FROM THE LIBRARY OF St^ILLIAM DLNCAN McKIM GRADUATE OF COLUMBIA UNIVERSITY A. B., 1875; A. M., 1878; M. D., 1878 RC7/ yG7 Columbia ^Bnitier^ttp mtl)fCitpoflfttJgark CoUcge of ^ijpjsiciang anb burgeons! Hibrarp 'era I VHvn .. , A CLINICAL TEXT-BOOK OF MEDICAL DIAGNOSIS FOR PHYSICIANS AND STUDENTS BASED ON THE MOST EECENT METHODS OF EXAMINATION. BY OSWALD VIERORDT, M.D., PROFESSOR OF MEDICINE AT THE UNIVERSITY OF HEIDELBERG, FORMERLY PRIVAT-DOCENT AT THE UNIVERSITY" OF LEIPZIG ; LATER, PROFESSOR OF MEDICINE AND DIRECTOR OF THE MEDICAL POLYCLINIC AT THE UNIVERSITY OF JENA. AUTHORIZED TRANSLATION FROM THE SECOND IMPROVED AND ENLARGED GERMAN EDITION, WITH ADDITIONS. BY FRANCIS H. STUART, A.M., M.D., MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF KINGS, NEW YORK ; FELLOW OF THE NEW Y'ORK ACADEMY OF MEDICINE, MEMBER OF THE BRITISH MEDICAL ASSOCIATION, ETC. WITH ONE HUNDRED AND SEVENTY-EIGHT ILLUSTRATIONS, Many of lohich are in colors. PHILADELPHIA: W. B. SAUNDERS 913 WALNUT STREET. 1891. \/ fc 7 Entered according to the Act of Congress, in the year 1891. by W. B. SAUNDERS, iu the Office of the Librarian of Congress at Washington. noRNAX, PRINTER, 100 NOUTH SEVENTH STREET. VORWORT DES AUTORS ZUR EXGLISCHEX AUFLAGE. E> crereicht mir zur lebliaften Genuo-thuuno;, Herrn Francis H. Stuart, MD. meinen Dank dafiir auszusprechen, dass er e? unter- nommen hat, meine Diagnostik in das Engliscbe zu tibersetzen. Ich bezweifle nicht, dass die Ubersetzung ihm gut gelungen ist, und gebe ihr den Wunscli mit auf den Weg, dass sie sicli in der neuen AYelt ebenso viele Freunde erwerben moge, "n'ie die deutsche Ausgabe in Deutschland gefunden hat. Heidelberg, 30sten Marz, 1S91. Prof. Dr. 0. YIERORDT, Director der Poliklinik. (i) Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/clinicaltextbook1891vier TRANSLATOR'S PREFACE. The "work of Avhich a translation is here offered is one of the best that has yet been written upon the subject. When it first came into the hands of the translator he had no thought of ever using it except as a work of reference. But as he read it he became convinced that it had such merit that it would certainly be welcomed by a large class of readers if it were rendered into English. Accordingly, after com- municating with the author and his publisher, the work of translation was begun, and has been prosecuted at such intervals of time as could be secured from an active professional life. If the work shall com- mend itself to others as it has to him, the translator will feel amply rewarded for the eifort he has made to put it into their hands. , Here and there slight additions have been made, which the trans- lator trusts will increase the value of the work. A very full index has been prepared, which, it is believed, comprises a reference to every material statement in the book. The translation was almost completed when a copy of the second edition of the original was received from the publisher. The author has made numerous additions which have enhanced its value, and the translation has been made to correspond with this enlarged edition. It is gratifying to the translator to find that a second edition has so soon been called for, and that his own favorable opinion has been further confirmed by the fact that Italian and Russian translations of the work have been made. FRANCIS H. STUART. 123 JoEALEMON Street, Brooklyn, N.Y., ^ March, 1891. (iii) AUTHOR'S PREFACE TO THE SECOND EDITIOI^. In this edition the book has received, as I think, not incon- siderable additions and improvements. To mention only the most important ones : The section upon the examination of the contents of the stomach has been almost entirely rewritten, and so have some portions of the section on the examination of the organs of the senses, especially that of the eye. The laryngoscopic examination of the larynx has been treated anew, and much more extensively than in the first edition. A short section, almost entirely new, has been added upon the enlargement of the vessels of the brain, and at the end of the book a concise presentation of those peculiarities of micro- organisms whose recognition and discrimination are made possible by cultures and inoculation. Finally, with the hearty co5peration of the publisher, the illustrations of the most important micro- organisms are printed in colors, and also some entirely new figures have been added. I am indebted to the friendly assistance of Professor Gartner in the department of bacteriology, of which I here make public acknowledgment. OSWALD VIERORDT. Jena, August, 1889. (V) PREFACE TO THE FIRST EDITION. The book which is here oiTerecI to the medical public ^vas under- taken at the solicitation of a number of associates, and in view of the experience -which I have acquired during more than four years of work as Teacher of Diagnosis in the Medical Clinic at the University of Leipsic. Originally I had in view a very extensive treatise com- prising a detailed explanation of normal and pathological anatomy and physiology as a foundation for diagnosis. But this plan I abandoned with a view to the convenience and general usefulness of the book. Regarding the principles which have guided me, and which I hope, particularly in the " Special Part," notwithstanding the brevity of the presentation, have been made plain, I may be permitted here to specify the following. I have here, as well as in my teaching, taken pains to emphasize that, besides availing ourselves of the constantly- increasing finer methods of diagnosis, the simple use of our senses, especially of the unaided eye, must not be forgotten. Still more the manifold labors with the microscope and in the laboratory ought not to permit the physician to forget that a preparation or a chemical reaction is not enough for a diamosis, but that the whole oro-anism must always be brought under consideration. In other words, in diagnosis as well as therapeutics this rule is imperative : We must individualize the case. Should the book to any extent antagonize the inclination of our time to theorizing, it would afford me especial satisfaction. OSWALD VIEROKDT. Leipsic, June, 1888. ( vii ) CONTENTS. PAKT I, CHAPTER I. INTRODUCTION. Anamnesis .... Mode of Taking the Anamnesis What the Anamnesis Comprises Previous History of the Patient The Present Disease PAGE 18 19 20 20 22 CHAPTER 11. EXAMINATION OF PATIENTS. What the Examination Comprises ........ 24 [Note by the Translator upon Keeping Records of Cases, and a Form for Recording the Results of a Medical Examination] ... 24 PART II CHAPTER III. GENERAL EXAMINATION I. The Psychical Condition of the Patient . II. The Position of the Patient III. The Structure of the Body and Nutrition IV. Skin and Subcutaneous Cellular Tissue . A. The State of Nutrition of the Skin . B. The Moisture of the Skin ; Perspiration 31 31 33 36 36 36 (ix) CONTENTS. c. The Color of the Skin 1. The Pale Skin 2. Abnormal Redness of Skin 3. The Blue-red Skin, Cyanosis . . . . 4. The Yellow Skin, Icterus, Jaundice .... 5. The Bronze Skin 6. The Gray Skin of Silver Deposit .... D. Other Pathological Appearances of the Skin which are of General Diagnostic Value . . . . . 1. Acute Exauthematous Diseases .... 2. Exanthemata from Poisons and the Use of Medicines 3. Hemorrhages in the Skin ...... 4. Scars . E. CEdema of the Skin and Subcutaneous Cellular Tissue (QSdema, Anasarca) ...... F. Emphysema of the Skin ....... The Temperature of the Body. Fever 1 . The Terms Used and the Method of Taking the Temperature 57 2. The Normal Temperature of the Body .... 3. Elevated Temperature. Fever ..... 4. The Subnormal Temperature 6. Diagnostic Value of the Temperature, especially of its Genera Course 6. Local Elevation or Lowering of the Temperature . PAKT III. 38 39 41 42 45 48 49 49 49 50 51 52 52 55 57 59 GO 63 64 71 CHAPTER IV. EXAMINATION OF THE RESPIRATORY APPARATUS. Examination of the Nose and Larynx . 73 1. The Nose 73 2. The Larynx 74 Examination of the Lungs 76 Topographical Anatomy of the Lungs ...... 76 The Anatomical Boundaries of the Lungs with Reference to the Thorax . . . . .77 Inspection of the Thorax 81 1. Normal Form of Thorax and Normal Respiration . . 81 2. Pathological Forms of Thorax 83 3. Anomalies of Respiration 89 COyTEXTS. XI PAGE Palpation of the Thorax ■ , 100 1. Pain caused by Pressure upon the Thorax .... 101 2. Testing the Movement during Eespiration .... 102 General and Preliminary Remarks Regarding Percussion . . 103 1. History and Methods 104 2. Qualities of Sounds 106 3. The Conditions that determine the Quality of the Sounds and their Production in the Body. The Feeling of Re- sistance 109 4. Topographical Percussion : Determining the Parietal Bound- aries of Organs ......... 116 Percussion of the Thorax, Especially of the Lungs . . . 118 1. Methods .' . . . 118 2. Xormal Sound over the Lungs, Trachea, and Larynx. The Normal Boundaries of the Lungs ..... 119 3. Abnormal Sound over the Lungs. Abnormal position of the Border of the Lungs ....... 12-5 The Second Quality of Sound which is found over Diseased Lungs ' . . .130 Auscultation of the Lungs 138 1. History. The Sphere of Auscultation at the Present Time 138 2. Methods of Auscultation 138 3. Auscultatory Signs in Normal Respiration .... 141 4. Pathological Sounds in the Respiratory Apparatus . . 144 Palpation of Vocal Fremitus (Auscultation of the Voice) . . 156 Exploratory Puncture of the Pleura 160 Methods of Measuring and Stethography 162 Measuring the Thorax . . . . . . . . . 162 Spirometry, Pneumatometry, and Stethography .... 163 Cough and Expectoration 164 Expectoration, Sputum ......... 167 1. General Characteristics of the Expectoration . . . 168 2. Foreign Substances in the Sputum which are Visible to the Unaided Eye ......... 171 3. Microscopical Examination of the Sputum .... 175 CHAPTER V. ESAMIXATIOX OF THE CIECULATOE,Y APPARATUS. Examination of the Heart 191 Anatomy of the Normal Heart 191 Preliminary Remarks necessary to Understand the Physical Phe- nomena of the Heart . 193 COyTKXTS. Inspection and Palpation of the Region of the Heart The Apex-beat Alteration in the Width and Strength of the Apex-beat The Neighborhood of the Heart in general The Epigastrium Percussion of the Heart Normal Percussion Figure of the Heart . Methods of Percussion ..... Enlargement of the Area of Heart-dulncss Diminution or Loss of Heart dulncss Displacement (dislocation) of the Heart-dulness Auscultation of the Heart ..... Method and Normal Condition .... Pathological Changes in the Heart-sounds Organic Endocardial Heart-murmurs Inorganic, Anaemic Murmurs. (Synonyms: accidental, murmurs.) ....... Pericardial Murmurs. [Friction-sounds.] Examination of the Arteries ...... I. The Pulse, its Palpation and Graphic Representation Palpation of the Pulse 1. The Normal Pulse 2. Pathological Frequency of the Pulse 3. Want of Rhythm of the Pulse 4. Quality of the Pulse .... 5. Symmetry of the Radial Pulse II. Other Phenomena in Arteries .... Examination of the Veins Inspection and Palpation of Veins .... 1. Increased Fulness of Veins .... 2. Phenomena of Circulation in the Jugular Veins 3. Phenomena of Circulation in Other Veins . 4. Venous Thrombosis Auscultation of Veins Examination of the Blood Preliminary Remarks 1. Color and Spectroscopic Character of the Blood 2. Microscopic Examination of the Blood blood PAOE 197 197 200 202 204 204 205 205 208 210 210 211 211 216 221 229 230 234 234 234 234 237 241 241 245 253 260 260 260 262 267 268 268 270 270 270 273 CHAPTER VI. EXAMINATION OF THE DIGESTIVE APPARATUS. Mouth, Palate, and Pharyngeal Cavity Examination of the (Esophagus 284 291 CONTENTS. xiii PAGE Examination of the Stomach , . 297 Anatomy of the Stomach 297 Inspection and Palpation of the Stomach . . . . . 299 Percussion of the Stomach 304 Auscultation of the Stomach 307 Examination of the Intestines 308 Inspection and Palpation . . 308 Percussion of the Intestine 311 Auscultation of the Intestine 312 Examination of the Peritoneum 312 Inspection of the Abdomen 313 Examination of the Liver . . . . . . . . .319 Inspection of the Liver 320 Palpation of the Liver 323 Percussion of the Liver 326 Examination of the Spleen . . 332 Inspection of the Spleen 834 Palpation of the Spleen 334 Percussion of the Spleen 336 Auscultation of the Spleen 339 Examination of the Pancreas, Omentum, Retro-peritoneal Glands . 340 Examination of the Contents of the Stomach ..... 841 Examination of the Process of Digestion ..... 342 Stomach-digestion and its Disturbances . . . . . 342 Mode of Procedure in Examining the Stomach-digestion . 347 Vomiting, and the Examination of What is Vomited .... 358 The Vomit 359 Animal Parasites ........... 377 CHAPTEE VII. EXAMINATION OF THK URINARY APPARATUS. Examination of the Kidneys . . . . . . Anatomy ........... Local Examination of the Kidneys ...... Pathological Conditions of the Kidneys Examination of the Ureters and Bladder ..... Examination of the Urine ........ (A) Normal Urine (B) Pathological Urine Sediments of Organic Bodies, or Direct Products of These Inorganic Sediments ....... Examination of the Urinary Constituents in Solution . Bile-pigments and Bile-acids ....... The Urine as Affected by Medicines 392 392 394 394 398 399 401 406 416 428 433 442 450 XIV CONTENTS. CHAPTER VIII. upon EX.VMINATIOX OF THE NERVOUS SYSTEM. Anatomy; Normal and Pathological Physiology .... 1. The Cortico-muscular Tract (the Pyramidal Tract, Flechsig) 2. The Sensitive or Centripetal Tracts .... 3. Centres and Tracts of the Special Senses 4. Remarks upon the Vessels Supplying the Brain . Symptomatology and Methods of Examination Examination of the Seat of Disease .... The Spinal Column ........ The Peripheral Nerves and their Surroundings Examination of the Condition of the ]\Iind . Disturbances of Sensibility 1. Sensitiveness to Peripheral Irritation .... [a) Sensibility of the Skin [b] Deep Sensibility . The Knowledge of Form (Stereognosis) ... 2. Sensible Phenomena of Irritation and Pain from Pressure Nerves 1. Parsesthesia . 2. Spontaneous Pain 3. Distribution of the Sensory Cutaneous Nerves . Disturbances of Motility 1. Paralysis ......... 2. Disturbance of the Nutrition and Tone of the Muscles 3. The Reflexes 1. Skin Reflex 2. Tendon Reflexes (periosteal, fascial reflex) . Electrical Examination of the Nerves and Muscles . Regarding the Physics, and the Instruments Employed Methods of Examination and their Physiological Results the Living Human Body General Methods, and Explanation of the Terms Employed in Galvanic Examinations ..... Method of Examination in Detail. Normal Condition 1. Points of Stimulation 2. Examination (a) Faradic Examination . . . •. {b) Galvanic Examination .... 3. What to Observe in Determining the Electrical Re- action . . . . r . . . Faradic Current Galvanic Current 4. upon PAOE 452 452 459 460 461 463 463 467 468 469 472 472 473 479 481 482 482 482 484 488 488 489 495 495 497 501 501 505 506 507 508 510 512 515 516 517 517 coNTEyrs. XV and 1. The Reaction of Degeneration (EaE) (a) Complete EaR [b) Partial EaR . . . Varieties of EaR (e) Mixed Electrical Reaction 2. Myotonic Reaction (Erb) 3. Diagnostic Value of the Electrical Condition 4. Mechanical Excitability of Muscles and Xerves 5. Coordination and Ataxia .... 6. Spasms of the Voluntary Muscles 7. Voluntary Muscles, their Innervation, their Function, the Diseases that Disturb Them Disturbances of Speech (Lalopathy) I. Dysarthria and Anarthria II. Aphasic Disturbances, Disturbance of Graphic Communica- tion (of Mimicking and Singing) Mode of Procedure in Testing for Aphasic Disturbances Sense Organs .......... Disturbances of the Vegetative System in Xervous Diseases . 1. General Phenomena ...... 2. Disturbances of the Respiratory Apparatus 3. Disturbances in the Circulatory Apparatus . 4. Disturbances of the Digestive Apparatus 5. Disturbances of the Urinary Apparatus 6. Disturbances of the Genital Apparatus 7. Disturbances of the Skin ..... Bones and Joints ....... The Diagnostic Value of the Symptoms in Xervous Diseases PAGE 519 619 519 523 523 524 524 526 527 530 536 548 548 549 555 561 575 575 575 576 577 579 580 581 583 583 APPENDIX. 1. Laryngoscopic Examination of the Larynx 589 Paralysis of the Muscles of the Larynx ...... 597 2. Examination with the Ophthalmoscope ...... 600 3. Bacteria which come under Consideration in the Diagnosis of In- ternal Diseases 602 E UK AT A. Page 307, line 9 from the bottom, ./y?- "making" read "striking." Page 831, line 11, insert "lobe" after "right." Pajre 344, line 8. for "and thereafter" read "or at most." Page 406, paragraph "3" should be as follows: "3. When the exudation or transudation in the serous cavities of the body, or the fluid in the cellular tissues (oedema), is resorbed, the daily excretion of urine sometimes amounts to four thousand grammes or more. The increased arterial pressure from quickening of the action of the heart, which occurs at the same time, is also a jiroini- nent factor in producing polyuria." (Paragraphs "3" and "4" should be renumbered so as to read "4" and "5" respectively.) Page 419, line 11, for "In lu^moglobin" read "In hnemoglobin- uria." Page 425, line 20, foi' "trichoma" read "trichomonas". Page 448, at the bottom of the page, not constituting a separate paragraph, should be added the following : " Legal (cited by Jaksch) has devised a test for acetone which is a useful preliminary one : Several cubic centimetres of urine are treated with a few drops of a concentrated solution of sodium nitroprusside and somewhat concen- trated liquor potasscC. If acetone be present, a bright-red color is seen, which quickly fades, but upon the addition of some acetic acid changes to purple or violet-red." Page 455, last line, for "of the spinal cord" read "the nerves of the spinal cord." Page 461, line 8, the words "The sense of taste" should begin a new paragraph, which should be preceded by "(d) Taste." Page 479, line 11, /or Paranyesthesia" read "Para-aneesthesia." Page 529, line 12 from the bottom, /or "corpus" read "corpora." Page 539, line 5 from the bottom, /or " push'' read " pushing." Page 558, line 16, /or "as" read "and." MEDICAL DIAGNOSIS. PART I. CHAPTER I. INTEODUCTION. The physician arrives at an opinion regarding his patient in two ways : by inquiry of the patient or of friends of the patient, and by his own objective examination. The result of the former is called the Anamnesis; the latter reveals the Present Condition of the Patient. The notes which the physician makes from time to time in the course of his continued observation of the patient, and in which he records the changing phenomena of the disease, constitute the History of the Case. The judgment formed in this way is expressed by the Diagnosis. In a narrow sense such a judgment simply consists in giving a name to the disease that is found; or, if there are several diseases together, or special complications of one, names to several diseases. But in the wider sense, a diagnosis must always consist of something more than this. The physician must endeavor to form a clear conception, in a given case, as to how the whole organism has been affected from the beginning, what is the character of the disease, or what harm it has wrought already in the organism as a whole, as well as locally. If in the narrow sense the diagnosis is schematic, so that the disease can be classified, then the diagnosis is in a broader sense indi- vidualized. A complete, exhaustive presentation of the peculiarity and severity of the existing disease and of the patient's prospects 2 (17) 18 MEDICAL DIAGNOSIS. (prognosis) is presented only by this method. This alone is a sure guide in treatment. "We attain to a diagnosis in this wider sense only by having our perception of the general behavior of patients quickened and by carefully combining with it the experience derived from previous examinations. Since the chief object of this work is the teaching of the examination of patients and the presentation of the methods of conducting it, we begin with but a very few words in regard to obtaining the Anamnesis. What is it necessary for the physician to know, beyond what his examination reveals, in order to recognize a given disease in itself and to form a critical judgment regarding the patient in a larger sense ? It is difficult to define this. Facts which appear insignificant in themselves in experience often exercise a decided influence upon the special diagnosis, and especially in forming a judgment regarding the constitution of the patient, or upon the timely recognition of a secondary disease. From having at hand clear knowledge of the symptoms of the difi'erent diseases, both of their remote or predisposing and of their directly exciting causes, the physician is constantly able to select what 15 essential from the past, and so to avoid too great prolixity. But it is always well for the beginner to secure as com- plete an anamnesis, or prior history, as possible, in order that he may allow nothing of importance to escape his attention. The anamnesis generally begins with and involves the question as to whether the disease is acute or chronic, what organs are affected, or are inclined to be diseased. This determines the examination to follow, in that certain organs are examined with greater exactitude than others. But the examiner must guard himself from too great influence or prejudice from the result of the anamnesis ; the objectivity of the objective examination must be kept in view ; and this, in turn, may give occasion for supplementing the anamnesis, by occasioning additional inquiries regarding certain occurrences and appearances, and thus a conclusion is finally reached. It is advisable for the student, under all circumstances, with all the patients he examines, and for the physician at least with his more important cases, to note INTRODUCTION. 19 down in regular order the results both of the anamnesis and of his examination. (See Translator's note, page 24 et seq.) Mode of Taking the Anamnesis. First, we always note the name, occupation, age, residence of the patient. Then we conduct, as simply as possible, a dialogue with the patient, or in the case of a child or of a person who is insensible, unconscious, or mentally disturbed, with his neighbors or relatives. How much we may allow them simply to tell, how much we must learn by asking questions, must depend upon the cultivation and intelligence of the person who is giving the information. We must particularly guard against asking the patient leading questions — that is, influencing his reply by the manner in which we put the questions. To the question : " Have you then really never had any pain in the bowels ?'' or, " Did you never have any pain in the bowels ?" we shall almost certainly receive an affirmative answer, either from indiiference, or from a desire to make his complaints as interesting as possible and enlarge upon them ; or, lastly, whether because he is of a very impres- sionable nature, and the mere calling to mind the question of pain suggests to him what in reality he has not had. On the other hand, we must exercise close scrutiny of what we learn, a scrutiny which it is generally best not to allow the patient to know of. This scrutiny may be made with reference- to three points : (a) We must not accept without further inquiry the name the patient gives to a disease he has formerly passed through, since mis- chief is often done by the laity in the use of the names of diseases, as of diphtheria, typhus, etc. In any doubtful case we inquire its symptoms, and also what the physician who attended the patient had called the disease. (b) The simulation of a disease is common. This was confined in large part to the domain of hysteria ; but, now-a-days, from certain social reasons, it is much more frequent. Neuralgia, rheumatism, trembling, spasms, lameness, also pains in the bowels, asthmatic attacks, are the conditions which are most often simulated. The attempt to deceive is made not only with reference to the anamnesis, but also during the objective examination. (c) The concealment of the appearances of disease is manifest with reference to the different sexual diseases, especially syphilis. Women, 20 MEDICAL DIAGNOSIS. moreover, often attempt to avoid all statements in regard to the sexual apparatus, even when it alone is diseased. Inebriates, and those who practise onanism, often confess their habits to the physician only with great reluctance. What the Anamnesis Comprises. The exact knowledge of the etiology and symptomatology of internal diseases is here the only correct guide, and, at the same time, gives us complete information respecting the cases which, under various cir- cumstances, come under consideration. We are content with indi- cating the essential point of view by the introduction of a few examples. AVe may divide every anamnesis into the following two parts : I. Previous history of the patient : This comprises all that it is important to know up to the beginning of the disease on account of which the patient consults the physician. II. The present disease : This relates to the exciting causes, the commencement, and the course to the present time. Previous History of the Patient. 1. hereditary disease (heredity). This is of importance in so many diseases that in each and every case we have to inquire regard- ing the parents, brothers and sisters of the patient, and also very often regarding the brothers, sisters, and parents of the parents. There especially come into view in this connection, syphilis, tuberculosis, diseases of the brain, and certain general neuroses. Heredity, as regards rheumatism, carcinoma, and diseases of the heart, is of sec- ondary importance, yet not immaterial. These diseases are in part inherited as such, in part they confer upon the descendants only the organic foundation, the disposition to the new development of the same or related diseases. Different descendants are variously divided by heredity. Often individuals, or a majority, are wholly exempt. It also happens that one generation is entirely passed over, and the trouble reappears in the following' generation (hence the question regarding the grandparents). Of the infectious diseases, smallpox and syphilis can, without INTRODUCTION. 21 doubt, be conveyed in utero; but the intra-uterine communication of tuberculosis from the mother to the child is extremely improbable. 2. The manner of life, habits, profession, occupation, residence, experiences as to fatigue, other harmful influences to which they have been exposed, whether they have descendants, and, in the case of women, the number and character of their confinements, compose this group. Under the manner of life are considered the diet, character of dwelling, and the clothing. Injurious habits play a very important part in the manner of life, especially immoderate use of alcohol and tobacco ; so, also, venereal excesses must be taken into account. But it is important to remember that, at least within certain limits, the harmful limit of these things differs with the individual. Profession and occupation on the one hand affect the whole consti- tution, and on the other are often to be regarded as predisposing or exciting causes of disease ; finally, they may exert a favorable or an unfavorable influence upon the course of an existing chronic disease. Thus, for instance, stonecutters and polishers, by continually inhaling fine dust from the stone, are very frequently inclined to bronchial attacks and diseases of the lungs ; thus, too, the occupations that have to do with lead (type-setting, type-polishing, painting), or with mer- cury (making mirrors, etc.), frequently cause chronic poisoning by these metals. Persons who are engaged about sheep, swine, horses, or with the fresh skins and hair of these animals, are apt to have malignant pustule and other diseases. The place of prior residence is to be considered with reference to miasmatic (intermittent), endemic diseases, or epidemics which may have prevailed there at that time. With travellers, exotic diseases, which less frequently occur in their native places, as lepra, certain exotic animal parasites, etc., must be thought of. As regards fatigue, army marches are to be regarded as particularly fruitful sources of disease ; so of exposure to harmful influences. A fall, slight, perhaps, but whose effects continue ; or a wound, without other immediate sequelae except that it does not heal — of these, account must be taken ; and also of very harmfiil momentary experiences, as sorrow, care, severe fright, anxiety. Where there is sterility we consider anomalies of the sexual apparatus of the man or woman, but especially the question of syphilis. The 22 MEDICAL DIAGNOSIS. puerperal period, even when it does not pursue an unfavorable course, may in vaiious ways be a source of disease. 3, Diseases which one has had, not- only acute diseases, but the temporary outbreak of a chronic disease ending in apparent or real recovery. Certain acute diseases may have as sequelae certain other diseases which either are directly connected with them, as paralysis following diphtheria, nephritis after scarlet fever ; or which appear after a shorter or longer period, as valvular disease of the heart from endo- carditis in acute articular rheumatism, arising during scarlet fever. The outbreaks of a chronic disease are often spoken of by patients as diseases which they have gone through ; as, especially, the primary and secondary affections of syphilis, temporary manifestations of tuberculosis of the lungs, etc. This point is of special importance in two ways : 1. There are certain acute diseases which one does not easily have a second time, as scarlet fever, measles, typhoid fever. On the other hand, others readily occur again, as erysipelas, pneumonia, articular rheumatism, typhlitis. 2. Certain diseases of childhood are especially to be con- sidered — for example, scrofulosis as early indications of tuberculosis ; manifestations of hereditary syphilis ; frequent convulsions as an early sign of anomalous condition of the nervous system. The dis- eases ordinarily designated as "children's diseases" generally have no significance as to the future, but yet sometimes, unfortunately, they leave lasting suflFering behind them, as emphysema after whooping- cough, etc. The Pkesent Disease. 1. The possible exciting causes must be first considered. It is especially important for the early diagnosis of an infectious disease to inquire whether the patient has been exposed to infection. Many diseases are conveyed by a very short exposure, others require a longer, or even a personal contact. Also the period of incubation must be considered. This is the period from the moment of infection until the outbreak of the disease. With most transferable diseases this period is of a known, somewhat exactly defined duration. More- over, "taking cold," over-exertion, improper eating and drinking, taking of poison, etc., come under consideration. INTR OD UGTION. 23 It is to be remarked that the laity often assume something as an exciting cause, thus especially "taking cold." 2. The first appearances and the course of the disease up to the time of examination. With chronic diseases the first appearances are sometimes at the beginning scarcely noticeable : they often consist only in a change from the previous behavior, unless the new condition in itself directly appears to be one of disease ; a person who previously had red cheeks becomes paler (all kinds of wasting diseases), a stout person without other reason becomes thin, one who always previously ate and drank little, all at once eats and drinks considerably (diabetes), a person formerly very orderly becomes disorderly, forgetful (disease of the brain, especially progressive paralysis). Even when they have made considerable progress, such gradually developing disturbances often are not at all noticed by ignorant and indifferent people. # CHAPTER II. EXAMINATION OF PATIENTS. The examination of the patient comprises : 1. A general examination, -which takes into account certain phe- nomena of disease vrhich concern the organism as a whole, and are the expression of a pathological change of the whole organism. 2. A special examination, which inquires into the different regions and organs, the secretions and excretions of the body. At the bed- side we generally proceed in such a way that, beginning at the head, we gradually go downward, in order to facilitate the investigation by examining contiguous organs. But in many cases it is better to group together organs that are functionally related, no matter what their anatomical location may be, since we thus quickly obtain a compre- hensive view of the way in which the affected organs or systems are disturbed. Thus, in diseases of the heart, the heart and bloodvessels, in diseases of the nervous system, the central and peripheral nervous systems are examined together. Sometimes, as in the case of very weak or very unruly patients, as children, the examination of the body must be very brief. Here the expertness of the physician espe- cially is put to the test to the utmost degree. It will best answer the purposes of study if the division of the subject throughout strictly conforms to the organ-systems, and hence the special part is divided into : I. Examination of the respiratory apparatus. II. Examination of the circulatory apparatus. III. Examination of the digestive apparatus. rV". Examination of the urinary apparatus, including also in part the sexual apparatus. V. Examination of the nervous system. [note by the translator upon keeping records of cases, and a form for recording the results of a medical examination. It is not practicable at the bedside to go through any set form for conducting the inquiry regarding the present illness. The most direct f24) EXAMINATION OF PATIENTS. 25 way of getting at it, and the one that will lead to the most satis- factory replies to our interrogatories, is to ask the question. What is your complaint ? How are you sick ? or some such direct question as this. In this way we get at once at the disease we are called upon first to diagnose and then to treat. As we proceed we will arrange the facts in our minds, and when we make the record, we shall place them in a: natural and logical order. Having a regular form for keeping records of cases soon develops an order of procedure in accordance with it. Case-taking is a most valuable aid to the student in clinical study. 1. He learns to make a systematic examination of the patients he sees. He forms the habit of bringing before his mind each factor in the case in orderly succession. There are two advantages from this. First. He forms the hahit of thoroughness in examining his cases. Second. He can readily compare one case with another — having ' arranged the factors of each in like order. While it is not necessary in making the examination to have or to follow strictly a printed form, yet it is desirable to have some regular form for making the record, so that cases that are similar can be readily compared. One case may require going over only a few points, in another it will be necessary to examine every organ in the body. 2. The memory is greatly strengthened. Memory depends upon attention and repetition. Case- taking cultivates both of these in an eminent degree. Facts and symptoms that else would escape notice entirely, or be only slightly noted, are brought prominently before the mind for consideration. Their value or bearing is weighed, and so they are strongly impressed upon the mind. 3. The mind is developed by this habit of carefully reflecting upon every feature of a case. Thought is both stimulated and made easy. Clearness and power of thought are increased. Independence of judgment is cultivated. Both knowledge and intellectual cultivation are acquired. " By knowledge is understood the mere possession of truths ; hy intellectual cultivation, or intellectual development, the power, acquired hy exercise of the higher faculties, of a more varied, vigorous and protracted activity." (Sir William Hamilton.) 4. Ease and habit of writing are almost unconsciously acquired. This is most valuable. The great majority of physicians keep no records of cases. Many never record or publish important ones, 26 MEDICAL DIAGNOSIS. because they have not the facility of writing which comes with prac- tice. Anythiriji is emy to the practised hand. " Who can estimate how much we have lost, from the fact that generations of men gifted with powers of acute and shrewd observation, have passed away without leaving one record behind them ? Think not that it is the hospital physician or surgeon alone who can advance the progress of medicine. There is not a practitioner who could not aid this great work. But he can only add to it with efficiency if he has faithfully recorded his observations^ and does not trust to the general and vague impressions of unassisted memory. Therefore, on all grounds, per- sonal to yourselves and general for medical science, so engrain this habit within you that it becomes a second nature." (Coupland.) The Axamxesis. Personal and Previous History. Name, Address, Birthplace, Age, Sex, Family history — Heredity : Father, Mother, Brothers, Sisters, Other relatives. Manner of life, habits, occupation, residence, etc., Previous diseases — character and results. (Xote each one that was of such a character as to have any lasting eflfect upon the health or vitality.) Present Illness. Duration, Possible exciting cause, How began — suddenly or not ; prodromal symptoms, Course of the disease till the time of examination. EXAMINATION OF PATIENTS. 27 Examination of the Patient. General examination : Appearance, Psychical condition, Position in bed, Structure and nutrition, Skin and subcutaneous tissues, Temperature, Pulse. This covers the general features of every case. Attention has been directed, by what has been learned thus far, to some one or more of the special organs or systems of the body. It is usually best first to examine that, and to make this examination very full and thorough. Then the remaining organs of the body can be examined with greater or less fulness, according as they are found to be affected by the principal disease, or as they are related to the one specially diseased. It is well to form the habit of following a certain order in examining each organ. One is much less apt to overlook any part ; and, too, as has already been pointed out, the records will be more easily con- sulted and compared. For this purpose, it is well to take the order of the text-book, so as to become thoroughly familiar with each subject. It is not of so much importance that this or that one is adopted, pro- vided it is a good one. But we have here a notable illustration of the truth and value of the Spanish proverb: " Beware of the man of one book." Presuming that those who use this work will follow the order laid down in it, the form now given conforms with the order in which the systems are treated. Special ExAMiyATiox. Examination of the respiratory apparatus : Nose, Mouth, Larynx. 28 MEDICAL DIAGNOSIS. Examination of the lungs : Inspection of thorax, Palpation of thorax, Percussion of thorax, Auscultation of lungs, Auscultation of voice, Measurement of thorax, Cough and expectoration. Examination of circulatory apparatus: Inspection and palpation of the region of the heart, Percussion of the heart, Apex-beat, Auscultation of heart, Examination of the arteries and veins. Examination of the blood. Examination of the digestive apparatus : Mouth, gums, and pharynx, Stomach, Intestines, Peritoneum, Liver, Spleen, Pancreas, Contents of the stomach and vomited matters. Feces. Examination of the urinary apparatus : Kidneys, Ureters and bladder. Examination of the urine: Amount in twenty-four hours. Reaction, Odor, Specific gravity, Sediment, Albumin, Blood, Bile, Sugar, Other constituents. . EXAMINATION OF PATIENTS. 29 Examination of the nervous system : Disturbances of sensibility, Location of, Superficial or deep, Motor disturbances, Disturbances of speech, Condition of the organs of special sense. PART 11. CHAPTEE III. GENERAL EXAMINATION. This consists of a number of subordinate divisions, namely: we have to consider : I. The psychical condition of the patient. II. The position in bed. . III. The general structure of the body and the nutrition. IV. The skin and the subcutaneous cellular tissue. V. The temperature and the pulse. I. The Psychical Condition of the Patient. From this — that is, from the clearness of his intelligence, his sus- ceptibility to external impressions, his power of thought, from the possible presence of depression or irritability — we may often obtain important points of diagnosis ; both for diagnosis in the narrower sense, certain diseases being accompanied with definite manifestations of this kind, and for diagnosis in a broader sense, since the severity of a disease, the possible turn for better or worse, often becomes manifest by the psychical condition of the patient. (Regarding this and the way in which the examination in this direction is conducted, see the section on " Examination of the Nervous System.") II. The Position of the Patient. This furnishes a very simple aid to diagnosis, because generally it can be determined by a single glance of the eye. From it conclusions in various directions may be drawn. People in health or only slightly sick usually assume the dorsal position, or a position upon one side, (31) 32 MEDICAL DIAGNOSIS. in a certain unconstrained comfortable position (the active dorsal or side position). On the contrary, patients who either are not wholly conscious, or who have become very weak, frequently are inclined to slide down toward the foot of the bed and sink into a heap there, a position which manifests weakness, and in some respects, but espe- cially for breathing, is very unfavorable (the passive dorsal and side position). In acute infectious diseases, more than elsewhere, the passive dorsal position is specially noteworthy. It is particularly so when apathy and clouded intelligence are combined with great muscular weakness, as is frequently the case in typhoid fever, where such a condition of the patient is so frequently and sometimes early present that it may aid in the diagnosis. But in still another way the position in bed is sometimes charac- teristic. Patients with acute affections q/ the chest organs involving only one side (pneumonia, pleurisy, pneumothorax) generally lie upon the side, and for the most part upon the side affected. This may be due to various causes. The pain caused by breathing is generally in this way diminished, because by lying upon the side the motion of that side is very much lessened, while, on the other hand, the motion of the opposite side in breathing is greater than when the patient lies upon the back ; hence the sound side, when the patient lies upon the diseased side, can better compensate for the loss of the portion diseased. In exudative pleuritis frequently there is the further advantage in lying upon the affected side that the exudation least interferes by pressure with the healthy side. Yet patients with pneumonia not infrequently lie upon the healthy side, because they have least pain in this position. That in diseases of the chest in general patients are inclined at the beginning of the disease to lie upon the sound side, and later upon the diseased side, I am not able to affirm. Difficult breathing, dyspnoea, if extreme, prompts one to assume the upright sitting posture in bed or in an easy chair — orthopnoea ; because in this attitude the action of the accessory muscles of respira- tion is more effective than when lying down. Orthopnoea may, there- fore, occur with all diseases which are accompanied with marked interference with respiration : as in narrowing of the air-passages in disease of the lungs (comparatively rare with phthisis — see under GENERAL EXAMINATION. 33 "Dyspnoea"), in diseases of the pleura, heart, pericardium, with lai'ge effusions into the abdominal cavity, which press the diaphragm up ; and in general dropsy with effusions into the cavities of the body. In the severest cases the patients may indeed be obliged to keep the sitting posture, even to sleep. The continued exertion of sitting and the diminished sleep obtained in this position, besides the great anxiety and excitement these patients generally have, usually quickly bring on exhaustion. Another group of characteristic situations and positions in bed refer to diseases of the hraiyi and its membranes. Thus meningitis betravs itself often at the first glance by opisthotonus, with the head boring into the pillow, so-called contraction of the neck ; in circumscribed disease of the cerebrum the head is sometimes persistently inclined to be drawn forcibly to one side : forcible contraction of the head ; in affections of the cerebellum, also of the crus cerebelli, we not infre- quently see the whole body continually, as one lies in bed, drawn sharply to one side, and, when turned over to the dorsal position, returning immediately again to this constrained position. These phenomena, however, are in part to be reckoned as convulsive con- ditions, which indeed bring about the greatest variety of characteristic positions and attitudes of the body. These latter, however, are gener- ally quite transitory. III. The Structure of the Body axd Nutritiox. The development of the skeleton determines the form of the body. Generally firm bones and broad, flat chest are characteristic of strong and enduring health : while those persons of delicate skeleton, espe- cially with slender ribs and narrow chest, are considered capable of both limited life and endurance. Yet this is only a general rule. "\Ye often see people of delicate build who are remai'kably tough and endurins:, both with reference to exertion and disease ; and not infre- quently we find robust people with little power of resistance, especially to acute diseases. Unusually small development of the skeleton is often observed in idiots and cretins ; and, in more rare cases, in dwarfs, without any other anomaly. The form of the thorax is of especial importance. With a slight 3 34 MEDICAL DIAGNOSIS. and narrow chest-cavity there is a proportionally frequent disposition to tuberculosis of the lungs ; and, on the other hand, a certain fulness carries with it a tendency to emphysema of the lungs. This will be more particularly spoken of under Respiratory Organs. The significance of the structure of the pelvis is manifest in the practice of obstetrics. The muscles, the subcutaneous tissues, and the skin furnish a means of judging of the nutrition, and also of the weight. In general, well-nourished and healthy persons have a certain volume and firm- ness of muscles. There is also a relation between the muscles and the skeleton. But even in perfectly normal persons there is a very marked difference in the volume of the muscles, which is not always explained by differences of occupation. By experience the eye grad- ually becomes quick in recognizing a suspiciously small muscular volume ; yet the firmness of the muscles is a better guide to an opinion than their volume. The fat of the subcutaneous tissues may be very differently de- veloped in persons of good health. As a rule, it varies with the age, being greater for the first years of life up to the forty-fifth or fiftieth year. Beyond this it again, as a rule, becomes less. It also some- times varies in a shorter time without being caused by disease, as in women at about twenty years of age. It varies also, as a matter of course, with the kind and the richness of food, as well as Avith the occupation. Loose adipose tissue generally indicates a weak organization. A marked degree of leanness of the subcutaneous tissue is, under all circumstances, suspicious, and suggests an examination as to whether it may be caused by disease. In the same way the accumu- lation of fat beyond a certain degree becomes pathological. The measure or degree can only be established by experience. Of much greater importance is a commencing, even though a slight, wasting away of the subcutaneous fat, and eventually also of the mus- cles. As we have said, this is sometimes physiological. It can also take place, as among the poorer classes, from very poor nourishment. But in the majority of cases it is caused by disease, and it is, there- fore, important not to overlook it. This wasting can only really be learned by the physician when he has known the patient for some time. When this is not the case he must rely upon the statements of GENERAL EXAMINATION. 