has developed at the 
 site of the vaccine pock. In point of fact, the lesion almost always remams 
 local at the seat of inoculation. 
 
 (c) Inhalation. — The vehicle is atmospheric dust to which bacilli are 
 attached. This dust in rooms occupied by the consumptive and around 
 his person is made up of the dried pulverized sputum. An obvious measure 
 of prophylaxis is to keep the sputum, discharged into suitable receptacles, 
 moist and disinfected until it can be destroyed by fire or otherwise effect- 
 ually disposed of. In some instances direct infection takes place by the 
 inhalation of tubercle bacilli contained in the fine particles of moist sputum 
 ejected by the patient in the act of coughing or even m conversation, and 
 remaining for a time suspended in the air in his immediate neighborhood. 
 Among the facts that lend support to the hypothesis of infection by inhala- 
 tion are the frequency with which the early lesions involve the larynx, 
 lungs, and bronchial glands; the prevalence of the disease in cloisters, 
 
788 MEDICAL DIAGNOSIS. 
 
 asylums, prisons, and other similar institutions, and the remarkable 
 investigations of Flick, who showed that not only certain localities but 
 also particular houses become infected, and that members of different 
 families successively occupying such houses succumb to the disease. 
 
 The degree of intimacy of association with the consumptive plays 
 an important part in the danger of the transmission of the disease. It is 
 no uncommon thing for a woman who has nursed a consumptive daughter 
 or sister to contract the disease and die of it in the course of some months. 
 This occurrence is infrequent among nurses, whose attendance is less close 
 and hours are less prolonged. The latter have also an advantage in their 
 technical knowledge of the dangers and in habits of prophylaxis. In the 
 case of husband and wife this danger of the transmission of pulmonary 
 tuberculosis is abundantly established by common observation and the 
 results of statistical inquiries. 
 
 (d) Infection hy Food. — The milk of tuberculous cows, and milk foods, 
 including butter made from it, have been shown to be capable of giving 
 rise to the disease. Tuberculous lesions of the udder are not necessary, 
 the milk of animals healthy in this respect having been shoAvn to be infec- 
 tious. Bovine tuberculosis constitutes a positive danger to the human 
 race. The frequency of tuberculosis of the intestines and mesenteric glands 
 in young children finds a ready explanation in infected milk. 
 
 The meat of tuberculous animals is not without clanger. It has been 
 shown experimentally to be infective to guinea-pigs. Thorough cooking 
 probably destroys the infecting principle; uncooked meats, smoked beef 
 and similar articles may convey the disease. Legal enactments against 
 the exposure for sale of the flesh of tuberculous animals are well founded. 
 
 A. Acute Miliary Tuberculosis. 
 
 Tubercle bacilli find their way into the blood from a focus of tuberculous 
 endangitis or the perforation of the vessel wall by a softening caseous mass. 
 
 Varieties. ^ — Three clinical forms occur: (a) the general or so-called 
 typhoid, characterized by the symptoms of an acute general infection; 
 (b) the pulmonary, in which the symptoms are chiefly referable to the 
 lungs, and (c) tuberculous meningitis. 
 
 (a) Generalized Miliary Tuberculosis. — Miliary nodules are thickly 
 disseminated throughout the various organs of the body. 
 
 Symptoms. — -The symptoms are those of an acute general infection, 
 and the condition presents many of the features of enteric fever, for which 
 it is often mistaken. The signs of local disease are rarely marked. The 
 onset is gradual after a period of rapidly failing health. In some of the 
 cases the onset is abrupt. Nose-bleeding is not common. The pulse is 
 rapid in proportion to the fever, not often dicrotic, and shows remarkable 
 variations in frequency within short periods of time. The fever increases, 
 the temperature being very irregular, usually much higher in the evening 
 than in the morning and often reaching 104° F. (40° C.) or more with 
 remissions of three or four degrees. In some of the cases the range is dis- 
 tinctly intermittent. Inverse temperatures are occasionally observed. 
 There is profound asthenia with rapid loss of flesh. Pulmonary symptoms. 
 
TUBERCULOSIS. 789 
 
 increased respiration frequency, especially early in the attack, and dyspnoea 
 with faint cyanosis, are common. Diffuse rales, the signs of a bronchitis 
 not unlike that of enteric fever, are heard, and in some of the cases there 
 may be dulness at an apex, or patches of subcrepitant and crepitant rales 
 at various parts of the chest. In a group of cases there is no fever or the 
 temperature does not exceed subfebrile ranges, and the true nature of the 
 disease is revealed only upon post-mortem examination. Delirium is less 
 common than somnolence and stupor, which deepen to coma, terminating 
 in death. Toward the last there may be an intensification of the lung 
 symptoms, or the evidences of involvement of the meninges. Cheyne- 
 Stokes respiration is common. 
 
 Diagnosis. — The direct diagnosis of this form of acute miliary tuber- 
 culosis rests upon the signs of a profound toxaemia, irregularity of the 
 temperature, the occurrence in some cases of an inverse range, the rapidity 
 and irregularity of the pulse, and the absence of the signs which character- 
 ize the other specific infections and septic processes. If there be localized 
 pulmonary signs, the history of glandular or bone tuberculosis, or menin- 
 geal symptoms, the diagnosis becomes more probable. Choroid tubercles, 
 or tubercle bacilli in the fluid obtained by lumbar puncture, or in the blood, 
 render it positive and final. 
 
 The DIFFERENTIAL DIAGNOSIS between general miliary tuberculosis and 
 enteric fever very often taxes the art of medicine to its utmost. This is 
 particularly the case when the onset is marked by bronchitis of some sever- 
 ity, attended by dyspnoea and faint cyanosis, with little cough. Under 
 these circumstances great rapidity and irregularity of respiration and 
 pulse, and in general terms a correspondence in their frequency, irregularity 
 of the temperature and conformity to the remittent or intermittent rather 
 than the subcontinuous type, signs of deficient oxygenation of the blood, 
 constipation, only slight enlargement of the spleen, herpes, the absence of 
 rose spots, and a leucoc3^tosis are in favor of miliary tuberculosis. The 
 following facts must receive due consideration. There are cases common 
 in childhood and not extremely rare in adult life in which the fever curve 
 of enteric fever is remittent throughout. Constipation is by no means rare 
 in enteric fever, and diarrhoea may occur in miliary tuberculosis. Enlarge- 
 ment of the spleen occurs in both diseases, but is neither so early nor, except 
 occasionally in children, so decided in tuberculosis. Herpes, though rare, 
 has been observed in enteric fever. Rose spots occur in tuberculosis, but 
 they are rare and appear singly rather than in crops, and do not present 
 the appearance nor run the course of the eruption which characterizes enteric 
 fever. Leucocytosis is common in miliary tuberculosis; leucopenia the 
 rule in enteric fever. But leucocytosis occurs in enteric fever compHcated 
 by inflammatory and suppurative processes. Albuminuria and the diazo 
 reaction may occur in both diseases. The Widal reaction may not be con- 
 clusive, since it may occur in an individual who has passed through an 
 attack of enteric fever and subsequently become tuberculous. Nor, for the 
 same reason, is the presence of Bacillus typhosus in the urine conclusive. 
 If that organism is, however, found in blood cultures the diagnosis of 
 enteric fever may be made. The two conditions may coexist and the 
 lesions of both diseases have been present upon post-mortem examination. 
 
790 MEDICAL DIAGNOSIS. 
 
 (b) The Pulmonary Form. — The acute phenomena develop in persons 
 who suffer from persistent cough or are known to have chronic pulmonary 
 tuberculosis, or, especially in children, may follow an infectious disease, 
 as measles or whooping-cough. 
 
 Symptoms. — The onset is like that of an acute bronchitis or broncho- 
 pneumonia. Troublesome cough, mucopurulent expectoration, sometimes 
 rusty sputum or blood spitting, dyspnoea, slight cyanosis, and a dusky 
 flushing of the cheeks are among the symptoms that attract attention. 
 In children especially, but sometimes also in adults, there are patch}- areas 
 of dulness at the bases posteriorly, with areas of tympanitic resonance, 
 the sign of collateral emphysema. Rales of larger size, both sibilant and 
 sonorous, may be heard; but much more commonly they are fine or coarse 
 crepitant. A grazing friction scarcely to be distinguished from the finest 
 subcrepitant or crepitant rales is the sign, as established by post-mortem 
 observations, of a miliary tuberculosis of the pleura. Bronchial breathing 
 of high pitch is, in children, often heard at the bases and opposite the root 
 of the lung. The temperature is not usually very high, 102°-103° F. (38.9°- 
 39.5° C), often irregular, and may be of inverse type. The pulse is irregular. 
 The spleen is usually enlarged. Toward the end cerebra' symptoms some- 
 times develop, the pulse grows more feeble and rapid, coarse rales obscure 
 the finer respiratory signs, and Cheyne-Stokes breathing occurs. The 
 duration of the disease varies from a fortnight or more in the acute to 
 several months in the chronic cases. 
 
 Diagnosis. — The direct diagnosis is not usually attended with diffi- 
 culty. In children this form of miliary tuberculosis very often follows 
 measles and whooping-cough and constitutes the principal danger in those 
 diseases. The history of chronic tuberculosis, pulmonary, glandular, or 
 joint, is of diagnostic importance. Tubercle in the choroid, when found, 
 establishes the diagnosis, but the proportion of cases in which it occurs is 
 limited. The occurrence of meningeal symptoms is important. Tubercle 
 bacilh are often absent from the sputum upon repeated examination; when 
 found their. significance is positive. 
 
 Differential Diagnosis. — This relates to non-tuberculous broncho- 
 pneumonia. The anamnesis is very important. A history of tuberculous 
 disease in any of its forms, even a chronic cough without impairment of 
 general health, merits careful consideration. The degree of dyspnoea and 
 cyanosis, tubercle bacilli, haemoptysis, and, above all, the persistence of the 
 fever and other symptoms are of diagnostic value. 
 
 (c) The Meningeal Form. — Acttte Tuberculous Meningitis. — An acute 
 miliary tuberculosis in which the membranes of the brain, less commonly 
 also those of the cord, are chiefly implicated. As the membranes of the 
 base are the common seat of the process, the affection is sometimes spoken 
 of as basilar meningitis. This form is especially common between the 
 second and fifth years of hfe. It is rare during the first year and relatively 
 infrequent in adult life. A primary tuberculous depot may usually be 
 discovered, most frequently in the bronchial or mesenteric glands. It may 
 be in the lungs, the middle ear, the bones, or genito-urinary organs. In a 
 small proportion of the cases the most careful autopsy fails to reveal the 
 local source of the infection. 
 
TUBERCULOSIS. 791 
 
 Symptoms.— There are frequently prodromal symptoms. These consist 
 of gradual loss of appetite and weight, irritability, fretfulness, and change 
 of disposition. There may be a history of recent measles or whooping- 
 cough, or of a fall. 
 
 Stage of Irritation. — The onset may be attended with a severe 
 general convulsion, or with the usual triad of meningeal symptoms — 
 headache, vomiting, and retraction of the muscles of the back of the neck, 
 the last being less marked than in cerebrospinal fever. Fever is present, 
 usually moderate but gradually increasing to 102°-103° F. (39° -39.5° C.)! 
 The pain is intense and paroxysmal, and the exacerbations are accompanied 
 by a short sudden scream — hydrocephalic cry. The child holds its hand to 
 its head, and sometimes screams continuously for hours at a time. The 
 vomiting is without apparent cause and is repeated from time to time. 
 The bowels are usually constipated. The retraction of the neck may be 
 slight at first and only manifest when the head is bent forward or rotated. 
 The respiration frequency remains normal, but the pulse, at first rapid, 
 becomes irregular and slow. Sleep is restless and accompanied by muscular 
 twitchings and sudden starts and cries. The pupils are as a rule con- 
 tracted, and very often to a greater degree upon one side than upon the 
 other. Kernig's sign is present. 
 
 Transitional Stage. — The signs of irritation gradually and irreg- 
 ularly subside. The vomiting ceases, the belly becomes retracted and 
 scaphoid, and constipation is stubborn. Headache is replaced by dulness, 
 stupor, and occasional delirium. The retraction of the neck continues, 
 the pupils are dilated and irregular, and strabismus is common. There 
 may be convulsions, or rigidity of various muscle groups. The respiration 
 is at times sighing and irregular, and when disturbed the child utters the 
 sudden, shrill cry so often heard in the disease. The temperature is irreg- 
 ular and atypical. Irregular patches of erythema are noted, and if the 
 skin is tapped with the finger-tip, or the nail drawn across it, a vivid red 
 spot or line shortly appears and only slowly fades — tache cerebrale — a 
 sign of little diagnostic value since it occurs in enteric fever, hysteria, and 
 other conditions in which there is relaxation of the peripheral vessels. 
 
 Stage of Paralysis. — The stupor deepens to coma and the patient 
 cannot be aroused. Muscular spasms occur and there ma}^ be general 
 convulsions. The pupils are dilated and irresponsive to light; there is 
 paralysis of ocular muscles, and ophthalmoscopic examination reveals 
 optic neuritis. Tubercles in the choroid are by no means always seen. 
 Tetanoid contractions, cataleptic states, tremor, and athetoid movements 
 occur, and in some cases there are hemiplegias or monoplegias. Aphasia 
 may occur. The pulse now becomes rapid and feeble, and the symptom- 
 complex known as the typhoid state, with dry tongue, muttering delirium, 
 involuntary discharges, and subnormal temperature, develops. The dura- 
 tion of the attack varies from two to four or five weeks. There is sometimes 
 a pre-agonistic rise of temperature. 
 
 A moderate leucocytosis is usually present during the whole course 
 of the attack. There are cases which begin with great abruptness and 
 intensity, in persons apparently in good health, and run their course in a 
 few days; on the other hand there are cases which run a chronic course, 
 with anomalous symptoms suggestive of tumor of the brain. 
 
792 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — The direct diagnosis of tuberculous meningitis rests upon 
 the presence of the signs of a local tuberculous process, the mode of 
 onset, which differs from that of cerebrospinal fever, the course of the 
 disease, and the results of lumbar puncture. The fluid withdrawn is usually 
 turbid and often contains tubercle bacilli. It is sometimes sterile. 
 
 Differential Diagnosis. — For the details of the differential diagnosis 
 between tuberculous meningitis and pneumococcus and streptococcus 
 meningitis and cerebrospinal fever see Cerebrospinal Fever. 
 
 B. Tuberculosis of the Lymph=nodes — Scrofula. 
 
 Tuberculosis of the lymph-nodes is more common in children than 
 in adults, but it occasionally occurs in middle life and infrequently in per- 
 sons of advanced age. Catarrhal inflammation of mucous membranes, 
 by which their resistance is impaired, is probably the most important 
 predisposing factor in this form of tuberculous disease. Tonsillitis and 
 nasopharyngeal catarrh doubtless stand in a causal relation to the cervical 
 adenitis so common in childhood; measles, pertussis, and recurrent attacks 
 of catarrhal bronchitis, to tuberculosis of the bronchial glands; and the 
 intestinal diseases to which infants are prone afford the gateway of infec- 
 tion of the mesenteric glands. 
 
 Glandular tuberculosis is very commonly a local form of the disease. 
 There is a remarkable tendency to encapsulation and latency. The deposi- 
 tion of lime salts is common. A long quiescent bronchial gland may become 
 the source of a local or general tuberculous process. 
 
 Varieties.— (a) Generalized, and (b) local tuberculosis of the 
 lymph-nodes are to be considered. 
 
 (a) The Generalized Form.— A form, of the disease in children char- 
 acterized by the successive implication of groups of glands, and terminat- 
 ing in a general tuberculous cachexia or in meningitis has been described. 
 
 (b) Local Tuberculous Adenitis. — The groups usually affected are, 
 in the order of their frequency, the cervical, the tracheobronchial, and the 
 mesenteric. The cervical glands are very frequently involved. The chil- 
 dren of the poor, and especially the negro, mostly suffer, but those living 
 in affluence do not wholly escape. Chronic rhinitis, tonsillitis, otitis media, 
 eczema capitis vel faciei, conjunctivitis, or keratitis may afford the port of 
 entry for the infection. 
 
 Cervical Glands. — Symptoms. — The submaxillary glands are most fre- 
 quently and usually first involved. The posterior cervical chain, the 
 glands above the clavicle, and the axillary glands are also affected in 
 many cases. The disease may affect one or both sides; when both, to a 
 much greater extent on one than the other. The bronchial glands may 
 also be tuberculous. Infection of the pleurae or lungs may subsequently 
 take place. The enlarged glands may at first be felt as discrete, smooth, 
 firm, and somewhat elastic tumors, over which the skin is freely movable. 
 They rapidly enlarge and coalesce, forming large disfiguring masses to 
 which the overlying skin becomes adherent, with subsequent inflamma- 
 tion and suppuration. If the resulting abscess be not opened, it breaks, 
 leaving a sinus which heals slowly, followed by a characteristic, retracted. 
 
TUBERCULOSIS. 
 
 793 
 
 unsightly scar. Fever is usually present during the active stage of the 
 process and the patient is anaemic. The process is slow, but many of the 
 cases, especially in children, ultimately recover. 
 
 Diagnosis. — Direct. — Indolent glandular enlargements in the neck 
 and axillary region, more marked on one side than the other, becoming 
 adherent and slowly softening with abscess formation, are usually tuber- 
 culous, especially in children who suffer from local catarrhal or inflam- 
 matory diseases of the upper air-passages, otitis media, eczema of the 
 head or face, chronic conjunctivitis or keratitis, or tuberculous disease in 
 other parts of the bod}'. 
 
 Differential. — Slight cervical adenitis occurs in connection with various 
 catarrhal processes and the exanthemata. As a rule these enlargements 
 gradually undergo resolution as the 
 primary disease subsides. Sometimes 
 they suppurate. This shorter course of 
 the process, the association with acute 
 disease, and the slighter degree of en- 
 largement are of diagnostic importance. 
 
 Hodgkin's disease may at first be 
 very difficult to recognize. The greater 
 frequency of tuberculous adenitis in 
 children, the early implication of the 
 glands in the submaxillary region, the 
 slow development, the tendency to 
 inflammatory adhesions among the 
 glands themselves and to the skin, and 
 to suppuration and abscess formation, 
 are in favor of the tuberculous nature 
 of the process. Limitation to a group 
 of glands, as the cervical or axillary, or to one side, is much more 
 common in tuberculous adenitis than in Hodgkin's disease. 
 
 Tracheobronchial Glands. — This form of tuberculosis is very common 
 in young children, and particularly so in the inmates of foundling asylums, 
 orphanages, and similar institutions. The glands may attain large size. 
 The trachea and bronchi may be flattened, and pressure may be exerted 
 upon the superior cava, the pulmonary artery, and the azygos vein. 
 The softening caseous contents of the glands may perforate into the 
 bronchi or trachea and cause asphyxia; into the great vessels with gen- 
 eral infection of the blood stream, or very rarely into the oesophagus. 
 Pulmonary infection very often occurs either by contiguity of tissue or 
 along the root of the lung. Pericardial tuberculosis may occur. 
 
 Symptoms. — Pressure symptoms occur, but they are less common and 
 less urgent than the anatomical conditions suggest. The enlarged mass 
 constitutes one of the forms of mediastinal tumor. Dyspnoea, paroxysmal, 
 brassy cough from pressure on the recurrent laryngeal nerves, cyanosis and 
 puffiness of the face from pressure on the superior cava, dysphagia from com- 
 pression of the oesophagus, are occasional symptoms. In the majority of 
 cases the mechanical disturbance is slight or absent altogether. Nor are defi- 
 nite physical signs common. Impaired resonance upon light percussion over 
 
 Fig. 274. — Chronic cervical adenitis. 
 
794 MEDICAL DIAGNOSIS. 
 
 the manubrium sterni may be noted, and slight relative dulness along the 
 spine in the upper dorsal region. These physical signs are, however, neither 
 so constant nor so well marked as to serve a useful purpose in the diagnosis. 
 
 Mesenteric QIands — Tabes Mesenterica. — A slight enlargement is com- 
 mon and may not give rise to special symptoms. As a rule the enlargement 
 is general and attains considerable size. The retroperitoneal glands are often 
 coincidently involved. Caseation and softening occur. Resorption of the 
 fluid portions and the deposition of lime salts sometimes take place. The 
 tuberculosis may be primary, infection having arisen by way of the 
 lesions of intestinal catarrh, or it may be secondary to tuberculous lesions 
 of the bowel. 
 
 Symptoms. — Tabes mesenterica is common in very young children. 
 The belly is enlarged and tympanitic; the enlarged glands cannot always 
 be felt; there is diarrhoea with thin, watery, and offensive stools. The 
 nutrition is deranged and the little patients are anaemic, puny, and wasted. 
 The superficial abdominal veins are often enlarged and conspicuous. There 
 is fever of hectic type. In a group of cases there is an associated tuber- 
 culous peritonitis, the belly is distended, firm, or doughy, and nodular 
 tumors may be felt. Massive tuberculous enlargement of the mesenteric 
 and retroperitoneal glands occasionally occurs in adults. 
 
 Diagnosis. — laired. — In young children the diagnosis is commonly 
 attended with no great difficulty. The appearance of the child is sug- 
 gestive. Sometimes the enlarged glands are palpable. Tuberculous 
 adenitis elsewhere, or the evidence of tuberculous disease of the lungs, is 
 of diagnostic importance. 
 
 Differential. — The diagnosis of the essential character of circum- 
 scribed tuberculous glandular masses in the abdomen, especially when they 
 are of considerable size, and in the adult without tuberculous disease of 
 the intestines, peritoneum, or lungs, is often attended with difficulty. The 
 differential diagnosis can in many of the cases only be reached by exclu- 
 sion and may even then remain in doubt. Tuberculin may be used. 
 
 C. Tuberculosis of the Serous Membranes. 
 
 General Tuberculosis of Serous Membranes. — The process may be 
 general, the pleurae, pericardium, and peritoneum being involved simul- 
 taneously or in rapid succession. There may be an acute miliary tuber- 
 culosis; a more chronic form with agglomeration of tuberculous material, 
 with caseation and inflammatory and suppurative lesions; and finally a 
 chronic proliferative process with firm tuberculous nodules, fibroid lesions, 
 great thickening of the membranes, and the absence of exudate. The 
 pericardium is less frequently involved than the pleurae and peritoneum. 
 
 Tuberculous Pleurisy. — The pleurisy may be acute, with fibrinous, 
 serofibrinous, purulent, or hemorrhagic exudate; or it may be chronic. 
 It is very often latent. Secondary and terminal forms occur. A rare form 
 of acute tuberculous pleurisy with ulceration and necrosis of the j^leura 
 has been described. Subacute cases with a serofibrinous exudate are very 
 common. They are almost constantly associated with circumscribed 
 tuberculous disease of the lungs, or with tracheobronchial adenitis. The 
 
TUBERCULOSIS. 
 
 795 
 
 exudate may become purulent. There are cases in which no signs of tuber- 
 culous disease can be found, in which after a period of latency varying from 
 a few weeks to many years, with excellent health, pulmonary or acute 
 miliary tuberculosis supervenes. The visceral pleura is always involved 
 in pulmonary tuberculosis extending to the periphery of the lung. Adhesions 
 with more or less thickening result. In the absence of protecting adhesions 
 a caseating mass in the lung may perforate the visceral pleura and cause 
 pyopneumothorax. Finally there is a chronic adhesive pleurisy with great 
 thickening and involvement of the interlobar pleura and the lung itself. 
 For the S3^mptomatology and diagnosis of tuberculous pleurisy see Pleurisy. 
 Tuberculosis of the Pericardium. — The process may be part of a gen- 
 eral miliary tuberculosis, or latent in cases of chronic tuberculosis or other 
 chronic disease, or it may cause a chronic adhesive pericarditis analogous 
 to the more common chronic adhesive pleurisy. There are acute cases 
 with fibrinous or plastic, serofibrinous, hemorrhagic, or purulent exudate, 
 and the ordinary symptoms of pericarditis, in which, in the absence of 
 tuberculous disease elsewhere, the true nature of the process cannot be 
 recognized intra vitarn. (See Pericarditis.) 
 
 Fig. 275. — Tuberculous peritonitis. Outline indicates a hard mass which was found on operation to consist 
 of areas of nodules matting together the intestines. — Rotch. 
 
 Tuberculosis of the Peritoneum. — There may be diffuse miliary 
 tuberculosis or circumscribed areas corresponding to tuberculous ulcera- 
 tion of the intestine, acute miliary tuberculosis with serofibrinous or 
 bloody exudate, chronic tuberculosis with agglomerations of tuberculous 
 tissue undergoing caseation and necrosis, chronic proliferative or fibroid 
 peritonitis with extensive adhesions and thickening of the capsule of the 
 liver and spleen. The infection takes place by way of the intestines, espe- 
 cially in children, and in adults is propagated from the Fallopian tubes or 
 the seminal vesicles, prostate, or testicle. In by far the largest proportion 
 of cases infection of the peritoneum is secondary to tuberculosis of the 
 lungs or pleura. Tuberculous peritonitis has been known to follow contu- 
 sion of the abdomen; it sometimes has its starting point in the hernial sac 
 and often constitutes a terminal condition in chronic visceral disease, 
 especially cirrhosis of the liver. 
 
 Symptoms. — Tuberculosis of the peritoneum presents peculiar clinical 
 phenomena which serve to distinguish it from peritonitis due to other causes. 
 
 The disease may be latent and discovered only upon operation, or 
 post mortem. In other cases the onset may be sudden with urgent symp- 
 toms, as fever, vomiting, pain, and tenderness. There are cases in which 
 the onset and early symptoms suggest enteric fever. 
 
796 MEDICAL DIAGNOSIS. 
 
 Fever occurs in the acute cases and the temperature often reaches 
 104° F. (40° C.) or more; in many of the cases the rise is only to sub- 
 febrile ranges — 100° F. (37.8° C). In the chronic cases fever is absent 
 and subnormal temperatures often occur. The pulse is variable and, in 
 the absence of fever, of moderate frequency. Tympanitis is common in the 
 acute cases, but in the chronic form the belly may be small and doughy. 
 Ascites of small amount is common; it is usually serous, but may be 
 purulent or hemorrhagic, and is sacculated from the beginning, or soon 
 becomes so. A diffuse pigmentation of the skin may suggest Addison's 
 disease. Irregular attacks of pain associated with fever and digestive dis- 
 turbance occur, and tenderness upon pressure is a more or less continuous 
 symptom. Dense infiltration of the omentum with tubercles and fibrinous 
 exudation may convert that structure into a thick, cord-like mass adherent 
 to the transverse colon and extending across the abdomen. This tumor- 
 like omental thickening may b^ recognized upon palpation. Similar masses 
 may be felt in other parts of the abdomen. Sacculated fluid exudates con- 
 fined by adhesions among the abdominal or pelvic organs, the mesentery, 
 and the walls, form cyst-like tumors which suggest ovarian or other cysts 
 and often lead to errors in diagnosis. 
 
 Less frequently the mesentery of the small intestine, the root of which 
 extends in an oblique direction from the lumbar vertebrae to the right sacro- 
 ihac symphysis, undergoes thickening and retraction, which is associated with 
 great shortening of the intestine and thickening of its walls in such a manner 
 that the bowel is drawn together into a tumor-like mass occupying the right 
 side of the abdomen. These changes may be so extensive as to involve the 
 bowel in its entire length. Massive enlargement of the mesenteric glands is 
 very often present in tuberculous peritonitis, especially in children. 
 
 Diagnosis. — The direct diagnosis of tuberculosis of the peritoneum is 
 attended with much difficulty in the acute cases with sudden onset, great 
 pain and tenderness, rigidity of the abdominal muscles, vomiting, and 
 fever. The presence of tuberculous lesions elsewhere, and in particular at 
 the apex of one lung, in the pleurae, bones, or genito-urinary tract, is of 
 great diagnostic importance. In this group of cases prompt operative 
 measures are indicated, not only in order to clear up the uncertainty as to 
 the causal conditions — surgical diagnosis — but also as the only curative 
 measure which yields promise of relief in several of the conditions, as per- 
 foration of the bowel or other hollow viscus, or the rupture of an abscess or 
 cyst, which cause acute peritonitis with precisely the same symptoms. 
 In the subacute forms the direct diagnosis cannot always be made. Per- 
 sistent abdominal symptoms in a tuberculous individual constitute suffi- 
 cient ground for a provisional diagnosis, which the subsequent course of 
 the case will frequently confirm. Many of the subacute cases are latent. 
 
 The diagnosis in the chronic forms depends upon the presence of the 
 general symptoms of chronic peritonitis, the recognition of tuberculous 
 foci in other parts of the body, encysted fluid exudate, or irregular tumor- 
 like masses within the abdomen, the tuberculin test, which may be used in 
 any doubtful case unattended by fever or with fever of only moderate range, 
 and the finding of tubercle bacilli in the fluid obtained by paracentesis, 
 or a positive reaction to the injection of such fluid into guinea-pigs. 
 
TUBERCULOSIS. 797 
 
 Differential. — The points of discrimination between peritonitis 
 due to other causes and tuberculous peritonitis have been indicated 
 in the foregoing paragraphs. Non-tuberculous neoplasms are usually 
 more local, circumscribed, and definite in their relation to the viscera, as 
 the kidneys, spleen, or hver. Fever is less apt to occur. But more impor- 
 tant still are the absence of prior or concurrent evidences of tuberculosis 
 elsewhere, and negative results of bacteriological tests. 
 
 The omental and intestinal tumors which occur in the chronic forms 
 are fairly distinctive and only lead to uncertainty in the case of malignant 
 disease. The differential diagnosis rests upon the anamnesis, the more rapid 
 wasting in cancer, and the differences in the cachexia of the two conditions. 
 
 Ovarian Cysts. — Errors of diagnosis are common. In some of the 
 cases of tuberculous peritonitis with encysted exudate the general health 
 is fairly well preserved. The physical signs may be similar in both condi- 
 tions. The contour in tuberculous pseudocysts is less regular; areas of 
 dulness upon percussion, or palpable nodular masses may be demonstrable. 
 
 Fig. 276. — Tympany due to tuberculous peritonitis. — German Hospital. 
 
 and changes in form or position may arise with variations in the amount of 
 gas in the coils of intestines. Depression of the vault of the vagina occurs 
 in both conditions. Tubal disease and nodular masses in one or both 
 ovarian regions are suggestive. Febrile outbreaks are common in tuber- 
 culosis, but rarely occur in non-inflammatory ovarian cysts. 
 
 Cirrhosis of the Liver. — If the ascites is so great as to interfere with 
 the palpation of the liver in a doubtful case, paracentesis is necessar}^ for 
 diagnostic purposes. A hemorrhagic fluid may be present in tuberculosis or 
 carcinoma. This occurrence, together with thickening of the peritoneum or 
 demonstrable tumors, or the evidence of tuberculosis or carcinoma in distant 
 organs is diagnostic. In a considerable proportion of the cases of hepatic 
 cirrhosis, tuberculosis of the peritoneum occurs as a terminal condition. 
 
 D. Tuberculosis of the Alimentary Canal. 
 
 Tuberculous lesions of the structures forming the digestive tract, 
 with the exception of the liver and intestines, are rare. 
 
 Lips, Tongue, and Mouth. — Tuberculous ulcers of these organs occur 
 in rare instances, mostly in association with laryngeal or pulmonary disease. 
 Upon the lips they are liable to be mistaken for chancre or epithelioma. 
 Tuberculous ulcers upon the tongue occur in the form of deep circumscribed 
 
798 MEDICAL DIAGNOSIS. 
 
 lesions, with well-defined but irregular borders and a caseous base. They 
 resist treatment, not being influenced by the iodides, and tend to spread. 
 The glands at the angle of the jaws are not enlarged. The salivary glands 
 are very rarely the seat of tuberculous infection. Tuberculosis of the hard 
 and soft ]3alate in rare instances is the result of the invasion of these struc- 
 tures from adjacent parts. The tonsils are frequently infected. There 
 may be superficial ulceration or diffuse infiltration with miliary tubercle. 
 Caseous depots may be present. Infection may take place by means of 
 tuberculous milk or other food, dust, or by the sputum in pulmonary 
 disease. The frequency of tuberculous cervical adenitis, especially in 
 children, finds an explanation in tonsillar disease. In ulcers of doubtful 
 character upon the lips and tongue, or elsewhere in the mouth, a portion of 
 the tissue may be excised for examination, or inoculations may be made. 
 In a suspicious ulcer of the tongue failure of the iodides and absence of 
 glandular involvement are against a diagnosis of syphihs. 
 
 Pharynx and CEsophagus. — In lar3'ngeal and chronic pulmonary 
 tuberculosis miliary tubercles and superficial ulceration frequently invade 
 the oropharynx. The latter condition, when associated with ulceration 
 of the epiglottis, is attended with great pain upon deglutition, and consti- 
 tutes a most distressing condition in laryngeal phthisis. Adenoid vegeta- 
 tions of the nasopharynx are in some instances infected. An extension 
 from the larynx may invade the upper part of the oesophagus. Rare cases 
 of tuberculous ulceration have been reported. 
 
 Stomach and Intestines. — Ulceration of the wall of the stomach is 
 a recognized pathological condition but the diagnosis cannot be made 
 during life, since the symptoms are the same as in ordinary peptic ulcer. 
 It has occasionally been observed post mortem in tuberculous subjects, 
 but non-tubercidous peptic ulcer is more liable to occur in those debili- 
 tated and rendered anaemic by tuberculous disease. The probability that 
 a peptic ulcer may become tuberculous is to be considered. Intestinal 
 tuberculosis may be primary, especially in children, and is then usually 
 followed by infection of the mesenteric glands or peritoneum. Primary 
 tuberculosis of the intestine in the adult is exceedingly rare. 
 
 Symptoms. — Irregular diarrhoea, colicky pains, and moderate fever 
 occur. Intestinal hemorrhage may be the initial symptom. Emaciation 
 and signs of tuberculosis of the lungs or elsewhere suggest the actual patho- 
 logical condition. There are cases in which the tuberculosis begins in the 
 csecal region, and the symptoms are circumscribed tenderness, slight 
 irregular fever, and diarrhoea alternating with constipation. When these 
 symptoms subside and recur after quiet intervals of varying duration, the 
 condition simulates a chronic appendicitis. Hemorrhage occurs and necrosis 
 may take place, causing peri-appendicular abscess or jDerforation into the 
 peritoneum. Thickening of the intestinal wall forms part of the process. 
 
 Secondary lesions are much more common. The lower portion of the 
 ileum and the large bowel are usually involved. Infection occurs by means 
 of the swallowed sputum, and the intestinal disease gives rise to trouble- 
 some and distressing symptoms in the later stages of many cases of phthisis. 
 The lymphatic glands are early involved and there is frequently extensive 
 ulceration of the mucous membrane of the small and large bowel. There 
 
TUBERCULOSIS. 799 
 
 may be ovoid ulcers in the ileum, corresponding to Peyer's patches, but as 
 a rule the tuberculous ulcer is transverse and in many cases annular. Its 
 borders and floor are thickened from the infiltration of tubercle, which 
 shows caseation at various points. The muscular coat is often involved, 
 patches of recent tubercles are seen upon the corresponding serosa, local 
 adhesions occur, forming knot-like masses among the intestinal coils, and 
 in rare instances perforation takes place. Sclerotic changes often proceed 
 side by side with caseation and necrosis, and lead to cicatrization, irregular 
 puckering, and stenosis. These lesions are sometimes localized in the 
 caecum and appendix, and form dense sausage-shaped tumors in the right 
 lower quadrant of the abdomen, slightly or not at all movable, painful 
 upon palpation, and suggestive of carcinoma. More extensive adhesions 
 and infiltration in this region sometimes occur, and in rare instances a fecal 
 fi-stula. Fistula in Ano — Anal Fistula. — This condition is in a large pro- 
 portion of the cases tuberculous and associated with pulmonary tuber- 
 culosis which is sometimes latent or obsolescent. Operation is occasionally 
 followed by a flaring of the lung trouble into activity, whether post hoc or 
 propter hoc cannot always be determined. This fact does not militate 
 against effectual operation by excision, since it is better to suffer from one 
 focus of tuberculosis than from two. 
 
 Secondary tuberculous ulceration of the intestine manifests itself 
 by a group of abdominal symptoms superadded to those of the 
 pre-existing disease, usually pulmonary. Less frequently the intestinal 
 lesions are secondary to tuberculosis of the peritoneum, the primary infec- 
 tion being in the lymph-nodes in children, or the genito-urinary tract in 
 adults of either sex. Abdominal pain, tenderness, loss of elasticity with 
 local doughiness or tumor formation, particularly in the right iliac region, 
 diarrhoea often alternating with constipation, and later the signs of stenosis 
 of the bowel, namely, local bloating, smooth sausage-shaped tumors indicat- 
 ing the contour of the distended gut, and stormy peristalsis, make up the 
 clinical picture. In the rare cases in which the obstruction becomes com- 
 plete the ominous characteristic symptoms of occlusion of the bowel 
 (q.v.) appear. 
 
 Diagnosis. — The direct diagnosis of primary tuberculosis of the 
 intestine cannot always be made even in children. It depends upon heredi- 
 tary predisposition, the possibility of feeding upon the milk of tuberculous 
 cows, irregular high fever, rapid emaciation and loss of strength, and the 
 presence in the stools of many tubercle bacilli upon repeated examination. 
 Secondary lesions may be diagnosticated when persistent abdominal symp- 
 toms, not yielding to treatment, come on in the course of pulmonary con- 
 sumption or local tuberculosis in other parts of the body, and in particular 
 when there are also localized physical signs indicative of intestinal thickening, 
 kinking, or obstruction. If fecal fistula develops and tubercle bacilli are 
 found in the discharge as well as in the stools, the diagnosis is positive. 
 
 Differential. — The discrimination between intestinal tuberculosis 
 and the conditions which resemble it cannot in all cases be made. Two 
 topics, however, demand especial mention — carcinoma and appendicitis. 
 
 Cachexia and pain occur as in carcinoma elsewhere. Fever is not a 
 prominent symptom. The temperature is on the contrary often subnormal. 
 
800 MEDICAL DIAGNOSIS. 
 
 Ribbon-shaped stools, foul-smelling stools in which blood, pus, and necrotic 
 fragments of the neoplasm are found, and the general symjjtoms of stenosis 
 are suggestive of cancer. Absence of tuberculosis elsewhere, negative 
 findings as to bacilli, and failure of the temperature rise after the injection 
 of tuberculin are of great diagnostic importance. 
 
 There are rare cases of tuberculosis of the caecum in which the process 
 invades the lymphoid tissue of the appendix — tuberculous appendicitis. 
 Primary attacks of appendicitis are so well characterized that the question 
 of tuberculosis does not enter into their consideration. The acute or sub- 
 acute character of the early symptoms even in the chronic cases would 
 appear in the anamnesis. Of diagnostic importance are other diffuse 
 abdominal symptoms, pain, tenderness, diarrhoea preceding the local 
 phenomena, and the coincidence of tuberculosis in other organs. It is not 
 to be forgotten that an attack of non-specific appendicitis may develop 
 in a tuberculous individual. 
 
 E. Tuberculosis of the Brain and Spinal Cord. 
 
 Tuberculosis occurs as an acute meningitis which, while chiefly basilar, 
 is almost always also spinal, and constitutes one of the manifestations of 
 the acute form of general or disseminated infection — acute miliary tuber- 
 culosis (q.v.); as a chronic meningo-encephalitis due to the development 
 of multiple tubercles, usually within circumscribed limits; and finally as 
 solitary tubercles (see p. 1260). 
 
 F. Tuberculosis of the Qenito=urinary Organs. 
 
 Tuberculosis of the genito-urinary tract is frequent and important. 
 Lesions have been observed in the foetus, and the occurrence of tuberculous 
 orchitis in very young children suggests the possibility of hereditary 
 transmission. In the preponderating majority of instances the disease is 
 secondary to disease of some distant organ, especially the lungs, and the 
 infection must be ascribed to transmission by way of the blood. In a 
 considerable proportion infection takes place from the peritoneum. Tubal 
 and vesical tuberculosis have, however, been observed in cases of intestinal 
 tuberculosis in which no evidence of the implication of the peritoneum 
 could be found. Less frequently the disease arises by direct infection from 
 the rectum to the bladder, or to the uterus or vagina, in consequence of 
 adhesions and fistula formation. Tuberculous abscesses in the pelvis may 
 be the source of infection of any of the genito-urinary organs. Vertebral 
 tuberculosis may implicate the kidney by direct extension. The possi- 
 bility of primary tuberculosis as the result of direct infection in sexual 
 intercourse appears very great. Whether or not accidental infection by 
 way of the vagina or urethra may take place from other sources, as infected 
 instruments or syringes, suppositories, or in digital examination, or by 
 transmission from the rectum by way of the clothing has not been fully 
 estabhshed. The infection may involve any of the tissues of the genito- 
 urinary system. It often extends rapidly, and in some cases there are 
 manifestations of the disease at different points at the same time. 
 
TUBERCULOSIS. 801 
 
 Tuberculosis of the Kidneys. — The disease may be secondary. In 
 acute general tuberculosis scattered tubercles are present in the substance 
 and upon the surface of the kidneys. In pulmonary tuberculosis there 
 may be scattered nodules, or pyelitis. Primary tuberculosis of the kidney 
 also occurs. In many of the cases the lesions are at the same time present 
 in the kidneys, extending to the pelvis and uterus, and in the bladder, 
 prostate, and seminal vesicles, and the seat of primary invasion is uncertain. 
 Renal tuberculosis is most frequent in middle life but may be met with at 
 any age. Males suffer much more frequently than females. 
 
 Symptoms. — The urine contains pus in varying amounts. There is 
 increased frequency of micturition. These symptoms often go on for 
 years without abnormal subjective sensations and with maintenance of 
 the general health. There may be tenderness upon firm pressure. In 
 exceptional cases the kidney may be greatly enlarged, or there may be 
 a pyonephrosis. Under such circumstances there may be a palpable 
 abdominal tumor. The urine is albuminous, and in addition to pus-cells 
 contains epithelium and granular debris. Tube-casts are not very common. 
 Tubercle bacilli are present. Hemorrhage may occur. As the disease 
 advances the other kidney becomes involved, and a tuberculous cachexia 
 with chills, irregular fever, sweating, and emaciation and progressive 
 asthenia ensues. The lungs are implicated and an acute disseminated 
 miliary tuberculosis occurs as a terminal event. Encysted caseous or 
 calcareous masses in the kidney are occasionally found in the post-mortem 
 room and point to the possibility of spontaneous cure. 
 
 Diagnosis. — Direct. — The above symptoms, associated with the 
 evidence of tuberculosis in the testicle or prostate, or in the tubes or 
 ovaries, the presence of tubercle bacilli in the urine, and a positive reac- 
 tion to the tuberculin test, justify a positive diagnosis. The differentiation 
 of the urine by catheterization of the ureters renders possible a diagnosis 
 of the kidney affected. The urine may contain bacilli from tuberculous 
 lesions in the bladder or elsewhere in the genito-urinary tract, and the fact 
 that the morphological and tinctorial characters of the smegma bacillus 
 are practically the same as those of the tubercle bacillus is to be borne in 
 mind. The specimen for examination in a doubtful case must be obtained 
 by catheterization under the strictest precautions against contamination, 
 and the possibility that even then smegma bacilli may be accidentally 
 present must not be forgotten. Inoculation tuberculosis caused by the 
 urinary sediment is proof positive of genito-urinary tuberculosis, but not 
 necessarily of tuberculosis of the kidney. 
 
 Differential. — It may be difficult to difTerentiate tuberculous pye- 
 lonephritis from calculous pyehtis. A history of attacks of renal colic, 
 various forms of crystalline sediment and blood-cells in the urine, or actual 
 hemorrhage, are in favor of the latter. Hemorrhage is much less common 
 in tuberculosis of the kidneys. 
 
 Suprarenal Capsules. — Tuberculosis of the adrenals with fibrocaseous 
 lesions is the most common anatomical change found in Addison's disease, 
 and may manifest itself by the symptoms of that disease (q.v.). 
 
 Tuberculosis of the Ureters and Bladder. — The symptoms of renal 
 tuberculosis are those of cystitis, and infection of the bladder is usually 
 secondary to infection of the kidneys on the one hand, or of the testes, 
 
 51 
 
802 MEDICAL DIAGNOSIS. 
 
 prostate, or seminal vesicles on the other. The process very often invades 
 the ureters from the pelvis of the kidney. Primary tuberculosis of the 
 bladder is a rare affection. 
 
 Tuberculosis of the Prostate and Seminal Vesicles. — These organs 
 are frequently the seat of tuberculous growths and caseous nodules. The 
 prostate is often found upon digital examination to be enlarged and nodular. 
 It is sometimes tender. There is great irritabihty of the bladder, vesical 
 tenesmus, frequent micturition or retention of urine, in which case the use 
 of the catheter is attended with great pain. Tuberculosis of the urethra 
 is rare. It may present the symptoms of stricture. 
 
 Tuberculosis of the Testes.— The diagnosis is usually unattended with 
 difficulty because the organ is accessible and the changes are somewhat char- 
 acteristic. The disease occurs in infants as well as in adults. One or both 
 testicles may be involved. It may be primary, but in most cases is second- 
 ary to pulmonary or other visceral or bone tuberculosis. It is frequently 
 associated with tuberculous peritonitis. The tuberculous testicle may be 
 recognized by the enlargement which principally affects the epididymis, 
 pain, tenderness, and only a moderately uneven surface. 
 
 The DIFFERENTIAL DIAGNOSIS between tuberculous and syphilitic dis- 
 ease of the testicle may be attended with uncertainty. In the latter, pain 
 and tenderness may be absent, the testicle itself rather small, the epididymis 
 involved, and the surface, owing to the agglomeration and various size of 
 the gummata, is more nodular and uneven. 
 
 Tuberculosis of the Fallopian Tubes and Ovaries. — The tubes are 
 very frequently affected. The disease is often primary. There is enlarge- 
 ment with great thickening and infiltration of the walls, upon which, in 
 some cases, irregularities of the surface ma}^ be felt. It may occur in chil- 
 dren and young girls, and is usually bilateral. The ovaries are secondarily 
 involved. Abscess formation and the extension to the peritoneum are 
 common. Implication of the uterus is extremely rare. 
 
 Diagnosis. — Direct. — This rests upon the local findings, such as enlarge- 
 ment and irregular thickening of the tubes, evidences of adhesions, s gns of 
 peritoneal tuberculosis or pulmonary phthisis, anaemia, loss of M^eight, fever 
 in the evening upon moderate exertion and at the menstrual period. 
 
 Differential. — Gonorrhceal salpingitis may be present without 
 serious derangement of the general health. The enlargement of the 
 tubes is not attended with the same degree of infiltration or irregularity 
 of the surface, the anamnesis is suggestive, and the presence of gonococci 
 in the discharges conclusive. 
 
 Tuberculosis of the Liver, Spleen, Myocardium, Endocardium, and 
 Arteries cannot be recognized with certainty during life. These forms of vis- 
 ceral tuberculosis are therefore rather of anatomical than of clinical interest. 
 
 G. Tuberculosis of the Lungs. 
 
 Pulmonary Tuberculosis; Phthisis; Consumption. 
 
 Varieties. — (a) Acute pneumonic phthisis; (b) chronic ulcerative 
 phthisis, and (c) fibroid phthisis. 
 
TUBERCULOSIS. 803 
 
 (a) ACUTE PNEUMONIC PHTHISIS. 
 
 According to the distribution of the lesions two types are recognized, 
 the pneumonic and the bronchopneumonic. 
 
 The Pneumonic Form. — A single lobe or an entire lung may be 
 involved. This form is much more common in adults than children, and 
 in males than females. 
 
 Symptoms. — The onset is usually abrupt, with a chill followed by 
 high fever, pain in the side, cough, and expectoration, at first scanty and 
 mucoid, later more abundant, often frothy and blood-stained. The attack 
 frequently occurs in the midst of apparent health; occasionally during the 
 course of an apparently ordinary mild influenza or "cold," and some- 
 times in an individual who has a tuberculous lesion regarded as obsolescent. 
 The respiration is rapid and dyspnoea may be urgent; the pulse is frequent 
 and variable. The physical signs are those of croupous pneumonia, feeble 
 vesicular murmur, with crepitus, later dulness, increased vocal fremitus, 
 and bronchial breathing. They correspond to the limits of a lobe or to a 
 whole lung, and when, as is often the case, they are also, in the course of 
 some days, found upon the opposite side the clinical picture is that of a 
 double pneumonia. 
 
 Diagnosis. — The direct diagnosis rests upon the course of the attack 
 and the finding of tubercle bacilli in the sputa. The latter have been 
 observed as early as the fourth day. As a rule their presence is not noted 
 until later. Fibres of elastic tissue constitute the signs of necrosis of the 
 pulmonary structure. The following clinical manifestations are suggestive 
 and should arouse a suspicion as to the character of the process: hereditary 
 predisposition to tuberculous infection; individual history of tuberculous 
 infection which may have remained subacute or become quiescent; physical 
 depression preceding the outbreak, especially if accompanied by cough 
 and expectoration; an irregular temperature range conforming rather to 
 the remittent than the continuous type; recurrent chills; circumscribed 
 patches of high-pitched, ringing, coarse crepitant rales persisting for 
 several days with but little change; a mucopurulent greenish expectora- 
 tion, and extremely feeble breath sounds over the affected region. 
 
 The DIFFERENTIAL DIAGNOSIS between acute pneumonic tuberculosis 
 and croupous pneumonia cannot be made in a large proportion of the cases 
 during the first week. There is, in truth, usually no suspicion that the case 
 is not one of ordinary pneumonia until even a longer time has elapsed. 
 
 Prognosis. — The outlook is in the highest degree unfavorable. Death 
 has occurred as early as the sixth day, more commonly after three or four 
 weeks, or as late as the second or third month. In a limited number of 
 cases the acute symptoms gradually subside and the case becomes one of 
 chronic phthisis. 
 
 The Bronchopneumonic Form. — The lesions are those of an acute case- 
 ous bronchopneumonia. Groups of lobules are affected, with crepitant tissue 
 intervening, but extensive areas or even an entire lobe may be involved. 
 
 A second form is due to the aspiration of blood and the contents of 
 tuberculous cavities into the finer bronchial tubes during haemoptysis 
 — tuberculous aspiration pneumonia. This condition may follow early 
 
804 MEDICAL DIAGNOSIS. 
 
 haemoptysis, which has not been preceded by marked symptoms, or 
 occur after hgemoptysis in the course of a chronic tuberculosis. 
 
 In a third form the caseous bronchopneumonia involves lobules at 
 both apices and in other parts of the lungs, causing patches of consolida- 
 tion varying in diameter from 1 to 3 or 4 cm. and sometimes scattered 
 uniformly throughout both lungs. 
 
 Symptoms. — These are the forms which constitute a majority of the 
 cases of acute pulmonary tuberculosis — phthisis Jiorida or galloping con- 
 sumption. They are common in adults but far more common in children. 
 The clinical picture varies greatly. In adults the disease may develop in 
 persons apparently well or in those who have been failing in weight and 
 strength. The onset is rapid but not abrupt. There are irregular chills, 
 fever of hectic type, sweating, loss of appetite, cough, and expectoration 
 which is usually slight. Blood spitting is sometimes the first event to 
 attract attention. The pulse and respiration frequency are high, and loss of 
 weight and strength is rapid and progressive. The physical signs may be 
 at first obscure, but presently diminished expansion, patchy dulness, 
 especially at an apex, vesiculobronchial respiration, and moist crepitant 
 and small mucous rales occur. The disease affects one, more commonly 
 both lungs. Tubercle bacilli and fibres of elastic tissue are present in the 
 sputa, often at an early date. The symptoms become more intense, and in 
 the course of two or three weeks in the more acute cases the patient falls 
 into the so-called typhoid state, with stupor, delirium, dry tongue, and 
 high fever. Meanwhile the physical signs, more extensive dulness, bronchial 
 breathing, high-pitched and coarser rales, indicate the extension and prog- 
 ress of the lesions. In some cases, however, the signs are obscured by the 
 development of areas of collateral emphysema. Softening may occur with 
 cavity formation and corresponding changes in the physical signs. In 
 children this form of pulmonary tuberculosis may arise as an independent 
 disease. Much more commonly it follows an acute infection, especially 
 measles and pertussis. In a majority of the cases the bronchopneumonia 
 which occurs as a sequel to diseases of this group is tuberculous. 
 
 Diagnosis. — The direct diagnosis of acute bronchopneumonic phthisis 
 rests upon the association of the foregoing symptoms and physical signs 
 with the presence of elastic fibi*es and tubercle bacilli in the sputa. 
 
 The DIFFERENTIAL DIAGNOSIS between tuberculous and non-tuberculous 
 bronchopneumonia is, in the early stages of the disease, and especially in 
 children, often impossible. Later the presence of elastic-tissue elements 
 and tubercle bacilli are decisive. Meanwhile the anamnesis is important. 
 A hereditary predisposition, association with individuals who are tuber- 
 culous, or dwelling in an infected house, or enlarged superficial lymphatics, 
 or a history of symptoms or signs indicative of enlarged bronchial glands 
 is important. The signs of marked apical lesions are highly suggestive 
 of tuberculous disease, but diffuse tuberculous bronchopneumonia may 
 occur without marked apex consolidation. 
 
 Prognosis. — The outlook is in the highest degree unfavorable. In adults 
 death may occur in the course of three or four weeks; in children within a 
 few days. There are cases, however, in which the disease runs a somewhat 
 more protracted course, and a limited number, both in adults and children, in 
 
TUBERCULOSIS. 805 
 
 which after the gravest symptoms the condition of the patient undergoes 
 some improvement and the case gradually passes into one of chronic phthisis. 
 
 (b) CHRONIC ULCERATIVE PHTHISIS. 
 
 This is the common form of chronic pulmonary tuberculosis. 
 
 The lesions vary greatly in kind, distribution, and extent. They 
 comprise nodular and miliary tubercles, tuberculous bronchopneumonia, 
 pneumonic inflammation of the vesicular structure surrounding the tuber- 
 cles, frequently presenting the appearance of ordinary red hepatization, 
 sometimes the more uniform diffuse tuberculous infiltration, cavities of 
 various size, together with collateral emphysema and changes in the 
 bronchi and bronchial glands and in the pleura, with firm, thick adhesions 
 or effusion, which may be serofibrinous, purulent, or hemorrhagic. The 
 tendency is, (a) to caseation, softening, ulceration, necrosis, and cavity 
 formation, and (b) to sclerosis. The latter process may result in the forma- 
 tion of a limiting membrane, by which the lesion is encapsulated, or, when 
 extensive, in traction deformities of the chest, and bronchiectasis. 
 
 The fact that the primary lesion or lesions in pulmonar}'- tuberculosis of 
 the chronic ulcerative type are local and circumscribed is of the greatest prac- 
 tical importance both in diagnosis and prognosis; first, because it underlies 
 the clinical division of the cases into incipient and advanced, and second; 
 because cases referable to the first group are mostly amenable to treatment. 
 
 The distribution of the lesions is in a majority of the cases as follows: 
 The earliest lesions are situated, not at the extreme apex of the lung, but 2 
 to 4 cm. below it and nearer the posterior and lateral surfaces than the 
 anterior surfaces. Extension from this point is downward and forward, 
 the upper lobe being progressively involved in regions corresponding to 
 the first, second, and third interspaces, and spreadmg upon both sides of 
 the midclavicular line. Less commonly the primary lesion is found in the 
 upper lobe at a point corresponding to the first and second interspaces 
 below the outer third of the clavicle. As the process extends downward, 
 the anterolateral region of the lobe is involved. Invasion of the middle 
 lobe of the right lung is usually by extension from the upper lobe. Second- 
 ary implication of the lower lobe begins at a point 2 to 4 cm. below its 
 apex at the level of the fifth dorsal spine, and extends downward and out- 
 ward in a line roughly corresponding to the inner border of the scapula 
 when the patient's hand is placed upon the opposite shoulder and the elbow 
 raised as high as possible. In the course of time the upper lobe of the 
 opposite lung usually becomes involved, the earliest lesions appearing a 
 short distance below the actual apex and rapidly becoming diffused. The 
 right upper lobe is first involved somewhat more commonly than the left. 
 Primary implication of the base is rare. 
 
 In advanced cases miliary tuberculosis, visceral tuberculosis involving 
 various organs, amyloid disease, and fatty liver occur. 
 
 The extension of the lesions is, (a) peripherally by the direct invasion 
 of contiguous tissue; (b) radially by means of the lymph current; (c) 
 by conveyance along the bronchial system, (i) in the direction of adjacent 
 or distant vesicular structures — inhalation, insufflation; (ii) in the direction 
 
806 MEDICAL DIAGNOSIS. 
 
 of the upper air-passages — laryngeal ulceration; (d) by transference; e.g., 
 to the digestive tract— secondary pharyngeal, hngual, or intestinal tuber- 
 culosis; by dissemination, as in the case of the rupture of a gland or other 
 encapsulated focus into a serous cavity, or a blood-vessel — acute miliary 
 tuberculosis. 
 
 The progress of the lesions is variable. On the one hand, infiltration, 
 caseation, softening, ulceration, necrosis, proceeding at different rates in 
 different foci; while, on the other hand, sclerotic changes encapsulate and 
 limit the advance of the disease and tend to circumscribe the process. 
 
 Symptoms. — As the primary infection is local, there is usually a period 
 of latency. The patient is tuberculous before he is consumptive, and, in the 
 fortunate cases, he may be tuberculous without ever becoming consumptive. 
 
 The MODE OF ONSET is determined by the degree of activity of the 
 tuberculous process and the nature of the reaction of the infected individ- 
 ual. It may be characterized by latency, with indefinite symptoms not 
 suggestive of pulmonary disease, or masked by the symptoms of grave 
 disease in other organs, tuberculous or non-tuberculous. 
 
 G astro-intestinal Symptoms. — Loss of appetite, gastric irritability and 
 vomiting, acid eructations frequently precede the pulmonary symptoms 
 for a considerable time. The cough is regarded as "a, stomach cough." 
 
 Anaemia. — In children and adolescents, especially young girls, there 
 is early chloro-ansemia with pallor, progressive weakness, palpitation and 
 headache upon exertion, and slight afternoon fever. Menstrual irregular- 
 ities, especially amenorrhoea, are suggestive. 
 
 Ague-like Fever. — Constitutional symptoms, recurring chills, fever, and 
 sweating characterize the onset in a considerable group of cases. When 
 such paroxysms recur with regularity and with only shght cough and 
 expectoration, especially in a malarious region or in an individual who 
 has previously suffered from ague, a false diagnosis may readily be made. 
 
 Pleurisy. — The early phenomena may be those of a persistent dry 
 pleurisy, the signs of which are sometimes restricted to the apex, sometimes 
 more extended. In other cases the impairment of health begins with pleural 
 effusion. The resorption or aspiration of the fluid is sooner or later followed 
 by the signs of consohdation in an upper lobe, and the symptoms of phthisis. 
 Many of these cases are, in fact, pleurogenous, with secondary pulmonary 
 infection, and the early dry cough is that of pleural irritation. In some 
 cases the lung lesions rapidly develop; in others an interval of weeks, 
 months, or even years may occur. 
 
 Hcemoptysis. — Blood spitting may be the first indication of the disease. 
 An abundant hemorrhage is sometimes followed by the rapid develop- 
 ment of the signs of a diffuse tuberculosis. In other cases haemoptysis 
 recurs from time to time before the positive physical signs of pulmonary 
 disea e can be recognized. It is probable that the local lesions almost 
 always antedate the pulmonary hemorrhage. 
 
 Bronchitis. — The great majority of cases begin with the signs of a 
 catarrhal bronchitis. The patients often suffer from nasopharyngeal 
 catarrh and manifest an especial tendency to "catch cold." At length 
 the cough becomes persistent, there is habitual expectoration, especially 
 in the morning, and upon examination the rales, which are heard widely 
 
Tuberculosis. 807 
 
 over the chest, are found to be more abundant and moist and of higher 
 pitch over the upper part of one lung, where there is also relative dulness 
 and deficient expansion. 
 
 Chronic Bronchitis a7id Emphysema.- — The terminal tuberculosis so 
 common in these conditions is usually masked for a considerable time by 
 the symptoms and signs of the primary condition. This is especially the 
 case when there are asthmatic symptoms. 
 
 Laryngitis. — The symptoms of pulmonary phthisis are frequently 
 preceded by hoarseness, occasional aphonia, and a laryngeal cough. It is 
 probable that, in the majority of these cases, tuberculous lesions already 
 exist in the lungs. 
 
 Tuberculosis of the cervical and axillary .lymph-glands may precede the 
 development of pulmonary tuberculosis for a long time, or coexist with 
 quiescent lesions in the lungs. 
 
 Stages. — The attempt to divide the course of the attack into a stage 
 of the growth and development of tubercles, a stage of caseation and 
 softening, and a stage of cavity formation has fortunately been abandoned. 
 In the first place, as new foci of disease are constantly forming in advancing 
 cases, all three of these anatomical conditions are frequently present at the 
 same time; secondly, they do not correspond with definite clinical periods, 
 and, finally, a patient in the so-called third stage, with signs of cavit}'' 
 formation, is often in a more favorable condition, with better prospect 
 for the arrest of his disease, than another in the first stage, with extensive 
 and rapidly advancing infiltration or diffuse foci. 
 
 The following schema was adopted by the National Association for 
 the Study and Prevention of Tuberculosis in 1905: 
 
 Slight initial lesion in the form of infiltration limited to the 
 apex or a small part of one lobe. 
 
 No tuberealous complications. Slight or no constitutional 
 S5"mptoms (particularly including gastric or intestinal dis- 
 turbance or rapid loss of weight). 
 
 Slight or no elevation of temperature or acceleration of 
 pulse at any time during the twenty-four hours, especially 
 after rest. 
 
 Expectoration usually .small in amount or absent. 
 
 Tubercle bacilli may be present or absent. 
 
 C No marked impairment of function either local or constitu- 
 tional. 
 Moderately advanced J Localized con.solidation moderate in extent with Httle or 
 
 I no evidence of destruction of tissue ; 
 
 I Or disseminated fibroid deposits. 
 [ No serious complications. 
 
 f Marked impairment of function, local and constitutional. 
 
 Far advanced J Localized consolidation intense ; 
 
 I Or disseminated areas of softening ; 
 [ Or .serious complications. 
 
 Acute miliary tuberculo.sis 
 
 Unimproved All e.ssential symptoms and signs unabated or increased. 
 
 f Constitutional symptoms lessened or entirely absent; physi- 
 
 Improved j qh\ .signs improved or unchanged ; cough and expectora- 
 
 l tion with bacilli usually present. 
 
 IAb.sence of all con.stitutional symptoms : expectoration and 
 bacilli may or may not ht present ; i)hysical signs .station- 
 ary or retrogressive ; the foregoing conditions to have 
 existed for at least two months. 
 
 f All constitutional svmptoms and expectoration with bacilli 
 
 Apparently cured J absent for a period of three months ; the i)hysical .signs to 
 
 t be those of a healed lesion. 
 
 _ C All constitutional symptoms and expectoration with bacilli 
 
 '^'^^" — i absent for a period of two years under ordinary conditions 
 
 I of life. 
 
 Incipient (favorable) 
 
808 MEDICAL DIAGNOSIS. 
 
 Trudeau's classification is as follows: 
 
 1. Incipient. — Cases in which both the physical and rational signs point to but slight 
 local and constitutional involvement. 
 
 2. Advanced. — Cases in which the localized disease process is either extensive or in an 
 advanced stage, or where, with a comparatively slight amount of pulmonary involvement, 
 the rational signs point to grave constitutional impairment or to some complication. 
 
 3. Far Advanced. — Cases in which both the rational and physical signs warrant the term. 
 
 4. Apparently Cured. — Cases in which the rational signs of phthisis and the bacilli in 
 the expectoration have been absent for at least three months or who have no expectora- 
 tion at all; any abnormal physical signs remaining being interpreted as indicative of a 
 healed lesion. 
 
 5. Arrested. — Cases in which cough, expectoration, and bacilli are still present, but in 
 which all constitutional disturbance has disappeared for several months; the physical 
 signs being interpreted as indicative of a retrogressive or arrested process, 
 
 "Closed" and ''Open" Pulmonary Tuhercidosis. — Too much stress 
 has been laid upon the importance of tubercle bacilli in the sputa in the 
 early diagnosis. These organisms do not appear until after the caseation 
 and softening of a tuberculous lesion situated near a bronchus or bron- 
 chiolus, into which tuberculous material finds its way by the necrosis of 
 the intervening tissue. The period prior to this event, which may extend 
 over weeks or months, or, in extreme cases, over years, is known as the 
 "closed period"; that which follows as the "open period." The -general 
 recognition of this distinction is desirable. 
 
 Symptoms of Incipient Pulmonary Tuberculosis. — The greater number 
 of these have already been described under the heading "mode of onset." 
 The association of haemic, circulatory, digestive, and nervous derangements 
 is especially important. 
 
 The ptdse is either persistently frequent but regular, or subject to 
 abnormal acceleration upon physical effort or mental excitement. The 
 temperature shows slight elevation upon exertion, after meals, and before 
 and during menstruation. The observations must be taken every two 
 hours during the day, while the patient is in repose. Subfebrile ranges — 
 99.5° F. — are significant. Chest pains are common. They are of two 
 kinds, pleural pain over the seat of a lesion, and a dull shoulder pain extend- 
 ing down the arm and sometimes mistaken for rheumatism. The cough is 
 frequently short and dry, a troublesome hacking brought on by exertion 
 or excitement or changes of external temperature. Very often it occurs 
 only on rising in the morning and persists in paroxj^sms until a small, 
 tough mucoid mass is expectorated, after which it is absent for the rest of 
 the day. The Sputum. — There is little characteristic in the expectorated 
 material. It is usually at this stage of the disease merely a grayish sago- 
 like mucus, containing alveolar cells which have undergone the myelin 
 degeneration. In the closed stage tubercle bacilli are absent, though one 
 or two may, in rare instances, be found as the result of inhalation. Repeated 
 examinations are necessary. Their continuous presence in the sputum is 
 the positive sign of tuberculosis in the open stage. The examination may 
 yield negative results for long periods in cases of quiescent limited upper 
 lobe lesions, and then, after an attack of some acute affection, as influenza, 
 or, in the midst of apparent health, bacilli may appear suddenly and last 
 a short time — transient open tuberculosis. Elastic fibres are not often 
 encountered in the incipient stages. 
 
TUBERCULOSIS. 809 
 
 Hcemoptysis. — This accident occurs in about 70 per cent, of all cases 
 of phthisis at some period in the course of the disease. The haemoptysis 
 which occurs in the incipient stage differs from that in the advanced stages 
 in being, as a rule, slight, recurrent, and due to oozing from patches of 
 acute congestion surrounding closed tuberculous foci, or to superficial 
 erosions of bronchial mucosa. In advanced phthisis the bleeding is due to 
 the erosion of a vessel in the wall of a cavity, or the rupture of an aneurism 
 of a branch of the pulmonary artery. It is usually profuse and not rarely 
 fatal. The expectorated blood in early haemoptysis — closed tuberculosis — 
 does not usually contain tubercle bacilli; that in the advanced stages is 
 often followed by expectoration containing those organisms. Large initial 
 blood spittings may, in rare instances, usher in the open stage and be 
 associated with bacillary sputum. 
 
 General Nutrition and Weight. — The toxins which give rise to anaemia, 
 vasomotor derangements, pseudodyspepsia, fever, and nervous erethism 
 interfere with nutritive processes and cause loss of weight which is often 
 rapid and striking. 
 
 Associated Diseases. — The patients are especially prone to catarrhal and 
 other inflammatory outbreaks. Coryza, laryngitis, bronchitis, pneumonia, 
 and pleurisy are common and may recur repeatedly in the same patient. 
 
 Hoarseness, due to subacute laryngeal catarrh with slight abductor 
 paresis, may be an early symptom. Actual paralysis of the recurrent is 
 less common. It may be due to pleural adhesions or to pressure upon the 
 recurrent by tuberculous lymph-glands. It much more frequently occurs 
 upon the left side. Phenomena of inferior importance are unequal dilata- 
 tion of the pupils, a reddish or bluish gingival hne, slight or transient enlarge- 
 ment of the thyroid gland, and albuminuria. 
 
 The Physical Signs in Incipient Pulmonary Tuberculosis. — Inspection 
 reveals very early a retarded and shghtly diminished respiratory excursus 
 in the infraclavicular region of the affected side. This sign may, in some 
 cases, be earlier detected by palpation. The vocal fremitus may also be 
 slightly increased. Percussion may show quite early relative dulness, often 
 slight but recognizable by the higher pitch and shorter duration of the 
 sound, and a slightly tympanitic quality. Auscultation yields even more 
 suggestive signs. There is an early deviation from the normal type of 
 breathing. The first change consists in the development of the quality 
 described as rough. The inspiratory murmur is enfeebled. Cog-wheel 
 or interrupted breathing is occasionally heard in the region imme- 
 diately adjacent to and below the portion of the lung involved. This 
 may, however, occur in other conditions. Moist crepitant and small mucous 
 rales are early signs, but in many cases they remain long absent. Rales, 
 not heard upon full inspiration, even full inspiration after coughing, may 
 in some cases be ehcited by a full inspiration followed by forced expiration, 
 with cough at the end of the latter. The rough breathing is presently 
 replaced by vesiculobronchial respiration which, as the lesion progresses, 
 becomes bronchovesicular and, later, as consolidation becomes complete — 
 advanced stage — bronchial. Pleural friction sounds of varjang quality 
 and intensity may often be heard over the affected region. They are some- 
 times transient, sometimes persistent. Basal friction sounds are also occa- 
 
810 MEDICAL DIAGNOSIS. 
 
 sionally heard in the incipient stage. Less frequent but very suggestive 
 when present, is a subclavian systolic murmur, more common, as a rule, 
 upon inspiration, though occasionally heard with expiration. This loud 
 systolic whiff, due to traction upon the vessel wall by pleural adhesions, is 
 a very striking phenomenon. Extension of the absolute cardiac dulness 
 to the right or left, as the case may be, constitutes an important sign. 
 
 The Diagnosis of Incipient Pulmonary Tuberculosis. — Direct Diagnosis. 
 — In the absence of cough and expectoration a positive diagnosis can 
 rarely be made. When these phenomena are present, and especially when 
 tubercle bacilli are found, the question as to the nature of the process 
 is at once settled. From the standpoint of therapeutics the recognition of 
 phthisis in the closed stage is of such importance that, in a suspected case, 
 a provisional diagnosis constitutes a motive for immediate and systematic 
 treatment. This provisional diagnosis rests not upon any single rational 
 symptom or physical sign of the stage of incipiency, but upon the associa- 
 tion of several of them in an individual in whom no other pathological 
 process by which to explain them can be demonstrated. The anamnesis 
 is important. Family predisposition, close habitual association with tuber- 
 culous persons, an unfavorable occupation, an unhygienic life may appear 
 as etiological factors, but their absence has only a negative value. 
 
 The bodily conformation may be misleading. The classical habitus 
 phthisicus — the phthinoid or paralytic chest — is symptomatic of advanced, 
 not of incipient phthisis. Recurrent hoarseness, bronchitis, anaemia, 
 dyspepsia, loss of weight, fever, and haemoptysis are symptoms of great 
 moment. Among the physical signs, diminished and retarded respiratory 
 excursus of that part of the chest corresponding to the limited lesions, 
 diminished resonance with a faint tympanitic quality, rough or vesiculo- 
 bronchial respiration, and a few moist, clicking rales or a prolonged whizzing 
 rale at the end of the first two or three inspirations are highly significant. 
 It is to be remembered that in slowly advancing lesions the signs may be 
 obscured by collateral emphysema. Not less significant is the localization 
 of those signs in an infraclavicular or axillary region. The variation of 
 auscultatory signs must be remembered — the fact that rales are sometimes 
 heard only after cough, the frequent temporary disappearance of crepitus 
 after several deep inspirations, the tendency of rales to disappear late in 
 the day and in dry weather, and the intensification of auscultatory phe- 
 nomena during menstruation. Rosenberger claims that tubercle bacilli 
 can be found in the blood even when absent in the sputum. In 
 any case in which the symptoms and signs warrant a provisional diagnosis, 
 the patient milst be carefully instructed as to his mode of life, the necessity 
 of keeping himself under systematic observation, and the importance of 
 the repetition of the examination at stated intervals. 
 
 Differential Diagnosis. — The mode of onset is to be considered. 
 The patient is in failing health; has he the symptoms and signs of phthisis, 
 latent or marked? Are his symptoms those which the toxins of tubercu- 
 losis cause? Superficial examination and hasty observation will not dis- 
 cover the answer to these questions. Above all, the practitioner must 
 avoid the delusion that every paroxysmal fever is malarial and every cough 
 in a dyspeptic a "stomach cough." Pleurisy is highly suspicious. Prob- 
 
TUBERCULOSIS. 
 
 811 
 
 ably two-thirds of the cases of persistent fibrinous pleurisy or pleural 
 effusion ultimately become tuberculous. Malaria may be recognized by the 
 blood examination. Hcevioptysis is common in mitral disease, especially 
 stenosis, and many cases of valvular disease of the heart are diagnosticated 
 phthisis. This error may be avoided b}^ a routine physical examination, 
 which must in every case include the heart. Cervico-axillary adenitis may 
 long coexist with a fair degree of health. It is well, however, to watch the 
 
 
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 Fig. 277. — Subcutaneous tuberculin test. Positive reaction. 
 
 infraclavicular regions, especially upon the side in which the tuberculous 
 glands are situated. Laryngitis. — Persistent hoarseness with swelling of the 
 arytenoids and slight adductor paresis is frequently the phenomenon of 
 pulmonary phthisis. Recurrent catarrhal and inflammatory affections in the 
 respiratory tract are ominous, especially when there are hereditary or per- 
 sonal predisposing factors to tuberculous infection. Infraclavicular or axil- 
 lary localizations are highly suggestive. The patient should be forewarned 
 and placed under treatment. Such reassuring phrases as " local bronchitis'^ 
 and "spot on the lung" are worse than obsolete; they are dishonest. 
 
812 MEDICAL DIAGNOSIS. 
 
 The Tuberculin Test. — If a case remains doubtful, or if, for personal 
 reasons, delay must be avoided, tuberculin may be employed. To the 
 objection as to danger, it may be affirmed that in the hands of innumerable 
 careful observers its cautious use has not been followed by untoward 
 effects. To the objection as to results, it is to be admitted that it has some- 
 times failed in cases of demonstrated tuberculosis, and that some degree 
 of reaction has occurred in non-tuberculous cases. No one, however, has 
 reported an intense reaction to tuberculin in a healthy person or in other 
 diseases. The mode of procedure is as follows: The patient is kept in bed 
 and the temperature taken every two hours from 8 a.m. to 10 p.m. for two 
 days. At the end of this period and in the early morning, at first .5, then 2 
 and finally, if required, 5 mg. of Koch's old tuberculin are injected at inter- 
 vals of three days. In children the dose is .10 to .5 mg., according to the 
 age. The temperatures are taken at intervals of two hours as before. 
 The constitutional reaction shows itself in fever which rises rapidly — 102° 
 to 104° F. (39°-40° C.)— and only gradually subsides. So long as it con- 
 tinues the patient must be kept in bed. Local reaction is frequently mani- 
 fest in the suspected chest area in the form of fine moist rales. As this 
 may occur in the absence of the febrile reaction, auscultation must be 
 performed twice daily. Sputum previously absent may be ejected during 
 or after the reaction and may contain bacilli. In other cases intense 
 general and local reaction may occur without expectoration. 
 
 The Ophthalmotuberculin Test. — The method proposed by Cal- 
 mette and Wolff- Eisner consists in the instillation of a drop of a 1 per cent, 
 tuberculin solution into the eye, which is followed by a conjunctival hyjDer- 
 ^^^ ^^ semia in infected individuals, while 
 
 in non-tuberculous individuals no 
 signs of irritation follow. 
 
 Fig. 278.— Eye-dropper with throttle for measured In Baldwin's cHnical StudieS & 
 
 filtered sterile normal saline solution 
 of two strengths and a measured drop (0.025 c.c.) were employed, the latter 
 to insure accuracy of dosage. A throttled eye-dropper with a calibrated 
 mark to 0.025 c.c. was used, the throttle permitting the control of the 
 liquid when filled to the mark. The technic is as follows: 
 
 "The two solutions of 0.33 per cent, and 0.5 per cent., respectively, 
 were employed successively in each eye. When the first failed to react the 
 stronger was instilled into the other eye after forty-eight hours. By this 
 method severe reactions may be avoided in cases of suspected tuberculosis, 
 though if time failed the stronger solution might be used without serious 
 discomfort being anticipated should a marked reaction follow. In order 
 to avoid any danger of contamination the solutions were sealed in glass 
 tubes containing three or four drops and then boiled. These can easily 
 be broken in a piece of gauze or cotton at a file mark. The eye-dropper is 
 then inserted, after being cleansed with alcohol and sterile saline solution. 
 Care is used to prevent the introduction of spicules of glass. The solution 
 should be warmed in cold weather. 
 
 " The lid of one eye is pulled down and the measured drop instilled as with 
 any other fluid by holding the eye-dropper parallel to the eye, but care should 
 be observed that it does not overflow on the cheek; this is easily accom- 
 plished by holding the hd down until the drop is distributed about the sac." 
 
TUBERCULOSIS. 
 
 813 
 
 Baldwin's Scheme for Recording Reactions. 
 
 Negative. — No difference in color when lower eyelids are pulled down 
 and compared. 
 
 Doubtful. Slight difference with redness of caruncle. 
 Positive. + = Distinct palpebral redness with secretion. 
 
 " + + = Ocular and palpebral redness with secretion well 
 
 marked. 
 •'* + 4- + =Deep injection of entire conjunctiva with oedema of 
 lids, photophobia, and secretion. 
 
 TABLE SHOWING RESULT IN 137 CASES— Baldwin. 
 
 I. Pulmonary tuberculosis. 
 No. cases, 45. 
 
 II. Pulmonary or other tuber- 
 culosis ; healed from 1 to 
 17 years. No. cases, 9. 
 
 III. Pulmonary or other tuber- 
 culosis suspected. No. 
 cases, 26. 
 
 IV. Apparently healthy per- 
 sons. No. cases, 57. 
 
 Reacted . . 
 Doubtful . 
 Negative . . 
 
 Reacted. . 
 Doubtful . 
 
 .42 
 . 1 
 . 2 (1 miliary and 1 tuberculin-treated). 
 
 1 (17 years). 
 
 (a) From history (14 cases) J Doubtful '. '. 
 
 I Negative . . 
 
 (b) From symptoms (8 cases) / Reacted . . . 
 
 I. Negative . , 
 
 (c) From physical signs (4 cases) . 
 
 f Reacted . . , 
 1 Negative . . 
 
 (d) With family history of tubercu- | g^tibtiJi ". ! 
 losis (18 cases). I Negative . , 
 
 (e) Constantly associated with tuber- 
 
 culous doctors, nurses, husbands 
 and wives of invalids (18 cases). 
 
 (f) With no family history or ex- f 
 
 posure (21 cases). { 
 
 Reacted .... 6 
 Negative ... 12 
 
 Reacted . 
 Negative 
 
 . 2 
 .19 
 
 Contraindications. — These include diseases of the conjunctiva, eyelids, 
 and cornea, and of the internal structures of the eye. Undue exposure to 
 dust, smoke,, or strong light should be 
 avoided during the test. The test is 
 superfluous when the diagnosis can 
 be made b}- physical or microscopic 
 examination. The repetition of the 
 test is not unattended with danger 
 due to sensitization. 
 
 Cutaneous Tuberculin Reac- 
 tion. — Von Pirquet, M^ho suggested 
 this test, employed at first a 25 per 
 cent, solution of old tuberculin, but 
 subsequentl}^ used the undiluted old 
 tuberculin. The inoculation is per- 
 formed on the forearm with a chisel- 
 .shaped in.strument, the skin having 
 been previously thoroughly cleansed 
 with ether. Any suitable instrument 
 may, however, be employed, and any convenient part of the body selected. 
 
 Positive Reaction. — If a papule of at least 5 millimetres in diameter 
 develops at the point of vaccination in twenty-four hours, the patient may 
 
 Fig. 279. — V Pirquet's method. 
 
814 MEDICAL DIAGNOSIS. 
 
 be regarded a& infected with tuberculosis. As a general rule the more 
 active the tuberculous process the more intense and extensive the cutaneous 
 reaction. Very intense reactions occur in glandular tuberculosis and in 
 these cases inflammatory changes in the skin beyond the borders of the 
 papule often occur — scrofulous reaction. The signs of reaction occur in 
 periods varying from two or three hours to several days and are later in 
 proportion to the degree of dilution of the tuberculin. No direct information 
 as to the period at which the infection has taken place, namely, as to whether 
 it is old or recent, its situation in the body or the extent of the lesions, is 
 afforded by the cutaneous test. 
 
 Negative Reaction. — Failure may be due to absence of tuberculous 
 infection or to various causes, among which von Pirquet especially enumer- 
 ates the following: (1) relative insusceptibility, which is rare in early 
 
 Fig. 280. — Petruschky's method: a, lower vaccination 1:10 negative, upper two 1:0 positive; b, lower 
 
 vaccination 1:10 and upper two 1:0 negative. 
 
 childhood but not infrequent in older persons having circumscribed lesions 
 which are encapsulated; (2) failure of the capacity for reaction in the last 
 stages of tuberculosis; (3) loss of the capacity to react in immunity pro- 
 duced by tuberculization, either by progressively increasing doses or by a 
 recent single dose of larger amount; (4) temporary disappearance of 
 the capacity of reaction during an attack of measles. 
 
 In a considerable proportion of cases the failure of the test is, therefore, 
 due to relative insusceptibility, and it has been shown that well-marked " sec- 
 ondary positive reaction" may be obtained upon the repetition of the test in 
 these cases. A primary reaction is, however, the sign of an active tuberculous 
 process. Petruschky makes, on the upper arm with the point of a cannula, 
 cross-lined vaccinations with old tuberculin in dilutions of 1 to 10, 1 to 5, or 
 1 to 0. He finds no reaction in fully cured cases, and that the test is without 
 danger and does not give rise to any important symptoms in any case. 
 Petruschky regards this procedure as an important means of early diagnosis. 
 
TUBERCULOSIS. 815 
 
 Tuberculin Inunction — Moro's Test. — This diagnostic procedure, 
 described as " a diagnostic measure without rupture of continuity of the 
 skin," consists in the inunction into the skin of the chest or abdomen, 
 over an area of 4 square inches, of a mass about the size of a pea of an 
 ointment composed of 5 c.c. of Koch's old tuberculin rubbed up with 5 
 grammes of anhydrous wool fat. Absorption takes place slowly, and on 
 the following day, or, more commonly, not until the second day, in cases 
 of previous or present tuberculous infection, a positive reaction shows itself 
 in the appearance of small papules in the area of inunction or its immediate 
 vicinity. These lesions vary in number and color from a few pale papules 
 to a numerous, thick-set crop that are very red. The skin may be reddened 
 and the seat of some itching. These cutaneous lesions wholly disappear in the 
 course of a week. They are not attended by other local or constitutional phe- 
 nomena. The test is negative when the skin shows no changes of any kind. 
 
 The Opsonic Method. — A. E. Wright and S. T. Reid,^ in a communi- 
 cation " On the Possibility of Determining the Presence or Absence of 
 Tuberculous Infection by the Examination of a Patient's Blood and Tissue 
 Fluids," have arrived at the following conclusions: 
 
 " (1) Conclusions which can be arrived at when we have at disposal 
 the results of a series of measurements: (a) Where a series of measure- 
 ments of the opsonic power of the blood reveals a persistently low opsonic 
 power with respect to the tubercle bacillus, it may be inferred, in the case 
 where there is evidence of a localized bacterial infection which suggests 
 tuberculosis, that the infection in question is tubercular in character, 
 (b) Where repeated examination reveals a persistently normal opsonic 
 power with respect to the tubercle bacillus, the diagnosis of tubercle may, 
 with probability, be excluded." 
 
 '' (2) Conclusions which may be arrived at where we have at disposal 
 the result of an isolated blood examination: (a) Where an isolated blood 
 examination reveals that the tuberculo-opsonic power of the blood is low, 
 we may — according as we have evidence of a localized bacterial infection 
 or of constitutional disturbance — infer with probability that we are deal- 
 ing with tuberculosis — in the former case with a localized tubercular 
 infection, in the latter with an active systemic infection, (b) Where an 
 isolated blood examination reveals that the tuberculo-opsonic power of 
 the blood is high, we may infer that we have to deal with a systemic tuber- 
 culous infection which is active, or has recently been active, (c) Where 
 the tuberculo-opsonic power is found normal, or nearly normal, while there 
 are symptoms which suggest tuberculosis, we are not warranted, apart 
 from the further test described below, in an-iving at a positive or a 
 negative diagnosis." 
 
 The further criterion to which reference was made in the preceding 
 paragraph is the following: When a serum, after it has been heated to 60° C. 
 for ten minutes, is found to retain, in any considerable measure, its power of 
 inciting phagocytosis, we may conclude that "incitor elements" have been 
 elaborated in the organism, either in response to autoinoculations occurring 
 spontaneously in the course of tubercular infection, or, as the case may be, 
 under the artificial stimulus supplied by the inoculation of tubercle vaccine. 
 
 1 Proceedings of the Royal Society, B Vol. LXXVII, 1906. 
 
816 MEDICAL DIAGNOSIS.. 
 
 Iodine Test. — The iodine salts, and especially potassium iodide in 
 moderate doses, may produce the physical signs of a local catarrh over a 
 suspected area (Striker). The signs of consolidation may also become 
 more definite. In the expectoration, which almost always follows, tubercle 
 bacilli are frequently found. 
 
 X-RAY Examination. — The results obtained are less definite than 
 in the advanced stages of the disease. The complicated apparatus and 
 great technical skill required also stand in the way of the general employ- 
 ment of this method in the diagnosis of pulmonary tuberculosis in the 
 incipient stage. 
 
 The pulmonary tuberculosis which so often occurs as a terminal condi- 
 tion in pneumonoconiosis, chronic bronchitis, and emphysema is not usually 
 recognizable in the incipient stage — masked tuberculosis. The symptoms 
 of the primarj^ disease are not so much altered as intensified. As the process 
 advances tubercle bacilli previously absent may be found in the sputa. 
 
 Symptoms of Moderately and Far Advanced Pulmonary Tuberculosis. — 
 There is no definite border-line between the stages. The difficulties in 
 diagnosis disappear. The symptoms and signs become definite and char- 
 acteristic. Any tyro can interpret the clinical picture. 
 
 1. Pulmonary Symptoms. — Cough may be slight but is usually promi- 
 nent and annoying. After cavity formation it is commonly paroxysmal; 
 with laryngeal involvement, husky and brassy. Sputum. — The expectora- 
 tion is variable. There may be little or none, even when cough, fever, and 
 rapid wasting are associated with the physical signs of extensive consolida- 
 tion. The mucoid expectoration of the early period presently shows scat- 
 tered grayish or grayish-green purulent masses in which tubercle bacilli 
 and elastic fibres may be found. With softening the expectoration becomes 
 more profuse and distinctly purulent. Nummular sputa are often present 
 after cavities have formed. The sputa sometimes contain calcareous 
 masses varying in diameter from 1 mm. to 1 or 2 cm., often of irregular 
 shape. They are the result of the deposition of lime salts in circumscribed 
 caseous masses. They find their way into a bronchus by the ulceration 
 and necrosis of the intervening tissue. Hcemoptysis. — The amount varies 
 from a trace to 500-750 c.c. In a majority of the attacks it does not 
 exceed 15 c.c. It is in many cases repeated, and a hemorrhagic form of 
 phthisis has been described. Hemorrhage into a lai'ge cavity may prove 
 fatal without any blood being expectorated. Bacilli and elastic fibres may 
 sometimes be discovered in the clots. After a day or two small black clots 
 and blood-casts of the smaller bronchi are often coughed up and an access 
 of fever may occur. Dyspncea. — The respiration is not usually increased 
 except upon exertion. 
 
 2. Constitutional Symptoms. — Fever is an important initial symp- 
 tom. It may be remittent in tj^pe, or intermittent and paroxysmal, with 
 ague-like perlodicit5^ The temperature is an important indication of the 
 progress of the disease. The periods of quiescence are afebrile and marked 
 by gain in weight, while those of activity are accompanied by fever and 
 loss of flesh. There are, however, rare cases in which, with advancing 
 lesions, pyrexia is absent. The fever of the incipient stage is sometimes 
 continuous, with slight daily remissions and exacerbations; that of the 
 
TUBERCULOSIS. 817 
 
 moderately advanced stage corresponds to the activity of the process, 
 and when present is of remittent or intermittent type, tending to subside 
 altogether when the patient is kept at rest; while that of the far advanced 
 period of the disease, with ulceration, necrosis, and the formation of cavi- 
 ties, is septic in character, — so-called hectic, — the range of temperature 
 being subnormal— 95°-96° F. (35°-35.5° C.)— in the morning between 10 
 A.M. and noon, and steadily rising to a maximum of 104°-105° F. (40°- 
 40.5° C.) between 6 and 11 p.m. Colliquative sweating frequently attends 
 the morning fall of temperature. The measurements should be made at 
 two-hourly periods in order to ascertain the actual minima and maxima. 
 Inverse temperatures are sometimes observed. Sweating.— Froiuse sweats 
 may occur, not only toward morning, but at any time at which the patient 
 sleeps. They may occur early but are much more common in the far ad- 
 vanced cases. Circulation. — The pulse-frequency is increased and variable. 
 It usually rises with the fever. The pulse is often large, soft, and compres- 
 sible. As the sign of vasomotor paresis, capillary and venous pulsation may 
 sometimes be seen. Loss of weight is a marked symptom. It is often rapid 
 and extreme — consumption; phthisis. During periods of quiescence it is 
 often arrested, and in favorable cases weight is regained. In rare cases 
 increase of weight occurs in the absence of other signs of improvement. 
 Anorexia, vomiting, intractable diarrhoea, osdema of the legs and feet with or 
 without albuminuria, are common in the stadium ultimum. Peripheral 
 neuritis, showing itself in extensor palsy of the wrists, more commonly the 
 feet, sometimes occurs. The mental condition in the terminal dyscrasia 
 is often remarkable— spes phthisica. The patients up to the very last busy 
 themselves with plans for the future, new methods of treatment, different 
 climates, business schemes, and the confident expectation of recovery. 
 
 Physical Signs in Advanced Pulmonary Tuberculosis. — Inspection. — The 
 thorax undergoes deformities corresponding to the progressive diminu- 
 tion in the volume of the lungs. It tends to assume permanently the 
 expiratory form. 
 
 Palpation.- — Diminished expansion at the apex may be determined 
 in the following manner: The examiner stands behind the patient, who is 
 seated, and gently grasps the shoulders with his hands, the tips of the 
 fingers being in the infraclavicular spaces, the thumbs resting upon the 
 upper part of the scapula?. The patient then slowly draws a deep breath; 
 to study the expansion at the bases the hands grasp the two sides of the 
 chest in a similar manner in the lower axillary regions. Lagging and 
 limitation of the excursus are signs of great significance. The vocal fremitus 
 is increased over areas of consolidation; over vomicae it may be increased 
 or diminished. It is usually enfeebled over thickened pleurae. 
 
 Percussion. — In doubtful cases percussion should be performed dur- 
 ing quiet breathing and upon full-held inspiration, as minor differences in 
 the sounds upon the two sides then become more marked. Slight relative 
 dulness may be recognized by the elevation of pitch which accompanies it. 
 Light percussion above, beneath, and over the clavicle should be practised. 
 The supraspinous fossae and the points corresponding to the apices of the 
 lower lobes are important regions. Dulness over consolidation and tym- 
 pany over vomicae is the rule; but scattered small tuberculous foci with 
 
 62 
 
818 MEDICAL DIAGNOSIS. 
 
 intervening air-containing vesicular structure, especially when there is 
 collateral emphysema, yields resonance with a tympanitic quality, and a 
 cavity filled with fluid will often yield a dull or, upon very nice percussion, 
 a flat percussion sign. Over large cavities, situated near the periphery 
 of the lung, the cracked-pot sound may be obtained. 
 
 Auscultation. — In the incipient stage the vesicular murmur is usually 
 enfeebled, sometimes scarcely audible. Rough breathing is an early sign. 
 Cog-wheel inspiration is often present, but it occurs in other conditions. 
 With advancing lesions vesiculobronchial, bronchovesicular, and bronchial 
 respiration succeed each other, to be finally replaced, as softening occurs 
 and vomicae form, by cavernous or amphoric breathing. Rales of all 
 kinds, from the crepitus of the beginning lesion to the gurgling of cavities, 
 attend the process. Rales are due largely to the accompanying bronchitis, 
 and vary in kind and number according to- the character of the secretion 
 and the activity of the process in different parts of the lung. Puerile respi- 
 ration may be heard over the adjacent unaffected lobes or over the opposite 
 lung. The vocal resonance is increased and bronchophony and pectoriloquy 
 may be elicited over areas of dense consolidation and cavities. Whispering 
 pectoriloquy is an important sign of large superficial cavities. Pleural 
 friction sounds are an important early sign and occur from time to time 
 during the progress of the case. At first usually near the apex, they occur 
 over advancing lesions in all points of the chest. Pleural friction at the left 
 anterior border of the lung, and especially over the lingula, frequently has 
 the cardiac rhythm — pleuropericardial friction. The signs of cavities are 
 very variable. Situated superficially, a cavity may cause a distinct shal- 
 low depression in one or two intercostal spaces. A rapidly formed cavity, 
 or several small cavities without much surrounding condensation or pleural 
 thickening, may yield a full, clear resonance in which the only modification 
 is a slightly tympanitic quality — vesiculotympanitic resonance. Tym- 
 panitic and amphoric resonance are usual. The pitch may be modified by 
 opening and closing the mouth — Wintrich's sign — or upon change of 
 posture — Gerhardt's sign. The cracked-pot sound can be brought out only 
 over fairly large cavities with thin walls and superficially situated, and 
 disappears for a time after it has once or twice been heard. Cavernous 
 respiration is usually soft and low pitched. It may, however, be tubular 
 or amphoric. Gurgling rales are common over large cavities and sometimes 
 have a ringing or metallic quality, especially during coughing. Increased 
 vocal resonance and whispering pectoriloquy are valuable signs. Over 
 large cavities in the upper lobes the heart sounds and sometimes a trans- 
 mitted systolic murmur are occasionally heard, and in rare cases sharp, 
 splashing rales having the cardiac rhythm. Over a layer of dense, con- 
 solidated lung extending to a large bronchus there may be signs — circum- 
 scribed tympanitic percussion note, amphoric respiration, and coarse moist 
 rales — which closely simulate those of a cavity. Light percussion, the 
 pitch of the sound not being raised by opening the mouth or change of 
 posture, and the absence of the cracked-pot sound may be of use in the 
 recognition of the actual condition. 
 
 Diagnosis of Advanced Pulmonary Tuberculosis. — The direct diagnosis 
 rests upon the physical signs and the presence of tubercle bacilli in 
 
TUBERCULOSIS. 819 
 
 the sputa. The symptoms are variable and acquire diagnostic value only 
 in proportion as they correspond with the signs of the lesions and their 
 distribution and evolution. 
 
 The spirometer has deservedly fallen into disuse in the diagnosis of 
 incipient tuberculosis of the lungs, and its use is attended with danger 
 in the advanced cases. The expectations raised by the publications of 
 Arloing and Courmont in regard to the use of tuberculous serum — agglu- 
 tination — in the diagnosis of tuberculous disease have not been realized. 
 
 Prognosis in Chronic Ulcerative Phthisis. — When proper treatment is 
 instituted in the stage of incipiency and rigorously carried out, the pros- 
 pect of a cure is good. The frequency with which limited obsolescent, 
 even healed tuberculous lesions are found post mortem in the lungs of 
 individuals dead of other diseases or by accident, bears ample testimony 
 to the intrinsic tendency to recovery. It has been said that more people 
 recover from pulmonary tuberculosis without being aware that they have 
 had it than die of it. 
 
 The prognosis in the advanced cases is unfavorable and in the far 
 advanced cases hopeless. In individual cases, the early recognition of the 
 disease, a good family history, limited local lesions, slight constitutional 
 reaction, and the disposition and means to make a business of getting well 
 are favorable conditions in the prognosis. The pleurogenous cases often 
 run a slow and relatively favorable course. The cases characterized by 
 recurrent blood spitting are unfavorable. Only in the worst cases is the 
 course of the disease relentlessly progressive. As a rule there are periods 
 varying from weeks to months in which the lesions remain quiescent, the 
 symptoms subside, the general health improves, and there is a gain in weight. 
 The duration varies from some months to several years, the average being 
 about two and a half years. A remarkable decrease in the death-rate 
 from consumption has taken place in recent years. This is to be ascribed 
 to the discovery of the tubercle bacillus, the recognition of the fact 
 that tuberculosis is an acquired rather than an inherited disease, and the 
 dissemination among the people of the knowledge by which its spread can 
 be restricted. 
 
 (c) FIBROID PHTHISIS. 
 
 This term is used to designate a very chronic tuberculous process in 
 the lungs, with relatively slight ulceration and much development of 
 fibrous tissue. It may begin as a tuberculous bronchopneumonia or fol- 
 low an ordinary ulcerative phthisis. In a large proportion of the cases it 
 begins as a chronic tuberculous pleurisy. The anatomical and clinical 
 condition is practically that of pulmonary cirrhosis. One or both lungs 
 may be affected; if both, one to a much greater extent than the other. 
 There are vomicae at the apex, surrounded by dense fibroid tissue, and bron- 
 chiectatic cavities elsewhere. The pleura is greatly thickened, and encap- 
 sulated cheesy masses, with patches of recent tubercle, and enlarged 
 bronchial glands are present. Am5^1oid disease of the liver, spleen, and 
 intestines develops in the advanced cases. 
 
 Symptoms. — Cough, often paroxysmal and more common in the morn- 
 ing, purulent expectoration, sometimes fetid, and dyspnoea upon exertion 
 
820 MEDICAL DIAGNOSIS. 
 
 constitute the symptom-complex. Blood spitting occurs. The patients 
 are thin, but frequently have fair health. Fever is not a common symptom. 
 
 Physical Signs. — The chest is flat, the shoulders lower, and the clav- 
 icles prominent. The vocal fremitus is diminished. Resonance is greatly 
 impaired and has the tympanitic quality. At the apex cavernous, at the 
 base bronchial, respirations are heard. Rales are not common, but coarse 
 moist and gurgling rales may be present when fluid collects in the cavities 
 or dilated bronchi. The superficial area of cardiac dulness is increased, 
 the impulse may be seen and felt in two or more interspaces, and the heart 
 is displaced toward the affected side. 
 
 Diagnosis. — Direct. — This rests upon the symptoms and physical 
 signs as detailed above. 
 
 Differential. — The distinction between tuberculous and non-tubercu- 
 lous pulmonary cirrhosis cannot in all cases be made intra vitam. The 
 presence of tubercle bacilli in the sputum is positive. When not found during 
 life they are often present in the lesions after death. Atrophic emphy- 
 sema presents some points of resemblance to fibroid phthisis, but differs 
 from it in being a symmetrical affection and occurring only in aged persons. 
 
 Prognosis. — The outlook is favorable as to life, unfavorable as to 
 recovery. The disease is chronic, lasting from ten to twenty or twenty- 
 five years. The patient is usually able to attend to his affairs. There are 
 cases characterized by recurrent hemorrhages, and death sometimes occurs 
 from haemoptysis. 
 
 Turban has suggested the following scheme for uniform records for 
 comparative statistics in tuberculosis of the lungs: 
 
 r I. Disease of slight severity, affecting at most one lobe 
 1 o* J- „ i . J « or two half lobes. 
 
 1. Stadium = extent and se- J jj Disease of slight severity, more extensive than I, but 
 
 lunL Q'sease m tne i affecting at most two lobes ; or severe, and affecting 
 
 ^' at most one lobe. 
 
 L III. All cases of greater extent and severity than II. 
 
 2. Disease quiescent or pro- 
 
 gressing. 
 
 o T« tu „f *;^„o-„„^ „„+ /To date from first occurrence of symptoms, such as per- 
 
 3. Length of time smce onset. | ^-^^^^^ ^^^^^^^ haemoptysis, or pleurisy. 
 
 4. General condition f Satisfactory. 
 
 (. Unsatisfactory. 
 
 5. Digestion f Normal. 
 
 (. Abnormal. 
 
 6. Pulse-frequency To be taken in morning during repose. 
 
 (Daily maxima over 101.3°. 
 Daily maxima between 99.7° and 101.3°. 
 Temperature normal with two-hourly rectal temperature 
 (mouth temperature 0.4°-0.5° lower). 
 
 '• ^tUltl^''''' ^°' "'^^' I Tubercle baclBI aTsl^t^' 
 infection. "j^ j^j.^^^ infection. 
 
 9. Tubercular complications. Name of affected organ. 
 10. Other complications / Name of disease : serious complications such as^heart dis- 
 
 ease, nephritis, or diabetes are to be noted. 
 Full, undiminished. 
 
 lost. 
 
 ,,„..- , f Full, undiminishe 
 
 11. Capacity for work J slightly reduced. 
 
 L Much reduced or 
 
 12. Result of treatment i N^f Improved. 
 
 I Died. 
 
 Nos. 1-10 are filled up on admission or commencement of treatment. 
 Nos. 11 and 12 on discharge. 
 
SYPHILIS. 821 
 
 XXXIII. SYPHILIS. 
 
 Definition. — A chronic specific infection, propagated by inoculation 
 and characterized by, (a) a pecuhar initial lesion — the chancre; (b) con- 
 stitutional symptoms with mucous and cutaneous lesions and enlargement 
 of the superficial lymph-nodes; and (c) the development of granulomatous 
 lesions in the various tissues of the body. These effects of the infection are 
 consecutive, and constitute (a) the primary stage, (b) the secondary stage, 
 and (c) the tertiary stage. Syphilis is frequently transmitted from the 
 parent to the child — hereditary syphilis. 
 
 Etiology. — Predisposing Influences. — Syphilis is a venereal disease 
 and is usually acquired by illicit sexual intercourse. When acquired by an 
 innocent person in the marital relation or by accidental means, it is 
 described as syphilis insontium. Individual susceptibility is universal 
 and affects all periods of life. Accidental infection is common among 
 medical men. The fingers are usually the site of the primary lesion. Chan- 
 cres upon the lip or tongue may result from the conveyance of the virus 
 by kissing, the use of drinking utensils, the pipe, and other indirect methods. 
 The infection is active in the oral and pharyngeal lesions — mucous patches. 
 Unnatural vices are responsible for a certain proportion of the primary 
 sores about the mouth. A nurse suckling a syphilitic infant may be inocu- 
 lated upon the nipple and is also liable to accidental inoculation upon the 
 lip, finger, or elsewhere. Local epidemics of syphiHs among infants from 
 arm-to-arm vaccination have been reported. Such accidents are no longer 
 possible. Syphilis has been transmitted in tattooing. Hereditary trans- 
 mission may take place from the father, the mother presenting no evidence 
 of infection — sperm inheritance, paternal heredity. In rare instances a 
 child begotten by a father in the active — secondary — stage has shown no 
 evidence of syphilis. In equally rare cases the child of a father who, after 
 thorough treatment, has shown no signs of the disease has developed 
 congenital syphilis. There are usually unknown factors in problems of this 
 nature. After vigorous systematic treatment, and the lapse of three years 
 after the entire disappearance of symptoms, a man may be allowed to marry 
 and is not Hkely either to infect his wife or to beget infected children. 
 
 Transmission from the mother is called germ inheritance — maternal 
 heredity. A woman suffering from syphihs in the active stage is liable, 
 when conception occurs, to bear a syphilitic child. As a rule both parents 
 are syphilitic, the one having infected the other. A very remarkable fact 
 is set forth in Colles's law, which, briefly stated, is this: A child that is 
 affected with hereditary syphilis, its mother showing no signs of the disease, 
 will not infect the mother. Such a child will infect its nurse or others, but 
 the mother appears to have acquired an immunity without manifesting 
 any of the usual phenomena of the disease. In the case of the mother 
 becoming infected after conception, the child may show the signs of con- 
 genital syphilis or, less frequently, it may escape. A parent or parents in 
 the stage of tertiary syphilis may have non-syphilitic children. 
 
 Exciting Cause. — Many organisms have been described in the 
 course of the last twenty-five years. Recent observations have estab- 
 lished the fact that the spirochaeta described by Schaudinn in 1905, and 
 
822 
 
 MEDICAL DIAGNOSIS. 
 
 Fig. 281. — Treponema pallidum in a chancre. 
 
 named by him Spirochceta pallida, is the cause of the disease. This organism 
 is very deHcate, closely coiled, having pointed ends, and motile. A larger 
 spiral organism found in association with it upon the surface of syphilitic 
 sores, and also upon the ulcerated surfaces of non-syphilitic lesions, and in 
 smegma from healthy men and women, he named Spirochseta refringens. 
 S. pallida- — Treponema pallidum. — has been found with great frequency in 
 syphilitic lesions at various stages of the disease, as well as in the organs 
 
 of congenital syphilis and the placenta, 
 and in greater numbers in the active 
 lesions. It has been found in the syph- 
 ilitic lesions of inoculated monkeys. 
 It has not yet been grown in culture. 
 
 (a) ACQUIRED SYPHILIS. 
 
 The Primary Stage. — A period of 
 incubation varying from two to four 
 weeks, exceptionally longer, elapses 
 between the inoculation and the appear- 
 ance of the initial sore. This lesion 
 consists of a small red papule, which 
 gradually enlarges and breaks down in 
 the centre, forming a circumscribed, 
 superficial ulcer, with a pecuhar hard, gristly, or cartilage-like movable 
 base, which still further increases in size and is known as the indurated or 
 hard chancre. This initial lesion may remain small and readily elude 
 observation when just within the urethra or in the female genitalia. In 
 the other localities it usually appears as a conspicuous and characteristic 
 sore. In the course of a week or two the associated lymph-nodes "undergo 
 a painless and indolent enlargement. 
 
 The Secondary Stage. — The earliest indications of constitutional 
 infection are usually manifest within a period varying from six to twelve 
 weeks. They consist of the following phenomena: Fever, usually so mild 
 as to attract little attention, 101° F. (38.5° C), sometimes marked, less 
 frequently severe. In type it may be subcontinuous, remittent, or inter- 
 mittent; in duration indefinite, sometimes onl}^ subsiding upon the vigor- 
 ous use of antisyphilitic treatment. It may not appear until late in the 
 course of the disease. The recognition of syphilitic fever is of great diag- 
 nostic importance. It may simulate malaria or the symptomatic fever of 
 advanced pulmonary tuberculosis, or hectic fever due to other causes. 
 
 Anamia. — The erythrocytes often fall rapidly to 3,000,000 and occa- 
 sionally lower. There is pallor with a sallow or muddy tinge of the skin. The 
 superficial lymph-nodes, especially the suboccipital and epitrochlear glands, 
 become enlarged and tender. Lassitude, headache, rhachialgia, and the vague 
 pains of a general infection are common. The designation syphilitic cachexia 
 has been applied to cases in which this symptom-group is pronounced. 
 
 Cutaneous Lesions — Syphilodermata. — The earliest eruption is usually 
 macular or roseolar. The individual spots are irregularly oval, of large 
 size and often run together. They are symmetrically distributed upon 
 
SYPHILIS. 823 
 
 the trunk and anterior surfaces of the arms and thighs. In color they are 
 reddish-brown, often so faint as to be scarcely observed, sometimes vivid 
 or coppery. This exanthem usually fades in the course of some weeks, but 
 sometimes recurs at subsequent periods in the course of the disease. Later 
 a papular eruption may appear upon the face and trunk, not unlike acne. 
 This syphilide occasionally appears upon the forehead just below the 
 edge of the hair — corona veneris. Frequently associated with it is a pustular 
 eruption, suggestive of the variolous rashes. This combination of papules 
 and pustules appearing upon the head and trunk, especially when syphilitic 
 fever is present, may give rise to an erroneous diagnosis of smallpox. Still 
 later squamous rashes appear, much like psoriasis but less scaly, coppery 
 in color, and often confined to the palms and soles. Papulosquamous 
 lesions are by no means rare. These eruptions frequently appear in the 
 above order, but sometimes in a different succession, and two or more are 
 often present at the same time. Symmetry and polymorphism are char- 
 acteristic of the syphilodermata in the secondary stage. Flat Condy- 
 lomata. — About the vulva and anus, upon the perineum, at the corners of 
 the mouth, occasionally at the umbilicus, and in the folds of the armpits 
 and groins, and elsewhere where the skin is constantly moist or there are 
 opposing cutaneous folds, there sornetimes appear, but not in all cases, 
 flat warty growths, slightly elevated, with distinct borders and a moist, 
 grayish surface. The secretion causing these lesions is inoculable and they 
 are in the highest degree characteristic of syphilis. Alopecia Syphilitica. — 
 Not rarely the hair, and often the eyebrows and lashes, fall out during the 
 secondary stage. The loss of hair may be in patches, like those of alopecia 
 areata, or there may be a general thinning. Onychia Syphilitica. — The nails 
 are, in some cases, affected by a syphilitic inflammation involving the 
 matrix, and are lost or become deformed. 
 
 Lesions of the Mucous Membranes. — The oral mucosa is chiefly affected. 
 About the time of the appearance of the rash the throat and mouth become 
 sore. There is a general erythematous angina, more intense than else- 
 where, upon the tonsils and pharynx, where are frequently visible small, 
 superficial ulcers with well-defined, scalloped borders and grayish-white 
 surfaces — mucous patches. These patches are also common on the tongue, 
 the lips, and the buccal mucosa. They are characteristic of syphilis and the 
 secretion from their surface is highly inoculable. Whitish patches upon 
 the tongue — leucomata — sometimes occur, especially in smokers. Papillary 
 hypertrophy of the mucosa about the vulva or at the verge of the anus 
 may give rise to warty excrescences of considerable size — condylomata. 
 
 Other lesions of diagnostic importance are iritis, which is often encountered 
 early in the secondary stage and tends to recur; much less frequently cho- 
 roiditis and retinitis, and deafness from otitis media or labyrinthine disease. 
 Abortion and miscarriage are common and repeated interrupted pregnancies 
 are very suggestive. Periostitis is a border-line lesion marking the late sec- 
 ondary or early tertiary stage. It especially involves the tibia, clavicles, 
 cranial bones, and less frequently the sternum. It is usually circumscribed 
 and often associated with nodes. Upon palpation the surface of the long 
 bones is rough, and nodular bosses may be felt upon the bones of the skull. 
 There is tenderness upon pressure, and pain, which is usually worse at night. 
 
824 MEDICAL DIAGNOSIS. 
 
 The Tertiary Stage. — There is no distinct time between the secondary 
 and tertiary stages. Tertiary lesions are sometimes present shortly after 
 infection; sometimes they make their appearance along with the phenom- 
 ena which are characteristic of the secondary stage; more commonly they 
 do not appear until a longer or shorter, often a remote, period after the 
 lesions of that stage have subsided. The third stage of syphilis is character- 
 ized by certain lesions of the skin, the development of gummata, disease 
 of the bones, and amyloid degenerations. Cutaneous Lesions. — Circum- 
 scribed nodular lesions are common. They appear in groups, which are 
 irregular, asymmetrical, and characterized by the formation of deep, 
 rounded ulcers which involve the deeper layers of the skin and tend to 
 coalesce, healing at one point and spreading at another, and leaving deep 
 scars as they heal. Rupia, a deep ulcerating tertiary lesion covered by 
 stratified, oyster-shell-like crusts, is much less common than formerl}^ 
 
 Gummata. — These lesions are circumscribed and vary in size from 
 minute bodies to tumors sometimes reaching five centimetres in diameter. 
 They develop in the skin, subcutaneous tissue, mucous membranes, internal 
 organs, muscles, and bones. In the bones they form dense, hard, hemi- 
 spherical, subperiosteal masses called nodes. Gummata of the skin and 
 subcutaneous tissue tend to break down and form deep ulcers, which heal 
 slowly and leave deep, disfiguring scars. Under treatment they are fre- 
 quently absorbed. Gummata of the mucous membranes are especially 
 common in the mouth, nose, and pharynx. They involve underlying struc- 
 tures and often give rise to extensive and deep ulceration and necrosis of 
 cartilage and bone. Perforation of the nasal septum, destruction of the 
 nasal bones, perforation and more or less extensive destruction of the hard 
 and soft palate, and adhesions of the uvula or soft palate to the pharyn- 
 geal wall are common effects. Ulceration and necrosis of the cartilages of 
 the larynx also occur. Stricture of the rectum is one of the results of gum- 
 matous infiltration and ulceration. Syphilomata are common in the internal 
 organs. They sometimes form agglomerations of large size. Their usual 
 course is to undergo fibroid metamorphosis w'th puckering and deformity. 
 Syphilitic nodes and periostitis have already been described. Further 
 lesions are extensive and deep necrosis, which may become perforating, 
 as in the bones of the cranium, the formation of exostoses which may 
 cause serious and obscure pressure symptoms, as in the brain or spinal 
 cord or the articulations. Syphilitic dactylitis, often followed by per- 
 manent deformity, is the manifestation of gummatous infiltration and 
 periostitis of the bones of the fingers and toes. Much less common 
 are gummata of the muscles and myositis syphilitica. Amyloid degen- 
 eration is common in syphilis even in the absence of chronic sup- 
 puration. It occurs especially in neglected cases of the acquired 
 disease and is rare in the congenital form. 
 
 (b) HEREDITARY SYPHILIS. 
 
 The infant may show the characteristic symptoms at birth or may 
 present the appearance of health. In the latter case the evidences of 
 infection appear in the course of one or two months. 
 
SYPHILIS. 825 
 
 1. Symptoms at Birth. — The child is undersized and usually wasted 
 and wrinkled. Bullae may be present on the wrists and ankles and scaly 
 patches upon the palmar and plantar surfaces. Mucous patches upon the 
 nasal and oral mucous membrane, rhagades at the angles of the mouth and 
 at the anus are characteristic. There is enlargement of the liver and spleen. 
 Nodular thickening of the bones and, in some cases, separation of the epiphy- 
 ses occur. Such children snuffle, are extremely feeble, are difficult to 
 feed, and usually perish within a short time. Hemorrhage is occasionally 
 encountered. It is more common at the navel but may be subcutaneous, 
 or there may be bleeding from the mucous surfaces. 
 
 2. Early Symptoms. — When born without symptoms, syphilitic 
 children are often plump and well nourished and remain so until some 
 time between the third and eighth weeks. The earliest symptoms are 
 usually those of a syphilitic endorhinitis, namely, impeded nasal respira- 
 tion, difficulty in nursing, snuffling, and a mucopurulent, sometimes bloody 
 discharge. In severe cases necrosis of the nasal bones may occur, followed 
 by characteristic deformity of the face. Involvement of the Eustachian 
 tubes and middle ear results in deafness. Such cases constitute one of the 
 groups of deaf-mutes. Cutaneous lesions appear about the same time. 
 They consist of a certain general muddy sallowness, in sharp contrast to 
 the fresh rosy skin of a healthy infant, patchy erythema or eczema, or 
 large, irregular coppery patches with well-defined borders. These erup- 
 tions are frequently first seen upon the buttocks, but may invade other 
 regions. A papular syphilide is common. Rhagades upon the lips and 
 especially at the corners of the mouth and at the anus are of diagnostic 
 importance. Mucous patches develop and are highly contagious. The 
 secretion from these lesions usually constitutes the means of infection in wet- 
 nurses and others. Alopecia, onychia, dactylitis also frequently occur as the 
 case goes on. A general adenopathy is not common, but the lymph-nodes 
 in relation to local lesions of the skin often undergo an indolent enlarge- 
 ment. The spleen is enlarged; the liver less constantly and to a less extent. 
 The large relative size of the liver in the new-born is to be kept in mind. 
 
 3. Later Symptoms. — Children suffering from congenital syphilis 
 may regain the appearance of health under judicious management. Very 
 frequently they remain undersized and badly nourished and look pre- 
 maturely old. The facies and cranial development are very often char- 
 acteristic. The skull is frequently asymmetrical, the forehead prominent, 
 the bridge of the nose in some cases depressed, the lips pouting, with 
 radiating linear scars, especially at the corners of the mouth. At the 
 second dentition and at puberty the symptoms of hereditary syphilis 
 frequently reappear. 
 
 Hutchinson Teeth — Notched Teeth. — The upper central incisors are peg- 
 shaped, shorter, and narrower than normal, and especially narrower at the 
 cutting edge than at the neck. The enamel is usually well formed, not 
 pitted and thinned as after prolonged non-specific sickness in infancy, 
 and there is at the cutting edge a single notch of varying depth in which 
 the enamel is deficient and the dentin exposed. 
 
 Other symptoms are interstitial keratitis, iritis, deafness of laby- 
 rinthine origin, bone lesions, and, in particular, a gummatous periostitis 
 
826 MEDICAL DIAGNOSIS. 
 
 which gradually causes marked thickening and deformity and which shows 
 an especial tendency to affect the tibiae. The nodes of late hereditary 
 syphilis are usually symmetrical and are sometimes mistaken for rickets. 
 They may first appear in adolescence. There may be enlargement of the 
 spleen and visceral gummata. 
 
 The question of the transmission of syphilis to the third generation 
 remains undecided. 
 
 (c) VISCERAL SYPHILIS. 
 
 1. Syphilis of the Central Nervous System (see Diseases of the 
 
 Nervous System). 
 
 Para- or Metasyphilitic Diseases. — The term parasyphilitic was sug- 
 gested by Fournier to designate a group of affections not directly due to 
 syphiKs, but much more common in those who have had that disease 
 than in others. This category includes tabes, paresis, certain types of 
 epilepsy, and forms of arteriosclerosis. They are not curable by mercury 
 and the iodides. 
 
 2. Syphilis of the Lungs. — Pulmonary syphilis is a very rare condition. 
 The following forms are described: (a) White Pneumonia of the Fatus. — 
 The process may involve extensive portions of a lobe or an entire lung. 
 The affected tissue is heavy, airless, and of a grayish-white color. The 
 alveoli are filled with desquamated epithelium and their walls are thick- 
 ened and infiltrated, (b) Gummata irregularly scattered throughout the 
 lung, especially in connection with the bronchi and more abundantly about 
 the root than elsewhere. There is an associated bronchopneumonia, (c) 
 Fibrous interstitial pneumonia beginning at the root of the lung and extend- 
 ing along the bronchi and vessels. This sclerotic process may begin in the 
 pleura and involve the connective-tissue framework, especially in the 
 interlobar tissue. It principally affects the portions of the lung adjacent 
 to the root. It is encountered in individuals with a syphilitic history or in 
 whom there are other forms of visceral syphilis, and is sometimes associated 
 with gummata. As in other forms of pulmonary sclerosis, bronchiectasis 
 is often present. 
 
 Symptoms. — The clinical manifestations are those of pulmonary 
 tul:)erculosis or pulmonary sclerosis. In the former case the absence of 
 tubercle bacilli upon repeated examination, and the absence of signs of 
 destructive lesions, as elastic tissue, are suggestive; in the latter the signs 
 of chronic interstitial pneumonia and of bronchiectasis are present. The 
 acute syphilitic pneumonia and chronic syphilitic phthisis of French authors 
 are not generally recognized as clinical entities. 
 
 3. Syphilis of the Liver. — The following forms are described: (a) 
 Diffuse Syphilitic Hepatitis. — This is common in congenital syphilis. The 
 organ is large and firm and shows the presence of minute and larger gummata 
 and extensive connective-tissue hj^perplasia. (b) Gummata. — In congenital 
 syphilis gummata of various sizes may occur at any period. In the acquired 
 disease they are usually among the later manifestations of the acute process. 
 They are commonly multiple and may attain the size of an orange. They 
 undergo fibroid changes with contraction and cause remarkable deform- 
 ities of the organ; in rare cases softening takes place with the formation 
 
SYPHILIS. 827 
 
 of one or more fluctuating tumors, (c) Syphilitic Perihepatitis. — Glisson's 
 capsule and the connective tissue along the portal canals are thickened. 
 Great vein obstruction may occur when the connective-tissue proliferation 
 extends along the large venous trunks, (d) Amyloid Liver. — This change 
 is very common in syphilis. Gummata may be present or a consecutive 
 diffuse hepatitis may occur. 
 
 Symptoms. — The clinical phenomena are by no means constant. 
 Congenital syphilitic hepatitis can scarcely be diagnosticated with preci- 
 sion even when suspected. The organ is enlarged and firm. There may 
 be jaundice. In the adult the symptom-complex of atrophic cirrhosis is 
 frequently present. The symptoms are sallowness or slight jaundice, 
 digestive disturbances, loss of weight, and ascites. 
 
 Irregularity in the outline of the liver dulness occurs in many of the 
 cases. The evolution and involution of gummata cause progressive and 
 retrogressive deformities of the liver which are of great importance in diag- 
 nosis. These syphilitic tumors are less dense in consistence than the 
 surrounding tissue in hepatitic or amyloid disease, and can in some cases 
 be differentiated from it upon palpation. In syphilitic perihepatitis an 
 audible and palpable friction rub may sometimes be recognized; jaundice 
 is present in one-third of the cases and may be intense. Pains in the 
 hepatic region occur and the signs of ascites and of splenic enlargement are 
 by no means rare. In amyloid liver the symptoms of amyloid disease in 
 other organs are usually present. The liver is enlarged, smooth, and firm, 
 Its outline may be irregular. There is commonly also enlargement of the 
 spleen. Anaemia, polyuria with albumin and casts, and a tendency to 
 dropsy are present. 
 
 4. Syphilis of the Digestive Tract. — The oesophagus and stomach are 
 very rarely involved. Ulceration of the small intestine is likewise uncom- 
 mon. The rectum is far more often affected. Rectal syphilis is more 
 common in women. The lesions are due to gummata in the submucous 
 tissue above the internal sphincter, which undergo ulcerative changes which 
 become chronic and on healing cause stenosis. There may be tenesmus, 
 discharge of bloody pus with the stools, and pain on defecation. Later 
 the symptoms are those of stenosis. 
 
 5. Syphilis of the Circulatory System. — The Heart. — Valvular lesions 
 are exceedingly infrequent. Both vegetations and gummata have, however, 
 been observed. Mural lesions are common. They comprise gummata, 
 fibroid induration, amyloid degeneration, and endarteritis obliterans. 
 Changes in the blood-vessels of the heart occur both in the congenital and 
 the acquired diseabe. Valvular lesions give rise to definite murmurs. 
 Syphilis of the myocardium may be present without symptoms; those 
 characteristic of myocarditis are usual. Sudden death may occur. 
 
 The Arteries. — There are two forms of syphilitic arteritis, an obliter- 
 ating endarteritis which is not distinctive, and a gummatous periarteritis 
 which involves especially the smaller arteries of the brain and the branches 
 of the coronary arteries, and is specific. Syphilitic changes in the arteries 
 are etiologically related to arteriosclerosis and aneurism. 
 
 6. Syphilis of the Kidneys. — Gummata and amyloid degeneration 
 constitute the common changes. The former cannot be recognized intra 
 
828 MEDICAL DIAGNOSIS. 
 
 vitam; the latter presents the usual symptoms. An acute syphilitic 
 nephritis^ without specific characters, has been described. 
 
 7. Syphilis of the Testicles. — Gummata in the substance of the testis 
 is not uncommon. It may be mistaken for tuberculosis. It is usually 
 painless and does not tend to invade the skin or to undergo softening or 
 suppuration. An interstitial orchitis may develop as a slowly progressive 
 affection unattended with pain and resulting in induration and atrophy. 
 One testis is usually affected to a greater extent than its fellow. 
 
 Diagnosis. — 1. General Diagnosis of Syphilis. — (a) The Primary Le- 
 sion. — The surgeon is more frequently consulted than the medical man. 
 In a suspicious sore the following points are of importance: a history of 
 exposure within a month or six weeks; induration; movability; sluggish 
 ulceration; scanty secretion; slight painless enlargement of the inguinal 
 glands. These traits belong equally to the chancre upon the genitalia and 
 elsewhere. The history of exposure may, however, be in default. The 
 patient may prefer to conceal the actual fact at the risk of his future health 
 as well as his character for veracity; or the inoculation may have occurred 
 in marital intercourse or otherwise by non-genital infection. The initial 
 lesion may not have attracted the patient's attention. This is especially 
 liable to occur in women. In man the lesion is sometimes inconspicuous 
 and may be mistaken for preputial herpes or an abrasion; or it may be 
 masked by coincident chancroids, or, when at the meatus or in the urethra, 
 by a gonorrhoea, or finally an extragenital chancre, even when well char- 
 acterized, may fail to arouse the suspicion of the practitioner as to its true 
 nature. There is only one diagnostic rule, namely, to preserve a guarded 
 and discreet openness of mind in all doubtful cases and carefully watch for 
 subsequent developments. 
 
 (b) The Seconbary Stage. — Consecutive events are important. 
 The history of exposure, especially when doubtful, and the history of a 
 subsequent sore, however doubtful, are of great diagnostic value. Sore 
 throat and roseola are usually the first symptoms which attract the patient's 
 attention. A painful erythematous angina, with tonsillar ulceration and 
 mucous patches, with a symmetrical, faint, brownish-red macular rash 
 upon the trunk, and painless enlargement of the inguinal, suboccipital, 
 and epitrochleal lymph-nodes, especially when associated with fever, 
 constitutes a symptom-complex upon which a direct diagnosis may be made. 
 Later polymorphous rashes, corona veneris, alopecia, irregular fever, and 
 anaemia are confirmatory. 
 
 Justus found that after the beginning of treatment by mercurial 
 inunction or hypodermically in cases of syphilis not previously treated 
 there was a haemoglobin reduction of from 10 to 20 per cent., followed by 
 a rise as the treatment was continued. Later observations have not 
 confirmed the diagnostic value of this test in doubtful cases. 
 
 The Wasserman Test. — This serum test requires a very careful technic 
 and is exposed to many sources of error. It therefore should only be 
 undertaken by trained laboratory workers.* During the two years that 
 have elapsed since it was first published the reliability of this diagnostic 
 method has been fully established. In a recent publication Wasserman 
 
 1 Consult Immune Sera: C. F. Bolduan, third edition, 1908. 
 
SYPHILIS. 829 
 
 has given the results of 3000 tests, of which 1010 were upon cases surely 
 non-syphilitic and used as controls. In 1982 syphilitic cases about 90 
 per cent, gave positive results. In cases without manifest symptoms at 
 the time, "latent syphilitis, " about 50 percent, gave positive reactions. 
 The chief value of this test is in cases with symptoms suggestive of syphilis 
 but a questionable anamnesis. 
 
 The Noguchi Butyric Acid Test. — This depends upon the fact that in 
 cases of secondary syphilis, untreated or but slightly treated, an increased 
 globulin content in the serum can be demonstrated by the precipitation 
 produced upon the addition of acid. The serum is mixed with half satu- 
 rated solution of ammonium sulphate, the precipitate separated by centrif- 
 ugating, and the supernatant fluid poured off. The precipitate, redissolved 
 in ten volumes of normal salt solution, is then treated by a 10 per cent, 
 solution of butyric acid in salt solution. In normal sera a slight opalescent 
 precipitate results, but in the sera of secondary syphilis the increased globu- 
 lin content is shown by a distinct flocculent precipitate which forms within 
 two hours. The spinal fluid may be employed instead of blood-serum. 
 
 (c) The Tertiary Stage. — The anamnesis is here also of great impor- 
 tance. It is often defective. Sometimes discretion suggests a very guarded 
 investigation of the past history of the patient. Inquiry should be made 
 concerning persistent rashes and falling of the hair. Careful inspection 
 of the throat and skin should be made for the signs of past lesions. 
 Scars in the groins are insufficient evidence. Suppurating buboes are 
 usually due to chancroids, not syphilis. Slowly progressive ulcerating lesions 
 of the skin, advancing in one direction and healing in another, — serpigin- 
 ous, — gumma and gummatous ulceration, perforation of the nasal septum, 
 of the hard or soft palate, necrosis of the nasal or cranial bones, the signs 
 of iritis, the presence of nodes, irregular periosteal thickening or exostosis, 
 especially upon the clavicles, tibiae, or bones of the skull, particularly when 
 two or more of them are associated, constitute diagnostic data of final 
 importance in the direct diagnosis. But these lesions are often wholly 
 absent and the sufferer from tertiary syphilis, and particularly the sufferer 
 from nervous syphilis, may be entirely free from the gross or visible 
 external manifestations of the disease. In many cases of nervous syphilis 
 it is impossible to elicit a history of marked secondary signs. 
 
 2. Diagnosis of Hereditary Sypliilis. — Repeated miscarriages are, in 
 connection with any of these phenomena, of diagnostic value. The efflo- 
 rescence of the characteristic rash associated with snuffles, mucous patches, 
 and rhagades within the first three months justifies the direct diagnosis. 
 At subsequent periods of life the characteristic facies, infantile develop- 
 ment, symmetrical nodes, notched teeth, and interstitial keratitis tell their 
 own story and may solve the problem of diagnosis in obscure nervous or 
 visceral disease. 
 
 3. Diagnosis of Visceral Syphilis. — The anamnesis and the presence 
 of the signs of former lesions are of primary importance. In the male 
 careful search should always be made for vestiges of the primary sore. 
 It is to be remembered that the manifestations of visceral syphilis are 
 usually not in themselves different from those of lesions due to other 
 pathological processes, and that their true nature can be recognized only 
 
830 MEDICAL DIAGNOSIS. 
 
 by the history of infection, the presence and association of characteristic 
 external phenomena, or the therapeutic test. 
 
 1. Syphilis of the Brain and Cord (see Diseases of the Nervous System). 
 
 2. Syphilis of the Lung. — The clinical diagnosis of this rare condition 
 in any of its forms can seldom be made with precision. Chronic interstitial 
 pneumonia with the signs of bronchiectasis, or chronic bronchopneumonia 
 in a person with a history of syphilis or presenting well-characterized 
 lesions in other parts of his body, may be of syphilitic origin. Tuber- 
 culosis of the lungs and gummata may coexist. 
 
 3. Syphilis of the Liver. — The diagnosis is most important, as it is 
 essential to the choice of treatment. The irregularly enlarged liver, with 
 soft circumscribed gummata, may suggest cyst, abscess, or malignant 
 tumor. Under such circumstances an unnecessary surgical operation might 
 be performed. A history of infection, collateral lesions, and fair general 
 heailth "Suggests syphilis. The diagnosis in gummata forming large con- 
 glomerate tumor masses in the right or left lobe in absence of collateral 
 evidence must remain obscure. In cirrhosis and perihepatitis recovery 
 under specific treatment is often the only sign. Irregularity of outline, 
 which, when there is ascites, can only be determined after paracentesis, 
 is very suggestive. Amyloid disease of the liver is commonly associated 
 with similar visceral changes elsewhere. 
 
 4. Syphilis of the Digestive Organs. — The history affords presumptive 
 evidence in disease of the oesophagus. Syphilis of the stomach cannot be 
 positively diagnosticated. The chronic course of syphilis of the rectum, 
 the symptoms of gradual stenosis of the gut, and the results of digital 
 examination by which a firm fibrous annular contraction is usually felt, 
 quite unlike the irregular, ragged surface of ulcerating cancer, are essential 
 diagnostic criteria. 
 
 5. The clinical diagnosis of syphilitic disease of the heart and arteries 
 must be a provisional one. Cardiovascular changes, in no respect differ- 
 ing in symptomatology from those occurring in syphilitic subjects, are 
 often due to other causes. 
 
 6. The diagnosis of renal syphilis cannot be made during life. 
 
 7. Syphilis of the Testes. — The recognition of syphilis in these organs 
 may be of great importance in obscure visceral disease. Syphilis, tuber- 
 culosis, and cancer are to be differentiated. Gummata involve the body of 
 the testicle and give rise to irregular conglomerated masses, unattended 
 with pain and showing no tendency to invade the skin or undergo soften- 
 ing. Tubercle more commonly affects the epididymis and is often associ- 
 ated with tHe signs of tuberculous disease elsewhere. Malignant disease 
 runs a more rapid course, attains a larger size, is attended with pain, and 
 tends to involve the skin and undergo ulceration. 
 
 Therapeutic Diagnosis. — Symptomatic treatment by mercury and the 
 iodides under suitable conditions will frequently cause the disappearance 
 of symptoms. Intermittent courses of treatment, repeated during long 
 periods of time, usually prevent the recurrence of symptoms, arrest the 
 tendency to abortion, and may be followed by the birth of healthy children 
 in whom neither the early nor the late manifestations of syphilis occur. 
 Obscure skin eruptions fade if of syphilitic origin. 
 
GONORRHCEA. 
 
 831 
 
 With reference to visceral syphilis the following facts are important: 
 The symptoms of nervous syphilis may, in early cases, disappear after the 
 use of antisyphilitic remedies; in pulmonary sj^^hilis the results are incon- 
 clusive; syphilis of the liver in certain of its forms is amenable to treat- 
 ment and in some cases the improvement is rapid and permanent; syphilis 
 of the heart and arteries shows retardation rather than cure and here the 
 therapeutic test is useless. The symptoms of the secondary stage yield 
 promptly, while in the tertiary stage the gummatous lesions yield more 
 or less gradually and the sclerotic lesions are but slightly if at all influenced. 
 The so-called parasyphilitic diseases are not cured by antisyphilitic treat- 
 ment. Finally there are rare cases of acute malignant syphilis which run 
 a rapidly fatal course wholly uninfluenced by treatment. 
 
 Prognosis. — Under early, systematic treatment, repeated from time 
 to time in courses of proper duration for a period of three or four years, 
 an apparent cure is, in the majority of cases, established and maintained. 
 
 XXXIV. GONORRHCEA. 
 
 Definition. — A contagious catarrhal inflammation of the genital 
 mucous membrane, chiefly propagated by impure sexual intercourse, and 
 due to the gonococcus of Neisser. 
 
 This wide-spread venereal infection is scarcelj^ inferior in importance 
 to syphilis. In truth, when we take into consideration the facts that syphilis 
 is much less virulent than formerly in its early and late constitutional 
 effects, and that it gives rise to symptoms which compel the most ignorant 
 and inexperienced to seek professional 
 advice at a period when it is still 
 amenable to treatment, and that gonor- 
 rhoea, while retaining all its capacity for 
 immediate and late harmfulness, is too 
 often regarded as a trifling local dis- 
 order, the very existence of which may 
 be unsuspected by the female patient, 
 we may even question whether gonor- 
 rhcEa is not the more serious disease 
 of the two. 
 
 The gonorrhoeal infection may 
 limit itself to the mucous membrane 
 of the genitalia — (1) the primary local 
 infection; it may invade the genito- 
 urinary organs by direct continuity 
 of structure — (2) secondary local infection; or finally, it may be swept 
 into the blood stream and give rise to (3) constitutional infection. 
 
 With reference to the spread of the infection in the genito-urinary tract, 
 it is a question of extent. Every case in the male is at first an infection of 
 the anterior urethra. With reference to systemic effects, it is a question of 
 degree; any case is liable to systemic disturbance, and malaise, feverishness, 
 head and back pains, and other symptoms of constitutional infection are 
 often present at the onset or later in the course of the attack. The fever 
 associated with the initial symptoms is due to the absorption of toxins. 
 
 Fig. 282. — Spread of pus containing gonococci. 
 
832 MEDICAL DIAGNOSIS. 
 
 The Primary Local Infection. — It is necessary for the purposes of 
 medical diagnosis to bear in mind the fact that the gonococcus may 
 persist in a shght urethral discharge capable of giving rise to the disease 
 for long periods after the patient has thought himself cured, and that 
 innocent women frequently become infected upon marriage. It is also to 
 be remembered that the existence of a urethral stricture bears a causal 
 relation to cystitis, pyelitis, persistent rhachialgia, lassitude, general 
 disability, and neurasthenia, and that in acute disease it may be the cause 
 of urinary retention. 
 
 Secondary Local Infection. — The gradual extension of the specific 
 inflammation from the mucous membrane primarily involved gives rise, in 
 the male, to posterior urethritis, epididymitis, prostatitis, periurethral 
 abscess; in the female to abscess of the vulvovaginal glands, metritis, sal- 
 pingitis, inflammation of the ovary, and, in rare cases, to acute peritonitis; 
 in both sexes to cystitis and pyelitis, usually mixed infections. 
 
 Constitutional Qonorrhoeal Infection. — Gonorrhceal Sepsis — Septi- 
 coPYiEMiA. — The presence of the gonococcus in the blood has been 
 demonstrated. There are cases of rapidly fatal general infection, usually 
 associated with suppurative lesions in the urinary tract. The symptoms 
 are chill, high temperature of irregular range, profuse sweats, muttering 
 delirium, and stupor deepening to coma. 
 
 Cardiac and Articular Localizations — Gonorrhceal Endocar- 
 ditis. — This localization is of frequent occurrence in gonococcus septicaemia. 
 Gonococci have been isolated from the blood during life, and the vegeta- 
 tions upon the valves after death. The endocarditis is often of the malig- 
 nant type. In a majority of the cases the endocarditis has followed an 
 arthritis, but it may occur in the absence of the joint affection or the 
 latter may follow it. Pericarditis may occur, and an acute gonorrhcEal 
 myocarditis has been observed. 
 
 Gonorrhceal Arthritis. — The designation gonorrhceal rheumatism is 
 erroneous and misleading and should be abandoned. This localization has 
 been observed in infants in connection with ophthalmia neonatorum and 
 in young children in whom gonorrhoea is common as the result of accidental 
 infection by towels or clothing, or of vicious practices. It is most common 
 between twenty and thirty. Males suffer from the joint affection more 
 frequently than females. It may occur at any time during the course of 
 the urethral discharge. Most commonly the arthritis begins during the 
 acute stage and is followed by a subsidence of the discharge, which is, 
 however, usually only temporary. It may occur after discharge has greatly 
 diminished or not for several weeks after the beginning of the attack. 
 A single joint may be affected; more commonly two or even three are 
 involved. Polyarthritis is rare and the migratory form characteristic of 
 acute rheumatism does not occur. The joints remain inflamed and only 
 slowly get well. The ankles, knees, and wrists are especially liable to gonor- 
 rhceal inflammation and the temporomaxillary, sternoclavicular, vertebral, 
 and sacro-iliac articulations are frequently attacked. The inflammation 
 is endo- and periarticular. In the latter case the exudate sometimes extends 
 along the sheaths of the tendons. The effusion into the joints is that of a 
 serous synovitis. It may be seropurulent. The gonococcus may be iso- 
 
EPHEMERAL FEVER. 833 
 
 lated from the endo- and the periarticular exudates. In some cases the 
 results are negative. Mixed infections — staphylococci, streptococci — occur. 
 
 Gonorrhceal arthritis tends to become chronic. Relapses are frequent; 
 disorganization or disabling ankylosis may result. Among the compli- 
 cations are iritis, endocarditis, pericarditis, and pleurisy. 
 
 Diagnosis. — Direct.— The anamnesis is most important. Caution is to 
 be exercised in questioning young girls and married persons of both sexes. 
 The existence of a mucopurulent urethral discharge is not positively con- 
 clusive. A young person suffering from gonorrhoea may also contract 
 rheumatic fever. In the female a vaginal discharge should be examined 
 for gonococci. Clinically, a limited number of joints involved, the persist- 
 ence of the inflammation without migration, the association of endocar- 
 ditis of the malignant form, and implication of the temporomaxillary, 
 sternoclavicular, or vertebral articulations are of diagnostic value. 
 
 Differential. — Rheumatic Fever. — The evanescent — migratory — char- 
 acter of the arthritis, the number of joints involved, — 'polyarthritis, — the 
 frequent rapid and complete resolution of the inflammation, a history of ■ 
 exposure to cold or wet, of previous attacks, of heredity, and the com- 
 monly lower intensity of an endocarditis, when present, are in favor 
 of rheumatic fever. Pycemic or Septic Arthritis. — The presence of a sup- 
 purative focus, caries, osteomyelitis with toxaemic phenomena, as irregular 
 chills, high fever of irregular remittent or intermittent type, profuse sweat- 
 ing, rapidly developing anaemia, the implication of a single joint or, at most, 
 two or three, and the evidences of large intra-articular effusion, are in 
 favor of septic arthritis. Goiit. — If the patient be a middle-aged male, 
 energetic and self-indulgent, the attack be sudden, the great toe, ankle, 
 knee, or wrist involved, the swelling tense, the surface livid and glossy, 
 and tophi be present around the small joints or in the helix of the ear, a 
 diagnosis of gout may safely be made. I have seen a calculus impacted 
 in the urethra cause a free purulent discharge, followed by an attack of 
 gout. Arthritis Deformans. — There are cases in which, for a time, the joint 
 affection, whether arthralgic, polyarthritic, or monarthritic, cannot be dis- 
 tinguished at the time of acute exacerbations from gonorrhceal arthritis. 
 No question arises in regard to the differential diagnosis except in cases of 
 recent or chronic urethritis in the male or leucorrhoea in the female. 
 
 Prognosis. — Gonorrhoeal infection in its systemic form is always a 
 serious matter. The virulent septic cases prove fatal in a few days or a 
 week or two; the endocarditis frequently assumes the malignant type; 
 the arthritis is commonly rebellious to treatment and not rarely is followed 
 by lasting, even permanent disability. Salicin and the salicylates are useless. 
 
 XXXV. EPHEMERAL FEVER— FEBRICULA-SIMPLE 
 CONTINUED FEVER. 
 
 Definition. — Fever of short duration, occurring in the absence of defi- 
 nite lesions or known specific cause, and characterized by elevation of 
 temperature and the derangements of function which commonly attend it. 
 Fever lasting twenty-four or forty-eight hours and ceasing completely is 
 designated ephemeral fever; an attack of three or four days' duration. 
 fehricula; and one lasting a week or more, simple continued fever. 
 
 53 
 
834 MEDICAL DIAGNOSIS. 
 
 Etiology. — Children and neurotic individuals are more liable to 
 transient febrile attacks than others — a fact due to the instability of the 
 heat-regulating mechanism. Several groups of cases are described: (a) 
 symptomatic, (b) toxic, and (c) infectious. 
 
 (a) In many cases the fever is doubtless due to unrecognized local 
 lesions, as in angina tonsillaris or catarrhal bronchitis of the larger tubes, 
 with little or no cough and no rales; or to slight injury such as results from 
 a fall upon the head. 
 
 (b) Among the toxic cases are those which arise from indigestion or 
 gastro-intestinal catarrh with the absorption of fever-producing substances. 
 The fever sometimes follows prolonged mental or physical effort, exposure 
 to damp and cold without definite lesions, exposure to the sun but not to 
 a degree sufficient to cause thermic fever, and the inhalation of the con- 
 centrated emanations from decomposing organic matter. There are 
 instances in which a number of persons have been at the same time taken 
 ill, with nausea, vomiting, fever, and, in some instances, collapse symptoms 
 after being present at a very offensive post-mortem examination or the 
 opening of an obstructed sewer or of a mortuary vault. 
 
 (c) Mild or abortive cases of the infectious diseases have been regarded 
 as febricula. Stille called attention to the occurrence of cases of cerebro- 
 spinal fever so mild that they can " only be recognized by the lurid light of 
 the epidemic." The true nature of the mildest form of enteric fever — 
 typhus levissimus — may be readily overlooked, and there are cases of scarlet 
 fever, measles, and rheumatic fever without distinctive symptoms beyond 
 a transient fever for two or three days — larval cases of the infectious diseases. 
 In view of these facts, it is evident that the more closely the cases of 
 transient fever without obvious symptoms are studied, the fewer will be 
 encountered that are really neither symptomatic nor specific, and there is a 
 tendency to do away with this group of fevers altogether as a nosological 
 entity. On the other hand, every practitioner occasionally encounters cases 
 for which no other place in the classification of diseases can be found. 
 
 Symptoms. — The onset is usually abrupt; exceptionally gradual with 
 lassitude and languor. The usual symptoms of febrile infection are present. 
 In rare instances, especially in children, there may be chilHness or a con- 
 vulsion. Defervescence takes place by crisis between the second and the 
 fourth days; if later, usually by rapid lysis. 
 
 A direct diagnosis may be made from the abrupt onset of the fever, 
 its short course and the critical termination in the absence of local lesions and 
 cutaneous rashes. The prognosis is invariably and essentially favorable. 
 
 XXXVI. ROCKY MOUNTAIN SPOTTED FEVER. 
 
 Tick Fever. 
 
 Definition. — An acute infectious endemic disease, prevalent in the 
 northwestern mountainous regions of the United States, and due to the 
 bite of a tick. It is characterized by the gradual onset of symptoms com- 
 mon in the acute infections, a papular or petechial eruption, and an irregular 
 fever of variable duration terminating by lysis. 
 
ROCKY MOUNTAIN SPOTTED FEVER. 835 
 
 This disease, tong known under designations sucli as " mountain fever, " 
 "black fever," and "spotted fever," iias recently been made the subject 
 of scientific investigation under the auspices of the Montana State Board 
 of Health (1902), the PubUc Health and Marine Hospital Service (1903), 
 and the American Medical Association (1906-1907), and is now recog- 
 nized as a nosological entity. 
 
 Etiology. — Predisposing Influences. — Certain districts in the Rocky 
 Mountains are the exclusive regions in which the disease occurs. The great 
 majority of the reported cases have been observed in April, May, and June. 
 A few have occurred in March and July. No period of life affords exemp- 
 tion. The disease has been noted as early as the second and as late as the 
 seventy-fourth year. Ranchmen, lumbermen, engineers, and prospectors 
 have supplied the greater number of cases. 
 
 Exciting Cause. — Despite various hypotheses, the infecting organism 
 has not yet been demonstrated. It is inoculated by the bite of a tick — 
 Dermacentor andersoni. Tick fever may be caused in monkeys and guinea- 
 pigs by the inoculation of the defibrinated blood of human beings suffer- 
 ing from the disease. Some observers have attributed the disease to the 
 inoculation of the infecting principle by mosquitoes. 
 
 Symptoms. — The average duration of the period of incubation appears 
 to be about seven days. The onset is attended by nausea and vomiting, 
 muscular pains, malaise, headache, and epistaxis, chilhness or a distinct 
 chill. The temperature rises abruptly to 103°-104° F. (39.5°-40° C.) and 
 its range may be subcontinuous or intermittent. At the expiration of from 
 sixteen to twenty days defervescence takes place, followed by subnormal 
 temperatures for a few days. In fatal cases the temperature usually 
 remains high, but a preagonistic fall sometimes occurs. The eruption shows 
 itself about the third or fifth day, first appearing upon the ankles, wrists, 
 and forehead, and gradually spreading over the whole body. It remains, 
 however, more abundant upon the extremities than upon the trunk. It 
 is at first maculopapular and disappears upon pressure. In the course of 
 a few days it becomes more distinctly papular and does not disappear upon 
 pressure or when the skin is made tense. Many of the spots become petechial 
 and in the severer cases more or less extensive ecchymosis occurs. The 
 intervening skin is congested, slightly cyanotic, and jaundiced. In favor- 
 able cases the eruption fades with the defervescence and its disappearance 
 is followed by desquamation. Gangrene of the penis or scrotum or of 
 the toes has been reported. In mild cases the rash may not appear. 
 Gastro-intestinal symptoms are prominent. The liver and spleen are 
 enlarged. The urine is diminished in volume, of high color and specific 
 gravity, and contains albumin and casts of all kinds. The blood 
 shows a moderate secondary anaemia and in some cases a moderate 
 leucocytosis — 13,000. 
 
 Diagnosis. — The direct diagnosis rests upon the endemic occurrence 
 of a disease having the above sj'^mptom-complex in particular localities 
 and at certain seasons of the year, a history of tick or mosquito bites, 
 sudden onset, chilliness or high continued or intermittent fever, the appear- 
 ance of the maculopapular eruption upon the third, fourth, or fifth day, 
 petechise, ecchymosis, and defervescence followed by desquamation. 
 
836 MEDICAL DIAGNOSIS. 
 
 Prognosis. — Rocky ]\Iountaiii spotted fever is a very fatal disease. 
 According to several observers the mortality varies from 70 to 90 per cent. 
 In some seasons the cases are mild and most of them have terminated in 
 recovery. Among the phenomena which in individual cases render the 
 outlook especially unfavorable are deep jaundice, extensive hemorrhage 
 into the skin, delirium, and exhaustion. 
 
 XXXVII. ICTERUS IXFECTIOSUS. 
 
 Weil's Disease; Acute Febrile Icterus. 
 
 Definition. — An acute infectious disease characterized by sudden 
 onset with chill, followed hj high fever and jaundice. 
 
 Etiology.— Predisposing Influences. — The clinical picture suggests 
 the severer cases of catarrhal jaundice and various febrile forms of gastro- 
 intestinal disease that may run their course with or without jaundice. 
 It corresponds very closely to the disease observed by Griesinger in Cairo, 
 and Kartulis in Alexandria, and described under the designation bilious 
 typhoid or typhus biliosus. Many cases reported as Weil's disease clearly 
 do not belong to that category, such as santonin poisoning, septica?mia, 
 abortive enteric fever, and the so-called hepatic form of enteric fever. 
 The view that AA'eil's disease is a form of rheumatic fever complicated by 
 a resorption icterus is not generally accepted. Some etiological considera- 
 tions support the assumption that the disease is the manifestation of a 
 specific infectious process. Among these are the following: The cases 
 which correspond to AYeil's description usually occur sporadicall}', but not 
 rarely thev appear in groups in circumscribed localities, and during the 
 hot season. Males are more affected than females — 90 per cent. Certain 
 occupations exert a predisposing influence, butchers, tanners, and laborers 
 in sewers being especially liable to the disease. It has been attributed to 
 the drinking of contaminated water, and epidemics, especially among 
 soldiers, have been ascribed to the swallowing of such water during bathing. 
 The disease is most frequent between the twenty-fifth and the fortieth 
 5'ears of life. It is uncommon in childhood, and rare after fifty. 
 
 Exciting Cause. — The researches of Jager render it probable that 
 an organism cultivated from the urine of living cases and from the organs 
 of a case dead of the disease — Proteus fluorescens — is the infecting agent. 
 
 Symptoms. — The attack begins abruptly, usually without prodromes 
 and often with a chill. Headache, vertigo, pain in the back and limbs occur. 
 There is great lassitude. The temperature rises rapidly to 104° F. (40° C.) 
 or higher, and is remittent in type. It lasts from eight to fourteen days. 
 There are recurrences of the fever, and in a considerable proportion of the 
 cases relapses occur. Stupor and delirium occur, and the resemblance of 
 some of the cases to enteric fever may be striking — a resemblance increased 
 by the early development of splenic enlargement. Jaundice makes its 
 appearance between the third and fifth days and is of variable intensity, 
 being in a considerable proportion of the cases deep and attended by 
 clay-colored stools. The liver is increased in size and tender upon pressure. 
 The urine is commonly albuminous, with hyahne and epithelial casts, and 
 
GLANDULAR FEVER. 837 
 
 sometimes contains red blood-corpuscles. Haematuria is not very uncom- 
 mon. In the fatal cases deep stupor, delirium, and coma precede death. 
 There is rapid wasting during the attack. Muscular pains persist after the 
 defervescence and are among the last symptoms to disappear. Angina 
 tonsillaris is occasionally an early complication. Herpes faciahs and other 
 cutaneous lesions, as erythema and hemorrhage into the skin, have been 
 observed. A group of the graver cases are hemorrhagic. Parotid bubo 
 is a rare complication. The duration of the attack varies from two to four 
 weeks, and the convalescence is slow. 
 
 Diagnosis. — The direct diagnosis rests upon the occurrence of jaundice 
 with the symptoms of an acute severe infection, quite unhke ordinary 
 catarrhal icterus on the one hand, and without the phenomena of the specific 
 infections on the other. The age, sex, and occupation of the patient are to 
 be considered. It is probable that some of the local epidemics reported as 
 catarrhal jaundice of severe type have been outbreaks of Weil's disease. 
 
 Prognosis. — The death-rate is low, most of the cases terminating in 
 recovery. 
 
 XXXVIII. GLANDULAR FEVER. 
 
 Definition. — An infectious disease of children, characterized by sud- 
 den onset, erythematous angina, enlargement of the tonsils, high fever of 
 short duration, and swelling and tenderness of the lymph-nodes of the 
 neck, particularly those along the posterior border of the sternocleido- 
 mastoid muscles. 
 
 Etiology. — Predisposing Influences. — Certain individuals, particu- 
 larly in childhood, exhibit a peculiar irritability of the superficial lymphatic 
 glands, some of which become enlarged and painful in almost any disease, 
 however trifling. Enlargement of the lymph-nodes is characteristic of 
 measles, rotheln, tuberculosis, syphilis, and many other diseases, and, when 
 acute, is commonly attended with some degree of fever. Glandular fever — 
 Driisenfieber of Pfeiffer — is a definite nosological entity, the predisposing 
 influences to which, except that it is almost exclusively a disease of child- 
 hood, are wholly unknown. It occurs sporadically and in epidemics. 
 
 The EXCITING CAUSE has not yet been determined. 
 
 Symptoms. ^The onset is sudden, with a rise of temperature to 101°- 
 103T. (3S.5°-39.5°C.). There is pain on moving the head and neck, 
 together with nausea, vomiting, and abdominal pain. The angina is not as 
 a rule intense nor of long duration. The adenopathy shows itself upon the 
 second or third day, the glands becoming enlarged in varying degree to 
 the size of a walnut, painful and tender to the touch. There is slight peri- 
 glandular oedema, but no general swelling or redness, and but little diffi- 
 culty in swallowing. In a limited proportion of the cases sul)sternal 
 uneasiness and an unproductive, paroxysmal cough are the signs of impli- 
 cation of the tracheal and peribronchial glands. The axillary, inguinal, 
 and mesenteric glands are sometimes involved. The fever is of short dura- 
 tion but the enlarged glands only slowly undergo involution. Suppuration 
 has been noted. 
 
 Diagnosis. — The direct diagnosis rests upon the presence of the foregoing 
 symptom-complex. The differential diagnosis must be made by exclusion. 
 
838 MEDICAL DIAGNOSIS. 
 
 Prognosis. — Recovery is the rule. The occurrence of suppuration in 
 some of the affected glands, otitis media, retropharyngeal abscess, and 
 severe, even hemorrhagic nephritis may protract the illness or cause it 
 to terminate in death; but these accidents are infrequent. 
 
 XXXIX. MILIARY FEVER. 
 
 Sweating Sickness. 
 
 Definition. — An acute infectious disease, characterized by fever, profuse 
 sweating, and an eruption of miliary vesicles. 
 
 Miliary fever, or the sweating sickness, prevailed extensive!}' in Eng- 
 land in the fifteenth and sixteenth centuries. Outbreaks have occurred 
 within recent years in France, Italy, and Austria. They have sometimes 
 extended over wide areas; more frequently they have been limited to 
 districts or villages. These epidemics have lasted in some instances three 
 or four weeks; in others they have run their course in a week or ten days. 
 When the disease shows itself it attacks, like influenza and dengue, a large 
 number of persons in a very short time. 
 
 Etiology. — Nothing is known of the pathogenic principle which gives 
 rise to miliary fever. 
 
 Symptoms. — After prodromal symptoms of short duration, the attack 
 sets in suddenly with moderate fever, profuse sweating, and epigastric dis- 
 tress. These symptoms are followed by an erythematous rash and the copious 
 eruption of miliary vesicles, most abundant upon the neck and trunk. In the 
 more severe cases the symptoms of an intense infection — high fever, profound 
 depression, hemorrhage, and delirium — are present. Desiccation and desqua- 
 mation occur. The duration of the disease varies from one to four weeks. 
 
 Diagnosis. — Direct. — This rests upon the development of an acute 
 Illness, characterized by the above symptoms, in a large proportion 
 of the inhabitants of a locality in rapid succession, and the absence of the 
 symptoms of influenza, dengue, or other infectious maladies. 
 
 Differential. — The sweating might suggest malaria, but the orderly 
 succession of chill, fever, and sweat which characterize the ague fit in 
 the regularly recurring forms, the well-defined periodicity, the effects 
 of quinine, and the presence of Laveran's parasite in the blood would 
 settle any doubt. Influenza bears a strong resemblance to miliary fever. 
 Its pandemic prevalence, the prominence of catarrhal symptoms, the 
 frequency of high fever, and the absence of the vesicular rash determine 
 the question of diagno.sis. Dengue differs from miliary fever in its geo- 
 graphical distribution, being a disease of tropical and subtropical climates; 
 in its mode of onset and course; in its early arthropathy; in its eruptions; 
 and in the fact that profuse sweating and a copious vesicular eruption are 
 uncommon. Rheumatic fever might suggest miliary fever by the abundant 
 perspirations which are common; but the prominence and migratory char- 
 acter of the arthritis, the higher fever, and the sporadic or endemic occur- 
 rence would at once dispel any uncertainty in regard to the diagnosis. 
 
 Prognosis. — In the more malignant forms death occurs in the course 
 of several hours. The mortality in the early course of epidemics is high. 
 In some of the recent outbreaks the death-rate has been low. 
 
FOOT-AND-MOUTH DISEASE. 839 
 
 XL. FOOT-AND-MOUTH DISEASE. 
 
 Aphthous Fever. 
 
 Definition. — An acute infectious disease of cattle, sheep, and pigs, 
 but also met with less frequently in other domestic animals, characterized 
 by fever, salivation, and a vesicular eruption upon the mucous membrane 
 of the mouth, nose, and conjunctiva, less frequently also upon that of the 
 vulva and upon the udder and teats. In the sheep, goat, and pig the affec- 
 tion manifests itself particularly about the hoof, while in the horse only 
 the oral mucous membrane is involved. This disease, whica occurs in 
 widespread epizootics, is readily transmissible to man, and numerous 
 epidemics have been described. It is more common as a sporadic affection. 
 
 Etiology. — Predisposing Influences. — All those occupations which 
 involve contact with animals suffering from the disease, their fodder or 
 manure, or the stables in which they are housed, predispose to the disease. 
 
 Exciting Cause. — The infecting principle has not been isolated. 
 Its presence in the contents of the vesicles and in the saliva, milk, and 
 urine, has been demonstrated by intravenous and intraperitoneal injec- 
 tion. It retains its virulence in stalls, fodder, and dung heaps for a period 
 of several months, and is capable of transportation to indefinite distances 
 by fomites. The most common source of infection m man is by the raw 
 milk of infected animals. Herbwig's experiments upon himself and his 
 assistants demonstrated this mode of transmission beyond doubt. The 
 cream also contains the virus, as well as butter, curds, and cheese made 
 from the infected milk. The possibility of acquiring the disease bj^ hand- 
 ling the meat of infected animals is to be considered, though prolonged 
 cooking may render it innoxious as an article of food. 
 
 Symptoms. — In man, after an incubation period of from three to 
 five or eight days, the disease begins with lassitude and pains in the head, 
 back, and limbs. These symptoms are associated with dryness of the mouth, 
 difficulty in swallowing, and nervous symptoms, such as vertigo and 
 insomnia. Complete loss of appetite, vomiting, and fever ensue. The last 
 is, however, by no means a constant symptom. In some cases there is 
 nose-bleeding. If the infection has occurred by way of the oral mucosa 
 there are seen, in the course of a day or more, vesicles which come out in 
 successive crops and are preceded by a more or less diffuse and very painful 
 inflammation. In the course of a short time the vesicles increase in size 
 and then rupture, leaving superficial ulcers which graduall}^ heal with 
 scars. There is salivation, great pain in eating, and a fetid breath. Urti- 
 caria and roseolous and scarlatiniform rashes appear, and in some cases crops 
 of vesicles resembling the vesicles upon the mucous membrane of the mouth. 
 The last gradually undergo desiccation and healing without ulceration. 
 When infection takes place by way of lesions upon the skin, constitutional 
 symptoms develop first, vesicles appear near the seat of infection, the 
 above-described rashes follow, and sometimes, but by no means invariably, 
 the vesicles subsequently develop in the mouth. 
 
 Diagnosis. — Direct. — This rests upon the presence of the foregoing- 
 symptoms in an individual who has been exposed to the danger of 
 
840 MEDICAL DIAGNOSIS. 
 
 contact with infected animals or their surroundings, or of eating infected 
 food products. In a doubtful case, experimental inoculation should be 
 practised and for this purpose the calf, on account of its greater suscepti- 
 bility, should be selected. 
 
 Differential. — The ordinary form of aphthous stomatitis is not 
 attended by the constitutional symptoms of a severe infection, nor 
 accompanied by cutaneous rashes. The vesicles run their course so rapidly 
 that they are seldom seen prior to the formation of the circumscribed painful 
 ulcers, with sharp edges and yellow bases, to which they give rise. The 
 acute exanthemata may be suggested by the constitutional symptoms 
 and the buccal and cutaneous eruptions. Varicella, however, usually lacks 
 the fever and lassitude of foot-and-mouth disease; measles is character- 
 ized by catarrhal symptoms not present in the affection, and scarlet fever 
 by a diffuse non-vesicular angina and generalized erythema developing 
 within forty-eight hours after an abrupt onset. Diphtheria, which may be 
 suggested by the appearance of the ulceration in the mouth in certain 
 cases, reveals its pathological identity by the Klebs-Loffler bacillus. In 
 any suspicious case the etiological factor in diagnosis is important. 
 
 Prognosis. — In a majority of the cases in adults recovery takes place 
 in two or three weeks. Owing to the difficulty in taking food, and the 
 serious nature of the gastro-intestinal derangements in children, the out- 
 look is far more serious, and progressive emaciation and debility are fre- 
 quently followed by death. Septic infection by way of the mucous and 
 cutaneous lesions may prolong the illness. 
 
 XLI. ERYSIPELOID OF ROSENBACH. 
 
 Erythema Migrans; Erythema Serpens. 
 
 Definition. — An erythematous inflammation of the fingers, due to 
 the inoculation of an, as yet, undetermined pathogenic principle, associated 
 with putrescent animal matter, and characterized by swelling, tension, 
 dark red or purplish discoloration, well-defined edges, and a tendency to 
 advance from the point of origin, with moderate pain, some itching and 
 burning, and the absence of constitutional symptoms. 
 
 Etiology. — Predisposing Influences. — Erysipeloid is a compara- 
 tively rare disease. It has been especially studied by Rosenbach in Germany 
 (1887), and Gilchrist (1904) and Jopson (1908) in this country. Occupa- 
 tion constitutes the most important predisposing influence. The affection 
 occurs almost without exception among those who are engaged in handling 
 dead animal matter under conditions which render it liable to putrefaction, 
 as dealers in fish (especially shell-fish), game, and poultry, and butchers 
 and cooks. Medical students, laboratory workers, and taxidermists are also 
 liable to the infection. Those who handle crabs are especially exposed to 
 the danger of contracting erysipeloid, which is sometimes spoken of as 
 "crab cellulitis." 
 
 Exciting Cause. — Rosenbach and others have described a cladothrix, 
 but subsequent investigators have failed to obtain such an organism. 
 The manner of inoculation, the nature of the lesions, the constant cHnical 
 
ERYTHEMA INFECTIOSUM. 841 
 
 course of the disease, and the pathological findings, which are those of 
 an inflammation of the entire corium, and, to some extent also, of the 
 subcutaneous tissue, are suggestive of a specific infection. No specific 
 organism has, however, been demonstrated. 
 
 Symptoms. — The infection results from an injury to the skin. There 
 may be a number of small wounds. The period of incubation varies from 
 a few hours to several days, being commonly, however, about forty-eight 
 hours. The inflamed skin is tense, livid, elevated above the level of the 
 adjacent surface, and characterized by a sharply defined border which 
 advances toward the hand and may invade the palm, the dorsum of the 
 hand, and other fingers than the one first affected. As the border advances 
 resolution takes place in the part first attacked. Suppuration does not 
 occur nor do vesicles, as a rule, develop. Complete recovery takes place in 
 a period varying from two or three to ten or fifteen days. Fever and 
 other constitutional symptoms do not occur. 
 
 Diagnosis. — The direct diagnosis rests upon the foregoing characters 
 and may usually be made without difficulty. The differential diagnosis 
 from the cellulitis caused by pyogenic organisms rests upon the mode of 
 infection in the latter, the occurrence of suppuration, and the presence of 
 pus-producing bacteria in the exudate; and from erysipelas by the absence 
 of constitutional symptoms and the trifling nature of the erysipeloid 
 affection. The prognosis is uniformly favorable. 
 
 XLII. ERYTHEMA INFECTIOSUM. 
 
 In 1896 Escherich described a feebly contagious disease of childhood 
 characterized by a rose-colored maculopapular rash with trifling subjec- 
 tive symptoms, among which a mild erythematous sore throat is mentioned. 
 The incubation period varies from six to fourteen days and the rash 
 appears first upon the face and consists of maculopapules, in some instances 
 sharply marginate, in others gradually fading into the healthy sldn. It 
 disappears momentarily upon pressure. In the course of twenty-four 
 hours it invades other parts of the body, sometimes presenting the appear- 
 ance of urticaria. It is especially marked upon the extensor and outer 
 surfaces of the extremities. It lasts from six to ten days, fading first 
 upon the face, where it first appeared, and is not followed by desquama- 
 tion. The superficial lymph-nodes are not enlarged. The attack does not 
 confer immunity from scarlet fever, measles, or rubella. No outbreaks 
 have been observed in America. The direct diagnosis rests upon the char- 
 acter of the rash and its distribution, the absence of constitutional symp- 
 toms, and mild transmissibility. The differential diagnosis from these 
 diseases depends upon the absence respectively of their specific etiologic 
 and clinical manifestations. Erythema infectiosum bears only the most 
 remote resemblance to scarlet fever, measles, rubella, urticaria, and certain 
 drug rashes. 
 
842 MEDICAL DIAGNOSIS. 
 
 II- 
 
 THE DIAGNOSIS OF DISEASES CAUSED BY ANIMAL PARASITES. 
 
 A. DISEASES DUE TO PROTOZOA, 
 i. Psorospermiasis. 
 
 This term is applied to the diseases produced by the sporozoa other 
 than hsemospiridia — protozoa that only live parasitically in the cells, tumors, 
 or organs of other animals. They are mostly cytozoa. This class includes 
 Gregarinida and Coccidiidea. The latter is the cause of a disease common 
 in the rabbit in which the liver is the seat of small whitish nodules, seen 
 upon section to be dilatations of biliary ducts. Coccidia are found in the 
 epithelial cells lining these cyst-like dilatations. Rainey's corpuscles or 
 tubes are ovoid bodies containing sickle-shaped, unicellular organisms — 
 Sarcocystis miescheriana — found within the sarcolemma of various ani- 
 mals, especially the hog. 
 
 Visceral Psorospermiasis; Coccidiosis. — Infection takes place by 
 swallowing the spores or oocj^sts containing spores. The gastric juice 
 causes the spores to open and frees the sporocytes, which by way of the 
 common duct reach the biliary ducts and penetrate the epithelial cells. 
 A limited number of cases has been observed in man. 
 
 Symptoms. — Those of severe infection: fever (sometimes intermittent), 
 dry tongue, nausea, diarrhoea, and tenderness over the liver and spleen, 
 which are enlarged. The parasites have also been found in the ureters 
 and kidneys. The diagnosis during life has not been made. 
 
 ii. Amoebic Dysentery. 
 
 Definition. — A colitis caused by Amoeba dysenterige and character- 
 ized by pain, tenesmus, and frequent stools containing mucus and blood. 
 Dysentery occurs as an acute and chronic disease. Liver abscess is common. 
 
 Etiology. — Predisposing Influences. — Dysentery is more prevalent 
 in tropical countries. In Egypt and India it is endemic, frequently epi- 
 demic. It occurs sporadically in all temperate climates. It is a water- 
 borne disease and infection may take place by drinking contaminated water, 
 or eating raw vegetables washed with it. 
 
 Exciting Cause. — Amoeba dysenterire, first described by Lambl in 
 1859, later by Losch in 1875, is classed among the Rhizopoda. This organ- 
 ism frequently exhibits the differentiation betw^een the hyaline ecto- and 
 the granular endosarc very clearly, especially in the pseudopodia. It 
 contains a vesicular nucleus and contracting vacuoles. Amoebse are seen 
 in great numbers in the stools, being found especially in the shreds of 
 mucus or pus, in the pus of liver abscess and abscess in other positions 
 which occasionally occur, and in the purulent expectoration in hepatic 
 abscess discharging by way of a pulmonary fistula. An amoeba frequently 
 
DISEASES DUE TO PROTOZOA. 843 
 
 contains red blood-corpuscles. They can be grown in cultures from the 
 stools and intestinal ulcers but not readily alone, a symbiotic organism 
 being required. Amoeba coli has been found in the stools of healthy per- 
 sons. There may be different varieties, of which some are non-pathogenic. 
 
 The lesions to which this organism gives rise are situated in the large 
 bowel, sometimes reaching as high as the lower part of the ileum. They 
 consist of an inflammatory infiltration of the submucosa, followed by 
 necrosis and sloughing of the mucous membrane, which results in the 
 formation of circumscribed round, oval, or irregular ulcers with overhanging 
 borders. The base of the individual ulcer consists, according to stage of 
 development, of the submucous, muscular, or serous coat of the gut. There 
 is a remarkable tendency to extend by undermining the mucous mem- 
 brane with the formation of deep, 
 serpiginous ulcerating tracts or fis- ^^s^ 
 
 tula. In severe cases the entire I^O-"-''' ,__ ^y, WJ 
 
 intestine is greatly thickened and "■^' ^ ^-^ 'l|j|ID"^'--: 
 
 extensively ulcerated. When the \ ■^, 
 
 process is less extensive, the rectum, "- \^'^'' . ^ 
 
 the hepatic and sigmoid flexures, and ' - v'' ', ', ' " 
 the caecum are points of selection. 
 
 Healing leads to extensive new form- - 
 
 ation of fibrous tissue and constric- ^'3' .. ;>C''^"""^^ ■ 
 
 tion of the bowel. 
 
 The lesions of the liver consist 
 of, (a) local necrosis of hepatic tissue 
 
 in scattered patches, and (b) abscess -. . ^g, %'t^ If^'v 
 
 formation. The abscess may be 
 multiple and scattered throughout 
 the organ, or single. The latter are 
 usually situated in the right lobe and ' ^Ty'' 
 under the convex or diaphragmatic i .-.. . .• . _ [■^T^"^] 
 
 surface; less frequently near the Fig. 283.— Amceba dysenterite. 
 
 concave intestinal surface. In the 
 
 former case rupture frequently takes place into the lung or pleura. 
 Less commonly, according to its location, the abscess may rupture into 
 the inferior vena cava, pericardium, peritoneum, stomach, intestine, or 
 the portal or hepatic vein. 
 
 Symptoms. — AcL'TE Form. — This form is characterized by sudden 
 onset, pain, tenesmus, frequent stools containing blood and mucus. Large 
 sloughs may be passed. There is fever, not often intense. Rapid emaciation 
 occurs and the patient maj^ die in the course of a week or two. Hemorrhage 
 of the bowels may take place or perforation with peritonitis. Recovery 
 is, however, the rule. In a considerable proportion of the cases the disease 
 becomes chronic. There is a moderate leucocytosis — 9000 to 16,000. 
 
 Chronic Form. — The disease may be insidious in onset. There are sub- 
 acute d5''senteric attacks with pain, frequent stools, mucus and blood, and slight 
 fever. These spells alternate with periods of constipation. The patients may 
 have fairly good health, but are liable to indigestion, and the attacks are 
 readily brought on by errors of diet, over-fatigue, sudden chilling and the like. 
 
 ■^^^" 
 
844 
 
 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — Direct. — The intestinal symptoms — pain, tenesmus, fre- 
 quent stools with blood and mucus — justify a diagnosis of dysentery; the 
 presence of amoebae in the discharges, a diagnosis of amcebic dysentery, 
 alike in the acute and chronic cases. 
 
 Hepatic abscess maybe entirely latent. More commonly there is enlarge- 
 ment of the liver at its upper or lower aspect with recurrent chills, fever, sweat- 
 ing, local pain, and oedema. The leucocytosis is high. With the establishment 
 of a pulmonary fistula there is dark expectoration containing amoebae. 
 
 Differential. — Bacillary Dysentery. — The diagnosis rests upon the 
 absence of amoebae and the agglutinating power of the blood-serum for 
 the bacilli, and the more pronounced toxaemia. Proctitis. — Tenesmus and 
 mucohemorrhagic stools may suggest dysentery, but the slight and 
 transient nature of the attack and its manifest local character are of diag- 
 nostic importance. 
 
 Prognosis. — Many cases recover but the tendency to recurrence is marked. 
 The mortality is about 25 per cent. Hepatic abscess adds greatly to the grav- 
 ity of the outlook. 
 
 iii. Trypanosomiasis. 
 
 Sleeping Sickness. 
 
 Definition. — A chronic disease caused in man by Trypanosoma 
 gambiense and characterized by undulant fever, rapid pulse, weakness, 
 
 _^ loss of flesh, and frequently a pro- 
 tracted lethargy. 
 
 Etiology. — Predisposing In- 
 fluences. — As a disease of horses 
 and cattle trypanosomiasis is known 
 as siirra in India and the Philippines 
 and is prevalent in South Africa. 
 Africa has, in fact, no less than six 
 trypanosomal diseases, all of them 
 very important: nagana, dourine, 
 galziekte, zouspana, Gambian horse 
 disease, and human trypanosomiasis. 
 Human trypanosomiasis is widely 
 distributed in Uganda and the West 
 Coast of Africa. It is conveyed by 
 the tsetse fly. 
 
 Exciting Cause. — This flagel- 
 late protozoon was first discovered 
 by Gruby in the blood of the frog 
 in 1843. The organism is a unicel- 
 lular, elongated body having an 
 undulating fold or membrane upon 
 the dorsal edge which terminates 
 in a flagellum of varying length. 
 Stained specimens show a large nucleus and a small chromatin mass near one 
 pole. It has recently been grown by Novy on artificial media in the labo- 
 
 fit-rofti 
 
 Fig. 284. — Trypanosoma gambiense. — After Bruce 
 and Nabarro. 
 
DISEASES DUE TO PROTOZOA. 845 
 
 ratory. It was later noted to be a common blood parasite in birds and fishes. 
 It was found in 1878 by Lewis in the rat and subsequently in cattle and 
 horses by Evans (1880) and Bruce (1895). Dutton first recognized trypano- 
 somes in the blood of human beings in 1902. Trypanosomes have been 
 observed with great frequency in the sleeping sickness or African lethargy 
 and have a causal relation to that disease. 
 
 Symptoms. — As in the case of rats and other animals, trypanosome 
 infection may be latent in human beings. Trypanosome Fever. — The 
 symptoms consist of irregular fever, rapid pulse, weakness, swelling of the 
 lymph-nodes and spleen, and oedema of the feet. This form of the disease 
 has been produced in monkeys by inoculation. Sleeping Sickness. — The 
 period of latency may be extremely prolonged, in some instances reaching 
 five years. In a case of Manson's, symptoms developed in a fortnight. 
 The early symptoms are dulness, apathy, headache, fever, difficulty in 
 walking, tremor of the hands, and mumbling speech. The fever and 
 drowsiness increase, the patient has to be aroused to take food and finally 
 cannot be aroused at all. Death usually results from some complication, 
 as septic meningitis. 
 
 Diagnosis. — Direct. — Exposure in an infected region, the history of 
 an insect bite (especially by the African tsetse fly, Glossina palpalis), the 
 varying but prolonged period of latency, the peculiar symptom-complex 
 (especially the progressively deepening lethargy), and the presence of try- 
 panosomes in the blood and cerebrospinal fluid are characteristic. 
 
 Prognosis. — Sleeping sickness is a very fatal disease. The duration 
 after distinctive symptoms have occurred varies from three to twelve 
 months. Recoveries have followed treatment by atoxyl. 
 
 iv. Dum=dum Fever. 
 
 Kala-azar. 
 
 Definition. — A chronic disease of the East due to a protozoon of 
 the flagellate type and characterized by irregular fever, pulmonary con- 
 gestion, anaemia, recurrent oedema of the feet, enlargement of the spleen 
 and liver, and occasionally subcutaneous hemorrhages. This disease 
 is identical with tropical cachexial fever and has been called Leishman- 
 Donovan disease. 
 
 Etiology. — Predisposing Influences. — Dum-dum fever is prevalent 
 in Oriental countries and occurs in Egypt. The European races rarely suffer. 
 
 Exciting Cause. — The bodies discovered by Leishman in 1900 and 
 independently by Donovan in 1903, and regarded by Laveran and Mesnil 
 as a new species of Piroplasma, have been found in the liver and spleen 
 by puncture during life and also, in the majority of cases, in the circulating 
 blood. They have been found in the mesenteric glands, intestinal ulcers, 
 and bone-marrow. In stained smears of the fluid from the spleen and liver 
 they appear as elongated oval or circular bodies with a spherical nucleus 
 against the capsule and a rod-like body on the other side. They occur singly 
 and in pairs and packed in phagocytic cells in the juice of the liver and 
 spleen and in zoogloea masses in the lung. Malarial parasites are not found. 
 
846 
 
 MEDICAL DIAGNOSIS. 
 
 Symptoms. — Constant enlargement of the spleen; usual but not 
 invariable enlargement of the liver; moderate anemia; leucopenia; irreg- 
 ular fever prolonged for many months with occasional remissions; hemor- 
 rhages, subcutaneous and from mucous surfaces, especially the gingival 
 and nasal mucosa; transitory oedemas, particularly of the legs and feet; 
 and more or less marked pallor and pigmentation of the skin — these consti- 
 tute the clinical picture. Dysenterj' and various secondary infections occur. 
 Prognosis. — Two forms of the disease are encountered, an intense form 
 with recurrent attacks of high fever and rapidly developing cachexia, 
 which terminates fatally in a few months, and a much milder form both 
 
 as regards fever and cachexia, 
 which runs a protracted 
 course, death usually resulting 
 from some intercurrent dis- 
 ease. The mortality, according 
 to Leishman, varies from 70 
 to 96 per cent. 
 
 V. Malarial Fevers. 
 
 Definition. — A group of 
 infectious diseases caused by 
 the Hsemosporidia (Plasmo- 
 dia) described by Laveran 
 and transmitted to man by 
 the bite of the similarly infected 
 mosquito, comprising, (a) regu- 
 larly intermitting periodical 
 fever of tertian or quartan 
 type, (b) irregular fever of 
 remittent or continued type, 
 and (c) a chronic cachexia 
 
 Fig. 285. — Leishman-Donovan bodies. 1, three par- 
 asites showing chromatin masses; 2, 3, 4, 5, parasites showing 
 fission. — After Christophers, a, parasite from spleen; 6, c, d, 
 e, large parasites from cultures; f,g.h, bodies showingflagella; 
 i. j, k, forms exhibiting unequal longitudinal fission; I, two 
 spirillar forms separated from parasite. — After Leishman. 
 
 -The geographical distribu- 
 
 and pernicious fever, often rapidly fatal, 
 with anaemia and enlargement of the spleen. 
 Etiology. — Predisposing I^FLUENCES 
 tion, formerly wide, is becoming more restricted. The conditions necessary 
 for the breeding of the mosquito, namely, heat and moisture, are every- 
 where predisposing factors to malaria. Regions of special prevalence are 
 found in tropical and subtropical countries, as Panama, Central America, 
 India, and Northern Africa, especially along the coasts and in the river 
 basins. In Europe, Southern Russia and Lower Italy are still highly 
 malarious. Germany and France are almost free, while the prevalence of 
 the disease in Holland and England has practically ceased. In the United 
 States the malarial fevers have steadily diminished since the colonial period. 
 At the time of the first settlement of the country the prevalent fevers were 
 malarial; as clearings Avere made and the soil tilled and drained, malarial 
 fevers and enteric fever prevailed side by side until at length malarial 
 fevers disappeared and enteric fever became predominant. Malarial fever 
 has almost disappeared from New England and New York. It is now com- 
 paratively infrequent in Eastern Pennsylvania, New Jersey, and Maryland. 
 
DESCRIPTION OF PLATE XIII. 
 
 The Parasite of Tertian Fever. (Drawn b}' Mr. Br5del for Thayer and Hewetson's paper, The Malarial 
 Fevers of Baltimore, Johns Hopkins Hospital Reports, Volume V. We copy the original legend.) 
 
 1. Normal red corpuscle. 
 2, 3, 4. Young hyaline forms. In 4, a corpuscle contains three distinct parasites. 
 5, 21, Beginning of a piginentatiou. The parasite was observed to form a true ring by the confluence 
 of two pseudopodia. During observation the body burst from the corpuscle, which became 
 decolorized and disappeared from view. The parasite became, almost immediately, 
 deformed and motionless, as shown in Fig. 21. 
 6, 7, 8. Partly developed pigmented forms. 
 
 9. Full grown body. 
 10-14. Segmenting bodies. 
 
 15. Form simulating a segmenting body. The significance of these forms, several of which have 
 been observed, is not clear to the writers, who have never met with similar bodies in stained 
 specimens so as to be able to study the structure of the individual segments. 
 16, 17. Precocious segmentation. 
 18, 19, 20. Large swollen and fragmenting extra-cellular bodies. 
 22. Flagellate body. 
 23, 24. "Vacuolization. 
 
 The Parasite op Quartan Fever. 
 
 25. Normal red corpuscle. 
 
 26. Young hyaline form. 
 
 27-34. Gradual development of the intra-corpuscular bodies. 
 
 35. Full grown body. The substance of the red corpuscle is no more visible in the fresh specimen. 
 36-39. Segmenting bodies. 
 
 40. Large swollen extra-cellular forms. 
 
 41. Flagellate body. 
 
 42. Vacuolization. 
 
PLATE XIII. 
 
 9 
 
 CJ^ 
 
 ^:-'. 
 
 m 
 
 ^ 
 
 
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 '"&\f ' ■"^^^. 
 
 o 
 
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 •V*'. 
 
 
 
 • 
 
DISEASES DUE TO PROTOZOA. 847 
 
 It still prevails in many regions of the South, especially on the Gulf Coast. 
 The Northwestern States, the Pacific Coast, and the regions north of the 
 St. Lawrence are practically free from it. 
 
 Season. — In the tropics the maximum prevalence corresponds to the 
 rainy season, the minimum to the dry. In temperate climates there are 
 a few cases in the spring, usually relapses — vernal intermittent. The greater 
 number of cases occur in the early autumn — primary infection. 
 
 Locality. — Genera of the subfamily Anophelina, the only mosquitoes 
 in which the malarial parasite of man develops, are distinctly rural insects, 
 breeding in small, shallow pools and stagnant waters, in contradistinction 
 to Culicinse, which prefer human habitations and cities and deposit 
 their ova in tanks and cisterns. Hence malarial diseases prevail more 
 extensively outside of cities. 
 
 Exciting Cause. — To Laveran, a French Army surgeon, is due the 
 credit of having discovered in 1880, in Algiers, in the blood of patients 
 suffering from malarial fever, the hsematozoon which he recognized as 
 parasitic and regarded as the cause of the disease. A great number of 
 observers have contributed to our knowledge of the subject. Among the 
 most important steps in the development of that knowledge are the follow- 
 ing: that the febrile paroxysm coincides with the sporulation or segmen- 
 tation of a group of parasites; that the tertian, quartan, and pernicious 
 fevers are due to different parasites; that infection takes place by the bite 
 of the mosquito, species of the subfamily Anophelinse; that the infecting 
 mosquito must itself be previously infected by the blood of an individual 
 suffering from malaria; and that the malarial parasites of man require 
 two different hosts for their complete development — the asexual cycle 
 taking place in the blood of man, the intermediate host, and the sexual 
 cycle in Anophelinffi, the definitive host. So far as our present knowledge 
 of the life history of the malarial parasites goes they exist only in the 
 mosquito and man. 
 
 The parasite belonging to the class Sporozoa, order Hsemosporidia, 
 has received many different names. It was designated Plasmodium malarice 
 by Marchiafava and Celli, and this term, although unsuitable according to 
 the rules of zoological nomenclature, has remained in general use. 
 
 The Parasite in Man. — Schizogonous Cycle. — Three species are recog- 
 nized, differing morphologically and in the form of fever which they cause. 
 They are (a) the tertian (Plasmodium vivax), (b) the quartan (Plasmodium 
 malarise), and (c) the estivo-autumnal (Plasmodium immaculatum). 
 
 Tertian Parasite (Plasmodium vivax). — This species is the cause 
 of tertian fever. Its cycle of development occupies forty-eight hours. 
 It appears first in the red blood-corpuscles as a round or irregular unpig- 
 mented body which gradually increases in size. In the course of a few 
 hours it has become ring-shaped and shows fine melanin granules. It 
 contains a large nuclear body in which there is a small chromatin mass. 
 There are now active amoeboid movements which do not cease upon expo- 
 sure to the temperature of the room. .The affected blood-corpuscles become 
 enlarged and lose their color. The pigment increases in amount. Toward 
 the end of forty-eight hours the full-grown parasite occupies the greater 
 part of the swollen corpuscle. At this time many of the parasites undergo 
 
848 MEDICAL DIAGNOSIS. 
 
 the process known as segmentation or sporulation, in which the melanin 
 granules are collected into a compact mass and the protoplasm divides 
 into spores, numbering from 15 to 20, mostly collected into an irregular 
 heap around the pigment mass, sometimes having a radial arrangement. 
 The spores — merozoites — which represent the sexually undifferentiated 
 individuals, finally separate from the central mass of pigment granules 
 and from each other, pass into the blood-serum, and, attacking fresh blood- 
 corpuscles, cause subsequent paroxysms of fever. Some of the full-grown 
 tertian parasites do not undergo this process of sporulation, but, attaining 
 a size larger than the reel corpuscles, show abundant coarse pigment 
 granules in active commotion and represent the sexually differentiated 
 forms — gametocytes. 
 
 Quartan Parasite (Plasmodium malarice). — This species is the 
 ■cause of quartan fever. Its cycle of development is seventy-two hours. 
 It appears abruptly after the paroxysm in the form of a small, unpigmented 
 body with sluggish amoeboid movements on the surface of the red corpuscle. 
 As it increases in size it penetrates within the corpuscle, where it presents 
 an appearance very much like that of the tertian parasite, but smaller. 
 At the end of twenty-four hours melanin granules, coarser than those of 
 the tertian parasite and mostly situated at the periphery, begin to form. 
 As the pigment increases and the parasite develops the amoeboid movements 
 become more sluggish and finally cease. Forty-eight hours after the attack 
 the parasites have attained a diameter of one-half to two-thirds that of 
 the corpuscle. In sixty hours they completely fill the corpuscles, of which 
 only a narrow rim of a yellowish-green or brassy tint remains, which in 
 turn presently disappears. The melanin grains assume a radial arrange- 
 ment and move toward the centre, while the periphery now becomes pig- 
 mentless and shows the indication of commencing segmentation, which 
 about the expiration of the third day is complete, each parasite separating 
 into nine to twelve spores, a process corresponding to a fresh attack of 
 fever. Sexually differentiated parasites — gametocytes — persist. 
 
 EsTivo-AUTUMNAL Parasite (Plasmodium immaculatum; Plasmo- 
 dium prcBcox). — This parasite is the cause of estivo-autumnal fever and 
 the various forms of malarial fever designated tropical, pernicious, and 
 malignant. It is very small, not exceeding when fully developed one-third 
 to one-half the diameter of the red blood-corpuscle. It is very active; 
 its pigment is colored, scanty, and finely granular. The affected corpuscles 
 are frequently shrunken, crenated, and brassy. Its cycle of development 
 is forty-eight hours, but the processes of pigment accumulation and develop- 
 ment are not often seen in the peripheral blood since they take place in 
 the spleen, liver, bone-marrow, and cerebral capillaries. The spores are 
 smaller than in the other species, arranged radially, and range in number 
 from 7 to 12. After the illness has lasted some days — never at first — larger, 
 crescentic, ovoid, and round bodies, highly refractive and containing central 
 masses of coarse pigment, are seen. The crescentic and ovoid bodies do not 
 undergo sporulation and represent gametocytes. If the disease continues 
 these bodies increase rapidly and finally may be the only form present. 
 
 These sexually differentiated forms — gametocytes — are incapable of 
 further development within the human host, but in the abstracted blood 
 
DESCRIPTIOX OF PLATE XIY. 
 
 The Parasite of Aestivo-Autujinal Fever. (Drawn by Mr. Brodel for Thayer and Hewetson's paper, 
 The Malarial Fevers of Baltimore, Johns Hopkins Hospital Reports, Vol. V. We copy the original 
 legend.) 
 
 1, 2. Small refractive ring-like bodies. 
 3-6. Larger disc-Like and amoeboid forms. 
 7. Ring-like body with a few pigment granules in a brassy, shrunken corpuscle. 
 8, 9, 10, 12. Similar pigmented bodies. 
 
 11. Amceboid body with pigment. 
 
 13. Body with a clump of pigment in a corpuscle, showing a retraction of the haemoglobin-con- 
 taining substance about th« parasite. 
 14r-20. Larger bodies with central pigment clumps or blocks. 
 
 21-24. Segmenting bodies from the spleen. Figs. 21-23 represent one body where the entire process 
 
 of segmentation was observed. The segments, eighteen in number, were accurately comited 
 
 before separation as in Fig. 23. The sudden separation of the segments, occurring as though 
 
 some retaining membrane were ruptured, was observed. 
 
 2.5-33. Crescents and ovoid bodies. Figs. 30 and 31 represent one body which was seen to extrude 
 
 slowly and, later, to withdraw two rounded protrusions. 
 34, 35. Round bodies. 
 
 36. "Gemmation," fragmentation. 
 
 37. Vacuolization of a crescent. 
 
 38-40. Flagellation. The figures represent one organism. The blood was taken from the ear at 4.15 
 p.m.; at 4117 the body was as represented in Fig. 38. At 4.27 the fiagella appeared ; at 4.33 
 two of the fiagella had already broken away from the mother body. 
 
 41-19. Phagocytosis. Traced by Dr. Oppenheimer with the camera lucida. 
 
PLATE XIV. 
 
 
 o 
 
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 .w> 
 
 ''•l..*'*^ 
 
 o 
 
 oj o 
 
 
 cl) 
 
DISEASES DUE TO PROTOZOA. 
 
 849 
 
 upon the slide or in the intestine of Anopheles the male elements — 
 microgametocytes — form actively moving flagella — viicrogametes — which 
 detach themselves and penetrate into the coarsely granular female forms 
 — macrogametes — which they fecundate. 
 
 The independence of the three species of malarial parasites, dis- 
 tinguished by their morphologic and pathologic characters, has been fully 
 established by the results obtained by the experimental inoculation of 
 the blood of patients suffering from malaria into the veins of healthy 
 persons. After a period of latency, varying with the particular species 
 
 i^HumanCyclem IMosquito Cy cb 
 
 Fig. 286. — Diagram of the complete life-cycle of the estivo-autumnal malaria parasite. 1-7, stages 
 in the development of the asexual cycle (schizogony) ; 8, spores or merozoites; b b', c c', d d', gameto- 
 cytes in blood of man, sexual cycle ; e', macrogamete ; e, microgametocyte ; /, macrogamete penetrated by 
 microgamete ; g, h. i, motile zygote, vermicule, or ookinete ; j-o, stages of development in the stomach wall 
 (sporogony); p, mature oocyst showing sporozoi'tes ; q, sporoid. — Based upon the plates of Grassi. 
 
 under investigation, the inoculated individuals have developed malarial 
 fever, always of the same type as that of the patient from whom the 
 blood was obtained. 
 
 The Parasite in the Mosquito. — The common genera of mosquito in 
 temperate climates are Culex and Anopheles. Of each there are many 
 species. The Culex appears to play no part in malarial infection, but 
 wherever there is malaria the Anopheles is to be found. If the Anopheles 
 has not been infected by sucking the blood of a human being suffering 
 from malaria, it is of course incapable of communicating the disease b}^ its 
 bite, and the parasite does not develop in cold climates. These two facts 
 serve to explain the presence of Anopheles in regions not malarious. Of 
 the many species of Anopheles described, it is probable that in temperate 
 54 
 
850 MEDICAL DIAGNOSIS. 
 
 cHmates the A. maculipennis is most active in the diffusion of malaria. 
 The distinction between Culex and Anopheles under ordinal-}* condi- 
 tions within a house is an easy matter and depends upon the following facts: 
 
 Culex: The Mature Insect. — The palpi in the female are short, pro- 
 jecting only a Httle distance beyond the base of the proboscis. The wings 
 show no special markings. Resting upon the wall or ceiling Culex holds 
 its posterior pair of legs turned up over its back, and its body, unless 
 dragged down by the weight of blood, is nearly j^arallel to the wall or ceiling. 
 
 AxoPHELES. — The palpi in the female are of nearlj^ the same length as 
 the proboscis. The wings of different species show distinct mottlings, 
 hence the names of species — A. maculopennis, A. punctipennis. The pos- 
 terior pair of legs, when the insect is resting, rest upon the wall or ceiling 
 or hang down, and the body is held at an angle of forty-five degrees with 
 the surface upon which it rests. The sex-ripe forms of the malarial para- 
 site, when taken into the stomach of Anopheles, rapidly mature with 
 flagellation and fecundation. The resulting motile fusiform body bores 
 into the wall of the mosquito's stomach and there rests, undergoing a 
 definite cycle of development, with the formation of oocysts at first oval, 
 later globular. The nuclei within these cysts divide into a great number 
 of daughter nuclei, which form sporoblasts, from wdiich sporozoites develop. 
 The mature oocysts burst and discharge their sporozoites into the body of 
 the host. Circulating in the blood these accumulate in the course of a few 
 hours within the cells of the venenosalivary glands and are inoculated 
 with the saHva by the bite of the insect. They are transformed in the 
 blood of the human host into the amoeboid form of the parasite and multiply 
 by sporulation (schizogony) until they attain sufficient numbers to produce 
 the paroxysm of fever. The early generations of parasites in the human 
 host are asexual, sexual differentiation occurring later. 
 
 The asexual forms serve as the means of prolonging the infection in 
 the human host; the sexual forms, sterile so long as they remain in the 
 human host, become fertile in the mosquito and maintain the life and 
 dissemination of the parasite. 
 
 Symptoms. — The cases may be grouped into the regularly intermitting 
 fevers, the irregular, remittent, or continued fevers, and malarial cachexia. 
 
 (a) The Regularly Intermitting Fevers ; the Agues. — 1 . Tertian Fever. 
 2. Quartan Fever. — The period of incubation varies from a few days to 
 a fortnight. Latent malarial infection, not attended by symptoms, may be 
 called into activity by removal from a malarious district, other change 
 of climate, or by an attack of illness. 
 
 The Paroxysm. — The febrile paroxysm, known as the '"chill" or 
 " ague fit," may be divided into three stages: cold, hot, and sweating. 
 
 Cold Stage.— There are usually premonitory symptoms, consisting of 
 lassitude, yawning, epigastric distress, sometimes nausea and vomiting, 
 and headache. Shivering occurs and quickly passes into a full}^ developed 
 rigor with chattering teeth, violent shaking of the whole body, and dis- 
 tressing sensations of cold. The face is cyanotic, the body and limbs 
 covered with goose-flesh, cold to the hand, and showing, when tested by 
 the surface thermometer, a subnormal temperature. At the same time the 
 rectal temperature is high— 105°-106° F. (40.5°-41° C). During this stage 
 
DISEASES DUE TO PROTOZOA. 
 
 851 
 
 nausea, vomiting, and headache may occur. The pulse is small, frequent, 
 and tense. The duration of the stage varies from ten or fifteen minutes 
 to an hour or more. The danger of the attack lies in the prolongation 
 of the cold stage. 
 
 Hot Stage. — The sensations of cold are replaced by those of heat; 
 pallor and cyanosis give way to flushing, and the appearance of collapse 
 is followed by that of more or less intense fever, with bounding pulse, 
 headache, and sometimes delirium. The rectal temperature does not rise, 
 having as a rule reached its maximum about the conclusion of the cold 
 stage. There is urgent thirst and the patient is distressed by subjective 
 sensations of heat. The duration of this stage varies from thirty minutes 
 to three or four hours. 
 
 Sweating Stage. — Perspiration starts in drops upon the forehead and face 
 and soon covers the entire body profusely. In some cases the sweating is 
 moderate. The duration of this stage is variable. At its conclusion the patient 
 commonly falls into a sleep from which he awakes refreshed but weak. 
 
 Fig. 287. — Tertian fever. — Craig. (Inter national Clinics.) 
 
 The duration of the entire paroxysm varies from an hour or two, asr 
 is common among the inhabitants of malarious districts, to six or eight 
 hours. The cold stage is sometimes slight and transient and occasionally 
 not followed by a hot stage. A more common variation from type consists 
 in the hot stage alone, followed by very slight sweating. During the 
 paroxysm the spleen is usually tender and palpable, herpes labialis occurs, 
 and there are the rational symptoms and physical signs of a mild bronchitis, 
 which passes off with the sweating stage. 
 
 In the intervals between the paroxysms the patient commonly feels 
 well and regards himself as in his usual health. The paroxysm is the 
 result of a haemodyscrasia, at once morphological and toxic, produced by 
 the segmentation of the parasites. 
 
 1. Tertian Fever. — In this type, caused by the presence in the 
 blood of the tertian parasite, the paroxysms recur every forty-eight 
 hours or every third day. Hence the name tertian. If two groups 
 of parasites, reaching maturity and undergoing segmentation every alter- 
 nate day, are present, there are daily — quotidian — paroxysms, and the 
 type is double tertian. 
 
852 
 
 MEDICAL DIAGNOSIS 
 
 2. Quartan Fever. — The paroxysm caused by sporulation of the 
 quartan parasites recurs about the end of seventy-two hours, or every 
 fourth day, and is for this reason known as quartan. If two groups of 
 parasites are present, maturing upon different days, paroxysms occur upon 
 successive days followed by a free day — double quartan; if three groups 
 are present the paroxysms occur daily — triple quartan, likewise quotidian. 
 
 Fig. 288. — Double tertian fever. — Craig. (International Clinics.) 
 
 The course of the regularly intermittent malarial fevers is greatly 
 influenced by circumstances. Mild cases frequently recover without treat- 
 ment, especially if removed from the opportunity of further infection and 
 kept in bed. Untreated cases are, however, liable to relapse. The attacks 
 yield promptly to proper treatment by quinine. Repeated reinfection or 
 the persistence of the disease results in ansemia and haemolytic jaundice, 
 ultimately in malarial cachexia. 
 
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 Fig. 289. — Quartan fever. — Craig. (International Clinics.) 
 
 (b) The Irregular, Remittent, Continued, and Pernicious Fevers.— This 
 type of fever prevails in Southern Italy and Russia, tropical countries, 
 and the Gulf Coast of the United States. Its milder forms occur in tem- 
 perate climates, chiefly in the latter part of summer and in the autumn, 
 hence the term estivo-autumnal fever. It is associated with the presence 
 in the blood of the parasite of the same name and is characterized by irregu- 
 
DISEASES DUE TO PROTOZOA. 
 
 853 
 
 larity and intensity. The irregularity is due to the fact that the parasite, 
 which has a cycle of development of apparently forty-eight hours, is sub- 
 ject to great variations in this respect and occurs in multiple groups which 
 do not tend to mature upon certain definite days; the intensity is due 
 to the virulence of the toxins produced by the organisms at the time of 
 sporulation, and their predilection for the cerebral capillaries and peri- 
 vascular spaces. 
 
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 intermittent with prolonged paroxysms, which may occur without chills 
 or chilliness. Another peculiarity is that the temperature rise is gradual 
 and the defervescence by lysis. The tendency to anticipation of the par- 
 oxysm is marked, and this feature with prolongation rapidly converts inter- 
 mittent into a remittent or continued fever. In other cases there is fever 
 of continued type without marked paroxysms, and the clinical picture is 
 suggestive of enteric fever. There is severe headache, flushed face, a bound- 
 
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 Fig. 290. — Estivo-autumna) fever. — Craig. {International Clinics.) 
 
 ing but not dicrotic pulse, and enlargement of the spleen. The tempera- 
 ture range is very often 102°-104° F. (38.9°-40° C.) with remissions and 
 exacerbations like those of enteric fever. Intestinal symptoms are not 
 often prominent. The frequent association of a moderate bronchitis with 
 the foregoing symptoms, together with moderate enlargement and tender- 
 ness of the spleen, adds to the clinical resemblance. Delirium may occur. 
 It is usually mild but may be active. Subicteroid discoloration of the 
 skin is common and begins early, and in a group of cases — bilious remittent 
 of the older writers — deep jaundice is associated with nausea and vomiting 
 and intense headache. The inappropriate and misleading designation, 
 typhomalarial fever, at one time applied to this group of malarial fevers, 
 has fortunately passed into disuse. 
 
 The course of the estivo-autumnal fevers is extremely variable, (a) 
 Mild Forms. — In the mildest cases the attack may run its course with 
 moderate fever and indefinite symptoms. The clinical picture suggests 
 simple continued fever or the mildest form of enteric fever — typhus levissi- 
 mus. (b) Severe Forms. — Other cases are more severe. The fever is 
 characterized by marked remissions and exacerbations. There is intense 
 headache, flushed face, delirium, jaundice, and vomiting, with enlargement 
 
854 MEDICAL DIAGNOSIS. 
 
 of the spleen and liver and epigastric tenderness — bilious remittent fever. 
 (c) Pernicious Fevers. — The important types are (i) the algid, (ii) the 
 comatose, and (iii) the hemorrhagic. 
 
 (i) Algid Form. — The attack may begin T\ath a prolonged chill. 
 More commonly there are merely subjective sensations of cold. Gastric 
 symptoms, nausea, vomiting, epigastric distress, are prominent. Extreme 
 prostration occurs and is associated with a feeble, small pulse and rapid, 
 shallow respiration. Frequent diarrhoea, in some instances attended with 
 rice-water discharges like those of cholera, may be present and with it great 
 diminution of the urine. Fever is at first absent, the temperature being, as 
 a rule, subnormal. Later irregular febrile exacerbations may occur. In 
 default of energetic treatment death takes place in the course of a few days 
 with the evidences of profound asthenia. -Sudoral, syncopal, cardialgic, 
 and choleraic varieties are described. 
 
 (ii) Comatose Foryn. — The attack begins abruptly with cerebral symp- 
 toms, as intense headache with acute delirium or stupor deepening to coma. 
 In some cases the seizure may be apoplectiform. A chili may mark the 
 onset, but this is not invariably the case. There is a hot, dry skin witk 
 high temperature. The patient may die without regaining consciousness; 
 or he may recover consciousness in the course of twelve or twenty-four 
 hours. The second or third attack is usually fatal. 
 
 (iii) Hemorrhagic Form. — This form is also designated hsemoglobinuria 
 and is identical with the African black-water fever. It is rare in tem- 
 perate climates, its chief distribution being on the Gulf Coast of the United 
 States, Central America, Lower Italy, and Africa. The disease is malarial, 
 but whether it is due to a special parasite or not remains to be settled. As 
 a rule the patients have suffered from repeated attacks of malarial fever and 
 are in poor health. Parasites have been found in the blood prior to, and in 
 a more limited number of cases at the onset of, the attack. Later they are 
 not found in a majority of the cases. The evidence that malarial haemo- 
 globinuria is caused by quinine is not conclusive. The attack begins with 
 fever, to which, in the course of a short time, hsemoglobinuria supervenes. 
 
 (c) Malarial Cachexia. — Prolonged exposure in a malarious district 
 with repeated infection by way of the parasites is frequently followed by 
 the development of an ansemia of high grade with enlargement of the 
 spleen. Emaciation, a muddy complexion with general cutaneous pig- 
 mentation, subcutaneous and retinal hemorrhages, breathlessness upon 
 exertion, oedema of the ankles, are usual symptoms. There is irregular 
 temperature varying from normal to subfebrile ranges with occasional 
 exacerbations— 102°-103° F. (.39°-39.5° C). The splenic enlargement is 
 often massive, constituting the tumor known in the Southern States as 
 ''ague cake.'' Hsematemesis occasionally occurs and may be fatal. 
 
 Diagnosis. — Direct. — The recognition of the essential nature of the 
 malarial fevers is not usually attended with difficulty. The two important 
 tests are the presence of the blood parasite and the curative effect of quinine. 
 A history of exposure, the well-defined periodicity of the regularly inter- 
 mitting tertian and quartan fevers, enlargement of the spleen, herpes, and 
 the absence of tuberculosis, syphilis, sepsis, or other causes of period- 
 ical fever are diagnostic criteria of secondary importance. 
 
DISEASES DUE TO FLUKES. 
 
 855 
 
 Differential. — The estivo-autumnal form often closely simulates 
 enteric fever. On the one hand the malarial parasite and control by qui- 
 nine, on the other the Widal reaction and the power] essness of any drug to 
 arrest the course of the attack, are positive tests. The parasites may be 
 demonstrated in fresh blood taken a few hours before the expected chill. 
 In doubtful cases a carefully prepared cover-slip preparation of the blood 
 may be stained for examination. The intermittent pyrexia which refuses 
 to yield to quinine in daily doses of 15 to 20 
 grains — gramme 1 to 1.3— properly admin- 
 istered by the mouth or hypodermically is 
 not malarial. The masked intermittents — 
 dumb ague — blurred types — which occur in 
 persistent infections or after inadequate treat- 
 ment manifest themselves by indefinite symp- 
 toms and attacks of irregular fever or an 
 afebrile temperature with an occasional chill. 
 Here the therapeutic test is conclusive. In 
 septic states wdth intermittent pyrexia, abscess, 
 malignant endocarditis, hepatic fever, and the 
 like a study of the blood is important, since 
 leucocytosis, which does not often occur in 
 uncomplicated malaria, is usually present in 
 these conditions. 
 
 Prognosis. — The malarial fevers of the 
 regularly intermitting forms and the estivo- 
 autumnal fevers of temperate climates yield 
 readily to treatment by quinine. If neglected 
 or when reinfection occurs they recur from 
 year to year with vernal or autumnal relapses. 
 Malarial cachexia may thus develop. The 
 prognosis in the tropical forms of estivo- 
 autumnal fever is grave. Life can be saved 
 in many of the cases only by the prompt, 
 skilful, and judicious administration of quinine Sect "o/q^hlhll"'— cirmin HospuS* 
 in sufficient doses, and the removal of the 
 
 patient from the danger of reinfection. The prognosis in malarial 
 cachexia is fairly good. Health may be regained by proper treatment 
 sufficiently prolonged. The main indication is the avoidance of reinfection. 
 
 
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 B. DISEASES DUE TO FLUKES-DISTOMIASIS. 
 
 The parasitic trematodes are wddely distributed among vertebrate 
 animals. These are important in man: (1) Fasciola hepatica — Distomum 
 hepaticum; (2) Paragonimus westermani — Distoma pulmonis; (3) Fascio- 
 lopsis (Distoma) buski; and (4) Schistosomum haematobium — Bilharzia 
 hsematobia. The following clinical forms of distomiasis are to be considered. 
 
 \. Hepatic Distomiasis. — Several species of liver flukes have been 
 observed in man, of which the most important is Opisthorchis sinensis, 
 widely distributed in the East, especially in Tonquin, China, and Japan. 
 
856 
 
 MEDICAL DIAGNOSIS. 
 
 Imported cases have been encountered in the United States. This para- 
 site is 10-14 mm, long by 2.4-3.9 mm. broad. The eggs are oval with a 
 well-defined operculum at the pointed pole. They measure 0.027-0.030 
 by 0.015-0.0175. The parasite infests the gall-bladder and gall-ducts of 
 domestic dogs and cats and human beings. They have also been found in 
 the pancreas of human beings. Their number is sometimes enormous. 
 The changes produced in the gall-ducts are local dilatations with sac- 
 culation and proliferation of the connective tissue of the wall, and in 
 
 the liver interstitial hepatitis 
 followed by atrophy. 
 
 Symptoms. — Intermit t ent 
 diarrhoea, sometimes bloody; en- 
 largement of the liver, with pain, 
 and jaundice which is intermittent; 
 and slight fever. After two or three 
 years oedema of the feet occurs, 
 followed by anasarca and ascites. 
 The ova are found in the stools. 
 Recovery takes place, but relapses 
 occur. The mortality is about 
 14 per cent. 
 
 2. Pulmonary Distomiasis. — 
 Paragonimus (Distoma) westermani 
 has been observed in China, Korea, 
 Formosa, and Japan. Imported 
 cases have been studied in the 
 United States. The body is red- 
 dish-brown in color and plump. It 
 is 8-10 mm. in length, 4-6 mm. in 
 breadth. The eggs are oval, brown- 
 ish-yellow, thin-shelled, and have 
 approximate average diameters of 
 0.09 mm. in length by 0.06 mm. in 
 breadth. They are found in large 
 numbers in the sputum. 
 
 Symptoms. — There is cough and 
 blood spitting but the symptoms 
 are usually slight. The patients are able to follow their occupations. 
 Copious haemoptysis sometimes occurs. Males are principally affected; 
 women and children rarely. The mode of infection has not been discovered. 
 
 3. Intestinal Distomiasis. — Fasciolopsis (Distoma) buski has only 
 been observed in the intestine of man. The cases have occurred in East- 
 ern and Southern Asia. Seven cases only have been reported (Braun). 
 
 4. Haemic Distomiasis — Bilharziasis. — A parasitic disease endemic in 
 Egypt, Abyssinia, The Sudan, and in many other districts of Africa. There 
 appears to be a centre of infection in Arabia. Elsewhere beyond the 
 borders of Africa it is encountered in imported cases. The parasite — 
 Schistosomum haematobium — was discovered by Bilharz in 1852. Unlike 
 the other flukes the sexes are separate and the male carries the female in 
 
 Fig. 292. — 1. Fasciola hepatica. — After Glaus. 2. Egg 
 of parasite. — After Braun. 
 
DISEASES DUE TO FLUKES. 
 
 857 
 
 a gynsecophorous canal. The male is of a whitish color and 12-14 mm. in 
 length, varying from 1 mm. to 0.4-0.5 mm. in diameter. The dorsal surface 
 of the posterior part of the body is covered with spinous papillae. The 
 female is filiform, pointed at the ends, about 20 mm. in length, and 0.25 mm. 
 in diameter. The eggs are oval, of a transparent yellow color, thin-shelled, 
 and provided with a terminal spine. They vary greatly in size. They 
 hatch in water. The development of the embryo has not been worked out. 
 Whether infection takes place by the mouth, the urethra, or through the 
 skin in bathing is unknown. The young specimens are found in the portal 
 vein, the sexes separate. Hence the males bearing the females penetrate 
 
 Fig. 293. — 1. Paragonimus westermani. — After Leukart. 2. Egg of parasite. — After Katsurada. 
 
 to the venous plexus of the pelvis, from which they reach the wall of the 
 bladder and rectum, the ova being deposited in the tissues but wandering 
 by means of the spine and being voided with the fseces and urine. They 
 are easily found in the latter, especially in the flakes of mucus present. 
 Many remain in the tissues, causing inflammatory irritation, fibroid thick- 
 ening, and papillomatous growths. Others collecting within the bladder 
 perish and undergo calcification, thus forming the nuclei of the vesical 
 calculi so common in' bilharziasis. The ova may be transported to distant 
 parts by the blood stream, and have been found in all the organs, though 
 in small numbers. 
 
 Symptoms. ^The infection is sometimes latent, the parasites giving 
 rise to no symptoms. This is especially the case while they remain in the 
 portal vein. Early symptoms are catarrh of the bladder, with pain in the 
 
858 MEDICAL DIAGNOSIS. 
 
 bladder and rectum and in the lumbar region. The urine is at first normal 
 in appearance, but after a time there is tenesmus with bloody mucus and 
 pus at intervals or daily. As the disease progresses the vesical inflammation 
 becomes more intense, the urine contains blood and pus in increasing 
 quantities, and calculi are found which produce their characteristic symp- 
 toms. The ureters, the pelvis of the kidneys, the kidneys, the rectum, and 
 occasional^ the vagina become involved. The nutrition is greatly impaired 
 and death may result from general marasmus. In a considerable proportion 
 of the cases it is due to urgemia, sepsis, or an intercurrent pneumonia. 
 Perineal and urethral abscess formation is comm^on. 
 
 Diagnosis. — The urinary symptoms are suggestive and the direct 
 diagnosis may be made bj^ finding the characteristic ova in the bloody 
 urine or in the blood and mucus discharged from the rectum. 
 
 Prognosis. — In mild infections under circumstances in which rein- 
 fection can be avoided, the symptoms sometimes disappear. As a rule, 
 the prognosis is highly unfavorable both as to mitigation of suffering and 
 as to recovery. 
 
 Katsurada in 1904 described a fluke, closely resembling Schistosomum 
 haematobium, to which he attributed an endemic disease, characterized by 
 enlargement of the liver and spleen, cachexia, and ascites, and to which he 
 gave the name S. japonicum. Three months later the same parasite was 
 found by Dr. John Catto and named by Blanchard Schistosoma cattoi. 
 The ova are smaller than those of S. haematobium, brownish in color, and 
 not provided with the characteristic terminal spine. This parasite infests 
 the blood-vessels of the intestinal canal and the organs related to it, and 
 the ova are found in the faeces. 
 
 In Porto Rico there exists a rectal form of bilharziasis in which 
 the ova are lateral-spined. Sambon has considered this a new species 
 and has called it S. mansoni. 
 
 C. DISEASES DUE TO CESTODES. 
 
 Tapeworms ; Hydatid Disease. 
 
 i. Intestinal Cestodes — Tapeworms. 
 
 Ce.stodes are flat worms without mouth or intestine, consisting of a 
 scolex and proglottides, which develop by generation in alternate hosts 
 and by gemmation with elongated tape-like colonies. They combine, 
 except in a limited number of species, the male and the female sexual 
 organs in the same segment. The scolex or head serves as the means of 
 attachment for the entire worm to the wall of the intestine and is for that 
 purpose provided with suctorial organs and clinging organs or booklets. 
 These organs of attachment are differently arranged in different species. 
 The narrow thread-like part immediately posterior to the scolex is known 
 as the neck. The proglottides or segments are joined to the scolex longi- 
 tudinally in such a manner that the youngest proglottis is nearest the neck 
 and the oldest most distant from it. 
 
 The number of segments varies in different species from a few to several 
 hundred. They are quadrangular and, as a rule, the younger ones have 
 
DISEASES DUE TO CESTODES, 
 
 859 
 
 their long diameter transverse to the long axis of the worm, those in the 
 middle are squarish, and the most distant have their long diameter in the 
 long axis of the worm. The lateral borders usually converge toward the 
 anterior extremit}^ in such a manner that the anterior border of the seg- 
 ment is shorter than the posterior border of the next younger segment 
 to which it is attached. About the middle of one margin is the projection 
 of the genital pore alternating irregularly. The uterus has a median trunk 
 with lateral branches, which may be seen when the 
 segment is lightly pressed between glass plates. 
 
 The segments, single or in tape-like sections 
 of several, become detached from the posterior 
 end and after lingering in the intestine for a time 
 are evacuated with the faeces, or work their way 
 out of the anus and are sometimes found in the 
 clothing of the host. In violent vomiting single 
 or several united segments may be ejected and 
 segments or an entire worm may find the way 
 through abnormal communications into contiguous 
 organs, as the bladder or the peritoneal cavity. 
 The length of tapeworms depends upon the size 
 and number of the segments. The largest species 
 may attain a length of 8 to 10 metres. 
 
 The number of genera is about eighty. Cer- 
 tain species in the adult, sexually ripe stage 
 infest the small intestine of man — the definitive 
 host; the corresponding larval forms live normally 
 in the intramuscular connective tissue and viscera 
 of certain animals which constitute the interme- 
 diate host. Exceptionally man, by swallowing 
 the embryos — oncospheres — becomes the host of 
 the larval forms — Cysticercus cellulosse; Echino- 
 coccus. The most common tapeworms of man are : 
 
 (a) Taenia Solium {Armed Tapeworm; Pork- 
 Tapeworm). — This cestode was so called because 
 it was supposed to exist as a solitary parasite in 
 the intestine. It is now known that two or more 
 tapeworms ma}- be present at the same time. 
 
 Average length 3 metres; head globular, 
 0.8-1.0 mm. in diameter and armed with a 
 double row of hooks; suckers hemispherical; neck 
 slender and o-lO mm. in length; proglottides 800-1000 in number when 
 mature and ready for detachment, 10-12 mm. in length by 5-6 mm. in 
 bi-eadth; genital pores alternate; uterus consists of a median trunk with 
 7-10 lateral branches on each side, some of which again branch; eggs oval 
 with very delicate shell; embryonal shell thick, globular, of a pale yellow- 
 ish color with radial stripes, 0.031-0.036 mm. in diameter; the embryo 
 armed with six hookiets. This parasite when fully developed is found 
 exclusively in the small intestine of man. The embryos are voided with 
 the faeces but undergo no further development unless taken into the stom- 
 
 FiG. 294. — Tsenia solium. 1, 
 ovum; 2, segment, showing uterus; 
 3, hook; 4, head. 
 
860 
 
 MEDICAL DIAGNOSIS. 
 
 ach of a suitable animal, especially the hog or man himself. The embryo 
 shells are then digested, the armed embryos are set free, and, finding their 
 way to various parts of the body, develop into the larvae or cysticerci. 
 
 The geographical distribution of T. solium corresponds in general 
 with that of the domestic hog and the customary use of raw or insuffi- 
 ciently cooked pork. It is relatively common 
 in North Germany, rare in the United States, 
 and for obvious reasons in Mussulman countries 
 and among the Jews. 
 
 (b) Taenia Saginata {T. medio canellata; 
 Unarmed Tapeworm; Beef Tapeworm). — Length 
 variable, up to 10 metres, even 36 metres; head 
 cubical, 1.5-2 mm. in diameter and without 
 booklets; suckers spherical and pigmented; 
 neck long and about half the diameter of the 
 scolex; proglottides average in number 1000; 
 when mature, pumpkin-seed shaped, 16-20 mm. 
 in length by 4-7 mm. in breadth; genital pores 
 irregularly alternate ; uterus median with twenty 
 to thirty-five lateral branches on each side, also 
 ramifying. Eggs globular, shell provided with 
 one or two filaments. Embryonal shell oval, 
 thick, transparent, and striated, measuring 0.03— 
 0.04 mm. in length by 0.02-0.03 mm. in breadth. 
 T. saginata in its adult stage is found only in 
 the intestinal canal of man. The ripe segments 
 and ova are voided in the faeces and swallowed 
 by cattle, in the muscles and organs of which 
 they develop into Cysticercus bovis. T. saginata 
 is the most common tapeworm of man and is 
 widely distributed. It is the ordinary tapeworm 
 of North America, is very common in Europe 
 and Africa, and has been known in the East for 
 centuries. The Jews, who are forbidden to eat 
 pork, especially suffer from the beef tapeworm. 
 The eating of uncooked beef is liable to be 
 followed by this form of parasite. 
 
 Much less common are: 
 
 (c) Taenia Cucumerina (T. elliptica; Dipy- 
 lidium canium). — A small tapeworm found in 
 great numbers in the intestines of the dog 
 
 and cat. The larvae develop in the lice and fleas of those animals. 
 This parasite is sometimes observed in little children. 
 
 (d) Taenia Nana {Hymenolepis nana). — A small parasite having the 
 genital pores all upon one side. This parasite is common in Italy. Stiles 
 states that H. nana is the most common tapeworm in children in the 
 United States. It is supposed to have cysticercus stages in the intestinal 
 villi, no secondary host being necessary. There are marked nervous 
 symptoms and signs of profound infection. 
 
 Fig. 295. — Tsenia saginata. 1, 
 ovum; 2, fully developed seg- 
 ment showing uterus; 3, head. 
 
DISEASES DUE TO CESTODES. 
 
 861 
 
 (e) Taenia Flavopunctata (Hymenolepis diminuta). — This small ces- 
 tode is extremely rare. The proglottides show posteriorly a yellow area 
 corresponding to the male sexual organs; hence the name. 
 
 (f) Taenia Lata (Dibothriocephalus latus; Bothriocephalus latus). — The 
 designation of this cestode indicates the lateral pitting of the head and 
 its relatively large size. Length up to 9 or more metres; head almond- 
 shaped, 2-3 mm. in length and flattened, a deep suctorial groove with sharp 
 edges being situated at each side; no hooklets; neck very thin; pro- 
 glottides numbering 3000-4500, greater in 
 breadth than in length ; eggs large with 
 brownish shells, deposited in the intestines, 
 voided with the faeces, and hatched in water. 
 The intermediary hosts are the pike and 
 other fish. This parasite is widely encoun- 
 tered in the Baltic provinces and Switzerland 
 and is the common tapeworm in Japan. 
 
 Etiology. — The eating of the raw or insuf- 
 ficiently cooked flesh of animals and fish, and 
 uncleanly habits, constitute predisposing influ- 
 ences of great moment. Tapeworm, owing to 
 systematic food inspection, is rapidly becoming 
 less prevalent in well organized communities. 
 The parasites may be encountered at any pe- 
 riod of hfe. They are common in children and 
 have been met with in infants at the breast. 
 
 Symptoms. — Tapeworms may give rise to 
 no inconvenience. They are rarely danger- 
 ous. Their presence may, however, occasion 
 symptoms, partly gastro- intestinal, partly 
 nervous. Among the former are a ravenous 
 appetite, abdominal uneasiness and distress, 
 nausea, and diarrhoea; among the latter, 
 nervous depression and hypochondria. Con- 
 vulsions, chorea, vertiginous attacks, often 
 attributed to the parasite, are rarely directly 
 caused by it. The cessation of any group of 
 symptoms upon its removal is important. 
 Autosuggestion is to be considered. On the 
 other hand troublesome symptoms are sometimes undoubtedly due to 
 intestinal irritation or to toxic substances, evolved by the worm, acting 
 upon the nervous system and the blood — haemolysis. The Bothriocephalus 
 may be the cause of a severe anaemia having the characters of pernicious 
 anaemia, which sometimes proves fatal, but which in some instances has 
 terminated in prompt recovery after the removal of the worm. 
 
 Diagnosis. — The presence of the segments in the stoolS or in the gar- 
 ments of the patient is positive. The ova and oncospheres may be found 
 in great numbers upon microscopic examination of the stools. Tapeworm 
 treatment should never be inaugurated until the direct diagnosis has been 
 made by the discovery of the segments or ova in the stools. Various sub- 
 
 FiG 296 — Tffinia lata 1, ovum; 2, 
 mature segment, 3, head. 
 
862 MEDICAL DIAGNOSIS. 
 
 stances found in the faeces, such as shreds of mucus, bits of aponeurosis or 
 tendon, or seeds are brought to the physician by the patient who suspects 
 that he has tapeworm. The differential diagnosis between the ova may be 
 uncertain, but the difference between T. sohum and T. saginata is at once 
 apparent upon examining the ripe segments between glass slides. The 
 rare species must be submitted to an expert. 
 
 The prognosis is favorable. There are several efficient tseniacides. 
 
 ii. Visceral Cestodes. 
 
 (a) Cysticercus Cellulosae. — Infection of human beings by cysticerci 
 takes place by the introduction of the ripe ova (oncospheres) of T. solium 
 into the stomach. This occurs by drinking contaminated water, eating 
 salads or other raw vegetables washed with such water, or in uncleanly 
 persons by their accidental introduction from the fingers. Autoinfection 
 doubtless frequently takes place in this manner and sometimes from the 
 retropulsion of the mature segments into the stomach in the act of vomit- 
 ing. The development of Cysticercus cellulosse takes from two to three 
 or four months. Their length of life in animals is unknown. After a time 
 they die and become calcified or undergo caseation. They have been found 
 in almost every organ in the human body. They appear in subcutaneous 
 tissues and in the muscles as ovoid whitish bodies, on the surface of which 
 a spot may be found which is the invaginated head. They are most com- 
 mon in the brain, in which they sometimes attain considerable size. They 
 infest next in the order of frequency the eye, muscles, heart, the sub- 
 cutaneous tissue, the lungs, and liver. They were demonstrated by Von 
 Graefe in the vitreous humor and many cases have since been recorded. 
 The number of cysticerci in a single individual varies from a few to 
 several thousand. 
 
 Symptoms. — In the hog the cysticerci are often present in enormous 
 numbers without impairing the nutrition or giving rise to noticeable 
 symptoms. In America they are extremely rare in man. When present 
 in small numbers in the subcutaneous tissues or the muscles they cause 
 little or no trouble. When present in large numbers or in regions where 
 their growth is unrestrained by pressure they may cause very marked 
 disturbances. Their general distribution causes muscular pain, stiffness, 
 tingling, and numbness; in the silent region of the brain they may cause no 
 symptoms, but elsewhere they have the same effect as other forms of tumor. 
 
 Diagnosis. — Direct. — In the eye a positive diagnosis can be made by 
 ophthalmoscopic examination. Subcutaneous nodules may be excised 
 and examined. The sublingual tissues should be examined in a sus- 
 pected case. The cysticercus of the ox has been found in man only 
 in a few instances. 
 
 (b) Echinococcus Disease. — The echinococci are the larvse of T. echino- 
 coccus, a minute cestode measuring 2.5-6 mm. in length and 0.06 mm. in 
 breadth, having a scolex armed with a double row of twenty-eight to fifty 
 hooklets on the rostellum and composed of three or four segments, of 
 which the posterior only is mature. The mature segment contains about 
 5000 ova. This parasite lives in the small intestine of the domestic dog. 
 
DISEASES DUE TO CESTODES. 
 
 863 
 
 The larval or cysticercus stage is passed in various organs of numerous 
 species of mammals, especially the sheep, ox, and hog. Man occasionallj^ 
 acquires echinococcus by ingesting the oncospheres in caressing or otherwise 
 coming into too close contact with infected dogs, or using the same dishes. 
 Structure and Development. — Echinococcus or bladder-worm 
 consists of a cyst or vesicle filled with a watery fluid, which may attain 
 in man the size of a child's head but in cattle does not often exceed the 
 dimensions of an orange or apple. The thin wall of the cyst consists of two 
 distinct layers, an external, laminated, cuticular membrane or capsule and 
 
 Fig. 297. — 1, Taenia echinococcus, 2, mother and daughter ey.'Sts (from Allen J. 
 Smith's preparation); 3, hooks. 
 
 an internal, germinal, or parenchymatous layer, the endo- 
 cyst. After a time the cyst acquires an outer or accidental 
 fibrous investment. The development in cattle is often 
 arrested at this point and the cysts are then known as 
 acephalocysts or sterile echinococcus cysts. In other cases 
 in domesticated animals brood capsules are formed within 
 the space, upon the outer surface of which the granular or 
 parenchj^matous layer is found. From this surface arise 
 little buds or projections which develop into scolices supplied 
 with four sucking discs and a circle of booklets. When 
 transferred to the intestine of the dog each scolex may con- 
 stitute the head of a mature tapeworm. This form is termed Echinococcus 
 veterinorum or fertile echinococcus cyst. In man the mother cyst forms 
 daughter cysts which resemble it in structure and organization and originate 
 from detached portions of the parenchymatous layer. These daughter cysts 
 may develop outwardly and lie between the outer wall of the mother cyst and 
 the adventitious fibrous capsule, or inwardly and, becoming detached from 
 the wall of the mother cyst, float free within the latter. Their number is 
 variable. The daughter cyst may remain sterile or in time may produce brood 
 capsules or granddaughter cysts. Finally the mother cyst may undergo 
 destruction and the daughter cysts, surrounded by thick capsules of 
 connective tissue, may form an irregular tumor mass — multilocular 
 echinococcus. The fluid is of a faint yellowish color, neutral or faintl}^ 
 acid in reaction, non-albuminous, and of a specific gravity of 1.005-1.015. 
 
864 MEDICAL DIAGNOSIS. 
 
 It contains sugar, inosite, leucin, tyrosin, and succinate of lime and 
 soda. Scolices and booklets may be found in tbe fluid of tbe cysts. 
 
 Tbe cbanges wbich tbe cysts undergo are as follows: (a) Deatb, 
 gradual resorption of tbe fluid contents, and the conversion of the cyst into 
 a granular, partially calcified mass. Such masses are not uncommon in 
 tbe liver, (b) Rupture, which may take place into a serous sac, a hollow 
 viscus or a bronchus, the intestine or tbe bladder, into tbe bile passages 
 or inferior vena cava, or externally. These accidents are all unfavorable, 
 though recovery may follow the external rupture of the cyst, (c) Suppura- 
 tion, which may occur with or without rupture and is most frequent in 
 hydatid cysts of the liver. 
 
 The geographical distribution of echinococcus disease is wide. In 
 Iceland and Australia it is most common. In European countries it is not 
 rare. It is extremely infrequent in the British Isles and North America. 
 
 Symptoms. — The condition is encountered at all ages, but is infre- 
 quent in children and old persons. The period of greatest liability com- 
 prises the third and fourth decades. Women are more frequently affected 
 than men. The organs most commonly involved are the liver, other 
 abdominal and pelvic organs, brain, and circulatory system. In a majority 
 of the cases one organ only is affected. The primary infection may, however, 
 implicate several organs; later, infection may take place, or in consequence 
 of accidental or surgical traumatism daughter cysts, brood capsules, or 
 scolices may find their way into a serous sac, especially the peritoneum, 
 and colonize, forming new tumors. Hydatids of the liver, when small 
 and deep-seated, cause neither symptoms nor physical signs. When large 
 and superficial they have the attributes of solid or cystic tumors in general. 
 Upon the anterior surface they appear as circumscribed round or oval 
 tumors of firm consistence or obscurely fluctuating; a cyst of the left lobe 
 may displace the heart upward and give rise to extensive dulness in the left 
 hypochondrium; a cyst of the right lobe yields dulness extending upward 
 into the chest. Hydatid Fremitus. — When the cyst is superficially situated, 
 it yields in some instances, upon direct finger percussion with the right hand 
 and palpation with the fingers of the left, a peculiar prolonged vibratile 
 tremor. Very large cysts are attended with distressing sensations of weight 
 and dragging, sometimes of actual pain. When suppuration occurs septic 
 symptoms arise. Rupture into the bile passages causes a suppurative 
 cholangitis with deep jaundice; into the vena cava sudden death from the 
 action of the daughter cysts as plugs in arresting the circulation at the 
 tricuspid orifice or in the pulmonary artery. A toxic substance in the fluid 
 contents, probably a leucomaine, causes, when introduced into the peri- 
 toneal cavity, a general peritonitis. To this substance has been attributed 
 the urticaria which frequently accompanies the rupture of hydatid cysts 
 or operation upon them. 
 
 Diagnosis of Hydatids of the Liver. — Direct. — Moderate-sized cysts 
 produce no symptoms by which they can be recognized. A large circular 
 or oval tumor or, in the case of multiple cysts, a similar large, irregular 
 mass, unaccompanied by pain, firm and elastic, or fluctuating, and espe- 
 ciallj'' when there is the hydatid tremor connected with the liver and not 
 attended by derangement of the health, justifies a provisional diagnosis of 
 
DISEASES DUE TO CESTODES. 865 
 
 hydatid cyst. If, upon exploratory puncture, a fluid having the above 
 characters and containing hooklets is withdrawn the diagnosis is positive. 
 If there is a history of acutely developing pulmonary symptoms — rupture 
 into the lung — and hooklets or cysts in the matter coughed up, the diag- 
 nosis is certain. The presence of hooklets in a doubtful fluid is diagnostic. 
 
 Differential. — Abscess. — When suppuration occurs the condition 
 is actuafly hepatic abscess. The history of a tumor in the hepatic region, 
 unaccompanied by failure of health, is suggestive of hydatid cyst; of dysen- 
 tery or traumatism in the absence of previous enlargement, in favor of pri- 
 mary abscess. Syphilis. — The tumor or tumors are firm and non-fluctuating. 
 The anamnesis is important. Cancer. — As a rule the course of the disease 
 is very different from that of carcinoma hepatis; but there are cases in 
 which the multiple tumor formation simulates cancer very closely. Large, 
 single tumors and fluctuation, especially the hydatid fremitus, are in favor 
 of hydatids. Dilatation of the Gall-bladder. — Empyema of the gall-bladder, 
 in the absence of adhesions, constitutes a pear-shaped tumor which is often 
 movable in a lateral direction more freely at its lower than its upper extrem- 
 ity. Hydronephrosis. — The discrimination is sometimes beset with diffi- 
 culties. In this condition the tumor may repeatedly disappear with great 
 diuresis. If a hydatid cyst ruptures into the bladder, hooklets may be found 
 in the urine. Pleural Effusion upon the Right Side. — The diagnostic difficul- 
 ties here also are great. Exploratory puncture is necessary. The character 
 of the fluid is distinctive. 
 
 Diagnosis of Hydatids of the Lungs and Pleura. — Lungs. — The direct 
 diagnosis cannot be made in the case of small cysts which produce only 
 trifling symptoms. Larger cysts compress the pulmonary tissue and lead 
 to inflammation and necrosis with ulceration into bronchi and the dis- 
 charge of membrane, daughter cysts, and hooklets. Hemorrhage is com- 
 mon. Pleurce. — Hemorrhage into the pleura with empyema and pleuro- 
 pulmonary fistula occurs. The condition simulates ordinary empyema but 
 the anatomical findings in the sputa — membranes, cysts, or hooklets — are 
 diagnostic. The larvae may first develop in the pleura and reach a large 
 volume, simulating effusion. The upper line of dulness is irregular. Inflam- 
 mation may ensue with perforation of the chest wall. The condition is a 
 serious one, liable to be followed by sepsis. 
 
 Diagnosis of Echinococcus of the Kidneys. — The kidney may be dilated 
 and simulate hydronephrosis. The diagnosis can be made only by an ex- 
 ploratory puncture and examination of the fluid. 
 
 Diagnosis of Echinococcus of the Brain. — The symptoms are not char- 
 acteristic, being those of tumor — persistent headache with vertigo and 
 vomiting, convulsions of Jacksonian type, and optic neuritis with atrophy. 
 The differential diagnosis cannot be made. Echinococcus cysts in the liver 
 or elsewhere would justify a probable diagnosis. Cystic disease of the 
 choroid plexus is to be considered. 
 
 A form of multilocular echinococcus, encountered in men and oxen in 
 Russia, Bavaria, Switzerland, and the Austrian Alps, deserves special 
 consideration. A few imported cases have occurred in North America. 
 The tumor is confined to the liver and consists of dense strands of connec- 
 tive tissue in which are embedded numerous cysts so that the cut section 
 55 
 
866 
 
 MEDICAL DIAGNOSIS. 
 
 has a honeycomb appearance. The cysts are filled with a transparent or 
 opaque gelatinous fluid and present the appearance of alveolar colloid 
 cancer. There is a tendency to disintegrating ulceration. The spleen is 
 usually enlarged. Jaundice is common. There is a ten- 
 dency to hemorrhage and the prognosis is unfavorable. 
 
 D. DISEASES DUE TO NEMATODES. 
 
 Nematodes are elongated round worms of a filiform 
 or fusiform shape, provided A'ith. a mouth and intestinal 
 apparatus. The sexes are in most species separate and 
 the male can be distinguished from the female by its 
 smaller and more slender form and spiral or incurvated 
 posterior extremity. Fertilization takes place within the 
 uterus, and the ova, according to the species, are deposited 
 before or during segmentation or with the embryo fully 
 developed. A few species are viviparous. The mode of 
 infection of the host differs according to the species of worm. 
 
 i. Ascariasis. 
 
 Ascaris Lumbricoides. — The body is spindle-shaped 
 and of a reddish or graj-ish-yellow color, with four longi- 
 tudinal bands and transverse markings. The male meas- 
 ures 12-25 cm. in length and about 3 mm. in transverse 
 diameter at its thickest part; the female from 20-40 cm. 
 by 5 mm. The ova are elhptical with a thick brownish- 
 red covering. The}^ measure 0.05-0.07 mm. in length by 
 0.04-0.05 mm. in breadth. They are deposited before 
 segmentation and are sometimes present in the stools in 
 great numbers. Generation takes place without inter- 
 mediate host. This nematode worm is the most common 
 parasite of man and is distributed over the entire world. 
 It is most frequent in young children, but occurs at all 
 periods of life. It is extremely common in the negro 
 races. As a rule only a few worms are present, but cases 
 have been reported in which hundreds of them have been 
 harbored by one individual. 
 
 The upper portion of the small intestine is the 
 normal habitat of the round worm. They migrate, how- 
 ever, into the stomach and are frequently evacuated by 
 vomiting. This is especially common in febrile diseases. 
 They sometimes pass through the oesophagus into the 
 pharynx and creep out through mouth or nostrils. They have been known 
 to penetrate the Eustachian tube and appear at the external auditory meatus. 
 They sometimes occupy the biliary and pancreatic ducts, or inflammatory 
 adhesions between the intestine and adjacent parts— tforw abscess. Pass- 
 ing from the pharynx into the larynx they have caused fatal asphyxia. 
 In other cases they have escaped into the trachea and, penetrating into the 
 
 Fig. 298. — Asca- 
 ris lumbricoides. 1, 
 ovum (after Braun) ; 
 2, female worm. 
 
DISEASES DUE TO NEMATODES. 
 
 867 
 
 bronchi, have been the occasion of gangrene of the lung. They sometimes 
 find their way into the bladder and are passed with the urine. These 
 wanderings are the cause of most serious and often unaccountable symptoms, 
 but in neurotic persons even the presence 
 of a small number of worms within the 
 intestine may give rise to nervous phe- 
 nomena — chiefly hysterical — which cease 
 upon their expulsion. In other cases 
 irregular fever with gastro-intestinal symp- 
 toms occurs. These symptoms have been 
 regarded as reflex, but are probably due 
 to a toxin. The presence of Ascaris 
 lumbricoides in the intestine may be 
 demonstrated by finding the ova upon 
 microscopical examination of the faeces. 
 Oxyuris Vermicularis (Thread Worm; 
 Seat Worm). — One of the most common 
 and widely distributed of human para- 
 sites. The color is whitish and the 
 females may be seen in lively movement 
 in the recently voided faces of infected 
 persons. The male measures 3-5 mm. in length and the female is 10 mm, 
 in length and 0.6 in breadth. The ova are deposited with the embryo fully 
 developed and are very rarely found in the faeces. This parasite lives 
 in the rectum and colon. It is usually present in enormous numbers. Its 
 wanderings are chiefly nocturnal and give rise to troublesome itching. The 
 localities affected are the sulcus between the nates, the perineum, and the 
 vulva. As the result of scratching, the larvae may be carried to the nose 
 and mouth and the patient reinfects himself, or he may infect others by 
 the hand directly or indirectly. The primary infection takes place by 
 means of water or fruits or vegetables eaten raw, or perhaps through 
 the intervention of flies. Direct development takes place without an 
 intermediate host. 
 
 Oxyuris in rare instances penetrates the wall of the gut and causes peri- 
 rectal abscess. Most common in children, it may be encountered at any age. 
 
 The symptoms in addition to local irritation and itching are restless- 
 ness, disturbed sleep, loss of appetite, and anaemia. 
 
 Fig. 299. — 1, dorsal asi>ect of head of 
 Ascaris lumbricoides; 2, ventral aspect of 
 head; 3, tail of male; 4, lateral aspect of tail 
 of female; 5, ventral surface of tail of 
 female — After Claus. 
 
 ii. Trichiniasis. 
 
 The disease is caused by the embryos of Trichinella spiralis, which pass 
 from the intestines and are distributed widely throughout the body, but 
 find the conditions necessary to their further development only in the 
 fibres of the transversely striated muscles, in which they develop into 
 encapsulated larvae. 
 
 Trichinella Spiralis. — The male measures 1.4-1.6 mm. in length 
 and 0.04 mm. in breadth; the female 3-4 mm. in length and 0.06 mm. in 
 diameter. This parasite in the adult stage inhabits the small intestine of 
 man and various mammals, especially the hog. The larvae are 0.8-1 mm. 
 
868 
 
 MEDICAL DIAGNOSIS. 
 
 in length and infest the striated muscles, in which they 
 lie coiled spiralh' in ovoid capsules which mostly have 
 their longitudinal axis parallel with the long axis 
 of the muscular fibres. 
 
 It has been experimental!}'' demonstrated that the 
 encysted larvae, shortl}^ after their introduction into 
 the stomach, are freed from their capsules by the 
 action of the gastric juice and pass into the upper part 
 of the small intestine, where they quickly attain their 
 adult form. Copulation takes place in the course of 
 two or three days, after which the males die and the 
 females, which are viviparous, penetrate the intestinal 
 mucosa and reach the lymph spaces, in which they 
 deposit their young. Carried by the tymph stream 
 and ultimately b}^ the blood current the embryos invade 
 the striated muscles, in which encapsulation takes place. 
 On the ninth or tenth clay after ingestion of the 
 affected flesh the first embryos have reached their 
 destination. Two or three embrj^os may occupy the 
 same capsule. The infested muscular fibres undergo 
 degeneration and lose their striation. The intra- 
 muscular connective tissue undergoes an inflammatory 
 hyperplasia and forms the cystic capsule. In the 
 course of several months the capsular walls, at first 
 translucent, undergo calcification, which, beginning at 
 the poles, gradually progresses until in the course of 
 time the enclosed larvae also become calcified. In 
 hogs calcification is usually long delayed, so that the 
 capsule may elude ordinary examination. 
 
 The larvae are not evenly distributed throughout 
 the muscular system. Favorable locations are the 
 intercostal muscles, the muscles of the diaphragm, 
 abdomen, larynx, and tongue. In their encysted state 
 the larvffi sometimes preserve their capacity for devel- 
 opment for many years. The beginning of calcification 
 marks the end of this period. Rats appear to be the 
 normal hosts of T. spiraHs. They infect themselves 
 by devouring the fiesh of their own kind and the hog 
 waste in abattoirs, and infect other animals, as pigs, 
 dogs, cats, etc., by which they are sometimes eaten. 
 Pigs are also infected by feeding upon the offal of 
 trichinous pigs. Man is infected by eating the raw or 
 insufficiently cooked flesh of infected hogs. The geo- 
 graphical distribution of T. spiraUs is much more 
 extensive than the occurrence of trichiniasis in man. 
 The custom of eating raw or only partially cooked 
 pork is the important cause of trichiniasis. Where 
 this custom does not prevail epidemics of trichiniasis do not occur, even 
 though there are great numbers of infected hogs. North Germany espe- 
 
 m 
 
 Fig. 300.— Trichinella 
 spiralis. 1, larval worm 
 encapsulated ; 2, male ; 
 3, female. 
 
DISEASES DUE TO NEMATODES. 8G9 
 
 cially suffers and affords many examples of grave epidemics. In South 
 Germany, France, England, and the United States the disease is infrequent. 
 Post-mortem investigations indicate that mild sporadic cases are more 
 common in this country than was formerly supposed and that they are 
 frequently overlooked. 
 
 The anatomical lesions consist of minute local wounds of the intestine 
 caused by the boring female trichinellse and important chiefly in proportion 
 to their number; of the lesions in the muscles, the primitive bundles under- 
 going granular degeneration with local myositis; and of important changes 
 in the blood, which shows a marked leucocytosis — 25,000-30,000. The 
 eosinophiles are enormously increased, comprising 20 per cent, or more of 
 all the leucocytes. Fatty degeneration of the liver and enlargement of 
 the superficial lymph-glands have been described. New broods of embryos 
 are produced from time to time and adult trichinse are found post mortem 
 in the intestine in cases fatal at the end of four or five weeks. 
 
