COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANpARD RC71 .J21 HX64123120 Atlas of methods of SAUNDERS' MEDICAL HAND-ATLASES. The series of books included under this title are authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which s, and cheapi Eac ous ilk most s pressio panied densed (hv ready servati< and ev hospitf will !-)( venien by the Wl heretol of thei enorm< jecteil tributi* best i elegai in ch( by the langu ^o\\ X Z.\ Columbia ^ntberjSfttp ^AtUrmtt SItbrarg numer- . b)- the nty im- acconi- 5 a con- offer a uch ob- :enters; routine ; books id con- rpreted it)n has because and an ;ir pro- nal dis- ises the '. most }ached istrated fferent Oanish, Swedish, and Hungarian. The same careful and competent editorial supervision has been secured in ^he English edition a>. in the originals. The tiinslations have been edited by the leading American specialists in th; different sub- jects. The volumes are of a uniform and convenient size (5 x "J^ inches), and are substantially bound in cloth. (For List of Books, Prices, etc. see back coverJ Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/atlasofmethodsofOOjako ATLAS OF METHODS OF Clinical Investigation, WITH AN EPITOME OF Clinical Diagnosis SPECIAL PATHOLOGY AND TREATMENT Internal Diseases BY DR. CHRISTFRIED JAKOB, Formerly First Assistant in the Medical Clinic at Erlangen. AUTHORIZED TRANSLATION FROM THE GERMAN. EDITED BY AUGUSTUS A. ESHNER, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; Physician to the Philadelphia Hospital, etc. With 182 Colored Illustrations upon 68 Plates, and 64 Illustrations in the Text. PHILADELPHIA W. B. SAUNDERS 925 Walnut Street I 898 Copyright, 1898, By W. B. SAUNDERS U.-- '^^■^ ELECTROTYPED BY WESTCOTT & THOMSON, PHILADA. PRESS OF W. B. SAUNDERS, PHILAOA. EDITOR'S NOTE. Of books on clinical medicine there is no deficiency, but the beauty, the clearness, and the accuracy of the illustrations in the original German volume, of which the present is a translation, seemed to be sufficient justifica- tion for adapting the work to the needs of American medical students and practitioners. As is indicated in the preface, a good illustration will often convey more and leave a deeper impression than the most elaborate description. Extensive modifications in the text have not been found necessary, and the translation has been free rather than literal, the endeavor having been to convey the spirit rather than the language of the original. The German volume has attained a deservedly large measure of popularity, and it is hoped that this reproduction in English will prove equally acceptable and useful. The original has been followed in placing trichinosis among infectious diseases of undetermined origin, although its dependence upon the trichina spiralis is recognized, and the parasite itself is described in its proper place. It has been thought well to add an index. PREFACE. This Atlas of the methods of clinical investigation contains a selection of the most important clinical condi- tions a knowledge of which the recent practitioner may acquire more readily and retain more permanently through good illustrations than through the most elaborate description. The various methods of investigation have been deline- ated as uniformly as possible. The illustrations of Part I are all from original preparations ;^ those of Part II are derived mostly from patients under immediate observa- tion. For the text of the Epitome, supplementary to the plates, the principle seemed sufficient that a portion of our diagnostic knowledge could with advantage be drawn from a concisely arranged compendium ; never, however, therapeutic modes of procedure ; for the latter the more elaborate text-book will be required. CHR. JAKOB. Bamberg, January, 1897. ' The drawings were made under my direction by Herr Krapf. DESCRIPTION OF PLATES. PART I. CLINICAL MICROSCOPY AND CHEMIC COLOR- REACTIONS. PLATE 1.— The Red Blood-corpuscles (Erythrocytes). Fig. 1. Fresh preparation of normal blood. Fig. 2. Stained preparation of normal blood. Fig. 3. Abnormal variations in size of the red blood-corpuscles. Fig. 4. Abnormal variations in form of the red blood-corpuscles. Fig. 5. Normal frogs' blood, stained. Fig. 6. Nucleated red blood-corpuscles of man. PLATE 2.— White Blood-corpuscles (Leukocytes). Fig. 1. Polynuclear leukocytes. Fig. 2. Mononuclear leukocytes. Fig. 3. Eosinophile cells (a-granules). Fig. 4. Basophile and neutrophile granulation. Fig. 5. Medullary cells (si)lenomedullary leukemia). Fig. 6. Medullary cells, with nuclei in process of division. PLATE 3.— The Blood in Various Diseases. Fig. 1. Simple profouiul anemia attending chronic nephritis. Fig. 2. Pernicious anemia. Fig. 3. Hemoglobinemia. Fig. 4. Leukocytosis attending croupous pneumonia (fresh). Fig. 5. Leukocytosis attending pneumonia (stained). Fig. 6. Blood-preparation from a case of typhoid fever. PLATE 4.— The Blood-state of Leukemia. Fig. 1. Fresh blood-preparation from a subject dead of leukemia. Figs. 2, 3, 4. Stained preparations from a case of splenomedullary leukemia. Fig. 5. Lymphatic leukemia. Fig. 6. Acute leukemia in a child half a year old. PLATE 5.— Parasites op the Blood. Fig. 1. Blood from a subject dead of anthrax. Fig. 2. Blood from a case of pyemia. Fig. 3. Pneumococci. Fig. 4. Spirilla of relapsing fever. Fig. 5. Blood from a case of malaria. Fig. 6. Malarial plasmodia. 6 DESCRIPTION OF PLATES. PLATE 6.— Blood-spectka and Blood-crystals. Fig. 1. Normal solar spectrum, oxyhemoglobin-spectrum, specti'um of reduced hemoglobin, of methemoglobin, of reduced CO- hemoglobin, of hematin. Fig. 2. Hematoidiu-crystals. Fig. 3. Teichmann's hemin-crystals. PLATE 7.— Microscopy of the Mouth and the Nasal Cavities. Fig. 1. Gingival deposit. Fig. 2. Thrush-fungus. Fig. 3. Spirochetal from a case of gangrenous stomatitis. Fig. 4. Secretion fi-om the nasal mucous membrane. Fig. 5. Diphtheria-bacilli. Fig. 6. Sectiou through diphtheria-membrane. PLATE a— Microscopy of the Sputum. Fig. 1. Normal sputum (unstained). Fig. 2. Normal sputum (stained). Fig. 3. Pigment- (soot) cells. Fig. 4. Pigment- (cardiac lesion) cells. Fig. 5. Sputum from an attack of asthma (unstained). Fig. 6. Sputum from a case of asthma (stained). PLATE 9. Fig. 1. Sputum from an abscess of the lung. Fig. 2. Sputum from gangrene of the lung. Fig. 3. Fibrinous coagulum. PLATE 10.— The Parasites of the Sputum. Fig. 1. Pneumococci in pneumonic sputum. Fig. 2. Staphylococci from an abscess of the lung. Figs. 3, 4. Sputum from a case of tuberculosis. Fig. 5. Sputum from a case of influenza-bronchitis. Fig. 6. Sputum from a case of actinomycosis of the lung. PLATE 11. — Microscopy op Contents of Stomach and Intestines. Fig. 1. (reneral view of gastric contents. Fig. 2. General view of the feces. Fig. 3. Intestinal contents from a case of cholera nostras. Fig. 4. Intestinal contents from a case of cholera asiatica. PLATE 12.— The Most Important Color-reactions of the Gas- tric Juice. Litraus-paper, congo-paper, phloroglucin- vanillin test, methyl- violet reaction, Uffelmann's reagent. PLATE 1.3.— Urinary Sediments. Fig. 1. Bri(;kdust sediment. Fig. 2. Yellowish friable sediment. Fig. 3. Bloody scdiiiKUit. Fig. 4. Sodium unit(\ Fig. 5. Uric-acid crystals. DESCRIPTION OF PLATES. 7 PLATE 14.— Crystalline Ukinaky Sediments. Fig. 1. Calcium oxalate. Fig. 2. Hippuric acid. Fig; 3. Ammouio-magnesium phosphate, triple phosphate. Fig. 4. Ammouium urate. Fig. 5. Calcium carbonate. Fig. 6. Calcium sulphate and calcium phosphate. PLATE 15.— Crystalline Urinary Sediments. Fia;. 1. Basic magnesium phosphate. Fig. 2. Cystin. Fig. 3. Leucin. Fig. 4. Tyrosiu. Fig. 5. Cholesterin. Fig. 6. Earthy phosphates and bacteria. PLATE 16.— Organized Urinary' Sediments. Fig. 1. Squamous epithelium from urethra and bladder. Fig. 2. Epithelial cells from the pelvis of the kidney. Fig. 3. Eenal epitheliuni. Fig. 4. Pus-cells. Fig. 5. Eed blood-corpuscles. Fig. 6. Spermatozoa. PLATE 17. — Urinary Tube-casts. Fig. 1. Cylindroids and hyaline tube-casts. Fig. 2. Coarsely and finely granular tube-casts. Fig. 3. Waxy tube -casts. Fig. 4. Blood-casts. Fig. 5. Fatty casts. PLATE 18.— Urinary Sediments attending Diseases of the Bladder and the Kidney's. Fig. 1. Sediment from cystitis. Fig. 2. Sediment from calculous pyelitis. Figs. 3, 4. Sediment from acute hemorrhagic nephritis. Fig. 5. Chronic nephritis— large red, variegated kidney. Fig. 6. Chronic nephritis— large white kidney. PLATE 19. Fig. 1. Sediment from chronic parenchymatous nephritis. Fig. 2. Sediment from true contracted kidney. Fig. 3. Sediment from febrile albuminuria. Fig. 4. Sediment from amyloid kidney. Fig. 5. Pus from gonorrhea. Fig. 6. Pus from tuberculous cystitis. PLATE 20.— The Most Important Color-reactions of the Urine. Figs. 1, 2, 3. Trommer's test for sugar. Fig. 4. Bismuth-test. Fig. 5. Moore's (caramel) test. Fig. 6. Ferric-chlorid reaction in diabetes. 8 DESCRIPTION OF PLATES. Fig. 7. Peptone-test. Fig. 8. Indican-test. Fig. 9. Test for biliary coloring-matter. Fig. 10. Heller's blood-test. Fig. 11. Test for melanin. Fig. 12. Diazo-reaction. PLATE 21.— Demonstration of some Medicaments in the Urine. Fig. 1. Demonstration of antipyriu. Fig. 2. Demonstration of salicylic acid. Fig. 3. Demonstration of bromin (potassium bromid). Fig. 4. Demonstration of iodin (potassium iodid). Contents of cysts, abscesses, etc. Fig. 5. Crystals of uric acid from a gouty nodule. Fig. 6. Hematoidin-crystals from an old abscess. Fig. 7. Echinococcus-fluid (evaporated). Fig. 8. Echinococcus-fluid (sediment). PLATE 22.— The Most Important Pyogenic Micro-organisms. Fig. 1. Staphylococcus pyogenes albus. Fig. 2. Streptococcus pyogenes. Fig. 3. Bacterium coli commune. Fig. 4. Proteus vulgaris. Fig- 5. Bacillus of glanders. Fig. fi. Typhoid-bacilli. PART II. NORMAL PROJECTION OF THE VISCERA AND PERCU= TORY TOPOGRAPHY. PLATE 23. — Projection of the Internal Organs upon the An- terior Aspect of the Body. PLATE 24.— Percutory and Auscultatory Topography. PLATE 25. — Pro.iection of the Internal Organs upon the Po.s- terior Aspect of the Body. PLATE 26.— Percutory Topography of the Back. PLATE 27.— Pro.iection of the Internal Organs upon the Lat- eral Aspects of the Trunk. PLATE 28.— Percutory Topography of the L.\teral Aspects of THE Trunk. SCHEMATA OF DISEASES OF LUNGS AND HEART. PLATE 29.— Croupous Pneumonia of the Posterior Inferior Portion of the Left Side. PLATE 30.— Croupous Pneumonia. PLATE 31.— Exudative Pleurisy on the Left Side Posteeiokly. PLATE 32.— Exudative Pleurisy on the Left Side. DESCRIPTION OF PLATES. 9 PLATE 33. — Exudative Pleurisy on the Right Side. PLATE 34.— Hydrothorax. PLATE 35. — Acute Diffuse Bronchitis. • PLATE 36. — Bronchopneumonia. PLATE 37. — Pulmonary Infarction. PLATE 38. — Pulmonary Emphysema. PLATE 39.— Incipient Pulmonary Tuberculosis. PLATE 40.— Progressive Pulmonary Tuberculosis. PLATE 41.— Pneumothorax. PLATE 42.— Pyopneumothorax. PLATE 43. — Uncompensated Cardiac Lesion. PLxiTE 44. — Compensated Mitral Stenosis. PLATE 45.— Mitral Insufficiency. PLATE 46. — Aortic Insufficiency. PLATE 47. — Tricuspid Insufficiency. PLATE 48. — Idiopathic Hypertrophy of the Heart. PLATE 49. — Exudative Pericarditis. PLATE 50. — Aneurism of the Aorta. DIAGRAMMATIC REPRESENTATION OF ABDOMINAL DISEASES. PLATE 51. Fig. a. Carcinoma of the cardia, with stenosis of the esophagus. Fig. 6. Normal and pathologic positions of the stomach. PLATE 52. — Cicatricial Stenosis of the Pylorus. PLATE 53. — Dilatation of the Stomach, with Carcinoma of the Pylorus. PLATE 54. — Carcinoma of the Stomach. PLATE 55. — Constricted Liver. PLxlTE 56. — Cirrhosis of the Liver. PLATE 57. — Melanosarcoma of the Liver. PLATE 58.— Cholelithiasis ; Hydrops of the Gall-bladder. PLATE 59. — Amyloid Degeneration. PLATE 60. — Splenomedullary Leukemia. PLATE 61.— Pancreatic Cyst. PLATE 62. — Ascites attending Cardiac Lesion. PLATE 63. — Carcinoma of the Intestine. PLATE 64.— Occlusion of the Bowel; Invagination. PLATE 65.— Perityphlitis. PLATE QQ. — Tuberculous Peritonitis. PLATE 67. — Perforative Peritonitis. PLATE 68. — Sarcoma of the Right Kidney. CONTENTS. SECTION I. PAGE Examination of the Patient 1-18 History 1-6 Present State 6-16 Subjective Symptoms 16-18 SECTION 11. General Consideeations upon Methods of Examination . 19-34 Microscopy 20-22 Examination with Mirrors 22 Thermometry 23 Exploratory Puncture 23 Bacteriologic Methods 24-28 Palpation 28 Percussion 29-31 Auscultation 31-34 SECTION III. Special Diagnosis of Diseases of the Internal Organs , 35-130 I. Examination of the Eespiratory Apparatus 35-54 1. Nose and Nasopharyngeal Space 35 2. Larynx and Trachea 36-40 3. Luiigs 40-48 Anatomic 40 Physiologic 41 Inspection 42 Spirometry - 42 Percussion 42-45 Auscultation 46-48 4. Puncture of the Pleura 49 5. The Sputum 50-54 II. Examination of the Circulatory Apparatus 54-79 1. Heart 54-66 Anatomic 54 Physiologic 54 Theory of Valvular Lesions 55-60 Derangement of Compensation 60 Inspection and Palpation 61 Percussion 62-64 Auscultation 64-66 11 12 CONTENTS. PAGE 2. The Blood-vessels 66-72 The Pulse 67-72 3. The Blood 72-79 III. Examination of the Digestive Apparatus 79-99 1. Mouth and Pharynx 79-81 2. Esophagus 81 3. Stomach 82-89 4. Liver 90-92 5. Spleen 92 * 6. Abdomen, Intestines, and Peritoneum 93-99 The Stools 97-99 IV. Examination of the Uropoietic System 99-115 1. Kidneys 99 2. Bladder 100 3. The Urine 100-115 V. Examination of Abnormalities of Metabolism 115-119 VI. The Most Important Parasites 120-130 SECTION IV. Epitome of Special Pathology and Treatment ..... 131-232 I. Infectious Diseases 131-161 A. Bacterial Infections 131-144 1. Tuberculous Diseases 131-137 2. Typhoid Fever 137-140 3. Diphtheria and Croup 140 4. Influenza 141 5. Asiatic Cholera 142 6. Leprosy 143 7. Anthrax 143 8. CTlanders 143 B. Coccus-infections 144-150 9. The Rheumatic Diseases 144-146 Acute Rheumatic Polyarthritis . 144 Acute Endocarditis 145 Acute Rheumatic Pleurisy 146 10. Cryptogenetic Septicopyemia 146 11. Croupous Pneumonia 147-149 12. Epidemic Cerebrospinal Meningitis 149 13. Erysipelas 150 C. Actinomyces-infections 150 D. Spirillum-infections 151 14. Relapsing Fever 151 E. Plasmodial Infections 151-153 15. Malarial finterniittent) Fever 151-153 F. Infectious Diseases of Undetermined Origin 153-161 The Acute Exanthemata 153 16. Morbilli (measles) 154 17. Scarlet Fever 155 18. Rubeola (Rotheln) 155 19. Variola (smallpox) 155-157 20. Varicella (chickenpox) 157 21. Epidemic Parotiditis (mumps) 157 22. Pertussis (whooping-cough) 157 CONTENTS. 13 PAGE 23. Cholera Morbus (cholera nostras) 158 24. Dysentery 158 25. Typhus Fever (spotted fever) 159 26. Hydrophobia (canine rabies) 160 27. The Pla£;ue 160 28. Yellow Fever 160 29. Trichinosis 160 II. Diseases of the Eespiratory Organs 161-177 A. Diseases of the Nose 161-162 1. Acute and Chronic Ehiuitis 161 2. Ozena 162 3. Epistaxis 162 B. Diseases of Larynx, Trachea, and Bronchi 163-167 4. Acute and Chronic Laryngitis . . 163 5. Edema of the Larynx 164 6. Tuberculosis of the Larynx 164 7. Syphilis of the Larynx 164 8. Paralysis of the Laryngeal Muscles (see p. 38) . . . 164 9. Spasm of the Glottis ^laryngismus stridulus) .... 164 10. Tumors of the Larynx 164 11. Acute and Chronic Bronchitis 165 12. Fetid Bronchitis 166 13. Bronchiectasis 166 14. Bronchial Asthma 167 C. Diseases of Lungs and Pleura 167-177 15. Croupous Pneumonia (see p. 147) 167 Differential Diagnosis between Pneumonia and Pleu- risy 167 16. Bronchopneumonia 168 17. Atelectasis of the Lung 168 18. Pulmonary Emphysema 169 19. Pulmonary Edema 170 20. Pulmonary Tuberculosis (see p. 132) 170 21. Pulmonary Gangrene 170 22. Pulmonary Abscess 171 23. Pneumonokonioses 171 24. Pulmonary Embolism (hemorrhagic infarction) . . . 171 25. Pleurisy 172-175 26. Pneumothorax 175 27. Hydrothorax 176 28. New-growths in the Chest 176 III. Diseases of the Circulatory Organs . 177-190 A. Diseases of the Heart 177-186 1. Acute Endocarditis 177 Table of Valvular Lesions 178-179 2. Valvular Lesions of the Heart 180-184 3. Idiopathic Hypertrophy of the Heart 184 4. Diseases of the Myocardium 185 5. Neurotic Disorders of the Heart 186 B. Diseases of the Pericardium 186-189 6. Pericarditis 186-188 7. Hydroperieardium, Hemopericardium, Pneumoperi- cardium 188-189 C. Diseases of the Bloodvessels 189 14 CONTENTS. PAGE 8. Arteriosclerosis . 189 9. Aneurism of the Aorta 190 IV. Diseases of the Digestive Organs 190-211 A. Diseases of the Mouth and the Pharynx 190 1. Stomatitis .... 190 2. Glossitis 192 3. Angina (tonsillitis) 192 4. Chronic Hypertrophy of the Tonsils 193 5. Dry Chronic Pharyngitis 193 B. Diseases of the Esophagus . . . . • 194 6. Stenosis of the Esophagus 194 C. Diseases of the Stomach • 195-199 7. Acute Gastritis • 195 8. Chronic Gastritis 195 9. Gastric Ulcer 196 10. Carcinoma of the Stomach . • . . 197 11. Dilatation of the Stomach 198 Pyloric Stenosis. Table 199 12. Nervous Dyspepsia . 199 D. Diseases of the Intestines 199-202 13. Intestinal Catarrh 199 14. Intestinal Tuberculosis 200 15. Carcinoma of the Bowel 201 16. Stenosis and Occlusion of the Bowel (ileus) 201 17. Habitual Constipation 202 18. Intestinal Parasites 202 E. Diseases of the Peritoneum 202-205 19. Perityi)hlitis 202 20. Acute Peritonitis 203 21. Chronic Peritonitis 204 22. Ascites 204 23. Carcinoma of the Peritoneum . 205 F. Diseases of the Liver 205-210 24. Catarrhal Jaundice 205 25. Cholelithiasis 206 26. Cirrhosis of the Liver 207 27. Acute Yellow Atrophy of the Liver 207 28. Carcinoma of the Liver 208 29. Syphilis of the Liver 208 30. Abscess of the Liver 208 31. Ecliinococcus of the Liver 208 32. Cyanotic (nutmeg) Liver 209 Fatty Degeneration of the Liver 209 Amyloid Liver 209 33. Constricted Liver 209 34. Thrombosis and Inflammation of the Portal Vein . . 209 Table of Diseases of the Liver 210 G. Diseases of Spleen 210 35. Enlargement of the Spleen 210 H. Diseases of the Pancreas 211 V. Diseases of the Uropoietic Organs 211-220 A. Diseases of the Kid n(\vs ." 211-218 1. Acute Hemorrhagic Nephritis 211 2. Chronic Nephritis 212 CONTENTS. 15 PAGE 3. True Contracted Kidney . 213 4. Cyanotic Kidney 214 Hemorrhagic Infarction 215 5. Amyloid Kidney 215 Table of Diseases of the Kidney 215 6. Pyelonephritis 215 7. Nephrolithiasis 216 8. Tuberculosis of the Kidney 217 9. Tumors of the Kidney (see p. 99) 217 10. Hydronephrosis 217 11. Wandering Kidney 218 B. Diseases of the Bladder 218-220 12. Cystitis 218 13. Tumors of the Bladder 219 14. Nocturnal Enuresis 219 VI. Diseases of the Blood and of the Bodily Metabolism . 220-227 A. Diseases of the Blood 220-224 1. Chlorosis 220 2. Anemia 220 3. Leukemia 221 4. Hemoglobinemia 223 5. Hemorrhagic Diathesis 223 B. Disorders of tlie Bodily Metabolism 224-227 6. Diabetes Mellitus, Diabetes Insipidus 224 7. Uric-acid Diathesis (gout) 225 8. Obesity 226 YII. Diseases of the Joints and Bones 227-228 1. Eachitis 227 2. Osteomalacia 227 3. Deforming Arthritis 227 4. Muscular Eheumatism 228 VIII. Some Important Forms of Poisoning 228-232 SECTION V. Therapeutic Notes 233-242 I. Dietetic Methods of Treatment 233-234 1. Dietary for Diseases of the Stomach 233 2. Fever-diet 233 3. Eest-cure 233 4. Eeduction-cure (for obesity) 234 5. Nutrient Enemata 234 6. Artificial Foods 234 II. Hydrotherapy 234-236 III. Treatment by Climate and Baths 236 IV. Physical Methods of Treatment 236-237 V. The Most Important Medicaments 237-242 CLINICAL MICROSCOPY AND CHEMIC COLOR-REACTIONS. (Plates 1-22.) Tab. 1, PLATE 1. THE RED BLOOD=CORPUSCLES (ERYTHROCYTES). Fig. 1. Fresh Preparation of Normal Blood. — The red blood-corpuscles mostly in rouleaux ; some with distinct central depressions; others standing on edge (biscuit-shaped); all of approximately the same size (7.6//). Three white blood-cor- puscles with distinct granulation of the protoplasm ; that in the middle coarsely granular ; the others finely granular. Sev- eral groups of blood-plates (like clusters of grapes). — Magnified 350 times. Fig. 2. Stained Preparation of Normal Blood. — The red blood-corpuscles deeply stained with eosin ; in the center (cor- responding with the concavity) less deeply. Five leukocytes with readily recognizable miclei (three polynuclear, two mono- nuclear. See Plate 2). — Magnified 350 times. Stained with hematoxylin and eosin. Note. — In this, as in all subsequent illustrations of the blood, the relation between the white and the red blood-corpuscles will be correct if the field as portra^'ed be conceived to contain three times as many red Ijlood-corpuscles as white, the number of white remaining as in the illustration. Fig. 3. Abnormal Variations in Size of the Red Blood- corpuscles. — Showing abnormally small (microcytes, from 2.2// downward), abnormally large red corpuscles (macrocytes, up to 15//). Some of the macrocytes are stained partially or totally of a violet hue instead of the normal red tint of eosin (anemic degeneration, alteration in tingibilit}^ of the stroma). Others present lighter areas (hemoglobinemic degeneration). — Magni- fied 400 times. Stained with methylene-blue and eosin. Fig. 4. Abnormal Variations in Form of the Red Blood- corpuscles. — Tlie red blood-corpuscles show all possible varia- tions of form, excrescences, etc. This condition is designated poikilocytosis. — Magnified 350 times. Stained with eosin. Fig. 5. Normal Frog's Blood, Stained.— The red blood-cor- puscles are much larger than in man. of oval shape, and pro- vided with longitudinal nuclei. A white blood-corpuscle with eosinophile gramilations (see Plate 2). — Magnified 300 times. Stained with methylene-blue and eosin. Fig. 6. Nucleated Red Blood-corpuscles of Man. — The red blood-corpuscles oi man are normally non-nucleated (only in the fetal state are they nucleated). In some diseases (leukemia, anemia) nucleated red corpuscles also appear, and in the form of erythrocytes of normal size (normoblasts) or as macrocytes (gigantoblasts). The nuclei may be in part absorbed; in part, however, they show intense staining of the chromatin, undergo division (by budding), and may esca]^e free from the red blood- corpuscles (free nuclei). The significance of this process (re- generation [?], transformation into white blood-corpuscles, espe- cially mononuclear [?J) is yet a matter of doubt. PLATE 2. WHITE BLOOD=CORPUSCLES (LEUKOCYTES). Fig. 1. Polynuclear Leukocytes. — They show partly lobu- lated and fissured, partly completely separated, nuclei. In the degenerated (dying) forms the nuclei are stained more feebly and the protoplasm undergoes disintegration (karyolysis). — Mag- nified 700 times. Stained with methylene-blue and eosin [upper half), hematoxylin and eosin {lower half). Fig. 2. Mononuclear Leukocytes. — They are distinctly smaller and display only a narrow zone of protoplasm. A dis- tinction is made between a large and a small form. Magnifica- tion and staining the same as in Fig. 1. Fig. 3. Eosinopliile Cells (a-Granules). — Leukocytes filled with bright bodies, unstained presenting a coarsely granular appearance, and staining intensely with eosin ; they contain the a-granules (Ehrlich). Eosinophile cells are mostly polynuclear ; strong pressure may cause them to rupture, with escape of the granules. A distinction is made between large, medium-sized, and small forms. Normally they exhibit ameboid movement. In addition to their presence in the blood (from 2 or 5 to 15% ) they are found also in the sputum (especially in cases of asthma), in nasal mucus, in gonorrheal pus, etc. The significance of the granules has not yet been determined. — Magnified 700 times. Stained with methylene-blue and eosin. If the stained prep- aration is rapidly washed in 10% potassic hydrate solution, the a-granules appear with especial distinctness. Fig. 4. Basophile and Neutrophile Granulation. — Left upper quadrant : Leukocytes with (mast-cell) granulation (y-gran- ules). The polynuclear cells contain moderately coarse granules that stain deeply with methylene-blue, dahlia, etc. Right upper quadrant: Leukocytes with fine basophile granulation ((5-gran- ules), especially in the marginal zone (mononuclear forms). Loiver half: Leukocytes with neutrophile (violet) granulation (f-granules). They correspond with the majority of the poly- nuclear leukocytes (and are found, also, in sputum and in pus in large numbers) and contain a fine, dust-like granulation. Left: stained with eosin; right: with Ehrlich 's triacid solution. — Magnified 800 times. Fig. 5. Medullary Cells (Spleno-medullary Leukemia). — These cells are ordinarily not found in normal blood, but ap- pear in large numl)ers in some varieties of leukemia. They have invariably large lobulated nuclei that usually do not stain deeply and generally exhil)it neutrophile granulation. Some contain, also, esinoj)hile granules. They are derived from the bone-marrow and, in contrast with the remaining leukocytes, disi)lay nf) ameboid movement. Fig. C). Medullary Cells, -with Nuclei in Process of Divis- ion. — From a case of leukemia. There were found the various stages of inchreet karyokinesis (a.ster, constriction, skein-form). • — Magnilied UXX) times. Stained with hematoxylin. Tab. 2. lithJnsi.v. ¥. Reiclihdld , Miinchen . Tab. 3. Lith.Ansi.v. F. Reiohhdld, Miinchen . PLATES. THE BLOOD IN VARIOUS DISEASES. Fig. 1. Simple Profound Anemia attending chronic neph- ritis. The red corpuscles exhibit poikilocytosis, and some mi- crocytes and macrocytes are present. Nucleated red corpus- cles are wanting. The white corpuscles are somewhat increased (leukocytosis) and are mostly polynuclear, with one eosinophile cell. The enumeration showed 1,700,000 red and 18,000 white corpuscles to the cubic millimeter, with only 42% of hemoglobin. — Magnified 300 times. Stained with hematoxylin and eosin. Fig. 2. Pernicious Anemia.— Marked poikilocytosis. Many microcytes and macrocytes, the latter showing anemic degenera- tion. Fairly numerous nucleated red corpuscles (normoblasts and gigantoblasts). White corpuscles somewhat increased. Enumeration : 600,000 red, 12,000 white corpuscles ; hemoglo- bin, 30%. Staining and magnification the same as in Fig. 1. Fig. 3. Hemoglobinemia (fresh preparation).— In a case of poisoning with potassic chlorate (prescribed as a gargle) there were found in the fresh blood numerous red corpuscles which had lost their hemoglobin totally or partially, and were swollen, pale, and changed in form (shadows and poikilocytes). The spectroscopic examination showed the methemoglobin-line in the red (see Plate 6, Fig. 1). The blood was of brownish hue. Fig. 4. Leukocytosis attending croupous pneumonia (fresh preparation). — During the course of a number of febrile diseases (pneumonia, cerebro-spinal meningitis, scarlet fever, etc.) there occurs throughout the course of the attack marked increase in the polynuclear leukocytes in the blood of the capillaries (un- equal distribution ?). If on examination of a fresh preparation of such blood an average of more than from 5 to 8 leukocytes is found in a single field, leukocytosis of about 15,000 may be pre- sumed to exist ; when the number of white corpuscles is from 12 to 15, the leukocytosis is more than 20,000. In the prepara- tion depicted there were more than 56,000 white blood-corpus- cles to the cubic millimeter (determined by counting). Fig. 5. Leukocytosis attending pneumonia (stained with hematoxylin and eosin). — The increase involves exclusively the polynuclear forms; no eosinophile cells are present. Fig. 6. Blood-preparation from a Case of Typhoid Fe- ver. — In contrast with pneumonia there is here no leukocy- tosis, but rather a diminution of the polynuclear elements. Staining the same as in Fig. 5. PLATE 4. BLOOD=STATE OF LEUKEMIA. Fig, 1. Fresh Blood-preparation from a Subject dead of Leukemia. — The white blood-corpuscles ure enormously increased. A count during life showed 860,000 white blood- corpuscles and 2,600,000 red blood-corpuscles to the cubic mil- limeter. Finely and coarsely granular (a-granides) leukocytes are easily recognized ; on the addition of acetic acid the nuclei also become distinct; there are many mononuclear cells (espe- cially large forms). In the blood after death Charcot-Leyden crystals have formed in large numbers (they are not to be seen during life). Fig. 2. Stained Preparation from a Case of Spleno- medullary Leukemia. — Stained with m ethyl ene-blue and eosin. — Magnified 300 times. Fig. 3. Preparation from the same blood stained with hema- toxylin and eosin. Fig. 4. Preparation of the same blood stained with triacid solution. In Figs. 2 and 3 the red corpuscles are stained red, the nuclei blue, the a-granules red, the basophile granules blue ; in Fig. 4 the red corpuscles are stained yellow, their nuclei green, the nuclei of the leukocytes bluish, the a-granules red, the neutro- phile granules violet. All of the preparations exhibit moderate poikilocytosis ; the white blood-corpuscles are markedly increased. This increase is contributed to by the ])()Iynuclear neutro])hile cells, and esi)e- cially the eosinophile cells; besides there are present (in con- trast to leukocytosis) large mononuclear medullary cells, in part exhibiting a-granulation. There are many nucleated r(Hl blood- cori)uscles. Fig. 5. Lymphatic Leukemia — Stained with hematoxylin and eosin. This figure repi-esents the small mononuclear foi-ms especially as greatly increased. Eosinophile cells and medul- lary cells, as well as nucleated red blood-corpuscles, are present in smaller luunber. Fig. 6. Acute Leukemia in a child half a year old. — The number of white blood-corpuscles was only 48,(XX) to the cubic millimeter; nevertheless microscopic (wamination dis- closed a leukemic state of the l)lood (nucleated nn], slight increase in mononuclear and eoshio))hile cells). Clinically there existed marked enlargement of the spleen. Tab, 4. PLATE 6. BLOOD=SPECTRA AND BLOOD=CRYSTALS. Fig. 1, a. Normal Solar Spectra, with the various absorp- tion-Hues marked by letters (A, B, C, D, a, b, a). The blood changes the spectrum of the hght pass- ing through (marked dilution of the blood is neces- sary) in such a way that, in accordance with the behavior of the hemoglobin present, various por- tions of the colored spectrum are obliterated or absorbed. There thus appear at various places black bands of varying thickness. b. Spectrum of blood rich in oxygen (oxyhemoglobin- spectrum) (two l)ands between D and E). c. Spectrum of reduced hemoglobin. d. Spectrum of methemoglobin (accompanying hemo- globinemia, destruction of the red blood-corpuscles through poisoning with potassic chlorate, pyrogallol, sulfonal, toadstools). e. Spectrum of reduced CO-hemoglobin. The reduc- tion accompanying carbon-monoxid poisoning is unattended with disaj)j)earance of the two bands between D and E; in contrast with reduced oxy- hemoglobin (Fig. c). f.-h. Spectra of hematin in acid and alkaline solutions and reduced (occurs in urine). Fig. 2. Hematoidin Crystals (from old hemorrhagic focus). — Partly in rhombic i)liites, partly in granules. Fig. 3. Teichmann's Hemin-crystals. — They serve for the demonstration of even slight traces of blood, old or recent. They are ol)tained by adding to the remnant of blood a crystal of sodic chlorid and a drop of glacial acetic acid, and effecting evaporation by gentle heat. Their recognition is of importance from a medico-legal point of view. Tab. 6. E I) 1 1 II 1 1 l! Ef^v^^^^^^^'yJi'^^^J^SiJw^sl^^^'ji^t^ia^lK^^^^K ! ■« IltkAnsi.v. F. Reiohholfl . Miinchen . Tab. 7, LnhAisi .V. F. ReicWidld, >liinclt»'; PLATE 7. MICROSCOPY OF THE MOUTH AND NA5AL CAVITIES. Fig. 1. Gingival deposit (unstained, with the addition of acetic acid). — There are present large squamous epithelial cells {a), partly covered by bacteria and granules of detritus ; numer- ous white blood-corpuscles (6) in process of fatty degeneration: variolis bacteria (c) : cocci, spirilla, bacilli, and especially large collections of a filamentous fungus: leptothrix bacillus [d], which bears an especial relation to decalcification of the teeth in connection with caries. — Magnified 350 times ; as are also the following figures. Fig. 2. Thrush-fungus. — This fungus (Oidium albicans) is present especially, in nursing infants suffering from digestive disorders and in cachectic individuals. It forms a dense white deposit upon the mucous membrane of the mouth and pharynx. Microscopically it presents threads and spore-formation. It has been found also in abscesses. Fig. 3. Spirochetse from a Case of Gangrenous Stoma- titis. — In a case of severe stomatitis actively motile spirilla (bacteria) were found in almost pure culture in two varieties (a coarse and a very delicate form) among the pus-corpuscles. Stained with gentian-violet. Fig. 4. Secretion from the Nasal Mucous Membrane. — There are present large and small squamous epithelial cells (a), cylindric epithelium, with cilia [b], leukocytes filled partly with fat-drops, partly with carbon-particles (c), eosinophile cells [d), cocci, especially diplococci [e), budding fungi {/), spores of molds (g), such as aspergillus, mucor, etc., from the air. Fig. 5. Diphtheria-bacilli. — (Streak-preparation, stained with magenta-red.) Derived from a diphtheric deposit upon the tonsils. Among the pus-corpuscles are nests of diphtheria- bacilli. These are slender rods, often somewhat thickened at the extremities (dumb-bell-shaped, club-shaped). The diag- nosis must be rendered certain by culture. (See Epitome.) In addition to the specific excitants there are present, also, numerous other bacteria, streptococci (mixed infection), diplo- cocci, and staphylococci. Fig. 6. Section through Diphtheria-membrane. Stained with carmine and methylene-blue. — Magnified 50 times. At a is the surface of the false membrane. At b this is separated from the subjacent structures. The low power permits recog- nition of the masses of bacteria (blue) among the collections of cells and fibrin. PLATE 8. MICROSCOPY OF THE SPUTUM. Fig. 1. Normal Sputum (unstained). — Magnified 350 times, as are the following figures. There are present squamous epithelium (a), cylindric epithelium (6), many leukocytes (c) imhedded in mucin threads, large cells filled with bright fat- granules [d), so-called alveolar epithelium (of doubtful origin, leukocytes ?), free myelin (g), isolated red blood-corpuscles (e), leukocytes filled with particles of carbon (soot-cells, /), free fot-drops (/?), bacteria (i). Fig. 2. Normal Sputum. — Stained with methylene-blue and eosin. The same picture as in Fig. 1. The nuclei of the cells, as w^ell as the numerous bacteria of the si^utum, appear more distinctly. An eosinophile cell is present. In several places is the so-called pulmonary sarcina, an innocuous coccus. Fig. 3. Pigment (soot) -cells (on the left unstained, on the right stained with methylene-blue). The distended cells (leu- kocytes ?, alveolar epithelium ?) contain large drops of myelin, and among these black particles of carbon and dust. Fig. 4. Pigment (cardiac lesion) -cells (unstained). In cases of pulmonary stasis (brown induration) resulting from cardiac lesions (mitral stenosis) the sputum contains characteristic large cells enclosing pigment-graiuiles varying in color between yellow and dark brown (altered hemogk)l)in). Fig. 5. Sputum from an Attack of Asthma (unstained). — In addition to the usual white blood-corpuscles there are present numerous leukocytes exhibiting bright, yellowish coarse granulations (a-granules) ; among these are numerous Charcot- Leyden asthma-crystals — colorless, pointed octahedra. In the middle of the field is a Curschmann si)iral, a convoluted spiral formation made up of numerous individual filaments and origi- nating in the smallest bronchioles (exudation?). Disseminated throughout the field are numerous a-granules derived from ruptured eosinophile cells. Fig. C. Sputum from a Case of Asthma. — Stained with methylene-l)lue and eosin, and subsecjuently treated with po- tassic hydrate. The eosinophile cells aj)j)ear distinctly, the disseminated (red) individual granules being readily distin- guishable from the (blue) stained micrococci. Tab. 8. Tab. 9. PLATE 9. Fig. 1. Sputum from an Abscess of the Lung. — The specimen was derived from a woman in whom a puhiionary ahsceiss had developed in conjunction with a severe attack of pneumonia. After the rupture of the abscess there were dis- charged for a long time the following structures : elastic fibers (bright, yellowish filaments of double contour variously con- torted), among which were large numbers of pus-corpuscles, for the most part in process of fatty degeneration ; free fat- globules, large and small, containing fat-crystals (melting when heated), numerous fine fiit-needles ; bacteria; isolated hemat- oidin-crystals and cholesterin-crystals. Fig. 2. Sputum from Gangrene of the Lung. — In the case of a niiiii witli chronic pulmonary tuberculosis there devel- oped pulmonary gangrene (necrosis of a sequestrum of tissue). In the highly offensive, brownish, viscid sputum were found: a large amount of detritus (small granules and fragments), fat- drops, fat-crystals, nuich lung-pigment lying in large masses, pus-corpuscles in all stages of disintegration, and large numbers of bacteria. Fig. 3. A large Fibrinous Coagulum (bronehial tree) from a case of diphtheria, coughed up through the cannula by a tracheotomized child. The preparation depicted in Plate 7, Fig. (>, was derived from this fibrinous tube, which represents a verital)le cast of the bronchi. Above and to the left is shown a smaller coagulum, such as is sometimes expectorated in cases of pneumonia or fibrinous bronchitis. Smaller coagula are best observed by agitating the sputum in considerable water, the casts then unfolding. PLATE 10. THE PARASITES OF THE SPUTUM. Fig. 1. Pneumococci in Pneumonic Sputum. — Among the blue-stained leukocytes and the red-stained red blood-cor- puscles are numerous diplococci of Fraenkel exhibiting distinct capsule-formation, together with other cocci. The diplococci are found also in the expectoration of healthy individuals, although rarely in such large number. Fig. 2. Staphylococci from an Abscess of the Lung. — In the diffluent pus discharged in large quantities in conse- quence of rupture of the abscess the staphylococcus pyogenes aureus (identity established by culture) was found in abundance. Stained with gentian-violet and eosin by Gram's method. Figs. 3 and 4. Sputum from a Case of Tuberculosis. — Treated with the specific stain (fuchsin and methylene-blue ; see text), the sputum, spread in a thin layer and fixed on a cover-glass, shows on the left isolated, upon the right exceed- ingly munerous tubercle-bacilli. All other bacteria are stained blue. A reliable diagnostic conclusion can scarcely be reached from the number of bacilli, which are generally very abundant in the pus from cavities. Fig. 5. Sputum from a Case of Influenza-bronchitis.— Stained with magenta-red. Among and within the pus-cor- puscles are found the influenza-bacilli : delicate rods, mostly arranged in pairs and lying in groups of considerable size. The other bacteria are all i)lumper. Fig. 6. Sputum from a Case of Actinomycosis of the Lung. — Stained with carmine and picric acid. Among the leukocytes can be seen granules that make up the micro- scopic yellow grains of the ray-fungus. These are found microscopically to consist of clubs (degenerated form) joined in the shape of a wreath or garland, and of threads or filaments (mycelium). Tab. 10. Tab. 11 ■■^ (p/>. i (I ^y/ rf-(,-; \^ ^^ \ ' >\m^. •f PLATE 11. MICROSCOPY OF CONTENTS OF STOMACH AND INTESTINES. Fig. 1. General View of Gastric Contents. — In the vom- ited or siphoned matters are found : squamous epithehal cells [a) from the esophagus and the mouth ; leukocytes (6) ; cylindric epithelial cells (c) ; particles of food, such as muscle-libers [d), fat-drops and fiit-crystals [e), starch-granules (/) ; chlorophyl- containing vegetable matters (g); spiral filaments (//); bac- teria (/), especially gastric sarcina [k), cocci resembling bales of goods, which are sometimes present in abnormal numbers in conjunction with fermentative processes ; budding fungi {1} ; at times also red blood-corpuscles, etc. Fig. 2. General View of the Feces. — In the feces are found : desquamated epithelial cells, leukocytes (a) ; undi- gested vegetable matters, spiral filaments; stone-cells (b), cu- ticular formations (e) ; cofiin-lid crystals (ammonio-magnesium phosphate, cl) ; fot-crystals {e), especiall}' numerous and forming distinct collections in acholic stools ; yeast-fungi (/). At times are found, also, infusoria: amceba coli (g), which when present in increased numbers may induce disease of the bowel (amebic enteritis), trichomonas intestinalis {h) ; cercomonas intestinalis (i). Ova of the following worms are of rather common occur- rence : ascaris [m), oxyuris (7i),trichocephalus (o),ankylostomum {p), bothriocephalus (q), ta?nia saginata (r), ta?nia solium (.s-). Fig. 3. Intestinal Contents from a Case of Cholera Nostras. — Stained by Gram's method. Derived from a man dead in eighteen hours from an attack of cholera morbus. In the preparation are seen immense numbers of desquamated intestinal cylindric epithelium, in part with distinct nuclei, and among them in pure culture streptococci pyogenes (etiologic relation?). Fig. 4. Intestinal Contents from a Case of Cholera Asiatica. — Stained with magenta-red. Among the masses of epithelial cells there lie in nests imbedded in strands of mucus cholera-bacilli^slender rods more or less comma-shaped. (For cultural demonstration see Epitome, p. 27.) PLATE 12. THE MOST IMPORTANT COLOR=REACTIONS OF THE GASTRIC JUICE. Fig. 1, a and b. When the gastrin juice reddens blue litmus- paper (b) — that is, exhibits an acid reaction — it may contain : free hydrochloric acid, hictic acid, and other organic acids, acid salts. Fig. 2, a and b. If red Congo-paper is stained bluish-black [b] by the gastric juice, only free hydrochloric acid or lactic acid is present. Fig. 3, a and b. If upon evaporation of the gastric juice in a porcelain dish, to which a few drops oi phloroglucin-vanillin solu- tion have been added, a distinct red ring appears, free hydro- chloric acid is present ; if the residue remains yellow, no free hydrochloric acid is present (anacidity). Fig. 4, a and b. If tlue gastric juice contains hydrochloric acid, the violet color of a dilute methyl-violet solution is converted into blue (6). (This test is not absolutely reliable.) Fig. 5, a and b. If the gastric juice contains lactic acid, it will change the violet color of Ujf'elmann's reagent (1% solution of carbolic acid, with 2 dro})s of iron chlorid) into a distinct yellow (6). This test is more reliable if performed with an ethereal extract of tlie gastric juice (lactic acid being soluble in ether). (For details see Epitome, p. 82, et seq.) Tab. 12. Tab. 13. PLATE 13. URINARY SEDIMENTS. The most important macroscopic varieties of urinary sedi- ment are represented in the three conical glasses. Fig. 1. Brick-dust Sediment. — This is formed only of uric acid, and is found in abundance in febrile states, after active bodily exertion, etc. It dissolves on heating. Fig. 2. Yellowish Friable Sediment. — This may consist of phosphates (soluble on addition of acid), of pus-corpuscles, of renal elements, of bacteria (demonstrable microscopically). Fig. 3. Bloody Sediment.— Demonstrable by Heller's blood- test (see Plate 20, Fig. 10), as well as by microscopic examination (renal or vesical hemorrhage, hemoglobinuria). Uric=acid Sediment. Fig. 4. Sodium Urate, in small yellowish granules, frequently adherent to other elements, especially casts, etc. Fig. 5. Uric-acid Crystals, varying in color from yellow to yellowish-brown, in large, not entirely regular plates, in whet- stone, dumb-bell, and comb-like form and arrangement. Both sediments occur only in urine of acid reaction, and are precipitated by addition of acid. They dissolve upon addition of potassium hydroxid. PLATE 14. CRYSTALLINE URINARY SEDIMENTS. Fig. 1. Calcium Oxalate. — This is found in acid urine, espe- cially in the characteristic form of an envelop, as large, but more frequently as quite small, glittering crystals. It is readily soluble in hydrochloric acid, insoluble in acetic acid. It is es- pecially abundant in cases of oxaluria (but quantitative deter- mination is necessary to verify the diagnosis). Fig. 2. Hippuric Acid. — This occurs but seldom in the urine (after ingestion of benzoic acid or after eating bilberries, etc.) and is without significance. Fig. 3. Ammonio-niagnesium Phosphate, Triple Phos- phate. — This appears as large rhombic cokimns (coffin-lid) and constitutes a common sediment in feebly acid or alkaline urine. Fig, 4. Animonium Urate. — This consists in the recent state of tufts or sheaves of fine, densely compressed needles. The needles are gradually so transformed as to appear as plump spheres with isolated needles projecting from the surface (thorn- apple form). Ammonium urate is common in alkaline urine (am m oniacal ferm en tati on) . Fig. 5. Calcium Carbonate. — This occurs in large spheres, often dumb-bell-shaped, or in small granules, which dissolve upon the addition of acetic acid, with effervescence (free CO.J. Fig. 6. Upper portion : Calcium Sulphate ; lower portion : 'Calcium Phosphate (without significance). Tab. 14. Tab. 15. PLATE 15. CRYSTALLINE URINARY SEDIMENTS. Fig. 1. Basic Mag-nesium Phosphate. — The rhombic plates are soluble in acetic acid; the crystals are not common. Fig. 2. Cystin. — The regular six-sided plates are insoluble in acetic acid, but soluble in ammonia. Cystin burns with a bluish -green flame. It occurs in cases of periodic cystinuria and of articular rheumatism (without significance). Fig. 3. Leucin. — The large or small yellow spheres form upon evaporation of the urinary sediment. Leucin occurs always in association with ty rosin. Both are terminal products of albu- minous metabolism (amido-acids). Fig. 4. Tyrosin. — This crystallizes in tufts or sheaves of fine or coarse needles and is soluble in ammonia. Leucin and tyrosin are found in the urine in cases of acute yellow atrophy of the liver, of phosphorus-poisoning, and of some infectious diseases, etc. Fig. 5. Cholesterin. — The fine plates occur but seldom ; among other conditions in association with echinococcus of the kidney, with filaria, with cystitis. Fig. 6. Li the ui)per half of the field is shown an amorphous, finely granular sediment of Earthy Phosphates (calcium and magnesium). This is sokible in acetic acid, without effervescence (as contrasted with calcium carbonate). In the lower half are found the various bacteria of urinary fermentation : budding ■ mgi, bacilli, collections of micrococci. PLATE 16. ORGANIZED URINARY SEDIMENTS. Fig. 1. Squamous Epithelium from Urethra and Blad- der. — The superficial layers of the bladder contain large squamous epithelial cells («), the deeper layers club-shaped cells with tenuous extremities (b). Frequently the cells are covered with bacteria. Fig. 2. Epithelial Cells from the Pelvis of the Kidney. — Epithelial cells with tenuous extremities and large nuclei. They are not to be differentiated with certainty from similar cells derived from the bladder. Fig. 3. Ronal Epithelium. — Characteristic cubic cells with large distinct nuclei, often involved in all stages of fatty degen- eration. They frequently form deposits upon renal tube-casts. Their presence in large numbers is significant of profound disease of the kidney. Fig. 4. Pus-cells. — Small, round cells, with indistinct nuclei, often collected in groups, often filled with fat-granules, often seated upon tube-casts. Fig. 5. Red Blood-corpuscles. — In all stages of contraction or distention if not recent. By dissolution of the hemoglobin there result the so-called shadows with double contour. The red cells often assume a thorn-apple form. Fig. 6. Spermatozoa. — Found not rarely in urinary sedi- ment (with especial fi-e(iuency in cases of spermatorrhea). At a are seen so-called Bottcher crystals; at b prostate granules; at c a testicular cast (from the prostate). Tab. 16. PLATE 18. URINARY SEDIMENTS ATTENDING DISEASES OF THE BLADDER AND THE KIDNEYS. Fig. 1. Sediment from Cystitis. — The very abundant sedi- ment contains : numerous epithelial cells from all layers of the bladder (in accordance with the severity of the aft'ection) ; numerous pus-corpuscles, frequently collected in masses; iso- lated red blood-corpuscles ; many bacteria ; coffin-lid and ammonium-urate crystals. Fig. 2. Sediment from Calculous Pyelitis. — There are present numerous epithelial cells, especially also cells with tenuous extremities, numerous pus-corpuscles (pus-casts), a considerable number of red blood-corpuscles, uric-acid crystals. Fig. 3. Sediment from Acute Hemorrhagic Nephritis. — Abundant sediment of hyaline casts and epithelial tube-casts, white and red blood-corpuscles free and seated upon casts. No fattily degenerated cells. Fig. 4. From the same disease after the lapse of two weeks. The hemorrhagic character has somewhat receded. There are present also granular and waxy casts and fattily degenerated epithelial cells. Fig. 5. Chronic Nephritis. — Large, red, variegated kid- ney. Numerous tube-casts, with leukocytes and renal epithe- lial cells attached, blood-casts, renal epithelial cells (not fattily degenerated), red and white blood-corpuscles. Fig. 6. Chronic Nephritis. — Large, white kidney. Numer- ous fatty granular casts, fattily degenerated epithelial cells (granule-cells), white blood-corpuscles, free fat-drops. Tab. 18. Tab. 19. PLATE 19. Fig. 1. Sediment from Chronic Parenchymatous Neph- ritis. — This consists of casts, some hyaline, some with cells at- tached (renal epithelium), some granular, some waxy ; renal epithelial cells (also fattily degenerated) ; white blood-corpus- cles. Fig. 2. Sediment from True Contracted Kidney. — The amount is scanty (centrifuge) and the deposit contains some hyaline casts, some epithelial casts, some renal epithelial cells, and white blood-corpuscles. Fig. 3. Sediment from Febrile Albuminuria. — There are present in considerable number hyaline tube-casts, some with sodium urate attached, and also white blood-corpuscles. Fig. 4. Sediment from Amyloid Kidney. — This contains (in small amount) hyaline tube-casts, some with leukocytes attached, some renal epithelial cells, and white blood-corpuscles. Fig. 5. Pus from Gonorrhea. — Stained with gentian-violet. Partly enclosed in individual leukocytes, partly free among them, are found the characteristic collections of gonococci (biscuit-form). Fig. 6. Pus from Tuberculous Cystitis. — In addition to individual tubercle-bacilli there is present a dense collection of bacilli. When the bacilli are not numerous the Dahmen pro- cedure is of advantage. (See Epitome, Section II., p. 26.) PLATE 20. THE MOST IMPORTANT COLOR-REACTIONS OF THE URINE. Figs. 1 to 3. Trommer's Test for Sugar. — Potassium hy- droxid and copper sulphate. Fig. 1. Urine free from sugar does not dissolve copper sulphate and assumes a greenish-yellow color on boiling. Fig. 2. Urine containing sugar dissolves the hydrated cupric oxid formed, with the development of a blue color, and precipi- tates on heating hydrated cuprous oxid in yellowish-red clouds (Fig. 3) — reduction-process. Fig. 4. Bismuth -test. — Addition of Nylander's solution (see Epitome, Section III, p. 108). On heating, metallic bis- muth is precipitated in black clouds if sugar be present. Fig. 5. Moore's (Caramel-) Test. — If to urine containing sugar is added one-third the quantity of potassium hj'droxid and heat applied (for three minutes), a chestnut-brown color results. Fig. 6. Ferric-chlorid Reaction in Diabetes. — This con- sists in the development of a Bordeaux-red color when diacetic acid is present in the urine, and is thought to indicate threaten- ing diabetic coma [?]. Fig. 7. Peptone-test. — When albumoses, etc., are present in the urine the addition of potassium hydroxid and solution of copper sulphate in the cold is followed by the development of a violet color. Fig. 8. Indican-test. — If urine and pure hydrochloric acid be mixed in equal parts, and calcium hypochlorit in solution be added drop by drop, any indoxyl present will be oxidized into blue indigo (various intestinal disorders, fermentative processes). The mixture may be further shaken with chloroform or ether. Fig. 9. Test for Biliary Coloring-matter. — On shaking with chloroform the urine from a case of jaundice the fluid assumes a yellow color (bilirubin). Fig. 10, Heller's Blood-test. — On the addition of one-third potassium hydroxid and boiling, the precipitated phosphates carry the blood coloring-matter with them to the bottom in the form of red clouds. Fig. 11. Test for Melanin. — In cases of melanotic sarcoma the urine treated with iron chlorid assumes a deep-black color. Fig. 12. Diazo-reaction. — In cases of typhoid fever, tuber- culosis, etc., the addition of a mixture of sulphaniHc acid and sodium nitrite (see Epitome, p. 113) gives rise to the develop- ment of a bright-red color, apparent also in the froth on shaking. Tab. 20. p ^ ! 1 I 1 i ■ 1 i Tab. 21 PLATE 21. DEMONSTRATION OF SOME MEDICAMENTS IN THE URINE. Fig. 1. Demonstration of Antipyrin in the Urine.— On addition of iron chlorid a brownish-red color results. Fig. 2. Demonstration of Salicylic Acid.— Iron chlorid in- duces an intense violet color. Fig. 3. Demonstration of Bromin (potassium bromid). — Addition of fresh chlorin-water and agitation with chloroform yield a yellow color. Fig. 4. Demonstration of lodin (potassium iodid). — Addition of several drops of fuming nitric acid and agitation with chloro- form yield a reddish-violet color. Contents of Cysts, Abscesses, etc. Fig. 5. Crystals of Uric Acid from a Gouty Nodule. — In a ruptured gouty nodule there were found in large numbers the crystals of uric acid depicted, suggestive of fat-needles, from which they differed, however, in their reactions. Fig. 6. Hematoidin -crystals from an Old Abscess. — Among the profoundly fattily degenerated pus-corpuscles and fat-drops there were found large numbers of hematoidin-crys- tals, partly free, partly included in cells, and partly in the form of red needles. Fig. 7. Echinococcus-fluid (evaporated). — There remain numerous crystals of sodium chlorid. Fig. 8. Echinococcus-fluid (sediment). — There are present numerous echinococcus-hooklets, portions of membrane (ex- hibiting characteristic lamination), and a calcified scolex. PLATE 22. THE MOST IMPORTANT PYOGENIC MICROORQAN= ISMS. Fig. 1. Staphylococcus Pyogenes Albus from an abscess of the parotid gland, complicating a case of typhoid fever (sec- ondary infection). Fig. 2. Streptococcus Pyogenes in the pus from a case of empyema secondary to pneumonia. Fig. 3. Bacterium Coli Commune in pus from a subphrenic abscess. Fig. 4. Proteus Vulgaris, together with other bacteria, from putrid perforation-peritonitis. Fig. 5. Bacillus of Glanders from pus evacuated from a cervical abscess. Fig. 6. Typhoid Bacilli. — Streak-preparation from the spleen of a subject dead of typhoid fever. Tab. 22. NORMAL PROJECTION OF THE VISCERA AND PERCUTORY TOPOGRAPHY. (Plates 23-28.) Tab. 23. PLATE 23. PROJECTION OF THE INTERNAL ORGANS UPON THE ANTERIOR ASPECT OF THE BODY. 1. The Lungs (blue outline). — The course of the pleurae (in- terrupted blue line) is readily visible. The pleurae project beyond the lower margins of the lungs on both sides (greatest separation in the axillary line 10 cm.), on the left also in the region of the heart, thus forming the compleinentary spaces. The Right Lung has three lobes : the upper extends to the upper border of the fourth rib, the middle from this point to the upper border of the sixth rib, with the lower lobe to the outside. The Left Lung has two lobes : the upper extends to the upper border of the sixth rib, with the lower at its outer side. 2. The Heart (red outline). — The base of the heart (above) corresponds with the second intercostal space. The right border (covered by lung) projects beyond the right sternal margin ; the left border lies slightly within the mammillary line. The apex- beat of the heart is situated in the fifth intercostal space on the left. Only a portion of the right ventricle (incisura cardiaca) is in contact with the chest-wall, the remainder being covered by lung. The origin of the aorta is at the base beneath the upper portion of the sternum. To its right is the superior vena cava, to its left the pulmonary artery. Only the margin of the left ventricle and auricle is to be seen from in front ; the remainder faces backward. 3. The Diaphragm (interrupted black line). — It stands at a slightly higher level on the right than on the left, and at a vary- ing level in accordance with respiration. Its highest point in the cadaver is at the level of the attachment of the fourth rib. 4. The Liver (brown outline). — The position of both lobes is self-evident. The gall-bladder is situated at a point where the lower margin of the liver intersects the costal arch (somewhat within the right mammillary line). 5. The Stomach (black outline). — The cardia lies behind the attachment of the left seventh rib, the fundus in the concavity of the left half of the diaphragm, the pylorus, covered by the margin of the liver, somewhat external to the right sternal line at the level of the apex of the ensiform cartilage or a little lower (individual variations). The greater curvature (lower limit of the stomach) lies several centimeters above the umbilicus. 6. The Colon (red outline) is readily seen in position. The cecum is situated in the right iliac fossa. PLATE 24. l5>ERCUT0RY AND AUSCULTATORY TOPOGRAPHY. The most important topographic Hues are : the mammillary Hne (M), tlie sternal Une (St), the parasternal Une (P) between the two, the median Une, and the anterior, middle, and posterior axillary lines. The clear, not tympanitic percussion-note of the lung (blue outline) extends on the right side in the mammillary line to the lower border of the sixth rib. From this point down- ward there is absolute liver-dulness to the costal arch. Below is the clear tympanitic note of the intestine. Upon the left side the pulmonary note in the mammillary line is only indistinctly separable from the tympanitic note of the con- tiguous stomach. The area of absolute cardiac dulness (doubly hatched red lines) begins at the left sternal line, at the lower border of the left fourth rib, extending on the right to the left sternal line and on the left to a point somewhat within the mammillary line. The area of relative cardiac dulness (portions of the heart covered by lung) becomes distinct only at times on deep per- cussion (horizontal red lines). Below, the cardiac dulness merges with the liver-dulness. Traube's semilunar space (interrupted black line) yields a deeply tympanitic note from the stomach. Its boundaries are, above, the lower border of the left lung; on the right, the liver- dulness; below, the costal arch ; on the left (see Plate 28, b), the splenic dulness. The points for auscultation of the heart-sounds are as follows : 1. For the aorta, the right sternal margin in the second inter- costal space (A), where are heard : duk duk duk duk (second sound louder than the first). 2. For the pulmonary artery, the left sternal margin in the second intercostal space (P), where are heard : duk duk duk duk. 3. For the mitral, the fifth intercostal space somewhat within the left mammillary line (M), where are heard : duk duk duk duk (systolic sound the louder). 4. For the tricuspid, insertion of fifth right rib, where are heard : duk duk duk duk. (For the theory of heart-sounds see Epitome, Section IL, Auscultation, p. 33.) Tab. 24. M P St M % ^ Tab. 25. LiihAisi.v. F. ReichhoM , Miinchen PLATE 25. PROJECTION OF THE INTERNAL ORGANS UPON THE POSTERIOR ASPECT OF THE BODY. 1. Lungs (blue outline). — The lower limits of the pleurae (in- terrupted blue line) extend lower upon both sides than the lower limits of the lungs. The upper lobe of each lung extends pos- teriorly to the level of the spinal process of the third dorsal vertebra, and from this point downward extends the lower lobe (to the spinal process of the eleventh dorsal vertebra). The bifurcation of tho trachea takes place between the third and fourth dorsal vertebrae, the right bronchus being somewhat larger than the left. 2. The Esophagus (black outline) pursues a slightly curved course along the spinal column. The . distance from the mouth to the intersection of the left bronchus is 23 cm. (9 in.), to the cardia, 40 cm. — lo| in. — (in adults). 3. The Spleen (brown outline) extends from the ninth to the eleventh rib on the left side. Anteriorly, it does not extend beyond the costo-articular line (from the loft sternoclavicular articulation to the apex of the eleventh rib). It is normally not palpable. 4. The Liver (brown outline) is in this illustration largelj' covered by lung ; on the right side inferiorly and laterally' it is in contact with the body-wall (in the axillary line between the tenth and eleventh ribs). 5. The Kidneys (red outline). — They extend from the twelfth dorsal to the upper border of the third lumbar ver- tebra. The left kidney is somewhat higher than the right. PLATE 26. PERCUTORY TOPOGRAPHY OF THE BACK. The clear, not tympanitic pulmonary percussion-note ex- tends on both sides from above (apex of the lung) downward (blue outline). At the level of the spinal process of the eleventh dorsal vertebra it gives way on the left to the splenic dulness and on the right to the liver-dulness (brown). Below both of these, on either side, is the kidney-dulness (red). The lower limit of the latter is at the level of the upper border of the third lumbar vertebra, the anterior limit about 10 cm. (4 in.) from the vertebral column, forming on the left with the lower limit of the splenic dulness the splenorenal angle of dulness, and on the right with the lower limit of liver-dulness theliepato- renal angle of dulness. On auscultation vesicular breathing is to be heard throughout the whole area of pulmonary reso- nance, only over the right apex with a blowing quality (tracheal breathing). Tab. 26. LitkAnsT y. F ReicWidld. Mvinchen I* Tab. 27. a PLATE 27. PROJECTION OF THE INTERNAL ORGANS UPON THE LATERAL ASPECTS OF THE TRUNK. Fig. a, right; Fig. 6, left side. To be compared with the explanation of Plate 23, which applies also to this. Lung- (blue) with its lobes. Heart (red). Diaphragrn (interrupted black line). Liver (brown). — Its position in the concavity of the right half of the diaphragm is readily appreciated (Fig. a). Stomach (black). — The fundus is situated in the concavity of the left half of the diaphragm (Fig. 6). Spleen (brown). Colon (red). PLATE 28. PERCUTORY TOPOGRAPHY OF THE LATERAL ASPECTS OF THE TRUNK. Fig. a. Right side (compare text of Plate 24). Down to the lower Hmits of the lung (blue) the percussion-note is clear but not tympanitic, meeting the liver-dulness (brown). The lower limit of liver-dulness lies in the axillary line between the tenth and eleventh ribs, follows the costal arch to the mammillary line, and passes upward midway between the ensiform cartilage and the umbilicus. Over the eleventh rib is the hepatoi^enal angle of dulness. Fig. h. Left side. Down to the blue line the pulmonary per- cussion-note is clear but not tympanitic ; here the note (limit not sharply defined) passes into the deeply tympanitic note of Traube's space (dotted black line) ; the posterior limit (brown, splenic dulness) is here to be seen. (Compare explanation of Plate 24.) Area of cardiac percussion-dulness (red) ; hepatic percussion- dulness (brown^ Tab. 28. a EXPLANATION OF SIGNS. n Percussion-phenomena. O Auscultatory phenomena ^M Absolute dulness. (yj Vesicular breathing. ^ Marked dulness. (^ Bronchial breathing. Illl Eelative dulness. Qi) Blowing breathing, j Clear, not tympanitic, f?) Ill-defined breathing. Clear, tympanitic. @ Absent breathing. Dull tympanitic. (?) Murmurs { (cn Crackling rales. C-^ Heart-sounds at the base. ^U Heart-sounds at the apex. (^ A Heart-sounds, second sound accentuated rMes and heart- murmurs. Tab, 29. i^ -s:rc LithAisi.v. F. Reichlwld , Miinchen PLATE 29. CROUPOUS PNEUMONIA OF THE POSTERIOR INFERIOR PORTION OF THE LEFT SIDE. History. — A soldier, 23 yeais old, was seized suddenly on the evening of April 24 at 8.30 o'clock, with a severe chill, vomit- ing, and pain in the left side of the chest. Soon there appeared irritative cough and a sense of heat. The temperature was 39.6° C. (103.3° F.). Objective examination yielded negative results. Treatment.— Mustard-leaf, cool applications, lemonade. On the following morning the temperature was 39.4° C. (102.9° F.), the pulse 108. The subjective symptoms were un- changed. The sputum was viscid and bloody. Physical Examination (see plate) disclosed at the base of the left chest posteriorly a hand's-breadth area of slight dulness, with a distinct tympanitic note. On auscultation slight blow- ing breathing was heard, with numerous inspiratory crepitant rales. Vocal fremitus was not diminished. A leukocytosis of 25,000 existed. Diagnosis. — Croupous pneumonia of the left lower lobe in the stage of congestion. Treatment. — Seltzer water with milk, lemonade with white wine. An injection of morphin (0.01 — gr. ^) was given for the relief of the severe, sharp pain in the side and an ice-bag was applied in this situation. PLATE 30. CROUPOUS PNEUMONIA. The patient whose case is illustrated in Plate 29 developed continued high fever, much thirst, headache, and respiratory difficulty. On the fifth day the temperature was 40.2° C. (104.4° F.), the pulse 118. The sputum was tough and brownish- red in color and contained microscopically many diplococci. Slight labial herpes had been present for two days and there were marked dyspnea and cyanosis. The leukocytosis had reached 42,000. On Percussion over the u^jper portion of the left half of the chest the note was tympanitic (relaxation of the apex of the lung). From the second intercostal space downward there was dulness of progressive intensity, with a tympanitic accompani- ment. The dulness passed over into that of the liver, the lower border of which was not displaced. On auscultation vesicular breathing was audible over the apex of the lung, without adventitious sounds. Over the second and third inter- costal spaces was heard loud bronchial breathing, without adven- titious sounds. Over the fourth and fifth intercostal spaces was heard bronchial breathing, with numerous fine mucous rales (es])('cially on inspiration). Diagnosis. — Croupous pneumonia of the lower half of the left upper lobe, in the stage of hepatization, in the middle in the stage of absorption. Treatment. — Equal parts of powdered digitalis and camphor (0.1 — gr. jss); cold applications. At night an injection of mor- phin (0.015 — gr. \) was given. * Tab. 30. ^ Tab 31 M^^ '-''^^ PLATE 31. EXUDATIVE PLEURISY ON THE LEFT SIDE POS- TERIORLY. History. — A woman, 30 years old, whose father and one sister had died of tuberculosis, had not felt well for some time and complained of irritative cough, pain in the side of the chest, evening chilliness, and loss of appetite. There was no expec- toration. On Examination the temperature was found to be 38.4^ C. (101. rF.), tli<' pulse 110. On Percussion a hand's-breath area of intense dulness, with a sense of marked resistance, was found upon the posterior Sispect of the lower portion of the left lialf of the chest, begin- ning at the level of the sj)inous process of the seventh dorsal vertebra,. On Auscultation feeble blowing breathing was heard, with fine crepitant rales during insj)iration. Vocal fremitus was markedly diminished. Ex[)loratory puncture disclosed the presence of a serous exu- date, which upon inoculation and culture proved sterile. Diagnosis. — Exudative pleurisy (tuberculous?) of the left side. Treatment. — Diuretics. Cold packs. Ems water with milk. Sustaining diet, PLATE 32. EXUDATIVE PLEURISY ON THE LEFT SIDE. The patient whose case is illustrated in Plate 31 exhibited on the following days slowly ascending, irregular fever, profuse sweats (especially at night), increasing respiratory difficulty, and palpitation of the heart. Sleep and appetite were poor. Examination on the seventh day disclosed a temperature of 39.1° C. (102.4° F.), and a pulse "of 126, with considerable dyspnea and slight cyanosis. On Percussion a highly tympanitic, ringing note was elicited at the upper portion of the anterior aspect of the left half of the chest, as low as the second intercostal space. From this point downward there was intense dulness passing into that of the cardiac area (oblique upper limit). Traube's semilunar space exhibited total dulness in its upper half, while in its lower half the note was highly tympanitic and ringing (gastric note). The right limit of absolute cardiac dulness extended beyond the right margin of the sternum. On Auscultation the breath-sounds were wanting over the lower half of the area of dulness and greatly enfeebled over the upper half, while the distant bronchial breathing was attended with a small number of fine, moist rales. The heart-sounds were normal. Diagnosis. — A large pleuritic effusion, filling up Traube's space and displacing the heart. Treatment consisted in puncture. The needle was intro- duced posteriorly (where the exudate reached the level of the spinal process of the fourth dorsal vertebra) in the eighth inter- costal space, and somewhat more than 1000 c.c. (a quart) of serous fluid was evacuated. Tab. 32. m 1-iili.Anst.v. F. Reichhnid , MiiitdiBn . Tab. 33. PLATE 33. EXUDATIVE PLEURISY ON THE RIGHT SIDE. History. — A student, 24 years old, had undertaken a short journey and found that his breathing was interfered with. In other respects he felt quite well [?]