35 the patient and Lis surroundings, and, therefore, this subject properly belongs to the " previous history." When the emaciation is marked, its proof is furnished by the condition of the skin. In these cases the skin of the patient's whole body is loose, and can easily be taken up in folds. Excessive wasting is denominated atrophy, emaciation ; and when this is accompanied by general loss of strength and failure of function, marasmus or cachexia. The weight of the body is an excellent index and one which is superior to all other signs of corpulence, and its increase or diminu- tion. The absolute value of the weight of the body in the different periods of life has no diagnostic interest, for the reason that it varies within wide limits. Likewise the relation of the weight of the body to the height and the circumference of the chest has scarcely any significance for our purposes. On the other hand, change in the body-weight wrought by disease is of the greatest importance. In chronic diseases this is an extremely valuable means of determining whether the disease is increasing, standing still, or is being recovered from. Taking the weight regularly (say, weekly) in cases of tubercu- losis is especially to be recommended, also in diseases of the digestive apparatus. In convalescence from acute diseases, following the weight of the body is also a very important aid, especially for the early recog- nition of the possibility of the disease becoming chronic, or of the presence of associated chronic diseases. Moreover, in all these cases we must remember that oedema (which see) produces a deceptive increase in the weight of the body. According to Bernhardt (cited by H. Vierordt), the relation of the weight of the body, P, to the height, H (in cm.), and to the average circumference of the chest, C (measured at the level of the nipples, in cm.), for the average individual, may be reckoned as follows : ^ = (24^/ kilograms. The weight of the body of the newly-born and its increase during the first months is of special significance. Regarding this subject, see works upon obstetrics and diseases of children, also Dates and Tables, by H. Vierordt. Diseases of the alimentary tract, more than others, produce emacia- 36 MEDICAL DIAGNOSIS. tion ; next, all febrile diseases, whether acute or chronic (of the latter especially tuberculosis), then severe forms of diabetes mellitus, and, finally, all malignant growths. A certain degree of emaciation can be produced by any disease of an internal organ. IV. Skin and Subcutaneous Cellular Tissue. In medical diagnosis the condition of the skin and subcutaneous tissue is considered with reference to the following points : A. The condition of general nutrition. B. The moisture of the skin ; perspiration. C. The color of the skin. D. Certain pathological appearances of general diagnostic value (characteristic eruptions, hemorrhages, scars, etc.). E. The presence of oedema. F. Possible emphysema of the skin. Skin diseases proper and certain acute infectious diseases, with special localization upon the skin (the co-called acute exanthematous diseases) are not considered in this work. A. the state of nutrition of the skin. In old age the nutrition of the skin is diminished over the whole body. This is physiological. In earlier years a noticeable general atrophy of the skin exists only where there is a very severe cachexia. The skin is then thin and generally dry. It loses its tone, and when taken up in a fold resumes its place slowly. The different forms of circumscribed atrophy of the skin which have been described do not interest us here. They belong to works upon skin diseases. B. THE moisture OF THE SKIN ; PERSPIRATION, Physiology teaches us that the moisture of the skin, as well as the visible secretion of perspiration, is influenced by various circumstances. It is increased during active exertion, by increased temperature of the blood, by moist heat, by mental impressions, especially fear; finally, by certain ingesta, as hot tea, by pilocarpine, etc. GENERAL EXAMINATION. 37 In some of these cases there is at the same time an increase of heat of the body, which is overcome by the perspiration, cooling being caused by its evaporation. Perspiration is a regulator of the temperature of the body. The loss of water by evaporation (the greater part of the insensible perspiration) in health is, cceteris paribus, greater at night than during the day. It seems to alternate with the secretion of the urine. In healthy people the secretion of perspiration is in this way very changeable. But it is still more so in cases of illness. It may be increased to such a degree that the whole bed may be wet through (hyperidrosis). On the other hand, it may be so diminished (hyphi- drosis) that the skin is perfectly dry (anidrosis). Hyperidrosis of the whole body is called hyperidrosis universalis ; if confined to a part of the body, hyperidrosis localis. The latter may be unilateral (hemi- drosis). A general perspiration may take place in cases of illness : 1. When there are present conditions which are analogous to those which produce it in persons in a state of health, as in cases of strong tetanic convulsions by the increased muscular work and heart-action. On the contrary, in cases of epileptic, hysterical, and other convul- sions we have either no perspiration or at least none corresponding with the very great muscular exertion ; in all possible diseased con- ditions connected with great excitement, especially fear, or with severe pain; and again, sometimes (not always, see below under Anidrosis) from a high degree of atmospheric heat, warm baths, moist warm pack, or sudorifics (pilocarpine, etc.). Morphine, also, with some persons, induces perspiration, 2. In difficult hreatJiing — dyspnoea. This is generally connected with sweating. (In the same way sweating sometimes occurs with heart disease, accompanied by an engorged condition of the " greater" circulation ; also with all diseases of the respiratory organs and their surroundings, which interfere with respiration.) 3. In febrile diseases. Sweating usually occurs with the fall of the temperature in these diseases. The most important instances are (a) the critical sweat of a rapid definitive decline of the fever, espe- cially frequent in pneumonia and relapsing fever; (6) the sweat which regularly accompanies the fall of temperature in intermittent fever and pyaemia (diseases which manifest themselves by rapid rise 38 MEDICAL DIAGNOSIS. and fall of temperature), the night-sweats of the hectic fever of phthisis and the sweat of the remittent (hectic) fever of typhoid fever ; and (c) the cold sweat of collapse (that is, the sudden failure of strength in the death struggle). Acute articular rheumatum manifests itself by considerable perspi- ration, which may not depend upon a fall of temperature. Finally, there is always the inclination to perspiration in the commencement of convalescence from severe diseases and in parturient patients, when there is great weakness and the heart is easily excited. Local sweating occurs in various neuroses, also in organic diseases of the nervous system. Theie is very frequently sweating of the whole of one side (hemidrosis), or of the head alone, as in Basedow's disease, migraine, hysteria ; localized disease of the brain, and in mental diseases. Diminished secretion of sweat, even to complete anidrosis, is ob- served chiefly in high continued fever. It is, moreover, a peculiarity of all diseases which are accompanied with considerable loss of water by the bowels or the kidneys, of severe diarrhoea of any kind, con- tracted kidney, and diabetes. The anidrosis which exists with general dropsy, in consequence of the aniemia of the skin produced by the pressure and stretching, has a peculiar appearance. The anidrosis of high fever and general dropsy is very persistent, often resisting all therapeutic measures, both those acting directly upon the skin (moist heat, etc.) and the medicines already mentioned. Qualitative alterations of sweat exist sometimes in severe jaundice, when it contains the coloring-matter of bile and is yellow in color ; also, when the urinary secretion is greatly diminished or entirely sup- pressed, as in nephritis, diseases of the urinary tract, and cholera. It then contains considerable quantities of urinary products, which, by the evaporation of the perspiration, crystallize upon the skin (espe- cially upon the nose and forehead) in small white scales. This is called uridrosis, the scales giving the reaction of urinary ingredients. C. THE COLOR OF THE SKIN. As is well known, races difier in the color of the skin, but even in the Indo-Germanic race there are variations depending upon the stock, the climate (blonde, brunette). In some nations the pale, in GEXERAL EXAMIXATIOX. 39 others a more florid, complexion, especially of the face, prepon- derates. We know that there are differences depending on the mode of life : also that, even as regards the so-called healthy color of skin, considerable individual variations exist. But, after all, the hue of the skin stands in intimate relation to a large number of diseases of in- ternal organs. It is considered most suitable to judge from the color of the countenance, the portion of the skin most generally reddened ; and, since on every hand we have opportunity for practice, it is well to sharpen the eye for critically examining this part of the bodv. But the color of the countenance can sometimes deceive us {vide especially under "red skin "). and it is therefore advisable always to examine the mucous membrane of the lips, mouth, and throat.-^ and. besides, to glance at the color of the skin of a part of the bodv usually covered bv the clothincr. ^ye recognize the following abnormal colorations of the skin : 1. A pale skin. 2. The abnormally red skin, 3. The blue-red cyanotic skin. 4. The yellow skin of icterus. 5. The bronze skin. 6. The gray skin produced by nitrate of silver. 1. The Pale Skin. This can to a certain extent be physiological, especially in persons who spend little time in the open air. In these cases a glance at the mucous membrane gives further information. But one can be de- ceived regarding such persons, who, having exposed the face (also arms and hands) frequently to radiant heat, or to cold and heat in rapid succession, often have a local redness of face. This redness of face may arise from other causes (p. 41), Only experience can enable one to distinguish between physiological paleness and that produced by disease. The recognition of the latter is frequently aided in that it is associated with a grayish, yellowish color (see below). The color of the skin is produced by the fulness ^ The conjunctival mucous membrane is not included. It is not decisive, since many persons in whom the teguments are elsewhere pale, at times have the conjunctiva easily injected. 40 MEDICAL DTAGXOSIS. of its capillary vessels. The abnormal paleness may be dependent upon disturbance of the circulation (and in consequence of diminished force of the heart or active narrowing of the peripheral arteries), or by a lessening of the quantity of the blood constituents, chiefly of the haemoglobin. "\Ye distinguish : (a) Temporary paleness, which is partly physiological and partly pathological. It occurs with strong emotion, especially fright ; in syncope or fainting ; in the chill of fever, which ordinarily accompanies a rapid, considerable elevation of temperature ; and in spasm of the capillary vessels, (b) Paleness lasting a longer or shorter time. This comes on sometimes quite rapidly, at least in the course of a few moments, during profuse hemorrhage and in sudden collapse — that is to say, in sudden failure of the heart as it occurs in acute, and sometimes chronic, diseases, and in acute poisoning. It is accompanied by a rapid and small pulse, increasing weakness, and, finally, loss of consciousness. Where there is external hemorrhage the condition is perfectly plain. But cases of severe internal hemorrhage, especially of the stomach or bowels, of ruptured aneurism, hemorrhage from internal wounds of any kind, are declared only by this sudden paleness, sometimes even before the patients themselves, if quiet in bed, complain of weakness. In a case of endocarditis which I saw, the patient became pale, as one does from an internal hemorrhage, Avith increased frequency of pulse and stupor, within less than ten minutes. At the autopsy there was found a recent total rupture of an aortic valve. This paleness can develop more slowly, within a few hours or days, by considerable repeated hemorrhages ; as a symptom of weakening of the heart's activity in all acute and chronic diseases of the heart and pericardium ; also in diseases of parts adjacent to the heart, as pleurisy and abdominal affections, with much pressure upon the dia- phragm, in case they interfere with the action of the heart ; finally, in many acute diseases, especially in diphtheria, in heart-failure from diseases affecting the muscular structure of the heart ; and very often, and in a very striking way, in acute catarrh of the stomach (acute dyspepsia). Finally, paleness of the skin comes on in certain conditions gener- ally unnoticeable, insidious, and is a chronic condition : in the so-called special diseases of the blood and of the blood-making organs — indeed, most unfortunately, from a diminution of the haemoglobin; hence, in GENERAL EXAMINATION. 41 chlorosis, also in pernicious anaemia, leukgemia, pseudoleukgemia. In this list also probably belongs malarial cachexia. Paleness is a symptom of all slowly-developing secondary ancemias (cachexia) as they occur in a large number of diseases, such as all chronic febrile diseases, especially tuberculosis ; in suppurations without fever ; in continuing slight hemorrhages, as in many tumors and in anky- lostoma [Egyptian chlorosis] ; in all chronic diseases of the digestive tract ; in most diseases of the female generative organs ; in the dif- ferent forms of chronic nephritis, especially the large white kidney ; in chronic poisoning, especially by mercury and lead ; sometimes, also, in constitutional syphilis ; in malignant growths, especially in cancer proper ; and in chronic diseases of the heart, but especially in fatty heart and mitral and aortic stenosis. In most of these conditions there is, moreover, not only paleness of the skin, but its color has a still further characteristic appearance. In severe anaemias we often have a peculiar waxy appearance, which not rarely has a yellow tone. A striking, light white skin often exists with the so-called large Avhite kidney, also in a certain proportion of the cases of lead-poisoning (which latter is often of a grayish white), of leukaemia and of tuberculosis. In chlorosis the skin has a greenish hue ; in diseases of the heart-muscle and in mitral insufficiency the skin is generally a smutty yellow, while in the cachexia of cancer it is often gray-yellow. In striking contrast is a large development of adipose tissue in cases of most marked paleness. This is very often so in diseases of the blood-making organs and in heart diseases. (It is not to be mistaken for oedema, vide under (Edema.) 2. Abjiormal Redness of Skin. This is an expression of a superfluity of normal blood, since a genuine plethora does not necessarily give rise to such a condition. G-eneral abnormal redness of the skin exists as a sign of hyperaemia of the cutaneous capillaries in high fevers — especially in continuous fevers. It also is present during the perspiration following a warm bath. Finally, in poisoning with atropine, even in very mild cases, it is developed like the redness of scarlet fever. (The scarlet-fever redness, being connected with a disease of the skin, dx)es not belong here.) 42 MEDICAL DIAGNOSIS Local redness, depending upon a dilatation of the capillaries, exists very frequently in the face, and indeed is physiological in those who labor in the sun. It comes and goes quickly, as in blushing (rubor pudicitiae), in nervously excitable persons in consequence of very slight psychical impressions, also not infrequently as a result of physical exertion. Moreover, Ave see redness of the face in fever ; finally, one-sided redness of face in the "paralytic" form of hemi- crania. Tuberculosis is characterized by a very marked variation in the fulness of the capillaries of the face : if the patients are entirely at rest and without fever they are generally pale, but under excitement or exertion, after eating, and, lastly, during fever, they exhibit a very striking, generally bright, redness of the cheeks, and often a sharply- defined spot (hectic redness). In the slight forms of anaemia, especially if it is associated with nervous irritability of heart (likewise with local vasomotor disturb- ances), there is sometimes intense redness of the face which may con- ceal the anaemia from the physician. For distinction of circumscribed hyperteraia from hemorrhage in the skin, see under the latter. 3. The Blue-red Skin, Cyanosis. This is most plain on the parts that normally are bright red, hence more than elsewhere on the mucous membranes, on the lips, cheeks, etc. ; also on the knees, the phalanges of the fingers, and under the finger-nails. A moderate degree of cyanosis, therefore, would only be discovered at these parts. A marked degree, on the other hand, exhibits a blue color spread over the whole body, while those parts, especially the mucous membrane, become black -blue. The cyanosis of the newborn, with heart-failure, is so striking to the experienced observer, that it is regarded by him as pathognomonic. One only sees anything like it in the death agony, and, exceptionally, in severe spasms with marked interference with breathing. The combination of cyanosis with great paleness is designated as " livid skin." Cyanosis arises from the blue-red color of the capillaries, and this, as is well known, is caused by an accumulation of carbonic acid and GENERAL EXAMINATION. 43 deficiency of oxygen — that is to say, by the venous or hypervenous character of the capillary contents. Carbonic acid in the blood (serum and red corpuscles) arises from : 1. Interference with the exchange of gases in the lungs. 2. From the slowing of the capillary circulation and the consequently dimin- ished gas-exchange in the tissues, that is to say, the diminished giving up of CO2 by the tissues to the blood. Cyanosis arises, therefore : 1. In disturbed respiration and circula- tion through the lungs ; 2. In disturbance of the " greater circulation," which may be general or circumscribed according as the stoppage may be general or local. The two causes may be combined. Here belong to 1 : (a) All conditions which cause a narrowing of the larger air- passages or of a large number of small bronchi : inflammation of the neighborhood of the pharynx or entrance to the larynx ; retro- pharyngeal abscess, angina Ludovici ; very exceptionally a diphtheria of the throat. (In all of these cases the interference with respiration is either direct or dependent on oedema of the glottis.^) The following are enumerated : spasm of the glottis, paralysis of the dilator of the glottis (crico-arytenoideus post.), all acute and chronic inflammations of the larynx, but especially croup ; tumors of the larynx ; cicatricial narrowing of the larynx ; foreign bodies in the larynx (something swallowed or vomited) ; also foreign bodies, croup and scars in the trachea or one or both primary bronchi, compression of these from without by enlarged glands, aneurism of the aorta, etc. ; mediastinal tumors, etc. ; bronchial spasm ; and severe diff"use bronchitis, espe- cially the acute croupous form. (b) All diseases of the lungs and diseases in the neighborhood of the lungs which hinder their expansion or wholly compress them: emphysema of the lungs ; all forms of consolidation ; pleuritic and great pericardial exudation, pneumothorax ; tumors in the chest- cavity ; abdominal diseases with marked upward pressure of the diaphragm. (c) Paralysis of the respiratory muscles : bulbar paralysis, periph- eral neuritis; paralysis of diaphragm from peritonitis; spasm of the 1 A very distressing case of suffocation from the lodgement of a large piece of meat in the pharynx, and the consequent closure of the entrance of the lai-yux, presented itself at the Leipzig medical clinic. 44 MEDICAL DIAGNOSIS. muscles of respiration, epilepsy, tetanus, but, on the other hand, very rarely hystero-epilepsy ; special muscular diseases : myopathic forms of progressive muscular atrophy, trichinosis, myositis ossificans. Disturbances of the circulation through the lungs occur in a number of the diseases which interfere with respiration. In emphysema a large number of capillary channels are closed, also in tuberculosis and other chronic lung affections ; a large pleural exudation not only compresses the lungs, but also the capillaries. This acts in the same way as a hindrance to respiration. (d) Diseases of the heart which result in obstruction of the pul- monary circulation. It is to be noticed that in the conditions named under [h) a disturbance of the respiration interferes with pulmonary cir- culation. Moreover, we must emphasize the fact that in several of these conditions (especially diseases of the pleura, of the peritoneum, in trichinosis of the diaphragm and intercostal muscles) the insufficient breathing, as well as the cyanosis, will be increased by the pain caused by the act of breathing. If the physician correctly I'ecognizes the chain of events he will be able to bring relief by the use of narcotics. In persons very much wasted, especially from tuberculosis, cyanosis may be absent even in spite of the loss of a large part of the breathing surface of the lungs, since the remaining normal portion suffices for supplying the required quantity of oxygen to the diminished quantity of blood. Under heading 2 : Slowing of the blood-current in the capillaries of the greater circula- tion is dependent upon stopping of the venous outlet. This can be general and caused by all the conditions of the first category, general cyanosis, or it can be occasioned by a venous stopping of an extremity or of the head, and so produce a local cyanosis. General venous damming occurs in diminished pumping power of the right ventricle (valvular deficiency, congenital stenosis of the pulmonary artery, diseases of the heart-muscle, large pericardial exu- dation with hindermg of the heart's action, considerable emphysema of the lungs with excessive damming of the smaller circulation), and in the rare case of compression of a large venous trunk just before it enters the right auricle (tumors of the mediastinum). Local venous stasis is caused by closure or marked narrowing of a more or less large venous trunk. This closure may be produced by GENERAL EXAMINATION. 45 compression or by thrombosis of the vein (compression of the cava or the extremity of a venous trunk by tumors) ; compression of the cava inferior in connection with the common iliac artery by very large effusion in the peritoneum, or by tumors ; atrophic thrombosis of a vein of the extremity, especially the femoral. Not infrequently the collateral veins of the skin take up the conveyance of the blood of the venous stasis ; they then become enlarged and sometimes tortuous {vide examination of the veins). For the cyanosis produced by certain poisons, see Examination of the Blood. 4. The Yellow Skin, Icterus, Jaundice. The jaundiced state of the skin exists in well-marked cases, with slight differences, almost equally over the surface of the whole body. It is found especially in the conjunctiva, and in slight cases exclu- sively there and in the other mucous membranes, if the observer will render the spot anaemic by pressure (best done by means of a micro- scopic slide pressed upon the everted lip or upon the tongue). Ac- cording to the intensity of the jaundice the tissues are but slightly tinged ivith yelloio, or citron color, or yellow-green. Only in very severe cases (melas-icterus) does the skin become green or brownish- yellow. Jaundice cannot be detected by the ordinary means of illumination, since the yellow, artificial light does not enable one to distinguish between white and yellow. In slight cases it will first be detected in the conjunctiva. But this must not be confounded with the yellow fat that sometimes exists there, especially in elderly people. In persons with yellow or brown skin the jaundice is revealed by an examination of the mucous membrane. The yellow color of the skin after taking picric acid or santonine has no relation to jaundice, We distinguish this condition from jaundice by analysis of the urine {q v) and by the etiology of the former. Jaundice of the skin is the yellow coloration of almost the whole body by the coloring matter of the bile in the blood. Very much the most frequent form is the jaundice of simple engorgement, hepato- genous or mechanical jaundice, according to the old designation. It is occasioned by a primary biliary engorgement in the liver, resulting 46 MEDICAL DIAGNOSIS. from a purely local interference with the discharge of bile. This interference is at the ductus choledochus, the transverse fissure of the liver, or Avithin the liver. But there are also so-called htematogenous forms of jaundice which have this in common, that at the first indication of the existence of jaundice there is haemoglobin^emia, because haemoglobin is set free from the red blood- corpuscles. In many of these cases (poisoning, see below), according to recent investigations, it is to be assumed that, from the decomposition of the red blood-corpuscles, there is secreted in the liver a very concentrated, thick bile, and that this cannot flow through the ductus choledochus, thus producing engorgement and jaundice. It is still uncertain whether this explanation can be applied to all cases of jaundice which are not to be referred to primary biliary engorgement. It is not inconceivable (although more and more doubtful) that hnematoidin or bilirubin (these two being identical) is formed from the haemoglobin which has become free within the blood- vessels. This would be a purely " blood-jaundice "in the old sense. In all these cases the coloring-matter of the bile passes into the urine, although when the jaundice is very slight it may not do so (see particularly under 2 of this section). The occurrence of the bile- acids in the blood and its appearance in the urine can, of course, only take place in primary or secondary jaundice due to engorgement. Hence, these would be an infallible indication as to whether the jaun- dice was due to engorgement, or was "blood-jaundice," provided there was, on the one hand, no trace of bile-acids in the normal urine ; or, on the other, if they very rapidly disappeared after passing into the blood. Thus, even in cases of undoubted engorgement- jaundice, the bile-acids might not appear in the urine. In very marked jaundice the coloring-matter of the bile is also found in the perspiration and in the saliva. It is to be remarked that by no means every case of haemoglobin- seraia results in jaundice ; sometimes it simply results in hsemoglobin- uria, sometimes also in urobilinuria, 1. Hepatic jaundice is almost always purely the result of a biliary stoppage. The cause of the penning-up of the bile may exist in the bowel ; in gastroduodenal catarrh, with catarrhal swelling of the mucous membrane, and accumulation of mucus in the ductus choled- ochus ; in tumors which press upon the duodenal orifice of the ductus GENERAL EXAMINATION. 47 choledochus, and especially cancer of the head of the pancreas ; in ascarides, or round-worms {q. v.) which enter the ductus choledochus ; and also in gall-stones, which lodge there. There may be compression of the hepatic duct or of the large gall- duct at the entrance of the liver by tumors (carcinoma, echinococcus), or by scars, or by closure of the same by gall-stones. Closure of many small bile-ducts may be caused by so-called intra-hepatic gall- stones ; possibly also compression of these by marked damming in the branches of the veins of the liver from general venous stasis ; finally, catarrh of the smallest bile-ducts may possibly cause bile stasis and jaundice, as in phosphorus-poisoning. In case the flow of bile is much hindered or is wholly stopped, then, partly from the want of bile and partly from the fatty contents, the stools become light, perhaps entirely white or gray-white. The par- ticulars of this condition of the stools and of urine in jaundice are explained in the chapters devoted to these subjects. In some cases of severe jaundice there may be still other appear- ances : itching, various skin affections, minute cutaneous hemorrhages, slowing of pulse, or simple nervous manifestations. In very severe, long-standing jaundice, there may be marked heart disturbances, hemorrhagic diathesis may develop, or, finally, there may arise severe nervous manifestations (cholasmia, cholsemic manifestations). Moreover, hepatic jaundice may be produced by the sudden diminu- tion of pressure in the portal vein while the pressure in the bile-ducts remains the same, as at the moment of birth — icterus neonatorum (Frerichs). 2. Hgemato-jaundice, whose primary cause is to be regarded as a decomposition of the blood, takes place in certain acute infectious dis- eases (pyaemia, yellow fever, probably also sometimes in pneumonia) ; and from certain poisons (chloroform, ether, chloral, chlorate of potash, solution of arsenic, toluylendiamin). In this case, as well as in the jaundice of damming, there may be bile coloring-matter in the urine. Not infrequently, as in pyaemia, well-marked signs of bile coloring- matter may be wanting, and this has diagnostic value for the assumption that we have a case of hsemato- jaundice. It is very important to notice that in real blood-jaundice the flow 48 MEDICAL DIAGNOSIS. of bile into the intestine is not disturbed, and hence there is no altera- tion of the color of the stools. Urohilin-icterus. In diseases of the liver, in prolonged hemor- rhages of whatever nature, also in the hemorrhagic diathesis, finally, in fever, a larger quantity of urobilin is removed by the urine (see Urine). Hence in rare cases a mild jaundice is observed : Uro- bilin-icterus (Gerhardt, Jaksch). The origin of urobilin is to be explained as follows : First hsema- toidin or bilirubin is formed, and then urobilin is formed from this by reduction in the tissues or in the bloodvessels. 5. The Bronze Skin. Unlike cyanosis and jaundice, this is a condition pertaining only to the skin and mucous membrane. We speak of the chief symptom, instead of the true anatomical seat, of the disease, viz., the supra- renal capsule — the so-called Addison's disease. (Very frequently it is tubercular.) [The association of this peculiar brown discoloration of the skin is not constant in Addison's disease. It is not so constant in cancerous, but is more common with cheesy, degeneration. The latter condition may be present without bronzing of the skin. On the other hand, the skin may be bronzed, just as "in Addison's dis- ease without the existence of cheesy degeneration or any other change in the supra-renal capsules. These facts have induced many observers to attribute the cutaneous discoloration rather to changes in the neighboring sympathetic nerves — the solar plexus and the semilunar ganglia."] The bronze skin is characterized by a brown, gray to black dis- coloration, especially of the face and hands. There is also the common normal pigmentation of the skin in spots. The discoloration may gradually extend over the whole surface of the body, only the nails and cornea remaining clear. It is very important to notice that the same discoloration appears upon the mucous membrane of the mouth, and more rarely upon the lips, as very sharply circumscribed, frequently quite small, brown specks. The discoloration is caused by deposit of pigment in the rete Mal- pighii. Of course, pressure with the finger does not at all diminish it. GENERAL EXAMINATION. 49 6. The G-ray Shin of Silver Deposit. After long-continued administration of nitrate of silver there may be deposits, in certain organs, of very fine black particles (metallic silver or silver albuminate ?), as in the kidneys, intestine, and also in the skin, and especially in the corium, the tunica propria of the sweat- glands. The skin of such persons, especially of the face and hands, is gray or blackish. The color is not changed by pressure. In severe cases we also observe corresponding gray specks in the mucous membrane of the mouth. In a strict sense this is not a diseased condition : these people are perfectly well. D. OTHER PATHOLOGICAL APPEARANCES OF THE SKIN OF GENERAL DIAGNOSTIC VALUE. 1. Acute Exanthematous Diseases. In some acute infectious diseases a characteristic eruption of the skin has so marked an appearance that these diseases are designated as "acute exanthemata." They are: Scarlet fever, measles, German measles, smallpox, and varicella. Here we may pass over these dis- eases, since they are closely connected with the complete description as they are taught at the bedside. On the other hand, there are certain other acute exanthematous diseases, less striking, but at the same time of great diagnostic im- portance. We may here briefly mention : (a) Roseola. This presents a small, round, rose-red, slightly ele- vated spot. It is generally scattered, is found most frequently upon the abdomen and lower part of the back, more rarely upon the breast and extremi- ties in typhoid fever. It appears about the beginning, and generally fades at the end, of the second week. Now and then secondary roseolar spots appear later, which are connected with exacerbations of the disease (involving new portions of the intestine ?). Secondly, they appear in most cases of typhus fever. But, except in light cases, they are in this disease petechial — i. e., location of small hemorrhages, which are slowly absorbed. 4 50 MEDICAL DIAGNOSIS. Further, they exist in some cases of acute miliary tuberculosis, and finally in animal poisoning. (b) Herpes facialis. This consists of a group of small vesicles upon a slightly red base. The vesicles contain at first clear water, then are cloudy, then yellow from pus contained in them. They may be con- fluent. After a few days they dry up and scale. Most frequently this exanthem is found in the neighborhood of the mouth — herpes labialis ; or of the nose — herpes nasalis ; it may also appear upon the cheeks or the ear. It makes its appearance at the beginning of some acute diseases and seems to be especially peculiar to very rapidly rising fever. Above all it accompanies croupous pneumonia, then epidemic cerebro-spinal meningitis (in this disease it is often quite extensive), finally, some- times in angina (angina herpetica), and a light febrile disease named in consequence, febris herpetica. An herpetic eruption also sometimes accompanies the development oiintermittent fever and the chill of pycemia. {c) Miliaria or sudamina. These are small, remarkably clear vesi- cles, which reflect the light strongly, generally in large numbers, especially upon the abdomen. They appear if a patient, after long- continued anhidrosis, begins to sweat profusely, especially in acute, but also sometimes in chronic, diseases. It is necessary to mention them here only because the explanation of their diagnostic, and like- wise pathological, meaning ought to be made prominent. Still other exanthemata of diagnostic importance could be mentioned here, as the (rare) scarlet redness in the beginning of typhoid fever, the different eruptions of sepsis, pyceynia, and other diseases. 2. Exanthemata from Poisons and the Use of Medicines. These are of varied character, since they sometimes resemble those of acute diseases, viz., scarlet fever, measles, etc. They may, there- fore, easily cause an error in diagnosis. It is sufficient here to point out the diagnostic importance of these exanthemata. The particulars regarding them belong to works on diseases of the skin, and also to pharmacology and toxicology. GENERAL EXAMINATION. 51 3. Hemorrhages in the Skin. They arise chiefly by diapedesis, and take place particularly, but not exclusively, in dependent parts, especially the lower extremities. They may be of every size — from the smallest perceivable point to the size of the palm of the hand, or even larger. The small, puncti- form hemorrhages, ecchymoses or petechise, are most apt to appear at the hair-follicles. The color of fresh hemorrhages is like venous blood. During absorption they are brown-red, later becoming bright brown. A hemorrhage is distinguished from a circumscribed inflammatory redness of skin in that it does not disappear upon pressure. (The small ecchymoses in the hair-follicles, mentioned above, are easily confounded with the latter, especially in cyanosis ; further, petechise in parts previously inflamed, as in measles, are easily overlooked.) Simplest test : Press a piece of glass, a microscope slide, upon the suspected spot. A hemorrhage is rendered more distinct, while the surrounding part becomes anaemic ; an inflammatory hypersemia, on the other hand, disappears. Hemorrhages appear: 1. As evidences of a marked hemorrhagic diathesis. They are then generally extensive in the skin, and, moreover, occur in con- nection with hemorrhages from internal organs. They occur in scorbutus, purpura hemorrhagica; in severe acute infectious diseases, especially pyaemia, smallpox, and scarlet fever ; in acute phosphorus- poisoning and acute yellow atrophy of the liver ; and in all severe cachexige. 2. Without internal hemorrhages, as a condition limited to the skin : in peliosis rheumatica [^. e., purpura occurring with severe pain in the extremities] ; also as small petechise ; almost constantly in typhus fever (see Roseola), often in measles, and scarlet fever ; more- over, on the legs when the convalescent patient first stands up, espe- cially after typhoid fever ; and in badly nourished persons where they have been bitten by pediculi. 3. In marked venous stasis, local as well as general (see Cyanosis). 4. As traumatic hemorrhages in and under the skin. They are sometimes of importance for determining the occurrence of an injury, especially upon the skull. 52 MEDICAL DIAGXOSIS. 4. Scars. These are often important marks for limiting or explaining the clininal history, which, by reason of the scars, can be confined to past local or general diseases, or to injuries received. Thus come under consideration " pock " (smallpox) marks and the scars which may remain after the different scrofulous and syphilitic diseases of the skin and deeper organs, especially the bones and glands. In internal medicine, scars from injuries have importance in many nervous diseases (injuries upon the head, the spine, in the course of peripheral nerves). Here also belong the scars of pregnancy., strice, upon the lower part of the abdomen and the upper part of the thigh. Exactly the same scars occur in marked oedema (see the following section), and also sometimes in very fat persons. E. (EDEMA OF THE SKIX AXD SUBCUTAXEOUS CELLULAR TISSUE ((EDEMA, anasarca). Bv these terms we designate an abnormal, marked saturation of the tissues with fluid, which fluid remains wholly or in part distributed in the cellular meshes and lymph-spaces, instead of a corresponding quantity of fluid existing in bulk, as its transudation takes place from the bloodvessels to be removed by the lymph-current. (Edema is recognized by puffiness of the skin causing increase of volume of the affected part, and hence, also, the normal contour, the prominences of the joints, as well as depressions, are obliterated, and, moreover, there is a tendency to an equal roundness. The skin is smooth, generally slightly shining, and hence very pale in conse- quence of the diminished circulation. It is very noticeable that the oedematous tissue loses its elasticity, so that a depression made by the point of the finger remains for a certain time, sometimes for hours. In general or widely extending cedema it is most manifest in de- pendent parts, or where the skin is tender and the subcutaneous cellular tissue is loose. Hence, in those persons who walk and stand it appears first at the ankles or on the dorsum of the feet (not on the soles and toes, since here the skin is too thick or closely attached ;) in bed-ridden patients, on the inner side of the thigh or in the scrotum GENERAL EXAMINATION. 53 and penis, where it is often enormous ; on the lower part of the back ; sometimes first of all, in the loose cellular tissue beneath the lower eyelid. One must examine all of these points if he would detect the first evidences of oedema. In very marked cases the deeper parts, especially the muscles, become oedematous; the legs may then attain enormous proportions. Moreover, in marked general dropsy there are fluid accumulations in the cavities of the body, giving rise to hydroperitoneum or hydrops ascites, hydrothorax, hydropericardium. In long-continued oedema the skin of the legs and the lower part of the abdomen may become thickened, as in elephantiasis. We recognize three causes for dropsy of the skin (as for dropsy in general) : 1. Venous stasis (hydrops mechanicus). 2. Altered condition of the blood, particularly its becoming watery. 3. Inflammations. Hence, these corresponding diseases cause cedema : 1. All diseases, local or general, which hinder the return of venous blood to the right side of the heart, as those that have been already mentioned under Cyanosis (see p. 44). In local stasis the oedema is naturally confined to the roots of the corresponding veins, as, for example, thrombosis of the right crural vein, causing dropsy of the right leg, or compression of the vena cava inferior by an abdominal tumor, causing dropsy of both lower ex- tremities. 2. All forms of hydrsemia (an?emia), acute and chronic nephritis, in which the diminished excretion of water, on the one side, and the loss of albumin from the blood, consequent upon the albuminuria (which see), on the other hand, occasions the hydrsemia, which is the chief factor in the condition which permits frequent and often marked oedema. Yet the hydr£emia does not always explain the existence of the oedema (Cohnheim and Leichtheim ; see under Albuminuria). All other kinds of anaemia (hydrsemia, see Blood) come under this head when they appear as diseases of the blood or of the blood-making organs, and are secondary to the appearance of wasting diseases and severe acute diseases (as oedema of the ankles, when the convalescent patient first stands up). The anaemia caused by long-continued slight hemorrhages (as those 54 MEDICAL DIAGNOSIS. occurring in ankylostomo-ansemia) may also lead to moderate oedema, for here also we have hydrsemia, in that the loss of blood is replaced by water in the blood. 3. (Edema, sometimes of considerable extent, occurs in the neigh- borhood of inflammation ( " inflammatory oedema," "collateral oedema' ). This may be of great diagnostic importance, since it sometimes reveals a deep-seated inflammation. This is of more interest to the surgeon. To the physician it is important, for instance, in pleuritis with oedema of the chest-wall. It shows, with tolerable certainty, that the pleuritis is purulent. Deep muscular abscesses in severe diseases, as in typhoid fever, may easily be overlooked, and may first be recognized by the appearance of oedema in the neighborhood, as along the femur. The oedema in these diff'erent, but so heterogeneous, cases does not have a uniform character : that from stasis is sometimes soft, some- times very elastic, the latter especially (in marked stasis) exists in the extremities, when it is often difiicult, and sometimes impossible, to leave the mark of the pressure with the finger ; moreover, in cases of nephritis, with a small quantity of urine and marked albuminuria, it is sometimes very considerable, but now and then softer. In the different anaemias the oedema is mostly slight — a scarcely noticeable puffin ess. Slight oedema disappears between morning and evening, or evening and morning, according to the change of position of the body. The question. Why does oedema result from venous stasis, hydraemia, or inflammation ? has not in all respects been satisfactorily answered. Until recently it seemed to be proved that this is entirely to be ascribed in these three conditions to an injury of the endothelium of the vessels, and by this means occasioning increased transudation into the tissues (Cohnheim). Recently the view has been advanced, and it seems to me has become well established, that the loss of elasticity and the diminished squeezing-out of lymph from the tissues by their being relaxed plays an important, perhaps a chief, part in causing oedema (Landerer). This relaxation of the tissues might be caused by the stasis from the increased transudation, or by the hydraemia from the deficient nourishment of the tissues by the morbidly thin blood ; or, finally, it might be caused by inflammation excited in the neighborhood. GENERAL EXAMINATION. 55 In conclusion, we must not omit to mention that, in rare cases, oedema exists without any other possible morbid disturbance. Here belong the essential oedema of children and the oedema of the feet after forced marches. F. EMPHYSEMA OF THE SKIN. By emphysema of the skin is understood the entrance of air into the cellular tissue. It may be limited to one region of the body, as the neck or the upper part of the chest, or the upper part of the abdomen. But it may be spread over almost the whole of the body. It is a very rare condition. "We recognize emphysema of the skin by the very pale skin over a region which is decidedly elevated above its surroundings. Indeed, on account of the loose fixation of the skin in certain parts, even de- pressions, as that over the clavicle, or the axillary space, or the inter- costal spaces, may he filled up, so that sometimes on a first glance at the part it seems like marked oedema. Sometimes at such places there may even be an elevation of the skin like a pillow. Upon pal- pation we find that the part is very yielding, like a soft pillow. Quite unlike oedema, however, the depression made by pressure immediately disappears. Moreover, upon palpating the part, we feel and hear an unusually fine crackling. The so-called spontaneous emphysema of the skin does not here concern us. It arises from decomposition of a blood extravasation, or abscesses with formation of putrid gases. The so-called emphysema of skin from aspiration arises from the entrance of air or gas into the subcutaneous tissue, either from without through a wound of the skin, or from within from an organ containing air or gas. (a) The entrance of air from without after a wound of the skin belongs to surgery. It is especially observed in wounds of the neck, of the breast, in the lower part of the face (so-called wounds of the mucous membrane). The wounds in question are sometimes remark- ably small. (5) Of much greater interest in themselves, as well as from a diag- nostic point of view, is emphysema from air or gas entering the cellular tissue from within. Under all circumstances it is occasioned by the 56 MEDICAL DIAGNOSIS. rupture, either spontaneously or traumatically, of the wall of an organ containing air or gas. Hence, emphysema^ from "aspiration" may arise — 1. From any portion of the respiratory tract, from the larynx down. Deep-seated ulceration of the larynx or trachea may invade the walls of these organs, and thus the air may escape and enter the sub- cutaneous cellular tissue. Cavities of the lungs (after previous, repeated adhesions between the pulmonary and parietal pleura) may ulcerate into the chest-wall, until, finally, communication with the cellular tissue is established. Then the pressure of a severe paroxysm of cough may cause the air in large quantity to spread out quickly under the skin. Single pul- monary alveoli may burst from any very high intra-thoracic pressure, as severe cough, especially in children with whooping-cough, bronchitis, or emphysema ; sharp crying ; severe exertion, as blowing on wind- instruments, or women in childbirth ; and air may enter under the pleura or into the inter-alveolar tissue, reach the mediastinum, pass along the mediastinal space into the subcutaneous tissue of the neck, and so spread onward. Wounds of the lungs (as fracture of the ribs without external wound) may either directly cause emphysema of skin, or, passing the mediastinum as above, take the same course. 2. From the oesophagus, stomach, or intestines, and, indeed, from the oesophagus again through the mediastinum ; from the stomach or intestines by adhesions with the abdominal wall and invasion of the cellular tissue there; from traumatic rupture of the oesophagus, more frequently from ulceration, especially in connection with carcinoma of the oesophagus ; with any kind of deep-seated ulcerations of the stomach and bowels. Sometimes there occurs extensive decomposition of the cellular tissue, especially if emphysema of the skin is produced by gases from the intestinal canal (mixed with intestinal contents). Very often, however, the emphysema remains without such action. It may then spontaneously disappear. But at the same time, the emphysema is generally a final development, partly on account of the severity of the ' The name " emphysema" is not quite accurate, since generally the air is driven in under pressure, as is shown by what follows. GENERAL EXAMINATION. 57 primary disease, and partly because it causes severe dyspncea, as, for instance, that in the mediastinum, and hence is a very serious condition. From a diagnostic point of view, emphysema of the skin is of great importance, since it affords a conclusion regarding the diseases men- tioned. Under some circumstances it may afford the first and only symptom, as in the affections of the oesophagus. V. The Temperature of the Body. Fever. It is a well-known peculiarity of warm-blooded animals that they, if the organization is otherwise sound, with remarkable constancy, maintain a certain internal temperature which is subject to very slight variations. If that peculiarity is lost, if the temperature departs from the normal, then, almost without exception, a morbid disturbance is present. A knowledge of this fact, and especially of the elevation of the specific heat in disease, attracted the attention of physicians to the temperature of the body from the earliest time. Recently, however, the measurement of the temperature has become of the greatest diag- nostic aid. In what way this is so will be explained at length. 1. The Terms Used and the Method of Taking the Temperature. Judging of the temperature by laying on of the hands is under all circumstances deceptive. Great errors cannot be avoided even if covered parts of the body are selected, while uncovered parts cool so rapidly as to furnish no standard. We measure the temperature with the Centigrade or Celsius's ther- mometer, with the scale divided into tenths, from about 30° to 45°. There is no need for a thermometer with indications below 30° (see below). In France the Reaumur scale is sometimes used ; in England and America the Fahrenheit is generally used. To convert from one standard to another the following formula is used : 1° C. = fo R. = (9 + 32)° Fahr. It is further to be remarked, that in Germany still, especially at the public baths, the baths are frequently measured and are prescribed according to Reaumur standard. 