 Symptoms. — Sporadic cases occur, but the disease is more commonly 
 endemic and local epidemics are common. The last can almost always be 
 directly traced to the pork supply and not rarely have followed a " Fest " 
 or entertainment in which uncooked ham, sausages, or similar food have 
 been largely partaken of. Trichinous flesh may be eaten without causing 
 trichiniasis. This occurs when the cysts have been thoroughly acted upon 
 by heat in cooking, when a limited number of embryos have been ingested, 
 and when active purgation has promptly occurred. 
 
 (a) Stage of Gastro-intestinal Irritation. — A few days after 
 eating trichinous meat loss of appetite, abdominal pain, vomiting, and 
 diarrhoea occur. These symptoms are of varying intensity, sometimes being 
 absent altogether, sometimes almost choleraic. These symptoms are 
 often attended with great general debility, (b) General Infection. — 
 The invasion of the muscles gives rise in man to a more or less intense 
 myositis, manifested by pain upon movement and pressure, swelling and 
 tension of the muscles, and oedema of the overlying skin. The muscles of 
 mastication and deglutition are especially involved and the predilection 
 of the embryos for the muscles of the diaphragm and the intercostal muscles 
 is the occasion of serious, sometimes fatal dyspnoea. The onset of these 
 symptoms, which follows infection in about ten days or two weeks, is 
 accompanied by fever of remittent or intermittent type — 102°-104° F. 
 (39°-40° C.) — and local oedemas, especially under the eyes. Excessive 
 sweating, itching, and urticaria occur. Antemia, rapid wasting, and loss of 
 strength are common. In the severer cases delirium, tremor, and dry tongue 
 occur. Albuminuria is common and polyuria may occur. 
 
 Diagnosis. — Direct. — When a number of persons fall ill at the same 
 time shortly after a festival or who are customers of the same pork butcher, 
 suspicion should be aroused. The finding of the parasites in the pork, in 
 the stools of the patients, in shreds of muscle removed for the purpose under 
 local anicsthesia; muscular tenderness upon movement or pressure; oedema 
 under the eyes; the blood count, showing high leucocytosis with marked 
 eosinophilia, constitute positive diagnostic criteria. 
 
 Trichinellse in the stools, when examined with a low power, appear as 
 short, silvery, glistening threads, which are sometimes still in movement. 
 
870 
 
 MEDICAL DIAGNOSIS. 
 
 Differential. — Enteric Fever. — Any resemblance that may occur is 
 superficial. On the one hand we have a definite symptom-group charac- 
 terized by the gradual rise of temperature, relatively slow pulse as compared 
 with the rise of temperature, palpable spleen, and rose spots, together with 
 a positive agglutination test; on the other the equally 
 characteristic symptom-complex described in the foregoing 
 paragraph. Rheumatic Fever. — Pain on movement and 
 tenderness are suggestive. But the joints and not the 
 muscles are involved and the oedema is periarticular. 
 Cholera. — The urgency of the intestinal symptoms and the 
 great number of persons simultaneously affected in some 
 of the epidemics has aroused the suspicion of cholera. 
 Rice-water discharges, collapse, and the rapid course of 
 the latter disease are diagnostic points of importance. 
 
 Prognosis. — The duration and severity of the attack 
 depends upon the number of the invading embryos. The 
 symptoms are aggravated by the access of fresh groups. 
 In mild cases the symptoms are slight and disappear in the 
 course of two or three weeks. In the more severe cases the 
 active symptonas continue for several weeks and convales- 
 cence is tardy. The death-rate varies from 1 or 2 to 20 or 
 30 per cent, in different outbreaks. Death most commonly 
 occurs in the fourth, fifth, or sixth week. 
 
 iii. Uncinariasis. 
 
 Ankylostomiasis; Hook=worm Disease. — The parasite 
 of this disease belongs to the Strongylidse. There are two 
 species parasitic in man, distinguished by specific ana- 
 tomical differences, especially in the mouth, and by differ- 
 ences in size — the (a) old-world Ankylostoma duodenale 
 and (b) Necator americanus. The general characters are 
 similar. The body is cylindrical, attenuated anteriorly, 
 and of a reddish color. The males measure 8-10 mm. in 
 
 length and 0.4-0.5 mm. in 
 breadth; the females 10-18 
 mm. in length. The eggs 
 are elliptical, thin -shelled, 
 and measure 0.05-0.06 mm. 
 by 0.03-0.0-1 mm. and arc 
 laid in a state of segmen- 
 tation. In the European 
 species the mouth is supplied 
 with four sharp, hook-like ventral teeth, projecting backward, and with 
 two teeth projecting forward on the dorsal surface, while in the 
 base of the oral cavity there is one tooth directed forward. The 
 Cauda bursa of the male has one small dorsal and two large lateral 
 alar processes. The development is direct without an intermediate host. 
 
 Fig. 301. — Ankylostoma duodenale, natural size below, and 
 much magnified male. — After Schulthess. 
 
DISEASES DUE TO NEMATODES. 
 
 871 
 
 The adult worm infests the duodenum, less frequently the jejunum, 
 and sucks blood with its head buried in the mucosa, changing its position 
 from time to time so that minute hemorrhages continue. The number of 
 worms varies from a few to a thousand or more. The duration of life in 
 the bowel is unknown. The disease is essentially chronic. It may be kept 
 up by the prolonged life of the parasite, or by reinfection. 
 
 This parasite is the cause of " Egyptian chlorosis, " the tunnel disease 
 of St. Gotthard, miners' and brickmakers' disease, and tropical anaemia. 
 It is widely distributed in warm countries, but occurs in all parts of the old 
 world. Since the Spanish-American War uncinariasis has attracted much 
 attention and Necator americanus (Stiles) has been found to be the cause 
 of the so-called southern anaemia. It is endemic in Virginia, North and 
 South Carolina, Georgia, Florida, Alabama, and Texas. It is extremely 
 prevalent in Porto Rico; less so in Cuba and Brazil. 
 
 The larvae live in water and moist soil. There are two hypotheses 
 as to the mode of their introduction: first, that they are ingested by the 
 
 Fig. 302. — Eggs of Uncinaria duodenalis. a, unsegmented; 6, with four segments and showing nuclear 
 spindles; c and d, later stages of segmentation. X 400. — Emerson. 
 
 mouth in drinking water, upon uncooked vegetables, from the soiled hands 
 of men who work and children who play in moist earth, or by clay eaters; 
 and second, that they penetrate the skin by way of the hair-follicles, and 
 are transported by the venous blood to the right side of the heart and the 
 lungs, whence they pass by way of the bronchi and trachea to the pharynx, 
 and are then swallowed. This extraordinary observation of Looss has been 
 confirmed by others, and Smith of Atlanta produced uncinariasis in man by 
 the application of mud containing the larvae to the arm. The long vexed 
 question of the relation of " ground itch " to uncinariasis is thus settled. 
 
 Symptoms. — The clinical phenomena are due to the constant, pro- 
 longed drain of blood from the intestinal mucosa by the parasites them- 
 selves and from the wounds which they have made, bacterial infection at 
 the site of the lesions, chronic local inflammation and thickening of the 
 bowel, and the deleterious action of toxins produced. 
 
 The ova are frequently found in the stools, especially in children, in 
 the absence of symptoms. From this fact it has been inferred that a 
 large number of the parasites are necessary to cause the disease. The 
 anaemia is the most striking condition. Some associated pigmentation 
 gives the skin a peculiar dirty appearance. The facies has been regarded 
 as characteristic, its peculiarities consisting in a pallid, waxy color with 
 faint pigmentation, and a lustreless, blank expression of the eyes. When 
 the disease is marked in children, nutrition and growth are seriously inter- 
 
872 MEDICAL DIAGNOSIS. 
 
 fered with. Enlargement of the liver and spleen, with oedema, occurs in 
 advanced cases, and the symptoms of anaemia — breathlesnesss and palpita- 
 tion upon exertion, pallor, puffiness, and headache — are common. The blood 
 shows corpuscular and haemoglobin reduction, infrequent leucocytosis, and 
 a moderate eosinophilia. In old cases with marked anaemia, which has 
 lasted a long time, the eosinophile count is low. 
 
 Diagnosis. — Direct. — The presence in fresh faeces of ova showing seg- 
 mentation, or in older faeces of ova containing the curled embryos within or 
 penetrating the thin shell, is characteristic. The blotting-paper test may be 
 employed. A little of the faeces placed on white blotting paper after an hour 
 will show a reddish color like blood. Eosinophilia is of diagnostic value. 
 
 Differential. — Pernicious Ancemia. — Many of the cases suggest this 
 condition. The presence of the ova in the stools, the locality from which 
 the patient comes, his occupation, the facies, the blood picture, and the 
 therapeutic test with thymol are all to be considered. 
 
 Prognosis. — The outlook under thymol treatment, except in advanced 
 cases with marked anaemia, is fairly favorable. 
 
 iv. Filariasis. 
 
 Filariae are long, slender nematodes, which live parasitically in the 
 serous cavities and subcutaneous tissues of the mammals which they infest. 
 The males are usually much smaller than the females, having the tail 
 sharply bent or spiral and being supplied with wing-like appendages. 
 
 Nineteen genera are described, of which the following are classed under 
 the general term Filaria sanguinis hominis: 
 
 1. Filaria bancrofti. — The male is colorless and measures 40 mm. in 
 length by 0.1 mm. in breadth. The female is of a brownish color and 70- 
 80 mm. in length, 0.2-0.3 mm. in diameter, and possessed of two uteri 
 which occupy the greater part of the body. The embryos are contained 
 in an elongated, scarcely perceptible membrane in which they move freely. 
 Their length is 0.13-0.3 mm., their breadth 0.007-0.011 mm. By way of 
 the lymph stream they reach the blood and are distributed to all parts of 
 the body. Their appearance in the peripheral circulation is peculiar, 
 showing a remarkable periodicity. During the day there are very few if 
 any to be found; but towards sunset they appear and steadily increase in 
 number until midnight, when they gradually decrease and disappear by 
 the middle of the morning. If the patients sleep during the day and remain 
 awake at night the order of the appearance of embryos is reversed, namely, 
 they are present during the day and not to be found at night. The further 
 development of filariae is associated with the mosquito, which constitutes 
 the intermediate host. 
 
 This parasite is distributed in nearly all tropical countries, and filariasis 
 is common in India, China, Japan, the Australasian Islands, Egypt, The 
 Sudan, Zanzibar, Madagascar, and the Southern United States. Sporadic 
 cases are occasionally encountered in the Middle States and elsewhere in 
 temperate climates in the course of routine examinations of the blood. 
 Some of these cases are imported, but there are instances in which the 
 source of the infection could not be traced. 
 
DISEASES DUE TO NEMATODES. 873 
 
 Symptoms. — In animals and during a long period of latency in man, 
 filarise may exist in the blood without causing any inconvenience. Their 
 presence becomes known only upon examination of the blood. After a 
 time anaemia, splenic enlargement, and irregular fever of moderate intensity 
 may occur. When the lymph-vessels become blocked by the adult worm 
 or the ova, characteristic conditions arise, namely, hsematochyluria, lymph 
 scrotum, and elephantiasis. 
 
 H^MATOCHYLURiA. — The urine is opaque, milky white, or blood- 
 tinged. On standing a reddish coagulum sometimes forms. Microscopic- 
 ally there are minute globules and molecular fat and erythrocytes in 
 varying numbers. The quantity of urine is normal or it may be increased. 
 The condition is intermittent, and 
 
 after passing chylous urine for a short iP*->'55chmi'cO''.oti , . - -- 
 
 period the patient commonly passes 
 for weeks or even months urine that 
 is normal. The general health is 
 often fair. In other cases there is 
 more or less uneasiness in the lumbar 
 region, anaemia, and vesical irritation, 
 with difficulty in passing the blood- 
 clots which form in the bladder. 
 
 Lymph Scrotum. — Blocking of 
 the lymph channels is followed by a 
 dilatation of the lymph plexuses that 
 is sometimes enormous. When the 
 scrotum is involved there is great 
 thickening of the tissues and the 
 
 distended lymph-vessels are plainly . 
 
 visible. Upon puncture a clear or 
 sometimes a turbid fluid exudes. 
 
 A form of elephantiasis follows 
 permanent occlusion of the lymph 
 channels of the lower extremities. 
 The lymphatic glands, especially in 
 the groin, are much enlarged. :^C(;"^ ' 
 
 Diagnosis. — The living embryos 
 in the recent blood are readily recog- 
 nized. Their presence is made known by the commotion which they cause 
 among the red corpuscles, and the worm itself, usually in active movement, 
 may be made out with a low power. Chylous urine may occur under other 
 circumstances not well understood. The non-parasitic form is very rare. 
 Withdrawal of fat from the diet is usually followed by disappearance of 
 the chylous appearance, but a glass or two of milk will render the urine 
 again opaque. 
 
 Most cases of elephantiasis in temperate climates are non-parasitic. 
 
 Prognosis. — A large proportion of the cases remain latent for an indefi- 
 nite period. Many of the cases of lymph scrotum and elephantiasis are 
 progressive, and the patient succumbs to exhaustion or intercurrent disease. 
 The removal of an adult worm from the enlarged inguinal lymph-glands 
 
 Fig. 303. — Microfilaria nocturna. 
 
874 
 
 MEDICAL DIAGNOSIS. 
 
 has been followed by the disappearance of the embryos from the blood. 
 If two or more were present this result would not occur. 
 
 2. Filaria diurna. — This parasite closely resembles F. bancrofti. 
 It appears in the blood during the day only, or at night when the patient 
 remains awake. Manson found the larvae in the blood of several negroes 
 from Congo. The mangrove fly is supposed to be the intermediate host. 
 F. loa is the adult form. 
 
 3. Filaria perstans. — The larva was discovered by Manson in 1S91. 
 Manson found in the blood of Carib Indians sent from British Guiana two 
 forms of larval filarise differing in type, one closely resembling those of F. 
 
 Fig. 304.- 
 
 Patient aged twenty-three years, affected with elephantiasis arabum. 
 aged forty-seven years. {International Clinics.) 
 
 b. Same patient, 
 
 perstans, the other slightly larger and likewise without a sheath. Daniels 
 in 1898 found the adult worm, both male and female. The female is 70- 
 80 mm. in length by 0.12 mm. in breadth; the male 45 mm. by 0.06 mm.; 
 the embryos 0.2 mm. in length by 0.004 in breadth and possess no sheath. 
 The adult worms inhabit the connective tissue of the mesentery at its 
 spinal attachment. This parasite infests the tribes who dwell in dense 
 swamps and deep forests. It abounds on the West Coast of Africa, in 
 British Guiana, and in Porto Rico. It may be observed in the blood both 
 during the night and day. It is thought to be the cause of a pustular disease 
 of the skin common among the negroes of the West Coast of Africa. The 
 intermediarv host has not been settled. 
 
DISEASES DUE TO NEMATODES. 
 
 875 
 
 V. Dracontiasis. 
 
 Guinea-worm Disease. 
 
 Filaria (Dracunculus) medinensis {Guinea-worm; Medina worm). — 
 The female measures 50-80 cm. in length and 0.5-2 mm. in diameter and 
 is cylindrical in form with a blunt 
 anterior extremity and a pointed 
 posterior end terminating in a hook. ff0^ 
 
 Fig. 305. — Filaria medinensis. 1, head; 
 2, 3, 4, larvse; 5, adult worm. — After Claus. 
 
 -Trichocephalus dispar. 1, egg; 
 2, female; 3, male. 
 
 Only the female has been known. 
 
 Quite recently, however, small worms Fig. 306.- 
 
 about 4 cm. in length were found 
 
 in two instances attached to the females and regarded by Charles, who 
 
 made the observation, as males. The uterus contains a great number of 
 
876 MEDICAL DIAGNOSIS. 
 
 living embryos, which may reach the open by the rupture of the body of 
 the adult female. They develop in the body of Cyclops. The male and 
 female are probably ingested by the mouth, the former dying and the latter, 
 after impregnation, finding its way to the subcutaneous tissues, in which it 
 slowly develops, remaining quiescent during a period of eight to ten months. 
 It feels like a coil of string under the skin. As the embryos develop the 
 adult worm slowly makes its way downward to the leg or foot, where it 
 forms a small vesicle or abscess, which bursts, leaving an ulcer in the base 
 of which its head appears. The uterus ruptures and the embryos are dis- 
 charged in a whitish fluid. The worm may now leave the host spontane- 
 ously. Guinea-worms are usually solitary,, but several have been observed 
 in the same individual. It attacks all races without distinction. It has 
 been known from the earliest historical periods. It is especially prevalent 
 in Africa and the West Indies, but imported cases are occasionally observed 
 in the United States. 
 
 When the worm first becomes palpable there is sometimes fever 
 together with an eosinophilia. 
 
 Trichocephalus dispar {T. trichiurvs; Whip-worm). — This parasite 
 may be recognized by the difference between its filiform anterior extremity 
 and its much thicker posterior portion. Its length is 40-50 mm., the male 
 being slightly shorter than the female. The ova are lemon-shaped, and 
 have a thick brownish shell at the ends of which are light yellow plugs or 
 buttons. They measure 0.05 mm. in their long diameter and 0.02 mm. in 
 their transverse diameter. This is a common and widely spread parasite 
 of man infesting the caecum and other parts of the intestine. It usually 
 gives rise to no symptomS; but exceptionally its presence in great numbers 
 is associated with anaemia and diarrhoea. 
 
 A number of less important nematode worms have been observed in 
 man, but the infrequency of their occurrence, and the facts that they do not 
 cause definite internal diseases and that their life history is mostly unknown 
 renders any extended consideration of them at this time inappropriate. 
 
 III. 
 THE DIAGNOSIS OF THE CHRONIC INTOXICATIONS. 
 
 I. ALCOHOLIC INTOXICATION; ALCOHOLISM. 
 
 The discussion here will be confined to a brief statement of the effects 
 of alcohol on the nervous system. As is well known this poison acts most 
 injuriously upon other tissues of the body also, but these effects are best 
 discussed under other and appropriate headings. 
 
 The ravages of alcohol are greater in modern life than among the 
 ancients, for the reason that strong alcoholic drinks are now distilled and 
 marketed at a low price. The first modern writer to attempt to treat this 
 subject adequately was Magnus Huss, who made his observations on the 
 Swedish brandv drinkers. 
 
ALCOHOLIC INTOXICATION. 877 
 
 Pathology. — Changes are found in the coats of the blood-vessels, in 
 the brain membranes, and in the neuroglia, as well as in the kidneys, liver, 
 stomach, and heart. Bevan Lewis and Berkley described with minute 
 care the changes in the central nervous system. According to Lewis these 
 changes are particularly marked in the blood-vessels and neuroglia, and 
 Berkley found microscopic changes in the neurons of the brain. Inflam- 
 mation of the peripheral nerves, constituting the well-known multiple 
 neuritis, is often seen in chronic alcoholics. 
 
 Symptoms. — Alcoholic intoxication is either acute or chronic. 
 
 Acute intoxication requires only a passing notice. In the first 
 stage there is exhilaration, with slight confusion of ideas; then follows a 
 stage in which memory is impaired, self-consciousness is obscured, and the 
 victim may be violent and even maniacal. In the terminal stage a condi- 
 tion of sleep, or even of stupor and coma, supervenes; the pupils are slightly 
 dilated, the face congested or even cyanosed, the breathing normal in fre- 
 quency, the pulse regular, and the consciousness usually not so lost but that 
 the patient can be roused slightly at least. After some hours he wakes 
 with a sense of depression, headache, nausea, and a dry mouth and throat. 
 Profound intoxication may simulate cerebral hemorrhage, uraemia, diabetic 
 coma, and opium poisoning. 
 
 Delirium tremens is caused by protracted acute poisoning. It is the 
 result of a disturbed nutrition of the brain-cells, and continues even after 
 the alcohol is withheld; in fact, it sometimes does not occur until after the 
 patient is deprived of his drink — the delirium potu suspense. This latter 
 form is seen especially in hospital practice — as after a fractured leg, a 
 surgical operation, or even in acute disease, such as pneumonia. The 
 patient may seem to do well for a day or two, when delirium suddenly 
 develops. 
 
 Delirium tremens is a psychosis in which the mental faculties are in 
 entire confusion, with terrifying hallucinations, such as the sight of snakes, 
 bats, and other repulsive objects, and the disturbing sounds of voices; 
 there is restlessness, tremor, incoherence, muttering, insomnia, aversion 
 to food, rapid pulse, and great physical prostration. The so-called typhoid 
 state may develop, with irregular fever and a dry brown tongue, and the 
 case may end fatally. The prognosis is in the main favorable, except in 
 old, broken-down topers. 
 
 Subacute forms of delirium occur, in which the patient is able to be 
 about and to continue his drinking. He is in a dream-like, confused state, 
 irritable, irresponsible, insomnious, unable to attend to his work, eating 
 little, and subject to violent outbursts in which he may even commit murder. 
 Alcoholic melancholia is also seen in some hard drinkers, and occasionally 
 leads to suicide. It occurs especially after protracted sprees. The affec- 
 tion known as mania a potu, often confused with delirium tremens, is, as 
 its name implies, a state of furious maniacal excitement, in which the 
 inebriate is especially dangerous. 
 
 The CHRONIC INTOXICATION from alcohol shows itself in the gradual 
 deterioration, mental, moral, and phj^sical, of the individual. The char- 
 acter and reliability of the man suffer; he is unfit for business or society; 
 subject to moral lapses of various kinds; untruthful, indifferent, cruel, and 
 
878 MEDICAL DIAGNOSIS. 
 
 sometimes dangerous. His memory and his mental faculties generally are 
 impaired. He has a bad color, injected capillaries, a tremor of his hands 
 and tongue, and is a poor eater and sleeper. There is always a chance also 
 that he has a bad liver and bad kidneys. Optic neuritis and atrophy ma}- 
 occur in chronic cases. 
 
 Neurasthenia and hysteria are among the conditions seen in chronic 
 alcoholics. These complications are seen especially in persons who drink 
 not to such great excess, as steadily — a form of slow chronic poisoning. 
 Chronic alcoholic insanity occasionally occurs in confirmed inebriates. 
 The patient has a form of paranoiac deterioration. In addition to the 
 mental failure already noted, he begins to have hallucinations of sight and 
 hearing, somewhat as in delirium tremens. He sees disgusting objects and 
 hears insulting voices, and these are readily excited by every fresh debauch. 
 He then begins to form delusions, often quite well systematized. They 
 are of the persecutory type: he has enemies, who are in league against him, 
 or who would poison him. Sometimes he is markedly hypochondriacal, 
 and has an animal or some unknown disease within him; but his com- 
 monest delusion is the delusion of marital infidelity. This is so common 
 as to be held typical by almost universal testimony; and whatever its 
 cause, whether due to failing sexual power or to the natural aversion of 
 the wife, it is in a sense pathognomonic. In time these persecutory delu- 
 sions may give way to delusions of an expansive type, just as in paranoia, 
 but by that time the chronic inebriate is usually passing into well-marked 
 dementia, and his case is hopeless. Some of these patients under the influ- 
 ence of their delusions commit crime. The terminal stage is one of per- 
 manent dementia. In France nearly 14 per cent, of the insane in the 
 asylums are alcoholics.^ In America the percentage may be not so high. 
 Epilepsy is sometimes a result of alcoholism. It is occasionally seen after 
 prolonged sprees in susceptible individuals, but often it sets in later in 
 life in chronic topers. In the latter case it is usually a sign of beginning 
 degradation of brain tissue. Alcoholic general paresis, or pseudoparesis, is 
 a condition which closely simulates the genuine disease. There is the 
 expansive psychosis, with tremor and speech defects, but these patients 
 may recover rapidly when they are deprived of their drink. Dipsomania is 
 the overpowering impulse to drink which is seen in a class of excitable 
 and neurotic persons, and which, according to Spitzka, is allied to periodical 
 mania. Korsakoff's psychosis is a mental disorder, seen especially in alco- 
 holic multiple neuritis, in which there is mental confusion with loss of 
 identity of time, place, and person, and a tendency to fabulation. 
 
 Diagnosis. — The diagnosis of the various forms of alcoholic intoxica- 
 tion is, as a rule, easy. The history in most cases is clear and condition 
 unmistakable. 
 
 Mistakes, however, occur in the diagnosis of acute drunkenness, 
 especially in hospital practice when the history is unknown. The odor 
 of the breath is entirely unreliable, for the drunken man, or even the man 
 who has only been drinking moderately, may have opium poisoning, or 
 uraemia, or cerebral hemorrhage, or a fractured skull. In opium poison- 
 ing there are contracted pupils and slow breathing, and the coma is more 
 
 1 Semaine M^d., July 10, 1907. 
 
OPIUM POISONING. 879 
 
 profound, as a rule, than in drunkenness. In cerebral hemorrhage there is 
 usually a hemiplegia, which is shown by the diminished resistance to pas- 
 sive motion on the paralyzed side, and there may be unequal pupils and 
 deviation of the head and eyes. Injury to the head, or fractured skull, is 
 usually detected on careful examination. Uraemia is indicated by the 
 state of the urine and the subnormal temperature, but the latter is seen 
 also in alcoholic intoxication, and the former is not always conclusive. 
 Convulsions are rare in drunkenness, but not unheard of. 
 
 Delirium tremens is not likely to be mistaken, but when it breaks 
 out suddenly in a surgical case or in pneumonia it may be confusing. The 
 tremor and peculiar wandering delirium, with frightful hallucinations, 
 are significant. Patients with delirium tremens should always be care- 
 fully examined for head injuries, fractured ribs, and other bodily damage; 
 also for pneumonia. 
 
 The other forms of alcoholic insanity are usually recognized with ease 
 from the history and the character of the symptoms as given above. 
 
 II. OPIUM POISONING; MORPHINISM. 
 
 The use of opium and its alkaloid, morphia, has increased greatly in 
 America, until it is now one of the recognized evils of the time. The drug 
 is taken in its crude form, or as laudanum, or occasionally as paregoric, 
 but the commonest practice is to use morphia by the hj^podermic 
 syringe. Accidental poisoning is rare, but suicide by laudanum or morphia 
 is more common. 
 
 Pathology .^Opium or morphia, when taken habitually, is a slow 
 and insidious poison to the nerve centres, but it does not cause such marked 
 organic changes in the tissues as does alcohol. In old habitues there 
 is often a condition of malnutrition or cachexia, shown bj' a sallow 
 complexion, loss of weight, and gastro-intestinal disorders; but some 
 narcomaniacs show remarkably little physical effect from the drug. 
 
 Symptoms. — The effects are acute and chronic. The symptoms of 
 acute poisoning, after an initial stage of excitement or dreaminess, are 
 somnolence, passing into stupor and coma, congestion and even cyanosis 
 of the face, full and slow pulse, slow respiration, and stronglj^ contracted 
 pupils. As death approaches the pupils may dilate widely, and they maj'- 
 even be unequal; the respirations are not only slow but also imperfect; 
 the surface pallid or cyanosed, and covered with a clammy sweat; and the 
 pulse rapid. Trismus and convulsions are rare symptoms. This stage of 
 opium poison closely resembles apoplexy and uraemia, and a positive 
 diagnosis cannot always be made unless the history is clear. 
 
 The chronic effects of opium poisoning are seen in the habitual users 
 of the drug, and they are most marked in the nervous system, especially 
 the brain. 
 
 Attempts have been made to distinguish the various forms of the 
 opium habit, and their pathological effects. In India opium is eaten; in 
 China it is smoked; and in America it is drunk as laudanum or used as 
 morphia under the skin. To draw distinctions between these varieties of 
 the same vice is, however, hardly possible. Opium, in whatever way it is 
 
S80 ■ MEDICAL DIAGNOSIS. 
 
 taken into the system, acts in the end very similarly, especially on the brain 
 and nerves. When taken by the mouth it acts, indeed, more directly and 
 injuriously upon the digestive system; nevertheless old habitues acquire 
 a wonderful tolerance. The opium habit becomes a disease, and this dis- 
 ease presents some well-marked symptoms. An abnormal mental state 
 results from the habitual use of the drug. There are moral perversions, 
 enfeebled will, loss of power of attention, and, in advanced cases, a delir- 
 ious delusional psychosis. In these chronic cases the victim is often insane 
 and irresponsible, although he may be able to present a fairly good front 
 and to conceal his disorder. There is loss of memory, loss of volition and 
 power of attention, loss of initiative and energy, diminished muscular power, 
 often with trembling, blunting of the higher moral and ethical sense, 
 insomnia, nutritive disturbances, and, finally, illusions, hallucinations, and 
 delusions. The tendency of the morphinomaniac to lie and to romance is 
 proverbial. The patient lives so much of his time in an unreal world that 
 he loses his ability to distinguish the true from the false. He becomes 
 both delusional and mendacious. In advanced stages the patient may 
 be violently insane, even maniacal, and may commit acts of violence. 
 Obscure medicolegal problems arise occasionally, for the narcomaniac is 
 sometimes also a kleptomaniac, a pyromaniac, etc.^ 
 
 The physical symptoms vary greatly; in fact, they can hardly be said 
 to be characteristic. Among them are anaemia, rapid exhaustion and lack 
 of endurance, tremor, itching of the skin, anorexia, constipation, wasting, 
 blunting of the special senses, and contracted pupils. The sexual power is 
 weakened and finally destroyed, and in women amenorrhoea is common. 
 Children born of mothers addicted to morphia have a low vitality and 
 often die early. 
 
 Diagnosis. — The only rule is to detect the habit. Obscure mental 
 changes, such as those mentioned above, may exist for a long while and not 
 excite suspicion; and he must be a shrewd diagnostician who can detect 
 the morphia taker by his mental symptoms alone. The history, therefore, 
 is all important. Spells of irritability and unrest occur when the victim is 
 deprived of his drug, and are followed by a mysterious calm and serenity 
 when he has taken his secret dose. But such signs require to be inter- 
 preted with great caution. Instances are known of judges presiding on 
 the bench, and clergymen preaching in their pulpits, when fully under 
 the influence of their accustomed doses. Diarrhoea, faintness, collapse, are 
 among the graver ''abstinence symptoms." 
 
 The morphia fiend may also take cocaine, and is occasionally addicted 
 to alcohol, with bromide or chloral as a help. These all-round drug-takers 
 sometimes break down in a state not unlike general paresis — a sort of 
 pseudoparesis — from which recovery is possible if they are pulled up in time. 
 
 A state of neurasthenia is seen in some morphia takers, especially in 
 women who take small doses and are successful in concealing the habit. 
 Hence the necessity of careful inquiry. The morphia taker often has 
 sores on the skin from the use of the needle. 
 
 1 Wharton and Still^'a Med. Jurisprudence, 5th ed. Chapt. on " Narcomania " by Lloyd, vol. i, p. 874. 
 
LEAD POISONING. 881 
 
 III. COCAINE POISONING; COCAINISM. 
 
 Erlenmeyer was the first to describe cocomania as a distinct disease. 
 The habit has prevailed only in recent years, for cocaine, the active 
 principle of the coca plant, was only discovered by Gardeke in 1855. 
 
 Symptoms. — The physical symptoms are loss of weight, muscular 
 weakness, tremor, anaesthesia, and disturbance of the heart and circulation. 
 
 The mental symptoms are marked. No other narcotic makes such a 
 pleasing impression on the brain. It is a sense of well-being, of strength, 
 and of entire happiness. But the duration is brief. Later, as the habit 
 is formed, a delusional insanity occurs, with hallucinations, which may 
 appear suddenly and develop rapidly. The delusions are of the persecutory 
 type, such as fear of enemies, suspicion of marital infidelity, and dread of 
 burglars. The hallucinations are both visual and auditory, and are dis- 
 turbing or alarming, such as the sight of insects, the sound of insulting 
 words, etc. One of the most characteristic is the so-called ''cocaine-bug:" 
 the patient imagines he feels a hard object beneath the skin of his fingers 
 or hand. It is called Magnan's sign, and is probably due to anajsthesia of 
 the sensory nerve-endings. 
 
 Cocaine is a virulent poison to the nervous system — much worse 
 and much more rapid in its effects than morphia. Many of these patients, 
 in fact, are also addicted to morphia. Their career is short; they go to 
 pieces quickly and suddenly; and for some time before the final collapse 
 they have their spells of depression, in which there is acute distress. They 
 are also, sometimes, excitable and violent. A peculiarity of some cases is 
 an extreme slowness of the mental processes, and prolixity in speech and 
 letter writing. The habit has much increased lately, especially among the 
 lower classes, even the negroes in some places becoming addicted. 
 
 Diagnosis. — This presents no difficulty, as a rule, for the secret will 
 out. It is important to bear in mind that a large number, probably the 
 majority, of cocomaniacs also use morphia. They are worse physical 
 wrecks, as a rule, than the pure morphia takers. Kerr says that the bodily 
 wasting appears quickly; there is great loss of the sense of time; and in 
 fatal cases stupor and coma, with convulsions, occur. Mosso directs atten- 
 tion to what he calls tetanus of the respiratory muscles. In some cases there 
 is great muscular unsteadiness. Insomnia is common, as in all drug takers 
 when deprived of their allowance. While individually these symptoms are 
 common to many conditions, it is the grouping of them that characterizes 
 the chronic poisoning by cocaine. Delusions and hallucinations are rather 
 more common than in chronic opium poisoning. Some of these patients 
 are covered with wounds and scars from the hypodermic needle. 
 
 IV. LEAD POISONING; PLUMBISM. 
 
 Lead is widely used in the arts; hence lead poisoning in its various 
 forms is not uncommon. The persons most exposed to the poison are 
 the workmen in white lead factories, painters, and smelters. Plumbism 
 occurs also in type-founders, file-makers, shot-makers, gilders, bronzers, 
 lace-makers, glass-cutters, plumbers, and in other artisans. 
 
 56 
 
882 MEDICAL DIAGNOSIS. 
 
 Chronic lead poisoning is sometimes unrecognized, for the patient 
 may have been exposed in unsuspected ways, as by hair-dye, food stuffs, 
 etc., drinking water, and may not even know himself the nature of his 
 ailment. The chromate of lead has been used by bakers to give color to 
 their products, as reported by D. D. Stewart, of Philadelphia; wines, beer, 
 and cider have been contaminated by lead pipes and lead vessels; and 
 sewing thread is sometimes weighted with lead, so that poisoning has 
 occurred in a seamstress from the constant biting off of the ends. 
 
 Pathology. — Lead affects many of the tissues. In the nervous system 
 it causes a peripheral neiu-itis, and also poisons the brain-cells, but the 
 pathological changes in the brain, according to Berkley, are not as yet 
 clearly demonstrated. Optic neuritis is seen occasionally. The motor 
 cells in the anterior horns of the spinal cord are sometimes affected. Con- 
 tracted kidneys and arteriosclerosis are not uncommon in chrome lead 
 poisoning. Gastro-intestinal irritation and inflammation are the results 
 of the ingestion of lead. T. Oliver found changes in the liver, such as 
 atrophy of the hepatic cells and increase of connective tissue. Lead is 
 found in the muscles and in other tissues, and ma}^ even be detected 
 in the urine and fseces for long periods after its introduction into the 
 system has stopped. 
 
 Symptoms. — These are acute and chronic. Acute lead poisoning 
 is marked hj pain in the stomach and bowel, vomiting, constipation or 
 diarrhoea, the stools being black from the sulphuret; cramps, neuralgic 
 pains, paralysis, and anaesthesia in the limbs; and finally syncope and 
 collapse. Convulsions and coma occur in some cases. Chronic lead 
 POISONING is known by the following symptoms: a blue line on the gums, 
 anaemia, colic, pain, vomiting, paralysis, anaesthesia, ataxia, tremor, 
 cramps, convulsions, encephalopathy, neurasthenic and hysterical symp- 
 toms, optic neuritis or atrophy, contracted kidneys, and the so-called 
 lead gout. 
 
 The blue line at the gingival border is very commonly seen, but it 
 has no necessary relationship to the severity of the other s^^mptoms. As a 
 diagnostic sign, however, it is of great value. Anaemia is said to be common 
 among lead miners, and it can occur in any one who is much exposed. 
 
 Colic and epigastric and precordial pains are very characteristic. The 
 familiar term " colica pictonum" dates from the seventeenth century 
 when the affection prevailed as an epidemic in Poitou from the contam- 
 ination of wine with lead. The attacks are often acute, are even seen 
 in persons onlj^ recently exposed to lead, and may or may not be asso- 
 ciated with wT-ist-drop. The coHc centres about the navel and is often 
 severe and usually without diarrhoea. It may be accompanied with vomit- 
 ing. This pain and distress about the precordia may simulate angina 
 pectoris or pericarditis. Myalgic and arthralgic pains are also observed, 
 especially about the knees and in the lumbar muscles, and they may 
 simulate gout. 
 
 Paralvsis is often seen. The commonest form is the familiar irrist- 
 droj), caused by involvement especially, but not exclusively, of the inter- 
 osseous branch of the musculospiral nerve. The supinator longus muscle 
 and the extensor of the metacarpal bone of the thumb, for some unknown 
 
LEAD POISONING. 883 
 
 reason, always escape, and as a rule there is no anaesthesia. The paralysis 
 is of the peripheral or flaccid type, with muscular atrophy and reactions 
 of degeneration. The hand falls at the wrist and is almost powerless, for 
 not only are the extensors paralyzed, but the flexors act at such disad- 
 vantage that they can only be partially brought into use, as can readily 
 be shown by asking the patient to grasp the observer's hand, when the 
 grip will be found weak; but if the hand is passively extended the grip is 
 much improved. This wrist-drop is always bilateral. In some cases the 
 paralysis is not confined to the extensors of the hand: the muscles of 
 the upper arms are occasionally involved, and the deltoids seem especially 
 prone to suffer. Again, the paralysis may be even more wide-spread, 
 involving the legs, and presenting the form of a more or less generalized 
 peripheral neuritis, with abolished deep reflexes. 
 
 A true progressive muscular atrophy and a pseudotabes, due to lead, 
 are occasionally seen. 
 
 Tremor and cramps are not common in lead poisoning; the former 
 resembles other forms of metallic tremor — it is at first fine, gradually 
 increases in amplitude, and is worse on voluntary movement and during 
 emotion. Anaesthesia likewise is rare in uncomplicated cases. This is 
 true especially of the cases of wrist-drop. Slight hypsesthesia or retarda- 
 tion may occasionally be seen. In the rare pseudotabes various modes of 
 anaesthesia are noted, especially deep anaesthesia, such as alteration in the 
 muscular sense, pressure sense, and sense of position. But there is a form 
 of hysterical anaesthesia which is not so rare, as has blen pointed out by 
 the French. It may be of the segmental type and is sometimes influenced 
 by suggestion. 
 
 Under the head of encephalopathy are included a group of symptoms 
 sometimes seen in lead poisoning. These comprise headache, confusion, 
 delirium, convulsions, and coma. The attack may come on suddenly, and 
 is seen even in persons not long exposed, but it is probably more common 
 in the victims of chronic poisoning. There is sometimes an initial head- 
 ache, with restlessness and insomnia, or the attack begins abruptly with 
 a fit. The delirium persists for some hours or even days, and is accom- 
 panied with hallucinations of sight and hearing. The convulsions may 
 recur, the delirium persisting between them. An isolated attack, without 
 delirium before or after it, may also occur. If the convulsions recur fre- 
 quently, the patient may pass into an epileptic status, with fever, coma, 
 stertorous breathing, rapid pulse, and failing vitality, and die. If these 
 attacks occur often there is risk of permanent damage to the brain, as is 
 shown by recurring epilepsy, maniacal seizures, melancholia, and dementia. 
 It must not be forgotten that a type of so-called hystero-epilepsy, totally 
 different from the preceding, sometimes occurs in lead poisoning; it is 
 purely hysterical, and is to be known by the hysterical stigmata. Changes 
 in the optic nerves occur in lead poisoning. Atrophy is observed, and it may 
 follow a neuritis. The association of kidney disease with chronic plumbism 
 must not be overlooked, and hence the possibility of albuminuric retinitis. 
 
 Neurasthenic and hysterical symptoms may complicate lead poison- 
 ing. Among the symptoms are anaesthesia, including hemianaesthesia and 
 segmental anaesthesia, tremor, hysterical paralysis, and hysterical con- 
 
884 MEDICAL DIAGNOSIS. 
 
 vulsions. The association of gout with plumbism is insisted on by many- 
 English physicians. They point to the contracted kidneys, arteriosclerosis, 
 arthralgia, and in some cases arthritic changes and deposits, as evidences 
 of this "lead-gout." Bright's disease is a not uncommon complication 
 of chronic lead poisoning. 
 
 Diagnosis. — When the history is clear the diagnosis is easy; but 
 when the history of exposure to lead is wanting, the case may be most 
 obscure. The blue line on the gums is of the greatest value, but it is not 
 always present. The precordial pain in lead poisoning may simulate 
 angina pectoris, but the history and the blue line are usually determina- 
 tive. The wrist-drop due to lead is always bilateral, although it may 
 be worse on one side; and the supinator longus and the extensor of the 
 metacarpal bone of the thumb escape; thus the case differs from one of 
 trauma of the musculospiral nerve, which is usually unilateral, and involves 
 more muscles. Other forms of paralysis are rare in lead poisoning, but 
 the history and the blue line are usually clear. The pseudotabes due to 
 lead is distinguished from locomotor ataxia by the presence of muscular 
 atrophy and the reactions of degeneration, and the absence of fulgurant 
 pains, Argyl-Robertson pupils, and other true tabetic symptoms. Lead 
 encephalopathy closely simulates uraemia, also idiopathic epilepsy. If 
 the history is obscure the difficulty may be great. The blue line would 
 be important, and there may be an absence of urinary symptoms. If the 
 history is clear there need be no great difficulty in the diagnosis of 
 epilepsy, of ursemfa, or of encephalopathy. 
 
 The stigmata of hysteria can usually be recognized with a little care. 
 Hemianesthesia and segmental anaesthesia are not caused by lead alone; 
 they are hysterical. 
 
 V. ARSENICAL POISONING. 
 
 Chronic poisoning by arsenic is much less common now than some 
 years ago, partly because of more widely disseminated knowledge con- 
 cerning the dangers of the use of this metal and its salts in the arts and 
 partly because of the enactment of laws hmiting the amount of arsenic 
 in wall-papers and dress goods. This form of intoxication is at present 
 occasionally encountered in persons engaged in certain occupations, as the 
 manufacture of wall-papers and other papers, playing cards, book covers, 
 and artificial flowers. Those who handle, and more particularly those who 
 wear, articles of apparel, such as stockings, gloves, and certain dress fabrics, 
 dyed with arsenical pigments in excess, or furs cured by arsenic, are exposed 
 to a theoretical danger which is, however, trifling as compared with that 
 of a generation ago. Not only the greens, as popularly supposed, but dyes 
 of various colors often contain arsenic in dangerous amounts. The danger 
 of acute or chronic poisoning as the result of the introduction of arsenic 
 into articles of food as a preservative is no longer to be considered. 
 
 It is a remarkable fact that a large proportion of cases of chronic 
 arsenical poisoning at the present time are caused by the use of this metal 
 for therapeutic purposes. This untoward occurrence may be due to exces- 
 sive doses, an improper prolongation of the treatment by proper doses, 
 
ARSENICAL POISONING. 885 
 
 or to an unusual degree of susceptibility on the part of certain individuals 
 to some of the toxic effects of arsenic. Patients and, in particular, those 
 subject to diseases of the skin frequently continue the use of prescriptions 
 containing arsenic without regularly reporting to the physician. It is 
 important that medical men should protect themselves and their patients 
 by emphasizing the risks attendant upon such a course. The growing 
 use of less toxic arsenical preparations, as atoxyl and sodium cacodylate, 
 will diminish this danger. 
 
 Arsenic eating, as practiced in Styria and elsewhere for the purpose 
 of stimulating the powers of endurance and the sexual capacity or improv- 
 ing the complexion, has in many cases resulted in chronic poisoning. The 
 presence of arsenic in beer, derived from the sulphuric acid used in the 
 manufacture of the glucose employed in brewmg, recently attracted much 
 attention in England as a source of danger. The use of Paris green and 
 other arsenical preparations as insecticides is attended with little risk in 
 itself. The chief danger lies in having such substances about under con- 
 ditions in which they may give rise to accidental or intentional poisoning. 
 Miners and smelters of ores containing arsenic are much exposed to the 
 danger of chronic poisoning. Acute arsenical poisoning is rarely acci- 
 dental, but by no means uncommon in suicidal or homicidal cases. 
 
 Pathology. — In the acute form gastro-enteritis, nephritis, and fatty 
 changes in the muscles and viscera, especially the liver, constitute the chief 
 lesions; in the chronic form anaemia, pigmentation of the skin^ and lesions 
 of the nervous system, particularly of the peripheral nerves, are common. 
 
 Symptoms. — The chief clinical manifestations of chronic arsenical 
 poisoning relate to the skin and the peripheral nervous system. The 
 general health may not be at first greatly impaired. As a rule, however, 
 anaemia, emaciation, loss of strength, cardiac asthenia, and vasomotor 
 derangements are present in varying degree. 
 
 The Skin. — Hyperidrosis, glossiness, local ulceration, herpes, and 
 erythromelalgia are occasionally observed. Pigmentation is very common 
 and often marked. It varies from a faint brownish-yellow to a deep brown, 
 and is sometimes distributed over the greater part of the surface; some- 
 times collected in circumscribed areas and frequently diffuse, with patches 
 of deeper coloring upon exposed parts, in the folds about the joints, and 
 in regions normally pigmented, as the nipples and pudenda, especially in 
 those of dark complexion. Small dense collections of pigment may form 
 and present the appearance of pigmented moles. Patches of pigmentation 
 are occasionally observed upon the mucous membranes. As a rule, to 
 which there are exceptions, the skin, after the exposure to arsenic ceases, 
 gradually resumes its normal appearance. Keratosis is less common. 
 It is usually confined to the palms and soles and occurs in circumscribed 
 patches. Epitheliomatous degeneration may occur. Less common are 
 erythema, which is sometimes symmetrical, polymorphous lesions, fur- 
 uncles, acne, depraved nutrition of the nails, and alopecia. Puffiness of 
 the eyelids is a common and early symptom. 
 
 The Nervous System. — The principal symptoms are those of a 
 peripheral neuritis, which involves the lower extremities much more com- 
 monly than the upper, and when both are affected the lower to a greater 
 
886 MEDICAL DIAGNOSIS. 
 
 degree. Motor derangements, varying from a slight palsy to actual paraly- 
 sis, may appear in a few hours, or not for several days after a single toxic 
 dose, when the acute gastro-intestinal and depressive symptoms have 
 wholly subsided. In some instances palsy has appeared several weeks 
 after a single poisonous dose, recovery having in the intervening period 
 been apparently complete. In chronic poisoning the paralysis develops 
 gradually after a variable period, the length of which is determined by 
 individual peculiarities and the degree of intoxication. Deeangements of 
 SENSATION consist of parajsthesias of various kinds, and pain. The latter 
 is frequently severe and associated with tenderness along the nerve-trunks. 
 Anaesthesia, hyperaesthesia, polyaesthesia, and other derangements of sen- 
 sation occur. The nervous symptoms, both motor and sensory, do not 
 often extend above the knees or elbows, and the thighs and arms, together 
 with the trunk, remain uninvolved. The sphincters escape. In severe 
 cases the muscles of the legs and feet and arms and hands undergo atrophy; 
 the knee-jerks are lost. Reactions of degeneration are present and con- 
 tractures occur. There are cases in which the resemblance to tabes is 
 very striking. Mental symptoms occur in severe and prolonged cases. 
 They comprise loss of memory, mental weakness, hallucinations of sight 
 and hearing, and may gradually assume the form of a terminal dementia. 
 
 Diagnosis. — Direct. — This rests upon the association of the fore- 
 going symptoms, especially those relating to the skin and nervous system, 
 and a histor}^ or knowledge of exposure to, or the ingestion of, arsenic. 
 The disappearance of the symptoms upon the removal of arsenic would 
 render the diagnosis positive. When any of the above symptoms arises 
 in a patient who is under treatment b}' arsenic for chronic skin disease, 
 angemia, chorea, habit-spasm, or Hodgkin's disease, or in any person who 
 is employed in arts or manufactures in which arsenic is freely used, or 
 who lives under conditions involving exposure to arsenic, who habitu- 
 ally eats it for any purpose, or who has a history of acute poisoning by 
 arsenic, a provisional diagnosis. of chronic arsenical poisoning is justified 
 but should be at once tested by the complete withdrawal of the patient 
 from exposure to the action of arsenic in any manner whatever. 
 
 Differential. — Peripheral neuritis due to other causes, as lead, 
 alcohol, and the infections. Lead palsy may be recognized by the absence 
 of pain, the more common and severe implication of the upper extremi- 
 ties, bilateral wrist-drop without involvement of the supinator longus or 
 the flexors, the blue line on the gums, colic and constipation, and a known 
 historv of exposure to lead. Alcoholic neuritis may be recognized by 
 pain, a history of alcoholic excesses, other signs of alcoholism, as the facies, 
 the condition of the mind, or visceral lesions, as for example fatty liver or 
 cirrhosis. Post-infectious neuritis usually shows a clear history of some 
 foregoing acute or chronic infectious disease, as enteric. fever, diphtheria, 
 or pulmonary tuberculosis. Tabes dorsalis may be distinguished from 
 the rare cases of arsenical poisoning which somewhat resemble it, by 
 the gradual onset, the commonly prolonged and progressive course, the 
 ocular phenomena, the various " crises," a history of syphilis in nearly 
 every case, the lightning pains, and the absence of the cutaneous lesions 
 produced by arsenic. 
 
POISONING BY MERCURY. 887 
 
 In any doubtful case it may be necessary to examine the urine for 
 the presence of arsenic, though it must be borne in mind that arsenic is 
 not always present in the urine when it is known to have been ingested, 
 and that when present it disappears within two or three weeks after its 
 administration has been discontinued. For this pm-pose it is best for the 
 practitioner to secure the services of a competent chemist. 
 
 VI. POISONING BY MERCURY. 
 
 As in the case of arsenic, chronic poisoning by mercury is far less 
 common than formerly, because the employment of this metal in the arts 
 is now much restricted and far greater care is exercised in its use in medicine. 
 
 Etiology. — As an occupation disease chronic mercurial poisoning 
 occasionally occurs in those emplo3^ed in making certain dyes, the use of 
 amalgams, the preparation of fulminate, the manufacture of fireworks, 
 among taxidermists, and in those engaged in the making of felts for hats 
 and other purposes (Edsall). Especially hazardous are occupations such 
 as the mining and smelting of mercurial ores. The manufacture of scien- 
 tific instruments depending upon the physical properties of mercury, as 
 thermometers,. barometers, and manometers, involves prolonged exposure 
 to the risk of a slow intoxication. The number of persons engaged in these 
 various occupations is comparatively limited, but for this very reason a 
 knowledge of the effects caused by mercury, while of relatively slight 
 importance to the general practitioner, is of especial interest to the h3^gienist 
 because they are preventable, and to the diagnostician because they are 
 rare. It is of diagnostic importance that not only those actually engaged 
 in occupations concerned with mercury are liable to this metallic intoxi- 
 cation, but also others who breathe an atmosphere containing volatilized 
 or dust-borne mercury, or drink water in the neighborhood of mines. 
 
 Pathology. — Chronic gastro-enteritis, anaemia, emaciation, and fatty 
 degeneration of the viscera are encountered. Neuritis is very rare. Its 
 occurrence has been questioned. 
 
 Mode of Access. — Chiefly by inhalation, since mercury volatilizes at 
 ordinary temperatures; to a subsidiary extent through the skin. In 
 medicinal mercurialization most commonly by ingestion; less frequent!}'- 
 MMnunction. Fortunately ptyalism, mercurial stomatitis (which see), is a 
 danger signal and usually leads to the immediate discontinuance of the drug. 
 
 Symptoms. — Ptyalism does not, however, alwa3^s occur in chronic 
 mercurial poisoning. In a small proportion of the cases it is an early and 
 persistent condition. Early symptoms are headache, disturbed and unre- 
 freshing sleep, and mental and ph^^sical depression, especially in the early 
 hours of the day. x4nsemia is common. The association of tremor and a 
 curious emotional condition suggestive of hysteria dominate the symptom- 
 complex. Tremor is usually at first absent when the patient is at rest, 
 but shows itself at once upon voluntary movement and is greatly aggra- 
 vated by emotional excitement. It chiefly involves the hands and lips, 
 but may, in severe cases, affect all the extremities to such an extent as to 
 interfere seriously with the ordinary movements of everyday life. In the 
 early cases the tremor is fine, but later it increases in amplitude and becomes 
 
888 MEDICAL DIAGNOSIS. 
 
 coarse and rapid. When it affects the muscles of articulation, speech is 
 much deranged and this, with the tremor of the lips and tongue, may 
 suggest disseminated sclerosis. Attacks of vertigo occasionally occur. In 
 grave cases muscular weakness, choreiform movements, and various palsies, 
 together with anaesthesia and other disturbances of sensation, are encount- 
 ered. These motor and sensory phenomena are, as a rule, irregularly 
 distributed, incomplete, and transitory. Epileptiform convulsions, paroxys- 
 mal tonic spasm involving chiefly the flexors of the forearm, and clonic 
 spasms also paroxysmal and affecting all the muscles of the body but with- 
 out loss of consciousness, have been described. The emotional derange- 
 ments assume a form highly suggestive of hysteria. But the conclusion 
 that groups of previously healthy individuals collected in one locality 
 from various sources and developing emotional symptoms along with the 
 other phenomena and the tremor, after prolonged exposure to mercurial 
 poisoning, should be hysterical is unwarranted. This group of symptoms 
 includes sensations of weakness, powerlessness, and fright, which, in rare 
 instances, gradually increase to actual obsessions of fear and doubt which 
 render the life of the patient one of abject wretchedness and have in some 
 instances amounted to a form of dementia. 
 
 Diagnosis. — Direct. — The fact of habitual exposure to mercury, 
 either in occupation, therapeutically, or under other circumstances men- 
 tioned under the subtitle etiology, together with the character of the tremor 
 and the emotional disturbances, render a positive diagnosis a comparatively 
 easy matter. If necessary a chemical examination of the urine may be made. 
 
 Differential. — The following conditions are to be considered: 
 Hysteria. — The presence of the stigmata of this condition (see article on 
 Hysteria) and of the visual phenomena, the intermittent and paroxysmal 
 character of the symptoms in many cases of hysteria, and the absence of 
 the peculiar tremor of mercurial intoxication, are significant. Dissemi- 
 nated Sclerosis. — The finer tremor, absence of emotional or hysterical 
 phenomena, the staccato speech, nystagmus, occasional focal phenomena, 
 and the persistent and progressive character of the symptoms, are impor- 
 tant in the differential diagnosis. Paralysis Agitans. — The passive tremor, 
 unemotional mental condition, peculiar mask-like facies, persistent muscu- 
 lar rigidity and festination of this condition are in strong contrast with 
 the symptom-complex of mercurial intoxication. Paresis. — The tremor 
 is suggestive, but the differentiation may be made without difficulty. The 
 emotional states are wholly different. In paresis delusions of grandeur 
 and perversions of the moral sense occur. There are apoplectiform seizures, 
 epileptiform convulsions, remarkable remissions of all symptoms, occa- 
 sional focal phenomena, and progressive mental and physical deteriora- 
 tion. Alcoholism. — The two conditions are frequently associated. The 
 anamnesis, the slight degree of influence of emotional states upon the 
 tremor, and the facies, dilated venules, circulatory and visceral conditions 
 attendant upon chronic alcoholism, are important. Plumbism. — The history 
 of exposure to lead, constipation, colic, the gingival line, and the wrist-drop 
 are characteristic. 
 
 Prognosis. — In the early cases the outlook is favorable. Even after 
 prolonged and well-characterized symptoms recovery may take place. 
 
PHOSPHORUS POISONING. 889 
 
 In such cases, however, tremor may persist. Persistent palsy, headache, 
 progressive anaemia, and the cachectic state are unfavorable as regards 
 prognosis. Change of occupation and complete freedom from exposure 
 are essential to recovery. If such requirements cannot be met the 
 prognosis is uncertain or unfavorable. 
 
 VII. PHOSPHORUS POISONING. 
 
 Etiology. — Acute poisoning by phosphorus is rare and usually results 
 from the swallowing of match-heads with suicidal intent. Chronic poison- 
 ing is likewise rare and occurs as an industrial disease in localities in which 
 matches are manufactured. 
 
 Pathology. — Acute Phosphorus Poisoning. — The coagulability of 
 the blood is reduced; there are diffuse hemorrhages into the skin and 
 viscera and from mucous surfaces; jaundice; fatty degeneration of the 
 muscles and parenchymatous organs, especially of the liver, which also 
 rapidly undergoes enlargement and changes to a bright saffron color. 
 Leucin, tyrosin, cystin, sarcolactic acid, peptones, and sugar are found in 
 the urine and blood. Acid intoxication occurs, as a result of which the 
 urinary ammonia is greatly increased and the urea decreased. In its 
 derangement of metabolic processes phosphorus acts like a ferment. 
 
 Chronic Phosphorus Poisoning. — In man the chief pathological 
 change consists of necrosis of the inferior maxilla with suppuration and 
 the formation of sequestra. Exceptionally the upper jaw bones are affected. 
 This process is accompanied by destructive ulceration of the soft parts 
 with more or less abundant pus formation. 
 
 Symptoms. — Acute poisoning presents a close clinical resemblance to 
 acute yellow atrophy. Early symptoms are vomiting and diarrhoea, 
 which presently subside, to return in the course of forty-eight or seventy 
 hours, and are then accompanied by intense jaundice, epigastric distress, 
 and diffuse pains in the muscles. At this time petechias, submucous hemor- 
 rhages, and blood in the vomitus and stools appear. When, as is not rarely 
 the case, match-heads have been taken to produce abortion, this accident 
 frequently occurs. There is profound asthenia, with maniacal excitement 
 which rapidly passes into stupor and coma and is followed by death. The 
 vomited matters may be phosphorescent. 
 
 The necrosis of the jaw, which constitutes the chief morbid condition 
 in the chronic form, commonly begins about a single tooth, with caries 
 and abscess formation. The process involves the tooth and surrounding 
 alveolar process and rapidly extends to the neighboring teeth and contigu- 
 ous structures. The pus is often abundant and very foul. It burrows in 
 various directions and may form sinuses which discharge in the neck. One 
 or several sequestra may form. Rapid anaemia and general sepsis may 
 occur, and in neglected cases amyloid disease, tuberculous infection, and 
 basal meningitis have been observed. 
 
 Diagnosis. — Both in acute and chronic phosphorus poisoning, the 
 diagnosis depends largely upon the anamnesis. In the former suicidal 
 intention, or rarely the eating of match-heads by young children; in the 
 latter the exposure to phosphorus, which is volatile at ordinary temper- 
 
890 MEDICAL DIAGNOSIS. 
 
 atureS; as an occupation risk, are of great diagnostic significance. The 
 main points of discrimination from acute yellow atrophy of the liver con- 
 sist in the period of relief which occurs in the interval between the early 
 gastro-intestinal symptoms in phosphorus poisoning and the graver phe- 
 nomena, the enlargement of the liver, the occasional absence of leucin and 
 tyrosin or their relatively smaller amount, and the less intense nervous 
 symptoms. There are, however, cases in which, in the absence of a clear 
 history, the differential diagnosis is attended with difficulty. As to chronic 
 poisoning, there are no conditions characterized by similar persistent 
 and extending necrotic processes in the jaw. Actinomycosis may be 
 recognized by the presence of the ray fungus in the pus. 
 
 Prognosis. — The mortality in acute poisoning is about 50 per cent. 
 The fatal issue occurs in less than a week. In the chronic form recovery 
 frequently follows early operation. In neglected or very severe cases, even 
 extensive resection may fail to arrest the advance of the necrotic process. 
 
 VIII. ACUTE AND CHRONIC POISONING BY ILLUMI- 
 NATING GAS. 
 
 Etiology. — A number of gases enter in varying proportion into the 
 composition of illuminating gas, but carbon monoxide constitutes the 
 chief toxic agent. Water gas is especially active as a poison, because of 
 the relatively large amount of carbon monoxide which it contains. 
 
 Acute poisoning commonly occurs as the result of the escape of gas 
 by way of an unlighted burner into sleeping-rooms. This has resulted 
 accidentally from a gust of wind, from leaving the gas turned on, from 
 ignorance, or with suicidal intent. This method of suicide has become ver}^ 
 common and when, as is usually the case, the access of air is carefully 
 guarded against and rubber hose, is used it is a very certain one. Acute 
 . poisoning may occur, however, in those employed in gas works, and I 
 have seen a case in which it resulted from the escape of gas from a street 
 main. Chronic poisoning is probably rare and is likely to arise among 
 those employed in gas works or those dwelling in houses into which slow 
 but continuous leakage occurs from pipes or fixtures. Toxic symptoms 
 may arise upon breathing an atmosphere containing 0.02 per cent, of 
 carbon monoxide; 0.05 is highly dangerous, and above this the air speedily 
 becomes irrespirable. 
 
 Pathology. — The toxic action is chiefly upon the red blood-corpuscles, 
 the oxyhsemogiobin being converted into carbon monoxide haemoglobin, 
 and the function of the affected corpuscles as carriers of oxygen and carbon 
 dioxide destroyed. The blood is cherry-red in color. There are areas of 
 bluish-red discoloration upon the neck, chest, and elsewhere, visceral 
 hypersemia, and local hemorrhages. In the chronic cases fatty degenera- 
 tion of the heart, anaemia, and enlargement of the spleen have been noted. 
 
 Symptoms. — The clinical phenomena depend upon the proportion of 
 gas in the atmosphere and the duration of exposure. Progressively they 
 are as follows: malaise, sensations of throbbing, especially in the head, 
 headache, vertigo, muscular weakness, nausea, vomiting, drowsiness, lose 
 
POISONING BY ILLUMINATING GAS. 891 
 
 of consciousness, and relaxation of the sphincters. Muscular twitchings 
 and general convulsions occur. In the comatose state there are rapid 
 respiration, a rapid and full pulse, and cyanosis. The blood is cherry-red 
 in color and there is leucocytosis, high in proportion to the gravity of the 
 case. When recovery takes place, sequels relating to the respiratory tract, 
 bronchitis, and bronchopneumonia are common. Lobar pneumonia is 
 rare. Cardiac derangements of a functional kind also occur. To these, in 
 many cases, are added gastric irritability and epigastric pain and tender- 
 ness, symptoms of a subacute gastritis. Icterus has been observed and 
 glycosuria is common. Local oedema and various inflammatory and 
 necrotic cutaneous lesions occur. Nervous symptoms are common and 
 important. They comprise various neuralgias and forms of neuritis, 
 tremors and choreiform movements, and neurasthenic manifestations, 
 among which fatigue symptoms are very marked. Amaurosis, nystagmus, 
 and ocular palsies may occur. Persistent headache, dulness of hearing, and 
 tinnitus have been noted. Psychical derangements vaiy from confusional 
 states with hallucinations to dementia. The foregoing sequels may develop 
 directly after exposure, or they may come on after several days or even 
 some weeks of apparent recovery and undergo gradual intensification. 
 In the suicidal cases the antecedent condition of the patient is to be con- 
 sidered in estimating the actual relation between the carbon monoxide 
 poisoning and the mental state at a more or less remote period after 
 recovery from such poisoning. The symptoms of chronic poisoning are 
 those of the milder forms of acute poisoning continued through an indefi- 
 nite period, namely, headache, vertigo, nausea, occasional vomiting, 
 muscular weakness, fatigue symptoms, and inability to perform the ordi- 
 nary physical and mental duties of life. A slow pulse, anaemia, and absence 
 of the deep reflexes have been observed. 
 
 Diagnosis. — Direct. — This rests upon the history of the case, which is 
 usually very clear, and the demonstration of carbon monoxide in the blood. 
 
 The most satisfactory tests are: (a) Hoppe-Seyler's sodium hydrate 
 test: A solution of specific gravity of L30 is added to the blood; if carbon 
 monoxide is present the clot formed is of bright red color, while with nor- 
 mal blood the color of the mass is greenish-brown, (b) Katagama's ammo- 
 nium sulphide and acetic acid test: To 10 c.c. of blood diluted with water 
 are added, first, 0.2 c.c. of ammonium sulphide solution, and then 0.2 c.c. 
 of 36 per cent, acetic acid. Blood containing carbon monoxide gives a 
 bright red precipitate; normal blood a green precipitate, (c) The Kunkel- 
 Welzer test consists in the addition to the undiluted blood of an equal 
 volume of 20 per cent, potassium ferrocyanide and a small quantity of 36 
 per cent, acetic acid. Carbon monoxide blood yields a bright red reaction, 
 while the color of normal blood changes to a deep brown. The spectro- 
 scopic test may be employed. 
 
 In a comatose patient of obscure or uncertain antecedents a positive 
 result may be of great importance, (a) in the immediate diagnosis, (b) in 
 determining the character of later morbid conditions, and (c) from a 
 medicolegal point of view . 
 
 Differential. — Alcoholic Coma. — The anamnesis is most impor- 
 tant. The fact is, however, to be borne in mind that a drunken man may 
 
892 MEDICAL DIAGNOSIS. 
 
 blow out the gas, turn the burner off and on again, or conclude to end 
 his life by gas poisoning. The history of a spree and the odor of alcohol 
 have, therefore, no positive value in the differentiation of these two condi- 
 tions. Of greater moment are the appearance of the blood, the above-named 
 tests, cyanosis, and the cutaneous hypersemia. Uramic Coma. — Urinary 
 suppression, the presence of albumin, and casts, dropsy, and cardiovas- 
 cular lesions are of importance, particularly when associated with negative 
 results upon testing for carbon monoxide in the blood. 
 
 The diagnosis of chronic poisoning by illuminating gas is not readily 
 made. When all the occupants of a dwelling habitually awake with nausea^ 
 headache, and vertigo and these symptoms steadily increase, and there is 
 associated muscular and mental weakness and depression, it would become 
 necessary to carefully test the gas-pipes and fixtures. Under such circum- 
 stances the gas present in the atmosphere might produce toxic symptoms, 
 though insufficient to give positive reactions either in the air or in the blood 
 of patients. If certain members of the household, upon removal to a differ- 
 ent locality, were gradually to recover their health, while those remain- 
 ing continued ill, chronic gas poisoning would become a sound provisional 
 diagnosis and the point of departure for further systematic investigation. 
 
 IV. 
 
 THE DIAGNOSIS OF FOOD POISONING. 
 
 Certain articles that are always injurious are, sometimes through 
 ignorance or by accident, used as foods. Examples of these are poisonous 
 mushrooms, which contain muscarine, and some species of fish. The poison 
 present in such substances is said to be endogenous. Entirely different are 
 the poisons which are occasionally present in foods otherwise normal. 
 These consist of, (a) poisonous metals, (b) animal parasites, (c) fungi, and 
 (d) bacteria. These poisons are exogenous. 
 
 (a) Poisonous Metals. — This subject is considered under the appropri- 
 ate headings (see pp. 881, 884, and 887, etc.). The contamination of water 
 in the neighborhood of mines — lead, mercury; of beer by arsenic (out- 
 break in Manchester in 1900) ; of wine (lead shot used in washing bottles) ; 
 the presence of chrome yellow as a coloring matter in cakes; and the possi- 
 bility that canned vegetables and other foods may become poisonous by 
 slow chemical changes of the lead in the solder or the tin, are to be con- 
 sidered. Under all these conditions the poisoning is chronic, the symptoms 
 are slowly progressive, and a number of persons are affected, very often 
 within the boundaries of a limited district, (b) Animal Parasites.— Cer- 
 tain meats are occasionally rendered poisonous by the presence of trichina 
 or cysticercus (q.v.). (c) Fungi. — The grains used for food may be infected 
 with the ergot fungus, spurred rye — Claviceps purpurea — and become 
 the cause of outbreaks of epidemic disease — ergotismus. (d) Bacteria. — 
 Vegetable micro-organisms constitute the chief factor in poisonous foods. 
 Meats obtained from diseased animals may give rise to actual infections. 
 
FOOD POISONING. 893 
 
 Poods contaminated with specific infectious organisms, for example, B. 
 typhosus, may cause circumscribed outbreaks of enteric fever. Finally 
 foods infected with saprophytic bacteria, which evolve poisonous products 
 in the substance of the food itself, may become highly poisonous — ptomaine 
 ■poisoning — a term which in popular parlance is used interchangeably 
 with "food poisoning." 
 
 I. Fish Poisoning — Icthyismus ; Ichthyotoxismus. — The toxic sub- 
 stances may be endogenous, as in species of Tetrodon and Diodon, found in 
 Japan and the East Indies. The nature of the poison is unknown. It is 
 located in the testicles and ovaries. In its effects it resembles curare. The 
 symptoms are vertigo, vomiting, dyspnoea, cyanosis, muscular relaxation, 
 and dilatation of the pupils. Death results very rapidly. This is the fugu 
 poisoning of Japan. In certain species of sturgeon, pike, and barb a poison- 
 ous substance is developed during the spawning season. The intoxication 
 is grave and often fatal, the symptoms being those of an acute gastro- 
 enteritis. Exogenous poisons are more common. If diseased fish is eaten 
 raw, the specific infection may be communicated, or wholesome and edible 
 feh may, if not properly cared for, speedily develop toxic substances 
 -associated with putrefactive changes. These substances, in some instances, 
 resist boiling, so that the infected flesh is also injurious after cooking. The 
 intensely poisonous ptomaines are present during the early days of putre- 
 faction, even before changes recognizable by the taste or smell have 
 occurred, while those of a later period are less toxic. The symptoms do 
 not usually appear until after a period of eight to twenty-four hours. 
 There are two groups of cases. In one the clinical phenomena relate chiefly 
 1)0 the nervous system. These are collapse symptoms, with subnormal 
 temperature, abdominal pain, dry mouth, inability to swallow, dull pain 
 in the belly, dyspnoea, and nervous symptoms, as vertigo, dilatation of the 
 pupils, and diplopia. In another group the clinical manifestations are 
 those of an acute gastro-enteritis, uncontrollable vomiting, griping pains, 
 diarrhoea, and profound cardiac asthenia. Beri-beri and leprosy have 
 been ascribed to the habitual eating of certain kinds of fish. 
 
 Shell-fish. — Poisoning by mussels is not uncommon in Europe and 
 'Great Britain. Brieger, in 1885, isolated a ptomaine — mytilotoxin — which 
 proved to be highly poisonous. It resists the temperature at which the 
 mussels are cooked, and in this respect mussel poisoning is analogous to 
 poisoning by mushrooms. The poison is not regarded as endogenous but 
 as the result of changes caused by bacteria present in polluted waters. 
 The symptoms are variable, sometimes not occurring until after the lapse 
 of several hours and being choleraic in character; in other cases not show- 
 ing themselves for a few days and indicating an action of the poison upon 
 the nervous system. They consist of a general urticarious eruption, 
 associated with asthma-like attacks of dyspnoea. Recovery takes place 
 in the course of several days. In other cases the symptoms come on 
 rapidly and resemble those produced by curara. Death has occurred 
 with great rapidity. 
 
 Oysters which have begun to decompose, and those obtained from 
 beds in waters defiled by sewage, frequently cause poisoning, with gastro- 
 intestinal symptoms. Intense and fatal poisoning from this cause is very 
 
894 MEDICAL DIAGNOSIS. 
 
 infrequent. Much more important is the occasional conveyance of specific 
 infections, especially that of enteric fever, and the causation of epidemics 
 by the eating of oysters and other shell-fish from sewage-polluted water. 
 
 Lobsters and crabs, when not fresh, frequently cause symptoms of 
 poisoning similar to those produced by other fish and shell-fish under like 
 circumstances. All kinds of canned fish may, under certain conditions, as 
 decomposition, or infection previous to canning, or injury to the cans, 
 develop poisonous qualities. 
 
 IL Meat Poisoning — Sausage Poisoning. — As in the case of fish 
 poisoning, the great majority of the cases are due to bacterial infection, 
 either specific, as in the case of animals infected at the time of slaughter, 
 or accidental, from contact with various articles that are unclean, or from 
 improper care in other respects. In the former case the organisms are 
 those comprised in the 'paratyphoid and paracolon groups; in the latter 
 they are saprophytes, as Proteus vulgaris and B. botulinus, or members of 
 the colon group. Clinically the cases may be referred to two categories: 
 first, those in which the symptoms chiefly relate to the nervous system, 
 and second, those in which they are gastro-intestinal. Botulismus — allan- 
 tiasis — sausage poisoning, a specific intoxication caused by B. botulinus, 
 comes on twenty-four or thirty-six hours after eating the food. The 
 sj^mptoms comprise, on the one hand, gastro-intestinal derangements, as 
 epigastric distress, nausea, vomiting, sometimes diarrhoea, sometimes con- 
 stipation, dryness of the mouth and throat, choking attacks, and stomatitis, 
 with tough, adherent secretion; on the other, nervous disorders, as dim- 
 ness of vision, mydriasis, diplopia, strangling sensations, aphonia and pro- 
 found muscular weakness. The pulse and temperature remain normal. 
 Recovery is slow. In fatal cases maniacal delirium, passing into coma, 
 constitutes a terminal event. 
 
 III. Poisoning by Milk and Milk Products. — Milk is especially 
 exposed to bacterial infection, and constitutes a favorable culture medium. 
 For these reasons as a raw food it is an abundant cause of intoxications 
 and infections. Boiled milk, properly protected until used, is safe. Path- 
 ogenic bacteria may reach milk directly from a diseased animal, as in 
 tuberculosis, or by way of water polluted with excreted matter, as in enteric 
 fever, or from cases of diphtheria or scarlet fever in various ways. The 
 gastro-intestinal diseases of infants in hot weather are due to the bacterial 
 infection of milk. Acute intoxications, in contradistinction to the specific 
 infections, are common, and not only milk itself, but also articles made 
 from it, such as ice-cream, custards, and cream puffs, may give rise to 
 serious poisoning. Vaughan isolated from cheese a poisonous ptomaine,- 
 w^hich has been found in milk, but among the milk poisons it is not "the 
 one most frequently present, nor is it the most active one." Of the many 
 different bacteria for which milk forms a culture medium, each has its 
 special toxin. The bacteria which have been especially studied belong 
 to the B. enteritidis group. These organisms do not cause any apparent 
 change in the milk, which presents an alkaline or amphoteric reaction, 
 and is not curdled. 
 
 Cheese frequently develops highly poisonous qualities. The acci- 
 dental introduction of various toxin-producing bacteria and their devel- 
 
FOOD POISONING. 895 
 
 opment are very common. The toxins are probably different, but have 
 not yet been fully studied. Tyrotoxicon was the first to be isolated. The 
 symptoms of cheese poisoning are those of acute gastro-intestinal irritation. 
 
 Diagnosis. — Food poisoning may be recognized by the history of the 
 case in respect to the eating of certain articles of food, and the character 
 of the symptoms, which are usually urgent and are nervous, or gastro- 
 intestinal, or both. In most instances it occurs in circumscribed epidemics, 
 and all the victims are seized at about the same time, which varies accord- 
 ing to the nature of the intoxication from a brief period to two or three 
 days. In a suspected case the careful investigation of the antecedent 
 facts, and the character of the symptoms, are sufficient for a provisional 
 diagnosis, which may be confirmed by bacteriological studies, including 
 agglutination tests. 
 
 IV. Grain and Vegetable Poisoning — Ergotismus. — The cause is a 
 parasitic fungus — Claviceps purpurea — which grows in the flowers of several 
 grains, especially rye, and is known as ergot. This substance contains a 
 number of toxic substances, among which the more important are sphace- 
 linic acid, regarded as the cause of the trophic or gangrenous form, and 
 cornutin, the cause of the nervous or convulsive form of the disease. Ergo- 
 tismus does not occur in this country, but is frequently epidemic in cer- 
 tain parts of Europe. It is due to prolonged ingestion of the poison and is 
 essentially a chronic intoxication, though the onset may be marked by 
 acute symptoms. In the gangrenous form, distant parts of the body in 
 which the circulation is feeble, as the toes, fingers, ears, and the tip of the 
 nose, suffer, and the tissue necrosis is preceded by tingling, anaesthesia, 
 muscular spasms, and signs of local congestion. In the nervous form, 
 the chief symptoms are weakness, headache, cramps in the muscles, and 
 contractures. There may be moderate fever with mania, and, in the 
 severer cases, melancholia and dementia occur. There are tabetic S5^mp- 
 toms, and at the autopsy sclerosis of the posterior columns has been 
 observed. 
 
 Lathyrismus; Lupinosis; Vetch Poisoning. — Chick-pea poisoning 
 occurs in extended outbreaks in Austria, Italy, Northern Africa, and India 
 as the result of the admixture of the powdered seeds of Lathyrus sativus 
 with flour from wheat and other cereals in the making of bread. The 
 symptoms are pain in the lumbar region, girdle sensations, spastic paralj^sis 
 of the lower extremities, which may increase to complete paraplegia, 
 tremor, and fever. 
 
 Pellagra; Maidismus. — An affection caused by the continued eating 
 of food prepared from fermented or diseased Indian corn. It has pre- 
 vailed in extensive epidemics in the south of p]urope, especially in Italy. 
 The actual cause has not as yet been demonstrated, but is probabh^ a 
 specific toxin evolved by the growth of bacteria. Early symptoms are 
 debihty, sleeplessness, pains in the spine, and gastro-intestinal derange- 
 ments. The skin becomes rough and dr}^; then follows desquamation, 
 with crusts and abscess formation. In the graver forms there are serious 
 nervous symptoms — spasms, paralysis of the lower extremities proceed- 
 ing to paraplegia, and, after repeated attacks, a terminal cachexia. 
 Melancholia and mania occur. 
 
896 MEDICAL DIAGNOSIS. 
 
 Potatoes. — Local outbreaks of acute poisoning traced to eating 
 potatoes that have sprouted have recently been recorded. The toxic 
 principle is solanin — present in considerable amounts as the result of the 
 growth of the Bacterium solaniferum colorabile and B. solaniferum non- 
 colorabile. The symptoms are those of an acute gastro-intestinal catarrh, 
 with headache, jaundice, and great prostration. 
 
 Examination of Food in Cases of Suspected Food Poisoning. — As much 
 of the food as can be obtained should be preserved for examination. The 
 quantity is usually small. The investigation should be conducted without 
 unnecessary delay. Meanwhile, perishable articles should be kept on ice 
 without the addition of chemical preservatives. The bacteriological 
 examination should precede the chemical unless there are clear indications 
 of poisoning by definite substances, as arsenic, lead, etc. 
 
 The methods comprise animal experimentation by feeding, the injec- 
 tion of sterile water in which the material has been macerated, further 
 injections of such macerations after filtration through a Berkshire or 
 Pasteur filter, and the determination, when necessary, of the presence of a 
 heat-resisting toxin by injecting the macerations after boiling. Culture and 
 agglutination methods are necessary. 
 
 V. 
 
 THE DIAGNOSIS OF AUTOINTOXICATIONS. 
 
 The term autointoxication is used to designate the intoxications of 
 endogenous metabolic origin. It has been used vaguely for a long time to 
 suggest hypothetical conditions rather than demonstrable facts. Quite 
 recently, under the application of scientific methods, the subject has been 
 to some extent cleared up. 
 
 I. Qastro=intestinaI Autointoxication. — There appears to be no proof 
 that intoxication takes place from the resorption of digestive juices, or 
 of the products of normal digestion, or of the abnormal products of diges- 
 tion, except in the case of the acetone bodies. Nor has it been demon- 
 strated that, in the normal action of bacteria upon the contents of the 
 alimentary canal, toxic substances are produced. Even in the case of 
 intestinal putrefaction, which, to some extent, is a normal process, an 
 increased amount does not necessarily mean an intoxication. Intestinal 
 putrefaction is largely dependent upon the diet; an excess of protein affords 
 an abundant medium for bacterial growth, yet there is no constant ratio 
 between the protein intake and the output of aromatic substances. An 
 increase of these bodies, especially indican in the urine, actually indicates 
 increased bacterial activity, whereas it is constantly assumed to be the 
 sign of an intoxication. Intestinal putrefaction is to be distinguished 
 from tissue putrefaction, which is the cause of an excess of aromatic bodies 
 in the urine. The aromatic bodies are not in themselves toxic. It has 
 been assumed that other substances of a poisonous character are produced 
 by putrefaction, and that these, Hke the amount of putrefaction, may be 
 
AUTOINTOXICATIONS. 897 
 
 approximately estimated by the aromatic substances. In point of fact the 
 aromatic substances in the urine afford no indication of the presence or 
 amount of any hypothetical poison and bear no constant relation to the 
 symptoms in any particular case. 
 
 Tetany. — The extremely rare and fatal tetany in adults, occurring in 
 the dilatation of stomach, has been attributed to poisons produced by 
 the decomposition of food. 
 
 Gastro-intestinal Attacks Associated with Cutaneous Symptoms. — The 
 seizures are acute and recur periodically. They consist of epigastric pain, 
 vomiting, diarrhoea, and various skin eruptions, most commonly urticaria 
 and erythema. Desquamation may occur. 
 
 Acute Paroxysmal Gastro-enteritis. — The attack occurs suddenly in the 
 absence of errors in diet, particularly in the absence of food poisoning. 
 The symptoms are vomiting, often uncontrollable; severe abdominal pain; 
 diarrhoea, frequently profuse; and tympanites; together with marked ner- 
 vous phenomena, as vertigo, spasms, shock, and in grave cases general 
 convulsions and coma. 
 
 Intestinal Obstruction. — This condition, either partial or complete, is 
 very commonly attended by symptoms of autointoxication, namely, head- 
 ache, fever, sleeplessness, and albuminuria, with increase in the aromatic sub- 
 stances in the urine; all of which subside when the obstruction is relieved. 
 
 Constipation. — Many symptoms are attributed to this condition, but 
 there are few that are constant and none that is characteristic. A furred 
 tongue, poor appetite, headache, lassitude, and mental depression may 
 occur in habitual constipation, but these symptoms are common in those 
 who have a regular daily action of the bowels. There are those who are 
 miserable if the daily morning movement is missed, while others are 
 uncomfortable if by drugs or injections their bowels are moved more 
 frequently than once in the course of some days. Coprcemia, a hypothetical 
 intestinal autointoxication from constipation, lacks the support of accu- 
 rate clinical observation and objective chemical investigation. The work of 
 Horace Fletcher has shown that constipation amounting to the evacuation 
 of small masses of dry faeces at intervals of several days is not incompatible 
 with excellent health. The secondary mechanical effect of the accumulation 
 of fecal matter in the intestines is considered under its appropriate heading. 
 
 Gastric Neurasthenic and Other Conditions Vaguely Described as Ner- 
 vous Dyspepsia. — This group of nervous affections is sometimes attrib- 
 uted, upon wholly insufficient evidence, to autointoxication, and the same 
 statement may be made in regard to a number of nervous diseases, as 
 migraine, neuritis, and epilepsy, and some of the psychoses, as melancholia 
 and forms of dementia. 
 
 I'he Ancemias. — The theory of Sir Andrew Clark in regard to fecal 
 poisoning as the cause of chlorosis rests upon an insufficient basis of fact 
 and is no longer accepted. That pernicious anaemia is probably due to 
 an autointoxication of intestinal origin finds support in the following facts, 
 namely: that a persistent haemolysis is the essential pathological process in 
 the disease; that the haemolytic process is active in the portal system; and 
 that there are, in many of the cases, atrophic changes in the gastro-intes- 
 tinal mucosa.^ The nature of the toxic agent has not been demonstrated, 
 57 
 
898 MEDICAL DIAGNOSIS. 
 
 II. The Retention Intoxications. — Biliary intoxication is due to the 
 biliary salts and the pigments. The toxic influence is exerted upon the 
 cells of the parenchymatous organs, the muscles, and the blood. Many 
 persons suffer from marked jaundice for considerable periods of time with- 
 out manifesting evidences of intoxication. Hepatic coma cannot, in the 
 strict sense, be ascribed to cholaemia, since it occurs in cirrhosis of the 
 liver, in which jaundice is a subordinate symptom or absent altogether. 
 It is probably due to derangement of the hepatic functions in metabolism. 
 
 III. Autointoxication from Extensive Abolition of the Function of 
 the Skin. — Extensive superficial burns are followed by rapidly oncoming 
 collapse, associated with acute degenerative changes in the cells of the 
 parenchymatous organs and muscles, and haemolysis — evidences of the 
 action of toxic agents, the nature of which is unknown. 
 
 IV. Acidosis. — Under this term are grouped the derangements of 
 metabolism which result from an excess of acids in catabolism — an acid 
 intoxication. The principal sources are: (a) the acids of carbohydrate 
 fermentation in the alimentary canal; (b) the sulphuric and phosphoric 
 acids derived from the catabolism of common protein and nuclein respec- 
 tively; (c) lactic acid; (d) the members of the acetone group, diacetic and 
 /?-oxybutyric acids derived from the fats (A. E. Taylor). This form of 
 autointoxication is encountered in diabetes, starvation, phosphorus poison- 
 ing, toxaemia of pregnancy, cyclic vomiting of children, in severe febrile 
 infections, after prolonged chloroform anaesthesia, in the cachexia of 
 carcinoma, and many other diseases. The condition may be caused by the 
 withdrawal of fixed alkalies or the toxic action of salts of the acid com- 
 pounds. James Ewing has shown "that the chemistry and pathological 
 anatomy of these diseases lends support to the view that there are two 
 distinct classes of acidosis following two experimental prototypes. 
 
 "Type I. — Hydrochloric Acid Poisoning. — Clinical forms: diabetes; 
 starvation. Chemistry: acetone compounds. Pathological anatomy: 
 no lesions. 
 
 "Type II. — Extirpation of the Liver or Eck Fistula. — Clinical forms: 
 phosphorus poisoning; toxaemia of pregnancy; cyclic vomiting; chloro- 
 form poisoning. Chemistry: lactic acid prominent; ammonia in excess 
 of any acetone compounds present. Pathological anatomy: extensive 
 fatty degeneration" (Ewing). 
 
 Notwithstanding the fact that considerable quantities of acids may 
 be present in the blood in combination, an acid reaction of the blood-serum 
 does not occur. It could only be a terminal phenomenon. 
 
 V. Gout in the present state of knowledge may be regarded as an auto- 
 intoxication dependent upon derangements of the purin metabolism; 
 VI. glycosuria and diabetes, as autointoxications arising in consequence 
 of faults in the carbohvdrate metabolism. 
 
HEAT-STROKE. 899 
 
 VI. 
 THE DIAGNOSIS OF HEAT-STROKE AND ELECTRIC STROKE. 
 
 HEAT-STROKE. 
 
 Heat-stroke is commonly seen in laboring men, and is also not unusual 
 in armies. In the United States Army, from 1868 to 1893, there were not 
 less than 1250 cases, with 47 deaths. 
 
 Pathology. — Congestion of the brain and membranes, as well as of 
 the lungs, is common. According to Gihon' loss of coagulabihty of the 
 blood is the one great lesion in coup de soleil. Rigor mortis and putre- 
 factive changes occur early. The post-mortem appearances are mostly 
 negative, but there is rigid contraction of the left ventricle of the heart, 
 while the right side and the great vessels contain partly coagulated dark 
 blood. Meningitis is one of the sequels of sun-stroke. The vitochemical 
 changes in the blood, muscles, and nerve-centres are not fully understood. 
 
 Symptoms. — Two forms are recognized: simple heat exhaustion, 
 and heat-stroke proper. 
 
 In heat exhaustion the patient usually collapses, and may even fall in 
 a partial or complete syncope. The surface of the skin is cool, the pulse 
 rapid and feeble, and the temperature may even be subnormal — as low as 
 95° or 96°. In the worst cases there is sometimes mental confusion, and 
 dehrium has been occasionally reported. The prognosis in these cases is 
 usually good, if the patient's general health is sound. 
 
 In heat-stroke proper the chief symptoms are as follows: headache, 
 oppression in the epigastrium, sometimes nausea and vomiting, a sense 
 of weakness, vertigo, dimness of vision, and unconsciousness, with fever 
 and rapid pulse. Coplin, among the sugar refiners of Philadelphia, also 
 describes a "cramp" in the epigastrium, and sometimes in the back 
 and the calves of the legs, as among the premonitory symptoms. Of the 
 various symptoms the only one that can be called pathognomonic is the 
 exceedingly high temperature. Richards, in the Rhode Island Hospital, 
 observed temperatures ranging as high as 110°, and Packard, in 31 cases 
 in the Pennsylvania Hospital, saw the temperatures range up to 110°, 
 111°, and even 112°. These are extreme cases, usually with contracted 
 pupils and profound unconsciousness, and many of these patients die. 
 Death sometimes occurs so quickly that a special or apoplectic type is recog- 
 nized, and if dyspnoea is prominent, the type is called asphyxial. Most 
 authors are in accord about the contracted pupils, but an exceptional 
 case of dilated pupils has been noted, and as death approaches the pupils 
 may dilate. Convulsions are not common. Great oppression of breathing 
 is sometimes experienced, with a sense of constriction of the chest. Pirrie, 
 in his cases in Central India, observed priapism and seminal emission just 
 before the seizure. Alcoholism is an active promoter of heat-stroke. Most 
 cases occur in persons who have been over-exerting themselves. 
 
 1 "Heat-stroke," in XX. Cent. Pract., vol. iii., p. 253. This article by Gihon is a useful review of 
 the whole subject, botli historical and clinical. 
 
900 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — Heat-stroke must be distinguished from cerebral hemor- 
 rhage, uraemia, alcohoHc intoxication, and opium poisoning; but from all 
 these conditions it differs in its history and its high temperature. The 
 history alone is so clear and suggestive in most cases that a mistake is 
 hardly possible. In uraemia a subnormal temperature is common, and 
 the condition of the urine is characteristic; if the temperature rises, as it 
 does in some cases, especially towards the end, it does not mount as high 
 as in sun-stroke. The contracted pupils in heat-stroke may suggest opium 
 poisoning, but in the latter there is slow respiration, and in the former 
 high temperature. In mere alcohohc intoxication we do not see pyrexia, 
 much less hyperpyrexia, nor contracted and immobile pupils. In fact, 
 in all comatose conditions, as in those just named, and in diabetic coma, 
 we do not see high fever, nor is there the history of exposure to heat. Injury 
 to the head can usually be excluded by the history and by careful physical 
 examination. In cerebral hemorrhage there is usually hemiplegia, which 
 can be recognized as a rule by the difference in resistance on the two sides. 
 The temperature often rises as death approaches. The attempt to distin- 
 guish sun-stroke from heat-stroke is not called for. 
 
 ELECTRIC STROKE. 
 
 Under this heading are included both lightning stroke and shocks 
 from dynamos. The vast extension of the use of electricity in recent years 
 has made these accidents not uncommon, and the use of the current as an 
 agent for executing criminals in the State of New York has furnished rare 
 opportunities for the systematic study of the subject. 
 
 Pathology. — Some of the lesions are purely surgical, such as the burns 
 which are caused by immediate contact with a "live" wire. It is impossible 
 to state in scientific terms what is the exact pathology of electric shock, 
 especially in cases of sudden death. The results of examinations are often 
 negative. Van Gieson, in autopsies on the bodies of criminals, found fluid 
 blood, but no recognizable changes in the tissues or organs. 
 
 Symptoms. — Macdonald and Ward have recorded the effects as noted 
 in the execution of four criminals at Sing Sing, N. Y.^ With a current of 
 1785 volts, passed through wet sponge electrodes from the forehead to the 
 calf of one leg, the heart continued to beat after the first contact of 27 
 seconds, and a noisy respiration was re-established after an interval of more 
 than one minute. After a second contact of 26| seconds respiration and 
 the heart action had ceased permanently. It seems that the action of the 
 heart is not permanently arrested as quickly as is respiration. With a 
 stronger voltage, as in a lightning stroke, it is possible that the respiration 
 and the heart are arrested instantaneously. 
 
 E. A. Spitzka, whose observations are based upon thirty-one electro- 
 cutions, finds that "the death is undoubtedly painless and instantaneous. 
 The vital mechanisms of life, circulation and respiration, cease with the 
 first contact. Consciousness is blotted out instantly and the prolonged 
 apphcation of the current as it is usually practised by Mr, E. F. Davis, 
 
 1 Medico-Legal Journal, vol. ix. Also XX. Cent. Pract., vol. iii. pp. 403-411. 
 
PREGNANCY. 901 
 
 the State electrician of New York, ensures the permanent derangement of 
 the vital functions so that there could be no recovery of these. Occasion- 
 ally, the drying of the sponges through undue generation of heat causes 
 desquamation or superficial blistering of the skin at the site of the elec- 
 trodes, but not often. Post-mortem discoloration, or lividity, often appears 
 during the first contact. The pupils of the eyes dilate instantly and remain 
 dilated in death." 
 
 Diagnosis. — This must depend largely, if not entirely, upon the history. 
 Burns on the surface of the body, as already said, are common from con- 
 tact with a " live" wire, but in the case of lightning stroke, while not unseen, 
 they do not appear to be so extensive or so common. 
 
 The after-effects in non-fatal cases usually consist in states of neu- 
 rasthenia and traumatic hysteria. Organic palsies, or permanent lesions 
 of any kind, seem to be rare sequels. 
 
 VII. 
 THE DIAGNOSIS OF PREGNANCY. 
 
 Under ordinary circumstances the question as to the existence of 
 pregnancy, as it presents itself to the general practitioner or to the specialist 
 in midwifery or in gynaecology, presents no difficulty. As a rule, the patient 
 has already made the diagnosis for herself. As it occurs, however, to the 
 medical diagnostician, it frequently assumes a high degree of importance 
 and involves responsibility of the gravest kind. This is especially the 
 case in illegitimacy in young girls, who very often stoutly deny exposure 
 to the possibility of such a condition until the approach of actual labor. 
 On the other hand, married women long childless sometimes positively 
 assert that their hopes are about to be realized, and enumerate in detail 
 and with precision the signs of the condition even to the motion of the 
 child, under circumstances in which the occurrence of such an event is 
 impossible— pseudocyesis. There are obvious reasons why the opinion of 
 the medical man is often first sought. 
 
 Early Gestation. — Symptoms. — Amenorrhoea in a healthy woman 
 previously regular is a symptom of primary importance, and usually the 
 first to arouse a suspicion on the part of the woman as to her condition. 
 Cessation of the menses, under these circumstances, is physiological and 
 unattended by the signs of the grave chronic diseases, as nephritis, tuber- 
 culosis, and the cachexias, in which it is pathological. Abrupt cessation 
 at a later period of life may also be physiological and mark the occurrence 
 of the grand climacteric. The occasional occurrence of this physiological 
 event at an unusually early period of life is to be borne in mind. On the 
 other hand, the recurrence of a menstrual flow for two or three months, 
 or in extremely rare instances throughout pregnancy, must be considered 
 in a doubtful case. Nausea is next in importance. It begins, as a rule, 
 from two to four weeks after amenorrhoea and may or may not be associated 
 with vomiting. It is troublesome and distressing at the hour of rising, 
 
902 MEDICAL DIAGNOSIS. 
 
 but the gravida may be annoyed by waves of nausea from time to time 
 during the day. Cravings for unusual articles of food, and hysterical 
 manifestations, may accompany the nausea. Constipation is common. 
 Further subjective manifestations are irritability of the bladder, increased 
 flow of saliva, and sensations of fulness and tingling in the breasts. 
 
 Signs. — Certain signs usually show themselves during the first two 
 months, and have a diagnostic value. Those relating to the breasts com- 
 prise general enlargement, a nodular fulness in the glandular area, slight 
 prominence of the nipple, pigmentation of the areola, and enlargement 
 of the sebaceous glands surrounding it. Pressure of the contents of the 
 ducts outward toward the nipple reveals the presence of a yellowish watery 
 fluid — colostrum. In multigravida a persistent secretion may follow lacta- 
 tion and simulate colostrum. Signs apparent upon examination of the 
 abdomen are pigmentation of the linea alba, flattening of the hypogastrium, 
 and retraction of the umbihcus. In fair women pigmentation may not 
 occur, and in fat women flattening and retraction are not marked. 
 
 Pelvic signs are more distinctive. Of these the more important are a 
 violaceous coloring of the cervical portion of the uterus, thinning and com- 
 pressibility of the junction of the cervix with the body, — Hegar's sign, — 
 lateral expansion of the fundus in anteflexion, and pulsation of the uterine 
 arteries. The body of the uterus presents a peculiar softness. The 
 presence in the os of a plug of tenacious mucus is, in connection with 
 the foregoing changes, very suggestive. 
 
 Advanced Pregnancy. — A tendency to constipation persists and 
 waves of nausea occur. Striation of the breasts, abdominal walls, and 
 upper parts of the thighs becomes conspicuous. There are elevation of 
 the fundus uteri and protrusion of the navel. Recurrent rhythmical con- 
 tractions of the uterus after the completion of the third month, unattended 
 with pain — Braxton Hicks's sign — are highly suggestive of pregnancy. 
 Finally, the rise and fall of the foetus in ballottement, the movements of 
 its limbs, and the sounds of its heart are positive and conclusive signs. 
 
 Diagnosis. — The direct diagnosis rests upon the presence of the 
 above symptoms and signs and becomes probable in proportion to the 
 number of them in association at the time of the examination. It assumes 
 greater certainty as pregnancy advances, and demonstrable signs, which 
 offer more positive indications, become associated with the symptoms. 
 
 Differential Diagnosis. — The Distinction between Normal Pregnancy 
 and Conditions which Simulate it. — As to special symptoms, the amenor- 
 rhcBa of pregnancy may usually be distinguished from pathological amen- 
 orrhcea by the anamnesis. The absence of a history of disease, such as 
 malaria, nephritis, an acute or chronic infection, is important. But the 
 fact that women subject to such diseases may become pregnant is not 
 to be overlooked. Amenorrhoea due to local pathological conditions — 
 heematometra, pyometra, and hydrometra — is attended by uterine colic, 
 and the enlargement of the organ does not present the softening of the 
 pregnant uterus. On the contrary, it offers a tense, fluctuating tumor. 
 The amenorrhoea of acquired atresia may be readily recognized by the 
 history and local conditions. The amenorrhoea of the menopause is rarely 
 abrupt, mostly partial and progressive, and frequently accompanied by 
 
PREGNANCY. 903 
 
 hysterical manifestations. Accumulations of omental fat or abdominal- 
 wall fat are common. Moreover, the uterus is not enlarged or softened, 
 and the other local signs of pregnancy recognizable upon vaginal examina- 
 tion are wholly absent. 
 
 Intra-abdominal tumors arising from the level of the pelvis are to be 
 distinguished from the gravid uterus by their consistency, as in the case 
 of fibromyomata, where the enlargement is tense, nodular, and of slow 
 growth. The impairment of the patient's health, and the attacks of pelveo- 
 peritonitis occurring with more or less regularity, together with the metror- 
 rhagia, are conclusively opposed to the diagnosis of pregnancy. Tumors 
 of the adnexa, and pelvic exudates, reveal their character both by the 
 local symptoms and by the situation in the pelvis of the swellings to which 
 they give rise. 
 
 Subjective manifestations of pregnancy which simulate functional 
 disturbances arising in disease, such as nausea and albuminuria, are to be 
 weighed relative to their association with other symptoms and with the 
 signs of pregnancy. The presence or absence of casts, the amount of urine 
 excreted, and the history of the case render it possible to differentiate the 
 albuminuria of pregnancy from that occurring in nephritis. 
 
 Abnormal Pregnancy and Simulative Conditions. — Abnormal preg- 
 nancy comprises, first, the development of the ovum in abnormal situa- 
 tions; second, pregnancy following the fertilization of the ovum in loco 
 but pursuing an abnormal course. 
 
 As to the points of difference in the diagnosis of tubal gestation and 
 cornual pregnancy from pelvic tumors simulating either of these condi- 
 tions, the irregular uterine bleeding, the pain, the collapse occurring with 
 rupture or tubal abortion, and the symptoms of internal bleeding, together 
 with the localization of a mass outside the uterus — all in the presence of 
 symptoms of early pregnancy — are suggestive. 
 
 Certain symptoms, which by their occurrence characterize the course 
 of pregnancy as abnormal, may give rise to confusion. The continuance 
 of menstruation, for instance, may obscure the diagnosis. The syncope 
 which occurs in pregnancy may likewise require the observation of associ- 
 ated symptoms to explain its presence. The oedema of pregnancy shows 
 itself in the presence of signs which distinguish it from the oedema of cardiac 
 disease and the anasarca of nephritis; it is usually progressive without 
 symptoms of nephritis, is not accompanied by pallor or waxiness of the 
 skin, and is evidently connected with the pressure of the uterus. 
 
 Finally, hydramnios may suggest the presence of a tumor within the 
 abdomen originating from some condition other than pregnancy. Hydram- 
 nios, however, may be diagnosticated by the presence of fluctuation, the 
 rapid increase in the size of the tumor, the location of the latter within 
 the abdomen, and the associated symptoms and signs of pregnancy. 
 
904 MEDICAL DIAGNOSIS. 
 
 VIII. 
 THE DIAGNOSIS OF CONSTITUTIONAL DISEASES. 
 
 I. GOUT. 
 
 Podagra. 
 
 Definition. — A disease of disordered metabolism, due to the presence 
 in the blood of uric acid in abnormal amounts, and characterized clinically 
 by attacks of acute arthritis involving one or several joints and recurring 
 at irregular intervals, the deposition of sodium biurate in and around the 
 joints, and irregular constitutional symptoms. 
 
 Etiology. — It is necessary to consider the gouty constitution and the 
 attack. An individual may present marked evidences of the gouty diathesis 
 and never experience an attack; or there may, fortunately, be long intervals 
 between the attacks, during which the health is excellent. As the disease 
 advances the attacks become more frequent and the general health is 
 progressively impaired. 
 
 Predisposing Influences. — Heredity. — The gouty constitution is 
 inherited more frequently than it is acquired. Transmission appears to 
 be more common in the male line, but in this connection the different 
 mode of life of the sexes is to be considered. In hereditary cases the attack 
 may occur in childhood. It is not common before thirty, but in a majority 
 of the cases the first attack occurs in early middle life. Alcoholic excesses, 
 and especially the habitual free use of alcoholic beverages — regular drink- 
 ing — is an important causative factor. Malt liquors tend to cause gout 
 more than wines, and these more than distilled spirits. Excesses in food 
 are more important still. Eating too much, without active exercise, is a 
 predisposing cause of the highest importance. Gouty persons are often 
 hard workers, with excellent appetites and good gastric digestion. More- 
 over, rich viands and fine wines are associated in the pleasures of the table. 
 But gout is not restricted to the rich; exhausting toil, poor food, and excesses 
 in beer may cause it — "poor man's gout." Chronic lead poisoning plays 
 an important part in the etiology of this disease. Sedentary Habits. — Lack 
 of fresh air and sunshine, with prolonged mental effort, predisposes to the 
 attack. Sydenham's " Whenever I return to my studies my gout returns 
 to me" is well known. 
 
 Exciting Causes. — When the attack is due, it may be brought on 
 by apparently trifling causes — an unusually hearty meal, a glass of cham- 
 pagne, sudden chilling, worry, or sudden depressing emotion, or mental 
 shock. It may also be precipitated by a slight injury or accident. 
 
 Pathology. — The nature of gout, beyond that it is due to faultj^ 
 metabolism with overproduction and deficient elimination of uric acid, is 
 unknown. The hypotheses regarding the actual part played by uric acid, 
 which is now regarded as one of the purin bodies derived from the nuclein 
 resulting from nuclear disintegration, in causing gout are very numerous. 
 None of them, however, arises to the dignity of a theory. 
 
GOUT. 905 
 
 Symptoms. — Gout may be acute, chronic, and irregular. 
 
 1. Acute Gout. — The attack is commonly preceded by prodromes, 
 which consist of fleeting pains in the small joints of the hands or feet, 
 restlessness, irritability, and dyspepsia with acid eructations. In some 
 cases there is an erythematous angina, broncliitis, or asthmatic symptoms. 
 The elimination of uric acid has been found to be diminished before and 
 during the early part of the attack. In many instances there are no pre- 
 monitory symptoms. The attack begins, as a rule, in the early morning 
 hours. There is agonizing pain in the metatarsophalangeal joint of the 
 great toe, more frequently the right, or the tarsometatarsal joints, especially 
 at the outer border of the foot. There is intra- and periarticular effusion; 
 the skin is hot, red, tense, and glistening. Tenderness is extreme and the 
 patient cannot endure the slightest pressure upon the affected part. There 
 is moderate fever, the temperature rising to 102°-103° F. (39°-39.5° C.) 
 and falling to normal toward the end of the attack by lysis. The intensity 
 of the symptoms somewhat abates in the morning, but the foot remains 
 swollen, red, and painful, and during the night the patient's sufferings are 
 again intensified. Other joints, and particularly the great toe of the oppo- 
 site foot, may become affected. The nocturnal exacerbations gradually 
 subside and, in the course of a few days or a week, the acute symptoms 
 disappear with itching and desquamation, but the affected joint remains 
 tender and swollen, often requiring the use of a loose shoe and crutches 
 for another week or more. SupjDuration in the affected joints does not 
 occur. Transient albuminuria or glycosuria may occur. There is a moder- 
 ate leucocytosis during the acute S3^mptoms. Physical and mental depres- 
 sion persist for a period, but after a time the patient regains his former 
 health. Recurrences follow at intervals varj'ing from a few months to a 
 year or more. In the later attacks not only the joints of the feet, but also 
 the knees, wrists, and fingers may be involved. 
 
 Retrocedent or Suppressed Gout; Visceral Gout. — These terms are 
 used to designate groups of symptoms, usually grave, indicative of disease 
 of internal organs, which sometimes arise coincidently with a sudden sub- 
 sidence of the local manifestations of the attack. The principal gi-oups 
 are, (a) gastro-intestinal — pain, vomiting, purging, and collapse, so severe 
 in some instances as to prove fatal; (b) cardiac — dyspnoea, precordial 
 pain and distress, arrhythmia, and tachycardia; and (c) delirium, stupor, 
 coma, or apoplectiform attacks. These symptoms are in many of the 
 cases uraemic. 
 
 Chronic Gout. — The attacks become more frequent and prolonged, 
 and many joints are affected. In debilitated persons and those suffering 
 from chronic lead poisoning, the attacks of arthritis may not occur — atypi- 
 cal gout. Deposits of sodium biurate — tophi — occur in the cartilages and 
 ligamentous structures of the joints, which, in the course of time, become 
 enlarged and deformed. The feet are first and most markedly affected, 
 then the hands to a less extent, and in some cases tophaceous deposits 
 form about the knees and elbows or in the line of the tendons. The cartilage 
 of the ear frequently contains tophi which appear as yellowish-white 
 nodules at the edge of the helix. Less frequently similar deposits take 
 place in the cartilages of the nose, eyelids, and larynx. The skin covering 
 
906 MEDICAL DIAGNOSIS. 
 
 the tophi frequently undergoes slow necrotic change, with ulceration 
 exposing the felted chalk-stones. As the disease advances the patients 
 become sallow and dyspeptic; the signs of arteriosclerosis develop; there 
 are cardiac hypertrophy, increased arterial tension, increased urine with 
 low specific gravity, slight albuminuria which may be intermittent, and 
 hyaline casts. Muscular cramps, especial!}^ affecting the calves of the legs 
 and starting in the predormitium, are common. Attacks of arthritis, 
 implicating one or several joints, characterized by pain, redness, and swell- 
 ing, occur with or without fever. Croupous pneumonia and apoplexy are 
 common terminal events, but death often results from uraemia or from an 
 acute inflammation of one of the great serous sacs. 
 
 Irregular Gout. — In addition to the attacks of arthritis and the 
 chalk-stones, there are diverse morbid conditions to which gouty subjects 
 and members of gouty families are alike especially liable, and which are 
 commonly regarded as irregular manifestations of gout. Among the more 
 important of these are cutaneous eruptions, and especially eczema; period- 
 ical gastro-intestinal catarrh — so-called bilious attacks; pulmonary affec- 
 tions, especially bronchitis and emphysema; cardiovascular lesions, 
 myocardial degenerations, arteriosclerosis, and aneurism and nervous 
 affections, among which migraine, headache, sciatica, and other neuralgias 
 are the more common. Burning sensations and itching of the feet at night 
 are very common and annoying symptoms. Among affections of the eye, 
 scleritis, iritis, cataract, glaucoma, and hemorrhagic retinitis have been 
 attributed to gout. It is the custom to regard gout as the cause of the 
 recession of the gums so common in advancing life. 
 
 The urinary conditions are more especially gouty because they are 
 based upon anatomical lesions of the kidneys. Chronic interstitial neph- 
 ritis, without characteristic changes, is not uncommon in gouty subjects. 
 More common are conditions believed to be distinctive, namely, a deposit of 
 urates in the intertubular tissue, mostly in the papillae; less frequently the 
 deposits occupy both the tissue and the tubules, and there are also minute 
 foci of necrosis in the cortex and medulla, in which are deposited crystals 
 of sodium urate. The clinical manifestations of gouty deposits are the 
 same as those of this form of chronic nephritis occurring in non-gouty 
 persons: increased output of urine, albuminuria (usually slight), low 
 specific gravity, hyaline casts, increased arterial tension, accentuated 
 aortic second sound, and uraemic symptoms. Prior to the development 
 of renal changes the urine is often very acid and high-colored and may, 
 upon standing, deposit crystals of uric acid. In chronic gout the 
 uric acid is diminished, as a rule, with occasional excess. Intermittent 
 glycosuria, traces of albumin, and tube casts may occur. Oxaluria is 
 common. Renal calculi are not infrequent. The association of vesical 
 calculi and gout is often observed. I have several times seen purulent 
 urethritis follow an attack of gout. 
 
 Diagnosis.- — The direct diagnosis of acute gout is usually a simple 
 matter. Recurrent attacks of arthritis, beginning in or limited to the 
 great toe, with a hereditary history of gout and a personal history of over- 
 indulgence in food and drink, are of positive diagnostic value. When 
 other joints are implicated and there is fever, and a satisfactory family 
 
GOUT. 907 
 
 and personal history cannot be obtained, there may be a question as to 
 the differential diagnosis between acute gout and rheumatic fever. The 
 following facts are in favor of the diagnosis of gout: the occupation and 
 habits of the patient; the involvement of a limited number of larger joints; 
 the persistence of the arthritis in the affected joint in contrast to the migra- 
 tory character of rheumatic arthritis; the appearance of the inflamed 
 joints, which are commonly tense, deeply red or violaceous, and shiny; 
 the suddenness of onset; and the condition of the urine, which shows a low 
 uric acid output in the beginning of the attack, with marked increase 
 toward its close. 
 
 The Diagnosis of Chronic Gout. — The history, the presence of 
 tophi, and the deformities are characteristic. A tophus in the neighbor- 
 hood of a joint is easily recognized. Tophi upon the ears appear earlier 
 and are positively diagnostic. Other things at the ear margin may be 
 mistaken for them: the helical apex, called from the English sculptor and 
 poet Woolner's tip; small sebaceous tumors; and fibroid nodules. The 
 last are very rare. In the felted material from an open tophus the needle- 
 shaped crystals of sodium biurate are characteristic. Garrod's uric acid 
 thread test may be tried. In a watch glass, 15 c.c. of blood-serum, which 
 may be obtained by blistering, are treated with 0.25 of acetic acid. A fine 
 thread immersed in it may show in a few hours crystals of uric acid. The 
 result is often negative in cases in which there is no question as to the 
 clinical diagnosis. An excess of uric acid in the circulating blood occurs 
 also in leukaemia and chlorosis. 
 
 The differential diagnosis between chronic gout and arthritis 
 deformans demands some words of consideration. This necessity arises 
 more from the misleading influence of the term ''rheumatic gout" than 
 from any real resemblance between the diseases. In the rare cases in which 
 the deformities of chronic gout arise insidiously, in the absence of acute 
 attacks, the following points are important: Arthritis deformans is com- 
 mon in women and among the poor and poorly nourished; spontaneous 
 pain in the affected joints is less common and less urgent; the deformities, 
 especially those of the hands, are more uniform and symmetrical; and 
 tophaceous deposits form no part of the pathology of the disease. 
 
 The diagnosis of irregular gout is based upon the family and 
 personal history of the patient, and the general experience of clinicians 
 that gouty individuals more frequently manifest these particular derange- 
 ments of health than others. The diagnosis of visceral gout depends, 
 likewise, upon the anamnesis and the fact that the onset of the symptoms, 
 indicating disease of a particular organ, corresponds in time to the sub- 
 sidence or disappearance of the familiar symptoms of the acute attack of 
 gout. The diagnosis of irregular, retrocedent, and visceral gout should be 
 made with some reserve and only in the case of a distinct hereditary 
 predisposition, or of an individual who has had acute attacks, or who shows 
 tophi or characteristic deformities, and in whom, in the absence of such 
 signs, other etiological factors can be excluded. 
 
908 MEDICAL DIAGNOSIS. 
 
 II. ARTHRITIS DEFORIViANS. 
 
 Definition. — A chronic disease of the joints, of undetermined causa- 
 tion, characterized anatomically by lesions of the synovial membrane 
 with hypertrophy of its fringes, atrophic changes in the cartilages and 
 bones, irregular hypertrophy of the bones, and wasting in the periarticular 
 structures; and clinically by characteristic deformities. 
 
 Etiology. — Predisposing Influences. — The synonyms rheumatic gout 
 and rheumatoid arthritis indicate the prevalent belief that arthritis deformans 
 has some relationship to those affections — a belief that finds little support 
 in fact. In less than one-third of the cases the family history shows a 
 tendency to joint disease — gout or rheumatism. Arthritis deformans in 
 successive generations is unusual. Two or more cases have been noted 
 in a family. Children are sometimes affected; young girls frequently; 
 the greater number of cases begin in early adult and middle life. Women 
 are affected more frequently than men. The disease very often first shows 
 itself about the time of the menopause, and is more common among women 
 who suffer from diseases of the reproductive organs. Habitual exposure 
 to cold and damp, hardship and privation, sudden mental shock, and de- 
 pressing emotions, appear to bear a causal relation to the disease. 
 
 Exciting Cause. — There are two theories: first, that the joint 
 affection is secondary to some disease of the nervous system; second, 
 that it is a chronic infection. The latter is now generally accepted. A 
 variety of micro-organisms have been found in the lesions, but none 
 that is uniformly present. The fact that, in a considerable proportion 
 of the cases, there is a history of gonorrhoea, does not, in view of 
 the wide prevalence of that disease, indicate a causal relation on the 
 part of the gonococcus. 
 
 Morbid Anatomy. — All the tissues which enter into the structures 
 of the affected joints are involved in the morbid process, but in which of 
 them the process starts cannot be affirmed with certainty. It is probable, 
 however, that the cartilages are first affected. The lesions consist of 
 fibrillation and atrophy of the cartilages; in the bones, eburnation, abra- 
 sion, and osteophyte formation; in the synovial membranes, thickening 
 and hypertrophy of the fringes and atrophy of the periarticular tissues. 
 Osteophytes developing at the margins of the bones may interfere with 
 movement. Bony ankylosis is rare in the joints of the extremities, but 
 common in the spine, which sometimes becomes rigid and immovable. 
 A late condition is contracture, with fixation of the joints in flexion. On 
 the other hand, the muscles are atrophied and the ligaments relaxed, so 
 that subluxation is common, especially in the knees and fingers. The 
 hands are greatly deformed and the fingers, under the influence of gravity, 
 show deflection to the ulnar side. Some of the joints are the seat of an 
 effusion. Neuritis occasionally occurs. The most striking feature of the 
 arthropathy is its symmetry. The changes in the cartilages and bones 
 are well shown in radiographs. 
 
 Clinical Varieties. — Heberden's nodes; the progressive polyarticular 
 form; the monarticular form; the vertebral form; and arthritis deformans 
 in children. 
 
ARTHRITIS DEFORMANS. 909 
 
 (a) Heberden's Nodes. — "Tumors attaining to the size of a pea, 
 which are sometimes developed near the third joints of the fingers. They 
 have certainly nothing in common with arthritis (gout), since they are 
 met with in many persons to whom that disease is unknown. They remain 
 throughout life, are devoid of all pain, and show no tendency to ulceration. 
 The deformity is more conspicuous than the inconvenience they cause, 
 though the movement of the fingers is somewhat impeded by them." They 
 occur much more commonly in women than in men, and about middle 
 life. The nodules may become tender and red. Tophi do not appear. 
 The larger joints are not involved. They are not influenced by treatment. 
 
 (b) The Progressive Polyarticular Form. — The acute variety 
 in the initial attack bears a close resemblance to rheumatic fever, for which 
 it is very often mistaken. It occurs frequently in young women among 
 the working classes, and especially in mill girls. It is common after child- 
 bearing and during lactation. It begins in some of the cases at the meno- 
 pause. The joints become swollen, tender, and painful upon movement; 
 there is fever and the patients become anaemic and weak, and rapidly lose 
 flesh. The attack passes over, leaving the affected joints slightly deformed. 
 From time to time similar attacks recur, each leaving, as it subsides, some 
 increase of deformity and further impairment of health, until at length 
 the patient becomes completely broken down and crippled. The small 
 joints of the hands and feet first and chiefly suffer, but the ankles, knees, 
 wrists, elbows, shoulders, and spine frequently become involved. Chronic 
 Form. — This variety is most common. Acute attacks may occur. Only 
 one or two joints may be at first affected; usually the hands are first in- 
 volved, then the knees or feet. Gradually new joints suffer until, in the 
 severe cases, scarcely an articulation escapes. As the disease progresses 
 the joints are symmetrically involved. The earliest symptoms are pain 
 on movement and slight swelling, which may be intra- or periarticular. 
 The pain varies greatly in intensity. There are cases in which a high degree 
 of deformity gradually comes to pass, without pain; others in which there 
 is pain only at the time of outbreaks of the arthritis, or at night; and a 
 few in which pain is intense and persistent. 
 
 The deformities are progressive. The joints are enlarged in part by 
 the outgrowth of osteophytes, in part by thickening of the capsular hga- 
 ments, and in part by subluxation. While they remain movable, crepita- 
 tion may be felt. The periarticular tissues, and especially the muscles, 
 undergo atrophy, and at length the function of the joints is wholly lost. 
 Osteophytes, adhesions, and infiltration of the tissues prevent movement, 
 and the joints become fixed, usually in strong flexion, so that in extreme 
 cases the patient lies completely helpless, unable to move any part of the 
 body except the eyes. Trophic changes, atrophy of the muscles, glossj^ 
 skin, pigmentation, and onychia occur, and numbness and tingling are 
 common. In many of the severe cases the joints of the hands and wrists 
 suffer to a less extent, and the ability to sew or write is in part retained. 
 A considerable proportion of the cripples caused by this form of arthritis 
 deformans maintain fair general health and a cheerful disposition. 
 
 (c) The Monarticular Form. — This form is usuallj^ seen in elderly 
 persons. The knee, hip, and shoulder are commonly involved. They very 
 
910 MEDICAL DIAGNOSIS. 
 
 often follow traumatism. In other cases they develop insidiously. Expos- 
 ure to damp cold appears to exert a predisposing influence, and aged fisher- 
 men, oystermen, and hunters often suffer. The joint lesions are the same 
 as in the polyarticular forms; the muscles rapidly waste, adhesions limit 
 the movements of the parts, and motion is extremely painful. 
 
 (d) The Vertebral Form. — Two varieties are recognized. In one, 
 the spine alone is involved. The disease begins with obscure meningeal 
 symptoms, with evidences of compression of nerve-roots, pain, anaesthesia, 
 loss of function, and wasting of spinal muscles, atrophy of the disks, and 
 progressive ankylosis of the vertebrae (Von Bechterew). In the second 
 variety, the hips and shoulders are also ankylosed — spondylosis rhizomelic 
 — (Strumpell-Marie). Spondyhtis deformans is more common in males 
 than in females. It may result from spinal injury. The early manifesta- 
 tions are sometimes confined to the cervical or to the lumbar region. In 
 other cases the entire spine gradually becomes rigid and immobile. There 
 may be marked kyphosis, with a rigid and immobile thorax and with 
 diaphragmatic breathing. 
 
 (e) Arthritis Deformans in Children. — The disease occurs in 
 early childhood. Girls are more commonly affected than boys. The 
 disease may present the same features as in adult life. In some cases 
 direct inheritance has been noted. Cold, privation, and unsanitary sur- 
 roundings are predisposing influences. The onset may be acute, with the 
 symptoms of infection, fever, profuse sweating, enlargement of the spleen 
 and superficial lymph-glands — Still's disease. One or. two joints may be 
 at first affected, and others later. There is loss of function together with 
 muscular atrophy. The prognosis is more favorable than in adult life. 
 
 Diagnosis. — The direct diagnosis depends upon the subacute 
 exacerbations of the joint affection, the fact that after each outbreak the 
 deformity is increased, the remarkable symmetry of the lesions, the per- 
 sistence of the process in the affected joints, the relaxations of the ligaments, 
 the atrophy of the muscles, and the progressive character of the disease. 
 The initial attack often presents a remarkable resemblance to subacute 
 rheumatic fever. 
 
 Differential Diagnosis. — From rheumatic fever the diagnosis may 
 be made by the permanence of the arthritis in particular joints, the persis- 
 tence of the lesions, the extreme infrequency of endo- or pericarditis, and the 
 incurability of the affection; and from gout by the history, the fact that 
 gout is mostly a disease of men and middle life, and the absence of tophi. 
 The monarticular forms are usually regarded as cases of chronic rheumatism. 
 
 III. THE RHEUMATOID AFFECTIONS. 
 
 Most of the cases of so-called chronic rheumatism are forms of ar- 
 thritis deformans, especially those in which a single joint is involved. A 
 majority of the cases of so-called muscular rheumatism are purely myalgic. 
 Nevertheless, out of deference to an almost universal custom, chronic 
 rheumatism and muscular rheumatism are permitted to retain their noso- 
 logical position. It is important to note the entire absence of etiological 
 and clinical relationship to rheumatic fever. 
 
RHEUMATOID AFFECTIONS. 911 
 
 A. Chronic Rheumatism. 
 
 Definition. — A chronic joint affection of elderly persons, character- 
 ized anatomically by synovial inflammation, capsular thickening, and 
 wasting of the periarticular tissues and the related muscles, and clinically 
 by stiffness, pain, and impairment of motion. 
 
 Etiology. — Predisposing influences are advanced age, occupations 
 which expose the individual to cold and damp — as in the case of washer- 
 women, ditch-diggers, and fishermen — poverty, and hardship. The exciting 
 cause is sometimes an injury, which may be slight. In many cases the 
 disease develops insidiously. 
 
 Morbid Anatomy. — The synovial inflammation is unattended by 
 effusion. There is thickening of the ligaments, especially of the capsular 
 ligament and the sheaths of the tendons. Erosion of the cartilages may 
 be found. There is marked atrophy of the muscles related to the affected 
 joint. Subluxation and other deformities are usually not marked until 
 late in the course of the disease. 
 
 Symptoms. — Pain, which is more marked in the morning and when 
 the weather changes; tenderness, which subsides after gentle massage; 
 stiffness, which is usually relieved to some extent by exercise, are the chief 
 symptoms. Swelling is commonly present, but not redness. A single 
 joint is often affected, as a knee, hip, or shoulder; in many cases several 
 joints are involved, more commonly the large than the small joints. Anky- 
 losis and more or less deformity may gradually come to pass. The subjects 
 are often broken down and anaemic. The prognosis as regards cure is not 
 hopeful. 
 
 B. Myalgia. 
 
 Muscular Rheumatism. 
 
 Definition. — An affection of the voluntary muscles and their fibrous 
 structures, of undetermined pathology, characterized by pain upon move- 
 ment and pressure. The disease is local and is designated by various 
 names, as lumbago, torticollis, pleurodynia, according to the parts involved. 
 
 Etiology. — Predisposing Influences. — The rheumatic and gouty 
 habit of body, laborious occupations, and those involving exposure to 
 cold and damp are important factors. Men suffer more frequently than 
 women. It is an affection of middle and late life. 
 
 Exciting Causes. — The attacks follow cold and exposure, especially 
 when heated. A draught of air may bring it on. Overuse of a group of 
 muscles is a frequent cause. The muscular pains and soreness after a first 
 horseback ride are myalgic. 
 
 Whether the pain and tenderness arise from some nutritional dis- 
 turbance of the muscle substance acting upon the sensory nei'ves of the 
 muscles, or these symptoms are due to a neuralgia of such nerves, has not 
 been positively settled. Myalgia is usually acute; it may be subacute 
 and is sometimes chronic. 
 
 Symptoms. — The disease is local. Constitutional derangements are 
 rare and due to pre-existing or accidental conditions. They consist of 
 
912 
 
 MEDICAL DIAGNOSIS. 
 
 loss of appetite, languor, and slight rise of temperature. Pain is the chief 
 symptom. It is rarely constant, but is acute, even agonizing, when the 
 affected muscles are contracted. It is sharp and cramp-like upon move- 
 ment, but dull and sore, or absent altogether, when the muscles are in 
 repose. Firm pressure causes soreness, as may be seen in lumbago — a 
 sign of diagnostic value. 
 
 According to the seat of the affection the following principal varieties 
 are described: Lumbago. — The erector muscles of the spine and their 
 attachments are affected. There is pain upon rising and turning. The 
 patient can lean over to lace his shoes, but cannot straighten his 
 
 back without pain. There is marked 
 tenderness upon firm pressure over 
 the affected muscles and their attach- 
 ments. The attack is of sudden onset 
 and often completely disabling. Tor- 
 ticollis — Wry-neck. — The sternoclei- 
 domastoid and adjacent muscles are 
 affected. In some instances the pos- 
 I terior cervical muscles are also involved. 
 
 I \ This form is very common. Young 
 
 f persons frequently suffer. The head 
 
 [ is held rigidly and cannot be rotated 
 
 r from side to side. Pleurodynia. — 
 
 I The intercostal muscles and, in some 
 
 «i^ r MI Mi cases, other chest muscles are painful 
 
 4 ,^ "^^^^B &^d tender upon pressure. The left 
 
 •^ ^ side is more commonly affected than 
 
 the right. A deep breath, coughing, 
 sneezing, even laughter may cause the 
 patient to cry out with pain. It is 
 to be distinguished from pleurisy by 
 the absence of friction rales and 
 from intercostal neuralgia by the 
 absence of painful points along the 
 course of the nerves, and the fact 
 that in the latter affection the pain is more paroxysmal. The epi- 
 gastric pain often seen in measles is myalgic. Other forms are 
 cephalodynia, in which the muscles of the scalp are involved; dorso- 
 clynia, scapulodynia, and so on. 
 
 Fig. 307. 
 
 -Acute rheumatic torticollis. - 
 Rotch. 
 
 IV. DIABETES. 
 
 Diabetes mellitus and diabetes insipidus have little in common except 
 a persistent increase in the amount of urine secreted. Glycosuria, a sympto- 
 matic condition characterized by the transient presence of sugar in the 
 urine, corresponds to polyuria, a symptomatic condition in which the 
 urinary output is greatly increased for a short time. These conditions 
 are to be distinguished from diabetes mellitus and diabetes insipidus, 
 which are substantive diseases. 
 
DIABETES. 913 
 
 A. Diabetes Mellitus. 
 
 Definition. — A chronic nutritional disease due to diminished capacity 
 for the combustion of carbohydrates, and characterized by the persistent 
 excretion of grape-sugar in the urine when moderate amounts of carbo- 
 hydrates are ingested, or even none at all in certain cases. Polyuria, 
 polydipsia, polyphagia, and emaciation are prominent but not constant 
 S3'mptoms. 
 
 Etiology. — Predisposing Influences. — Diabetes mellitus prevails 
 in every part of the world, but more extensively in some countries than in 
 others. Southern Italy and India suffer to an especial degree. The disease 
 is about as prevalent in the United States as in Europe and appears to be 
 increasing upon both sides of the Atlantic. In all countries it is more 
 common among those living in affluence than among the poor. The 
 Semitic race manifests an especial predisposition to the disease. This 
 racial peculiarity has been noted by competent observers in various 
 countries. In the United States the negroes suffer to a less extent than the 
 whites. The predisposition is very commonly inherited. The remarkable 
 prevalence of diabetes among the Hebrews is in many of the cases due to this 
 tendency. Not only is the disease observed in successive generations in the 
 direct, but also in collateral, lines, and it occasionally occurs at an early age 
 in two or more children of the same family. The descendants of gouty or 
 obese persons show an especial liability to diabetes. R. Schmitz first 
 directed attention to the possibility of the transmission of the disease 
 from one person to another. A long and intimate association, as in the 
 case of a wife taking care of a husband suffering from the disease, has, in 
 rare instances, been followed by the development of the same symptoms. 
 Previous good health on the part of the second individual, with absence of 
 hereditary predisposition, has been established in those cases. They are 
 extremely rare and the transmissibility of the disease appears highly 
 improbable. Diabetes mellitus is more common in men than in women, 
 the ratio, according to available statistics, being about three to two. The 
 disease mav occur at any period of life. Infants at the breast are sometimes 
 affected, but such cases are extremely rare; they also run a rapid and fatal 
 course. Hereditary influences are usually in evidence, and several of the 
 children in one family may be afTected. But diabetes mellitus is essentially 
 an affection of adult life. A majority of the cases come under observation 
 between the third and the sixth decades. The disease is often discovered 
 upon routine medical examination for hfe insurance or other purposes, 
 and has already existed in many cases for a considerable time. Diabetes 
 is much more common among persons living in afHuence than among the 
 poor. Those who live luxurious, aimless, and idle lives are peculiarly hable 
 to the disease. The wear and tear of a strenuous intellectual hfe, especially 
 when coupled with great anxiety and mental excitement, contribute a 
 predisposing influence of great importance. Absorbing application to 
 business, excesses at table, and a sedentary life are important factors in 
 producing the disease. Those Avho dwell in cities suffer in greater propor- 
 tion than countrymen. It is, however, to be noted in this connection that 
 the disease is less apt to be recognized in the latter class. Neurotic persons 
 
 58 
 
914 MEDICAL DIAGNOSIS. 
 
 are more commonly affected than those of a phlegmatic temperament, a 
 fact to be considered in the matter of the great relative frequency of the 
 disease among the Jews. Gout, syphihs, and malaria have been regarded 
 as predisposing influences. It was at one time thought that the children 
 of phthisical parents were especially liable to diabetes. The disease fre- 
 quently develops during the course of chronic nervous affections; still more 
 frequently forms of nervous disease, particularly neuralgia, neuritis, and 
 neurasthenia, are dependent upon the diabetes, and arise as intercurrent 
 affections during its course. Diabetes occurs among the insane, but not, 
 according to the statistics of large institutions, in greater proportion than 
 in general hospitals. Obesity is frequently associated with diabetes. In 
 a majority of such cases the obesity precedes the diabetes often by a period 
 of years. Under these circumstances the disease commonly runs a favor- 
 able course, the glycosuria diminishing, even disappearing under a moder- 
 ately strict regimen, and reappearing when the rules are neglected. ]\Iuch 
 less favorable are the cases in which obesity and diabetes are simultaneously 
 developed in early life. The form that develops consecutively to obesity has 
 been designated "lipogenous diabetes." Von Noorden, who believes that 
 in the obese cases the burning up of sugar is interfered with, and not its con- 
 version into fat, proposes for this form the term " diabetogenous obesity." 
 
 Exciting Causes. — Psychical. — Mental shock, intense nervous strain, 
 worry, and violent depressing emotions are frequently followed by diabetes. 
 Physical. — Disease or injury of the brain or spinal cord, an irritative lesion 
 of the diabetic centre, and epilepsy may also give rise to the disease. The 
 infectious febrile diseases, especially enteric fever, influenza, diphtheria, 
 rheumatic fever, and syphilis, appear in some instances to have been the 
 starting point of diabetes, the symptoms of which have shown themselves 
 either during or directly after the attack. Under all these circumstances 
 the causal importance of the particular event or condition depends upon the 
 known absence of glycosuria prior to its occurrence. In the vast majority 
 of cases diabetes mellitus develops insidiously, Avithout discoverable cause. 
 
 Pancreatic Diabetes. — It has long been kno^Mi that diabetes and disease 
 of the pancreas are occasionally associated, and Lancereaux described, 
 in 1877, a special form of diabetes under the name diabete pancreatique. 
 The discoveries of Minkowski and von Mering, in 1899, aroused intense 
 interest in this subject. The facts are, first, that experimental extirpation 
 of the pancreas is followed by glycosuria; second, that if a portion of the 
 gland is allowed to remain, glycosuria does not occur; third, that in a 
 considerable proportion of the cases of diabetes, lesions of the pancreas 
 have been found — sclerosis, chronic interstitial inflammation, hyaline 
 degeneration of the islands of Langerhans; fourth, that the glycosuria is 
 secondar}^ to the lesions of the pancreas. The theory of an internal secre- 
 tion containing a glycolytic body necessary to the proper combustion of 
 glucose in the muscles supplies the key to the above facts. Pancreatic 
 disease causes diabetes bj^ arresting the formation of the internal secretion 
 of the organ. 
 
 Carbohydrate Metabolism. — In health the carboliydrates of the food 
 are stored in the liver and muscles in the form of glycogen. This substance 
 is also formed from the proteids of the food, and under certain conditions 
 
DIABETES. 915 
 
 glucose is formed from the proteids of the tissues of the body. The glycogen 
 is again converted into glucose and given up gradually to the blood, in 
 which it circulates in a 0.1 to 0.2 per cent, solution, to be distributed to the 
 muscles, where it undergoes combustion, with the production of heat and 
 energy. According to the investigations of the younger Cohnheim this 
 is brought about by the action of the glycolytic bodies, one derived from 
 the muscles, the other from the pancreas. 
 
 Whenever the glucose in the blood is in excess of 0.2 per cent, glycosuria 
 results. This may occur in the absence or in the excess of the glycolytic 
 body; by the sudden ingestion of an excess of carbohydrates — more 
 than 180 to 250 grammes, fasting — alimentary glycosuria; and by derange- 
 ments of circulatory disturbances or instability of the glycogen-storing 
 mechanism. 
 
 Symptoms. — In a large proportion of the cases the onset is insidious 
 and not attended by symptoms which attract the attention of the patient. 
 In some instances, in physicians and others who have examined their urine 
 at intervals, the disease has been preceded by an intermittent glycosuria, 
 which, after a period of months or years, has become persistent. There 
 are other cases in which, under treatment, glycosuria has disappeared, to 
 recur when the strict regimen has been relaxed. The existence of the 
 disease is usually recognized by the occurrence of conspicuous symptoms, 
 as polyuria, polydipsia, polyphagia, emaciation, or pudendal pruritus, or 
 by the discovery of sugar in the urine upon examination as a matter of 
 routine or for life insurance. 
 
 In rare instances it follows an injury, profound depressing emotion, 
 or a chill. There are cases in which thirst is not inordinate and the amount 
 of urine not excessive. The tongue in established cases is usually red, dry, 
 and denuded of epithelium; the saliva scanty; and the gums swollen and 
 spongy. There are constipation and lumbar pain. The skin is dry and 
 harsh and perspiration is scanty or absent altogether. In women prui'itus 
 vulvae is a common and distressing symptom, and general pruritus is of 
 frequent occurrence in both sexes. The pulse-frequency is high and there 
 is increased arterial tension. The temperature is commonly slightly sub- 
 normal. Emaciation is common and rapid in young subjects, but older 
 persons may preserve their weight for long periods. 
 
 The Urine. — Under a rigorous regimen the quantity may not be 
 greatly increased, and it may be reduced to normal during an intercurrent 
 febrile disease. It is, however, commonly increased to three or four litres 
 in cases of moderate severity, and maj^ reach as much as twenty litres in 
 twenty-four hours in grave cases. The specific gravity i-anges from 1.030 
 to 1.045, but in exceptional cases may be low, 1.015 to 1.020, a fact to be 
 borne in mind in the diagnosis. It is pale in color, with a faint greenish 
 tinge, and has a mawkish, sweetish odor, and is said to have a sweetish 
 taste. Sugar is present in amounts varying from 1.5 to 5 or even 10 per 
 cent. The total quantity excreted in twenty-four hours ranges from 300 
 to 750 grammes or more. 
 
 Tests for Glucose. — The most satisfactory tests for clinical purposes 
 are Fehling's, Trommer's, the bismuth test, the fermentation test, and 
 polariscopy. If close results are desired the chemical tests may be con- 
 
916 
 
 MEDICAL DIAGNOSIS. 
 
 trolled by fermentation or the polariscope. The urea and calcium salts are 
 increased, the uric acid does not show important changes, and the phos- 
 phates may be much increased. 
 
 Phosphatic Diabetes.— This term has been applied to cases in which 
 there is an excessive excretion of phosphates, with symptoms similar to 
 those of diabetes mellitus but with inconstant glycosuria. 
 
 Acetone and diacetic acid are often present. The presence of these 
 substances in the urine is conclusive evidence that /3-oxybutyric acid, of 
 
 
 
 
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 Fig. 308. — Chronic diabetes mellitus; male, age 44. Chart showing daily variations in the intake of 
 fluid, the amount of urine, the quantity of sugar and urea, the specific gravity, and body weight. — Jefifer- 
 son Hospital. 
 
 which they are derivatives, is being produced within the organism. There 
 are three stages in the excretion of the acetone bodies: (a) acetone alone 
 in the urine — this substance is exhaled with the expired air; (b) diacetic 
 acid is also present in the urine; and (c) /3-oxybutyric acid is present in the 
 urine in addition to acetone and diacetic acid. Much of the acetone fails 
 of excretion by the urine, since, being highly volatile, it passes off by the 
 respirator}^ surfaces and lends its characteristic odor to the atmosphere 
 about the patient. The presence in the urine of these bodies is of the highest 
 clinical importance, since ;3-oxybutyric acid is the cause of diabetic coma. 
 Glycogen has been found in the urine. Albumin is common, especially 
 in the advanced stages of the disease. Pneumaturia. — Gas in rare instances 
 
DIABETES. 
 
 917 
 
 of diabetes passes from the urethra Avith a bubbhng sound. Its presence 
 is the result of fermentative processes in the urine within the bladder. An 
 associated cystitis is common. 
 
 The Blood. — Hypergly- 
 csemia is constant. An increase 
 in the cellular elements — poly- 
 cythaemia ■ — may occur, the 
 erythrocytes reaching 6,000,- 
 000 or 7,000,000 per cubic 
 millimetre. In coma there is 
 leucocytosis, and /3-oxybutyric 
 acid is present. Lipwmia. — 
 Large quantities of fat are 
 often present in the blood. 
 The plasma presents a milky 
 appearance, and if the blood 
 is allowed to stand in a glass 
 a thick creamy layer forms at 
 the top, the nature of which 
 is apparent upon testing with 
 ether, osmic acid, and other 
 substances which possess char- 
 acteristic reactions with fats. 
 A similar fatty layer is obtained 
 by centrifugalization. The fat 
 particles may be readily seen 
 upon microscopical examina- 
 tion of the fresh blood. The 
 fat is identical with that of the 
 chyle and is therefore probably 
 derived directly from the food. 
 The methylene blue reaction 
 — Williamson, Bremer — is of 
 diagnostic value. 
 
 Complications. — The dia- 
 betic has less power of resist- 
 ance against pathogenic influ- 
 ences than others, and suffers 
 in a remarkable manner from 
 complications. Among these 
 the following are especially 
 important: Skin. — Local in- 
 flammations, and in particular 
 boils and carbuncles, are 
 common. These lesions have 
 their origin in cracks or fis- 
 sures of the skin by way of 
 which infection occurs. Wounds and injuries heal slowly and granula- 
 tion tissue has an especial tendency to slough. Gangrene is common 
 
 
 
 
 INTAKE- 
 
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 Fig. 309. — Acute diabetes mellitus; male, age 27. Chart 
 .showing daily variations in the intake of fluid, tlie amount 
 of urine, the quantity of .sugar and urea, the specific 
 gravity, and the body weight. — Jefferson Hospital. 
 
918 MEDICAL DIAGNOSIS. 
 
 and is due to arteriosclerosis. In rare instances perforating ulcer of the 
 foot has been observed. I have recently seen symmetrical perforating ulcer 
 of the ball of the foot in a woman aged 52. Eczema maj^ occur. Pruritus 
 is common, and pruritus vulvae is an early and harassing complication. A 
 balanitis may occur in men. Bronzing of the skin — diahete bronze — is a 
 rare cutaneous manifestation associated with hsemochromatosis. The 
 skin is usually dry and harsh, but profuse sweating may occur in terminal 
 conditions. Xanthoma and purpura occur as in other chronic affections, 
 but have no direct etiological relation with diabetes. The Lungs. — 
 Pulmonary affections are common terminal events. Croupous pneumonia 
 ind bronchopneumonia occur as acute complications. Gangrene may 
 supervene and pulmonary abscess has been observed. Pulmonary tuber- 
 culosis of the bronchopneumonic type is common. It runs, as a rule, a 
 rapid course. The Kidneys. — The signs of nephritis, albuminuria, and 
 casts very often occur in the later stages of diabetes mellitus. (Edema of 
 the feet and legs may occur, but the polyuria prevents general anasarca. 
 Dropsy may precede coma. Cystitis may occur. The Sexual Organs. — 
 
 Amenorrhoea may come on early, or the men- 
 strual function may continue more or less 
 regularly to an advanced stage of the dis- 
 ease. Impotence is common and often an 
 early symptom. Conception is not unusual, 
 but is often followed by abortion. Pregnancy 
 is followed by an aggravation of the diabetic 
 symptoms. The Nervous System. — Diabetic 
 Fig. 310.— Diab. u. gaugrene. coma is the most important of the complica- 
 tions on the part of the nervous system. This 
 affection "represents the culmination of the specific diabetic intoxica- 
 tion" (Von Noorden). It is often preceded by gastric symptoms, as loss 
 of appetite, nausea, vomiting, epigastric tenderness, and constipation, 
 which extend over days or weeks and are followed by mental dulness, 
 drowsiness, and fatigue symptoms. The dulness increases and the patient, 
 though capable of being roused, quickly falls back into stupor, like a drunken 
 man. The respiration becomes full and deep, without being much increased 
 in frequency. The pulse is quickened, but remains strong and full. Cyanosis 
 is not constant. Finalh^ drowsiness gives way to coma, and in the course 
 of twenty to thirty-six hours death terminates the scene. In another 
 group of cases coma suddenly supervenes in persons who, if not well and 
 strong, are in their usual health. This fatal complication often follows 
 some unusual bodily or mental effort. Again, coma diabeticum may follow 
 an acute infectious or septic process, or alcoholic intoxication, or ether 
 or chloroform narcosis induced for surgical purposes. The diagnosis may 
 be obscure when the diabetic becomes comatose in consequence of apoplexy 
 or ursemia. 
 
 jMinor forms of diabetic intoxication may explain the numbness and 
 tingling, which are common symptoms, and the neuralgias, which some- 
 times affect the upper or lower extremities, sometimes a single nerve- 
 trunk, as the third or the sciatic. Herpes zoster is encountered in diabetes, 
 but not more frequently than in the non-diabetic. 
 
DIABETES. 919 
 
 Tabetic symptoms, lightning pains, loss of knee-jerks, and extensor 
 palsies, manifested by a steppage gait, are mostly the manifestations of a 
 peripheral neuritis, though changes in the posterior columns have been 
 described. Paraplegic symptoms are due to neuritis. 
 
 The Organs of Special Sense. — Cataract, almost always double, 
 is a late development and occurs in cases in which the glycosuria is of 
 high grade. It develops with great rapidity in young diabetics, but more 
 slowly in the elderly, in which it cannot be differentiated from the senile 
 form. Retinitis, due to associated renal disease, or the ordinary hemor- 
 rhagic form, may occur, and optic neuritis followed by atrophy. Sudden 
 amaurosis without ophthalmoscopic changes may come on in the early 
 stages of diabetes. Changes in the organs of hearing, smell, and taste are not 
 common. Otitis media may occur and be followed by mastoid disease. 
 
 Diagnosis. — Direct Diagnosis. — The presence of grape-sugar in the 
 urine, continuing for weeks, months, or years, even upon a diet containing 
 carbohydrates in moderate amounts, is the fundamental diagnostic criterion. 
 Of secondary importance in the diagnosis because they are not constant 
 are inordinate thirst, excessive appetite, the excretion of abnormally large 
 quantities of urine, and loss of weight. Very often all these symptoms are 
 present and give rise to a characteristic clinical picture. The occasional 
 temporary absence of sugar under a diet which does not contain carbo- 
 hydrates, or during an acute illness, does not constitute an objection to 
 this diagnosis, since such a diet cannot be indefinitely continued, and 
 sugar reappears in the urine when carbohydrates are added, and also 
 reappears upon convalescence from an intercurrent febrile disease. 
 
 In the examination of the urine for sugar the total quantity for twenty- 
 four hours is collected, that of the day and of the night separately. Both 
 the percentage and the total quantity of sugar are ascertained. The pres- 
 ence or absence of acetone and oxybut^^ric acid is also noted and tests for 
 albumin are made. The specific gravity and reaction are recorded. 
 
 The quantitative estimation of the ammonia is of great importance, 
 since it permits conclusions in regard to the approximate amount of oxy- 
 butyric acid which is excreted at the same time. When more than 2 grammes 
 of ammonia are excreted in twenty-four hours, there is danger of coma. 
 
 It is to be remembered that the glycuronates, which sometimes precede 
 the excretion of sugar and are frequently associated with sugar in the 
 urine, reduce alkaline copper solutions but do not ferment, and that the 
 homogentisic acid of alkaptonuria reacts to the copper tests but not to 
 Nylander's bismuth test, nor to fermentation. The fermentation test is 
 the most reliable single test, but must, in doubtful cases, be controlled by 
 other tests, since the yeast sometimes contains sugar. 
 
 Differential Diagnosis. — N on-diabetic Glycosuria. (a) Transient 
 Glycosuria. — In rare instances this condition follows concussion of the 
 brain, cerebral apoplexy, severe neuralgias, and profound depressing 
 emotion. The sugar is present usually for a few hours, in some instances 
 for a few days, and shows no tendency to recur. 
 
 Under this heading must also be grouped the acvite forms of glycosuria, 
 lasting but a few hours, which accompany poisoning by morphine, amyl 
 nitrite, carbonic oxide, chloralamide, and nitrobenzole; the rare glycosuria 
 
920 MEDICAL DIAGNOSIS. 
 
 noted in biliary coliC; and that observed in hydrocyanic poisoning. Phlorid- 
 zin Poisoning; Renal Glycosuria. — The sugar is present so long as the admin- 
 istration of phloridzin is continued, alike when carbohydrates have been 
 ingested, or the animal is fed upon a proteid diet or is fasting. 
 
 (b) Intermittent Glycosuria. — This condition occasionally occurs in 
 gouty persons and in the non-gouty as the precursor of diabetes. The 
 assimilation limit for carbohydrates may be determined by the administra- 
 tion of 100 grammes of glucose in solution, two hours after a breakfast of 
 a roll and butter with coffee, during a period in which glycosuria is absent. 
 This amount of sugar should not, in a healthy person, cause glycosuria. 
 The excretion of sugar indicates a fault in the storage or metabolism of 
 the carbohydrates. Many cases of diabetes mellitus begin as intermittent 
 glycosuria. 
 
 (c) Alimentary Glycosuria. — The limit of assimilation for glucose in 
 the healthy subject varies from 120 to 200 grammes in a single dose. If 
 this be exceeded glycosuria occurs, but only a portion of the quantity 
 ingested appears in the urine, the remainder being stored as glycogen in 
 the liver and muscles for future use. The limit for cane sugar is about the 
 same, that for milk sugar rhuch lower, and for maltose in many individuals 
 very low. It is stated by Von Noorden that in some persons half a litre 
 of beer is sufficient to give rise to sugar in the urine and that this fact 
 should be known to avoid the danger of mistaking a harmless symptom 
 for a serious disease. 
 
 (d) Malingering. — Persons have been known to feign diabetes by 
 dissolving sugar in the urine. The specific gravity is high and the reactions 
 those of cane sugar; but verj^ well-informed patients may use glucose for 
 this purpose. The fraud is, however, easy of detection. 
 
 (e) Glycosuria in Pregnancy and the Lying-in State.- — Sugar occurs 
 under two circumstances: First, the pregnant woman may have been 
 diabetic before conception or may have become so during pregnancy. The 
 reactions are those of grape-sugar and the significance is unfavorable; 
 secondly, milk sugar may be resorbecl from the breasts and excreted by 
 the kidneys. This occurs when there is a hypersecretion of milk or, for 
 some reason, such as fissure of the nipple or the removal of the child, there 
 is an interruption of its withdrawal. The reactions are those of lactose 
 and the prognosis is favorable, the sugar disappearing as the secretion of 
 milk is arrested. The condition is not glycosuria but puerperal lactosuria. 
 
 Prognosis. — The dangers of diabetes consist in lowered nutrition, 
 diminished powers of resistance to intercurrent diseases, inflammatory 
 and chronic degenerative processes, and, in the severe cases, an abnormal 
 production of acids. 
 
 Favorable prognostic indications are onset or recognition of the 
 disease at an advanced period of life, absence of emaciation, the gouty 
 habit of body, the occurrence in the patient's family of other cases running 
 a mild course, slight glycosuria, and tolerance for moderate amounts of 
 carbohydrates. The prognosis is unfavorable when the disease begins at 
 an early age and when other cases of severe type have occurred in the 
 patient's family. Rapid emaciation, grave intercurrent affections or com- 
 plications, intense glycosuria, and intolerance for carbohydrates are of 
 
DIABETES. 921 
 
 ominous prognosis. The patient's circumstances and ability to avail him- 
 self of favorable personal influences, such as the avoidance of overwork 
 and worry, are very important. Finally, the excretion of ammonia in 
 large amounts and the presence of the acetone bodies in the urine are of 
 immediate gravity, because they are the common heralds of coma. 
 
 B. Diabetes Insipidus. 
 
 Definition. — A chronic disease characterized by great thirst and the 
 habitual discharge of excessive quantities of urine of low specific gravity. 
 
 This affection is a primary or idiopathic disease and is to be differen- 
 tiated from the transient or persistent hypersecretion of urine, which is 
 symptomatic of certain forms of chronic Bright's disease and some affec- 
 tions of the nervous system. 
 
 Etiology. — -Predisposing Influences. — Heredity exerts an impor- 
 tant influence. Cases have been known to occur in four generations. The 
 disease is sometimes congenital. There is very often a history of chronic 
 disease on the part of the parents of the patient. Diabetes, ?'enal affections, 
 pulmonary phthisis, gout, and rheumatism have been noted. Diabetes 
 insipidus most commonly develops in early life. It is relatively frequent 
 in young children and rarely begins after thirty. It is more common in 
 males than in females. 
 
 Exciting Cause. — The actual cause is unknown. The disease usually 
 develops insidiousl}^ without assignable cause. It has in some instances 
 been attributed to excessive quantities of water or beer, and has followed 
 an acute infectious disease, especially influenza. In young children malnu- 
 trition arising from neglect, insufficient food, and constitutional taint 
 have been assigned as a cause; in older persons acquired syphilis, alcohol- 
 ism, worry, anxiety, and prolonged exposure to cold. 
 
 Symptoms. — The two symptoms which are characteristic are an 
 excessive quantity of urine without sugar, and intense thirst. 
 
 The Urine. — The quantity voided is enormous. It often reaches 
 twenty or thirty pints in twenty-four hours. Fifty-six pints have been 
 noted. It may even at times exceed the fluid ingested, the difference 
 being made up of fluid withdrawn from the tissues of the body and the 
 food. It is pale in color and limpid, the specific gravity varying between 
 1.001 and 1.007. The reaction is faintl}^ acid or neutral. The total urinary 
 solids are increased by one-fourth or one-third. Inosite — muscle sugar — 
 is occasionally present in small amounts. Albumin is usually absent until 
 late and grape-sugar is occasionally present toward the close, when the symp- 
 toms of diabetes mellitus sometimes occur. Thirst. — This symptom is 
 proportionate to the quantity of urine. As much as fifty pints of fluid 
 have been consumed by a patient in the course of a day. There is usually 
 a remarkable thirst for alcoholic beverages. Bulimia. — The appetite is 
 usually enormous and the digestion well performed. These conditions 
 fail, however, in the terminal dyscrasia, when there may be complete 
 anorexia, flatulence, and unmanageable diarrhoea. The patients are often 
 well nourished and healthy-looking for years, the main troubles being 
 unquenchable thirst and frequent micturition. Emaciation is an early 
 
922 MEDICAL DIAGNOSIS. 
 
 symptom and becomes, toward the last, extreme. The sahva is scanty, 
 the mouth dry, perspiration sHght, and the skin dry and harsh. 
 
 Diagnosis. — Direct. — Extreme thirst, excessive habitual secretion 
 of non-saccharine urine of low specific gravit}^, and emaciation justify the 
 diagnosis of diabetes insipidus. 
 
 Differential. — The distinction between the idiopathic disease and 
 S5^mptomatic polyuria is extremely important. The following forms of 
 the latter are to be considered: Diabetes Mellitus. — Persistent glycosuria 
 and high specific gravity are important. If sugar appears in diabetes insip- 
 idus it is usually in faint traces and transitory. To this statement an excep- 
 tion must be made in regard to the cases in which diabetes mellitus consti- 
 tutes a terminal condition. Diseases of the Nervous System.. — Polyuria is a 
 conspicuous symptom in certain cases of brain tumor, lesions of the medulla, 
 and intracranial hemorrhage. It occurs also with some frequency in cere- 
 bral syphilis and has been observed in lesions of the cord. Hysterical 
 Polyuria. — Copious, limpid urine of low specific gravit}^ may simulate 
 diabetes insipidus. The condition is transitory and the characteristic 
 features of hysteria render the diagnosis a simple matter. Contracted 
 Kidney. — There is frequently a large amount of urine of low specific gravity. 
 Albumin is at times absent. It is, however, much more commonly present 
 in association with granular and hyaline casts. The signs of arteriosclerosis 
 and cardiac hypertrophy are important. Polyuria in Abdominal Diseases. — 
 This symptom is sometimes prominent in tuberculous peritonitis, aneurism 
 of the abdominal aorta or iliac arteries, tumors of various kinds, and espe- 
 cially malignant new growths. Hydronephrosis. — The periodical discharge 
 of large quantities of urine in connection with the subsidence of fluctuating 
 abdominal tumor, which slowly reforms during the intervals, is of positive 
 diagnostic significance. Intercurrent Polyuria in Enteric Fever. — I have 
 reported a case of excessive urinary discharge, reaching a maximum of 
 six litres in twenty-four hours, with slight increase of total urinary solids, 
 occurring during the course of an otherwise mild attack of enteric fever, 
 with disappearance of the polyuria upon convalescence. Other similar 
 cases have been observed. Malingering. — Water may be added to the 
 urine, but the absence of thirst, bulimia, and emaciation would lead to a 
 suspicion of fraud which may be readily exposed upon investigation. 
 
 Prognosis. — The course of diabetes insipidus is extremely variable. 
 It may be acute and rapid, or continue for many years with but slight 
 deterioration of the general health. Recovery may occur and spontaneous 
 cures have been noted. Death commonly results from some intercurrent 
 affection. 
 
 V. NUTRITIONAL DISEASES. 
 A. Scurvy. 
 
 Scorbutus. 
 
 Definition. — A nutritional disease, due mainly to improper food, 
 and characterized by ansemia, great debiHty, swollen and ulcerated gums, 
 and subcutaneous, submucous, and subperiosteal hemorrhages. 
 
SCURVY. . 923 
 
 Etiology. — Predisposing Influences. — Scurvy is a disease of unsan- 
 itary conditions and has occurred in all parts of the world in which such 
 conditions prevail. It has been known from the earliest historical periods 
 a,nd has been the scourge of armies in the field, soldiers and sailors on long 
 voyages, and the peoples of beleaguered cities. This disease may occur 
 in any climate, but is more common in northern climates and cold countries. 
 It is more frequent in cold weather than in warm, in rigorous winters than 
 in mild, and in periods of famine. Among adults males suffer more fre- 
 quently than females, and more severely. In besieged cities where the 
 conditions affecting the sexes have been very similar, the proportion of men 
 affected has exceeded that of women. It is most common in adult life, but 
 affects children and the aged. A special form is known as infantile scurvy. 
 Malaria, syphilis, dysentery, alcoholism, defective teeth, and gastro-intes- 
 tinal disorders constitute predisposing influences of recognized importance. 
 Anxiety, prolonged fear, nervous depression, and nostalgia play an impor- 
 tant part in the predisposition to the disease, but are incapable of causing it. 
 
 P.'^THOGENESis. — There are four hypotheses as to the essential cause 
 of the disease: 
 
 1. That it is due to the absence in the food of certain substances 
 present in fresh vegetables. The nature of these substances has not been 
 positively determined. They have been thought to be various organic 
 salts present in fruits and vegetables; or the potassium salts (Garrod). 
 According to Ralfe the lacking substances are the malates, citrates, and 
 lactates, from which are derived the carbonates upon which the alkalinity 
 of the blood depends. This view appears to be disproved by the fact that 
 scurvy does not prevail among the Esquimaux, who live exclusively upon 
 animal foods and fats which are often tainted, and that of Nansen and 
 other Arctic explorers who, living for months upon a similar diet in most 
 unhygienic surroundings, escaped the disease. 
 
 2. That it is due to toxic substances of unknown character, products 
 of decomposition, in the food. 
 
 3. That it is essentially a toxaemia, resulting from the absorption of 
 poisonous substances from the gastro-intestinal tract, produced by 
 microorganisms in the intestinal contents. 
 
 4. That it is an infection depending upon an unknown specific micro- 
 organism, for which depressing influences, unsanitary conditions, and 
 improper food prepare the soil. 
 
 It is to be noted that prolonged insufficiency of food — starvation — on 
 the one hand does not necessarily result in scurvy, and that, upon the 
 other, the disease may occur with an abundant diet of improper and 
 monotonous food. 
 
 Symptoms. — Scurvy occurs as an epidemic, endemic, and sporadic 
 disease. Sporadic cases are often encountered in prisons, almshouses, 
 hospitals, and other similar institutions, and occasionally among well-to-do 
 persons in private life, who, as a matter of fancy, or for some other reason, 
 have lived for a long period upon a restricted and unvaried diet. In the 
 United States, where scurvy is at present a rare disease, these sporadic 
 cases are often unrecognized. The disease is insidious in its development. 
 It may be subacute or chronic. In very rare cases the onset is abrupt. 
 
924 MEDICAL DIAGNOSIS. 
 
 The course in ordinary cases is progressive and attended by fluctuations 
 in the intensity of the symptoms. The earh^ manifestations consist of 
 weakness, pallor, and loss of weight. The gums become swollen, spongy, 
 and ulcerated. Sometimes they show the continuous oozing of blood. 
 The teeth are loosened and frequentlj^ fall out. The tongue is enlarged, 
 red, and frequently heavily coated. Submucous hemorrhages in the mouth 
 occur and the breath is disgustingly fetid. The skin becomes dry and 
 harsh and petechise appear in and around the hair-follicles, at first upon 
 the legs and later upon the arms and trunk. Subperiosteal extravasations 
 upon the legs often give rise to painful nodes, which sometimes break 
 down and form deep ulcerations. Subcutaneous hemorrhages occur at 
 points of injury or pressure, and brawny indurations occur in the subcu- 
 taneous tissues, with discoloration of the overlying skin. Epistaxis is 
 common and free bleeding from other mucous surfaces takes place in the 
 graver cases. Hemorrhagic infarcts in the lungs and spleen with character- 
 istic symptoms may be noted. Feeble action of the heart with arrhythmia 
 and palpitation are frequent and there is often a basic sj^stolic murmur. 
 There is anorexia and inability to masticate food owing to the condition 
 of the gums. Constipation is the rule. Arthritis has been noted. The 
 urine is albuminous. Urea is diminished. The other constituents show 
 inconstant changes. Mental depression and languor are common. Delirium 
 and coma occur as terminal events. Subconjunctival and intra-ocular 
 hemorrhages are of common occurrence and hemeralopia and nyctalopia 
 are occasional symptoms. Fever is not usual, but pyrexia of irregular 
 type may occur in the presence of complications, such as pleurisy, peri- 
 carditis, or abscess formation. 
 
 Complications and Sequels. — Abscesses, inflammation of the serous 
 sacs with hemorrhagic effusion, croupous pneumonia and bronchopneu- 
 monia, pulmonary gangrene, and pulmonary oedema as terminal events 
 constitute the most serious complications. Gastro-intestinal complications 
 are common. Ankjdosis of joints that have been inflamed, particularly 
 the elbow, knee, and ankle, may cause permanent deformity, 
 
 Diagnosis. — The dikect diagnosis in the epidemic and endemic 
 disease is unattended with difficulty. The surroundings and circumstances 
 of the patient, the condition of the gums, the petechias and ecchymoses, 
 the languor and anaemia, the nodes due to subperiosteal bleeding, and the 
 results of dietetic and hygienic treatment establish the nature of the disease. 
 
 Differential DiAGNOSis.-^The diagnosis in sporadic cases may 
 be difficult, especially in persons living in affluence in whom errors of diet 
 and unhygienic surroundings are unsuspected. The foregoing diagnostic 
 criteria are important. The lesions of the gums are absent in early infancy 
 prior to dentition, and in aged persons who have lost their teeth. Peri- 
 carditis and pleural effusion of scorbutic origin may, in the absence of the 
 lesions of the gums and subcutaneous hemorrhages, give rise to serious 
 diagnostic difficult3\ The anamnesis, the evidences of deep-seated hemor- 
 rhages, and the results of treatment are important. Puryura. — The various 
 forms of purpura differ from scurvy in their causal relations, the absence 
 of the peculiar lesions of the gums, and the absence of the deeper-seated 
 hemorrhages. 
 
INFANTILE SCURVY. 925 
 
 Therapeutic Diagnosis. — An abundance of fresh vegetables and 
 meat, such as constitutes an ordinary wholesome mixed diet, is visually 
 followed by a remarkable disappearance of the symptoms, even in cases 
 of great severity. The articles of diet which have the reputation of being 
 especially valuable comprise potatoes, lettuce, cabbage, spinach, and 
 fresh fruits and fruit juices, as lemon and lime juice. From the time that 
 the regulations of the Board of Trade have required that a sufficient quantity 
 of such articles be included in ships' supplies, the occurrence of scurvy 
 among sailors has become a rare event. 
 
 Prognosis. — The cases are apt to recover unless the causal conditions 
 persist or they are far advanced when treatment is begun. This disease 
 is now infrequent and the mortality low. Death results from progressive 
 inanition, sudden syncope, large serous effusions, pneumonia, pulmonary 
 cedema, meningeal hemorrhage, or sepsis. 
 
 B. Infantile Scurvy. 
 
 Barlow's Disease. 
 
 Definition. — A nutritional disease of young infants, due to improper 
 food and characterized by subperiosteal hemorrhages, particularly in the 
 lower extremities, a form of pseudoparalysis, and a cachectic condition. 
 Our knowledge of this disease, which was formerly confounded with rickets 
 and infantile syphilis, is of comparatively recent origin (1881-83). 
 
 Etiology. — Predisposing Influences. — Infantile scurvy is more 
 common among the well-to-do than among the poor, a condition to be 
 explained, first, by the fact that the children of the former are more com- 
 monly fed upon artificial foods, and second, that among the latter the 
 child has at an early age a more varied diet, into which enter to some 
 extent articles of ordinary table food quite unknown to children of the 
 same period among the affluent. Scurvy begins most commonly between 
 the sixth and eighteenth months. It is rare earlier, but has been observed 
 as late as the fifth year. Rheumatism, syphilis, and rickets have been 
 supposed to bear a causal relation to infantile scurvy. Of these the first 
 two have nothing to do with the disease in question and the last, though 
 sometimes associated with it, is wholly different in its etiology, pathology, 
 and symptomatology, and when present in the same individual persists 
 when the scorbutic symptoms have disappeared. 
 
 The Immediate Cause. — Improper diet is the cause of this disease. 
 The various commercial foods, including condensed milk (especially when 
 prepared with water), sterilized milk, and other artificial foods (particularly 
 when administered in unvarying monotonj^), are found to have consti- 
 tuted the diet in almost every case for a considerable period prior to the 
 manifestation of the symptoms. 
 
 Symptoms. — The disease shows itself as an insidiously developing 
 cachexia. The child is fretful and peevish. It lies quiet when undisturbed, 
 with its thighs and legs strongly flexed, but screams when any attemjit 
 is made to extend them. Obscure swellings due to subpei-iosteal hemor- 
 rhages mav be observed on both lower extremities but i\\e\ are not svm- 
 
926 MEDICAL DIAGNOSIS. 
 
 metrical. These ill-defined, tumor-like prominences occupy the lower 
 ends of the femurs, the tibiae, and less frequently the bones of the forearms. 
 They are most marked just above the epiphyseal junction and extend 
 along the shafts of the bones. Similar swellings may sometimes be found, 
 upon the scapulae. The overlying tissues are boggy and slightly cedema- 
 tous and the skin is somewhat tense. As the disease progresses the whole 
 limb becomes thickened. Presently the limbs assume a different position, 
 being no longer drawn up, but everted and motionless — 'pseudoparalysis. 
 The joints are not involved. Separation of the epiphyses and fracture 
 may occur in severe cases, these lesions being manifest by crepitus and 
 further deformity. Barlow described a remarkable depression of the 
 sternum and costal cartilages. Proptosis of the eyeballs, more marked 
 upon one side than the other, with oedema and slight discoloration of the 
 eyelids, may occur in advanced cases. Petechiae occur, but are much less 
 conspicuous than in the scurvy of adults, but hemorrhages from the mucous 
 surfaces are common. Anaemia — 3,000,000 to 2,000,000 or lower — is 
 proportionate to the severity of the case. The white corpuscles show 
 no constant changes. The color of the skin is pallid and earthy; 
 emaciation is not a marked feature; asthenia is extreme. The tempera- 
 ture may be normal or slightly subnormal, with occasional transient 
 rises to 102° or more, these usually accompanying the signs of fresh 
 subperiosteal hemorrhages. If the teeth have appeared the gums may 
 be swollen and spongy. 
 
 Diagnosis. — Direct. — It is a matter of surprise that the true character 
 of infantile scurvy is so often overlooked. Few diseases of infants present 
 a more characteristic symptom-complex or a more obvious etiology. The 
 attitude, the behavior of the child upon being handled, the anaemia, the 
 elongated, subperiosteal nodes and thickening of the limbs, the immobile, 
 forced flexion of the limbs in the early, and the pseudoparalysis in the 
 later, course of the af?"ection are diagnostic. Proptosis and oedema of the 
 eyeballs are significant. 
 
 Differential. — Rickets. — The gastro-intestinal symptoms are more 
 prominent than in scurvy. The rachitic rosary and the lesions of the bones 
 are characteristic. The boggy swellings, protrusion of the eyeballs, pe- 
 techiae, and spongy gums when the teeth are present do not occur in rickets. 
 The two diseases may, however, be associated. The forms of purpura 
 resemble scurvy only in the presence of petechial and other hemorrhages, 
 but the distribution of these lesions and the absence of all else character- 
 istic of the latter disease render the diagnosis an easy matter. Infantile 
 Paralysis. — The pseudoparalysis may suggest this affection, but the history 
 of the case, the sudden onset, the absence of pain, tenderness, and the 
 localized swellings are diagnostic. Syphilitic Pseudoparalysis; Parrofs 
 Disease. — Sudden loss of motion in the lower or upper limbs, or both, 
 with great pain on passive movement, and crepitus due to a separation of 
 the epiphyses may present a superficial resemblance to infantile scurvy. 
 This resemblance ceases upon a proper consideration of the anamnesis 
 and the lesions. The diagnostic criteria of congenital syphilis are usually 
 unmistakable. In any doubtful case an etiological diagnosis based upon 
 the nature of the diet will be helpful. 
 
RICKETS. 927 
 
 Prognosis. — The outlook is favorable in cases early recognized. Com- 
 plete recovery, with the disappearance of the lesions, often takes place 
 in the course of two to four weeks after the institution of a proper diet. 
 More advanced cases recover more slowly. 
 
 C. Rickets. 
 
 Rhachitis. 
 
 Definition. — A disease of infants due to improper diet and character- 
 ized by impaired nutrition of the tissues of the body and specific alterations 
 of the skeleton. 
 
 Etiology. — Predisposing Influences. — All those conditions which 
 involve neglect of hygiene, and especially of alimentary hygiene, favor 
 the development of rickets. The geographical distribution of this disease 
 is wide. It abounds in great cities and crowded industrial centres. It is 
 more common in Europe than America. In this country it is especially 
 prevalent among the children of recent immigrants. The great frequency 
 of rickets among the children in the Italian and negro colonies of American 
 cities is due not to racial but to social conditions. Rickets affects male 
 and female children to the same extent and degree. If we except the 
 rare condition known as fetal rickets — achondroplasia, chondrodystro- 
 phia foetalis — and the late form described by Jenner- — the osteomalacia of 
 puberty — rickets is a disease of the first two years of life, a period corre- 
 sponding to the first dentition. It rarely begins before the sixth month 
 or after the third year. Rickets is especially a disease of poverty and all 
 that poverty entails — want of sunlight and want of fresh air, neglect, 
 j51th, and insufficient and improper food. Rickets, like scurvy, occasionall)^ 
 occurs as a sporadic disease in the families of the well-to-do. Rickets has 
 been looked upon as a manifestation of congenital syphilis, but this view 
 has been abandoned alike upon etiological and pathological grounds. A 
 syphilitic child is not rhachitic, though it may acquire rickets, and the 
 two conditions frequently coexist. There is no evidence that rickets is 
 hereditary. The endemic and epidemic prevalence of the disease, under 
 certain social conditions, is neither evidence of its hereditarj'- nature nor 
 of its contagiousness, as has been assumed. 
 
 The Cause. — An improper diet is the essential cause of the disease. 
 Prolonged lactation and suckling the child after pregnancy has occurred 
 bring the rnilk of the nursing mother within the category of improper 
 food. Cow's milk, foods rich in starches, condensed milk, and the various 
 commercial infant's foods are responsible for a large proportion of the cases. 
 Deficiency in fat and proteids, and failure in the assimilation of the lime 
 salts, constitute the chief alimentary defects. 
 
 The Pathogenesis. — The following are the chief h3'potheses: (1) 
 Rickets is a manifestation of congenital syphilis (Parrot) , (2) a trophic 
 disease of the bones, resulting from nervous derangements; (3) an infec- 
 tion; (4) a disease of nutrition due to faulty alimentary hygiene. Of 
 these, the last, in various modified forms, is the view now generally 
 maintained. 
 
928 MEDICAL DIAGNOSIS. 
 
 Symptoms. — Rickets is a chronic disease of insidious onset, beginning 
 during the first dentition and usually before the child begins to walk. It 
 is preceded by digestive disorders of varying degree, and impaired nutrition, 
 but not necessarily by emaciation. The child is often pallid, plump, and 
 soft. Slight fever, irritability, and poor sleep are suggestive symptoms. 
 He is feeble and unsteady on his feet and disinclined to walk. There is 
 diffuse tenderness of the tissues and unwillingness to be handled or touched. 
 Free sweating, especially about the head and neck, is common. The weak- 
 ness of the muscles, and especially in the legs, is suggestive of partial 
 paralysis — pseudoparalysis of rickets. The skeletal changes appear early 
 in the course of the disease and are characteristic. They consist of: 1. The 
 "rhachitic rosary," composed of nodular enlargements of the ribs at 
 their juncture with the cartilages on both sides. These enlargements 
 may be readily felt upon palpation and in thin children may be recognized 
 upon inspection. They appear early and gradually increase in size until 
 
 Fig. 311. — Rickets. Showing the epiphyseal enlargements, the rosary, the distended belly, and the de- 
 formities as a whole. — Pennsylvania Hospital. 
 
 some time in the second year, after which they gradually disappear. 2. 
 Changes in the Thorax. — Shallow furrows, corresponding to the junc- 
 tion of the cartilages with the ribs, pass obhquely downward and outward. 
 A similar transverse depression extends from the level of the ensiform 
 cartilage toward the infra-axillary space — Harrison's groove. The sternum 
 projects, particularly in its lower half, giving rise to the prominent deform- 
 ity known as chicken- or fig eon-breast. These changes in the contour of 
 the chest are not peculiar to rickets and may occur in any condition habitu- 
 ally interfering with inspiration in early life. 3. Changes in the Head. — 
 As a rule the head appears large, the frontal and parietal eminences are 
 exaggerated, and the fontanelles remain open for a long time. The fore- 
 head is prominent, the top of the skull flattened, and, in some cases, the 
 head viewed from above appears square — caput quadratum. Craniofahes. — 
 There are circumscribed areas, mostly in the occipital, parietal, and squa- 
 mous portions of the temporal bones, in which, in consequence of decalcifica- 
 tion, the skull may yield to the pressure of the finger, giving rise to " parch- 
 ment crackling." This condition has been observed also in syphilis. A 
 systolic murmur may frequently be heard over the anterior fontanelle or 
 in the temporal region. This auscultatory phenomenon is sometimes 
 
RICKETS. 
 
 929 
 
 heard in healthy children. The bones of the face also show changes, espe- 
 cially in the maxilla;, which are small and angular. The normal course of 
 dentition is deranged and retarded. The first teeth may not appear until 
 some time in the second year and undergo caries at the time of their eru ,- 
 tion. The cephalic changes of rickets are very often first in the point of 
 time. 4. Changes in the Pelvis. — The changes in the pelvis are 
 of especial importance in female children, 
 since they lead to deformities with narrow- 
 ing, which interfere with natural labor and 
 frequently render it impossible. 5. Changes 
 IN the Extremities. — The scapula? are not 
 usually affected. The clavicles are often 
 thickened at the sternal ends and at the point 
 of insertion of the sternocleido muscles; 
 their curves are exaggerated and they are 
 shortened. The rhachitic deformities are 
 most conspicuous in the long bones. They 
 consist of enlargements in the region of the 
 junction of the shaft and epiphysis, and 
 curvatures, which in the lower extremities 
 cause a corresponding diminution in the 
 height of the individual. The enlargements 
 in the upper extremities are most marked 
 at the distal ends of the radius and ulna. 
 To a less degree the lower end of the 
 humerus may be affected. The Rhachitic 
 Hand. — Koplik has described a deformity 
 of the hands which occurs in rickets, con- 
 sisting in thickening and bowing of the pha- 
 langes of the fingers, associated with laxity 
 of the ligamentous structures of the phalan- 
 geal joints. The changes give rise to a some- 
 what characteristic appearance of elongation 
 of the fingers and plumpness of the whole 
 hand. They have been observed in connec- 
 tion with the ordinary lesions and deformities 
 of well-marked rickets. In cases attended 
 by pains in the bones ''the rhachitic hand" 
 may suggest syphilis, but the association of 
 the lesions of infantile syphilis renders the 
 
 differential diagnosis easy. In the lower extremities the lower end of the 
 tibia, of the fibula, and of the femur show progressive enlargements propor- 
 tionate to the severity of the case. If the child walks, the femurs are curved 
 forward and the bones of the legs forward and outward. Exceptionally 
 the curves may cause the deformity known as knock-knee. These abnormal 
 curvatures are due to the muscular traction and the weight of the body 
 upon the decalcified and softened bone. 
 
 The liver is enlarged; the spleen enlarged and palpable. There is 
 usually more or less flatulent distention. These conditions combine to 
 59 
 
 Fig. 312. — The skeleton of the body 
 shown in Fig. 311. 
 
930 MEDICAL DIAGNOSIS. 
 
 render the belly large and protuberant, a condition made more conspicu- 
 ous by the relatively small size of the thorax. 
 
 The urine shows no constant changes. There is slight ansemia; the 
 X. ^moglobin is decreased; leucocytosis may or may not be present. The 
 neivous symptoms increase with the severity of the other symptoms. 
 Convulsions are common. Tetany and laryngismus stridulus are occa- 
 sional intercurrent affections. The growth of the child is greatly retarded 
 and many dwarfs are rhachitic. 
 
 Diagnosis. — Direct. — Many cases are so slight as to escape recogni- 
 tion. Weakness, fretfulness, pallor, diffuse soreness, profuse sweating of 
 the head during sleep, an open fontanelle, and irregular evening fever 
 justify a provisional diagnosis, especially when defects of hygiene and 
 diet exist. When to these symptoms are added the skeletal changes above 
 described, especially those which first appear, namely, the rosary and 
 craniotabes, it becomes positive. 
 
 Prognosis. — The slighter forms are amenable to treatment and recovery 
 takes place without deformity. The graver cases recover more slowly and 
 with lasting skeletal changes. The disease is essentially chronic, and, though 
 not in itself fatal, renders the patient peculiarly liable to intercurrent 
 affections, while it at the same time diminishes the powers of resistance. 
 
 D. Obesity. 
 
 Definition. — An excessive development of fat. 
 
 The condition is not always pathological. It is better to be fat and 
 enjoy a normal amount of health and vigor than to reduce the fat by an 
 unwise and rigorous regimen and depleting drugs, and become an invalid. 
 
 Etiology. — Predisposing Influences. — The hereditary tendency to 
 obesity may be demonstrated in about fifty per cent, of the cases. This 
 tendency may be manifest in childhood, in women after the first pregnancy, 
 or not until middle life. It is more common in women than in men. Not 
 alone in the hereditary cases, but also in those in which the tendency is 
 acquired, is the condition more common in the female. There is a manifest 
 relation between sexual inactivity and the tendency to corpulence. In 
 males the tendency to accumulate excessive fat frequently begins in the 
 fifth decade of life; in females at puberty, during the period of child- 
 bearing, and at the grand climacteric. The distribution of fat varies at 
 different periods of life. In infancy and childhood the undue accumulation 
 is chiefly subcutaneous; in middle life it is visceral as well as subcutaneous, 
 while in the aged the subcutaneous fat may disappear and that in the 
 omentum, mesentery, pericardium, mediastinum, and around the kidneys 
 persist. Persons of phlegmatic temperament, given to repose and the 
 pleasures of the table, are more disposed to obesity than those who are 
 sanguine, active, and self-denying. 
 
 The Actual Causes. — In general, obesity is due to the ingestion of 
 excessive and improper food and an indolent and inactive life, but to this 
 statement there are many exceptions. There are fat persons who are 
 small eaters and exercise constant care in the selection of their diet, and 
 among the obese are to be found men of superior intelligence and energy. 
 
OBESITY. 931 
 
 Fats, starches, and sugars taken in excess cause obesity. The habitual 
 ingestion of large quantities of fluids and the abuse of alcohol are important 
 etiological factors. 
 
 Symptoms. — Oertel describes a plethoric and an anaemic form. The 
 first is more common in men who are high livers and consume much beer. 
 The face is flushed, the subcutaneous and visceral fat are increased, but 
 the muscular power is preserved for a long time. The second is especially 
 encountered in chlorotic girls and anaemic women. The face is pallid, the 
 skin white, the subcutaneous fat especially abundant, and the muscular 
 power feeble. The ankles are often slightly cedematous. The hands and 
 feet long remain free from disfiguring fat. Both types are too familiar to 
 require detailed description. 
 
 Diagnosis. — Direct. — The recognition of obesity is a matter of little 
 difficulty. The contour of the body and the disproportion between the 
 height and weight of the individual are diagnostic. More difficulty arises 
 in determining the line at which normal corpulence proper to the age, 
 habits, and hereditary peculiarities of the individual ends, and obesity 
 with its inconveniences and dangers begins. This can only be done by a 
 careful study of individual cases. 
 
 Differential. — (Edema. — The irregular, doughy masses of sub- 
 cutaneous fat, with the sharp folds of the skin and general distribution 
 which characterize obesity, are in sharp contrast to the smooth, tense, 
 glistening skin of anasarca, with its tendency to accumulate in the depend- 
 ent tissues, where there is characteristic pitting upon pressure. Myxccdema. 
 — The dense subcutaneous infiltration, symmetrical and of moderate 
 extent, not pitting upon pressure, the implication of the hands, the pads, 
 the mental state, and the prompt reaction to thyroid medication render the 
 diagnosis clear. Emphysema of the S^ibcutaneous Tissues. — This rare con- 
 dition may suggest obesity, but the history of the case, the circumscription 
 of the sweUing, and crackling upon palpation are characteristic. 
 
 Prognosis. — The outlook, varying with the causes, degree, symptoms, 
 complications, and the disposition of the patient, ranges from favorable 
 to positively ominous. It is less favorable in the hereditary than in the 
 acquired form, in the anaemic than in the plethoric, and in the cases in 
 which feeble action of the heart, arteriosclerosis, gout, albuminuria, or 
 diabetes is present. Obese persons bear intercurrent febrile infections 
 badly and usually make a tardy and unsatisfactory convalescence because 
 of the slow regeneration of red blood-corpuscles and enfeebled recupera- 
 tive powers. 
 
 Adiposis Tuberosa Simplex. — Under this term Anders has described 
 a rare condition encountered in obese persons, characterized by the presence 
 of circumscribed masses of fat in the subcutaneous tissues, particularly 
 in the extremities and abdomen, and forming distinct, moderately dense, 
 slightly movable, somewhat flattened tumors varying in size from a bean 
 to a hen's egg and in number from six to twenty-four or more. These 
 masses are not elevated above the surface and show no tendency to fuse 
 together. They are sensitive to palpation and are sometimes, but not 
 always, the seat of pain of variable intensity. The overlying skin is not 
 adherent. Their etiology is not clear, but their relationship to corpulency 
 
932 MEDICAL DIAGNOSIS. 
 
 is manifest from the fact that they disappear as that condition is reduced 
 under treatment. Adiposis tuberosa simplex is to be distinguished from; 
 (1) Adiposis dolorosa — Dercu77i's disease — which is not amenable to treat- 
 ment, and in which definite changes in the thyroid gland and the pituitary 
 body, together with extensive interstitial neuritis and degeneration of the 
 columns of Goll, have been found post mortem. (2) Lipomata. — Fatty 
 tumors which are painless, soft and doughy, globular in shape, often lobu- 
 lated, usually distinctly elevated above the surface, and which occur 
 independently of general obesity and remain uninfluenced by treatment. 
 (3) Adenolipomatosis, in which fatty accumulations develop in relation 
 with the lymph-nodes of the neck, axillae, or groins. These fat masses 
 are symmetrical in distribution and occur in various chronic constitutional 
 diseases, and only rarely are associated with general obesity. In fact, 
 they may persist when, in consequence of the progress of the associated 
 malady, emaciation has occurred or cachexia developed. 
 
 Adiposis Dolorosa. — Definition. — Dercum first called attention to 
 " a disorder characterized by irregular, symmetrical deposits of fatty 
 masses in various portions of the body, preceded by or attended with pain." 
 
 The disease occurs chiefly but not exclusively in women at middle 
 life. Neuralgic pains precede and accompany the disorder. Irregular 
 hyperaesthesia and parsesthesia occur. Fatty masses, sometimes of enor- 
 mous size, lumpy, soft, and pendulous, form at various points of the body, 
 in association with a general great increase of the subcutaneous fat. The 
 face, hands, and feet are not affected. Atrophy of the thyroid body has 
 been noted in some of the cases, and the administration of thyroid extract 
 has been followed by relief of the neuralgia and diminution of "the fat. 
 Lesions of the pituitary body with interstitial neuritis and degeneration 
 of the columns of Goll have also been found post mortem. The essential 
 nature of the trouble is unknown. This disease differs from other forms 
 of obesity in its unknown etiology, the distribution of the fat in masses, 
 and the presence of marked nervous symptoms, especially pain. 
 
 VI. AMYLOID DISEASE. 
 
 Lardaceous Disease; Waxy or Bacony Infdtration; Amyloidosis. 
 
 Definition. — A secondary affection in suppuration and syphilis, 
 characterized by the formation and deposition of amyloid material or 
 lardacein in the walls of the arteries and the viscera. 
 
 Pathologically, lardaceous disease is regarded as a degenerative change 
 involving certain elements in the blood and an infiltration in the tissues 
 of the organs. The process is general or constitutional. It affects no par- 
 ticular organ locally, but many organs and tissues at the same time, though 
 not to the same degree. The organs commonly affected are, in the order 
 of frequency, the kidney, the spleen, the liver, the intestines, the adrenals, 
 and the lymph-glands. The pancreas, thyroids, testis, oesophagus, and 
 endocardium are less frequently involved. The amyloid material is 
 deposited at first in the arterioles, and in certain anatomical structures or 
 regions, as the intermediate or hepatic artery zone of the liver lobule, the 
 
AMYLOID DISEASE. 933 
 
 Malpighian tufts and the cortex generally in the kidney, the Malpighian 
 bodies in the spleen, and the arterioles in the mucous membranes. In 
 many of the cases the material is distributed throughout the whole of the 
 organ, with the result that the solid viscera are increased in bulk, sometimes 
 to an enormous extent. This increase is sometimes, especially in the kidney, 
 followed by contraction. 
 
 Etiology. — Suppuration, chronic or recent, with or without discharge, 
 is present in the great majority of the cases. Pulmonary tubercvdosis 
 and disease of bone are the most frequent causes of suppuration antecedent 
 to amyloid disease. Tuberculosis without suppuration does not appear 
 to be a factor. On the other hand, suppuration, in the absence of tuber- 
 culosis or other specific constitutional infection, is a very common ante- 
 cedent. Syphilis without purulent lesions must be recognized as a cause. 
 Malaria is a possible cause, but its agency is still in question. As a rule, 
 the suppuration has been prolonged, but there are exceptions to this rule. 
 The amyloid process develops during the suppurative process, but may 
 not cause recognizable clinical manifestations until after suppuration 
 has continued for years, or not until after it has ceased. Males are more 
 liable than females, not because of any differences incident to sex, but 
 because they are more exposed to injuries and diseases attended by purulent 
 lesions, and to syphilis. The predisposition associated with age is shown 
 by the rarity of amyloid disease before ten and after fifty. It is most 
 common between twenty and forty. 
 
 Symptoms. — There are general manifestations of amyloid disease 
 irrespective of the visceral changes. The suppurative primary diseases 
 have almost always produced changes that are characteristic, or at least 
 suggestive. These are manifest in the signs of advanced phthisis, the 
 deformities of old empyema or bone disease, especially those forms which 
 involve the spine and joints. Since such processes are attended with wast- 
 ing, the pinched features, emaciated frame, and shrunken extremities are 
 highly suggestive, especially as they are associated with a prominent or 
 enormously distended abdomen due to the overgrown size of the amyloid 
 viscera. A muddy pallor of the skin, dropsical effusions in the dependent 
 parts, diarrhoea, polyuria, thirst, albuminuria, and great weakness complete 
 the picture. The onset is insidious. 
 
 It is customary to describe the clinical manifestations of amyloid 
 disease in the organs in connection with the various diseases of each; it 
 seems, however, more appropriate and more useful for the purposes of the 
 diagnostician to consider them here. 
 
 1. Amyloid Kidney. — The process is associated with wide-spread 
 am5doid degeneration in other viscera due to suppurative diseases or syphi- 
 lis. It has been attributed also in some instances to leuksemia, chronic 
 lead intoxication, and gout. It is frequently associated with the chronic 
 form of parenchymatous nephritis. The kidney is usually much increased 
 in size; in exceptional cases it does not exceed the normal kidney in this 
 respect. The surface is smooth and the stellate veins are conspicuous. 
 The organ is firm. Upon section the cortex is thickened, the glomeruli dis- 
 tinct, and the pyramids of a deep red color. The iodine test shows a deep 
 mahogany color most marked in the Malpighian tufts and straight vessels. 
 
934 MEDICAL DIAGNOSIS. 
 
 Symptoms. — There are urinary features of importance. The quantity 
 is increased, the color pale and transparent, the specific gravity low. Albu- 
 min is, as a rule, abundant; exceptionally there is a mere trace or it may 
 be absent. Hyaline, fatty, and granular tube-casts are present, and occa- 
 sionally the amyloid color-reaction may be obtained. Dropsy is usually 
 present, but there are cases in which it does not occur. Diarrhoea is com- 
 mon. Increased arterial tension, cardiac hypertrophy, retinal lesions, 
 and uraemia do not occur except in cases of amyloid degeneration affecting 
 the small granular kidney. 
 
 Diagnosis. — The renal symptoms alone have little diagnostic value. 
 Their development in connection with prolonged suppuration or syphilis, 
 and in association with an enlarged liver and spleen, and persistent diar- 
 rhoea, is highly suggestive. 
 
 2. Amyloid Liver. — The etiological relations of this condition are the 
 same. It constitutes an important visceral manifestation of amyloid disease. 
 The organ is large and may attain an enormous size. It is firm, dense, and 
 resistant. Upon section the surface is pale and presents at the edges a slightly 
 translucent appearance. It responds to the iodine test by the development 
 of a mahogany-brown color in the affected areas. The capsule is smooth and 
 the borders of the enlarged organ are rounded and blunt. Exceptionally the 
 margins are sharp and well-defined. The enlargement is commonly uniform. 
 
 Symptoms. — There are no characteristic hej^atic features. Jaundice 
 does not occur. The stools are sometimes light but not clay-colored. 
 There are no signs of portal obstruction. The spleen is often enlarged. 
 
 Diagnosis. — The history taken in connection with progressive enlarge- 
 ment of the liver which, upon palpation, yields the above signs, together 
 with enlarged spleen, polyuria with or wdthout albumin, and diarrhoea, 
 constitutes positive evidence of the presence of amyloid disease. 
 
 3. Amyloid Spleen. — The organ is not usually greatly enlarged but 
 can be readily recognized upon palpation. Its edges are thick and rounded 
 and its consistence dense. Upon section the lardaceous infiltration is seen 
 to affect especially the Malpighian bodies, which are prominent and glisten- 
 ing, giving rise to the appearance described as "sago spleen." In some 
 cases the intervening tissue is more or less diffusely affected. 
 
 There are no special symptoms. 
 
 Diagnosis. — A history of suppuration or syphilis, a cachectic state, 
 emaciation, prominent abdomen clue to coincident enlargement of the 
 liver, urinary changes, and diarrhoea when present justify the assumption 
 that an enlarged spleen is amyloid. 
 
 4. Amyloid Disease of the Intestines. — The blood-vessels of the entire 
 digestive tract may be affected. More commonly the small intestine, 
 especially the ileum, or the colon is the seat of the disease. 
 
 Symptoms. — When slight in intensity or of limited extent the disease 
 presents no features by which it can be recognized clinically. The one 
 symptom of advanced or extensive amyloid degeneration in the intestines 
 is persistent diarrhoea. The stools are variable in consistency and number. 
 They are usually thin and liquid but without distinctive characters. Espe- 
 cially are they not bloody. They are not attended by colic or tenesmus 
 and the abdomen is not sensitive to pressure. 
 
GASTRITIS. 935 
 
 Diagnosis. — The recognition of the disease is difficult and uncertain, 
 since diarrhoea without pain and tenderness and equally intractable may 
 occur in various other intestinal diseases. The association of this symptom 
 with the above-described clinical manifestations in a person suffering, 
 or who has suffered, from prolonged suppuration, or who has syphilis, 
 renders it in the highest degree probable that there is amyloid disease of 
 the gut. 
 
 Prognosis in Amyloid Disease. — The outlook is doubly unfavorable. 
 The antecedent disease is a frequent, the amyloid disease a common, 
 cause of death. The highest mortality among the visceral forms relates 
 to the kidneys, the next to the intestines. Extensive lardaceous degen- 
 eration of the liver and spleen may occur without special symptoms of 
 importance, and without great impairment of health in addition to 
 that caused by the primary disease. 
 
 IX. 
 
 THE DIAGNOSIS OF THE DISEASES OF THE 
 DIGESTIVE SYSTEM. 
 
 (diseases of the mouth, tongue, gums, salivary glands, pharynx, 
 
 TONSILS, and OSSOPHAGUS ARE CONSIDERED IN PART III.) 
 
 I. DISEASES OF THE STOMACH, 
 i. Acute Gastritis. 
 
 The following forms are recognized: toxic, phlegmonous, diphtheritic, 
 parasitic, and dietetic. 
 
 1. Toxic Gastritis. — An intense form of inflammation produced by 
 various irritant and corrosive poisons. It varies in degree according to 
 the nature, concentration, and quantity of the poison, and the length of 
 time it has remained in contact with the gastric mucosa. 
 
 Symptoms. — Sudden pain, nausea, retching, and vomiting occur. 
 The vomitus in severe cases consists of blood-stained food remnants, 
 mucus, shreds of mucous membrane, and the poison itself. Thirst and 
 dysphagia are distressing. Later there is usually diarrhoea. Collapse 
 comes on rapidly; the temperature, at first subnormal, rises later; and 
 jaundice is not uncommon. Epigastric and abdominal tenderness may be 
 followed by the signs of general peritonitis. Death occurs from the intoxi- 
 cation, or from exhaustion, convulsions, or suffocation. When recovery 
 takes place, ulceration with stenoses or chronic gastritis supervene. The 
 direct diagnosis depends upon the anamnesis, the evidences of the corrod- 
 ing poison upon the lips, mouth, and pharynx,- the odor of the breath in 
 certain cases, the presence of the vial or package which contained the 
 poison, the analysis of the vomitus, the analysis of the urine, and the fore- 
 going associated symptoms. The prognosis is, in the main, unfavorable. 
 
936 MEDICAL DIAGNOSIS. 
 
 It depends, however, upon the nature of the poison, its amount, the time 
 elapsing before its removal or the administration of antidotes, the direct 
 damage to the stomach itself, the intensity of the collapse, and the 
 occurrence of peritonitis. 
 
 2. Phleg-monous Gastritis. — Acute diffuse or circumscribed suppura- 
 tive inflammation of the gastric submucosa. 
 
 Etiology. — This is a verj^ rare affection. The cases are primary, in 
 which alcohoUsm appears to be a predisposing influence, and trauma, 
 faulty diet, and various irritant poisons the exciting causes; and secondary, 
 in which the various general febrile infections, sepsis, and peptic or car- 
 cinomatous ulceration constitute the primary disease. Streptococcus 
 infection is most common. The colon bacillus may be present. Cases 
 have been reported at evers^ period of life between ten and ninety. Phleg- 
 monous gastritis is four times as common in males as in females. 
 
 Symptoms. — In the circumscribed variety the symptoms are obscure. 
 Pain may be absent. There may be a circumscribed tumor in the epigas- 
 trium, and vomiting of pus and blood. In the diffuse form the onset is 
 sudden, -^ith a rigor, severe prostration, and a rise of temperature to 104°- 
 105° F. (40°-40.5° C). Gastric symptoms speedily supervene. They 
 consist of the urgent and continuous vomiting of pus, mucus, and bile, 
 epigastric pain and tenderness, and, in rare instances, the signs of a 
 fluctuating tumor. In the course of a brief period general abdominal 
 tenderness, meteorism, and other signs of peritonitis usually appear. 
 
 The diagnosis has rarely been made intra vitam. The occurrence of 
 the above sj^mptoms in the course of a severe general infection or sepsis 
 would be suggestive. The differential diagnosis concerns perigastritis 
 following peptic ulcer, circumscribed peritonitis, acute pancreatitis, chole- 
 cystitis, and toxic gastritis. The prognosis is in the highest degree unfavor- 
 able. Of the reported cases 95 per cent, have terminated fatally. 
 
 3. Diphtheritic Gastritis. — Pseudomembranous inflammation of the 
 gastric mucosa occurs as a true diphtheria of the stomach in cases of inva- 
 sion by the Klebs-Loffler bacillus in diphtheria of the cesophagus, throat, 
 or upper respiratory passages, but it is a very rare complication. More 
 commonly it occurs as a complication of other infectious diseases, as enteric 
 fever, pneumonia, the exanthemata, and sepsis. In children tuberculosis 
 is often the primary infectious disease. A condition closely resembling 
 diphtheritic gastritis may be produced by corrosive poisons. The char- 
 acteristic lesion is the presence of the pseudomembrane, which may be 
 diffuse, patchy, or arranged in irregular streaks- extending from the cardia 
 to the pylorus. The superficial layer is formed by a coagulation necrosis. 
 The bacteriological findings vary. Streptococci, tubercle bacilli, and Klebs- 
 Loffler bacilli have been more commonly isolated. The symptoms are not 
 characteristic. Vomited membrane may have been dislodged from the 
 upper air-passages, or the pharynx or oesophagus. The diagnosis, with a 
 very few exceptions, has not been made during life. 
 
 4. Parasitic Gastritis. — Inflammation of the stomach as the result of 
 infection by various pathogenic organisms by way of the blood and lymph 
 stream — infectious gastritis — is of common occurrence. This form occurs 
 in various septic conditions, enteric fever, pneumonia, and the exanthemata. 
 
GASTRITIS. 937 
 
 The presence of moulds and yeasts in lesions of the gastric mucosa renders 
 it probable that, under certain circumstances, those agencies may cause 
 or aggravate such conditions as inflammation, erosion, and ulceration. 
 Among the growths obtained by lavage or observed post mortem are mucor 
 mycelia, forms of leptothrix, thread fungi, Oidium lactis and albicans, 
 favus, and Penicillium glaucum. The symptoms are not characteristic 
 and their dependence upon the presence of fungi is uncertain. The subject 
 is of anatomical rather than of clinical importance. 
 
 5. Dietetic gastritis is of common occurrence and great clinical 
 importance. 
 
 Etiology. — Individual and family predisposition are common. Gouty 
 subjects are peculiarly liable to subacute and acute gastritis. 
 
 The exciting causes comprise excesses at table, highly seasoned foods, 
 unwholesome, indigestible, or tainted articles of food, large amounts of 
 unduly cold or hot fluid, and alcohol. 
 
 Symptoms. — Habitual sensations of weight and gastric distress char- 
 acterize the subacute forms. The more acute variety is associated with 
 colicky pain, distention, fulness, and vomiting, which are often relieved by 
 removing the offending material. In very acute cases the inflammation 
 persists with the pain, colic, and hypersecretion of mucus and gastric fluid. 
 Under such circumstances vomiting does not always afford relief. Bile 
 frequently appears in the vomited matter. The early vomitus may contain 
 undigested food, hydrochloric, lactic, and butyric acids, and have a butyric 
 odor; the subsequent vomitings consist principally of water and mucus 
 and are of a light green color. Diarrhoea may occur. Only in very severe 
 cases is there fever. The tongue is coated, the pulse and general condition 
 are usually good. Improvement commonly takes place in a few hours; 
 occasionally an attack lasts two or three days. Slight fulness in the epigas- 
 trium and tenderness on pressure over the stomach are common in severe 
 cases. Two or three days of persistent vomiting may be followed by 
 retraction of the abdomen. 
 
 Diagnosis. — Direct. — Epigastric pain, nausea, and vomiting, follow- 
 ing or referable to some indiscretion of the diet, justify a diagnosis of simple 
 acute gastritis, particularly in the absence of fever or marked general 
 symptoms. Fever, rapid pulse, and prostration, with persistent vomiting, 
 should arouse the suspicion of an acute infection, cholecystitis, or intes- 
 tinal or pyloric obstruction. 
 
 Differential. — If associated with fever at the onset, acute gastritis 
 must be differentiated from, (a) various infections, as scarlet fever, menin- 
 gitis. In acute gastritis the constitutional symptoms are less severe, 
 there is absence of local or other phenomena peculiar to the specific infec- 
 tions, less intense pyrexia, and, as a rule, early improvement, (b) Mild 
 or Abortive Enteric Fever. — Acute gastritis has a more rapid onset, an abrupt 
 rise of temperature rather than the step-like rise, and rose spots, bronchitis, 
 enlarged spleen, and diarrhoea do not occur, (c) Severe pain may suggest 
 gall-stone colic, but the pain is usually less severe; the vomiting and pain 
 of gastritis are more continuous; chilliness or a chill does not occur; and 
 the general symptoms are less pronounced. Marked icterus is absent, 
 though the possibility of an associated duodenitis with catarrhal jaundice 
 
938 MEDICAL DIAGNOSIS. 
 
 is to be borne in mind, (d) Gastric Crises of Locomotor Ataxia. — The 
 Argyll-Robertson pupil, ataxia, and loss of knee-jerks are distinctive. If 
 associated with persistent vomiting, acute gastritis must be differentiated 
 from, (e) pyloric obstruction and intestinal obstruction. In both of these 
 conditions the local signs are apt to be marked, serious general symptoms 
 are present, and the history of the condition is different. 
 
 ii. Chronic Gastritis. 
 
 Chronic Gastric Catarrh. 
 
 Definition.— Chronic inflammation of the gastric mucosa, giving rise 
 to mucus in excess and alterations in the gastric juice, associated with 
 marked disturbance of the digestion and weakening of the muscular coat. 
 
 Etiology. — In many families there is a predisposition to chronic 
 gastritis — chronic dyspepsia. Many constitutional diseases act as pre- 
 disposing factors. Careless habits of eating and drinking, and the persistent 
 use of gastric irritants are the chief causes. Chronic congestion of the 
 stomach, the result of heart disease or hepatic cirrhosis, commonly ends 
 in chronic gastritis, and most of the local gastric diseases, as cancer and 
 ulcer, bring about the same condition. 
 
 Symptoms. — Headache, drowsiness, dizziness, inaptitude for work, 
 and sallow complexion are common general symptoms. A coated tongue, 
 bad taste in the mouth, aphthous stomatitis, chronic pharyngitis are usually 
 present. A variable and capricious appetite, occasional repugnance for 
 food, burning sensations in the oesophagus and at the cardiac end of the 
 stomach — heart-burn — are early symptoms. Distress and weight in the 
 stomach, oppression, distention, and actual pain (more particularly after 
 meals), belching of gas, and eructations of bitter fluid soon occur if the 
 condition persists. Nausea may be an early symptom. Vomiting usually 
 appears late and occurs soon after eating or in the morning before food. 
 That which occurs after a meal contains mucus in excess. Undigested 
 food, indicating retention, fermentation of the carbohydrates, diminished 
 amount of free H CI and ferments (or none at all), and traces of lactic and 
 butyric acids are characteristic of delayed vomiting in rare cases. The 
 vomitus has a sour odor. That occurring early in the day is composed of 
 small amounts of thick mucus. 
 
 The Ewald test-breakfast may be below the normal amount, or, where 
 dilatation has occurred, it may be in excess. At times it is brought up with 
 difficulty owing to the thick grayish mucus. The toast or bread may 
 have passed out of the stomach completely, or it may remain in vary- 
 ing amounts mixed with mucus and poorly minced. Early in the disease 
 the free HCl may be normal in amount or even slightly increased; later it 
 is diminished or absent. Lactic acid is not usually present. Both peptic 
 digestion and the milk-curdling reaction for rennin may be absent. Further 
 proof of muscular weakness and excess of mucus follows the washing of 
 the stomach after the removal of the test-meal. The water used must 
 often be removed by suction or siphonage instead of gushing back as is 
 the case when poured into a normal stomach. It contains numerous mucus 
 
DILATATION OF THE STOMACH. 939 
 
 flakes, which accumulate in a stringy mass on the surface. Inflation often 
 shows dilatation at the lower border, reaching the level of the umbilicus. 
 
 Differential Diagnosis. — 1. Ulcer of the Stomach. — In chronic gastritis 
 the pain is less intense and more continuous, less aggravated after food, 
 and more diffuse. The decline in general health is less marked and rapid, 
 and there is absence of haematemesis or blood in the stools. A coated 
 tongue is common in chronic gastritis, while a clean red tongue is usually 
 present in the hyperacid conditions in which ulcer occurs. There is no point 
 of extreme local tenderness in chronic gastritis and no evidence of obstruc- 
 tion and muscular hypertrophy such as are sometimes demonstrable in 
 chronic ulcer. 
 
 The results of gastric analysis in chronic gastritis and peptic ulcer are 
 in strong contrast (see Gastric Ulcer). The chemical and physical condi- 
 tions of the vomitus are, however, much modified when gastritis and ulcer 
 are associated, as not rarely happens. 
 
 2. Cancer of the Stomach. — The differential diagnosis in the absence of 
 tumor is at times almost impossible. The loss of flesh and strength in 
 chronic gastritis is rarely so rapid as in cancer. A protracted course is in 
 favor of gastritis. Pain and vomiting are less marked, less persistent, and 
 more amenable to treatment in chronic gastritis than in carcinoma ventriculi. 
 For differences in the results of gastric analysis see Cancer of the Stomach. 
 
 3. Pernicious Ancemia with Gastric Symptoms. — The gastric condition is 
 usually a chronic anacid gastritis. The differentiation rests upon the compar- 
 atively rapid and extreme deterioration of health and the blood examination. 
 
 4. Gastric Neuroses. — The conditions are frequentl)^ associated. The 
 irregular dietetic . habits and despondency characteristic of neurasthenia 
 often cause chronic gastritis. Chronic gastritis is more amenable to die- 
 tetic treatment. Articles of food, such as tea, coffee, alcohol, and hot 
 stimulating drinks, which aggravate the symptoms of gastritis often allay 
 the subjective symptoms of a neurosis. Regulation and restriction of the 
 diet is usually beneficial in gastritis; not so, as a rule, in the neuroses. 
 Fermentation and consequent flatulence and belching are more pronounced 
 in gastritis; the flatulence of the neuroses is largely due to air swallowed 
 or worked into the stomach. Anaemia is more marked in chronic gastritis 
 than in the gastric neuroses. 
 
 The analysis of the stomach contents in chronic gastritis shows mucus 
 in excess, lack of free acid, and fermentative changes; in the neuroses a 
 normal or excessive acidity without mucus. 
 
 Prognosis. — Cases of chronic gastritis seen early and systematically 
 treated get well. Advanced cases are comfortable only on a non-irritating 
 diet and require continuous therapeutic management. 
 
 iii. Dilatation of the Stomach. 
 
 Gastrectasis. 
 
 Enlargement of the stomach, usually attended with weakening and 
 thinning of the various coats, and supersecretion. Acute and chronic 
 dilatations are recognized. 
 
940 MEDICAL DIAGNOSIS. 
 
 Acute Dilatation. — The etiology is not well understood. The condi- 
 tion is that of paralytic distention of the organ. Among the assigned causes 
 are local and general debilitating conditions, trauma, general anaesthesia 
 and other forms of narcotism, and dietetic errors, especially excesses in beer. 
 Post-mortem findings point to acute dilatation as a terminal condition in 
 acute illness, especially pneumonia and cardiac disease. 
 
 Symptoms. — Sudden collapse symptoms, the vomiting of enormous 
 amounts of fluid, moderate pain, and pressure symptoms from distention, 
 as dyspnoea and cardiac oppression, constitute the symptom-complex. 
 The fluid reaccumulates as fast as vomited, the pylorus remaining in a 
 condition of spasmodic closure. 
 
 Physical Signs. — The physical signs of enormous distention of the 
 stomach are present. The enlargement is often such that its true outline 
 is lost. Peristalsis is not observed. The removal of large amounts of fluid, 
 as much as eight or nine pints, by the stomach-tube and subsidence of the 
 distention are, as a rule, followed by only transient relief of symptoms. 
 This fluid is dark brown or clear and contains traces of blood and bile. 
 Its odor is foul but not fecal. HCl is present in diminished but variable 
 amounts, and there are in some cases traces of lactic acid. Constipation, 
 oliguria, and torturing thirst not easily allayed aie among the symptoms. 
 
 Diagnosis. — Direct. — Acute symptoms of collapse and oppression, 
 epigastric pain, profuse vomiting of dark or clear fluid, marked distention 
 of the stomach (the signs indicating fluid rather than gas), and the rapid 
 reaccumulation of fluid after removal are the diagnostic criteria. The 
 condition is not always recognized during life. 
 
 Differential. — Acute Obstruction of the Pylorus and Upper Duo- 
 denum. — Active peristalsis, moderate distention, and a relatively small 
 accumulation of fluid, not immediately returning after withdrawal by 
 vomiting or the tube, point to pyloric obstruction. 
 
 Acute Obstruction of the Duodenum below the Entrance of the Bile and 
 Pancreatic Ducts or of the Intestine Still Lower Down. — The presence of 
 considerable quantities of bile and pancreatic fluid in the vomitus or 
 material removed would be significant. A fecal odor in the vomitus would 
 suggest obstruction lower down. 
 
 Prognosis. — The condition is almost always fatal. 
 
 Chronic Dilatation. — Etiology. — There may be a family tendency. 
 General and gastric debilitating conditions constitute predisposing influ- 
 ences. Habitual overdistention from excesses in eating or drinking may 
 induce dilatation without pyloric obstruction being present. The 
 majority of cases arise from obstruction at the pylorus, from cancer, 
 ulcer with cicatricial contraction, adhesions to the gall-bladder, kink'ng 
 of • the duodenum, or stretching of the gastric walls already weakened 
 by chronic gastritis. 
 
 Symptoms. — The condition may exist for an indefinite period without 
 symptoms. In cases occurring independently of cancer or ulcer the loss 
 of weight and strength is less rapid and anaemia and cachexia may not be 
 present. Thirst, constipation, headache, torpor, and dizziness are common 
 symptoms. Persistent dyspepsia, flatulency, belching, eructations, nausea, 
 and eventually recurrent vomiting of large amounts of fermented undi- 
 
DILATATION OF THE STOMACH. 941 
 
 gested food characterize the course of the affection. The dyspeptic symp- 
 toms resemble those of chronic gastritis, and comprise pain and weight 
 immediately or shortly after eating, or hyperacidity four or five hours 
 after the meal. Retention vomiting is common. Pain, in the absence of 
 hyperacidity, is not usual except in carcinoma or ulcer. 
 
 Physical Signs. — Thinning of the abdominal wall is usually present 
 with the general wasting. The skin is often dry and harsh. Inspection. — 
 The abdomen may show general fulness, or the epigastrium, hypochon- 
 dria, or supra-umbilical region may be especially prominent. The stomach 
 may be distinctly outlined, its greater curvature sometimes reaching nto 
 the pelvis. Displacement of the pylorus and lesser curvature may 
 outline the whole stomach as a dilated sac lying in great part below 
 the umbilicus. Peristalsis from left to right is easily distinguished. In 
 obstructive cases it ends in the hypertrophied pylorus or tumor mass. 
 On palpation " clapotage " or splashing of fluid is readily obtained when 
 the dilatation reaches the umbilicus. The cushiony condition of the air- 
 distended stomach is readily felt. Percussion yields tympany. In the 
 erect posture the lower limit of the stomach can be determined by the 
 dulness of the contained fluid. Auscultation reveals nothing important. 
 
 Inflation with air through the tube or by COg shows distention reach- 
 ing to the umbilicus or below it. The whole stomach can often be outHned. 
 Usually, however, the outline obtained does not include the lesser curva- 
 ture. Auscultation. — The cask-like tympany produced in the distended 
 stomach by quickly compressing or relaxing the bulb of the tube, or by 
 percussing with the finger, is readily heard with the stethoscope and can 
 be followed over the whole stomach, being lost on passing the stetho- 
 scope's bell away from the immediate area of the stomach. Inflation with 
 water has no practical value. 
 
 Large bismuth meals are of service in photographing the outline of the 
 stomach by the Rontgen rays. Both recumbent and erect positions must 
 be employed. Transillumination can at best only give us the lower border 
 of the stomach. 
 
 The vomitus is variable. That of dilatation consequent upon chronic 
 gastritis shows mucus, usually absence of free HCl, marked fermentation; 
 that associated with cancer frequently has an odor of putrefaction in 
 addition to that of fermentation; the vomitus in which much free HCl is 
 present is rarely foul, the HCl acting as an antiseptic. The amount may 
 be enormous. 
 
 The test-meal removed in an hour may come away with several hun- 
 dred c.c. additional fluid. Much mucus is present in chronic gastritis. 
 The toast is poorly minced and almost wholly returned. Free HCl may be 
 present in excess, even in very advanced cases, or may be absent, as in cases 
 of cancer or gastritis. Lactic acid may be persistently present in cancer. 
 It tends, however, to disappear under systematic lavage. The weakness 
 of the gastric muscle is shown by the necessity of using suction and 
 siphonago to remove the contents of the stomach. 
 
 Diagnosis. — Direct. — Persistent dyspepsia, flatulence, eructations, and 
 vomiting of large amounts of long-retained fermented food remains are 
 suggestive. Distention, the outlining of an enlarged displaced stomach, 
 
942 MEDICAL DIAGNOSIS. 
 
 visible peristalsis, and an abnormally large amount of gastric contents after 
 a test-meal are conclusive. Inspection alone may make the diagnosis. 
 A pyloric tumor with its associated signs suggests gastrectasis. 
 
 Differential. — The anamnesis distinguishes dilatation of the stomach 
 from cystic conditions of the mesentery, gall-bladder, and ovary, and from 
 chronic dilatations of the colon. The last is not associated with "retention 
 vomiting; " it shows the intestinal outlines and peristalsis from right to left, 
 and can be reduced by passage of the rectal tube. The use of the stomach- 
 tube is of great diagnostic importance. 
 
 Prognosis. — Dilatation of the stomach, when recent and unattended 
 by obstruction at the pylorus, and not excessive, may permanently subside. 
 Many cases require systematic lavage. Operative measures are required 
 for the relief of marked dilatation with pyloric obstruction. 
 
 iv. Gastric Ulcer. 
 
 Definition. — Ulceration of the gastric mucosa in any part of its extent, 
 due to nutritional disturbance in a circumscribed region and the action of 
 the gastric juice. The necrotic areas may occur in the lower end of the 
 oesophagus and in the duodenum as low as the papilla of Vater. They 
 involve the various coats of the stomach and sometimes perforate. They 
 are usually round or oval, with clean-cut edges in the acute and irregular 
 indurated borders :'n the chronic cases. 
 
 Etiology. — Anaemia and chlorosis predispose to the affection. The 
 disease is more common in the working classes. Heredity has some influ- 
 ence. Hyperacidity of the gastric juice is usually present. Trauma or 
 large superficial burns may be direct causes. Septic cases occur. 
 
 Symptoms. — General symptoms are often absent. Loss of weight and 
 strength, and progressive anaemia, often of extreme degree, are common. 
 Constipation is usual. Simple dyspepsia, distress and fulness after eating, 
 flatulence, and belching are common symptoms. In such cases there is 
 often normal acidity. In the more severe cases the dyspepsia is more 
 intense; nausea and vomiting occurring three or four hours after eating, 
 or severe agonizing pain on taking food and lasting two or three hours or 
 more, or not beginning until the height of gastric acidity is reached, two or 
 three hours after the meal, are frequent symptoms. At times the pain 
 is gnawing in character, more marked when the stomach is empty, and 
 relieved by food. Cases of this type usually show a high degree of acidity. 
 The pain is referred to the epigastrium, often radiating to the back and 
 sides. Vomiting may give relief. Hemorrhage is common and may be the 
 first symptom. The blood may be passed either by the mouth or bowel. 
 Concealed hemorrhage may occur with characteristic symptoms. Recur- 
 rent hemorrhage may end fatally, I have seen a single profuse hemorrhage 
 followed by death in a man in apparent health. Small continued hemor- 
 rhages may only be recognized by blood tests. The testing for occult 
 blood in the stools is most important in such cases. 
 
 The symptoms may continue for years. Perforation of the stomach 
 and peritonitis may be the first clear indications of an ulcer. The local 
 symptoms in old cases with pyloric obstruction are those of gastrectasis. 
 
GASTRIC ULCER. 943 
 
 flatulence, dyspepsia, nausea, and retention vomiting. In early cases, in 
 the absence of obstruction there may be nothing to indicate disease of the 
 stomach. In others tenderness in the epigastrium, mostly acutely localized, 
 may be the onh" symptom. During the inactive stage of an ulcer near the 
 pylorus or in the duodenum temporary signs of pyloric obstruction may 
 develop. These are probably due to spasmodic closure of the pylorus and 
 the infiltration of the neighboring tissue. Fulness of the epigastrium, the 
 outline of the enlarged stomach, and visible peristalsis may be evident. 
 The thickened and hypertrophied pylorus can sometimes be felt during 
 contraction. Tenderness over the pylorus is often marked. In chronic 
 cases the physical signs indicate tumor formation due to scarring or pucker- 
 ing of the ulcerated area, thickening and muscular hypertrophy, and 
 hour-glass contraction. These are often much more manifest upon inflation. 
 
 Gastric Analysis. — The vomitus or gastric contents from the fasting 
 stomach, usually thin, watery, and light green in color, frequently contain 
 large amounts of free HCl. The gastric contents removed after the ordi- 
 nary test-meals are usually in excess of the normal and generally contain 
 some mucus and a small amount of well-mixed food residue. They show 
 a high total acidity, a high degree of free HCl, pepsin and rennin, no lactic 
 or butyric acid. Traces of blood by chemical tests are common. Under the 
 microscope small round cells and pus-cells can be demonstrated in most 
 cases when the ulceration is active. The red blood-cells are, as a rule, 
 disintegrated by the high acidity. In the older cases, the same high per- 
 centage of free HCl and hypersecretion is found, together with mucus from 
 the coexisting chronic gastritis. The vomitus in cases with obstruction is 
 sometimes of enormous quantity, containing free HCl and mucus. It is 
 acid in odor but rarely foul. The high total acidity and free HCl are 
 occasionally absent in well-marked cases of gastric ulcer. 
 
 Diagnosis. — Direct. — The diagnosis rests upon persistent dyspepsia, 
 anaemia with loss of weight and strength, marked circumscribed tender- 
 ness in the epigastrium, a high degree of gastric acidity, and occult blood 
 in the faeces, gastric contents, or vomitus. In marked cases intense 
 pain after eating, vomiting, nausea, the sudden appearance of haematem- 
 esis or tarry stools, with rapidly developing weakness and anaemia occur. 
 In long-standing cases the symptoms and signs of pyloric obstruction or 
 gastric malformation are significant. 
 
 Differential. — 1. Chronic Gastritis. — In ulcer the high degree of 
 acidity of the gastric juice, the presence of occult blood in the gastric 
 contents and faeces, the more marked tenderness or local pain are distinc- 
 tive. A well-defined haematemesis or the passage of blood per rectum is 
 conclusive. 2. Gastric Superacidity. — Loss of weight is common to both; 
 anaemia is more common in ulcer. Localized pain is more marked in ulcer; 
 nausea and vomiting, pain after eating, haematemesis, tarry stools, occult 
 blood in the faeces or gastric contents are not symptoms of superacidity. 
 Relief of pain on taking food is suggestive of simple hj'peracidity, in which 
 signs of obstruction and marked retention do not, as a rule, occur. 3. 
 Carcinoma of the Stomach. — Sudden onset with haematemesis, hemorrhage 
 from the bowels, and perforation are suggestive of ulcer. The history of 
 many years' duration is against cancer. Cachexia develops rapidly in 
 
944 MEDICAL DIAGNOSIS. 
 
 cancer, is unusual in ulcer. Haematemesis or hemorrhage from the bowels 
 is common in ulcer, as is hyperacidity of the gastric juice, while the pres- 
 ence of lactic and butyric acids is unusual. Absent or diminished free HCl 
 is common in cancer, the presence of lactic and butyric acids frequent. 
 
 The signs of a tumor are, as a rule, present early in cancer, but late 
 if at all, and associated with scar formation, in ulcer. Pyloric obstruction 
 is an early condition in cancer. 
 
 V. Cancer of the Stomach. 
 
 Carcinoma Ventricidi. 
 
 Definition. — Cancerous infiltration of the stomach walls, occurring 
 most frequently toward the pylorus and about the lesser curvature. 
 
 Etiology. — The predisposition has been thought to be hereditary. A 
 chronic gastric ulcer not infrequently becomes the seat of a carcinoma. 
 Middle and advanced life is the time of common occurrence, but there is 
 no "age of cancer." Irritation of the stomach by improper diet, injury, 
 or pressure from without have all been considered as exciting causes. 
 
 Symptoms. — Rapid anaemia, loss of strength and weight, and early 
 developing cachexia in a middle-aged person are suggestive. Persistent 
 distress in the stomach after eating or even when the stomach is empty, 
 often amounting to intense pain, is an early symptom. Nausea and ano- 
 rexia soon follow. Vomiting may be an early symptom. If there is marked 
 obstruction at the pylorus with consequent dilatation, the vomitus may 
 be of large volume and foul odor. The vomiting of altered blood (" coffee- 
 ground vomit") and passage of small amounts of blood in the stools occur. 
 Constipation is often present. 
 
 Physical Signs. — Inspection may show nothing, especially in early 
 cases. Metastasis may be seen in the supraclavicular fossa or beneath the 
 skin of the abdomen. Fulness of the epigastrium and left hypochondrium, 
 visible outline of the stomach, displaced and distended visible peristalsis 
 (usually from left to right), and distinct contracting tumor may be observed. 
 Inflation will often produce peristalsis and bring a tumor mass, not other- 
 wise recognizable, into evidence. Inflation will often show the abnormal 
 size and position of the stomach. Palpation also may reveal nothing at 
 first, especially if the tumor is posterior or adherent. Careful and repeated 
 palpation, aided by "dipping" and slapping the abdomen, may reveal the 
 presence of a new growth. Inflation aids palpation at times by bringing 
 the tumor into the field of examination. The movements of the tumor, 
 with respiration, with movements of the body, with the aortic pulsation, 
 and from the muscular contraction, should be noted. 
 
 Gastric Analysis. — Vomitus or a test-meal containing traces of blood 
 and showing no free hydrochloric acid and a lowered total acidity must 
 be regarded as suspicious in all cases. Lactic acid is usually to be found 
 in the vomitus after a mixed meal if there is any degree of stagnation, and 
 in the test-meals given in late cases. Alter a few days' lavage it diminishes 
 and may disappear. Butyric acid will be found in the vomitus under the 
 same conditions as lactic acid. Pepsin and rennin are usually to be found. 
 
HYPERTROPHIC STENOSIS OF THE PYLORUS. 945 
 
 Pieces of cancer tissue should be looked for. Oppler-Boas bacilli are 
 found more frequently in the vomitus of cancer than in any other condi- 
 tion. They disappear quickly under lavage. Pus-cells, sarcinae, yeast 
 cells, and many bacteria may be seen. Free HCl is not alwaj^s absent, 
 and may even be present in excess. With obstruction at the pylorus 
 the amount of material obtained after a test-meal will be excessive. 
 
 Diagnosis. — Direct. — Persistent dyspepsia, pain, loss of weight and 
 strength, anaemia, a tumor in the gastric area, signs of displacement and 
 dilatation of the stomach, absence of free HCl, presence of lactic acid, and 
 Oppler-Boas bacilli in the test-meal or vomitus, an excessive amount of 
 vomitus, and gastric contents with evidences of stagnation are the main 
 points in the diagnosis. 
 
 Differential. — Chronic Gastritis (see Chronic Gastritis). Pernicious 
 Ancemia. — Gastric symptoms with absence of free HCl often occur, but 
 this condition may be distinguished by the blood examination. The anaemia 
 of cancer rarely falls as low as in pernicious anaemia. The color index is 
 low in cancer. There may be a slight leucocytosis, and the presence of 
 megaloblasts is rarely noted. In general the blood picture is that of a 
 secondary anaemia. Haematemesis, tarry stools, the reaction for occult 
 blood in the faeces and gastric contents are indicative of a gastric 
 lesion. Severe Secondary Ancemia with Gastric Symptoms. — The presence 
 of lactic acid in the test-meal, the absence of free HCl, the presence 
 of a tumor, and occult or gross blood in the gastric contents and faeces 
 point to cancer. 
 
 Prognosis. — Unless an early diagnosis makes a total extirpation of 
 the tumor possible the course is steadily downward. Gastro-enterostomy 
 may be of service. Temporary improvement usually follows the institu- 
 tion of lavage in cases that have marked obstruction at the pylorus. 
 
 vi. Hypertrophic Stenosis of the Pylorus. 
 
 Definition. — Obstruction of the pylorus from hypertrophy of the 
 musculature and the submucous tissue. 
 
 Etiology. — Most of the reported cases are in infants and are congenital; 
 even those reported in adults are considered to be late developing cases. 
 The same conditions that induce pyloric spasm, namely, nervous and direct 
 irritation, are possible exciting causes. 
 
 Symptoms. — The symptoms and physical signs are those of obstruc- 
 tion at the pylorus. 
 
 Diagnosis. — Direct. — Symptoms of obstruction at the pylorus, visible 
 peristalsis, and palpable pyloric tumor occurring in infants are diagnostic 
 of the condition. In adults the condition can hardly be distinguished 
 from simple pyloric spasm. 
 
 Differential. — There is no other condition which can be confused 
 with hypertrophic stenosis in infants except pyloric spasm. Relief follow- 
 ing general and dietetic treatment would justify the diagnosis of the latter 
 affection. True hypertrophic stenosis in adults cannot always be distin- 
 guished from other forms of pyloric tumor or obstruction. It may be 
 differentiated from spasm of the pylorus by the fact that the latter is not 
 60 
 
94G MEDICAL DIAGNOSIS. 
 
 followed by permanent lesions, as tumor or dilatation. Its occurrence in 
 early infancy is against its being confounded with either cancer or ulcer. 
 In adult cases the absence of anaemia and wasting, cachexia, hemorrhage, 
 and occult blood are of diagnostic value. 
 
 vii. Tuberculosis of the Stomach. 
 
 Tuberculous ulceration of the stomach is discussed under Tuberculosis. 
 
 viii. The Gastric Neuroses. 
 
 The gastric neuroses, nervous disorders of the stomach, "nervous 
 dyspepsia, " include a host of conditions many of which are explained and 
 described by their names. With a few exceptions, which comprise the 
 nervous disorders of secretion, they are characterized by the predominance 
 of symptoms over physical signs. Disorders of sensation, secretion, and of 
 the motor function are recognized. 
 
 1. Disorders of Sensation. — (a) Gastric Hyperaesthesia. — A condi- 
 tion of oversensitiveness of the gastric mucous membrane. Etiology. — 
 The general nervous state is the predisposing influence. Any article of 
 food may be the exciting cause. Overacidity of the gastric juice in an 
 empty stomach is a frequent cause. Symptoms. — Neurasthenia or hyster- 
 ical symptoms are common; wasting or anaemia is infrequent. Gastric 
 distress, gnawing sensations, burning in the stomach immediately or shortly 
 after taking food or when the stomach is empty are the main features. 
 The sensation seems to be that of feeling the stomach doing its work. 
 Stimulants or condiments often relieve the symptoms. There is often 
 tenderness over the stomach. The gastric contents after a test-meal usually 
 yield normal results. Diagnosis. — Direct. — Hysterical or neurasthenic 
 manifestations, gastric symptoms occurring before there has been time for 
 acid to accumulate or for fermentation to begin, negative physical exami- 
 nation and negative results of the gastric analysis are suggestive. Differ- 
 ential. — Gastric Hyperacidity. — The gastric analysis sometimes shows slight 
 hyperacidity; as a rule, the analysis serves to distinguish simple hyper- 
 aesthesia from hyperacidity. The symptoms in hyperacidity develop later — 
 three to four hours after a meai. Chronic Gastritis. — The sensory S3^mp- 
 toms in some forms of chronic gastritis are practically the same but they 
 are definitely related to certain articles of diet. The gastric analysis of 
 chronic gastritis shows distinct differences (see Chronic Gastritis). Gastric 
 Ulcer. — Hyperaesthesia rarely produces anaemia or wasting. There is no 
 vomiting, no haematemesis or tarry stools, no signs of pyloric obstruction, 
 no occult blood in faeces or gastric contents, and usually no hyperacidity 
 of the gastric juice. Gastric Cancer. — Absence of anaemia and cachexia, 
 absence of vomiting, hemorrhages, gross and occult, absence of a tumor or 
 signs of dilatation and obstruction, a normal condition of the gastric juice 
 favor the diagnosis of hyperaesthesia. 
 
 Prognosis. — Recovery depends upon the course of the general ner- 
 vous condit'on. Persistence of the symptoms may reduce the patient to 
 an extreme degree. 
 
GASTRIC NEUROSES. 947 
 
 Anorexia nervosa is considered in the sections on hysteria and neuras- 
 thenia. Excessive hunger, bulimia, absence of the sense of repletion — 
 acoria — are often merely symptoms of hyperacidity. They may occur, 
 however, with a normal condition of the gastric juice. 
 
 (b) Qastralgia; Gastrodynia. — Severe paroxysmal pain in the stom- 
 ach, often pciiodic, not referable to ulcer, cancer, or organic nervous disease 
 (gastric crises of tabes) . This is often symptomatic of excessive acid secre- 
 tion. Etiology. — The predisposing influence is always neurotic. An 
 exciting cause cannot always be found, the gastralgic attacks occurring 
 more or less independently of food ingestion. Symptoms. — There are almost 
 always general nervous symptoms. Acute grinding pain in the epigastrium 
 and gastric region, which radiates to the back, is the main feature. Vomit- 
 ing is unusual. Pressure may or may not relieve the pain. Tenderness on 
 deep pressure is the rule. Diagnosis. — Acute periodic painful attacks 
 with no evidence of gastritis, ulcer, hyperacidity, or of locomotor ataxia. 
 Marked general nervous symptoms are suggestive. The differential diag- 
 nosis concerns cancer, peptic ulcer, the gastric crisis of tabes, and biliary 
 colic. Cancer and Ulcer. — The nervous symptoms and the general condi- 
 tion of the patient in gastralgia are important diagnostic points, since many 
 cases of gastralgia show absence or even excess of HCl in the gastric juice. 
 Negative occult blood-tests of the faeces and gastric material, absence of 
 anaemia and cachexia, of tumor mass and physical signs are in favor of 
 gastralgia Gastric Crisis of Tabes. — Absence of the knee-jerk and other 
 tabetic phenomena are conclusive. Gall-stone Colic. — The distinction is 
 sometimes extremely difficult, since the pain of gall-stone colic may be 
 referred to the epigastrium, subsequent jaundice may not occur, and the 
 calculus may be masked in the faeces or not passed from the duct. Prog- 
 nosis. — The prognosis in gastralgia is usually favorable. It depends upon 
 the course of the general nervous condition. 
 
 2. Disorders of Secretion. — Three main varieties are recognized: 
 supersecretion, hyperacidity of the gastric juice, and hypoacidity and 
 anacidity. 
 
 Either hyper- or hypoacidity may be associated with supersecretion; 
 hyperacidity and supersecretion is the more frequent combination. 
 
 (a) Supersecretion ; Gastrosuccorrhoea. — A condition in which excess of 
 gastric juice is secreted continuously, — Teichmann's disease, — or period- 
 ically, — Rosshach's disease; nervous gastroxynsis, — usually in association 
 with a certain degree of dilatation of the stomach from a general relaxation 
 of its muscular tone. Etiology. — General neurasthenia is the main pre- 
 disposing cause. Stimulants and tobacco are occasionally exciting causes. 
 Symptoms. — Neurasthenic symptoms are almost always present. In the 
 per'odic form there occurs suddenly the accumulation of large amounts of 
 fluid, associated usually with gnawing distress or even pain, eructations 
 or vomiting of a clear watery fluid ensue and may persist for several days. 
 The secretion is enormous and independent of food, the symptoms often 
 occurring in the early morning. If hyperacidity is present the irritation 
 of oesophagus and pharynx may occasion great distress. The continuous 
 form ends frequenth^ in dilatation of the stomach from the persistent 
 pyloric spasm so often present and the weight of the accumulating fluid 
 
948 MEDICAL DIAGNOSIS. 
 
 upon the relaxed muscles. Physical Signs. — Dipping palpation may 
 give clapotage. Percussion in the erect position may show a level of fluid 
 in a position lower than normal. The stomach-tube, passed in the morning 
 or at other times when the stomach is presumably empty, may bring away 
 as much as 200 to 300 c.c. of fluid, often highly acid from free HCl. Infla- 
 tion shows a moderate degree of dilatation. Spasm of the pylorus and 
 peristalsis may be seen and felt. The test-meal may be returned after an 
 hour with an accumulation of several hundred c.c. of a high or normal 
 degree of total acidity and with a large or normal amount of free HCl. 
 Mucus is not in excess; lactic acid is not present. In late cases of continu- 
 ous supersecretion the condition is practically that of dilatation. Diag- 
 nosis. — Direct. — The continuous or periodical presence in the stomach of 
 an excess of fluid having the above characters and its accumulation inde- 
 pendently of the stimulation of food are the main characteristics of the 
 condition. Differential: — Acute Gastritis. — Acute gastritis usually has a 
 distinct and recognizable etiology. The fluid vomited is smaller in quantity, 
 usually anacid, and contains mucus. Acute Dilatation. — In acute dilata- 
 tion the general symptoms are marked from the outset. The condition 
 is much more serious, and neither vomiting nor lavage has much effect 
 upon the course of the attack. Chronic Dilatation. — Supersecretion often 
 ends in dilatation. Simple supersecretion in its early stages, however, 
 has a different history. Retention vomiting and the physical signs of 
 marked dilatation do not occur. Prognosis. — This depends upon the 
 nervous state; as a rule it is good. 
 
 (b) Hyperacidity; Hyperchlorhydria. — Excess of free HCl in the gastric, 
 juice. Etiology. — Hysteria and general neurasthenia predispose to the 
 condition. Irregular habits of eating, stimulants, tobacco, and an 
 excess of proteid nourishment are common exciting causes. Symptoms. — 
 The general nervous symptoms of the underlying condition are present. 
 Headache, hunger, and constipation are common. Gastric hyperesthesia 
 is frequently present. Supersecretion often coexists. Gnawing distress, 
 burning, or severe pain developing two to four hours after eating, 
 relieved in turn by eating proteid food, are local symptoms. When 
 vomiting occurs the symptoms are usually relieved. The tongue is com- 
 monly clean, red, and moist, and there is epigastric tenderness. The test- 
 meal is usually expelled vigorously and in excessive quantity, as some 
 degree of supersecretion is almost always present. The digestion of the 
 starch is retarded. The total aciditj^, instead of a normal 40, may reach 
 120 or 150. Free HCl may be as high as 90 to 110. If the condition has 
 been persistent mucus may be present. Lactic acid is absent. Many round 
 epithelial cells showing mitosis may at times be seen under the micro- 
 scope. The vomitus on account of its high HCl percentage does not readily 
 ferment. Bacteria are not present in any large numbers. Meat digestion 
 can be shown to be rapid. Diagnosis. — Direct. — Distress two to four 
 hours after eating, relieved by taking food, a high degree of free acid in the 
 vomitus, and the results of the chemical examination of the gastric contents 
 constitute the basis of a direct diagnosis. Differential. — Ulcer. — Hyper- 
 acidity of the gastric juice is common in ulcer. Pain immediately after 
 eating is usual in ulcer, and vomiting is more common. Local tenderness 
 
GASTRIC NEUROSES. 949 
 
 or pain, a history of haematemesis or tarry stool, loss of weight, anaemia, 
 occult blood in gastric contents and fseces are important. The two con- 
 ditions often coexist, the ulcer being unrecognized. Laboratory methods 
 are imperatively required in doubtful cases. Cancer, with normally acid or 
 hyperacid gastric juice. The general symptoms, as loss of weight, cachexia, 
 anaemia, the persistence of local symptoms, as vomiting and pain, are dis- 
 tinctive of cancer, while occult blood in the faeces or gastric contents, or gross 
 hemorrhages are against the diagnosis of simple hyperacidity. The diag- 
 nosis may, in rare cases, be impossible until a palpable tumor is detected 
 or a dense shadow appears in the skiagram. Prognosis. — The condition 
 may last for years. Relief under appropriate treatment is the rule. 
 
 (c) Hypoacidity ; Anacidity ; Hypochlorhydria. — Conditions of the gas- 
 tric juice in which the free HCl is of low value, or lacking. Etiology. — 
 Hysteria and depressed nervous states are predisposing causes or even the 
 exciting cause. It is to be remembered that the Ewald test-meal may fail 
 to provoke much secretion. Low HCl in organic disease occurs as follows: 
 in subacute and chronic gastritis, early carcinoma, dilatation of the stom- 
 ach, and various chronic diseases of the abdominal viscera. Symptoms. — 
 Symptoms are frequently absent. Fermentation, flatulence, a feeling of 
 dulness, or other manifestations of indigestion occur. Diarrhoea, anaemia, 
 and pallor are more common than in the other secretory disorders. Local 
 signs are absent. A coated tongue is usual. Inflation reveals nothing. 
 The test-meal is brought away either as normal amount, or thick and pasty 
 from lack of fluid. Starch digestion has progressed. There is persistently 
 a low degree of free HCl, and the total acidity is also low, or there may be 
 no reaction for either acidity or free acid. Lactic acid is absent. Mucus 
 is not in excess. Pepsin and rennin are present. When the gastric secre- 
 tion is completely absent, as occurs in rare instances, the condition is 
 designated "achylia gastrica. " 
 
 Diagnosis. — Direct. — Persistent absence of free HCl, or its presence 
 in an abnormally low percentage half an hour or one and a half hours after 
 the test-meal, is suggestive. General nervous symptoms and the absence 
 of localizing gastric phenomena are important. Differential. — Chronic 
 Gastritis. — The relation of symptoms to food is more marked in gastritis. 
 Dyspeptic symptoms are more marked, vomiting and nausea more pro- 
 nounced in gastritis, and mucus in excess is common. Nervous symptoms 
 are not especially prominent in gastritis. Cancer. — In cancer constitu- 
 tional symptoms are more marked. Pain, vomiting, nausea, occult and 
 gross hemorrhages, anaemia, wasting, physical signs of tumor and dilata- 
 tion may be present. The test-meal may show no distinguishing feature. 
 The presence of lactic acid and blood is in favor of cancer. The Anacidity 
 Seen in Pernicious Ancemia. — The blood picture is the only means of 
 differentiation ; the gastric conditions are undistinguishable. 
 
 Prognosis. — The condition often persists unrelieved. Occasionally 
 the secretion of free HCl may be restored. 
 
 3. Disorders of the Motor Functions. — With one or two exceptions 
 disorders of the motor functions of the stomach are the expression of 
 hysteria or are cultivated habits. They are usually not associated with 
 gastric distress and show no physical signs or changes in the gastric juice. 
 
950 MEDICAL DIAGNOSIS. 
 
 Some of them, as rumination, peristaltic unrest, gurgling, and singultus, 
 need no special description here. Nervous vomiting, relaxation of the car- 
 diac orifice is unattended by nausea or symptoms of irritation. The ease 
 with which the gastric contents are regurgitated and the absence of the 
 signs of fermentation, hyperacidity, etc., are of diagnostic importance. 
 
 Spasm of the cardiac orifice may be differentiated from oesophageal 
 stricture by the use of oesophageal sounds and bougies. The regurgitation 
 of unaltered food, without the chemical reaction of gastric juice, is 
 characteristic of stricture or diverticula of the oesophagus. 
 
 Spasm of the pylorus is frequently associated with hyperacidity. Gas- 
 tric distention, flatulence, belching, colick}'- pain, are common associated 
 symptoms. In thin subjects the contracted pylorus can be seen and felt. 
 Visible peristalsis may occur. The diagnosis from organic disease may be 
 difficult. The good general condition of the patient, the absence of severe 
 local signs, a normal or excessive acidity of the gastric juice are in favor 
 of a neurosis 
 
 Relaxation of the pylorus occasionally occurs, the stomach emptying 
 itseK almost at once. The condition is usually discovered accidentally 
 during attempts at removing a test-meal. 
 
 Gastric Atony. — Atony of the gastric muscles is usually part of general 
 muscular relaxation seen in nervous and exhausted states. It is practi- 
 cally a condition of moderate dilatation without pyloric obstruction. 
 The coexistence of neurotic symptoms or other disease is important in 
 its recognition. 
 
 The prognosis of the motor neuroses of the stomach depends upon the 
 underlying nervous condition and is usually good. 
 
 ix. Qastroptosis. 
 
 Definition. — A prolapse of the stomach from its natural position, due 
 to stretching of its ligamentous attachments, usually associated with 
 ptosis of other organs, especially the kidneys, liver, and large intestine. 
 
 Etiology. — The predisposing influences are neurasthenic states with 
 weakened and relaxed musculature. Possibly the bad carriage and 
 slouching forward of many neurasthenics who always require "straight- 
 ening up" may be an exciting cause. Repeated pregnancies, recurring 
 ascites, stretching, relaxing, and diastasis of the abdominal muscles are 
 frequent causes. 
 
 Symptoms. — Cases in which the neurotic element is absent may show 
 no symptoms, even with the stomach far out of place. As the stomach 
 drags downward, however, kinking at the duodenum is likely to occur, 
 since duodenal ptosis does not follow to any marked degree, and symp- 
 toms of mild obstruction may develop. In the markedly neurotic, gastrop- 
 tosis once estabhshed seems to give rise to or keep in continuance many 
 general symptoms, such as faintness, weakness, continued exhaustion, 
 headache, depression, dragging pain in the back and abdomen, loss of 
 weight and strength, sallowness, and sHght anaemia. Flatulence from 
 slight obstructive kinking at the duodenum, various forms of nervous 
 dyspepsia, constipation, colicky abdominal pain are common symptoms. 
 
GASTROPTOSIS. 951 
 
 Persistence of the ptosis and obstruction, eventually causing chronic gas- 
 tritis and distinct dilatation as well, will give rise to the symptoms char- 
 acteristic of these conditions. Symptoms due to ptosis of the liver, kidneys, 
 and transverse colon are usually coexistent. 
 
 Physical Signs. — Marked relaxation and thinning of the abdominal 
 walls may be evident. If the patient lifts his head and shoulders from the 
 couch, "diastasis recti" can often be easily made out. Peristalsis of the 
 stomach or intestine is readily seen between the two flat band-like recti 
 muscles. If much flatulence is present the stomach can be seen outlined 
 and occupying the umbilical region or even reaching into the pelvis, the 
 lesser curvature falling as low as the umbilicus. Palpation shows whether 
 or not other organs, as the hver, kidneys, or spleen, are displaced, and on 
 "dipping" whether or not clapotage is present. Palpable peristalsis is not 
 as evident as in true obstructions, though the pylorus in contraction can 
 frequently be made out. The relaxation and thinning of the abdominal walls 
 is also readily appreciated by the touch. xA.uscultatory percussion yields 
 gastric tympany practically normal in outline but completely displaced 
 downward. Inflation gives characteristic results. The stomach is entirely 
 displaced downward; the cardiac portion stretched downward; the lesser 
 curvature clearly outlined about the umbilicus in more or less natural rela- 
 tionship to the greater. The stomach may show but little or no evidence 
 of dilatation. The test-meal may show normal acidity of the gastric juice 
 and normal amount of free HCl or hyperacid, hypoacid, or anacid juice. 
 There is usually some degree of retention and evidence of poor action of 
 the gastric muscles, the bread or material used not being well minced or 
 digested. Mucus may or not be present. The passage of food from the stom- 
 ach, and absorption are delayed, as can be demonstrated by the potassium 
 iodide test. 
 
 The X-ray examination is an important aid in the diagnosis of 
 gastroptosis. 
 
 Diagnosis. — Direct. — Gastric and neurasthenic symptoms, displace- 
 ment of liver and kidneys, relaxed abdominal walls, presence of the stom- 
 ach in an abnormal^ low area, the organ remaining more or less normal 
 in size and shape, the lesser curvature in the usual relation to the greater, 
 are characteristic of the condition. 
 