. On Examination the temj^erature in the morning was found to be normal (the pulse 96). Dyspnea was apparently not pro- nounced. On Percussion the note was found clear and slightly tym- panitic at the upper portion of the anterior aspect of the right half of the chest. From the upper border of the third rib downward there was profound dulness, with a sense of resist- ance, merging with the area of hepatic percussion-dulness. The left limit of cardiac dulness extended to the mammillary line, where the apex-beat also was visible. The area of hepatic per- cussion-dulness extended two fingers' breadth below the costal margin. Posteriorly dulness on percussion extended from the spinous process of the fifth dorsal vertebra downward, with abolition of vocal fremitus. On Auscultation there was scarcely audible blowing breath- ing over the area of dulness, without adventitious sounds. Diagnosis. — Exudative right-sided pleurisy, with displace- ment of heart and liver. Treatment consisted in puncture, 900 cu. cm. of serous exu- date being evacuated. Recovery was uncomplicated. PLATE 34. HYDROTHORAX. History. — A young man of 18 years had felt ill for two weeks. There had been frequent vomiting, with hiss of appetite, respir- atory difficulty, irritative cough, and swelling of the lower ex- tremities. On Examination the temperature was found normal, the pulse 80. There was edema of the eyelids, the cheeks, and the extremities. On Percussion there was found marked dulness on both sides posteriorly, beginning at the level of the spinal process of the fifth dorsal vertebra, and progressively increasing in in- tensity downward. Inferiorly there was a pronounced sense of resistance. On Auscultation there was found throughout the areas of duhiess on l)oth sides enfeebled vesicular breathing, with num- erous crepitant rales during in.spiration, and diminished vocal fremitus. The urine contained a considerable amount of albumin, etc. Diagnosis. — Acute nephritis, with edema and hydrothorax. Treatment. — Diaphoresis, warm baths, warm packs, with milk-diet and later mild diuretics. Tab. 34. Tab. 35. ) a a® ^" vn) n n PLATE 35. ACUTE DIFFUSE BRONCHITIS. History. — A woman, 35 years old, was seized rather suddenly with chilliness, cough, and hoarseness. The irritative cough grew more and more distressing, while the expectoration was tough and viscid. There were also respiratory difficulty, lan- guor, and loss of appetite. On Examination the temperature was found to be normal, the pulse 80. The sputum was mucopurulent. On Percussion the limits of pulmonary resonance were found normal, and everywhere the note was clear and reso- nant. On Auscultation there were found posteriorly upon both sides, but especially over the lower portions, roughened vesic- ular breathing, with somewhat prolonged expiration, accom- panied by many medium-sized and fine mucous rales, inter- mingled, especially above, with coarse, snoring, and sibilant rales. This snoring was distinctly appreciable to the applied hand. The physical conditions were the same anteriorly, although the rales were less numerous. Diagnosis. — Acute diffuse bronchitis. Treatment. — Alkaline waters, tea, expectorants, codein (0.02 PLATE 36. BRONCHO=PNEUMONIA. History. — In a case of typhoid fever there occurred at the end of the second week, in conjunction with cough that had been present from the beginning, an increase in the respiratory difficulty and in the expectoration, with much irritative cough and catarrhal sputum of a purulent but not bloody character. On Examination the temperature in the evening was found to be 4>-«ri»«Si-r Tab. 39. 0a I PLATE 39. . INCIPIENT PULMONARY TUBERCULOSIS. History. — A girl, 16 years old, with hereditary predisposition (father dead of pulmonary disease), manifested slowly pro- gressive emaciation, cough and expectoration, with pallor and fatigue. On Examination the temperature in the morning was found to be normal, the pulse 108. Chlorosis was marked and venous blowing in the ears was present. The sputum was purulent. The thorax was small, flat and long, and emaciated. The left supraclavicular fossa was somewhat retracted. On Percussion moderately marked impairment of resonance was found over the apex of the left lung. Upon the right the percussion-note was clear. On Auscultation the breathing at the left apex was en- feebled and ill-defined, with prolonged Ijlowing expiration and numerous fine moist rales. The sputum contained tubercle- bacilli. Diag-nosis. — Tuberculosis of the apex of the right lung. Treatment. — Milk-diet, rest in bed, pills of iron and arsenic- later residence in the country. PLATE 40. PROGRESSIVE PULMONARY TUBERCULOSIS. History. — A laborer, 25 years old, presented cough for a year and a half, had been bed-ridden for two months, was greatly emaciated, sweated profusely especially at night, had been almost completely hoarse for three months, and had had diar- rhea for several weeks. Expectoration was copious. During the night there was sudden evacuation of in the neighborhood of eight ounces of bright-red blood. On Examination the temperature was found to be 39.2° C. (102.6° F.), the pulse 116. The sputum consisted of almost pure blood, partly liquid, partly clotted. On Percussion, made wit^i great care, dulness was found upon the anterior aspect of the right chest from above down to the fourth intercostal space. From this point the note was clearer to the upper margin of the seventh rib. In the second intercostal space tympany was marked, and became more pronounced and more distinct when the mouth was opened (Wintrich's change of note). There was also dulness on per- cussion over the apex of the left lung anteriorly. On Auscultation the amphoric bronchial breathing at the upper portion of the anterior asjDCct of the right chest was at times entirely obscured by numerous coarse, moist crackling and sonorous rales; lower down the breathing was loud and bronchial, with medium-sized moist rales. Over the upper portion of the anterior aspect of the left chest the breathing was blowing, with isolated crackling. Laryngoscopic examination disclosed ulcerative destruction of the right vocal band. (See Epitome, Fig. 37.) Diagnosis. — Progressive bilateral pulmonary tuberculosis, with cavity-formation in the right upper lobe ; laryngeal and intestinal tuberculosis ; recent hemoptysis. Treatment. — Ice-bag to the upper portion of the anterior aspect of the right chest, lemonade, pills of ergotin, morphin. Tab. 40. * Tab. 41 D© 1 Uth . AnMt /-: fieichhold. Miinchen . PLATE 41. PNEUMOTHORAX. History. — A tuVjerculous subject, with physical signs of in- volvement of both lungs, was awakened suddenly during the night with severe dyspnea, oppression in breathing, and pains in the chest. On Examination there were found to be marked dyspnea and cyanosis. The temperature was 36.4° C. (97.6° F.). The left half of the thorax was greatly distended and took no part in respiration. On Percussion there was found upon both sides anteriorly clear, not tympanitic, pulmonary resonance, which appeared only upon the left to be strikingly full and deep. Upon the right side the clear note extended to the lower border of the seventh rib (vicarious emphysema) ; upon the left the loud, not (!) tympa- nitic note extended down to Traube's space. The area of cardiac percussion-dulness had disappeared from its normal situation and was found over the lower portion of the sternum. The cardiac apex-beat could not be felt. On Auscultation there was found, upon the right, bronchial breathing, with isolated rA,les, especially at the apex ; below, the breathing was vesicular. Upon the left no breath-sounds at all could be heard. On percussion with the rod-pleximeter a dis- tinct metallic note was audible. There was no succussion- sound, but occasionally metallic tinkling was heard. Diagnosis. — Closed pneumothorax. Treatment. — Injection of morphin. PLATE 42. PYOPNEUMOTHORAX. History. — In a case of pulmonary tuberculosis the right half of the chest became strikingly distended and failed to take part in the dyspneic breathing. There had, however, been no complaint of striking change in the subjective condition during the preceding weeks. On Percussion the note upon the anterior aspect of the right half of the chest was found strikingly loud, but not tympanitic, down to the fourth intercostal space, while below this point there was absolute dulness. The area of hepatic percussion- dulness extended three-fingers' breadth beyond the costal margin. Over the anterior aspect of the upper portion of the left side of the chest there was dictinct dulness on jjercussion, with tym- panitic accompaniment, down to the second intercostal space. From this point downward there was clear, not tympanitic pul- monary resonance. On Auscultation the breath-sounds were wanting over the anterior aspect of the right half of the chest, but abundant metallic tinkling was present, with a metallic note on per- cussion with the rod-pleximeter. \N'hen the patient was shaken at the shoulders loud metallic splashing was heard throughout the whole room (succussion). The level of the lower limit of dulness varied at once with change in the patient's posture, being higher in the erect and lower in the recumbent posture. Exploratory puncture in the fifth intercostal space disclosed the presence of diffluent pus. Diagnosis. — Pyopneumothorax, Treatment. — Operative evacuation of the purulent accumu- lation. Tab. 42, ° © D® i I DIAGRAMMATIC REPRESENTATION OF DISEASES OF THE HEART. (Plates -13-50.) Tab. 43. © PLATE 43. UNCOMPENSATED CARDIAC LESION. History. — A woman, 32 years old, bad had reijcatedly severe attacks of acute articular rheumatism, and had complained for years of resj)iratory difficulty (esi)ecially in ascending stairs) and of cough. Within three weeks these symptoms had become so aggravated that the patient could no longer go about, and, seated in bed, with the windows open, she scarcely got enough air. The lower extremities and the abdomen had been greatly swollen for two weeks and there was loss of ajjpetite, with headache. On Examination there were noted marked cyanosis and dysp- nea (orthopnea). The temperature was normal, and the pulse (see tracing) extremely small, quite irregular, and running (not to be counted). Edema and ascites were present. On Percussion the lungs were found free from noteworthy alteration (bronchitis). The upper limit of cardiac dulness was found at the lower border of the third rib ; the right limit three fingers' breadth to the right of the right sternal margin ; the left in the mammillary line. The ajjex-beat also was in the mammil- lary line, and there was marked epigastric pulsation. The area of hepatic dulness extended beyond the costal margin (cyanotic liver). The external jugular vein exhibited marked pulsation. On Auscultation there were heard over all of the cardiac ori- fices two not very loud blowing murmurs (ch ch ch ch). The action of the heart was greatly accelerated and irregular, and following every four or five quick beats there were one or two slower ones. Diagnosis. — Valvular lesion of the heart in the stage of rup- tured compensation (precise diagnosis at present not possible with certainty; mitral stenosis suspected). Dilatation of the right ventricle. Treatment. — Powdered digitalis leaves 0.15 (gr. ijss) every two hours. Pulsc-truciiig of uncompensated mitral stenosis. PLATE 44. COMPENSATED MITRAL STENOSIS. History. — The case represented in Plate 43, exhibited on the fourth day, after taking 2.5 grams (gr. xl) of digitahs the fol- lowing phenomena : On Examination the temperature was found to be normal, the pulse (see tracing) 96, and almost perfectly regular and quite vigorous, though small. The edema had disappeared. Even in the recumbent posture quiet respiration was possible. On Percussion the upper limit of cardiac dulness was found at the lower border of the fourth rib; the right limit slightly to the right of the median line ; the left limit somewhat within the mammillary line. The area of hepatic dulness was again normal. On Auscultation over the mitral orifice there was heard a presystolic (also diastolic!) short, rolling murmur preceding the first sound, with a more distinct second sound (rduk — duk rduk — duk) ; over the tricuspid orifice the sounds were clear (duk duk duk) ; over the aorta, duk duk duk duk ; over the pulmonary artery, duk duk (!) duk duk (!) ; the pulmonary second sound was markedly accentuated. Diagnosis. — Stenosis of the mitral orifice ; hypertrophy of the right ventricle. (For the theory of valvular lesions, see Epitome, Section III, circulatory apparatus p. 55.) Tracing from the same case as Plate 43, after the action of digitaU§. Tab. 44. ^: 9 Lith.Anst E Retchhold, Miinchen. Tab. 45. LUh . Anst /'.' Hfiichhold, Mii/tdwi . PLATE 45. MITRAL INSUFFICIENCY. On Percussion the upper limit of cardiac dulness was found at the lower border of the third rib ; the right limit at the left mar- gin of the sternum ; the left limit in the left mammillary line. The cardiac apex-beat was situated in the left mammillary line in the fifth intercostal space, and could be felt to heave vigorously. On Auscultation there was heard over the mitral orifice a loud blowing systolic murmur in addition to the first sound, while the second sound was clear (duch duk duch duk) ; over the tricuspid the sounds were clear (duk duk) ; over the aorta : duk duk ; over the pulmonary artery : duk duk. The pulse was regular, strong, and fairly tense. Diagnosis. — Insufficiency of the mitral valves and hyper- trophy of the left ventricle. PLATE 46. AORTIC INSUFFICIENCY. On Percussion the upper limit of cardiac clulness was found at the lower border of the third rib ; the right limit at the left margin of the sternum ; the left limit, two-fingers' breadth ex- ternal to the left mammillary line. The apex-beat was situated in the fifth and sixth intercostal spaces, tw;ji-fingers' breadth ex- ternal to the mammillDry lirxC. It was strongly heaving and exr tended, on both inspection and palpation. On Auscultation over the aorta the first sound was clear, with a loud rushing diastolic murmur (duk duch duk duch) (audible in the typical situation, and better still at the left mar- gin of th: sternum in the third intercostal space) ; over the pul- monary artery, duk duk duk duk ; over the mitral orifice (a soft systolic murmur), duch duk duch. duk; over the tricus- pid, duk duk duk duk. The pulse was running (celer), large, and extremely tense. The radial artery was musical. Double sounds were heard over the femoral artery, and double murmurs upon strong pressure. Capillary pulsation was distinct at the finger-nails. Diagnosis. — Insufficiency of the aortic valves. Tab. 46. (yh H I ! Tab. 47. PLATE 47. TRICUSPID INSUFFICIENCY. This cardiac lesion occurs usually in conjunction with other valvular lesions (mitral stenosis, etc.) when compensation be- comes deranged. It is here for didactic reasons represented as existing alone. On Percussion the upper limit of cardiac dulness was found at the upper border of the third rib ; the right limit 3 cm. (1 in.) to the right of the right margin of the sternum, especially in the third intercostal space (dilatation of the auricle) ; the left limit somewhat within the mammillary line. The apex-beat was in the mammillary line in the fifth intercostal space. On Auscultation, over the tricuspid orifice was heard a loud, blowing sj'stolic murmur, with a faint first sound, and a clear but faint second sound (duch duk duch duk). When the first sound became entirely lost the murmur sounded ch duk ch duk. There were, beside, marked epigastric pulsa- tion and a positive systolic venous pulse (jugular vein, hepatic vein). Diagnosis. — Insufficiency of the tricuspid valves. PLATE 48. IDIOPATHIC HYPERTROPHY OF THE HEART. History. — A beer-brewer, 46 years old, had complained for several months of increasing respiratory difficulty, cough, sleep- lessness, fulness in the head, and attacks of vertigo. On Examination there was found a marked degree of obesity, with a deeply reddened face, watery eyes, and tremulous tongue. There was also a slight degree of pulmonary emphysema. On Percussion in the cardiac area, with the patient in the recumbent posture, no distinct result was obtained. The limits of cardiac dulness (upon deep percussion) appeared extended in all directions, and it became more distinct when the patient inclined the body forward. On Auscultation clear but not very loud sounds were heard at all of the cardiac orifices. The pulmonary second sound was accentuated. The apex-beat was in the fifth intercostal space one-finger's breadth external to the mammillary line (most important symptom). Epigastric pulsation was pro- nounced. The urine was free from albumin. Diagnosis. — Idiopathic hypertrophy of the heart, with dila- tation of both ventricles. Treatment. — Digitalis; restriction of the amount of fluids (alcoholics). Tab. 48. LitLSnsi.v. F. ReicWiold, ^liinchen Tab. 49. # Litli.AnA -1- Tab. 65. Lith.Anst.v. F. Reiclihold, Miinthen PLATE 65. PERITYPHLITIS. History. — A man, 21 years old, was suddenly seized with severe pain in the abdomen, together with vomiting. The bowels had been perfectly regular. Every movement was attended with intense pain, especially upon the right side. During the night there occurred repeated vomiting. On Examination the temperature was found to be 38.8° C. (101.8° F.), the pulse 104, and strong. The abdomen was greatly distended; the patient twitched upon slightest touch. On ]Dal- pation a firmly resistant area, about a hand's breadth in extent, w^as found in the right iliac fossa, limited to the left and above by a sharp border, over w^hich (on gentle percussion) the note < was found to be dull. Vomiting recurred frequently. Other organs presented no abnormality. The urine contained a small quantity of albumin and yielded the reaction for in- dican. Diagnosis. — Perityphlitis from perforation of the vermiform appendix. Treatment. — Ice-bag, tincture of opium (twenty drops every two hours), small amounts of milk and broth. Course. — During the following days there was slight fever and the pulse was good. On the fourth day there was an exac- erbation of the fever, with vomiting. The resistant area had enlarged in an upward direction. Exploratory puncture dis- closed the presence of disorganized pus. Treatment. — Operative evacuation of the abscess, resection of the perforated vermiform appendix. PLATE 66. TUBERCULOUS PERITONITIS. History. — A man, 66 years old, had suffered for eight weeks from loss of appetite, with at times frequent vomiting and diarrhea, as well as persistent abdominal pain. During this time he had emaciated greatly, and for two weeks had been compelled to remain abed. There had for a long time been some cough. Upon Examination there was found a high degree of emaciation, with marked edema of the lower extremities. The temperature was 36.8° C. (98.2° F.), the pulse 126, very small and irregular. Over the apex of the right lung the percussion- note was distinctly impaired, with enfeebled breathing and coarse rales. The diaphragm was elevated. The abdomen was greatly distended (liaving a circumfer- ence of 104 cm. (41 in.) at the level of the umbilicus). The percussion-note was tympanitic only in the epigastrium ; else- where it was dull. A distinct sense of fluctuation could be detected. The sputum contained tubercle-bacilli. Exploratory puncture disclosed the presence of a hemorrhagic exudate. Diagnosis. — Tuberculous peritonitis. Treatment. — Celiotomy was waived on account of the debil- itated state of the patient. On tapping eight quarts of deeply blood-stained fluid were evacuated. Following this procedure thick, nodular tumor-masses of a hand's breadth extent were palpable at the level of the umbil- icus, and were somewhat movable (tuberculosis of the perito- neum). Tab. 66. lith^si v. F. ReicWiold , Miinchen . Tab. 67. **«!5Sa^aEg£Sij:w»^S;liVJ^ PLATE 67. PERFORATIVE PERITONITIS. History. — A man, 27 years old, had suffered for a number of years from symptoms of chronic gastric ulceration (vomiting, on one occasion hemoptysis, acid eructations, gastric pain). After a mid-day meal he was suddenly seized with severe ab- dominal pain, with loss of consciousness and in the course of the following hours persistent vomiting and pain. On Examination on the following day (immediate celiot- omy having been declined) the patient was found to be in a state of collapse, the nose pointed, the face pale, and perspiration upon the brow. There occurred repeated biUous vomiting, with hiccough. The temperature was 36.5° C. (97.7° F.), the pulse very small — 146. The abdomen was greatly distended, like a balloon, and all manipulation (in spite of the administration of opium) caused exquisite pain. In the dependent portions of the body there was a hand's breadth area of dulness on percussion. The he- patic percussion-dulness w^as lost and replaced by a loud, tympanitic note. On agitation a distinct metallic splashing sound was eh cited. When the patient lay upon the left side the splenic dulness was replaced by a loud, t3anpanitic note (accumulation of air). Diag-nosis. — Perforation of a gastric ulcer, with rupture into the peritoneal cavity, entrance of air, and purulent perito- nitis. Treatment. — Celiotomy now entirely hopeless; morphin, camphor. Death after three hours. PLATE 68. SARCOMA OF THE RIGHT KIDNEY. History. — A child, 4 years old, had been losing flesh rapidly for two months, at first without appreciable cause. It was rest- less at night and complained of abdominal pain. The abdomen was always greatly distended. On one occasion the urine was found to be deeply bloody. On Examination the child was found to be greatly emaciated and anemic. The temperature was normal, the pulse 144. The lungs exhibited no abnormality. The abdomen was protuberant, particularly upon the right side. In this situation could be felt a firm, smooth tumor extending from the lumbar region be- neath the costal arch and forward to the umbilicus. This mass was not movable with respiration. The area of hepatic per- cussion-dulness merged laterally with that of the tumor, not exceeding its normal limits toward the middle line, where the liver could not be felt to be enlarged. After administration of castor-oil and resulting copious evacu- ation of the bowels there appeared (Fig. b) from above down- w'ard within the previous area of absolute dulness a small band- like zone of tympanitic percussion (ascending colon). There was hematuria, and vermicular blood-clots were expelled with the urine. Diagnosis. — Sarcoma of the right kidney. Treatment. — Attempt at extirpation. Tab. 68. a SECTION I. EXAMINATION OF THE PATIENT. In order to be of service to a patient it is essential to recognize the ailment from which he suffers, and to this end systematic clinical investigation is necessary. This is divided into two parts : 1 . The histoiyj the previous state, as elicited by inquiry. 2. The present state, as determined by systematic ex- amination. Upon both of these is based the diagnosis. The history includes : a. The antecedents and the previous life of the patient from the medical point of view ; h. The origin and the development of the existing morbid state. The history is obtained by carefully directed inquiry on the part of the physician. Before taking up the history in detail it is well to attempt to gain by a few questions an approximate idea as to the probable seat of the disease. Important conclusions as to the nature of the existing disorder may sometimes be reached from a knowledge of certain historic data, and these are herewith mentioned : 1. Personal. — a. Age. — Some diseases occur with preference at certain periods of life : Diseases of infancy (diarrhea, intestinal catarrh, dis- orders of dentition, rachitis, eclampsia) ; Diseases of childhood (acute exanthemata, measles, scarlet fever, chicken-pox, R5theln, whooping-cough, diphtheria, scrofulosis, eczema, certain nervous diseases) ; Diseases of puberty (chlorosis, tuberculosis, nervous disorders) ; 2 EXAMINATION OF THE PATIENT. Diseases of adult life (venereal diseases, pneumonia, metabolic disturbances, gout, diabetes, obesity ; alcohol- ism) ; Diseases of advanced life (carcinoma, arteriosclerosis, deforming arthritis, emphysema, etc.). 6. Sex. — The disposition to many diseases as related to sex is variable : Males (emphysema, hypertrophy of the heart, alcohol- ism, injuries and their sequelae, occupation-diseases, etc.). Females (menstrual disorders, puerperal disorders and their sequelae, chlorosis, constipation, hysteria). c. Occupation. — See below. 2. Heredity. — Hereditary predisposition is especially of significance with relation to the following diseases : tuberculosis (of lungs, glands, bones, joints), syphilis, nervous diseases (neurasthenia, hereditary system-degen- erations, mental disorders), diabetes, gout, neoplasms (carcinoma, sarcoma), hemophilia, etc. 3. Social Relations. — Careful inquiry as to the mode of life is of importance (luxurious habits, deficient or insufficient nutrition). Alcoholic and venereal excesses, excessive use of tobacco, addiction to morphin and to cocain should be investigated. Notj:. — It is not sufficient to ask how much beer, wine, etc., is being taken at the time of examination, but liow much had been taken pre- viously. In this way reliable information will be gained. It is of the utmost importance to make inquiry as to the occupation (as to whether there is sufficient time for recrea- tion, Avhether the work is regular or irregular, whether attended with mental or physical strain — as at school). Some pursuits occasion direct injury to health : pul- monary diseases (bronchitis, emphysema) in millers, bakers, stone-masons, workers in factories, or sawmills, or iron-foundries. Intoxications with lead, zinc, arsenic, and mercury occur among plasterers, painters, composi- tors, and workers in mills. Beer-brewers suffi^r from diseases of heart, kidneys, nervous system, and liver in THE HISTORY. 3 consequence of the excessive ingestion of beer (from six- teen to twenty quarts a day). The situation of dwelling-houses is of significance in relation to some endemic diseases (malaria, articular rheumatism), as well as the contemporaneous occurrence of infectious disease in the neighborhood of a patient suffering from epidemic disease, such as typhoid fever, meningitis, diphtheria, scarlet fever, small-pox, cholera, etc. fso I E M IF V YT m m K X 11 ur i60 m 80 ttO 20 A A / ^ ; 'a' """--. ^ •' 1 \ ^ \ "»> / ►, / \ /A.. i •. ,.-• fi '•, 1 \ / S' } ^ 1 '. ■t\. 1 / I f \ \ -^ ^ / K^ K __^^ s . ^ ■s,/ i N v^ 1 — ' .^ • L .. N^ ---4--J 1 , Tuberculosis- - Cholerine - - - Cholera infantum Fig. 1.— Mortality-curve of a large city according to months ; shows increase in the mortality from tuberculosis during May, and from cholerine (cholera morbus) in August. Some diseases are related to climate and season of the year (dysentery, cholera morbus, etc.). It is important, further, to make inquiry with regard to the previous state of health, and to diseases already recovered from. With regard to the first, especial im- portance attaches to the periods of infancy and childhood and puberty (advent of menstruation, etc.) ; and whether or not the constitutional state is a feeble or a robust one. Further, attention is directed to the appearance, the com- plexion, the mental attitude. Among previous diseases the infectious diseases are of 4 EXAMINATION OF THE PATIENT. especial importance, on account of the possible occurrence of sequelffi ; thus diphtheria (sequelse : nephritis, heart- disease, paralysis), scarlet fever (nephritis, suppuration of the middle ear), acute articular rheumatism (heart-disease, chorea), whooping-cough (tuberculosis). Tuberculous suppuration (of glands, bones, and joints) and syphilitic exanthemata are of the greatest significance. Further, previously frequently repeated attacks of colic (gall-stones, renal calculi), hematemesis (gastric ulcer), hemoptysis (diseases of lungs and heart), frequent catar- rhal states (tuberculosis, emphysema), pleurisy (tubercu- losis). Human beings are susceptible to repeated attacks of pneumonia, angina, polyarthritis, erysipelas. As a rule, they suffer from one attack only of typhoid fever, scarlet fever, measles, etc. (Recovery from infection confers immunity.) Concerning the origin of the diseases named, it is im- portant to inquire into the causes assigned by the patient as operative (traumatism, cold, strain, errors in diet, etc.). Then the mode of onset is to be accurately determined : whether acute (especially infectious diseases, such as pneumonia, malaria, scarlet fever, erysipelas) ; subacute (typhoid fever, whooping-cough) ; or chronic (tubercu- losis). Inquiry is next made as to the further course of the disease, and concerning especially prominent symptoms, and finally a mode of treatment is decided upon. To these ends investigation is first directed to the following train of constitutional symptoms : Bodily Vigor. — Can the patient yet walk, and how far ; or is he bed-ridden, and for how long. A pronounced sense of weakness accompanies progres- sive wasting diseases, such as carcinoma, pulmonary tuber- culosis, chronic ne})hritis, leukemia, severe diabetes ; also febrile states and anemia, chlorosis, neurasthenia, and chronic diseases of the gastro-intestinal tract. Emaciation. — Former body-weight ; appearance ; com- THE HISTORY. 5 plexiou (cachectic appearance associated with carci- noma). Appetite. — Impaired in febrile disorders, gastric catarrh, carcinoma, etc. ; markedly increased in diabetes and dur- ing convalescence (typhoid). Thirst. — Increased in febrile states, after sweating and diarrhea, in diabetes. Sleep. — Poor in febrile states, in association with pain, with nervous unrest and overactivity ; great desire for sleep in chlorosis, uremia, and neurasthenia. Febrile Symptoms. — Feeling of heat or of chilliness, thirst, headache. Chill attends malaria, pyemia, onset of pneumonia, ulcerative endocarditis, etc. Tendency to sweating. Night-sweats attend pulmon- ary tuberculosis. Especial inquiry is then directed to all the various parts of the body, beginning with the head. Head. — Pain, vertigo (attending nervous disorders, anemia, ocular disorders, diseases of the ear), derange- ments of the special senses, coryza, difficulty in degluti- tion, etc. Throat. — Voice (hoarseness attending catarrh, paraly- sis, ulceration of the vocal bands). Chest. — Pain in the side (pleuritic ?) ; cough (catarrh of the air-passages, pneumonia, dry pleurisy, tuberculosis, circulatory disorders — cardiac lesions) ; breathing (embar- rassed in all profound disorders of the respiratory and circulatory organs, and in conjunction with severe anemia) ; expectoration (amount, color) ; palpitation of the heart (nervous, in febrile states, in conjunction with diseases of the heart and with exophthalmic goiter). Abdomen. — Pain, vomiting (acute poisoning, gastritis, gastric ulcer [blood], carcinoma [chocolate-brown], dila- tation of the stomach [large amounts], nervous dyspepsia, stenosis of the esophagus [immediately after ingestion of food], obstruction of the bowel [fecal vomiting, tor- mina], uremia [toxic], initial symptom of many infectious 6 EXAMINATION OF THE PATIENT. diseases, cerebral diseases [tumor, hydrocephalus, menin- gitis]) ; acid eructation (heart-burn) attends hyperacidity, gastric ulcer, neurasthenia, lactic-acid fermentation (gas- tric catarrh, carcinoma). The Bowels. — Constipation or diarrhea (intestinal catarrh, cholera, intestinal tuberculosis, etc.). Flatulence (intestinal atony, corpulence, abnormal fer- mentative processes in stomach or bowel). Micturition (pain, amount). Extremities. — Pain, swelling (venous thrombosis, gen- eral circulatory disorders, nephritis, cachexia). It will be necessary to inquire in regard to all of these points only in exceptional cases. The proper selection will occasion the experienced physician no difficulty. The beginner and the student, however, should adhere to the schematic arrangement. Further, in accordance with the nature of the case, special manifestations will at times require more detailed study. The statements of patients must generally be received with a certain amount of reserve, especially voluntary expressions of opinion and diagnoses of previous disease. It is best to be guided by the existing symptoms. Ex- aggerations are, as a rule, readily appreciated. THE PRESENT STATE. This refers to both general and special conditions, and includes all that can be learned by objective examina- tion of the patient at the time. A. General Manifestations. In this place will be considered those manifestations that are appreciable at a glance, without further investi- gation. 1. The state of consciousness and of intelligence (whether the sensorium be clear or clouded). Apathy, sopor, or coma may attend severe febrile diseases (typhoid, meningitis, septicemia, etc.), cerebral diseases, intoxica- THE PRESENT STATE. 7 tions ; delirium and hallucinations also may be present. Is there marked stupidity, or even idiocy ? Speech and writing : disorders of articulation, dysarthria ; aphasia (motor [ataxic], sensory, agraphia, alexia, optic [mind- blindness]). Memory. 2. Height and Bodily Development (proportions). 3. Nutritive State. — Emaciation attends wasting diseases : carcinoma, pulmonary tuberculosis, leukemia ; severe diseases of the stomach and the esophagus. The skin under these conditions can be raised in large, loose folds. 4. Bodily Vigor. — Estimated in ambulant patients by the gait, whether debilitated, bent, or difficult and drag- ging ; in bed-patients by the posture, whether the normal active position, or passive sinking back into the pillows. 5. Posture. — In addition to active and passive attitude in bed, attention is to be directed to certain forced posi- tions, such as a constant sitting posture (orthopnea), at- tending shortness of breath, lying on the side (in con- junction with unilateral diseases of lungs and pleurae). In febrile and delirious states, etc., there may be, among other things, constant throwing of the body to and fro (jactitation). 6. Constitution and Habitus. — Tuberculous habi- tus : thin, emaciated neck, small chest, pallid complexion. Apoplectic habitus : reddened face, thick neck, barrel- shaped chest, obesity. 7. Skeleton (slender or robust). — Deformities of the thorax : kyphosis, scoliosis, lordosis — posterior, lateral, or anterior curvature of the spine ; kyphoscoliosis is most frequent. 8. Musculature (firm, hard, or flabby). — Condition of the muscles (noteworthy atrophy of the extremities, of the muscles of the chest, etc.). 9. The Skin and the Subcutaneous Connective Tissue. a. Color. — Abnormal pallor (anemia, internal hemor- rhage) ; redness (fever, excitement, apoplexy) ; yellowish 8 EXAMINATION OF THE PATIENT or brownish discoloration (jaundice from occlusion of the biliary passages and in conjunction with septic processes) ; bronzing (Addison's disease) ; grayish discoloration (argy- ria, deposit of silver) ; cyanosis (bluish-red discoloration of lips, cheeks, nails, etc.), accompanying insufficient ab- sorption of oxygen into the blood, with simultaneous retention of carbon dioxid (circulatory disorders, pul- monary disease). h. Exanthemata. — A number of cutaneous eruptions are of great diagnostic significance. Measles : coarse papules in crescentic arrangement, sometimes confluent ; scarlet fever : at first punctate, later confluent ; the roseola of typhoid fever : small, round red spots on the trunk ; herjDes attending pneu- monia, malaria, cerebrospinal meningitis : groups of vesicles on the lips, nose, etc. (wanting in typhoid fever and tuberculous meningitis) ; miliaria (sweating-sickness) : small, clear vesicles, without significance ; drug-exan- thems : erythema following the use of antipyrin, quinin, etc., acne following the use of iodids and bromids ; chick- en-pox : papules transformed into vesicles ; small-pox : papules progressively increasing in size, changing into vesicles, and these into pustules ; various syphilitic cuta- neous eruptions (macular, papular, pustular syphilid) ; the effects of scratching (scabies, pruritus, icterus, etc.). c. Abnormal Sweating-, especially at the period of defervescence in pneumonia (critical sweat), malaria, sep- ticemia, etc. ; night-sweats (tuberculosis) ; cold sweats (colic, death-agony, etc.). d. Hemorrhages (petechise) — purpura hsemorrhagica, scorbutus, septicemia, severe scarlet fever, etc. e. Cicatrices. — Of especial importance are those sec- ondary to syphilis, the glandular cicatrices of the neck (tuberculosis), the deeply retracted cicatrices of previous caries, and those of small-pox. /. Edema. — Swelling of the skin through collection of fluid in the subcutaneous connective tissue occurs in con- junction with inflammations (painful, redness of the skin), THE PRESENT STATE. 9 with acute nephritis (face first aifected) ; with venous stasis, either local (phlebitis, thrombosis), or general (de- rangements of cardiac compensation, cachexia, marasmus, hydremic edema) ; finally angioneurotic edema. g. Cutaneous Emphysema (entrance of air into the subcutaneous connective tissue : swelling, crepitation on palpation) follows external injuries, and injuries and ulceration of the lungs (through the mediastinum), the larynx, the intestines. io. The Bodily Temperature. — Normal, between 36.5° and 37.5° C. _(97°-99.5° F.j. Lower temperatures attend collapse, during critical defervescence ; higher tem- peratures, fever, also heatstroke and sunstroke. Febrile Symptoms. — Reddened face, dry lips, trem- ulous tongue, hot, burning skin, marked thirst, delirium, sweating, chill, accelerated pulse. The following distinctions are made : Suhfehrile temperature (from 37.5° to 38° C— 99.5°- 100.4° F.). mght fever (from 38° to 38.5° C— 100.4°-101.3° F.). Moderate fever (from 38.5° to 39.5° C— 101.3°-103.1° F.). High fever (up to 40.5° C— 104.9° F.). Hyperpyretic temperature (above 41.5° C. — 106.7° F.). After determining the existence of fever, inquiry is made into its mode of origin. It may set in abruptly with a chill (acute disease), or its onset may be insidious (tuberculosis). Next the type of fever is to be established : Continued fever (the temperature pursues approximately the same level, at most varying 1° during the day), observed especially in typhoid fever. Remittent fever (daily variations of more than 1°). The remission generally takes place in the morning ; an inverse relation is sometimes noted, especially in tuber- culosis (hectic fever). Intermittent fever (afebrile intervals of varying dura- tion), noted especially in pyemia and malaria. (See charts.) 10 EXAMINATION OF THE PATIENT. The course of the fever is best studied by means of appropriate charts. In many infectious diseases the course of the fever is typical, the initial stage (rise of i 2 3 Jf S 6 7 6 ^ " \ ~"C t fBO itO 3 i J X - T 3 E r 4 llfO 3ff _ L _ : t 1Z0 38 _: . i too 37 ^^: :^1: ..-h.. .11'' H 1 1 7 '' 2i: : i t^^^^^ \ Vi ^l Z i C- T ^ T 80 36 Fig. 2.— Continued fever ; crisis on the seventh day of an attack of croupous pneumonia. Fig. 4.— Intermittent malarial fever (tertian type). /GO R, obtuse angle (emphysema) ; < R, acute angle (paralytic thorax). Respiration. — Symmetric in time ; or one side lags behind the other (tuberculosis, pleurisy, pneumonia). Type. — Costal (women), costo-abdominal (men) ; easy, or requiring eifort, accelerated, dyspneic. Dyspnea. — In- spiratory in conjunction with stenosis of the upper air- passages ; especially expiratory in connection with asthma, emphysema, bronchitis ; mixed in connection with infil- tration of the lungs, compression, circulatory disorders, fever, painful breathing, meteorism of high degree, paraly- sis of the diaphragm ; inspiratory retraction of the thorax (especially in connection with the dyspnea of children). Cheyne-Stokes breathing: gradual resumption after a pause. Biofs breathing: with intervals of varying, length. Pulsation. — Apex-beat (see aneurismal pulsation — either side of the upper portion of the sternum) ; event- 14 EXAMINATION OF THE PATIENT. ually together with protrusion in connection with aneur- ism of the aorta. Lungs. — a. Percussion. — Comparison of the qualities of the note on both sides, anteriorly and posteriorly ; de- termination of the limits of the lungs and their motility. Statement of areas of abnormal dulness, of areas of abnormal tympanitic resonance ; precise determination of the limits of such areas (with relation to ribs and spinous processes). h. Auscultation. — Comparison of the breath-sounds on both sides with regard to character, relation of expiration and inspiration, intensity, and adventitious sounds. Auscultation of the voice. Studv of vocal resonance and of succussion-sounds. c. Eventual exploratory puncture of the pleural cavity. Heart. — Inspection and Palpation. — Abnormal prom- inences (precordial projection) ; situation of the apex-beat (within or without the mammillary line) ; estimated vigor and resistance of the heart-beat. The presence of epigastric pulsation, visible or only palpable. Percussion. — Determination of the upper right and left limits. Absolute and relative dulness. Auscultation of the Four Orifices. — Observation as to vigor, purity, rhythm, and accentuation of the sounds. Murmurs according to character, localization, relation to systole and diastole. Pulse. — Accurate deitermi nation of frequency, rhythm, size, fulness, tension, celerity. Comparison of the pulse upon both sides. Vessels. — Arteriosclerotic changes (calcareous deposits, tortuosity of the arteries), abnormal pulsation, capillary pulse. Sounds and murmurs over the large and small arteries, venous hum. 4. Abdomen. Form. — Distended (gas, ascites, tumors, peritonitis), retracted (meningitis). THE PRESENT STATE. 15 Symmetry (when tumors are present, usually asym- metric). Palpation. — Tension of the abdominal walls (in con- junction with pain, peritonitis, and meteorism) ; super- ficies, limits, and mobility of tumors possibly present, of the liver ; palpation of the spleen and of the usual sites of hernia. Generation of splashing sounds (dilatation of the stomach), detection of fluctuation (ascites). Measurement of the abdomen at the level of the umbilicus. Percussion, — a.. Of the liver; determination of the lower border ; situation and extent of the gall-bladder. h. Of the spleen, upper and lower anterior boundaries. c. Of the kidneys. d. Of tumors possibly present, of a distended bladder, etc. e. Of ascites possibly present ; accurate determination of upper limit ; alterations w^ith change in posture. Exploratory puncture in the case of cysts, ascites, perityphlitis. Probing the stomach, possibly distention, irrigation, etc. Examination of the rectum, of the genito-urinary organs. 5. The Bxtremities. The lymphatic glands of the axillary, inguinal, and other regions. Alterations in joints and bones. Drum-stick (clubbed) fingers (chronic disease of the lungs, congenital disease of the heart). State of motility, of sensibility, of the reflexes, coor- dination, gait. 6. The Sputum. As regards amount, separation into layers on standing, color, admixtures. Microscopy (unstained and stained preparations) ; bacteria. It may be necessary to examine microscopically and chemically also the nasal mucus, the saliva, and gingival deposits. 16 EXAMINATION OF THE PATIENT. 7. The Gastric Contents. — (Vomited matters or those obtained by siphonage.) Admixture with blood. Microscopy and chemistry (determination of acidity). 8. The Feces (admixture of blood, of pus, of mucus). Microscopy. Parasites. 9. The Urine. — Amount, specific gravity, color, chem- istry (albumin, sugar, etc.), microscopy. 10. Blood. — Microscopy. Examination of fresh and stained preparations. Enumeration. 11. l^xamination of Bye, Bar, I^arynx, and Nares. Sphygmography and other scientific precise methods of investigation. SUBJECTIVE SYMPTOMS. Pain of all kinds is usually the first manifestation mentioned by patients seeking medical advice. As sus- picion will, in consequence, thus be directed in certain directions, some brief consideration will be given to this symptom. The diagnostic significance of subjective symp- toms is naturally very variable. Under certain circum- stances they may lead at once to diagnostic conclusions (for instance, certain forms of colicky pain), and even apparently slight symptoms should never be ignored as entirely without significance. It is important to inquire into the character of the pain. This may be : inflammatory (throbbing), nervous (shooting), rheumatic (fugacious, wandering). Syphilitic pains occur especially at night, and are of the character of boring bone-pains. Colicky ])ain is spasmodic and very intense. The pain may occur paroxysmally (nervous pain), and recur period- ically (neuralgia). Intoxications of all sorts (alcohol, nicotin, morphin, etc.), as well as auto-intoxications (nephritis, gout, dia- betes, gastro-intestinal disorders), are attended with attacks of pain with especial frequency. The localization of the pain is of considerable signifi- SUBJECTIVE SYMPTOMS. 17 cance. Headache is an important symptom of tumor of the brain (in association with papillitis and vomiting)^ of meningitis (with rigidity of the neck, fever, etc.), of neu- ralgia (radiating in the area of distribution of various nerve-branches, as^ for instance, the supraorbital, the occipitalis major, etc.), of neurasthenia (habitual head- ache, heredity), migraine (unilateral, vomiting, flittering scotoma), of anemia and chlorosis (toxic ?), of infectious diseases (especially typhoid fever, beginning tuberculosis, etc.), of intoxications (uremia attending nephritis, nico- tin-poisoning, etc.), of diseases of the eye (muscular in- sufficiencies, iritis, etc.), of the ear (catarrh of the middle ear, etc.), of the nose and its accessory cavities (catarrh, empyema, polyps, tumors). When jjain in the face is present there are to be thought of neuralgia (infraorbital, inframaxillary, alveolar), dis- eases of the nasal cavities, and diseases of the teeth. Difficulty in deglutition suggests inflammatory conditions of the tonsils, of the palate, abscess-formation, ulcerative processes in the pharynx (syphilis) or the epiglottis (tuberculosis), diseases of the esophagus (stricture). The most frequent variety of jpain involving the trunk is muscular pain (rheumatism, the strain of coughing, in- volving the diaphragm and the muscles of neck, chest, and abdomen). Neuralgia (intercostal, lumbar, herpes zoster). Pleuritic, Pericarditic, Peritonitic Pains. — Typically, the pain of perityphlitis is usually localized in the cecal (right iliac) region. The pain of angina j^^ctoris is sharp, vice-like, in the region of the heart, and often also in the arms. Colicky Pains. — Cardialgia, spasm of the stomach (neurasthenia, gastric ulcer, dilatation, etc.), in the epi- gastrium ; gall-stone colic, radiating from the liver ; renal colic, pain in the course of the ureter, also attending wandering kidney ; intestinal colic (intestinal catarrh, in- carceration of the bowel) ; lead-colic (plumbism), severe abdominal pains with constipation. 2 18 EXAMINATION OF THE PATIENT. Attacks of ill-defined colicky pain should suggest the crises of locomotor ataxia, or girdle-sense. Pain in micturition attends gonorrhea (especially before and during the act), cystitis (especially after the act), the passage of calculi or gravel, hypertrophy of the prostate, and strictures. Pain attends evacuation of the boivels in connection with spasm of the sphincter (tenesmus), in consequence of severe diarrhea or of ulceration ; with fissures of the anus and fistulae ; with hemorrhoids ; with obstinate con- stipation. Pains in the extremities are most commonly of the fol- lowing varieties : rheumatic muscular pains, pains induced through traumatism (contusions, etc.) ; further inflamma- tory pains (phlegmons, tenovaginitis, phlebitis) ; in con- sequence of osseous deformities (curvatures of the spinal column, flat-foot) ; gouty pains (podagra, chiragra) ; neu- ralgic pains (sciatica) ; pains dependent upon circulatory disorders, such as phlebectasia (leg-ulcer), phlebitis, arteriosclerosis (gangrene, asphyxia). SECTION II. GENERAL CONSIDERATIONS UPON METHODS OF INVESTIGATION. The various methods of investigation that have been developed in the course of time are all based upon employment of the five senses, with the aid of which, supplemented in numerous ways by instruments and reagents, successful inquiry can be made into the nature of existing morbid processes. In applying these methods clear notions must be had as to their limitations and reliability, and the significance of the results obtained is to be modified accordingly. The methods of investigation may be classified as fol- lows : r ' Form ; I. Immediate in- Color ; spection of Position ; _ Mobility. 1. With instruments : a. Microscopy of — a. Fresh preparations ; /?. Stained streak-preparations and sec- c tions ; o y. Enumeration. h. Mirror examinations : ^ - CO a. Ophthalmoscopy ; o — ( II. Mediate in- /3. Laryngoscopy ; ■^' spection y. Otoscopy, rhinoscopy ; (5. Cystoscopy, gastroscopy (endoscopy). c. Thermometry. d. Mensuration with tape, compasses, cyr- tometer. e. Spirometry (measurement of the pulmon- ary capacity). /. Graphic methods : a. Spliygmography ; . /^. Cardiography, etc. 19 o a spection. 20 METHODS OF INVESTIGATION. g. Exploratory puncture ; h. Bacteriologic methods, etc. 2. With reagents : ,T Tir T X • Cheniic investigation (qualitative and ^ . 11. Mediate in- ^ quantitative) of-< a. Blood ; 6. Urine ; c. Sputum ; d. Gastric and intestinal contents, etc. c f I. Without instruments : •2 I Palpation of the surface of the body and the accessory cavities g, I (touch). 'rt 1 II. With instruments : f 1. Esophagus and stomach ; ^ I Examination with the k 2. Urethra and bladder ; pq 1^ sound of — i 3. Nose, larynx, etc. C. Examination through the sense of hearing : 1. lujinediate percussion with the I. Percussion : examination of the linger; internal organs with regard -| 2. Mediate percussion (finger- to their air-content. I finger, finger -pleximeter, [ plexor-pleximeter). II. Auscultation : examination of { 1. Immediate ; murmurs generated within \ 2. Through the mediation of the the interior of the body, i stethoscope. D. The sense of smell may be employed in examina- tion of the nrine^ of the sputum (offensive expectoration), pus (putrid), as well as in the application of certain chemic methods. The application of the most important methods in gen- eral and the instruments necessaiy therefor, in so far as these are of significance for the practising physician, will now be briefly considered in the order tabulated. Special details are to be looked for in Section III. 1. Microscopy. Instruments Required : Microscope (with at least two objectives, one for high and one for low ])Ower, 80-500) ; medium ocular, stand with rack and pinion, revolving iris-diaphragm, illumin- ating apparatus. Immersion-systems are not necessary, though desirable. Platinum needle, pipets, watch-glasses. MICROSCOPY. 21 Slides (English form), cover-glasses. Reagents : 0.6 per cent, sodium-chlorid solution (indif- ferent) ; 1 per cent, acetic-acid solution (for clearing albuminous bodies) ; glycerin (for clearing and preserva- tion) ; osmic acid (0.5 per cent.), stains fat black ; alkalies (3 per cent.), for elastic fibers ; formalin (10 per cent.), a good hardening-agent — e. g., for blood -preparations ; Lugol's solution of iodin (yellowish-brown stain) ; eosin- solution and Bismarck-brown (1 per cent.), stain cells diffusely ; hematoxylin and methylene-blue stain the nuclei ; fuchsin and gentian-violet (1 per cent.) are most commonly used to stain bacteria. Good double stains are obtained by means of solutions of hematoxylin and eosin, and methylene-blue and eosin. ^ For imbedding specimens Canada balsam (dissolved in xylol) is used. Unstained Preparations. For the study of unstained preparations the smallest amount possible of the material to be examined is used, and this is spread upon a slide in a thin layer by means of a platinum needle previously sterilized (by heating in a flame). Further, reagents, such as sodium chlorid, acetic acid, solution of iodin, osmic acid, may be added. A cover-glass is applied firmly to the slide in order to expel air-bubbles. In viewing unstained preparations through the microscope the light should not be too strong. Stained Preparations. After the material to be examined has been spread in a thin layer upon the cover-glass the preparation is per- mitted to dry in the air, without the application of heat, for fifteen minutes and more. It is then passed slowly ^ The best stains are those of Gruebler, of Leipsic. The solution of hematoxylin and eosin is constituted as follows : Hematoxylin, 5. ; Acetic acid, 20. ; Distilled water, alcohol, glycerin, of each, 100. ; Alum in excess ; Eosin, 0.5. To be filtered whenever used. Duration of staining, ten to twenty hours. 22 METHODS OF INVESTIGATION. three times (in the case of blood eight or ten times) through the flame of a Bunsen burner or of a spirit- lamp in order to fix the structures. Next several drops of the staining-solution are placed upon the spread prep- aration and the cover-glass is warmed until the vapor of steam escapes (one minute usually suffices) ; then the cover-slip is washed in water, the excess of which is removed with bibulous paper, and dried in the air, with final enclosure in Canada balsam. The staining can be effected also in a watch-glass containing the stain, with the application of heat. The most convenient staining-procedure, which is suf- ficient for preliminary examination in most cases, is that with the solution of methylene-blue and eosin.^ The nuclei of the cells and bacteria appear blue, the bodies of the cells and the red blood-corpuscles red. In un- stained preparations structure is shoAvn better, and fat- drops remain unchanged, but not in stained preparations, in which, however, the nuclei of the cells and bacteria ap- pear more conspicuously. Stained preparations, further, may be preserved, while pencil-drawings of fresh prepar- ations should always be made and systematically preserved, together with notes of date, name, and other conditions. Sediments. Solid substances found suspended in considerable fluid, such as urine, exudates, etc., are permitted to settle in conical glasses, and in the course of from three to ten hours the sediment can be sucked up by means of a pipet. The sediment can be obtained to better advantage and more speedily by means of centrifugation. 2. ^Examination with Mirrors. For the successful examination of the cavities of the body with the aid of mirrors it is desirable to have a suitable space which can be enclosed in black cloth. ^ The solution of methylene-bliie and eosin is constituted of — Concentrated aqueous solution of rnetliylene-blne, 60. ; J per cent, solution of eosin in 70 per cent, alcohol, 20. ; Distilled water, 40. ; 20 per cent, solution of potassic hydrate, 12 drops. THERMOMETRY. 23 A good petrolenm-lamp with a circular wick and cylin- dric chimney will answer as a source of light. By means of a reflector the light is thrown into the cavity to be examined — e. g., the eyeball, the mouth, etc. In making laryngoscopic examinations the reflector is fastened upon the forehead. A small laryngoscopic mir- ror, warmed in order to avoid deposition of vapor, is slowly introduced, while the extended tongue is held firmly. The patient is made to say " hae ^' in inspiration. After a little experience examinations of this kind are readily made. In examination of the nose and ear suitable specula are employed, and the light is projected through these. By varying the position of the reflector all portions of these cavities can be successively illuminated. Concerning details of the technic the larger text-books must be consulted. 3. Thermometry. In studying the temperature of the body clinical (self- registering) thermometers are employed, the column of mercury remaining at the level to which it was elevated, and being shaken down by a sudden, vigorous jerk before being used again. The temperature may be taken in the axilla, in the rectum, in the mouth, or in the fold of the groin. The instrument should be permitted to remain in situ for from three to ten minutes, and when applied to the external skin all moisture should previously have been removed. The exposure in these situations should also be longer than within the mucous cavities. The axillary temperature is about one degree lower than that of the rectum, and about half a degree lower than that of the mouth. The temperature is, as a rule, taken morning and even- ing, and systematically recorded upon appropriate charts. 4. l^xploratory Puncture. The object of exploratory puncture is to convey infor- mation with regard to the presence of deep-seated accu- 24 METHODS OF INVESTIGATION. mulations of fluid, pus, blood, etc. The procedure is to be employed only when the diagnosis cannot be reached by means of other methods. Properly practised, it is entirely without danger. For this purpose so-called exploratory syringes are employed, which are provided with longer and stronger needles than ordinary hypo- dermic syringes. The needles are sterilized by boiling both before and after being used, and are carefully dried before being put away. Puncture is usually made in the situation of most marked dulness, the overlying skin being previously cleansed most carefully and then washed with alcohol and 3 per cent, solution of carbolic acid. In introducing the needle the resistance of the penetrated layers should be noted (thick cicatrices, abscess-membranes). Should fluid not appear immediately, the needle is cautiously introduced more deeply or is slightly withdrawn and the attempt repeated. The opening of puncture may be closed with aseptic collodion or a bit of adhesive plaster. Exploratory puncture is most frequently practised in cases of exudative pleurisy (to determine whether the exudation is serous, purulent, or hemorrhagic), of exu- dative pericarditis, of abdominal tumors (cysts, hydro- nephrosis), of abscess-formation (perityphlitis). Of late, it has become customary to practise explora- tory puncture of the spinal membranes in the lumbar region in cases of meningitis, hydrocephalus, and hemor- rhage, to determine the nature of the contents of the subdural lymph-space. 5. Bacteriologic Methods of Investigation. a. Staining. — For the preparation of cover-glass speci- mens, see p. 21. All bacteria stain well with basic aniline dyes (meth- ylene-blue, gentian-violet, fuchsin, Bismarck-brown). It is best to have these stains in concentrated stock-solution, which may be appropriately diluted as required (five drops to one-tenth of a test-tube of water). Methylene-blue and Bismarck-brown stain more slowly. BACTERIOLOGIC METHODS. 25 while fuchsin, and especially gentian-violet, readily over- stain. Especially useful staining-solutions are Loeffler's alkaline methylene-blue solution^ and Ziehl's carbol- fuchsin solution.^ For double staining the solution of methylene-blue and eosin (see p. 22) may be employed. For the isolated staining of bacteria Gram's method may be pursued, though not universally applicable. For this are required : fresh gentian-violet-aniline-water solu- tion (prepared by adding ten drops of aniline oil to one- fourth of a test-tube of distilled water, agitating the mix- ture, filtering, and adding to the filtrate five drops of a concentrated solution of gentian-violet. With this solu- tion the cover-glass preparation is stained without heat for one minute, and when dry is placed in LugoPs solution of iodin for one minute. It is then dried and exposed to the influence of absolute alcohol for ten minutes. After being washed in water it is stained with eosin or with Bismarck-brown. The bacteria appear blue and all other structures red or brown. This stain is applicable to staphylococci, streptococci, pneumococci, tetanus-bacilli, anthrax-bacilli, tubercle- bacilli, but not to cholera-bacilli, typhoid-bacilli, in- fluenza-bacilli, spirilla of relapsing fever, gonococci. For tubercle-bacilli there is a specific stain, as these organisms retain the stain more tenaciously than other microorganisms, even when treated with acids. The most convenient and the most reliable method is as fol- lows : The dry cover-slip preparation is stained for fifteen minutes in a warm carbol-fuchsin solution. It is then decolorized for several seconds in a 5 per cent, solution ^ Concentrated alcoholic solution of methylene-blae, 30. ; Potassium hydroxid (0.01 per cent.), 100.; Loeffler's solution of methylene-blue. ^ Fuchsin, 1. ; Alcohol, 10. ; Li(|uefied carbolic acid, 5. ; Distilled water, 100. ; Carbol-fuchsin. 26 METHODS OF tNVESTlGATIO]^. of sulphuric acid. After being washed with water the preparation is counterstained with methylene-blue. It is now washed again, then dried slowly in the air or more rapidly over the flame of a Bunsen burner, and finally imbedded in Canada balsam. When but small numbers of the bacilli are present the following mode of procedure may be pursued : A half test-tubeful of pus, sputum, etc., is boiled for fifteen min- utes over a water-bath. Preparations are then made from the resulting precipitate, which contains coagulated albu- minous bodies and tubercle-bacilli (Dahmen's procedure). 6. Citltlvafion. — For the clinician the demonstration of cholera-bacilli, anthrax-bacilli, diphtheria-bacilli, pyo- genic microorganisms, by culture-methods is of import- ance, and under certain circumstances also that of typhoid- bacilli and gonococci. To these ends test-tubes contain- ing solid culture-media are kept in readiness, nutrient agar-agar (which retains its firmness at the temperature of the body), and nutrient gelatin (which liquefies at this temperature), being perhaps the most available. There will be further required various shallow dishes, empty test-tubes, etc., sterilized by dry heat at a tempera- ture of 160° C. (320° F.). Anthrax-bacilli ; Pyogenic Microorganisms. — Anthrax- matters and purulent exudates are inoculated by strok- ing a previously heated platinum needle upon the sur- face of hardened agar or gelatin. In a warm tempera- ture there develop within twenty-four hours colonies, which are studied further microscopically in cover-glass preparations. The characteristic colonies of these respec- tive micro5rganisms are then inoculated upon new tubes, and in this way ]iure cultures are obtained. Anthrax-bacilli form brownish-yellow colonies, with masses of densely interwoven wavy threads ; the staphy- lococcus albus white, the staphylococcus aureus golden- yellow, the staphylococcus citrcus round-yellow colonies, the streptococcus pyogenes small grayish points, and like- wise the diplococcus pneumoniae. BACTERIOLOGIC METHODS. 27 Cholera-bacilli. — A small flocculus of the suspected dejection is introduced into a test-tube half-filled with sterile 1 per cent, peptone-solution containing 0.5 per cent, sodium chlorid. At a temperature of 37° C. (98.6° F.) the bacilli appear in positive cases in the course of eight or ten hours upon the surface in pure culture. From time to time microscopic preparations are made. With a drop of the culture inoculations are made upon warmed liquid gelatin, which is then poured into a steril- ized dish and permitted to solidify. At a temperature of from 20° to 22° C. (68°-71.6° F.) in the thermostat the colonies appear somewhat depressed in from thirty- six to forty-eight hours (through liquefaction of the gela- tin). The colonies present a light-yellow, granular ap- pearance, as if studded with small bits of glass, and being slightly serrated at the margin (with low power). Diphtheria-bacilli. — Inoculations are made upon gly- cerin-agar or upon simple agar smeared with human blood, the infective material being spread upon the sur- face of the culture-medium. In the course of from twelve to sixteen hours, at a temperature of 37° C. (98.6° F.), characteristic colonies resembling bright white drops are developed. Typhoicl-bacilli. — Pure cultures may be obtained by pouring into dishes gelatin inoculated with material from a typhoid stool. In the course of two or three days the colonies are distinctly visible, displaying a light-brownish color and a somewhat irregular border. Cultivated in this way they exhibit, however, too few points of differ- entiation from other bacteria (for instance, the bacterium coli, various water-bacteria, etc.). Their growth upon boiled sterile potato is quite characteristic, resulting in the development of a very delicate, scarcely visible, moist deposit. Further, typhoid-bacilli do not cause coagula- tion of sterile milk, and do not induce gas-formation in solutions of grape-sugar, as, for instance, does the bacte- rium coli. Of late the Gruber-Widal serum-reaction (agglutina- 28 METHODS OF INVESTIGATION. tion and immobilization of typhoid-bacilli exposed to blood-serum from a case of typhoid fever) has proved to be a valuable means of diagnosis and of identification of typhoid-bacilli. (For further particulars see p. 140.) c. Inoculation. — In doubtful cases the demonstration of the presence of tubercle-bacilli in exudates, etc., may be made by injecting into the abdominal cavity of guinea- pigs or rabbits a hypodermic syringeful of the material secured with antiseptic precautions. In the course of from four to six weeks, in a positive case, tuberculosis of the peritoneum will be distinctly demonstrable. A similar course of procedure may be pursued also for the demonstration of the diplococcus pneumoniae. Death occurs after two or three days, and in the blood may be found immense numbers of diplococci. 