68 MEDICAL DIAGNOSIS. Regarding the selection of the instrument, it concerns us to remember that there are many incorrect thermometers. Exact com- parison with a standard at the time of purchase, and at least every two years thereafter, is indispensable, since all thermometers register somewhat higher with age. Thermometers with a cylindrical column of mercury are to be preferred, since they are more reliable and like- wise easier to use. Maximal thermometers are strongly recommended, but the index must work exactly ; moreover, it is of course always to be remembered that every time before using the thermometer the index must be shaken down as far as (in certain cases below) the normal mark. When a comparison with a normal thermometer cannot be made, an approximate determination may be made by taking the temperature in the axilla of a healthy person upon say six different days an hour after breakfast. A thermometer which is correct in its reading; must then give an average reading of 37° C. or a little less (Liebermeister). The temperature may be taken in the axilla, the rectum, or in the vagina. (Taking the temperature in the mouth, and especially from freshly-passed urine, is to be avoided.) Of the three places mentioned, the rectum or vagina would be preferred, since their temperature most nearly corresponds with that of the inside of the body, since the ther- mometer lies very equally in either of these situations, and because it requires less time, the maximum being there soonest reached. But from reasons of delicacy we only take the temperature there when it is not possible to take it in the axilla. Therefore, ordinarily, the thermometer is placed in the axilla (which should be first carefully wiped dry, if it is moist) as high as possible, and then the flexed arm should be pressed against the chest. [The maximum is indicated in from three to five minutes. Some thermom- eters accurately indicate it in one minute ; but these are so delicate as to require special care to avoid breaking. The thermometer is to be left in as long as the index continues to rise. One can easily ascertain how long a given thermometer requires by testing it in warm water at various temperatures.] If the patient is unconscious the arm must be held. In cases of marked unconsciousness, of unruly persons, and of children, it is better to take the temperature in the rectum or vagina. If there are fecal accumulations in the rectum the result is unre- GENERAL EXAMINATION. 59 liable. The thermometer is to be oiled and passed in to the depth of about 5 cm. The maximum is indicated in about five minutes. In the rectum the temperature is usually about 0.2° C. = 0.36° F. higher than in the axilla. If the thermometer is not self-registering, it must, of course, be read before it is removed. After using the thermometer in either the rectum or vagina it must, in every case, even when there is no infec- tious disease of either of these organs, be carefully disinfected. [No matter where the thermometer is used, it ought always to be imme- diately cleaned most thoroughly.] A single use of the thermometer may be of great value. But it is still more important, as will be shown below, to follow the state of the temperature progressively, and to ascertain its course. For this pur- pose it is necessary to measure it at stated intervals. How frequently this must be done in order to ascertain the course of the temperature, must be determined by the particular disease. The thermometer should be used at least twice in twenty-four hours (at about 8 A. M. and again at about 5 p. M.). In diseases with high fever, according to the rapidity with which the oscillations of the temperature are completed, the thermometer must be used every three hours, every two hours, or even hourly. Where the changes of temperature are very marked, it may be of interest to observe it every quarter-hour. It is to be understood that, where it is proper to do so, the use of the thermometer should, as far as possible, be suspended at night, in order not unnecessarily to disturb the patient's sleep. The record of the course of the temperature may be indicated by a curve. Charts suitable for this purpose of various kinds are to be had. They serve also for the record of the pulse and respiration. Now-a-days, in every case of severe fever, the physician ought to prepare such a fever-curve. In what follows, the statements regarding the temperature refer to measurements taken throughout in the axilla. 2. The Normal Temperature of the Body. The average temperature is 37° C, and varies from this about 1J°: from 36.25° to 37.5° C. The variations are of different kinds and have different causes. Of least interest, since they are only very insignificant, are those de- 60 MEDICAL DIAGNOSIS. pendent upon age (in children, except the day after birth, a few tenths higher than later; in old people, again, a litile higher) ; an elevation after meals ; an elevation after severe exertion. But the periodic daily variations are more important. They follow the following course : In early morning, between two and six, the " daily minimum " is reached, and then with considerable (not per- fect) regularity it rises to the " daily maximum," between 5 and 8 in the evening. From that point it again, during the night, declines. The difference between the minimum and maximum, the ^' daily dif- ference," is about 1° C. (in rare cases even nearly 2° C). After severe exertion, the temperature rises quite a considerable amount higher, especially in the sun (Obernier observed that in the case of a person running it rose to 39.6° C.) and in very warm baths. 3. Elevated Temperature. Fever. Every elevation of temperature which is not dependent in a marked way upon over-heating or severe exertion of the body, we call fever. The febrile elevation of temperature is generally for a certain dura- tion, but it may exist in single cases as a single short period, " a febrile paroxysm."' But it is here important to remember that fever does not alone consist of an elevation of temperature, but is a complex symptom, whose separate manifestations are occasioned partly by an increase of tissue-changes, partly by disturbance of the functions of certain organs. To it also belong the elevation of the specific heat; also general feeling of being sick, relaxation, sometimes mental disturb- ances ; increased frequency of pulse and respiration with exhalation of CO2; loss of appetite, increased thirst, disturbance of bowels. The urine is generally diminished in quantity, with increase of excretory products of the body, especially of urinary products, of uric acid and diminished chlorides. In case the fever continues there is notable wasting. Although a part of these appearances may be caused by over-heating of the organism, yet in febrile disease they are doubtless not to be regarded as simple results of high temperature. Hence it results, among other things, that the increased frequency of the pulse, ^ The definition of fever as " a continued elevation of temperature," therefore, is not suitable. GENERAL EXAMINATION. 61 the mental manifestations, and the disturbances of the bowels, do not have a constant relation to the height of the temperature, but, on the contrary, have a markedly different expression according to the cause of the fever — that is, the nature of the disease. Nevertheless, the height of the temperature is a very practical index of the severity of the fever, and these two factors clinically become fully identified. But the physician must never forget to pay attention to still other manifestations of fever beside. "With reference to bodily temperature, Wunderlich has prepared the following table : I. Normal temperature, ^1°- to 37.4° C. II. Subfebrile temperature, 37.5° to 38° C. III. Febrile temperature, a, slight fever, 38° to 38.4° C; 5, moderate fever, 38.5° to 39° C. morning, and 39.5° C. evening ;^ c, considerable fever, 39.5° C. morning, and 40.5° C. evening ; c?, high fever, 39.5° C. morning, and 40.5 C. evening. \Comparison of Thermometric Scales: Cent. Fahr. 34° 93.2° 35 95 36 96.8 Normal temperature, 37 98.6 Normal temperature. 38 100.4 39 102.2 40 104 41 105.8 42 107.6 43 109.4] If the temperature reaches 42° C. then we speak of hyperpyrexia, hyperpyretic fever. While the higher temperatures even of high fevers do not occasion direct danger to the organization, in hyperpyrexia the temperature is directly dangerous to life : it generally leads to a fatal issue. 1 Regarding this difference between morning and evening temperatures, see under Eemission. 62 MEDICAL DIAGXOSIS. There is uncertainty regarding the highest temperatures that have been observed. Temperatures of 45° C. have been published as curiosities. One case of injury to the spine, which resulted in re- covery, is reported by Teale to have repeatedly had a temperature of 122° F. = 50° C. The course of the temperature in twenty-four hours can vary much only in fever. Most fevers show distinct fluctuations, in that toward morning the temperature falls more or less, remission, until it reaches the daily minimum, thence in the course of the day it rises, exacerba- tion, and toward evening reaches the daily maximum. The difference between the daily maximum and the daily minimum in fever is called, as in normal temperature, the daily difference. While the course of the temperature in fever is analogous to that of health, not unfrequently the minimum and maximum come at quite a different time, as, for instance, the maximum may be at midday or at midnight ; a complete reverse may even take place so that the maxi- mum occurs in the morning and the minimum in the evening : typus inversus. From this it is seen how the temperature must be exactly measured every hour of the day and night if it is of importance to know whether a patient has fever or not. There have been cases when the persons were thought to be without fever until the physician thought of ascer- taining the temperature at night. * The exacerbation of the fever is frequently connected with shivering. If the temperature rises very rapidly (it may rise several degrees in a single hour) generally there is a chill, that is, a decided feeling of chilliness with severe shaking of the whole body, chattering of teeth, when the high internal temperature of the body is then ver}'' quickly contrasted with the subjective feeling of chilliness. The skin is at first pale, livid, and generally cool ; toward the end of the chill, how- ever, it is regularly very hot. On the other hand, a rapid remission of the temperature is generally accompanied with sweats. According to the amount of the dailv difference we distinguish three types of fever: Continued fever : daily difference not more than 1° C. (chiefly high temperature). Remittent fever : daily difference over 1° C. GENERAL EXAMINATION. 63 Intermittent fever : maximum very high, minimum within the normal (or even-below). An important peculiarity of fever is that the temperature does not long remain at the same point, as it does in health. It is very changeable. Warm clothing, high temperature of the room, and sometimes the taking of nourishment, cause a very marked rise of the temperature in fever ; likewise also psychical influences, as fright or anger. On the other hand, a cool room and (especially) a cool bath, also gradual loss of blood, as in menstruation, cause it to fall. It is absolutely necessary to know this if we wish to ascertain the cause of many remarkable variations of temperature in fever. Moreover, the sudden fall of the temperature is sometimes a sure indication of an internal hemorrhage. 4. The Subnormal Temperature. It begins at 36.25° C. ; the lowest observed temperature is 22° C. 1. It is observed in febrile diseases as an expression of two directly opposite conditions, namely : a. In a sudden fall of the high fever with an advance to recovery, the " crisis," the critical decline of the fever. In this case the tem- perature falls during perspiration sometimes to below 34° C, and only in the course of one, two, or three days again returns to the normal. We recognize the " crisis " by the simultaneous diminution of the frequency of the pulse and the respiration, and the feeling of comfort and returning health by the patient. b. In the so-called collapse. In this condition there is generally a very rapid fall of the temperature, and at the same time a sudden failure of the heart, with (as is the contrary in " crisis ") increase of the frequency of the pulse, with paleness and general failure of strength. The condition of collapse may pass over, when there generally is an immediate rise of temperature again to the former point ; or it may pass on to a fatal termination. On the chart of the fever- curve the line of the falling temperature is crossed by the rising line of the line of the pulse-curve in a charac- teristic way (see Pulse). Sometimes, in a case of collapse ending fatally, the pulse-line sinks parallel with the temperature-line (see Pulse). 2. It occurs sometimes temporarily in severe hemorrhages, also g4 MEDICAL DIAGyOSIS. sometimes in all kinds of chronic diseases, especialh' in those of the heart and the lungs. If the temperature suddenly falls, accompanied by vreakness of the heart and general prostration, then also we speak of collapse. 3. Continuing subnormal teynperature, extending into a number of weeks, is very rai'e. It may exist in all severe wasting diseases and in diseases of the brain. 5. Diagnostic Value of the Temperature, especially of its General Course. Under certain circumstances a single, or, in other words, the first measurement of the temperature may be of the greatest diagnostic value. Of this a few examples may be given. 1. Frequently the elevated temperature, with some indistinctive complaints (or, in the case of children, abstinence from food with rest- lessness), is the only sign of a disease just commencing, or of one that has been going on for some time. Ascertaining the temperature is then of great service, in that it leads to a more careful examination and more extended observation, and to directing suitable care of the patient. A high morning temperature points directly to an acute infectious disease. 2. In marked cachexia, without distinct organic disease, the exist- ence of temporary fever indicates with considerable probability tuber- culosis. 3. A single chill accompanied with a rise of the temperature to about 40° C. may, in a given case, say of a disease which from expe- rience sometimes causes suppuration, lead to the diagnosis of suppura- tion, as in gall-stones, renal calculi, after injuries to the skull, as brain abscess; also here belongs puerperal fever, or, under certain circum- stances, it may possibly be malaria. But the continued observation of the course of the temperature is of still greater importance. It advances medical knowledge in various ways : 1. The course of the fever in a number of diseases is so typical that from the temperature alone the diagnosis may often be made with great probability, sometimes with certainty. At any rate it is always, taken in association with other symptoms, an important aid in diagnosis. GENERAL EXAMINATION. 65 2, Moreover, during the progress of- a febrile disease, the tempe- rature not infrequently gives notice, by its unusual behavior, of the occurrence of an unusual event. Hence, not infrequently, we first become aware of an exacerbation or of a complication in a given dis- ease by a specially high rise of the temperature. A sudden fall of the temperature may give notice of collapse, or a change to a fatal issue, or an internal hemorrhage, as of the bowels in typhoid fever. In the following the most important typical courses of fever are briefly set forth : 1. Continued fever exists especially in two diseases : Typhoid fever and croupous pneumonia ; also in typhus fever, sometimes in erysipelas and miliary tuberculosis. In a case of severe fever, with the diagnosis doubtful, a fever continued through several days points with proba- bility to typhoid fever ; and next to acute miliary tuberculosis. ' In abdominal typhus [typhoid fever] the fever rises for several days by equal steps, "initial period"; reaches the summit, at which it remains as a continued fever one, two, or more weeks ; then it, as a rule, gradually becomes a remittent fever, of such a character that at first the daily maximum remains high, with the minimum going lower ("the double stage" ["the long-continued paroxysm"] — the mini- mum may even go below the normal) ; then the defervescence begins. Initial period. Acme. Defervescence. Fever-curve of a regular mild typhoid fever. (Wunderlich.) the maximum declining; this usually reaches the normal in a few days. The remittent and defervescent stages may be protracted for 5 66 MEDICAL DIAGNOSIS. some time, even as much as a week : " slow typhus." Moreover, the temperature may, after it has somewhat declined, again rise : " recur- rence "; or the disease, after the temperature has reached the normal, may begin anew, in the same manner as at first : "renewing" (see regarding these points Figs. 1, 2, 3). Long-continued paroxysm of typhoid fever. There are all manner of variations from this behavior of the tem- perature in typhoid fever, so that a single case seldom really pursues a typical course. Particular variations partly declare themselves by Fig. .3. '■■■■■■■■— ■■ ■■—— ■■■■■■■■■■IBeBBg— ■■■■■■■■■■■■ liSBSiSliliHiSiiinSBSEi^H^iiF 3ti tumm\mmmt H HBB BiiaaggaH HHES BiiliB-- !'—■ ■■■■■■■■■■■■■■■■■■■■■— ■■■■■i'iSSSBB ■ ■Ml ■ WAT narai s&as ■■■■'■■■■■nBriBM ■!!■■■■■■■■■ ■■■■■■ aaaaanTiBwiiaMHnv.iBfJ ■■■■■■ ■■■■■■ ■■■■ ■■■■ ■■■■ ^■^^'■■■^■■■■■■■■■■11 eSiiassfiBSBSi !h: Defervescence. Typhoid fever, with recurrence of fever. Second attack. the earlier change of the temperature to the changeable character, mentioned on page 67 ; but the fever- curve will especially be aflfected GENERAL EXAMINA TION, 67 by the administration of antipyretics.^ But, particularly, every exacerbation of the temperature should cause the physician to think of complications, and a fall of the temperature, of collapse, and also of possible intestinal hemorrhage. In pneumonia (see Figs. 4 and 5) the temperature rises very rapidly ("-initial period," lasting a few hours), often accompanied by chill, then remaining as a high continued fever. From this it may decline, also very rapidly — in a few houi^s — to or below the normal, with a simultaneous decline of the pulse and the respiration, and generally with severe sweating. Or the defervescence may be some- FiG. 4. Day of illness : 1 ■■■■■■■■■■■■■■■■■■■■ ■■■■^■■■■■■■■■■■■■■H 40° ■MViBHMHIIVWBMinHHBHHHH ■WrjH.WaiHKnHiWJillHHHHHHH ■'■■■WHHHTJHkVMIIHBHHHHH ■■■■^■■■■■■^/■■■■■■■■■H 30 ■■■■■■■[■■■■■■IBHHBBHH ■!■■■■■ ■■■■■■■!■■■■■■■ ■■■■■■HHHHHHHMHHHHHH ■(■■■■■{■■■■■■■MBHHHHB ■{■■■naillHHBBBBHBHHHHH 6>i ■■■■■■■llHHHHHHBBHBBBa ■■■■■■■■■■■■■■■■■■■SB ■■■■■■■■■■■■■■■■BfiBB ■■■■■■■■■■■■■■■■■■■■ji s: ■■■■■■■■■■■■■^■■■■BB ■■■■■■■■■■■■■M^H^IIRS ■■■■■■■■■■■■■AWki^fismg ■■■■■■■■■BBSSBSSSaSEB 36 ■SBSBSBBBBBSBBSBSiBBB Pseudo-crisis. Fever curve of croupous pneumonia. (Steumpell.) what slower, occupying one or two days. The former way is called " crisis " (critical sweat), the latter 'Hysis"; mid"way between these two is " protracted crisis." Sometimes the day before the crisis the temperature suddenly falls very rapidly, and then again rises — " pseudo-crisis " (distinguished 1 The antipyretic treatment, especially with internal remedies, has, no doubt/ the result of rendering the course of the fever untypical, and so destroying its diagnostic value. Therefore, until the diagnosis has been established in a case of febrile disease, the internal antipyretic treatment ought, if possible, to be suspended. 68 ME Die A L DIAG NOSIS. from collapse by the pulse and the general condition, as referred to under "the subnormal temperature"). Or there is exacerbation of the temperature just before the crisis, rising from, say, 40° to 41° C. — "critical perturbation." Fig. Pay of illness ■'■■KiinwHi — — iiiiBiiBi SBSBSiSISS! SEaiiliig ■■ ■■■■■■' Baa Pseudo-crisis and crisis in jineu- monia. (Wunderlicu.j Fkj. 6. Remittent and intermittent fever (catarrhal pneumonia). (Wunderlich.) 2. Remitteyit fever is often met with. It may exist some time during the course of any febrile disease. While the temperature of continued fever is generally high — about 40° — the fever may remit whatever its height. If the maximum is low, the minimum is possibly normal — a behavior which, strictly speaking, must be considered as intermittent fever. Remittent fever belongs especially to chronic tuberculosis. Fig. 7. !■■ ■■I ■ ■■■■■■■■■■■■■■■■■■■■■'IB! laiiSiiSBBBw ■»*«'■■■<■■ <■» I IVBIBI ■BniS !■■■■■«■■ VAWAvrivaif /■'■■■■ ■Br — iHHi^S SBSSS. 5 ilSSifiM&Siiili iiiSilBaBiwiiviimfi! u\mm Hectic fever in tuberculosis of the lungs. If the maximal points of the curve are high, the temperature often falls pretty rapidly, accompanied with chills and night-sweats {hectic fever). Similar conditions are observed in the fever of pus formation. GENERAL EXAMIXA TIOX. 69 3. Intermittent fever, in a general sense, occurs in combination with remittent fever (see Fig. 7). The hectic fever mentioned above as accompanying remittent typhus, is often also an intermittent, in which the minimum may even be subnormal. Fig. S. 3 4 41° 40 ■«■ ■IKTil IBl'll BHMI ■■I ■■■ IliHBn timnmM ■III ■iJHiiiai nBIHIIAHIII ■ ■llillllJ ■iriiii'ii ■■ ■■JWIUBIM— ss!rs£is;in ■■iniHBi ■■iiiBwir' ■■iiiBaii I^IIBIII ■■iniii SbHSss Pyaemia with, rapidly fatal course. (WrXDEELICH.) Fig. 9. 41° ■■IIH ■■■■■■■ ■■ilH.BHHaaBg ■■IIHIBH ■■■■■ JBiBBiiaiiBBSa ■■■■■■■■■■■■■B BBIIBIHBIBaBB ■HIBIIHIIBBM ^■■■■■■BH —M BMBIBIIBIIMM^ ■■■■■■■■I I^BM _IBIHHBIBHBB BMilHHBISBSB RMHIIHBIHBBB BHIIfflllBIHBI — ■lirflllHigHL^ ■■■■■■iFiiriii — ■■■BMBi'A'IBI Quotidian intermittent fever. (WUNDEELICH.) A peculiar form of intermittent fever is observed in pyiTemia, -where the temperature during chill may rise two, three, or more times in twentv-four hours, and soon fall, with sweat and great exhaustion, Fig. 10. Fig. 11. ssbbSsSbbss BMHaBIB^VIII ■ IIBBBIBBi'^BWI ■IIBaBIIBIMaT ■ ■■I BSi^iBii SSfflSSKIBSBI ■BiraiiigiBia!! ■BinHMHiiaB!Snj ■ ■i'HBIKIHIIBina'Al^ — I'MtmM'JBWfciaBii ■■BBIM ■■—llWii Tertian intermittent fever. (WrKDEELICH.) ma&iss mmiImw— ■■■■IBM ■HII ■BMBBMMIIM— ■1 ■■■■ BIHHHHH SSSB SS5S ■■■BHB !■■■■■ &■■■■■ !■■■■■ ■IBBBBM !■■■■■ ■■BBBH IBBBna SS8BS SBB/J! ■MBBBBIf— M 1^ ^■■IIBBB.BH ■SnHMIIIHViHB im.nBI.IIHBKJBB ■HlHHIilBlimBai ■■■ BIBSVBfflllBBSk^BS ■■irAvaHi'iHaHBWBi BIBI'iBLTHai ■■■■■K^H ^mftnmiHBBaBa Quartan intermittent fever. (WuKDERLICH.) then again rising. The pulse is generally very frequent, and the patient often gives the impression, by the great prostration during the 70 MEDIC A L DIA G NOSIS. sweating stage, of going into collapse ; in fact, a condition of collapse sometimes exists with the fall of the temperature (see Fig. 8). In a narrower sense, however, we designate as intermittent fever the course of temperature of a special form of malaria. In this there is a continual alternation between times without fever (apyrexia) ; a quick, high rise, and, after a short time, again, a rapid fall of tem- perature (often below normal) — "fever paroxysm.'' Severe chills and perspiration accompany these attacks of fever. The attacks recur with great regularity, either every twenty-four hours (quotidian), or forty-eight hours (tertian), or seventy-two hours (quartan). Some- times the attacks recur one or more hours earlier on successive days (anticipating), or they may recur later each time (postponing). In these forms of fever the diagnosis is made certain by the fever-curve (see Figs. 9, 10, 11). Fio. 12. 42° ■■■■■■■■■■■I !■■■■■■■■■■! B ■■■■■■■■■■■■ ■'■■■■■■■■■■I nimBaaaaHBHi 'muamnnKmmmmm% EBiraiiTAwnaHBHi ■I i^vimmmiMmmmt ■■■UHWillliaHHHI •— «■■■■ sasi ■■■■■■IIWII ■■■■■■IIBIII ■■■■■■laaiiii ■■■■■■nmiii ■ ■■■laBBlBIII ■SgHBBaifiii ■ ■■■!■ ■MBIlia IKIHWBII iSB! ■^^■H ■■■■■■ ■■■■■■■■■n I ■§■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■SBBSBSBSSSSSS HSBB*""*"'*""** ■■■■■■■■■<■■■■ ■SiBSBSriSSBnSS ^^■■■■■■■■■■liVrBHBaBHBHMaHHaBIBHHVmBIHHBHBH ■BBBHBIIBIBBMiraBaaHBHBHBBBBiaBIBBBrJHnBHBHn ■BaBgBaBiBviiiniL's^BaBaBKHHBgBBiBHHim'inBnSS ■ B1BMBWBIBBBl'BMB«k1MB>JBWBBBBBMMIMWMIWMgS SB —BBi BM BIBIBB/BlBaBBWWBfBWlMMBBIBB ■■■'■■■ BB»ttTiga ■■■■BHBBIBIirJBBaBBBBBBBiBBHBBiBBBavaSBnaSlMiS BIBiBI—MBIBflBIBWBMBW.'aWBWWMWWWMMM— '^BiMiS BBBBBaHBaBiiaaBaaaaBiaaBaaaBBaaB'iiBHBBBBBBBB KBB"Bai"™''"B""i"**9*""*""BBBBK»BiBBBBBBBBB BBiBBiWBBiriBBiBBBBBBBHBHBBBHBBkJ».^BlBBBBSaBBB 1. Apyrexia. 1. Relapse. 2. Apyrexia. Febris recurrens. (Wunderlich.) Compare p. 69. 4. Recurrent fever only exists as a renewal of a febrile disease, or a disease known as recurring typhus. There is an attack of fever very like that of pneumonia, with sharp transitions and very severe sweating, the temperature falling often to 34° or 35° C, and apyrexia; then a relapse after five to eight days, with a chill, followed by a high continued fever, which, in turn, ends in five or six days by a critical GENERAL EXAMINATION. 71 sweat ; new apyrexia, fresh relapse ; and so, over and over again, but each new attack with less fever and of shorter duration. 5. Not infrequently a quite irregular fever will be met with. Its course is such that sometimes one cannot speak of any daily remission — at least, the lowest daily temperature comes at a variable hour of the day or night. But this fever may be of diagnostic value. In acute meningitis a continuing irregular movement of the temperature speaks against tuberculosis and against ordinary purulent meningitis, but, on the contrary, for epidemic cerebro- spinal meningitis. Again, a pronounced irregular fever in an acute disease in general speaks against any of those diseases which manifest themselves by any typical fever. 6. Local Elevation or Lowering of the Temperature. 1. Elevation of the temperature. In internal medicine this is seldom of diagnostic aid. We meet it where there is any kind of inflammation which is near the surface, as in surgery. In unilateral pneumonia, also, a careful measurement shows an elevation of the temperature in the axilla of the affected side. In recent paralysis of any sort the temperature of that side is somewhat higher for a short time ; then the temperature usually falls. Rare cases of hysteria exhibit a one-sided elevation of temperature with redness of the skin and perspiration. 2. Lowering of the temperature. This is the expression of local disturbance of the circulation. In heart-failure, also in collapse and near- approaching death, the extremities and also the nose become cool. Coolness of the affected limb is observed in venous thrombosis, in paralysis of long standing in consequence of diminished venous blood-current, and in arterial embolism and thrombosis. PART III. SPECIAL DIAGNOSIS. CHAPTER lY. EXAMINATION OF THE EESPIRATORY APPAEATUS. EXAMINATIOiSr OF THE NoSE AND LaRYNX. 1. The Nose. Inspection of the nose sometimes reveals diseased conditions which concern the bony structure, and, therefore, belong to surgery : defor- mities, fistulse, ulcers, with deeply-seated destructive process at the root of the nose. Only one of these conditions has interest for us as physicians : the so-called saddle nose, arising from necrosis and removal of a part of the bony framework of the nose, is an almost infallible sign of consti- tutional syphilis. Swelling and redness of the nostrils indicate inflammation of the nasal mucous membrane. Not infrequently we also see traces of a muco-purulent or purulent, sometimes an ill-looking bloody, serous secretion ; the latter is sometimes offensive in odor. Patients with obstructed nose (with severe catarrh or tumors) breathe through the mouth. On the other hand, in severe dyspnoea [q. V.) there is likewise motion of the alse nasi. ^pistaxis shows itself most plainly by the flow of blood from the nose. However, with persons entirely unconscious, or healthy persons while asleep upon the back, may have the blood flow backward into the pharynx or even into the stomach. Then the hemorrhage may be overlooked, or the first symptom of epistaxis may be vomiting of blood. (73) 74 SPECIAL DIAGNOSIS. In all important diseases of the nose it is necessary to make use of the nasal speculum. (For the use of this in examinations, see the Appendix.) Palpation of the interior of the nose may be necessary (see works upon Surgery). Acute muco-purulent and purulent catarrh of the nose is symp- tomatic in measles, diphtheria, and equinia. Chronic catarrh is a common symptom of scrofula (in which disease the whole nose is often swollen) and of syphilis. In the former disease there is sometimes an inflammatory thickening of the whole nose, particularly of its lower Avails. Inflammation of an acute form, with very foul-smelling and ill-looking secretion, most frequently indicates diphtheria of the nose and pharynx. 2. The Larynx. The larynx is examined with reference to its functions (voice, cough, breathing) and the local appearances ; the latter includes the external and internal examination (see also under Sputum). (a) The Function. — The voice is changed in all aflections of the larynx. It may be muflled, rough, hoarse, even to the entire loss of voice — " aphonia." In severe diseases it may have a whistling or sibilant (strident) quality : This indicates stenosis of the larynx; or it is very hoarse and deep : this points to deep-seated ulceration. In diseases of the larynx the cough is hoarse, loud, or barking. In extensive destruction and in certain paralyses of the crico-aryte- noid muscles, cough is either more difficult or is impossible, since the power to close the glottis preceding the cough, as is normally the case, is wanting (see Cough). Breathing is obstructed in all conditions that narrow the larynx, as in inflammation resulting in hypertrophy, in new formations, in scars with contraction. Then there is an inspiratory and expiratory dyspnoea (which see), and a peculiar noise of stenosis, " stridor laryn- geus." In marked stenosis, especially when the thorax is weak, as in children, there is a drawing-in of the lower part of the thorax in front, in the region of the insertion of the diaphragm (see the chapter on Anomalies of Respiration). Stenosis only in inspiration, causing inspiratory dyspnoea, is ob- EXAMINATION OF THE RESPIRATORY APPARATUS. 75 served in paralysis of the crico-arjtenoid muscles, the dilators of the larynx. Laryngeal stenosis is distinguished from tracheal stenosis at the first glance, in that in the former condition the larynx moves up and down with each breath, and the neck is stretched to the fullest extent, while in the latter the larynx remains quiet and the head is always somewhat bent forward. (h) Local Examination. — The external examination is made with reference to pain, to deformities revealed to the sight or touch (these are very rare, resulting from destruction by periostitis), and laryngeal fremitus. Laryngeal fremitus is a trembling of the thyroid cartilage during speech. It is stronger or weaker on one side in unilateral paralysis. It has no special diagnostic value. The internal examination. By great care, and in the case of patients who have themselves under good control, sometimes the entrance to the larynx and the tissues even as far as the glottis can be touched. This method, however, has now little value, since it has been entirely superseded by the examination with the laryngeal mirror, which is the best means of examining the larynx. (Regarding its use see the Appendix.) In inflammatory conditions, patients complain of pain in speaking, but sometimes, even with severe disturbances, there is no pain ; now and then there is dyspnoea, especially on exertion. Pain in swallow- ing in chronic diseases of the larynx frequently indicates serious con- ditions : extension of new formation (carcinoma) toward the oesophagus, or destructive suppuration. The leading symptomatic indications of diseases of the larynx with reference to other possible internal diseases, are as follows : acute laryngitis, with manifestations of an acute infectious disease, points especially to measles, croup (and also to smallpox). Chronic laryn- gitis points to tuberculosis and syphilis ; to constriction by scars, to syphilis. Of paralyses, recurring paralysis is of special diagnostic importance, since it often arises from pressure upon nerves, espe- cially upon the left side from aneurism of the aorta, carcinoma of the oesophagus, tumors of all kinds in the mediastinum. Certain paral- yses indicate hysteria. 76 special diagnosis. Examination of the Lungs, topographical anatomy of the lungs. For localizing the surface of the chest with reference to height and depth Ave make use partly of anatomical prominences and partly (for determining the breadth) of certain local lines which we think of as drawn upon the surface of the thorax. Upon the front side of the thorax are the important anatomical regions : the fossa supraclavicularis (above the clavicle and bounded by the sterno-cleido-mastoid and trapezius muscles) and the fossa in- fraclavicularis. The latter has no distinct lower boundary. We under- stand it as the region immediately below the clavicle, about as far as to the second rib. From the second rib downward we designate the height by the ribs and intercostal spaces : as above the fourth, under the fourth rib, the fourth intercostal space. The number of the par- ticular rib is determined by counting from the second rib downward. It is always easy to find this rib : it is in articulation with the sternum exactly where the manubrium and corpus sterni unite, ordinarily forming a very slight angle (angulus Ludovici), and this place is plainly to be felt, and often seen, as a cross-line or prominence. We feel for this prominence and find the second rib to be its prolongation. WTe count the ribs from that downward, feeling somewhat obliquely outward as we go down. Morenheim's depression [the outer part of the infraclavicular depression] and the so-called Sibson's furrow (the under border of the pectoralis major) are sometimes, although not very practically, useful as points for locating internal organs. For determining the breadth the vertical lines now to be mentioned are useful (the subject is supposed to be standing) : the middle line, drawn through the sternum ; the two sternal lines, drawn parallel along the sides of the sternum ; the mammillary lines, drawn through the male nipple ; and the parasternal lines, drawn midway between the sternal and the mammillary lines. On the two sides we determine the height by the ribs, which we count in front ; and the breadth by the middle axillary line (drawn through the middle of the axilla, the arm being extended sidewise), the anterior and posterior axillary lines (drawn perpendicularly from EXAMIXATION OF THE RESPIRATORY APPARATUS. 77 the points where the pectoralis major and latissimus dorsi muscles leave the thorax, with the arm raised sidewise to the horizontal). Upon the back, we name the fossa supraspinata ; above that, the suprascapular space ; the fossa infraspinata ; the interscapular space, between the two scapulae ; the infrascapular space, under the shoulder- blades. Exact determination of height is made by counting the ribs, which, however, are difficult to count, especially in fat persons. Thej can be determined by three methods : (a) By counting the vertebral prominences from the vertebra prominens (the seventh cervical). (b) By counting from the lower angle of the scapula ; this over- hangs the seventh rib in the average person when the shoulders hang comfortably and the arms rest against the chest with the fore- arms folded lightly. (c) By the point of the twelfth rib, which is easily felt (the best way for the lower ribs). Moreover, we have the scapular line, which is drawn upon the two sides of the spine through the lower angle of the scapulae (at the point already mentioned under (5)). It is to be observed that some of the vertical lines are not deter- mined exactly. This is true regarding the mammillary line (always very important) more than any other. In women it is generally very variable. On this account it is always to be thought of as drawn upon a male thorax. But even in the male the nipple is an uncertain point. By much practice the eye is cultivated so as to recognize what is to be regarded as the average location of the nipple in the male, and by this we must always correct the mammillary line. The attempts to substitute other lines for this one have not been accepted. The designation "infrascapular space" is little used. The expres- sions, " right, left; behind, below," correspond to it, and are much to be recommended: behind or below the right, the left, scapula. THE ANATOMICAL BOUNDARIES OF THE LUNGS WITH REFERENCE TO THE THORAX. In front the lungs reach to the sixth, and behind to the tenth, rib, and are almost everywhere directly in contact with the chest-wall. They are not in contact with the chest-wall in the neighborhood of the heart nor behind a small portion of the upper part of the sternum. 78 SPECIA L DIA GXOSIS. The accompanying figure exhibits the anatomical boundaries of the lungs. They project with their summits into the fossa clavicularis from three to five cm. above the clavicle, and with their inner anterior borders converging downward, so that behind the angulus Ludovici, not exactly behind the middle of the sternum, but a little to the left, they come to lie very close to each other ; then they continue parallel Fig. 13. Position of the thoracic viscera, of the stomach and of the liver, from in front. The portions of the heart and liver which are drawn with unbroken hatched lines represent the parietal portions of tho^a organs. The portions that are not in contact with the chest-wall, but are covered hj the lungs, are represented by broken (clear) hatched lines. The line ef, border of the right lung; g h, border of the left lung; dotted lines ( ) a b and c d, the boundaries of the complementary pleural space ; i, the boundary between the right upper and middle lobes ; k, the boundary between the right middle and lower lobes of the lung; /, boundary between the left upper and lower lobes; w, greater curvature of the 3tJ Clear ; Covering of the body : Diagrammatic representation of percussion over a thick covering of the body. The short arrow indicates weak, the long one strong, percussion. With weak percussion we have absolutely deadened resonance; with strong percussion a clear, although less intense, sound (indicated by the hatched triangle). would, after all, be found where we percussed over airless structure of sufficient size, in case an organ containing air was not directly in contact with it. If we percuss still less strongly, we should, as a matter of course, the sooner receive an absolutely deadened sound. In the human body we have next to consider the internal organs not containing air, called " parietal " if they lie in contact with the wall of the body ; and, also, the coverings (subcutaneous fat, muscles, 114 SPECIAL DIAGNOSIS. bones) if they are of sufficient magnitude. Thus, frequently, in the neighborhood where the heart is parietal, and, further, where the liver also is, even with strong percussion there is absolutely deadened sound. Not infrequently, however, especially over the heart, absolute deaden- ing does not exist, since the structures containing air lying under or near by may be reached chiefly through transmission by the chest- wall, though it may be only by its vibration, and may give the clear sound belonging to the air-containing structures. As regards the skeletal coverings^ in abnormally fat persons, and in oedematous diseases, these sometimes attain such proportions that even strong percussion yields an absolutely deadened sound ; in normal, moderately fat persons it is only the fossa infraspinata that very frequently gives absolutely deadened sound. But, further, parietal tumors, and especially fluid accumulations in the pleura and peritoneum (more rarely, thickening of the lungs), occasion absolutely deadened sound in case they, together with the skeletal covering, possess sufficient depth and breadth. Moreover, over ribs markedly bowed, as over the point of sharpest bending-out of the thorax in kypho-scoliosis, absolutely deadened sound may take the place of the lung sound; also, here, often a peculiar change of the lung (aplasia) plays some part. Relatively deadened sound occurs where air-containing structures of only small size are percussed, or where structures containing air are only feebly shaken by percussion, or where these two conditions are met with together. Thus, a relatively deadened sound is obtained with feeble percussion of air-containing structures, while strong per- cussion of the same yields a clear sound ; the blow reaches only a small volume of the air-containing organ, and it moreover causes in it oscillations of only moderate amplitude. Likewise, where the volume of lung-tissue is small, as over the apices and just over the lower border of the lungs, the sound is relatively deadened, and this is true even with strongest percussion, since there is here only a small portion of air- containing material to be acted upon. Finally, every layer of airless tissue which lies over an air-containing tissue or space causes a deadening of the percussion-sound of the latter — i. e., a rela- tively deadened sound — if the overlying layer is not so thick as to cause an absolutely deadened sound. Subcutaneous fat, muscles, bones, parietal tumors, thickening of lungs, layers of fluid, callosities EXAMIXATIOX OF THE RESPIRATORY APPARATUS. II5 — all these, as overlying airless masses, deaden the sound in proportion to their size. A special description is required both of parietal and of deeply seated airless parts which normallv contain air, such as appear Fig. 20. Clear:- , _ ^. ,.^ *^L ?^ \^ \ Crystals of haematoidin. Needles of fatty acids. (After Struempell.) They indicate that blood has been long retained : in gangrene with formation of abscess ; in the pus of empyema which has perforated a long time before, as in one case that came under my observation of a slow hemorrhage into the lungs from a thoracic aortic aneurism. EXAMIXATIOX OF THE RESPIRATORY APPARATUS. 181 Sometimes there are spots macroscopically visible when there is hsematoidin in the sputum. (See p. 172.) Crystals of fatty acid (margaric acid crystals, see Tig. 35). They are long, thin, slender needles, slightly or very markedly bent, which are found singly, in large bundles or druses, or quite irregularly arranged. They are generally distinguished from elastic fibres by the uniformity of their curving. "When a portion of sputum is dried in the air, without heat, they are completely dissolved upon the addi- tion of ether, while the elastic fibres under the same circumstances are not changed. They occur generally in masses, in gangrene of the lungs and fetid bro7ie7i{tis, and especially in the lumps or plugs pre- viously mentioned (page 174) ; they are also found in the plugs which are formed in inflamed tonsils (see) ; finally, they may occur singly in any muco-purulent sputum, especially after standing in a warm place for some time. Fm. 36. Crystals of cholesterine. (After Steuempell.) (Jholesterine crystals. These are thin rhombic plates with the corners cut out, which become green and then red when treated with dilute sulphuric acid and tincture of iodine. They are sometimes found in old perforating pus, also in tuberculosis. Cliarcot-Leyden s crystals. These are slight, somewhat blue, shining, elongated octahedrals of great variety of size, sometimes visible with a simple microscope, often only to be seen with a No. 8 Hartnack. They seem to be identical with the crystals found in the blood and marrow in leuhcsmia, also sometimes occurrinof in the feces. They probably consist of a mucous substance (Salkowski). 182 SPECIAL DIAGNOSIS. As a sign of bronchial asthma they are of great diagnostic impor- tance (see Spirals) ; they then occur most abundantly during and after the attacks (Leyden). They are less frequently found in acute bronchitis, chronic croupous bronchitis, and tuberculosis. Fto. 37. Charcot-Leyden's asthma crystals. (After Riegel.) The points in the expectoration of asthma where these are found can often be easily recognized with the naked eye as dry crumbs (see p. 174). They are very often mixed with peculiar, fine, granulated round cells which look as if filled with dust ; at the same time with these are found spindle-formed figures with a slight glistening — a transition stage to Charcot's crystals (?). These crystals are found especially numerous upon and in the "spirals," and also with them these spindle-formed cells. In isolated cases there are found in the sputum tyrosin {fetid bron- chitis, empyema, according to Leyden), oxalate of lime {diabetes, Fiirbringer; asthma, Ungar), and triple phosphate (see chapter on Urine, the section upon these substances). Animal parasites. We may have whole echinococcus bladders or their fragments (recognized upon cross-section by the remarkable. EX A MINA TION OF THE R ESP IRA TOR Y A PPARA TUS. 183 uniform streaking), and also the hooks of the scolices in the sputum, in case one of these parasites enters the bronchial tubes by rupture from the lungs or liver (slight increase in size). Fig. 38. Echinoeoccus. (Scolices, hooks, after Heller ) The (exotic) Bistoma jJu^monale (Balz) which causes hemorrhage without any other manifestation, declares itself by its eggs in the sputum (to be seen by the simple microscope). Fig. 39. Echinoeoccus membrane, cross-section enlarged. Infusoria (Monas, Cercomonas- Kannenherg) are found in gangrene ; they are seemingly without significance. Fungi (for the macroscopic evidences of the presence of some of them see p. 175). 184 SPECIAL DIAGNOSIS. Leptothrix huccalis is present in the yellow scum arising on sputum that has been standing some time, as has already been mentioned, in the bronchial plugs in putrid bronchitis (besides crystals of fatty acids), and also occurring separately. Either it is first mixed in the sputum in the mouth, or it has entered the air-passages from the mouth ; but it is present there without any known pathological significance. Specific reaction: With iodine and potass, iod., blue- red. Without this reaction it may be confounded with elastic threads, even with fatty acids (see the chapter on the Digestive Apparatus). Fig. 40. Tubercle bacilli in the Bpiitum, first colored with anilin-fuchsine and then with methylene-blue. Zeiss's homog. immersion j'j, Oc. 4, camera lucida drawing. Mag- nified about 1000 diam. Sareina pulmonaUs is a fungus formed by division from developing endogenous spores (Hauser). While it is similar, although smaller, it has nothing to do with sareina ventriculi. The recent views upon their frequent presence may be somewhat questioned (confounded with Miernccus tetragenus (?) Fliigge). It has no known pathological significance. EXAMINATION OF THE RESPIRATORY APPARATUS. 185 Tubercle bacillus (Koch). This generally occurs in the purulent parts of the sputum of tuberculosis of the lungs or trachea. Excep- tionally it may be mixed with the sputum from the throat and pharynx (nose), in case a tubercle breaks up at that point. They are generally very abundant in the so-called "lintels," and (rarely) in very small white scales (see p. 175). These split fungi ai-e straight or moderately — rarely much — bent, very thin rods of somewhat variable length (2 to almost 4 ^.^ — that is, very like the diameter of a moderate-sized white blood corpuscle). They often contain spores. On account of their thinness and because they are without motion, they are with difficulty seen in the sputum unless they are colored. In order to bring them into view we stain them, and by a method which at the same time produces a special reaction, and so a very certain proof that it is the tubercle bacillus and not one of the numerous other bacilli. It is to be magnified 600-400, or, for those accustomed to examine for it, 300 diameters — that is to say, with a -^^ Abbe oil immersion lens, or a Hartnack No, 8 or at most No. 7. Methods. I. (Weigert, Ehrlich.) With perfectly clean needles we place some sputum upon a plate with a black surface, and there spread it out with the needles. From this is selected a suitable por- tion (see above) and place it upon a glass cover, and then it is to be broken up with the needles. Upon this is now placed another glass cover and the two are pressed firmly together. What is squeezed out upon the edges is to be washed away, and then the two glasses are to be carefully separated, so that there may remain upon each the thinnest possible layer, equally distributed. These are then laid aside to dry. Then 20 drops of anilin oil are thoroughly mixed with a reagent glass full of distilled water, it being shaken till it is intimately mixed. The mixture is allowed to stand for a short time, and then some of it is to be filtered through a moistened filter into a watch-glass. From a previously prepared concentrated alcoholic solution of gentian- violet there is then to be added sufficient to make the mixture turbid or to cause a slight metallic shimmer to appear upon the surface ; about 6 drops are necessary. Good fuchsine S. is necessary. The glass covers are allowed to dry in the air, and then each is passed three times through the flame of a spirit-lamp and laid in the \} The Greek letter fj, represents one-thousandth of a millimetre (^= 0.001 mm.), and is the sign'of a micro-millimetre, or a micron-l 186 SPECIAL DIAGNOSIS. coloring-solution with the sputum side down. The watch-glass, covered over, is allowed to stand for twenty-four hours, or it is slowly warmed over the spirit-lamp until a slight deposit of moisture appears not only upon the edges, but also upon the middle, and then it is set aside for about ten minutes. The manipulation is continued by washing the glass cover in water and then for a few seconds dipping it in a mixture of one part of nitric acid and two of water (without letting go of it with- the pincers) until it, being again washed in water, continues to show a slight violet shimmer. Then the preparation may be immediately examined in water : the tubercle bacilli are colored an intense violet, while all the rest is colored a pale reddish tone. It is advisable to stain the glass cover a second time with a watery solution of methylene-blue, which is done by placing it in this solution for a minute or two after taking it out of the acid mixture and thoroughly Avashing it with water, then again washing it, when it may be examined. Instead of fuchsine- and methylene-blue we may, in exactly the same way, employ Bismarck-brown or the gentian- violet,. The pre- parations are preserved by first drying them in the air, then passing them three times through the flame before laying them upon an object- glass upon which has been placed a drop of xylo-Canada balsam. The staining with the nitric acid solution must not be too strong, else the bacilli lose their coloring. With preparations that are to be preserved, the nitric acid must be very carefully removed by repeated washings with water, because the acid destroys the color. The alcoholic gentian-violet, as well as the fuchsine solution, retains its color very well. Sometimes the Bismarck-brown, and also the methylene-blue, must be filtered before using. Besides these, one needs for his work a black plate, two needles, a pincette with broad beak, some watch-glasses, object-glasses and covers, and a spirit-lamp. Biedert has recently recommended the following method for demonstrating the bacilli when they are scant in numbers : A tea- spoonful of sputum and two teaspoonfuls of water are boiled with fifteen drops of solution of caustic soda, then four teaspoonfuls more of water are added and the whole again boiled till it forms a homogeneous fluid. It is allowed to stand for two days (not longer) in a conical glass ; possible bacilli (and elastic fibres) form a sediment. The sedi- ment is stained, not by the method described above, but by the EXAMINATION OF THE RESPIRATORY APPARATUS. 