 Differential. — Dilatation of the Stomach. — Gastrectasis and gastrop- 
 tosis often coexist. Symptoms such as nausea, copious vomiting, thirst, 
 and wasting are significant of dilatation. So also are visible and palpable 
 peristalsis and the signs of hypertrophied musculature. In dilatation the 
 enlargement principally displaces the greater curvature downward, the 
 lesser curvature remaining more or less fixed except in the case of movable 
 tumor involving the pyloric extremity. The gastric contents removed 
 in cases of dilatation are usualh' excessive, 300-600 c.c, whereas in gastrop- 
 tosis there may be but a few c.c. more than normal. 
 
 Prognosis. — A markedly prolapsed stomach probably never returns 
 to its former position. Untreated cases usually terminate in dilatation or 
 become complicated with chronic gastritis. In many cases a surgical 
 procedure is necessary to maintain the stomach in a position to properly 
 empty itself. 
 
952 MEDICAL DIAGNOSIS. 
 
 II. DISEASES OF THE INTESTINES. 
 i. Enteritis. 
 
 Inflammation of the intestines. Any part or the whole of the gut may 
 be involved. There are important clinical and pathological distinctions 
 between inflammation of the large and of the small intestine. 
 
 Catarrhal Enteritis.- — Definition. — A disordered condition of the small 
 intestine associated with increased secretion and frequent watery or soft- 
 ened stools. Abdominal pain, mucous stools, and evidences of disordered 
 intestinal digestion occur. Acute and chronic forms are described. 
 
 Etiology. — Predisposing Influences. — Certain individuals are espe- 
 cially liable to catarrh of the bowels as a result of either dietetic or climatic 
 conditions. In women and children intestinal catarrh occurs very readily. 
 Habitual dietetic errors and chronic disease predispose to the develop- 
 ment of catarrhal enteritis. Exciting Cause. — Frequent attacks of acute 
 enteritis may lead to a chronic catarrhal condition. Unwholesome food, 
 toxic food products, certain poisons, as arsenic and mercury, nervous 
 irritability, gastric disorders, particularly hyperacidity, intestinal affections, 
 tubercular ulceration, enteric fever, excessive use of purgatives, and sud- 
 den changes from a warm to a cold temperature are exciting causes. Vari- 
 ations in the composition of the intestinal juices, arising independently 
 or due to lack of proper stimulus on the part of the gastric juice, may play 
 an important part. 
 
 Symptoms. — General symptoms, such as depression, exhaustion, 
 thirst, anorexia, nausea, are common to acute and chronic enteritis. 
 Wasting occurs very rapidly in the former, and may be accompanied 
 by fever. 
 
 Abdominal colic is more common in acute than in chronic enteritis. 
 It is apt to occur shortly after eating and is usually referred to the mid- 
 abdomen. Abdominal tenderness is commonly present. In the chronic 
 cases pain is not a conspicuous symptom. 
 
 Diarrhoea is the main feature of the disorder. It may exist as, (a) 
 frequent, watery, brownish colored, unoffensive acid movements, well 
 mixed with brownish sago-like soft mucus. The absence of fetor is largely 
 due to the fact that time for fermentation and decomposition is lacking. 
 Microscopical examination shows excess of undigested food remnants. 
 On standing such stools show gas formation and develop an intense putre- 
 factive odor. This particular form of diarrhoea usually attends the acute 
 cases, (b) Less frequent soft mushy stools, often distinctly pale and 
 putty-like (pultaceous stools), very offensive when passed. At times no 
 undue frequency is to be observed. There is an intimate mixture of fine 
 sago-like mucus. The pallor is due to undigested fat; the mucus and fine 
 gas bubbles to fermented carbohydrates. Microscopically, undigested 
 food particles are abundant. Fat droplets, fatty acid crystals^ soaps, 
 starch, meat fibres are in excess. Bile-stained epithelium and mucus can 
 be seen. The reaction is intensely acid. Gas production occurs on stand- 
 ing. Neither occult nor gross blood is to be detected in uncomplicated 
 catarrhs. 
 
ENTERITIS. 953 
 
 Fetor of the breath and a pasty tongue are common. In thin subjects 
 visible peristalsis may be seen. The pulse is usually slow. The urine is 
 diminished in amount and contains indican, very frequently also albumin 
 and casts. 
 
 Diagnosis. — Abdominal pain and tenderness, diarrhoea, the presence 
 in the movements of fine particles of bile-stained mucus and excess of undi- 
 gested food are significant. Fermentation, acidity and pallor of the stool 
 are indicative of intestinal catarrh. Occult or gross blood would indicate 
 ulcerative or hemorrhagic conditions. Large flakes or masses of mucus 
 occur in membranous enteritis. Time and the Widal reaction will distin- 
 guish the cases with fever from typhus abdominalis. 
 
 Prognosis. — In the acute cases the outlook is mostly favorable. 
 Repeated attacks of acute enteritis may end in the chronic form. 
 Even protracted cases occasionally terminate in recovery. 
 
 Phlegmonous Enteritis. — Acute suppurative inflammation of the 
 submucous tissue of the small intestine, occurring anywhere in its course, 
 either as a primary disease or as a secondary affection in various intestinal 
 accidents. 
 
 I. Primary Phlegmonous Enteritis. — A disease of very rare occurrence. 
 Etiology. — Predisposing Influences. — We know nothing of the conditions 
 likely to induce primary phlegmonous enteritis. The Exciting Cause. — 
 Acute bacterial infection by pyogenic organisms, usually the Streptococcus 
 pyogenes or the Bacillus coli communis. Symptoms. — The symptoms are 
 those of acute peritonitis. There is no definite classical picture of the 
 disease. Diarrhoea is not a necessary accompaniment. Diagnosis. — The 
 diagnosis has not been made during life. Prognosis. — The disease is 
 invariably fatal. 
 
 II. Secondary Phlegmonous Enteritis. — A condition occurring in 
 connection with various intestinal disorders. Embolism, carcinomatous 
 and tuberculous ulceration, intussusception, strangulation may be com- 
 plicated by phlegmonous enteritis. Etiology. — Predisposing Influences. — 
 The above conditions predispose. Exciting Cause. — Infection by pyogenic 
 organisms as the result of an infected embolus, thrombosis, extensive 
 ulceration, or complete obstruction of the intestine from any cause. Symp- 
 toms. — The symptoms are those of the primary disorder plus those of peri- 
 tonitis. There are no distinguishing features of the disease. Diagnosis. — 
 The symptoms of peritonitis superadded to those of the existing intestinal 
 condition may suggest phlegmon formation. The differentiation between 
 developing phlegmonous enteritis and peritonitis is not possible. The 
 PROGNOSIS is lethal. Recovery from phlegmonous inflammation does 
 not occur. 
 
 Diphtheritic Enteritis. — Definition. — An inflammatory disorder of the 
 intestine, usually secondary, associated with necrosis, ulceration, and the 
 formation of pseudomembrane. Etiology. — Predisposing Influences. — 
 Chronic diseases predispose to the affection. Cancer, Bright's disease, 
 cirrhosis of the liver may be especially mentioned. Diphtheritic enteritis 
 is frequently a terminal infection. Exciting Causes. — Acute infections, 
 as enteric fever and pneumonia, and certain poisons, as mercury, lead, and 
 arsenic, are among the exciting causes. 
 
954 MEDICAL DIAGNOSIS. 
 
 Symptoms.— The condition may exist without s3'mptoms. Thirst, 
 fetor of the breath, loss of appetite, diarrhoea, ill-defined pain, dryness of 
 the skin, and wasting are sj^mptoms when the lesions are in the small 
 intestine, tenesmus and diarrhoea when the lower bowel is involved. The 
 toxic cases usually present the very acute symptoms. The chnical picture 
 of the primary affection may completely mask the intestinal condition. 
 Fever maj' or ma}^ not be present. The disease may last for many weeks. 
 Indicanuria, increased sulphate excretion, and albuminuria are common. 
 The faeces are not characteristic. Poor digestion of all elements is evident 
 and the stools may be pale from undigested fat, frothy and fermenting 
 from the starch remnants, and intensely fetid from decomposing pro- 
 teids. Unaltered blood and pus may be present. Occult blood can 
 usually be detected. 
 
 Differential Diagnosis — Catarrhal Enteritis. — The symptoms in diph- 
 theritic enteritis are more urgent. Severe pain, bloody and purulent 
 mucoid stools suggest diphtheritic enteritis. The primarj'- infection or the 
 history of chronic or acute poisoning should arouse suspicion as to the 
 nature of the intestinal affection. Membranous or Mucous Enterocolitis. — 
 Diphtheritic enteritis is an inflammatory necrosing disease wdth a necrotic 
 fibrinous membrane formation. Mucous enterocolitis is a neurosis asso- 
 ciated with but transient if any inflammation and an increased mucus 
 formation. Diphtheritic enteritis is usually a grave disorder associated 
 with wasting and serious symptoms; mucous enterocolitis often allows 
 progressive increase of weight and strength. The stools of the latter condi- 
 tion are usually normal fecal material plus mucus. Save in an acute attack 
 blood is not present. 
 
 Prognosis. — Occurring as a terminal infection in chronic disorders diph- 
 theritic enteritis usually ends fatally. In the acute infections the primary 
 disease is the important element in prognosis. The diphtheritic enteritis 
 following the administration of poisons is always serious and often fatal. 
 
 ii. Diarrhoeal Disorders of Children. 
 
 Definition. — Acute and chronic disturbances of the gastro-intestinal 
 tract in infants, associated with diarrhoea and various clinical and patho- 
 logical conditions. They are usually the result of, (1) disordered digestion, 
 (2) absorption of toxic products, (3) acute infection. 
 
 Etiology. — Predisposing Influences. — Feeble and poorly developed 
 infants, those suffering from illness, and those nursed by ailing mothers 
 are especially predisposed to intestinal disorders. The change from breast 
 to artificial feeding, particularly in the summer months, exposes the 
 intestinal tract to infection and favors the absorption of toxins. 
 
 Exciting Causes. — Improper food, proteid or carbohydrate excess, 
 the ingestion of milk contaminated by bacteria and their products, and, 
 finally, a specific bacterial dysenteric infection through the milk, water, or 
 other means, are the exciting causes. The dysentery due to the Shiga 
 bacillus and allied organisms includes a great number of cases formerly 
 considered due to intestinal decomposition and toxaemia — probably the 
 majority of the so-called summer diarrhoeas. 
 
DIARRHCEAL DISORDERS OF CHILDREN. 955 
 
 Symptoms. — Several forms of infantile diarrhoea are recognized: 
 (1) dietetic, (2) toxic and bacterial, (3) inflammator}^, (4) chronic. 
 
 1. Dietetic. Acute Gastro=enteritis. — Fever, rapid pulse, anorexia, 
 restlessness, crying, are initial phenomena. Convulsions may occur. 
 Vomiting and diarrhoea soon ensue. The abdomen is distended, and 
 there are evidences of abdominal pain. The vomitus is not character- 
 istic. The stools, six to twelve or more in the twenty-four hours, are brown, 
 watery at first, and in the mild cases becoming greenish, offensive, with 
 green-brown mucus and fragments of undigested milk or food. In the 
 more severe cases there is an increase of fever, together wdth prostration 
 and diarrhoea and persistent offensive green acid stools. The common 
 organisms of the intestine are always present in abundance. 
 
 2. Toxic and Bacterial Diarrhoeas. — Infection or toxaemia may be 
 superadded to the dietetic gastro-enteritis. More commonly the toxic and 
 bacterial diarrhoeas occur independently, following the ingestion of infected 
 milk, or W-thout evident cause. Cholera Infantum. — The onset is abrupt and 
 characterized by convulsions, restlessness or stupor, marked prostrat on, 
 rapid wasting, and all the evidences of a severe toxaemia or infection. 
 The temperature rises rapidly to 104°-105° F. (40°-55° C.) ; thirst is pro- 
 nounced, and the skin is clammy and turgid, or inelastic and shrivelled 
 in consequence of the loss of fluids by the bowel. Death may ensue in 
 twenty-four to forty-eight hours. The bowel movements, brownish or 
 greenish at first, but soon becoming gray and watery with abundant 
 mucus and flocculi, are incessant. There is little or no odor and the 
 reaction is alkaline. Blood and pus are unusual. The Shiga and allied 
 dysentery bacilli, together with other organisms, are present in these cases. 
 
 3. Inflammatory Diarrticeas. — Either of the preceding forms may be 
 followed by a localized ulcerative dysenteric ileocolitis, or the condition 
 may be inflammatory from the start. Even though digestion and absorp- 
 tion may be little affected, the inflammatory and ulcerated condition of the 
 lower i'.eum and colon gives rise to fever, pain, tenesmus, and frequent 
 bloody or mucopurulent stools. Free pus or blood, usually from the 
 lower part of the colon, may be passed. The odor of these stools is not 
 necessarily offensive and the fecal remnants may show a fair degree of 
 digestion. The various dysentery bacilli and the Streptococcus pyogenes 
 are frequently found in these cases. Diphtheritic or membranous entero- 
 colitis is a common sequel. 
 
 4. Chronic Diarrhoea. — Repeated attacks of dietetic diarrhoea may lead 
 to chronic catarrhal enteritis. The inflammatory ileocolitis may persist 
 for months. Failure to gain weight, loss of appetite, a dry wrinkled skin, 
 nervousness, and general evidences of failing nutrition are evident. Per- 
 sistent catarrh of the upper bowel is characterized by five or six loose 
 greenish daily movements, offensive, and with excess of mucus. Undi- 
 gested food is easily detected. Fermentation from the carboh\-drates may 
 be demonstrable. The putrid odor of albuminous decomposition may be 
 recognized if the protcids are poorly digested. In chronic ileocolitis pain 
 frequently occurs upon defecation. Mucus persists in large quantities. 
 Blood and pus may be absent. The stools may have resumed their normal 
 brown yellow color. Dysentery bacilli are found in some of these cases. 
 
956 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — In most instances the diagnosis is evident. Cases with 
 persistent fever may require a Widal reaction to distinguish them from 
 typhoid. In the chronic cases the tuberculin test may help to exclude 
 intestinal tuberculosis. Bacteriological examination of the stools is neces- 
 sary to differentiate the various forms. Serum diagnosis has not yielded 
 positive results. 
 
 Prognosis. — In the dietetic forms with careful treatment the prognosis 
 is good. The acute toxic and infectious cases have always a grave prog- 
 nosis; only the strong infants survive. The prognosis in the inflammatory 
 diarrhoeas is likewise grave. If the infant survive the' acute attack there 
 is always the probability of an ensuing chronic ileocolitis. 
 
 In the chronic diarrhoeas only exceptional cases recover, and often 
 only after months. Many cases ultimately die of inanition or some acute 
 terminal infection. 
 
 iii. Ulceration of the Intestines. 
 
 1. Ulceration Restricted to the 5mall Intestine. — (a) Duodenal Ulcer; 
 Peptic Ulcer. — Non-malignant ulcer of the duodenum above the papilla of 
 Vater and of the same nature as gastric ulcer. 
 
 Etiology. — Irregular habits in regard to eating, over-indulgence in 
 alcohol, and chronic gastritis with hyperacidity are important predisposing 
 factors. The immediate cause is obscure. The etiology of duodenal ulcer 
 is the same as that of gastric ulcer, and the two conditions are frequently 
 associated. 
 
 The ulcers may be acute or chronic. The former are circular or 
 punched-out and more or less superficial; the latter often funnel-shaped, 
 with thickened, indurated, and sloping borders. Duodenal ulcers are 
 mostly near the pylorus and frequently upon the anterior wall of the gut. 
 Gradual cicatrization with stenosis and dilatation of the stomach, obstruc- 
 tion of the biliary and pancreatic ducts, hemorrhage from erosion of large 
 arterial trunks, and perforation are common. 
 
 (b) Peptic Ulcer of the Jejunum. — ^This condition occurs after gastro- 
 jejunostomy, the common site being near the point of attachment to the 
 stomach. The causes are the same as those which lead to duodenal peptic 
 ulcer. Hyperacidity plays an important role. Perforation may occur 
 with circumscribed or general peritonitis. 
 
 Symptoms. — In both its general and local symptoms duodenal ulcer 
 may be indistinguishable from gastric ulcer. Pain is less common in duo- 
 denal ulcer, and is apt to be late, occurring three to five hours after eating. 
 It is referred to the right hypochondrium. Vomiting and dyspeptic symp- 
 toms are less frequent. Hasmatemesis may never occur, the blood being 
 passed entirely by the bowel. Such hemorrhages and the resultant anaemia 
 may be the only symptoms at first of deep ulceration. There may be 
 an acutely locaHzed painful area as in gastric ulcer. The test-meal shows 
 nothing more than in gastric ulcer. Inflation and other modes of exam- 
 ination show nothing distinctive. 
 
 Diagnosis. — Sudden hemorrhage from the bowel (tarry stools) or 
 persistent evidence of blood in the stools by chemical test (occult blood), 
 
ULCERATION OF THE INTESTINES. 957 
 
 rapid or slowly progressive anaemia, pain in the right hypochondrium, 
 occurring some hours after eating, justify the suspicion of duodenal ulcer. 
 A positive diagnosis may be impossible. 
 
 Differential Diagnosis. — Gastric hyperacidity with pyloric spasm 
 and gastralgia are to be considered. The occurrence of hemorrhage, 
 gross or occult, anaemia, and the subsequent changes due to narrowing of 
 the duodenum are important. In gall-stone disease, jaundice, the absence of 
 blood in the faeces, and the paroxysmal character of the pain are suggestive. 
 
 (c) Duodenal Ulceration Following Extensive Burns of the Skin. — ^This 
 form of intestinal ulceration occurs in about 6 per cent, of all fatal 
 burns. The ulcers may be single or multiple, but rarely exceed six in num- 
 ber. The usual site is in the horizontal portion of the duodenum. They 
 are long, narrow, and irregular in outline and commonly superficial. They 
 have been found as early as the second day and as late as the third week, 
 but most frequently about the end of the first week. They are more com- 
 mon in burns of the trunk than of the limbs, and in females than males. 
 
 Various hypotheses have been advanced to explain the restriction of 
 this form of ulceration to the duodenum. Hunter assumes that, as a result 
 of the impairment of function of the skin, toxic substances capable of 
 causing ulceration of the duodenal mucous membrane are excreted with 
 the bile. Embolism of the duodenal arteries and destruction of the anti- 
 ferments in the mucous cells, with impairment of resistance to the digestive 
 power of the gastric juice, are other explanations. 
 
 2. Ulceration Peculiar to the Large Intestine. — (a) Stercoral ulcera- 
 tion of the sigmoid flexure or colon, due to pressure of impacted faeces, 
 (b) Dysenteric ulceration. 
 
 3. Ulcerative Conditions Occurring in both Small and Large lntes= 
 tines include tuberculous, malignant, syphilitic, thrombotic, embolic, 
 and simple follicular ulceration. 
 
 The ulceration of enteric fever is fully considered in the section on 
 the Infectious Diseases. 
 
 Etiology. — Predisposing Influences. — Any exhausting condition 
 and old age favor the development of simple ulceration. Tuberculous 
 or malignant ulceration may be primary or secondary. 
 
 Exciting Cause. — Pressure of the impacted faeces is the exciting 
 cause in stercoral ulcer. The swallowing of tubercle bacilli in the sputum 
 or food is the cause of primary tuberculous ulceration. The local deter- 
 mining cause of syphilitic, malignant, and many thrombotic ulcerations 
 is unknown. Embolic ulceration follows the blocking of arterial twigs 
 in the intestinal wall. The exciting cause of simple follicular ulceration 
 is often an acute toxic enterocolitis, an unchecked diarrhoea, or persistent 
 gastro-intestinal abuse. Syphilitic and tuberculous ulceration are con- 
 sidered in the section on the diagnosis of the specific infectious diseases. 
 
 Symptoms. — General symptoms ar3 wasting, anaemia, thirst, and, 
 in tuberculous and syphilitic ulceration, slight fever. Subnormal tempera- 
 ture is more frequent. The symptoms of an associated neoplasm or obstruc- 
 tion are to be considered. 
 
 A prominent symptom is persistent diarrhoea, usuall}^ painless if the 
 ulceration is in the small intestine, attended with pain and tenesmus when 
 
958 MEDICAL DIAGNOSIS. 
 
 it involves the large bowel. Abdominal tenderness is generally present. 
 Mucus, pus, and visible blood may be present in large quantities when 
 the affection is in the colon. Thin watery movements are suggestive of 
 small intestinal ulceration. Occult blood and excess of undigested food 
 are usually demonstrable in the stools. Normal digestion of food sub- 
 stances may be but little interfered with even when the process is in the 
 small bowel, and the examination of the faeces may fail to show excess of 
 food remnants. Ulceration in the ileum may be unattended by diarrhoea. 
 
 Physical Signs. — A scaphoid abdomen, palpable thickening of the trans- 
 verse colon, visible peristalsis, tenderness or pain on pressure, particularly 
 along the course of the large bowel, in some cases complete absence of tym- 
 pany may be observed. The physical signs of a neoplasm may coexist. 
 Direct inspection of the sigmoid and descending colon may show the ulcer- 
 ating area and is often the only positive proof of the existence of colonic ulcer. 
 
 Diagnosis. — Direct. — No combination of symptoms is conclusive 
 evidence of ulceration. Detection by means of the Kelly tubes is of course 
 final. The distinction of the various forms of ulceration may be impossible 
 without direct inspection of the ulcerated area. Clinically the course of 
 stercoral and follicular ulcers is usually favorable after the removal of the 
 cause; that of malignant and tuberculous ulcerations unfavorable. Ster- 
 coral ulcers are large, few in number or single, clean cut, show little or no 
 induration or inflammatory reaction. Follicular ulcerations are apt to be 
 numerous, small, and distinctly outlined. Considerable inflammation of 
 surrounding tissue is usually present. Malignant ulceration is usually 
 attended by considerable infiltration of adjacent tissues. Scrapings from 
 the surface may show characteristic microscopical findings. Tuberculous 
 ulceration of the lower bowel is unusual. The tuberculous ulcer is dis- 
 tinctly marked; tubercles may be seen. Scrapings may show tubercle 
 bacilli, giant cells, or characteristic microscopical tubercles. Amoebae coli 
 are present in the faeces in the ulceration of amoebic dysentery. 
 
 Differential. — Acute and Chronic Intestinal Catarrh. — The persist- 
 ence of the symptoms, the more marked wasting, anaemia, and cachexia 
 suggest ulceration. Direct examination by means of specula affords, in 
 many cases, the only sure means of differentiation. The presence of 
 small tissue fragments in the faeces is evidence of ulceration. Occult 
 blood may be present in both conditions. The Intestinal Neuroses. — The 
 more serious general symptoms, the presence of blood, mucus, and pus, 
 and direct examination of the bowel are of diagnostic value. 
 
 Prognosis. — The outlook is usually favorable in stercoral and follic- 
 ular ulceration. The course of malignant and tubercular disease of the 
 bowel is usually uninfluenced by treatment. The prognosis in syphilitic, 
 thrombotic, and embolic ulcerations is uncertain. The majority of such 
 conditions are only recognized post mortem. 
 
 iv. Intestinal Stenosis and Obstruction. 
 
 Narrowing and occlusion of the lumen of the intestine due to a variety 
 of causes, and occurring anywhere in the course of the bowel from the 
 pylorus to the rectum. 
 
INTESTINAL STENOSIS AND OBSTRUCTION. 959 
 
 1. Stenosis or Incomplete Obstruction. — Etiology. — Predisposing 
 Influences. — Previous acute inflammatory conditions and malignant 
 disease are the most important. Women, for obvious reasons, are espe- 
 cially predisposed to intestinal stenosis; their greater liability to enterop- 
 tosis also increases their liability to stenosis from the kinking or twisting 
 of misplaced intestines. 
 
 Exciting Causes. — The direct causes are many and may be 
 enumerated according to the location of the narrowing. In the small 
 intestine the cicatrices of duodenal ulcers, gall-bladder and common bile- 
 duct disease, diseases of the head of the pancreas, cancer of the duodenum, 
 jejunum, or ileum, omental and peritoneal adhesions, and accidents, as 
 hernia, adhesions or compression caused by new growths, and involvement 
 of the gut in inflammatory diseases of the appendix or pelvic organs are 
 the most common causes. In the large intestine peritoneal and appen- 
 dicular adhesion, adhesions to the gall-bladder, adhesions to and com- 
 pression by pelvic tumors are common causes of stenosis. Cicatricial 
 narrowing following dysenteric and stercoraceous ulceration is an occa- 
 sional cause. Tuberculous ulceration of the large bowel is less often followed 
 by stenosis, while syphilis of the rectum, with ulceration and resulting 
 narrowing, is a frequent cause. Cancerous invasion of the rectum and sig- 
 moid flexui'e is one of the most common causes of intestinal stenosis. 
 
 Symptoms. — General. — General symptoms in intestinal stenosis may 
 depend upon the cause more than upon the narrowing of the bowel. 
 Anaemia, wasting, and loss of appetite occur early in cancerous stricture 
 and in tuberculous and syphilitic disease, whether the stenosis is of extreme 
 grade or not. In the mechanical stenosis due to pressure and adhesions, 
 unless they are near enough to the stomach to cause early dilatation 
 and vomiting, wasting may not occur and anaemia may be long absent. 
 Mental and physical depression are usually marked in persistent stenosis. 
 Thirst is a common symptom; oliguria occurs. 
 
 Local Symptoms. — ^The situation is important. The fluid contents 
 of the upper bowel may be easily forced through an opening which would 
 be occluded or readily obstructed by the solid faeces of the lower bowel. 
 Stenosis above the ileum sooner or later produces a dilatation of the 
 stomach with marked local gastric symptoms. Stenosis in the colon is 
 likely to be attended by constipation, a symptom not common in narrow- 
 ing at a higher level. Finally, tenesmus and intensely painful muscular 
 contractions are limited to stenoses of the large bowel. 
 
 Stenosis of the Duodenum and Jejunum. — Distention after eating, 
 eructations, gradually increasing and persistent nausea, and finally vomit- 
 ing are common local symptoms. Persistent biliary vomiting suggests 
 stenosis below the papilla of Vater, while symptoms of disturbed hepatic 
 and pancreatic function occur when the common and pancreatic ducts 
 are involved in the lesion causing obstruction. Painful contractions of 
 the intestine are not usual in stenosis of the upper parts of the small intes- 
 tine. The vomitus is that of gastric dilatation; it is not fecal. Bile is 
 present under the conditions just mentioned. Pancreatic ferments maj' 
 be recognized. Blood tests may be positive if ulceration exists. The 
 faeces are not distinctive. Associated occlusion of the bile and pancreatic 
 
960 MEDICAL DIAGNOSIS. 
 
 ducts may show unabsorbed fat and undigested proteids, and carbohy- 
 drates in excess. Blood tests will be positive if there is ulceration. 
 
 Stenosis of the Ileum. — Distention following the intake of food is less 
 common. The stomach is not usually dilated. Nausea and vomiting 
 of gastric and intestinal contents occur, but not continuously. Stenosis 
 situated low in the ileum may be associated with a slightly fecal smelling 
 vomitus. Painful contractions of the bowel do not often occur, but in 
 some cases persistent crampy pain with moderate distention is the only 
 symptom. Many ileal stenoses never reveal themselves till a sudden 
 occlusion produces an acute obstruction. 
 
 Stenosis of the Large Bowel. — Distention of extreme degree may be 
 present, particularly if the stenosis is very low. Constipation is the rule, 
 or constipation alternating with diarrhoea. Vomiting occurs occasionally, 
 but is only fecal when it has persisted for some hours and acute obstruc- 
 tive symptoms have supervened. Tenesmus and painful muscular con- 
 tractions of a periodic type are characteristic of lower bowel stenosis. 
 With ulceration blood is present in the faeces. There is, however, no 
 characteristic stool in stenosis of the lower bowel. 
 
 Physical Signs. — Inspection. — The existence of ansemia and cachexia, 
 and wasting are to be noted. Marked distention is often apparent 
 in stenosis of the large bowel. Stenosis of the small bowel is less apt 
 to give rise to extreme distention. A distended stomach may be 
 apparent in cases of duodenal stenosis. Inspection frequently shows a 
 tense intestinal tube (intestinal rigidity) or several, one above the other 
 (ladder pattern), and these rigid distended parts may further show 
 energetic peristaltic movements running up to and ending in the obstruc- 
 tion and sometimes bringing a stenosing tumor into view. The colon or 
 its sigmoid flexure may be clearly outlined. The latter may occupy the 
 whole abdomen. Inspection may also reveal tumors, a protruding hernia, 
 fulness in the hernial tracts^ and the scars of abdominal operations which 
 suggest adhesions or constricting bands. Palpation. — The rigidity of 
 an intestinal tube above a stenosis is easily appreciated. Peristalsis with 
 muscular hypertrophy and a stenosing tumor of the bowel may be felt. 
 Abdominal tumor, hernia, adherent scars, and the like can be readily 
 examined. Percussion is of limited value. Auscultation, beyond 
 allowing us to hear fluids trickling through an aperture and to conclude 
 that it is still patent, does not afford any aid in diagnosis. 
 
 Inflation of the stomach in the endeavor to determine duodenal steno- 
 sis gives no clear result. Inflation of the large bowel may, in thin subjects, 
 reveal a stenosis in the upper part of the sigmoid flexure. Stenosis of the 
 descending colon or transverse colon may become evident, but as a general 
 rule the natural distention above the stenosis is more distinctive. Rectal 
 examination in intestinal stenosis may reveal the occluding mass of a pel- 
 vic tumor, narrowing of the. anus and lower rectum due to stricture, or 
 the rough, hardened, ulcerating edges of a malignant growth. Vaginal 
 examination may at times reveal palpable tumors or stenosing condi- 
 tions in the pelvis or adjoining intestines. Proctoscopic and sigmoido- 
 scoPic examination will show the presence of stenosing conditions, 
 cicatrizing ulcers, syphilitic or fibroid stricture, or the narrowing of the 
 
INTESTINAL STENOSIS AND OBSTRUCTION. 961 
 
 intestinal tube from outside pressure. The X-rays after bismuth injec- 
 tion or ingestion may yield important diagnostic facts. A well-outlined 
 sigmoid or colon may show acute kinking, a tumor, or constriction 
 preventing the passage of the bismuth beyond a certain point even 
 after many hours. Less accurate information must be expected in 
 stenosis of the small intestine. 
 
 Diagnosis. — Direct. — Distention, abdominal pain, cramp-colic, tenes- 
 mus, constipation, or alternating diarrhoea suggest stenosis of the large 
 bowel. Persistent gastric symptoms and gastrectasis, recurrent vomiting 
 with no evidence of pyloric tumor or pyloric obstruction, and continuous 
 biliary vomiting direct attention to the small bowel as the seat of trouble. 
 The recognition of an intestinal tumor, the appearance of intestinal rigidity, 
 intestinal patterns, visible peristalsis, and visible and palpable muscular 
 hypertrophy make the diagnosis sure. Fecal vomiting, which usually 
 indicates that the condition has passed from stenosis to complete 
 obstruction, localizes the obstruction a very short distance either above 
 or below the ileocsecal valve. 
 
 Differential. — Nervous Dyspepsia, Nervous Flatulence and Vomiting, 
 Enteralgia. — Gastric dilatation as seen in duodenal stenosis, intestinal 
 rigidity, intestinal patterns, and visible and palpable intestinal peristalsis 
 do not occur in the neuroses. Vomiting in the neuroses is easy, 
 is apt to occur immediately after eating, and the vomitus is usually 
 undigested, odorless food. General symptoms with the exception of wast- 
 ing are less marked. Lead Colic. — ^The diagnosis may be impossible, since 
 temporary stenosis undoubtedly takes place during the spasmodic con- 
 traction. Marked anaemia, with the early symptoms of intestinal disorder, 
 and a blue line on the gums may be the only distinguishing features. 
 Persistent Vomiting of Alcoholism, Locomotor Ataxia, Gastroxynsis. — In these 
 conditions the general symptoms are practically absent. The history is 
 different, and in tabes characteristic ocular and nervous phenomena are 
 present. The vomitus in these conditions consists of mucus and a watery 
 gastric secretion, and never contains food remnants or has a fecal odor, no 
 matter how persistent and profuse it may be. Distention of the Intes- 
 tines (Paretic Distention) of Acute Fever; Idiopathic Dilatation of the Colon. 
 — In these conditions stenosis, pain, coHc, complete constipation, and 
 vomiting are absent, though faint visible peristaltic and intestinal pat- 
 terns may sometimes be seen. Obstruction hypertrophy and palpable 
 muscular contraction do not occur. 
 
 Prognosis. — The prognosis depends upon the cause of the stenosis. 
 Cancerous stenosis, unless a diagnosis has been made in time to allow 
 resection, is fatal. Any simple stenosis may terminate suddenly in a fatal 
 obstruction, but the majority can be reheved by operation. 
 
 2. Complete Obstruction. — Many chronic stenoses end in acute 
 obstruction. Various accidents, strangulation, twistings of the bowel, 
 volvulus, etc., produce the same results — complete occlusion of the 
 bowel, the retention of flatus and intestinal contents, and the sudden 
 development of serious symptoms. 
 
 Etiology. — Predisposing Causes. — Chronic Stenosis. — Bands of adhe- 
 sion and open hernial canals constitute predisposing factors. 
 
 61 
 
962 MEDICAL DIAGNOSIS. 
 
 Exciting Causes. — Excesses at table or accumulation of the residua 
 of coarse food or of other material may suddenly block the narrowed gut. 
 Twisting of the bowel, various hernial accidents, and intussusception 
 are immediate causes. The settling of a large pelvic tumor is a not 
 uncommon direct cause of acute obstruction. Foreign bodies, gall-stones, 
 accumulation of parasites, and impaction of faeces are also direct causes. 
 Almost any acute abdominal inflammation may give rise to acute 
 obstruction. 
 
 Symptoms. — The general symptoms are marked and severe. In simple 
 stenosis, so long as a narrowed opening remains patent, general symp- 
 toms may be absent. Large collections of fecal material may accumulate 
 without causing marked discomfort, but the moment the obstruction 
 becomes complete serious symptoms supervene. Rise in the pulse- 
 rate, increased vascular tension, slight elevation of temperature followed 
 by the signs of prostration and collapse, pallor, sweating, facies abdom- 
 inalis, thready pulse, and shallow respiration constitute a symptom-com- 
 plex at once alarming and significant. Thirst and oliguria are constant, 
 intense grinding pain, eructations, nausea, and persistent vomiting, at first of 
 gastric juice, later of gastric fluid commingled with bile or intestinal con- 
 tents and bile, and, when the obstruction is below the ileocsecal valve, of 
 distinctly fecal material, speedily occur. The vomitus in obstruction of the 
 lower ileum may have a faintly fecal odor. Distention is a constant phe- 
 nomenon and is more marked the lower the obstruction. Volvulus and 
 intussusception may be accompanied by the passage of blood, and in sigmoid 
 obstruction tenesmus with bloody mucous discharges occur. Neither faeces 
 nor flatus are passed per rectum. In unrelieved cases peritonitis rapidly 
 develops with intestinal paresis, generalized pain, and marked meteorism. 
 
 Diagnosis. — Direct. — Grave general symptoms, abdominal pain 
 with intense exacerbations, tenesmus, nausea, eructations, persistent 
 vomiting eventually becoming of a fecal character, absolute failure to 
 pass flatus and faeces, distention, intestinal patterns, rigidity, and tumefac- 
 tion of the intestine as the contraction reaches the obstruction are the 
 main diagnostic features. Changes in the urine such as the appearance of 
 excess of sulphates (indican) are not diagnostic. Leucocytosis is not 
 constant and therefore not an important diagnostic feature. 
 
 Differential. — There are but few conditions which simulate acute 
 obstruction. Thrombosis of the mesenteric vessels, acute pancreatitis, and 
 acute enteritis with relaxation of the intestinal coils, pain, and vomiting, 
 may be mentioned. The absence of intestinal patterns, rigidity, and visible 
 and palpable peristalsis are of value in differentiating these conditions 
 from acute obstruction in cases seen prior to the development of peri- 
 tonitis and paralytic distention. Acute appendicitis with peritonitis may 
 closely resemble acute obstruction. A history of attacks of pain in the 
 region of the appendix is often obtained. The diagnosis may be difficult. 
 Spontaneous relief is rare. Early surgical intervention is imperative. 
 In neglected cases death ensues in the course of three to six days. 
 
 Obstruction of the large bowel from accumulation of hardened faeces 
 is rarely complete. Fecal obstruction can be differentiated from stenosis 
 due to other causes by the recognition of the accumulated masses, the 
 
DILATATION OF THE INTESTINES. 963 
 
 comparative mildness of the general and local symptoms, the absence of 
 marked visible and palpable intestinal peristalsis, and the relief afforded 
 by judicious therapeutic measures. 
 
 V. Dilatation of the Intestines — Idiopathic Dilatation of 
 
 the Colon. 
 
 Definition. — Chronic dilatation of the colon and sigmoid flexure, not 
 due to stricture or accumulation of faeces. 
 
 Etiology. — Predisposing causes are unknown. A history of chronic 
 constipation is usually obtained. The condition usually occurs in quite 
 young persons and children. The pseudocyesis of middle-aged women 
 depends largely upon dilatation of the colon and sigmoid flexure. 
 
 Exciting Causes. — Fecal accumulation plus paretic distention of the 
 bowel occurring repeatedly produces the condition. Spasmodic contraction 
 of the rectum must coexist. Idiopathic dilatation due to structural 
 abnormalities is a probable cause. 
 
 Symptoms. — The general health may be but little affected. Acute 
 symptoms rarely occur. Extreme distention gives rise to respiratory and 
 cardiac oppression. Constipation is the rule, but diarrhoea occurs. The 
 most prominent symptom is distention. Pain, colic, and obstructive 
 symptoms are absent. The distress that accompanies distention of the 
 small intestine is not observed in idiopathic dilatation of the colon. Enor- 
 mous distention of the abdomen, thinning of the abdominal walls, the 
 presence of linese atropicae, and glazing of the skin are seen. With 
 marked wasting of the abdominal walls the outline of the sigmoid flexure 
 rising from the pelvis and reaching to the costal margin, or the outline 
 of the colon, can be made out. Peristalsis is not pronounced. Palpation 
 shows the distention to be gaseous. No resistance or solidity is felt; no 
 fluctuation wave obtained. Percussion gives a marked tympany every- 
 where, even in the loins up to the base of the lungs behind, and often 
 shows an obliteration of the liver dulness in front. The passage of a soft 
 rubber tube into the sigmoid flexure relieves distention by allowing the 
 exit of air and shows what part of the bowel is affected. Reinflation 
 through the tube produces a gradual ballooning and outlining of the sig- 
 moid or colon. Examination by means of the speculum shows merely the 
 relaxed condition of the colon when the air is expelled. 
 
 Diagnosis. — Direct. — The absence of serious local and general symp- 
 toms, constipation, extreme chronic distention with outlining of the sigmoid 
 or parts of the colon, the disappearance of distention on passing the rectal 
 tube, and the results of inflation are characteristic. 
 
 Differential. — The genera! symptoms and the relief of the disten- 
 tion by the tube differentiate dilatation of the colon horn gastredasis. 
 The shape and position of the stomach are radically different. Distention 
 of the Small Intestine due to Obstruction or Paretic Conditions of the Mus- 
 culature. — The general symptoms of disease of the small intestine are more 
 marked. Intestinal patterns are smaller and more numerous; peristalsis 
 (save in paretic distention) may be seen. Distention of the Large Bowel 
 due to Stricture, Malignant Growth, etc. — The distention due to obstruction 
 
964 MEDICAL DIAGNOSIS. 
 
 is associated with signs of associated muscular hypertrophy. Visible or 
 palpable active peristalsis, pain, and colic are common. General symp- 
 toms rapidly develop. The obstruction can often be recognized by the 
 speculum or examining finger, or upon palpation through the abdominal 
 wall. Fluid Accumulations. — Bulging of the flanks, movable dulness on 
 turning, fluctuation wave, flatness on percussion readily distinguish fluid 
 accumulation from gaseous distention. 
 
 Prognosis. — The disease in itself is rarely fatal. In the idiopathic 
 cases death commonly occurs early in life. General treatment has 
 little effect. Removal of the distended sections of the colon and 
 sigmoid flexure has been tried. 
 
 vi. Appendicitis. 
 
 Definition. — Inflammation of the vermiform appendix. 
 
 The conception of appendicitis is a modern one, dating from the 
 studies of Reginald Fitz (1886). It includes and explains the facts relat- 
 ing to foreign bodies in the appendix; catarrhal, diffuse, purulent, and 
 necrotic inflammation of that organ; ulceration, gangrene, cyst formation, 
 and abscess of the appendix; chronic, recurrent, and obliterative inflam- 
 mation; peri-appendicular abscess, typhlitis, perityphlitis, and iliac phleg- 
 mon; and local and general peritonitis having its starting-point in the 
 ileocsecal region. 
 
 These conditions constitute phases in the evolution of a single proc- 
 ess — appendicitis. The central fact is infection of the appendix. 
 
 The infection may be a local manifestation of a general infection, as, 
 for example, influenza or pneumonia; or a purely local process, as in the 
 case of foreign bodies, fecal concretions, the extensions of an inflammation 
 from the caecum, or when injury to the appendix results from strains or 
 blows; and finally the infection may be associated with a specific local 
 lesion in a general disease, as when typhoid ulceration involves the lymph 
 tissue in the appendix. Kelynak (1903) suggested that acute appendicitis 
 is a metastatic inflammation arising from a distant primary focus of 
 infection. Other observers, notably Apolant and Kretz, have recently 
 advanced the opinion that ''appendicitis begins as a metastatic disease 
 of the adenoid tissue, and that the lymphatic apparatus of the throat 
 and nose is to be regarded as the most frequent primary localization and 
 portal of entry of the infection." The recognition of the unity of the 
 process under varying etiological conditions and in varying clinicopatho- 
 logical manifestations is the key to its diagnosis and treatment. 
 
 Etiology. — Predisposing Influences. — Appendicitis is the most 
 important and one of the most common of the acute diseases of the intes- 
 tine. There are no especial causal relations connected with country, race, 
 social conditions, or occupation, save that it has been held that those whose 
 occupations involve habitual strain and heavy lifting suffer more com- 
 monly than others. About half the cases occur before the twentieth year. 
 It is rare in infancy but common in childhood and adolescence. Cases 
 have been observed as late as the seventh and eighth decades. It is equally 
 common in the two sexes. The symptoms have occasionally followed a 
 
APPENDICITIS. 965 
 
 fall or blow upon the abdomen. Indiscretion in diet, especially over- 
 eating, and exposure to cold and fatigue are conditions frequently 
 mentioned in the anamnesis. The acute infections, in particular influ- 
 enza, pneumonia, and rheumatic fever, sometimes are attended with or 
 followed by appendicitis. A majority of the cases, however, arise in 
 ordinary health without any obvious or discernible determining cause. 
 Two or three cases in the same house at or about the same time have 
 occasionally been observed. 
 
 The Exciting Cause. — Various pyogenic organisms have been found 
 in the early lesions, among which Bacterium coli communis and Strepto- 
 coccus pyogenes are common. A lesion of the mucosa, caused by the pres- 
 ence of a foreign body, fecal concretions, retained secretions, or traumatism, 
 probably constitutes the point of entrance for pathogenic bacteria. 
 
 Nature of the Pathological Process. — The character of the lesions is 
 determined by the intensity of the infection and the reaction of the tissues 
 involved. Broadly speaking, the lapse of time between the onset of the 
 attack and the condition at any given hour has a most important bearing 
 upon the anatomical diagnosis; that is to say, the early lesions are 
 relatively simple and limited, the later complex and extensive. But to 
 this rule there are many exceptions. In a large group of cases, the so- 
 called catarrhal cases, the inflammation runs a favorable course, resolu- 
 tion takes place in a short time, and in a few days the patient is conva- 
 lescent. But the recovery is by no means always complete in the sense of 
 an anatomical restitutio ad integrarn. The inflammation subsides but the 
 appendix remains infected and lesions of a chronic and progressive nature 
 persist- — infiltrations of the mucosa and submucosa, connective-tissue 
 overgrowth, local atrophies involving especially the longitudinal and cir- 
 cular muscular fibres, stricture-like narrowings, retained secretions, cyst 
 formation, angular kinking, adhesions, and other deformities. It is in such 
 cases that the teasing pains known as appendicular colic occur, in which 
 there is persistent discomfort and frequent tenderness in the right lower 
 quadrant, in which inflammatory flare-ups recur, and in which at any 
 time necrosis, perforation, abscess formation, or general peritonitis may 
 suddenly arise. They constitute the cases of so-called recurrent appendi- 
 citis, an unfortunate and misleading term since this form of the disease 
 is in point of fact essentially chronic with occasional exacerbations — a 
 smouldering fire with now and then an ominous puff of flame. On the 
 other hand there are cases in which the symptoms of onset are urgent, 
 and necrosis and perforation follow in the course of a few hours. Many 
 of the cases, however, make a substantive recovery and live on without 
 subsequent attacks. Others, which constitute a large proportion of all 
 cases, go on more or less rapidly from bad to worse, terminating in abscess 
 formation and chronic invalidism, or general peritonitis and death. 
 
 The natural history of appendicitis is indicated in the following table. 
 
 The course of the attack may be interrupted and in a majority of the 
 cases its more serious events and unfavorable terminations arrested by 
 early surgical intervention. 
 
 Symptoms. — The significance of the clinical phenomena becomes more 
 apparent from a careful consideration of the following pathological data: 
 
966 
 
 MEDICAL DIAGNOSIS. 
 
 
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APPENDICITIS. 967 
 
 Catarrhal inflammation of the appendix may be acute, subacute, or 
 chronic. The mucosa is slightly involved, being s-wollen, injected, and 
 the seat of an increased secretion. Inflammatory thickening may cause 
 retention of the secretion and persistence of the infection. In the subacute 
 form symptoms may be absent. In the acute form they are of variable 
 intensity, consisting of pain and tenderness in the right lower quadrant of 
 the abdomen, together with loss of appetite, nausea, and occasional fever, 
 which is usually of slight intensity and brief duration. In the chronic form 
 there is persistent tenderness with a sense of thickening upon deep palpa- 
 tion, vague and often intractable gastro-intestinal symptoms, neurasthenia, 
 and in some instances an associated mucous colitis. 
 
 Acute diffuse inflammation is more common. The infection extends 
 from the mucosa to the deeper structures. There is inflammatory thick- 
 ening and hypersemia which involves the serous investment. Erosion and 
 ulceration of the mucosa are common. The symptoms are more severe 
 than in the acute form and the duration of the attack is prolonged. 
 
 Acute suppurative inflammation may supervene. There may be 
 purulent infiltration of the wall of the organ, or the lumen may be occluded 
 so that the pus distal to the stricture forms an abscess cavity. The symp- 
 toms are now more severe and a mass may be felt through the abdominal 
 wall. An extension of the purulent infection or a small perforation may 
 be followed by peri-appendicular suppuration and cause a distinct fluc- 
 tuating tumor. Septic phenomena are often present, as irregular fever, 
 sweating, rapidly developing anaemia, and gastro-intestinal symptoms, 
 especially nausea and vomiting. In many of the cases, however, these 
 symptoms do not occur. Fever in particular may be wholly absent. 
 
 Ulceration may follow catarrhal or diffuse inflammation and cause 
 more or less extensive subacute local peritonitis with adhesions. More 
 rarely it may cause perforation with abscess formation. The lesion 
 advances slowly and is far less likely than gangrene to cause general 
 peritonitis. There are no special symptoms of ulceration other than those 
 ■due to the subacute circumscribed adhesive peritonitis which it causes, 
 namely, local pain, tenderness, rigidity, and a more or less well-defined 
 tumor mass. 
 
 Gangrene is common. It may occur in the course of a few hours after 
 the symptoms of onset. In a case in which pain was first felt after the bath 
 at eight in the morning, the whole appendix was found necrotic upon 
 operation at five in the afternoon. Instances of this kind are by no 
 means exceptional. More commonly gangrene takes place, in unrecognized 
 cases or those in which operation is refused, in two or three days or later. 
 
 The necrotic process may involve the tip, or a circumscribed patch, 
 or the entire organ, or it may be confined to the region of its attachment 
 to the caecum. The appendix may slough off and be found loose in the 
 pus of an appendicular abscess. When the necrotic tip has previously 
 become adherent to a neighboring hollow organ, as the colon or bladder, 
 a fistulous communication may be found. The appendix has in some 
 instances perforated into a hernial sac. The necrosis has occasionally 
 involved the wall of an artery, as one of the iliacs, to which adhesions 
 have formed, and led to fatal hemorrhage. Perforation, which only 
 
968 MEDICAL DIAGNOSIS. 
 
 occasionally occurs in the acute diffuse and suppurative forms, is the usual 
 outcome of the gangrenous variety. The opening is commonly single, 
 but multiple perforations may occur. When previously formed adhesions 
 confine the escaping contents of the appendix, an abscess is found which 
 varies in size and may, in the absence of operation, ultimately discharge 
 into the bowel or bladder, vagina, or externally. 
 
 Chronic appendicitis constitutes a common condition when the acute 
 symptoms subside without operation. The appendix may be thickened 
 and deformed, adherent to the gut, or embedded in a mass of irregularly 
 puckered peritoneal adhesions. Its lumen may be more or less completely 
 obliterated, or it may be converted into a series of cysts separated by 
 stricture-like occlusions, or, finally, it may contain foreign bodies or fecal 
 concretions. There are cases in which no symptoms are present, but it is 
 more common to find occasional pain, persistent tenderness, and intestinal 
 symptoms. When acute exacerbations of these symptoms occur the 
 condition is known as recurrent appendicitis, falsely so called. 
 
 In another group of cases chronic appendicitis takes the form of a 
 progressive primary fibrosis, a progressive involution process, not char- 
 acterized by symptoms and terminating in complete atrophy of the organ. 
 
 The bodies found in the lumen of the inflamed appendix are, as a rule, 
 to which there are few exceptions, fecal in character. The pus varies in 
 amount and consistence. It may be soft and easily expressed, or consist 
 of dense, compact masses resembling date-stones or grape seeds. A series 
 of three or even more such masses may occupy the canal of the appendix. 
 Sometimes there is only one, which is short and rounded, or elongated and 
 curved. Of foreign bodies the most common are pins. 
 
 The symptom-complex of acute appendicitis is most variable. Cer- 
 tain symptoms are, however, suggestive, their association significant. 
 The chief of these are pain, tenderness, and gastro-intestinal disturbance. 
 Of subordinate importance are fever, muscular rigidity, deep induration, 
 and leucocytosis. We cannot be satisfied with an affirmative reply to the 
 question: Has this patient appendicitis? We must ask ourselves further: 
 What stage in its evolution has the process reached? Is the appendix 
 alone affected? Are there signs of abscess formation? Is there local 
 adhesive peritonitis without or with pus? Are there signs of a beginning 
 general peritonitis? In other words. What are the lesions? 
 
 1. Pain. — The pain is usually sudden, mostly severe. It is some- 
 times sharp and stitch-like; sometimes dulj. and aching. It is often coliclcy; 
 almost always continuous with exacerbations. It is usually referred to the 
 right lower quadrant of the abdomen, but may be diffuse or central. In 
 the chronic cases a diffuse central pain is very often present for weeks or 
 months before the pain in the right iliac fossa is felt. It may be referred 
 to the region of the gall-bladder or to the right lumbar region, or extend 
 in these directions; or it may extend in a similar way to the perineum or 
 right testicle. Under these circumstances the pain of appendicitis has been 
 mistaken for biliary or renal colic. These referred pains have been ascribed 
 to the position of the appendix, which has been found in some instances 
 elongated in the direction of the liver or kidney, in others downwards 
 into the pelvis. 
 
APPENDICITIS. 969 
 
 2. Tenderness. — Firm, deep pressure over the affected area usually 
 causes pain. A circumscribed spot situated at the intersection of a line 
 drawn from the umbilicus to the anterior superior spine of the ilium 
 and a second line corresponding to the outer border of the right rectus 
 muscle, first described by McBurney and known as McBurney's point, is 
 in well-marked cases decidedly, even exquisitely, tender to the pressure of 
 a single finger. Deep pressure with the open hand upon the left side of the 
 abdomen frequently causes or aggravates the pain in the right iliac fossa. 
 The patients usually assume the dorsal decubitus with the right knee 
 flexed, and pain is elicited or increased by extending the limb. 
 
 3. Gastro-intestinal Symptoms. — There are loss of appetite, 
 thirst, nausea, and very often vomiting which ceases in the course of some 
 hours. Constipation is the rule. Diarrhoea occasionally occurs in cliildren. 
 The patients are often able to recall the eating of an unusually hearty 
 meal or some indigestible article of diet, or undue exertion or exposure 
 after food, and attribute pain and tenderness to indigestion or coUc or a 
 bilious attack. 
 
 4. Fever. — An initial chill or chilliness is very rare. It is said that 
 fever is always present at the onset. If so, it is very often transient and 
 has disappeared before the case comes under medical observation. Fre- 
 quently the temperature is normal when the patient is first seen, and in 
 favorable cases remains so. Many cases show subfebrile temperatures not 
 reaching 101° F. (38.5° C), and fever of irregular type— 102°-3° F.— is 
 not uncommon. There are cases in which, with abscess formation or gen- 
 eral peritonitis, the temperature remains low, and others in which fever 
 gradually subsides and the patient enters upon convalescence without 
 serious symptoms. Too great reliance upon the thermometer may prove 
 misleading. 
 
 5. Muscular Rigidity. — Spastic tension of the abdominal wall upon 
 the right side, especially over the rectus muscle, is common in severe cases. 
 In many cases this symptom is not present. Its presence is suggestive 
 of a beginning local peritonitis. 
 
 6. Induration. — Upon deep palpation a circumscribed sensation of 
 resistance may frequently be detected. This sign is often well defined and 
 situated at or near McBurney's point. In very rare instances the thick- 
 ened appendix may be distinctly recognized upon palpation. In other 
 cases there is a diffuse ill-defined boggyness with some impairment of 
 resonance upon percussion. Upon the supervention of pus the signs of a 
 solid or fluctuating tumor are characteristic. Necrosis and perforation may 
 take place without either induration or a palpable tumor, especially in the 
 early gangrenous cases. 
 
 7. Leucocytosis. — In appendicitis unaccompanied by suppuration, 
 gangrene, or serous inflammation, there is usually little increase in the 
 leucocytes. In cases which have gone on to abscess formation, necrosis, 
 and local or general peritonitis, leucocyte counts of 15,000 or more per 
 cubic millimetre are the rule. Normal counts or slight leucocytosis may 
 occur in cases characterized by early gangrene and perforation, — so-called 
 fulminant appendicitis, — and in suppurative cases in which absorption 
 does not take place from the abscess cavity. 
 
970 MEDICAL DIAGNOSIS. 
 
 S. Inconstant and therefore unimportant symptoms are vesical 
 irritability, oliguria, and albuminuria. As in man}^ other acute inflam- 
 matory affections, there is moderate early anaemia of secondary type. In 
 cases attended with prolonged suppuration, with sepsis, ansemia becomes 
 pronounced with a reduction of haemoglobin to 30 or 40 per cent, and an 
 erythrocyte count of 3,000,000 per cubic millimetre or less. 
 
 The course of a case of simple appendicitis terminating favorably is 
 usually as follows: The gastro-intestinal symptoms subside, the tongue 
 cleans, and the constipation ceases spontaneously. The appetite and 
 strength return. The pain gi-adually disappears, but tenderness outlasts 
 it for some days or a week or two. Local induration progressively 
 diminishes and convalescence is soon fully established. The persistence 
 of a distinct circumscribed tumor is very liable to be followed by 
 recurrent outbreaks. 
 
 Abscess and peritonitis are sequels of appendicitis. 
 
 Abscess. — The conditions revealed at operation shed much light upon 
 the development and course of appendicular abscess. Perforation either 
 as the result of ulceration or necrosis is the common cause of peri-appen- 
 dicular suppuration. In exceptional cases it occurs in consequence of 
 general suppurative inflammation of the appendix. Pus may be found in 
 the course of two or three days, but more commonly towards the close of a 
 week. The symptoms are aggravated. There are more or less pronounced 
 signs of sepsis and fever of irregular type. There are, however, cases in 
 which fever is wholly absent. The pain and tenderness are often increased. 
 The abscess cavity is usually in relation with the appendix and the adjacent 
 coils of intestine, which are adherent among themselves as the result of 
 local plastic peritonitis. In some of the recurrent cases there are one or 
 more small collections of pus in an irregular mass formed by dense adhesions 
 and puckering of the wall of the gut. More commonly the abscess cavity 
 is single and its size corresponds to the duration of the case. When small 
 and deeply seated, especially if below the pelvic line, it may elude external 
 palpation but be detected upon vaginal examination. As a rule, it forms 
 a palpable or visible tumor of variable size in the right iliac fossa, which 
 in some cases is distinctly fluctuating. The pus shows the usual ten- 
 dency to burrow and may discharge into the bowel, vagina, or bladder, 
 or externally. 
 
 Peritonitis. — General infection of the peritoneum may at once result 
 from early necrosis, prior to the formation of circumscribing adhesions, 
 or later from the rupture of already formed adhesions. In the fulminant 
 cases the symptoms of general peritonitis may follow those of appendicitis 
 so rapidly that it is not always possible to determine the nature of the 
 primary process. Ordinarily the onset of peritonitis is attended by sudden 
 aggravation of the previous symptoms. The pain, tenderness, and rigidity 
 become more marked and extend over the entire abdomen. Nausea and 
 vomiting are more severe. The pulse becomes small and rapid, the tongue 
 dry, and the urine scanty or suppressed. After a time meteorism, absence 
 of peristaltic movement, dorsal decubitus with flexed thighs, and the 
 characteristic facies complete a well recognized clinical picture. Cessation 
 of pain and a clear mind are the heralds of death. 
 
APPENDICITIS. 971 
 
 Diagnosis. — Dikect. — The recognition of acute appendicitis rests 
 upon the association of sudden pain and tenderness in the right iliac region 
 with nausea or vomiting. The presence of a circumscribed tumor or deep 
 resistance and rigidity of the right rectus muscle are significant. The 
 age of the patient is suggestive, since appendicitis is very common before 
 and comparatively rare after thirty. Conditions having some resemblance 
 to appendicitis are to be carefully excluded, as, for example, hepatic and 
 renal colic, dysmenorrhoea, and tubo-ovarian disease. The diagnostic 
 importance of the blood counting may be readily overestimated. 
 
 Differential. — 1. Cholecystitis. — When the inflamed appendix lies 
 upwards, the pain and tenderness may suggest gall-bladder disease. In 
 the latter careful physical examination will usually reveal increased dul- 
 ness and circumscribed tenderness in the region of the gall-bladder, and a 
 history of recurrent attacks without tendency to inflammatory tumor 
 or abscess formation. 2. Renal Colic. — It is only in the rare cases in which 
 the appendix extends backwards that uncertainty arises. The pain of 
 renal colic is usually more severe and more distinctly paroxysmal than 
 that of appendicitis. It arises in the lumbar region, extends forward and 
 downward towards the groin, and is attended by retraction of the testicle. 
 The diagnosis in some cases of persistent kidney colic with hydronephrosis 
 is very difficult. The X-ray examination may be of service. Dietel's 
 crises in floating kidney present remote resemblances to acute appendi- 
 citis. 3. Dysmenorrhoea. — Menstrual colic, especially in an hysterical girl, 
 may suggest appendicitis, but the seat of the pain, the period in the month, 
 recurrence, the absence of a tumor, or the stigmata of hysteria are signif- 
 icant. 4, Disease of the Right Tube and Ovary. — A careful vaginal exam- 
 ination is necessary. The recognition of salpingitis or an enlarged, tender, 
 prolapsed, or adherent ovary, together with a history of menstrual derange- 
 ments or previous pelvic pain would be of diagnostic importance. The 
 fact that such conditions are frequently associated with an infected appen- 
 dix is by no means to be overlooked. 5. Mucous colitis is sometimes asso- 
 ciated with chronic appendicitis without distinctive signs of the latter 
 affection. In such a case I have seen a diseased appendix removed with 
 decided improvement in the mucous disease and general health. 6. Local 
 abscess in the ciBcal region associated with malignant disease of the gut 
 cannot always be distinguished from appendicular abscess. The anamnesis 
 is important. An exploratory incision may be necessary. The situation 
 of the tumor and oedema in perinephric abscess are of diagnostic importance. 
 7. Intussusception, volvulus, and other forms of intestinal obstruction pre- 
 sent in the beginning only remote resemblances to appendicitis. Ster- 
 coraceous vomiting, so significant in these conditions, does not occur in 
 appendicitis, nor do the tenesmus and bloody stools common in intus- 
 susception, especially in children, nor the sausage-like tumor, mostly on 
 the left side, nor the invaginated gut upon rectal examination. 8. Enteric 
 Fever. — There is no real difficulty in well-defined cases. Both the pain 
 and tenderness are milder, vomiting is rare, fever is higher and the 
 temperature tends to run a typical course, and headache is a prominent 
 symptom. Later splenic tumor, rose spots, disproportion between the 
 pulse-frequency and temperature, and the results of laboratory methods are 
 
972 MEDICAL DIAGNOSIS. 
 
 conclusive. The occasional occurrence of typhoid ulceration of the appendix 
 and of appendicitis as an intercurrent affection in enteric fever is not to 
 be overlooked. Perforation of the appendix may occur in the second or 
 third week or during convalescence. 9. General Peritonitis. — In the absence 
 of a history of the case the peritonitis which follows acute appendicitis 
 cannot be differentiated from that due to other causes. 
 
 Prognosis. — The mortahty is stated to be 2 per cent, of all cases, but 
 the general statistics are without value since the death-rate is dependent 
 upon extremely variable data relating to diagnosis and operation. The 
 death-rate in early operations is low. The statistics vary from 2 to 10 per 
 cent, according to the time of operation. The immediate recognition of the 
 condition may be of vital importance to the patient. In cases character- 
 ized by recurrence, operation in a quiescent interval is attended with 
 comparatively slight risk. The outlook in neglected cases is grave. The 
 patient's general health may be undermined by prolonged suppuration 
 and sepsis, or death may follow pylephlebitis or hemorrhage from an artery 
 or vein. A very large proportion of cases in which early operation is neg- 
 lected die of peritonitis. The fact that the course of the lesion in any given 
 case can neither be foreseen from the beginning nor controlled by any other 
 sure means, constitutes full justification for early operation. 
 
 vii. Enteroptosis. 
 
 Definition. — Falling forward or dragging downward of the intestines 
 from stretching of their mesenteric attachments, practically always affect- 
 ing the large intestine, and frequently associated with ptosis of the 
 stomach, liver, and kidneys — splanchnoptosis or Glenard's disease. 
 
 Etiology. — See Gastroptosis. 
 
 Symptoms. — The general symptoms are often the only symptoms. 
 The condition may exist for years without producing discomfort. The 
 inherent weakness of the tissues which support the abdominal viscera is 
 in turn aggravated by the gastro-enteroptosis. Persistent weakness, 
 abdominal distress, pain in the back and loins, headache, torpor, dulness 
 are common. The patients are always neurasthenic. Hyperchlorhydria 
 or hypochlorhydria may occur. The local symptoms are varied. Abdom- 
 inal discomfort, burning sensation, the weight of the prolapsed abdominal 
 organs, colicky, irregularly recurring pains, nausea, anorexia, constipation, 
 diarrhoea, abdominal distention are symptoms of enteroptosis. Obstruction 
 from kinking is rare. Many of the so-called cases of intestinal indigestion 
 belong here. Mucous diarrhoea and mucous stools are not uncommon. 
 
 Physical Signs. — These have been described under gastroptosis. In 
 enteroptosis the transverse colon is the part of the intestine mostly affected 
 and most readily demonstrated. Even on inspection the outline of the 
 displaced bowel may be evident at and below the umbilicus. Peristalsis 
 from' right to left may be observed. Palpation will frequently reveal 
 displacement of the liver and kidneys. At times the spasmodically 
 contracted transverse colon can be clearly felt. 
 
 Diagnosis. — Direct. — The abnormal position of the colon, displace- 
 ments of other organs, and diastasis recti are diagnostic features. 
 
INTESTINAL INDIGESTION. 973 
 
 Inflation with the tube passed high up will often clearly distend the 
 colon in its various positions. Simultaneous distention of the stomach 
 prevents errors. The X-ray examination after bismuth injections may 
 be of confirmatory value. 
 
 Differential, — Gastroptosis. — These conditions commonly occur 
 together. The absence of gastric symptoms and the normal position of 
 the stomach on inflation may be observed in exceptional cases. Malignant 
 Disease of the Bowel. — The long history of enteroptosis, ptosis of other 
 organs, and diastasis recti, absence of marked anaemia or cachexia, absence 
 of a tumor mass with palpable muscular contraction, absence of occult 
 blood in the stools are in favor of enteroptosis. 
 
 Prognosis.' — The condition may never cause trouble. A suitable 
 abdominal support may relieve the symptoms but cannot permanently 
 restore a prolapsed intestine to its normal position. 
 
 viii. Intestinal Indigestion. 
 
 Definition. — Disorders of digestion in the intestine, usually due to 
 deficiency of the pancreatic ferments and characterized by the excretion 
 of abnormal amounts of the various food matters ingested. 
 
 Etiology. — Predisposing Influences. — Nervous disorders of the 
 stomach or intestine predispose to intestinal indigestion. 
 
 Exciting Causes. — Anacidity of the gastric juice, obstruction of 
 the bile-ducts, pancreatic ducts, chronic intestinal disorders, chronic appen- 
 dicitis, and dietetic errors are causes of intestinal indigestion. The definite 
 cause that in many instances apparently interferes with the "secretin" 
 production and the pancreatic supply is unknown. 
 
 Symptoms. — The general symptoms may be those of a neurosis: 
 headache, coated tongue, persistent loss of weight without obvious cause 
 or without symptoms. Habitual inability to digest certain articles is fre- 
 quent. Pain in various regions of the abdomen, flatulence, and burning 
 sensations are common. Constipation, diarrhoea, or pultaceous stools 
 may occur. Foul-smelling flatus and fseces that decompose and ferment 
 on standing are usual. 
 
 Physical Signs. — Abdominal distention may occur as the sign of 
 active intestinal fermentation. Tenderness can usually be elicited. 
 Examination of the fseces shows excess of fat and fatty acids, and 
 much undigested proteid, or carbohydrate (see Fseces). The various 
 tests (bead test, desmoid test, absorption tests) show impaired digestion 
 and absorption. 
 
 Diagnosis. — Direct. — Chronic abdominal distress and symptoms 
 of disturbance of nutrition, evacuation of abnormal amounts of undigested 
 material as proved by chemical and microscopical tests, absence of phys- 
 ical signs of neoplasm, absence of blood from the stools and of fever are 
 important diagnostic features. 
 
 Differential. — Intestinal Neuroses. — The differentiation is often 
 impossible as a neurosis may coexist with the intestinal indigestion. The 
 condition of the fseces is important. Mucous- stools must be distinguished 
 from undigested material. Neoplasm; Ulceration. — Chronicity, absence of 
 
974 MEDICAL DIAGNOSIS. 
 
 blood from the faeces, absence of physical signs of obstruction or tumor, 
 the persistent presence of undigested material in the fseces indicate 
 intestinal indigestion. 
 
 Prognosis. — If the cause can be removed resumption of normal diges- 
 tive power may return. The withholding of certain forms of food, — fat, 
 carbohydrate or proteid, as indicated by the fseces, — may be continually 
 necessary. JMany cases persist unrelieved by treatment. 
 
 ix. Intestinal Neuroses. 
 
 Definition. — Disorders of sensation and of the secretory and motor 
 functions of the intestine. 
 
 Etiology. — Predisposing Influences. — All conditions which pre- 
 dispose to functional nervous disorders may be considered as predisposing 
 influences. ,. . 
 
 Exciting Causes. — Shock or emotional outbreaks may precipitate 
 an intestinal neurosis. The more common exciting causes are strain, 
 worry, irregular habits of life, and dietetic errors. 
 
 Symptoms. — Symptoms common to all intestinal neuroses are nervous 
 depression, exhaustion, and derangements of the normal function, sallow- 
 ness of the complexion, and emaciation. When the digestive function of 
 the intestines is not impaired a physical appearance of well-being is often 
 seen. There is rarely any evidence in the faeces of impaired digestive 
 activity. Common sensory symptoms are a feeling of weight or distention 
 in the abdomen, the subjective perception of the intestine in peristalsis, 
 persistent general discomfort or soreness in the intestines, and colicky 
 pains which are often severe. These pains may simulate appendicitis, 
 biliary, renal, or lead colic, or the tabetic crises. Motor disturbances give 
 rise to nervous diarrhoea, intestinal rumblings and gurglings, or to spas- 
 modic contractions of the bowel with constipation and pain. Explosive 
 flatulence is a common motor neurosis. Retention of intestinal air or 
 gases and distressing flatulent distention is frequently the result of intes- 
 tinal spasm. Reverse peristalsis with fecal vomiting as a motor neurosis 
 is rare. Few secretory neuroses are recognized. Diarrhoea and consti- 
 pation are often due to motor causes. Membranous or mucous enteritis 
 and colitis are practically the only secretory neuroses. The main features 
 of these affections are severe abdominal pain, constipation, and the passage 
 of large amounts of mucus, unformed and jelly-like, in opaque, firm flakes, 
 or in large tubular casts. Bile-stained mucus is said to come from the small 
 intestine; the paler variety from the large. 
 
 Several motor neuroses may occur in association. Physical exami- 
 nation usually yields negative results. In typical cases the abdomen may 
 be scaphoid. Tenderness is common, particularly along the course of the 
 colon. It is often marked over the caecum. In mucous colitis, redness 
 of the mucosa and excess of mucus can be seen on examination with 
 the speculum. 
 
 Diagnosis. — Direct. — Persistent intestinal distress in a neurotic 
 individual, the absence of the local signs of obstruction or neoplasm, the 
 absence of anaemia and cachexia, a normal condition of the faeces as to 
 
INTESTINAL NEOPLASMS. 975 
 
 their constitutent fats, carbohydrates, and proteids, abnormal amounts 
 of mucus, and the absence of parasites and their ova justify the suspicion 
 of a neurotic basis for the intestinal disorder. 
 
 Differential. — Intestinal Obstruction. — A neurosis, even when asso- 
 ciated with severe pain, constipation, and distention, rarely shows general 
 symptoms, such as rapid pulse and collapse. Fever is absent, vomiting 
 is less usual; local signs of obstruction are absent. The bowels are usually 
 easily opened by the proper means. The detection of mucus in the stools 
 in large amounts or in tubular form is important evidence in favor of a 
 neurosis. Intestinal New Growths. — Tuberculosis of the intestine, anaemia, 
 and cachexia are unusual in neuroses; local signs are absent. Tests for 
 blood in the stools are negative. The general neurotic condition of the 
 patient is a most important feature. In gall-stone colic subsequent jaun- 
 dice, bile-stained urine, and detection of gall-stones in the faeces are 
 important diagnostic points. Rapid pulse, fever, and persistent tenderness 
 over the liver are usual in gall-stone attacks. In renal colic hsematuria 
 and occurrence of fever may be the only distinguishing features; in lead 
 colic anaemia, "blue line," persistent constipation, and a history of 
 exposure are important. With tabetic crises other features of tabes are 
 present, for example, absent knee-jerks, Argyll-Robertson pupil, ataxia. 
 Appendicitis. — Cases of intestinal neurosis are sometimes operated upon 
 as appendicitis. The differentiation in some of the chronic cases may be 
 extremely difficult. In the neuroses leucocytosis and muscular rigidity 
 do not occur. Since mucous colitis is the condition most likely to simulate 
 appendiceal disease mucous stools should be carefully looked for. 
 
 Prognosis. — The intestinal neuroses are refractory to treatment and 
 often require years of careful management. Confirmed cases are often 
 unrelieved by any form of general or local treatment. 
 
 X. Intestinal Neoplasms. 
 
 New growths or tumors of the intestines, principally malignant. Benign 
 tumors, lipomata, adenomata, myomata, polypoid growths also occur. 
 
 L Malignant Growths. — Carcinomata. — Cancer of the intestines may 
 involve any part of the bowel from the duodenum to the rectum. The 
 large bowel is more frequently affected and especially the rectum. The 
 growths are usually primary and tend to assume the annular form and to 
 ulcerate, producing obstruction and hemorrhage. 
 
 Symptoms. — The general symptoms of mahgnant disease of the intes- 
 tines are loss of appetite and strength, persistent and rapid loss of weight, 
 early and severe anaemia, and rapidly developing cachexia. In many 
 cases local symptoms are not recognized for a considerable time, a fact 
 which lends importance to the general early derangements of health. 
 The earlier local symptoms are those of partial obstruction and ulceration, 
 colic, flatulent distention, and vomiting if the growth is in the duo- 
 denum, tenderness when it is situated in the large bowel. Malignant 
 disease in the duodenum soon produces obstructive dilatation of the 
 stomach with its characteristic symptoms. Persistent biliary vomiting 
 indicates obstruction below the papilla of Vater. Duodenal cancer is often 
 
976 MEDICAL DIAGNOSIS. 
 
 associated with occlusion of the common bile and pancreatic ducts. Pain 
 in the neighborhood of the growth itself, apart from the recurring colic 
 of the obstruction-hypertrophy, is only marked in large-bowel cancers, 
 and is of a dull aching or intense gnawing character. Hsematemesis may 
 occur in duodenal cancers. Black, tarry, or bright hemorrhagic stools 
 are seen in the cases in which the growth is situated lower down. Diar- 
 rhoea, constipation, or dysenteric symptoms may be present in cancer of 
 the lower bowel. Later local symptoms are those of complete obstruction, 
 perforation, and metastatic deposits in the glands of the abdomen, in the 
 liver, and elsewhere. 
 
 Physical Signs. — Careful and repeated inspection and palpation 
 are necessary. Important signs are distention, particularly marked in 
 low-lying tumors, intestinal patterns, visible peristalsis, and a visible or 
 palpable tumor. Transmitted pulsation from the aorta may occur. Pal- 
 pation with the fiat of the hand, superficial at first, then deep, slowly cover- 
 ing the whole abdomen, is important in obscure cases. Small tumors may 
 escape observation. Tumors of the duodenum may be central and do not 
 move with the diaphragm; tumors of the jejunum and ileum are also 
 usually central, but may appear in other regions, and are often freely mov- 
 able. Tumors of the caecum and transverse colon are movable but not so 
 freely as those of the sigmoid flexure. Contraction of hypertrophied mus- 
 culature, causing tension and hardening of the tumor mass, may be fre- 
 quently observed. Movement of the tumor mass with respiration and 
 with postural changes is, in the absence of adhesions, common to all tumors 
 of the intestine save those situated in the duodenum and at the colonic 
 flexures and rectum, and is readily appreciated by the examining hand. 
 Palpable pulsation suggestive of an aneurism may be obtained over a 
 tumor in relation with the abdominal aorta or the large iliac vessels. Tumor 
 of the sigmoid may drop into the pelvis and be felt upon examination per 
 rectum or per vaginam. During contraction of the intestine and forcing 
 of the intestinal contents through the narrowing lumen, loud and sharp 
 gurgling is often heard. Inflation of the stomach, slapping the abdomen 
 with a cold wet towel will at times start up muscular action in the intes- 
 tine and produce physical signs. Inflation of the sigmoid flexure and 
 colon may bring a tumor into view, or the signs of stenosis of the bowel 
 may appear. The X-ray examination frequently affords evidence of the 
 presence and situation of a tumor. The characteristics of the vomitus 
 in cases where the disease is situated in the duodenum are those of 
 pyloric obstruction. The significance of biliary vomiting has been dis- 
 cussed. Occult blood is present when ulceration has occurred. 
 
 The faeces present no characteristic signs. Occult blood is always 
 present with ulceration and is suggestive when local signs and symptoms 
 are absent. Bloody mucous discharges and mucopurulent stools are 
 frequent in tumors of the lower bowel. Carcinomatous tissue fragments 
 are sometimes found in the stools when ulceration of the growth has 
 taken place. The physical signs presented in examination by means of 
 the proctoscope and sigmoidoscope are obstruction to the passage of the 
 tubes, localized or annular thickening, thickened and ulcerated areas. 
 Small tissue fragments may be removed and examined. 
 
ANOMALIES OF THE LIVER. 977 
 
 Diagnosis. — Direct. — Loss of appetite, persistent wasting, progres- 
 sive anaemia are suggestive. Signs of obstruction, pain, colic, vomiting, 
 distention, visible peristalsis, visible and palpable contractile tumor are 
 indicative of a new growth in a muscular organ, as the intestine. Occult 
 blood in the faeces or vomitus is an important sign of ulceration. 
 
 Differential. — IS! on-malignant Partial Obstructions. — The history of old 
 inflammatory abdominal conditions may be suggestive of non-mahgnant 
 obstruction. Absence of progressive anaemia and cachexia is an important 
 point. The absence of hemorrhage, either occult or gross, particularly if 
 the condition has persisted for some time, is in favor of a non-malignant 
 condition. A tumor is rarely visible or palpable in non-malignant obstruc- 
 tion save just at the point of obstruction and at the time of contraction of 
 the hypertrophied musculature. Impacted Fceces, Scybala, etc. — There is 
 absence of anaemia and cachexia, wasting is unusual, signs of obstruction 
 are commonly wanting. The evidences of hypertrophied intestinal mus- 
 culature do not appear. Visible peristalsis is only present when obstruc- 
 tion is complete. Occult blood is not present nor do hemorrhages take 
 place unless laceration of the mucosa of the rectum or anus has occurred. 
 The scybalous tumor masses may be multiple and follow the course of the 
 large bowel. They are not contractile but doughy and can at times be 
 broken in situ. They can usually be removed by proper measures and 
 are often readily distinguished by sigmoidoscopic examination. 
 
 Prognosis. — The outlook in intestinal carcinomata is hopeless unless 
 the condition is early recognized and the case submitted to operation. 
 In disease of the lower bowel, an artificial anus — colostomy — may prolong 
 life for months; acute secondary accidents, as rupture of the bowel and 
 complete obstruction, occur. 
 
 Sarcomata. — Sarcomata of the intestine are rare. They attain larger 
 size, are less circumscribed and of more rapid growth than carcinomata. The 
 general symptoms of anaemia and cachexia progress with alarming rapidity. 
 Stenosis of the bowel does not occur, since the growth diffuses through large 
 areas of the submucosa, hence visible peristalsis and contractile tumor 
 masses are rarely observed. Hemorrhage is less common. The small 
 intestine and the rectum are the favorite locations of intestinal sarcomata. 
 
 2. Benign Tumors. — The benign tumors, principally polypi, occur most 
 frequently in the rectum and large bowel. Hemorrhage and tenesmus are the 
 most marked features. The diagnosis of these and other benign tumors that 
 lie out of reach of the sigmoidoscope must be attended with difficulty. 
 Only when they reach large size do they produce signs of obstruction. 
 
 III. DISEASES OF THE LIVER, 
 i. Anatomical Anomalies of the Liver. 
 
 The contour of the liver is modified by the shape of the thorax and 
 the pressure of adjacent organs. Abscess and tumors within the substance 
 of the hver, as echinococcus, gummata, and malignant growths, cause 
 departures from the normal form of the organ. In transposition of the 
 viscera the shape of the liver is the reverse of normal. The convex anterior 
 surface is frequently marked by parallel depressions corresponding to the ribs. 
 62 
 
978 MEDICAL DIAGNOSIS. 
 
 Remarkable changes in shape are produced by the permanent pres- 
 sure of clothing — corset liver; lacing liver. That portion of the right lobe 
 which is below the groove of compression may reach to the level of the 
 crest of the ilium. It is separated from the main portion of the organ by 
 a deep depression, the result of pressure atrophy, which produces in many 
 cases great thinning, and in extreme cases an entire disappearance of the 
 liver tissue, so that the corset lobe is connected with the liver by a flat 
 band of connective tissue containing only bile-ducts and blood-vessels. 
 The portion thus separated not only occupies an abnormal position, but 
 it is also more or less freely movable according to the degree of atrophy of 
 the compressed part. It, therefore, frequently simulates floating kidney, 
 intestinal tumor, or other movable tumors occasionally found in this situ- 
 ation, especially when a loop of intestine has found its way into the groove. 
 From these conditions it is to be differentiated by, (a) its ascent and descent 
 with the respiratory movements of the diaphragm; (b) its continuity with 
 
 the liver as demonstrable in many cases by 
 percussion; (c) the continuous border of the 
 anterior inferior surface of the liver and the 
 corset lobe as recognized upon repeated, care- 
 ful palpation, and finally, (d) by the presence 
 of the notch or angle in the border at the point 
 where the groove terminates anteriorly. 
 Another deformity produced by the habitual 
 pressure of clothing consists in an elongation of 
 the entire right lobe downward. This change 
 may be mistaken for enlargement of the organ. 
 These changes are common in women but 
 comparatively infrequent in men — belt liver. 
 Various changes in the position of the 
 
 Fig. 313. — Corset liver. •,. , , rni n 
 
 liver are encountered. ihese are usually 
 the result of continuous pressure. Rotations upon the transverse axis may 
 occur forward from the pressure of the clothing or backward from the pres- 
 sure of abdominal tumors. The entire organ is frequently displaced down- 
 ward, as in emphysema, pleural effusion, or subphrenic abscess, and upward 
 by ascites, massive tympany, or ovarian or other abdominal tumors. 
 
 ii. Movable Liver. 
 
 Hepar Mobilis; Hepatoptosis. 
 
 Definition. — Marked displacement of the liver with abnormal mobility. 
 
 Etiology. — A slight degree of mobility occurs in enteroptosis and 
 after large and long-continued ascites. True floating liver is extremely 
 rare. It is associated with atrophy and relaxation of the abdominal walls 
 and separation of the abdominal muscles, and large hernias in which the 
 sac encloses many coils of intestines. The traction that the abdominal 
 wall in pendulous abdomen exerts upon the liver by means of the liga- 
 mentum teres is a concomitant cause. Mechanical violence such as severe 
 exertion or vomiting, persistent cough, falls, tight lacing, and rapid emacia- 
 
JAUNDICE— ICTERUS. 979 
 
 tion have been regarded as etiological factors in floating liver. The fre- 
 quency of these events as compared with the extreme infrequency of 
 floating liver renders it in a high degree improbable that they play the part 
 assigned to them in the causation of the latter condition. Therefore it is 
 likely that floating liver can only occur in cases of congenital tendency to 
 relaxation and elongation of the ligaments of the organ, or in which an 
 actual mesohepar is present. 
 
 Symptoms. — There is, as a rule, no tenderness upon pressure. Pain 
 is a common symptom. It is referred to the right hypochondrium and 
 the epigastrium, and extends to the right shoulder and lumbar region. 
 It is dull and dragging, and intensified by sudden movements. Spon- 
 taneous paroxysmal pain, bearing-down sensations, attacks of colic, with 
 belching, meteorism, and constipation, and anomalous abdominal sen- 
 sations are common. The pain is usually relieved by firm pressure upon 
 the tumor or by lying down. Respiratory disturbances and palpitation 
 occur. Hemorrhage from the stomach and bowels, ascites, hemorrhoids, 
 and oedema of the legs and feet have been observed. Jaundice is rare, 
 but the skin usually has a subicteroid hue. 
 
 Physical Signs. — The abdominal tumor occupies the right side and 
 may extend as low as the pubic arch. The convex surface is directed for- 
 ward and the entire organ is rotated to the right. The contour may be 
 made out upon palpation. In the dorsal decubitus the liver may be 
 replaced by gentle pressure unless fixed by adhesions — an extremely rare 
 condition. Upon percussion when the liver is dislocated the pulmonary 
 resonance passes directly into the tympany due to the intestines which 
 have found their way into the space between the liver and the diaphragm. 
 
 Diagnosis. — A direct diagnosis rests upon the position of the 
 tumor, its contour, its large size, and the possibility of replacing the 
 dislocated liver in its normal position. The diagnosis is greatly obscured 
 by the presence of ascites and by the diminished mobility resulting from 
 adhesions in the abnormal position. 
 
 The DIFFERENTIAL DIAGNOSIS involves the consideration of a greatly 
 thickened mesentery and tumor of the kidney. Neither of these tumor 
 masses is associated with tympanitic resonance in the normal area of liver 
 dulness, nor can either of them be made by manual pressure to pass into 
 the normal position of the liver. Floating liver occurs chiefly in women. 
 
 iii. Jaundice — Icterus. 
 
 This symptom-complex has been described in a previous section and the 
 mechanism and significance of obstructive and toxaemic jaundice discussed. 
 The following special forms are of clinical interest: 
 
 1. Icterus Psychicus (Icterus ex Emotione). — Sudden jaundice has 
 been attributed to anger, fright, terror, and a gross insult. Associated 
 symptoms are anxiety, epigastric distress, and diarrhoea. The jaundice 
 passes away in a short time. The cases are not well authenticated and 
 no wholly satisfactory explanation has been adduced for emotional jaundice. 
 
 2. Hereditary Icterus. — The cases are rare and may be regarded 
 as clinical curiosities. Icterus neonatorum has been observed in every 
 
980 MEDICAL DIAGNOSIS. 
 
 member of large families in two generations. Another group includes 
 cases of jaundice in a mother and three of her children, appearing 
 in childhood and persisting for years without other evidences of ill 
 health. The jaundice was of mild type. There was no enlargement 
 of the liver or spleen. 
 
 3. Icterus Gravidarum. — Women in adanced pregnancy occasion- 
 ally suffer from a form of catarrhal jaundice due to the pressure exerted 
 upon the under surface of the liver by the enlarged uterus. Fecal accumu- 
 lation acts as an additional cause of bile stasis, and the deformities of the 
 liver resulting from lacing increase the tendency. The death of the foetus 
 or miscarriage may occur. The jaundice disappears after parturition. 
 
 4. Icterus Menstrualis. — Mild icterus has frequently been observed 
 just prior to and during menstruation. When the discharge becomes free 
 the jaundice abates. Enlargement of the liver and decolored faeces have 
 been noted. 
 
 5. Biliousness. — Many persons, whose health is otherwise good, 
 occasionally suffer from gastro-intestinal derangements, with headache, 
 furred tongue, sensations of depression and malaise, and a subicteroid 
 discoloration of the conjunctivae or skin. Relief of these symptoms follows 
 abstinence from food and mild purgation. 
 
 6. Starvation Jaundice. — Subicteroid discoloration of the con- 
 junctivae and skin is frequently present in persons who for any reason are 
 unable to take food for several days. This is witnessed in insane persons 
 who refuse food, and in stricture of the oesophagus, whether spasmodic 
 or organic. 
 
 7. Syphilitic Jaundice. — Icterus appears in certain cases of severe 
 syphilis coincidently with the secondary eruption. Its symptomatic char- 
 acter is shown by its prompt disappearance under antisyphilitic treatment. 
 This form of jaundice is to be differentiated from accidental jaundice, 
 such as occurs in tertiary syphilis as a consequence of diffuse hepatitis 
 or gumma of the liver, and from a coincident catarrhal jaundice. 
 
 8. Icterus Follow^ing the Extravasation of Blood. — Yellowness 
 of the conjunctivae and skin may be observed after large hemorrhages into 
 the skin or cavities of the body in scurvy, and after injuries or in lesions 
 of the genital tract in women. The jaundice appears after several days, 
 is not intense, and gradually fades in the course of some days or weeks. 
 Bile pigments are present in the urine. 
 
 9. Icterus Following HiEMOGLOBiN^EMiA. — This variety of jaundice 
 is very marked after the attacks of haemoglobinuria which follow exposure 
 to cold or overexertion in persons suffering from malaria or syphilis. Fever, 
 splenic enlargement, haemoglobinuria, and jaundice constitute the symptom- 
 complex. The urine contains bile pigments. 
 
 ; 10. Toxic Icterus. — A large number of poisons are followed by 
 
 icterus. Among them the following are important: arseniuretted hydrogen, 
 certain mushrooms, toluylendiamin, glycerin, the bile acids, the chlorates, 
 aniline and its derivative acetanilide, and the nitrites. Filix mas and 
 santonin may cause a yellow discoloration of the skin. Icterus follows 
 poisoning by phosphorus and lead. A very rapid icterus develops after 
 snake bite. 
 
ICTERUS NEONATORUM. 981 
 
 11. Infectious Icterus. — Yellow fever and relapsing fever are 
 characterized by marked icterus. Septic conditions and pneumonia are 
 frequently, enteric fever occasionally, attended by jaundice. 
 
 12. Epidemic Icterus. — When a number of persons living under the 
 same conditions develop jaundice, as occasionally occurs in boarding 
 schools, camps, barracks, or prisons, the term epidemic jaundice is war- 
 ranted. Many large and small epidemics have been described in the liter- 
 ature. These epidemics are usually of short duration; in a few instances 
 they have lasted several months. The disease commonly assumes the 
 guise of ordinary catarrhal jaundice and runs a benign course; in some 
 instances it is severe and many deaths occur. In pregnant and parturient 
 women the prognosis is grave. Epidemic icterus has been attributed to 
 atmospheric or climatic influences, dietetic faults, and infectious causes. 
 A combination of these agents m^ay be operative. 
 
 13. Postvaccinal Jaundice. — In rare instances jaundice has 
 appeared in groups of cases among revaccinated persons. The jaundice has 
 occurred at intervals of a few days to several months. It has been attrib- 
 uted to wound infection. This form of epidemic jaundice is rare and its 
 association with vaccination is probably accidental. It is much more 
 likely due to other local influences affecting groups of persons who 
 happen to have been vaccinated. 
 
 iv. Icterus Neonatorum — Physiological Icterus. 
 
 Definition. — A variety of icterus common in the new-born occur- 
 ring independently of any particular disease or lesion and pursuing a 
 favorable course. 
 
 Etiology. — This affection occurs in about one-half of all babies. It is 
 more common in foundling hospitals than in private practice, in premature 
 infants than in those born at term, in boys than girls, and in cases where 
 parturition has occurred under chloroform. The pathogenesis of the con- 
 dition is not clear. It has been attributed to rapid destruction of erythro- 
 cytes after birth, to stasis in the smaller bile-ducts, to resorption of bile 
 from the intestine, and to oedema of the periportal connective tissue. 
 
 Symptoms. — The jaundice appears upon the second or third day 
 after birth and first upon the face and chest, rapidly extending to the 
 rest of the body. It fades more or less rapidly in the course of ten or twelve 
 days. The general condition of the child is otherwise normal. The urine 
 is normal and does not contain bile pigment in solution. The stools, after 
 the discharge of meconium, have their usual golden-yellow color. The 
 pulse-frequency is not lowered. 
 
 Diagnosis. — Direct. — The comparative mildness of the jaundice 
 and the complete absence of serious symptoms suffice to establish the nature 
 of the affection. Its gradual disappearance within two or exceptionally 
 as late as three or four weeks is not followed by recurrence. 
 
 Differential. — In the following forms of jaundice in the new-born 
 the discoloration is more intense and associated with serious symptoms: 
 (a) congenital absence of the common or hepatic duct; (b) congenital 
 syphilitic hepatitis, in which the characteristic external lesions of syphilis 
 
982 MEDICAL DIAGNOSIS. 
 
 are also manifest, and (c) septic infection by way of the umbilical vein, 
 a fatal form of sepsis associated with phlebitis and, in some instances, 
 with umbilical hemorrhage. Icterus may occur in the new-born as a result 
 of obstruction of the bile-ducts, acute fatty degeneration of the livor, and 
 epidemic hsemoglobinuria. 
 
 Prognosis. — The physiological icterus of the new-born is never fatal. 
 
 V. Acute Yellow Atrophy. 
 
 Malignant Jaundice; Icterus Gravis. 
 
 Definition. — An acute disease characterized anatomically by diffuse 
 necrosis of the liver-cells with great diminution in the size of the organ, 
 and clinically by intense jaundice and cerebral symptoms. 
 
 Etiology. — Predisposing Influences. — Acute yellow atrophy is 
 rare. It is more common in women than in men in the proportion of 
 about 8 to 5. This difference is in part explained by the fact that preg- 
 nant women are frequently affected after the fourth month or at the time 
 of parturition. The greater number of cases occur between the twentieth 
 and fortieth years. Acute yellow atrophy is comparatively rare among chil- 
 dren. It has been observed to follow osteomyeHtis, erysipelas, sepsis, 
 enteric and relapsing fever, and syphilis. It has been attributed to ptomaine 
 and mushroom poisoning, to alcohol and to chloroform, to fright, and 
 to profound depressing emotions. The symptoms caused by phosphorus 
 poisoning resemble those of acute yellow atrophy, but the conditions are 
 neither etiologically nor pathologically identical. In rare instances acute 
 yellow atrophy has occurred as an intercurrent disease in hypertrophic 
 cirrhosis, bile stasis, and fatty degeneration of the liver. 
 
 The Exciting Cause. — The actual pathogenic principle is unknown. 
 Various micro-organisms, especially streptococcus and Bacillus coli, have 
 been found in the liver, but in many of the cases examined no bacteria have 
 been present. 
 
 Morbid Anatomy. — The liver is greatly reduced in size, flaccid, and 
 folded upon itself. Its capsule is wrinkled and of a dirty yellowish-green 
 color. Upon section the surface is mottled and the outlines of the lobules 
 are indistinct. These are yellowish masses surrounded by a dark reddish 
 tissue, the latter representing a more advanced stage. Microscopically 
 the hepatic cells are indistinct, bile stained, and in all stages of granular 
 and fatty degeneration and necrosis. The capillary vessels and bile-ducts 
 are destroyed, with resulting minute hemorrhages and extravasation of bile. 
 
 Symptoms. — The attack usually begins as an acute gastric catarrh, 
 which is shortly followed by more or less intense jaundice with clay- 
 colored stools — the initial stage. In the course of some days or, less fre- 
 quently, two or three weeks, during which the symptoms have remained 
 comparatively mild, the second stage sets in suddenly with vomiting, rest- 
 lessness, stupor, delirium, convulsions, and coma. Hemorrhages into the 
 skin and from mucous surfaces are common. The jaundice becomes more 
 intense. Pregnant women usually abort. There may be pain in the region 
 of the liver. The temperature is normal or subnormal, rising toward the 
 
CATARRHAL JAUNDICE. 983 
 
 end. Exceptionally there is marked fever throughout the attack. The 
 tongue is coated and dry. The action of the heart, normal or slow in the 
 initial stage, becomes rapid and feeble in the second stage, with enfeeble- 
 ment of the first sound and not rarely a soft, blowing, systolic murmur. 
 The liver, which is enlarged in the first stage, undergoes, with the develop- 
 ment of the cerebral symptoms, a rapid diminution in volume. There may 
 be complete absence of hepatic dulness, as the flaccid organ folds upon 
 itself and falls away from the abdominal wall, coils of intestines taking its 
 place. The splenic dulness is increased. The abdomen is very sensitive, 
 particularly in the epigastric zone, and there is spontaneous pain. The 
 urine is slightly decreased, contains bile pigments, generally small quan- 
 tities of albumin and tube-casts. Products of disordered metabolism, 
 such as leucin, tyrosin, and sarcolactic acid, are also present. Urea is much 
 diminished and the percentage of nitrogen present as ammonia correspond- 
 ingly increased. Leucin and tyrosin are sometimes absent from the urine. 
 Albumoses are sometimes present in small amounts. 
 
 Diagnosis. — Direct. — Intense jaundice, vomiting, diminished area 
 of liver dulness, hemorrhages, enlarged spleen, grave cerebral symptoms, 
 together with leucin and tyrosin in the urine, constitute a characteristic 
 symptom-complex. The initial stage cannot be distinguished from ordi- 
 nary gastroduodenal catarrh with jaundice. 
 
 Differential. — Hypertrophic Cirrhosis. — In rare cases there are 
 intense cerebral symptoms, but enlargement of the liver, fever, the absence 
 of leucin and tyrosin, and the long course of the disease prior to acute 
 cerebral symptoms are distinctive. 
 
 Acute Phosphorus Poisoning. — The symptoms may be almost iden- 
 tical, particularly in respect of hemorrhages, jaundice, and decrease in 
 liver dulness, but the gastric symptoms are usually more intense and set 
 in directly after the ingestion of the poison without a prodromal or initial 
 stage, the icterus rather abruptly on the third day, and leucin and tyrosin 
 are said to be absent from the urine. A dilated transverse colon may so 
 displace the liver upward as to simulate atrophy, but the gradual reduction 
 in the area of liver dulness from day to day is most significant. 
 
 Prognosis. — The disease is almost always fatal. The outlook is more 
 unfavorable when cerebral symptoms occur early. The duration of the 
 illness varies from a few days to two or three months. About half the cases 
 die between the fifth and fourteenth days, about one-third within five 
 weeks. The duration of the characteristic stage varies from one or two 
 days to a week. In the cases that run a favorable course the cerebral 
 symptoms are less violent and the duration of the disease is prolonged. 
 
 vi. Diseases of the Bile Passages and Gall=bladder. 
 
 CATARRHAL JAUNDICE. 
 
 Icterus Gastroduodenalis; Icterus Simplex. 
 
 Definition.^ — Jaundice due to swelling and mucus in the intestinal 
 portion of the common duct, the result of the extension of gastro- 
 intestinal catarrh. 
 
984 MEDICAL DIAGNOSIS. 
 
 Etiology. — Predisposing Influences. — Catarrhal jaundice is a com- 
 mon affection and is probably always associated with catarrhal inflam- 
 mation of the duodenal mucosa. All conditions which predispose to the 
 latter affection therefore favor its occurrence. Chief among these are 
 chronic alcoholism, chronic gastric catarrh, conditions favoring portal 
 obstruction, chronic valvular disease, and chronic nephritis. Malaria is 
 a well-recognized cause. The affection also frequently occurs in connec- 
 tion with the acute infections, particularly enteric fever and pneumonia. 
 
 Age exerts an important predisposing influence. Catarrhal jaundice 
 is a disease of young persons and is rare in middle and advanced age. It 
 is common in children after the second year. In adult life it is more common 
 in males than females. 
 
 The Exciting Cause. — The immediate cause is usually an acute 
 indigestion, sudden cold or exposure, or unusual physical strain with irreg- 
 ular meals. In many cases no causal factor can be discovered. When a 
 number of persons are exposed to the same local influences, as in a school,^ 
 a circumscribed epidemic of catarrhal jaundice may occur. 
 
 Morbid Anatomy. — The mucous membrane of the terminal portion, 
 of the common duct is swollen and the ampulla of Vater may be obstructed 
 by a plug of tenacious mucus. It is possible that the catarrhal process 
 may invade the smaller ducts, but of this we have no definite knowledge. 
 
 Eppinger recently found in the case of a girl who was instantly killed 
 by an accident on the ninth day of an attack of catarrhal jaundice that 
 the portion of the common duct which lies within the wall of the intestine 
 was impermeable and that the occlusion was due to hyperplasia of the 
 lymphoid tissue of the mucosa of the duct. It is probable that certain 
 cases of catarrhal jaundice are due to inflammatory swelling; others to 
 "the presence of a plug of tenacious mucus, and yet others to a hyperplastic 
 condition of the lymphoid tissue which surrounds the mucous glands of 
 the appendix in varying proportion in different individuals. 
 
 Symptoms. — In many cases the jaundice is preceded by epigastric 
 distress, loss of appetite, a coated tongue, and nausea and vomiting. Not 
 rarely there are also present headache, vertigo, mental depression. Fever 
 is not common, but the temperature may reach 101°-102° F. (38.3°-38.9° 
 C). The bowels are constipated and the stools hght in color but rarely 
 entirely free from bile pigment. The urine contains bile pigments and is 
 scanty and sedimentary but not often albuminous. Hyaline casts are 
 common. The skin and conjunctivae are more or less deej^ly jaundiced, 
 but the olive green of chronic jaundice does not occur. The nervous symp- 
 toms of jaundice are present in varying degree, especially pruritus and 
 drowsiness. Slowing of the pulse and respiration is less frequent. The 
 liver is usually slightly enlarged. The gall-bladder is rarely palpable. 
 Slight enlargement of the spleen is not uncommon. There are cases in 
 which the above symptoms do not occur and the patient's knowledge of 
 his being jaundiced is obtained from the looking-glass or the inquiries of 
 his friends. The duration of the affection is from two to six or eight 
 weeks, the jaundice gradually fading, the bile pigment first reappearing 
 in the stools, next disappearing from the urine and finally from the 
 sclera. There are cases of catarrhal jaundice which last two or three 
 
CHRONIC ANGIOCHOLITIS. 985 
 
 months with remissions and exacerbations, but the diagnosis in such 
 cases must be guarded, especially in elderly persons. 
 
 Diagnosis.— Direct. — The diagnosis may usually be made without 
 reserve from the youth of the patient, his previous fair health, the symp- 
 toms of gastric catarrh, the moderate intensity of the jaundice, and the 
 short duration of the affection. 
 
 Differential. — The diagnosis from cirrhosis, cholelithiasis, carcinoma^ 
 and Weil's disease is considered under those respective headings, to which 
 the reader is referred. It is important to remember that catarrhal jaundice 
 is rare in old persons and that a jaundice persisting beyond six or eight 
 weeks can only be regarded as catarrhal after a rigid process of exclusion 
 in regard to all other possible causes. 
 
 Prognosis. — The outlook in simple uncomplicated catarrhal jaundice 
 is highly favorable. It is a benign affection. 
 
 CHRONIC ANGIOCHOLITIS. 
 
 Definition. — Chronic inflammation of the bile-ducts. It may be 
 catarrhal or suppurative. 
 
 1. Chronic catarrhal cholangitis may occur as a sequel of acute catarrh. 
 It is always combined with obstruction of the common duct, and is there- 
 fore an associated condition in cholelithiasis, parasites, cancer, stricture, 
 and compression of the common duct from without. The obstruction may 
 be complete or incomplete. 
 
 (a) Complete Obstruction. — The bile passages, the gall-bladder, and 
 the intrahepatic ducts are dilated and contain clear mucus, which is usually 
 sterile. The patients are persistently and deeply jaundiced. Fever is 
 commonly absent. 
 
 (b) Incomplete Obstruction. — There are one or more calculi in the 
 common duct and, as a rule, in the gall-bladder, or there is pressure from 
 the outside. The bile may escape in small amounts continuously, or the 
 obstruction may be intermittent. The bile passages and gall-bladder are 
 not usually greatly dilated. They contain a thin, bile-stained mucus. 
 The jaundice may vary in intensity and the stools show the presence of 
 bile pigments. Febrile attacks, — hepatic fever, — characterized by chills^ 
 rapid rise of temperature, and profuse sweating, are common in this form 
 of obstruction and are doubtless caused by infection. 
 
 2. Suppurative cholangitis affects the large and small ducts. In the 
 majority of the cases the gall-bladder is also involved. There is dilatation 
 of the bile passages and particularly of the common ducts. The walls are 
 thickened. The intrahepatic ducts are much dilated, and minute collec- 
 tions of pus mixed with bile are formed by the suppurating ducts and 
 disintegrating hepatic tissue. There is usually distention of the gall- 
 bladder, which is filled with pus, occlusion of the cystic duct, and adhesive 
 inflammation of the gall-bladder to adjacent parts. Suppurative cholan- 
 gitis constitutes one of the most serious complications of cholelithiasis. 
 It occurs also in consequence of the presence of foreign bodies, as fish bones, 
 or intestinal parasites, as ascarides, which find their way into the ducts 
 from the intestine, and in connection with cancer of the ducts. It is a 
 somewhat rare sequel of enteric fever, pyaemia, and dysentery. 
 
986 MEDICAL DIAGNOSIS. 
 
 The onset is insidious. The symptoms vary in intensity and are iiot 
 always characteristic. As a rule they are severe, consisting of jaundice, 
 enlargement of the liver, pain and tenderness in the region of the gall- 
 bladder, which is often distended, fever of septic type, and a marked 
 leucocytosis. There is commonly a history of biliarj^ colic. Pylephle- 
 bitis, endocarditis, purulent meningitis, and peritonitis are occasional 
 complications. 
 
 The diagnosis of suppurative cholangitis rests upon a history of gall- 
 stones, jaundice, intermittent fever of hectic type, tenderness and pain in 
 the region of the gall-bladder. The fever is to be distinguished from malaria 
 by the leucocytosis, the variable periodicity, and above all by the absence 
 of blood parasites. A tender point in the region of the twelfth dorsal verte- 
 bra, 2.5 to 3 cm. from the middle line, may be present in inflammation of 
 the bile-ducts (Boas). In cases occurring in association with the acute 
 infections jaundice may be absent or slight. The differential diagnosis 
 between certain cases of suppurative cholangitis and abscess of the liver 
 may be attended wdth difficulty. In favor of the latter condition are 
 absence of jaundice, slight fever or even subnormal temperature, and the 
 absence of tenderness and pain in the region of the gall-bladder. 
 
 The outlook is highly unfavorable. The reestablishment of biliary 
 drainage by the escape of the stone or its removal by operation may be 
 followed by recovery. In a case recently under my observation operation 
 failed and there were many small calculi pocketed in abscess cavities 
 throughout the liver. 
 
 VARIOUS LESIONS OF THE BILE PASSAGES. 
 
 It is convenient to consider ulceration, perforation, stricture, and 
 fistulse of the bile-ducts in connection with cholelithiasis, which is their 
 usual cause. 
 
 The lumen of the common duct may be partially or completely 
 occluded by the seeds of fruit and by certain parasites, among which 
 lumbricoid worms are common and echinococci and distomata rare causes 
 of obstruction in man. 
 
 Obstruction by pressure from without is more common. Carcinoma 
 or fibroid thickening of the head of the pancreas, or, in rare instances, 
 cancer of the pylorus, enlarged lymph-glands, abdominal tumors, and 
 aneurism of the coeliac axis may compress the common duct. 
 
 The symptoms have already been described in connection with com- 
 plete and incomplete obstruction under the heading Chronic Angiochohtis. 
 Complete permanent occlusion of the common duct terminates in death. 
 The conditions which cause occlusion by pressure from without are usually 
 fatal. The diagnosis of the cause of the obstruction may be difficult. 
 Colic, with variable jaundice and intermittent fever, suggests cholehthiasis. 
 Cancerous disease in the rectum or genito-urinary tract, or the stomach 
 or intestines, points to secondary glandular infiltration as the cause of 
 biliary stasis and jaundice. Accessible groups of lymph-nodes and, in 
 particular, the clavicular lymphatic glands may also be enlarged. The gall- 
 bladder is frequently distended and may be distinctly palpable. 
 
INFLAMMATION OF THE GALL-BLADDER. 987 
 
 INFLAMMATION OF THE GALL-BLADDER; CHOLECYSTITIS. 
 
 The condition maj' be acute or chronic. 
 
 1. Acute Cholecystitis. — The inflammation may be catarrhal, sup- 
 purative, or phlegmonous. These forms sometimes represent different 
 degrees of intensity. 
 
 Etiology. ■ — Acute cholecystitis is commonly due to gall-stones. It 
 may, however, result from bacterial invasion in the absence of cholelithiasis. 
 It is common in the infectious fevers and a subacute form is very 
 often met with in enteric fever. The usual pathogenic organisms are 
 the colon bacillus, the bacillus of Eberth, the pneumococcus, strepto- 
 coccus, and staphylococcus. The condition is frequently associated with 
 cholangitis and dilatation of the bile passages. The gall-bladder is usually 
 distended. In subacute cases of long duration distention may be pre- 
 vented by fibrous thickening of the walls. Adhesions with the adjacent 
 parts of the liver or the omentum or colon may take place. The cystic 
 duct is frequently occluded even in the absence of an impacted calculus. 
 The enlargement sometimes takes place upward and inward and 
 there is no palpable tumor. The contents may be a thin, dark-greenish 
 mucus, or mucopurulent, purulent, or hemorrhagic. Perforation may 
 take place, with abscess formation limited by the adhesions or into the 
 peritoneal cavity. 
 
 Symptoms. — In the milder forms there may be simply some tumefac- 
 tion with dulness, circumscribed tenderness, and a rise of temperature. 
 This form is common in enteric fever. The severe forms are ushered in 
 with intense paroxysmal pain in the region of the gall-bladder, the epi- 
 gastrium, or in the right upper quadrant of the abdomen. With this are 
 associated nausea and vomiting, arrest of peristalsis, rigidity of the abdom- 
 inal muscles and especially of the rectus upon the right side, and fever. 
 The enlarged gall-bladder may be sometimes recognized upon palpation 
 and percussion, but as a rule the extreme tenderness interferes with 
 physical examination. In the absence of gall-stones jaundice does not 
 commonly occur. 
 
 Diagnosis. — Direct. — The milder forms are readily recognized; in 
 the more severe cases the condition is often very obscure. The anamnesis 
 is important. The above symptom-complex occurring in a patient who 
 has had attacks of hepatic colic or cholecystitis, or who is convalescent 
 from enteric fever or pneumonia, is significant. The recurrent forms are 
 readily diagnosticated. It is important to remember that cholecystitis 
 may occur without gall-stone disease. 
 
 Differential. — The condition may simulate acute obstruction of 
 the bowels or appendicitis. While these conditions may be differentiated 
 from acute cholecystitis by characteristic symptoms in a large proportion 
 of the cases, there are instances in which the actual organ affected has been 
 revealed only upon operation. 
 
 Prognosis. — The outlook depends upon the intensity of the inflam- 
 matory process. The purulent and phlegmonous forms are usually fatal. 
 Timely surgical intervention may be the means of saving life. The danger 
 of perforation is to be constantly borne in mind. 
 
988 MEDICAL DIAGNOSIS. 
 
 2. Chronic Cholecystitis. — The common cause of chronic cholecystitis 
 is cholehthiasis. The disease may arise in consequence of extension of the 
 infiammation in cholangitis. The muscular and connective-tissue elements 
 of the wall are involved. When the contents undergo resorption, or escape 
 through the cystic duct or by way of a fistulous opening, the thickened 
 wall contracts and the gall-bladder becomes permanently reduced in size. 
 Its walls under these circumstances are sometimes the seat of calcareous 
 changes. Pericholecystitis may develop with diffuse swelling around the 
 organ, and later fluctuation. The cystic duct may be completely occluded 
 by a calculus or by cicatrices. The bile is then absorbed, the mucous 
 membrane, however, continues to secrete an abnormal mucus, and the 
 gall-bladder undergoes gradual distention with thickening of its walls 
 and sometimes more or less extensive peritoneal adhesions. The contained 
 liquid may be light in color and bile-free, — dropsy of the gall-bladder, — - 
 or it may be pus — empyema. Gall-stones are frequently present. 
 
 Symptoms. — When the dilatation is slight the gall-bladder extends 
 below the border of the liver but cannot be palpated unless the abdominal 
 walls are thin. As the enlargement proceeds it constitutes a palpable 
 pear-shaped tumor, which is movable from side to side and may be dis- 
 placed backward by moderate pressure, but which resumes its position 
 when the pressure is withdrawn. The enlarged gall-bladder moves upward 
 and downward with the respiratory play of the diaphragm and partakes 
 of the movements of the liver. It may be greatly enlarged and elongated, 
 and instances have been noted in which the contents have amounted to a 
 litre. When the fundus presents toward the abdominal wall and a loop 
 of intestine has found its way into the space between the fundus and the 
 liver, the condition may simulate an echinococcus or ovarian cyst or 
 hydronephrosis. If the walls of the abdomen are thin and relaxed, the 
 tumor formed by a dilated gall-bladder may be visible. Urgent as the- 
 symptoms attending the disease which has caused the dilatation may 
 have been, the condition itself usually causes no important subjective 
 symptoms. When pain and tenderness are present they are commonly- 
 due to local adhesions and peritonitis. 
 
 Diagnosis. — Direct. — The diagnosis may be difficalt. The anamnesis, 
 the palpable and visible tumor connected with the liver and partaking of 
 its movements, its cystic nature, its elasticity, its gourd-shaped outline, 
 its mobility and tendency to at once resume the position from which it 
 has been manipulated constitute adequate data for a positive diagnosis. 
 The nature of the contents can only be ascertained by their removal. 
 For this purpose an exploratory coeliotomy can be performed, — never an 
 exploratory puncture, which is attended with the danger of the escape of 
 a portion of the fluid into the peritoneal sac. 
 
 Differential. — The diagnosis from an echinococcus cyst may be 
 attended with great difficulty. The hemispherical form, more restricted 
 movements, and hydatid thrill are significant. In hydronephrosis the 
 deeper origin, relatively slighter mobility, except in floating Iddney, and 
 the outline are of diagnostic importance, and the occasional disappearance 
 of the tumor with great diuresis seen in intermittent hydronephrosis would 
 be distinctive. Ovarian cysts spring from the pelvis and can be shown 
 
CHOLELITHIASIS. 989 
 
 by vaginal and bimanual examination not to be connected with the liver 
 but with the uterus. 
 
 Prognosis. — In many cases it is favorable after the tumor has ceased 
 to enlarge and is of moderate size. The inconvenience resulting from its 
 presence and pressure upon adjacent organs, and the danger of adhesions 
 and fistula formation, and, in particular, the danger of rupture justify drain- 
 age or excision, which is often followed by complete restoration to health. 
 
 CANCER OF THE BILE=DUCTS AND GALL-BLADDER. 
 
 Primary malignant disease of the gall-bladder is commonly asso- 
 ciated with gall-stones — 70 to 100 per cent, according to various statistics. 
 The symptoms of the condition often gradually supervene upon those 
 caused by biliary calculus. The fundus is often the starting-point of the 
 growth, which early becomes manifest as a dense tumor in the region of 
 the gall-bladder, developing downward and toward the median line, and 
 not movable by reason of firm adhesions and implication of the surround- 
 ing tissue. The mass may attain large dimensions. The gall-bladder is 
 sometimes greatly distended. The condition is much more common in 
 males than females and commonly appears after the fortieth year of hfe. 
 Pain is a prominent symptom. It is often paroxysmal but continues 
 throughout the intervals. There is also more or less tenderness. Jaundice 
 is present in a majority of the cases. It may be due to implication of the 
 ducts or to pressure upon their walls. 
 
 Primary cancer of the bile passages is comparatively rare. The com- 
 mon duct is usually the starting-point of the growth, which may involve 
 the walls of the ampulla of Vater and invade the hepatic and cystic ducts. 
 There is rarely a palpable tumor. Jaundice occurs early and is persistent. 
 If the carcinomatous infiltration involves the portal vein ascites results. 
 There is often profound anaemia, but early cachexia may not be present. 
 Cholsemia is a common terminal condition. Extension to the liver gives 
 rise to symptoms characteristic of carcinoma of that organ. 
 
 CHOLELITHIASIS. 
 
 Gall-stone Disease. 
 
 Definition. — A condition characterized by the formation and presence 
 of bihary calcuh in the gall-bladder or bile passages. The great majority 
 of gall-stones are formed in the gall-bladder. 
 
 Etiology. — Predisposing Influences. — All conditions which give 
 rise to the stasis of bile in the gall-bladder predispose to cholelithiasis. 
 The outflow of bile may be impeded by partial or complete occlusion of 
 the bile-ducts by catarrhal swelling of their mucous membrane, the pres- 
 ence of calculi or parasites, adhesions in the region of the porta, or compres- 
 sion by enlarged lymph-glands, the head of the pancreas, or the duodenum. 
 Atrophy of the musculature of the gall-bladder from distention or age may 
 lead to stagnation of the bile. Lacing plays an important part, (a) by 
 restricting the movements of the diaphragm, (b) by causing elongation 
 of the liver, displacement of the gall-bladder, and bending or twisting of 
 
990 MEDICAL DIAGNOSIS. 
 
 the cystic duct, (c) by inducing changes in the anatomical relations which 
 expose the cystic duct to compression, especially when there is, as is fre- 
 quently the case, displacement of the right kidney, and (d) by causing 
 gastroduodenal catarrh which may be followed by cholangitis and chole- 
 cystitis. Relaxation of the abdominal walls and enteroptosis favor the 
 stagnation of bile in the gall-bladder. Lack of exercise, prolonged rest in 
 bed in convalescence from acute or in chronic disease, and sedentary occu- 
 pations constitute predisposing factors of importance, especially when 
 combined with overfeeding and constipation. Cardiac affections, and in 
 particular mitral stenosis, predispose to gall-stone disease by the passive 
 visceral congestion and catarrhal processes to which they give rise and 
 by the sedentary life which they enforce. There are great differences in 
 the prevalence of gall-stone disease in different localities and different 
 countries, as determined by post-mortem statistics, — a fact ascribed to- 
 local differences in mode of life, occupation, and the influence of endemic 
 diseases, which by causing gastro-intestinal catarrh may become indirect 
 factors in the production of calculi. The rare cases reported in the new- 
 born and in infancy are simply clinical curiosities. The disease is rare 
 under thirty. The liability increases progressively after forty. Women 
 suffer more frequently than rnen in the proportion of 3 to 2. The pressure 
 of the pregnant uterus upon the bile-ducts and its interference with the 
 movements of the diaphragm, and the relaxation of the abdominal wall 
 after frequent pregnancies are to be considered. The more sedentary life 
 of women constitutes a predisposing influence of importance. 
 
 The Origin of Gall-stones. — The theory of Naunyn is generally 
 accepted. A catarrhal condition of the mucosa of the gall-bladder, lead- 
 ing to an increased formation of cholesterin and lime salts, is the primary 
 cause of the formation of gall-stones. This lithogenous catarrh may be 
 produced by various causes, but the most important factor in its produc- 
 tion is the presence of various bacteria. Among those which have been 
 isolated are the colon bacilli, streptococci, staphylococci, pneumococci, 
 and typhoid bacilli. They may gain access to the gall-bladder by way of 
 the blood, or from the intestine by way of the common and cystic ducts. 
 They have been demonstrated in the centre of a gall-stone. Cholesterin, 
 lime salts, and bilirubin deposited around collections of epithelial debris 
 and bacteria constitute the beginnings of biliary calculi. The masses thus 
 formed grow in size by the gradual accretion of similar substances. Gall- 
 stones have been experimentally produced by the injection of cultures of 
 bacteria into the gall-bladder of animals. The above facts account for the 
 frequent occurrence of cholelithiasis after the acute infectious fevers, 
 especially enteric fever. 
 
 The Chemical and Physical Characters of Gall-stones. — Gall- 
 stones are composed chiefly of cholesterin, bilirubin in combination with 
 calcium, and calcium carbonate. These constituents are present in vary- 
 ing proportions. Ordinary calculi consist of 70 to 90 per cent, of amorphous 
 or crystalline cholesterin. The small, dark stones found in the ducts are 
 principally composed of pigment in combination with calcium and calcium 
 carbonate. Free bile pigment is not usually present. Traces of iron, man- 
 ganese, and copper, and bile acids and fatty acids are also present. The 
 
CHOLELITHIASIS. 991 
 
 • 
 
 color of the stones is not uniform, but irregular, and depends upon the 
 quantity, character, and mode of deposit of the pigment which they con- 
 tain. White or pale fawn-colored calculi consist of nearly pure cholesterin. 
 Other stones may be yellow, greenish, or brown. An excess of pigment 
 may give them a dark reddish-brown or black color. The cortex, main 
 body, and nucleus are usually colored differently. The consistency also 
 varies. Cholesterin stones are often so soft that they may be crushed 
 between the fingers. Recently formed concretions are commonly soft; 
 older ones may be harder with a soft central nucleus. The outer layer 
 may be hard and enclose an unformed mass of cholesterin. The larger 
 the proportion of lime salts the harder the calculus. Section usually shows 
 the cholesterin to be deposited in concentric layers with radiating crystal- 
 line striae, the result of recrystallization. 
 
 Gall-stones vary in number from one to hundreds or even a thousand 
 or more. Single stones are usually ovoid and may be of large size — 3 or 4 
 cm. or, in one reported instance, 7.5 cm. in long diameter. The solitary 
 stone is usually closely embraced by the gall-bladder. Multiple calculi 
 are commonly polygonal, with smooth, faceted surfaces, and owe this form 
 to the pressure exerted among themselves while soft. Traces of faceting 
 may be seen in the small calculi numbered by hundreds occasionally met 
 with. It sometimes happens that a small number of ovoid, unfaceted 
 calculi are found. They are of the dense variety and consist largely of the 
 bilirubin-calcium combination. When this form is present in great num- 
 bers, the individual stones are not larger than small shot and are spoken 
 of as gall-sand. Gall-stones impacted in the ducts sometimes undergo 
 enlargement by further accretions of cholesterin and lime salts. Stones 
 are found in this situation of such a size that they could not have passed 
 through the cystic duct. Small, ovoid, greenish-black calculi are some- 
 times found in the intrahepatic bile-ducts, especially in cirrhosis of the 
 liver. In a majority of the instances they are all of the same variety 
 and composed of bilirubin-calcium. In fact, in cases in which numerous 
 gall-stones are present, they are almost always all of the same variety. 
 
 Symptoms. — The subject of cholelithiasis may be clinically consid- 
 ered under the following headings: gall-stones quiescent in the gall-bladder; 
 the symptoms which attend the passage of a stone through the ducts; the 
 symptoms produced by the permanent obstruction of the ducts; ulcer- 
 ative lesions caused by gall-stones; and gall-stones in the intestines. 
 
 1. Gall-stones Quiescent in the Gall=bladder. — In a great majority of 
 cases biliary calculi, so long as they remain in the gall-bladder in which 
 they are formed, produce no symptoms. Their presence in this viscus is 
 frequently discovered at the autopsy in cases in which they have caused 
 no manifestations whatever during life. According to Kehr symptoms 
 occur in only about 5 per cent, of all cases. Persons who suffer from 
 repeated attacks of biliary coHc frequently have no trouble from them 
 during the intervals. In a small proportion of the cases there are symptoms 
 which suggest their presence, even though they are not sufficiently char- 
 acteristic to justify a positive diagnosis. When, however, such symptoms 
 occur during the intervals between attacks of colic, especially when such 
 attacks have been followed by the passage of faceted calculi, their signif- 
 
992 MEDICAL DIAGNOSIS. 
 
 • 
 
 icance is clear. These symptoms consist of subjective sensations of weight 
 in the right hypochondrium, aggravated some hours after taking food, 
 frequent dull pain in the region of the gall-bladder radiating toward the 
 right shoulder and the lumbar region, and nervous and mental derange- 
 ments such as are common in neurasthenia — depression, irritability, pre- 
 cordial and epigastric distress, and headache, coryza, and flying neuralgic 
 pains. Upon physical examination the gall-bladder may sometimes be 
 found to be enlarged and palpable, and in very rare instances a fremitus 
 caused by the movement of multiple calculi among themselves may 
 be detected. 
 
 Gall-stones in the intrahepatic ducts rarely give rise to symptoms. 
 If numerous or large they may occasion pain, enlargement of the liver, or 
 jaundice, but these symptoms are. not of diagnostic value. When infection 
 takes place they cause diffuse intrahepatic cholangitis. 
 
 2. The Symptoms Attending the Passage of a Qall-stone Through the 
 Ducts. — Gall-stones occasionally become arrested in the cystic or the com- 
 mon duct without causing pain. Small stones may traverse these passages 
 without giving rise to colic. This has been observed in cases in which the 
 repeated passage of larger stones is inierred to have caused a gradual 
 dilatation of the ducts. When stones of a larger size are passed by 
 the bowel in the absence of a history of colic, it is probable that they 
 have reached the intestine by way of a fistulous communication with 
 the gall-bladder or ducts. 
 
 Biliary Colic. — Commonly the passage of a gall-stone is attended by the 
 symptoms of gall-stone colic. The attack usually begins with violent pain in 
 the right hypochondrium with its focus of intensity in the region of the gall- 
 bladder. In some cases the pain is referred to the epigastrium or the lower 
 thoracic region, or on both sides, or to the right mammary region. It may 
 radiate toward the abdomen or back, and occasionally to the right shoulder. 
 It is usually agonizing and the patient groans and rolls about in uncontrolla- 
 ble distress, or he may twist his body to the right, or sit with his thighs and 
 knees strongly flexed and his body bent forward so as to relax the abdomr 
 inal muscles. There may be temporary remissions of pain which are fol- 
 lowed by exacerbations of greater violence. The gall-bladder is often 
 palpable and tender, and the liver may be somewhat enlarged, with ten- 
 derness over the hepatic area. Vomiting, chills or chilliness, a rise of tem- 
 perature sometimes to 103°-104° F. (39.5°-40° C), profuse sweating, and 
 great general relaxation occur. In casp'^ ^' arked by high fever there may 
 be enlargement of the spleen and febrile albuminuria. It is probable that 
 there are under these circumstances bacterial invasion and acute chol- 
 ecystitis. The fact that the symptoms of gall-stone colic are sometimes 
 present in acute cholecystitis without gall-stones is not to be overlooked. 
 Jaundice is a common symptom. It does not occur so long as the stone is 
 engaged in the cystic duct, but follows the lodgement of the stone in the 
 common duct. When the stone is of small size and passes rapidly through 
 the common duct into the intestine, jaundice may not occur. In any case 
 jaundice does not occur until several hours, often twenty-four, have 
 elapsed from the beginning of the attack. It is usually transient, but 
 may persist for several days or weeks. The jaundice is the very type of 
 
CHOLELITHIASIS. 993 
 
 obstructive jaundice and is associated with clay-colored stools, the 
 presence of bile pigments in the urine, itching of the skin, and other 
 characteristic symptoms. 
 
 The duration of the attack varies from a few hours to several days. 
 When the stone escapes into the intestine the pain ceases, often as abruptly 
 as it began, leaving some degree of local tenderness, which rapidly subsides, 
 and lassitude, from which the patient gradually recovers. Not rarely the 
 stone lodges in the ampulla of Vater and acts as a ball-valve, causing recur- 
 rent attacks of pain and jaundice. The pain is a true coHc caused by the 
 spasmodic contraction of the musculature of the bile-ducts and the violent 
 pressure of the stone upon the mucous membrane. The swelling and 
 tenderness of the gall-bladder and liver are due to bile stasis and conse- 
 quent distention of these organs. In bacillary invasion there is the super- 
 added pain of inflammation. Rare accidents are fatal syncope and the 
 rupture of the gall-bladder into the peritoneal sac. Palpitation and pre- 
 cordial distress may occur, while general convulsions and hysterical seizures 
 are occasionally observed in neurotic subjects. 
 
 Direct Diagnosis of Biliary Colic. — The diagnosis rests upon 
 the location of the focus of pain, its radiation, local tenderness, the abrupt 
 onset of the attack, vomiting, chill or chilliness, with fever and the symp- 
 toms of obstructive jaundice. The history of previous attacks is sugges- 
 tive; the presence of gall-stones in the stools is conclusive. Their absence 
 is, however, only of negative importance in diagnosis. It may be due to 
 a faulty method of examination, to the return into the gall-bladder of a 
 stone which has engaged in the cystic duct, to cessation of muscular spasm 
 in the walls of the ducts, to the passage of the stone from the narrow cystic 
 duct into the wide common duct and its retention there, and, finally, to 
 the disintegration of the stone in the intestine. 
 
 The stools must be thoroughly stirred with a large quantity of water 
 and poured through a fine-meshed sieve. The coarser particles are retained 
 and can be examined. A double bag of netting may be arranged upon a 
 stout wire ring like a landing net and placed in the bowl of the water- 
 closet. The faeces may be washed by repeated flushing and the retained 
 particles examined for calculi. If they are not at first found every stool 
 should be examined for several daj^s, as they may be retained in the 
 intestine for some time. Force should not be used in the examination, 
 since recently formed biliary calc."''' -are soft and may readily be disin- 
 tegrated in handling them. The seeds of various fruits, particles of bone, 
 and small fecal concretions are sometimes brought to the physician as 
 gall-stones, and the rounded saponaceous masses voided after the ingestion 
 of large quantities of olive oil are frequently mistaken for them, but these 
 substances never contain cholesterin or bile pigment in quantity, nor do 
 they present the internal structure of gall-stones. 
 
 Differential Diagnosis. — In right-sided renal colic the pain begins 
 in the lumbar region and radiates toward the groin. There is retraction 
 of the testicle and pain in the glans penis. Jaundice, tenderness in the 
 region of the gall-bladder, and fever are not usually present. A calculus 
 may be voided by way of the urethra. Peptic ulcer may suggest biliary 
 colic. The pain, however, usually follows the ingestion of food and is burn- 
 63 
 
994 MEDICAL DIAGNOSIS.. 
 
 ing in character, passing to the back. The vomiting is less urgent and 
 the vomitus may contain blood. There is localized epigastric tenderness 
 and anaemia. Nervous hepatic colic — the pseudobiliary colic of nervous 
 women — may lead to an erroneous diagnosis. The pain is referred to the 
 right side and may radiate to the back or shoulder. It is dull and dragging 
 rather than colicky. The attack follows emotional excitement or fatigue. 
 There may be tenderness upon pressure, but jaundice does not occur. 
 Intestinal colic is relieved by belching, the passage of flatus, or defecation. 
 It is more generalized and less intense than biliary colic and not followed 
 by jaundice. Lead colic may simulate gall-stone colic, but the occupation 
 of the patient is suggestive, while stubborn constipation, the gingival line, 
 wrist-drop, hard arteries, and albuminuria constitute a characteristic 
 symptom-complex. Jaundice is absent. 
 
 3. The Symptoms Caused by Permanent Obstruction of the Ducts by QaH= 
 stones. — The obstruction may involve the cystic duct, the common duct, or 
 the hepatic ducts. 
 
 I. Obstruction of the Cystic Duct. — Occlusion of the cystic duct 
 by a calculus or by the contraction of a cicatrix following ulceration does 
 not always cause serious symptoms. It is liable to be followed by, (a) 
 dropsy of the gall-bladder — hydrops vesicce fellece. The tumor is cystic 
 and gourd-shaped or pear-shaped, its narrow extremity being at its con- 
 nection with the liver. The contents in recent cases are bile mixed with 
 mucus or mucopus, — in older cases a clear, thin mucus containing albumin 
 and of variable reaction to litmus paper. The tumor projects downward 
 and may attain large dimensions. It is freely movable from side to side, 
 unless fixed by adhesions, and when pushed backward turns to its original 
 position as soon as the pressure is withdrawn. When the belly wall 
 is thin and relaxed the outline of the distended gall-bladder may be visible, 
 fluctuation may be eHcited upon light bimanual percussion and palpation, 
 and when there are many calculi present gall-stone crepitus may be felt, 
 (b) Atrophy of the Gall-bladder. — This condition frequently follows dropsy 
 of the gall-bladder. The contents undergo gradual resorption and the 
 bladder contracts around any stones that it may contain, or, in the 
 absence of a stone, into a small fibrous mass, or there may be diverticula 
 in which calculi are embedded. In old cases of this kind lime salts are 
 sometimes deposited upon the mucosa or in the bladder wall, (c) Acute 
 cholecystitis, usually simple but in rare cases phlegmonous, (d) Suppura- 
 tive cholecystitis — empyema of the gall-bladder. The gall-bladder may be 
 greatly enlarged and contain as much as a litre of pus. Perforation may 
 take place into the peritoneal cavity; more commonly adhesions take 
 place with abscess formation. 
 
 The occurrence of these conditions may constitute the first direct 
 evidence of cholelithiasis. Under no circumstances should exploratory 
 puncture be performed. Aspiration has been followed by fatal results. 
 
 II. Obstruction of the Common Duct. — The duct may be occluded 
 by a single stone in the ampulla of Vater or in any part of its course or by 
 a number of stones which may also extend into the cystic and hepatic ducts. 
 The obstruction may be, (a) complete. The calculus is tightly impacted 
 in the common duct, or a large stone in the cystic duct compresses 
 
CHOLELITHIASIS. 995 
 
 the common duct at its upper part or the hepatic duct. There is complete 
 bile stasis with deep and persistent jaundice and without septic phenomena. 
 The common duct behind the obstruction, and the cystic and hepatic ducts 
 may be enormously dilated and simulate the gall-bladder, for which they 
 have been mistaken. The condition cannot always be differentiated from 
 compression of the duct by new gi'owths, though pain, a history of biliary 
 colic, and absence of dilatation of the gall-bladder are in favor of a diagnosis 
 of complete obstruction by gall-stones. Or, (b) incom'plete. In this form 
 there is cholangitis, which may be simple or suppurative. («) Incomplete 
 obstruction with non-suppurative cholangitis. There may be a single 
 movable calculus in the diverticulum of Vater or in the duct above it, — 
 ball-valve mechanism, — or a small faceted stone partially impacted, or 
 a series of stones. The ducts above the obstruction are dilated, but the 
 gall-bladder is often contracted. There are variations in the degree of 
 jaundice and in the amount of bile pigment in the faeces. The liver is only 
 slightly enlarged and the gall-bladder, as a rule, not at all distended. Finally 
 there are irregular attacks of fever accompanied with demonstrable enlarge- 
 ment of the spleen. In well-marked cases of ball-valve calculus the 
 paroxysms of fever are irregularly recurrent and resemble attacks of ague. 
 They are characterized by remarkable rises of temperature, — 103°-106° F. 
 (39.5°-41.1° C), — intense chills, profuse sweating, gastric disturbances and 
 hepatic tenderness and pain. The jaundice is variable and often intense. 
 The resemblance to malaria is superficial, the periodicity not being regular, 
 the blood parasite not present, and quinine useless. This fever is known as 
 hepatic fever or the hepatic intermittent fever of Charcot. The attacks in 
 many instances recur after irregular intervals, during which the tempera- 
 ture is normal, for many months. 
 
 Courvoisier's Law. — In the great majority of cases of obstruction of the 
 common duct by gall-stone the gall-bladder is contracted; in the majority 
 of cases of obstruction from other causes the gall-bladder is dilated, 
 
 (/?) Incomplete obstruction with suppurative cholangitis. The 
 ducts are invaded by pyogenic organisms. The suppurative inflammation 
 may extend to the intrahepatic ducts — diffuse intrahepatic cholangitis — 
 and to the gall-bladder — empyema. Abscess of the liver and perforation 
 of the gall-bladder with abscess formation may occur. There are septic 
 phenomena. The hver is enlarged and tender; jaundice is of moderate 
 intensity and persistent and there is fever of intermittent or remittent 
 type. The course of the disease is comparatively short and the termination 
 fatal. This is by no means rare as a terminal condition in old cases of 
 cholelithiasis. 
 
 In cholelithiasis of the common duct there is frequently an asso- 
 ciated catarrhal or interstitial pancreatitis and Cammidge's test may show 
 characteristic cr3'stals. 
 
 4. Ulcerative Lesions Caused by Gall-stones. — Biliary fistulse are far 
 from uncommon. Ulceration of the bile passages may occur without 
 symptoms. As a rule, however, they tend to grave derangements of health. 
 By the erosion of arterial branches in the course of the formation of fistu- 
 lous tracts in various directions, they may cause hemorrhages which may 
 be latent or manifest in the stools or vomit. In rare instances gall-stones 
 
996 MEDICAL DIAGNOSIS. 
 
 have perforated into the portal vein. Much more common are fistulous 
 communications with the intestinal tract. The stomach is involved com- 
 paratively rarely, the duodenum frequently, the small intestine much 
 less commonly, while fistulous communications with the colon have been 
 occasionally encountered. There are instances of fistulse involving the 
 ureters, with the passage of stones into the bladder and of the direct pas- 
 sage of biliary calculi into the urinary bladder. Perforation into the pleura 
 and into the lung may also occur. Cutaneous fistulas of spontaneous origin 
 are ver}^ uncommon, though they are by no means rare after operation. 
 They usually open in the region of the fundus of the gall-bladder, but may 
 appear near the umbilicus or above the pubes. The formation of these 
 ulcerative tracts is always preceded by adhesions between the viscera 
 directly involved and followed by the discharge of biliary calculi into 
 the distant organ. The tracts themselves are often long and tortuous 
 and sometimes there are diverticula containing gall-stones. Abscess 
 formation is common. 
 
 5. Qall=stones in the Intestines. — When by way of the common duct, 
 as sometimes may occur, or by a fistulous tract, a large gall-stone finds its 
 way into the gut, it may cause intestinal obstruction, either directly or by 
 ulceration followed by cicatricial contraction. The obstruction may occur 
 at the pylorus and cause symptoms suggestive of carcinoma. More com- 
 monly it is in the lower part of the ileum. In the region of the caecum the 
 condition may simulate appendicitis. A small stone may enter the appendix 
 or a diverticulum. A stone in the colon may sometimes be recognized upon 
 rectal examination. 
 
 Diagnosis. — Cholelithiasis is recognized during life in a small propor- 
 tion of the cases only. The direct diagnosis while the gall-stones remain 
 quiescent in the gall-bladder may, in rare instances, be made by the dis- 
 covery of a tumor in the region of the gall-bladder in which gall-stones 
 may be felt. The walls of the bladder may be thickened by chronic inflam- 
 mation or the seat of nodular carcinomatous growths. The differential 
 diagnosis between an enlarged gall-bladder and a tumor of the kidney 
 depends upon the fact that the former may be pushed backward into the 
 abdomen, but directly returns to its former position, while the latter will 
 remain in the position into which it is replaced. 
 
 Cholelithiasis cannot, as a rule, be demonstrated by the X-rays, since 
 the stones are mostly composed of cholesterin and organic matter which 
 do not cast a shadow, and such shadows as are cast by those more densely 
 constituted are obscured by the shadow of the Hver. 
 
 The attack of colic is commonly the first positive sign of gall-stone 
 disease. The symptoms of biliary colic and the differential diagnosis 
 between that affection and others which resemble it have already been 
 discussed. The discovery of gall-stones in the stools constitutes a positive 
 diagnostic sign. 
 
 Exploratory puncture of the gall-bladder is attended with the danger 
 of the escape of some of the contained fluid into the peritoneum and a 
 general peritonitis. It is therefore to be emphatically condemned. An 
 exploratory operation by incision is, on the other hand, comparatively safe 
 and wholly justifiable in the presence of obscure and dangerous symptoms. 
 
AFFECTIONS OF THE BLOOD-VESSELS OF THE LIVER. 997 
 
 Prognosis. — The fact that in a large majority of the cases no symp- 
 toms occur, and that the diagnosis is so often simply a post-mortem finding, 
 justifies the assertion that cholelithiasis is a benign disease. Although it is 
 so often latent it is not, however, free from danger. On the contrary, the 
 migration of the stones by way of the natural passages and, to a greater 
 extent, by artificial channels caused by ulceration and adhesions may be 
 attended by great suffering and serious risk of life. Even under these cir- 
 cumstances the outlook is not wholly unfavorable. AVhen infection of the 
 bile passages and gall-bladder has taken place with septic fever, especially 
 when empyema of the gall-bladder, suppurative cholangitis, or abscess of 
 the liver has occurred as a complication, the prognosis is highly unfavor- 
 able. The general recognition of the fact that cholelithiasis is a surgical 
 disease has rendered the prognosis far more favorable than it was at a 
 period when the sole dependence was upon drugs and mineral waters. 
 
 vii. Affections of the BIood=vessels of the Liver. 
 
 L Anaemia. — Nothing is known of anaemia of the liver as a clinical 
 condition. 
 
 2. HyperaEmia. — Two forms are to be considered, active and passive. 
 
 (a) Active Hypersemia; Congestion of the Liver. — The liver is one of 
 the most vascular organs of the body. The rapid influx of blood by way 
 of the portal vessels during digestion brings about a physiological hyper- 
 semia which is transient, but which in the cases of persistent overindulgence 
 in the pleasures of the table may become the cause of functional or even 
 of organic changes. Excessive quantities of food, strong spices, coffee, 
 and especially alcohol are credited with causing hypersemia of the liver, a 
 condition to which sedentary habits also contribute. The condition thus 
 caused constitutes a conspicuous feature in general plethora and obesity, and 
 is frequently associatQ,d with gout, gravel, and glycosuria. Toxic agencies 
 such as are present in the acute fevers and malaria, and, indirectly, the mode 
 of life common among Europeans in tropical climates are causal factors. 
 
 Symptoms. — The manifestations of active hypersemia of the liver are 
 indefinite and rarely present alone. They consist of sensations of pressure 
 and fulness in the right hypochondrium and epigastrium, which may 
 amount to actual pain and are sometimes intensified by movement, deep 
 respiration, and pressure. They are associated with the evidences of enlarge- 
 ment of the organ and certain symptoms of deranged digestion, such as 
 epigastric weight, heart -burn, flatulence, and fulness in the head. In 
 some instances a periodical recurrence of this group of morbid phenomena 
 accompanies the return of menstruation or the suppression of the flow, 
 or the arrest of an habitual hemorrhoidal flux. A slight icterus frequently 
 accompanies the attack of hypersemia of the liver. The tendency to the 
 development of organic disease as a result of permanent hypersemia is to 
 be considered. 
 
 (b) Passive Congestion. — This form of hypersemia is much more com- 
 mon. All conditions which favor the accumulation of blood in the venous 
 system and the transference of blood-pressure from the arterial to the 
 venous side of the circulation lead to passive hypersemia of the liver, which 
 
998 MEDICAL DIAGNOSIS. 
 
 constitutes, in fact, an important part of the general visceral congestion 
 characteristic of such states. Cardiac affections, both valvular and myo- 
 cardial, especially when the power of the right ventricle is diminished, 
 are important etiological factors. Pulmonary diseases which cause mechan- 
 ical interference with the pulmonary circulation, such as acute and chronic 
 bronchitis, emphysema, consolidation of the lung from exudate or sclerosis, 
 tumors, and extensive pleural effusion or adhesions, also give rise to pas- 
 sive hepatic congestion, partly by reducing the calibre of the pulmonary 
 vessels and partly by restricting the respiratory excursus. Deformities of 
 the spinal column may act in the same way. Local hypersemia is seen in the 
 corset liver in the part separated from the main organ. The liver is enlarged, 
 dense, and of a deep brownish-red color — the cyanotic or cardiac liver. 
 Later it may be contracted, owing to the overgrowth of connective tissue. 
 
 Symptoms. — In the early stages symptoms are absent or subordinated 
 to those of the general condition. Later epigastric fulness, especially after 
 eating, dyspeptic disturbances and hemorrhoids occur. Haematemesis 
 may occur. The portal obstruction may cause ascites. A mild jaundice is 
 common. The stools may be clay-colored, and bile pigments may be 
 present in the urine. Physical examination shows the liver to be 
 enlarged. It is usually tender, especially below the arch of the ribs or 
 upon pressure with the flat hand. Liver pulsation is often present. 
 
 Diagnosis. — The passive hypersemic liver varies in size, whereas the 
 enlargement of the liver from other lesions is persistent. This fact, con- 
 sidered in connection with the various etiological factors above enumerated, 
 has great diagnostic significance. 
 
 3. Diseases of the Portal Vein. — (a) Occlusion or narrowing of 
 THE portal vein may be caused by, (1) acute or chronic inflammation 
 of the vessel wall or by its invasion by a neoplasm; (2) compression from 
 without by tumors, enlarged lymph-glands, gall-stones, or the cicatricial 
 contraction of the adjacent parts, especially such as result from syphilis 
 and tuberculosis; (3) mechanical obstruction caused by Distoma haema- 
 tobium; and finally (4) from other causes not clearly understood, (b) 
 Thrombosis. — The foregoing conditions cause slowing of the blood stream 
 in the portal vein and thus favpr thrombus formation, which may occur 
 in cirrhosis, syphilis of the liver, malignant growths involving the wall of 
 the vein, hyperplasia of the lymph-glands in the porta, compression or 
 perforation of the walls of the vessel by hepatic calculi, parasite invasion, 
 and arteriosclerosis. The coagulation forms a wall-thrombus, which may 
 partially or wholly occlude the vein, (c) Adhesive Pylephlebitis. — In 
 rare instances a collateral circulation is established, the thrombus becomes 
 thoroughly organized, and the vein is converted into a fibrous cord. 
 
 Symptoms. — The condition manifests itself by acute symptoms which 
 may supervene in the course of hepatic cirrhosis, chronic peritonitis, or 
 abdominal tumor, or occur suddenly in persons apparently well. These 
 symptoms consist of sudden intense epigastric pain with haematemesis, 
 melsena, followed, in the course of a few days, by ascites and enlargement of 
 the spleen. Icterus is sometimes present. 
 
 (d) Suppurative Pylephlebitis. — This condition is due to infection 
 by pyogenic bacteria. It is secondary to intestinal ulceration such as 
 
ABSCESS OF THE LIVER. 999 
 
 occurs in dysentery, enteric fever, or tuberculosis, to suppurative foci, as 
 appendicitis, pelvic abscesses, ischiorectal abscess, inflamed hemorrhoids, or 
 fistula. Multiple abscess formation occurs within the branches of the portal 
 vein. Septic phenomena are rapidly developed. They consist of irregular 
 chills, fever of rapid and extreme oscillation of temperature, colliquative 
 sweating, and profound asthenia. Local symptoms are not constant. There 
 may be tenderness and pain over the liver and spleen, the latter being 
 enlarged. Icterus is not usually marked. 
 
 4. Diseases of the Hepatic Artery. — (a) Dilatation occurs in cir- 
 rhosis of the liver, (b) Sclerotic changes in the wall are common. These 
 conditions are of pathological rather than of clinical interest, (c) Aneurism 
 is infrequent. A number of cases have been studied cHnically. The diag- 
 nosis is obscure. Important symptoms are pain, hemorrhage from the 
 bowel and uterus. A pulsating tumor has never been found. The cases 
 closely simulate gall-stone disease or duodenal ulcer. The combination of 
 the symptoms of these two conditions is of diagnostic significance. Death 
 may occur suddenly from hemorrhage into the gastro-intestinal tract or 
 into the peritoneum. 
 
 5. Diseases of the Hepatic Veins. — (a) Dilatation occurs when the 
 right heart is permanently dilated and hypertrophied. (b) Stenosis is far 
 less common. It may be due to, (1) compression by tumors, especially 
 gummata and enlarged lymph-nodes ; (2) disease of the vessel walls ; (3) 
 thrombosis; and (4) embolism. The symptoms are obscure and the clin- 
 ical diagnosis is uncertain. The spleen is palpable, the liver enlarged, and 
 ascites occurs, (c) Thrombosis may occur as a result of stenosis, (d) Emboli 
 may pass into the hepatic veins from the right auricle when the blood current 
 is reversed, as may occur in tricuspid insufficiency. The subsequent course 
 of embolism and thrombosis of the hepatic veins varies according to the 
 nature of the cause of the occlusion, namely, whether it be simple, infected, 
 or the result of malignant disease. Infarcts are occasionally encountered. 
 
 viii. Abscess of the Liver^ — Suppurative Hepatitis. 
 
 Definition. — Suppuration within the liver, either in the parenchyma 
 or in connection with the blood-vessels or bile passages. 
 
 The following forms occur: (1) solitary abscess, (2) embolic or pysemic 
 abscesses, (3) suppurative pylephlebitis, (4) suppurative cholangitis, (5) 
 local abscess formation caused by foreign bodies or parasites. 
 
 The distinction sometimes made between primary and secondary 
 abscesses of the liver cannot always be observed. Those abscesses due to 
 traumatism or the extension of suppurative processes from the gall-bladder 
 or bile-ducts are primary; those in which infection has taken place by way 
 of the blood stream are secondary. 
 
 Etiology. — Predisposing Influences. — Residence in the tropics, espe- 
 cially when associated with excesses at table and overindulgence in alcohol, 
 amoebic dysentery, cholelithiasis, appendicitis, traumatism in the region of 
 the liver and blows upon the head, ulceration of the intestines and suppu- 
 rative processes in the pelvis, general sepsis with metastatic abscesses, and 
 echinococcus cysts in the liver are all predisposing factors of importance. 
 
1000 MEDICAL DIAGNOSIS. 
 
 The Exciting Cause. — Infection of the liver substance, the blood- 
 vessels, the bile-ducts, or the gall-bladder by pyogenic organisms is the 
 direct cause of hepatic abscess. The avenues of infection are the portal 
 vein, the hepatic vessels, the common duct, and penetrating wounds or 
 fistulous tracts. The organisms found in hepatic abscess comprise Amoebae 
 dysenteriae, streptococci, colon bacilli, pneumococci, typhoid bacilli, 
 Bacillus pyogenes, and actinomyces. 
 
 Morbid Anatomy. — Tropical abscess is usually solitary, though two or 
 more abscesses are occasionally encountered. When single, the abscess is 
 commonly situated in the right lobe, extending to the upper surface, less 
 frequently toward the concave surface of the organ. Recent abscesses, as 
 seen at the surface of the liver, are of a grayish-yellow color with a well- 
 defined outline. In a more advanced stage the walls are shreddy and 
 necrotic and contain a greenish- or reddish-brown viscid pus commingled 
 with blood, in which there are fragments of liver tissue. This fluid shows 
 fatty and granular detritus, cellular elements, occasionally Charcot-Leyden 
 crystals, and amoebae, which are also present in the tissue forming the wall. 
 Cultures are commonly sterile. The abscess wall consists of an inner necrotic 
 layer, a middle layer in which there is proliferation of connective tissue, 
 and an outer layer of intense hyperaemic tissue. The chronic abscesses 
 frequently have an extremely dense wall. Rupture may occur into the lower 
 lobe of the right lung, into the pleura (causing an empyema), into the vena 
 cava, the portal or hepatic veins, or into the stomach, intestine, peritoneum, 
 pericardium, or externally. Perforation into the right kidney is a rare 
 event. Traumatic abscess is usually single and has no distinctive anatom- 
 ical characters. Pyaemic abscesses are almost always multiple and may be 
 very numerous. When large they are due to the coalescence of several small 
 cavities. The infected emboli find their way to the liver through the hepatic 
 artery or form infected thrombi in the portal vein. Echinococcus cysts 
 undergo suppurative changes as the result of infection following trauma 
 or inflammation of the bile passages. The abscesses may be of great size, 
 and contracted hydatids, dead scolices, shreds of the cyst wall, fat, and 
 bilirubin may be found in the pus. 
 
 Symptoms. — 1. Solitary Abscess. — This condition is common among 
 Europeans in the tropics and chiefly affects males. It occurs also in the 
 temperate zones. It is almost always associated with amoebic dysentery, 
 though cases occur in which no history of dysentery can be obtained. The 
 abscess may present no definite symptoms and finally reveal its presence 
 by rupture which may prove fatal. The principal symptoms are fever, 
 pain, tenderness, and septic phenomena. Enlargement of the liver may 
 be demonstrated. The temperature is irregular. There is paroxysmal 
 fever of intermittent type, sometimes of regular, sometimes of irregular, 
 periodicity, the temperature frequently falling to subnormal ranges. 
 Rigors are followed by rises of temperature to 103°-105° F. (39.5°-40.5°C.), 
 followed by copious sweating. The condition frequently simulates a 
 malarial intermittent fever. In the chronic cases fever may be absent. 
 Pain referred to the region of the liver, the back, the epigastrium, or the 
 right shoulder is a common symptom. It is often associated with sen- 
 sations of weight and dragging in the right hypochondrium, much increased 
 
ABSCESS OF THE LIVER. 1001 
 
 when the patient turns upon his left side, and with tenderness upon pres- 
 sure at the costal margin in the mammillary line. The shoulder pain is 
 due to irritation of the terminal filaments of the right phrenic nerve which 
 are distributed to the capsule of the liver. The stimulus is transmitted 
 to the fourth cervical, which anastomoses with the phrenic and sends 
 sensory branches to the shoulder. The facies of the patient is sallow, 
 pallid, muddy, and faintly icteroid. Irregular diarrhoea, digestive dis- 
 turbances, and great mental depression are common. Leucocytosis is 
 sometimes present, often absent, and therefore not usually of diagnostic 
 value. Enlargement of the liver is most marked in the right lobe and 
 upward. This condition is in contrast with many diseases of the liver 
 in which the enlargement is in a downward direction, as fat infiltra- 
 tion, hypertrophic cirrhosis, and carcinoma. The upper margin of liver 
 dulness is usually higher in the back near the spine than anteriorly. In 
 extensive abscess formation the lower margin of the liver may extend a 
 hand's breadth below the edge of the ribs. The entire right hypochon- 
 drium may bulge, the ribs protrude and be widely separated, and fluctua- 
 tion may be detected. Palpation may be painful. The margin of the 
 liver is felt to be rounded and blunt, the superficial venules over the liver 
 may be dilated, and there may be circumscribed cyanosis with oedema. 
 Upon deep respiration a friction fremitus may sometimes be detected. 
 Perforation into the lung may occur or amoebic infection through the 
 diaphragm without rupture. The base of the right lower lobe shows signs 
 of consolidation, there is intense paroxysmal cough, with characteristic 
 expectoration resembling anchovy sauce and containing Amoebae coli in 
 varying numbers and actively motile. The color of the expectoration is 
 due to altered blood. The sputum may be blood-tinged or bright red and 
 very abundant. It may contain pus and shreds of liver tissue. Recovery 
 may take place in the course of several weeks. Perforation into the pleura 
 causes empyema with characteristic symptoms and physical signs; into 
 the pericardium is followed by fatal collapse; into the stomach gives rise 
 to vomiting of blood-tinged fetid pus; into the intestine to the presence of 
 pus in the stools. Coincident with the escape of pus in these various 
 directions there is sudden subsidence of the liver tumor, together with 
 sensations of collapse. Rupture into the vena cava is followed by rapid 
 death with symptoms of asphyxia. In the rare cases of perforation 
 of a liver abscess into the pelvis of the right kidney, the urine con- 
 tains pus of a brownish-red color which may show the presence of 
 liver-cells or blood-corpuscles. 
 
 2, Embolic or Py^emic Abscesses. — The multiple small abscesses 
 in the liver, which occur in some cases of general septicopyaemia, may cause 
 pain and tenderness in the hepatic region and a slight subicteroid discolor- 
 ation of the skin. When these symptoms are superadded to the rigors, 
 high temperature, sweating, and prostration of the septic condition, and 
 especially when a suppurative focus can be discovered, the diagnosis of 
 metastatic abscesses in the liver may be made. 
 
 3. Suppurative Pylephlebitis. — The clinical manifestations are the 
 same as in pyaemic abscess. The liver is enlarged and tender, there is fever 
 of septic type, and a muddy, icteroid skin. 
 
1002 MEDICAL DIAGNOSIS. 
 
 4. Suppurative Cholangitis. — The history of attacks of gall-stone 
 colic or of the recovery of gall-stones from the stools, and the symptoms of 
 cholangitis or the presence of a distended gall-bladder are important for 
 the diagnosis. 
 
 5. Foreign Bodies and Parasites. — Needles have penetrated the 
 wall of the CESophagus or stomach and entered the liver substance, causing 
 abscess. A needle or a fish-bone has been known to perforate a branch 
 of the portal vein and give rise to pylephlebitis. The part played by 
 echinococcus cysts in producing liver abscess has been described. The 
 IDenetration of round worms into the common duct and, less commonly, 
 the presence of flukes have caused suppurative processes. These parasites 
 probably act merely as carriers of pyogenic germs. 
 
 Diagnosis. — Direct. — Abscess of the liver is often latent and wholly 
 overlooked, notwithstanding the fact that the patients almost always 
 present the appearance of serious illness. This is due to the fact that 
 local symptoms may be altogether absent or subordinated to those of the 
 primary disease. When pain, tenderness, and enlargement of the liver are 
 present, and a source of infection can be found in the structures tributary 
 to the portal vein; or a focus of purulent inflammation elsewhere; or when 
 there is a history of traumatism involving the liver, or of bone injury, 
 especially injury to the bones of the skull, or of cholelithiasis, a positive 
 diagnosis may be made. Nevertheless the symptoms are frequently obscure, 
 and the diagnosis, even when abscess is suspected, cannot in many cases 
 be positively determined. This statement is especially true of abscesses 
 of moderate size centrally situated in the substance of the liver, and of 
 the multiple small abscesses which occur in general septic conditions and 
 in acute cholangitis and pylephlebitis. Of positive diagnostic import are 
 pain referred to the region of the liver and the right shoulder, enlargement 
 of the liver in an upward direction, bulging, particularly when circum- 
 scribed, and fluctuation. Examination by the X-rays yields, as a rule, 
 unsatisfactory results, owing to the density of the liver, but in exceptional 
 cases may be of service. 
 
 Differential. — The following conditions are to be considered: 
 (a) Malarial Fever. — The regularly intermittent fever often closely simu- 
 lates malarial fever, but the absence of marked splenic enlargement and 
 of the malarial blood parasite, and the failure of quinine to control the 
 fever are of diagnostic significance, (b) Right-sided Empyema. — When 
 the abscess ruptures into the pleura an empyema is produced, but perfora- 
 tion of the lung commonly follows, and the true nature of the condition 
 is revealed upon the expectoration of pus resembling anchovy sauce and 
 containing amoebae. (c) Subphrenic Abscess. — The downward displace- 
 ment of the liver, the fact that the lower border of the lung descends upon 
 deep inspiration, and a history of gastric ulcer may be of service in the dif- 
 ferentiation from hepatic abscess. When gas is also present, — pyopneumo- 
 thorax subphrenicus. — the diagnosis is less difficult, (d) Abscess of the 
 Abdominal Wall. — Perforation through the abdominal wall presents little 
 difficulty. A mural abscess may closely simulate liver abscess. Such 
 lesions, usually associated with tuberculosis of the ribs, are superficially 
 situated, and an exploratory needle does not follow the movements of 
 
FATTY LIVER. 1003 
 
 respiration. The liver is not enlarged, (e) Empyema of the Gall-bladder. — 
 The situation of the tumor, its gourd-like outline, and some degree of 
 lateral movement upon pressure are important points in diagnosis, (f) 
 Echinococcus Cysts. — Slowness of growth, absence of fever and signs of 
 inflammation, very obscure fluctuation, and the hydatid thrill are char- 
 acteristic of these cysts. When thej^ become infected the differential 
 diagnosis from hepatic abscess is attended with great difficulty. The 
 presence of hooklets or shreds of cyst walls in the pus is of positive diag- 
 nostic significance, (g) Abscess of the Left Lobe. — An abscess in this posi- 
 tion is uncommon. It may, in the absence of inflammatory symptoms, 
 simulate carcinoma ventriculi, from which it may be distinguished by 
 the age of the patient, the history of the case, an examination of the gastric 
 contents, and the presence of foci of infection in the intestines or elsew^here. 
 (h) Aneurism of the Aorta. — Hepatic abscess to which the movements of 
 the aorta are transmitted may simulate an aneurism in the region of the 
 coeliac axis. In abscess the pulsation is to and fro, not expansile, diastolic 
 shock is absent, a bruit is not heard, and the pain is less severe and par- 
 oxysmal than in aneurism and has a different focus of maximum intensity, 
 (i) Hepatic Fever. — The intense fever with chills and sweating which occurs 
 in certain cases of gall-stone disease is frequently regarded as due to abscess 
 of the liver. It is now known that this symptom may occur in the absence 
 of suppuration. The fever occurs in paroxysms, which may have a regular 
 periodicity or recur at irregular, often prolonged, intervals, during which 
 there is complete apyrexia and the nutrition may be fairly well maintained. 
 The varying jaundice, which is intensified during the febrile attacks, is sug- 
 gestive, and the long duration of the condition is of diagnostic importance. 
 
 Exploratory puncture may be made in a doubtful case. The patient 
 must be etherized and the skin cleansed as in any surgical operation. The 
 aspirator needle, which should be of large calibre, should be introduced 
 at the suspected point in the infra-axillary region or over the area of 
 hepatic dulness behind. Repeated puncture may be necessary. 
 
 Prognosis. — The outlook in pysemic abscesses is ominous. In diffuse 
 suppurative cholangitis and pylephlebitis and in traumatic abscess it is 
 highly unfavorable. In solitary, tropical abscess it is much more hope- 
 ful. Recovery may take place after aspiration or incision. In the more 
 chronic cases of solitary abscess, perforation into the lung or the intestine 
 or through the skin may be followed by recovery. In individual cases 
 marked septic phenomena, persistence of dysenteric symptoms or of sup- 
 puration in pelvic abscess or bone disease, the supervention of amyloid 
 disease, and the development of cachexia are highly unfavorable. The 
 danger of rupture into the vena cava, the pericardium, or the peritoneum 
 renders the prognosis uncertain. 
 
 ix. Fatty Liver. 
 
 Definition. — This term is used to designate all conditions charac- 
 terized by an abnormal increase in the fat of the liver. 
 
 Under physiological conditions the fat in the liver-cells varies and 
 is dependent upon the amount and character of the food. The ingestion 
 
1004 MEDICAL DIAGNOSIS. 
 
 of large quantities of fat is followed by an increase of fat-globules in the 
 peripheral cells of the acini. This increase is transient, disappearing in 
 the course of several hours. 
 
 Pathologically two different forms of fatty liver occur — fatty infiltra- 
 tion and fatty degeneration. These forms sometimes coexist. Fatty 
 infiltration is the result of an increased deposit of fat in the parenchyma 
 of the liver in the absence of fatty change in the protoplasm of the cells. 
 
 Fatty degeneration consists of a destruction of the protoplasm of the 
 cells with fat accumulation. 
 
 Etiology. — Fatty infiltration occurs in general obesity and in persons 
 who habitually consume inordinate amounts of fats and carbohydrates; 
 at the middle periods of life; and in many women after the menopause. 
 It is common in conditions in which there is deficient oxidation, marked 
 anaemia, advanced phthisis, or the cachexias. Chronic alcoholism leads 
 to fatty degeneration of the liver by interfering with the oxygenation of 
 fats and carbohydrates, the oxygen being largely required for the com- 
 bustion of the alcohol consumed. Fatty degeneration is caused by certain 
 poisons, as phosphorus, the toxin of acute yellow atrophy, and arsenic, 
 mercury, and antimony. 
 
 Morbid Anatomy. — The ordinary fatty liver — fatty infiltration — is uni- 
 formly enlarged and may reach double the normal weight. It is smooth, of a 
 pale yellow or drab color, and greasy. In fatty cirrhosis the surface shows 
 irregular granular prominences. On section the light yellow color and empty 
 blood-vessels are noticeable and the knife is smeared with grayish-white fat. 
 Microscopically the cells are distended with small and large fat droplets. 
 
 Symptoms. — Clinically fatty infiltration is to be distinguished from 
 fatty degeneration. In the former the parenchyma is not degenerated 
 but simply contains an excess of fat. The hepatic functions are therefore 
 maintained, and general s^^mptoms do not occur. In the latter the liver- 
 cells are affected by a degenerative process, their functions are no longer 
 performed normally, and grave symptoms are present, as in acute yellow 
 atrophy, q.v., and phosphorus poisoning. The symptoms in fatty infiltra- 
 tion are not well defined. The appearance of the patient and the symp- 
 toms referable to other organs are dependent upon the primary disease. 
 Jaundice does not occur. The stools may be light-colored or even whitish- 
 gray, and putty-like in consistency. The urine does not contain bile pig- 
 ments in excess. Hemorrhoids may occur, but the signs of portal obstruc- 
 tion are not common. In obese persons the ph3^sical signs are often 
 obscure, but in phthisis and cachectic conditions the greatly enlarged liver 
 may be sometimes visible through the belly wall and almost always recog- 
 nized upon palpation. It is smooth, with a rounded lower border, pro- 
 jecting far below the margin of the ribs, and is painless. 
 
 Diagnosis. — Slight grades of fatty liver cannot be recognized during life. 
 When the condition is well developed it is, except in the case of great obesity, 
 easy of recognition. The great enlargement, smooth surface, and nearly nor- 
 mal contour are characteristic. The underlying disease, as anaemia, phthisis, 
 the various cachexias, is of diagnostic importance. The soft consistence 
 enables us to exclude amyloid liver, leukaemic tumors, and hyperaemia. 
 
 Prognosis. — Fatty liver is a secondary pathological condition, and 
 the prognosis is that of the primary disease. 
 
CHRONIC INTERSTITIAL HEPATITIS. 1005 
 
 X. Chronic Interstitial Hepatitis. 
 
 Cirrhosis of the Liver. 
 
 Definition. — A chronic disease of the Hver due to various toxic or 
 infectious causes, mechanical irritation, or stasis of blood or bile, and 
 characterized by an overgrowth of the interstitial connective tissue of 
 the organ. 
 
 It is of interest to investigate the etymological significance of this 
 unfortunate word "cirrhosis," originally selected by Laennec to describe 
 an anatomical peculiarity of the contracted liver far from constant, and 
 subsequently applied to changes in other viscera attended by an over- 
 growth of connective tissue, so that there have been those who have spoken 
 of cirrhosis of the kidney, cirrhosis of the lungs, and the like. The word 
 is derived from the Greek xtppo^, tawny or orange-yellow, the color of the 
 liver substance in some of the cases. It has nothing whatever to do, save 
 by a remote and misleading association, with the sclerotic changes due to 
 hyperplasia of connective-tissue stroma. 
 
 The difficulties in the diagnosis of hepatic cirrhosis are not, as in most 
 other diseases, accidental. They do not arise from the peculiarities of 
 individual cases. They are essential and due to the fact that no definition 
 can be framed that at once pathologically and clinically includes all the 
 cases. This arises from Laennec's choice of a term descriptive of an incon- 
 stant phenomenon and without pathological significance. "Cirrhosis" is 
 conspicuous among the nosological terms that hamper medicine and 
 obstruct the progress of knowledge. If it could be erased from the list of 
 diseases our conception of the various conditions to which it is applied 
 would be greatly simplified. The one underlying lesion common to all of 
 them is an overgrowth of the fibrous tissue of the liver. The term chronic 
 interstitial hepatitis is at once descriptive of the anatomicopathological 
 condition and sufficiently comprehensive to include all the cases. Its 
 more general use is to be desired. 
 
 Etiology. — The etiological relations of individual cases may be indi- 
 cated by qualifying adjectives: 
 
 (a) In general toxic, and in particular alcoholic, plumbic, gouty, 
 diabetic, rachitic, and the like. We must include here forms of interstitial 
 hepatitis due to chronic phosphorus poisoning and the abuse of condiments. 
 The assumption that intestinal autointoxication gives rise to interstitial 
 hepatitis requires confirmation. 
 
 (b) In general infectious; in particular the specific febrile infections, 
 are occasionally followed by chronic interstitial hepatitis. Malaria pro- 
 duces similar changes, and syphilis gives rise to three well-characterized 
 forms, namely, diffuse syphilitic hepatitis, commonly congenital, gummata 
 which undergo fibroid transformation, and an extensive perihepatitis 
 with increase in connective tissue of the portal canals. 
 
 (c) Mechanical irritation. The long-continued exposure to an atmos- 
 phere laden with dust particles such as produce pneumonoconiosis, whether 
 these be mineral or metallic, may also give rise to an inflammatory process 
 in the connective tissue of the liver. 
 
1006 MEDICAL DIAGNOSIS. 
 
 (d) Congestive; the chronic hypersemia of the blood-vessels occurring 
 in heart disease gives rise to an interstitial hepatitis — the cardiac liver. 
 
 (e) Obstructive, the result of chronic obstruction in the bile-ducts. 
 Pathology and Classification.— Vaughan, in a recent study of the 
 
 subject, concludes that so-called atrophic and hypertrophic cirrhosis are 
 not different forms of the same disease but wholly different diseases. 
 He states that the former is known as atrophic cirrhosis because from its 
 earliest possible recognition the liver is less than normal in size; while 
 the hypertrophic is known as such because at every stage of the disease 
 the liver is larger than normal; that the atrophic is known as venous cir- 
 rhosis because of the early and constant involvement of the intrahepatic 
 branches of the portal vein, the hypertrophic as biliary cirrhosis because 
 of the early appearance and constancy of icterus; that in atrophic cirrhosis 
 the primary destructive changes are in the hepatic cells, while in hyper- 
 trophic cirrhosis the epithelium of the gall-ducts is the site of the primary 
 involvement; that the former might be known as toxic, the latter as in- 
 fective cirrhosis. 
 
 This clear-cut classification, while in some respects convenient and 
 while it provides categories for well-marked cases of widely different mor- 
 bid conditions, by no means meets the requirements of all the cases and 
 does not appear to be wholly justified upon etiological, anatomical, or 
 clinical grounds. There are cases of atrophic cirrhosis in the causation of 
 which alcohol plays no part, and cases of hypertrophic cirrhosis in hard 
 drinkers. My clinical experience leads me to believe that alcohol is a very 
 common cause of the latter form of cirrhosis. 
 
 Cases of cirrhosis of the liver without jaundice and with the evidences 
 of a high degree of portal obstruction, in which the liver is normal in size 
 or slightly enlarged, are by no means rare. In addition to these there is 
 the fatty cirrhosis common in beer-drinkers. There is a large group of 
 cases in which the symptoms are neither those of the atrophic nor the 
 hypertrophic form. These are designated mixed forms, and are thought 
 to be due to the coexistence of the two forms, the toxic and the infective, 
 in the same individual. On the other hand, Hawkins of St. Thomas's 
 Hospital, in the article on cirrhosis of the liver in Allbutt's System, expresses 
 the opinion that the terms "atrophic" and "hypertrophic" are scarcel}^ 
 worth retaining. "The former," he observes, "has lost much of its 
 fitness now that statistics show that the hob-nailed liver, to which it was 
 originally applied, is not necessarily small, but is often increased both in 
 size and weight," while "the phrase hypertrophic cirrhosis has become so 
 complicated by the postulate of a biliary cirrhosis that its significance is 
 vague and uncertain." Hawkins does not recognize a vascular or toxic 
 form corresponding to the atrophic form of writers — Laennec's cirrhosis — 
 and a biliary or infectious form — Hanot's cirrhosis, — but states that " two 
 forms of cirrhosis of the liver are induced by the excessive use of alcohol." 
 These two forms are separated both in their morbid anatomy and in their 
 clinical features. In the first, which is by far the more common, the newly 
 developed fibrous tissue is "multilobular," that is, it tends to surround 
 large groups of hepatic lobules. This form is commonly associated with 
 ascites but seldom with jaundice. In the second and less common form 
 
CHRONIC INTERSTITIAL HEPATITIS 1007 
 
 of alcoholic cirrhosis the new tissue is mostly developed around single lobules 
 and the condition is properly described as '' unilobular, " There is little 
 tendency to ascites, while jaundice is common. 
 
 In this connection may be mentioned Flexner's researches in regard 
 to the new tissue in cirrhosis of the liver. He found both the white fibrous 
 tissue and the elastic tissue increased and the chief distinction between 
 the histology of the atrophic and hypertrophic cirrhosis to depend upon 
 the degree of extralobular growth and the freedom with which the lobules 
 are invaded, and that "in hypertrophic cirrhosis there would appear to 
 be less interlobular growth and an earlier and finer intralobular growth." 
 
 Symptoms. — Clinically not all forms of interstitial hepatitis can be 
 recognized. The symptoms are often vague and referable to other organs, 
 especially those of the gastro-intestinal tract. In many of the cases the 
 condition during life can only be suspected, the morbid phenomena being 
 those of the primary disorder. Direct physical signs are available for 
 diagnosis only when there are definite changes in the size or contour of 
 the liver. Hence the cases of chronic interstitial hepatitis, whatever their 
 course, must be arranged in three groups according as the liver is found 
 upon physical exploration to be, (a) of about the normal size, (b) atrophic, 
 and (c) hypertrophic. 
 
 (a) Since there are no characteristic symptoms in many cases of chronic 
 interstitial hepatitis, and since in many of the cases the liver remains of 
 normal size throughout and is always of normal size until the disease 
 has made some progress, it follows that the diagnosis is impossible in 
 a considerable proportion of the cases and in the earlier stages of all cases. 
 The most that can be done is to assume that when certain etiological 
 factors, as alcoholism, malaria, valvular disease of the heart with failing 
 compensation, are operative, and more or less well-pronounced gastrohepatic 
 symptoms present, the patient may have an interstitial hepatitis. The 
 diagnosis under such circumstances must be purely an anatomical one, 
 and this is frequently the case in the fatty form of interstitial hepatitis 
 in which symptoms directly referable to the liver are often absent, and 
 not rarely in the multilobular form either with or without atrophy. In 
 the latter instance the true nature of the malady may reveal itself in sudden 
 copious hsematemesis or in the peculiar toxaemia caused bj^ the' entrance of 
 portal blood, which has not traversed the liver, into the general circulation. 
 
 When, however, there are decided changes in the size of the liver 
 the state of affairs is wholly different. The interstitial hepatitis reveals 
 itself not only in physical signs, but also in symptoms of significance. 
 
 (b) The liver is diminished in size — Laennec's cirrhosis. A high 
 degree of atrophy may occur, provided the collateral circulation has been 
 established, without the development of ascites or other symptoms which 
 attract the attention of the patient to the liver. As a general rule, howevei-, 
 the malnutrition, vomiting, the enlargement of the spleen, hemorrhoids, 
 the distended superficial abdominal veins, and the increased girth caused 
 by the ascites are diagnostic. It is of cardinal importance also to remem- 
 ber that all these phenomena can occur in an interstitial hepatitis in which 
 the liver is not only not atrophic but even somewhat enlarged. Under 
 these circumstances jaundice is not usually present. 
 
1008 
 
 MEDICAL DIAGNOSIS. 
 
 (c) The liver is increased in size. The hypertrophic form of chronic 
 interstitial hepatitis, — Hanoi's disease, — like the forms already consid- 
 ered, may present extreme difficulties in diagnosis in its early stages. 
 The liver may be as yet of normal size. The early icterus may resemble 
 that of catarrhal jaundice — a resemblance heightened by its fluctuation 
 or temporary disappearance, and by the occurrence of fever. The recur- 
 rence or persistence of the jaundice, its intensity, and the presence of bile 
 
 in the stools are of diagnostic 
 1 importance. When the disease is 
 established the uniform enlarge- 
 ment of the liver, the splenic 
 tumor, the deep and persistent 
 jaundice, and the occasional 
 attacks of fever are diagnostic. 
 The fever is of subcontinuous or 
 remittent type and extends over 
 periods of days or weeks. Chills 
 and sweating are not common, as 
 in the fever of impacted gall-stone 
 — Charcot's or true hepatic fever. 
 Diagnosis. — Direct. — The 
 diagnosis of well-defined cirrhosis 
 of the liver, the terminal condi- 
 tion, is usually a simple matter. 
 Whether it be the atrophic form 
 of Laennec or the hypertrophic 
 form of Hanot, the symptom- 
 complex in most of the cases is 
 characteristic. In the former the 
 pinched face with its distended 
 venules and muddy or subicteroid 
 hue, — fades hepatica, — the spare 
 chest and thin arms, the distended 
 belly with its conspicuous super- 
 ficial veins, and the diminished 
 area of liver dulness leave no 
 doubt of the nature of the malady. 
 In the latter the jaundice, the 
 fairly well-preserved nutrition, the 
 big liver without ascites, and occa- 
 sional irregular fever render the diagnosis equally clear. The two conditions 
 are clinically distinct because they are the manifestations of essentially 
 different pathological lesions. The one thing that these lesions have in com- 
 mon is an overgrowth of the interstitial connective tissue of the liver. It 
 might be said that they have nothing in common clinically save that they 
 are diseases of the liver. Yet they are described respectively as the atrophic 
 form and the hypertrophic form of the same affection, hepatic cirrhosis. 
 The diagnosis of hepatic capsulitis — the capsular cirrhosis of authors — 
 is usually attended by insuperable difficulties. The symptoms are those 
 
 Fig. 314. — Ascites due to atrophic cirrhosis of the 
 liver. — Jefferson Hospital. 
 
NEW GROWTHS IN THE LIVER. 1009 
 
 of the atrophic form of chronic interstitial nephritis. Jaundice is not 
 usually present. The kidneys are granular. This condition may be asso- 
 ciated with perisplenitis and proliferative peritonitis. 
 
 Differential. — Adhesive pylephlebitis closely resembles the atrophic 
 form of interstitial hepatitis. The etiological factors and the rapidity with 
 which the peritoneal effusion develops and reforms after tapping, as was 
 shown in a case recently in my service in the Pennsylvania Hospital, are 
 important in the differential diagnosis. It is said that thrombosis of the 
 portal vein is followed by an atrophy of the liver, which renders the diag- 
 nosis difficult. In the cases that have come under my observation death 
 has occurred in the course of a few weeks, and t»he liver was of normal size. 
 
 Prognosis. — In the atrophic form the outlook is highly unfavorable. 
 From the time at which the diagnosis can be made the duration of the 
 disease does not usually exceed a year or two, often not more than a few 
 months. Atrophic cirrhosis in advanced stages has been found post mortem 
 in cases in which no characteristic symptoms were present during life. 
 Life has been much prolonged in some of the successful cases of omentopexy. 
 
 In the hypertrophic form the disease, after it has reached a stage in 
 which a positive diagnosis can be made, runs an unfavorable course. The 
 progress is often slow and the disease for a long period may not continu- 
 ously prevent the patient from conducting his business or taking part in 
 the ordinary affairs of life. 
 
 xi. New Growths in the Liver. 
 
 Neoplasms of the liver are benign and malignant. The benign are 
 fibroma and angioma; the malignant are carcinoma, sarcoma, and malig- 
 nant adenoma. Carcinoma and sarcoma may be primary or secondary. 
 
 1. Benign New Growths. — These are of no great clinical importance. 
 
 (a) Fibromata. — These tumors consist of dense connective tissue 
 and are frequently found post mortem. They are usually small and cause 
 no symptoms during life. In very rare instances they are of larger size, 
 and when so situated as to compress the bile passages and prevent the 
 discharge of bile into the intestine they may cause cholangitis and death 
 from cholsemia. 
 
 Diagnosis. — In a suspected case an exploratory laparotomy should 
 be performed in the hope that the tumor may be found and removed. 
 
 (b) Angiomata. — These vascular tumors are also described under 
 the terms cavernomata and telangiectasis. They are commonly multiple 
 and of small size, causing no symptoms. They may be found at all ages 
 and have been observed in the foetus. In very rare instances they are 
 solitary and of large size, — an orange, — the pregnant uterus. They then 
 give rise to pressure symptoms. 
 
 Diagnosis. — Small angiomata cannot be recognized by clinical methods. 
 In some instances the surface of the liver is nodular. A large tumor giving 
 rise to distressing pressure symptoms may justify a diagnosis by exclusion. 
 Its true nature can only be positively determined by an exploratory incision. 
 
 Prognosis. — The outlook is favorable as regards life. Large solitary 
 angiomata have been successfully resected. 
 
 64 
 
1010 MEDICAL DIAGNOSIS. 
 
 2. Malignant Tumors of the Liver. — Cancer of the gall-bladder 
 and bile-ducts and its relation to cancer of the liver has already been 
 considered. 
 
 Malignant tumors of the liver are of great clinical importance. 
 
 (a) Carcinoma Hepatis. — Carcinoma invades the liver less frequently 
 than the uterus, the stomach, or the breast. Cancer of the liver may occur 
 at any age and has been observed in the new-born. A number of cases of 
 primary carcinoma of the liver have been observed in children. The part 
 played by heredity in cancer of the liver is uncertain. About 17 per cent, 
 of the cases show hereditary predisposition. Half the cases are first 
 observed after the fortieth year. Primarj^ cancer of the liver is more 
 common in men and is frequently associated with cirrhosis. Secondary 
 cancer is much more frequent in women, a fact attributed to the remark- 
 able tendency to cancer of the uterus, ovaries, and breasts. Primarj' 
 cancer is common in the gall-bladder, rare in the parenchyma of the 
 organ. The frequent association of gall-stone disease with cancer of the 
 gall-bladder and bile-ducts is attributed to the chronic irritation caused 
 by the presence of calculi. 
 
 Primary carcinoma presents three principal types: (i) Massive 
 Carcinoma. — The liver is greatly enlarged, its surface usually smooth. 
 On section the growth is sharply contrasted with the normal tissue which 
 surrounds it. It is grayish-white and not usually softened. It is of verj^ 
 great size and at first solitary, though later surrounded by smaller metas- 
 tatic nodules, (ii) Nodular Carcinoma. — Round, grayish-white, or yellow 
 nodules of cancerous tissue of varying size are irregularly scattered 
 throughout the liver. The occasional occurrence of one large mass sur- 
 rounded by numerous smaller and less dense nodules makes it probable 
 that the former is the original seat of the disease. The liver is not usually 
 greatly enlarged. Sclerotic changes are common and the organ may be 
 reduced in size. Transitional forms between massive and nodular cancer 
 occur. (iii) Adenocarcinoma with Cirrhosis. — The liver is usually con- 
 tracted but may be enlarged. The surface is dark green, with irregularly 
 distributed yellowish nodules of varying size beneath the capsule. The 
 adenomata appear throughout the liver substance as small round masses 
 varjang in size from a millet-seed to a pea. Sometimes only a single tumor 
 is present. 
 
 Secondary Carcinoma. — The liver may be enormously enlarged. Nod- 
 ules are present upon its surface, which may often be felt and seen through 
 the abdominal walls. They may be dense or soft, and frequently, in con- 
 sequence of retraction of the connective tissue, are distinctly umbilicated — 
 Farre's tubercles. The tumors are irregularly scattered throughout the 
 substance of the organ. They are usually light in color, grayish-white or 
 greenish, and sharply defined, both on the surface and in the interior of 
 the liver, from the surrounding liver substance, which is often hj'-persemic. 
 The nodules themselves are often hemorrhagic. They may be present in 
 such numbers as almost completelv to replace the hver parenchyma. 
 
 Histologically the primary cancers are epitheliomata; the secondary 
 cancers are of the same structure as the respective primary growths — as 
 a rule, alveolar or cylindrical carcinomata. 
 
NEW GROWTHS IN THE LIVER. 1011 
 
 (b) Sarcoma. — Sarcoma of the liver is much less common than car- 
 cinoma. Primary sarcoma is very rare. Most of the cases are secondary, 
 though the primary growth may be so small as to be easily overlooked. 
 Melanosarcoma is the must common and most important variety. It 
 appears in rare cases as a primary tumor. As a rule, it is secondary to 
 pigmented sarcoma of the eye or skin. The primary growth is of diag- 
 nostic importance. The secondary sarcomata of the liver sometimes form 
 enormous tumors. They occur either as large nodular masses throughout 
 the Hver or as diffuse, infiltrating growths. In the latter form the enlarge- 
 ment of the liver is less marked. On section the surface is black or marbled. 
 They constitute part of a widely extended metastatic process in which 
 many viscera are often involved. 
 
 Symptoms of Malignant Disease of the Liver. — The condition may be 
 latent, especially when the growth develops centrally or in the diaphrag- 
 matic surface of the hver, or the symptoms may be overshadowed by those 
 of the primary tumor. When a primary cancerous growth in any organ, 
 as the breast, stomach, or rectum, is present or has been removed, the 
 secondary nature of a neoplasm in the hver is obvious. When no such 
 growth is discoverable, it is not alwaj^s possible to determine whether 
 cancer of the liver is primary or secondary. Loss of appetite and nausea 
 are early symptoms. Vomiting is less common. Emaciation and loss of 
 strength are marked and progressive. The skin loses its elasticity and 
 becomes dry, wrinkled, and of a muddy color. Sensations of fulness and 
 weight in the epigastrium and right hypochondrium are followed by pain 
 which extends to the chest and right shoulder. The liver is commonly 
 enlarged, tender upon pressure, and nodular. In some cases of primary 
 cancer, and in those cases in which cirrhosis is marked, the liver may be of 
 normal size or even contracted. Persistent jaundice is present in more 
 than half the cases. It is intense when there is compression of the common 
 duct. Ascites is much less frequent. It occurs as the result of compression 
 of the portal vein, or its invasion by the growth, advancing cirrhosis, or 
 extension of the growth to the peritoneum. The anaemia is progressive. 
 (Edema of the feet or general oedema occurs; there are signs of metastasis 
 to the pleurse and peritoneum. Fever of continuous or remittent type 
 occurs and death results from asthenia. The blood shows the changes of 
 secondary anaemia which may be of high grade. Poikilocytosis may be 
 present. Profuse diarrhoea may cause concentration of the blood. 
 
 Physical Signs. — Inspection. — The abdomen is distended, especially 
 in the epigastric zone and upon the right side. In advanced cases the 
 nodular surface and even the umbilication of the nodules may be visible 
 through the emaciated abdominal wall. The superficial veins are usually 
 enlarged. Palpation. — The enlargement may be recognized and the 
 border felt some distance below the margin of the ribs. When the left 
 lobe is affected, a distinct tumor may be felt in the epigastrium. The 
 surface is commonly irregularly nodular, with an uneven margin and dis- 
 tinct central depressions in many of the nodules. In cases of diffuse infil- 
 tration the sui'face is usually smooth. It is also hard. Enlargement of 
 the superficial lymph-nodes, especially the inguinal, supraclavicular, and 
 cervical nodules, is common. When slight it is not due to metastasis and 
 
1012 MEDICAL DIAGNOSIS. 
 
 not of diagnostic importance. Actual metastasis with decided enlargement 
 of the left supraclavicular gland occasionally occurs in malignant disease 
 of the abdominal organs. Percussion. — The upper and lower limits of 
 dulness may be determined and the progress of the growth estimated, the 
 presence and increase of ascites observed, and pleural and peritoneal new 
 growths recognized. The spleen is not usually enlarged. 
 
 Diagnosis. — Direct. — Enlargement of the liver, which may be 
 smooth or nodular, and in particular when the nodules are umbilicated; 
 cachexia; compression symptoms in the territory of the portal vein or 
 vena cava — ascites, oedema; in the territory of the bile passages — jaun- 
 dice; signs of metastasis in the pleurae, lungs, or peritoneum, constitute a 
 characteristic symptom-complex. In the presence of a primary growth 
 or the history of one removed, the direct diagnosis may be made. In the 
 absence of such a primary growth the diagnosis remains uncertain in 
 proportion as one or more of the above groups of clinical phenomena are 
 ill defined or absent. The Rontgen rays may be of great service in the 
 diagnosis of doubtful cases in which localized dense neoplasms exist in 
 regions inaccessible to the ordinary means of clinical examination. 
 
 Sarcomata of the liver are mostly secondary growths. In melano- 
 sarcoma the primary growths are commonly in the choroid or the skin. 
 The enlargement is rapid and reaches a high grade. Multiple tumors are 
 often present in the skin, and metastases are widely extended. Melanuria 
 is an inconstant but important symptom. The liver tumor may not develop 
 until some months after the removal of an eyeball, as in a case of mine 
 in the Philadelphia Hospital. 
 
 Differential. — Fatty Liver. — The uniform enlargement and smooth 
 surface are suggestive of cancerous infiltration, especially in the fatty liver 
 of emaciation and cachexia. But the soft consistency of the enlarged liver, 
 its slow growth, and the absence of jaundice are important. Amyloid 
 Liver. — A history of suppuration or syphilis, enlargement of the spleen, 
 urinary phenomena, in particular albumin and casts which take the iodine 
 test, and a less rapid and marked cachexia are diagnostic. Gummatous 
 nodules may greatly embarrass the diagnosis. Echinococcus of the Liver. — 
 Ordinary echinococcus cysts are little likely to be confounded with 
 malignant disease. The enlargement with hard nodules upon the surface, 
 characteristic of multilocular echinococcus, may give rise to uncertainty, 
 especially as jaundice and ascites are frequent in both conditions. The 
 slow progress of multilocular echinococcus, the enlargement of the spleen, 
 and the slight tendency to cachexia are important in the differentiation. 
 Exploratory puncture may bring away softened material containing 
 cholesterin and hsematoidin crystals. Chronic Interstitial Hepatitis — 
 Hypertrophic Cirrhosis. — The absence of emaciation and cachexia, of 
 pain and tenderness, and of a primary focus are of diagnostic importance. 
 The enlarged liver is less dense than in infiltrated cancer and the jaundice 
 more variable in intensity. Atrophic Cirrhosis. — The muddy complexion 
 or jaundice, wasting, ascites, and other signs of portal obstruction common 
 to the two affections may cause great uncertainty. Differential points are 
 an alcoholic history, tardy course, enlargement of the spleen, and the 
 absence of primary malignant disease in other organs in cirrhosis. That 
 
PANCREATITIS. 1013 
 
 form of hepatic cancer with cirrhosis in which the liver is reduced in size 
 cannot, in the absence of a primary focus or metastasis, be recognized 
 during hfe. 
 
 Prognosis. — The outlook is in the highest degree unfavorable. The 
 duration of the disease rarely exceeds eighteen months. Secondary cancers 
 run a much more rapid course than the forms associated with cirrhosis. 
 Resection of malignant growths in the liver has been performed. 
 
 IV. DISEASES OF THE PANCREAS, 
 i. Hemorrhage into the Pancreas. 
 
 The hemorrhage usually occurs as a manifestation of the necrosis 
 incident to acute pancreatitis. There are instances, however, in which 
 large hemorrhage into the organ and adjacent structures has occurred in 
 the absence of inflammation. 
 
 The etiology is that of acute hemorrhagic pancreatitis. The condition 
 occurs in middle life. 
 
 Symptoms. — The onset is sudden. The patients are usually in their 
 ordinary health. In some instances there have been digestive symptoms 
 or previous attacks of biliary colic. Pain is intense and located in the 
 upper part of the abdomen. It is sharp, sometimes colicky, and increases 
 in severity. It is accompanied by nausea and vomiting, which are frequent 
 and intractable but not followed by relief. The patient becomes restless, 
 anxious, and depressed. The surface is cold and covered with a clammy 
 sweat. The pulse is feeble, rapid, and thready. The appearance of the 
 patient is that common in internal hemorrhage. There is epigastric ten- 
 derness followed by tympany which is usually moderate. The temperature 
 is normal or subnormal, the patient falls into syncope which terminates 
 fatally in the course of twenty-four or forty-eight hours, 
 
 ii. Acute Pancreatitis. 
 
 (a) ACUTE HEMORRHAGIC PANCREATITIS. 
 
 Definition. — The term acute hemorrhagic pancreatitis is employed 
 to designate a rapidly developing destructive procesS; — necrosis, — accom- 
 panied by hemorrhage into the substance of the organ and adjacent parts, 
 and in nearly all cases by disseminated areas of fat necrosis. In some 
 instances there is no evidence of inflammation; in others there are inflam- 
 matory changes. 
 
 Etiology. — Predisposing Influences. — It is in the highest degree 
 probable that cholelithiasis is the chief predisposing influence to acute 
 hemorrhagic pancreatitis. This hypothesis is supported by the following 
 facts: It has been experimentally shown that similar lesions are produced 
 by the injection of bile into the gland by way of the duct of Wirsung; 
 the condition is of common occurrence in individuals suffering from chol- 
 ehthiasis; biliary calculi are present in the bile-ducts or in the duodenum 
 in a large proportion of the cases; and an impacted gall-stone has been 
 
1014 MEDICAL DIAGNOSIS. 
 
 found, as in a case reported by Halstead and quoted by Opie. at the duo- 
 denal opening of the ampulla of Vater not of sufficient size to occlude 
 either the common duct or the pancreatic duct, and thus converting them 
 into a continuous closed channel. 
 
 The Exciting Cause. — The statement of Opie that, "While at pres- 
 ent it cannot be denied that other causes may produce the condition, only 
 one etiological factor has been demonstrated, namely, the impaction of 
 a gall-stone in the diverticulum of Vater, diverting bile into the pancreatic 
 duct" is unquestionably true. The immediate cause then is a mechanical 
 one. The bile and the pancreatic secretion are present at low pressure, 
 but the bile is forced into the pancreatic duct by the contractions of the 
 gall-bladder, and in some of the cases the walls of the pancreatic duct 
 have been stained with bile. 
 
 In the cases in which no evidence of gall-stone disease is found upon 
 post-mortem examination two conditions may occur: first, a neoplasm 
 interfering with the discharge of the bile into the duodenum; and second, 
 occlusion of a narrow^ canal between the ampulla of Vater and the duo- 
 denum by catarrhal swelling or a plug of tenacious mucus. 
 
 Symptoms. — No sharp line of demarcation can be drawn between 
 acute, gangrenous, and suppurative pancreatitis, which are in fact con- 
 secutive processes in cases in which death does not take place rapidly. 
 The attack may have been preceded by attacks of biliary colic, or it may 
 supervene upon such an occurrence. Again, since anatomical studies of the 
 relative diameter of the common duct and the canal leading from the 
 diverticulum of Vater into the duodenum have shown that a small calculus 
 readily passing through the common duct may fully occlude the duodenal 
 opening, the onset of the symptoms of acute pancreatitis may constitute 
 the first clinical phenomena of gall-stone disease. 
 
 There is little to add to the terse and graphic description of Fitz: 
 "' It (the attack) begins with intense pain, especially in the upper abdomen, 
 soon followed by vomiting, which is likely to be more or less obstinate, 
 and not infrequently by sHght epigastric swelling and tenderness with 
 obstinate constipation. A normal or subnormal temperature may be 
 present, and symptoms of collapse precede by a few hours death, which 
 is most likely to occur between the second and fourth days." Nausea is 
 marked and continues between the attacks of vomiting. The vomitus is 
 not characteristic. It does not at first contain bile. Collapse symptoms 
 occur early and, considered in connection with the above symptoms and 
 the rapidly fatal result, suggest acute poisoning. 
 
 Diagnosis. — Direct. — The diagnosis rests upon the sudden occur- 
 rence of the foregoing symptoms in an adult who has suffered from 
 chronic gastroduodenal catarrh or from attacks of biliary colic; the 
 location of the pain and tenderness in the upper abdomen; the absence 
 of the distinct; board-like rigidity characteristic of earl}' peritonitis 
 and an early high leucocytosis. Da Costa, in seven counts in four 
 cases at the German Hospital in Philadelphia, found a leucocj^tosis 
 ranging from 11,000 to 30,000. If the patient survives, circumscribed 
 epigastric fulness, v/hich may be tense and tympanitic or dull upon 
 percussion, may develop. 
 
PANCREATITIS. 1015 
 
 Opie has suggested that the fat-splitting ferment, which, free in the 
 tissues, causes the fat necrosis, may be excreted by the kidneys, and, 
 using the ethyl butyrate method of Castle and Loevenhardt, which 
 depends upon the power of a fat-splitting ferment to decompose that 
 substaace with the liberation of butyric acid, was able in one instance 
 to demonstrate the presence of a marked acid reaction, while a control 
 specimen remained unchanged.^ 
 
 Differential. — Acute Poisoning. — The anamnesis is important. 
 In poisoning by meat or fish a number of persons are usually simulta- 
 neously affected. There is a period of prodromes consisting of languor, 
 nausea, and griping pain in the belly. The attack begins suddenly with 
 chilliness, faintness, and headache. Collapse symptoms supervene with 
 vomiting and diarrhoea, which is often uncontrollable. In poisoning by 
 corrosive chemicals the surrounding circumstances, certain marks upon 
 the lips and garments, and the behavior of the patient are important. 
 Collapse is preceded by intense pain in the stomach, followed by colic 
 and in many instances by diarrhoea. Strangulated Hernia. — In a doubtful 
 case the sites of hernial tumors are to be carefully examined; the history 
 is important; constipation and fecal vomiting are significant. Intestinal 
 Obstruction. — In acute obstruction we find constipation, abdominal pain, 
 and vomiting. The pain is at first colicky, later continuous and severe. 
 Vomiting is an early symptom. Nausea is less marked than retching. 
 The vomitus consists at first of the stomach contents, then of bile-stained 
 mucus, and finally of a darkish liquid with a fecal odor. In many cases 
 neither faeces nor flatus are passed by the bowel; in some the contents of 
 the bowel below the constriction are voided. Abdominal tenderness and 
 tympany come on later. If the obstruction be seated in the small bowel 
 the distention may be slight, but it is not confined to the epigastrium. 
 Pain and tenderness are later symptoms and are not circumscribed. Col- 
 lapse symptoms are not usually at first present. There is, as a rule, a very 
 high leucocytosis, 60,000 or more. Acute hemorrhagic pancreatitis is 
 very often mistaken for intestinal obstruction. Embolism of the Larger 
 Mesenteric Vessels — Infarction of the Bowel. — This accident gives rise to 
 sudden colic, nausea, vomiting, and bloody diarrhoea. The condition 
 resembles acute obstruction, marked tympanites develops, and death 
 occurs in collapse. Perforative Peritonitis. — The differentiation becomes 
 apparent when the symptoms are enumerated. In perforation of an ulcer 
 of the stomach, bowels, or gall-bladder, necrosis of the appendix, rupture 
 of an abscess of the liver, spleen, kidney, or Fallopian tube, chilliness or 
 rigor, intense abdominal pain, and exquisite tenderness are early symptoms. 
 The pain and tenderness are general but more intense as a rule in the region 
 of the perforating lesion. There is early spastic contraction of the abdom- 
 inal muscles upon one or both sides — a very significant sign. The patient 
 assumes and maintains an attitude by which the tension of the abdominal 
 muscles is diminished, and lies with his head and shoulders elevated and 
 his thighs and legs strongly flexed. Later the tension relaxes, the abdomen 
 becomes tympanitic, and both pain and tenderness abate. When there 
 is a history of gall-stone disease the differential diagnosis becomes as 
 
 1 Diseases of the Pancreas, Opie, 1903, p. 322. 
 
1016 MEDICAL DIAGNOSIS. 
 
 important as it is obscure. Absence of muscular tension, circumscribed 
 pain and tenderness in the epigastrium, and early profound collapse are 
 suggestive of pancreatitis. 
 
 Cammidge found that in cases of pancreatic disease a peculiar 
 substance, probably pentose, is present in the urine and can be detected 
 by its forming long, yellow, flexible crystals arranged in sheaves in the 
 presence of phenylhydrazine. The test is very elaborate and can onl}^ 
 be carried out in a laboratory. 
 
 (b) GANGRENOUS PANCREATITIS. 
 
 Etiology. — Necrosis of the whole or a portion of the gland may follow 
 hemorrhage or hemorrhagic pancreatitis in the cases in which death does 
 not occur in the first three or four days. The tissue of the pancreas is dry 
 and friable, and the necrotic organ lies nearly free in the omental cavity. 
 Death usually occurs in the course of two or three weeks. There are 
 recorded cases in which the necrotic pancreas has. been discharged by 
 way of the rectum, with recovery. 
 
 Symptoms. — The clinical symptoms are those of acute hemorrhagic 
 pancreatitis, but the illness is of longer duration. As the gangrenous 
 pancreas occupies a position in the posterior wall of the lesser peritoneal 
 cavity, peritonitis ensues, and this cavity becomes filled with pus and 
 necrotic material. These changes are followed by fever, delirium, and 
 the general symptoms of septic infection. 
 
 Diagnosis. — The condition cannot be positively determined during 
 life. A probable diagnosis rests upon the occurrence of the symptoms 
 of acute hemorrhagic pancreatitis with a prolongation of life, and the 
 occurrence of septic phenomena. 
 
 (c) ACUTE SUPPURATIVE PANCREATITIS— PANCREATIC ABSCESS. 
 
 Suppurative inflammation of the pancreas presents nothing charac- 
 teristic, with the exception that it most commonly occurs as a later stage 
 of acute hemorrhagic and gangrenous pancreatitis. There may be a single 
 large abscess, multiple small abscesses, or diffuse purulent infiltration. 
 The lesser peritoneal cavity may be distended with pus. 
 
 Etiology. — Cholelithiasis constitutes a predisposing influence. The 
 actual cause of the disease is to be found in an antecedent hemorrhagic 
 pancreatitis. In some cases the condition has followed traumatism. 
 
 Symptoms. — The clinical manifestations follow those of acute hem- 
 orrhagic pancreatitis and are the result of the invasion of the necrotic 
 pancreatic and peripancreatic tissues by pus-producing organisms. There 
 may be epigastric prominence, or a deep-seated mass may be felt in the 
 median line. Irregular chills and fever, with profuse sweating and pro- 
 gressive loss of flesh and strength, occur. In some instances the disease 
 runs a protracted course with irregular fever, epigastric pain, and vomit- 
 ing. Slight icterus, fatty diarrhoea, and glycosuria occur in some cases. 
 Perforation into the stomach, duodenum, or peritoneum may occur. Portal 
 thrombosis has been noted. 
 
PANCREATITIS. 1017 
 
 Diagnosis. — The recognition of the condition is extremely difficult. 
 Circumscribed epigastric prominence or a resistant deep-seated mass in 
 connection with the above symptoms is suggestive. The gravity of the 
 condition justifies surgical diagnosis by an exploratory operation. 
 
 Prognosis. — The prognosis in the acute cases is uniformly fatal, death 
 occurring in the course of twenty-four or thirty-six hours. In a limited 
 number of subacute cases, in which life has been prolonged, spontaneous 
 recovery has occurred with the discharge of a portion of the necrosed gland 
 by the bowel, or surgical operation has been followed by cure. 
 
 iii. Chronic Pancreatitis. 
 
 The gland undergoes sclerotic changes as the result of chronic inflam- 
 mation. It is sometimes diminished in size; in other cases it is larger than 
 normal, and may form a palpable epigastric tumor. Two types of interstitial 
 inflammation have been distinguished — an interlobar and an interacinous. 
 
 Etiology. — Predisposing Influences. — Age is important. Chronic 
 pancreatitis is much more common between the fortieth and sixtieth years 
 of life than at any other period. The disease is frequently secondary to- 
 disease of the intestine and bile passages, and of the liver. 
 
 Exciting Cause. — Inflammatory irritants may reach the organ by 
 way of the duct of Wirsung or Santorini. Obstruction to the outflow of 
 the pancreatic secretion may be followed by chronic pancreatitis. A form 
 of interstitial pancreatitis of the new-born occurs in syphilis. A history 
 of tuberculosis, syphilis, and the abuse of alcohol may frequently be 
 obtained. The association of cirrhosis of the liver with chronic pancreatitis 
 has been noted. 
 
 Symptoms. — The symptoms are obscure, and the condition is rarely 
 recognized during life. At operations for surgical diseases involving the 
 gall-bladder and bile passages the head of the pancreas is not infrequently 
 found enlarged and is so hard as to suggest malignant neoplasm. In such 
 cases it has frequently happened that the patient has recovered and remained 
 well for years. Usually there is a history of epigastric pain, nausea, and 
 persistent vomiting. The signs of arteriosclerosis are frequently present. 
 The enlarged head of the pancreas may press upon the common bile- 
 duct and produce jaundice. Fatty diarrhoea, glycosuria, and diabetes 
 may occur. The islands of Langerhans are the source of a glycolytic fer- 
 ment necessary to the metabolism of the carbohydrates. Functional 
 or organic disease of these bodies may be followed by an accumulation 
 of glucose in the blood and by glycosuria — pancreatic diabetes. Minor 
 functional derangements may give rise to alimentary glycosuria, that is, 
 glycosuria following the ingestion at once, while fasting, of amounts of 
 glucose less than about 200 grammes — the quantity which can be taken in 
 health without causing glycosuria. 
 
 Hyaline Degeneration of the Pancreas. — Opie has especially drawn 
 attention to this condition. It affects chiefly the islands of Langerhans 
 and is associated with diabetes mellitus. It may occur as an inde- 
 pendent condition, or may be associated with a moderate degree of 
 increase in the interstitial tissue, or arteriosclerosis. It is equally 
 
1018 MEDICAL DIAGNOSIS. 
 
 common in the two sexes, and has been chiefly observed after middle 
 Hfe. Chronic interstitial pancreatitis of the interacinous type has been 
 present in the -majority of the cases. 
 
 iv. Pancreatic Calculi. 
 
 Pancreatic lithiasis is a rare condition. It may cause chronic inter- 
 stitial pancreatitis, dilatation of the duct, a large retention cyst, acute 
 suppurative inflammation, or finally, as in the case of cholelithiasis, 
 carcinoma. 
 
 Symptoms. — In pancreatic colic the pain is sudden, intense, and 
 paroxysmal. It has its maximum intensity at the costal margin to the 
 left of the middle line, and passes through to the back. Fatty diarrhoea 
 and glycosuria occur, but are not constant. Vomiting may occur. Pan- 
 creatic calculi are in some instances associated with gall-stone disease. 
 
 Diagnosis. — Direct. — -The occurrence of the above symptoms in 
 paroxysms, usually at intervals of months or years, without jaundice, is 
 suggestive. The presence in the stools, after the attack, of round, smooth 
 or rough, opaque, white calculi, which are composed chiefly of calcium 
 carbonate, renders the diagnosis positive. 
 
 Differential. — The symptoms when small stones are passed may 
 suggest gastralgia or gastric ulcer; in other cases cholecystitis or a biliary 
 calculus in the cystic duct. The focus of pain upon the left side and the 
 character of the stones, if passed, are diagnostic. > 
 
 V. Pancreatic Cysts. 
 
 The term pancreatic cyst has been used to designate any cystic tumor 
 in, or associated with, the pancreas, although such tumors differ among 
 themselves, etiologically, in situation and in clinical features. 
 
 Varieties. — Congenital cystic disease; retention cysts; proliferative 
 cysts; hemorrhagic cysts; hydatid cysts; and pseudocysts. 
 
 Etiology. — Sex is without influence, the condition having been observed 
 in about the same number of men and women. Age is important, the 
 largest proportion of cases reported being between twenty and forty 
 years. Cases have been noted in the new-born, and between the sixtieth 
 and seventieth years. The greater number of cysts are caused by trauma- 
 tism, inflammation, or impacted calculi. They may occupy any part of 
 the gland. Congenital cystic disease may occur in the pancreas as in the 
 kidney and liver. The causes of retention cysts are the impaction of cal- 
 cuh, cicatricial stenosis, pressure upon the duct, and dislocation of a part 
 of the organ. Proliferative cysts are of two kinds: simple, or cyst adenoma, 
 and malignant, or cystic epithelioma. There is a marked tendency to hem- 
 orrhage into pancreatic cysts. Collections of blood in the substance of 
 the organ are characteristic of the acute forms of necrosis and inflamma- 
 tion. Hydatid cysts are exceedingly rare. Pseudocysts are circvimscribed 
 collections of fluid found in the proximity of the pancreas, but not having 
 their origin in the substance of the gland. They commonly occupy the 
 lesser peritoneum. 
 
PANCREATIC CYSTS. 1019 
 
 The fluid is usually thick and viscid, alkaline, of variable color, 
 clear, milky, yellow, green, or brownish-black. There is usually, in the 
 colori^d fluids, an admixture of blood. The specific gravity varies from 
 1.010 to 1.020 or higher. Serum albumin, paraglobuhn, mucin, and urea 
 are present. The presence of fat-splitting, proteolytic, or diastasic ferments 
 cannot usually be demonstrated, although the last may sometimes be 
 found. The secretion of the chemically inflamed pancreas may contain 
 only traces of these ferments, and cannot find its way into the cyst unless 
 there is free communication with the glandular parenchyma. Moreover, 
 similar ferments have been demonstrated in the contents of mesenteric 
 and ovarian cysts. The discharge from a fistula resulting from ooeration 
 may contain the pancreatic ferments. 
 
 Symptoms and Signs. — In small cysts symptoms are absent or indef- 
 inite. In larger cysts there are pressure symptoms, especially epigastric 
 discomfort, weight, and fulness. Pain, especially after food, confined to 
 the upper part of the abdomen, radiating to the back and toward the 
 left, vomiting, and constipation occur. Jaundice, usually slight, may 
 result from the pressure of a cyst in the head of the pancreas upon the com- 
 mon duct. Light-colored stools containing free fat and much undigested 
 muscle fibre are significant but by no means constant. Alimentary 
 glycosuria and diabetes occur onl}^ in cases in which there is extensive 
 destruction of the gland. 
 
 The cystic tumor lies behind the posterior layer of peritoneum, which 
 forms the lesser sac. In the great majority of cases the enlarging tumor 
 displaces the stomach upward and to the right, and the transverse colon 
 downward, and approaches the surface below the greater curvature of 
 the stomach; occasionally it presents above the upper border of the stom- 
 ach; and finally it may push itself between the layers of the transverse 
 mesocolon and force the transverse colon before it, or displace both the 
 transverse colon and the stomach upward. 
 
 The tumor occupies the epigastrium, at first usually to the left of the 
 middle line between the costal border and the umbilicus. It may lie in 
 the middle line, or more rarely to the right. It is usually smooth, spher- 
 ical or oval, elastic, and tense. It may attain enormous dimensions and 
 reach to the symphysis pubis, suggesting an ovarian or parovarian cyst. 
 It is commonly immovable, or but slightly movable, either upon pressure 
 or with the respiration, but in rare cases may be feebly so in consequence 
 of its attachment to the tail or body of the pancreas by a narrow pedicle. 
 When small it may resemble a solid mass, and transmitted aortic pulsa- 
 tion may suggest an aneurism. In large pancreatic cysts fluctuation can 
 almost always be elicited. There is flatness upon percussion. 
 
 Diagnosis. — Diuect. — The presence of a cystic tumor located — or 
 at first located — in the upper abdomen and having the above features is 
 of diagnostic significance. Inflation of the stomach and colon may be 
 important, especially in small cysts. The contents may be removed for 
 examination by aspiration — an unsafe procedure, to be employed only 
 in extreme cases. A history of recent traumatism, as a kick or blow upon 
 the epigastrium, is important. 
 
1020 MEDICAL DIAGNOSIS. 
 
 Differential. — Various cystic tumors present i^oints of resemblance 
 to pancreatic cysts. Among the more important are the following: Ovarian 
 Cysts. — Only enormous cysts of the pancreas can give rise to difficulties. 
 Examination of the pelvic organs, preferably in the Trendelenburg position, 
 the distention of the colon with air, and the history of the case will remove 
 every doubt even in those cases in which the appearance of the abdomen 
 closely resembles that caused by tumor of the ovary. Cysts of the liver are 
 usually hydatid. When in the left lobe, they can scarcely be differentiated 
 from pancreatic cyst except by aspiration of the fluid or an exploratory 
 operation. An enormously distended gall-bladder may simulate pancreatic 
 cyst. Cyst of the suprarenal capsule, especially upon the left side, may 
 be readily mistaken for cyst of the pancreas. The differential diagnosis 
 by physical signs alone is not possible. Cysts of the Kidney, Hydrone- 
 phrosis, Pyonephrosis. — The tumor moves to some degree with respiration; 
 it is distinctly unilateral, and occupies the lumbar region rather than the 
 epigastrium. The relation of the colon to it may be determined by per- 
 cussion after inflation. Renal symptoms, such as aching pain, frequent 
 micturition, and the previous disappearance of the tumor with the passage 
 of a great quantity of water, or hemorrhage from the genito-urinary tract, 
 point to the kidney. Cysts of the Mesentery. — These tumors are character- 
 ized by their location near the umbilicus, movability in a lateral or rotary 
 direction, and tympany around the circumference of the mass, and in a 
 band across it. If a pancreatic cyst develops between the layers of the 
 transverse mesocolon the band of resonance will be due to the colon. 
 Omental Cysts. — A cyst developing in the omentum directly below the 
 stomach would push the stomach up and the transverse colon down. By 
 the physical signs the diagnosis would not be possible. The anamnesis 
 and the general symptoms might justify a provisional diagnosis. Cysts of 
 the posterior wall of the stomach, cysts of the spleen, and certain retroperitoneal 
 cysts are of very rare occurrence and present unusual diagnostic difficulties. 
 In many of the cases the differential diagnosis between these tumors and 
 cysts of the pancreas is impossible. 
 
 Prognosis. — The condition, if early diagnosticated and relieved by 
 operation, usually terminates in recovery. To this statement a reservation 
 must be made in regard to hemorrhagic cysts. 
 
 vi. Tumors of the Pancreas. 
 
 Neoplasms are rare. Sarcoma, adenoma, and lymphoma are extremely 
 infrequent. Carcinoma mostly involves the head of the organ, is often 
 primary, and commonly occurs after middle life. Miliary tubercle is an 
 accompaniment of acute miliary tuberculosis. Syphilis occurs in the form 
 of chronic interstitial inflammation or gummata. The frequency with 
 which the head of the organ is involved, especially in carcinoma, accounts 
 for certain symptoms. The tumor exerts pressure upon the common bile- 
 duct, the pancreatic duct, the duodenum, and the pylorus. The stomachy 
 colon, aorta, vena cava, portal vein, superior mesenteric vein, and the 
 splenic artery and vein may also be compressed. The breaking down of 
 the growth may cause perforation of any of these organs. 
 
ASCITES. 1021 
 
 Etiology. — Carcinoma. — Men are more frequently affected than 
 women. The condition has been found with greatest frequency between 
 forty and sixty years. 
 
 Symptoms. — In some cases the symptoms are obscure. Generally 
 epigastric pain radiating to the back, often intense and aggravated at 
 night, is a prominent symptom. Jaundice, a gall-bladder tumor, and 
 enlargement of the liver are common. A tumor in the pyloric region, and 
 fixed, may often be made out. There is rapid wasting. Constipation is 
 usual; the stools are large and contain free fat and undigested muscle 
 fibre in unusual amount. Sugar may be present in the urine, and the 
 symptoms of diabetes may be noted. A subnormal temperature also occurs. 
 A dense shadow may be noted upon X-ray examination. 
 
 Diagnosis. — Direct. — The occurrence of the above symptoms with 
 cachexia renders the diagnosis of carcinoma of the pancreas positive. 
 
 Differential. — In default of a definite symptom-complex the 
 possibility of interstitial pancreatitis, or malignant disease of the common 
 duct, the liver, or the pylorus is to be considered. Chronic Pancreatitis. — 
 A long histor}'", recurrent painful attacks, and epigastric tenderness are in 
 favor of benign disease; loss of flesh is less marked than in carcinoma, 
 and vascular disturbances and dropsy are far less common. Anaemia is 
 less pronounced, and cachexia is absent. Cancer of the Bile-ducts. — There 
 is almost always a history of gall-stone disease. If the duct of Wirsung be 
 involved the differential diagnosis cannot be made; if not, the destructive 
 signs of pancreatic disease, especially the rapid wasting, will be absent. 
 Cancer of the Liver. — Enlargement of the liver with nodules upon its sur- 
 face and borders, and moderate jaundice, or its absence, are diagnostic. 
 Cancer of the Pylorus. — Marked gastric symptoms, retention vomiting, 
 dilatation of the stomach, absence of free hydrochloric acid, and the 
 presence of altered blood in the vomited matters are against pancreatic 
 carcinoma alone, but the conditions are frequently associated. 
 
 V. DISEASES OF THE PERITONEUM, 
 i. Ascites. 
 
 Abdominal Dropsy — Hydroperitoneum. 
 
 Definition. — An accumulation of serous fluid in the peritoneal cavity. 
 
 Etiology. — General Causes. — The accumulation may be part of a 
 general dropsy caused by derangement of the mechanism of the circula- 
 tion, as in disease of the heart. In some cases of heart disease the drop- 
 sical effusion may be limited to the peritoneum. Ascites occurs also in 
 various forms of hydraemia and in advanced renal dropsy. Local 
 Causes. — Chronic inflammation of the peritoneum; portal obstruction; 
 abdominal tumors. 
 
 Character of the Ascitic Fluid. — The fluid in ascites from stasis is clear, 
 yellowish or greenish-yellow, alkaline in reaction, of a specific gravity 
 of 1.010-1.015, and contains in solution the soluble substances of the 
 blood. Red blood-corpuscles are also present, usually in small numbers. 
 
1022 MEDICAL DIAGNOSIS. 
 
 In inflammatory ascites the fluid contains flakes of fibrin, other masses 
 of coagulated material, large numbers of pus-corpuscles when it is puru- 
 lent, and many blood-corpuscles when it is hemorrhagic. In cancerous 
 ascites molecular debris and cancer-cells may be present. Various bac- 
 teria, as streptococci, staphylococci, colon bacilh, gonococci, B. typhosi, 
 pneumococci, and tubercle bacilh may also be present. The presence of 
 tubercle bacilli may be determined by inoscopy. The differential diag- 
 nosis between transudation and exudation cannot always be made from 
 the characters of the fluid alone. For this purpose neither the albumin 
 percentage nor the specific gravity avails. Cytodiagnosis is far less useful 
 in the determination of the nature of peritoneal than that of pleural effu- 
 sions. The effusion in cirrhosis is sometimes darker in color than in other 
 conditions, and that in cancer and tuberculosis is usually hemorrhagic. 
 In the cells of carcinomatous ascites mitosis is more common than in other 
 forms, and the cells in melanotic sarcoma may contain pigment granules, 
 though the fluid is clear. 
 
 Chylous and Chyliform Ascites. — The fluid is milky in appearance and 
 resembles chyle. Quincke recognized two essentially different forms, 
 one a transudate, — ascites chylosus, which owes its characters to the 
 actual presence of chyle, — the other ascites adiposus, — chyliform or 
 pseudochylous, — the appearance of which is due to the admixture of fat 
 derived from the metamorphosis of the disintegrating cells of an inflam- 
 matory exudate or the endothelium. Fat is present in both forms in 
 minute dust-like particles. In chylous ascites there are very few cells in 
 a state of fatty degeneration. In chyliform ascites,' on the other hand, 
 there are many cells containing fat granules. The presence of sugar does 
 not justify the conclusion that a milky ascites is chylous, since it has been 
 definitely established that sugar may be present in any form of transudate 
 or exudate in the serous sacs. Both of these fluids, subjected to agitation 
 with ether after the addition of potassium hydroxide, clear up to a greater 
 or less extent, and both respond to the osmic acid and other tests for fat. 
 They are bacteria free and do not undergo decomposition for indefinite 
 periods. Upon standing they separate into a thick sedimentary layer, 
 and a fatty, cream-like layer at the top. 
 
 Milky, Non-fatty Ascites. — The fluid resembles the fatty forms, but 
 neither microscopically nor clinically reveals the presence of fat. The 
 milk-like appearance has been ascribed to various proteid and mucoid 
 substances, and to lecithin, but the subject is still under investigation. 
 
 Hcemo peritoneum may result from traumatism and the rupture of 
 viscera, as the liver, spleen, or mesentery. It occurs also in extra-uterine 
 fetation and the rupture of aneurism. Recurrent hemorrhage into the 
 peritoneum has been observed in the absence of assignable cause. Blood- 
 stained fluid may be present in acute pancreatitis, volvulus, twisting of 
 the pedicle of an ovarian cyst, and other similar conditions. 
 
 Symptoms. — These vary according to the amount of fluid. Small 
 amounts occasion no discomfort, and the gradual accumulations of a con- 
 siderable ascites may not be realized by the patient. It is very common in 
 the ascites associated with cirrhosis of the liver for the patient to first 
 become aware of his condition by his inability to make his waistband 
 
ASCITES. 1023 
 
 meet. Large accumulations of fluid give rise to much distress by pressure 
 and tension of the abdominal walls, sensations of fulness and weight, ami 
 interference with the play of the diaphragm, causing dyspnoea and cyanosis. 
 (Edema of the lower extremities and pudenda, occurring subsequently to 
 large ascites, is due to interference with the retui-n of the blood by the 
 pressure of the fluid upon the ascending vena cava, and interference with 
 the action of the heart by upward pressure against the diaphragm. The 
 superficial venous trunks — mammary, epigastric — are frequently widened 
 and tortuous, and reveal, upon stripping, the upward current of the 
 contained blood. 
 
 Physical Signs. — (See Methods of Physical Diagnosis, Part II.) 
 
 Diagnosis. — Small quantities of fluid gravitate into the pelvis and 
 fail to manifest themselves by the signs elicited upon external examina- 
 tion. If necessary, the patient may be placed in the knee-elbow posture 
 when a small collection of ascitic fluid gravitating into the most dependent 
 region may be recognized upon percussion, or a finger may be lightly 
 pressed into the inguinal ring, the patient being in the erect posture. 
 Gentle tapping will cause a wave which is felt by the finger. Again the 
 finger, introduced into the rectum or vagina, the patient being in such a 
 position that the fluid gravitates into the cul-de-sac of Douglas, may 
 perceive the fluctuation produced by tapping on the lower part of the 
 belly wall. Less than 1500-2000 c.c. cannot be detected by physical 
 examination. 
 
 Paracentesis Abdominis. — The patient should sit on a chair or upon the 
 side of a low bed, with his knees separated and a large jar or small tub 
 between his feet. The puncture should be made in the median line midway 
 between the symphysis and navel, under strict antiseptic jDrecautions, 
 with a straight trocar, one-eighth of an inch in diameter; it should be 
 determined by previous percussion that an intestinal coil does not lie 
 beneath the point at which the patient is to be tapped. Pressure should 
 be applied by a many-tailed bandage to the abdominal wall as the fluid 
 escapes. If the canula becomes obstructed by floating intestine, a change 
 in direction or the insertion of a probe will clear it. Fluids ma}^ be allowed 
 to escape until the flow ceases. A strip of adhesive plaster may be placed 
 over the opening, some oozing from which is likely to occur. 
 
 Differential Diagnosis. — Large cysts may simulate ascites. The 
 error is most common in cysts of the ovary; much more rare are pancreatic 
 cysts of such size. There is tympanitic resonance in the flanks, and the 
 circular or oval area of tympany is not present in the umbilical region. 
 Examination per vaginam may yield important information. Enormous 
 lipomata have been mistaken for ascites. There is an obscure sense of 
 fluctuation, but the shifting areas of tympany characteristic of ascites 
 do not occur. The condition is exceedingly rare; females are chiefly 
 affected; the tumor develops in middle life, and is of slow growth. An 
 overdistended bladder may reach to the umbilicus, or above it, and has 
 been mistaken for ascites. The dribbling of urine, — incontinence of reten- 
 tion, — and the outline of the swelling should put the practitioner upon his 
 guard. The catheter will at once settle the matter. Encysted injlammatory 
 exudates, when large, may simulate ascites, especially when pain and fever. 
 
1024 MEDICAL DIAGNOSIS. 
 
 or other constitutional symptoms, are no longer present. In most cases 
 the careful employment of the methods of physical examination is 
 adequate for the diagnosis. 
 
 ii. Acute General Peritonitis. 
 
 Definition. — Acute diffuse inflammation of the peritoneum. 
 
 Etiology. — The peritoneum is peculiarly exposed to local and general 
 infection by traumatism, extension from the viscera which it invests, the 
 perforation of hollow viscera, rupture of the capsules of organs or the walls 
 of abscesses, and by way of the lymph channels and the blood. Peritonitis 
 may be primary or secondary. 
 
 1. Primary Peritonitis. — Infection takes place by the blood or by the 
 lymph stream, and not as the result of any lesion of the viscera with which 
 the peritoneum is in relation, or any wound or surgical operation. Acute 
 general peritonitis is sometimes attributed to exposure to cold or damp, 
 and has then been described as rheumatic. The form which occurs as a 
 terminal event in renal disease, gout, and arteriosclerosis is more common. 
 Whether or not these forms of peritonitis — idiopathic peritonitis — are 
 in the strict sense primary remains unsettled. 
 
 2. Secondary Peritonitis. — From the point of view of the source 
 of infection, three groups of cases may be recognized, (a) Those in which 
 the infection of the peritoneum takes place from without by way of trau- 
 matism or surgical operation, (b) Those in which one of the abdominal 
 organs, or an abscess, ruptures and its contents are discharged into the 
 peritoneal cavity. Intestinal perforation is the most common accident of 
 this kind, (c) The cases in which bacteria find their way through the wall 
 of the intestine in the absence of a large or small solution of continuity, 
 or enter the .peritoneal cavity by way of the lymph channels, as in certain 
 forms of puerperal peritonitis, or peritonitis consecutive to infection of 
 the pleura. 
 
 Bacteriology of Acute Peritonitis. — One or several varieties of 
 bacteria may be found in the exudate — single or mixed infection. Those 
 which are the most important are the Streptococcus pyogenes, the Dip- 
 lococcus pneumoniae, and the Bacillus coli communis. These are frequently 
 present alone — monoinfection. In rare instances the Staphylococcus 
 pyogenes aureus has been found in pure culture in the peritoneal exudate. 
 The gonococcus may also cause peritonitis, whether in simple or mixed 
 infection has not yet been positively determined. In simple infection 
 the following organisms have also been found: Micrococcus lanceolatus, 
 B. pyocyaneus, and the B. influenzae. In so-called primary — idiopathic — 
 peritonitis, and in postoperative peritionitis, simple infection is much more 
 common than mixed infection; in the secondary forms mixed infection 
 is more common, but monoinfection may occur. 
 
 Clinical Etiology. — The vast majority of cases which arise in conse- 
 quence of disease of the abdominal or pelvic organs invested by peritoneum, 
 or in near topical relation to the peritoneal cavity, are demonstrably 
 ""secondary." The organs most commonly involved in the primary affec- 
 tion are the intestines and the reproductive organs in the female. 
 
PERITONITIS. 1025 
 
 Intestines. — In the order of frequency and importance, lesions of 
 the vermiform appendix stand first. Intestinal ulceration, especially the 
 ulcers of enteric fever and peptic ulcer in the duodenum, come next. Other 
 forms of intestinal ulcer, as tuberculous, dysenteric, diphtheritic, are less 
 apt to cause perforation, and when this accident occurs it is usually into 
 a region of the peritoneum shut off by adhesions and often already the 
 seat of a circumscribed abscess. Certain forms of intestinal ulcer, both 
 acute, as after extensive burns of the surface, or peptic ulcer, and chronic, 
 as those which occur occasionally in scurvy and leukaemia, show no ten- 
 dency to perforation. Carcinoma causes chronic adhesive peritonitis 
 and circumscribed abscess formation, but scarcely ever acute diffuse 
 inflammation of the peritoneum. Acute Occlusion of the Bowel. — Volvulus 
 and strangulation and less frequently intussusception give rise to peri- 
 tonitis. Chronic stenosis is rarely the cause of this condition. Rupture 
 of the bowel, like perforation, is at once followed by general peritonitis. 
 
 The Stomach. — Peptic ulcer and carcinoma may prove the point 
 of departure for acute peritonitis. Sudden perforation, before adhesions 
 have formed, may occur; more commonly, adhesions with adjacent vis- 
 cera take place as the result of a local peritonitis, with abscess formation 
 or perforation into the colon. 
 
 Liver, Gall-bladder and Bile Passages. — Perihepatitis and local 
 adhesive inflammation are common in diseases of these organs, but acute 
 diffuse peritonitis is infrequent. It may result from rupture of an abscess 
 or hydatid cyst, or from strangulation or acute intestinal obstruction 
 caused by pericholecystitic adhesions. An abscess about an infected gall- 
 bladder has, in rare instances, ruptured into the general cavity of the 
 peritoneum. 
 
 The Spleen. — Acute diffuse peritonitis arising from disease of this 
 organ is rare. Rupture of the capsule from traumatism, and the rupture 
 of an abscess before adhesions to neighboring viscera have formed, are 
 the two principal events. 
 
 The Pancreas. — Acute hemorrhagic pancreatitis gives rise to inflam- 
 mation of the lesser peritoneum, and when the patient survives for a period 
 general peritonitis may occur by extension. The rupture of a pancreatic 
 abscess into the general peritoneum is an extremely rare event. 
 
 Kidneys and Bladder. — Acute diffuse purulent peritonitis occa- 
 sionally results from the rupture of an abscess of the kidney. Rupture 
 of a hydronephrosis may not be followed by peritonitis, if the urine does 
 not contain pathogenic bacteria. Perforation of the bladder as the result 
 of ulceration, or the more serious forms of diphtheritic ulceration, may 
 result in a localized abscess or in acute peritonitis. 
 
 The Genital Organs. — Acute gonococcus peritonitis, having its 
 starting-point from the vas deferens or seminal vesicles, is exceedingly 
 rare. In the female, however, the sexual organs constitute the most fre- 
 quent starting-point of acute peritonitis. Puerperal peritonitis is the 
 most common form. Gonococcus infection is an extremely common cause 
 of pelvic peritonitis, and occasionally, in young girls, of acute general 
 peritonitis, which may also occur in children suffering from vulvovaginitis 
 by extension to the tubes. 
 
 65 
 
1026 MEDICAL DIAGNOSIS. 
 
 Lesions of the Abdominal Parietes, Mesenteric and Retro- 
 peritoneal Glands, and Inflammatory Disease op the Other Serous 
 Cavities. — Peritonitis sometimes arises in consequence of inflammation 
 or suppuration in the abdominal walls, the burrowing of psoas or other 
 abscesses, rectal disease, or caries of the vertebra, ribs, or bones of the 
 pelvis. It may also be secondary to disease of the mesenteric glands, 
 especially in tuberculous disease, and enteric fever — pseudo-abscess. 
 Pleurisy, pulmonary abscess, gangrene of the lung, and purulent pericar- 
 ditis may be followed by acute general peritonitis in consequence of 
 infection through the diaphragm. 
 
 Acute Infectious Diseases, — Acute peritonitis sometimes occurs 
 in the course of rheumatic fever. It is common in septic conditions and 
 especially in puerperal sepsis. It is extremely rare in the continued and 
 eruptive fevers, and when it occurs in the course of these infections is 
 secondary to some local lesion, as perforation in enteric fever. It sometimes 
 occurs in erysipelas, especially when the abdominal walls are involved, 
 in influenza of the gastro-intestinal form, and in pneumonia. 
 
 Peritonitis in the Fcetus and New-born. — A septic peritonitis 
 of the foetus arises in consequence of infection from the mother by way of 
 the placental circulation. Not alone the peritoneum, but also the other 
 serous cavities, the pleurae, pericardium, and meninges are affected. In 
 the new-born, infection by way of the umbilical wound, usually through 
 the lymph channels, is a frequent cause of general peritonitis. 
 
 The blood-vessels of the peritoneum in recent cases are more or less 
 deeply injected, and the coils of intestine distended and bound together by 
 lymph. The exudate may be fibrinous, serofibrinous, purulent, gangrenous^ 
 or hemorrhagic. The fluid exudate varies in amount from a few small col- 
 lections of clear serum among the adherent loops of bowel to many litres. 
 
 Symptoms. — The symptoms of peritonitis in general may be arranged 
 in the following groups: (a) Symptoms immediately due to the peritoneal 
 inflammation, — pain and the phenomena denoting the presence and amount 
 of the exudate, (b) Symptoms caused by derangements of organs and 
 structures implicated in the process, as the stomach, intestine, bladder,, 
 abdominal muscles, and diaphragm, — vomiting, constipation, meteorism^ 
 frequent and painful micturition, early rigidity, and late paresis of the 
 abdominal walls, hiccough, (c) Constitutional or toxsemic symptoms: 
 fever with its attendant phenomena, circulatory disturbances, anaemia,, 
 modifications of the urine, nutritional disorders, and manifestations of sepsis. 
 These symptoms show great variation in their intensity and association in 
 the different forms of peritonitis and in different cases. 
 
 (a) Peritoneal Symptoms. — Pain and tenderness in the abdomen charac- 
 terize the onset. The pain is severe and continuous, the tenderness exquis- 
 ite. In non-perforative cases the pain gradually reaches its maximum ; in 
 perforative cases it is almost always extremely severe from the onset. 
 In enteric fever and other stuporous states the occasional absence of pain 
 is due to the mental condition. The pain is continuous, and not only is it 
 increased by pressure, but also by movement. The patient lies motionless 
 in the dorsal posture, with the legs and thighs flexed. Respiration is 
 shallow, rapid, and of the costal type. Cough is suppressed, and sneezing 
 
PERITONITIS. 1027 
 
 is attended with agonizing pain. To this persistent, characteristic pain is 
 superadded coHc due to intestinal peristalsis, and recurring in paroxysms. 
 The pain and tenderness may be present uniformly over the whole abdo- 
 men. It is very often most intense below the umbilicus. Frequently, 
 but not invariably, these symptoms are most, intense in the area cor- 
 responding to the starting-point of the inflammation, as the ileocsecal 
 region, the pelvis, or the epigastrium. 
 
 A fibrinous exudate sometimes manifests itself by a friction sound, 
 usually best heard in the upper part of the abdomen, over the liver or 
 spleen. A fluid exudate gradually collects in a majority of the cases. 
 Its presence may be first recognized by dulness in the flanks. As it 
 increases, it gives rise to the characteristic physical signs described 
 under the heading "Physical Diagnosis" (see Part II). 
 
 (b) Visceral Symptoms. — Vomiting is one of the earliest symptoms in 
 acute peritonitis, and greatly increases the pain. It usually continues 
 several days, not ceasing until the fatal termination, an improvement in 
 the patient's condition, or the outpouring of a large exudate. In the 
 last instance, the cessation of vomiting may be an unfavorable sign. The 
 vomitus consists, at first, of the gastric contents; later, of a bile-stained 
 greenish fluid, and in some instances of blackish material with a fecal odor. 
 Vomiting may be absent in large perforation of the stomach. Constipa- 
 tion is the rule; in some cases the bowels move spontaneously every 
 day or two; in puerperal septic peritonitis diarrhoea is common. Hiccough 
 is a common and distressing symptom. 
 
 Muscular rigidity, the result of reflex irritation, is an early and 
 extremely valuable sign of acute peritonitis. It may cause retraction, 
 even a scaphoid abdomen, and by restraining peristalsis may diminish 
 the pain. It is especially marked in peritonitis due to perforation. In 
 rapidly fatal cases the abdomen may be flat and rigid throughout the 
 entire course of the attack. 
 
 Painful micturition is due to traction exerted upon the inflamed peri- 
 toneum by the contractions of the bladder. Retention of urine is common, 
 especially in men. More often there is great vesical irritability, with 
 frequent micturition. The urine is diminished, high colored, and often 
 contains albumin. It is characteristic of acute diffuse peritonitis that the 
 urine contains large quantities of indican. The micro-organisms which 
 cause the disease have been present. As the rigidity passes away, 
 meteorism takes its place. It is due to paresis of the intestine, and may 
 appear early in the disease, especially in the perforative cases. In extreme 
 cases the bowel is completely paralyzed, and no auscultatory signs of 
 peristalsis can be heard, the belly is enormously distended, especially in 
 its upper and middle segments, and the skin is tense, smooth, and glisten- 
 ing. In puerperal peritonitis the distention, owing to the relaxation of 
 the stretched walls, is greater than in other forms. The splenic dulness 
 may be obliterated; the liver dulness is greatly diminished and may 
 wholly disappear in the midclavicular line; the diaphragm is pushed up 
 so that the apex beat of the heart may be felt in the fourth intercostal 
 space. The obliteration of liver dulness in the front of the body may be 
 due to tympany alone, and is not, therefore, a positive sign of pneumo- 
 
1028 MEDICAL DIAGNOSIS. 
 
 peritoneum or of the perforation of an air-containing viscus. If, when 
 the patient is turned upon his left side, dulness disappears in the axillary 
 line, there is free air in the cavity of the peritoneum, 
 
 (c) General Symptoms. — The attack begins, in a majority of the cases, 
 with chilKness or a rigor. Fever follows, but is not constant and does 
 not conform to type. The temperature may rise suddenly to a consider- 
 able height, but does not often exceed 104° F. (40° C), or it maj^ gi-adually 
 rise for several days. In either case it becomes irregular or drops to normal 
 as the attack progresses. As death approaches, the temperature may show 
 rapid oscillations. In perforative peritonitis, the temperature very often 
 drops to subnormal ranges, — ten^erature of coUapse, — and remains there 
 until death. The pulse is rapid, small, and wiry. Its frequency' is 120-160 
 per minute and bears no constant relation to the temperature. 
 
 Leucocj^osis of the poljmuclear neutropliilic type, 18,000-40,000, is 
 found, except in the gravest cases, in which there maj^ be leucopenia. 
 
 The clinical picture of acute diffuse peritonitis, from the time that 
 the disease is fully established, is very characteristic. The facies indicates 
 great suffering and anxiety and presents the signs of collapse. The nose 
 is pinched and pointed, the eyes are sunken, the temples flattened; there 
 is cyanosis, and the brow is wet with drops of sweat — facies Hippocratica. 
 The patient lies motionless, the respirations are shallow and rapid, the 
 pulse is thi'eady, the knees are dra^^Ti up, the hands and feet cold and 
 shrunken. 
 
 This form of peritonitis usually terminates fatally. The perforative 
 forms often run their course witliin forty-eight hours; the non-perforative 
 forms in four or five, or sometimes in eight or ten, daj's. Exceptionally 
 death occurs verj^ suddenly, with signs of cardiac paralysis. 
 
 Diagnosis. — Direct. — The diagnosis rests upon the sudden onset 
 of intense abdominal pain, tenderness, fever, vomiting, rigidity of the 
 abdominal muscles, and collapse symptoms. When the attack is fully 
 developed the facies and attitude are very suggestive. Inquiry into the 
 previous health will often reveal the primary cause of the attack. It is 
 to be borne in mind that intestinal perforation and disease of the pehdc 
 organs in females are the most common primary conditions. A history 
 of attacks of pain in the iliac region suggests perforating appendicitis; 
 of pain after eating, epigastric tenderness, heematemesis, or dark blood 
 in the stools, peptic ulcer; of recent headache, nose-bleeding, prostration, 
 and diarrhcea, the ambulant form of enteric fever. In females recent 
 abortion or confinement, acute suppurative disease of the pelvic viscera, 
 or salpingitis are common antecedent conditions. In enteric fever the 
 signs of perforation may be masked b}' the patient's mental condition. 
 In many of the cases the pre\T[ous condition cannot be determined. 
 
 Differential. — The following conditions are often mistaken for 
 peritonitis: Acute Enterocolitis. — The pain is colicky, and less continuous; 
 the tenderness is less acute, and more Hmited; diarrhcea is a more prom- 
 inent symptom, and early rigidity and subsequent tjmipany are not so 
 conspicuous. In the severe cases there may be a very marked degree of 
 collapse. Intestinal ohst ruction, volvuhis, and strangulation may not only 
 cause peritonitis, but they often also simulate it, the symptoms in common 
 
PERITONITIS. 1029 
 
 being pain, tenderness, vomiting, and tympanites. Muscular rigidity is 
 not so marked, local distention of the bowel, violent peristaltic move- 
 ments, and the more tardy development of tympany and collapse 
 point to occlusion of the bowel rather than inflammation of the peritoneum. 
 Rupture of a tubal pregnancy or an abdominal aneurism may give rise 
 to symptoms suggestive of perforative peritonitis. The history is very 
 important. Restlessness and air hunger are much more marked in large 
 internal hemorrhage than in inflammation. Embolism of the superior 
 mesenteric artery may be attended with sudden agonizing pain, frequent 
 vomiting, collapse, and tympany. Acute Hemorrhagic Pancreatitis. — A 
 history of gall-stone disease and the localization of pain in the epigastrium 
 are important in the diagnosis. In perforative and rupture cases, in which 
 the peritoneum is suddenly flooded with the contents of the intestine or 
 pus, death frequently takes place from shock in the course of a few hours, 
 before an actual inflammation has time to develop. Hysteria may mimic 
 peritonitis. 
 
 iii. Acute Circumscribed Peritonitis. 
 
 This form of inflammation of the peritoneum is, (1) adhesive, or 
 (2) purulent. 
 
 1. Adhesive inflammation is of very frequent occurrence in local 
 disease of the abdominal organs. It is usually narrowly circumscribed, 
 and unattended by other immediate symptoms than pain and tenderness, 
 the manifestations of the primary affection dominating the clinical picture. 
 The anatomical changas consist in vascular injection, fibrin formation, 
 and slight serous exudation. The organs involved are chiefly the liver, 
 gall-bladder and bile passages, spleen, stomach, coils of intestines, 
 the appendix vermiformis, and the sexual organs in the female. Peri- 
 hepatitis, perisplenitis, either circumscribed or involving the whole organ, 
 belong to this category. Intestinal adhesions following local disease or 
 operation, adhesive inflammation affecting the gall-bladder, bile-ducts, 
 duodenum, and the pyloric end of the stomach, or a similar process involv- 
 ing the Fallopian tubes or ovaries may be the cause of distressing subse- 
 quent symptoms. Tuberculous, cancerous, suppurative, or hydatid disease 
 may be the cause of localized peritonitis. 
 
 2. Purulent. — Infection with pus-producing micro-organisms may 
 be primary and cause acute suppurative circumscribed peritonitis, or it 
 may occur later and lead to the formation of localized abscess and small 
 pockets of pus among the adhesions and other lesions resulting from the 
 non-suppurative form, so that a transitional condition may be recognized. 
 There are certain points in which acute suppurative circumscribed peri- 
 tonitis preferably arises; among these, the region of the appendix, the 
 pelvic organs in the female, and the lesser peritoneum are most important. 
 
 (a) Appendicular Abscess. — The most common cause of acute cir- 
 cumscribed suppurative peritonitis is appendicitis — a condition fully 
 described under the heading '^ Diseases of the Intestines" (q. v.). 
 
 (b) Pelvic Peritonitis. — Suppurative inflammations, septic, tuber- 
 culous, or gonorrheal, are very common. They result in the formation 
 of perimetric and parametric abscesses. Salpingitis and abscesses of the 
 
1030 MEDICAL DIAGNOSIS. 
 
 broad ligament occur. Suppuration is frequently preceded by extensive 
 adhesive inflammation. General peritonitis may arise by extension of 
 the infection, or by rupture. 
 
 (c) Subphrenic Peritonitis. — Inflammation may involve the lesser 
 peritoneum alone, and inflammatory exudates may be confined to its 
 cavity. Perforating ulcers of the stomach, duodenum, or colon are some- 
 times so situated that they communicate directly with it, and into it pan- 
 creatic hemorrhages and abscesses may be discharged. Effusions into 
 this space may cause an oval, smooth, tense tumor, extending into the 
 epigastric, umbilical, and left hypochondriac regions, and simulating a 
 pancreatic cyst. The physical signs vary greatly from time to time, accord- 
 ing to the condition of the adjacent stomach. If the latter is distended 
 with food, the line of demarcation between it and the tumor cannot be 
 made out either by percussion or palpation, while if it is filled with gas, 
 it may yield tympanitic resonance over the greater part or the whole 
 of the tumor, causing it at times to altogether disappear. A subphrenic 
 abscess has, in rare cases, followed pneumonia or empyema; more fre- 
 quently it results from an appendicular abscess, a renal or hepatic abscess, 
 or trauma. It may occur in connection with cancer of the stomach. 
 
 The diagnosis of simple subphrenic abscess is difficult, because 
 the signs and symptoms are very frequently indefinite. The sub- 
 jective symptoms attract attention to the upper part of the abdomen. 
 Among these pain is most important, and may be referred to the right or 
 left side, the back, and so forth, according to the seat of the abscess. It 
 may be localized, or radiate into the abdomen or lower thoracic belt. When 
 the pain is local it is usually associated with tenderness. Circumscribed 
 phenomena in the epigastrium or left hypochondrium are suggestive. 
 Fluctuation is rare and present only when the abscess is superficial. In 
 rare cases there is circumscribed oedema of the overlying skin. 
 
 Pyopneumothorax Subphrenicus — Leyden. — When the subphrenic 
 abscess is due to a perforating peptic ulcer air is also almost always 
 present and the condition simulates pneumothorax. 
 
 Symptoms. — The nature of the condition is obscure and in a majority 
 of the cases not recognized intra vitam. The symptoms vary according 
 to the cause. The pus collection between the liver and the diaphragm, 
 whether in relation with the right or the left lobe when air is not also pres- 
 ent, closely simulates an encysted empyema at the base of the pleural sac. 
 When it occurs in association with pneumonia, or empyema, or an abscess 
 in a neighboring organ, the symptoms of the primary affection are more 
 or less rapidly, often suddenly, reinforced by those of the new affection, 
 namely, severe epigastric pain, urgent and persistent vomiting, and respir- 
 atory embarrassment. In rapidly developing cases shock may also occur. 
 Later symptoms are chills, irregular fever of septic type, anaemia, and 
 rapid wasting. Burrowing may occur into the pleura or, in the case of 
 pleural adhesions, into the lung, with paroxysmal cough and copious 
 purulent expectoration. When caused by a perforating ulcer of the 
 stomach or duodenum, the onset is abrupt, with great pain, and the 
 vomited material is bilious or bloody. When the abscess cavity con- 
 tains gas, the diaphragm may be forced upward upon the right side as 
 
PERITONITIS. 1031 
 
 far as the third rib, and the liver displaced downward; when upon the 
 left side, the heart is displaced upward. 
 