6. Palpation. Manual palpation is performed with the tips of the fingers, the nails being cut short. Through practice and exercise the sense of touch may be highly developed, a matter of considerable importance in palpation of the abdomen. Palpation is directed to the study of certain movements, such as the apex-beat of the heart, epigastric pulsation, arterial pulsation, etc., with regard to localization, extent, and strength. With the hand laid flat vocal fremitus (the vibration of the voice transmitted to the chest-wall) is studied. This may be increased or diminished abnormally in accordance with the state of the conductors of sound (bronchi, lungs). Abnormal friction-sounds (pleuritic friction, dry rales) may also be thus felt. Abnormal enlargement of organs (liver, spleen, etc.) may be felt through the relaxed abdominal walls (quiet breathing, with open mouth, in a comfortable position, the lower extremities being slightly drawn up). Should the results of palpation be uncertain (small tumors, adi- pose abdominal walls, pain, etc.), the examination should be made under chloroform-narcosis. In the case of PERCUSSION. 29 tumors especial attention should be directed to mobility with respiration and other movements. The presence of free fluid in the abdominal cavity (ascites) is determined by the existence of fluctuation, the wave generated by quickly tapping one side of the abdo- men (with the hand of a second person placed on edge in the median line, to prevent the transmission of the move- ment of the abdominal wall) being felt with the hand applied upon the opposite side. In making examinations with sounds or probes these are first moistened with water, or with oil, to facilitate their introduction. When a probe is to be introduced into the esophagus the patient should preferably be seated upon a chair with a high back, and be instructed to breathe quietly, the probe being permitted to pass over the fingers of the left hand introduced into the mouth. 7. Percussion.^ In accordance with the amount of air present in a body, this will yield upon tapping a special note (full or empty barrel). As, however, the internal viscera contain varying amounts of air, percussion furnishes a means of— 1. Determining the boundaries that separate one from the other organs of varying air-content that lie in close proximity ; and 2. Of reaching conclusions as to pathologic states of organs from abnormal variations in the note they yield. Percussion is either immediate (direct tapping of the surface of the body) or mediate (interposition of a solid body, such as the finger or a pleximeter, in tapping).^ ^ Percussion was discovered by L. Auenbrugger, of Vienna (1761), " In ventum novum ex percussione thoracis, etc.," and its application was further extended by Corvisart. Piorry invented the pleximeter in 1826, and Wintricli the percussion-hammer in 1841. '' Immediate auscultation has long been practised (succussio Hippo- cratis) ; mediate auscultation w^as discovered by Laennec (1816, Tralte de r Auscultation mediate, etc.), who determined the auscultatory phe^ noraena of most diseases. Skoda subsequently elaborated critically the results of Laennec's observations. 30 METHODS OF INVESTIGATION. The simplest and best mode of practising percussion consists in the use of the fingers of both hands. The palmar aspect of the middle finger of the left hand is firmly applied to the surface of the body, and receives blows struck with the middle finger of the right hand flexed at a right angle at the first interphalangeal joint. Especial care should be taken that the movement is made from the wrist. This mode of percussion should be practised until a distinct note is obtained upon the thigh. Then resort may be had to percussion with ham- mer and pleximeter. The determination of the percu- tory limits of an organ is effected in general through light percussion. The different qualities of note thus elicitable are — 1. A dully loio note, yielded upon percussion of airless bodies, whether fluid or solid ; and 2. A clear J loud note, yielded upon percussion of organs containing air. Between these two extremes there exist gradations, as with increasing size of the vibrating layer of air the note becomes clearer, w^hile with diminishing size it becomes duller. Under the latter conditions the designation rela- tive dulness is employed. When there is a total absence of air the note becomes absolutely dull. The clear and the relatively dull note may be either tympanitic (ring- ing) or not, according as the vibrations follqw one another with relative periodicity or not. It is tymjmmtic when the vibrations take place in a space with walls not too tense ; but when the tension is great the note is no longer tympanitic. The tympanitic note may further be high-pitched or low-pitched, in accordance with the number of vibrations in a unit of time. The smaller the cavity the higher the note. A variety of the tympanitic note is the metallic sound (depending upon a predominance of higher overtones). This may be heard over cavities with smooth walls. Upon tapping with the stile of the percussion-hammer A USCULTA TION. 31 upon the applied pleximeter the bell-like note is heard with especial distinctness through a stethoscope. A dull note is yielded normally by all solid portions of the body (for instance, the thigh, the head, the region of the vertebral column) ; further by the heart, the liver, the spleen, the kidneys, where these lie in close contact with the walls of the body. In situations in which air-con- taining organs lie between solid viscera and the walls of the body there is developed a relatively dull note. The lungs yield a clear but not tympanitic note, while stomach, bowel, larynx, and trachea yield a tympanitic note. Pathologic dulness develops when solid or liquid sub- stances displace air-containing organs or contained air ; a pathologic clear note when solid organs are displaced by air ; abnormal tympany over relaxed lungs and when cavities have formed in the lungs.^ 8. Auscultation. There are generated within the body a variety of sounds of normal or pathologic character, which may be heard in part at some distance (certain rales and splashing- sounds), in part only on applying the ear to the body- wall. For the distinct and isolated auscultation of these sounds the stethoscope is generally employed as a con- ductor. The instrument should be applied vertically and firmly, though without undue pressure. The mechanism of the origin of the murmurs is a variable one. It is referable partly to the vibration of currents of air, partly to the movement of fluid in spaces filled with air, partly to the tension of membranes and muscles, the rubbing of roughened surfaces upon one another, and the like. The most important sounds thus developed in con- nection with respiration are — 1. The vesicular respiratory murmur, which is heard ^ The lungs removed from the thorax, and thus freed from tension and relaxed, yield a tympanitic note. 32 METHODS OF INVESTIGATION. over the normal, breathing lung. It is generated wherever pulmonary alveolar respiration (cellular respiration) takes place. Where this murmur is wanting pathologically the conclusion is justified that there exists derangement of vesicular respiratory function. Vesicular breathing is distinctly audible only during inspiration and corresponds with a soft v. 2. The bronchial irspiratory murmur (resembling the rushing sound generated on blowing through a tube) is heard normally over the larynx, the trachea, and the bronchi, and under pathologic conditions when vesicular breathing is abolished, and only that of the bronchi is audible. It is louder during expiration than during inspiration and corresponds to the sharp ch. An especial form of ringing breathing is amphoric breathing (corresponding with the sound produced by blowing over the opening of a bottle). This occurs under similar conditions as the metallic percussion-note. 3. Transmission of the Voice. — During speech a mur- muring sound is heard over the healthy lung, which may be enfeebled or exaggerated pathologically. Enfeeble- ment occurs in conjunction with obstruction of the bronchi and displacement of the lungs from the chest-wall ; exaggeration (bronchophony, pectoriloquy) in connection with condensation of the pulmonary tissue. Egophony (bleating-sound) is noted in connection with incomplete compression of the lung. 4. Rales occur when fluid is present in the bronchi, through the bursting of air-bubbles, and when the walls of the smallest bronchial tubes stick together and are sud- denly pulled apart. They may be scanty or numerous, dry or moist, ringing or toneless, in accordance with the character of the fluid (viscid, mucous, liquid), and the space within which they are generated (large or small bronchi, cavities). 5. Pleuritic friction occurs in conjunction with deposits upon the pleural surfaces. It occurs intermittently and resembles the creaking of leather. A USCULTA TION. 3^ 6. Succussion-sounds (metallic splashing-sounds) occur in association with seropneumothorax (simultaneous presence of fluid and air in the pleural cavity) when the patient is abruptly shaken from the shoulders. Murmurs generated in the circulation are divisible into those heard over the heart and those heard over the vessels. Over the healthy heart two sounds can be heard at all of the orifices. Through the sudden tension of the valves there results the aortic and pulmonary second sound (diastolic), as well as the mitral and tricuspid first sound (systolic). To the latter the contraction of the muscular wall of the heart also contributes. Through the systolic tension of the walls of the vessels there results the first sound over the aorta and the pulmonary artery. The second sound over the mitral and tricuspid is transmitted from the aorta and pulmonary artery. These sounds may be stronger (second aortic, second pulmonary, first mitral, first tricuspid) or weaker in accordance Avith differences in tension. They may be more or less irregular in rhythm in accordance with the synchronousness in the activity of the ventricles and auricles (division, duplica- tion). They may finally be entirely wanting in connec- tion with disturbances of valvular activity, being replaced or separated by murmurs. The heart-murmurs heard in connection with valvular lesions arise from the generation of abnormal currents in the blood-stream, whether due to the forcing onward of blood through narrowed orifices (stenosis) or regurgitation through abnormal orifices (insufficiency). The acoustic transmission of these sounds takes place best in the direc- tion of the blood-stream responsible for their generation. The murmurs may be blowing, bubbling, purring, rasping, rumbling. It is important to determine the situation at which they are best heard and the period of their occurrence (whether systolic, diastolic, or pre- systolic). From these organic murmurs are to be distinguished 3 34 METHODS OF INVESTIGATION. so-called accidental murmurs, which may occur, in the absence of valvular lesions, in connection with disturb- ances of myocardial activity and in the rapidity of move- ment of the blood-stream (anemia, fever, etc.). They are almost exclusively systolic and of a soft, blowing character. In the presence of deposits upon the pericardial layers there results pericarditic friction (intermittent, rough, and apparently closer to the ear than endocarditic friction). Over the large vessels (subclavian, carotid) the same sounds are audible as over the aorta. Over the smaller vessels normally only upon pressure with the stethoscope a diastolic murmur can be heard, and with increasing pressure a distinct sound. Abnormal sounds over the vessels occur in connection with aortic insufficiency. Over the jugular vein in anemic persons a peculiar continuous hii7n may often be heard, which is probably attributable to the increased rapidity of the blood-stream in an imperfectly filled vein. Of murmurs generated in the digestive tract ausculta- tion may be directed to the study of the sivaUotvlng-soundy which may be heard at the termination of the esophagus in the epigastrium, or posteriorly to the left of the spinal column, immediately after the act of swallowing, as a short splashing-murmur, and which may be absent under pathologic conditions (stenosis). Anteriorly there may be heard in addition to the first also a second swallowing- sound (secondary murmur), due to the formation and rupture of air-bubbles. Intestincd murmurs result through peristalsis, in con- junction with the simultaneous presence of gases and fluids, and are abundant Avith increased peristalsis. Loud splashh) (/-sounds develop 'in the stomach under normal and pathologic conditions (dilatation). When })eritonitic deposits form upon the surface of the bowel and the liver per itonitic friction or creaking may under some circum- stances be heard. SECTION III. SPECIAL DIAGNOSIS OF DISEASES OF THE INTERNAL ORGANS. I. EXAMINATION OF THE RESPIRATORY APPARATUS. I. Nose and Nasopharyngeal Space. The form of the nose may be modified by defects in the septum : for instance, it may be depressed in the shape of a saddle, as a result of syphilitic disease. At the entrance of the nares eczema is likely to develop in conjunction with catarrhal conditions. If nasal breathing be obstructed (by catarrh or tumors), breathing through the mouth takes its place vicariously (as indicated es- pecially by snoring at night and great dryness of the mouth in the morning). When dyspnea exists the nasal alee become dilated in consequence of the respiratory effort. Further examination is made with the aid of a nasal mirror (anterior and posterior rhinoscopy) ; also by means of sounds or probes. Anterior rkinosGopy is practised by means of a nasal speculum and a reflecting mirror. Attention is directed to the position of the septum (deflections may cause difficulty in breathing), to the presence of ulcers (syphilitic perforations, tuberculous ulceration) ; also to the form of the turbinated bodies (swelling, hypertrophy ; nasal asthma may arise from this source reflexly), to the presence of polypi (mucoid- vitreous masses), to abnormal collections of crusts (ozena, in association with fetid odor). Epwtaxis is frequently associated with a circumscribed area of ulceration upon the septum. This occurs especially in connection with chlorosis, profound chronic visceral 35 36 EXAMINATION OF RESPIRATORY APPARATUS. disease, and leukemia. Suppuration in the accessory cav- ities (empyema of the frontal sinuses, or of the maxillary sinuses) is demonstrable by puncture. PoHterior rhinoscopy is practised in a similar manner to laryngoscopy, except that smaller pharyngeal mirrors are employed. These are introduced behind the nvula and are illuminated by means of a reflecting mirror, the tongue being held out of the way by means of a depressor. Fig. 5.— Rhinoscopic view of the nasopharyngeal space : s. septum ; w, tubal prominence ; Ch, choana ; R, fossa of Rosenmliller ; o, orifice of tube ; u, uvula ; pg, palatoglossal process. By this means especially may be recognized retronasal tumors, the most frequent of Avhich are adenoid vegeta- tions (hypertrophy of the pharyngeal tonsils in the fossa of Rosenmiiller in children), whicli may also be palpated by means of tlie finger. (Symptoms : obstructed nasal breathing, constantly open mouth, hardness of hearing, mental deficiency.) 2. Larynx and Trachea. The diseases of the larynx manifest themselves, in accordance with their character and localization, in dis- LARYNX AND TRACHEA. 37 tiirbances of breathing, of voice-formation, and of the act of deglutition. In cases of dyspnea dependent upon stenosis of the larynx this organ makes wide respiratory excursions and the head is thrown backward ; while in cases of stenosis below the larynx (tracheal stenosis) this organ remains still and the head is bent forward. Suffocative attacks occur in connection with tumors, especially when seated upon the vocal bands ; with spasm of the muscles of the glottis and with paralysis of the muscles that separate the vocal bands in inspiration (posterior crico-arytenoid). Laryngeal dyspnea is inspiratory and attended with loud stridor (hissing sound). In addition to the diseases named it occurs most frequently in association with laryn- geal croup (narrowing of the lumen of the larynx by deposits of membrane) and Avith edema of the glottis. Laryngeal cough is sometimes strikingly loud and barking (croupy cough). Even slight irritation of the larynx is capable of inducing intense reflex cough. During normal respiration the chink of the glottis is widened (respiratory glottis) in inspiration through the action of the posterior crico-arytenoid muscles (abductors). It is closed during expiration through the action of the lateral crico-arytenoid and the interarytenoid muscles (adductors). For the production of voice the vocal bands must be rendered tense through the action of the cricothyroid muscles and especially and principally through the action of the thyro-arytenoid. All of the muscles of the larynx receive their nervous supply through the inferior (recurrent) laryngeal nerve, with the exception of the cricothyroid muscle, which receives its supply through the superior laryngeal nerve. Both nerves are branches of the vagus (accessory nucleus in the lower portion of the medulla oblongata). If the tension of the vocal bands is not properly eflected, hoarseness results (catarrhal swelling, ulcerative processes, paralysis of the vocal bands). Aphonia is the 38 EXAMINATION OF hespihatohy apparatus. condition in which only whispering voice is possible. A shrill voice (abnormally high and thin) occurs principally in association with functional disorders. Double voice (diplophonia) occurs in connection with some forms of tumor of the vocal bands. When nasal obstruction exists (catarrh, tumors) the voice becomes " stopped up." In failure of the palate to close (ulceration, paralysis) the voice becomes nasal and open. By means of laryngoscopic examination (for technic see p. 23) a view is obtained of the epiglottis above, the aryepiglottic folds upon the sides, and the interarytenoid region posteriorly between the arytenoid cartilages. Within the space bounded by these parts are seated the white, tendinous true vocal bands and above them the ventricular bands (Figs. 6 and 7). •^■'**?7''^*'l'' *> Fig. 6.— Phonation. Fig. 7.— Inspiration. Attention is directed to the movements of the vocal bands during respiration and phonation ; also to abnormal redness, swelling, ulceration, tumor-formation. Redness attends catarrhal conditions (rose vocal bands). dwelling occurs under like conditions, as Avell as in conjunction with deeply situated abscesses (perichondritis). Ulceration (of the vocal bands, of the epiglottis, of the interarytenoid space) is mostly tuberculous (Fig. 8), less commonly syi)hilitic (with radiating cicatrices). Tumors. — Polypi seated upon the vocal bands, fibroma, carcinoma of the vocal bands. Paralysis of the vocal bands : from catarrh, neuritis (postdiphtheric), compression-neuritis, disease of the me- dullary nuclei (tabes, sclerosis, syringomyelia), in cases LARYNX AND TRACHEA. 39 of hysteria. The most frequent variety is paralysis of the thyro-arytenoid muscle (Fig. 9, oval glottis) : aphonia, Fig. 8.— Tuberculous laryngitis. 'i^^^0^* Fig. 9.— Paralysis of the thyro-ary- tenoids. (Phouation.) no dyspnea (attending laryngitis, functional over-activity, hysteria). Next in frequency \^ paralysis of the transverse arytenoid muscle (Fig. 10), which results in a small trian- gular fissure between the arytenoid cartilages during pho- nation : hoarseness, no dyspnea (catarrh, hysteria). Paralysis of the posterior crico-arytenoid (Fig. 11) is attended with pronounced inspiratory dyspnea if bilateral (failure of the chink of the glottis to open during inspira- tion), while the voice remains normal (tabes, sclerosis, sy- ringomelia). Fig. 10.— Paralysis of the transverse aryte- noid. (Phonation.) Fig. 11. —Paralysis of the posterior crico-ary- tenoid. (Inspiration.) Fig. 12. — Paralysis of the right recurrent lar- yngeal nerve. (Inspi- ration.) Paralysis of the recurrent laryngeal nerve : the affected vocal band is completely immobile in the cadaveric atti- tude, while the unparalyzed band exhibits an abnormally wide range of movement. The voice is feeble, but there is no dyspnea. When the paralysis is bilateral corre- 40 EXAMINATION OF RESPIRATORY APPARATUS. sjiondiiig conditions are found : aphonia, no dyspnea, toneless cough. Causes : neuritis ; compression by an aneurism of the aorta or a goiter ; attends tabes, etc. Paralysis of the epiglottis (postdiphtheric) is attended with difficulty in swallowing, together with cough. 3. Lungs. Anatomic. The lungs are contained .air-tight within the pleural cavities. The right lung has three (upper, middle, and lower) lobes, the left but two (upper and lower). The pleural caA^ties are not entirely occupied by the lungs, as the reflection of the serous membrane extends a greater distance (up to 9 cm. — 3^ in.) below on both sides, and at the cardiac fissure upon the left, resulting in the forma- tion of the complementary spaces, which are almost filled by the lungs only upon the deepest inspiration. The base of the lung is applied directly to the diaphragm. The topograi^hiG relations of the lungs with the thoracic skeleton are of importance. Anteriorly the ribs are used as landmarks for the indication of varying levels, while upon the back the spinous processes of the vertebrae from the seventh cervical downward serve a similar purpose. Other coordinates sometimes employed to indicate the lateral relations of the lungs are furnished by a number of imaginary vertical lines : the median line, through the middle of the sternum ; the sternal line, through the sternal margin ; the mammillary line, through the nipple ; between the last two is the parasternal line ; finally there are the anterior, middle, and posterior axillary lines (the last passing through the lower angle of the scapula). Rig-ht Lung". — Upper limit : anteriorly, from 2 to 4 cm. (|-1J in.) above the clavicle ; posteriorly, at the level of the seventh cervical vertebra. Median limit : somewhat to the left of the median line to the insertion of the sixth rib. Lower limit : lower border of the sixth rib (mammil- lary line), lower border of the seventh rib (anterior axil- LUNGS. 41 lary line), level of the ninth rib (scapular line), level of the spinous process of the eleventh dorsal vertebra (pos- teriorly). The boundary between the right upper and middle lobes, anteriorly, corresponds with the upper border of the fourth rib ; posteriorly, it pursues an oblique course from the third dorsal vertebra downward and outward. The Left Lung- has corresponding relations, the upper lobe reaching anteriorly to the sixth rib (see Plate 23 et seq.). The level of the diaphragm corresponds with the insertion of the fourth rib during deep expiration. It is somewhat higher upon the right side than upon the left. (For further particulars see Plates 23-25.) During respiratioi;i the margins of the lungs move in the mammillary line a distance of from 2 to 4 cm. (f to H in.). The respiratory mobility is greatest in the ax- illary line (10 cm .-—4 in.). Physiologic. During respiration the lungs engage in no active move- ment. The motor energy is furnished by the diaphragm and the thoracic muscles, and the lungs follow passively the dilatation of the thorax thus effected. The respiratory interchange of gases takes place be- tween the alveoli of the lungs and the pulmonary capil- laries. The inspired air contains 79 per cent, of nitrogen, 21 per cent, of oxygen, and 0.04 per cent, of carbon dioxid, together with watery vapor taken up in the air-passages (nose, larynx). The expired air contains a larger propor- tion of carbon dioxid (4 per cent.), less oxygen (16 per cent.), and is saturated with Avatery vapor. From 900 to 1200 grams of carbon dioxid are expired daily (the larger amounts under conditions of greater activity). When the interchange of gases is in any way deranged in con- sequence of disease of the air-passages, the alveoli or the capillary circulation (diseases of the heart, diseases of the blood), the deficiency must be made good as far as possi- ble by increased activity of the respiratory processes, and there thus results dyspnea. 42 EXAMINATION OF RESPIRATORY APPARATUS, Spirometry. The vital capacity of the hmgs — that is, the amount of air that can be inhaled on deep inspiration after the deep- est possible expiration — equals in men from 3000 to 4000 cu.cm. ; in women from 2000 to 3000 cu.cm. The pul- monary capacity is measured by means of a spirometer. It is diminished pathologically in conjunction with all diseases of the lungs and with meteorism. Inspection. Before entering upon any other examination observa- tion should be directed to the degree of development, the form, and the symmetry of the thorax, the character of the respiration, etc. (For particulars see p. 13.) Percussion of the Lungs. (For theoretic considera- tions see p. 29.) Percussion is practised first upon the right, then upon the left— 1. In the supraclavicular fossa (preferably from behind forward) ; 2. In the individual intercostal spaces in the mammil- lary line downward ; 3. Over the back from above downward in successive areas a hand's breath from the middle line until upon the right absolute dulness is reached, the note at each level on the right side being compared with the corresponding note upon the left. Over the normal lung is yielded pulmonary resonance — that is, a clear, not tympanitic note, extending upon the right to the lower border of the sixth rib. Below this point is the liver-dulness. Upon the left side pulmonary resonance extends to about the same level as on the right, although this limit is somewiiat difficult of determination on account of the presence of the stomach, likewise con- taining air, though yielding a tympanitic note. Upon the back pulmonary resonance continues to the level of the spinous process of the eleventh dorsal vertebra. Displaceincnt upward of the lower limits of the lungs (from elevation of the diaphragm) occurs in conjunction LUNGS. 43 with meteorism^ ascites, tumors of the abdomen (bilateral) ; also with contraction of the lungs and the pleura (unilat- eral). Displacement doivnward of the limits of the lungs (to the ninth rib) occurs, apart from the respiratory displacement, in conjunction with pulmonary emphysema (permanent) and asthma (transient). The normal respiratory displacement may be entirely wanting if the lungs are adherent, and in cases of extreme emphysema. Dulness upon percussion over the lungs may result from : 1. Infiltration of the lungs (filling up of the alveoli with liquid or solid masses, which displace the air), which occurs in conjunction with pneumonia, tuberculosis, in- farction, abscess-formation, gangrene, tumors ; 2. Atelectasis, absence of air in consequence of com- pression of the lungs, or as a result of spontaneous ab- sorption of the air, with insufficient supply (occluded bronchi) ; 3. Displacement of the lungs from the walls of the thorax, in consequence of accumulation of fluid in the pleural cavity (pleuritic exudate, hydrothorax), and of the presence of dense adhesions and of tumors. Together with the dulness associated with the condi- tions named in the third group, the percussing finger appreciates a sense of marked resistance. An infiltrated area of lung must have an extent of at least 4 cm., and an accumulation of fluid must equal at least 400 ca.cm., in order to be distinctly demonstrable by dulness on percussion. Dulness over the apices is suggestive rather of tuber- culosis ; over the lower lobes, of pneumonia or pleurisy. The upper limit of pleuritic dulness pursues an oblique course from above and behind, forward and downward, in consequence of the posture of the body at the time when the exudation took place. When air and fluid are simultaneously present in the pleural cavity (sero-pyopneumothorax) the level and the 44 EXAMINATION OF RESPIRATORY APPARATUS. plane of the fluid vary with the posture of the patient. This change in level is Avanting in connection with pleu- ritic effusions, in consequence of inflammatory adhesions. Symptoms of Displacement of the Lungs. — When fluid and air gain entrance into the pleural cavity, as well as when tumors are present, adjacent organs are displaced from their normal situations. Upon the right side the liver is pushed downward, the heart and the mediastinum toward the left, while upon the left side the heart is dis- placed toward the right. The complementary pleural spaces become filled with fluid. These evidences of dis- placement are readily demonstrable by percussion, the normal limits of dulness of heart and liver being dis- placed. Although the dulness due to a pleural effusion upon the right side is not to be separated from that of the liver, similar dulness upon the left side can be readily separated from the tympanitic note of the contiguous stomach. This tympanitic area normally present below the left lung (Traube's semilunar space) becomes dull upon percussion in its upper half when left-sided exudative pleurisy exists. This physical sign aids in the differentia- tion of the last-named condition from left-sided pneu- monia, in conjunction with which the complementary space naturally remains uninvolved, and Traube's space retains the normal tympanitic note of the stomach. A tympanitw note over the lungs is found — 1. Above the level of pleuritic effusions, from loss of pulmonary tension ; 2. Over pneumonic and tuberculous infiltrates (dull- tympanitic) ; 3. When abnormal excavations have formed (caverns), and have attained at least the size of a walnut (tubercu- losis, bronchiectasis, gangrene) ; 4. At times in cases of pneumothorax, if the tension of the contained air be not too great. When the tension is high, as it is the more commonly, the note is abnorm- ally full, deep, and not tympanitic. A distinction is to be made between the high tympanitic LUNGS. 45 and the deep tympanitic note, in accordance with the size of the cavity. A metallic note occurs — 1. Over very large cavities with smooth walls (as large as a fist) ; 2. In cases of pneumothorax (pleximeter-rod percus- sion, see p. 30). The cracked-pot sound occurs when upon deep percussion the air is compelled to escape through a narrow opening (stenotic murmur). It is found : 1. Over caverns communicating by a small opening with the bronchi ; 2. Over relaxed or infiltrated pulmonary tissue (rare). Normally it is heard frequently upon percussion of crying children. Ringing sounds sometimes resemble the tinkling of coins. Varkdions in the percussion-note. By these are understood changes from a tympanitic note to one of higher or lower pitch. 1. Wintrich's change in percussion-note. On open- ing the mouth a higher note, on closing the mouth a deeper note is developed. This is heard over caverns and over pneumothorax when direct communication with a bronchus exists. It is present normally upon percus- sion over the larynx. 2. Friedreich's respiratory change in percussion-note. Over caverns the note under some circumstances becomes higher on deep inspiration. 3. Gerhardt's postural change in percussion-note. When caverns are filled partly with air and partly with fluid the note becomes deeper or higher on change of position (sitting, recambency), in accordance with the direction of the longest diameter of the cavity. 4. Biermer's change in percussion-note. In cases of sero-pneumothorax the note becomes deeper when the patient sits up, in consequence of enlargement of the air- space. 46 EXAMINATION OF RESPIRATORY APPARATUS. Auscultation of the Lungs. This is practised in the same situations and in the same manner as percussion of the lungs, comparing the sides with one another. At the apices of the lungs anteriorly (supraclavicular fossse) auscultation may be more advantageously practised with the aid of a stethoscope. In the remaining portions direct auscultation is equally applicable. Over the healthy lung is heard everywhere pure vesic- ular breathing (vesicular inspiration, short expiration). Only at the upper portion of the right side posteriorly is the blowing breathing of trachea and bronchus to be heard. In children the breathing is particularly loud and rough (puerile breathing). In the region of the heart a slight exaggeration of the breathing takes place with every systole (systolic vesicu- lar breathing). Pathologic Vesicular Breathing. — Exaggerated vesicular breathing is found when resistance is encountered in the bronchi, as from swelling or accumulation of secretion, and in cases of bronchitis. Enfeebled vesicular breathing occurs in conjunction with occlusion of the bronchi (catarrh), with pulmonary em- physema (diminished aeration of the lungs), over small pleuritic effusions (displacement of the lung from the chest- wall). Prolongation and accentuation of expiration take place when resistance is present in the bronchi (swelling, nar- rowing, accumulation of mucus), in cases of bronchitis, of asthma, and of pulmonary emphysema. Jerhing inspiration is especially common over tlie apices of the lungs in cases of beginning pulmonary tuberculosis. Bronchial breathing is heard — 1. When infiltration of the lung exists (pneumonia, tuberculosis, gangrene, actinomycosis) ; 2. When the lungs are compressed (by large effusions), LUNGS. 47 if, as a result, vesicular breathing is abolished and only the tubular breathing of the bronchi is audible ; 3. Over cavities communicating with a bronchus. Over the apex of the lung bronchial breathing usually signifies tuberculous involvement ; over the lower lobe, frequently pneumonia, less commonly bronchiectasis, pleurisy, gangrene. Amphoric breathing is a ringing, blowing breathing that occurs over large cavities with smooth walls and over open pneumothorax (together with metallic rales and a metallic note upon percussion). Metamorphosing breathing (over caverns) begins as vesicular breathing, and then becomes bronchial. Undefined breatJiing (neither vesicular nor bronchial) occurs when aeration is imperfect at the apices of the lungs under both normal and pathologic conditions (be- ginning tuberculosis, pleuritic adhesions). Absence of breath-sounds is noted over large pleuritic exudates, over closed pneumothorax, and temporarily when the bronchi are occluded. Rales occur in greater or lesser number when mucus, blood, or pus is present in bronchi and in caverns. Dry rales (coarse, snoring, whistling rales) occur when the secretion is viscid. Whistling is indicative of catarrh or stenosis of the smallest bronchi. Hoist rales (small, medium-sized, large) occur when the secretion is thin and liquid, varying in accordance with the size of the bronchi. Large moist rales are indicative of caverns. Crepitant rales are generated by the sudden separa- tion of the walls of alveoli and bronchioles previously glued by secretion, and occur in conjunction with atelec- tasis, beginning pneumonic infiltration, and beginning resolution (crepitatio indux and crepitatio redux), in cases of pulmonary edema, of miliary tuberculosis, and of com- pression of the lung. Not uncommonly they attend the first deep inspirations, even upon auscultation of healthy lungs, especially low down posteriorly. 48 EXAMINATION OF RESPIRATORY APPARATUS. Ringing rales are heard over caverns and extensive compression and infiltration of the kings (transmission from the large bronchi). MetalliG rales are described under amphoric breath- ing (p. 47). . . . . ; Hippocratic succussion (metallic splashing-sounds) may be heard at some distance from the patient in cases of st^o-pneumothorax and of pyo-pneumothorax upon vigor- ous shaking. Under these conditions there develops also metallic tinkling. Pleuritic friction-sounds occur most frequently in asso- ciation with dry, fibrinous pleurisy, disappearing when exudation takes place and recurring with absorption of the fluid. They are usually heard loudly over the lower lobes, especially upon their lateral aspects. They are naturally absent in case of adhesive pleurisy. Friction- sounds may be present when deposition of tubercles takes place upon the pleura. The sounds become louder upon deep inspiration. Auscultation of the Voice, Pectoral or Vocal Fremitus. — Enfeehlement of the transmitted voice (upon counting 99, etc.) for both ear and hand occurs — 1. When the bronchi through which the sound is trans- mitted are occluded (by secretion, tumors, or stenosis) ; 2. When either fluid or air has found its way between the lungs and the chest-wall (pleurisy, hydrothorax, pneu- mothorax) ; 3. When the voice is enfeebled. Exaggeration of the transmitted voice for the ear (bronchophony ; when marked, pectoriloquy ; when at- tended with a bleating sound, egophony) and for the hand (increased pectoral fremitus, marked vibration) occurs in association with condensation of the pulmonary tissue (pneumonia, above pleuritic exudates, over caverns with dense walls, alsj over pleuritic thickening). PUNCTURE OF THE PLEURA. 49 4. Puncture of the Pleura. When symptoms are present indicative of a pleural effusion : boardlike dulness, especially over the lower portions of the chest, with a sense of resistance ; en- feebled breathing, with crepitant rales ; abolished pectoral fremitus, with a tympanitic note above the dulness ; dis- placement of liver and heart (if right-sided) ; displacement of heart, obliteration of Traube's semilunar space (if left- sided) — resort may be had to exploratory puncture to determine the character of the effusion, especially if the dulness continues to increase. The needle is usually introduced in the seventh, eighth, or ninth intercostal space one or two hands^ -breadth from the vertebral column (for technic, see page 24). The fluid thus obtained may be — 1. Serous, light yellowish (pneumonia, sepsis, rheumatic pleurisy, tuberculous pleurisy) ; 2. Hemorrhagic (carcinomatous pleurisy, tuberculous pleurisy) ; 3. Purulent (empyema) ; 4. Putrid (gangrene, from intestinal perforation). Microscopic examination (carcinoma-cells), and espe- cially bacteriologic examination (see p. 24), including staining, culture, and finally inoculation (tubercle-bacilli), are further of importance. There may be found staphy- lococci, streptococci, diplococci, bacterium coli, tubercle- bacilli,^ actinomyces-fungus. If the pleurisy have terminated, the introduced needle encounters only dense thickening and adhesions. The . development of this condition is recognized by the con- traction and retraction of the corresponding portion of the chest. A sacculated exudate may, however, persist for a long time in the midst of such adhesions. Exudates are rich in albumin (coagulation on heating) and fibrin (spontaneous coagulation). ^Negative bacteriologic findings do not exclude tuberculous pleurisy, the exudate attending this condition being usually sterile. 4 50 EXAMINATION OF RESPIRATORY APPARATUS. Transudates^ on the other hand, do not coagulate, or at most become slightly turbid when heated. The specific gravity of exudates is usually above 1018, that of transudates below 1015. 5. The Sputum. The presence of fluid in the bronchi induces reflex cough through irritation of the sensory bronchial nerves (vagus), with expulsion of the irritating material. Cough is a complicated expiratory movement. The chink of the glottis is first closed spasmodically, so that the bronchial column of air is exposed to a higher degree of pressure through the increased expiratory movement. Then sudden opening of the glottis permits explosive escape of the air, which carries any sputum present with it. Cough is rendered difficult or impossible when the respiratory muscles or the adductors of the vocal bands are paralyzed ; when severe pain is present (pleurisy, pneumonia) ; when marked weakness exists ; and in states of coma (development of catarrhal pneumonia or of pulmonary edema). The expeGtoratioii is constituted of — 1. The secretion of the alveoli and of the bronchial and laryngeal mucous membranes ; 2. Certain inspired elements (dust, carbon) ; 3. Material derived from cavities and perforations (pus, putrid matters, blood, portions of food) ; 4. Admixture from pharynx, mouth, and nares. The following varieties of sputum are to be distin- guished : 1. Pure mucous sputum (sticky, glassy), observed in cases of bronchitis and of beginning tuberculosis ; 2. Pure purulent sputum (thickish, confluent, yellow- ish), observed in cases of broncho-blennorrhea, of abscess of the lung, of rupture of empyemata, etc. ; 3. Mucopurulent sputum (globular, nummular), ob- served in cases of bronchitis, of broncho-blennorrhea, and of tuberculosis; THE SPUTUM. 51 4. Serous sputum (quite diffluent and frothy), observed in cases of pulmonary edema (with slight admixture of blood : prune-juice like) ; . 5. Hemorrhagic sputum, observed — a. In cases of croupous pneumonia (bloody-mucous, rust-brown, tough, viscid) ; h. In cases of pulmonary infarction (hemorrhagic in- farction from pulmonary embolism) ; c. In association with marked stasis in the pulmonary circulation (cardiac lesions) ; d. In conjunction with violent paroxysms of cough, derived from pharynx or larynx ; e. In the form of pure blood, bright-red, frothy sputum (hemoptysis), from erosion of blood-vessels through ulcera- tive processes, in cases of pulmonary tuberculosis, of bronchiectasis, and of gangrene, and less commonly in cases of malignant tumors, of rupture of an aortic aneu- rism, and of rupture of varices in the bronchi ; /. In cases of simulation and of hysteria (bleeding from the gums). Fibrinous coagula (bronchial casts) occur in association with pneumonia, diphtheria, and fibrinous bronchitis. Sputum in layers. When sputum that is partly serous, partly mucous, partly purulent, and abundant (bronchorrhea, bronchiec- tasis), is placed in a beaker it separates into distinct layers : an upper frothy mucous, a middle serous, and a lower purulent layer. Color. — The sputum may be — Red, from admixture of blood ; Brown, from disintegration of blood present ; Ocher-yellow, in cases of perforating abscess of the liver (bilirubin) and of abscess of the lung (hematoidin) ; Egg-yellow, from the action of bacteria (sarcinse) in purulent sputum ; Blackish, from admixture of carbon-particles ; Greenish, in cases of neumonia with delayed resolu- tion and in cases of bilious pneumonia (icterus). 52 EXA3IIXAT10N OF RESPIRATORY APPARATUS. A putrid odor is present in cases of fetid bronchitis and of gangrene, from the presence of putrefactive bacteria. Microscopy (see Phites 7 to 10. Technic, see p. 21). Sputum contains normally — a. Epithelial cells : Squamous epithelium from the mouth and from the true vocal bands ; Cylindric epithelium (uncommon) from the nose, the larynx, the trachea, and the bronchi ; Alveolar epithelium (large round cells filled with mye- lin, fat-drops, and carbon-particles), of doubtful origin ; 6. White blood-corpuscles (in a state of more or less advanced fatty degeneration) from all portions of the respiratory tract ; c. Red blood-corpuscles (quite isolated) ; d. Mucin-threads (nose, bronchi) ; e. Bacteria (cocci, sarcinse, bacilli, mycelial fungi from the mouth, molds from the nose). Pathologically, there may be present — a. Cellular and tissue elements : Leukocytes in all stages of disintegration, containing fat and coloring-matter (rupture of abscess) ; Eosinophile cells are numerous in cases of asthma, and isolated in cases of chronic bronchitis. These are large cells filled with bright, yellowish granules (r/-granules), which become distinctly visible when stained Avith eosin. They may be stained with methylene-blue and eosin, and become especially distinct when briefly immersed in 10 per cent, potassic hydroxid after being stained. Cardiac- lesion cells, in connection with chronic pulmon- ary stasis (especially mitral stenosis). These are large cells filled with yellowish-brown pigment-granules derived from hemoglobin (alveolar epithelial cells and leuko- cytes ?). Shreds of lung-tissue, discolored particles consisting of detritus, lung-black, leukocytes, bacteria, fat-crystals, fat- drops, occurring in cases of pulmonary gangrene and of pulmonary abscess. THE SPUTUM. 53 Elastic fibers (bright-yellow filaments of double con- tour) are found in connection with all destructive pro- cesses in the lungs (tuberculosis, pulmonary abscess) ; they are usually absent in cases of pulmonary gangrene, in consequence of the solvent action of a ferment pres- ent. They become especially distinct upon addition of 10 per cent, potassic hydroxid, and are usually found in the caseous plugs (lentils) of tuberculosis. Curschmann's spirals (corkscrew-like filaments of mucus wound about a central thread) are formed in the bronchi- oles in cases of bronchial asthma, of capillary bronchitis (through exudation ?). They are present generally in the sago-masses, and are most readily distinguished when the sputum is spread in a thin layer upon a black back- ground. Echinococcus-hooklets and vesicles occur in cases of echinococcus of the lung or of rupture of an echinococcus- cyst of liver, kidney, etc. h. Crystals : Needles and spheres of fatty acids (gangrene, fetid bronchitis, abscess) are present in the so-called Dittrich's plugs (whitish-yellow, friable, fetid granules). Charcot-Leyden crystals, pointed vitreous octahedra (accidentally in cases of bronchial asthma). Cholesterin-plates, leucin -spheres, tyrosin- needles, in cases of pulmonary abscess, of fetid bronchitis, and of bronchiectasis. Hematoidin-crystals (brownish-red rhombic plates, spheres, needles), following hemorrhages in cases of abscess of the lung or rupture of an abscess from a neighboring organ. They may be free or enclosed within cells. c. Bacteria (for staining technic, see p. 24). Tuberde-bacilli (for demonstration, see p. 25). Even when present in small numbers only, the diagnosis is established. Negative findings are not conclusive. Tu- bercle-bacilli are to be found with greatest certainty in the so-called lentils of the sputum. 54 EXAMINATION OF CIRCULATORY APPARATUS. Influenza-bacilli. — Stain with magenta-red. Tliey are usually demonstrable in large numbers in cases of influ- enza-catarrh and in influenza pneumonia. Pneumococci. — Stain by Gram's method. They are found abundantly in the sputum in cases of pneumonia, but occur also in the sputum of healthy persons. Actinomyces-granules. — These are distinctly visible macroscopically as yellow granules when viewed upon a black background. Anthrax-bacilli have been found in the sputum of the infrequent cases of pulmonary anthrax. Aspergillus Mycelium (molds) is found in cases of aspergillous pneumonomycosis (secondary infection in old cases of tuberculosis, pulmonary infection, etc.). Thrush-fungus (oi'dium) is found in the mouth, esoph- agus, etc., of children and debilitated individuals. For details concerning these parasites, see Section VI. II. EXAMINATION OF THE CIRCULATORY APPARATUS, 1. Heart. Anatomic. — The heart is a hollow muscular organ, lying obliquely upon the diaphragm and contained within the pericardium. It is contained two thirds in the left and one-third in the right half of the body, and extends from the lower border of the second rib at its insertion into the sternum to the upper border of the sixth costal carti- lage. It is in large part covered by the median margins of the lungs, and is in direct contact with the chest- wall throughout only a small extent (to the left of the sternum, from the fourth to the sixth intercostal space, cardiac fissure of the left lung). Above and to i\\Q right is situated the base of the heart, Avith the related large vessels, while the apex is situated below and to the left in the fifth intercostal space, somewhat internal to the left mammillary line. Physiolog-ic. — The activity of the heart furnishes the driving-force for the circulation of the blood ; the accom- HEART. 55 panying diagrams (Fig. 13) illustrate this mechanism. Fig. 13, a, shows the position of the valves of the heart during the contraction of the ventricles (systole) ; Fig. 13, b, their position during relaxation (diastole). a, systole. 5, diastole. Fig. 13. — Diagrammatic representation of the normal action of the heart (showing position of the valves, direction of the blood-stream, and degree of blood-pressure) . During the ventricular systole the aortic and pulmon- ary valves are open, while the mitral and tricuspid are closed. The blood passes out of the left ventricle through the aorta into the arteries, capillaries, and veins of the body to the right auricle ; also from the right ventricle, through the pulmonary artery, into the pulmonary arte- ries, capillaries, and veins to the left auricle. During the ventricular diastole the mitral and tricuspid valves are open, while the aortic and pulmonary are closed. The blood courses from the left auricle into the left ventricle, from the right auricle into the right ventricle. The direction of the prevailing blood-pressure is indicated by the arrows. It is thus obvious that without exact functional activity of the valvular mechanism circulatory disturbances must at once arise. Theory of Valvular Lesions. — If a heart- valve does not close completely at the proper time {insufficiency of the valve), a current of blood will flow abnormally through the unclosed orifice. Absolute insufficiency results from contraction of the free extremity of a valve- 56 EXAMINATION OF CIRCULATORY APPARATUS. leaflet, relative insufficiency from abnormal dilatation of an orifice, so that the normal valve is no longer sufficient to effect its perfect closure. \yhen an orifice of the heart is narrowed pathologically {stenosis of the orifice) a smaller amount of blood will pass in a unit of time. Stenosis occurs from circular calcifica- tion, adhesion, and contraction of valves and orifices. As a result of the conditions named, one portion of the heart will either receive too much blood from an abnormal source (insufficiency), or, if it cannot adequately expel its contents (stenosis), it will retain too much blood. In either event there results blood stasis, and in consequence dilatation of the respective heart-cavity. If this be not neutralized by increased activity of that portion of the heart, it may lead to further stasis in the circulation physiologically behind it. Such neutralization is effected through hypertrophy of the muscular wall of the affected segment. If the further injurious action of the derange- ment be thus overcome, the resulting condition is desig- nated compensation of the cardiac lesion. The establish- ment of compensation implies that the blood-pressure relations in the general and pulmonary circulation are restored to the normal. A distinction is to be made between primary and secondary hypertrophy. If a cavity of the heart be dilated, the effects may be neutralized by secondary hypertrophy. Primary hypertrophy, on the other hand, develops in response to simple increase in the pressure to be overcome, without simultaneous dilatation. The most important valvular lesions are — 1. Insuficiency of the mitral valve (Fig. 14). During the ventricular systole (Fig. 14, a) the blood passes from the left ventricle not only into the aorta, but, in consequence of insufficiency of the mitral valve, also into the left auricle, with the generation of a systolic murmur. The left auricle thus receives blood from two sources during diastole, and in consequence dilatation and secondary hypertrophy result. The stasis extends to HEART. 57 the pulmonary circulation, with increase in the blood- pressure ; as a result a greater amount of work is required of the right ventricle, which undergoes primary hyper- trophy. a, systole. b, diastole. Fig. 14. — Diagrammatic representation of mitral insuf&eieney (pathologic in- crease of pressure is indicated by arrows). During the ventricular diastole (Fig. 14, b) a larger amount of blood than normal streams out of the dilated and secondarily hypertrophied left auricle into the left a, systole. b, diastole. Fig. 15.— Diagrammatic representation of mitral stenosis. ventricle, in consequence of which dilatation and sec- ondary hypertrophy of this portion of the heart also take place. 2. Stenosis of the mitral orifice (Fig. 15). During the ventricular diastole (Fig. 15, 6) the Mood, 58 EXAMmATlON OF CIRCVLATORY APPARATUS. in consequence of stenosis at the mitral orifice, passes only with difficulty from the left auricle into the left ventricle, with the development of a diastolic murmur. The left auricle does not empty itself completely, so that dilatation results, with secondary hypertrophy of this part of the heart, and at the same time stasis in the pulmonary circulation, as the left auricle can undergo only a slight degree of hypertrophy, which is insufficient to meet the demands of its increased work. As a result an increased burden is thrown upon the right ventricle during systole, and this chamber undergoes hypertrophy. The left ventricle remains unchanged, as it receives a deficiency of blood. 3. Insufficiency of the aortic valve (Fig. 16). a, sj'stole. 5, diastole. Fig. 16.— Diagrammatic representation of aortic insufficiency. During the ventricular diastole (Fig. 16, b) the blood, in consequence of insufficiency of the aortic valve, flows from the aorta back into the left ventricle, with the generation of a diastolic murmur. The ventricle thus receives during the diastole blood from two sources, and in consequence undergoes dilatation. This leads to sec- ondary hypertrophy, which in turn results in more blood being sent into the aorta than before, in order that it may suffer without detriment the loss of blood due to regur- gitation during diastole. All other conditions remain unchanged. BEAUT. 59 4. Stenosis of the aortic orifice (Fig. 17). During the ventricular systole (Fig. 17, a) the blood, in consequence of stenosis at the aortic orifice, passes only with difficulty into the aorta, with the generation of a systolic murmur. Some blood would thus be retained in a, systole. b, diastole. Fig. 17.— Diagrammatic representation of aortic stenosis. the left ventricle, so that dilatation would result if the obstruction were not overcome through primary hyper- trophy of the left ventricle. 5. Insufficiency of the tricuspid valve (Fig. 18). a, systole. 6, diastole. Fig. 18.— Diagrammatic representation of tricuspid insufficiency. During the ventricular systole (Fig. 18, a) the blood, in consequence of insufficiency of the tricuspid valve, passes from the right ventricle not only into the pulmo- 60 EXAMINATION OF CIRCULATORY APPARATUS. naiy artery, but also into the right auricle, with the generation of a systolic murmur. The auricle thus receives during its diastole blood from two sources, and undergoes dilatation and secondary hypertrophy. During the ventricular diastole (Fig. 18, b) the right ventricle receives thus more blood than usual. It also undergoes dilatation and secondary hypertrophy, in con- sequence of which compensation becomes established. As, however, the right auricle, in consequence of its small muscular reserve, soon gives way, the stasis grad- ually extends also to the venae cavse and the veins beyond. With increasing dilatation of the veins their valves become relatively insufficient, and the blood regurgitated into the auricle during the ventricular systole is forced back also into the superior and inferior venae cavse, with the generation of a jugular and an hepatic venous pulse. In this way there will be brought about overfilling of the general venous circulation. The mechanism of the remaining uncommon valvular lesions may be comprehended from the princi])les laid down. Derangement of Compensation. Just as in connection with the valvular lesion last described, so also will there, in conjunction with the other lesions, after compensation has been maintained for some time, occur finally failure of the auricle or of the ventricle, when the muscular power of the hyper- trophied heart is no longer sufficient. There then de- velops dilatation of this segment of the organ, and the result of the irremediable stasis that follows is an over- filling of the venous circulation at the expense of the arterial. As, further, too little blood is arterialized in the lungs, in consequence of the retarded circulation, the blood is deprived of oxygen and does not sufticiently get rid of carbon dioxid, and the result is increased venosity. In turn there is developed dyspnea, which occasions increased resj)iratory effort as a sort of further com- pensation, and cyanosis when this form of pulmonary compensation no longer suffices. HEART. 61 In consequence of the venous stasis the blood is not sufficiently emptied out of the capillaries and lymph- channels, and an accumulation of blood-serum, in the form of a transudation through the walls of the vessels, takes place into the interstices of the tissues, with the de- velopment of swelling and anasarca. These changes are noted first only in the dependent portions, from the influ- ence of gravitation ; then also in the cavities of the body and over the whole body. The venous stasis manifests itself further in swelling of the liver and of the spleen. At the same time, in a vicious circle, the secretion of urine is diminished in consequence of the retarded circu- lation of blood in the kidney (cyanotic kidney). All of these manifestations together constitute the characteristic picture of derangement of compensation, which may de- velop, further, in connection with all other diseases of the heart besides valvular lesions. Inspection and Palpation of the Precordium. Prominence of the precordium (bulging) is found in conjunction with some valvular lesions, with mitral stenosis, etc. (especially in children), and with exudative pericarditis. Visible pulsation : Normal : in the situation of the apex-beat ; feeble pulsation in the epigastrium ; Pathologic: in conjunction with contraction of the lung in the second, third, and fourth intercostal spaces, with aneurismal formation ; marked epigastric pulsation (dilatation of the right ventricle). Systolic retraction at the apex of the heart may be pres- ent in conjunction with adhesions of the pericardium. The ajoex-beat is indicative of the furthest limit of visible and palpable movement of the heart to the left and downward. Its determination furnishes, therefore, an important index : the left border of the heart. Nor- mally it lies in the fifth intercostal space somewhat within the mammillary line. In children it is somewhat higher, in old persons somewhat lower. 62 EXAMINATION OF CIRCULATORY APPARATUS. Permanent displacement of the apex-beat takes place : 1. Upward, with elevation of the diaphragm (meteor- ism, ascites, abdominal tnmors, gravidity) ; 2. DowniDordy with hypertrophy of the left ventricle, with aortic anenrism, with depression of the diaphragm (pleurisy, pneumothorax) ; 3. Toward the left, with dilatation and hypertrophy of the left ventricle, Avith displacement (right-sided exudate or pneumothorax), with left-sided pleural contraction (tracfion) ; 4. Toward the right, with displacement (left-sided exu- date or pneumothorax), or through right-sided contrac- tions. Temporary displacements, particularly toward the left, occur in the lateral decubitus. Enftehlement of the apex-beat occurs in conjunction with obesity, overlying of the lungs, feebleness of the heart, pericarditic effusion (the apex-beat lying within the left limit of dulness). Augmentation of the apex-beat occurs in connection with unusual physical effort, febrile states, hypertrophy and dilatation of the heart. Thrill in the precordium may be felt in connection with : a. Stenotic murmurs (purring tremor) : with mitral stenosis, diastolic ; with aortic stenosis, systolic ; b. Aneurism of the aorta or of the pulmonary artery ; c. Pericarditic friction. Percussion of the Heart. — Percussion (light) is prac- tised to determine — The upper lirnit of cardiac dulness. The examination is begun in the left sternal line, with the finger applied horizontally, parallel with the intercostal s})aces, and pass- ing from above downward. Normally, this limit is found at the lower border of the fourth rib. Tlic right limit of c'dvd'mc duhiess. Tlie finger is placed vertically external to the right mammillary line at the level of the fifth or sixth rib and passing from right to HEART. 63 left. Normally, this limit is found at the left margin of the sternum. The left limit of cardiac dulness is studied in the same way as the right, except that the finger is placed first in the axillary line, passing toward the right. Normally, it is found somewhat internal to the left mammillary line (in the same situation as the apex-beat). - In this manner, passing from the area yielding a clear note to that yielding a dull note, the absolute cardiac dulness is determined ; that is, that portion of the chest to which the heart is directly applied without interposi- tion of pulmonary tissue. (For details see Plate 23.) The absolute cardiac dulness is surrounded by a finger's- breadth zone of relative dulness ; that is, that portion of the chest which upon deep percussion yields uncertain dulness, by reason of the interposition of the margins of the lungs between the heart and the chest-wall. This has but little significance. Inferiorly, the cardiac dulness passes without difPer- entiation into that of the liver. Increase in the area of absolute cardiac dulness occurs — 1. Toward the left, in conjunction with hypertrophy and dilatation of the left ventricle, with displacement (exudation), with left-sided retraction of the lung ; 2. Toward the right, in conjunction with dilatation of the right ventricle, wdth accumulation of fat beneath the sternum, with displacement ; 3. Toward the left and right, in conjunction with exu- dative pericarditis, hydropericardium (triangular area of dulness, with the apex at the manubrium sterni), con- traction of the lung, elevation of the diaphragm. Diminution in the area of cardiac dulness occurs in connection with pulmonary emphysema (becoming more distinct when the body is bent forward) in consequence of overlying by the distended lungs. In cases of pneumopericardium the cardiac dulness is replaced by a tympanitic or metallic note. Abnormal duhiess attends — (34 EXA3nNATI0N OF CIRCULATORY APPARATUS. 1 . Patulousness of the duct of Botal : a small quadri- lateral area of dulness superimposed upon the cardiac dulness ; 2. Aneurism of the aorta : an area of dulness at the level of insertion of the second and third ribs upon the right, either separated from or continuous with the car- diac dulness. 3. Mediastinal tumors : quite irregular areas of dulness over the sternum. Auscultation of the Heart (for theoretic considera- tions see p. 33). The four points of auscultation (points of greatest intensity of the heart-sounds) are — For the mitral sounds : the apex of the heart. For the tricuspid sounds : the insertion of the fifth right rib. For the aortic sounds : the second intercostal space to the right of the sternal margin. For the pulmonary sounds : the second intercostal space to the left of the sternal margin. In each of these situations are heard two sounds, a systolic and a diastolic. At the venous orifices the systolic (duk duk), at the arterial orifices the diastolic sound (duk duk) is accentuated. Abnormal acceiituation of the first mitral sound occurs in conjunction with increased activity of the heart in febrile states, Avitli chlorosis, neurasthenia, hypertrophy of the left ventricle. Abnormal accentuation of the second aortic sound occurs in conjunction with hypertrophy of the left ventricle (nephritis, cardiac lesion). Abnormal accentuation of the second p)idm,07iary sound occurs in conjunction with hypertrophy of the right ven- tricle, and is an important sign of increase of blood-press- ure in tlie ])ulm()nary circulation. In consequence of relaxation of the right ventricle the accentuation of the second pulmonary sound is less distinct with all derangements of compensation than HEART. 65 with efficient compensation. The remaining sounds also may, under these conditions, be fainter and less distinct. Metallic heart-sounds occur in conjunction with pneu- mopericardium and with caverns in the lung. Division (duplication) of the first sound at the apex occurs in connection with hypertrophy of the heart (chronic nephritis) ; a presystolic sound (auricular con- traction), with mitral stenosis (although a murmur may be wanting) ; division of the second sound over the large vessels (asynchronous valvular closure, with disturbance in the coincidence of ventricular activity) occurs under variable conditions (fever, diseafje of the heart, and also even in health). Galloping rhythm (triple heart-sounds : duk duk duk) occurs in conjunction with weakness of the heart in consequence of asynchronous ventricular activity, and is a sign of ill omen. Heart-murmurs (for theoretic consideration see p. 33). Systolic murmurs occur between the beginning of the first and that of the second sound. Diastolic murmurs occur between the beginning of the second and that of the first sound. Diastolic murmurs heard shortly before the systolic sound are designated presystolic. The heart-sounds may be heard simultaneously with or in advance of the murmur, or not at all. The intensity of the murmur is not a certain guide as to the gravity of the valvular lesion. Diastolic murmurs are usually faint, but of greater significance than possible coincident systolic murmurs. Murmurs are referred to the valves or orifices in the area of Avhose sounds (points of auscultation) they are best heard, with the exception of the murmur due to aortic insufficiency. Systolic (blowing) murmurs at the mitral and tricuspid orifices occur in conjunction with insufficiency ; at the aorta and pulmonary artery, with stenosis. (See the dia- grammatic representations of heart-lesions, p. 55 et seq.) 66 EXAMINATION OF CIRCULATORY APPARATUS. Diastolic murmurs at the mitral (frequently also pre- systolic and rumbling) and tricuspid orifices occur as a result of stenosis ; at the aorta and pulmonary artery, as a result of insufficiency. Aortic diastolic murmurs (rush- ing) are heard best to the left of the sternum at the attachment of the third rib, thus somewhat lower than the normal area of auscultation, in accordance Avith the direction of the regurgitant blood-stream. Accidental systolic murmurs (often loud and blowing) are heard especially at the base of the heart, and are imattended with any other symptom of a valvular lesion, such as dilatation, hypertrophy, or alteration of pulse. Pericardial mvurmurs are heard best over the upper portion of the sternum. They do not confine themselves to systole or diastole, but follow intermittently, are scratch- ing, often quadruple (locomotive murmur), seeming nearer to the ear than endocardial murmurs, and losing in dis- tinctness on deep inspiration. Extra-peri car dial (pleuritic) murmurs resemble pleuritic friction (creaking), disappearing generally Avhen the breath is held after deep inspiration or deep expiration. Crepi- tation synchronous with the action of the heart is heard in conjunction with emphysema of the mediastinum. 