187 method recommended by Ziehl-Neelsen : instead of the aniline water and gentian-violet, we use a mixture of 90 parts of a 5-per-cent. solution of carbolic acid and 10 parts of concentrated alcoholic solu- tion of fuchsine, staining by heat as above described ; the other pro- cedures are also the same as above referred to. Where one is not accustomed to examine for bacillus tuberculosis, for the purpose of controlling the degree of staining some sputum that is known to contain the bacillus should be colored at the same time. II. A new and decidedly useful mode of procedure is given by Gabett. A dry preparation, which has been passed through a flame, is placed for two minutes in a solution of 1 part of fuchsine S in 100 parts of a 50-per-cent. solution of carbolic acid and 10 parts of abso- lute alcohol, and then, immediately after, for one minute in a solution of two parts of methylene-blue to 100 parts of 25-per-cent. sulphuric acid. It is rinsed with water, and then, for preservation, is washed with alcohol, dried, and mounted in Canada balsam. For the sake of greater certainty, it may be warmed in the first solution. The preparations are very beautiful and permanent. The method seems to be a very distinct one. It is necessary to make very thin, and likewise uniformly thin, preparations. The tubercle bacilli are distinctly recognized by their red (or blue) staining. Since the spores that may be present are not stained, they may be seen in the interior of bacilli as clear points, and they may be so abundant as to cause the bacilli, when only slightly magnified, to look like the chain coccus (Fig. 40). The presence of this bacillus in the sputum indicates tuberculosis of the lungs (unless there may be tuberculosis of the larynx). Quite a close approximation of the severity of the disease may be made by their abundance, but more closely by the quantity of the spores. Bacilli may often be discovered when the physical signs are still indis- tinct or are altogether wanting. Absence of the bacilli at a single examination is without value. So, also, when the sputum is scanty and not very purulent, if they are absent in repeated examinations this fact is to be considered with greater caution. On the other hand, in sputum that is not too scantily purulent, the constant failure to find bacilli points with greater probability against tuberculosis. It is to be understood that 188 SPECIAL DIAGNOSIS. the staining material is as it should be (see above), that the staining has been properly done, and that the most careful examination of the preparation has been made. The culture-test, with the material in question, would come still nearer the truth. (See also in Appendix.) Pneumonia cocci : The reports regarding these cocci are still con- flicting. Friedljinder has found micrococci both in the sputum and in the tissue-fluid, of oval form, single, or two or three arranged together, lying in a capsule which can be stained. But Friedlander himself acknowledges that, without the existence of pneumonia, these cocci — or cocci which cannot be microscopically distinguished from them — are also found in the sputum. We have found Friedlander's cocci Fig. 41. Frankel's pneumonia coccus, bred from the expectoration. Prepared by Prof. Gartner. Oil immersion lens, one-twelfth; eye-piece No. 4. in numerous cases of broncho-pneumonia and bronchitis. The cocci which A. Frankel found in the lungs in pneumonia are lancet-shaped and they generally occur as double cocci, and are, like Friedlander's, in a capsule. Frankel's coccus is likewise found in empyema and meningitis, which complicate croupous pneumonia. It also occurs in normal saliva. Finally, Pio Foa has discovered in the tissue-juice of the pneumonic lung a diplococcus inclosed in a capsule which is very like both of the cocci named above. Staining of Friedlander's coccus : A dry covering-glass preparation is placed for a few minutes in a 1-per-cent. solution of acetic acid, then this is blown away with a pipette ; dry in the air ; dip for a few seconds in aniline water-gentian-violet (see above), rinse in water (Friedlander.) Frankel's coccus is stained with all aniline dyes. Pio Foa recommends Gram's method for his coccus. 3. Micrococci and haciUi of all sorts, also spiroehceten, are found EXAMINATION OF THE RESPIRATORY APPARATUS. 189 in every specimen of mouth-sputum. They are very much increased in fetid bronchitis, in bronchiectatic cavities, and gangrene of the lungs; and also in every sputum that has stood long and become foul. Fig. 42. ^m^ •'>S>., Micrococci, bacilli, spirals, spirochseten, from the expectoration. (After Pfltjegge.) There may be a simple staining of the dry preparation with methylene-blue, after which it is to be rinsed in water. Or, the prepa- ration, stained according to Gram, with gentian-violet aniline water (see p. 187), may be taken from this and immersed for two or three minutes Fig. 43. t" ^ 'Mimr' ^^^-^^ Actinomyces. (After v. Jaksch.) in the following preparation : Iodine, 1, potass, iod., 2, aq. destil., 300 ; then in absolute alcohol till the color disappears. Only the microbes are stained, but these are intensely colored. 4. Actinomyces. In actinomycosis of the lungs or of the pleura, actinomyces, in isolated cases, are found in the sputum. I have observed them in the characteristic small kernels (see p. 175). It is recognized by the projections, like clubs, closely pressed together, which project from the surface of a confused mass, which look much like detritus. We can best see the club-like projections without 190 SPECIAL DIAGNOSIS. Staining. The fungus can be distinctly stained by Gram's method [described on the preceding page]. Mould (aspergillus, mucor) and isolated yeast-cells, when seen in the sputum are without significance. The microbe of whooping-cough of Letzerich and Berger still needs confirmation. Chemical Examination. — This has a minor place, considered with reference to diagnosis. There occur in the sputum albuminous corpuscles in the form of mucin, nuclein, serum-albumin. The latter is very abundant in oedema of the lungs. Peptone is found very abundantly in the sputum after the crisis of pneumonia (Kosselt) ; it is also found in excess in all purulent sputum. Temporary fatty acids occur very abundantly in gangrene of the lungs (Hoppe-Seyler, Leyden, and Jaffe). Finally, it is notable that in gangrene of the lungs and bronchitis there is found a ferment like the pancreas ferment (Filehne, Stol- nikow). CHAP TEE Y. exa:\iinatiox of the circulatory apparatus. EXAMIXATIOX OF THE HeART. The development of the methods of local examination of the heai't is closely connected with the introduction of percussion and ausculta- tion. So we have here also chiefly to thank Laennec and Skoda, as well as Piorry, Friedreich, Bamber, and Gerhardt. ANATOMY OF THE XORMAL HEART. The heart lies upon the diaphragm, sloping obliquely forward in such a way that its long axis is inclined forward and toward the left. It extends from about 8 or 9 centimetres to the left of the median line (apex of the heart), to about 4 or 5 centimetres to the right of the same {i.e., about one and a half finger-breadths to the right of the right border of the sternum — right auricle), so that about two- thirds of the heart is in the left half of the chest, and one-third in the right half. Its highest point (the left auricle) is at the lower border of the sternal insertion of the second rib, its lowest point at the upper border of the sixth costal cartilage, or the fifth intercostal space (see Fig. 4-4). The three borders of the heart are formed as follows : the right by the right auricle, the lower by the right ventricle, and the left bv the left ventricle. The latter lies with onlv a diminishing; portion on the anterior surface, much the greater part of which is formed by the right ventricle. The figure (Fig. 44) shows how the lungs glide over the heart, so that only a small four-cornered portion, belonging exclusively to the right ventricle, is in contact with the wall of the chest. Of the bor- ders of this superficial part of the heart, the one toward the right lies between the middle line and the left sternal hne, the upper behind the fourth rib, the left somewhat outside of the left parasternal line. Below, the heart is in relation with the liver in such a way that it (191; 192 SPECIA L DIA GNOSIS. overlaps the latter Avith its lower border. It can be seen from the course of the line c d, which indicates the complementary space of the incisura cardiaca lob. sup. sinistra, what a considerable portion of the heart which is in contact with the chest-wall would became still smaller if the lung should completely fill the complementary space. Fig. 44. "^^ TO Position of the contents of the thorax, of the stomach, and of the liver from in front. (Weil-Luschka.) The portions of the heart and liver which are drawn with unbroken hatched lines represent the extent to which these organs are in contact with the chest- wall. The portions that are not in contact with the chest- wall, but are covered by the lungs, are represented by broken (clear) hatched lines, ef, border of the right lung, ^r A, border of the left lung; a b a.nd c d {. . . .), the boundaries of the complementary pleural sinus. i, boundary between the upper and middle lobes of the right hing; k boundary between the middle and lower lobe of the right lung ; I, boundary between the upper and lower lobe of the left lung, w, stomach (greater curvature). These are the location and extent as they are found in the adult in the dorsal or upright position. With children the heart (as well as the diaphragm and the lower borders of the lungs) is about one rib higher. It is also, since it is proportionately larger, to a larger extent in con- tact with the wall of the chest ; with increasing age, on the other hand, it moves lower down (to the lower border of the sixth rib (the EXAMINATION OF THE CIRCULATORY APPARATUS. I93 sixth intercostal space) with a smaller portion parietal, since, the lungs lie over it to a larger extent. In the side position, especially on the left side, the heart always sinks very considerably to the lower side. (See under Apex-beat.) Situs viscerum inversus exhibits the heart in such a way that *' right" and "left" are exactly reversed, like the reflection in a mirror. Hence we need not say anything more about it. Pkeliminart Remarks necessary to Understand the Physical Phenomena of the Heart. What follows is a brief explanation of those facts regarding the physiology and the general pathology of the heart, which must be always kept in mind by the educated physician in examining and forming a judgment of the heart. 1. The movement of the blood in the heart. The blood flows from the body through the cavce into the right auricle, from whence, during the ventricular diastole, it passes through the right auriculo-ven- tricular opening, the tricuspid valve, into the right ventricle, being urged forward toward the end of the diastole by the weak muscular contraction of the right auricle. The systole which immediately fol- lows drives the blood out of the ventricle, the tricuspid valve being at the same time closed, through the open pulmonary semilunar valve into the pulmonary artery. The blood, prevented from flowing back into the ventricle during the diastole which immediately follows by the closure of the pulmonary semilunar valve, passes through the lungs, and from them flows into the left auricle, whence, by the dias- tole of the ventricle, it flows through the left auriculo-ventricular opening, the mitral valve, into the left ventricle, whither it is again assisted at the end of the diastole by the contraction of the auricle. The left ventricle discharges its contents during the systole (the mitral valve being closed) into the commencement of the aorta, through the open aortic-semilunar valve, whence it is prevented from returning to the ventricle when the pressure from the ventricle ceases and the diastole begins, by the closure of the aortic semilunar valve. The blood then flows from the conus aortce. into the body. 2. Valvular insufficiency and its effects iqjon the movement of the blood. From the foregoing it is evident that the openings of the 13 194 SPECIAL DIAGNOSIS. heart are very important factors, on the one side being the entrance and exit of the ventricles, and on the other being the location of the valves of the heart which hinder any backward flow of the blood. The motion of ^the blood can only in two ways be interfered with by pathological processes at the openings of the heart : either by nar- rowing at the opening (stenosis of valve), or by the valves losing their power to close {insufficiency of the particular valve). Stenosis of an opening may be caused by products of endocarditis, which cause adhesion of the flaps of the valve, with formation of a cicatricial narrowing ring at the base of the valves. Insufiiciency may likewise be caused by endocarditis (general shortening of the flaps and of the tendinous processes of the papillary muscles), and this is the most frequent cause of insufficiency ; but the condition may also arise from a distention of the opening so that the flaps are too short to close it (relative valvular insufficiency, in weak heart with dilatation). An opening that is narrowed hinders the passage of the blood through it. If it is an auriculo-ventricular opening {mitral or tri- cuspid stenosis), then, at the moment of diastole of the heart, the blood is hindered in its entrance into the ventricles : there is imperfect filling of the ventricles ; if it is an arterial opening that is narrowed {aortic or pulmonary stenosis), then the exit of the blood from the ventricles at the systole is interfered with. If the valvular mechanism is in such a condition that it cannot perfectly close, then at the moment when it ought to close it allows a part of the blood to flow backward. If the difficulty is with the entrance to the ventricles {insufficiency of mitral or tricuspid valve), then with the systole a part of the contents of the ventricle flows back into the auricle ; but if the deficiency is at the outlet of the ventricle {insufficiency of the aortic or pulmonary valve), then at the end of the systole, during the diastole which follows, a part of the blood that has just been thrown into the artery will be thrown back into the ventricle. In one respect all the defects that have been mentioned are alike : they check the blood current, they cause a stasis of blood in that chamber of the heart which is, with reference to the direction of the blood current, just behind the defective opening. Thus a defect of an arterial opening causes stasis in the corresponding ventricle ; a defect EXAMINATION OF THE CIRCULATORY APPARATUS. 195 in an auriculo-ventricular opening occasions stasis in the corresponding auricle, and also beyond this in the corresponding veins. 3. Compensation, accommodation of valvular deficiency. The abnormal resistance which is exerted against the blood-current from the valvular defect would immediately lead to more considerable dis- turbances of the blood-current if it were not promptly equalized by the increased work of that section of the heart lying (in the course of the blood-current) above the point of resistance. But this does not con- tinue, for with increased work the overloaded section of the heart becomes hypertrophied — compensatory liypei'trophy. This condition is extremely simple in defects at the aortic opening. They are com- pensated by hypertrophy of the left ventricle, which is associated with dilatation (eccentric dilatation). The latter is especially marked in insufficiency of the aortic valve, and this is explained by the fact that, with aortic insufficiency, the left ventricle during the diastole receives blood from two sources, hence very much more than normal. With mitral'insufficiency the auricle must accommodate for the defect; but, notwithstanding the fact that it becomes dilated and hypertrophied, it cannot perform the necessary work, cannot overcome the stagnation : the accumulated blood passes through it to the veins of the lungs, capillaries and arteries of the lungs, and so on till it reaches the right ventricle ; this becomes dilated and hypertrophied, and thus causes the increase of the propulsive power necessary for the accommodation. Though defect of the valve of the pulmonary artery is rare, the actual consequences are the same as of defect of the aortic valve, defect of the tricuspid, which is likewise rare, with the exception of relative insufficiency, and produces accommodation of hypertrophy of the right auricle, but only to a very slight degree ; for the increased pressure in the general venous system has no effect upon the pressure in the arteries of the body, and hence cannot produce any notable compensatory hypertrophy of the left ventricle. Thus, insufficiency and stenosis of the aorta cause hypertrophy of the left, and insufficiency and stenosis of the mitral valve hypertrophy of the right, ventricle. But with mitral insufficiency something more follows : during the diastole of the left ventricle there flows into it from the dilated auricle the blood which has accumulated there under very much increased pressure and in increased quantity ; it becomes dilated^ and, since it also has to dispose of the increased quantity of 196 SPECIAL DIAGNOSIS. blood, which it does by driving part of it forward into the aorta and part backward through the mitral orifice into the auricle, it also becomes hypertrophied. Hence mitral insufficiency leads to hyper- trophy and dilatation of both ventricles. These different hypertrophies are aids in the diagnosis of the indi- vidual valvular lesions. 4. Hypertrophy of the heart from other causes. Besides the val- vular defects, certain other conditions lead to hypertrophy : thus, the left ventricle becomes hypertrophied by the increased resistance in the general arterial system produced by sclerosis of the arteries ; it sometimes results from continued excessive muscular exertion {idio- pathic hypertrophy)., further, from different forms of chronic nephritis, and in this it is more marked the longer the general vigor is main- tained (hence most marked in renal atrophy) ; finally, also in acute nephritis., if it lasts long enough. The right ventricle becomes hypertrophied whenever there is continued increased resistance in the pulmonary circulation, most regularly and markedly in emphysema (from destruction of the capillaries of the lungs from atrophy of the tissue), in marked contraction of the lutigs, in marked kyphoscoliosis. 5. The form of the heart is changed in consequence of the hyper- trophy (and dilatation) : hypertrophy of the left ventricle broadens the heart to the left and somewhat lengthens it ; if there is dilatation also, the broadening to the left is still more increased. Hypertrophy and dilatation to the right ventricle simply broaden the heart to the right. Hypertrophy and dilatation of both ventricles broaden the heart in both directions and lengthen it. 6. Simple dilatation. This results entirely from weakness or paralysis, and is dependent upon a diminished tone of the heart-muscle with a simultaneous loss of its power to contract. It may also occur in a heart that was previously dilated and hypertrophied, and it then results in a very great enlargement of the heart. In dilatation of the heart the enlargrement is nearlv svmmetrical in all directions. The diagnosis between enlargement of the heart from hypertrophy (with dilatation) and the dilatation just mentioned is chiefly made by the consideration of the evidences of the amount of work the heart is doing. 7. TJie extent to ivhich the heart is in contact with the chest-wall is in very close relation to the size of the heart (regarding the peri- EXAMINATION OF THE CIRCULATORY APPARATUS. 197 cardium, see later). An enlarged heart always has a larger area in contact with the chest-wall than does a normal heart, if there are no conditions in the neighborhood of the heart which keep it away from the chest- wall. This may be occasioned by emphysema of the lungs, or by an increase in the volume of the lungs, whether from anomaly of both lungs or only of the left lung, either chronic or temporary. In emphysema a normal heart therefore would be to a less extent parietal than if the lungs were normal ; hence in case of emphysema an enlarged heart may possibly not be manifest by its size, as it would be if the lungs were normal. When there are both enlargement of the heart and emphysema of the lungs the heart may be found to be parietal only to the normal extent, or may be so to an even less extent than normal (overlying of the heart). Still another condition has its effect : inflammatory adhesion of the border of the lungs at the incisura cardiaca with the parietal pleura. This unchangeably determines the parietal relation of the heart. And yet, often in this condition, just the opposite takes place, as in the pre- vious case ; from shrinking, the lung is somewhat drawn away from the heart and thus it is more largely parietal than, according to its size, it would be. Enlargement of the heart may thus be simulated. Hence in forming an opinion as to the size of the heart from the extent to which it is in contact with the chest-wall we must always bear in mind the possibility of the presence of these conditions (see Percussion ; " absolute heart dulness "). INSPECTION AND PALPATION OF THE REGION OF THE HEART.'^ Both these methods of examining the heart, like the foregoing, will be best practised in a moderately high dorsal position. There are technical difficulties in examining a patient either standing or sitting; but sometimes in severe heart diseases the latter cannot be avoided on account of the existence of ortJiopnoea (see pp. 32, 97). Palpation may be performed either with the tips of the first and second fingers, or with the fiat, bare hand. The Apex-heat. Normal conditions. The apex-beat is of the greatest importance as an anatomical starting-point, for it corresponds either exactly to 1 The' two methods of examination have such close connection with reference to the heart that to separate them would seem to be artificial. 198 SPECIAL DIAGNOSIS. the apex or to a spot very close to it, a little nearer to the median line. In the majority of healthy persons it is recognizable, by the eye, as well as by the finger applied to the spot, as a rhythmical and systolic projection forward about the breadth of the finger, which in the adult in the upright or dorsal position occurs in the fifth intercostal space just within the mammillary line ; only exceptionally, chiefly with persons with very short chest, it is found in the fourth intercostal space. In children, up to the age of ten years, it is usually found in the fourth intercostal space and either in the mammillary line or just outside of it (see above in the section on Anatomy). In old age, on the contrary, it is sometimes found in the sixth intercostal space. Much fat, or the mamma, also narrow intercostal spaces, render it invisible, but yet it may generally be felt. Moreover, without a distinct cause, it may sometimes be entirely wanting in healthy persons. Quiet breathing produces no change in the apex-beat. With deep inspiration, it is covered by the distended lung, which then occupies the complementary space ; if it be still evident, it moves sometimes an intercostal space lower down, corresponding to the inspiratory sinking of the diaphragm. The effect of change of posture is very noticeable in the side posi- tion : the left-side position moves the apex-beat outward beyond the mammillary line, even as far as the anterior axillary line ; the right- side position causes the beat to disappear or moves it somewhat to the right. Physical exertion and mental excitement, the chief physiological disturbers of the heart's action, may noticeably change the apex-beat in perfectly sound persons, but still more in nervous persons : it may become plainly stronger and even broader, or move somewhat to the left. There is much dispute as to the cause of the apex-heat. It is certain that it is produced by a variety of causes. Briefly stated they are as follows : 1. Change in the form of the heart at the systole: its transverse measurement (antero-posteriorly) increases (Ludvig) ; the apex moves forward, to the right, and upward (Filehne, Penzoldt). 2. Change in the location of the heart : it revolves upon its long axis, so that the stronger left ventricle moves toward the front. EXAMINATION OF THE CIRCULATORY APPARATUS. 199 The assumption that has hitherto been made that the apex-beat is wholly or in part to be explained by the recoil (the so-called Gutbrod- Skoda, better Alderson's, theory), must henceforth be regarded as abandoned, since Martius has proved that, at the time when the apex- stroke takes place, the semilunar valves are not yet closed, and the gush of the blood into the vessels consequently does not begin till the apex-stroke is over. Displacement (dislocation) of the apex-heat in disease. It may be brought about : (a) by dislocation of the heart, (h) by enlargement of the heart. {a) Dislocation of the heart. The apex-beat is a very important sign for determining this, since the other methods often have a very indefinite result, or may entirely fail. Deformity of the thorax may cause displacement in all possible directions. It may happen that in a chest that is flattened or pressed- in in the neighborhood of the heart the apex-beat (likewise the heart) will be found considerably outward or considerably inward. Emphysema of the lungs., in case the apex-beat is not lost by the overlapping, presses it down into the sixth intercostal space (depression of the diaphragm). • In exudative pleuritis and jjneicmothorax the heart and apex-beat are pushed toward the sound side, in the worst cases as far to the left as the middle axillary line, but to the right very rarely beyond the mammillary line. Likewise, the mediastinum and the base of the heart move over, although not so far as the apex. 3Iediastinal tumors may have the same effect as pleuritis of the right side. In pleurisy of the right side the apex is sometimes pushed not only to the left but also upward into the fourth intercostal space. We are not certain why this is so. It is highly improbable that the left lobe of the liver rises up while the right is dragged down, for the point of traction, the suspensory ligament, brings it still lower by the pressure of the exudation upon the right side. The location of the heart when pressed upon is subject to many disturbances, which we cannot describe at this time. Shrinking of the Imigs and of the side of the chest after a pleuritis draws the mediastinum and the heart into the diseased side, and at the same time draws the diaphragm up ; hence in shrinking of the right side the heart moves upward and to the right side, but in disease of the left side it is drawn upward or upward and to the left. 200 SPECIAL DIAGNOSIS. If the heart chances to be drawn to the right so much as to bring it under or close up to the sternum, where the intercostal spaces are very narrow, of course we cannot observe the apex-beat. In exudative pleuritis it sometimes happens that the heart becomes fixed by inflammatory adhesions, and then the apex-beat remains at that point even after the cause of the displacement has been removed. Elevation of the diaphragm as a result of peritonitis or of simple mechanical pressure from below, or from neurotic paralysis of the diaphragm, causes dislocation of the heart upwai'd or upward and to the left. (6) Enlargement of the heart. Sypertrophy and dilatation of the left ventricle are made manifest by displacement of the apex-beat outward or outward and downward, and under some circumstances as far as to the posterior axillary line and the eighth intercostal space. The apex-beat is also broader and stronger, see below. The conditions which bring about hypertrophy and dilatation of the left side have been referred to on page 195. Likewise hyper- trophy and dilatation of the right ventricle displace the apex-beat a little toward the left, since the large right ventricle pushes the left somewhat to one side. But the displacement is always quite small, at most not beyond the mammillary line. Alteration in the Width and Strength of the Apex-heat. We judge of the breadth both by inspection and palpation. We seldom have an increase in the breadth without an increase in the strength as well : in the normal heart, if it becomes parietal over a larger area from shrinking of the lungs ; moreover, I have sometimes seen it with deformity of the chest (without hypertrophy of the heart) and where there was marked wasting, so that the patient was very lean. As a rule, breadth of the apex-beat is associated with a strong beat. The strength of the apex-beat can only be made out by palpation. By constant practice with the hand it can be distinctly recognized. An apex-beat that is so strong that it lifts the finger that is mod- erately pressing over it is called "heaving." Temporary, often notably strengthened and moderately broadened impulse is caused by increased heart- work (see above) in consequence EXAMINATION OF THE CIRCULATORY APPARATUS. 201 of exertion and mental excitement. For this reason the heart ought always to be examined only when these two conditions can be excluded. In nervous palpitation^ Basedow" s disease, and sometimes in chronic nicotine-poisoning, the heart-beat may for a time be very much stronger and even somewhat broader, as an indication of the increased work of the heart, without any organic change in it. The same thing occurs, though in a moderate degree, in fever. Moreover the apex- beat may be stronger at the same time that the heart's work is not increased if the heart is pressed firmly against the chest-wall, as in mediastinal tumors. Continued strength and breadth of apex-heat is the most important sign of hypertrophy of the left ventricle. In well-marked cases the beat is "heaving," and is as wide as several fingers — being displaced toward the left and downward (see above). It is assumed that an enlarged heart works with strength increased in proportion to its increased volume. If the heart becomes weak, then there is a diminution as regards the breadth and strength ; and yet it may be distinctly recognized as diseased. In many cases it is difficult to separate the apex-beat from the "heart-beat" in general, for which see p. 203. Weakening of the apex-heat. It has been mentioned already that the apex-beat may be weak in persons who are perfectly healthy, or it may be entirely wanting. Pathologically it is diminished or lost : By the activity of the heart being concealed by overlapping : from emphysema of the lungs, by a pleuritic or pericardial exudation, and by tumors. By oedeyna, emphysema of the skin, inflammatory diseases of the chest-wall in the neighborhood of the heart. By diminution of the work of the heart, as takes place with any kind of degeneration of the heart-muscle ; here we may mention : myocarditis, lipomatosis cordis, weakness or degeneration of an hyper- trophied heart, especially with incompensation with valvular deficiency, weakness in febrile diseases (especially collapse). The disappearance of an apex-beat which has previously been dis- tinct is sometimes the only sure, and hence is a very important, sign of the development of exudative pericarditis. But diminution of the 202 SPECIAL DIAGNOSIS. work of the heart is more distinctly declared at the radial pulse than by the apex-beat ; see below for the explanation of the meaning of all these conditions. Moreover, the radial pulse is the only direct meas- urer of what the heart does in all the above-mentioned cases of con- cealment of the work of the heart. It is especially important in pericarditis. Where the apex-beat is covered by fluid in the pericardium it often again becomes distinct when the patient sits up or bends forward, because the heart then, on account of its greater weight, rests against the chest-wall. It is then often found in the sixth intercostal space, because the distended pericardium presses the diaphragm down. This sign, of course, is wanting in cases where the apex-beat is missed from weakness of the heart. Further, the apex-beat is wanting where there are i^ericardial adhesions (see below under Systolic Drawing-in), and sometimes in stenosis of the commencement of the aorta, and this notwithstandino' the existence of hypertrophy of the left ventricle (slow ventricular contraction resulting fi-om difficulty in emptying itself). So far as experience goes, '■'systolic drawing-in'' in the neighbor- hood of the apex-beat has no diagnostic value. Regarding systolic drawing-in of the whole lower region of the heart, see below. Doubling of the apex-heat, so that a single pulsation of the carotid corresponds to two beats at the apex, occurs in hemisystole (Levden). By this we have understood an action of the heart in which both ven- tricles do not contract exactly simultaneously, so that then the con- traction of the left ventricle, as well as the right, causes an apex-beat. But it is probable that we here have in these cases simply an alternating action of the heart (see Pulsus Alternans), in which the contraction of the heart is too feeble to produce a perceptible pulse every time. The application of the graphic method to the apex-beat (cardi- ography) has thus far yielded no notable contribution to pathologv. T7ie Neighborhood of the Heart in general. Projection of the neighborhood of the heart, including the ribs and sterpum, takes place gradually in marked hypertrophy and dilatation ; when there are hypertrophy and dilatation of both ventricles or of the EXAMINATION OF THE CIRCULATORY APPARATUS. 203 right alone the swelling extends sometimes beyond the sternum ; in hypertrophy of the left ventricle alone it lies more to the left. Peri- carditis exudativa sometimes causes a distinct swelling. This sign depends upon two factors : the size of the heart or of the pericardium, and the flexibility of the chest-wall. If the latter is marked the swelling develops quickly, as in acute pericarditis, and is very marked (enlargement of the heart in children) ; when the thorax is rigid there may be no projection, though the heart is very large. This condition is not to be confounded with the pressing forward of the heart from mediastinal tumors — aneurism. Generally when there is a broad heart-beat in the intercostal spaces in the neighborhood of the heart, and even upon the ribs and sternum, it is from a hyper- trophy of the heart. But, also, when there is contraction of the left lung, with the heart free from attachment, the motions of the heart may be seen as well as felt over a broader extent in the intercostal spaces. If, in such cases, the heart's action is excited, there is the impression of a notable hypertrophy of the heart, even when the heart is quite normal in size. If, in a case where the heart, from dilatation or retraction of the lungs, is more extensively parietal, weakness of the heart occurs, then we not infrequently see a broader waving in the intercostal spaces, which, by its evident lack of energy, is visibly in contrast with its former powerful motions. It is sometimes very difiicult to distinguish a broadened heart-beat from the ordinary apex-beat ; but generally it can be distinguished by its having peculiar vigor, more than other heart motions. Pulsations at the base of the heart sharply limited to the second intercostal space on the right and left side of the sternum come from the aorta or pulmonary artery. They are rarely visible; generally they can only be felt. . If they are systolic they may indicate aneurism of these vessels. More frequently we may feel a diastolic shock, but especially upon the left over the pulmonary artery. If the lungs and heart are normal it cannot be felt ; but if the lungs are drawn back from the base of the heart (by shrinking, or by enlargement of the heart), or if there is thickening, then it may be felt, especially if it is simultaneously strengthened by hypertrophy of the right ventricle. In emphysema of the lungs there exists the peculiar condition that, al- though the closure of the pulmonary valve is in a marked degree stronger, yet it cannot be made out because the inflated lung lies over it. 204 SPECIAL DIAGNOSIS. Pulsation in the region about the heart occurs in empyema lying near the heart upon the left side (empyema pulsans) ; farther in, aortic aneurism (which see). Although systolic drawing-in at the apex of the heart is of no significance (see above), yet systolic drawing-in of several intercostal spaces in the neighborhood of the heart,, but especially of the ribs and the lower part of the sternum, is of diagnostic value : it is probable that there is pericarditis aclhesiva with mediastinal pericarditis, accompanied by thickening. But yet these signs may be entirely wanting, although the condition is present ; and, on the other hand, they may be observed in cases where this condition does not exist. The drawing-in may be caused by a dense mediastinum being adherent to the spine and again by pericardial adhesion to the chest-wall; its contraction — that is, its constantly becoming shorter — must of necessity cause a drawing-in of the chest- wall. ^^ Buzzing " and friction-sounds that may be felt in the neighborhood of the heart accompany very marked endocardial or pericardial sounds (see under Auscultation). The Epigastrium. In inspecting and palpating the heart this must always be considered. Systolic tremhling, or even systolic pulsation, may be observed here if the heart, more particularly the right ventricle, is drawn nearer the abdominal wall by the depression of the diaphragm, but especially is this the case when, at the same time, the right ventricle is hypertrophied — emphysema of the lungs. This epigastric pulsation must not be confounded with that which is to be seen from the abdominal aorta when the abdomen is very empty, and the abdominal wall very thin, whether the aorta pulsates normally strongly or not, or whether there is an aneurism of the abdominal aorta. This pulsation is, moreover, best transmitted when a tumor of the lymphatic glands, of the stomach, or a thin but firm liver, lies over the aorta. Sometimes (not always) the pulse is felt noticeably later than the systole of the heart. PERCUSSIOX OF THE HEART. This has for its object the determination : 1. Of the absolute, "small" dulness of the heart, which corre- EXAMINATIOX OF THE CIRCULATORY APPARATUS. 205 spends with the portion of the heart that is in contact with the chest- wall ; and which has an almost definite relation to the size of the heart. 2. The so-called relative heart-dulness, which lies above and to the left of the absolute dulness, and which is determined by the thinness of the lungs around its border (see above, page 124). It often stands indirectly in some relation to the size of the heart, but it is not appli- cable for ascertaining it. It does not even show the exact size of the heart. To these two, Ebstein has added : 3. Palpatory/ percussion of the " heart's resistance," which is deter- mined by ascertaining the anatomical size of the heart ; regarding this method see below. Normal Percussion Figure of the Heart. Methods of Percussiox. 1. Absolute heart-dulness. This is determined by light per- cussion, and corresponds, in fact, to the portion of the heart that is parietal. In two respects it departs from this, though not essen- tially ; the small strip of the heart which is parietal behind the sternum between its left border and the inner border of the right lung, is not dull as would be expected, but gives a clear sound, as indeed occurs over the whole surface of the sternum (see above, page 123) ; on the other hand, the lingula of percussion is con- cealed, since it is not strong enough ; over it we notice absolutely deadened sound. Thus we have the following figure of the absolute heart dulness in persons in middle life (Fig. 45) : the boundary on the right is the left sternal line, the upper boundary lies upon the fourth rib, the left boundary is outside of the left parasternal line. The lower boundary toward the liver cannot be exactly determined, it being defined by the apex-beat, and generally also by the upper border of the sixth rib. In children the area of heart-dulness (absolute) is somewhat greater, the heart being relatively larger, the upper boundary in the third intercostal space ; hence the apex-beat is generally in the fourth intercostal space, the left boundary near the mammillary line ; in old age, however, it is smaller (from inflation of the lungs) about over the fifth rib, or the parasternal line. 206 SPECIAL DIAGNOSIS. In quiet breathing the dulness does not distinctly change ; in deep inspiration it is very decidedly diminished, or entirely disappears, because the costal cartilages come close together at the sternum. Compare the course of the boundary of the complementary space (Fig. 44). It makes no difference whether the examination is made in the dorsal or the upright position. Examination upon the side makes considerable alteration of the area of dulness. Fig. 45. Percussion boundary of the luns^s in front (Weil), g h. The upper limits of the lungs; ef, the lower limits of the lungs; b d, boundary between the lungs and heart at the incisura cardiaea. The strongly hatched surface represents the portions of the heart and liver that are in contact with the wall of the chest; the lighter hatching the so- called relative heart and liver deadness (see later), m. Spleen deadness. The beginner is apt to be much confused, because in a considerable part of the location of heart-dulness, even ■within the entire region, he "will find a tympanitic resonance. This is especially frequent in short persons with a short, thick thorax and a full abdomen. The resonance is from the stomach, which lies under the heart, and is more promptly elicited by strong than by weak percussion. When there is an otherwise normal condition of the heart and lungs this phenomenon has no pathological significance. EXAMINATION OF THE CIRCULATORY APPARATUS. 207 2. Relative heart- dulness. This forms a border around the abso- lute dulness to the left and above it, and it corresponds with the thinned-out portion of the lungs. It is revealed by stronger, and, in its upper part, by comparative percussion. It no doubt depends, in a certain degree, upon the perceptions of the individual making the examination as to where he will fix the limits between it and those of n^ormal lung sound. Hence, an individual examiner may, if he is accustomed to examine carefully with reference to its determination, be able to fix upon a line of demarcation very satisfactorily for him- self, but difi'erent examiners would not be able to agree among them- selves. Hence, the diflferences among authors as to the size and diag- nostic value of the area of relative heart-dulness. According to Weil, its course is as follows (see Fig. 45) : It begins above at the lower border of the third rib, continues in a curve down- ward toward the left, within the mammillary line. In rare cases there is also a relative dulness at the right of the absolute dulness, which is limited by the lower end of the sternum. In children the relative dulness begins in the third intercostal space, it extends some- what beyond the left mammillary line, and is also constantly present on the right, and, indeed, reaches even beyond the right side of the sternum. Whatever may be the meaning and value which these two regions of dulness may have as subjects for instruction and knowledge for physicians, there is no doubt that at least that of absolute dulness must be considered, since only regarding it is perfect agreement pos- sible, and since the amount of time and trouble which every student and young physician can and must employ in the practice of percus- sion sufiices for learning how to determine it. It is true, that in pathological cases a difficulty accompanies the determination of absolute dulness ; it indicates the parietal state of the heart, but this is dependent, not alone upon the size of the heart, but also upon that of the lungs, though, of course, in an opposite sense. This may make a conclusion regarding the size of the heart from the extent of absolute dulness difficult ; however, a person who accustoms himself every time he makes an examination to consider carefully the condition of the lungs when he is determining by per- ' cussion the figure of the heart, whether there is emphysema or shrink- ■ age — such a person may very materially diminish this difficulty. 208 SPECIAL DIAGNOSIS. Opinion is divided regarding Ebstein's newer method of determin- ing by direct palpatory percussion the resistance of the heart as the true image of the total size of the heart. Indeed, Eichhorst is the only one who warmly espouses the idea. It seems to me that there is no doubt of its use in many cases — that is to say, in those with delicate thorax having thin coverino; of flesh. At the same time I cannot recommend it as a subject for instruction to others, since it is liable to give rise to many mistakes, and in my opinion it is very difficult to learn. Riess has recently very strongly entered a plea for relative heart- dulness. He thinks that by a consideration of the relative dulness a figure could be di-awn which would very nearly represent the anatom- ical boundaries of the heart. We think this is going much too far, and that we must maintain the position that we have set forth above. 3. Method of percussing the heart. We percuss strongly on both sides close to the sternum going downward, and note the upper boundary of relative heart-dulness ; then we percuss lightly the upper boundary of absolute heart-dulness ; next we percuss upon the outer ends of radii drawn from the middle of what is thought to be area of absolute dulness (first the one obliquely upward to the right, then from the right, always beginning beyond the sternum ; then on the left obliquely upward ; lastly, from the left), always strongly at first to determine a possible relative dulness, then lightly for the absolute. At first we percuss at longer intervening spaces, of at least 1| centi- metres, and when a diff"erence of resonance is found then at short intervals of space over the particular region. In Fig. 45 the lines and the directions in which we ought to percuss are designated by arrows. Enlargement of the Area of Heart-dulness. Generally, relative and absolute dulness exist in about equal pro- portions, but, now and then, the relative may be very small. Always in enlargement of the right side of the heart, and sometimes in enlargement of the left side, relative dulness toward the right is increased as compared with the absolute. Heart-dulness is increased : 1. In hypertrophy and dilatation of the heart. If of the right ventricle, the dulness spreads toward the right, sometimes also slightly EXA^IIXATIOy OF THE CIRCULATORY APPARATUS. 209 toward the left, the whole involving the right half-circle. If the left ventricle is changed, the increased dulness is toward the left and downward, not infrequently also upward, but scarcely any, or at most very little, toward the right. Regarding a small independent dulness which sometimes is found on the right near the upper end of the sternum, see Aorta. 2. In dilatation of the heart (weak heart). This causes the pre- viously existing dulness, it may be of a normal heart or of one that was already hypertrophied, to spread out on both sides. (For dis- tinguishing from hypertrophy see "apex-beat" and " radial pulse.") 