 Diagnosis. — Subphrenic pyopneumothorax is very frequently over- 
 looked. The physical signs are those of pneumothorax or pyopneumo- 
 thorax upon the right or left side, according as the abscess cavity is situated 
 upon the right or the left side of the suspensory ligament. The antecedent 
 symptoms, in the majority of the cases, point to disease of the abdominal 
 organs and not to disease of the lungs or pleurae. Upon forced inspira- 
 tion the lower border of the compressed lung is depressed in subphrenic 
 abscess; the liver is usually depressed to a remarkable degree, and its 
 lower border is distinctly palpable. The heart is displaced upward rather 
 than laterally. In both conditions the intercostal spaces may be either 
 obliterated or bulging. As the greater number of cases are the result of 
 perforating peptic ulcer, the local symptoms appear very suddenly, while 
 the general symptoms are usually more severe than in ordinary cases of 
 pneumothorax. Exploratory puncture may be made for diagnostic pur- 
 poses. The presence of material from the gastro-intestinal tract at once 
 determines the differential diagnosis. The position of the diaphragm may 
 be positively determined by skiagraphy. In pyopneumothorax it forms 
 the floor, in pyothorax subphrenicus the roof, of the abscess cavity. 
 
 iv. Chronic Peritonitis. 
 
 (a) Local Adhesive Peritonitis.- — The inflammation of the peritoneum 
 which follows operations or accompanies local disease of the abdominal 
 viscera is more frequently chronic than acute. When it involves coils of 
 intestines, it gives rise to partial stenosis with constipation and cohcky 
 pains, and may ultimately be the cause of acute obstruction of the intestine 
 by strangulation. 
 
 (b) Diffuse Adhesive Peritonitis. — In tuberculosis and general car- 
 cinomatous infiltration of the peritoneum the adhesions are sometimes so 
 extensive as to entirely obliterate the cavity. This form of peritonitis is 
 rare in other conditions, but has been encountered in tumors of the peri- 
 toneum, and after trauma. It occurs also in syphilis during intra-uterine life. 
 
 Symptoms. — The condition may not be attended with definite symp- 
 toms. Pain and tenderness are usually present. 
 
 (c) Chronic Proliferative Peritonitis. — There is great thickening of 
 the membrane, without extensive adhesions. Moderate serous effusion may 
 be present. The mesentery is shortened, and the omentum may be rolled 
 into a firm transverse tumor. In some instances there is a general chronic 
 inflammation of the serous membranes, — Concato's disease, polyorrhom- 
 enitis, — involving with the peritoneum both pleurae and the pericardium. 
 This form of peritonitis occurs in the subjects of chronic alcoholism, in 
 chronic passive congestion, and in tumors, but is especially associated with 
 cirrhosis of the liver. 
 
 Symptoms. — The disease may be latent, the symptoms being sub- 
 ordinated to those of the primary condition. They comprise abdominal 
 uneasiness and distention, colicky pains, constipation, and diarrhoea. 
 Jaundice is sometimes present. Ascites may occur, or the shortening of 
 
1032 MEDICAL DIAGNOSIS. 
 
 the mesentery, the consequent drawing together of the intestines into a 
 tumor-hke mass, and the retracted and indurated omentum may simulate 
 tumors of various abdominal organs. 
 
 Diagnosis. — The direct diagnosis rests upon the concurrence of 
 alcoholism, cirrhosis of the liver, chronic intestinal disease, chronic 
 nephritis, with symptoms of peritoneal disease, and ill-defined tumor-like 
 masses in the abdomen. It is confirmed if the evidences of bilateral chronic 
 pleurisy and indurative mediastinitis are present. 
 
 The Differential Diagnosis. — This relates to the recognition of 
 the condition, notwithstanding the resemblance of some of its features 
 to tumors of the stomach, liver, or other abdominal organs. To this the 
 vagueness and irregularity of the symptoms and signs, their variations 
 as time goes on, the primary affection, and the evidence of chronic disease 
 in the other serous sacs all contribute. The anomalous nature of the 
 pseudotumors and their independence of the organs may, when the 
 effusion is not too abundant, be recognized upon careful palpation. 
 
 V. Tuberculous Peritonitis. 
 
 Tuberculosis of the Peritoneum. 
 
 The diagnosis of this condition has been fully considered under the appro- 
 priate subcaption of Tuberculosis, in the section on The Infectious Diseases. 
 It has, in recent times, acquired peculiar importance in consequence of the 
 remarkable success attending laparotomy in certain forms of the disease. 
 
 vi. New Growths in the Peritoneum. 
 
 Neoplasms of the peritoneum are rare. They comprise benign and 
 malignant tumors. 
 
 1. Benign Tumors. — Cysts of various kinds, lipomata, fibromata, 
 myxomata, angiomata, and other rarer forms are occasionally encountered. 
 They may occupy any region, but are more often found in the omentum 
 and mesentery than elsewhere. They are single or multiple, (a) Cysts. — 
 Cystic tumors are found in the omentum, more frequently in the mesentery. 
 Cysts of the mesentery may be classified according to their contents into 
 serous, chylous, hemorrhagic, dermoid, and hydatid cysts. Serous C5''sts 
 are very rare. They may be single or multiple. Chylous cysts contain 
 a milk-like opaque fluid having the characteristics of chyle, and are prob- 
 ably due to the retention of chyle in the lacteals, or receptaculum chyli. 
 They have been regarded as embryonic. They are usually found in the 
 mesentery. Hemorrhagic cysts are commonly the result of trauma, and 
 contain a brownish-red fluid. They may be chylous or of peripancreatic 
 origin. Dermoid cysts containing hair, bone, treth, and mucilaginous 
 material have been found in the omentum and mesentery. They may be 
 multiple. Hydatid cysts usually occupy the omentum or mesentery. 
 When primary, the cyst is commonly single. Secondary hydatid disease 
 of the peritoneum is much more common. The cysts are usually multiple, 
 and may be present in enormous numbers. Mesenteric and omental cysts 
 
NEW GROWTHS IN THE PERITONEUM. 1033 
 
 vary greatly in size. They may reach a capacity of several litres, (b) 
 LiPOMATA are met with in the subperitoneal tissues of the anterior abdom- 
 inal wall. They are usually small, but may attain such size as to simulate 
 ascites. They may also develop in the omentum or in the mesentery, and 
 grow to such a size that they completely fill the abdominal cavity. They 
 may be of retroperitoneal origin. They occur more commonly in women, 
 and after middle life. They are of slow growth and, yielding an obscure 
 sense of fluctuation, suggest ascites, (c) Fibrous tumors of the perito- 
 neum are rare. They may arise from the omentum, mesentery, or the 
 pelvic organs, and reach the size of the closed fist. Other benign tumors 
 are exceedingly rare. 
 
 Symptoms. — Recurrent vomiting, constipation, and pain may pre- 
 cede the discovery of the tumor, which may occupy various positions 
 and may be single or multiple. Mesenteric tumors are, as a rule, freely 
 movable and may thus be distinguished from pancreatic cysts, retroperi- 
 toneal tumors, and tumors of the uterus and its appendages. An ovarian 
 cyst with a long pedicle may, however, be very movable. Malignant tumors 
 early contract adhesions and are usually fixed. The differential diagnosis 
 between mesenteric and omental tumors is often attended with insurmount- 
 able difficulties. It can as a rule only be made upon abdominal section. 
 
 2. Malignant New Growths. — These are primary and secondary. 
 They are of more common occurrence than the benign forms, (a) Most 
 PRIMARY MALIGNANT GROWTHS of the peritoneum are endotheliomata. 
 Sarcomata may occur in rare instances as primary growths starting in 
 the mesentery and omentum. They may reach an enormous size, (b) 
 Much more common are secondary carcinomata. The peritoneum is 
 involved by metastasis from distant organs, or by direct extension from 
 organs which it invests. The primary growth may involve the mamma, 
 pancreas, stomach, intestines, especially the. colon, and the rectum, or 
 the uterus. In many of the cases of diffuse carcinomatous growths in the 
 peritoneum there are the signs of an associated inflammation — carci- 
 nomatous peritonitis. In this form of peritonitis the exudate is usually 
 encysted. It may consist of a yellowish serum, or a blood-stained fluid; 
 it may be chylous, or chyliform. It is very rarely purulent. Peritoneal 
 carcinoma is more common in middle and advanced life than earlier. It 
 occurs with somewhat greater frequency in women than in men. 
 
 Symptoms. — Pain may be absent altogether. When present it is 
 less severe than in other forms of peritonitis. Vomiting, constipation 
 with attacks of diarrhoea, hiccough, and tympanites are common symp- 
 toms. Fluid exudate may be absent, scanty, abundant, freely movable, 
 or encysted. After the withdrawal of the fluid, irregular and ill-defined 
 tumor masses may be recognized upon palpation, especially the rolled 
 omentum lying transversely or obliquely across the upper part of the 
 abdomen, as a firm sausage-like growth, as in tuberculous and prolifera- 
 tive peritonitis. The fluid may be hemorrhagic, and contain large multinu- 
 clear cells, or groups of cells, and the number of cells showing mitosis is 
 greater than in simple or tuberculous effusions (Dock). The temperature 
 is usually normal or subnormal. Fever is, however, sometimes present. 
 The cachexia may be marked, and emaciation is progressive. 
 
1034 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — Direct. — With the evidences of the primary disease, or 
 the history of the removal of a carcinomatous breast or uterus, the diag- 
 nosis may be made without difficulty. The age of the patient, the presence 
 of nodular masses about the navel, and enlarged inguinal glands are 
 important. If no primary focus can be found the diagnosis may be obscure. 
 
 Differential. — The clinical resemblance to tuberculous peritonitis, 
 as regards the symptoms, the tumor masses, and the physical signs, may 
 be very close. As a rule, the multiple nodules of cancer are larger than 
 those of tuberculosis. Cancer is an affection of the later periods of life, 
 tuberculosis of the peritoneum of its earlier periods. But to this rule 
 there are many exceptions. Inflammation and sinus formation, with 
 discharge of pus from the navel, sometimes occurs in tuberculosis. In 
 the absence of tuberculous disease elsewhere the diagnosis becomes diffi- 
 cult, since the clinical phenomena of tuberculous peritonitis not only 
 closely resemble those of carcinomatous peritonitis, but both have features 
 in common with the chronic proliferative form and diffuse hydatids of 
 the peritoneum. In the last, the hydatid fremitus, and booklets in the 
 aspirated fluid, are of positive diagnostic value. 
 
 vii. Retroperitoneal Sarcoma. 
 
 Retroperitoneal sarcoma (Lobstein's cancer) is a rare affection. Steel 
 finds that it occurs most frequently in the first, fourth, and sixth decades 
 of life. Males are somewhat more commonly affected than females. The 
 tumor may spring from the lumbar region, on the right side somewhat 
 more frequently than the left, from the posterior wall of the abdomen 
 near the attachment of the mesentery, or, less frequently, from the pelvis. 
 The growths may arise from the retroperitoneal lymph-glands, the con- 
 nective tissue around the vessels, or from the remains of the Wolffian 
 body. They are often lobulated and are very prone to degeneration, with 
 hemorrhage and the formation of pseudocysts. 
 
 Symptoms. — Vague digestive derangements and dragging abdominal 
 pain are followed by pressure symptoms, such as neuralgic pains in the 
 lumbar region, abdomen, legs, and genitalia, and then oedema of the lower 
 extremities. There may be partial occlusion of the intestine. In a case of 
 sarcoma of the retroperitoneal lymphatic glands, recently under my observa- 
 tion, none of these symptoms was present. There are the signs of a deep- 
 seated tumor, situated centrally or to the right or left of the median line, 
 sometimes moving slightly with respiration, more commonly fixed, usually 
 solid but sometimes cystic — pseudocysts. When the tumor is situated 
 laterally, it is obliquely crossed by the colon, which it pushes forward as it 
 increases in size. The health is rapidly impaired, and cachexia develops. 
 
 Diagnosis. — The diagnosis rests upon the presence of the above 
 phenomena in association with a rapidly growing central or lateral tumor 
 about the level of the umbihcus. The differential diagnosis between 
 retroperitoneal sarcoma and tumors arising from the kidneys and sup- 
 rarenal capsules cannot always be made. 
 
CATARRH. 1035 
 
 X. > 
 
 THE DIAGNOSIS OF DISEASES OF THE RESPIRATORY SYSTEM. 
 
 I. DISEASES OF THE NOSE, 
 i. Acute Nasal Catarrh. 
 
 Coryza; Acute Rhinitis; Cold, or Cold in the Head. 
 
 Definition. — Acute catarrhal inflammation of the mucous membrane 
 of the nasal cavities. 
 
 Etiology. — Acute nasal catarrh is very common. It is in most instances 
 an independent affection, but it occurs also in the acute infectious diseases. 
 It often follows exposure to cold or damp, especially when such exposure 
 is partial, as in wetting the feet, or sitting upon damp ground. It frequently 
 prevails extensively in cold, damp, and changeable weather. Such local 
 epidemics are to be distinguished from true influenza or grippe, to which 
 they bear a superficial resemblance. House epidemics of coryza occa- 
 sionally arise under circumstances that point to the contagiousness of the 
 affection. Children are especially prone to it. It occurs in infants in con- 
 sequence of gastric or intestinal irritation, indigestion, or the presence of 
 intestinal worms, and is occasionally the result of injuries inflicted by 
 foreign bodies — buttons, grains of corn, pebbles, peas, cherry-pits, and 
 similar objects — introduced into the anterior nasal chambers. It results 
 from the action of mechanical or chemical irritants upon the nasal mucous 
 membrane. Among these are dust, smoke, ipecacuanha, and the fumes of 
 ammonia, bromine, and iodine. Annoying coryza often follows the internal 
 administration of iodine. 
 
 Coryza as a manifestation of acute constitutional infection is an early 
 and prominent symptom of measles, influenza, and pertussis. It is some- 
 times associated with the ophthalmia of the new-born as the result of 
 gonorrhoeal infection incurred during parturition, and occurs as an early 
 manifestation of congenital syphilis. 
 
 Symptoms. — The attack begins suddenly, with chilliness or shivering, 
 a decided feeling of malaise, headache, and repeated sneezing. There is 
 feverishness, with slight quickening of the pulse, a dry skin, and muscular 
 pains. The nose at first feels dry and stuffy and mouth-breathing is neces- 
 sary. The sense of smell is lost, that of taste greatly impaired; the voice 
 acquires a peculiar nasal twang, and nursing infants, being unable to breathe 
 through the nose, are suckled with difficulty. The catarrhal inflammation 
 tends to involve the contiguous mucous tracts. In the course of a few 
 hours from the beginning of the attack there may be a flow of thin, clear, 
 irritating mucus, which excoriates the edges of the nostrils and the upper 
 lip and renders the use of the handkerchief painful. Herpes labialis is 
 common. About the second or third day the secretion becomes muco- 
 purulent, opaque, thick, tenacious, and abundant, and tends to accumu- 
 
1036 MEDICAL DIAGNOSIS. 
 
 late in the nasal cavities. The swelling of the mucous membrane subsides^ 
 nose-breathing is re-established, and recovery takes place within a week 
 or ten days. Repeated attacks of the acute affection tend to produce the 
 chronic form of the disease. Most of the cases are subacute, with symptoms 
 of moderate intensity, little or no constitutional disturbance, and run 
 their course in two or three days. 
 
 Diagnosis. — There is no difficulty in the diagnosis of simple acute 
 nasal catarrh. Healthy new-born infants are not likely to suffer from 
 snuffles. This affection, when associated with ophthalmia, is due to the 
 same specific infection. When due to syphilis it is associated with charac- 
 teristic lesions. Acute nasal catarrh in children, due to the lodgement of 
 foreign bodies, is prolonged, and the discharge, after a time, is frequently 
 admixed with blood. Furthermore, it is almost always one-sided. In such 
 cases a careful examination of the nasal chambers must be made. The 
 progress of a case of measles or influenza will speedily dissipate any uncer- 
 tainty as to the nature of the acute catarrh with which each of these diseases: 
 begins. The coryza of iodism ceases upon the withdrawal of the drug. 
 
 ii. Chronic Nasal Catarrh. 
 
 Definition. — Chronic catarrhal inflammation of the mucous mem- 
 brane of the nasal cavities. The cases may be arranged in three groups — 
 rhinitis simplex, rhinitis hypertrophica, and rhinitis atrophica. 
 
 Etiology. — Repeated attacks of acute nasal catarrh may end in the 
 chronic form of the disease. Habitual exposure to cold and draughts, a 
 changeable and humid atmosphere, and the constant inhalation of dust 
 are among the causes of chronic rhinitis. Insufficient food, inadequate 
 clothing, improper ventilation, want of sunlight and fresh air, and other 
 unhygienic conditions are predisposing influences. Chronic nasal catarrh 
 is frequently a manifestation of local syphilitic or tuberculous processes. 
 The nasal catarrh of early fife tends to assume the atrophic form — a fact 
 which emphasizes the importance of the prompt and efficient treatment 
 of every case of rhinitis. Congenital asymmetry of the nasal fossae, with 
 marked deflection of the septum, hypertrophy of the adenoid tissue in 
 the vault of the pharynx, traumatism, foreign bodies, and nasal polypi 
 are local causes of chronic nasal catarrh. 
 
 Simple Chronic Nasal Catarrh (Rhinitis Simplex.) — This term is 
 used to designate the transitional condition between prolonged or neglected 
 acute catarrh and that in which hypertrophic or atrophic lesions are pres- 
 ent. The mucous membrane is irritable and there is a constant sensation 
 of discomfort in the nose. Catarrhal symptoms follow trifling exposure. 
 The erectile tissue is relaxed and is readily distended with blood, so that 
 one or both nostrils are frequently occluded. The secretion is increased; it 
 is variable in consistency, being sometimes thin and watery, sometimes 
 thick and tenacious. Upon inspection the mucous lining of the nasal 
 chambers is seen to be red, watery, and irregularly swollen. 
 
 Chronic Hypertrophic Nasal Catarrh {Rhinitis Hypertrophica). — 
 Obstructed nasal respiration, constant, often abundant, discharge of mucus 
 or mucopus, frequent sneezing, nasal cough, hawking, and expectoration 
 
CATARRH. 1037 
 
 of tenacious mucus, dryness of the throat, habitual mouth-breathing, 
 especially at night, and disturbed sleep are symptoms. The voice has a 
 peculiar nasal quality, and the hearing is very frequently impaired. In 
 infants the inability to take nourishment without frequent interruption 
 for respiration leads to malnutrition, and the nasal obstruction may cause 
 attacks of suffocative spasm. In older children habitual mouth-breathing 
 begets a peculiar, dull, facial expression, mental hebetude, and retardation 
 of the development of the thorax, with characteristic deformities. The 
 mucous membrane of the nasal chambers is congested throughout, and its 
 epithelial and subepithelial tissues are hypertrophied. The characteristic 
 lesion consists in permanent enlargement of the turbinate bodies. There 
 is marked increase in the connective tissue with cell infiltration, dilatation 
 of the sinuses of the erectile tissue, and loss of contractility in their walls. 
 In a large proportion of the cases hypertrophy of the adenoid tissue in 
 the nasopharynx and catarrhal or follicular pharyngitis occur — naso- 
 pharyngeal catarrh. 
 
 Chronic Atrophic or Dry Nasal Catarrh {Rhinitis Atrophica, 
 Rhinitis Fcetidus Atrophicus, Ozcena). — A chronic affection of the nose, 
 constituting the terminal stage of neglected cases of rhinitis simplex and 
 rhinitis hypertrophica. It is characterized by atrophy of the mucous 
 membrane, with shrinkage of the turbinated bodies and diminution of the 
 nasal secretion, which becomes mucopurulent or purulent and undergoes 
 inspissation, with the formation of adherent and frequently offensive 
 crusts. Upon inspection grayish crusts are seen, the removal of which 
 exposes a smooth, pale, or a slightly excoriated, mucous surface. Actual 
 ulceration is rare. The turbinate bodies are greatly reduced in size, their 
 sinuses obliterated, their connective tissue contracted. The entire lining 
 membrane of the nostrils is atrophied. The mucous membrane of the 
 pharynx is often dry and glazed. The sense of smell is lost. Ozsena is 
 present in a large proportion of the cases, but not in all. Odors having 
 the same intensity and foulness are occasionally encountered in other 
 affections of the nose attended with ulceration, as syphilis, the traumatism 
 produced by foreign bodies, and caries and necrosis due to other causes. 
 Atrophic rhinitis is more common in females than in males. In confirmed 
 cases the outlook as regards cure is hopeless; as regards relief from the 
 formation and retention of crusts and from the odor, much may be accom- 
 plished so long as a judicious treatment is persistently followed out. 
 
 iii. Autumnal Catarrh. 
 
 Hay or Rose Cold; Hay Asthma; Hay Fever; Summer Catarrh; Catarrhus 
 
 ^stivus; Periodic Coryza. 
 
 Definition. — An affection of the upper air-passages, characterized 
 by irritability of the mucous membrane, with catarrhal and asthmatic 
 manifestations, by the abruptness of the onset of the attack, which recurs 
 annually at or near a fixed date in the spring, summer, or early autumn, 
 and by its immediate cessation upon the patient's reaching certain localities 
 or upon the occurrence of frost. 
 
1038 MEDICAL DIAGNOSIS. 
 
 Etiology. — The exciting causes are certain irritants in the atmosphere 
 which act upon a supersensitive nasal mucous membrane in individuals 
 of neurotic temperament. Among the most important of these is the 
 pollen of various plants. This is not, as was for a long time supposed, 
 the sole cause of the attack. Inorganic dust of various kinds, the odors 
 of certain flowers and other substances, emanations from animals, as the 
 horse, and from feathers are capable of intensifying the symptoms during 
 the attack and also of inducing similar symptoms at other seasons of the 
 year. The intense glare of the summer sun, excessive heat, overexertion, 
 and indigestion commonly aggravate the attack. That these agencies 
 are, as has been affirmed, exciting causes of the disease is questionable. 
 Hay fever and bronchial asthma are not only closel}' associated clinically, 
 but they also resemble each other in respect of the causes b}^ which the 
 attack may be excited. Local nasal trouble plays an important part in 
 the etiology of the disease. The resemblance to asthma in this respect 
 is striking. The causal relation between nasal disease and bronchial asthma 
 is fully recognized. A similar relation between disease of the nasal mucous 
 membrane and hay fever has also been demonstrated. The lesions are 
 those of hypertrophic rhinitis. There is in manj^ cases deflection of the 
 septum. Superadded to these is the presence of areas of hyperesthesia 
 in the nasal mucosa — hypersesthesia often so exquisite that the touch of 
 a probe will instantly excite the characteristic train of symptoms. This 
 local sensitiveness is an almost constant factor in the etiology of the disease. 
 Its presence in persons who do not suffer from autumnal catarrh proves, 
 however, that something more is required; that is, the neurotic constitu- 
 tion. Males suffer more frequently than females. The disease may develop 
 at any period in life. More than 33 per cent, of the cases begin before the 
 age of twenty years. Dwellers in cities are especially liable to the disease, 
 but those who live in the country do not enjoy exemption. The affection 
 may show itself wherever the pecuHar irritants which excite it and persons 
 of neurotic constitution, with hypersesthetic nasal mucous membranes, 
 are found together. There are certain localities in which the disease does 
 not prevail. These regions are usually circumscribed and j^ossess in com- 
 mon the attribute of an uncultivated soil. They are mostly mountainous, 
 as certain districts in the White Mountains, the Adirondacks, and the 
 Catskills. But elevation is not the essential factor. ReHef may be experi- 
 enced in any wilderness, at certain sea-shore places, on islands, or at sea. 
 
 The prominence of the psychical element in many cases is remarkable. 
 In one case J. N. Mackenzie induced the attack by means of an artificial 
 rose. In a large proportion of the cases recurrence of the attack takes place 
 year after year on a certain day of the month — a fact for which no rational 
 explanation bej^ond the hypothesis of expectant attention has been found. 
 
 Symptoms. — The attack makes its annual return at or about the 
 same date. There is sometimes a period of prodromes which consist of 
 lassitude and nervous irritability. The onset is abrupt. Itching of the 
 palate and throat is a most annoying symptom, both common and charac- 
 teristic. I have seen cases in which, year after year, this persistent itching 
 constituted the chief local symptom. Frequent uncontrollable sneezing; 
 nasal obstruction; free rhinorrhcea, usually thin and watery, sometimes 
 
EPISTAXIS. 1039 
 
 mucopurulent; great irritation of the eyes with itching of the Hds and 
 lachrymation; loss of the sense of smell; impairment of that of taste, and 
 not rarely disturbances of hearing, constitute the usual symptoms. These 
 occur in paroxysms and are aggravated by changes of temperature, by 
 sunlight, and the open air. Constitutional disturbances consist of sub- 
 jective sensations of heat and cold, great lassitude, complete loss of appe- 
 tite, and sleeplessness. After a time the catarrh extends to the bronchi 
 and the patient is annoyed by cough; asthmatic symptoms are common 
 and add greatly to the distress of the patient. The symptoms vary in 
 localization and in intensity, and in the same person in succeeding years. 
 The whole duration of the attack, if not cut short by change of climate, 
 is about six weeks. The autumnal cases usually cease abruptly upon the 
 appearance of frost. 
 
 Prognosis. — The prognosis is favorable as regards recovery from any 
 given attack and as regards length of life. The prognosis as regards the 
 recurrence of the attack is much less hopeful. 
 
 iv. Epistaxis. 
 
 Nose-bleed. 
 
 Definition. — Bleeding from the nasal passages. 
 
 Etiology. — Bleeding from the nose may be due to local or constitu- 
 tional causes or to a combination of both. In children its occurrence is 
 favored by the great vascularity of the nasal mucous membrane, the fre- 
 quent presence of "hemorrhagic spots," and erosions of the septum caused 
 by picking the nose. Other local causes are chronic rhinitis, intranasal 
 ulceration, new growths, the presence of foreign bodies, and various kinds 
 of traumatism, especially contusions of the face. 
 
 In fractures involving the bones of the face and cranium blood may 
 escape from the accessory sinuses or from the middle ear by way of the 
 nose, or in hemorrhage from the lungs, oesophagus, or stomach, some 
 part of the blood may be discharged from the nose. These blood-losses^ 
 not from, but merely hy way of, the nose, do not in a strict sense constitute 
 epistaxis — a term restricted by systematic writers to hemorrhage having 
 its source within the nasal passages. 
 
 Among the constitutional causes are exposure to extreme coid or 
 undue heat, or to a rarefied atmosphere, as in the ascent of high mountains 
 and in balloon ascensions. It frequently occurs in both sexes at the age 
 of puberty. It may result from the suppression of the menstrual flow or 
 follow the sudden arrest of a habitual hemorrhoidal discharge. It is of 
 frequent occurrence in anaemia in its various forms, and in persons of 
 plethoric habit. The tendency to nose-bleed is hereditary. In haemophilia 
 nose-bleed constitutes a common manifestation of the hemorrhagic diath- 
 esis. It is also common in scurvy and purpura, and occurs in erysipelas, 
 the malarial and the malignant fevers, and in nasal diphtheria. Slight 
 nose-bleed occurs in the first week of tj^phoid fever with such frequency 
 as to acquire diagnostic importance. Nose-bleed not infrequently results 
 from the congestion and shock of the violent convulsive cough of pertussis. 
 
1040 MEDICAL DIAGNOSIS. 
 
 It is by no means a rare symptom in advanced disease of the kidneys and 
 in various affections of the liver. In the venous engorgement of cardiac 
 and pulmonary diseases, even with marked cyanosis, nose-bleed is uncom- 
 mon. Finally, it may result from violent mental emotion. 
 
 When epistaxis is due to general causes, the blood escapes by capillary 
 oozing from one, rarely two or three, limited areas of the respiratory por- 
 tion of the cartilaginous septum, and in most instances it proceeds from 
 one side only. In a very small proportion of the cases it comes from the 
 turbinate bodies or from the floor of the nostril. The mucous membrane 
 is deeply congested, of a violaceous-red color, and shows minute spots 
 of ecchymosis. 
 
 Symptoms. — Prodromes sometimes occur. They consist of giddiness, 
 fulness in the head, and a sensation of dryness, tickling, or obstruction in 
 the nostrils, which impels the patient to more or less forcibly blow the nose. 
 More frequently these symptoms are absent, the bleeding occurring sud- 
 denly and without warning. The blood may flow in drops or for a time 
 in a continuous stream. Ordinary, slight nose-bleed generally ceases in 
 a short time and is without immediate clinical importance whatever may 
 be its remote significance. The graver bleedings may be protracted for 
 hours or days, and while a fatal case is of rare occurrence, serious conse- 
 quences are likely to follow profuse hemorrhage. The arrest takes place 
 by clotting at the point of oozing. It is important to examine the pharynx, 
 as the clot in the nostril may lead to the escape of blood by way of the 
 posterior nares and its being swallowed. The vomiting of blood thus 
 swallowed may be mistaken for hsematemesis; its expulsion by cough, for 
 haemoptysis, but not if due care be observed in the investigation of the case. 
 
 II. DISEASES OF THE LARYNX, 
 i. Acute Catarrhal Laryngitis. 
 
 Definition. — Catarrhal inflammation of the mucous membrane of the 
 larynx. 
 
 Etiology. — ''Taking cold," exposure to a cold, damp atmosphere, 
 overuse of the voice in speaking, shouting, or singing, especially under 
 unfavorable atmospheric conditions, as in crowded and badly ventilated 
 halls or in the open air, are common causes of acute laryngitis. It may 
 follow the inhalation of air charged with smoke or irritating gases or vapors. 
 Less frequently it is due to the lodgement of foreign bodies, the action of 
 very hot liquids or corrosive poisons, or external violence. It occurs as a 
 local manifestation of measles, influenza, and variola, and as a complica- 
 tion in other acute infectious diseases, as scarlet fever, enteric fever, and 
 erysipelas. Catarrhal laryngitis is frequently associated with catarrh of 
 the nasopharynx and bronchi. The predisposition to largynitis varies 
 greatly in different families and individuals. 
 
 Symptoms. — There is a sensation of dryness and tickling in the throat; 
 the inspiration of cold air and talking cause pain. Cough is a prominent 
 symptom. It is tickling and hoarse, or "laryngeal" in character; at first 
 dry, later attended with scanty mucopurulent expectoration, which in 
 
LARYNGITIS. 1041 
 
 severe cases may be slightly streaked with blood. The voice, at first husky, 
 grows rapidly hoarse, and at length may be completely lost. Dyspnoea is 
 not common in adults, but it is a very frequent symptom in early life, 
 usually occurring in paroxysms and at night. In severe cases cough is 
 very harassing, deglutition is painful, and there may be urgent dyspnoea. 
 Laryngoscopic examination shows that the mucosa is reddened and swollen, 
 especially between the arytenoid cartilages and in the aryepiglottic folds. 
 When the inflammation is intense the vocal cords present superficial 
 erosions, and minute hemorrhages are seen at various points of the laryngeal 
 mucous membrane. A scanty exudation of altered mucus is irregularly 
 scattered upon the surface. In phonation there may often be observed 
 imperfect approximation of the vocal cords, due to implication of the 
 intrinsic muscles of the larynx in the inflammatory process. 
 
 The constitutional symptoms vary; they are not usually severe. 
 Moderate fever, with headache and loss of appetite, may occur. The attack 
 lasts from a few days to a week or more and terminates in recovery. Neg- 
 lected cases may assume the chronic form. 
 
 ii. Acute Laryngitis of Children. 
 
 Spasmodic Croup; False Croup. 
 
 The special feature consists in paroxysmal exacerbations, suffocative in 
 character and occurring at night. These are due to the relative smallness of 
 the larynx in infancy, the narrowness of the rima, the looseness and vascu- 
 larity of the mucous membrane, and the greater reflex excitability of the ner- 
 vous system. The disease is a common one, occurring with frequency during 
 the first dentition, and particularly during the second and third years. 
 
 Etiology. — Exposure to cold and damp, chilling of the surface, violent 
 screaming, the inhalation of steam, smoke, and dust, and indigestion are 
 causes of acute laryngitis in infants. It occurs more frequently in the 
 cold, damp months of winter and spring than in the summer and autumn. 
 It is somewhat more common in male than in female children, and certain 
 families and individuals manifest an especial liability. 
 
 The attack may come on abruptly or be preceded by fretfulness, loss 
 of appetite, and trifling elevation of temperature, huskiness or complete 
 aphonia, and a harsh, croupy cough. Inspiration is prolonged and stridu- 
 lous; there is recession of the suprasternal and supraclavicular spaces; 
 the pulse is frequent and small, and the lips and finger-tips are cyanotic. 
 There is great restlessness, and the expression indicates anxiety and distress. 
 The attack presently passes off, either spontaneously or after the adminis- 
 tration of simple remedies. The child presently falls asleep again and rests 
 until morning; or the attack may be repeated once or several times in the 
 course of the night. On the following day he scarcely seems ill and plays 
 about as usual, but toward evening the croupy cough reappears and during 
 the night the attacks of croup occur as before, to be again repeated, as a 
 rule, upon the third and rarely upon the fourth night, but with diminishing 
 severity. After that there remains simply a trifling bronchial catarrh, 
 which in the course of a few days disappears. 
 66 
 
1042 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — Direct. — Acute laryngitis of the adult rarely presents 
 difficulty in diagnosis. The severer cases suggest oedema of the larynx — 
 acute laryngeal oedema — while those attended by complete loss of voice 
 may be mistaken for hysterical aphonia or paralysis of the vocal cords due 
 to other causes. These questions are at once settled by the laryngoscope. 
 
 Differential. — In children the diagnosis of acute laryngitis is, in 
 certain cases, attended with serious difficulty. The condition is to be 
 distinguished from laryngismus stridulus by the presence of fever, the 
 catarrhal symptoms, the mode of onset, the character of the paroxysms, 
 their nocturnal occurrence, the hoarseness and loss of voice, the absence 
 of the prolonged crowing inspiration which terminates the attack of laryn- 
 gismus, and the course and duration of the disease. 
 
 The diagnosis between spasmodic croup and laryngeal diphtheria — 
 membranous croup — may be for a time impossible. The principal points 
 in favor of spasmodic croup are the milder character of the constitutional 
 symptoms which precede the signs of laryngeal obstruction, the paroxys- 
 mal nature of the obstruction, and the complete relief between the 
 attacks, the progressive amelioration of the symptoms after the second 
 night, the absence of exudation upon the tonsils and adjacent parts, and 
 the absence of enlargement of the cervical nodes. 
 
 Prognosis. — The outlook is favorable. The most alarming symptoms, 
 as a rule, promptly subside after the emesis caused by ipecac, or after a 
 warm bath and the proper administration of simple sedative remedies. 
 
 iii. Subacute Laryngitis. 
 
 By far the larger number of cases of catarrhal laryngitis are of the 
 mildest type. The patients are not ill; the only symptoms are a slight 
 tickling cough, with hoarseness or aphonia. 
 
 The condition acquires importance from its great relative frequency; 
 from the fact that, being accompanied by trifling subjective symptoms, 
 it is likely to be neglected; and, finally, because in many cases prolonged, 
 habitual exposure to the original cause, or use of the voice when the larynx 
 is slightly congested or inflamed, convert a passing local indisposition 
 into a serious disease. In fact the larger proportion of cases of chronic 
 laryngitis arise in this way. 
 
 iv. Chronic Laryngitis. 
 
 Etiology. — This form may be the sequel of an acute attack; more 
 commonly it is the result of the persistent action of causes which give 
 rise to subacute catarrh. Improper use of the voice and its habitual over- 
 use in singing, public speaking, or shouting in the open air are very common 
 causes of chronic laryngitis. It is sometimes associated with chronic 
 pharyngitis and especially with that form which is caused by habitual 
 overindulgence in alcohol and tobacco, with certain cases of marked 
 obstruction to nasal respiration, and cases of elongation of the uvula. 
 Chronic laryngitis is more common in males than in females and is especially 
 a disease of middle life. 
 
LARYNGITIS. 1043 
 
 Symptoms. — There is a tickling sensation in the throat accompanied 
 by a desire to obtain relief by coughing. As a rule pain is not present except 
 after prolonged use of the voice or coughing. Many patients complain 
 of a disagreeable feeling of dryness. The voice is rough and hoarse and 
 at times almost lost. The cough is ringing, loud, deep; expectoration is 
 as a rule scanty and tenacious, but occasionally abundant and sometimes 
 fetid. Upon laryngoscopic examination the mucous membrane is found 
 irregularly thickened and discolored, but the redness is less intense than 
 in the acute form. The vocal cords are of a grayish-red color, and in debili- 
 tated and cachectic persons there may be seen minute superficial erosions. 
 The epiglottis is in many cases irregularly thickened. The general health 
 is often impaired. 
 
 Diagnosis. — The local sensations, chronic alteration of the voice, 
 and peculiar cough suggest the true nature of the affection, but a positive 
 diagnosis can be made only after careful laryngoscopic examination. In 
 everj^ case of chronic laryngitis the history of the patient in all particulars 
 must be carefully investigated in order to determine whether or not the 
 local affection be primary, or secondary to some other disease, as alcoholism, 
 tuberculosis or syphilis. 
 
 V. GEdematous Laryngitis. 
 
 Acute Laryngeal (Edeina; CEdema of the Glottis. 
 
 Etiology. — CEdema of the mucous and submucous tissues of the 
 larynx occasionally occurs as a serious and frequently fatal complication 
 in the course of acute catarrhal laryngitis, whether due to cold or to internal 
 or external traumatism; in chronic disease of the larynx, as tuberculosis 
 and syphilis; in connection with perichondritis of the larynx; as a compli- 
 cation of severe inflammatory affections of neighboring structures, as the 
 tonsils, parotid glands, or the cellular tissue of the neck; in the course of 
 acute infectious diseases, as scarlatina, typhoid fever, variola, and ery- 
 sipelas; and, finally, as an extension of the general oedema in acute or 
 chronic nephritis. 
 
 Symptoms. — Rapidly progressive dyspnoea is the chief symptom. 
 It is at first inspiratory; later also expiratory. Respiration is accompanied 
 by loud stridor. The voice becomes husky and soon fails. Signs of impend- 
 ing suffocation supervene, and unless relief is afforded death takes place 
 in the course of a few hours. If a laryngoscopic examination prove success- 
 ful, the epiglottic and aryepiglottic folds are seen to be greatly swollen, 
 the latter almost meeting laterally; the false cords are also oedematous. 
 These changes can be felt with the finger, and upon depressing the tongue 
 the swollen rim of the epiglottis may sometimes be brought into view. 
 
 The diagnosis is unattended with difficulty and depends upon physical 
 exploration. 
 
1044 MEDICAL DIAGNOSIS. 
 
 vi. Pseudomembranous Laryngitis. 
 
 True Croup; Membranous Croup; Fibrinous Laryngitis. 
 
 Definition. — Inflammation of the mucous membrane of the larynx. 
 resulting in the formation of a pseudomembrane or pellicle composed of 
 a network of fibrin, embracing in its meshes leucocytes and necrotic 
 epitheHum. 
 
 Etiology. — Any agent capable of destroying the protecting epithelium 
 of the laryngeal mucous membrane, thus permitting the escape of serum 
 and white blood-corpuscles, may give rise to the formation of a pseudo- 
 membrane. Hence, this form of laryngitis may result, (a) from trauma- 
 tism, as the inhalation of steam, hot smoke, or irritating and corrosive 
 chemicals in the form of vapor or solution; (b) from the action of certain 
 pathogenic micro-organisms. 
 
 Pseudomembranous laryngitis occurs at all seasons of the year. It 
 especially affects j'oung children between the ages of two and six. Cases 
 in children under two and over seven 3'ears of age are much less common. 
 Exceptionally the disease occurs at a later period of life. Boj^s are some- 
 what more liable than girls. This affection frequently occurs as a compli- 
 cation in scarlet fever and measles. In by far the greater number of cases 
 it is a manifestation of diphtheria. 
 
 Symptoms. — The symptoms usually develop in the course of an attack 
 of faucial diphtheria or of one of the exanthemata. Less frequently they 
 arise as the manifestations of a primary laryngeal diphtheria. They point 
 to progressive impairment of the functions of the larj^nx, wdth increasing 
 obstruction to respiration and its consequences, and consist of hoarseness, 
 aphonia, explosive and croupy cough, stridulous respiration, dj'spncea, 
 recessions, restlessness, cyanosis, and stupor. 
 
 Diagnosis. — Acute progressive laryngeal stenosis in a young child is 
 nearly always due to pseudomembranous laryngitis. If traces of the exu- 
 date can be discovered upon inspection of the throat, or if. upon phj'sical 
 examination, there can be detected coarse or whistling tracheal ralesT or 
 finally, if shreds of membrane are expectorated after paroxysms of explosive 
 cough, the diagnosis becomes sure. It is equally so. in the absence of 
 such confirmatory evidence, if the case occur in a locality already the scene 
 of an epidemic of diphtheria. The fact that, even in pseudomembranous 
 laryngitis, the signs of obstruction are at first paroxysmal and followed 
 by intervals of partial relief must alwaj's be borne in mind. For this reason 
 the earl}^ differential diagnosis betw^een this disease and spasmodic laryn- 
 gitis is not, in all instances, possible. In the latter, however, the intervals 
 of relief are more complete and prolonged, the paroxysm not usually recur- 
 ring until the succeeding night; the tendency is to progressive amelioration 
 of the symptoms rather than j^rogressive aggravation, and the signs of 
 grave constitutional disturbance do not show themselves. 
 
 Prognosis. — Pseudomembranous laryngitis is. in the absence of treat- 
 ment, an extremely fatal disease. The diphtheritic form, under the admin- 
 istration of antitoxin, frequently terminates in recovery. It is therefore 
 imperatively necessary to at once employ this remedy. 
 
LARYNGITIS. 1045 
 
 vii. Tuberculous Laryngitis. 
 
 Laryngeal Phthisis; Throat Consumption. 
 
 Definition.— Inflammation of the tissues of the larynx caused by- 
 local tuberculosis. 
 
 Etiology. — Tuberculosis of the larynx may occur as a primary disease. 
 Much more frequently, however, it is secondary to pulmonary tuberculosis. 
 When the earliest symptoms are laryngeal, the disease remains for a time 
 localized, but eventually the lungs become involved. Secondary tubercu- 
 lous laryngitis occurs in more than 25 per cent, of the pulmonary cases. 
 The laryngeal symptoms are pronounced and the lesions extensive and 
 advanced in a much smaller percentage. A majority of the cases occur 
 in males — a fact attributed to their greater hability to chronic catarrhal 
 laryngitis, which acts as a predisposing cause. Not every case of chronic 
 laryngitis in a consumptive individual is tuberculous. The mechanical irri- 
 tation of frequent and severe cough and the contact of the sputum may 
 cause chronic catarrhal laryngitis, which is aggravated by the condition 
 of the patient, and which undoubtedly, after a time, predisposes to infec- 
 tion. In the tuberculous cases the mucous membrane is of a grayish, 
 pale color, irregularly mottled and congested; it is at first swollen and 
 studded with miliary tubercles, which by their coalescence form scattered 
 tuberculous nodules. These nodules undergo caseation, as a result of 
 which there form more or less extensive superficial ulcers, which show a 
 tendency to spread. The floor of these ulcers is covered by a grayish 
 exudation, and they are surrounded by a border of infiltrated and swollen 
 tissue. They occur most frequently upon the arytenoids, in the inter- 
 arytenoid space, upon the true cords, and on the epiglottis. The destruc- 
 tion of tissue extends deeply, implicating the submucosa, and in severe 
 cases the perichondrium and cartilages, which undergo more or less 
 extensive necrosis — tuberculous perichondritis and chondritis. The ulcers 
 occasionally extend to the back of the tongue, to the pharynx, to the upper 
 part of the oesophagus, and in severe cases to the pillars of the fauces and 
 the tonsils. Complete erosion of the true cords not infrequently occurs, 
 and the epiglottis is often destroyed throughout the greater part of its extent. 
 
 Symptoms. — The earlier symptoms are those of chronic laryngitis 
 due to other causes. There is slight huskiness, which is at first intermittent 
 and disappears after resting the voice. It soon becomes continuous, and 
 gives place to a peculiar hoarseness, which in the advanced stages of the 
 disease usually passes into complete aphonia. Cough is tickling, paroxys- 
 mal, and unproductive; it has the peculiar quality known as laryngeal, 
 and may be distinguished in the same patient from the mere nervous 
 cough of bronchial irritation. It is not at first distressing, but in cases of 
 advanced ulceration it becomes husky and high-pitched, and is attended 
 with pain. Spontaneous pain is not very common. There is often tender- 
 ness upon external pressure. Dsyphagia is a prominent and most distressing 
 symptom in advanced cases, especially when the epiglottis is involved, 
 the arytenoids are extensively destroyed, or there is ulceration of the 
 pharyngeal wall. In such cases the administration of nourishment is 
 
1046 MEDICAL DIAGNOSIS. 
 
 attended with difficulty, the attempt to take food of any kind giving rise 
 to severe pain, urgent paroxj^sms of cough, and frequentl}^ to suffocative 
 attacks. The difficulty in swallowing adds greatly to the sufferings of 
 the patient and constitutes the most distressing symptom of the terminal 
 stage of this form of tuberculosis. In the earlier stages the laryngoscope 
 reveals the appearances due to chronic laryngeal catarrh. There is, how- 
 ever, greater pallor of the mucous membrane, together with some thick- 
 ening over the arytenoids. Later the picture is characteristic. The vocal 
 cords are thickened and eroded, and their motility is impaired; the epiglottis 
 and arytenoid are infiltrated, and at various points superficial grayish 
 ulcers with ill-defined borders are seen; finally, deep ulceration, with 
 extensive loss of substance, occurs. 
 
 Diagnosis. — Direct. — In the earlier stages, especially in the absence 
 of the evidences of pulmonary tuberculosis, the diagnosis of tuberculous 
 laryngitis cannot always be made. Pallor of the laryngeal mucous mem- 
 brane, thickening of the arytenoids, general failure of health on the part 
 of the patient, and absence of response to local and constitutional treat- 
 ment lead to the suspicion of tuberculous disease. This suspicion is con- 
 firmed by the appearance of the characteristic ulceration, the evidences 
 of pulmonary tuberculosis, or the detection of tubercle bacilli in the sputum 
 or the exudate scraped from the floor of the laryngeal ulcer. In selected 
 cases the tuberculin tests may be made. 
 
 Differential. — The diagnosis between tuberculosis and syphilis of 
 the larynx is, in certain cases, attended with some degree of difficulty. 
 In this connection, the greater tendency of syphilis to invade the pharynx, 
 the fact that tuberculous ulceration of the larj^nx is, in general, progressive 
 and continuously destructive, while syphilitic ulceration frequently shows 
 a disposition to heal at one point while advancing at others, and, finally, 
 the history of specific inflammatory or ulcerative lesions in other parts of 
 the body in syphilis should receive due consideration. 
 
 Prognosis. — The course of tuberculous larj-ngitis is, as a rule, in the 
 highest degree unfavorable. While, in the Hterature of the subject, cases 
 of marked ameHoration, or even of cure, especially in the primary form, 
 are reported, the disease is so constant!}^ fatal that the instances in which 
 more than a temporary arrest occurs must be regarded as exceptional. 
 
 viii. Syphilitic Laryngitis. 
 
 Definition. — Inflammation of the larynx, occurring as a manifestation 
 of s^^philis, either hereditary or acquired. 
 
 Etiology. — The larynx is very frequently involved in syphiHtic inflam- 
 mation. 
 
 The catarrhal laryngitis of secondary syphilis presents nothing char- 
 acteristic. Symmetrical superficial ulceration of the true and false cords 
 occurs. Mucous patches, when present elsewhere, confirm the diagnosis, 
 but they are not common in the larynx. 
 
 Much more frequent and important are tertiary lesions. Gummata, 
 multiple or single, develop in the submucous tissues. They may undergo 
 resolution, or, as is much more frequently the case, they break down, 
 
LARYNGISMUS STRIDULUS. 1047 
 
 giving rise to extensive and deep ulceration, which ma}^ involve the carti- 
 lages. Sometimes the disease begins as a perichondritis attended with 
 suppuration, and rapidly causing necrosis of the cartilages. In such cases 
 external fistulae maj'- be formed. In the course of the ulceration, erosion 
 of the walls of arterial branches may give rise to free hemorrhage, or an 
 acute oedema may prove rapidly fatal. The gummata develop most com- 
 monly at the base of the epiglottis or in the ventricles. They may attain 
 the size of a nut and occasion serious stenosis of the larynx. The sclerosis 
 which attends their resorption, or the cicatrices resulting from the healing 
 of the ulcers, are often the occasion of marked deformity of the larynx, with 
 progressive stenosis. 
 
 The gummatous infiltration of inherited syphilis in either the early 
 or the later form leads to ulceration, which tends to extend deeply and 
 involve the cartilages. The healing of such ulcers is also likely to be 
 followed by cicatricial stenosis and deformity. 
 
 Symptoms. — Secondary syphilis of the larynx gives rise to hoarseness 
 and laryngeal irritation. The symptoms of the tertiary lesions are of the 
 most serious character, consisting during the stage of active ulceration of 
 aphonia, cough, pain, dj^spncea, dysphagia, and in the stage of cicatriza- 
 tion of a more or less grave and progressive mechanical obstruction to 
 respiration. The symptoms show themselves in the hereditary disease 
 commonly within the first six months of life; exceptionally, after puberty. 
 
 Diagnosis. — The history of the case and of other specific cutaneous 
 inflammatory or ulcerative lesions, or the presence of such lesions or their 
 scars, renders the diagnosis in a majority of the cases a simple matter. 
 
 Prognosis. — Under early and prolonged antisyphilitic treatment the 
 outlook is favorable. With the general improvement the laryngeal symp- 
 toms subside. In old cases with stenosis, tracheotomy may be necessary. 
 
 ix. Laryngismus Stridulus. 
 
 Definition. — A neurosis, the prominent symptom of which is spasmodic 
 closure of the glottis, associated, in severe attacks, with spasm of the 
 diaphragm and other muscles of respiration. The relaxation of the spasm 
 is accompanied by a prolonged, high-pitched, crowing inspiratory sound, 
 from which the affection receives its name. 
 
 Etiology. — Laryngismus stridulus occurs almost exclusively before 
 the end of the third year of life. It is more common in boys than in girls. 
 A large proportion of the cases occur in rhachitic children, but those in 
 fair health may develop the attack without warning. The paroxysm may 
 be excited by a variety of causes, either physical or emotional. Among 
 these are sucking, sudden movements, violent crying, the bath, indigestion, 
 and dentition. They also occur in the absence of such causes — on waking 
 from sleep, for example — and more frequently by night than during the 
 •day. The seizure may present, especially in older children, a curious 
 -appearance of being voluntary, and is sometimes regarded at first as a fit 
 of passion or of holding the breath. 
 
 Symptoms. — The attack may be preceded by an occasional catch in 
 the breath or by slight crowing sounds; as a rule it comes on without 
 
1048 MEDICAL DIAGNOSIS. 
 
 premonitory symptoms. There is complete arrest of respiration. The 
 chest is fixed, the head thrown back, the face, at first pale, quickly becomes 
 cyanotic, the eyes are wide open and staring. There is often twitching 
 of the facial muscles. In the severer cases there may be opisthotonos, 
 carpopedal spasm, or general convulsions. The attack lasts from a few 
 seconds to a minute or more. Death has taken place during the paroxys-m 
 from prolonged stoppage of respiration or from impaction of the epiglottis. 
 As the cyanosis deepens the spasm jnelds; the air slowly enters the lungs 
 again through the relaxing glottis, with the characteristic prolonged, 
 high-pitched, crowing sound, and the attack ends in a spell of coughing 
 or crying. The seizures vary greatly in severity and number. After a 
 few repetitions they may cease altogether, or they may come on very 
 frequently both by day and by night, and recur during a period of months. 
 
 Diagnosis. — The absence of fever, hoarseness, and cough in the inter- 
 vals between the attacks, the suddenness and completeness of the arrest 
 of breathing, the short duration of the paroxysm, the peculiar prolonged 
 crowing inspiration with which it ends, and the associated convulsive 
 phenomena, taken together, form a characteristic clinical picture not to 
 be mistaken for any other malady. When death occurs in the paroxysm 
 the crowing is absent, and the sudden asphyxia may remain unexplained. 
 
 Prognosis. — As regards the spasm the outlook is favorable, the fatal 
 cases being few in number. Children who suffer from laryngismus stridulus 
 are, as a rule, frail, and a large proportion of them succumb to intercurrent 
 disease. 
 
 X. Chronic Infantile Stridor. 
 
 Definition. — The chief symptom consists of an almost continuous 
 coarse, low-pitched, inspiratory stridor, which is present both when the 
 child is awake and during sleep. 
 
 Etiology. — The cause is unknown. 
 
 Symptoms. — The stridor varies in intensity, being much aggravated 
 by excitement. It sometimes ceases wholly for a few hours. As the disease- 
 gradually passes off, it occurs only at intervals and when the child is lively 
 or excited. Expiration is usually normal; it may be accompanied by a. 
 few coarse mucous rales. Retraction of the thorax does not often occur,, 
 and when present is slight. In one case only have I encountered faint 
 cyanosis, and in that instance there were, during the eighteen months of 
 stridulous breathing, three transient general convulsions. The case ended 
 in recovery. As a rule the affection does not seem to interfere with the 
 general health of the child. 
 
 xi. Paralysis of the Laryngeal Muscles. 
 
 The larynx is supplied by the superior laryngeal and inferior or recur- 
 rent laryngeal branches of the vagus. These are joined by branches of 
 the sympathetic. The superior laryngeal nerves supply the mucous mem- 
 brane of the upper portion of the larynx, including the epiglottis, as far 
 as the true cords. They also supply the cricothyroid, the thyro-epiglottic 
 and the aryteno-epiglottic muscles, and the arytenoid muscles which alsa 
 
PARALYSIS OF THE LARYNGEAL MUSCLES. 1049 
 
 derive motor filaments from the recurrents. The inferior or recurrent 
 laryngeals curve around the arch of the aorta on the left side and the sub- 
 clavian on the right, and ascend between the trachea and oesophagus to 
 supply the laryngeal mucous membrane below the cords and all the muscles 
 of the larynx except the cricothyroids. The superior and inferior laryngeal 
 nerves on each side communicate with each other in two places, namely, 
 at the back of the larynx and on the side of the larynx under the ala of the 
 thyroid cartilage. The motor filaments of these branches of the vagus 
 are derived from the spinal accessory. 
 
 In paralysis of the laryngeal muscles the lesion may be: 
 
 1. Central, involving the nucleus of the accessory nerve in the medulla. 
 The laryngeal paralyses of this group arise as a result of syphilis affecting 
 the medulla oblongata, acute and chronic bulbar paralysis, multiple sclero- 
 sis, and locomotor ataxia. The hysterical paralyses of the larynx must 
 also be regarded as of cerebral origin. 
 
 2. The lesion may affect the fibres of the recurrent laryngeal in the 
 course of the vagus or the accessory nerve. This group includes the cases 
 in which the paralysis is due to pressure by new growths, and there are 
 cases in which the trunk of the nerve is wounded or injured in surgical 
 operations above the point at which the recurrents are given off. 
 
 3. The lesion may directly involve the laryngeal nerves. The majority 
 of the cases of laryngeal paralysis are included in this group. The recur- 
 rents are, by reason of their remarkable course, especially liable to abnormal 
 pressure by new growths, both within the thorax and in the neck. The 
 left, vvhich curves around the aorta, is exposed to greater risk of injury 
 than the right, which passes no lower in the chest than the subclavian. 
 Either may be included in the dense pleural thickening at the apices which 
 occurs in certain forms of pulmonary tuberculosis. Paralysis of the right 
 is in rare instances caused by aneurism of the subclavian artery. The 
 left is likely to be injured by the pressure of an aneurism of the arch of the 
 aorta, a mediastinal tumor, enlargement of the bronchial glands, and in 
 rare cases of a massive pericardia] effusion. Both, as they ascend between 
 the trachea and the oesophagus, are occasionally involved in carcinoma 
 of the latter, or compressed by enlargement of the thyroid gland. Paralysis 
 of the recurrents occurs as a very rare sequel of diphtheria and as a result 
 of chronic alcoholism. 
 
 4. The lesion may be confined to the larynx. The loss of power is 
 purely muscular and amounts merely to a paresis. This occurs in various 
 diseases, and is due to inflammatory infiltration of the submucous tissues 
 with altered nutrition of the muscles. 
 
 5. Finally, cases of laryngeal paralysis occui- for which no adequate 
 cause can be discovered. 
 
 The following are the more important forms of larjmgeal paralysis: 
 1. Complete Paralysis of the Recurrent Nerve. — This condition 
 occurs as the result of lesions dividing or completely destroying the recur- 
 rent or its fibres in the vagus, or as a manifestation of neuritis due to diph- 
 theria or other causes, or in consequence of advanced disease in the medulla. 
 It may be unilateral or bilateral. When the parah'sis is unilateral, the 
 vocal cord on the affected side occupies the median or so-called cadaveric 
 
1050 MEDICAL DIAGNOSIS. 
 
 position, and is motionless upon inspiration, expiration, and attempts 
 at phonation. In phonation the vocal cord and the arytenoid of the sound 
 side pass beyond the median line. The voice is harsh, it easily breaks 
 into a falsetto, and speaking is attended with effort. The cough is likewise 
 harsh and brassy. Dyspnoea is not a symptom. In complete bilateral 
 paralysis^a very rare condition — the cords occupy the median position 
 and are immobile; their edges are slightly concave, as the aperture is 
 sufficiently wide for respiration; dyspnoea is absent except upon exertion. 
 Aphonia is complete and coughing is impossible. 
 
 2. Bilateral Paralysis of the Abductors. — The posterior crico- 
 arytenoids are involved. This form of laryngeal paralysis may occur as 
 a central affection in the course of bulbar paralysis, multiple sclerosis, 
 and locomotor ataxia. It may be produced by pressure upon both vagi 
 or upon both recurrents. It is encountered as a rare form of hysterical 
 palsy. Abductor paralysis may follow exposure to cold or may arise in 
 the course of a laryngeal catarrh. The cords are approximated as in pho- 
 nation. The glottis is not opened in inspiration; on the contrary, it acts 
 like a valve, and is narrowed by the pressure of the air to a small slit. In- 
 spiration is therefore difficult, prolonged, and stridulous, while expiration 
 is unimpeded. Phonation is not affected. The abihty to cough remains. 
 This form of laryngeal paralj^sis is rare, but is attended with the danger of 
 sudden suffocation. If the symptoms are progressive and the dyspnoea con- 
 stant tracheotomy becomes necessary and the tube miust be constantly worn. 
 
 3. Unilateral Abductor Paralysis. — One cord only may be affected 
 in pressure-paralysis involving the recurrent of one side. Aneurism of 
 the arch of the aorta, exerting pressure upon the left nerve, is by far the 
 most common cause of this condition. The right nerve is especially liable 
 to be involved in pleural thickening and retraction of the apex of the lung 
 in the course of pulmonary tuberculosis. The vocal cord on the affected 
 side remains fixed in the middle line during inspiration. The voice is 
 sometimes unaffected; more commonly it is slightly harsh or rough. 
 Dyspnoea and stridor are not often present. The movements of the other 
 cord are normal. 
 
 4. Adductor Paralysis, — In the more common forms of adductor 
 paralysis the lateral crico-arytenoids, the arytenoid, and the thyro-aryte- 
 noids, are implicated. It occurs as the result of exposure to cold or from 
 overuse of the voice, and is very often the cause of loss of voice in catarrhal 
 laryngitis; it is the usual form of paralysis in hysterical aphonia. The 
 laryngoscope reveals the normal position and movement of the cords in 
 respiration but their total failure to approximate on attempts at phonation. 
 There is neither stridor nor dyspnoea; ability to cough is not affected, 
 but aphonia is complete. Adductor paralysis may be partial. It is com- 
 monly bilateral, but in exceptional cases unilateral. In bilateral paresis 
 of the thyro-arytenoids the glottis does not close completely on phonation, 
 the margins of the cords being separated by an oval space. If one cord 
 only is affected its margin remains concave. In paralysis of the arytenoid, 
 which seldom occurs alone, the vocal cords are brought together in their 
 anterior extent, but the failure of the arytenoid cartilages to approximate 
 leaves a narrow triangular opening at the interarytenoid space. 
 
BRONCHITIS. 1051 
 
 III. DISEASES OF THE BRONCHI, 
 i. Bronchitis. 
 
 Definition. — Inflammation of the whole or anj^ part of the bronchial 
 mucous membrane. It occurs as an acute or chronic disease. It is bilateral 
 and usually limited to the larger or medium-sized tubes. When it extends 
 to the smaller and terminal bronchi it is spoken of as "capillary bronchitis/' 
 but this condition is always associated with collapse and inflammation of 
 the corresponding air-vesicles, constituting bronchopneumonia. 
 
 (a) ACUTE BRONCHITIS. 
 
 This very common affection is not often serious in the middle periods 
 of life. In mfancy and old age it tends to involve the smaller tubes and is 
 often a fatal disease. 
 
 Etiology. — ChilHng of the surface, and especially wet feet, tend to 
 produce engorgement of the bronchial vessels and the microbic infection 
 to which bronchial catarrhal inflammation is due. Overheated dwellings, 
 a damp or dust-laden atmosphere, and, in rare instances, the inhalation of 
 irritating gases — chlorine, bromine, etc. — are also etiological factors. 
 Certain persons suffer from a peculiar susceptibility and develop the disease 
 upon sHght exposure to its causes. It very often arises as the extension 
 downward of an ordinary coryza, the result of "catching cold," and is 
 common in damp, cold, and changeable weather, when it often prevails 
 in local epidemics. Acute bronchitis constitutes an important element 
 in measles, pertussis, and asthma, and is frequently met with in the ague 
 fit of malaria, and early in the course of enteric fever. 
 
 Pathology. — The significance of the cUnical phenomena rests upon 
 the anatomical changes, which in the main consist of redness and conges- 
 tion of the mucosa, swelling and oedema of the submucosa, infiltration of 
 the tissues with leucocytes, desquamation of the epithehum in its ciliated 
 and embryonic forms, and the secretion of mucus and pus. 
 
 Symptoms. — The onset is frequently characterized by symptoms of 
 constitutional infection, chilliness, crawling sensations, fever, — 101°-103° 
 F. (38.5°-39.5° C), — bodily and mental depression, languor, and pains in 
 the back and limbs. There are sensations of substernal pain and constric- 
 tion, a rough, dry, and sometimes ringing cough, often paroxysmal and 
 distressing, and much uneasiness and pain in the chest, especially along 
 the insertions of the diaphragm. In the course of a day or more the cough 
 loosens, with much reKef of the respiratory symptoms and disappearance 
 of the fever and other evidences of constitutional trouble. The expectora- 
 tion becomes free, abundant, and mucopurulent, and later purulent and 
 nummular. 
 
 Physical Signs. — Bronchitis of the larger tubes may yield no abnormal 
 physical signs. The percussion sound is not altered in an uncomplicated 
 acute bronchitis. Upon auscultation in the early stage drj^ rales, sonorous 
 and sibilant, are heard at various points on both sides of the chest. They 
 vary in size and quahty, often disappearing after efforts of coughing. 
 
1052 
 
 MEDICAL DIAGNOSIS. 
 
 When the cough becomes loose and the expectoration fluid and abundant 
 the rales become moist and bubbling. Rhonchal fremitus is often present, 
 especially in children. The respiratory murmur is vesicular, never bron- 
 chial. If the bronchial secretion is very abundant, there may be slight 
 temporary dyspnoea and enfeeblement of the vocal fremitus, both of which 
 disappear after cough with free expectoration. The intensity and course 
 of the disease are variable. The attack in many cases scarcely amounts 
 to an illness. Adults in previous good health usually recover in the course of 
 
 a few days, the fever sub- 
 siding by rapid lysis, and 
 cough and expectoration 
 gradually diminishing. 
 
 Diagnosis. — In in- 
 fants, the aged, and 
 debilitated persons at all 
 periods of life, there is 
 danger that the bron- 
 chial catarrh may invade 
 the fine tubes and cause 
 bronchopneumonia. A 
 daily examination should 
 be made as a matter of 
 routine. It is important 
 alike from the standpoint 
 of diagnosis, prognosis, 
 and treatment to note 
 whether the rales are dry 
 or moist, since these qual- 
 ities are indicative of the 
 physical characters and 
 amount of bronchial 
 secretion, and whether 
 they are coarse, medium- 
 sized, or small, since vari- 
 ations in this respect 
 correspond to variations in the diameter of the tubes involved. Subcrepi- 
 tant and crepitant rales at the bases posteriorly, together with faint 
 vesiculobronchial breathing and relative dulness, are the signs of extension 
 to the finer tubes. With these signs there is a rise of temperature, 
 increased respiration and pulse-frequency, restlessness, slight cyanosis, and 
 the general appearance of an aggravation of the illness. 
 
 In isolated cases of measles the differential diagnosis cannot be made 
 until the appearance of Koplik's sign or the exanthem; in pertussis it 
 cannot be affirmed until the whoop comes, though cough in paroxj^sms 
 which cause vomiting and are worse at night is suggestive. Bronchitis is 
 by no means rare in the early stage of enteric fever, and there are 
 occasional cases in which for a few days cough and expectoration are 
 prominent symptoms. 
 
 
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 Fig, 315. — Acute bronchitis, Woraan aged 50. — German Hospital. 
 
BRONCHITIS. 1053 
 
 (b) CHRONIC BRONCHITIS. 
 
 The affection very rarely arises as the termination of a single attack 
 of acute bronchitis. It sometimes follows the repeated attacks which 
 result from continuous exposure to the cause of catarrhal affections. 
 
 Etiology. — Chronic bronchitis is a secondar}^ disease. It constitutes 
 an important manifestation of certain circulatory derangements, as heart 
 disease,, thoracic aneurism, arteriosclerosis, some chronic pulmonary affec- 
 tions, as pneumoconiosis, asthma, and emphysema, and constitutional 
 conditions, as gout and chronic ursemia. Important predisj^osing influ- 
 ences are chmate and season. The winter cough of elderly and invalid 
 persons is well known and is often absent when the patients are able to 
 avoid the cold and changeable weather of the north by a temporary stay 
 in a warm, dry, and equable climate. The influence of age is marked. 
 Acute bronchitis is a disease of the young; chronic bronchitis a disease 
 of the old. Chronic bronchitis is more common in men. It sometimes 
 comes on in women at an early age without obvious cause and runs an 
 indefinite course, with mild symptoms and slight secondary changes — 
 bronchiectasis and emphysema. 
 
 Pathology. — The lesions are not evenly distributed. They affect 
 different parts of the bronchial mucosa in varying degree and in irregular 
 patches, and consist of loss of epithelium, atrophy of the glands and mus- 
 cularis, thinning of the mucous membrane, and dilatation of the walls 
 of the tubes. Bronchiectasis and emphysema gradually come to pass. 
 
 Symptoms. — There is cough of variable severity, less troublesome 
 in dry warm weather and always w^orse in the cold and changeable weather 
 of winter and early spring. There are often paroxysms in the morning, 
 with comparative freedom throughout the day. In some cases cough is 
 especially troublesome at night. The sputum has no constant characters. 
 It differs in different cases and at different times in the same case. In 
 the dry catarrh expectoration is absent. As a rule it is abundant, coming 
 up in considerable quantities at a time. Sometimes there is a little tena- 
 cious mass of clear mucus at intervals. Very common is a clear, thin fluid. 
 In the advanced cases shortness of breath is common upon exertion. It 
 is due to emphysema and to some extent also to cardiac weakness. Fever 
 is absent. There is no pain. The general health is often good, and the 
 patients may be fully able to attend to their affairs. The disease is, how- 
 ever, progressive, and tends to an ultimate dj'scrasia with advanced emphy- 
 sema, bronchiectasis, and dilatation of the right heart. 
 
 Physical Signs.— In the early stages the physical signs do not differ 
 from those of the stage of expectoration in acute bronchitis. Already 
 perhaps the percussion sound has the vesiculotympanitic quality. There 
 is prolongation of the expiratory sound, and various rales are heard, some 
 sonorous, some sibilant, and occasionally moist rales of ever}' size. At the 
 bases posteriorly there are heard subcrepitant and crepitant rales, and when 
 there is much fluid secretion there may be slight impairment of resonance. 
 
 Clinical Varieties.— (1) Dry Bronchitis; Catarrhe Sec. — This form is 
 characterized by troublesome, paroxysmal cough, with slight expectoration, 
 sometimes none at all. It is not uncommon in old people with emphysema. 
 
1054 MEDICAL DIAGNOSIS. 
 
 (2) Bronchorrhoea. — The expectoration is profuse, two or more pints 
 sometimes being brought up in the course of twenty-four hours. It may 
 be thin and watery — bronchorrhoea serosa — or thick and uniformly purulent, 
 or, and this is most common, it may consist of a thin pus with greenish 
 clumps. Bronchorrhoea is to be distinguished from bronchiectasis, to which, 
 by soakage and the dilating pressm^e of the accumulating secretion, it 
 tends to give rise. The retained fluid may undergo decomposition. 
 
 (3) Putrid Bronchitis. — Foul-smelling expectoration may occur in a 
 number of different conditions. These comprise anatomical lesions in 
 which secretions are retained, as bronchiectasis, vomicae, empyema with 
 bronchopulmonary fistula, and pulmonary abscess. In addition to these, 
 there is a special form of bronchitis characterized by sputum having the 
 odor of decomposition. This form is comparatively rare. The expectora- 
 tion is abundant, of a dirty yellowish-gray color, thin, and separates upon 
 standing into three layers, an uppermost, greenish-yellow in color, con- 
 sisting of thin froth, a middle transparent serous layer, and an opaque, 
 purulent sediment, in which may sometimes be found small, whitish-gray 
 masses — Dittrich's plugs. Putrid bronchitis may be followed by aspira- 
 tion pneumonia, abscess, or gangrene. It can be differentiated from 
 bronchiectasis only when the latter forms cavities sufficiently large to 
 yield characteristic physical signs, the sputa being practically the same 
 in the two conditions; from vomicae by the presence of tubercle bacilli 
 in the sputum, and the signs of a cavity, usually in the neighborhood of 
 an apex; from gangrene by the presence of shreds of necrotic pulmonary 
 tissue, and finally, from empyema communicating with a bronchus, by 
 the more distinctlj^ purulent sputa, its expectoration in larger quantities 
 at a time, the greater readiness with which it is brought up when the patient 
 lies upon one — the unaffected — side, and the physical signs, which indicate 
 a unilateral and circumscribed lesion. 
 
 (c) FIBRINOUS BRONCHITIS. 
 
 Plastic or Crouvous Bronchitis. 
 
 Bronchial casts are occasionally found in infralaryngeal diphtheria, 
 in croupous pneumonia, in chronic valvular disease of the heart, and in 
 the stadium ultimum of pulmonary tuberculosis. They have also been 
 found in the copious albuminous expectoration which, in very rare instances, 
 supervenes upon the removal of a pleural effusion by aspiration. After 
 haemoptysis branching blood-casts are frequently expectorated. All 
 these conditions are to be distinguished from fibrinous bronchitis, a form 
 of bronchitis characterized by the formation, in limited branches, of casts 
 or moulds of the bronchial tubes which give rise to urgent dyspnoea and 
 are expelled in violent paroxysms of cough. There are acute and chronic 
 forms, without direct etiological relationship. Acute Fibrinous Bron- 
 chitis. — This form usually occurs as an intercurrent affection in the febrile 
 infectious diseases. There is bronchitis with increasing dyspnoea; in some 
 cases a rise in temperature and chills have been noted. Casts are coughed 
 up. They are usually arborescent, sometimes merely a straight short 
 
BRONCHIECTASIS. 1055 
 
 mould of a single tube, with its terminal subdivisions. In fatal cases the 
 casts have been found in the tubes. Chronic Fibrinous Bronchitis. — This 
 form occurs as a primary affection. It is a rare disease. It is more common 
 in middle life and in men than in women. The exciting cause is unknown. 
 The attacks recur at intervals with more or less regularity for long periods 
 of time. There are signs of bronchitis, with fever. Hsemoptysis occurs. 
 Dyspnoea is marked. Cyanosis may be present. The physical signs may 
 be localized or, if diffuse, they are intensified over the affected area. There 
 is enfeeblement or absence of the respiratory murmur, without impairment 
 of resonance, together with many rales on coughing. The respiratory 
 movement upon the affected side is diminished. The expectoration of 
 the casts is attended with distressing cough and suffocative phenomena. 
 They are usually ejected in a ball-like coil embedded in mucus and blood. 
 Unrolled they appear as large, whitish, arborescent forms, of which the 
 main trunk is sometimes 2 cm. in diameter and as many as 10 cm. in length. 
 On cross section they are solid, sometimes with a minute central canal, 
 circumferentially stratified, containing minute bubbles of air, and, in some 
 cases, little clots of blood. Microscopically there are present red and white 
 blood-corpuscles, alveolar epithelium, and in some cases Charcot-Leyden 
 crystals and Curschmann's spirals. Upon the expectoration of the casts 
 the symptoms are immediately relieved. The form and size of the casts 
 in repeated attacks is often similar. This fact would only justify the con- 
 clusion that the same bronchial distribution has been affected when the 
 localization of the physical signs has occurred in the same region of the 
 chest. The cause of the cast formation in limited branches of the bronchia 
 and its recurrence at intervals is unknown. 
 
 Prognosis. — In acute bronchitis recovery is the rule, except in debil- 
 itated persons and at the extremes of Hfe; in chronic bronchitis the prog- 
 nosis as to life is favorable, as to recovery unfavorable; in fibrinous 
 bronchitis the prognosis is uncertain, both as to life and recovery. 
 
 ii. Bronchiectasis. 
 
 Definition. — Dilatation of bronchial tubes. Dilatation of the finer 
 subdivisions is designated bronchiolectasis. Two principal forms of this 
 anatomical condition are recognized — the cylindrical or fusiform, and 
 the saccular or globular. These are sometimes present in the same lung. 
 As a rule there are several dilatations in different portions of both lungs. 
 Occasionally the bronchiectasis is single, especially in chronic bronchitis 
 with emphysema. A form described as bronchiectasis universalis occurs 
 as a congenital condition and is sometimes encountered in chronic inter- 
 stitial pneumonia; one lung only is affected. The bronchial tubes are 
 represented by a series of dilatations surrounded by dense sclerotic lung 
 tissue. The ordinary forms are common in chronic phthisis affecting 
 the apex, in chronic pleurisy at the base, and in emphysema. They vary 
 greatly in size. The interior of bronchiectatic cavities is lined with a 
 smooth membrane, from which the normal cylindrical epithelium has 
 disappeared. At the dependent parts, as the result of accumulated secre- 
 tions, there are areas of ulceration. All the layers of the bronchial wall 
 are stretched and atrophied. The contents are often intensely fetid. Bron- 
 
1056 MEDICAL DIAGNOSIS. 
 
 chiolectasis may occur as an acute condition after the febrile infections. 
 or in chronic form in the bronchitis of old persons. 
 
 Etiology. — The mechanical factors are twofold: (a) weakening of 
 the tone of the bronchial wall as the result of impaired nutrition, and soak- 
 age and dilatation in consequence of the pressure of the contained air in 
 severe cough, together with the weight of accumulated fluid — pulsion 
 dilolation; and (b) traction upon the wall of bronchi in the case of pleural 
 adhesions and hyperplasia of the connective-tissue framework of the lung 
 as in pulmonary cirrhosis — tension dilatation. 
 
 Symptoms. — In large dilatations the cough and expectoration are 
 characteristic. After several hours, usually twenty-four, during which 
 cough has been slight or absent altogether, a violent and prolonged par- 
 oxysm will occur with profuse expectoration. The attack commonly 
 comes on in the morning and often follows a change in posture. The 
 expectoration, which varies in dail}^ quantity from 250 to 750 c.c. and 
 may reach a litre, is often brought up in repeated mouthfuls. This phenom- 
 enon is due to the fact that the altered mucosa of the cavity does not 
 react to the gradually accumulating secretion. When, by reason of the 
 amount or upon change in position, there is an overflow into the communi- 
 cating bronchus, the cough reflex is immediately excited and the parox- 
 ysm continues until the accumulation is expectorated. The sputum (see 
 page 458). Haemoptysis is common, usually slight, occasionally severe. 
 Dyspnoea and cyanosis upon exertion are common. Metastatic abscess 
 of the brain and septic phenomena occasionally occur. As a rule, how- 
 ever, the condition runs a chronic course, with clubbing of the finger- 
 tips and incurvation of the nails, — drumstick fingers, — and in some cases 
 a fair degree of health. 
 
 Physical Signs. — The physical signs in limited bronchiectasis, and 
 in the acute and chronic forms of bronchiectasis, are not characteristic. 
 When the dilatations ai'e sufficiently large and superficially situated 
 they yield upon examination and often in an exquisite manner tympanitic 
 or amphoric resonance, the cracked-pot sound, Wintrich's phenomenon, 
 and an intensification of the vocal fremitus over the affected area. Whisper- 
 ing pectoriloquy may be present. There are circumscribed flattening 
 over the bronchiectatic cavity and diminished respiratory excursus upon 
 the affected side. 
 
 Diagnosis. — Direct. — The diagnosis rests upon the history of a chronic 
 pulmonary affection; the signs of a large unilateral cavity, which are 
 gradually effaced as the secretion reaccumulates, and suddenly reappear 
 after several spells of coughing in which large quantities of sputum are 
 ejected; circumscribed flattening; and limited respiratory movement 
 upon the affected side. There are cases in which, with the distinctive 
 cough and expectoration, the dilatation cannot be located by the physical 
 signs or the X-rays, and others in which, with excessive sputum, only 
 diffuse dilatations of moderate size have been found after death. 
 
 Differential. — Vomicce. — The anamnesis is suggestive. In favor 
 of the phthisical origin of the cavity are its location in the upper lobe, 
 especially if the opposite apex or the apex of the lower lobe upon the same 
 side shows signs of consolidation, and sputum that is nummular, oP; if 
 
TRACHEOBRONCHIAL STENOSIS. 1057 
 
 fluid, expectorated at relatively short intervals and in smaller amounts, 
 and containing pulmonary elastic fibres. If tubercle bacilli are present 
 the diagnosis of phthisis is positive. The frequent association of phthisical 
 cavities with bronchiectasis must be borne in mind. 
 
 Circumscribed pyopneumothorax with bronchopulmonary fistula, 
 pulmonary abscess, pulmonary gangrene, and putrid bronchitis present 
 points of resemblance to bronchiectasis so close that, in some instances, 
 the differential diagnosis may be extremely difficult. The anamnesis is 
 important. In pyopneumothorax there is the history of the initial sudden 
 discharge of considerable quantities of purulent sputum; in abscess and 
 gangrene a history of sudden development and rapid course; in puti'id bron- 
 chitis a history of chronic bronchitis without special unilateral locahzation. 
 Bronchiectasis is invariably a secondary affection of gradual development, 
 and more frequently situated centrally than at the periphery of the lung. 
 
 Prognosis. — The cavities tend to enlarge. When a single large cavity 
 can be located and treated by drainage and other appropriate surgical 
 measures, the expectation of relief may be entertained. 
 
 iii. Tracheobronchial Stenosis. 
 
 Definition. — Narrowing of the lumen of the trachea or bronchial tubes. 
 
 Etiology. — The lumen of the tracheobronchial tree may be narrowed 
 above the bifurcation by the pressure of goitre, oesophageal or mediastinal 
 tumors, and aortic aneurism; both above and below the bifurcation by 
 enlarged tracheobronchial glands and neoplasms, especially carcinoma; 
 and below it by pericardial effusion and enlarged bronchial glands. It is 
 also narrowed by conditions which arise within the lumen of the trachea 
 or bronchi, among the most important of which are the following: polypi 
 and other new growths; acute oedema of the tracheobronchial mucous 
 membrane, such as results from the inhalation of irritating fumes, inflam- 
 matory thickening of the mucous membrane; croupous exudates, as in 
 infralaryngeal diphtheria and in fibrinous bronchitis; cicatrices, especially 
 in syphilis; exuberant granulations from the irritation of a tracheotomy 
 tube and foreign bodies. 
 
 Symptoms. — The symptoms differ in intensity, according to the 
 extent of the obstruction and the rapidity with which it comes on. They 
 are more urgent when the stenosis is sudden and when it is tracheal. They 
 consist of inspiratory dyspnoea, suffocative phenomena, anxiety, restless- 
 ness, cyanosis, a tense, full, and slow pulse with inspiratory intermission, 
 and, after a time, venous engorgement, dilatation of the right heart, visceral 
 congestions, and diminution or complete suppression of urine. 
 
 Physical Signs. — The facies and attitude differ little from those of 
 laryngeal obstruction. There is inspiratory retraction of the supraclavicu- 
 lar and intercostal spaces and of the epigastrium. If the stenosis be tracheal 
 these signs are bilateral; if it involve a main bronchus they are more pro- 
 nounced upon the affected side. Percussion yields hyperresonance with 
 a slightly tympanitic quality. The absence of dulness excludes all con- 
 ditions of inflammatory exudate, consolidation of the lung, pleural effu- 
 sion, or new growth as the cause of the dyspna^a. The vesicular murmur 
 
 67 
 
1058 MEDICAL DIAGNOSIS. 
 
 is enfeebled or quite inaudible; bronchial breathing is absent; coarse 
 dry or moist rales, often heard at a distance, decrease of vocal fremitus, 
 and a faint or whispering voice are important phenomena of stenosis. 
 
 Diagnosis. — The differential diagnosis between laryngeal and tracheo- 
 bronchial stenosis is of the highest practical importance. Among the 
 symptoms which point to the larynx as the site of the obstruction are the 
 abnormally increased respiratory movements of the larynx, the fixed 
 attitude with the head somewhat thrown back, and the peculiar croupy, 
 metallic quality in the respiration and cough — laryngeal cough. The 
 question, however, is immediately settled by an examination with the 
 laryngoscope. 
 
 Causal Diagnosis. — The examination of the trachea with the larjmgo- 
 scope, when practicable, will determine the presence or absence of stenosis 
 in that organ, and, when present, its nature. But there are often difficulties 
 in the examination which are insurmountable. Goitre is manifest; tumor 
 of the oesophagus is associated with dysphagia; mediastinal new growths 
 and aneurism of the arch of the aorta are attended in common by signs 
 of tumor, with displacement of the anterior border of the lung and venous 
 obstruction, and separately by signs which, in the case of aneurism 
 when present, are distinctive, as thrill, diastolic shock, and systolic pulsa- 
 tion. The presence of enlarged bronchial glands may be suspected when 
 tuberculous lymph-nodes are elsewhere present. Malignant disease may 
 be suspected when there are intermittent hemorrhagic sputum, enlarged 
 lymphatics in the neck or axilla, and an otherwise inexplicable cachexia. 
 A history of syphilis and specific lesions of the palate or larynx would 
 lend importance to the assumption of cicatricial stenosis. The recurrence 
 of attacks of fibrinous bronchitis with the expectoration of characteristic 
 casts renders the diagnosis positive. Foreign bodies are easy of diagnosis. 
 There is almost always a history, though under most unusual circumstances 
 or in the case of the insane no history can be obtained. A fixed attitude, 
 sudden attacks of suffocation, and the result of X-ray examination in the 
 case of metallic and certain other substances are of diagnostic importance. 
 
 Prognosis. — In tracheobronchial stenosis the prognosis is as variable 
 as the cause. 
 
 iv. Bronchial Asthma. 
 
 Nervous Asthma. 
 
 Definition. — A neurosis characterized by paroxysmal dyspnoea, a sense 
 of constriction of the chest, and irregular recurrence. The symptoms and 
 signs denote hypersemia and swelling of the mucous membrane of the finer 
 bronchial tubes, and the attack may be produced by direct or reflex irritation. 
 
 Asthma is not to be confounded with the dyspnoea of cardiac or renal 
 disease, or that supervening upon exertion in emphysema and other chronic 
 affections of the lungs and pleurae. 
 
 Three principal hypotheses are advanced: (1) that the attack is 
 due to spasm of the bronchial muscles; (2) that it is the result of hyper- 
 semia and turgescence of the bronchial mucosa; (3) that it is caused by a 
 peculiar inflammation of the bronchioles. It is probable that all three 
 
BRONCHIAL ASTHMA. 1059 
 
 of these conditions — namely, swelling, spasm, and exudate^nre present at 
 the same time. Other views of less importance attribute the affection to 
 spasm of the diaphragm or of all the inspiratory muscles. It has been 
 suggested that the condition is similar to that in hay fever, with special 
 manifestations due to differences in the anatomical site of the lesions. 
 The sudden onset of the symptoms, the common association of asthma and 
 hay fever, and the neurotic constitution of the subjects of these affections 
 lend probability to this opinion. 
 
 Etiology. — Predisposing Influences. — The neurotic temperament, 
 which is transmitted from generation to generation, frequently carries 
 with it the tendency to asthma. Asthma and epilepsy are sometimes 
 associated. Males are more liable to the affection than females. Age 
 plays an important part in the predisposition. Asthma usually begins 
 early in life, often in childhood, and may continue throughout life. Pertussis 
 is sometimes followed by asthma, and chronic bronchial catarrh is often 
 accompanied by the attacks. These attacks are sharply differentiated 
 from the dyspnoea which attends exertion, from which they are to be 
 distinguished. Idiosyncrasy is important. The odors of certain plants 
 or flowers, hay, artificial perfumes, ipecaciianha, and the emanations 
 from animals, as the horse or cat. immediately cause the attack in certain 
 persons. Violent emotions, especially if disagreeable, may act in the same 
 way. Excesses at the table and certain articles of diet may be followed 
 by the outbreak. Many persons remain free from the disease in the city, 
 but at once suffer in the country or in some particular part of the country, 
 or suffer in the city, but miss the attacks in the country or at the sea-shore. 
 Others cannot use a feather pillow or sleep in a particular room. The 
 most common source of reflex irritation is to be found in the mucosa of 
 the upper respiratory tract. Forms of rhinitis, nasal polypi, hypertrophies 
 of the inferior turbinated bones, enlarged tonsils, or adenoid vegetations 
 are frequently present in asthmatics and relief very often follows their 
 proper surgical treatment. The causal influence of uterine and ovarian 
 disease is much less than at one time supposed. In old cases every " cold" 
 may be attended with the paroxysm. 
 
 Symptoms. — The health is often excellent in the intervals between 
 the attacks. The onset is sometimes preceded by prodromes, among which 
 are chilliness, oppression in breathing, dyspeptic phenomena, vesical 
 irritability, and mental depression. The attack mostly comes on at night, 
 the patient waking from sleep with distressing difficulty in breathing, and 
 oppression. There rapidly develops a paroxysm of the most urgent 
 dyspnoea. Inspiration and expiration are both affected. The patient 
 struggles for air. The respiratory muscles, and especially those which 
 aid in expiratory efforts, are brought into forcible action. The abdominal 
 muscles are tense and board-like. The expiration is prolonged. The 
 face is pale, the expression anxious, and the patient refuses to talk. He 
 may rush to the open window and gasp for air, with his arms fixed upon 
 the framie. Small quantities of high-colored urine are passed at short 
 intervals. There is a short, dry cough, with a peculiar, scanty, viscid 
 expectoration. The duration of the attack varies from a bad qu.arter of 
 an hour to half a day or longer. There are cases in which, with remissions 
 
1060 MEDICAL DIAGNOSIS. 
 
 and exacerbations; the symptoms last for thirty-six or forty-eight hours. 
 In severe paroxysms air hunger becomes urgent; restlessness, pallor, and 
 cyanosis are accompanied by sweating, cold extremities, and a small, 
 quick pulse. The intensity of the symptoms now abates; the cough be- 
 comes loose, the expectoration fluid and free, large quantities of urine may 
 be passed, and in a short time there is complete relief. The patient now 
 usually falls asleep. He may awake quite well or one or more further 
 attacks may follow. Urticaria and in rare instances angioneurotic oedema 
 have been observed during the attack. The sputum in the beginning of 
 the attack contains Curschmann's spirals, Charcot-Leyden crystals, together 
 with many leucocytes, mostly eosinophiles. 
 
 Physical Signs. — Inspection. — The chest has the inspiratory form. 
 It appears large and suggests emphysema. The condition is, in fact, an 
 acute emphysema, such as occurs also in pertussis. Under these circum- 
 stances the residual air is increased and the tidal air diminished, and in 
 proportion as the ratio between them is deranged the chest becomes fixed 
 and the dyspnoea urgent. The short, quick inspiration and the prolonged 
 expiration are of diagnostic importance. Percussion. — In mild attacks 
 the signs upon percussion are little modified, the change amounting simply 
 to a moderate hyperresonance, but in severe attacks the percussidn 
 sound is vesiculotympanitic. The pulmonary resonance extends down- 
 ward two or three interspaces or more, the superficial cardiac dulness 
 is much diminished, and the margins of the overdistended lungs 
 scarcely change their position with the respiratory movements. Aus- 
 cultation. — The vesicular murmur is enfeebled. Great numbers of sibi- 
 lant and sonorous rales are heard in all parts of the chest, and often from 
 every part of the room. These rales constantly change in quality, pitch, 
 and loudness, and are much more prolonged and intense upon inspiration 
 than upon expiration. With free expectoration the rales become moist. 
 The attacks recur at varying intervals. They sometimes come on in a 
 series of three or four at night, with catarrhal symptoms in the daytime. 
 
 Diagnosis. — Direct. — The clinical picture is distinctive. Among 
 the important criteria are sudden onset, mostly at night; expiratory 
 dyspnoea; acute overdistention of the thorax as shown by the physical 
 signs upon inspection and percussion; scanty expectoration with Cursch- 
 mann's spirals and Charcot-Leyden crystals; loud wheezing and groaning 
 rales; later abundant expectoration, with moist rales and relief of 
 dyspnoea; eosinophilia. 
 
 Differential. — Emphysema and Chronic Bronchitis. — The associa- 
 tion of emphysema and bronchial asthma is a double one. The asthmatic 
 tends to become emphysematous on the one hand, while, upon the other, 
 attacks of asthma are common in emphysema. The obvious relationship 
 between these conditions and chronic bronchitis has alread}'' been indicated. 
 Spasm of the Glottis. — There may be true spasm, as in the laryngeal crisis 
 of tabes. The dyspnoea is inspiratory and noisy, the respiratory move- 
 ments of the larynx are extensive. The lungs are not overdistended, 
 there is inspiratory retraction of the epigastric zone, and the peculiar 
 cough, rales, and expectoration of asthma are not present. Adductor 
 spasm is of short duration, while the paroxysm of asthma is often pro- 
 
CIRCULATORY DERANGEMENTS. 1061 
 
 longed. Laryngismus Stridulus. — This form of adductor spasm of children 
 is characterized by apncea. followed upon relaxation by a long-drawn inspi- 
 ratory crowing sound. Cardiac and Renal Dyspncea. — So-called cardiac 
 and renal asthma have nothing in common with true asthma except dys- 
 pnoea. To call them asthma is a nosological error alike inconvenient to 
 the teacher and misleading to the student. 
 
 Prognosis. — The symptoms are often alarming, but death does not 
 occur during the attack. The removal of the sources of reflex irritation 
 in the upper air-passages, improvement in the general condition of the 
 patient, or permanent residence in a suitable climate is often followed 
 by lasting relief. 
 
 IV. DISEASES OF THE PULMONARY TISSUE, 
 i. Circulatory Derangements. 
 
 (a) Pulmonary Congestion. — Congestion of the lungs is usually a 
 symptomatic affection. There are two forms — active and passive. 
 
 1. Active Congestion of the Lungs. — The inhalation of overheated 
 air, smoke, and other irritating substances, and overaction of the heart 
 may cause this condition. The sudden death of firemen, open-air orators, 
 and drunkards after exposure has been ascribed to it. The symptoms 
 comprise great dyspnoea, oppression, feeble pulse, and cyanosis. The 
 physical signs are restricted respiratory movements, impaired resonance, 
 faint vesicular murmur, and fine rales. The mechanical interference with 
 the circulation in pneumonia, intense bronchitis, pleurisy, and tuberculosis 
 leads to overdistention of the capillaries in the adjacent lung tissue — 
 collateral fluxion. The importance of this condition arises chiefly from 
 the danger of oedema. 
 
 2. Passive Congestion. — Two forms are recognized — mechanical and 
 hypostatic. Mechanical Congestion. — The condition is most marked in 
 the dependent portion of the lungs. The essential factor is an obstacle to 
 the return of the blood to the left ventricle. Its occurrence is favored by 
 all conditions which restrict the respiratory expansion and contraction of 
 the lungs and thus interfere with the normal movement of the blood current 
 in the pulmonary vessels. Mechanical congestion of the lungs occurs in 
 mitral stenosis and incompetency, emphysema, and in consequence of the 
 pressure of tumors. The lung undergoes the changes known as brown 
 induration. So long as compensation is maintained this condition is not 
 marked by special symptoms of importance. When it is lost, dyspnoea, 
 cough, and expectoration, often blood-stained and containing alveolar cells 
 with blood pigment, occur. Hypostatic Congestion. — The bases in this 
 condition also are engorged with blood and serum. The condition is bi- 
 lateral, one side being usually more deeply and more extensively congested 
 than the other. Lobular patches may be airless, and bits of the alTected 
 tissue may sink in water. To this extreme condition are applied the terms 
 splenization and hypostatic pneumonia. In fact there are frequently pres- 
 ent in the congested regions foci of bronchopneumonia. Hypostatic conges- 
 tion is common in protracted acute illness, as enteric fever; in chronic wast- 
 
1062 MEDICAL DIAGNOSIS. 
 
 ing diseases, as tuberculosis and cancer; in injury and disease of the brain, 
 especially apoplexy, and in prolonged coma. There are no characteristic 
 symptoms and the diagnosis rests upon the presence, over the lower lobes 
 posteriorly, of impaired resonance, feeble respiratory sounds, patches of 
 bronchovesicular breathing, and small mucous or subcrepitant rales. 
 
 (b) Pulmonary CEdema. — There are two forms of oedema of the 
 lungs — general and collateral. 
 
 The termination of intense congestion of the lungs is, in many cases, 
 the transudation of blood-serum from the overdistended capillary vessels 
 into the vesicles themselves and their walls. The escape of serum into the 
 small and later into larger bronchi follows and is of clinical importance. 
 Pathologically the condition is one of serous infiltration of the pulmonary 
 tissue, with accumulation in the air-cells and bronchi. The cedematous 
 lung is heavy, pits on pressure, and exudes abundantly from the cut surface 
 clear or blood-tinged serum. 
 
 1. General (Edema. — (Edema from Engorgement; Stasis (Edema. — The 
 oedema is bilateral and involves the whole of both lungs. The bases are 
 especially affected. Causal factors are overdistention of the capillary 
 vessels, hydraemia which leads to nutritive changes in the walls of the 
 vessels and a weakened left ventricle. The condition is very often a termi- 
 nal one and accompanies the death agony. It is common in affections 
 characterized by dropsies, as fatal anaemias, disease of the heart and 
 kidneys, especially the cardiorenal affection, and cachexias generally. It 
 occurs also without previous dropsy in cerebral diseases, acute pulmonary 
 congestion, and angina pectoris. General oedema of the uninvolved 
 portions of the lungs may occur in the stadium ultimum of croupous 
 pneumonia. 
 
 2. Collateral (Edema. — Local (Edema of the Lungs. — This condition is 
 the outcome of the collateral fluxion in the pulmonary tissue bordering on 
 pneumonias, infarcts, active foci of tuberculous inflammation, or new 
 growths. The cut surface exudes a bloody serum. The entire lung is not 
 involved and the opposite lung may wholly escape. This constitutes the 
 form known as inflammatory oedema. 
 
 Symptoms. — Pulmonary oedema may develop gradually or with great 
 suddenness. The symptoms of the pre-existing malady are aggravated. 
 Progressive dyspnoea, cough, copious, frothy, thin, fluid sputum which, in 
 the case of collateral oedema, is often bloody, characterize the condition 
 (see Part III, page 458). As it progresses cyanosis and the stupor and 
 convulsive tremblings which indicate the action of carbon dioxide upon 
 the n.ervous system occur. Fever does not usually accompany stasis 
 oedema, but in inflammatory oedema there may be a rise in temperature. 
 
 Physical Signs. — The percussion resonance is usually somewhat 
 impaired over the bases posteriorly and has the tympanitic quality. In 
 very abundant serous transudation there may be dulness. Upon auscul- 
 tation the respiratory murmur is enfeebled, and over the whole extent 
 of the involved lung tissue are heard moist bronchial subcrepitant and 
 crepitant rales. Vesiculobronchial or pure bronchial breathing may be 
 heard in hmited areas at the bases in intense oedema, and corresponds to 
 the areas of dulness. 
 
CIRCULATORY DERANGEMENTS. 1063 
 
 Diagnosis. — Direct. — The diagnosis of general oedema of the lungs 
 rests upon the occurrence of the above described symptoms in cases of 
 oedematous or cachectic disease, cerebral disease or injury, angina pectoris, 
 and impairment of the power of the left ventricle, especially when the 
 power of the right heart is fairly well maintained. Collateral oedema may 
 be at least provisionally diagnosticated when, in pneumonia or other 
 inflammatory conditions, infarct, active circumscribed tuberculosis, or 
 new growths, the symptoms are aggravated, the temperature rises, many 
 moist rales are heard in the adjacent lung, and there is an abundant thin, 
 blood-stained sputum. In rare instances acute oedema of the lungs follows 
 the withdrawal of a pleural effusion by aspiration. The sputum is copious 
 and has the characters above described. It is the result of the sudden 
 removal of pressure upon the pulmonary vessels. Even more rare is the 
 perforation of the lung by a serous pleural effusion. There are coarse 
 rales usually confined to the affected side, and an abundant expectoration 
 presenting the characters of the sputum in oedema but with a larger 
 albumin content. 
 
 Prognosis. — General oedema of the lungs is frequently one of the 
 manifestations of dissolution. There are, however, cases that recover 
 under proper treatment. The outlook is at the best uncertain. Collateral 
 oedema may mark an unfavorable turn in an acute illness or, as is fre- 
 quently the case, subside under energetic management and be the point of 
 departure for lasting improvement. 
 
 (c) Pulmonary Hemorrhage. — There are two forms. In the first 
 the blood escapes into the bronchi and is expectorated — bronchopulmonary 
 hemorrhage; in the second the blood is effused into the tissue of the lungs 
 and air-cells — pulmonary apoplexy, hemorrhagic infarct. 
 
 1. Bronchopulmonary Hemorrhage. — Bronchorrhagia; Hoemoptysis. (See 
 Part III, page 458.) 
 
 2. Pulmonary Apoplexy. — Pneumorrhagia; Infarct. — Anatomically two 
 conditions are encountered: diffuse infiltration and hemorrhagic infarct. 
 
 Diffuse Hemorrhagic Infiltration of the Lungs. — The lung tissue and 
 air-cells are densely and uniformly infiltrated with extravasated blood. 
 The cut surface presents a smooth, somewhat gelatinous appearance and 
 a blackish color. The condition is rare. It occurs more frequently in the 
 hemorrhagic fevers, less often in sepsis and acute cerebral disease. The 
 symptoms are dyspnoea, cyanosis, bloody sputum, blackish in color, and 
 the nervous phenomena of collapse. Resonance is impaired. This form 
 of hemorrhage is of no great diagnostic importance, since it constitutes 
 the terminal event in an otherwise fatal malady. 
 
 Hemorrhagic Infarct. — The extravasation of blood is due to the arrest of 
 circulation in a branch of the pulmonary artery by an embolus or thrombus. 
 The anatomical condition and the symptoms differ greatly according to 
 the location of the occlusion. If it occiirs in the trunk or a main branch 
 of the pulmonary artery, the whole or a large part of the blood is i)revented 
 from entering the pulmonary circuit, and there is dilatation of the right 
 heart, a small, thready, arterial pulse, intense dyspnoea, cyanosis, and 
 death from apna^a — pulmonary apoplexy. As the clinical manifestations 
 from cardiac paralysis are the same the diagnosis remains an uncertain one. 
 
1064 MEDICAL DIAGNOSIS. 
 
 When the obstruction takes place in a smaller branch of the pulmo- 
 nary artery infarction usually occurs. These lesions are commonly at the 
 periphery of the lung, and wedge-shaped, with the base resting upon the 
 pleura, which is inflamed. Exceptionally they are located within the 
 tissue of the lung and they are then irregularly oblong. Recent infarcts 
 present the appearance of a blood-clot in the pulmonary tissue. The 
 air-cells and their walls and the capillaries are packed with red blood- 
 corpuscles. Infarcts are commonly multiple, exceptionally single. They 
 vary in size from a pigeon's egg upward and may occupy a large portion 
 of a lobe. In the arterial branch of supply may commonly be fovmd the 
 embolus or thrombus in the neighborhood of the apex. These obstructions, 
 notwithstanding the fact that the pulmonary arteries are terminal, do not 
 always cause infarction, owing to the width and free anastomosis of the 
 capillaries and the ability of the bronchial vessels to maintain the circula- 
 tion. The changes in the infarct are similar to those in blood-clots in other 
 situations. The color becomes reddish-brown; the tissues contract, and 
 are finally converted into a puckered, pigmented, fibroid nodule. The 
 source of the embolus is to be sought in the right heart or peripheral venous 
 system. The white thrombi which form in the right auricular appendix,, 
 the vegetations which develop upon the tricuspid leaflets in the rare cases- 
 of right-sided endocarditis, fibrin formations among the columnar carnese 
 may be swept by the venous blood stream into the ramification of the pul- 
 monary arter}^ and become lodged. Any condition which tends to weaken 
 the action of the right ventricle predisposes to this accident. Among 
 these are valvular disease, especially mitral affections and myocardial 
 degenerations. These emboli are not usually septic. Emboli from inflam- 
 matory or suppurating foci in various regions are infected and cause not 
 a simple infarct but a metastatic abscess. When the general condition 
 is septic, numerous small suppurating foci develop in the lung — pycemic 
 abscesses. These cannot always be recognized during life. When, however, 
 a more extensive portion of the lung undergoes septic infarction pulmonary 
 abscess results. 
 
 Symptoms. — The symptoms are neither constant nor distinctive. 
 An initial chill may occur. It is, however, never so severe or prolonged as 
 the ordinary chill of croupous pneumonia. Cyanosis, increased respira- 
 tory frequency, and dyspnoea at once develop. These symptoms vary 
 in proportion to the number, and especially the size, of the infarctions. 
 They may be slight or altogether absent. There is cough and the sputurp 
 contains blood (see Part III, page 459). 
 
 Physical Signs. — There is circumscribed dulness, more commonly 
 in the lower lobes, especially on the right side, with bronchial breathing 
 and high-pitched small mucous rales. Pleural friction over a limited 
 area may very often be demonstrated. 
 
 Diagnosis. ^ — Direct. — The diagnosis cannot always be made with 
 certainty. The sudden occurrence of the above rational symptoms and 
 physical signs in the course of chronic disease of the heart, or thrombosis 
 of a crural or other vein, or some distant inflammatory or suppurative 
 process warrants a provisional diagnosis. 
 
CIRCULATORY DERANGEMENTS. 1065 
 
 Differential. — Croupous Pneumonia. — There is a superficial resem- 
 blance in some of the cases; but the situation and outlme of the consolida- 
 tion, the character of the sputum in which the blood or haemoglobin is 
 more intimately mixed than in infarction, and the results of the laboratory- 
 examination of the sputum, which contains pneumococci, are distinctive. 
 HcEmoptysis in Mitral Disease, especially Mitral Stenosis. — The occurrence 
 of blood spitting, usually in small amounts and extending over a period 
 of days or weeks, may suggest infarction. The differential diagnosis in 
 the absence of physical signs or marked pulmonary symptoms is impos- 
 sible. The blood may be due to engorgement of the pulmonary vessels. 
 Its recurrence after exertion and at long intervals is in favor of the latter 
 view. Malignant Disease of the Lung. — Blood spitting and signs of con- 
 solidation are present in both conditions. Pain, wasting, localizing physical 
 signs, which gradually include more territory, cachexia, the presence of 
 new growths elsewhere, and in particular of pigmented nsevi or warts, 
 with secondary nodules in the skin or subcutaneous tissues, implication 
 of the lymph-nodes, or a history of the removal of a malignant growth, 
 justify a provisional, and in well-marked cases a positive, diagnosis of 
 cancer or sarcoma of the lung. 
 
 Air Embolism; Fat Embolism. — An embolus is any body transported 
 by the circulating blood and capable, when arrested by the narrowness 
 of the vessel, of obstructing the circulation. Emboli are usually too large 
 to pass through the capillaries. They may be composed of fibrin masses, 
 fragments of thrombi, vegetations or calcareous particles from endocardial 
 vegetations, or fragments of neoplasms, which have penetrated the wall 
 of a vessel. They may be infected or non-infected. There are two sub- 
 stances, differing from ordinary emboli in not consisting of solid bodies, 
 which may give rise to urgent or fatal consequences when arrested in the 
 capillaries of the pulmonary circulation; these are air and fat. 
 
 Etiology. — Air embolism occurs under certain circumstances when 
 a vein is lacerated. Fat or oil embolism may follow fracture or injury to 
 a bone, with escape of marrow into the tissues, or extensive laceration of 
 adipose tissue, or its rapid breaking down in suppurative processes. 
 
 Symptoms. — The symptoms of air embolism are urgent or even fatal 
 in cases in which the quantity of air is sufficient to form large numbers of 
 bubbles which cannot pass the pulmonary capillaries — an embolic shower. 
 They consist of an extreme degree of air hunger, loss of consciousness, 
 convulsions, and collapse, and usually prove fatal in a brief period, some- 
 times instantly. In rare cases, however, these most alarming manifesta- 
 tions improve in consequence of the rapid absorption of the air. and prompt 
 recovery takes place — a fortunate event not seen Avhen multiple embolism, 
 the embolic shower, is due to solid emboli. When the air bubble entering 
 the vein is small or the air enters slowly the symptoms are commonly less 
 urgent. No symptoms attend the presence of the most minute air bubbles 
 which, having passed the wider pulmonary capillaries, are arrested in the 
 capillaries of other organs. 
 
 Since the fat globules obstruct only the finest vessels in the lungs 
 and only gradually enter the circulation, the sudden pulmonary symptoms 
 seen in air embolism rarely present themselves. As a rule no symptoms 
 
1066 MEDICAL DIAGNOSIS. 
 
 occur until some hours or days have elapsed from the time of the injury. 
 Severe dyspnoea, oedema of the lungs, great depression, and coma may 
 occur. As the fat emboli have no tendency to cause blood coagulation 
 or thrombosis, they are gradually forced on under the pressure of the 
 blood stream, or undergo resorption, and recovery takes place. The fat 
 particles which pass the lungs may reach the cerebral capillaries or be 
 arrested in the renal glomeruli. In the latter case they may be voided in 
 the urine. Death is uncommon in fat embolism. 
 
 ii. Diseases Characterized by Changes in the Vesicular 
 Structure of the Lungs. 
 
 (a) PULMONARY EMPHYSEMA. 
 
 Vesicular Emphysema; Substantive Emphysema; Pseudohypertrophic 
 
 Emphysema. 
 
 Definition. — A chronic disease of the lungs, in which the infundibula 
 and vesicles are dilated and their walls atrophied. 
 
 This is a v/ell-defined clinical affection, and characterized by enlarge- 
 ment of the lungs, changes in the contour of the chest, incomplete aeration 
 of the blood, and varying degrees of dyspnoea, especially upon exertion. 
 It is to be distinguished from acute vesicular emphysema, compensatory 
 emphysema, and interstitial and atrophic forms. 
 
 Etiology. — Heredity constitutes an important predisposing influence. 
 The disease is frequently encountered in successive generations or in several 
 members of a family, and is not uncommon in childhood. It has been 
 ascribed to congenital defects in the development of the elastic fibres. 
 Long-continued habitual intra-alveolar pressure, acting upon a congenitally 
 defective alveolar structure, causes distention which tends to become per- 
 manent. The hyperinflation of the lungs which occurs in the paroxysms of 
 whooping-cough and asthma is often the starting-point of emphysema. 
 Repeated attacks of bronchitis or chronic bronchitis are often present. It 
 is common also in players upon wind instruments, glass-blowers, and 
 those whose work demands heavy lifting or prolonged muscular strain. 
 The tension under these circumstances is expiratory. In violent attacks of 
 cough and in straining, the glottis is closed and the intrathoracic tension 
 greatly heightened. The parts of the lungs least supported by the chest 
 wall, namely, the apices and anterior and inferior margins, show the most 
 developed lesions of emphysema. 
 
 Anatomically the primary changes are in the lungs; the secondary 
 changes in the wall of the thorax. 
 
 The lungs are voluminous, their margins meeting in the anterior 
 mediastinum and extending downward to the extent of two fingers' 
 breadth or more. The diaphragm is correspondingly displaced in a down- 
 ward direction. They have lost their normal contractilitj^ and do not 
 retract when the costal pleura is incised nor when withdrawn from the 
 chest and laid upon the table. At the apices and borders there are seen 
 beneath the pleura greatly distended air-vesicles, varying in diameter from 
 
PULMONARY EMPHYSEMA. 1067 
 
 1 to 3 mm., and sometimes attaining the size of a pigeon's egg. There 
 is marked diminution in the pigment usually found in the subpleural 
 lymph-spaces. The atrophy of the distended vesicular walls leads to loss 
 of their pumping function and permanent pressure upon the capillaries, 
 and this to diminution in the intervesicular vascular suppl3\ The infun- 
 dibula are dilated, but bronchiectasis is not very common. The chambers 
 of the right heart are dilated and hypertrophied. The pulmonary artery 
 is in some instances dilated and atheromatous. 
 
 The chest permanently assumes the inspiratory form and the costal 
 cartilages progressively undergo calcification and lose their elasticity. 
 
 Symptoms. — The derangement of function is twofold. First, the 
 residual air is greatly increased and the tidal air correspondingly decreased 
 in volume, and second, the pulmonary circulation is diminished. If these 
 facts are borne in mind the significance of the symptoms is obvious. The 
 lesions are gradually developed and it is only after they have made some 
 progress that the characteristic symptoms and signs occur. At first there 
 is merely dyspnoea and faint lividity upon exertion, and the chest merely 
 looks full with the inspiratory contour. When the disease is fully developed 
 the following symptoms are present: Dyspnoea. — The elasticity of the 
 vesicular structure being to a great extent impaired, expiration is pro- 
 longed and difficult. The dyspnoea is chiefly expiratory. The loss of resili- 
 ency in the costal cartilages, the permanent maximum distention of the 
 thorax, and the restricted play of the diaphragm render inspiration also 
 difficult, even with the aid of the auxiliary muscles of respiration. The 
 dyspnoea may be felt upon slight exertion or it may be continuous. It 
 is increased upon the occurrence of the exacerbations of bronchitis, to 
 which the patient suffering from emphysema is so liable. The breathing 
 is puffy and wheezy. Asthmatic Attacks. — The dyspnoea under certain 
 circumstances, and especially after ''taking cold," often assumes a paroxys- 
 mal intensity, differing in no respect from true spasmodic asthma. Cough 
 is a common symptom. It is due to the associated bronchitis. It is com- 
 monly wheezy and feebly explosive, and without much expectoration. 
 It is usually less troublesome in warm, dry weather, and constitutes the 
 recurrent winter cough of many elderly persons. Cyanosis. — The patients 
 are frequently able to go about with lividity of high grade. This symptom 
 is variable and may amount merely to a certain blueness of the lips and 
 finger-nails while the patient is at rest. 
 
 Intermittent Cervical Hernia of the Lung of Spontaneous Origin. — 
 C. B. Farr has reported a case of this kind and collected seven other 
 instances from the literature. As a rule the condition accompanied 
 chronic bronchitis with emphysema. It was unilateral in five cases 
 and bilateral in three. These protrusions are of the form and size of a 
 pear, with the base below and the apex extending upward. They 
 are not present upon quiet breathing but prominent during cough and 
 are the seat of a faint rustling murmur. They are resonant on percus- 
 sion and may be reduced by gentle taxis. In several of the cases a 
 hernial ring could be felt. They are to be differentiated from enlarge- 
 ments of the sinuses of the jugular veins, abscesses, and an empyema 
 which presents in the neck. 
 
1068 MEDICAL DIAGNOSIS. 
 
 Physical Signs.— Inspection. — In advanced cases the deformity of 
 the chest is typical. It is barrel-shaped (see p. 64). The elevation of the 
 sternum and ribs gives the neck a shortened appearance. The respiratory 
 movements appear forcible, but the thorax does not expand. Many 
 dilated superficial venules are seen along the line of attachment of the 
 diaphragm. The cardiac impulse is not visible. Epigastric pulsation 
 and dilated cervical veins, sometimes pulsating, are signs of a dilated and 
 overdistended right heart. The deformity of the chest is less marked in 
 those cases in which emphysema has commenced in advanced life at a 
 period when the cartilages have already become calcified. Palpation. — 
 The lack of respiratory excursus is very obvious upon palpation. The 
 vocal fremitus is enfeebled. The impulse of the heart cannot be located. 
 Ttiere is pulsation over the lower sternal and epigastric regions. Mensura- 
 tion. — The restricted expansion of the chest is confirmed by careful measure- 
 ment, and the rounded contour by the cyrtometer. Percussion. — The reso- 
 nance is of vesiculotympanitic quality, especially sonorous over the lateral 
 and posterior regions. The percussion sound has been compared with that 
 eHcited upon tapping a bandbox — Schachtelton. More important than the 
 quahty of the percussion sound are the borders of the expanded lungs which 
 it marks. They are extended in every direction and may reach in front 
 to the eighth rib and below it, behind to the level of the twelfth dorsal or 
 even the second lumbar vertebra. The cardiac dulness may be completely 
 obliterated. The hver and splenic dulness are much lowered. Auscultation. 
 — The vesicular murmur is greatly enfeebled. Its very faintness is sug- 
 gestive. The expiratory element is not often audible. Instead of it, how- 
 ever, there are many sibilant and wheezy rales. The sounds of the heart 
 are faint and distant, the pulmonary second sound is often accentuated, 
 and in advanced cases a tricuspid regurgitant murmur may be heard. 
 
 The effect of the lesions of emphysema upon the circulation is to 
 obstruct the pulmonary circuit; to dilate and enfeeble the right ventricle; 
 to diminish the arterial blood; and to increase the accumulation of venous 
 blood. The enfeeblement of the right heart is, however, delayed by com- 
 pensatory hypertrophy by which the circulatory faults are postponed. 
 Ultimately, however, compensation fails and the results of venous engorge- 
 ment become manifest. These are persistent cyanosis, pulsation in the 
 veins of the neck, hepatic enlargement, diminished secretion of albuminous 
 urino, oedema, anasarca and effusions into the great serous sacs, and 
 gastric and intestinal catarrh. When these conditions are present there 
 is almost always a compHcating catarrhal bronchitis, manifest by the 
 ordinary symptoms of cough and expectoration, the latter being usually 
 mucoid and viscid, sometimes purulent. The presence of blood is not 
 common and suggests either a compHcating tuberculosis or pulmonary 
 infarct. The general nutrition is impaired. 
 
 Diagnosis. — Direct. — In well-developed cases the condition may 
 be at once recognized by the contour and diminished mobility of the chest, 
 the dyspnoea and cyanotic lips, the spare frame, and a facies which is 
 very suggestive to those who have observed many cases. The physical 
 signs, and especially the displaced boundaries of the lungs as determined 
 by percussion, are confirmatory. 
 
PULMONARY EMPHYSEMA. 1069 
 
 Differential. — Acute Vesicular Emphysema; Acute Over-inflation 
 of the Lungs. — During the paroxysm of bronchial asthma and pertussis, 
 and in bronchitis of the smaller tubes, the lungs are frequently much 
 distended. The chest maintains the inspiratory form, and upon a single 
 examination the condition might be confounded with emphysema. The 
 anamnesis is important. The borders of the lung are enlarged, but not 
 beyond the limits of normal full-held inspiration, and in the course of a 
 little time after the termination of the primary disease they regain their 
 normal position upon inspiration and expiration. In congenital weakness 
 of the lung tissue such attacks may become the point of departure for 
 true emphysema. A similar condition occurs in cases of cardiac dyspnoea 
 and angina pectoris. The lungs are distended, their borders extended, 
 and the expiration is prolonged and accompanied by wheezing rales. 
 Compensatory Emphyserna; Vicarious Emphysema. — When local lesions 
 in the lung or pleura interfere with expansion upon inspiration, the unaf- 
 fected tissue takes upon itself increased functional activity — vicarious 
 respiration. This change may involve parts adjacent to the lesion, an adjoin- 
 ing lobe, or the opposite lung. It occurs in bronchopneumonia and around 
 tuberculous foci and cicatrices, the air-cells of the unaffected lobules under- 
 going a vicarious distention; in pulmonary cirrhosis, the unaffected lung 
 undergoing vicarious enlargement, and to a less extent in pleural adhesions 
 and effusions and in pneumothorax. This process, at first truly compen- 
 satory and physiological, becomes after a time pathological. The vesicular 
 walls and capillaries undergo atrophy; a circumscribed or partial emphy- 
 sema comes to pass. In bronchopneumonia or pulmonary tuberculosis 
 with scattered lobular lesions the distention of the adjacent air-cells masks 
 the dulness and may render the diagnosis obscure; in retracted and cir- 
 rhotic conditions of one lung, such as follow the resorption of the pleural 
 effusion, the borders of the opposite lung are much distended and may 
 be followed by careful percussion, not only in their inferior extent, but 
 also over the area of superficial cardiac dulness and beyond the median 
 line toward' the contracted side. Atrophic Emphysema; Atrophy of the 
 Lungs; Senile Emphysema. — This is a purely senile change and is occasion- 
 ally encountered in wizened old people with small, narrow chests which 
 are permanently in the expiratory form. The alveolar walls and inter- 
 alveolar capillaries are extensively atrophied, and the alveoli in places 
 converted into series of large communicating cells. The lungs themselves 
 are small and the thorax conforms to the changes in the contained organs. 
 It is flattened, the shoulders droop, the costal angle is acute, the neck 
 appears elongated. The diaphragm is high. The right heart does not 
 show dilatation and hypertrophy as in large-lunged emphysema, because 
 it also undergoes a corresponding senile involution. The respiratory 
 muscles are atrophic. Interstitial Emphysema. — Small bubbles of air 
 find their way into the interlobular and subpleural tissues. Their access 
 is by way of tracheotomy or other surgical or accidental wounds of the 
 neck or throat; less frequently through rupture of the alveolar walls by 
 violent coughing, contusions of the chest, or ulceration. When the opening 
 is near the root of the lung air may pass to the mediastinal connective 
 tissue. The condition is rare. Mediastinal emphysema may be diagnosti- 
 
1070 MEDICAL DIAGNOSIS. 
 
 cated when the causal factors are present together with crepitating sub- 
 cutaneous emphysema of the neck or chest, absence of cardiac dulness 
 and impulse, obliteration of the sternal ends of the intercostal spaces, 
 and upon auscultation a fine crepitus synchronous with the action of the 
 heart. The veins of the neck are distended. Subpleural and interlobular 
 emphysema not extending to the mediastinum does not usually present 
 positive diagnostic phenomena. Rupture of an air bleb in subpleural 
 emphysema may cause pneumothorax. 
 
 Prognosis. — Substantive emphysema is incurable, but much can be 
 done to relieve the sufferings of the patient and to prolong his life. Treat- 
 ment of the bronchitis, a favorable climate, and attention to the state of 
 the heart are important. Death usually occurs in consequence of some 
 intercurrent disease, as pneumonia or bronchopneumonia. 
 
 (b) PULMONARY ATELECTASIS. 
 
 Collapse of the Lung. 
 
 Definition. — An airless condition of lobules or parts of the lung, the 
 
 vesicles being in a state of collapse and not occupied by fluid or solid exudate 
 or other pathological products. It is congenital or acquired. 
 
 Congenital Atelectasis. — The lung is airless at birth, or remains 
 only partially expanded in consequence of deficient inspiratory efforts or 
 obstruction of the respiratory passages by meconium or mucus. The 
 respiration is feeble, ultimately gasping, shallow and rapid, the lower 
 part of the thorax and the epigastrium are retracted during inspiration, 
 there is universal deep, bluish-black cyanosis, together with muscular 
 twitchings or general shivering convulsions. 
 
 Acquired Atelectasis. — This is a secondary anatomical lesion. 
 It is caused in two ways: (a) by obstruction of small bronchi by mucus 
 or swelling of the mucosa — as in bronchopneumonia, the intra-alveolar 
 air undergoing resorption by the capillaries and the vesicles collapsing 
 by virtue of the elasticity of their walls; or (b) by pressure upon the 
 lung such as occurs in pleural or pericardial effusions, pneumothorax and 
 pneumopericardium, tumors of the lungs or pleura, mediastinal tumors 
 or massive enlargement of the heart, scoliosis, and abdominal disorders 
 which restrict the movements of the diaphragm, including persistent 
 meteorism, large ascites, and visceral and other tumors. Diffuse atelectasis 
 may arise in paretic conditions involving the muscles of respiration. 
 
 Symptoms. — The clinical phenomena vary according to the extent of 
 lung tissue involved. In slight cases they are not distinctive. There may 
 be moderate dyspnoea, cyanosis, a vesiculotympanitic percussion sound, 
 and enfeebled vesicular murmur. When extensive atelectasis is present, 
 especially if superficial, there are signs of consolidation, namely, dulness, 
 increased vocal fremitus, bronchial respiration, and bronchophony. If 
 there are in the affected region lobules which are incompletely collapsed, 
 the percussion sound has the tympanitic quality and there is persistent 
 fine crepitus. The clinical picture is usually, however, dominated by the 
 symptoms of the primary affection. A condition showing the above symp- 
 tom-complex which is transitory, that is, which passes off in the course of 
 twenty-four hours, is from this very fact almost sure to be due to atelectasis. 
 
BRONCHOPNEUMONIA. 1071 
 
 (c) BRONCHOPNEUMONIA^ 
 
 Lobular Pneumonia; Catarrhal Pneumonia; So-called Capillary Bronchitis. 
 
 Definition. — Inflammation of capillary or terminal bronchi and the 
 air-vesicles which constitute the corresponding pulmonary lobules. There 
 are several forms, all of which are caused by bacterial invasion of the lungs. 
 The disease may be primary or secondary and is characterized clinically 
 by symptoms of infection and interference with the respiratory function. 
 
 Etiology. — Predisposing Influences. — Bronchopneumonia is com- 
 mon at the extremes of life. In children the relatively small size of the 
 bronchi, their more abundant vascular supply, and the more rapid and 
 exuberant growth of the epithelium of the bronchial mucosa constitute 
 predisposing factors of great importance; while in the aged tissue relaxa- 
 tion, tendencies to passive congestion, and diminished reflex excitability 
 on the part of the bronchial mucous membrane act in the same way. Bron- 
 chopneumonia is more prevalent in the winter and spring than at other 
 seasons of the year. It is more common among the poorer classes. In 
 the great majority of the cases bronchopneumonia occurs as a secondary 
 or intercurrent process. There are two principal groups of cases: 1. Those 
 in which it arises in the course of simple bronchitis or an acute infectious 
 disease in which bronchitis forms part of the symptom-complex, as measles, 
 pertussis, diphtheria, scarlet fever, influenza, and less frequently the 
 variolous diseases, erysipelas, and enteric fever. It is a common complica- 
 tion of the acute intestinal diseases of infancy. Bronchopneumonia is a 
 grave complication in all these affections and constitutes the cause of 
 death in the majority of fatal cases. Its frequency corresponds closely 
 to their epidemic prevalence. It is far less common in the acute febrile 
 diseases of middle life. In the aged it is a common complication and fre- 
 quently forms the terminal event in various acute and chronic diseases. 
 The consolidating lesions of pulmonary tuberculosis are due to chronic 
 localized tuberculous bronchopneumonia. 2. Aspiration or deglutition 
 pneumonia. In the stupor of the low fevers and in comatose states of all 
 kinds the reflex excitability of the larynx is lowered, and the secretions of 
 the mouth, minute portions of drink, and particles of food during the act 
 of swallowing are drawn into the trachea and bronchi. In this situation 
 they set up an active bronchitis which by extension rapidly involves the 
 smaller bronchi and gives rise to an intense bronchopneumonia. This 
 accident is very common after operations upon the throat, nose, larynx, 
 and trachea. Most cases of ether pneumonia arise in this way. The infect- 
 ing material may come from within the chest itself; severe bronchopneu- 
 monia not rarely follows haemoptysis and occasionally the aspiration of the 
 contents of a bronchiectatic cavity, or pus from an empyema which has 
 found its way into the lung by way of a bronchopulmonary fistula is fol- 
 lowed by this disease. The extension of tuberculosis from one part of a lung 
 to another, or to the opposite lung, is due in some instances to aspiration. 
 
 Exciting Cause. — Various micro-organisms are associated w'ith the 
 lesions of bronchopneumonia. In the primary form which attacks young 
 children in previous health the common organism is the pneumococcus, 
 
1072 MEDICAL DIAGNOSIS. 
 
 which may be found in pure culture. In the secondary forms the strepto- 
 coccus is the common infecting agent, but mixed infections are usual. The 
 organisms present are the Bacillus pneumoniae of Friedlander, Streptococcus 
 pyogenes, Staphylococcus albus et aureus. The Klebs-Loffler bacillus 
 is frequently found in the bronchopneumonia of diphtheria, and Pfeiffer's 
 bacillus in influenza pneumonias. 
 
 The lesions consist in interstitial inflammation of the bronchi and 
 alveolar walls. The small bronchi are plugged with exudate composed of 
 leucocytes and swollen epithelium; their walls are swollen, infiltrated 
 with cells, and traversed by distended capillaries, and there is dense peri- 
 bronchial infiltration. The vesicles are filled with leucocytes and swollen 
 epithelium, and rarely show the dense accumulations of red corpuscles 
 and the fibrillated fibrin seen in croupous pneumonia. 
 
 The pathological unit is the inflamed pulmonary lobule. Hence the 
 descriptive term lobular pneumonia. According to the distribution of 
 the lesions three anatomical forms exist: 1. There is more or less intense 
 bronchitis extending to the finer tubes, without the gross evidences of 
 lobular consolidation, but with the microscopic findings of inflammation. 
 This form is bilateral. 2. The foci of inflammation are scattered through- 
 out the lung tissue, with lobular collapse and infiltrated lobules felt as hard 
 nodules. These patches of bronchopneumonia are sometimes isolated 
 with strands of congested or uninflamed tissue intervening and areas of 
 collateral emphysema, and sometimes massed in groups of considerable 
 size. This form is also bilateral. 3. The greater part of a lobe is often 
 involved — the pseudolobar form of bronchopneumonia. Even in this 
 form the consolidation is not uniform as in croupous pneumonia, but 
 there are more or less extensive tracts of deeply congested but still crepitant 
 tissue scattered among the inflamed lobules. 
 
 The terminations are in resolution, suppuration or gangrene, or fibro- 
 sis. In the tuberculous forms, which are very common in previously ap- 
 parently healthy children, bronchopneumonia terminates in caseation or 
 chronic fibroid changes. Such cases often follow measles, pertussis, or 
 diphtheria and may be the result of the lighting up of a latent tuberculosis 
 or of tuberculous infection at the time. 
 
 Symptoms. — The onset of the primary form is abrupt. It is marked 
 by convulsions and sudden rise of temperature. Cerebral symptoms are 
 frequent and often intense. The defervescence may be critical. These 
 cases, which run a course analogous to that of croupous pneumonia and 
 present similar symptoms and localized physical signs, when they terminate 
 fatally often show pseudolobar consolidation and the pneumococcus in 
 the lesions. 
 
 The secondary forms are preceded bj^ the signs of a bronchitis extend- 
 ing to the smaller tubes. The disease develops gradually without chill 
 or convulsion. The I'ever is of variable intensity— 102°-104° F. (39°-40° C.) 
 — and does not conform to type, being irregularly remittent. The skin is 
 hot and dry. There is cough, which is hard, dry, and distressing. The 
 respiration frequency may reach 60 to 80 per minute, and cyanosis soon 
 appears. Other evidences of deficient oxygenation of the blood are fre- 
 quent, small, thready pulse, stupor, restlessness, and occasional convulsive 
 
BRONCHOPNEUMONIA. 
 
 1073 
 
 tremor. The cough becomes less urgent, the child no longer struggles 
 for air, the face becomes suffused and loses its anxious expression, and 
 death occurs from cardiac paralysis. Sputum (see Part III, page 457). 
 
 Physical Signs. — Upon inspection there are early signs of obstruction 
 in the terminal bronchi, inspiratory retraction of the intercostal spaces 
 and lower sternal and epigastric regions, rapid, shallow, jerky respiration, 
 and cyanosis of the lips and finger-tips. Percussion. — Death may occur 
 before signs of consolidation develop. There may be merely vesiculo- 
 tympanitic resonance. If consolidation is present impaired resonance, 
 sometimes actual dulness, is found at the bases in scattered areas. To 
 
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 Fig. 316. — Bronchopneumonia in a man aged seventy-six. 
 
 elicit it in the latter case demands very careful light percussion. Com- 
 pensatory emphysema may mask small areas of dulness. Auscultation 
 in the early stages reveals only the signs of the extension of the bronchitis 
 to the finer tubes, namely, many diffuse small mucous and some crepitant 
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 Clinical Varieties. — 1. Primary Form. — It is a question whether 
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 monia — pneumococcus pneumonia. The primary form is rare in adults. 
 68 
 
1074 
 
 MEDICAL DIAGNOSIS. 
 
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 Catarrh. — The overwhelming cases were so designated by the earlier 
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 two or three days, are most appropriately described under this term. 
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 Fig. 318. — Fatal bronchopneumonia. 
 Man aged seventy-six. 
 
 severe forms of bronchitis, both in children and adults. This form assumes 
 great importance in diagnosis, since it may be merely a simple pathological 
 condition, on the one hand, or an insidiously developing tuberculous bron- 
 chopneumonia, upon the other. 5. Ether Pneumonia; Postoterative 
 Pneumonia. — This form of bronchopneumonia usualty is pseudolobar and 
 presents close resemblances to croupous pneumonia. The anaesthesia bron- 
 chitis which precedes the pneumonic symptoms, the low temperature 
 range, the absence of bloody sputum, and the course of the attack are 
 significant. In a majority of the cases it is an inhalation pneumonia. 
 
 Course and Duration. — Bronchopneumonia is not a self-limited 
 disease. The primary cases, which suggest croupous pneumonia, run a 
 short course and frequently terminate by crisis. The secondary cases 
 
CHRONIC INTERSTITIAL PNEUMONIA. 1075 
 
 are often prolonged and the defervescence is by lysis. Fatal cases in chil- 
 dren often come to an end in from 3 to 5 days. The duration of favorable 
 cases is from 1 to 4 or 5 weeks. Recovery may still take place after an 
 illness of 8 or 10 weeks. In protracted cases tuberculosis is to be feared. 
 
 Diagnosis. — Direct. — A positive diagnosis cannot be made unless 
 the signs of consolidation are present. Circumscribed areas of relative 
 dulness, usually bilateral with vesiculotympanitic resonance interspersed, 
 together with high-pitched, small mucous and crepitant rales, bronchial 
 breathing, bronchophony, and increased vocal fremitus are diagnostic 
 in the primary as well as in the secondary forms. In cases in which the 
 lesions are massed in a single lobe, careful physical examination will almost 
 always show a focus of consolidation upon the opposite side. The signs 
 of consolidation are often absent, especially early in the attack. The 
 diagnosis is even then probable if in bronchitis the temperature rises to 
 104° F. (40° C), the cough becomes short, harassing, and painful, the 
 respiration and pulse-frequency become high, cyanosis develops, and 
 diffuse, high-pitched fine rales are heard. 
 
 Differential. — Croupous Pneumonia (see page 728). Acute Miliary 
 Tuberculosis (see page 790). Acute Tuberculous Bronchopneumonia (see 
 page 804). Atelectasis. — The dulness and rales of this condition are modi- 
 fied and sometimes even disappear upon change of posture. Fever is not 
 an essential concomitant. If present it is usually due to an associated 
 bronchitis. Meningitis. — In infants marked cerebral symptoms sometimes 
 occur, and the condition closely simulates meningitis. The differential 
 diagnosis between tuberculous meningitis and bronchopneumonia with 
 cerebral symptoms can in some cases only be made by time. 
 
 Prognosis. — The outlook is much more favorable in the primary than 
 in the secondary forms. It is greatly influenced by the age of the patient. 
 Within the first year almost every case dies; until the fifth year from 30 to 
 50 per cent. ; in the aged the prognosis is ominous. Pale, fat, flabby children 
 do not bear the disease well. Aspiration pneumonia is a very fatal disease, 
 especially that form which follows operations upon the mouth and throat. 
 
 iii. Diseases of the Lungs Characterized by Interstitial 
 
 Inflammation. 
 
 (a) CHRONIC INTERSTITIAL PNEUMONIA. 
 
 Cirrhosis of the Lung. 
 
 Definition. — Chronic inflammation of the lung with increase of the 
 interstitial tissue and decrease in the vesicular tissue, with general indura- 
 tion and contraction. There are two forms, the local or circumscribed, 
 and the diffuse, involving the greater part of one or both lungs. 
 
 1. Local Pulmonary Fibrosis. — This condition is very common. 
 It occurs as a secondary process in inflammatory diseases of the lung, as 
 bronchitis, croupous pneumonia, and bronchopneumonia. It constitutes 
 an important feature in the complex lesions of tuberculosis and the chief 
 final local process in obsolescent or cured tuberculous disease. It is the 
 
1076 MEDICAL DIAGNOSIS. 
 
 termination of pulmonary atelectasis prolonged through the stages of com- 
 pression and carnification until the tissue has become organized and expan- 
 sion is no longer possible. Hence it is a feature of the lung tissue adjacent 
 to aneurisms, tumors, abscesses, hydatids, and gummata. It is especially 
 important as the outcome of neglected pleural effusion, because by the 
 early withdrawal of the exudate the pressure atelectasis may be relieved 
 and subsequent fibroid changes minimized. The clinical phenomena of 
 local fibroid changes are subordinate to those of the primary disease which 
 it accompanies. Retraction of the supra- or infraclavicular spaces, or cir- 
 cumscribed retraction elsewhere, is suggestive. Nevertheless the diagnosis 
 must often be provisional rather than positive. The chief importance of 
 the condition arises from its often constituting the point of departure for 
 fibroid changes involving the entire lung. 
 
 2. Diffuse Pulmonary Fibrosis. — To a certain extent the etiological 
 factors are the same as in the localized form. Thus the fibroid changes 
 in chronic bronchitis and emphysema, and associated with bronchiecta- 
 sis, are usually diffuse. When the condition follows pressure atelectasis 
 it may be diffuse when the greater part of a lobe or lung is compromised. 
 Other conditions which may be followed by chronic interstitial pneumonia 
 are the irritation of a foreign body long retained in a bronchus, chronic 
 bronchopneumonia, in rare instances unresolved croupous pneumonia, 
 pleurisy, the connective-tissue overgrowth invading the lung from a chronic 
 fibrinous pleural exudate — the pleurogenous form of chronic interstitial 
 pneumonia — and syphilis. 
 
 Two forms are recognized, (a) Lobar Interstitial Pneumonia. — The 
 disease is unilateral. The entire lung is usually involved. It frequently 
 appears as a small, dense, airless mass of tissue lying along the spine. It 
 is densely indurated, showing upon section a compact, grayish, fibroid 
 tissue traversed by the bronchi and blood-vessels. In the pleurogenous 
 form the lung is bound to the wall of the thorax by dense, thick, pleural 
 adhesions. When the process has been intrapulmonary from the beginning 
 the pleural adhesions may be of only moderate thickness. Bronchiectasis 
 is common and often very extensive. In tuberculous cases vomicse and 
 caseating foci are present and the opposite lung shows evidences of tubercle. 
 The right heart is hypertrophied, and atheroma and local arteriosclerosis 
 are frequently encountered. The heart is displaced toward the affected 
 side. The opposite lung is emphysematous — vicarious emphysema — and 
 its border extends beyond the median line toward the affected side, 
 (b) Disseminated Interstitial Pneumonia. — The condition is bilateral. 
 There are circumscribed areas of fibrosis separated by lung tissue more or 
 less emphysematous — collateral vicarious emphysema. These fibroid islets 
 are deeply situated in the lung tissue and more frequently in the lower 
 lobes. They surround bronchiectatic dilatations. 
 
 Symptoms. — Fever when present is due to an acute associated process, 
 or to tuberculosis. There are cough, dyspnoea upon exertion, and expecto- 
 ration, which may show the special characteristics of the sputum of bron- 
 chiectasis. Haemoptysis is fairly common, especially in the tuberculous 
 cases. The affection is the very type of a chronic disease but the adapta- 
 tions are remarkable. The general health is often remarkably good when 
 
CHRONIC INTERSTITIAL PNEUMONIA. 1077 
 
 the extent and nature of .the lesions are considered, and the patients are 
 capable of conducting their affairs. 
 
 Physical Signs. — Inspection. — The deformity of the chest in well- 
 developed cases is conspicuous both in the unilateral and bilateral types 
 of the affection, though in the latter retraction is more or less modified 
 by compensatory emphysema. In the unilateral variety the affected side 
 of the thorax is retracted and immobile. The ribs approach each other 
 so that the intercostal spaces are obliterated, or the ribs may overlap. The 
 shoulder droops and there is lateral curvature of the spine, the concavity 
 in the dorsal region being toward the affected side. The respiratory 
 muscles and those of the shoulder and arm are wasted. The semicircum- 
 ference of the affected side is much diminished and remains uninfluenced 
 by respiratory effort. The heart is strongly displaced toward the affected 
 side, being drawn over by the contracting lung. The changes in the cardiac 
 phenomena are much more apparent when the left lung is involved. Under 
 these circumstances there may be an extensive area of pulsation in the 
 second, third, and fourth interspaces to the left of the sternal border. When 
 the right lung is affected the cardiac impulse may be wholly obliterated 
 by the extending median border of the emphysematous left lung. The 
 unaffected side is in strong contrast with its large size, wide intercostal 
 spaces, and free respiratory excursus. Palpation. — If the bronchi are 
 unobstructed the vocal fremitus is increased over the affected side. There 
 is usually epigastric pulsation transmitted from the right heart. Cardiac 
 pulsation is well felt in the second, third, and fourth interspaces in left- 
 sided fibrosis, and in some cases there is a short diastolic thrill to the left 
 of the pulmonary area. Percussion. — Dulness is usually marked and 
 may be extreme at the apex and base. When the bronchi are extensively 
 dilated the percussion sound has the tympanitic quality. This may be 
 especially marked in the axillary region. Over the opposite lung there is 
 hyperresonance. Upon linear percussion the anterior border of the unaf- 
 fected lung is found to be displaced as far as, or even beyond, the sternal 
 border on the affected side, and its lower border displaced downward, 
 while the lower border of the affected lung and the related organ, i.e., 
 liver or spleen, are displaced upward and show no respiratory movement. 
 Auscultation. — There is more or less widely extended bronchial respira- 
 tion. At the apex the quality may be cavernous or amphoric; at the base 
 feeble and distant. In some cases small mucous rales are heard. There 
 is bronchophony and, if bronchial dilatation extends to the periphery of 
 the lung, whispering pectoriloquy may be heard. The pulmonary second 
 sound is accentuated and endocardial murmurs frequently appear toward 
 the close of the disease as dilatation and failure of the right heart come on. 
 
 Diagnosis. — In the disseminated form the diagnosis may be obscure. 
 The symptoms and signs may be simply those of bronchiectasis. In the 
 unilateral form the diagnosis is unattended with difficulty. The underlying 
 condition cannot, however, always be determined. The resemblance to 
 fibroid phthisis is often very close. Signs of disease in the opposite lung, 
 especially at the apex, fever, haemoptysis, and foci of moist rales are in 
 favor of a diagnosis of tuberculosis. Tubercle bacilli in the sputum are 
 conclusive. 
 
1078 MEDICAL DIAGNOSIS. 
 
 Prognosis. — The outlook as regards life is favorable; as regards 
 recovery hopeless. The patients live many years and often have no great 
 inconvenience except from cough, expectoration, and dyspnoea upon exer- 
 tion. The powers of resistance are diminished and they readily succumb 
 to intercurrent disease. Otherwise death is commonly due to progressive 
 failure of the right heart or amyloid disease. 
 
 (b) PNEUMONOCONIOSIS. 
 
 Definition. — Disseminated fibrosis of the lungs caused by the habitual 
 inhalation of a dust-laden atmosphere in various occupations. 
 
 Etiology. — Pneumonoconiosis is the very type of an occupation 
 disease. Several varieties are described, according to the character of 
 the work and the nature of the dust inhaled: aidhracosis or coal miners' 
 disease; siderosis, the form caused by inhaling metallic dust, especially 
 iron oxide, and brass and bronze particles; chalicosis, due to mineral 
 dusts, as stonecutters' consumption or the grinders' rot of the workers in 
 cutlery. Similar affections occur in workers in flax and cotton and in 
 grain shovellers. 
 
 The condition of the lungs in advanced cases of the disease caused by 
 different substances is practically the same. The interstitial inflammation 
 starts from the peribronchial lymph-nodes in which the dust particles 
 excite proliferation of connective tissue, and in the early stages of the 
 process, esi3ecially in anthracosis, is confined to these tissues. There is an 
 associated chronic bronchitis to which many of the symptoms are due. 
 Bronchiectasis is common and in a majority of the cases the clinical picture 
 is that of a chronic bronchitis with emphysema. In anthracosis there is 
 a carbon-laden black spit. In advanced cases softening occurs in the 
 indurated nodules, and small cavities are formed which in some cases 
 suppurate and discharge a purulent fluid by way of the bronchi. Notwith- 
 standing the prevalence of anthracosis among coal miners tuberculous 
 phthisis is comparatively rare. 
 
 Symptoms. — The disease does not show itself until after long exposure 
 to the dust. There are the general signs of failing health, with cough, 
 expectoration, often abundant, dyspnoea, and wheezing, especially upon 
 exertion. The mucopurulent sputum in anthracosis is blackish. It is 
 popularly known as ''black spit." That of the other forms is light or 
 grayish in color, without gross characteristics. In chalicosis glittering 
 crystalloid particles of silicious material may be seen. Under the micro- 
 scope the dust particles are seen in the alveolar epithelium. Tuberculosis 
 may form the terminal condition. 
 
 Diagnosis. — The direct diagnosis is not as a rule difficult. The anam- 
 nesis, the gradual development of the affection after years of exposure, 
 the symptoms of chronic bronchitis with emphysema and bronchiectasis, 
 the mucopurulent sputum with the special characteristics mentioned, 
 and the absence of tubercle bacilli are all of diagnostic importance. 
 
 Prognosis. — The outlook is favorable if the condition is recognized 
 early and the patient can change his work. Otherwise the cases run a 
 progressive though very chronic course. 
 
PULMONARY ABSCESS. 1079 
 
 iv. Diseases of the Lungs due to Suppuration and 
 
 Necrosis. 
 
 (a) PULMONARY ABSCESS. 
 
 Definition. — Localized collections of pus in cavities formed by the 
 disintegration of lung tissue. 
 
 Etiology. — Pulmonary abscess is a secondary process due to the 
 intense action of various pyogenic organisms, among which streptococci 
 and staphylococci are the most common. It may occur under the 
 following conditions: 
 
 1. Acute Inflammation. — Suppuration may follow croupous pneu- 
 monia. It occurs in two forms: first, the purulent infiltration which con- 
 stitutes an advanced stage of gray hepatization, and second, the much 
 more rare condition of actual abscess cavity. The latter are usually small, 
 multiple, with shreddy walls, and frequently contain necrotic tissue. 
 They tend by fusion to form larger abscesses. Purulent infiltration and 
 abscess are sometimes present in the same lung. Abscess is more common 
 in bronchopneumonia, especially the form known as aspiration or degluti- 
 tion pneumonia. In the low fevers and stuporous and comatose conditions, 
 after wounds of the neck and operations upon the nose, throat, and mouth, 
 and suppurative diseases of these parts, an intense acute bronchitis fre- 
 quently arises, which by extension involves the distant tubules and causes 
 purulent bronchopneumonia. Multiple abscesses, mostly minute but 
 frequently attaining the size of an orange, may result. A similar condition 
 may follow the inflammation caused by a foreign body lodged in a bronchus. 
 Pulmonary abscess is a relatively common sequel of epidemic influenza. 
 2. Traumatism. — Perforation of the lung from without, as in stab or 
 gunshot wounds, laceration of the lung by a fractured rib, and analogous 
 accidents, may cause pulmonary abscess. 3. Perforation from Within. — 
 Sudden invasion of the lung by purulent or otherwise infected substances 
 from adjacent organs is a common cause of abscess. Cancer of the oesopha- 
 gus, abscess of the liver, a suppurating hydatid cyst, or the aspiration of 
 the pus in empyema suddenly rupturing into the lung may cause abscess. 
 4. Infective Emboli. — Metastatic abscesses in the lung are common 
 in septic — pyemic — states. The purulent foci are multiple, mostly sub- 
 pleural, and at first wedge-shaped. They are commonly small, but occa- 
 sionally extensive purulent infection occurs. The related pleura is inflamed 
 and covered with a thick, greenish lymph. Occasionally softening and 
 perforation are followed by pneumothorax. 5. Tuberculous Abscesses. 
 — Circumscribed local suppurative processes enter largely into the com- 
 plex lesions of pulmonary tuberculosis, especially in the later course of 
 the disease. They are associated with caseation and cavity formation, 
 and give rise to important and significant symptoms and physical signs. 
 
 Symptoms. — As in other suppurative processes there are irregular 
 chills and fever. In pneumonia the general symptoms are aggravated, 
 the sputum becomes purulent, and the signs of a cavity can sometimes be 
 demonstrated. In pytemia the local symptoms of pulmonary abscess are 
 obscured by the general symptoms of sepsis, and the condition is usually 
 
1080 MEDICAL DIAGNOSIS. 
 
 overlooked. Aside from the presence of pus in large amounts the sputum 
 presents characters of diagnostic importance (see Part III, page 457). 
 
 Physical Signs.^The signs of a cavity which empties itself under 
 the stress of violent paroxysms of cough, and again refills, may be elicited 
 upon physical examination when the abscess is of sufficient size and situ- 
 ated in the periphery of the lung. In small abscesses the signs are often 
 wholly inconclusive. 
 
 Diagnosis. — Direct. — When the above symptoms and signs are pres- 
 ent, especially when the etiological factors essential to diagnosis can be 
 established and purulent sputum containing elastic fibres and the other 
 characters named accompanies the cough, the diagnosis is positive. In 
 many cases, however, it is at best provisional,, and not rarely abscess 
 in the lungs not suspected during life is found upon the post-mortem table. 
 
 Differential. — Collections of Pus Perforating into the Lung. — Accu- 
 mulations that may break into the lung occur in empyema, subphrenic 
 abscess, hepatic abscess, suppurating hydatid cyst, in spinal caries, and 
 other suppurative processes in adjacent viscera. The differential diag- 
 nosis rests upon the presence of symptoms and signs significant of such 
 pathological conditions, and especially upon the absence of the elastic 
 fibres from the expectorated pus. Bronchiectasis. — The etiological factors 
 are different. Both are secondary affections, but bronchiectasis is a chronic, 
 pulmonary abscess an acute, affection. The cough is more urgent and less 
 constant in bronchiectasis, and the sputum more foul and does not as a rule 
 contain elastic fibres, which, when present, are less abundant than in 
 abscess. Pulmonary Cavities in Tuberculosis. — Etiological considerations 
 are important. The slow development of phthisical cavities, their antecedent 
 ■and concomitant phenomena, the characters of the sputum, and the pres- 
 ence of tubercle bacilli are of positive diagnostic significance. Pulmonary 
 Gangrene. — The sputum in gangrene of the lung has an extremely intense, 
 putrid odor not often present in the purulent expectoration of pulmonary 
 abscess, and contains shreds of decomposing lung tissue, which can be 
 readily detected when it is spread out upon a glass plate. These shreds 
 frequently present the structure of the pulmonary alveoli. 
 
 (b) GANGRENE OF THE LUNG. 
 
 Definition. — Decomposition of lung tissue caused by the action of the 
 bacteria of putrefaction. It may be diffuse or circumscribed. 
 
 Etiology. — Sphacelus of the lung occurs as an anatomical condition 
 under a variety of circumstances. Impaired vitality of the tissues from 
 general or local causes is a necessary predisposing factor. The subjects 
 are commonly greatly debilitated by long-continued chronic or grave 
 acute disease. Severe general disturbances of nutrition, such as are caused 
 by prolonged infections or disease of the bones, or arise in malignant 
 disease or diabetes mellitus, constitute predisposing influences of impor- 
 tance. Equally important are bronchiectasis, especially that form of bron- 
 chiectasis which occurs as the result of the pressure of a tumor or aneurism, 
 tuberculous cavities and putrid bronchitis, since the putrid contents of 
 the cavities or bronchi often cause secondary gangrene when aspirated 
 
GANGRENE OF THE LUNG. 1081 
 
 into the adjacent tissues. Among the acute diseases in which gangrene 
 of the lung occurs are croupous pneumonia, particular!}- when it affects 
 debilitated or diabetic persons; aspiration bronchopneumonia, whether 
 the infectious material be derived from the nose or throat of the 
 patient, or from some focus of disease adjacent to the lung, as cancer of 
 the oesophagus, abscess of the hver, or empyema; emboHsm of the pul- 
 monary artery, especially when the embolus is infected, as in pyaemia or 
 necrosis of the bones, and in enteric fever thrombosis of one of the principal 
 branches of the pulmonary artery. No satisfactory explanation of the 
 occasional occurrence of gangrene under these circumstances, when it 
 remains absent in the majority of similar cases, has been advanced. 
 
 1. Diffuse Pulmonary Gangrene. — This form is very rare. It has 
 been observed after croupous pneumonia and in the most intense cases of 
 aspiration pneumonia. It may also occur after the occlusion of a large branch 
 of the pulmonary artery by an embolus or thrombus. A large portion or 
 the whole of a lobe may undergo putrefaction in the course of a day or two. 
 
 2. The Circumscribed Form. — The gangrenous portions of lung are 
 surrounded by an intensely congested and oedematous border of tissue. 
 The lesions may be single or multiple. They are more commonly situated 
 in the lower lobes than the upper and in the peripheral than in the central 
 parts of the lung. The greenish-black gangrenous tissue rapidly softens, 
 with the form^ation of an irregular cavity with shreddy walls and an 
 abundant, horribly offensive fluid. 
 
 Symptoms. — The expectoration is profuse, thin, and green or brownish 
 in color. Its odor is exceedingly fetid, disgusting, and penetrating. In some 
 instances it is mawkishly sweet. It is not only present upon the breath but 
 also pervades the atmosphere of the patient's room (see Part III, p. 457). 
 The symptoms of the primary affection and constitutional debility usually 
 precede the characteristic phenomena of gangrene of the lung. There is 
 commonly a mioderate fever associated with rapid pulse and great general 
 depression. Hemorrhage is not uncommon and may prove fatal. 
 
 Physical Signs. — The signs in the diffuse form are those of infiltration, 
 impaired resonance, with the tympanitic quality, and vesiculobronchial 
 or bronchial respiration. In the circumscribed form the signs of a cavity 
 predominate. Very often in limited gangrene the signs may elude detection. 
 Severe bronchitis is common. 
 
 Diagnosis. — Direct. — The sputum and the odor of the breath are char- 
 acteristic. The presence of shreds of gangrenous alveolar tissue is conclusive. 
 
 Differential. — From putrid bronchitis and bronchiectasis gangrene 
 of the lung cannot always be differentiated, except by the presence of 
 lung tissue in the sputum, and when this is found in old standing cases 
 it constitutes positive evidence of secondary gangrene. 
 
 Prognosis. — Pulmonary gangrene is almost always a terminal event. 
 The patient sinks rapidly and dies from exhaustion. When the gangrenous 
 area can be localized, and the condition of the patient is favorable, a surgical 
 operation may be the means of saving life. In rare cases of circumscrilied 
 gangrene encapsulation has taken place, and still more rarely recovery 
 has occurred after the expectoration of pieces of gangrenous lung of 
 considerable size. 
 
1082 MEDICAL DIAGNOSIS. 
 
 V. New Growths in the Lungs. 
 
 Neoplasms in the lungs are usually malignant. They are primary 
 or secondary. The former are rare; the latter comparatively common. 
 
 1. Primary Tumors. — Carcinoma is the usual form. Much more 
 rare are primary sarcoma and endothelioma. The growth usually invades 
 one lung and forms a large mass, which may ultimately break down and 
 give rise to a cavity. Diffuse cancerous infiltration may simulate tuber- 
 culous bronchopneumonia. Diffuse miliary infiltration has been described 
 — carcinosis 'pulmonum miliaris. 
 
 2. Secondary New Grow^ths. — Every variety of malignant growth 
 may by metastasis invade the lungs. In comparatively rare instances 
 the secondary growth may be solitary, and chiefly involves the pleura. 
 Usually they are multiple and occupy both lungs. Large tracts of pul- 
 monary tissue may be densely invaded. The primary tumor is usually 
 mammary, in the gastro-intestinal or genito-urinary tract, or in the bone. 
 It may be epithehoma, scirrhus, colloid, sarcoma, enchondroma, or osteoma. 
 In melanosarcoma the primary growth may have its starting-point in a 
 pigmented mole. In Hodgldn's disease the growth may perforate the 
 sternum and widely involve the lungs, or it may reach the lungs by way 
 of the tracheal and bronchial lymph-nodes. In cancerous disease there 
 is commonly secondary implication of the tracheal and bronchial glands, 
 and less often of the cervical chains. Other superficial glands, includ- 
 ing the inguinal, may be enlarged. Pleurisy is common. It may be 
 cancerous or serofibrinous. Frequently both conditions are present. 
 Not rarely the effusion is hemorrhagic. 
 
 Etiology. — New growths in the lungs occur with gi^eatest frequency 
 in middle life. Males suffer more commonly from primary mahgnant 
 disease of the lungs and pleura; women from the secondary form. 
 
 Symptoms. — The clinical picture is not well defined, especially in the 
 primary form. It sometimes suggests chronic pneumonia, sometimes a 
 mediastinal tumor or thoracic aneurism, or again there may be nothing 
 to suggest an affection of the lungs. Pain is usually present when the 
 pleura is affected. It may be substernal. Cough is not constant. It is 
 frequently aggravated in certain postures and may be dry and attended 
 wdth pain. There is in many cases a jelly-like bloody sputum which is 
 highly suggestive, though it may occur in other conditions. Dyspnoea 
 upon exertion is a sj^mptom of large growths or extensive infiltration, and 
 may be parox5^smal. Pleural effusion, often found upon aspiration to be 
 hemorrhagic, may develop. The lymph-nodes of the axilla or above the 
 inner end of the clavicle are frequently enlarged. There is progressive 
 wasting and cachexia, and toward the end irregular fever of remittent 
 type. Pressure symptoms are common. These consist of distention of 
 the large veins, with cyanosis of the face and one or both arms, enlarged 
 and tortuous veins over the upper part of the chest, distressing dyspnoea 
 or stridor from compression of the trachea or large bronchi, brassy cough, 
 and aphonia fi-om pressure upon recurrent laryngeal nerves. In large 
 unilateral tumors the heart is displaced toward the opposite side and the 
 diaphragm depressed. 
 
DISEASES OF THE MEDIASTIXOI. 1083 
 
 Physical Signs. — The signs may be due to the tumor itself or to an 
 accompanying pleural effusion. In the latter case the affected side is 
 enlarged, the intercostal depressions obliterated, the respiratory move- 
 ment restricted. The vocal fremitus is diminished. Upon percussion and 
 auscultation the signs are modified by the presence of fluid and its amount, 
 which is not usually great. Even when it is considerable, the tumor affects 
 its distribution and upper lines. There is dulness which may be complete 
 at the base. The breath sounds are feeble and distant. There may be 
 well-characterized bronchial breathing. 
 
 Diagnosis. — Direct. — In primary cases the diagnosis may be difficult 
 or impossible. Important criteria are strictly unilateral phenomena, 
 irregular character and distribution of the physical signs, dark, jelly-like, 
 mucoid, bloody expectoration, tendency to cachexia, and implication of 
 superficial lymph-nodes. If carcinomatous tissue elements are found in 
 the sputum or the growth perforates the chest wall — ver}^ rare events — 
 the diagnosis is positive. The X-ray examination is important. In a 
 case of single large growth in the lower lobe of the right lung, with 
 multiple pigmented cutaneous lesions, occurring in a man aged sixty-four, 
 the results of physical examination were fully confirmed. In the secondary 
 form a probable diagnosis may be made with some confidence when the 
 above described pulmonary symptoms arise in the course of several months 
 after the recognition of a primary malignant tumor, as of the breast, womb, 
 stomach, or bowel, with or without operation. 
 
 Differential. — The recognition of a mediastinal new growth or an 
 aneurism of the aorta, in contradistinction from new growths in the lungs, 
 may involve serious diagnostic difficulties. 
 
 Prognosis.— The course of malignant growths in the lungs is lethal, 
 the end occurring within a year or two, and not rarely within a few months 
 after the appearance of the symptoms. 
 
 V. DISEASES OF THE MEDIASTINUM. 
 
 Enlarged lymphatic glands, suppurative h'mphadenitis, abscess, inter- 
 stitial emphysema, chronic indurative mediastinitis, and new growths are 
 to be considered. 
 
 1. Enlargement of the lymphatic glands m the mediastinum accom- 
 panies inflammation of the bronchi, bronchopneumonia and the specific 
 infections, croupous pneumonia, measles, pertussis, and tuberculosis. This 
 constant anatomical change does not commonly attain sufficient dimensions 
 to cause definite symptoms or physical signs; exceptionally pressure upon 
 the trachea may cause a paroxysmal, brassy cough, and dulness over the 
 manubrium sterni, in the upper part of the interscapular region, or a modi- 
 fication of the sound upon direct percussion over the upper dorsal spines. 
 
 2. Suppurative Lymphadenitis. — Suppuration may occur in the tra- 
 cheal or bronchial lymphatic glands as the result of ordinary inflammation. 
 More commonly it is of tuberculous origin. The symptoms are obscure. 
 Perforation into a bronchus, the oesophagus, or the aorta may occur. In 
 other cases the fluid contents of the glandular abscess are absorbed, lime 
 salts are deposited, and the condition becomes one of anatomical rather 
 than clinical interest. 
 
1084 MEDICAL DIAGNOSIS. 
 
 3. Mediastinal Abscess.- — The abscess cavity usually occupies the 
 anterior mediastinum. The condition may be acute or chronic. The 
 acute cases are due to traumatism or occur in connection with the acute 
 febrile infections; the chronic cases are as a rule tuberculous. Males are 
 more commonly affected. The pus shows a disposition to burrow and 
 may find its way through an intercostal space, into the abdomen, may 
 rupture into the trachea or oesophagus, or may perforate the sternum. 
 
 Symptoms. — Substernal pain is constant. In the acute cases it is 
 severe and throbbing, and accompanied with chills, fever, and sweating. 
 Large abscesses may give rise to pressure symptoms and dyspnoea. There 
 may be resorption of the fluid and inspissation. 
 
 Physical Signs. — A fluctuating tumor may appear in the episternal 
 space or at the sternal border. In the latter situation it may suggest 
 empyema necessitatis. Pulsating synchronously with the heart it may 
 simulate a pulsating empyema or an aneurism. From pulsating empyema 
 it may be distinguished by the absence of the signs of pleural effusion; 
 from aneurism by absence of murmur, of diastolic shock, and of the expan- 
 sile character in the pulsation. Exploratory puncture with a fine needle 
 may be performed. 
 
 4. Emphysema. — The escape of air into the connective-tissue spaces 
 of the mediastinum is an occasional event after traumatism or surgical 
 operations upon the neck, as tracheotomy, and in pertussis. It may be 
 associated with pneumothorax. There are no special symptoms. Crack- 
 ling rales having the rhythm of the heart are heard over the sternal region. 
 If the air finds its way into the subcutaneous tissue of the neck the crepitus 
 may be recognized upon kneading the tissues lightly with the finger-tips. 
 Etiological factors are important. 
 
 5. Indurative Mediastinitis.— Adherent pericardium wdth chronic pro- 
 liferative mediastinitis is a rare condition. The heart is greatly enlarged. 
 Its action is hampered by the extensive adhesions to the adjacent parts; 
 its signs obscured by the greatly thickened fibrous tissue of the mediasti- 
 num. Friction sounds may sometimes be heard along the sternal borders. 
 The nutrition of the heart muscle ultimately fails, and dyspnoea, cyanosis, 
 and anasarca develop. 
 
 6. Mediastinal New Growths. — The common varieties are carcinoma 
 and sarcoma. Dermoid cysts, hydatid cysts, and lymphomata, fibromata, 
 lipomata, enchondromata, and gummata are of comparatively infrequent 
 occurrence. The tumor may have its origin in the thymus, the lymph- 
 glands, or the pleura or lung. Tumors of the anterior mediastinum originate 
 from the remnants of the thymus of the connective tissue; those of the 
 middle and posterior mediastinum from the h^mph-nodes. Primary 
 tumors are more commonly sarcoma than carcinoma. Among personal 
 predisposing influences age and sex are important. Mediastinal tumor 
 most frequently develops in the fifth decade of life and in men. 
 
 Symptoms. — The important manifestations of a tumor developing 
 in or encroaching upon the mediastinal spaces are displacement and pres- 
 sure symptoms. These symptoms relate to the heart, great vessels and 
 nerves, the trachea, bronchi, lungs, and pleurae, and the oesophagus. The 
 symptoms depend upon the size of the new growth, and its immediate 
 
DISEASES OF THE MEDIASTINUM. 1085 
 
 location. . A small tumor may not be the occasion of any derangement 
 of function. On the other hand, as the growth increases, remarkable adap- 
 tations take place, and life may be maintained despite great compression 
 and dislocation of the heart and lung. The pressure of the tumor exerted 
 upon the wall of the heart interferes with diastole and diminishes the 
 volume of blood thrown into the aorta with the ventricular systole. The 
 pulse is therefore small and frequent. The dislocation of the organ is 
 backward or downward in tumors of the anterior mediastinum, with dis- 
 placement of the apex beat to the left. The liver or spleen is also dis- 
 placed downward by large mediastinal tumors. There may be cardiac 
 dyspnoea from pressure. The presence of the tumor interferes with respira- 
 tion and produces of itself a slight degree of cyanosis, which is increased 
 by pressure upon large venous trunks. When the intrathoracic portion 
 of the inferior vena cava is affected, venous distention and cedema of the 
 abdomen and lower extremities result; when the superior vena cava is 
 compromised, swelling and oedema in the face and both upper extremities 
 may occur, together with signs of interference with the cerebral circula- 
 tion, such as headache, vertigo, and ringing in the ears. A collateral venous 
 circulation may be established in either case with great distention of the 
 superficial veins of the abdomen or thorax. Pressure upon and obstruction 
 of the right or left innominate vein is more common. This hinderance to 
 the return of the venous blood manifests itself by oedema of the face and 
 arm of the corresponding side, and enlargement of the superficial veins of 
 the thorax. The arterial trunks yield less readily to the presence of the 
 tumor than the veins. When the pressure becomes so great as to interfere 
 with the lumen of the subclavian or innominate, the pulse upon the affected 
 side is enfeebled. Pressure upon the recurrent laryngeal nerves causes 
 dyspnoea, aphonia, and the severe, brassy, paroxj^smal cough often present. 
 The laryngoscope should be used. Pressure upon the phrenic may cause 
 hiccough and shallow respiration; upon the vagus asthmatic attacks and 
 dysphagia in the absence of direct pressure upon the oesophagus, and 
 bradycardia or tachycardia. Implication of the sympathetic may cause 
 dilatation or contraction of the pupil upon the affected side — inequality 
 of the pupils. Dyspnoea is an early and constant symptom. It is due to 
 various factors, as pressure upon the heart, the recurrent laryngeal nerves, 
 the trachea, the lungs themselves, or the presence of a pleural effusion. It 
 is often slight when the patient is quiet, but severe and distressing upon 
 exertion. The mechanical compression of considerable portions of a lung 
 manifests itself in dyspnoea of inspiratory type with slow and deep respira- 
 tory movements. In extreme conditions of pressure there is orthopnoea. 
 When the pressure is unilateral there may be inspiratory depression of 
 the intercostal spaces. Areas of fibrinous pleurisy are attended with local 
 pains and friction sounds. Compression of the oesophagus renders the 
 act of swallowing difficult or in extreme cases impossible. 
 
 Physical Signs. — Insj)ection. — Orthopnea, cedema, and cyanosis of 
 the face, arm, and upper part of the chest, and varicose enlargement of the 
 superficial mammary and epigastric veins are often seen. But in many 
 cases these signs are absent. In old cases there may be clubbing of the 
 finger-tips and incurvation of the nails. There may be bulging of the 
 
1086 MEDICAL DIAGNOSIS. 
 
 sternum. The new growth may even erode the bone or perforate the chest 
 wall at the sternal border. The impulse of the heart may be displaced tO' 
 the left and downward. Respiratory derangements are conspicuous. In 
 some cases inspiratory retraction of the soft parts of one side denotes 
 unilateral compression of a main bronchus or the large part of the lung. 
 Diminished respiratory excursus upon one side may be a sign of pleural 
 effusion. Palpation. — Vocal fremitus is absent over the tumor and over 
 pleural effusions. If the tumor pulsates it lacks the forcible, expansile 
 impulse of an aneurism. Percussion. — Dulness of a high grade and in- 
 creased resistance are present over the tumor. The borders of the area 
 of dulness are irregular, and do not correspond to the outline of the heart 
 or of the margin of an infiltrated lung. The dull area is continuous with 
 the dulness of a pleural effusion when the latter is present and its persist- 
 ence after the withdrawal of the fluid is of diagnostic significance. Auscul- 
 tation. — The respiratory murmur retains its vesicular qualitj^, in the main, 
 but is enfeebled. At the borders of the tumor it may, owing to pressure 
 atelectasis, have the bronchial quality. Stridor is the sign of compression . 
 of the trachea or a main bronchus. 
 
 Diagnosis. — Direct. — An area of dulness in the sternal region, with 
 irregular and advancing borders, bulging of the breast-bone, dyspnoea of 
 inspiratory type, absence of respiratory murmur, displacement of the heart 
 and of the liver or spleen, signs of obstruction of the venous circulation, 
 of pressure upon the vagi, the sympathetic, the phrenic, and the recurrent 
 laryngeal nerves, the trachea, bronchi, or the lung itself, and dysphagia 
 constitute a symptom-complex upon which the diagnosis of mediastinal 
 tumor may be confidently made. The association of a number of them 
 justifies a provisional diagnosis. When, however, to several of these signs 
 are added the presence of enlarged superficial lymph-nodes and the visible 
 and palpable evidences of a tumor perforating the sternum or the chest 
 wall at the borders of the sternum, or advancing into the episternal notch, 
 the diagnosis becomes positive. 
 
 Differential. — Obscure pressure symptoms may arise in consequence 
 of the presence of a small mediastinal tumor, tuberculous tracheal or bron- 
 chial glands, gummata or syphilitic cicatrices, or a small aneurism. The 
 differential diagnosis of these conditions cannot be made nor can a positive 
 diagnosis of mediastinal tumor be reached until abnormal dulness associated 
 with distinct evidences of intrathoracic pressure appear. With reference to 
 the differential diagnosis, pericardial and pleural effusions, malignant 
 disease of the pleura, and aneurism of the aorta demand special considera- 
 tion. Pericardial Effusion. — Fluid pericardial and pleural exudates pro- 
 gressively displace the organs contained in the mediastinum; mediastinal 
 new growths compress them. A fiat percussion sound is the sign of both 
 conditions; but the area of flatness in uncomplicated effusion into the 
 serous sacs has definite and regular outlines, whereas in mediastinal tumor 
 its borders are irregular and anomalous. In pericardial effusion the apex 
 beat may be faintly palpable within the dull area and more distinct when 
 the patient bends forward. In this attitude the dulness is also slightly 
 increased in its transverse diameter. In mediastinal tumor, on the other 
 hand, the cardiac impulse is at the left border of the dull area, which is 
 
DISEASES OF THE MEDIASTINUM. 1087 
 
 not affected by change of posture. In cases in which the tumor extends 
 between the apex of the heart and the wall of the chest no impulse can be 
 detected. Pleural Effusion. — This condition is frequently associated with 
 mediastinal tumor. Under these circumstances the physical signs are 
 anomalous. The persistence of dulness of irregular outline and compres- 
 sion symptoms after the withdrawal of the fluid are significant. Dyspnoea 
 upon exertion, and dislocation of adjacent organs, unilateral prominence 
 of the chest wall with diminished respiratory excursus upon the same 
 side, point to pleural effusion. In tumor the vocal fremitus is more com- 
 monly preserved, signs of pressure upon the recurrent are more frequent 
 and more marked, and dysphagia is often present. An exploratory punc- 
 ture will at once clear up any uncertainty. Malignant Disease of the Pleura. 
 — More obscure is the differential diagnosis when this condition is pres- 
 ent, especially if the new growth takes origin from the costal pleura and 
 has attained considerable size. These tumors cause local bulging of the 
 chest wall, dulness of irregular outline, effusion into the pleural sac, and 
 compression of the lung, large venous trunks, and the oesophagus, and they 
 may invade the mediastinal spaces. In the latter case they constitute a 
 variety of mediastinal tumors. Aneurism of the Thoracic Aorta. — The 
 differential diagnosis between mediastinal tumor and aneurism may be 
 very difficult, especially in areas in which the outline of the aneurism is 
 irregular and the sac more or less occupied by firm clot. The symptoms 
 of both are due to pressure, and the effects of pressure are practicall}^ the 
 same, whether it be exerted by a solid tumor or one distended with blood. 
 The following data are in favor of mediastinal tumor: marked cyanosis, 
 venous engorgement, and the enlarged superficial veins of collateral circu- 
 lation; right-sided oedema of the face and arm; absence of diastolic shock; 
 absence of tracheal tugging; relatively short duration; if pulsation be 
 present, it is limited in extent, especially in large tumors, and not expan- 
 sile in character; if murmurs be present, they are usually systolic only; 
 enlargement of the lymph-nodes and a firm nodular, rather than an 
 elastic, mass palpable at the sternal notch. The following render the 
 diagnosis of aneurism probable; absence of oedema and cyanosis, and the 
 absence of enlarged superficial veins upon the thorax and abdomen; the 
 presence of diastolic shock and tracheal tugging; prolonged duration; 
 expansile, heaving, and forcible pulsation, either in areas in which the 
 tumor lies in relation with the chest wall or has perforated the sternum; 
 double murmurs, inequality of the radial pulses, and severe boring pain 
 radiating to the back, arms, and neck. Loud murmurs heard over a con- 
 siderable area are common in aneurism, but murmurs may be wholly 
 absent, whereas in mediastinal tumor murmurs are only occasionally heard. 
 
 Examination by the X-rays yields conclusive results when the shadow 
 .shows in any part the rounded expansile pulsation of an aneurismal sac. 
 Rest in bed, a limited diet, the restriction of fluid, and the administration 
 of potassium iodide may be followed by relief of pain in aneurism. 
 
 Diagnosis of the Location of Mediastinal Tumors. — Developing in the 
 anterior mediastinum, new growths push forward and sometimes erode the 
 sternum. They may frequently be felt in the suprasternal notch. The 
 symptoms indicate compression of venous trunks. D5'spna'a is often 
 
10S8 MEDICAL DIAGNOSIS. 
 
 urgent, and the lymphatic glands of the neck are often enlarged. When the 
 growth occupies the middle and posterior mediastinum the physical signs 
 may be obscure. Pressure is especially exerted upon the oesophagus and 
 the recurrent laryngeal nerves. Dysphagia, urgent dyspnaa, and a brassy, 
 laryngeal cough occur. In tumors springing from the pleura or lung 
 symptoms of pressure upon the blood-vessels, nerves, and gullet are less 
 marked; signs indicating compression of the lung itself more prominent. 
 A complicating pleural effusion is common. There is a tendency to rapid, 
 emaciation and cachexia. 
 
 Diagnosis of the Character of Mediastinal Tumors. — The most com- 
 mon forms are carcinoma and sarcoma, the former developing as a 
 rule later in life than the latter, but there are many exceptions to this 
 statement. Rapidity of growth, metastatic tumors, glandular enlargement, 
 loss of weight, anaemia, cachexia, subnormal temperature, and cutaneous 
 pigmentation point to carcinoma. In sarcoma the weight and the appear- 
 ance of fair nutrition may be long maintained. 
 
 Prognosis. — Acute enlargement of the tracheal and bronchial Ij^mphatic 
 glands usually subsides with the pulmonary disease of which it is a feature. 
 Suppurating glands may rupture into contiguous structures or undergo 
 retrogressive changes, with resorption of the fluid and deposition of lime 
 salts. Tuberculous glands remain enlarged, with the tendency to caseation 
 and softening. Abscess is a serious affection, but a fair proportion of the 
 cases are amenable to surgical treatment. Chronic proliferative medias- 
 tinitis is a progressive disease tending to destroy life by impairing the 
 function of the heart. The conditions under which mediastinal emphysema 
 occur are usually of grave prognostic import. Finally, mediastinal tumors 
 are in a large proportion of the cases malignant and without hope. 
 
 VI. DISEASES OF THE PLEURA, 
 i. Pleurisy. 
 
 Definition. — Inflammation of the pleura. The cases may be grouped 
 according to various principles of classification. Etiologically primary 
 and secondary forms may be recognized, but this distinction cannot always 
 be made at the bedside; clinically the disease may run an acute or chronic 
 course, but forms characterized by similar features differ greatly in intensity 
 and duration. The anatomical division into dry or plastic pleurisy and 
 pleurisy with effusion is most convenient for descriptive purposes. 
 
 (a) Fibrinous or Plastic Pleurisy. 
 
 Pleuritis Sicca. 
 
 Acute Dry Pleurisy. — The pleural membrane is the seat of a fibrinous 
 exudate of varying thickness, arranged in a single layer or in superimposed 
 strata. This form of pleurisy apparently occurs in some instances as a 
 primary disease after exposure to cold or contusion of the chest. It is 
 far more frequent as a secondary affection in acute and chronic diseases of 
 the lung when the lesions extend to the pleura. It is an almost constant 
 
PLEURISY. 1089 
 
 accompaniment of croupous pneumonia and very common in broncho- 
 pneumonia. Pulmonary infarct, abscess, gangrene, and malignant disease 
 cause inflammation of the pleura when they extend to the periphery of 
 the lung. Dry pleurisy is a constant accompaniment of chronic pulmonary 
 tuberculosis, alike when the primary infection involves the lung or the 
 pleura itself. 
 
 Symptoms. — The subjective symptoms of pleural irritation are pres- 
 ent, namely, the pain known as stitch in the side, and dry cough. Fever 
 of moderate intensity is usually also present. The pain is usually 
 referred to the region of the nipple or the axilla. In diaphragmatic 
 pleurisy the pain is often referred to the abdomen, especially in children. 
 It is increased upon deep breathing. The respiratory movement is there- 
 fore consciously or unconsciously somewhat restricted, and the patient 
 presses his hand upon the affected side when he coughs. Cough is 
 sometimes absent. 
 
 Physical Signs. — Inspection. — The respirator}' movement is somewhat 
 limited upon the affected side. Palpation. — A distinct friction fremitus 
 may very often be felt. This sign is due to roughening of the opposed 
 pleural surfaces. Percussion. — There is no change in the sound, but upon 
 linear percussion a limited inspiratory descent of the lower border of the 
 Jung upon the affected side may be made out. Auscultation.- — A pleural 
 friction rub, the almost constant and always distinct sign of dry pleurisy, 
 is heard. When the plastic exudate affects the pleura in the neighborhood 
 of the heart the friction sounds occur, not only synchronousl}^ with the 
 respiratory movements, but also with the cardiac revolution — pleuropcri- 
 cardial friction. In miliary tuberculosis involving the pleura a fine, widely 
 diffused friction sound may be heard. 
 
 Diagnosis. — Direct. — The friction sound is of positive diagnostic 
 significance. When it is not heard the diagnosis of fibrinous pleuris)'' can- 
 not be affirmed. Pain in the side, increased upon cough and deep breath- 
 ing, occurs in other conditions. Even when the friction sound is present, 
 "we cannot in every case be sure that the pleurisy of which it is the sign is 
 not associated with pneumonia, or the forerunner of pleural effusion. Time 
 is therefore in certain cases essential to the diagnosis. 
 
 Differential. — Pleurodynia. — Myalgia of the intercostal muscles of 
 one side, intensified by cough and deep breathing, and by pressure 
 often over a circumscribed area, may be mistaken for dry pleurisy. 
 It is more common upon the left side. The absence of friction sounds 
 and the constitutional condition under which myalgias arise render the 
 differential diagnosis an easy matter. Intercostal Neuralgia. — The pain 
 is limited to the course of nerve-trunks and is paroxysmal. There are 
 tender points. The disease is common in neurotic and hysterical women. 
 It is a chronic affection. Friction sounds do not occur. Neuritis of Inter- 
 costal Nerves. — Whether associated with herpes zoster, spinal caries, or 
 disease of the cord, or due to the pressure of a tumor or aneurism, this 
 painful affection of the chest is sometimes mistaken for pleurisy. The 
 one essential diagnostic point is the presence or absence of friction sounds. 
 Causal factors are important, and the distribution of the pain along 
 nerve-trunks with points douloureux is significant. 
 69 
 
1090 MEDICAL DIAGNOSIS. 
 
 Prognosis. — The outlook is mostly favorable. In the primary form, 
 after a few days adhesions take place, the friction murmur disappears, 
 and the pain ceases. The secondary forms often run the same course. 
 
 Chronic Dry Pleurisy. — There are three forms: primitive dr}^ pleurisy, 
 that form which follows the resorption or withdrawal of pleural effusions, 
 and tuberculous dry pleurisy. 
 
 1. Primitive Dry Pleurisy. — This variety may develop insidiously 
 without marked symptoms, and be first recognized by the accidental dis- 
 covery of the friction fremitus, or it may, as is commonly the case, be the 
 outcome of the acute disease. Limited or general pleural adhesions take 
 place. The respiratory function is but little affected. With general bilat- 
 eral adhesions the respiratory play of the chest is restricted. Percussion 
 is normal. The excursus of the lower border of resonance is dimin- 
 ished and the lessened movements of the diaphragm are confirmed by 
 Litten's sign. This form of pleurisy may result in remarkable thickening 
 and connective-tissue proliferation within the lung, with contraction and 
 induration — 'pulmonary cirrhosis. 
 
 2. Adhesive Pleurisy Following the Removal op Exudates. — 
 Upon resorption of an effusion, or its removal by aspiration or otherwise, 
 the pleural surfaces unite and the fibrinous material becomes organized. 
 This process is most marked at the base of the chest and gives rise to a 
 characteristic deformity, in which there is flattening, with narrowing of 
 the intercostal spaces and overlapping of the ribs, deficient expansion, 
 enfeebled respiratory murmur, and dulness. The pathological change is 
 largely due to prolonged pressure atelectasis, a fact of great importance 
 as bearing upon the prompt removal of pleural effusions. The condition 
 follows serofibrinous pleurisy, empj^ema, and traumatism of the chest, 
 especially gunshot and stab wounds. It is of every grade, from the slight 
 retraction of the chest wall following a rapidly removed serofibrinous 
 effusion, relieved by respiratory gymnastics, particularly in young persons, 
 to the gross and disfiguring deformity which is seen after neglected effusions 
 of all kinds, especially old empyemata, and is associated with a permanently 
 compressed, airless, fibroid and bronchiectatic lung. 
 
 3. Tuberculous Dry Pleurisy. — The course of tuberculous dry 
 pleurisy is from the onset essentially chronic and characterized by great 
 thickening, together with implication of the connective-tissue framework 
 of the limg. It may involve both sides and usually begins at an apex. 
 Proliferating pericarditis or peritonitis may be also present. 
 
 Flushing or sweating of one cheek and dilatation of a pupil may 
 occur when the pleural thickening implicates the upper thoracic ganglion. 
 
 The differential diagnosis l^etween a circumscribed pleural effusion 
 and great pleural thickening is in many cases extremely difficult, a fact 
 not surprising in view of the physical condition and the occasional pres- 
 ence of small collections of residual fluid in the thickened pleura. Dulness, 
 even flatness, feeble respiratory sounds, diminished vocal resonance, and 
 absent vocal fremitus occur in both conditions. The use of the aspirator 
 will usually at once determine the diagnosis. 
 
PLEURISY. 1091 
 
 (b) Pleurisy with Effusion. 
 
 Pleuritis Exudativa. 
 
 Definition. — Inflammation of the pleura in which fluid exudate is 
 associated with the fibrin. 
 
 Pleural inflammation is due to microbic infection. The organisms 
 present in the exudate are, with greatest frequency, the tubercle bacillus, 
 the pneumococcus, and the streptococcus; far less commonly the staphy- 
 lococcus, Bacterium coli commune, Friedlander's bacillus, the bacillus of 
 Eberth, and the Klebs-Loffler bacillus. Mixed infections occur. Accord- 
 ing to the character of the effusion the following forms are recognized: 
 serofibrinous, purulent, hemorrhagic, and chyliform. 
 
 SEROFIBRINOUS PLEURISY. 
 
 This term is not used to designate those cases in which small quanti- 
 ties of serum are entangled in the meshes of a loose plastic exudate, but 
 to describe considerable collections of fluid which, unless prevented by 
 adhesions, accumulate under the influence of gravity in the dependent 
 parts of the pleural sac. 
 
 Etiology. — Predisposing Influences. — The cases may be divided 
 into idiopathic and secondary. Idiopathic or primary pleurisy often 
 quickly follows a wetting or chill in an apparently healthy person. The 
 majority of the cases are, however, tuberculous. Serofibrinous pleurisy 
 may follow injury to the chest. With reference to personal predisposition, 
 hospital statistics show a greater liability on the part of males — 5 to 1 — 
 and in middle life, especially between 40 and 50. The disease occurs, 
 however, at all ages. Secondary pleurisy occurs not only in connection 
 with tuberculous disease of the lung, or tuberculous lesions in distant 
 parts of the body, but also in croupous pneumonia and bronchopneumonia, 
 malignant disease of the pleura or lung, pericarditis, rheumatic fever, 
 enteric fever, diseases of the liver, and chronic nephritis. 
 
 Exciting Causes. — Exposure to cold and damp and traumatism 
 lower local tissue resistance to pathogenic micro-organisms. 
 
 Morbid Anatomy. — The serous and fibrinous exudates are present 
 in varying proportions. Fibrin may be scanty, or form thick, shaggy 
 layers upon the pulmonary and costal pleurae and curd-like masses or 
 flocculi which float in the serum and collect in the most dependent part 
 of the pleural sac. The fluid is clear or slightly turbid, according to the 
 relative abundance of cells and fibrin masses which it contains. It is 
 of a pale citron or lemon color, but may be darker. It coagulates on boil- 
 ing, but sometimes on standing undergoes spontaneous coagulation. Chemi- 
 cally it resembles blood-serum. It may show the presence of cholesterin, 
 uric acid, or sugar. Microscopically there are seen leucocj^tes, endothelial 
 cells, fibrin shreds, and erythrocytes. The fluid, according to its volume, 
 exerts prevSsure upon the lungs and adjacent organs. In small effusions 
 the lower lobe is compressed and partially atelectic; in large effusions the 
 entire lung may be reduced to a flat, airless, carnified mass lying against 
 
1092 MEDICAL DIAGNOSIS. 
 
 the spine. In large effusions the mediastinum and heart are displaced 
 toward the opposite side, the diaphragm is depressed, and with it the 
 liver or spleen, as the case may be. 
 
 Symptoms. — Serofibrinous pleurisy may begin insidiously or with 
 acute symptoms. The former mode of onset is more common in children 
 and aged persons and in the secondary forms which develop in acute or 
 chronic disease. The chief symptoms are shortness of breath on exertion 
 and rapid anaemia. The latter may be preceded by prodromes, or a chill 
 with fever and pleural pain may suddenly occur. If relatively mild these 
 symptoms suggest acute plastic pleurisy; if severe, croupous pneumonia. 
 The pain is severe, lancinating, and aggravated by deep breathing. It is 
 referred to the nipple or axillary region; sometimes, probably when the 
 diaphragmatic pleura is involved, to the umbilical region or the hypo- 
 chondriac region of the affected side, suggesting gastralgia, gastric ulcer, 
 or an acute inflammatory infradiaphragmatic inflammation, as cholecys- 
 titis or appendicitis. In rare cases the pain is located in the lumbar region. 
 The temperature rises gradually rather than rapidly and attains an aver- 
 age of 102°-103° F. (39°-39.5° C). The fever is atypical and irregular 
 and of varying duration. Surface observations show in the early course 
 of the disease a slightly higher elevation upon the affected side. Cough 
 as a rule is present. It is accompanied by scanty, mucous expectoration. 
 When this contains blood, a larval pneumonia is to be suspected. Dyspnoea 
 is at first due to the fever and pain; later to circumscription of the respiratory 
 surface in consequence of the compression of the lung. The more rapidly 
 the fluid accumulates the more urgent the shortness of breath. A large 
 effusion if slowly formed may cause little or no dyspnosa so long as the 
 patient lies quietly in bed. A moderate leucocytosis — 12,000 to 15,000 — 
 is present during the febrile period. In a small proportion of the cases the 
 leucocytes are below normal. 
 
 Physical Signs. — Inspection. — The patient prefers to lie upon his 
 back slightly propped up on pillows or upon the affected side. In large 
 effusions the contour of the affected side appears to be abnormally full, 
 and the chest may show upon measurement, due allowance being made 
 for the normal disparity, an increase of 2 or 3 cm. in the semicircumference. 
 The intercostal furrows are absent. The immobility of the affected side 
 is often in striking contrast to the movement of the sound side, which is 
 exaggerated by vicarious function. In right-sided effusion the apex of 
 the heart may be displaced to the fourth interspace beyond the mammiDary 
 Ime, or even as far as the left anterior axillary line; in left effusions the 
 apex may lie behind the sternum and no impulse be seen; or there may 
 be a visible impulse in the third or fourth interspaces as far to the right 
 as the nipple line. Palpation. — The signs obtained upon inspection are 
 confirmed by the sense of touch. The vocal fremitus is diminished or 
 absent. In children the fremitus attendant upon crying is sometimes 
 transmitted along the chest wall to the affected side. It ma}' be present 
 in circumscribed areas over large effusions when there are locaUiied old 
 pleural adhesions. Fluctuation is not a sign of simple serofibrinous 
 pleurisy, and oedema of the chest wall scarcely ever occurs. Mensura- 
 tion. — The difference in the contour between the sides as determined by 
 
PLEURISY. 
 
 1093 
 
 the cyrtometer is very striking. There is an increase in the anteroposterior 
 diameter, together with an increase in the semicircumference. The 
 difference in respiratory expansion may be accurately measured by the 
 saddle-tape. Percussion. — The percussion sound over the effusion is 
 flat, and the percussing finger perceives an absence of elasticity which is 
 very suggestive. Above the level of the fluid, Skodaic resonance — the sign 
 of relaxation of vital intrapulmonary tension — may be elicited in front 
 and to a less degree behind. The upper line of flatness is not horizontal, 
 but rises in a curve resembling the italic letter /S, starting at its lowest 
 point from the spine and rising to the axilla, from which it descends obliquely 
 in a straight line to the sternum. This line, known as " Ettis's line of flat- 
 ness," has been estabhshed by abundant clinical and experimental studies. 
 It is much modified when the patient has been confined to bed during the 
 accumulation of the fiuid, when there are lesions in the lung which modify 
 its shape and consistence, and when the compression of the lung is inter- 
 
 FiG. 319. — Ellis's curve; moderate pleural 
 effusion; patient in upright posture. 
 
 Fig. 320. — Anterior line of flatness. 
 
 fered with by pleural adhesions. It is effaced when the fluid rises above 
 the third rib. The flat percussion sound on the right side is continuous 
 with that of the liver, from which it cannot be discriminated; on the left 
 in the mammillary line it extends to Traube's semiliinar space, the convex 
 upper border of which becomes gradually flattened as the fluid increases. 
 The rising and falling of the upper line of dulness, as the effusion increases 
 or undergoes resorption, may be demonstrated by careful, light percussion 
 and markings upon the skin at intervals of two or three days. In moderate 
 effusions in which the lung is not confined by adhesions movable dulness 
 may be demonstrated by marking the upper line of dulness in the anterior 
 surface while the patient is in the erect or sitting posture, and again after 
 some time spent in the dorsal decubitus. Massive effusions reach the 
 clavicle and even extend to the sternal border of the opposite side. The 
 downward dislocation of the liver or spleen may be demonstrated by 
 linear percussion, which enables us to demonstrate the lower borders of 
 these organs respectively. The liver is depressed in very lai-ge left effu- 
 sions by reason of the dislocation of the heart toward the right, the crowd- 
 ing of the lung in the right pleural cavity, and the general depression 
 of the diaphragm. 
 
1094 
 
 MEDICAL DIAGNOSIS. 
 
 Normal Paravertebral Triangles of Relative Dulness. — Upon percussion 
 over the spine from above downward, the resonance is progressively dimin- 
 ished in the lower thoracic region. This impairment of resonance also 
 extends laterally in such a m.anner as to form on each side of the lower 
 thoracic spine a narrow triangle of relative dulness, the base of which 
 corresponds to the lower limit of normal pulmonary resonance. 
 
 Koranyi's (Grocco's) Sign; Abnormal Paravertebral Triangles of Dul- 
 ness. — These triangles appear upon the sound side in pleural effusion, and 
 may differ from the normal triangles only in respect of the degree of dul- 
 ness. More commonly they differ also in extent. The procedure is as 
 follows: (1) The borders of the effusion are determined by percussion. 
 (2) The base of the lung upon the sound side is ascertained by percussing 
 from above downward. (3) The degree of resonance over the spinous 
 processes is learned by percussion also from above downward, and the 
 point at which relative dulness begins is noted. This commonly is at the 
 
 Fig. 321. — Normal paravertebral triangles. 
 
 Fig. 322. — Right pleural effusion with triangle 
 of dense paravertebral dulness on left side. 
 
 level of impaired resonance, or slightly above the level of flatness on the 
 side of the effusion. (4) Percussion upon the sound side in a direction 
 toward the spine in serial horizontal lines from above downward reveals 
 a paravertebral right-angled triangle of dulness, the vertical side of which 
 corresponds to the spine and rises to or slightly above the level of the 
 effusion on the opposite side, the base to the lower border of the lung, 
 while the hypothenuse extends from the apex to the outer and lowest 
 point of dulness. The base line varies with the volume of the effusion and 
 may reach 6 or 10 cm. in length. The triangle is usually larger in right- than 
 in left-sided effusions. The respiratory murmur, vocal resonance, and 
 vocal fremitus are enfeebled over this area of dulness. The phenomenon 
 occurs alike in hydrothorax and in serofibrinous and purulent effusions. 
 The base line is longer in purulent than in serous effusions. The triangle 
 in free effusions disappears upon change from the upright to the recumbent 
 posture. The explanation of the paravertebral triangles of dulness is not 
 clear. It is probable that under normal conditions the vibrations of the 
 lung tissue are to some extent inhibited by the bodies of the vertebras 
 against which it rests, and that an effusion upon the opposite side acts as 
 a "mute" or damper and still further interferes with the vibrations of 
 the lung in the costovertebral recess of the sound side. 
 
PLEURISY. 1095 
 
 Auscultation. — In the beginning of the attack friction sounds 
 having the quality and situation of the friction signs in acute fibrinous 
 pleurisy are heard. When the case has been under observation from the 
 beginning, the rapid replacement of this sign by flatness is of the highest 
 diagnostic significance. As the fluid undergoes resorption and the pleural 
 surfaces once more come in contact, friction soimds are again heard. At 
 this period they are grating or creaking, or fine and moist, like the crepitus 
 of pneumonia, and are heard just above the level of flatness. As expansion 
 of compressed vesicular tissue accompanies the process of resorption, 
 there are crepitant rales to be heard. As the fluid accumulates, the respira- 
 tory murmur becomes at first feeble and distant. Later, while retaining 
 its distant quality it assumes the bronchial character and may be amphoric. 
 Cavernous respiration associated with rales, especially in children, may 
 suggest a cavity. Over large effusions the respiratory sounds may be 
 wholly absent. Above the level of the fluid the respiration is vesiculo- 
 bronchial or bronchial. The vocal resonance is usually diminished or 
 absent. In rare instances there is bronchophony, ^gophony is sometimes 
 heard in the scapular region in medium-sized effusions. The whispered 
 voice is better transmitted through a serous than a purulent effusion — 
 Bacelli's sign. 
 
 The Heart. — The diastole is restricted by pressure. The sounds are 
 therefore usually less distinct than normal. There is a diminished flow 
 of blood into the arteries, which causes small pulse and a tendency to 
 cyanosis and oliguria. Murmurs are not uncommon in the displaced heart, 
 and a pleuropericardial friction may be detected in many cases. 
 
 Clinical Course of Serofibrinous Pleurisy. — The cases may be grouped 
 according to the amount of fluid, which varies up to 4 litres. Less 
 than 500 c.c. cannot be satisfactorily demonstrated in an adult. There 
 are many cases in which the effusion does not exceed this amount and 
 manifests itself by limited dulness at the base of the chest and immobility 
 of the lower border of pulmonary resonance. Spontaneous arrest of the 
 process occurs and resorption begins — slight effusion. In another group 
 the fluid reaches to the level of the fourth rib in front and resorption is 
 more tardy — moderate effusion. Again the upper line of flatness may reach 
 the second rib — large effusion; and finally there are cases in which the 
 outpour of the serous exudate appears to be limited only by the capacity 
 of the pleural sac, and the whole side is distended and flat, the signs of 
 fluid reaching to the clavicle and beyond the opposite sternal border — 
 massive effusion. 
 
 In slight effusions the fever subsides, the cough ceases, and recovery 
 takes place in the course of a week or ten days. Some impairment of 
 resonance with feeble respiratory sounds usually persists for a longer 
 period. In moderate and large effusions the tendency is to spontaneous 
 resorption, but the process is slow and permanent damage to the lung 
 results from prolonged pressure atelectasis. In this group there is commonly, 
 but by no means invariably, a gradual subsidence of fever. The exceptional 
 cases in which fever persists impair the usefulness of this symptom in the 
 differential diagnosis between serofibrinous and purulent pleurisies. Mas- 
 sive effusions when the intrapleural pressure is extreme are usually attended 
 
1096 MEDICAL DIAGNOSIS. 
 
 with distressing pressure symptoms. In cases in which the accumulation 
 of fluid has been slow, the patient may experience merely a sense of weight 
 and oppression, with shortness of breath upon exertion. Large effusions 
 arrest the pumping function of the thoracic organs, and thereby diminish 
 the outflow of arterial blood from, and the inflow of venous blood to, the 
 heart, and the movement of the lymph. They show little or no tendency 
 to undergo resorption. Serofibrinous effusions in very rare instances 
 have perforated the lung or the chest wall. In massive effusions with 
 great dislocation of the heart there is danger of sudden death, an accident 
 attributed to various causes, as heart-clot, embolism of the pulmonary 
 artery, paralysis of the heart muscle, and twists or kinking of the great 
 vessels. The last of these explanations is purely hypothetical. Sudden 
 oedema of the functionating lung occurs when death is not immediate. 
 
 PURULENT PLEURISY: EMPYEMA. 
 
 This designation is applied to those cases of pleural inflammation 
 characterized by the formation of pus. When pus finds its way into the 
 pleural sac by perforation from neighboring structures the condition is 
 known as pyothorax. 
 
 Etiology. — Predisposing Influences. — Empyema is mostly a 
 secondary affection. It occurs as a sequel to the infectious febrile diseases, 
 especially scarlet fever, and is common after croupous pneumonia and 
 bronchopneumonia and in connection with abscess and gangrene of the 
 lung. It constitutes a rare complication of pulmonary tuberculosis, occur- 
 ring in tuberculous bronchopneumonia and less frequently in consequence 
 of pleural infection from a caseating lesion or a subpleural tuberculous 
 abscess. Direct infection from without may also occur, as in fracture of 
 a rib or a penetrating wound of the chest. It occurs at every age and is 
 common in young infants, in whom a false diagnosis of pneumonia is 
 frequently made. 
 
 Exciting Cause. — The usual organisms in their order of frequency 
 are the pneumococcus, the ordinary pyogenic bacteria, and the tubercle 
 bacillus. The influenza bacillus and the Bacterium coli communis have 
 been found in rare instances. Empyema is not a stage in the course of 
 serofibrinous pleurisy. The conversion of the serous into the purulent 
 effusion is unusual. In very rare instances serofibrinous effusions have 
 been infected in aspiration. 
 
 Morbid Anatomy. — The lung is compressed to an airless mass. The 
 pleural surfaces are thickened, and are the seat of a grayish-white granular 
 exudate. Upon the costal layer may be seen superficial erosions and some- 
 times the openings of fistulous tracts. The fluid has the gross and micro- 
 scopical characters of ordinary pus, varying from a thin to a thick or 
 creamy consistence. Its odor is sometimes sweetish, but in many cases, 
 especially those following wounds or associated with gangrene, it is 
 horribly fetid. 
 
 Symptoms. — An abrupt onset with acute symptoms is rare. The 
 common beginning is insidious, with an intensification of the symptoms 
 of the primary affection. Cough is neither frequent nor urgent; there is 
 
PLEURISY. 1097 
 
 little or no expectoration, and dyspnoea, except m large effusions, is present 
 only upon exertion. The symptoms of sepsis, as pallor, chilliness, irregular 
 fever, and more or less profuse sweating, are very common, especially in 
 children. There is a high leucocytosis, 40,000 or more per cubic millimetre. 
 Physical Signs. — The signs elicited upon physical examination are 
 the same as in serofibrinous pleurisy, with the following superadded: 
 marked bulging of the affected side with obliteration, even prominence, 
 of the intercostal spaces in the lower segment of the chest, especially in 
 children. In many cases oedema and cyanotic discoloration of the lower 
 part of the chest with dilatation of the venules. Whispering pectoriloquy 
 is not heard over the effusion — Bacelli's sign. Distinct bronchial breath- 
 ing, transmitted along the chest wall, is often heard over the effusion in 
 young children, a sign which may lead to a false diagnosis of pneumonia. 
 Displacement phenomena, affecting the heart, liver, and spleen, are 
 more pronounced than in serofibrinous effusion, a fact attributed to the 
 greater weight of the fluid, but probably due to the greater impairment 
 in the tonicity of the tissues from the imbibition of toxin laden fluids. 
 
 VARIETIES OF PURULENT PLEURISY. 
 
 Empyema Necessitatis. — The pus by erosion of the costal pleura 
 finds its way through an intercostal space and forms a subcutaneous, 
 fluctuating tumor. This tumor may appear at various parts of the chest, 
 but is usually situated anteriorly from the third to the sixth interspace. 
 After a time if left to itself it opens, and an oblique fistulous communica- 
 tion with the pleural cavity is established, which continues to discharge 
 pus for an indefinite time. When near the heart the tumor may pulsate. 
 It is usually hemispherical and diminished in size upon full inspiration. 
 
 Pulsating Pleural Effusion. — The pulsation is synchronous with the 
 cardiac revolution, and may be intrapleural and manifest in the lower 
 intercostal space, in the anterolateral aspect of the chest, or show itself 
 merely in an empyema necessitatis. The pulsation occurs in old cases, 
 almost always upon the left side, and with one exception among the 
 reported cases the effusion has been purulent. Various explanations have 
 been advanced, none of which has met with general acceptance. 
 
 Encysted or Circumscribed Pleural Effusion. — The effusion is limited 
 by pleural adhesions. The encysted fluid may vary in amount and suggest 
 abscess of the lung, or two or more loculi may communicate with each 
 other by narrow openings. It is sometimes serofibrinous but usually pur- 
 ulent. These collections may be situated between the pulmonary and 
 costal pleura, especially in the posterolateral region of the chest between 
 the base of the lung and the diaphragm, or they may be interlobar. 
 
 HEMORRHAGIC PLEURISY. 
 
 The exudate is mixed with blood. The condition is to be distinguished 
 from ha3mothorax, which arises in the absence of pleural inflammation 
 when blood escapes into the pleural sac from traumatism, the rupture of 
 an aneurism, or the compression of thoracic veins by a new growth. 
 
1098 MEDICAL DIAGNOSIS. 
 
 Etiology. — Hemorrhagic effusion is of comparatively infrequent 
 occurrence. It is encountered in pleurisy under the following conditions: 
 in the malignant and hemorrhagic forms of the acute febrile infections; 
 in visceral diseases associated with extensive vascular changes, as chronic 
 nephritis and cirrhosis of the liver; in tuberculous disease, both miliary 
 tuberculosis of the pleura and the more chronic pleural tuberculosis which 
 accompanies chronic ulcerative phthisis; in primary and secondary malig- 
 nant disease of the pleura, — carcinoma and sarcoma, — very rarely in 
 so-called idiopathic or primary serofibrinous pleurisy, in which, however, 
 red corpuscles are always to some extent present. 
 
 CHYLIFORM PLEURAL EFFUSIONS: HYDROPS ADIPOSUS. 
 
 The exudate has a milky appearance due to the fatty metamorphosis 
 of endothelial and other cellular elements. The condition is not to be con- 
 founded with chylous effusion which it closely resembles. The fact is not 
 to be overlooked that a mixture of chyliform exudates and chylous 
 transudates may be present — as in a case recently under my care. 
 
 Etiology. — Chyliform effusions owe their peculiar appearance to, (a) 
 the presence of cells that have undergone fatty degeneration, as in car- 
 cinoma of the pleura, tubercular pleurisy, non-tuberculous exudate, pleurisy 
 and abscess of the lung, and (b) to abnormal fat in the blood — lipsemia. 
 
 Diagnosis. — The nature of the effusion cannot be suspected during 
 life unless it is withdrawn by aspiration. The fluid is yellow, whey-like, 
 and cheesy. Upon standing there collects upon the surface a cream-like 
 layer, showing under the microscope small globules, mostly in the form 
 of collections of highly refractive granules with large indistinct nuclei. 
 In the underlying fluid are leucocytes and larger cellular elements which, 
 in consequence of differences in the amount of fat, show all possible tran- 
 sitional forms. (Compare this description with that of chylous effusion, 
 p. 1103.) Pseudochylous effusions have been ascribed to the presence of 
 lecithin, and Edsall has described a non-fatty pleural effusion in which 
 the opacity was due to altered globulins. 
 
 The Diagnosis of Pleurisy with Effusion. — Direct. — The diagnosis 
 rests upon the physical signs. In large effusions the physical examination 
 yields conclusive results. The signs may be divided into primary, or those 
 dependent upon the presence of the fluid per se, and secondary, or those 
 due to the pressure of the fluid upon adjacent organs — displacement signs. 
 Among the more important of the primary signs are restricted respiratory 
 movement, flat percussion, absence of vocal fremitus, feeble and distant 
 breath sounds, and diminished or absent vocal resonance. The important 
 secondary signs are displacement of the heart toward the opposite side, 
 as shown by a visible or palpable impulse, or, in its absence, by the point 
 of maximum intensity of the first sound; downward dislocation and immo- 
 bility of the liver when the pleural effusion is right-sided; flattening of 
 the convex upper border of Traube's semilunar space; and displacement 
 of the spleen when the effusion is left-sided. Linear percussion shows 
 restriction or absence of movement of the borders of the lung on the affected 
 side, and inspection increased — vicarious — respiratory movement upon 
 
PLEURISY. 1099 
 
 the opposite side. Difficulties arise in moderate effusions. Here the 
 primary symptoms are usually characteristic but the valuable aid afforded 
 by displacement phenomena is lacking. The methods of physical diagnosis 
 must be employed with great nicety in doubtful cases. The >S-shaped 
 upper line of dulness, movable dulness when present, linear percussion, 
 flatness below and Skodaic resonance above the border line, absent or 
 enfeebled breath sounds, and absent or enfeebled vocal resonance and 
 vocal fremitus are significant. When several or all of these signs are present 
 the diagnosis of effusion can be made with some confidence. In small 
 effusions the diagnostic problem becomes more difficult and more inter- 
 esting. The same signs are present, but to recognize them demands the 
 highest skill. Finally, we have the aspirator needle which can be used 
 in any case of doubt. There are several reasons why the aspirator should 
 be used in exploratory puncture rather than the hypodermic syringe. 
 The needles are longer and of larger calibre, an important matter in en- 
 cysted effusions or where there is thick pus; when the exudate is sero- 
 fibrinous the exploratory puncture becomes at once a therapeutic pro- 
 cedure and a single operation takes the place of two, and when pus is 
 present the ocular demonstration prepares the patient for the necessary 
 later surgical operation of drainage. 
 
 The apparatus and spot selected must be sterilized, according to sur- 
 gical requirements, directly before the operation. The needle should be 
 introduced at a level in which the ordinary signs of effusion, as dulness, 
 absent or enfeebled respiration, and absent or diminished fremitus, are 
 well defined. As a rule, in ordinary effusions the sixth or seventh inter- 
 space in the midaxillary line, or a spot just below the angle of the scapula, 
 may be chosen. If the puncture is made too low the needle simply pene- 
 trates the costodiaphragmatic reflexion of the pleura and may enter the 
 liver; if too high it will be inserted into the compressed lung above the 
 level of the effusion. The point selected for an exploratory puncture in a 
 circumscribed lesion will be determined by the physical signs. It is an 
 imperative rule to test the instrument with sterile water immediately 
 before it is used. 
 
 Differential. — It is in the atypical cases that special difficulties arise. 
 
 Croupous Pneumonia. — The general rule that increased vocal fremitus 
 occurs in pneumonic consolidation and diminished or absent vocal fremitus 
 in effusion is subject to exceptions. In consolidation a plug or mass of 
 tough mucus may obstruct a main bronchus and arrest the vibrations, 
 while in effusion they may be distinctly transmitted along bands of old 
 pleural adhesions, or in children from the opposite side along the elastic 
 walls of the chest. The occurrence of bronchophony and bronchial res- 
 piration in certain cases add to the difficulty. The following points are 
 to be considered: 
 
 (1) In pleurisy, onset with moderate fever and no rigor; at most 
 chilliness or slight chill; (2) dulness increasing to flatness at the base and 
 posteriorly, and extending upward and forward; a peculiar sensation 
 of inelasticity to the percussing finger; (3) vocal fremitus, enfeebled or 
 abolished in the great majority of cases; (4) bronchial respiration, if heard 
 at all, at the upper level of dulness or in patches; usually distant and 
 
1100 MEDICAL DIAGNOSIS. 
 
 faint; (5) bronchophony not intense, segophony common in the scapular 
 region; (6) friction sounds when the case is seen early and at the upper 
 border of dulness upon resorption of the fluid, when crepitus may be pres- 
 ent; (7) in large effusions displacement signs; (8) sputum, mucoid 
 when present, very rarely blood-tinged ; (9) fever of irregular remittent type. 
 
 In pneumonia, (1) onset abrupt with chill, often prolonged and severe; 
 (2) dulness rather than flatness, coextensive with the borders of a lobe or 
 lobes; (3) vocah fremitus, marked and corresponding to the dulness, and 
 especially when, if feeble or absent, it reappears after cough and the 
 expectoration of tough mucoid sputum; (4) bronchial breathing most 
 marked over area of greatest dulness and often whiffing or snoring in 
 character; (5) bronchophony marked; segophony rare; (6) crepitant rales, 
 high-pitched and in ''showers of crackles" diffused over an area of dul- 
 ness and disappearing when bronchial breathing becomes intense; (7) dis- 
 placement phenomena absent; (8) rusty or prune-juice sputum the rule; 
 (9) high temperature of typical range, self-limited course, and critical 
 defervescence. Pleurisy with effusion is frequently associated with croup- 
 ous pneumonia and bronchopneumonia. 
 
 Pericardial Effusion. — When large this condition may simulate left- 
 sided pleural effusion. The outline of the area of dulness anteriorly, its 
 convexity to the right of the sternum, Skodaic resonance at the base and 
 in the axillary region, absence of cardiac impulse on the right, and a degree 
 of dyspnoea and cardiac feebleness not seen in moderate pleural effusions 
 are of diagnostic importance. 
 
 Hydrothorax. — When unilateral, this condition cannot always be differ- 
 entiated from serofibrinous pleurisy by the ordinary methods of physical 
 examination. It occurs in heart disease with great enlargement or dilatation. 
 The diagnosis rests upon concomitant conditions and character of the fluid. 
 
 Intrathoracic Tumors. — New growths of the lung, pleura, and medias- 
 tinum may be mistaken for pleural effusion. The situation of the dulness 
 and its irregular outline, the signs of marked compression of the large 
 venous trunks, important nerves, and hollow organs, as the trachea, bronchi, 
 and oesophagus, indications of malignant disease in other parts of the body, 
 and enlargement of superficial lymph-nodes should prevent this error. 
 Intrathoracic tumors are very often complicated by pleural effusion. 
 
 Aneurism. — Pulsating empyema necessitatis may suggest aortic aneu- 
 rism. The location of the tumor, usually at the base of the chest, the 
 absence of murmurs, diastolic shock, and tracheal tugging, and the fact that 
 on deep inspiration the tumor diminishes in size and tension are against 
 the diagnosis of aneurism. A fine exploratory needle may be introduced. 
 
 Extrapleural Abscess. — This rare condition is to be differentiated from 
 pleural effusion by the absence of the signs of compression of the lungs and 
 the displacement of adjacent organs. When such an abscess is opened pneu- 
 mothorax does not occur and a probe does not enter the pleural cavity. 
 
 Subphrenic Abscess. — This condition may suggest a moderate pleural 
 effusion, from which it may be differentiated by the persistence of the 
 respiratory movement of the lower border of the lung, the presence of 
 food particles in the aspirated fluid when the condition is due to gastric 
 ulcer, perihepatic friction, and the absence of pneumothorax upon puncture. 
 
PLEURISY. 1101 
 
 Tumors of the Liver. — Abscess, hydatid cyst, and carcinoma in the 
 right lobe of the liver may displace the diai3hragm upward, compress the 
 lung, and cause dulness and feeble respiratory murmur. If large they may 
 also dislocate the cardiac impulse slightly to the left. The diagnosis of 
 hepatic enlargement rests upon the retention of the respiratory movement 
 of the lower border of the lung, friction sounds over the area of dulness, 
 and demonstrable convexity of the upper line of dulness. Exploratory 
 puncture may be performed. 
 
 Perforation of the diaphragm may, when adhesions to the liver have 
 taken place, cause a condition not to be differentiated clinically from 
 hepatic abscess, unless the case has been observed from its onset, or 
 pus which is characteristic of hepatic abscess is expectorated or obtained 
 by operation. 
 
 The Diagnosis of the Character of the Effusion. — This may be readily 
 settled by the use of the aspirator needle. With this means at our dis- 
 posal the clinical symptoms, which are somewhat uncertain, assume sec- 
 ondary importance. A serofibrinous effusion is suggested by comparatively 
 mild onset, the absence of the evidence of previous disease, the transmission 
 of the whispered voice, and in general a mild course characterized merely 
 by malnutrition, anaemia, and dyspnoea upon exertion. That the effusion 
 is purulent is rendered probable by the presence of pneumonia, influenza, 
 sepsis or phthisis, irregular chills, high fever and copious sweating, non- 
 transmission of the whispered voice, oedema and cyanosis of the lower 
 portion of the affected side, and a high leucocytosis. But pus may be 
 present in default of several of these symptoms, on the one hand, and, on 
 the other, severe septic phenomena may accompany a moderate, even a 
 small circumscribed serous effusion. Hemorrhagic and chyliform fluids 
 can be recognized only when withdrawn. 
 
 The Diagnosis of the Pathological Process. — The examination of the 
 fluid is of great service both as regards diagnosis and prognosis. A major- 
 ity of serofibrinous effusions are of tuberculous origin. Tuberculous foci 
 may or may not be present in the lungs. The methods of examination 
 comprise cytodiagnosis, which may be employed at the bedside, and animal 
 inoculation, microscopy, and culture methods, which are available only in 
 the laboratory. Lymphocytes generally predominate in tuberculous 
 effusions; a polynuclear leucocyte preponderance suggests acute infection, 
 and a large number of endothelial cells is found in mechanical effusion or 
 transudate. Inoculation methods, with small amounts of the fluid, as 
 usually practiced are negative, but when larger quantities, as 15 c.c, are 
 used, the result has confirmed the clinical and pathological findings in 
 regard to the preponderance of tuberculous cases in serofibrinous effusions. 
 If actual fragments of cancerous tissue are present the diagnosis is 
 positive. Bacteria are present in small numbers in clear exudates. In 
 purulent exudates they are present in great numbers, sometimes a single 
 variety, sometimes several varieties. Streptococci are most commonly 
 present. The infection may be direct from the lung, as in broncho- 
 pneumonia or streptococcus pneumonia, or from distant foci. Less com- 
 mon is pneumococcus infection, which is usually secondar}^, exceptionally 
 primary. 
 
1102 MEDICAL DIAGNOSIS. 
 
 The Prognostic Value of the Bacteriological Examination of the 
 Fluid. — A sterile fluid usually may be regarded as of tuberculous origin. 
 The presence of the pneumococcus is relatively favorable, since the cases 
 generally run a satisfactory course and recovery may take place after a 
 single aspiration. Streptococcus pleurisy is the most unfavorable of all 
 forms. It is frequently associated with general septicaemia and leads up 
 to the fatal issue. The mixed infections are of unfavorable import. 
 
 The Prognosis of Purulent Pleural Effusions. — Empyema is an essen- 
 tially chronic disease. If neglected the outlook as to recovery is extremely 
 unfavorable, and when spontaneous recovery occurs it is only partial. 
 Early and efficient drainage is followed by a large proportion of satisfactory 
 recoveries. The most unfavorable cases are those which arise in the course 
 of general streptococcus infection. Untreated cases may terminate: 1. 
 In small empyemata, by gradual resorption of the fluid and the deposition 
 of lime salts. 2. By the discharge of the pus through the lung, more com- 
 monly after the establishment of a bronchopulmonary fistula, very rarely 
 by soakage without the formation of a demonstrable fistula. In the former 
 case pneumothorax almost always occurs, in the latter probably never. 
 If sudden rupture occurs life may be destroyed by suffocation. 3. By 
 the perforation of the costal or diaphragmatic pleura and the formation 
 of empyema necessitatis which, though usually in the anterior surface of 
 the chest, may be at any point, including the lumbar region and the iliac 
 fossa, where it simulates a lumbar or psoas abscess. Under these circum- 
 stances there is usually permanent atelectasis of the lung with fibroid 
 changes, great pleural thickening, and contraction and deformity of the 
 chest. A fair degree of health may be maintained for a varying period, 
 but if the patient survive there is clubbing of the finger-tips, amyloid dis- 
 ease develops, and ultimately tuberculosis in a large proportion of the cases. 
 
 Morbid States Characterized by the Transudation of 
 
 Serum or Chyle, or the Eruption of Pus, Blood, or 
 
 Air Into the Pleural Sac. 
 
 (a) HYDROTHORAX. 
 
 Definition. — The accumulation of simple non-inflammatory fluid in 
 the pleural cavities. It occurs as a secondary affection in many diseases, 
 chiefly those attended by dropsy. 
 
 Etiology. — The primary disease may involve the kidneys, the heart, 
 or the blood. There is usually more or less anasarca, exceptionally merely 
 slight oedema of the feet. Hydrothorax is in many cases the precursor 
 of death. In disease of the kidneys it is commonly bilateral, the effusion 
 being greater on one side, usually the right. In chronic valvular disease 
 with hypertrophy and dilatation, the effusion is always more marked 
 and sometimes solely upon the right side, and it promptly returns 
 after repeated aspiration. The right-sided hydrothorax of cardiac dis- 
 ease has been ascribed to pressure upon the azygos veins, but it is prob- 
 ably due to the larger space in the left thorax occupied by the enlarged 
 heart. Extensive old pleural adhesions may prevent accumulation upon 
 
PYOTHORAX. 1103 
 
 one side. The pleural membranes are not the seat of a fibrinous exudate, 
 being smooth and glistening. The fluid is clear and free from fibrin floc- 
 culi. It is usually moderate in amount. The symptoms are dyspnoea, 
 often amounting to orthopncsa, and an aggravation of those due to the 
 primary disease. The physical signs are those of pleural effusion. 
 
 Diagnosis. — The condition may be differentiated from serofibrinous 
 pleurisy by the nature of the primary disease, the absence of fever, of 
 displacement symptoms, of friction sounds, and the relatively prompt 
 change in the line of dulness with change of posture. 
 
 ^) CHYLOUS PLEURAL EFFUSION— HYDROPS CHYLOSUS. 
 
 Definition. — An accumulation of chyle from the thoracic duct or the 
 lacteals by transudation or direct discharge into the pleural sac. 
 
 Etiology. — The special causes of chylous effusion into the pleural 
 sac are, (a) conditions leading to an escape of chyle, as external violence, 
 disease or occlusion of the chyliferous vessels, carcinoma of the pleura, 
 occlusion of the left subclavian vein, compression of the duct by a tumor, 
 malignant lymphoma, disease of lymphatic vessels, sclerosis, lymphan- 
 giectasis, and filariasis, and (b) the discharge of a chylous ascites into the 
 pleural cavity by way of the lymph spaces. 
 
 Symptoms. — The symptoms and physical signs do not differ in any 
 particular from those of a pleural effusion. 
 
 Diagnosis. — There are no means by which the nature of the fluid can' 
 be determined intra viiam except by the withdrawal of a portion of it. 
 In many of the reported cases its presence was first recognized at the 
 autopsy. The fluid bears the closest resemblance to milk, is literally milk- 
 like. It is opaque white in color, with a faint yellowish or creamy shade, 
 slightly alkaline, and of a specific gravity of about 1,017. Microscopically 
 there are seen great numbers of minute, dust-like granules in active, molec- 
 ular movement, a few larger fatty bodies scattered separately or in groups, 
 a few leucocytes, larger cells containing distinct, highly refracted granules, 
 and a very few erythrocytes. Shaken with ether in a test-tube after the 
 addition of a few drops of potassium hydroxide, the fluid becomes trans- 
 parent and almost colorless. Upon the addition of osmic acid it becomes 
 black in color. The morphological elements are almost exclusively leuco- 
 cytes and, in great preponderance, lymphocytes. The fluid is sterile. The 
 foregoing characters serve to distinguish chylous effusion — transudates — 
 from chyliform effusions — exudates (see p. 1098). The presence of grape- 
 sugar is without diagnostic importance, since the fact has recently been 
 established that this substance may frequently be demonstrated in ordinary 
 serous transudates and exudates, and may therefore be expected in 
 chyliform exudates. 
 
 (c) PYOTHORAX. 
 
 The sudden rupture of a hepatic, subphrenic, mediastinal, or pul- 
 monary abscess into the pleural sac may take place. This accident is 
 usually prevented by more or less extensive pleural adhesions. When it 
 occurs, general infection of the pleura immediately follows with the 
 
1104 MEDICAL DIAGNOSIS 
 
 conversion of pyothorax into purulent pleurisy. Communication with 
 the bronchi or with a subplirenic pneumothorax will give rise to the 
 association of air with the pus — pyopneumothorax. 
 
 (d) H/CMOTHORAX. 
 
 Hemorrhage into the pleural cavity results from trauma, the rupture 
 of an aneurism, the pressure of a tumor upon the thoracic veins, and in 
 rare instances from pulmonary gangrene. The sudden manifestation of the 
 symptoms of internal hemorrhage, pallor, collapse, small, thready pulse, 
 coupled with the physical signs of pleural effusion justify a provisional 
 diagnosis. The withdrawal of blood upon exploratory puncture renders 
 the diagnosis positive. 
 
 (e) PNEUMOTHORAX. 
 
 Hydropneumothorax; Hcemopneumothorax; Pyopneumothorax. 
 
 Definition. — Air in the pleural cavity. This condition is extremely 
 rare. Infection of the pleura takes place in almost every instance, and 
 in the course of a short time the air is associated with fluid — hydropneumo- 
 thorax, hcemopneumothorax, or pyopneumothorax. 
 
 There exists in the normal pleural cavity a negative pressure, by 
 reason of which the lung fills the chest in a state of vital tension. When, 
 'through any communication with the external atmosphere, the tension 
 is relieved, the distended lung collapses to the limits of its inherent elas- 
 ticity, and a volume of air, equivalent to the differences in the mass of the 
 lung under normal distention and under balanced intrapulmonary and 
 intrapleural pressure, enters the pleural sac — pneumothorax. This balance 
 is, however, maintained only in the case of the communication remaining 
 freely open as in some external wounds or perforation through consolidated 
 lung tissue. Under other circumstances a valvular action is established, 
 particularly in the perforation through the lung, and the intrapleural 
 pressure gradually becomes positive. While the balance is maintained, 
 the mediastinum is drawn toward the opposite side, and the diaphragm 
 somewhat depressed; when the pressure becomes positive, displacement 
 phenomena become more marked, the mediastinum is pushed further to- 
 ward the sound side, and the diaphragm pushed downward. 
 
 Etiology. — Pneumothorax is caused by: 1. Perforating wounds 
 of the pleura: (a) through the chest wall, as in the case of stabs and gun- 
 shot injuries, aspiration and other surgical operations; (b) internal trauma, 
 as when sharp or pointed foreign bodies are swallowed, or an emphy- 
 sematous lung or one tied down by local adhesions is torn in violent 
 efforts at lifting or in paroxysms of cough. The accident may even occur 
 in the absence of straining. The air may gradually undergo resorption. 
 More commonly pleurisy with effusion follows. 2. Perforation of the 
 pleura by ulceration or necrosis: (a) from without, as in (i) diseases of the 
 lung: (a) tuberculosis, by far the most common cause, the perforating 
 lesion being the softening of a caseous mass or the rupture of a rapidly 
 forming cavity before limiting pleural adhesions have taken place. (^) 
 
PNEUMOTHORAX. 
 
 1105 
 
 Necrosis of lung tissue in septic conditions, as septic bronchopneumonia, 
 gangrene, and very rarely infarctions. (ii) Malignant disease of the 
 oesophagus. (iii) Infradiaphragmatic lesions, as (a) subphrenic abscess, 
 (/?) abscess of the liver, (;-) malignant disease of the stomach or colon, 
 (b) From within, as in empyema, with the formation of a bronchopul- 
 monary or pleurobronchial fistula. 3. As the result of the development 
 in pleural exudates of the gas-producing bacillus — B. aerogenes cap- 
 sulatus of Welch. 
 
 In rare cases pneumothorax is double, and recurrent cases have been 
 reported. The condition is common in adults, exceptional in children. 
 
 riorbid Anatomy. — The air space is usually large, the lung compressed 
 and carnified, the pleura inflamed, and serous or purulent effusion present. 
 The confined air may escape through a 
 cannula with a whistling sound and 
 force enough to blow out a candle. 
 
 Symptoms. — The occurrence of 
 pneumothorax is usually attended by 
 sudden pain in the side, distressing 
 shortness of breath, slight cyanosis, and 
 feeble pulse. In old tuberculous cases 
 it may occur insidiously. 
 
 Physical Signs.— The results of 
 physical examination are characteris- 
 tic. Inspection.- — The affected side is 
 enlarged, the intercostal spaces bulge, 
 and the respiratory excursus is greatly 
 diminished. The impulse of the heart 
 is displaced toward the opposite side, 
 absent or greatly diminished. Percussion. — The signs depend upon 
 the degree of intrapleural tension and the amount of fluid present. 
 When tension is moderate the physical conditions necessary to the pro- 
 duction of tympanitic resonance are present, and as these conditions vary 
 the quality of tympany changes from clear, high-pitched hyperresonance 
 to the flat, woodeny tympany of Skodaic resonance. When tension is 
 extreme the physical conditions underlying tympany no longer exist, 
 and the percussion sound is muffled and dull — a fact of great importance 
 in diagnosis. There is flatness at the base due to effused fluid, its upper 
 horizontal line indicating the height to which the effusion rises and chang- 
 ing with change of ■posture—movable dulness. Auscultation. — The breath 
 sounds are feeble and distant and have the amphoric quality. They are 
 in strong contrast with the loud puerile vesicular murmur of the sound 
 side. The voice has also a peculiar, amphoric quality. The ringing musical 
 rale known as metallic tinkling or gutta cadens is heard upon deep breathing 
 or coughing. The coin test is also present and of positive diagnostic value. 
 Finally, the swash of the free fluid within the pleural cavity upon energetic 
 sudden changes of the patient's body — Hippocr-atic succussion—may often 
 be heard at a distance, or even by the patient himself. In that form of 
 pneumothorax in which there is free communication with a bronchus 
 through consolidated lung, the bulging of the intercostal spaces and dis- 
 
 70 
 
 Fig. 323. — Horizontal line of surface of 
 effusion in pyopneumothorax; patient in the 
 upright position. This line shifts with change 
 of posture. 
 
 Palpation. — Vocal fremitus is 
 
1106 MEDICAL DIAGNOSIS. 
 
 placement signs are less marked, coarse, gurgling rales are observed at 
 times, and there is the occasional expectoration of a thin, purulent fluid. 
 In rare instances of left-sidea pneumothorax the heart sounds may have a. 
 metallic echoing quality. 
 
 Diagnosis. — Direct. — The signs are characteristic and the diagnosis^ 
 even when in consequence of old adhesions the air space is limited, may 
 be made with confidence. 
 
 Differential. — The following conditions may give rise to uncer- 
 tainty: Cirrhosis of the Left Lung. — The high position of the diaphragm 
 with a dilated stomach yields tympany in the lower part of the left chesty 
 amphoric sounds, and sometimes gastric succussion. The various sounds 
 are little influenced by respiration. Percussion when the stomach is filled 
 with fluid and the fact that the impulse of the heart is displaced toward 
 the left are conclusive. Diaphragmatic Hernia. — This condition when 
 congenital may be misleading. After a crushing accident the metallic 
 sounds are related to peristaltic rather than respiratory movements, and 
 the difficulty in passing the tube at the cardiac orifice, owing to the dis- 
 location of the stomach, is suggestive. Pyopneumothorax Suhphrenicus 
 of Leyden. — The anamnesis is important — symptoms of gastric or duodenal 
 ulcer, chronic intestinal disease, hepatic or splenic abscess usually precede 
 this condition. Cough and sputum are not commonly present; the heart 
 is slightlj" displaced, the liver much lowered. The lower border of the lung 
 rises and falls, as shown by percussion and auscultation, upon deep res- 
 piratory efforts, and movable dulness cannot be made out. Large Intra- 
 pulmonary Cavities. — Two conditions are to be considered: first, the 
 breaking down of the greater part of a lung — a very rare event — in which 
 the physical arrangement closely resembles ordinary pneumothorax; 
 and second, the cavities resulting from pulmonary abscess, gangrene, or 
 bronchiectasis, or the ordinary cavities of phthisis, which may simulate 
 circumscribed pneumothorax, which is likewise of extremely rare occur- 
 rence. In the first of these conditions the amphoric quality of the respir- 
 atory and voice sounds may be intense, but the succussion splash, the coin 
 sound, and displacement phenomena are absent. In extremely rare cases, 
 however, coin percussion may yield the bell-like resonance over a cavity. 
 Smaller cavities may be differentiated from circumscribed pneumothorax 
 by the presence or increase of the vocal fremitus, absence of chest disten- 
 tion, sinking of the intercostal spaces over the cavity, and changes in the 
 physical signs, upon percussion and auscultation, after severe cough with 
 copious expectoration. The location of the cavity is without diagnostic 
 importance-, since sacculated pneumothorax may occur at the apex, while 
 the cavities following abscess and gangrene are usually in the lower lobe, 
 those of bronchiectasis may occupy any portion of the lung, and those of 
 phthisis, while usually apical, are sometimes situated at the base. 
 
 Prognosis. — Spontaneous pneumothorax, occurring upon effort in 
 a person suffering from emphysema or with local pleural adhesion, fre- 
 quently terminates in recovery with resorption of the air. The traumatic 
 and surgical cases also do well. There is a group of tuberculous cases in 
 which the occurrence of pneumothorax appears to arrest the progress of 
 the disease. There are chronic cases of open pneumothorax, the fistula 
 
ANOMALIES OF THE KIDNEYS. 1107 
 
 .being either pleurobronchial or external, which last for years, the patients 
 being able to go about and attend to their affairs. In pneumothorax 
 acutissimus death may take place within an hour or in the course of the 
 first day, though the catastrophe may be averted by the use of the trocar 
 and cannula. As a rule, the cases occurring in tuberculosis die in a few 
 days or weeks. 
 
 Masked Pneumothorax. — This term has been applied to cases in which 
 the symptoms of pneumothorax, namely, intense pleural pain, dyspnoea, 
 pressure phenomena, and displacement of the mediastinal organs and 
 diaphragm, have suddenly occurred in the course of advanced tuberculosis 
 in the absence of the usual signs of pneumothorax upon auscultation and 
 percussion. In the course of some days these signs gradually appear, and 
 a circumscribed pneumothorax may be demonstrated. They are at first 
 obscured by the deep situation of the collection of extrapulmonary air, 
 which has escaped by way of an opening into the mediastinum, an inter- 
 lobar space, or a space between the base of the lung and the diaphragm, 
 and is retained by previously formed pleural adhesions. Deep-seated cir- 
 cumscribed pneumothorax is sometimes encountered post mortem in cases 
 in which neither the signs nor symptoms have been observed during life. 
 
 XL 
 THE DIAGNOSIS OF DISEASES OF THE KIDNEYS. 
 
 I. ANATOMICAL ANOMALIES OF THE KIDNEYS. 
 
 The kidneys may be displaced, with or without deformity; the displace- 
 ment may be congenital or acquired. They may vary in number: con- 
 genital absence of one or both kidneys, supernumerary kidneys, atrophy 
 of one kidney. They may be anomalous in form: general departures 
 from type, as lobulation; hypertrophy of one or both organs, and fusion 
 — horse-shoe kidney, sigmoid kidney, 
 disk-shaped kidney. Finally, there 
 may be variations in the blood- 
 vessels, pelvis, and ureters. 
 
 Of these abnormal conditions 
 the hypertrophied kidney can be 
 diagnosticated only when the affected 
 organ is movable and is recognized 
 upon palpation through the abdom- 
 inal wall; the horse-shoe kidney only 
 when it has descended to a position 
 
 , ,, c , 1 Fig. 324. — " Horse-shoe "kidnev — German Ho.spital. 
 
 just above the promontory oi the 
 
 sacrum and can be felt through thin abdominal walls as a prevertebral 
 tumor with a non-expansile pulsation communicated from the underlying 
 aorta, upon which it in part rests; a single kidney may be suspected when 
 tympanitic percussion resonance is constantly elicited in one lumbar 
 region and no movable kidney is palpable, or when, after an attack of 
 
1108 MEDICAL DIAGNOSIS. 
 
 renal colic w'th impaction, complete anuria and ultimately fatal ursemia 
 occur. In rare cases the impaction of a calculus upon one side may be 
 followed by anuria when both kidneys are present. Other anomalies 
 cannot be recognized during life. 
 
 II. MOVABLE KIDNEY. 
 
 Ren Mohilis; Palpable Kidney; Floating or Wandering Kidney; Nephroptosis. 
 
 Etiology. — The condition may be congenital, the kidney being sur- 
 rounded by peritoneum which forms a mesonephron. Far more commonly 
 it is acquired. It is probable that congenital defects in the mechanism of 
 attachment are at fault in all cases. Wasting of the perirenal fat is a factor. 
 Movable kidney has been observed at all ages, but is most usual in middle 
 life. It is more common in women than men in the proportion of 7 to 1 — 
 a fact attributed to compression of the base of the chest by the corset 
 and the change in the position of the uterus and the relaxation of the 
 abdominal wall after repeated child-bearing. It occurs, however, in 
 women who have never borne children. It is mostly unilateral, several 
 times as often on the right side as on the left, and occasionally double. 
 The greater frequency on the right side is attributed to the relation of the 
 right kidney to the liver and the respiratory movement communicated to 
 it by the latter organ. In the anamnesis there is sometimes an antecedent 
 history of injury or strain. The kidney undergoes dislocation together 
 with the other abdominal viscera in Glenard's disease — enteroptosis. 
 
 Symptoms. — In a large proportion of the cases there are no definite 
 or characteristic symptoms. Neurasthenic and gastro-intestinal symptoms 
 are common. Constipation is frequent and fecal obstruction may occur. 
 Dragging pains in the lumbar region, especially upon prolonged standing, 
 are observed. Neuralgic pains in the abdomen occur. The tumor, which is 
 often accidentally discovered by the patient, is not tender upon gentle 
 pressure, but when firmly compressed there is a dull, sickening pain. Dietl's 
 Crises. — In some cases of floating kidney there are paroxysmal attacks, 
 characterized by abdominal pain, nausea, and vomiting, with chills, fever, 
 and collapse. These attacks have been mistaken for renal colic, acute 
 intestinal disease, and appendicitis, but the kidney may be felt and is 
 tender, swollen, and less freely movable than usual. The urine during the 
 attack may contain uric acid or calcium oxalates in excess, and inter- 
 mittent hsematuria may occur. These paroxysms have been ascribed to 
 torsion of the renal vessels. Intermittent hydronephrosis sometimes occurs. 
 The nervous symptoms of movable kidney are important. In women 
 hysterical manifestations, in men hypochondriasis are common. Such 
 patients are very susceptible to suggestion, and their sufferings are often 
 much increased when the diagnosis is communicated to them. In other 
 cases a plain statement of the cause of the trouble is followed by relief. 
 
 Physical Examination. — The patient should be placed upon his back, 
 with the abdominal muscles relaxed. In well-marked cases the tumor is 
 plainly visible and palpable in the erect posture. Ordinarily, upon bimanual 
 palpation in the dorsal decubitus, one hand being placed in the lumbar 
 
MOVABLE KIDNEY. 1109 
 
 region, the other in the hypochondrium, with gentle manipulation during 
 full respiratory movements, the kidney, if movable, may be recognized by 
 the fingers upon the abdomen as an oval, smooth mass. By this manoeuvre 
 various degrees of mobility may be determined. (1) Palpable Kidney. — 
 The lower end of the organ may be felt upon deep palpation just below 
 the edge of the ribs in the nipple line — a condition of little or no clinical 
 import. (2) Movable Kidney. — Upon deep inspiration the fingers upon 
 the abdomen may, if there is little abdominal fat, be pressed over the upper 
 end of the kidney, which can be thus fixed for the time but has no wider 
 excursion — a degree of dislocation the importance of which is frequently 
 overrated. (3) Floating or Wandering Kidney. — The organ may ^ be 
 felt as an oval, smooth, solid tumor, having the size and contour of the 
 kidney. In some instances the hilum and pulsating renal artery can be 
 recognized. This tumor is freely movable, and sometimes lies just above 
 Poupart's ligament, or may by gentle pressure be displaced to the median 
 line or beyond it. In different postures the wandering kidney changes its 
 position, falling forward in the knee-elbow position, and away from the 
 abdominal wall in the dorsal decubitus, when it is often possible to slip it 
 upward into its normal place. To this degree of displacement belong the 
 more distressing symptoms of ren mobilis. Dilatation and downward dis- 
 placement of the stomach can be demonstrated in a large proportion of 
 the cases, especially in women. 
 
 Diagnosis. — Direct. — A positive diagnosis can usually be made in 
 palpable and movable kidney by the position of the smooth, rounded, 
 firm tumor, which descends with deep inspiration and can be made to dis- 
 appear by pressure upward and backward, particularly when, as sometimes 
 happens upon repeated examination, flattening or tympanitic resonance is 
 found in the renal region ujDon the same side. Floating kidney rarely 
 presents difficulty in diagnosis. 
 
 Differential. — Tumor of the Gall-bladder. — The mass presents at 
 the border of the ribs, has the respiratory movement of the liver, cannot 
 be grasped from above, and when forced backward immediately returns 
 to its former position. Its movement is less extensive than in floating 
 kidney and is, roughly speaking, in the arc of a circle having its centre in 
 the normal position of the gall-bladder. Furthermore, in tumors of the 
 gall-bladder the upper margin reaches and is continuous with the Uver. 
 Other tumors of the liver and tumors of the bowel are fixed and do not 
 present the characteristic contour of the kidney. Movable Spleen. — Any 
 doubt as to whether a movable tumor upon the left side is the kidney or 
 spleen is at once settled by the shape of the tumor and the presence or 
 absence of the normal area of dulness in the splenic region. Tumor of the 
 Pylorus. — Carcinoma in this region may be freely movable. Under such 
 circumstances the shape of the tumor, its relation to the stomach, filled 
 and emptied by means of the stomach tube, dulness in both renal regions, 
 and the prominence of gastric symptoms arc of diagnostic value. Ovarian 
 Cysts. — The facts that the tumor arises from the pelvis, that its outline is 
 round or globular, that it is elastic rather than firm, and that it cannot be 
 made to disappear into the normal position of the kidney, readily settle 
 any doubt as to the differential diagnosis. 
 
1110 MEDICAL DIAGNOSIS. 
 
 Prognosis. — The outlook as to permanent fixation is less hopeful than 
 as to reUef by the adjustments that follow 'mprovement in the general health. 
 Nephropexy and nephrorrhaphy, with and without decapsulation, have many 
 successes and many failures to their credit. Relief in many cases may be 
 obtained by a suitable belt and pad and treatment of the neurasthenia. 
 
 III. CIRCULATORY DERANGEMENTS. 
 
 Theoretically anaemia and congestion occur. 
 
 (a) Renal Anaemia. — ^The oncometric observations of Mendelsohn 
 indicate that the kidneys are small and bloodless in acute fever. This 
 investigator holds that the scant}^, high-colored urine of febrile states is 
 due to anaemia. Clinicians have generally attributed it to renal conges- 
 tion. No positive diagnosis of anaemia of the kidneys can be made. 
 
 (b) Congestion of the Kidneys. — Active Congestion. — Etiology. — 
 Certain drugs, as the terebinthinates and cantharides, when taken in over- 
 doses, are accredited with causing congestion of the kidnej^s. Exposure 
 to damp and cold, various poisons and irritants have the same effect. 
 Active hyperaemia is characteristic of the onset of acute nephritis, from 
 which it cannot be clinically differentiated. Post mortem the kidney is 
 large, dark, and soft, and upon section drips blood. The condition is typical 
 in postscarlatinal nephritis. The urine is scanty, densely albuminous, 
 and contains red blood-corpuscles and tube-casts. 
 
 Passive Congestion. — Etiology. — The hyperaemia is mechanical. It 
 results from the transference of blood-pressure from the arterial to the 
 venous side of the circulation, which occurs in cardiac disease and emphy- 
 sema, and locally from pressure upon the renal veins by the pregnant 
 uterus, abdominal tumors, and large ascites. The condition found post 
 mortem is known as cyanotic induration, and is a form of chronic diffuse 
 nephritis. The urine is diminished, dark red in color, of high specific 
 gravity, and contains albumin in moderate amount, with hyaline tube- 
 casts. A few red blood-corpuscles may be present in the sediment. The 
 line between congestion and nephritis cannot always be drawn at tlie bed- 
 side. Hyaline casts only, moderate albumin, isolated red corpuscles, total 
 absence of uraemic symptoms, cynosis rather than pallor, and iirprove- 
 ment upon the administration of digitalis suggest, in a heart case, the 
 diagnosis of congestion rather than nephritis. Prognosis. — The causal 
 conditions in chronic hyperaemia of the kidneys are such as to render the 
 prognosis unfavorable. Congestion tends to pass into nephritis. 
 
 (c) Hemorrhagic Infarct of the Kidney. — Etiology. — Embolism of 
 renal arteries occurs in valvular disease, endarteritis, and traumatism 
 involving the renal artery. Symptoms. — Sudden pain in the region of the 
 kidney upon one side, with corresponding tenderness upon pressure, and 
 haematuria constitute the symptoms in well-marked cases. These sj^mp- 
 toms are all transient, the pain and tenderness subsiding in the course of 
 a day or two, the blood disappearing from the urine in three or fovr days, 
 and the albumin a short time later. In the majority of instances in which 
 infarcts are found post mortem no clinical symptoms have been noted. 
 Diagnosis. — Hemorrhagic infarct of the kidney cannot, as a rule, be diag- 
 
URiEMIA. 
 
 1111 
 
 nosticated during life. When the above symptoms occur in a patient in 
 whom the etiological facte rs are present, or in whom embolic processes 
 elsewhere can be demonstrated, the diagnosis is positive. Prognosis. — 
 The outlook is that of the underlying morbid condition. Old infarcts of 
 the kidneys are often found in post-mortem examinations. 
 
 c. 
 
 r-42<> 
 
 IV. UREMIA. 
 
 Definition. — A toxaemia developing in the course of acute or chronic 
 nephritis and other conditions characterized by deficient urinary secre- 
 tion or complete anuria, and manifested by irregularly associated nervous 
 and gastro-intestinal symptoms. 
 
 Various hypotheses have been advanced regarding the pathology of 
 uraemia, among which the following are important: 1. That it is due to 
 the accumulation of excrementitious substances normally eliminated by 
 the kidneys, especially urea, salts, and nitrogenous bodies. 2. That it is 
 caused by toxins evolved in the course of abnormal tissue metabolism, 
 of the nature of which nothing positive is known. Uraemia has been 
 attributed to derangements of a hypo- 
 thetical internal secretion of the kidney. 
 3. That the nervous symptoms are 
 largely due to local cerebral oedema. 
 
 Symptoms. — Uraemia may be of 
 •every grade of intensity and of the most 
 variable duration. Latent, acute, and 
 chronic forms are therefore described. 
 
 The Latent Form. — This form 
 has been especially studied in cases of 
 complete anuria. The patient may 
 suffer very little inconvenience. Pre- 
 hminary headache and the alternation 
 ■of convulsions and coma seen in acute 
 uraemia are often absent. The mind 
 remains clear, the pupils are contracted, 
 muscular twitchings and vomiting 
 •occur. The temperature is subnormal. 
 
 The Acute Form. — The onset is 
 preceded by headache, mental con- 
 fusion, dulness, and drowsiness. The 
 attack begins abruptly with vomit- 
 ing and diarrhoea, or convulsions alter- 
 nating with or followed by coma, 
 or coma may develop in the absence 
 of convulsions. Such an attack very 
 often occurs in persons in whom no 
 previous indications of nephritis have been observed. Fever of irregular 
 type is frequently present, and may be, in acute nephritis, a manifes- 
 tation of the underlying disease or symptomatic of some complication, as 
 an intercurrent inflammatory or infectious process, itself the cause of the 
 uraemia, or the fever may be part of the uraemic symptom-complex. 
 