2. The Blood-vessels. Auscultation of the carotid artery is practised at the middle of the inner border of the sterno-cleido-mastoid muscle, and of the subclavian artery in the supraclavicu- lar fossa (lateral segment). Normally, there are heard over these large vessels a cardiac systolic sound, due to tension of their walls, and a cardiac diastolic sound, due to transmission of the aortic second sound. The cardiac systole corresponds with the arterial diastole, and vice versd. Sydolic murmurs occur in the carotid in conjunction with aortic insufficiency, from entrance of the blood under high pressure ; with aortic stenosis and arterio- sclerosis, and in febrile states. THE BLOOD-VESSELS. 67 Over the small arteries, normally free from sounds if heavy pressure be not made with the stethoscope, a dis- tinct sound is sometimes heard in connection with aortic insufficiency (palmar arch, ulnar artery). A double sound over the femoral artery is sometimes heard in association with aortic insufficiency, mitral ste- nosis, lead-poisoning, in consequence of increased arterial pressure. Duroziez's double sound is heard over the femoral ar- tery (in conjunction with aortic insufficiency) when a cer- tain degree of pressure is made with the stethoscope. Jt appears as a loud systolic and a faint diastolic blow. Murmurs over the vessels are heard also in conjunction with aneurismal formations. The Veins. The jug-ular veins, at the outer margin of the sterno- cleido-mastoid muscles, exhibit pulsatile increase and diminution in size (diastolic, presystolic venous pulse) in conjunction with lesions of the heart. The true systolic venous pulse is observed in connection with tricuspid insufficiency. (See p. 60.) At the same time there exists also visible pulsation of the liver (sys- tolic hepatic venous pulse). Upon auscultation of the jugular vein in chlorotic pa- tients a venous hum may be heard, which is increased on torsion of the head. It may in rare cases be heard also over the femoral vein. The Pulse. Frequency. — Normally, it ranges between 60 and 80 ; in children, over 100, up to 140. Acceleration (tachycardia, pulsus frequens) occurs in connection with excessive muscular exertion, with excite- ment, following meals, in febrile states, in connection with diseases of the heart (particularly with derangements of compensation), neurasthenia (in paroxysms), exoph- thalmic goiter, in states of collapse (over 160), and with paralysis of the vagus. Retardation (bradycardia, pulsus rarus) attends irrita- 68 EXAMINATION OF CIRCULATORY APPARATUS. tion of the vagus (meningitis, cerebral compression), diseases of the myocardium, aortic stenosis ; and occurs as a result of the action of digitalis. Rhythm. — Irregular pulse (intermittent pulse) attends cardiac lesions (especially derangements of compensation and mitral stenosis), sclerosis of the coronary arteries, adhesive pericarditis, etc. Alternating indse (one pulse-beat to every two con- tractions of the heart). Blgeminate, trigeminate pulse (omission of every third or every fourth beat respectively). Paradoxic pulse (becoming smaller during inspiration) accompanies pericardial adhesions. Inequality in size of the radial pulses is noticed in con- junction with aneurisms, embolism of the brachial artery, inequality in caliber of the artery. Celerity (rapid or tardy ascent of the pulse-wave) : quick pulse (pulsus celer), slow pulse (pulsus tardus). Pulsus celer (running) attends aortic insufficiency, lead- poisoning, interstitial nephritis (increased arterial press- ure). Pulsus tardus attends aortic and mitral stenosis, arterio- sclerosis, aneurism. Size (pulsus altus, pulsus parvus). Pulsus altus is observed in febrile states and in asso- ciation with cardiac hypertrophy of all kinds (especially attending aortic insufficiency). Pulsus parvus is observed especially in connection with mitral stenosis. Hardness (dependent upon the tension of the artery). Pidsus durus occurs in connection with liypertrophy of the left ventricle, with contracted kindey, with lead-colic. Pulsus mollis is found in febrile states, in connection with mitral stenosis and Avith anemia. In feeling the pulse the state of the wall of the vessel is also noted. Of especial importance is the existence of abnormal rigidity, calcification (nodular or beaded arteries), or marked tortuosity of the arteries (radial, brachial, tern- THE BLOOD-VESSELS. 69 poral). A conclusion as to the existence of arteriosclerosis of the aorta cannot, however, be reliably based upon de- monstrable sclerosis of the peripheral arteries, and vice versa. Sphygmography (pulse-tracing). By means of the sphygmograph the pulse may in part be more thoroughly analyzed (especially its temporal course) and be permanently recorded. Normal Tracing (Figs. 19 and 20) : Fig. 19. — Normal pulse-tracing (rapid rotation of the drum). Fig. 20.— Normal pulse-tracing (slow rotation of the drum). The uninterrupted, oblique ascending line (percussion- wave) is followed by a more slowly descending inter- rupted line, marked by secondary elevations (tidal or predicrotic wave [a], recoil or dicrotic wave [6]).^ Pulse-tracing of the Febrile State: With increasing fever, the tension of the vessel-wall diminishes, and the elevation due to recoil of the blood becomes very marked and palpable (dicrotism), while the elevations due to the elasticity of the blood-vessel dis- ^ The notches above the tracing are made by the chronometer (5 per second). 70 EXAMINATION OF CIRCULATORY APPARATUS. appear. Figs. 21, 22, and 23 show the alterations in the pulse during an attack of intermittent fever. At the beginning of the attack at 6 p.m. the pulse- tracing exhibited no peculiarity. At 11 P.M. the temperature was 39.9° C. (103.8° F.), the pulse 128 and distinctly dicrotic. The tracing (Fig. 21) shows a distinct elevation in the descending line (catadicrotism). Fig. 22. Fk;. 23. At 12.30 A.M. the temperature was 40.6° C. (105° F.), the pulse 146 and markedly dicrotic. The tracing (Fig. 22) shows a marked elevation between the descending and the ascending line (dicrotism). At 1.30 A.M. the temperature was 41.3° C. (106.3° F.), the pulse 1 60. The tracing (Fig. 23) shows an elevation in the ascending line {anadicrotism). A similar condition is illustrated in Fig. 24 (dicrotism in typhoid fever). Finally, when the action of the heart is excessively rapid the elevation due to the wave of recoil may coin- cide with the elevation due to the subsequent percus- sion-wave, so that the pulse becomes monocrotic. THE BLOOD-VESSELS. 71 When, on the other hand, the tension of the artery is abnormally great, the elevations due to the elasticity of the vessel become more numerous and more distinct. Fig. 24. Pulsus parvus, pulsus irregularis (mitral stenosis) : Fig. 25. (Slight elevation and irregularity of the pulse-tracing.) Fig. 25. Fig. 26. Pulsus celer (aortic insufficiency) : Fig. 26. (Steep ascent, rapid fall of the percussion-wave.) Pulsus tardus (aortic stenosis) : Fig. 27. (The ascend- ing line is small, the apex blunt, the descending line pro- longed and scarcely interrupted.) 72 EXAMINATION OF CIRCULATORY APPARATUS. Fig. 27. Fig. 28. Pulsus irregularis (arteriosclerois of the coronary arte- ries) : Fig. 28. (Omission of every third pulse-beat.) 3. The Blood (Plates 1 to 6). Arterial blood is bright red, in consequence of the presence of oxyhemoglobin, while venous blood is dark red in color. The specific gravity of the blood varies between 1050 and 1060. The blood consists of blood- plasma (serum and fibrin) and of the morphotic elements (red and white blood-corpuscles, blood-plates). The red corpuscles (erythrocytes) are the oxygen- carriers (oxyhemoglobin) of the blood, and in healthy men are present to the number of about 5,000,000 to the cu. mm., and in women to the number of about 4,500,000. The average diameter of the red blood-corpuscles is 7.6 n (6.5-9.3 /i). The erythrocytes exhibit the well-known disc-shape, with a central depression. They are unpro- vided with nuclei and in fresh preparations exhibit a tendency to form rouleaux. They are very sensitive structures, swelling up in water and losing the coloring- THE BLOOD. 73 matter (hemoglobin) contained within their stroma. When dried or acted upon by certain reagents (solution of urea, etc.) they become crenated and take on thornapple-forms. The hemoglobin consists of an albuminous body (glob- ulin) and an iron-containing pigment, known as hematin. Hematin chlorid (hemin) crystallizes in characteristic brownish rhombic plates (Plate 6, Fig. 3). The "white corpuscles (leukocjrtep) are present in the blood to the number of about 7500 (6000 to 9000) to the cu. mm. The majority exhibit active ameboid movement upon a warmed stage. They are colorless, distinctly granular, and possess nuclei that become especially dis- tinct upon addition of acetic acid and upon staining. They vary in size from 5 to 15 //. In accordance Avith the character of their nuclei the following varieties of white corpuscles are distinguished : 1. Large polynudear (with several lobulated nuclei; from 65 to 70 per cent.). 2. Small mononuclear (with a single nucleus ; about 25 per cent.). A large and a small form of mononuclear leukocyte can be distinguished. 3. Transitional forms (leukocytes in process of degen- eration ; about 5 per cent.). The white blood-corpuscles contain within their proto- plasm small bodies (granulations), Avhich can be differen- tiated in accordance with their size, and especially in accordance with their affinity for certain stains (acid or basic aniline colors) : 1. Acidophile, JEosinophile Cells. — These contain coarse granules (a-granules), which are stained a bright red with eosin. They represent about from 1 to 5 per cent. of the leukocytes and are polynudear cells. 2. Basophile Cells. — These contain either a. Coarse granules (y-granules ; mast-cells), or b. Fine granules (o-granules). Both varieties of granules stain deeply with methylene- blue, etc. The majority of mononuclear cells contain such granules (20 to 25 per cent.). 74 EXAMINATION OF CIRCULATORY APPARATUS. 3. Neutrophile Cells. — These contain numerous dust- like granules (s-granules), which stain violet with solu- tions of neutral stains. These granules are contained within the polynuclear cells (70 per cent.). Whether or not a single cell may contain several va- rieties of granules (amphophlle cells) is yet a matter of doubt. The nature and the significance of the granules (albuminous bodies) have likewise not yet been determined. For further details, see Plate 2. Blood-plates. — These occur in grape-like (sometimes also in cylindric) arrangement in masses to the number of about 200,000 to the cu. mm. They appear to stand in a certain relation to the leukocytes with regard to coagulation of the fibrin. With regard to the genesis of the red and the white blood-corpuscles, it is only known with certainty that they are formed in the bone-marrow, in the spleen, and in the lymphatic glands. The erythrocytes develop in the red bone-marrow from nucleated cells (erythroblasts) ; the mononuclear leukocytes apparently in part in the lymphatic glands ; the remainder in part in the spleen. Existing knowledge upon this subject, however, is yet contradictory. Methods of ^Examination and their Results. 1. Spectroscopy of the Blood (see Plate 6). The examination can be satisfactorily made with the hand-spectroscope in place of the large spectroscope. From three to five drops of blood are placed in a test- tube containing water, wdiich is then held between the opening of the spectroscope and a source of light. The normal blood-spectrum shows between the absorp- tion-lines D and E two black bands (oxyhemoglobin). If the solution of blood be reduced by addition of several drops of a solution of ammonium sulpliid or copper sul- phate, these two bands disappear, and are replaced by a new wider band (reduced hemoglobin). In cases of carbon-monoxid poisoning the oxyhemo- globin is converted into CO-hemoglobin, whose spectrum THE BLOOD. 75 corresponds in the main with that of the former. If reduction be eifected, however, the two absorption-bands do not disappear (differentiation from oxyhemoglobin- spectrum ; stronger combination of CO). In certain cases of hemoglobinemia (disintegration of erythrocytes in the blood), following poisoning with potassic chlorate, etc., methemoglobin is formed in the blood. The spectrum then shows between A and a a small intense band, while the spectrum beyond green is completely absorbed. (See Plate 6, Fig. 1, d.) 2. Estimation of the Heraog-lobin. The hemoglobin is most conveniently estimated by means of the apparatus of Gowers. Hermetically sealed in a small glass tube is a solution of red color (carmine- glycerin), corresponding in its intensity with a 1 per cent, solution of normal blood. AVith this normal solution is to be compared the blood to be studied. To 20 cu. mm. of the latter, carefully taken up with a pipet, water is added successively until the intensity of the red color corresponds with that of the normal solution. In making the comparison the tubes are held in front of white paper, and the percentage of hemoglobin is read from the accom- panying scale (error of about 5 per cent.). Diminution in the amount of hemoglobin, oligochrom- emicij may fall as low as 15 per cent, of the normal, and occurs in connection with chlorosis and all forms of anemia. The amount is increased in connection with pulmonary stenosis. IN^ormally, 100 cu. cm. of blood contain from 13 to 14 grams of hemoglobin. 3. Enumeration of the Red and White Blood-cor- puscles. For this purpose the apparatus of Thoma-Zeiss is employed. In an absolutely dry capillary tube (washed with alco- hol and ether) is drawn up 0.5 (or 1) cu. mm. of blood, which is diluted with water to the mark 101. The two are then well intermixed, and a drop is placed in the 76 EXAMINATION OF CIRCULATORY APPARATUS. chamber of a suitably constructed slide, the presence of air-bubbles being obviated. Of the large squares scratched on the slide (each containing sixteen small squares) the contents of not less than fourteen are counted, and the result is determined by the following formula : X. 200.4000 ^ ^ ^jjg number of cells counted, 14.16 ' -^— cu. mm. = the area of a small square. 4000 If leu. mm. of blood has been used, the multiple should be 100, instead of 200. The enumeration of the white blood-corpuscles is made with a larger capillary tube, and a 1 per cent, solution of acetic acid is used (to destroy the red blood-corpuscles) as a diluent, instead of water. The other steps in the pro- cedure are the same as those for enumeration of the red cells. Diminution in the number of red blood-corpuscles (oligo- cythemia) occurs (as low as 500,000) in connection Avith pernicious anemia, the secondary anemias (not with chlo- rosis), leukemia, profound loss of blood. Increase in the number of ichite blood-corpuscles occurs — 1. As a transient manifestation (leukocytosis) : physio- logically (about 10,000 to 12,000) after digestion, in the new-born, during pregnancy ; pathologically (to 60,000), in a number of infectious diseases (pneumonia, purulent meningitis, erysipelas, scarlet fever, diphtheria, polyar- thritis, pyemia). Further, leukocytosis is not rarely found, but not with absolute regularity, in cases of chlorosis, in cachectic states (carcinoma, hydremia), in the death-agony. The increase under these conditions affects especially the polynuclear cells with ameboid movement. The eo- sinophile cells are regularly present in but small numbers in inflammatory states, but they are increased under con- ditions not yet precisely determined in some forms of anemia, in cases of asthma, etc. THE BLOOD. 77 2. Permanent increase in the number of leukocytes occurs in conjunction with leukemia (50,000 to 300,000 in the cu. mm.). For the establishment of the diagnosis of leukemia marked increase in the number of leukocytes (which ex- hibits wide variations even in individual cases) alone is, however, not sufficient, but it must be supplemented by the results of further clinical investigation, especially microscopic examination. As the number of erythrocytes is almost constantly diminished in cases of leukemia, the normal relation between the red and the white blood-corpuscles may be reduced as low as 2 to 1, instead of the normal 700 to 1. 4. Microscopic Examination of the Blood. A puncture with a sharp, triangular needle is quickly made in the carefully cleansed and dried finger-tip, the first drop of blood escaping being removed, and the sec- ond being taken upon an absolutely dry cover-glass (washed with alcohol and ether). Upon this is placed a second cover-glass, and the two are separated, with slight pressure, by means of forceps. Especial care is to be taken to prevent the access of moisture to the cover-slips in order to avoid destruction of the erythrocytes through the presence of water. With the prepared surface up- ward the preparation is permitted to dry in the air (for half an hour). In the meantime the fresh blood can be examined, a cover-glass with a drop of blood being gently pressed upon a slide. With partial illumination attention will be directed to — 1. The Erythrocytes. a. The size of the red blood-corpuscles (measurement with the ocular micrometer). Abnormally small erythrocytes, microcytes, from 2 to 6 /i in diameter, are found in cases of anemia, chlorosis, and leukemia. Abnormally large erythrocytes, macrocytes, from 10 to 15 // in diameter, are found under like conditions. 78 EXAMINATION OF CIRCULATORY APPARATUS. b. The Form. — Changes in form are often of artificial nature, but occurring extensively and in marked degree they justify a conclusion as to abnormally increased labil- ity in the consistence of the erythrocytes. In cases of profound anemia the most varied alterations in form are frequently found (protrusions, indentations, serrations, pear-shaped, kidney-shaped appearances). This condition is designated poikilocytosis. c. The Coloi'. — The normal yellowish-red hue of the blood may be replaced by a paler appearance, especially in cases of chlorosis. d. The tendency of the blood-cells to form rouleaux is diminished in cases of anemia. 2. The Leukocytes. In unstained preparations an approximate deter- mination of the number of white blood-corpuscles is possible. With a magnification of 500, every five white blood-corpuscles in the field of the microscope corre- spond to 8000 in the cu.mm. If, therefore, on examination of twenty fields an average of fifteen leukocytes in each be found, it may be estimated that there exists a leuko- cytosis of about 24,000. The ameboid movement of the white corpuscles may also be observed in unstained prep- arations. The eosinophile cells are to l)e recognized by their bright, yellowish, coarse granulation. Stained Preparations. — The cover-slip, spread with a drop of blood and dried in the air, is fixed by being passed rapidly ten times through the flame of an alcohol lamp or a Bunsen burner, or better, by being heated for two hours at a temperature of 120° C. (248° F.), or by being exposed for ten minutes in a 1 per cent, solution of formol-alcohol, or by exposure for one hour in equal parts of absolute ether and alcohol. Staining solutions (best obtained from Gruebler, of Leipsic) : 1. 1 per cent, watery solution of eosin. 2. Solution of methylene-blue and eosin. (See p. 22.) 3. Eosin, aurantia and nigrosin, of each 2., glycerin 30. MOUTH AND PHARYNX. 79 4. Ehrlich's solution of hematoxylin and eosin. (See p. 21.) 5. Ehrli ell's triacid solution (contains a basic, an acid, and a neutral aniline stain). 6. Ehrlich's neutral stain (containing acid fuchsin and methylene-blue). It is best next to proceed with the staining of a fixed preparation with methylene-blue and eosin, the specimen being exposed for ten minutes, with heat. The remain- ing preparations are treated for twenty-four hours with the solution of eosin, aurantia, and nigrosin, and with Ehrlich's solution of hematoxylin and eosin. They are then washed, dried in the air, and mounted in Canada balsam. With Ehrlich's triacid solution and Ehrlich's neutral solution the exposure should be about five min- utes. The stained preparations exhibit well the nuclei and the forms of the blood-corpuscles, the granulations of the leukocytes, and the presence of possible parasites. Only those who have made themselves familiar with stained preparations can be depended upon to recognize the varied conditions in fresh preparations. Concerning the individual peculiarities to be observed in stained preparations, as well as their significance, ref- erence should be made to Plates 1 to 6, and the accom- panying text. III. EXAMINATION OF THE DIGESTIVE APPARATUS. I. Mouth and Pharynx. Lips. There may be present eruptions of herpes (frequently accompanying pneumonia, meningitis, malaria, etc.), cya- nosis (diseases of the heart and of the lungs), marked pallor (anemia), dryness, fissures (attending fever), brown- ish, fuliginous deposit (typhoid fever). Teeth and Gums. The deciduous teeth appear in pairs on an average every two months from between the fifth and the eighth 80 EXAMINATION OF DIGESTIVE APPARATUS. month of life, the lower usually in advance of the corre- sponding upper pairs, and in the following order : From the eighth to the twelfth month, the median in- cisors ; From the twelfth to the sixteenth month, the lateral incisors ; From the sixteenth to the twentieth month, the ante- rior molars ; From the twentieth to the twenty-fourth month the four canine ; From the twenty-fourth to the thirtieth month, the posterior molars. The permanent teeth begin to make their appearance at the seventh year in much the same order, four appear- ing each year in the place of the exfoliated deciduous teeth. The first bicuspid appears in the ninth, the sec- ond bicuspid in the tenth year. Three molars complete the set, the last of wdiich may not appear before the third decade. Imperfect teeth interfere with normal digestion (defi- cient mastication and insalivation). Stomatitis, gingivitis (swelling, redness, crust-forma- tion, and ulceration) attend mercurial poisoning, scor- butus, and aphthae. A blue line (blackish deposit of lead sulphate at the margin of the gums) occurs as a result of lead-poisoning. Tongue. A coated tongue (epithelial desquamation, remnants of food, bacteria) attends gastric catarrh ; a smooth moist tongue, hyperacidity ; a smooth tremulous tongue, chronic alcoholism ; a dry, brownish, fissured tongue, febrile states ; a leathery tongue, coma and collapse ; the ^' strawberry " tongue, scarlet fever. Palate and Tonsils. Attention is to be directed to abnormal redness and swelling (catarrhal angina, abscess-formation, scarlet fever). DepjosiUi attend follicular angina (isolated, disseminated ESOPHAGUS. 81 whitish plugs of pus), diphtheria (coherent, grayish-white coating consisting of fibrin, pus, and bacteria, and leav- ing a bleeding surface when removed with forceps), thrush-vegetations (fungous masses of oidium albicans observed in children and in comatose states). Ulceration and Perforation of the Palate: adhesions to the" pharynx in cases of syphilis. Pharynx. Chronic Pharyngitis (attending alcoholism, occurring in smokers, singers, and those who work in dust) is char- acterized by a smooth, shining atrophic appearance of the mucous membrane, with swollen follicles and the forma- tion of tough secretion. Retrojjharyngeal Abscess (visible and palpable promi- nence of the posterior wall of the pharynx) should suggest itself when symptoms of profound septic infection are present, in conjunction with difficulty in swallowing and in breathing. It occurs in the sequence of glandular and vertebral disease, especially in children. For the microscopy of the buccal cavity, see Plate 7. 2. Esophagus. The esophagus is 25 cm. (9J in.) long ; the distance from the margin of the teeth to the beginning of the esophagus is additionally 15 cm. (6 in.) ; so that the dis- tance from the margin of the teeth to the cardia is 40 cm. (15 J in.). The distance from the margin of the teeth to the intersection of the esophagus by the left bronchus is 23 cm. — 9 in. (important in examination with a sound). In making examinations with a sound (for the method, see p. 29) it is best to employ a hard, solid, or preferably a soft, hollow instrument. The use of the sound is con- traindicated when aneurism of the aorta is suspected, in order to avoid possible perforation. If the esophagus be patulous, the sound passes readily into the stomach (with certainty if it can be introduced beyond a distance of 40 cm. — 15| in.). In cases of narrowing of the esophagus obstruction to 6 82 EXAMINATION OF DIGESTIVE APPARATUS. the passage of a sound is encountered at a corresponding level. An obstruction at a distance of 23 cm. (9 in.) from the margin of the teeth will be at the level of the junction of the esophagus with the left bronchus (diver- ticula, glandular swellings, aneurism, cicatrices) ; one at a distance of from 38 to 40 cm. (15-15J in.) at the level of the cardia (most frequently carcinoma). Esophageal diverticula (saccular dilatations) may be seated at the beginning of the esophagus (pulsion-diver- ticula). When filled with food they may compress the esophagus and be visible through the neck as distinct swellings. They may also be more deeply seated (trac- tion-diverticula), resulting from contraction of adjacent glands. They may give rise to abnormal commilnications between esophagus, bronchi, and large vessels, but they are not accessible to accurate diagnosis, being frequently found accidentally upon postmortem examiitJition. Above the point of narrowing there is usually a sec- ondary dilatation of the esophagus. The vomiting attending esophageal stenosis is charac- teristic. It takes place often directly after the ingestion of food, and the patient is conscious of a sense of stoppage. The swallowing sound (see p. 34) may be wanting or delayed when narrowing of the esophagus exists. 3. Stomach. Anatomic. The stomach lies for five-sixths of its extent in the left half of the body, and for its remaining one-sixth in the right half. The fundus lies in the concavity of the left half of the diaphragm. The greater curvature, the lower limit of the stomach, passes from 2 to 4 cm. (}— 1|^ in.) above the umbilicus ; the lesser curvature is covered by the margin of the liver, as is also the pylorus, which lies in the right sternal line at the level of the ninth costo- chondral junction (sometimes higher, sometimes \o\y^v in individual cases). Tliat portion of tlie stomach which lies in contact with the anterior and lower portion of the STOMACH. 83 left half of the thorax gives rise to the tympanitic note of Traube's semilunar space. The boundaries of this space are, therefore, the left lower margin of the lung (above) ; the left border of the liver (on the right) ; the splenic dulness (on the left) ; the left costal arch (below). (See Plate 24.) Physiologic. AYhen the masticated bolus reaches the stomach gastric digestion sets in, with the secretion of hydrochloric acid and pepsin (proferment pepsinogen). As a result the albuminous bodies are converted into acid albuminates throuo^h combination with hydrochloric acid, and with the simultaneous action of the pepsin they are transformed, through intermediate stages (albumoses), into peptone-like bodies in part soluble. So-called free hyclrochloric acid (not in combination with albuminous bodies) is distinctly demonstrable half an hour after the ingestion of a meal. The total acidity (free and combined hydrochloric acid) equals from 1.5 to 2 per cent, one hour after the ingestion of food. In addition to hydrochloric acid, other (organic) acids are formed in the process of gastric digestion. These develop as a result of fermentation (bacterial activity) from starch and sugar : lactic acid, acetic acid, butyric acid. The acid fermentation is related to the production of hydrochloric acid. The more acid present the less is the amount of organic acids (antagonism). In accordance with the amount and the character of the meal the stomach gradually empties its contents into the bowel by peristaltic contractions. An ordinary mid-day meal should have disappeared from the normal stomach after six hours. The fasting healthy stomach should therefore be empty early in the morning. Deviations froiti the normal process of gastric digestion consist — 1. In variations in the amount of hydrochloric acid produced. There may be too much (hyperacidity), or too little (anacidity). 84 EXAMINATION OF DIGESTIVE APPARATUS. 2. In the amount of organic acids formed (abnormal in association with anacidity). 3. In derangement of the act of evacuation of the stomach. Retarded emptying of the stomach (motor in- sufficiency) occurs in conjunction with diminished physical vigor, or with abnormally increased resistance (pyloric stenosis). Inspection. The stomach may be made visible by distention with gas. Especially in marked cases of dilatation may the entire contour of the viscus become distinctly visible. It is important in this connection to recognize the peri- staltic movements of the stomach, a\ hich take place from the left above to the right below, and may be elicited by gentle tapping. Palpation. Strictly circumscribed severe pain in the epigastric region, increased upon pressure, is suggestive of ulcer of the stomach. Tumors in the region of the stomach, especially of the greater curvature (carcinoma), may be distinctly felt in the region of the umbilicus when the abdominal walls are relaxed (if necessary, anesthesia may be induced). Tumors of the stomach, in contrast with those of the liver, are but little movable with respiration. In the region of the pylorus there occur, in addition to carcinoma, hypertrophic cicatrix-formations (associated with hyperacidity), which may be palpable as small tumors. For description of splashing-sounds, see p. 34. They are of diagnostic significance only in conjunction with other symptoms. Percussion. This yields reliable results only in combination with other methods of investigation (filling the stomach with air or witli water). Under these circumstances there can be detcjrmiued tlie situation of the lower boundary of the stomach and the existence of possible dilatation. If this STOMACH. 85 lower boundary is situated at or below the level of the umbilicus, it may be concluded that dilatation of the stomach exists, providing that enteroptosis be not pres- ent — that is, an abnormally low position of the abdominal viscera. The stomach can be distended with gas by the adminis- tration of a spoonful of sodium bicarbonate followed by a spoonful of tartaric acid. The carbonic acid evolved causes distention of the stomach, and the deep, full per- cussion-note of the stomach is distinctly separable from the higher note yielded by the intestine. By introducing the stomach-tube air may be injected directly, or by means of irrigation with the tube the boundaries of the stomach may be determined by percussion, the resulting area of dulness corresponding ^vith the lowest portion of the viscus. Frequently the distention of the stomach thus produced is also distinctly visible. The Study of Gastric Digestion. It is important to determine accurately the secretion of hydrochloric acid, the presence of organic acids, and the motor activity of the stomach. 1. Qualitative determination of free hydrochloric acid, (See Plate 12.) If the gastric juice contain free hydro- chloric acid, a. Blue litmus-paper becomes red on immersion ; 6. Red congo-paper becomes intensely bluish-black ; c. Dilute solution of methyl-violet is changed in color from violet to blue on addition of several drops of the gastric juice ; d. On mixing several drops of Glinzburg's reagent (phloroglucin 2.0, vanillin 1.0, absolute alcohol 30.0) with several drops of the gastric juice in a porcelain dish a distinct red band results on evaporation. The last test {d) is the most reliable ; it will detect the presence of hydrochloric acid even when in very great di- lution (as little as 0.05 per cent.). Tests h and c may yield positive reactions also in the presence of organic acids ; test a also in the presence of acid salts (phosphates). 86 EXAMINATION OF DIGESTIVE APPARATUS. 2. Qualitative determination of ladle acid. Of organic acids, lactic acid is the most important. Its detection is effected by means of Uifelmann's reagent (to 10 en. cm. of a 1 per cent, solution of carbolic acid are added two drops of iron-chlorid solution), which is always to be prepared fresh. The original bluish- violet tint of the reagent becomes yellow on the addition of gastric juice containing lactic acid. The test is more reliable if the lactic acid be isolated from the gastric juice by agitation with ether, and the extract is used in making the reaction. Quantitative determination of the total acidity. The quantitative determination of hydrochloric acid alone is difficult and time-consuming. For clinical pur- poses, however, it suffices to determine tlie total acidity of the gastric juice resulting from the combination of free hydrochloric acid, free organic acids, and acid salts. The result, estimated as hydrochloric acid, will naturally be somewhat too large. In making the determination 10 cu. cm. of unfiltered gas- tric juice are titrated with yV normal soda-solution. Two drops of an alcoholic solution of phenolplithalein are added as an indicator to the measured amount of gastric juice diluted with water until colorless. The soda-solu- tion is allowed carefully to drip from the pipet, the re- action being terminated when the mixture retains a faint rose hue. If 5 cu. cm. of the soda-solution have been needed for 10 cu. cm. of gastric juice, 100 cu. cm. of the latter would have required 50 cu. cm. of the soda-solution, so that the total acidity would be 50 per cent. ; 1 cu. cm. of the nor- mal soda-solution contains 0.004 g. of sodium hydroxid and 50 cu. cm. 0.2. The amount of hydrochloric acid is determined according to the following formula : nCl = ^^-5 X 0.2 ^ ^ .jg2 ^^^^ 40 ^ The course of examination may proceed as follows : STOMACH. 87 1. The stomach is washed out early in the morning , fast- ing. — If on introduction of the tube nothing can be ex- pressed from the stomach (with the co-operation of the patient), and if upon irrigation of the stomach with warm water only this is returned, it can be concluded that the stomach is normally empty. If the patient by press- ure expels fluid after the introduction of the tube, there exists hypersecretion, and examination for hydrochloric acid is made. If this be distinctly demonstrable, there exists also hyperacidity. Hypersecretion with hyperacidity occurs in conjunction with ulceration of the stomach and with nervous acid dyspepsia. If the stomach contain remnants of food, there exists motor insufficiency. 2. The trial-breakfast. — This consists of one cup of tea and a roll. From one-half to three-quarters of an hour after ingestion the gastric contents are expressed through the tube and the filtrate is examined for hydrochloric and lactic acids. The filtrate should normally respond to all of the tests for hydrochloric acid. Especially must the phloroglu- cin-vanillin test yield a positive reaction ; otherwise there exists anacidity. In this event the test for lactic acid will yield a posi- tive reaction. A pronounced lactic-acid reaction (after previous thorough irrigation of the stomach) is suggestive, as a rule, of carcinoma. Anacidity may exist in conjunction with chronic gas- tric catarrh, with atrophy of the gastric mucous membrane, with anemia, and especially with carcinoma. If an active reaction be yielded to the tests for hydrochloric acid, car- cinoma can be excluded with considerable certainty. If the stomach has been thoroughly washed out before the trial-breakfast is given, removing possible stagnant organic acids, the unfiltered gastric contents can be em- ployed for the determination of the total acidity, and from the amount of the estimated hydrochloric acid a conclu- 88 EXAMINATION OF DIGESTIVE APPARATUS. sion can be reached as to the existence of possible hyper- acidity. 3. The trial-meal, — This consists of beefsteali (200 to 250 g.). After the lapse of six hours the stomach should be found completely empty on irrigation ; otherwise motor insufficiency exists. The contraindications to Avashing out the stomach are grave diseases of lungs and heart, recent hemorrhage from the stomach, aneurism of the aorta. For further investigation of the motor activity of the stomach the salol-test among others may be employed. With the meal 2 g. of salol are given in wafer. The salol passes through the stomach without decomposition and is broken up in the alkaline contents of the intestine into salicylic acid and phenol. If the motor activity be normal the former appears in the urine in from three- quarters of an hour to an hour, a violet color developing upon the addition of iron chlorid. In case of motor in- sufficiency the reaction will not take place earlier than after the lapse of from two to five hours, and it may per- sist for two days. The capability of digesting albumin is tested by expos- ing flakes of fibrin to the action of the filtered gastric juice. Normally solution takes place in from six to eight hours. If this have not taken place in the period named in a warm temperature, while solution occurs upon the addition of several drops of 1 per cent, hydrochloric acid, it is to be concluded that hydrochloric acid is absent. If even now the fibrin remains undissolved, pepsin is absent. Through the action of the labfermcnt (pexin) of the normal stomach fresh milk is coagulated in from one- quarter to one-half of an hour on the addition of several drops of filtered gastric juice. Vomiting". Vomiting results from antiperistaltic contractions of the stomach, with simultaneous contraction of the diaphragm and the abdominal muscles, and closure of the pylorus and opening of the cardia. STOMACH. 89 The act of vomiting follows direct or reflex irritation of the vomiting-center in the medulla oblongata : Directly through the action of emetics, poisons (chloro form), toxic diseases (uremia, fever) ; Reflexly from the stomach (ulceration, carcinoma, catarrh, etc.), from the intestines and the peritoneum (ste- nosis of the bowel, peritonitis), in conjunction with gra- vidity, diseases of the brain, etc. Periodic vomiting occurs in cases of cholelithiasis (in conjunction with attacks of colic), of tabes dorsalis (gastric crises), of neurasthenia. Repeated vomiting of large amounts is characteristic of dilatation of the stomach. Vomiting of blood (hematemesis) occurs in conjunction with ulceration of the stomach (fresh, dark-red blood), with carcinoma (disintegrated colfee-ground blood), with erosion (acids, alkalies), vicariously in connection with anomalies of menstruation. Expectorated blood (hemoptysis) is bright red and frothy if it have not been previously swallowed and vomited subsequently. Fecal vomiting occurs in conjunction with occlusion of the bowel (incarceration, intussusception, volvulus). Morning vomiting on an empty stomach is indicative of chronic pharyngeal catarrh (sensitive mucous mem- brane), and is common in alcoholics. Constitution of the vomited matters. — These contain particles of food in process of digestion and of fermenta- tion, albuminous bodies (albumoses, peptone, leucin, ty- rosin), starch, carbohydrates (through fermentation yield- ing lactic acid butyric acid, acetic acid, valerianic acid), fat and fatty acids, coagulated milk, swallowed saliva (yield- ing a red color on addition of iron chlorid in consequence of the presence of potassium rhodanate), mucus (from esophagus and stomach), bile (from the duodenum, espe- cially in connection with severe nausea), urea (uremia). For the microscopy of the vomited matters Plate 11, Fig. 1, may be consulted. 90 EXAMINATION OF DIGESTIVE APPARATW, 4. Liver. The liver lies three-quarters in the right and only one- quarter in the left half of tJie body. Its convex surface lies in close approximation with the diaphragm. The organ is entirely covered with peritoneum. Its sharp, lower border is situated at about the level of the eleventh rib in the axillary line on the right side ; it intersects the costal arch (ninth costal cartilage) in the mammillary line ; it passes midway between the umbili- cus and the root of the ensiform cartilage in the median line ; and is at the level of the eighth costal cartilage in the left parasternal line. (See Plate 23.) The gall-bladder lies exactly at the point where the liver emerges from beneath the right half of the costal arch — that is, at the level of the ninth costal cartilage somewhat within the mammillary line. In children the liver is relatively larger than in adults. The liver follows all movements of the diaphragm (respiration, elevation and depression). The most important functions of the liver are : a. The elaboration and secretion of bile (digestion of fats) ; 6. The conversion of the sugar of the food into glyco- c. The disposition of disintegrated red corpuscles, of toxic substances, etc. The most important symptoms of disease of the liver are jaundice and ascites. Jaundiae (deposition of biliary coloring-matter in the skin, sclera, etc.) results in consequence of the passage of the biliary constituents into the blood, in conjunction with occlusion of the biliary passages (choledoch duct, hepatic duct, biliary ca])illaries), resulting from catarrh, from the formation of calculi, from the presence of tumors (carci- noma), as well as in conjunction with certain infectious diseases (enormous destruction of erythrocytes in the liver). The ])ulsc is slow (influence of the biliary acids). If the access of bile to the intestine is prevented, the LIVER. 91 digestion of fats is rendered difficult, and the stools become acholic (free from biliary coloring-matter), grayish-white and clay-colored, and they contain many fat-crystals. Some of the bile circulating in the blood is excreted with the urine, which as a result becomes dark brown in color, and on shaking forms a yellowish foam (for the reactions see Section III., p. 112). Simple jaundice results from catarrhal swelling of the choledoch duct in conjunction with duodenal catarrh, and is of short duration (from two to four or six weeks). Grave jaundice (of longer duration, attended with nutri- tive disturbances, pain, chills) occurs in conjunction with cholelithiasis (repeated attacks of colic, vomiting), with car- cinoma of the liver or biliary passages (cachexia, tumors of the liver), with cirrhosis of the liver (associated with ascites), with abscess of the liver (fever, chills). Amyloid liver, fatty liver, and echinococcus also are usually unat- tended with jaundice. Ascites (dropsy of the peritoneum) occurs in conjunc- tion with pressure upon the portal vein or embarrassment of the circulation of blood in the liver-capillaries in con- sequence of stasis in the veins of the peritoneum, the omentum, the stomach, etc., with closure and with com- pression of the portal vein (tumors, thrombosis), with cirrhosis of the liver, rarely with syphilis and carcinoma of the liver. The spleen is enlarged simultaneously (cy- anotic spleen). Ascites due to disease of the liver is not attended with edema of the lower extremities (in contrast with general stasis from disease of the heart). Edema of the lower extremities may, however, appear subsequently (in consequence of compression of the abdominal veins). Palpation. The normal liver is not palpable below the costal arch in the mammillary line. The lower border of the liver becomes palpable — When the liver is displaced downward (pleurisy, pneu- mothorax, tumors) and also when a wandering liver is present ; 92 EXAMINATION OF DIGESTIVE APPARATUS. When the liver is enlarged, or constricted (movable lobe, fissure), or cyanotic, or fatty, or amyloid ; When hypertrophic cirrhosis, carcinoma, syphilis, or abscess exists. The palpable margin of the liver may be — Hard and smooth : cyanotic liver, amyloid liver (blunt), hypertrophic cirrhosis, echinococcus ; softer : fatty liver ; Irregular, nodular : cirrhosis, carcinoma, syphilis, and at times with (superficial) abscesses. Percussion. — Normal liver-dulness : The upper limit in the mammillary line corresponds with the lower border of the sixth rib ; the lower limit coincides with the lower border (see anatomic notes). Dhnhiution in the area of hepatic percussion-dulness occurs in conjunction — 1. With respiration (on deep inspiration the upper limit is displaced downward) ; with emphysema, as a result of overlapping of the lung ; 2. With meteorism, overlap])ing of the intestines, as- cites, abdominal tumors ; 3. With the entrance of air into the abdominal cavity (perforative peritonitis) ; 4. With cirrhosis of the liver; 5. With acute yelloAv atrophy of the liver. Increase in the area of hepatic percussion-dulness is observed in conjunction with cyanotic liver, hypertrophic cirrhosis, amyloid liver, fatty liver, carcinoma, echinococ- cus, abscess-formation. The enlarged gall-bladder can be demonstrated by pal- pation and by percussion below the ninth costal cartilage in conjunction with an accumulation of calculi (nodular), with carcinoma (uneven, solid tumor), with hydrops from chronic occlusion by calculus-formation or from oblitera- tion (smooth, tense). 5. Spleen. The spleen is situated in the left hypochondrium, reaching from the ninth to the eleventh rib, with its pos- ABDOMEN, INTESTINES, AND PERITONEUM. 93 terior boundary about 2 cm. from the body of the tenth dorsal vertebra. Anteriorly it does not extend beyond the costo-articular line (from the left sterno-clavicular articu- lation to the apex of the eleventh rib). The area of splenic dulness corresponds with these boundaries. The normal spleen is not palpable, and when it becomes so it may be concluded that it is either displaced or enlarged. Palpation of the spleen is practised by having the patient lie upon the right side, with the thighs drawn up, the ulnar border of the hand being gradually introduced beneath the left half of the costal arch. By this means it may be possible, especially on deep inspiration, to feel a solid, resisting body. The area of splenic percussion-dulness is determined by percussing first from above downward parallel with the left intercostal spaces (thus obliquely downward) until dulness is reached. The finger is now placed at right angles to its former position, and percussion is practised in a forward direction until a tympanitic note is yielded (the bowels having been previously emptied). Displacement of the spleen takes place in conjunction with pleurisy and pneumothorax (downward), with met- eorism, ascites, abdominal tumors, and w^andering spleen. Enlargement of the spleen takes place in conjunction with infectious diseases (typhoid, malaria, pyemia, etc.), amyloid degeneration, cirrhosis of the liver, stasis in the general circulation (cyanotic spleen), hemorrhagic infarc- tion (embolism) of the spleen, leukemia (frequently dis- tinct indentations are palpable). Abolition of splenic didness occurs in conjunction with perforative peritonitis (accumulation of air over the spleen in right lateral decubitus). 6. Abdomen, Intestines, and Peritoneum. In health the abdomen is slightly convex, takes part in the rhythmic movements of respiration, and yields a tym- panitic note on percussion (slight dulness only over con- siderable fecal accumulations in the large intestine). 94 EXAMINATION OF DIGESTIVE APPARATUS. Abnormal i^etractlon of the abdominal walls takes place in conjunction with intestinal colic (lead-colic), meningitis (scaphoid abdomen), and marked emaciation (carcinoma). Distention of the abdomen occurs in conjunction with : 1. Meteor ism (accumulation of gas in the intestines). The abdomen is uniformly balloon-like-shaped and yields everywhere a loud, high note, without fluctuation. Meteor- ism attends obstinate constipation, abnormal fermenta- tive processes (intestinal catarrh), typhoid fever. It is especially marked in conjunction with stenosis and occlu- sion of the bowel, ileus (incarcerated hernia, invagina- tion, torsion of the bowel), in association with fecal vom- iting and collapse ; further with acute peritonitis (only bilious, but not feculent vomiting, tenderness, collapse). Fig. 29.— Ascitic effusion, with dorsal decubitus. 2. Ascites (accumulation of fluid free in the abdominal cavity). The distention affects especially the lateral aspects of the abdomen (bulging). Absolute dulness is present, in accordance with the posture (see Figs. 29 and 30), always in the dependent portions (displacement of the fluid by gravity) ; the upper boundary of the dulness is crescentic. The intestines are displaced to the upper portion of the abdomen, where they yield a clear tympan- itic note. If the ascites be excessive, the intestines may be held down by their mesenteric attachment so as ABDOMEN, INTESTINES, AND PERITONEUM. 95 nowhere to reach the abdominal wall, and the dulness on percussion thus becomes complete. If the ascites be but slight, dulness appears in the region of the umbilicus when the prone position is assumed. The fluid in the abdominal cavity yields a distinct Fig. 30.— Ascitic effusion, with lateral decubitus. sense of fluctuation upon palpation (wavy movement). Exploratory puncture is always indicated for confirma- tion. Ascites due to stasis occurs in conjunction with : 1. Diseases of the portal vein and of the liver (stasis in the portal circulation, the peritoneal veins, etc.). At the same time the spleen is enlarged. 2. General dropsy from derangement of compensation in connection with heart-disease, and associated with edema of the extremities, infiltration of the thoracic and abdominal walls, cyanotic kidney, etc. The transudate contains little albumin and has a spe- cific gravity of between 1006 and 1015. Inflammatory ascites occurs in conjunction with — 1. Tuberculous peritonitis; 2. Carcinoma of the peritoneum. The diagnosis is based upon the demonstration of tuber- culosis or carcinoma in other organs (pulmonary tubercu- 96 EXAMINATION OF DIGESTIVE APPARATUS. losis, glandular tuberculosis, pleurisy, carcinoma of stom- ach, rectum, ovary, or uterus). The extravasated fluid is richer in albumin and has a specific gravity of more than 1018 (to be measured with the areometer at room-temperature). If the exudate in a case of chronic peritonitis is saccu- lated, variations in dulness do not take place with changes in posture. 3. The entrance of air into the abdominal cavity (per- forative peritonitis). This may occur in conjunction with perforation of a chronic ulcer of the stomach, with tuberculous, dysen- teric, and typhoid ulceration, and with perforation of the vermiform appendix. The accumulation of air occupies the uppermost position, displacing the liver entirely or largely in the dorsal decubitus (disappearance of the liver-dulness) and the splenic dulness in the right lateral decubitus. Fre- quently also fluid is demonstrable at the same time in the dependent portions of the abdomen. 4. Tumors. The distention due to the presence of new- growths is usually unsymmetric, as are also the area of dulness on percussion and the phenomena disclosed on palpation. Frequently also ascites is present at the same time. The tumors may originate from the liver (enlargement ; carcinoma, especially metastatic), from the stomach (car- cinoma), from the spleen (malaria, leukemia), from the omentum (carcinoma, tuberculosis), from the pancreas (cysts), from the intestine (exudation ; perityphlitis, in the cecal region ; carcinoma), from the ovaries (cysts), from the uterus (gravidity, myomata, fibromata), from the aorta (aneurism), from the vertebral column (abscess), from the kidneys (sarcoma). When the existence of a tumor is suspected examina- tion should be made always before and after evacuation of the bowels (scybala are of a doughy consistence and are usually palpable). ABDOMEN, INTESTINES, AND PERITONEUM. 97 The point of origin of a new-formation should be deter- mined, if possible. If cysts or exudates are present, explor- atory puncture is important. Ovarian and uterine tumors exhibit (in contrast with ascitic dulness) a convex upper boundary, the dulness being situated in the middle of the abdomen, while the note on either side is clear. The Stools. The normal stool is of a brownish color (in consequence of reduction of biliary coloring-matter, hydrobilirubin, effected through bacterial activity). The stool of the nursing-infant (milk-stool) is yellowish. The stool con- tains the undigested elements of the food (especially vege- table residue), together with the remains of unabsorbed digestive fluids (bile, intestinal juice). The coloi' of the stools becomes especially striking in conjunction with — Jaundice : grayish-white (fatty stool, acholic stool) ; Diarrhea: greenish (unchanged biliary coloring-mat- ter); The administration of iron and bismuth: black (sul- phur salts) ; The administration of calomel : greenish-brown (biliary coloring-matter and mercury sulphid) ; The admixture of blood: blackish-brown, tar-like (when the blood comes from the stomach or the upper portion of the small intestine), in cases of gastric hemor- rhage, of embolism of the mesenteric artery, and of ty- phoid fever ; bright red (when the blood comes from the large intestine) in cases of hemorrhoids, of intestinal ulceration, and of dysentery ; Typhoid fever : pea-soup-like ; Asiatic cholera: ricewater-like. Admixture of mucus may occur in conjunction with — Catarrh of the large intestine (covering the surface of the feces) ; Catarrh of the small intestine (intimately admixed with feces, sago-grains) ; Catarrh of the duodenum (bilious mucus) ; 7 98 EXAMINATION OF DIGESTIVE APPARATUS. Dysentery (blood-streaked) ; Ulceration (purulent), occurring in cases of dysenteric, syphilitic, and tuberculous ulceration ; Membranous enteritis (mucous colic of nervous indi- viduals) ; occurring as tubular casts of the mucous mem- brane ; Carcinoma of the rectum (pure or bloody mucus). Pus is found in the stools in conjunction with — Rupture of an abscess (paratyphlitis, suppurating cysts, exudates) ; Dysentery (sanious) ; Ulceration of the rectum (syphilis, tuberculosis, carci- noma). Calculi are found in conjunction with — Cholelithiasis (cholesterin, bilirubin, and lime), Fecal concretions (especially of lime and magnesia). Constipation occurs in conjunction with — 1. Intestinal atony in cases of neurasthenia, of insuffi- cient bodily exercise, in bed-ridden patients, in cases of habitual obstipation, of opium -addiction, and of pyloric stenosis ; 2. Stenosis or occlusion of the bowel (ileus) ; in the presence of either of these conditions there is no discharge of flatus. Diarrhea occurs — 1. As a result of nervous influences (rapidly transient excitation of intestinal peristalsis) ; 2. In conjunction with abnormal fermentative processes in the intestine (cholera morbus, cholerine, cholera) as a result of the development of toxic substances ; 3. In conjunction with chronic intestinal catarrh, amy- loid disease of the intestine (deficient resorption of nutri- tive substances) ; 4. In conjunction with ulcerative processes (typhoid fever, tuberculosis, dysentery, syphilis) ; 5. In conjunction with circulatory disturbances (stasis in the portal vein, general stasis) ; 6. In conjunction with tabes (crises), with uremia, etc. KIDNEYS. 99 For the microscopy of the stools, Plate 11, Fig. 2, should be consulted. The most important parasites found in the stools are cholera-bacilli, typhoid-bacilli, tubercle-bacilli, amebse, and certain worms. (See page 120 et seq.) When hel- minthiasis exists microscopic examination discloses the presence of large numbers of the respective ova, and at times also Charcot-Leyden crystals (see Plate 8, Fig. 5). IV. EXAMINATION OF THE UROPOIETIC SYSTEM. 1. Kidneys. The kidneys extend from the twelfth dorsal to the upper border of the third lumbar vertebra. The right kidney is in contact above with the liver, the left with the spleen. The kidney becomes palpable only w^hen displaced (wandering kidney), and in the presence of neoplasms : congenital sarcomata, carcinomata (solid tumors, rapid growth, cachexia, hematuria, vermicular blood-clots) ; when the seat of an echinococcus-cyst (fluctuation, with echinococcus-hooklets, shreds of membrane, and consider- able sodium chlorid in the fluid removed by puncture — see Plate 21, Figs. 7 and 8), or of hydronephrosis (alternate filling and evacuation of the cystically dilated pelvis of the kidney, with possible demonstration of urea). These tumors are immovable with respiration. Percussion. — The normal area of renal percussion-dul- ness is continuous with that of the liver and spleen re- spectively, forming with the latter an angle open outward, and extending about 10 cm. (4. in.) laterally from the spinous processes of the vertebra. Normal renal percussion-dulness is wanting in cases of wandering kidney (more common on the right than on the left). It is increased in conjunction with all forms of tumor of the kidney. As such tumors (in contrast with other forms of tumor) lie necessarily beneath the colon, a tympanitic band appears in the area of dulness on evac- 100 EXAMINATION OF THE UROPOIETIC SYSTEM. uation of the colon, and more distinctly on the introduc- tion of air (see Plate 68). 2. Bladder. The bladder becomes demonstrable in the median line above the symphysis pubis only when greatly distended. Tumors of the bladder (carcinoma, villous carcinoma) may at times be palpable through the rectum or the vagina. For accurate examination, catheterization and the use of the endoscope are necessary. 3. The Urine. The urine is secreted from the blood by the kidneys, and contains the excreted salts dissolved in water and the end-products of albuminous disintegration in the body. The results of examination of the urine thus permit of a conclusion with regard to this important metabolic process. They further afford an indication as to the state of the kidneys, in- connection with disease of which cer- tain elements appear abnormally in the urine (epithelial cells, tube-casts, albumin, blood), as well as in conjunc- tion with diseases of the remainder of the urinary tract (pelvis of the kidney, ureters bladder, urethra). Important alterations in the urine occur further in con- nection with diseases of the heart (cyanotic kidney), with diseases of the liver (biliary coloring-matter), with cer- tain metabolic disorders (diabetes, gout, etc.), with intoxi- cations (lead, iodin, mercury, etc.). The amount of urine secreted in twenty-four hours is 1500 cu.cm. (47 oz.). Diminution in the amount secreted (under 500 cu. cm.) occurs in conjunction with profuse sweating (fever), diar- rhea, cholera (anuria), with diseases of the kidney and of the heart (acute nephritis, cyanotic kidney), with the formation of inflammatory exudations. Increase in tlie amount (above 3000 cu. cm., polyuria) occurs after the ingestion of hirge amounts of fluid, in conjunction with diabetes mellitus and insipidus, with THE URINE. 101 contracted kidney and with the elimination of exudates and transudates. The specific gravity (to be measured with the urometer at room-temperature) is normally 1017 (1010 to 1025). It exceeds 1025 wlien urine is concentrated and in cases of diabetes mellitus. It falls below 1010 in cases of con- tracted kidney and of diabetes insipidus. If the last two figures of the specific gravity be mul- tiplied by 2.33 (Haeser's coefficient), the result represents the proportion of solid elements in grams contained in 1000 cu. cm. of urine. Color and Sediment. The normal yellow color of the urine is altered in ac- cordance with the degree of concentration. The more concentrated, the darker ; the greater the amount of water present, the lighter. A blood-red color is noted when admixture with blood occurs ; a dark-brown color (foam yellow) when jaundice is present (biliary coloring-matter) ; a dark color (blackish-green) when carbolic acid has been absorbed and when melanin is present (melanosarcoma). Urine that is clear when first evacuated often becomes turbid on cooling, in consequence of precipitation of uric acid (the precipitate is redissolved upon the application of heat). If the urine is permitted to stand in a conical vessel (sediment), there forms in the lowest portion the so-called nubecula (mucoid cloud). After the urine has stood for some time it becomes turbid in consequence of ammoniacal fermentation (bacterial activity) and there is thrown down a sediment of phosphates, which are redis- solved upon the addition of acids. (With regard to the remaining urinary sediments, see Plates 13, 14, 15). The reaction of urine is acid (blue litmus paper is red- dened), in consequence of the presence of acid salts (acid sodium phosphate and uric acid). When the urine is feebly acid it becomes turbid when heated (dissipation of carbon dioxid, and as a result throw- ing out of solution of earthy phosphates) j on the addi- 102 EXAMINATION OF THE UROPOIETIC SYSTEM. tion of acid these salts are redissolved (in contrast with the cloudiness due to albumin). The urine may be alkaline from the presence of potas- sium carbonate and sodium carbonate (fixed alkali ; red litmus-paper is changed to blue when immersed) through the intermediation of the food ; or from the presence of ammonium carbonate (volatile alkali ; moistened litmus- paper held above is changed to blue ; ammonium chlorid vapor developed when a glass rod moistened with hydro- chloric acid is held above) ; or from the transformation of uric acid into ammonium carbonate (bacterial activity) : NH2 NH40 CO + 2H2O = CO NH2 NH40 The degree of acidity of the urine is greater after the ingestion of meat, cheese, and cereals (from the develop- ment of phosphoric acid and sul])huric acid out of albu- minous bodies). It is diminished after the ingestion of berries, fruits, and potatoes (potassium carbonate), after the direct administration of alkalies (carbonated waters, etc.), in conjunction with loss of hydrochloric acid (vom- iting, hyperacidity), and with chlorosis. Chemic Examination of the Urine. (a) Nonnal inorganic constituents. Chlorids {from 10 to 15 grams — 150 to 225 grains — of sodium chlorid daily). The chlorids in the urine are diminished in febrile states and in conjunction with in- anition. On the addition of a 10 per cent, solution of silver nitrate to the urine acidulated with nitric acid sil- ver chlorid is normally precipitated in dense flakes ; while in pneumonia, for instance, only a slight turbidity results. The quantitative estimation of the chlorids may be made by titration after the methods of Mohr and of Volhard-Salkowski (see text-books of physiologic chem- istry). Sulphates (2 grams — 30 grains — of sulphuric acid daily). Sulphuric acid appears in the urine united in part with THE URINE. 103 sodium, potassium, magnesium, and calcium (sulphates), and in part with organic substances, such as phenol, in- doxyl, scatoxyl, in the form of ether-sulphuric acids. Through the combination of these aromatic substances, resulting from intestinal putrefaction, with sulphuric acid these poisonous bodies are eliminated (thus in cases of carbolic-acid poisoning the sulphates are greatly dimin- ished). The sulphates are precipitated from urine acid- ulated with acetic acid in the form of barium sulphate upon the addition of a 10 per cent, solution of barium chlorid. The ether-sulphuric acids present in the filtrate are decomposed by boiling with concentrated hydrochloric acid, and are precipitated as barium salts. Their amount affords a means of estimating the intensity of intestinal putrefaction. Carbonates. — Calcium carbonate, magnesium carbonate, ammonium carbonate. On addition of acids carbon dioxid is set free, with effervescence. Phosphates. — Acid, neutral, and basic salts, with sodium, potassium, ammonium, calcium, magnesium. In cases of phosphaturia the daily elimination of phos- phoric acid exceeds 3 grams — 45 grains (to be determined only by quantitative analysis, according to the method of Neubauer). Nitrates and nitrites are found in urine in only small amounts. Sodium (from 4 to 6 grams — 60 to 90 grains — NaaO) ; potassium (from 2 to 3 grams — 30 to 45 grains — KgO) ; ammonia (from 0.5 to 0.8 gram — 7^ to 12 grains — daily in fresh urine). The amount of ammonia is increased in cases of diabetes (up to 6 grams — 90 grains — daily), in conjunction with diseases of the liver and with fermenta- tion of urine (from urea). Potassium is present in larger quantity (from three to six times as large) than sodium when there is excessive dis- integration of albumin (in cases of fever and of inanition). Calcium (0.16 gram — 2^ grains — CaO) ; magnesium (0.23 gram — 3^ grains — MgO daily). 104 EXAMINATION OF THE UBOPOIETIC SYSTEM, b. Normal Organic Constituents of the Urine. NH2 Urea I CO \ NH, Daily amount from 20 to 40 grams (from 6 to 10 drams) ; increased with excessive disintegration of albu- min (diabetes, leukemia, fever, phosphorus-poisoning) up to 100 grams — 3 ounces ; diminished in conjunction with certain diseases of the kidney and of the liver (acute yellow atrophy of the liver), and with inanition. Qualitative determination (also for the vomited matter in cases of uremia). Evaporation to the consistence of sirup ; extraction with alcohol ; evaporation of the fil- trate ; solution in a small amount of water ; addition of nitric acid. On cooling, urea nitrate separates in the form of rhombic and six-sided plates. Quantitative determination of the amount of nitrogen may be made according to the methods of Liebig-Pfliiger and of Kjeldahl. Uric acid (CJi^'Nfi^) ; from 0.5 to 1 gram — 7^ to 15 grains — daily. Qualitative Determination by the murexid test. — Evapo- ration Avith several drops of nitric acid develops an orange- red spot, which when touched with ammonia assumes a purple color, and becomes blue on addition of potassium hydroxid. Uric acid is found in urine as acid sodium urate (brick- dust sediment) and as free uric acid ; in urine that has undergone decomposition it appears in the form of am- monium urate. It represents the terminal product of dis- integration of the nucleins (albuminous substances of the cell-nuclei). It is increased in amount in cases of leuke- mia (from increased destruction of leukocytes), and at times in cases of gout. Indican (potassium indoxyl-sulphate) is increased in the urine in the presence of augmented intestinal putre- faction, especially in cases of peritonitis, occlusion of the THE URINE. 