3. Fluid in the pericardium (pericarditis exudativa and hydro- pericardium). Generally, this causes the dulness to enlarge at first upward and then to the right and left. Not infrequently the area of dulness has a three-cornered shape — one point above close to the sternum, one on the right on the other side of the sternum below, and one on the left also below on the outer side of the mammillary line ; the relative dulness is generally very small. If the exudation is very large, the lung surrounding it is generally retracted, and hence around the dulness there is a border of tympanitic resonance. In sitting, the area of dulness is greater than in lying, and, when bending forward, still greater than in sitting, because there is a change in the extent of that which is parietal. Regarding the apex-beat in pericarditis, see p. 202 ; in the latter disease it is often deeper and not on the left border of the dulness, as in enlarged heart, but further toward the right and generally within the mammillary line (a not unimportant point in differential diagnosis). The pulse (which see) is often important, 4. With normal heart, but to a greater extent parietal, on account of retraction of the lung. In this case the mobility of the border of the lungs in deep breathing is completely wanting. The apex-beat may be normal, but by simultaneous displacement it is further to the left. 5. Apparent enlargement of the heart is noticed if anywhere in its neighborhood there is a diseased condition which causes absolute dul- ness. Of this kind we may name thickening of the lungs, of the pleura, of the mediastinum, and especially aneurism. It is almost impossible to mark the boundary between the heart and such patho- logical structures, since we are denied the aid of percussion ;. on the 14 210 SPECIAL DIAGNOSIS. other hand, an approximate determination may often be attained during auscultation by the appearances of motion (apex-beat, etc.), and sometimes by the vocal fremitus. Pulsating affections give especial difficulty, as aneurism and the empyema pulsans previously mentioned. Here the object is some- times attained by repeated examinations. For distinguishing em- pyema pulsans from aneurism, see the latter. Diminution or Loss of Heart-dulness. This takes place : 1. In emphysema of the lungs. It affects the parietal condition of the heart, whether it is normal or enlarged. If the heart is normal there is considerable diminution of the area of dulness, even, possibly, to its entire disappearance. If the heart is, at the same time, enlarged (as it has already been mentioned, it generally is in consequence of the emphysema, which causes hypertrophy of the right ventricle), the emphysema makes the dulness smaller than it would be with a heart of the same size and normal lungs. Hence, when there is emphysema we must make some addition to the extent of the dulness we are able to map out before we form a judgment regarding the heart. A normal area of heart-dulness, with the existence of a marked emphysema, indicates considerable hypertrophy of the heart, if there is no adhesion of the borders of the lungs. Hence, we must notice their active movability. 2. In pneumo-perieardium, entrance of air into the pericardium, either from without by an external injury or from within by perfora- tion of the oesophagus, stomach, or intestine, we may have the condi- tion of pneumothorax. There is then tympanitic or abnormally loud and deep resonance in the neighborhood of the heart (also, metallic heart-sound). Finally (very rarely) in emphysema of the mediastinum. (See p. 57.) Displacement (dislocation) of the Heart-dulness. This, of course, arises from displacement of the heart, as is declared by the apex-beat ; but in this case, for various reasons, it is generally an imperfect sign of such change. For one thing, it often happens EXAMINATION OF THE CIRCULATORY APPARATUS. 211 that the condition which causes the dislocation itself presents dulness, which invades the region of heart-dulness. This is the case when a pleuritic exudation displaces the heart, or when shrinking of the pleura or lungs distorts the heart. Again, it is usually especially difficult to determine the location of the heart by percussion if there exists a vicarious emphysema on the left side simultaneously with considerable shrinking on the right. In this case the heart is sometimes moved over to the middle of the thorax [mesocardia). Still further, the extent to which the heart is parietal is frequently changed by dislocation ; thus, when the diaphragm stands very high the heart is pushed upward, usually causing an increased area of dulness, since the heart is then more flat against the chest than is normal. If there is an aj)ex-beat in such cases, it is a very sure sign ; often it is necessary to employ auscultation to aid in establishing by the location of the greatest intensity of sound, at least approximatively, the position of the heart. Auscultation of the Heart. Method and Normal Condition. Method. Ordinarily we are to auscultate the heart exclusively by the stethoscope. After long practice and experience the examiner may think it advisable to compare what he hears with the stethoscope with the results of direct auscultation ; but these are exceptions. The very urgent reason for the use of the stethoscope is that by it we are able to distinguish as sharply as it is possible to do the impressions of sound which come from the different points, so as to be able to refer every sign to its proper place of origin. First of all, we are to examine the patient when he is in the greatest possible quietude of body and mind ; in some cases we may then, after we have begun, find it advantageous to increase the activity of the heart by having the patient make a certain amount of exertion (as by sitting up in bed several times in succession or moving about), since we can thus sometimes obtain certain signs clearer. This will be referred to from time to time. The position of the patient during the examination will, in general, be the same as for percussion, already 212 SPECIAL DIAGNOSIS. referred to. However, we often hear much plainer in the upright position, and hence in doubtful cases auscultation in this position is not to be neglected. More than anywhere else, in auscultation of the heart it is neces- sary to examine several times. The rapidity and strength of the heart's action, and possible extraneous sounds, have a great influence upon the distinctness of Avhat is heard. In severe diseases of the heart, especially with heart-failure from different causes which will be mentioned, the impression is generally so confused that no physician of experience will pronounce a definite opinion until, by appropriate treatment, the heart has been restored to a degree of strength. Normal condition. Over the whole region of the heart, and for a certain distance beyond it, we hear, corresponding with each pulsation of the heart, two "sounds " — one coincides with the ventricular con- traction, the "systolic," the "first" sound: one, which is heard at the beginning of the diastole, the "diastolic," the "second" sound. Corresponding with the greater duration of the diastole, the pause between the second and the following first sound is always greater than that between the first and second. The rhythm in general is as represented here : 12 12 12 12 Syst. Diast. Syst. Diast. Syst. Diast. Syst. Diast. The apex-beat coincides in time with the systolic sound, and like- wise, as we can directly observe, with the pulse in the common carotid in the neck. But the pulse of the peripheral arteries occurs notice- ably later, so that the radial pulse is felt between the first and second sounds of the heart. The expression "tone" is not to be taken in a strictly acoustic sense. In reality it is a short, sharply-defined noise which only approaches a tone. But the term is not so inappropriately selected, as everyone must be impressed who compares these phenomena of sounds with the peculiar heart-sounds to be spoken of hereafter. These two — the first and second heart-tones — can be heard over the whole region of the heart ; but at different points they are of different nature and origin, as is partly declared by the character of their tone, A part of each sound has its origin in each of the four portions of the heart, and hence is in all eightfold : EXAMINATION OF THE CIRCULATORY APPARATUS. 213 1. The sudden tension and closure of the mitral and tricuspid valves cause a systolic sound, which naturally is most distinctly heard in the neighborhood of these valves or over the ventricles. 2. The closure of the semilunar aortic and pulmonary valves causes a diastolic flapping tone, heard most distinctly over those valves or in their neighborhood. 3. The sudden contraction of the ventricle causes a dull systolic sound of short duration. 4. The sudden filling of the conus arteriosus, aortic and pulmonary, in consequence of the motion of the blood, or, more probably, of the sudden tension of the walls of these vessels, causes a short, somewhat ringing sound. Thus, we see that the valves have a very essential part in the pro- duction of the heart-sound ; and since, as has already been remarked in the "preliminary observations" [p. 194], the heart-sounds arising in certain circumstances are only connected with the valves or the different openings, these are the chief consideration in auscultation. Hence, we have chiefly to attend to the auscultation of the mitral valve, the mitral orifice, the aortic valve, the aortic orifice, etc. Hence, it follows that we always first listen at those four points of the chest which lie nearest to these valves. But experience has shown that for two of these this is not the best method, as is easily understood from the anatomical relations. We cannot auscultate the aortic valves at the point of the chest which lies nearest to them, since they are obliquely behind the pulmonary valves, and at that point the sound which comes from the pulmonary artery and its valves predominates; hence, we must auscultate at the beginning of the aorta ; and we do not ordinarily hear the sounds of the mitral most distinctly at the point where it is located, since a layer of lung there covers the heart, but better at the apex of the heart. The points of election for auscultating the heart are as follows (compare Fig. 46) : Mitral valve 1 -TO, -1 , • 1 ■ r Apex of the heart. liCit auricuio- ventricular opening J ^ Tricuspid valve ") -D- 1 , -1 • > Over the sternum. Kight auricular opening J Aortic semilunar (ost. aort.) : 2d intercostal space, right of sternum. Pulm. semilunar (ost. pulm.) : 2d intercostal space, left of sternum. 214 SPECIAL DIAGNOSIS. The accompanying figure exhibits the situation of the openings and the points where they may be best auscultated. We see that the auscultation-points of the mitral and aortic valves are so related to the respective openings that they lie downward from them with reference to the normal course of the blood-current. Fig. 46. The anatomical situation and the points for auscultating the valves of the heart and its orifices. The small letters show the location of the valves: the large ones the points for auscultating, a^^ the aorta; m3i"= mitral valve ; 2'-^ = the pulmonary orifice; 9 ■ ■ ■■■■■■■■■ ]r,o 40° 110 39 ino 37 IBSSBIBBB&SSSb — ■■■■■■■■■■■ rilHfill BSHKSBraSSa SSSSSSnSRBBIBS BSIBBBSSSBSBBIhI EBBBir ini Diminution of frequency of pulse after critical fall of temperature iu pneumonia. The unbroken line represents the temperature-curve, the broken one the pulse-curve. Abdominal typhus in tlie third to the fourth \veek. The rise in the pulse corresponds with the beginning of pneumonia. the pulse — to every degree of heat above 37° the pulse increases 8 beats above the normal (Liebermeister) ; but there are very great variations from this proportion, according to the kind of febrile disease, its localization in particular organs, and, further, with the age of the patient, the strength of the heart. Thus, in abdominal typhus, so long as it is not complicated, there is only a moderate quickening of EXAMINATION OF THE CIRCULATORY APPARATUS. 239 the pulse ; hence, in this disease, a pulse of 120 has a graver meaning than, for example, it has in pneumonia. This moderate quickening of the pulse, peculiar to typhus abdominalis, is even an aid in diagnosis in severe cases, as distinguishing it from acute miliary tuberculosis and pycemia. It has already been mentioned that in nvcningitis there is slowing of the pulse; when meningitis is added to a febrile disease it may lower the pulse, previously quickened, to the normal, or may even bring it below the normal. On the other hand, during an abdominal typhus, the addition of a complicating ^:)wewmon/a will, under some circumstances, be first noticed by the increased frequency of the pulse. (See Fig. 62.) PiQ. 63. Fig. 64. 200 42° 160 40 140 39 120 38 100 37 80 36 aiH ■■■HHBHH BsnesBB BBSSBBB isssBsga ^■■BHnHH ■HIIHHHi ■■■{■■■a ^■■1 —■■llfllHfllB^ ■■■■■■■■H ■■■ia»B"s ■■HSiriBHg ■■■MflKiiHgg ■MWMBHg -JHgViMflHB ■■MfJianHg TiHHHBHI ■ubihbbbl ■!■■■■«■ WMMMmmmmm Very rapid action of the heart (mitral insufficiency). P. T. 180 41° 160 40 120 38 80 36 aiikaa ■HMIKISgMI mmm. Very rapid action of the heart (convalescence from typhus; sus- picion of mitral insufficiency). Febrile diseases with complicating heart disease usually have a quicker pulse than the same diseases when the heart is normal. With children the pulse is always very much higher in febrile diseases than with adults. In the course of febrile diseases the constant observation of the 240 SPECIAL DIAGNOSIS. frequency of the pulse is of the greatest importance for estimating the strength of the lieart, and with it the general vigor, or showing the occurrence of complications, etc. (See further, hereafter.) It is also to be observed that in fever the frequency of the pulse is immediately increased by the least exertion or by excitement. In general it is an unfavorable sign when adults have a pulse of over 120, and the case requires special consideration. But when it reaches 140 it is a grave symptom. 2. In valvular disease of the heart., except only in stenosis of the aorta (see above), and also even with complete compensation. Attacks of great frequency of the pulse — 180 and over — are infrequent occur- rences, which chiefly accompany mitral defects {palpitation of the heart). Fig. 65. r. T. 160 40° 140 S9 120 38 100 37 80 36 ■■IBII ■■lair wiman ■■K«lfil BSSSillSSIISIIH SaBSBIIBEBilillB ■■(^■■■■■■■BiBill gBisI II ■■■■II ■■■■II KHiL ■« UEl Increased frequency of the pulse in fatal collapse (erysipelas). 3. In heart-failure or paralysis. Thus, in the collapse of febrile diseases (see Fig 65), where there is a simultaneous fall of the temperature and rise of the pulse ; in the arrested compensation of heart disease, and in weakening of the heart in consequence of disease of the substance of the heart; finally, with central and peripheral paralysis of the vagus. 4. In certain neuroses : Basedow's disease, nervous palpitation, angina pectoris (without the nature of this phenomenon being clear). 5. In any condition of anxiety., and with severe pain. EXAMINATION OF THE CIRCULATORY APPARATUS. 241 3. Want of Rhythm of the Pulse. Instead of the normal equal succession of the beats there may be complete irregularity (arhyth??i) ; in the most marked degree this is so in mitral stenosis (even when there is perfect compensation). Moderate or marked arhythm is very frequent in myocarditis (sometimes the inequality of the pulse is here the only sic/n). It occurs during the stage of incompensation in all cases of heart-defect, and sometimes in all forms of marked heart- weakness. Moreover, the inequality of the pulse [irregularity of volume] is more important in judging of the weakness of the heart than arhythm. If, in such arhythm, there are individual pauses in which no pulse is felt, then Ave speak of "suspended" pulse, which may be pulsus deficiens — that is, the pauses indicate real pauses in the action of the heart; or it may be a, jjulsus intermittens: they result from weak contractions of the heart, which cannot be felt as far as the radial. We determine, in a given case, which of the two kinds of pulse it is by auscultating the heart. But there are other forms of irregularity of pulse in which the irregularity of the beats follows a rule : 2:»m?s-m.s higeminus, p. trigeminus (where two or three beats are regular and then follows a longer pause). These forms generally indicate moderate weakness of the heart. Lastly, we must mention an especially frequent form of irregularity which stands somewhat between the two last-named forms and com- plete irregularity — the pulsus inter cidens : after several perfectly regular beats, suddenly there is one that follows immediately after the last regular one (which is also always weaker), then there generally follows a slight pause. Most frequently it indicates considerable weakness of heart, and is often the forerunner of severe heart-weak- ness. It occurs in valvular disease and myocarditis. In order to determine the succession of pulse-beats it is sometimes useful to employ the graphic method (which see). 4. Quality of the Pulse. As has been already mentioned above, a correct judgment of the size and tension of the radial artery and of the size and form of the 16 242 SPECIAL DIAGNOSIS individual waves can only be attained by much practice. It is indis- pensably necessary that there should be acuteness of feeling in the examining finger, much experience of what is normal and what is pathological, and of the boundaries between the two, which cannot be sharply defined in Avords. The inequality of the examination must be taken into consideration, as it is affected by somewhat individual differences of the location of the arteries, the difference in the subcutaneous fat, or as affected by arterial sclerosis. The exact examination of the pulse may not be possible on account of the abnormal course of the radial artery — the most frequent variation being where the artery winds around the radius to its dorsal surface above the stj^loid pi'ocess. We distinguish the different forms of pulse according to the follow- ing points of view : 1. According to the size of the pulse: full or empty pulse, pulsus plenus — vacuus; a not very clear method of designation. It would be much more suitable to describe the average fulness of the artery, or, still better, its thickness at the moment of its systole — that is, in the depression between two pulse-waves. In this sense the pulse is full in almost all those cases in which it is large in so far as it depends upon work of the heart, which is strong or increased. But it further depends, to a certain extent, upon the amount of blood in the system; a certain fulness of the pulse, which, in a strong person, is not remark- able, in an anemic subject indicates a pathological increase in the work of the heart. Within certain limits, moreover, the difference in the fulness of the pulse is individual, being simply dependent upon the internal diameter of the arteries. We are not to confound a full pulse with a case where there is thickening of the wall of the artery by arterial sclerosis. Larger and small pulse : pulsus magnus — parvus. When the ivork of the heart is simply increased, and still more when there is hyper- trophy of the left ventricle^ the pulse is large. There is an exception to this when we have the two valvular defects, in which the left ven- tricle, notwithstanding its hypertrophy, is able to force only a mod- erate quantity of blood into the aorta (aortic stenosis, see under pulsus tardus), and mitral insufficiency. The reason for the former is clear ; the explanation of the latter is, that with every systole a part of the blood contained in the left ventricle flows back into the left auricle. EXAMINATION OF THE CIRCULATORY APPARATUS. 243 Absence of pulse depends upon diminished work of the heart, upon an obstruction between the heart and the aortic system (aortic steno- sis, aneurism), and upon marked anaemia. It is present in the highest degree in mitral stenosis, since in this condition the left ventricle con- tains an abnormally small quantity of blood, and hence it can drive but little into the aorta. If the pulse is very small, and at the same time very empty, it is called thread-like or filiform. The trembling pulse [jyulsus tremulus) is caused by a moderately full artery, in which the wave is impercept- ibly small. Both are noticed when the heart is very weak. Regular and irregular pulse [as to volume] : j^^^sus cequalis — in- cequalis. As was previously stated, there occur in health insignificant ii'regularities in the individual pulse-waves. A very marked inequality is a most important sign of weak heart, more important than the irregularity which almost always accompanies it. Only in mitral ste- nosis we have a very markedly unequal (and irregular) pulse without the heart being really weak. Often, too, there exists in a measure a condition between inequality and irregularity as follows : A pulse follows the previous one with a shorter pause, then after a longer pause there is one with a stronger beat. Especially in pulsus intercidens (see p. 241) the between-beat that immediately follows a pulse-wave is always small. Pulsus alternans is so called when a larger wave alternates with a smaller one. At the same time it is generally bigeminus. (See above.) We call a pulse pulsus paradoxus which has the peculiarity that in deep breathing, toward the end of inspiration, it becomes weaker, or is once or more times omitted. It is an important sign oi pericarditis adhcesiva with callous mediastino-pericarditis, and it arises from the breaking or distortion of large arterial branches as the thorax is broadened in the act of inspiration and the diaphragm is pressed down. 2. "We distinguish the form of the pulse- wave as quick or slow, pulsus celer — tardus. Here also belongs the pulsus dierotus. In the quick pulse the artery quickly enlarges and immediately becomes narrow with a like quick contraction. But with a slow pulse the enlargement and contraction are slower than normal, and the artery also lingers in the diastole during a portion of time which a trained 244 SPECIAL DIAGNOSIS. finger may recognize. With the quick pulse the examiner notices that the stroke is very short, while in the latter it is more a pressure in the vessel against the palpating finger. ^\evj i^uhns magnus may exhibit a moderate celerity. Only in aortic insufficiency the pulse is decidedly quick. It is a miniature picture of the large fluctuations of pressure in the aorta which quickly follow one another, as with every systole it receives from the dilated and hypertrophied left ventricle an abnormally large quantity of blood which it immediately disposes of in two directions — sending part back again into the ventricle, and part forward into the body. It is remarkable that also in heart-weakness there is sometimes a light, quick pulse. It is true that it is always very easy to compress it, and between the pulse-waves the walls of the artery fall together very decidedly (pulsus vacuus, and at the same time celer). Pulsus tardus is an especial peculiarity of aortic stenosis, and at the same time it is generally smaller than normal. How much it may be diminished in size depends upon the degree of stenosis and the strength of the heart. Pulsus tardus occurs also with arterial scle- rosis, likewise with lead colic, but also sometimes with other colics as well as in peritonitis. Pulsus dicrotus will be more exactly described with the sphygmog- raphy of the pulse (see p. 248), 3. According to the hardness of the pulse (tension of the arterial wall) we distinguish hard or tense, and soft pulse, pulsus durus {ten- sus) — mollis. Here we must especially guard against confounding it with arterial sclerosis, which imparts to the wall of the vessel a hard- ness which has nothing to do with its tension. We test the hardness of the pulse by endeavoring to compress it with the finger ; it is easy to compress a soft pulse. Again, it is really the power of the heart that produces these pecu- liarities, as well as the active tension of the wall of the vessel. In heart- weakness the small pulse is also always a soft pulse ; the large pulse is likewise often hard. With pulsus tardus there is almost always a strong action of the heart, and if the heart is hypertrophied the pulse at the same time is often hai'd. When the pulse is quick there are constantly marked variations in its hardness. The hardness of the pulse is especially characteristic in contracted kidney with hypertrophy of the heart, also in lead colic (" wire pulse"). EXAMINATION OF THE CIRCULATOR F APPARATUS. 245 The pulse is tense also in ajyoplexy cerebri and in commencing menin- gitis, no doubt from irritation of the vasomotor centre. V. Basch has constructed a sphygmomanometer, which is very use- ful for measuring exactly the tension in the arterial wall, and thus the blood-pressure. Unfortunately, we cannot affirm that the absolute height of the blood-pressure in its finer gradations leads to .results that have diagnostic value. The reason of this is that, as v. Basch himself found, the limits of the normal are very wide apart; moreover, from the fact that the arterial pressure is the result of two forces acting in opposition, the contraction of the heart and the active contraction of the vessel. Lastly, as has already been intimated, the anatomical peculiarity of the arteries (arterial sclerosis) has an influence upon the hardness — that is, the compressibility of the pulse. Yet, after all, we think that v. Basch's instrument is very excellent for determining the variations of the blood-pressure in the course of making observations upon a patient. 5. Symmetry of the Radial Pulse. As has been already mentioned, apart from anatomical variations of the artery upon one side, the pulse upon the two sides is perfectly alike as to time and quality. It may be disturbed, even to complete absence of the pulse upon one side. 1. By surgical diseases of the arm, as fracture of the bone, injuries or operations which displace the radial, or which result in narrowing, compression, or cicatricial contraction of the radial, brachial, or axillary artery ; in which case the pulse upon that side is found to be smaller. 2. By tumors of the chest cavity, of the supra- or infra-clavicular fossa, or of the axilla, which press upon the innominate, subclavian, or axillary artery of one side. They weaken the radial pulse even to complete obliteration. 3. By aneurism of the aorta, innominate (in what way, see below), also by aneurism of the subclavian, axillary, and brachial (all very rare ; see works upon surgery). 4. By emboli and autocthonous clots toward the centre from the location of the pulse. In this case the pulse is commonly entirely wanting. 5. In pneumothorax, also large pleuritic exudation with com- 246 SPECIAL DIAGNOSIS. pression and distortion of the subclavian. Sometimes the pulse upon the affected side is smaller, also frequently later. Sphygmography of the Radial Pulse. — K. Yierordt originated the idea of sphygmography. With continued improvements of the apparatus the idea has been further developed by Marey, Wolffs Landois. Sommerhrodt, Riegel [and others]. Sommerbrodt's sphygmograph is the one now most generally used, but it has defects. Recently Ludwig has very decidedly improved upon ^Marey's instrument, as it seems to rae. It can be obtained fi'om Petzold, instrument-maker, in Leipzig. [The instrument devised by Dr. Richardson, of London, is, in the opinion of the Translator, the most practically useful one yet brought out.] The sphygmograph has little value for the purposes of diagnosis, but is of great value in clinical instruction. In health the pulse-curve obtained Avith this instrument shows elevations and depressions, ascending and descending line correspond- ing with the expansion and collapse of the artery. The expressions "apex curve" (c g) and " curve at the base " (b) do not need further explanation. At both these points the curve stops only a very small portion of time. The ascension line (a 1) is even almost perpendicular; that is, the rise follows very quickly. The descent (d) is more drawn out and shows several small waves, which generally (not always) may be distinguished as a marked elevation (r), the backward-stroke elevation, caused by a wave of blood which results from the closure of the semi- lunar valve, and two (sometimes also three) or only one weaker, elevation produced by elasticity (e) ; the elastic secondary oscillation of the wall of the artery (according to Landois, but otherwise explained by others). The elevation (r), the "recoil," has hitherto been regarded as a positive centrifugal wave due to the closure of the aortic valves. But recent investigations have shown that this positive wave is cen- tripetal, and that it is probably to be regarded as a reflected wave from the peripheral end of the circulation of the body, as from the I end of a closed tube (v. Frey and Krehl). The opinion formerly expressed that r was more marked the nearer we were to the heart, by the new theory would be explained by saying that it was the sum- mation of the reflected waves arising from the various arterial regions. EXAMIXATIOX OF THE CIRCULATORY APPARATUS. 247 It is worthy of notice with regai'd to the backward-stroke elevation that it increases witH the diminution of the tension of the artery. Thus it is a sort of indication of the blood-pressure. But the eleva- tion produced by elasticity is just the opposite. It is to be remarked Fig. 66. Xormal pulse-curve in a healthy man, aged twenty-five years. (After Eichhorst.) regarding the sphygmography of other arteries that r becomes more marked the nearer we go to the heart. The following are the essential pathological forms of sphygmo- graphic pulse-waves : 1. A descending line with several very marked elasticity elevations, but smaller backward-stroke elevations (often difficult to make out) which correspond with the increased tension in the aortic system {lead colic, contracted 'kidney and acute nephritis, etc.). Fig. 6T. 2. On the other hand, diminution of the elasticity elevation with more marked backward-stroke elevation shows diminished blood- pressure. Such increase of r is called '"dicrotic," and the pulse "dicrotic pulse." Such a pulse, even if it is only moderately pro- nounced, can be recognized by palpation. It occurs in certain condi- tions which accompany a moderate diminution of strength of the heart, but especially a diminution of the tone of the arteries : a. In acute febrile diseases, and indeed in so marked a degree and so early in typhus ahdominalis that in diagnosis we may attach some, though small, value to this symptom. 248 SPECIAL DIAGNOSIS. h. In chronic toasting diseases, especially febrile, more than others in tuberculosis. Here, according to my observation, it is not infre- quent. 0. In otlier weak conditions, as after great loss of blood, and in general in all forms of anaemia. Fig. 68. Different forms of dicrotic pulse. (After Eichhorst.) The above curves show that in the dicrotic pulse the backward-stroke elevation may fall in the descending line [suh-dicrotic pulse), as well as in the middle of the basis curve {complete dicrotic pulse), likewise in the ascending line of the next following wave {super-dicrotic p)ulse). The so-called monocrotic pulse (no visible backward-stroke elevation) is a sort of super-dicrotic pulse. What has been said in general regarding dicrotic pulse expresses the diagnostic value of all these forms of pulse. 3. To the pulsus celer corresponds a curve with a very steep ascending line and an unnaturally high apex-curve (in consequence of the quickness of the arterial diastole the recording lever of the appa- ratus is always thrown too high up). Moreover, the apex-curve is EXAMINATION OF THE CIRCULATORY APPARATUS. 249 sharp-pointed, and the descending line is almost as steep as the ascending line. The elasticity elevations are marked. With pulsus celer due to co-otic insufficiency there is, of course, no backward-stroke elevation, as the semilunar valve does not close. Compare "vvhat has been said on p. 243 upon Pulsus celer. Fig. Tjg. Pulse-curve in aortic insufficiency. (After Struempell.) 4. Pulsus tardus, as in palpation (see p. 244) so in the curve, is the exact opposite of the preceding. With it there are usually more com- plete loss of the elasticity elevation and indistinct backward-stroke elevation. Fig. 70. Pulse-curve in stenosis of the aortic orifice. (Ibid.) Fig. 71. Pulsus tardus in atheroma of the arteries. (After Eichhorst.) A peculiar combination of pulsus celer and tardus manifests itself with insufficiency and stenosis of the aorta. 250 S FECI A L DIA GNOSIS. Fig. 72. Piilso with anacrotic elevation in aortic insufficiency with moderate stenosis of the orifice and arterial sclerosis. In pulsus tardus the quickness of the apparatus is completely wanting on account of the slowness of the ascension, hence it always seems small in comparison with the normal pulse-wave; and with that of pulsus celer (see above) still smaller than is really the case. It is quite impossible to form an estimate of the size of the pulse from the sphygmographic curve. The unequal pulse will generally be very beautifully delineated by the apparatus, but it cannot be more exactly depicted than it can be learned by exact palpation. It is true that the apparatus includes small waves that the finger cannot recog- nize, but often these cannot be distinguished from the elevations indicating the backward stroke. Fig. 73. Pulse-curve with marked mitral stenosis. (After Struempell.) The rliythm of the pulse will, of course, even if only for a very short distance, be very well exhibited, and it is in this direction that the graphic delineation is very useful in giving instruction. But here sphygmography is wholly wanting for diagnostic purposes, since every notable useful irregularity can be felt just as well. Annexed is an example of pulsus bigeminus (after Riegel). Fig. 74. Pulsus bigeminus. (After PiIEGEL.) EXAMINATION OF THE CIRCULATORY APPARATUS. 251 DiAGXosTic Value of the Examination of the Pulse. — From what has been said it is sufficiently evident that for the purposes of diagnosis palpation of the radial pulse is preferable to sphyg- mography. The latter is more circumstantial, and gives, at best, to one sufficiently practised in palpation in general, no better result than that it occasionally shows a dicrotic pulse which the sense of touch does not detect. It very easily even deceives, especially regard- ing the size of the pulse, but sometimes also its form, from reasons that lie in the apparatus. The great value of the sphygmograph for the clinician consists almost exclusively in its usefulness in giving instruc- tion, for exhibiting a characteristic anomaly of the pulse to a large number of hearers, or it may serve to show a pupil what he ought to feel. In what follows will be briefly indicated in which direction the examination of the pulse is of value for diagnosis, and how it can be turned to account. 1. The pulse very often directly serves to determine the diagnosis ; not that it alone is sufficient, but in connection with other phenomena it is. We are to bear in mind here what has previously been said regarding the behavior of the pulse in the various febrile diseases. But in diseases of the heart it especially has such an important place that a diagnosis is never to be made without taking into consideration the condition of the pulse. In what follows is brought together what can be said regarding the behavior of the pulse in the most important of the diseases of the heart. In mitral insufficiency the pulse does not markedly or notably vary from the normal. But in addition the signs of hypertrophy of the right and left ventricles are present : systolic murmur at the apex. Mitral stenosis : Pulse absent, unequal, or irregular, its frequency often much increased. (In addition, signs of hypertrophy of the right ventricle and a presystolic murmur at the apex.) Aortic insufficiency: Pulse quick, frequency either normal or increased ; generally equal and regular. In addition there are the signs of hypertrophy of the left ventricle and a diastolic blowing murmur at the aorta. (For the conditions at certain arteries, etc., see p. 256.) 252 SPECIAL DIAGNOSIS. Stenosis of the aorta : Pulse small, slow, normal or diminished fre- quency, equal and regular. In addition, signs of hypertrophy of the left ventricle ; only the apex-beat is often very strong and a systolic murmur heard over the aorta. Myocarditis: Pulse more or less small and soft, almost always irregular in quality, and generally so in time (here especially we have sometimes pulsus incidens, bigeminus). Frequency is increased, normal, or diminished. Nothing abnormal at the heart, or signs of dilatation of one or both ventricles (or of hypertrophy) ; no murmurs. Pericarditis exudativa: Pulse strong if the heart remains so, generally somewhat quickened. In addition, at the heart all signs of its activity diminished or removed by being covered over, marked dulness ; in paralysis of the heart no pulse, or very much quickened ; sometimes pulsus paradoxus. We are particularly to notice the opposite condition of the pulse in aortic insufficiency and stenosis, and also that in myocarditis the pulse may be the only sign. In combined valvular disease the pulse is of importance in two ways : it betrays the existence of a second valvular disease besides the one already made out, as is especially the case in mitral insufficiency and stenosis. The latter near the former may be overlooked because very slight, or may even be entirely wanting, and because it produces hypertrophy of the right ventricle, which is also produced by the former, for there may be a very small, unequal, irregular pulse, which alone indicates the stenosis. Also, an aortic stenosis, besides insuffi- ciency of the aorta, is sometimes certainly discovered only by the pulse, since there may be a weak systolic murmur at the aorta without stenosis. Thus the question as to which cardiac orifice is concerned in the murmur, or whether we have one murmur widely conducted, or two murmurs independent of each other, may be determined by the pulse. Moreover, in a patient with combined valvular disease the pulse may very greatly assist in determining which disease is the more marked or important. This is especially true in insufficiency and stenosis of the aorta (the distinctness of the murmurs is, of course, not at all indicative, see above), also of the mitral, or for combined disease of the aortic and mitral valves. Thus we would diagnosticate a preponderating insufficiency and a EXAMINATION OF THE CIRCULATORY APPARATUS. 253 very slight stenosis of the aorta when we have the signs of hyper- trophy of the left ventricle, a loud sawing systolic and a very slight diastolic aortic murmur and a pronounced pulsus eeler. Thus, with the signs of aortic insufficiency and mitral stenosis, a very small pulse points to the preponderance of the latter. It is impossible to make a diagnosis of the particular heart-lesion, either from the general symptoms or from the pulse, so long as there is continued evidence of incompensation. Moreover, in the cases where the heart and its action are concealed, especially in pericarditis exudativa, also in emphysema, sometimes in marked deformity of the thorax, displacement of the heart, tumors of the chest-wall, the pulse is the only sure sign of what work the left ventricle is doing. In pericarditis the contrariety that exists between a diminishing apex-beat, the slight, almost imperceptible, heart-sound, and a strong pulse, is sometimes a very important diagnostic point. 2. The pulse enables us to judge of the strength of the heart in all other possible, especially febrile, diseases. Even the first examination of the pulse furnishes, in this case, important information; but the signification of indications furnished by repeated examinations of the pulse (palpation and representation of its varying frequence upon the temperature-chart) becomes very much more valuable. These indica- tions furnish still more important diagnostic points, some of which have already been spoken of. They have reference to the beginning of complications in acute infectious diseases, especially those affecting the heart, the lungs (which are very frequent), the kidneys, as in scarlet fever, when the pulse has greater tension and diminished frequence, and to the brain (decline in frequency in meningitis) ; also, the eifect of treatment, as of cold baths, may be determined partly by the behavior of the pulse ; in general, it often determines the treatment ; further, we are to mention all diseases which in any way affect the heart, as pleuritis, pericarditis, peritonitis, in which the pulse, especially as a measure of treatment, has any part. II. OTHER PHENOMENA IN ARTERIES. The Aorta. — Sometimes a pulsation is to be seen and felt in the neck; exceptionally, also, in health (higher location of the arch); likewise, in hypertrophy of the left ventricle (most marked in aortic 254 SPECIAL DIAGNOSIS. insufficiency., since this causes a broadening of the commencement of the aorta) ; and, finally, in aneurism of the arch of the aorta. The occurrence of pulsation that can be seen and felt in the right second intercostal space is always pathological. It occurs in hyper- trophy of the left ventricle, and also especially in insufficiency of the aorta ; further, in aneurism of the aorta., see below. In rare cases, Avhen there is marked hypertrophy, the second aortic sound may be felt (of course, this can never occur in aortic insufficiency). In rare cases of aortic insufficiency the commencement of the aorta is accessible for percussion. It is to be remembered that here it is very much broadened, and to the right of the sternum, from the lower border of the second rib to the third rib, there is a small area of dulness. Sometimes over the aorta (in the right second intercostal space), in marked atheroma, there ought to be heard a systolic murmur, even when there is no endocarditis aortica. Aneurism of the aorta requires a special description. It most frequently occurs in the ascending portion or the arch of the aorta, and gives rise to the following phenomena : Only when the aneurism is large is a swelling to be seen, and this, if present, is seen either above the sternum or close to the right of it. It generally pulsates — that is, becomes larger in all directions — with the systole of the heart. From stagnation (see p. 261) the enlarged veins of the skin are very early visible ; later they may become red from inflammation, or even be necrotic. In large aneurism, under some circumstances, when we pal- pate, we feel the pulsation, and besides, not infrequently, a peculiar whizzing or rushing. With large tumors, also, it further shows that the bones and cartilages over them have been absorbed. Repeated meas- urement of the thorax shows a gradual increase of the sterno-vertebral diameter. Percussion generally very early exhibits dulness, usually on the right, close to the sternum and over the manubrium ; more rarely to the left of the sternum, and this either in connection with the area of heart-dulness or distinct from it. Auscultation not infrequently re- veals the systolic whizzing, which has already been referred to as being felt, or also only two dull, impure sounds, or they may not be heard at all. The radial pulse, also the carotid, is not infrequently early upon one side smaller and a little later than on the other in consequence of the compression of the particular branches of the aorta or distortion of their openings at the point of origin. Aneurism of the ascending aorta EXAMIXATIOX OF THE CIRCULATORV APPARATUS. 955 affects the vessels of the right side, and of the arch of the aorta some- times affects those of the left side. Not infrequently, also, there exists insufficiency of the aoj'ta with hypertrophy of the heart. As by all tumors in its neighborhood, the heart may be crowded toward the left side ; also, we see, in examining the larynx, evidences of pressure by these tumors upon the trachea, the oesophagus, the left (seldom the right) recurrent nerve, and the large veins of the body (p. 261). Aneurism of the innominate produces about the same symptoms as aneurism of the ascending aorta, only generally somewhat higher up. Aneui'ism of the descending aorta (rare) may cause corresponding phenomena upon the left side, posteriorly, near the spine. The pulse in the abdominal aorta and its branches is usually later. Aneurism of the abdominal aorta (likewise rare) is generally at the level of the tripus coeliacus. It may be felt as a pulsating tumor in the upper part of the abdomen, and sometimes exhibits the whizzing mentioned above. Considerable stenosis or even closure of the aorta at the junction of the ductus arteriosus is a very rare congenital condition which is recog- nized by the fact that certain arteries furnish collateral circulation between the ascending aorta and the region of the descending thoracic aorta, or the abdominal aorta. These collateral vessels become very much enlarged, and pulsate so as to be seen and felt. Diagnosticallv, the most important are the internal mammary, the anterior superior and inferior epigastric anteriorly, the transversus scapulae and dorsalis posteriorly. The Pulmoxart Artery. — In very rare cases aneurism of the pulmonary artery may give rise to almost the same symptoms as aneurism of the aorta, except in being at the left of the sternum. A systolic murmur over the pulmonary artery may, besides, be caused by stenosis of the pulmonary opening or by narrowing of the artery itself. This may be congenital or be developed later, in the latter case by shrinking of the upper portion of the left lung. In such cases the second pulmonary sound is generally accentuated (hypertrophy of the right ventricle), and, under some circumstances, may even be felt (see above). The Other Arteries. — Excepting during excitement of the heart (by mental excitement or physical exertion), we observe in health a visible pulsation of the carotid in the neck just under the angle of the 256 SPECIAL DIAGNOSIS. jaw ; also of the temporal artery. A marked pulsation of the carotid, especially when there is perfect mental and physical quietude, or, again, a general visible pulsation of smaller vessels, as of the temporal, the brachial, in the sulcus of the brachial muscle or at the bend of the elbow, of the radial, peroneal, dorsalis pedis, points to hyjyertrophy of the left ventricle. These abnormal pulsations are most marked in insufficiency of the aortic valves and in arterial sclerosis ; in the first case on account of the fulness of the pulse, in the latter case on account of the thickened and stiffened vessels being prominent. In both classes of cases the smaller arteries are very tortuous. Here, also, a capillary pulse is to be mentioned : alternating between marked fulness and emptiness of the capillaries occasioned by the pulse in the arteries, the pulse may become visible under the finger- nails, more rarely over the tendons, in case these variations are con- nected with a large and quick pulse in the arteries, which, in turn, have large and quick alternations of size. Then, in examining the finger-nail, we see the red part rhythmically become alternately white and red : capillary pulse of the bed of the nail.^ This is a sign of aortic insufficiency with marked hypertrophy of the left ventricle (which would also be present in some cases of marasmus). Palpation. Medium-sized and small arteries sometimes feel thickened and moderately stiff, or scattered in their walls we feel separate rigid patches, very like the plates of cartilage of the bronchial tubes, or the rings of a small trachea (" goose's throat "). The latter become especially plain if we slip the tip of the finger up and down along the course of the artery. This is the condition in arterial sclerosis. Hence, the vessels are often tortuous (see above), and show variations of the pulse (see). It is very easy to recognize arterial sclerosis in the temporal, radial, and brachial arteries. From the condition of these we can correctly estimate the condition of other arteries of the same size. Palpation of the radial artery has already been described. Of the other arteries of the extremities the pulse of which we can feel in health, we may mention the brachial, in many persons the ulnar, the crural, the popliteal, and in most people the peroneal. Increased \} This is often an unfavorable situation for making the observation. Quincke, who first described the capillary pulse, now recommends rubbing gently a spot upon tha forehead. Berliner klin. Wochenschr., March 24, 1890.] EXAMINATION OF THE CIRCULATORY APPARATUS. £57 pulsation in arteries that can be felt, its occurrence in small arteries that can be felt, which in health are never made out, takes place in aortic insufficiency. A pulsation that can be felt in the dorsalis pedis artery is here very frequent, but the same thing may take place in still smaller arteries — in the digital, in the coronarise labii inferior., superior., and the like. Vei'y exceptionally in aortic insufficiency we may even observe an "arterial liver- pulse " — that is, a continuous to-and-fro swelling of the liver from the marked pulse in the arteries of the liver (quite like the venous liver-pulse, see p. 266). Still more rare is an arterial pulse at the spleen (see under Examination of the Spleen). When in symmetrical vessels, like the two radials, we find a pulse that is unequal as to strength or time, we may generally conclude that there is a mechanical hindrance to the passage of the blood- current. We then have to seek toward the centre from the weaker or later pulsating artery for a compressing tumor, thrombosis (autoch- thonous or embolic), or for an aneurism. Moreover, there are observed variations of the pulse in symmetrical vessels, caused by vasomotor influences from the nerve-centres. Finally, we must not overlook the possibility of anatomical variations. Auscultation. Mode of procedure : Here, it is to be understood throughout, the stethoscope is to be employed, and that ordinarily it is to rest upon the surface without pressure. We auscultate the carotid with the neck somewhat extended, but not stretched, in the intersterno-cleido-mastoid fossa or at the angle of the jaw; the sub- clavian, in the angle between the clavicle and the clavicular head of the sterno-cleido-mastoid muscle; the brachial, on the inner border of the biceps in the bend of the elbow, with the arm slightly extended ; the crural, close below Poupart's ligament. Normal condition. In health we usually hear over the carotid, as well as the subclavian, two sounds — one corresponding to the pulse, with the systole of the heart (the conducted aortic first sound and local diastolic sound in the vessel). In individual cases the first sound is impure, or is entirely wanting. In health the diastolic heart-sound is never wanting. We sometimes hear over the abdominal aorta and the crural artery a sound which corresponds with the pulse, or at any rate arises locally from the tension of the vessels. We usually hear nothing over any of the small vessels. If we press with the stetho- 17 258 SPECIAL DIAGNOSIS. scope over the given vessel, then we hear the so-called acoustic pressure-sound, not alone over the aorta and subclavian, but also regularly over the abdominal aorta and crural artery, and usually, also, over the brachial. Thus, over these vessels by moderate pressure we hear a pressure-murmur corresponding to the arterial pulse ; by stronger pressure, which almost, but not quite, closes the artery, this murmur is changed into a tone — pressure-tone. That these acoustic phenomena, resulting from pressure, are everywhere present, are the chief reasons why the pathological conditions over the large vessels, which are to be mentioned later, have only conditional diagnostic value. We must also mention a phenomenon frequently present in healthy children, called "cerebral blowing"; it is heard between the third month and the sixth year, with the systole of the heart, or, more exactly, as a blowing corresponding with the carotid pulse, which is heard sometimes light, sometimes tolerably loud, over the fontanelle while still open, but also sometimes after it has closed, and elsewhere over the head. Jurasz has, in most cases, found at the same time a blowing over the carotid, and thinks that the cerebral blowing is merely this murmur conducted upward. He explains the latter by the compression which the carotid sustains in the carotid canal during the development of the skull. Pathological conditions. In aortic stenosis there will be heard over the carotid, in place of the first sound, a rough systolic heart- murmur (the stethoscope must rest very lightly). In aortic insufficiency the second sound of the carotid and sub- clavian is wanting, or it is replaced by blowing with the diastole of the heart (rare). This, as well as the systolic murmur previously mentioned, is conducted from the mouth of the aorta. The former, arising in a current of blood flowing forward, would naturally, as a rule, be more loudly conducted than the latter, which comes from a backward-flowing blood-current. Sounds in such arteries as in health very seldom or never furnish a sound, accompany aortic insufficiency, being produced by the quick and strong tension of the vessels during their diastole. We then hear a sound corresponding with the pulse over the crural, brachial, radial, even the ulnai% peroneal, dorsalis pedis arteries ; sometimes, even, over still smaller vessels. A sound is also observed over the crural EXAMINATION OF THE CIRCULATORY APPARATUS. 