 
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 Fig. 325. — Chronic parenchymatovis nephritis. 
 Ursemia; convulsions; recoverj'. 
 
1112 MEDICAL DIAGNOSIS. 
 
 The Chronic Form. — The patient may go about and in a way attend 
 to his affairs, He suffers, however, from headache, vertigo, confusion, 
 drowsiness, and pruritus, and very often has transient muscular twitch- 
 ings. Dyspnoea, which may be continuous or paroxysmal, and is fre- 
 quently nocturnal only, is a common symptom in chronic ursemia. It is 
 often regarded as asthma. The respi^tion is sometimes Cheyne-Stokes 
 in type. Itching, numbness, and cramps in the calves of the legs also occur. 
 Local palsies, hemiplegias, and monoplegias occur, and are frequently tran- 
 sient. The psychoses of chronic ursemia are important. They very often 
 occur in persons not known to have nephritis. Mania and delusional insanity 
 are common. Delusions of persecution, suicidal tendencies, and melancholia 
 occur. The alienist may be in doubt whether an insane person has nephritis, 
 or a patient suffering from nephritis has an uraemic psychosis — an uncertainty 
 which emphasizes the artificial character of nosological classifications. 
 
 The convulsions of uraemia may occur abruptly or after a spell of head- 
 ache and restlessness. They closely resemble the epileptic seizure, though 
 the epileptic cry is said not to occur. The repetition of the general convul- 
 sion with unconsciousness in the intervals may suggest " status epilepticus." 
 Jacksonian epilepsy may occur. The temperature sinks as a rule after the 
 attack. Uraemic amaurosis may occur after a convulsive attack, or in 
 the absence of convulsions. It may pass off in the course of a few days. 
 The ophthalmoscopic findings are negative. Uraemic deafness of the same 
 fleeting character has also been obser-ved. 
 
 Persons suffering from chronic uraemia frequently have no appetite 
 and a foul tongue and breath. The stomatitis sometimes present has no 
 special characters. 
 
 In grave cases of acute uraemia a frost-like efflorescence of urea has 
 sometimes been observed upon the skin. Acute inflammations of the 
 serous membranes, endocarditis, pericarditis, pleurisy, peritonitis, and, 
 much more rarely, meningitis occur as terminal events in patients suffer- 
 ing from conditions in which chronic ursemia has developed. 
 
 Diagnosis. — Direct. — The diagnosis of ursemia depends upon the 
 association of nephritis and nervous symptoms of more or less irregular 
 character and combination. In cases of anuria from any cause a direct 
 diagnosis is justified. In other cases an examination of the urine yields 
 definite data. The nervous symptoms are often such that a diagnosis by 
 exclusion becomes necessary. The copious vomitus in some cases may 
 have the odor of ammonia, since the urea in the gastric contents may 
 have undergone the change into ammonium carbonate. The determina- 
 tion of the urea output in the urine cannot be relied upon as indicating 
 the approach of ursemic symptoms. 
 
 The diagnosis of the latent uraemia of Roberts rests upon the asso- 
 ciation of certain of the milder symptoms of the condition with more or 
 less complete anuria. In acute fully developed ursemia with vomiting, 
 convulsions, coma, amaurosis, and stertorous or Cheyne-Stokes respiration, 
 the symptom-complex is so characteristic that errors in diagnosis seldom 
 occur. If some of these symptoms suddenly develop as the result of intoxi- 
 cations or severe infectious processes, in persons not suffering from 
 nephritis, the presence of albumin in relatively small amounts and hyaline 
 
UREMIA. 1113 
 
 casts only, without red blood-corpuscles or other tube-casts, particularly 
 if the specific gravity of the urine be not abnormally low, is of diagnostic 
 value. Nor is it always easy to recognize the nausea, vomiting, and diar- 
 rhoea of the gastro-intestinal form as ursemic. Chronic ursemia is even 
 more difficult of recognition. Asthma-like attacks with shortness of 
 breath, especially at night, may lead to an incorrect diagnosis in cases in 
 which the nervous symptoms are slight and ill-defined. The acute attack 
 very often occurs in the course of the chronic condition. The pupils are 
 inconstant. They may be dilated or normal. The j)resence of albuminuric 
 retinitis may be of positive diagnostic significance. 
 
 Differential. — 1. Cerebral Disease. — (a) The ursemic attack, with 
 sudden loss of consciousness, and hemiplegia, especially when these symp- 
 toms are associated with convulsions, may present the clinical picture of 
 apoplexy from cerebral hemorrhage or thrombosis. In favor of the latter 
 diagnosis are the abruptness of the onset, the completeness of the loss of 
 power, conjugate deviation, and persistence of the symptoms. It is char- 
 acteristic of the nervous symptoms of ursemia that they are incomplete 
 and transitory, (b) Meningitis. — Sudden coma following headache and 
 vomiting, without localizing phenomena but attended by albuminuria, 
 may present great difficulties in diagnosis. The results of spinal puncture 
 are important Stiffness of the neck, paralysis of cerebral nerves, retrac- 
 tion of the abdomen, and Kernig's sign occur in meningitis, (c) Tumors. — 
 The symptoms of coarse lesions of the brain may suggest ursemia. Jack- 
 sonian and general convulsions, vomiting, headache, vertigo, and hemi- 
 plegia and monoplegia occur in both conditions. But in anatomical lesions 
 the symptoms are chronic and usually though not always progressive, 
 while in ursemia characterized by such symptoms the attack is sudden 
 and frequently transitory. 2. Severe Infections. — There are cases of 
 ursemia in which stupor, a dry tongue, rapid, feeble pulse, muscular twitch- 
 ing, and fever persist for weeks, and the appearance of the patient suggests 
 an acute specific disease with secondary infection. These cases may re- 
 semble: (a) Enteric Fever. — The differentiation from ursemia depends 
 upon the presence of a pulse relatively slow, as compared with the rise 
 of temperature, splenic tumor, rose rash, a temperature range conforming 
 to type, and a positive Widal reaction, (b) Miliary Tuberculosis. — The 
 pulmonary symptoms and signs, the signs of an associated pleurisy or 
 pericarditis, and choroidal tubercles when present suffice to establish the 
 true nature of the affection, (c) Septic Conditions. — Local necrotic proc- 
 esses, multiple foci of inflammation, irregular chills, fever and sweating, 
 embolic phenomena are diagnostic. 3. Intoxications. — Ursemic coma 
 may be mistaken for poisoning by alcohol or opium. The anamnesis is 
 important. In all cases the urine must be drawn and examined. The cir- 
 cumstances in which the patient is found and the odor of the breath may 
 be suggestive, (a) Alcohol. — The temperature is subnormal, the pupils 
 usually dilated, the coma often incomplete; if it alternates with delirium 
 the latter is of peculiar type and attended with tremor, (b) Opium. — 
 Contracted pupils, slow pulse and respiration, profound stupor from 
 which the patient cannot be roused favor the diagnosis of opium poisoning 
 rather than ursemia. 
 
1114 MEDICAL DIAGNOSIS. 
 
 Prognosis. — As ursemia is a secondary toxsemia the prognosis depends 
 upon that of the primary disease. Latent ursemia dependent upon anuria 
 may disappear when the flow of urine is re-established. The urtemia of 
 acute nephritis disappears with recovery from the renal condition; that 
 of the chronic forms may be transient and recurrent. A patient in the 
 Pennsylvania Hospital was unconscious for several days, with convulsions 
 alternating with coma, but recovered and lived four or five years, working 
 as a laborer. Sudden ursemic coma is common in chronic interstitial nephri- 
 tis, and may be the first indication of renal disease. It is frequently fatal. 
 
 V. INFLAMMATION OF THE KIDNEYS. 
 
 The inflammations of the kidneys comprised under the general term 
 Bright's disease cannot be satisfactorily classified, either from the clinical 
 or the pathological stand point. Still less can the clinical varieties be 
 c'osely coordinated with the post-mortem findings. Clinically the cases 
 may be grouped as acute and chronic; anatomically they are all diffuse; 
 that is to say, epithelial, vascular, and intertubular tissues are involved, 
 but, since the changes in these structures vary in degree, parenchymatous, 
 glomerular, and interstitial forms are recognized, according as one or the 
 other of these groups of tissues is particularly affected. 
 
 (a) Acute Nephritis. 
 
 Acute Parenchymatous Nephritis; Acute Bright's Disease. 
 
 Definition. — Acute diffuse inflammation of the kidneys, caused by 
 the action of cold, poisons, or the toxins of the infectious diseases, and 
 characterized by scanty urine containing albumin, blood-corpuscles, and 
 tube-casts, a tendenc}^ to dropsy, and evidences of toxsemia. 
 
 Etiology. — Exposure to cold and wet is very often followed in the 
 course of a day or two by the evidences of acute nephritis. Trench diggers 
 and other laborers in low wet places are especially liable. It is common 
 after the exposure incident to a debauch. Certain drugs, as cantharides, 
 internally administered or externally applied, turpentine, balsam of Peru, 
 potassium chlorate, naphthol, and certain acids, as sulphuric acid, salicylic 
 acid, and phenol, in excessive doses are sometimes followed by this form 
 of nephritis. The nephritis which frequently follows scarlet fever is typical. 
 Less common and usually less intense is the acute nephritis associated 
 with pneumonia, enteric fever, influenza, and diphtheria. The acute 
 nephritis of yellow fever and cholera is of severe type. Nephritis may occur 
 in association with variola, varicella, meningitis, syphilis, septic condi- 
 tions, purpura, and angina tonsillaris. The acute nephritis of pregnancy 
 is probably caused by toxins of unknown nature, and the remarkable form 
 which occurs after extensive burns and other cutaneous lesions probably 
 belongs to this group. 
 
 Symptoms. — The general symptoms after exposure to cold and wet 
 usually develop suddenlj^; after poisoning and the infections, gradually. 
 The onset in children may be attended with convulsions; in adults, by a 
 
NEPHRITIS. 1115 
 
 chill or chilliness. - Much more common are such initial symptoms as pain 
 in the back, nausea, vomiting, and headache. PaLor, puffiness about the 
 eyes, and oedema of the ankles are very often the first symptoms to call 
 attention to the kidneys. Fever is not constant. It is more common in 
 children than adults. The temperature may reach 102°- 103° F. (38.9°-39.5° 
 C). Its range does not conform to type. 
 
 The urinary changes are characteristic. The quantity is at first greatly 
 diminished. Anuria may occur. Usually a few ounces — 100 to 200 c.c. — 
 are secreted in twenty-four hours. The specific gravity is high — 1.020 to 
 1.030. Later, when the secretion is re-establ shed, the specific gravity falls 
 to normal or below it. The percentage of urea is high, but the total quan- 
 tity is greatly reduced. Owing to the excess of solids the urine is not 
 transparent. It varies in color from a mere smokiness to the dense, opaque 
 brown of porter. These changes are due to the presence of blood, but the 
 urine is never bright red. Upon standing an abundant, dark, coarse sedi- 
 ment is precipitated, which consists of red blood-corpuscles, epithehum 
 from the urinary tract, uric acid and other crystals, and hyaline, granular, 
 blood, and epithelial tube-casts. Albumin is abundant and upon testing 
 precipitates in coarse, curdy flakes. Upon the application of heat the urine 
 may solidify in the test-tube. The foregoing urinary changes are of highest 
 grade in the beginning of the attack. They are to some extent a measure 
 of the severity of the disease and they gradually lessen as improvement 
 occurs in favorable cases. 
 
 Dropsy, though exceptionally absent, is a frequent and important 
 symptom. It varies from mere puffiness about the eyelids to a general 
 anasarca with effusion into the serous sacs. It is a peculiarity of the dropsy 
 oi acute nephritis that it is irregular in its distribution and does not always 
 gravitate according to the posture of the patient. The degree of oedema is 
 greater after colds, in pregnancy, and after scarlatina than after the other 
 infections. In the nephritis of diphtheria there may be little or none. There 
 are cases of post-scarlatinal nephritis in which effusion into the serous 
 cavities occurs with scanty subcutaneous oedema. Pulmonary oedema 
 and oedema of the glottis may occur. Anaemia is an early and marked 
 condition. Epistaxis is common and symptomatic purpura not infre- 
 quent. The pulse tension may be increased and the aortic second sound 
 accentuated. Acute dilatation of the heart may occur. Albuminuric 
 retinitis is comparatively infrequent, though retinal hemorrhages are 
 occasionally encountered. 
 
 Ursemic symptoms, among which we include the preliminary anorexia, 
 dulness, and headache, and the initial nausea and vomiting, are almost 
 constant. When to these minor symptoms caused by the retention of 
 excrementitious substances are added convulsions and coma, the condi- 
 tion of acute uraemia is fully established. This may occur at any period 
 in the course of the attack. 
 
 Diagnosis. — Direct. — The general symptoms are variable and by no 
 means characteristic. Pallor, with slight puffiness of the ankles or eyelids, 
 may be present in the absence of subjective sensations of impaired health; 
 or the symptoms of the causal affection may mask those of the nephritis. 
 This is apt to be the case in pregnancy. It is therefore imperative that the 
 
1116 MEDICAL DIAGNOSIS. 
 
 urine be examined at intervals of two or three weeks as a matter ot routme 
 during gestation. The cHnical picture of acute nephritis in the acute 
 cases following cold, or occurring after scarlatina, is such as to justify 
 a positive diagnosis. In the insidiously developing cases the conditions 
 may be less obvious. The urinary findings as given above are of diagnostic 
 significance. The presence of blood-corpuscles with blood and epithelial 
 casts is characteristic. 
 
 Differential. — 1. Febrile or toxic albuminuria cannot in all cases 
 be distinctly differentiated from an infectious nephritis. In favor of the 
 former is the absence of special symptoms, pallor, slight oedema, or uraemic 
 phenomena, and certain characters of the urine, namely, albuminuria of 
 hghter degree and transitorj^ duration, lower specific gravity and larger 
 quantity of the urine, and the absence of blood-corpuscles and blood and 
 epithelial casts. 
 
 2. Intercurrent acute nephritis in the course of chronic nephritis. This 
 condition is by no means infrequent. The acute attack has the clinical 
 phenomena of the primary affection and is often regarded as primary. 
 Attention to the anamnesis, which shows antecedent poor health, charac- 
 terized by weakness and lassitude, headache, gastric derangements, 
 pallor, and slight or transitory oedema, and usually the absence of any 
 recent definite causal factor, may explain the occurrence of acute dropsy 
 with toxic phenomena. The urinary changes are less sharply defined 
 than in the primary cases, and a tense pulse with cardiac hypertrophy and 
 accentuated aortic second sound, and particularly albuminuric retinitis, 
 render the diagnosis of coexistent chronic nephritis certain, 
 
 3. Glomerular Nephritis. — The attempt to differentiate cases in which 
 vascular changes are primar.y and severe, while the epithelium and inter- 
 tubular tissues are affected to a less degree, constitutes an extreme refine- 
 ment of diagnosis. This condition is present in post-scarlatinal nephritis, 
 a variety characterized by anuria, extreme dropsy, and acute uraemic 
 symptoms. The absence of epithelial casts might under such circumstances 
 have some degree of diagnostic significance. 
 
 Prognosis. — The outlook depends more upon the course than upon 
 the immediate condition of the patient. It is more unfavorable in post- 
 scarlatinal and puerperal nephritis than in other forms. Acute nephritis 
 following cold is less dangerous. That which follows the various infections 
 other than scarlet fever, is usually of milder type. Complete and rapid 
 recovery may follow the intense forms associated with 3^ellow fever and 
 cholera. The death-rate in infancy is not lower than 33 per cent. The 
 prognosis as to entire recovery is uncertain. Acute nephritis is very often 
 the point of departure for the chronic form. Even with apparent recovery 
 there remains an especial liabihty to attacks later in life. At the onset 
 neither the dropsy, the amount of urine, nor the proportion of albumin 
 which it contains justifies a positive prognosis. Urgent uraemic symp- 
 toms are always alarming. In the gravest acute nephritis dropsy may 
 be absent. Complete anuria lasting for a day or two may occur in cases 
 terminating favorably, and dense albuminuria often gradually disappears. 
 Low arterial tension, intense anaemia, persistence of dropsy, effusion into 
 the serous sacs, continuing albuminuria of high grade, and chronic uraemic 
 
NEPHRITIS. 1117 
 
 symptoms are of unfavorable prognostic import. Cases thus characterized 
 are Hable to an acute fatal exacerbation, or escaping that; to a chronic 
 course. The absence of these conditions is favorable. Recovery may be 
 practically complete in four or six weeks. In other cases a favorable 
 termination may occur at the end of several months. 
 
 (b) Chronic Nephritis. 
 
 Chronic Bright's Disease. 
 
 Anatomically two principal forms are encountered, namely, chronic 
 parenchymatous nephritis and chronic interstitial nephritis, and these respec- 
 tively manifest themselves by a more or less well-defined symptom-complex. 
 
 1. CHRONIC PARENCHYMATOUS NEPHRITIS. 
 
 Chronic Desquamative Nephritis; Chronic Tubal Nephritis. 
 
 Definition. — Chronic diffuse inflammation of the kidneys, occurring 
 as a sequel of acute nephritis or developing insidiously, and characterized 
 by albuminous urine of high specific gravity, containing tube-casts. 
 
 Etiology. — This form of nephritis frequently follows the acute variety 
 and is due to the same causes. In many cases it insidiously develops after 
 an acute attack in the course of a chronic infection. It is common in 
 persons who have suffered from repeated attacks of malarial fever, and in 
 chronic alcoholism. It is met with at all ages, but is especially common 
 in early adult life, and in children as a sequel of scarlatinal nephritis. 
 In adult life it is more frequent in males than females. 
 
 The kidneys may show the changes which constitute the large white 
 kidney, the small white or pale granular kidney, or the kidney of chronic 
 hemorrhagic nephritis. Whether the pale granular kidney is a condition 
 consecutive to the large white kidney, or an independent pathological 
 process from the beginning, is not positively known. These two conditions 
 cannot be differentiated clinically either by the symptoms or by the com- 
 position and contents of the urine. A protracted course, with the symp- 
 toms and urinary changes of parenchymatous nephritis passing by degrees 
 into those suggestive of the chronic interstitial form, would support the 
 opinion that the small white kidney may be a later stage of the large 
 white kidney. 
 
 Symptoms. — When consecutive to the acute form, chronic paren- 
 chymatous nephritis presents similar, though less urgent, symptoms. A 
 majority of the patients, after a period of failing health with ill-defined 
 symptoms, become pallid and puffy about the eyelids and ankles, or the 
 albumin and casts are discovered upon routine examination of the urine. 
 
 The urine, especially in the earlier course of the disease, is diminished 
 in quantity, averaging in the adult 750 to 1000 c.c. in the course of twent)'- 
 four hours. With increasing dropsy the output usually diminishes, to again 
 increase as the dropsical effusion undergoes resorption. It is dirty yellow 
 in color and turbid from the presence of urates. Upon standing it precipi- 
 
1118 MEDICAL DIAGNOSIS. 
 
 tates a sediment, which reveals upon examination leucocytes, often red 
 blood-corpuscles, epithehum from the urinary passages, and many tube- 
 casts, hyahne, granular, fatty, and epithelial. Albumin is usually abundant,, 
 showing a relative decrease during repose and an increase after exercise. 
 It varies in amount from .5 to 2 per cent. The specific gravity is above 
 normal, varying from L025 to 1.035. As the case progresses, the average 
 daily quantity of urine augments, while the average daily amount of 
 albumin excreted declines, and the specific gravity falls. The daily 
 amount of urea fluctuates, but the average is below the normal. The 
 presence of blood in considerable quantities is suggestive of chronic 
 hemorrhagic nephritis. 
 
 The tendency to dropsy is characteristic of this form of nephritis. 
 The eyelids and ankles early in the disease, the subcutaneous tissues 
 generally later, and toward the close the serous sacs become the seat of 
 dropsical effusions. The loose tissues of the genitalia in both sexes, and 
 dependent parts in general, become in advanced cases highly distended and 
 oedematous. Ursemic symptoms, especially headache and drowsiness, are 
 common. Gastro-intestinal symptoms, anorexia, nausea, vomiting, and diar- 
 rhoea belong to this group. Convulsions may occur as the end approaches. 
 Albuminuric retinitis is not common early in the disease. Hypertrophy 
 of the heart is of less frequent occurrence and less marked than in 
 the chronic interstitial form. The longer the duration of the disease the 
 greater the tendency to cardiac enlargement. The pulse tension is usually 
 increased, the aortic second sound accentuated, and some degree of arterio- 
 sclerosis gradually develops. In chronic parenchymatous nephritis there is 
 a peculiar tendency to bronchitis, pneumonia, pleurisy, and pericarditis. 
 
 Diagnosis. — Direct. — The recognition of this form of nephritis 
 depends upon the association of the above-described urinary changes, the 
 tendency to dropsy, and mild ursemic symptoms, as headache, drowsiness, 
 loss of appetite, and nausea. In mild cases the diagnosis must rest upon 
 the condition of the urine. The facies, which exhibits marked pallor, a 
 dull, pasty complexion, and puffy eyelids, is suggestive. 
 
 Prognosis. — The prognosis is grave, both as to life and as to recovery. 
 A limited proportion of cases under very strict and judicious management, 
 especially among children, recover in the course of a year or two. The 
 greater number have already, when the diagnosis is made, entered upon 
 a life of chronic invalidism. The scene closes with increasing and 
 unmanageable dropsy, acute ursemic symptoms, or intercurrent acute 
 inflammation, usually of the pleurae or pericardium. 
 
 2. CHRONIC INTERSTITIAL NEPHRITIS. 
 
 Contracted or Granular Kidney; Sclerosis of the Kidney; Gouty Kidney. 
 
 Definition. — Chronic diffuse inflammation of the kidneys, associated 
 with overgrowth of intertubular connective tissue, and characterized by 
 insidious development, increased urine of low specific gravity, albuminuria, 
 which is usually slight and often intermittent, arteriosclerosis, and little 
 tendency to dropsy. 
 
NEPHRITIS. 1119 
 
 Anatomically, there is marked increase in the connective tissue, with 
 degeneration of the parenchymatous structures. The process is essentially 
 atrophic, the atrophy probably beginning in the glomerules and tubules, 
 and being followed by increase in the connective tissue. Three forms are 
 described: (a) The pale granular kidney, to which reference has already 
 been made — secondary atrophic kidney; (b) the contracted kidney, occurring 
 as an independent affection — primary atrophic kidney; and (c) sclerosis of 
 the kidneys, developing in connection with cardiovascular disease — arterio- 
 sclerotic atrophy of the kidney. 
 
 Etiology. — The pale granular kidney probably constitutes a later 
 stage of the large white kidney, in which atrophic changes in the secreting 
 structures have been followed by connective-tissue overgrowth. The pri- 
 mary contracted kidney is the result of a gradual degenerative process. 
 Many of the cases occur in the absence of discoverable cause and may be 
 due to premature senile involution. Hereditary influences, early arterio- 
 sclerosis, syphilis, and gout are causal factors. Chronic intoxications, 
 especially alcohol and lead, play an important part in the etiology of 
 sclerosis of the kidney. Habitual excesses at table, especially the eating 
 of large quantities of meat, are particularly injurious. The arteriosclerotic 
 form is associated with cardiac hypertrophy and sclerosis of the arterial 
 walls. It is common in active, energetic men, who work hard and eat 
 and drink too much. Habitual anxiety and worry, and inability to endure 
 the stress of life favor the development of the vascular changes of which 
 contracted kidney is the outcome. This form of renal disease is much more 
 common after forty than in early life, and in men than in women. In this 
 country arteriosclerosis develops at an earlier age among the Slav immi- 
 grants than in persons of other nationalities. 
 
 Symptoms. — The changes in the kidneys are insidious and frequently 
 reach an advanced stage before they cause symptoms that attract atten- 
 tion. Acute ursemic symptoms frequently constitute the first marked 
 i^anifestations of the disease. The earlier symptoms, headache, frequent 
 micturition, and digestive disorders are often disregarded by the patient. 
 More commonly the general health becomes gradually impaired. The 
 patient is weak and breathless upon exertion. He rises frequently to 
 pass urine, suffers from habitual headache, and complains of nausea and 
 occasional vomiting. 
 
 The composition of the urine varies to some extent according to the 
 variety of the renal atrophy. In the secondary form the quantity of the 
 urine is less and the amount of albumin greater than in the primary form. 
 The specific gravity is more nearly normal, that is, higher. There are 
 various kinds of casts and a few red blood-corpuscles in the sediment. 
 The tendency to dropsy is more marked. In the primary form the quantity 
 of urine is much increased above normal and frequently reaches as much 
 as four litres. This polyuria is the cause of an abnormal thirst. The 
 color is pale yellow, the transparency clear, and the specific gravity low — 
 1.005 to 1.012. A scanty sediment is deposited, in which are found a few- 
 hyaline and granular tube-casts, granular epithelial cells, leucocytes, and 
 rarely red blood-corpuscles. The amount of albumin is small, especially 
 after repose. It increases during attacks of intercurrent disease or with 
 
1120 MEDICAL DIAGNOSIS. 
 
 cardiac weakness, when the quantity of urine is diminished. It is char- 
 acteristic of this form of nephritis that there are often albumin-free periods, 
 especially in the early part of the day. The casts in some instances disap- 
 pear even while the urine remains albuminous. The urinary solids are 
 decreased, especially urea. Temporarily the urea may reach normal, 
 and uric acid, phosphoric acid, the chlorides, and ammonia may approach 
 normal. In the arteriosclerotic form polj'uria is less common, the color 
 of the urine is normal, the albumin is more abundant and more constant, 
 and there are hyaline and granular casts, which may at times disappear. 
 
 Dropsy, so long as the power of the hypertrophied heart and the 
 polyuria are maintained, is absent or scanty. Pretibial oedema msij be 
 noted, or slight puffiness of the ankles. The heart is hypertrophied, the 
 left ventricle being first affected. The apex is displaced to the left and 
 downward. The impulse is forcible and sometimes heaving. The aortic 
 second sound is accentuated. There may be reduplication of the first sound, 
 or an apex systolic murmur transmitted to the axilla. Toward the close 
 the hypertrophy fails and the signs of dilatation are pronounced, together 
 with lessened urine, increased albumin, and mounting dropsy. The pulse 
 is hard and tense. The superficial arterial walls are thickened and incom- 
 pressible. The radials can be rolled with the finger like a wh p-cord upon 
 the underlying bone. The temporals are prominent and tortuous. There 
 is early and persistent increase of blood-pressure. Epistaxis is common 
 and may be troublesome. Hemorrhages into the skin occur. Headache is 
 a very common symptom. The symptoms in advanced cases are mostly 
 due to the cardiovascular conditions, or to uremia. To the former group 
 are to be referred sudden oedema of the glottis or lungs, pleural effusion, 
 and some cases of cardiac d3^spnoea. This symptom may resemble asthma 
 and is often troublesome at night. Cerebral hemorrhage is not uncommon. 
 Fully 40 per cent, of the cases of apoplexy occur in persons suffering from 
 contracted kidneys. To ursemia, either in its chronic or acute forms, must 
 be referred certain of the cases of nocturnal dyspnoea — so-called renal 
 asthma, Cheyne-Stokes respiration, nausea, vomiting, which is often uncon- 
 trollable, and diarrhoea. The complexion is usually pallid and muddy. 
 Sweating is uncommon. The urea "frost" may be deposited after free 
 perspiration. Pruritus and eczema are common. Muscular cramps occur, 
 especially on waking in the morning. Albuminuric retinitis occurs more 
 frequently than in any other form of nephritis. Visual troubles, in a 
 large proportion of the cases, lead to the discovery of the actual condition. 
 Sudden blindness without ophthalmoscopic findings — uraemic amaurosis — 
 is sometimes observed. Hemorrhages beneath the conjunctivae or into the 
 eyelids occur. Tinnitus aurium or cerebri, vertigo, and nervous deafness 
 are encountered. 
 
 Persons subject to chronic interstitial nephritis are peculiarly hable 
 to severe intercurrent diseases. Bronchitis and pneumonia are common. 
 Inflammatory affections of the serous membranes, as acute pleurisy and 
 pericarditis, occur. 
 
 Diagnosis. — The early stages of chronic interstitial nephritis present 
 no characteristic clinical phenomena. The anatomical condition may be 
 advanced in cases unattended by evidences of ill health prior to the occur- 
 
PYELITIS. 1121 
 
 rence of the acute disease which has been the cause of death. The asso- 
 -ciation of cardiac hypertrophy, sclerotic arteries, high pulse tension, 
 accentuated aortic second sound, with copious urine of low specific gravity 
 containing an inconstant trace of albumin and a few hyaline and granular 
 casts, justifies a positive diagnosis. The urine should be repeatedly exam- 
 ined, specimens being taken at night and in the morning. The condition 
 is often discovered accidentally in examination for life insurance, and 
 sometimes overlooked under the same circumstances. 
 
 The diagnosis of small granular kidney cannot be positively made 
 from the symptoms and urinary composition. It is rendered probable by 
 a previous history of acute or chronic parenchymatous nephritis. Nor 
 can the arteriosclerotic form be distinguished from the other varieties 
 with certainty. The diagnosis becomes probable when the patient is past 
 forty and has marked cardiac hypertrophy, hardened arteries, increased 
 pulse tension, and ursemic symptoms, and particularly when the progress 
 of the case is comparatively rapid. 
 
 Prognosis. — The outlook as regards recovery is hopeless. The disease 
 is incurable. As regards prolongation of life and a fair degree of health, 
 the prognosis is not altogether without encouragement. Many of the cases, 
 under careful management and with a self-denying and regular manner of 
 living, make slow progress and continue for years without passing into 
 invalidism. The symptoms of chronic uraemia are danger signals; those of 
 acute uraemia heralds of catastrophe. The signs of cardiac failure are 
 usually the beginning of the end. 
 
 VI. PYELITIS. 
 
 Definition. — Inflammation of the pelvis of the kidney, due to direct 
 bacterial infection by way of the blood or the ureters and lymphatics. 
 
 When the inflammation extends to the substance of the kidney the 
 condition is designated pyelonephritis; when the entire organ is involved, 
 pyonephrosis or renal abscess; the form due to tuberculosis is known as 
 nephrophthisis. 
 
 Etiology. — Under ordinary conditions the kidneys are capable of 
 eliminating, without damage to themselves, the pathogenic organisms 
 reaching them by way of the blood stream or ureters and lymph channels 
 in constitutional or local infection. When, however, their resistance to 
 pathogenic influences is diminished by such general causes as prolonged 
 malnutrition, anaemia, cold, or over-exertion, or by local conditions, as 
 congestion, nephritis, pressure upon the kidney or ureter, twisting of the 
 ureter in displacement or operation, infection occurs. Whether this takes 
 place from the side of the blood current or from the urinary tract, the pelvis 
 of the kidney is first affected — pyelitis. The colon bacillus, Bacillus pro- 
 teus, streptococcus, and staphylococcus albus have been found in pure 
 cultures. The tubercle bacillus is the cause of a special form of pyelitis. 
 That form which occurs in gonorrhosa is caused not by the gonococcus 
 but by associated pyogenic organisms. 
 
 Morbid Anatomy. — Pyelitis may be catarrhal or suppurative. The 
 tuberculous form begins locally, the kidney gradually becoming infil- 
 71 
 
1122 MEDICAL DIAGNOSIS. 
 
 trated with tubercle which undergoes caseation and softening, with ultimate 
 transformation into cretaceous masses from the resorption of fluid ele- 
 ments and the deposition of lime salts. It is associated with tuberculosis 
 of the ureters, bladder, and prostate and testicles, or the ovaries or Fallo- 
 pian tubes — urogenital tuberculosis. Pyelitis due to local causes usually 
 affects one kidney; that caused by general conditions may involve one 
 or both; the form consecutive to cystitis, following enlarged prostate, 
 stricture, catheter infection, and surgical operation, is bilateral and 
 extends to the kidney substance. The acute supj^urative pyelonephritis 
 which follows operations is known as surgical kidney. 
 
 Symptoms. — The pyelitis which accompanies the acute infections 
 usually causes no symptoms by which it can be recognized during life. 
 There may be pain in the back and deep tenderness over the affected 
 kidney. The urine is albuminous, turbid, sometimes acid, sometimes 
 alkaline, and contains a few pus-cells, transitional epithelial cells, and red 
 blood-corpuscles, rarely tube-casts. Recurrent attacks occur in which, 
 after an interval during which the patient has had clear urine and no 
 special symptoms, the urine suddenly becomes turbid and smoky, and 
 contains albumin and pus-cells, the change being accompanied by pain 
 in the lumbar region, chills, fever, and profuse sweating. 
 
 In chronic pyelitis the pus in the urine varies in amount and may at 
 times wholly disappear — a phenomenon due to the blocking of the ureter 
 when one kidney only is affected, and associated in some cases with the 
 signs of a tumor in the renal region. In acute pyelonephritis shreds of 
 renal tissue are sometimes present, together with tube-casts which may 
 be composed of pus-cells or bacteria. The urine is usually increased 
 in amount and contains albumin in proportion to the pus and blood 
 present. Its reaction varies, being usually alkaline, but sometimes acid, 
 according to the infecting bacterium. It is commonly acid in the clear 
 intervals when the pyuria is intermittent, and alkaline when there is an 
 associated cystitis. 
 
 Paroxysmal fever, intermittent in type and associated with chills 
 and sweating, is very common. The attacks are sometimes ague-like and 
 recur with a periodicity so regular that they closely simulate malaria. 
 After a time the chills cease and the fever assumes the hectic type. Chronic 
 pyelitis is usually accompanied by emaciation, anaemia, and progressive 
 impairment of health. Sepsis with secondary abscess formation may 
 develop — septicopysemia. The symptoms in some cases suggest enteric 
 fever, but the diagnostic clinical and laboratory criteria of that disease 
 are wholly lacking. There is a considerable group of cases familiar to 
 practitioners in which, with intermittent or persistent pyuria, fairly good 
 general health is maintained. A knowledge of this fact is important in 
 connection with surgical considerations. Dryness of the mouth, vomiting, 
 profound asthenia, and drowsiness passing into coma, with dyspnoea — a 
 condition suggestive of diabetic coma — sometimes constitute a terminal 
 symptom-complex. At one time attributed to intoxication by ammoniacal 
 products of decomposing urine, this condition has been regarded as an 
 ammoniaemia. It is probably due to intoxication products of decomposing 
 urine or pus, or specific bacterial toxins. It differs from uraemia in the 
 
PERINEPHRIC ABSCESS. 1123 
 
 absence of convulsions and retinitis. Paraplegia, variously ascribed to 
 myelitis, peripheral neuritis, or reflex causes, is not uncommon. 
 
 The local swelling in the renal region varies in size from time to time. 
 It may attain large size and give rise to signs of fluctuation in pyonephrosis 
 — abscess of the kidney. 
 
 Diagnosis. — Direct. — The constant or intermittent presence of pus 
 and blood in the urine, the occurrence of renal tissue, the absence of tube- 
 casts, a tumor in the renal region inconstant in size or showing deep fluctua- 
 tion in the absence of oedema, one-sided lumbar pain and tenderness, and 
 chills, fever, sweating, wasting, and anaemia justify a positive diagnosis. 
 In the absence of several of these clinical phenomena a provisional diagnosis 
 may be made. 
 
 Differential. — Tuberculous pyelonephritis may be diagnosticated 
 when, with the above symptoms, tubercle bacilli are present in the puru- 
 lent urine. In doubtful cases laboratory methods must be employed, 
 especially the inoculation of guinea-pigs. Evidences of tuberculous disease 
 in the urinary passages or genital organs are of diagnostic importance. 
 The discrimination between pyelitis and pyelonephritis cannot always be 
 made with precision. The presence of minute bits of renal tissue in the 
 urine or a tender tumor in the region of the kidney would point to the 
 latter condition. A deep fluctuating tumor points to renal abscess. 
 Abscess within the capsule of the kidney is to be distinguished from 
 perirenal abscess by the more circumscribed outline of the tumor, the 
 absence of oedema, and the anamnesis, but the differential diagnosis is 
 sometimes impracticable. 
 
 Cystitis and pyelitis are frequently associated. The polyuria, inter- 
 mitting pyuria when present, the pain, tenderness, and tumor mass in 
 one lumbar region, and the absence of frequent micturition and vesical 
 tenesmus are in favor of the latter affection. The anamnesis is important. 
 The cystoscope and catheterization of the ureters may be employed in 
 doubtful cases. 
 
 Prognosis. — The cases associated with the acute febrile infections 
 usually recover with the convalescence from the primary disease. The 
 tuberculous form, when the kidney only is infected, may terminate in 
 recovery, with cretaceous masses replacing more or less renal tissue. In 
 abscess the outlook is unfavorable. Amyloid disease, fatal sepsis, or 
 peritonitis from perforation may occur. The diagnosis assumes importance 
 in view of the possibility of relief by surgery. 
 
 VII. PERINEPHRIC ABSCESS. 
 
 Paranephritis; Perirenal Abscess. 
 
 Definition. — Suppurative inflammation of the connective tissue 
 surrounding the kidney. 
 
 Etiology. — Perinephric abscess may follow blows and injuries, the 
 acute febrile infections, especially in children, inflammation of the kidney 
 or ureter, perforation of the appendix or bowel, or result from a perforating 
 empyema or spinal caries. 
 
1124 MEDICAL DIAGNOSIS. 
 
 Morbid Anatomy. — The pus cavity is usually extensive, and the 
 adjacent tissues cedematous. The accumulation is usually posterior, but 
 may be anterior, to the kidney. It shows a strong tendency to burrow, 
 and may perforate into the pleura, the bowel, the peritoneum, the bladder, 
 or vagina, or follow the direction of gravitating spinal pus along the sheath 
 of the psoas muscle or the iliac fascia, or finally the abscess if left to itself 
 may burst externally. 
 
 Symptoms. — Pain in the region of the kidney, aggravated by pres- 
 sure, or referred to the hip-joint, or inside of the thigh, and associated 
 with retraction of the testicle, a limping gait, flexed thigh, stooping posture, 
 and rigid spine, deep induration and oedema, and a tumor mass upon 
 palpation between the last rib and the crest of the ilium, normal urine 
 unless the primary pus depot is within the capsule of the kidney, and the 
 constitutional evidences of pus make up the clinical picture. 
 
 Diagnosis. — The direct diagnosis is justified by the above associa- 
 tion of symptoms. Pus-free urine, and oedema overlying the tumor, and 
 deep fluctuation are significant. It is not always possible to determine 
 whether the infection comes from the kidney or some source outside of it. 
 Here the history is important. 
 
 Differential. — The pain and attitude may closely simulate hip- 
 joint disease; but the essential symptoms are wanting, and the tumor 
 and oedema in the region of the kidney are conclusive. When the abscess 
 points in the inguinal region spinal caries must be excluded. 
 
 VIII. NEPHROLITHIASIS. 
 
 Renal Calculus; Renal Infarct. 
 
 Definition. — A condition characterized by the presence in the substance 
 or pelvis of the kidney, or in the ureter, of concretions formed by the depo- 
 sition of certain of the constituents of the urine normally held in solution. 
 
 Renal Infarct. — The deposition of urinary salts in the substance of 
 the kidneys occurs under the following circumstances: In the new-born in 
 the shape of uric acid crystalline masses in the tubules, and especially at 
 the apices of the pyramids— wWc acid infarcts; in chronic gout, sodium 
 and ammonium urate in whitish linear deposits, chiefly in the pyramids — 
 sodium urate infarcts; and dense white linear deposits of calcium phosphate 
 or carbonate in the pyramids, chiefly in aged persons — calcareous infarcts. 
 
 Renal Calculus. — The concretions which form in the pelvis and 
 calices constitute, according to their size, sand, gravel, or stone. Renal 
 sand consists of gritty particles of a size not too large to traverse the urinary 
 passages without arrest. These minute calculi are frequently voided in the 
 urine in considerable quantities at intervals for j^ears, without causing 
 symptoms. They form a characteristic coarse urinary sediment. The 
 term gravel is applied to larger concretions, ranging in size from a canary 
 seed to a pea, usually multiple, sometimes single, round and smooth, or 
 irregular and rough, which form in the pelvis and calices, and passing into 
 the ureter cause renal colic. Kidney stones, dendritic or coral calculi, are 
 larger concretions, which attain dimensions in the pelvis which prevent 
 
NEPHROLITHIASIS. 1125 
 
 their entering the ureter. Gradually increasing in size, they often form 
 remarkable branching casts or moulds of the pelvis and calices. Ureteral 
 Calculi. — The orifice of the ureter may be blocked by a large calculus, 
 formed in the pelvis of the kidney, or a calculus may be arrested at any 
 point in its course from the kidney to the bladder. 
 
 Chemical Composition of Renal Calculi. — These concretions do not 
 represent mere precipitations of crystallizable or other solid constituents of 
 the urine. They are composed in the first place of mixtures of various sub- 
 stances of this kind, arranged irregularly or in concentric layers, and in the 
 second place they contain various proteid substances present as the result 
 of inflammatory irritation of the tissues with which they are in contact, 
 and finally bacteria are frequently found in the somewhat irregularly dif- 
 ferentiated central nucleus. The principal varieties consist of: Uric Acid 
 and Urates. — This is the common form and constitutes renal sand, small 
 single calculi, and the large branching kidney stones. They are of a yel- 
 lowish or brownish-red color, smooth or slightly irregular surface, and 
 dense consistence. The large stones are composed of concentric strata 
 and are ver}^ hard. They consist of uric acid and urates in varying pro- 
 portions. In urinary sand the crystalline particles may consist of uric 
 acid alone; in children calculi composed of urates occur. Calcium Oxalate. 
 — Mulberry calculi are of a brownish or black color, rough and mammil- 
 lated or pointed surface, and very hard. They are composed of oxalate 
 of lime and uric acid, the former predominating. Calcium Phosphate 
 and Ammoniomagnesium Phosphate. — Phosphatic calculi are composed of 
 these salts, together with small quantities of calcium carbonate. They are 
 of a whitish or pale fawn color, crystalline or chalk-like surface, and light 
 consistence. They are sometimes friable. They are common, and the 
 substances of which they are composed are deposited as an outer layer 
 upon uric acid or oxalate calculi. Cystin, Xanthin, and Indigo. — Calculi 
 chiefly composed of these substances are occasionally met with. 
 
 Immediate Effects upon the Kidney. — In many cases the kidney 
 manifests a remarkable tolerance for the slowly forming calculus. Single 
 or multiple stones may be found post mortem without lesions of the kid- 
 ney or a history of renal symptoms. Urinary sand or small round uric acid 
 calculi are often passed at intervals by persons otherwise in good health. 
 Large dendritic calculi cause induration and atrophy of the kidney substance. 
 When infection takes place, calculous pyelitis and pyonephrosis result. 
 
 Etiology. — The subjects of uric acid and calcium oxalate crystals are 
 usually adults of good constitution, active, and given to the pleasures of 
 the table. Many of them are gouty. The urine is highly acid and contains 
 uric acid in excess. Phosphatic calculi are met with in anaemic persons in 
 poor health, often women with alkaline, sedimentary urine. In general, 
 renal calculus is much more common in men than in women; in infancy 
 and late adult life than in the middle periods. Dyspepsia, migraine, and a 
 sedentary life are predisposing influences. 
 
 Symptoms. — Nephrolithiasis may be latent. Persons pass renal sand 
 occasionally without local or general derangement of health. Sometimes 
 a large dendritic calculus is unattended by symptoms. As a rule two sets 
 of definite symptoms occur. 
 
1126 MEDICAL DIAGNOSIS. 
 
 1. SYMPTOMS OF Stone in the Kidney. — These are: (a) Pain, which 
 may be dull and continuous, or paroxysmal. It is usually referred to the 
 lumbar region of the affected side, and sometimes radiates to the scrotum 
 or glans penis. It may extend to the opposite side of the back. It may be 
 aggravated by a misstep or sudden jarring of the body. Nephralgia is 
 common in movable kidney, and occurs in the absence of renal calculus, 
 (b) Hcematuria. — Microscopic blood in the urine is very common. The 
 amount of blood may cause smokiness, or, exceptionally, give a bright red 
 tinge to the urine. Haematuria may be continuous, or it may recur at 
 intervals, coming on spontaneously or after exertion, and ceasing upon 
 rest. Bleeding is more common when the calculus is lodged in the ureter 
 than when it remains in the pelvis of the kidney, (c) Pyuria. — Pus in the 
 urine is the indication of calculous pyelitis, which may exist for a long 
 time without causing serious symptoms, or may result in pyelonephritis 
 or renal abscess, (d) Septic Phenoviena. — There are cases in which 
 paroxysms of intense pain, with chills, high fever, — 104° to 106° F. (40°- 
 41.1° C), — and sweating occur at varying but irregular intervals. The 
 urine becomes turbid and contains blood and transitional epithelium, but 
 remains free from pus. These attacks, often regarded as malaria, are more 
 like hepatic fever. Their recognition depends upon the positive evidence 
 of nephrolithiasis and negative signs as regards malaria, i.e., absence of 
 blood parasites and failure of quinine. When calculus is established, 
 irregular chills, fever and sweating, anaemia, wasting, pyuria, and smoky 
 urine are commonly present. 
 
 2. Symptoms of Renal Colic. — The attack begins with dull pain in 
 the renal region, which presently extends to the flank and toward the 
 groin. This pain is continuous with excruciating exacerbations and points 
 of focal intensity in the glans penis and testicle, which is retracted. It is 
 accompanied by a most urgent continuous vesical tenesmus and desire to 
 pass water, which is without result beyond a few drops of bloody urine, 
 the voidance of which is attended with distressing scalding sensations. 
 Rectal tenesmus and intense nausea and vomiting frequently add to the 
 distress of the patient. Restlessness, anxiet}^ pallor, shivering, cold 
 sweats, feeble pulse, and other collapse symptoms are usuallv also present. 
 Fever may occur, 101°- 103° F. (38.3°-39.5° C). The 'attack ceases 
 abruptly, with sensations of relief as the calculus jjasses into the bladder 
 or returns into the pelvis of the kidney. Its duration varies from 
 about an hour to a day or more. In the longer attacks there are 
 periods of remission. 
 
 During the attacks an acute hydronephrosis develops upon the afTected 
 side, which is relieved upon the escape of the calculus into the bladder 
 with the discharge of a large quantity of urine. A large amount of clear 
 urine may be discharged from the sound kidney during the course of the 
 attack. Renal colic does not always terminate in complete relief. The 
 calculus may become impacted in the ureter and cause hydronephrosis 
 and haematuria; in extremely rare cases it may rupture into the peritoneal 
 cavity or the intestine, or may form an abscess and perforate the skin. 
 Again, anuria may occur under the following circumstances: with a nor- 
 mal kidney on the opposite side, from functional arrest, in consequence of 
 
HYDRONEPHROSIS. 1127 
 
 nervous irritation; with a previously diseased kidney from the same cause; 
 with a single kidney. These conditions are rare. 
 
 Death occurs from uraemia, as a rule within ten or twelve days after 
 complete anuria has set in, exceptionally not for two or three weeks. 
 
 Diagnosis. — Direct. — Other forms of paroxysmal pain may be mis- 
 taken for renal colic, but the seat of the pain, its definite extension toward 
 the groin, with local intensification in the testicle and glans, together with 
 hematuria, are characteristic. When direct evidence of the existence of 
 a calculus, as previous attacks with the passage of one, or the voidance of 
 one subsequent to the attack, can be secured, the diagnosis becomes cer- 
 tain. The recognition of a calculus in the pelvis of the kidney or in the 
 ureter, or the grating of several calculi upon palpation, has been mentioned, 
 but I have no personal knowledge of such signs. 
 
 Differential.- — Similar paroxysms of colicky pain are attributed to 
 accumulation of renal sand, uric acid, or oxalates in the pelvis of the kidney. 
 Dietl's crises, the nephritic crises of tabes, and clots of blood in renal 
 hemorrhage, such as occur in cancer, may closely simulate renal colic. 
 Biliary colic and intestinal colic rarely give rise to uncertainty. The dif- 
 ferential diagnosis must be reached by a careful study of the individual 
 case. A diagnosis by exclusion may be necessary. 
 
 The diagnosis of nephrolithiasis depends upon the foregoing symp- 
 toms, the occurrence of renal colic, and the shadows cast by the Rontgen 
 rays. This means of diagnosis is imperatively required in order to deter- 
 mine the presence and position of calculi, and whether they exist in one or 
 both kidneys in connection with the considerations of surgical intervention. 
 
 The differential diagnosis between renal and vesical calculus may 
 sometimes be in doubt. In the lattei" the pain is usually bilateral, more 
 common at the neck of the bladder. The tenesmus is continuous, with 
 frequent micturition, and the sound will detect the presence of the stone. 
 
 Prognosis. — Many cases are recurrent. There is the ultimate danger 
 of calculous pyelitis. The more serious accidents of renal colic and actual 
 obstruction are rare. Many lives have been saved by surgical procedures. 
 
 IX. HYDRONEPHROSIS. 
 
 Definition. — A collection of urinary fluid in the pelvis and calyx of 
 the kidney due to obstruction of the ureter, forming a cyst by the disten- 
 tion and atrophy of the organ. 
 
 Etiology. — Hydronephrosis may be congenital owing to develop- 
 mental defects, and may be of sufficient size to interfere wdth parturition. 
 Much more commonly it is acquired. The obstruction may be in the ure- 
 thra or in the bladder. In suddenly developing polyuria the normal ureter 
 may be incapable of carrying off the excess of urine, and an acute hydro- 
 nephrosis result. The ui-oter may be occluded by calculus, stricture follow- 
 ing ulcer, or torsion or kinking in movable kidney. It may be blocked b}^ 
 neoplasms, particularly tubercle or cancer. Compression from without, 
 by cicatricial adhesions or bands, or by abdominal or pelvic tumors, is a 
 more common cause. Bilateral hydronephrosis may result from the impli- 
 cation of both ureters by any of the lesions just named. When, however, 
 
1128 MEDICAL DIAGNOSIS. 
 
 the obstruction is in the bladder, the hydronephrosis is almost always 
 double. The common conditions are cancer,- which may involve only one 
 ureteral orifice, habitual urinary distention of the bladder in prostatic 
 hypertrophy or stricture, and the extreme thickening and contraction of 
 the bladder wall which accompanies these conditions. 
 
 The fluid accumulates, causing distention of the ureter above the 
 obstruction, but especially of the pelvis of the kidney. Pyelitis may occur, 
 but usually the kidney substance undergoes a simple, progressive atrophy, 
 forming in extreme cases a large cyst, upon the inner surface of which 
 traces of renal tissue may be found. As the secretion of urine diminishes 
 mucus and serum accumulate until the cyst contains a pale yellow or 
 straw-colored fluid, holding in solution traces of the urinary solids and 
 frequently a little albumin. There may be turbidity from the presence of 
 pus. The cyst thus formed njay attain an enormous size and simulate 
 ascites. Cardiac hypertrophy is frequently associated with hydronephrosis. 
 Exceptionally complete occlusion of the ureter is followed by atrophy of 
 the kidney without dilatation. 
 
 Symptoms. — The urinary conditions are by no means constant. In 
 one-sided hydronephrosis with complete occlusion, the urine from the 
 vicariously acting opposite kidney may be normal in quantity and com- 
 position. When the condition is bilateral, oliguria and, ultimatelj^, com- 
 plete anuria result and death occurs with ursemic symptoms. Intermittent 
 hydronephrosis arises when a valve-like obstruction yields to the pres- 
 sure of the accumulated fluid, or the twisted or kinked ureter is restored 
 to its natural condition. Under these circumstances there is a sudden large 
 discharge of clear urinary fluid with the subsidence of the tumor. When 
 the obstruction recurs the cystic tumor reappears, to vanish again when 
 the obstruction is relieved — flush-tank symptom. Intermittent hydro- 
 nephrosis may continue for years. It is unilateral, commonly associated 
 with movable kidney, and usually occurs in women. In cases in which 
 pyelitis exists the urine may be normal when the tumor is forming and 
 turbid from the presence of mucus, pus, or blood as the tumor subsides. 
 
 Physical Signs. — When the tumor attains sufficient size it may be 
 recognized upon palpation or inspection. If unilateral and of moderate 
 size, it occupies the renal region; when large it may simulate ovarian or 
 other cysts; an enormous hydronephrosis may be mistaken for peritoneal 
 effusion. It may also simulate solid tumors of the kidney or enlarged 
 retroperitoneal glands. The physical signs of hydronephrosis and a large 
 renal abscess are the same. The latter is, however, usually attended by 
 septic phenomena. They consist of dulness in the renal region with deep 
 fluctuation. When the tumor presents anteriorly, the ascending colon on 
 the right side, the descending colon on the left, usually yields an oblique 
 band of tympany. 
 
 Diagnosis. — Direct. — Hydronephrosis can only be recognized when 
 it gives rise to a fluctuating tumor. Even then it is readily confounded 
 with other cysts. The greatest difficulties arise when the condition involves 
 a displaced kidney; the least, in the intermittent form. The relation of 
 the tympanitic colon to the tumor is important. The sac may be aspi- 
 rated. The fluid obtained is of low specific gravity, commonly clear, and 
 
CYSTS OF THE KIDNEY. 1129 
 
 contains urea and urinary salts, and transitional epithelium. In very old 
 cases with extreme atrophy of the kidney substance, the fluid may contain 
 nothing characteristic. 
 
 Differential. — Ovarian Cysts. — Large hydronephrosis is frequently 
 mistaken for an ovarian tumor. The latter may be differentiated by its 
 mobility, except in the case of hydronephrosis involving a floating kidney. 
 Hydronephrosis has its starting-point in the renal region, whereas ovarian 
 tumors spring from the pelvis, as can be determined by bimanual 
 examination externally, or with the fingers of one hand in the vagina, 
 later in the rectum, and the other hand upon the abdomen. By this mode 
 of examination the relation of the uterine appendages and the presence 
 or absence of a pedicle can be determined. In ovarian disease disturbances 
 of function — for example, amenorrhoea — are not constant, just as in hydro- 
 nephrosis the condition of the urine varies in different cases. Renal Cysts. 
 — The differentiation is mostly impossible. In the new-born cystic kidneys 
 and hydronephrosis may present the same signs. When the abdominal 
 wall is congenitally defective the dilated bladder and ureters may be 
 readily observed. Echinococcus cysts of the kidney may be suspected if 
 daughter cysts or hooklets are found in the urine or in non-albuminous 
 fluid obtained by exploratory puncture. But a positive diagnosis of 
 echinococcus cyst of the kidney can only be made when it is possible to 
 exclude such a condition perforating into the urinary passages. The 
 hydatid thrill is by no means constant. Mesenteric Cysts. — These tumors 
 vary in size from the closed fist to a cocoanut and are commonly situated 
 in the lower right quadrant of the abdomen. They are freely movable, 
 of oval contour, smooth surface, elastic, and fluctuating. Paroxysms of 
 pain and vomiting are often associated with their presence. Ascites. — 
 The differential diagnosis may be difficult in bilateral hydronephrosis. 
 Movable dulness upon change of position, the absence of tympany in the 
 flanks, and the character of the fluid in peritoneal effusion are important. 
 
 Prognosis. — Unilateral hydronephrosis when quiescent constitutes a 
 benign tumor, but the prognosis must in all cases be guarded. The con- 
 dition acquires importance by progressive increase in size, the danger of 
 rupture into the peritoneum or lung, pyonephrosis, and the possibility of 
 the blocking of the other ureter, with anuiia followed by urasmia. The 
 fluid may discharge by way of the ureter and never reaccumulate. Inter- 
 mittent hydronephrosis may cause little inconvenience and finally undergo 
 spontaneous cure. When double, the condition is far more serious, and 
 the outlook depends upon the possibility of relieving the condition which 
 causes the obstruction — urethral stricture, prostatic enlargement, tumor- 
 pressure. The cases due to malignant disease are without hope. 
 
 X. CYSTS OF THE KIDNEY. 
 
 The multiple small cysts due to obstruction of uriniferous tubules in 
 chronic nephritis, and larger solitary cysts sometimes seen post mortem 
 in kidneys otherwise normal, do not cause symptoms or signs by which 
 they can be recognized during life. Rare forms are. combined cystic disease 
 of the liver and kidneys, and paranephric cysts. Of greater importance 
 
1130 
 
 MEDICAL DIAGNOSIS. 
 
 clinically are: Congenital Cystic Kidneys. — The organs arc enormously 
 enlarged and consist of a mass of round or oblong cysts, varying in diame- 
 ter from 0.5 to 3 centimetres, with kidney tissue sufficient to discharge 
 the renal function distributed in the interspaces. The fluid contained in 
 these cysts varies in color from clear to opaque reddish or black, and in 
 consistence from limpid to colloid. It contains albumin and other pro- 
 teids, cholesterin plates, crystals of hsematoidin and ammoniomagnesium 
 phosphate, and fat droplets. 
 
 Etiology. — Cystic kidneys occur in the foetus and may be the cause 
 of dystocia. They are regarded as developmental defects. They are 
 
 Fig. 326. — Congenital cystic kidneys. — German Hospital. 
 
 sometimes associated with hydrocephalus, defects of the bladder, and 
 malformations of the extremities. The cystic condition increases with 
 age and is encountered in young adults, the tumors often attaining great 
 size. The condition is usually bilateral, though unilateral cases have been 
 observed. The condition has been noted in several members of a family. 
 
 Symptoms. — The urine is abundant, of low specific gravity, and 
 contains albumin in small amounts and hyaline and granular casts. Re- 
 current hsematuria may be noted. There is pallor, a muddy skin, and 
 not rarely diffuse cutaneous pigmentation. 
 
 Physical Signs. — The physical examination reveals the evidences of 
 cardiovascular disease — enlargement of the heart, accentuated aortic sec- 
 ond sound, hardening of the arteries — and the signs of double tumor in 
 the renal region extending forward, elastic but non-fluctuating, and, when 
 
TUMORS OF THE KIDNEY. 1131 
 
 distinctly palpable through the belly walls, irregularly nodular. I have 
 observed these signs in a unilateral case in which the diagnosis was 
 confirmed by operation. 
 
 The symptoms, urinary conditions, and general physical signs are 
 those of chronic nephritis; the local signs, those of renal tumors. 
 
 The diagnosis rests upon the association of the foregoing symptoms 
 and signs. The recognition of the condition derives its importance from 
 the fact that, as a rule, to which there are very few exceptions, surgical 
 intervention is positively contraindicated. 
 
 Prognosis. — The outlook is not favorable. Death results in many 
 cases before or directly after birth. If the patient survive infancy, death 
 occurs before thirty from cardiovascular changes or uraemia. 
 
 XI. TUMORS OF THE KIDNEY. 
 
 Solid tumors of the kidney are benign and malignant. Benign tumors 
 comprise fibroma, lipoma, myxoma, angioma, gumma, and adenoma. 
 They do not give rise to symptoms referable to the kidneys, nor do they, 
 as a rule, attain such a size as to respond to the methods of physical exam- 
 ination — inspection, palpation. They are, however, of anatomical rather 
 than clinical interest. 
 
 Malignant neoplasms — carcinoma, sarcoma — are primary or second- 
 ary. The}' are accompanied by distinct symptoms, both general and 
 urinary, and frequentl}^ grow to a large size. 
 
 Renal carcinoma is a rare lesion and when small may not reveal its 
 presence during life. Larger cancers cause conspicuous abdominal tumors, 
 usually immovable upon deep respiration or palpation, occupying the 
 upper quadrants of the abdomen in relation with the liver or spleen, 
 obliquely traversed by the ascending or descending colon as the case may 
 be, and of an irregular surface and consistence. 
 
 Sarcoma of the kidney is much more common. It constitutes a 
 frequent form of abdominal tumor among children, especially the primary 
 variety. The growth reaches a large size and may greatly distend the 
 abdomen. It is almost always unilateral and presents objective characters 
 similar to those of carcinoma, save that it is commonly less nodular and 
 softer, in some cases even fluctuating over extensive or limited areas. 
 
 Hypernephroma, which may develop from suprarenal tissue excep- 
 tionally upon the kidney, as a rule within its substance, is a very common 
 form of renal tumor. This neoplasm may be found upon post-mortem 
 examination as small tumors within the cortex, or it may form large tumors 
 having the characters of malignant growths of the kidneys in general. 
 Metastases occur. 
 
 Symptoms of Malignant Tumors of the Kidney. — Pain, usually of a 
 dull, dragging character and referred to the flank upon the affected 
 side, is common. It may radiate to the thigh or extend to the pleura. 
 There are large growths in which pain does not occur. Emaciation is 
 commonly progressive and rapid, and a high grade of cachexia is usual. 
 There are cases, however, especially of sarcoma, in which the nutriticm 
 and strength are fairly well maintained. Pressure upon the abdominal 
 
1132 
 
 MEDICAL DIAGNOSIS. 
 
 veins may cause venous distention and cedema of one or both lower 
 extremities, and ascites. Pressure upon nerve-trunks may cause pain or 
 pressure neuritis in the distribution of the intercostals or the crural nerves. 
 Metastatic growths occur in various organs, and, in particular, in the 
 lungs. They may occasion special symptoms. If the spinal cord is 
 involved paraplegia may result. 
 
 The urine contains blood at some time in the course of a majority 
 of the cases. The hsematuria is intermittent, the urine being practically 
 normal during the intervals. If the growth involves the pelvis the urine 
 may be turbid and albuminous. The blood is sometimes fluid, sometimes 
 clotted. It is characteristic of the hsematuria of mahgnant disease of the 
 kidney that blood-casts of the ureter, sometimes of the pelvis of the kid- 
 ney, are occasionally passed. The passage of these clots is attended with 
 intense pain like that of renal colic. In rare instances cancer elements 
 
 have been discovered in the urine. 
 Physical Signs. — If the growth involves 
 a floating kidney, the organ may remain 
 for some time movable and be found in 
 the iliac fossa. When the kidney is 
 affected in situ the tumor is stationary, 
 unilateral, and develops from the upper 
 and posterior region of the abdomen. 
 Other attributes have been mentioned. 
 Bimanual palpation is important. The 
 relation of the colon as indicated by 
 the tympanitic percussion sign which 
 it yields is of great value in the 
 differential diagnosis. 
 
 Diagnosis. — Direct. — The diagnosis 
 of malignant tumor of the kidney in 
 well-developed cases maybe readily made 
 when all of the above symptoms and signs enter into the symptom-complex. 
 In proportion as several of them are absent the diagnosis becomes uncertain. 
 The nature of the neoplasm cannot in all cases be positively determined. 
 Carcinoma is more common in adult life, attended with a greater tendency to 
 wasting and cachexia, and to haematuria. Sarcoma is far more common 
 under ten years of age; it frequently runs its course without hsematuria, and 
 may be attended with little disturbance of the general health. If primarj^ 
 or metastatic growths accessible to direct examination are present, the 
 determination of their character settles any diagnostic uncertainty as to 
 the nature of the renal tumor. The examination of tissue elements found 
 in the urine, or obtained by exploratory puncture, may yield conclusive 
 results. The recent investigations of Kelly and others render it probable 
 that a large proportion of the cases described as primary carcinoma and 
 sarcoma of the kidneys are hypernephromata. 
 
 Differential. — Tumors of the Pelvic Organs. — Tumors of the kidney 
 are frequently mistaken for ovarian tumors. The greater mobility of the 
 latter, their development from the pelvis, their relation to the uterus and 
 the presence of a pedicle as determined by vaginal examination, and 
 
 Fig. 327. — Suprarenal sarcoma; metastases in 
 the skull. — Robert Hutchinson. 
 
ANAEMIA. 1133 
 
 derangement of sexual functions, as menstruation, are significant. Tlie 
 presence or absence of intermittent haematuria is important. Tumors of 
 the uterus are less likely to present diagnostic difficulties. Retroperitoneal 
 sarcoma — Lobstein's cancer — may give rise to diagnostic uncertainty, 
 particularly in children. Both conditions form very large tumors. The 
 disease of the lymphatic glands is more central and less movable. It may 
 extend to the kidneys. In the advanced stages the diagnosis cannot 
 always be made. 
 
 The careful application of the methods of physical diagnosis in con- 
 nection with the facts relative to tumors of the kidneys renders their 
 discrimination from tumors of the liver and spleen an easy matter. 
 
 Prognosis. — The outlook is unfavorable. The extirpation of a small 
 growth has in a low percentage of the cases been followed by recovery. 
 
 XII. 
 
 THE DIAGNOSIS OF DISEASES OF THE BLOOD AND 
 DUCTLESS GLANDS. 
 
 DISEASES OF THE BLOOD. 
 
 I. ANiEMIA. 
 
 Definition. — A morbid condition of the blood characterized by a 
 diminution of the erythrocytes or the haemoglobin, or of both. 
 
 i. General Considerations. 
 
 Pallor of the skin and mucous membranes is in a high degree 
 suggestive of anaemia. For a positive diagnosis, however, a systematic 
 microscopic examination is essential. By this method only can the exist- 
 ence of anaemia in every case be recognized and the nature of the 
 anaemia positively determined. 
 
 Pseudo-anemia. — There are individuals in whom marked pallor of 
 the skin and mucous membranes suggests anaemia, but whose blood shows, 
 upon microscopical examination, a normal number of erythrocytes and a 
 normal percentage of haemoglobin. Such persons usually owe their pallor 
 to one or another of the following conditions: (1) hereditary peculiarities 
 of the integuments, among which is an opaque but non-pigmentcd skin 
 deficient in capillary network; (2) prolonged life in tropical regions, the 
 so-called tropical anaemia; (3) chronic nephritis, arteriosclerosis, certain 
 cases of cardiac disease, neurasthenia, and tuberculosis; (4) habitual 
 indoor life, as in prisoners, — the so-called "prison pallor," — Avorkers in 
 sweat-shops, miners, and others whose occupations and circumstances 
 deprive them of sunlight and fresh air. 
 
 There are transitory conditions in which pallor of the skin and mucous 
 surfaces is ischaemic rather than anaemic, as syncoj)e, rigor, chilling of the 
 surface, fatigue, pain, and sudden intense emotions, especially fear. The 
 
1134 MEDICAL DIAGNOSIS. 
 
 volume of the blood and its corpuscular values are unchanged, but it 
 retires from the surface and accumulates in the viscera and deeper tissues 
 of the body. The tidal blood flows and ebbs, not rhj^thmically, but under 
 the influences of various physiological and pathological influences. 
 
 Local An.^mia. — The distribution of the blood mass is controlled by 
 the arteries, which contract or dilate under the influence of the central or 
 peripheral vasomotor ganglia. Hence afflux and deflux, physiological 
 within limits; pathological in excess. In one territory congestion; in 
 another anaemia. Cerebral anaemia with faintness or syncope results from 
 sudden dilatation of the mesenteric vessels, such as is caused by intense 
 emotion, pain, the rapid removal of pressure, as in the abrupt change to 
 the upright posture, or a copious stool in advanced aortic incompetence, 
 or the evacuation of a large ascites. Chronic anaemia of the central ner- 
 vous system may be the cause of many of the vague symptoms in cardiac 
 disease and enteroptosis. Local anaemias due to spasm of peripheral 
 vessels, such as is seen in Raynaud's disease, causing asphyxia of the 
 extremities, may affect visceral vessels, causing functional derangements, 
 or circumscribed areas of brain tissue, and give rise to transitory palsies, 
 aphasia, or hemicrania. 
 
 General Anemia. — The general anaemias are primary, essential or 
 cytogenic, and secondary or symptomatic. 
 
 ii. Primary Ansemia. 
 
 The blood-making organs are at fault. The etiology is obscure. 
 The essential lesions involve the blood as a tissue. Clinical phenomena 
 manifest in other structures are secondary to changes in the blood. This 
 group comprises chlorosis, pernicious anaemia, and splenic anaemia. 
 
 (a) CHLOROSIS. 
 
 Definition. — Anaemia of undetermined cause, common in females at or 
 shortly after the age of puberty, and characterized by a peculiar greenish- 
 yellow pallor of the skin, constipation, breathlessness upon exertion, and 
 marked relative diminution of the haemoglobin. 
 
 Etiology. — Predisposing Influences. — Sex is paramount. Chlorosis 
 occurs only in females. The period of onset corresponds to that of puberty, 
 and varies from about the thirteenth to the seventeenth year. Earlier 
 than this period it is uncommon; later it is due to recurrences, which are 
 sometimes multiple. The disease may occur in successive generations, 
 and the daughters of mothers who had suffered from chlorosis are often 
 chlorotic. Several girls in the same family often manifest the disease. 
 The condition is sometimes associated with hypoplasia of the aorta and 
 sexual organs. The disease occurs in every walk of life, but is much more 
 common among the poorer classes and working girls in factory towns and 
 large cities. It is not uncommon among domestic servants. Among 
 farmers' daughters it is rare. Lack of exercise, of fresh air and sunshine, 
 and insufficient and improper food are important predisposing influences. 
 The subjects of the disease are often lethargic and phlegmatic; sometimes 
 
ANEMIA. 1135 
 
 emotional and nervous. The disease has, upon insufficient grounds, been 
 regarded as a neurosis, attributed to coprtemia from constipation and to 
 the wearing of the corset. 
 
 The Exciting Cause. — The actual cause of chlorosis is unknown. 
 It is apparently due to a functional default of the blood-making organs — 
 defect of hsemogenesis — incident to the functional maturity of the 
 reproductive organs. 
 
 Symptoms. — Pallor is marked, and the skin has a faint yellowish- 
 green tinge to which is clue the designation chlorosis, or green sickness. 
 The conjunctivse are faintly bluish and the mucous membranes of the 
 mouth and lips very pale. In some cases the normal pigmentation about 
 the folds of the joints is slightl}^ intensified. The subcutaneous fat is 
 frequently increased and there is an increased turgor of the integumentary 
 tissues. There may be actual oedema of the face and ankles. There are 
 rare cases in which the cheeks have a reddish color, especially upon exer- 
 tion or during excitement — chlorosis Jiorida, chlorosis rubra. Gastro- 
 intestinal symptoms are common and often prominent. The appetite is 
 capricious. The school-girl's fondness for pickles and bits of chalk is 
 well known. Hyperacidity is often present and associated with epigastric 
 distress. Dilatation of the stomach, gastroptosis, and movable right 
 kidney are frequently present. Constipation is a common and troublesome 
 condition. Dyspnoea, palpitation, and vertigo occur upon exertion, as 
 in the rapid ascent of a flight of stairs. The heart is frequenth^ dilated and 
 the apex displaced slightly to the left. A systolic murmur in the mitral 
 area may be the sign of relative insufficiency. Much more common are 
 systolic murmurs at the base, particularly in the pulmonary area. Distinct 
 pulsation in the second left intercostal space is not uncommon. Diastolic 
 murmurs are infrequent. A distinct, loud, continuous, venous hum may 
 be heard over the jugular vein on the right side — iiun's murmur, bruit de 
 diable, humviing-to'p murmur. Pulsation may sometimes be seen in the 
 veins of the neck; less frequently in the peripheral veins. Thrombosis 
 may occur in the cerebral sinuses or in the left femoral vein. In the latter 
 event there is danger of pulmonary infarct. Slight enlargement of the 
 thyroid body is not uncommon. It may be associated with Joffroy's sign. 
 Amenorrhoea and dysmenorrhoea are common. Hysterical manifestations 
 occur in a large proportion of the cases. Headache, coldness of the extrem- 
 ities, and mental depression are prominent symptoms. Moderate rises of 
 temperature are occasionally observed. 
 
 The Blood. — The droplet is pale and flows freely from the puncture. 
 It is characterized by transparency and fluidity as contrasted with normal 
 blood. The coagulation period is short and the specific gravity decreased. 
 The alkalinity of the blood, according to most observers, remains normal. 
 There is marked absolute decrease in the hemoglobin; and a high degree of 
 diminution in haemoglobin relative to the reduction in the number of 
 erythrocytes, as manifested by low color indices, constitutes a character- 
 istic phenomenon of chlorotic blood. Microscopically the erythrocytes are 
 moderately decreased, usually to about 4,000,000 per cubic millimetre. 
 They may fall as low as 8,000,000 or even 2,000,000 in severe cases. There 
 is a slight general diminution in their average diameter. Nucleated forms 
 
1136 MEDICAL DIAGNOSIS. 
 
 — normoblasts — are occasionally present. Poikilocytosis is common and 
 may be marked in severe cases. Microcytosis also occurs in the graver 
 cases. Polychromatophilia is rare. The leucocytes are usually normal 
 or slightly increased. There is relative increase in the number of lympho- 
 cytes. Small percentages of myeloc5i:es occur in severe cases. Eosino- 
 philes are absent in the majority of the cases. 
 
 Pseudochlorosis. — This term has been applied to a rare condition in 
 which the characteristic symptom-complex is present, but no marked change 
 in the blood can be discovered upon ordinary clinical examination. It has 
 been assumed that the actual condition of the blood as regards the relation 
 between the haemoglobin and erythrocytes is masked by a diminution in 
 the volume of plasma. 
 
 Diagnosis. — The direct diagnosis of chlorosis is unattended with 
 difficulty. The pallor, the pearly or bluish conjunctivae, the preservation 
 of subcutaneous fat occurring in a girl at or shortly after puberty con- 
 stitute a characteristic clinical picture. Headache, breathlessness upon 
 exertion, and gastro-intestinal sj^mptoms, especially constipation, are of 
 diagnostic value, particularly in the absence of visceral disease attended 
 by anaemia and dropsy, as disease of the heart, or forms of nephritis, or 
 chronic infections, as tuberculosis, sj^philis, or malaria. In the majority 
 of cases the characters of the blood differentiate chlorosis from other forms 
 of anaemia; but the fact is not to be overlooked that there are cases of 
 secondary anaemia, particularly in the above-mentioned organic and infec- 
 tious diseases, in which changes in the blood closely corresponding to 
 those of chlorosis occur. 
 
 Differential Diagnosis. — Cardiac Disease. — The dyspnoea and pal- 
 pitation upon exertion frequently suggest valvular disease of the heart. 
 The anamnesis is important. A history of rheumatic or scarlet fever, 
 foUow^ed by such symptoms becoming progressively more severe; distinct 
 cardiac enlargement; murmurs having characteristic points of maximum 
 intensity, definite lines of propagation, and constant relations to the rev- 
 olution of the heart; the absence of a venous hum, are in favor of disease 
 of the heart. The sex and age of the patient are highly important. Renal 
 Disease. — General pallor and some degree of anasarca, as shown in puffi- 
 ness of the face and oedema of the feet, may be suggestive of nephritis — a 
 diagnosis at once negatived by the absence of albumin and casts. The 
 possibility of transient albuminuria — albuminuria of adolescence — is to be 
 borne in mind. The intermittent nature of this form of albuminuria and 
 its tendenc}^ to disappear upon rest are significant. Tuberculosis. — The 
 pallor of the early stages of pulmonary tuberculosis in a 3'oung girl may 
 simulate chlorosis. Cough, wasting, positive physical signs, rapid pulse, 
 and a slight rise of temperature recurring about the same time every day, 
 increased by exercise and at the time of menstruation, point to phthisis. 
 The examination of the blood is essential. The deficiency of the haemoglobin 
 in chlorosis may be apparent when a drop of blood is allowed to fall upon 
 a piece of white blotting paper or a handkerchief, the blood of a healthy 
 person being used for contrast. Malaria. — The character of the febrile 
 paroxysm and the presence of malarial parasites in the blood are conclu- 
 sive. Syphilis. — The rapid anaemia and the fever of secondary syphilis 
 
ANiEMIA. 1137 
 
 may give rise to doubts as to the diagnosis. The macular syphihde, 
 adenopathy and mucous patches are diagnostic. When a chlorotic girl 
 contracts syphilis the question of diagnosis becomes complicated. 
 
 Prognosis. — The prognosis is favorable. The majority of cases 
 recover under treatment in the course of a few weeks. The tendency ' 
 to repeated attacks persists in some cases for several years. The influ- 
 ence of pregnancy and lactation in arresting this tendency is usually 
 positive. The administration of iron in proper doses appears in a majority 
 of cases to exert a specific curative influence— a fact that might be of 
 diagnostic importance in a doubtful case. 
 
 (b) PERNICIOUS AN/GMIA. 
 Idiopathic or Progressive Ancemia. 
 
 Definition. — Severe anaemia developing either idiopathically or in 
 the absence of discoverable adequate cause, and characterized by a 
 progressively unfavorable course, maintenance of body weight, and con- 
 stant changes in the blood, namely, great reduction in the number of 
 erythrocytes, megalocytosis, microcytosis, poikilocytosis, the presence of 
 erythroblasts, and relative increase in haemoglobin. 
 
 Etiology. — Clinically several different groups of cases may be recog- 
 nized which present the symptoms of progressive pernicious anaemia, but 
 are due to different causes. A majority of the cases correspond to the 
 description of Addison, and arise in the absence of the usual causes of anae- 
 mia. Intense progressive anaemia, presenting all the clinical features of 
 pernicious anaemia, is occasionally encountered, (a) in child-bearing women, 
 beginning either during pregnancy or after parturition; (b) in gastro- 
 intestinal diseases, particularly atrophy of the stomach; and (c) in certain 
 forms of intestinal parasitism, especially uncinariasis and the presence of 
 the Bothriocephalus latus. The blood picture seen in the anaemia which 
 follows certain cases of nitrobenzol poisoning is similar to that of pernicious 
 anaemia. Cases have been observed in every quarter of the globe. The 
 onset is gradual and wholly independent of seasonal influences. The 
 exacerbations which follow remissions under treatment sometimes occur 
 in the spring of the year. The onset of the disease is most common in late 
 middle life. It has been observed at all ages. Excluding the cases which 
 begin during pregnancy and lactation, it would appear that males are much 
 more frequently affected than females. Rare cases have been encoun- 
 tered in parents and children — a fact which does not warrant the assump- 
 tion that the tendency to the disease is transmitted from the parent 
 to the offspring. Severe nervous or mental shock and prolonged intense 
 depressing emotions have in many instances been followed by the onset of 
 the disease. The researches of William Hunter lend support to the conclu- 
 sion that this form of anaemia is due to chronic septic infection associated 
 with lesions of the gums or mouth, and gastric and intestinal sepsis, which 
 lead to haemolysis. 
 
 Symptoms. — The onset is insidious, and the symptoms are those of a 
 profound and progi'essive anaemia. Pallor of the skin and visible mucous 
 
 72 
 
1138 
 
 MEDICAL DIAGNOSIS. 
 
 membranes, languor, breathlessness upon slight exertion or emotional 
 excitement, flabbiness of the tissues associated with remarkable preser- 
 vation of the subcutaneous fat and slight pufliness about the ankles, 
 extreme debility, make up the clinical picture. In a majority of the cases 
 there is irregular fever of moderate intensity. Cardiovascular symptoms 
 consist of faintness, dyspnoea and palpitation upon exertion, a full, soft, 
 and compressible pulse, visible pulsation of the superficially placed arteries, 
 and hsemic murmurs. The pulse not rarely resembles the water-hammer 
 pulse of aortic regurgitation, — Corrigmi's pulse, — a resemblance frequently 
 increased by the presence of capillar}^ and a penetrating venous pulsation. 
 There is a marked tendency to hemorrhage from the mucous membranes 
 
 and into the skin. Retinal hemor- 
 rhages are common as in other 
 grave anaemias. Gastro -intestinal 
 Sym-ptovis. — The appetite fails, and 
 in advanced cases anorexia is com- 
 plete. The mouth is dry, the tongue 
 furred, often sore, the gums are 
 ulcerated, and the breath is offen- 
 sive. Nausea and vomiting are 
 common. Attacks of diarrhoea 
 occur without apparent cause. The 
 urine is abundant and usually of low 
 specific gravity; sometimes pale, 
 sometimes of a deep sherry color, 
 due to the presence of urobilin. The 
 skin is blanched, smooth and waxy 
 in appearance. It is commonly 
 intensely pale, frequent»Iy of a faint 
 lemon color, especially marked upon 
 the hands, sometimes subicteroid, 
 and less commonly pigmented as in 
 Addison's disease. The pigment 
 may be more or less uniformly 
 distributed, or deposited in irregular 
 patches. It is sometimes associated with patches of vitiligo. In some cases 
 the cutaneous pigmentation follows the prolonged administration of arsenic. 
 Spinal symptoms may be encountered as the result of degeneration 
 involving the posterior and lateral columns, and in some cases extending 
 beyond these tracts to the anterior part of the cord. They may appear 
 earlier than the blood changes, but more commonly not until the disease 
 is well advanced. They consist of numbness and tingling in the legs and 
 feet, weakness, and in some cases severe pain. The reflexes are increased. 
 Later similar symptoms may involve the upper extremities. There may 
 be marked ataxia, with disturbance of the functions of the bladder and 
 rectum. After a time loss of sensation may occur, with flaccidity and 
 abolition of the reflexes. 
 
 The Blood. — There is absolute diminution of the haemoglobin, which 
 is, however, increased relatively to the number of red cells, so that the 
 
 Fig. .328. — Piu:meiitation of th 
 pernicious anaemia. 
 
 skin in a case of 
 -Packard. 
 
ANEMIA. 1139 
 
 color index is high. The erythrocytes show a great numerical decrease, 
 often to 1,000,000, or in terminal states to 500,000 per cubic millimetre. 
 Erythroblasts are constant, the common form being megaloblastic. Poikilo- 
 cytosis is constant and marked. Megalocytes and microcytes occur, the 
 former being more common and more marked. Polychromatophilia is 
 found in many of the erythrocytes, both non-nucleated and nucleated. 
 The leucocytes are usually decreased, often markedly so. A relative 
 increase in the lymphocytes is common. Myelocytes are usually present. 
 The eosinophiles are almost always decreased in number and frequently 
 absent altogether. The number of blood-plaques is variable. Blood crises 
 (von Noorden) are characterized by the appearance in the blood of large 
 numbers of nucleated red blood-corpuscles, very often in successive crops, 
 and are usually of sudden onset and brief duration, sometimes lasting 
 but a few hours. These crises are common in severe anaemia following 
 hemorrhage and in chlorosis, and not rare in some forms of leukaemia and 
 in pernicious ansemia, and are usually followed by periods of temporary 
 improvement in the blood count. The blood crises of pernicious ansemia 
 are more commonly of the megaloblastic type and are frequently followed 
 by the death of the patient. When of the normoblastic type they may be 
 followed by an actual increase in the erythrocytes. 
 
 Aplastic Anemia. — This term has been applied to a limited group of 
 cases presenting the S3"mptoms of pernicious ansemia but characterized 
 by atrophy of the erythroblastic tissue in the bone-marrow. Clinical 
 differences between this variety and the ordinary form of pernicious 
 ansemia are found in its earlier occurrence, a majority of the cases having 
 occurred before the thirty-fifth year of life; its greater frequency among 
 females than males; its rapid course, unattended by remissions and usually 
 terminating within a period measured by months; a greater tendency to 
 hemorrhage. Differences in the blood picture consist in a lower color index 
 than in the ordinary form; a marked increase in the percentage of lympho- 
 cytes; the absence, as a rule, of erythroblasts; the absence or comparative 
 infrequency of poikilocytosis, anisocytosis (differences in the size of the 
 erythrocytes), polychromatophilia; and the great diminution of the blood- 
 plates. Pathologically the most constant and striking change is manifest 
 in the marrow of the long bones, from which the erythroblastic tissue has 
 disappeared, leaving the medullary cavities filled with fat. That this 
 change has occurred in all the bones has not as yet been demonstrated in 
 any case. The femur is used as a standard, and if its marrow is yellow 
 and homogeneous throughout, the form of ansemia may be regarded as 
 aplastic. Diagnosis.— The direct diagnosis cannot be made tJitra vitam.. 
 It is rendered probable by the concurrence of the above clinical symp- 
 toms and hsematological findings, but finally rests upon the post-mortem 
 examination of the marrow of the bones. 
 
 Diagnosis. — The direct diagnosis of pernicious anaemia can only be 
 made by a microscopical examination of the blood. In general practice 
 the true nature of the disease is not often suspected in its earlier course 
 and rarely recognized after it has made some progress. Even the blood 
 changes are not at all times present in every case in the beginning. A 
 severe ansemia insidiously arising in the absence of any obvious cause, 
 
1140 MEDICAL DIAGNOSIS. 
 
 pursuing an unevenly progressive course but little influenced by treat- 
 ment; preservation of the subcutaneous fat and body weight to a remark- 
 able degree; a blanched, smooth, and waxy appearance of the surface, 
 which has a faint lemon-yellow tint; extreme languor and breathlessness 
 upon exertion; a tendency to hemorrhage into the skin or from mucous 
 surfaces; retinal hemorrhage; gastric symptoms; and the occurrence of 
 febrile paroxysms of moderate intensity constitute a symptom-complex 
 which is highly characteristic. A blood picture showing the association of 
 oligocythsemia of high grade, falling in many cases below 1,000,000 per 
 cubic millimetre; erythroblasts mostly of the megaloblastic type; poikilo- 
 cytosis; great variation in the size of the erythrocytes; a high color index; 
 and leukopenia render the diagnosis positive. 
 
 Differential. — 1. Grave secondary ancBmias, such as occur after 
 copious hemorrhages (especially a prolonged habitual blood loss), visceral 
 cancer (especially carcinoma ventriculi), and in advanced syphilis, often 
 present clinical symptoms precisely similar to those of pernicious ansemia. 
 The anamnesis is important. As a rule, an obvious cause for the anaemia 
 may be discovered. There are, however, cases in w^hich malignant disease 
 cannot be located, or the history of syphilis is obscure. The actual patho- 
 logical condition then rests upon the examination of the blood. The 
 following points are of diagnostic importance: In secondary anaemia, (a) 
 the oligocythsemia is less marked, the count rarely falling below 1,000,000 
 per cubic millimetre; (b) the color index is lower; (c) leucocytosis is often 
 present; (d) megalocytosis does not occur. The fault does not primarily 
 involve the haematopoietic organs. The blood changes result from, and 
 are secondary to, constitutional diseases, as certain of the acute and chronic 
 infections and intoxications, diabetes, parasitism and nutritional dis- 
 orders, local anatomical lesions which seriously interfere with the functions 
 of important viscera,— as the heart, lungs, the organs of digestion, or the 
 kidneys, — ^ malignant disease, or to hemorrhage. The anaemia is due to 
 deficient blood formation — haemogenesis; excessive blood destruction — 
 haemolysis; or the association of these two processes. Severe secondary 
 anaemia, when long continued, may exhaust the function of the blood- 
 making organs in such a manner as to be converted into primary ana&mia. 
 2. Chlorosis. — There are often clinical phenomena present which suggest 
 pernicious anaemia, namely, preservation of subcutaneous fat, smooth, 
 waxy, and faintly greenish-yellow tint of the skin, pallor of mucous sur- 
 faces and pearly tint of sclera, breathlessness, and languor; but the blood 
 examination shows essential differences. The following points are to be 
 considered: (a) In chlorosis we have to do with a haemoglobin rather 
 than a corpuscular anaemia; hence a low color index, the reverse of the 
 condition in pernicious anaemia; (b) there is a general diminution in the 
 diameter of the er3^throcytes; (c) megaloblasts may occasionally be 
 encountered, but are never present in great numbers — nucleated red 
 corpuscles when seen are almost always normoblasts; (d) leukopenia of 
 high grade is not common; (e) myelocytes may be observed in small 
 numbers in both diseases, but are much less common in chlorosis. 3. 
 Bothriocephahis Anmnia. — The therapeutic test yields positive results. 
 Metabolic products of the intestinal parasite have been thought to possess 
 
AN.EMIA. 1141 
 
 hsemolytic properties. Its expulsion may be promptly followed by an 
 improvement in the general health and the restoration of the blood to 
 its normal condition, the megaloblasts and oligocythsemia disappearing 
 and the color index falling to the usual range of health. 4. Various Affec- 
 tions. — In the absence of a blood examination the lemon-yellow tint of 
 the skin may suggest jaundice, from which pernicious anaemia is to be 
 differentiated by the pearl}'' sclera, the fact that bile pigments are not 
 present in the urine, and the absence of definite signs and symptoms 
 indicating disease of the liver or bile passages; the anaemia, puffiness of 
 the face, and swelling of the ankles may simulate nephritis, especially if, 
 as is sometimes the case, albumin is found in the urine, a view not sus- 
 tained by the results of close analysis of the urine and the history of the 
 case; palpitation, dyspnoea, and the condition of the arteries point to 
 cardiac disease, but the anamnesis and physical signs lend little support 
 to such a diagnosis; finally, nervous symptoms, such as numbness of the 
 legs and feet, less commonly of the hands, pain, sometimes very severe, 
 impairment of station and gait, and loss of the deep reflexes arouse the 
 suspicion that the affection is of spinal origin, a diagnosis always obscure 
 but much influenced by the blood examination, since pernicious anaemia has 
 not been found to arise as a secondary affection in spinal degenerations, while 
 posterolateral sclerosis has been frequently observed in this form of anaemia. 
 Prognosis. — The course of the disease is not, as a rule, steadily pro- 
 gressive. There are periods of improvement followed by relapse. Many 
 cases go on in this way for j^ears. There are cases which run a very 
 rapid course and end fatally within a few months. The average duration 
 is about a year or fifteen months. Occasionally recoveries have been 
 recorded. The following conditions are of bad omen: an oligocythaemia 
 of less than 1,000,000 per cubic millimetre, a high percentage of megalo- 
 blasts and blood crises of megaloblastic type, the inability to take arsenic,, 
 tendency to hemorrhage, gastro-intestinal disturbances, and, as in almost 
 all grave chronic diseases, the privations and disabilities incident to poverty. 
 
 (c) SPLENIC AN/CMIA. 
 
 This affection is considered under the heading Diagnosis of Diseases 
 of the Spleen. 
 
 iii. Secondary or Symptomatic Anaemia. 
 
 Under this heading are included those forms of anaemia caused by 
 acute and long repeated hemorrhages, certain intestinal parasites, unhy- 
 gienic surroundings, insufficient food, prolonged lactation, the metal poison- 
 ings, acute and chronic infections, acute and chronic visceral diseases, 
 especially nephritis and cardiac disease, and malignant growths. 
 
 In moderate cases the freshly drawn blood presents an appearance 
 nearly normal, but in cases of intense secondary anaemia it may look like 
 serum faintly tinged with crimson. In the latter case the tendency to 
 rouleaux is slight. The coagulation period is diminished in proportion to 
 the intensity of the anaemia. The further changes in the blood are as 
 
1142 
 
 MEDICAL DIAGNOSIS. 
 
 follows: haemoglobin diminished to an extent proportionate to the energy 
 of the cause; color index correspondingly decreased; erythrocytes dimin- 
 ished to a varying degree; nucleated forms in intense anaemia, the normo- 
 blastic type prevailing; departures from normal in the size and shape, and 
 polychromatophilia in severe cases; leucoc}i:osis commonly present; 
 polynuclear neutrophiles relatively increased; lymphocytes decreased; 
 lymphocytosis may occur in severe and prolonged cases; myelocytes in 
 small numbers; blood-plaques increased. 
 
 
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 Fig. 329. — Chart showing variations in the number of erythrocytes and in the percentage of hsemoglobin 
 , in posthemorrhagic ansemia due to gastric ulcer. 
 
 Posthemorrhagic An.cmia. — An examination directly after the 
 blood loss may fail to show diminution in the hsemoglobin or corpuscles 
 by reason of the oligsemia. Fluid is, however, rapidly taken from the 
 tissues into the capillaries so that a condition of hydrsemia ensues and the 
 decrease in hsemoglobin and erj^throcj^es becomes apparent, the minimum 
 counts occurring some time within the course of a week. A more or less 
 marked leucocytosis commonly occurs and persists for about a week, 
 gradually declining. A gradual regeneration of the blood takes place in 
 uncomplicated cases and is completed in from three to four weeks, the 
 hsemoglobin reaching normal at a later period than the erythrocj^tes. 
 
LEUKAEMIA. 1143 
 
 Secondary anaemia is very common in childhood. It may be 
 congenital,, as in syphilis and other infections, or acquired, as in (a) 
 hemorrhages of various kinds, particularly from the navel, after cir- 
 cumcision, and in the purpura group, or (b) from general causes, as 
 malnutrition, improper hygiene, syphilis, rickets, tuberculosis, the fevers, 
 sepsis, gastro-intestinal and other visceral diseases, nephritis, acute 
 disease of the heart, and malignant disease. 
 
 II. LEUKAEMIA. 
 
 Definition. — An affection of undetermined causation, characterized 
 by an enormous but fluctuating increase in the leucocytes, decided de- 
 crease in the erythrocytes and haemoglobin, and lesions of the spleen, 
 lymphatic glands, or bone-marrow. 
 
 Varieties. — Two well-defined clinical varieties are recognized: (1) 
 myelogenous or splenomedullary leukaemia, and (2) lymphatic leukaemia. 
 The splenomedullary is much the more common type. Combined forms 
 and variations are not infrequent. 
 
 Etiology. — Predisposing Influences. — The disease has been encoun- 
 tered at all periods of life, from early infancy to the seventieth year. 
 It is most common in the third, fourth, and fifth decades. Leukaemia is 
 more common in males than females in the ratio of about two to one. 
 Cases have been observed in pregnancy, and the disease not rarely develops 
 at the grand climacteric. There are instances in which leukaemia has been 
 observed in successive generations, and a leukaemic mother has borne 
 eukaemic children. On the other hand, leukaemic mothers have borne 
 non-leukaemic children, and a woman showing no signs of the disease has 
 borne a leukaemic child. Leukaemia occurs in all parts of the world. It 
 is not rare in the United States. Cases have been observed in almost all 
 kinds of domestic animals. 
 
 Exciting Cause. — The disease has upon inadequate grounds been 
 attributed to malaria. It has followed blows and grave bodily injury. 
 The tendencies to hemorrhage and to habitual nose-bleeding, which have 
 been regarded as etiological, are much more probably early manifestations 
 of an affection the true nature of which has been revealed by a study of 
 the blood. In point of fact nothing is as yet known of the actual cause. 
 
 General Symptoms. — The onset is insidious and ma}' be associated 
 with persistent and intractable gastro-intestinal symptoms. In some 
 instances the patients present the appearance of fairly good health until 
 the occurrence of grave symptoms shortly before death. A lad of sixteen 
 was supposed to be in his usual health until the occurrence of hemorrhage 
 from the stomach, which proved fatal in the course of two daj's. Such 
 cases are not very uncommon. Epistaxis is a frequent symptom. Pallor, 
 palpitation, and dyspncea upon exertion are very common. Distention 
 of the abdomen due to splenic tumor and enlargement of the liver may 
 first attract the attention of the patient. Tenderness over the sternum 
 or the long bones occurs in many of the cases. Diffuse enlargement of the 
 superficial lymph-nodes, which are generall}' of moderate consistency, 
 not adherent among themselves or to the skin, and variable in size from 
 
1144 
 
 MEDICAL DIAGNOSIS. 
 
 time to time, is common in tlie Ij'-mphatic form. The groups usually 
 involved are the cervical, axillary, and inguinal. These changes may be 
 restricted to the mesenteric and other deep groups without demonstrable 
 signs of enlargement during life, and there are cases in which the bone- 
 marrow alone is involved, without enlargement of the spleen or lymphatic 
 glands. There may be a high degree of emaciation and anasarca, or 
 effusion into the serous sacs. 
 
 i. Myelogenous or Splenomedullary Leuksemia. 
 
 Symptoms. — Gradual enlargement of the spleen is usually the most 
 conspicuous clinical phenomenon. The enlarged organ extends downward 
 and to the right, and may reach the level of the pubic arch and pass beyond 
 the median line. Its well-defined border and often the notch or notches 
 may be distinctly felt. It is usually painless, but occasionally both pain 
 
 and tenderness are present. Peri- 
 
 '^'^r^w^'^^;m!'~^r^'T^r'~-^w.v^ 
 
 splenic friction may, in such cases, 
 be recognized upon auscultation and 
 palpation. Minor fluctuations in 
 size may be observed: enlargement 
 during digestion, and diminution 
 during fasting and after diarrhoea 
 or free hemorrhage. Fluctuations 
 of greater amplitude frequently occur 
 as spontaneous events in the natural 
 history of the disease, or in conse- 
 quence of the administration of 
 arsenic or other therapeutic meas- 
 ures. Massive splenic enlargement 
 causes pressure symptoms, among 
 which the more common are distress 
 after eating and constipation. 
 G astro-intestinal symptoms occur in 
 the course of almost every case. 
 Nausea and vomiting may be early 
 and persistent. Diarrhoea is common. 
 Hemorrhage from the bowel is not 
 common. It may be due to chronic 
 dysentery. Fatal obstruction of the 
 bowel may be caused by pressure 
 of the enlarged spleen upon the 
 intestine. Jaundice is a rare symp- 
 tom. Peritonitis and ascites may 
 also be caused by the pressure of 
 a massive spleen. Symptoms due 
 to circulatory derangements and the 
 changes in the blood are prominent. The cardiac impulse is displaced 
 upward an interspace or more by the big spleen; hsemic murmurs may be 
 heard. The pulse is usually of large volume and rapid, but soft and com- 
 
 FiG. 330. — Splenomedullary leuksemia 
 tended abdomen due to massive enlargement of 
 the spleen. — Jefferson Hospital. 
 
LEUKEMIA. 
 
 1145 
 
 pressible. The dyspnoea is anaemic. Hemorrhage is a very common symp- 
 tom. Epistaxis, bleeding from the gums, hsematemesis, purpura, retinal 
 hemorrhage, and cerebral hemorrhage are frequent. Haemoptysis and 
 hsematuria are much less common. Fluid exudates into the serous sacs 
 a,re usually hemorrhagic. (Edema of the feet and general anasarca are 
 terminal conditions. As in all the grave anaemias, headache, vertigo, and 
 syncopal attacks are of frequent occurrence. Leukaemic retinitis may be 
 due to hemorrhage or minute leukaemic deposits. Optic neuritis is rare. 
 Deafness is common and the syndrome known as Meniere's disease has been 
 observed. With the exception of a constant excess of uric acid the urine 
 presents no characteristic changes. Priapism has been frequently noted. 
 It may be an early and persistent symptom. Pneumonia or pulmonary 
 oedema are common terminal events. 
 
 
 
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 Fig. 331. — Chart showing variations in the number of leucocytes, erythrocytes, and in the lisemoglobin 
 percentage in a case of splenomedullary leukaemia. 
 
 The Blood. — The haemoglobin is diminished not rarely as much as 
 50 per cent. The color index is correspondingly low. Exceptionally the 
 color index is high. 
 
 Diminution in the number of erythrocytes is constant but not 
 extreme. Counts falling below 2,000,000 are rare. Nucleated erythrocytes 
 are very numerous, the normoblastic type being in excess. Megaloblasts 
 are relatively less numerous and frequently present in atypical forms. 
 Deformities in size and shape are present in varying degrees, dependent 
 upon the extent of the haemoglobin loss and cellular diminution, together 
 with polychromatophilia affecting both the nucleated and non-nucleated 
 erythrocytes. 
 
 The leucocytes arc enormously increased. Counts of 300,000 per 
 cubic millimetre are common, of 500,000 by no means rare, and of 1,000,000 
 occasional. When the oligocythaemia is marked the whites may nearly 
 
1146 
 
 MEDICAL DIAGNOSIS. 
 
 equal or even exceed the reds. The number fluctuates widely from time to 
 time in the course of the disease, and frequently undergoes remarkable 
 diminution under the free administration of arsenic. Wide diurnal fluc- 
 tuations are observed in some cases, the lower counts being noted late 
 in the day. Extreme changes occur in certain cases, both in the blood 
 picture and in the general condition, so that periods arise in which there 
 
 are neither symptoms nor signs of leukaemia 
 present. These remarkable remissions 
 are not, however, permanent. Such rever- 
 sions to the normal blood conditions accom- 
 panied by involution of the splenic tumor 
 have frequently followed the therapeutic 
 use of the Rontgen raj's. Myelocytes in 
 great numbers are present and constitute 
 at least 20 per cent, of all leucocytes, as 
 determined by the differential count in the 
 majority of the cases. The polynu clear 
 neutrophiles are much increased, but their 
 percentage is relatively low. Many of these 
 cells are dwarfed and deformed. The rela- 
 tive percentage of lymphocytes is much 
 below normal. Eosinophilia is almost 
 invariably present. In the majority of 
 cases mast-cells are present in consider- 
 able numbers and the blood-plaques are 
 much increased. 
 
 ii. Lymphatic Leuksemia. 
 
 Symptoms. — The general symptoms 
 are similar to those of the myelogenous 
 form. There is enlargement of the lymph- 
 nodes, which may involve the superficial 
 or merely the deeper groups and is usually 
 associated with more or less marked 
 enlargement of the spleen. In the acute 
 cases the lymph structures of the mouth, 
 tongue, and pharynx may be enlarged. 
 Enlargement of the thymus gland is some- 
 times present in this group of cases and may be the cause of characteristic 
 symptoms: stridulous respiration with dyspnoea, usually paroxysmal. 
 
 The Blood. — Haemoglobin is much diminished and the color index 
 correspondingly low. The erythrocytes are reduced in number to 3,000,000 
 per cubic millimetre or lower. Nucleated red cells are scanty, those of the 
 normoblastic type predominating. Deformities in size and contour and the 
 tinctorial reactions are proportionate to the degree of degeneration of 
 the blood— anaemia. The leucocytes are much increased in number, but 
 not to the extent often seen in myelogenous leukaemia, counts above 
 200,000 being comparatively unusual. The differential count shows this 
 
 Fig. .3.32. — Chronic lymphatic leukaemia. 
 — Jefferson Hospital. 
 
LEUKEMIA. 1147 
 
 increase to be largely due to an excess of large and small lymphocytes, 
 which comprise about 90 per cent, of all forms. There are numerous atypi- 
 cal forms. The relative proportion of polynuclear neutrophils is much 
 reduced, those cells not usually exceeding 5 or 10 per cent, of all forms. 
 Myelocytes are present in almost all cases, but in very small numbers. 
 Eosinophiles are also present in the majoritj^ of the cases in scanty numbers. 
 The blood-plaques are increased. 
 
 Leukanaemia. — Leube has used this term to designate a symptom- 
 complex consisting of intense anaemia with changes in the form of both the 
 erythrocytes and leucocytes — conditions sometimes described as transi- 
 tional or mixed forms of leukaemia and pernicious anaemia. He expressly 
 reserves this term for forms of blood disease in which " both leucocytes 
 and erythrocytes are uniformly and decidedly damaged in their develop- 
 ment, and the case can neither be put in the category of leukaemia nor in 
 that of pernicious anaemia." The cases are of sudden onset, with signs sug- 
 gestive of an acute infectious process. In some of the cases there is severe 
 tonsillar angina; in others stomatitis, extreme pallor, weakness, fever, 
 hemorrhages, hyperplasia of the spleen, and moderate enlargement of the 
 liver. Enlargement of the lymph-nodes is not constant. The course is 
 unfavorable; the duration varies from a few days to several weeks. 
 
 Chloroma. — The blood changes in this rare affection are similar to 
 those of lymphatic leukaemia. There is progressive diminution of the 
 haemoglobin and erythrocytes, associated with increase in the leucocytes. 
 Deformities in size and shape in the erythrocytes, and nucleated forms, 
 chiefly normoblasts, show themselves as the anaemia becomes more 
 intense. There is marked lymphocytosis. The symptom-complex consists 
 of progressive weakness, pallor, orbital pain, exophthalmus, deafness, and 
 elastic swellings in the orbital and temporal regions. There is irregular 
 hyperplasia of the bone-marrow with subperiosteal infiltrations and tumor- 
 like metastases of greenish color — so-called " green cancer." The blood 
 condition closely resembles acute lymphatic leukaemia, and chloroma has 
 been regarded as a malignant form of leukaemia with greenish infiltrations 
 and metastases. 
 
 Diagnosis. — The direct diagnosis can only be made by a micro- 
 scopical examination of the blood. The disease is always leukaemia when 
 the proportion of leucocytes to erythrocytes is 1 to 15 or less; when the 
 leucocyte count is more than thirty times greater than normal and when 
 at the same time many of the cells are conspicuously immature — mj^elo- 
 cytes, large lymphocytes, and nucleated red corpuscles. 
 
 Even in cases in which there is a temporary return to the normal 
 ratio between the leucocytes and the erythrocytes, immature forms very 
 rarely seen in normal blood — erythroblasts and myelocytes — are present 
 in sufficient numbers to warrant a provisional diagnosis of leukaemia in 
 the absence of a previous knowledge of the conditions of the blood. 
 
 Differential. — The discrimination between myelogenous and lym- 
 phatic leukaemia can only be made by the blood examination. In the 
 myelogenous form the type of the blood is myelocytic, that is to say, 
 myelocytes are present in enormous numbers together with an increase 
 in the eosinophiles and mast-cells; oligocythaemia is moderate, erythro- 
 
1148 MEDICAL DIAGNOSIS. 
 
 blasts are numerous, the normoblastic type predominating. In the lym- 
 phatic form the blood type is lymphocytic, namely, there is an excessive 
 increase in the lymphocytes, myelocytes being absent, or present in very 
 scanty numbers; there are very few eosinophiles or mast-cells; oligocy- 
 thsemia is marked; and erythroblasts are few in number and proportionate 
 to the general deterioration of the blood. 
 
 The clinical manifestations as regards the spleen and superficial 
 lymph-nodes do not afford a basis for the differential diagnosis between 
 the two forms of leukaemia; but this fact is without importance since an 
 examination of the blood is essential to the general diagnosis. 
 
 Hodgkin's Disease. — The enlargements of the lymph-nodes and of the 
 spleen in this affection often closely simulate leukaemia. The differential 
 diagnosis rests upon the fact that the blood is normal or presents the 
 changes which occur in the various forms of secondary anaemia. Associated 
 inflammatory or infectious processes when present may cause an increase 
 of leucocytes with the characters of a polynuclear neutrophile leucocytosis. 
 
 Chloroma may be recognized by the exophthalmus, orbital pains, and 
 elastic tumor formations. 
 
 Splenic Anceviia.— The remarkable size of the splenic tumor, absence 
 of enlargement of the superficial lymph-nodes, and a high grade of anaemia 
 with leukopenia constitute positive differential criteria. Banti's disease, 
 the terminal stage of splenic anaemia, is characterized by hypertrophic 
 cirrhosis of the liver, jaundice, and ascites. 
 
 The diagnosis of leukaemia rests wholly upon the microscopical exam- 
 ination of the blood. Other conditions which, by reason of the presence of 
 superficial lymphatic enlargements or splenic enlargement associated with 
 more or less pronounced secondary anaemia, resemble leukaemia may be 
 at once differentiated by the findings in the blood. It is only necessary 
 in this connection to name the splenic tumor of chronic malarial infection; 
 amyloid disease; malignant growths, cysts, and abscess; enlargements 
 involving the left kidney, as hydronephrosis, cysts, perinephric cysts; 
 abscess and malignant disease or cysts of the pancreas; and retroperi- 
 toneal sarcoma — all of which present resemblances to splenic tumor; and 
 the hyperplasias of the lymphatic glands which occur in tuberculosis, 
 syphilis, and malignant disease. 
 
 Hasty conclusions in a suspected case, in which the ratio of leucocytes 
 to erythrocytes is normal, are unwarrantable because remarkable falls in 
 the morbidly increased whites occur, (a) in the natural history of the 
 disease; (b) during or immediately after acute intercurrent affections, as 
 influenza, enteric fever, sepsis; (c) after the administration of drugs, — as 
 arsenic and quinine, — the injection of nuclein, tuberculin, and antidiph- 
 theritic serum, and the use of the X-rays. 
 
 Prognosis.— The outlook is in a high degree unfavorable. The number 
 of permanent recoveries reported is limited. Remarkable and prolonged 
 remissions occur. The influence of the X-rays upon the disease in some 
 cases is to be considered. The acute lymphatic variety is peculiarly malig- 
 nant and often runs a rapid course. The myelogenous form sometimes 
 extends over eight or ten years, with remissions, even intermissions, and 
 exacerbations. Progressive deterioration of the blood, hemorrhages, marked 
 
HODGKIN'S DISEASE. 1149 
 
 gastro-intestinal disturbances (especially intractable diarrhoea), fever, dropsy, 
 and massive enlargement of the spleen are of unfavorable significance. 
 Mikulicz's Disease. — There is gradual, symmetrical, painless enlarge- 
 ment of the lachrymal glands, followed by similar changes in the salivary 
 glands. Special predisposing influences are not recognized, though males 
 suffer more frequently than females and in the majority of the cases the 
 disease has occurred between the twentieth and fortieth years of life. 
 The condition is generally regarded as an infection, but a special patho- 
 genic agent has not been demonstrated. It has been attributed to tuber- 
 culous infection, syphilis, and hypothyroidism. Howard, whose recent 
 studies of the subject are of great importance, regards the cases as con- 
 stituting not a simple morbid entity but a clinical syndrome varying in 
 its etiology, form, and course, and comprising isolated and symmetrical 
 disease of the lachrymal and salivary glands due to simple lymphomata, 
 pseudoleuksemia, leukeemia, tuberculosis, and syphilis. This observer 
 arranges the cases in three groups: (a) the simple form, in which only 
 the lachrymal and salivary glands are involved, neither the adjacent nor 
 distant lymphatics being affected and the blood picture remaining normal 
 for years, (b) Pseudoleuksemia. In this group of cases the clinical mani- 
 festations are similar to the simple form except that the lymphatic glands, 
 either locally or generally, are involved. The enlargement is variable in 
 degree. Softening and caseation do not occur. The spleen may be 
 enlarged. The blood may be normal or there may be a moderate second- 
 ary anaemia. In other cases there is a relative or absolute increase in the 
 small lymphocytes, and in some cases large lymphocytes are present, (c) 
 Leukaemia. In this group, in addition to the enlargement of the lachrymal 
 and salivary glands of both sides there are the characteristic general 
 enlargements of the lymphatic glands and a blood picture of leukaemia of 
 the lymphatic type with the usual clinical phenomena — progressive weak- 
 ness, irregular fever, slight oedema, and tendency to hemorrhage. 
 
 III. HODGKIN'S DISEASE. 
 
 Pseudoleukcemia. 
 
 Definition. — An affection of undetermined causation characterized 
 by successive enlargement of the lymph-nodes (those upon one side of the 
 neck being first involved) and of the spleen; the deposition of metastatic 
 nodules in the various viscera, especially the spleen, liver, and lungs; and 
 marked secondary anaemia with cachexia. 
 
 Etiology. — Predisposing Influences. — The disease usually appears 
 in childhood, adolescence, or early adult life. It is very rare after the fourth 
 decade. It is more common in males than in females in about the propor- 
 tion of six to one. The occasional occurrence of cases in a parent or child, 
 or among the children of the same family, about the same time, suggests 
 rather the action of a local cause or direct infection than the hereditary 
 or family transmission of the disease. Malaria, syphilis, and tuberculosis 
 have been regarded upon wholly insufficient grounds as predisposing 
 influences. 
 
1150 MEDICAL DIAGNOSIS. 
 
 Exciting Cause. — The pathogenic agent is wholly unknown. The 
 disease has been thought to be of infectious origin, but no results have 
 followed bacteriological studies. Among the chnical facts which support 
 this opinion are the following: Hodgkin's disease has frequently followed 
 irritative lesions of the throat and upper air-passages and sometimes 
 acute affections attended by inflammatory irritation of the mucous mem- 
 brane of those parts, as influenza, measles, or pertussis; preliminary disease 
 of the tonsils; early locaUzation in the cervical glands; gradual extension 
 from one group of lymphatic glands to another, with recurrence of fever; and 
 the acute course of some of the cases. 
 
 There are clinical resemblances to lymphosarcoma, which are not 
 borne out by the results of histological studies of the affected glands in the 
 two diseases, and to glandular tuberculosis, which are negatived by the 
 following facts: (a) absence of tubercle bacilli and the failure of inoculation 
 experiments in a majority of cases studied; (b) absence of reaction to the 
 tuberculin test in well-characterized cases; and (c) specific histological char- 
 acters in Hodgkin's disease. The view that Hodgkin's disease is a form of 
 lymphatic tuberculosis has arisen from the fact that secondary tuberculous 
 infection not infrequently occurs, especially in the terminal stages. 
 
 Morbid Anatomy. — The internal lymph-nodes are also generally 
 enlarged — those of the thorax, the retroperitoneal, and the abdominal 
 glands in the order named — and form large, firm masses, which give rise 
 to the pressure symptoms which constitute striking clinical phenomena 
 of the disease. The veins are especially liable to compression. The nerve- 
 trunks and ureters do not always escape. The lymph-nodes even when 
 greatly enlarged are not often adherent, nor is there a special tendency to 
 capsular infiltration or invasion of contiguous structures. Caseation and 
 necrosis do not occur in the absence of secondary infection. The spleen 
 and liver are enlarged and the seat of scattered lymphoid masses. 
 
 Symptoms. — The most striking and usually the earliest clinical phe- 
 nomenon is the enlargement of one or several lymph-nodes at the angle of 
 the jaw. This enlargement is gradual and may attract little attention 
 until several weeks have elapsed. The swollen glands are painless and 
 may be recognized upon palpation as separate and distinct. They are 
 not usually adherent to the skin. In some cases they are adherent among 
 themselves. The peculiar adenopathy is progressive. The glands first 
 involved gradually increase in size, adjacent groups in the lower part of 
 the neck presently become implicated, then those in the axilla, the inguinal 
 region, and sometimes those at the elbow and in the popliteal space. The 
 lesions, at first unilateral, after a time appear upon the other side, but as 
 corresponding groups are not usually enlarged to the same extent, they are 
 irregularly symmetrical. The enlargement is, as a rule, most marked 
 upon the side of the neck, where the masses often exceed the size of the 
 fist and give rise to conspicuous deformities. It is not so great in the 
 axillary and inguinal regions. The enlarged glands are at first of moderate 
 consistence and ma}'' be moved under the skin; later in the course of the 
 disease they become harder and more or less adherent to the subjacent 
 tissues. Tonsillitis, sometimes chronic, frequently precedes the early 
 glandular changes in the neck; but this is not always the case and there 
 
HODGKIN'S Dli^EASE. 
 
 1151 
 
 are instances in which the lymph-nodes in this region remain unaffected 
 in the presence of every other feature of the malady. The evidences of 
 enlargement of the internal lymph-nodes do not usually show themselves 
 until after the changes in the superficial groups have made considerable 
 progress. In fact there are rare cases of Hodgkin's disease in which the 
 external glands are not at all or but slightly increased in size. Lymph- 
 nodes of the digestive tract, namely, the tonsils, the adenoid masses at 
 the base of the tongue and in the 
 pharynx, and the solitary and agmi- 
 nate glands of the intestines, are 
 frequently implicated without giving 
 rise to marked symptoms. The 
 spleen is usually enlarged, but not 
 to the extent often seen in spleno- 
 medullary leukaemia. 
 
 Anaemia does not show itself 
 until the malady has made some 
 progress. After a time the changes 
 in the blood, characteristic of anaemia 
 of secondary type, develop rapidly in 
 the acute cases; more gradually in 
 the chronic forms of the disease. At 
 a period when the symptom-complex 
 is fully established, the condition of 
 the blood is as follows: haemoglobin 
 decreased to about 50 per cent., not 
 commonly much below this; color 
 index usually low; moderate erythro- 
 cyte reduction, rarely below 2,000,000 
 per cubic centimetre; nucleated 
 forms rare, when present of the nor- 
 moblastic type; leucocytes normal or 
 slightly increased, the increase often 
 transient; relative increase of poly- 
 nuclear neutrophiles or lymphocytes ; 
 no increase of eosinophiles. 
 
 Three groups of symptoms 
 may be recognized, namely, those 
 
 due to the enlarged glands, those due to the luueinia, and the cachexia. 
 But the symptom -complex is not W(>11 defined. 
 
 (a) Symptoms Due to Lymphatic Hyperplasia. — Supcrjicial. — 
 External deformities and impairment of function, as of inox-cment and the 
 like. The prominence of these symptoms depends ui)on the location and 
 degree of enlargement of the affected groups of glands. Deep. — Pressure 
 symptoms, consisting of cough, dysphagia, dyspnoea, dilatation of super- 
 ficial veins, c3'anosis, local disturbances of circulation, vaiious dropsies, 
 oedema, and effusions into the serous sacs. Deraugenu^nts of function due 
 to pressure doubtless contribute to the cachexia. Neuralgias in various 
 distributions are caused by pressure upon de(^p or supei-fieial nerve-trunks. 
 
 Fir,. 3,3.3. — Ilodgkin's dispiise. — Jpfferson Hospital 
 
1152 MEDICAL DIAGNOSIS. 
 
 (b) Symptoms Due to the Anemia. — Pallor, headache, dyspnoea in 
 some cases, asthenia, anasarca, hemorrhages, and fever. The last symp- 
 tom may occm- as a mild, irregular pyrexia early in the course of the dis- 
 ease, the attacks often being associated with sudden increase in the size 
 of the affected glands; as an irregular ague-like paroxysmal fever when 
 the disease has reached an advanced stage; and finally in the form of 
 the '^ chronic relapsing fever" of Pel, or ''recurring glandular fever" of 
 Ebstein, in which febrile periods of from ten to fourteen days' duration, 
 and either intermittent or remittent in type, alternate with irregular 
 periods of apyrexia lasting several days. In view of the frequency with 
 which intercurrent and terminal infections occur in Hodgkin's disease, 
 the likelihood that these forms of fever are not primarily symptomatic of 
 the disease under consideration must be considered. 
 
 (c) The Cachexia. — The general disturbances of nutrition ultimately 
 reach a high grade. Extreme pallor, emaciation, profound asthenia, 
 bronzing of the skin in some of the cases, hemorrhages into the skin and 
 from various mucous surfaces, together with the tumor masses in the infe- 
 rior carotid triangle and the occipital region and elsewhere, constitute a 
 striking and most suggestive clinical j)icture. 
 
 Diagnosis. — The direct diagnosis rests upon the association of a 
 widespread affection of the lymph-nodes involving progressively super- 
 ficial and deep chains, anaemia of high grade and secondary type, and 
 cachexia. The researches of Reed, Longcope, and others have settled the 
 question as to the specific nature of the histological lesions in Hodgkin's 
 disease and the uncertainties as to its relationship with tuberculosis, 
 lymphosarcoma, and leukaemia. The association of the following changes 
 is characteristic: proliferation of connective-tissue stroma resulting in 
 fibrosis, and in a majority of the cases numbers of eosinophiles. These 
 facts fully justify the excision of one or more superficial glands in a doubt- 
 ful case for histological examination. 
 
 Differential. — Tuberculosis adenitis rarely develops after the twenty- 
 fifth year. The enlargement frequently involves the glands of the neck 
 upon one or both sides. Inflammatory adhesions between the individual 
 glands and to the adjacent structures, and in particular to the overlying 
 skin, are the rule. There is tenderness, and a tendency to softening, sup- 
 puration, and caseation with sinus formation. The process is sluggish and 
 mostly limited to one or two groups of glands, rarely extending to distant 
 regions. The signs of tuberculous lesions in the mouth (especially in the 
 tonsils), in the skin, bones, lungs, or other viscera are suggestive. The 
 presence of tubercle bacilli in the excised glandular tissue is suggestive of a 
 tuberculous process, but the coexistence of the two diseases is by no means 
 rare, while the definite histological lesions of Hodgkin's disease are distinc- 
 tive. In afebrile cases the tuberculin tests may be emplo3^ed. 
 
 Syphilitic Adenitis. — The glands in direct relation to the initial lesion, 
 usually the inguinal, are commonly first affected, the glands of the neck 
 being primarily involved only when there are buccal or labial lesions. 
 The adenopathy is general, with an especial tendency to implication of 
 the postcervical and epitrochlear glands. The enlargement is moderate, 
 firm, painless, and not accompanied by a tendency to form adhesions to 
 
PURPURA. 1153 
 
 contiguous structures. A history of exposure, the presence or vestigia of 
 an initial lesion, secondary manifestations, and the effects of mercurial 
 treatment are of diagnostic importance. 
 
 Leukcemia (see p. 1148). 
 
 Lymphosarcoma. — The conditions are very often mistaken for each 
 other. In lymphosarcoma the masses are of rapid growth and may attain 
 great size; adhesions among individual glands and to adjacent structures, 
 with inflammatory changes attended by redness, tenderness, and local 
 oedema, are common. Softening and fluctuation suggestive of abscess 
 formation are frequent. The cutaneous veins are often enlarged and 
 tortuous, pain is sometimes a prominent symptom, and there are 
 progressive infiltrations and metastases. 
 
 It is important in the differential diagnosis of Hodgkin's disease 
 that this affection is characterized by a progressive implication of suc- 
 cessive groups of glands, while in those affections, with the exception of 
 syphilis, to which it may sometimes bear a superficial resemblance, the 
 lesions are limited to single glands or, at most, to two or three groups which 
 are anatomically related and become affected at or about the same time. 
 
 Prognosis. — The disease runs its course with exacerbations of varying 
 intensity and remissions of irregular duration. Acute cases may end fatally 
 in two or three months. Very chronic forms may last three or four years. 
 The average duration is about one year. Urgent pressure symptoms, 
 intense anaemia, hemorrhages, and early cachexia are of unfavorable prog- 
 nostic significance. The outcome is lethal, but remarkable improvement 
 in the blood and other clinical phenomena has followed the use of the 
 X-rays, the early extirpation of the enlarged glands, and the administra- 
 tion by the mouth and subcutaneously of arsenic in the form of Fowler's 
 solution, or of sodium cacodylate. 
 
 IV. DISEASES CHARACTERIZED BY HEMORRHAGE. 
 
 The Hemorrhagic Diathesis; Morbus Maculosus. 
 
 The essential symptom is hemorrhage, which may be into the skin, 
 from the mucous surfaces, subserous, or into the viscera. 
 
 (a) Purpura. 
 
 Definition. — An affection which appears spontaneously, and is char- 
 acterized by hemorrhages into the skin, mucous membranes, and internal 
 organs. The following forms are recognized: (1) purpura simplex; (2) 
 purpura hsemorrhagica or morbus maculosus Werlhofii; (3) purpura rheu- 
 matica or peliosis rheumatica; (4) purpura with visceral symptoms; and 
 (5) symptomatic purpura. There are those, as Litten, who regard these 
 as manifestations of the same disease, differing in intensity. 
 
 Purpura always occurs as a sporadic affection and never, like scurvy, 
 in local outbreaks or as an endemic disease, or like the hemorrhagic cases 
 of the infections — variola, varicella — during the course of epidemics. It is 
 not a common disease. 
 
 73 
 
1154 MEDICAL DIAGNOSIS. 
 
 Etiology. — Predisposing Influences. — Females are somewhat more 
 disposed than males. The greatest liability is in middle life, but neither 
 infancy nor old age escapes. Purpura sometimes has developed during 
 the convalescence from enteric fever, malaria, scarlet fever, and measles, 
 and in the course of all forms of nephritis, especially the interstitial variety. 
 Intense nervous shock, such as attends fright, fever, or pain, has been 
 followed by the occurrence of purpura. 
 
 Exciting Cause. — No immediate cause can usually be discovered. 
 The hypothesis that purpura is an infectious disease has not yet received 
 demonstrable support. Unfavorable conditions of life, damp and insalu- 
 brious dwellings, and chilling of the body have been regarded upon 
 inadequate grounds as etiological factors. 
 
 1. Purpura Simplex. — Symptoms. — Isolated hemorrhagic spots upon 
 the skin may constitute the only manifestation of the disease. They vary 
 from a mere point in diameter to patches of considerable size. The latter 
 are not common in simple purpura. Purpuric spots are more commonly 
 and more abundantly distributed on the lower extremities than elsewhere. 
 They are at first bright red in color, but rapidly become darker, and fade, 
 leaving patches of brownish pigmentation which gradually undergo resorp- 
 tion. These spots do not disappear upon pressure or when the skin 
 is made tense. In some cases the spots appear abruptly and wholly with- 
 out prodromes, more commonly they are preceded by symptoms such as 
 attend the initial stage of a mild infection, lassitude, loss of appetite, 
 nausea, and fever. The disease sometimes lasts but a day or so and is 
 marked by a single crop of hemorrhages into the skin; in other cases its 
 course may extend over a week or two and be marked by successive crops 
 of petechiae. The spots are scattered over the arms, abdomen, and legs. 
 They are rarely seen upon the face. The course of this variety of purpura 
 is favorable. In a few days, or at most a fortnight, the spots have disap- 
 peared and the patient has regained his usual health. A slight degree of 
 anaemia and transient albuminuria may occur during convalescence. It 
 is much more common in children than adults, and is often associated 
 with diarrhoea and slight rheumatoid pains and swelling of the joints. 
 Diagnosis. — The direct diagnosis of purpura simplex may be made 
 when, in the absence of a primary antecedent affection, the purpuric erup- 
 tion appears after trifling derangements of health and disappears in the 
 course of a few days or at most a week or two. The differential diag- 
 nosis from other forms of purpura depends upon the mildness of the 
 attack, its short duration, and the absence of special characteristic mani- 
 festations, such as copious hemorrhages into the skin, hemorrhages from 
 mucous surfaces, fever, joint affection, urgent gastro-intestinal symptoms. 
 tendency to recur, and so forth. 
 
 2. Purpura Haemorrhagica ; Morbus Maculosus ; Werlhof s Disease. 
 — The cutaneous hemorrhages are abundant and extensive, and there is 
 bleeding from mucous surfaces. This form of purpura sometimes attacks 
 individuals in apparent health, but is far more common in delicate children 
 or adolescents, especially girls. It may also occur without prodromes 
 and run an afebrile course. When fever is present it is of moderate inten- 
 sity— 101°-102° F. (38.5°-39° C). Gastric disturbances, a mild rheuma- 
 
PURPURA. 1155 
 
 toid affection of the joints, and albuminuria occur in many of the cases. 
 The cutaneous hemorrhages are profuse and extensive, and in some in- 
 stances extensive areas or even the greater part of the surface of the body 
 are involved, so that the discolored space in some portions of the body 
 greatly exceeds that of the normal skin. Frequently, but not always, 
 there is bleeding from mucous surfaces, usually first in the form of epistaxis, 
 which is soon followed by hemorrhage from the buccal and gingival 
 mucous surfaces, hsematuria, haemoptysis, and bleeding from the bowel. 
 Under these circumstances profound anaemia may rapidly develop. Death 
 may result from the loss of blood. Purpura Fulminans. — A malignant 
 variety which occasionally occurs in children may cause death in the course 
 of twenty-four or forty-eight hours from extensive cutaneous hemorrhage 
 with or without bleeding from mucous surfaces. The course of the disease 
 is often protracted, with frequent relapses, which are apt to occur when 
 the patient attempts to leave his bed, and leads to great debility and 
 anaemia, with vertigo, cardiac palpitation, and syncopal attacks. The 
 DIRECT DIAGNOSIS of Werlhof's disease depends upon the severity of the 
 affection, the prominence and extent of the cutaneous hemorrhage and 
 bleeding from mucous surfaces. 
 
 It is to be differentiated from purpura simplex on the one hand by 
 the above criteria, and from purpura rheumatica npon the other by the 
 infrequency and mildness of the arthritis, the absence of urticaria and 
 erythema, the tendency to hemorrhage from mucous surfaces. From scurvy 
 it is to be distinguished by the conditions under which the disease develops, 
 its more or less abrupt occurrence in an individual of fair previous health, 
 and the absence of swelling of the gums; from the malignant or hemor- 
 rhagic forms of the infectious diseases by the symptoms of the onset in 
 the latter, the gravity of the attack, the first appearance of petechiae upon 
 the forehead and wrists, their association with abortive eruptions or exten- 
 sive suggillations. 
 
 3. Purpura Rheumatica ; Peliosis Rheumatica ; Schonlein's Disease, 
 — This hemorrhagic affection is characterized by an eruption in which the 
 spots "never coalesce," a multiple arthritis, and protracted course. It 
 occurs in young adults, chiefly in males and usually in individuals who 
 have a delicate, highly vascular skin and have previously suffered from 
 rheumatism. It frequently begins with angina tonsillaris, fever of moder- 
 ate intensity, — 102° F. (39° C), — and rheumatoid pains in the joints, 
 especially the ankles, knees, the joints of the hands, and the shoulders. 
 The affected joints are painful to the touch and upon movement and the 
 seat of endo- and periarticular exudate. The eruption appears first upon 
 the lower extremities or over the affected joints. It is frequently merely 
 purpuric, but may show urticarious wheals, erythematous patches, or 
 infiltrated areas suggestive of erythema nodosum. Vesication may occur. 
 Local oedema occasionally appears, especially about the face — febrile 
 purpuric oedema. The eruption tends to recur in crops and may con- 
 tinue to reappear for several weeks. The patients are sensitive to cold, 
 and fresh outbreaks occur upon rising from bed or any chilling of the sur- 
 face. Attacks at the same season in successive years have been noted. 
 The urine has no special characters. It sometimes contains albumin. The 
 
1156 MEDICAL DIAGNOSIS. 
 
 DIRECT DIAGNOSIS of Schoiilein's disease rests upon the association of a 
 well-defined joint affection with purpura, which tends to recur in crops, 
 erythema, and local oedema. The joint affection is usually mild and shows 
 neither the evanescence characteristic of rheumatic fever nor the persist- 
 ence of gonorrhceal arthritis. Differential. — The existence of Schon- 
 lein's disease as a nosological entity has been much questioned. It has 
 been regarded as true rheumatism, from which it is easily distinguished 
 by the eruption, which tends to recur, and the almost constant absence of 
 cardiac lesions; as a form of gonorrhceal arthritis, a view that cannot 
 be entertained, since gonorrhoea, though sometimes present, is mostly 
 absent; as an intense form of purpura with rheumatoid symptoms, an 
 opinion which finds some support in the fact that mild multiple arthritis 
 is not uncommon in the hemorrhagic diseases. 
 
 4. Purpura and Visceral Symptoms ; Purpura Abdominalis ; 
 Henoch's Purpura. — The cutaneous hemorrhages are accompanied by 
 abdominal symptoms, vomiting, diarrhoea, often hemorrhagic, and colic. 
 These symptoms occur in paroxysms separated by intervals of several 
 weeks or months. The disease is most common in childhood and adoles- 
 cence, but may occur in early adult life. It is much more common in males 
 than females. It frequently attacks individuals living in poverty and 
 want, but is by no means unknown among the affluent. There is a varjdng 
 period of impaired health with headache, weakness, and loss of appetite, 
 followed by subacute or acute arthritis affecting one or more joints, and 
 moderate fever. Purpura now appears, often but not invariably upon the 
 legs and feet, but spreading to the trunks and elsewhere, and being par- 
 ticularl}^ abundant in the neighborhood of the affected joints. The hem- 
 orrhagic eruption is associated in varying degree with erythema, patches 
 of oedema, and urticaria. Coincidently with the eruption the above men- 
 tioned abdominal symptoms appear. Epistaxis and hemorrhage from 
 other mucous tracts occur. The colic, most intense about the umbilicus, 
 is often especially severe and protracted; the abdomen is retracted and 
 tender; there is complete loss of appetite; retching is frequent and dis- 
 tressing; the spleen is enlarged; the pulse small and frequent, and in 
 many instances there is alarming exhaustion. In fact it is to this variety 
 of purpura that the rapidly fatal purpura fulminans is to be referred. 
 Nephritis is of frequent occurrence and may persist. These symptoms in 
 the ordinary cases undergo gradual amelioration, and the infant enters 
 upon an apparent convalescence, only to suffer from similar paroxysms 
 at varying intervals. The duration is variable. The attack may last for 
 several days, and recurrences may extend over a period of months or 
 even years. The prognosis in children is favorable — mortality less than 5 
 per cent.; in adults less so — mortality about 23 per cent. 
 
 The direct diagnosis of this form of purpura rests upon the asso- 
 ciation of purpura with erythema and urticaria, visceral symptoms, espe- 
 cially the abdominal crises, and nephritis, the joint affection and fever, 
 and the paroxysmal nature of the recurrent attacks. This affection, con- 
 cerning the cause of which we have no definite knowledge, presents a 
 well-defined symptom-complex. The differential diagnosis requires no 
 special consideration. 
 
PURPURA. • 1157 
 
 The blood changes in the various forms of purpura are similar and 
 without diagnostic significance. They are those of secondary anaemia of 
 varying intensity, with leucocytosis. The coagulation time is much 
 protracted, in some cases reaching ten or even fifteen minutes. 
 
 5. Symptomatic Purpura. — Purpura is a symptom, not a disease, yet 
 in the foregoing affections it is a symptom of such prominence as to justify 
 the older use of the term to designate a group of diseases the etiology of 
 which is as yet unknown, and of which cutaneous hemorrhage is the only 
 common and constant phenomenon. But purpura is also a very common 
 symptom in many conditions and well-defined diseases. This form is 
 known as symptomatic purpura. Traumatic. — The ecchymosis which 
 follows a blow or contusion does not differ in appearance or course from 
 similar cutaneous hemorrhages occurring in disease. Mechanical purpura 
 may result from severe transient venous stasis, as in whooping-cough or 
 epilepsy, or more prolonged interference with the circulation, as the pres- 
 sure of a splint or bandage. Toxic. — The venom of snakes causes rapid 
 and extensive blood extravasations Jaundice, especially when prolonged, 
 is frequently associated with petechise. Among the drug exanthems pur- 
 pura occupies an important place and may follow the administration of 
 copaiba, ergot, quinine, belladonna, mercury, and the iodides. There is 
 usually an idiosyncrasy. The question as to whether the cutaneous hemor- 
 rhage is due to the drug or the disease for which the drug has been given 
 is always to be considered. There is no question as to the significance of 
 a petechial rash in ergotism or the specific effect of the iodides in causing 
 this symptom in certain cases. In the case of the iodides, coryza, angina 
 tonsillaris, erythema, and fever may accompany the purpura. These 
 symptoms may quickly follow small doses of the drug. Infectious.^ 
 The ordinary rashes of typhus and cerebrospinal fever are purpuric; sim- 
 ilar lesions of the skin occur in sepsis and especially in malignant endo- 
 carditis; petechise and ecchymoses characterize the malignant forms of 
 measles, scarlet fever, and smallpox. In that form of variola known as 
 purpura variolosa there are petechias and most extensive suggillations of 
 blood. Cachectic. — The terminal dyscrasia of cancer, chronic nephritis, 
 Hodgkin's disease, tuberculosis, and other incurable wasting diseases is 
 frequently accompanied by petechial eruptions, usually confined to the 
 lower extremities. A similar form occurs in old age and prolonged want of 
 food, and extensive purpura is characteristic of scurvy. Neurotic. — 
 Myelopathic purpura occasionally occurs in spinal diseases, particularly 
 forms of myelitis, especially transverse myelitis. The bleeding may be 
 associated with trophic disturbances, erythema, and localized sweating. 
 It occurs also in rai'e instances in tabes in the course of the lightning pains, 
 and in association with herpes, oedema, and local sweating. Purpura may 
 occur in the distribution of the affected nerve in severe neuralgia. The 
 ''stigmata" or bleeding points of hysteria, when not artificially produced 
 for purposes of deception, must be referred to this category. 
 
1158 MEDICAL DIAGNOSIS. 
 
 (b) Haemophilia. 
 
 Bleeders' Disease. 
 
 Definition. — A constitutional anomaly mostly hereditary, — vitium 
 primce formationis, — very rarely acquired, which manifests itself by the 
 occurrence of uncontrollable bleeding, either spontaneous or from trau- 
 matism which may be slight, and occasionally by hgemarthrosis sometimes 
 followed by permanent deformity. 
 
 Haemophilia is a hereditary and congenital condition; hemorrhage, 
 which shows neither tendency to stop nor yields to treatment, the sign by 
 which it makes itself known. In the absence of a history and of bleeding, 
 there are no indications of the constitutional fault. 
 
 Etiology. — Predisposing Influences. — Grandidier has described 
 hsemophilia as the most hereditary of all hereditary diseases. The occa- 
 sional occurrence of fatal hemorrhage from trifling wounds has long been 
 known, but the transmission of the tendency from generation to genera- 
 tion has been especially studied during the last century. In the well- 
 known Appleton-Swain family there have been bleeders for nearly two 
 hundred years. Grandidier gives the history of 200 bleeder families. In 
 some instances the transmission is direct from the parents to the children. 
 Usually, however, the transmission follows a peculiar law of heredity, 
 namely, that the females transmit while the males acquire the condition. 
 Exceptionally females also acquire it. From this it follows that haemo- 
 philia is much more common in males than in females. The actual ratio is 
 about 13 to 1. It is the rule that in a bleeder family a woman not a bleeder 
 transmits the condition to her children without having acquired it herself, 
 a generation having thus escaped. Men who are bleeders, but whose wives 
 are not descendants of bleeder families, do not always beget bleeder chil- 
 dren, and men who are members of bleeder families, but themselves not 
 bleeders and whose wives do not belong to bleeder families, rarely beget 
 bleeder children. Certain lines in bleeder families thus tend to become nor- 
 mal. It has occasionally happened that children born to parents neither of 
 whom belong to bleeder families have been bleeders — congenital hcBmophilia, 
 spontaneous haemophilia. Haemophilia is more common in Germany, Eng- 
 land, and the United States than elsewhere. The condition is usually 
 discovered in infancy or early childhood. Social conditions are apparently 
 without influence. In some bleeder families a neuropathic constitution has 
 been recognized. As a rule the stock is fine, the families large, the members 
 healthy and robust looking, with good skins and delicate complexions. 
 
 The actual cause of haemophilia remains unknown 
 
 Pathogenesis. — Various theories have been advanced. Among them 
 are habitual disproportion between the volume of blood and the vessels; 
 hydraemic plethora; abnormal composition of the blood; an increase in 
 the red corpuscles — erythrocythaemia; fragility of the vessels; pathogenic 
 infection; and deficiency in the fibrin ferment. None of these have met 
 the requirements of the condition. 
 
 Symptoms. — The existence of haemophilia is usually discovered in 
 consequence of trauma. The hemorrhage cannot be controlled, or is 
 
HAEMOPHILIA. 1159 
 
 arrested with difficulty and onlj- after prolonged effort. There are various 
 grades of severity, from the mildest to the most severe which terminates 
 fatally. The hemorrhage may be spontaneous or traumatic. The trau- 
 matism is often so slight as to escape attention, as the contusion resulting 
 from a slight fall or blow, or chastisement. Spontaneous hemorrhages are 
 sometimes preceded by fulness in the head, vertigo, tinnitus, palpitation, 
 and nausea. Thej^ may be superficial, as from mucous surfaces, namely, 
 that of the nose, mouth, female genitalia, urinary passages; or from the 
 lungs, stomach, or intestines, or finally from cicatrices or ulcers upon the 
 skin. Interstitial spontaneous hemorrhages are usually superficial. They 
 chiefly occur in "the scalp, face, scrotum; less frequently upon the extremi- 
 ties, and rarely upon the trunk. It is probable that the majority of such 
 cases are in point of fact the result of slight traumatism. They consist of 
 petechiae, ecchymoses, and subcutaneous hsematomata. The ordinary 
 forms of trauma by which haemophilia is manifest in external hemorrhage 
 comprise abrasions, scratches, cuts, wounds, and surgical incisions. The 
 bleedings named in the order of frequency are from the nose, mouth, 
 bowels, urethra, vulva, stomach, lungs. Less frequently continuous 
 bleeding takes place from areas of skin, especially upon the head and the 
 scrotum, the tongue, eyelids, conjunctiva, finger-tips, lobe of the ear, and 
 vulva. Bleeding from the head is far more common and usually more 
 severe than from the extremities or trunk. Trifling operations, as lancing 
 the gums, the extraction of a tooth, circumcision, or venesection, have been 
 followed by fatal hemorrhage. Lethal hemorrhage has followed the rup- 
 ture of the hymen in coitus. The bleeding usually is of the type described 
 as parenchymatous; there is capillary oozing, more or less abundant, from 
 every point of the exposed surface. It is not common to find flowing 
 vessels of an}^ size. It is continuous and may last for hours or for many 
 days. After a time syncope may occur and the bleeding cease. Pro- 
 longed bleeding is often followed by death. Epistaxis may prove fatal in 
 twenty-four or thirty-six hours. The coagulation time of the blood is 
 much retarded. With Wright's instrument it has varied from twenty to 
 forty-five minutes as compared with three to six minutes with normal 
 blood. The arthropathies of haemophilia are rheumatoid in character. 
 They occur both spontaneously and after contusions. The knees and 
 elbows are most commonly affected. The onset is acute, with swelling, 
 pain, redness, and slight fever. Less commonly there is haemarthrosis 
 without fever. Repeated hemorrhage into the joints and muscles may 
 occur in the absence of external or subcutaneous bleeding, and give rise 
 to a false diagnosis of chronic rheumatism or tuberculosis. The resulting 
 deformities sometimes suggest arthritis deformans. 
 
 Diagnosis. — Direct. — The recognition of haemophilia depends upon 
 the family history and the occurrence of persistent or uncontrollable hem- 
 orrhage. Neither the family history alone, since there are members of 
 bleeder families who are not bleeders, nor a single unmanageable bleeding 
 from a trifling cause, since difficult local hemorrhages are common enough 
 in those who are not hsemophilic, justifies a positive diagnosis. The asso- 
 ciation of an hereditary tendency to repeated stubborn bleeding from 
 slight injury with arthritis is highly suggestive. Even heredity is absent 
 
1160 MEDICAL DIAGNOSIS. 
 
 in the spontaneous or congenital cases. Differential. — Habitual epis- 
 taxis and haematuria are not attended with the tendency to hemorrhages 
 from slight wounds or cuts. In the hereditary local bleedings from the 
 nose or mouthy associated with telangiectasis of mucous membranes, and 
 na?vi, the blood losses arise from definite lesions, and arthropathies are 
 absent. Purpura rheumatica presents points of resemblance to haemo- 
 philia, especially in the prominence of the arthritis. There may be more 
 than one case in a family, but the peculiar form of heredity seen in bleeder 
 families does not occur, and there are multiple spontaneous hemorrhages 
 rather than excessive bleedings from limited surfaces. 
 
 Prognosis. — The outlook is unfavorable; many of the cases die in 
 early infancy, a majority before puberty. The hsemophilic tendency 
 becomes less marked as life advances, but the subjects rarely reach seventy. 
 The prognosis is less favorable in boys than girls. Death does not often 
 occur in a first bleeding, but it occasionally results from uncontrollable 
 bleeding after ritual circumcision. Females who are hsemophilic are apt 
 to menstruate early and freely, but neither this function nor that of par- 
 turition is attended in bleeder families with an especial tendency to danger- 
 ous blood loss. Any form of hemorrhage may, however, prove fatal; 
 that which is most frequently so being epistaxis. 
 
 (e) The Hemorrhagic Diseases of the New=born. 
 
 Acute Fatty Degeneration of the New=born ; Buhl's Disease. — This 
 rare affection is characterized by fatty degeneration of the heart, liver, and 
 kidneys, and hemorrhages in the various organs. The chief symptoms 
 are inanition and external hemorrhages, of which the more common are 
 omphalorrhagia, melsena, and hsematemesis. Bleeding may also take 
 place from the mouth, nose,, eye, and ear. The infant is soon in a condi- 
 tion of asphyxia, from which resuscitation is only partial, and dies at 
 once or in the course of a week or ten days. The skin is cyanotic and 
 icteric. An anatomical diagnosis cannot be made in the absence of a micro- 
 scopical diagnosis. It is therefore probable that the condition is very often 
 overlooked. The differentiation from phosphorus and arsenic poisoning, 
 in which similar parenchymatous changes in the viscera occur, may be 
 apparent from a study of the circumstances; from sepsis, with interstitial 
 hemorrhages and fatty degeneration, it may be difficult. Infection by 
 way of the cord must be excluded. The prognosis is lethal. 
 
 Infectious Hsemoglobinuria of the New-born ; Epidemic HaBmoglo- 
 binuria; Winckel's Disease. — This obscure affection arises as an endemic 
 or epidemic disease in lying-in hospitals. It begins about the fourth day of 
 hfe and is characterized by marked cyanosis with icterus, hsemoglobinuria, 
 somnolence, and collapse without fever. Vomiting and diarrhoea are com- 
 mon. The urine contains small amounts of albumin and methaemoglobin. 
 EpitheHal granular and blood-casts are also present. It may attack strong, 
 well-developed children. It runs a rapid course and is extremely fatal. 
 Death may be preceded by convulsions. The etiology is unknown. The 
 post-mortem findings are in some cases similar to those of Buhl's disease. 
 The spleen is enlarged. The diagnosis rests upon the occurrence of asso- 
 
ANOMALIES OF THE SPLEEN. 1161 
 
 ciated cyanosis and icterus, the sudden onset upon the fourth day, the 
 character of the urine, and the endemic or epidemic prevalence of the 
 affection in an institution. The disease is to be distinguished from Buhl's 
 disease by its onset some days after birth and the urinary conditions, and 
 from icterus neonatorum by the severity of the process. 
 
 " Hemorrhagic Disease of tiie New=born"; Morbus Maculosus Neona- 
 torum. — Townsend has made a thorough study of a condition of not 
 infrequent occurrence and uniform symptomatology, which has been de- 
 scribed under the above terms. This affection is self-limited, attended with 
 moderate fever, and occurs almost always within the first week of life. 
 Hemorrhage arises from the mouth, nose, bowels, and navel. Petechise 
 and ecchymoses are common. Visceral hemorrhages and bloody collec- 
 tions in the serous sacs are found upon post-mortem examination. The 
 children are very anaemic in appearance, but the peripheral blood may 
 show an increase in haemoglobin and erythrocytes. In a case of Town- 
 send's the haemoglobin was 125 per cent, and the erythrocytes 6,245,600. 
 The affection is of brief duration. The mortality is about 60 per cent. 
 When recovery takes place it is usually complete and permanent. The 
 diagnosis may be based upon the general character of the disease, its 
 manifestly infectious nature, its self-limited course, and its prevalence in 
 institutions. It is to be distinguished from other forms of disease of the 
 new-born, characterized by hemorrhage, which have been described, and 
 especially from haemophilia. A general rather than a local tendency to 
 hemorrhage is of diagnostic significance. It is probable that many of the 
 cases described as melaena neonatorum belong to this category. 
 
 DISEASES OF THE DUCTLESS GLANDS. 
 
 I. DISEASES OF THE SPLEEN, 
 i. Anatomical Anomalies. 
 
 Complete absence of the spleen occasionally occurs in association with 
 other developmental faults. Much more commonly the organ is rudimen- 
 tary. Very frequently there are accessory spleens — splenunculi — the 
 supernumerary spleen or spleens lying within the folds of the gastro- 
 splenic omentum and other processes of the peritoneum passing to the 
 spleen. Abnormal lobulation and departures from the usual shape are 
 common. These abnormalities are of no clinical interest. Entire 
 absence of the spleeij may be unattended by functional disturbances. 
 
 In complete transpositio viscerum the spleen occupies a position 
 upon the right side corresponding to its normal position on the left. 
 Under these circumstances it is sometimes represented by a number 
 of lienculi which may be arranged in a cluster or loosely separated. 
 Exceptionally the transposition may involve only the liver and spleen. 
 Displacement may occur in the new-born downward as the result of 
 abdominal deformities or umbilical hernia, upward in consequence 
 of congenital diaphragmatic hernia. The^e displacements are of minor 
 clinical interest. 
 
1162 MEDICAL DIAGNOSIS. 
 
 ii. Movable Spleen. 
 
 Lien Mobilis; Wandering Spleen. 
 
 This condition is sometimes the result of congenital elongation of the 
 gastrolienal ligament; sometimes of a similar elongation acquired through 
 mechanical influences, such as pressure, blows, the succussion of violent, 
 continuous coughing, the traction of peritoneal adhesions, and the weight 
 of the enlarged organ itself. Wandering spleen is most commonly encoun- 
 tered in women suffering from enteroptosis. 
 
 Symptoms. — The dislocation is downward and forward, and the 
 organ may reach a position below the level of the umbilicus or even pass 
 into the pelvis, or it may form part of the contents of a large inguinal 
 hernial sac. It is, as a rule, more or less enlarged. Subjective symptoms 
 may *be wholly absent, and the condition may be accidentally discovered. 
 More commonly there are sensations of weight and dragging, with diffuse 
 dull pain in the left flank. Colic, constipation, dysuria, and neuralgia 
 may result from derangement of the various structures upon which the 
 displaced and enlarged spleen exerts traction or pressure. The obstruc- 
 tion to the circulation sometimes causes great distention of the splenic 
 vein. Torsion of the pedicle may lead to strangulation with great pain, 
 tenderness, and local swelling, followed by necrosis with local or general 
 peritonitis. 
 
 Physical Signs. — The upper end of the organ may sometimes be felt 
 below the edge of the ribs, an important diagnostic point in the differen- 
 tiation between an enlarged and a dislocated spleen. Palpation detects 
 the indented median, the outer rounded, and the sharp lower border. 
 The respiratory movements do not affect the dislocated spleen as they do 
 the normal or merely enlarged organ. The normal dulness in the left 
 hypochondrium is replaced by tympany. 
 
 Diagnosis. — The diagnosis is usually unattended by difficulty. The 
 size, shape, and position of the organ, its free mobility, and the absence 
 of dulness in the normal position of the spleen serve to distinguish it 
 from the various abdominal or pelvic tumors, which its presence in an 
 abnormal position might suggest. 
 
 iii. Acute Splenic Tumor. 
 
 The spleen undergoes enlargement in the acute febrile infections. 
 The degree of enlargement varies in different diseases and in different 
 cases of the same disease. The enlargement is almost constant in malaria, 
 and so common in enteric fever as to constitute a phenomenon of diagnos- 
 tic importance, It is also very frequent in typhus and relapsing fever, 
 and occurs in pneumonia, smallpox and the other exanthemata, anthrax 
 and septic conditions. Moderate splenic enlargement is frequently observed 
 in acute miliary tuberculosis, secondary syphilis, and cerebrospinal fever. 
 It occurs also, but is less common and less marked, in various acute 
 catarrhal inflammatory conditions of the respiratory system, as coryza, 
 tonsillitis, and bronchitis. 
 
SPLENIC TUMOR. 1163 
 
 Symptoms are usually wholly absent. In exceptional cases there are 
 sensations of weight and .tension in the left flank, and some discomfort is 
 experienced when pressure is made over the splenic region. 
 
 Physical Signs. — Inspection. — In rare instances in persons with little 
 subcutaneous fat the side may slightly bulge and the outline of the lower 
 border of the enlarged viscus may be seen below the margin of the ribs, 
 especially upon deep inspiration. Palpation. — By this method moderate 
 degrees of splenic enlargement may be recognized. The patient should be 
 partly upon the right side, with his knees and thighs moderately flexed, 
 and his head and shoulders supported upon a pillow. The physician stand- 
 ing to the left of the patient performs bimanual palpation, the palms of 
 his right hand exerting pressure over the splenic area in the posterolateral 
 aspect of the chest, while the fingers of his left hand are passed firmly 
 upward beneath the margin of the ribs in front, the patient at the same 
 time being directed to breathe slowly and deeply with an open mouth. 
 The spleen descends with each deep inspiration and if enlarged may be 
 readily felt by the fingers of the left hand. When the enlargement is con- 
 siderable, the notches in the anterior border may be palpated, and in 
 very rare instances pulsation has been recognized. Percussion. — This 
 method of examination yields unsatisfactory results in moderate degrees 
 of enlargement and cannot be depended upon. Errors occur in gaseous 
 distention of the stomach, meteorism, fecal accumulations in the colon, 
 and enlargement of the left kidney. When the spleen is considerably 
 enlarged this method is more satisfactory. Very light direct percussion 
 with the dorsal surface of the finger-tip yields satisfactory results, as does 
 auscultatory percussion. Auscultation. — Intermittent and continuous soft 
 murmurs have been heard in the splenic area in the malarial paroxysm 
 and in relapsing fever. 
 
 iv. Chronic Splenic Tumor. 
 
 Hypertrophy of the Spleen; Congestive Hypertrophy. 
 
 Chronic enlargement may follow acute splenic tumor and be due to 
 the action of infectious principles. It occurs also in chronic malaria, 
 leukaemia, cirrhosis of the liver, and cardiac affections. The organ may 
 be increased to twenty-five or thirty times its normal size. Its surface 
 is commonly smooth and there is thickening of the capsule. 
 
 Symptoms. — When the enlargement is of moderate size there are 
 often no subjective symptoms. When it is considerable, weight, dragging, 
 and a dull pain in the left side are experienced. Interference with the 
 respiratory play of the diaphragm may cause dyspnoea, especially when 
 the patient lies upon his left side. Traction upon the stomach maj^ lead to 
 loss of appetite, indigestion, nausea, and vomiting. Cardiac palpitation, 
 oedema of the ankles, and colic occur. Anaemia is often marked. Hemor- 
 rhages and especially ha^moj^tysis are occasionally present. 
 
 Physical Signs. — The left side of the abdomen and the left hypo- 
 chondrium may be distended. The visible and palpable tumor is popularly 
 known in malarial districts as "ague cake." The lower and anterior mar- 
 
1164 MEDICAL DIAGNOSIS. 
 
 gins are often distinctly palpable with their characteristic features, and 
 may, in extreme cases, reach to the brim of the pelvis and to the right of 
 the median line respectively. Upon auscultation friction sounds may 
 sometimes he heard. The bruits occasionally heard in acute splenic tumor 
 are not present. In cases of moderate enlargement in which there are no 
 adhesions, the spleen may be so freely movable as to constitute one of the 
 forms of movable spleen. 
 
 Diagnosis.- — Direct. — The physical signs elicited upon inspection, 
 palpation, and percussion, the presence of dulness in the normal splenic 
 area, together with its uninterrupted extension to abnormal limits down- 
 ward and forward and the well-defined borders notched in the anterior 
 and rounded in the inferior lines, and more or less distinct participation 
 of the tumor mass in deep respiratory movements of the diaphragm jus- 
 tify a diagnosis of hypertrophy of the spleen. 
 
 Differential. — The nature of the enlargement may be obscure. 
 In leukaemia the condition of the blood is diagnostic. In Hodgkin's 
 disease the history is important, and the presence of enlarged superficial 
 lymph-nodes, especially when they form groups or masses in the cervical, 
 axillary, or inguinal regions, is suggestive. In congenital syphilis and 
 rickets the associated phenomena are significant. In splenic abscess^ 
 fluctuation and fever, together with other septic phenomena, point to the 
 presence of pus. Echinococcus cysts of the sjDleen are rare and may give 
 rise to uncertainty. Rupture into the intestine or externally may afford 
 clinical evidences by which the true condition may be recognized during 
 life, and rupture into the peritoneum may cause fulminant peritonitis, 
 but these accidents are among the most infrequent of clinical occurrences. 
 Malignant disease of the spleen is attended with grave disturbances of the 
 general health, cachexia, and metastasis. 
 
 Tumors of the kidney usually occupy a lower position and are less 
 movable. They are crossed diagonally by the colon and often associated 
 with urinary symptoms of importance. Nephromata are common in 
 early life, and hydronephrosis and pyonephrosis at all ages. A diagnosis 
 of splenic hypertrophy or abscess should never be made until after every 
 form of renal tumor has been excluded. A tumor of the fundus of the 
 stomach, of the colon, or the omentum may, as a rule, be differentiated 
 without difficulty from enlargement of the spleen. 
 
 Moderate enlargement is usually present in movable spleen. The 
 latter condition is characterized bj^ the free movement of the organ, its 
 contour, and by resonance in the region of normal splenic dulness. 
 
 Prognosis. — The outlook depends upon the cause of the enlargement. 
 Congestive and malarial spleens often undergo remarkable diminution in 
 size. The leukaemic spleen shows wide oscillations in volume in the course 
 of the disease and under treatment. Enlarged spleens may become smaller 
 during pregnancy. The enlargement may exist for ^-^ears without detri- 
 ment to health. 
 
SPLENIC TUMOR. 1165 
 
 V. Splenic Tumor with Anaemia. 
 
 Primitive Splenomegaly; Splenic Ancemia; Banti's Disease. 
 
 Anaemia is characteristic of many conditions in which the spleen is 
 enlarged, especially the primary anaemias, as leukaemia and pernicious 
 anaemia. Secondary anaemia accompanies splenic enlargement in Hodg- 
 kin's disease, chronic malaria, and various forms of hepatic cirrhosis. 
 Idiopathic splenomegaly with secondary anaemia occurs in a group of cases 
 of which the following types are the most important: 
 
 (a) Primitive Splenomegaly. — Marked and persistent enlargement 
 may occur without associated disease and with but slight blood changes, 
 and give rise to no symptoms other than those caused by the pressure and 
 weight of the enlarged organ. 
 
 (b) Splenic Anaemia. — The spleen is very large. There is marked 
 anaemia of secondary type. Hemorrhages, particularly hsematemesis, are 
 common. Purpura, melanoderma, and oedema of the lower extremities 
 occur. The disease runs a very chronic course. 
 
 ■ (c) Banti's Disease. — The advanced stages of splenic anaemia are 
 characterized in a sub-group of cases by secondary cirrhosis of the liver 
 with subicteroid discoloration of the skin, or actual jaundice and ascites. 
 Diagnosis. — The direct diagnosis of splenic anaemia rests upon the 
 association of primitive splenomegaly with secondary anaemia, and the 
 absence of enlargement of the lymph-nodes. 
 
 The differential diagnosis between splenic anaemia and pernicious 
 anaemia depends upon the morphological characters of the blood, the 
 relatively high haemoglobin percentage, and small size of the spleen in the 
 latter affection. Leukaemia may be at once differentiated by the blood 
 picture, and Hodgkin's disease by the enlargement of the lymph-glands 
 and their peculiar massing in the cervical, axillary, and inguinal regions. 
 Banti's disease and hepatic cirrhosis present similar pictures, but in the 
 former the splenic enlargement is primary and of long duration before the 
 changes in the liver and the resulting jaundice and ascites make their 
 appearance. A history of alcoholism is of diagnostic importance. 
 
 vi. Splenic Tumor with Polycythsemia and Cyanosis. 
 
 Osier and others have recently described a condition characterized by 
 cyanosis, an increase in the number of the red blood-corpuscles to 9,000,000 
 or even 13,000,000 to the cmm., and enlargement of the spleen. Headache, 
 giddiness, and constipation are common symptoms. The cause of the 
 disease is wdiolly unknown. It occurs in adults. The cyanosis is more 
 marked in cold than in warm weather. Urinary changes, as low specific 
 gravity, a trace of albumin, and hyaline and granular casts, are common. 
 The condition is a persistent one. Such causes of c^^anosis as emphysema, 
 congenital and acquired heart disease, pulmonary sclerosis, and acetanilid 
 poisoning must be excluded in making the diagnosis. The polycythsemia 
 observed in those who have resided at high altitudes must also be 
 borne in mind. 
 
1166 MEDICAL DIAGNOSIS. 
 
 vii. Splenic Capsulitis — Perisplenic Peritonitis. 
 
 Inflammation of the capsule of the spleen occurs in arteriosclerotic 
 atrophy of the organ, and in particular in the senile form, in acute splenitis, 
 infarction, and abscess. It is met with also in local and general peritonitis 
 and in chronic proliferative peritonitis. In many cases the capsular peri- 
 splenitis results from the extension of inflammation from neighboring organs, 
 as the fundus of the stomach, the pancreas, and loops of intestine, and 
 adhesions between these structures and the spleen are found. 
 
 Symptoms. — The clinical manifestations are often subordinate to 
 those of the associated disease, as in gastric ulcer, pancreatic disease, or 
 general peritonitis. In other cases circumscribed pain, tenderness, and 
 swelling are associated with fever and much general disturbance of health. 
 
 The prognosis depends upon the nature of the primary disease. Cap- 
 sular thickening and adhesions are frequently found upon post-mortem 
 examination in cases in which no history of acute symptoms has been 
 obtained. 
 
 viii. Infarct of the Spleen. 
 
 Embolism of the terminal branches of the splenic artery may occur in. 
 endocarditis, thrombosis of the left heart, and atheroma of the thoracic 
 aorta. The infarcts thus caused may be single or multiple. They vary 
 greatly in size. They are pyramidal in shape, the apex presenting toward 
 the helium and the base toward the periphery of the organ, the corresponding 
 capsule being very frequently the seat of a circumscribed plastic inflam- 
 mation. The infarct, hemorrhagic at first, may undergo softening or a 
 gradual cicatricial change which results in a contracting and pigmented 
 scar. Infected emboli undergo softening with abscess formation. 
 
 Symptoms. — A chill, sudden severe pain and tenderness in the region 
 of the spleen, which at the same time becomes enlarged, sometimes vomit- 
 ing and collapse symptoms, constitute the symptom-complex. When 
 these symptoms occur in endocarditis or in cases in which there are signs 
 pointing to atheroma, the diagnosis of splenic infarct becomes highly 
 probable. If there are coincident indications of renal infarct, such as 
 severe pain referred to the loins, and hemorrhagic and albuminous urine, 
 the diagnosis is positive. A friction sound may be heard. In many cases 
 in which the anatomical diagnosis is made neither symptoms nor the signs 
 of enlargement of the spleen were present during hfe. 
 
 ix. Suppurative Splenitis — Abscess of the Spleen. 
 
 This condition results from direct infection by pyogenic micro-organ- 
 isms. There are two forms: simple and embohc. The former may result 
 from traumatism or be secondary to infective processes in adjacent struc- 
 tures or infection by way of the blood. The latter occurs in septic condi- 
 tions, the infected emboH being derived from local suppurative foci in 
 distant parts. The simple abscess is usually single. It may vary in 
 size from a cherry to the dimensions of the enlarged and overdistended 
 spleen, the substance of which it replaces. Embohc abscesses are small 
 
DISEASES OF THE THYMUS GLAND. 1167 
 
 and numerous, and begin as infarcts which rapidly undergo softening and 
 are converted into collections of pus. 
 
 Symptoms. — The symptoms are those of infarction, namely, localized 
 pain and tenderness, splenic enlargement, and irregular fever. They 
 develop rapidly in embolic, more gradually in simple, abscess. There may 
 be cough and dyspnoea due to interference with the movement of the 
 diaphragm; gastric derangement caused by sepsis; oedema of the lower 
 extremities arising from compression of the abdominal veins. 
 
 Physical Signs. — The lower end of the spleen may be palpated below 
 the margin of the ribs. Fluctuation may be elicited. The rupture of the 
 abscess may be followed by sudden pain and collapse symptoms, and the 
 discharge of a considerable quantity of pus by vomiting or by the bowel, 
 or in rare instances by way of the bronchi or the urinary passages. 
 
 Prognosis. — A great majority of the cases die. Recovery may take 
 place by the resorption of the fluid contents of a small cavity and inspissa- 
 tion, or after the evacuation of the pus spontaneously or by a surgical 
 operation. 
 
 X. Rupture of the Spleen. 
 
 Spontaneous rupture must be extremely rare. It is said to occur in 
 connection with the acute enlargement of the organ in enteric and malarial 
 fevers. Undue force in palpation or some similar traumatism may be 
 suspected. Rupture of the spleen has been noted in childbirth. Severe 
 blows, contusions, or penetrating wounds have caused rupture of the 
 normal spleen. The rupture may occur at the site of an infarct, or an 
 abscess may give way. The symptoms denote sudden internal hemorrhage 
 associated with intense pain in the splenic region. There may be extended 
 dulness in the splenic region or in the flanks due to collections of blood. 
 The abdomen may be swollen and the seat of general distress. 
 
 The diagnosis becomes probable when, in the presence of acute or 
 chronic enlargement of the spleen, or in the case of direct violence to the 
 left side of the trunk, sudden intense local pain, collapse symptoms, and 
 pallor arise, together with signs of increasing enlargement of the spleen or 
 accumulation of fluid in the flanks. An exploratory laparotomy should be 
 performed without delay. 
 
 Prognosis. — In a few instances spontaneous recovery has resulted, 
 as shown by the cicatrix when death has occurred at a remote period after 
 the accident. Most of the cases are promptly fatal. Immediate operation 
 has been the means of saving life. Localized tumors of the spleen, the 
 so-called splenic adenomata, which consist of localized hyperplasias of 
 splenic tissue within the spleen itself, fibromata, gummata, primary and 
 secondary sarcomata, hydatid and other cysts are rare conditions of 
 pathological rather than clinical interest. 
 
 II. DISEASES OF THE THYMUS GLAND. 
 
 The functions of this transitional organ are unknown. It has been 
 accredited with a hypothetical internal secretion capable of antagonizing 
 infections, a hypothesis which accounts for the comparative immunity of 
 
1168 MEDICAL DIAGNOSIS. 
 
 young infants against many of the acute febrile infections. The weight of 
 the thymus gland at birth is variously estimated at from 8 to 13 grammes. 
 It gradually increases in size till the end of the second year, from which 
 period it undergoes progressive atrophy, until at puberty it is a shrivelled 
 mass containing only traces of its original structure. 
 
 I. Persistence of the Thymus.^ — This occurs under varied conditions 
 which may be causal or accidental, but are not understood. It is usually a 
 post-mortem finding, but may be suspected when localized dulness along 
 the sternal border on the left side from the second to the fourth rib 
 may be made out. Persistent thymus has been frequently observed in 
 exophthalmic goitre. 
 
 II. Hypertrophy. — Enlargement of the thymus has been regarded 
 as the cause of thymic asthma or laryngismus stridulus — a condition attrib- 
 uted to the pressure of the enlarged organ. Dyspnoea, laryngeal cough, 
 and bronchial rales in young infants have been caused by hypertrophy of 
 the thymus and relieved by partial excision, but that it is the cause of 
 laryngismus stridulus is by no means established. Sudden death may occur 
 in lymphatism in infants with hypertrophy of the thymus. The children 
 are found dead in bed or die in a short time with symptoms of asphyxia. 
 In certain cases of sudden death in adults the thymus has been found 
 greatly enlarged with signs of status lymphaticus. Hypertrophy of the 
 thymus has been occasionally present in epilepsy. 
 
 III. Atrophy. — Primary atrophy of the thymus in infants may be 
 attended with general atrophy in the absence of other symptoms. 
 Secondary atrophy attends tuberculous and other wasting diseases. 
 
 IV. Hemorrhages. — Extravasations of blood in the substance of the 
 gland have been frequently found in children dead of asphyxia. 
 
 V. Tumors of the thymus are sarcoma, lymphosarcoma, dermoid 
 and other cysts, and gumma. Miliary tuberculosis and gumma are rare 
 pathological findings. Mediastinal tumors frequently have their origin 
 in the thymus. 
 
 The majority of the diseases of the thymus gland cannot be recog- 
 nized during life, and are of pathological rather than clinical interest. 
 
 III. STATUS LYMPHATICUS; LYMPHATISM; CON- 
 STITUTIO LYMPHATICA. 
 
 Definition. — A constitutional condition characterized by hyperplasia 
 of the lymph-nodes and lymphatic tissues generally, the spleen, the thymus, 
 and the bone-marrow, and the liability to sudden death. 
 
 Morbid Anatomy. — The lymph-nodes of the pharynx, thorax, and 
 abdomen are chiefly affected. The superficial glands of the cervical, 
 axillary, and inguinal regions may be involved. As a rule, the enlargement 
 is moderate in degree and sj^mmetrical, and differs in this respect from 
 that of Hodgkin's disease. The enlargement of the spleen is moderate, 
 the thymus is persistent and usually hypertrophied, and the yellow marrow 
 of the long bones may be replaced by red marrow. The thyroid body is 
 enlarged, and hypoplasia of the heart and aorta is present. Many of the 
 subjects are rhachitic. 
 
ACUTE THYROIDITIS. 1169 
 
 Etiology. — The condition has been variously ascribed to heredity 
 and to over-irritability of the lymphatic tissue. It occurs principally in 
 children and young persons. The association with rickets is probably 
 accidental. 
 
 Clinical Phenomena. — The patients are fat and flabby, and have 
 pallid, opaque skins. Hypertrophy of the tonsils and overgrowth of the 
 pharyngeal adenoid tissue, swelling of the thyroid, overgrowth of the 
 thymus (as indicated by dulness over the manubrium sterni, especially at 
 its left border), enlargement of the superficial lymph-nodes, and espe- 
 cially signs of enlargement of the mesenteric glands, are present. Moderate 
 enlargement of the spleen is suggestive. 
 
 Diagnosis. — When the foregoing signs are well marked the diagnosis 
 may be made with some confidence, but a positive diagnosis cannot often 
 be affirmed. The number of cases in which the lesions of lymphatism have 
 been found after unlooked-for death, under circumstances in which such 
 an event has appeared unaccountable — as the injection of diphtheria anti- 
 toxin serum for prophylactic purposes, chloroform or ether anaesthesia for 
 trifling operations in young children, during the bathing of young children 
 wholly without apparent cause, and occasionally during convalescence 
 from the acute febrile infections — have given the condition a sinister signifi- 
 cance. This fatal occurrence has been attributed to the pressure of the 
 hypertrophied thymus upon the trachea, or to a perverted or excessive 
 internal thymus secretion — lymphotoxsemia. 
 
 The DIFFERENTIAL DIAGNOSIS from Hodgkiu's disease rests upon the 
 more marked and asymmetrical enlargement of the superficial glands, and 
 the absence of hypertrophy of the pharyngeal lymph structures in the 
 latter affection; from glandular fever, upon the acute and self-limited 
 course of the latter disease, the presence of fever, and the subsidence of the 
 enlargement of the lymph-nodes after defervescence. 
 
 Prognosis. — The subjects of lymphatism have feeble powers of resist- 
 ance, and in consequence of the hypoplasia of the heart and aorta are 
 especially liable to sudden death. 
 
 IV. DISEASES OF THE THYROID GLAND, 
 i. Acute Thyroiditis. 
 
 Acute inflammation of the thyroid gland is rare. It may follow trau- 
 matism. Much more commonly it occurs in association with an acute 
 infectious disease, as enteric fever, scarlet fever, diphtheria, rheumatic 
 fever, pneumonia, or mumps. In a case recently under my observa- 
 tion it developed in the course of an attack of influenza. In very 
 rare instances acute thyroiditis has been noted as a primary affection. 
 
 Symptoms. — The whole gland may be affected, or only one lobe. 
 The attack begins with a chill or chilliness followed by high fever. Swelling, 
 , pain, and tenderness rapidly develop. Externally there may be redness 
 with engorgement of the superficial veins, and cyanosis. Internal pressure 
 upon the blood-vessels, oesophagus, and trachea causes headache, dysphagia, 
 dyspnoea, and stridor. As a rule, resolution takes place in the course 
 
 74 
 
1170 MEDICAL DIAGNOSIS. 
 
 of several days or a week or two. Occasionally suppuration occurs. 
 Destruction of the entire gland has been followed by myxoedema. 
 (Edema of the glottis may occur. Myxoedema has been observed after 
 an attack of acute thyroiditis. 
 
 ii. Goitre — Bronchocele. 
 
 Definition. — Hypertrophy of the thyroid gland. This term includes 
 all enlargements of the thyroid gland not caused by inflammation, new 
 growths, tuberculosis, syphilis, Graves's disease, and animal parasites. 
 The anatomical varieties of goitre are, (a) parenchymatous, (b) vascular, 
 and (c) cystic. 
 
 Goitre occurs as a sporadic and as an endemic disease. 
 
 1. Sporadic Goitre. — The temporary congestions which give rise to 
 enlargement of the thyroid body in girls at puberty, in many women 
 during menstruation, and in some during pregnancy cannot be regarded 
 as goitres. Nor do the transient swellings caused by the pressure of a 
 tight collar or excessive use of the voice constitute goitre. Enlargement of 
 the gland due to parenchymatous, vascular, or cystic lesions, and more 
 or less persistent, is not uncommon and occurs almost without exception 
 in the female sex. Age is a predisposing factor of some importance. There 
 are rare cases of congenital goitre. The disease is uncommon in childhood. 
 It frequently first appears after puberty or in early adult life, but may not 
 appear until fifty or later. 
 
 2. Endemic Goitre. — This affection is prevalent in circumscribed 
 regions in many parts of the world. These regions are frequently but not 
 exclusively mountainous, or deep valleys surrounded by mountains. 
 Sometimes they are plains, especially in lake countries. Parts of Switzer- 
 land, the southern slopes of the Italian Alps, the Himalayas, the hill country 
 of China, and some regions in Siberia are seats of endemic goitre, either 
 alone or in association with cretinism. The disease is rare in North Amer- 
 ica. In occurs in some parts of Pennsylvania, the parts about the eastern 
 end of Lake Ontario, and in the Province of Quebec. 
 
 The exciting cause of endemic goitre is supposed to be contained in 
 the drinking water of goitrous districts. This opinion is supported by the 
 following facts, which are generally accepted: 
 
 i. A healthy family coming to reside in a goitrous district presently 
 may develop goitre among its members. 
 
 ii. Drinking water from a new and distant source has been followed 
 by subsidence of goitre. 
 
 iii. An outbreak has followed the introduction of water from a 
 goitrous region. 
 
 iv. Certain wells in Europe have had the reputation of causing goitre 
 in those habitually drinking their waters. 
 
 Symptoms. — The enlargement may involve the entire gland, or only 
 one lobe. Moderate-sized goitres cause no annoyance beyond that due to 
 the deformity which they produce. Large tumors may give rise to dyspncea 
 by pressure upon the trachea; small tumors extending beneath the sternum 
 may compress the veins. In extreme cases the goitre may compress the 
 
EXOPHTHALMIC GOITRE. 1171 
 
 oesophagus and give rise to difficulty in deglutition. Sudden death has 
 occurred in large goitres from pressure upon the vagi, or hemorrhage into the 
 substance of the gland or the adjacent tissues. 
 
 Accessory Thyroids; Parathyroids. — These may He in the thyroid 
 or near it. Their number varies, rarely, however, exceeding four. In some 
 instances thyroid tissue is situated at the root of the tongue, in the medias- 
 tinum, or even in the pleural cavity. A lingual thyroid may exist in the 
 substance of the tongue or attached to the hyoid bone. 
 
 Diagnosis. — Direct. — The disease may be readily recognized. It is 
 an important characteristic of all tumors of the thyroid gland that they 
 move upward in deglutition. 
 
 Differential. — Goitre is to be discriminated from, (a) adenomata, 
 simple or malignant; (b) malignant neoplasmata, both carcinomatous and 
 sarcomatous. The important diagnostic criteria are the smooth parenchy- 
 matous enlargement involving one lobe or the entire gland; the uniform 
 vascular enlargement with distinct varix arrangement, pulsation, and 
 murmur; or recognizable agglomerate cyst formation. 
 
 Prognosis. — Treatment is not usually satisfactory. Iodine and the 
 iodides, ergot, and counterirritants, much recommended, are not always 
 successful. Thyroid extract is of questionable value. Large goitres may be 
 removed. 
 
 iii. Exophthalmic Goitre. 
 
 Hyperthyrea; Graves's Disease; Basedow's or Parry's Disease. 
 
 Definition. — A disease caused by derangement of the internal 
 secretion of the thyroid body, and characterized by exophthalmus, 
 enlargement of the thyroid, tachycardia, and tremor. 
 
 Pathology. — Various views in regard to the essential nature of this 
 affection have been from time to time entertained, but that which now 
 has the most satisfactory basis of support is that it is a primary disease 
 of the thyroid gland, resulting in an increased or deranged internal secre- 
 tion. In defense of this view the following facts are adduced: 
 
 i. The active proliferation in glandular substance during the progress 
 of the disease. 
 
 ii. The production of symptoms resembling those of exophthalmic 
 goitre by the administration of thyroid extract. 
 
 iii. The fact that thyroid extract usually aggravates the symptoms 
 of the disease. 
 
 Etiology. — Predisposing Influences. — Sex. — The disease is common 
 in women; comparatively rare in men. Age. — The onset usually occurs 
 in early adult life, somewhere between the eighteenth and fortieth years. 
 Rare cases have been observed in infancy. Heredity. — It sometimes occurs 
 in several members of the same family, and has been observed in three 
 successive generations. 
 
 Exciting Cause. — Acute infections, especially tonsillitis, rheumatic 
 fever, and influenza, have been noted in many instances shortly before the 
 onset of exophthalmic goitre. More significant are severe depressing 
 emotions, worry, anxiety, fright, and overfatigue as antecedent conditions 
 
1172 
 
 MEDICAL DIAGNOSIS. 
 
 and possible causal factors. There is a close resemblance between the 
 immediate effects of sudden fright or terror and the symptoms of exoph- 
 thalmic goitre, namely, exophthalmus, tachycardia, and tremor. 
 
 Symptoms. — The cardinal symptoms have been mentioned in the 
 definition, namely, exophthalmus, goitre, overaction of the heart, and 
 
 tremor. With these are usually 
 associated anaemia, emaciation, 
 sweating, diarrhoea, and irregular 
 or suppressed menstruation. The 
 cardinal clinical phenomena vary 
 in degree and in the order of 
 their development. 
 
 1. Exophthalmus. — In some 
 instances the protrusion is so great 
 as to prevent closure of the eye- 
 lids. In others it is so slight as 
 to be scarcely noticeable. It is 
 frequently different in degree upon 
 the two sides and sometimes dis- 
 tinctly unilateral. Commonly a 
 In rare instances 
 
 Fig. 334. — Exophthalmic goitre. — German Hospital 
 
 rim of white is seen above and below the cornea 
 the eyes maj^ be dislocated from their sockets. 
 
 Graefe's Sign. — When the eyeball is moved downward the upper lid 
 does not follow it as in normal conditions. Dalrym^le' s Sign. — The palpe- 
 bral fissure is wider than normal, owing to spasmodic retraction of the 
 upper lid. Stellwag's Sign. — Infrequent, irregular, and incomplete winking. 
 Moehius's Sign. — Insufficient power of convergence for near objects. The 
 foregoing signs are commonly associated. Joffroy's Sign. — When the head 
 is bowed forward and the patient 
 asked to look up without changing P* 
 his posture, the forehead is not 
 wrinkled as occurs in health. 
 
 Pupillary changes and retinal 
 lesions are rare. Defects of vision 
 are uncommon. Subjective ocular 
 symptoms, as sensations of pres- 
 sure and phosphenes, occur. 
 Ulceration of the cornea may take 
 place, and in extreme cases destruc- 
 tion of the eyeball. Pulsation of 
 the retinal arteries is frequent. 
 
 2. ENL.A.RGEMEXT OF THE 
 
 Thyroid Body. — The enlargement 
 is usually moderate. Usually both lobes are affected, as a rule unsymmet- 
 rically, and more commonly the right to a greater extent than the left. 
 The swollen gland is generally soft, but may be dense and hard, espe- 
 cially when goitre has preceded the disease. Distinct pulsation, thrill, 
 and a systolic or continuous murmur are common phenomena. Sometimes 
 the murmur is double. The thyroid enlargement undergoes remarkable 
 
 Fig. 33.5. — Exophthalmic goitre. — German Hospital. 
 
EXOPHTHALMIC GOITRE. 1173 
 
 fluctuations in volume, increasing for a time and then subsiding, or 
 undergoing repeated changes in the course of a short time. The attention 
 of the patient is often first called to this symptom by the tightness of 
 the neckband or collar. 
 
 3. Circulatory Derangements. — This group of symptoms consti- 
 tutes the most constant and striking features of the disease. Tachycardia 
 is always present. The pulse-frequency varies from 90 to 100 beats in the 
 minute in the early course of the disease, to 100 to 130 and even 140 to 
 160 in severe and advanced cases. The rate is usually increased upon 
 effort and under the influence of emotion. Forcible pulsations of the ves- 
 sels at the root of the neck are associated with increased cardiac action 
 and a greatly extended visible impulse. As a rule, the patients complain of 
 palpitation and sometimes feel the sensation widely over the body. In 
 some cases the overaction of the heart causes little discomfort. The heart 
 is almost always dilated and sometimes hypertrophied. Its action is, as 
 a rule, regular, but in grave cases arrhythmia is often marked. Systolic 
 murmurs are common at the apex and across the base of the heart. The 
 heart sounds are often intense, and may, in some instances, be heard at 
 some distance from the body of the patient. Acute dilatation of the heart 
 may occur. There may be visible pulsation of the peripheral arteries and 
 the pulse-beat may be felt in the palms and finger-tips. A capillary pulse 
 is common and the venous pulsation in the back of the hand may often 
 be seen. Flushing of the neck and face is often pronounced. 
 
 4. Tremor. — This cardinal symptom is a variable one. It may be 
 forcible and annoying, involving not only the extremities but also the 
 head, or so slight as to be discovered only upon careful examination. It 
 is entirely involuntary, of limited extent, and about eight or nine to the 
 second. It is usually symmetrical, but may be more marked upon one 
 side, or confined to, or more distinct in, a single limb. 
 
 Anaemia, emaciation, and loss of strength are common. Fever is 
 rare, but subjective sensations of heat, and copious perspirations, are 
 common symptoms. Vomiting and diarrhoea occur in the absence of 
 obvious cause. The electrical resistance is diminished, a fact attributed 
 to the moisture of the skin due to vasomotor dilatation. Pigmentation is 
 not uncommon. The parts chiefly affected are the face, neck, trunk, 
 nipples, and flexures of the arms and thighs. In rare instances there is a 
 general bronzing like that of Addison's disease; in other cases an irregular 
 patchy discoloration. Patches of leucoderma may appear. Transient 
 oedema is common and myxoedema is occasionally seen. The nutrition of 
 the hair suffers and complete alopecia may occur. The teeth sometimes 
 undergo rapid decay. Albuminuria, glycosuria, and true diabetes are 
 occasionally encountered in the course of the disease. Menstrual derange- 
 ments are common. When pregnancy occurs the condition of the patient 
 often improves and the foetus is born at term. 
 
 Nervous and mental symptoms are very common. Tremors, cramps 
 of the hands and feet, a sensation of giving way at the knees, and increased 
 tendon reflexes are observed. Irritability, altered disposition, and mental 
 depression occur in most of the cases. The acute mania which sometimes 
 precedes death has been attributed to sudden, intense thyroid intoxication. 
 
1174 MEDICAL DIAGNOSIS. 
 
 Course and Duration. — Incomplete forms are common and often 
 overlooked. They may be characterized by tachycardia, nervous irrita- 
 bility, slight tremor, and little enlargement of the thyroid or protrusion of 
 the eyes. There are acute and chronic forms. The latter are more com- 
 mon. Acute cases usually occur in childhood. They may last a few days 
 or several weeks and get well. Relapses may occur. As a rule, when in 
 adults the disease is well marked, recovery is infrequent. Death occurs 
 from intercurrent affections. 
 
 Diagnosis. — When the four cardinal symptoms are associated a posi- 
 tive diagnosis can be made. Difficulty may arise in the rudimentary 
 forms. Absence of exophthalmus or of thyroid enlargement is not often 
 complete. These symptoms when slight are, in association with tremor 
 and tachycardia, most significant. Anaemia, pigmentation, emaciation, 
 and mental changes aid the diagnosis. 
 
 Prognosis. — The disease is essentially chronic. Acute cases are excep- 
 tional. A guarded prognosis should be given. In individual cases the more 
 urgent the symptoms the less favorable the outlook. When the symp- 
 toms are mild the prospect of recovery is proportionately better. Cases 
 in which the onset is sudden and severe, after fright, sometimes recover 
 in a short time, 
 
 iv. Myxoedema. 
 
 Athyria; GulVs Disease. 
 
 Definition. — A constitutional disease caused by the impairment or 
 loss of function of the thyroid gland, and characterized anatomically by 
 absence, atrophy, or goitrous degeneration of the thyroid, and clinically 
 ,by profound nutritional changes, a firm, inelastic swelling of the skin and 
 subcutaneous tissues, and nervous and mental symptoms. 
 
 Varieties. — Three forms are recognized: the infantile, or cretinism; 
 the adult, or myxoedema proper; and postoperative myxcedema, or cachexia 
 strumipriva. 
 
 Etiology. — The sporadic form of cretinism is due to the absence of 
 the thyroid or suppression of its function. The endemic form occurs under 
 local conditions associated with goitre, and is encountered in parts of 
 France, Switzerland, and Northern Italy. The myxcedema of adults may 
 develop at any period of life from puberty to seventy. More than half 
 the cases begin between thirty and fifty. The disease is more common in 
 females than in males in the ratio of about 6 to 1. In certain famihes 
 myxcedema has been observed in two generations and there are numerous 
 reports of its occurrence in several members of the same family. With 
 reference to its geographical distribution, it is comparatively common in 
 cold chmates and very rare in the tropics. More cases have been observed 
 in Great Britain and Europe than elsewhere. Many cases have been recog- 
 nized in America. It is uncommon in Philadelphia. The colored races 
 are said not to suffer from the affection. No walk of life is exempt, though 
 it appears to be more common among the poor, a fact probably explained 
 by the relatively larger numbers constituting this class. It is more fre- 
 quent among married women and especially among those who have borne 
 
MYXCEDEMA. 
 
 1175 
 
 children than in others and has been thought to have some relation to the 
 menopause, since many of the cases begin about the age at which the 
 child-bearing function ceases. Occasionally it has followed symptoms 
 of exophthalmic goitre. Postoperative myxoedema follows the total 
 extirpation of the thyroid and the accessory thyroids. The cases of 
 thyroidectomy to which cachexia has not supervened are thought to have 
 been incomplete, an unobserved portion of the gland or accessory thyroids 
 having remained. 
 
 The symptoms of cretinism differ from those of the adult form, 
 but those of the latter and of the postoperative form are identical. 
 
 1. Cretinism. ^ — This affection 
 occurs as a sporadic and as an 
 endemic disease. There is retarda- 
 tion of physical and mental develop- 
 ment. The condition is not usually 
 recognized until toward the end of 
 the first year, but becomes com- 
 pletely developed in the course of 
 the second year. At this time the 
 clinical picture is characteristic. 
 The face is large, round, and bloated; 
 the eyelids are puffy and congested; 
 the nose is flattened and the alse are 
 thickened and coarse; the lips are 
 full and swollen; the tongue is large 
 and protrudes from the mouth. 
 There is constant drooling. The 
 eruption of the teeth is delayed, and 
 they soon become carious. The 
 complexion is pasty and sallow; the 
 expression dull and fatuous. The 
 fontanelles remain open. The belly 
 is protuberant, the hands and feet 
 are clumsy and ill-formed, the legs 
 short, the muscles weak and flabby, 
 and the child is unable to stand or 
 walk. The hair is thin and brittle and the skin dry and harsh. The rectal 
 temperature is commonly subnormal and there is great sensitiveness to 
 cold. The mental condition remains undeveloped. Speech is acquired 
 late and is rudimentary. There are various degrees of idiocy. Older 
 cretins are dull and amiable, not often vicious, and present many of the 
 characteristics of infancy at the age of ten or fifteen years. The fatty 
 tumors seen in the myxosdema of adults are very common. 
 
 Diagnosis. — The direct diagnosis is unattended with difficulty. 
 The facies, the retardation of physical and mental development, the fat 
 pads, and the subnormal temperature are distinctive. 
 
 Differential Diagnosis. — The early cases are sometimes mistaken 
 for rickets. In the latter affection sweating of the head, craniotabes, 
 restlessness at night in the early stages, and special deformities, as the 
 
 Fig. 336. — Cretinism; female, 9 years old. — Rotcli. 
 
1176 
 
 MEDICAL DIAGNOSIS. 
 
 rosary, enlargement of the epiphyses at the wrist and ankles, and bow- 
 legs in the later stages, are characteristic. Juvenile Cretinism. — The forms 
 that begin at the age of five or later in children previously well nourished 
 and healthy, in consequence of atrophic changes in the thyroid following 
 an acute febrile infection, are comparatively rare. Occasional cases of 
 transient mild cretinism are seen in children in the second or third year 
 and may be ascribed to functional derangements of the thyroid. 
 
 2. Myxoedema of Adults; Gull's Disease. — As a rule, the disease 
 develops insidiously; exceptionally in the case of young adults it may be 
 recognizable in the course of a few weeks. Languor, subjective sensations 
 of cold, tardiness of movement, change of expression due to myxoede- 
 matous infiltration of the subcutaneous tissues of the face, and increase in 
 the size and weight of the body are early symptoms. 
 
 The following phenomena are characteristic of the fully developed 
 affection: (a) Dense, inelastic swelling of the skin and subcutaneous 
 
 Fig. 337. — a, adult type of myxoedema. b, six weeks later; a reduction in weight of 20 pounds under 
 thyroid therapy. — Jefferson Hospital. 
 
 tissues, which does not pit upon pressure. This swelHng is general but is 
 most marked in parts where the subcutaneous tissues are loose. It is 
 frequently first noticed in the face, sometimes in the lower extremities 
 and the backs of the hands, (b) A change in the facies due to the swelling, 
 which obhterates the lines of expression. The eyelids are swollen; the 
 upper eyelid tends to droop; the eyebrows are habitually elevated; the 
 forehead is corrugated by deep transverse wrinkles; the nose thickened 
 and enlarged; the cheeks are full, large, sometimes pendulous, and often 
 the seat of a circumscribed, pinkish flush. The lips are thickened and 
 coarse and the mouth appears to be enlarged. Similar changes are seen 
 in the ears and the parts about the angles of the jaw. (c) The hands and 
 fingers are swollen and lose their expressiveness, assuming a thick, flat 
 shape which has been described as "spade-like." Similar changes take 
 place in the feet, (d) A general increase in the size and weight of the 
 body, which may be mistaken for obesity, but which differs from that con- 
 dition in the distribution of the swelling and the texture of the tissues. 
 
MYXCEDEMA. 1177 
 
 (e) Local swellings of the skin and subcutaneous tissues, especially in the 
 supraclaviculai' regions and in the posterior aspect of the neck. The occa- 
 sional occurrence of fibrofatty pads in the retroclavicular spaces in healthy 
 persons is to be borne in mind, (f) Changes in the thyroid gland, which 
 cannot be felt at all or is of uncertain size in many of the cases, distinctly 
 atrophic in others, and normal or increased in size in a very small propor- 
 tion, (g) Dryness and roughness of the skin, thinness and brittleness of 
 the hair, and alopecia which affects not only the scalp but the brows and 
 axillary and pudendal regions. Similar atrophic changes affect the nails, 
 which become cracked and discolored, while the teeth undergo rapid caries 
 and become loose, (h) Subnormal temperature. The range is often con- 
 tinuously a degree or more of Fahrenheit's scale below normal and fre- 
 quently several degrees. Temperatures of 95°-93° F. (35°-34° C.) or even 
 lower have often been observed. Remarkable falls to 77° F. and 66° F. 
 (25°-19° C.) have occurred before death, (i) Muscular weakness and 
 slowness of voluntary movements, (j) Mental changes, especially slowness 
 of apprehension and response, impairment of memory, sensitiveness, and 
 irritability. The speech is tardy and drawling. Hallucinations are com- 
 mon. Fixed delusions may develop, and insanity terminating in dementia 
 occurs. Albuminuria and glycosuria occasionally occur. 
 
 3. Postoperative Myxoedema ; Cachexia Strumipriva. — The symp- 
 toms are those of the common form in adults. 
 
 Diagnosis. — The diagnosis is unattended with difficulty. From renal 
 or cardiorenal dropsy myxoedema is to be differentiated by the character 
 of the oedema, its failure to pit upon pressure, the absence of renal and 
 cardiac lesions, the small thyroid, low temperature, the mental symptoms, 
 and the promptly remedial effect of thyroid extract. From ordinary obesity 
 the diagnosis is readily made. 
 
 Prognosis. — Formerly the outlook was practically hopeless. The 
 patients improved somewhat in warm weather, but became worse as the 
 cooler season approached. The course of the disease was chronic and 
 progressive, sometimes extending over a period of ten or fifteen years. 
 Death was due to intercurrent disease, very often to tuberculosis. At 
 present in a majority of instances the prognosis is favorable. Treatment 
 by thyroid extract causes the symptoms to disappear in a few months, 
 and the continued administration of this remedial principle maintains 
 the improvement. 
 
 4. Hypoparathyreosis; Status Parathyreoprivus. — These terms have 
 been suggested by Halsted to designate degrees of the cachexia caused 
 by the removal of some or all of the parathyroid bodies. It may also be 
 caused by the arrest of the blood supply of those glandules in ligation of 
 the thryoid arteries in partial thyroidectomy. Cachexia thyreopriva in 
 many of the cases has been a complex condition made up of thyroid and 
 parathyroid privation. 
 
 Among the symptoms of cachexia parathyreopriva tetany occupies 
 the first place. This varies in degree from a subtetanic condition to the 
 most violent manifestations of postoperative tetany, often terminating 
 in death. Bleeding, with infusion of salt solution into the veins, the sub- 
 cutaneous or intravenous injection of an extract or emulsion of the para- 
 
1178 MEDICAL DIAGNOSIS. 
 
 thyroid glands, and finally the injection of a nucleoproteid prepared by 
 Beebe from an emulsion of parathyroids, are followed by temporary relief 
 of the tetany in parathyroidectomized animals, and favorable results in 
 human beings have been reported by several observers abroad and by 
 Halsted in one case in this country. Better and lasting results may be 
 confidently expected from the transplantation or implantation of the living 
 parathyroid gland. These glandules appear to play an important part 
 in calcium metabolism, since their removal is followed by an increased 
 excretion of calcium and diminution of the calcium content of the 
 tissues. In dogs suffering from the most violent postoperative tetany, 
 with muscular rigidity, clonic spasm, extremely rapid respiration and 
 pulse, all the symptoms can be instantly dispelled by the injection of a 
 calcium salt, the acetate or lactate, in 0.5 gramme doses, into the jugular 
 vein (MacCallum). 
 
 V. DISEASES OF THE ADRENAL BODIES. 
 
 General Considerations. — The symptomatology of disease of the supra- 
 renal bodies is obscure. Marked lesions of these organs have been found 
 at autopsy in cases in which, during life, no symptoms suggestive of any 
 disease involving them have been observed. In another group of cases 
 tumor, pressure symjDtoms, and lumbar and sacral pain have suggested 
 disease of these bodies. Again metastatic growths in various organs have 
 been ascribed to malignant disease in the suprarenals. Finally, a charac- 
 teristic symptom-complex — Addison's disease — has been found to be asso- 
 ciated in a large proportion of the cases, but not in all, with definite lesions 
 of these organs. 
 
 Addison's Disease. 
 
 Definition. — A constitutional disease, due to modification or cessation 
 of the internal secretion of the adrenal glands in consequence of destruc- 
 tive lesions, usually tuberculous, and characterized by asthenia, gastro- 
 intestinal irritability, and pigmentation of the skin. 
 
 Etiology.— Predisposing Influences. — Addison's disease . is a rare 
 affection. The most common and important predisposing influence is 
 tuberculosis. It is somewhat more common in males than in females. 
 It may occur at any period of life, but less frequently before twenty and 
 after sixty than in the intervening stages. Malaria, alcoholism, depress- 
 ing emotions, exposure, and traumatism have been regarded as causes of 
 this as of many other diseases. In so far as they predispose to tuberculous 
 infection they may act in this way. 
 
 Morbid Anatomy. — Very common are tuberculous deposits with 
 caseous changes. Comparatively rare are atrophy, — either simple or result- 
 ing from chronic interstitial changes, — malignant disease, and interstitial 
 hemorrhage. In a small group of cases the organs have been found normal, 
 but inflammatory or pressure changes have been present in the semilunar 
 ganglia. Cicatricial tissue implicating the semilunar ganglia and adrenals, 
 together with sclerotic and pigmentary changes in the nerves, is not 
 uncommon. The thyroid gland in the absence of cancerous infiltration is 
 
ADDISON'S DISEASE. 
 
 1179 
 
 usually small; the thymous sometimes persistent; the spleen enlarged or 
 the seat of amyloid change. 
 
 Pathology. — Two principal hypotheses have been advanced: 1. That 
 Addison's disease is an affection of the abdominal sympathetic system 
 caused by disease involving the suprarenal bodies, or the solar plexus or 
 semilunar ganglia. 2. That it is the result of loss of the function of the 
 suprarenals. The theory of an internal secre- 
 tion essential to normal metabolism now 
 appears to be fully established. 
 
 Symptoms.^ — The onset is usually insid- 
 ious. Little has been added to the descrip- 
 tion of Addison, — " Anaemia, general languor 
 or debility, remarkable feebleness of the 
 heart's action, irritability of the stomach, 
 and a peculiar change of color in the skin." 
 This description may be somewhat amplified. 
 
 1. Asthenia. — The first symptom is 
 commonly a sense of fatigue in the per- 
 formance of every-day accustomed duties. 
 Fatigue symptoms, at first intermittent, 
 soon become constant. Weakness is both 
 muscular and circulatory. This may be 
 marked, while the muscles still feel firm and 
 the general nutrition and weight are pre- 
 served. The cardiac asthenia may be parox- 
 ysmal and lead to attacks of vertigo or 
 syncope. Headache is common and pain 
 in the loins may be an early and suggestive 
 symptom. 
 
 The examination of the blood has 
 yielded variable results. Anaemia is by no 
 means a constant phenomenon. 
 
 Mental dulness is frequently observed. 
 
 2. Disturbances of the Digestive 
 Organs. — These appear gradually. Ano- 
 rexia, epigastric distress, nausea and vom- 
 iting, and attacks of diarrhoea without 
 obvious cause occur with varying promi- 
 nence in a majority of the cases throughout 
 the course of the disease. In a small proportion of the cases they are 
 absent. Epigastric and abdominal pain are common toward the end. 
 Gastro-intestinal symptoms may occur early. 
 
 3. Pigmentation of the Skin. — Sooner or later a dark pigmentation 
 of the skin appears. In many cases this is the first symptom to attract 
 attention. The pigment accumulation is gradual. The affected portions 
 of the skin are at first yellowish- or grayish-brown and later become brown 
 or even blackish. The discoloration in well-marked cases is diffuse but 
 never uniform. It usually begins in the parts exposed to the light and in 
 those normally the seat of pigment deposits, and is deepest in those areas 
 
 Fig 
 
 338. — Addison's disease; s 
 distribution of bronzing. 
 
1180 MEDICAL DIAGNOSIS. 
 
 and in regions subjected to the habitual pressure of the clothing. The 
 face, backs of the hands, nipples and their areolae, the genitalia, axillary 
 folds, and parts pressed by the waistband, garters, and collar are especially 
 pigmented. There may be diffuse patches of deep discoloration with 
 indistinct borders, or small dark pigment areas with well-defined borders 
 upon a less deeply pigmented surface. Patches of leucoderma are occa- 
 sionally seen. The mucous membranes of the lips and mouth are frequently 
 the seat of an irregular patchy pigmentation. Less commonly a similar 
 discoloration affects the conjunctivae or the vaginal mucosa. The course 
 of the disease is essentially chronic, and marked by normal or subnormal 
 temperature, subjective sensations of cold, suppression of menstruation, 
 and the gradual development of cachexia. Urinary changes are incon- 
 stant. Increased pigments have been observed. Dropsy is rare. Death 
 may occur early in the disease from sudden syncope. More commonly 
 it is the result of progressive asthenia or advancing tuberculous lesions. 
 It is sometimes preceded by acute toxaemic phenomena, urgent vomit- 
 ing and diarrhoea, delirium with motor excitement, and convulsions fol- 
 lowed by coma. 
 
 Diagnosis. — Direct. — A positive diagnosis may be made from the 
 association of the following symptoms: general languor and debility, 
 remarkable feebleness of the heart's action, irritability of the stomach 
 and irregular diarrhoea, a peculiar pigmentation of the skin and mucous 
 membranes. In the early stages the diagnosis may be impossible. It is 
 to be borne in mind that Addison's disease may occur without pigmentation. 
 
 The mere presence of pigmentation does not, however, warrant a 
 diagnosis of Addison's disease. It may occur in the following conditions: 
 physiological peculiarities due to racial and climatic influence; accidental 
 pigmentation of the skin and mucous membranes in persons otherwise 
 healthy; the mild cutaneous pigmentation of aged persons; chronic 
 malaria; various cachectic states, especially those due to cancer and 
 tuberculosis; pellagra; leukaemia; as the result of scratching in various 
 chronic skin diseases attended by itching — prurigo, eczema, phthiriasis; 
 diffuse melanosarcoma of the skin; rare cases of exophthalmic goitre; 
 scleroderma; pregnancy and uterine disease; haemochromatosis such as 
 may occur in rare cases in association with hypertrophic cirrhosis of the 
 liver and diabetes mellitus — diabete bronze; certain cases of pancreatic 
 disease; chronic arsenical poisoning; and argyria. Chronic jaundice has 
 been confounded with the pigmentation of Addison's disease, an error that 
 ought not to occur. Much difficulty attends the recognition of the actual 
 condition when jaundice develops in the course of the disease and is 
 associated with abnormal pigmentation. 
 
 Differential. — In a doubtful case the foregoing conditions must be 
 successively excluded as the cause of pigmentation by the systematic 
 application of the rules of diagnosis, and the presence of asthenia, cardiac 
 weakness, and gastro-intestinal symptoms determined before a positive 
 diagnosis is made. In view of the tuberculous nature of the suprarenal 
 disease in the majority of the cases the tuberculin test may be employed. 
 
 Prognosis. — The disease is probably always fatal. The rare reported 
 recoveries have been ascribed to errors in diagnosis, or the mistaking of a 
 
ACROMEGALY. 1181 
 
 prolonged remission such as sometimes occurs in the very chronic cases for 
 an actual recovery from the disease. Cases unattended by bronzing of 
 the skin are often rapidly fatal. The average duration is about two years. 
 There are exceptional cases of very long duration — ten to thirteen years. 
 
 VI. ACROMEGALY. 
 
 Definition. — A trophic disease characterized by symmetrical over- 
 growth in the soft parts and bones of the face and extremities, with 
 deformities of the spinal column and thorax. 
 
 Etiology. — Predisposing Influences. — It is a disease of early adult 
 life, most of the cases having first shown themselves in the third decade. 
 No case has been noted at an earlier age than twenty, and in only a few 
 has the onset occurred after thirty-five. Males and females are equally 
 liable, with the exception that in cases beginning at a late period more 
 women suffer. The disease is not common but its geographical distribu- 
 tion is wide. Many of those who suffer from acromegaly w^ere persons of 
 previously large growth. 
 
 The EXCITING CAUSE is wholly unknown. The etiological part often 
 assigned to trauma and psychic stress has no basis in fact. Nor can any 
 causal relation between acromegaly and the acute or chronic infections be 
 demonstrated. 
 
 Symptoms. — The disease develops gradually, the early symptoms 
 consisting of lassitude and vague pains, and abnormal sensations — parces- 
 thesice — in the head and extremities. Amenorrhcea and impotence are 
 very common. The characteristic anatomical changes are first noticed in 
 the face. The lines of expression are altered and the countenance is dis- 
 torted. The skull is enlarged; the superciliary ridges are very marked and 
 prominent; the zygomatic arches protrude, and there is remarkable hyper- 
 trophy of the upper and lower jaw bones, the latter projecting in a con- 
 spicuous manner. The alveolar processes are similarly enlarged and the 
 teeth are separated. The soft parts undergo corresponding and even more 
 marked changes. The eyebrows are bushy and thick and almost meet in 
 the median line; the eyelids are greatly thickened; the nose is conspicuously 
 enlarged; the ears are enormously hypertrophied; and the lips swollen. 
 Some degree of exophthalmus is often present and may vary in extent from 
 time to time. Enlargement of the tongue is a very common lesion. This 
 organ attains in some cases such dimensions that it is impossible to close 
 the mouth. Similar and progressively increasing deformities involve the 
 hands and feet, and are rendered especially noticeable by the relatively 
 small size of the arms and legs, which do not share to any marked extent 
 in the enlargement of the extremities. The thickening affects alike the 
 bones and soft parts, and while not greatly interfering with the functions 
 of the hands, causes the remarkable appearance described as spade-like. 
 The nails are broadened but not incurvated and the drum-stick bulbous 
 enlargement of pulmonary osteo-arthropathy is not seen. The feet are 
 generally enlarged, the great toe being especially increased in size. The 
 skin of the affected parts commonly preserves its natural appearance. 
 In some instances, however, it becomes coarse and pigmented. As the 
 
1182 
 
 MEDICAL DIAGNOSIS. 
 
 disease advances the spine becomes affected. There are hyperostoses and 
 exostoses of the vertebral processes, ankylosis of the vertebrae, and kypho- 
 sis. The clavicles are enlarged and there is a gradual enlargement of 
 the ribs. The thyroid body may be atrophied or hypertrophied, but 
 such changes are not constant. There are cases in which the thymus is 
 enlarged. In a very large proportion of autopsies — 73 in 77 — the hypoph- 
 ysis cerebri has been found to be affected. 
 Very often it has been increased in size, some- 
 times to that of an egg. Sometimes the increase 
 is in an upward, sometimes in a downward direc- 
 tion. The histological changes are not constant. 
 Glandular hyperplasia, softening, cystic degenera- 
 tion, and fibrosis are described. Many of the cases 
 have been regarded as malignant. Symptoms 
 suggestive of cerebral tumor, namely, headache, 
 vertigo, somnolence, are not infrequent. Ocular 
 symptoms, bitemporal hemianopia, optic atrophy, 
 and oculomotor palsies occur. The great frequency 
 with which lesions of the hypophysis have been 
 found lends support to the hypothesis that this 
 organ is the source of an internal secretion by 
 which the growth of the body is regulated, and 
 that acromegaly is the result of some vitiation or 
 defect in that secretion. 
 
 Diagnosis. — The direct diagnosis of acromeg- 
 aly is unattended with difficulty. In no other 
 affection do similar anatomical changes in the 
 bones and soft parts occur. The differential 
 diagnosis from gigantism depends ujjon the specific 
 nature of the changes in acromegaly, and the fact 
 that they are for a long time chiefly confined to 
 the face and extremities, the vertebral column 
 and thorax being later involved. It is never- 
 theless true that acromegaly frequently develops 
 in persons of large frame. From the rare cases of 
 progressive overgrowth of one member or a part 
 of it, or of one side of the body, acromegaly is to be distinguished by 
 the fact that the hypertrophies are symmetrical and chiefly confined for 
 a long period to the face and extremities. 
 
 Prognosis. — The disease may run a chronic, progressive course of a 
 score or more of years. There are cases which terminate in death in four 
 or five years. Restoration to normal conditions does not occur. A majority 
 of the cases die of some intercurrent affection, as diabetes, cancer, or 
 croupous pneumonia. 
 
 Fig. 339. — Acromegaly ; 
 diabetes mellitus; in a woman 
 aged 46. — Jefferson Hospital. 
 
MYOCARDITIS. 1183 
 
 XIII. 
 THE DIAGNOSIS OF DISEASES OF THE CIRCULATORY SYSTEM. 
 
 DISEASES OF THE HEART. 
 
 I. ABNORMAL POSITIONS OF THE HEART. 
 
 Congenital displacement is rare. It occurs in general transversus vis- 
 cerum. The apex lies to the right; the right ventricle toward the ante- 
 rior chest wall; the left ventricle behind it; while the pulmonary artery 
 lies at the right border and the aorta at the left border of the sternum. 
 Transposition of the heart alone — dextrocardia — is usually associated with 
 complicated developmental anomalies affecting both the arteries and 
 chambers. The heart is displaced to the left in congenital arrest of de- 
 velopment of the left lung. Children with complete defect of the anterior 
 chest wall and abdomen with protrusion of the heart — ectopia cordis — 
 are usually stillborn or die shortly after birth. When there is merely a 
 fissure of the sternum caused by defective development of the manubrium 
 and body, the heart remains in its normal position and may be studied 
 through the overlying soft tissues. 
 
 Acquired displacements are far more common and of greater diagnostic 
 significance. Sudden death which sometimes occurs in massive pleural 
 effusions has been ascribed to abrupt, angular bending or twisting of the 
 inferior vena cava. The upward displacement of the heart, which occurs 
 in the retraction of the lungs in patients long bed-ridden, or in meteorism, 
 ascites, pregnancy, and large abdominal tumors, may lead to an erroneous 
 diagnosis of dilatation of the heart. The high position of the apex and of 
 the inferior border of the lung are significant. Large subphrenic abscesses 
 displace the heart toward the opposite side and thus increase the resemb- 
 lance to empyema, while a massive spleen, as in leukaemia, displaces the 
 apex upward and outward. 
 
 The displacements of the heart toward the sound side in pleural effu- 
 sions and pneumothorax, and toward the affected side in the contraction 
 of the lung after resorption of a large pleural exudate, or in fibroid phthisis, 
 are too familiar to lead to diagnostic errors. The fact that the displaced 
 heart, in consequence of adhesions, occasionally remains upon the sound 
 side is less generally understood. In pulmonary emphysema the disloca- 
 tion of the heart is downward. Aneurisms of the ascending and transverse 
 portions of the arch of the aorta displace the heart downward and toward 
 the left. 
 
 II. DISEASES OF THE MYOCARDIUM, 
 i. Acute Myocarditis. 
 
 Definition. — Acute inflammation of the wall of the heart. Patho- 
 logically parenchymatous and interstitial forms are recognized. There is 
 cell infiltration of the interstitial tissue, associated with granular, fatty, 
 
1184 MEDICAL DIAGNOSIS. 
 
 and hyaline degeneration of the muscle fibres, and loss o'i their contractile 
 elements. There are three varieties: 1. Primary Acute Myocarditis. — 
 In the absence of any recognized cause, or after a wetting, the symptoms 
 of an acute interstitial inflammation of the myocardium develop with 
 irregular fever and great weakness, and after a course of several days 
 or a week or two terminate in death. Primary acute myocarditis is 
 an exceedingly rare affection, the occurrence of which as a separate 
 disease has been questioned. 2. Secondary Acute Myocarditis. — 
 This variety occurs in the course of or during the convalescence from 
 many of the specific infectious diseases. 3. Acute Septic Myocarditis. 
 — In a majority of the cases infection of the myocardium takes place 
 by way of the coronary arteries. There are commonly multiple miliary 
 abscesses. In other instances abscess formation follows the direct inva- 
 sion of the heart muscles from the valvular or mural lesions of a septic 
 endocarditis. 
 
 Etiology. — Predisposing Influences. — These are wholly unknown. 
 No plausible explanation of the fact that the myocardium suffers in some 
 cases of infectious disease and sepsis, and escapes in others, has yet been 
 adduced. There is nothing in age, sex, or previous health to account for 
 this difference. Acute secondary myocarditis occurs in diphtheria, enteric 
 and typhus fevers, scarlet fever, rheumatic fever, variola, and gonorrhoea! 
 infection. It is especially frequent in association with diphtheria. The 
 septic form is less common. 
 
 Exciting Cause. — The primary form has followed cold and exposure 
 and traumatism to the left chest. The local action of specific toxins, the 
 arrest of minute infected emboli in the branches of the coronary arteries, 
 and direct bacterial invasion from the endocardium are the immediate 
 causes of the myocardial inflammation. 
 
 Symptoms.^ — The clinical manifestations are usualh^ obscured by those 
 of the primary affection. Profound cardiac asthenia manifests itself by 
 feeble heart sounds, a scarcely perceptible radial pulse, arrhythmia, and 
 acute dilatation. Sudden increase of pallor, apathy, somnolence, and pre- 
 cordial distress occur. Vomiting is common and sometimes urgent. In 
 some cases there is restlessness and agitation; in others subjective sensa- 
 tions are absent and the gravity of the complication reveals itself only by 
 the objective manifestations. 
 
 Diagnosis. — Direct. — The diagnosis must, in a majority of the cases, 
 be a provisional one. Only in the light of later events, often at a remote 
 period in cases that have recovered, can the cause of the grave cardiac 
 symptoms during the acute attack be recognized. The symptoms of chronic 
 myocardial changes in an individual who has passed through a grave attack 
 of one of the febrile infections are significant. 
 
 Differential. — The intensity of the process varies. The average 
 cases are to be differentiated from the acute cardiac asthenia of influenza 
 by the rapidity with which the latter develops and the peculiar psychic 
 manifestations with which it is so frequently associated; from acute cardiac 
 exhaustion from overwork or athletic excesses by the history of the case ; 
 and from all of these by their occurrence in the absence of especial exposure 
 to wet and cold, or of an acute infection, or of sepsis. 
 
MYOCARDITIS. 1185 
 
 Prognosis. — The outlook depends largely upon that of the primary 
 disease, to which the complication adds additional gravity. In diphtheria 
 it is extremely grave; in gonorrhceal infection scarcely less so. In rheu- 
 matic fever it is more favorable, and in that form which occurs in the con- 
 valescence from enteric fever and scarlatina recovery is the rule. The 
 prognosis in the septic cases is unfavorable. The danger of sudden death, 
 even in cases in which the symptoms are of moderate grade, is always to 
 be considered. It is probable that the sudden death which occasionally 
 occurs in the late convalescence of croupous pneumonia is due to acute 
 myocarditis. 
 
 ii. Chronic Myocarditis. 
 
 Chronic Insufficiency of the Heart Muscle; Myodegeneratio Cordis. 
 
 Definition. — Chronic inflammation of the heart muscle, characterized 
 anatomically by round-celled infiltration of the interstitial connective 
 tissue, followed by fibrosis and parenchymatous degeneration of the mus- 
 cular fibres, and clinically by impairment of the function of the heart. 
 
 Etiology. — Predisposing Influences. — Chronic myocarditis in its 
 simplest form is a late manifestation of acute myocarditis in cases that 
 survive. From this point of view the acute infections constitute pre- 
 disposing influences of great importance. It is especially common after 
 rheumatic fever, occurring occasionally in cases without valvular disease, 
 and being, to some extent at least, a constant accompaniment of chronic 
 valvular disease. It often has its beginning in extensive pericardial ad- 
 hesions. It may follow diphtheria, enteric fever, variola, scarlet fever, 
 gonorrhoea, and the septic cases in which recovery as to the general condi- 
 tion takes place. Chronic myocarditis very rarely has its origin in the 
 lesions of syphilis. It is met with in chronic alcoholism and in saturnine 
 intoxication. Arteriosclerosis, gout, and chronic renal disease especially 
 predispose to this form of myocarditis. Habitual overstrain of the heart, 
 such as occurs in athletes and those who follow laborious occupations, as 
 stevedores, iron workers, coal passers, and the like, is a predisposing influ- 
 ence of great importance; nor can we overlook the part played by pro- 
 longed mental stress and depressing emotions. When to any of the fore- 
 going factors are added improper and insufficient food, on the one hand, 
 or, on the other hand, a sedentary life and habitual overeating, the danger 
 of mj^ocarditis is greatly increased. 
 
 In the great majority of the cases the symptoms first appear after the 
 fortieth year. They may occur at a much earlier period. The insufficiency 
 of the heart following the acute infections with or without valvular disease 
 is due to myocardial lesions. The average age of first manifestations in the 
 adult is later in women than in' men. Men suffer more commonly than 
 women, a fact in harmony with the different modes of living in the sexes 
 in early and middle adult life. Several active predisposing influences are 
 frequently present in the same case. 
 
 Exciting Cause. — The immediate causes are, (1) a disproportion 
 between the power of the heart and the work which it is called upon to 
 perform, (2) infectious, and (3) toxic. These may be active in various 
 
 75 
 
1186 MEDICAL DIAGNOSIS. 
 
 combinations. It is not always possible to determine the actual cause 
 or even to ascertain that which predominates. 
 
 Symptoms. — The clinical picture is a variable one. Its fundamental 
 characters depend upon a single pathological condition, namely, cardiac 
 inadequacy. The want of power varies in degree. It may be shght and 
 only manifest upon unusual effort, or so great that the circulation fails to 
 meet the ordinary needs of the organism at rest. An early and an advanced 
 stage have been described. This division is misleading, since the disease 
 is not always progressive, and there are cases in which the early stage is 
 absent or the advance of the disease so rapid that the beginnings are not 
 recognized, and cases in which periods of improvement occur, and, finally, 
 a small proportion of cases in which, after a time, an actual recovery takes 
 place. According as the grade of the fibrosis and degeneration and their 
 extent vary, so varies the intensity of the symptoms. Furthermore, the 
 range of symptoms varies according to the anatomical and physiological 
 peculiarities of the individual, the integrity of his organs, and condition of 
 his nervous system. 
 
 In the beginning the attention of the patient is aroused by subjective 
 symptoms, as palpitation, precordial distress, or pain and oppression induced 
 by physical or mental effort. In another group of cases, after repeated 
 mild attacks of angina or a single severe attack, the general symptoms of 
 cardiac insufficiency develop. Moderate effort, the daily work, mounting 
 stairs, cHmbing a gentle ascent, a generous meal, cause oppression and 
 shortness of breath. Presently in many cases a moderate dyspnoea persists. 
 Epigastric weight, loss of appetite, constipation or diarrhoea, and slight 
 pretibial oedema mark an advance in the progress of the malady. Loss 
 of strength, anaemia, emaciation, dizziness, and syncopal attacks may now 
 occur. The grave symptoms consist of continuous dyspnoea of greater in- 
 tensity and interrupted by asthmatic attacks, icterus, ohguria, albuminuria, 
 increasing oedema, and effusions into the serous sacs. The pallor becomes 
 more marked, and cyanosis varying in degree appears around the lips and 
 at the finger-tips. The nervous symptoms are intensified. Palpitation, pre- 
 cordial pain, and oppression may be continuous or recur in alarming par- 
 oxysms. Complications are frequent and in many cases terminal. The 
 more common are bronchitis and bronchopneumonia. Less frequent are 
 inflammations of the serous membranes, pleurisy, pericarditis, and peri- 
 tonitis. At any period in the course of the disease blood-stained sputa may 
 be noted. 
 
 Physical Signs. — Early in the disease the signs of moderate dilatation 
 of the left ventricle and, to a less extent, of the right ventricle are apparent. 
 In many of the cases, however, and especially in those in which the signs 
 of valvular disease are absent, and those characterized by angina pectoris, 
 the heart is not enlarged. With improvement in the general symptoms, 
 the early dilatation of the heart usually disappears. The sounds may be 
 for a long time normal. In some cases the first sound is accompanied by a 
 faint inconstant murmur and the second pulmonary is accentuated; or 
 again a mitral systolic murmur, sometimes indistinct and soft, sometimes 
 loud and well marked, accompanies or replaces the first sound — the murmur 
 of muscular mitral insufficiency. This murmur sometimes has a musical 
 
MYOCARDITIS. 1187 
 
 quality. Other murmurs are not common in the milder cases of myocar- 
 ditis. In the graver cases dihatation to the left and upward, and usually 
 toward the right, is almost constant. The transverse dulness is increased 
 and the ajoex beat displaced to the left and slightly upward. The enlarge- 
 ment of the heart frequently increases and diminishes in accordance with 
 the varying intensity of the symptoms, but a return of the heart to its 
 normal size is no longer to be hoped for. Upon auscultation the increased 
 muscular insufficiency is manifest in a well-characterized mitral systolic 
 murmur, which after a time is associated with a tricuspid systolic murmur. 
 Very rarely a faint aortic diastolic murmur may be recognized. These 
 murmurs in many cases undergo rapid changes, corresponding to the degree 
 of dilatation with the gain or loss in the power of the heart, and sometimes 
 wholly disappear. In other cases they are persistent, and, when associated 
 with hypertrophy, as in chronic nephritis, they cannot always be differenti- 
 ated from the murmurs of organic valvular disease. 
 
 The pulse is usually weak and small. Sometimes, especially in the 
 form of chronic myocarditis associated with interstitial nephritis, it shows 
 increased tension. Its frequency is much increased by moderate exertion. 
 In a majority of the milder cases arrhythmia does not occur; exceptionally 
 it is an early sign. In a small proportion of the cases the pulse is slow. 
 As the insufficiency becomes more marked the pulse-frequency augments 
 and arrhythmia appears. The latter is often of high grade, both as to the 
 time of the beats and as to their force. The inequality of the ventricular 
 contractions is such that many of them fail to transmit the pulse-wave 
 to the radials, so that the pulse counted at the wrist is less frequent than 
 the impulse counted at the apex. 
 
 The following forms demand separate consideration: The Inflam- 
 matory Form. — The symptoms are those already described. The affec- 
 tion occurs as a later stage of acute myocarditis, showing itself in some 
 instances during the convalescence from the primary disease; in others 
 not until a remote period. There are cases in which recovery takes place. 
 In this connection it is to be noted that fibroid degeneration is sometimes: 
 the reparative process by which destructive lesions are corrected. The; 
 Form Due to Diseases of the Coronary Arteries. — Sclerosis of the 
 Coronary Arteries. — The lesion consists chiefly of a thickening of the intima. 
 It is either diffuse or circumscribed, and leads to narrowing of the lumen 
 of the affected vascular twigs. The left coronary artery and its branches 
 are involved much more commonly and to a greater extent than the right. 
 When the narrowing of the lumen is of high grade, or there is complete 
 occlusion of the affected vessels, infarction of the heart muscle — myomalacia 
 cordis (Ziegler) — occurs. The necrotic focus is invaded by connective- 
 tissue elements and converted into a fibroid cicatrix. There may be a 
 diffuse increase of the interstitial tissue. This variety of chronic myocar- 
 ditis presents symptoms of muscular insufficiency, but is especially char- 
 acterized by a tendency to angina pectoris and so-called cardiac asthma, 
 a special liability to precordial pain, and the signs of narrowing of the 
 aortic orifice. In fact, arteriosclerosis of the coronary arteries is very 
 commonly associated with similar pathological changes in the aortic valves 
 and the beginning of the vessel itself. A systolic aortic murmur, usually 
 
1188 MEDICAL DIAGNOSIS. 
 
 not so loud and coarse nor beginning so promptly with the systole as in 
 pure valvular stenosis, and followed by a well-marked, even accentuated, 
 second sound, is usually heard. Dulness to the right of the sternum in the 
 second and third interspaces and jugular pulsation are associated signs. 
 Embolism and Thrombosis of the Coronary Arteries. — These lesions cause 
 myocardial infarct. Thrombosis may result from sclerosis; embolism 
 from various forms of infection, or very rarely from fragments of athero- 
 matous plates. Death directly follows the closure of the coronary artery 
 at its origin. Elsewhere the occlusion of the artery is follow^ed by infarc- 
 tion and death after several days or, in rare cases in which the extent of 
 the softening is limited, by recovery. The local necrosis may lead to rup- 
 ture of the heart. The changes in the heart muscle depend upon the extent 
 and degree of the sclerosis and the rapidity with which the blood supply 
 to the muscle is arrested. 
 
 Carotid 
 
 Cardiac Aj> ex' ^^^^-^^ 
 
 .►. h h h h r; h >v T' " ^ f > ■''' ' ^ ■' r. :t h ^ K h -h ti__''_'u_j*\ .^ !l ll \-i-—i'. — h — h_A_h — h__/i._.>u_n — .\_J'_'i 
 
 Tiwie ^^TO" ■ ^^ 
 
 Fig 340 — ^Tracing of the carotid arterv and cardiac apex in chronic myocarditis showing irregularity in 
 time' and in force. * Ventricular contraction not of sufficient strength to produce a distinct carotid wave. 
 
 General Arteriosclerosis in Chronic Myocarditis. — Habitual 
 increase in the arterial blood-pressure is an important cause of chronic 
 myocarditis. Prolonged muscular exertion, toxic substances, and arterio- 
 sclerosis alone or associated with chronic disease of the kidneys are potent 
 factors. The changes in the myocardium develop gi-aduahy, and the symp- 
 toms and course of the disease are not different from those of the ordinary 
 form. Middle-aged men who have lived well suffer from this form and the 
 early symptoms in such cases are usually abdominal— fulness, weight, 
 flatulence, and constipation. 
 
 Syphilis of the Heart. — Single or multiple gummata are very rare. 
 Diffuse interstitial myocarditis is more common. SyphiHs of the heart 
 may be congenital or acquired. In the acquired form it is usually a tertiary 
 maiaifestation. The condition is very often latent, but when well developed 
 it corresponds cUnically to the ordinary form of chronic myocarditis. 
 
 Nutritional Disorders and Chronic Myocarditis. — The myo- 
 cardium suffers in the same way as the skeletal muscles. Previously 
 existing myocarditis constitutes an important predisposing influence. 
 The cardiac insufficiency may show itself in the morning when the duties 
 of the day are undertaken after an insuflicient breakfast. Free purgation 
 
MYOCARDITIS. 1189 
 
 may cause symptoms. A too strict antidiabetic diet and the injudicious 
 treatment of obesity are to be considered. This form of cardiac inadequacy 
 is common in the gouty, partly because of anomalous metabolism, partly 
 because of insufficient food, and often as the result of an unwise use of col- 
 chicum or other drugs. To this category must also be referred the feeble 
 heart of anaemia and chlorosis, together with the atrophy of the heart in 
 the acute febrile infections, tuberculosis, and starvation. Long recumbency, 
 as in illness or those who from other causes are bed-ridden, leads to gradual 
 heart starvation. The symptoms are those of cardiac dilatation, dyspnoea 
 upon exertion, gastrohepatic distress, oedema of the lower extremities, 
 and general asthenia. 
 
 Diagnosis. — Direct. — Objective phenomena dependent upon changes 
 in the heart upon which to base a diagnosis are usually absent. The anam- 
 nesis and the cardinal condition of weakness of the heart, as manifest by 
 rational symptoms, justify a provisional diagnosis. A positive diagnosis 
 may be reached by the method of exclusion. In a considerable proportion 
 it cannot be reached at all. 
 
 In the anamnesis the age of the patient, his mode of life, the history 
 of antecedent disease are important. The present condition of the super- 
 ficial arteries, the blood-pressure, the ophthalmoscopic evidences of changes 
 in the walls of the retinal arteries, the specific gravity of the urine and the 
 presence or absence of albumin, tophaceous deposits in the ears or around 
 the small joints, and the occurrence of asthma-like seizures, precordial 
 pain, and angina pectoris are all to be carefully investigated. Dyspnoea, 
 precordial and abdominal distress, diminution in the urine, and oedema 
 are most significant symptoms; feebleness of the heart sounds, a weak or 
 undiscoverable impulse, a faint or inconstant mitral systolic murmur are 
 signs of importance. A marked increase in the pulse-frequency upon slight 
 exertion is very suggestive. 
 
 The diagnosis of sclerosis of the coronary arteries may be made when, 
 in a person of middle age presenting the signs of sclerosis of the aortic 
 valves or atheroma of the ascending aorta, attacks of paroxysmal dyspnoea 
 or angina pectoris occur in connection with the manifestations of cardiac 
 inadequacy. The diagnosis of coronary embolism and thrombosis is usually 
 impossible. These conditions frequently arise in advanced cases without 
 any chnical manifestation whatever. The evidences of general arterio- 
 sclerosis in a case characterized by the signs of great and persistent cardiac 
 weakness are of diagnostic importance. The symptoms of chronic nephritis, ' 
 and, in particular, of contracted kidney, are also significant. Finally, tran- 
 sient attacks of increased cardiac asthenia in persons improperly nourished, 
 overworked, much torn by the stress of life, or suffering from acute or 
 chronic disease, are very often the manifestations of heart starvation. 
 
 Differential. — The Cardiac Neuroses. — The differential diagnosis is 
 rendered uncertain, especially in the early cases of chronic myocarditis, 
 by the fact that the murmurs and especially neurasthenic symptoms are 
 very common in myocarditis. A history of accidental or surgical trauma, 
 overwork, anxiety, grief, onanism, sexual excess, hysteria, speak for a 
 cardiac neurosis. The age of the patient is of some value in diagnosis. 
 Under forty the neuroses are more common; after forty myocarditis. 
 
1190 MEDICAL DIAGNOSIS. 
 
 Chronic Valvular Disease. — Here also the frequent association of the two 
 conditions gives rise to nice problems in differential diagnosis. The difficulty 
 relates usually to mitral insufficiency. The question concerns the nature 
 of the cardiac insufficiency. Is it valvular or muscular? A systolic murmur, 
 accentuation of the second pulmonary sound, and cardiac dilatation occur 
 in both conditions. Hypertrophy of the left ventricle and a strong impulse 
 are in favor of valvular disease. These conditions may be absent in moder- 
 ate mitral insufficiency, or the hypertrophy may be due to renal disease or 
 adherent pericardium, or again the impulse may be obscured in emphysema. 
 Under these circumstances a history of rheumatic fever, or the infrequency 
 of myocarditis in childhood, or of uncombined mitral insufficiency in the 
 aged is to be considered. Furthermore the murmur of muscular insuffi- 
 ciency is changeable and may wholly disappear with improvement of the 
 condition of the myocardium under rest and treatment. In fact the out- 
 come of a reasonable management of the case is of diagnostic value, since 
 interstitial changes and parenchymatous degeneration are usually pro- 
 gressive and ultimately give rise to symptoms that cannot be misunderstood. 
 Prognosis. — Chronic myocarditis can scarcely be said to end in recov- 
 ery. Circumscribed lesions may be repaired by the development of fibroid 
 tissue. As a rule the outlook is absolutely unfavorable. Much depends 
 upon the circumstances of the patient and his ability to bring himself under 
 discipline. The sooner this is done and the slighter the lesions, the better 
 the outlook. Sometimes improvement and the postponement of the lethal 
 disaster occur in the most alarming cases. 
 
 iii. Hypertrophy and Dilatation. 
 
 (a) HYPERTROPHY OF THE HEART. 
 
 Definition. — An anatomical condition characterized by an over- 
 growth of the myocardium. A single chamber may be involved, or one 
 side, or the whole heart. The left ventricle is most commonly affected. 
 
 The wall may be thickened without enlargement of the chamber, or 
 the chamber may be dilated, — eccentric hypertrophy; combined hypertrophy 
 and dilatation, — and this is by far the most common form. Thickening of 
 the walls with diminished capacity of the chambers may be simulated by 
 post-mortem conditions — so-called concentric hypertrophy. 
 
 Etiology. — The work of the heart is increased but the nutrition of its 
 wall is maintained, (a) In its simplest form hypertrophy is caused by 
 habitual excessive muscular exertion. It is not possible to say when phys- 
 iological increase passes over to actual hypertrophy. The heart of the iron 
 worker is much larger than that of the clerk. Muscular work increases 
 blood-pressure. General arteriosclerosis, particularly that form associated 
 with chronic nephritis, toxic substances, as lead, alcohol, and the poisons 
 of gout, increases the arterial tension and is a common cause of hypertrophy, 
 (b) The freedom of the movements of the heart is hampered by extensive 
 pericardial adhesions, by local or general interstitial myocarditis, and by 
 the neuroses which give rise to cardiac overaction, especially exophthalmic 
 goitre, tachycardia, and those resulting from the abuse of various stimulants 
 
HYPERTROPHY AND DILATATION. 1191 
 
 and narcotics, especially tea and coffee. The heart works at a disadvantage 
 and if its nutrition remains fairly good undergoes hypertrophy, (c) The 
 amount of blood which the heart has to propel is increased in aortic and 
 mitral insufficiency, since with every revolution of the heart a given quan- 
 tity of blood passes to and fro through the affected orifice like a shuttle- 
 cock and demands a proportionate increase in cardiac power to maintain 
 the equihbrium of the circulation. Habitual excesses at table and, in 
 particular, the consumption of enormous quantities of beer, have been 
 shown to give rise to cardiac hypertrophy, (d) Resistance to the free out- 
 flow of blood caused by narrowing of an orifice causes hypertrophy of the 
 wall of the affected chamber, as the left ventricle in aortic stenosis, the 
 left auricle in mitral stenosis and lesions of the pulmonary valve. Con- 
 genital narrowing of the aorta or of the arterial system in general is another 
 cause of hypertrophy. 
 
 The various conditions which primarily or chiefly cause hypertrophy 
 of the left ventricle ultimately cause also hypertrophy of the right ventricle. 
 Hypertrophy of the right ventricle arises also in other conditions which 
 increase the resistance in the pulmonary vessels, such as emphysema, 
 fibrosis of the lungs, and deformities of the chest. The left auricle under- 
 goes dilatation with hypertrophy in mitral disease, especially stenosis; 
 the right in conditions characterized by increased blood-pressure in the 
 pulmonary circuit, both of valvular and of pulmonary origin. 
 
 Enormous enlargement of the heart — cor hovinum — is usually due to 
 aortic insufficiency, chronic mediastinitis, or chronic interstitial nephritis. 
 
 Hypertrophy of the heart is essentially a conservative process. Its 
 development is gradual and for a time keeps pace with the advance of the 
 lesions with which it is associated. So long as the equilibrium of the cir- 
 culation is maintained, the hypertrophy is compensatory; when the hyper- 
 trophy begins to fail, the compensation is impaired; when dilatation is 
 marked and cardiac insufficiency is extreme, the compensation is said to 
 be ruptured or broken. , 
 
 Moderate hypertrophy is unattended by marked direct symptoms. 
 In fact it prevents to a great extent the manifestations of the underlying 
 disease. Sensations of fulness, aggravated when lying upon the left side, 
 easily induced overaction, and the consciousness of precordial pulsation or 
 throbbing in the neck or head sometimes occur in advanced cases. 
 
 The physical signs depend upon the degree of hypertrophy and its 
 preponderance over the accompanying dilatation, and the extent to which 
 the heart is covered by the overlying borders of the lungs. When the 
 hypertrophy is advanced and dilatation yet subordinated to it, the diagnosis 
 may be readily made. Upon inspection the impulse is strong and extended 
 to the left and downward. In marked enlargement it is heaving, and the 
 whole precordial area may pulsate. There is pulsation at the root of the 
 neck. A visible pulsation in the epigastrium occurs in hypertrophy of the 
 right ventricle. Palpation confirms the signs obtained by inspection, and 
 in women with large mammae may enable the examiner to ascertain the 
 position of the apex when inspection and percussion are ineffectual. The 
 radial pulse is full, strong, and rather slow. Upon percussion the areas 
 of relative and absolute dulness are usually both increased; in large- 
 
1192 MEDICAL DIAGNOSIS. 
 
 lunged persons and cases of emphysema, the relative dulness only. Exten- 
 sion of deep dulness to the left and upward is a sign of hypertrophy of the 
 left ventricle; to the right and downward a sign of hypertrophy of the right 
 ventricle. Upon auscultation the first sound is loud, often booming and 
 prolonged; the second aortic sound accentuated in left ventricle hyper- 
 trophy, the second pulmonary accentuated when the right ventricle is 
 involved. Accentuation of the second aortic occurs, however, in those 
 conditions of high tension of the systemic arteries which cause left ventricle 
 hypertrophy, and accentuation of the second pulmonary in those which 
 interfere with the normal flow of blood through the pulmonary vessels. 
 
 (b) DILATATION OF THE HEART. 
 
 Definition. — Dilatation of the heart is an anatomical condition, char- 
 acterized by an increase in the size of its chambers due to stretching of its 
 walls. Dilatation may affect one or more chambers of the heart. It may 
 be acute or chronic. Acute dilatation is usually primary; chronic dilata- 
 tion secondary to cardiac insufficiency or valvular disease. A previously 
 ■diseased heart is more liable to acute dilatation than a normal heart. 
 
 The capacity of the chambers of the heart varies considerably within 
 normal limits. Pathological enlargement — dilatation — exists when the 
 affected cha,mber is unable to empty itself of blood in systole, and is per- 
 manent. The myocardium, like other muscles, increases within certain 
 limits with use, especially if the increase in work is gradual and nutrition 
 is maintained. 
 
 Etiology. — Dilatation results from a disproportion between the power 
 of the heart muscle and the work which it has to do. In other words, the 
 pressure within the chambers may be increased or the muscular wall may 
 be weakened. These factors may act singly or in combination. Increased 
 pressure arises when there is an abnormal quantity of blood to be propelled 
 or an abnormal resistance to be overcome. Under certain conditions, as 
 in the gradually developing sclerotic form of aortic stenosis, and in the 
 cardiovascular changes of chronic nephritis, the left ventricle may not 
 undergo dilatation but hypertrophy. 
 
 Severe and prolonged muscular effort is a common cause of acute 
 dilatation, as in mountain climbing or prolonged tests of endurance. The 
 condition is known as heart strain. The symptoms are breathlessness 
 upon exertion, cyanosis, lassitude, mental depression, and swelling of the 
 ankles; the signs feebleness of the cardiac impulse, small, rapid, irregular 
 and intermittent pulse, faint heart sounds, and upon percussion the evi- 
 dences of enlargement of both the superficial and deep areas of dulness, 
 increase in the area of liver dulness, and hypostatic congestion of the lungs. 
 Relative insufficiency is shown by the development of a mitral systolic 
 murmur, and the safety valve function of the tricuspid by a systolic murmur 
 at the lower border of the sternum to the right. Under appropriate treat- 
 ment, into which rest in the recumbent posture largely enters, gradual 
 recovery takes place with disappearance of the signs of dilatation. In 
 many cases they recur upon further unusual effort, and in some the damage 
 to the wall of the heart is permanent. Acute dilatation occurs also in 
 
FATTY HEART. 1193 
 
 consequence of undue effort after acute illness, in Graves's disease, exoph- 
 thalmic goitre, and paroxysmal tachycardia. It may follow any unusual 
 effort in a case of chronic myocarditis. 
 
 The ultimate tendency of chronic myocarditis is to dilatation. In 
 many forms the increase in the size of the chambers and stretching of the 
 walls begin early; in others not until after an initial hypertrophy. The 
 symptoms are those of cardiac insufficiency; the signs those of enlarge- 
 ment of the heart, displacement of the apex to the left and downward, 
 feeble, undulating impulse extending over several intercostal spaces, and 
 faint cardiac sounds reverting to the fetal type. Dropsy and the evidences 
 of visceral congestion are present in well-marked cases. 
 
 Valvular disease is a constant cause of dilatation of the heart. In 
 stenosis a portion of the normal quantity of blood that should pass the 
 affected orifice is held back in systole; in incompetency a portion of the 
 quantity that has passed the orifice flows back in diastole. In one case the 
 blood entering the chamber meets blood that should have passed on; in 
 the other blood enters the chamber in diastole from two opposite directions, 
 one physiological, the other pathological. The result is dilatation of the 
 affected chamber and transference of the increased blood-pressure back- 
 ward from the site of the valvular lesion, from ventricle to auricle on the 
 left side, through the pulmonary circuit, to ventricle and then to auricle on 
 the right. 
 
 Hypertrophy at first, then dilatation of the left ventricle thus results 
 from aortic stenosis and from aortic insufficiency; hypertrophy and dila- 
 tation of the left auricle from mitral stenosis and mitral insufficiency; 
 pulmonary hypersemia from either stenosis or insufficiency of the aortic 
 or mitral valve systems; hypertrophy and dilatation of the right ventricle 
 from pulmonary hypersemia due to valvular disease of the left side of the 
 heart, or to intrapulmonary conditions which increase the resistance in the 
 pulmonary circuit; hypertrophy and dilatation of the right auricle from 
 overdistention of the right ventricle. 
 
 Whenever dilatation is in excess of h5^pertrophy there is a tendency 
 to the transference of blood-pressure from the arterial to the venous side 
 of the circulation. 
 
 When the myocardium is weakened by, (a) the toxins of the acute 
 infections, (b) the extension of the inflammation in endocarditis or peri- 
 carditis, (c) the malnutrition of starvation in any form, anaemia, or chloro- 
 sis, dilatation may result in the absence of increase in the blood-pressure. 
 
 iv. Fatty Heart. 
 
 Fatty Overgrowth; Fatty Infiltration; Cardiac Inadequacy of the Obese; 
 
 Cor Adiposum. 
 
 Definition. — A condition common in fat persons, characterized 
 anatomically by excess of fat beneath the epicardium and among the 
 strands of muscular fibres, and clinically by cardiac insufficiency. 
 
 It has been customary to include, under the designation fatty heart, 
 fatty degeneration of the heart muscle and fat overgrowth or infiltration. 
 
1194 MEDICAL DIAGNOSIS. 
 
 The present tendency, however, is to restrict the term to the peculiar 
 changes that occur in corpulent persons, since fatty degeneration is 
 a common form of parenchymatous degeneration in myocarditis due 
 to many different causes, and wholly without distinctive etiological or 
 clinical features. 
 
 Fatty degeneration of the heart is common in the infectious fevers, 
 wasting diseases, and the cachexias. It is very marked in acute yellow 
 atrophy of the Hver, phosphorus poisoning, and pernicious anaemia. It 
 constitutes one of the most important changes of old age. The degenera- 
 tion may also under all these conditions affect the various viscera. The 
 wall of the heart may be locally or generally involved. The heart muscle 
 is flabby, relaxed, and friable. The color is that of the ''faded leaf." The 
 heart when thrown upon the table sinks into a shapeless mass. Micro- 
 scopically the fibres are filled with minute fat globules. 
 
 The condition under consideration is entirely different. It is essen- 
 tially an affection of the corpulent. There is an excess of the subperi- 
 cardial fat, so great in some instances as to wholly envelop the muscle in 
 a casing of fat. It is usually more abundant in the intraventricular 
 grooves, along the course of the coronary arteries, and upon the wall of the 
 right ventricle. It penetrates the muscles, separating the fibres, and may 
 extend to the endocardium. The heart is dilated and its wall flabby and 
 relaxed. Upon microscopical examination the muscular fibres are found 
 to be atrophied and in some instances to have undergone fatty degenera- 
 tion. There is a disproportion between the size of the heart and the re- 
 quirements of the body. In many fat persons with well-developed muscles 
 cardiac insufficiency does not occur. Cardiac symptoms are marked in 
 that type of obesity characterized by anaemia, flabby muscles, and indolence. 
 Etiology. — The causes of fatty infiltration of the heart are those of 
 the obesity of which it constitutes such an important part. The middle 
 periods of life, the male sex, heredity, addiction to the pleasures of the table, 
 much fluid, malt liquors and alcohol in general, luxurious habits, and indo- 
 lence are potent factors in the production of corpulence and the fatty heart. 
 Symptoms. — The cHnical manifestations are those of cardiac inade- 
 quacy, dyspnoea, a feeble pulse, much accelerated upon effort and com- 
 monly intermittent and irregular. Poor appetite, much thirst, and 
 constipation are common. Such patients are often drowsy by day and 
 sleepless by night. Dropsy of the lower extremities is sometimes marked. 
 Physical Signs. — The methods of physical examination usually yield 
 unsatisfactory results by reason of the excess of subcutaneous fat. This is 
 particularly true of inspection, palpation, and percussion. The results of 
 auscultation are sometimes more satisfactory. The heart sounds are usually 
 feeble and distant. When, however, they are well defined and the aortic 
 sound distinct, they may be regarded as indicating fairly well-maintained 
 myocardial nutrition. When, on the other hand, the first sound is extremely 
 faint or replaced by a systolic murmur, the aortic sound feeble, and the 
 pulmonic sound accentuated though feeble, the integrity of the heart muscle 
 is greatly impaired. 
 
 Diagnosis. — The recognition of fatty heart depends upon the associa- 
 tion of cardiac insufficiency with obesity. 
 
RUPTURE OF THE HEART. 1195 
 
 The DIFFERENTIAL DIAGNOSIS between this condition and the primary 
 anaemias, especially chlorosis and pernicious anaemia, may be made by a 
 proper blood examination. The blood of corpulent persons of the pallid 
 type who suffer from fatty heart may show the characters of a more or 
 less marked secondary anaemia, but not, in the absence of specific lesions, 
 the characters of the primary anaemias. 
 
 Prognosis. — The outlook in general is unfavorable and is rendered 
 more so by unwise attempts to reduce the weight of the body by insufficient 
 food, unduly increased exercise, exhausting baths, or depressing drugs. 
 Thickened arteries, paroxysmal dyspnoea, and angina pectoris are of 
 ominous significance. 
 