105 bowel, perityphlitis, coprostasis, putrid-suppurative pro- cesses. It is formed from the iiidol generated within the intestine, and is demonstrable in the urine as indigo-blue (oxidation). Test for Indican. — Addition of hydrochloric acid to an equal portion of urine ; addition drop by drop of a freshly prepared solution of potassium chlorate, with agi- tation (not too much to be added) ; further agitation with chloroform yields a blue color. The demonstration of indigo-red is without significance (Rosenbach's reaction). Phenols (phenol hydroquinone, cresol) appear in the urine as ether-sulphuric acids. They also are increased in the presence of intestinal putrefaction. Test for Phenol. — To 100 cu. cm. of urine are added 5 cu. cm. of concentrated sulphuric acid, and distillation effected. The addition of bromin-water to the distillate yields a yellowish- white precipitate of tribromphenol. Normally from 0.02 to 0.05 gram (^ to f grain) phenol is eliminated daily. Xanthin and hypoxanthin (the latter is abundant in cases of leukemia). HippuriG acid and creatinin have hitherto been consid- ered without significance. Oxalic acid (from 0.01 to 0.03 gram — ^ to -^ grain — ■ daily) is found especially in the form of calcium oxalate. c. Pathologic Ingredients of the Urine. Albumin is generally found in the form of serum-albu- min and of serum-globulin, less commonly as albumoses, propeptones, fibrin, and nucleo-albumin. It appears con- stantly in conjunction with diseases of the kidney (espe- cially nephritis) or of the urinary passages ; and transi- ently in cases of fever, of venous stasis, etc. It is probable that physiologic albuniinwna (sometimes cyclic) occurs in healthy individuals, but the amount of albumin eliminated is quite small (less than 0.05 per cent.). The condition has been observed following active exercise, profound excitement, and large meals. 106 EXAMINATION OF THE UROPOIETIC SYSTEM. When blood or pus is present in addition to albumin, the latter may have been derived from the plasma of the former (spurious albuminuria). A conclusion as to in- volvement of the kidneys is to be reached from the pres- ence of other elements (tube-casts, renal epithelium). The following are the most important tests for albu- min : 1. The Boiling Test. — The urine is heated in a test-tube to the boiling-point, and several drops of dilute nitric acid are added. The albumin is coagulated, any phos- phates precipitated at the same time being redissolved by the acid. The precipitation of the albumin takes place in the test-tube in the course of several hours, and by this means an approximate estimate of the amount may be formed. Slight turbidity (traces) = 0.01 per cent, albumin. An appreciable sediment at the bottom of the tube = 0.05 per cent. The precipitate occupies yo ^he column of urine = 0.1 fo u u u X " " " -0.25% " " " I " " " =0.5% u u u 1. a u '' =1% If the entire column has coagulated, the amount of albumin = from 2 to 3 per cent. 2. Acetic-acid Potassium-ferrocyanid Test. — The urine is acidulated with several drops of acetic acid, and a 5 per cent, solution of potassium ferrocyanid is added drop by drop. Any albumin present will be coagulated. 3. Esbach^s ^^ quantitative^^ test for albumin permits of an approximately quantitative estimation. A graduated test-tube, designated an albuminiraeter, is filled with urine to a point marked U, and with Esbach's reagent (consisting of citric acid 5, picronitric acid 2.5, distilled water 245) to a point marked K. The two are well mixed by shaking, and in the course of twelve hours the percentage of albumin can be read from the scale. Other tests (Heller's nitric-acid test, acetic-acid sodium- THE URINE. 107 chlorid test, etc.) are superfluous. For country practice capsules containing the necessary reagents (citric acid, sodium chlorid, and mercuric chlorid) are serviceable. Albumoses (formerly taken for peptones) are present in urine especially in conjunction with suppurative pro- cesses in some part of the body (pyogenic variety), with ulceration of the bowel, with pneumonia (stage of resolu- tion), with purulent meningitis (in contradistinction from tuberculous meningitis), with a number of diseases of the liver. They may be demonstrated by the biuret-test after removal of albumin by boiling and filtration (develop- ment of a violet color on addition of potassium hydroxid and several drops of a 1 per cent, solution of copper sul- phate). Salkowski\s Test. — To 20 cu. cm. of urine freed from albumin hydrochloric acid is added, and then phosphor- molybdic acid ; the resulting precipitate is warmed, washed with water, dissolved in dilute potassium hydroxid, and again warmed until a yellow color appears. On cooling the biuret-test is made. Nudeo-alhumin (formerly taken for mucin). If to the urine, diluted with water and filtered, an abundance of acetic acid be added, nucleo-albumin is precipitated. Glucose (grape-sugar). Urine containing sugar has a high specific gravity (above 1025). The presence at times of sugar in normal urine has not yet been conclu- sively demonstrated, although it is probable. Reducing- substances that are not sugar are often present. Glycosuria is the main symptom of diabetes mellitus. A distinction is made between a mild form (elimination of sugar only after ingestion of carbohydrates (aliment- ary glycosuria) and a severe form (elimination of sugar also upon a diet of meats and fats ; as much as 10 per cent, of sugar may be present).^ The most important qualitative tests for sugar : 1. Reduction-tests. — Grape-sugar has the property of ^ A diabetic patient under my observation excreted on one occasion 1.09 kg. of grape-sugar in twenty-four hours in 9000 cu. cm. of urine. 108 EXAMINATION OF THE UROPOIETIC SYSTE3I reducing substances susceptible of reduction (e. g., cop- per oxid, bismuth oxid). As, however, other substances in the urine (e. g., creatinin, uric acid, turpentine, copaiba, salicylic acid) possess a similar property, these tests are not absolutely conclusive. Trommer^s Test. — To the urine is added one-third its volume of potassium hydroxid (turbidity results from the precipitation of phosphates) ; then 10 per cent, solution of copper sulphate is added drop by drop. If the urine contain sugar, the hydrated copper oxid formed will remain in solution (clear, azure-blue color), as it will also in urine containing albumin, ammonia, etc. If the urine contain none of these solvent substances, the addition of the copper sulphate results in the formation of a greenish flocculent precipitate. In the presence of sugar there results upon heating the upper layer, and even before boiling, a cloudy precipitate, at first yellowish, then pro- nouncedly yellowish-red, which gradually distributes itself downward. The blue hydrated copper oxid is re- duced to red cuprous oxid. (Cu(HO)2 is converted into CU2O.) The test yields a positive reaction in the presence of more than 0.5 per cent, of sugar. Nyktnder^s Test. — To the urine is added one-tenth its volume of Nylander's reagent (bismuth subnitrate 2, po- tassium and sodium tartrate 4, sodium hydroxid 100 cu. cm.). In the presence of sugar the upper layer assumes a black color on the application of heat, from precipitation of reduced metallic bismuth. This test will yield a positive reaction when sugar is present in amount equal to 0.1 per cent, and less. 2. 3Ioore^s Test. — On adding to urine one-third its volume of potassic hydroxid and boiling from two to five minutes a chestnut-brown color is developed, from con- version of sugar into caramel, which may be recognized by its odor. The reaction becomes distinct when not less than 0.5 per cent, of sugar is present. 3. The Fermentatmi-tcst. — This is the most reliable test for sugar, and is to be employed in all doubtful cases. THE iTBtNR 109 Grape-sugar is broken up by fermentation into alcohol and carbon dioxid on addition of yeast. The accumula- tion of carbon dioxid is the greater the larger the amount of sugar present. Of three fermentation-tubes, there is introduced into each respectively — a. The urine to be examined, together with yeast ; h. A solution of grape-sugar, together with yeast ; c. Urine free from sugar, together with yeast. /^ Fig. 31 a, Fig. 31 6. Fermentation-tubes (a) before and (b) after the fermentation of urine containing sugar. The tubes are permitted to stand in a warm room. After the lapse of twelve hours, often even earlier, car- bon dioxid will be present in tube a if the urine contain sugar. There should be no carbon dioxid in tube c, un- less the yeast have contained sugar. Should no carbon dioxid be present in tube a, but be present in tube h, in- dicating that the yeast has been active, it may be con- cluded that the urine is free from sugar. The test is applicable when not less than 0.1 per cent, of sugar is present. 4. In the 'polarization-apparatus urine containing sugar, 110 EXAMINATION OF THE UROPOIETIC SYSTEM. even in as small amount as 0.1 per cent., deflects the plane of polarized light to the right, in greater degree as the amount of sugar present is larger. For this purpose a suitable apparatus is constructed by Schmidt and Haensch, of Berlin. If the urine be not perfectly clear, it should be filtered after addition of one-tenth volume of lead acetate, and albumin must have been previously removed. The percentage of sugar contained may be read directly from the scale. 5. Phenylhydrazin Test. — A small quantity of phenyl- hydrazin chlorid (about 0.4) is added to 10 cu. cm. of a warmed 10 per cent, solution of sodium acetate. To the mixture are added 10 cu. cm. of urine, and the whole is placed upon a hot water-bath for an hour. In the pres- ence of sugar there form yellow needle-like crystals of phenylglucosazon, which melt at 205° C. If these occur in small amounts, their presence is to be determined microscopically. Glycuronic acid appears in crystals of similar appearance, but with a lower melting-point. Quantitative Determination of Sugar. 1. Fermentation-test with Einhorn's sacchari meter, which is graduated empirically. Ten cu. cm. of urine are meas- ured and introduced, together with yeast, into a tube. In accordance with its specific gravity the urine must have been previously diluted — if from 1018 to 1022 twice, if from 1022 to 1028 five times, and if from 1028 to 1038 ten times. More reliable still is the determination with the areo- saccharimeter of Schuetz. The flask is filled with urine up to a given mark, and one gram of yeast is added. The vessel is placed in water so that the spindle is immersed, by means of shot, up to the mark per cent. After fer- mentation for from twenty-four to thirty-six hours at room- temperature the percentage is to be read from a scale. 2. Titration with FehUncfs Solution. — Fehling's solution consists of copper sulphate 34.689, potassium and sodium tartrate 173, official sodium hydroxid 100, distilled water THE URINE. Ill sufficient to make one liter. It is best to keep the solu- tions of the two salts separate, and mix them just before they are to be used. 0.01 gram sugar reduces 2 cu. cm. of this solution. 0.005 gram sugar reduces 1 cu. cm. of this solution. The urine, especially if it contain a large proportion of sugar, is diluted ten times with distilled water and by means of a buret it is added, drop by drop, to 10 cu. cm. of boiling Fehling's solution, previously diluted with 20 cu. cm. of water, until the blue color of the solution has disappeared. If y cu. cm. of urine have been used, the proportion of sugar is estimated according to the follow- ing formula : . = 10. 10 X 0.005 X 100 ^ 50 p^^ ^^„, y y 3. Polarization 3fethod (see p. 109). — In addition to grape-sugar, milk-sugar (in nursing-women) and inosite also may be present in the urine, but these are without significance. Blood. The urine may present the color of blood — 1. From admixture of red blood-corpuscles (hematu- ria) ; and 2. From the presence of free blood coloring-matter in solution, without blood-corpuscles (hemoglobinuria). The differentiation is to be made by means of micro- scopic examination. Hematuria occurs in conjunction with some forms of inflammation of the kidney, with embolism, with nephro- lithiasis, with tumors of the kidney and of the bladder, with vesical calculi, etc. Hemoglohiniiria occurs in conjunction with some forms of poisoning, also after transfusion, burns, etc., and together with hemoglobinemia. On spectroscopic examination there will be found the blood-spectra delineated in Plate 6, and more particularly the spectrum of oxyhemoglobin, of methemoglobin, and 112 EXAMINATION OF THE UEOPOIETIC SYSTEM. of hematin. In addition, the spectrum of hematoporphy- rin (two bands in the yellow, etc.) will be found in cases of poisoning with trional and with sulfonal. Hellers Test for Blood. — The addition of one-third po- tassium hydroxid destroys the erythrocytes, and the hemoglobin is set free. On boiling, the latter is carried down with the precipitate of phosphates as a brownish- red flocculent sediment. Biliary Coloring-matter. When jaundice is present bilirubin (which on oxida- tion is converted into biliverdin) appears in the urine. On the other hand, hydrobilirubin (urobilin), reduced in the intestine from bilirubin through putrefactive pro- cesses, is absent when access of bile to the bowel is en- tirely cut off. Icteric urine is dark brown in color, and its foam yellow. When shaken with chloroform the bili- rubin is dissolved and gives rise to a yellow color. If the urine be carefully poured into a vessel containing concen- trated nitric acid, together with several drops of fuming nitric acid, changing rings of "color are formed — green, violet, red, yellow (Gmelin^s test). To demonstrate the presence of biliary acids (in the presence of jaundice) gradual evaporation of a mixture of five drops of urine, a little cane-sugar, and one drop of sul- phuric acid in a porcelain dish gives rise to a purple color. Acetone and diacetic acid are found in the urine when albumin is disintegrated in large amounts (high fever, advanced tuberculosis, diabetes, carcinoma, etc.). Diacetic acid yields a Bordeaux-red color on addition of iron chlorid. Its presence is indicative of threatened diabetic coma, although it occurs under other conditions as well. At the same time, oxybutyr>.; ac'.d also is often present. Acetone yields, after over-distillation :,f 500 cu. cm. of urine acidulated with hydrochloric acid, a yellowish-white preci})itate of iodoform on addition of several drops of LugoPs solution of iodin with potassium hydroxid (Lie- ben's test). THE URINE. 113 Melanin occurs, also in the form of melanogen, in the urine of patients suffering from melanotic tumors. When the urine is permitted to stand a dark color develops, which on addition of iron chlorid becomes black. Fat gives rise to a fine milky turbidity (chyluria). It is dissolved upon shaking with ether after addition of potassium hydroxid. Chyluria occurs in association with tilaria sanguinis hominis (in the tropics), and with occlu- sion of the thoracic duct, etc. The Diazo-reaction of Ehrlich. — A number of febrile diseases (typhoid fever, pneumonia, miliary tuberculosis, septicemia, pulmonary tuberculosis, etc.) are attended with the presence in the urine of certain not intimately known aromatic substances which yield a red color in the pres- ence of sulfodiazobenzol. A mixture of 50 cu. cm. of sulphanilic solution (sulphanilic acid 0.5, hydrochloric acid 5.0, distilled water 100) and 1 cu. cm. of sodium-nitrite solution (sodium nitrite 0.5, distilled water 100) is added to urine in equal parts, together with one-eighth volume of ammonia, and the whole combination is agitated. The foam, as well as the fluid, should be bright red to make a positive reaction. The reaction is characteristic of ty- phoid fever, and is wanting in cases of meningitis. Hydrogen sulphid in fresh urine (sometimes attending cystitis) is readily recognized by its offensive odor. A strip of paper impregnated with lead acetate becomes brown on exposure, from the formation of lead sulphid. Pneumaturia (see p. 125). Ifedicaments in the Urine (see Plate 21). Among the drugs that may appear in the urine the fol- lowing are worthy of mention (for details textbooks of toxicology should be consulted) : Antifebrin. — On boiling the urine with hydrochloric acid, cooling, and addition of 3 per cent, solution of car- bolic acid and iron chlorid a red color is developed that becomes blue on addition of ammonia. Antipyrin. — Addition of iron chlorid yields a red color. Lead.- — Organic substances present are destroyed by 8 114 EXAMINATION OF THE UROPOIETIC SYSTEM. evaporation, with addition of hydrochloric acid and a small amount of potassic chlorate to the point of decolor- ization. The chlorin is then driven oif, and sodium hy- droxid added until the reaction is feebly acid. Exposure to hydrogen sulphid yields a brown color due to lead sul- pliid. Bromin. — Addition of fuming nitric acid and agitation with chloroform yield a yellowish color. Carbolic Acid. — The urine exhibits a dark-green color. The test is described on p. 105 ; the test for ether-sul- phuric acid on p. 103. Balsam of Copaiba and Oil of Sandalwood. — Applica- tion of heat and addition of hydrochloric acid yield a pretty red color. lodin. — Addition of fuming nitric acid and agitation with chloroform yield a reddish-violet color. Rhubarb and senna (chrysophanic acid), santonin (urine of straw-yellow color). — On addition of sodium hydroxid a red color develops that disappears again when santonin is present. SalicyliG Acid. — Addition of iron chlorid yields a violet color. Turpentine. — The urine has an odor of violets. Examination of Renal and Vesical Calculi. — These may be constituted of uric acid, and are then hard, smooth, and between yellow and reddish-brown in color. They are recognized by the murexid test (see p. 104). Calcium-oxalate calculi resemble mulberries in appear- ance, and are very hard, nodular, and brownish in color ; they dissolve in mineral acids, without effervescence. Fhosphatic calculi are soft, friable, and Avhitish in color. Calculi formed of carbonates are chalk-like and smooth, and exhibit eifervescence on addition of acid. Cystin cal- culi are small, smooth, and yellowish in color ; they are soluble in ammonia and on evaporation of the solution they form six-sided crystalline plates recognizable micro- scopically. Xanthin calculi are cinnamon-brown in color, antl exhibit a sliiny surface when rubbed together. CONSTITUTION OF THE BODY. 115 (For details of analyses larger text-books should be consulted.) Microscopy of Urinary Sediments. — See Plates 13 to 19. V. EXAMINATION OF ABNORMALITIES OP METABOLISM. To maintain the stability and the continuity of the sub- stances constituting the human body (albuminous bodies, fats, carbohydrates, water, and salts), as well as for the generation of energy and heat, the materials burned up in the accomplishment of these purposes (excrementitious products) must be adequately replaced. This is effected by the ingestion of nutritive substances containing the chemic substances named (food-stuffs) in sufficient amount. 1. The albuminous bodies are nitrogenous substances of complex constitution which are contained in meat (20 per cent.), milk (4 per cent.), bread (8 per cent.), cheese (30 per cent.), legumins (21 per cent.), rice (8 per cent.), vegetables (2 per cent.), eggs (14 per cent.), etc. They are converted in the stomach and intestines into soluble albumoses and peptones, and as such absorbed. Within the body they undergo various syntheses (muscle-albumin, hemoglobin, nuclein, and many other substances) and forms of disintegration. They break up, in part during the process of digestion, in part later within the body, into a urea-containing (nitrogenous) and an aromatic rem- nant (CgHg-containing). Both of these are excreted in 1-1 / ^^A the urine, the one as urea co \ ammonia, creatin, and hippuric acid, and the other as phenol, indol, skatol, combined with sulphuric acid (see p. 103). Uric acid is derived from the disintegrated nuclein. A further rem- nant of the albuminous bodies must be a fat-like body, inasmuch as fat may be accumulated upon an exclusively albuminous diet. The albuminous bodies contain 1 6 per cent, of nitrogen (albumin : nitrogen = 6.25 : 1). A certain proportion of 116 ABNORMALITIES OF METABOLISM. these is absolutely necessary for the maintenance of the bodily nutrition (from 90 or 100 to 120 grams daily — that is, from 14 to 20 grams nitrogen). If less be given, the body burns up its own albumin, and suffers a corre- sponding loss. If more albumin be given with the food, more also is destroyed and more nitrogen is eliminated in the urine, so that the body is thus maintained in a condi- tion of nitrogenous equilibrium. In the production of energy and of heat the metabolism of albumin is not increased, the body eliminating, whether at rest or engaged in activity, other things being equal, the same amount of nitrogen. On the other hand, a debilitated individual destroys comparatively less daily than a robust person supplied with an abundance of albu- min ; so that the latter has need also for a larger supply of albumin. Simultaneous administration of carbohydrates and fats leads to diminished destruction of albumin, so that a cer- tain portion of the albumin-need may be supplied through these articles of food. Abnormal increase in the amount of albumin-destruc- tion in the body (therefore also in the nitrogenous elim- ination) takes place in febrile states and in cachectic dis- eases (carcinoma, profound anemia, leukemia, chronic nephritis). The measure of albuminous metabolism is furnished by the determination for twenty-four hours of the amount of nitrogen in the food, in the urine, and in the stools. Nitrogenous metabolism = nitrogen present in the urine + nitrogen present in the stools — nitrogen ingested with food. The stools contain about 0.8 of nitrogen, in the fasting state 0.2 per day, as determined by the method of Kjeldahl, which is described in works on physiologic chemistry. One gram of nitrogen = 6.25 grams of albumin = 29.4 grams of muscle = 2.143 grams of urea. When intestinal putrefaction is present in conjunction with inflammatory process, etc., a portion of the albu- CONSTITUTION OF THE BODY. 117 minoLis matters is converted by the action of microorgan- isms into poisonous substances (toxins), the intimate nature of which is as yet imperfectly known. Among these are methylamin, dimethylamin, trimethylamin, cholin, neurin, muscarin, cadaverin, etc. If the products of nitrogenous metabolism (urea, etc.) are not adequately eliminated in consequence of disease of the kidneys, such as nephritis, there results a condi- tion of intoxication by reason of their retention, such as uremia. Other substances representing end-products of albumin- ous disintegration, such as the amido-acids, leucin, tyro- sin, and asparagin acid (earlier stages of urea), also appear in the urine in conjunction with some diseases of the liver, especially acute yellow atrophy, the liver constituting one of the most important depots for the formation of urea in the body. 2. Carbohydrates and fats (non-albuminous foods) con- stitute, through their disintegration in the body (oxida- tion), the main source of energy and heat. Oxidation of the carbohydrates takes place especially in the muscles (glycogen), while the fats, by reason of their large carbon- content, are the main source of heat. The end-products of the oxidation-processes, especially carbon dioxid, are eliminated from the body through the respiratory process. The disintegration of non-nitrogenous substances, and likewise the need for these substances, are thus the greater the more energy and heat demanded of the organism. An increase of this metabolism occurs also in febrile states, together w^ith increased heat-production. In diabetes mellitus the body has in varying degree lost its capability of consuming the carbohydrates. As a result, grape-sugar passes from the blood into the urine. The nutritive needs of the body must therefore be satis- fied with albuminous and fatty substances. The disease appears in a severe and a mild form (see p. 107). In severe cases sugar is also formed from albuminous bodies. 118 ABNORMALITIES OF METABOLISM. Constitution of the Pood. If the body receives the required amount of albumin, the three varieties of nutritive material may be repre- sented, with regard to the further composition of the daily amount of food, in accordance with their metabolic value. As a standard of measurement the heat-unit (calory) is employed — that is, the amount of heat re- quired to raise the temperature of 1 kilogram of water 1° C. One gram of albumin will furnish 4.1 calories; 1 gram of fat, 9.3 calories; 1 gram of carboliydrates, 4.1 calories. Accordingly, 100 grams of fat are isodynamic with 232 grams of starch, with 256 grams of glucose, and with 211 grams of albumin. A strong, active individual requires daily at least 3000 calories, increasing to 6000 calories, which are provided for as follows : Albumin, 120 grams = 480 calories. Fats, 60 '' =- 540 " Carbohydrates, 500 " = 3000 " Considerable variations from these figures are possible. In judging of the nutritive economy it is necessary always to consider the state of previous nutrition, the expenditure of energy and of heat, the bodily weight, the state of the nutrition, the digestive capability, and the pecuniary cost of the respective articles of food. Emaciated subjects require only from 800 to 1200 calo- ries, wliilc a healthy man in a state of hunger generates 2300 calories. The guide as to the nutrition is furnished by the bodily weight, apart from the formation and absorp- tion of edema, of exudates, and of hydremia, etc. CONSTITUTION OF THE FOOD. 119 o era 1 3 3 S' ^ 3 c/3 S 3 cr . . ni.'jQ o c-fc CTQ fD ^. 2 S &.;5 O , — '-' Q > fl) S I- ^ 1— ' "^ (3- O . . CL, II a? 3 '. B o . a. P CO on O •-^ *^ O o .t-'003 O 00 ^ ►^ to 05 I-" ^-- to to ^> p p^-'p to GO--' to GOCOCO tOp*-kUpi— 'P ^^ >-t to rf^ t-' rf^ to W *lO CO ■— f— CC bo CO ?■•? I+- h-* C71 to I—' II 3 P on; "p 'p^'w'p 'p'p^ '^^ p p'lo'co'co CO = ^ O bo CO 'rfi. CO CO bi ^ O bi f-i *i. Cn Crt cp oo en— '"-^^a -— ^ — ^ a> rfi. O"— '■—-■— ' ■^^3 o S ^ S_^ S ^ V ^S -s • Pi o o CO t-i o to 00 1— » o J-* 01 ^-» pip^t-'Cnp^COpcln^pi bi «o h-i 'bi'ciCi'oiotoi'— ' --J to CO o' 3 C3i HjJ t-ii— 'OOCitOtOO^Oi coj-'j-'pipiwoopi-'coootop top4^ p to lu I;^ I-' ^ * h-' io GO CO o bi ' co 'o^ to rfs' --I ^ CO po COO h3 as *- »-' 1— ' ^-j :^o ^ t> ► *—• to to CO to 00 to I—" t— ' O'T^ tn- o GO p to to p to p to GO to to O -^?^S:o' biji-bs to bi* ^'h-' coco bi 3 tOtf t:^, Oi P 1 fB o 0^3 '^1 5' 1 ^ — ' r*" i Q OT m V-i \-^ ^ irt- Oi ^ pi Cn p p 3- "h-i rfi. '• Cn '^ V ,-.p CO ^"^ I 3 Si* I o w \ K ' \y > , ,y V V V^ - \ A A . ^- tu.Jl.^\_±^tJt_'^Jt± t^^^J^ " - T^t^ " t n ^ t ^ ,/n to lI . V - - V ■--/-- -X ' -""" 1^0 39 . r , 3 ^ r r- ¥\ t ---r^t-^— z-z— -z— izS-H==E-5-r— =- ,.n v^ -^2"? = -- = = E- + -E-II 1 Z . Z — t-iztz-.zi III /*'Z7 38 ^^ ^\^u U ^ ^ ZT --1 ^^tlilCLj jrn T- ' . > % ^ ^ ' ' /'', "^ V I ' ■ ^ ^ , ' '"" «*' _^J k Z ll 'iL ^ vJ V V ^ ' \, r^ ^' ^-^ - 7^ P-T\ '^ , ^ v/ V ^ ^ - ^ V^ V. , "^^ _ , -^ -_:w ±v 5 ^-^- - -^ n 1 ^ )t^ Jtn 3i: H 71 t-^ iJ- -^J.- - dzzE _ - 5 i- -^ -J 1 - f- . 1 1 First stage (ascent). Second stage (acme). Third stage (decline). Fig. 38.— Temperature-chart from a case of typhoid fever. The second stage or acme of the disease occupies the second week, and is marked by continued fever, with a temperature at about 40° C. (104° F.) ; a dry, fissured tongue ; rose-spots upon the abdomeu, thorax, etc. ; en- largement of the spleen, recognizable by palpation ; gur- gling in the ileocecal region ; diarrliea with peasoup-like stools; meteorism ; diazo-reaction (see Plate 20, Fig. 12). There is no leukocytosis (see Plate '^>, Fig. 6). Diffuse bronchitis is usually present. The febrile manifestations are pronounced and the pulse is dicrotic (see Fig. 39). BACTERIAL INFECTIONS. 139 There may be coma and delirium. The patient occupies the dorsal decubitus^ and is exposed to the danger of the formation of bedsores. The stage of decline occupies the third week. The fever begins to decline^ fall- ing a degree or more in the morning, and rising slightly less in the evening. Later it continues to subside more gradually. Relapses (see Fig. 40) oc- cur frequently from six to ^i.v.V.+ A^^^. ^A-^-., +1,^ ^^^1,",,^ Fig. 39.— Pulse-tracing from a case of eight days alter the dechne typhoid fever, showing dicrotism. of the fever, and are of short duration. Convalescence may, however, be much retarded in consequence. Gomplications occur most frequently dur- ing the last week : intestinal hemorrhage, perforative ■/ 2 J U s 6 7 S 9 iO // /^ /J /A /s y^ 1 ; 1 1 1 1 1 1 \ i 1 ! 1 1 I~ \ 1 t; /60 tiO \ 1 1 '^ 1 ^ , T 1 ■ ."i i '. !/ / /T" / IB- t ■ ( ^ fttO 39 ; t 'fl \ 1 JZ 1 y /' 1 I 1 v tn / \ y ' } I 12(1 38 1 } 1 ' , ' ' ft 1 / I ' \. l\ I / \ 1 ' i J I \ / i [_ 1 ! , A h I J ^ / 400 37 ir,, / uA / ^ , ' \ > \ 1 '; 1 ' 1' 1 ^ \l 'V I /■' 1 _ .. A \ I V \l / / H r/^ I 4 A V w \, ^ 1 SO 36 \ \ I K ,1 A ;,'! V ^ i '■ ^.'i V \ \ ^ f V / '.' y^ ! _ LJ _ _ ____ 1 _ _ __ 1 1 1 _ _ _ Defervescence. Relapse, Fig. 40.— Temperature-chart from a case of typhoid fever with relapse, and death from perforative peritonitis. peritonitis, glandular abscesses, otitis media, parotiditis, venous thrombosis, pneumonia (catarrhal, less commonly fibrinous). Diagnosis. — Diagnostic importance is to be attached 140 INFECTIOUS DISEASES. especiall)^ to the characteristic mode of onset (absence of chill, as well as of leukocytosis and of herpes), and the roseola. The Gruher- Widal seruyn-test yields a positive reaction in almost all cases after the eighth day, and often even earlier. A few drops of blood (about 2 cu. cm.) are ob- tained by puncture of the finger with suitable aseptic pre- cautions ; the serum that separates is introduced into a narrow test-tube containing sterile bouillon, which is then inoculated with living typhoid-bacilli and kept at the temperature of the body. In the course of a few hours agglutination and sedimentation, with loss of motility of the bacilli, take place if the case be one of typhoid fever. A positive reaction is occasionally yielded in cases of other disease than typhoid fever. The prognosis is dependent upon the condition of the heart, the intensity of fever, and possible complications. Treatment. — Bland, unirritating, liquid diet (milk, broths, eggs, beef-juice, in abundance), calomel, gr. ix, in three doses at the onset. An ice-bag or Leiter's tubes upon the head. Cold packs, cold baths at 20° C. {.T \ . » . 100 37 ,^ \ . 1" !"' ? / "^ ^^ \ \ \ '^ \- .4_^ .1 11 \j -¥■ -\j- -» T so 36 Fig. 45.— Temperature-chart from a case of quotidian malarial fever. Fig. 46.— Temperature-chart from a case of tertian intermittent fever. ache is present and sometimes delirium. The spleen is greatly enlarged and palpable. In the third stage defer- vescence occurs by crisis, with profuse perspiration. The paroxysms last usually from six or eight to ten hours and are repeated either daily (quotidian, see Fig. 45), or every second day (tertian, see Fig. 46), or every third day (quartan, see Fig. 47). Frequently the parox- ysms do not recur always at the same hour of the day, but usually every succeeding paroxysm occurs from two to three hours earlier than the preceding paroxysm (antic- ipating type), or later (postponing type). INFECTIONS OF UNDETERMINED ORIGIN. 153 Atypical Varieties. — Pernicious malarial fever occurs especially in profoundly malarial regions (Italy, the valley of the Danube). Masked malaria (fever atypical or want- ingj severe intermitting neuralgia). Chronic malarial cachexia (following repeated acute outbreaks, with chronic enlargement of the spleen). Diagnosis. — The febrile paroxysms alone are typical of the disease (the chills attending pyemia are not dissipated by the administration of quinin). Atypical varieties may be confounded with latent tuberculosis. The detection of Plasmodia in the blood is absolutely conclusive. -f z 3 ^ s 6 7 s 9 iO /y /2 /J 1 /ffO liO , lifO 19 1 ^_ _ _ _ , _ aO 38 — - ^- — - — — — -A — - , 1 \ 4Q0 37 \ A 1 /\ -A- 1? / v/ ^ ' ( '\ r '^ / \ \/ 4_ / V ~^ W- ' ^ 1 80 36 1 "•" _ _ 1 I Fig. 47.— Temperature-chart from a ease of quartan intermittent fever. Treatment. — Quinin sulphate, gr. xxv-gr. xxx six hours before the expected attack (causes destruction of the germinating plasmodia). In chronic cases arsenic should be administered and baths directed. F. Infectious Diseases of Undetermined Origin. In a number of the diseases about to be described (measles, smallpox, whooping-cough, cholera morbus, dysentery, etc.) bacteria, etc., have been repeatedly found to which causative activity has been attributed. The acute exanthemata : these constitute the most fre- 154 INFECTIOUS DISEASES. quent diseases of childhood, recovery from one attack of which confers immunity to subsequent infection with the same disease. 16. MorhUli (measles). The period of incubation is ten days, and toward its close prodromal sympAoms (cough, coryza, vomiting) appear for two or three days. The disease sets in with a chill, high fever (Fig. 48), and vomiting. Conjunctivitis, photophobia, cough, coryza, are added. The exanthem appears on the third or i 2 J u 5 6 7 S 1 /60 kO t / \ A A \/ n , ■ \ Itif) 39 \ t V 1 V \( UO 3S \ 1 ,' \ • WO 37 \ \ . 80 36 , 1 i 2 J 4 S G 7 S 9 1 A ; \ JL /60 liO ^ / A V y \/ \ ' V , /\ V • M liiO 39 . \i V aO 38 ' \ ^ V /OO 37 .\ \ 80 36 Fig. 48.— Temperature-chart from a case of morbilli. Fig. 49.— Temperature-chart from a case of scarlet fever. fourth day, with elevation of temperature. It consists of macules in geographic arrangement, somewhat raised like wheals, and it appears first upon the forehead. The tem- perature begins to decline by lysis on the sixth day. Desquamation of bran-like scales sets in between the sixth and the tenth day. Complications and Sequelce. — Hemorrhagic exanthem, bronchopneumonia, atelectasis, suppuration of the middle ear, conjunctivitis, croup, tuberculosis. Treatment. — Baths, packs, milk, eggs, expectorants, and if necessary antipyretics. DISEASES OF UNDETERMINED ORIGIN 155 17. Scarlet Fever. The period of incubation is from two to seven days. The prodromes occupy from one to two days and the most constant is vomiting. The attack sets in with a chill and rapidly ascending temperature (Fig. 49). The symptoms point to profound general infection. Angina is present and occasions difficulty in degkitition. The papillae of the tongue are prominent and give rise to the so-called straw- berry tongue. On the second day the eruption appears on the face and neck, the chin escaping, at first as small disseminated red spots, later becoming confluent and pre- senting a scarlet hue. After the fourth day the tempera- ture declines by lysis. Desquamation occurs in large sheets and continues for from five to fifteen days. Complications and Sequelce. — Acute hemorrhagic neph- ritis (edema), diphtheria (usually fatal), otitis media, endo- carditis, encephalitis, articular rheumatism, glandular abscesses, etc. Treatment. — Baths, douches, packs, gargles, acid drinks, stimulants, symptomatic. 18. Rubeola (R5theln). This is a mild infectious disease lasting from two to three days. It is attended with a red macular exanthem. The fever is slight. Conjunctivitis may be present, together with slight catarrhal manifestations. Desqua- mation does not occur. 19. Variola (smallpox). The p)eriod of incubation is from ten to thirteen days. Prodromes may continue for two or three days. The stage of invasion is characterized by chill, high fever, symptoms of general infection, pains in the sacral region, cutaneous erythema, petechise. In the eruptive stage, which occurs between the fourth and the ninth day, the exanthem is present upon the face, upon the body, and also upon the mucous membranes. It appears at first as red spots that soon become elevated into small nodules. These in turn are transformed into vesicles, which become filled with pus and form pustules. In the suppurative 156 INFECTIO US DISEASES. stage, which occurs from the ninth to the twelfth day, the temperature again rises and is of an intermittent, septic, ^60 tiO i^n .19 420 38 wo 37 so 36 ^^ 5 $ E 5 s 11 ii m 8 H 5 S ? ^5 // /? s /J ? /^ 5^ /f g //$• 5- Fig. 50.— Temperature-chart from a case of smallpox, suppurative type. There is also delirium and there may be metastatic suppuration. In the stage of desiccation the pustules discharge their contents and dry up, while the fever declines by lysis. Dccrustation goes on for from four to six days, leav- ing cicatrices at first bluish pink, but subsequently be- coming snow-white. Ilodijications. — Vario- loid is a mild form of va- riolous infection, unattend- ed with suppuration. It occurs in those who have been vaccinated or have passed through an attack of small])()x. In hemor- rhagic variola hemorrhage takes place into the pustules, the skin, and the mucous nu'nd)ranes. This is tlie se- verest form, and is known as bla(tk smallpox. i Z 3 U 5 6 7 8 9 jcn i.n 4Ln 10 ^ t, — ^ ^ a c 7 fXU JO — - — I . t,^ t J ^ jnn 11 _ _ E JS, 1UU 61 .Zv-T^ t^Z^ V v-t V 5 5 *- -•- "V MH If: — _ _ Fig. 51. -Temperature-chart from a case of varioloid. DISEASES OF UNDETERMINED ORIGIN. 157 Complications and Sequeke. — Abscess-formation, gan- grene of the skin, diseases of eye and ear, pneumonia, nephritis, myelitis. Treatment. — Baths, symptomatic, stimulants, prophy- laxis, vaccination every six to ten years. 20. Varicella (chicken-pox). This is a mild infectious disease occurring almost exclu- sively in children. It is unattended with noteworthy pro- dromata. Small vesicles appear in irregular order upon the skin and mucous membranes, replacing previous red spots, and dry up in the course of several days. The fever is irregular and may reach 39° C. (102.2° F.). In some cases nephritis may occur as a sequel. 21. Epidemic Parotiditis (mumps). This is a mild infectious disease occurring usually in children. Amid febrile manifestations the parotid, also the submaxillary gland, and at times the testicles, become painfully swollen. The attack lasts several days. Sup- puration is uncommon. 22. Pertussis (whooping-cough). This is a common infectious disease among children, and is feared on account of its long duration and its sequelae. The catarrhal stage lasts from several days to weeks, and is attended with cough and mild febrile symptoms. The spasmodic stage occupies from four to six weeks. It is characterized by the occurrence of paroxysms of cough of a peculiar whooping character (deep, stridulous inspiration, with a short expiratory cough), frequently attended with vomiting and conjunctival hemorrhage. From ten to thirty or sixty attacks may occur daily, and they are particularly frequent at night. In the stage of decline there is gradual subsidence of the paroxysm in both frequency and severity. SequelcE. — Bronchopneumonia, pulmonary tuberculosis, anemia, emphysema. Treatment. — Change of air, much out-of-door life, moist packs, cold ablutions. Each paroxysm attended with 158 INFECTIOUS DISEASES. vomiting should be followed immediately by the adminis- tration of nourishment (milk, eggs, broth, etc.). Bromo- form from three or five to ten drops may be given thrice daily. Sozoiodol may be insufflated into the nares and ethereal oils may be inhaled. Bromin, codein, and bella- donna may be administered internally. 23. Cholera Morbus (cholera nostras). This occurs frequently in children, but also in adults, and particularly in the summer months, in consequence of the multiplication of streptococci in the intestines (see Plate 11, Fig. 3 ; Fig. 1, p. 3). The disease sets in suddenly, with severe vomiting and diarrhea. The stools are watery and the pain is colicky. There is thirst, together with profound colkipse, heart-failure, anuria. The attack lasts from six to twelve or twenty hours. Convalescence is protracted. The diagnosis may eventually require bacteriologic examination of the stools for cholera-bacilli (see p. 27). Treatment. — Opium, calomel, bismuth, astringent wine, mucilaginous soups, poultices, stimulants, and possibly infusions of saline solution. In children, milk should be withdrawn and mucilagin- ous decoctions and artificial food given. 24. Difsentery. This disorder is characterized by ulceration of the large intestine, following diphtheric destruction, possibly due to the activity of amebse. After a period of several days of diarrhea aggravation takes place between the third and the fifth day, with the development of severe diar- rhea, painful tormina (griping), and tenesmus (bearing down). There is, besides, a sense of chilliness and pros- tration. The fever is irregular. Collapse may take place. The attack lasts from three to five days. The stools contiiin mucus, pus, and blood. Complications. — Nephritis, pneumonia, perforative peri- tonitis. The jpy^ognosis is grave. Treatment, — Castor-oil, calomel, opium, suppositories, DISEASES OF UNDETERMINED ORIGIN 159 saline infusions, mucilaginous enemata, concentrated liquid diet, stimulants, hot packs, disinfection of the stools. 25. Typhus Fever (spotted fever). The period of ineubation is from seven to fourteen days. After a short prodromal period (in contrast with ty- phoid fever) the temperature rises quickly to a high degree, with a feeling of coldness. The fever is continued, the temperature ranging in the neighborhood of 40° C. (104° F.). Vomiting is present, /60 tiO fifO J.9 120 JS wo 37 80 36 i 2 s 1^ ¥ t 5; m-- s f 8 4 m H % P i /? ? 2 a % /^ /f I //$• 5^ // E t -/s a 1 1 1 1 1 1 1 Fig. 52. — Temperature-chart from a case of typhus fever. with nervous disturbances and delirium. The spleen is enlarged. From the third to the fifth day a roseolous exanthem appears upon the trunk and the extremities and becomes transformed into petechial hemorrhages. The state is a typhoid one and bronchitis is likely to be pres- ent. The attack lasts from two to three weeks. Should death not occur from heart-failure the fever declines rap- idly. The mortality from the disease is between 10 and 20 per cent. Treatment. — Baths, packs, albuminous diet, generous administration of liquids, stimulants. 160 INFECTIOUS DISEASES. 26. Hydrophobia (canine rabies). Infection occurs through the bites of dogs, wolves, etc. The toxic substance is present in the spinal cord. The period of incubation may extend over many months. The prodromal period covers several days and may be attended with a melancholic state of mind, irritability, anorexia, and insomnia. In the hydrophobic stage spasm of the esophageal mus- cles occurs when an attempt is made to take food or drink. The glottis is closed spasmodically and breathing is difficult. There are, besides, salivation, delirium, hallucinations. Death often occurs in collapse in the course of several days. Treatment. — Protective inoculation, cauterization of the wound, narcotics (chloral, morphin), stimulants. 27. The Plague. The plague formerly occurred repeatedly in Germany as an epidemic disease, being known in the sixteenth century as ^^ black death.'' It is characterized by a profound sep- tic state. There occurs universal suppurative lymph- adenitis (buboes), with hemorrhages. The mortality ranges from sixty to ninety per cent. 28. Yellow Fever. This disease occurs endemically in the tropics, particu- larly upon the coast in certain regions of America, Africa, and Asia. Transmission takes place through marine in- tercourse. The attack sets in suddenly, with a chill, high fever, and vomiting. The extremities are painful. After three or four days jaundice appears. The temperature again rises and hemorrhages may take place into the stomach and bowels, with albuminuria and anuria. The mortality is from 15 to 50 per cent. Treatment. — Castor-oil, calomel, baths. 29. Trichinosis. This is a parasitic disease due to the invasion of the tissues of the body by embryo trichinae (see p. 127). The DISEASES OF THE NOSE. 161 intestinal p'arasites remain within the bowel for from six to eight weeks. Eight or ten clays after infection has taken place the embryos begin their migration. The first symptoms include gastro-intestinal disorders, with nausea, diarrhea, and febrile manifestations, the tem- perature rising as high as 40° C. (104° F.). At the beginning of the second week pain is felt in the muscles upon movement and upon pressure. Mastication, deglu- tition, articulation, and respiration (bronchitis, broncho- pneumonia) are painful. There may be also edema of the face and of the extremities and, further, delirium and collapse. Convalescence may be greatly retarded. Diagnosis. — The painfulness of the muscles is import- ant in distinction from articular rheumatism ; the edema in distinction from typhoid fever. Excision of a bit of muscle may be eventually necessary. Examination of the feces often fails to yield conclusive information. Treatment. — Castor-oil, calomel, glycerin, morphin, sodium salicylate, warm packs. II. DISEASES OP THE RESPIRATORY ORGANS. A. Diseases of the Nose. 1. Aeute and Chronic Rhinitis (coryza). Acute rhinitis is an infectious catarrhal inflammation of the nasal mucous membrane, attended Avith mild febrile manifestations, headache, and obstructed nasal breathing. The secretion is at first abundant and mucous, but later purulent. The affection is serious in infants through interference with nursing. Frequently repeated attacks of nasal catarrh or fre- quent exposure to moist and cold air, in dusty rooms, etc., leads to the development of chronic nasal catarrh. This occurs with especial frequency in individuals with con- genital deformities of the nose, such as deflections of the septum, hypertrophy of the turbinate bodies ; and in anemic and scrofulous children. Under these conditions the nasal mucous membrane becomes partly hypertrophic 11 162 DISEASES OF THE RESPIRATORY ORGANS. and thickened, partly atrophic and attenuated. The secretion drys up into crusts with especial readiness in the atrophic variety. Beneath the crusts ulcerative changes may take place. Treatment. — Insufflations of menthol ; carbolic acid and alcohol, each 10 ; liquor ammonise, 5 (by inhalation) ; applications of cocain ; irrigation with sodium chlorid in cases of acute rhinitis. Chronic nasal catarrh may be treated with insufflations of europhen, sozoiodol, aristol, boric acid ; or irrigation with sodium chlorid, solution of salicylic and boric acids ; or with applications of silver nitrate, tannic acid and glycerin, etc. 2. Ozena (fetid nasal catarrh). This disorder occurs as a complication of chronic atro- phic rhinitis with crust-formation. The decomposition of the secretion through the activity of putrefactive bac- teria brings about the characteristic oiFensive odor. Fre- quently the disease is indicative of more deeply seated suppurative processes, such as empyema of the maxillary antrum, of the sphenoid sinuses, caries, etc., which may be detected by the use of the probe in conjunction with aspiration. Treatment. — Antiseptic irrigation and insufflation, etc. (see special text-books). 3. Epistaxis (bleeding from the nose). This occurs especially in cases of chlorosis and anemia ; also frequently in cases of contracted kidney, leukemia, cardiac lesions, and acute infectious diseases. Not rarely there are present upon the nasal septum small telangiec- tatic areas of the mucous membrane, after cauterization of which the bleeding ceases. To eifect control of the hemorrhage vinegar-water, etc., may be insufflated, or a tampon may have to be employed, if the hemorrhage be severe, passed from behind forward with the aid of a Bellocq cannula. (For further refer- ences to diseases of the nasal cavity, see p. 35. For details, reference should be made to special text-books.) DISEASES OF LARYNX, TRACHEA, AND BRONCHI. 163 B. Diseases of Larynx, Trachea, and Bronchi. 4. Acute and Chronic Laryngitis. Acute laryngitis is an infectious, mildly febrile, catar- rhal disease. Hoarseness is present, in consequence of defective closure of the glottis, and there is irritative cough, with viscid sputum. The vocal bands present a rose-red color and the ventricular bands are swollen and overlie the former — chorditis vocalis superior (see Fig. 53). Often there is slight paresis of the vocal bands, giving rise to the oval glottis (Fig. 54). Treatment. — Cold applications about the throat ; ad- ministration of hot milk with Selters or Ems water; codein. In children the tumefaction of the mucous membrane Fig. 53.— Chorditis vocalis superior. Fig. 54.— Paralysis of the thyro- arytenoids. (Phonation.) may give rise to croupy manifestations, dyspnea, pseudo- croup. Chronic laryngitis occurs in teachers and singers and in alcoholics. In addition to hoarseness, there is present a troublesome- tickling sensation, with a feeling of dry- ness in the throat. The disease is very obstinate. The vocal bands present a grayish-red color. The follicles are swollen and the mucous membrane is thickened and indurated. Treatment. — Inhalations (Ems water, Soden water, so- lutions of tannic acid and alum) ; applications of silver nitrate solution, from 3 to 10 per cent.; insufflation of powders; bath cures (Ems, Soden, Reichenhall, etc.). 164 DISEASES OF THE RESPIRATORY ORGANS. 5. Edema of the Larynx. This is characterized by swelling of the aryepiglottic ligaments, with resulting marked stenosis of the larynx, giving rise to suffocative attacks. It occurs in conjunc- tion with inflammatory and catarrhal disorders of the larynx, with the presence of foreign bodies in the larynx, with traumatisms, ulcerations and with general edema. Treatment. — Incisions into the edematous parts ; trache- otomy. 6. Tuberculosis of the Larynx (see p. 134). 7. Syphilis of the Larynx. Of noteworthy importance are only the tertiary lesions. In consequence of the breaking down of gummata deep ulcerations form, and stenosis results from cicatrization and secondary contraction. Treatment. — Mercurial inunctions ; for stenosis, intuba- tion, tracheotomy. 8. Paralysis of the Laryngeal 3Iuscles (see p. 38). 9. Spasm of the Glottis (Laryngismus stridulus). This condition is characterized by repeated attacks of spasm, with severe suffocative paroxysms, and it occurs in scrofulous and rachitic children and in cases of hysteria and of tabes dorsal is. Treatment. — Removal of the primary disorder, regula- tion of the diet, cold frictions. In the attack cold douches may be employed, together with hot enemata and artificial breathing. 10. Tumors of the Larynx. These usually arise from the vocal bands and the ven- tricular bands and give rise to disturbances of speech (such as hoarseness, ])iping voice, diplophonia), and difficulty in breathing (inspiratory dyspnea, suffocative attacks). It is important to determine whether the neoplasms be benign (fibroma, adenoma, polypi, circumscribed growths) or malignant (carcinoma, rarely sarcoma : diffuse, often ulcerative swelling, lym])hatic glandular enlargement). Partial excision and histologic examination may be neces- sary. DISEASES OF LARYNX, TRACHEA, AND BRONCHI. 165 The treatment is surgical. 11. Acute and Chronic Bronchitis. Acute bronchitis is an infectious febrile disease of the bronchial mucous membrane of greater or less severity, attended with swelling, hyperemia and increased secretion. The symptoms include irritative cough, expectoration, at first mucous, later purulent, pain in the chest, muscular pain (expiratory muscles of respiration, especially the abdominal and the intercostal muscles). The pulmonary percussion-note is unchanged. On ausculation coarse dry or moist rales are heard in greater or less abundance in accordance with the extent of the morbid process, together with prolonged expiration. In cases of capillary bron- chitis, with involvement of the smallest bronchi, moist rales with wheezing are heard. Treatment. — Abundant administration of liquids (Ems water, milk, tea), moist packs, warm baths, codein, ex- pectorants. Chronic bronchitis results from constant exposure to dusty air,. as in factories, etc. It often persists for years and in consequence of the frequently repeated paroxysms of coughing leads to emphysema of the lung and circula- tory disturbance. Catarrh of the apices of the lungs, especially if uni- lateral, is suggestive of tuberculosis. Hypostatic bron- chitis occurs in conjunction with cardiac lesions and dis- eases of the kidney. Bronchoblennorrhea is attended with copious diffluent expectoration, the sputum when permitted to stand sepa- rating into layers (see p. 51). Dry catarrh is attended with annoying cough and tough mucous sputum and respiratory difficulty. The results of auscultation vary in accordance with the character and amount of the secretion : numerous medium-sized moist rales, especially over the lower lobes, or coarse, snoring, whistling dry rales (sonorous and sibi- lant). Treatment. — Change of air ; sojourn at sea, in southern 166 DISEASES OF THE RESPIRATORY ORGANS. climates, at altitudes, inhalations of oil of pines, turpentine, mineral waters, moist packs, frictions, expectorants, etc. Crouj)ous bronchitis is an uncommon disorder attended with the formation of membrane upon the mucosa (fibrin- ous exudation). It is characterized by paroxysms of dyspnea and cough. The expectorated matters contain bronchial casts, Curschmann's spirals, Charcot-Leyden crystals (see p. 53). There is usually some fever. Treatment. — Potassium iodid, expectorants, emetics, inhalations of lime-water, alkaline waters, etc. 12. Fetid Bronchitis. This results from the decomposition of stagnant secre- tion in the bronchi through the activity of putrefactive bacteria, and is a common accompaniment of bronchiec- tasis. There is usually fever, together with abundant fetid sputum that upon standing separates into layers (see p. 51). In the purulent layer so-called Dittrich's plugs (grayish- white particles) are found, together with fat- crystals, bacteria, and masses of detritus. Frequently the fingers are drumstick-shaped, from bulbous thickening of the terminal phlanges. Metastatic suppurative processes may develop, particularly in the brain. Treatment. — Oil of pines, turpentine, myrtol by inhala- tion. 13. Bronchiectasis. Saccular or cylindric dilatation of the medium-sized and especially of the smaller bronchi, principally of the lower lobes of the lungs, as a result of accumulation of secretion may occur in consequence of atrophy and abnor- mal yielding of the bronchial walls. The surrounding pulmonary tissue becomes destroyed, and there occur fre- quently secondary catarrhal infiltration and interstitial contraction. The sputum is abundant, at times being ejected in mouthfuls, as in cases of bronchoblennorrhea and of fetid bronchitis. Frequently tuberculosis is a secondary complication. Upon examination there is found dulness on percussion, especially over the lower lobes of the lungs, together with coarse mucous and also DISEASES OF LUNGS AND PLEURA. 167 ringing rales. At a later period the percussion-note may be tympanitic, and the breathing bronchial, from the ex- istence of a cavity. At times there may also be hemopty- sis and the fingers may be drumstick-shaped. Treatment. — See chronic and fetid bronchitis (pp. 165, 166). 14. Bronchial Asthma. This is characterized by paroxysms of acute expiratory dyspnea in consequence of spasmodic narrowing of the smaller bronchi. It occurs frequently in nervous individ- uals, and is sometimes induced through reflex influences, such as diseases of the nose. The attacks occur especially at night, and are attended with laborious wheezing inspiration and prolonged expira- tion. The boundaries of the lungs are extended during the attack (acute dilatation) and percussion yields a strikingly full, loud note. On auscultation numerous faint whistling and creaking rales are heard, with enfeebled vesicular murmur and prolonged expiration. The sputum is scanty, viscid and mucous, and con- tains leukocytes, eosinophile cells, Charcot-Leyden crys- tals, Curschmann's spirals (see Plate 8, Figs. 5 and 6). Treatment. — Attention should be directed to possible disease of the nose. Cold frictions and a sojourn at sea are to be recommended. During the attack potassium iodid and morphin may be given, with inhalation of ig- nited stramonium powder or of vapor of pyridin, etc. C. Diseases of Lungs and Pleura. 15. Croupous Pneumonia (see p. 147). Differential diagnosis between pneumonia and pleurisy : Pneumonia. Pleurisy (see p. 172). Onset. — Always acute, witli chill. Usually subacute, less commonly acute ; rarely with chill. PerciLssioji . — At first relative dul- From the outset intense absolute ness, with tympanitic accompan- dulness, with a sense of resist- ient ; later intense duiness, with- ance. out a sense of resistance. 168 DISEASES OF THE RESPIRATORY ORGANS. Pneumonia. Pleurisy. Auscultation. — Loud bronchial Enfeebleraent or absence of breath- breathing over the area of ing over area of most marked most marked diilness. diilness. Vocal Fremitus. — Usually in- Always enfeebled, creased ; enfeebled only with * accumulation of secretion. Bronchophony. — Loud. Faint; egophony. Displacement. — Of neighboring or- Marked displacement of liver, gans, slight. heart, spleen. Sputum. — Blood- streaked, rust-col- Wanting or catarrhal, ored, prunejuice-like. In doubtful cases exploratory puncture will yield con- clusive evidence. The exudate present should always be examined bacteriologically. (Inoculation upon agar-agar, etc., see p. 26). 16. Bronchopneumonia (lobular pneumonia). Lobular pneumonia is usually secondary to previously existing bronchitis, and occurs most frequently in con- junction Avith various infectious diseases, such as measles, whooping-cough, smallpox, typhoid fever and influenza, and with cardiac lesions. It is frequent in children and in the aged. The morbid lesion consists in disseminated, small, bronchopneumonic, cellular infiltrates (without fibrinous exudation and free from red blood-corpuscles), especially in the lower lobes (through accumulation of secretion). The fever is irregular and there are sweats and difficulty in breathing. Over the aifected areas the percussion-note is impaired in greater or less degree, and numerous moist rales can be heard, together with bronchial breathing. Treatment. — Baths, cold sponging, douching, moist packs, milk-diet, expectorants. 17. Atelectasis. This condition results from the absorption of air from portions of lung whose bronchi are occluded by secretion. In consequence the aifected portion of lung becomes col- lapsed and free from air. The condition often accompan- ies the bronchitis complicating measles and whooping- cough. Atelectasis may occur further when the lung is DISEASES OF LUNGS AND PLEURA. 169 compressed by pleuritic exudate, or as a result of hydro- thorax, pneumothorax, or the presence of tumors, etc. The breathing is accelerated and retraction of the chest- wall occurs in inspiration. Percussion over the atelectatic areas yields dulness. Treatment. — See Bronchopneumonia. Respiratory gym- nastics, treatment of the primary disorder. 18. Pulmonary Emphysema. A distinction is to be made between simple increase in the size of the lung (acute dilatation) and true emphy- sema. In the latter condition permanent inspiratory dis- tention leads to atrophy of the alveolar septa (rarefaction of the lung-structure). Emphysema is caused principally by chronic bronchitis, the constant cough and obstruction to expiration leading to loss of elasticity of the lungs. It oc- curs also in conjunction with whooping-cough, asthma, etc. In consequence of the increased resistance in the pul- monary capillaries (which are eventually destroyed), there results stasis in the pulmonary circulation, with consecu- tive dilatation and hypertrophy of the right ventricle. The principal symptoms are shortness of breath and cyanosis, labored, greatly prolonged expiration, marked prominence of the accessory muscles of respiration (sterno- cleido-mastoid, etc.), cough and embarrassed expectora- tion. The boundaries of the lungs reach anteriorly to the seventh or the eighth rib (the liver-dulness being in consequence diminished), posteriorly to the twelfth dorsal vertebra. The cardiac dulness is entirely obscured by the pulmonary resonance when percussion is practised with the body bent forward. On auscultation physical signs of chronic bronchitis are elicited, with markedly pro- longed expiration. Epigastric pulsation is visible, and the pulmonary second sound is accentuated. The demon- strable respiratory mobility increases in accordance with the severity of the disturbance. The emphysematous thorax is described on p. 13. Complications. — Derangements of compensation of the right ventricle, pneumonia. 170 DISEASES OF THE RESPIRATORY ORGANS. Treatment. — See Chronic Brbnchitis. Potassium iodid, later digitalis, pulmonary gymnastics, pneumatic chamber, compression of the chest, etc. 19. Pulmonary Edema. Acute paralysis of the heart, and particularly of the left ventricle, is attended with transudation of hemor- rhagic serous fluid into the pulmonary alveoli. This con- dition occurs commonly immediately before death. Symptonw. — Increasingly labored, noisy (rattling) breathing, cyanosis, embarrassed expectoration of bloody, serous, frothy sputum. On auscultation numerous med- ium-sized and large moist rales are heard over the entire lung, totally obscuring the respiratory murmur. Treatment. — Stimulants, injection of camphor and ether (from three to five large syringefuls, one hourly), mustard- plaster, venesection. 20. Pulmonary Tuberculosis (see p. 132). 21. Pulmonary Gangrene. Putrid decomposition of portions of lung (sequestra- tion) may occur as a complication of aspiration-pneu- monia, perforation of empyemata, abscesses, fetid bron- chitis, pyemic metastases (septic emboli), perforation of the esophagus into the bronchi (traction-diverticula), diabetes mellitus, etc.). Symptoms. — Irregular, high fever, dyspnea, pain in the side. The sputum is abundant, offensive, and on stand- ing separates into three layers. In it may be found gan- grenous shreds of lung-parenchyma, crystals of fatty acids, detritus, lung-pigment, fat-drops. Elastic fibers are wanting, from the presence of a solv- ent ferment (see Plate 9, Fig. 2). There is dulness on percussion (frequently simultaneous pleurisy), with bronchial breathing and rales. Complications. — Purulent, putrid pleurisy, pneumo- thorax, pericarditis, metastatic abscess in the brain, etc. Treatment. — See Fetid Bronchitis. Operative inter- vention may be necessary. DISEASES OF LUNGS AND PLEURA. 171 22. Pulmonary Abscess. This may occur as a complication or sequel of pneu- monia, infarction, traumatism and embolic processes. There are present symptoms of compression of the lung (dyspnea, irritative cough, pain in the side) and febrile manifestations (chills). There is dulness on per- cussion over the affected area, with enfeebled bronchial breathing and rales. Perforation may take place into a bronchus (purulent sputum, elastic fibers — see Plate 9, Fig. 1), into the pleural cavity (empyema), etc. A con- clusive diagnosis is to be reached only through explora- tory puncture. 23. Pneumonokonioses (diseases due to the inhalation of -dust). The afTections of this group occur in those who are compelled constantly to inhale mineral or vegetable dust, the fine particles being deposited in the lung- structure. In coal-miners the condition is known as anthracosis ; in stone-workers as chalicosis ; in iron-workers as siderosis. Those who work in tobacco also may inhale the dust of tobacco. Persons thus affected exhibit symptoms of chronic bronchitis, as well as a diminished resistance to secondary infection, such as pneumonia and more especi- ally tuberculosis. 24. Pulmonary Embolism (hemorrhagic infarction). If an embolus gain entrance into a pulmonary artery it may, if it be sufficiently large, cause immediate death ; smaller emboli occlude only the narrower vessels and give rise to hemorrhagic infarction of the area normally supplied with blood by the obstructed vessel (venous stasis, with expression of air). The embolus may be derived from the right heart, in consequence of dilata- tion ; or from the veins of the body, in consequence of phlebitis, etc. The symptoms include sudden dyspnea, irritative cough, and pain in the side. The sputum is bloody and fever is present. On physical examination the pulmonary reson- ance is impaired over the site of embolism and the breath- 172 DISEASES OF THE RESPIRATORY ORGANS. ing is bronchial, while rales may be heard over a small area, though frequently they are wanting. Treatment. — Morphin, digitalis, ice-bag, rest in a com- fortable position. 25. Pleurisy. Etiology. — The rheumatic variety is considered at p. 146 ; the tuberculous variety at p. 135. The aifection occurs in conjunction with pneumonia, pulmonary infarc- tion, gangrene, abscess-formation, glandular suppuration, caries of the ribs or vertebral column, etc. A distinction is made between dry pleurisy, attended with the formation of a fibrinous exudate upon the pre- viously smooth surface of the pleura (which is a particularly common association with tuberculosis), and exudative pleu- risy, attended with extravasation of a serous, albuminous, or serofibrinous, serocellular, purulent, hemorrhagic, or putrid exudate, in accordance with the nature of the causative agent. The onset is frequently subacute, less commonly acute, with chill and severe pain in the side (which disappears, however, as the exudate forms, together with disappear- ance of the friction). Cough is severe and dyspnea is present in consequence of the pain. There is no expecto- ration. On physical examination dulness on percussion is want- ing in cases of dry pleurisy. On the other hand, there is distinct creaking pleuritic friction, synchronous with the breathing and occurring in jerks, also palpable with the hand and usually observed over the lower lobe. When a pleuritic efltusion has taken place there is in- tense dulness, with a sense of resistance and enfeebled breathing, frequently also crepitant rales from compression of the lung ; but subsequently there are no adventitious sounds. Vocal fremitus is diminished and egophony is present. Above the level of the exudate, especially in front, the percussion-note is distinctly tympanitic, in con- sequence of relaxation of the lung. In cases of right- sided effusion the liver is displaced downward and the DISEASES OF LUNGS AND PLEURA. 173 heart toward the left, while in case of left-sided effusion Traube's semilunar space is obliterated (the normal tym- panitic note being replaced by dulness) and the heart is displaced toward the right and upward. At the beginning of the attack the patient prefers to lie upon the unaffected side to avoid pain ; later, upon the affected side in order to breathe more freely with the healthy side. The affected side may bulge and be behind the other in movement. The upper boundary of dulness usually is oblique from above and behind, downward and forward, in consequence of the development of the effusion in the dorsal decubitus ; Fig. 55.— Right-sided exudative pleuritis. and no alteration in the level takes place with change of posture (in contrast with seropneumothorax), in conse- quence of fibrinous adhesions. During the stage of ab- sorption the level of the exudate regularly remains high- est in the axillary region, declining anteriorly and poste- riorly (Ellis -Damoiseau curve). The variety of pleurisy is determined by means of exploratory puncture, together with microscopic and bac- teriologic investigation (see p. 49 et seq.). If the exudate be sterile, the fact is suggestive of tuberculosis. Under other conditions pyogenic cocci, diplococci, etc., are found. Cure of the pleurisy takes place through absorption of 174 DISEASES OF THE RESPIRATORY ORGANS. the exudate (increased elimination of urine), and con- traction of the affected side (see Fig. 56), with thickening and induration. Diagnosis. — See pp. 167, 168. Treatment. — If the level of the exudate reaches ante- riorly to that of the second intercostal space, puncture should be made at once. After careful cleansing of the Fig. 56.