259 in high fever, as well as in ancemia and chlorosis (and as well in some healthy persons). A double sound over the crural artery (Traube) is heard in individual cases of aortic insufficiency. But this phenomenon has also, although very exceptionally, been observed with mitral stenosis (Weil), likewise in lead-poisoning (Matterstock), lastly, in pregnancy (Gerhardt). Much more important is the double murmur which is heard when considerable pressure is made with the stethoscope — Duroziez's double murmur. In the experience of observers thus far, this occurs only with aortic insufficiency, and this when there is good compensation, and this has all the greater significance from the fact that it is decidedly more frequent than was previously supposed. Double sound, as well as double murmur, can only occur when there is a large and quick pulse. In the first phenomenon, the double sound is caused by the sudden collapse of the artery ; with double murmur, the second murmur is probably to be explained by the short reflux blood-current which may be assumed to flow into the large vessels when there is aortic insufficiency (?). A double sound can also be heard over the crural artery if one of the two sounds, or even if both sounds arise from the crural vein. (See, regarding this, in the next chapter.) A systolic subclavian murmur is sometimes heard on both sides, or sometimes only on one side (especially the left), as a very disturbing addition to the breath-sounds at the apex of the lungs. It is stronger, or, perhaps, only to be heard toward the end of inspiration. When it occurs upon both sides it, as a rule, does not indicate a pathological condition ; when unilateral it also has no significance, and yet it always gives the suspicion of phthisis, with which we often meet it. It is explained by a temporary pulling or bending, and, hence, nar- rowing of the subclavian artery during deep breathing. In phthisis this is caused by adhesion of the pleural surfaces at the anterior sur- face of the apex of the lungs. We do not know exactly why this murmur occurs also with persons apparently perfectly healthy, but it may possibly be from the same cause. Loud blowing murmurs over the lymphatic glands sometimes occur in all forms of struma. These murmurs may be felt. They are not infrequent with struma of Basedow's disease, but here they are caused by the excited action of the heart. 260 SPECIAL DIAGNOSIS. The murmurs which in some cases are heard over aneurism have been already mentioned. Examination of the Veins. We examine chiefly, in many cases exclusively, the jugular veins (external and internal in the neck), but also the cutaneous veins of the body and extremities. Only in special cases (thrombosis) do the deep veins of the extremities become accessible for examination. The ophthalmoscopic examination of the ophthalmic veins does not come within the scope of this book. It is important that w^e are able to judge of the abnormal fulness (engorgement) of certain deep veins by its effect upon particular internal organs, as enlargement of the liver and spleen, also ascites, and, lastly, the suppression of urine. The examination of the veins is made by inspection, or sometimes by palpation, and auscultation. INSPECTION AND PALPATION OF VEINS. By these means we ascertain the degree of fulness, the condition of the circulation, and, under some circumstances, the existence of venous thrombosis. An unusually empty condition of the veins does not come under consideration. This Avould also be very diflficult to deter- mine, for the reason that even in health, especially in fat people, the superficial veins may be indistinct or entirely invisible. It remains to describe : 1. Increased fulness of veins ; 2. Circu- lation in the veins of the neck ; 3. Circulation in the other veins ; 4. Venous thrombosis. 1. Increased Fulness of Veins. This is the result of stoppage of the blood in its course toward the centre. It is general or local, according to the cause of the engorge- ment — whether this be central or at some place in the course of the nerves that control the circulation. General increased fulness is the result of general venous engorge- ment. We first recognize it by the swelling of the internal and external jugular veins upon both sides The first of these is usually visible in health (but not always, especially in fat people), coursing EXAMINATION OF THE CIRCULATORY APPARATUS. 261 obliquely over the sterno-cleido-mastoid muscle. When the head is turned toward the opposite side it usually swells still more. "With the increased fulness it becomes distinct, perhaps can be felt. With normal fulness the internal jugular cannot be made out, situated, as it is, under the sterno-cleido-mastoid muscle, where it is divided into the clavicular and sternal portion just in the angle between these at the bottom of the intersterno-cleido-mastoid fossa. Where it passes into the bulb us jugularis it has a valve (ordinarily exactly at the upper border of the sterno-clavicular articulation, but sometimes, especially in consequence of the engorgement, located somewhat higher up). Abnormal fulness of the jugular vein fills up the inter- sterno - cleido mastoid fossa, or it may cause a projection there. Dorsal posture increases the fulness. Fulness of the cutaneous veins of the trunk and extremities, not occurring without general engorge- ment, is usually not so pronounced as that of the veins of the neck, especially on account of the marked cedema which accompanies the damming. Important associated symptoms of general engorgement are cyanosis, oedema, effusion into the cavities of the body, enlarge- ment of liver and spleen, disturbance of the bowels, and so-called suppression of urine (which see). This condition arises when the right heart is not able to propel the required quantity of blood into the lungs. It occurs in various dis- eases of the heart, in emphysema of the lungs, and in all the conditions that lead to marked interference with the action of the heart, especially pericarditis. The most marked engorgement occurs in general when the right side of the heart is paralyzed after it has been obliged for a long time previously to meet unusual demands, and hence has become hypertrophied ; hence with mitral, and, more rarely, pulmonary defects and emphysema, and likewise, in the very rare tricuspid stenosis and insufficiency (see under 3). Greneral abnormal fulness of the veins may also be the result, exceptionally, of diminished flow of blood from the two cavse into the right auricle in consequence of pressure by a mediastinal tumor. Local increased fulness of the veins may be caused by a considerable narrowing or closure anywhere of a venous trunk by a thrombus or by compression. The larger the vessel thus aflFected, the more extensive the area of abnormal fulness. Thus sometimes abnormal fulness of the jugular and its branches, also of the ophthalmic vein (recognized 262 SPECIAL DIAGNOSIS. by the ophthalmoscope), will be caused by a mediastinal tumor which presses upon the cava. Also the superficial veins of the skull between the ear and the fontanelle will become distended and tortuous if the longitudinal sinus of the dura is stopped. Fulness of the veins of an arm points to compression of the axillary vein (generally tumors or scars from operations in the axilla). The swelling of single small cutaneous veins over the sternum and in its neighborhood is a very important early sign of mediastinal tumor. The cutaneous veins of the leg are enlarged when there is thrombosis or compression of the femoral vein of that side. The veins of both legs may swell as the result of double thrombosis or compression of the vena cava inferior or both iliac veins (ascites, tumors). In all these cases there may be local oedema (which see). This may even give a better and earlier sign of local engorgement, but, on the other hand, it may conceal the fulness of the veins. In the majority of such cases the cutaneous veins supply the neces- sary collateral circulation. But this is especially the case in engorge- ment of the portal vein (see also Enlargement of the Spleen and Ascites), whether due to cirrhosis of the liver or compression or thrombosis of the portal trunk. Here we may see the abdominal veins enlarged, part of which go upward to the thorax and part down to the inguinal region. In individual cases there is a crown of such veins around the navel — " caput Medusse " — since the umbilical vein, remaining open, receives a part of the overflow of blood which the portal is not able to carry. Very extensive enlargement and tortuosity of a large part of the cutaneous veins of the trunk, or of the chest (generally symmetrical), or enlargement of single cutaneous veins of an extremity also occurs without any possible assignable cause (perhaps closure of a deep branch), so that recently we are inclined to the assumption that in such cases there is a congenital condition or disease of the wall of the vein itself. 2. Phenomena of Circulation in the Jugular Veins. Respiratory motions. The suction-action of the chest with inspi- ration causes a rapid emptying of the blood from the veins of the body into the heart during inspiration, as well as during expiration. On EXAMINATION OF THE CIRCULATORY APPARATUS. 263 the Other hand, a forced expiration, likewise strong effort, and very especially the increased internal pressure within the chest which takes place in coughing before each cough-impulse, checks the dis- charge. The alteration in the fulness of the veins in the neighbor- hood of the heart which is thus caused is usually only to be ob- served in the jugular veins. But in normal fulness of these veins the simple respiratory oscillation of their volume is not noticeable. Suoh veins only distinctly swell with marked pressing and coughing (whoop- ing-cough), and then the veins of the face become very full. Yet when the veins of the neck are constantly abnormally full or engorged, then in ordinary breathing they show a corresponding to-and-fro swelling, and with forced expiration, pressing or coughing, they stand out very distinctly. The bulb us Jugular is may then appear as a round bunch between the heads of the two sterno-cleido-mastoidei muscles ; but even the whole internal jugular may swell and contract if the valve over the bulb does not close. This phenomenon occurs in the jmost marked degree with the labored expiration of emphysema. Here, also, in very rare cases, this variation in the fulness extends to the cutaneous veins of the face, the chest, and arms. The opposite condition of the veins of the neck, becoming tumid with inspiration and emptying with expiration, may be caused by cal- lous mediastinitis (mediastino-pericarditis). The cause of the phe- nomenon, like that oi pulsus paradoxus (which see), is the traction and bending of the large vessels during inspiration (Kausmaul). Venous pulse. Circulatory movements in the veins or the neck, which directly or indirectly depend upon the action of the heart, and hence are rhythmic, are designated as venous pulse. This motion may be communicated, or be really in the vessels (autochthonous, real pulse). The former is only the pulsation in the carotid communicated to the internal jugular, which shows most frequently and plainly when the carotid pulsates very strongly, or when the internal jugular is very full, or if both conditions exist. (For distinction between this and genuine systolic venous pulse, see p. 267.) We divide the real venous pulse, pulsation in the veins of the neck, into that which occurs in health, the so-called "normal," or negative; and the positive, which is always pathological. The normal venous pulse is presystolic, and usually is only observed in the external jugular. It would be best designated as a collapse of the vein 264 SPECIAL DIAGNOSIS. accompanying the systole of the heart ; for the external jugular, ex- actly corresponding with the apex-beat and the carotid pulse, quickly empties itself and immediately again slowly fills, sometimes visibly in two intervals, so that it attains its complete distention before the next systole of the heart, and hence is presystolic. This phenomenon depends upon the part the auricle plays in the action of the heart : during the ventricular systole it is in diastole, Fig. 74. Normal venous pulse or venous collapse with systole of the heart, and (broken line) carotid pulse. (After Riegel.) and thus favors the flow of blood from the veins. Shortly after the beginning of the ventricular diastole it begins to contract, and thus the flow of the venous blood from the cava into the auricle is impeded. It seems to me that the first elevation of the ascending side of the tracing of the curve of the venous pulse has not yet been explained. In health this pulse is seen to a very small, scarcely noticeable degree ; it is beautifully seen in dogs when the jugular is laid bare. In healthy persons, without any known reason, it is in some cases strong enough to be observed. But it is still stronger sometimes when the external jugular is abnormally full, hence in engorgement. Often this pulse occurs only indistinctly, its rhythm is difiicult to recognize, and also aff'ected by the pulsations of the carotid. Then we speak of undulation in the veins of the neck. The positive venous pulse is systolic, hence is contemporaneous with the carotid pulse. It is a pathognomonic sign of insufficiency of the tricuspid valve, and is caused by the contraction of the right ventricle, which causes a regurgitant positive blood-wave into the cava and its nearest branches through the imperfectly closed right ostium EXAMIXATIOX OF THE CIRCULATORY APPARATUS. 265 venosum. It first and most markedly appears in the internal jugulars or their bulb, and generally only here. The very direct course of the innominate and right jugular from the cava causes the right jugular vein to shoAv the phenomenon more frequently and stronger than the left. If the valve of the vein closes above the bulb of the jugular then the regurgitant wave ends there. This pushes the bulb up and dis- FiG. 75. Positive jugular pulse compared with. (Cj carotid pulse. (After Riegel.) tends it, and it is then seen, enlarged and pulsating, in the inter- sterno-cleido-mastoid fossa (bulbar pulse). The bound of the pulse- wave against the valve sometimes causes a valvular sound in the jugular. But ordinarily the valve is insufficient from previous en- gorgement (or is congenitally so), or it becomes so from the distending action of the pulse, and then the pulse-wave passes into the internal 266 SPECIAL DIAGNOSIS. jugular, and exceptionally also into its branches in the face. This systolic pulse must likewise be supposed to be propagated to a certain extent also in all other veins that are directly given off from the cava; but they cannot be examined in a large venous territory: the veins of the liver. Here the pulse manifests itself by a constant systolic swelling and diastolic collapse of the organ, the venous liver pulse. Palpation of a liver thus constantly enlarged frequently shows the phenomenon of systolic venous pulse to a high degree. The systolic jugular pulse may be graphically represented, as is shown in Fig. 75. The mode of procedure in palpating the liver is as follows : One hand is placed upon the right hypochondrium or the epigastrium, the other is passed around the chest at the level of the eleventh and twelfth ribs posteriorly. We can then feel that the organ is systolically enlarged, and thus we may avoid confounding it with lifting up of the liver by the aorta or even with marked epigastric pulsation. More- over, we recognize the liver-pulse in this way easier — that is sooner — than by simply palpating in front. The liver is usually enlarged, almost always by the previously existing stagnation (see Enlargement of the Liver) ; at least, it immediately becomes so if tricuspid insuf- ficiency occurs, as we very distinctly observed in a case of mitral insufficiency and stenosis, in which relative tricuspid insufficiency occurred, then subsided and again reappeared. Arterial liver-pulse is exactly like venous liver-pulse in its phenomena (in aortic insufficiency, see p. 257). For the production of a recognizable venous liver-pulse, as well as a strong jugular-pulse, there is, of course, required a certain moderate, and, if it has not been met with before, also it must not bo too fre- quent action of the heart. As the heart grows more and more weak the liver-pulse fails and the jugular-pulse gradually becomes smaller and more slow, until finally there is only a slight to-and-fro movement toward swelling of the vein. In order to make a differential diagnosis of the different kinds of pulse in the veins of the neck it is necessary to bear in mind the following : 1. The imparted pulse will be best distinguished from the positive real pulsation, occurring at the same time with it, by placing the finger, or, better still, a pleximeter, with its edge in the middle of the neck upon the vein : if the pulsation is communicated it disappears EXAMINATION OF THE CIRCULATORY APPARATUS. 267 in the central empty portion and becomes more distinct in the periphery from the engorgement of the distended portion ; on the other hand, a positive genuine pulse remains centrally unchanged. 2. The negative true pulse is distinguished from the positive and from the communicated pulsation generally by comparison with the apex-beat as well as by comparison with the carotid pulse. (We seize the left carotid, and at the same time observe the right jugular.) It is also to be observed that with the negative pulse the collapse of the vein is usually quick and that it refills slowly. In this way, with a little practice, one can often immediately judge correctly. In order more exactly to observe and study these phenomena it is well to have the patient for a time breathe very superficially, or, if possible, to hold the breath, so as to eliminate the respiratory to-and- fro swelling of the veins. We must still mention some occurrences that are extremely rare or are of very little diagnostic value : Diastolic collapse of the cervical veins (Friedreich), which looks very like systolic venous pulse, sometimes occurs in adhesive pericar- ditis and callous mediastinitis, and is connected with systolic drawing- in in the neighborhood of the heart which occurs with this condition. The springing forward in the diastole, together with the forward movement of the anterior wall of the chest, probably produces an aspiration of the contents of the large veins. Systolic venous pulse may exceptionally occur with mitral insuf- ficiency and open foramen ovale : through the latter and the left ostium venosum the contraction of the left ventricle produces a recurrent pulse-wave in the cavse and their nearest branches (very rare, being thus far only observed in one case). Double positive venous pulse (Leyden) is observed in hemisystole. 3. Phenomena of Circulation in other Veins. Systolic true pulse may, as has already been mentioned, be propagated to the veins of the face, but this is rare. It has, in individual cases, even been observed in the cutaneous veins of the arm, in the small branches of the internal mammary (of which I have seen one case), in the vena cava inferior (Geigel), etc. The so-called progressive venous pulse (Quincke) has been seen in 268 SPECIAL DIAGNOSIS. the veins of the hand and the back of the foot with existing capillary pulse (aortic insufficiency, also in severe anaemia ; likewise reported to have been seen in health), as a pulse-wave flowing centrally, and later appearing as the radial pulse (a very great rarity). It can be regarded as nothing else than the arterial pulse propagated through the capillaries. 4. Venous Thrombosis. The transformation of the soft venous tubes into firm round cords that can be felt exhibits venous thrombosis. The thrombosed vein may often also be perceived by pressure. In internal medicine, of especial interest and importance is thrombosis of the large veins of the lower extremities as it sometimes occurs in the course of severe acute infectious diseases, as the result of chronic invalidism, and in marasmus of the aged. Frequently, but never while resting in bed, it occurs in the oedema of engorgement in the affected limb. AUSCULTATION OF VEINS. 1. Sounds and murmurs of short duration are sometimes heard over the jugular and crural veins : In tricuspid insufficiency there is a systolic recurrent blood-wave, which, by its impulse against the closing valve above the bulbus jugularis and against those in the crural vein at Poupart's ligament, and also by the sudden tension of the vein itself, causes a sound which will be heard by very lightly placing the stethoscope at these points. But a sound has also been heard where the crural valve was defective. In such cases it must be alone caused by the sudden tension of the venous tube. If these valves are insufficient there may be a corre- sponding short murmur (very rare). Jugular sound generally accompanies the bulbar pulse of tricuspid insufficiency. A venous sound over the crural is, however, rare, because the recurrent wave only exceptionally reaches this vessel. Quite exceptionally there may be with tricuspid insufficiency a double sound over the crural vein, indicating first auricular, then ventricular, contraction (Friedreich). It can be distinguished with certainty from the sounds, double sounds, and murmurs of the crural artery only when there exist signs of aortic or tricuspid insufficiency (hence, how EXAMIXATIOX OF THE CIRCULATORY APPARATUS. 269 small is the diagnostic value of these phenomena I). Crural, arterial, and venous sounds may be combined "when there exist at the same time aortic and tricuspid insufficiency. I^ow and then, even in health, especially in thin persons, a sound is produced over the crural vein by sudden straining or coughing (expiratory valvular sound in the crural vein — Friedreich). 2. A continuous murmur, designated as venous humming, venous murmur, or buzzing, is often heard in anaemic, and especially in chlorotic, patients, but sometimes also in many healthy persons, over the jugular veins. It is usually louder on the right side. It sounds like a regular hummino; or a verv fine "5\-hizzino; or like the hummins: of a top. If it is very marked it can also be felt. The murmur is caused by the whirl in the blood as it flows from the narrow jugular into its wider bulb. The whirls are the more marked, the more rapid the stream ; and hence the murmur becomes louder in deep inspiration, and for the same reason it is generally louder in the upright position than when lying down. And likewise it is not infrequently louder in the diastole than in the systole of the heart. Also, the predominance of the right jugular over the left is explained by the difference in the rapidity of the current caused by the different shape of opening into the cava (see above, p. 265). This murmur will be increased by slight compression, as may be produced by the stethoscope or by turning the head to the opposite side. This latter effect comes from the tension of the fascia colli, and probably also from the contraction of the omo-hyoideus muscle. As to what the occurrence of this murmur means we must rest upon the old idea that it chiefly occurs with anaemic and especially chlorotic patients. Friedreich's claim that it is more marked in these cases, while in health it is usually only to be heard as a soft humming, seems to me to be very far-fetched. Strictly speaking, no diagnostic importance is to be attached to this phenomenon. Similar murmurs occur exceptionally in other veins, and it is to be noted, almost exclusively in anemia ; thus in the large veins of the extremities and also in the intrathoracic trunks. Here the murmur is always much stronger during the heart's diastole and can thus appear to be interrupted. It has already been mentioned that Sahli declared the anaemic heart-murmurs to be in part propagated from the venous trunks in the chest. 270 special diagnosis. Examination of the Blood. preliminary remarks. In health the entire quantity of blood in the body amounts to about one-thirteenth of its weight. At the bedside we can in no way reach an approximation of the quantity of the blood, although it is evident that the capacity of the arteries (assuming that there is an equal pro- portion of blood in the circulation) must in general determine the total quantity of blood. But the loss arising from this defect in our methods of examination is only very small, because, according to our present knowledge, the quantity of the blood is affected in a way that is characteristic and understood by us only in isolated conditions, as for instance, immediately after loss of blood, with extensive watery discharges, as in Asiatic cholera and in severe diarrhoea, especially in children. On the other hand, according to our present knowledge of path- ology, and our methods of examination, there are a number of condi- tions of the blood which relate to its morphological constituents or morphological admixtures, which are, as also the amount of hsemo- globin, and certain relations of this substance with 0, COj, etc., of the greatest importance in recognizing certain diseases. There are some less important diagnostic chemical departures from the normal. Besides the inspection of the skin, which is not entirely without value, the methods which chiefly come into consideration are : the examina- tion of a drop of blood with the naked eye, spectroscopic examination, and that which is made with certain apparatus for approximative determination of the intensity of the color (amount of hsemoglobin). 1. Color and Spectroscopic Character of the Blood. Blood taken directly from a healthy person is of a recognized color ; if arterial it is brighter, rich in oxygen, that is, rich in oxyhsemo- globin. If venous, it is darker ; if bluish-red, it is poor in oxygen. The marked deficiency of oxygen in the blood of a person suffering from dyspnoea or venous engorgement, or both, makes the blood very dark. In carbonic acid poisoning the blood is bright cherry-red ; from chlorate of potash, anilin, and in severe poisoning by hydro- EXAMINATION OF THE CIRCULATORY APPARATUS. 27] cyanic acid, and nitrobenzole it is brownish-red or chocolate color. In severe anaemia and chlorosis (hydrsemia) the blood is watery ; in marked leukaemia it looks a peculiar whitish- red as if mixed with milk, or chocolate color. These changes in. the color of the blood all have an effect upon the color of the patient's skin, as has partly already been mentioned. Hence patients with carbonic acid poisoning look strikingly rosy, while poisoning with chlorate of potash causes the skin and mucous membrane to be the color of anilin, nitrobenzole, a cyanotic or a pecu- liar grayish blue, even black. These discolorations of the skin, as well as the differences in the color of a drop of blood obtained by pricking with a needle, have too little distinction to be directly of diagnostic use. But, especially with regard to the poisons that have been men- tioned, if they are recognized as unusual, they demand that a timely and thorough examination of the blood be made by the spectroscope or microscope. In this lies the great value of a knowledge of these discolorations. For recognizing hasmoglobinsemia (from the haemoglobin that appears in solution in the serum of the blood originating from the red blood-corpuscles) it is necessary to employ a wet cupping-glass. The blood thus withdrawn is allowed to stand covered for twenty -four hours, if possible in an ice chest, and then the serum, separated from the coagulum, is to be examined. That from normal blood is yellow, in haemoglobinsemia it is rubin-red, and in the spectroscope gives the bands of oxy haemoglobin (see below). Approximative determination of the amount of haemoglobin : A diminution in the amount of the haemoglobin may be conditioned upon a diminished number of red corpuscles or upon a decrease in the amount in single corpuscles, or upon both (see below). It is recog- nized by the paleness, and if the loss be very great, the practised eye recognizes it by the clear watery look of a drop of blood. A variety of apparatus, called haemochromometer, has been devised for deter- mining this condition (Quincke, Bizzozero), but recently these have been surpassed in simplicity and utility by the hsemometer of Fleischl. The principle of this is as follows : A certain very small quantity of blood (obtained by a prick) is thinned by a definite quantity of water, and then by lamp or gaslight the color of this mixture is compared with the color of a glass wedge 272 SPECIAL DIAGXOSIS. which has been colored with Cassius' gold purple and carries a movable scale. Upon this scale the figure 100 corresponds with the intensity of color of a mixture of normal blood. Material that has less intensity has the numbers 90, 80, etc., down to 10, thus giving directly the percentage relation of the mixture of blood that is being examined to that of normal blood with reference to the quantity of haemoglobin. Thus 90 indicates, if the mixture of blood has been properly prepared and corresponds in color Avith the color of the glass wedge at that point of the scale, that this blood contains only ninety per centum of normal quantity of haemoglobin. But the determination of the exact quantity of haemoglobin can only be made by quantitative spectrum analysis (K. Yierordt). It would exceed the limits of this book to give a description of the method of procedure. Spectroscopic condition of the blood. In certain cases its examin- ation has decided significance. Recently it has been rendered very much more easy by very practical clinical and uncomplicated apparatus, of which we may mention the spectroscope devised by Desaga (Heidel- berg), and still more recently Hering's very cheap spectroscope without lenses. According to our own experience and also the opinion of Jaksch, the latter after a little practice is entirely satisfactory for clinical purposes. In three classes of cases the spectroscopic examination of the blood fives a A'aluable result : in htemoglobinaemia there is no doubt about the presence of the coloring matter of the blood in the serum (see previous page) if the serum shows the absorption band of oxyhfemoglobin ; one in yellow near green (close to D, Frauenhofer), and one in green near the former, between D and E. Moreover, in carbonic oxide poisoning there appear in the blood two absorption-bands which are very near the two above mentioned, only a little nearer the violet line, and hence they may be confounded with them, but they are very distinctly separated from bands of oxyhsemoglobin in that they do not disappear on the addition of ammonium sulphate (since carbonic oxyhaemoglobin is not thus reduced). Lastly, it has recently been discovered that in poisoning with chloride of calcium methsmoglobin occurs in the blood, and this indeed in the living body. In acid and neutral solu- tions this causes an absorption-band in yellow (between C and D, besides three others more faint), which coincide with that of haematin, EXAMINATION OF THE CIRCULATORY APPARATUS. 273 but which are distinguished from it in that upon the addition of ammo- nium sulphate it first gives place to the absorption-bands of oxyhsemo- globin, then to that of 0, free heemoglobin (a broader band in green and yellow from D almost to E). In alkaline solution, methsemoglobin shows a narrow band in yellow near to D, and one in yellow-green and green. There are still other changes in the blood partly relating to its color and partly relating to its behavior in the spectrum, when animals are poisoned, but they do not seem to require mention in this book. 2. Microscopic Examination of the Blood. 3Iode of procedure. When we wish to examine a patient's blood we first clean an object-glass and a cover as carefully as possible. Then cleaning the tip of the finger with water or a 1 to 2 per cent, solution of salt as carefully as possible, we puncture the finger-tip with a clean needle and allow a drop of blood as it escapes to fall upon the object-glass and without pressure cover it, or we move the cover lightly, without disturbing the finger, over the escaping blood, and then immediately very cautiously place it upon the object-glass. It is not advisable to squeeze the patient's finger in order to force the blood out. In examining for microorganisms all instruments or apparatus must be especially cleaned, and the finger scrubbed with soap and a brush, then with alcohol and ether. According to the special object of the examination we employ a magnifying power of from 300 to 700 diameters. If, instead of the finger, we prick the lobe of the ear, it is just as well, and the whole proceeding is much less painful to the patient. The normal structures of the blood consist of red and white blood- corpuscles, and blood-plates. Clinically the latter of these have pre- viously had no interest. The pathological conditions that are recog- nizable by the microscope may be divided into alterations in the number or appearance of the blood- cells, and into foreign substances, as microorganisns. In general, we again distinguish the changes in the number and character of the blood-corpuscles with reference to diminution of the red corpuscles (oligocythsemia) and changes in the structure and size 18 274 SPECIAL DIAGNOSIS. of the red corpuscles (poikilocythsemia and microcythaemia). But these forms often pass into each other. 1. Oligocythsemia, diminution in the number of red corpuscles, is the change which takes place in anaemia (not in chlorosis). If very marked, it is even recognized by the watery appearance of a drop of blood. At all events, by the practised eye it may be recognized without farther examination of the ordinary microscopical preparation (although very little reliance can be placed upon such a superficial examination). For exactly determining the number of blood-corpuscles we employ an apparatus devised for counting the corpuscles in a given quantity of blood. It is in the first place to be remarked that counting of the red corpuscles is very seldom absolutely necessary for making a diagnosis of the different forms of anaemia (of which see below), but it may be of great value in judging of the course of a given disease, especially as regards the effect of treatment. The Thoma-Zeiss apparatus for counting the number of corpuscles is the best of all those now in use. It consists of a mixer and a Hayem's counting chamber. The mixer serves to distribute the blood in as equal a manner as possible, a very important point. For thinning the blood a 3 per cent, solution of salt is recommended. The mixer is a kind of measuring pipette with a very fine canal, and with a spherical enlargement containing a little glass ball. The portion of the tube below the cavity has the marks 0.5 and 1.0. Just above the cavity is the mark 101, The first two marks are those to which the blood, directly after it has been drawn from the finger, is sucked. If we wish a mixture of 1 to 200 we draw it up to 0.5 ; if a mixture of 1 to 100 to 1.0. In both cases we wash off the blood clino-ino; to the point, and draw in a 3 per cent, solution of salt to 101. Then the mixer is shaken several times so that the glass ball equally mixes its contents. We next expel the contents of the fine tube, which consist of salt solution, after which we fill from the mixture a Hayem's counting chamber. This consists of an object-glass with a circular excavation ; it is a space exactly 1 mm. deep, the floor of which is divided into microscopic squares, whose sides are ^V ™™- long. The cubic capacity of the space over each square is -^^ X -^V X iV c.mm, = :foVo cmm. EXAMINATION OF THE CIRCULATORY APPARATUS. 275 Into this cavity some of the blood-mixture is blown and then covered with a glass cover after carefully expelling any air bubbles. After waiting a moment in order that the blood-corpuscles may as far as possible equally distribute themselves, we magnify it about 50 diameters and count the number of corpuscles in the larger number of the above-named squares, and thus obtain an average of the contents of say sixteen of them. If we count these sixteen squares several times we shall secure a more accurate determination. We can calculate the number of corpuscles in a cubic millimetre from the proportions of the mixture and the cubic contents of the squares, as given above. Immediately after use, the mixer must be most carefully washed with water, alcohol and ether. Normally, in a cubic millimetre of human blood, there are in the male about five million, in the female about four and a half million red corpuscles (C. Yierordt, Laache). We may only positively affirm that there is a pathological diminution when, examining a case for the first time, the enumeration gives half of the number or less. The least quantity observed in disease is about 400,000 to the cubic millimetre. Besides diminution in the number of red corpuscles, in anaemia (hydrsemia) we observe the following : 1. They manifest diminished or even no tendency to the formation of rouleaux, which is a well- known peculiarity of normal blood. 2. Star forms, mulberry forms, which are also usual in normal blood as soon as it is withdrawn, seldom or do not occur at all. 3. The red corpuscles are paler in simple ansemia (very markedly so in chlorosis), on account of the diminished amount of hsemoglobin. The opposite condition is not infrequent in poikilo-microcythajmia (which see). 4. In a certain proportion of cases there occurs a slight alteration in the form and size of the red corpuscles, as referred to under 3. 5. The white corpuscles are, in proportion to the red, somewhat increased (relative leucocythsemia). Oligocythsemia is always connected with diminished amount of hsemoglobin in the blood, whether there is a diminution in the number of the red corpuscles or the individual corpuscles are paler. The diseases in which both conditions exist are the different forms of anaemia, pernicious anaemia, leucaemia. On the other hand, only a 276 SPECIAL DIAGNOSIS. diminished quantity of haemoglobin in the blQod, that is to say, no notable diminution in the number of red corpuscles, occurs in chlorosis. In observing the progress of the first-named diseases we must make an enumeration and examine with reference to the amount of hicmoglobin, while in chlorosis it is only necessary to examine for the latter. In the former case the number of red corpuscles and the haemoglobin seem to go hand in hand. Hence it seems to me that, especially on account of its simplicity and its approximate accuracy, Fleischrs haemometer may be very strongly recommended to physicians for examining the color of the blood in the course of an anjemia (strictly speaking, chlorosis), thus answering in a great majority of cases, on account of the particular care which the enumeration requires, unless there should be some indication for counting the corpuscles. 2. Alterations in the size and form of the red corpuscles. Formerly this was, in its totahty, considered as a diagnostic sign of pernicious anaemia. Now we know that there are other conditions that accom- pany such variations. The simplest way of determining the size is to compare a preparation of blood with that of a healthy person (the examiner himself). The normal average of red blood-corpuscles is 7, 7-8, ^. Microcythsemia. By this we understand the occurrence of forms containing haemoglobin, which are smaller than red blood-corpuscles, in which the form is nearly or quite perfect, or, if they are very small, they are simply globular. We see the former in the new formations of blood after hemorrhages, and also in all kinds of anaemia. They are probably young red corpuscles. The latter — microcytes, strictly so-called — occur especially frequently in pernicious anaemia, and also in all other forms of anaemia. The supposition that they are formed upon the glass slide is possibly correct, because they may even be found in normal blood when the preparation contains air, is pressed, or is old. I have never seen them when examining a perfectly fresh, otherwise normal preparation of blood, except at the border (the eflfect of air). Macrocytes — abnormally large red corpuscles, besides those of normal size and very small ones — occur in individual cases of marked and simple anaemia, but especially in pernicious anaemia. This disease must always be suspected when they are present. Corpuscles EXAMINATION OF THE CIRCULATORY APPARATUS. 277 that are larger than normal are almost always also poikilocytes, like the following : Poikilocytes, strictly speaking, are red corpuscles changed in form. They may assume the greatest variety of forms — club, biscuit, pear, flask, and drum-stick are the most usual forms. In many ways poikilocytes correspond to enlarged red corpuscles. In individual cases they exhibit amoeboid movements. In a wider sense we employ the expression poikilocytosis to a mixture of such forms with micro- cytes and macrocytes, which are almost always present. Fig. 76. d f: d 8 c^. Poikilo-, macro-, microcytosis (as represented by the letters d, b, c). a, normal blood- corpuscle; e, product of decomposition of a red blood -corpuscle; /, nucleated red blood- corpuscle (marked anaemia). (After Quincke.) We must avoid confounding with them the mulberry and thorn- apple forms, which occur normally, or mechanical or chemical products, by using the greatest care in making the preparations and then imme- diately examining them. Poikilocytosis is not at all a pathogtiomonic symptom of pernicious ansemia, although in other forms of ansemia it does not occur so regularly and in so marked a degree as in pernicious anaemia. It may occur w^ith any severe form of anaemia and cachexia, as in tape- . worm, or cancer-cachexia. As a matter of course, all these changes in the red corpuscles usually very notably accompany diminution in their number and of the amount of haemoglobin. Hence, as has already been mentioned, the amount of haemoglobin in separate blood-corpuscles is not infre- quently increased. 278 SPECIAL DIAGNOSIS. 3. Increase of the -white blood-corpuscles (leukaemia, leucocvtosis). The proportion of white blood-corpuscles to the red in normal blood, drawn bj pricking the finger, if we take the average of the reported observations, is about 1 : 400 to 1 : 700, which is a considerable variation. Where this proportion varies temporarily and slightly in favor of the Avhite corpuscles, we designate the condition as leucocytosis ; if it is long continued and verv marked, as leukemia. Ordinarily we can easily distinguish at the first glance between these two conditions, since leukaemia is generally accompanied with a very marked increase, and leucocytosis with but a slight increase of the white cells. Hence, we rarely have cases that are on the border between the two. Fig. 77. Blood of leukaemia. (After Funke.) During digestion, leucocytosis is observed as a physiological condi- tion. It is also seen in acute infectious diseases, especially in typhoid fever and in relapsing fever, inflammation of the spleen, etc. "We have inflammatory leucocytosis in swelling of the lymphatic glands from inflammation of all kinds, especially in erysipelas. Lastly, we meet with cachectic or hydraemic leucocytosis in all forms of anaemia, and this may be either relative, dependent upon a diminution of the red corpuscles, or, as enumeration shows, it may be absolute. In the latter case, it is explained by the undoubted slowing of the lymph- current in consequence of hydraemia. EXAMINATION OF THE CIRCULATORY APPARATUS. 279 Under the microscope, leukasmia is manifest in that usually there is a remarkable increase in the white corpuscles. Very frequently there has been found a proportion of 1 white cell to 10 red cells. When the proportion is more than 1 to 20, many wish to apply the term leukaemia. In extreme cases, which are rare, the number of red and white corpuscles become about equal. At any rate, the number of red corpuscles is always diminished : Jaksch found the average of a number of cases to be two to three million cells (red and white) in a cubic millimetre of blood. The size of the white corpuscles usually remains normal ; but very often re- markably large leucocytes are found, some of which have strikingly large nuclei. Moreover, we sometimes find nucleated red corpuscles (probably transition forms from the white to red). The red corpuscles often have the forms of poikilocytosis. Ehrlich found a remarkable behavior of leucocytes — that is, their protoplasmic granules — in the presence of certain aniline colors. His most important result is the discovery that only in leukaemia are there found in the blood white cells called eosinophile — that is, that are distinctly colored with eosin. In doubtful cases this fact would seem to be useful in diagnosing leukasmia. Ehrlich dries a preparation upon a covering glass, as thin as possible, in the air or exsiccator, heats it for ten to twelve hours in a drying chamber at 120°-130° C, and quickly stains it with eosin-glycerin. Then he washes it with water, and mounts it dry in Canada balsam. Opinion is divided as to whether it is possible to recognize the different pathological, anatomical, or clinical forms of leukaemia by the condition of the blood — that is, to discriminate whether the leu- kaemia exists by participation with lymph-glands, the spleen, medulla of the bones (lymphatic, splenic, myelogenic leukaemia). It seems true that the above-mentioned transition-forms between red and white blood-corpuscles point to alterations in the medulla of the bones. Moreover, many think that the small cells are more connected with the lymph-glands and the large ones with the spleen. In extremely rare cases of leukaemia, crystals are found in the blood (Charcot) : they are colorless, shining, long octahedral, like Charcot's crystals found in the stools and expectoration, or they are identical with them. 280 SPECIAL DIAGNOSIS. 