 V. Various Degenerations, New Growths, and Parasites 
 
 of the Heart. 
 
 Degenerations of the heart muscle not already considered ara amy- 
 loid degeneration, the hyaline transformation of Zenker, and calcareous 
 infiltration. None of these is recognizable during, life nor of clinical 
 interest. 
 
 Tumors of the heart are commonly carcinoma and sarcoma. They 
 are usually secondary. Fibroma, lipoma, myoma, gumma, and leukaemic 
 infiltrations are extremely rare. Malignant tumors very commonly lead 
 to pericarditis, which may be plastic or purulent. 
 
 Of the parasites which affect the myocardium, the echinococcus is the 
 most common. It selects the right ventricle twice as often as the left. 
 So long as it remains within the myocardium it does not occasion symptoms. 
 When it finds its way into the interior of the heart it gives rise to embolism, 
 especially in the lungs. The cysticercus and trichinella find access to the 
 heart muscle, but do not occasion symptoms. 
 
 vi. Wounds and Foreign Bodies. 
 
 External injuries, as stabs and gunshot wounds, are very common. 
 Their diagnosis is obvious. The subject belongs to surgery, and has ac- 
 quired great importance in consequence of the recent success which, in 
 stab wounds, has attended the prompt exposure of the heart and suturing 
 of the wound. Internal injuries are extremely rare. They are caused by 
 foreign bodies — a bone or artificial denture ulcerating its way from the 
 oesophagus, or in the case of insane or hysterical persons by pins or needles 
 that have been swallowed. In the former instance the nature of the lesion 
 would be recognized by the history of the case and sudden fatal haema- 
 temesis, in the latter pericarditis would occur; but a positive etiological 
 diagnosis intra vitam cannot be made. 
 
 vii. Rupture of the Heart. 
 
 This accident may occur as the result of the arrest of the blood supply 
 to the affected area in consequence of sclerosis or embolism of a branch 
 of a coronary artery, inducing acute softening — myomalacia cordis. The 
 
1196 MEDICAL DIAGNOSIS. 
 
 heart wall may undergo similar circumscribed impairment from suppura- 
 tive m3^ocarditis or a softening gumma. Local fatty degeneration is the 
 most common cause. The rupture occurs most frequently on the anterior 
 wall of the left ventricle near the septum. The softened area gradually 
 yields, and upon some effort which causes heightened intraventricular 
 pressure, as ascending a staircase or straining at stool, it suddenly gives 
 way and the escape of blood into the pericardial sac — hcemopericardium — 
 is followed by death. Rupture in the posterior wall of the left ventricle 
 is much less common, and rupture of the wall of the right ventricle or the 
 auricles very rare. 
 
 Traumatic rupture of the heart may result from violent blows or con- 
 tusions of the thorax, such as occur in falls or railroad accidents. This 
 variety of heart rupture is more apt to involve the right ventricle or an 
 auricle. In some cases the borders of the rent maintain their position. 
 Pericardial adhesions may occur and death may be postponed for several 
 hours or days. 
 
 Diagnosis. — In the majority of the cases death results at once and the 
 diagnosis is impossible. When the opening is small, signs of internal 
 hemorrhage — feeble pulse, oppression, air hunger, ghastly pallor, and 
 orthopnoea — are suggestive. When pericardial adhesions exist the blood 
 outflow is hindered and hfe may be correspondingly prolonged. 
 
 Prognosis. — The outlook, however, is without hope. 
 
 viii. Aneurism of the Heart. 
 
 Aneurism of a valve may result from malignant endocarditis. The 
 condition is not common. The aortic valves are affected with greater 
 frequency than the mitral. The cusp shows a bulging in the direction of 
 the ventricle, which presently ruptures, causing acute insufficiency. The 
 signs are not characteristic and are obscured by the primary changes. 
 A positive diagnosis cannot be made. 
 
 Aneurism of the wall is also a rare condition. Its most common posi- 
 tion is the left ventricle in the region of the apex, which is the portion 
 of the wall of the heart most commonly affected in the fibroid degeneration 
 of chronic myocarditis. 
 
 Etiology. — This condition mostly follows chronic myocarditis, but 
 has been observed in acute mural endocarditis. Wounds of the heart and 
 gumma are also etiological factors. The dilatation is usually single, but 
 may be multiple. 
 
 Diagnosis. — Direct. — The symptoms are not characteristic. The 
 associated myocarditis causes cardiac inadequacy, manifest by the usual 
 clinical phenomena. When the tumor attains considerable size it is usually 
 lined by laminated clots and may give rise to irregular enlargement of the 
 diameters of deep cardiac dulness. In other cases there may be bulging 
 in the region of the apex and perforation of the wall of the chest. 
 
 The DIFFERENTIAL DIAGNOSIS from mediastinal or pleural tumor is 
 to be considered. The feeble pulse of cardiac inadequacy may be in marked 
 contrast to the cardiac impulse. The X-rays may be of service in the 
 differential diagnosis. 
 
PERICARDITIS. 1197 
 
 ix. Atrophy of the Heart. 
 
 Definition. — A diminution of the heart in weight and size. A single 
 chamber or the entire heart may be atrophied. 
 
 The term hypoplasia of the heart is used to designate congenital 
 undersize. 
 
 The myocardium is of a dark, reddish-brown color, and abnormally 
 resistant. The surface is often marked or puckered. The muscle fibres 
 are diminished in size, their transverse striae indistinct and presenting 
 collections of yellowish-brown pigment near the nuclei. 
 
 Etiology. — The small size of the left ventricle in extreme mitral steno- 
 sis may be looked upon as an example of atrophy of a single chamber of 
 the heart. Common causes are starvation and wasting diseases, as cancer, 
 diabetes, protracted suppuration, and, in particular, phthisis. Brown 
 atrophy of the heart is common in advanced valvular disease and old age — 
 the senile heart. 
 
 Symptoms. — The symptoms are those of cardiac inadequacy — feeble 
 and rapid action, especially upon exertion, weak and irregular pulse, faint 
 sounds, and indistinct impulse. The shrunken lungs usually increase the 
 area of superficial dulness, but the diameters of deep dulness are reduced. 
 
 Diagnosis. — The calcification of the costal cartilages in the aged often 
 renders the examination of the heart by percussion very difficult and 
 unsatisfactory. The X-ray examination yields more definite signs of a 
 reduction in the size of the organ. The cHnical phenomena are much 
 subordinated to those of the primary affection. 
 
 Prognosis. — The outlook is that of the primary disease. The ultimate 
 failure of the circulation is often largely due to cardiac atrophy. 
 
 III. DISEASES OF THE PERICARDIUM, 
 i. Pericarditis. 
 
 Definition. — Inflammation of the pericardium resulting from trau- 
 matism, infection, the extension of inflammation from contiguous 
 structures, or toxic conditions. 
 
 Etiology. — Idiopathic or spontaneous pericarditis is a purely theo- 
 retical conception. The extremely rare cases of pericarditis in children 
 without other indications of local or constitutional disease are probably 
 due to latent tuberculosis, or tonsillitis or other infection, or to an obscure 
 toxaemia. Traumatic pericarditis may become the subject of medical 
 diagnosis when the injury is from within, as in the case of the ulceration of 
 a foreign body from the oesophagus, or injury by needles or pins that have 
 been swallowed. Infection is the most common cause. The greater num- 
 ber of cases occur in connection with rheumatic fever. The pericarditis 
 may precede the joint affection. Next in frequency are the cases due to 
 tuberculosis. To this etiological group are to be referred the cases of 
 pericarditis which follow blows and contusions of the chest, and those which 
 occur in alcoholics. The pericarditis may, for a time, be the only clinical 
 manifestation of the tuberculous infection. Less commonly pericarditis 
 
1198 MEDICAL DIAGNOSIS. 
 
 is secondary to sepsis, especially that caused by acute necrosis or puer- 
 peral infection, or the toxaemia of scarlet fever and the other acute 
 febrile infections. 
 
 Extension of the inflammation from the endocardium may account for 
 the common association of endo- and pericarditis in rheumatic fever, or the 
 later pericardial inflammation may be also a direct manifestation of rheu- 
 matism. This mode of infection is common in pleurisy and pneumonia, 
 and may occur in oesophageal carcinoma, tuberculous or bronchiectatic 
 cavities closely adjacent to the pericardium, tuberculous mediastinitis, per- 
 forating gastric ulcer, or subphrenic abscess. That form which sometimes 
 occurs in purulent myocarditis, ulcerative endocarditis, aneurism of the 
 aorta, disease of the ribs and sternum or the vertebraB arises in a major- 
 ity of the cases by direct extension. Toxic pericarditis is not rarely a 
 terminal condition in chronic nephritis, especially the interstitial variety. 
 It is occasionally present but usually latent in gout, scurvy, diabetes, and 
 arteriosclerosis. Among the infrequent causes of pericarditis are syphilis, 
 carcinoma and sarcoma of the pericardium, echinococci or cysticerci, and 
 actinomycosis. The micro-organisms most frequently encountered in the 
 exudate are the ordinary pyogenic bacteria, the pneumococcus, and the 
 tubercle bacillus. 
 
 The inflammatory exudate may be fibrinous, serofibrinous, hemor- 
 rhagic, or purulent. The terminal condition in cases that recover is that 
 of more or less complete adhesion between the pericardial surfaces — 
 adherent pericardium. It is customary to describe separately dry or fibri- 
 nous pericarditis, pericarditis with effusion, and adherent pericardium; 
 but it is important to bear in mind the fact that these, in a majority of 
 instances, are successive stages in a continuous process. Like other inflam- 
 mations, pericarditis may be acute or chronic. 
 
 (a) FIBRINOUS, PLASTIC, OR DRY PERICARDITIS. 
 
 Pericarditis Sicca. 
 
 In the simple acute cases the inflammation involves first the epicardial 
 or visceral layer; later the pericardial layer of the serous pericardium. 
 The fibrinous exudate may be circumscribed or general. Its arrangement 
 varies greatly. Sometimes it presents the appearance seen when two 
 buttered surfaces are separated; sometimes there are hairy ridges in 
 irregular parallel lines, — cor villosum, — or again there may be a stratified 
 or a honeycombed appearance. There is, as a rule, a variable amount of 
 fluid entangled in the meshes of the fibrin, but in chronic tuberculous 
 cases with great thickening fluid is absent. The myocardium immediately 
 subjacent is inflamed. The frequent coexistence of endocarditis is of 
 clinical as well as etiological interest. 
 
 Symptoms. — Plastic pericarditis is sometimes latent. Even in marked 
 cases the subjective phenomena may be indefinite. Pain is common. It 
 is usually substernal or referred to the region of the apex. Less frequently 
 it radiates to the neck and arm, especially on the left side. It may be- 
 stitch-like and lancinating, or dull and heavy; persistent or paroxysmal.. 
 
PERICARDITIS. 1199 
 
 The fever of the primary disease may be aggravated, but the terminal 
 pericarditis of nephritis may be unattended by a rise of temperature. 
 
 Physical Signs. — Upon inspection the signs are usually negative. 
 The breathing may be rapid and shallow or there may be orthopnoea. 
 Palpation in a considerable proportion of the cases reveals a more or less 
 distinct friction fremitus. The pulse is usually accelerated — 120 to 140 
 to the minute. The percussion borders of the heart are not enlarged in 
 simple fibrinous pericarditis. In old cases the myocardium may undergo 
 dilatation. Auscultation. — The pericardial friction sound is most vari- 
 able in character. It is frequently of a soft grazing or brushing quality. 
 More commonly it is rubbing or grating and has been compared with the 
 creaking of new leather. It appears to be superficial, as though produced 
 close to the surface, and is increased by moderate pressure, in some cases 
 obHterated by strong pressure with- the stethoscope. Its intensity varies 
 from a scarcely audible whiff to a loud coarse sound, directly appreciable 
 to the ear. Its loudness is not dependent upon the amount of fibrinous 
 exudate. It is sometimes absent when the fibrin is abundant, as in cor 
 villosum; sometimes distinct when there is merely a thin layer. The 
 intensity is modified by posture and undergoes remarkable changes from 
 day to day in the course of the attack. The pericardial friction sound is 
 usually to-and-fro, corresponding to the systole and diastole of the ven- 
 tricles, but it does not bear the definite relations of endocardial murmurs 
 to the cardiac cycle. It is sometimes single and in rare instances triple, 
 having a somewhat irregular canter rhythm. Its systolic and diastolic 
 portions have usually, but not invariably, the same quality and pitch. 
 They are almost always of unequal length. It is heard over the body of 
 the heart; sometimes most distinctly in the second, third, and fourth left 
 intercostal spaces and adjacent parts of the sternum, sometimes at the 
 base over the pericardial reflections upon the great vessels, and again in 
 the region of the apex. It is usually limited to a small area, but may be 
 distinctly heard over a large part of the pericardium. It is, however, 
 always circumscribed and never transmitted beyond the boundaries of the 
 heart in definite lines corresponding to the vessels, as is the case with endo- 
 cardial murmurs. When pericardial effusion takes place the friction sound 
 disappears over the body of the heart, but, except in large effusions, may 
 still be heard in a limited region at the base. 
 
 Diagnosis. — The direct diagnosis of fibrinous pericarditis depends 
 upon the recognition of a friction sound having the foregoing characters, 
 location, and correspondence to the revolution of the heart. 
 
 Differential. — The distinction between endocardial murmurs and 
 exocardial friction sounds is based upon the well-recognized characters of 
 each. A double aortic murmur, particularly when accompanied by a 
 thrill, may lead to error, but not if due heed be given to its sameness from 
 time to time, lines of propagation, the correspondence of its systoHc and 
 diastolic elements with the cycle of the heart, and the associated arterial 
 changes. 
 
 Pleurisy. — Pleural friction is not usually restricted to the cardiac 
 borders of the lung, and when heard elsewhere serves to explain a pleuro- 
 pericardial friction, which is due to movements of the pleural surfaces 
 
1200 MEDICAL DIAGNOSIS. 
 
 induced by the action of the heart. This sign is by no means infrequent 
 at the left anterior margin of the lung in croupous pneumonia, and is some- 
 times encountered in phthisis. It disappears upon full-held inspiration, 
 and on ordinary breathing is more distinct during the expiratory period. 
 Clicking and crepitant rales, occasionally heard in the region of the apex 
 and recurring with the ventricular systole, are readily differentiated from 
 pericardial friction. 
 
 It is stated that pericardial friction sounds are sometimes produced 
 by milk spots on the surface of the ventricles, concretions, and in the dry 
 condition of the tissues occurring in cholera, but such conditions are not 
 to be confounded with true pericarditis. 
 
 Prognosis. — The course of fibrinous pericarditis as such is favorable. 
 In some days or weeks recovery may take place without any cHnical mani- 
 festation of injury to the heart. The inflammation may indeed run its 
 course in the absence of subjective phenomena, the friction sound being 
 the only objective sign. More commonly there are more or less urgent 
 symptoms. The danger of serofibrinous, hemorrhagic, or purulent effusion,^ 
 of impHcation of the myocardium with acute symptoms, and of extensive 
 pericardial adhesions leading to chronic myocarditis invests every case 
 with importance. As an intercurrent affection it adds to the gravity 
 of the primary disease. 
 
 (b) PERICARDITIS WITH EFFUSION. 
 
 Pericarditis Exudativa. 
 
 There is no abrupt hne of separation between dry pericarditis and 
 pericarditis with effusion. In the meshes of an abundant fibrinous exu- 
 date there are small collections of serum; in serofibrinous effusions the 
 pericardial surfaces are covered with fibrin, flakes of which float free in 
 the fluid. The effusion may be serofibrinous, hemorrhagic, or purulent. 
 
 Etiologically serofibrinous effusion is usually a so-called second stage 
 in the evolution of the attack of pericarditis, and may arise in any of the 
 conditions in which plastic pericarditis occurs. Blood elements are present 
 in varying amounts. Hemorrhagic effusions owe their characteristic ap- 
 pearance to an excess of blood. They are met with in tuberculous and 
 cancerous pericarditis, and in those forms which occur in hemorrhagic 
 conditions, as scorbutus and purpura, and in the aged. The quantity of 
 blood varies from an amount only appreciable upon microscopical or chem- 
 ical examination to almost pure blood. The effusion may be purulent in 
 tuberculous cases. It is Hkely to be so in those due to sepsis or internal 
 or external traumatism, or when an effusion arises in consequence of infec- 
 tion from a contiguous bronchiectatic cavity or vomica. The volume of 
 the effusion is extremely variable. Experimentally the normal sac will 
 contain without distention 150 to 200 c.c. Upon forcible distention, with 
 compression of the heart, from 500 to 800 c.c. may be injected. The in- 
 flamed pericardium is more distensible, and with the adjustments which 
 take place under the gradual accumulation of an effusion, as much as 1500 
 or even 2000 c.c. have been observed. 
 
PERICARDITIS. 1201 
 
 Symptoms. — The condition is frequently latent. There are cases in 
 which moderate pericardial effusions run a favorable course without heart 
 symptoms, resorption taking place in the course of two or three weeks. 
 More commonly the early symptoms consist of chilliness, precordial pain, 
 and fever. In well-developed cases there are two main groups of symptoms, 
 constitutional and local. The constitutional symptoms are very often 
 masked by those of the primary affection, and moderate terminal effusions 
 are more frequently recognized in the post-mortem room than in the ward. 
 In children general symptoms, as feverishness, dyspnoea, loss of appetite, 
 fretfulness, languor, and a rapidly developing pallor, may occur in the 
 absence of precordial pain or other symptoms suggestive of the actual 
 condition. Pallor, weakness, insomnia, loss of appetite, dyspnoea and 
 orthopnoea, melancholia and a disposition to suicide, and in grave cases 
 restlessness, somnolence, delirium, and a tendency to coma are among the 
 symptoms of pericardial effusion. The local symptoms arise from the 
 inflammation, from the derangement of the circulation, and from pressure. 
 The pain is referred to the precordium; less commonly to the epigastrium. 
 It is usually sharp and lancinating; sometimes dull and aching; excep- 
 tionally it amounts only to a sense of distress and discomfort. It is usually 
 continuous with exacerbations, but may be paroxysmal with intervals of 
 relief. It is intensified by pressure with the stethoscope. Derangements 
 of the circulation are manifest in cyanosis of varying intensity, shortness 
 of breath, anxiety, and the sensation of air hunger. The patient prefers 
 to lie upon the left side; in large effusions he is obliged to be propped up 
 with pillows in the semirecumbent posture or to sit up in bed. The pulse 
 is rapid, small, and frequently arrhythmic. In large effusions with thicken- 
 ing of the parietal pericardium the pulse may become very feeble or quite 
 imperceptible during inspiration — pulsus paradoxiciis. It is sometimes 
 smaller in the left than in the right carotid and radial arteries. The 
 circulatory symptoms are due in part to the direct pressure of the 
 effusion upon the heart, the effects of which are greater upon the thin- 
 walled auricles than upon the ventricles, and to the implication of the 
 myocardium directly in relation with the inflamed epicardium. The 
 symptoms due to pressure upon other organs are a sense of precordial 
 oppression and weight in the epigastrium, dysphagia, aphonia, a laryn- 
 geal cough, distention of the veins of the neck, and dyspnoea from 
 compression of the left lung. 
 
 Physical Signs. — Inspection. — In small effusions there are no dis- 
 tinctive signs. In moderate and large effusions the respiratory excursus 
 upon the left side is diminished in consequence of pressure atelectasis of 
 the lower lobe. Pericardial effusions compress the left lung to a far greater 
 extent than the right. The epigastrium is prominent, owing to the depres- 
 sion of the diaphragm and liver. In children and young persons precordial 
 prominence, widening and slight bulging of the lower intercostal spaces, 
 and in some cases a feeble wavy cardiac impulse may be present. Palpa- 
 tion. — A cardiac impulse due to the contraction of the right ventricle 
 may be feebly felt in the fourth interspace; in other cases the apex beat 
 may be lower than normal in consequence of the depression of the dia- 
 phragm. Very often no precordial impulse can be detected. Friction 
 
 76 
 
1202 
 
 MEDICAL DIAGNOSIS. 
 
 fremitus vanishes as the layers of the pericardium are separated by the 
 effusion, except at the base, where it may sometimes be felt, especially in 
 the erect posture. Fluctuation is not a sign of pericardial effusion. In 
 massive effusions bulging of the left retroclavicular space has been observed 
 and elevation of the clavicle, so that the first rib may be palpated to the 
 sternum— ^rs^ rib sign. Percussion. — This method of physical diagnosis 
 yields most important signs. The effusion collects first in the most depend- 
 ent part of the sac and gradually rises as it increases in amount. Its presence 
 may be first appreciated by an absence of resonance at the sternal end of 
 the fifth right intercostal space— the cardiohepatic angle. At this point 
 in normal and dilated hearts the vertical border of the cardiac dulness 
 and the transverse upper border of the hepatic dulness make a well-defined 
 right angle. In early effusion and in certain cases of obesity this angle is 
 replaced by a curve having its concavity upward and outward toward the 
 lung — Rotch's sign. As the effusion increases the precordial dulness extends 
 
 Fig. 341. — Moderate pericardial effusion; 
 quadrilateral flatness with border of relative 
 dulness; effacement of cardiohepatic angle. 
 
 Fig. 342. — Massive pericardial effusion; 
 pyramidal area of flatness with truncated apex; 
 right border of relative dulness; downward 
 displacement of liver. 
 
 toward the left and upward, later toward the right, displacing the borders 
 of the lung and forming at first a quadrilateral area of dulness with rounded 
 corners, which with larger effusions assumes a pear-shaped outline, the 
 larger end lying at the inferior border and extending beyond the sternal 
 margin on the right, and beyond' the position of the apex and the mid- 
 clavicular line on the left. In large effusions the dulness may invade 
 Traube's semilunar space. The truncated apex of this figure reaches into 
 the upper sternal region. As the diameters of this figure are gradually 
 reached, the area of superficial precordial dulness advances more rapidly 
 than that of the deep or absolute dulness, until at length they nearly coin- 
 cide. A circumscribed area of dulness or flatness may sometimes be 
 found at the base of the left chest posteriorly between the inferior angle of 
 the scapula and the vertebrae. Old pericardial adhesions, compression of 
 the left lung, and coexistent pleural effusions greatly modify these changes 
 in the percussion signs. Auscultation. — The friction sound disappears 
 over the body of the heart but may be heard at the base, very rarely at 
 the apex. The first sound is obscure and indistinct; the second pulmo- 
 
PERICARDITIS. 1203 
 
 nary sound accentuated. The action of the heart is rapid and often 
 arrhythmic. A systolic endocardial murmur may sometimes be detected. 
 As resorption takes place the first sound becomes more distinct and the 
 friction sound may be again heard. 
 
 Diagnosis. — The direct diagnosis of pericardial effusion may be 
 made without difficulty when the case has been seen from the outset 
 and the above-described percussion signs have supervened upon peri- 
 cardial friction sounds. Of especial value in the early recognition of effu- 
 sion is Rotch's modification of the cardiohepatic angle. Very important 
 is the triangular outhne of dulness in large effusions. A sign too httle 
 appreciated is the progressive encroachment of the borders of the super- 
 ficial dulness upon the area of deep dulness. The X-ray examination 
 may be of service. 
 
 Differential. — Dilatation of the heart very often presents extreme 
 difficulty in the differential diagnosis. Careful cHnicians have tapped the 
 right ventricle instead of a pericardial sac distended with fluid. Dulness 
 in the cardiohepatic angle, a quadrilateral area of dulness with rounded 
 corners, the close approach of the borders of superficial to those of deep 
 dulness, especially when the dulness extends to the left beyond the apex 
 beat, constitute an association of physical signs of great importance. The 
 truncated apex of the triangular area of dulness in large effusions, a cir- 
 cumscribed area of dulness near the angle of the left scapula, and signs of 
 compression of the left lung have also diagnostic value. But most of these 
 conditions may be present in dilated heart. In some cases of hypertrophy 
 of the right ventricle the deep cardiac dulness due to the left ventricle 
 extends beyond the position of the visible impulse. An undulatory 
 impulse seen or felt in two or more interspaces, distinct though feeble 
 heart sounds, valvular in character and having the fetal rhythm, and 
 postural changes in the upper borders of the dulness, are signs suggestive 
 of effusion. Overfilled veins, cyanosis, aphonia, dysphagia, and other 
 pressure symptoms are without value in the differential diagnosis, since 
 they may occur alike in large pericardial effusions and extreme dilatation 
 of the heart. 
 
 Left-sided Pleural Effusion. — This condition, unless the fluid be en- 
 cysted, is not often mistaken for pericardial effusion, but large pericardial 
 effusions may closely simulate pleurisy. In the latter condition the heart 
 is displaced toward the right, its impulse and sounds are distinct, the flat- 
 ness extends around the base of the chest, the overlying compressed luno- 
 yields tympanitic percussion resonance, Traube's semilunar space is oblit- 
 erated, the spleen is displaced downward and its respiratory excursus 
 restricted, and finally dysphagia is not a pressure symptom in pleurisy. 
 Vocal fremitus is usually distinct over an atelectatic lung, feeble or absent 
 over fiuid. The pericardial effusions which occasionally occur in pneu- 
 monia present unusual difficulties in diagnosis. The signs are masked by 
 those of the primary lesion. There is no border-line change from dulness 
 to clearness or tympany; at the left border of the heart the extension of 
 dulness to the right of the sternum may be ascribed to the dilatation of a 
 failing right heart. The modification of the cardiohepatic angle would 
 suggest pericarditis, but it is likely to be overlooked. 
 
1204 MEDICAL DIAGNOSIS. 
 
 The recognition of tumors of the lung, pleura, or mediastinum, or 
 of aneurisms of the aortic or pulmonary artery, depends upon a cHnical 
 course and physical signs that are widely divergent from those of 
 pericarditis with effusion. 
 
 The character of the fluid can be determined with certainty only by 
 an exploratory puncture. Paracentesis of the pericardium for diagnostic 
 purposes cannot, however, be considered a justifiable procedure. When 
 performed as a measure of treatment the gross and microscopical charac- 
 ters of the fluid are of diagnostic importance. Various sites are recom- 
 mended for the insertion of the needle. The fourth or fifth left intercostal 
 space near the sternum; the same interspaces to the left of the midclavic- 
 ular line and within the border of the flatness on percussion; a point 
 high in the angle formed by the ensiform cartilage and the left costal 
 margin and the fifth right interspace 2 cm. from the sternal border when 
 this area is flat upon percussion, are situations recommended. A small 
 aspirator needle should be employed and strict surgical antisepsis 
 observed. In rheumatic, renal, and tuberculous cases the fluid is usually 
 serofibrinous; in senile, purpuric, and cancerous cases hemorrhagic; and in 
 septic conditions it is commonly purulent. The gravity of the general symp- 
 toms usually depends upon the nature and intensity of the primary dis- 
 ease. When this is not the case it corresponds rather to the severity of 
 the pericarditis, the amount of the effusion, and the rapidity with which it 
 is formed, than to its character. 
 
 Prognosis. — The signs of effusion may, in many cases, be recognized 
 within a few days of the detection of the friction sound. The accumulation 
 in rheumatic fever, nephritis, scurvy, and some septic cases is rapid, while 
 in tuberculous cases it is usually slow. Serofibrinous effusions of moderate 
 volume frequently undergo resorption, which may be complete as shown 
 by the retrogression of the dulness in the course of four or five weeks. 
 Reappearance of the friction sound may occur but is less common than in 
 pleural effusions. Occasional post-mortem findings, namely, grayish 
 material in various stages of calcareous change in the pericardium, render 
 it probable that under certain circumstances a purulent effusion may 
 undergo resorption. Very large effusions show little tendency to undergo 
 resorption, and unless removed by operative measures — dissection layer 
 by layer, or paracentesis — rapidly prove fatal by compression of the heart 
 and other mechanical effects. Purulent effusions, unless reheved by opera- 
 tion and drainage, terminate, as a rule, in death. The pericarditis with 
 effusion in scurvy, chronic nephritis, and pysemia is almost always a ter- 
 minal condition. Heart comphcations are frequently present. There is 
 myocarditis involving the myocardium directly in relation with the inflamed 
 epicardium. Endocarditis is often also present, particularly in the rheu- 
 matic cases. Old valvular lesions with associated myocardial changes may 
 at the same time obscure the diagnosis and unfavorably affect the prog- 
 nosis. When recovery takes place the pericardial surfaces become adherent. 
 The prognosis is relatively unfavorable as the primary constitutional 
 condition is grave, the effusion large, and its accumulation rapid. 
 
ADHERENT PERICARDIUM. 1205 
 
 ii. Adherent Pericardium. 
 
 Synechia Pericardii; Obliteration of the Pericardial Sac. 
 
 Pericardial adhesions constitute a constant anatomical sequel of 
 pericarditis, both in its latent and manifest forms. The extent of the 
 adhesions is exceedingly variable. In many cases there are merely thread- 
 like strings or bands of organized tissue extending from the visceral to the 
 parietal pericardium; in others the adhesion between their membranes is 
 universal and so close as to suggest congenital absence of the pericardium. 
 The adjacent pleura is frequently involved and in extreme cases the heart 
 is embedded in a dense, thick connective-tissue mass including the fibrous 
 pericardium and the structures with which it is in relation — chronic 
 adhesive mediastinitis. 
 
 The cases of simple pericardial adhesion may be divided into two 
 groups: 
 
 (a) Those presenting no clinical manifestations and found upon post- 
 mortem examination. This group includes the cases of limited adhesions 
 and the threads and bands which scarcely affect the free movement of 
 the heart within the sac, and some of the cases in which more general 
 adhesions exist. 
 
 (b) Those in which, as a result of the pericarditis and adhesions, 
 chronic myocarditis has occurred, with hypertrophy and dilatation and the 
 symptoms of cardiac inadequacy. These cases do not always show general 
 obliteration of the sac. A high grade of hypertrophy may occur with only 
 partial adhesion between the layers. 
 
 Symptoms. — There are cases in which the history and physical signs 
 are positive, but for a long period symptoms of heart disease are absent. 
 After a time the symptoms are those of hypertrophy, then dilatation and 
 a failing heart. 
 
 Physical Signs. — Inspection. — In young persons there may be promi- 
 nence of the pericardium in consequence of hypertrophy, with an impulse 
 visible in the fourth, fifth, and sometimes the sixth interspace and to the 
 left of the midclavicular line. While the hypertrophy remains marked the 
 impulse may be strong and heaving, but when it gives way to dilatation 
 the impulse becomes more extended and undulatory, and there is systolic 
 retraction in the neighborhood of the apex. The systolic indrawing may 
 extend to other parts of the cardiac area. It is sometimes seen at the base 
 of the heart and may be confined to this region. An energetic retraction 
 in the parts about the ensiform cartilage upon the left is sometimes seen. 
 In cases in which there are strong cardiodiaphragmatic adhesions a visible 
 systolic retraction may be detected in the lower left ribs and interspaces 
 behind — Broadbent's sign. Respiratory movement of the epigastrium 
 may be embarrassed by the pericardial adhesions. Friedreich's sign, 
 diastolic collapse of the cervical veins, is sometimes seen. Palpation. — 
 The signs obtained by inspection are confirmed and there is often to be 
 felt a distinct diastolic shock. The movements of the apex, under the 
 influence of gravity, upon change of posture are less marked than under 
 normal conditions. Pulsus paradoxus may be present. Percussion shows 
 
1206 MEDICAL DIAGNOSIS 
 
 an increase in the transverse diameter of the heart, and since there are 
 usually also pleural adhesions the area of superficial cardiac dulness may 
 not be influenced by the respiratory movements. Auscultation. — The 
 signs are not distinctive. There is very often the murmur of an associated 
 endocarditis, especially in the rheumatic cases. With dilatation there is 
 usually the systolic mitral murmur of relative insufficiency. Other murmurs 
 have been described, especially a presystolic murmur, but these are 
 inconstant and accidental. 
 
 Diagnosis. — The direct diagnosis of pericardial adhesion rests upon 
 the history of pericarditis and the presence of the foregoing signs upon 
 physical examination. In some cases a positive diagnosis cannot be made; 
 in others it can be made with certaint}'' even in the absence of a history of 
 pericarditis. The cases that present the greatest difficulty are those in 
 which there are adhesions between the pericardium and epicardium with- 
 out adhesions to the adjacent structures; the cases in which the diagnosis * 
 may often be made with confidence are those in which there are extensive 
 adhesions, not only between the visceral and parietal pericardium, but also 
 between the fibrous pericardium and the surrounding parts — chronic 
 indurative mediastinitis. Too great importance may be given to systohc 
 retraction of the intercostal space in the region of the apex. This, in the 
 absence of pericardial adhesions, may be due to atmospheric pressure 
 when the energetically contracting ventricles are not followed by the border 
 of the lung with sufficient promptness. It may also occur in hypertrophy 
 and dilatation of the right ventricle when the left ventricle remains small. 
 The impulse is that of the right ventricle, and to the left of it there may in 
 some cases be seen distinct systoHc retraction. As a rule, to which there 
 are, however, exceptions, the retraction in adherent pericardium is more 
 energetic than that induced by atmospheric pressure. When systoHc 
 retraction occurs under observation after an attack of pericarditis the 
 diagnosis of adherent pericardium may be made. In a doubtful case the 
 shadow cast by the Rontgen rays may be of service. It may show irregular 
 contour of the heart, a feeble, restricted cardiac pulsation, and diminished 
 play of the diaphragm, especially in its central parts. 
 
 Prognosis. — The outlook in simple obliteration of the pericardium 
 depends upon the influence of the primary pericarditis and the subsequent 
 adhesions upon the myocardium. So long as the heart retains its function 
 the prognosis is favorable. Upon the supervention of the signs of cardiac 
 insufficiency it becomes unfavorable. 
 
 iii. Hydropericardium; Hydrops Pericardii. 
 
 Dropsy of the pericardium occurs in connection with general dropsy 
 in the course of renal, less frequently of heart disease, and in association 
 with effusions into the other great serous sacs, the pleurae and peritoneum. 
 In rare cases of scarlet fever this condition has been observed in the absence 
 of dropsy in other parts. Normally the pericardial sac contains a small 
 amount of clear yellow serum, 5-10 c.c. In hydropericardium the quantity 
 rarely exceeds 150-200 c.c. This transudate is clear, yellowish, and may 
 contain a few red blood-corpuscles. The pericardium is smooth and glisten- 
 
ENDOCARDITIS. 1207 
 
 ing. Chylous effusion is a very rare condition. Hydropericardium presents 
 the physical signs of a moderate pericardial effusion, from which it cannot 
 be differentiated except by the history and the associated clinical phenom- 
 ena. It does not directly tend to cause death, but constitutes an additional 
 danger in the serious affections in which it arises as a complication. 
 
 iv. Hsemopericardium. 
 
 Hemorrhage into the pericardial sac is to be differentiated from 
 hemorrhagic pericardial effusion. It results from wounds or rupture of 
 the heart or of an aneurism of the aorta, pulmonary artery, or coronary 
 arteries, and has been observed as a consequence of ulceration in malig- 
 nant endocarditis. As a rule, death occurs immediately with the symptoms 
 of internal hemorrhage. In extremely rare instances the bleeding is more 
 slow, especially in cases of rupture of the heart, and time permits an exam- 
 ination of the cases with a view to their diagnosis and treatment. The 
 signs are then of a more or less rapidly accumulating pericardial effusion; 
 the symptoms those of more or less abundant internal hemorrhage. 
 The prognosis is in the highest degree unfavorable. Traumatic cases may 
 recover after immediate operation — suturing the incised wall and draining 
 the pericardium. 
 
 V. Pneumopericardium. 
 
 Air or gas in the pericardial sac is an exceedingly rare condition. 
 It may result from external wounds, perforation of the oesophagus or stom- 
 ach, subphrenic pyopneumothorax, a tuberculous cavity involving the peri- 
 cardium, or spontaneously without solution of continuity in the sac from 
 the presence of the Bacillus aerogenes capsulatus. The area of cardiac dul- 
 ness is replaced by tympany. The impulse in the recumbent posture dis- 
 appears, though it may be felt when the patient sits up. The movements 
 of the heart are accompanied by coarse, churning, gurgling noises, and the 
 heart sounds have a loud, metallic ring, which may be heard at some 
 distance from the chest. Fluid is usually also present. 
 
 vi. Calcification of the Pericardium. 
 
 Deposition of lime salts sometimes takes place in tuberculous peri- 
 carditis and in pyopericardium with resorption of- the fluid. The condition 
 may be partial or complete, so that the heart is encased in a sort of bony 
 shell. Strangely enough it is usually latent, though a diagnosis of adherent 
 pericardium has been made. The lesion is exceedingly rare. 
 
 IV. DISEASES OF THE ENDOCARDIUM. 
 i. Endocarditis. 
 
 Definition. — Inflammation of the lining membrane of the heart. 
 
 In by far the greater number of the cases the inflammatory process is 
 restricted to the valves — valvular endocarditis; exceptionally it extends 
 to the lining membrane of the wall of the heart — mural endocarditis. 
 
 Two forms of endocarditis are recognized, acute and chronic. 
 
1208 MEDICAL DIAGNOSIS. 
 
 (a) Acute Endocarditis. 
 
 Acute endocarditis is of every grade of intensity. Its milder forms 
 run a favorable course, and the inflammatory lesions, though they impair 
 the function of the valves, are not destructive. Its severe forms are at- 
 tended with grave symptoms and usually end in death, and the lesions 
 comprise ulceration and necrosis of the affected valves and adjacent parts. 
 It is convenient to describe separately acute simple or benign endocarditis, 
 and acute idcerative, infective, or malignant endocarditis. Between these 
 two forms there is no abrupt anatomical or clinical dividing line. 
 
 The lesions in simple endocarditis consist of minute wart-like vegeta- 
 tions, hence the descriptive terms vegetative or verrucose endocarditis. 
 The left side of the heart is involved more commonly than the right, and 
 the mitral than the aortic leaflets. These vegetations are arranged in lines 
 upon the auricular surface of the auriculoventricular leaflets and the ventric- 
 ular surface of the sigmoid cusps a little distance back of the free edges of 
 the valves. The clinical course of the disease is determined by the subse- 
 quent changes in the valvular lesions, which may result in organization 
 with trifling permanent alteration; in progressive sclerotic changes and 
 deformity — chronic valvidar disease; in the detachment of loose vegetations 
 and embolism; or finally in an overgrowth of the vegetations and ulcerative 
 destruction of the valve leaflets — malignant endocarditis. In the last, not 
 only the leaflets but also adjacent parts may be destroyed, with perfora- 
 tion of a valve, the septum, or the wall of the heart, and, owing to 
 the loosely organized character of the exuberant vegetations, multiple 
 embolism is common. 
 
 The valve systems affected are in the order of frequency as follows: 
 mitral alone, aortic alone, aortic and mitral together, tricuspid, and pul- 
 monary. The walls of the heart are involved, as a rule, only in connection 
 with the valves. Endocarditis in fetal life usually involves the right side 
 of the heart. 
 
 Etiology. — Predisposing Influences. — Acute endocarditis, both 
 simple and malignant, has been met with under circumstances in which 
 no antecedent or primary disease or lesion could be demonstrated. In 
 the majoritj^ of instances it is a secondary affection. Simple Endocarditis. — 
 Rheumatic fever is by far the most common jDrimary affection. Chorea, 
 tonsilhtis, scarlet fever, and croupous pneumonia are very frequent. It is 
 rare in enteric fever, measles, diphtheria, variola, and varicella. In gout, 
 diabetes, chronic nephritis, and cancer simple endocarditis is occasionally 
 observed. Acute endocarditis is common in old cases of valvular disease — 
 recurrent endocarditis. Malignant Endocarditis. — Here also rheumatic 
 fever, pneumonia, and other acute infections play an important part as 
 the primary disease. But it is especially in septic processes that mahgnant 
 endocarditis occurs. Recurrent endocarditis is frequently mahgnant in 
 type. Mahgnant endocarditis constitutes a grave danger in gonorrhoeal 
 infection, especially in the male. The malignant form is exceedingly rare 
 in enteric fever, diphtheria, tuberculosis, dysentery, and scarlet fever. 
 
 Heredity plays an important role in the predisposition to endocarditis. 
 There are many families in which the liability is plainly manifest in succes- 
 
ENDOCARDITIS. 1209 
 
 sive generations. Rheumatic endocarditis is especially common in child- 
 hood and early adult life. It may, however, occur at any age. After forty 
 the liability to a first attack of rheumatic fever is slight. Chorea is more 
 common in girls than in boys, and it is in accordance with this fact that the 
 incidence of simple endocarditis is somewhat greater in females. The 
 especial liability to sepsis which attends the child-bearing function con- 
 stitutes an important predisposing influence to the graver forms of 
 endocarditis. 
 
 Exciting Cause. — The pyogenic bacteria which are present in the 
 lesions of the primary disease are found in the valvular vegetations and in 
 the infected emboli common in mahgnant endocarditis. One or more 
 varieties may be identified in the same case. The more common are strep- 
 tococci, staphylococci, pneumococci, and gonococci. Much less frequently 
 the bacillus of enteric fever, diphtheria, tuberculosis, and the Bacillus coli 
 communis have been found. In the simple endocarditis of chronic diseases 
 and cachectic states micro-organisms are frequently absent. 
 
 SIMPLE ENDOCARDITIS. 
 
 Symptoms. — This form very often runs a latent course without modi- 
 fication of the symptoms of the primary affection. In other cases increased 
 pulse-frequency, slight irregularity in the action of the heart, a sense of 
 precordial oppression, and attacks of dyspnoea occur. There may or may 
 not be a rise of temperature in rheumatic cases without fresh joint affection. 
 In young children rheumatic endocarditis may occur with trifling mani- 
 festations of illness and without arthritis, the true nature of the attack 
 being revealed by the physical signs, the subsequent valvular disease, 
 and recurrent attacks of well-characterized articular rheumatism. Again, 
 to these symptoms there may be added the manifestations of acute cardiac 
 insufficiency and grave constitutional disturbances — irregular, rapid, and 
 feeble pulse, faintness, oppression, orthopnoea, high fever not conforming 
 to type, profuse perspirations, and extreme pallor. Such cases lie on the 
 border-line between simple and malignant endocarditis. 
 
 Physical Signs. — A murmur may develop at one of the valvular 
 areas. Commonly the first sound is impure at the beginning or slightly 
 rough. This change increases to a murmur which gradually becomes 
 distinct. The second sound may be reduplicated, its pulmonary element 
 accentuated. There may be slight increase in the transverse diameter 
 of the heart and displacement of the apex to the left, signs of implication 
 of the myocardium. 
 
 Diagnosis. — Simple endocarditis in many of the cases is discovered 
 only by systematic routine examination. Very often it is not recognized 
 at all. Recent endocarditis is sometimes found in cases of nephritis or 
 carcinoma in which no murmur has been heard. When heard the murmur 
 may be due to relative or muscular insufficiency, or to valvular disease 
 resulting from acute endocarditis in the past. If it has developed under 
 observation the latter possibility may be excluded but not the former. 
 If it becomes more distinct and persists beyond the convalescence from the 
 primary disease, a diagnosis of acute endocarditis is justified. 
 
1210 MEDICAL DIAGNOSIS. 
 
 MALIGNANT ENDOCARDITIS. 
 
 Symptoms. — There are two groups of symptoms: those due. to the 
 primary disease or the sepsis to which it has given rise, and those due to 
 the endocarditis. Either of these groups may dominate the cHnical picture. 
 To the first belong irregular fever, copious sweating, profound anaemia, 
 delirium, and loss of strength; to the second group a curious air hunger, 
 paroxysmal dyspnoea, orthopnoea, palpitation, frequent and irregular action 
 of the heart, and the phenomena caused by emboli in various tissues and 
 organs. A very common point of entrance for the infection is in lesions 
 of the female reproductive organs. Injuries of the integument, boils and 
 abscesses, suppuration of the middle ear, inflamed hemorrhoids, gonor- 
 rhoea in the male, croupous pneumonia, and suppurative disease of the 
 liver or of bone are frequent causes. Old valvular disease of the heart is 
 very common. The anamnesis is of great value in the diagnosis. In a 
 doubtful case this ground must be carefully gone over. Septic, typhoid, 
 cerebral, and cardiac forms are described, but the picture is a very diverse 
 one and the distinctions are by no means clear. The Septic Form. — There 
 is usually a history of puerperal infection, a neglected wound, acute necro- 
 sis, or gonorrhoea. Severe rigors, irregular pyrexia, colliquative sweating, 
 and vomiting are common. Heart symptoms are sometimes subordinate 
 and the signs overlooked. Embohsm is common. The Typhoid Form. — 
 The temperature is high and subcontinuous or remittent in type. There 
 are great depression, diarrhoea, sometimes tympany, drenching sweats, de- 
 lirium, somnolence, and a tendency to coma. Heart symptoms are often 
 obscure. Murmurs may be absent. The Cerebral Form. — The onset 
 is abrupt with the signs of a basilar or cerebrospinal meningitis. Sud- 
 den violent delirium is followed by coma. The Cardiac or Recurrent 
 Form. — This variety occurs in individuals who are the subjects of chronic 
 valvular disease. The symptoms are very variable. The attack may run 
 a rapidly fatal course with septic or so-called typhoid phenomena and 
 high fever, or recovery take place after several weeks. Repeated attacks 
 with the clinical manifestations of an acute endocarditis may occur. 
 
 Embolism may cause the most diverse manifestations, among which 
 are delirium, coma, hemiplegia, monoplegia, and central derangements of 
 vision and hearing in consequence of implication of arterial branches in the 
 brain or meninges; pain in the splenic area from infarction and perisplen- 
 itis; pain in the lumbar region and bloody urine from Infarction of one or 
 both the kidneys; and abscesses in the subcutaneous tissues, which are 
 often multiple. The last are common in the legs and feet, less so in the 
 arms, occasional in the buttocks or shoulders, and infrequent in the face 
 or neck. To this cause must also be ascribed the retinal hemorrhage which 
 sometimes occurs, and the rare complication of suppurative panophthal- 
 mitis. Erythematous and petechial rashes are common. Jaundice occa- 
 sionally occurs. As in other forms of sepsis, diarrhoea is often troublesome. 
 Leucocytosis is usually present. 
 
 Physical Signs.' — There are no signs of importance upon inspection. 
 Palpation yields valuable information as to the character and extent of the 
 impulse, which is frequently somewhat displaced to the right and may be 
 
ENDOCARDITIS. 1211 
 
 sometimes felt in two interspaces. Thrills in the mitral and aortic areas 
 may be felt. Percussion shows the heart to be moderately enlarged in its 
 transverse diameter, especially to the right of the sternal border — dilata- 
 tion of the right ventricle. Upon auscultation the signs are by no means 
 constant. Errors in diagnosis may be avoided by bearing in mind the fact 
 that in a considerable proportion of the cases no murmur can be detected 
 upon careful search. Usually, how^ever, there are well-marked, often harsh, 
 murmurs in the mitral and aortic areas, mostly systolic in time, but fre- 
 quently also presystolic or diastolic as the case may be, and often chang- 
 ing their quality, rhythm, and intensity from time to time. This variability 
 in the murmurs and in thrills when present corresponds to changes in the 
 dimensions and other physical characters of the lesions, and constitutes a 
 diagnostic sign of the highest importance. 
 
 Diagnosis of Malignant Endocarditis. — Direct. — In the absence of 
 the physical signs of endocarditis and of embolism the recognition of the 
 disease may be impossible. Sepsis, associated with murmurs which vary 
 in character and intensity, or the signs of embolism form the basis for a 
 positive diagnosis. 
 
 Differential. — The following conditions are to be considered: Acute 
 Simple Endocarditis. — The general symptoms in the malignant form are 
 much more intense. Recurrent chills, irregular pyrexia, and profuse 
 sweating occur. Embolic processes are far more common. There are border- 
 line cases which may be referred to either category, but in these the absence 
 of a focus of infection is in favor of a severe form of the benign type of the 
 disease. In the malignant cases leucocytosis, petechial eruptions, and the 
 urinary findings of acute nephritis are of diagnostic importance. Blood 
 cultures may yield conclusive results. Enteric Fever. — Many of the cases 
 are at first regarded as irregular forms of enteric fever. The gradual rise 
 of temperature in the latter disease, the slowness of the pulse in proportion 
 to the pyrexia, the greater enlargement of the spleen, the rose rash, and a 
 positive Widal reaction constitute a symptom-complex not seen in any 
 other affection. It is true that a rose spot or two may sometimes be found 
 in a septic case. Grave cases of enteric fever with secondary infection may 
 become distinctly septic and develop malignant endocarditis. Typhus 
 Fever. — This now infrequent disease usually occurs in local outbreaks, and 
 is characterized by early intense headache, stupor, a peculiar petechial 
 rash appearing about the fourth day and all over the body except the face, 
 and an average course of about fourteen days. Hemorrhagic Smallpox. — 
 This rare malignant vaiiety of variola occurs only in the unvaccinated 
 and has little in common with ulcerative endocarditis except its profoundly 
 infectious nature and rapidly fatal issue. Malarial Fever. — In some of the 
 cases of malignant endocarditis the ague-like paroxysms of chill, fever, and 
 sweating recur with a periodicity suggestive of malarial infection. The 
 absence of the blood parasite and the total failure of quinine to influence 
 the progress of the disease are conclusive. 
 
 Prognosis. — The immediate outlook in the simple form of acute endo- 
 carditis is favorable. In the majority of instances, however, it proves to 
 be the point of departure for chronic valvular disease. The remote conse- 
 quences are therefore often grave. An attack in early life may prove the 
 
1212 MEDICAL DIAGNOSIS. 
 
 cause of protracted and irremediable disability and ill health. The prog- 
 nosis in the malignant form is highly unfavorable. Most of the cases end 
 in death. Those that recover are of the cardiac type and recurrences are 
 common. The duration of malignant endocarditis varies from a few days 
 to several weeks. 
 
 (b) Chronic Endocarditis. 
 
 Definition. — Connective-tissue new formation in the valvular endo- 
 cardium, having its beginning in, (a) acute endocarditis, (b) the extension 
 of arteriosclerosis from the arterial system, or (c) occurring as a primary 
 affection and leading to various deformities of the valves and impairment 
 of their function. 
 
 (a) The vegetations and thrombi become organized, with the pro- 
 duction of nodular fibroid thickening at the margins and later throughout 
 the substance of the leaflets. The connective-tissue overgrowth undergoes 
 contraction, with thickening, incurving of the edges of the leaflets, and other 
 coarse deformities. This process affects the left side of the heart and the 
 mitral valve system more frequently than the aortic, (b) The sclerotic 
 change in the valves arises independently of an antecedent acute endo- 
 carditis, and is one of the manifestations of a general or more or less exten- 
 sive fibroid transformation affecting the arterial system — arteriosclerosis. 
 In antenatal life the right heart is usually affected; after birth the left 
 heart. This process generally involves the aortic valves but often extends 
 to the mitral, and in rare instances affects the mitral without implication 
 of the aortic, (c) Primary sclerosis occurs as the result of habitual pro- 
 longed and severe muscular effort. The aortic valves especially suffer in 
 this form of chronic endocarditis. The toxins of syphihs and gout, the 
 intoxications of lead and alcohol, prolonged anxiety, grief and worry, and 
 the tissue changes incident to old age are credited with the production of 
 sclerotic changes in the valves. Whatever the mode of origin the result is 
 the same, deformity and impairment of function. 
 
 The deformities are various and arise from thickening, curling, adhe- 
 sions, superficial necrotic changes, the deposition of lime salts, loss of 
 elasticity, and the stretching of parts still capable of yielding to pressure. 
 The papillary muscles show sclerotic changes, particularly at their tips. 
 The chordge tendinese are shortened and thickened and in some instances 
 destroyed. Chronic mural endocarditis shows itself in grayish-white patches 
 upon the endocardium of the wall and may be due to myocardial changes. 
 
 The effect of the valvular lesions is insufficiency or stenosis, which may 
 be single or combined. 
 
 The derangement of function in both insufficiency and stenosis con- 
 sists in an interference of the normal course of a part of the blood stream. 
 In insufficiency the affected blood is permitted to flow back through the 
 orifice — regurgitation; in stenosis it is held back at the orifice. In the 
 combined lesions some of the blood is held back and some passes back. 
 The altered valves can neither be completely closed nor fully opened. The 
 over-filled chamber and increased resistance demand increased work on 
 the part of the heart, and this leads to hypertrophy. When the increase 
 in work and the increase in power are equal the balance of the circulation is 
 
ENDOCARDITIS. 1213 
 
 maintained and the lesion is said to be compensated. The tendency on 
 the part of the valvular lesion is to progress. That on the part of the com- 
 pensating hypertrophy is to advance at an equal rate. Thus compensation 
 advances hand in hand with the lesion, and symptoms are absent. This 
 process goes on, however, at the cost of corresponding impairment of the 
 reserve power of the heart. There may be no symptoms while the heart 
 does only its ordinary work, but the capacity for extraordinary work is 
 progressively impaired. A sudden violent effort, hill climbing, worry, the 
 stress of life, an acute illness reveal beginning cardiac inadequacy. It is 
 fortunate that in the physical signs of valvular disease we have, while com- 
 pensation is still maintained, the means of recognizing the condition and 
 can institute measures to avert disaster. There are cases, however, in 
 which compensation does not occur. The lesion is too great or has 
 developed too rapidly, or the myocardium is unsound, and dilatation 
 takes place at once. 
 
 After a time the compensation becomes impaired. This change may 
 be due to further advance in the valvular lesion, with which the heart 
 muscle is unable to keep pace, or to the insufficiency to which the hyper- 
 trophied muscular tissue is peculiarly prone. The manifestations are not 
 different from those of chronic myocarditis due to other causes. They 
 vary progressive!}^ in degree. Hence the terms impaired compensation. 
 broken or lost compensation, de-compensation. 
 
 It is in valvular disease that a functional diagnosis is of the highest 
 importance. Not so much what is the lesion or the valve system involved, 
 as how it affects the function of the heart, is the question in the individual 
 case. The condition of the heart muscle is far and away more important 
 than the valvular lesion. Is the compensation maintained or impaired? 
 This is the main point. If impaired, to what extent? Upon the reply 
 to these questions the management of the case and the future of the 
 patient depend. 
 
 When the valvular lesion is compensated the arterial pressure is normal. 
 Under ordinary circumstances there is no dyspnoea upon moderate exertion. 
 Cyanosis is not present. The liver is not enlarged, and the normal amount 
 of urine is voided. We think too much of the condition of the valves; too 
 little of that of the myocardium. The former is beyond the reach of j^ro- 
 phylaxis and cure. Intelligent attention to the latter means, in many cases, 
 the relief of distressing symptoms and the postponement of disaster. When 
 compensation fails the heart is enlarged toward the right, there is dys- 
 pnoea upon slight exertion or even at rest, orthopnoea, faint cyanosis, 
 enlargement of the area of liver dulness, a feeble impulse, and a small, 
 rapid, often irregular pulse, — all manifestations of cardiac inadequacy. 
 
 About 75 per cent, of the cases are due to acute endocarditis, about 
 12 per cent, to arteriosclerosis, and the remainder to primary valvular 
 sclerosis and other causes. Of the cases resulting from acute endocarditis 
 nearly 60 per cent, are due to rheumatic fever. The distribution of the 
 lesions in valvular disease following rheumatism is, according to Romberg, 
 as follows : mitral about 59 per cent. ; mitral and aortic 29 per cent. ; aortic 
 alone 9 per cent.; and mitral and triscupid, and with these the aortic and 
 pulmonary, 3 per cent. 
 
1214 MEDICAL DIAGNOSIS. 
 
 As to age, the greater number of the cases originating in rheumatic 
 endocarditis are first recognized between the tenth and thirtieth years. 
 The chronic endocarditis of early Hfe is mostly due to acute endocarditis; 
 that of advancing years to sclerosis. The two sexes are liable nearly to the 
 same degree. Other predisposing influences are unimportant. 
 
 V. CHRONIC VALVULAR DISEASE, 
 i. Aortic Insufficiency. 
 
 Aortic Incompetence; Aortic Regurgitation; Corrigan's Disease. 
 
 The valves fail to close the aortic orifice and a portion of the blood 
 that has passed into the aorta with the systole returns to the ventricle 
 during diastole. 
 
 The loss of function is, in a great majority of the cases, the result of 
 deformity of the valves; in others it is due to dilatation of the aortic ring — 
 relative aortic incompetency. 
 
 The deformity may be, (a) congenital, and arise from the fusion of 
 two semilunar leaflets at their lateral borders, or from a narrow slit par- 
 allel with and close to the free edge. Such valves frequently show sclerotic 
 changes, (b) The result of acute endocarditis in which the insufficiency is 
 caused by the vegetations, or by ulceration and necrosis, or by adhesions 
 with the later changes which attend sclerosis, (c) The manifestation of 
 progressive sclerotic processes, thickening, rigidity, incurving at the 
 borders, and shortening of the valves, (d) Rupture of a valve segment, 
 an accident due to excessive muscular strain, probably never occurring 
 in previously sound valves and very infrequent in disease, if the ulcerated 
 and necrotic valves of malignant endocarditis be excepted. 
 
 Dilatation of the outlet may occur in arteriosclerosis involving the 
 aorta immediately above the outlet, in aneurism of the ascending portion 
 of the aortic arch, and in advanced age as a senile change. In aortic in- 
 sufficiency due to acute endocarditis there is frequently also some degree 
 of stenosis; in the form associated with arteriosclerosis narrowing is 
 comparatively rare. 
 
 Etiology. — Aortic insufficiency may occur at any age. It is, however, 
 chiefly met with in middle life and is far more common in males than in 
 females. Rheumatic fever and other acute infections associated with 
 acute endocarditis, conditions which favor arteriosclerosis, as occupations 
 involving continuous and prolonged excessive muscular effort, injudicious 
 devotion to athletics, poisons such as lead and alcohol, and gout and 
 syphilis are important etiological factors. 
 
 Direct Effects upon the Heart and Vessels. — The reflux of blood causes 
 overdistention of the left ventricle and diminution of the normal amount 
 in the aorta and its branches. The failure of the valves to close deprives 
 the blood in the arterial tree of its normal base of support, which is trans- 
 ferred in a degree corresponding to the valvular defect to the ventricular 
 wall. The cavity of the ventricle is overdistended. Dilatation occurs 
 and is followed by hypertrophy. In the sclerotic forms the compensation 
 
AORTIC INSUFFICIENCY. 1215 
 
 follows the lesion and symptoms do not for a time occur. In the suddenly 
 developing cases — ulcerative lesions, rupture — compensation does not 
 occur, and the gravest symptoms of acute dilatation of the heart imme- 
 diately follow. The cardiac hypertrophy and dilatation are often extreme. 
 There may be associated lesions of the mitral leaflets. Relative mitral 
 insufficiency results from the enlargement of the mitral ring. The left 
 auricle thereupon undergoes dilatation and hypertrophy, and "as the case 
 progresses similar changes take place in the right chambers of the heart. 
 With each systole the dilated and hypertrophied ventricle sends into the 
 arteries an increased amount of blood with augmented force. There is 
 immediate but momentary widening and elongation of these vessels 
 visible in their superficial branches — locomotor pulsation. 
 
 Symptoms. — Compensation may be fully maintained for a long time. 
 Pain is among the earlier symptoms. It is sometimes dull and limited to 
 the precordia; sometimes sharp and paroxysmal, radiating to the neck 
 and left arm. Angina pectoris is common. Anaemia is also a compara- 
 tively early manifestation. 
 
 As compensation fails, symptoms of cerebral anaemia occur upon 
 sudden effort, rising from bed, or in the act of defecation. Among these 
 are headache, vertigo, phosphenes, and faintness. Presently to these are 
 added precordial distress, and sometimes palpitation, dyspnoea, and 
 oedema of the feet. Cyanosis is not common and blood-streaked sputa 
 less frequent than in other forms of chronic valvular disease. Insomnia 
 and annoying dreams, delirium and hallucinations, and a suicidal tendency 
 are symptoms of the later stages. Irregular fever and embolism in various 
 arterial distributions may be the manifestations of an intercurrent acute 
 endocarditis. 
 
 Physical Signs. — Inspection yields characteristic signs. This is a 
 valvular disease which may often be recognized, when the patient is 
 stripped to the waist, by inspection alone. There are the evidences of a 
 high grade of cardiac hypertrophy, namely, dislocation of the apex beat 
 to the left and downward occasionally as far as the line of the anterior 
 axillary fold and the seventh 
 or eighth interspace; a widely 
 extended heaving impulse; 
 prominence in the precordial 
 area, especially in young per- 
 sons; throbbing at the root of 
 the neck. The superficial arte- 
 ries abruptly expand and almost 
 as suddenly collapse. With 
 
 each pulsation they are thrown Fig. 343.— Aortic regurgitation; carotid tracing. 
 
 into sinuous curves, which are 
 
 conspicuous in the temporals, brachials, and radials. The pulsating aorta 
 may be seen in the episternal notch and in the epigastrium. Capillar)^ 
 pulsation follows the line drawn upon the forehead with the finger-tip, 
 or may be seen in the finger-nails, or, in marked cases, it may occur 
 at times spontaneously in the hands and face. Venous pulsation is 
 sometimes visible, especially in the large veins of the back of the 
 
1216 MEDICAL DIAGNOSIS. 
 
 hands. The pulse has the pecuHarities of the Corrigan or water-nammer 
 pulse. It is appreciably retarded, large, quick, and rapidly receding. 
 It is for this reason spoken of as the collapsing pulse. This last pecul- 
 iarity is intensified when the hand is raised. Upon palpation a forcible 
 impulse may be located in two or three intercostal spaces, and general 
 heaving of the chest perceived by palpation with the whole hand. A 
 diastoHc thrill may sometimes be felt. SystoHc depression, when present, 
 is not so often the sign of pericardial adhesion as of atmospheric pressure. 
 Upon ophthalmoscopic examination the retinal arteries are seen to pul- 
 sate. In aortic regurgitation of high grade there is sometimes seen distinct 
 backward nodding of the head corresponding to the systole. Upon per- 
 cussion, since the hypertrophied heart pushes the lung before it, the area 
 of superficial dulness and that of deep dulness are alike greatly increased, 
 especially downward and to the left. In extreme enlargement of the left 
 ventricle the right heart is displaced to the right. 
 
 Upon auscultation there is to be heard at the base of the heart and 
 downward a diastohc murmur, caused by the reflux of blood through the 
 insufficiently guarded aortic orifice into the ventricle. This murmur is 
 
 Fig. 344. — Aortic regurgitation; radical tracing. 
 
 often faint at the aortic cartilage, but usually distinct or loud at the sternal 
 end of the third left intercostal space or third cartilage, over the seat of 
 the valve, and propagated along the left border of the sternum to the 
 ensiform cartilage. The diastolic murmur of aortic insufficiency is, in 
 many cases, more distinct in the pulmonary than in the aortic punctum 
 maximum. It usually is loud at the beginning and rapidly becomes fainter 
 and lasts throughout the period of diastole. The murmur of aortic insuf- 
 ficiency may, in some cases, be more distinct in the recumbent than in 
 the erect posture. The second aortic sound is either wholly inaudible, 
 being replaced by the murmur, or faintly heard over the aortic cartilage, 
 or finally, when absent at that point, it may be heard over the carotid. 
 The first sound may be normal at the base. A systolic murmur is not 
 always the sign of combined stenosis. It is commonly short, and when 
 coarse and accompanied by a thrill it may be the sign of rigid lesions pro- 
 jecting into the aortic space without actual narrowing, or of abrupt aortic 
 dilatation. While compensation remains good, the first sound at the apex 
 is normal or simply intensified and prolonged. When it fails, the systolic 
 murmur of relative mitral insufficiency is heard. 
 
 Flint's Murmur. — A coarse, rumbhng murmur, presystolic in time, 
 heard in a limited area just above the apex, and accompanied by a thrill. 
 This murmur has the same qualities and time relation to the cardiac revolu- 
 tion as the murmur of mitral stenosis, but it is not associated with the sharp 
 first sound, the abrupt impulse, and the pulsation in the second and third 
 
AORTIC STENOSIS. 1217 
 
 interspaces which characterize well-marked cases of mitral stenosis. It 
 is not heard continuously, but comes and goes under conditions not 
 well understood, and is met with in a large proportion of the cases of 
 uncomplicated aortic insufficiency. 
 
 Over the larger arteries, and especially over the femoral, there is some- 
 times heard a double murmur — Duroziez's murmur. The arteries between 
 the pulse-beats are abnormally empty and soft. The systolic blood-pres- 
 sure is high and the diastolic pressure abnormally low. The sphygmo- 
 gram is characterized by abrupt high ascent, sharp summit, and faintly 
 marked dicrotic notch. 
 
 Diagnosis. — The direct diagnosis of aortic insufficiency rests upon 
 the presence of a diastolic murmur, cardiac hypertrophy, and the pulse 
 of Corrigan — pulsus celer. It finds support in the occurrence of Flint's 
 murmur, or an associated aortic systolic or mitral systolic murmur, — rela- 
 tive insufficiency, — and in the tendency to massive hypertrophy. There 
 are cases in which the diastolic murm^ur cannot be heard, or a systolic mur- 
 mur only is present, yet the pulse and cardiac hypertrophy point to insuf- 
 ficiency of the aortic valve. In high fever with great loss of arterial tone, 
 intense anaemia, some cases of hysteria and neurasthenia, and the more 
 acute forms of exophthalmic goitre, the conditions of the peripheral cir- 
 culation are very suggestive of aortic insufficiency, but in all these the 
 history of the case and the concomitant symptoms and physical signs are 
 of help in the differential diagnosis. 
 
 Prognosis. — The compensation may be maintained for years without 
 symptoms referable to the heart, and the patient lead a fairly active life. 
 The outlook is better when the valvular defect follows acute endocarditis 
 and develops early in life. Associated mitral lesions are unfavorable. 
 Relative mitral insufficiency, by which the arterial conditions are modified, 
 tends to transfer the stress of compensation from the left ventricle to 
 the auricle and thence to the right heart. Sudden death is a danger. 
 It often occurs without marked previous symptoms of heart disease. 
 When compensation fails more gradually, the characteristic symptoms 
 of progressive cardiac inadequacy arise. 
 
 ii. Aortic Stenosis. 
 
 Aortic Obstruction. 
 
 The aortic outlet is narrowed or constricted. A portion of the blood 
 which should pass into the aorta with the ventricular systole is held back 
 with every revolution of the heart. That function of the valve which 
 consists in the retreat of its segments into contact with the wall of the aorta 
 before the blood stream is impaired. This affection is comparatively rare. 
 
 The lesion may be, (a) congenital, in which case the cusps may be 
 united to form a thin diaphragm-like membrane with a small slit-like 
 opening, or there may be a subvalvular stenosis the result of prenatal 
 endocarditis; (b) the result of an acute endocarditis with adhesions, stif- 
 fening, and vegetations which have undergone fibroid and calcareous 
 changes; or (c) the outcome of an arteriosclerotic process. Very often the 
 77 
 
121S MEDICAL DIAGNOSIS. 
 
 last are associated with extensive atheromatous changes in the aorta, and 
 the sigmoid valves are buttressed out by rigid calcareous masses in the 
 sinuses of Valsalva. Under these circumstances the blood supply to the 
 coronary arteries is diminished and myocardial degeneration hastened. 
 
 The obstruction to the outflow of the blood throws increased work 
 upon the left ventricle, which undergoes hypertrophy. Thus compensa- 
 tion is established. So long as compensation is maintained, the ventricle 
 undergoes little or no dilatation, but it appears small in view of the great 
 thickness of the wall and is, therefore, sometimes spoken of as concentric 
 hypertrophy in contradistinction to the ordinary eccentric hypertrophy 
 seen in aortic or mitral insufficiency. When compensation fails the left 
 auricle undergoes dilatation and hypertrophy of its wall, there is increase 
 of the blood-pressure in the pulmonary circuit and stress upon the right 
 ventricle. 
 
 Of aortic stenosis it is especially true that the valves can neither fully 
 open nor completely close. Combined stenosis and insufficiency are 
 therefore common; uncomplicated stenosis is rare. 
 
 Relative stenosis is that condition in which with a normal aortic ring 
 
 and valve cusps there is abrupt dilatation of the aorta immediately beyond. 
 
 Etiology. — This is a rare valvular affection. Its incidence is greater 
 
 in males than females, and it occurs with more frequency in old men with 
 
 atheromatous arteries than at an earlier period of life. 
 
 Symptoms. — With fair compensation there are no special symptoms, 
 and aortic stenosis may reach a high grade without marked .evidences of 
 derangement of the general health. Among the symptoms which attract 
 the attention of the patient to his circulation are those indicative of tran- 
 sient cerebral anaemia — vertigo and faintness. In some cases epileptiform 
 seizures have been observed. Palpitation and precordial pain are less 
 common. As compensation fails the symptoms of cardiac inadequacy 
 are progressively developed. 
 
 Physical Signs. — Inspection shows, as a rule, a heaving impulse due 
 to the left ventricle hypertrophy, situated at the normal place or slightly 
 to the left. As compensation fails and dilatation of the left and later of 
 the right ventricle takes place, the impulse is displaced beyond the mid- 
 clavicular line. A distinct thrill corresponding in time and duration 
 
 to the systolic murmur 
 may be detected at the 
 sternal border or at the 
 right side of the root 
 of the neck over the 
 carotid. The pulse is 
 somewhat retarded. In 
 
 Fig. 345. — Aortic stenosis: radial tracing. , , , ■, 
 
 other respects, namely, 
 as to volume and tension, it often preserves its normal characters, though in 
 stenosis of high grade it may be small and slow, with the filling of the 
 arteries well maintained between the beats. The sphygmogram shows a 
 slow rise, a broad summit, and a slow decline. There is in most of the cases 
 in advanced life evidence of marked arteriosclerosis. Upon palpation the 
 position of the apex beat may be obscured by pericardial adhesions or an 
 
AORTIC STENOSIS. 1219 
 
 emphysematous lung. Upon percussion while compensation is still main- 
 tained, the transverse diameter of the absolute dulness and that of the 
 relative dulness of the heart are little if at all increased. Auscultation 
 discloses in the second right intercostal space at the sternal border a very- 
 distinct systolic murmur, usually coarse and harsh. This murmur is among 
 the loudest of the heart murmurs and may sometimes be heard at a distance 
 of some feet from the patient. Not infrequently it has a musical quality 
 during some part of its course. It is distinctly transmitted to the carotids 
 and subclavians, especially upon the right side; less plainly over the heart, 
 but in some cases it may be heard at the apex. Very characteristic is the 
 absence of the second aortic sound. A second sound heard at the aortic car- 
 tilage is in most cases transmitted from the pulmonary valve. When compen- 
 sation fails the murmur may be faint and distant and the thrill disappear. 
 
 Diagnosis. — Direct. — Aortic stenosis may be recognized by the 
 association of a loud, rough, or musical systolic murmur having its point 
 of maximum intensity at the aortic punctum maximum, and accompanied 
 by a thrill, the signs of hypertrophy of the left ventricle, an inaudible or 
 faint aortic second sound, and a slow, regular pulse of moderate tension. 
 
 Differential. — Errors of diagnosis are common. They arise from 
 attaching too great importance to a systolic murmur in the aortic area 
 in the absence of actual signs of lesions of the valve and hypertrophy of 
 the ventricle. The following conditions in which such a murmur may be 
 heard are to be considered : Sclerosis of the aorta directly beyond the valve, 
 or of a cusp without narrowing of the orifice may, particularly when asso- 
 ciated with the cardiac hypertrophy of nephritis, closely simulate aortic 
 stenosis. In favor of the former condition would be an accentuated aortic 
 second sound, and a small, regular, and rather slow pulse. Aneurism of 
 the Ascending Portion of the Arch. — A history of syphilis or strain, pressure 
 symptoms, — as pain, dyspnoea, or cough, — inequality of the pulses, displace- 
 ment of the heart as a whole rather than hypertrophy of the left ventricle, 
 circumscribed dulness and bulging with or without a thrill, tracheal tugging, 
 and diastolic shock, all or several, when present, justify a diagnosis of 
 aneurism. An X-ray examination may be of great service in a doubtful 
 case. In ancemic conditions the basic murmur is often loudest in the aortic 
 area. This soft bruit is very different from the loud, harsh murmur of 
 stenosis; the aortic second sound is heard, there is not usually hypertrophy 
 of the left ventricle, the pulse is more frequent, and anaemia may be dem- 
 onstrated upon examination of the blood. Relative aortic stenosis may 
 be suspected when, with a systolic aortic murmur, the second aortic sound 
 is preserved, left ventricle hypertrophy is lacking, and signs of dilatation 
 of the aorta are found upon percussion or by palpation with the finger-tip 
 in the episternal notch. 
 
 Prognosis. — Cases following acute endocarditis in early life with good 
 compensation may go on without cardiac symptoms for many years. 
 Those due to arteriosclerosis beginning in advancing life are of much less 
 favorable outlook. The changes are essentially progressive, the coronary 
 arteries are liable to become involved, and with the development of myo- 
 carditis compensation fails. This form of chronic valvular disease is not 
 attended with an especial liability to sudden death. 
 
1220 MEDICAL DIAGNOSIS. 
 
 iii. Mitral Insufficiency. 
 
 Mitral Incompetence; Mitral Regurgitation. 
 
 A portion of the blood in the left ventricle, which upon systole should 
 pass onward into the aorta, leaks back through the auriculoventricular 
 orifice into the left auricle. Mitral insufficiency is the result of valvular 
 disease, or it may occur without lesions of the valves in consequence of 
 dilatation of the heart — relative insufficiency — or of derangement of the 
 mechanism by which the leaflets are brought into effectual coaptation — 
 muscular insufficiency. 
 
 Mitral Insufficiency Due to Chronic Valvular Disease. — The 
 structural defects in the valves are in the great majority of the cases the 
 result of acute endocarditis; infrequently the outcome of primary sclerotic 
 processes. They consist of an overgrowth of fibroid tissue with thickening 
 and shortening of the segments, adhesions between their borders, shorten- 
 ing of the chordae tendinese, and the deposition of lime salts in the new- 
 formed tissues. In advanced cases the altered valves are often transformed 
 into a thick, rigid calcareous diaphragm perforated by an irregular oval 
 opening. Owing to the nature of the lesions uncomplicated mitral insuf- 
 ficiency is rare, the condition being, as a rule, associated with some degree 
 of stenosis. 
 
 The effect upon the heart is as follows: 
 
 (a) With each ventricular systole a quantity of blood, varying accord- 
 ing to the valvular defect, is returned from the ventricle to the left auricle. 
 This results in an overdistention of the auricle with dilatation and 
 hypertrophy. 
 
 (b) The left ventricle undergoes dilatation in consequence of the 
 increased volume of blood received from the overfilled auricle. It, how- 
 ever, empties itself in the normal time and becomes hypertrophied to 
 meet the increased work. Notwithstanding the amount of blood returned 
 to the auricle, the normal quantity enters the general circulation. 
 
 (c) In the minor degrees of mitral insufficiency, the dilatation and 
 hypertrophy of the left chambers of the heart suffice for compensation. 
 
 (d) In higher grades, the increased blood-pressure due to the over- 
 filling of the left auricle is transferred to the pulmonary veins, and by way 
 of the capillaries to the branches of the pulmonary artery, and thence to 
 the right ventricle, which in turn undergoes hypertrophy. 
 
 (e) So long as the compensation thus established is maintained the 
 right ventricle does not undergo dilatation. 
 
 (f) The prolonged overfilling of the pulmonary vessels produces brown 
 induration of the lungs. 
 
 (g) The compensation may be indefinitely prolonged, but after a 
 time it fails, the left ventricle no longer discharges the normal amount of 
 blood into the aorta, the right ventricle begins to dilate, there is relative 
 insufficiency of the tricuspid valves, and the right auricle becomes dilated. 
 The pressure is transferred to the venous system, and the passive visceral 
 congestions, dropsies, anaemic and other symptoms of cardiac dyscrasia 
 begin to show themselves. 
 
MITRAL INSUFFICIENCY. 1221 
 
 Etiology. — -Mitral insufficiency is the most common of the chronic 
 valvular diseases. Predisposing Influences. — These are found chiefly 
 in the acute infections, in the course of which acute endocarditis occurs, 
 especially rheumatic fever. Age, therefore, also constitutes an important 
 predisposing factor, mitral valvular disease being especially a disease of 
 childhood and early adult life. It may be said that the valvular diseases 
 of early life are of inflammatory origin; those of advanced life sclerotic. 
 Sex appears to be wholly without influence. 
 
 Exciting Cause. — The immediate cause of the deformity of the 
 valves is to be found in the advance of lesions having their point of depar- 
 ture in previous inflammation or sclerosis. 
 
 Symptoms. — While compensation is maintained there are no dis- 
 tinctive symptoms. With insufficiency of high grade there may be merely 
 slight dyspnoea upon unusual effort, and a rather marked tendency to 
 attacks of bronchial catarrh. When compensation is incomplete the 
 symptoms are very suggestive. Faint cyanosis, dilated superficial venules, 
 dyspnoea and palpitation upon moderate effort, and frequently recurring 
 bronchitis, often accompanied by blood-streaked sputa or haemoptysis, 
 constitute the clinical picture. Nevertheless, such patients often continue 
 to work and take pleasure in life for a long period. 
 
 With broken compensation the disability is complete. The symptoms 
 are those of advanced cardiac inadequacy, palpitation, feeble, irregular 
 heart action, an irregular, feeble pulse, arrhythmia, dyspnoea, and harass- 
 ing cough with thin blood-stained sputa containing alveolar cells with 
 pigment granules — Herzfehlerzellen. Precordial distress and a sensation 
 of heart failure are common. Another group of symptoms comprise those 
 due to passive congestions. Among these are pallor, faint cyanosis, yel- 
 lowness of the skin, drowsiness, insomnia, dropsy beginning at the ankles 
 and rising to the body with accumulations in the loose tissues around the 
 pudenda, in parts that are dependent, as the buttocks and flanks, and in the 
 serous sacs, and diminished urine with albumin, casts, and blood-corpuscles. 
 Even at this stage compensation may be by rest and treatment to some 
 extent restored, only to be lost again in a little while. Death is not usually 
 sudden, although at the last it may come quickly. Recurrent endocar- 
 ditis is common and frequently of the malignant type. Subacute peri- 
 carditis is common. Among the intercurrent diseases to which the patients 
 appear to be especially liable are bronchitis, bronchopneumonia, pleurisy, 
 pulmonary infarct, and cerebral embolism. There is also a marked ten- 
 dency to cerebral and retinal hemorrhage and to epistaxis. Febrile attacks 
 are common in the absence of assignable cause. But the rise in temperature 
 may often be explained by demonstrable infectious or septic conditions. 
 
 Physical Signs. — With fair compensation the cardiac enlargement 
 is moderate. The impulse is displaced to the left and stronger than normal. 
 When the compensation is l:)roken it is extended, undulatory, and feeble. 
 Palpation determines the force and extent of the impulse. With compen- 
 sation it is forcible and heaving; in failure it is feeble and extended. In 
 a small proportion of the cases a faint systolic thrill may be detected at 
 the apex. The pulse with compensation is full and regular, but it may be 
 of low tension. As compensation fails it becomes small, feeble usually, 
 
1222 
 
 MEDICAL DIAGNOSIS. 
 
 somewhat increased in frequency, and arrhythmic. The irregularity per- 
 sists when compensation is restored, and the pulse of mitral insuflEiciency 
 once irregular is almost always irregular. The transverse dulness is 
 increased toward the left and to some extent upward. It does not usually 
 extend to the right while compensation is maintained. Exceptionally 
 in large hypertrophy of the left ventricle the right ventricle may be dis- 
 placed beyond its normal position toward the right. With failing com- 
 pensation the dilated right ventricle gives increased dulness to the right 
 of the sternal border. Upon auscultation there is heard a systohc murmur 
 having its point of maximum intensity at the apex and being transmitted 
 in all directions, but most distinctly in the direction of the axilla. In 
 
 Fig. 346. — Mitral regurgitation; good compensation; radial tracing. 
 
 some cases this murmur is loudest along the left border of the sternum 
 or in the pulmonary area. It may also be heard along the lower part 
 of the inner border of the left scapula. It is sharp, less frequently 
 soft and blowing, and sometimes musical, especially toward the end. 
 Its intensity varies from time to time. It may be more distinct in the 
 erect than in the recumbent posture, but it is usually audible in both 
 
 Fig. 347. — Mitral regurgitation; radial tracing. 
 
 attitudes. It may accompany or wholly replace the first sound of the 
 heart. The second pulmonary sound is accentuated. A more or less 
 distinct presystolic murmur is the sign of a combined stenosis but it is 
 by no means always to be heard. 
 
 Relative and Muscular Insufficiency. — (a) Relative insuffi- 
 ciency of the left auriculoventricular valve — mitral valve system — results 
 from overdistention of the auriculoventricular ring. It occurs in acute 
 dilatation of the heart, — heart-strain; the heart starvation of acute illness 
 and chlorosis or anaemia,— and is then described as primary; and in aortic 
 regurgitation and aortic stenosis upon failure of compensation, when it 
 is known as secondary relative insufficiency. 
 
 The etiological factors are those of acute or gradual dilatation. The 
 pathological condition is stretching of the ventricular ring; the derange- 
 ment of function, incompetence of the valve system. The rational 
 symptoms and physical signs are those of valvular insufficiency. 
 
MITRAL INSUFFICIENCY. 1223 
 
 (b) Muscular insufficiency may involve the mitral or the tricuspid 
 valve system. It is due to a derangement of the mechanism by which the 
 closure takes place. There may be evidences of moderate dilatation of the 
 auriculoventricular ring, but these are often absent. Pathological changes 
 in the myocardium are, however, present. There is myocarditis involving 
 the ring muscle at the base of the ventricle and the papillary muscles. 
 The occasional occurrence of transitory systolic mitral murmurs in other- 
 wise healthy men, in the absence of a history of acute cardiac dilatation, 
 justifies the assumption that muscular insufficiency may sometimes be 
 purely functional. It may aid the understanding of this somev/hat obscure 
 subject to recall the fact that the auriculoventricular valves are held in close 
 contact during systole, not merely at their margins but throughout their 
 auricular faces, by the pressure of the blood upon their ventricular surfaces. 
 
 Diagnosis. — The direct diagnosis of mitral insufficiency may be 
 attended with difficulty. A systolic murmur having its point of maximum 
 intensity at the apex, propagated to the axilla, and heard at the angle of the 
 scapula; accentuation of the pulmonary second sound; and the signs of hyper- 
 trophy of the left ventricle, namely, increase in the transverse diameter to 
 the left, and a strong impulse, are important but not in every case conclusive. 
 
 The DIFFERENTIAL DIAGNOSIS between valvular and relative and 
 muscular insufficiency cannot always be made. Here the anamnesis is 
 very useful. In the latter groups of cases a history of acute illness, as 
 diphtheria, enteric fever, or influenza, but no history of recent rheumatism 
 or scarlet fever, recent blood loss or other cause of secondary anaemia, and 
 primary anaemias, as chlorosis or pernicious anaemia, are very suggestive. 
 The signs of arteriosclerosis and of chronic nephritis must be considered 
 when the diagnosis is obscure. These conditions are frequently associated 
 with myocarditis and muscular insufficiency. The almost constant asso- 
 ciation of some degree of stenosis with insufficiency gives to a presystolic 
 murmur and thrill great value in a doubtful case. 
 
 Prognosis. — Mitral insufficiency is the most common and the least 
 deadly of the chronic valvular diseases. Whether or not minor lesions 
 ever terminate in recovery may well be questioned. It is certain, however, 
 that there are many cases in which full compensation is early established 
 and maintained through life. The signs persist, but cardiac symptoms are 
 absent. The outlook is more favorable in the cases which follow acute 
 endocarditis than in those originating in sclerotic processes; when the 
 disease begins in adolescence or early adult life than in childhood or the 
 aged; in those who are able and willing to lead quiet, orderly, and well- 
 disciplined lives than in those whose circumstances demand unremitting 
 toil, or whose habits are irregular and self-indulgent. The extent of the 
 leakage, as indicated by the degree of dilatation and hypertrophy, the com- 
 pleteness of compensation, the presence of secondary morbid conditions 
 or of other valvular lesions or extensive pericardial adhesions has an impor- 
 tant bearing upon the prognosis. The liability to recurrent acute endo- 
 carditis adds to the gravity of the condition. Among the common causes 
 of death are cardiac insufficiency in the sense of complete loss of contrac- 
 tile power, pulmonary infarct, cerebral embolism, nephritis, and acute 
 intercurrent disease. 
 
1224 MEDICAL DIAGNOSIS. 
 
 iv. Mitral Stenosis. 
 
 The mitral orifice is narrowed or constricted and the passage of the 
 blood from the left auricle to the left ventricle is impeded. The lesion 
 is commonly the result of acute endocarditis in early life. It consists of 
 thickening and contraction of the segments of the mitral valve or the 
 ring, or both. Anatomically there are various forms. The more impor- 
 tant are, (a) great thickening of the valves with a mere oblong fissure or 
 chink — buttonhole contraction. The ring is often much contracted, (b) 
 The projection from the line of the base of the segments of thick nodular 
 fibroid masses, often in part calcareous, into the lumen of the orifice. The 
 segments themselves may be thickened but are sometimes but slightly 
 affected, (c) The valves are adherent at their borders but thin and elon- 
 gated, projecting into the ventricle and opening at the tip by a constricted 
 orifice — funnel-shaped stenosis, (d) Narrowing of the mitral ring without 
 marked changes in the valve — probably a congenital condition. The 
 chordae tendinese are shortened and thickened, and in some instances the 
 tips of the papillary muscles are inserted into the deformed valves. 
 
 The degree of stenosis varies from the tip of the finger to an opening 
 that will only admit a medium-sized Bowman's probe. The heart is mod- 
 erately enlarged, the hypertrophy affecting the left auricle and right ven- 
 tricle. The left ventricle, except in cases in which there is also marked 
 insufficiency of the valve, is usually small. The derangement of function 
 consists in the overfiUing of the auricle with increase in its work during the 
 ventricular diastole. The wall of the auricle undergoes hypertrophy, which 
 for a time may compensate the defect. The pressure is transferred through 
 the pulmonary circuit to the right ventricle, upon which the compensation 
 largely falls, and which at first undergoes hypertrophy without dilatation. 
 When compensation fails, there is relative incompetency of the tricuspid 
 valve and transference of pressure to the venous side of the general circula- 
 tion. In consequence of the inabihty of the left auricle to maintain compen- 
 sation, as a rule, and the action of the hypertrophied right ventricle through 
 the pulmonary circuit, the compensation in mitral stenosis is rarely complete. 
 
 Etiology. — Predisposing Influences. — Uncomplicated mitral ste- 
 nosis is a rare affection. In almost all the cases there is some degree of 
 mitral insufficiency. Age is important. A few of the cases are congenital; 
 the greater number occur in early life. The evidences of the lesion may 
 first attract attention at any period of life. There is a remarkable pre- 
 ponderance of cases in females. The ratio varies according to various 
 statistics from 2 to even 4 to 1. This disparity of incidence affects only 
 the cases in persons under middle age in whom the lesions are commonly 
 due to endocarditis, and does not appear in the statistics of the old cases^ 
 which are almost always of sclerotic origin. 
 
 Exciting Cause. — Acute endocarditis in the course of an attack of 
 rheumatism, chorea, scarlet fever, or one of the other acute infections of 
 childhood may be the starting-point of mitral stenosis. The acute and 
 repeated tension upon the heart valves in whooping-cough may act in the 
 same way. In a remarkably large proportion of the cases the anamnesis 
 is silent as to the cause. 
 
MITRAL STENOSIS. 
 
 1225 
 
 Symptoms. — Fair compensation is often maintained for years, during 
 which symptoms are absent. As it gradually fails dyspnoea upon exertion 
 first attracts attention. Pressure paralysis of the left recurrent laryngeal 
 nerve from the enlarged auricle has been observed. Cerebral embolism is by 
 no means rare. The frequency with which haemoptysis occurs while compen- 
 sation is yet fair is interesting. The cases are often mistaken for incipient 
 phthisis. The tendency to dropsy is less marked than in mitral insufficiency. 
 
 Physical Signs. — Upon inspection there is very often, especially in 
 the young, precordial prominence due to hypertrophy of the right ven- 
 tricle. The apex beat is commonly displaced but sHghtly toward the left, 
 and may be indistinct, the visible impulse being at the lower end of the 
 sternum and extending to the 
 left costal cartilages. The pul- 
 sation of the conus arteriosus 
 may often be visible at the ster- 
 nal end of the third and fourth 
 left interspaces. As compensa- 
 tion fails, the impulse loses its 
 power, and signs of back pressure in the systemic veins appear, as distention 
 of the superficial veins, especially the jugulars, with pulsation due to con- 
 traction of the right ventricle and enlargement of the liver. Upon palpation 
 there is recognized in at least three-fourths of the cases a very distinct 
 thrill. This sign is usually coarse in character, diastolic or presystolic in 
 time, confined to an area above the apex, usually in the fourth and fifth 
 interspaces, and circumscribed. It is more intense and slightly more 
 extended during expiration and runs up to a short, sharp apex beat. This 
 
 Fig. 348. — Mitral stenosis; carotid tracing. 
 
 Fig. 349. — Mitral regurgitation and stenosis; radial tracing. 
 
 thrill is of the highest diagnostic significance. It is the tactile equivalent 
 of the characteristic murmur of mitral stenosis. It may, however, fre- 
 quently be felt when no murmur can be detected at this time in the cardiac 
 cycle. In stenosis of moderate grade, so long as compensation is good the 
 pulse has no special characters. Upon failure of compensation it becomes 
 small, soft, and arrhythmic. Upon percussion the dulness in fair compen- 
 sation extends but slightly to the left of the normal line, rarely much beyond 
 the midclavicular line, and little to the right of its normal limits. When, 
 however, compensation is broken, the transverse diameter of deep cardiac 
 dulness is decidedly increased, reaching beyond the midclavicular line on 
 the left and beyond the parasternal line on the right. Auscultation reveals , 
 a characteristic murmur which corresponds in situation and in time of its 
 occui'rence in the revolution of the heart to the thrill which has been! 
 described above, and which is its auditory equivalent. This mur-i 
 
1226 MEDICAL DIAGNOSIS. 
 
 mur is rough and A'ibratile in character, increasing in intensity toward 
 its close, and terminates abruptly in the tap which constitutes the first 
 sound. It occurs in four modifications. In the greater number of cases 
 it occupies the entire period of the diastole, and is increased in intensity 
 at the time of the auricular contraction which immediately precedes the 
 ventricular systole; it maybe heard at the beginning and at the close 
 of the diastole; it may be present in the mid-diastoHc period; and 
 finally it is in some cases heard only in the moment immediately preceding 
 the first sound. The intensity of this murmur is extremely variable. It 
 may be the loudest of heart murmurs, or very soft and faint, or, finally, 
 it may be wholly inaudible when the patient is at rest, and only heard 
 after exertion. It may at times have a pecuHar rumbling quahty. Its 
 loudness depends in part upon the character of the lesions and in part upon 
 the force of the blood stream. It is in accordance with this fact that, as 
 compensation fails, the murmur can no longer be heard, but only the sharp 
 first sound in the mitral area, or the one, two, three of the gallop rhythm. 
 If, however, under rest and treatment compensation is for a time re-estab- 
 Hshed the murmur reappears. This change is often met with in actual 
 practice and has been the cause of many disputes as to diagnosis. 
 
 The first sound is short, valvular, and very loud. It has in many cases 
 the character of the second sound and is frequently mistaken for it. Under 
 this error the murmur is naturally assumed to be systoHc and the condi- 
 tion that of mitral insufficiency. This mistake is to be avoided by deter- 
 mining the time of the auscultatory signs by palpation of the cardiac impulse 
 or carotid pulse at the moment of auscultation. The alteration in the first 
 sound is due to the quick contraction of the left ventricle upon an abnor- 
 mally small blood content. The second pulmonary sound is strongly 
 accentuated. 
 
 Diagnosis. — The direct diagnosis is in well-marked cases not diffi- 
 cult. It rests upon the association of the presystolic thrill and murmur 
 with the signs of hypertrophy of the right ventricle, the absence of signs 
 of enlargement of the left ventricle, the loud snapping character of the 
 first sound, and the accentuation of the pulmonary second sound. 
 
 Prognosis. — In general the outlook is less favorable than in mitral 
 insufficiency. This form of chronic valvular disease is only second to 
 aortic insufficiency in the gravity of the prognosis. Sudden death is some- 
 what more frequent than in mitral insufficiency, but occurs usually after 
 the compensation has become greatly impaired. Among the more common 
 causes of death are progressive cardiac asthenia, pulmonary infarction or 
 oedema, and acute intercurrent disease. More than any other chronic 
 valvular disease of the heart, mitral stenosis is associated with tuberculosis, 
 and to the latter the termination must in many of the cases be attributed. 
 
 V. Pulmonary Insufficiency and Stenosis. 
 
 Lesions of the pulmonary valves are extremely rare. Murmurs having 
 their point of maximum intensity in the pulmonary area are common. 
 They are usually systolic. They are sometimes present in health, especially 
 in children, and are best heard during expiration and in the recumbent 
 
TRICUSPID INSUFFICIENCY AND STENOSIS. 
 
 1227 
 
 posture, in the rapidly acting heart, in anaemia and chlorosis; and it is 
 in the last that cardiorespiratory murmurs are usually heard. 
 
 Insufficiency. — This is a rare congenital lesion. It may occur in malig- 
 nant endocarditis. Relative insufficiency may result from overdistention 
 of the pulmonary artery. There are dilatation and hypertrophy of the 
 right ventricle, epigastric pulsation, a heaving impulse over the lower 
 sternal region, and a soft diastolic murmur at the second left costal carti- 
 lage and third intercostal space, much more distinct upon expiration. 
 This condition is to be differentiated from aortic insufficiency, to which 
 it has superfi^jial resemblances, by the presence of epigastric pulsation and 
 other signs of hypertrophy of the right ventricle, and the condition of the 
 systemic arteries. 
 
 Stenosis. — This practically occurs only as a congenital lesion and is 
 always associated with other developmental anomahes. Sclerotic changes 
 occur and the deformed valves are especially disposed to acute endocar- 
 ditis. There are no special symptoms. Among the physical signs are a 
 systolic murmur and thrill in the second left intercostal space at the sternal 
 border, a faint or inaudible second sound, and the evidences of hypertrophy 
 of the right ventricle. The pressure of an aortic aneurism may narrow the 
 pulmonary outlet, or the cicatrices of syphilitic lesions the conus arteriosus, 
 and give rise to similar signs. The diagnosis may sometimes be made with 
 precision. 
 
 vi. Tricuspid Insufficiency and Stenosis. 
 
 Insufficiency. — This valvular defect is extremely rare as the result of 
 endocarditis involving the right side of the heart. Relative insufficiency is, 
 however, very common as a secondary condition in the period of failing 
 compensation in disease of the aortic and mitral valves, especially the 
 latter. It occurs also in advanced 
 fibroid phthisis, emphysema, and 
 other pulmonary d i s e a s e s- in 
 which there is permanent obstruc- 
 tion of the pulmonary circulation. 
 The auricle is dilated and hyper- 
 tr op hied. The return of the 
 venous blood is impeded and the 
 supply to the pulmonary artery 
 diminished. The symptoms of 
 retarded pulmonary circulation 
 and visceral congestions charac- 
 terize this condition. The physi- 
 cal signs are chiefly due to the 
 enlargement of the right auricle 
 
 and the reflux of blood from the right ventricle through the tricuspid orifice. 
 They consist of increase in the transverse dulness to the right of the sternum 
 with occasional pulsation at the sternal ends of the lower interspaces; a sys- 
 tolic murmur, usually soft and low-pitched, having its point of maximum 
 intensity over the lower part of the sternum and propagated in the direction 
 of the right axilla; and finally pulse-waves in the veins of the neck, more 
 
 Fig. 350. — Venous pulse of tricuspid insufficiency. 
 Upper tracing — venous pulse; lower tracing — apex beat. 
 
1228 
 
 MEDICAL DIAGNOSIS. 
 
 marked upon the right side. The venous pulse is synchronous with the 
 carotid pulse and apex beat. It is sometimes transmitted to the subclavian 
 and axillary veins. It may, by way of the vena cava and hepatic veins, 
 reach the liver and cause the phenomenon known as pulsating liver, an 
 expansile pulsation in the organ best appreciated upon bimanual palpation^ 
 
 vii. PHYSICAL SIGNS OF UNCOMBINED VALVULAR LESIONS OF THE LEFT 
 HEART, COMPENSATION BEING MAINTAINED. 
 
 
 Mitral 
 
 AortiQf 
 
 
 Insufficiency 
 
 Stenosis 
 
 Insufficiency 
 
 Stenosis 
 
 Impulse 
 
 Increased in extent. 
 
 Often ill-defined and 
 
 Extended, heaving. 
 
 Variable; some- 
 
 
 Displaced to left 
 
 extended, but not 
 
 forcible and dis- 
 
 times feeble and 
 
 
 
 much beyond the 
 
 placed downward 
 
 indistinct ; often 
 
 
 
 midclavicular line. 
 
 and to the left 
 
 slow, heaving 
 
 
 
 Preceded by thrill 
 
 
 and forcible. 
 Moderately dis- 
 placed to the left. 
 
 Cardiac dul- 
 
 Increased transverse- 
 
 Increased to the right 
 
 Increased to a greater 
 
 Moderately in- 
 
 ness 
 
 ly and downward. 
 
 of the sternum and 
 
 extent than in any 
 
 creased to the left. 
 
 
 It may extend be- 
 
 along its left border; 
 
 other valvular le- 
 
 
 
 yond the right bor- 
 
 not usually beyond 
 
 sion. Principally 
 
 
 
 der of the sternum 
 
 the midclavicular 
 
 downward and to 
 
 
 
 and beyond the left 
 
 line 
 
 the left 
 
 
 
 midclavicular line 
 
 
 
 
 Murmurs 
 
 Systolic at apex ac- 
 
 Coarse, presystolic, 
 
 Diastolic, prolonged, 
 
 Coarse, systolic, of 
 
 
 companying or re- 
 
 terminating in the 
 
 accompanying 
 
 maximum inten- 
 
 
 placing the first 
 
 first sound and lim- 
 
 or wholly replacing 
 
 sity at aortic car- 
 
 
 sound. Transmit- 
 
 ited to the region of 
 
 the aortic second 
 
 tilage and propa- 
 
 
 ted toward left ax- 
 
 the apex 
 
 sound, and propa- 
 
 gated into the 
 
 
 illa. May be heard 
 
 
 gated from the base 
 
 great vessels. 
 
 
 at the back ; some- 
 
 
 of the heart down- 
 
 
 
 times widely over 
 
 
 ward along the ster- 
 
 
 
 chest 
 
 
 num and to the left 
 
 
 As social ed 
 
 Accentuation of pul- 
 
 Presystolic thrill ; im- 
 
 A systolic shock in 
 
 Systolic thrill in 
 
 signs 
 
 monary second 
 
 pulse of conus ar- 
 
 the larger arteries 
 
 aortic area, absent 
 
 
 sound 
 
 teriosus of right 
 
 and sometimes a 
 
 or feeble aortic 
 
 
 
 ventricle in fourth 
 
 double murmur— 
 
 second sound. 
 
 
 
 and third, some- 
 
 Duroziez's sign. 
 
 Occasionally a di- 
 
 
 
 times in second left 
 
 The aortic second 
 
 astolic murmur. 
 
 
 
 interspaces. A clear. 
 
 sound may be heard 
 
 
 
 
 well-defined first 
 
 over the right ca- 
 
 
 
 
 sound. Accentu- 
 
 rotid when absent 
 
 
 
 
 ation of pulmonary 
 
 in aortic area 
 
 
 
 
 second sound. Re- 
 
 
 
 
 
 duplication of 
 
 
 
 
 
 second sound 
 
 
 
 Pulse 
 
 Full, regular, frequent 
 
 Smaller in volume 
 
 Water-hammer, c o 1- 
 
 Small, of fair ten- 
 
 
 and usually of low 
 
 than normal and 
 
 lapsi ng — Corrigan 's 
 
 sion, regular, and 
 
 
 tension. Upon fail- 
 
 frequently arrhyth- 
 
 pulse 
 
 usually somewhat 
 
 
 ure of compensation 
 
 mic 
 
 
 slower than nor- 
 
 
 there is usually ar- 
 
 
 
 mal. 
 
 
 rhythmia which is 
 
 
 
 
 
 commonly persist- 
 
 
 
 
 
 ent 
 
 
 
 
 and to be differentiated from the ''jogging" liver, which rises and sinks 
 under the influence of the movements of the heart or aorta but does not 
 expand and contract. 
 
 Stenosis. — Tricuspid stenosis is a rare form of valvular disease. It 
 may be congenital, in which case it is almost invariably associated with 
 other cardiac anomahes; or acquired, when it presents deformities similar 
 to those seen in mitral stenosis. It is usually associated with some degree 
 of incompetence of the tricuspidahs and with diseases of the other valve 
 
COMBINED VALVULAR DISEASES. 1229 
 
 systems, most commonly the mitral. In a large proportion of the cases 
 there has been a history of rheumatic fever; in a few a history of syphilis. 
 This form of chronic valvular disease is far more common in females than 
 in males. It has, in a majority of the cases, been first observed early in 
 adult life. It is so rarely an isolated lesion that its symptoms are commonly 
 obscured by those of the associated affections. They are those of general 
 venous engorgement. Distention of the jugulars, cyanosis of the lips and 
 face, tenderness over the liver, and dropsy are common. The physical 
 signs are also usually subordinate to those of the associated valvular disease. 
 Percussion shows increased dulness to the right of the sternum. When, in 
 a case of mitral stenosis, there is a second presystolic murmur best heard 
 at the base of the ensiform cartilage at the right, associated with a pre- 
 systolic thrill, and these are of different character from those in the mitral 
 area, tricuspid stenosis may be diagnosticated. The clinical diagnosis is, 
 however, uncertain. Almost all the cases have been discovered upon the 
 post-mortem table, the condition not having been suspected during life. 
 
 viii. Combined Valvular Diseases. 
 
 There are two cardinal facts in regard to chronic valvular disease. 
 First, that the lesions are very rarely uncompHcated, and second, that the 
 condition of the myocardium is much more important than the state of 
 the valves. While the recognition of these facts renders heart disease 
 complex and difficult as regards diagnosis, it greatly simplifies it in respect 
 of prognosis and the recognition of the indications for treatment. The 
 valvular damage is irreparable, but injury to the myocardium may be 
 postponed or to some extent repaired. The diagnosis, to be of service, 
 must be at once anatomical and functional. It undertakes to determine 
 what valve system is defective; whether the defect gives rise to obstruction 
 or incompetence or both, and in the last of these conditions which defect 
 predominates; whether more than one valve system is involved, and in 
 what manner; and finally the condition of the myocardium — is its contrac- 
 tile function increased to the point of full compensation? Is the increase 
 maintained? Is it failing? From this point of view the combined lesions 
 acquire especial clinical importance. In aortic and mitral insufficiency 
 resulting from acute endocarditis a progressive stenosis may favorably 
 modify the condition of the heart by diminishing the regurgitation. Aortic 
 lesions and, in particular, aortic regurgitation are more frequently simple 
 than mitral lesions. Relative and muscular mitral and tricuspid insuffi- 
 ciency are frequently uncombined. 
 
 Especially common is the combination of mitral insufficiency with 
 steftosis of the mitral orifice. The greater the one, the less the other of 
 these defects. This combination is very often associated with other valvu- 
 lar lesions. Next in order of frequency is the association of aortic insuffi- 
 ciency and mitral insufficiency, or combined mitral insufficiency and 
 stenosis. Combined aortic insufficiency and stenosis is less common but 
 not rarely associated with other valvular lesions. In proportion as the 
 stenosis is marked the insufficiency is diminished and a progressive 
 narrowing of the orifice in insufficiency may be conservative. 
 
1230 
 
 MEDICAL DIAGNOSIS. 
 
 The frequent association of tricuspid disease with mitral lesions has 
 already been noted, especially that of tricuspid and mitral stenosis. The 
 diagnosis of these and other combined lesions depends upon the recognition 
 of the associated signs and demands the painstaking study of every phe- 
 nomenon in any particular case. 
 
 VI. CONGENITAL LESIONS OF THE HEART. 
 
 These lesions are of two kinds, developmental and inflammatory. 
 Developmental Defects. — To this group are to be referred the 
 following anomalies: 
 
 (a) Defects of the whole heart, as acardia, double heart, ectopia 
 
 cordis — conditions not, as a rule, of 
 diagnostic interest, (b) Defects of 
 the septa, which may, by the absence 
 of both the auricular and ventricu- 
 lar septum, convert the heart into a 
 double chamber — the bilocular heart; 
 or by the absence of the ventricular 
 septum only, convert it into a three- 
 chambered viscus — the trilocular 
 heart, (c) Patent foramen ovale, 
 (d) Defects of the valves, which 
 may be increased or diminished in 
 number, or adherent. These ana- 
 tomical defects involve the semilunar 
 cusps of the aortic and pulmonary 
 valves, but not the segments of the 
 auriculoventricular valves, (e) 
 Transposition of the large vessels. 
 
 Fetal Endocarditis. — The 
 right heart is usually affected. Pul- 
 monary stenosis is a common result. 
 Complete obliteration of the pul- 
 monary orifice is associated with 
 persistence of the ductus arteriosus 
 and patulence of the foramen or 
 other defect in the ventricular wall. 
 Congenital lesions at the aortic 
 orifice are rare. 
 
 Developmental anomalies are 
 usually multiple. They not infre- 
 quently are the seat of sclerotic 
 processes. 
 
 Symptoms. — Cyanosis, general 
 
 duskiness of the surface, a persistent 
 
 low external temperature, dyspnoea 
 
 and cough, increase in the red blood-corpuscles, the drum-stick deformity 
 
 of the fingers and toes, and finally retarded physical and mental develop- 
 
 351.— Chilibf. 
 
 German 
 
HEART BLOCK. 1231 
 
 merit are usually present. Associated developmental defects in the mouth, 
 genitalia, or elsewhere are common. In infants the presence of endocardial 
 murmurs with or without enlargement of the heart constitutes an important 
 diagnostic criterion. 
 
 Diagnosis. — The diagnosis rests upon the association of several or 
 all of the above conditions in a child or young adult in whose case there is 
 a history of having been a "blue baby," or having had ''the blue disease." 
 The differential diagnosis of the various congenital defects must be deter- 
 mined by a special study of the physical signs in individual cases. In many 
 of the cases a positive diagnosis of the particular lesions cannot be made. 
 
 VII. HEART BLOCK; THE STOKES- ADAMS 
 SYNDROME. 
 
 Definition. — A condition characterized by bradycardia, with transient 
 attacks of vertigo and syncope, and momentary epileptiform seizures. 
 
 Erlanger's classification based on that of Wenckebach (Osier) is as 
 follows : 
 
 Arrhythmia resulting from decreased conductivity in the auriculo- 
 ventricular function — heart block. Characteristics: auricular rhythm per- 
 fect, rate normal or accelerated; ventricular rhythm may or may not be 
 perfect; if perfect its rate will be one-half of that of the auricles, or less; 
 if not perfect the irregularities will bear some direct relation to the con- 
 tractions of the auricles. 
 
 (a) Partial heart block: (1) occasional ventricular silence; (2) 
 regularly recurring ventricular silence, either one ventricular beat missed 
 in 7, 6, 5, 4, etc., auricular beats, or a 2 : 1, 3 : 1, 4:1 rhythm, or either 
 of these alternating. 
 
 (b) Complete heart block: auricular and ventricular rhythms perfect 
 but independent. 
 
 (c) Paroxysmal bradycardia (Stokes-Adams disease affecting the ven- 
 tricular rate alone). 
 
 Etiology. — Arteriosclerosis and syphilis play an important part in the 
 causation of heart block. The lesions involve the auriculoventricular 
 bundle of His, a narrow neuromuscular band constituting the only muscular 
 connection between the auricles and ventricles, which serves as a path- 
 way for the stimulus, by which the heart contracts, from the auricles, in 
 which it originates, to the ventricles. Robinson found in the Museum of 
 the Pennsylvania Hospital a heart in which a gumma is situated upon the 
 septum in such a position as to involve this muscular bundle, and upon 
 looking up the clinical records discovered, after the lapse of twenty-five 
 years, that bradycardia had been a prominent symptom in the case. There 
 is a group of cases in which no lesions are found after death and in which 
 the condition appears to be a neurosis. The cases due to syphilis have 
 occurred in early adult life; those due to sclerotic processes at a later 
 period. One of my cases, a woman, was fifty-two; another a man of seventy. 
 
 Symptoms. — Bradycardia is usually persistent, sometimes paroxys- 
 mal. The ventricular beats may fall to 20, or as low as 5 per minute. 
 The pulse is usually tense. Its frequency is not increased, as under normal 
 
1232 
 
 MEDICAL DIAGNOSIS. 
 
 conditions, by posture, exercise, excitement, or stimulants. A feeble venous 
 pulsation may be detected in the right jugular synchronous with the 
 auricular contractions. The cerebral symptoms are attributable to the 
 delay between the ventricular contractions. Momentary vertigo and syn- 
 cope are common, the attacks recurring many times in the course of twenty- 
 four hours. The loss of consciousness is often attended by slight muscular 
 twitchings which especially involve the face and arms. 
 
 Diagnosis. — The Stokes-Adams disease is to be distinguished from the 
 physiological bradycardia occasionally seen in pregnancy, from that of 
 old age, and that which occurs in the inanition of hunger. It must also 
 be differentiated from the pathological slow pulse of convalescence from 
 
 Jugular 
 
 Carotid 
 
 Ca>rdiao Ap&x 
 
 o. as 
 
 RJUUi-JUuuuiJU\-JVJiJuu'LJiJLJUi-ru;uup. 
 
 uu'iJuuun_,TJUui_^jouuuui_n_pJV-run._n_'i_n_ruii_.r 
 
 Fig. 352. — Stokes-Adams syndrome. Tracing of the jugular, carotid and apex beat, 
 traction; s, ventricular contraction. — Jefferson Hospital. 
 
 a, auricular con- 
 
 acute disease, of certain gastric affections, especially ulcer and carcinoma, 
 of jaundice, of fatty heart, and of uraemia. Abnormal slowness of the pulse 
 is present also in some cases of anaemia and chlorosis, and in diseases of the 
 nervous system, as brain tumor, affections of the cervical cord, and apoplexy. 
 Certain poisons, as opium, alcohol, lead, and digitahs, cause bradycardia. 
 The differential diagnosis between heart block and any of these conditions 
 rests upon the essential difference between the frequency of the auricular 
 contractions as manifest in the jugular pulsation and those of the ventricles 
 as felt in the radials and at the apex, the occurrence of cerebral symptoms, 
 and the exclusion of other causes. In many cases of cardiac insufficiency 
 a considerable proportion of the ventricular systoles fail to transmit a 
 pulse-wave to the wrist. The apex beats must be counted in all cases of 
 slow pulse. 
 
ANGINA PECTORIS. 1233 
 
 Prognosis. — The outlook is favorable in the neurotic cases. Ener- 
 getic antiluetic treatment should be instituted when a history or mani- 
 festations of syphilis are in evidence. In aged persons with arteriosclerosis, 
 treatment has little effect and the condition continues until death. 
 
 VIII. ANGINA PECTORIS. 
 
 Stenocardia; Angina Pectoris Vera. 
 
 Definition. — True angina pectoris is a symptom-complex occurring 
 in individuals who suffer from sclerotic changes involving the ascending 
 aorta and coronary arteries, and characterized by recurrent paroxysms 
 of agonizing pain in the precordial region, extending to the neck and arms, 
 especially upon the left side, and often accompanied by a sense of impend- 
 ing death. 
 
 Etiology. — Predisposing Influences. — All conditions which tend 
 to the production of arteriosclerosis may be looked upon as influences pre- 
 disposing to angina pectoris. Age is of great importance. The great 
 majority of the cases first declare themselves after the fiftieth year. At- 
 tacks occasionally occur at an earlier age, but they are comparatively infre- 
 quent, while the few cases which have been recorded in childhood do not 
 militate against the general rule. Sex exerts a remarkable influence, not 
 in itself, but in the bearing which it has on the mode of life of the individual. 
 Heredity plays an important part. It is by no means rare for angina pec- 
 toris to occur in successive generations. To gout, syphilis, and alcohol are 
 justly attributed causal influences of weight. Diabetics are prone to the 
 attacks. It has occurred after influenza. 
 
 Exciting Cause. — Any exertion, especially any sudden exertion which 
 calls upon the heart for increased effort, may bring on the attack. The 
 effort is usually a familiar one, as hurry to catch a car, ascending a flight 
 of stairs, or stooping over to lace the shoes. Emotional excitement is a 
 common exciting cause. A fit of anger may precipitate a fatal attack. 
 The paroxysm frequently follows a hearty meal. I often say to patients: 
 Do not hurry, do not worry, and do not eat too much. Exposure to cold 
 is a common cause of the attack. Several of these causes are often asso- 
 ciated, as hurry and exposure to cold, or some annoyance after a full meal. 
 The attack seldom comes on when the patient is at rest both physically 
 and mentally. On the other hand there are cases in which the attack occurs 
 immediately upon waking from sleep. 
 
 The Paroxysm. — The attack begins suddenly, very often without 
 warning, and in a few moments attains its full intensity. There are three 
 essential phenomena: (1) Pain, commonly described as agonizing, referred 
 to the precordium and mostly to the region beneath the manubrium. This 
 pain radiates to the left side of the chest, to the neck, and to the ulnar 
 distribution in the left arm. In rare cases the pain is first felt in the wrist 
 or arm. The right side is in some instances also affected. (2) The steno- 
 cardia of Heberden. The sensation is that of being crushed in a vice, 
 or as if the heart were being "grasped by a mailed hand." It is to this 
 sensation that the fixation of the muscles of the patient is probably 
 78 
 
1234 MEDICAL DIAGNOSIS. 
 
 due, for at the height of the paroxysm he is usually motionless, almost 
 rigid, while at the beginning and end he is agitated, restless, and anxious. 
 (3) The sense of impending death. The face denotes the anguish which 
 the patient feels. It is pallid, gray, and bathed in sweat. The pulse is 
 often full and slow; its tension greatly increased. It may, however, he 
 nearly normal. The heart sounds are commonly feeble, but clear, and not 
 rarely a soft apex murmur may be heard. Vomiting is not unusual, and 
 death may occur during the act. The duration of the attack does not 
 usually exceed four or five minutes, but recurrences are common, so that 
 the agony may last, with remissions all too brief, for several hours. This 
 is, however, unusual. Nocturnal attacks are usually very severe and 
 longer in duration than those which occur by day. Instant death during 
 the attack is not uncommon. In other cases the patient may fall into a 
 syncope and not revive. Those who suffer from angina pectoris are liable 
 to sudden death in the intervals between the attacks. The paroxysm 
 subsides as suddenly as it came on, often with belching, the passing of a 
 large quantity of clear urine, exhaustion, and asthmatic symptoms. There 
 are other cases in which the patient, while much distressed and exhausted, 
 is, in the course of an hour or two, able to resume his occupation. The first 
 paroxysm has in many cases proved fatal; in other cases the attacks recur 
 at varying intervals for many years. The first attack may not be followed 
 by a second for a period of months or years, and there are instances of 
 a series of violent attacks followed by no recurrence for a long period. 
 
 Angina sine Dolore. — Gairdner used this term to designate ''an 
 element of subjective abnormal sensation present in cardiac diseases, 
 which when it is not localized through the coincidence of pain is a specially 
 indefinable and indescribable sensation." There are undoubtedly cases 
 of heart disease in which paroxysms of profound disturbance of the nervous 
 system referable to the heart occur in the absence of pain, but with an 
 agonizing fear of impending death. 
 
 There are many explanations concerning the attack of angina pectoris, 
 among which that of paroxysmal ischsemia or intermittent claudication is 
 the best as a working hypothesis, but none of which as yet fully meets the 
 requirements of the condition. 
 
 Diagnosis. — The direct diagnosis rests upon the association of par- 
 oxysms having the foregoing characteristics with the evidences of general 
 arteriosclerosis and chronic myocarditis. Increased arterial tension, a 
 history of gout, alcoholism, or syphilis, and advanced life are of the nature 
 of corroborative evidence. 
 
 FUNCTIONAL ANGINA PECTORIS; PSEUDO=ANQINA PECTORIS. 
 
 Two principal groups are described: the neurotic and the toxic. 
 
 Neurotic Angina Pectoris. — This form is common in hysterical and 
 neurasthenic women. It may occur at any age. The attacks are not 
 precipitated by muscular effort or cold, but by the multitudinous worries 
 to which such persons subject themselves, and not rarely by injadicious 
 eating. They recur with a periodicity which is remarkable and are more 
 common in the night, a point in which they especially differ from angina 
 
FUNCTIONAL AFFECTIONS OF THE HEART. 1235 
 
 associated with coronary or aortic sclerosis. They are usually attended by 
 nervous symptoms — flatulent distention of the stomach and belching — 
 and are often prolonged for several hours, with continuous agitation and 
 restlessness. There are forms in which the paroxysm is characterized by 
 coldness and numbness of the extremities, with agonizing substernal 
 pains, great restlessness, and a tendency to syncope — vasomotor variety. 
 
 Toxic Angina.- — This form is attributed to excesses in tea, coffee, and 
 tobacco. It includes ''tobacco heart." As a rule pain is less marked than 
 sensations of anxiety and precordial oppression, with derangements of the 
 cardiac rhythm. Attacks occur which are characterized by vertigo, pallor, 
 a small, tense pulse, faintness, precordial distress, perspirations, and cold- 
 ness of the hands and feet. There are three groups of cases: first, the 
 irritable heart of smokers; second, cases characterized by precordial pain, 
 which may be persistent and severe but is not agonizing; and third, cases 
 in which the symptoms are those of an organic angina and there are evi- 
 dences of arteriosclerosis. In the first two of these groups recovery follows 
 abstinence from the narcotic, but in the third recovery is only partial. 
 
 The diagnosis of functional angina pectoris depends upon the presence 
 of the neurotic constitution, the absence of the signs of arteriosclerosis or 
 chronic myocarditis, the character of the paroxysms, which, however severe 
 they may be, have neither the short duration nor the essential features of 
 angina vera. The younger age, the sex, and the different nature of the causes 
 by which the paroxysms are excited have diagnostic significance. There 
 are varying grades of intensity, both in organic and in functional angina 
 pectoris, as shown in the recurring paroxysms in the same patient, and it 
 is not the intensity but the character of the attack which is diagnostic. 
 
 IX. THE FUNCTIONAL AFFECTIONS OF THE 
 
 HEART. 
 
 The Cardiac Neuroses. 
 
 Definition. — The functional affections of the heart include those 
 motor and sensory derangements which occur in the absence of demon- 
 strable anatomical changes in the organ. 
 
 The qualifying adjective "functional" is used in its common sense, to 
 denote the absence of anatomical lesions demonstrable during life or after 
 death. It is appropriately employed in this connection to designate, not 
 lesions of the heart itself, but rather disorders of its innervation. Hence 
 these affections are also properly spoken of as cardiac neuroses. 
 
 It is important to observe that all the morbid phenomena noted in 
 functional disorders may attend the structural diseases of the heart. 
 
 The functional affections of the heart are: 
 A. Motor: 
 
 1. Derangements of rhythm, 
 
 (a) Arrhythmia. 
 
 (b) Rapid heart — tachycardia. 
 
 (c) Slow heart — bradycardia (brachycardia). 
 
 2. Momentary arrest — syncope. 
 
1236 MEDICAL DIAGNOSIS. 
 
 B. Sensory: 
 
 Subjective sensations referred to the precordia. 
 
 (a) Heart consciousness. 
 
 (b) Precordial distress. 
 
 (c) Precordial pain. 
 
 C. Motor and sensory combined: 
 
 Palpitation. 
 
 Etiology. — Predisposing Influences. — These comprise, (a) a weak 
 and delicate organization associated with an impressionable nervous 
 system; (b) anaemic conditions; (c) lithsemia and allied derangements of 
 metabolism and excretion; and (d) morbid conditions directly affecting 
 the nervous system, as organic diseases of the brain and cord, chorea, 
 epilepsy, and the acute and chronic infections. 
 
 Certain of these conditions are inherited, others acquired. Thus the 
 descendants of nervous or insane parents, those begotten of elderly persons, 
 those who have in infancy been exposed to privation and neglect, or who 
 have suffered from serious or protracted disease, are especially prone to 
 functional disturbances of the heart. To a less extent is this true of gouty, 
 tuberculous, and syphilitic persons. 
 
 Functional derangements of the heart are much less frequent in 
 childhood than in adult life. 
 
 The EXCITING CAUSES include: (A) those acting upon the nervous 
 system, (a) directly, as intense mental emotion, fear, anger, grief; or (b) 
 reflexly, as gastro-intestinal irritation, intestinal parasites, or foreign bodies 
 in the intestinal canal; and (B) those acting, by means of mechanical 
 disturbance of the circulation, upon the heart, as violent exercise or exertion. 
 
 Symptoms. — In general terms the symptoms of the functional disorders 
 of the heart consist in derangement of the motor functions and abnormal 
 sensations referred to the precordia. These motor and sensory derange- 
 ments are not always associated. More commonly the movement of the 
 heart is deranged, its action being accelerated, retarded, or irregular, 
 without abnormal sensations; occasionally derangement of rhythm occurs 
 in connection with precordial distress or pain or a sense of oppression; and 
 in comparatively rare instances precordial pain occurs in the absence of 
 motor disturbance. 
 
 When the functional disorder is paroxysmal or of a high grade of 
 intensity, it is usually accompanied by increased frequency of respiration, 
 and very often by pallor of the face and slight cyanosis. Especially is 
 pallor associated with syncope. 
 
 When the derangement is not paroxysmal, but persistent, the rhythm 
 of the respiration is not usually disturbed. 
 
 Physical examination yields a limited number of definite signs. The 
 frequency of the heart's action and the degree and character of the arrhyth- 
 mia are recognized upon palpation. By this method of examination we 
 also detect, especially on palpation, the change in the character of the 
 impulse, which is increased in force. We observe also by this means and 
 by inspection that the impulse is extended. We determine by the position 
 of the apex beat, and may confirm the observation by percussion, that the 
 heart is not enlarged. Upon auscultation the first sound is found to be 
 
FUNCTIONAL AFFECTIONS OF THE HEART. 1237 
 
 sharp and valvular and shortened in duration, while the second sound 
 remains distinct or is accentuated. In very rapidly acting or very irregular 
 hearts transient murmurs, usually mitral systolic, are common. 
 
 A. Motor: 1. Derangements of Rhythm. — The cardiac mechanism 
 is now regarded as myogenic rather than neurogenic; that is to say, inherent 
 in the heart muscle rather than due to the influence and control of the vagi 
 and sympathetic nerves under the influence of higher centres. The fol- 
 lowing classification of the forms of arrhythmia is that of Joseph Erlanger, 
 based upon that of Wenckeback: ^ 
 
 T. Arrhythmia Resulting from Decreased Conductivity in the Auriculoventric- 
 ular Junction — Heart Block. 
 A. Partial heart block. B. Complete heart block. C. Paroxysmal 
 bradycardia. 
 II. Arrhytlimia Resulting from Increased Irritability of the Heart. 
 
 A. Ventricular extra-systoles, characterized by an early systole, which 
 
 is associated with the phenomena of a retrograde impulse. There 
 may be one or more extra-systoles following a normal systole ; 
 when regularly recurring, one or more extra-systoles after 5, 4, 3, 
 2, or 1 normal systoles, the last giving the bigeminal or trigeminal 
 pulse, or there may be irregularly recurring extra-systoles causing 
 delirium cordis. 
 
 B. Auricular extra-systoles. 
 
 III. Arrhythmia Resulting from the Influence of Extrinsic Nerves upon the 
 
 Heart-rate. — (1) Vagus effects. (2) Accelerator effects. 
 
 IV. Arrhythmia Resulting from Disturbed Diastolic Filling of the Heart. 
 
 A. Disturbed filling resulting from violent respiratory movements ; 
 
 may give the paradoxical pulse. 
 
 B. Disturbed filling from adherent pericardium or mediastinal tumor ; 
 
 may give the paradoxical pulse. 
 
 C. Associated respiratory and cardiac rhythm. Alternating pulse (?). 
 
 (a) Arrhythmia in time and volume and intermission of the pulse is 
 due to extra-systoles, which occur in various groupings and combinations, 
 giving rise to pulsus bigeminus, trigeminus, and so on, according to the 
 transmission of the extra pulse-beats to the peripheral arteries. Extra- 
 systoles occur under the most varying conditions. Arrhythmia may be 
 manifest as an individual peculiarity, wholly independent of health or 
 disease. There are individuals who have marked cardiac irregularity, — 
 arrhythmia, intermission, — wholly without derangement of the fvmction 
 of the circulation and usually without consciousness of the abnormality. 
 Extra-systoles are common in irritable heart, such as occurs in debilitated 
 and neurasthenic persons; in overtrained athletes; in those who are given 
 to the abuse of narcotics, as tea, coffee, tobacco, and alcohol, or to sexual 
 excesses; and in the subjects of autointoxications of various kinds. They 
 are common in overdistention of the stomach with food, and in various 
 forms of dyspepsia, especially gastric flatulency — probably as manifesta- 
 tions of reflex irritation. They may be the result of abnormall}^ high blood- 
 pressure. Finally, they are common in organic disease of the heart, as 
 myocarditis, dilatation, sclerosis of the coronary arteries, and rupture of 
 compensation in chronic valvular disease of various kinds. It is evident 
 that the extra-systoles of organic disease are far more important and 
 significant than those due to irregular physiological stimuli or abnormal 
 reflex or toxic stimuli, that are controllable or transient. 
 
 1 Osier, Practice of Medicine, 6th ed., 1905, p. 834. 
 
1238 MEDICAL DIAGNOSIS. 
 
 (b) Rapid Heart ; Tachycardia. — Frequent revolution of the heart 
 is sometimes an individual peculiarity. The pulse may be 100 per minute, 
 and more frequent after meals and under excitement or active exercise. 
 The rapid pulse caused by fright may continue for an indefinite time. 
 The accelerated pulses symptomatic of fever and of exophthalm;c goitre 
 are of toxic causation and cannot be regarded as cardiac neuroses, nor does 
 the frequent pulse sometimes present at the menopause, or that due to 
 reflex influences from disease of the pelvic organs, belong to this category. 
 
 Paroxysmal or Essential Tachycardia.- — This remarkable affection occurs 
 in the absence of the ordinary nervous or organic conditions which give 
 rise to symptomatic heart hurry. It may begin early in life and continue 
 for years without manifestations of organic disease of the heart. The 
 attacks occur abruptly in the midst of ordinary health, and continue for 
 some minutes, hours, or days, and cease as suddenly as they began. They 
 are characterized by faintness, oppression, moderate palpitation, pallor, 
 dyspnoea, and a pulse-frequency that may exceed 200 per minute. The heart 
 sounds are of fetal type. Occasionally simple intermissions occur. In some 
 cases there is distinct arrhythmia. At the close of the attack the pulse 
 becomes relatively slow and full, sometimes not exceeding in frequency 
 half or even one-third that of the paroxysm. The attacks recur at intervals 
 of days or years, the general condition of the patient being meanwhile 
 normal. They are brought on in many cases by physical effort or emotional 
 stress. In other instances they occur in the absence of recognizable exciting 
 cause. The attack is rarely if ever fatal. In exceptional cases the disease 
 ceases after a series of paroxysms. 
 
 (c) Slow Heart; Bradycardia. — Slow heart may be an individual pe- 
 culiarity. The physiological and pathological conditions under which 
 slowness of the pulse may occur have already been considered. It is of 
 cardinal importance to determine the heart frequency by palpation of the 
 apex beat or auscultation of the heart sounds, since there are cases in 
 
 . which half the beats do not transmit a pulse-wave to the wrist. 
 
 A form of paroxysmal bradycardia has been described (Hoffman). 
 ■ 2. Momentary Arrest; Syncope. — Faintness is common in nervous 
 and impressionable persons. It may result from sudden shock or intense 
 excitement. Blood loss (even when sHght), profuse diarrhoea, extreme 
 fatigue, and severe pain may cause faintness or actual syncope. Emotional 
 children may faint at the sight of blood. A boy of seven fainted at the 
 sight of the denuded spot upon his arm caused in vaccination. A healthy 
 girl of eight, of shy and timid disposition, fainted at the dinner table upon 
 being suddenly addressed by a person whom she did not know. 
 
 B. Sensory. — Subjective sensations referred to the precordia. 
 
 (a) Heart Consciousness. — Neurotic and neurasthenic individuals 
 frequently complain of disagreeable sensations in the region of the heart. 
 They feel the extra-systole and the compensatory pause, and use such 
 phrases as 'Hhe heart stumbled," or "the heart turned over," to express 
 the sensation. But in many cases of arrhythmia there are no subjective 
 sensations. It is a mistake to call the attention of patients to arrhythmia 
 or intermissions of which they are unaware, since the consciousness of such 
 irregularities is often a cause of great distress. 
 
ARTERIOSCLEROSIS. 1239 
 
 (b) Distress. — Precordial distress is common in neurotic individuals, 
 both in functional and organic disease of the heart. It is extreme in the 
 overacting heart of violent exertion and is the essential element in palpita- 
 tion. It is common in intense emotion. It may be reflex in character and 
 is frequently due to gastro-intestinal derangements. It is often transient. 
 
 (c) Precordial Pain. — This neurosis is common in nervous indi- 
 viduals. It occurs in valvular disease of the heart, especially in aortic 
 and mitral stenosis and the later periods of aortic insufficiency, and in the 
 forms of myocarditis associated with sclerosis of the coronary arteries. 
 It is the chief element in angina pectoris and an important symptom in 
 aneurism of the aorta. 
 
 C. Motor and Sensory Combined. — Palpitation. — The most extreme 
 motor disturbance of the cardiac rhythm may occur in the absence of 
 consciousness of any cardiac irregularity, and distressing precordial sensa- 
 tions may, on the other hand, be experienced while the heart's action is 
 regular and orderly. In palpitation there is irregular or forcible action, 
 perceptible and usually distressing to the individual. This combination of 
 motor and sensory derangements constitutes palpitation. It is of frequent 
 occurrence in neurotic individuals, and is common at puberty, the grand 
 climacteric, and during menstruation. It is frequently encountered in 
 hysteria and in neurasthenia, and constitutes an important element in the 
 symptom-complex known as cardiac neurasthenia. It may occur in normal 
 individuals in consequence of violent emotion. It is a symptom of irritable 
 heart whether due to over-exercise, excesses in venery, or over-indulgence 
 in tea, coffee, tobacco, or alcohol; and finally it is a common factor of 
 cardiac insufficiency from any cause. As a rule, palpitation is more violent 
 and distressing in irritable heart than in valvular or myocardial disease. 
 The symptoms vary from a mere fluttering of the heart to a violent pulsa- 
 tion with great distress and anxiety. In the latter case the heart's action 
 may be slow or rapid; regular or irregular. The sounds may be clear and 
 ringing, the second accentuated, and murmurs wholly absent. In some 
 cases there are basic or apex murmurs, which disappear when the attack is 
 over. The attacks are of variable duration, but do not often exceed an 
 hour or two. 
 
 DISEASES OF THE ARTERIES. 
 
 I. ARTERIOSCLEROSIS. 
 
 Definition. — A disease of the arterial system characterized anatomi- 
 cally by nutritional changes in the media and adventitia with compensatory 
 thickening in the intima, which thickening subsequently involves all the 
 coats; and clinically by functional derangements in the various viscera. 
 
 The anatomical changes may be diffuse or localized. In the diffuse 
 variety the arteries are dilated and tortuous, their walls thickened and 
 inelastic, and the intima the seat of irregular thickening, calcareous 
 plates, and atheromatous ulcers; in the localized or circumscribed form 
 yellowish-white, rounded, nodular patches, raised above the surface, are 
 irregularly scattered along the intima. Diffuse and nodular sclerosis are 
 commonly associated. 
 
1240 MEDICAL DIAGNOSIS. 
 
 In senile arteriosclerosis the arteries are dilated and tortuous, the walls 
 thin and rigid, and the subendothelial tissue the seat of circumscribed 
 collections of softened or broken-down material — atheromatous abscesses. 
 When these collections rupture into the lumen of the artery they give 
 rise to atheromatous ulcers. 
 
 In the various forms the degeneration of the media may be marked 
 in the smaller arteries. The capillaries are thickened and may be obliter- 
 ated. The connective-tissue overgrowth leads to more or less complete 
 atrophy of the muscular and connective-tissue elements. In some cases 
 characterized by general or local increase in blood-pressure the muscular 
 fibres of the media may be preserved or even hypertrophied. 
 
 In consequence of these changes the larger and middle-sized arteries 
 are dilated; the smaller, by reason of the thickening of the intima, are 
 narrowed and very often wholly obliterated — endarteritis obliterans. 
 
 The ramifications of certain arteries are involved with greater fre- 
 quency than others. In the series of cases studied by pupils of Thoma 
 and analyzed by Bergmann, sclerotic changes were found in the ulnar 
 artery in 94 per cent., the tibialis antica 93, the subclavian 88, arteries of 
 the brain 87, internal carotid 87, radial 86, splenic 82, popliteal 79, external 
 carotid 78, axillary 71, femoral 69, common carotid 68, ascending aorta 
 67, abdominal aorta 64, external iliac 58, and brachial 55. The minute 
 arteries of the various organs are involved in the arteriosclerotic process. 
 These lesions are especially common in the heart, brain, kidneys, liver, and 
 pancreas. Sclerosis of the pulmonary artery and its branches is a constant 
 concomitant of lesions such as chronic disease of the mitral valve, emphy- 
 sema, and fibroid phthisis, which cause persistent increase of the blood- 
 pressure in the pulmonary circulation. The artery may be dilated, with 
 insufficiency of the semilunar valve system, its primary and secondary 
 branches the seat of aneurismal dilatation, and its smaller branches highly 
 sclerotic. The sclerotic process frequently extends to the capillaries and 
 may also affect the veins, which not infrequently are sclerotic in the absence 
 of similar changes in the arteries. 
 
 Etiology. — The following factors are of importance in the causation of 
 arteriosclerosis : 
 
 1. Persistent High Blood-pressure and Sudden, Frequent, and Extreme 
 Alternations of Pressure. — There are many conditions which bring about 
 habitual strain upon the arteries. Among the more important are: (a) 
 Habitual hard work. This accounts for the great frequency of arterio- 
 sclerosis among the laboring classes, and the fact that working men more 
 frequently suffer from sclerotic changes in the upper extremities and 
 women in the same walk of life in the lower extremities, while such changes 
 in the arteries of the extremities are infrequent in persons whose occupa- 
 tions are not laborious (Romberg). The muscular effort habitually increases 
 the peripheral resistance and raises the intra-arterial pressure, (b) Ner- 
 vous influences — the strenuous fife in which physical effort, mental stress, 
 and excitement combine to tax alike the brain and the heart. In this con- 
 nection the frequency with which arteriosclerosis is present in neurasthenia 
 is to be considered, (c) Obesity. The increased effort demanded by the 
 ordinary movements of fife and by the larger volume of the circulating 
 
ARTERIOSCLEROSIS. 1241 
 
 blood tends to arteriosclerosis, and especially to arteriosclerosis of the 
 coronary arteries, (d) Chronic interstitial nephritis is associated with 
 persistent increase of blood-pressure and sclerotic changes in the arterial 
 walls. (e) Frequently repeated and extreme changes in temperature, 
 such as are necessary in certain crafts, tend by the abrupt contraction and 
 dilatation of the superficial vessels to the production of arteriosclerosis, 
 (f) The strain upon the arteries in aortic insufficiency rapidly brings 
 about sclerosis of their walls. 
 
 2. Chronic Intoxications. — (a) The abuse of tea, coffee, tobacco, and 
 alcohol is credited with a causal influence which is doubtless over-estimated. 
 These narcotics, and especially alcohol, may exert an indirect effect by 
 increasing nervous excitability, (b) Lead, diabetes, and gout play an 
 important role. The mode of action has not been explained. Their asso- 
 ciation with interstitial nephritis is to be considered, (c) Renal disease. 
 There are two groups of cases, primary interstitial nephritis and nephritis 
 associated with general arteriosclerosis. (d) The infectious diseases, 
 especially malaria, rheumatic fever, and enteric fever, appear in some 
 cases to be the starting-point of progressive arteriosclerotic changes, (e) 
 Excesses at table. There can be no doubt of the importance of over-eating 
 as a factor in the causation of arteriosclerosis, and that the results of such 
 excesses belong in the category of the chronic intoxications is equally 
 beyond question. 
 
 3. Syphilis is a causal factor of great moment. In syphilitic subjects 
 arteriosclerosis develops early and attains a high grade. The distinction 
 between arteriosclerosis and the specific vascular lesions of syphilis is to 
 be made. 
 
 4. Heredity. — The predisposition to arteriosclerosis varies greatly in 
 different families. Inherited anatomical peculiarities, as congenital nar- 
 rowness of the arteries and thickness of their walls, are attended with the 
 liability to early sclerosis. These arterial changes appear early among the 
 peasant immigrants from Italy and other countries of Southern Europe. 
 
 5. Age. — The view is generally entertained that arteriosclerosis is a 
 manifestation of senile involution. There are, however, aged persons in 
 whom little or no evidence of the disease is apparent. It is probable that 
 in many cases the arteriosclerosis of old persons is a late result of the action 
 of other causes operative in earlier life. In fact several of the above 
 etiological factors are usually to be recognized in the anamnesis. This is 
 especially the case in connection with syphilis. 
 
 It is in accordance with the above facts that arteriosclerosis is 
 more common after middle life than at an earlier period, and in men 
 than in women. 
 
 Symptoms. — Arteriosclerosis begins insidiously and may long remain 
 latent. There are, however, cases in which the vascular changes attain a 
 high grade in the course of a very few years. When symptoms become 
 manifest they may be general or local, according to the vascular distribu- 
 tion chiefly affected. 
 
 The general symptoms are in many cases not different from those of 
 old age. The skin becomes harsh, wrinkled, and inelastic; subcutaneous fat 
 is reduced over the chest and extremities and accumulates upon the 
 
1242 MEDICAL DIAGNOSIS. 
 
 abdomen; the muscles waste; the viscera undergo atrophic changes; and 
 there is manifest loss of bodily and mental power. Dyspeptic symptoms 
 are often prominent. Characteristic phenomena relate to the circulation. 
 The blood-pressure is increased, the superficial arteries are thickened and 
 hard, there is hypertrophy of the left ventricle and accentuation of the 
 aortic second sound, which has often a clear, ringing quality. There are, 
 however, cases in which the blood-pressure remains low and the hyper- 
 trophy of the left ventricle is moderate. An increased flow of urine of low 
 specific gravity and transient traces of albumin, together with occasional 
 hyaline casts, is not uncommon. 
 
 The local symptoms depend upon the grade of the vascular lesions and 
 the organ or structure principally involved, as the heart, brain, kidneys, 
 or extremities. 
 
 1. Cardiac Symptoms and Signs. — The effect of persistent resistance 
 to the flow of the blood in the peripheral arteries is hypertrophy of the left 
 ventricle, with the symptoms and physical signs of that condition. When 
 the coronary arteries are involved, local or general myocardial degenera- 
 tions occur with their attendant symptoms, which are those of cardiac 
 insufficiency. Angina pectoris, aneurism of the heart, local softening, 
 rupture, or sudden death may result. When dilatation supervenes the 
 systolic apex murmur of relative mitral insufficiency is heard, and the 
 symptoms of extreme cardiac insufficiency arise, dyspnoea while at rest, 
 somnolence, scanty urine, dropsies and effusions into the serous sacs. 
 Dilatation of the ascending aorta may give rise to tympany or dulness at 
 the sternal end of the second right intercostal space or palpable pulsation 
 in the episternal notch and a soft systolic murmur with an accentuated 
 second aortic sound when the aortic valves are capable of closure, and 
 may be well shown by the Rontgen rays. 
 
 2. Cerebral Symptoms. — Among the early symptoms are sensations 
 of fulness and pressure in the head, insomnia, distress, anxiety, and vertig- 
 inous attacks. As the vascular lesions progress mental symptoms develop. 
 The attention flags, the recollection of recent events fails, the patient 
 becomes indifferent about his personal appearance and less considerate of 
 others. Self-restraint may be impaired. Actual vertigo, transient loss of 
 consciousness, and temporary derangements of speech are among the 
 symptoms of advanced arteriosclerosis. Repeated attacks of hemiplegia, 
 monoplegia, and aphasia may occur with the signs of organic lesions and 
 terminate in complete recovery in the course of a few hours or a day or two. 
 The Stokes-Adams syndrome is occasionally observed. Tinnitus cerebri 
 and tinnitus aurium are common and often distressing symptoms. The 
 cerebral symptoms of arteriosclerosis include those of the lesions of the 
 brain due to persistent obstruction of the smaller vessels, and accidents, 
 such as thrombosis, embolism, and hemorrhage. 
 
 3. Renal Symptoms. — These correspond to those of chronic inter- 
 stitial nephritis. The association of this form of renal disease and arterio- 
 sclerosis is common. Arteriosclerosis predisposes to nephritis; chronic 
 nephritis to general sclerosis. When the patient has not been under obser- 
 vation from the beginning it is impossible to determine which is the primary, 
 which the secondary, affection. In either case the renal symptoms may 
 
ARTERIOSCLEROSIS. 1243 
 
 dominate the clinical picture; more commonly, however, the cardinal 
 symptoms are those of myocardial disease. The condition constitutes one 
 of the forms of cardiorenal disease. Glycosuria is a frequent indication of 
 sclerosis of the pancreatic arteries. 
 
 4. Vasomotor Symptoms. — Sensations of cold and numbness in the 
 hands and feet, fulness or lightness in the head, tingling and pulsation in 
 the fingers, dynamic pulsation in the abdominal aorta, and congestion 
 of the feet and legs are very common. 
 
 5. The Extremities. — The symptoms due to sclerosis of the periph- 
 eral vessels are comparatively infrequent. The diminished capillary cir- 
 culation gives rise to more or less marked pallor, which is not rarely an 
 early symptom. Its association with loss of weight and strength suggests 
 anaemia or even the development of visceral cancer, especially in cases in 
 which the signs of changes in the heart or brain are not prominent. 
 
 Intermittent Claudication; Dysbasia Angiosclerotic a; Crural Angina. 
 — This constitutes a somewhat common and very striking clinical mani- 
 festation of sclerosis in the arteries of the lower extremities. It depends 
 upon the fact that while at rest the blood supply to the muscles, 
 diminished as it is by the narrowing of the lumen of the peripheral vessels, 
 is yet sufficient for their physiological requirements or even for moderate 
 use, but when muscular effort is made the blood supply is inadequate and 
 severe cramp-like contractions ensue. After walking a short distance the 
 patient experiences in one or both legs sensations of numbness, tingling, 
 heat or cold, tension and pain. The skin becomes pale and cyanotic. If 
 the effort is not discontinued more or less severe cramp and muscular 
 disability follow. These symptoms cease upon rest, only to return upon 
 further effort. In extreme cases the spasms recur upon moderate effort 
 and the muscles undergo gradual atrophy. 
 
 Diagnosis. — The direct diagnosis of arteriosclerosis may be made when 
 increased blood-pressure, thickened and tortuous superficial arteries, 
 hypertrophy of the left ventricle, and accentuation of the aortic second 
 sound are present. The thickened radial artery can often be rolled under 
 the finger upon the radius like a whip-cord, or it may show irregular, nodular 
 projections along its course like a string of wampum, or present little aneu- 
 rismal-like circumscribed dilatations. A high degree of sclerosis in the 
 superficial arteries may exist without a corresponding condition in the 
 arteries of the parenchymatous organs, and the converse is true. Another 
 important fact in diagnosis is that advanced arteriosclerosis may involve 
 a vascular territory or organ, as the kidneys or brain, without, in the absence 
 of general sclerotic changes, increasing the blood-pressure, and, therefore, 
 without causing left ventricle hypertrophy or marked accentuation of 
 the aortic second sound. When there is marked deposition of lime salts 
 in the affected arterial walls in the legs and feet, the X-ray examination 
 yields positive results, but it is useless in the deeply seatetl arteries of the 
 trunk, with the exception of the aorta, the shadow of which is broadened 
 and intensified in places by the presence of thickened atheromatous plates. 
 Etiological considerations are important in the diagnosis. 
 
 Prognosis.— The course of arteriosclerosis shows extreme variations. 
 The disease may involve the peripheral circulation and be wholly latent as 
 
1244 MEDICAL DIAGNOSIS. 
 
 to symptoms. Cases of this kind go on from year to year without serious 
 impairment of health. It may, on the other hand, rapidly give rise to 
 distinctive changes in organs that are necessary to life. Finally, it not 
 uncommonly sets up a vascular dyscrasia in which the entire body and its 
 organs are involved in progressive nutritional and atrophic changes, which 
 terminate in death in the course of a few years. In selected cases of pe- 
 ripheral sclerosis the removal of the cause and regulation of the mode of 
 life very often favorably influence the progress of the disease and may 
 arrest it. In cases due to syphilis an energetic antiluetic treatment may 
 be followed by an arrest of the sclerotic process. 
 
 II. ANEURISM. 
 
 Definition. — A circumscribed dilatation of an artery. This anatomical 
 condition is to be distinguished from the diffuse widening of the larger 
 arteries which occurs in arteriosclerosis. 
 
 Aneurisms are divided: 
 
 (a) According to their form into fusiform or cylindroid, in which there 
 is uniform dilatation of the vessel, and sacculated, in which there is a lateral 
 bulging or protrusion of the wall. 
 
 (b) According to the composition of the wall into tme, in which the 
 wall is composed of one or more of the coats of the artery, and false, in 
 which there is a rupture of all the coats and the blood is confined by the 
 surrounding tissues. This distinction is not important, since a false aneu- 
 rism is in reality a hematoma and the differentiation between true and 
 false aneurisms cannot in all cases be made after death, much less during life. 
 
 (c) According to other anatomical peculiarities into cirsoid, in which 
 an artery and its branches are involved in the dilatation, dissecting, in which 
 the blood collects between the coats of the artery — this type occurs in the 
 aorta and occasionally forms a complete double tube — and arteriovenous, 
 in which there is a communication between an artery and a vein. There 
 may be a sac between the artery and vein, but more commonly the com- 
 munication is direct and the vein which yields to the intra- arterial pressure 
 is dilated, tortuous, and pulsating — aneurismal varix. 
 
 i. Aneurism of the Aorta. 
 
 Aneurisms of the aorta are usually fusiform or sacculated. The latter 
 is more common. The combination of these forms is occasionally encoun- 
 tered. Dissecting aneurisms are rare. Still more rare are arteriovenous 
 aneurisms. The essential anatomical condition is dilatation, under the 
 intra-arterial pressure, of the vessel wall, weakened by disease. In fusi- 
 form dilatation all three coats of the vessel are dilated. In sacculated 
 aneurism the intima may extend into the sac some distance; the media 
 undergoes atrophic changes and extensive destruction. The wall of the 
 sac is in the greater part of its extent formed by the adventitia, which is 
 thickened, infiltrated, and fused with the surrounding tissues. The com- 
 munication with the aorta is by an opening of variable size. The interior 
 of the sac is lined by superimposed laminae of coagulated blood, those 
 
ANEURISM. 1245 
 
 which are peripheral being dense and of a whitish color; those which are 
 central being soft and red. The arrangement of these coagula is neither 
 symmetrical nor constant, and important modifications of the pressure 
 symptoms and physical signs arise in consequence of the yielding of the sac 
 to the internal pressure in various directions at different periods in the 
 course of the affection. In rare instances, small aneurisms having narrow 
 communications with the lumen of the aorta are completely filled with 
 coagula and thus undergo spontaneous obliteration with the formation of 
 a small nodular tumor. As the conditions which give rise to sacculated 
 aneurism involve different portions of the wall of the aorta multiple aneu- 
 risms are by no means rare. In size sacculated aneurisms vary from a 
 walnut to a large cocoanut; in shape they are globular, but as they 
 increase in size the wall yields more at one point than another in such a 
 manner that irregular protrusions occur. Aneurisms may occur in any 
 part of the aorta, from just above the ring to the iliac bifurcation. The 
 most common site is in the ascending portion of the arch to the right. 
 
 Etiology. — Arteriosclerosis, syphilitic aortitis, and trauma are the 
 most important etiological factors. The great majority of aortic aneurisms 
 are due to those causes acting singly or in combination. Far less frequent 
 are cases due to the action of micro-organisms. 
 
 (a) Arteriosclerosis leads to diffuse weakening of the wall, which 
 yields to the pressure of the blood at a period when compensatory thick- 
 ening of the intima has not yet occurred, and undergoes dilatation. 
 Sacculated aneurism may occasionally have its origin in arteriosclerosis. 
 
 (b) Syphilis plays a most important role. Sacculated aneurism is in 
 a large proportion of the cases syphilitic. Whether the process has its 
 beginning comparatively early in the changes in the wall due to gumma 
 or at a later period in consequence of the loss of elasticity in scar tissue 
 remains undetermined. The lesions of a patch of syphilitic aortitis 
 constitute the point of diminished resistance. 
 
 (c) Traumatism. — When the media and adventitia are weakened, a 
 sudden increase of the blood-pressure may lacerate the intima. A violent 
 contusion, a fall, a blow upon the chest may be followed by the gradual 
 development of an aneurism. 
 
 (d) Micro-organisms. — Multiple aneurisms of the aorta and other 
 arteries have occasionally been observed in connection with malignant 
 endocarditis. Various bacteria have been found in the lesions. Weakening 
 of the wall of the vessel in consequence of an ulcerative process analogous 
 to that affecting the valves doubtless constitutes the early lesion. 
 
 (e) Traction Aneurisms. — An exceedingly rare form of aneurism is 
 caused in the concavity of the aortic arch at the point of insertion of an 
 insufficiently elongated remnant of the duct of Botallo. 
 
 Among other predisposing influences of secondary importance are the 
 following: Age. — Aortic aneurism is much more common between the 
 fortieth and sixtieth years than at any other period of life. Sex. — Men 
 suffer more frequently than women in the proportion of 4 or 5 to 1, a pre- 
 ponderance due not to inherent anatomical differences but to the far greater 
 exposure to the common causes. Habits. — The direct influence of alcohol 
 has probably been over-rated. Its indirect influence in leading to exposure 
 
1246 MEDICAL DIAGNOSIS. 
 
 to the danger of contracting syphilis is very great. Occupations which 
 involve great muscular effort and those which are attended with the 
 danger of violent blows and contusions of the chest may be regarded as 
 predisposing to thoracic aneurism. 
 
 An aneurism of the aorta is a vascular tumor which may be wholly 
 latent or manifest itself by symptoms, usually effects of pressure, and 
 physical signs which differ according to its situation and the relative amount 
 of stratified clot and blood which it contains. It is convenient to consider 
 separately aneurism of the thoracic aorta and aneurism of the abdominal 
 aorta. 
 
 (a) ANEURISM OF THE THORACIC AORTA. 
 
 Symptoms. — The relative prominence of subjective symptoms and 
 physical signs depends upon the situation and size of the aneurism. The 
 cases may be arranged in four groups. 
 
 1. The Aneurism is Latent. — Symptoms are wholly absent, or 
 vague and not suggestive of the actual condition. There are no physical 
 signs. This group includes the cases of moderate fusiform dilatation, 
 small sacculated aneurisms in the ascending aorta, and especially those 
 immediately above the sinuses of Valsalva. The last not rarely rupture 
 into the pericardium. The diagnosis is made after death. 
 
 2. Symptoms are Prominent. — Pressure symptoms are present, but 
 the nature of the lesion cannot be determined. To this category are to 
 be referred small sacculated aneurisms of the transverse and descending 
 portions of the. arch compressing the trachea or left main bronchus and the 
 recurrent laryngeal nerve, and larger sacs in various situations, containing 
 much laminated clot and yielding the signs of a solid tumor rather than 
 those of an aneurism, and sacs upon the descending aorta just above the 
 diaphragm, especially those eroding the vertebrae. 
 
 3. Signs are Prominent. — There are associated subjective symp- 
 toms but they are distinctly subordinate to the objective manifestations 
 of expansile pulsation, circumscribed dulness, thrill, diastolic shock, and 
 tracheal tugging. This group comprises certain aneurisms of the convexity 
 of the ascending portion of the arch which project to the right and exert 
 moderate pressure chiefly upon the right lung, and some large aneurisms 
 in this situation which have eroded the chest wall and formed projecting 
 external tumors, with great relief from the pressure symptoms of an 
 earlier period in the course of the disease. In both these sub-groups 
 the contrast between the prominence of the physical signs and the 
 moderate intensity of the symptoms may be very marked. Broadbent's 
 division into the aneurism of symptoms and the aneurism of physical 
 signs serves an important purpose in indicating the data upon which to 
 base a diagnosis. 
 
 4. Symptoms are Severe and Signs are Distinctive. — Under 
 this heading may be grouped a great majority of aneurisms of the ascend-' 
 ing and transverse portions of the arch which have attained considerable 
 size and are sufficiently free from coagula to constitute pulsating tumors. 
 Both those still within the chest and those which have perforated the chest 
 wall and form external masses belong to this group; also those aneurisms 
 
ANEURISM. 
 
 1247 
 
 of the descending aorta which compress the left lung or erode the vertebrae, 
 and in particular those which erode the ribs and appear as external tumors 
 at the back. 
 
 The connective-tissue overgrowth in the inflammatory capsule involves 
 and compresses the nerve-trunks with which the tumor comes into con- 
 tact. To this fact is to be attributed the pain so characteristic of growing 
 aneurismal tumors, the palsies of the recurrent laryngeals and pneumo- 
 gastric, and derangements of the sympathetic. 
 
 When neighboring blood-vessels are implicated in, the growth, to 
 which the venous trunks and the pulmonary artery are particularly liable, 
 they are narrowed and the veins may be completely compressed, or per- 
 
 FiG. 353. — Aneurism of the arch of tlie 
 aorta protruding through the sternum. — Ger- 
 man Hospital. 
 
 Fig. 3.54. — Aneurism of the arch of the aorta 
 protruding through the sternum. The same 
 patient one year later. Death occurred suddenly 
 from external rupture through the skin. 
 
 foration into the superior vena cava may take place. In a similar manner 
 the trachea, a main bronchus, or the oesophagus may be involved and 
 compressed, or the sac may rupture into these organs. 
 
 The sternum, costal cartilages, ribs, and the bodies of the vertebrae 
 undergo more or less extensive erosion under the pressure of the distending 
 sac. In rare instances portions of the bony wall of the chest are enclosed 
 in the advancing sac, and a fragment of a rib or the end of a partly eroded 
 clavicle is found within its capsule. 
 
 Hemorrhage. — The adventitia, even when reinforced by encapsulating 
 connective tissue, may, in the course of a short time, yield to the blood- 
 pressure. When the rupture takes place into the trachea, a bronchus, 
 the oesophagus or stomach, the pleura or pericardium, death usually occurs 
 at once. If the sac is surrounded bv dense connective tissue a hsematoma 
 
1248 
 
 MEDICAL DIAGNOSIS. 
 
 is formed immediately at the seat of rupture and infiltrating the adjacent 
 parts. Under these circumstances the bleeding may be arrested for a 
 period/ only, however, to recur from time to time until fatal hemorrhage 
 ultimately takes place. The blood loss depends upon the amount of throm- 
 bus within the sac. If there is a considerable quantity of stratified clot, 
 as is usually the case in aneurisms that have perforated the wall of the 
 chest and ruptured externally, the bleeding may be moderate and for a time 
 controllable. Recurrent hemorrhage frequently takes place in such cases 
 
 for weeks or months. Protracted 
 or recurrent small bleedings may 
 occur under similar conditions into 
 the trachea, bronchi, or oesophagus. 
 Pain is an early and important 
 symptom. It may be in the sac 
 itself, — intrinsic, — due to irritation 
 of the sac or internal pressure. This 
 pain is dull, aching, and substernal. 
 More commonly it is in the adjacent 
 parts, — extrinsic, — due to irritation 
 of nerve-trunks implicated in the 
 advancing capsule or subjected to 
 pressure. This kind of pain is con- 
 tinuous, with paroxysmal exacerba- 
 tions of great intensity, and is 
 particularly severe at the time of 
 erosion of the vertebrae or the wall of 
 the chest. It is described as sharp, 
 lancinating, cutting, boring, and the 
 like. It often radiates along the 
 intercostal nerves, or into the side 
 of the neck and down the left arm. 
 When the bodies of the vertebrae are 
 eroded, the pain radiates in the course 
 of the intercostal nerves and is often 
 
 _ .Fig. 355.— Aneurism of ascending aorta. Relief intense. Suggesting herpeS ZOSter Or 
 of pain upon appearance of external tumor, which • , , n i • ^t^^ • r 
 
 occurred under observation.— Jefferson Hospital. lUterCOStal Ueuraigia. i he pam 01 
 
 aneurism, usually spoken of as neu- 
 ralgic, is in point of fact a symptom of pressure neuritis. When the aneurism 
 is situated at the root of the aorta, attacks of angina pectoris of varying 
 intensity may occur, with radiation to the left side of the neck and arm. 
 
 Cough is a common symptom. It may be caused by irritation pressure 
 upon the vagus or recurrent laryngeal nerve, compression of the trachea 
 or a main bronchus, in which event it is often associated with stridor, or 
 by bronchitis. The expectoration is often blood-stained from interference 
 with the venous circulation or from granulations at a point of impending 
 rupture. In bronchitis and bronchiectasis it is thin and abundant. It is 
 sometimes purulent and offensive. 
 
 Dyspnoea may be laryngeal, tracheal, or pulmonary, and these forms 
 are sometimes present in the same case. Laryngeal dyspnoea is due to 
 
 A 
 
ANEURISM. 
 
 1249 
 
 irritation of the recurrent nerve and is usually associated with a ringing 
 brassy cough, aphonia, and hoarseness. The tracheal form has its origin 
 in direct compression of the windpipe or left primary bronchus and is 
 accompanied by stridor; wMle pulmonary dyspnoea may be caused by 
 compression of one or both lungs by an enormous aneurism of the lower 
 or posterior wall of the transverse arch. 
 
 Dysphagia may arise when the sac develops in relation with the 
 gullet. It may be due to oesophagismus or stenosis from compression. 
 A clinical rule, in no case to be disregarded, is never to pass an 
 oesophageal bougie if there is rea- 
 son to suspect thoracic aneurism. 
 
 The signs of a thoracic aneurism 
 are due, (a) to the tumor itself, and (b) 
 to pressure upon adjacent structures. 
 
 Physical Signs. — Inspection. 
 — In a large proportion of the early 
 cases, and in many throughout the 
 whole course of the disease, this 
 method yields no physical signs. The 
 tumor while still wholly intrathoracic 
 may cause local bulging of the chest 
 wall with widening of the intercostal 
 spaces and visible pulsation. The 
 signs may elude observation save in 
 a good light and with oblique illu- 
 mination. When perforation of the 
 chest has occurred there is a more 
 or less prominent external pulsating 
 tumor, at the summit of which, in 
 late cases, the skin may be livid or 
 necrotic and the seat of hemorrhagic 
 oozing. Such tumors are most com- 
 mon at the upper part of the sternum 
 and to the right, and are sometimes 
 of large size, extending also to the 
 
 left. When the innominate is involved the pulsating prominence pro- 
 jects above the right clavicle and episternal notch. An aneurism of the 
 descending aorta may give rise to a tumor to the left of the spine. 
 Pressure upon venous trunks frequentl}^ causes congestion of the face and 
 eyes, and enlargement of the superficial veins of the trunk and arm. These 
 signs are much more common upon the right side. In consequence of pres- 
 sure upon the sympathetic occasional differences in the pupils arise. Irri- 
 tation of the upper dorsal or lower cervical ganglion upon the affected 
 side is attended with dilatation of the pupil, which may or maj^ not be 
 accompanied by pallor of the face upon the same side; while destructive 
 pressure is followed by contraction of the pupil and in some cases by flush- 
 ing and sweating upon the same side of the face. The larynx may be seen 
 to be displaced to the left, much more frequently to the right, by the pres- 
 sure of an aneurismal tumor, and in large aneurisms of the arch tracheal 
 
 79 
 
 Fig. 356. — Aneurism of the aorta and innominate 
 artery. 
 
1250 MEDICAL DIAGNOSIS. 
 
 tugging may sometimes be seen. The visible apex beat is displaced down- 
 ward and to the left, indicating more commonly dislocation of the heart 
 from pressm-e than dislocation of the apex from hypertrophy. 
 
 Palpation. — This method confirms the signs obtained upon inspec- 
 tion. The extent, force, and expansile character of the pulsation are deter- 
 mined by this method of physical diagnosis. Intrathoracic aneurisms of 
 considerable size may cause general expansion of the upper part of the 
 thorax in its anteroposterior diameter, which is best recognized by biman- 
 ual palpation, one hand being firmly applied to the back, the other to the 
 front of the chest. There may be merely a diffuse pulsation. An aneurism 
 which has perforated the wall of the chest forms a distinct tumor with 
 expansile pulsation, the denseness of which is determined by the amount 
 of coagula. Very rarely the sac is thin-walled and fluctuating. There 
 is usually a distinct diastolic shock, which may be intense and is of diag- 
 nostic significance. A systolic thrill may often be felt but is to be distin- 
 guished from the thrill of a dilated aorta and from the thrill which is pres- 
 ent in aortic stenosis. Retardation of the pulse is common. The radials 
 
 maybe unequal in time 
 and volume. When 
 
 l/vJ 
 
 '^Afi A 
 
 
 the sac is very large 
 the pulse in the arterial 
 trunks beyond it may 
 be scarcely perceptible. 
 Tracheal tugging 
 is common in aneu- 
 
 FiG. 357.— Upper tracing— carotid pulse in a case of aneurism of the ,,;s,^^s, ^.f fl-,p tranSVerse 
 arch of the aorta. Lower tracing— thrill over aneurismal tumor. lisms Oi Llie Udlibveibe 
 
 arch and is a very 
 important sign in deep-seated sacs not manifest by other signs. This 
 phenomenon is not, however, pathognomonic of aortic aneurisms. It 
 may occur in mediastinal tumors and in enlargement of the peribronchial 
 lymph-nodes when so situated as to cause close adhesions between the 
 aorta and the left primary bronchus. 
 
 Percussion. — Deeply situated aneurisms of small size yield no signs. 
 The percussion signs of larger aneurisms which approach the chest wall 
 depend upon the fact that they displace the lungs. The pulmonary reso- 
 nance is replaced in aneurisms of the ascending Hmb of the arch by circum- 
 scribed flatness, usually to the right of the manubrium sterni; in aneurisms 
 of the transverse arch by flatness in the upper sternal region to the left of 
 the sternal border; and in those of the descending aorta by flatness along 
 the left side of the spine and in the scapular region. The area of flatness 
 corresponds to the region of contact between the tumor and the inner wall 
 of the thorax, and is surrounded by a very narrow border of dulness and 
 an outer border of tympanitic resonance, the width of which is determined 
 by the extent to which the circumjacent lung is compressed. 
 
 Auscultation.— Murmurs may be absent even in aneurisms of large 
 size. The greater the amount of stratified coagula the more nearly the 
 aneurism resembles a solid mediastinal tumor. An accentuated second 
 sound is a common and significant sign. A systohc murmur is often heard; 
 less frequently a diastohc murmur, which is not a sign of the aneurism but 
 
ANEURISM. 1251 
 
 of an associated aortic insufficiency. An extremely rare continuous mur- 
 mur with rhythmical whiffs corresponding to the systole heard over the 
 manubrium is a sign of an arteriovenous aneurism or communication with 
 the pulmonary artery. A systolic murmur may sometimes be heard over 
 the trachea or at the open mouth of the patient. 
 
 The following clinical phenomena associated with aneurisms of differ- 
 ent parts of the aorta are of diagnostic importance: 
 
 Aneurism of the Ascending Portion of the Arch. — Small sacs close to 
 the root of the aorta are latent. Larger aneurisms arise most frequently 
 from the convexity and develop toward the right. Deep-seated pain is 
 an early symptom. It is most severe behind the manubrium and radiates 
 to the neck, shoulders, and arms, more frequently the left than the right. 
 Flatness in the sternal end of the second, third, and sometimes also the 
 first intercostal space indicates the extension of the tumor to the right. 
 In this region the heart sounds are loud and the second aortic sound is 
 commonly ringing and accentuated. 
 Expansile pulsation is present. The 
 apex of the heart is displaced down- 
 ward and to the left. Aneurisms of 
 this part of the aorta may, in rare 
 instances, communicate with the 
 superior vena cava or compress the 
 inferior vena cava, causing oedema of 
 the lower extremities, and ascites. 
 An aneurism springing from the con- 
 cavity of the ascending portion may 
 extend beyond the left sternal border. 
 The right recurrent laryngeal nerve 
 
 is exposed to pressure. Sclerosis of Fig. 358.— Aneurism of ascendinfr portion of the 
 ■■^ ■■- . , . , . arch of the aorta. 
 
 the coronary arteries, sclerotic lesions 
 
 of the aortic cusps, and relative insufficiency are common. When a 
 sacculated aneurism in this position attains considerable size, the over- 
 lying manubrium and cartilages and ribs to its right form a distinct, 
 rounded, pulsating prominence, which in the course of time may cause 
 absorption of the wall of the chest and appear as an external tumor. 
 Systolic murmurs are common and are occasionally audible at a distance 
 from the chest. Compression of the neighboring veins occurs early. The 
 jugulars, especially the right, are prominent. The little venous twigs over- 
 lying the tumor are enlarged. The trachea and left bronchus are frequently 
 compressed. Tracheal tugging may occur when firm adhesions with 
 the trachea or bronchus are established. Difficulty in swallowing is not 
 common in aneurisms in this situation. 
 
 Aneurism of the Transverse Portion of the Arch. — The sac may cause 
 prominence of the manubrium and the cartilages and ribs to its right, as 
 in aneurisms of the ascending aorta. The innominate is frequently involved, 
 with the appearance of an external pulsating tumor at the sternoclavicular 
 articulation and extending upward into the neck. Compression of the left 
 recurrent laryngeal nerve is common. An early symptom is hoarseness 
 with a curious high-pitched vibrating quality of the voice. In slight palsy 
 
1252 
 
 MEDICAL DIAGNOSIS. 
 
 Fig. 359. — Unilateral clubbed fingers in aneurism of the 
 descending arm of the aortic arch. — Groedel's case. 
 
 and in older cases the voice may be unchanged. Pupillary derangements 
 are sometimes observed. Compression of the trachea and left bronchus, 
 and tracheal tugging are very common. Dysphagia is more frequent 
 than in aneurisms in other portions of the aorta. The sac sometimes 
 includes portions of the ascending and transverse arch, causing dulness to 
 the right and upward, and can often be felt pulsating in the episternal notch. 
 Sacculated aneurisms in the concavity of the arch are always difficult of 
 recognition. Even when of moderate size they may cause persistent, even 
 
 fatal, haemoptysis. They elude 
 physical examination and rarely 
 attain a size sufficient to displace 
 the heart. This form of aneu- 
 rism may be suspected when, 
 with persistent or recurring 
 haemoptysis in the absence of rec- 
 ognizable cause, are associated 
 paralysis of the left recurrent 
 nerve, dislocation of the trachea 
 and larynx to the right, tracheal 
 tugging, stridor, and dysphagia; 
 but none of these is constant. 
 Aneurism of the Descending Arch. — These tumors may also be latent. 
 Pain is a common symptom. It may be intrinsic. Very often, how^ever, 
 it is due to erosion of the dorsal vertebrae. Dyspnoea and stridor from 
 compression of the left bronchus and lung, bronchitis, bronchiectasis, and 
 bronchorrhoea may occur. Left-sided recurrent nerve palsy or paralysis, 
 difficulty in deglutition, left pupillary phenomena are of diagnostic impor- 
 tance. When the sac is large, retardation of the crural pulse as compared 
 with the radials or the apex beat is a less important sign. At the left ster- 
 nal border in the first and second 
 intercostal spaces there may be dul- 
 ness, with distinct heart sounds, 
 murmurs, and pulsation. Perfora- 
 tion may take place and an external 
 tumor present in this region — an 
 uncommon event. 
 
 Aneurisms of the Descending 
 Thoracic Aorta. — The sac is usually 
 low down, resting upon the dia- 
 phragm and the left side of the 
 bodies of the lower dorsal vertebrae, 
 
 which are eroded. Among the pressure phenomena are dysphagia, intense 
 pain radiating to the left, pleuritic friction, impaired resonance, together 
 with feeble respiratory sounds and small mucous rales in the lower scapular 
 region near the spine. A pulsating external tumor may present in the 
 back. Pain is usually present, but the other phenomena may be wholly 
 absent and the condition overlooked. 
 
 As a rule large aneurisms are sacculated and increase in size without 
 involving other portions of the aorta than that from which they spring. 
 
 Fig. 360. — Sphygmograms in aneurism of the 
 descending arm of aortic arch. I, right radial pulse; 
 II, left radial. Same case as Fig. 359. — Groedel. 
 
ANEURISM. 
 
 1253 
 
 Fig. 361. — Orthodiagraphic outline of left bor- 
 der of aneurism of descending limb of arch of the 
 aorta, showing displacement of the heart downward 
 and to the left. Same case as Fig. 359. — Groedel. 
 
 Exceptionally an aneurism arising from one portion enlarges by involving 
 adjacent parts of the aorta until several parts are successively implicated, 
 as the ascending portion, the transverse arch, and to some extent the 
 descending arch. Under such circumstances the rational symptoms and 
 physical signs of aneurism in the various localities are successively 
 
 developed. Still more rarely mul- 
 tiple aneurisms are present. In the 
 latter case one may be recognized 
 by suggestive symptoms and char- 
 acteristic signs, while the others 
 may escape detection. 
 
 ®_w^^^^^^^T^^;&^>^ o ) Diagnosis. — Direct. — There 
 
 ^^^^^^^^^^#^-';^?^ are cases in which a positive diag- 
 
 nosis cannot be made. Aneurisms 
 of the root of the aorta and of the 
 concavity of the arch, when small, are 
 usually wholly latent. The anamne- 
 sis is important. Syphilis, occupa- 
 tion, strain, blows and contusions 
 of the chest are highly suggestive. 
 Alcoholism is of secondary impor- 
 tance. Middle age and the male sex 
 are predisposing influences of weight. 
 Among the symptoms those which arise from intrathoracic pressure are 
 significant. These comprise pain, dyspnoea, stridor, cough, dysphagia, 
 pupillary differences, and a peculiar hoarseness with a high-pitched, shrill, 
 vibrating quality of the voice. Among physical signs which point strongly 
 to aneurism are, in the areas named, circumscribed flatness shading off to 
 dulness, prominence with pulsation, a systolic murmur, systolic thrill, dia- 
 stolic shock, displacement of the apex downward and to the left (especially 
 when the signs of cardiac enlarge- 
 ment are absent), enlargement of 
 superficial veins, inequality of radial 
 pulses, a retardation or absence of 
 crural pulsation and tracheal tug- 
 ging. None of these clinical phenom- 
 ena is diagnostic. The association 
 of all of them is conclusive. When 
 several of them are present the diag- 
 nosis becomes probable. An external 
 tumor with distinctly expansile pul- 
 sation and diastolic shock justifies a 
 positive diagnosis. Two facts are to be borne in mind. First, an enlarged 
 lymph-node lying directly over a large vessel may pulsate synchronously 
 with the action of the heart, but the pulsation is not expansile; and second, 
 tracheal tugging may be present when, in mediastinal tumor or enlarged 
 peribronchial lymph-nodes, there are close adhesions between the aorta and 
 the left bronchus. Tracheal tugging is, therefore, not a pathognomonic sign 
 of aneurism. The X-ra^ are of great value as showing, upon fluoroscopic 
 
 Fig. 362.- 
 
 .\neurism of the descending thoracic 
 aorta. 
 
1254 MEDICAL DIAGNOSIS. 
 
 examination, a shadow in an abnormal situation, the borders of which expand 
 and contract with the diastole and systole of the heart. Such a shadow is 
 to be differentiated from the non-expansile movement which attends the 
 advance and retreat of a tumor moved by the pulsation of the aorta or heart. 
 The shadow of an aneurism attached to the trachea or left bronchus may 
 rise with the act of deglutition, while tumors, in consequence of their firm 
 attachments to the surrounding structures, are not affected by swallowing. 
 The situation of an aneurism may be determined by the foregoing 
 symptoms and signs. But there are exceptions to this rule. Thus a sac 
 springing from the ascending portion of the arch may present at the left 
 border of the arch, while one connected with the descending portion may 
 extend to the right of the manubrium and cause pulsation in the right 
 interscapular space; and the possibility that an elongated aneurism of the 
 ascending portion may cause dulness and pulsation to the right of the 
 lower part of the sternum must be considered. 
 
 Differential. — Sclerosis of the aorta can scarcely be differentiated 
 from fusiform aneurismal dilatation of the aorta. The fluoroscopic shadow 
 is circumscribed in saccular aneurisms; diffuse and uniform in arterioscle- 
 rosis and the dilatation which occurs in functional derangements, as some 
 cases of neurasthenia and exophthalmic goitre. Pain, which is an early 
 and continuing symptom in aneurism, is not a prominent symptom in 
 sclerosis. Dynamic Pulsation. — Increased dulness at the level of the upper 
 part of the manubrium and pulsation in the episternal notch are sometimes 
 present in cases in which, at the autopsy, no dilatation of the aorta is 
 found. This form of widening of the aorta, if persistent, cannot, during 
 life, be differentiated from fusiform aneurism. Dislocation of the Aorta 
 in Spinal Curvature. — The convex border of the ascending limb of the arch 
 may be displaced in such a manner as to cause dulness and forcible pulsa- 
 tion beyond the right border of the sternum and simulate an aneurism. 
 Pressure symptoms and pain are usually absent, the pulsation is not expan- 
 sile, and there is no diastoHc shock. Solid Intrathoracic Tumors. — These 
 are very often malignant. They take origin in the mediastinal lymph- 
 nodes, the pleura or lungs, the thyroid body, or the oesophagus. A per- 
 sistent thymus may be greatly enlarged. Such new growths commonly 
 show a tendency to develop both to the right and left of the sternal borders, 
 and not, as is usually the case in aneurism, upon one side. The heart 
 sounds are not so loud as in aneurism, and diastolic shock is not felt. Mur- 
 murs may occur but are far less common. Differences in the radial and 
 retardation in the crural pulse are Hkewise absent. Glandular metastases 
 may be present in the neck — a sign of great significance. Pulsation is 
 common but not expansile. Symptoms of pressure upon the recurrent 
 laryngeal nerves are common, but other pressure symptoms are less prom- 
 inent than in aneurism. The outline of an aneurismal sac is rounded and 
 usually regular; that of a tumor uneven and irregular. The course of 
 malignant disease is rapid, emaciation pronounced, and cachexia early 
 developed; that of aneurism relatively slow, and the fatal issue may occur 
 while the general nutrition is yet fair. There may be the history of a 
 primary growth which has been removed, or the indications of its presence 
 in a distant organ or part. Thoracic tumors and aneurisms containing 
 
ANEURISM. 
 
 1255 
 
 much stratified clot cannot always, when deep seated, be differentiated. 
 New Growths Involving the Wall of the Chest. — Osteosarcoma may involve 
 the sternum or ribs. The overlying veins are greatly enlarged and tortuous. 
 The osseous structures are palpably enlarged and involved. There is local 
 prominence, but the symptom-complex of aneurism is not present. Caries, 
 osteomyeHtis, or actinomycosis may cause a rounded, fluctuating tumor 
 near the sternum or ribs. In aneurism the bony structures of the chest 
 wall may be recognized as overlying the tumor, and, when perforation has 
 taken place, as entering into the formation of the opening through which 
 the tumor protrudes, while in abscess they may be recognized as under- 
 lying the fluctuating tumor and separating it from the cavity of the thorax. 
 In the very rare cases of mediastinal abscess the onset is abrupt, substernal 
 
 Fig. 363. — Bulging of the anterior wall 
 of the chest in a case of. mediastinal tumor. 
 — Jefferson Hospital. 
 
 Fig. 364.- 
 
 -Abscess of the chest wall. — Jefferson 
 Hospital. 
 
 pain is intense and persistent, and there are grave constitutional symptoms. 
 Pulsating Empyema. — Intrathoracic pulsating empyemata give rise to 
 more or less diffuse pulsation upon the left side in the anterolateral aspect 
 of the chest. The signs of pleural effusion are present, the heart is usually 
 displaced to the right, and Traube's semilunar space modified. Empyema 
 necessitatis, when the tumor is in relation with the heart and pulsates, 
 may simulate aneurism. The signs of left-sided pleural effusion, the fact 
 that the tumor diminishes upon inspiration and increases upon expiration, 
 the absence of heaving, forcible impulse, and diastolic shock, of the 
 pressure symptoms incident to aneurism, and of tracheal tugging are 
 conclusive. Aortic Stenosis. — A systolic murmur and thrill may suggest 
 aneurism, but a consideration of the history of the case, the nature of the 
 subjective symptoms, and the objective signs of the two conditions render 
 the differential diagnosis an easy matter. 
 
1256 MEDICAL DIAGNOSIS. 
 
 The Course. — The progress is irregular. Symptoms usually precede 
 signs. There are periods of arrest. The contour of the sac and the pres- 
 sure phenomena undergo from time to time changes due to changes in the 
 accumulation of clot, its organization or failure to organize at different 
 places, and uneven yielding of the wall under arterial pressure in various 
 regions. In sacs that have perforated the chest wall such local expansions 
 and retractions not rarely take place under the eye. They may be invoked 
 in explanation of changes in the degree of dysphagia, the dyspnoea and 
 stridor, the pupillary differences, and the locality and intensity of the pain. 
 A knowledge of these facts justifies caution in ascribing diminution or even 
 disappearance of certain pressure symptoms to an actual improvement 
 in the underlying condition. Sacs that rapidly increase in size give rise 
 to more urgent pressure symptoms and are more liable to early perfora- 
 tion than those whose growth is slow. The urgency of pressure symptoms 
 depends in part upon the size of the sac and in part upon its location. 
 Aneurisms of the ascending aorta cause compression of the trachea, a 
 primary bronchus, or the oesophagus, only when they have attained con- 
 siderable size; while a small sac in the concavity of the arch may compress 
 the left bronchus, or a medium-sized sac springing from the inner aspect 
 of the descending portion may cause difficulty in deglutition. Perforation 
 "occurs earlier in dissecting than in other forms of aneurism. In sacs con- 
 taining much clot the perforation may be small and the bleeding moderate. 
 The blood loss is oftenj however, rapid and fatal. It may be spontaneously 
 arrested by a layer of clot which may permanently close the rent. As 
 a rule, when hemorrhage is arrested it recurs from time to time and finally 
 proves fatal. Rupture takes place most frequently into the pleural sac or 
 a bronchus; less commonly externally, into the pericardium, the retro- 
 peritoneal connective tissue, or the peritoneal cavity; not often into the 
 oesophagus, stomach, or intestine; and extremely rarely into the descending 
 vena cava, the pulmonary artery, or an auricle. When the hemorrhage is 
 free, death occurs at once with symptoms of internal bleeding. Perfora- 
 tion into the pericardium is usually fatal at once; into the retroperitoneal 
 tissues it is usually delayed for a longer period. In the latter situation 
 perforation is attended with intense pain and may at first simulate per- 
 foration peritonitis or embolism of the mesenteric artery. When the rent 
 is small or the bleeding restrained by the adjacent structures, there are 
 signs of internal hemorrhage, but life is prolonged for a period. I saw a 
 patient who lived eight hours. Bleeding into a pleural sac causes the 
 signs of an effusion; into a bronchus, haemoptysis which may suggest 
 phthisis or be moderate and prolonged, giving rise to a suspicion of pul- 
 monary cancer; into the stomach, hsematemesis; into the gut, bloody 
 stools. Fragments of a thrombus may be detached, causing embolism, 
 most commonly of a cerebral artery. 
 
 Prognosis.— Spontaneous cure cannot occur in fusiform aneurisms. 
 Small sacs with narrow openings in rare instances become filled with clot 
 which undergoes organization. In dissecting aneurisms a distant com- 
 munication with the lumen of the aorta may be established, thus forming 
 along the old course a new channel for the blood stream. These are rare 
 events. In a majority of instances, aneurism of the aorta terminates in 
 
ANEURISM. 
 
 1257 
 
 death in the course of six months to three years. The average duration 
 is about one year. Exceptionally life may be prolonged for several years. 
 A time prognosis in individual cases is hazardous. Slowly developing 
 and arrested aneurisms are of relatively favorable prognosis as compared 
 with those of rapid growth, but unforeseen accidents may at any moment 
 occur. Favorable conditions of 
 life and treatment render, in 
 exceptional instances, the prog- 
 nosis less unfavorable. 
 
 (b) ANEURISM OF THE AB- 
 DOMINAL AORTA. 
 
 Aneurism of the aorta is far 
 less common below the diaphragm 
 than above it. It may be fusi- 
 form or sacculated. In rare 
 instances there are two or more 
 — multiple aneurism. Still more 
 rare in this region is dissecting 
 aneurism. The most common 
 situation is directly below the 
 diaphragm and upon the anterior 
 wall of the aorta, where the sac 
 forms a distinct rounded tumor 
 in the epigastric region in the 
 median line and extending to the 
 left. As the sac enlarges it pro- 
 jects into the left hypochondrium 
 and may occupy a large part of 
 the left side of the abdomen. 
 When it projects posteriorly it 
 causes erosion of the vertebral 
 bodies, or may give rise to distinct 
 spinal symptoms, and, increasing 
 in dimension, may extend into 
 the chest and rupture into the 
 pleura or form an external tumor 
 in the lumbar region. Perfora- 
 tion into the retroperitoneal space 
 
 may give rise to a progressively enlarging haematoma extending into the 
 left lumbar region and simulating a sarcoma. 
 
 Symptoms. — Pain is an early symptom. It is referred to the back 
 and is often persistent, radiating to the left flank and marked by intense 
 exacerbations, suggestive of intercostal neuralgia, or renal colic. In many 
 of the cases there are pain-free intervals, or a dull, deep-seated pain in 
 the back increased by movement or jarring of the body. The pain 
 not rarely extends into the abdomen with exacerbations which simulate 
 colic — belly-ache. 
 
 Fig. 365 
 
 iniiial aorta. — Inter 
 
1258 MEDICAL DIAGNOSIS. 
 
 Physical Signs. — Upon inspection epigastric pulsation may be pres- 
 ent, frequently a diffuse prominence, and occasionally a distinct circum- 
 scribed tumor. Palpation reveals a tumor mass, rounded, smooth, and the 
 seat of forcible, expansile pulsation. A systohc thrill is common. Percus- 
 sion. — A large sac approaches the anterior wall of the abdomen and causes 
 dulness, which may be continuous with that of the left lobe of the liver. 
 Auscultation reveals a systolic murmur usually best heard over the tumor 
 and transmitted into the crural arteries, sometimes more distinct over the 
 lower dorsal and upper lumbar vertebrae. In some cases there is also a 
 diastolic murmur. These murmurs do not accompany the heart sounds, 
 but follow them. Large aneurisms of the abdominal aorta displace the 
 stomach and to some extent also the liver downward. Distinct retarda- 
 tion of the pulse in the crural arteries occurs when the sac is large. 
 
 Diagnosis. — Direct. — A distinct circumscribed epigastric tumor in the 
 median line and extending to the left, which can be grasped and which is the 
 seat of expansile pulsation, justifies a positive diagnosis of abdominal aneu- 
 rism. In the absence of this symptom-complex the diagnosis cannot be 
 made. It is of use to note that in aneurism the pulsation is epigastric, while 
 dynamic pulsation is most marked immediately above or at the umbilicus. 
 
 Differential. — Dynamic Pulsation. — The throbbing aorta is very 
 common in nervous women. This pulsation is often very forcible and to 
 a slight extent distinctly expansile, but it is not associated with a tumor, 
 and the course of the aorta may often be felt upon palpation. A systolic 
 murmur may be easily produced by the pressure of the stethoscope. Asso- 
 ciated nervous symptoms, and the disappearance of pulsation under the 
 influence of suggestion or other powerful psychic influences are of diagnos- 
 tic importance. Tumors of the Pylorus, Pancreas, or the Left Lobe of the 
 Liver. — New growths overlying the aorta in the epigastrium rise and sink 
 with the movements of the arterial wall and are frequently mistaken for 
 aneurism. The fact that the tumor is not expansile is of diagnostic impor- 
 tance. The absence of murmurs points to tumor rather than aneurism. 
 The pressure of a tumor in contact with the aorta may cause stenosis and 
 a systolic murmur. The crural pulse is not affected. The disappearance 
 of pulsation in the knee-elbow posture, when the tumor falls away from 
 the aorta, is an important sign. The X-rays are of less value as aids to 
 diagnosis in abdominal than in thoracic aneurisms. 
 
 Prognosis. — Aneurisms of the abdominal aorta almost always end 
 in death. In rare instances small sacs with a narrow communication with 
 the lumen of the aorta have undergone obliteration by the deposit and 
 organization of clots. Death commonly follows rupture, which may take 
 place into the retroperitoneal tissues, pleura, peritoneum, or intestine. 
 Far less frequently death is due to embolism of the superior mesenteric 
 artery, complete occlusion of the aorta by clot, or paraplegia following 
 erosion of the spine and compression of the cord. 
 
 ii. Aneurism of the Coeliac Axis and its Branches. 
 
 This branch is frequently involved in aneurism of the abdominal aorta. 
 A negro, twenty-six years old, who was syphilitic, suffered from intense 
 
ANEURISM. 1259 
 
 paroxysmal pain radiating to the back and both sides of the abdomen. 
 No tumor could be discovered. Death occurred suddenly with symptoms 
 of internal hemorrhage. At the autopsy there was found an aneurism 
 of the axis the size of a small orange, which had ruptured into the peri- 
 toneum. The splenic artery is occasionally the seat of small, sometimes 
 of large, aneurismal sacs. Epigastric pain, vomiting, haematemesis, and 
 hemorrhage from the bowel may occur. A deep-seated tumor extending 
 to the left with or without pulsation, and dulness reaching to the spleen, 
 are significant. Rupture into the colon may occur. Aneurism of the 
 superior mesenteric artery may cause a movable pulsating tumor, which 
 is often the seat of a systolic murmur but is not associated with retardation 
 of the crural pulse. Symptoms of mesenteric infarction may occur. Aneu- 
 rism of the hepatic artery is extremely rare. The symptoms are obscure 
 and a positive diagnosis is impossible. Rupture into the bile passages 
 may occur. The differential diagnosis between aneurisms of these arteries 
 and aneurisms of the aorta is commonly attended with insurmountable 
 difficulties. 
 
 iii. Arteriovenous Aneurism. 
 
 That form which results from the rupture of an aneurism of the ascend- 
 ing portion of the arch of the aorta into the descending vena cava is of 
 special clinical interest. It is, however, extremely rare. The symptoms 
 usually occur abruptly and consist of marked dilatation of the veins of 
 the upper part of the body, with cyanosis and cEdema. A continuous 
 murmur with systolic intensification and a systolic thrill may be recognized. 
 
 iv. Periarteritis Nodosa ; Congenital Aneurism. 
 
 The medium-sized arteries, especially those of the muscles, and the 
 heart, spleen, liver, kidneys, intestines, and the skin are the seat of whitish 
 nodular masses, varying in size from a small shot to a large pea, and great 
 numbers of small aneurismal dilatations. The disease has occurred in 
 both sexes. It manifests itself most commonly in early and middle adult 
 life. It has been ascribed to syphilis and to septic conditions. It is ex- 
 tremely rare. The prominent symptoms are weakness, anaemia, and 
 rapidity of the pulse. There is at first fever, which presently falls without 
 a corresponding decline in the pulse-frequency. When the muscular 
 branches are involved, pain, weakness, and atrophy occur. When the 
 arteries of the gastro-intestinal canal are the seat of the lesions, epigastric 
 pain, thirst, anorexia, nausea and vomiting, and diarrhoea or constipation 
 are prominent symptoms. Hemorrhage from the bowels has been observed. 
 Scanty urine, of low specific gravity, albumin, and casts occur. Urea is di- 
 minished. Anaemia is marked. Leucocytosis is common. The course of the 
 disease is progressive, and death occurs at the end of the second or third 
 month. Recovery is exceptional. The diagnosis is usually post mortem. 
 The nature of the affection may be suspected when, in connection with 
 the foregoing symptom-complex, nodular thickenings may be felt in the 
 course of accessible arteries. 
 
1260 MEDICAL DIAGNOSIS. 
 
 XIV. 
 
 ' THE DIAGNOSIS OF DISEASES OF THE NERVOUS SYSTEM. 
 
 DISEASES OF THE BRAIN. 
 
 I. MENINGITIS. 
 
 Inflammation of the membranes of the brain is common to a variety 
 of affections. Thus, there are purulent meningitis, tuberculous meningitis, 
 syphilitic meningitis, and meningitis due to injury, or associated with 
 disease of bone, or with general paresis. For descriptive purposes we 
 distinguish between inflammation of the dura — pachymeningitis — and 
 inflammation of the pia, — le2:>tomeningitis,— although the two membranes 
 are often involved together. 
 
 Inflammation of the dura mater may occur from septic infection, and 
 may be purulent. The commonest causes are injury, infection, and necro- 
 sis of bone. Thus disease of the middle ear is the most frequent cause, 
 but cases may arise from infection through the nose by way of the cribri- 
 form plate. Fracture of the skull may sometimes be the starting-point. 
 Large quantities of pus may be present, and the pia mater and brain 
 substance may be involved as well as the dura. There is a variety in 
 which the pus is localized or pocketed between the skull and the dura, 
 usually secondary to injury of the skull or to caries or bone syphilis — the 
 so-called pachymeningitis externa. 
 
 A distinct form of pachymeningitis is the disease known as hsematoma 
 of the dura mater — the pachymeningitis hcemorrhagica of Virchow. It 
 occurs especially in the chronic insane and in old alcoholic patients. There 
 is observed beneath the dura a layer, quite thick, which looks like organized 
 blood-clot; this often exists, in fact, in several layers, as though caused 
 by successive hemorrhages. Sometimes the appearance is that of a very 
 delicate vascular membrane, enclosing in its meshes blood which is more 
 or less organized. Cysts may be found and other evidences of breaking 
 down of the new tissue. 
 
 The symptoms of pachymeningitis are obscure, being masked by the 
 general condition of the patient, who is usually a chronic lunatic or a 
 confirmed inebriate. A similar lesion has been described after sunstroke^ 
 and may account for the headache and mental changes. 
 
 Simple, idiopathic, or isolated inflammation of the pia mate? is such 
 a debatable condition as scarcely to be considered' a chnical entity. The 
 forms of leptomeningitis which we usually distinguish at the bedside are 
 those that occur in septic infection, such as in otitis media, and in cerebro- 
 spinal fever, syphilis, and tuberculosis. A very characteristic form is that 
 seen in general paresis, in which the pia mater is thickened and opaque and 
 so adherent to the summits of the convolutions that it is stripped with diffi- 
 culty, and usually carries away with it a portion of the brain substance. 
 Quincke has described a serous meningitis in which the pia-arachnoid 
 
ACUTE HEMORRHAGIC ENCEPHALITIS. 1261 
 
 especially is involved; it is characterized by mild symptoms, slight fever, 
 and headache, with some stiffness of the back of the neck; and optic 
 neuritis is not uncommon with it. 
 
 Symptoms. — The general symptoms of leptomeningitis are headache, 
 fever, delirium, convulsions, rigidity of the neck and face muscles, exag- 
 gerated reflexes, followed later by paralysis and coma. 
 
 Tuberculous Meningitis (see page 790). 
 
 Epidemic Cerebrospinal Meningitis (see page 730). 
 
 Septic meningitis may be caused by otitis media, in which case the 
 microbe is usually a streptococcus or staphylococcus; or it may be caused 
 by the pneumococcus. This meningitis is associated with pus forma- 
 tion, also with pachymeningitis and purulent cerebritis, and in not a 
 few cases leads to brain abscess. 
 
 Diagnosis. — Meningitis, whether in the dura or the pia mater, depends 
 upon so many causes and is associated with so many pathological proc- 
 esses that it is difficult to lay down uniform rules for the diagnosis. The 
 first essential is to seek for the cause, such as a middle-ear disease, 
 tuberculosis, meningococcic or other infection, injury to the bones of the 
 skull, caries, sunstroke, syphilis, etc. 
 
 Symptoms of irritation appear early. These are headache simulat- 
 ing neuralgia, vomiting, optic neuritis, fever, stiffness of muscles, and 
 perhaps convulsions, with irritability of temper, change of disposition, 
 and even somnolence, delirium, or stupor. Later the symptoms are 
 indicative of pressure and profound toxsemia: thus we see various 
 paralyses, increasing stupor merging into coma, rapid pulse, and 
 failing powers. 
 
 Meningitis of various kinds may be mistaken for mere neuralgia, but 
 the history and associated symptoms of organic disease should prevent 
 error. Where headache, vomiting, and constipation are early symptoms, 
 as in tuberculous meningitis, the case may suggest gastric or intestinal 
 disorder, but the onset of more pronounced brain symptoms, such as 
 convulsions, stupor, and various paralyses, is unmistakable. The best 
 single general rule for the distinguishing of meningitis is to be on the look- 
 out in suspected cases for the evidences of organic disease of the brain, 
 and to trace these to their cause. Lumbar puncture may shed important 
 light in cases of infection. 
 
 II. ACUTE HEMORRHAGIC ENCEPHALITIS. 
 
 The disease is characterized by multiple foci of congestion and 
 both punctate and massive hemorrhage, with infiltration of leucocytes, 
 minute emboli, and localized necrosis of the brain-tissue. The mem- 
 branes are usually not involved. The reported cases have mostly 
 followed the infectious diseases, such as influenza, mumps, erysipelas, 
 pneumonia, typhoid and typhus fever, and malaria. Nephritis has been 
 observed in some cases. The disease is probably caused by the local action 
 of micro-organisms or by their toxins. Oppenheim called attention to the 
 resemblance of the disease process to the polioencephalitis superior of 
 Wernicke and to the polioencephalitis anterior of Striimpell. 
 
1262 MEDICAL DIAGNOSIS. 
 
 Symptoms. — The symptoms are suggestive of meningitis, which, 
 however, is not present. There are headache, vomiting, convulsions, 
 localized palsies, and affections of consciousness. Rigidity of the neck 
 sometimes occurs. Fever is not constant, and there may even be sub- 
 normal temperature. The pulse at first may be slow, but in fatal cases 
 the pulse becomes rapid, the respirations shallow, coma sets in, and 
 death occurs in a few days or weeks. Recovery has been claimed in 
 a few cases. 
 
 Diagnosis. — The disease is likely to be confounded with meningitis, 
 and the distinction between the two is not of practical importance, as the 
 course and treatment are nearly the same. In most cases an accurate 
 diagnosis has only been made after death. This form of encephalitis may 
 be suspected when grave cerebral symptoms occur in the course of, or 
 immediately following, any of the infectious diseases mentioned. 
 
 III. PURULENT MENINGO-ENCEPHALITIS AND 
 BRAIN ABSCESS. 
 
 Pus-forming inflammation within the cranium assumes several forms. 
 There may be a diffuse purulent meningitis, or, as is more common, a 
 meningo-encephalitis; and there may be abscess. The clinical distinction 
 between these forms is not easy. 
 
 Etiology. — The causes are the various pyogenic micro-organisms. 
 One of the commonest is seen in purulent otitis media; and more rarely 
 other cranial bones, especially the bones of the nose and the orbit, and their 
 sinuses, may be the starting-point. Accessory sinuses of the nose are fre- 
 quently infected, and this infection may travel by way of the frontal sinus, 
 sphenoidal sinus, ethmoid cells, or the antrum of Highmore. The strepto- 
 coccus is the chief germ in otitic brain abscess. Septic infection, arising 
 from any focus in the body, may cause a metastatic brain abscess, but 
 this complication is rather more common in ulcerative endocarditis, 
 abscess of the liver, abscess and gangrene of the lung, and empyema. 
 Trauma of the skull may also cause abscess of the brain. Suppurative 
 meningitis occurs in tuberculosis and in cerebrospinal fever. 
 
 Pathology. — The membranes, especially the pia-arachnoid, are inflamed 
 and opaque in purulent meningitis, and pus is diffused beneath them. 
 This pus often follows along the perivascular spaces and the fissures of the 
 brain, appearing as white streaks. In some cases it is more copious, and 
 forms collections beneath the membranes, especially at the base. The 
 cerebral tissue is often involved, the gray and white matter being infil- 
 trated, oedematous, and softened in places. There may also be sinus throm- 
 bosis, with engorgement of veins on the outside surface of the skull. When 
 abscess forms it is either diffuse or circumscribed. In the former case the 
 collection of pus is merely an accident of a more or less diffused purulent 
 meningitis. The circumscribed abscess is contained within a limited area, 
 and its walls may even be thickened, forming a barrier between the pus 
 and the brain tissue. These circumscribed abscesses are most common 
 in the temporal lobe of the cerebrum and in the cerebellum. In some 
 cases multiple abscesses are formed, especially in metastasis. 
 
MENINGO-ENGEPHALITIS AND BRAIN ABSCESS. 1263 
 
 Symptoms. — These are general and focal. Among the general symp- 
 toms we include those which indicate a grave cerebral disorder; and among 
 the focal symptoms those which indicate its location in the brain. The 
 general symptoms are fever, headache, vomiting, convulsions, paralysis, 
 optic neuritis, and affections of consciousness. Fever is not constant nor 
 always of one type; it may be slight and easily overlooked; again it may 
 be more pronounced, and accompanied with chills and sweating. It 
 may depend as much on the primary condition (otitis media, abscess of 
 the lung, etc.) as on the brain lesion. Per contra, in some cases of brain 
 abscess the temperature is subnormal and the pulse very slow. Headache 
 is usually present in suppurative meningitis, but it is not an altogether 
 constant symptom in brain abscess. It was present in 78 out of 169 cases 
 in AUport's table. In some cases, however, it is an early indication of an 
 insidious onset. Its localizing value is not always great; in cerebellar 
 abscess, for instance, the pain has been observed in other parts of the 
 cranium, even in the frontal region. Occasionally, however, the pain is 
 strictly localized at the region of the abscess, and pressure and percussion 
 on the skull at that point may be painful. Vomiting is frequent in cerebel- 
 lar abscess, but more rare in diffuse purulent meningitis; and it is usu- 
 ally of the cerebral type — propulsive and not dependent on food in the 
 stomach. Convulsions may or may not be present; there is no posi- 
 tive rule about them. They sometimes have localizing value. The same 
 can be said of paralysis. Optic neuritis is a most important symptom of 
 abscess of the brain, although not present in all cases. In children, if the 
 pus formation be rapid, optic neuritis will soon ensue. It has no localiz- 
 ing value, but its presence in cases of latent or suspected abscess is most 
 significant. Affections of consciousness are common in all forms of 
 suppurative disease of the brain, and they range from mere apathy and 
 stupor to wild delirium and profound coma. In cases of latent abscess 
 changes in the temper and personality, such as irritability and depression, 
 are observed. 
 
 By the focal symptoms we attempt to determine the site of the 
 abscess. These symptoms are mostly pain, paralysis, and convulsions. 
 
 Pain, as already said, is not altogether reliable as a guide. Both in 
 cerebellar and temporosphenoidal abscess the pain is sometimes frontal, 
 or it may be more generally diffused. When sharply localized, as in the 
 occiput or nuchal region, especially if it is increased by percussion, it 
 may prove a safe guide. 
 
 Paralysis may be clearly indicative of the site, especially if the abscess 
 involves the motor regions, as the pre-Rolandic area and its subcortical 
 connections. This may occur either in frontal or parietal abscess, the pus 
 extending backward or forward respectively. We then have hemiplegia 
 or monoplegia (facial, brachial, or crural), according to the centres involved, 
 and in left-sided lesions there is aphasia. Sensory aphasia, especially 
 word deafness, is strongly indicative of a temporal abscess on the left side, 
 such as is common to ear disease, and it has led the way to successful 
 operation. Temporal abscess may also give rise to hemiplegia by pressure 
 across the Sylvian fossa upon the internal capsule; hence this symptom 
 may be misleading. Hemiplegia has even been caused by abscess of the 
 
1264 MEDICAL DIAGNOSIS. 
 
 cerebellum. The hemiplegia in such cases is probably caused by pres- 
 sure on the pons or medulla oblongata. In this way also cerebellar abscess 
 may cause other pontile symptoms, as paralysis of the fifth, sixth, seventh, 
 and eighth nerves, and the mid-brain may even suffer, with a conse- 
 quent partial ophthalmoplegia. According to Allport's table strabismus 
 occurred in 10 out of 98 cases of abscess of the brain, not all cerebellar. 
 From these various data it is seen that paralytic symptoms must be 
 interpreted with care. For instance, thrombus of the cavernous sinus, 
 which might occur in^any purulent process in the brain, causes an oph- 
 thalmoplegia, as may also an abscess of the temporal lobe by pressure 
 on the third and sixth nerves. 
 
 Involvement of the sensory tract, causing hemiansesthesia and hemi- 
 anopsia, has been reported, especially in abscess of the right temporal 
 lobe. Various affections of the visual fields may be caused by abscess 
 in the occipital lobe. 
 
 Focal epilepsy usually indicates a lesion in or about the motor region, 
 but this symptom is not so common as in brain tumor. Unilateral con- 
 vulsions have been reported in cases of abscesses at various sites, even 
 in the cerebellum. Tonic spasm in the nape of the neck may be caused 
 by abscess of the cerebellum. 
 
 When a thrombus forms in a sinus the veins on the outside of the 
 skull may be congested: thus in thrombus of the cavernous sinus the 
 veins of the orbit are engorged; and the veins at the base of the nose and 
 on the brow are sometimes congested from thrombus of the superior 
 longitudinal sinus. 
 
 Among other noteworthy symptoms are vertigo, incoordination, loss 
 of equilibration, especially but not always in cerebellar abscess, and 
 abolished knee-jerks. Macewen has noted this last symptom in cases of 
 cerebellar abscess, and it has been seen in cerebellar tumor, especially of 
 the middle lobe. Occasionally it is not continuous, the reflex disappearing 
 and reappearing. Knapp has seen a case of cerebellar lesion in which 
 only one knee-jerk was lost, and that on the side opposite to the lesion. 
 Abscess of the frontal lobe may cause obscure mental symptoms, especially 
 retarded cerebration. In Allport's collection of 98 cases of abscess of the 
 brain, 40 occurred in the temporal lobe, 31 in the cerebellum, 7 in the 
 parietal lobe, and the remainder in various other regions. In 5 cases 
 there was diffuse subdural abscess. 
 
 Diagnosis. — Purulent meningitis and brain abscess, although included 
 here under one heading and having much in common, should be distin- 
 guished from each other if possible. The two conditions may coexist, 
 or the one merge into the other, and the dividing fine is not easily 
 detected. Focal symptoms are not likely to be seen in diffuse purulent 
 meningitis, and the course of this disease is more acute and rapid; in fact, 
 death may occur in a few days. Abscess is likely to be much slower, 
 especially the circumscribed abscess with well-formed walls; and in this 
 connection the latent abscess must not be overlooked; this may endure 
 for weeks, even months, with only very obscure symptoms. In fact, a 
 latent or premonitory stage is not uncommon in solitary abscess of the 
 brain, but in diffuse abscess, and especially multiple abscess, such as is 
 
SINUS THROMBOSIS. 1265 
 
 caused by metastasis from some septic process outside the brain, the case 
 is Hkely to be more rapid and more like a diffuse suppurative meningo- 
 encephahtis. 
 
 Some authors attempt to distinguish extradural abscess, such as may 
 occur in trauma and even in otitis. The local symptoms of such an infec- 
 tion are usually evident, as pain, swelling, venous engorgement. The 
 presence of an external wound is important. 
 
 Tumor of the brain is distinguished from abscess by its different 
 ■clinical history, its slower onset, the absence of a septic process of origin, 
 and, as a rule, of chill and fever. But in rare cases tumor of the brain is 
 complicated with suppuration. Optic neuritis is rather more common in 
 tumor, but only little reliance can be placed on that fact. The evolution 
 of symptoms is usually more gradual and progressive in the case of tumor. 
 
 Cerebellar abscess may simulate Meniere's disease by vertigo and 
 occasional deafness. The clinical history, however, is different, and in 
 case of abscess there are likely to be fever, headache, and mental changes. 
 
 Cerebral hemorrhage and softening may simulate abscess when the 
 latter is fully formed, but the clinical history is so entirely different that 
 the distinction is easy, as a rule. An abrupt onset of symptoms may 
 occur in case of latent abscess, if the pus breaks from its cavity, causing 
 paralysis, convulsion, coma, etc.; and in such a case the differentiation 
 is perplexing. 
 
 In all cases of septic infection, such as suppurating otitis, abscess of 
 the lung, etc., the onset of cerebral symptoms should excite suspicion, 
 and the case should be carefully scrutinized. Lumbar puncture may give 
 valuable information. 
 
 IV. SINUS THROMBOSIS. 
 
 Thrombosis of the cranial sinuses is either primary or secondary. 
 In the former the thrombus arises from some general blood state, in the 
 latter from some disease, usually septic, in the immediate neighborhood. 
 
 Etiology. — Primary thrombosis is seen in conditions of exhaustion, 
 often as a terminal symptom; thus it occurs in advanced stages of tuber- 
 culosis, carcinoma, the infectious diseases, as typhoid fever, and in the 
 diarrhoeas of infancy. It is favored by a weakened heart and by the 
 sluggish circulation in the sinuses. It has been seen also in chlorosis 
 and anaemia. 
 
 Secondary thrombosis results from disease of the walls of the sinus, 
 hence especially from injury or caries of bone. Its commonest cause is 
 otitis media, in which case the lateral and transverse sinuses especially 
 are involved. It also arises by way of the nasal bones, and in fact, though 
 rarely, from any other bones of the cranium which become the seat of 
 caries. It is sometimes caused by fractures; and it also arises from 
 septic^ processes within the skull, such as a purulent meningitis from any 
 cause, or from a general septicaemia or pyaemia arising from causes outside 
 the cranium. Facial erysipelas may be a cause. 
 
 Pathology. — In septic or secondary thrombosis the sinus is partly 
 or entirely filled with a white or grayish-white mass, adherent to the walls. 
 
 80 
 
1266 MEDICAL DIAGNOSIS. 
 
 This mass may be purulent and sanious, and the walls of the sinus are 
 inflamed; infiltrated, and discolored, while the contiguous bone in many- 
 cases, as in otitis, is carious and softened. In recent cases the thrombic 
 mass is soft and easily broken up, but in older cases it is quite firm and 
 fibrous. It may extend for some distance through the sinus, even into 
 some of the tributary veins, thus causing engorgement of veins, with 
 swelling and oedema, on the outside of the skull. These septic thrombi 
 are not seldom associated with other septic lesions, such as purulent 
 meningitis, purulent encephalitis, and even brain abscess. 
 
 Symptoms. — These are general and local. In the case of the second- 
 ary septic thrombi the general symptoms may be masked by those of the 
 general pyaemia; thus there is fever, usually of a septic type, with headache 
 and changes in consciousness, and there are not seldom the evidences of 
 meningitis. Convulsions sometimes occur, and various paralyses, and 
 occasionally a high grade of choked disk. In the case of primary throm- 
 bosis we have to consider the original disease and its exhausting effects, 
 but superadded to these we observe grave cerebral symptoms of sudden 
 onset, such as headache, vomiting, stupor, followed by a gradually deep- 
 ening coma, possibly with convulsions; but local paralytic symptoms are 
 rare in this form. There may, however, be hemiplegia, or even a general 
 flaccid paresis. 
 
 The local symptoms are sometimes conspicuous. They depend usually 
 upon engorgement of tributary veins on the outside of the skull and upon 
 paralysis of certain cranial nerves. 
 
 In thrombosis of the cavernous sinus there are protrusion of the eye, 
 sweUing and discoloration of the tissues about the eye, engorgement of 
 the veins of the orbit and the frontal veins, which communicate through 
 the orbit with this sinus, possibly choked disk, and paralysis of the third, 
 fourth, and sixth nerves, which run through the sinus. There may also 
 be pain or anaesthesia in the ophthalmic division of the fifth nerve. The 
 central retinal vein may also be the seat of a thrombus. 
 
 Thrombosis of the superior longitudinal sinus may cause cyanotic 
 swelling and oedema on the brow, and in rare cases nose-bleed. Infection 
 of this sinus may occur through the nasal bones and be accompanied with 
 a purulent meningo-encephahtis. The commonest site of cranial throm- 
 bosis is in the lateral and transverse sinuses in cases of otitis media. The 
 local symptoms are disguised by the local bone disease. The most signifi- 
 cant are pain and oedema over the mastoid. Otitis media is the most 
 common cause of grave general infection of the cranial contents, the most 
 serious being abscess. Irritation from this focus may cause recurring epi- 
 leptic fits. The jugular vein, external or internal, may be the seat of 
 thrombus, which may even be palpable. A gravity abscess may simulate 
 phlebitis of the jugular; and the glossopharyngeal, vagus, accessory, and 
 hypoglossal nerves have been paralyzed in some of these cases. 
 
 Diagnosis. — A local diagnosis is hardly practicable for any other of 
 the cranial sinuses than those mentioned above. It is, of course, much 
 simphfied in cases in which circumscribed oedema occurs. The general 
 diagnosis is often difficult and problematical. Thrombosis is to be sus- 
 pected when grave cerebral. symptoms, such as headache, vomiting, con- 
 
CEREBRAL HEMORRHAGE. 1267 
 
 vulsions, stupor, and unconsciousness, occur suddenly in cases of septic 
 infection, such as otitis media and facial erysipelas, and in wasting 
 diseases, such as tuberculosis, carcinoma, infectious diseases, and infan- 
 tile diarrhoea. But a differential diagnosis from meningitis, abscess, and 
 softening is not always possible, and in fact some of these conditions may 
 be associated with thrombosis. Thrombi of the cerebral veins are some- 
 times the cause of hemiplegia and diplegia in young children. Smithers 
 has recently called attention to hemiplegia in typhoid fever, caused by 
 thrombi in the cerebral arteries.^ 
 
 V. CEEEBRAL HEMORRHAGE. 
 
 Etiology. — The cause of this accident is primarily some disease of the 
 blood-vessels, excluding, as we do here, hemorrhage from trauma. The 
 diseases of the blood-vessels are chiefly arterial sclerosis or atheroma, 
 occurring usually after middle life, and more rarely syphilis, occurring at 
 any period of life and not rarely in young adults. It is not to be over- 
 looked, however, that the hemiplegia of syphilis is usually due to an 
 inflammation and thickening of the walls of a blood-vessel rather than to 
 a hemorrhage. 
 
 Pathology. — Atheroma of the blood-vessels is a common affection in 
 later life. It is rare to see an autopsy in a person past fifty without some 
 evidences of it, and in persons of sixty and seventy it is not unusual to see 
 the circle of Willis at the base of the brain so thickened and hardened that 
 the vessels are like pipe-stems. From these main arteries at the base 
 the branches that pass up through the anterior perforated space to the 
 lenticular nucleus and internal capsule are especially liable to suffer. 
 More rarely the branches from the posterior cerebral or those from the 
 basilar, vertebral, and cerebellar arteries are affected. The atheromatous 
 arteries are frequently the seat of minute dilatations, aneurismal in 
 character, and it is one of these that is likely to give way. The hemor- 
 rhage is usually within the substance of the brain; meningeal hemorrhage 
 from arterial disease being rare, although common from trauma. Occa- 
 sionally, however, a hemorrhage breaks through to the surface. The 
 most common seat of hemorrhage is in the lenticular nucleus, which is a 
 part of the basal ganglion (corpus striatum) within the brain. The 
 hemorrhage occurs in such a way as to press upon or destroy the internal 
 capsule which contains the motor and sensory tracts. The weakened artery 
 at this point was called by Charcot the " artery of cerebral hemorrhage." 
 
 In recent cases the blood is either still fluid or partly clotted, and it 
 occupies a ragged cavity which it has torn out of the substance of the 
 brain. In old cases this cavity is often found walled off, forming a cyst, 
 filled with a reddish or yellowish fluid. In rapidly fatal cases it is some- 
 times found that the blood has broken through into the lateral ventricle, 
 or even to the outer surface of the brain. Multiple hemorrhages may 
 occur, and sometimes the hemorrhage is in the parietal or occipital lobe, 
 or even in the pons. Hemorrhage in the cerebellum is less common than 
 in the cerebrum. 
 
 1 Journal of the Am. Med. Assn., Aug. 3, 1907, p. 389. 
 
1268 
 
 MEDICAL DIAGNOSIS. 
 
 Instead of hemorrhage a diseased blood-vessel may cause thrombosis. 
 There is then secondary softening, but clinically the two conditions are 
 much aHke and it is quite impossible, as a rule, to distinguish them. Soft- 
 ening is also caused by embolism, with very similar results. 
 
 In long-standing cases of hemiplegia there occurs a descending degen- 
 eration of the motor tract, which may be traced through the peduncle, 
 
 the pons, the decussation in the 
 medulla, and the spinal cord. 
 
 Symptoms. — Cerebral hemor- 
 rhage causes what is popularly 
 known either as a "stroke" or an 
 '^ apoplexy." These two conditions 
 are distinguished chiefly by the state 
 of the consciousness; in the former 
 the mind may be clear, in the latter 
 there is stupor or coma. In either 
 case there is likely to be paralysis, 
 according to the site of the lesion. 
 In the lenticular nucleus and 
 internal capsule, the most common 
 site, hemorrhage causes hemiplegia 
 on the opposite side. The arm and 
 leg are paralyzed, the arm rather 
 more so, and in some cases the lower 
 part of the face and one side of the 
 tongue. The upper portion of the 
 face is not involved, so the patient 
 can still shut his eyes and wrinkle his 
 forehead. The tongue, if involved, 
 is protruded toward the paralyzed 
 side. In some cases there is hemi- 
 ansesthesia, and even hemianopsia, 
 the affection of the sensory fibres 
 showing that the clot has involved 
 the posterior portions of the internal 
 capsule. There may also be various 
 forms of aphasia if the lesion is in 
 the left hemisphere. 
 
 When the hemorrhage involves 
 the island of Reil and the posterior 
 end of the third frontal convolution 
 on the left side there is motor 
 
 Fig. 
 
 366. — Old left hemiplegia with contractures. 
 — Lloyd. 
 
 aphasia. When the left superior 
 temporal convolution is involved there is auditory aphasia, word-deafness 
 and object-deafness; and when the left angular gyrus is invaded there is 
 visual aphasia, word-blindness and object-blindness. Various mixed forms 
 of aphasia, the so-called sensorimotor aphasia, may occur from hemor- 
 rhage into various portions of these speech centres (the so-called language 
 zone) and their subcortical connections in the left hemisphere. 
 
CEREBRAL HEMORRHAGE. 1269 
 
 Hemorrhage in the frontal lobe, if it does not involve the motor centres 
 or tracts, may cause very obscure symptoms, more especially mental 
 changes, such as retardation of the mental processes, loss of the power of 
 attention, etc. 
 
 Hemorrhage in the superior parietal lobule may cause ataxia of the 
 limbs on the opposite side, and sensory changes, especially astereognosis. 
 
 Hemorrhage in the occipital lobe may cause hemianopsia and other 
 partial defects in the visual fields, and also some inability to recognize and 
 name objects by sight. 
 
 In the cerebellum hemorrhage may cause intense vertigo, loss of 
 equilibration, forced and pitching movements, and vomiting; and if the 
 clot is big enough to make pressure on the mid-brain and pons, there may 
 be hemiplegia, hemianaesthesia, and involvement of the oculomotor, fifth, 
 sixth, seventh, and eighth nerves; but these latter symptoms are rare, 
 and are rather indicative of either a mid-brain or a pontile lesion. Thus 
 hemorrhage in the pons causes the hemiplegia alternans, in which the 
 arm and leg are paralyzed on the opposite side while the sixth, seventh, 
 eighth, and possibly the fifth nerves are paralyzed on the side of the lesion; 
 this is so especially if the lesion is low in the pons. If the lesion is high, 
 the cranial nerves named may be paralyzed on the opposite side, that is, 
 on the same side as the hemiplegia. In rare cases a very circumscribed 
 lesion that involves the nucleus of the sixth nerve may also cause diabetes 
 or polyuria. 
 
 In hemorrhage in the mid-brain (corpora quadrigemina and cerebral 
 peduncles) the oculomotor and fourth nerves may be paralyzed on the side 
 of the lesion, while the hemiplegia is on the opposite side, presenting a type of 
 hemiplegia alternans which is sometimes called the "syndrome of Weber." 
 
 Hemorrhage in the medulla oblongata is extremely rare, and is incom- 
 patible with prolongation of life if the respiratory centres are involved. 
 
 In the apoplectic state consciousness may be partially or entirely lost; 
 the breathing becomes stertorous, the cheeks puff out with every breathy 
 and the pulse may be full and strong. If the case advances toward an 
 unfavorable ending, the pulse becomes thin and rapid, the temperature 
 rises, unconsciousness is profound, the pupils do not react to light and may 
 be unequal. Cheyne-Stokes respiration may set in, and death is often 
 hastened by an oedema of the lungs. In the apoplectic cases the hemi- 
 I^legia can sometimes be determined by the loss of resistance to passive 
 motion on the paralyzed side. 
 
 In some cases the reflexes are not at first greatly affected. In cases 
 of massive hemorrhage with shock and unconsciousness, the knee-jerk on 
 the paralyzed side may be abolished. In patients who survive and 
 partially recover, the deep reflexes become exaggerated on the paralyzed 
 side, the muscles are contractured, and there results a characteristic 
 hemiplegic attitude and gait. Ankle clonus and Babinski's reflex are 
 usually present in these patients. 
 
 The state of the pupils is not constant; in the early stages the light 
 reflex may be preserved; but with deep unconsciousness it is usually abol- 
 ished. The pupils are sometimes slightly unequal; or they may be of normal 
 size or even dilated. In pontile hemorrhage they may be contracted. 
 
1270 MEDICAL DIAGNOSIS. 
 
 Lateral deviation of the head and eyes is sometimes seen in the apo- 
 plectic cases, the head and eyes being turned away from the paralyzed 
 side — conjugate deviation. If a spastic state sets in from irritation of the 
 brain-cortex or motor tracts, especially if convulsions occur, as sometimes 
 happens, the head and eyes are forcibly drawn towards the paralyzed 
 side. In rare cases there results a "posthemiplegic chorea" — a bad term, 
 as the disorder is not a true chorea, but a wide to-and-fro tremor. 
 
 Diagnosis. — Cerebral hemorrhage, especially when it causes uncon- 
 sciousness, requires to be distinguished from uraemia, diabetic coma, post- 
 epileptic coma, opium poisoning, alcoholic drunkenness, and trauma. 
 The problem is sometimes a difficult one. As a general rule hemorrhage 
 causes a hemiplegia, which can usually be determined, even in cases of 
 unconsciousness, by some difference in the resistance to passive motion on 
 the two sides: on the paralyzed side the limbs are entirely flaccid and 
 fall dead, while on the other side there is usually some resistance. In 
 profound unconsciousness, however, the difference may be difficult to 
 recognize. In cases of a simple paral3'tic "stroke" without unconscious- 
 ness the problem is much simplified, as the history of a sudden attack of 
 hemiplegia is usually determinative. Even in these cases there may be 
 at first some confusion of mind and clouding of consciousness. 
 
 Uraemic com-a is often ascertainable from the history of the case. 
 The presence of albumin and casts in the urine cannot determine the 
 question positively because a patient with nephritis may have a cerebral 
 hemorrhage or thrombus, while a patient with apoplexy may have albu- 
 minuria. Moreover, there are sometimes seen in nephritis attacks of 
 hemiplegia, which pass away with other ursemic symptoms. Transient 
 aphasia and brachial monoplegia of ursemic origin sometimes occur and 
 may simulate organic lesion in the brain. In uraemic coma there may be 
 prolonged subnormal temperature. In spite of the exceptions noted, 
 uraemic coma is, on the whole, indicated by the state of the urine, the 
 history of the case, the subnormal temperature, the usual absence of 
 hemiplegia and other symptoms of a focal lesion, and sometimes by the 
 uraemic odor. Convulsions are in favor of uraemia, although they some- 
 times occur in hemorrhage. Albuminuric retinitis is also in favor of 
 uraemia. These are doubtful cases which only time can solve. 
 
 Diabetic coma is indicated by the glycosuria, diaceturia, and acet- 
 onuria, the history of the case, and the absence of hemiplegia. The crisis 
 may be ushered in with headache and delirium, and the peculiar dys- 
 pnoea, called by Kiissmaul "air-hunger," but these prodromes are not seen 
 in every case. 
 
 Postepileptic coma usually clears up in a few hours at most. The 
 history of the case is significant. Convulsions may occur in cerebral 
 hemorrhage, but they, are rare. Focal epilepsy, in which a hemiplegia or 
 monoplegia may persist for some time, may be puzzling, but the history 
 of the case and the course should prevent error, especially if focal symp- 
 toms are caused by organic lesion, such as tumor. In epileptic "status" 
 the fits recur at frequent intervals (as many as twenty-five and even more 
 in a day), the patient profoundly unconscious between the paroxysms, with 
 weak pulse, and sometimes with high temperature. 
 
CEREBRAL SOFTENING. 1271 
 
 Opium poisoning is, as a rule, easily recognized by the history, 
 the contracted pupils, and the slow respiration; in cases in which 
 the history is unknown mistakes are possible. Massive hemorrhage, 
 especially ventricular hemorrhage, may cause profound unconsciousness, 
 immobile rather than contracted pupils, and labored breathing, while the 
 hemiplegia may be masked; pontile hemorrhage is said particularly to 
 simulate opiums poisoning, especially in the contracted pupils. The 
 extremely slow breathing of opium narcosis, however, is not likely to be 
 seen in hemorrhage; while in the poisoning there is never hemiplegia, 
 nor conjugate deviation of the head and eyes; and, finally, the extreme 
 bilateral myosis is hardly equalled in cases of apoplexy, in which 
 inequality of the pupils is more common. The pupil dilates as death 
 approaches in opium poisoning. 
 
 Alcoholic intoxication is known by the history, by the odor of alcohol, 
 and by the fact that the stupor or unconsciousness is usually not so pro- 
 found as in apoplexy. None of these data is entirely reliable. A 
 drunken man may have a cerebral hemorrhage, hence the odor of alcohol 
 on the breath is a most unreliable test for this, as for any case. Hemi- 
 plegia is, of course, conclusive as against mere alcoholism, and unequal 
 pupils suggest apoplexy. A few hours usually determine whether a 
 doubtful case is one of drunkenness. 
 
 Trauma may cause a condition closely simulating or even identical 
 with apoplexy, as, for instance, when it causes a cerebral hemorrhage. 
 The history is most important. In all cases a careful inspection of 
 the scalp and skull should be made in order to detect contusion or fracture. 
 
 Hysteria may possibly simulate apoplexy, but only superficially. 
 The unconsciousness is usually not profound; the patient is often open to 
 suggestion; there may be characteristic stigmata; the pupils respond 
 freely to light; and deep ovarian pressure usually brings some response. 
 
 The differential diagnosis between cerebral hemorrhage and embolism 
 is difficult and may be impossible. At most there are suggestions, not 
 positive grounds, for an opinion. Hemorrhage usually occurs in persons 
 at and beyond middle life; embolism in persons at anj?- age in whom there 
 has been a vegetative endocarditis. Hemorrhage is rather more prone 
 to cause loss of consciousness than is an embolus. Associated cardiac and 
 renal disease, being productive of diseased blood-vessels, may cause hem- 
 orrhage. The same is true of syphilis, although syphilitic hemiplegia is 
 more frequently caused by meningitis and endarteritis at the base of 
 the brain. 
 
 VI. CEREBRAL SOFTENING. 
 
 Softening may result from any process that obstructs a blood-vessel; 
 hence an endarteritis, causing thickening of an artery, as in syphilis; a 
 thrombus from disease of the arterial walls, as in atheroma; and finally, 
 an embolus,, from the vegetations of endocarditis — all these may cause 
 cerebral softening. 
 
 Pathology. — Thrombus and embolus produce results so nearly iden- 
 tical that they cannot be distinguished clinicalh^ The special impor- 
 tance of embolus, from the clinical standpoint, lies in the fact that it may 
 
1272 MEDICAL DIAGNOSIS. 
 
 occur in young persons and produce all the symptoms of an apoplectic or 
 hemiplegic stroke. It occurs in vegetative endocarditis. It is also com- 
 mon in malignant endocarditis, and sometimes occurs in other forms of 
 sepsis. Thus hemiplegia may happen in the puerperium. Thrombosis 
 occurs in some blood states other than sepsis, such as anaemia and 
 chlorosis; it is most common, however, in disease of the coats of the 
 blood-vessels, as atheroma and syphilis. The vessels most' involved are 
 those that form the circle of Willis or some of their branches, especially 
 the middle cerebral artery. Softening of the cei-ebellum and pons is 
 occasionally seen. 
 
 The area involved does not always break down at once; in fact a 
 comparatively long time may elapse before it softens. This leads to 
 deceptive appearances at autopsies. When the tissue has once become 
 soft it may be quite diffluent, and in color may be white, yellow, or 
 
 red; according to the amount of 
 blood elements contained in it. 
 
 Symptoms. — These are similar 
 to those caused by hemorrhage. 
 Hemiplegia is the commonest result, 
 but other paralyses, such as mono- 
 plegia, hemianesthesia, and hemi- 
 anopsia, occur, as in hemorrhage, 
 according to the seat of the lesion. 
 Aphasia is not uncommon when the 
 softening occurs in the lenticular 
 nucleus or the cortical speech cen- 
 tres or in their subcortical connecting 
 
 Fig. 367. — Softening of the brain in the motor area -j.„„pj-„ • fl-,p Ipff V,prm'«nViPrf> A r^n 
 ofihe right hemisphere, due to embolus.— Lloyd. ^ractb m lUO leit UemiSpUere. ApO- 
 
 plectic symptoms, with confusion, 
 stupor, or loss of consciousness, may be present if a large area is 
 involved, but they are rather more uncommon than in hemorrhage. 
 Occasionally the onset of symptoms is gradual and the course pro- 
 gressive, especially if small successive thrombi occur, but usually in the 
 case of embolus the onset is sudden. Prodromes also occur in case of 
 atheroma, such as vertigo, headache, and failure of memory and other 
 mental powers. In some cases we see transient hemiplegia and other 
 paralyses, due doubtless to the fact that the circulation, after being 
 obstructed, may be restored. But in most cases there is left some per- 
 manent loss, such as hemiplegia and aphasia. Thrombus of the carotid 
 or of the basilar artery causes grave symptoms, such as profound uncon- 
 sciousness and failure of respiration; and in the case of the basilar artery 
 there may at first be staggering, ataxia, or even a cerebellar gait. 
 
 Diagnosis. — The distinction between hemorrhage and embolus largely 
 depends on the presence of a lesion in the heart producing emboli, and 
 this is more common in young persons. Hemorrhage due to atheroma is 
 an affection of advanced life. Apoplectic symptoms, such as coma, are 
 more common in hemorrhage; but the distinction between these two 
 states is often problematical. Sinus thrombosis or syphilitic endarteritis 
 may cause a hemiplegia. Syphilitic hemiplegia cannot always be posi- 
 
CEREBRAL PALSIES OF CHILDREN. 
 
 1273 
 
 tively recognized unless there is a clear luetic history. If there are head- 
 ache, involvement of cranial nerves, especially the third, and an irregular 
 mode of onset, the diagnosis is much more probable. In a young adult 
 the absence of a cardiac lesion, such as could cause embolism, is 
 further suggestive of syphilis as the cause of the hemiplegia. 
 
 VII. THE CEREBRAL PALSIES OF CHILDREN. 
 
 Children are sometimes the victims of hemiplegia, diplegia, para- 
 plegia, and speech defects, due to affections of the brain. As these condi- 
 tions present some special features they demand special notice apart 
 from similar affections in adults. 
 
 Pathology. — Cerebral hemorrhage is rare in children, unless in the 
 case of accident or trauma, especially at birth. These birth palsies are 
 usually due to meningeal hem- 
 orrhage, caused by a general 
 asphyxia, which in its turn is 
 caused by prolonged pressure 
 on the placenta. This is indi- 
 cated by the fact that hemor- 
 rhage in the new-born is some- 
 times observed beneath other 
 serous membranes, as, for 
 instance, the capsule of the 
 liver. Hence intracranial hem- 
 orrhage is not necessarily caused 
 by tlie forceps, although this 
 may be a factor in some cases. 
 Hemorrhage may also be caused 
 by the paroxysms of whooping- 
 cough. A cerebral sclerosis 
 occurs in young children; and 
 
 Striimpell suggested that there may be also a polioencephahtis. Vascular 
 lesions, as periarteritis and embolism, are doubtless the causes of extensive 
 destructive changes in the brains of children, following upon the infectious 
 diseases. It is not to be forgotten that hereditary, or even acquired, 
 syphilis may cause cerebral palsies in children. Thrombosis of the cere- 
 bral veins may cause juvenile hemiplegia and diplegia. It occurs 
 occasionally in typhoid fever, measles, etc. Thrombosis of the cranial 
 sinuses is also occasionally observed. Hemorrhage is sometimes present 
 beneath the membranes of the spinal cord. 
 
 A destructive lesion may result in the formation of a cavity in the 
 cerebrum — the so-called porencephalus. 
 
 Symptoms. — The commonest forms of these palsies in children are 
 hemiplegia, diplegia, and paraplegia. 
 
 The onset of the affection may be insidious, or at least not promptly 
 recognized, as in very young children, and especially in the birth cases. 
 When the onset is acute the affection may be ushered in with con- 
 vulsions and coma, but this is by no means a universal rule. The 
 
 Fig. 368. — Porencephalus. — Lloyd. 
 
1274 
 
 MEDICAL DIAGNOSIS. 
 
 "stroke" caused by embolus is sudden, just as in adults. Among 
 other and minor symptoms are slight fever, vertigo, and vomiting. 
 
 Confusion and delirium are sometimes seen. 
 Hemiplegia is the most common form. 
 At first the paralysis is flaccid, but in a 
 later stage contractures set in and the para- 
 lyzed limbs are much hampered and even 
 deformed. They do not grow quite normally, 
 but true muscular atrophy, as seen in spinal 
 cases, is not present. The deep reflexes are 
 exaggerated. In some cases athetosis is 
 present. If the lesion is in the left cerebral 
 hemisphere grave speech defects are present, 
 but these differ somewhat from genuine 
 aphasia, because if the lesion comes on in 
 very early life before the child has learned 
 to talk, the speech is undeveloped rather 
 than impaired. The face in old standing 
 cases is usually not paralyzed, and the arm 
 is more paralyzed and contractured than the 
 leg. As a rule there is no hemiansesthesia. 
 The limbs may be cold and blue, but the 
 reactions of degeneration are not present, 
 and fibrillation is not seen. The gait is typi- 
 cally hemiplegic, and the arm is usually carried 
 flexed and contractured at both the elbow and 
 wrist. The bladder and bowel are not paralyzed. 
 Diplegia is simply a double hemiplegia, 
 and is sometimes called bilateral spastic hemi- 
 -oid infantile hemiplegia, piggj^. The Spasticity of the limbs is espe- 
 cially noticeable, not because the contractures are worse than in hemiplegia, 
 but because, being on both sides, they give the patient a characteristic 
 
 Fig. 369. 
 
 Fig. 370. — Congenital diplegia; earlj- stage. — Young. 
 
 aspect. In one respect, however, the contractures in diplegia appear to 
 differ from those of hemiplegia — they are somewhat more marked in the 
 
CEREBRAL PALSIES OF CHILDREN. 
 
 1275 
 
 lower limbs. This gives the child a characteristic gait, if he is still able 
 to walk. The limbs are usually adducted and extended, and the feet may 
 be crossed and held in the position of 
 equino-varus. The deep reflexes are 
 exaggerated; sensation is unim- 
 paired; and the upper limbs share in 
 the rigidity. In these cases of double 
 hemiplegia there may be imbecility 
 or idiocy. Epilepsy and athetosis 
 may complicate the case; speech 
 defects are common; and strabis- 
 mus and nystagmus are sometimes 
 seen. The condition depends on a 
 lesion which involves both hemi- 
 spheres, and the destruction of brain 
 tissue is sometimes great. 
 
 Paraplegia of cerebral origin 
 has been described only in recent 
 years, and its pathology is still a mat- 
 ter of some obscurity. Some authors 
 claim that it depends upon a limited 
 brain lesion, in which the leg areas 
 alone are involved, while others 
 attribute it to a primary lateral 
 sclerosis. It is practically identical 
 with the spastic paralysis of the 
 legs as seen in diplegia, but the 
 arms are not involved. There may 
 be epilepsy, athetosis, and idiocy, 
 just as in the other forms of cere- 
 bral palsy in children. Paralysis of 
 the bladder and bowel is not a necessary part of the symptom-complex, 
 as in spinal paraplegia, but incontinence may result from the mental defects. 
 
 Fig. 371. — Spastic diplegia; athetosis. — Lloyd. 
 
 Fio. 372. — Spastic diplegia; epilepsy; idiocy. — Lloyd. 
 
 Monoplegia, 
 palsy in children. 
 
 either brachial or crural, is a rare form of cerebral 
 In this form one arm or one leg alone is involved. 
 
1276 
 
 MEDICAL DIAGNOSIS. 
 
 In this connection brief mention may be made of Little'' s disease. The 
 affection is in fact a form of cerebral palsy, in which the motor-conducting 
 paths from the brain are injured, diseased, or undeveloped. Hence its 
 clinical form is that of a diplegia or a paraplegia, according to the extent 
 of the injury. It occurs especially in children who are prematurely born. 
 Some writers seem inclined to limit the term to mild cases in which the 
 cerebral faculties are not much involved, convulsions are absent, and the 
 tendency to improvement is marked, but there seems to be no good 
 
 reason for retaining it as a desig- 
 nation for a distinct disease.^ 
 
 Sachs has described a condition 
 which he calls amaurotic family 
 idiocy, in which the child, soon after 
 birth, becomes weak and lethargic; 
 blindness, due to degenerative changes 
 in the optic nerves, ensues; and spas- 
 tic paralysis with increased tendon 
 reflexes may be added. In some 
 cases nystagmus, strabismus, and 
 deafness are noted. There are no 
 convulsions, but there is well-marked 
 idiocy; and death occurs in early 
 childhood. Several cases have been 
 observed in one family. The condition 
 is one of failure of development 
 (agenesis) of the nerve-centres; its 
 causation is obscure. 
 
 Diagnosis. — The diagnosis is, as 
 a rule, not difficult. The spastic 
 paralysis, usually hemiplegic or diple- 
 gic in type, with exaggerated reflexes,, 
 absence of muscular atrophy and 
 electrical changes, and the associated 
 mental defects, often with athetosis 
 and epilepsy, distinguish these cases 
 clearly from diseases of the spinal cord, especially anterior poliomyelitis. 
 Gross lesion of the brain, such as tumor, might simulate these cases, but 
 the history and course are different, and optic neuritis is often present in 
 the case of tumor. 
 
 Paraplegia of cerebral origin may simulate a spinal paraplegia, but 
 in the latter there are no true cerebral symptoms, such as idiocy and 
 epilepsy, and the bladder and bowel are almost always paralyzed. In 
 case the lumbar cord is involved the paralysis is flaccid, with atrophy, 
 lost knee-jerks, and even the reactions of degeneration. The historj^ and 
 course are also different. Infantile paralysis, due to acute anterior polio- 
 myelitis, is usually confined to one limb; muscular atrophy occurs with lost 
 knee-jerk and reactions of degeneration, and there are no cerebral symptoms. 
 
 Fig. 373. — Attitude in cerebral palsy; paraplegic 
 type. — Young. 
 
 1 For an excellent account of Little's disease see Brissaud's Lecons siir les Maladies Nerveuses 
 Paris, 1895, p. 108. 
 
HYDROCEPHALUS 
 
 1277 
 
 Obstetrical paralysis, especially of the brachial plexus, could hardly 
 be confounded with a cerebral palsy. The paralysis is flaccid, the muscles 
 waste, the deep reflexes are lost, electrical changes are present, and cere- 
 bral symptoms are wanting. 
 
 The spastic rigidity of rickets and of tetany is distinguished by the 
 associated symptoms of those diseases, the history, and the etiology. 
 
 VIII. HYDROCEPHALUS. 
 
 Pathology. — The lateral ventricles are enormously distended; the 
 ependyma thickened; and the foramen of Monro or the aqueduct of Sylvius, 
 or both, are possibly occluded. The brain may be so stretched as to be 
 little more than a shell, the convo- 
 lutions thin and flattened, and the 
 sulci almost obliterated. The basal 
 ganglia, the mid-brain, pons, medulla 
 oblongata, and cerebellum are some- 
 times compressed and only partly 
 developed. The choroid plexus may 
 be thickened and congested. The 
 bones of the skull are thin and trans- 
 lucent, and usually the sutures and 
 fontanelles are widely distended, the 
 former as much even as an inch. 
 The essential elements, or neurons, 
 of the cortex suffer greatly, and the 
 optic tracts and cranial nerves may 
 be degenerated. 
 
 Etiology. — The causation is 
 obscure. Some observers attribute 
 the disease to occlusion of one or 
 other of the natural foramina, such 
 as the foramen of Monro, the aqueduct of Sylvius, or the foramen of 
 Magendie. Not enough attention has been paid to the state of the choroid 
 plexus and veins of Galen. Recently much has been written by Lees, Barlow, 
 and others about a posterior basic meningitis, which causes occlusion of 
 the foramen of Magendie, with consequent distention of the ventricles. 
 
 Symptoms. — Besides the distention of the skull there are seen 
 various defects of development of the brain and nervous system. There 
 may be mental impairment, ranging from slight imbecility to complete 
 idiocy. In rare cases, however, there is preserved quite a remarkable 
 mental integrity. 
 
 The motor symptoms are often prominent; there is hemiplegia, 
 diplegia, or monoplegia; the muscles are usually spastic, even contrac- 
 tured, and the deep reflexes are exaggerated. The eyes may be deflected 
 downward, and there may be various forms of oculomotor palsy, with 
 nystagmus. Other symptoms more or less common are convulsions, pain, 
 as shown by the "hydrocephalic cry" (but this is more common in acute 
 tuberculous meningitis), blindness, and incontinence. In extreme cases the 
 
 Fig. 374. — Hydrocephalus. — Lloyd. 
 
1278 MEDICAL DIAGNOSIS. 
 
 child is bed-ridden from inability to hold up the enormously distended 
 head. Occasionally hydrocephalus is associated with spina bifida. 
 
 Diagnosis. — This presents no difficulty in the advanced cases; the 
 child's appearance is enough. In early stages, however, the diagnosis 
 must rest on the child's evident failure properly to develop, and on the 
 gradual enlargement of the head. Hydrocephalus sometimes begins before 
 birth, and the skull may be greatly distended, causing grave dystocia. 
 
 IX. INTRACRANIAL ANEURISMS. 
 
 The larger aneurisms which develop on the main intracranial arteries, 
 particularly at the base, will be discussed. The arteries usually involved 
 are those that form the circle of Willis, and their branches, especially the 
 middle cerebral. The internal carotid, cerebellar, and basilar arteries also 
 are sometimes affected. 
 
 Pathology. — Diseases affecting the coats of the arteries, especially 
 atheroma and syphilis, are the determining causes. Trauma also acts in 
 this way. Emboli from vegetating endocarditis may be a cause. The 
 aneurism is either fusiform or sacculated; it is likely to increase rapidly, 
 and it eventually bursts with fatal effect. 
 
 Symptoms. — The aneurism acts by compression like a brain tumor. 
 Some authors describe a thrill or murmur audible on the skull or over the 
 great vessels. The patient sometimes has a subjective sense of pulsation. 
 Headache, vertigo, vomiting, and affections of consciousness occur. In 
 some cases the aneurism is latent until rupture occurs, while in other 
 ases the symptoms are paroxysmal, from successive small bleedings. 
 Aneurism of the internal carotid may compress the optic nerve or optic 
 tract, the nerves of the eyeball, and the first division of the fifth nerve, 
 and as it increases may even cause hemiplegia, and, if it is on the 
 left side, aphasia. Starr observed a case of left third nerve paralysis with 
 right hemiplegia. The optic chiasm may be compressed by aneurism of 
 the carotid and especially of the anterior communicating artery. Various 
 affections of the retinal and visual fields thus result, and bilateral tem- 
 poral hemianopsia has been reported. Aneurism of the anterior cerebral 
 causes symptoms similar to those of the preceding, except when it is far 
 to the front, when it may involve no cranial nerves and cause only 
 obscure compression symptoms in the frontal lobes. Aneurism of the 
 middle cerebral, especially if well within the Sylvian fissure, causes hemi- 
 plegia; possibly hemiansesthesia and hemianopsia; and, on the left side, 
 aphasia. The third nerve may be compressed. There may be loss of smell 
 on the affected side in the case of aneurism of any one of these arteries 
 near the olfactory nerve. Aneurism of the posterior communicating artery 
 may involve the optic tract and the third and sixth nerves; and if it 
 grow very large, it may compress the peduncle, causing hemiplegia. 
 Aneurism of the posterior cerebral may compress the peduncle and 
 the third and sixth nerves, causing hemiplegia alternans; and if it should 
 involve the occipital lobes it might cause various affections of the visual 
 fields. Aneurisms of the basilar and vertebral arteries cause pontile and 
 bulbar symptoms. The most -striking is the compression bulbar palsy 
 
TUMORS OF THE BRAIN. 1279 
 
 sometimes seen. If the pons alone is involved there may or may not be 
 unilateral symptoms, such as hemiplegia alternans — paralysis of the sixth 
 and seventh nerves on one side with opposite hemiplegia. If the medulla 
 oblongata is involved the bulbar symptoms are dysarthria, dysphagia, 
 paralysis of the tongue and lips, and sometimes respiratory symptoms, 
 especially when the head is thrown forward. 
 
 Diagnosis. — Intracranial aneurism simulates a brain tumor, and the 
 distinction between it and a neoplasm cannot always be made. A mur- 
 mur, having the cardiac rhythm controlled by pressure on the carotid, is 
 suggestive of aneurism, but even this sign is not reliable, for such a mur- 
 mur has been heard in other lesions. Starr claims to have heard a loud 
 double murmur over the Sylvian region in a case of extensive softening. 
 Murmurs in the head have also been heard in cases of tumor (when the 
 growth is near a large artery), in anaemia, in hydrocephalus, in exophthal- 
 mic goitre, and in several cases of loud endocardial murmurs, which I have 
 observed. There are therefore no positive rules for diagnosis. The history 
 and course may be the same in aneurism as in tumor of the brain. Mills 
 calls attention to pulsating exophthalmus as a sign of aneurism of the 
 internal carotid. 
 