— Left-sided pleuritic contraction. skin with soap, alcohol, and 5 per cent, solution of carbolic acid, a suitable needle previously sterilized by boiling is in- troduced rapidly and forcefully in the sixth or seventh inter- costal space in the scapular line. The exudate is permitted to esca})e through a rubber tube into a receptacle partially filled with water, the flow being interrupted from time to time. From 1500 to 1800 cu. cm. may be readily evacu- DISEASES OF LUNGS AND PLEURA. 175 ated in this manner, and the wound of puncture is closed with a bit of adhesive plaster. Even in the absence of the foregoing absolute indication early aspiration of the eifusion often exerts a favorable influence. It is further to be employed when absorption is tardy. There may be used also mustard-paper, moist packs, ice-bags, diuretics, antirheumatics, morphin. In cases of empyema operative procedures are indi- cated. 26. Pneumothorax. Entrance of air into the pleural cavity may occur in con- sequence of injuries to the chest, of rupture due to a pul- monary cavity, tuberculosis, gangrene, abscess of the lung, etc. In accordance as the opening is constantly patulous or becomes so only with inspiration, or is again closed, the condition is designated as open or valvular or closed pneumothorax. If fluid also, as serum or pus, is present at the same time in the pleural cavity, the condition is designated as seropneumothorax or pyopneumothorax respectively. In consequence of the entrance of air the correspond- ing lung is subjected to marked compression, as a result of Avhich there occur suddenly severe dyspnea, sharp pain, often a condition of collapse, fall of temperature (for in- stance in tuberculosis). The affected side is greatly dis- tended and immovable during respiration. The percus- sion-note is strikingly deep and full, but as a rule not tympanitic. On percussion with plexor and pleximeter a metallic note is elicited (see p. 30). The vesicular mur- mur is wanting (in cases of open pneumothorax the breathing in amphoric). If, in addition to air, fluid also is present, the level of the fluid changes temporarily with change in posture. Liver and heart are displaced. Ex- ploratory puncture may be required. Treatment. — This is to be governed by the nature of the primary disorder. Traumatic pneumothorax may be completely absorbed. Eventually operative evacuation may be required, as in cases of emjjyema. 176 DISEASES OF THE RESPIRATORY ORGANS. 27. Hydrothorax. Bilateral accumulation of fluid transudate (containing a deficiency of albumin) in the pleural cavity, especially upon the left side and below, occurs in conjunction with acute nephritis and conditions of stasis attending diseases of the heart. Hydrothorax gives rise to symptoms of compression of the lungs similar to those due to pleuritic exudation, ex- cept that they are bilateral, rather than unilateral : dul- ness on percussion, with a sense of resistance and enfeeble- ment of respiration. The fluid removed by aspiration has a specific gravity below 1015, while that of the pleu- ritic exudate is above 1017. Symptoms. — Difficulty in breathing, irritative cough, cyanosis. Treatment. — Diuretics, diaphoretics, hot packs. Hemothorax results from hemorrhage into the pleural cavity, as from rupture of an aneurism or traumatic rup- ture of blood-vessels. 28. Neiv-groicths in the Chest. Among the new-growths that may occur within the thorax are carcinomata and sarcomata of the lungs and pleurae as well as of the mediastinal glands (primary and metastatic), gummata, echinococcus of the lung. The symptoms, which at first are equivocal, are essen- tially as follows : increasing difficulty in respiration, irri- tative cough, pain. Later, there occur abnormal promi- nence of the chest and irregularly limited areas of dul- ness, with absence of respiratory murmur and symptoms of displacement of viscera. There will also be evidences of compression. Distention of the cutaneous veins (as well as those upon the arm of the corresponding side), edema of the chest-wall, of the neck, the face, difliculty in deglutition (compression of the esophagus), neuralgic pain (from pressure uj3on nerve-plexuses) and paralysis (of the arm), bronchial stenosis, paralysis of the recurrent laryngeal n(;rve (see p. 39). If the tumors be malignant, there will be also cachexia DISEASES OF THE HEART. 177 and enlargement of lymphatic glands. Frequently hem- orrhagic pleurisy is a complication, with the presence possibly of carcinoma-cells in the exudate. In cases of echinococcus rupture into a bronchus may take place (see Plate 21, Figs. 7 and 8). Treatment. — Arsenic, mercurial inunctions, operation. The prognosis is dubious. m. DISEASES OP THE CIRCULATORY ORGANS. A. Diseases of the Heart. 1. Acute Endocarditis. This occurs seldom as a primary disorder, but usually as a secondary infection (see p. 145) in cases of rheumatic polyarthritis, following attacks of scarlet fever, measles, diphtheria, smallpox, pneumonia, gonorrhea, pyemia. A distinction is made between a benign (verrucose) and a malignant (idcerative) variety. Both are attended with fibrinous deposits upon the endocardium, in which the respective causative agents are found (pyogenic cocci, diplococci, gonococci, etc.). In the benign variety the fibrinous deposits take the form of small nodular vegeta- tions ; while in the malignant variety there form floating coagula and, in consequence of necrosis, ulceration, ren- dering possible embolic distribution of the infectious material. Exacerbations are also not rare in benign endocarditis (^recurring variety). The symptoms, apart from the primary disorder, are often but slight : high fever and palpitation of the heart. Objectively there are tachycardia, a systolic mur- mur of varying intensity, a valvular pulmonary second sound, dilatation of the heart. The actual diagnosis is often made only from the sequelae. In the ulcerative form these are mostly due to the emboli, which, as they are usually septic, give rise to metastatic, pyemic pro- cesses, attended with chills. The lesions of the benign variety may either heal perfectly or, through cicatricial contraction, calcification, etc., give rise to shortening of 12 178 DISEASES OF THE CIRCULATORY ORGANS. =J£ ertro- Dllatation Apex-beat Epigastric Pulsation Murmur Sounds Cardiac Dulness Pulse Miscella- neous Mitral Insuffi- ciency. Hypertrophy of the right ventricle ; hypertrophy and dilatation of the left ventricle. Dilatation and hy- pertrophy of the left auricle. Somewhatincreased, displaced toward the left. Usually present. Systolic blowing murmur, in addi- tion to the first sound, at the apex of the heart ; sec- ond sound faint. Pulmonary second sound markedly accentuated. Increase of dulness at first toward the left, later also to- ward the right (in- creasing dilatation and hypertrophy of the right ven- tricle). Strong, without peculiarity. At the apex a systolic thrill (purring tre- mor) is palpable. This is a very com- mon lesion, and the prognosis is favor- able. Mitral Stenosis. Aortic Insuffi- ciency. Hypertrophy of the right ventricle. Dilatation and hyper- trophy of the left auricle. Not increased ; often displaced toward the left. Marked visible pulsa- tion. Diastolic, often pre- systolic, usually faint rumbling or galloping murmur at the apex; first sound very loud. Pulmonary second sound' markedly accentuated ; often divided. Increase of dulness, markedly toward the riglit, less to- ward the left (dis- placement of the left ventricle in consequence of hj'- pertrophy and dila- tation of the right ventricle). Very small ; of slight tension; often irreg- ular and intermit- tent. Severe cardiac lesion ; o ft e n associated with other valvular lesions (especially insufficiency) ; fre- quently brown in- duration of the lungs (cardiac-les- ion cells, tendency to bronchitis, em- boli*; marked sub- jective manifesta- tions; cyanosis. Marked hypertrophy of the left ventricle. Displaced far toward the left and down- ward; markedly heaving, extended, massive apex-beat. Loud rushing dias- tolic murmur at mid-sternum ; f r e - quently also a short systolic murmur at the apex (relative mitral insuffi- ciency), etc. Markedly increased toward the left (to the axillary line). Pulsus celer marked; running-pulse ; visi- ble capillary pulse (diastolic pallor at the finger-nails) ; palpable hepatic pulse. Abnormal sounds over the small arte- ries (brachial, radial, palmar arch); double sound over the femoral artery, double mur- mur (see p. 07). Frequent, favorable valvular lesion ; re- mains compensated for a long time. Derangements of compensation of se- rious import. DISEASES OF THE HEART. 179 Aortic Stenosls. Moderate hypertrophy of the left ventricle. Somewhat displaced to- ward the left ; usually not greatly increased. Sawing, long-continued, diastolic murniiir, espe- cially to the right of the upper part of the ster- num ; the remaining sounds mostly faint. Tricuspid Insufficiency. Hypertrophy of the right ventricle. Normal situation. Present. Systolic murmur at lower extremity of sternum. Pulmonary Stenosis. Marked hypertrophy of the right ventricle. Displaced somewhat to- ward the left. Marked. Loud systolic murmur to the left of the upper part of the sternum. Systolic thrill palpable. Pulmonary second sound Pulmonary second sound not accentuated. feeble. Increase of dulness to- Increase of dulness to ward the left, later also toward the right. Very slow, tardy ; of slight fulness; small. An uncommon cardiac lesion. Freqiaent attacks of syn- cope and vertigo (cere- bral anemia). ward right, especially also upward. Usually poorly filled ; car- diac-systolic venous pulse ' in the jugular veins ; hepatic venous pulse. Usually secondary to de- rangements of compen- sation of the other and especially mitral valvu- lar lesions ; relative in- sufficiency (see p. 56). Marked symptoms of stasis. Marked increase of dul- ness toward the right ; slighter increase toward the left (displacement). Without peculiarity. In most cases congenital; often associated with other developmental anomalies of the heart ; marked cyanosis; drum- stick fingers ; death us- ually at puberty or be- fore. 180 DISEASES OF THE CIRCULATORY ORGANS. valves and narrowing of orifices — that is, to valvular lesions of the heart. Treatment — Rest, ice-bags, salicylic preparations, eventually digitalis. 2. Valvular Lesions of the Heart. Abnormal relations between the valvular apparatus and the orifices of the heart are caused by thickenings and shortenings of the valve-leaflets, so that these no longer close adequately ; and by cicatricial narrowing and calcification of the orifices. Under the conditions first named there results insufficiency of the valve ; under the conditions second named, stenosis of the orifice. The pathologic alterations referred to occur in the sequence of acute endocarditis, as well as of arterio- sclerosis (syphilis, alcoholism, chronic nephritis) ; further, they are in part congenital (especially valvular lesions of the right side of the heart). In accordance with the localization of the lesion at one or more of the four valves and orifices there result eight varieties of valvular defects (insufficiency of mitral, tricuspid, aortic, and pul- monary valves and stenosis of the corresponding orifices). For a consideration of the theory of the most important valvular lesions reference should be made to p. 55 et seq. The special clinical manifestations attending them are out- lined in the preceding table, pp. 178, 179. Most valvular lesions of the heart occasion symptoms during the first period of their existence only in the se- quence of unusual strain upon the heart, especially mitral and aortic insufficiency. Advan(!ed cases, as well as the presence together of several lesions, but especially mitral obstruction, even at an early period, give rise to the follow- ing symptoms, usually in varying intensity : cardiac dysp- nea and cyanosis, continuously or in paroxysms (cardiac asthma), sense of oppression, vertigo, headache, circulatory disturbances (gastric catarrh, in consequence of venous sta- sis), palpitation of the heart, cough (hypostatic bronchitis). After stasis in the pulmonary circulation has existed for a long time brown induration of the lung results, of the ex- DISEASES OF THE HEART. 181 istence of which the presence in the sputum of so-called cardiac-lesion cells (see Plate 8, Fig. 4) affords an indica- tion. Temporary derangements of compensation (see p. 60) occasion increase of dyspnea and cyanosis, further edema, ascites, hydrothorax, cyanotic kidney (albuminuria), cyanotic liver, cyanotic spleen, emboli (brain, kidney). Fig. 57. — Pulse-tracing from a case of uncompensated mitral stenosis. Diagnosis. — Of importance especially are the situation, the character, and the time of occurrence of the murmur, and, above all, the state of the pulse and the condition of the heart (see table, pp. 178, 179). Treatment. — For derangement of compensation : pow- dered digitalis leaves, from 0.1 to 0.15 (gr. jss-gr. ijss) every one and a half or two hours until physiologic effects Fig. 58.— Pulse-tracing from the same case as Fig. 57 after administration of digitalis. are produced, as indicated by the pulse ; infusion of digi- talis (from 1 to 1.5 to 120. [from gr. xv-gr. xx to four ounces] every two hours ; 3. to 150. [gr. xlv to five ounces], one-third by enema, twice or thrice daily). Figs. 57 and 58 illustrate the pulse of mitral stenosis before and after the action of digitalis. 182 DISEASES OF THE CIRCULATORY ORGANS. If digitalis is not well borne in any form, but not be- fore, resort may be had to caifein, 0.2 (gr. iij) four times »daily; spartein, 0.0015 (gr. J^) thrice daily; infusion of adonis vernalis, 5. to 150. (gr. Ixxv to live ounces) ; infusion of convallaria majalis, 5. to 150. (gr. Ixxv to five ounces); tincture of strophanthus, 10 drops thrice daily ; diuretics ; stim- ulants ; morphin. For cardiac dropsy : calomel, 0.2 (gr. iij) from 3 to 5 times daily, following or si- multaneously with digitalis ; powdered digitalis leaves 0.15 (gr. ij) ; calomel, 0.2 (gr. iij), 5 times daily ; gargle of potassium chlorate (stomatitis) ; other diuretics (potas- sium acetate ; theobro- min sodio-salicylate [5.-8. — gr. lxxv-.5ij — daily] ; squill ; po- tassium and sodium borotartrate); elevated posture ; application ^^^ of bandages ; massage of the swollen extrem- ities ; aspiration of the Fig. 59.— Drum-stick fingers in a case of pulmo- oopif po li vdrotliorn x nary stenosis. "^^^^ '^'^7 "^ , ^ . '' or hydropericarduun ; scarification of the skin, employment of capillary trocar for chronic edema of the skin. In the stage of compensation : avoidance of all excessive physical exercise (bicycling), limitation of the amount of fluid ingested (alcohol) ; roborant nutrition ; cold spongings ; regular exercise afoot; baths (Nauheim, Kissingen, etc.). DISEASES OF THE HEART. 183 Congenital Lesions of the Heart The valvular lesions (tricuspid stenosis and pulmonary insufficiency) not mentioned in the foregoing table on, account of their rarity occur, as well as pulmonary steno- sis, usually in consequence of congenital narrowing or defect, generally in combination with other developmental anomalies (patulousness of the foramen ovale, of the duct of Botal, deficiency in the ventricular septum, in the origin of the large vessels). The accompanying photographs illustrate the conditions present- ed by two boys suffer- ing from lesions of the kind just named, under observation at the City Hospital of Bamberg. Fig. 59 represents a case of typical pulmo- nary stenosis (cyanosis ; hypertrophy of the right ventricle ; dis- placement of the left ventricle ; increased area of cardiac dulness [the normal area of dulness being shown by interrupted lines] ; systolic murmur at the base of the heart, heard loudest in the situation of the small circle ; drum-stick fingers). Fig. 60 exhibits, in addition to the symptoms of pulmonary stenosis, a band of dulness (patulous duct of Botal [?]) at the upper portion of the sternum above the cardiac dulness. The patient presented, beside, a spastic brachial monoplegia, probably in consequence of a previous embolism, perhaps conveyed Fig. 60.— Pulmonary stenosis. 184 DISEASES OF THE CIRCULATORY ORGANS. from the right side of the heart through the patulous foramen ovale. When the foramen ovale fails to close (see Fig. 61, a and h) the venous blood passes in part from the right auricle, without having passed through the lungs, into the left auricle and ventricle, with resulting admixture of venous and arterial blood, and marked cyanosis. The prognosis is always unfavorable by reason of the insufficiency of the arterialization of the blood constantly present, and the usually enfeebled development of the child (tendency to tuberculosis, to severe derangements a. h. Fig. 61. — Patulous foramen ovale. Diagrammatic representation of the circu- lation during the systole (a) and the diastole (6). of compensation). Children thus affected rarely pass the age of ten or fifteen years. 3. Idiopathic Hi/perfrophy of the Heart. The designation idiopathic hypertrophy is applied to cases in which the enlargement of the heart is unattended with the existence of a demonstrable valvular lesion, as indicated by purity of the sounds. Hypertrophy of the left ventricle develops in the sequence of abnormal resistance in the general circulation, of arte- riosclerosis (rigidity of the arteries) and of contracted kidney (increased blood-pressure in consequence of con- striction of the small vessels as a result of toxic influ- ences); further, in the sequence of excessive ingestion of fluids and of food (use of beer), as well as of continued physical overactivity (athletes, gymnasts, oarsmen, etc.). DISEASES OF THE HEART. 185 Hypertrophy of the right ventricle develops in conjunc- tion with increased resistance in the pulmonary circula- tion, with emphysema, with contracting pleurisy and pneumonia, with atelectasis, with kyphoscoliosis. The symptoms are the same as those that attend valvular lesions. When insufficiency of the muscular structure of the affiscted ventricle appears, symptoms of derangement of compensation set in (see p. 60) ; marked dilatation is attended with relative insufficiency (systolic murmur). Treatment. — It is necessary first to determine the etiologic factor and then to effect its removal. In other respects the treatment is like that of valvular lesions. 4. Diseases of the Myocardium. Fatty degeneration of the myocardium is the usual out- come of diseases of the heart (valvular lesions, idiopathic diseases), associated with hypertrophy and dilatation. The development of this condition is recognized by fail- ure of digitalis to bring about improvement, the diseased myocardium being no longer able to overcome the dilata- tion. The occurrence of fatty degeneration is induced with especial frequency through the activity of certain toxic substances (alcohol, typhoid fever, scarlet fever, diphtheria) ; further in consequence of anemia, inanition, etc. Fibroid degeneration (myocarditis) consists in partial transformation of the muscular structure of the heart into tendinous connective tissue. It occurs in conjunction with disease of the coronary arteries (arteriosclerosis, syphilis). The most important symptoms are attacks of oppression, angina pectoris, embolic processes from mural thrombi, hypertrophy and dilatation of the heart, and especially striking arrhythmia of the pulse, with intermis- sion of the heart's action. Derangements of compensation are always grave. The disorder occurs frequently in association with idiopathic hypertrophy. Rupture of the heart and aneurism-formation may take |)lace. Treatment (see Cardiac Valvular Lesions). — Potassium iodid, mercurial inunctions, and morphin may be required. 186 DISEASES OF THE CIRCULATORY ORGANS. 5. Neurotic Disorders of the Heart. Nervous palpitation of the heart (a sense of vigorous cardiac activity), with or without tachycardia (accelerated action of the heart), occurs in part permanently in cases of exophthalmic goiter, in part transiently in cases of neurasthenia, of anemia after active physical exercise, following excitement, in cases of hypochondriasis, with relative infrequency (usually only in the stage of deranged compensation) in connection with valvular lesions of the heart and diseases of the myocardium. Treatment. — Hardening, cold frictions, systematic bod- ily and mental activity, iron, bromid, etc., cold compresses, baths (carbonated). Angina pectoris (stenocardia) is characterized by attacks of intense pain and oppression in the precordium, radi- ating to the arm, the shoulder, and the back, associated with a condition approaching collapse. It occurs in nervous individuals, in heavy smokers, in conjunction with sclerosis of the coronary arteries and with medias- tinal tumors. Treatment. — Cutaneous irritants (mustard), hot or ice- cold compresses, injections of morphin, chloralamid (from 2 to 3 grams — gr. xxx-gr. xlv) ; nitroglycerin (0.003 — gr. yV — daily) ; sodium nitrite (2 per cent.), etc. Fatty Heart. — This designation is applied to a series of manifestations in obese individuals which are largely of nervous origin and in part dependent also upon morbid conditions of the myocardium. Syraptmas. — Sense of oppression, dyspnea, palpitation of the heart, painful sensations, etc. Treatment. — Regulation of the amount of fluid and of food ingested. Increase in the muscular activity through systematic mountain-climbing under medical direction and other forms of gymnastic exercises. B. Diseases of the Pericardium. 6. Pericarditis. This is usually secondary to rheumatic polyarthritis, DISEASES OF THE PERICARDIUM. 187 scarlet fever, diphtheria ; it attends also contracted kid- ney, alcoholism, pleurisy, phlebitis, tuberculosis, etc. A distinction is to be made between fibrinous (villous deposit), exudative, hemorrhagic (tuberculosis, neoplasms), and purulent (pyemia) varieties. Symptoms. — Severe, stabbing pain in the precordium, pain in swallowing, sense of oppression, anxiety, dyspnea, irregular fever, enfeebled apex-beat. Dry Pericarditis. — Loud, rasping pericarditic friction, not synchronous with the action of the heart, especially at the upper portion of the sternum ; disappearing with increase in the exudation and returning with its absorp- tion. Exudative Pericarditis (see Fig. 62). — The area of car- diac dulness is considerably increased in all directions and Fig. 62.— Exudative pericarditis. is of triangular outline (see Plate 49). The apex-beat, if at all palpable, can be felt within the area of dulness and not at its boundary, as it is in connection with hyper- trophy and dilatation. The heart-sounds are very faint, but pure. The pulse is accelerated, sometimes irregular. With the absorption of the exudate there result exten- sive adhesions of the pericardium, often entirely obliterat- ing its cavity. These occasion disturbances in the activ- ity of the heart (secondary degeneration and atrophy of the myocardium). The condition may be manifested objectively by systolic retraction in the situation of the 188 DISEASES OF THE CIRCULATORY ORGANS. apex-beat, with irregular (Fig. 63) and paradoxic pulse (see p. 68) — diastolic collapse of the veins. The prognosis is dependent upon the etiologic factors, as determined by exploratory puncture in the fifth inter- costal space to the left of the sternum. Treatment. — Digitalis, strophanthus, morphin, ice-bag, mustard-plaster, quiet, comfortable posture, diuretics. If the exudation be large, aspiration may be practised ; if purulent, surgical intervention will be necessary. 7. Hydropericardium (Dropsy of the Pericardium). This consists in an accumulation of transudate in connec- tion with general venous stasis and often due to a cardiac lesion in the stage of compensatory derangement ; it may attend acute nephritis and the severe anemias. Fig. 63.— Irregular pulse attending pericardial adhesions. Symptoms. — Dyspnea, sense of anxiety, oppression, irritative cough. Objective manifestations : enlargement of the area of cardiac dulness, as in exudative pericard- itis, enfeebled apex-beat, faint and dull but pure sounds, no friction-murmur. Treatment. — In addition to the treatment of the prim- ary disorder diuretics, digitalis, calomel, etc., maybe pre- scribed, and finally aspiration may be practised. Hemopericardium. — A collection of blood in the peri- cardium takes place in the sequence of injuries, rupture of an aneurism of the aorta and of the coronary arteries and of the heart (myocarditis, etc.). The symptoms are like those of hydropericardium, with the addition of suddenly developed anemia, coma, and a fatal termination. DISEASES OF THE VESSELS. 189 PneumopeiHcardium. — An accumulation of air in the pericardium takes place in the sequence of perforation of pulmonary or of abdominal abscesses. It gives rise to abolition of the cardiac dulness, with metallic murmurs synchronous with the heart's action, and a metallic note upon percussion with plexor and pleximeter (as in pneu- mothorax). The prognosis is dubious. C. Diseases of the Vessels. 8. Arteriosclerosis. Loss of elasticity of the arteries through thickening of the intima, deposition of lime-salts in the intima and media, with secondary fatty degeneration and atherom- FiG. 64. — Pulsus tardus of arteriosclerosis. atous (softening) ulcers in the intima. The condition is manifested by tortuosity and rigidity of the vessels (temporal, radial, brachial). It occurs in advanced life (especially in the aorta, the temporal, the brachial, and the coronary arteries) and at an earlier period as a result of alcoholism, syphilis, lead-poisoning, gout, chronic neph- ritis, etc. In consequence of the increased resistance in the general circulation, from rigidity of the arteries, the left ventricle undergoes hypertrophy and dilatation. Often systolic murmurs are audible. The pulse is retarded (Fig. 67) and the vessel feels hard. Sequelce. — Emboli (fibrinous coagula) and hemorrhages (miliary aneurisms) give rise to apoplexies and disturb- 190 DISEASES OF THE DIGESTIVE ORGANS. ances in the cerebral circulation, to vertigo, headache, tinnitus aurium, etc. Attacks of angina pectoris may occur, from involvement of the coronary arteries ; and contracted kidney may result. The recognition of calci- fication of the radial artery does not justify a conclusion as to the existence of general arteriosclerosis, as involve- ment of the aorta may be unattended with similar involve- ment of the radial. The prognosis is dubious. Treatment. — Mild courses of baths at Carlsbad or a cure at Kissingen. Baths (carbonated, etc.) with caution ; possibly potassium iodid ; otherwise symptomatic. ^ 9. Aiieurism of the Aorta. This condition may attend arteriosclerosis and syphilis. It is mostly situated upon the ascending portion or the arch of the aorta. It is manifested by the presence of a pulsating swelling in the second and third intercostal spaces to the left of the sternum, with dulness on percus- sion over or adjacent to the upper portion of the sternum, in cases of large aneurism merging with the cardiac dul- ness. On auscultation a loud vibratory systolic (also dias- tolic) murmur can be heard. On palpation a thrill can be felt. The left ventricle undergoes hypertrophy and dilatation. The radial pulses are unequal. The prognosis is dubious. Treoiment. — Potassium iodid, ergotin, compression, perhaps surgical intervention. IV. DISEASES OF THE DIGESTIVE ORGANS. A. Diseases of the Mouth and the Pharynx. 1. Stomatitis. Inflammation of the gums is in most cases of infectious or toxic origin. Catarrhal stomatitis is attended with swelling, redness, painfulness of the gums and of the mucous lining of the cheeks, and is manifested by marked salivation, fetid breathy depom position-processes, epithelial desquamation, DISEASES OF THE MOUTH AND THE PHARYNX. 191 bacterial multiplication. It occurs in conjunction with caries of the teeth, injuries clue to chemic substances (acids, tobacco), and with other infectious diseases (measles, syphilis). Necrotia stomatitis presents an aggravation of the fore- going symptoms, to the point of necrotic destruction of the mucous membrane, with loosening of the teeth, hem- orrhages, purulent pasty deposit upon the gums, exquisite pain, marked salivation, swelling of the lymphatic glands. This condition may be transformed into : Ulcerative stomatitis ; after exfoliation of the necrotic tissues superficial ulcers appear, especially at the corners of the mouth, at the junction of the cheeks and the jaws, and at the points where the teeth lie in contact with the buccal mucous membrane. This variety of stomatitis occurs especially in conjunction with mercurial poisoning (calomel, blue ointment, and in artisans). Aphthous Stomatitis (aphthae). — This is a disease of the mucous membrane of the mouth, tongue, and palate, dependent in children (through the milk of cows affected with foot-and-mouth disease) upon an as yet undiscovered infectious agent. It is characterized by the presence of small, round, white spots, somewhat depressed and sur- rounded by an area of redness (fibrinous exudate in the necrotic mucosa). Bednar^s Aphthce. — These are usually insignificant, atro- phic white spots upon the hard palate of nursing infants. Treatment. — Cleanliness ; care of the teeth ; withdrawal of mercurial treatment ; astringent gargles (tannic acid, alum, borax in solution of from 1 to 5 per cent.) ; anti- septics (carbolic acid, 1 or 2 per cent., etc.) ; potassium permanganate, 0.1 per cent. ; potassium chlorate, 2 per cent. ; solution of hydrogen dioxid, 2 per cent. ; applica- tions of tincture of myrrh, tincture of rhatany ; in severe cases applications of silver nitrate. Thrush-deposits (see p. 121) should be treated with applications of solution of borax (5 per cent.), or with solutions of resorcin (1 or 2 per cent.). 192 DISEASES OF THE DIGESTIVE ORGANS. 2. Glossitis, Pare7ichymatous glossitis may be attended with abscess- formation, fever, tumefaction and intense painfulness of the tongue, and also interference with respiration. It is to be treated with applications of ice and early incision. Dissecting glossitis is attended with the formation of numerous fissures and excoriations of the tongue^ and requires applications of silver nitrate. Leukoplakia buccalis (geographic tongue, tylosis) con- sists in the formation of cloudy, white thickenings of the epithelium upon the tongue, and also upon the buccal mucous membrane. The condition is without significance and is often mistaken as syphilitic. Ludwig^s Angina. — This is a parenchymatous inflam- mation of the floor of the mouth, attended with tumefac- tion of the submaxillary, salivary, and lymphatic glands, symptoms of profound constitutional disturbance, and danger of edema of the larynx. IVeatment. — Early incision. 3. Angina (Tonsillitis). This is an infectious inflammation of the tonsils, de- pendent upon the activity of pyogenic cocci. Catarrhal angina attends scarlet fever, aphthous stom- atitis, etc., and is characterized by redness, sAvelling, and painfulness of the tonsils and of the soft palate. There is no deposit, although fever, headache, etc., are present. Lacunar angina is the most common variety, and is characterized by the presence of purulent plugs in the lacunae of the tonsils, which do not coalesce. The lym- phatic glands are enlarged. Necrotic angina, is characterized by the presence of pasty, grayish-white deposits, not involving the uvula. The appearances are suggestive of diphtheria, and the diagnosis should be based upon microscopic and bacterio- logic examination (see p. 27). Diphtheric angina is attended with the presence of white deposits advancing from both sides toward the palate and uvula until they meet (see p. 140). DISEASES OF THE MOUTH AND THE PHARYNX. 193 Parenchymatous angina is characterized by abscess- formation, marked swelling and tension of the tonsil and the palatine arch, usually upon one side only. The con- dition is attended with great pain, and swallowing is im- possible. Treatment. — Gargles of potassium chlorate (2 per cent.), alum, potassium permanganate, solutions of carbolic acid ; or inhalations ; ice ; cold applications. When suppuration is threatened poultices should be employed, and when an abscess has formed early incision should be practised. 4. Chr 07110 Hypertrophy of the Tonsils. This condition as seen in children is usually congenital. The patients manifest a predisposition to anginas. The condition is attended with interference with breathing and with speech (which is rendered nasal), and with snoring, restless sleep. It is a common accompaniment of scrofu- losis. Treatment. — Nutrition ; salt baths ; frictions ; excision of the hypertrophied parts with the tonsilitome or with the knife. 5. Dry Chronic Pharyngitis. Chronic Pharyngeal Catarrh occurs frequently in asso- ciation with chronic retronasal catarrh in smokers, alco- holics, anemic individuals, etc. The mucous membrane undergoes atrophy and presents a pale, smooth, glazed appearance, and is frequently covered with tough secre- tion or crusts. The patient suffers from an annoying sense of dryness, of burning and of scratching in the throat, with constant hawking, and sometimes morning vomiting from heightened reflex irritability. Treatment. — Nasal douches (sodium chlorid, sodium bicarbonate, alum) ; insufflation of sozoiodol, tannic acid, silver nitrate (from 0.3 to 0.5 [gr. v-gr. viij] to 10. [sijss] of starch) ; applications of glycerin and iodin, etc. ; inhalations ; baths (Reichenhall, Ems, Kreuznach, etc.). Adenoid Vegetations of the Nasophai'ynx (see p. 36). Treatment. — Extirpation ; galvanocautery. Retropharyngeal abscess (see p. 81). 13 194 DISEASES OF THE DIGESTIVE ORGANS. Treatment. — Immediate incision. Paralysis of the Palate; Paralysis of the Pharynx. — Both of these conditions sometimes follow diphtheria, in consequence of neuritis of toxic origin. The former is attended with the regurgitation through the nose of fluids swallowed, with a nasal tone of voice and difficulty or impossibility of gargling ; paralysis of the pharynx, with difficulty or impossibility of swallowing. B. Diseases of the Esophagus. Inflammatory processes (from catarrh, chemic irritants) and ulceration (corrosive, tuberculous, syphilitic, decubital) are not common, and are of significance only with regard to their sequelae (stenosis). Diverticula are described on p. 82. 6. Stenosis of the Esophagus. This condition may result in consequence of compres- sion from without (mediastinal tumors, aneurism of the aorta, inflammatory processes, caseous bronchial glands), of obstruction (by impacted foreign bodies or accumula- tions of aphthae), of cicatricial narrowing (syphilitic scars, corrosions, etc.), as well as of carcinoma of the esophagus (this is the commonest cause). With the gradually increasing stenosis there occurs difficulty in swallowing, solid articles of food giving rise to a sense of obstruction and lodgment, with regurgita- tion, eructation, vomiting. The emaciation attains an extraordinary degree in cases of marked stenosis and finally complete inanition. The most important information is gained through the use of the sound (see pp. 29, 81), which may also affi^rd information as to the nature of the obstruction. If this be seated at a distance of 23 cm. (9 inches) from the margin of the teeth, it is likely to be dependent upon glandular tumors, aneurism, etc. ; if, however, it be seated at a distance of 40 cm. (15| inches) or slightly less, it is to be attributed to carcinoma of the cardiac orifice of the stomach. DISEASES OF THE STOMACH. 195 Cicatricial stenosis is to be recognized from the his- tory. It is often seated high up, at the entrance to the esophagus. A suspicion of carcinoma will be strength- ened by the presence of marked cachexia, metastatic deposits, and advanced years. Treatment. — Surgical intervention will be required eventually (dilatation with bougies after esophagotomy, introduction of nourishment through a gastric fistule). The food should be liquid and mushy, and the tube may be necessary for its introduction. Nutrient enemata (milk, eggs, beef-tea, etc., see Section V, morphin) may be required. C. Diseases of the Stomach. 7. Acute Gasb'itis. Acute gastric catarrh is in part infectious and toxic (infectious diseases, cholera morbus), in part a direct result of errors in diet. Symptoms. — A sense of oppression in the epigastrium, anorexia, nausea, vomiting, eructation, diminished pro- duction of hydrochloric acid. Treatment. — Diet, hydrochloric acid, mild purgatives. 8. Chronic Gastritis. This condition occurs in conjunction with alcoholism, anemia, chronic nephritis, heart-disease (hypostatic catarrh), carious teeth, etc. There is frequently deficient secretion of hydrochloric acid, though not invariably. Other symptoms include tenderness on pressure in the epigastrium, persistent impairment of appetite, moderate emaciation, nausea, eructation (especially upon an empty stomach), vomiting of mucus, heartburn (due to lactic acid from fermentation), hypochondriasis. Diagnosis. — Carcinoma is to be excluded (cachexia, presence of a palpable tumor, history). Inquiry into the etiology (nephritis, heart-disease, alcoholism, etc.). Ex- amination of the gastric juice (see p. 85 et seq.). Treatment should be directed to the primary disorder. The diet should be regulated, fatty, indigestible foods 196 DISEASES OF THE DIGESTIVE ORGANS. being avoided. From time to time a milk-diet should be prescribed, and cold frictions and massage of the epigas- trium be practised. Attention should be directed to regu- lation of the intestinal movements, by means of enemata of oil, glycerin, or water. Courses at Marienbad, Carls- bad, Kissingen, may be advised. Dilute hydrochloric acid should be given after each meal if anacidity is present. Stomachics may be required, and possibly lavage of the stomach with solutions of boric acid, etc. Phlegmonous gastritis is attended with suppuration in and beneath the mucous membrane, and occurs in con- junction with septic infection. The prognosis is dubious. 9. Gastric Ulcer. Chronic ulceration of the stomach is seated mostly in the neighborhood of the pylorus and upon the lesser curvature. It invades the wall of the stomach to a vary- ing depth. The condition may be caused by circulatory disorders of various kinds, in consequence of which cer- tain areas become anemic and undergo autodigestion. It is common in anemic individuals, and especially in women. Symptoms. — Circumscribed pain, occurring sponta- neously, after the ingestion of food and upon pressure ; hyperacidity, with the presence of hydrochloric acid in the fasting stomach ; heartburn ; frequent vomiting ; constipation ; from time to time hematemesis, with the ejection of dark blood (blood may also appear in the stools). Recovery may be followed by cicatricial deform- ity (hour-glass contraction, pyloric stenosis). Often the ulcers are multiple. Not rarely carcinoma develops sec- ondarily upon the cicatrix left by previous ulceration. If the ulcer be deep, there is danger of perforative peri- tonitis. Diagnosis. — Circumscribed pain and hematemesis are the most important symptoms. Nervous dyspepsia must be excluded. In many cases characteristic symptoms are entirely wanting (latent ulcer). DISEASES OF THE STOMACH. 197 Treatment. — Rest in bed ; hot applications at intervals ; liquid diet (milk, eggs, broths), sodium bicarbonate (^j) with bismuth (gr. xxiv) in small quantities ; Carlsbad water or salts ; large doses of bismuth in mucilaginous vehicles. (See Dietary, Section V.) Duodenal Ulcer. — This sometimes follows burns of the skin. It is frequently unattended with symptoms, although hemorrhage may take place, the blood appear- ing in the stools or being ejected by vomiting. Symp- toms of peritonitis may appear, with pain, especially in the right hypochondrium. 1 0. Carcinoma of the Stomach. This occurs mostly in persons between the age of 40 and 60 years. The new-growth is usually a cylindric epithelial carcinoma (diifuse scirrhus, or individual carci- nomatous nodules). The neoplasm is usually seated at the pylorus and upon the lesser curvature. The symptoms are of insidious onset. The appetite is impaired and strength fails. There is complaint of gas- tric derangement, with pain, eructation, heart-burn (due to lactic acid from fermentation). Later there occur vomiting of food, and also stagnation of food. Event- ually hematemesis takes place, the blood appearing in masses, resembling coftee-grounds (for demonstration of hemin crystals see Plate 6, Fig. 3). The further prog- ress of the case is marked by increasing cachexia, an- acidity, with the presence of considerable lactic acid in the gastric juice. Frequently a tumor is palpable in the region of the stomach, being slightly movable with respi- ration if not adherent to the liver. Metastases are com- mon, especially in the liver. The duration of the dis- ease may be from six months to a year and a half. Treatment. — Symptomatic ; easily digested food (meat- juice, artificial food, milk, eggs) ; hydrochloric acid ; ex- tract of condurango ; possibly gastroenterostomy. If the diagnosis be made early (circumscribed tumors, absence of hydrochloric acid), radical extirpation of the new- growth may be undertaken. 198 DISEASES OF THE DIGESTIVE OUGAM. 11. Dilatation of the Stomach. This occurs most commonly in conjunction with pyloric stenosis, due to cicatricial stenosis following ulceration, the presence of tumors (carcinoma), rarely compression from without (tumors in the neighborhood of the liver, wandering kidney, etc.). The stenosis is at first compen- sated for through hypertrophy of the muscular wall of the stomach, but later progressive dilatation occurs. In con- sequence of the stagnation of food fermentative processes result. Atonic dilatation of the stomach occurs directly from over-distention in those who eat and drink exces- sively, and in cases of chronic catarrh. The condition is usually associated with hyperacidity. Symptoms. — Pains in the stomach from two to five hours after the ingestion of food ; vomiting of large amounts at the same time or later ; heart-burn ; acid eruc- tations. The appetite is usually good. Nevertheless, there is progressive emaciation. The pain is mitigated by the vomiting. The dilated stomach, as well as its peristaltic activity, is sometimes discernible from the ex- terior. Splashing sounds may be elicited on agitation of the body. The enlargement of the viscus may be de- monstrated by distending it with carbon dioxid, or with Avater (see p. 85 and Plate 51, 6). The stomach may be considered dilated if under these circumstances its lower boundary extends to the level of the umbilicus or below. Treatment. — See treatment of gastric ulcer. Systematic lavage (evening or morning) ; chopped meat; milk ; gruel; eggs ; massage ; electricity. If emaciation be not too far advanced (body-weight !) : pyloroplasty or gastroenter- ostomy. Eventually nutritive enemata. For the fer- mentative disorders : magnesia and powdered charcoal in small quantities. Irrigation with solution of boric acid. In reaching a prognosis as to the results of surgical in- tervention it is important to determine whether the sten- osis of the pylorus is benign (cicatricial) or malignant (carcinomatous). DISEASES OF THE INTESTINES. Pyloric Stenosis. 199 Duration Course Tumor Appetite Hydrochloric Acid Lactic Acid Vomiting Benign. Long (from 5 to 15 years). With intervals of improve- ment. Usually wanting ; rarely benign hypertrophy. Almost always good. Usually present. Usually wanting. Brings relief. Malignant, Short (from 6 months to 1^ years). Progressive aggravation. Usually present. Poor. Almost always wanting. Always present. Causes exhaustion. 12. Nervous Dyspepsia. A distinction is to be made between simple nervous dyspepsia (attended with pressure in the epigastrium, pain, vomiting, without hyperacidity) and acid dyspepsia (with marked hyperacidity, in addition to the foregoing symptoms). The nutrition is generally well preserved. The disorder occurs frequently in chlorotic and nervous individuals. Diagnosis. — Ulcer is to be excluded. This is not always possible. Treatment. — Cold sponging ; active exercise ; possibly iron ; nutritious diet ; massage ; electricity ; baths ; psy- chotherapy. D. Diseases of the Intestines. 13. Intestinal Catarrh. Acute intestinal catarr^h attends colds, infectious diseases, acute intoxications. The more important symptoms are abdominal pains, colic, diarrhea, and tenesmus. The stools present a green- ish appearance, from the presence of undecomposed bile, and there is considerable admixture of mucus, especially in cases of catarrh of the large bowel. Exhaustion may attend profound catarrhal states. 200 DISEASES OF THE DIGESTIVE ORGANS. Treatment. — Rest in bed ; hot applications ; astringent wines ; cocoa ; mucilaginous soups ; powdered opium (from 0.03 to 0.05 — gr. ss-gr. f — frequently) ; opium and tannic acid in powder; tannigen (1.0 — gr. xv), etc. Chronic intestinal catarrh attends infectious diseases, alcoholism, diseases of kidneys and liver, etc. Symptoms. — Alternating diarrhea and obstinate consti- pation for months or years. Sense of discomfort in the abdomen, with flatulence and meteorism. The stools contain abundant admixture of mucus. If the small intestine also be involved, the stools contain undigested particles of food (lientery). When ulcerative processes are present in the colon pus and blood appear in the stools. 3Iemhranous enteritis is attended with the painful dis- charge of muco-membranous shreds, in conjunction with nervous intestinal catarrh and attacks of colic in neuras- thenic individuals. Treatment. — Courses at Carlsbad or Kissingen ; milk- diet ; warm packs ; massage ; systematic irrigation of the bowels ; avoidance of indigestible and especially farina- ceous food, of fatty meats and of salads ; proscription of the use of alcohol. In nursing infants acute enteritis due to spoiled milk (infection) is characterized by diarrhea, with frequent greenish stools, often together with vomiting and loss of strength. Chronic diarrhea becomes attended with in- creasing cachexia (pedatrophy) in consequence of pro- gressive atrophy of the mucous membrane of the entire gastro-intestinal tract. Treatment. — Withdrawal of milk for several days, with the substitution of mucilaginous decoctions ; albumin- water ; artificial foods, hydrochloric acid, bismuth sub- nitrate. 14. Intestinal Tuberculosis. This occurs mostly as a complication in cases of pul- monary tuberculosis (see p. 1 34). Syphilis of the Bowel. — Syphilitic ulceration of the DISEASE^S OF THE INTESTINES. 201 rectum is not at all uncommon, and recovery may be fol- lowed by stenotic cicatrices (funnel-shaped stenosis). Symptoms. — Diarrhea, bloody stools, tenesmus, etc. Treatment — Antisyphilitic remedies ; surgical dilata- tion for stenosis. 15. Carcinoma of the Bowel. Carcinoma rarely develops in the small intestine. When it does, it appears in the form of solid tumors, usually freely movable and circumscribed, whose presence gives rise eventually to symptoms of occlusion of the bowel. The most common variety is carcinoma of the rectum, which may exist for a long time without occasion- ing symptoms, but which later causes chronic diarrhea, te- nesmus, mucous and bloody stools, difficulty in defecation, sciatica, etc. Sometimes the progressive cachexia, or per- haps metastasis to the liver, may lead to digital examina- tion of the rectum and the discovery of the new-growth. The treatment must eventually be surgical. 16. Stenosis and Occlusion of the Bowel (Ileus). Etiology. — Foreign bodies, fecal accumulations, tumors, cicatricial strictures, axial torsion, incarcerated hernia, invagination (in children), constriction of the bowel (internal hernia, abnormal ligaments or bands). Stenosis is attended with difficulty in defecation (the stools being band-like or globular), abdominal pains, meteorism, nausea. Occlusion is attended with irremediable constipation, together with cessation of flatulent discharge, severe nausea and retching, and abdominal pain, vomiting, at first bilious, later feculent, constant eructation, hiccough, and marked prostration. Diagnosis. — Inquiry should be made as to the cause of the condition and the usual sites of hernia examined. Intussusception is attended with mucous and ' bloody stools, and the presence of a sausage-shaped tumor. Treatment. — Immediate celiotomy or herniotomy ; opium (0.05 — gr. ^ — every two hours) ; ice ; lavage of the stomach ; rectal irrigation. 202 DISEASES OF THE DIGESTIVE ORGANS. 17. Habitual Constipation. This occurs in nervous, hypochondriacal, and anemic individuals, and especially in children and women. It occurs in conjunction with chronic catarrhal states of the stomach and the intestines, and with sedentary occupa- tions. Treatment. — Vegetables and fruits in abundance ; rye- bread, bran-bread ; active exercise in the open air ; mass- age of the abdomen ; frictions ; enemata of glycerin, of oil, and of water ; faradization ; courses at Kissingen, Carlsbad, Franzensbad, etc. ; possibly rhubarb, cascara sagrada, tamarinds, aperient waters. When hemorrhoids are present : cold affusions ; pro- vision for regular evacuation of the bowels ; hemorrhoidal pessary ; radical operation. 18. Intestinal Parasites. 1. Tape-ivo7ins (see p. 128) occasion unpleasant sensa- tions, digestive derangement, nervous states, diarrhea, etc. In a suspected case castor-oil should be given and the stools examined for proglottides and ova. Treatment. — Extract of filix mas (2.0 — gr. xxx — in capsules, five or six at intervals of half an hour), followed in three hours by a tablespoonful of castor-oil every two hours. Particular care should be taken to secure the head. 2. Ascarides (see p. 126). — Santonin (0.05 — grain | — several times daily). 3. Oxyures (see p. 126) cause annoying itching in the region of the anus. The treatment consists in the ad- ministration of enemata of garlic rubbed up in milk ; naphthalin (O.lo to 0.4 — gr. ijss-gr. vj — four times in twenty-four hours); castor-oil ; calomel. 4. Ankylostomimi (see p. 126) requires the same treat- ment as tape-worm ; drastics. E. Diseases of the Peritoneum. 1 9 . Perityph litis. This is a form of local peritonitis following perforation of the vermiform appendix, which usually results in con- DISEASES OE TBE PERlTONEVM. 203 sequence of fecal accumulation in the appendix (fecal concretions). Symptoms. — Rather sudden occurrence of abdominal pain, especially in the right iliac fossa, with vomiting, eructation, constipation, meteorism, and moderate fever. There is dulness on percussion in the ileo-cecal region (right iliac fossa), with a sense of resistance, due to exu- dation and adhesive peritonitis. If the inflammation of the peritoneum be progressive and attended with accumu- lation of pus in the abdominal cavity, the fever, which had previously subsided, rises higher than it had been, while the pulse becomes softer and more frequent, the meteorism more marked, and the general condition more grave, and hiccough and collapse appear. Treatment. — Tincture of opium, 20 drops every two hours, until complete relief from pain is secured ; ice- bag ; cold drinks ; no purgatives. Enemata may be em- ployed after the disease has pursued a favorable course for a week. If aggravation takes place, as well as when an abscess forms, immediate celiotomy is to be under- taken (exploratory puncture is entirely without danger). 20. Acute Peritonitis. This usually occurs in conjunction with rupture of abscesses (perinephric, parametric, subphrenic, hepatic, tubal), with ulcerations of stomach and bowels (gastric ulcer, duodenal ulcer, typhoid fever, dysentery, intestinal tuberculosis), with incarceration of the bowel ; further in cases of pyemia and of puerperal fever and in the sequence of pleurisy and pericarditis, and as a result of injuries. A distinction is to be made between circumscrihed peri- tonitis (rapid formation of adhesions, without constitu- tional infection) and diffuse peritonitis ; further between sero-jibi'inous and purulent and putrid peritonitis (depend- ent upon infectious agents : toxins, staphylococci, strepto- cocci, bacterium coli commune, proteus, etc.). Symptoms. — Severe abdominal pain, vomiting, greatly distended abdomen, elevation of the diaphragm. The 204 DISEASES OF THE DIGESTIVE OMGANS. percussion-note is tympanitic everywhere ; or if exuda- tion have taken place, there is duhiess in the dependent portions. When air is present within the abdominal cavity (perforative peritonitis, see p. 96) the liver-dulness, and when the patient lies upon the right side the splenic dul- ness, disappears through displacement by the air. After the lapse of several hours there is rapid failure of the patient, who presents a collapsed appearance (Hippo- cratic facies), with heart-failure. Treatment. — Circumscribed peritonitis is to be treated with opium, etc. (see perityphlitis) ; diffuse peritonitis (after exploratory puncture) by celiotomy, ice, opium (from 0.05 to 0.1 — gr. |-gr. jss). 21. Chronic Peritonitis. This is usually tuberculous (see p. 136). A distinction is to be made between a dry (adhesive) and an exudative variety. The former leads to extensive adhesions of the intestine, with unfavorable prognosis and marasmus ; from the latter recovery may take place after celiotomy, pro- vided the operation be not undertaken too late. Among the symptoms are persistent fever, abdominal pain, presence of a serous exudate (as demonstrated by exploratory puncture) and of tuberculosis elsewhere. Peritoneal tuberculosis is frequently attended with the presence of large tuberculous tumors of the omentum and hemorrhagic exudations. The prognosis is unfavorable. 22. Ascites. This consists in an accumulation of fluid in the perito- neal cavity in consequence of venous stasis. It occurs in conjunction with diseases of the liver and portal vein (cirrhosis, carcinoma, thrombosis), with general venous stasis (heart-disease in the stage of derangement of com- pensation), and with diseases of the kidneys. Among the symptoms are distention of the abdomen, with especial prominence of the lateral portions ; eleva- tion of the diaphragm ; dulness on percussion in the dependent portions ; with a sense of fluctuation. The DISEASES OF THE LIVER. 205 dulness varies with change in posture, as the eifusion usually finds its Avay to the most dependent part. Fre- quently there is edema of the lower extremities, from pressure upon the ascending vena cava. Exploratory puncture discloses the presence of a serous exudate, the fluid exhibiting a specific gravity below 1015 (see p. 95). The differential diagnosis from ovarian cysts, etc., is discussed on p. 94 et seq. In these other conditions there is wanting especially the change in percussion- note with change in posture, etc. Treatment should be directed to the primary disorder ; digitalis ; potassium and sodium borotartrate ; calomel ; aspiration. 23. Carcinoma of the Peritoneum. This usually occurs by metastasis from stomach, liver, rectum, or uterus. It is attended with a copious ascitic effusion, usually hemorrhagic, with tumors of the omen- tum, pain, cachexia. F. Diseases of the Liver. 24. Catarrhal Jaundice. This results from extension of catarrhal swelling from the duodenum to the biliary passages, and may be of infec- tious character. The obstruction to the flow of bile into the intestine leads to the development of jaundice, together with anorexia, nausea, vomiting, abdominal pain. The jaundice may last from two or four to eight weeks. It is characterized by a yellowish discoloration of the skin of the whole body and of the sclera, together with annoy- ing itching, slowing of the pulse, and gastric derangement. The stools are clay-colored, from the absence of biliary col- oring-matter and the presence of considerable unabsorbed fat and fat-needles. The urine is brown, and on shaking forms a yellow foam (see p. 11 2). The liver may be enlarged from stasis of bile and the gall-bladder may be dilated. The prognosis is favorable. Treatment. — Carlsbad, Muhlbrunnen, Kissingen waters, etc. ; diet ; no fat. 206 DISEASES OF THE DIGESTIVE ORGANS. Chronic jaundice results in rare cases as a consequence of obliteration of the choledoch duct (chronic fibrous cholangitis). It is attended with progressive emaciation, cachexia, convulsions, coma, delirium, hemorrhages (cholemia, intoxication). WeiPs disease is probably an infectious disorder attended with fever, jaundice, herpes, rheumatic pain, enlargement of the spleen, and nephritis. It lasts for two weeks, and the prognosis is good. 25. Cholelithiasis. The formation of calculi (cholesterin, bilirubin, lime- salts) in the biliary passages and in the gall-bladder occurs most commonly in women between 40 and 60 years of age. Hereditary predisposition appears to be of influence in the etiology. The principal symptom is biliary colic, dependent upon impaction of a calculus in the biliary passages. This consists in intense pain in the region of the liver and the stomach, with vomiting, chills, fever, enlargement of the spleen. Such attacks of colic, lasting from one or two to four days, may be repeated at intervals of varying length. At the conclusion of the attack jaundice appears if the stone have not been impacted in the cystic duct, in which situation it is capable of giving rise only to stasis in the gall-bladder (dropsy of the gall-bladder), through absorption of the bile when the case pursues a chronic course). Permanent impaction gives rise to chronic jaun- dice. As a result of ulceration, abscesses may form in consequence of migration of cocci from the bowel, with the occurrence of pyemic chills, perforative peritonitis, metastatic suppurative processes, etc. If the gall-bladder be filled with calculi, these may be palpable, with the development of crepitation. Gall- stones may be present in the stools. Diagnosis. — Colic associated with gastric ulcer and ner- vous attacks unattended with jaundice are to be excluded. The prognosis is dubious. Frequent repetitions are unfavorable ; as is also chronic jaundice. DISEASES OF THE LIVER. 207 Treatment— In the attacks, poultices, extract of opium (0.06 to 0.1 — gr. j-gr. jss — several times daily), mor- phin subcutaneously ; later, enemata ; then a course at Carlsbad ; sodium salicylate, sodium bicarbonate, of each 15., a small quantity thrice daily. 26. Cirrhosis of the Liver. A distinction should be made between hypertrophic and atrophic cirrhosis, the latter representing frequently the terminal stage. The affection occurs most commonly in conjunction with chronic alcoholism, also with tuberculous peritonitis and chronic malaria. In the first stage the liver is enlarged, through infil- tration and fatty degeneration. Its surface is hard, its border smooth. Slight jaundice is common. The spleen is enlarged and chronic gastrointestinal catarrh is present. In the second stage the liver is diminished in size, from disappearance of parenchyma and hyperplasia of the in- terstitial connective tissue. The surface of the organ is nodular and hard, its margin irregular. Jaundice may be wanting. The occurrence of stasis in the portal vein is mani- fested by ascites, swelling of the spleen, chronic gastro- intestinal catarrh, distention of the abdominal veins, and progressive cachexia. Complications. — There are frequently also contracted kidney, hypertrophy of the heart (alcohol), etc. Treatment. — Course at Carlsbad ; calomel ; diuretics ; digitalis ; aspiration ; prophylaxis. 27. Acute Yellow Atrophy of the Liver. This is a profound infectious disease terminating in death in the course of a few days. It sets in with vomiting, fever, and jaundice. Con- sciousness is greatly disturbed (coma and delirium). The liver becomes smaller from day to day in consequence of fatty degeneration and resorption. The urine contains leucin, tyrosin (see Plate 15, Figs. 3 and 4), and much ammonia^ with diminished elimination of urea. 208 DISEASES OF THE DIGESTIVE ORGANS, 28. Carcinoma of the Liver. This is usually metastatic from stomachj rectum, or esophagus ; less commonly primary in the biliary passages. It gives rise to the presence of irregular enlargement of the liver, often to an enormous degree, together with the presence of multiple palpable tumors. There is usually jaundice, more rarely ascites. Progressive cachexia is a feature. 29. Syphilis of the Liver. Tertiary syphilis may be attended with the develop- ment of gummata in the liver, with infiltration and tume- faction, secondary cicatricial constriction, giving rise to lobulation. Ascites and enlargement of the spleen are common, jaundice rare. Pain is a marked symptom and marasmus may ensue. Treatment. — Potassium iodid and mercurial inunctions ; not always successful. 30. Abscess of the Liver. This occurs in conjunction with cholelithiasis, pyemia, ulceration of the bowel, etc. It is characterized by the occurrence of severe chills, with high fever, attacks of intense pain, vomiting, enlargement of the liver, seldom jaundice, no ascites, eventually fluctuation (exploratory puncture). The prognosis is unfavorable. Rupture may take place and excite perforative peritonitis. Treatment. — Surgical intervention. 31. EchinococGus (see p. 128) of the liver gives rise to enlargement of the organ, with the development of fluctuating, tensely elastic tumors. Hydatid fremitus (audible vibration on shock-like tapping) is often present. Eventually there may be also ascites, enlargement of the spleen, jaundice. Exploratory puncture discloses the presence of fluid free from alV)umin, and containing much succinic acid and sodium chlorid (see Plate 21, Fig. 7), together with booklets, scolices, and portions of mem- brane (see Plate 21, Fig. 8). JVea^me;i^,^Surgical intervention. DISEASES OF THE LIVER. 209 32. Cyanotic {Nutmeg) Live7\ This condition of the liver occurs in conjunction with all forms of ht^art-disease in the stage of derangement of compensation. There is pain on pressure in the region of the liver and the abdomen is prominent. The surface of the liver is hard^ its margin sharp and smooth. At the same time there is usually ascites, the liver remaining large after its disappearance. The urine is scanty and concen- trated^ and edema, cyanosis, etc., are likely to be present. Treatment. — Digitalis ; diuretics ; aspiration of the ascites. Fatty degeneration of the liver occurs in conjunction with anemia, phosphorus-poisoning, arsenical poisoning, excessive indulgence in alcohol (see cirrhosis), and cyanotic liver. The condition is mostly unattended with distinctive symptoms. The liver is usually large and its margin smooth. At times secondary atrophy follows. Amyloid degeneration of the liver occurs in conjunction with chronic suppurative processes, tertiary syphilis, chronic pulmonary tuberculosis, caries, etc. The liver is large, hard, and dense, with a blunt margin. There are usually at the same time enlargement of the spleen and amyloid degeneration of the kidneys. 33. Constricted Liver. This deformity results generally from the long-con- tinued use of constrictions about the waist, and it is accordingly more common in women than in men. It can often be detected by palpation beneath the right half of the costal arch. Sometimes a distinct fissure can be felt. The condition is attended with pain, and predis- poses to the formation of biliary calculi. 34. Thrombosis and Inflammation of the Portal Vein. Thrombosis of the portal vein occurs as a result of compression by tumors (adjacent carcinoma, syphilis), of cicatricial contraction (cirrhosis, etc.). It gives rise in turn to ascites, enlargement of the spleen, gastric and in- testinal hemorrhages, caput Medusae (dilatation of the 14 210 DISEASES OF THE DIGESTIVE ORGANS. veins surrounding the umbilicus, with the formation of anastomoses). If agents capable of inducing inflamma- tion gain access to the thrombus (in conjunction Avith idceration of the stomach, or bowels, gall-stones, perityph- litic abscesses, inflammation of the umbilical vein in infants, etc.), symptoms of profound pyemia develop in addition to those enumerated (see abscess of the liver). Diagnostic Features of the more Common Diseases of the Liver. Cyanotic Liver Acute Yel- low Atro- pliy Cirrhosis (First Stage) Cirrhosis (Second Stage) Chole- lithiasis Carcinoma Syphilis Echinococ- cus Amyloid Disease Abscess Volume. Enlarged. Dimin- ished. Enlarged. Dimin- ished. Enlarged. Enlarged. Enlarged. Enlarged. Enlarged. Enlarged. Consist- ence. Firm. Firm. Firm. Hard. Firm. Hard. Hard. Soft. Hard. Soft. Liver-margin, liver-surface. Smooth. Smooth. Smooth. Nodular. Smooth : pos- sibly disten- tion of gall- bladder. Nodular. Lobulated. Lobulated. Blunt. Bulging. Jaundice. Absent. Absent. Absent. Present. Present. Present. Present. Absent. Absent. Absent. Ascites, splenic en- largement. Present. Absent. Absent. Present. Absent. Present. Present. Absent. Absent. Absent. Q. Diseases of Spleen. 35. Enlargement of the Spleen. This may occur as the result of stasis (cyanotic spleen) in conjunction with diseases of the liver and the heart ; further with infectious diseases (typhoid fever, malarial fever, pyemia, etc.), with embolism (endocarditis, arterio- sclerosis), with amyloid disease (see Amyloid Liver, p. 203), with leukemia (p. 221). Symptoms arise only when the enlargement is extreme (leukemia). The most DISEASES OF THE KIDNEYS. 211 marked are painful sensations, especially upon muscular eifort, and dyspnea. In all of the conditions named the spleen is distinctly palpable as a hard, solid tumor. Frequently a depression (incisure) can be felt in the body of the organ. A wan- dering spleen also may become palpable. The treatment varies in accordance with the primary disorder, and may require the administration of arsenic or quiniuj or the application of bandages. H. Diseases of the Pancreas. Of these maybe mentioned atrophic processes occur- ring in some cases of diabetes, hemorrhages (sometimes leading to sudden death from anemia), carcinoma, and cystic formations (see Plate 61). The diagnosis may require exploratory puncture, and the ti^eatment surgical intervention. V. DISEASES OP THE UROPOIETIC ORGANS. A. Diseases of the Kidneys. 