4. Abnormal additions to the blood. Of these we first mention melan?emia and lipi^^mia. Melancemia occurs directly after severe attacks of malaria and in malarial disease. AVe sometimes find, swimming free in the blood, brownish-black or yellow-brown lumps and granules, or, also, white blood-corpuscles filled with such granules. They result from breaking up of red corpuscles. By Upcemia we understand the occurrence of extremely fine drops of fat in the blood, as in drunkards, in diabetes, and in chyluria; but they are also sometimes seen in health. In recent times we have learned to recognize microorganisms as most important additions to human blood. They are exclusively schizomycetes. Fig. 78. Anthrax bacilli in the arterial human blood (fuchsine-staining. Ziess's homogeneous immersion lens xj, eye piece 4, camera lucida, magnified about 1000 diameters). The white line in the middle of the bacilli indicates only reflections. Prepared by Dr. Freimuth in Danzig. Anthrax bacilli in the blood has been repeatedly established in poisoning by anthrax, although always in considerable quantity. The defect in the microscopical proof does not exclude, however, a general infection : a test by vaccinating mice may, however, succeed. We may have several bacilli of anthrax often occurring together, not threads ; spores may be entirely Avanting. The bacilli are recog- EXAMINATION OF THE CIRCULATORY APPARATUS. £81 nized, without staining, as tolerably thick clubs, possibly twice the length of the diameter of a red blood-corpuscle. Regarding, staining, see below. O Eecurrent spirals in the blood (After Jaksch.) The first microorganisms that were seen in the blood were the recurrent spirals (Obermaier). We find them during an attack of recurrent fever. They disappear shortly before the decline of the fever. By careful examination they can always be demonstrated, although sometimes there are only a few of them. In a fresh drop of blood they appear (Hartnack 8, Zeiss F) as extremely fine threads, about five times as long as the diameter of a red corpuscle, with extremely active spiral, serpentine motion. They occur either singly or several close together, sometimes lying together like a group of rats' tails. I have very often first seen them near white blood- corpuscles. The white or red corpuscle against which it lies is usually set slightly in motion by the microbe, and hence we find them there first. Moreover, there often occurs in the blood slight leukocytosis ; also, we sometimes meet with shining granules (elemen- tary granules ? spores ?). As to staining, which, after a little practice, is not necessary, see below. Tuhercle bacillus exists in the blood as the sign of miliary tubercu- losis. But in this disease we may lack this proof. With the excep- tion of one case observed by Jaksch, it always occurs quite isolated. A special treatment is required for obtaining this microbe. We arrange a thin layer of blood upon the glass cover just as we do a preparation of sputum (see Sputum). Typhus bacilli have in several cases been found in the blood as a 282 SPECIAL DIAGNOSIS. short (one-third the diameter of a red corpuscle), thick club, rounded at the end. See Examination of the Stools (for staining, see below). The hacilli of glanders are, in general, a little longer than the pre- ceding, but considerably slimmer. Tiiey have likewise been found a number of times in the blood of this disease. It is necessary to stain them (see below). Plasmodium malarice is still doubtful, although Marchiafava and Celli are tolerably certain that they have produced malaria by infec- tion where it did not previously exist. They are protoplasmic bodies within the red corpuscles, Avhich can be stained by methylene-blue. The greatest care and cleanliness are necessary in arranging a preparation of blood for microscopic examination for microorganisms, although the minutire of disinfection and sterilization, as in preparing for culture, are not required. In malignant pustule ^xid.fehris recurrens staining can be dispensed Avith. When it is necessary to stain a preparation, it is prepared by drying a small drop of blood which has been spread out and made as thin as possible by pressing two covers together. Then they are separated, allowed to dry in the air, and afterward passed two or three times through the flame of a spirit-lamp or a Bunsen's burner. If, now, we wish to examine for tubercle bacilli, a special treatment is necessary, as has already been described under Sputum. For other microorganisms we stain with basic aniline colors (vesuvine, fuchsine, particularly methylene-blue, etc.), and then carefully rinse and examine in water, or, after drying, in Canada balsam. The staining is much more beautiful if we first briefly dip them in Fig. 80. Fig. 81. Distoma haematobium with eggs. Filaria sanguinis hominis. (After Jaksch.) (After Jaksch.) gentian-violet-aniline water (see above under Sputum), and then stain them a few minutes in Gram's iodine-iodide-of-potassium solution (iodine 1 part, iodide of potassium 2 parts, aq. destil. 300 parts), then in absolute alcohol. EXAMIXATIOX OF THE CIRCULATORY APPARATUS. 283 Finally, we briefly refer to two animal parasites which are met with in the blood, though they do not belong in this book : the filaria san- guinis hominis, which causes hsematochyluria (in British India and Brazil), generally only found in the blood at night-time, and distoma hcematohium (Bilharz), which causes a kind of hoematuria, chiefly occurring in Egypt. (See under Urine.) Chemical Examixatiox of the Blood. — We content ourselves with a few hints regarding this department, since it lies almost entirely outside of the limits of diagnosis. Becently, in certain diseases, the degree of alkalescence of freshly- drawn blood has been determined by various methods, and it has been found that in severe anaemia, fever, and diabetes (Jaksch) the alkalescence is considerably diminished. Uric acid in unusual quantity has been found in the blood in gout. The quickness with which blood coagulates after it has been with- drawn varies in different diseases. In health, coagulation takes place in about nine minutes. It is slower than this where the nutrition is chronically disturbed. (H. Yierordt.) CHAPTER YI. EXAMINATION OF THE DIGESTIVE APPARATUS. Mouth, Palate, and Pharyngeal Cavity. The inspection of these parts requires good illumination, and for a portion of them, in many cases, a quick view. Bright daylight is better than artificial light. The mouth is to be opened widely, the tongue protruded, and not only put out, but, for inspecting its borders, turned from side to side. (For examining it with reference to paralysis, see Nervous System.) In order to inspect the mucous membrane of the mouth, we turn out the upper and lower lips with the finger, the mouth being closed ; then, the mouth being opened, we carefully lift the mucous membrane of the cheeks from the back teeth with a mouth-spatula (made of ivory, hard rubber, horn, or metal). The gums are examined by opening the mouth as widely as possible and holding the tongue down carefully Avith a tongue-depressor (a teaspoon serves very well). The back of the mouth is best brought into view by having the patient say distinctly "se" (full elevation of the soft palate). The patient should be required to drink some water, also to clear the throat thoroughly before it is examined. If w^e meet with opposition, especially in children, it is sometimes necessary to hold the nose, and thus compel them to open the mouth. When a child cries, we are able to see very well. It is often useful to cause the sensation of strangling by putting the tongue-depressor far back, and thus Ave are able to see the tonsils better — of course, only for an instant. [One learns, by practice, to take a very perfect and com- plete view of the Avhole cavity of the mouth and pharynx in this instant of strangulation, and then can carry the mental picture long enough to note all its particulars.] But Ave must guard against being too harsh or rough with children with diphtheria, or with any very sick patient. In diphtheria, imme- (284) EXAMINATION OF THE DIGESTIVE APPARATUS. 285 diate death may follow an effort at examining the throat. With those who are unconscious, it is necessary to cause gagging in. order to inspect the posterior part of the mouth. In marked cases of this character, it is often impossible to obtain a view at all. Palpation is only rarely employed for examining the tongue, floor of the mouth (making counter-pressure from without), the tonsils, or the back part of the pharynx. We employ the index, or this and the middle fingers, which have been carefully washed in the presence of the patient. The odor from the mouth is, in many cases, important. A foul odor — foetor ex ore — results from imperfect cleansing of the teeth, caries of the teeth, or dyspepsia. From this odor we distinguish the stale, and at the same time foul, fetor from considerable old deposit in the mouth of patients who are very ill. If the sense of smell is acute, one can also distinguish a slight cadaveric odor upon patients who are very sick, even if the mouth is quite clean, and sometimes it precedes death. Of much more diagnostic value are the different odors which we meet with in poisoning from prussic acid, phosphorus, alcohol, and chloroform ; but the two former, even in recent cases, may possibly be wanting. Lastly, we mention the odor of fruit, wrongly called "acetone" odor, very like fresh apples, which sometimes occurs with the so-called chloride of iron reaction of the urine (see) in diabetes, especially before or during the onset of diabetic coma. The lips. With regard to their color (pale, cyanosed, etc.), we can refer to what has already been said when speaking of the mucous membrane. Dryness of the lips is seen in connection with dryness of the tongue (which see). There is marked dryness in severe febrile diseases, with a dirty looking crust adherent to the mucous membrane, which easily bleeds when this is removed (fuliginous deposit). Small cracks (rhagades, crevices) are, in themselves, without significance. On the contrary, in children, rhagades are an important, generally a positive, sign of hereditary syphilis. The teeth and gums. We must take both into consideration, and, besides, as to whether the teeth are sound. In small children we notice whether the first teeth have all come ; in the later years of childhood, the change to the permanent set. There is often marked caries of the teeth in diabetes mellitus, 28g SPECIAL DIAGNOSIS. though it is very common without this disease. A circular excavation of the lower edge of the upper middle incisor teeth of the second dentition [Hutchinson's teeth] is usually a positive, almost pathogno- monic, sign of congenital si/philis (with catarrh of the middle-ear and parenchymatous keratitis, the whole forming the infallible Hutchin- son's triad). Imperfect and diseased teeth, interfering with mastica- tion, are often the chief cause of dyspepsia. Loosening of the teeth, and the gums discolored bluish-red, receding from the teeth, easily bleeding, and even inflamed, are important symptoms of scorbutus. Loose teeth, with moderate swelling, is a sign of chronic poisoning with mercury. A grayish deposit upon the teeth, and a gray line along the dental border of the gums, results from chronic lead-poisoning. In poisoning by copper, we have sometimes the same condition, only the color is greener. The eruption of the first teeth is a source of much disturbance in the mouth of the little patients. Occasionally it gives rise to serious disturbances — diarrhoea in rare cases, epileptiform attacks (eclampsia of children, infantile convulsions, spasms of dentition), also spasm of the glottis. Second dentition and the eruption of the wisdom-teeth are not infrequently accompanied with limited or general oral dis- turbances, sometimes likewise the cause of abscess. To the red border upon the gum, observed by Fredricq-Thompson, which in young subjects is said to bd a very suspicious sign of tuberculosis, we have given careful attention for a long time, and conclude that it has no significance. The tongue. For paralysis and neurotic atrophy of the tongue, see undei'. the Nervous System. Enlargement of the tongue, if slight, is only to be determined from the indentations on its borders by the lower teeth. This occurs with the various forms of stomatitis. Marked enlargement of the tongue may be caused by parenchymatous glossitis, tumors, and also by severe angina, which produce venous engorgement of the tongue. Moreover, there are very great individual variations in the size of the tongue. Circumscribed swelling and hardness, or the latter alone, are the first evidences of cai'cinomatous or syphilitic formation-s of the tongue. It is extremely difficult to make the very important difi'erential diag- EXAMINATION OF THE DIGESTIVE APPARATUS. 287 nosis between these new growths, and usually it can only be made by microscopically examining a small piece, which can easily be removed from it. (See, regarding this, in works upon surgery.) Wounds and the resulting scars, sometimes accompanied with swelling, are frequent appearances after epileptic attacks, and result from biting the tongue (see Scars). We never see the tongue bitten in hystero-epilepsy. If the tongue trembles when it is protruded, or if it does so when within the mouth, it is a valuable sign of chronic alcoholism. This is also the case in severe fevers, and especially early in typhus. In these cases, when there is marked hebetude, the patient often will not draw in his tongue after protruding it unless he is directed to do so. The color of the tongue is aifected by that of the blood : cyanosis affords the most marked instance of this. It is quite common to find local redness with febrile conditions. It often goes side by side with the febrile redness of the cheeks. Mulberry tongue is one in which there is a decided redness with swelling of the papillEe, and is an important sign of scarlet fever, which, in individual cases, may develop before the cutaneous eruption. Very often the coating of the tongue conceals the color of the mucous membrane. When the saliva is glutinous or diminished it causes the tongue to be sticky or dry. In connection with dryness of the throat, febrile diseases cause thirst. When the fever is very high, the dryness is often increased by the patient keeping his mouth constantly open. Then the surface of the tongue, if free from coating, first becomes horny, then quickly very smooth, and soon rough and cracked. Coating of the tongue, as a thin white layer, is often constant in health. When a tongue which previously was clean becomes coated, especially if thickly coated, it indicates dyspepsia. There is very marked coating of the tongue in severe acute and chronic diseases of the stomach and with the dyspepsia of fever. With the latter, it is often discolored brownish-red from small hemorrhages of the mucous membrane. When there is great dryness of the tongue, it becomes crusty and adheres so closely that when removed the mucous membrane bleeds. Articles of diet may cause temporary coating, or they may color the coating that is already there (milk, cocoa, coffee, etc.). A thick white — often, also, a discolored — coating on the tongue may depend upon the development of thrush (Oidium albicans). In 288 SPECIAL DIAGXOSIS. very pronounced cases it forms separate small tufts about the size of a millet-seed Avhich spread out and coalesce. It is cheesy and tolerably adherent. It may cover the surface of the tongue, the soft and hard palate, the mucous membrane of the cheeks ; it may even extend down into the oesophagus ; occasionally, we see the whole surface of the mouth and throat covered with it. Small children have it quite often ; adults only in cases of severe illness when the care of the mouth is neglected, especially in fevers, diabetes, tuberculosis, etc. Whenever there is a thick coating in the mouth we must think of this growth, because its early recognition is very important. The diagnosis is promptly made by the aid of the microscope (see below). For scars from biting of the tongue during an attack of epilepsy, see above under Wounds. Dense, often depressed, scars upon the surface of the tongue indicate healed syphilitic ulcers. When there is a suspicion of syphilis, the mucous membrane of the mouth must be examined with the greatest care (scars, ulcers [mucous patches]) ; also, when there is a possibility of poisoning with strong mineral acids or alkalies, corrosive sublimate, carbolic acid (superficial gray color and under it marked injection of the mucous membrane, raw patches). It may also be the seat of catarrhal ulcers as well as of the develop- ment of thrush (see above). Cancrum oris (Noma) usually begins with a circumscribed bluish-black discoloration of the mucous mem- brane of the cheek or an ulcer with this condition around it and with a thick, inflammatory infiltration of the cheek. It is a kind of spontaneous gangrene with a decided reactive inflammation in poor, wasting children. It is a rare disease. We examine the floor of the mouth by palpation from within and without. It may be the seat of very dangerous inflammation (angina Ludwigii). Salivary glands and saliva. Of the former we notice only the parotid gland. When it is inflamed there are pain and swelling, and if it proceeds to the formation of an abscess, there are also redness and fluctuation above the angle of the jaw. The saliva is increased (salivation, ptyalism) by all kinds of irrita- tion that affect the mucous membrane of the mouth : physiologically by eating, pathologically by all inflammatory conditions of the mouth (ulcers, inflammation of the gums in connection with affections of the EXA3IINATI0X OF THE DIGESTIVE APPARATUS. 289 teeth, dental abscess, etc. ; corrosive action of acids, alkalies in the mouth and throat) ; also, in chronic mercurial poisoning, and, lastly, sometimes in disease of the medulla oblongata (see Bulbar Paralysis). The saliva is diminished in febrile diseases, in diabetes, in severe diarrhoea (cholera). Thus far the chemical examination of the saliva has been of no diagnostic value. It is of interest that in nephritis it may contain urea, and also that thus far there has never been discov- ered in it any coloring matter from the bile nor any sugar. Many substances, like iodide of potassium, after they have entered the stomach appear remarkably quickly in the saliva. Microscopic examination of the contents of the mouth. Normally we find flat epithelial cells from the upper layer of the mucous mem- brane of the mouth, separate white blood-corpuscles, and likewise micrococci, bacilli, and spirochseti (especially a microbe like the cholera bacillus and one like the recurrens spirilla). Among these microorganisms, no doubt, there are some which may become patho- genic for the individuals in whom they occur. In the coating of the teeth we find these microorganisms very abundantly, and besides the leptothrix buccalis (long bacilli, often forming long threads, which are colored blue-red by iodide of potassium, see Fig. 82), Leptothrix buccalis, 1000 : 1 (after Flugge). There is an unusually large quantity of the different schizomycetes, especially cocci, in any case where the contents of the mouth are decomposed {scorbutus, severe chronic mercurial poisoning, in any severe disease where there is difficulty in swallowing, especially if the mouth is not carefully cleaned). "We also usually find an abundance of red and white blood-corpuscles. 19 290 SPECIAL DIAGNOSIS. In the coramori white coatin^ of the tongue there are abundant flat epithelial cells and fungi ; these, together with a quantity of brown detritus, as well as red corpuscles, are found in the coating when discoloi-ed. It is easy to recognize the thrush fungus under the microscope by the characteristic, tolerably broad, light fungus-threads (they are more than half as broad as a white blood-corpuscle) and by their roundish- oval, clear granules. Inflammation in the mouth proceeding from the inferior maxilla may, in rare cases, give rise to actinomyces. Whenever there is a discharge of pus into the mouth we must remember the characteristic kernels (see p. 175; Microscopic Examination, see p. 189). Of the soft palate, we are chiefly interested in the tonsils. We take note of their size and the appearance of their surface. Large tonsils with deep, empty lacunae indicate frequent attacks of tonsillitis; prominent white scars, syphilis. If active disease be present, we are to notice whether there are plugs in the lacunse {follicular tonsillitis); whether there is a deposit upon the tonsils, and, in case there is, whether it is confined only to the tonsils and lacunne (in both cases, angina neerotica) ; whether it extends over upon the arches (diph- theria); whether it is loose or adherent, testing it with the spatula, and whether we find beneath it a necrosis of the tonsil going on. Diphtheria may cause a deposit upon the arches of the pharynx, the uvula, all of the soft palate, and even a part of the hard palate. We recognize an abscess of the tonsil by its [usually] being on one side only, with swelling of the anterior arch, by the fluctuation (which is felt with the finger). Long-continued ulcers of the tonsils and soft palate are generally syphilitic; more rarely, tubercular. In the latter case there is often a broad, reticulated, purulent discoloration of the mucous membrane, which reminds one of slightly-inflamed pleura covered with a fine fibrinous exudate. (Paralysis of the Throat, see Nervous System.) In the pharynx, we look for possible chronic or acute inflammation and ulcers ; in children who, for some unknown reason, swallow badly and have distress in breathing, for possible swelling of the posterior pharyngeal wall (retropharyngeal abscess, the fluctuation in which may be detected by palpation). We must always examine the lymphatic glands in the neck in con- EXAMINATION OF THE DIGESTIVE APPARATUS. 291 nection with the examination of the throat. In all acute inflammations of the latter they swell, most markedly in diphtheria, also in chronic inflammations, especially syphilis. In diseases of the palate and pharynx the microscope gives very little assistance. It is chiefly useful in tuberculosis. When there is a suspicion of a tubercular ulcer, we scrape a little directly from the surface of the ulcer, but yet we cannot be certain that we have not taken some tubercular sputum which has adhered there. Long- standing plugs from lacunge (often quite free from irritation) frequently contain leptothrix (pharyngomycosis leptothricia). The important diiferential diagnosis between diphtheria and benign necrosis of the tonsils cannot, with our present knowledge, be made by the aid of the microscope. Pharyngomycosis leptothricia (algosis faucium leptothricia) may, as has been observed in individual cases, extend from the tonsils, par- ticularly to the follicular glands at the root of the tongue, or even still further into the trachea itself. They manifest themselves as a number of distinct, elevated, yellowish- white specks. The nature of these deposits is easily recognized under the microscope, especially after the addition of iodine (see preceding page). Examination of the (Esophagus. Preliminary anatomical remarks : The oesophagus begins at the level of the cricoid cartilage of the larynx (= the lower border of the sixth cervical vertebra), and extends .to the stomach, at about the height of the base of the xiphoid process. At first it lies immediately in front of the vertebrae, then it comes a little forward, and, at about the seventh dorsal vertebra, it bends a little to the right, then again to the left, to reach the oesophageal opening in the diaphragm. In adults, the oesophagus is about twenty-five cm. long. When we employ an oesophageal sound, we estimate the distance from the incisor teeth to the stomach at about seventeen cm., in the newly born, while with adults it is about forty cm. In the latter, the distance from the incisor teeth to the bifurcation of the trachea is about twenty-two cm. The oesophagus does not have the same diameter throughout : its narrowest points are at the commencement, and the point where it perforates the diaphragm. The neighboring organs with which it has 292 SPECIAL DIAGNOSIS. important relations in different diseases are : the trachea for the upper seven to eight cm. of the oesophagus, the bronchial glands, the pleura, the pericardium, the aorta from the bifurcation of the trachea down- ward, lastly, the recurrent nerve from the bifurcation upward. It is only in the neck that the oesophagus can be felt from without. Below, we cannot employ the usual methods of examination. Characteristic diflGculties almost always occur with certain diseases of this organ, namely, with those conditions which result in stenosis (stricture) : there are more or less deeply-seated diflficulties in swal- lowing ; the patient, after taking food, has a feeling of pressure, or even of pain, in the neck or the chest — a feeling that what has been taken cannot be passed down. According to the place or degree of the stenosis, the patient experiences difficulty only after taking large, slightly comminuted bites of food, or even after swallowing soup or fluids, either immediately after the former or only after many bites or swallows. Moreover, the food may be regurgitated, wholly or in part, some time after it has been taken. Then we distinguish it from vomiting by the absence of odor, of acid reaction, and of muriatic acid. Pain in swallowing, without stenosis, occurs with inflammation of the mucous membrane of the oesophagus or in its near neighbor- hood (mediastinum). Examination of the oesophagus is almost confined to direct palpa- tion from within by means of the sound, excepting that, in the cervical portion, we can employ inspection and palpation from without. Auscultation furnishes little, percussion no, aid. But it is very important in many cases to examine the neighborhood, particularly the thorax. Only in exceptional cases do inspection and palpation of the cervical portion yield any result, because the great majority of diseases of the oesophagus are located quite below the bifurcation of the trachea. We can feel a carcinoma of the cervical portion (likewise swelling of the glands of the neck); we can feel, and often also see, pulsating diverticula when they are full — that is, after the patient has eaten. Carcinoma of the lower end of the oesophagus can be felt from the abdomen, if the cardiac end of the stomach is encroached upon. Pain from pressure in the neck occurs in the conditions above named and in inflammations, as after swallowing acids and alkalies. EXAMINATION OF THE DIGESTIVE APPARATUS. 293 Direct Palpation ; Examination with the Sound. — For diagnostic sounding of the oesophagus we employ either a whalebone or English oesophageal sound. The former consists of a thin staff with an olive-shaped ivory knob screwed upon one end. We have knobs of different sizes, in order to determine and measure the degree of the stenosis (see below). Before using, we are to make certain that the bulb is secure upon the staff, and also that the staff is perfectly smooth, so as not to catch anywhere and thus mislead us. This sound furnishes the most positive information, and yet it requires the greatest dexterity and caution in using it. The English oesophageal sound is a cylindrical India-rubber tube, tolerably stiff when cold, with its end slightly smaller and closed, but having two openings at the side. Before using, it must be somewhat softened by dipping it in warm water. We must have at hand several such sounds of different sizes. The end should always be rounded and perfectly smooth, so as not to produce a rupture. Before introducing it, we are to moisten only the knob of the whalebone sound, but the whole of the English sound with glycerin or white- of-egg (not with olive oil, nor with water). The patient sits upon a chair or the edge of the bed with the chin somewhat elevated. The index and middle fingers of the left hand are introduced into the mouth, and with them we slowly feel as far as the root of the tongue. Then we seize the sound with the right hand, like a pen-holder, and slowly push it along the tongue under the two fingers. As soon as it passes beyond the ends of the fingers, we press its end somewhat downward with the tip of the fingers, and at the same time elevate the right hand, so that the sound may not strike against the back of the throat. The sound is then with gentle pressure pushed on, always holding it as if writing. The left hand is now withdrawn. Special precautionary measures, such as placing a cork between the teeth, or anything to hold the jaw, are usually not necessary, since this operation is not performed upon unwilling or unconscious patients (see Sounding the Stomach). Only with children are we sometimes obliged to use the cork. Many patients bear a skilfully-performed sounding very well, but others can only become accustomed to it from considering its beneficial results. If the motions of strangling are not severe, we need not be disturbed by them, but if there is vomiting we must at once withdraw the sound in order that there may 294 SPECIAL DIAGNOSIS. be no swallowing. A slight spasm of the glottis and momentary arrest of breathing have no significance, yet attention is called to the second paragraph below. We sometimes meet with a resistance which is not pathological : 1. At the posterior wall of the throat, but only with unskilful intro- duction of the sound (see above). 2. Sometimes, if the cricoid cartilage of the larynx overlaps the oesophagus somewhat, from the point of the sound striking against it; this is easily passed by withdrawing it a little, and then pushing it on again. 3. By spasm of the oesophagus, caused by the sound, which disappears soon by waiting. Two occurrences may endanger the life of a patient: 1. The intro- duction of the sound into the trachea, which very rarely happens. At any rate, as soon as there is marked difficulty in breathing the sound is to be withdrawn. If the patient is able to pronounce "a" clearly, moreover, if the portion of the sound introduced is longer than the trachea, then we know that it has not entered the trachea. Other signs are deceptive, 2. A still greater danger is that the wall of the oesophagus may be injured or ruptured. This results from narrowing of the canal, if it has become thin and frasrile from a crumbling new formation, or by an ulceration, or when an abscess or aneurism near the oesophagus is thus perforated. The results of these are either ichorous mediastinus or pleurisy with fatal termination, or if an aneu- rism, with immediately fatal hemorrhage. We must never employ force if the sound meets with resistances If we can confirm the suspicion of an aneurism by examining the chest, we are always to omit using the sound. Examination with the sound gives information in the following ways : 1. Sometimes a deep-seated pain occurs after the examination has been made several times, although the sound has only been introduced a certain distance. It may depend upon inflammation in that neighbor- hood (for determining its height, see under " Stenosis"), upon an ulcer, a carcinoma not causing stenosis, a purulent oesophagitis, or perioeso- phagitis. 2. The sound meets with resistance. Then the patient, in many cases, is sensible of pressure, or has a sensation of pain ; sometimes there is severe strangulation. We move the sound back and forth, and endeavor to advance it with very slight pressure. We mount a smaller knob upon the whalebone sound, or take a thinner rubber one. But EXAMINATION OF THE DIGESTIVE APPARATUS. 295 the smaller the sound the greater the danger, and hence greater caution is required in using it. If we are at length able to advance it further, then we feel resist- ance just so long as the knob is in the stenosed portion. After passing the narrowed part, it again passes easily, but, of course, meets with resistance at the same point as it is withdrawn. We obtain information regarding the situation of a stricture, by bearing in mind the rules given when referring to the anatomy of the parts. We introduce the sound as far as the stenosis, note the loca- tion, starting from the incisor teeth (by seizing the sound accurately with the fingers), draw it out and measure it. Regarding the degree and length of the stenosis : we learn the former by the thickness of the sound that will just pass the stricture; the length of the stricture will best be ascertained by employing whale- bone sounds, in that we can mark the place where the incisor teeth touch the sound when it enters the stenosis, and as it passes through the stenosis. Also, if there is a double stenosis, it is indicated (see Fig. 83). We can learn almost nothing regarding the nature of the stenosis, unless we should catch in the fenestrum of an India-rubber sound a shred of tissue which would enable us to diagnose a carcinoma, or unless we should meet with the condition described in the next sec- tion (3). Fig. 8.3. Diagrammatic representation of sounding the oesophagus when there is a short, long, and a double stenosis. 3. By repeated introductions of the sound, we are sometimes able to pass it through, but if again we meet with an insuperable obstruc- tion we must be very careful : this points to a diverticulum, though 296 SPECIAL DIAGNOSIS. Fig. 84. not indeed with absolute certainty, since it may be met with in other kinds of stenosis, 4. In a case of stenosis which we have repeatedly examined, we suddenly find ourselves unable to get the smallest sound through, where it has frequently passed easily. This may indicate an obstruction by a foreign body, as was the case in one instance under my observation, which ended fatally, where a cherry stone was found in the stenosis. 5. The end of the sound may meet with opposition upon one side and not upon the other. This indicates a dilatation of the oesophagus (generally above the stenosis). Stenosis may be caused by scars resulting from swallowing a corrosive fluid some time before (Anamnesis), or by carcinoma of the oesophagus, or by diverticula (see above under 3) ; these are generally high up in the oesoph- agus; or by compression of the oesoph- agus. Congenital stenosis (difficulty in swallowing from birth), and stenosis caused by thrush., are both very rare. Examination of the neighborhood of the oesophagus, that is of the neck and thorax, is of the greatest importance. We are thus able to discover compressing tumors, or to exclude them with probability. We may aid the diagnosis by giving attention to the larynx, and observing whether there is a recurrent paralysis, which may exist even though the voice be quite clear. Compression of the recurrent nerve sometimes occurs in carcinoma of the oesophagus, with aneurism of the aorta (particularly the left nerve). Moreover, we take into considera- tion the examination of the chest, especially whenever there is any evidence of a rupture, as in pleuritis, gangrene of the lungs, rupture into the trachea or bronchus, with coughing up of particles of food ; pericarditis, and emphysema of the skin (see). Percussion of the oesophagus itself can be of almost no aid. Large diverticula in the neck may show dulness, provided they are full. Exceptionally, a dilatation above a stenosis in the thoracic portion may, if full, also produce dulness. a. Sounding the oesopha- gus when the diverticulum is full; b. sounding when the diverticulum is empty. EXAMINATION OF THE DIGESTIVE APPARATUS. 297 Auscultation of the oesophagus is of very subordinate value. It can be employed as far as to the seventh thoracic vertebra at the left of the spine, in examining the lower part of the oesophagus ; or we may listen over the spine or to the right of it. In health, when fluids are being swallowed, we can hear a gurgling in the whole extent of the oesophagus. When there is stenosis, we sometimes notice that the gurgling ceases just at that point. The sounds of swallowing which we hear ^t the stomach are less certain signs than this phenomenon ; in health, there is sometimes heard a sound six or seven seconds after an act of swallowing, as of something being pressed through, and some- times preceding this is a sound of squirting (Kronecker and Meltzer, B. Frankel). (Esophagoscopy (illuminating the oesophagus with an electric light) has not yet attained a position as a recognized method of examination. Examination of the Stomach. Topography of the abdomen. This is represented in the accom- panying figure. We form the different sections by prolonging the mam- millary lines (or a line which passes from the middle of Poupart's ligament upon each side) ; also by lines which, in the upright position, are drawn through the ends of the eleventh ribs, and through the anterior superior spines of the ilei. By these latter lines, the section lying between the mammillary lines is divided into the epigastrium, mesogastrium, and hypogastrium. It is further to be added that the region, dir,ectly over Poupart's ligament, which extends inward toward the symphysis pubis, and outward somewhat over the middle of the ligament, is called the inguinal region, and the territory below the ends of the ribs, the hypochondrium. So far as the abdominal contents are parietal, their relations to the separate regions of the abdomen are plainly indicated in the accompanying figure. ANATOMY OF THE STOMACH. Only a little more than the pyloric portion [one-sixth] of the stomach lies in the right half of the body, the rest [five-sixths] being on the left of the median line. It slopes obliquely from the left downward toward the right, so that the cardia is about behind the 298 SPECIAL DIAGNOSIS. Sternal insertion of the seventh rib, the pylorus between the right sternal and parasternal lines, on a level with the apex of the xiphoid cartilage. The fundus — the portion situated the highest, clinging to the left side of the dome of the diaphragm — rises as high as the fourth Fig. 85. Right mammillary line Left mammillary line. CA RJ- RJla. CD. Position of the abdominal contents. CA. Ascending colon. CD. Descending colon. RJ-C. Ileocecal region. BJ. Inguinal region. RHs. Left hypochondrium, EE. Epigastrium. RU. Umbilical region. H. Hypogastrium. intercostal space. The lesser curvature forms a bow with its con- vexity arranged obliquely downward toward the left. It, with the cardia and pylorus, which it connects, lies more posteriorly, covered by the liver, while the greater curvature extends forward toward the abdominal wall ; so that a line drawn from the lowest point of the EXAMINATION OF THE DIGESTIVE APPARATUS. 299 lesser, to the lowest point of the greater, curvature would incline forward and downward. The situation of the greater curvature varies very much with the degree of distention of the stomach. In health, it only very exceptionally extends to the umbilicus. The fundus of the stomach is adjacent to the diaphragm, the spleen, and the left kidney ; its greater curvature, and also the lower part of its posterior surface, to the transverse colon ; the pylorus, lesser curvature, and that portion of its anterior surface which is near to these, to the left lobe of the liver. Behind and above the stomach, situated at the upper part of its posterior surface, is the sinus of the peritoneal cavity, the bursa omentalis (pathologically not unimportant), and also the pancreas. "When the stomach is moderately distended, a part of the anterior surface, and the greater curvature, are parietal, so far as they are not prevented by the lung or heart from above, or by the spleen on the left, and by the left lobe of the liver on the right. That part of the parietal surface of the stomach which is covered by the left lower portion of the ribs comprises the important region to which Traube gave the name of " halfmoon-shaped space." We see from this description that, with moderate distention, only a small part of the healthy stomach can be directly examined. The most important parts, the cardia and pylorus, are bent deeply in. But we have a favorable moment for examining the latter in certain pathological conditions, where it is desirable to be able to judge of it, it being often pushed down with the lesser curvature below the liver. INSPECTION AND PALPATION OF THE STOMACH. There is scarcely any place where inspection and palpation are so closely connected as at the abdomen, and especially the stomach. The patient is placed so as to lie comfortably, with the upper portion of the body moderately raised. We look at the region of the stomach with the greatest care, illuminating it from all possible directions ; then palpate with the tips of the first, second, and third fingers, and thus notice first the tenderness (always at first proceeding very cautiously), then the objective condition, finally completing the palpa- tion with inspection, or vice versa. The result of the two methods of examination will be affected by 300 SPECIAL DIAGNOSIS. several factors — bj the size, sharpness of the boundaries, and density (resistance) which we discover in the abdominal wall, and its condition. As regards the latter, it is important for the examiner to avoid causing contraction of the abdominal muscles, by having the patient in the recumbent posture, cautioning him to keep the muscles lax, and by proceeding slowly with the palpation, the hands being warmed. Contraction of the recti abdominis, with their short tumor-like sec- tions of muscle, may very much disturb, or even deceive, one in making an examination. As to the general thickness of the abdominal walls in chronic diseases of the stomach, especially if very severe, this is very much lessened by wasting — a condition favorable for making an examination. The normal stomach cannot at all distinctly be recognized or defined through the abdominal wall. It can only exceptionally be done when there is extreme emaciation. I remember two cases where, in extremely wasted females with very lax walls, the greater curvature and peristalsis of the anterior wall of the stomach could be clearly seen. In both cases the stomach was very slightly distended, and in both cases the autopsy showed a normal condition of the stomach. On the other hand, the healthy stomach, distended with food or gas, sometimes enables us to imagine its condition by the projection in the epigastrium, and still more by a high halfmoon-shaped space — that is, by tympanitic resonance over the left lower lobe of the lung in the side (see under Percussion). We can sharply bound a healthy stomach only in individual cases when it is inflated with gas (see method of procedure, p. 301).' Thus, it has been found that the greater curvature of a normal stomach, when very greatly distended, may reach as far as the umbilicus. Of course, we cannot ascertain the location of the lesser curvature. Moreover, the distensibility of the healthy stomach varies very much with different persons, so that on trial one person earlier, and another later, has diflBculty, especially oppression, which marks the limit of distention. The chief pathological signs furnished by the stomach are, its dis- tention or displacement, its thickness, and amount of peristaltic action of its walls, also signs of circumscribed tumors in its walls. Other important signs are to be added to those already mentioned. Pain upon pressure during palpation requires a special description. EXAMINATION OF THE DIGESTIVE APPARATUS. gQl Distention is more or less distinctly made out by inspection and palpation, according to its extent and the thinness of the abdominal walls. But it may also entirely elude examination. In favorable cases, we can see and feel (easily when looking down from the patient's head) the greater curvature. To a varying extent it moves down, often below the umbilicus, more rarely nearly to the symphysis, and in so doing it shows the bend toward the left. The position of the greater curvature, of course, varies with the degree of fulness of the stomach, but usually, unless artificially emptied, as by emesis or the stomach-pump, it does not come up above the umbilicus. Thus, the pyloric portion behaves peculiarly, in that it influences the situation of the stomach and renders the pylorus, as well as the lesser curva- ture accessible for examination. When the stomach is, for the time being, distended by a large quantity of food, in the upright position of the patient, it pulls the pylorus forward from under the liver, and with it, under some circumstances, the lesser curvature. This, in rare cases, is seen in the upper epigastrium, in a line convex down- ward (when the light falls from the foot of the bed), when it may even be felt. Also the portio pylorica, and the pylorus itself, may be felt (see under Tumors). In consequence of this displacement of the pylorus, the whole stomach slopes more strongly downward toward the right. In rare cases, the pylorus stands as low down, without there being any dilatation of the stomach. The condition is congenital, or caused by strong adhesions (Kussmaul). As has , already been mentioned, the distinctness with which the figure of the stomach can be made out is largely influenced by the ex'tent of its fulness. Hence, for the purpose of making the examina- tion, we must artificially distend it (Frerichs). Until very recently, this was always done with carbonic acid, by giving the patient as much as two teaspoonfuls of tartaric acid and bicarbonate of soda dis- solved in a little water. The gas quickly develops in the stomach, and demonstrates clearly the situation and size of the organ, rendering the examination of its walls easy (see under Peristalsis and Hyper- trophy). But this procedure sometimes gives rise to a feeling of oppression, and even of symptoms of collapse ; and recently there has been devised a method of inflating the stomach which is much more to be recommended, because the amount of gas for distending the 302 SPECIAL DIAGNOSIS. stomach can be regulated exactly, and, if necessary, it can be emptied out in an instant. A Nekton stomach-sound is introduced (just as in sounding the oesophagus), and then the stomach is inflated with air through the sound by means of an India-rubber ball, introducing as much as is necessary, or as the patient can bear. At any time the air can immediately be let out through the sound. By inflating the stomach, Eichhorst has several times easily recog- nized the so-called hour-glass stomach (twice it was formed by a scar which strictured it in the middle). In the same way, we can discover that the pylorus does not close, by the fact that the gas blown in does not distend the stomach, but immediately enters the small intestine. Ziemssen still gives the preference to distention with carbonic acid. In his last communication he gives the proportions for adult men as seven grammes of bicarbonate of soda and six grammes of tartaric acid, for adult women, one gramme less of each. The sound may be employed in the same way as with the oesophagus to determine stenosis at the cardia, due to cancer. (The employment of an English oesophageal sound for ascertaining the size of the stomach [Leube] requires the greatest caution. The sound is intro- duced into the stomach and pushed on until it meets resistance at the greater curvature, and then we ascertain where the end of the sound is by palpation from Avithout.) Regarding palpation by striking and the resulting splashing, see under Auscultation. In the neighborhood of the stomach we may have epigastric pulsation (see p. 20-4), liver-pulse (see p. 266), lastly it may be communicated from the aorta or from aneurism of the abdominal aorta. With tumors of the stomach, the pulsation from the aorta is usually very distinctly transmitted. Increased resistance; peristaltic motions. The former occurs simultaneously with the general distention of the stomach in conse- quence of the hypertrophy of the muscular portion, which generally accompanies dilatation of the stomach. Hence, it is an indirect sign of dilatation. If it is found within a limited area, as in the right half of the epi- gastrium, even if it is not sharply defined, it may indicate carcinoma. We must be careful not to confound it with contraction of one of the bellies of the rectus abdominis. Peristaltic motions which can be felt as well as seen are very important, being often the first signs of EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 303 a hypertrophy, and, thus, a dilatation. By their situation and extent, they may also indica-te the size of the stomach. It is very rare for them to occur without dilatation — in nervous " peristaltic unrest" of the stomach (Kussmaul). Generally it extends in the normal direc- tion from the fundus to the pyloric region. But sometimes it is reversed (marked pyloric stenosis, Kussmaul) — antiperistalsis. It will often be excited or increased by gentle strokes, and by faradization; sometimes by irritation of the skin, as by simply uncovering it. With very lean persons, we must think of the possibility of it being, under some conditions, intestinal peristalsis. Tumors in the region of the stomach are often neither to be felt nor seen. They cannot* be demonstrated, if they are connected with a part of the stomach that is not parietal : cardia, lesser curvature, posterior wall of the stomach, commencing cancer of the pylorus. These tumors are most frequently cancer of the stomach (more rarely a dense scar from ulcer), and are most often located to the right of the middle line, because they belong to the portio pylorica or to the pylorus itself In the latter case, they can generally only be felt when the pylorus is pushed downward, as has already been mentioned. Carcinoma usually feels uneven and dense. Less frequently it is smooth, and can then easily be overlooked, or be mistaken for a belly of the rectus (see above, under Resistance). Swelling of the stomach during deep breathing, as a result of the movements of the diaphragm, usually does not take place at all, for the reason that the stomach is not a solid body. We observe a slight, or possibly a marked, respira- tory displacement when there is adhesion of the distended pylorus and the liver (see), or if there is a tumor which extends from the sub- phrenic region to a parietal portion of the stomach. Dense scars from ulcers and the infrequent hypertrophy of the pylorus, also solid bodies that have been swallowed, may feel like tumors. Mistaking them for scybala in the transverse colon (see Intestine) is not likely to happen. In all diseases of the stomach, pain upon pressure during palpation may be wanting. It is absent least frequently with ulcer of the stomach. If there is pain, it may vary very much : in acute catarrh of the stomach, also sometimes in chronic, it is dull and quite diffuse ; with ulcer, it is often very much circumscribed, limited to a spot the size of a dime, extremely severe, often shooting through to the back 304 SPECIAL DIAGNOSIS. (especially toward the left) ; in carcinoma, there is sometimes a marked insensibility, sometimes a more diffuse, sometimes a narrowly-defined, pain of various intensity. PERCUSSION OF THE STOMACH. This applies to that portion of the anterior wall of the stomach which lies against the abdomen and the anterior (left lower) wall of the thorax. It yields, in much the greater majority of cases, a very deep tympanitic sound ; and sometimes, when there is marked tension Fig. 86. Percussion boundary of the lungs in front. (Weil.) ff,h, the upper boundary of the lungs; e,f, the lower boundary of the lungs; 5, cJ, boundary between the lung and heart at the incisura cardiaca. The dark hatched surface represents the portions of the heart and liver that are in contact with the chest-wall; the light hatching, the so-called relative heart- and liver deadness (see later), m, spleen-deadness ; n, the average position of the lower boundary of the stomach. of the stomach, a clear non-tympanitic sound. If the stomach con- tains a considerable amount of food it may, in part (especially in standing), have an absolutely dull sound. But we hardly ever find it dull throughout the whole extent of that portion of the stomach that EXAMINATION OF THE DIGESTIVE APPARATUS. 