 X. TUMORS OF THE BRAIN. 
 
 Under this term are included all new growths within the cranium, 
 whether within the brain, in the membranes, or springing from the bones 
 of the skull. These tumors are comparatively rare, but in any large 
 neurological clinic several of them are likely to be seen in the course of 
 a year. 
 
 Pathology. — Intracranial tumors are of various kinds. In a series 
 of 100 cases, analyzed by Mills and Lloyd, 16 were gliomata, 15 sarco- 
 mata, 13 gummata, 13 tuberculous, 7 carcinomata, 16 unclassified, and the 
 remainder of various forms. An area of congestion, inflammation, soft- 
 ening, or hemorrhage is sometimes seen about the tumor; more rarely 
 suppuration. The cerebrospinal fluid may be increased, and in some cases 
 the ventricles are distended, this depending on the seat of the neoplasm. 
 The tumor may be encapsulated, especially if it be a meningeal growth, in 
 which case it is sometimes easily shelled out. If the tumor is within the 
 substance of the brain, as, for instance, in one of the cerebral hemispheres, 
 this may appear swollen, and even slightly flattened and discolored from 
 pressure. Occasionally the cranial nerves are pressed upon or stretched 
 over the surface of tumors at the base. In some cases the new growth 
 closely resembles brain tissue. Tumors of the brain are sometimes multiple, 
 and in the case of carcinomata they may be metastatic. 
 
 Symptoms. — The onset of a tumor is usually insidious, and the course 
 gradual and even slow. The symptoms are general and local. 
 
 The general symptoms are such as are common to all kinds of brain 
 tumors, and indicate in a more or less distinctive Avay the presence of an 
 intracranial lesion. These symptoms are headache, vertigo, vomiting, 
 convulsions, paralysis, ataxia, sensory changes, optic neuritis, and affec- 
 tions of consciousness. Headache is a very common symptom of brain 
 tumor. In the early stages it may be slight, increasing later to great 
 
1280 MEDICAL DIAGNOSIS. 
 
 intensity. Sometimes it is paroxysmal; sometimes, but rarely, it is 
 absent (in 5 out of the 100 tabulated cases); occasionally it is localized. 
 It is not easily controlled by drugs. Vertigo, with which we may include 
 affections of equilibration, forced movements, and ataxia, is seen in many 
 cases. Some of these symptoms, such as affections of equilibration and 
 forced movements, are highly characteristic of cerebellar tumor; but 
 vertigo is not confined to subtentorial growths. Vomiting is usually of the 
 propulsive kind, irrespective of food in the stomach; in other words, of 
 the type known as cerebral. It is by no means constant, but when 
 associated with other general symptoms it is highly suggestive. It may 
 be unaccompanied with nausea. Convulsions occur in many cases; they 
 are either general or focal. The former are seen in practically all kinds 
 of cases; the latter are indicative, as a rule, of irritation of the motor 
 centres in the cortex. By focal convulsion we mean one commencing in 
 or confined to one or a few groups of muscles. Paralysis in some form is 
 usually present, and it may or may not be an early symptom. It is 
 more appropriately discussed among the local symptoms, as may also 
 be said of the sensory changes. Optic neuritis is a frequent symptom, but 
 it occurs also in other conditions, especially in brain abscess, purulent 
 encephalitis, and brain syphilis. In brain tumor it occurs in at least 80 
 per cent, according to Gowers, Bramwell, and others. From another 
 view-point Oppenheim claims that of all cases of choked disk 90 per cent, 
 are due to tumor of the brain. Affections of consciousness range all the 
 way from slight stupor to profound coma. The emotions may be affected, 
 and hysterical symptoms are sometimes seen. 
 
 The local symptoms are such as indicate the site of the tumor. 
 The most important of these symptoms are the various forms of 
 paralj^sis. Thus hemiplegia indicates that either the motor cortex or the 
 descending motor tracts are involved. A monoplegia, as of the leg, arm, 
 or face, is especially indicative of a lesion of the respective centre in the 
 pre-Rolandic area. Aphasia points to involvement of the left cerebrum, 
 in one or other speech centre, according to the t3^pe of the aphasia. Paraly- 
 sis of the various cranial nerves, especially the third, fourth, fifth, sixth, 
 seventh, eighth, and twelfth, is often of definite localizing value, as will 
 be shown presently. An ataxic form of paralysis is sometimes seen in 
 lesions of the superior parietal lobule. Affections of sensation may take 
 the form of hemianesthesia, hemianopsia, astereognosis, or localized 
 anaesthesia, and will be considered with the focal diagnosis. Focal 
 convulsions, of the type known as Jacksonian epilepsy, indicate 
 usually a lesion in the respective motor centres. When associated with 
 focal paralysis they are especially typical of a focal lesion in the motor 
 area. It must be borne in mind that a convulsion may have a focal type 
 at the beginning, passing later into a general convulsion; in such cases a 
 focal origin of the convulsion is usually indicated, hence such fits have 
 diagnostic value. 
 
 The focal diagnosis for tumors at various sites in the brain is briefly 
 indicated as follows: 
 
 Tumors of the frontal lobe may give few if any localizing symptoms 
 unless they involve the motor area. The mental changes are sometimes 
 
TUMORS OF THE BRAIN. 
 
 1281 
 
 Fig. 375. — Paralysis of the sixth nerve of both 
 sides and of tlie right seventh nerve, in a case of 
 pontile tumor. — Lloyd. 
 
 characteristic, and may consist of alterations of character, lack of power 
 
 of attention, and especially retarded cerebration. If the motor area is 
 
 involved, a tumor in the upper part 
 
 of the pre-central gyrus, or on the 
 
 mesial aspect of that region, causes 
 
 paralysis of the opposite leg; in the 
 
 middle part of the gyrus, paralysis 
 
 of the arm; and in the lower part, 
 
 paralysis of the face. On the left side 
 
 a tumor involving the posterior part 
 
 of the third frontal convolution 
 
 causes motor aphasia. 
 
 Tumors of the parietal lobe may 
 
 also cause focal paralysis and con- 
 vulsions by pressure on the pre-cen- 
 tral gyrus; and if located on the left 
 
 side they may cause motor aphasia 
 
 for the same reason. Affections of 
 
 the superior parietal lobule cause 
 
 astereognosis and ataxic paralysis of 
 
 the opposite leg or arm or both. If 
 
 the posterior part of the internal 
 
 capsule is involved there is hemian- 
 
 aesthesia, and possibly hemianopsia, on the opposite side. If the angular 
 
 gyrus is involved there may be visual aphasia and word-blindness. Tumors 
 
 of the occipital lobe cause hemi- 
 anopsia, possibly also hemianaes- 
 thesia; and also visual aphasia, 
 word -blindness, and object -blind- 
 ness. Tumors of the temporal lobe 
 may cause hemiplegia and hemian- 
 sesthesia by pressure on the internal 
 capsule, if they are large enough, 
 but the most typical symptom, if 
 the tumor is on the left side and 
 involves the first two temporal gyri, 
 is word -deafness and auditory 
 aphasia. Tumors of the mfd-brain 
 often cause a hemiplegia alternans, 
 in which the hemiplegia is on the 
 opposite side, while paralysis of the 
 oculomotor nerve is on the side of 
 the lesion — the so-called " S3mdrome 
 of Weber." Tumors of the pons 
 may also cause a hemiplegia alter- 
 nans, in which with an opposite 
 
 hemiplegia there is paralysis of the sixth and seventh nerves, possibly also 
 
 of the fifth and eighth nerves, on the side of the tumor. Sometimes both 
 
 sixth nerves are involved. These cranial nerve paralyses vary somewhat 
 81 
 
 Fig. 37G. — Paralysis of the seventh nerve, right 
 side, and of both sixth nerves. Case of pontile 
 tumor; patient attempting to close her eyes. — Lloyd. 
 
12S2 
 
 MEDICAL DIAGXOSIS. 
 
 according to the site of the growth. Thus if the tumor is located high in the 
 pons, above the decussation of the motor paths for these cranial nerves, 
 the hemiplegia and the paralysis of the nerv-es are both on the opposite 
 side. A favorite site for these tumors is in the cerebellopontile angle. 
 
 Tumors of the cerebellum give a Tvide variety of symptoms, the most 
 characteristic being loss of equilibration, cerebellar ataxia (in tumor of 
 the vermis), and forced movements (in tumor of the peduncles, especially 
 the middle peduncle\ If the tumor presses upon the mid-brain, pons, or 
 medulla oblongata, there may be characteristic paralysis of the several 
 cranial nerves which have their nuclei in those structures, just as in tumors 
 of those parts, and even hemiplegia. The knee-jerks may be lost, or may 
 even go and come, but this symptom is not always seen. Tumors of the 
 basal ganglia cause hemiplegia, hemianassthesia, and hemianopsia, and on 
 the left side aphasia or paraphasia. Tumors of the membranes at the 
 
 base of the brain, according to their 
 location, cause paralysis of the 
 various cranial nerves, especially the 
 third, fourth, fifth, and sixth. Lloyd 
 reported a case of total unilateral 
 ophthalmoplegia, with anaesthesia 
 of the first di^dsion of the fifth 
 nerve, caused by a sypliiloma just 
 behind the orbit. Tumors of the 
 medulla oblongata are rare; they 
 cause paralysis of the twelfth nerve 
 and of the motor tracts, and diffi- 
 culty in swallowing and in respira- 
 tion. In some cases brain tumor is 
 latent, especially if it occupy a 
 so-called silcrd region of the brain. 
 Diagnosis. — The above brief 
 sketch sets forth the principles of 
 local diagnosis; but brain tumors 
 both general and local, and these 
 
 Fig. 3, 7.- — Tumor of the cerebellum, showingforced 
 movement to one side. — Llovd. 
 
 cause a wide varietv 
 
 or symptoms. 
 
 must be interpreted with care. A successful local diagnosis is frequently 
 possible, and is often made. 
 
 Tumor may simulate abscess, but the history and course are usually 
 different; there is no history of a precedent focus of suppuration, there 
 is no eAddence of sepsis, the evolution is more gi-adual, and as a rule the 
 duration is longer. Hemorrhage is not likely to be mistaken for tumor; 
 the onset is entirely different. It is sudden, the sj^mptoms are established 
 quickly, and the case is not progressive. Yet tumor in the motor region, 
 causing hemiplegia, has been mistaken for a long-standing parah^ic 
 "stroke" due to hemorrhage. The history, the presence of optic neuritis 
 and of headache in the case of tumor should prevent error. Syphilis of 
 the brain may possibly simulate brain tumor, especialh' if the headache 
 and optic neuritis are associated with focal symptoms, but the symptoms 
 of syphilis often pursue an irregular course, quite unlike the steady prog- 
 ress of a tumor. Nevertheless, sypliilis may cause a gummatous tumor. 
 
PARASITES IX THE BRAIX 12S3 
 
 In truth, tumor of the brain does not closely simulate any other lesion; 
 the onset, the course, the duration, and the grouping of symptoms are all 
 sufficient as a rule to prevent error. It is well, however, in this connection 
 not to overlook those curious cases in which hysterical symptoms have 
 masked the symptoms of brain tumor and led to error. 
 
 XI. PARASITES IX THE BRAIX. 
 
 The commonest is the Cysticercus cellulosa?. the larval form of the 
 Taenia solium, or pork tape-worm. Occasionally the echinococcus. or 
 hydatid, is observed. 
 
 Pathology, — The parasites exist as cysts, of the size of a millet-seed 
 to that of a grape or even a walnut. They may be found in the sub- 
 stance of the brain, or beneath the membranes, or floating free in the 
 ventricles. The last is the most common. There is usually an ependymitis 
 and great increase of the ventricular fluid. The parasites are found in 
 both the lateral and the fourth ventricle. 
 
 Symptoms. — The nature of the disorder may be obscure. In a case 
 observed by Lloyd ^ in the Philadelphia Hospital the earliest symptoms were 
 apoplectiform attacks, followed by severe headache, hemiparesis. ataxia, dis- 
 turbance of equilibration, exaggerated knee-jerks, incontinence of urine and 
 faeces, drowsiness, loss of power of attention, speech defects, trismus, and 
 failing vision. There were no convulsions nor optic neuritis. Death occurred 
 in coma. At the autopsy eighteen cysts, some as large as a chestnut, clear 
 and satin-like, were found floating in the right ventricle, which was enor- 
 mously distended. One small cyst was found adherent in the fourth ven- 
 tricle. There was ependymitis, and the aqueduct of S^'lvius w^as occluded. 
 
 The patient in Lloyd's case insisted that when he moved his head he 
 could feel something rolling within it. 
 
 The symptoms are not the same in all cases; much depends upon the 
 number, size, and location of the cysts. Convulsions are not uncommon, 
 and affections of consciousness are frequent. Headache is a constant 
 symptom, and choked disk is sometimes observed. A cysticercus has 
 been seen in the eye.- On the whole, the symptoms are irregular. 
 
 Diagnosis. — The diagnosis is most difficult, and the chances are that 
 the true nature of the case will not be discovered until the autopsy. This 
 is especialh' so in America, where the infection is rare. 
 
 Because of the irregularity of the symptoms, with headache, drowsi- 
 ness, convulsions, and various forms of paralysis, the case may easily be 
 mistaken for one of syphilis of the brain; also for brain tumor. There 
 are no pathognomonic signs, and in any case the diagnosis must be prob- 
 lematical. The subjective sense of an object rolling in the head is the most 
 distinctive sign that we have seen noted. It is quite impossible, as a rule, 
 to trace the origin of the infection in the character of the patient's diet. 
 There may be no tape-worm in the bowel, for autoinfection is not common, 
 the eggs being usually introduced from without. If cysts are found under 
 the retina or skin or in the muscles, the presence of similar growths in the 
 brain is rendered highly probable. 
 
 1 Philadelphia Med. Journal. March 19. 1S9S. 
 
 ^Oliver, Ophthalmoscopy, in Keatiug's Cyclopaedia of the Diseases of Childreu, vol. iv, p. 238. 
 
1284 MEDICAL DIAGNOSIS. 
 
 XII. SYPHILIS OF THE BRAIN. 
 
 Syphilis in the spinal cord or brain begins its work, as a rule, upon 
 the arteries. The inner and sometimes the outer coat of the vessel 
 becomes infiltrated and thickened, as Heubner has pointed out. The 
 inflammation then spreads to the meninges, and there results an exuda- 
 tive meningitis, which still further involves the blood-vessels and even 
 invades the brain tissue and the cranial nerves. 
 
 Pathology. — There may be syphilis of the convexity, or of the base, 
 or of both. At the base we often see the most typical picture of thickened 
 membranes and gummatous infiltration. There is usually an associated 
 cerebritis, especially near the surface, and deeper in there may be soften- 
 ing or hemorrhage from obstruction of the arteries or from rupture of their 
 diseased walls. A common seat for this form of meningitis is between the 
 cerebral peduncles and at the anterior perforated space, where the 
 arteries run up to supply the interior of the brain, especially the lenticu- 
 lar nucleus and internal capsule. The basilar and vertebral arteries may 
 also be involved. On the convexity there is seen sometimes a leptomen- 
 ingitis or a pachymeningitis, or both. Occasionally the gummatous new 
 growth forms a veritable tumor. It is thus understood that the syphilitic 
 process causes damage to the brain by pressure, by inflammation, by scle- 
 rosis, by softening and hemorrhage, and by involving the cranial nerves. 
 It also acts by elaborating secondary products — toxins. 
 
 Symptoms. — These may be exceedingly irregular, sometimes advanc- 
 ing quickly and then receding, or remaining for a long time stationary. 
 From the character of the lesions it is evident that the symptoms may be 
 multiform and show the invasion of many different parts of the brain. 
 
 Of general symptoms headache is common; . it may be especially 
 severe at night, causing insomnia. There may be vertigo and vomiting. 
 Psychical changes are observed. There are drowsiness, stupor, confusion, 
 dementia, even delirium and maniacal excitement. Convulsions, either 
 general or focal, may occur in brain syphilis. The focal convulsions are 
 usually indicative of a lesion at some part of the motor area. When the 
 motor area is invaded, as by a small patch of infiltration or sclerosis, 
 there is focal paralysis as well as focal epilepsy. The cranial . nerves at 
 the base of the brain are often involved. Optic neuritis is seen, some- 
 times as an early symptom. Primary optic atrophy is not so common. 
 The third nerve, one or all of its roots, is peculiarly exposed in the inter- 
 peduncular space to the action of the poison; next to it in frequency 
 the sixth nerve, one or both. Ricord had a saying that syphilis puts its 
 sign manual on the third nerve. Because of the involvement of the 
 arteries, softening or hemorrhage results, especially in the lenticular 
 nucleus and internal capsule, causing hemiplegia, hemiansesthesia, and 
 aphasia. 
 
 The mid-brain may be involved, as shown by ophthalmoplegia and 
 even by an alternate hemiplegia, in which the third nerve is involved on 
 the side of the lesion, with hemiplegia of the opposite side. Pontile and 
 bulbar symptoms result when the basilar artery is affected. There may 
 be sixth or seventh nerve palsy on one side, with hemiplegia on the opposite 
 
GENERAL PARESIS. 12S5 
 
 side. Combined facial and trigeminal paralysis due to pontile syphilis has 
 been noted. An apoplectic bulbar palsy, due to arterial disease, some- 
 times specific, has been described. 
 
 Syphilitic tumors occur in various regions of the brain, and act like 
 other tumors. 
 
 The symptoms of brain syphilis are often controlled by specific treat- 
 ment, especially in the early stages, before destruction of tissue has occurred. 
 - In some cases there are associated spinal symptoms — cerebrospinal 
 syphilis. 
 
 Diagnosis. — The mode of onset and progress may suggest syphilis. 
 The symptoms are often insidious, advancing irregularly, receding, then 
 again advancing. This is seen in syphilitic hemiplegia. There may be 
 slight apoplectiform attacks, then slight hemiparesis, then improvement, 
 then a more grave attack, and so on. This can readily be understood 
 from the nature of the syphilitic meningitis and endarteritis, interfering 
 with circulation. The third nerve palsy is also sometimes irregular; only 
 one or two branches may be involved at first, then later the whole nerve, 
 due to the gradual involvement of the several roots of this nerve in the 
 interpeduncular space. The history of the case is often clear, but some- 
 times it is not reliable. The multiformity of symptoms is often charac- 
 teristic, and the presence of spinal lesions is generally conclusive. It may 
 be difficult to distinguish syphilis in some cases from brain tumor, and 
 often impossible to say whether a tumor is syphilitic or not. Brain 
 tumors, as a rule, are more focal and constant in their symptomatology, 
 and more regularly progressive. The therapeutic test should always be 
 made. Tuberculous meningitis has a more rapid course than syphilitic 
 meningitis; it is not amenable to drugs, and is uniformly fatal. There 
 is also fever and slowing of the pulse, and the disease is commonly seen in 
 children, whereas the syphilitic form is more common in adults. A febrile 
 reaction is sometimes, though rarely, seen in brain syphilis. The hemi- 
 plegia of syphilis cannot always be easily distinguished from hemiplegia 
 due to other causes. If there is a clear history of syphilis, no endocardial 
 lesion to cause embolism, and the accident occurs in a young adult; 
 and if, especially, there be headache, involvement of one or other cranial 
 nerve, particularly the third, and the symptoms are of rather irregular 
 onset and course, the evidence is in favor of syphilis. 
 
 XIII. GENERAL PARESIS. 
 
 General paresis is a degenerative disease of the brain cortex, medul- 
 lary tracts, and nerves. Syphilis and over-strain, especially business 
 worry, are probably active but not exclusive causes. The disease occurs 
 more frequently in men than in women; and in the white than in the 
 colored races. The French attach much importance to alcoholism. It is 
 more common in civilized countries and among the better classes, but 
 Krafft-Ebing's statement that it is always due to " civilization and 
 syphilization" is probably more resonant than correct. 
 
 Pathology. — There is a destructive process in the tissues of the brain. 
 This process shows itself in the small vessels of the membranes, leading to 
 
1286 MEDICAL DIAGNOSIS. 
 
 congestion, obstruction of the circulation and the lymph stream, morbid 
 increase of the neuroglia, hardening and atrophy of the cortex, thickening 
 of the membranes, minute hemorrhages, extravasation of the cerebro- 
 spinal fluid, distention of the ventricles, and impaired nutrition and 
 destruction of the neurons in the brain cortex.^ 
 
 Symptoms. — General paresis is usually divided into four stages. 
 
 In the first stage the prodromes appear, such as change of character, 
 spells of irritability or even of depression, inattention to business, erratic 
 conduct, and moral lapses. Insomnia, or its opposite, somnolence, may 
 occur. Alcoholic and sexual excesses are common. 
 
 In the second stage the period of grandiose delusions sets. in. The 
 patient has most extravagant ideas of his wealth, of his personal impor- 
 tance, even of his sexual prowess. He becomes talkative, boastful, and 
 slightly demented. Along with these mental changes appear physical 
 changes. There is tremor of the muscles of the face, tongue, hands, and 
 limbs; speech becomes drawling, stammering, or staccato; the hand- 
 writing is unsteady, and words are dropped or run together just as in 
 speech. The gait is weakened and incoordinate, with increased knee- 
 jerks as a rule. There may be myosis, or irregularity and inequality of 
 the pupils, and sometimes the Argyll-Robertson symptom, in which the 
 light reflex is lost while the movement on accommodation remains. There 
 may also be optic atrophy. 
 
 In the third stage the disease assumes a more chronic aspect, and 
 dementia is more advanced. In this stage especially we see crises of 
 epilepsy, apoplexy, hemiplegia, or maniacal excitement. The paralytic 
 symptoms increase. 
 
 In the fourth stage the patient is in terminal dementia, paralyzed, 
 bedridden, almost or quite speechless, with incontinence of urine and 
 faeces — a total wreck, until death ends the scene in exhaustion or in an 
 epileptic or apoplectic crisis. 
 
 In rare cases arthropathies form, especially when the disease is asso- 
 ciated with posterior sclerosis of the spinal cord. 
 
 In some cases remissions occur, of quite long duration, but the hopes 
 raised by them are fallacious, for the disease is fatal. 
 
 Diagnosis. — This may present some difficulty in the early stages, as 
 between this disease and disseminated syphilis of the brain. But in the 
 latter there is not seen the characteristic psychosis, with grandiose 
 delusions, and the disease does not present the regular evolution that 
 is seen in general paresis. Still, the diagnosis is not always easy. The 
 therapeutic test may help to solve the problem, but it must be borne in mind 
 that general paretics do not bear well the heroic antisyphilitic drugging. 
 Striking examples of cerebral lues, resembling the early stages of general 
 paresis, sometimes make good recoveries under a judicious treatment. 
 These are probably the kind of cases that are reported as cures of general 
 paresis. The Argyll-Robertson pupil would point to the latter disease. 
 
 There is a pseudoparesis induced by alcohol and promoted by morphia, 
 cocaine, etc., which closely resembles the genuine disease, especially in 
 
 1 Bevan Lewis, Mental Diseases, 2d edit., p. 548; Berkley, Mental Diseases, p. 197. These two 
 works give the best accounts of the morbid anatomy of general paresis. 
 
SENILE DEGENERATION. 
 
 1287 
 
 the tremor and speech defects, but recovery occurs promptly on the 
 withdrawal of the poison. The history in these cases is suggestive, and 
 they do not present quite such a typical expansive psychosis as in 
 general paresis; the mental condition is usually one of enfeeblement 
 with hallucinatory delirium, which, however, may be rather grandiose. 
 
 The distinction between neuras- 
 thenia and the early stages of paresis 
 is not difficult. 
 
 Multiple sclerosis differs from 
 general paresis in the history of the 
 case, in the nystagmus and intention 
 tremor, and in the absence of the 
 expansive psychosis. 
 
 XIV. SENILE DEGENERA- 
 TION. 
 
 The fundamental change in the 
 central nervous system in old age is 
 probably atheroma of the blood- 
 vessels. It is a trite saying that a 
 man's life is only as long as the life 
 of his arteries. Some of the effects 
 of this arterial degeneration have 
 already been discussed in the chap- 
 ters on cerebral hemorrhage and soft- 
 ening. There are other conditions, 
 however, so identified with senility 
 that they merit especial, though brief, 
 attention. Whether or not they all 
 depend on changes in the blood-ves- 
 sels may still be an open question. 
 
 Cerebral Symptoms. — The 
 most conspicuous of these are 
 undoubtedly the mental changes 
 which occur in old age. There is 
 loss of memory and failure of the 
 mental powers so familiar to all. 
 such as senile melancholia, delusional insanity, maniacal episodes, and 
 dementia, belong rather to psychiatry than to clinical medicine. 
 
 The early symptoms of atheroma of the cerebral arteries are not easily 
 recognized. Among them are tinnitus, vertigo, throbbing or fulness in 
 the head, transient attacks of mental confusion, slight paresis, aphasia, 
 and headache. The throbbing or beating in the head is sometimes almost 
 enough to suggest aneurism, especially when accompanied by headache. It 
 may even depend in some cases on slight aneurismal dilatations. We must 
 not overlook in these cases associated disorders in the heart and kidneys. 
 
 Senile Epilepsy. — The onset of epilepsy in old age is occasionally 
 observed. It is doubtless helped on in some cases by alcoholism. The 
 
 Fig. 378. — Arthropathy in general paresis. — Lloyd, 
 Philadelphia Hospital Reports, vol. ii. 
 
 The various psychoses of the aged, 
 
1288 MEDICAL DIAGNOSIS. 
 
 prime cause is probably degenerative change in the brain cortex. The 
 epileptic seizure in senile patients is practically like that seen in ordinary 
 epilepsy. It is necessary to exclude uraemia. 
 
 Senile Tremor. — In some old persons a very pronounced tremor is 
 seen. It usually begins as a fine movement in the hands, most marked on 
 exertion. Later it may spread, especially to the neck, causing a shaking 
 of the head. In advanced stages it is even present during rest, but it 
 disappears during sleep. It is not accompanied with the muscular rigidity 
 and the characteristic attitude, expression, and gait of paralysis agitans, 
 although intermediate cases are seen, and the two conditions have some 
 points of contact. 
 
 Senile Paraplegia. — A spastic paresis of the legs, more rarely of 
 the arms also, occurs in the aged. There may, or may not, be anaesthesia 
 and weakness of the sphincters. The cases usually resemble primary 
 lateral sclerosis, without loss of sensation or involvement of the bladder 
 and bowel. This condition may depend on primary changes in the cord, 
 especially in the lateral tracts, or it is possibly due to small foci of 
 softening in the motor regions of the brain. These patients often, have 
 well' marked mental deterioration. 
 
 Alcoholism and Drug Habits in the Aged. — Evil habits creep 
 on insidiously in some old people who may always have led strictly tem- 
 perate lives. Bevan Lewis calls attention to the frightful impetus which 
 the excessive use of alcohol lends to the retrograde changes which natu- 
 rally occur in the brain in old age. The opium habit may be formed by 
 the aged. 
 
 XV. ACUTE DELIRIUM. 
 
 This disease was first described by Luther Bell, an American alienist, 
 and is sometimes called from him Bell's mania.^ It is also called typho- 
 mania and delirium grave. 
 
 Pathology. — The disease is probably an acute infection, and may 
 be caused by a variety of germs. Bacteriological studies have not led 
 to uniform results. Berkley says that in a malady which may be caused 
 by so many agents, a sole cause is not to be expected. 
 
 Symptoms. — The onset is usually abrupt and the course very rapid. 
 Delirium sets in acutely and advances quickly to stupor and coma. The 
 tongue becomes dry and brown, and sordes form. The pulse is rapid and 
 compressible. There are muscular unsteadiness, tremor, and incoordination. 
 The temperature rises but pursues no regular course. There is aversion 
 to food, and the vital powers soon fail. Death may occur in a few days. 
 Cases of longer duration are seen to follow the puerperium, and are 
 probably due to sepsis; but in the typical cases no cause can be made out. 
 
 Diagnosis. — The diagnosis rests upon the abrupt onset, the rapid 
 course, and the tendency to speedy death without obvious cause. Bac- 
 teriological studies should be made. Perhaps with our increasing knowl- 
 edge of microbian pathology the nature of these cases will be made clear. 
 The possibility of poisoning by alcohol, syphilis, lead, or malaria must 
 
 I Bell described the disease at a meeting of the Association of Superintendents of American 
 Asylums, in 1849. 
 
MULTIPLE SCLEROSIS. 1289 
 
 not be ignored. Fulminating attacks of typhoid fever, measles, and 
 scarlatina may simulate delirium grave, but can usually be recognized by 
 the associated symptoms. Uraemia must also be excluded. 
 
 XVI. MULTIPLE SCLEROSIS. 
 
 This disease, also called insular, or disseminated, sclerosis, is marked 
 by foci of degeneration scattered through the brain and spinal cord. 
 
 Pathology. — The foci vary in size from that of a small bird-shot to 
 that of a pea or a chestnut, and there may be even larger areas involved. 
 They are difTerent in color from, and harder in consistence than, the brain 
 tissue. Histologically they consist of hardened connective tissue and 
 infiltrated blood-vessels, with degenerated nerve-fibres, although many 
 fibres are seen intact, penetrating the diseased tissue — a fact which is 
 supposed to explain one of the chief symptoms, the intention tremor. The 
 cause of multiple sclerosis is not known; it is not believed to be syphilis, 
 although diffuse syphilitic lesions sometimes cause a state which clinically 
 is not very unlike multiple sclerosis. The fact that the disease sometimes 
 follows the infectious diseases, such as smallpox, typhoid fever, etc., does 
 not explain its causation. The same may be said of its appearance in 
 metal workers. 
 
 Symptoms. — The affection is one of early adult life; it rarely appears 
 after the thirtieth year, and it is not uncommon in young women. 
 
 There are three symptoms which especially distinguish insular scle- 
 rosis — intention tremor, scanning speech, and nystagmus. 
 
 The intention tremor is an early symptom. As its name implies, it 
 appears on voluntary motion; the arm, for instance, showing wide jerky 
 tremors when the patient attempts to use it, as for carrying a glass of 
 water to the lips. The motion is then so violent that often a large part 
 of the water is spilled. The tremor is coarse, with wide amplitude and few 
 vibrations to the second. While the patient is at rest, it is absent. The 
 tremor extends to the face, tongue, and limbs, causing other symptoms, 
 especially scanning speech and an unsteady gait. 
 
 The speech is usually scanning rather than staccato, although in all 
 cases the words are uttered slowly, and sometimes with pauses between 
 them. In a few rare cases bulbar symptoms have been seen, such as paraly- 
 sis and wasting of the tongue. Pseudobulbar palsy has also been noted. 
 
 The nystagmus is usually a prominent symptom, and is most marked 
 when the patient turns the eyeballs to one side — lateral nystagmus. 
 Sometimes a rotary nystagmus is seen, in which the eyeballs are rolled 
 on their axes. Even when the eyes are fixed straight ahead slight oscilla- 
 tions are sometimes seen. 
 
 The gait is usually spastic, and the deep reflexes are exaggerated in 
 consequence of involvement of the lateral tracts in the insular foci at 
 various levels. Abolition of the cremasteric reflex is claimed by Collins. 
 The bladder and bowel are not paralyzed; if there are exceptions to this 
 rule, they must be very rare. 
 
 In advanced stages the mental faculties may suffer, and crises of an 
 apoplectiform kind may be seen. Optic atrophy is present in some cases. 
 
1290 MEDICAL DIAGNOSIS. 
 
 Gowers claims that even when the optic nerve is involved in a patch of 
 sclerosis many fibres pass through unharmed and a fair degree of vision is 
 retained; but the visual fields are variously affected. One optic nerve 
 may be more injured than the other. Uhthoff, who analyzed 100 cases 
 of multiple sclerosis, found the optic nerves affected in 40. He also found 
 paralysis in one or other of the ocular muscles in 17 of his cases. Involve- 
 ment of the pupils was rare. Muscular atrophy sometimes occurs, and a 
 slight ataxia. 
 
 Sensory symptoms are usually remarkable for their absence. Pain is 
 sometimes felt, and various but slight modes of anaesthesia are sometimes 
 present and are most likely to be found in the distal parts of the limbs. 
 
 The course of multiple sclerosis is chronic; remissions occur, and even 
 slight improvement, but the disease is incurable. 
 
 Diagnosis. — The diagnosis is easily made from the association of the 
 three cardinal symptoms. Nystagmus and scanning speech are seen in 
 Friedreich's disease, but they are then associated with ataxia and lost 
 knee-jerks, and the disease is usually a famihal one. In disseminated 
 syphilis the course is more rapid, the mind more involved, the evolution 
 of symptoms is not characteristic, and scanning speech and nystagmus 
 are not seen as a rule. General paresis shows scanning speech, tremor, 
 and ocular changes, but the expansive psychosis, the history, the evolu- 
 tion, the more marked tremor of the facial muscles, all serve to distinguish 
 it. The cremasteric reflex is likely to be preserved, but we do not insist 
 here upon this sign as distinctive. 
 
 Multiple sclerosis may be simulated by hysteria, in which, however, 
 symptoms that can only be accounted for by organic lesions, such as 
 nystagmus and optic atrophy, are never found. Cases of hysterical pseu- 
 dosclerosis are usually of traumatic origin. The differential diagnosis is 
 most important. Other hj'sterical stigmata are not always present. Some- 
 what similar cases follow exposure to mercury or lead. 
 
 XVII. DISEASES OF THE MID-BRAIN. 
 
 The mid-brain is composed in part of the cerebral peduncles, which 
 contain the motor tracts from the cerebrum; its dorsal part consists of the 
 corpora quadrigemina, and it is penetrated by the aqueduct of Sylvius, 
 underneath which are located the nuclei of the third and fourth nerves. 
 The sensory tract, or fillet, runs up just behind each peduncle. 
 
 Pathology. — Tumors are sometimes observed in this region, and more 
 rarely hemorrhage and softening. Wernicke has described an acute 
 destructive process located in the gray matter about the aqueduct, which 
 he has named superior jyolio encephalitis. The meninges in the inter- 
 peduncular space are not infrequently the seat of syphilitic meningitis. 
 
 Symptoms. — Tumors of the mid-brain are usually unilateral, and 
 cause hemiplegia alternans, in which there is an opposite hemiplegia, 
 with or without hemiansesthesia, associated with paralysis of the third 
 nerve on the side of the lesion. Other symptoms of tumor are usually 
 present, such as optic neuritis, headache, vertigo, vomiting, changes in 
 consciousness, and more rarely convulsions. A somewhat similar train 
 
NUCLEAR OPHTHALMOPLEGIA. 1291 
 
 of symptoms may be caused by cerebellar tumors, if these make pressure 
 on the mid-brain; but in cerebellar tumors there is likely to be in addition 
 some disorder of equilibration. A meningeal tumor in the interpeduncular 
 space may paralyze both third nerves. 
 
 In Wernicke's acute superior polioencephalitis there is a destructive 
 process in the mid-brain, and sometimes in the gray matter of the third 
 ventricle. The floor of the aqueduct of Sylvius, hence the oculomotor 
 nuclei, and even the peduncles, are involved. The symptoms are paralysis 
 of the third and fourth nerves, nystagmus, optic neuritis, and rapid pros- 
 tration, sometimes with ataxia, dysarthria, and even paralysis of the face 
 and extremities. Death is common in from eight to fourteen days. 
 
 Hemorrhage and softening in the mid-brain are rare. The symptoms 
 are those of a focal lesion, such as ophthalmoplegia of various kinds, accord- 
 ing to the nuclei involved, hemiplegia alternans, etc. 
 
 Diagnosis. — This rests upon the grouping of symptoms as described 
 above. The most characteristic is the hemiplegia alternans, in which the 
 third nerve is paralyzed on the side of the lesion and the hemiplegia is on 
 the opposite side. In Wernicke's disease the association of symptoms and 
 the rapidly acute course, often with fatal ending, are characteristic. The 
 disease is to be distinguished from bulbar palsy by the history and course 
 and especially by the different cranial nerves involved. In the mid-brain 
 lesion the eyes are paralyzed; in the bulbar lesion, the tongue and lips. 
 
 Interpeduncular syphilitic meningitis is distinguished by the head- 
 ache, the third nerve palsy, the irregular course, the absence usually of 
 hemiplegia, and the history. There may, however, be hemiplegia if either 
 peduncle is softened by syphilitic endarteritis. Complete paralysis of both 
 third nerves is not common; in fact, the third nerve palsy may change 
 from time to time, and it is usually unilateral. 
 
 XVIII. NUCLEAR OPHTHALMOPLEGIA. 
 
 By this term is meant an affection in which the muscles of the eye- 
 balls and upper lids are paralyzed by reason of disease of the nuclei of 
 their motor nerves. The disease is often chronic and selective, for it picks 
 out gradually the nuclei of the third and fourth nerves, which are in the 
 mid-brain, and those of the sixth nerves, which are in the pons, some 
 distance away. Consequently it is neither a purely mid-brain nor a purely 
 pontile disease. 
 
 Hutchinson was one of the first to describe a pure nuclear ophthal- 
 moplegia. Later Wernicke described an acute destructive process invad- 
 ing the floor of the aqueduct of Sylvius and neighboring parts in the 
 mid-brain, which he called superior polioencephalitis to distinguish it from 
 bulbar disease, which he called inferior polioencephalitis; but cases of this 
 affection often present other than purely nuclear ophthalmoplegic sjmip- 
 toms, as, for instance, optic neuritis, nystagmus, facial paresis, dysarthria, 
 ataxia, and even hemiplegia; in other words, it is not a purely nuclear 
 disease. It is best to limit the description, therefore, to the nuclear disease, 
 a sufficient number of cases of which have now been reported to entitle it 
 to distinction as a substantive affection. 
 
1292 
 
 MEDICAL DIAGNOSIS. 
 
 Pathology. — The disease process has some resemblance to the chronic 
 
 or subacute forms of anterior poliomyehtis, inasmuch as the multipolar 
 ganglion cells are gradually destroyed. From this form there are all 
 grades, apparently, up to the highly acute types in which the process 
 is more wide-spread and the case may end fatally in a few days. 
 
 Symptoms. — Brissaud has proposed a useful classification of the 
 ophthalmoplegias as follows: The affection is total if all the muscles of the 
 eyes, both exterior and interior, are involved; 'partial, if only some muscles 
 are paralyzed; complete, if the paralysis in the affected muscles is absolute; 
 and incomplete, if the affected muscles are not absolutely paralyzed, but 
 only paretic. Hutchinson describes an ophthalmoplegia externa in which 
 the interior muscles, that is, the iris and ciliary muscle, escape; and the 
 opposite form is the ophthalmoplegia interna in which only the iris and 
 
 ciliary muscle are paralyzed. This 
 is possible, because the nuclei for 
 the iris and ciliary body lie some 
 distance anterior to the other nuclei. 
 Finally, ophthalmoplegia may be 
 either unilateral or bilateral, but the 
 unilateral cases are never nuclear, 
 as will be explained later. All these 
 nuclei, except the sixth, lie under- 
 neath the aqueduct of Sylvius ; 
 those for the iris and ciliary body, 
 however, lie somewhat farther for- 
 ward, even in the walls of the 
 third ventricle. 
 
 In a case, studied by Lloyd, the 
 patient, a woman aged 35, noticed 
 first external strabismus in the right 
 e5^e, then ptosis, then extel-nal stra- 
 bismus in the left eye, and finally, after some months, loss of all ocular move- 
 ments except in the left external rectus. This patient had headache and 
 abolished knee-jerks, but no fulgurant pains and no ataxia. There was pos- 
 sibly some beginning optic atrophy. No history of syphilis was obtainable. 
 In most of the described cases this gradual progress has been noted, 
 significaht of a slowly progressive nuclear disease. First one ocular muscle 
 and then another, in one eye and then in the other, becomes paralyzed 
 until all, or nearly all, are involved. Various forms of strabismus occur, 
 until the eyeballs become motionless and ptosis is complete. It is 
 occasionally seen in young persons, even in children, and Mobius called 
 it then ''infantile nuclear atrophy." 
 
 Diagnosis. — Syphilitic meningitis between the cerebral peduncles 
 may involve the roots of the third nerves, and may possibly, but not 
 probably, extend to the sixth. Headache is present, and possibly optic 
 neuritis, but the resemblance to nuclear disease may be striking. Syph- 
 ilis, however, would hardly give the picture of gradual and persistent 
 progress, without remission, with first one muscle and then another in 
 each eye becoming paralyzed. Syphilis of the third nerve is often 
 
 riG.379. — Nuclear ophthalmoplegia. — Philadelphia 
 Hospital — Lloyd. 
 
NUCLEAR OPHTHALMOPLEGIA. 
 
 1293 
 
 unilateral. Moreover, in interpeduncular syphilis the paralysis is confined 
 to the third nerve; the fourth and sixth escape. 
 
 Tumor of the mid-brain does not invade the nuclei alone; it usually 
 causes paralysis of the limbs, sometimes a hemiplegia alternans, that is, 
 paralysis of the third nerve on the side of the lesion with opposite hemi- 
 plegia; also optic neuritis, headache, and pressure symptoms. This may 
 be true, also, of extensive syphilitic disease. 
 
 Wernicke's acute superior polioencephalitis is known bj' its history, 
 its rapid course, its invasion of other than nuclear territory, and its 
 consequent wider range of symptoms. 
 
 Nuclear ophthalmoplegia, rarely or never total, occurs in locomotor 
 ataxia, but it is not usually an early symptom, and it is associated with 
 true tabetic symptoms, such as ataxia, fulgurant pains, optic atrophy, 
 lost knee-jerks, etc. The commonest 
 form is bilateral ptosis. Some 
 observers claim, however, that a 
 chronic progressive ophthalmoplegia 
 is sometimes a precursor of tabes 
 dorsalis, combined sclerosis, multiple 
 sclerosis, or even progressive mus- 
 cular atrophy. Hence a cautious 
 diagno&is is called for, since it may 
 take months or even years to deter- 
 mine the question. 
 
 Unilateral ophthalmoplegia, 
 total and complete, is never nuclear, 
 since nuclear disease is always bilat- 
 eral. The one-sided cases are usually 
 caused by some local lesion at the 
 base of the brain. The first division 
 of the fifth nerve is likely to be 
 involved in these basilar cases ; hence 
 there is anaesthesia of the conjunc- 
 tiva and brow on one side; and if the 
 
 second and third divisions of the fifth nerve are involved, the anaesthesia 
 extends over one-half of the face and tongue. These cases should not be 
 mistaken for isolated paralysis of individual nerves, in which the loss of 
 power is confined to the nerve affected. The third or the sixth nerve on 
 one side is occasionally paralyzed by trauma. 
 
 Paralysis of Associated Movements of the Eyes. — These are 
 the lateral, the upward, and the downward movements, and the move- 
 ment of convergence. The evidence is in favor of a centre in the 
 brain cortex for associated ocular movements. Griinbaum and Sher- 
 rington found a centre for lateral movements of the head and eyes in 
 the frontal lobe somewhat apart from the rest of the motor area, and 
 Ferrier has shown from many recorded instances that conjugate deviation 
 of the head and eyes is caused by a lesion in the posterior end of the middle 
 frontal gyrus. Perinaud, Mott, and others hold that this ocular centre is 
 subdivided for the various associated movements; thus, one part is for 
 
 Fig. 380. — Nuclear ophthalmoplegia. Upper 
 lids supported in order to show the position of the 
 eyeballs. — Philadelphia Hospital — Lloyd . 
 
1294 
 
 MEDICAL DIAGNOSIS. 
 
 the lateral, another for the upward, and still another for the downward 
 movements. As a fact, however, it is the conjugate lateral movement 
 which is usually affected, and this is seen in a variety of lesions, as, for 
 instance, in large cerebral hemorrhage, and in thrombic and embolic 
 softening. Any lesion which affects this centre directly or cuts off its 
 underlying connections may cause conjugate lateral deviation of the 
 head and eyes. The patient looks toward the side of the lesion when the 
 paralysis is complete; but if the lesion is an irritative one, as in focal or 
 one-sided epilepsy, he looks away frojn the lesion. The lateral deviation 
 of the eyes that is caused by a cerebral lesion is usually temporary, and it 
 is associated with lateral deviation of the head. It is thus distinguished 
 
 from the lateral deviation of the 
 eyes which is sometimes seen in 
 lesions in the pons, located in the 
 posterior longitudinal bundle, by 
 which the nuclei of the third, 
 fourth, and sixth nerves are joined. 
 In these pontile cases the paralysis 
 is not transient, it is not likely to 
 be associated with deviation of the 
 head, it may be accompanied with 
 other pontile symptoms, and the 
 deviation is sometimes, but not 
 always, away from the side of 
 the lesion. 
 
 Paralysis of the associated 
 upward movements of the eyes is 
 sometimes seen, and is sometimes 
 accompanied with paralysis of 
 convergence. The associated 
 downward movements may be 
 paralyzed, but this isolated paral- 
 ysis is rare; it is usually associated 
 with paralysis of the upward move- 
 ments. The lesion in these cases is located on or near the floor of the 
 aqueduct of Sylvius, and it may be a tumor, a syphilitic inflammation, or 
 a spot of softening. It is possible, however, that paralysis of associated 
 upward or downward movements may be caused by a lesion cutting off 
 the cortical centres from the nuclei in the mid-brain. Wernicke has 
 called this condition pseudo-ophthalmoplegia, and Lloyd has recently 
 reported a case of pseudobulbar palsy, due to bilateral lesions in the len- 
 ticular nuclei, in which there was loss of power in the associated upward 
 movement of the eyes. 
 
 Marie claims that paralysis of associated ocular movements ma}'' be 
 caused by hysteria; but in such a case the affection would more likely be 
 a spasm of the opposing muscles than a true paralysis. Thus a spasm 
 of both superior recti muscles, pulling both eyes upward, would present 
 the appearance of a paralysis of the inferior recti and the superior 
 oblique muscles, whose function it is to pull the eyes downward. The 
 
 Fig. 381.- 
 
 -A case of unilateral ophthalmoplegia.- 
 Lloyd. 
 
DISEASES OF THE CEREBELLUM. 1295 
 
 patient would probably present other hysterical symptoms. Gilles de la 
 Tourette thinks that hysterical paralysis of any of the eye muscles is rare, 
 and that the real affection is a spasm or contraction of the opposing 
 muscles. There is, for instance, an hysterical blepharospasm which may 
 simulate a bilateral ptosis. 
 
 The muscles of accommodation (ciliary) and of convergence (internal 
 rectus) usually act together, and in both eyes at the same time. Thus 
 vision is accommodated for near objects. But the conjoint action of the 
 two internal recti for convergence may be interfered with, and convergence 
 may be paralyzed while these two muscles continue to act in other asso- 
 ciated movements. Perlia has described a special nucleus for convergence 
 beneath the middle line of the aqueduct of Sylvius — called Perlia's central 
 nucleus. A destructive lesion at this point presumably causes isolated 
 paralysis of convergence; that is, the internal recti muscles fail to turn 
 the eyeballs inward in attempts at convergence, but they may act properly 
 in associated lateral movements to the right or left. 
 
 In determining these various paralyses of associated movements- it 
 must be borne in mind that the eyeballs roll away from the paralyzed 
 muscles: thus, if the upward movement is paralyzed the eyeballs roll down- 
 ward, and vice versa. If there is right conjugate lateral deviation, the mus- 
 cles paralyzed are the left external rectus and the right internal rectus. 
 
 XIX. DISEASES OF THE CEREBELLUM. 
 
 Tumor, abscess, and other focal lesions of the cerebellum have been 
 considered under a previous heading. Besides tumor and abscess there 
 are occasionally seen softening and terminal cysts in the cerebellum, due 
 to occlusion of the blood-vessels, as in syphilis and atheroma. Exten- 
 sive softening of one cerebellar hemisphere may occur with little or no 
 evidence of cerebellar disease. Atrophy and sclerosis of the cerebellum 
 are also seen in cases of arrest of development, and in the cerebellar form 
 of hereditary ataxia. 
 
 Symptoms. — In gross lesions of the cerebellum incoordination and 
 forced movements are often seen. There may be wide staggering and 
 swaying, the patient standing with the legs far apart, or there may be 
 reeling and even rotary movements. These symptoms are attributed to 
 lesions of the middle lobe. Forced movements are supposed to depend 
 rather on lesion of the middle cerebellar peduncles. They may be so 
 aggravated that the patient cannot even sit upright in bed, but is forced 
 to one side. Paralysis of the oculomotor nuclei is sometimes caused by 
 pressure on the mid-brain; and pontile symptoms, such as paralysis of the 
 fifth, sixth, seventh, and eighth nerves, and even hemiplegia, are also 
 caused by gross lesions of the cerebellum pressing on the pons. Optic 
 neuritis or atrophy is common, and headache, vomiting, and vertigo are 
 seen just as in other intracranial affections. When one cerebral hemi- 
 sphere is alone affected there may be few if any symptoms, but this is 
 not a universal rule. The knee-jerks are variously affected. In some 
 cases of tumor or abscess they disappear, and even return again, or they 
 are merely exaggerated or diminished, as the case may be, or they are 
 
1296 MEDICAL DIAGNOSIS. 
 
 not the same on both sides. The functions of the cerebellum are still 
 obscure, but they evidently are largely concerned with equilibration, as 
 is proved by the diseases of the organ. 
 
 Cerebellar hereditary ataxia is an affection nearly allied to the 
 spinal hereditary ataxia of Friedreich, but there are well-marked differ- 
 ences between the two. It develops according to most authors rather 
 later in life but has in some cases dated from a very early period, if indeed 
 it were not congenital. In addition to ataxia there are speech defects, 
 not mere scanning but rather an incoordinate and explosive type of 
 speech; exaggerated knee-jerks; and optic atrophy. Nystagmus is occa- 
 sionally seen. The disease may be familial, as in a remarkable series of 
 cases reported by Sanger Brown. Lloyd is convinced that there are differ- 
 ent types of cerebellar ataxia; that not all are necessarily familial or 
 hereditary; and that optic atrophy is not always present. The most 
 typical symptoms seem to be the ataxia, which is not always so extreme 
 as in Friedreich's disease, and the incoordinate explosive speech. The 
 knee-jerks are probably preserved or even increased in most cases. Some 
 of these cases may be due to injury at birth. Some form of atrophy of the 
 cerebellum has usually been found after death, but again the findings 
 have been practically negative. The cerebellar tracts in the cord were 
 involved in one of Brown's cases. 
 
 Diagnosis. — The diagnosis between Friedreich's ataxia and the cere- 
 bellar hereditary ataxia rests upon the difference in the speech defects, 
 and upon the preservation or even increase of the knee-jerks, and possibly 
 the presence of optic atrophy in the latter form. In chorea there is not a 
 true ataxia but rather involuntary irregular movements, and an absence 
 of the characteristic speech. Optic atrophy is not seen. The history 
 and evolution are also different, chorea having a much more abrupt 
 onset and a more acute course, with a tendency to recover. In insular 
 sclerosis there is intention tremor and spastic gait, but the nystagmus 
 and affections of speech may cause some resemblance, and the distinction 
 should be made with care. 
 
 XX. DISEASES OF THE PONS. 
 
 The pons is well named, for it is a bridge by way of which many nerve- 
 tracts take their course. It is also the seat of the nuclei of several impor- 
 tant cranial nerves, namely, the fifth, sixth and seventh. The pyramidal 
 or motor tracts from the brain pass down through the anterior parts of 
 the pons, and the great sensory tract, known as the median and lateral 
 fillet, passes upward through the deeper portion. The transverse fibres 
 of the pons connect the hemispheres of the cerebellum with the opposite 
 cerebral hemispheres, and other important cerebellar connections are 
 probably made through the middle peduncles; and finally the cochlear 
 nerve, or nerve of hearing, enters the lower outer part of the pons, and it, 
 as well as the auditory tract to the posterior quadrigeminal bodies, passes 
 through the mid-region of this great bridge. 
 
 Pathology. — Tumors, hemorrhage, softening, and meningitis are the 
 chief lesions here, as in other regions of the brain. 
 
DISEASES OF THE PONS. 
 
 1297 
 
 Symptoms. — In such a complicated structure the symptoms vary 
 widely; one of the most characteristic symptoms is the hemiplegia alter- 
 nans, in which there is an opposite hemiplegia with paralysis of the 
 sixth nerve causing internal strabismus, and of the seventh nerve causing 
 facial paralysis on the side of the lesion; in some cases the fifth is 
 also involved, also the eighth. The sixth nerves, which pass out near the 
 median line, may both be involved even in a lesion which is mainl}^ uni- 
 lateral. The above symptom-complex points to a lesion in the lower and 
 anterior half of the pons, and if it is a tumor it is most likely to be menin- 
 geal and located in the cerebellopontile angle. Mills has reported a case 
 of limited softening in the lower ventral part of the pons near the median 
 line, in which paralysis of the left sixth and paresis of the right sixth nerve 
 were associated with left hemiplegia. There apparently was no facial palsy. 
 The facial nerve may exhibit remarkable resisting power, as in a case 
 observed by Lloyd, in which the seventh nerve was bent over the surface 
 of a tumor in this region, and yet there had been no paralysis of the face. 
 In some cases both roots of the auditory nerve are not simultaneously 
 involved; as one of these roots subserves hearing (the cochlear nerve) and 
 the other probably subserves equilibration (the vestibular nerve), it is 
 well to test these two functions separately. 
 
 If the lesion is high in the pons, above the level where the motor tracts 
 for the sixth and seventh nerves decussate, the paralysis of these nerves will 
 be on the side opposite the lesion and on the same side as the hemiplegia. 
 
 Involvement of the fifth nerve 
 causes anaesthesia of one side of the 
 brow, face, and tongue (in whole or 
 in part, according to the extent of 
 the involvement), the eyeball of the 
 affected side, and paralysis of the 
 muscles of mastication — the tem- 
 poral, masseter, and pterygoids. A 
 neuroparalytic ophthalmia may 
 result and totally destroy the eye. 
 
 Superficial or meningeal lesions, 
 unless they make deep pressure, are 
 not likely to involve the sensory 
 tract (the fillet), which lies deeply 
 within; nevertheless in all cases of 
 suspected pontile lesion the limbs 
 should be carefully tested for anaes- 
 thesia, including the tactile, the 
 thermal, and the pain senses. 
 
 Deep lesions of the pons may 
 cause headache, vertigo, hemiplegia, 
 hemiansesthesia, dysarthria, paraly- 
 sis of the tongue (not nuclear), con- 
 vergent strabismus or even lateral deviation of the eyes, inability to 
 swallow, and intense emotionalism, with involuntary spasmodic laughter in 
 some cases. Rotation of the head to one side has been noted; also }irofuse 
 82 
 
 Fig. 382. — Woman with deviation of the eyes 
 toward the right, of tlie head toward the left. 
 Case of hemiplegia alternans inferioris encephahti- 
 di.s pontis (crossed lieiniplegia from inferior enceph- 
 ahtis of the pous). — Oppenheim. 
 
1298 MEDICAL DIAGNOSIS. 
 
 sweating, vasomotor symptoms, and even epistaxis. Conjugate deviation 
 of the head and eyes is said to be caused sometimes by a lesion high 
 in the pons. Deviation of the eyes is away from the side of the lesion if 
 this is in the posterior longitudinal fasciculus; and cases have been 
 reported in which the eyes were rolled to one side and the head to the 
 other in the hemiplegia alternans. 
 
 The symptom-complex described as pseudobulbar palsy is probably 
 caused in some cases by a pontile lesion. 
 
 Diagnosis. — This is made from the pecuhar grouping of symptoms 
 as given above. A question may arise as to the nature of the lesion, whether 
 it be a tumor, a hemorrhage, a softening, or a syphilitic meningitis. Tumor 
 is usually slow in onset and gradual in its course; hemorrhage and softening 
 abrupt in onset and not progressive; syphilitic meningitis may not be easily 
 distinguishable from tumor, but irregularity in the development and course 
 of the symptoms,, as well as a luetic history, points to specific disease. 
 
 XXI. BULBAR PALSY. 
 
 In the account of progressive muscular atrophy and amyotrophic 
 lateral sclerosis the degeneration of the ganglion cells in the anterior, or 
 motor, horns of the spinal cord, which is characteristic of these diseases, is 
 described. We have now to describe a disease which depends upon a 
 similar degeneration of motor gangHon cells, but these cells are located 
 higher in the medullary gray matter and preside over special functions; 
 they are the motor neurons which arise in the bulb, or medulla oblongata, 
 and especially in the nuclei of the ninth (glossopharyngeal), tenth (pneu- 
 mogastric), and twelfth (hypoglossal) nerves. This disease is known as 
 bulbar palsy, or labio-glosso-pharyngeal paralysis. 
 
 Pathology. — There is found a degeneration of the large multipolar 
 cells in the nuclei of origin of the ninth, tenth, and twelfth nerves in the 
 medulla, and possibly of the seventh nerve in the pons. Thus in the nucleus 
 ambiguus, which contains the motor cell-bodies of the ninth nerve, these 
 multipolar cells are found greatly changed; they have shrunken in size, 
 present evidence of chromatolysis and displacement of the nuclei, and the 
 nerve-fibrils are diminished in number. In advanced or severe cases it is 
 evident that many cell-bodies have entirely disappeared. The same changes 
 are found in the nucleus of the twelfth nerve, which is entirely a motor 
 nerve. In the case of the ninth, which is a mixed nerve, the sensory ganglia 
 (the jugular and petrous) are not involved. The diseased cells, however, 
 are not confined to the regions just mentioned, but are found in that 
 rather extensive mass of gray matter in the bulb from which arise motor 
 fibres not only for the ninth but also for the tenth (pneumogastric) and 
 even the spinal accessory. In some cases the roots of the bulbar nerves 
 are degenerated, and occasionally some degeneration is observed in the 
 pyramidal tracts of the cord. This sclerosis of the motor columns marks 
 the connection of this disease with progressive muscular atrophy and 
 amyotrophic lateral sclerosis, for that there is" some relationship is evident 
 not only from the similarity of the degeneration in the motor nuclei, but 
 from the fact that bulbar palsy may precede or compHcate either of these 
 two diseases, especially the latter. 
 
BULBAR PALSY. 
 
 1299 
 
 Symptoms. — The initial symptoms usually are disorders of speech* 
 The articulation becomes imperfect, especially for labials and Unguals, 
 due to beginning paresis of the lips and tongue. Nasal speech occurs, and 
 finally a very distressing dysarthria, in which the patient finds it almost 
 impossible to make himself understood. The attempt at speech is fatigu- 
 ing, and finally may be almost abandoned. Deglutition in turn becomes 
 impaired. The patient can manage the bolus of food only wath difficulty, 
 especially in passing it back into the pharynx. There may be regurgita- 
 tion of fluids through the nose, or out between the paralyzed lips, and 
 attacks of strangling, coughing, and 
 vomiting result. Mastication also is 
 somewhat impaired. Phonation is 
 altered, and becomes monotonous. 
 Respiration may also be embar- 
 rassed. The loss of power in the 
 lips causes inability to whistle or to 
 show the teeth. The lower part of 
 the face becomes immobile and ex- 
 pressionless; the lips are flaccid and 
 partially open, and drooling or drib- 
 bling of saliva results. The tongue 
 becomes so palsied that it cannot 
 be protruded, but lies almost or 
 quite motionless in the mouth. The 
 paralysis is atrophic; hence all the 
 affected muscles waste and lose tone. 
 The tongue is flabby, wasted, and 
 fissured. The lips are thin and life- 
 less. The pharyngeal reflex may be 
 abolished, but sensation is not 
 involved. The velum palati hangs 
 flaccid, and the laryngoscope may 
 reveal paralysis of the adductors of 
 the vocal cords. As a rule, the muscles of the upper part of the face 
 and of the eyes are not involved. 
 
 Occasionally there is evidence of lateral sclerosis, as exaggerated 
 knee-jerks and some spasticity of the gait. This indicates, as already 
 said, the kinship of this disease to amyotrophic lateral sclerosis. 
 
 The electrical reactions may be partially altered, but true reactions 
 of degeneration are seldom seen. This is for the same reason that holds 
 in progressive muscular atrophy; as long as any muscle fibres remain in 
 connection with the gradually wasting nuclei they react to the current. 
 
 The onset of bulbar paralysis is usually insidious, the course is 
 slow and chronic, and the disease is incurable. Acute cases, with rapidly 
 developing symptoms, have been reported, but they are rare. 
 
 Diagnosis. — There is not much possibility of confusing true bulbar 
 paralysis with any other disease. Diphtheritic paralysis has been mis- 
 taken for it, but in that disease there is no paralysis of the tongue and lips, 
 and the history and course are different. The mistake is most likely to 
 
 Fig. 383. — Atrophy of tongue due to partial bulbar 
 paralysis. — Lloyti. 
 
1300 
 
 MEDICAL DIAGNOSIS. 
 
 occur from regarding the paralysis of the velum palati and the dysphagia 
 as evidences of an acute onset of bulbar paralysis; but the history of sore 
 throat, the paralysis of accommodation, and the evidences of a multiple 
 neuritis are usually sufficient to identify postdiphtheritic paralysis. 
 
 The distinction between true bulbar paralysis and myasthenia gravis 
 presents some difficulty, but the subject is discussed in connection with 
 the latter disease. 
 
 Organic disease, such as tumor of the pons or medulla, may simulate 
 bulbar paralysis — may, in fact, cause a bulbar palsy — but other evidences 
 will be present of gross organic disease, such as are described under the 
 head of Tumors of the Brain. 
 
 There is an apoplectic bulbar palsy due to hemorrhage or vascular 
 disease in the bulb and pons. It may simulate atrophic bulbar paralysis, 
 but its sudden onset, often with apoplectiform symptoms, is characteristic. 
 In some non-fatal cases there may even be a tendency for some of the 
 earlier symptoms to improve. 
 
 An acute disease of the gray matter of the bulb, analogous to the acute 
 anterior poliomyelitis of children, has been reported by Wernicke and others 
 — the so-called acute polioencephalitis inferior. The history and nature of 
 the attack are usually sufficient to distinguish it. The symptoms are those 
 of bulbar palsy of rapid onset. Wernicke associates this disease with a 
 _ _ _ similar affection of the nuclei in the 
 
 ; ] mid-brain, causing ophthalmoplegia 
 
 — the acute polioencephalitis superior. 
 
 XXII. PSEUDOBULBAR 
 PALSY. 
 
 The term pseudobulbar palsy 
 applies to a labio-glosso-pharyngeal 
 paralysis which is of cerebral, not of 
 nuclear, origin. To -understand it 
 we must bear in mind that there are 
 centres in the motor cortex of the 
 brain for the hps, the tongue, the 
 muscles of mastication, the pharynx, 
 and the larynx, and that these cen- 
 tres are connected with the nuclei of 
 the facial, the motor branch of the 
 fifth, the hypoglossal, the pneumo- 
 gastric, and the glossopharyngeal 
 nerves by the motor conducting 
 paths, which run down through the 
 internal capsule, cerebral peduncle, 
 and pons. These nuclei are located in the pons and medulla oblongata. 
 Hence a lesion which interrupts these motor tracts from the brain causes 
 bulbar or pontobulbar symptoms: there is paralysis of the lips, tongue, 
 and the muscles of mastication, of deglutition, and possibly of phonation. 
 Symptoms. — A few such cases have been reported, and the accompany- 
 ing illustrations represent two such patients from the service of J. Hendrie 
 
 Fig. 384. — Pseudobulbar palsy, showing paral 
 ysis of the lips, tongue, and lower jaw, from lesion; 
 in the lenticular nuclei. — Lloyd. 
 
PSEUDOBULBAR PALSY. 
 
 1301 
 
 Fig. 385.- 
 
 Pseudobulbar palsy; involuntary laufjli- 
 ter. — Lloyd. 
 
 Lloyd in the Philadelphia Hospital. The nature and location of the lesions 
 
 in such cases are not always clear. As the symptoms are usually bilateral, 
 
 it is not easy to interpret them as 
 
 due to a unilateral lesion. Sometimes ■ ' 
 
 the symptoms in their entirety occur 
 
 only after sudden apoplectiform 
 
 attacks, and the inference is that 
 
 bilateral vascular lesions, such as 
 
 could be caused by atheroma or 
 
 syphilis, are the cause. In one of 
 
 Lloyd's cases bilateral lesions were 
 
 found in the lenticular nuclei. 
 
 There may be hemiplegic or 
 
 diplegic symptoms, not always 
 
 well marked. 
 
 The muscles of the tongue and 
 
 lips and of mastication and degluti- 
 tion may be completely paralyzed. 
 
 In one of the cases here depicted the 
 
 tongue was motionless, the mouth 
 
 hung open because of paralysis of 
 
 the temporal and masseter muscles, 
 
 the lips were paralyzed, and the 
 
 patient could only swallow by 
 
 thrusting the bolus of food far back into his pharynx with his finger. 
 The paralysis is central, as shown by the absence of muscular atrophy, 
 
 of fibrillation, and of the reactions of degeneration. A peculiar symptom 
 
 is spasmodic involuntary laughter or 
 crying. It is well shown in tile cuts. 
 Brissaud thought that this indicated 
 lesions of the optic thalami. 
 
 • Cerebral symptoms sometimes 
 occur in these patients, such as apha- 
 sia, dysarthria, dementia, hemianop- 
 sia, etc. There is also seen in rare 
 cases conjugate paralysis of the 
 eyes; in one of the above cases there 
 was paralysis of the upward move- 
 ment of both eyes. 
 
 Among other symptoms rarely 
 seen are optic neuritis or atrophy, 
 and respiratory troubles. Anses- 
 thesia is not commonly observed. 
 There has been more speculation 
 than actual post-mortem o])servation 
 
 fjjout the seat of the lesion; and Oppenheim, who reviews the subject, comes 
 
 to no very definite conclusion. Brissaud places the lesion, or lesions, in the 
 
 posterior part of the optic thalami; ^ this was not so in Lloyd's recent case. 
 
 1 Legons sur les Maladies Nerveuses, Paris, 1895, p. 440. 
 
 Fig. 386. — Involuntary laughter in a case of pseu 
 dobulbar palsy. — Lloyd. 
 
1302 
 
 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — The disease is distinguished from true bulbar palsy by 
 the abrupt onset, the central character of the symptoms, — the absence of 
 atrophy, of fibrillation, and of electrical changes, — by the associated 
 cerebral symptoms, and by the history. 
 
 DISEASES OF THE CRANIAL NERVES. 
 
 The cranial or cerebral nerves comprise twelve pairs ot symmetri- 
 cally arranged nerve-trunks which are immediately connected with the 
 brain and pass through various foramina at the base of the skull to be 
 distributed, with the exception of the tenth pair, to the structures of 
 the head and neck. 
 
 These pairs of nerves are numbered according to the order in which 
 they penetrate the dura from before backward from the first to the twelfth. 
 They have., moreover, received designations descriptive of their functions 
 or distribution. Some of them are wholly motor; others convey impulses 
 of special sense; while certain of them transmit impulses of common sen- 
 sation and motion. 
 
 THE CRANIAL XERVES. 
 
 I 
 
 II 
 III 
 
 IV 
 
 v 
 
 VI 
 
 vn 
 
 VIII 
 
 IX 
 
 X 
 
 XI 
 
 xn 
 
 Olfactory 
 
 Optic 
 
 Oculomotor 
 
 Trochlear 
 
 Trigeminal 
 
 AbdnceBt 
 
 Facial 
 
 Auditory, 
 
 ( a) Cochlear division . 
 
 (b) Vestibular division 
 Glossopharyngeal 
 
 Pneumogastric or vagus . 
 
 Spinal accessory. 
 Hypoglossal 
 
 Function. 
 
 Special sense of smell. 
 
 Special sense of sight. 
 
 Motor to eye muscles and levator palpebrse superioris. 
 
 Motor to superior oblique muscle. 
 
 Common sensation to structures of head. 
 
 Motor to muscles of mastication. 
 
 Motor to external rectus muscle. 
 
 Motor to muscles of head (scalp and face) and neck (platysma). 
 
 Probably secretory to submaxillary and sublingual glands. 
 
 Sensory "(taste) toanterior two-thirds of tongue. 
 
 Hearing. 
 
 Equilibration. 
 
 Special sense of taste. 
 
 Common sensation to part of tongue and to pharynx and middle ear. 
 
 Motor to some muscles of pharynx. 
 
 Common sensation to part of tongue, pharynx, oesophagus, stomach, 
 and respiratory organs. 
 
 Motor (in conjunction with bulbar part of spinal accessory) to mus- 
 cles of pharynx, cesophagus, stomach and intestine, and respiratory 
 organs : inhibitory impulses to heart. 
 
 Spinal part : Motor to sternomastoid and trapezius muscles. 
 
 Motor to muscles of tongue. 
 
 Modern knowledge concerning the relative position of the cell-bodies 
 of motor and sensory neurons renders necessary a readjustment of the 
 former views concerning the superficial and deep origin of the cranial 
 nerves and their course from the brain to parts outside the skull. Only the 
 motor fibres of the cranial nerves arise from nerve-cells within the cere- 
 brospinal axis, while the fibres which transmit sensory impulses have 
 their origin from cell-bodies forming ganglia situated outside of the central 
 nervous system and in the course of the nerve- trunks. The term " deep 
 origin" as indicating cell-groups constituting nuclei within the brain and 
 ''superficial origin" as indicating the point of attachment to the surface 
 of the brain can only be properly employed in regard to motor nerves and 
 the fibres of motor and sensory nerves which convey motor impulses. 
 
DISEASES OF THE CRANIAL NERVES. 1303 
 
 The cell-groups with which the terminal arborizations of the sensory fibres 
 come into relation within the cerebral substance are not nuclei of origin 
 but of termination — nuclei of reception. The impulses which they receive 
 are transmitted to various parts of the brain by neurons of the second, 
 third, or even higher order. The motor nerves then have their deep origin 
 within the substance of the brain, their superficial origin at the point of 
 their attachment to the surface of the brain, and their exit from the skull 
 by the various foramina. The sensory nerves have their origin in their 
 respective ganglia, their entrance into the skull by way of certain foramina, 
 their points of attachment to the brain, and their nuclei of reception. 
 Finally, the nerves of common sensation and motion, viewed from the 
 standpoint of the direction of the impulses which they convey, whether 
 the}'- be afferent or efferent, contain fibres which enter the brain and fibres 
 which make their exit by way of the respective foramina. 
 
 Every cranial nerve is directly or indirectly in relation with groups 
 of neurons in the cerebral cortex. These groups constitute the higher 
 cortical centres, the location of which in the case of many of the nerves 
 has been more or less accurately determined. 
 
 I. FIRST NERVE. 
 
 The term olfactory nerve, formerly employed to designate the olfac- 
 tory bulb and tract as well as the filaments, is now employed to describe 
 the paths of conduction represented by a number of minute filaments 
 which connect the perceptive elements situated within the Schneiderian 
 mucous membrane with the olfactory lobe. In man the olfactory bulb 
 and tract with its roots represent as rudimentary structures the more 
 developed olfactory lobe of animals in which the sense of smell is keen. 
 The true olfactory nerves, which number about twenty, are the axons of 
 the neurons — the olfactory cells — which are situated in the olfactory 
 area. This space is limited in extent, .comprising on the outer nasal 
 wall less than the mesial surface of the superior turbinate bone and a 
 slightly more extended distribution upon the upper part of the nasal 
 septum. These filaments pass upAvard by way of openings in the crib- 
 riform plate of the ethmoid bone and enter the olfactory bulb by its 
 under surface. 
 
 Lesions of the nasal mucous membrane involving the olfactory area or 
 the upper turbinate bone or the adjacent part of the septum, are attended 
 with impairment or loss of the sense of smell. Lesions of the uncinate 
 gyrus may also cause loss of smell upon one or both sides. The conduction 
 path may also be destroyed in fractures of the base of the skull in the 
 anterior fossa, involving the cribriform plate. Irritative lesions cause- 
 perversion of the sense of smell — parosmia; destructive lesions partial or 
 complete loss — anosmia. Hallucinations of the olfactory sense may be 
 symptomatic of hysteria, insanity, or tabes, and constitute one of the 
 various forms of aura in epilepsy. 
 
 The sense of smell may be tested by presenting to each nostril in 
 turn bottles containing familiar aromatic substances, as the oils of clove, 
 peppermint, or asafa^tida. 
 
1304 MEDICAL DIAGNOSIS. 
 
 II. SECOND NERVE. 
 
 The ganglion cells among the rods and cones of the retina are the 
 beginnings of the optic nerve; its apparent origin at the papilla is simply 
 the point where the axons from these retinal cell-bodies, coming together, 
 form the trunk of the nerve. 
 
 The ophthalmoscope is of special value in neurologic diagnosis because 
 it lays bare, in the papilla, a great nerve close to the brain. Of the lesions 
 thus directly revealed, papilhtis or optic neuritis is usually a symptom of 
 intracranial pressure or inflammation. When attended with much swell- 
 ing it becomes " choked disk," since the optic foramen, unyielding, squeezes 
 the swollen fibres. For the same reason optic neuritis is prone to pass into 
 optic atrophy; but the latter is often primary, as in tabes, the optic nerve 
 being, hke other sensory roots, hable to degeneration in this disease. 
 
 For the consideration of vision in neurology, the retina is divided into 
 lateral halves. The fibres from the right half-retinas (nasal half of left 
 retina, temporal half of right) run together at the chiasm to form the right 
 optic tract. Their arrangement is like that of the lines for driving a team 
 of horses, the right line (as the optic tract) dividing to go to the right 
 side of each horse's head (as to the right half of each retina) and, mutatis 
 mutandis, the same applies to the left half-retinas. The partial decussa- 
 tion at the chiasm, then, is a device to make the two eyes, like a team of 
 horses, act as one (binocular vision). 
 
 The optic tract passing back winds around the brain-stem (crus) to 
 enter it dorsally after the manner of spinal sensory roots. It meets here its 
 superior cell-bodies in three structures, the pregeminum, the pregeniculum, 
 and the pulvinar, which constitute the ''primary optic centres." From 
 these cell-bodies, axons (the optic radiations) arise to pass into the 
 posterior part of the internal capsule and outside the posterior horn of the 
 lateral ventricle to the cortical optic centre in the cuneus, or, more exactly, 
 in the region bordering the calcarine fissure. Lesion at any point in this 
 path from the chiasm to the occipital cortex affects the half-retinas of the 
 same side. Thus it appears that physiologically there is no cross-way in 
 the optic path within the brain; yet just as an object touching the left 
 side of the body is felt in the right half of the cerebrum through a cross- 
 ing within the brain-stem, so an object on the left (in the left half-field of 
 vision) is seen by the right half of the cerebrum through a crossing, not of 
 nerve-fibres but of rays of light within the eyeballs (vitreous chambers) ; and 
 as lesion of the right touch-path (fillet) causes left hemiansesthesia, so lesion 
 of the right optic path, by affecting the right half-retinas, causes blindness 
 of the left half-fields, called left hemianopsia. The varieties of hemianopsia 
 • are named by the fields which are darkened, not by the blind part of the 
 retina. Tumor of the pituitary body by pressure at the chiasm destroying 
 the inner fibres of each nerve from the nasal half of each retina causes 
 temporal hemianopsia. More severe pressure may cause total blindness. 
 
 The optic tract may be pressed upon by tumor at the base, some- 
 times growing from the temporal lobe. There is hemianopsia, with 
 Wernicke's sign and general symptoms of brain tumor. The primary 
 optic centres may be the seat of a tumor or they may be pressed upon 
 bv a tumor of the middle lobe (vermis) of the cerebellum. 
 
DISEASES OF THE CRANIAL NERVES. 
 
 1305 
 
 The optic radiations may be involved in tumor, hemorrhage, or soft- 
 ening at the hind part of the internal capsule, adding hemianopsia to 
 the symptoms of capsular lesion; or one of these lesions may implicate 
 the radiations farther back in 
 the subcortex, when hemian- 
 opsia may exist alone; or a 
 lesion in the angular gyrus may 
 invade the radiations beneath, 
 adding hemianopsia to the 
 cortical symptoms of mind- 
 blindness, etc. 
 
 Lesions in the vicinity of 
 the calcarine fissure cause 
 hemianopsia; occasional!}' 
 they are bilateral, causing 
 double hemianopsia which 
 amounts to total blindness 
 (amaurosis). The half-retinas 
 are, as it were, mapped out 
 upon the cuneus, so that, half 
 of it being destroyed, there is 
 blindness in a quarter of the 
 opposite fields (quadrantic 
 hemianopsia). Color appears 
 to be separately represented. 
 On the outer surface of the 
 cerebrum, in the angular gyrus, 
 apparently, is a higher centre 
 for visual concepts. "With 
 lesion there the patient has 
 mind - blindness, including 
 word-blindness. 
 
 The mid-brain, receiving 
 the great sensory eye-nerve 
 (optic), sends back to the eye 
 its chief motor nerve (third 
 or motor ocuH). These two 
 nerves are the limbs of the 
 reflex- arc through which the 
 pupils react to light; and lesion 
 of either may cause among 
 other symptoms impairment 
 of the light reflex. 
 
 Wernicke's " hemianopic 
 pupillary inaction" is a sign of lesion at the base of the brain (see p. 373). 
 
 The third nerve nuclei just beneath the anterior gemina are connected 
 with these bodies, or with the optic tract in front of them, by collateral 
 fibres to complete the light reflex arc, and lesion (usually tabetic or paretic 
 degeneration) of these collaterals may impair the light reflex alone, causing 
 
 occ: i ^^ 
 
 CUNEUS. 
 
 Fig. 387. — Diagram of visual system. Modified from 
 Vialet. OP. T., optic tract ; INT. CAP., internal capsule ; 
 OP. R., optic radiation; THO., optic thalamus ; EXT. GEN., 
 external geniculate body; C. QU., corpora quadrigemina ; 
 MS., motor speech centre; AS. auditory speech centre; 
 VS., visual speech centre. 
 
 Lesions at the points indicated by the figures in the dia- 
 gram cause the following morbid conditions : 1, blindness 
 of the corresponding eye; 2, bitemporal hemianopsia; 
 
 3, nasal hemianopsia; 3, and 3', binasal hemianopsia; 
 
 4, right lateral homonymous hemianopsia with Wernicke's 
 hemianopic pupillary inaction sign; .5, left lateral homon- 
 ymous hemianopsia with normal pupillary reflexes ; 6, right 
 lateral homonymous hemianopsia with normal pupillary 
 reflexes; 7, amblyopia 'especially on the side opposite the 
 lesion) ; 8, on the left side, word-blindness. 
 
1306 MEDICAL DIAGNOSIS. 
 
 reflex iridoplegia without other eye-symptoms. Loss of the hght-reaction 
 of the iris with the preservation of the reaction in convergence and accom- 
 modation is called the Argyll-Robertson pupil. It occurs in tabes and in 
 paresis. 
 
 OPTIC NEURITIS— PAPILLITIS. 
 
 Inflammation of the optic nerve, visible with the ophthalmoscope. 
 When the swelling causes bulging of the nerve-head to the extent of two 
 diopters or more it is called choked disk. An affection of the nerve 
 back of the eyeball, causing peculiar symptoms, is called retrobulbar 
 neuritis. Sclerosis of the nerve, seen in the papilla, is optic atrophy. 
 Ordinarily, as the sequel of optic neuritis, it is consecutive atrophy; when 
 a part of the degeneration in tabes, etc., it is primary; when a symptom 
 of brain disease, like tumor, secondary optic atrophy. 
 
 Impairment of vision and of the iris-reflex to light, both in varying 
 degree, with ophthalmoscopic changes in the disk, indicate disease of the 
 optic nerve. The field of vision is contracted, sometimes irregularly. The 
 diagnosis rests mainly upon ophthalmoscopic examination; the prognosis 
 upon the cause of the condition. In general it is grave. 
 
 III. THIRD, FOURTH, AND SIXTH NERVES (MOTOR 
 NERVES OF THE EYE). 
 
 Supplying the internal muscles of the eyeball, except the dilator fibres 
 of the iris, and the external muscles, except the external rectus and the 
 superior oblique, the third nerve is the most important motor nerve of 
 the eye, whence its name, motor oculi. 
 
 As cortical centres control movements, not muscles or nerves, the third 
 nerve with its opposite actions is not totally affected in cerebral palsies. 
 When in a case of head injury one pupil is dilated and immobile, this 
 (Hutchinson pupil) is said to be pathognomonic of extradural hemorrhage. 
 
 The internal rectus, supplied by the third nerve, when paralyzed, per- 
 mits the eyeball to turn outward (divergent strabismus); there is double 
 vision with the secondary image on the opposite side (crossed diplopia). 
 The inferior rectus being paralyzed, the eyeball fails to move down- 
 ward and to some extent outward; of the double vision, the secondary 
 image is below. The superior rectus paralyzed, the eyeball does not move 
 upward, nor perfectly outward; the secondary image is above. To look 
 with this eye the head is thrown back. The inferior oblique is opposite, in 
 action and in the effects of paralysis, to the inferior rectus. The superior 
 oblique, supplied by a separate nerve, the fourth or trochlear, is often 
 paralyzed; the effects are opposite to those of paralysis of the superior 
 rectus. The fourth nucleus, under the posterior geminum, is a continua- 
 tion of the third. The sixth nucleus, in the lower part of the pons, is another 
 link in the chain of gray matter for the ocular muscles. The external 
 rectus, supplied by the sixth or abducent nerve, is more often affected 
 alone than any other ocular muscle. When the entire third nerve is para- 
 lyzed the eyehd droops (ptosis), the eye turns outward by the action of 
 the sixth nerve, and slightly downward by the action of the fourth, the 
 
DISEASES OF THE CRANIAL NERVES. 
 
 1307 
 
 pupil is larger than its fellow and fails to react to light or in accomniotla- 
 tion. Lesions of the trunk of the nerve are generally unilateral; the}- may 
 affect the extra-ocular muscles, while sparing the iris-movements and 
 accommodation. The third nerve- trunk in the orbit may be injured, as 
 by a blow on the temple, or compressed by an orbital growth. It may 
 be the seat of neuritis, from rheumatism, alcoholism, or diphtheria, or 
 of degeneration in tabes. Within the skull it may be implicated in menin- 
 gitis or compressed by tumor or aneurism. In its course through the crus 
 it may be compressed by tumor, or suddenly paralyzed by hemorrhage, 
 embolism, or thrombosis, commonly associated, by implication of the 
 motor pathway, with hemiplegia of the opposite side (Weber's syndrome). 
 In the cortex there is no representation of the third nerve as a whole, but 
 of the various movements governed by it. In traumatism of the con- 
 vexity on one side inducing extradural hemorrhage, the pupil of this side 
 may be dilated and immobile (Hutchinson pupil). Lesions, as apoplexy, 
 affecting the motor pathway within the cerebrum often cause conjugate 
 deviation of the eyes, with the head ordinarily toward the side of the 
 lesion. Finally, syphilitic disease, either gumma, meningitis, or neuritis, 
 often selects the third nerve. The palsy of myasthenia gravis is often in 
 the domain of the third nerve (recurring palsy — ophthalmic migraine). 
 Nuclear Ocular Palsies. — (See p. 1291.) 
 
 IV. FIFTH NERVE. 
 
 The fifth or trifacial is the great nerve of common sensation for the 
 head. Its motor branch, for mastication, is subsidiary. The surfaces sup- 
 
 Ophthalmic- 
 
 Maxillary 
 
 Oplithalmic 
 
 . ,. Occipitalis 
 Ljf^!*^ininor 
 
 Fig. 388. — Showing distribution of cutaneous brandies of trigeminal and cervical spinal nerves. — Piersol. 
 
 plied by its three Ijranches, namely, the ophthalmic and the superioi' and 
 inferior maxillary nerves, are shown in the accompanying illustrations. 
 
1308 
 
 MEDICAL DIAGNOSIS. 
 
 Supra-troehlear 
 1.V 
 
 1.V 
 jfaealUV 
 
 Entering the cranium — the first branch by the sphenoidal fissure, the 
 second by the foramen ovale, the third by the foramen rotundum — the 
 branches unite in the Gasserian ganghon, thence to enter the side of 
 the pons, midway between its upper and lower borders. At this level, 
 in the back of the pons is the main nucleus of the fifth, but a chain of 
 gray matter and connecting fibres (mid-brain root) extending alongside the 
 aqueduct of Sylvius forms the motor root, which leaves the pons just 
 above the sensory root and passes under the Gasserian ganglion, and a 
 similar chain descending at the side of the medulla conveys sensory 
 impulses down to the cervical cord. 
 
 Diseases of the Fifth Cranial Nerve. — Branches of the fifth may be 
 the seat of neuralgia, from cold or from dental affections; they may be 
 
 damaged by wounds. Sclerosis of 
 the Gasserian ganglion may be the 
 cause of facial hemiatrophy; it is 
 the usual cause of trifacial neuralgia 
 or tic douloureux, and may be the 
 seat of irritation, giving rise to 
 herpes zoster of the face. Hemor- 
 rhage, tumors,, or other lesions within 
 the pons, paralyzing the fifth, cause 
 anaesthesia of various areas of the 
 face. Meningitis, syphilitic lesions, 
 tumors beneath the pons often im- 
 plicate the roots of the fifth. 
 
 Symptoms. — Disease of the fifth 
 nerve may cause first neuralgic pain, 
 but the chief effect is anaesthesia in 
 the distribution of one or more of 
 its branches to the middle line of 
 the face. A touch upon the con- 
 junctiva is not felt, and does not 
 excite the flow of tears. Fumes in the nostril have no effect, and on the 
 tongue, especially its anterior two-thirds, substances whose taste-qualities 
 are allied to touch are not recognized. The salivary secretion fails, the 
 mucous membranes are dry, and from slight injury ulcers may form upon 
 them, particularly over the cornda, which becomes clouded, opaque, and 
 may perforate, leading to panophthalmia (neuroparalytic ophthalmia). 
 The motor portion of the fifth being paralyzed, the jaws are not closed 
 so firmly on the affected side, and in opening deviate toward that side. 
 The weaker action of the temporal and masseter can be felt by the fingers. 
 Diagnosis. — Anaesthesia of half the face, including the mucous mem- 
 branes, when it exists alone points to lesion of the Gasserian ganglion or 
 of the nerve-trunk between this and the pons. Anaesthesia corresponding 
 to one branch of the fifth may be due to lesion at any point in the course 
 of the branch. When the fifth nerve and the cranial nerves next in order— 
 the sixth or seventh, fourth, or third — are affected together, the lesion is 
 at the base of the brain involving the roots of these nerves. Anaesthesia 
 of one side of the face and of the arm and leg of the same side (hemian- 
 
 FiG. 389. — Normal distribution of the fifth 
 nerve to the face. 1. V, ophthalmic division; S. V, 
 superior maxillary; 3. V, inferior maxillary. The 
 names on the different areas indicate the branches 
 supplying them. (Flower.) — Posey and Spiller. 
 
DISEASES OF THE CRANIAL NERVES. 1309 
 
 sesthesia) points to lesion in the posterior third of the posterior limb of the 
 internal capsule; but of the face on one side and of the arm and leg opposite 
 (crossed anaesthesia) lesion in the pons, on the side of the facial anaesthesia. 
 With the latter there may be loss of the associated movement of the eyes 
 to this side and there may be a corresponding crossed motor paralysis. 
 
 Differential Diagnosis. — Hysterical hemianaesthesia is not associ- 
 ated with dryness of the mucous membranes; the tears flow on irritation of 
 the conjunctiva and the special senses are afTected on the anaesthetic side. 
 
 Tic Douloureux. — This is an aggravated and persistent form of 
 neuralgia in the trigeminal nerve. 
 
 Pathology. — The disease has often been described as idiopathic, but 
 recent observations, especially by Horsley, Rose, Putnam, Spiller, and 
 others, have tended to show that there are degenerative or sclerotic proc- 
 esses in the nerve-fibres and in the Gasserian ganglion. The tendency for 
 the disease to pass slowly but surely from one branch to the other, even 
 after the branch first affected has been excised, seems to indicate that the 
 process spreads from one group of neuron cells to the others in the Gas- 
 serian ganglion in somewhat the same way as the motor neurons of the 
 anterior horns of the spinal cord are involved in progressive muscular 
 atrophy. The essential causes of this process are obscure. 
 
 Symptoms. — The chief and usually the only symptom is pain. 
 Lachrymation, flushing of the face, and spasmodic movements of the facial 
 muscles are occasionally seen. Herpes has been observed in some cases, 
 but it is doubtful whether it belongs to the disease proper. 
 
 The pain is intense, atrocious, even agonizing. It sometimes occurs 
 in paroxysms or exacerbations, but in many cases there is more or less 
 constant suffering. The paroxysms are usually spontaneous, but they 
 can also be excited by trifling causes, such as movements of the face, 
 attempts at talking or eating, or even a draught of qold air. It is character- 
 istic of tic douloureux to begin in one division, or even in one branch, of 
 the fifth nerve, and then to spread in time to other branches. The progress 
 is usually slow and chronic. Many cases -are operated on, but excision of 
 the offending branch, while often giving relief for longer or shorter periods, 
 seldom effects a radical cure, the pain returning in another branch. 
 
 Spasm of the facial muscles is seen in some cases and even consti- 
 tutes a special type of the disease (the so-called convulsive or epileptiform 
 tic), but it is not common. The pains in these cases are usually paroxysmal 
 and severe; they occur with lightning-like quickness, and the facial mus- 
 cles are thrown into twitchings and spasmodic movements. The taking 
 of food is sometimes seriously interfered with by the pain. 
 
 Paralysis and anaesthesia are not seen in tic douloureux. Inhibition 
 of movement is caused by the pain and the fear of pain, but neither 
 the facial nor the masticatory muscles (the latter of which are supplied 
 by the motor branch of the fifth nerve) are truly paralyzed. Anaes- 
 thesia in the territory of the fifth nerve is also absent as an almost 
 universal rule; a few exceptions have been noted, but they properly 
 raise a question whether the case is typical. Neurotrophic disorder of 
 the eye, as seen in organic disease of the fifth nerve, is also not observed. 
 The affection is unilateral. 
 
1310 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — The disease is unmistakable. The gradual establishment 
 of severe pain in one branch of the fifth nerve, its progress in time to other 
 branches, its intractability, and the facial spasms (when they occur) are 
 easily recognized. The only doubt that may arise is with reference to the 
 causation and pathology. 
 
 Organic lesions of the fifth nerve, such as occur from tumors, meningitis, 
 etc., may cause pain, but usually they also cause anaesthesia of the face, 
 brow, eye, and tongue, and paralysis of the masticatory muscles, and the 
 pain is not always intense or strictly limited to a branch of the trigeminus. 
 Moreover, in such cases the symptoms are seldom confined to the fifth nerve. 
 
 The term "epileptiform," as applied to the type in which facial 
 spasms occur, is a misnomer. The disease has no relation to epilepsy. 
 
 Masticating Spasm. — Tonic spasm in the domain of the motor 
 fifth occurs as trismus or "lockjaw" in tetanus; occasionally in tetany, 
 in hysteria, and reflexly in dental affections, like caries of a molar. Clonic 
 spasm, noticeable in a chill and in the epileptic convulsion, occurs rarely 
 as an isolated affection called "chattering teeth." 
 
 V. SEVENTH NERVE. 
 
 The seventh or facial nerve, arising from the nucleus ambiguus, passes 
 behind and over the sixth nucleus and out at the side of the pons near its 
 lower border. With the eighth it enters the internal auditory meatus, 
 then alone passes in the Fallopian canal close to the tympanum, and finally, 
 through the stylomastoid foramen, emerges upon the face. 
 
 Paralysis of the facial muscles may be supranuclear or central as the 
 result of lesion of the centre in the lower Rolandic cortex, or of the fibres 
 from this centre passing down through the brain, commonly as a part of 
 hemiplegia; or nuclear in consequence of lesion of the nucleus in the pons; 
 or infranuclear from lesion of the nerve-trunk at any point. The ordinary 
 form of facial palsy is "peripheral" from neuritis in the Fallopian canal, 
 and is called Bell's palsy. Hemorrhage or softening in the pons, damaging 
 one facial nucleus, may paralyze the face on that side and affect the adja- 
 cent motor pathway, the arm and leg of the other side (crossed paralysis). 
 The seventh nerve may also be paralyzed in that rare form of tetanus 
 known as cephalic tetanus. 
 
 At its emergence from the pons the seventh nerve may be implicated 
 in meningitis, or compressed by a new growth, which may also involve the 
 sixth and eighth nerves. Within the Fallopian canal the seventh nerve 
 may be encroached upon by caries of the temporal bone from middle-ear 
 disease. It may be damaged in operations. 
 
 Bell's Palsy. — This affection is ascribed to neuritis from exposure. 
 The nerve swells in its bony case and is compressed. The corresponding 
 half of the face is rapidly paralyzed. 
 
 Symptoms. — The lines of expression are smoothed out; the mouth 
 droops on that side, and the lower eyelid sags and lets the tears run down. 
 In "showing the teeth," the mouth and cheek are dragged toward the 
 sound side; in looking up. the forehead does not wrinkle on the affected 
 side; and in the attempt to close the eye, the lids remain apart. 
 
DISEASES OF THE CRANIAL NERVES. 1311 
 
 The palate moves sj^mmetrically and the tongue is protruded in the 
 middle line, though by the distortion of the mouth it appears to deviate. 
 Liquid, in drinking, or saliva runs from the corner of the mouth, and in 
 chewing the food gathers in the cheek. The sense of taste on the front of 
 the tongue, supplied by the chorda tympani, is impaired in some cases, as 
 this nerve accompanies the facial within the Fallopian canal for a short dis- 
 tance. The reaction of degeneration occurs typically in facial palsy. 
 Both nerve and muscle show diminishing irritability to faradism after a 
 few days, while to galvanism the muscle contracts excessivel}", and in the 
 serial order of the reaction of degeneration. Bell's palsy is rarely sudden, 
 but usually rapid, developing in a few hours or days. It lasts ordinarily 
 two or three months. In severe cases, after four or five months, contrac- 
 tures of the affected muscles deepen the lines of expression, so that the 
 face appears normal or the sound side looks weaker. 
 
 Diagnosis. — In recent cases the condition is obvious. In older ones 
 the muscular contracture and overaction may conceal it; but strong 
 movements in showing the teeth or closing the eyes will show the difference 
 of the two sides. Cerebral (supranuclear) paralysis of the facial is usually 
 a part of hemiplegia. In this form the upper half of the face (orbicularis 
 palpebrse, frontalis, and corrugator supercilii) regains power in a few clays, 
 through its bilateral innervation from the cortex; and even the lower half 
 moves fairly with emotion, as in quiet smiling. In the cerebral form the 
 supra-orbital reflex is preserved. Lesion at the base of the brain is indicated 
 by concomitant paralysis of adjacent nerves, particularly the sixth and 
 eighth. Deafness with facial palsy may result from tumor also involving 
 the eighth nerve. In peripheral (nerve-trunk) palsies the entire half of 
 the face is affected for all movements, voluntary or emotional, and the 
 electrical reaction shows degeneration. 
 
 Prognosis. — Early return of power though slight is a good sign. Toward 
 the end of the second week of paralysis an electrical examination gives valu- 
 able information. If at this time the faradic irritability is simply lessened, 
 the paralysis will disappear in about two months; if lost, the outlook is 
 bad, though some return of power is possible after several months. With 
 the loss of faradic irritability occur the true reactions of degeneration to 
 the galvanic current. 
 
 Facial Spasm. — As a symptom this occurs in epilepsy and chorea, in 
 facial paralysis, in cerebral palsies as a part of athetosis, and as habit 
 spasm. The habitual occurrence of spasm in one or several muscle-groups 
 of the face is called convulsive tic. The orbicularis palpebrse and the zygo- 
 matics are its most frequent seat. Convulsive tic is a disease of later middle 
 life (forty-five to sixty) more frequent in women. Prolonged anxiety is a 
 factor; also, reflexly, a great variety of painful affections, as caries of a tooth. 
 
 Symptoms. — In the usual form of convulsive tic the eye is squeezed 
 shut and the angle of the mouth drawn out and up momentarily at inter- 
 vals. It is generally made worse by disturbing emotions. The spasm 
 may be more extensive, involving other muscles of the face, mouth, 
 neck, or arms, and especially in the platysma, which stands out on the side 
 of the neck. In severe cases the spasm occurs in numerous quick jerks 
 or frequently repeated contractions in the course of two or three minutes. 
 
1312 MEDICAL DIAGNOSIS. 
 
 Convulsive tic, usually slight at first, increases gradually in the intensity 
 and frequency of the spasm, and in the extent of the musculature involved. 
 It is likely to continue indefinitely, but sometimes ceases after years. 
 Intermissions of several months may happen. 
 
 Diagnosis. — Facial spasm is unmistakable. The spasm may be symp- 
 tomatic of some gross disease. True convulsive tic is idiopathic. Sources 
 of reflex irritation in the teeth, eyes, etc., must be investigated. Intra- 
 cranial disease, causing facial spasm, may be tumor or other lesion of the 
 face centre in the cortex, or of the root of the seventh nerve beneath the 
 pons. From such a cause the affected muscles often will be found paretic, 
 or will become paralyzed. 
 
 VI. EIGHTH NERVE. 
 
 The auditory nerve is physiologically two nerves — the cochlear for 
 hearing, the vestibular for equilibration. From the distributions in the 
 internal ear (the cochlea and the semicircular canals) the two parts, 
 united as the eighth nerve, pass from the internal auditory meatus into 
 the side of the pons. Here the two parts of the nerve, again separating, 
 embrace the inferior cerebellar peduncle, the cochlear on its outer side, 
 the vestibular on the inner, to connect with various nuclei in the pons 
 and thence to seek different central goals. The cochlear fibres pass up in 
 the lateral fillet, and by way of the postgeminum and postgeniculum reach 
 the auditory centre in the first temporal convolution. The vestibular 
 fibres pass to the middle lobe of the cerebellum. 
 
 Deafness. — Total deafness from birth or early childhood, depriving 
 the child of speech, constitutes deaf-mutism. Acquired deafness fre- 
 quently depends on disease of the labyrinth; but this is often secondary 
 to middle-ear disease, particularly of the chronic catarrhal variety, or to 
 meningitis by extension through one of the foramina. Basal fracture 
 often enters the internal ear; The eighth nerve at its junction with the 
 pons may be involved in meningitis, aneurism, or tumor, particularly 
 fibroma of the nerve sheath. Degenerative disease, as tabes, may attack 
 the eighth nerve. Pontine lesions rarely affect this nerve; but at the 
 level of the posterior geminum, in the hinder part of the internal capsule 
 or in the first temporal convolution, the auditory pathway may be dam- 
 aged by tumor, hemorrhage, softening, etc., causing deafness of the oppo- 
 site ear. Impaired hearing may be functional, as in hysteria. 
 
 Symptoms. — If no objective signs of obstruction of the external 
 meatus or disease of the middle ear are present, deafness may be ascribed 
 to conditions which affect the reception of sound in the labyrinth or its 
 conduction by the auditory nerve, or to lesions involving the central audi- 
 tory tract. This is especially the case when the deafness is unilateral. 
 When the sound of a tuning-fork held against the mastoid process — bone 
 conduction — has ceased to be heard but is again perceived when the 
 instrument is • moved to a position opposite the external meatus — aerial 
 conduction — labyrinthine disease may be suspected. When in unilateral 
 deafness the sound of a tuning-fork in contact with the vertex at the 
 middle line is perceived more distinctly on the side of the deaf ear, the 
 
DISEASES OF THE CRANIAL NERVES. 1313 
 
 fault of hearing is due to the conducting apparatus; when it is heard 
 more distinctly or only in the sound ear the deafness is caused by laby- 
 rinthine disease. In the latter condition there is an interval varying from 
 one to several seconds between the time at which the patient ceases to 
 hear the sound and the examiner ceases to feel the vibrations of the fork. 
 There are no direct means by which deafness arising from lesion of the 
 auditory nerve in its course can, in the absence of the signs of involvement 
 of adjacent structures, be distinguished from that caused by disease of the 
 auditory centres. 
 
 The locality of the eighth nerve-root, spoken of as the pontocerebellar 
 angle, is a favorite seat of tumor (fibroma) which grows from the sheath 
 of this nerve. This is recognized by its pressure-effects, paralysis of the 
 facial and external rectus on the same side, deafness, vertigo, and inco- 
 ordination, the latter partly of cerebellar origin. Deafness from a higher 
 seat, the quadrigeminal region, or the internal capsule (posterior extremity) 
 is usually associated with hemianopsia, and sometimes with other disturb- 
 ances on the same side. Cortical deafness is likely to be of special char- 
 acter (word-deafness, etc.) related to aphasia. Sudden deafness indicates 
 a vascular lesion, especially hemorrhage, most frequently in the internal 
 ear. Hysterical deafness may be recognized by the associated symptoms. 
 
 Auditory Irritation. — Uncomfortable acuteness of hearing (hyper- 
 acusis) is ordinarily hysterical, though observed occasionally in facial 
 palsy. Tinnitus aurium embraces simple subjective noises, as ringing, 
 hissing, and roaring, referred either to the ear or to some part of the head. 
 More elaborate sounds, as words seemingly spoken in the ears, in other 
 parts of the body, or at a distance, are called auditory hallucinations. 
 Tinnitus is a common symptom in the various diseases of the internal ear, 
 as well as of the middle ear and external meatus. Tinnitus may arise 
 especially in elderly persons, without definite cause. It is common in 
 neurasthenia. In some cases it has a pulsating character, and is then 
 referred to vasomotor disturbance in the internal ear. Head injuries, 
 sudden loud noises, and, above all, the habitual subjection to noise (as in 
 boiler-makers) dispose to it. Tinnitus is commonly associated with partial 
 deafness, but may be accompanied by hyperacusis. 
 
 Diagnosis. — Irritation of the cortical centre (first temporal convolu- 
 tion) is a cause of hallucinations of hearing, not of simple tinnitus. Tinnitus 
 due to irritation of the eighth nerve-trunk is known by the associated 
 symptoms. Disease of the internal ear is the commonest cause. 
 
 Prognosis. — In a case of organic origin the prognosis is that of the 
 primary disease. In functional disease, like neurasthenia, the symptom 
 subsides as the patient improves. In some instances tinnitus is stubbornly 
 persistent. 
 
 Meniere's Disease. — An affection characterized by noises in the ear, 
 sudden attacks of vertigo with nausea and vomiting, and nervous deafness, 
 which in many cases is progressive. The attacks are often apoplectiform, 
 with momentary loss of consciousness. 
 
 This disease was first described by Meniere in 1861. The term should 
 be restricted to the affection characterized by the complexus of symptoms 
 about to be described. 
 83 
 
1314 MEDICAL DIAGNOSIS. 
 
 Etiology. — Age plays an important part in the predisposition. The 
 affection is very rare in early life. In a large proportion of the cases the 
 attacks first show themselves between forty-five and fifty-five, but they 
 may come on much later. Men suffer more frequently than women. 
 Nothing is known of the exciting causes. 
 
 Symptoms. — The disease is paroxysmal, the attacks occurring at 
 irregular intervals, and very often in series, several of which may take place 
 in one day or on successive days. Such series or single attacks may be 
 separated by intervals of weeks or even months. The attack begins sud- 
 denly with tinnitus aurium and subjective or objective vertigo of such 
 intensity that the patient, in order to prevent himself from falling, is obliged 
 immediately to catch some support or to sit or lie down. If loss of con- 
 sciousness occurs it is momentary. Occasionally ocular symptoms accom- 
 pany the attack. These consist of diplopia or nystagmus. Forced move- 
 ments may occur, and in the intervals of frequent attacks there is an 
 impairment of equilibrium, so that the patient walks with difficulty. The 
 attack is usually of short duration. As the vertigo passes off the patient 
 is pale, breaks into a profuse sweat, suffers from nausea, or there may be 
 actual vomiting. As a rule, there is no disease of the middle ear. When 
 it is present the association is accidental. The deafness, which is nervous, 
 usually affects one ear only. It is progressive but never complete. When 
 deafness becomes complete the vertigo ceases, the end organs of the nerve 
 being destroyed. 
 
 Three principal theories have been suggested to account for the phe- 
 nomena of Meniere's disease: 1. That the symptoms are due to lesions 
 of the labyrinth. There is progressive degeneration of the nerve or its 
 end organs. 2. That the disease is a vasomotor neurosis of the vessels of 
 the labyrinth. 3. That the primary trouble consists in an affection of the 
 centres for hearing and equilibration. Of these the first is at present 
 generally accepted. 
 
 Diagnosis. — The direct diagnosis of Meniere's disease rests upon the 
 paroxysmal vertigo, the apoplectiform seizure, the occurrence of tinnitus, 
 nausea, and vomiting, and the progressive nervous deafness. The differen- 
 tial diagnosis between the vertigo which is so prominent a symptom and 
 other forms of vertigo depends upon the association of the foregoing symp- 
 toms, the paroxysmal nature of the attack, and the absence of other 
 pathological states usually attended with vertigo. 
 
 Prognosis. — This is uncertain. A small proportion of the cases termi- 
 nate, after a variable duration, in complete recovery, with total loss of 
 hearing in the affected side. More commonly the disease proves persistent 
 and intractable, and, with periods of exacerbation and improvement for 
 which no explanation is to be found, continues throughout life. In rare 
 instances the symptoms are so severe that the patients become bed-ndden. 
 
 VII. NINTH NERVE. 
 
 The ninth, tenth, and eleventh nuclei form a continuous chain of gray 
 matter, and the nerves a continuous hne of fibres springing from the 
 side of the medulla, in the order of their numbering. The ninth or 
 
DISEASES OF THE CRANIAL NERVES. 1315 
 
 glossopharyngeal, mainly sensory, supplies the back of the tongue, the 
 soft palate, tonsils, and adjacent pharynx, with the Eustachian tube 
 and middle ear. The muscles of the upper pharynx are probably governed 
 by the ninth. 
 
 Tumors or meningitis affect the ninth usually in company with other 
 nerves. Swallowing is embarrassed by lesions of the nerve-trunk or, as in 
 glosso-labio-laryngeal paralysis, by degeneration of its nucleus. 
 
 VIII. TENTH NERVE. 
 
 The tenth nerve, termed the pneumogastric or vagus, arises in the 
 medulla by a line of nuclei and fibres continued downward from those of 
 the ninth. It is the chief of the "bulbar" nerves in the variety and 
 importance of its functions, supplying motor fibres to the muscles of the 
 pharynx, oesophagus, stomach, and intestines, and to those of the larynx, 
 trachea, and bronchi; sensory fibres to the dura mater, external ear, 
 pharynx, oesophagus, stomach, larynx, trachea, bronchi, and the peri- 
 cardium; and spinal fibres to the heart, liver, spleen, pancreas, kidneys, 
 suprarenal bodies, and intestinal blood-vessels. The "respiratory centre" 
 and "cardiac centre" are thus contained in the vagus nucleus, though for 
 these vital functions, as for vasomotor regulation and for the movements 
 of the stomach and intestines, the sympathetic acts in connection with 
 this nerve. 
 
 The tenth nucleus may be implicated in softening, hemorrhage, or 
 tumor of the medulla, usually with adjacent nuclei, inducing paralytic 
 effects in combination known as "bulbar symp'toms." Degeneration of 
 the tenth nucleus in glosso-labio-laryngeal paralysis (chronic bulbar palsy) 
 and its inflammatory destruction in acute bulbar palsy are responsible 
 for the impaired phonation, difficult swallowing (mainly), and embarrassed 
 cardiac and respiratory action. In cerebral disease, particularly bilateral 
 softening in the neighborhood of the internal capsules, these symptoms are 
 due to the destruction of the motor fibres destined to these nuclei (pseudo- 
 bulbar paralysis). The root of the vagus may be the source of these symp- 
 toms in like combination from basilar meningitis, tumor, or aneurism of 
 the vertebral artery. 
 
 In the neck the nerve-trunk accompanying the carotid, or lower down 
 winding over the subclavian, may be compressed by an aneurism or tumor, 
 or damaged in operation. This nerve is involved in toxic or infectious 
 neuritis more frequently than is ordinarily thought. The affection of the 
 pneumogastric nucleus or trunk may be of a degree to induce irritative 
 symptoms (slowness of the heart's action, spasm of the larynx, and 
 vomiting), or paralytic symptoms (paralysis of the larynx, embarrassed 
 respiration, and rapid pulse). 
 
 The inferior or recurrent laryngeal nerve, branching from the tenth at 
 the base of the neck, winds around the great vessels — the aorta on the left, 
 the subclavian on the right side — and ascends back of the trachea to the 
 larynx, of which it supplies the most important muscles. 
 
1316 
 
 MEDICAL DIAGNOSIS. 
 
 IX. ELEVENTH NERVE. 
 
 The accessory fibres of the. spinal accessory join the vagus nerve, of 
 which they form mainly the recurrent laryngeal branch. The spinal por- 
 tion, composed of several motor roots of the cervical cord, forms part of 
 the cervical plexus and supplies the sternomastoid and the upper portion 
 of the trapezius muscle. Spasm of these muscles causes torticollis. 
 Paralysis of the muscles suppHed by the spinal accessory results from 
 degeneration of the cervical gray matter in progressive muscular atrophy, 
 from lesion of the trunk, in meningitis or brain tumor, and from wounds, 
 tumors, vertebral disease, etc., in the neck. Paralysis of the sternomastoid 
 alone may result from a wound of this muscle, severing the nerve-trunk 
 within it. In paralysis of one spinal accessory, the head cannot be turned 
 to the other side, the sternomastoid and the upper border of the trapezius 
 are relaxed and in time wasted, and all movements about the shoulder, as 
 raising the arm, are embarrassed. When this paralysis is bilateral the 
 head falls backward or forward, according as the sternomastoid or the 
 trapezius is more affected. 
 
 Bilateral paralysis of the spinal accessory is conspicuous in menin- 
 gitis, especially the tuberculous form of childhood, and in progressive 
 muscular atrophy. Lesion of the nerve at the base of the brain, 
 including the accessory part (laryngeal fibres), paralyzes the vocal cords, 
 
 and is likely at the same time to 
 implicate the hypoglossal or the glosso- 
 pharyngeal and paralyze the tongue 
 or the palate. 
 
 Torticollis or Wry=neck — Acces= 
 sory Spasm. — True torticollis is a devi- 
 ation of the head due to abnormal action 
 of the muscles supplied by this nerve. 
 It may be a fixed deformity — congenital 
 wry-neck — or due to spasm — spasmodic 
 wry -neck. In congenital torticollis 
 there is atrophy of neck muscles, prin- 
 cipally the sternomastoid, in conse- 
 quence of prenatal poliomyelitis or of 
 injury to the muscles during labor. 
 Contraction of the sternomastoid tilts 
 the head toward the affected side and 
 at the same time rotates the face 
 toward the opposite side. The muscle 
 stands out rigid. 
 
 Spasmodic torticollis is of the 
 nature of facial tic, and like it may be 
 either tonic or clonic. The position of 
 the head ordinarily is governed by the sternomastoid, but in some cases 
 there is backward tilting in consequence of contraction of the trapezius. 
 When the affection is bilateral the trapezii draw the head backward, — 
 retrocollic spasm, — aided by both sternomastoids, and the frontales 
 
 Pig. 390. — Torticollis (Jochimsthal). — Young. 
 
DISEASES OF THE CRANIAL NERVES. 1317 
 
 muscles in association raise the eyebrows. Spasmodic torticollis appears 
 usually in middle life, is more frequent in women, and has been ascribed 
 to a variety of causes. Its source in typical cases is probably cortical. 
 It may be ushered in by pain and stiffness about the neck, but as a rule 
 the spasm sets in gradually. It generally centres in the sternomastoid 
 and may be confined to it, but the trapezius of the same side and the 
 splenius of the other are commonly associated with the sternomastoid 
 in spasm. The head is tilted sidewise and slightly backward and twisted 
 to the other side, more frequently the left. 
 
 In bilateral (retrocolhc) spasm the face is turned upward and the eye- 
 brows raised synchronously. Ordinarily with the tonic variety of torticollis, 
 as it becomes intense, clonic spasms are associated. The intensity varies, 
 and intermissions are frequent. The affection may involve various muscles 
 of the arm or face. The affected neck muscles hypertrophy in time. 
 
 The diagnosis is obvious. The rotation of the head to one side and its 
 sHght inclination to the other side, on which the sternomastoid muscle 
 stands out prominently, especially when this position is emphasized by 
 clonic jerkings, cannot be mistaken. So-called rheumatic torticollis, 
 *' stiff-neck," is marked by its acute appearance, often after exposure, with 
 lameness and tenderness of the neck muscles. "False torticollis" is an 
 unnatural position of the head from gross disease in the neck, most fre- 
 quently of vertebrae, as Pott's disease and spondylitis deformans. In these 
 conditions the sternomastoid is prominent on the side to which the head is 
 turned. Hysl^erical torticollis occurs in younger persons with other signs 
 of hysteria. True torticollis is more common in middle life. 
 
 Congenital torticollis may be relieved by operation. Spasmodic tor- 
 ticollis is chronic and intractable. Often after increasing for years it 
 becomes stationary. There are cases in which remissions are frequent 
 and intermissions occur, sometimes lasting many months. The disease 
 is of no consequence beyond annoyance and embarrassment. Patients 
 sometimes complain of fatigue or pain in the affected muscles. 
 
 X. TWELFTH NERVE. 
 
 The hypoglossal nerve, governing the muscles attached to the hyoid 
 bone, controls the movements of the tongue. Within the cranium and 
 in the upper part of the neck it is near the pneumogastric and spinal acces- 
 sory nerves, with which it often is associated in disease, and the lips have 
 some nuclear connection of movement with the tongue. In bulbar paraly- 
 sis, acute and chronic, the hypoglossal nuclei are a focus of the disease; 
 and they occasionally are degenerated in tabes and paresis. In hemiplegia 
 the cerebral — supranuclear — fibres for the tongue are commonly included 
 in the lesion between the lower part of the motor cortex and the hypo- 
 glossal nucleus in the medulla. The roots in the medulla may be damaged 
 by hemorrhage or by tumor, which usually implicates the main pathway 
 to the opposite arm and leg; or the roots emerging from the medulla may 
 be involved, often with the tenth and eleventh, in meningitis, syphilis, or 
 tumor. In the upper part of the neck various gross diseases or wounds 
 may injure the hypoglossal trunk with the spinal accessory. 
 
1318 MEDICAL DIAGNOSIS. 
 
 Paralysis of the tongue without sensory disturbance is the effect of 
 hypoglossal lesion. When this is bilateral the tongue is motionless. When 
 paralyzed on one side the tongue^ protruded, curves toward the affected 
 side, speech is thick, and chewing is awkward. The affected half in time 
 wastes, shows fibrillary tremors, and is puckered with transverse folds. 
 When the lesion is nuclear, as in bulbar palsy, the lips share in the atrophy; 
 when it is cerebral the tongue shows no trophic change. Associated 
 particularly with double hemiplegia, paralysis of the tongue, with other 
 bulbar symptoms, constitutes ''pseudobulbar paralysis." 
 
 Paralysis of the tongue from cerebral disease is commonly a part of 
 hemiplegia. Nuclear palsy is generally bilateral and a part of "bulbar 
 palsy," recognizable by its combination of paralyses with atrophy, in 
 particular of the tongue. The similar combination of palsies in pseudo- 
 bulbar paralysis is not associated with atrophy nor with evidence of hemi- 
 plegia weakness.- Paralysis of one-half of the tongue and of the opposite 
 arm and leg — a form of crossed paralysis — indicates a lesion of the medulla 
 at the level of the hypoglossal nucleus on the side on which the tongue is 
 paralyzed and wasted. Paralysis of half the tongue, usually with atrophy, 
 and associated by implication of the spinal accessory, with paralysis of 
 the palate and vocal cord on the same side (Hughlings Jackson), points 
 to lesion of the nerve within the skull or in the upper part of the neck. 
 The prognosis depends on the seat and character of the lesion. As a rule, 
 it is unfavorable; the likelihood of improvement is slight, even in the 
 syphilitic cases. # 
 
 Spasm of the tongue is an incident of the epileptic convulsion and of 
 chorea. It occurs ailso as a rare phenomenon in hysteria. 
 
 DISEASES OF THE SPINAL CORD. 
 
 I. SPINAL MENINGITIS. 
 
 Two varieties are usually mentioned — leptomeningitis, inflammation 
 of the pia and arachnoid, and pachymeningitis, inflammation of the dura. 
 Syphilis causes a meningomyelitis in which both membranes may be 
 involved. Tuberculous meningitis of the cord is very rare, unless asso- 
 ciated with the same affection of the brain. A meningomyelitis is caused 
 by spinal caries, and in these cases the cord as well as the membranes 
 is involved. Cerebrospinal fever is an acute infectious disease which 
 involves the membranes of both the brain and cord. There is an affec- 
 tion called hypertrophic pachymeningitis, especially of the cervical region, 
 in which the dura is much thickened and the cord more or less involved; it 
 is sometimes caused by trauma, but in many cases the causation is not 
 clear. Purulent meningitis of septic origin is common; sometimes such 
 an infection extends from the membranes of the brain, as after an otitis 
 media; or from the pelvis, as in the puerperium.' A pneumococcus 
 infection occurs. 
 
 Pathology. — The membranes are congested, thickened, and some- 
 times covered with a fibrinous or purulent exudate. The nerve-roots are 
 
MYELITIS. 1319 
 
 often implicated, and the cord itself may be involved in various degrees. 
 The offending microbe can often be isolated after a lumbar puncture. 
 
 Symptoms. — Irritation of the nerve-roots is an early symptom; hence 
 there are pain, stiffness of the back, opisthotonos, contractures of muscles, 
 and even slight clonic spasms. Kernig's sign is usualty present. Later in 
 the case there may be pressure symptoms, as paralysis and anaesthesia. 
 In very acute cases there may be chill and fever. 
 
 Pachymeningitis cervicalis hypertrophica is an affection almost sui 
 generis, especially as caused by trauma. It may closely resemble syrin- 
 gomyeha. There is flaccid atrophic paralysis of the shoulders and arms, 
 spastic paralysis of the lower limbs, and, in some cases, the disso- 
 ciation symptom, that is, abolition of the pain and thermal senses with 
 preservation of the tactile sense. There may also be pain and stiffness 
 about the neck. 
 
 Diagnosis. — It is scarcely possible to distinguish a- pure meningitis 
 from a meningomyelitis; the symptoms of disease of the membranes are 
 likely to be associated with some evidence of implication of the cord. 
 Where symptoms of irritation predominate, as pain, stiffness, hyperses- 
 thesia, etc., we may suspect that the membranes are the more concerned. 
 Later, when paralysis and anaesthesia with incontinence appear, we inter- 
 pret these symptoms to mean that the cord is involved. The eccentric 
 pains, felt at points in the chest or abdomen, may suggest some deep- 
 seated visceral disease, but the diagnosis can usually be made from the 
 associated symptoms. The determination of syphiHs as a cause of men- 
 ingitis is always of first importance. The history of the case may point 
 that way, but it is not always to be reHed on, especially when it is 
 negative. 
 
 II. MYELITIS. • 
 
 This term should be restricted to true inflammation of the spinal 
 cord. In the past, however, it has been loosely used for a variety of 
 lesions, such as softening and the destructive effects of trauma. When 
 the term is properly restricted it will be found that genuine myelitis 
 is not a common affection. 
 
 Etiology. — This disease is doubtless due in every case to some form 
 of infection or toxaemia. The old ideas that it was caused by exposure 
 to cold, to worry, to sexual excesses, and other such far-fetched notions 
 are no longer credible. At most, cold can act but as a predisposing cause. 
 It is even doubtful whether alcohol causes myehtis. * SyphiHs undoubtedly 
 causes a meningomyelitis, but this is such a distinct affection that it is 
 treated under a separate heading. Among the causes assigned are the 
 infectious diseases, such as septic infection, varicella, gonorrhoea, and 
 measles. It is claimed that malaria may cause it. Typhoid fever and 
 smallpox may cause multiple neuritis, which might be mistaken for myeli- 
 tis by a careless observer. In fact, these two latter diseases must be care- 
 fully distinguished. A destructive myehtis may be caused by spinal caries 
 of tuberculous origin, but otherwise tubercle does not often attack the 
 cord. Injury may cause extensive lesions in the spinal cord, and these 
 may become secondarily infected, but they are not primarily inflamma- 
 
1320 MEDICAL DIAGNOSIS. 
 
 tory, nor do they become so in every case. Cancer of the vertebra may 
 also cause myelitis. There are also special forms of myelitis, such as the 
 anterior poliomyelitis, or inflammation of the anterior horns of the gray 
 matter, but these affections are described apart. Finally, cases occur in 
 which acute transverse softening is found post mortem, suggesting the 
 idea of acute infection, but the cause is obscure. In fact, not a few cases 
 of myehtis, and myelitic softening, cannot be satisfactorily accounted- for. 
 
 The spinal membranes are often involved in cases of myelitis, so that 
 in effect the condition is one of meningomyelitis, and the cause, whatever 
 it be, may act primarily on the membranes. 
 
 Pathology. — This disease may be transverse, focal, disseminated, or 
 diffused. In transverse myelitis the lesion implicates the whole thickness 
 of the cord, but it may be comparatively limited in its upward and down- 
 ward extent; in fact, not more than one, two, or three segments may be 
 involved. Focal myelitis, described by some authors, is much more rare; 
 as the name imphes, the lesion is discrete; and in the disseminated variety 
 there are more than one such lesion scattered in various places in the cord. 
 Diffused myelitis is merely that variety in which the inflammatory process 
 is more widely and continuously extended. The inflamed area may be 
 variously discolored; in some cases it is congested and bright red or pink, 
 in others rather yellowish, in others white. Its consistence varies, but 
 it is usually softer than the normal cord, and it may be so soft as to 
 flow out under the knife. This is the condition often called "white" or 
 "red" or "yellow" softening. The color is merely due to the elements of 
 the blood contained in the softened area. The tissue is usually necrotic, 
 but it is not necessarily purulent. Pus-cells may, however, be found. The 
 membranes may or may not be involved, congested, and thickened, and 
 there are cellular infiltration and thickenin oi the blood-vessels. 
 
 Symptoms. — It is best to describe the symptoms of myehtis according 
 to the level at which the lesion is located. 
 
 If the lesion is in the cervical region, all the functions of the cord below 
 that point may be partly or entirely involved. There will be spastic paral- 
 ysis in the lower limbs, exaggerated knee-jerks and other reflexes, ankle 
 clonus, and Babinski's reflex; incontinence of urine and faeces, if the 
 lesion is transverse or even extensive; anaesthesia to all modes of sensa- 
 tion; possibly bed-sores; in the upper limbs also spastic paralysis, 
 unless the anterior horns of gray matter in the cervical enlargement are 
 involved, in which case there may be, especially in chronic cases, extensive 
 muscular atrophy, even with fibrillation, in the shoulders, arms, and 
 hands, with flaccid paralysis. Anaesthesia is also more or less complete 
 in the trunk, arms, and hands, and the muscles of respiration may be 
 involved. If the lesion extends to or above the fourth segment there 
 is danger of death from involvement of the phrenic nerve. There may be 
 a girdle sense in the neck or upper part of the chest. As a rule, pain is not 
 an urgent symptom, unless the membranes and nerve-roots are implicated. 
 The pupils may be dilated or contracted, according as the oculopupillary 
 centre is irritated or paralyzed. A total transverse lesion abolishes 
 all functions below its level, but such a lesion in the neck is seldom 
 compatible with prolonged life. 
 
MYELITIS. 1321 
 
 In the dorsal region the lesion causes symptoms in the trunk and 
 lower limbs only. There is likely to be a spastic paraplegia, sometimes 
 with contractures, exaggerated reflexes and clonus, Babinski's sign, incon- 
 tinence of urine and faeces, anaesthesia to all modes of sensation, and a 
 girdle sense about the trunk, or pain radiating through the chest or abdo- 
 men, according to the exact level of the inflammation. There may be a 
 zone of hyperaesthesia marking the upper limits of the lesion and caused 
 by irritation of the membranes or nerve-roots. Bed-sores of an aggra- 
 vated type may form. If the lesion is totally transverse these symptoms 
 are absolute; if, however, the lesion involves only certain structures of the 
 cord, the symptoms may vary within wide limits. Thus, motion may be 
 more involved than sensation; control of the bladder may not be entirely 
 lost; the patient may be able to walk with a weak and spastic gait; and 
 pain may not be urgent. In spinal caries the paralysis is often more motor 
 than sensory, due to the bone lesion being located in front of the cord. 
 
 In the lumbar region myelitis causes an atrophic or flaccid paralysis 
 of the lower limbs, due to the fact that the anterior horns of gray matter 
 are involved. There is also paralysis of the bladder and rectum in grave 
 cases, bed-sores, pain in the legs, loss of sensation in the lower trunk and 
 lower limbs, and abohshed knee-jerks. But here as elsewhere the symp- 
 toms will vary somewhat with the extent of the lesion. 
 
 The course of myelitis may be acute or exceedingly chronic. The patient 
 may recover up to a certain point, and then remain more or less perma- 
 nently crippled. Entire recovery is rare. A fatal result is not uncommon. 
 In the myelitis of Pott's disease a good recovery is sometimes obtained. 
 
 Diagnosis. — Myehtis is to be distinguished especially from locomotor 
 ataxia, syringomyelia, and multiple neuritis. It may also closely resemble 
 some forms of syphihs of the cord. When it is due to trauma or spinal 
 caries the cause is usually apparent. 
 
 From locomotor ataxia it is distinguished by the mode of onset, which 
 is usually much more abrupt. There is absence of the fulgurant pains, 
 the peculiar ataxic gait, the swaying with closed eyes, the abolished knee- 
 jerks (unless in lumbar myehtis, in which case, however, there is flaccid 
 paralysis and muscular atrophy in the lower limbs, very different from 
 tabes). There is also absence of the Argyll-Robertson pupil, with optic 
 atrophy; and the paralysis of the bladder and bowel is much more com- 
 jDlete and of earlier onset than in locomotor ataxia. 
 
 In sj^ringomyelia the symptom-complex is quite different from ordi- 
 nary myelitis. There is especially the dissociation symptom, in which 
 the temperature and pain senses are abolished without impairment of tac- 
 tile sensation; also scohosis, arthropathies, and vasomotor changes. The 
 onset is also more gradual than in myelitis; the bladder and bowel are not 
 so likely to be involved. Still, some cases of traumatic meningomj-elitis of 
 the cervical cord closely resemble syringomyelia, and are distinguishable 
 only with care. The history of trauma in these cases is significant. 
 
 In multiple neuritis the symptoms are distinctly- peripheral. The 
 nerve-trunks are involved, and are often painful on pressure. The mus- 
 cular masses, especially the calf, are exquisitely sensitive. The paralysis 
 is flaccid, and the muscles waste. The reactions of degeneration may be 
 
1322 MEDICAL DIAGNOSIS. 
 
 present. The deep reflexes are abolished. The anaesthesia, while present 
 in varying degrees, is not always seen in such extensive areas as in myelitis. 
 The bladder and bowel, as a rule, are not involved. There may be mental 
 symptoms — the so-called Korsakoff's psychosis — and there is a history 
 of exposure to alcohol, to lead, to arsenic, or to diphtheria. 
 
 It is often difficult to say whether or not a myelitis is due to syphiKs, 
 but in some forms of syphilis of the cord the type is quite distinct. In 
 some cases of cord-syphilis, but not by any means in all, there may be, or 
 may have been, some involvement of the cerebrum or cranial nerves. 
 Lumbar puncture may throw some light on the causation and pathology 
 of myelitis. 
 
 The constitutional reaction in myelitis at the beginning is*not marked, 
 except in the acute anterior poliomyelitis of children. There may, how- 
 ever, be some fever and weakness of the pulse. In advanced cases, with 
 bed-sores and incontinence of urine, symptoms of sepsis may occur. Infec- 
 tion of the bladder is always a grave complication. It may be due to 
 the use of the catheter. 
 
 III. ANTERIOR POLIOMYELITIS. 
 
 Inflammation of the anterior horns of gray matter in the spinal cord 
 may occur as an acute or a subacute disease. The acute form is usually 
 a disorder of childhood, although adults are not entirely exempt. In 
 children it is called infantile paralysis. The subacute form is rare, and is 
 usually seen in adults. The disease known as progressive muscular atrophy, 
 or chronic anterior poliomyelitis, is also a disorder of adults, but its inflam- 
 matory nature may be doubted. It is a slowly progressive degeneration 
 of the ganglion cells in the anterior horns. 
 
 The cause of acute and subacute anterior poliomyelitis is now gener- 
 ally believed to be an infection or toxaemia. Infantile paralysis has been 
 known to prevail as an epidemic, as in the instance reported by Medion, 
 in which 44 cases occurred within a few weeks in one town in Sweden. 
 Epidemics have been observed in the United States. A series of 126 cases 
 occurred in Rutland, Vt., in 1894. An epidemic, or very prevalent type, 
 of the disease occurred in New York City in the summer and autumn of 
 1907, and the affection was rather more common than usual in other parts 
 of the United States. Isolated cases sometimes follow the infectious 
 diseases, as measles, scarlet fever, whooping-cough, and diphtheria. 
 
 Pathology. — In the early stage there is hyperaemia of the horns and 
 some congestion of the cord; the ganglion cells are swollen and indistinct; 
 the vessels are engorged, and white cells are seen migrated from them. 
 Later the ganglion cells are atrophied or even entirely destroyed; the 
 nerve fibrils are obliterated, and the horns are reduced in size. The 
 disease may be located in either the cervical or lumbar enlargement. In 
 the subacute form the lesions may be found more extensively spread; the 
 anterior horns in many parts of the cord are involved, and in some cases 
 the neighboring white matter is invaded. 
 
 Symptoms. — Infantile paralysis begins rather abruptly, and with 
 constitutional reaction. There is fever; sometimes moderate stupor and 
 
ANTERIOR POLIOMYELITIS. 1323 
 
 deUrium; and convulsions may occur. Some daj^s may eLipse before the true 
 nature of the disease is recognized, and then it is found that the child is 
 paralj^zed in one or more limbs. This paralysis is flaccid, with abolished 
 reflexes. Pain is not prominent, as a rule, and may even be entirely 
 absent; but in rare cases it may be severe and rheumatoid in character 
 in the early stages. The initial palsy may involve the whole limb, but as 
 time passes a partial recovery takes place, until finally the paralysis is 
 located, and remains stationary, in a few muscles or a group of muscles. 
 There is no anaesthesia in the paralyzed part. The bladder and bowel are 
 not involved. Infantile palsy is a common cause of club-foot, the type 
 of deformity depending upon the group of muscles paralyzed. The reac- 
 tions of degeneration are present, and the muscles do not show fibrillation. 
 In the arm the muscles oftenest damaged are the deltoid, biceps, bra- 
 chialis anticus, and supinator longus. Deformity of the hand is not com- 
 mon. The paralyzed limb does not grow normalh', but remains partially 
 stunted and even shortened. 
 
 In the recent epidemic in Nev\' York bulbar symptoms were some- 
 times seen, even in mild cases in which recovery ensued. Meningeal 
 symptoms, such as pain, rhachialgia, and rigidity, were marked, and 
 sometimes there was photophobia. Nothing was found in the cerebro- 
 spinal fluid or in the blood to show the cause, although the disease 
 had some resemblance to epidemic cerebrospinal meningitis. According 
 to Harbitz and Scheel, the brain and bulb were often involved in epi- 
 demics in Norway. 
 
 The subacute form of this disease is a much more grave affection. It 
 was described by Duchenne, who recognized an ascending and a descend- 
 ing type. In the former the disease begins in the lower extremities, and 
 later invades the upper limbs; in the latter the course is the reverse; but 
 some of Duchenne's cases may have been instances of Landry's disease. 
 The paralysis in genuine cases is characteristic of a lesion of the anterior 
 horn; the muscles become atrophied, and they may show fibrillation. 
 Bramwell points out that the paralysis precedes the atrophy, that the 
 reflexes are abolished, and the reactions of degeneration are present. In 
 cases in which recovery occurs there may be permanent parah'sis in some 
 muscles. Sensory and bladder symptoms are wanting. Bulbar symptoms 
 have been reported. The disease is rare. 
 
 Diagnosis. — Infantile paralysis in its initial stage may be mistaken 
 for an acute febrile infection, or, if a fit occurs, for infantile convul- 
 sions; and the paralysis may be overlooked for several days, especially 
 in very young children. After the paralysis is noted the disease is not 
 likely to be mistaken. The flaccid palsy, the abolished reflexes, the onset 
 of wasting, all coming on after the symptoms of an acute infection, 
 without anaesthesia, and limited to one limb or part of one limb, are 
 unmistakable. The disease may also resemble multiple neuritis, which is 
 sometimes seen in children; but multiple neuritis is more wide-spread and 
 symmetrical, pain in the affected limbs is more common, the cause may 
 be traced in some poison, and complete recovery may occur. 
 
 The subacute form in adults bears a resemblance to multiple neuritis, 
 but the fibrillation in the muscles, and the absence of sensory symptoms 
 
1324 MEDICAL DIAGNOSIS. 
 
 and of pain on pressure over nerve-trunks and muscles, serve to distinguish 
 it. The reactions of degeneration may not be so promptly estabhshed as 
 in multiple neuritis. 
 
 The resemblance of the subacute form to Landry's paralysis may be 
 close; but the latter is a more acute affection, and the tendency to a 
 fatal ending is more marked. Fibrillation is not seen in Landry's disease, 
 but neither is it reported in all cases of subacute inflammation of the 
 anterior gray horns. The two affections have not a little in common. 
 
 In myasthenia gravis there is the rapid exhaustion on exertion, and 
 the affected muscles do not atrophy or show fibrillation. In all these three 
 affections, namely, subacute anterior pohomyelitis, Landry's paralysis, 
 and myasthenia gravis, the exact causation and pathology are not yet 
 clearly understood; they seem to depend on a poisoning of the motor 
 neurons, or, in the case of myasthenia gravis, on some affection of the 
 muscular fibres, and the motor symptoms are not altogether dissimilar. 
 
 IV. ACUTE ASCENDING PARALYSIS. 
 
 This disease was first described by Landry in 1859, and is usually 
 called by his name. It was for a long time depicted as a disease without 
 a pathology, but the more refined methods of recent days have tended 
 to make it out an affection of the peripheral motor neurons. 
 
 Pathology. — We cannot claim that the pathology of Landry's paraly- 
 sis is satisfactorily established. Some observers, as Bailey and Ewing, 
 have found changes in the ganghon cells in the anterior horns of gray 
 matter and in the bulb. Among these changes are chromatolysis and 
 swelhng of the axis-cyhnder; also foci of inflammation and capillary hem- 
 orrhages in the cord and medulla oblongata. Changes have also been 
 found in the peripheral nerves. The cause is unknown. 
 
 Symptoms. — The disease usually begins as a flaccid paralysis in the 
 lower Hmbs, and extends upward, involving the muscles of the trunk, the 
 arms, and finally the bulb. Anaesthesia is not present, although there 
 may be some shght dulness or retardation of sensation. The muscles do 
 not waste perceptibly, but in rapidly fatal cases there is not time. The 
 electrical reactions may be preserved. There is no incontinence, as a rule, 
 although exceptions occur. In some cases the initial symptoms are in the 
 bulb and upper extremities — the descending type. The mind is not 
 affected. Fever is not common, although some rise in temperature is 
 occasionally noted. There may be hyperidrosis. The course of the disease 
 is sometimes very rapid. Death results from exhaustion and asphyxia. 
 A few recoveries have been claimed. 
 
 Diagnosis. — Landry's paralysis resembles a rapidly fatal multiple 
 neuritis more than anything else, and if the pathology be proved to be 
 a toxic affection of the motor neurons, it is almost identical with neuritis, 
 except that the usual sensory symptoms are almost altogether wanting. 
 It is not hkely to be confounded with any other disease, unless it be with 
 myasthenia gravis, in which the history and course are different and the 
 exhaustion symptom is marked. It is possible, however, that in myas- 
 thenia gravis there may be some involvement of the motor neurons. 
 
PROGRESSIVE MUSCULAR ATROPHY. 1325 
 
 V. PROGRESSIVE MUSCULAR ATROPHY. 
 
 This is a degenerative process in the spinal cord, usually chronic, 
 which affects chiefly the anterior horns of gray matter, especially in 
 the cervical region. This is the disease called, from its anatomy, chronic 
 anterior poliomyelitis; and from its clinical form, progressive muscular 
 atrophy. 
 
 Pathology. — Chronic anterior poliomyehtis is a destructive process 
 which invades the anterior horns of gray matter. Whether it is an 
 inflammatory process may well be doubted. It has the appearance under 
 the microscope of being a degeneration of the motor neurons. Thus the 
 large ganglionic cells are shrunken or even destroyed, the interlacing 
 nerve fiibrils of the anterior horns are obliterated, and these horns are 
 smaller than normal. Thus far the anatomical picture is simple. But 
 there are cases in which this identical process is found, and in which is 
 seen in addition a degeneration of the lateral, or crossed, pyramidal 
 tracts. Where this association exists the clinical form differs, for in addi- 
 tion to muscular atrophy there is seen a spastic paralysis with exaggerated 
 reflexes. This latter affection has been given a distinct name — amyo- 
 trophic lateral sclerosis — and is described in most text-books as a distinct 
 disease. Some neurologists believe these two so-called diseases are merely 
 different forms of the same pathological process. They may be right, but 
 for convenience' sake and to conform to custom the two affections will 
 here be described separately. It is to be remembered in any case that 
 these two clinical forms represent disease of the motor neurons: in 
 anterior poliomyelitis it is the neurons of the lower order which are 
 affected, whereas in amyotrophic lateral sclerosis not only the neurons 
 of the lower, but also those of the upper order are involved.^ 
 
 Symptoms. — The disease usually begins with wasting of the muscles 
 of the hands, especially of the thenar and hypothenar groups, and the inter- 
 ossei. Later the muscles of the forearms become involved, then those of 
 the upper arms and shoulders. This is called the Aran-Duchenne type. 
 Other forms appear, as, for instance, early wasting of the deltoids, supra- 
 and infraspinati, and biceps — the upper arm type. In some rather rare 
 or advanced cases the muscles of the lower limbs are involved. The 
 neck and trunk muscles may also waste. Various deformities occur, such 
 as the claw hand, or ''main en griffe, " in which the proximal phalanges 
 are over-extended and the distal phalanges are flexed; and the so-called 
 monkey hand, or "Affenhand" of the Germans, the ''main de singe" of 
 the French, which is caused by overaction of the long extensor of the 
 thumb, causing the metacarpal bone to be displaced backward and to lie 
 in the same plane as the metacarpal bones of the fingers. In the lower 
 limbs various forms of club-foot result. As the wasting progresses, loss 
 of power occurs, until in advanced cases the wasted arms hang powerless 
 at the sides. In the pure forms, that is, in cases in which the lateral tracts 
 are not involved, there is no spastic paralysis, and the reflexes, either of 
 the arms or legs, are not increased. In advanced cases the reflexes in the 
 
 1 R. T. Williamson: "Amyotrophic Lateral Sclerosis and Progressive Muscular Atrophy " Edinburgh 
 
 Med. Journal, April, 1907, p. 304. 
 
1326 MEDICAL DIAGNOSIS. 
 
 affected muscles may be much diminished or even lost; but this is not 
 invariable, for even in very much wasted muscles a sharp tap will some- 
 times elicit a slight response. The affected muscles are the seat of fibrillary 
 twitchings. The complete reactions of degeneration are not present, 
 although some modal change and partial reaction may be seen in advanced 
 cases. There is no anaesthesia of any kind, nor are the bladder and bowel 
 affected. Scoliosis does not occur. In cases in which the neck muscles 
 are greatly wasted there may be head-drop, but this symptom occurs 
 more frequently in amyotrophic lateral sclerosis. As a rule, there are no 
 bulbar or oculomotor symptoms. The disease may be very chronic, lasting 
 for many years. Some aberrant forms are seen, but the above are the 
 most common types. The disease, as a rule, begins in adult life. It is 
 progressive and incurable. 
 
 Diagnosis. — The distinction has already been made clear between 
 this affection and amyotrophic lateral sclerosis. In the latter disease there 
 is spastic paralysis in addition to the muscular atrophy, and this spasticity 
 with exaggerated reflexes is seen in the wasted arm muscles as well as in 
 the lower limbs, in which there may be little or no wasting. In pure cases 
 of progressive muscular atrophy there is no real spasticity in the affected 
 muscles and no spastic paralysis of the lower limbs. It must be acknowl- 
 edged, however, that the dividing hne between the two diseases is not 
 always sharply defined. In progressive muscular atrophy increased reflexes 
 with some spasticity of the limbs are sometimes observed. 
 
 The disease may resemble syringomyelia, but is to be distinguished 
 by the absence of the dissociation sensory syndrome, and of the trophic 
 lesions, arthropathies, and scoliosis. 
 
 From pachymeningitis of the cervical cord it is to be distinguished 
 also by the absence of sensory symptoms and of pressure palsies of the cord. 
 
 From multiple neuritis it is distinguished by its history and course, 
 the absence of sensory symptoms, the distribution of the muscular atrophy, 
 the absence of reactions of degeneration, the fibrillary twitchings, and the 
 preserved or even increased reflexes. 
 
 The various muscular dystrophies often resemble progressive muscular 
 atrophy of spinal origin. They usually begin in childhood, however, and 
 the muscles do not present fibrillary tremors, nor are the reflexes preserved. 
 They are sometimes hereditary and more than one case may occur in a 
 family. Several types are recognized and will be described under their 
 appropriate headings. 
 
 In some cases of myelitis there are muscular atrophies and spastic 
 paralysis, but the onset is more rapid and the course of the disease more 
 acute; sensory symptoms are present, and there is paralysis of the bladder 
 and rectum. 
 
 In the advanced stages of locomotor ataxia there is sometimes seen 
 extensive muscular atrophy, but the history of the case, the fulgurant 
 pains, the ataxia, the aboHshed knee-jerks, the atony of the bladder, the 
 optic atrophy, the Argjdl-Robertson pupil all serve to distinguish tabes. 
 
 So, also, in Friedreich's ataxia there may be some degree of muscular 
 atrophy in later stages of the disease, but the history and the typical symp- 
 toms, as ataxia, nystagmus, and the affection of speech, will prevent error. 
 
AMYOTROPHIC LATERAL SCLEROSIS. 
 
 1327 
 
 VI. AMYOTROPHIC LATERAL SCLEROSIS. 
 
 Amyotrophic lateral sclerosis may be said to be a progressive mus- 
 cular atrophy plus a lateral sclerosis. The two affections may be syn- 
 dromes of one and the same pathological process, depending for their 
 differences upon a mere difference in the distribution of the lesions in the 
 cord. Amyotrophic lateral sclerosis was first described by Charcot, and is 
 sometimes called by his name. 
 
 Pathology. — The lateral tracts are sclerosed, sometimes throughout 
 their entire length in the cord, the process stopping in the medulla; and 
 Alfred W. Campbell has traced the degeneration as far as the brain 
 cortex, where it is seen especially in 
 the large Betz cells in the motor 
 region — that is, the ascending frontal 
 convolution and paracentral lobule. 
 The degeneration of the anterior 
 horns in the cervical region is marked, 
 and sometimes the gray matter in 
 the medulla oblongata is involved. 
 
 Symptoms. — The disease begins 
 as a muscular atrophy, most marked 
 at first in the hands, but gradually 
 including the arms, shoulders, neck, 
 and even the trunk. In this respect 
 its appearance is like progressive 
 muscular atrophy. The essential 
 muscles of the hands are much 
 involved, and ''claw hand" or ''mon- 
 key hand" may develop; the arms 
 become so powerless that they hang 
 useless at the sides; the muscles of 
 the neck atrophy and permit the 
 head to fall forward on the chest, and 
 when the patient raises the head it goes up into place with a quick jerk 
 somewhat like the closing of a blade of a penknife; in rare cases bulbar 
 symptoms occur, the patient having difficulty in swallowing and the voice 
 having a nasal twang. Fibrillary twitchings are present. The muscular 
 atrophy seldom invades the lower limbs. 
 
 Along with the atrophy appear the evidences of sclerosis of the lateral 
 tracts. Even in the wasting muscles there is hypertonus, and the reflexes 
 are increased. The paretic arms may be slightly spastic. The biceps- 
 jerks, triceps-jerks, and wrist-jerks are exaggerated. The spastic paresis 
 of the lower limbs is very marked; the patient walks with a feeble but 
 .spastic gait, the feet dragging the floor. The reflexes are all exaggerated, 
 such as the knee-jerks and ankle clonus, and there is seen the plantar 
 extensor reflex of the great toe — the Babinski reflex. There is no anaes- 
 thesia, nor any paralysis of the bladder or bowel. 
 
 Diagnosis. — The rules for differential diagnosis are practically^ the 
 same as in the case of progressive muscular atrophy, and have already 
 been given under the head of that disease. 
 
 Fig. 391. 
 
 Amyotrophic lateral sclerosis, showing 
 head-d rop . — Lloyd . 
 
1328 MEDICAL DIAGNOSIS. 
 
 It is not always easy to distinguish these two diseases from each other, 
 for in truth they shade into each other and may practically be only vari- 
 ants of the same morbid process. Dejerine claims that bulbar symptoms 
 do not occur in true progressive muscular atrophy, and that they are indic- 
 ative of amyotrophic lateral sclerosis. The latter disease runs a more 
 rapid course than the former. The increase of the deep reflexes, the spastic 
 gait, and the paralysis of the muscles before the onset of atrophy are in 
 favor of amyotrophic lateral sclerosis. 
 
 VII. PRIMARY LATERAL SCLEROSIS. 
 
 Some authors, as Charcot, Erb, and Dreschfeld, have described a 
 sclerosis of the lateral tracts which appears to be primary, that is, it does 
 not depend upon a focal lesion, and is not associated with degeneration 
 of other structures or tracts of the cord. 
 
 Symptoms. — The symptoms are the same as those already described 
 for amyotrophic lateral sclerosis, minus the muscular atrophy. There 
 is spastic paralysis of the legs, with " clasp-knife rigidity," in which the 
 limb, when passively extended, resists, then suddenly yields, as in the 
 closing of the blade of a knife. The arms are sometimes involved. The 
 deep reflexes are all exaggerated. There is no anaesthesia, nor paralysis 
 of the bladder or bowel. 
 
 Diagnosis.— It is particularly necessary to eliminate every focal lesion 
 from which lateral sclerosis could occur as a descending degeneration, and 
 every disease of other structures than the lateral tracts. The affection is 
 rare, and thus far partakes rather of the nature of a pathological curiosity. 
 Mills has described an ascending hemiplegia which goes by his name, and 
 which has its origin in the cord; the lateral tract of one side is especially 
 involved. It is probably distinct from the affection here described. Spinal 
 syphilis may simulate this disease, especially when the specific lesion is 
 confined to the lateral aspects of the cord. It may also be simulated in 
 the early stages of multiple sclerosis. 
 
 It is to be distinguished from some degenerative brain and cord 
 affections; as that described by Striimpell, in which spastic paralysis 
 occurred in several members of the same family; and from spastic diplegia 
 in children, the result of focal lesions in the brain, in which cases there is 
 likely to be mental defect. 
 
 VIII. LOCOMOTOR ATAXIA. 
 
 This disease, also called tabes dorsalis, is characterized by a degenera- 
 tion of the posterior columns of the spinal cord. It has been recognized 
 only within comparatively recent years, and was first described clinically 
 about 1840 by Romberg, who, however, did not recognize its morbid 
 anatomy. Todd, of England, and Cruveilhier, of France, were among the 
 first to associate it with disease of the posterior columns. 
 
 Pathology. — There has been much discussion as to the exact seat of 
 the initial lesion in tabes. Vulpian, Charcot, and others held that it was 
 primarily an inflammation of the posterior nerve-roots. Others, as Marie, 
 
LOCOMOTOR ATAXIA. 1329 
 
 Marinesco, and Wollenburg, contend that the gangHon cells in the posterior 
 gangha are the first involved. Leyden and Goldschneider hold that the 
 starting-point is in the peripheral sensory nerve endings; while still 
 others, as Nageotte,. Redlich, and Obersteiner, believe that the disease 
 begins as a meningitis, affecting especially the posterior nerve-roots. Fer- 
 rier concludes that none of these theories is satisfactory, but that the 
 essential lesion of tabes is a dystrophy, similar to that induced by certain 
 toxic agents, affecting the sensory protoneuron as a whole. The disease, 
 however, is not confined to the spinal protoneuron, but may affect the 
 optic, the sympathetic, and certain motor neurons. 
 
 When fully established locomotor ataxia shows a degeneration espe- 
 cially marked in Goll's columns in the cervical region, in Burdach's columns 
 more or less marked at various levels of the cord, and in the lumbar 
 region in the areas known as the handelettes externes of Pierret. There 
 is a rare cervical type in which the columns of Goll in the neck entirely 
 escape. There is also optic degeneration, and in advanced cases mus- 
 cular atrophy. The posterior nerve-roots are degenerated, and there is 
 leptomeningitis. Syphilis is assigned by many as the invariable cause 
 of tabes. 
 
 Symptoms. — Locomotor ataxia is known by an ataxic gait, loss of 
 static equilibrium, abolished knee-jerks, crises and fulgurant pains, sensory 
 changes, atony of the bladder, loss of sexual power, optic atrophy, and 
 the Argyll-Robertson pupil. Other but rare symptoms are muscular 
 atrophy, arthropathies, and trophic lesions. 
 
 The ataxic gait of tabes is its most conspicuous symptom. It is not 
 due to paralysis but to incoordination. There may be full motor power, 
 even an excessive use of power, but the muscles do not act in harmony 
 with the will. The patient walks with the feet well apart; the foot is 
 lifted high from the ground,, thrown out widely, and brought down with a 
 stamp, the heel striking the floor first. It is evident that the patient feels 
 the unreliability of his gait, for he watches the floor^ and aids his progress 
 by the use of his eyes. Hence he walks with especial difficulty in the dark 
 and in coming downstairs. He may not be able to walk at all with his 
 eyes closed. The ataxia may also be marked in the arms and hands, as 
 in touching the tip of the nose with the forefinger (with closed eyes), unbut- 
 toning his coat, etc. It is also seen when the patient^ is lying down and 
 attempts to move his legs. It is often an early symptom, but may be 
 preceded by fulgurant pains and changes in the pupils. 
 
 The loss of static equilibrium is seen when the patient attempts to 
 stand without support and with his feet close together; but it is much 
 increased when he closes his eyes. He then sways violently and in some 
 cases would even fall. This is the Romberg symptom. 
 
 The knee-jerks are abolished early in tabes. This is one of the most 
 constant symptoms, and is the Westphal sign. The other deep reflexes 
 are also lost. 
 
 The fulgurant pains are usually an early symptom. They are light- 
 ning-like and severe, and felt most in the lower limbs. They may prevent 
 sleep, and are most urgent in their demand for relief. They are usually 
 paroxysmal, and may remit for days and even weeks. Closely associated 
 84 
 
1330 MEDICAL DIAGNOSIS. 
 
 with these pains are the girdle sense and various crises. The former is 
 felt as a band tied about the waist or abdomen, or about the chest, or 
 even about one limb. The crises are bouts of pain felt in various parts 
 of the body, especially in the epigastric region, hut sometimes in the thorax, 
 the larynx, or even the rectum. They may simulate some disorder of one 
 or other internal organ. The laryngeal crises cause a sense of strangling 
 and excite cough. According to Semon the essential cause is a paralysis 
 of the abductors of the vocal cords, and the attacks may begin with a 
 sense of tickling, or even pain in the throat, followed quickly by a sense 
 of suffocation; among accessory symptoms are dizziness, mental confusion, 
 and even loss of consciousness with convulsive movements, but the attacks 
 are in no sense epileptic. Involuntary passage of urine and faeces is occa- 
 sionally present. 
 
 There are various disorders of sensation. Tactile anaesthesia is not 
 always present, or it may be present in only limited areas; in other cases, 
 especially in the advanced stages, it may be extensive. There may be 
 paraesthesia, or altered sense. Thus, the patient may have abnormal 
 feelings in the soles of the feet, causing him to feel as though he were walk- 
 ing on some soft substance, as velvet or mud. There may also be numb- 
 ness, or formication, or a sense of cold. Alteration of the thermal sense, 
 however, is not usually marked. Analgesia is common: the patient has 
 lost the sense of pain, particularly in the legs; pinching or sticking with 
 a pin is not felt as pain. There is often loss of muscular sense and sense 
 of position; also of the sense of pressure and sense of active and passive 
 motion; and some writers attach great importance to these changes in 
 deep sensibility as the fundamental cause of the ataxia. 
 
 Some loss of power in the bladder is often an early symptom; at 
 first there is difficulty in extrusion, later there may be retention or even 
 incontinence. Loss of sexual power is not uncommon; occasionally, in the 
 early stages, there is sexual excitement. 
 
 Optic atrophy is frequent in tabes, but its exact frequency is a subject 
 of some debate. Gowers, in 70 cases of posterior sclerosis, found only 9 
 with this condition; Voight in 52 cases found 9; and Erb in 56 cases 
 found 7. Optic atrophy may appear early, sometimes before the onset of 
 ataxia. It is primary; that is, it is not dependent on a preceding neuritis. 
 It may progress to complete blindness, but its progress is often slow. 
 Changes in the pupils are likely to be early symptoms of tabes. The 
 sympathetic reflex from irritating the skin of the neck is often lost. There 
 may be myosis, sometimes extreme; the pupils are contracted. Some- 
 times they are unequal, and even irregular in outline. Later in the disease 
 they may be widely dilated. But the commonest change is the Argyll- 
 Robertson pupil. 
 
 The exterior muscles also of the eyes are sometimes involved. 
 Thus, there may be ptosis of one or of both upper lids. Other 
 paralyses of the third nerve and of the sixth are also seen, but are 
 not so common. 
 
 Among the rarer symptoms of tabes are arthropathies. These may 
 affect the knee, ankle, hip, elbow, or shoulder. A very typical form is 
 that seen in the knee. The joint is the seat of a painless swelling; there 
 
LOCOMOTOR ATAXIA. 
 
 1331 
 
 is denudation of the artic-ular surfaces, grating, effusion of fluid, osteo- 
 phytes, and deformity. The joint is relaxed, allowing the knee to be over- 
 extended, or bent backward. The whole leg may be enlarged and brawny. 
 In the shoulder and hip an atrophic form of arthropathy is seen; there is 
 preternatural mobility. Sometimes painless fractures occur. A condition 
 known as hypotonia exists: the joints may allow a much wider range of 
 motion than normal. Thus, when the patient lies upon his back, the whole 
 lower limb, straightened at the knee, may be so extended that, in extreme 
 cases, the foot may even rest alongside the neck. 
 
 Of trophic lesions one of the most characteristic is the mal perforans, 
 or perforating ulcer. This forms on the ball of the foot or great toe; it is 
 deep, painless, and obstinate in healing. 
 
 Muscular atrophy is seen in some 
 advanced cases of posterior sclerosis, 
 and may be extreme and accompanied 
 with loss of power. It is probably 
 dependent on involvement of the ante- 
 rior nerve-roots or anterior horns, or 
 on a peripheral neuritis. 
 
 The course of tabes is usually 
 chronic. It is a disease of long, dura- 
 tion, often extending over many 
 years. In the advanced stages the 
 patient becomes a wreck; unable to 
 leave his chair, or even his bed, the 
 victim of painful crises, partially or 
 entirely blind, with incontinence of 
 urine and possibly with one or more 
 arthropathies. 
 
 There is a sensory type of tabes. 
 This is marked by early optic atro- 
 phy, proceeding to complete blind- 
 ness, associated with severe lancinating 
 pains and crises, with lost knee-jerks, 
 but without impairment of gait. This form may persist for many years, 
 finally developing ataxia. Buzzard reported a case which preserved 
 this type for fifteen years, and Gowers mentions one in which optic 
 atrophy had existed for twenty years before the onset of incoordination. 
 This type is peculiarly liable to arthropathies. 
 
 Locomotor ataxia sometimes coexists with general paresis. It may 
 precede that disease, as is the more common way, or in some cases 
 it may follow it. 
 
 There is a juvenile tabes, which is the result of hereditary syphilis. 
 The disease, however, is usually one of adult Hfe, the initial symptoms 
 generally showing themselves between the ages of 30 and 40 years. It 
 is not limited to any race or country, but is seen wherever syphilis abounds; 
 and the statement, at one time current, that locomotor ataxia does not 
 occur in the negro race, is erroneous. It is not so common among women 
 in any race as among men. 
 
 Fig. 392. — Arthropathy of the left ankle- 
 joint in locomotor ataxia.— Lloyd. 
 
1332 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — Locomotor ataxia is to be distinguished from multiple 
 neuritis by the f ulgurant pains, the crises, the pupillary changes, the bladder 
 symptoms, and the absence of true paralysis with atrophy and the reac- 
 tions of degeneration. There is a pseudotabes due to multiple neuritis, 
 in which ataxia is marked, but the history of the case (as exposure 
 to lead or alcohol), the flaccid paralysis, with atrophy and electrical 
 changes, the painful nerve-trunks and muscles, which differ from the 
 lancinating pains of true tabes, as well as the absence of the optic atrophy 
 and pupillary changes, serve to distinguish it. It is true that muscular 
 atrophy with loss of power may occur in advanced stages of tabes, but the 
 other tabetic symptoms and the history of the case should prevent error. 
 
 From syringomyelia, in which there sometimes occurs an ataxic type, 
 tabes is distinguished by the absence of the dissociation syndrome, of the 
 scoliosis, of the spastic paralysis in the legs with exaggerated knee-jerks, and 
 of the muscular atrophy in the shoulders and arms. Arthropathies occur 
 in both diseases. Optic atrophy is seldom if ever seen in syringomyelia. 
 
 Progressive muscular atrophy is hardly to be confounded with tabes. 
 The muscular atrophy, often with preserved or even exaggerated reflexes, 
 and the absence of ataxia, crises, optic atrophy, and the Argyll-Robertson 
 pupil, are sufficient to distinguish the one from the other. The same may 
 be said of amyotrophic lateral sclerosis. 
 
 From multiple sclerosis tabes is distinguished by the ataxia, which is 
 not the same as the intention tremor of the former disease, in which the 
 movement is jerky, tremulous, and very marked only on voluntary motion. 
 Moreover, in multiple sclerosis there is usually a spastic gait with exagger- 
 ated reflexes, and an absence of f ulgurant pains and crises; nystagmus 
 and scanning speech are observed; optic atrophy may be present, but 
 only rarely; the Argyll-Robertson pupil is not seen. 
 
 The painful crises of tabes, occurring in the chest or abdomen, may 
 simulate disease of spme internal organ, as angina pectoris, or gastric 
 ulcer, or some affection of the bowel. The resemblance is only superficial, 
 and the coexistence of other tabetic symptoms points to the correct diag- 
 nosis. The laryngeal crises sometimes simulate laryngismus stridulus, 
 especially in the crowing inspiration at the end of the attack, and even 
 epilepsy, when consciousness is lost and spasmodic movements occur; 
 but the diagnosis is to be made from the associated tabetic symptoms in 
 the pupils, the gait, and the reflexes. 
 
 In various forms of myelitis there may be a girdle sense, and in 
 inflammation of the lumbar cord loss of the knee-jerks; but usually the 
 knee-jerks are exaggerated, and the optic and pupillary symptoms are 
 wanting. There is spastic paralysis in the legs, sometimes incontinence 
 of urine and faeces early in the case, and the general history is different. 
 Crises and fulgurant pains are wanting. Anaesthesia, clearly delimited 
 at its upper margin, is often present. In the meningomyelitis of syphihs 
 we sometimes see an ataxic paraplegia, in which the incoordination is l^ery 
 similar to that of tabes; but it is associated with a spastic state of the 
 lower limbs and exaggerated knee-jerks. 
 
 Tabes may coexist with, or lead up to, general paresis, but the peculiar 
 mental symptoms serve to distinguish these diseases. 
 
ATAXIC PARAPLEGIA. . 1333 
 
 IX. ATAXIC PARAPLEGIA. 
 
 This is a syndrome caused by a combined sclerosis of the lateral and 
 posterior columns of the spinal cord. 
 
 Pathology. — There is a posterior sclerosis very much as in locomotor 
 ataxia, and in addition a sclerosis of the lateral columns of the cord, but 
 more especially of the crossed pyramidal tracts. Occasionally the direct cere- 
 bellar tracts are also involved; but it is rather rare for other parts of the 
 anterolateral columns to be invaded, as, for instance, Gowers's tracts or the 
 direct pyramidal tracts. The disease seems to be a system disease, con- 
 fining itself to certain definite tracts, and not a diffused myelitis. There 
 is a form of syphilitic meningomyelitis, however, which closely resembles 
 combined sclerosis both clinically and anatomically: in this form, the 
 inflammation is located in the lateral and posterior aspects of the cord; 
 but the membranes are involved first and the posterior and lateral columns 
 are affected secondarily. 
 
 Symptoms. — Because of its morbid anatomy it is easy to understand 
 that ataxic paraplegia partakes of the nature both of locomotor ataxia 
 and spastic or primary lateral sclerosis. This idea, however, requires some 
 qualification, for those two diseases cause some contrary symptoms, such 
 as lost knee-jerks by the one and exaggerated knee-jerks by the other, 
 and the two symptoms cannot coexist in the same person. As usually 
 seen, the share of the disease contributed by the posterior sclerosis is the 
 ataxia. There may be some other tabetic symptoms, as lancinating 
 pains, sensory changes, and optic atrophy, but they are rare. Except for 
 the ataxia the disease takes its form largely from the sclerosis of the 
 lateral tracts. There is a spastic gait, with exaggerated reflexes, and 
 these with the ataxia produce a rather confusing picture. 
 
 There is a type of the disease in w^hich the tabetic symptoms pre- 
 dominate, and there is then seen the ataxia with lost knee-jerks, fulgurant 
 pains, and bladder weakness, combined with some loss of power due to the 
 lateral sclerosis. According to Oppenheim this predominance of the ataxia 
 and other symptoms of posterior sclerosis is likely to appear in the more, 
 advanced stages. 
 
 Some authors claim that the muscle tonus is lowered, or at least not 
 increased. This may be so in cases in which the posterior columns are the: 
 more involved; but in many cases, and especially in advanced stages,, 
 there is increased tonus along with the spastic paraplegia. The type of 
 the case, whether more ataxic or more paraplegic and spastic, will depend 
 upon which region of the cord is more affected. 
 
 Diagnosis. — The disease is not likely to be mistaken for any other. 
 The combination of ataxia with a spastic gait is distinctive. Multiple 
 sclerosis may be simulated by ataxic paraplegia, but in multiple sclero- 
 sis there is not a true ataxia, but rather an intention tremor, with 
 nystagmus and speech defects. From some forms of spinal syphilis the 
 distinction is not always easy. Diffused myelitis may also resemble com- 
 bined sclerosis, but the symptoms are not so characteristic of a system 
 disease. The ataxia closely resembles that of tabes dorsalis, but the 
 spastic paraplegia, with exaggerated knee-jerks, marks the difference. 
 
1334 MEDICAL DIAGXOSIS. 
 
 X. HEREDITARY ATAXIA. 
 
 This affection, also called Friedreich's disease, is a family rather than 
 an hereditary disorder. It is often seen in several brothers or sisters, but 
 is seldom directly herechtary. It is due to degeneration of several tracts 
 of the spinal cord, especially the posterior columns, but the lateral tracts, 
 and sometimes the direct cerebellar tracts and Clarke's columns, may also 
 be involved. The affection of the posterior columns seems to give the 
 disease most of its individuality. 
 
 Symptoms. — The patient has an ataxic or staggering gait, in v,-hich 
 he keeps his feet far apart and sways his body violently. The gait is not 
 identical with that of locomotor ataxia; the stamping is not so marked, 
 the swaying of the body is more conspicuous, and the jDrogTession has 
 something in it that even suggests a cerebellar lesion. There may also 
 be violent ataxic movements while sitting or even reclining. The swajang 
 is not particularly increased by closing the eyes. Later there are ataxic 
 movements in the arms. The knee-jerks are abolished. Anaesthesia is 
 not present, unless in the advanced stages, and then not alwa3's. True 
 paralysis of the legs occurs also in advanced stages, and there may even 
 be marked muscular atrophy. ScoKosis sometimes occurs and a form of 
 club-foot with characteristic over-extension of the gi'eat toe. In some 
 cases a Babinski reflex has been seen. The fulgurant pains and crises of 
 true tabes are not seen, nor is there paralysis of the bladder. Especially 
 characteristic are the nj'stagmus and speech defects. The former is usually 
 of the lateral variety. The speech is slow, labored, staccato, or scanning. 
 Optic atrophy and ophthalmoplegias do not occur. The disease begins 
 in childhood, as a rule, although in a few cases it has not appeared untU 
 early adult life. It is an incurable affection, and steadily, but sometimes 
 slowly, progi-essive. 
 
 Diagnosis. — From locomotor ataxia Friedreich's ataxia is distin- 
 guished by its early onset, its family association, its freedom from crises 
 and bladder atony, its 'exemption from optic atrophy and ophthalmople- 
 gias, its nystagmus, and its speech defects. 
 
 Multiple sclerosis may simulate this disease, but it is rare in early 
 childhood. It presents spastic paralysis with exaggerated knee-jerks, 
 intention tremor, sometimes an optic atrophy, and it is not seen as a 
 family affection. 
 
 In cerebellar ataxia there may be exaggerated knee-jerks, optic atro- 
 phv. ataxic speech, and a more distinct cerebellar gait than in Friedreich's 
 disease. Still these two affections have much in common. 
 
 The ataxic movements in this disease may simulate chorea and various 
 kinds of tremors; but the association with the other symptoms is usually 
 enough to prevent error. These movements have not the rh}i:hm of trem- 
 ors, and they are not of the involimtary nature of choreic jerldngs. In 
 chorea the movements persist while the patient is at rest; in Friedreich's 
 disease thev are seen only dining voluntary motion. 
 
SYRINGOMYELIA. 
 
 1335 
 
 XI. SYRINGOMYELIA. 
 
 This term is applied to a process in the cord which results in the for- 
 mation of a cavity. This process is a gliomatosis^ or proliferation of a 
 gliomatous tissue which breaks down in the centre. It is not a mere dila- 
 tation of the central canal of the cord, for this canal may not be included 
 in the cavity, as was first pointed out by Simon in 1875. Dilatation of 
 the central canal may result from other conditions, and is then properly 
 called hydromyelia. 
 
 Pathology. — The overgrowth of gliomatous tissue is usually most 
 marked in the gray matter. When this tissue breaks down, the resulting 
 cavity is of greater or less extent. It may extend across the cord almost 
 
 Fin. 393. — Syringomyelia in the cervical region. — Lloy 
 
 symmetrically on either side; in other cases it tends to follow one or other 
 horn of gray matter. The resulting injury to the structures of the cord 
 may be extensive. The anterior horns are involved, the lateral tracts 
 below the lesion are degenerated, and the posterior horns may be almost 
 cut off from the rest of the cord; but the posterior columns may largely 
 escape. The location of the central canal is usually marked by a collection 
 of ependymal cells on the anterior border of the cavity. The walls of the 
 cavity are sometimes lined with a sort of membrane formed from glioma- 
 tous tissue. The lesion may be largely located in the cervical region, the 
 cavity extending upward and downward in various shapes and to various 
 levels. In a few cases the dorsal cord is most involved; in others, the 
 lumbar cord. The cord at the seat of lesion is often flattened and ribbon-like. 
 
1336 
 
 MEDICAL DIAGNOSIS. 
 
 Symptoms. — There is degeneration of the anterior horns. If the 
 cavity is in the cervical cord, there results extensive muscular atrophy 
 of the shoulders and arms with a flaccid paralysis and fibrillary tremors. 
 Occasionally, however, the type of paralysis in the wasted limb is spastic, 
 and the reactions of degeneration are wanting. The degeneration of the 
 lateral tracts causes a spastic paralysis of the lower Hmbs, with exaggerated 
 knee-jerks. The paralysis in rare instances is hemiplegic, and in some 
 
 cases ataxia has been seen. The sensory 
 symptoms are most characteristic: they 
 constitute the so-called dissociation S}^- 
 drome. There is loss of the sense of heat, 
 cold, and pain, with preservation of the 
 tactile sense. The location of this syn- 
 drome depends upon the seat and extent 
 of the lesion: it may be most marked on 
 the trunk, but it is also seen on the 
 extremities. It may also be more marked 
 on one side, and it occurs in areas of va- 
 rious extent. Occasionally some areas of 
 tactile anaesthesia are also found. Trophic 
 lesions occur. Maculae appear on the skin 
 of the legs; the toe-nails are enlarged and 
 thickened, with transverse ridges. In the 
 tj^pe known as Morvan's disease there are 
 painless destructive lesions of the fingers. 
 Scoliosis is not uncommon; and occasion- 
 ally an arthropathy of one or other joint 
 is seen just as in locomotor ataxia. Among 
 the rarer symptoms are paralysis of the 
 muscles of respiration, bulbar and oculo- 
 motor symptoms, paralysis of the vocal 
 cords, nystagmus, painless fractures, and 
 various skin eruptions, such as urticaria 
 and pemphigus. Bladder symptoms are 
 usually not present. 
 
 Diagnosis. — Syringomyelia is to be 
 distinguished especially from progressive 
 muscular atrophy and amyotrophic lateral 
 sclerosis. To both diseases it bears a 
 resemblance because of the muscular atrophy of the shoulders and arms 
 and the spastic paralysis in the legs; but it differs from both in its dis- 
 sociation sensory syndrome and in its trophic lesions. The disease known 
 as pachymeningitis hypertrophica of the cervical cord sometimes bears a 
 striking resemblance to syringomyelia, even in its sensory symptoms. 
 There may be the same loss of sense for pain, heat, and cold, with pres- 
 ervation of tactile sense; muscular atrophy of the shoulders and arms; 
 and spastic paralysis of the legs; but in the former disease there is often 
 a history of trauma, and in some cases the stiffness and deformity fol- 
 lowing upon fracture of the vertebrae are seen. 
 
 Fig. 394. — Syringomyelia, showing 
 scoliosis, muscular atrophy of the shoul- 
 der, and arthropathy of the ankle. — 
 Lloyd. 
 
SYPHILIS OF SPINAL CORD AND MEMBRANES. 1337 
 
 Morvan's disease is a form of syringomyelia in which there are painless 
 destructive whitlows of the fingers (the panaris analgesique of French 
 writers). Morvan claimed that the disease is distinguished, however, from 
 syringomyelia, by the predominance of trophic lesions and the loss of 
 tactile sense; but there may be the same muscular atrophy, scoliosis, and 
 even arthropathy, and the two affections are probably closely allied. 
 This type so much resembles some forms of lepros}" that Zambaco and 
 others have even claimed that syringomj^elia is a form of leprosy — a curi- 
 ous instance of confusing a resemblance with an identity. There is no 
 central gliomatosis in leprosy, and there are many distijictions, too 
 numerous to mention here, which are described under that disease. The 
 anaesthetic form of leprosy is dependent on a neuritis, not a cord lesion. 
 
 Charcot pointed out that one of the trophic lesions of syringomyelia 
 is an enlargement of the hand closelj^ resembhng acromegalia. In his 
 case the change was limited to one hand, and was symptomatic of glioma- 
 tosis. In some cases the parah'sis is largely unilateral, resembling hemi- 
 plegia of cerebral origin; but the other cord symptoms distinguish it. 
 
 Dejerine contends that Friedreich's ataxia is due to a gliomatous 
 change in the cord; and in a series of 12 autopsies in Griffith's collection 
 of cases cavities were found in three. Doubtless in rare cases in which 
 the posterior columns are much involved and ataxia results, the resem- 
 blance of syringomyelia to hereditary ataxia is manifest, but the sensory 
 and trophic lesions of the one, and the speech defects and nystagmus of 
 the other, serve to distinguish them. Thus in syringomyelia the knee- 
 jerks are exaggerated, except in the rare tabetic form; in Friedreich's 
 ataxia they are abolished, while in the latter there are speech defects 
 w^hich are not seen in the former, as well as a familial history in many 
 cases. Nystagmus is most rare in syringomyelia, while it is common 
 in Friedreich's disease. Finally, the dissociation symptom, muscular 
 atrophy, arthropathies and other trophic lesions are all suggestive of 
 syringomyelia; which disease, moreover, rarel}' begins in early youth. 
 
 In the rare cases in which ataxia occurs, especially if there should be 
 a spinal arthropathy and lost knee-jerks, the resemblance to locomotor 
 ataxia may be striking, but the sensory symptoms, the muscular atroph}?-, 
 the scoliosis, and the other trophic lesions would establish the diagnosis. 
 The knee-jerks are not always lost in the ataxic form. 
 
 XII. SYPHILIS OF THE SPINAL CORD 
 AND MEMBRANES. 
 
 Syphilis may confine its ravages entirely to the spinal cord and 
 membranes, or it may affect both the spinal contents and the brain. The 
 diffused cerebrospinal syphilis is usually more conspicuous for its brain 
 symptoms, but evidences of involvement of the cord can often be 
 found on close inspection. 
 
 Pathology.— The essential lesion of syphihs of the nervous system is 
 an initial endarteritis. The membranes, however, are soon involved, and 
 the resulting meningitis then spreads to the contiguous nervous structures. 
 It is highly characteristic of the syphilitic inflammation to become exuda- 
 
1338 MEDICAL DIAGNOSIS. 
 
 tive; there then results a thickening of the membranes, a plastic exudate, 
 and very often a gummatous neoplasm. In some forms the resulting 
 meningomyelitis presents but little exudation and practically no gumma. 
 Thickening and even obstruction of blood-vessels may occur, leading to 
 various degrees of necrosis or softening. In the spinal cord the lesion 
 may be largely confined to the membranes, especially the pia, with only a 
 limited area of peripheral myelitis underneath. This condition is especially 
 seen about the lateral or posterolateral columns. In other cases the disease 
 process is more diffused, without reference to the various tracts and 
 systems of the cord, thus causing various bizarre combinations, and 
 symptoms of disseminated myelitis. 
 
 Symptoms. — Because of its irregular distribution and various degrees, 
 the syphilitic process gives rise to manifold and irregular symptoms. 
 In some cases there is merely a meningomyelitis, more or less circum- 
 scribed, with some resulting softening. The symptoms are then practically 
 the same as have already been described under the head of myelitis. In 
 the more diffused or disseminated form, the symptoms are irregular. Irri- 
 tation of the nerve-roots is common, with resulting pains, girdle sense, and 
 stiff back. There may be spastic paraplegia, impairment of the nerve 
 supply to the bladder, and various forms of anaesthesia. Sometimes there 
 is muscular atrophy, and even monoplegia. As a rule, spinal syphilis 
 does not cause a so-called "system-disease." Exceptions to this rule 
 occur, however, especially in the form described by Erb and sometimes 
 called by his name. In Erb's paralysis the lesion is a meningomyelitis 
 of the lateral aspects of the cord. There results a spastic paralysis of 
 the legs, with exaggerated knee-jerks, low muscle tension, that is, without 
 contractures; with weakness of the bladder, and usually no involvement 
 of sensation. In some cases, however, the lesion includes the posterior 
 aspects of the cord, and there is then added an ataxia, possibly with 
 some alterations of sensation. This condition closely resembles ataxic 
 paraplegia. 
 
 Another form of spinal syphilis is seen in the gummatous tumor. This 
 may be located at almost any level of the cord, or sometimes in the cauda 
 equina. Its symptomatology will depend upon its location and extent, 
 the same as in any other tumor of the spinal cord. 
 
 The clinical picture of spinal syphilis varies; there may be reces- 
 sions and improvement; at other times, an irregular advance with 
 remissions. Pure "system-diseases" are rare, except in Erb's type; 
 and the affection may especially change under specific treatment. In 
 some cases there may be cerebral symptoms, and involvement of one 
 or more cranial nerves. 
 
 Sj^philis is now believed by many neurologists to be the sole cause of 
 locomotor ataxia. The lesion in tabes, however, does not always present 
 the type of an exudative meningomyelitis, but it is rather a parenchymatous 
 change, a dystrophy confined to the sensory protoneuron. Nevertheless 
 there are some pathologists, as Nageotte and others, who believe that 
 even in locomotor ataxia the initial lesion is a meningitis affecting the 
 posterior nerve-roots. However that may be, tabes dorsalis is usually 
 described as a distinct disease. 
 
TUMORS OF THE SPINAL CORD. 1339 
 
 Diagnosis. — From ordinary myelitis it is not always easy to distin- 
 guish syphilis of the spinal cord; in fact, the syphilitic lesion may consist 
 largely of a meningomyelitis. Syphilis is hkely to cause an irregular 
 distribution of symptoms, but this fact is not of as much diagnostic 
 importance as some writers contend. There are cases of myelitis, or 
 meningomyelitis, with or without softening, in which it is not possible to 
 make a differential diagnosis. The problem is simplified in cases in which 
 there is a clear history of syphilitic infection. The therapeutic test is not 
 always determinative, although sometimes helpful. In cases in which 
 there is some associated cerebral syphilis the diagnosis is more evident. 
 
 The same difficulty occurs in cases of Erb's palsy, for this affection 
 closely resembles primary lateral sclerosis (the so-called primary spastic 
 paraplegia), except that in the former the bladder is often involved, 
 slight sensory changes occur, and the muscle tone is not increased. In 
 Erb's palsy there may also be irritative symptoms, as pain and the girdle 
 sense, due to involvement of the posterior nerve-roots. This is particu- 
 larly so in cases in which the lesion spreads to and upon the posterior 
 columns. We then see a condition of ataxic paraplegia, which is prac- 
 tically indistinguishable from the combined sclerosis which some authors 
 describe as a system disease of non-syphilitic origin. These fine problems 
 in diagnosis cannot always be satisfactorily solved, but in all such cases 
 the history of syphilis in the patient should be carefully sought; and 
 whether this is found or not, the antisyphilitic treatment should be given 
 a fair trial. 
 
 Some authors attempt to make a distinction between locomotor 
 ataxia and syphilitic leptomeningitis extending to the posterior columns. 
 In the latter disease there are sensory symptoms ■ and ataxia closely 
 resembling these symptoms in tabes, but the other distinctive tabetic 
 symptoms, such as optic atrophy, Argyll-Robertson pupil, crises, and 
 arthropathies, are wanting. 
 
 • * 
 
 XIII. TUMORS OF THE SPINAL CORD. 
 
 We include here not only tumors of the cord proper but also tumors 
 of the membranes, for the distinction between them is not clinically pos- 
 sible. We also include tumors of the vertebrae, for although these are 
 sometimes distinguishable at the bedside from intraspinal growths, their 
 clinical features are similar. Tumors of the spinal cord proper aj-e rare; 
 those springing from the membranes are the more common. In 50 cases 
 collected by Mills and Lloyd, the largest number were sarcomata, 
 gliomata, or gummata. In nearly one-half of these cases the tumor was 
 in the cervical region; the dorsal region was involved next in frequency, 
 and then the lumbar region. The cauda equina was also involved in a 
 few cases. 
 
 Symptoms. — In most cases the symptoms indicate irritation early 
 of the nerve-roots and membranes, and later pressure on the cord. Hence 
 pain is often an early or initial symptom; it may be intense, neuralgic, 
 persisting for a long time in one region, and may radiate or be located far 
 from the cord (eccentric pain). It may be associated with hypersesthesia, 
 
1340 MEDICAL DIAGNOSIS. 
 
 hyperalgesia, parsesthesia, or even anaesthesia, and there may be a subjec- 
 tive sense of numbness in some localized part, and even a girdle sense. 
 With the pain there may be some stiffness of the spine, and contracture 
 of some or other muscle groups. As the case progresses the symptoms of 
 pressure show themselves; there is paralysis of one or other limb or group 
 of muscles, and anaesthesia is more marked and more extensive. There 
 may be anaesthesia dolorosa, that is, absence of sensation to objective 
 tests, with the presence of pain in the affected part. Paralysis of the 
 bladder and bowel may eventually come on. In fact, we see the symptoms 
 of either a partially transverse or even (in advanced cases) a totally trans- 
 verse lesion. The distribution of these symptoms will, of course, vary 
 according to the seat of the lesion. In a very advanced stage there will 
 be total paralysis below the seat of lesion, contractures, deviation of the 
 spine, anaesthesia, incontinence, bed-sores, cystitis, alteration in the re- 
 flexes, dyspnoea, tachycardia or bradycardia, in cervical cases dysphagia, 
 and even bulbar and ophthalmic symptoms. In some cases there is pain 
 on pressure or palpation over the site of the tumor, and pain on twisting 
 or bending the spine. 
 
 Diagnosis. — The mode of onset is often suggestive. The initial symp- 
 toms are likely to be irritative, hence pain. This pain may be eccentric and 
 localized in the distribution of one or of a few nerves. Paresis begins also 
 as a localized symptom; it may at first be more marked in one limb or 
 even in one group of muscles. Later the symptoms are more suggestive 
 of compression of the cord, as anaesthesia, paraplegia, incontinence, and 
 bed-sores. In some cases the symptoms are markedly unilateral, causing 
 the so-called Brown-Sequard paralysis, or an approach to it. 
 
 From syphilis of the cord it is not always possible to distinguish tumor. 
 In fact syphihs may cause a gummatous tumor. The mode of onset is 
 more suggestive of a neoplasm. The therapeutic test with the iodides is 
 not reliable. The progress of the disease in tumor is rather more per- 
 sistent and hopeless than in most cases of syphilitic meningomyelitis. 
 
 From myelitis and acute softening the distinction is often to be made 
 by the more abrupt onset of these affections. The symptoms of a trans- 
 verse lesion are much sooner established than in tumor; and the initial 
 pain, so marked in case of neoplasm, may be wanting. Unilateral symp- 
 toms are not common in myelitis and softening. In hemorrhage the 
 onset is sudden, often caused by trauma, and the disease reaches its 
 acme in a short time. In spinal caries the bone lesion can usually be 
 detected by inspection. The X-ray may demonstrate the lesion. In very 
 early cases, before deformity appears, it may be possible to elicit pain by 
 jarring the spine, and there may be stiffness of the back, and pain on 
 passive movements of the trunk. 
 
 In traumatism the case can usually be distinguished by the history. 
 Still, it is well to recall that tumor may follow trauma. Aneurism of 
 the aorta may erode the spine and cause symptoms, first of irritation and 
 later of pressure. It is only to be detected by exploration and by the 
 methods of physical diagnosis. Cancer of the vertebrae usually causes 
 very urgent symptoms, especially of initial pain, and later of pressure on 
 the cord or nerve-roots. The nature of the lesion may remain for some time 
 
INJURIES TO THE SPINAL CORD. 1341 
 
 obscure; or there may be the history of precedent cancer. The symptoms 
 soon become extremely aggravated, and the patient becomes cachectic. 
 
 In neuritis there is soreness of the nerve-trunks, with paralysis of 
 motion or of sensation, or of both, in areas supplied by the individual 
 nerves. In early stages motion is more likely to be impaired than sensa- 
 tion. Muscular atrophy occurs. Compression symptoms, and involve- 
 ment of the bladder and rectum, are wanting. Still, the distinction is not 
 always easy between neuritis and intraspinal tumor, especially if the new 
 growth affects chiefly the nerve-roots, as in the cauda equina. 
 
 The eccentric or localized pain of tumor, especially in the early stage, 
 may closely simulate a mere neuralgia, or even a disease of some internal 
 organ, as in the chest or abdomen. The differential diagnosis must depend 
 on the association of the symptoms; for instance, of other symptoms of cord- 
 lesion, on the one hand, or of disease of the suspected viscus, on the other. 
 
 The local or regional diagnosis is to be made as in cases of myelitis or 
 trauma. 
 
 XIV. INJURIES TO THE SPINAL CORD. 
 
 The spinal cord is subject to injury by blows, falls, crushings, stab- 
 wounds, and gun-shot wounds. The commonest injuries are those which 
 also cause fracture and dislocation of the vertebrae. It is not essential, 
 however, that there should be a fracture or dislocation of vertebrae, as 
 fatal injury has been done to the cord by falls, without visible injury to 
 the bones. Gun-shot wounds are common, and a few instances are on 
 record of the cord being injured or partly severed by a stab with a knife 
 or stiletto. The commonest seat of injuries to the cord is in the neck; 
 next in the dorsal region. The lumbar region, being more massive and 
 better protected by large muscles, is not so often involved. It has been 
 supposed in some cases that a vertebra may be partly dislocated and 
 then spring back into place, thus causing a crushing of the cord. Fracture 
 is not always associated with dislocation, nor vice versa. 
 
 The lesion in most of these cases is severe. The cord is either partly 
 disintegrated, or entirely so in its transverse diameter. It is softened and 
 necrosed, and may be the seat of hemorrhage. There may also be hemor- 
 rhage within the spinal membranes. In long-standing cases in which there 
 have been attempts at repair, there is much scar tissue, together with 
 degeneration of various tracts in the cord. 
 
 Symptoms. — The symptoms depend upon the seat of the lesion. 
 
 Injury to the cervical region causes a characteristic symptom-group, 
 which varies according to the extent of the injury. There is a spastic 
 paralysis of the legs, more or less complete, with paralysis of the bladder 
 and rectum. The knee-jerks are, as a rule, increased, although in totally 
 transverse lesions the knee-jerks may be abolished at first. Later, if 
 the patient survives, they may return and become exaggerated. This 
 is also true of the other deep reflexes. Contractures of the leg muscles 
 often supervene, and bed-sores may form very rapidly about the buttocks 
 or on the sacrum. The arms are totally or only partly paralyzed, accord- 
 ing as the cervical enlargement and the roots of the brachial plexus are 
 or are not totally involved. In some cases the arms lie paralyzed and 
 
1342 
 
 MEDICAL DIAGNOSIS. 
 
 flaccid at the side; in other cases some power is retained, especially 
 power of flexion of the arm at the elbow, and contractures supervene. 
 Wasting of the muscles of the shoulders, arms, and hands is likely to set 
 in if the cervical enlargement is injured. Sensation may be entirely 
 abohshed below the line of injury. If the lesion is low in the neck the 
 
 anaesthesia may not 
 involve the shoulders and 
 outer aspects of the upper 
 arms. Pain on moving 
 the neck may be severe. 
 If the injury extends 
 above the fourth cervical 
 segment the phrenic nerve 
 may be paralyzed and 
 cause death. The pupil- 
 lary centre in the cord may 
 be injured, with conse- 
 quent contraction of the 
 pupil; if it is only irri- 
 tated the pupil is dilated. 
 In some cases of injury 
 to the cervical cord the 
 clinical picture closely 
 resembles syringomyelia. 
 There is atrophic paral- 
 ysis of the shoulders, arms 
 and hands, spastic paral- 
 ysis of the legs, with the 
 dissociationsensory symp- 
 toms as seen in syringo- 
 myelia. In such cases 
 there is usually deformity 
 of the cervical spine from 
 the old injury, and sub- 
 sequent ankylosis. 
 
 Injury to the dorsal 
 region causes spastic para- 
 plegia and all the other 
 symptoms as described 
 above except those in the upper extremities. The anaesthesia when 
 present gives a valuable clue to the uppermost limit of the injury. There 
 may be a zone of hyperaesthesia at the extreme upper limit, due to 
 irritation of the nerve-roots; and pain may radiate through the trunk 
 at this level for the same reason. 
 
 Injury to the lumbar region also causes paralysis of the legs, bladder, 
 and rectum, but if the lumbar enlargement is involved the paralysis of the 
 legs is flaccid, with abplished knee-jerks, wasting of the muscles, and elec- 
 trical changes. Anaesthesia may be present on the buttocks, genitalia, 
 perineum, thighs, and legs. Pain in the legs may also be present. 
 
 Fig. 395.- 
 
 -Trauma of the cervical region of the spinal cord, simu- 
 lating syringomyelia. — Lloyd. 
 
HEMORRHAGE IN SPINAL CORD AND MEMBRANES. 1343 
 
 A unilateral lesion of the cord may cause the so-called Brown-Sequard 
 syndrome: there is paralysis of motion on the side of the lesion and loss 
 of sensation on the opposite side, but this sensory loss is in the tempera- 
 ture and pain sense rather than in the tactile sense. If, however, the pos- 
 terior column of one side is affected there is tactile anaesthesia also, but it 
 is on the side of the lesion. 
 
 Diagnosis. — To determine the exact seat of the lesion the practitioner 
 should study the uppermost limits of the anaesthesia, and the muscle-groups 
 involved, and compare them with a chart and table of the spinal segments. 
 In this way an exact local diagnosis may be reached (pp. 313-314). 
 
 The history of the case is usually sufficient to establish the clinical 
 diagnosis. It is not always possible to say whether the lesion is a mere 
 hemorrhage in the substance of the cord, or in the membranes, or whether 
 it is a crush of the cord. Practically the distinction is not of much impor- 
 tance so far as the welfare of the patient is concerned. It is more important 
 to ascertain, if possible, whether the cord is merely affected by pressure, 
 or whether it is actually crushed, especially when surgical intervention is 
 contemplated. But this is seldom possible before operation. The reason 
 why laminectomy is so seldom beneficial in these cases is that the cord has 
 been damaged beyond the power of surgery to repair. Clinically these 
 cases closely resemble myelitis; and in some of them secondary inflam- 
 mation may be present. Abolition of the knee-jerks may indicate a total 
 transverse lesion and is usually of grave import. 
 
 XV. HEMORRHAGE IN THE SPINAL CORD 
 AND MEMBRANES. 
 
 Hemorrhage in the spinal cord, or hsematomyelia, is usually the result 
 of injury. It may be associated with a crush of the cord due to vio- 
 lence, or with fracture or dislocation of the vertebrae. In a few cases of 
 injury, however, the hemorrhage 
 may be the only lesion. Thus 
 cases have been reported of great 
 violence, as a fall down a long 
 flight of stairs, in which the bones 
 were uninjured, and even the 
 membranes escaped, and yet a 
 small and rapidly fatal hemor- 
 rhage was found in the substance 
 of the cord. The hemorrhage may 
 be in the gray matter, or close to 
 it, and may cause extensive 
 destruction of the spinal medulla. 
 It may be so small as not to be 
 apparent until the cord is sec- 
 tioned, or it may cause an appear- 
 ance of pallor or slight swelling on the surface. In some cases the 
 blood breaks through to the surface and is present in the meninges. 
 Minute capillary hemorrhages may be the starting-point for necrotic soft- 
 
 FiG. 396. — Hsematomyelia. — Lloyd. 
 
1344 MEDICAL DIAGNOSIS. 
 
 ening. Van Gieson has found long slender columns of necrosis in the 
 "Cord, causing narrow cavities, which he thinks may be due to traumatic 
 hemorrhage. They extend for long distances both above and below the 
 main lesion. Meningeal hemorrhage may also occur from trauma. 
 
 Spontaneous, or non-traumatic, hemorrhage in the spinal cord is rare. 
 The primary lesion is probably vascular, due to some weakness or disease 
 of the blood-vessels. It is remarkable that such vascular lesions, which 
 are so common in the brain, are apparently so uncommon in the spinal 
 cord. It has been doubted by competent pathologists whether arterio- 
 sclerosis, as well as thrombosis and embolism, occurs in the cord; but 
 there is not sufficient ground for dogmatic statements in the negative. 
 It seems more probable that some cases of hemorrhage and hemorrhagic 
 softening in the cord may be due to such lesions. 
 
 Symptoms. — The symptoms come on rapidly, even suddenly, and 
 may cause profound shock; but even in the traumatic cases this rule is 
 not absolute, for hours may elapse before all the symptoms are estab- 
 lished. This is probably due to the fact that a small hemorrhage, once 
 started, continues for some time to progress, with gradually increasing 
 effect. Especially in meningeal hemorrhage this gradual onset is seen, 
 and perhaps more so in the lower part of the spinal canal, where the 
 Cauda equina is involved. Many hours have been known to elapse before 
 the paralysis was complete. In such a case presumably the blood gradu- 
 ally settles and clots in the lower part of the spinal canal. There may be 
 complete paralysis of all the muscles below the level of the lesion. If the 
 lesion is in the neck, the muscles of the chest may be paralyzed. The 
 respiration is then diaphragmatic and irregular. 
 
 All modes of sensation may be absolutely lost below the level of the 
 lesion. These symptoms, however, vary. Some hours may elapse before 
 they are fully established, and later, even in unfavorable cases, sensation 
 has been known to return in part. Thus the patient may have a return 
 of tactile sense in some limited area; or of pain sense, or thermic sense, 
 or sense of position, one or all. The bladder and rectum may be para- 
 lyzed, and priapism may occur. 
 
 The reflexes, especially the knee-jerks, may be retained and soon 
 become exaggerated. If the lesion is totally transverse, the knee-jerks 
 are likely to be abolished, although they may return in time. Occasion- 
 ally they are not lost until after some days. Total abolition of the 
 knee-jerks, therefore, in a hemorrhage above the lumbar enlargement is 
 not a favorable sign, for it indicates an extensive lesion. If the hemor- 
 rhage is in the lumbar enlargement the knee-jerks will probably also be 
 abolished, but this is from interference with the reflex centres in the cord; 
 hence it is not necessarily so ominous a symptom. The ciliary reflex 
 from irritation of the skin of the neck may be absent in cases of hemor- 
 rhage in the cervical region; hence there may be spastic myosis. If this 
 centre is only irritated there is symptomatic mydriasis in one or both eyes. 
 
 Pain may be an urgent symptom. In Kindred's case, in which the 
 hemorrhage was in the fourth dorsal segment, there was an initial agonizing 
 pain simulating angina pectoris. Pain may persist, and it may even be felt 
 far below the level of the lesion, if this is not totally transverse; this probably 
 
SOFTENING OF THE SPINAL CORD. 1345 
 
 because free blood escapes in the meninges and causes pressure and irritation 
 at lower levels. The girdle or ''cincture" feeling is present in some cases. 
 
 In brief, the symptoms of hsematomyelia, whether traumatic or non- 
 traumatic, are those of a complete or almost complete transverse lesion 
 of the cord. Abolition of the knee-jerks may be seen. The locahzing 
 symptoms depend upon the exact level at which the lesion occurs, and 
 they have already been described under the head of myelitis. 
 
 The course of severe cases is usually rapid. In Kindred's case of spon- 
 taneous hemorrhage death came in six hours. If the lesion is totally 
 transverse, with abolished knee-jerks and rapidly forming bed-sores, the 
 prognosis is highly unfavorable. If the lesion is high in the neck death 
 may come from paralysis of the phrenic nerve. 
 
 High temperature and excessive sweating are seen toward the end 
 in fatal cases. In a case recorded by Lloyd moist skin was noted above, 
 and dry skin below, the line of anaesthesia toward the end. 
 
 In hemorrhage in the membranes, when the cord itself is not involved 
 and not much pressed upon, the outlook is more favorable, although per- 
 manent crippling in some form is not unusual. Pain is often a prominent 
 symptom, and the anaesthesia and pain may follow individual nerve-trunks. 
 In the legs, if the cauda equina is involved, there is a flaccid paralysis with 
 muscular atrophy and abolished reflexes, somewhat like a multiple neuritis, 
 but with paralysis of the bladder and bowel. 
 
 Diagnosis. — In traumatic cases the diagnosis is not difficult, except 
 to distinguish hemorrhage from crush, and this is often not possible, nor 
 is it of great practical importance. The history of the case points unerringly 
 to a grave lesion of the cord. It is important to distinguish fracture, 
 and this can be done only by a careful surgical examination, aided by 
 the X-rays. Haematomyelia is not Hkely to be mistaken for a disease of 
 any internal organ, and yet in dorsal hemorrhage the initial symptoms 
 have simulated angina pectoris. But the speedy onset of paralysis, anaes- 
 thesia, priapism, and incontinence would distinguish the cord lesion. So, 
 too, of pain from lumbar hemorrhage simulating disease of abdominal 
 viscera. The supreme difficulty in non-traumatic cases is to distinguish 
 haematomyelia from transverse myelitis, acute white softening, and 
 pachymeningitis. The sudden onset and rapid course serve better than 
 all other symptoms to distinguish hemorrhage from any of these condi- 
 tions; but the diagnosis in non-traumatic cases may remain obscure. 
 The extreme rarity of spontaneous haematomyelia must not be overlooked 
 in coming to a conclusion. Softening and hemorrhage being due often 
 to the same causes, and being part of the same pathological process, a 
 dogmatic diagnosis between them may sometimes not be practicable. 
 
 The exact seat, or level, of the lesion is to be determined as in 
 injury or myelitis. 
 
 XVI. SOFTENING OF THE SPINAL CORD. 
 
 Acute softening of the cord is often confused with myelitis, and indeed 
 in some cases it may be impossible to distinguish between them at the 
 bedside. The subject has already been discussed under the head of 
 85 
 
1346 MEDICAL DIAGNOSIS. 
 
 myelitis. The latter term properly indicates an inflammation, and this in 
 turn is due to some infection; whereas softening may presumably be 
 caused by a vascular lesion, such as embolus or thrombus. Nevertheless, 
 softening is sometimes secondary to inflammation; and it also results 
 from trauma. Weiss has recorded a case of softening of the cord occur- 
 ring suddenly in a boy who had mitral disease. Gowers refers to a sim- 
 ilar case. The inference is that cardiac emboli were the causes of the 
 softening. The symptoms are so similar to those which occur in myelitis 
 that it is not necessary to describe them again. The onset of the disease, 
 however, may be more abrupt. 
 
 XVII. THE CAISSON DISEASE. 
 
 The caisson is a large compartment, inverted, in which a constant 
 supply of compressed air is maintained in order to counteract the pressure 
 of the water from without, thus allowing men to work upon the founda- 
 tions of piers. The caisson disease is an affection, largely of the central 
 nervous system, and especially of the spinal cord, caused by working in 
 the compressed air of these compartments. The highest pressure attained 
 at the St. Louis bridge was 50 lbs. to the square inch, the normal pressure 
 of the atmosphere being 15 lbs. By some observers the mischief is attrib- 
 uted to the emerging from the compressed air while the system is over- 
 heated and fatigued with the hard labor. 
 
 Pathology. — Van Rensselaer studied the cord in a case of this 
 disease and found extensive changes. A disseminated necrotic area was 
 found in the dorsal region, with ascending degeneration in the columns 
 of Goll and in the direct cerebellar tract, and descending degeneration in 
 the pyramidal tracts, respectively above and below the mid-dorsal lesion. 
 The necrosis seemed to be confined to the white substance, the gray 
 matter not being involved. Possibly with the more refined methods 
 now used, this entire exemption of the cells of the gray matter might 
 not be found. No hemorrhages were seen. The fanciful theory that 
 air-bubbles or air-emboh cause the softening need not be discussed here. 
 Brooks has recently studied the blood-pressure in 75 workmen before, 
 during, and after working in the caisson, and found no marked change 
 in arterial pressure. 
 
 Symptoms. — The initial symptoms do not appear until after the 
 workman emerges into the outer air. Some minutes, even hours, may 
 elapse. There is usually severe epigastric pain, with vomiting, then very 
 severe pain in the back and lumbar region, along the spine, and shooting 
 down the legs. Smith described these pains as of a tearing character and 
 intolerable. Anaesthesia shows itself promptly, often of the type known 
 as "anaesthesia dolorosa," and advances with the motor symptoms. The 
 paralysis is usually in the form of a paraplegia, although in some cases 
 the arms also have been involved. The bladder and rectum are commonly 
 paralyzed. Bed-sores form. 
 
 Brain symptoms are seen in the more severe cases, and especially in 
 fatal cases. There are headache and vertigo, and in fatal cases uncon- 
 sciousness supervenes before death. Pelton describes a comatose type, 
 
AFFECTIONS OF THE CAUDA EQUINA. 1347 
 
 which may appear suddenly, with cyanosis, and is usually fatal. The 
 duration in mild cases is from a few hours to six or eight days. In severe; 
 cases death ma}^ result in a few days. 
 
 The viscera are not, as a rule, seriously involved. There may be 
 bronchial irritation and cough. The urine has usually a high specific 
 gravity. Perforation of the ear drum and catarrh of the middle ear have 
 been observed. 
 
 Diagnosis. — The import of severe spinal symptoms, such as para- 
 plegia, anaesthesia, and incontinence, in a caisson worker soon after 
 quitting work is unmistakable. The disease, as described by most ob- 
 servers, is of spinal or central origin, as proved also by such autopsies as 
 the one made by Van Rensselaer, and is not a mere peripheral neuritis, 
 due to carbonic acid poisoning, as others have contended. Still, it is not 
 unlikely that the peripheral neurons may be found involved in some cases. 
 An affection similar in every way to the caisson disease occurs in divers. 
 
 XVIII. AFFECTIONS OF THE CAUDA EQUINA. 
 
 The Cauda equina is the leash of nerve-roots lying in the lower end 
 of the spinal canal. These are the nerve-roots that come off from the 
 lumbar and sacral segments. The spinal cord ends about opposite the 
 second lumbar vertebra; consequently the nerve-roots from its lower 
 segments have to traverse comparatively long distances before uniting 
 to form the lower spinal nerves at or about their respective foramina 
 of exit from the spinal canal. These prolonged nerve-roots are the 
 Cauda equina. 
 
 Pathology. — The cauda equina maybe the seat of injury or disease. 
 The injuries are similar to those that cause damage to the cord itself. 
 Thus there may be fracture or dislocation of the vertebrae, rupture of the 
 membranes, or traumatic hemorrhage, sometimes with secondary inflam- 
 mation. Fractures and dislocations of the lower parts of the spine are 
 not so common as in the dorsal and cervical regions, for the parts are 
 massive and protected by large muscles; nevertheless they sometimes 
 occur. But a traumatic meningeal hemorrhage may settle from still 
 higher levels and press upon the strands of the cauda equina. Septic 
 meningitis may occur in the lower part of the spinal canal, sometimes 
 during the puerperium, or from other causes, such as a sloughing bed- 
 sore. Syphilitic meningitis may also occur, and syphilitic tumor, or 
 gumma, is not so very uncommon. Other varieties of tumor may also be 
 seen. It is well to bear in mind that although the cauda equina, being 
 composed of nerve-fibres, is anatomically a part of the peripheral nervous 
 system, nevertheless, being contained within the spinal canal and enclosed 
 within the spinal meninges, it has practically some points of resemblance 
 to central structures. 
 
 Symptoms. — Pain is a common symptom in meningitis or neuritis 
 of the cauda equina, and is due to involvement of the sensory roots. 
 It may be felt in the lower part of the abdomen or pelvis, or it may 
 be transmitted to the legs and feet. It is sometimes lancinating or 
 neuralgic, or burning as in neuritis, and may be associated with glossy skin 
 
1348 MEDICAL DIAGNOSIS. 
 
 and cutaneous hypersesthesia. Anaesthesia may also occur; it may be 
 variously distributed, and is sometimes segmental in type, especially 
 when the lesion is localized, as in the case of hemorrhage, and involves 
 only the lower parts of the leash of nerves. This is explained by the 
 fact that each succeeding pair of nerves from below upward represents 
 a distinct segment of the cord. 
 
 The paralysis is peripheral in type;, that is, it is of the flaccid variety, 
 with atrophy of the muscles and changes in the electrical reactions. The 
 knee-jerks are abolished, unless the roots from the upper lumbar segments 
 escape. This type of paralysis is due to the fact that the strands of the 
 Cauda equina belong anatomically to the peripheral nervous system. 
 
 In a few cases the knee-jerks are exaggerated, as when the lesion 
 extends gradually from below upward and acts as an irritant to the roots 
 from the upper lumbar segments. The distribution of the paralysis varies. 
 In some cases muscular groups only are involved, as the peronei, sural, 
 hamstring, etc., thus indicating a segmental type. 
 
 The bladder and bowel may be paralyzed, and priapism or even normal 
 erections do not occur as a rule. Bed-sores are not uncommon. In some 
 cases painful contractures are present in the legs. 
 
 Tumors of the cauda equina cause a great variety of symptoms. All 
 depends upon the level at which the tumor is located and its extent. Pain 
 is an early symptom, possibly felt low in the back, in the pelvis, or in the 
 legs. Later, pressure symptoms develop, and consist of various forms of 
 paralysis, usually of the peripheral type. The symptoms thus gradually 
 extend as from a centre. The bladder and bowel may be affected. 
 
 Diagnosis. — The diseases from which these affections have to be 
 differentiated are myelitis, multiple neuritis, and locomotor ataxia. In 
 traumatic cases the history is usually sufficient to distinguish them. From 
 myelitis the peculiar segmental distribution of the symptoms, the 
 flaccid atrophic paralysis, the reactions of degeneration, and the lost 
 knee-jerks suffice to make clear the difference. .It must be admitted, 
 however, that in myelitis involving the lumbar enlargement all these 
 symptoms might be present, and in such a case an exact diagnosis may 
 not be practicable. 
 
 ■ Inflammation of the cauda equina may closely simulate multiple 
 neuritis, but multiple neuritis is seldom confined to the legs, and the blad- 
 der and bowel are, as a rule practically without exception, not involved. 
 In the cases of alcoholic multiple neuritis in which the lower Hmbs 
 alone are paralyzed, the exemption of the bladder and bowel would serve 
 to point out the difference. The pains, too, are of a different kind in mul- 
 tiple neuritis, being more local and peripheral, and felt most acutely on 
 pressure on the nerves and muscles. 
 
 Disease of the cauda equina resembles locomotor ataxia only remotely, 
 and chiefly in the pain and lost knee-jerks. There are no true tabetic 
 symptoms, as ataxia, pupillary changes, and optic atrophy; and even the 
 pain is not like the paroxysmal fulgurant pain of tabes. Moreover in tabes 
 we do not see distinct segmental anaesthesia, and the muscles, at least in 
 the early stages, are not paralyzed and degenerated. 
 
 Tumor of the cauda equina is discussed with tumors of the spinal cord. 
 
DISEASES OF THE SPINAL NERVES. 1349 
 
 XIX. SPINA BIFIDA. 
 
 Spina bifida is a developmental defect, caused by failure of the verte- 
 bral ai'ches (which grow from the mesoblastic somites in the embryo) to 
 coalesce behind the spinal cord and between it and the skin of the back. 
 SeA'eral varieties of deformity result according to the tissues involved 
 (see p. 16). 
 
 Spina bifida is sometimes associated with other developmental defects, 
 especially hydrocephalus. 
 
 This condition usually presents no difficulty in diagnosis, although the 
 defect is not always detected at once in the new-born child. The small 
 tumor on the back tends to grow, and in time may become very large. The 
 important point is to determine the variety of the bifid spine. In menin- 
 gomyelocele the spinal cord and nerves are involved, and paraplegic symp- 
 toms are always present. This distinction is important, especially from a 
 surgical stand-point, for any operation for the excision or obliteration of 
 the sac in this variety, even if successful, must inevitably leave the child 
 a more or less hopeless cripple. In simple meningocele the results may be 
 better, as the cord is not involved. 
 
 The tumor is usually in the lumbar, lumbosacral, or sacral region. 
 It is infrequent in the cervical and upper dorsal regions. 
 
 Spina bifida requires to be distinguished from certain other embryo- 
 logical defects, such as congenital tumors in the sacrococcygeal region, 
 dermoid cysts, and teratomata, but these fall within the purview of surgery. 
 
 DISEASES OF THE SPINAL NERVES. 
 
 I. MULTIPLE NEURITIS. 
 
 This disease, also called peripheral neuritis or polyneuritis, is, as its 
 name indicates, an inflammation, more or less wide-spread, of the nerves. 
 
 Etiology. — Multiple neuritis is caused by a great variety of poisons, 
 the most common being alcohol, lead, arsenic, mercury, and some of the 
 infectious diseases, especially diphtheria. Cases also occur after typhoid 
 fever, and more rarely after smallpox; also in diabetes. Beriberi is a form 
 of multiple neuritis, the exact causation of which is still undetermined. 
 Among the rarer causes of polyneuritis are carbon monoxide and carbon 
 bisulphide. Phosphorus may also cause neuritis, and in ergotism there is 
 involvement of the sensory and motor nerves. The anaesthetic form of 
 leprosy is due to a neuritis. 
 
 Pathology. — There are two forms usually described — the paren- 
 chymatous and the interstitial. Whatever may be the cause of multiple 
 neuritis, its essential morbid anatomy is much the same, and sometimes 
 the cases partake of both forms. There are segmentation of the mj^elin, 
 proliferation of the nuclei of the sheath of Schwann, and destruction of 
 the axis-cylinder. In many cases there are also some overgrowth of the 
 connective tissue and alterations in the blood-vessels. In the purely 
 parenchymatous form there is destruction of the neuron, even including 
 its cell-body; but according to Berkley, in experimental poisoning with 
 
1350 MEDICAL DIAGNOSIS. 
 
 alcohol, the earliest changes appear to be in the blood-vessels of the nervous 
 system. The seat of the most active changes is usually in the peripherj'- 
 of the nerves. As the cord is approached the disease process diminishes. 
 At the present time, however, the tendency is to find some evidence of 
 degeneration even in the cord, due doubtless to the peripheral neurons 
 being implicated as far as their course in the spinal medulla — as, for 
 instance, in the posterior columns. 
 
 Symptoms. — The most common form of multiple neuritis is that 
 which is caused by alcohol. This may be taken as a type, although some 
 of the other forms, notably that caused by diphtheria, differ from it in 
 certain particulars, as will be pointed out. 
 
 In alcoholic neuritis the earliest symptom is usually pain. This 
 pain is felt especially in the nerve-trunks and in the muscular masses, 
 such as the calves of the legs. It is commonly of an intense burning char- 
 acter, and is so urgent that for a while it may mask the other symptoms. 
 When fully developed this pain is quite unmistakable; it is increased 
 by pressure and by handling the parts; and the patient, especially if a 
 
 y^* — -, 
 
 Fig. 397. — Alcoholic multiple neuritis, showing wrist- and foot-drop. — Lloyd. 
 
 woman, will cry out and even weep when the limbs, and particularly the 
 legs, are handled. The toes and soles of the feet may be exquisitely sen- 
 sitive, and sometimes exhibit some erythema. This is the state known as 
 causalgia. The pain is increased on voluntary motion, and is usually 
 worse in the legs and feet; but it may not be absent in the upper limbs. 
 Pain is not present in all cases. Other sensory symptoms are parsesthesia 
 and various grades of anaesthesia. The thermal sense may be affected 
 in advanced cases, and the electrical sensibility may be impaired, especially 
 to mild currents; but strong currents, particularly if they cause muscular 
 contraction, are most painful. 
 
 Of motor symptoms the commonest are cramps, tremors, paralysis, 
 contractures, and ataxia. Cramps occur early, but the}'" are not seen in 
 all cases. Tremors are occasionally seen in the weakened muscles, and 
 are especially common in the alcoholic cases. Paralysis is the most 
 common motor symptom. This is of the flaccid or peripheral type; the 
 muscles waste and become flabby, and complete reactions of degeneration 
 are seen. The distribution of this paralysis is characteristic; it invades 
 all four limbs, and is most marked in the extensor muscles; hence there 
 are wrist-drop and foot-drop. It is also most marked in the distal muscles; 
 that is, in the muscles furthest from the trunk; hence the forearms and 
 
DISEASES OF THE SPINAL NERVES. 
 
 1351 
 
 hands, and legs and feet, are more paralyzed than the upper arms and 
 thighs. The trunk muscles, however, do not escape, and the external 
 muscles of respiration may be seriously involved. There is also tachy- 
 cardia. The bladder and bowel are not paralyzed, as a rule, although a 
 few doubtful cases are recorded. In the alcoholic cases the cranial nerves, 
 except the vagus, are not often affected. Paralysis of the abducens nerve 
 and optic neuritis have been observed. 
 
 Muscular contractures are not uncommon in advanced cases; they 
 are most marked in the flexor muscles, which are the least paralyzed. 
 These contractures hold the limbs, especially the legs, in a semiflexed 
 position; they are hard to overcome, and greatly retard recovery. 
 
 Ataxia is seen occasionally, 
 giving rise to 'pseudotabes. The 
 incoordination is not unlike that of 
 locomotor ataxia. It occurs in the 
 alcoholic cases and in those caused 
 by lead. 
 
 The reflexes are usually abol- 
 ished. This is true especially of the 
 deep, or tendon, reflexes. The knee- 
 jerks, as a rule, are lost early; in 
 some cases, however, they may 
 persist much diminished. Some 
 observers claim that the deep reflexes 
 are exaggerated; but such exceptions 
 are extremely rare, and they are diffi- 
 cult to explain except on the theory 
 of irritation of the sensory neurons. 
 The superficial, or skin, reflexes are- 
 not so promptly or uniformly lost, 
 and in cases in which there is marked 
 hyperaesthesia they may even be 
 very active; but in advanced cases, 
 particularly when there is anaes- 
 thesia, these reflexes are abolished. 
 
 Of trophic lesions the commonest is atrophy of the muscles. Oildema 
 of the paralyzed legs is sometimes seen, and occasionally erythema, as 
 of the soles of the feet. Ulcers and skin lesions are very uncommon; but 
 trophic bed-sores, especially about the malleoli, have been observed in 
 the post-typhoid cases. Glossy skin may be entirely absent. Profuse 
 sweating is seen in some cases. 
 
 In severe cases the weakness of the heart muscle maybe the determining 
 cause of death. Paralysis of the external respiratory muscles constitutes 
 an additional source of danger. The phrenic nerve is not often involved. 
 
 In some of the alcoholic cases a characteristic psychosis occurs. It 
 is characterized by a wandering delirium, with hallucinations of sight and 
 hearing, confusion of identity of time, place, and persons, and a tend- 
 ency to fabulation. Atypical cases of alcohohc multiple neuritis occur. 
 Occasionally, the patient has little if any pain, while the motor paralysis 
 
 Fig. 398. — Alcoholic polyneuritis, with marked mus- 
 cular atrophy and wrist-drop. — Singleton Smith. 
 
1352 
 
 MEDICAL DIAGNOSIS. 
 
 may be extreme. This motor type may or may not be associated with 
 great ataxia, and constitutes a form of -pseudotabes. It does not follow, 
 however, that in all cases of pseudotabes there is an absence of pain. 
 Another rather rare form is that in which the paralysis is confined to the 
 lower limbs. The usual pain and sore muscles in the calves are present, 
 but there is an absence of bladder and rectal troubles, such as occur 
 in cord lesions. The knee-jerks are lost. 
 
 In lead neuritis the clinical picture is somewhat different. The 
 distribution of the paralysis is usually much less extensive; as, for 
 instance, in the cases in which the extensors of the forearms are alone 
 
 __ involved. In some rare cases, how- 
 ever, there is a more wide-spread 
 paralysis, and the upper arms, 
 shoulders, and even the lower limbs 
 are affected. There is a form of 
 lead palsy closely resembling pro- 
 gressive muscular atrophy. The 
 pseudotabes may also occur, but 
 as a rule sensation is not much 
 involved in lead cases, and pain is 
 rarely observed. 
 
 Postdiphtheritic paralysis (q. 
 V. — diphtheria) . 
 
 The two most specialized forms 
 of multiple neuritis are beriberi and 
 the ancesthetic variety of leprosy (q. 
 V. — beriberi; leprosy). 
 
 In diabetes mellitus neuralgic 
 pains of a severe type sometimes 
 occur, and occasionally angesthesia, 
 especially of the legs, and along 
 with this may occur some paralysis, 
 and atrophy of the muscles, with 
 [ X; ■^•i.™ } lost knee-jerks. 
 
 HHHfe x\ The forms of multiple neu- 
 
 i^^^^^ ''^\\ J ^'^^^^ ^^^ ^^ arsenic, mercury, 
 
 L- "- '■' ' typhoid fever, smallpox, and 
 
 most other infectious diseases show 
 nothing very distinctive. 
 Diagnosis. — The disease with which multiple neuritis is most likely 
 to be confused is locomotor ataxia, and this is true especially of the ataxic 
 type of polyneuritis. But polyneuritis differs from tabes in its mode of 
 onset, which is usually much more brusque; in its history, which usually 
 points to the poison or infection which causes it; in the pain, which is 
 constant, burning, and neuralgic, and much increased by pressure, while 
 in tabes the pains are lancinating, paroxysmal, and not affected by pres- 
 sure, unless sometimes, indeed, they are relieved by it; in the paralysis 
 and muscular atrophy, which are late phenomena in tabes and often 
 absent even late in the disease; in the reactions of degeneration; in the 
 
 Fig. 399. — Peripheral neuritis, with foot-drop of right 
 side, after enteric fever. — Pennsylvania Hospital. 
 
DISEASES OF THE SPINAL NERVES. 1353 
 
 gait, which is high-stepping in neuritis, with foot-drop, the toe grazing the 
 ground (the so-called "turkey-gobbler walk"), due to paralysis of the 
 extensor muscles, while in tabes it is incoordinate, the foot being flung 
 far out and the heels striking the ground first — a distinction which is 
 seen even in pseudotabes of neuritic origin. Moreover, in locomotor 
 ataxia there are the true tabetic phenomena, such as optic atrophy, Argyll- 
 Robertson pupil, atony of the bladder, sexual impotence, and arthropa- 
 thies, which are not seen in polyneuritis, although in the form due to 
 lead, optic neuritis and atrophy sometimes occur. In both diseases the 
 knee-jerks are abolished, and the loss of static equilibrium may be seen 
 in the pseudotabes as well as in the true tabes. Sensory changes are 
 somewhat similar in the two diseases, except that deep sensibility (the 
 sense of position, of pressure, and of voluntary and passive motion) is 
 more likely to be abolished in tabes, while the sup'erficial sensibility 
 (tactile sense especially) is preserved. But these modes of sensation are 
 sometimes affected also in multiple neuritis. 
 
 Various forms of myelitis simulate multiple neuritis. In the sub- 
 acute and chronic anterior poliomyelitis there is a flaccid paralysis with 
 muscular atrophy, but pain is not conspicuous and may be entirely want- 
 ing, and fibrillation of the muscles is seen. Sometimes the tendon reflexes 
 are not entirely lost. The reactions of degeneration are not complete; 
 and finally the history and evolution are different. Transverse myelitis 
 is marked by spastic paraplegia, with exaggerated knee-jerks, and incon- 
 tinence. When the lumbar enlargement is involved there may be flaccid 
 paralysis, but the bladder and bowel are paralyzed, and the symptoms 
 are confined to the lower limbs-. 
 
 In the myopathies the evolution of the disease is extremely slow; 
 pain is not conspicuous, or it is even wanting,, anaesthesia is usually absent, 
 and the history of the case is different. The neuritic form of the myop- 
 a.thies has more in common with neuritis, and may even depend upon a 
 slow neuritis, but the course is extremely slow, the disease is sometimes 
 familial, and the history is different. Some of these forms begin in child- 
 hood, whereas multiple neuritis is usually, but not always, a disease of 
 adult life. A few cases of alcoholic multiple neuritis have been reported 
 in children. 
 
 Hysteria may simulate multiple neuritis, but only superficially, and 
 more particularly in chronic cases, with anorexia and wasting and con- 
 tractures of muscles. But there are no true reactions of degeneration; 
 the tendon reflexes are preserved or even increased; hysterical stigmata 
 are present; and the history is characteristic. 
 
 II. THE CERVICAL NERVES AND CERVICAL PLEXUS. 
 
 The cervical plexus is formed from the four upper cervical nerves. 
 These nerves after issuing from the spinal canal divide into anterior and 
 posterior branches; it is from the anterior branches alone that the cer- 
 vical plexus is formed. The posterior branches are largely sensory, and 
 the largest nerve arising from these is the great occipital nerve. The most 
 important branch of the plexus proper is the phrenic nerve. 
 
1354 MEDICAL DIAGNOSIS. 
 
 Pathology. — This group of cervical nerves may be involved in dis- 
 eases about the base of the skull and the upper cervical vertebrae. Among 
 these especially are spinal caries, and, very rarely, new growths. Fracture 
 and dislocation of these vertebrae occasionally occur. Pure neuralgic 
 affections also may be seated in these nerve branches. 
 
 Symptoms." — Neuralgia of the great occipital nerve, which is dis- 
 tributed to the occiput as high as the vertex, is a distressing malady. 
 There are painful points, especially where the nerve penetrates the 
 trapezius muscle, and over the boss of the parietal bone. The pain is 
 usually paroxysmal. This nerve may also be involved in dislocation of 
 the atlas, as in a case reported by Lloyd, in which there was anaesthesia 
 in the distribution of the great occipital (see Fig. 388). This is explained 
 by the fact .that the nerve is a branch of the second cervical nerve which 
 issues from the si5ine between the atlas and the axis. In spinal caries and 
 new growths there is not only pain but also stiffness of the neck muscles, 
 and this may also be seen in meningitis in the posterior basic region of 
 the brain. In some cases of torticollis it is probable that some of the 
 motor branches of the plexus are involved. 
 
 Diagnosis. — Care is required especially to detect if possible any organic 
 lesion, as new growths, spinal caries, fracture, basal meningitis, etc. 
 
 III. THE PHRENIC NERVE. 
 
 This nerve supplies the diaphragm. It arises from the third and 
 fourth cervical nerves, and therefore has its central origin in the third 
 and fourth cervical segments of the spinal cord. It receives a small branch 
 also from the fifth cervical. In the neck it is deeply situated and passes 
 between the subclavian artery and subclavian vein. It is supplied to the 
 under surface of the diaphragm. 
 
 Pathology. — Owing to its deep situation in the neck and chest the 
 phrenic nerve is not often injured. It may be involved in blows and wounds 
 of the neck and in surgical operations; also in caries of the cervical spine, 
 and in cervical meningitis. In injuries to the cervical cord, due to fracture 
 or dislocation of the vertebrae, this nerve is sometimes involved in its 
 centres of origin. This complication is then the immediate cause of death. 
 In some of the cases in which the lesion is lower in the cervical cord, 
 and the external respiratory muscles are paralyzed, life may hang upon 
 the phrenic nerve, the respiration being entirely diaphragmatic. This 
 nerve is said also to be involved sometimes in alcohohc multiple neuritis 
 and in diphtheritic paralysis. It may also be pressed upon by tumors. 
 
 Symptoms. — Paralysis of both phrenic nerves causes complete paral- 
 ysis of the diaphragm. Respiration is entirely by the external respiratory 
 muscles. Dyspnoea may or may not be present. Bronchitis and pneu- 
 monia are among the risks in these cases. 
 
 Diagnosis. — The symptom may be overlooked, especially if only one 
 phrenic nerve is affected. On close inspection, however, it is seen in the 
 latter case that the movement of the diaphragm on the affected side is 
 impaired, and when both nerves are paralyzed the failure of the diaphragm 
 to descend is evident. Compensatory action of the external respiratory 
 muscles causes exaggeration of the costal type of respiration. 
 
DISEASES OF THE SPINAL NERVES. 1355 
 
 IV. THE BRACHIAL PLEXUS. 
 
 The brachial plexus is formed from the anterior branches of the 
 last four cervical nerves and of the first dorsal nerve. It begins close 
 to the vertebrae and extends to just beneath the clavicle, where it gives 
 origin to its main nerve-trunks. These trunks go to form the cir- 
 cumflex, musculospiral, musculocutaneous, median, ulnar, and internal 
 cutaneous nerves. Hence the brachial plexus supphes with motor 
 and sensory filaments the shoulder and upper limb. These various 
 nerve-trunks, however, take origin from the brachial plexus in such 
 a way that none of them is derived entirely from any one spinal 
 nerve-root. 
 
 Pathology. — The brachial plexus may be the seat of severe neuralgia, 
 trauma, inflammation, and neoplasm. Neuralgic affections are often of 
 obscure nature; they may be caused by rheumatism or gout, possibly 
 also by exposure and by slight grades of inflammation. Tumors are 
 rare; aneurism sometimes acts as a cause. Trauma may cause exten- 
 sive lesions. Fracture of the clavicle and dislocation of the head of the 
 humerus, especially the subcoracoid form, may cause injury to the plexus. 
 Spinal caries may cause irritation of the nerve-roots. 
 
 Symptoms. — In neuralgia usually the sensory fibres alone are 
 involved. Painful points are present, as where the nerve-trunks are most 
 exposed or most easily subjected to pressure; hence, on the side of the 
 vertebrae, in the axilla, and on the musculospiral nerve in the upper 
 arm, and on the ulnar and radial nerves in the forearm. If inflammation 
 is present there may be areas of parsesthesia and anaesthesia, and vaso- 
 motor and trophic lesions. In these cases the motor fibres also suffer, 
 parah'sis resulting. The pain is sometimes intense. 
 
 In traumatic cases the pain may be very severe, and various forms of 
 paraly.sis i*esult according as the lesion is total or partial; also glossy skin 
 and other trophic lesions, such as muscular atrophy; also contractures 
 in old-standing cases. In organic lesions of the plexus from whatever 
 cause there may be complete or almost complete brachial monoplegia. 
 All voluntary movements are lost when the lesion is a total one, and the 
 arm then hangs inert at the side. The shoulder may be kept slightly 
 elevated by over-action of the trapezius muscle. The paralysis is flaccid, 
 with reactions of degeneration, and the tendon-reflexes are lost. The 
 pain may be severe, paroxysmal, ill-defined, and may interfere with 
 sleep. In total lesion the anaesthesia involves the hand and forearm 
 and the outer aspect of the upper arm. The tip of the shoulder is not 
 involved, as it is supplied by the cervical plexus, and the inner aspect 
 of the upper arm also escapes, as it is supplied by the first three 
 dorsal nerves. The upper arm type, according to Erb, is caused by 
 injury to the fifth and sixth cervical roots; the lower arm type by 
 injury to the seventh and eighth cervical and dorsal roots. The upper 
 arm type causes paralysis of the deltoid, biceps, brachialis anticus, 
 supinator longus, and possibly the infraspinatus, supraspinatus, and serra- 
 tus magnus. The lower arm type involves more the muscles of the lower 
 arm and hand. 
 
1356 MEDICAL DIAGNOSIS. 
 
 Diagnosis. — The diagnosis is easy, and is made from the peculiar 
 distribution of the symptoms. Cases vary according to the extent and 
 completeness of the lesion. The cause in pure brachial neuralgia may 
 be obscure; and careful search should be made for organic lesions, such 
 as neuromata, aneurism, and vertebral disease. 
 
 V. THE ANTERIOR THORACIC NERVES. 
 
 These nerves are not of great clinical importance except as pointers 
 in some cases of injury to the brachial plexus. They are two in number. 
 The external nerve is a branch from the outer cord of this plexus and 
 supplies the pectoralis major muscle; the internal nerve arises from the 
 inner cord and supplies both the pectoralis major and minor muscles. 
 They are consequently likely to be involved in a lesion high in the 
 plexus, but they escape in a lesion as low as the retroclavicular portion 
 of that system of nerves. Paralysis of the two pectoral muscles impairs 
 the use of the arm; but the incapacity to the patient is not as 
 great as might be supposed. Forced adduction of the arm across the 
 chest is affected. 
 
 There are a few cases on record of congenital absence of the two 
 pectoral muscles on one side. Whether this anomaly depends on primary 
 defect of the two nerves, is not determined. There is surprisingly little 
 embarrassment to the patient, and in one case the individual was a 
 laboring man who had found no inconvenience from his defect. 
 
 VI. THE POSTERIOR THORACIC NERVE. 
 
 The posterior, or long, thoracic nerve (the external respiratory nerve 
 of Bell) arises from the fifth and sixth cervical nerves. It passes through 
 the middle scalene muscle in the neck, and runs upon the outer surface 
 of the serratus magnus muscle, which it supplies with a filament at each 
 of its digitations. It supplies no other muscle. 
 
 Pathology. — This nerve is most exposed to injury at and about 
 the point where it penetrates the middle scalenus muscle in the neck. 
 Thus it has been injured by carrying heavy weights on the shoulder; 
 possibly also by mere muscular exertion, acting directly through the 
 middle scalene muscle. Cases have occurred thus in parturition. It 
 may also be injured by blows upon the chest and by axillary wounds. 
 The nerve is probably also involved in some cases of alcoholic multiple 
 neuritis in which disease paralysis of the external respiratory muscles 
 is not uncommon. Rare cases have been seen to follow typhoid fever 
 and diphtheria. 
 
 Symptoms. — Paralysis of the serratus magnus muscle is the only 
 result of injury to this nerve. This paralysis causes an excessive mobility 
 of the scapula, which stands out from the chest wall, giving the patient a 
 peculiar "winged" appearance. This is best shown when the patient 
 elevates the arm: the posterior edge of the scapula then flies out from 
 the chest wall and rotates its inferior angle upward and outward, while 
 the acromion descends. The movement of the arm is thus somewhat 
 
DISEASES OF THE SPINAL NERVES. 1357 
 
 embarras-secl, as it is deprived of the basis of support normally given by 
 the shoulder-blade. The chest wall on the affected side is not properly 
 expanded in inspiration. In traumatic cases pain may be felt in the 
 neck. The affection is generally unilateral, but bilateral cases have 
 been reported. 
 
 Diagnosis. — The paralysis is easily recognized by the pecuhar '' wing- 
 ing " of the scapula. 
 
 VII. THE CIRCUMFLEX NERVE. 
 
 This nerve supplies the deltoid and teres minor muscles, and gives 
 sensation to the skin over the lower and posterior parts of the deltoid. 
 It arises from the posterior trunk of the brachial plexus in common with 
 the musculospiral nerve, and in order to reach its destination it winds 
 around the neck of the humerus — a fact of great cHnical significance. It 
 enters the deltoid from the under surface. 
 
 Pathology. — The commonest cause of injury to the circumflex nerve 
 is dislocation of the head of the humerus. The nerve may also be injured 
 in fractures of the neck of the humerus. A rare instance is reported by 
 Raymond of injury to both circumflex nerves by pressure during sleep, the 
 patient lying on his back with the arms elevated and the hands clasped 
 behind the neck. One or both nerves may be injured also during surgical 
 anaesthesia. This nerve is not usually the seat of spontaneous or primary 
 neuritis, although it may be affected in lead poisoning and in diabetes. 
 It lies too deep to be often injured by external causes. In cases of 
 arthritis, rheumatic or otherwise, of the shoulder-joint there may be some 
 wasting and paralysis of the deltoid muscle. 
 
 Symptoms. — Paralysis of the deltoid muscle is shown by inability 
 to lift the arm from the side and to elevate . and hold it above the 
 head. Loss of power in the teres minor causes inability to rotate the 
 head of the humerus outward. As these two muscles take part in 
 various combined movements with the muscles of the upper arm and 
 shoulder, their paralysis is very disabling. The anaesthesia, occupying 
 but a small area, may readily be overlooked, and in fact cannot in some 
 cases be found even by careful search. 
 
 Diagnosis. — Paralysis of the deltoid and teres minor muscles is 
 unmistakable from the peculiar disablement of the arm. The greatest risk 
 of error is in cases of dislocation of the shoulder-joint, when the practi- 
 tioner omits to prepare the patient's mind for the possibihty of this 
 comphcation. A week or more may elapse before the paralysis is recog- 
 nized, especially if the shoulder has been kept bandaged and pain has 
 prevented movement in the joint. The paralysis is of the flaccid type, 
 and the deltoid muscle may waste rapidly and give the reactions of 
 degeneration. Cases have been recorded in which recovery did not take 
 place for fully a year. 
 
 Arthritis causes immobility of the shoulder-joint, but the joint is 
 usually ankylosed and the scapula moves with the humerus. In some 
 of these cases there is more or less atrophy and loss of power in the 
 deltoid muscle. 
 
1358 MEDICAL DIAGNOSIS. 
 
 VIII. THE MUSCULOSPIRAL NERVE. 
 
 This nerve is the largest branch of the brachial plexus. It winds 
 around the humerus from within, behind, to the outer side of the arm 
 in a spiral groove beneath the triceps muscle. It divides, near the 
 external condyle, into two terminal branches, the radial and the posterior 
 interosseous nerves. In the upper arm its main trunk supplies branches 
 to the triceps, anconeus, extensor carpi radialis longior, supinator longus, 
 and in part to the brachialis anticus. The interosseous branch, below the 
 elbow, supplies the extensor muscles of the wrist, thumb, and fingers. 
 The musculospiral nerve, and its main branch, the radial, supply sensa- 
 tion to the posterior aspect of the arm, the anterior aspect of the lower 
 part of the arm, and the back part of the forearm, hand, and fingers, 
 except possibly the extreme tips of the thumb and first three fingers, 
 which, according to Richelot, are supplied by the median nerve. 
 
 Pathology.- — The musculospiral nerve may be injured in various 
 ways. It is exposed to pressure during sleep, when the patient Hes with 
 his head upon his arm; this is particularly so in the sleep of alcoholic 
 drunkenness. The nerve is injured occasionally by the pressure of the 
 head of a crutch. Bilateral palsy may be caused in this way. It is also 
 liable to gun-shot and other wounds, but these are rare. The posterior 
 interosseous branch in the forearm is particularly vulnerable to lead 
 poisoning, the well-known wrist-drop resulting. The musculospiral nerve 
 is also injured sometimes in fracture of the humerus, in dislocation of the 
 elbow, and even by sudden and violent muscular action of the arm. 
 
 Symptoms.- — These depend upon the seat of the injury. If the main 
 trunk is injured high in the upper arm all the muscles supplied by the 
 nerve are paralyzed, including the triceps. This is the case usually in the 
 crutch palsy. In the case of pressure during sleep the triceps usually 
 escapes, and then the paralysis is only in the supinator longus and the 
 extensors of the wrist and fingers; occasionally, however, the supinator 
 longus escapes. When the paralysis is complete the patient cannot supi- 
 nate the hand, nor extend the hand at the wrist, nor extend the fingers. 
 The resulting wrist-drop is characteristic. A curious result is seen in. 
 diminished power of flexion of the hand and fingers, not that the flexors are 
 truly paralyzed, but according to a physiological law that when the antag- 
 onistic muscles are paralyzed the protagonists lose some of their power 
 apparently from failure of a basis of support. This is shown if the hand 
 is passively over-extended, for then the power of the grip is much strength- 
 ened. The loss of power of supination excites an effort of compensation 
 in the patient, in which he rotates the humerus outward and jjresses the 
 arm strongly against the side. The basal phalanges cannot be extended, 
 but the other phalanges, being extended by the interossei, which are 
 supplied by the ulnar, can be extended rather weakly, but best if the 
 basal phalanges be extended passively. As a rule, however, in wrist-drop 
 the fingers are flexed and the thumb turned in and depressed. The paralysis 
 of the supinator longus and brachialis anticus causes some loss of power of 
 flexion of the forearm on the arm, but the latter muscle is not much 
 involved, as it does not receive its whole supply from this nerve. In lead 
 
DISEASES OF THE SPINAL NERVES. 1359 
 
 palsy, as a rule, the supinator longus escapes and may stand out con- 
 spicuously among the wasted muscles. The extensor of the metacarpal 
 bone of the thumb may also escape. The muscles most involved in lead 
 paralysis are the extensors of the wrist and fingers. 
 
 Sensation may be not much impaired in pressure cases and in lead 
 palsy. When present from a total transverse lesion, anaesthesia is dis- 
 tributed about as follows: When the lesion is high in the upper arm the 
 loss of sensation is located on the posterior part of the arm, the anterior 
 aspect of the lower part of the arm, the back of the forearm, especially 
 on the radial side, and the back of the hand and fingers, except the tips 
 of the thumb and the first three fingers. When the lesion is lower, as in 
 pressure cases, loss of sensation, if present, is only seen below the elbow. 
 As in all peripheral palsies there may be marked atrophy of the muscles, 
 lost tendon reflexes, and reactions of degeneration. 
 
 Diagnosis. — The paralysis is so characteristic that a mistake is hardly 
 possible. Lead palsy is bilateral, although occasionally it is worse on one 
 side than the other; it is to be distinguished from the extensor paralysis 
 of alcoholic multiple neuritis by the history; by the pains and the wider 
 extent of the paralysis in alcoholic cases; and by the escape of the supi- 
 nator longus in lead cases. Pressure cases and traumatic cases generally 
 are unilateral. The history is usually clear. 
 
 IX. THE MEDIAN NERVE. 
 
 The median is properly called the fellow of the ulnar nerve, as both 
 are flexors of the wrist, hand, and fingers. It arises from the brachial 
 plexus and passes down by the side of the brachial artery. All its 
 branches are given off in the forearm and hand. It supplies all the 
 muscles on the front of the forearm except the flexor carpi ulnaris and 
 the inner half of the flexor profundus digitorum, which are suppHed by the 
 ulnar. In the hand it supplies the abductor, the opponens, and the 
 short flexor of the thumb; also the first two lumbricales. Its functions 
 therefore are largely flexor and pronator. It also gives sensation to the 
 radial side of the palm and to the palmar surfaces of the thumb, fore 
 and middle fingers, and the radial side of the ring finger. According 
 to some observers it also supplies the dorsal aspect of the tips of these 
 fingers and the thumb. 
 
 Pathology. — The median nerve may be injured in many ways. It 
 is not often involved by pressure during sleep, nor is it injured as often 
 as the ulnar. 
 
 Symptoms. — One of the most characteristic symptoms of paralysis 
 of the median nerve is inability to pronate the forearm; this cannot be 
 accomphshed beyond the mid-position, and the patient supplements the 
 attempt by rotating the humerus inward. Another characteristic symp- 
 tom is inability to oppose the thumb to the tips of the fingers; the thumb, 
 in fact, is much hampered in many of its movements, including flexion 
 and abduction. Still other symptoms are impaired flexion of the wrist, 
 which is then done entirely through the ulnar nerve, with consequently 
 marked deviation of the hand toward the ulnar side; and loss of flexion 
 
1360 
 
 MEDICAL DIAGNOSIS. 
 
 of the phalanges, except the distal phalanges of the ring and little fingers, 
 which are supplied thi'ough the ulnar. The unopposed extensor action of 
 the interossei muscles may cause a subluxation of the joints between the 
 second and third phalanges. Anaesthesia is present on the radial side of the 
 palm, the palmar surfaces of the thumb, fore and middle fingers, the radial 
 side of the ring finger, and the dorsal tips of these fingers and thumb. 
 Trophic lesions are very common in injuries of the median nerve. 
 Diagnosis. — This is usually clear from the history of the case and the 
 characteristic distribution of the symptoms. The loss of power of com- 
 plete pronation, the awkward flexion of the wrist with deviation of the 
 hand to the ulnar side, the disablement of the thumb, and the loss of 
 power of flexion of the fingers, together with the classical ansesthesia, 
 are determinative. The muscular atrophy and reactions of degeneration 
 
 help to distinguish the case 
 from one of cerebral origin. 
 The trophic lesions, if present, 
 are especially significant, 
 
 X. THE ULNAR 
 NERVE. 
 
 The ulnar nerve is one of 
 the two flexor nerves of the 
 wrist, hand, and fingers. It 
 arises from the brachial plexus 
 and passes down the inner side 
 of the upper arm in close prox- 
 imity to the brachial artery. 
 At the elbow it passes behind the internal condyle, where it can readily be 
 felt in most persons, and where pressure upon it causes a tingling sensation. 
 It supphes the flexor carpi ulnaris, part of the flexor profundus digitorum, 
 the muscles of the httle finger, the interosseous muscles, two of the lum- 
 bricales, the adductor pollicis, and one head of the flexor brevis pollicis. 
 It gives sensation to the ulnar side of the forearm and hand, the httle 
 finger, and the ulnar side of the ring finger. By reason of its distribu- 
 tion this nerve presides over the ulnar flexion of the wrist, the flexion 
 in part of the fingers, the adduction and abduction and other finer 
 movements of the fingers, also extension of the second and third phalanges 
 and flexion of the first phalanges, and the movements of the thumb 
 toward the palm. 
 
 Pathology. — This nerve is much exposed to injury, as by wounds, 
 pressure, dislocation, and fractures. It may also be involved in tumors 
 and malignant growths, and in surgical operations. Pressure may occur 
 during sleep, especially during alcoholic sleep and the unconsciousness 
 caused by ether or chloroform; also during parturition. 
 
 Symptoms. — Paralysis of the ulnar nerve causes a charactei'istic 
 disability. Flexion of the wrist is impaired, and on attempts at flexion 
 there is a deviation of the hand toward the radial side. Flexion of the 
 little and ring finger is es^Decially impaired, and the little finger is almost 
 
 Fig. 400.- 
 
 -Distribution of anaesthesia in paralysis of 
 the median nerv^e. 
 
DISEASES OF THE SPINAL NERVES. 1361 
 
 entirely paralyzed. Adduction of the thumb is lost, hence the patient's 
 inability to grasp objects. Flexion of the first phalanges and extension 
 of the last two phalanges are impaired, but the loss of flexion is less in the 
 first two fingers which are supplied in part by the median nerve. The 
 finer movements of the fingers are abolished. In long-standing cases a 
 characteristic deformity results which is called the "main-en-griffe"; 
 the first phalanges become over-extended, much more so than is possible 
 by voluntary power, and the last two phalanges are strongly flexecl. This 
 deformity, however, is not so marked as in cases of anterior poliomyelitis, 
 because the lumbricales of the first two fingers are not involved in ulnar 
 paralysis, being supplied by the median nerve. Muscular atrophy is 
 usually marked; the interosseous spaces are hollowed out, the palm is 
 wasted, and the hypothenar eminence is atrophied. Anaesthesia involves 
 the ulnar side of the arm for some distance above the wrist, also the ulnar 
 side of the hand on both the palmar and dorsal aspects, the whole of the 
 little finger, and the ulnar side of the ring finger. 
 
 Diagnosis.— This is comparatively easy, because of the characteristic 
 disablement and deformity. Some care may be necessary in cases due 
 to pressure, as during sleep, or parturition, or surgical anaesthesia. The 
 history of the case, however, is usually clear, and the resulting paralysis 
 is unmistakable. In a case occurring during the delirium of typhoid fever, 
 the paralysis was riot detected until the patient's mind became clear and 
 he himself called attention to the loss of power. In irritative injuries, such 
 as gun-shot wounds, trophic lesions ma}^ result, such as glossy skin and 
 oedema, and these may be accompanied with burning pain or "causalgia." 
 
 XI. THE INTERCOSTAL NERVES. 
 
 These nerves are branches of the twelve dorsal nerves. The}^ are 
 separate from each other in the sense that they do not form a plexus. 
 Each nerve runs forward in an intercostal space, and for part of its course 
 it is in close proximity to the pleura. 
 
 The intercostal nerves may be variously affected, and they some- 
 times furnish important indications for diagnosis. This is especially so 
 in diseases of the spinal cord. Thus a spinal meningitis or a spinal tumor 
 may irritate the roots of one or more dorsal nerves, and this may point 
 to the location of the lesion. It may also simulate an intercostal neu- 
 ralgia. The same is true of spinal caries. In all such organic lesions 
 the diagnosis is to be made by a study of other attendant symptoms. 
 Aneurism of the thoracic aorta may, by irritating a dorsal nerve-root, 
 simulate disease of the spinal cord. Herpes zoster frequently attacks 
 one of the dorsal roots, its point of attack being probably the posterior 
 ganglion, and the pain and characteristic eruption follow closely the distri- 
 bution of the nerve affected. Intercostal neuralgia is to be distinguished 
 from pleurisy. The affection known as mastodynia, or neuralgia of the 
 breast, is often a puzzling affection, and is commonly seen in neurotic or 
 hysterical women. Fracture of the ribs is usually attended with severe 
 pain in the intercostal nerves, and the diagnosis may require great care, 
 especially where the history of trauma is obscure. 
 