1 . Acute Hemorrhagic Nephritis. The anatomic alterations consist in cloudy swelling, fatty degeneration, and necrosis of the renal epithe- lium. The disease is less commonly primary (from exposure to cold), but it occurs usually in conjunction with acute infectious diseases (scarlet fever, diphtheria, small-pox, endocarditis, etc.) as a result of intoxication. It may also occur in consequence of poisoning with cantharides, potassium chlorate, turpentine, salol, etc. The duration of the disease is from three or six to ten weeks. The symptoms include headache of gradually increasing severity, nausea, vomiting, edema of the eyelids, the face, the extremities, the scrotum, ascites, hydrothorax, hydropericardium . This form of renal dropsy depends probably upon an abnormal permeability of the walls of the vessels induced 212 DISEASES OF THE UROPOIETIC ORGANS. by the activity of toxic metabolic processes, and not as a result of stasis (see Cardiac Dropsy, p. 61). The urine is much diminished in amount and is concen- trated. It presents the appearance of blood and it con- tains much albumin. The abundant sediment contains many hyaline and epithelial tube-casts, Avhite and red blood-corpuscles and renal e})ithelium, while the urea, the chlorids, and the phosphates are diminished. The specific gravity is high. Through the retention of the substances named, to- gether with others (extractives), there results uremia : coma, somnolence, epileptiform and eclamptic attacks, vomiting, headache, amaurosis. In reaching a diagnosis chronic recurring nephritis is to be excluded. The prognosis is rendered grave by the existence of effusions into the serous cavities (hydrothorax, etc.) and by uremia. The disease may be gradually transformed into chronic nephritis. Treatment. — Milk-diet, hot packs, diaphoresis, hot baths, diaphoretics (tea, pilocarpin, 0.02 [gr. i]), digi- talis, mild diuretics (sodium acetate, theobromin sodio- salicylate), aspiration. If uremia develop, enemata of digitalis may be administered, together with morphin. 2. Chronic Nephritis. Subchronic and chronic nephritis may develop in the sequence of acute nephritis, in conjunction with alcohol- ism and in many cases without obvious cause. Chronic pai^enehymatons nephritii<, occurring as a prim- ary disorder, with fatty degeneration of the renal epithe- lium, is present in many cases unnoticed for a long time, until increasing emaciation and anemia, disturbances in the activity of the heart, chronic catarrhal conditions (from stasis), the occurrence of edema or uremia (with respiratory difficulty and migraine) cause the patient to seek professional advice. Chronic nephritis causes almost always disturl)ances in the nutrition and in blood-formation, thus leading to sec- ondary anemia. Hypertrophy of the heart also may take DISEASES OF THE KIDNEYS. 213 place (see Contracted Kidney, p. 213). Uremia and edema are of common occurrence. In addition to the acute variety of uremia, it is the chronic variety, characterized by migrainous conditions, headache, vomiting, diarrhea, dyspnea (uremic asthma), that commonly occurs. There may be also albuminuric retinitis. The urine is usually secreted in diminished amount. It is usually turbid and deposits considerable sediment. There may be considerable admixture of blood and a large amount of albumin. The disease lasts from one or two to four years, and recovery is uncom- mon. The following varieties of chronic nephritis may be distinguished : (a) Large red, variegated kidney ; chronic hemorrhagic nephritis. The sediment contains many tube-casts, together with white and especially red blood-corpuscles. (b) Large white fatty kidney, with fatty degeneration of the renal epithelium. The sediment contains tube- casts covered with large numbers of fat-globules, and much fattily degenerated renal epithelium and leuko- cytes. (c) Secondarily contracted kidney (connective-tissue contraction). This is frequently the terminal stage of the foregoing varieties, if uremia, edema, or heart-failure have not previously led to a fatal termination. Li this form of the disease the amount of urine secreted is more abundant than in the forms described under (a) and (6), while the secretion itself is of light color and the sedi- ment smaller ; admixture of blood is uncommon. Hyper- trophy of the heart develops as a rule. The diagnosis is considered on p. 215. Treatment. — Milk-diet ; warm baths ; cold frictions ; abstinence from all irritating articles of food (condiments, alcohol) ; Faching, Wildung, and Bilin waters ; avoid- ance of cold ; iron ; iodin ; arsenic. 3. True Contracted Kidney. Granular atrophy of the kidney (increased develop- 214 DISEASES OF THE UROPOIETIC ORGANS. ment of the interstitial connective tissue, with contraction, and destruction of the renal parenchyma) develops in conjunction with chronic alcoholism, arteriosclerosis, gout, lead-poisoning ; less commonly with syphilis, malaria, etc. The duration of the disease is from four or six to ten or more years. In consequence of the reten- tion of certain noxious metabolic products there results contraction of the peripheral small arteries, giving rise to a tense pulse, and in consequence to increase in the arte- rial pressure. The circulatory obstruction thus occasioned is neutralized by hypertrophy of the left ventricle (com- pensation). For a time the increased work of the heart is adequate for the needs of the circulation, but finally derangements of compensation set in (catarrhal states of the bronchi, the stomach, the intestines, etc., from stasis, respiratory difficulty, pneumonia). There may now appear also edema and ascites (in consequence of stasis in the circulation). Frequently there are marked anemia and albuminuric retinitis. The urine is secreted in large amounts (from 3000 to 4000 cu. cm.). It is pale, and its degree of concentration slight. The specific gravity is quite low, and there is marked diminution in all the solid constituents (urea, etc.). The amount of albumin present is small and at times it may be entirely wanting. The sediment is scanty, and only individual tube-casts and white blood-corpus- cles, as well as epithelial cells, can be found. The diagnosis is indicated in the table on p. 215. Treatment. — Removal of the cause of the disease (alco- hol, lead) ; administration of alkaline waters ; employ- ment of baths (Nauheim, Baden-Baden, Kissingen, iron springs, etc.) ; observance of a milk-diet, etc. ; digitalis ; potassium iodid. 4. Cyanotic Kidney. This condition occurs in conjunction with diseases of the heart (derangements of compensation) and venous hyper- emia. The retarded cinnilation of blood through the kid- neys exerts an injurious influence upon the renal epithelium. DISEASES OF THE KIDNEY. 21 D The urine is much diminished in amount, greatly con- centrated, and dark in appearance. It contains a moderate amount of albumin and is of high specific gravity. The sediment is scanty and contains hyaline tube-casts and a small number of white and red blood-corpuscles. Treatment. — Digitalis. Hemorrhagic infarction also occurs in conjunction with disease of the heart (endocarditis). Symptoms are often wanting, and they may appear as transitory slight hema- turia, or pains in the loins (perinephritis). 5. Amyloid Kidney. For the etiology, see Amyloid Liver, p. 209. The urine is usually abundant, of pale-yellow color, and of normal or diminished specific gravity. It contains a large amount of albumin and deposits a slight sediment consisting of isolated white blood-corpuscles and hyaline tube-casts. Hypertrophy of the heart does not take place. Frequently marked edema (amyloid disease of the vessels ?) occurs, while uremia and retinitis do not. Eventually progressive anemia and marasmus make their appearance. Diagnosis of Diseases of the Kidney. Acute Nephritis. Chronic Par- enchymatous Nephritis. True Contracted Kidney Cyanotic Kidney. Amyloid Kidney. Amount o f Urine Specific Gravity Amount o f Albumin Sediment Hypertrophy of tlie Heart Small. High. Abundant. Much. Absent. Normal. Normal. Abundant. Much. Usually pres- ent. Very abund- ant. Low. Small or none. Little. Always pres- ent. Very small. High. Small. Little. Generally present. Abundant. Low. Abundant. Little. Absent. 6. Pyelonephritis. Catarrhal and suppurative inflammation of the pelvis of the kidney, with or without suppurative inflammation of the kidney, is usually secondary to general infection 216 DISEASES OF THE UROPOIETIC ORGANS. (pyemia, perforative peritonitis, etc.), renal calculi, cyst- itis (ascending), and especially when paralysis of the bladder exists, in the puerperal state, etc. If the disorder be of metastatic origin, embolic collec- tions of bacteria (staphylococci, streptococci) can be found in the substance of the kidney. The most important excitant of ascending pyelitis, other than those already named, is the bacterium coli commune. Symptoms. — Severe pain in the loins and in the course of the ureter ; irregular fever, with chills, sweats, pros- tration ; abundant urinary sediment consisting in part of pure pus, in part of admixture with epithelium from the pelvis of the kidney and red blood-corpuscles (calculi), less commonly tube-casts (toxic nephritis). The urine is usually of acid reaction. In the event of perinephric abscess-formation there is increase in the pain, with edema of the adjacent soft tissues. Diagnosis. — Tuberculosis is to be excluded, by exam- ination of the urinary sediment for tubercle-bacilli. The etiologic factor is to be looked for. Treatment. — Attention should be directed to the prim- ary disorder ; milk-diet ; Wildung, Vichy, Neuenahr waters ; balsams (copaiba, turpentine), astringents (tan- nic acid, lead acetate) internally ; also salicylic acid, etc. Eventually surgical treatment may be required. 7. Nej)hrolit/iiasis. Excretion of renal sand, constituted principally of phosphates or urates (see p. 114), often takes place, with- out distinctive symptoms. If, however, large concre- tions form in the pelvis of the kidney, impaction within the ureter may take place and give rise to attacks of renal colic. These are characterized by pain of the utmost in- tensity, radiating from the region of the kidney toAvard the groin and the scrotum, together with anuria, collapse, and vomiting. Such attacks may last from several hours to days. In consequence of the mechanical irritation there results catarrhal, perhaps ulcerative, pyelitis, which is DISEASES OF THE KIDNEY. 217 characterized by the presence of pus and especially of blood in the urine. The disorder usually pursues a chronic course, and it may be complicated by the forma- tion of abscesses and of purulent pyelonephritis. If the urine be acid, uratic calculi, if alkaline phos- phatic calculi especially form. Diagnosis. — Of importance are the character of the attacks of colic and the occurrence of hematuria. Treatment. — Moderation in the use of meat, with a pre- ponderance of vegetable food ; abstinence from alcohol ; abundance of liquids, especially the alkaline waters ; active bodily exercise, systematic gymnastics ; sodium bicarbonate, lithium bicarbonate, urea (10. — 2J drams — daily), lysidin, pij)erazin, etc. If the calculus be constituted of phosphates, acids, lactic acid (from 0.5 to 1. — gr. vijss-gr. xv — in solution) or salicylic acid, may be administered. In attacks of colic opium, morphin, hot packs, and cutaneous irritants may be employed. Surgical intervention may be ultimately required. 8. Taberculosis of the Kidney. Eruptions of tubercles in the kidney, with caseation in the structure of the organ and in the pelvis of the kidney, occur usually in conjunction with tuberculosis in other portions of the body (lungs, glands, prostate, bladder, etc.). Among the symptoms are those of purulent pyeloneph- ritis, without indications of pyemia, together with abun- dant elimination of pus and the presence of caseous mat- ters and of tubercle-bacilli in the urine. Treatment. — If the disease be unilateral, as determined by the use of the cystoscope, the affected kidney should be extirpated. Other measures to be employed are men- tioned under pyelonephritis. 9. Tumors of the Kidney (see p. 99). 10. Hydronephrosis. Accumulation of fluid within the pelvis of the kidney occurs in consequence of kinking or obstruction of the 218 DISEASES OF THE UROPOIETIC ORGANS. ureter (renal calculi, tumors, wandering kidney, preg- nancy, inflammatory processes, tumors of the prostate, tumors of the bladder), and of atrophy of the kidney from pressure. The swelling that results is of variable size in conse- quence of the varying amount of fluid present (in con- tradistinction from echinococcus), and urea can be demon- strated in the fluid obtained on exploratory puncture, al- though this may be wanting if the disorder have existed for a long time. The diagnosis is considered upon p. 99. 11. Wandering Kidney. This condition occurs frequently in women, and by reason of the changes in the position of the organ gives rise to pain, with especial frequency upon the right side, in the sacral region, and the abdomen. It is attended further with vomiting, attacks of colic, and hydronephro- sis if the ureter becomes kinked. The diagnosis is based upon the presence of a movable, sensitive, kidney-shaped body in one or other hypochon- drium, as determined by bimanual examination, while the normal area of renal dulness is wanting. Treatment. — Massage ; compressive and supporting bandages ; finally nephrorrhaphy. B. Diseases of the Bladder. 12. Cystitis. Acute catarrh of the bladder occurs in conjunction with infectious diseases (typhoid fever, etc.), as a result of catheterization, in conjunction with intoxications, with pregnancy, and in the sequence of gonorrhea, etc. The symptoms consist in pain in evacuation of the urine, frequent desire to urinate, spasm of the sphincter vesicae, dull pain in the region of the bladder and fever. The U7'ine is turbid and contains much mucus, as well as blood, epithelial cells, and pus-cor])uscles. On stand- ing, it speedily undergoes ammoniacal fermentation, with the development of coffinlid and thorn-apple crystals (see Plate 18, Fig. 1). DISEASES OF THE BLADDER 219 Bacteria also are present in large numbers. Chronic catarrh of the bladder results especially in con- junction with paralysis of the bladder (attending diseases of the spinal cord), with strictures of the urethra^ stone in the bladder, and hypertrophy of the prostate. Diagnosis. — Inquiry should be directed toward the etiologic factor. The presence of stone in the bladder is indicated by repeated hematuria and pain radiating to- ward the head of the penis, with at times retention of urine. Examination with the sound may confirm the diagnosis. Tuberculosis is to be excluded. Treatment. — Removal of vesical calculi ; treatment of strictures ; abundant use of liquids (much milk, infusion of uva ursi, Wildung and Faching waters) ; no beer, etc. ; hot cataplasms, morphin-suppositories ; belladonna. In the more chronic varieties of the disorder balsam of copaiba, balsam of tolu, turpentine, tannic acid, irriga- tion of the bladder with solutions of boric acid or zinc sulphate, or with emulsion of iodoform, will prove useful. Tubercidous Cystitis. — The symptoms and conditions are much the same as those that have just been described, together with abundant elimination of pus and the pres- ence of tubercle-bacilli in the urine. Treatment. — In addition to that indicated, surgical in- tervention may be necessary. 13. Tumors of the Bladder. These are usually papillomata (improperly designated villous carcinomata), less commonly true carcinomata. The symptoms include recurring hematuria and pain, together with evidences of chronic cystitis. The diagnosis is to be determined by palpation through the rectum or the vagina, through catheterization and the cystoscope. The treatment may finally require surgical intervention. 14. Nocturnal Enuresis. This disorder is observed in conjunction with nocturnal epilepsy and in nervous, debilitated children, from weak- ness of the sphincter vesicae. 220 DISEASES OF THE BLOOD, ETC. The treatment includes cold sponging, regularity in evacuation of the urine, electricity, elevation of the pel- vis by raising the foot of the bed, etc. VI. DISEASES OF THE BLOOD, AND OF THE BODILY METABOLISM. A. Diseases of the Blood (Plates 1 to 4). 1. Chlorosis. This occurs commonly in girls at the period of puberty. It is attended with derangement in blood-formation and in gastro-intestinal digestion, and with nervous disturb- ances. There is pallor of skin and mucous membranes, with frequent gastric disturbances, vomiting, headache, lassitude, drowsiness, palpitation of the heart (accidental murmurs), venous hum, shortness of breath (from defici- ency of oxyhemoglobin). Examination of the blood discloses no special diminu- tion in the number of erythrocytes, but, on the contrary, marked deficiency in hemoglobin (for method of deter- mination, see p. 75). The number of leukocytes remains normal. Complications. — Diseases of the myocardium (dilata- tion), ulcer of the stomach, hysteria. Diagnosis. — Tuberculosis is to be excluded. Emacia- tion is usually wanting. Treatment. — Rest ; sleep ; milk ; eggs ; cool frictions ; salt baths ; iron (Bland's pill, ferratin, etc.). The admin- istration of alcohol (in tlie form of red wine) is quite without utility. Steel baths may be advised. 2. Anemia. Acute anemia attends marked loss of blood occurring in consequence of injuries of arteries, menorrliagia, etc. Among the symptoms are pallor of the face and an appear- ance of collapse, coldness of the skin, a condition of coma, convulsions, amaurosis (anemia of the retina). Treatment. — Control of liemorrhage by means of tam- pons ; depression of the head ; provisional bandaging DISEASES OF THE BLOOD. 221 of the extremities ; saline infusions ; injections of cam- phor and ether ; enemata of water. Chronic secondary anemia is the common sequel of all chronic wasting diseases, especially of chronic nephritis, tuberculosis, carcinoma, chronic suppuration, gastric and intestinal catarrh, malaria, chronic intoxications (lead, mercury, etc.). It attends also ankylostomiasis, the pres- ence of teniae, and it occurs in cases of neurasthenia, etc. Symptoms. — Lassitude, anorexia, sense of fear, head- ache, palpitation of the heart, pallor, gastric derange- ment, and a host of other nervous disturbances. Examination of the blood shows the number of red corpuscles to be greatly diminished, with changes in form and size (poikilocytes, microcytes, macrocytes). Nucle- ated red corpuscles are uncommon. The leukocytes are frequently increased in number, but only the polynuclear variety. The proportion of hemoglobin is diminished in correspondence with the number of red corpuscles. The jyrognosis is dependent upon the nature of the primary disorder. Treatment. — Rest ; baths ; forced feeding ; massage ; electricity ; iron ; arsenic ; sojourn in the mountains. Pernicious anemia (primary anemia) is progressive in course and almost always terminates fatally. It is attended with hemorrhages into the retina, petechise, and fatty degeneration of various organs and structures. There is constant diminution in the number of erythrocytes, to as low as 400,000 in the cu. mm., and nucleated red blood- corpuscles are usually present (normoblasts and giganto- blasts). The proportion of hemoglobin is reduced, but usually not in correspondence with the oligocythemia. The number of leukocytes remains normal. The etiology of the disorder is obscure. The treatment does not differ materially from that of secondary anemia. Arsenic is the most reliable remedy. Bone-marrow has been used. 3. Leukemia (Plates 4 and 60). This disorder is probably dependent upon disease of 222 DISEASES OF THE BLOOD, ETC. the blood-forming organs (the spleen, the bone-marrow, the lymphatic glands). It is characterized by diminution in the number of erythrocytes, with increase in the num- ber of leukocytes, and is manifested clinically by pro- gressiye anemia and cachexia. The disease may last from one to two years, and its cause is quite unknown. A distinction is made between lymphatic, myelogenous, and splenic varieties, but as a rule the type of the disease is mixed. The first is characterized especially by great enlargement of the lymphatic glands, the last by marked increase in the size of the spleen. The disorder is gradual in onset and attended with progressive emaciation, anemia, respiratory difficulty, and pain in the side. The abdomen becomes swollen, and there is frequently irregular fever, with nervous disturb- ances and pain in the bones, especially on percussion, and particularly over the sternum. In addition to the enlargement of the spleen, which may reach enormous proportions, there are frequently increase in the size of the liver (from infiltration) and also infiltration of the kidneys and of the retina, and hemorrhages into the skin. The blood presents a yeast-like color. The number of erythrocytes is greatly diminished (to as low as 2,500,000 or even 1,000,000 and less), and frequently nucleated red blood-corpuscles are present. The proportion of hemo- globin also is diminished. The number of leukocytes is enormously increased (up to from 200,000 or 400,000 to 600,000 in the cu. mm.). The proportion of red to white corpuscles may thus reach 2 to 1. The increase in the leukocytes involves less the polynuclear (see leukocytosis, p. 76) than the mononuclear cells. Especially numerous are found medullary cells (myelocytes), which are usually not present in normal blood. Besides, the eosinophile cells also are often increased (see Plate 4). In cases of lymphemia, the small mononuclear cells (associated with enlargement of the lymphatic glands) preponderate ; in cases of the more common, splenomed- DISEASES OF THE BLOOD. 223 ullary, variety, the eosinophile and the medullary cells ; in cases of acute leukemia (terminating fatally in the course of sev^eral weeks), also the mononuclear cells (usually in conjunction with a pronounced hemorrhagic diathesis). In the bodies of subjects dead of leukemia Charcot-Leyden crystals form in the blood. In the urine the uric acid is usually increased. Treatment. — Arsenic, quinin, potassium iodid, iron iodid, phosphorus, richly albuminous diet, baths, etc. Pseudoleukemia is attended with the presence of symp- toms similar to those of leukemia (splenic enlargement, cachexia, anemia), but without increase in the number of leukocytes. Hodgkin^s disease is characterized by the presence of multiple glandular enlargement (lymphosarcoma). It pursues a rapidly pernicious course. The state of the blood appears to be normal. The treatment conforms to that just indicated. 4. Hemoglob'memia. Destruction of red blood-corpuscles in the vessels, with the presence of free hemoglobin in the blood, occurs . in conjunction with various forms of poisoning (potassium chlorate, anilin, nitrobenzol, antifebrin, hydrogen arse- nite, toadstools, etc.), in the sequence of transfusion and of burns, and in conjunction with profound infection (syphilis, scarlet fever, etc.). Symptoms. — Chills, fever, vomiting, languor, slight jaundice. The urine contains hemoglobin (see p. Ill), without the presence of red blood-corpuscles in the sediment. The prognosis is usually favorable. 5. Hemorrhagic Diathesis. A tendency to the extravasation of blood under the skin (petechise), to bleeding from the gums, to hemor- rhage from the bowels and beneath the periosteum, occurs in conjunction with various diseases. The etiology is unknown. (a) Scorbutus occurs frequently in sailors, from want 224 DISEASES OF THE BLOOD, ETC. of fresh vegetables, of variation in diet, and as a result of exposure to cold, etc. Amid symptoms of general prostration there occur numerous hemorrhages beneath the skin and mucous membranes, as well as from the stomach, the kidneys, etc. There may be, further, ulcera- tive stomatitis, swelling of the joints, etc. Treatmejit. — Vegetables, fruit, lemonade, quinin, etc. (6) Pm-pura (morbus maculosus Werlhofii) is charac- terized by multiple hemorrhages into the skin, by fever, and by prostration. (c) Peliosis rheumatica is attended with swelling of the joints and pain, with hemorrhages, especially in the ex- tremities. Treatment. — Ergotin, quinin, salicylic acid. (d) Hemophilia (bleeders' disease) consists in a familial tendency to severe hemorrhages, even upon the slightest provocation, as from cuts, extraction of teeth, etc. B. Disorders of the Bodily Metabolism. 6. Diabetes Mellitus. The designation glycosuria is applied to the transitory elimination of glucose in the urine. This occurs in the sequence of various forms of poisoning (hydrocyanic acid, morphin, phloridzin), of traumatism, especially of the nervous system, concussion of the brain, etc. (punc- ture-center of the medulla oblongata). The designation diabetes mellitus^ on the otlier hand, is applied to the inability of the body to consume the sugar taken up from the gastro-intestinal tract, together with the persistent elimination of this substance in the urine. Several varieties of the disorder are distiuguished : Alimentary Glycosuria. — Elimination of glucose ouly after ingestion of food containing sugar; this is a mild form. Diabetes of the Obese. — Attended with the elimination "jf usually small amounts of sugar. The nervous variety: occurring in cases of neurasthenia, etc. ; and finally a severe variety : in which the oxidation DISORDERS OF THE BODILY METABOLISM. 225 of glucose is greatly disturbed and albuminous metabolism takes place as a result in increasing degree. The etiology is undetermined, although heredity is of influence. Symptomis. — There is striking desire for food, in the face of constant loss of strength and weight, with marked thirst, even throughout the night, the mouth being con- stantly dry ; polyuria, from five to eight quarts of pale urine of high specific gravity (above 1020) being excreted daily; the presence of sugar in the urine (see p. 107 et seq,) ; also pruritus, furunculosis, gangrene, impotence, cataract, diabetic neuritis (abolition of knee-jerks, ataxia, sciatica), deposits of thrush in the mouth, diabetic coma (convul- sions, somnolence, dyspnea, odor of chloroform from the mouth), acetone-oxybutyric-acid intoxication (iron chlorid reaction, see p. 112). Cases of diabetes manifest a special tendency to pulmonary tuberculosis, nervous disturbances, etc. Diagnosis. — In all cases of obscure chronic disease the urine should be examined for sugar ; and if this be found present, the quantity should be deteft*mined, as well as the influence of the food uj)on its elimination and the amount. Treatment. — Approximate but not absolute avoidance of all articles of food containing sugar or starch (confec- tions, potatoes, farinaceous foods, beer, sweet wines), with the substitution therefor of food rich in fats and albumin, green vegetables, stewed fruits, little bread, saccharin, together with gymnastic exercises, a course at Carlsbad, baths (Carlsbad, Neuenahr, Vichy), frictions, opium (0.02 — grain -|) for thirst. Diabetes insipidus occurs in nervous individuals and in the sequence of traumatism. It is attended with poly- uria and polydipsia. The urine is passed in large amounts, is of low specific gravity and free from sugar. Wasting may be a prominent feature of the disease. . 7. Uric-acid Diathesis (gout, uratic arthritis). Deposition of uric acid in the tissues of the body takes 15 226 DISEASES OF THE BLOOD, ETC. place most commonly in the articular cartilages, in the cartilages of the ear, in the tendons and fascia, the skin, and the kidneys. Among the etiologie factors are heredity, alcoholism, obesity, lead-poisoning, gluttony, etc. In cases of typical gout paroxysms are repeated from time to time. These are attended with marked swelling, redness, and painfulness of the great toe (podagra, meta- tarsophalangeal articulation), the thumb and the joints of the hand (chiragra), the shoulder-joint (omagra, etc.). At the same time there occurs also vomiting, while the appetite is lost. In the further course of the disease deposition of urates takes place (tophi, gouty nodules), giving rise to deformities of joints, together with the development of chronic gastric and intestinal catarrh (visceral gout), bronchial catarrh, and finally to con- tracted kidney (renal gout). Treatment. — Restriction of the amount of meat ; avoid- ance of fat and fat-producing food ; predominance of vegetables ; alcohol is to be interdicted ; gymnastics ; massage ; systematic pedestrian journeys ; warm baths (Wiesbaden, Baden-Baden, Teplitz, etc.) ; moor-baths. In the gouty attack narcotics may be administered ; hot or cold packs employed ; cotton batting applied ; salophen, etc., administered ; later lithium carbonate, urea (10 to 15 grains), lysidin, uricedin, piperazin, etc. 8. Obesity. This condition is frequently hereditary. It occurs in conjunction with indulgence in an excess of food, and particularly of liquids (beer, coffee), with deficient phys- ical activity. The more troublesome symptoms are difficulty in breath- inii;;, obstinate constipation, meteorism, intertrigo, excessive diaphoresis. It is often attended with idiopathic hyper- tro])hy of the heart, and frequently with nervous derange- ment of the action of the heart. Treatment. — Systematic pedestrianism ; restriction of the amount of fluids ingested (coffee, soup, beer, wine, DISEASES OF THE JOINTS AND BONES. 227 milk) ; small amounts of farinaceous food, sweets and fat, with a larger amount of meat and vegetables ; fruit ; a course at Carlsbad, Marienbad, Kissingen, etc. VII. DISEASES OF THE JOINTS AND BONES. 1. Rachitis (English disease). This occurs between the first and third years of life, and is attended with chronic inflammatory changes in the epiphyseal cartilages, etc., deficient deposition of calcium salts, deformity of bones, usually in conjunction with derangement of gastro-intestinal activity. Among the physical signs are enlargement of the epiph- yses ; curvature of the extremities ; protracted failure of the fontanels to close ; delayed dentition ; craniotabes (softening of the occipital bones) ; projection of the sternum and retraction of the ribs (through the action of the diaphragm), giving rise to chicken-breastedness ; spinal curvature, pelvic deformity, etc. Usually there exist also anemia, meteorism, etc. Treatment. — Phosphorus and codliver-oil (0.02 to 150. — gr. ^-^v) ; sool-baths ; nutritious diet ; recumbency upon a firm mattress (the deformities often being favored by carrying the children about) ; abundant exposure in the open air. 2. Osteomalacia. This condition depends upon abnormal absorption of the bone-salts of the pelvis, the vertebral column, the extremities, especially in women (pregnancy, puerperium), and the consequent development of deformities of the skeleton. The prognosis is doubtful. The treatment is the same as that described for ra- chitis. 3. Deforming Arthritis (rheumatoid arthritis). This occurs in the sequence of repeated attacks of acute articular rheumatism (p. 144), or spontaneously, especially in washerwomen and laborers. It is observed 228 S03IE IMPORTANT FORMS OF POISONING. also in cases of tabes dorsalis. It occurs usually at an advanced period of life. The condition is attended with thickening of the articular cartilages, the formation of outgrowths and osteophytes, and villous processes and roughening of the surfaces of the joints. The fingers are deflected outward at the metacarpophalangeal articula- tions, and, with the hands, are more or less fixed. Pain is present on walking, in consequence of senile changes in the hip-joint. Treatment. — Massage, sand-baths, moor-baths, electric- ity, arsenic. 4. Muscular Rheumatism. This occurs principally in the sequence of exposure to cold. For several days at a time severe muscular pain attends all movement. When the muscles of tlie lower part of the back are affected {lumbago) stooping and turn- ing are impossible, and radiating pain is present. Rheu- matic torticollis (wry-neck) is attended with pain in the muscles at the nape of the neck, interfering Avith move- ment. Deep-seated disease is to be excluded (neuritis, tabes, nephritis, bone-disease, etc.), especially when symp- toms of chronic rheumatism are present. Treatment. — Hot packs ; steam-bath ; mustard-plaster ; massage ; electricity ; salicylates, etc. VIII. SOME IMPORTANT FORMS OF POISONING. 1. Acids and Alkalies (H^SO^, HCl, HNO3, NaOH, KOH, etc.). Among the results of the action of these are corrosion and destruction of the walls of the mouth, the esophagus, and the pharynx, together with hematemesis, bloody diar- rhea, and collapse. Treatment. — For poisoning with acids : milk, magnesia, chalk, ice. For poisoning with caustic alkalies : vinegar, lemon-juice, mucilaginous mixtures, ether. Emetics are not to be employed, and the sound should not be introduced into the stomach. SOME IMPORTANT FORMS OF POISONING. 229 2. Mercury. Poisoning with mercuric chloricl is attended with corro- sion, gastro-enteritis, anuria, and collaj^se. Treatment. — Milk, albuminous solutions, iron in pow- der-form ; narcotics. Chronic mercurialism is characterized by ulcerative stomatitis, enteritis, and anemia, together with mercurial tremor. Treatment — Withdrawal of mercury, gargles with potassium chlorate, potassium iodid, baths. 3. Phosphorus. This gives rise to a sense of burning in the throat, garlicky eructations and vomiting, with diarrhea and jaundice (fatty degeneration of the liver). Treatment. — Lavage of the stomach, copper sulphate, oil of turpentine, but no fat. In cases of chronic phosphorus-pois'^oning necrosis of the lower jaw often takes place. 4. Arsenic. This gives rise to gastro-enteritis, syncope, cyanosis, collapse. Treatment. — Lavage, emetics, mixture of magnesia and hydrated iron oxid. 5. Lead. This is attended with the appearance of a blue line at the margin of the gums, together with colicky pain in the abdomen, obstinate constipation, anemia, contracted kid- ney, wrist-drop from paralysis of the extensors of the hand. Treatment. — Potassium iodid, sool-baths, electricity. 6. Alcohol. Acute alcoholism may result from an ordinary debauch. Chronic alcoholism is attended with puffiness of the face, bleared eyes, tremulousness of the tongue, tremor of the hands, chronic catarrh of the mucous membranes, hyper- trophy of the heart, contracted kidney, cirrhosis of the liver, and neuritis. Delirium tremens is marked by the occurrence of visual hallucinations (of animals) and maniacal states. 230 SOME IMPORTANT FORMS OF POISONING. Treatment. — Narcotics with care ; cool baths. 7. CJdoroform. This gives rise to loss of consciousness, abolition of all reflexes, dilatation of the pupils, paralysis of respiration and of the heart. Treatment. — Artificial respiration, galvanization of the phrenic nerve, douches. 8. Iodoform. This gives rise to vertigo, maniacal attacks, hallucina- tions, and coma. Treatment. — Stimulants, baths, atropin. 9. Carbon Monoxid. This gives rise to disturbance of consciousness, roar- ing in the ears, vomiting, pallor, cyanosis of the face, convulsions, paralysis of respiration, subnormal tempera- ture, albuminuria, and glycosuria. The blood displays the spectrum of CO hemoglobin (see Plate 6). Treatment. — Artificial respiration, stimulants, transfu- sion. 10. Hydrocyanic Acid (potassium cyanid). This gives rise to the odor of bitter almonds, retarded respiration, abolition of reflexes, convulsions, paralysis of the heart, and rapid death. Treatment. — Emetics, artificial respiration, douches, stimulants, hydrated iron oxid, chlorin-water. 11. Carbolic Acid. This gives rise to corrosion, gastritis, coma, paralysis of the heart, nephritis. The urine is dark, and of olive- green color (see pp. 101, 105). Treatment. — Lavage of the stomach, lime-water, sodium sulphate. 12. Atropin (belladonna). This gives rise to dryness of the throat, thirst, vertigo, hallucinations, mydriasis, tachycardia. Treatment. — Morphin, physostigmin, pilocarpin. 13. Digitalis (foxglove). This gives rise to vomiting, slowing of the pulse, col- lapse, and somnolence. SOME IMPORTANT FORMS OF POISONING. 231 Treatment. — Emetics, lavage of the stomach, tannic acid, stimulants (camphor and ether, black coffee, liquor ammonii anisatus). 14. Nicotin. Acute nicotin-poisoning gives rise to slowing of the pulse, vomiting, salivation, delirium, coma, tetanic attacks. Chronic nicotin-poisoning induces palpitation of the heart, asthmatic and anginal attacks, tremor, ambly- opia (fluttering scotoma), chronic catarrh, and symptoms resembling those of tabes. The treatment is symptomatic, and the use of tobacco should be forbidden. 15. Morphin, Acute morphin-poisoning is characterized by nausea, vomiting, coma, narrowing of the pupils, slowing of the pulse, and Cheyne-Stokes breathing. Treatment. — Emetics (zinc sulphate), lavage of the stomach, tannic acid, black coffee, atropin, stimulants, cool baths, artificial respiration. Chronic morphin-poisoning gives rise to anemia, insom- nia, prostration, vertigo, morbid fear, psychoses. The treatment consists in withdrawal of the drug, prefer- ably in an institution, and is in other respects symptomatic. 16. Ergot. Acute ergotism is attended with gastro-enteritis, vertigo, sopor, derangement of respiration. Treatment. — Emetics, purgatives, tannic acid, stimu- lants. Chronic ergotism is attended with symptoms resembling those of tabes ; paresthesise of the extremities, abolition of the knee-jerks, convulsions, psychoses, gangrene. The treatment is symptomatic. 17. Toadstool-poisoning. This is attended with gastro-enteritis, hemoglobinemia, delirium, epileptiform attacks, narrowing of the pupils, salivation, sopor. Treatment. — Emetics, drastics, tannic acid, stimulants. The antidote to muscarin is atropin. 232 SOME IMPORTANT FORMS OF POISONING. 18. Sausage-poisoning and Jiea^-poisomn^ (Bo tulismus). These are attended with gastro-enteritis, vertigo, pupil- lary changes, ptosis (in cases of sausage-poisoning), oculo- motor palsy, dysphagia, heart-failure, collapse, fever. Treatment. — Emetics, cathartics, calomel, stimulants, warm baths with douches, nutritive enemata. When called to a case of poisoning it is best to take with one, in addition to the stomach-tube, the following : (1) Apomorphin hydrochlorate 0.03 (gr. ss), distilled water 4. (f3J). Dose : from one- half to a syringeful sub- cutaneously as an emetic. (2) Calcined magnesia q.s. ; to be taken in teaspoonful doses in water, in cases of poisoning with acids, etc. (3) Tannic acid 0.5 (gr. vijss) ; to be divided in ten equal parts, one of which is to be taken every ten min- utes, in cases of alkaloidal poisoning. (4) Four per cent, solution of morphin, of which from one-half to three-quarters of a syringeful may be injected subcutaneously. (5) Camphor 4. (5j), ether 16. (f^iv) ; of which from two to four syringefuls may be injected subcutaneously every four hours. SECTION Y. THERAPEUTIC NOTES. I. DIETETIC METHODS OF TREATMENT. 1. Diet for diseases of the stomach, especially gastric ulcer. First meal : milk, meat-juice, bouillon, Zwieback, Sel- ters water. Second meal : eggs soft-boiled or raw, rice, sago boiled in milk, mucilaginous soups, bran, stewed chicken, squab, calves' feet. Third meal : chipped ham, beefsteak, mashed potatoes, boiled rice, coffee, tea. Fourth meal : roast beef, roast veal, game (deer, part- ridge, hare), fish (pike), chicken, broiled squab, wheat- bread, soup, stewed fruit, light farinaceous articles. Forbidden : fat meat, pork, goose, turkey, sweets, dumplings, potatoes, puddings, liquors, strong spices. 2. Fever-diet: milk, eggs, soups, beef- juice, peptones, chicken, squab, calves' feet, jellies, fruit-juices, ice-cream, white wine in Selters water, lemonade. 3. Rest-cure (for cases of neurasthenia, anemia, tuber- culosis and other chronic diseases) : 1. Milk (with possibly the addition of some coffee, tea, or Selters water), from two to four quarts daily at intervals of two hours. As substitutes whey, kefyr, etc., may be employed. In the intervals small amounts of buttered bread. Zwieback, cold and warm roasts, fowl, game, veal or steak may be given, with green vegetables, farinaceous food, and stewed fruit. (2) At the beginning complete rest in bed should be 233 234 THERAPEUTIC NOTES. insisted upon. Later, rest in the open air may be permitted. Then, general massage of the Avhole body should be practised daily for half an hour, and perhaps also faradization of the abdomen. The treatment should be continued from four to six weeks, and is best carried out in an institution. 4. Reduction-cwe (for obesity). (a) Systematic walking (gradual mountain-climbing), especially in the morning and afternoon, for from two to four hours daily. (6) Restriction of the amount of liquids ingested to between 1500 and 2000 cu. cm. ; little soup, coffee, tea, sauces ; no beer, wine, or liquor ; some cider with Selters water. (c) Little farinaceous food, bread, sugar, confections, fats ; more meat of all kinds, green vegetables, lean cheese, fruit. {d) Cold spongings ; cold half- baths. 5. Nutrient Enemata. Following a cleansing enema, from 50 to 200 grams of one or other of the following are administered two or three times daily : the yolks of from two to four eggs in mucilaginous soup, milk, 20 per cent, solution of glucose, beef-juice ; or Leube's mixture of beef and pan- creas : 3 parts of beef, 1 of pancreas chopped, uncooked, into fragments and mixed with two parts of water, pos- sibly with the addition of hydrochloric acid and pepsin. 6. Artificial Foods (for emaciated patients). Condensed milk, cream-mixture, children's foods, meat- extract, meat-solution, beef-juice, beef-peptones, meat^ powder. II. HYDROTHERAPY. (a) Friction and flagellation are generally practised morning and evening, the body or only a portion being enveloped in a wet cloth at a temperature of from 15° to 20° (59° to 68° F.) for from two to five minutes. The procedure may be followed by rest or some activity. HYDROTHERAPY. 235 (b) Wet packs in linen cloths also may be applied to the whole body or to only a portion. They are con- tinued from one to five hours and in cases of fever may be renewed hourly. The body is to be subsequently dried. Sometimes a wet cloth is wrapped about a part and enclosed in an impermeable material, such as gutta percha, taffeta, etc. (c) Cold douches are usually directed to individual parts of the body, such as the trunk or the extremities. (d) Cataplasms are made with bread, linseed, potatoes, etc., and are employed to alleviate the pain of colic and of inflammation, etc. (e) Baths may be full, half, hip and partial. Steam baths, lasting from fifteen to thirty minutes, with subsequent douche, and Roman baths, lasting for an hour, are employed in cases of rheumatism and of dropsy. Hot baths (above 30° R. — 99.5° F.) and warm baths (between 26° and 30° R.— 90.5°-99.5° F.) are employed in anemic states, in cases of nephritis, during convales- ence, etc. They are continued for from twenty to thirty minutes. Cool baths (from 16° to 22°— 68°-81.5° F.) are em- ployed in cases of high fever, of intoxication, and of con- vulsions, as well as for hardening the system. They are continued for from three to nineteen minutes. Medicated Baths. Addition of salt (sodium chlorid, bathing salt, from 5 to 10 lbs.), in cases of anemia, scrofulosis, rachitis, etc. Moor-baths (about 50 lbs. of peat-soil or bog-earth, or from 5 to 10 lbs. of moor extract), in cases of rheuma- tism, gout, neuralgia, etc. Sool-baths (from 2 to 5 quarts of brine, sool salts), in scrofulosis, anemia, gout, etc. Pine-needle baths (from 100. to 200. of pine-needle extract) ; bran-baths (5 lbs. of wheat bran) ; sand-baths (warm, dry sea-sand) ; in cases of chronic arthritis, eto. 236 THERAPEUTIC NOTES. m. TREATMENT BY CLIMATE AND BATHS. Among numerous health-resorts the following may be mentioned : (1) For diseases of the respiratory organs: Ems, Belt- ers, Reichenhall, Giesshiibl, Soden, Vichy, Neunahr, Assmannshausen, Wiesbaden, Kissingen, Sylt, Nor- derney, etc. Especially for 'pulmonary tuberculosis: Falkenstein, Gorbersdorf, St. Blasien, Meran, St. Moritz, Davos, Montreaux, Mentone, Riviera, etc. (2) For diseases of the heart: Nauheim, Oeynhausen, Homburg, Wiesbaden, Baden-Baden, elevated resorts, sea-baths. (3) For disorders of the stomach and intestines: Kissingen, Neuenahr, Bilin, Wiesbaden, Baden-Baden, Homburg, Carlsbad. (4) For diseases of the bodily metabolism (obesity, gout, etc.) : Marienbad, Carlsbad, Franzensbad, Friedrichshall, Elster, Ofen, Tarasp, etc. (5) For cases of anemia, etc. : Schwalbach, Briickenau, Steben, Alexandersbad, Franzensbad, Elster, Pyrmont, etc. (6) For diseases of the kidneys and bladder : Fachingen, Wilclungen, Vichy. ^ (7) For diseases of the liver (gall-stones) : Carlsbad, Kissingen, Franzensbad, Ofen, etc. (8) For diseases of the joints (neuralgia, etc.) : Briick- enau, Aibling, Homburg, Franzensbad, Assmannshausen, Baden-Baden, Wiesbaden, Kissingen, etc. IV. PHYSICAL METHODS OP TREATMENT. 1. Electricity. This is frequently employed in the form of the gal- vanic or the faradic current. The former is believed to exert a more profound influ- ence than the latter. Painful (the anode is sedative, the THE MOST IMPORTANT MEDICAMENTS. 237 kathode stimulating) and central disorders yield to gal- vanism, peripheral disorders, and especially motor palsies to faradism. Sometimes frictional or static electricity is employed. Too strong currents should not be employed, and a reliable galvanometer should be used. 2. Massage. This may take the form of stroking, kneading, hack- ing and rolling, daily, for from a quarter to half an hour, preceded by inunction with oil or petrolatum, and followed by warm coverings. It is useful in the treatment of pain- ful diseases of the muscles, bones and joints, chronic rheu- matism, nervous diseases, anemia, etc. 3. Gymnastics. This includes the intelligent pursuit of such exercises as bicycling, rowing, turning, pedestrian tours, ball-play- ing, and the like; as well as home-gymnastics with various forms of apparatus, for half an hour daily before eating ; and finally resistance-gymnastics with apparatus, for an hour or two daily. Pneumotherapy. — Respiration in rarefied or compressed air, possibly in conjunction with inhalation of various medicaments (sodium chlorid, sool, ethereal oils, etc.), is employed in various sanatoria, in the treatment of asthma, emphysema, pulmonary tuberculosis, chronic bronchitis, etc. V. THE MOST IMPORTANT MEDICAMENTS. 1. Antipyretics J Antirheumatics, etc. : Quinin hydrochlorate, 0.5-2. (gr. vijss-gr. xxx) in cachets, twice or thrice daily. Sodium salicylate, 2.-5. (gr. xxx-gr. Ixxv) " Salicylic acid, 0.5 (gr. vijss) " Salol, 2. (gr. xxx) " Salophen, 1.-2. (gr. xv-gr. xxx) " Salipyrin, 1.-2. (gr. xv-gr. xxx) " Antipyrin, 1. (gr. xv) " Antifebrin, • 0.20-0.5 (gr. iij-gr. vijss) " Phenacetin, 0.5-1. (gr. vijss-gr. xv) " twice daily. 6 to 10 times daily. 3 or 4 times daily, twice or thrice daily. 2 to 4 times daily. 2 to 5 times daily, twice or thrice daily. 3 or 4 times daily. 2. Acids: Dilute hydrochloric acid, from 5 to 10 drops in water, 238 THERAPEUTIC NOTES. thrice daily ; from 1 to 2 per cent, of lemon-juice in various mixtures. 3. Expectorants: Infusion of ipecac-root 0.3-0.5 (gr. v-gr. vijss) to 120. (f 5iv) ; tablespoon ful every two hours. Infusion of senega-root, 10. (sijss) to 120. (f^iv); table- spoonful every two hours. Liquor ammonii anisatus, 3 per cent., or in drops from iive to ten thrice daily. Ammonium chlorid, 5. (gr. Ixxv) to 120. (f ,liv) ; from a dessertspoonful to a tablespoonful every two hours. Apomorphin, 0.03-0.05 (gr. ss-gr. |) to 150. (fsv); tablespoonful every two hours. Benzoic acid, 0.1-0.3 (gr. jss-gr. ivss), in cachets, every three hours. Potassium iodid, 5. (gr. Ixxv) to 150. (f ^v) ; table- spoonful thrice daily. Balsam of Peru, oil of turpentine, myrtol, creosote, etc., in gelatin capsules of from 0.1 to 0.5 (gr. jss-gr. vjss), several times daily. 4. Inhalants : Sodium chlorid, 1 per cent. Sodium bicarbonate, 1 per cent. Ammonium chlorid, 1 per cent. Ems water, etc. Potassium bromid, 2 per cent. Tannic acid, 2 per cent. Lime-water, 50 per cent. Turpentine, balsam of Peru, cherry-laurel water, etc., in drop-doses. 5. Topical Applications : lodin, 0.5 (gr. vijss) ; potassium iodid, 2.5 (gr. xxxvijss) ; glycerin, 25. (f 5vj). Borax and glycerin, 5. (gr. Ixxv) to 25. (f Syj). Silver nitrate, from 1. to 10. (gr. xv-3ijss) to 50. (f 5Jss). 6. Gargles : Potassium chlorate, 2 per cent. Alum, from 3 to 5 per cent. THE MOST IMPORTANT MEDICAMENTS. 239 Borax, 3 per cent. Potassium permanganate, from 0.1 to 0.5 per cent. Hydrogen clioxid, 2 per cent. 1." Cardiants (see pp. 181, 182). Powdered digitalis-leaves, 0.1 to 0.15 (gr. jss-gr. ijss), in cachets, every two hours ; or infusion, 1. or 2. (gr. xv- xxx) to 120. (fjiv). Caifein, 0.2 (gr. iij), in cachets, three or four times daily. Tincture of strophanthus, from 10 to 15 drops thrice daily. Camphor and ether 5. (gr. Ixxv) to 20. (f 3v) ; two or three syringefuls subcutaneously at hourly intervals. 8. Stomachics: Dilute hydrochloric acid, from five to ten drops in water several times daily. Bitter tincture, compound tincture of cinchona, a tea- spoonful thrice daily. Tincture of rhubarb, a teaspoonful thrice daily. Sodium bicarbonate, 30. (^j) ; bismuth subnitrate, 1.5 (gr. xxijss) ; from ten to twenty grains every two hours. 9. Emetics: Apomorphin, 0.05 (gr. f) to 5. (TTllxxv) ; from a half to one syringeful subcutaneously. Copper sulphate, 1, (gr. xv) to 50. (f5 jss) ; one or two teaspoon fuls. 10. Laxatives: Castor-oil, one or two teaspoonfuls ; may also be given in capsules. Carlsbad salt (sodium sulphate, 50. (Ijss) ; sodium bicarbonate, 6. (3jss) ; sodium chlorid, 3. (gr. xlv) ; dose : a teaspoonful. Magnesium sulphate, 50. (ijss) ; sodium bicarbonate, 10. (sijss) ; dose : from ten to twenty grains. Magnesium sulphate, 30. (sj) ; powdered rhubarb-root, 10. (sijss) ; dose : from ten to twenty grains. Calomel. 0.3 to 0.5 (gr. v-gr. vijss), three or four times daily. Infusion of senna-leaves, 10. (sijss) to 120. (f iiv). 240 THERAPEUTIC NOTES. Extract of aloes, extract of rhubarb, of each 5. (gr. Ixxv), with powder and juice of licorice sufficient to make 100 pills ; one twice or thrice daily. Glycerin enemata, 5. to 20. (TTLlxxv-fsv) ; oil enemata, etc. ; suppositories ; enemata of simple water. 11. Adringents : Infusion of calumba-root, 15. (.^iv) to 150. (f ^v) ; table- spoonful at intervals of two hours. Decoction of salep-root, 1. (gr. xv) to 150. (f 5v) ; table- spoonful at intervals of two hours. Gum-mixture, at hourly intervals. Tannic acid, 0.05 to 0.1 (gr. f-gr. ijss) to 100. (^iijss). Bismuth subnitrate or salicylate, from 0.5 to 2. (gr. vijss-gr. xxx) to 100. (f siijss). Opium, extract of opium, from 0.02 to 0.04 (gr. ^gr. ss), from three to five times daily. Tincture of opium, from 10 to 20 drops, from three to five times daily. Tincture of opium, from 10 to 20 drops, from three to five times daily. 12. Anfhehnintics : Santonin, from 0.03 to 0.05 (gr. ^gr. f ), two or three times daily. Calomel, from 0.05 or 0.1 to 0.3 (gr. |-gr. jss-gr. v), three or four times daily. Extract of filix mas recently prepared, from 10. to 12. (Sijss-siij), in capsules each containing 2. (gr. xxx). 13. Diuretics (see Digitalis) : Calomel, 0.2 (gr. iij), three or four times daily. Solution of potassium acetate, 20. (3v) to 120. (f^iv). Squill, from 0.05 to 0.3 (gr. f-gr. v), from three to five times daily. Potassium and sodium borotartrate, from 10. to 15. (.^ijss-^iv) to 120. (fliv). Theobromin sodiosalicylate, 2. (gr. xxx), from three to five times daily. Special diuretics (juniper-berries, petroselinum, ononis-|/V root, THE MOST IMPORTANT MEDICAMENTS. 241 14. Diaphoretics : Pilocar])in hydrochlorate, 0.2 (gr. iij) to 10. (fsijss) ; dose : one-half to one syringeful snbcutaneously. Special diaphoretics (linden-flowers, elder-flowers, chamomile-flowers). 15. Narcotics, hypnotics : Morphin hydrochlorate, from 0.01 to 0.03 (gr. ^gr. ss), from three to five times daily; or 0.1 (gr. jss) to 10. (f Sijss) ; dose : one syringeful subcutaneously. Chloral hydrate, from 2. to 3. (gr. xxx-gr. xlv), in cachet. Chloralamid, 2. (^ss) in cachet. Sulfonal, from 1.5 to 2. (gr. xx-gr. xxx), in cachet. Trional, from 1.5 to 2. (gr. xx to gr. xxx) in cachet, followed by a cup of tea, etc. Potassium bromid, from 2. to 5. (gr. xxx-gr. Ixxv), in milk. Cocain hydrochlorate, from 0.5 to 1.5 (gr. vijss-gr. xxijss) to 10. (f^ijss), for topical application. 16. Rohorants, etc. : Blaud's pill (iron sulphate, potassium carbonate, each 15. (siv) ; tragacanth, sufficient to make 100 pills). Dose : from one to three pills thrice daily. Sirup of iron iodid, from a quarter to a half teaspoon- ful thrice daily ; best given in extract of malt. Saccharated iron oxid, from gr. v.-gr. x, every four hours. Solution of iron albuminate, a teaspoonful thrice daily. Ferratin, 0.1 (gr. jss), thrice daily. Quinin sulphate, from 0.03 to 0.1 (gr. ss-gr. jss), in pill ; dose : from three to five daily. Arsenous acid, from 0.0025 to 0.004 (gr. ^^-gv. -^), in pills ; dose : from three to five daily. Solution of potassium arsenite, from three or five to eight drops thrice daily. Extract of ergot, 0.5 (gr. vijss) in pills ; dose : from three to five daily. 16 242 THERAPEUTIC NOTES. A tropin sulphate, 0.0005 (gr. y^) in pill, thrice daily. In writing prescriptions complex formulae should be avoided, as it is difficult to analyze the results of their activity, and the cost is unnecessarily increased. INDEX. Abdomen, 5, 14 distention of, 94 examination of, 93 exploratory puncture of, 15 form of, 14 measurement of, 15 palpation of, 15 percussion of, 16 retraction of, 94 symmetry of, 15 Abscess of liver, 208 old, hematoidin-crvstals from, PI. 21 pulmonary, 171 retropharyngeal, 81, 193 Abscesses, contents of, PI. 21 Accentuation of heart-sounds, 64 Accidental murmurs, 66 Acetone in urine, 112 Achorion schoenleinii, 121 Acidity, total, of gastric juice, 83 determination of, 86 Acidophile cells, 73 Acids, 237 poisoning with, 228 treatment of, 228 Actinomyces-fungus, 125 -granules in sputum, 54 -infections, 150 Actinomycosis, 150 treatment of, 150 Adenoid vegetations of the naso- pharynx, 193 treatment of, 193 Adult life, diseases of, 2 Advanced life, diseases of, 2 Age, 1 Albumin in urine, 105 tests for, 106 Albuminous bodies, 115 Albuminuria, febrile, sediment from, PI. 19 physiologic, 105 Albumoses, 107 Alcohol, poisoning with, 229 treatment of, 230 Alkalies, poisoning with, 228 treatment of, 228 Ammonia in urine, 103 Ammonio-magnesium phosphate in urine, PI. 1 Ammonium urate in urine, PI. 14 Amoeba coli, 130 Amphophile cells, 74 Amphoric breathing, 47 Amyloid degeneration of liver, 209 kidney, 215 sediment from, PL 19 Anadicrotism, 70 Anemia, 220 acute, 220 symptoms of, 220 treatment of, 220 chronic secondary, 221 blood in, 221 prognosis of, 221 symptoms of, 221 treatment of, 221 climatic treatment of, 236 pernicious, 221 etiology of, 221 treatment of, 221 simple profound, PL 3 Aneurism of the aorta, PL 50, p. 190 Angina, catarrhal, 192 diphtheric, 192 lacunar, 192 Ludwig's 192 necrotic, 192 parenchymatous, 193 pectoris, 186 treatment of, 186 simple, 192 treatment of, 193 Angle, epigastric, 13 Anguillula intestinalis, 127 243 244 INDEX. Ankylostomum, 202 duodenale, 126 Aiithelmintics, 240 Anthrax, 143 treatment of, 143 -bacilli, 26, 123, 143 in sputum, 54 Antipyretics, 237 Antipyrin in urine, PI. 21 Antirheumatics, 237 Aorta, aneurism of, PI. 50, p. 190 prognosis of, 190 treatment of, 190 Aortic insuthciency, PI. 46 orifice, stenosis of, 59 valve, insufficiency of, 58 Apex-beat, 61 augmentation of, 62 displacement of, 62 enfeeblement of, 62 Aphthae, 191 Bednar's, 191 Appetite, 5 Argas reflexus, 126 Arsenic, poisoning with. 229 treatment of, 229 Arteriosclerosis, 189 prognosis of, 190 sequelse of, 189 treatment of, 190 Arthritis, deforming, 227 treatment of, 228 Artificial foods, 234 Arytenoid muscle, transverse, paral- ysis of, 39 Ascarides, 202 Ascaris lumbricoides, 126 Ascites, 91, 94, 204 attending cardiac lesion, PI. 62 due to stasis, 95 inflammatory, 95 symptoms of, 204 treatment of, 205 Aspergillus fumigatus, 121 -mycelium in sputum, 54 Asthma, bronchial, 167 sputum from, PI. 8 treatment of, 167 Astringents, 240 Atelectasis, 168 treatment of, 168 Atropin, poisoning with, 230 treatment of, 230 Auscultation, 31 of cardiac orifices, 14 Auscultation of heart, 64 of lungs, 14, 46 of voice, 48 Auscultatory topography, PL 24 Bacilli, 123 Back, percutoiy topography of, PI. 26 Bacteria, 132 Bacterial infection, 131 Bacteriologic methods of investiga- tion, 24 Bacterium coll commune, PI. 22, p. 125 lactis serogenes, 125 Basophile cells, 73 granulation, PI. 2 Baths, 235 bran, 235 cool, 235 hot, 235 medicated, 235 moor, 235 pine-needle, 235 Roman, 235 sand, 235 sool, 235 steam, 235 treatment by, 236 warm, 235 Bednar's aphthae, 191 Biermer's change in percussion- note, 45 Biliary acids in urine, 112 coloring-matter, PI. 20 in urine, 112 Blot's breathing, 13 Bismuth-test, PI. 20 Bladder, 100 acute catarrh of, 218 symptoms of, 218 urine in, 218 chronic catarrh of, 219 diseases of, 218 climatic treatment of, 236 urinarv sediments attending, PI. i8 squamous epithelium from, PI. 16 tumors of, 219 diagnosis of, 219 symptoms of, 219 treatment of, 219 Bleeders' disease, 224 Blood, 16, 72 arterial, 72 INDEX. 245 Blood, diseases of, 220 in stools, 97 in urine, 111 in various diseases, PI. 3 microscopic examination of, 77 normal, fresh preparation of, PI. 1 frog's, stained, PI. 1 stained preparation of, PI. 1 parasites of, PI. 5 spectroscopy of, 74 venous, 72 -casts, PI. 17 -corpuscles, enumeration of, 75 red, PI. 1, 16, p. 72 abnormal variations in form of, PI. 1 in size of, PL 1 nucleated, of man, PI. 1 white, PI. 2, p. 73 -crystals, PI. 6 -plates, 74 -preparation from a case of ty- phoid fever, PI. 3 -spectra, PI. 6 -state of leukemia, PI. 14 -test. Heller's, PI. 20 -vessels, examination of, 66 systolic murmurs over, 66 Bloody sediment, PI. 13 Bodily development, 7 temperature, 9 vigor, 4, 7 Body, projection of internal organs upon anterior aspect of, PL 23 upon posterior aspect of, PL 25 Bones, diseases of, 227 Bothriocephalus latus, 129 Botulismus, 232 Bowel, carcinoma of, 201 occlusion of, PL 64, p. 201 .stenosis of, 201 Bowels, 6 evacuation of, pain in, 18 Breakfast, trial, 87 Breathing, amphoric, 47 Biot's 13 bronchial, 46 Cheyne-Stokes, 13 metamorphosing, 47 undefined, 47 vesicular, 46 Breath-sounds, absence of, 47 Brickdust sediment in urine, PL 13 Bromin in urine, PL 21 Bronchial breathing, 46 respiratory murmur, 32 Bronchiectasis, 166 treatment of, 167 Bronchitis, acute, 165 treatment of, 165 acute difiuse, PL 35 chronic, 165 treatment of, 165 croupous, 166 treatment of, 166 fetid, 166 treatment of, 166 Bronchoblennorrhea, 165 Bronchopneumonia, PL 36, p. 168 treatment of, 168 Buccal mucous membrane, 12 Budding fungi, 121 Calcium carbonate, PL 14 in urine, 103 oxalate, PL 14 calculi of, 114 phosphate, PL 14 sulphate, PL 14 Calculi, calcium-oxalate, 114 cystin, 114 in stools, 98 of carbonates, 114 phosphatic, 114 renal and vesical, examination of, 114 uric acid, 114 xanthin, 114 Calculous pyelitis, sediment from, PL 18 Carbohydrates, 117 Carbolic acid, poisoning with, 230 treatment of, 230 Carbon monoxid, poisoning with, 230 treatment of, 230 Carbonates, calculi of, 114 in urine, 103 Carcinoma of the bowel, 201 treatment of, 201 of the cardia, with stenosis of the esophagus, PL 51 of the pylorus, dilatation of the stomach with, PL 53 of the stomach, PL 54, p. 197 Cardia, carcinoma of, with stenosis of the esophagus, PL 51 246 INDEX. Cardiac lesion, ascites attending, PI. G2 cells in sputum, 52 uncompensated, PI. 43 Card i ants, 239 Catadi erotism, 70 Cataplasms, 235 Catarrh, dry, 1G5 Cellular elements in sputum, 52 Cestodes, 128 Character of pain, 1(5 Charcot-Leyden crystals in sputum, 53 Chest, 5 new-growths in, 176 Cheyne-Stokes breathing, 13 Chicken-pox, 157 Childhood, diseases of, 1 Chill, 5 Chlorids in urine, 102 Chloroform, poisDuing with, 230 treatment of, 230 Chlorosis, 220 blood in, 220 complications of, 220 diagnosis of, 220 treatment of, 210 Cholelithiasis, PI. 58, p. 206 diagnosis of, 206 prognosis of, 206 symptoms of, 206 treatment of, 206 Cholera asiatica, 142 complications of, 142 diagnosis of, 142 incubation of, 142 intestinal contents of, PI. 11 treatment of, 142 morbus, 158 diagnosis of, 1.58 treatment of, 158 nostras (see Ciiolera Morbus), 158 intestinal contents of, PI. 11 -bacilli, 27, 124, 142 Cholesterin in urine, PI. 15 -plates in sputum, 53 Cicatrices, 8 Circulatory apparatus, examination of, 54 organs, diseases of, 177 Cirrhosis of the liver, PI. 56, p. 207 Clearness on percussion, 30 Climate, 3 treatment by, 236 Coagulum, fibrinous, PI. 9 Coccus- infections, 144 Colicky pain, 17 Colon,"Pl. 23, 27 Color, 7 -reactions of the gastric juice, PI. 12 of the urine, PI. 20 Compensation, derangement of, 60 Conditions, special, 11 Connective tissue, subcutaneous, 7 Consciousness, 6 Constipation, 98 habitual, 202 treatment of, 202 Constitution, 7 Constricted liver, 209 Continued fever, 9 Coryza, 161 Cough, 50 laryngeal, .37 Creatinin in urine, 105 Crepitant rales, 47 Crico-arytenoid, posterior, paralysis of, .39 Croup, 141 Croupous bronchitis, 166 pneumonia, PI. 29, 30, p. 147, 167 Cryptogenetic septicopyemia, 146 Crystals in sputum, 53 Cultivation, 26 Curschmann's spirals in sputum, 53 Cutaneous emphvsema, 9 Cylindroids, PI. 17 Cystin, PI. 15 calculi, 114 Cystitis, 218 diagnosis of, 219 sediment from, PI. 18 treatment of, 219 tuberculous, 219 pus from, PI. 19 treatment of, 219 Cysts, contents of, PI. 21 Degeneration, amyloid, PI. 59 Deglutition, difficulty in, 17 Demodex folliculorum, 126 Development, bodily, 7 Diabetes, ferric-chlorid reaction in, PI. 20 insipidus, 225 mcllitus, 224 diagnosis of, 225 etiology of, 225 INDEX. 247 Diabetes mellitus, symptoms of, 225 treatment of, 225 nervous, 224 of the obese, 224 severe, 224 Diacetic acid in urine, 112 Diaphoretics, 241 Diaphragm, PI. 23, 27 Diarrhea, 98 Diazo-reactiou, PI. 20, p. 113 Dicrotism, 70 Diet for diseases of stomach, 233 Dietetic methods of treatment, 233 Digestion, gastric, 85 Digestive apparatus, 79 organs, diseases of, 190 Digitalis, poisoning with, 230 treatment of, 231 Dilatation of the stomach, with car- cinoma of the pylorus, PI. 53 Diphtheria, 140 diagnosis of, 141 sequelfe of, 141 treatment of, 141 -bacilli, PI. 7, p. 27, 124, 140 -membrane, PI. 7 Diphtheric angina, 192 Diplococcus of Fraenkel, 122 Displacement of lung, symptoms of, 44 Distoma hsematobium, 129 hepaticum, 129 pulmonale, 129 Dittrich's plugs in sputum, 53 Diuretics, 240 Diverticula, esophageal, 82 Division of the first sound of the heart, 65 Double sound over femoral artery, 67 Douches, cold, 235 Dulness, cardiac, abnormal, 63 absolute, 63 relative, 63 on percussion, 30 of lungs, 43 Duodenal ulcer, 197 Duplication of the first sound of the heart, 65 Duroziez's double sound, 67 Dwelling-houses, situation of, 3 Dysentery, 158 complications of, 158 prognosis of, 158 treatment of, 158 Dyspepsia, nervous, 199 diagnosis of, 199 treatment of, 199 Dyspnea, 13 laryngeal, 37 EcHixococcus of liver, 208 -fluid, PI. 21 -booklets in sputum, 53 Edema, 8 of larynx, 164 pulmonary, 170 symptoms of, 170 treatment of, 170 Elastic fibers in sputum, 53 Electricity, 236 Emaciation, 4 Embolism, pulmonary, 171 symptoms of, 171 treatment of, 172 EmeMcs, 239 Emphysema, cutaneous, 9 pulmonary, PI. 38, p. 160 complications of, 169 treatment of, 170 Endocarditis, acute, 145, 177 symptoms of, 177 treatment of, 180 benign, 177 malignant, 177 recurring, 177 ulcerative, 177 verrucose, 177 Enemata, nutrient, 234 English disease, 227 Enteritis, acute, 200 treatment of, 200 membranous, 200 : Enuresis, nocturnal, 219 treatment of, 220 Eosinophile cells, PI. 2, p. 73 in sputum, 52 Epigastric angle, 13 Epiglottis, paralysis of, '40 Epistaxis, 35, 162 Epithelial cells in pelvis of kidney, PI. 16 Epithelium, renal, PL 16 squamous, from urethra and blad- der, PI. 16 Ergot, poisoning with, 231 treatment of, 231 Erysipelas, 150 prognosis of, 150 treatment of, 150 248 INDEX. Erythrocytes, PI. 1, p. 72, 77 Esbach's test for albumin, 106 Esophageal diverticula, 82 Esophagus, PI. 25, p. 12, 81 carcinoma of the cardia, with ste- nosis of the, PI. 51 diseases of, 194 narrowing of, 81 stenosis of, 194 treatment of, 195 Examination of patient, 1 with mirrors, 22 Exanthemata, 8 acute, 153 Expectorants, 238 Expectoration, 50 Expiration, prolongation and ac- centuation of, 46 Exploratory puncture, 23 Extrapericardial murmurs, 66 Extremities, 6, 15 pain in, 18 Exudates, pleural, 49 Eyes, 11 Face, pain in, 17 Fat in urine, 113 Fats, 117 Fatty acids in sputum, 53 casts, PI. 17 Febrile albuminuria, sediment from, PI. 19 symptoms, 5, 9 Feces, 16 general view of, PI. 11 Fehling's solution, titration with, for sugar, 110 Femoral artery, double sound over, 67 Fermentation-test for sugar, 108, 110 Ferric-chlorid reaction in diabetes, PI. 20 Fever, continued, 9 high, 9 intermittent, 9 moderate, 9 remittent, 9 slight, 9 -diet, 233 Fibrinous coagula in sputum, 51 Filaria medinensis, 127 sanguinis, 127 Flagellation, 234 Food, constituents of, 118 Foods, artificial, 234 Form of abdomen, 14 Fremitus, pectoral or vocal, 48 Friction, 234 pericarditic, 34 peritonitic, 34 pleuritic, 32 -sounds, pleuritic, 48 Friedreich's respiratory change in percussion-note, 45 Gall-bladder, hydrops of, PI. 58 Galloping rhythm, 65 Gangrene, pulmonary, 170 complications of, 170 symptoms of, 170 treatment of, 170 Gargles, 238 Gastric catarrh, acute, 195 symptoms of, 195 treatment of, 195 contents, 16 general view of, PI. 11 digestion, 85 juice, 83 color-reactions of, PI. 12 ulcer, 196 diagnosis of, 196 symptoms of, 196 treatment of, 197 Gastritis, acute, 195 chronic, 195 diagnosis of, 195 treatment of, 195 phlegmonous, 196 General manifestations, 6 Gerhardt's postural change in per- cussion-note, 45 Gingival deposit, PI, 7 Glanders, 143 bacillus of, PI. 22, p. 143 treatment of, 144 -bacilli, 124 Glandular cicatrices, 12 swellings, 12 tuberculosis, 134 Glossitis, 192 dissecting, 192 parenchymatous, 192 treatment of, 192 Glottis, spasm of, 164 treatment of, 164 Glucose, 107 tests for, 107 Glycosuria, 107, 224 INDEX. 249 Glycosuria, alimentary, 224 Gmelin's test for bile, 112 Gonococcus, 123 Gonorrhea, pus from, PI. 19 Gout, 226 treatment of, 226 Gouty nodule, uric acid from, PI. 21 Granular tube-casts, PI. 17 Gregarines, 130 Gums, 12, 79 Gymnastics, 237 Habitus, 7 Head, 5, 11 Headache, 17 Health, previous, 3 Heart, PL 23, 27, p. 14 anatomy of, 54 auscultation of, 64 congenital lesions of, 183 prognosis of, 184 diseases of, 177 climatic treatment of, 236 examination of, 54 fatty, 186 symptoms of, 186 treatment of, 186 idiopathic hypertrophy of, PI. 48, p. 184 symptoms of, 185 treatment of, 185 inspection of, 14 nervous palpitation of, 186 treatment of, 186 neurotic disorders of, 186 palpation of, 14 percussion of, 14, 62 physiology of, 54 valvular lesions of, 180 diagnosis of, 181 theory of, 55 treatment of, 181 -murmurs, 33, 65 diastolic, 66 systolic, 65 -sounds, accentuation of, 64 metallic, 65 Height, 7 Heller's blood-test, PI. 20 test for blood, 112 Hematoidin-crystals, PI. 6 from an old abscess, PI. 21 in sputum, 53 Hematuria, 111 Hemin-crystals, PI. 6 Hemoglobin, estimation of, 75 Hemoglobinemia, PI. 3, p. 223 prognosis of, 223 symptoms of, 223 urine of, 223 Hemoglobinuria, 111 Hemopericardium, 188 symptoms of, 188 Hemophilia, 224 Hemorrhages, 8 Hemorrhagic diathesis, 223 etiology of, 223 Hemorrhoids, 202 Hemothorax, 176 Heredity, 2 High-pitched tympanitic note, 30 Hippuric acid, PI. 14 in urine, 105 History, 1 Hodgkin's disease, 223 blood of, 223 treatment of, 223 Hum, venous, 34 Hyaline tube-casts, PI. 17 Hydrochloric acid, 3 determination of, 85 Hydrocyanic acid, poisoning with, 230 treatment of, 230 Hydrogen sulphid in urine, 113 Hydronephrosis, 217 Hydropericardium, 188 symptoms of, 188 treatment of, 188 Hydrophobia, 160 hydrophobic stage of, 160 incubation of, 160 prodromes of, 160 treatment of, 160 Hydrops of the gall-bladder, PL 58 Hvdrotherapy, 234 Hydrothorax, PL 34, p. 176 symptoms of, 176 treatment of, 176 Hyperpyretic temperature, 9 Hypertrophy of the heart, idio- pathic, PL 48, p. 184 Hypnotics, 241 Hypoxanthin in urine, 105 Indican in urine, 104 Indican-test, PL 20 Infancy, diseases of, 1 250 INDEX. Infarction, hemorrhagic, of kidney, 215 of lung, 171 pulmonary, PI. 37 Infectious diseases, 131 of undetermined origin, 153 Influenza, 141 complications of, 142 treatment of, 142 -bacilli, 124, 141 in sputum, 54 -bronchitis, sputum from, PI. 10 Inhalants, 238 Inoculation, 28 Insects, 126 Inspection of heart, 14 of lungs, 42 Instruments for microscopy, 20 Insufficiency, aortic, PI. 46 of aortic valve, 58 of mitral valve, 56 of tricuspid valve, 59 tricuspid, PI. 47 Intelligence, 6 Intermittent fever, 9 Internal organs, projection of, upon anterior aspect of the body, PI. 23 upon lateral aspects of trunk, PI. 27 upon posterior aspect of body, PL 25 special diagnosis of diseases of, 35 Intestinal catarrh, 199 acute, 190 symptoms of, 199 treatment of, 200 chronic, 200 symptoms of, 200 treatment of, 200 contents of cholera Asiatica, PI. 11 nostras, PI. 11 murmurs, 34 parasites, 202 tuberculosis, 134, 200 Intestines, diseases of, 199 climatic treatment of, 236 microscopy of, PI. 11 Invagination of the bowel, PI. 64 Investigation, bacteriologic meth- ods of, 24 methods of, 19 lodin in urine, PI. 21 Iodoform, poisoning with, 230 treatment of, 230 Ixodes, 126 Jaundice, 90 catarrhal, 205 prognosis of, 205 treatment of, 205 chronic, 206 Jerking inspiration, 46 Joints, diseases of, 227 climatic treatment of, 236 Jugular vein, pulsation of, 12 Kidney, 99 amyloid, 215 etiology of, 215 sediment from, PI. 19 urine of, 215 cyanotic 214 treatment of, 215 hemorrhagic infarction of, 215 pelvis of, epithelial cells from, PI. 16 sarcoma of the, PI. 68 table of diseases of, 215 true contracted, 213 diagnosis of, 214 sediment from, PI. 19 treatment of, 214 urine of, 214 tuberculosis of, 217 symptoms of, 217 treatment of, 217 tumors of, 217 wandering, 218 diagnosis of, 218 treatment of, 218 Kidneys, PI. 25 diseases of, 211 climatic treatment of, 236 urinary sediments attending, PI. is percussion of, 99 Laryngeal dyspnea, 37 stenosis, 141 tuberculosis, 134 Laryngismus stridulus, 164 Laryngitis, acutc^, 163 trcalmcnt of, 163 chronic, 163 treatment of, 163 Larynx, 12 edema of, 164 INDEX. 251 Larynx, edema of, treatment of, 164 examination of, 36 syphilis of, 164 treatment of, 164 tumors of, 164 treatment of, 165 Lavage, 87 Laxatives, 239 Lead, poisoning with, 229 treatment of, 229 Leprosy, 143 mutilating, 143 tuberous, 113 -bacilli, 124, 143 Leptothrix buccalis, 121 Leucin, PI. 15 -spheres in sputum, 53 Leukemia, 221 acute, PI. 4, p. 223 blood of, 222 blood-state of, PI. 4 lymphatic, PI. 4 splenomedullary, PI. 2, 60, p. 222 blood from, PI. 4 treatment of, 223 Leukocytes, PI. 2, p. 73, 78 in sputum, 52 mononuclear, PI. 2 polynuclear, PI. 2 Leukocytosis, PI. 3, p. 76 Leukoplakia buccalis, 192 Leydenia gemmipara, 130 Lips, 11, 79 Liver, PL 23, 25, 27, p. 25, 90 abscess of, 208 acute yellow atrophy of, 207 prognosis of, 208 treatment of, 208 amyloid degeneration of, 209 carcinoma of, 208 cirrhosis of, PI. 56, p. 207 atrophic, 207 complications of, 207 first stage of, 207 hypertrophic, 207 second stage of, 207 treatment of. 207 constricted, PI. 55, p. 209 cj' an otic, 209 treatment of, 209 diseases of, 209 climatic treatment of, 236 table of, 210 echinococcus of, 208 treatment of, 208 Liver, fatty degeneration of, 209 melanosarcoma of the, PI. 57 nutmeg-, 209 palpation of, 91 percussion of, 92 syphilis of, 208 treatment of, 208 Localization of pain, 16 Low-pitched tympanitic note, 30 Ludwig's angina, 192 Lumbago, 228 Lung, PI. 27 abscess of, sputum from, PI. 9 staphylococci from, PI. 10 actinomvcosis of, sputum from, PI. 10 gangrene of, sputum from, PI. 9 hemorrhagic infarction of, 175 left, 41 right, 40 Lungs, PI. 23, 25, p. 14, 40 anatomy of, 40 auscultation of, 14, 46 displacement downward of lower limits of, 43 symptoms of, 44 upward of lower limits of, 42 dulness upon percussion of, 43 inspection of, 42 metallic note over, 45 percussion of, 14, 42 physiology of, 41 spirometry of, 42 topographic relations of, 40 tympanitic note over, 44 variations in percussion-note over, 45 -tissue in sputum, 52 Lymphemia, 222 Magnesium in urine, 103 phosphate, basic, PI. 15 Malaria, blood from a (iase of, PI. 5 Malarial cachexia, 153 fever, 151 atypical varieties of, 153 diagnosis of, 153 incubation of, 152 masked, 153 onset of, 152 pernicious, 153 treatment of, 153 Plasmodia, PI. 5 Manifestations, general, 6 Massage, 237 252 INDEX. Meal, trial, 88 Measles (see Morbilli), 154 Measurement of abdomen, 15 Meat-poisoning, 232 treatment of, 232 Medicaments, 237 in urine, PI. 21, p. 113 Medullary cells, PI. 2 Me,a;astoma entericum, 129 Melanin in urine, 113 test for, PI. 20 Melanosarcoma of the liver, PI. 57 Membranous enteritis, 200 Meningitis, basilar, 136 epidemic cerebrospinal, 149 diagnosis of, 149 sequelae of, 149 treatment of, 150 tuberculous, 136 diagnosis of, 137 treatment of, 137 Mensuration of thorax, 13 Mercury, poisoning with, 229 treatment of, 229 Metabolism, abnormalities of, ex- amination of, 115 bodily, disorders of, 224 disorders of, climatic treatment of, 236 Metallic heart-sounds, 65 note over lungs, 45 percussion-note, 30 Metamorphosing breathing, 47 Meteorism, 94 Micrococci, 122 Micrococcus tetragenus, 123 Micro-organisms, pyogenic, PI. 22, p. 26 Microscopy, 20 instruments for, 20 Microsporon furfur, 121 Micturition, pain in, 18 Miliary tuberculosis, 136 Mirrors, examination with, 22 Mitral insufficiency, PI. 45 orifice, stenosis of, 57 stenosis, compensated, PI. 44 valve, insufficiency of, 56 Molds, 120 Monocrotism, 70 Moore's (caramel-) test, PI. 20 test for sugar, 108 Morbilli, 154 complications of, 154 incubation of, 154 Morbilli, prodromes of, 154 sequelae of, 154 treatment of, 154 Morphin, poisoning with, 231 treatment of, 231 Mouth, 11, 79 microscopy of, PI. 7 Mucor corymbifer, 120 Mucus in stools, 97 Mumps, 157 Murexid test, 104 Murmurs, heart-, 33 intestinal, 34 systolic, over blood-vessels, 66 Musculature, 9 Mycosis, intestinal, 143 Myocarditis, 185 Myocardium, diseases of, 185 treatment of, 185 fatty degeneration of, 185 fibroid degeneration of, 185 Narcotics, 241 Nasal catarrh, chronic, 161 fetid, 162 cavities, microscopy of, PI. 7 mucous membrane, secretion from, PI. 7 Nasopharyngeal state, examina- tion of, 35 Nasopharynx, adenoid vegetations of, 193 Neck, 12 Nematodes, 126 Nephritis, acute hemorrhagic, 211 prognosis of, 212 sediment from, PI. 18 symptoms of, 211 treatment of, 212 urine of, 212 chronic, PI. 18, p. 212 diagnosis of, 213 treatment of, 213 parenchymatous, 212 sediment from, PI. 19 Nephrolithiasis, 216 diagnosis of, 217 Neuralgia, 17 Neurotic disorders of the heart, 186 Neutrophile cells, 74 granulation, PI. 2 New-gi'owths in the chest, 176 symptoms of, 176 treatment of, 177 INDEX. 253 Nicotin, poisouing with, 231 treatment of, 231 Nitrates and nitrites in urine, 103 Nose, 11 diseases of, 161 examination of, 35 Nucleo-albumin, 107 Nutmeg-liver, 209 Nutrient enemata, 234 Nutritive state, 7 Nylander's test for sugar, 108 Obesity, 226 symptoms of, 226 treatment of, 226 Occlusion of bowel, PL 64, p. 201 diagnosis of, 201 treatment of, 201 Occupation, 2 O'idium albicans, 121 lactis, 121 Oil of sandalwood in urine, 114 Oligocbromemia, 7") Oligocythemia, 76 Orifices, cardiac, auscultation of, 14 Osteomalacia, 227 prognosis of, 227 treatment of, 227 Oxalic acid in urine, 105 Oxyures, 202 Oxyuris vermicularis, 126 Ozena, 162 treatment of, 162 Packs, wet, 235 Pain, 16 character of, 16 colicky, 17 in evacuation of the bowels, 18 in extremities, 18 in face, 17 in micturition, 18 involving the trunk, 17 localization of, 16 pericarditic, 17 peritonitic, 17 pleuritic, 17 Palate, 12, 80 paralysis of, 194 Palpation, 28 of abdomen, 15 of heart, 14 of liver, 92 of stomach, 84 Palpitation of heart, nervous, 186 Pancreas, diseases of, 211 diagnosis of, 211 treatment of, 211 Pancreatic cyst, PI. 61 Paralysis of epiglottis, 40 of posterior crico-arytenoid, 39 of recurrent laryngeal nerve, 39 of thyro-arytenoid muscle, 39 of transverse arytenoid muscle, 39 of vocal bands, 38 Parasites, 120 animal, 126 intestinal, 202 of the sputum, PI. 10 vegetable, 120 Parotiditis, epidemic, 157 Patient, examination of, 1 Pediculi, 126 Peliosis rheumatica, 224 Pelvis of kidney, epithelial cells from, PI. 16 Penicillium glaucum, 120 Peptone-test, PI. 20 Percussion, 29 clearness on, 30 dulness on, 30 of abdomen, 15 of heart, 14, 62 of kidneys, 99 of liver, 92 of lungs, 14, 42 of stomach, 84 tympanitic, 30 -note, Biermer's change in, 45 Friedreich's respiratory change in, 45 Gerhardt's postural change in, 45 metallic, 30 over lungs, variations in, 45 Wintrich's change in, 45 Percutory topographv, PI. 24 of the back, PI. 26 of the lateral aspects of the trunk, PI. 28 Perforative peritonitis, PI. 67 Pericardial murmurs, 66 Pericarditic friction, 34 pain, 17 Pericarditis, 186 dry, 187 prognosis of, 188 symptoms of, 187 treatment of, 188 254 INDEX. Pericarditis, exudative, PI. 49, p. 187 fibrinous, 187 hemorrliagic, 187 tuberculous, loo Pericardium, diseases of, 186 Peritoneum, carcinoma of, 205 diseases of, 202 Peritonitic friction, 34 pain, 17 Peritonitis, acute, 203 symptoms of, 203 treatment of, 204 chronic, 204 prognosis of, 204 symptoms of, 204 circumscribed, 203 difluse, 203 perforative, PI. 67 purulent, 203 putrid, 203 serofibrinous, 203 tuberculous, PI. Gii, p. 136 treatment of, 136 Perityphlitis, PI. 65, p. 202 symptoms of, 203 treatment of, 203 Pernicious auemia, PI. 3 Personal, 1 Pertussis, 157 catarrhal stage of, 157 sequelai of, 157 spasmodic stage of, 157 stage of decline of, 157 treatment of, 157 Pharyngeal catarrh, chronic, 193 treatment of, 193 cough, 37 Pharyngitis, dry chronic, 193 Pharynx, 12, 79, 81 paralysis of, 194 Phenols in urine, 105 Phenylhydrazin-test for sugar, 110 Phosphates, earthy, PI. 15 in urine, 103 IMiosphatic calculi, 114 Phosphorus, poisoning with, 229 treatment of, 229 Phthirius pubcs, 126 Physical methods of treatment, 236 Pigment-cells, PI. 8 Plague, 100 Plasmodia, 130 Plasmodia! infections, 151 Pleura, puncture of, 49 Pleural cavity, exploratory punc- ture of, 14 exudates, 49 transudates, 50 Pleurisy, 172 acute rheumatic, 146 treatment of, 146 diagnosis of, 167, 174 dry, 172 etiology of, 172 exudative, PI. 31, 32, p. 172 on the right side, PI. 33 onset of, 172 physical examination of, 172 treatment of, 174 tuberculous, 135 Pleuritic friction, 32 pain, 17 Pneumococci from the blood, PI. 5 in pneumonic sjmtum, PI. 10 in sputum, 54 Pneumococcus, 122 Pneumonia, croupous, PI. 29, 30, p. 147 abnormal terminations of, 148 complications of, 148 diagnosis of, 148, 167 prognosis of, 148 treatment of, 149 lobular, 168 Pneumokon loses, 171 Pneumopericardium, 189 prognosis of, 189 Pneumotherapy, 237 Pneumothorax, PI. 41, p. 175 treatment of, 175 Poisoning, 228 Polarization -apparatus for detect- ing sugar, 109 -method for estimating sugar. 111 Polyarthritis, acute rheumatic, 144 Portal vein, inflammation of, 209 thrombosis of, 209 Posture, 7 Potassium in urine, 103 Precordium, inspection and palpa- tion of, 61 thrill in, 62 visible pulsation in, 61 Preparations, stained, 21 unstained, 21 Present state, 6 Projection of internal organs upon the anterior aspect of the body, PI. 23 INDEX. 255 Projection of internal organs upon the lateral aspects of the trunk, PL 27 upon the posterior aspect of the body, PL 25 Proteus vulgaris, PL 22 Protozoa, 129 Pseudoleukemia, 223 Puberty, diseases of, 1 Pulex irritans, 126 penetrans, 126 Pulmonary abscess, 171 emphysema, PL 38 gangrene, 170 infarction, PL 37 tuberculosis, 132 incipient, PL 39 progressive, PL 40 Pulsation, 13 visible, in the precordium, 61 Pulse, 11, 14, 67 acceleration of, 67 celerity of, 68 hardness of, 68 retardation of, 67 rhythm of, 68 size of, 68 Puncture, exploratory, 23 of abdomen, 15 of pleural cavity, 14 of pleura, 49 Purpura, 224 Pus from gonorrhea, PL 19 from tuberculous cystitis, PL 19 in stools, 98 -cells, PL 16 Pustule, malignant, 143 Pyelitis, calculous, sediment from, PL 18 Pyelonephritis, 215 diagnosis of, 216 symptoms of, 216 treatment of, 216 Pyemia, blood from, PL 5 Pyloric stenosis, 199 Pylorus, cicatricial stenosis of the, PL 52 dilatation of the stomach, with carcinoma of the, PL 53 Pyogenic micro-organisms, PL 22, p. 26 Pyopneumothorax, PL 42 Rachitis, 227 physical signs of, 227 Rachitis, treatment of, 227 Eales, 32, 47 crepitant, 47 dry, 47 metallic, 48 moist, 47 ringing, 48 Recurrent laryngeal nerve, paraly- sis of, 39 Redness of vocal bands, 38 Reduction-cure, 234 -tests for glucose, 107 Relapsing fever, 151 diagnosis of, 151 incubation of, 151 spirilla of, PL 5, p, 125 treatment of, 151 Remittent fever, 9 Renal epithelium, PL 16 Respiration, 13 type of, 13 Respiratory apparatus, 35 examination of, 35 muscles, 12 organs, diseases of, 161 climatic treatment of, 236 Rest-cure, 233 Retraction, systolic, 61 Retropharyngeal abscess, 81, 193 Rheumatic diseases, 144 torticollis, 228 Rheumatism, muscular, 228 treatment of, 228 Rhinitis, acute, 161 Rhinoscopy, anterior, 35 posterior, 36 Rhythm, galloping, 65 Roborants, 241 Rotheln (see Rubeola), 155 Round worms, 126 Salicylic acid in urine, PL 21 Salkowski's test for albumoses, 107 Sandalwood, oil of, in urine, 114 Sarcina ventriculi, 123 Sarcoma of the kidney, PL 68 Sarcoptes scabiei, 126 Sausage-poisoning, 232 treatment of, 232 Scarlet fever, 155 comidications of, 155 incubation of, 155 prodromes of, 155 sequelae of, 155 treatment of, 155 256 INDEX. Scorbutus, 223 treatment of, 224 Season, 3 Sediments, 22 crystalline urinary, PI. 14, 15 urinary, PI. 13 attending diseases of bladder and kidneys, PI. 18 organized, PI. 16 Septicopyemia, cryptogenetic, 146 diagnosis of, 147 prognosis and treatment of, 147 Serum-test for typhoid fever, 140 Sex, 2 Shape of thorax, 13 Skeleton, 7 Skin, 7 Sleep, 5 Small -pox (see Variola), 155 Social relations, 2 Sodium in urine, 103 urate in urine, PI. 13 Special condition, 11 Spectra, normal solar, PI. 6 Spectroscopy of the blood, 74 Spermatozoa, PI. 16 Sphygmography, 69 Spirilla of relai^sing fever, PI. 5, p. 125 Spirillum-infections, 151 Spirochfeta buccalis, 125 Spirochetse from gangrenous stoma- titis, PI. 7 Spirometry of lungs, 42 Splashing-sounds, 34 Spleen, PI. 25, 27, p. 92 diseases of, 210 displacement of, 93 enlargement of, 93, 210 treatment of, 211 palpation of, 93 wandering, 211 Splenic dulness, abolition of, 93 Splenomedullary leukemia, PI. 2, 60. p. 222" Spool- worm, 126 Spotted fever, 159 Sputum, 15, 50 actinomyces-granules in, 54 anthrax-bacilli in, 54 aspergillus-mycelium in. 54 bacteria in, 53 cardiac-lesion cells in, 52 cellular elements in, 52 Charcot-Leyden crystals in, 53 Sputum, cholesterin-plates in, 53 color of, 51 crystals in, 53 Curschmann's spirals in, 53 Dittrich's plugs in, 53 echinococcus-hooklets in, 53 elastic fibers in, 53 eosinophile cells in, 52 fibrinous coagula in, 51 from a case of tuberculosis, PI. 10 from abscess of lung, PI. 9 from actinomycosis of the lung, PI. 10 from gangrene of lung, PI. 9 from influenza-bronchitis, PI. 10 hematoidin-crystals in, 53 in layers, 51 influenza-bacilli in, 54 leucin-spheres in, 53 leukocytes in, 52 lung-tissue in, 52 microscopy of, PI. 8, p. 52 parasites of, PI. 10 pneumococci in, 54 pneumonic, PL 10 thrush-fungus in, 54 tissue-elements in, 52 tubercle-bacilli in, 53 tyrosin-needles in, 53 Stained preparations, 21 Staining, 24 solution, 78 Staphylococci from abscess of lung, PI. 10 Staphylococcus pyogenes, 122 albus, PI. 22 State, present, 6 Stenocardia, 186 Stenosis, cicatricial, of the pylorus, PI. 52 mitral, compensated, PI. 44 of aortic orifice, 59 of bowel, 201 of esophagus, carcinoma of the cardia, with, PI. 51 of mitral orifice, 57 Stomach, PI. 23, 27, p. 82 anatomy of, 82 carcinoma of, PI. 54, p. 197 symptoms of, 197 treatment of, 197 diet for diseases of, 233 dilatation of, 198 prognosis of, 198 symptoms of, 198 INDEX, 257 stomach, dilatation of, treatment of, 198 with carcinoma of the pylorus, PI. 53 diseases of, 195 climatic treatment of, 236 inspection of, 84 microscopy of, PI. 11 normal and pathologic position of, PI. 51 palpation of, 84 percussion of, 84 physiology of, 83 Stomachics, 239 Stomatitis, 190 aphthous, 191 catarrhal, 190 gangrenous, spirochetse from, PI. 7 necrotic, 191 treatment of, 191 ulcerative, 191 Stools, 97 blood in, 97 calculi in, 98 color of, 97 mucus in, 97 pus. in, 98 Streptococcus pyogenes, PI. 22, p. 122 Subcutaneous connective tissue, 7 Subfebrile temperature, 9 Subjective symptoms, 16 Succussion, Hippocratic, 48 -sounds, 33 Sucking worms, 129 Sugar, quantitative determination of, 110 Trommer's test for, PI. 20 Sulphates in urine, 102 Swallowing sound, 34 Sweating, 5 abnormal, 8 Swelling of vocal bands, 38 Symmetry of abdomen, 15 of thorax. 13 Symptoms, subjective, 16 Syphilis of bowel, 200 symptoms of, 201 treatment of, 201 of larynx, 164 of liver, 208 T^NiA echinococcus, 128 nana, 128 17 Taenia saginata, 128 solium, 128 Tape-worm, 202 treatment of, 202 Tape-worms, 128 Teeth, 11, 79 Temperature, bodily, 9 hyperpyretic, 9 subfebrile, 9 Tetanus-bacilli, 124 Therapeutic notes, 233 Thermometry, 23 Thirst, 5 Thorax, 13 mensuration of, 13 shape of, 13 symmetry of, 13 Thrill in the precordium, 62 Throat, 5 Thrush-deposits, 191 -fungus in sputum, 54 Thyro-arytenoid muscle, paralysis of, 39 Thyroid gland, 12 Tissue-elements in sputum, 52 Toadstool-poisoning, 231 treatment of, 231 Tongue, 11, 80 geographic, 192 Tonsillitis, 192 Tonsils, 12, 80 chronic hypertrophy of, 193 treatment of, 193 Topical applications, 238 Topography, percutory and auscul- tatory, PI. 24 of the back, PL 26 of the lateral aspects of the trunk, PI. 28 Torticollis, rheumatic, 228 Trachea, examination of, 36 Transmission of voice, 32 Transudates, pleural, 50 Trematodes, 129 Trichina spiralis, 127 Trichinosis, 160 diagnosis of, 161 treatment of, 161 Trichocephalus dispar, 126 Tricophyton tonsurans, 121 Tricuspid insufficiency, PI. 47 valve, insufficiency of, 59 Trommer's test for sugar, PI. 20, p. 108 Trunk, pain involving, 17 258 INDEX. Trunk, percutory topography of lateral aspects of, PI. 28 projection of internal organs upon lateral aspects of, Pi. 27 Tube-casts, urinary, PI. 17 Tubercle-bacilli, 131 in sputum, 53 -bacillus, 123 Tuberculosis, generalized, 136 glandular, 134 treatment of, 134 intestinal, 134, 200 treatment of, 135 laryngeal, 134 complications of, 134 treatment of, 134 localized, 132 miliary, 136 of kidney, 217 pulmonary, 132 advanced, symptoms of, 132 climatic treatment of, 236 complications of, 133 first symptoms of, 132 incipient, PI. 39 progressive, PI. 40 terminal symptoms of, 132 treatment of, 133 sputum from, PI. 10 urogenital, 135 treatment of, 135 Tuberculous cystitis, 219 pus from, PI. 19 diseases, 131 meningitis, 136 pericarditis, 135 peritonitis, PI. 66, p. 136 pleurisy, 135 Tumors of vocal bands, 38 Tylosis, 192 Tvmpanitic note over the lungs, 44 high-pitched, 30 low-pitched, 30 percussion, 30 Type of respiration, 13 Tyi)hoid fever, 137 l)lood-preparation from a case of, PI. 3 complications of, 139 convalescence from. 139 diagnosis of, 139 incubation of, 138 initial stage of, 138 prodromes of, 138 prognosis of, 140 Typhoid fever, relapses of, 139 second stage of, 138 serum-test for, 140 third stage of, 139 treatment of, 140 -bacilli, PI. 22, p. 27, 124, 137 Typhus fever, 159 incubation of, 159 prodromal period of, 159 treatment of, 159 Tyrosin, PI. 15 -needles in sputum, 53 Ulcer, duodenal, 197 gastric, 196 Ulceration of vocal bands, 38 Undefined breathing, 47 Unstained preparations, 21 Urea in urine, 104 Urethra, squamous epithelium from, PI. 16 Uric acid from a gouty nodule, PI. 21 in urine, 104 Uric-acid crystals in urine, PI. 13 diathesis, 225 etiology of, 226 sediment in urine, PI. 13 Urinary sediments, PI. 13 attending diseases of the blad- der and the kidneys, PI. 18 crystalline, PI. 14, 15 organized, PI. 16 tube-casts, PI. 17 Urine, 16, 100 acetone in, 112 albumin in, 105 ammonia in, 103 amount of, 100 antifebrin in, 113 antipyrin in, PI. 21, p. 113 balsam of copaipa in, 114 biliary acids in, 112 coloring-matter in, 112 blood in. 111 bromin in, 114 calcium in, 103 carl)olic acid in, 114 carbonates in, 103 chemic examination of, 102 chlorids in, 102 color of, 101 -reactions of, PI. 20 creatinin in, 105 diacetic acid in, 112 INDEX, 259 Urine, fat in, 113 hippuric acid in, 105 hydrogen sulphid in, 113 hypoxanthin in, 105 iudican in, 104 iodin in, 114 lead in, 113 magnesium in, 103 medicaments iu, PI. 21 melanin in, 113 nitrates and nitrites in, 103 normal inorganic constituents of, 102 organic constituents of, 104 oil of sandalwood in, 114 oxalic acid in, 105 pathologic ingredients of, 105 phenols in, 105 phosphates in, 103 potassium in, 103 reaction of, 101 rhubarb in, 114 salicylic acid in, 114 santonin in, 114 sediment in, 101 senna in, 114 sodium in, 103 urate in, PL 13 specific gravity of, 101 sulphates in, 102 turpentine in, 114 urea in, 104 uric acid in, 104 crystals in, PI. 13 xanthin in, 105 yellowish friable sediment in, PI. 13 Urogenital tuberculosis, 135 Uropoietic organs, diseases of, 211 system, examination of, 99 Valvular lesions of the heart, 180 theory of, 55 Varicella, 157 Variola, 155 complications of, 157 eruptive stage of, 155 Variola, incubation of, 155 modifications of, 156 prodromes of, 155 sequelse of, 157 stage of desiccation of, 156 stage of invasion of, 155 suppurative stage of, 155 treatment of, 157 Varioloid, 156 Veins, examination of, 67 Venous hum, 34, 67 pulse, systolic, 67 Ventricle, left, hypertrophy of, 184 right, hypertrophy of, 185 Vermes, 126 Vesicular breathing, enfeebled, 46 exaggerated, 46 pathologic, 46 respiratory murmur, 31 Vessels, 14 diseases of, 189 Vigor, bodily, 4, 7 Vocal bands, paralysis of, 38 redness of, 38 swelling of, 38 tumors of, 38 ulceration of, 38 Voice, auscultation of, 48 transmission of, 32 Vomited matter, constitution of, 89 Vomiting, 88 Waxy tube-casts, PI. 17 Weil's disease, 206 Werlhof 's disease, 224 Whooping-cough (see Pertussis), 157 Wintrich's change in percussion- note, 45 Xanthin in urine, 105 -calculi, 114 Yeast-fungi, 121 Yellow fever, 160 treatment of, 160 Yellowish friable sediment in urine, PI. 13 STANDARD Medical and Surgical Works PUBLISHED BY W. 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Prices: Cloth, ^7.00 net; Sheep or Half-Morocco, ^8.00 net. The arrangement of this volume has been based, so far as possible, upon modern pathologic doctrines, beginning with the intoxications, and following with infections, diseases due to internal parasites, diseases of undetermined origin, and finally the disorders of the several bodily systems — digestive, re- spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to include also a consideration of the disorders of pregnancy. The list of contributors comprises the names of many who have acquired dis- tinction as practitioners and teachers of practice, of clinical medicine, and of the specialties. CONTRIBUTORS : Dr. I. E. Atkinson, Baltimore, Md. Sanger Brown, Chicago, lil. John B. Chapin, Philadelphia, Pa. William C. Dabney, Charlottesville, Va. John Chalmers DaCosta, Philada., Pa. I. N. Danforth, Chicago, 111. John L. Dawson, Jr., Charleston, S. C. F. X. Dercum, Philadelphia, Pa. George Dock, Ann Arbor, Mich. Robert T. Edes, Jamaica Plain, Mass. Augustus A. Eshner, Philadelphia, Pa. J. T. Eskridge, Denver, Ccl. F. Forchheimer, Cincinnati, O. Carl Frese, Philadelphia, Pa. Edwin E. Graham, Philadelphia, Pa. John Guiteras, Philadelphia, Pa. Frederick P. Henry, Philadelphia, Pa. Guy Hinsdale, Philadelphia, Pa. Orville Horwitz, Philadelphia, Pa. W. W. Johnston, Washington, D. C. Ernest Laplace, Philadelphia, Pa. A. Laveran, Pans, France. Dr. James Hendrie Lloyd, Philadelphia, Pa. John Noland Mackenzie, Baltimore, Md. J. W. McLaughlin, Austin, Texas. A. Lawrence Mason, Boston, Mass. Charles K. Mills, Philadelphia, Pa. John K. Mitchell, Philadelphia, Pa. W. P. Northrup. New York City. William Osier, Baltimore, Md. Frederick A. Packard, Philadelphia, Pa. Theophilus Parvin, Philadelphia, Pa. Beaven Rake, London, England. E. O. Shakespeare. Philadelphia, Pa. Wharton Sinkler, Philadelphia. Pa. Louis Stan-, Philadelphia, Pa. Henry W. Stelwagon, Philadelphia, Pa. James Stewart, Montreal, Canada. Charles G. Stockton, Buffalo, N. Y. James Tyson, Philadelphia, Pa. Victor C. Vaughan, Ann Arbor, Mich. James T. Whittaker, Cincinnati, O. J. C. Wilson, Philadelphia, Pa. The articles, with two exceptions, are the contributions of American writers. Written from the standpoint of the practitioner, the aim of the work is to facili- tate the application of knowledge to the prevention, the cure, and the allevia- tion of disease. The endeavor throughout has been to conform to the title of the book — Applied Therapeutics — to^indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. While the scientific superiority and the practical desirability of the metric system of weights and measures is admitted, it has not been deemed best to discard entirely the older system of figures, so that both sets have been given where occasion demanded. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Richard C. Norris, M. D. ; Art Editor, Robert L, Dickinson, M. D. One handsome octavo volume of over looo pages, vv^ith nearly 900 colored and half-tone illustrations. Prices : Cloth, ^7.00 ; Sheep or Half-Morocco, $8.00. The advent of each successive volume of the series of the American Text- Books has been signalized by the most flattering comment from both the Press and the Profession. The high consideration received by these text-books, and their attainment to an authoritative position in current medical literature, have been matters of deep international interest, which finds its fullest expression in the demand for these publications from all parts of the civilized world. In the preparation of the "American Text-Book of Obstetrics" the editor has called to his aid proficient collaborators whose professional prominence entitles them to recognition, and whose disquisitions exemplify Practical Obstetrics. While these writers were each assigned special themes for dis- cussion, the correlation of the subject-matter is, nevertheless, such as ensures logical connection in treatment, the deductions of which thoroughly represent the latest advances in the science, and which elucidate the best modern methods of procedtire. The more conspicuous feature of the treatise is its wealth of illustrative matter. The production of the illustrations had been in progress for several years, under the personal supervision of Robert L. Dickinson, M. D., to whose artistic judgment and professional experience is due the most sumptuously illustrated work of the period. By means of the photographic art, combined with the skill of the artist and draughtsman, conventional illustration is super- seded by rational methods of delineation. Furthermore, the volume is a revelation as to the possibilities that may be reached in mechanical execution, through the unsparing hand of its publisher. CONTRIBUTOR^^ Dr. James C. Cameron. Edward P. Davis. Robert L. Dickinson. Charles Warrington Earle. James H. Etheridge. Henry J. Garr5gues. Barton Cooke Hirst. Charles Jewett. Dr. Howard A. Kelly. Richard C. Norris. Chauncey D. Palmer. Theophilus Parvin. George A. Piersol. Edward Reynolds. Henry Schwarz. " At first-glance we are overwhelmed by the magnitude of this work in several respects, viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- ment who have taken part in its production, then by the profuseness and character of the illustrations, and last, but not least, the conciseness and clearness with which the text is ren- dered. This is an entirely new composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy the front rank in their specialty, and there are many of them. We cannot turn over these pages without being struck by the superb illustrations which adorn so many of them. We are confident that this most practical work will find instant appreciation by practitioners as well as students." — New York Medical Tuttes. Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that 1 have ever seen. I congratulate you and thank you for this superb work which alone is sufficient to place you first in the ranks of medical publishers. With profound respect I am sincerely yours, Alex. J. C. Skene. W. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK ON THE THEORY AND PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal- octavo volumes of about looo pages each, with illustrations to elucidate the text wherever necessary. Price per Volume : Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net. VOI.UME I. CON TAIJTS : Hygiene. — Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing). — Scarla- tina, Measles, Rotheln, Variola, Varioloid, Vaccinia, Varicella, Mumps, Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus. — Tubercu- losis, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever. — Nervous, Muscular, and Mental Diseases etc. VOLiUME II. CONTAINS: Urine (Chemistry and Microscopy). — Kid- ney and Lungs. — Air-passages (Larynx and Bronchi) and Pleura. — Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. — Peritoneum, Liver, and Pancreas. — Diathet- ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithaemia, and Diabetes.) — Blood and Spleen. — Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. The articles are not written as though addressed to students in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causa- tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formulae. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the knowledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without consulting works specially devoted to the subject. CONTRIBUTORS : Dr. J. S. Billings, Philadelphia. Francis Delafield, New York. Reginald H. Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. William Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Giiman Thompson, New York. W. H. Welch, Baltimore. James T. Whittaker, Cincinnati. James C. Wilson, Philadelphia. Horatio C. Wood, Philadelphia. " We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second ".nd last volume leads us to modify that verdict and to say that the completed work is, in our opinion, thh best of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be." — New York Medical yournal. "A library upon modern medical art. The work must promote the wider diffusion of sound knowledge." — American Lancet. " A trusty counsellor for the practitioner or senior student, on which he may implicitly rely." — Edinburgh Medical Journal. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal-octavo volume of 1250 pages (10x7 inches), with 500 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Prices: Cloth, ^7.00 net; Sheep or Half- Morocco, ;^8.oo net. SECOND EDITION, REVISED AND ENLARGED, With a Section devoted to •' The Use of the Rbntgen Rays in Surgery." The want of a text-book which could be used by the practitioner and at the same time be recommended to the medical student has been deeply felt, espe- cially by teachers of surgery; hence, when it was suggested to a number of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. While there is no distinctive Amer- ican Surgery, yet America has contributed very largely to the progress of modern surgery, and among the foremost of those who have aided in developing this art and science will be found the authors of the present volume. All of them are teachers of surgery in leading medical schools and hospitals in the United States and Canada. Especial prominence has been given to Surgical Bacteriology, a feature which is believed to be unique in a surgical text-book in the English language. Asep- sis and Antisepsis have received particular attention. The text is brought well up to date in such important branches as cerebral, spinal, intestinal, and pelvic surgery, the most important and newest operations in these departments being described and illustrated. The text of the entire book has been submitted to all the authors for their mutual criticism and revision — an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the important sur- gical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens. CONTRIBUTORS : Dr. Charles H. Burnett, Philadelphia. Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York. William W. Keen, Philadelphia. Charles B. Nancrede, Ann Arbor, Mich. Roswell Park, BuflFalo, N. Y. Lewis S. Pilcher, New York. Dr. Nicholas Senn, Chicago. Francis J. Shepherd, Montreal, Canada. Lewis A. Stimson, New York. William Thomson, Philadelphia. J. Collins Warren, Boston. J. William White, Philadelphia. "If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet. W. B. SAUNDERS' For Sale by Subscription, AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J, M. Baldy, M. D. Forming a handsome royal-octavo volume, with 341 illustrations in text and 38 colored and half-tone plates. Prices : Cloth, ^6.00 net; Sheep or Half-Morocco, ^7.00 net. SECOND EDITION, THOROUGHLY REVISED. In this volume all anatomical descriptions, excepdng those essential to a clear understanding of the text, have been omitted, the illustrations being largely de- pended upon to elucidate the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to dis- cuss mooted points, still the most important of these have been noted and ex- plained. The operations recommended are fully illustrated, so that the reader, having a picture of the procedure described in the text under his eye, cannot fail to grasp the idea. All extraneous matter and discussions have been carefully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who hgure as the authors. CONTRIBUTORS : Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. ). H. Etheridge. William Goodell. Dr. Howard A. Kelly. Florian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. " The most notable contribution to gynecological literature since 1887, .... and the most complete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book surpasses anything we have seen." — Boston Medical and Surgical yournal. " A valuable addition to the literature of Gynecology. The writers are progressive, aggressive, and earnest in their convictions." — Medical Nezvs, Philadelphia. " A thoroughly modern text-book, and gives reliable and well-tempered advice and in struction." — Edinburgh Medical Journal. " The harmony of its conclusions and the homogeneity of its style give it an individuality which suggests a single rather than a multiple authorship." — Annals of Surgery. " It must command attention and respect as a worthy representation of our adv.nnced clinical teaching." — American Journal 0/ Medical Sciences. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M. D., assisted by THOMPSON S. Westcott, M. D. In one handsome royal-8va volume of 1250 pages, profusely illustrated with wood-cuts, half-tone and colored plates. Net Prices : Cloth, $7.00; Sheep or Half-Morocco, $8.00. SECOND EDITION, REVISED AND ENLARGED. The plan of this work embraces a series of original articles written by some sixty well-known podiatrists, representing collecti%'ely the teachings of the most prominent medical schools and colleges of America. The work is intended to be a PRACTICAL book, suitable for constant and handy reference by the practi- tioner and the advanced student. Especial attention has been given to the latest accepted teachings upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- dren, with the introduction of many special formulae and therapeutic procedures. Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose and Throat, and the Skin ; while the introductory chapters cover fully the important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro- cedures coming within the province of the medical practitioner are carefully considered. CONTRIBUTORS I Dr. S. S. Adams, Washington John Ashhurst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada. David Bovaird, New York. Dillon Brown, New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. W. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald Church, Chicago. Floyd M. Crandall, New York. Andrew F. Currier, New York. Roland G. Curtin, Philadelphia J. M. DaCost-a, Philadelphia. 1. N. Danforth, Chicago. Edward P. Davis, Philadelphia. John B. Deaver, Philadelphia. G. E. de Schweinitz, Philadelphia. John Doming, New York. Charles Warrington Earle, Chicago. Wm. A. Edwards, San Diego, Cal. F. Forchheimer, Cincinnati. J. Henry Fruitnight, New York. J. P. Crozer Griffith, Philadelphia. W. A. Hardaway. St. Louis. M. P Hatfield, Chicago. Barton Cooke Hirst, Philadelphia. H. Illoway, Cincinnati. Henry Jackson, Boston. Charles G. Jennings, Detroit. Henry Koplik, New York. Dr. Thomas S. Latimer, Baltimore. Albert R. Leeds, Hoboken, N. J. J. Hendrie Lloyd, Philadelphia. George Roe Lockwood, New York. Henry M. Lyman, Chicago. Francis T. Miles, Baltimore. Charles K Mills, Philadelphia. James E. Moore, Minneapolis. F. Gordon Morrill, Boston. John H. Musser, Philadelphia. Thomas R. Neilson, Philadelphia, W. P. Northrup, New York. William Osier, Baltimore. Frederick A. Packard, Philadelphia. William Pepper, Philadelphia. Frederick Peterson, New York. W. T. Plant, Syracuse, New York. William M. Powell, Atlantic City. B. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia F. C. Shattuck, Boston. J. Lewis Smith, New York. Louis Starr, Philadelphia. M. Allen Starr, New York. Charles W. Townsend, Boston. James Tyson, Philadelphia. '.V. 8. Thayer, Baltimore. "Victor C. Vaughan, Ann Arbor, Mich Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J. William White, Philadelphia. J. C. Wilson, Philadelphia. 10 W. B. SAUNDERS' A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia; Vice-President of the American Paediatric Society; Ex-President of the Association of Life Insurance Medical Directors ; Editor " Cyclo- paedia of the Diseases of Children," etc.; and Henry Hamilton, author of "A New Translation of Virgil's ^neid into English Rhyme;" co- author of "Saunders' Medical Lexicon," etc.; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A, Packard, M. D. With an Appendix containing important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- gery, Poisons and their Antidotes, Weights and Measures, Thermometric Scales, New Official and Unofficial Drugs, etc. One very attractive volume of over 800 pages. Second Revised Edition, Prices: Cloth, ^^5. 00 net ; Sheep or Half-Morocco, ^6.00 net ; with Denison's Patent Ready-Refer- ence Index; without patent index, Cloth, $4.00 net; Sheep or Half- Morocco, ^5.00 net. PROFESSIONAL. OPINIONS. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Henry M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. LiNDSLEY, M. D., Professor of Theory and Practice 0/ Medicine, Medical Dept. Yale University ; Secretary Connecticut State Board of Health, New Haven, Conn, AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per Volume, 1^2.50 net. This autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early stniggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men — surgeons, physicians, divines, lawyers, states- men, scientists, etc. — with whom he was brought in contact in America and in Europe ; the whole forming a retrospect of more than three-quarters of a century. CATALOGUE OF MEDICAL WORKS. II SURGICAL PATHOLOGY AND THERAPEUTICS. By John Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- ment Harvard University ; Surgeon to the Massachusetts General Hospital, etc. A handsome octavo volume of 832 pages, vi^ith 136 relief and litho- graphic illustrations, ■}>'^ of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Prices : Cloth, ^6.00 net; Half-Morocco, ^7.00 net. " The volume is for the bedside, the amphitheatre, and the ward. It deals with things not as we see them through the microscope alone, but as the prac- titioner -sees their effect in his patients ; not only as they appear in and affect culture-media, but also as they influence the human body ; and, following up the demonstrations of the nature of diseases, the author points out their logical treatment." [New York Medical Journal). " It is the handsomest specimen of book-making -5^ * * that has ever been issued from the American medical press" [American Journal of the Medical Sciences, Philadelphia). Without Exception, the Illustrations are the Best ever Seen in a Work of this Kind. "A most striking and very excellent feature of this book is its illustrations. Without ex- ception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. * * * Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section." — Annals qf Surgery, Philadelphia. PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 engravings, including full-page colored plates. Prices : Cloth, $6.00 net j Half-Morocco, ^7.00 net. Books specially devoted to this subject are few, and in our text-books and systems of surgery this part of surgical pathology is usually condensed to a de- gree incompatible with its scientific and clinical importance. The author spent many years in collecting the material for this work, and has taken great pains to present it in a manner that should prove useful as a text-book for the student, a work of reference for the busy practitioner, and a reliable, safe guide for the surgeon. The more difficult operations are fully described and illustrated. More than one hundred of the illustrations are original, while the remainder were selected from books and medical journals not readily accessible. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, .... and the author has given a notable and lasting contribution to surgery." — journal qf American Medical A !:so' ciation, Chicago. 12 IV. B. SAUNDERS' MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Fifth Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume of 600 pages. 194 fine wood-cuts m the text, many of them in colors. Prices: Cloth, ^4.00 net; Sheep or Half- Morocco, $5.00 net. FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND ENLARGED GERMAN EDITION. In this work, as in no other hitherto published, are given fufi and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. This valuable work is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- LITIC AFFECTIONS. (American Edition.) Translation from the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- sician to, and Physician to the department for Diseases of the Skin at, the Middlesex Hospital, London. Photo-lithochromes from the famous models of dermatological and syphilitic cases in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, at $3.00 per Part. Parts i to 8 now ready. "The plates are beautifully executed." — Jonathan Hutchinson, M. D. (London Hospital). "The plates in this Atlas are remarkably accurate and artistic reproductions oi typical examples of skin disease. The work will be of great value to the practitioner and student." — William Anderson, M. D. (St. Thomas Hospital). " If the succeeding parts of this Atlas are to be similar to Part i, now before us, we have no hesitation in cordially recommending it to the favorable notice of our readers as one of the finest dermatological aliases with which we are acquainted." — Glasgow Medical yournal, Aug., 1895. " Of all the atlases of skin diseases which have been published in recent years, the present one promises to be of greatest interest and value, especially from the standpoint of the general practitioner " — Ainerican Medico-Surgical Bulletin, Feb. 22, 1896. "The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit." — New York Medical Journal, Feb. 15, 1896. " An interesting feature of the Atlas is the descriptive text, which is written for each picture by the physician who treated the case or at whose instigation the models have been made. We predict for this truly beautiful work a large circulation in all parts of the medical world where the names .S"^. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. i, 1896. CATALOGUE OF MEDICAL WORKS. 1 3 PRACTICAL POINTS IN NURSING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass. ; Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated with 73 engravings in the text, and 9 colored and half-tone plates. Cloth. Price, ^1.75 net. SECOND EDITION, THOROUGHLY REVISED. In this volume the author explains, in popular language and in the shortest possible form, the entire range of private nursing as distinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. An especially valuable feature of the work will be found in the directions to the nurse how to itnprovise everything ordinarily needed in the sick-room, where the embarrassment of the nurse, owing to the want of proper appliances, is fre- quently extreme. The work has been logically divided into the following sections : I. The Nurse : her responsibilities, qualifications, equipment, etc. II. The Sick-Room : its selection, preparation, and management. III. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- cologic cases. IV. Nursing in Accidents and Emergencies. V. Nursing in Special Medical Cases. VI. Nursing of the New-born and Sick Children. VII. Physiology and Descriptive Anatomy. The Appendix contains much information in compact form that will be found of great value to the nurse, including Rules for Feeding the Sick; Recipes for Invalid Foods and Beverages; Tables of Weights and Measures; Table for Computing the Date of Labor; List of Abbreviations ; Dose-List; and a full and complete Glossary of Medical Terms and Nursing Treatment. "This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise and how to prepare everj'thing ordinarily needed in the illness of her patient." — American Journal of Obstetrics and Diseases of Women and Children, Aug., 1896. A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and Prevention of Infective Diseases and an account of Yeasts and Moulds, Haematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- fessor of Comparative Pathology and Bacteriology, King's College, London. A handsome octavo volume of 700 pages, with 273 engravings in the text, and 22 original and colored plates. Price, ^6.50 net. This book, though nominally a Fourth Edition of Professor Crookshank's " Manual of Bacteriology," is practically a new work, the old one having been reconstructed, greatly enlarged, revised throughout, and largely rewritten, forming a text-book for the Bacteriological Laboratory, for Medical Ofticers of Health, and for Veterinary Inspectors. 14 IV. B. SAUNDERS' A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- TICAL. For the Use of Students. By Arthur Clarkson, M. B., CM., Edin,, formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in the Yorkshire College, Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 beautifully colored original illustrations. Price, strongly bound in Cloth, ;g6.oo net. The purpose of the writer in this work has been to furnish the student of His- tology, in one volume, with both the descriptive and the practical part of the science. The first two chapters are devoted to the consideration of the general methods of Histology ; subsequently, in each chapter, the structure of the tissue or organ is first systematically described, the student is then taken tutorially over the specimens illustrating it, and, finally, an appendix affords a short note of the methods of preparation. "We would most cordially recommend it to all students of histology." — Dublin Medical Journal . "It is pleasant to give unqualified praise to the colored illustrations ; . . . the standard is high, and many of them are not only extremely beautiful, but very clear and demonstra- tive. . . . The plan of the book is excellent." — Liverpool Medical Journal. ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, B. A., Camb. A series of collotype illustrations, with descriptive text, illustrating the applications of the New Photography to Medicine and Sur- gery. Price, per Part, ^i.oo. Parts I, to V. now ready. The object of this publication is to put on record in permanent form some of the most striking applications of the new photography to the needs of Medicine and Surgery. The progress of this new art has been so rapid that, although Prof. Rontgen's discovery is only a thing of yesterday, it has already taken its place among the approved and accepted aids to diagnosis. WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc, M. B., D. P. H., Lecturer on Public Health, King's College, London; Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus- trated. Handsomely bound in Cloth, with gold side and back stamps. Price, ^2.25 net. This work will furnish any one interested in public health the information requisite for forming an opinion as to whether any supply or proposed supply is sufficiently wholesome and abundant, and whether the cost can be considered reasonable. The work does not pretend to be a treatise on Engineering, yet it contains sufficient detail to enable any one who has studied it to consider intelligently any scheme which may be submitted for supplying a community with water. CATALOGUE OF MEDICAL WORKS. 1 5 DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- tice. By G. E. DE SCHWEINITZ, M. D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. A handsome royal- octavo volume of 679 pages, with 256 fine illustrations, many of which are original, and 2 chromo-lithographic plates. Prices : Cloth, ^4.00 net ; Sheep or Half-Morocco, ^5.00 net. The object of this work is to present to the student, and to the practitioner who is beginning work in the fields of ophthalmology, a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question ; and the method of examination, the symptomatology leading to a diagnosis, and the treatment of the various ocular defects have been brought into prominence. THIRD EDITION, THOROUGHLY REVISED. The entire book has been thoroughly revised. In addition to this general revision, special paragraphs on the following new matter have been introduced : Filamentous Keratitis, Blood -staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies in the Papilla, Monocular Diplopia, Subconjunctival Injections of Germicides, Infiltiation-Ansesthesia, and Steriliza- tion of Collyria. Brief mention of Ophthalmia Nodosa, Electric Ophthalmia, and Angioid Streaks in the Retina also finds place. An Appendix has been added, containing a full description of the method of determining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, and the rotations of the eyes with the tropometer of Stevens. The chapter on Operations has been enlarged and rewritten. " A clearlywritten, comprehensive manual. . . . One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science."— British Medical Journal. " The work is characterized by a lucidity of expression which leaves the reader in no doubt as to the meaning of the language employed. . . . We know of no work in which these diseases are dealt with more satisfactorily, and indications for treatment more clearly given, and in harmony with the practice of the most advanced ophthalmologists." — Mari- time Medical News. " It is hardly too much to say that for the student and practitioner begirming the study of Ophthalmology, it is the best single volume at present published." — Medical News. " The latest and one of the best books on Ophthalmology. The book is thoroughly up to date, and is certainly a work which not only commends itself to the student, but is a ready reference for the busy practitioner." — International Medical Review. PROFESSIO^TAIi OPISTIONS. "A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D. Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. "Contains in concise and reliable form the accepted views of Ophthalmic Science." William Thomson, M. D., Profesfpr 0/ Ophthalmology, yefferson Medical College, Philadelphia, Pa. 1 6 IV. B. SAUNDERS' TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- cially written for Students of Medicine. By Joseph McFarland, M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, ^2.50 net. SECOND EDITION, REVISED AND GREATLY ENLARGED. The work is intended to be a text-book for the medical student and for the practitioner who has had no recent laboratory training in this department of medi- cal science. The instructions given as to needed apparatus, cultures, stainings, microscopic examinations, etc. are ample for the student's needs, and will afibrd to the physician much information that will interest and profit him relative to a subject which modern science shows to go far in explaining the etiology of many diseased conditions. In this second edition the work has been brought up to date in all depart- ments of the subject, and numerous additions have been made to the technique in the endeavor to make the book fulfil the double purpose of a systematic work upon bacteria and a laboratory guide. " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written. — Lofidon Lajicet, Aug. 29, 1896. " The author has succeded admirably in presenting the essential details of bacteriological technics, together with a judiciously chosen summary of our present knowledge of pathogenic bacteria. . . . The work, we think, should have a wide circulation among English-speaking students of medicine." — N. V. Medical Journal, April 4, 1896. " The book will be found of considerable use by medical men who have not had a special bacteriological training, and who desire to understand this important branch of medical science." — Edinburgh Medical Journal, July, 1896. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- nary Science, Sheffield Scientific School, Yale University. Illustrated. Price, Cloth, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work " It is a convenient and useful little work, and will more than repay the outlay necessary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages." — American Med.- Surg. Bulletin. FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. Bound in limp cloth, flush edges. Price, 25 cents net. Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- ing — Intervals between Feedings — Increase in Amount of Food at Different Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- stitute for Mother's Milk — Objections to Sterilization or " Pasteurization " of Milk — Advances made in the Method of Artificial Feeding of Infants. CATALOGUE OF MEDICAL WORKS. \y ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection " By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, ^2.00 net. Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy, " The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting-room." — -Journal of American Medical Association. "Should be in the hands of every medical student." — Cleveland Medical Gazette. "A concise and judicious work." — Buffalo Medical and Surgical Journal. A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Penn- sylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations, and includes the following sections : General Diseases, Diseases of the Digestive Organs, Diseases of the Respiratory System, Diseases of the Circulatory System, Diseases of the Nervous Sys- tem, Diseases of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each section is prefaced by a chapter on General Symptomatology. Post 8vo, 520 pages. Numerous illustrations and selected fonnulae. Price, ^2.50, bound in flexible leather. FIFTH EDITION, REVISED AND ENLARGED. Contributions to the science of medicine have poured in so rapidly during the last quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enabled, by classification, to group allied symp- toms, and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the prac- tice of medicine. 1 8 fV. B. SAUNDERS yiP^\i\\iP^\. OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 445 pages. Price, Cloth, ^5^2.25. SECOND EDITION, REVISED. This wholly new volume, which is based on the last edition of the Pharma- copoeia, comprehends the following sections : Physiological Action of Drugs ; Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of Diseases ; the treatment being elucidated by more than two hundred formulae. "The author is to be congratulated upon having presented the medical student with as accurate a manual of therapeutics as it is possible to prepare." — Therapeutic Gazette. " Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable and accurate." — New York Medical Journal. " The author has faithfully presented modern therapeutics in a comprehensive work, . . . and it will be found a reliable ^\\\A&." —University Medical Magazine. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 253 pages. Price, $1.2^. SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that^if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical importance of the new agents, "Especially valuable because of its completeness, its accuracy, its systematic consider- ation of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner." — Chicago Clinical Review. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x 13^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. CATALOGUE OF MEDICAL WORKS. 1 9 SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M. D., editor of " Cyclopaedia of Diseases of Children," etc. ; author of the " New Pronouncing Dictionaiy of Medicine;" and Henr\ Hamilton, author of " A New Translation of Virgil's ^Eneid into Eng- lish Verse;" co-author of a " New Pronouncing Dictionary of Medicine." A new and revised edition. 32mo, 282 pages. Prices: Cloth, 75 cents: Leather Tucks, ^i.oo. This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market, which, dating as they do from 1855 ^^ 1884, are of but trifling use to the student by their not containing the hundreds of new words now used in current litera- ture, especially those relating to Electricity and Bacteriology. " Remarkably accurate in terminology, accentuation, and definition." — Journal of Amer- ican Medical Association. " Brief, yet complete .... it contains the very latest nomenclature in even the newest departments of medicine." — New York Medical Record. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1800 Formulae, selected from several hundred of the best-known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions ; with an Appendix containing Posological Table, Formulae and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Fourth edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, ^1.75 net. A concise, clear, and correct record of the many hundreds of famous formulae which are found scattered through the works of the most eminent physicians and surgeons of the world. The work is helpful to the student and practitioner alike, as through it they become acquainted with numerous formulae which are not found in text-books, but have been collected from among the rising genera- tion of the pi-ofession, college professors, and hospital physicians and surgeons. " This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given is unusually reliable." — New York Medical Record. " Designed to be of immense help to the general practitioner in the exercise of his daily calling." — Boston Medical and Surreal Journal. 20 fV. B. SAUNDERS' DISEASES OF WOMEN. By Henry J. Garrigues, A. M., M. D., Professor of Gynecology and Obstetrics in the New York School of Clinical Medicine; Gynecologist to St. Mark's Hospital and to the German Dis- pensary, New York City, In one handsome octavo volume of 728 pages, illustrated by 335 engravings and colored plates. Prices : Cloth, j^4.oo net ; Sheep or Half Morocco, ^5.00 net. A PRACTICAL work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of \hc female genitalia, besides exemplifying, whenever needed, morbid condi- tions, instruments, apparatus, and operations. Second Edition, Thoroughly Revised, The first edition of this work rnet with a most appreciative reception by the medical press and profession both in this country and abroad, and was adopted as a text-book or recommended as a book of reference by nearly otie hundred colleges in the United States and Canada. The author has availed himself of the opportunity afforded by this revision to embody the latest approved advances in the treatment employed in this important branch of Medicine. He has also more extensively expressed his own opinion on the comparative value of the different methods of treatment employed. "One of the best text-books for students and practitioners which has been published in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants may not be available, will find in this book invaluable counsel and help." Thad. a. Reamy, M. D., LL.D., Profesatr of Clinical Gynecology , Medical College of Ohio ; Gynecologist to the Good Samaritan and Cincinnati Hospitals. A SYLLABUS OF GYNECOLOGY, arranged in conformity witli "An American Text-Book of Gynecology." By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. Price, Cloth (interleaved), $1.00 net. Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already f)ossess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- room, as the subject is presented in a manner at once systematic, clear, succinct, ?nd practical. CATALOGUE OF MEDICAL WORKS. 21 A MANUAL OF PHYSIOLOGY, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University ; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Handsome octavo volume of 800 pages, with 278 illustrations in the text, and 5 colored plates. Price, Cloth, ^3.50 net. " It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the stibject." — London Lancet. " Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Professor Stewart's volume." — British Medical Journal. ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- sis in the Rush Medical College, Chicago; Attending Physician to the Central Free Dispensary, Department of Rhinology, Laryngology, and Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers. Price, ^1.25 net. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M, D., Lecturer on Clinical and Operative Obstetrics, University of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, ^2.00 net. ** This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant; no minor matters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise." — New York Medical Record. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with *' An American Text-Book of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This, the latest work of its eminent author, himself one of the contributors to "An American Text-Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome of or supplement to the larger work. " The author has evidently spared no pains in making his Syllabus thoroughly comprehen- sive, and has added new matter and alluded to the most recent authors and operations. Full references are also given to all requisite details of surgical anatomy and pathology." — British Medical Journal, London. 22 W, B. SAUNDERS' AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. SECOND EDITION, REVISED FORM. A convenient blank, suitable for all operations, giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. On the back of each blank is a list of instruments used — viz. general instru ments, etc., required for all operations ; and special instruments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito-urinar}' organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur- geon's office or in the hospital operating-room. "Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed " — New York DIedical Record "Covers about all that can be needed in any operation." — American Lancet. " The plan is a capital one." — Boston Medical and Surgical yournal. LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, Cloth, ^^2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. " There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation." — Americaii journal of Pharmacy. DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women ; with an Introduction by Sir Henry Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, Cloth, $1.50. Useful to those who have to nurse, feed, and prescribe for the sick. In each case the accepted causation of the disease and the reasons for the special diet prescribed are briefly described. Medical men will find the dietaries and recipes practically useful, and likely to save them trouble in directing the dietetic treatment of patients. CATALOGUE OF MEDICAL WORKS. 23 HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Pgediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections ; also, numerous cuts to elucidate the text. Second edition. Price, Cloth, ^2.00 net. " This is by far the most useful book v/hich has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science." — The Medical News, Philadelphia. NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 pages, profusely illustrated. Price, Cloth, ^2.00 net. This original work on the important subject of nursing is at once comprehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desidera- tum with those entrusted with the management of hospitals and the instruction of nurses in training-schools. It is also of especial value to the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- trated. Price, ^2.00 net. " For the use of the practitioner who, when away from home, has not the opportunity of consulting a library or of calling a friend in consultation. He then, being thrown upon his own resources, will find this book of benefit in guiding and assisting him in emergencies." INFANT'S WEIGHT CHART. Designed by J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children in the University of Penn- sylvania. 25 charts in each pad. Price per pad, 50 cents net, A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. 24 W. B. SAUNDERS' THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. 404 pages, with 67 illustrations in the text, and 5 plates. i2mo. Price, ^1.50. SECOND EDITION, REVISED. A reliable guide not only for mothers, but also for medical students and practitioners vi^hose opportunities for observing children have been limited. " The whole book is characterized by rare good sense, and is evidently written by a mas- ter hand. It can be read with benefit not only by mothers, but by medical students and by :iny practitioners who have not had large opportunities for observing chMren."— American yjurnal of Obstetrics. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or the sick-room. By Honnor Morten, author of " How to Become a Nurse," " Sketches of Hospital Life," etc. i6mo, 140 pages. Price, Cloth, ^i.oo. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, M. D., Visiting Physicia-n to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital ; Assistant Bacteriologist, Brooklyn Health Department. Price, Cloth, ^1.50 (Send for specimen List.) One hundred and sixty detachable (perforated) diet lists for Albuminuria, Anaemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, Gout or Uric-Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable sheets of Sick-Room Dietary, containing full instructions for preparation of easily-digested foods necessary for invalids. Each list is numbered only, the disease for which it is to be used in no case being mentioned, an index key being reserved for the physician's private use. DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN DISEASE. By Louis Starr, M. D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size)., perforated and neatly bound in flexible morocco. Price, ^1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each blank indicates the ingredients, but not the quantities^ of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formula foi tfie preparation of diluents and foods are appended. njtis ''^'