 86 
 
1362 MEDICAL DIAGNOSIS. 
 
 XII. THE LUMBAR PLEXUS. 
 
 This plexus is formed from the twelfth dorsal and the first four lumbar 
 nerves. The fifth lumbar nerve does not enter into this formation, but 
 after receiving a branch from the fourth, goes, as the lumbosacral cord, 
 to help form the sacral plexus deep in the true pelvis. This formation 
 of the lumbosacral cord has not a little clinical importance, as will be 
 shown later. The principal nerves arising from the lumbar plexus are 
 the iliohypogastric, the ilio-inguinal, the external and internal inguinal, 
 the anterior crural, and the obturator. The iliohypogastric nerve supplies 
 sensation to the skin of the gluteal and hypogastric regions. It is of little 
 clinical importance. The ilio-inguinal nerve is both motor and sensory. 
 It supplies the internal oblique muscle. It passes out at the external 
 abdominal ring and is distributed to the skin of the scrotum in the male 
 and of the labium in the female, and to the upper inner part of the thigh. 
 The genitocrural nerve is of clinical significance as supplying the crem- 
 asteric muscle. It might be involved in psoas abscess, as it penetrates 
 the psoas muscle. The external inguinal or external cutaneous nerve is 
 the sensory nerve of the outer part of the thigh as far down as the knee. 
 Its posterior branch supplies the outer posterior part of the thigh as far 
 as the middle third. The anterior crural and obturator nerves, because 
 of their importance, are described under separate headings. From the 
 nature of their origin and relations, however, they are often involved in 
 lesions of the lumbar plexus. 
 
 Pathology. — The lumbar plexus is less frequently the seat of injuries 
 and disease than either the brachial or sacral plexus. Its anatomical 
 position, deep within the body, explains this comparative exemption. 
 The lumbar plexus, being merely a continuation of the nerves which 
 have their origins just within the spinal canal, is closely associated with 
 these parts in its pathology. Falls and crushing injuries may possibly 
 involve the lumbar plexus as well as the intraspinal nerve-roots. 
 Tumors within the body may also cause pressure or irritation. Lumbar 
 and psoas abscess may variously affect these nerve-cords. Finally, par- 
 turition may do injury to the anterior crural and the obturator nerves. 
 
 Symptoms. — These vary widely according to the particular nerve- 
 cords involved. A good method of diagnosis is carefully to study the 
 motor, sensory, and reflex phenomena seriatiw., and then by grouping these, 
 to arrive at a conclusion as to what parts of the plexus are involved. 
 
 The pain caused by these lesions may be most misleading. Lydston 
 has reported a case of acute lumbar abscess which, by irritating some 
 strands of the lumbar plexus, simulated nephritic colic: the pain was in 
 the iliolumbar region. Psoas abscess may cause pain and paralysis 
 in the anterior crural nerve, which passes through the psoas muscle. 
 It may also involve the genitocrural nerve. Referred or distal pain is 
 sometimes a puzzling symptom from this cause, such as pain on the 
 inner side of the knee and down the inner side of the leg following 
 the course and distribution of the anterior crural and its long saphenous 
 branch. The knee pain due to hip-joint disease is another example, 
 probably due to irritation of the obturator nerve. 
 
DISEASES OF THE SPINAL NERVES. 1363 
 
 The motor and reflex symptoms depend upon the nerves imphcated. 
 If the anterior crural is involved the knee-jerk is lost and the extensor 
 muscles of the thigh and leg are paralyzed. The cremasteric reflex may be 
 lost by involvement of the genitocrural nerve. Paralysis of the obtu- 
 rator causes loss of power of adduction in the thigh. Paralysis of the 
 bowel and bladder is not caused by involvement of the lumbar plexus. 
 
 Diagnocis. — This has been indicated in the foregoing description of 
 the pathology and symptoms. It is most important to search for gross 
 local lesions, such as abscess, tumor, and vertebral disease. Injuries to 
 the plexus are rare; they sometimes occur as results of child-birth, 
 
 XIII. THE ANTERIOR CRURAL NERVE. 
 
 This nerve arises from the lumbar plexus and passes out of the pelvis 
 beneath Poupart's ligament on the outer side of the femoral artery. It 
 supplies the muscles on the anterior of the thigh, which act as extensors 
 of the leg; within the pelvis it passes through the psoas muscle, and sup- 
 plies the iliacus. It gives sensation to the front and inner surfaces of the 
 thigh, and by its main branch, the long saphenous, to the inner side of the 
 leg and foot as far sometimes as the great toe. 
 
 Pathology. — The anterior crural may be involved in psoas abscess, 
 as the nerve passes through the fibres of the psoas muscle. Other deep- 
 seated abscesses in the pelvis might also affect it, but lumbar abscess is 
 more likely to affect other and higher branches of the lumbar plexus. 
 Injury to the anterior crural nerve is rare. Fullerton reports the case of 
 a dwarf in which pressure during labor caused transient injury to this 
 nerve; and it may also be hurt in some forms of dislocation of the hip, 
 but only rarely. 
 
 Symptoms. — There is paralysis of the quadriceps extensor muscle with 
 consequent inability to extend the leg. This paralysis is flaccid, with 
 atrophy, and the knee-jerk is abolished. If the iliacus muscle is involved 
 within the pelvis, there is inability to flex the thigh, which is characteris- 
 tically shown by the patient lifting the thigh with his hands when asked 
 to cross the lame leg over the other. This movement also is embarrassed 
 by the paralysis of the sartorius. Pain may be present and is experienced 
 from Poupart's ligament to the inner side of the knee, and thence down 
 the inner side of the leg even to the foot and great toe. In psoas abscess 
 this pain is sometimes distal and is relieved by flexing the thigh on the 
 pelvis with the knee kept bent. Anaesthesia involves the anterior and 
 internal surfaces of the thigh and the inner surface of the leg and foot 
 following the course of the long saphenous branch. 
 
 Diagnosis. — Psoas abscess may simulate crural neuralgia. The 
 paralysis of the nerve is readil}" determined by the characteristic loss of 
 power in the iliacus, sartorius, pectineus, and quadriceps extensor mus- 
 cles, with lost knee-jerk, and by the distribution of the anaesthesia and 
 pain. Irritation of the roots of this nerve might be caused by a tumor in 
 or near the spine, or by disease of the lumbar vertebra. It may also be 
 paralyzed by aneurism of the femoral artery. Diabetes has been known 
 to cause paralysis and neuralgia in both crural nerves. 
 
1364 MEDICAL DIAGNOSIS. 
 
 XIV. THE OBTURATOR NERVE. 
 
 This nerve, after rising from the second, third, and fourth lumbar 
 nerves, and penetrating the inner fibres of the psoas muscle, runs along 
 the inner and lateral wall of the pelvis to the obturator foramen, by which 
 it emerges. It suppHes the obturator externus and adductors of the thigh, 
 the articulations of the hip and knee, and the skin of the inner side of the 
 thigh, and, possibly by its communication with the long saphenous nerve, 
 of the leg also. 
 
 Pathology. — Because of its deep position injury to the obturator 
 nerve is rare. Some obstetricians believe that it is sometimes involved in 
 puerperal cases, as by the forceps, or the child's head, or in pelvic inflam- 
 mation. The pain in the knee in the early stages of hip-joint disease is 
 usually ascribed to irritation of the obturator nerve, which sends fila- 
 ments to both joints; but some orthopaedists explain it as due to mus- 
 cular spasm. Obturator hernia and pelvic tumors may compress the 
 nerve, and it may be irritated by psoas abscess. 
 
 Symptoms. — Paralysis of the obturator nerve interferes with crossing 
 the affected leg over its fellow, and with outward rotation of the thigh. 
 The anaesthesia is on the inner side of the thigh and perhaps of the leg, 
 but it may not be marked. 
 
 Diagnosis. — This is indicated in the account of the symptoms. The 
 knee pain in hip-joint disease has led to error. In an obscure case it is 
 well to bear in mind the possibility also of a psoas abscess. 
 
 XV. THE SACRAL PLEXUS. 
 
 The sacral plexus lies deep in the pelvis. It is formed from the lumbo- 
 sacral cord, which arises from the fourth and fifth lumbar segments, and 
 from the three upper sacral nerves and a part of the fourth sacral nerve. 
 It gives origin to four main nerves, the superior gluteal, pudic, small 
 sciatic, and great sciatic. 
 
 Pathology. — The sacral plexus may be injured by tumors within the 
 pelvis and diseases of the womb, ovaries, or rectum; by pressure during 
 labor; by wounds; and it may be the seat of neuritis. 
 
 Symptoms. — These vary widely, according to the particular nerve- 
 cords involved. 
 
 Pain is a common symptom, and may be felt about the buttock, hip, 
 perineum, and even down the thigh and in the leg, foot, and toes, following 
 the course of the great or small sciatic nerves. Paralysis of various muscles 
 is also present, and this paralysis may even present certain types, accord- 
 ing to the nerves involved. The bladder and bowel may be paralyzed. 
 For a proper understanding of these cases it is best to describe the vari- 
 ous types of the affection. 
 
 One of the commonest and most important is the 'peroneal type. 
 This is particularly likely to occur after child-birth. After instrumental 
 delivery, or even after normal labor in rare instances, the patient has 
 pain in the foot and toes; this is soon followed by loss of power in the 
 extensor muscles of these parts, such as the peronei, the tibialis anticus, 
 
DISEASES OF THE SPINAL NERVES. 1365 
 
 and the long extensor of the toes. The patient in walking has foot-drop 
 and lifts the foot high, the toes dragging along the floor. The paralysis is 
 flaccid, the muscles atrophy, and complete reactions of degeneration are 
 seen. The knee-jerks are not abolished. Anaesthesia may be present on 
 the outer part of the leg and on the dorsum of the foot and toes. The 
 explanation of this affection lies in the fact, that the external popliteal or 
 peroneal nerve is a continuation of the lumbosacral cord in the pelvis, 
 and that this lumbosacral cord is particularly exposed to injury by pres- 
 sure where it runs over the brim of the true pelvis in passing down to the 
 sacral plexus. In these cases there may also be some loss of power in the 
 gluteus medius muscle, which derives its motor supply from a branch of the 
 lumbosacral cord. In most of these puerperal cases the affection is uni- 
 lateral; occasionally, however, there is a bilateral paralysis, presenting a 
 rather different type. 
 
 The form of paralysis varies. All depends upon the particular nerves 
 involved. Occasionally the great sciatic nerve alone is impaired by some 
 intrapelvic lesion, and the case then presents the picture of an ordinary 
 sciatica. A small ovarian tumor has been known to cause pain and loss 
 of power in the buttock. In some of the post-partum cases pain is the 
 chief or only symptom. 
 
 Diagnosis. — It is of first importance that the practitioner should 
 determine the cause. When this has once been done the nature of the 
 case usually becomes clear. 
 
 The chief difficulty is to distinguish these cases from affections of the 
 Cauda equina. The history, however, usually points to an intrapelvic 
 lesion, as in the puerperal and gynaecological cases, and an expert investi- 
 gation 'per vaginam or yer rectum will generally detect a local cause if it 
 is present. The examination by the rectum is especially important, as by 
 this means the nerve-trunks can be palpated. Affections of the cauda 
 equina are usually bilateral; while those of the sacral plexus are often, 
 unilateral; but this latter rule is not absolute. 
 
 Hysteria may simulate these affections, but this psychoneurosis is to 
 be recognized by the mental state, history, and peculiar hysterical stigmata. 
 
 Cancer of the rectum, as well as ovarian tumor, has been mistaken 
 for sciatica or some form of pelvic neuralgia. 
 
 XVI. THE SCIATIC NERVES. 
 
 The great sciatic arises from the sacral plexus and passes out of 
 the pelvis by the sacrosciatic foramen, where it is readily accessible to 
 pressure between the great trochanter and the tuberosity of the ischium. 
 It supplies in the thigh the hamstring muscles — the biceps femoris, the 
 semimembranosus, and semitendinosus — and divides just above the pop- 
 liteal space into two main branches, the internal popliteal and exter- 
 nal popliteal (or peroneal) nerves. These two branches supply all the 
 muscles below the knee (both extensor and flexor) and give sensation to 
 most of the leg and foot, the parts not supplied by it being a strip along 
 the inner side of the leg which is supplied by the long saphenous nerve, 
 and the upper part of the calf which is supplied by the small sciatic. 
 
1366 MEDICAL DIAGNOSIS. 
 
 The small sciatic also arises from the sacral plexus and passes out of 
 the pelvis alongside of the great sciatic; it supplies the gluteus maximus 
 muscle (through the inferior genital nerve), and a well-defined area of 
 the skin which includes the buttock, the perineum, and a strip running 
 down the back of the thigh to and including the upper part of the calf. 
 
 Pathology. — - The great sciatic nerve may be the seat of wounds, 
 inflammation, and tumors. It is sometimes injured in dislocations of 
 the hip, also in forceps deliveries, and hy pelvic tumors and even masses 
 of faeces. Inflammation of the nerve constitutes the disease known as 
 "sciatica." Opportunities to examine the nerve are rare in sciatica, but 
 in a few instances on record the nerve-trunk has been found swollen and 
 congested. In the operation for stretching, a similar state has been 
 found. Gout, rheumatism, syphilis, alcoholism, and lead have all been 
 assigned as causes of sciatica. Exposure to cold, especially after great or 
 prolonged muscular effort or a wetting, may cause the attack. Fournier 
 said that it may follow gonorrhoea. 
 
 Symptoms. — In organic lesions, such as injury or tumor, the symp- 
 toms are characteristic. Pain is an early symptom, sometimes with 
 twitching of the muscles and drawing up of the leg. If the nerve is sev- 
 ered or in any way completely paralyzed, there is loss of power in the 
 hamstring muscles and in all the muscles below the knee, with anaesthesia 
 on the outer side of the leg, dorsum of the foot, the toes, the sole, and a 
 portion of the inner and back part of the leg. The regions that are exempt 
 are a narrow strip on the inner side of the leg, supplied by the long saphe- 
 nous nerve, and the upper part of the calf, supplied by the small sciatic. 
 The muscles atrophy, and reactions of degeneration are present. The 
 knee-jerk may not be lost. Trophic ulcers sometimes occur. 
 
 Pain is the common and sometimes the only symptom in sciatica. 
 This pain is severe and neuralgic in type, especially felt about the upper 
 and back part of the thigh. It may also extend down along the course of 
 the nerve and be particularly intense in the calf of the leg and even in the 
 foot and toes. Any unusual motion in the leg may aggravate it, as 
 suddenly bending the thigh. In such cases the forcible action of the 
 pyriformis muscle probably causes pressure on the hypersensitive nerve- 
 trunk at its exit from the pelvis. In the earlj^ stages the pain may be 
 paroxysmal; later it is constant, dull, and aching, or even severe and 
 shooting. Sensitive points are found at the exit from the pelvis, behind 
 the knee, at the head of the fibula, and on the back of the foot. The trunk 
 of the nerve in the thigh is usually extremely sensitive to pressure. Firm 
 pressure between the great trochanter and the tuberosity of the ischium 
 is usually most painful. 
 
 Paraesthesia is sometimes observed, as burning and tingling in the 
 areas of distribution of the sensory nerve endings. Anaesthesia is not com- 
 mon, and when present may escape detection if not carefully sought for. 
 
 Motor involvement is not common in sciatica. There is usually 
 no true paralysis of muscles, no atrophy, or reactions of degeneration. 
 The knee-jerk, as a rule, is not affected. The Achilles-tendon jerk 
 may be lost. Inhibition of motion is not uncommon, but this is due 
 to pain. The gait is affected for the same reason, and there may be 
 
DISEASES OF THE SPINAL NERVES. 1367 
 
 sKght scoliosis. The muscles may become flabby and wasted from dis- 
 use. Trophic lesions are rare. Herpes may occur. 
 
 The small sciatic nerve may be injured along with the great sciatic 
 at the point where they emerge together from the pelvis. Instances in 
 which it is injured alone must be very rare. Its paralysis causes loss of 
 power in the gluteus maximus muscle, which is shown in inability to 
 rise from a sitting position. This paralysis, however, is due to involve- 
 ment of the inferior gluteal nerve, which, according to Gray, is closely 
 associated with, rather than a branch of, the small sciatic. Anaesthesia is 
 present on the buttock, the perineum, and the back part of the thigh and 
 popliteal space as far as the upper third of the calf. 
 
 Diagnosis. — If there is some organic cause, as injury or tumor, the 
 history of the case^ and a careful physical examination usually reveal it, 
 and, with the characteristic motor and sensory symptoms, disclose the 
 nature of the case. 
 
 It is easy, as a rule, to recognize sciatica. Pelvic abscesses, disease 
 of the uterus and ovaries, large fecal accumulations, and especially cancer 
 of the rectum have been mistaken for sciatica. Bone disease in the lum- 
 bosacral spine may simulate sciatica by irritating the nerve-roots. Hip- 
 joint disease is to be distinguished by the pain on moving the joint, 
 restriction of motion, alteration in the length and position of the limb, 
 tilting of the pelvis, and the other classical symptoms. Obscure cases 
 always call for a rectal examination or vaginal examination. Appendicitis 
 may cause deep-seated pains in the pelvis, but is not likely to be mis- 
 taken for sciatica. In sciatica the most distinctive symptom is the pain 
 on pressure on the nerve-trunk. A sign pointed out by Lasegue is of diag- 
 nostic value — when the patient lies on his back and the extended limb is 
 elevated, pain is not felt until an angle of about 90° is reached, and this 
 pain is then relieved by bending the leg at the knee. The disease is 
 unilateral in the vast majority of cases, bilateral sciatica being usually 
 symptomatic of organic disease, such as myelitis, tumor, spinal caries, 
 or affections of the cauda equina. Still, cases of genuine bilateral sciatica 
 have been seen, especially in constitutional diseases, as gout and diabetes. 
 
 XVII. THE INTERNAL POPLITEAL NERVE. 
 
 This nerve is a continuation of the great sciatic. It supplies the 
 flexors of the foot and toes (the calf muscles and muscles of the sole), and 
 gives sensation to the outer part of the back of the leg, to the sole, and 
 in part to the toes. 
 
 Pathology. — The internal popliteal, or posterior tibial nerve as it is 
 called in its extension down into the leg, is so deeply situated that it is 
 but seldom injured. It shares, however, in some diseases with other 
 nerves, especially such affections as cause muscular atrophy and club- 
 foot. In many of these cases, however, the seat of the lesion is in the 
 anterior gray matter of the cord rather than in the nerve itself. 
 
 Symptoms. — Paralysis of the flexor muscles of the foot — the soleus, 
 gastrocnemius, and plantaris — which are supplied by this ner^^e, causes 
 the form of club-foot known as valgus, sometimes associated with cal- 
 
1368 MEDICAL DIAGNOSIS. 
 
 caneiis. Thus flexion of the foot is impaired, and the unopposed pero- 
 neus longus pulls the outer edge of the foot upward. The patient tends 
 to walk on the inner edge of his foot and on the heel, and he cannot lift 
 himself on his toes. When the nerve is injured, loss of sensation is found 
 on the lower part of the back of the leg and on the sole. 
 
 Diagnosis. — The diagnosis is easily made from the characteristic dis- 
 tribution of the paralysis and anaesthesia. 
 
 XVIII. THE PERONEAL NERVE. 
 
 The peroneal or external popliteal nerve is in appearance a branch of 
 the great sciatic arising in or just above the popliteal space, but accord- 
 ing to some observers its fibres are really derived from the lumbosacral 
 cord in the pelvis, as is proved by the occasional high division of the 
 great sciatic within the pelvis, in which cases the peroneal is seen to be a 
 continuation of one of these branches, which itself is a continuation of 
 the lumbosacral cord. It passes into the leg behind the head of the 
 fibula, where it may easily be palpated and where it is especially exposed 
 to injury. It supplies the extensor muscles of the foot and toes, and gives 
 sensation to the lower and outer part of the leg, the inner and outer parts 
 of the ankle and foot, the dorsum of the foot, the inner side of the great 
 toe, and the adjoining sides of the other toes. 
 
 Pathology. — This nerve is sometimes paralyzed by trauma acting 
 upon it near the head of the fibula. It may also be involved in fracture 
 of the fibula. The peroneal is particularly liable to involvement in cases 
 of alcoholic multiple neuritis in association with other nerves; and in the 
 polyneuritis following typhoid fever this nerve, as well as the ulnar, is 
 apt to be conspicuously affected. There is also a form of muscular atro- 
 phy — the so-called Charcot-Marie-Tooth type — in which the muscles sup- 
 plied by the peroneal nerve suffer especially. The disease is likely to- 
 begin in these muscles, but later the hands and forearms become affected. 
 It probably depends upon a peripheral neuritis, and is sometimes a 
 familial affection. Thus Ormerod observed three cases of this disease 
 following measles in one family. The distal muscles are more affected 
 than the proximal. In puerperal palsy the fibres going to form the pero- 
 neal nerve may suffer from pressure of the child's head on the lumbosacral 
 cord and sacral plexus. Among rare causes of peroneal palsy are the 
 application of an Esmarch tourniquet, and the pressure of stilts. It is a 
 curious fact that for some obscure reason potato-pickers and others who work 
 in a stooping position sometimes get paralysis of this nerve (Oppenheim). 
 
 Symptoms. — There is loss of power of extension of the foot and toes, 
 with consequent foot-drop in walking. The first phalanges of the toes 
 may be flexed by contracture of the interossei. The ansesthesia is on the 
 outer side of the lower leg and ankle, the dorsum of the foot, and the toes. 
 According to some observers the inner side of the ankle is anaesthetic. 
 
 Diagnosis. — The diagnosis is easily made from the characteristic dis- 
 tribution of the symptoms. The paralysis of this nerve is distinguished 
 from that of its main trunk, the sciatic, by the escape of the parts supplied 
 by the internal popliteal, and of the hamstring muscles. 
 
CHOREA. 1369 
 
 GENERAL NERVOUS DISEASES. 
 
 I. CHOREA; SYDENHAM'S CHOREA. 
 
 St. Vitus' s Dance. 
 
 A disease of children and young adults, characterized by continuous, 
 irregular, involuntary muscular contractions and psychical derangements. 
 
 This substantive affection has nothing in common with a number of 
 other diseases unfortunately described as chorea or choreiform, except 
 abnormal muscular movements. 
 
 Etiology. — Predisposing Influences. — The disease appears in 
 successive generations in certain families. The readily transmitted neu- 
 rotic constitution plays a more important role. The nervous, excitable 
 children of nervous parents are especially liable to chorea. Chorea 
 is particularly a disease of childhood and adolescence. It is rare before 
 the fifth year and after the fifteenth. The cases in early adult life 
 almost always occur in women. The disease occurs about three times as 
 often in females as in males. Chorea is more common among the chil- 
 dren of the poor, but is frequently observed among those living in afflu- 
 ence. It is rare amo-ng negroes. The disease is relatively frequent among 
 bright, intelligent school children, especially girls, between ten and fifteen, 
 who are encouraged by their teachers to unreasonable and unnatural appli- 
 cation to study. Anaemia and general poor health often precede the 
 attack, but, on the other hand, it frequently occurs in well-nourished chil- 
 dren. The disease frequently develops in chlorotic girls. Scarlet fever is 
 sometimes followed by chorea. This sequence also occurs as regards 
 whooping-cough and other diseases of childhood; but there is no satisfac- 
 tory evidence of a causal relation between these infections and chorea. 
 In older persons chorea has been observed after gonorrhoea and sepsis. 
 Chorea frequently develops shortly after an attack of acute rheumatism, 
 and in a group of cases the arthritis is so mild and the choreic symptoms 
 are so prominent as to justify a doubt as to whether or not rheumatic 
 fever has actually been present. In other cases there is a history of rheu- 
 matic fever months or years before the development of the chorea. Under 
 either of these conditions the evidences of endocarditis or chronic val- 
 vular disease may or may not be present. The endocardial murmurs 
 present in a case of chorea may be due to actual valvular lesions, to 
 irregular action of the heart, or to anaemia. A woman suffering from 
 chorea may become pregnant; and the disease may develop during preg- 
 nancy or after parturition. It has been observed in repeated pregnan- 
 cies. It begins more frequently in the early than in the later months 
 and is often of the severe type — chorea insaniens. About twenty per 
 cent, of the cases in pregnant women terminate in death. The causal 
 relation of pregnancy is shown by the fact that the chorea ceases upon 
 the occurrence of abortion or miscarriage, or delivery at full term. 
 
 The Exciting Causes. — In the present state of knowledge it 
 must be assumed that various pathogenic agencies act as the immediate 
 exciting cause of chorea. Among these are: emotional shock, especially 
 
1370 MEDICAL DIAGNOSIS. 
 
 fright; mental shock, particularly in young women; and some conditions 
 associated with rheumatic fever and acute or chronic endocarditis, the 
 nature of which is not understood. The attack has followed a slight injury 
 or a surgical operation and has been attributed to reflex causes, as intes- 
 tinal worms or genital irritation. It has been stated, but not substan- 
 tiated, that ocular defects may cause the disease. Finally, the disease 
 frequently develops in the absence of any noticeable cause. 
 
 Hypotheses of Chorea. — The view that it is a pure neurosis appears 
 to be widely accepted. The embolic view has some basis of support 
 in the experimental chorea produced in animals by the injection of 
 indifferent substances in fine particles. Cases occur in the absence of 
 endocarditis and without embolism, and with endocarditis but without 
 embolism. That chorea is an infectious disease is an opinion which has 
 the support of many observers. The fact that the attack in an impor- 
 tant proportion of the cases directly follows fright or other profound 
 emotional disturbance, and the prominent psychical derangements militate 
 against this view. 
 
 Symptoms. — Two forms may be recognized: (1) the ordinary form 
 in which the symptoms are of variable intensity, and (2) the maniacal 
 form — chorea insaniens. 
 
 (1) The Ordinary Form. — The onset of the disease is insidious. 
 The child gradually becomes awkward, clumsy, and restless. He cannot 
 sit still. There is a marked change in disposition. He appears to be care- 
 less and indifferent, and upon correction has spells of crying or becomes 
 sullen. In the course of some days the characteristic involuntary move- 
 ments begin. In the mild cases only one hand or the side of the face is 
 affected — hemichorea; in the more severe cases both sides are involved, 
 but one side to a greater degree than the other. In a well-marked case, 
 the child cannot remain quiet, but is in continual motion. The face 
 twitches, the arms are abducted, adducted, rotated, the hands extended, 
 the fingers separated and at once withdrawn and flexed; the head and 
 trunk are rotated and alternately flexed and extended. The gait may be 
 disordered so that progression is unnatural and difficult. These and other 
 movements are rapidly repeated in the most bizarre and disorderly 
 manner, and often with convulsive suddenness. They are manifestly pur- 
 poseless and constantly vary in extent and direction — ''insanity of the 
 muscles." The hands and arms are most affected, the face next, and 
 to a less extent the trunk and lower extremities. The tongue is pro- 
 truded and withdrawn with a jerking movement; words are uttered 
 with an irregular, jerking cadence, and in grave cases the patient often 
 does not talk at all for hours or even days together. The diaphragm 
 may be involved, a condition which is manifest by irregular, spasmodic 
 breathing. Attempts at voluntary movements increase the involuntar}'- 
 twitchings. There may be transient loss of power in a limb or the entire 
 side. This is usually a mere paresis, but in certain cases it is marked 
 — paralytic chorea. 
 
 Emotional influences increase the muscular movements. The con- 
 sciousness of being under observation almost always intensifies them. As a 
 rule they cease during sleep. 
 
CHOREA. 1371 
 
 Sensory derangements are not common. In certain cases of hemi- 
 chorea there is tenderness on pressure and spontaneous pain. Tender 
 points in the line of nerve trunks are rare. 
 
 Psychical derangements occur in a majority of the cases. They are 
 usually moderate; sometimes intense. The antecedent neurotic element 
 is to be considered. Irritability, peevishness, and weakness of memory 
 are present. These symptoms often increase, especially in adults, until a 
 condition of mania is established. There is no distinct line of separation 
 between the ordinary forms and those which are most severe. 
 
 (2) Chorea Insaniens. — This most intense form does not often 
 occur in children, but is not very rare in young women, and especially in 
 pregnancy. The muscular movements are excessive and continuous. 
 The patient cannot remain standing or lie in bed. There is an uncon- 
 trollable jactitation, movement of the eyes and lips, inability to pause 
 to take food or for any purpose, associated with a veritable psychosis 
 with mental confusion, maniacal excitement, and hallucinatory delirium. 
 After a time the patient falls into a state of profound exhaustion, with 
 apathy or melancholia. The temperature may rise to 102°-104° F. 
 (38°-40° C.) and in fatal cases hyperpyrexia has been observed. 
 
 The muscles do not waste, their electric excitability is not affected, 
 and the deep reflexes remain normal. 
 
 Ocular Phenomena. — The pupils are often dilated, but the light reflex 
 is retained. The muscular twitchings may give rise to transient strabis- 
 mus. A concentric contraction of the visual field has been observed. 
 The ophthalmoscopic findings are mostly negative, though a few cases of 
 optic neuritis have been reported. 
 
 Course of the Attack. — The duration of the disease in children varies 
 usually between six and twelve weeks. There is a remarkable tendency 
 to recurrence, which often takes place in the spring of the year. Two or 
 three attacks are common; as many as five or six have been noted. The 
 tendency to recovery appears to be spontaneous. The chorea of adults 
 runs a longer course. A chronic intermittent form has been described. 
 
 Diagnosis. — Direct. — This is, as a rule, made without difficulty. It 
 rests upon the character of the muscular movements, their distribution, 
 the age of the patient, the psychical phenomena, the frequent coincidence 
 of rheumatic arthritis, endocarditis, or chronic valvular disease, and the 
 tendency to spontaneous recovery. The absence of the signs of organic 
 disease of the nervous system is of diagnostic importance. 
 
 Differential. — There are several affections occurring in children 
 which present superficial resemblances to Sydenham's chorea. 
 
 Multi'ple Cerebral Sclerosis. — Weakness, incoordination, tremor, and 
 ataxia are characteristic. The gait is spastic paretic; the course chronic, 
 with little tendency to improvement. The reflexes are increased and the 
 intelligence is impaired. Has been described as chorea spastica. 
 
 Certain Disorders of Motility Associated with Hemiplegia. — Post- 
 hemiplegic hemichorea is a term used to designate the involuntary move- 
 ments on one side of the body which manifest themselves in one muscular 
 group after another and give rise to coarse trembling and awkwardness. 
 A prehemiplegic chorea may occur but is much more rare. 
 
1372 MEDICAL DIAGNOSIS. 
 
 Athetosis or hemiathetosis consists in slow involuntary movements 
 chiefly affecting the muscles of the fingers and toes. There are movements 
 of flexion and extension, adduction and abduction, which occur with occa- 
 sional interruptions both during the waking hours and in sleep, or only 
 upon attempts to use the member, or under excitement. The fingers 
 may be over-extended and spread apart while the hand remains flexed, 
 or some fingers may be flexed and others extended at the same moment. 
 
 Hereditary Ataxia; Friedreich's Disease. — The chronic nature of the 
 affection, its occurrence in several members of a family, the ataxia, 
 tremor, scoliosis, and talipes, together with the nystagmus, the scanning 
 speech, and the slow, irregular muscular movements, render the recogni- 
 tion of this disease a comparatively easy matter. 
 
 Hysteria. — The movements of so-called hysterical chorea are usually 
 rhythmical and wholly different from those of acute chorea. The stigmata of 
 hysteria are present and the psychical derangements are more marked than 
 in the chorea of childhood. The two affections are sometimes associated. 
 
 Prognosis. — In children the outlook is good. Most of the cases ter- 
 minate in complete recovery. Death may result from exhaustion in the 
 severest cases. The mortality is from 2 to 3 per cent. Chorea in adults, 
 and especially chorea insaniens, is a much more serious affection. In 
 the chorea of pregnancy the death-rate is about 25 per cent. Rapid loss 
 of flesh, delirium, and a rise of temperature are ominous symptoms. 
 
 THE CHOREIFORM AFFECTIONS. 
 
 Several affections characterized by irregular, involuntary muscular 
 movements are described as chorea. This nosological error is extremely 
 unfortunate and misleading, since these diseases not only have no etio- 
 logical and but little clinical relationship among themselves, but also none 
 whatever to Sydenham's chorea. 
 
 Chorea Major ; Epidemic Chorea. — It is a matter of history that at 
 times of religious excitement in the Middle Ages there were extensive 
 popular outbreaks marked by great excitement, gesticulations, and danc- 
 ing. Under such circumstances pilgrimages were made in the Rhine 
 provinces to the shrine of Saint Vitus at Zebern. This martyr as a saint 
 of succor was invoked for protection against sudden death and against 
 many diseases and distempers, notably chorea, which thus came to 
 be called Saint Vitus's dance. Limited outbreaks of a similar character 
 occurred in the nineteenth century and in this country in Kentucky. The 
 fantastic pilgrimages of the Doukhobors in Manitoba are of this nature. 
 These folk uprisings under the stimulus of religious fervor are hysterical 
 manifestations and have nothing to do with Sydenham's chorea. 
 
 Habit Chorea ; Habit Spasm ; The Tics. — These affections have been 
 misnamed chorea. They have no relationship with Sydenham's chorea. 
 
 Momentary grimaces or twitchings of bundles of facial muscles are not 
 uncommon in otherwise healthy adults and are of no clinical significance. 
 
 Tic Convulsive ; Gilles de la Tourette's Disease. — A psychosis char- 
 acterized by involuntary violent muscular movements affecting certain 
 muscle groups, as the facial and brachial, or generalized; explosive utter- 
 
CHOREA. 
 
 1373 
 
 'ances, which may be inarticulate, sometimes resembling the bark of a dog, 
 or the repetition of words (echolalia), accompanied by involuntary move- 
 ments, or the repetition of obscene words (coprolalia), or the spasmodic 
 and involuntary imitation of movements (echokinesis), and in many of 
 the cases by curious mental impulses or fixed ideas, as the impulse to touch 
 certain objects {folie de toucher), or the obsession of names (onomoto- 
 mania); or the insane habit of counting with worriment about numbers 
 (arithmomania) . 
 
 The affection, as a rule, begins in childhood about the time of the 
 second dentition and affects neurotic individuals. The outlook is not 
 favorable, but some of the cases recover. Allied to tic convulsive is the 
 affection known as — 
 
 Saltatory Spasm ; Static Reflex Spasm of Bamberger ; Palmus. — 
 This is probably not an independent disease but in some cases a form 
 
 Fig. 401. — Gilles de la Tourette's disease in four phases. — Pennsylvania Hospital. 
 
 of tic; in others a manifestation of hysteria; and again a manifestation of 
 increase in the skin- and deep-reflexes. The spasms do not occur when 
 the patient is at rest or in the recumbent posture. When he touches the 
 floor with his feet he begins to hop, Jump^ and dance about as the result 
 of clonic convulsive contractions of the muscles of the legs and feet, and 
 in particular of the muscles of the calves of the legs. It occurs in both 
 sexes and at any age; in many cases without obvious cause; in others 
 after emotional disturbance or in the convalescence from an infection. 
 It has been observed in dancers as an occupation neurosis. The prog- 
 nosis is favorable; recovery usualh^ takes place in the course of a few 
 months. The condition occasionally persists for years. 
 
 Jumpers. — This form of saltatory spasm has been observed as a 
 local or family neurosis in Maine and parts of Canada. It is characterized 
 by sudden jumping, with outcries, echolalia, and echokinesis. A similar 
 affection has been observed in parts of Siberia — myriachit — and in Java, 
 where it is known as latah. 
 
1374 MEDICAL DIAGNOSIS. 
 
 Chronic Progressive Chorea; Hereditary Chorea; Huntingdon's 
 Disease. — An affection of early middle life, mostly hereditary, charac- 
 terized by irregular muscular movements, disorders of speech, and irri- 
 tabihty and mental weakness gradually leading to dementia. This affec- 
 tion was first described by Huntingdon, of Long Island, who observed 
 it in famihes in whom it has occurred for four or five generations. The 
 part played by heredity is a conspicuous feature, though cases have been 
 observed in which this etiological factor was absent. Men and women 
 alike suffer. The onset is usually between the thirtieth and fortieth years, 
 and is insidious, without apparent exciting cause. In rare instances it has 
 followed profound and depressing emotion. 
 
 The symptoms are motor and psychical. The motor phenomena con- 
 sist of involuntary, purposeless movements, manifest at first in slight 
 degree in hmited muscle-groups, as the hands or face, but gradually in- 
 creasing in force and extent until all the voluntary muscles are. involved. 
 These movements are disorderly and irregular, of wider excursus and less 
 abrupt than in chorea, and cause almost continuous grimaces and gestic- 
 ulations, increased by excitement and interrupted only during sleep. 
 At first and to some extent throughout the course of the disease they are 
 capable of some degree of temporary control by the force of the will, but 
 presently recur again with renewed violence. In the later stages the gait 
 is much impaired. The body is inchned forward, the trunk sways, and 
 the movement of the legs is irregular, uncertain, and staggering — often 
 arrested for a moment after a few steps. Muscular power is retained 
 until toward the end, when palsies may occur. The deep reflexes are 
 usually increased. Sensation and the special senses are not affected. 
 
 Psychical phenomena are irritabihty, excitabihty, and depression. 
 Suicide is not uncommon. As the disease advances there are periods of 
 apathy and progressive dementia. Speech is slow, hesitating, and indis- 
 tinct, the words being slurred and ill-pronounced. 
 
 The prognosis is invariably unfavorable. The disease is incurable. 
 Its duration varies from ten to twenty or thirty years. ^ The termination 
 is usually caused by some intercurrent disease or a progressive cachexia. 
 
 II. EPILEPSY. 
 
 A disease of the nervous system characterized by attacks of uncon- 
 sciousness, with or without convulsions, recurring at irregular periods. 
 In very rare instances consciousness is not wholly lost. 
 
 The following phases occur, independently or in association: 
 L Grand Mai. — Loss of consciousness with general convulsions, at 
 first tonic, then clonic. 
 
 2. Petit Mai. — Momentary loss of consciousness without convulsions. 
 
 3. Status Epilepticus. — Convulsive attacks recur in rapid succession, 
 consciousness not being regained in the intervals between them. 
 
 4. The Psychical Epileptic Equivalent. — Outbreaks of mania or other 
 mental symptoms, as automatism, take the place of the fit. 
 
 5. Jacksonian Epilepsy. — The convulsive attack begins in a hmited 
 muscle group and may be unilateral and unattended by loss of conscious- 
 ness; later consciousness may be lost and the convulsions general. 
 
EPILEPSY. 1375 
 
 Etiology. — Predisposing Influences. — Age plays an important 
 role. In a large proportion of the cases the first attack occurs in early 
 childhood; in the majority before the twentieth year. Many but by no 
 means all of the cases occurring in adult life are symptomatic of a local 
 lesion. In rare instances the disease begins in old persons. Sex is with- 
 out influence. In children males appear to be slightly more liable; in 
 adults there are more cases among males than females. Direct inheri- 
 tance is comparatively infrequent, but the children of neurotic families, in 
 which neuralgias, palsies, hysteria, and insanity have occurred, are more 
 liable to become epileptic than the descendants of healthy stock. Pater- 
 nal or maternal intemperance, especially when associated with syphilis 
 or insanity, is frequently found in the anamnesis. Epileptic convulsions 
 are not very uncommon in the subjects of chronic alcoholism. Epilepsy 
 may occur in syphilitic subjects; more commonly the convulsive seizures 
 are epileptiform and symptomatic of syphilitic disease of the brain. The 
 general convulsions which occur in pathological primary dentition, or in 
 children at the onset of acute infections, in uraemia, in pregnancy, and in 
 chronic lead poisoning cannot in all instances be distinguished from 
 idiopathic or essential epilepsy. 
 
 Exciting Causes. — The first attack sometimes follows fright; 
 sometimes an injury; less frequently one of the acute febrile infections. 
 Masturbation has been regarded as a common cause of epilepsy upon 
 insufficient evidence. The fact that certain local irritants give rise to 
 epilepsy, which ceases upon their removal, is incontestably established. 
 Among them are preputial adhesions, collections of smegma behind the 
 corona, intestinal worms, a foreign body in the ear or nose, an irritable 
 scar, phimosis, and a testicle retained in the inguinal canal. It is neces- 
 sary to assume a strong predisposition in such cases. In some of them 
 the attacks persist after the correction of the offending condition. Over- 
 eating and indigestion are very often followed by a fit, and a seizure may 
 follow trauma, gall-stone, or renal colic, or a trifling surgical operation. 
 Epileptiform convulsions occur in heart block — Stokes-Adams disease. 
 
 Symptoms. — The recurring fits are the characteristic and in many 
 cases the only feature of the disease. In the intervals the health of the 
 patient is often excellent; in certain cases and in the later stages it may be 
 much impaired. 
 
 1. Grand Mai; Major Epilepsy. — The attack is frequently preceded 
 by a localized sensory manifestation called an aura. Aurte may be: (a) 
 Psychical. — The patient experiences a sensation of strangeness or terror, 
 or a feehng of confusion, or he may fall into a vague, dreamy state, or 
 become extremely gay or furious, (b) Visceral. — In this form of aura the 
 sensation is referred to various organs. It is described as the pneumo- 
 gastric aura. Uneasy sensations in the epigastrium are more common. 
 Sometimes the disagreeable sensation may be intestinal. In other cases 
 it is precordial and attended by anxiety and palpitation, (c) Pe7Hpheral. 
 — The sensation may begin in the hand or in a finger and extend toward 
 the body before consciousness is lost, (d) Visual. — The aura may take 
 the form of phosphenes or color sensations or in rare cases of particular 
 objects, (e) Auditory. — Noises or ringing in the ear, curious sounds diffi- 
 
1376 MEDICAL DIAGNOSIS. 
 
 cult to describe, musical tones, or voices. (f) Olfactory or Gustatory. — 
 These are rare. They consist of strong odors, almost always unpleasant 
 or disagreeable, or foul tastes and the like. The aura is usually of short 
 duration, the attack coming on in a few seconds. In other cases it may 
 be prolonged. 
 
 Premonitory Forced Movements. — In some cases the aura does not 
 occur, but in its place there are definite forced movements. The patient 
 turns rapidly or twirls upon his toes, or runs a few steps or even to and fro 
 a number of times. 
 
 The Epileptic Cry. — At the onset of the attack the patient very often 
 utters a loud scream or yell. 
 
 The attack is instantaneous. Consciousness is at once completely 
 lost and the patient falls as if shot. Slight injuries are common, and 
 grave, even fatal accidents, as fracture of the skull, sometimes occur. 
 The FIT consists of three stages, — (1) tonic spasm, (2) clonic convulsions, 
 and (3) coma. 
 
 (1) Tonic Spasm. — There is a spastic rigidity of the muscles, includ- 
 ing the respiratory muscles, so that respiration is at once arrested. The 
 face is at first pale, then red, and directly bloated and cyanotic; the eyelids 
 are closed or open, the eyes fixed, the pupils dilated, and the iris is irre- 
 sponsive to light. At the very first there may be a momentary contrac- 
 tion of the pupil, but this soon gives place to dilatation. The head is 
 forcibly extended or turned to one side, the arms are rigidly extended or 
 flexed, the thumbs adducted, and the fingers clinched. The legs may be 
 rigidly extended, or flexed. The tongue may be protruded and caught 
 between the fixed jaws. The fseces and urine may be discharged. This 
 period lasts from a few seconds to half a minute. Toward its close there 
 is tremor, which ushers in the second stage. 
 
 (2) Clonic Convulsions. — The muscular contractions now intermit. 
 Tremor gives way to rapid and violent spasms. The limbs are tossed 
 about with force. The muscles of the face are violently contracted; the 
 eyes roll from side to side or are turned up, and the eyelids open and close 
 forcibly. The jaw muscles are in violent clonic spasm and the tongue 
 is lacerated by the teeth, A frothy saliva, often stained with blood, is 
 discharged with the violent respiratory movements. Further discharges 
 of urine and fseces may now occur and there is occasionally an ejaculation 
 of semen. This period lasts from one to three or four minutes. The con- 
 vulsions become less violent and gradually subside and the patient passes 
 into the third stage of the attack. 
 
 (3) Coma. — The limbs are relaxed and the unconsciousness is pro- 
 found. The breathing is stertorous and the face flushed but no longer 
 cyanosed. After a time the patient may be aroused, but is dazed and 
 confused and relapses into a deep sleep which lasts for hours. 
 
 The following clinical phenomena occur, but are not constant: 
 Vomiting after the attack. Slight rise of temperature, — one to two 
 degrees of Fahrenheit's scale. In the status epilepticus higher tempera- 
 tures are observed. Abohtion of the reflexes. The conjunctival, corneal, 
 and pupillary reflexes are all abohshed during the attack. The deep reflexes 
 may, however, be increased and ankle clonus evoked. Subcutaneous and 
 
EPILEPSY. 1377 
 
 subconjunctival extravasations of blood; the former chiefly about the 
 face and neck. Albuminuria during the attack; polyuria subsequently; 
 ■occasionally an increased urea output. 
 
 The aura is not always followed by the fit. When it begins in an 
 extremity, particularly in the hand, the attack may be prevented in some 
 cases by immediate compression of the member by a string or ligature or 
 by energetic pulling or rubbing of the part. 
 
 2. Petit Mai ; Minor Epilepsy. — Momentary loss of consciousness is 
 the chief, often the only symptom. The unconsciousness usually is so 
 brief — a few seconds to half a minute — that the patient does not fall, but 
 •directly resumes his occupation or conversation as if nothing had occurred 
 to interrupt it. The face usually becomes pale, the eyes are set and staring, 
 and anything in the hands may be dropped. The tongue is not bitten and 
 involuntary discharges do not occur. In many of the cases shght spas- 
 modic movements of the facial muscles may be noticed. 
 
 The attack may take the form of transient vertigo, the true nature 
 of which, in the absence of unconsciousness and twitchings of the Hps, 
 tongue, or eyehds, cannot be recognized. Following the attack of petit 
 mal there may be slight incoherency or automatic actions, such as begin- 
 ning to undress, spitting, or rubbing the face or head. The patient may 
 in other cases fall without the occurrence of convulsions. There may be 
 jerking of the limbs, tremor, or sudden visual sensations. The significance 
 of these phenomena is revealed by their occurrence in persons who mani- 
 fest well-characterized attacks. An aura is rare and many patients are 
 unaware of the occurrence of the attacks. As a rule convulsions gradually 
 develop, and in many of the cases petit mal and grand mal are associated. 
 
 3. Status Epilepticus. — The patient passes from one convulsive seiz- 
 ure into another, consciousness not being regained in the intervals. The 
 pulse and respiration are rapid, the temperature rises, and the attack 
 frequently terminates in death. Hyperpyrexia is not uncommon and 
 temperatures of 107°-111° F. (41.7°-43.9° C.) have been observed. Status 
 epilepticus may last two or three days. 
 
 4. Psychical Epileptic Equivalents. — Remarkable psychical disturb- 
 ances sometimes take the place of the fits or alternate with them. 
 The patients perform extraordinary and apparently premeditated acts of 
 which they have no knowledge or subsequent recollection. They run 
 about, wander away, throw away their clothing, commit violent, even 
 murderous assaults without motive and without self-restraint. These 
 psychical states are not easily distinguished from the maniacal states 
 which sometimes follow the attacks — postepileptic delirium. These 
 conditions may last for hours or for several days. They usually come on 
 suddenly without premonitory symptoms. 
 
 Other derangements which are regarded as equivalents are sudden 
 and profuse sweating, sudden sleep (narcolepsy), the automatic repe- 
 tition of meaningless words or phrases (verbigeration), and attacks of 
 general tremor with impaired consciousness. 
 
 5. Jacksonian Epilepsy ; Cortical, Partial, or Symptomatic Epilepsy. 
 — Consciousness is not at first lost. It may be preserved throughout 
 the attack. The attacks are the result of irritative lesions of the motor 
 
 87 
 
1378 MEDICAL DIAGNOSIS. 
 
 zone, as tumor, inflammatory softening, acute and chronic meningitis, hemor- 
 rhage, abscess, and trauma. They occur also in general paresis. The spasm 
 begins in a limited group of muscles of the face, arm, or leg. Numbness 
 or tingling is followed by limited spasm, which extends and involves a limb 
 or the side of the face. The spasms may be localized for a long time; 
 but ultimately tend to become general. Posthemiplegic epilepsy is of the 
 Jacksonian type. The convulsions may for a long time be confined to the 
 paralyzed side, beginning in the hand or foot without unconsciousness. 
 
 The mental state of the epileptic is often normal. More commonly 
 there is absence of self-control, associated with depression and irritability. 
 As the disease progresses there is often impairment of intelligence and 
 memory. The seizures may occur daily for a period and then at longer 
 intervals; in other cases they may occur only once in many months. 
 It is common for them to recur at irregular intervals of two or three weeks. 
 The attacks of petit mal may occur many times a day. The attacks are 
 more common by day than at night. Nocturnal epilepsy may go on for 
 a long time without being recognized. In women the attacks frequently 
 occur at or near the menstrual period. 
 
 Diagnosis. — Direct. — Major epilepsy declares itself by the aura, the 
 cry, the instant loss of consciousness, and the consecutive tonic and clonic 
 spasm followed by coma or stupor. The relaxation of the sphincters and 
 the bitten tongue are distinctive. The recurrence of the fits at irregular 
 periods is an essential feature. 
 
 The minor attacks are characterized by momentary loss of consciousness 
 or vertigo. Twitching of the facial muscles is suggestive. Their frequent 
 recurrence and association with grand mal are diagnostic. Status epilep- 
 ticus occurs as a culminating condition to be known not only by the recur- 
 ring convulsions and intervening coma, but also by the history of the case. 
 Psychical equivalents of the attack can only be recognized in the light of 
 the anamnesis. There is nothing distinctive in the delirium, mania, or delu- 
 sions. The diagnosis of Jacksonian epilepsy rests upon its characteristic 
 symptoms, local spasm, and retention of consciousness. The recognition 
 of the peculiar condition of which it is symptomatic is often difficult. 
 
 Differential. — The importance of the distinction between true epi- 
 lepsy — the so-called idiopathic form — and symptomatic or epileptiform 
 convulsions cannot be over-estimated. To the latter belong convulsions 
 of the Jacksonian type. The diagnosis of epilepsy can never be made 
 from a single attack, particularly when it has not been seen by the phy- 
 sician. Syncope may be mistaken by the untrained for epilepsy. The 
 unconsciousness is not so complete as in epilepsy, nor is it preceded by an 
 aura, accompanied by tonic and clonic convulsions, involuntary dis- 
 charges, or followed by coma or automatic actions. Meniere's disease 
 may simulate an epileptic seizure, but aural phenomena are present and 
 the characteristic symptom-complex of epilepsy is absent. Toxic Condi- 
 tions. — The general convulsions of pathological puerperal states, uraemia, 
 lead intoxication, and other toxic conditions are not to be confounded 
 with epilepsy. The underlying causes of these symptomatic seizures are 
 usually plainly manifest. When they occur in individuals previously 
 epileptic, their essential nature may remain in doubt. 
 
EPILEPSY. 1379 
 
 General Convulsions of Infancy; Eclampsia. — These are due to direct 
 irritation of the cerebral cortex, reflex irritation, and toxic influences. 
 In early infancy epilepsy is the least obvious diagnosis and should never 
 be made until other causes have been excluded. In older children the 
 seizures may be symptomatic of peripheral irritation or intestinal worms, 
 or they may replace the chill which in adults marks the onset of an acute 
 infectious disease. When they are repeated, only prolonged observation 
 will justify a positive diagnosis. Complete restoration to the usual health 
 in the course of a few hours, especially in a child who presents the stigmata 
 of degeneration, is an important point in favor of a diagnosis of epilepsy. 
 
 Coarse Cerebral Lesions. — Cerebral focal disease and meningocortical 
 lesions may cause symptomatic or partial epilepsy. When the convul- 
 sions rapidly become general they may closely simulate general epilepsy. 
 In truth the border line between the two forms is not always sharply 
 drawn. The symptomatic convulsive seizures that occur in general paresis 
 are commonly unilateral and not attended by loss of consciousness. 
 
 Hysteria.— {^ee p. 1384.) 
 
 Hystero-epilepsy. — The rare forms of major hysteria are attended with 
 recurrent convulsions, which may be readily distinguished from repeated 
 epileptic seizures or the status epilepticus by the emotional prodromes, 
 the hysterogenetic points, globus, contortions, histrionic poses, and hallu- 
 cinations. There are mixed forms of hysteria and epilepsy and transitional 
 forms. In other words the hysterical person may be also an epileptic. 
 
 Simulated Epilepsy. — The normal light reflex, absence of dilatation 
 of the pupil, the absence of instantaneous pallor at the onset of the 
 attack, the lack of the characteristic cyanosis and flushing, and the 
 condition of the patient after the attack are of diagnostic value. The 
 convulsion may be feigned, but the tongue is not bitten and postepileptic 
 coma and mental confusion cannot be imitated. 
 
 Prognosis. — In the great majority of cases epilepsy is an incurable 
 disease. No case can be looked upon as having recovered unless there has 
 been complete freedom from the attack for a period of several years. The 
 outlook is less favorable when the disease begins in infancy or childhood 
 than in the cases in which it begins at puberty. When it begins between 
 the twentieth and thirty-fifth years complete recovery is rare. The more 
 frequent the attacks and the longer the period in which they have con- 
 tinued to recur, the more unfavorable the prospect of recovery. The prog- 
 nosis is unfavorable in degenerates and those suffering from inherited or 
 acquired mental disease. Recovery is more rare in females than in males. 
 The severity of the individual attack has no direct relation to the prog- 
 nosis, except that the outlook is less favorable when the disease begins as 
 petit mal, and that in the status epilepticus about one-half the cases die 
 in the attack. Epileptics are frequently short lived. The attack in itself 
 is not especially dangerous to life. In very rare instances asphyxia or 
 cardiac rupture may occur. The seizure is attended with the risk of serious, 
 even fatal injury which may result from sudden loss of consciousness. 
 The patient may fall from a height or under a vehicle or into a fire or 
 water. The outlook is more favorable in symptomatic convulsions than 
 in essential epilepsy. 
 
1380 MEDICAL DIAGNOSIS. 
 
 III. HYSTERIA. 
 
 Hysteria is a psychoneurosis, in which the mental state induces and 
 dominates a great variety of physical symptoms. Its name, which is 
 derived from the Greek word for the uterus, indicates an error which has 
 prevailed for more than two thousand years, for hysteria has no neces- 
 sary relation with the womb. It occurs in men and in young children as 
 well as in women. Heredity is a common cause, as was demonstrated by 
 Briquet. Next in importance is trauma, and then mental excitement 
 and moral shock. Toxaemia, metallic poisoning, and acute disease all act 
 as occasional causes. 
 
 Pathology. — Hysteria has no recognized pathology. It is a so-called 
 functional disease. The theory that it depends on minute structural 
 changes in the neurons is possibly correct, for all function depends upon 
 structure, but we have no way of ascertaining these changes. 
 
 Symptoms. — Hysteria is most common in children and young adults. 
 It rarely appears after middle life. 
 
 The French divide the symptoms into two great classes, — the par- 
 oxysmal and the interparoxysmal. 
 
 The 'paroxysm,, or fit, is divided into four periods. Prodromes or aurse 
 may usher in the first period; the former usually are changes in temper 
 and disposition, the latter are the clavus, a circumscribed pain in the head, 
 the globus hystericus, a sense of a ball rising in the throat, and ovarian 
 hypersesthesia. Other and more rare prodromes and aurse are seen. 
 
 The first, or epileptoid, period is marked by a sudden, tonic spasm, 
 in which the patient lies rigid or even in opisthotonus, with hands clenched, 
 eyes fixed or even crossed, and arms extended in the position of a cross; 
 the breath is labored, the pulse slightly accelerated, and consciousness is 
 obtunded but seldom or never entirely lost. The tongue is not bitten, 
 the pupils are not affected, incontinence of urine does not occur, and the 
 patient does not injure herself in falling. It is this stage which most closely 
 resembles epilepsy. But the clonic spasms which supervene are not exactly 
 like those of epilepsy; they are usually more irregular, and often have 
 something of a voluntary aspect. The eyelids present a slight tremor. 
 
 The second is called by the school of Charcot the period of " clown- 
 ism." The patient throws herself into grotesque attitudes; she seems as 
 one possessed, and indeed she was believed, in the Middle Ages, to be 
 controlled by a demon. Extreme opisthotonus is one of the commonest 
 positions assumed by the grand hysteric. 
 
 In the third period the patient seems to act a part; she is dramatic, 
 sometimes pathetic, always extreme. This is the histrionic stage, in which 
 the conduct is evidently the mirror of certain mental states. It has been 
 greatly elaborated by the French school, and by means of hypnotism and 
 suggestion has been not a little overdone. 
 
 The fourth period is that of delirium — so-called. The patient subsides 
 into a state of weeping and declamation; sometimes there are spells of 
 laughing. 
 
 The hysterical fit is not always typical; there are aberrant or abor- 
 tive forms. In this country we seldom see the Avhole tableau. The first 
 
HYSTERIA. 
 
 1381 
 
 period is the commonest, with a brief histrionic display, followed by a crisis 
 of weeping and laughter. Among the very rare aberrant forms are ecstasy, 
 somnambulism, catalepsy, and trance. Tourette and Cathelineau have 
 tried to show that the nutrition is affected in a characteristic way; there 
 is loss of weight, with increased excretion of urea, but during the lethargic 
 trance-like stage the urea diminishes. Some of the sensational stories of 
 the dead returning to life, as in the case of Lady Russell, who revived at 
 her own funeral, were doubtless founded on cases of hysterical trance. 
 
 The inter 'paroxysmal symptoms are motor, sensory, and visceral. 
 
 The motor symptoms are 
 paralysis, contracture, tremor, 
 and incoordination. 
 
 The paralysis may take the 
 form of a monoplegia, a hemi- 
 plegia, a paraplegia, or a total 
 palsy. It is sometimes limited to 
 one or a few muscles, as of the 
 hand, arm, face, tongue, pharynx, 
 or larynx. The paralysis in the 
 extremities is likely to be accom- 
 panied with contracture; the deep 
 reflexes are not abolished, nor is 
 there true muscular atrophy, or 
 reactions of degeneration. The 
 paralysis is not, as a rule, limited 
 to the distribution of particular 
 nerve-trunks; in other words, it 
 is central, not peripheral. The 
 paralyzed part may become 
 cedematous, blue, and mottled, 
 especially in traumatic cases. 
 Hysterical paralysis is usually 
 persistent for long periods, but 
 occasionally it is transitory and 
 recurring; and mild grades may 
 
 f^\T(^-n l-i(=> f rfineffirr-arl frnm cnVlp to Fig. 402. — Hysterical hemiplegia, .showing glossolabin- 
 even Oe iransieriea IlOm SlUe to brachial spasm of left side.— Stewart. 
 
 side. Sometimes a permanent 
 
 cure is effected suddenly. In hemiplegia the leg is usually more paralyzed 
 than the arm, and the face and tongue are not affected. In paraplegia 
 there may be anuria but not incontinence. In total paralysis all four 
 limbs are involved, but the face and trunk escape. Chevalier was able 
 to find only 21 authentic cases on record. 
 
 Contracture sometimes coexists with paralysis, but the rule is not 
 universal. The paralyzed limb is not always contractured, neither is the 
 contractured limb always paralyzed. The contracture does not always 
 relax during sleep, but it relaxes under ether or chloroform. It may 
 come and go; in some cases it is painful, and it can sometimes be 
 re-established by pressure on the main nerve-trunk. Surprising cases 
 are on record of long-persisting hysterical contractures. They sometimes 
 
1382 
 
 MEDICAL DIAGNOSIS. 
 
 follow trauma, or the grand convulsion, or sudden shock, and are often 
 accompanied with other stigmata, such as aphonia, anaesthesia, etc. 
 
 Tremor is of several types: the most common is that which resembles 
 the intention tremor of multiple sclerosis; of wide amplitude, absent 
 during repose, increased by volition, and likely to be caused by trauma, 
 or by metallic poisoning (lead and mercury). The 'Hype Rendu" closely 
 resembles this tremor, except that it may persist during repose, and is 
 merely aggravated by volition. Dutil has also described a very fine tremor 
 of from 8 to 12 vibrations to the second. Westphal's pseudosclerosis is 
 doubtless a form of hysterical tremor. 
 
 Astasia-abasia is one of the curios of hysteria. It consists of a loss 
 of power of standing (astasia) and of walking (abasia). There is no true 
 
 loss of power or any necessary loss of 
 sensation, and when the patient sits or 
 reclines there is usually no incoordina- 
 tion. Progression on all fours is even 
 possible. The gait consists in a series 
 of wild, incoordinate movements of the 
 legs, with alternate bendings backward 
 and forward of the body. But little prog- 
 ress is made, and the patient requires 
 support on each side. There is some- 
 times an alternate stiffening and relax- 
 ation of the back and legs, causing a 
 tendency to opisthotonus and a rising on 
 the toes. Astasia-abasia is most likely 
 to be caused by trauma and emotion, 
 and is most frequent in young persons. 
 Sensory changes consist of anaes- 
 thesia, hyperaesthesia, and paraesthesia. 
 Anaesthesia is of various kinds, such 
 as hemianaesthesia, segmental anaes- 
 thesia of a limb, and anaesthesia in 
 patches. Hemianaesthesia is usually 
 complete; that is, it extends from the crown of the head to the sole 
 of the foot, and is often accompanied with anaesthesia of the mu- 
 cous membranes of the eye, nose, tongue, mouth, and throat. It is 
 sharply delimited at the median line, and can sometimes be transferred 
 from one side to the other by suggestion. The special senses, sight, 
 hearing, smell, and taste, may be involved on the affected side. 
 Segmental anaesthesia of a limb is not uncommon; the area is sharply 
 delimited above by a transverse boundary line, thus presenting the shape 
 of a stocking or a gauntlet. Irregular anaesthesia in spots and curious 
 geometrical figures, scattered at random over the surface of the body, 
 and changing repeatedly, is quite characteristic. These various sensory 
 stigmata play, and have jDlayed, an important role in hysteria. In the 
 Middle Ages, during the witchcraft crazes, they were known as the 
 "marks of the devil" {stigmata diaboli). The anaesthesia of hysteria, in 
 whatever form, is very real and very profound, and even involves the 
 
 Fig. 403. — Hysterical contracture. — Lloyd. 
 
HYSTERIA. 1383 
 
 subcutaneous tissues and the nerve-trunks. The patient may not know of 
 its existence, and it requires careful tests for its demonstration. Accord- 
 ing to Pitres hysterical anaesthesia is never isolated tactile anaesthesia; 
 in other words, one or more of the other forms of anaesthesia — such as 
 analgesia, thermo-anaesthesia, and even electro-anaesthesia — are always 
 present, and in some cases there is a loss of sensibility to all modes of 
 sensation. Loss of muscular sense is a rare phenomenon. The electro- 
 anaesthesia may be preserved, however, when all other modes are lost, 
 but not inevitably. Hyperaesthesia is found in certain zones or terri- 
 tories, as along the spine, and especiall}^ in the ovarian region, where 
 pressure may excite a fit or cause other hysterical stigmata. These are 
 the so-called hysterogenous zones. Paraesthesia, consisting of altered 
 sensation, is not so common or significant. 
 
 Of the special senses the eyes present the most important changes; 
 there is contraction of the visual fields, and reversal of the color fields, 
 the red being larger in extent than the blue. Hemianopsia is rare. Total 
 blindness or amaurosis has been noted. Blepharospasm, or spasm of 
 the orbicular muscle, is seen, and may be mistaken for paralysis (ptosis), 
 but true paralysis of any of the ocular muscles is extremely rare. Lloj'd 
 has seen true iridoplegia in hysteria. Spasm of one or other ocular 
 muscle may cause strabismus, and be mistaken for paralysis of the 
 opposing muscle. 
 
 Hysterical deafness, anosmia, and loss of taste are occasionally seen. 
 
 Visceral symptoms of various kinds are observed. Anuria is not 
 uncommon; the patient may even require to be catheterized — a bad pro- 
 cedure in hysteria, since it tends to confirm the weakness. Incontinence 
 is not seen. Hysterical vomiting — anorexia nervosa — consists of a regur- 
 gitation of food, rather than a true vomiting. The food is rejected before 
 it reaches the stomach in most cases. The curious habit known as 
 merycism, or chewing the cud, in which the patient regurgitates and 
 remasticates the food, is a closely allied symptom. In hysterical vomiting 
 there is no nausea, but the patient may emaciate and present other hys- 
 terical stigmata; in some cases, however, the nutrition is wonderfully 
 preserved. Rapid respiration is sometimes seen, the respirations running 
 as high as seventy or more to the minute; but the pulse is not acceler- 
 ated, the color remains good, and there is no real dyspnoea. The breathing 
 is shallow or. panting. Occasionally, without increased breathing, there is 
 tachycardia, wdiich may even persist in spite of prolonged rest in bed. 
 Persistent cough is sometimes a perplexing and exasperating symp- 
 tom, as are also bouts of yawning. The cough is unattended with the 
 physical signs of lung disease; and the yawning occurs in paroxysms, 
 much exaggerated and prolonged, but not noisy. Aphonia is not rare. 
 The patient may talk in a whisper, but sometimes is quite speechless, 
 and even voiceless. Instances are reported of the natural voice returning 
 during laughter or even during sleep, but a cure does not necessarily fol- 
 low. Phantom tumor can be caused by contracture of the abdominal 
 muscles. The French writers describe pyrexia, or pseudopyrexia. Some 
 of the temperatures recorded are quite incredible. The subject requires 
 further study. 
 
1384 MEDICAL DIAGNOSIS. 
 
 The 'psychical state in hysteria is most important, for it is the essential 
 one. To investigate it requires expert knowledge and skill, and it is suf- 
 ficient here to say that one of its chief features is suggestibility (as the 
 French call it), in which the patient's mind is peculiarly iniiDressionable to 
 outside influences and to hypnotism. 
 
 Diagnosis. — To begin with, the practitioner should disabuse his mind 
 of the vulgar prejudice that hysteria is a simulated disease. The hysterical 
 patient is not a humbug or malingerer. The affection is very real, and 
 these patients are genuine sufferers. Many of them are useful members of 
 society; some of them, to be sure, are weaklings, and a few are even degen- 
 erates, but they are none the less entitled to consideration. 
 
 It is commonly said that hysteria simulates all diseases; but the 
 truth is that it simulates none exactly. There is always something sui 
 generis in the hysterical stigmata. On the other hand, hysteria itself is 
 sometimes simulated by designing persons, especially young women, but 
 the counterfeit is usually detected with ease. No person can simulate 
 successfully, especially for long periods, the paralysis, the contracture, 
 the anaesthesia, or in fact any of the more important stigmata of 
 hysteria. If any one doubts this, let him try to simulate contracture 
 of the arm for a week. 
 
 There is often confusion between hysteria and neurasthenia, especially 
 in the traumatic cases; and, in fact, many of the so-called traumatic 
 neuroses are hysterical. The two conditions merge into each other,, and 
 the dividing line is not easily determined in some cases. The mental state 
 of suggestibility is highly characteristic of hysteria; also the tendency of 
 symptoms to come and go, and to be influenced by hypnotism. In genu- 
 ine neurasthenia this is not so marked. Moreover, in neurasthenia we do 
 not see the characteristic permanent stigmata of hysteria, such as the 
 paralyses, anaesthesias, aphonia, anuria, etc. 
 
 The hysterical fit can closely simulate that of epilepsy, but there is 
 no biting of the tongue, no frothing at the mouth, no injury to the person, 
 no involuntary passage of urine, and the pupils are not affected. The 
 state of the pupils may be a criterion of great value, for in the epileptic 
 fit the pupils dilate after a momentary contraction in the tonic stage. 
 In mild cases, however, such as petit mal, the pupil in epilepsy may respond 
 to light. The state of the* consciousness is appealed to by many as 
 a true test of epilepsy, but it is not always reliable. Doubtless the pro- 
 found unconsciousness of grand mal is not seen in hysteria, but in petit 
 mal the consciousness is often but momentarily confused, hardly lost, and 
 these are cases that might be simulated by hysteria. Yet hysteria is not 
 usually so momentary as petit mal; and in the hysterical fit, it is true 
 that, as a rule, consciousness is not so completely abolished as in grand 
 mal. The hysterical fit can sometimes be induced by pressure on the 
 ovarian region, and it is likely to be followed by hysterical stigmata, such 
 as anaesthesia or even paralysis. Finally the last three periods of the 
 hysterical fit are determinative, for they are never seen in epilepsy; but 
 neither are they always seen in hysteria. It is important to bear in mind 
 that hysteria and epilepsy can coexist in the same patient and present a 
 confusing picture, but the crises are separate. 
 
HYPNOTISM. 1385 
 
 The diagnosis of the various permanent stigmata, such as paralysis, 
 tremor, astasia-abasia, anaesthesia, vomiting, phantom tumor, etc., has been 
 indicated in the description of those symptoms. Taken alone, they some- 
 times closely simulate organic disease, but they are usually associated 
 with other hysterical stigmata, and this fact and the history are determina- 
 tive. Ovarian pain, hysterical in origin, is not seldom mistaken for evidence 
 of organic disease, and women are thus subjected to operation and needless 
 mutilation. To guard against this too common error the practitioner should 
 study his case well with reference to other hysterical stigmata. 
 
 IV. HYPNOTISM. 
 
 It is impossible to define hypnotism, or hypnosis, in satisfactory 
 terms. It is a mental state, resembling, but not identical with, sleep, in 
 which consciousness is variously affected, but in which the mind usually 
 remains open to suggestion, especially from the person who stands in re- 
 lation of hypnotizer to the patient. In the opinion of some good observers 
 hypnotism is merely a form of induced hysteria. 
 
 Pathology. — Like all the psychoses, hypnotism cannot be said to 
 have a recognizable pathology. It is common in hysterical patients, but 
 neurotic and imaginative persons are also susceptible. It is rarely seen 
 in the insane. 
 
 Symptoms. • — We may recognize hei^e the three stages of Charcot, 
 merely premising that they are not sharply defined in all cases, especially 
 the minor cases. 
 
 In the cataleptic stage the patient assumes a statuesque attitude, 
 with partially opened eyes, blunted sensibility, and a readiness to receive 
 and act upon suggestion. In many cases it is not possible to proceed 
 beyond this stage, which may be regarded as a minor form of hypnotism. 
 
 In the lethargic stage the patient passes into a more sleep-like state. 
 The special senses and general sensibility are much impaired, the muscu- 
 lar system is relaxed, and the consciousness is deeply affected. Such 
 patients are not as open to suggestion as in the preceding stage. They are 
 usually highly neurotic individuals, and in some cases they may even 
 pass into a trance. 
 
 In the somnambulic stage we see a state which has often been mis- 
 called ''double personality." The patient's special senses are acute, 
 but she is oblivious of much that transpires about her, although open to 
 suggestion from the hypnotizer. The patient seems to be acting a dream. 
 
 Hypnotism can usually be excited by fixing the patient's attention 
 on some particular object and keeping the eyes in a strained and fixed 
 position. The French use bright objects, revolving mirrors, etc. The 
 patient gradually becomes drilled and goes into the hypnotic state on the 
 slightest provocation. 
 
 Much speculation, and much that is merel}^ fanciful, has been written 
 about hypnotism, but it is sufficient to bear in mind that it is a psychosis, 
 or mental affection, in which the patient exists in a sort of dream-like 
 state, in which suggestion from without can be made to play a prominent 
 part, and in which hysteria is always an important factor. 
 
1386 MEDICAL DIAGNOSIS. 
 
 V. NEURASTHENIA. 
 
 Neurasthenia is defined by Savill as a state of irritable weakness 
 of the entire nervous system, characterized by hypersensitiveness, head- 
 ache, inaptitude for mental work, disturbed sleep, irritability of temper, 
 restlessness, nervousness, vague pains, and affections of the vasomotor 
 and sympathetic systems. The disease has been much exploited in recent 
 years, for it is not uncommon, especially among the overworked popula- 
 tions of our large cities. 
 
 Pathology. — There is no recognized pathology. The nerve centres 
 are at fault, and the most plausible explanation is that these centres are 
 not properly nourished. There is, however, a large mental element in 
 these cases, and, as in all psychoses and neuroses, the affection is usually 
 defined as functional. Among the causes, heredity, overwork, trauma, 
 and the excessive use of alcohol and tobacco are the commonest. 
 
 Symptoms. — The symptoms are so multiform that only a generalized 
 view will be attempted here for purposes especially of diagnosis. 
 
 The cardinal symptoms are mental ones — the despondency, the 
 inability to apply the mind and to work, and the general nervous- 
 ness. Some patients are not a little hj^pochondriacal, and in others 
 an hysterical element is present, but the disease is not essentially either 
 hypochondria or hysteria. Introspection and discouragement are promi- 
 nent. Upon this psychical state are ingrafted some characteristic 
 bodily ailments. 
 
 Headache is not uncommon, and a hypersensitive spine is frequent, 
 especially in traumatic cases and in women. There are sensitive point? 
 along the spine, and the least exertion aggravates these and causes a sense 
 of exhaustion. Pain may also be transmitted to the limbs, and sometimes 
 there are bodily pains suggestive of visceral disease. Disturbance of sleep 
 is common; there is either insomnia or broken and restless sleep, so that 
 the patient arises in the morning unrefreshed. Ugly dreams are often a 
 feature of the traumatic cases, the patient seeing again the frightful 
 accident through which he has passed. Nutrition is sometimes greatly 
 impaired, the patients emaciating and becoming anaemic; and they are often 
 bedridden, especially if they are women, and present the appearance of 
 extreme illness. Inability to take and digest a sufficient c^uantity of food 
 is a troublesome feature; and there may even be dilatation of the stomach 
 or gastroptosis. On the other hand, some neurasthenics are remarkably 
 well nourished; these are the fat neurasthenics, who are not the least 
 troublesome patients. Morbid blushing and flushing are sometimes seen; 
 and the heart may be accelerated in spite of prolonged rest. Palpitation 
 annoys these patients on slight exertion. Paralysis is not commonly seen, 
 but in the traumatic cases there may be inhibited or impaired movement 
 on account of pain. Genuine paralysis points either to hysteria or to 
 organic injury. The same is true of anaesthesia; it is rare, and its pres- 
 ence is usually due to an hysterical element. Tremor is occasionally seen, 
 and requires to be carefully distinguished fi'om other tremors, such as 
 those of alcoholism and hysteria. The knee-jerks are usually free, some- 
 times exaggerated, never lost. 
 
NEURASTHENIA. 1387 
 
 Of the special senses the eyes suffer most; there may be eye-strain 
 and pain on using the eyes. Tinnitus, vertigo, and noises in the head, 
 or a sense of fuhiess, are present in some cases. Some patients have a 
 strange sense of mental vacuity. 
 
 Sexual weakness is not unusual in men, and the sexual act causes 
 profound exhaustion, weakness in the back, and headache, which may 
 endure for a day or so. 
 
 In this connection it is well to consider briefly the traumatic neuroses. 
 They are in fact largely neurasthenic, although a few are purely hyster- 
 ical. It is too much to say, however, that all these traumatic cases are 
 purely functional. Some of these patients suffer from organic lesions, 
 such as bruises, sprains, and wrenches of the muscular and tendinous 
 attachments, especially of the spine. The so-called ''railway spine" is 
 not always purely neurasthenic, but may be in part the result of shock 
 and sprain. The same may be said of some of the obscure injuries to the 
 hip and other joints; there is a large neurasthenic element, but it is very 
 often not the whole story. These cases are of exceptional importance 
 because they lead so often to Htigation; and the controversy over them 
 is frequently acute. 
 
 All neurasthenics are quickly and easily fatigued, both by mental and 
 physical exertion. Inability to concentrate the mind is not uncommon; 
 and of other mental phenomena the most important are the so-called 
 obsessions. They consist of imperative and inhibitive ideas, and are seen 
 in the state known as psychasthenia, which belongs rather to psychiatry 
 than to clinical medicine. 
 
 Diagnosis. — Since Beard invented the term, neurasthenia has been 
 used very loosely to cover a wide variety of symptoms. When properly 
 guarded, however, the term has a legitimate use, and, although it is 
 hardlj^ capable of exact definition, it covers a symptom-complex which is 
 fairly recognizable; and this has been described above. The diagnosis 
 must depend upon a careful consideration of those symptoms, and the 
 practitioner must not forget that a neurasthenic state often accompanies 
 other diseases, even grave organic ones. The only rule is to exercise care 
 and judgment, and to go by a process of exclusion. 
 
 The most common error is to confuse neurasthenia and hysteria; 
 in fact, some writers in describing the traumatic neuroses do not hesitate 
 to include hysterical symptoms indiscriminately with those of neuras- 
 thenia. This is wrong. Hysteria is a much more clearly defined disease 
 than is neurasthenia, and it should be kept apart whenever possible. The 
 mental state, and the various stigmata, such as paralysis, anaesthesia, 
 contracted visual fields, not to mention the convulsions, are enough to 
 distinguish it in most cases. It is often caused by trauma, and frec^uently 
 figures in court in damage suits, as neurasthenia. There is no doubt, 
 however, that hysteria can coexist with neurasthenia, just as it can coexist 
 with epilepsy. 
 
 Hypochondriasis is a state in which there are delusions about the health, 
 rather than real disorders of the health. The hipped state of mind in some 
 neurasthenics suggests a resemblance, but there are not the deep-seated hypo- 
 chondriacal delusions in the one, nor the genuine sufferings in the other. 
 
1388 MEDICAL DIAGNOSIS. 
 
 In traumatic cases it is important not to overlook organic injury and 
 to call everything neurasthenic. Grave errors have thus been committed. 
 
 Secret drug habits, especially the use of morphia^ sometimes induce 
 a neurasthenic state, and the true nature of the case may be overlooked. 
 Hence it is important to inquire carefulh' into the habits. The same is 
 true of alcohol and tobacco, and even of tea and coffee. 
 
 Some of the ^actims of onanism can properly be classed as neuras- 
 thenics, but in them there is usually a marked h5'pochondriacal element. 
 These persons are the easy prey of the advertising charlatans, and their 
 symptoms are sometimes concealed or repressed for fear of exposure. 
 
 VI. THE OCCUPATION NEUROSES. 
 
 These include a variety of affections which ai'ise from overuse in the 
 course of occupation. They are sometimes called the fatigue neuroses, 
 and are located largely in the neuromuscular apparatus. The commonest 
 forms are scrivener's palsy, telegrapher's cramp, piano-player's hand, and 
 some forms of clergj^man's sore throat; and some not so common are seen 
 in fiddlers, bricklayers, and others. 
 
 Pathology. — The objection to the term "neurosis" in this connec- 
 tion lies in its implied meaning that the disease is functional. No disease 
 is purely functional in the sense that it does not depend on organic change, 
 for there must be some change, however slight and transient. In some of 
 these cases we even see evidences of structural change, such as muscular 
 atrophy, persistent pain, etc.; and we may regard all of them as instances 
 of disordered nutrition both of the nerve-cells and of the muscular attach- 
 ments. Farther than this it is not possible to go. 
 
 Symptoms. — It will be best to consider a few of these affections in 
 regular order. 
 
 Scrivener's palsy, or writer's cramp, is marked particularly by spasm, 
 tremor, and incoordination. Pain and vasomotor disorders are some- 
 times seen. Paralysis and anaesthesia are doubtful symptoms. Three 
 types are noted, — the sjDasmodic, the paralytic, and the tremulous, — but 
 the distinction is not always clear in practice. The spasm affects chiefly 
 the small muscles engaged in writing, and as a rule is only manifested on 
 attempts at writing — not in other coordinate movements. There are 
 exceptions, however, to this rule. The muscles are held in cramp-like 
 rigidity, wholly prei^enting the act of writing. In some cases the muscles 
 of the forearm, upper arm, and shoulder are affected, and rare cases 
 are seen in which even distant muscles, as those of the foot, or of the 
 other hand and arm, are involved. The spasm is not a true cramjD, for it 
 is non-painful; but exceptions to this rule occur. It is quite involuntary, 
 and may even persist for some moments after the attempt at writing has 
 ceased. Tremor and incoordinate jerky movements are sometimes seen. 
 Paralysis is extremely rare, but a stage of slight paresis may follow the 
 cramp. Pain, or a painful sense of fatigue, is sometimes present, together 
 with painful points on the nerve-trunks. Neuralgic pains are observed in 
 a few cases. Anaesthesia is very rare. It is probably an hysterical symp- 
 tom. Vasomotor and trophic disorders are not common; turgescence of 
 
OCCUPATION NEUROSES. 1389 
 
 the limb and flushing of the face are among the former; and such observ- 
 ers as Eulenburg and Gowers claim to have seen muscular atrophy. It 
 has also been seen in a blacksmith, in a saddler, in a tailor, in a dragoon 
 (from holding the reins), in a morocco-worker, and in a player on the bass 
 violin. Atrophy of individual muscles, or small groups of muscles, is 
 seen in some artisans who overuse these muscles, as the small muscles 
 of the hand in locksmiths; and ulnar paralysis and atrophy in glass 
 blowers from pressure rather than overuse. 
 
 Telegrapher^s cramp is closely allied to the preceding; in fact it is 
 identical with it except that the cause and the seat of the spasm differ. 
 It was first described by Onimus in 1875 and called by him mal telegraph- 
 ique. Fulton studied the movements engaged in using the Morse instru- 
 ment, which particular instrument has been held most to blame. The 
 letters are made by a series of dots and strokes which require a fine muscu- 
 
 FiG. 404. — Telegrapher's cramp. — Lloyd. 
 
 lar movement, and when the dispatcher is working rapidly and for long 
 stretches the strain on the muscular apparatus is great. Fulton estimated 
 that an operator makes between thirty and forty thousand contractions 
 per hour. The word ''occupation," for instance, contains ten letters 
 and requires twenty-five distinct impressions. One of these patients 
 had worked as long as fourteen hours a day. Another said that his first 
 difficulty arose in making the letter B ( ) ; his hand would act invol- 
 untarily and make the dash and four dots ( ) which means the 
 
 numeral 8. Finally his greatest difficulty was experienced in maldng the 
 
 letter P ( ), the rapid succession of dots causing a cramp. In another 
 
 patient the cramp was painful and was located in the extensors, pulling 
 the hand away from the key (Fig. 404). Worry and discouragement are 
 often seen in these operators; it is easy to make mistakes in transmitting, 
 and these may be serious; consequently a neurasthenic state is often 
 present, which is not improved by alcohol and tobacco. 
 
 The telegraph operator can train his other hand rather more easily 
 than the scrivener, because the movements are less complex; but in time 
 the second hand is likely to become affected in both cases. It is easy for 
 the disabled telegrapher to become the victim of writer's cramp. 
 
1390 MEDICAL DIAGNOSIS. 
 
 The dysphonia and aphonia of professional voice-users have many 
 points of similarity to writer's cramp. There is a spasmodic type and a 
 paralytic type. In singers the voice may break down in the midst of 
 song, although the natural voice for speaking may remain, thus showing 
 how a particular function is involved. In the so-called clergyman's sore 
 throat there may really be some pharyngitis or laryngitis, but the nervous 
 element too is usually well marked. There is indeed a well-marked 
 hysterical element in many of these cases of aphonia. Thus Mackenzie 
 reported the case of a fish-hawker who lost his voice suddenly while 
 crying his wares; he was voiceless for four months, and was then cured 
 promptly with electricity. 
 
 It is needless to describe in detail the long list of the fatigue neuroses. 
 Among the artisans and artists affected are grinders, blacksmiths, en- 
 gravers, cigarette-rollers, pianists, violinists, bricklayers, tailors, and type- 
 setters. Milker's spasm is seen in this country and is said to be common 
 among the cow-herds of the Tyrol. Miner's nystagmus is a curious form. 
 
 Diagnosis. — The history and the symptoms are unmistakable. It is 
 always well to recall that a neurasthenic state is often seen in these patients, 
 and that it may complicate the clinical picture. This is still more so of 
 hysteria. Some of the symptoms seen are distinctly hysterical, as, for 
 instance, paralysis and anaesthesia in writer's cramp, for these two symp- 
 toms are probably never seen in pure cases. The same is true of aphonia 
 in habitual voice-users; it usually bears all the marks of an hysterical 
 affection. Still, these facts do not necessarily obscure the diagnosis. 
 Writer's cramp has been confused with other diseases in which writing is 
 affected. Among such diseases are hemiplegia with aphasia and agraphia, 
 general paresis, locomotor ataxia, paralysis agitans, disseminated sclerosis, 
 chorea, progressive muscular atrophy, alcohohc and metalhc poisoning, 
 and neuritis. 
 
 VII. MIGRAINE. 
 
 Hemicrania, migraine, or sick headache, is one of the explosive 
 neuroses. Its chief symptoms are disorders of vision, pain in the head, 
 and vomiting. It is paroxysmal, but has no regular periodicity, as a rule, 
 and it is often hereditary or familial. Mobius claimed that 90 per cent, 
 of the cases show heredity. 
 
 Etiology. — This is unknown. English physicians are fond of asso- 
 ciating "megrim" with gout, and in France it was Trousseau who said, 
 ''migraine and gout are sisters." But these assertions are not proofs. 
 Reflex causes, eye-strain, adenoids, womb disease, and even decayed teeth 
 have been assigned as causes, without much reason. The disease may 
 possibly be due to autoinfection, and gastro-intestinal disorders some- 
 times excite attacks. 
 
 Symptoms. — Migraine usually begins in early life. The initial symp- 
 tom of the paroxysm is an aura, usually sensory, and in the vast majority 
 of cases visual. The visual aurse consist of attacks of amblyopia in which 
 a part or the whole of the visual fields is obscured; thus scotomata and 
 even hemianopia occur. There are also scintillations, zigzag hues, shaped 
 like a fortification, flashes of light, blazing or flaming splotches, and in. 
 
MIGRAINE. 1391 
 
 very rare cases illusions, as of the forms of animals or terrifying appari- 
 tions. Oscillation of the pupil (the so-called hippus) is sometimes seen. 
 Other sensory aurae occur, as a numb or tingling feeling in the face, tongue, 
 or one limb. It is characteristic of the aura of migraine to disappear 
 just before the onset of pain. 
 
 The pain of migraine is an intense neuralgia in the distribution of 
 the fifth nerve. It is usually described as a hemicrania, but it is not 
 always confined to one side. Occasionally, however, it is strictly localized 
 in one branch of the trigeminus, especially the ophthalmic division. The 
 pain increases gradually, until it reaches its acme, and it may endure only 
 for a few hours or even for a day or two. It is usually terminated by the 
 occurrence of vomiting, which thus constitutes the third or terminal stage 
 of the paroxysm. 
 
 Gastric disorder is one of the three characteristic symptoms of 
 migraine. Aversion to food, and even nausea, may occur early in the 
 attack, and sometimes vomiting begins early; but commonly vomiting 
 is a late or terminal symptom. In many cases the patient is promptly 
 relieved by emesis. 
 
 Aberrant types of migraine are seen, in which one or other of the 
 cardinal symptoms is wanting. The commonest is the mild form in which 
 the visual aura is followed by slight headache, which is only transient, 
 and the paroxysm aborts without the third stage, or stage of vomiting. 
 
 A curious and rare form is the psychical migraine, in which mental 
 disorders of various kinds predominate. There is confusion of ideas, with 
 emotional excitement or depression, attending the visual aura, and pain 
 may or may not be marked. Incoherence and even aphasia have been 
 noted, and Liveing attempted to show, with remarkable prescience, that, 
 the aphasia always occurs in cases in which the sensory aura, as numb- 
 ness of the hand, is on the right side, thus indicating a left-sided cerebral 
 lesion. Genuine substitutional attacks have been noted, just as in epilepsy; 
 thus Sir George Airy observed in his own person the attack complicated 
 with transient impairment of speech and memory without either head- 
 ache or numbness. Tissot observed a case in which attacks of habitual 
 migraine were at length completely replaced by fits of disordered ideation. 
 Hysteria doubtless complicates some cases of migraine. 
 
 Ophthalmoplegic migraine is the form in which the paroxysm is com- 
 plicated with paralysis of some of the ocular muscles. The muscles 
 involved are those usually supplied by the third nerve; but occasionally 
 the fourth or the sixth nerve is affected. The pain is usually severe, 
 and is followed quickly by the paralysis, which may endure for days or 
 even weeks. The bout of pain is commonly terminated by a crisis of 
 vomiting, as in ordinary migraine, but the paralysis constitutes the 
 true terminal stage, and may be total and complete in the third nerve; 
 that is to say, all the muscles supplied by that nerve are involved and are 
 completely paralyzed. There is ptosis, external strabismus, and the pupil 
 does not react to light or on accommodation. In some cases, however, 
 the paralysis is not total or not complete. The duration varies. In 
 Schilling's case the palsy lasted for from four to six weeks, and in Pari- 
 naud's case from two to three months; but in many cases the duration 
 
1392 MEDICAL DIAGNOSIS. 
 
 is only for a few days. The paralysis, as a rule, to which there are few 
 exceptions, always occurs in the same eye in successive attacks. In some 
 cases the paroxysms observe a true periodicity; in Suckling's case they 
 occurred every two weeks. Many of these cases date from early childhood. 
 Occasionally a permanent palsy results after repeated seizures. Paralysis 
 of the fourth nerve has been noted by Leizenberger; and conjoint paraly- 
 sis of the third and fourth has also been seen. Paralysis of the sixth 
 nerve, either alone or in association with some of the fibres of the third 
 nerve, has been reported. De Schweinitz saw a case of abducent palsy, 
 with migraine, which had begun in early life. A very rare case is that of 
 Possolimo in which a recurring paralysis of the seventh or facial nerve 
 was always ushered in by a migrainous attack. Anaesthesia of the fifth 
 nerve has been noted in a very few cases, especially in the first and 
 second divisions, or even in the supra-orbital branch alone. Troemer 
 has reported a case of ophthalmoplegia interna following severe attacks 
 of migraine. The pupil was widely dilated and immobile to light, but 
 the other ocular muscles were not affected. 
 
 All forms of migraine tend to grow less or even to disappear in 
 middle life. 
 
 Diagnosis. — The ordinary migraine is easily recognized; in fact, the 
 patient usually knows well enough himself what he has. The beginning 
 in early life, and the peculiar evolution of the paroxysm, from the aura 
 to the critical vomiting, are unmistakable. Simple neuralgic attacks, 
 which are not uncommon, are known by the absence of the true migrain- 
 ous symptoms, such as the aura, the explosive onset, and the crisis of 
 vomiting. 
 
 Migraine has been likened to epilepsy, especially by Hughlings Jackson 
 and his followers, the resemblance being based largely on the abrupt onset 
 with an aura; but the likeness is superficial. In migraine there are no 
 convulsions, and the disease does not merge into epilepsy. Migraine 
 and epilepsy may however coexist in the same person, but the attacks 
 are separate. 
 
 Ophthalmoplegic migraine simulates organic disease, especially tumor 
 and syphilis of the brain. The paroxysmal nature of the attack, however, 
 and the tendency for the paralysis of the third nerve to disappear are 
 against brain tumor, as is also the history of the case. In brain tumor, 
 moreover, there are usually other symptoms, such as choked disk and 
 other and more wide-spread paralysis, and the course is progressive. 
 
 Syphilitic meningitis between the peduncles causes paralysis of one 
 third nerve, sometimes of both third nerves, and this paralysis may even 
 be evanescent, with severe headache; but the history is not that of 
 migraine, nor is the onset so abrupt, the cure so complete, and the 
 headache so paroxysmal, with a crisis of vomiting, as in migraine. 
 Moreover, there are likely to be other nerves involved in syphihs, 
 such as the optic nerves, or even a hemiplegia, and the symptoms are 
 irregular. Ophthalmoplegic migraine is always unilateral; syphilis may 
 or may not be so. One of Charcot's cases of migraine had paralysis 
 first of the sixth nerve on one side, then of the third nerve on the 
 other, but the case was unique. 
 
PARALYSIS AGITANS. 1393 
 
 Paroxysmal or recurrent palsy of the oculomotor nerve has been 
 noted also in tubercular meningitis, in otorrhoea, and in nasal catarrh, 
 but the history in these cases and the associated symptoms are against 
 mere migraine. 
 
 Some observers claim a relationship between tabes dorsalis and migraine 
 — suggested by the recurrent palsy of the third nerve, sometimes seen in 
 tabes. But it is not scientific to call the recurrent palsy of the third nerve 
 in tabes migrainous; for this palsy is probably due to nuclear disease, 
 and it is to be known by its association with other tabetic symptoms. 
 The same may be said of the association of migraine and general paresis. 
 
 Hysteria may unquestionably complicate or simulate migraine, 
 especially in the emotional and psychic symptoms, and in the contraction 
 of the visual fields, which might suggest scotoma. But genuine paralysis 
 of the third nerve is probably never seen in hysteria, although it is some- 
 times simulated by a blepharospasm. 
 
 VIII. PARALYSIS AGITANS. 
 
 This affection is usually called a disease of old age; nevertheless it occa- 
 sionally begins in comparatively early middle life; seldom, however, before 
 the age of forty. It is also called shaking palsy, or Parkinson's disease. 
 
 Pathology. — The cause and pathology are obscure. Recently C. D. 
 Camp has made an elaborate study of a series of cases, many of them from 
 the Blockley Clinic in Philadelphia, in which he endeavors to show that 
 the essential changes are in the muscular fibres; and he suggests that 
 there may be alteration in the secretion of the parathyroid glands. The 
 ordinary changes of senility, such as atheroma of the cerebral blood- 
 vessels, are commonly found in these patients, but it does not follow, as 
 Dana and a few observers have suggested, that these changes are causative. 
 Some sclerosis of the posterior and lateral tracts of the cord is occasionally 
 observed; also some atrophy of the cerebral convolutions, pigmentation 
 of the motor neurons, and increase of interstitial tissue. 
 
 Symptoms. — The disease is of gradual onset and chronic course, and 
 it is rather more common in men than in women. The chief symptoms 
 are tremor, rigidity, paralysis, and affection of the gait. It usually begins 
 with tremor in the hands, sometimes more marked at first in one hand. 
 
 The tremor is a regular to and fro or up and down movement, especi- 
 ally marked in the hands, persisting during repose, and temporarily arrested 
 by voluntary motion. The amplitude varies; sometimes it is slight, at 
 others wide and violent, particularly if the patient is aroused or excited. 
 The arrest on volition is but for a moment; the tremor then returns in 
 spite of the patient, and may even be aggravated for a short period. This 
 is seen on attempts at writing. In the lower limbs the tremor is usually 
 not so marked, and is sometimes even absent. It is seen occasionally in 
 the facial muscles, and in the tongue, especially when it is protruded. 
 The statement that the head is not involved is not correct for all cases. 
 Nystagmus is not present. The tremor cea.ses during sleep. 
 
 Rigidity is usuall}^ most marked in the hands, arms, back, neck, and 
 face, and its effect is to give the patient a peculiar attitude and expression. 
 88 
 
1394 MEDICAL DIAGNOSIS. 
 
 Later the lower limbs are involved. The hands are held in the position 
 known as the ''obstetric hand/' the fingers partly extended, the finger- 
 tips approximated; and the thumb held close. The constant slight move- 
 ment of the end of the thumb and tips of the fingers gives the appearance 
 in some cases of rolling pills. The arms are generally flexed at the elbows; 
 the back is bent forward, the head is bowed, and the face has a character- 
 istic mask-like expression. In those rare cases in which the tremor is 
 lacking this mask-like expression and statuesque attitude are enough to 
 establish the diagnosis. The active, intelligent expression of the eyes is 
 sometimes in marked contrast with the expressionless face. The rigidity 
 of the limbs is very noticeable on attempts at passive motion. The speech 
 is often low and feeble but not characteristically changed. 
 
 Paresis, or weakness of the muscles, is not uncommon as the case 
 advances; it is doubtless due in part to the embarrassment caused by the 
 tremor and rigidity, but that there is true loss of power there can be no 
 doubt. In advanced cases a genuine paralysis exists, and the patient is 
 confined to a chair, or is even bed-ridden. The knee-jerks may be increased, 
 but there is not usually a true paraplegia, for the bladder is not involved. 
 Sensation is not affected, as a rule; but some patients complain of a sub- 
 jective sense of heat or cold; and the surface temperature, according to 
 Gowers, may be increased. 
 
 Alteration in the gait is shown in the condition known as propulsion 
 or festination. The patient seems to be propelled forward. With head 
 bowed and back bent forward he goes at a shuffling gait or a jog trot, grad- 
 ually increasing until he brings up against some person or thing which is 
 his objective point. It seems as though he must inevitably fall, which, 
 however, he seldom does. Trousseau said that the patient seemed to be 
 chasing his centre of gravity. Sometimes there is retropulsion; and very 
 rarely lateropulsion. 
 
 The mental faculties are not affected except by the changes incident 
 to old age. Parkinson made the curious observation that in a hemiplegic 
 attack the tremor in the paralj^zed limb was arrested, sometimes, however, 
 to return. When the disease begins in early middle life the patient often 
 looks prematurely senile. Very rarely the disease is unilateral. 
 
 Diagnosis. — This is not difficult, for paralysis agitans apes no other 
 malady unless it be some forms of senile tremor; but senile tremor is 
 usually coarser, it is almost always of the intention type, it involves 
 the head; and the characteristic attitude, expression, and gait are 
 wanting. In elderly men, given to the overuse of alcohol and tobacco, 
 a tremor sometimes develops which it not so much senile as toxic. It is 
 worse on voluntary movement, and is not associated with the character- 
 istic symptoms of paralysis agitans. There should be no confusion between 
 Parkinson's disease and multiple sclerosis; the intention tremor, the 
 nystagmus, the scanning speech, the onset in earlier life, are not seen in 
 the former. 
 
 There are a few other tremors which it is well to recall in this connection. 
 
 A coarse tremor sometimes occurs in the traumatic neuroses and in 
 hysteria. The French describe all these neurotic tremors as hysterical, 
 and they are probably correct. The cases of pseudosclerosis, described by 
 
TETANY. 1395 
 
 Westphal, were doubtless of the same class. In most of these traumatic 
 and hysteroidal cases the tremor is usually of the intention type, that is, 
 it is worse on voluntary movement, and it is rather coarse; moreover the 
 history and progress are suggestive. These cases often occur in young 
 persons; the attitude, gait and expression are not those of Parkinson's 
 disease; and, finally, hysterical stigmata are often present. In an 
 occasional case the tremor may be fine. 
 
 The tremor due to metallic poisoning (by lead and mercury especi- 
 ally) is similar to the hysterical tremor. 
 
 The tremor of alcoholism is also largely of the intention type and is 
 coarse and irregular; it is easily known by the history. 
 
 IX. TETANY. 
 
 This disease is characterized by tonic, cramp-like spasms, especially 
 in the fingers, hands, and upper limbs. It occurs in epidemics in some 
 countries, especially in and about Vienna, Northern Italy and Sweden. 
 The cause is obscure. Tetany may be of infectious origin, and it is also 
 seen in ergotism, in the diarrhoea and rickets of young children, in 
 nursing women, after extirpation of the thyroid gland, and in dilata- 
 tion of the stomach. Chvostek advances the theory that the real cause 
 is a defective action of the parathyroid glands. According to the statistics 
 of Frankl-Hochwart, shoemakers and tailors seem peculiarly vulnerable. 
 The disease is rare in America. 
 
 Pathology. — This is quite unknown, for post-mortem findings have 
 not been uniform or characteristic. 
 
 Symptoms. — The tetanic spasms are oftenest seen in the small muscles 
 of the fingers and hands, causing flexion of the basal phalanges, extension 
 of the distal phalanges, and turning in of the thumb. This is sometimes 
 called the "obstetric hand." The wrist and elbow are flexed. The toes 
 may be similarly affected; also the calf muscles. 
 
 The spasms are often painful, and usually intermittent. They can 
 sometimes be excited by pressure on the nerve-trunks or main vessels — 
 Trousseau's sign. 
 
 There is increase of the mechanical and electrical irritability. Tapping 
 on nerve-trunks causes a lively contraction (Chvostek's sign), often well 
 marked in the face; and the galvanic current, even of mild power, causes 
 active, even tetanic, responses, which may increase, rather than diminish, 
 with repeated stimulation. The nerves may be hypersensitive to pressure. 
 
 Other muscles, such as of the trunk, tongue, and respiration, are 
 involved in severe cases, and the ocular muscles, according to Kunn, may 
 be affected. Nystagmus has been seen. Other ocular symptoms noted 
 by a few observers, and which are evidently very rare, if they belong to 
 the disease at all, are neuroretinitis, optic atrophy, unequal pupils, 
 diplopia, cramp of the eye-muscles, especially blepharospasm, reddening 
 of the conjunctivae, and lachrymation. Slight paresis and anaesthesia (or 
 hypsesthesia) are present in the limbs after severe attacks of the cramps. 
 
 There is no affection of consciousness, as a rule, but in severe cases 
 constitutional reaction, such as fever, accelerated pulse, etc., is seen. 
 
1396 MEDICAL DIAGNOSIS. 
 
 Sometimes the disease ends fatally, especially when caused by some 
 of the more serious conditions mentioned above. A patient in the Phil- 
 adelphia Hospital died of exhaustion and pulmonary oedema; but the 
 prognosis appears to be good in the majority of simple cases. 
 
 Diagnosis. — The tetanic symptoms are so characteristic that the 
 diagnosis is easy. 
 
 The cramps seen in chronic uraemia are not to be mistaken for tetany. 
 
 The French describe an hysterical type of tetany, but it cannot be 
 made to cover all cases; when the disease is truly hysterical the mental 
 state and the presence of other stigmata suggest the right diagnosis, and 
 such signs as Trousseau's and Chvostek's are wanting. 
 
 It is probable that a variety of affections cause tetanoid symptoms, 
 and further study is necessary to shed light on these obscure cases, 
 Tetany has no relation to true tetanus, and does not resemble it. 
 
 X. THE TICS. 
 
 The tics, or maladie des tics, or habit spasms, are peculiar motor dis- 
 orders in which one or more groups of muscles are thrown into regular 
 and oft-repeated contractions, resembling a voluntary act. The muscles 
 most frequently affected are those of the eyes, face, mouth, tongue, and 
 neck, but in some cases the muscles of the limbs are involved. 
 
 Pathology. — The French, who have described the tics most carefully, 
 point out the underlying mental state. The tic has a quasi-voluntary 
 character, and in its origin it is volitional or impulsive. Gradually the 
 movement becomes fixed as a motor habit, and can no longer be con- 
 trolled, or only imperfectly controlled, by the patient, and then at the 
 cost of mental distress and anxiety. Usually there is no very distinct 
 motive or associated idea in the mind; the tic is merely an impulse, which 
 grows into a habit. In proof of its psychic character, however, is the fact 
 that in some rare cases the movements are thus associated with definite 
 ideas in the patient's mind, emotional or otherwise, of which the tic is 
 the facial expression; and in extreme cases there may be obsessions, 
 especially of speech, the patient being impelled to give utterance to some 
 set of words, even an indecency — the so-called coprolalia. In fact, the 
 tics are closely allied to the obsessions; they are due to a sort of 
 imperative motor impulse, and they are usually found in neurotic and 
 degenerate patients. 
 
 Symptoms. — As no two cases are exactly alike it is difficult to give a 
 brief description of the tics. Blepharospasm is common, and with it is 
 often seen an associated movement of the face and even of the tongue and 
 larynx. Odd grimaces are the result, and these may even be, or seem to 
 be, the expressions of various mental states, as grief, surprise, pain, or 
 joy. When unilateral, as is often the case, the one-sided expression can 
 best be interpreted by covering the sound side of the face. In many cases, 
 however, there is no such expression, but merely a distortion of the fea- 
 tures. When the neck muscles are affected there are various move- 
 ments simulating torticollis. Sometimes associated movements of the 
 arm, hand, leg, or foot are seen. 
 
RAYNAUD'S DISEASE. 1397 
 
 The tics occur in regularly recurring bouts, the intervals varying 
 from a few minutes to much longer periods. They can sometimes be con- 
 trolled for a time by an effort of will, but the effort causes mental discom- 
 fort, and the patient seeks relief in what Church has called a "spasmodic 
 debauch," in which for a time the tic is repeated rapidly and frequently. 
 
 The tics commonly begin in childhood or in young persons. Occasion- 
 ally they appear later in life; and blepharospasm may have its origin 
 in some affection of the eye, and gradually become fixed as a habit. 
 
 Diagnosis. — As already said, the tics are allied to the obsessions and 
 to various neuroses. They are easily recognized by the conspicuous motor 
 disorder; j^et they have sometimes been confused with forms of epidemic 
 hysteria, such as in the "jumpers" of Maine and Canada, and the disease 
 known as "latah" among the Malays, and " myreachit" in Siberia, in which 
 imitation and suggestion are prominent factors. But the tics are not a 
 form of hysteria; they do not occur in epidemics; they are but little influ- 
 enced by suggestion; and they are too apt to be incurable. It is likewise an 
 error to describe this disease, as some authors do, under the head of chorea. 
 There is nothing choreic about it. In young children these habit spasms in 
 the face, neck, and shoulders, at the very beginning, may suggest St. Vitus's 
 dance, but the tic is more localized, more habitual, and more persistent 
 than the movements in chorea, and there is always a volitional element in 
 it. There is a mild grade of tic in children which tends to recover. 
 
 The true tics are to be distinguished from the spasmodic form of 
 tic douloureux, which is a form of facial neuralgia in which the facial 
 muscles are thrown into spasm by the action of pain. In the habit tics 
 pain is absent. 
 
 Stammerers sometimes develop a kind of associated spasm in the face 
 or even in a limb. When the embarrassment of speech is great the facial 
 muscles are contorted, and even the hand and arm may be moved spas- 
 modically. This cannot be called a tic in the proper sense of the word. 
 
 The tics differ from mere spasm by the psychic element in them. In 
 pure spasm the affection is in the neuromuscular apparatus, and there 
 is no mental collaboration. Such a spasm, purely local, oft repeated, and 
 not involving consciousness, is sometimes seen in some isolated muscle- 
 groups, as, for instance, in the head and neck, constituting the disease 
 known as torticollis. It is usually not controllable by the patient's will, 
 and the cause and pathology are obscure. 
 
 VASOMOTOR AND TROPHIC DISEASES. 
 
 I. RAYNAUD'S DISEASE. 
 
 This is a trophic disease in which the extremities, especially the fingers 
 and toes, are the seat of recurring pallor, congestion, and even gangrene. 
 The affection was first described by Raynaud in 1862. It is apparently 
 of vasomotor origin, and has three types or stages — local syncope, local 
 asphyxia, and local gangrene. 
 
 Pathology. — The disease seems to be essentially due to vasomotor 
 disorder. Neuritis and arterial sclerosis, or endarteritis obliterans, are 
 
1398 MEDICAL DIAGNOSIS. 
 
 not necessary parts of the process, although they may be present as sec- 
 ondary phenomena in late stages. This whole subject of the pathology, 
 however, is still obscure. 
 
 Symptoms. — In local syncope the parts become blanched, shrivelled 
 and cold; the appearance is similar to that caused by exposure to cold, 
 as in the so-called "dead fingers." The parts affected are usually the 
 fingers and toes, and the affection is symmetrical. The fingers feel numb, 
 and there are anaesthesia and analgesia, but as a rule no loss of the sense 
 of heat and cold. The affection is most common in cold weather, and it is 
 paroxysmal and recurrent, the attacks lasting from a few minutes to 
 several hours. There is no real paralysis, but the fingers may be awkward 
 or even powerless from the numbness and stiffness. There is usually no 
 pain; merely tingling and numbness. 
 
 In local asphyxia the reverse of the preceding picture is seen; it is a 
 stage of reaction, apparently, although it is not necessarily preceded by 
 a well-marked stage of syncope. The skin becomes dusky, red, purplish, 
 or even almost black; the parts, as the fingers, are congested; the surface 
 is cold; the tactile sense is impaired; and the members may be most pain- 
 ful. The radial pulse remains unchanged. As in syncope, the attacks are 
 paroxysmal and recurrent, and even occur in cycles. The affected fingers 
 are usually involved in turn, and the congestion disappears first from one 
 part and then another. Occasionally the nose, ears, and face are invaded. 
 
 The local or symmetrical gangrene may follow either the syncopal stage 
 or the asphyxial stage. The parts are cold, usually shrivelled, and bullse 
 form; these break and reveal black spots, which result in localized destruc- 
 tion. The ends of the fingers are destroyed, or the under parts of the toes. 
 The spots sometimes heal, leaving a healthy scar. The pain is often severe. 
 
 Among accessory sj^mptoms should be mentioned haemoglobinuria, 
 which, being associated with chill and slight fever, and having a paroxys- 
 mal course, has led to the suspicion of malaria; an idea which seems to 
 find some favor with Barlow. Amblyopia is also occasionally seen, and 
 may depend on" alteration in the calibre of the retinal vessels, as verified 
 by Galezowski. Temporary changes in the joints have been noted, also 
 hemiplegia and aphasia, and in rare cases even mental symptoms. Epilepsy, 
 or attacks suspiciously like it, has been reported. 
 
 Diagnosis. — There are various forms of gangrene which must not be 
 mistaken for Raynaud's disease. The disorder closely resembles chil- 
 blain or frost bite, but the history is sufficient to prevent error. Raynaud's 
 disease is a recurring affection, whereas frost bite is a simple and soHtary 
 accident, and by no means always symmetrical. 
 
 It also resembles ergotism, but the history alone should distinguish 
 the two. 
 
 So also of the gangrene of diabetes, in which the glycosuria and the 
 asymmetrical character of the gangrene are significant. 
 
 Erythromelalgia resembles the asphyxial stage of Raynaud's disease, 
 but in the former the affected limb is hot, pulsating, and more uniformly 
 painful than in the latter; moreover, it does not present sensory changes, 
 and gangrene does not result. Nevertheless, the two affections have some 
 affinity. It has been claimed that they are identical. 
 
ERYTHROMELALGIA. 1399 
 
 Morvan's disease closely simulates the late or gangrenous stage, of 
 Raynaud's disease; but the former is closely allied to syringomyelia or 
 central gliomatosis, and there is a peripheral neuritis and thickening of 
 the arterial coats. Hence in Morvan's disease there is usually seen muscu- 
 lar atrophy in the extremities, anaesthesia of all the modes of sensation, 
 changes in the deep reflexes, and possibly scoliosis or kyphosis. The 
 history is not that of recurring paroxysms, and the whitlows are painless. 
 
 Injury to a nerve, especially the median nerve, may cause gangrene 
 of the finger-tips, as in a case lately recorded by Sneve, but the history 
 usually is clear, the affection is unilateral, and the paralysis and anaesthesia 
 are characteristic. 
 
 Local gangrene may result from the obstruction of an artery, as 
 in the condition called endarteritis obliterans, the pathology of which 
 is obscure. 
 
 We do not agree with Oppenheim in confusing the various trophic 
 lesions of tabes, syringomyelia, and even hysteria with those of Raynaud's 
 disease. The associated symptoms of these diseases are sufficient to dis- 
 tinguish them. 
 
 Barker has recently called attention to the subject of acrocyanosis 
 in which there is anaesthesia with gangrene of the toes. It seems to be a 
 vasomotor affection and may have to be distinguished from. Raynaud's 
 disease by the difference in the state of sensation. 
 
 II. ERYTHROMELALGIA. 
 
 The affection to which Weir Mitchell gave this name in 1878 is de- 
 scribed by that author as a chronic disease in which a part or parts of the 
 body, usually one or more extremities, suffer with pain, flushing, and local 
 fever, made far worse if the parts hang down. 
 
 Pathology. — The disease has often been ascribed to vasomotor dis- 
 order. Lately, however, the tendency has been to attribute it to a periph- 
 eral neuritis; although careful examination has not always supported 
 this view. In most cases changes in the blood-vessels, as atheroma and 
 arterial sclerosis, have been present. Finally it has been suggested that 
 there is a central or cord lesion, and cases have been reported by Collier in 
 multiple sclerosis, tabes, and myelitis. It is also seen in hemiplegia. The 
 disease has been observed not infrequently in workmen who do heavy 
 labor and stand for long periods; and Sturgis suggests that it has points 
 of resemblance to the occupation neuroses, such as writer's cramp. On 
 the whole the question of the pathology is still an open one. The weight 
 of evidence seems in favor of a conjoint arterial sclerosis and peripheral 
 neuritis; while a central influence may also act. 
 
 Symptoms. — When the limb hangs down it becomes congested and 
 rose-red, or even of a dark violaceous hue; the arteries throb; and the 
 local temperature of the skin rises. Pain is usually present, and may be 
 severe, of a burning or neuralgic kind, worse on pressure, and generally 
 relieved when the limb is again elevated; but sometimes it persists in a 
 minor degree even then. It is worse in summer, and is relieved by the 
 apphcation of cold. Sensation of all kinds is preserved. The disease may 
 
1400 MEDICAL DIAGNOSIS. 
 
 be asymmetrical, and is not followed by gangrene, although a somewhat 
 similar condition has been seen to precede senile gangrene. The symp- 
 toms, when in the feet, are usually provoked by walking and standing. 
 It may be questioned whether erythromelalgia is a distinct disease, or 
 anything more than a symptom of various diseases. 
 
 Diagnosis. — The distinction from senile gangrene is sufficiently shown 
 in the account of the symptoms. In erythromelalgia the painful swelling 
 is not constant, but is aggravated by the dependent position, and it does 
 not lead to destruction of tissue. 
 
 Raynaud's disease is not dependent on position; it begins as an ischae- 
 mia; pain is inconstant; there is anaesthesia, analgesia, and lowered tem- 
 perature; and there is a local, and usually a symmetrical, gangrene. But 
 Voorhees, in a recent paper, maintains that the two diseases are merely 
 different phases of the same condition. 
 
 The disease has some resemblance to neuritis and injury to the nerves, 
 but there are not the objective symptoms, such as paralysis, anaesthesia, 
 and trophic changes; when these occur it is doubtful whether the case is 
 one of pure erythromelalgia. 
 
 It is well to recall, however, that some of the above data for differ- 
 entiation are not entirely reliable, for pallor, ischaemia, sensory changes, 
 etc., have been noted in cases closely resembling erythromelalgia, and gan- 
 grene has even followed in some of them, as in one of Mitchell's cases. 
 
 The blue oedema of hysteria is usually confined to one limb; it is 
 likely to be associated with loss of power, and it is often non-painful; 
 moreover, the history and other hysterical symptoms are significant. 
 These hysterical cases usually follow trauma. 
 
 III. ANGIONEUROTIC (EDEMA. 
 
 This is a sort of pseudo-urticaria, occurring usually in weakened or 
 neurotic persons. It is also called giant urticaria, or Quincke's disease. 
 
 Pathology. — The affection is probably of vasomotor origin, although 
 the essential cause and its mode of action are obscure. Several instances 
 are given, as by Osier and by Milroy, of hereditary transmission through 
 five and six generations. 
 
 Symptoms. — Locahzed swellings occur on the skin in various regions. 
 These are somewhat like wheals, or hives, but they are painless, and do 
 not itch. They are at first, as a rule, sHghtly pale, but flushing soon follows. 
 The subcutaneous tissue is involved in the oedema, and sometimes the 
 mucous membranes are invaded. Thus croupy symptoms have been caused, 
 and death has even been ascribed to angioneurotic oedema of the glottis. 
 Gastro-intestinal symptoms, such as colic and vomiting, are sometimes seen. 
 
 Cerebral symptoms are caused by these angioneuroses. Thus we 
 sometimes see flushing of the face and head, palpitation, throbbing in the 
 temples, tinnitus, dimness of vision, confusion, and emotional disorder. 
 Such cases are not uncommon in neurasthenic and hysterical patients. 
 
 Diagnosis. — The disease looks a little Hke urticaria, but there is no 
 burning or itching. Some authors, however, incline to identify the two, 
 and claim that itching occurs, but this is doubtful of real cases. 
 
HEMIFACIAL ATROPHY. 1401 
 
 When marked cerebral symptoms occur, as m tne cases of ''rush of 
 blood to the head/' there may be some remote resemblance to epilepsy, 
 but the history of the case and the well-marked vasomotor disorder should 
 prevent error. 
 
 Similar phenomena are sometimes seen in old alcoholic cases, and in 
 exophthalmic goitre. Purpura, with urticaria and haemoglobinuria, is 
 doubtless a different disease. 
 
 IV. HEMIFACIAL ATROPHY. 
 
 This is an affection in which, as the name signifies, atrophic changes 
 on one side of the face, brow, and skull are seen. 
 
 Pathology. — Autopsies have been rare; probably the most instruc- 
 tive was one by Mendel, in which he found neuritis of the left trigeminal 
 nerve, most marked in the second division, with atrophy of the descending 
 root and of the substantia ferruginea. Homen found a dural tumor com- 
 pressing the Gasserian ganghon. The disease is a trophic one, probably 
 depending on changes in the fifth nerve, although operations on the Gas- 
 serian ganglion have not fully sustained this theory. Some ascribe it to 
 changes in the sympathetic nerves. The subject is still obscure. 
 
 Symptoms. — The changes are in the skin, subcutaneous tissue, and 
 bone. The muscles supplied by the seventh nerve escape. 
 
 The initial symptom is changed color in a limited area of the skin; 
 this may spread until it involves the entire side of the face. The atrophy 
 of the skin follows, but it may be very slow. Atrophy of the bones is more 
 rare. The color of the hair of the beard, eyebrows, and head is sometimes 
 changed to white. The affected part does not sweat in some cases; and 
 some writers have observed lowered temperature (tq- of a degree). Taste 
 is sometimes involved; hearing seldom; sight never. The facial muscles 
 are not paralyzed, but the masticatory muscles, supplied by the motor 
 branch of the fifth nerve, have been found wasted, according to some 
 authors. Twitching of the facial muscles is sometimes seen. 
 
 The above are the essential features of the disease. In some cases 
 trigeminal neuralgia is present, and there may be parsesthesia,- as numb- 
 ness and tingling, but objective anaesthesia is uncommon. 
 
 In a few cases hemifacial atrophy has appeared in the chronic insane: 
 and in a few instances a hemilingual atrophy has appeared along with a 
 hemiplegia. 
 
 Diagnosis. — This presents no difficulty. The appearance of the 
 atrophied tissue is unmistakable. 
 
 In morphoea the bones are not involved; and in scleroderma, accord- 
 ing to Duhring, there is an hypertrophy rather than atrophy, and the 
 tissue is hardened. 
 
 In Bell's palsy the facial muscles are atrophied, and there is paralysis 
 with reactions of degeneration, but the skin and bones are not affected. 
 Turner says that the faradic excitability of the facial muscles in hemi- 
 atrophy is increased and that this arises from lessened resistance owing to 
 the disappearance of the subcutaneous fat. The history in Bell's palsy 
 is usuallv clear the affection is acute, and the muscles alone are involved. 
 
1402 
 
 MEDICAL DIAGNOSIS. 
 
 So, too, in progressive muscular atrophy and in muscular dystrophy, 
 when the face is invaded, the muscles alone are involved, the affection is 
 bilateral, and the course and appearance are entirely different. 
 
 V. OSTEITIS DEFORMANS: PAGET'S DISEASE. 
 
 Definition. — A rare disease of the bones, characterized by the absorp- 
 tion and new formation of bone tissue, which remains for a time uncalcified 
 and leads to curvatures, over-growth and other deformities of the skeleton. 
 
 Up to 1900 only 66 undoubted cases had been reported and in 1902 
 onlv 11 cases had been observed in North America. 
 
 Fig. 405. — Osteitis deformans. — Jefferson Hospital. 
 
 Etiology. — Predisposixg Ixfluexces. — Both sexes are liable to 
 the disease. Of the reported cases about twice as many occurred in males 
 as in females. Age is more important. The first symptoms have com- 
 monly shown themselves after the fortieth year. The onset of the disease 
 in one instance occurred about the age of twenty-one. As the disease is 
 chronic and progressive and in most instances unattended by subjective 
 symptoms, the cases have usually come under observation at a period 
 more or less remote from the time of onset. In the majority of instances 
 the first symptoms have been observed in middle rather than in advanced 
 life. The influence of heredity is uncertain. In three instances, however, 
 cases have occurred in two members of the same family. Occupation is 
 altogether without influence in predisposing to the disease. 
 
 Association with Other Diseases. — It has been assumed that there is 
 some causal relation between lesions of the nervous system and osteitis 
 
OSTEITIS DEFORMANS. 
 
 1403 
 
 deformans. No constant relationship has, however, been estabhshed and in 
 the greater number of the cases there has been an entire absence of phe- 
 nomena indicating nervous or visceral disease. Arthritis deformans has in a 
 few instances coexisted with osteitis deformans. This association appears 
 to have been a coincidence and there is no reason to believe that there is 
 any causal relationship or interdependence between the two affections. 
 
 The EXCITING CAUSE of the disease remains wholly unknown. 
 
 Symptoms. — The manifestations of osteitis deformans are chiefly objec- 
 tive. The onset is insidious, sometimes involving a single bone or a limited 
 number of bones, but in the course of time showing a tendency to symmetri- 
 cal involvement of the skeleton. Individuals suffering from this disease 
 
 Fig. 406. — Skiagram showing deformity of radius 
 and ulna. 
 
 Fig. 407.— Skiagram showing deformity of tibia 
 and fibula. 
 
 present as the result of definite skeletal deformities a remarkable resem- 
 blance to each other. There is thickening of the bones of the skull and an 
 alteration in its shape. The calvarium becomes flattened, the brow broad, 
 the parietal regions prominent. The general circumference is increased so 
 that the patient has to wear a larger hat than formerly. The face is irregu- 
 larly egg-shaped or triangular, the base being at the forehead and the apex 
 at the chin. The head is carried forward with the chin sunk upon the 
 breast. There is cervicodorsal kyphosis, flattening of the thorax at the 
 upper part, spreading at its base, the abdomen is diamond-shaped and 
 shows a deep transverse sulcus, the hips are increased in width and the 
 lower extremities markedly curved outward and forward, while owing to 
 the decrease in height amounting in some instances to several inches, the 
 arms appear disproportionately long — like those of the anthropoid apes. 
 
1404 MEDICAL DIAGNOSIS. 
 
 Pain in the bones is noted in the early course of many of the cases. 
 In some instances it has been intense. In others it has occurred chiefly 
 at night or after fatigue. As the disease progresses the pains have become 
 less severe. In a large proportion of the cases pain has not been observed. 
 The absence of pain may be explained by the very insidious development 
 of the process. 
 
 General muscular atrophy is characteristic of the advanced disease. 
 This is doubtless to some extent due to senile changes in the muscles. 
 There appears, however, to be a definite relationship between the osseous 
 deformities and the muscular atrophy. 
 
 Diagnosis. — The direct diagnosis in well-developed cases is unattended 
 by difficulty. The changes in the shape of the head and in the long bones, 
 the diminution in stature, the kyphosis and the peculiar deformities of 
 the thorax and abdomen make up a definite clinical picture not seen in 
 other maladies. The absence of causally related visceral disease and in 
 most instances the absence of the manifestations of lesions of the nervous 
 system and the unimpaired general health are to be noted. 
 
 The differential diagnosis involves the consideration of the following 
 diseases: 
 
 1. Osteomalacia. — In this affection there is gradual softening and 
 subsequent bending of the bones in which spontaneous fractures frequently 
 occur. There is a feeling of weakness in the lower extremities so that 
 the patient walks with difficulty and requires support. There seems to 
 be some relationship between osteomalacia and osteitis deformans, the 
 essential distinction consisting in the fact that in the latter there is a ten- 
 dency to the irregular and eccentric formation of new bone. 
 
 2. Leontiasis Ossea. — In this rare affection there is hyperostosis 
 of the bones of the skull and face. Osteophytes develop upon the lower 
 jaw and at the margins of the orbits and upon the outer and inner table 
 of the skull. In the latter situation they may cause symptoms of menin- 
 gitis or tumor. The narrowing of the canals of exit for the cranial nerves 
 may give rise to blindness, deafness, anosmia and peripheral derangements 
 of sensation and loss of motion. 
 
 3. Rickets. — This disease of early life presents changes in the bone 
 and other associated symptoms that are characteristic. The bending 
 of the ribs, enlargement of the wrists, squareness of the forehead, open 
 fontanelles are derangements of early developmental processes, not modi- 
 fications of mature structures. The deformities produced by rickets bear 
 only a superficial resemblance to those caused by osteitis deformans. 
 
 4. Acromegaly. — The thick, heavy lips, protruding under jaw and 
 broad deformed face and the enlargement of the head in its anteroposterior 
 diameter bear no resemblance to the cranial and facial changes in osteitis 
 deformans. In acromegaly the bones of the hands and feet and in some 
 instances the epiphyses of the long bones are involved, while in osteitis 
 deformans the changes in the long bones mainly involve the diaphysis, 
 and the bones of the feet commonly escape. 
 
 5. Pseudohypertrophic pulmonary osteo-arthropathy — a dis- 
 ease characterized by enlargement and deformity of the fingers, hands, 
 wrists, feet and ankles, occurring in patients suffering from certain chronic 
 
ACHONDROPLASIA. - 1405 
 
 pulmonary affections. This deforming affection of the osseous system bears 
 only a remote resemblance to osteitis deformans. The absence of changes 
 in the cranium, the escape of the shafts of the long bones and the constant 
 presence of intrathoracic lesions constitute points of radical difference. 
 
 Prognosis. — Osteitis deformans is slowly progressive and requires 
 a number of years, varying from five to fifteen, to attain its maximum 
 development. It has little influence upon the general health and is not a 
 direct cause of death. 
 
 VI. ACHONDROPLASIA: CHONDRODYSTROPHIA 
 
 FGETALIS. 
 
 Definition. — A form of dwarfism characterized by micromyelia and 
 macrocephalia, the trunk being of about the normal size. This remark- 
 able disease of fetal life was first described by Virchow (1858) who regarded 
 it as a form of fetal or congenital rhachitis. Parrot (1878) suggested 
 the- name achondroplasia. The most satisfactory account is that of P. 
 Marie (1900). 
 
 Etiology. — Predisposing influences and the exciting cause are alike 
 wholly unknown. 
 
 Patliology. — There is a dystrophy of the epiphyseal cartilages from the 
 earliest period of osteogenesis. The growth of the bones of the extremi- 
 ties at the epiphyseal cartilages is defective or arrested so that they 
 do not normally increase in length. The bones which develop from a 
 primitive membranous matrix, without passing through the stage of car- 
 tilaginous formation, as the clavicle, ribs and certain of the cranial bones, 
 are not involved in the dystrophy, a fact which accounts for the great 
 difference in the development of the extremities and that of the trunk 
 and head. The dystrophy has been ascribed to the action of an unknown 
 toxic agent circulating in the blood to which the epiphyseal cartilage sub- 
 stance is peculiarly obnoxious — perhaps a vitiated internal secretion 
 having to do with the regulation of the normal growth of the bod3\ 
 
 Clinical Characteristics. — The disease is essentially an affection of 
 fetal life. By far the greater number of cases die in iitero or shortly after 
 birth. Most of those who survive die in childhood. A few reach adult 
 life. In a limited number of cases the disease has appeared to commence 
 shortly after birth. These constitute the dwarfs known as micromelic. 
 
 The deformities are characteristic. Both the upper and the lower 
 extremities are symmetrically shortened. The arm is shorter than the 
 forearm; the thigh shorter than the leg. The lower limbs are bent, an 
 exaggeration of normal curves. The development of the trunk is about 
 normal. The enlargement of the head is characteristic. It may suggest 
 hydrocephalus. The head is not only large; it is also rounded with exag- 
 gerated parietal and frontal bosses. The features are large and coarse, 
 especially the nose, which is depressed at its root and rounded at its point 
 with flaring nostrils. There is lordosis affecting the lumbar vertebra and in 
 females contraction of the pelvis. The hand is small and square, the fingers 
 short, of about the same length and spreading — a deformity which has 
 been designated the trident hand. The scapulae are short. The muscles are 
 usually well developed. The genital organs are normal. Many of the sub- 
 
1406 MEDICAL DIAGNOSIS. 
 
 jects of this disease are obese. The mental powers are as a rule good; in 
 some of the reported cases defective. Comby thinks it probable that the 
 court dwarfs were achondroplasiacs as they are apt to be very intelligent. 
 
 The direct diagnosis of achondroplasia is unattended with difficulty. 
 
 It is to be differentiated from rickets, of which it was at one time 
 regarded as a prenatal type by the skeletal changes which do not involve 
 the trunk and are wholly dissimilar in the extremities and from cretinism, 
 of which it was formerly considered a fetal form by the higher degree of 
 intelligence, the peculiar deformities of the long bones which are shortened 
 and of I'elatively great thickness in the shaft and by the fact that 
 improvement does not follow the administration of thyroid extract. 
 
 XV. 
 
 THE DIAGNOSIS OF DISEASES OF THE MUSCLES. 
 
 I. MYOSITIS. 
 
 Definition. — Inflammation of the skeletal muscles. 
 Primary inflammation of the muscles may occur as an acute, subacute 
 or chronic disease. The following forms are recognized: 
 
 1. Infectious Myositis. — This form is very common in Japan. It 
 may affect one or many muscles. Of 32 cases studied bacteriologically 
 by Miyake, 2 yielded negative results; 27 yielded a pure culture of the 
 staphylococcus pyogenes aureus; 2 the cultures of the albus and aureus 
 and 1 the streptococcus. The onset is sudden. There is fever often high, 
 great depression, induration of the muscles followed by abscesses and, 
 unless the pus is completely evacuated, sepsis. 
 
 2. Dermatomyositis. — Many muscles are usually affected. The 
 overlying skin is inflamed and oedematous. The muscles are tender, 
 painful and stiff and upon palpation feel inelastic and dough-like. The 
 affection progressively involves new groups of muscles. Upon post-mortem 
 examination, the muscle substance is firm but fragile and the seat of 
 serous infiltration, fatty degeneration and proliferation of the interstitial 
 connective tissue. This form of myositis resembles trichinosis, from which 
 it cannot be differentiated except by the microscopical examination of 
 a bit of the affected muscle. 
 
 3. Neuromyositis. — This name was suggested by Senator for a 
 group of cases characterized by marked disorders of sensation. 
 
 4. Polymyositis Hemorrhagica. — These cases present the clinical 
 phenomena of dermatomyositis but to these are added grave circulatory 
 symptoms due to the implication of the myocardium in the process. The 
 muscles show more or less extensive interstitial hemorrhages. This 
 variety is extremely rare. 
 
 5. Myositis Ossificans. — Two forms are described, a local and a 
 progressive. The first affects a limited muscle mass and is stationary. 
 The second develops early in life, advances by irregularly recurring 
 attacks and progressively involves many muscle groups. The number 
 
THE MYOPATHIES. 
 
 U07 
 
 of boys who suffer from this affection appears to be five times as great as 
 that of girls. It is commonly first recognized in late infancy or childhood. 
 The muscles of the neck, trunk and upper extremities are usually involved, 
 the hands and lower extremities escaping. The masseters are sometimes 
 affected. The other muscles of the face escape. The process by which 
 the ossification occurs consists in cyanotic congestion in a localized area 
 of the tissues which upon pressure are found to be of doughy consistency 
 and very painful. After repeated attacks, bony nodules are found within 
 the muscles at the seat of the trouble and exostoses develop. Impairment 
 of function follows and muscular movements are greatly restricted. The 
 general health is not usually disturbed. There is no fever. Developmental 
 
 Fig. 408. — Showing exostoses, and full amount of abduction — Walker. 
 
 defects are common. They include microdactylia, ankylosis of the inter- 
 phalangeal articulations, hallus valgus and other deformities of the great 
 toe and malformations of the genital organs. Warren Walker, to whose 
 article I am indebted for some of the above facts, has recently reported 
 a most interesting case. The disease is very rare. 
 
 II. THE MYOPATHIES. 
 
 By this term we understand essential changes in the muscles, marked 
 by atrophy and loss of power, and not depending on changes in the central 
 or peripheral nervous system. 
 
 Pathology. — In the pure myopathies the changes are confined to 
 the muscles. There is atrophy of the muscular fibres, sometimes asso- 
 
1408 MEDICAL DIAGNOSIS. 
 
 ciated with or preceded by swelling in some of them. The nuclei of the 
 fibres may increase, and there is proHferation of the fibrous tissue. Fatty 
 deposits occur, and ultimately the muscular fibres show spHtting and 
 longitudinal striations, with the formation of vacuoles. The cause is not 
 definitely known, but there is probably a congenital defect of development 
 or of nutrition of the essential elements of the muscles. As a rule the 
 spinal cord and nerves are normal, although is some cases the motor nerve- 
 endings are involved; and a question arises whether indeed there is not 
 a juvenile type which is not a pure myopathy, but depends upon a periph- 
 eral neuritits or nerve dystrophy. The form known as the Charcot- 
 Marie-Tooth type is apparently not a pure myopathy at all, but rather 
 a muscular atrophy dependent upon a degeneration of the peripheral 
 nerves — a so-called primary neuritic atrophy, as shown in autopsies made 
 by Virchow and others. A well-marked type is that in which some of the 
 muscles undergo an increase in bulk, but this is a pseudohypertrophy, 
 in which the over-growth is not in the muscular elements proper. Various 
 other types of the affection occur, which are rather clinical than anatom- 
 ical; in fact, these types are probably only varieties of the same degen- 
 erative process. It is proper to note that some observers believe that 
 most of these cases are dependent upon a dystrophy of the nerve-endings. 
 The pathology of the myopathies is still somewhat obscure. 
 
 Symptoms. — The onset usually occurs early in life, and may be hered- 
 itary or familial. The trunk muscles are affected early in the disease, 
 and the arms and thighs also suffer. There is an absence of fibrillary 
 twitching in the muscles, and the complete reactions of degeneration are 
 not seen. Much refinement of description has been indulged in. The 
 commonest types are as follows: 
 
 A juvenile type, or scapulohumeral form, which appears in children, 
 and in which the muscles of the shoulder and arm are first affected. 
 
 The facio-scapulo-humeral type, in which, as the name implies, the 
 muscles of the face, shoulder and arm are especially involved. It differs 
 little from the former, chiefly, in fact, in the affection of the face. 
 
 The peroneal or leg type, in which the lower extremities, especially 
 the peroneal muscles, are implicated. 
 
 Pseudomuscular hypertrophy, in which some of the muscles, espe- 
 .cially those of the calf, are enlarged, while others, especially of the back 
 and arms, are atrophied. The enlargement of the calf muscles is not a 
 true hypertrophy, but is due largely to a deposit of fat. 
 
 The Charcot-Marie-Tooth type, or primary neuritic atrophy, in 
 which the distal muscles of the arms and legs especially suffer, and in 
 which there is fibrillation along with the atrophy, often with preservation 
 of the knee-jerks, without contractures and occurring as a familial affec- 
 tion. As already said, this type is not a pure myopathy. 
 
 The results of these various atrophies, or dystrophies, are various 
 forms of paralysis. Wasting may become extreme, with consequent com- 
 plete loss of power. The trunk muscles are so affected in some cases that 
 extreme lordosis occurs. When the face is attacked we see the so-called 
 ''myopathic face," in which the oral muscles are especially involved. 
 The muscles of mastication and deglutition, as well as of the eye, are not 
 
THOMSEN'S DISEASE. 1409 
 
 affected. When the arm and shoulder muscles are involved there results 
 great weakness in the upper extremities, with some deformities of the 
 hands. In the lower limbs the thigh muscles may be so wasted and weak- 
 ened that the patient cannot stand, much less walk; and in the legs the 
 destruction of the muscles causes various forms of club-foot. In extreme 
 cases no particular "type" is presented, but the patient has extensive 
 atrophy of all the limbs and of many of the trunk muscles, and may 
 become a so-called ''living skeleton." In the pseudohypertrophic form the 
 enlarged calves stand out conspicuously, and are hard and brawny to the 
 touch; but the patient usually presents wasting of the arms and trunk. 
 He shows a special difficulty in rising from the floor, climbing with his 
 two hands, as it were, up his legs. In the myopathies there is no involve- 
 ment of sensation, nor of the bladder or bowel, nor of the mental faculties. 
 The affection is chronic and incurable. 
 
 Diagnosis. — The student or practitioner need not be so much con- 
 cerned to make out ''types" or varieties as to establish a general diagnosis 
 of muscular dystrophy. For this purpose the history of the case is first 
 considered, and then the peculiar atrophy, associated perhaps in some 
 muscles with pseudohypertrophy, without fibrillation, reactions of degener- 
 ation, sensory changes or incontinence. These points, some or all, 
 serve to distinguish the affection from the progressive muscular atrophy 
 of adults, or from acute multiple neuritis, or from myelitis as the case may 
 be. From infantile paralysis or acute anterior poliomyelitis the disease 
 is distinguished by the slow onset, its progressive character and wide 
 extent, the preservation of the electrical responses to an advanced stage, 
 and the general history. 
 
 The primary neuritic atrophy of Charcot, Marie, and Tooth presents 
 some special points which give it a place almost unique. It somewhat 
 resembles progressive muscular atrophy, also multiple neuritis. It is dis- 
 tinguished, however, by being often a familial affection, beginning rather 
 early in life, very chronic, and the wasted muscles are the distal groups 
 of the extremities. Fibrillation is common and foot-drop is seen. The 
 knee-jerks may be preserved, and sensory symptoms are wanting. 
 
 In the cerebral palsies of children we see hemiplegia, diplegia, para- 
 plegia and rarely, monoplegia. The paralysis is spastic, with exaggerated 
 tendon reflexes and without true muscular atrophy; and in some cases 
 there are cerebral symptoms, as epilepsy and various grades of idiocy. 
 
 III. THOMSEN'S DISEASE: MYOTONIA. 
 
 This is a bizarre affection, seen by but few persons, and described 
 by most writers in terms exactly alike. It was first reported by a Dr. 
 Thomsen, for whom it is named, and in whose family it seems to have 
 prevailed to an unprecedented extent. As it is claimed to be congenital, 
 hereditary, and familial it is sometimes called 7nyotonia congenita. 
 
 Pathology. — The disease has no pathology that anyone has yet dis- 
 covered. But little significance is to be attached to such slight changes 
 as are reported by Erb, Dejerine, and a few others, and which seem to 
 consist in nothing but a little increase in size of the muscle fibres. 
 89 
 
1410 MEDICAL DIAGNOSIS. 
 
 Symptoms. — Muscular rigidity, or cramp, occurring on voluntary- 
 movements or attempts at such movements, is the chief symptom, A 
 condition of tonic spasm sets in when the patient, especially after a long 
 rest, attempts to use certain muscles or groups of muscles. These spasms 
 do not seem to be painful; at least, pain is not insisted on by some writers. 
 In some cases a few muscles only are involved; in others almost the whole 
 musculature of the body is thrown into tonic spasms. There is no loss of 
 consciousness. 
 
 Some effort has been made to show that the muscles present a special 
 or so-called "myotonic reaction" to electricity. This consists in a state, 
 more or less transient, of slight contracture and tonic spasm, which varies 
 somewhat with the kind of current used and with its strength. With 
 faradism there is a tonic contracture of long duration; with galvanism 
 only labile currents produce contractures, which are sluggish in character. 
 There is also increase of mechanical irritability, which is shown by the 
 muscle giving a sluggish tonic contraction on percussion, especially at 
 the point struck. 
 
 Diagnosis. — This is not difficult, for the disease is like none other. 
 An attempt should always be made to exclude hysteria. 
 
 IV. PARAMYOCLONUS MULTIPLEX. 
 
 Friedreich, in 1881, described a disease which has been dubbed with 
 this cumbersome name. Few persons seem to have seen it, or anything 
 like it; and some good authorities deny its existence. It has no recognized 
 cause or morbid anatomy. 
 
 Symptoms. — As described by most writers, the disease is manifested 
 by a series of short, quick, irregular, shock-like contractions of the 
 muscles of the extremities and trunk. The face usually escapes. The 
 contractions are not unlike those caused by electric shocks. The intelli- 
 gence, the sensory system, and the sphincters are not involved. 
 
 Diagnosis. — Hysteria is not to be ignored. Lloyd refers to aggra- 
 vated cases of hysterical tremor, with coarse irregular jerkings, which 
 suggested to him the picture of paramyoclonus as drawn in some books. 
 These are probably the patients who get well. 
 
 The chorea electrica of Bergeron, Henoch and others is probably a 
 true chorea, although cases of it have been described as paramyoclonus 
 multiplex. Dubini's chorea, also called electrical, is very rare, and is 
 said to be associated with fever, muscular atrophy, and paralysis. It is 
 an infectious disease, seen mostly in Italy. 
 
 V. MYASTHENIA GRAVIS. 
 
 The disease to which Jolly gave this name may be said to be still on 
 trial. Both clinically and pathologically it is as yet a subject of dispute. 
 It may be defined as a syndrome in which there is rapid exhaustion of the 
 muscles supplied by the bulb, as well as of some of the eye muscles and 
 muscles of the extremities. The tendency is towards a fatal termination. 
 The disease is also called asthenic bulbar palsy. 
 
MYASTHENIA GRAVIS. 1411 
 
 Pathology. — Almost by unanimous consent the Germans, who have 
 done most to secure the recognition of this syndrome, declare that the 
 anatomical examinations in the brain and cord are negative. Maier claimed 
 to have found alterations in the anterior roots of the spinal nerves, and 
 Marinesco and Widal reported changes in the ganglion cells^ but Oppen- 
 heim denies the validity of these findings. In America, anatomical 
 studies have been made by Hun, Burr and McCarthy, and others, and 
 there is a disposition to see changes in the thymus gland and lymphoid 
 infiltration in the muscles as the true causes of the disease. The subject 
 is still far from settled. 
 
 Symptoms. — Rapid exhaustion of certain muscles or groups of muscles 
 seems to be the cardinal symptom. The patient may begin using the 
 muscles with normal vigor, but they rapidly exhaust, sometimes with 
 alarming results. Thus there occur dysarthria, dysphonia, dysphagia, 
 dyspnoea, ptosis, in short, the evidences of paralysis of muscles supplied 
 by the third, fifth, seventh, tenth and twelfth nerves. Along with this 
 the extremities are often involved, and the respiratory muscles weak- 
 ened, so that the prostration of the patient may be extreme and danger- 
 ous. These attacks may be paroxysmal, excited especially by voluntary 
 use, and in fact the progress of the disease is often by stages. 
 
 Jolly observed the "myasthenic reaction" to faradic stimulation, by 
 which is meant the rapid exhaustion of the muscles by the faradic current. 
 This reaction is claimed by some to be pathognomonic. There is no mus- 
 cular atrophy; no fibrillation; no involvement of sensations; no optic 
 atrophy; no paralysis of the bladder or bowel; no abolition of the tendon 
 reflexes (as a rule) ; no affection of consciousness. Hun's patient, however, 
 had attacks of extreme weakness, or collapse, in which the mind was not 
 clear and the heart's action was depressed. The attacks resembled angina 
 sine dolore, or even heart block. 
 
 Cases vary in the distribution of the symptoms. In some patients 
 the bulbar symptoms are the most marked; in others the exhaustion is 
 more wide-spread. Some cases extend over a period of years, and the 
 disease may have marked remissions and exacerbations. A fatal result 
 is to be apprehended. 
 
 Diagnosis. — The disease resembles Landry's paralysis, except in its 
 tendency to remission and in the absence of evidence of organic central 
 disease. It is probable, however, that some reported cases are allied to, 
 if not identical with, Landry's disease. 
 
 In acute anterior poliomyelitis the evidence of organic central disease 
 is clear; as for instance, a flaccid paralysis with loss of the tendon reflexes 
 and with the reactions of degeneration. The disease is ushered in as an 
 acute febrile affection; it is not one of remissions and exacerbations, and 
 the paralysis is obstinately located, as a rule, in one limb and even in one 
 set of muscles. Bulbar symptoms are not common, although not unnoted 
 especially in epidemic anterior poliomyelitis. 
 
 From true bulbar palsy the asthenic form is distinguished especially 
 by the history and the absence of evidence of nuclear disease. In the 
 former there is an insidious onset, a slow course, and the affected muscles 
 slowly waste, and present fibrillation and gradual loss of power. 
 
1412 MEDICAL DIAGNOSIS. 
 
 Hysteria may closely simulate myasthenia gravis. The exhaustion 
 symptom and the myasthenic reaction to faradism should serve to dis- 
 tinguish the two affections. Hysteria seldom presents bulbar symptoms, 
 although there may be aphonia, globus, oesophagismus, and retching. 
 Hysterical ptosis is not unheard of. 
 
 It is necessary to utter a warning against placing too much confidence 
 in the exhaustion symptom. Something very like it can be seen in neuras- 
 thenia; and, in fact, a weakened muscle from whatever cause (as in 
 neuritis or dystroph}'-) exhausts rapidly on being used.* 
 
 'See Campbell and Bramwell for a critical digest of myasthenia gravis, Brain, 1900. 
 
INDEX. 
 
 A. 
 
 Abdomen, 21 
 
 imaginary or conventional lines of, 21 
 
 natural lines of, 21 
 
 palpation in examination of, 97 
 
 percussion in examination of, 143 
 
 quadrants of, 23 
 
 visceral regions of, 23 
 Abdominal dropsy, 1021 
 
 viscera, 32 
 
 topographical anatomy of, 32 
 Abscess, atheromatous, 1240 
 
 in appendicitis, 970 
 
 mediastinal, 1084 
 
 of brain, 1262 
 
 of kidney, 1123 
 
 of liver, 999 
 
 of spleen, 1166 
 
 pancreatic, 1016 
 
 perinephric, 1123 
 
 perirenal, 1123 
 
 pulmonary, 1079 
 Accessory spasm, 1316 
 Acetone, 292 
 
 tests for, 292 
 Achondroplasia, 927, 1405 
 Acidosis, 898 
 Acrocyanosis, 1399 
 Acromegaly, 1181, 1404 
 
 shape of head and face in, 396 
 
 skeletal changes in, 403 
 Acroparsesthesia, 584 
 Actinomycosis, 773 
 
 cutaneous, 775 
 
 gastro-intestinal, 774 
 
 joints in, 408 
 
 respiratory, 775 
 Acute polyarthritis (see Rheumatic fever), 
 746 
 
 yellow atrophy, 982 
 Addison's disease, 1178 
 Adenolipomatosis, 932 
 Adiposis dolorosa, 932 
 
 tuberosa simplex, 931 
 Adrenal bodies, diseases of, 1178 
 ^gophony, 165 
 Affenhand, 1325 
 Agglutination reaction, 246 
 Agoraphobia, 596 
 Aichmophobia, 596 
 Albinism, 535 
 Albuminuria, 285 
 
 accidental, 286 
 
 renal, 285 
 Albumose, 287 
 Alcoholic intoxication, 876 
 
 neuritis, 1350 
 Alcoholism, 876 
 
 Alcoholism, acute, 877 
 
 chronic, 876 
 
 diagnosis of, 878 
 
 in aged, 1288 
 
 symptoms of, 877 
 Alkaptone bodies, 293 
 Alopecia, 547 
 Amaurosis, 369 
 
 hysterical, 373 
 Amblyopia, 369 
 Amenorrhoea, 556 
 Amoebic dysentery, 842 
 acute form, 843 
 chronic form, 843 
 Amyloid disease, 932 
 
 of intestines, 934 
 of kidney, 933 
 of liver, 934 
 of spleen, 934 
 Amyloidosis, 932 
 
 Amyotrophic lateral sclerosis, 1327 
 Anacidity, 949 
 Anaemia, 1133 
 
 aplastic, 1139 
 
 general, 1134 
 
 idiopathic, 1137 
 
 local, 1134 
 
 pernicious, 1137 
 
 post-hemorrhagic, 1142 
 
 primary, 1134 
 
 progressive, 1137 
 
 pseudo-, 1133 
 
 renal, 1110 
 
 secondary or symptomatic, 1141 
 
 splenic, 1141, 1165 
 Anaemic headache, 569 
 Anal fistula in tuberculosis, 799 
 Anamnesis, the, 39 
 Anasarca, 537 
 Anencephalia, 10 
 Aneurism, 1244 
 
 arteriovenous, 1259 
 
 cirsoid, 1244 
 
 congenital, 1259 
 
 cylindroid, 1244 
 
 dissecting, 1244 
 
 false, 1244 
 
 fusiform, 1244 
 
 headache in intracranial, 571 
 
 intracranial, 1278 
 
 of abdominal aorta, 1257 
 
 of aorta, 1244 
 
 of coeliac axis and its branches, 1258 
 
 of heart, 1196 
 
 of thoracic aorta, 1246 
 cough in, 1248 
 course of, 1256 
 diagnosis of, 1253 
 
 1413 
 
1414 
 
 INDEX. 
 
 Aneurism of thoracic aorta, dysphagia in, 
 1249 
 dyspnoea in, 1248 
 hemorrhage in, 1247 
 pain in, 1248 
 physical signs of, 1249 
 prognosis of, 1256 
 symptoms of, 1246 
 sacculated, 1244 
 true, 1244 
 Aneurismal varix, 1244 
 Angina, crural, 1243 
 Ludovici, 495 
 pseudodiphtheritic, 713 
 Vincent's, 713 
 Angina pectoris, 1233 
 
 functional, 1234 
 neurotic, 1234 
 pseudo-, 1234 
 toxic, 1235 
 vera, 1233 
 Angina sine dolore, 1234 
 Angiocholitis, chronic, 985 
 Angiomata of liver, 1009 
 Angioneurotic oedema, 1400 
 Anidrosis, 536 
 Ankylostomiasis, 870 
 Anorexia, 500 
 Anterior crural nerve, 1363 
 
 thoracic nerves, 1356 
 Anthrax, 776 
 
 diagnosis of, 779 
 external, 777 
 internal, 778 
 Anuria, 551 
 
 Aorta, aneurism of, 1244 
 Aortic incompetence, 1214 
 insufficiency, 1214 
 obstruction, 1217 
 regurgitation, 1214 
 stenosis, 1217 
 Aphasia, 326 
 
 Aphonia of professional voice-users, 1390 
 Aphthous fever. 839 
 Apoplexy, 1268' 
 
 pulmonary, 1063 
 Appearance, 390 
 Appendicitis, 964 
 abscess in, 970 
 course of, 970 
 diagnosis of, 971 
 
 nature of pathological process in, 965 
 prognosis of, 972 
 symptoms of, 965 
 table of natural history of, 966 
 Appendix vermiformis, 33 
 Appetite, 500 
 
 loss of, 500 
 Aran-Duchenne type of muscular atrophy, 
 
 1325 
 Arcus senilis, 359 
 
 Argyll-Robertson symptom in general pare- 
 sis, 1286 
 Arithmomania, 1373 
 Arrhythmia, 1237 
 Arsenical poisoning, 884 
 Arteries, diseases of, 1239 
 
 Arteries, tuberculosis of, 802 
 Arteriosclerosis, 376, 1239 
 Arteriovenous aneurism, 1259 
 Arthritis, gonorrhoeal, 407 
 
 infective, 406 
 
 in hemorrhagic diseases, 407 
 
 primary, 405 
 
 tuberculous, 407 
 Arthritis deformans, 406, 908 
 diagnosis of, 910 
 Heberden's nodes in, 909 
 in children, 910 
 monarticular form, 909 
 morbid anatomy of, 908 
 progressive polyarticular form, 909 
 vertebral form, 910 
 Ascariasis, 866 
 Ascaris lumbricoides, 866 
 Ascites, 539, 1021 
 Ascitic fluid, adiposus, 1022 
 characters of, 1021 
 chylous and chyliform, 1022 
 inflammatory, 1022 
 milky, non-fatty, 1022 
 Astasia-abasia, 416, 1382 
 Asthenic bulbar palsy, 1410 
 Asthma, bronchial, 1058 
 
 hay, 1037 
 
 nervous, 1058 
 Ataxia, cerebellar hereditary, 1296 
 
 hereditary, 1334 
 
 locomotor, 1328 
 Ataxic gait, 1329 
 
 paraplegia, 1333 
 Atheromatous abscess, 1240 
 Athyria, 1174 
 
 Atrophic paralyses, the, 412 
 Atrophy, acute yellow, 982 
 
 degenerative muscular, 410 
 
 hemifacial, 1401 
 
 infantile nuclear, 1292 
 
 of hair, 547 
 
 of heart, 1197 
 
 of muscles, 409 
 
 of thymus, 1168 
 
 progressive muscular, 1325 
 Attitude, 415 
 Auditory irritation, 1313 
 
 nerve, 1312 
 Auscultation, 147 
 
 methods of, 147 
 
 of circulatory organs, 166 
 
 of oesophagus, 495 
 
 of veins, 192, 193 
 
 of voice, 164 
 
 technic of, 149 
 Auscultatory percussion, 130 
 Autointoxication, 896 
 
 from extensive abolition of function of 
 skin, 898 
 
 gastro-intestinal, 896 
 
 retention, 898 
 
 B. 
 
 Babinski reflex, 1327 
 Bacelli's sign, 166, 1095 
 Bacillary dysentery, 756 
 
INDEX. 
 
 141") 
 
 Bacillus, anthracis, 776 
 
 Eberth's, 715 
 
 fusiformis, 713 
 
 Klebs-Loffler, 706 
 
 leprae, 780 
 
 mallei, 771 
 
 pestis, 757 
 
 tuberculosis, 784 
 
 typhosus, 606 
 
 xerosis, 706 
 Backache, 574 
 Bacterismia, 263 
 Banti's disease, 1165 
 Barlow's disease, 925 
 Basedow's disease, 1171 
 Bednar's aphtha, 491 
 Belching, 503 
 Bell's mania, 1288 
 
 palsy, 1310 
 Beri-beri, 761 
 
 diagnosis of, 763 
 
 forms of, 762 
 Bile-ducts, cancer of, 989 
 Bile-passages, diseases of, 983 
 Bilharziasis, 856 
 BiHary colic, 992 
 BiUous typhoid, 836 
 Black vomit in yellow fever, 751 
 Bladder, 38 
 
 tuberculosis of, 801 
 Bleeders' disease, 1158 
 Blepharospasm, 357 
 Blood, 229 
 
 bacteriological examination of, 245 
 
 character of, in chlorosis, 1135 
 in dengue, 704 
 in diabetes, 917 
 in Hodgkin's disease, 1151 
 in lymphatic leukaemia, 1146 
 in myelogenous leukaemia, 1145 
 in pernicious anaemia, 1138 
 
 ductless glands and, diseases of, 1133 
 
 estimating specific gravity of, 243 
 time of coagulation of, 243 
 
 examination of, general results of, 252 
 in malarial fever, 263 
 methods of, 229 
 
 in stools, 520 
 
 opsonic index of, 249 
 
 tests for diabetes, 251 
 Blood-cells, differential counting of, 233 
 
 red, in urine, 272 
 nucleated, 256 
 number of, 254 
 Blood-platelets, 257 
 
 enumeration of, 237 
 Blood-vessels of hver, affections of, 997 
 Blue line on gums in lead poisoning, 882 
 Body, 398 
 
 form and nutrition of, 398 
 
 weight of, 399 
 Bones, 402 
 Brachial plexus, 1355 
 Bradycardia, 467, 1238 
 Brain, abscess of, 1262 
 
 diagnosis of echinococcus of, 865 
 
 diseases of, 1260 
 
 Brain, parasites in, 1283 
 
 syphilis of, 1284 
 
 tumors of, 1279 
 
 headache in, 570 
 Break-bone fever, 702 
 Breast, chicken, 403 
 Breathing, 152 
 
 bronchial, in disease, 155 
 in health, 152 
 
 bronchovesicular, 154 
 
 tracheal, 152 
 
 vesicular, in disease, 156 
 in health, 153 
 Bremer's test for diabetes, 251, 917 
 Bright's disease, acute, 1114 
 
 chronic, 1117 
 Broadbent's sign, 1205 
 Bronchi, diseases of, 1051 
 Bronchial asthma, 1058 
 Bronchiectasis, 1055 
 Bronchitis, 1051 
 
 acute, 1051 
 
 capillary, 1051, 1071 
 
 chronic, 1053 
 
 dry, 1053 
 
 fibrinous, 1054 
 
 plastic or croupous, 1054 
 
 putrid, 1054 
 Bronchocele, 1170 
 Bronchopneumonia, 1071 
 Bronchorrhagia, 1063 
 Bronchorrhoea, 1054 
 Bronchorrhoea serosa, 1054 
 Brown-Sequard paralysis, 1340 
 Bruit de diable, 1135 
 Bubonic plague, 757 
 Buhl's disease, 1160 
 Bulbar palsy, 1298 
 
 asthenic form, 1410 
 pseudo-, 1300 
 
 Cachexia, 392 
 
 Cachexia strumipriva, 1177 
 
 Caecum, 33 
 
 Caisson disease, 1346 
 
 Calculi, binary, 522 
 
 pancreatic, 523, 1018 
 
 renal, 1124 
 
 ureteral, 1125 
 
 urinary, 277 
 Cammidge's test, 294 
 Cancer (see Carcinoma) 
 Capillary pulse, 473 
 Capsular cirrhosis of authors, 1008 
 Caput Medusae, 545 
 
 succedaneum, 9 
 Carcinoma hepatis, 1010 
 
 intestinal, 975 
 
 of bile-ducts, 989 
 
 of stomach, 944 
 
 renal, 1131 
 
 ventriculi, 944 
 Cardiac cycle, 168 
 
 inadequacy of the obese, 1193 
 
 neuroses, 1235 
 
1416 
 
 INDEX. 
 
 Cardiac cycle, orifice, spasm of, 950 
 Carphologia, 598 
 Case-taking, 39 
 
 analytical method, 40 
 
 synthetic method, 39 
 Catalepsy. 599 
 Cataract', 369 
 Catarrh, acute nasal, 1035 
 
 autumnal, 1037 
 
 chronic gastric, 938 
 
 chronic nasal, 1036 
 
 dry nasal, 1037 
 
 suffocative, 1074 
 
 summer, 1037 
 Catarrhe sec, 1053 
 Catarrhus aestivus, 1037 
 Cauda equina, affections of, 1347 
 Causalgia, 1350 
 Cellulitis of the neck, 495 
 Cephalalgia, 568 
 Cephalhaematoma, 9 
 Cerebellar hereditary ataxia, 1296 
 Cerebellum, diseases of, 1295 
 Cerebral abscess, headache in, 570 
 
 disease, regional diagnosis of, 324 
 
 hemorrhage, 1267 
 
 parsesthesise, 583 
 
 softening, 1271 
 Cerebrospinal fever, 730 
 
 anomalous forms of, 733 
 complications and sequels of, 734 
 diagnosis of, 735 
 prognosis of, 737 
 
 symptoms of ordinary forms of, 731 
 Cerebrospinal fluid, 304 
 Cer\ical nerve, 1353 
 
 plexus, 1353 
 Cestodes, diseases due to, 858 
 
 intestinal, 858 
 
 ^dsceral, 862 
 Chalazion, 356 
 Charcot-!^Iarie-Tooth type of muscular 
 
 atrophy, 1368 
 Charcot's joints, 580 
 Chattering teeth, 1310 
 Chejme-Stokes respiration, 439 
 Chicken breast, 403 
 
 in rickets, 928 
 Chicken-pox (see Varicella), 668 
 Chills in typhoid fever, 611 
 Chloroma, 1147 
 Chlorosis, 1134 
 
 florida, 1135 
 
 rubra, 1135 
 Cholangitis, chronic catarrhal, 985 
 
 suppurative, 985 
 Cholecystitis, acute, 987 
 
 chronic, 988 
 Cholelithiasis, 989 
 
 diagnosis of, 996 
 
 prognosis of, 997 
 
 symptoms of, 991 
 Cholera, 752 
 
 Asiatic, 752 
 
 complications and sequels of, 755 
 
 diagnosis of, 755 
 
 infectiosa, 752 
 
 Cholera, sicca, 754 
 
 symptoms of, 754 
 
 typhoid, 755 
 Chondrodvstrophia fcetalis, 927, 1405 
 Chorea, 1369 
 
 chronic progressive, 1374 
 
 course of attack, 1371 
 
 Dubini's, 1410 
 
 electrica, 1410 
 
 epidemic, 1372 
 
 habit, 1372 
 
 hereditary, 1374 
 
 hypotheses of, 1370 
 
 insaniens, 1371 
 
 major, 1372 
 
 ocular phenomena in, 1371 
 
 ordinary form, 1370 
 
 paralytic, 1370 
 Choreiform affections, the, 1372 
 Chromidrosis, 536 
 
 Chronic intoxications, diagnosis of, 876 
 Chvostek's symptom, 591 
 Chylous fluids, 304 
 Cicatrices, 489, 543 
 Circulation, 460 
 
 Circulatory derangements in exophthalmic 
 goitre, 1173 
 of kidneys, 1110 
 of lungs, 1061 
 Circulatory organs, auscultation of, 166 
 
 diseases of, 1183 
 Circumflex nerve, 1357 
 Cirrhosis of liver, 1005 
 
 of lung, 1075 
 Clasp-knife rigidity, 1328 
 Claustrophobia, 596 
 Clavdcles, 12 
 Cla\nas in hysteria, 1380 
 Claw hand (main en griffe), 1325 
 Clinical charts, 58 
 Cocaine-bug, 881 
 Cocainism, 881 
 Cocomania, 881 
 Coin percussion, 140 
 Cold, "hay" or "rose," 1037 
 
 in head, 1035 
 CoUc, biliary, 992 
 
 renal, 1126 
 Colica pictonum, 882 
 Colitis, mucous, 516 
 Colon, 33 
 
 idiopathic dilatation of, 963 
 Color index, 242 
 Coma, 598, 599 
 
 from poisonous gases, 601 
 
 in apoplexy, 600 
 
 in cerebral disease, 600 
 
 in convulsions, 601 
 
 in diabetes, 601 
 
 in epilepsy, 602 
 
 in hj-steria, 602 
 
 in infective diseases, 600 
 
 in narcotic poisoning, 601 
 
 in traumatism of head, 600 
 
 in uraemia, 601 
 Coma vigil, 598 
 Common bile-duct, 36 
 
INDEX. 
 
 1417 
 
 Common bile-duct, obstruction of, 994 
 Congenital aneurism, 1259 
 
 cystic kidneys, 1130 
 
 lesions of the heart, 1230 
 Conjunctiva, 357 
 
 diphtheria of, 358 
 
 elevation of, 358 
 
 hemorrhage beneath, 358 
 
 inflammation of, 357 
 
 roughness of, 358 
 
 tumors and cysts in, 358 
 
 uric acid deposits in, 358 
 Consciousness, derangements of, 595 
 Constipation, 512 
 
 associated symptoms of, 515 
 
 causes of, 512 
 
 constitutional derangements of, 515 
 Constitutio lymphatica, 1168 
 Consumption (see Tuberculosis), 802 
 Contracted kidney, 1118 
 Convulsions, 588 
 Coprsemia, 897 
 Coprolalia, 1373 
 Cor adiposum, 1193 
 
 bovinum, 182, 1191 
 
 villosum, 1198 
 Cornea, 358 
 
 Coronary arteries, embolism and throm- 
 bosis of, 1188 
 sclerosis of in myocarditis, 1187 
 Corpuscles, estimation of the relative vol- 
 ume of, 242 
 Corrigan's disease, 1214 
 
 pulse, 1138 
 Coryza, 1035 
 
 periodic, 1037 
 Cough, 444 
 
 chnical varieties of, 448 
 
 ear, 447 
 
 in aneurism of thoracic aorta, 1248 
 
 in dentition, 448 
 
 in hysteria, 1383 
 
 in pneumonia, 719 
 
 in pulmonary emphysema, 1067 
 
 liver, 448 
 
 mediastinal, 448 
 
 nervous, 448 
 
 pharyngeal, 447 
 
 significance of, in diagnosis, 446 
 
 stomach, 447 
 Courvoisier's law, 995 
 Cowpox, 663 
 
 Cramp, telegrapher's, 1389 
 Cranial nerves, diseases of, 1302 
 Craniotabes, in rickets, 928 
 Crepitant rales, 160 
 Crepitation, 94 
 Crepitus indux, 160 
 
 redux, 160 
 Cretinism, 1175 
 
 shape of face in, 396 
 Croup, false, 1041 
 
 membranous, 1044 
 
 spasmodic, 1041 
 
 true, 1044 
 Croupous pneumonia, 714 
 abscess in, 724 
 
 Croupous pneumonia, clinical varities of, 725 
 
 complications and sequels of, 722 
 
 convalescence in, 724 
 
 delayed resolution of, 724 
 
 diagnosis of, 727 
 
 endocarditis in, 722 
 
 gangrene in, 724 
 
 gastro-intestinal and other abdom- 
 inal complications in, 723 
 
 immunity from, 715 
 
 jaundice in, 724 
 
 meningitis in, 723 
 
 metapneumonic empyema in, 722 
 
 meteorism in, 724 
 
 pathological anatomy of, 716 
 
 pericarditis in, 722 
 
 physical examination, 721 
 
 pleurisy in, 722 
 
 prognosis, 728 
 
 resolution of, 724 
 
 sjmiptoms of, 717 
 
 thrombosis in, 723 
 Crural angina, 1243 
 Cryoscopy, 294 
 Curschmann's spirals, 297 
 Cutaneous hemorrhages, 542 
 Cyanosis, 441, 528 
 
 in pulmonary emphysema, 1067 
 Cyrtometry, 106 
 Cystic duct, 36 
 
 obstruction of, 994 
 Cysticercus cellulosae, 862 
 Cysts, 305 
 
 hydatid, 306 
 of kidney, 1129 
 ovarian, 306 
 pancreatic, 305, 1018 
 Cytodiagnosis, 303 
 
 D. 
 
 Dalrymple's sign, 1172 
 Dare's method, 237 
 
 technic of, 238 
 " Dead fingers, " 1398 
 Deafness, 1312 
 Decubitus, 412 
 Defecation, 511 
 
 painful, 518 
 Degeneration, senile, 1287 
 
 stigmata of, 346 
 Delirium, 596 
 
 acute, 1288 
 
 grave, 1288 
 Delirium potu suspenso, 877 
 
 tremens, 597, 877 
 Dengue, 702 
 Dercum's disease, 932 
 Dermacentor andersoni, 835 
 Dermatographism, 528 
 Desquamation, 543 
 Dextrocardia, 1183 
 Diabete bronze, 918 
 Diabetes, 912 
 
 an autointoxication, 898 
 
 pancreatic, 1017 
 Diabetes insipidus, 921 
 
1418 
 
 INDEX. 
 
 Diabetes mellitus, 913 
 blood in, 917 
 
 carbohydrate metabolism in, 914 
 coma in, 918 
 complications of, 917 
 diagnosis of, 919 
 multiple neuritis in, 1352 
 pancreatic, 914 
 phosphatic, 916 
 pneumaturia in, 916 
 prognosis of, 920 
 symptoms of, 915 
 test for detection of, 251 
 tests for glucose in, 915 
 urine in, 915 
 Diacetic acid, 292 
 Diagnosis, 1 
 
 definition of, 1 
 methods of, 3 
 object of, 3 
 requirements of, 2 
 Diaphragm phenomenon, 69 
 Diarrhoea, 515 
 
 associated symptoms of, 517 
 forms of, 516 
 Diarrhoeal disorders of children, 954 
 chronic, 955 
 dietetic, 955 
 inflammatory, 955 
 toxic and bacterial, 955 
 Diastasis recti, 951 
 Diathesis, 391 
 Dicrotism, 471 
 Dietl's crises, 578, 1108 
 Digestive system, 477 
 
 diseases of, 935 
 Diphtheria, 105 
 
 antitoxin treatment of, 712 
 complications and sequels of, 711 
 diagnosis of, 712 
 faucial, 707 
 laryngeal, 708 
 nasal, 708 
 prognosis of, 713 
 symptoms of, 707 
 toxins of, 707 
 Diphtheritic toxsemia, 710 
 Diplegia in children, 1274 
 Diplococcus intracellularis meningitidis, 730 
 
 pneumoniae, 300, 714 
 Dipsomania, 878 
 Disease, Addison's, 1178 
 amyloid, 932 
 Banti's, 1165 
 Barlow's, 925 
 Basedow's, 1171 
 bleeder's, 1158 
 Bright' s, 1114 
 Buhl's, 1160 
 caisson, 1346 
 cerebral, 324 
 chronic valvular, 1214 
 Corrigan's, 1214 
 Dercum's, 932 
 gall-stone, 989 
 Gilles de la Tourette's, 1372 
 Glenard's, 972 
 
 Disease, Graves's, 1171 
 
 Gull's, 1174 
 
 Hanot's, 1008 
 
 Hodgkin's, 1149 
 
 hook-worm, 870 
 
 Huntingdon's, 1374 
 
 Little's, 1276 
 
 Meniere's, 1313 
 
 Mikulicz's, 1149 
 
 Morvan's, 1337 
 
 Paget's, 1402 
 
 Parkinson's, 1393 
 
 Parrv's, 1171 
 
 Quicke's, 1400 
 
 Raynaud's, 1397 
 
 Schonlein's, 1155 
 
 Thomsen's, 1409 
 
 Werlhof's, 1154 
 
 Winckel's, 1160 
 Diseases characterized by hemorrhage, 
 1153 
 
 combined valvular, 1229 
 
 constitutional, 904 
 
 general nervous, 1369 
 
 hemorrhagic, of the new-born, 1160 
 
 nutritional, 922 
 
 of adrenal bodies, 1178 
 
 of arteries, 1239 
 
 of bile-passages and gall-bladder, 983 
 
 of blood, 1133 
 
 of brain, 1260 
 
 of bronchi, 1051 
 
 of cerebellum, 1295 
 
 of circulatory system, 1183 
 
 of cranial nerves, 1302 
 
 of endocardium, 1207 
 
 of heart, 1183 
 
 of hepatic artery, 999 
 
 of hepatic veins, 999 
 
 of intestines, 952 
 
 of kidneys, 1107 
 
 of larynx, 1040 
 
 of liver, 977 
 
 of mediastinum, 1083 
 
 of muscles, 1406 
 
 of myocardium, 1183 
 
 of nervous system, 1260 
 
 of nose, 1035 
 
 of pancreas, 1013 
 
 of pericardium, 1197 
 
 of peritoneum, 1021 
 
 of pleura, 1088 
 
 of pons, 1296 
 
 of portal vein, 998 
 
 of pulmonary tissue, 1061 
 
 of respiratory system, 1035 
 
 of spinal cord, 1318 
 
 of spinal nerves, 1349 
 
 of spleen, 1161 
 
 of stomach, 935 
 
 of thymus gland, 1167 
 
 of thyroid gland, 1169 
 
 vasomotor and trophic, 1397 
 Dissecting aneurism, 1244 
 Distomiasis, 855 
 
 hsemic, 856 
 
 hepatic, 855 
 
INDEX. 
 
 1419 
 
 Distomiasis, intestinal, 850 
 
 pulmonary, 856 
 Dittrich's plugs, 1054 
 Diverticula of oesophagus, 498 
 pulsion, 499 
 traction, 499 
 Dracontiasis, 875 
 Dracunculus medinensis, 875 
 Dreams, 603 
 Dropsy, 537 
 
 abdominal, 1021 
 
 in acute nephritis, 1115 
 
 in chronic nephritis, 1117 
 Drusenfieber of Pfeiffer, 837 
 Dubini's chorea, 1410 
 
 Dulness, normal and abnormal paraverte- 
 bral triangles of relative, 1094 
 Dum-dum fever, 845 
 Duodenal ulcer, 956 
 
 following extensive burns of skin, 
 957 
 Duroziez's murmur, 1217 
 Dysbasia angiosclerolica, 1243 
 Dyscrasia, 392 
 Dysentery, amoebic, 842 
 
 bacillary, 756 
 Dysmenorrhoea, 557 
 Dysphagia in aneurism of thoracic aorta, 
 
 1249 
 Dysphonia of professional voice-users, 1390 
 Dyspnoea, 440 
 
 facies of, 440. 
 
 forms of, 441 
 
 from aneurism of thoracic aorta, 1248 
 
 in bronchial asthma, 443 
 
 in bronchitis, 443 
 
 in emphysema, 443 
 
 in pneumonia, 719 
 
 of anaemia, 444 
 
 in pulmonary emphysema, 1067 
 
 of fever, 444 
 
 so-called ursemic, 443 
 Dysuria, 549 
 
 E. 
 
 Ear: Eustachian tube, 228 
 
 external auditory canal, 227 
 
 pharynx, 228 
 
 tympanic membrane, 228 
 Eberth's bacillus, 715 
 Ecchymoses, 542 
 Echinococcus disease, 862 
 Echokinesis, 1373 
 Echolalia, 1373 
 Ectopia cordis, 1183 
 Eczema of tongue, 489 
 Ehrlich's diazo reaction, 293 
 
 triple stain, 231 
 Einhorn's bead test of digestive activity, 209 
 Electric strike, 900 
 Electro-diagnosis, 337 
 Elephantiasis graecorum, 780 
 Ellis s line of flatness, 1093 
 Embolism, air, 1065 
 
 fat, 1065 
 Embryocardia, 176 
 
 Emotional states, 595 
 
 Emphysema, collateral vicarious, 1076 
 
 pseudohypertrophic, 1066 
 
 pulmonary, 1066 
 
 subcutaneous, 542 
 
 substantive, 1066 
 
 vesicular, 1066 
 Emprosthotonos, 415 
 
 in tetanus, 765 
 Empyema, 1096 
 
 necessitatis, 1097 
 Encephalitis, acute hemorrhagic, 1261 
 
 purulent meningo-, 1262 
 Encephalocele, 10 
 Encephalopathy, lead, 883 
 Endarteritis obliterans, 1240 
 Endocarditis, 1207 
 
 acute, 1208 
 
 cerebral form, 1210 
 
 chronic, 1212 
 
 fetal, 1230 
 
 in pneumonia, 722 
 
 in rheumatism, 748 
 
 malignant, 1210 
 
 mural, 1207 
 
 recurrent form, 1210 
 
 septic form, 1210 
 
 simple, 1209 
 
 typhoid form, 1210 
 
 valvular, 1207 
 
 vegetative or verrucose, 1208 
 Endocardium, diseases of, 1207 
 Enteric fever (see Typhoid fever), 605 
 Enteritis, 952 
 
 catarrhal, 952 
 
 diphtheritic, 953 
 
 phlegmonous, 953 
 Enteroliths, 523 
 Enteroptosis, 972 
 Ephemeral fever, 833 
 Epidemic cerebrospinal meningitis, 730 
 
 parotitis (see Miunps), 694 
 
 roseola, 687 
 Epilepsy, 1374 
 
 as result of alcoholism, 878 
 
 cortical, partial, or symptomatic, 1377 
 
 diagnosis of, 1378 
 
 Jacksonian, 1377 
 
 major, 1375 
 
 minor, 1377 
 
 premonitory forced movements in, 1376 
 
 prognosis of, 1379 
 
 senile, 1287 
 
 symptoms of, 1375 
 Epileptic cry, 1376 
 
 fit, 1376 
 Epistaxis, 1039 
 Erb's paralysis, 1338 
 Ergotismus, 895 
 Eructations, 503 
 Erysipelas, 737 
 
 of eyelids, 356 
 Erysipeloid of Rosenbach, 840 
 Erythema infectiosum, 841 
 migrans, 840 
 serpens, 840 
 variolosa, 650 
 
1420 
 
 INDEX. 
 
 Erythrocytes, 233, 253 
 
 abnormal, 255 
 
 enumeration of, 233 
 Erythromelalgia, 1399 
 Ewald's test breakfast, 200 
 Exanthemata, the, 394 
 Exophthalmic goitre, 354, 1171 
 
 tremor in, 592 
 Exophthalmos, 1172 
 Exploratory puncture, 300 
 External antipyretics, 435 
 Extrahepatic bile-passages, 36 
 Extremities, changes in, in rickets, 929 
 Exudates, 301 
 
 bacteriological examination of, 302 
 
 cytological examination of, 302 
 Eye, examination of, 351 
 
 motor nerves of, 1306 
 Eyeball, 353 
 
 protrusion of, 353 
 
 retraction of, 354 
 
 tension of, 355 
 Eyelids, 355 
 
 marginal inflammation of, 355 
 
 oedema of, 355 
 
 Face, 9 
 
 regions of, 9 
 Facial nerve, 1310 
 
 spasm, 1311 
 Facies, 392 
 
 Hippocratica, 537, 1028 
 
 myopathica, 411 
 
 of acute peritonitis, 393 
 
 of enteric fever, 393 
 
 of exophthalmic goitre, 396 
 
 of hepatic disease, 395, 1008 
 
 of leprosy, 397 
 
 of malaria, 395 
 
 of mental and nervous disease, 397 
 
 of mumps, 394 
 
 of pneumonia, 393 
 
 of renal disease, 395 
 
 of rickets, 395 
 
 of syphilis, 395 
 
 of tetanus, 394 
 Fseces, 214 
 
 chemical examination of, 219 
 
 fermentation of, 216 
 
 microscopical examination of, 217 
 Fallopian tubes, tuberculosis of, 802 
 Farcy, 771 
 Farcy-buds, 772 
 Farcy-pipes, 772 
 Farre's tubercles, 1010 
 
 Fatty degeneration, acute, of the new-born, 
 1160 
 
 heart, 1193 
 
 infiltration, 1193 
 
 hver, 1003 
 
 overgrowth, 1193 
 Febricula, 833 
 Fetal movements, 103 
 Fever, 421 
 
 aphthous, 839 
 
 Fever, atypical, 426 
 
 bed, 431 
 
 break-bone, 702 
 
 causes of, 421 
 
 cerebrospinal, 730 
 
 dum-dum, 845 
 
 emaciation of, 423 
 
 ephemeral, 833 
 
 estivo-autumnal, 852 
 
 glandular, 837 
 
 hay, 1037 
 
 idiopathic, 424 
 
 in appendicitis, 969 
 
 in Hodgkin's disease, 1152 
 
 in pneumonia, 717 
 
 in pyelitis, 1122 
 
 in typhoid fever, 609 
 
 lung, 714 
 
 malarial, 846 
 
 Malta, 759 
 
 miliary, 838 
 
 paratyphoid, 639 
 
 paroxysmal, 431 
 
 periodical, 431 
 
 pulse in, 422 
 
 quartan, 852 
 
 relapsing, 644 
 
 respiration in, 423 
 
 rheumatic, 746 
 
 Rocky Mountain spotted, 834 
 
 scarlet, 670 
 
 simple continued, 833 
 
 stages of, 427 
 
 symptoms of, 422 
 
 tertian, 851 
 
 tick, 834 
 
 type in, 424 
 
 typhoid, 605 
 
 typhus, 641 
 
 varieties of, 424 
 
 yellow, 750 
 Fibrillation, 593 
 Fibrinous pneumonia, 714 
 Fibromata of liver, 1009 
 Fievre charbonneuse, 777 
 Fifth cranial nerve, diseases of, 1308 
 Filaria, forms of, 872, 874, 875 
 Filariasis, 872 
 First-rib sign, 1202 
 Fish poisoning, 893 
 Flexner's researches i\i cirrhosis of the liver, 
 
 1007 
 Flint's murmur, 1216 
 Fluid veins, theory of, 152 
 Flukes, diseases due to, 855 
 Folie de toucher, 1373 
 Fontanelles, 8 
 Food poisoning, 892 
 
 examination of food in cases sus- 
 pected of, 896 
 Foot-and-mouth-disease, 839 
 Foreign bodies in heart, 1195 
 Fourth disease, 689 
 Fremitus, 95 
 
 friction, 96, 162 
 
 hydatid, 864 
 
 rhonchal, 97 
 
INDEX. 
 
 1421 
 
 Fremitus, vocal, 95 
 Friction, pericardial, 189 
 
 pleuropericardial, 189 
 Friction fremitus, 96, 162 
 
 sounds, 162 
 
 subpleural, 164 
 Friedreich's ataxia, 1334 
 
 sign, in adherent pericardium, 1205 
 Furunculosis, 543 
 
 Gait, 417 
 
 ataxic, 418, 1329 
 
 festinating, 418 
 
 hemiplegic, 417 
 
 in chorea, 418 
 
 in hereditary ataxia, 1334 
 
 of sciatica, 418 
 
 paraplegic, 417 
 
 reeling or staggering, 418 
 
 spastic, 417 
 
 steppage, 417 
 
 waddling, 417 
 Gall-bladder, 36 
 
 atrophy of, 994 
 
 cancer of, 989 
 
 diseases of, 983 
 
 dropsy of, 994 
 
 inflammation of, 987 
 Galloping consumption, 804 
 Gallop rhythm, 176 
 Gall-stone disease, 989 
 Gall-stones, chemical and physical charac- 
 ters of, 990 
 
 in intestines, 996 
 
 origin of, 990 
 
 quiescent in gall-bladder, 991 
 
 symptoms attending passage of, 
 through ducts, 992 
 
 symptoms caused by permanent ob- 
 struction of ducts by, 994 
 
 ulcerative lesions caused by, 995 
 Gangrene of lung, 1080 
 Gastralgia, 947 
 Gastrectasis, 939 
 Gastric atony, 950 
 
 catarrh, chronic, 938 
 
 neuroses, 946 
 
 disorders of secretion, 947 
 disorders of motor functions, 949 
 disorders of sensation, 946 
 
 ulcer, 942 
 Gastritis, acute, 935 
 
 chronic, 938 
 
 diagnosis of, 937 
 
 dietetic, 937 
 
 diphtheritic, 936 
 
 infectious, 936 
 
 parasitic, 936 
 
 phlegmonous, 936 
 
 toxic, 935 
 Gastrodynia, 947 
 Gastro-enteritis, acute, 955 
 Gastro-intestinal symptoms in appendicitis, 
 969 
 in pernicious ansemia, 1138 
 
 Gastroptosis, 950 
 Gastrorrhagia, 509 
 Gastroscopy, 197 
 Gastrosuccorrhoea, 947 
 Gastroxynsis, nervous, 947 
 General nervous diseases, 1369 
 
 paresis, 1285 
 Genito-urinary system, 548 
 
 tuberculosis of, 800 
 Gerhardt's sign, 818 
 German measles, 687 
 Gilles de la Tourette's disease, 1372 
 Glanders, 771 
 Glandular fever, 837 
 Glaucoma, acute, 369 
 Glenard's disease, 972 
 Globus hystericus, 1380 
 Glosso-pharyngeal nerve, 1314 
 Glossy skin, 544 
 Glycosuria, 290 
 
 an autointoxication, 898 
 Goitre, 1170 
 
 endemic, 1170 
 
 exophthalmic, 1171 
 
 facies of exophthalmic, 396 
 
 sporadic, 1170 
 Gonorrhoea, 831 
 Gonorrhoeal arthritis, 832 
 
 endocarditis, 832 
 
 infection, 832 
 
 sepsis, 832 
 Gout, 904 
 
 acute, 905 
 
 an autointoxication, 898 
 
 association of, with plumbism, 884 
 
 chronic, 905 
 
 diagnosis of, 906 
 
 irregular, 906 
 
 joints in, 406 
 
 poor man's, 905 
 
 retrocedent, 905 
 
 suppressed, 905 
 
 visceral, 915 
 Gouty kidney, 1118 
 Gowers haemocytometer, 137 
 Graefe's sign, 1172 
 Grain poisoning, 895 
 Grand mal, 1375 
 Granular kidney, 1118 
 Graves's disease, 1171 
 Great vessels, 30 
 Grocco's sign, 1094 
 Guinea-worm disease, 875 
 Gullet, 26 
 Gull's disease, 1176 
 Gummata in acquired syphilis, 824 
 
 of Hver, 826 
 
 of lungs, 826 
 Gums, 481 
 
 H 
 
 Habit spasm, 1372 
 Habitus phthisicus, 810 
 Hsematemesis, 509 
 Hsematidrosis, 536 
 Hsematocrit, Deland's, 242 
 
1422 
 
 INDEX. 
 
 Hsematoma, 542 
 Hsematuria, 552 
 Haemocytometer, 237 
 
 Gowers's, 237 
 
 OUver's, 237 
 
 Thoma-Zeiss, 233 
 Hsemogenesis, 253 
 Haemoglobin estimation, 237. 255 
 Hsemoglobina^mia, 255 
 Haemoglobinometer, Powers's, 240 
 
 Meischer's, 239 
 
 Oliver's, 240 
 
 Tallqvist's, 238 
 Hsemoglobinuria, 552 
 
 epidemic, 1160 
 
 infectious, of the new-born, 1160 
 Hsemokonia, 257 
 Haemolysis, 253 
 Haemometer, Sahli's, 241 
 
 Von Fleischl's, 238 
 Haemopericardium, 1207 
 Haemoperitoneum, 1022 
 Haemophilia, 1158 
 Haemopneumothorax, 1104 
 Haemoptysis, 1063 
 Haemothorax, 1104 
 Hair, 547 
 
 Hammerschlag's method, 243 
 Hanot's disease, 1008 
 Harrison's groove in rickets, 928 
 Hay cold, 1037 
 
 fever, 1037 
 Head, 9 
 
 changes of, in rickets, 928 
 
 defonnities of, 9 
 Headache, 567 
 
 anaemic, 569 
 
 associated symptoms, 572 
 
 distribution of, 568 
 
 functional, 568, 572 
 
 in intracranial aneurism, 571 
 
 organic, 568, 572 
 
 reflex, 571 
 
 significance of, 569 
 
 varieties of, 568 
 Heart, 28 
 
 abnormal positions of, 1183 
 
 aneurism of, 1196 
 
 atrophy of, 1197 
 
 congenital lesions of, 1230 
 
 dilatation of, 1192 
 
 direct effect of aortic insufficiency 
 upon, 1214 
 
 diseases of, 1183 
 
 fatty, 1193 _ 
 
 foreign bodies in, 1195 
 
 functional affections of, 1235 
 
 hypertrophy of, 1190 
 
 in pleurisy, 1095 
 
 new growths in, 1195 
 
 parasites of, 1195 
 
 percussion of, in disease, 141 
 
 rapid, 1238 
 
 relation of, to anterior wall of chest, 29 
 
 rupture of, 1195 
 
 slow, 1238 
 
 syphilis of, 1188 ^ 
 
 Heart, various degenerations of, 1195 
 
 wounds of, 1195 
 Heart-block, 1231 
 Heart-burn, 503 
 
 Heart-muscle, chronic insufficiency of, 1185 
 Heart^sounds, accentuation of, 174 
 
 in disease, 172 
 
 normal, 168 
 Heat exhaustion, 899 
 Heat-stroke, 899 
 Heberden's nodes, 909 
 Hegar's sign in pregnancy, 902 
 Heller's test, 283 
 Hemianopsia, 371 
 Hemicrania, 1390 
 Hemifacial atrophy, 1401 
 Hemiplegia, attitude in, 416 
 
 in children, 1274 
 Hemorrhage, bronchopulmonary, 1063 
 
 cerebral, 1267 
 
 diseases characterized by, 1153 
 
 in aneurism of thoracic aorta, 1247 
 
 in spinal cord and membranes, 1343 
 
 into pancreas, 1013 
 
 pulmonary, 1063 
 Hemorrhagic diathesis, 1153 
 
 diseases of the new-born, 1160 
 
 infarct, 1063 
 Hepar mobilis, 978 
 Hepatic artery, diseases of, 999 
 
 duct, 36 
 
 veins, diseases of, 999 
 Hepatitis, chronic interstitial, 1005 
 
 suppurative, 999 
 Hepatoptosis, 978 
 Hereditary ataxia, 1334 
 Herpes zoster, 356 
 Herzfehlerzellen, 1221 
 Hiccough, 445 
 
 Hick's, Braxton, sign in pregnancy, 902 
 Hippocratic facies, 537 
 
 fingers, 546 
 
 succussion, 1105 
 Hippus, 1391 
 Hodgkin's disease, 1149 
 Hook-worm disease, 870 
 Huntingdon's disease, 1374 
 Hutchinson pupil, 1307 
 
 teeth, 480, 825 
 Hydatid disease (see Echinococcus) 
 Hydraemia, 539 
 Hydrarthrosis, 539 
 Hydrocephalic cry, 791 
 Hydrocephalus, 10, 539, 1277 
 
 shape of head and face in, 395 
 Hydro-encephalocele, 10 
 Hydronephrosis, 306, 1127 
 Hydropericardium, 538, 1206 
 Hydroperitoneum, 1021 
 Hydrophobia, 767 
 Hydropneimiothorax, 1104 
 Hydrops acUposTis, 1098 
 
 chylosus, 1103 
 
 pericardii, 1206 
 
 vesicae felleae, 994 
 Hydrothorax, 539, 1102 
 Hyperacidity, 948 
 
INDEX. 
 
 1423 
 
 Hypersemia of liver, 997 
 Hyperaesthesia, gastric, 946 
 Hyperchlorliydria, 948 
 Hyperidrosis, 535 
 Hypernephroma, 1131 
 Hyperpyrexia, 433 
 Hyperthyrea, 1171 
 Hypertrichosis, 547 
 Hypertrophy, congestive, 1163 
 
 of adenoid tissue of pharynx, 396 
 
 of heart. 1190 
 
 of muscles, 409 
 
 of spleen, 1163 
 
 of tonsils, 396 
 Hypnosis, 1385 
 Hypnotism, 1385 
 Hypoacidity, 949 
 Hypochlorhydria, 949 
 Hypochondriasis, 1387 
 Hypoglossal nerve, 1317 
 Hypoparathyreosis, 1177 
 Hypostatic congestion of lungs, 1061 
 Hypothermia, 433 
 Hysteria, 1380 
 
 in alcoholism, 878 
 Hysterical fit, 1384 
 
 Ichthyismus, 893 
 Ichthyotoxismus, 893 
 Icterus, 530, 979 
 
 acute febrile, 836 
 
 gastroduodenalis, 983 
 
 gravis, 982 
 
 infectiosus, 836 
 
 neonatorum, 981 
 
 physiological, 981 
 
 simplex, 983 
 Idiocy, amaurotic family, 1276 
 Idiopathic fever, 424 
 
 Illuminating gas, acute and chronic poison- 
 ing by, 890 
 blood tests in diagnosis of, 891 
 Impotence, 554 
 Incontinence, fecal, 518 
 
 of urine, 550 
 Indican, 281 
 
 Indigestion, intestinal, 973 
 Infantile eclampsia, 601 
 
 paralysis, 1322 
 Infants, posture and movements of, 418 
 Infection, definition of, 742 
 Inflation of the stomach, 196 
 Influenza, 697 
 
 complications and sequels of, 700 
 Inoscopy, 302 
 
 Insanity, chronic alcoholic, 878 
 Insomnia, 603 
 Inspection. 62 
 
 of abdomen, 74 
 
 of thorax, 62 
 Intercostal nerves, 1361 
 Intermittent claudication, 1243 
 Internal popliteal nerve, 1367 
 Intestinal cestodes, 858 
 
 indigestion, 973 
 
 Intestinal neoplasms, 975 
 
 neuroses, 974 
 
 obstruction, 958 
 
 symptoms of autointoxication in, 
 897 
 
 stenosis, 958 
 Intestines, 33 
 
 amyloid disease of, 934 
 
 dilatation of, 963 
 
 diseases of, 952 
 
 examination of, 209 
 
 tuberculosis of, 798 
 
 ulceration of, 956 
 Intracranial aneurisms, 1278 
 Intussusception, 521 
 Iodine test in tuberculosis, 816 
 Iris, pigmentation of, 359 
 Iritis, 362 
 
 J. 
 
 Jacksonian epilepsy, 1377 
 in uraemia, 1112 
 Jaundice, 530, 979 
 
 black, 530 
 
 catarrhal, 983 
 
 forms of, 979 
 
 in pneumonia, 724 
 
 malignant, 982 
 
 obstructive, 530 
 
 toxsemic, 5.32 
 Joffroy's sign, 1172 
 Joints, 403 
 Jumpers, 1373 
 
 K. 
 
 Kakke, 761 
 
 Kala-azar, 845 
 Kenophobia, 596 
 Keratitis, interstitial, 359 
 
 ulcerative, 358 
 Kernig's sign, 643 
 Kidney, abscess of, 1123 
 
 amyloid, 933 
 
 contracted, 1118 
 
 cysts of, 1129 
 
 floating, 1108, 1109 
 
 gouty, Ills 
 
 granular, 1118 
 
 hemorrhagic infarct of, 1110 
 
 movable, 1 108, 1109 
 
 palpable, 1109 
 
 sarcoma of, 1131 
 
 «clerosis of, 1118 
 
 surgical, 1122 
 
 tumors of, 1131 
 
 wandering, 1109 
 Kidneys, 38 
 
 anatomical anomalies of, 1107 
 
 circulatory derangements of, 1110 
 
 congenital cystic, 1130 
 
 congestion of, 1110 
 
 diagnosis of echinococcus of, 865 
 
 diseases of, 1107 
 
 in diabetes, 918 
 
 inflammation of, 1114 
 
1424 
 
 INDEX. 
 
 Kidneys, palpation in examination of, 102 
 
 syphilis of, 827 
 
 tuberculosis of, 801 
 Kinepox, 663 
 Klebs-Loffler bacilli. 706 
 Koranjd's sign, 1094 
 Korsakoff's psychosis, 878 
 in myelitis, 1322 
 Kyphosis, 15 
 
 Lachrymal sac, inflammation of, 356 
 
 "Lacing" liver, 978 
 
 Lactose, 291 
 
 Laennec's cirrhosis, 1007 
 
 Lagophthalmos, 357 
 
 La grippe (see Influenza), 697 
 
 Landry's paralysis, 1324 
 
 Lardaceous disease, 932 
 
 Laryngeal muscles, paralysis of, 1048 
 
 phthisis, 1045 
 Laryngismus stridulus, 1047 
 Laryngitis, acute catarrhal, 1040 
 
 acute, in children, 1041 
 
 chronic, 1042 
 
 fibrinous, 1044 
 
 oedematous, 1043 
 
 pseudomembranous, 1044 
 
 subacute, 1042 
 
 syphihtic, 1046 
 
 tuberculous, 1045 
 Laryngoscopy, 224 
 Larynx, 11 
 
 diseases of, 1040 
 
 examination of, 225 
 Latah, 1373 
 Lateral sclerosis, amyotrophic, 1327 
 
 primary, 1328 
 Lathyrismus, 895 
 Lead neuritis, 1352 
 
 poisoning, 881 
 Le coeur medicale, 166 
 Leontiasis ossea, 1404 
 Lepra, 780 
 Leprosy, 780 
 
 anaesthetic, 782 
 
 diagnosis of, 784 
 
 mixed or complete, 784 
 
 prognosis of, 784 
 
 shape of face in, 397 
 
 symptoms of, 781 
 
 tuberculous, 781 
 Leptomeningitis, 1260 
 Lethargy, 599 
 Leucocytes, 257 
 
 development of, 259 
 
 enumeration of, 233 
 
 in urine, 272 
 
 mast-cells, 258 
 
 number of, 260 
 
 technic of counting, 236 
 Leucocytosis in appendicitis, 969 
 
 pathological, 261 
 
 physiological, 260 
 Leucopenia, 262 
 Leucoplakia, 489 
 
 Leucorrhoea, 555 
 Leuksemia, 1143 
 
 lymphatic, 1146 
 
 myelogenous or splenomedullary, 1144 
 
 pseudo-, 1149 
 Leukansemia, 1147 
 Lien mobilis, 1162 
 Lienteric diarrhoea, 517 
 Lipomata, 932 
 Lips, 477 
 
 tuberculosis of, 797 
 Litten's sign, 69 
 Little's disease, 1276 
 Liver, 34 
 
 abscess of, 999 
 
 acute yellow atrophy of, 982 
 
 amyloid, 934 
 
 anatomical anomalies of, 977 
 
 angiomata of, 1009 
 
 cirrhosis of, 1005 
 
 congestion of, 997 
 
 "corset" or "lacing," 978 
 
 diagnosis of hydatids of, 864 
 
 diseases of, 977 
 
 fatty, 1003 
 
 movable, 978 
 
 new growths in, 1009 
 
 pulsation of, 476 
 
 syphilis of, 826 
 
 tuberculosis of, 802 
 Lobar pneumonia, 714 
 Lobstein's cancer, 1034 
 Lockjaw, 763 
 Locomotor ataxia, 1328 
 
 relation of syphilis to, 1338 
 Locomotor pulsation, 1215 
 Lordosis, 15 
 Ludwag's angina, 495 
 Lumbago, 912 
 Lumbar plexus, 1362 
 Lung, cirrhosis of, 1075 
 
 collapse of, 1070 
 
 gangrene of, 1080 
 Lung fever, 714 
 Lungs, 26 
 
 diagnosis of hydatids of, 865 
 
 diseases of, characterized by changes 
 in vesicular structure of, 1066 
 characterized by interstitial inflam- 
 mation, 1075 
 due to suppuration and necrosis, 
 1079 
 
 in diabetes, 918 
 
 new growths in, 1082 
 
 syphilis of, 826 
 
 tuberculosis of, 802 
 Lupinosis, 895 
 Lymphatism, 1168 
 Lymphocytes, 258 
 LymphcBdema, 541 
 Lyssa, 767 
 
 M. 
 
 Madura foot, 776 
 
 Magnan's sign in cocainism, 881 
 
 Maidismus, 895 
 
INDEX. 
 
 1425 
 
 "Main de singe," 1325 
 "Main en griffe, 1325 
 Maladie des tics, 1396 
 Malarial cachexia, 854 
 fevers, 846 
 
 algid form of, 854 
 
 comatose form of, 854 
 
 continued and pernicious forms of, 
 
 852 
 diagnosis of, 854 
 estivo-autumnal, 852 
 hemorrhagic form of, 854 
 irregular remittent, 852 
 parasite in man, 847 
 parasite in mosquito, 849 
 prognosis of, 855 
 quartan, 852 
 regularly intermitting forms of, 
 
 850 
 symptoms of, 850 
 tertian, 851 
 Malingering, 6 
 Malta fever, 759 
 Mai telegraphique, 1389 
 Mania a potu, 877 
 Mania, Bell's, 1288 
 Mannkopf's svmptom, 581 
 "Marks of the devil," 1382 
 Masticating spasm, 1310 
 McBurnev's point, 969 
 Measles, 681 
 black, 684 
 
 complications and sequels of, 685 
 German, 687 
 Meat poisoning, 894 
 Mechanical congestion of lungs, 1061 
 Median nerve, 1359 
 Mediastinitis, indurative, 1084 
 Mediastinum, 28 
 
 abscess of, 1083 
 diseases of, 1083 
 emphysema of, 1084 
 new growths of, 1084 
 suppurative lymphadenitis in, 1083 
 ^ledical thermometry, 53 
 
 topography, 8 
 Melancholia, alcohohc, 877 
 Melanoderma, 533 
 Menidrosis, 536 
 Meniere's disease, 1313 
 Meningitis, 1260 
 
 in pneumonia, 723 
 septic, 1261 
 serous, 1260 
 spinal, 1318 
 Meningocele, 10 
 Menorrhagia, 556 
 Menstrual derangements, 550 
 Mensuration, 105 
 Mercurv, poisoning by, 887 
 Merycism, 503, 1383 
 Metailophobia, 596 
 Metasyphilitic diseases, 826 
 Meteorism in pneumonia, 724 
 Methannoglobin, 255 
 Method of Russell and Brodie, 244 
 Metrorrhagia, 557 
 90 
 
 Micrococcus melitensis, 759 
 Micturition, 548 
 
 freqvient, 550 
 
 slow, 550 
 Mid-brain, diseases of, 1290 
 Migraine, 1390 
 
 ophthalmoplegic, 1391 
 
 psychical, 1391 
 Mikulicz's disease, 1149 
 Miliarv fever, 838 
 Milk-leg, 580 
 Mitral incompetence, 1220 
 
 insufficiency, 1220 
 
 regurgitation, 1220 
 
 stenosis, 1224 
 Moebius's sign, 1172 
 Monoplegia in children, 1275 
 Morbid sleep, 604 
 Morbilli, 681 
 Morbus cseruleus, 529 
 
 maculosus, 1154 
 
 neonatorum, 1161 
 Morc's test in tuberculosis, 815 
 Morphinism, 879 
 Morvan's disease, 1337 
 Motor nerves of eye, 1306 
 
 symptoms, 320 
 
 system, 308 
 Mouth, 477 
 Movable kidney, 1108 
 
 Hver, 978 
 Mucous colitis, 516 
 Multiple sclerosis, 1289 
 Mumps, 694 
 
 complications and sequels of, 696 
 Murmur, humming-top, 1135 
 
 Nun's, 193, 1135 
 Murmurs, cardiopulmonary, 189 
 
 endocardial, 177 
 
 of aneurisms, 190 
 Muscles, diseases of, 1406 
 
 ocular, paralysis of, 363 
 Muscular atrophy, degenerative, 410 
 progressive, 1325 
 
 rigidity in appendicitis, 969 
 
 sense, 345 
 Musculature, 409 
 Musculospiral nerve, 1358 
 Myalgia, 911 
 Myasthenia gravis, 1410 
 Mycetoma, 776 
 Myelajmia, 262 
 Myelitis, 1319 
 Myelocytes, 259 
 Myocarditis, acute, 1183 
 
 chronic, 1185 
 
 form due to diseases of the coronary 
 arteries, 1187 
 
 general arteriosclerosis in, 1188 
 
 inflammatory form, 1187 
 
 in rheumatism, 748 
 
 nutritional disorders and, 1188 
 Myocardium, diseases of, 1183 
 Myodegeneratio cordis, 1185 
 Myoidema, 410 
 Myomalacia cordis, 1187 
 Myopathies, the, 1407 
 
1426 
 
 INDEX. 
 
 Myositis, 1406 
 
 dermato-, 1406 
 
 infectious, 1406 
 
 neuro-, 1406 
 
 ossificans, 1406 
 Myotonia, 1409 
 
 congenita, 1409 
 Myotonic reaction, 1410 
 Mvriachit, 1373 
 Mytilotoxin, 893 
 Myxcedema, 1174 
 
 of adults, 1176 
 
 postoperative, 1177 
 
 shape of face in, 396 
 
 N. 
 
 Nails, 546 
 
 Narcolepsy, 604 
 
 Naunyn's theory of origin of gall-stones, 
 
 990 
 Nausea, 503 
 
 Nematodes, diseases due to, 866 
 Neoplasms, intestinal, 975 
 Nephritis, acute, 1114 
 
 dropsy in, 1115 
 parenchymatous, 1114 
 urine in, 1115 
 chronic, 1114 
 
 desquamative, 1117 
 dropsy in, 1117 
 interstitial, 1118 
 parenchymatous, 1117 
 tubal, 1117 
 urine in, 1117, 1119 
 Nephrolithiasis, 1124 
 Nephroptosis, 1108 
 Nerve, anterior crural, 1363 
 circumflex, 1357 
 internal popliteal, 1367 
 median, 1359 
 musculospiral, 1358 
 obturator, 1364 
 peroneal, 1368 
 phrenic, 1354 
 posterior thoracic, 1356 
 ulnar, 1360 
 Nerves, anterior thoracic, 1356 
 cervical, 1353 
 cranial, diseases of, 1302 
 eighth (auditory), 1312 
 eleventh (spinal accessory), 1316 
 fifth (trigeminal), 1307 
 first (olfactory), 1303 
 ninth (glosso-pharyngeal), 1314 
 second (optic), 1304 
 seventh (facial), 1310 
 tenth (pneumogastric), 1315 
 third, fourth, and sixth (motor 
 
 nerves of eye), 1306 
 twelfth (hypoglossal), 1317 
 intercostal, 1361 
 sciatic, 1365 
 Nei'vous diarrhoea, 516 
 dyspepsia, 946 
 system, diseases of, 1260 
 divisions of, 304 
 
 Nervous system, examination of patient, 319 
 in diabetes, 918 
 
 preliminary consideration of, 306 
 Neurasthenia, 1386 
 
 in alcoholism, 878 
 Neuritis, alcoholic, 1350 
 
 lead, 1352 
 
 multiple, 1349 
 
 optic, 374, 1306 
 
 peripheral, 1349 
 Neuron, 306 
 
 Neuropathic joint affections, 408 
 Neuroses, gastric, 946 
 
 in peritoneum, 1032 
 
 intestinal, 974 
 
 occupation, 1388 
 
 traumatic, 1387 
 New growths in heart, 1195 
 in liver, 1009 
 in lungs, 1082 
 mediastinal, 1084 
 Nightmare, 603 
 Night-sweats, 535 
 Night-terrors, 603 
 Ninth nerve, 1314 
 Noguchi butyric acid test, the, for syphilis, 
 
 829 
 Normoblasts, 256 
 Nose, diseases of, 1035 
 
 examination of, 222 
 Nose-bleed, 1039 
 Nucleo-albumin, 286 
 Nun's murmur, 193, 1135 
 Nutritional diseases, 922 
 Nylander's bismuth test in diabetes, 919 
 Nystagmus, 354 
 
 in multiple sclerosis, 1289 
 
 O. 
 
 Obesity, 930 
 
 Obsessions, 596 
 
 " Obstetric hand, " 1394, 1395 
 
 Obstruction, intestinal, 958 
 
 complete, 961 
 Obturator nerve, 1364 
 Occupation neuroses, 1388 
 Ocular muscles, 363 
 
 paralysis of, 363 
 (Edema, 537 
 
 acute laryngeal, 1043 
 
 angioneurotic, 1400 
 
 of glottis, 1043 
 
 pulmonary, 1062 
 (Esophageal sound, 496 
 OEsophagismus, 498 
 CEsophagoscopy, 496 
 (Esophagus, 26, 495 
 
 alterations in calibre of, 497 
 
 auscultation of, 496 
 
 diverticula of, 498 
 
 inflammation of, 499 
 
 malignant stricture of, 497 
 
 obstruction of, 498 
 
 paralysis of, 500 
 
 pressure of, 498 
 
 spasmodic stricture of, 498 
 
INDEX. 
 
 1427 
 
 Q^lsophagus, stenosis of, 497 
 
 symptoms of disease of, 497 
 
 tuberculosis of, 798 
 
 X-ray examination of, 497 
 Olfactory nerves, 1303 
 Oligochromsemia, 525 
 Oliguria, 548 
 
 Oliver's hiemocytometer, 237 
 Onomotomania, 1373 
 Onychia, 546 
 
 Ophthalmoplegia, nuclear, 1291 
 Ophthalmotuberculin test, 812 
 
 Baldwin's scheme for recording 
 reactions, 813 
 Opisthotonos, 414, 415 
 
 in tetanus, 765 
 Opium poisoning, 879 
 
 Opsonic method, the, in diagnosis of tuber- 
 culosis, 815 
 Optic nerve, 1304 
 
 atrophy in tabes, 1330 
 primary, 375 
 secondary, 375 
 Optic neuritis, 1306 
 Organs of respiration, diagnosis of in disease, 
 
 151 
 Orthodiagraphy, 386 
 Orthopnoeaj 413 
 Orthotonos, 415 
 
 in tetanus, 765 
 Osteitis deformans, 1402 
 Osteomalacia, 403, 1404 
 
 of puberty, 927 
 Otoscopy, 226 
 
 Ovaries, tuberculosis of, 802 
 Oxyuris vermicularis, 867 
 Ozajna, 1037 
 
 Pachymeningitis, 1260 
 
 externa, 1260 
 
 haemorrhagica of Virchow, 1260 
 Paget's disease, 1402 
 
 skeletal changes in, 413 
 Pain, 558 
 
 distribution of, 565 
 
 etiology of, 559 
 
 feigned, 565 
 
 in alcoholic neuritis, 1350 
 
 in aneurism of thoracic aorta, 1248 
 
 in appendicitis, 968 
 
 in body, 574 
 
 in caisson disease, 1346 
 
 in ear, 574 
 
 in extremities, 579 
 
 in eye, 573 
 
 in face, 573 
 
 in head, 567 
 
 in locomotor ataxia, 1329 
 
 in pneumonia, 718 
 
 in scalp, 572 
 
 in tumors of spinal cord, 1339 
 
 localization of, 567 
 
 mode of expression of, 560 
 
 modifications by physical and psychical 
 causes, 564 
 
 Pain, referred, 566 
 
 to mouth, 574 
 significance of, 566 
 sinus, 574 
 varieties of, 562 
 Painful crises, 567 
 Palate, 491 
 Pallor of skin, 525 
 Palmus, 1313 
 Palpation, 90 
 
 in examination of abdomen, 97 
 of stomach, 194 
 of thorax, 90 
 Palsies, cerebral, of children, 1273 
 Palsv, Bell's, 1310 
 bulbar, 1298 
 pseudobulbar, 1300 
 scrivener's, 1388 
 shaking, 1393 
 Pancreas, 37 
 
 diseases of, 1013 
 hemorrhage into, 1013 
 hyaline degeneration of, 1017 
 tumors of, 1020 
 Pancreatic abscess, 1016 
 calculi, 523, 1018 
 cysts, 1018 
 diabetes, 1017 
 Pancreatitis, acute, 1013 
 
 acute hemorrhagic, 1013 
 acute suppurative, 1016 
 chronic, 1017 
 gangrenous, 1016 
 Papillitis, 374, 1306 
 Paracentesis abdominis, 1023 
 Paracolons, 639 
 ParsBsthesia, 582 
 cerebral, 583 
 forms of, 583 
 Paralysis, acute ascending, 1324 
 agitans, 1393 
 
 attitude in, 416 
 Brown-Sequard, 1340 
 Erb's, 1338 
 infantile, 1322 
 in lead poisoning, 882 
 Landry's, 1324 
 
 of associated movements of eyes, 1293 
 of laryngeal muscles, 1048 
 Paramyoclonus multiplex, 1410 
 Paranephritis, 1123 
 Paraplegia, ataxic, 1333 
 in Children, 1275 
 senile, 1288 
 Parasyphilitic diseases, 826 
 Parathyroids, 1171 
 Paratyphoid fevers, 639, 617 
 " Paratyphoids," 639 
 Parchment crackling in rickets, 928 
 Paresis, alcoholic general, 878 
 
 general, 1285 
 Parkinson's disease, 1393 
 Parry's disease, 1171 
 Pavor nocturnus, 603 
 Pectoriloquy, 165 
 Peliosis rheumatica, 1155 
 Pellagra, 875 8!»5 
 
1428 
 
 INDEX. 
 
 Pelvis, changes of, in rickets, 929 
 Peptic ulcer of jejunum, 956 
 Percussion, 120 
 
 auscultatory, 130 
 
 methods of,"^ 129 
 
 of chest, 130 
 
 of heart, 141 
 
 of stomach, 195 
 
 si2;ns elicited upon, 126 
 
 te'chnic of, 122 
 
 theory of, 121 
 Perforating ulcer in tabes, 1331 
 Perforation, intestinal, in typhoid fever, 614 
 Periarteritis nodosa, 1259 
 Pericardial sac, obliteration of, 1205 
 Pericarditis, 1197 
 
 dry, 1198 
 
 exudative, 1200 
 
 fibrinous, 1198 
 
 in pneumonia, 722 
 
 in rheumatism, 748 
 
 plastic, 1198 
 
 sicca, 1198 
 
 with effusion, 1200 
 Pericardium, 28 
 
 adherent, 1205 
 
 calcification of, 1207 
 
 diseases of, 1197 
 
 tuberculosis of, 795 
 Perinephric abscess, 1123 
 Perirenal abscess, 1123 
 Perisplenic peritonitis, 1166 
 Peritoneum, diseases of, 1021 
 
 new growths in, 1032 
 
 tuberculosis of, 795 
 Peritonitis, acute circumscribed, 1029 
 
 acute general, 1024 
 
 appendicular, 970, 1029 
 
 bacteriology of acute, 1024 
 
 chronic, 1031 
 
 chronic proliferative, 1031 
 
 clinical etiology of, 1024 
 
 diagnosis of, 1028 
 
 diffuse adhesive, 1031 
 
 in acute infectious diseases, 1026 
 
 in foetus and new-born, 1026 
 
 local adhesive, 1031 
 
 pelvic, 1029 
 
 perisplenic, 1166 
 
 primary, 1024 
 
 secondary, 1024 
 
 subphrenic, 1030 
 
 symptoms of, 1026 
 
 tuberculous, 1032 
 Peroneal nerve, 1368 
 Peroneal type of paralysis, 1364 
 Pertussis (see Whooping-cough), 689 
 Petechias, 542 
 Petit rnal, 1377 
 
 Peyer's patches in typhoid fever, 614 
 Pharynx, 493 
 
 cyanosis of, 493 
 
 innervation of, 495 
 
 pulsation of, 4^3 
 
 tuberculosis of, 798 
 
 ulceration of, 494 
 Phobias, 596 - 
 
 Phosphorus poisoning, 889 
 
 resemblance of acute yellow atro- 
 phy to, 889 
 Phrenic nerve, 1354 
 Phthisis, acute pneumonic, 803 
 bronchopneumonic form, 803 
 chronic ulcerative, 805 
 
 " closed " and " open, " 808 
 diagnosis of advanced, 818 
 diagnosis of incipient, 810 
 modes of onset, 806 
 physical signs in advanced, 
 
 817 
 physical signs in incipient, 809 
 prognosis of, 819 
 stages of, 807 
 
 symptoms of incipient, 808 
 symptoms of moderately and 
 far advanced, 816 
 fibroid, 819 
 florida, 804 
 pneumonic form, 803 
 Physical diagnosis, 61 
 Pica, 502 
 Pigmentation, 533 
 
 in Addison's disease, 534 
 in hepatic disease, 534 
 Plague, 757 
 
 bubonic, 757 
 
 modes of transmission, 758 
 pneumonic, 759 
 septic, 759 
 Plasma, 253 
 
 estimation of relative volume of, 242 
 Plasmodium immaculaturn, 848 
 malarite, 848 
 vivax, 847 
 Pleura, diseases of, 1088 
 Pleura;, 26 
 
 . diagnosis of hydatids of, 865 
 Pleural effusion, chyliform, 1098 
 . ! chylous, 1103 
 
 . encysted or circumscribed, 1097 
 hemorrhagic, 1097 
 pulsating, 1097 
 purulent, 1096 
 serofibrinous, 1091 
 Pleural sac, morbid states characterized 
 by transudation of serum or chyle, or 
 eruption of pus, blood, or air into, 1102 
 Pleurisy, 1088 
 
 acute dry, 1088 
 
 adhesive, following removal of exu- 
 dates, 1090 
 chronic dry, 1090 
 diagnosis of, with effusion, 1098 
 exudative, 1091 
 fibrinous, 1088 
 hemorrhagic, 1097 
 plastic, 1088 
 primitive dry, 1090 
 purulent, 1096 
 serofibrinous, 1091 
 tuberculous, 794 
 tuberculous dry, 1090 
 with effusion, 1091 
 Pleuritis sicca, 1088 
 
INDEX. 
 
 1429 
 
 Pleurodynia, 912 
 Pleuropericardial friction, 1089 
 Pleuropneumonia, 714 
 Pleurothotonos, 415 
 
 in tetanus, 765 
 Pleximetrv, 123 
 Plumbisni, 881 
 
 Pneumococcus septicsemia, 715 
 Pneumogastric nerve, 1315 
 Pneumonia, abortive, 726 
 
 anaesthesia, 727 
 
 apex, 725 
 
 asthenic, 726 
 
 catarrhal, 1071 
 
 central, 725 
 
 chronic interstitial, 1075 
 
 contusion, 727 
 
 crossed, 717 
 
 croupous, 714 
 
 disseminated interstitial, 1076 
 
 double, 725 
 
 ether, 1074 
 
 fibrinous, 714 
 
 in emphysematous persons, 725 
 
 intense, 726 
 
 lobar, 714 
 
 lobar interstitial, 1076 
 
 lobular, 1071 
 
 masked forms, 1074 
 
 massive, 725 
 
 migratory, 725 
 
 postoperative, 727, 1074 
 
 primary form, 1073 
 
 rudimentary, 726 
 
 secondary forms, 1074 
 
 toxic, 726 
 
 typhoid, 726 
 Pneumonoconiosis, 1078 
 Pneumopericardium, 1207 
 Pneumorrhagia, 1063 
 Pneumothorax, 441, 1104 
 
 masked, 1107 
 Podagra, 904 
 Poikilocytes, 256 
 Poisoning, arsenical, 884 
 
 by cocaine, 881 
 
 by fish, 893 
 
 by food, 892 
 
 by grain, 895 
 
 bv illuminating gas, 890 
 
 by lead, 881 
 
 by meat, 894 
 
 by mercury, 887 
 
 by milk and milk products, 894 
 
 by opium, 879 
 
 by phosphorus, 889 
 
 by potatoes, 896 
 
 by vegetables, 895 
 
 ptomaine, 893 
 
 vetch, 895 
 PolioencephaUtis inferior, 1300 
 
 superior, 1290, 1291 
 Poliomyelitis, anterior, 1322 
 Polygraph, clinical, 112 
 Polymyositis hemorrhagica, 1406 
 Polyneuritis, 1349 
 Polynuclear eosinophiles, 258 
 
 Polynuclear neutrophiles, 258 
 
 Polyphagia, 501 
 
 Polyuria, 548 
 
 Pons, diseases of, 1296 
 
 Portal vein, diseases of, 998 
 
 occlusion or narrowing of, 998 
 thrombosis of, 998 
 Postepileptic mania, 597 
 Posterior thoracic nerve, 1356 
 Posture, 412 
 
 dorsal, 413 
 
 lateral, 413 
 
 sitting, 413 
 
 ventral, 414 
 Potato poisoning, 896 
 Pregnancy, 901 
 
 diagnosis of, 902 
 Priapism, 553 
 Primary bronchi, 25 
 Progressive muscular atrophy, 1325 
 Prostate, tuberculosis of, 802 
 Proteus fiuorescens, 836 
 Protozoa, diseases due to, 842 
 Pruritus vulvae, 555 
 Pseudobulbar palsy, 1300 
 Pseudochlorosis, 1136 
 Pseudodiphtheria, 712 
 
 Pseudohypertrophic paralysis, attitude in, 
 416 
 
 pulmonary osteo-arthropathy, 1404 
 Psorospermiasis, 842 
 Psychasthenia, 1387 
 Psychical conditions, 593 
 intelligence, 593 
 memory, 594 
 Psychical epileptic equivalents, 1377 
 Ptomaine poisoning, 893 
 Ptosis, 357 
 Pulmonary abscess, 1079 
 
 apoplexy, 1063 
 
 atelectasis, 1070 
 
 congestion, 1061 
 
 emphysema, 1066 
 
 hemorrhage, 1063 
 
 insufficiency and stenosis, 1226 
 
 oedema, 1062 
 
 osteo-arthropathy, 403 
 
 tissue, diseases of, 1061 
 Pulsation, 100, 460 
 
 of Uver, 476 
 Pulse, 463 
 
 anomalies of, 472 
 
 capillary, 473 
 
 celerity, 470 
 
 collapsing, 1216 
 
 frequency of, 464 
 
 irregularity of, 469 
 
 rhythm, 4*68 
 
 tension, 470 
 
 venous, 474 
 
 volume, 469 
 Pulsus paradoxicus, 1201 
 Puncta maxima, 169 
 Puncture, exploratory, 300 
 Pupil, 360 
 
 abnormal reactions of, 361 
 
 normal reactions of, 360 
 
1430 
 
 INDEX. 
 
 Pupillary tract, mydriatic, 360 
 
 myotic, 360 
 Purpura, 1153 
 
 abdominalis, 1156 
 
 and visceral symptoms, 1156 
 
 cachetic, 1157 
 
 fulminous, 1155 
 
 hsemorrhagica, 1154 
 
 Henoch's, 1156 
 
 infectious, 1157 
 
 neurotic, 1157 
 
 rheumatica, 1155 
 
 simplex, 1154 
 
 symptomatic, 1157 
 
 toxic, 1157 
 
 traumatic, 1157 
 
 variolosa, 656 
 Purpuric oedema, febrile, 1155 
 Pustule, malignant, 776 
 Pyaemia (see Sepsis), 742 
 PyeUtis, 1121 
 Pylephlebitis, adhesive, 998 
 
 suppurative, 998 
 Pylorus, hypertrophic stenosis of, 945 
 
 relaxation of, 950 
 
 spasm of, 950 
 Pyopneumothorax, 1104 
 Pyopneumothorax subphrenicus, 1030 
 Pyothorax, 1103 
 Pyrexia a symptom of fever, 423 
 Pyrhophobia, 596 
 Pyrosis, 503 
 
 Q. 
 
 Quantitative tests, 204 
 Quicke's disease, 1400 
 
 R. 
 
 Rabies, 767 
 
 Rag-picker's disease, 780 
 Railwav spine, 1387 
 Rales, 159 
 
 crepitant, 160 
 
 dry, 159 
 
 moist, 159 
 
 varieties and significance, 160, 161 
 Rapid heart, 465, 1238 
 Rash in typhoid fever, 612 
 Raynaud's disease, 1397 
 Records, 41 
 
 scheme for, 41 
 Redness of skin, 527 
 
 from drugs, 528 
 in fever, 527 
 Reflexes, 331 
 Regurgitation, 503 
 Relapsing fever, 644 
 
 complications and sequels of, 646 
 Renal ansemia, 1110 
 
 calculus, 1124 
 
 chemical composition of, 1125 
 immediate effects of, 1125 
 
 colic, symptoms of, 1126 
 
 infarct, 1124 
 Ren mobilis, 1108 
 
 Rennin, test for, 203 
 
 Reproductive organs, 553 
 
 Resonance, vocal, varieties and significance 
 
 of, 164, 165 
 Respiration, 436 
 
 Cheyne-Stokes, 439 
 
 jerking, 440 
 
 meningeal, 439 
 
 type in, 438 
 Respiratory movements, 438 
 
 characteristic derangements of, 439 
 oligopnoea, 438 
 polypnoea, 439 
 Respiratory system, diseases of, 1035 
 Restlessness, 414 
 Retinal hemorrhage, 375 
 
 obstruction of vessels, 376 
 Retinitis, 375 
 Rhachialgia, 574 
 Rhachitic hand, 929 
 
 rosary, 928 
 Rhachitis (see Rickets), 927 
 Rheumatic fever, 746 
 
 hyperpyrexia in, 747 
 joints in, 405 
 Rheumatism, acute, 746 
 
 cerebral, 747 
 
 chronic, 405, 911 
 
 muscular, 911 
 Rheumatoid affections, the, 910 
 Rhinitis, acute, 1035 
 
 atrophica, 1037 
 
 hypertrophica, 1036 
 
 simplex, 1036 
 Rhinoscopy, anterior, 222 
 
 posterior, 223 
 Rickets, 927, 1404 
 
 cause of, 927 
 
 fetal, 927^ 
 
 skeletal changes in, 403 
 Riegel's test-meal, 201 
 Riga's disease, 488 
 Risus sardonicus, 765 
 Rivalta's test, 302 
 Rocky mountain spotted fever, 834 
 Romberg's symptom, 416, 1329 
 Rontgen rays, examination of intestines 
 with, 213 
 examination of stomach with, 197 
 Rose cold, 1037 
 Roseola variolosa, 650 
 Rossbach's disease, 947 
 Rotch's sign, 1202 
 Rotheln, 687 
 Rubella, 687 
 Rubeola, 681 
 Rumination, 503 
 
 Sacral plexus, 1364 
 
 Sahli's desmoid test, 206 
 
 Salol test, for motor power of stomach, 207 
 
 Saltatory spasm, 1373 
 
 Sarcoma of kidney, 1131 
 
 of liver, 1011 
 
 retroperitoneal, 1034 
 
INDEX. 
 
 1431 
 
 Sarcomata, intestinal, 977 
 Sausage poisoning, 894 
 Scapulae, the, 17 
 Scarlatina, 670 
 Scarlet fever, 670 
 
 complications and sequels, 677 
 diagnosis of, 679 
 prognosis of, 680 
 symptoms of, 672 
 varieties, 675 
 Scars, 543 
 
 Schachtelton percussion sound, 1068 
 Schizogonous cycle, 847 
 Schmidt's nucleus test for pancreatic 
 
 disease, 218 
 Schonlein's disease, 1155 
 Sciatica, 1366 
 Sciatic nerves, 1365 
 Sclera, inflammation of, 358 
 Sclerema neonatorum, 542 
 Scleroderma, 541 
 Sclerosis, amyotrophic lateral, 1327 
 
 multiple, 1289 
 
 of coronary arteries, 1187 
 
 primary lateral, 1328 
 Scoliosis, 15 
 
 in chronic sciatica, 416 
 Scorbutus, 922 
 Scrivener's palsy, 1388 
 Scrofula, 792 
 Scurvy, 922 
 
 infantile, 925 
 Sclerosis, 542 
 Seat worm, 867 
 Senile degeneration, 1287 
 Senile heart, the, 1197 
 Sensory symptoms, 322 
 Sensory system, 314 
 Sepsis, 742 
 
 symptomatology of, 743 
 Septicaemia (see Sepsis), 742 
 
 pneumococcus, 715 
 Septicopyaemia (see Sepsis), 742 
 Serum globulin in urine, 286 
 Serum test, macroscopical, 248 
 
 microscopical, 246 
 technic of, 246 
 Sexual organs in diabetes, 918 
 Shaking palsy, 1393 
 Sick headache, 1390 
 Sign, Bacelli's, 166 
 Signs, 389 
 
 Simple continued fever, 833 
 Sinus thrombosis, 1265 
 Skeletal changes, 403 
 
 in acromegaly, 403 
 in Paget's disease, 403 
 in rickets, 403 
 Skin, 524 
 
 collateral circulation in, 544 
 
 fulness of, 536 
 
 moisture of, 535 
 
 vagabond's, 533 
 Skodaic resonance in pneumonia, 721 
 Skull, 8 
 
 regions of, 8 
 Sleep drunkenness, 604 
 
 Sleeping sickness, 844 
 
 Slow heart, 1238 
 
 Smallpox, 647 
 
 Softening of the brain, 1271 
 
 Somnambulism, 604 
 
 Somnolence, 598 
 
 Sopor, 598 
 
 Sordes, 481 
 
 Spasm, accessory, 1316 
 
 habit, 1372 
 
 of cardiac orifice, 950 
 
 of face, 1311 
 
 saltatory, 1373 
 
 static reflex, of Bamberger, 1373 
 Speech (see Aphasia), 326 
 Spermatorrhoea, 555 
 Sphygmograms, diagnostic significance of, 
 
 110 
 Sphygmograph, 106 
 
 Dudgeon's, 106 
 Sphygmomanometer, 115 
 
 technic of, 115 
 Sphygmomanometer, Beall's, 117 
 
 Janeway's, 117 
 
 Mason's, 117 
 
 Stanton's, 116 
 Spina bifida, 16, 1349 
 Spinal accessory nerve, 1316 
 Spinal cord, diseases of, 1318 
 injuries to, 1341 
 softening of, 1345 
 tuberculosis of, 800 
 tumors of, 1339 
 Spinal cord and membranes, hemorrhage 
 in, 1343 
 syphilis of, 1337 
 Spinal localization, 329 
 Spinal meningitis, 1318 
 Spinal nerves, diseases of, 1349 
 Spirals, Curschmann's, 297 
 Spirochseta of Vincent, 713 
 Spirochseta pallida, 822 
 Spirometry, 105 
 Splanchnoptosis, 972 
 Spleen, 37 
 
 abscess of, 1166 
 
 amyloid, 934 
 
 anatomical anomalies of, 1161 
 
 diseases of, 1161 
 
 hypertrophy of, 1163 
 
 infarct of, 1166 
 
 movable, 1162 
 
 palpation in examination of, 102 
 
 rupture of, 1167 
 
 tuberculosis of, 802 
 
 wandering, 1162 
 Splenic anaemia, 1165 
 
 capsulitis, 1166 
 
 tumor, acute, 1162 
 chronic, 1163 
 with anaemia, 1165 
 with polycythaemia and cvanosis, 
 1165 
 Splenitis, suppurative, 1166 
 Splenomegaly, primitive, 1165 
 Sputum, 296, 451 
 
 animal parasites in, 298 
 
1432 
 
 INDEX. 
 
 Sputum, crj'-stals in, 297 
 
 Curschmann's spirals in, 297 
 
 elastic tissue in, 297 
 
 epithelial cells in, 296 
 
 in abscess of lung, 457 
 
 in acute miliary tuberculosis, 456 
 
 in bronchiectasis, 458 
 
 in bronchitis, 455 
 
 in bronchopneumonia, 457 
 
 in bronchopulmonary hemorrhage, 45S 
 
 in chronic valvular disease, 459 
 
 in croupous bronchitis, 455 
 
 in croupous pneumonia, 456 
 
 in gangrene of lungs, 457 
 
 in infarcts, 459 
 
 in oedema of lungs, 458 
 
 in perforating empyema, 457 
 
 in pulmonary tuberculosis, 455 
 
 in putrid bronchitis, 458 
 
 leucocytes in, 296 
 
 microscopical examination of, 296 
 
 red blood-cells in, 297 
 
 vegetable parasites in, 298 
 Stains, EhrHch's triple, 231 
 
 Jenner's, 231 
 
 Leishman's, 231 
 
 Plehn's, 232 
 Static reflex spasm of Bamberger, 1373 
 Station, 416 
 Status epilepticus, 1377 
 
 lymphaticus, 1168 
 
 prsesens, 39 
 
 parathyreoprivus, 1177 
 
 vertiginosis, 587 
 Stell wag's sign, 1172 
 Stenocardia, 1233 
 Stenosis, aortic, 1217 
 
 intestinal, 958 
 
 mitral, 1224 
 
 of duodenum and jejunum, 959 
 
 of ileum, 960 
 
 of large bowel. 960 
 
 pulmonary, 1227 
 
 tracheobronchial, 1057 
 
 tricuspid, 1228 
 Stereoskiagraphy, 388 
 Stertor, 445 
 Stethoscope, 148 
 "Stiff-neck," 1317 
 Stigmata of degeneration, 346 
 anatomical, 347 
 physiological, 350 
 psvchic, 350 
 Stigmata diaboli, 1382 
 Stokes- Adams syndrome, 123 
 Stomach, 32 
 
 cancer of, 964 
 
 dilatation of, 939 
 acute, 940 
 chronic, 940 
 
 diseases of, 935 
 
 examination of, 194 
 
 inflation of, 196 
 
 nervous disorders of, 946 
 
 tuberculosis of, 798, 946 
 Stomach-tube, 197 
 
 contraindications for use of, 199 
 
 Stools, 518 
 
 abnormal substances in, 520 
 
 blood in, 520 
 
 fatty, 522 
 
 foreign bodies in, 524 
 
 gall-stones in, 522 
 
 gross physical characters of, 518 
 
 intestinal concretions in, 523 
 
 intestinal parasites in, 524 
 
 intestinal sand in, 523 
 
 mucus in, 520 
 
 pancreatic calculi in, 523 
 
 pus in, 522 
 
 sloughs in, 524 
 Strangury, 549 
 
 Streptococcus erysipelatis, 738 
 Streptothrix actinomyces, 773 
 Striations, 543 
 
 Stridor, chronic infantile, 1048 
 Stroke, apoplectic, 1268 
 
 electric, 900 
 
 heat, 899 
 Stupor, 598 
 St. Vitus's dance, 1369 
 Succussion, 94 
 Suggillation, 542 
 Supersecretion, 947 
 Suppurative hepatitis, 999 
 Suprarenal capsules, 801 
 Surface thermometry, 57 
 Surgical kidney, 1122 
 Sutures, 8 
 
 Sweating sickness, 838 
 Sydenham's chorea, 1369 
 Symptoms, 389 
 Syncope, 598 
 Syndrome, 389 
 
 dissociation, 1336 
 Svnechia pericardii, 1205 
 Syphilis, 821 
 
 acquired, 822 
 
 and locomotor ataxia, 1338 
 
 cerebrospinal, 1285 
 
 diagnosis of, 828 
 
 fades of, 395 
 
 gummata in, 824 
 
 hereditary, 824 
 
 of brain, 1284 
 
 of circulatory sj'stem, 827 
 
 of digestive tract, 827 
 
 of eyelids, 356 
 
 of heart, 1188 
 
 of joints, 407 
 
 of kidneys, 827 
 
 of liver, 826 
 
 of lungs, 826 
 
 of spinal cord and membranes, 1337 
 
 of testicles, 828 
 
 prognosis of, 831 
 
 therapeutic diagnosis rt^ S30 
 
 visceral, 826 
 Syringomyelia, 1335 
 
 Tabes, juvenile, 1331 
 pseudo-, 1332 
 sensory type, 1331 
 
INDEX. 
 
 1433 
 
 Tabes dorsalis (see Locomotor ataxia), 1328 
 
 niesenterica, 794 
 Tache cerebrale, 527 
 Tachycarciia, 467, 1238 
 
 paroxysmal or essential, 1238 
 T«nia, varieties of, 859, 860, 861 
 Tapeworms, 858 
 Tarry stools, 217 
 Teeth, 479 
 
 caries, 481 
 
 first dentition, 479 
 
 Hutchinson's, 480 
 
 second dentition, 480 
 
 shape and structure of, 480 
 Teichmann's disease, 947 
 Telegrapher's cramp, 1389 
 Temperament, 391 
 Temperature, 419 
 
 abnormal, 421 
 
 action of drugs upon, 434 
 
 heat mechanism of, 419 
 
 in disease, 55 
 
 significance of abnormal, 435 
 
 subnormal, 433 
 " Temperature charts, " 58 
 Tenderness, 580 
 
 abdominal, 582 
 
 in appendicitis, 969 
 
 in extremities, 584 
 
 in face, head, neck, and thorax, 581 
 Tenesmus, 564 
 
 rectal, 517 
 Tenth nerve, 1315 
 Test meals, 200 
 Testes, tuberculosis of, 802 
 Tests for free HCl, 202 
 
 for lactic acid, 202 
 Tetanus, 763 
 
 cephalic, 766 
 
 facies of, 394 
 
 neonatorum, 766 
 
 puerperal, 766 
 Tetany, 1395 
 
 from autointoxication, 897 
 Therapeutic test in diphtheria, 712 
 Thermogenesis, 419 
 Thermolysis, 420 
 Thermotaxis, 420 
 Thirst, 502 
 
 Thoma-Zeiss hajmocytometer, the, 233 
 Thomsen's disease, 1409 
 Thoracic organs, 25 
 
 percussion of, in disease, 134 
 topographical anatomy of, 25 
 Thoracometry, 105 
 Thorax, 13 
 
 changes of, in rickets, 928 
 
 landmarks of, 13 
 
 lines and spaces of, 17 
 
 regional divisions of, 19 
 Thread worm, 867 
 Thrills, 94 
 
 Throat consumption, 1045 
 Thrombosis in pneumonia, 723 
 Thynms gland, 25 
 
 atrophy of, 1168 
 diseases of, 1167 
 
 Thymus gland, hemorrhages of, 1168 
 hypertrophy of, 1168 
 persistence of, 1168 
 tumors of, 1168 
 Thyroid body, 11 
 
 enlargement of, in exophthalmic 
 goitre, 1172 
 
 gland, diseases of, 1169 
 Thyroiditis, acute, 1169 
 Thyroids, accessory, 1171. 
 Tic convulsive, 1312 
 
 douloureux, 1309 
 Tick fever, 834 
 Tics, the, 1372, 1396 
 " Tobacco heart, " 1235 
 Tongue, 482 
 
 coating of, 485 
 
 eczema of, 489 
 
 fissures of, 487 
 
 moisture of, 484 
 
 motihty of, 482 
 
 mucous membrane of, 484 
 
 mucous patches on, 488 
 
 size of, 483 
 
 tuberculosis of, 797 
 
 tumors of, 489 
 
 ulcers of, 487 
 Tonsils, 492 
 Torticollis, 912, 1316 
 
 false, 1317 
 Toxaemia, definition of, 742 
 
 headache in, 570 
 Trachea, 25 
 Tracheal tugging, 97 
 Tracheobronchial stenosis, 1057 
 Transillumination, 196 
 Transudates, 301 
 Tremor, 592 
 
 forms of, 592 
 
 in exophthalmic goitre, 1173 
 
 in hysteria, 1382 
 
 senile, 1288 
 Treponema pallidum, 822 
 Trichinella spiralis, 867 
 Trichiniasis, 867 
 Trichocephalus dispar, 876 
 Tricuspid insufficiency and stenosis, 1227 
 Trident hand, 1405 
 Trismus, 765 
 Trophic diseases, 1397 
 
 disturbances, 341 
 Trousseau's symptom, 591 
 Trypanosoma gambiense, 844 
 Trypanosomiasis, 844 
 Tube-casts in urine, 273 
 
 clinical significance of, 275 
 Tubercle bacillus, 298 
 
 methods of examination for, 299 
 Tuberculin innunction, 815 
 
 test, 812 
 Tuberculosis, 784 
 
 acute miliary, 788 
 
 generalized, 788 
 meningeal form, 790 
 pulmonary form, 790 
 
 modes of infection, 787 
 
 of alimentary canal, 797 
 
1434 
 
 INDEX. 
 
 Tuberculosis of arteries, 802 
 
 of bladder, 801 . , 
 
 of brain and spinal cord, 800 
 of Fallopian tubes, 802 
 of genito-urinary organs, 800 
 of kidnevs, 801 
 of liver, 802 
 of lungs, 802 
 of lymph-nodes, 792 
 of myocardium, 802 
 of ovaries, 802 
 of pericardium, 795 
 of peritoneum, 795, 1032 
 of prostate and seminal vesicles, 802 
 of serous membranes, 794 
 of spleen, 802 
 of stomach, 798 
 of testes, 802 
 of ureters, 801 
 pathogenic organism of, 786 
 pulmonary, 802 
 Tumor of brain, headache in, 570 
 Tumors, benign, 977 
 of brain, 1279 
 of spinal cord, 1339 
 of tongue, 489 
 Turban's scheme, 820 
 Turgor, 536 
 Tussis convulsiva (see Whooping-cough), 
 
 689 
 " Typhoid carriers, " 620 
 Typhoid fever, 605 
 
 agglutination test in, 628 
 association of other diseases with, 
 
 625 
 chills in, 611 
 
 complications and sequels of, 619 
 course of disease, 607 
 definition of, 605 
 diagnosis of, 627 
 
 of intestinal perforation, 637 
 effect of, upon certain chronic 
 
 diseases, 625 
 etiology of, 605 
 exciting cause of, 606 
 fever in, 609 
 in aged, 619 
 in children, 618 
 in pregnancy, 619 
 nervous system in, 609 
 ophthalmic reaction in diagnosis 
 
 of, 629 
 period of incubation, 607 
 prognosis of, 637 
 pulse in, 612 
 rash in, 612 
 relapse, 625 
 
 stage of prodromes, 607 
 symptoms of especial importance 
 in diagnosis, 609 
 relating to abdominal organs, 
 612 
 varieties of, 616 
 Typhoid spine, 625 
 Typhus biliosus, 836 
 Typhus fever, 641 
 
 complications and sequels of, 643 
 
 Typhus fever, prognosis and mortality, 644 
 Typhus levissimus, 617 
 siderans, 643 
 
 U. 
 
 Uffelman's test for free lactic acid, 202 
 Ulcer, duodenal, 956 
 
 gastric, 942 
 
 peptic, of jejunum, 956 
 
 perforating, in tabes, 1331 
 Ulceration of intestines, 956 
 Ulnar nerve, 1360 
 Uncinariasis, 870 
 Uraemia, 1111 
 
 Ureters, tuberculosis of, 801 
 Uric acid, 267 
 Urinary calculi, 277 
 
 pigments, 281 
 Urination, 548 
 Urine, 264 
 
 albumins in, 282 
 
 animal parasites in, 276 
 
 bacteria in, 276 
 
 cellular deposits in, 271 
 
 chemical examination of, 277 
 
 fat in, 294 
 
 in acute nephritis, 1115 
 
 in chronic nephritis, 1117, 1119, 
 
 incontinence of, 550 
 
 in diabetes insipidus, 921 
 
 in diabetes mellitus, 915 
 
 indican in, 281 
 
 microscopical examination of, 266 
 
 oxalates in, 266 
 
 phosphates in, 269 
 
 physical examination of, 267 
 
 red blood-cells in, 272 
 
 retention of, 551 
 
 sulphates in, 267 
 
 suppression of, 551 
 
 tests for glucose in, 288 
 
 tube-casts in, 273 
 
 urea in, 278 
 
 uric acid in, 267, 279 
 Urogenital tuberculosis, 1122 
 Urticaria, giant, 1400 
 
 V. 
 
 Vaccination, 663 
 
 technic of, 664 
 Vaccinia, 663 
 Vagabond's skin, 533 
 Valve areas, 169 
 
 aortic, 169 
 
 mitral, 169 
 
 pulmonary, 169 
 
 tricuspid, 169 
 Valvular disease, chronic, 1214 
 
 mitral insufficiency due to, 
 1220 
 Valvular diseases, combined, 1229 
 Varicella, 668 
 Variola, 647 
 Variola modificata, 657 
 
 complications and sequels of, 658 
 
INDEX. 
 
 1435 
 
 Variola pustulosa hsemorrhagica, 657 
 Variola sine eruptione, 658 
 Variola vera, 651 
 
 confluent form, 653 
 discrete form, 651 
 hemorrhagic forms, 656 
 stage of desiccation and decrusta- 
 tion, 655 
 Varioloid, 657 
 Vasomotor diseases, 1397 
 Veins, auscultation of, 192, 193 
 Venous hum, 193 
 Venous pulse, 474 
 
 forms of, 474 
 Vertigo, 586 
 
 forms of, 587 
 in Meniere's disease, 1314 
 Vesical tenesmus 549 
 Vetch poisoning, 895 
 Vibices, 542 
 Vincent's angina, 713 
 Msion, affections of, 367 
 Vitiligo, 535 
 
 Vocal resonance, amphoric, 165 
 diminished, 165 
 increased, 164 
 normal, 164 
 Voice, 164 
 
 auscultation of, 164 
 Volume index, 242 
 Vomiting, 504 
 bilious, 509 
 of blood, 509 
 purulent, 511 
 stercoraceous, 510 
 Vomitus, 508 
 
 gross characteristics of, 508 
 odor of, 511 
 parasites in, 511 
 quantity of, 511 
 reaction of, 511 
 Von Pirquet's cutaneous tuberculin reac- 
 tion, 813 
 
 W. 
 
 Waking numbness, 604 
 Walking typhoid, 618 
 
 Wasserman test, the, for syphilis, 828 
 Waxy or bacony infiltration, 932 
 Weber's syndrome, 1307 
 Weil's disease, 836 
 Werlhof's disease, 1154 
 Westphal sign, 1329 
 Whip-worm, 876 
 Whispering pectoriloquy', 165 
 Whooping-cough, 689 
 
 complications and sequels of, 692 
 Widal test, 628 
 
 Williamson's test for diabetes, 251 
 Winckel's disease, 1160 
 Windpipe, 25 
 Wintrich's sign, 818 
 Wool-sorter's disease, 776, 778 
 Word-deafness, 1313 
 Wounds of the heart, 1195 
 Wright's method, 244 
 Wrist-drop in lead poisoning, 882 
 Wry-neck, 912, 1316 
 
 X. 
 
 Xanthelasma of eyelids, 356 
 Xanthin bases, 279 
 Xerostomia, 485 
 X-ray, 377 
 
 apparatus for use of, 377 
 examination of abdomen with, 384 
 of extremities with, 386 
 of head, neck, and thorax with, 
 378 
 in diagnosis of bronchitis, 384 
 of emphysema, 382 
 of gastroptosis, 951 
 of phthisis, 379 
 of pleurisy with effusion and 
 
 pneumonia, 382 
 of pulmonary tuberculosis, 816 
 technic in use of, 377 
 
 Yellow fever, 750 
 
 varieties of, 751 
 
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