305 is parietal, because it almost always contains considerable gas as well as food. The tympanitic, as well as the non-tympanitic, stomach- sound frequently has a metallic quality. The boundaries of the stomach are determined by topographical percussion (see Fig. 86). On the side toward the liver, there is a dull sound; it is often difficult to make out, because the border of the liver is thin (see Per- cussion of the Liver). On the side toward the lung, theie is a non- tympanitic, clear sound. Here it is often difficult to mark sharplv the boundary line, on account of the thinness of the border of the lung and the similarity of the two sounds. Sometimes we can determine a boundary toward the heart, should its apex reach further toward the left than the liver ; sometimes toward the spleen, if the stomach should be stretched out somewhat. We can separate it from the large and small intestine, both of which give a tympanitic sound. Except these last named, the boundary lines are all dependent upon the situation and size of the surrounding organs. Therefore, and because there are no true boundary lines for the stomach, except its parietal boundaries, we do not employ percussion for the stomach. The only real boundary is that on the side toward the intestine, which gives the situation of the greater curvature. But it is almost always very difficult to determine this line (there being a tympanitic sound on both sides of it, with only a difference in pitch). We can hardly even maintain its correctness without the aid of inspection and palpation. Thus, percussion of the stomach, for the great majority of cases, has an extremely doubtful value. On the whole, we get the best results from percussion in health, and particularly when the stomach has been artificially dilated. With the former, we then find that thegi'eater curvature usually is somewhat above the umbilicus, sometimes reaching to it. When the stomach is moder- ately full, it commonly stands about midway between the apex of the xiphoid process and the umbilicus. If the stomach is dilated, the boundary is lower down (see Inspection, Palpation). Likewise, should the lesser curvature be lower down, it can be made out by the aid of percussion. Another procedure, but one which is not always successful, is first to empty the stomach as much as possible (see Emesis), then to percuss 20 306 SPECIAL DIAGNOSIS. the abdomen, the patient being in the standing position. Usually we do not find any boundary for the stomach. Then we have the patient drink freely, and again percuss while he is standing. In the lower part of the stomach, hence above the greater curvature, about in the middle line, we shall find a dulness which indicates the situation of the greater curvature, and thus a possible dilatation may be recognized (modified after Penzoldt). This dulness may sometimes be directly proved, without any preliminary procedure, if the stomach is partly filled with fluid. The dulness disappears when the patient lies down. There is distinct dulness with tumors of the abdomen (strong per- cussion) only when they are very thick, and this is not often the case. Hence they usually give stomach-resonance. But tumors of the liver and spleen, on the other hand, almost always are dull because they are larger. Yet this difierence is not an entirely sure sign. Rod-pleximeter-percussion (see p. 136) over the stomach usually gives a beautiful silver tone. It is employed for determining the boundary, under the supposition that in this way the person who is listening over the stomach must hear the high silver tone just so long as his assistant percusses over the stomach ; but the result of this pro- cedure is hardly ever positive enough to give it value. That part of the left lower lobe of the lung is designated as the " circular stomach-lung space," where a tympanitic sound may be heard with strong percussion (Ferber). We may likewise speak of a " circular stomach-liver space," sometimes even of a "stomach-heart space " (see page 206). None of these have any value for determining the size of the stomach. The Half-moon-shaped Space (Traube^. — It is that portion of the lower left part of the thorax which lies below the lung (or heart) between the liver and spleen, and, as a rule, in health gives a tympa- nitic sound, most frequently a stomach sound, but not infrequently also an intestinal sound, or both. It is discovered by gentle per- cussion. Occasionally, in health, we here find dulness instead of tympanites, and then only when the stomach is decidedly full, or when the full transverse colon is here parietal, or when the greater omentum is unusually loaded with fat (Weil). In enlargement of the liver, of the left heart, and of the spleen, this space will always be found correspondingly smaller. But its behavior in certain conditions of the left lung, or of the left pleura, is EXAMIXATIOX OF THE DIGESTIVE APPARATUS. gQJ of especial diagnostic interest. Exudation in the left pleura usually causes dulness correspondingly early in the upper portion of this space, in that it first collects in the complementary pleural sinus. As the exudation increases, the half- moon-shaped space diminishes more and more, the dulness sometimes extending as far as the bend of the ribs, depending upon the amount of downward pressure of the diaphragm (unless there are pleuritic adhesions in the pleural sinus, in which case we do not have the space diminished). As the pleuritic exudation is absorbed, the space resumes its normal proportions, and if there is shrinking after the absorption, it becomes greater than normal, for the reason that the lower border of the lungs does not again come down to its former place, and, on the other hand, the diaphragm stands higher. Rarely, with pneumonia of the Avhole left lung, or its lower lobe, the half-moon-shaped space becomes very slightly smaller, as a result of the enlargement of the lung during hepatization, and also, probably, from a small pleuritic exudation. It is to be observed that in an acute disease of the left half of the chest, an early distinct diminution of the half-moon-shaped space is made manifest by a certain degree of dulness ; a marked diminution of the space indicates very plainly a pleuritic exudation ; and if there is extensive dulness in the left half of the chest, if the differential diag- nosis between pneumonia and pleurisy is uncertain (see p. 158). then a decided diminution in the size of the space speaks with strong emphasis in favor of the latter. AUSCrLTATIOX OF THE STOMACH. This has value in only one direction, but that is not to be under- valued. When palpation is made by strokes upon the region of the stomach, making more or less strongly, according to the sensibility of the patient, veiT short blows with the tips of the fingers, we some- times hear a splashing which is loud enough to be heard at a distance. This results from a certain relation between the fluid and the gas in the stomach even in health, but very much more frequently in dilata- tion. Hence, in making a careful examination of the stomach, we must always employ it. In itself it does not indicate anything, even though it is often found when the examination is frequently repeated. If we apply the ear when the stomach is inflated with carbonic acid 308 SPECIAL DIAGNOSIS. we shall hear a loud seething. We can recognize the same thing, but less distinctly, in dilatation of the stomach with fermentation of its contents. It is evident from the above that very often anatomical diseases of the stomach exist without any physical signs. This is almost always the case in the different forms of nervous dyspepsia, which are accom- panied with marked subjective symptoms. Hence, in most cases of affection of the stomach, the examination of its contents gives much more important conclusions than the local examination. Therefore, especial attention is called to the former. Examination of the Intestines, inspection and palpation. In employing the former, there must of course be illumination. The patient being in the dorsal position, we inspect the trunk as a whole, from a distance ; in detail, close at hand, palpating with a warm hand. Then, carefully grasping a part, we notice always first as to the amount of tenderness, when, if there is any suspicion of simula- tion or exaggeration, it is best not to ask whether we are causing pain, but simply to notice the result of a moderate and also stronger pres- sure. After completing the first examination, which gives one the bearings of the case, inspection and palpation go very closely, hand in hand, together ; for this reason, we speak of them together. Pain produced by pressure [Tenderness]. A diflfuse dull pain often occurs with intestinal catarrh. A like diffuse, but generally an extremely severe, pain is observed with acute general peritonitis. Circumscribed tenderness is especially frequent in the right iliac fossa. It is often quite marked in abdominal typhus, often more severe in intestinal tuberculosis, moderately severe in typhlitis and affections of the vermiform appendix, in both the last-named diseases generally (not always), in connection with other local signs (which see). Pain in the left iliac fossa is connected with the descending colon (especially dysentery). Very circumscribed severe pain shifting about, may occur with a circumscribed affection of the small intestine, as invagi- nation (see Palpation, Intestinal Tuberculosis). In many cases ruptures EXAMINATION OF THE DIGESTIVE APPARATUS. 309 require very especial attention. Works upon surgery are to be con- sulted regarding these. It is to be further remarked that pain in the abdomen, according to its location, may come from any of the oro^ans contained in its cavity, and also from its walls ; from the anterior abdominal wall (abscess) ; pain in the inguinal region, from psoas abscess in the iliac regions, from the sacral spines (inflammation, tumors). The general extent of the abdomen may be diminished by a layer of fat, by gas in the intestines (intestinal meteorism, tympanites), as it occurs continually, scarcely pathologically, after hearty eating, often with a large development of fat ; but we may also have it in every variety of degree as a pathological condition : in acute and chronic catarrh of the intestine, intestinal stenosis, in acute and chronic perito- nitis, and in abdominal typhus, where it is often of diagnostic value. According to the amount of distention, the abdomen is more or less full, which changes its normal soft condition to one of marked resist- ance. When there is marked meteorism, the liver and diaphragm are pressed upon, and by the latter the lungs and heart are pressed upward. In a case of typhus I once saw an extensive inflammatory under- mining of the abdominal wall, which very closely simulated meteorism by considerably distending the abdomen, which proved to be an abscess in the abdominal muscle. For distention of the abdomen with fluid and air in the peritoneal sac, see Peritoneum. There may be circumscribed distention of the abdomen from a great variety of causes : most frequently from some condition in the peri- toneum (which see, and also the next page under Tumors). Diminished volume of the abdomen (drawing-in, sinking-in) results from an insufficient amount of nourishment from any cause (especially from diseases of the oesophagus, pyloric stenosis, any cachexia — in short, from any disease that requires, or results, in restricted diet. Usually this condition is more especially manifested by the absence of fat and wasting of the abdominal muscles. A particularly marked — the so-called "scaphoid" — drawing-in, probably related to an active contraction of the abdominal muscles, occurs in meningitis, particularly basilar, and in lead- colic. Intestinal peristalsis exceptionally can be seen when the abdominal wall is very thin and lax. It occurs almost exclusively in women 310 SPECIAL DIAGNOSIS. ■who have had children (particularly if there is a separation of the recti muscles). It is to be distinguished from its similarity to what is described as pathological peristalsis only by the absence of other phenomena, and by the narrowness of the intestinal figure. Peristalsis that is pathological is an important visible and palpable sign of stenosis of the intestine, and occurs in the portion of intestine above the stenosis. We observe a round projection, with the slow motions of a worm, now disappearing and often immediately reappearing in a spot not far distant, so that we have the phenomenon of peristakis. The intestine, as it becomes prominent, is moderately resistant, and is often distinctly distended. [During the instant of greatest disten- tion the prominence is more distinctly tympanitic] The resistance may become greater in chronic stenosis of the intestine with hypertrophy. Sometimes the last swelling — that is, the one just above the point of stenosis — is the largest, and subsides with a loud cooing or bursting sound. This phenomenon may have a very great variety of manifes- tations, generally with a pressing, choking pain, and it may manifest itself under gentle blows, with faradization, or even by merely ex- posing the surface to the air. It is usually very difficult to draw any conclusion regarding the portion of the intestine involved by the location of the phenomenon or the direction of the peristalsis. On account of its thickness, we are apt to mistake a dilated loop of small intestine for a portion of the colon. Circumscribed tumors of the intestine are always felt before they can be seen. They may be : 1. Balls of feces, scybala, in the large intestine, often recognized by being arranged in a circular form, by their location (which is often deceptive), or by their retaining an indentation. Sometimes we are only able to be positive regarding their nature by their disappearance after free purgation. 2. Tumors of the intestine are either new formations, which are generally very firm, uneven, or, from invagination of one portion of the small intestine into another or into the large intestine, which are round vermiform tumors. The former are entirely fixed, the latter may suddenly disappear. Both may be connected with signs of stenosis of the intestine. If they belong to the small intestine, they usually more or less change their location. (For distinguishing these tumors from those of the other abdominal oi'gans, of the peritoneum, and of the abdominal wall, see below. For inflammatory tumors of the intestine, perityphlitis, etc., see Peritoneum.) EXAMINATION OF THE DIGESTIVE APPARATUS. 311 Tumors of the rectum cannot be recognized from the abdomen (see for these, below). Those at the point of union between the- transverse and the descending colon are often recognized late, because they lie concealed. They may easily be confounded with tumors of the spleen or with the kidneys (which see). In this connection we must bear in mind the phenomena of stenosis. (For peritoneal friction-sounds, see Peritoneum ; for cooing-sounds that can be felt, see Auscultation of the Intestine.) Palpation of the rectum. The rectum must be examined with the finger if the movement of the bowels or the character of the stools indicate disease of this organ, or if disease in the neighborhood (as the wall of the true pelvis, the prostate in men, the uterus and its annexEe in women) is suspected. In making the examination, we first obtain a view of the anus externally (as to varices, pedunculated new forma- tions, which sometimes come into view at the anus from above the flexure, an external rectal fistula). Sometimes it is also necessary to obtain a thorough emptying of the bowel beforehand. The index- finger is to be oiled and introduced with the patient either lying on the side or back. (For examining during narcosis by introducing the whole hand, see works upon surgery.) When the rectal sound is employed, in order to reach a stenosis beyond the reach of the finger, the greatest care is necessary. It is best to employ a sound open at the end, so as to throw in some lukewarm water by means of an irrigator, so that any obstruction to the passing of the sound may be gotten out of the way. Sometimes a large quantity of water is thus employed., as recommended by Hagar (see also the works upon surgery for the emplQyment of the mirror in making the examination). Distending the descending colon by inflating it with air introduced from the anus through the sound, if carefully done, is not dangerous, and is very strongly recommended for determining the location of the colon with reference to other organs, tumors (see spleen, kidneys), the figure and condition of the colon itself. PEKCUSSION OF THE INTESTINE. Generally the intestine gives a tympanitic sound ; with meteorism with great tension, it may become clear non-tympanitic. Over large intes- tinal loops, and also over the stomach (with like tension), the sound is 312 SPECIAL DIAGNOSIS. deeper than over narrow portions ; over lax portions, it is deeper than over those under strong tension. But we can hardly ever determine as to the width of any portion of intestine by the resonance, chiefly because of the influence of tension, which, for a single loop of intestine, we cannot at all control. Hence, we cannot with certainty determine by percussion the boundary between the colon and small intestine, a dilatation above a stenosis from another portion, or intestine from the stomach. At most, Ave can only determine the boundary of the descending colon by artificially inflating it. (For determining by percussion the boundaries of the abdominal organs that do not contain air, see under the different ones.) Intes- tinal tumors do not always become so large as to give dulness. In percussing them, we first press tolerably deeply with the finger used as pleximeter, and if we do not find dulness we press still deeper, in order that we may push aside any fold of intestine that may lie over the tumor ("deep percussion," Weil). AUSCULTATION OF THE INTESTINE. Borhorygmi and splashings, which may often be heard at a distance, and are in themselves very troublesome (especially in women who have had children), do not have any further significance. A loud cooing is not without diagnostic value, if it occurs at the close of an attack of pain like strangulation. Even if we cannot see any intes- tinal peristalsis, we must remember the possibility of stenosis of the intestine. Although formerly too much importance was attached to it, yet there is some diagnostic value in the cooing, which is more fre- quently felt than seen in the ileo-csecal region in typhoid fever (ilio- caical cooing). Examination of the Peritoneum. Pathological conditions of the peritoneum are, in part, of such a character that they affect the outer layers, the coverings of the other abdominal viscera, hence possible anomalies of the peritoneum may be overlooked in the direct examination. Thus, very many diseases of other abdominal organs are combined with those of the peritoneum. This fact and the anatomical interrelations of the diaphragm and certain other organs make it very difficult to give a separate descrip- EXAMINATION OF THE DIGESTIVE APPARATUS. 313 tion of its physical diagnosis. In what follows we mention what may- be learned in peritoneal diseases by the separate methods of examina- tion, but we call attention to the point that the examiner ought to learn to give his attention to all the abdominal organs, by inspection, palpation, etc., at the same time. INSPECTION OP THE ABDOMEN. In diseases of the peritoneum, this .may reveal distention of the abdomen, which may be quite considerable, and quite like intestinal meteorism. Meteorismus peritonei — that is, escape of air into the abdominal cavity from the intestine or stomach — is a very serious condition, which always results in peritonitis. (See below.) There is general, though often unequal, distention when there is freely-movable fluid in the peritoneal cavity, ascites. Such a fluid effusion collects in the most dependent part of the abdominal cavity, first in the true pelvis ; then, as the amount increases, it rises higher, reaching the abdominal wall, where its level may stand at different heights. The abdominal organs that contain air float upon the top of the fluid so far as the peritoneal fold permits. In consequence of the increased internal pressure, the abdomen is broader, and the lower part contains the fluid, while the intestine, containing air, lies at the upper part, and is in contact with the abdominal wall. But the fluid, since it is freely movable, occupies always the most dependent part with every change of position of the body, and, if the tension of the abdominal wall is not too great, there often results an unequal disten- tion of the abdomen which varies with the position of the body. In the dorsal position, it is quite toward the sides ; when lying upon the side, it is over the inguinal and lumbar regions upon each side; while in the sitting posture, it fills the dependent abdominal sides, the upper portions being empty ; and in standing, the lower part of the abdomen projects. If there is so large an effusion as to fill the abdo- men very full there is no change in the distention, and it is also more regular, like that we have with marked meteorism, (Regarding the high position of the diaphragm, when there is distention of the abdo- men, see Respiratory Organs and Liver.) If the skin is examined when there is marked eff'usion it will not at all look as it usually does : on account of the tension, it is smooth. 314 SPECIAL DIAGXOSIS. shining, and shows, especially in the dependent parts, a peculiar bluish shimmer. When the tension is of long standing, there are colorless streaks or striae which are formed in the skin by the con- tinuous stretching, as in the scars resulting from pregnancy, so-called from their chief cause. The umbilicus may be obliterated or even project. In marked ascites, the cutaneous veins of the abdomen are found enlarged, since, as collateral veins, they must take up the over- flow of the intra-abdominal veins, which are compressed. Under some circumstances, there may be oedema of the legs from compression of the iliac veins. (Regarding the caput medusce and the abdominal veins in general in cirrhosis of the liver, see under Liver.) Ascites that moves about generally results from transudation into the abdominal cavity from stasis, being rarely, except in the beginning of a disease, dependent upon inflammatory exudations. In the former case, it is either a partial indication of general dropsy, and connected with oedema (see), or entirely the result of obstruction of the portal vein (cirrhosis of the liver, compression, and thrombosis of the vein). In the latter case it is a sign of peritonitis. (See under Palpation, Percussion.) Circumscribed distention of the abdomen, where there has been little or no change in posture, may be due to inflammatory fluid exudations, which are enclosed between adhesions of the intestine to itself or the abdominal wall, or by any kind of tumor in the abdominal cavity ; and also by tumors or abscess in the abdominal wall itself Circum- scribed distention, with inflammatory redness, indicates a discharge outward of an abscess, either fecal or some other collection of pus in the abdominal cavity, or of the abdominal wall. In diseases of the peritoneum, palpation gives very important signs : Pain in all inflammatory afi"ections. It is usually very severe in acute peritonitis, sometimes so great that the slightest motion, or even the lightest covering upon the abdomen, cannot be borne. This sensi- bility is an important indication of peritonitis, especially in distinguish- ing the ordinary intestinal meteorism from the intestinal meteorism with peritonitis, sometimes also in distinguishing inflammatory ascites from dropsical ascites. Circumscribed pain may indicate a circumscribed peritonitis, as it occurs more particularly over tumors, abscess of the stomach and intestine. In chronic peritonitis, especially in tubercu- losis, sometimes there is entire absence of tenderness. EXAMINATION OF THE DIGESTIVE APPARATUS. 3I5 Now and then, in chronic peritonitis there is a general, more or less symmetrical, hardness of the abdominal wall — that is to say, it feels as if it were thickened. This is to be distinguished from the general increased resistance from tension due to marked distention of the abdomen from meteorism and ascites. Thus, there is a marked differ- ence between the resistance of fluid and that of meteorism in a fold of intestine. The latter has more the feeling of an air-pillow, the former is more like a material substance. But we recognize fluid with much more certainty by the feeling of fluctuation, undulation. A hand is laid flat upon the surface of the abdomen, and then the abdominal wall is tapped lightly with one or two fingers, just as in direct percussion. If both hands are used, fluctuation is found in a place where there is an accumulation of fluid, and the stroke of the wave is felt with every tap of the fingers. In this way the presence of even a small amount of fluid in the abdominal cavity can be made out with great certainty. When there is great effusion under high pressure this sign may fail. On the other hand, we may be deceived in the case of persons who have a large accumulation of fat in the abdomen by the trembling of the layers of fat, and possibly, also, by the fat in the abdominal cavity, in the omentum especially. Very much increase of resistance, and thus an indistinct fluctuation, generally occurs when the peritoneal fluid is encysted. Circumscribed hard resistance, now like a round ball and again cord-like, occurs with extremely great variations in chronic peritonitis, not alone of the tubercular variety, but also in the so-called simple peritonitis from in- flammatory new formations ; nevertheless, the former is usually the much more frequent condition. Particularly often in this, although sometimes also in simple chronic peritonitis, we feel above the navel a dense transverse string : the omentum is shrunken and thickened by inflammatory products. Besides there are usually, but not always, the signs of encysted" or even of free fluid in the peritoneal cavity. Exactly the same phenomena are present in carcinoma and sarcoma of the peritoneum. There occurs in an acute way resistance in the neighborhood of the caecum in typhlitis and perityphlitis. Here there is generally a cir- cumscribed globular, or flattened globular, tumor, usually immovable, which, at first at least, is extremely tender. It indicates a fixed mass of feces in the caecum, or an inflammatory deposit upon the serous side 316 SPECIAL DIAGNOSIS. of the caecum, or both. In inflammatory cases, there remains for a long time, or even permanently after recovery, a dense spot (a scar from shrunken inflammatory new formation in the peritoneum). In inflam- mation of the vermiform appendix, we can seldom affirm that there is a tumor. Palpation of the peritoneum through the vagina in order to -dis- cover whether there are tumors, exudations in Douglas's space and anywhere in the neighborhood of the uterus, especially the different forms of peritonitis, belongs to gynecology. It is not necessary to measure the circumference of the abdomen for establishing a diagnosis, but yet it is valuable for the purpose of observing the course of an abdominal affection, and particularly for ascertaining the increase and diminution of fluid exudations. It is generally sufficient to measure the abdominal circumference across the navel and the lower lumbar vertebrae. It is better also to measure the distance between the xiphoid process and the symphysis pubis. Percussion gives valuable information regarding the peritoneum, as to whether there is fluid eff"usion in the peritoneal cavity, its location and nature. By percussing with some force at what we suppose to be the boundary line, we can easily determine the boundary between the dulness of fluid and the tympanitic resonance of the intestine ; but we can never distinguish it from that of those organs that do not con- tain air, as the liver, spleen, etc. The superior surface of a freely- movable effusion is always horizontal, and hence its upper boundary line must correspond to a section of a horizontal plane drawn through the abdomen, in whatever position the patient may assume. When- ever the patient changes his position, immediately the eff"usion changes its relations to the abdominal cavity (see above, under Inspection). Hence the result of percussion changes with the position of the body : if the patient lies upon the right side, then the portion of the abdo- men which is now lowest gives a deadened sound, while the upper boundary is horizontal ; in the left half of the cavity, there is tympan- itic resonance ; if the patient turns upon the left side, this is now dull, and the right is tympanitic. This is an important sign, not only that the fluid is movable, but often that there is fluid present. Small effu- sions, which rarely rise only a little above the pelvis, will hence be first recognized by percussing when the patient stands upright. If there is then dulness above the symphysis pubis, it immediately disappears EXAMINATION OF THE DIGESTIVE APPARATUS. SIJ when the patient lies upon the back. Very large effusions may fill the abdomen so full that the intestines, on account of a short mesen- tery, cannot float, and hence cannot come in contact with the abdom- inal wall. Then the strongly-distended abdomen gives a dull sound throughout, and we sometimes notice a change of the boundary of dul- ness only in the position on the side, Avhen the upper portion gives a clear sound. When the fluid moves about with difficulty, slowly and incompletely changing its location with the change of position of the body, and still more if it is entirely immovable, inflammatory exudation with glueing or adhesion of the intestines together and to the abdominal wall is indicated. If the fluid does not move it is said to be en- cysted. But not infrequently even inflammatory exudation, at least in the beginning of its effusion, is freely movable. Percussion may be an important aid in recognizing m,eteorismus peritonei in so far that in many cases, if adhesions have not already been formed before the occurrence of perforation, it gives a perfectly uniform tympanitic or, if the tension is great, a non-tympanitic sound over the whole abdomen, also over the region of the liver and spleen, and besides, on account of the diaphragm being arched high up, as far as the fifth, or even the fourth, rib. Not infrequently in this way we obtain Heubner's rod-pleximeter phenomenon (see p. 112). Subphrenic peritonitis, pyopneumothorax subphrenicus (Leyden), subphrenic abscess. We understand by this an ichorous-purulent, sacculated peritonitis below the diaphragm. From paralysis (partly also from irritation), the diaphragm is pushed very high into the thorax, causing a marked retraction or compression of the lung of that side. That half of the thorax is broadened, and by the presence of pus and gas in the cavity, one is apt to mistake the condition for pyopneumothorax. Peritonitis of this character usually begins at the stomach as an ulcer, or at the intestine, especially at the vermiform appendix and caecum. In making a differential diagnosis, we observe whether, in the status prcesens or in the previous development, there were indications of disease of the lungs or, on the other hand, of the abdomen, and also whether the luug of the diseased side still performs the motions of respiration. During puncture, it has frequently been found that the pressure rises during inspiration in a subphrenic cavity. 318 SPECIAL LAGNOSIS. while it falls, of course, in a pleur: cavity. This can be recognized by the varying rapidity of dischare from the aperture made by the needle, or by introducing a manomter into the cavity. The presence of air which has e3aped into the peritoneal cavity is shown in many cases by the clear, metallic ringing, intestinal sound in the upper part of the abdominal ivity, sometimes even a metallic, transmitted breathing sound, whiclit yields to auscultation. More- over, with the inflammatory deposs upon the reduplications of the peritoneum, especially over the her and spleen, there occurs syn- chronously with breathing a peritaeal friction sound, exactly corre- sponding to the pleuritic friction sund. It is very rarely produced by peristalsis over the intestines, f the friction sound is pronounced, it can also be felt. When it is advisable, as a therap utic measure, to draw off fluid from the peritoneal cavity by puncture, may be of diagnostic value in two ways : 1. It is then possible to examinthe organs in the abdominal cavity, which previously were concealed y the ascites. Not only does the fluid prevent the examination of le organs more or less completely covered by it, but the folds of the itestine floating upon it also do so, in that they crowd in between ce;ain parts, especially the liver and spleen, and the anterior abdomial wall. When the abdomen has been emptied, its wall, which befo) was tensely stretched, is very lax, and this renders the examinatio extremely easy. Hence we can now usually very easily discover t3 diseases which caused the effusion (cirrhosis of the liver, tumors, iiich press upon the portal vein ; cancer of the stomach, ovarian tmor, etc.), or certain results of peri- tonitis (bands of scar tissue, wteh compress the intestine, swollen mesentery, etc.). 2. The fluid that has been diwn off can be examined. It is as important to do this as to examir pleural fluid (which see, p. 160). The ordinary hypodermic synge, holding one gramme — not the one recommended for puncturir the pleura — is to be employed for puncturing the abdomen. Exploratory puncture, by meas of a large hypodermic syringe, is useful in distinguishing encystecperitoneal fluid from the solid and fluid contents of certain tumors fde Abdominal Tumors). OhylouB ascites has been obse/'ed in some cases of compression of EXAMIXATIOX OF THE DJ !:-;TIVE APPARATUS. the thoracic duct ; the ascitic fluid i to a varying extent, in appearance. It contains molecule 4' fat and a ferment tha sugar. Examination oFniE Liver. Anatomy. — The liver, covered by le peritoneum, lies cle>'^ to diaphragm — within its arch — and is eld in place by the s . , ons^ ligament and by the intra-abdominabressure exerted upon its Fig. 87 Location of the thoracic contents, of the stoach, and of the liver, from in front. (Weil-Lcschka.) The unbroken hatched linei jpresent the portions of the heart and liver that are in contact with the thoracic wall, The portions of these organs that are not in parietal contact and are covered by the 1 gs are represented by the light hatf;h- ing. c/( ), border of the right lung; gh{- <, border of the left lung; aJ,andcrf ( ), boundary of the complementary pleura inua; i. boundary between the upper and middle lobe's of the right lung; k, boundai )etween the middle and lower lobes; I, boundary between the upper and lower lob of the left lung; w, stomach (greater curvature). surface. About three-fourths of it is n the right side of the body, and one-fourth in the left. With rerence to its superficial topog- raphy, a larger portion of it belongs o the right hypochondrmm, 320 SPECIAL DIAGNOSIS. extending into the epigastrium, and with a small portion into the left hypochondrium. Usually it does not extend so far to the left as the apex of the heart. Above, the lungs and heart glide over it, and it glides over the stomach (see Fig. 13, p. 78). The extent to which its surface is in contact with the thoracic wall is determined by the relation of its upper surface to the diaphragm. Hence, during expiration it rises in the right half of the body as high as the fourth intercostal space, and with its extreme left end to the fifth rib. The lower border, in the scapular and middle axillary line, stands about at the eleventh rib, in the mammillary line, just at the border of the ribs, then proceeds obliquely upward toward the left, thi'ough the epigastrium, under the left border of the ribs, and almost to the apex of the heart. In the middle line, it stands about midway between the xiphoid process and the umbilicus. The gall-bladder lies just where the lower border of the liver passes under the right border of the ribs, hence close within the right mammillary line. The organs that border upon the liver are the lungs, heart, and the diaphragm above, and the right kidney, colon and stomach below. That portion of its upper convex surface which is not covered by the lungs or heart is parietal. This parietal portion is very small behind. As it comes forward, it is much broader, and is, for the most part, covered by the chest-wall, except in the epigastrium, where it is free from its bony covering. With children, the liver is in all dimensions proportionally larger, so that its lower border is in the axillary line below the border of the ribs. Normally, the liver, strictly speaking, only moves in connection with the diaphragm. INSPECTION OF THE LIVER. This is made with the body in the dorsal position moderately elevated. In the healthy condition, in adults, absolutely nothing can be made out. The right and left hypochondriac regions are exactly alike. In small children, we can sometimes notice a moderate projection of the right hypochondrium. EXAMINATION OF THE DIGESTIVE APPARATUS. 321 Projection of the right hypochondrium, or also of the epigastrium and the region below the right border of the ribs, indicates enlarge- ment of the liver. This must be pretty well marked, in order to be noticed in this way. Where the thorax is very stiff, the ribs do not usually project; but when the ribs are very flexible (children, young females), where it can relatively easily take place, the projection of the abdominal wall is plainer if the abdomen is a little full and the covering thin. Fig. Location of the lungs, liver, spleen, and of the kidneys, from behind. (Weil-Luschka.) The liver and spleen are represented by the same kind of hatching as in Fig. 87. ab ( ), lower border of the lungs; cd {. . . .), complementary space; i ( ), border of the liver; e/(. . . .),. boundary between the upper and lower lobes of the lungs; g, boundary between the upper and middle lobes of the right lung. * If the projection is entirely of the portion of the abdomen below the border of the ribs, it points more to a displacement of the liver downward. There may be very marked distention when an enlarged liver is so displaced. It is very rare to see or to feel the lower border of the liver. But it may be, if, on account of enlargement or displacement, or both, it 21 322 SPECIAL DIAGNOSIS. is located low down, and if the abdominal wall is thin. We can then also observe how the border of the liver moves downward with the motion of the diaphragm in deep inspiration. For observing this the light must come from the head of the bed. When the wall is very thin, tumors on the surfiice of the liver in contact with the abdominal wall, or on the lower surface of the border, and also a distended gall-bladder, can be seen. With deep breathing, they make the motions of the diaphragm very plain, and they transmit the motions to tumors of the stomach or omentum, which may be adherent to them, or, like them, visible. Finally, arterial or venous liver-pulse may be visible, especially the latter, which always accompanies enlargement of the liver. Enlargement of the liver may be dependent upon diiferent diseases of this organ. In engorgement of the liver, especially in mitral defects and in emphysema, in fatty or amyloid liver, or when it is due to obstruction of the gall-bladder, and in diffuse hepatitis, in certain acute infectious diseases, the enlargement of the liver is tolerably uniform, its form being retained. It manifests itself by its lower border moving down into the abdomen, but, on the other hand, the diaphragm is pressed upward only when the liver is very greatly enlarged, or when the general abdominal pressure is increased (espe- cially in ascites) The liver is irregularly enlarged in carcinoma, echinococcus, generally in syphilis, and in abscess. To what extent it is noticeable depends upon the location of the swelling, whether anterior, inferior, or superior, with displacement of the diaphragm. Downward displacement or dislocation of the liver occurs generally with depression of the diaphragm, with severe emphysema, with pleurisy or pneumothorax of the right side. Left-sided pleurisy or pneumothorax, pericarditis, though generally only to a slight degree, press the point of the left lobe of the liver downward, and thus the lower border of the liver in the epigastrium is horizontal. Moreover, under some circumstances the liver is pressed downward by sub- phrenic abscess (see above), which at the same time pushes up the diaphragm. Lastly, here belongs the "wandering" liver, due to relaxation of the suspensory ligament (occurring in women who have borne children). It is only in the two conditions last named that it is not in contact with the diaphragm. EXAMINATION OF THE DIGESTIVE APPARATUS. 323 it is to be observed that the lower border of the liver moves down- ward not only when it is enlarged, but also when it is displaced. These two conditions will be distinguished chiefly by palpation and percussion, and the consideration of the accompanying conditions of the oro-ans in the chest and abdomen. Displacement of the liver upward, can, of course only take place when the diaphragm is higher than normal, as in retraction of the luncrs, pressure from below, inflammatory or neurotic paralysis of the diaphragm. PALPATIOX OF THE LIVER. In every relation, this is the most important and certain method of examining this organ, and hence must be most diligently practised by the beginner. It is best to have the patient in the dorsal position, and the abdominal wall as relaxed as possible. We first seize, with the warm hands, the whole abdominal sac, have the patient open the mouth and breathe quietly. Drawing up the limbs is of little aid and disturbs the examination. We very frequently make use of deep breathing, because in this way the parts hidden under the ribs move deeper, and the border or any small uitevenness, etc., can be felt more distinctly as it moves against the examining fingers; and lastly, because the liver can be distinguished from other organs (kidney, colon, omentum, often stomach, abdominal wall) by its motions during deep breathing. By striking palpation we understand a brusque stroke with the tips of the fingers. We employ it in meteorism and ascites in order to push aside for the moment a layer of intestine lying over the liver or fluid, and thus be able to reach the liver with the tips of the fingers, (See, moreover, what is said on page 318 regarding palpation of the abdomen after puncture.) Normally, in the adult, with the ordinary thickness of abdominal wall, we can feel scarcely anything of the liver. If there is a thin lax wall (especially in women), we not infrequently feel the edge of the liver in the mammillary line at the border of the ribs, seldom also in the epigastrium, particularly if it is pressed down in deep inspira- tion. In children it is often very distinct. For example, we take a condition bordering on the normal, the so-called constricted liver, a disease almost without significance. It occurs in women who have laced themselves very tightly for a long 324 SPECIAL DIAGNOSIS. time. Corresponding to the anatomical condition of the liver, vre can feel a tongue-like prolongation of the right lobe, which prolongation is separated from the mass of the liver by a constricting furrow close under the border of the ribs. Sometimes the constricted liver is sensi- tive on pressure. In ascertaining the pathological conditions of the liver by palpation a series of points of view come under consideration : 1. The existence of tenderness. There is no tenderness with the fatty, amyloid, cirrhotic liver, with echinococcus (if there is no forma- tion of pus), nor engorged liver (infrequent), if it has been for a long time uniformly engorged ; the syphilitic liver is usually not tender, but sometimes it is so. Generally, in the beginning of cirrhosis the liver is sensitive, also in biliarv en";orgement. Accordinof to the extent to which the peritoneum is involved, carcinoma of the liver may be entirely without tenderness, or it may be very sensitive, also, when engorgement of the liver has rapidly developed, it may be very tender. When an abscess of the liver is parietal, possibly involving the peri- toneum, there is a circumscribed area of great tenderness ; with deep- seated abscess, there is no pain. Tenderness of the liver may, besides, be caused by chronic (often tubercular) peiltonitis, without there being any trouble with the liver itself. 2. The size and form. Depression of the lower border, without change in form, indicates uniform enlargement, but possibly also dis- placement. Unless there is considerable enlargement, it is often difficult to distinguish between these two conditions. If there is simultaneously tenderness and hardness (see below), or if there are conditions of other organs which make enlargement of the liver prob- able, as valvular disease of the heart with engorgement, a disease causing an amyloid condition, then we are very seldom wrong in the supposition that there is an enlargement. On the other hand, for example, the existence of pleuritic exudation, dextra, etc. (see above), makes displacement more probable. There also may be at the same time enlargement and downward displacement. But it must be remem- bered that, when a liver is markedly displaced downward, the impres- sion is easily made that it is also enlarged, because, by traction about its transverse axis, it becomes parietal to a larger extent. When a downward- displaced liver is distinctly movable by pressure with the finger, in such a way that in the dorsal position it can be EXAMINATION OF THE DIGESTIVE APPARATUS. 325 brought back to its normal position, then we have a "wandering" liver. The form of the liver is recognized with varying distinctness, accord- ing to the increased extent to which it lies against the abdominal wall, when it may be enlarged. It has already been mentioned under what conditions the liver retains its form. Tumors of all kinds (especially carcinoma, gummata, echinococcus) and scars (syphilis) change its form. Whole portions of the parenchyma of the liver may often, not always, be marked off by the scars of syphilis if they are very deep: "lobulated liver." 3. Again, the surface of the liver can be judged by the portion of the upper surface or the lower border which is accessible to palpation, and we can do this best by moving the finger-tips with the abdominal wall back and forth over the liver. In individual cases it is only possible to feel a portion of the lower surface. In engorgement of the liver, in fatty liver, in amyloid liver, in a portion of the first stage of cirrhosis, and in the so-called hypertrojphio liver, the surface will be found to be smooth ; also, in echinococcus, carcinoma, and syphilis of the liver, if we palpate a portion entirely free from tumor or scars. Small inequali- ties, generally to a certain extent uniform over the whole palpable portions of the surface, sometimes so fine that if the abdominal wall is thick it is difficult to feel them, are the characteristic signs of ordinary cirrhosis of the liver (interstitial hepatitis, granulated liver) toward the end of the first stage and into the second. Here, for two reasons, it is usually very difficult to reach the liver with the fingers : first, because in the second stage it is smaller, and hence is to a less extent parietal, and second, because the disease is commonly associated with ascites. For this reason, what has been said regarding "stroking palpation " and examination after puncture, applies especially here. It is further to be remarked that the surface of the liver in chronic, and especially in tubercular peritonitis, may feel tuberculated in conse- quence of inflammatory growths upon the serous coat, and this without there being any cirrhosis (although not infrequently this exists at the same time). Large rough tumors, from the size of a cherry to that of an apple, often mingled with small knots, are the usual appearances with carcinoma of the liver. We can sometimes recognize upon the top of these carcinomatous knots a depression, the cancer navel ; but they are of neither positive nor negative diagnostic weight. More 326 SPECIAL DIAGNOSIS. smooth, flat projections, especially if, besides, we can feel scar-like depressions, indicate the presence of syphilitic gummata. JEchino- C0CCU8 causes smooth tumors which, according to their location, are flat or elevated, or they may even stand out prominently from the surface of the liver; thus also abscess of the liver causes smooth promi- nences of diff"erent sizes and elevations. 4. The consistence of the liver is uniformly, and generally markedly, increased in amyloid disease, engorged liver, and in cirrhosis. Car- cinoma manifests itself, as elsewhere, usually by great density. Abscess of the liver and echinococcus bladders may distinctly fluctu- ate; the latter often, if tightly full, feel dense as well as elastic, and we can sometimes recognize by quick, short strokes of the opposing hands a peculiar Avhizzing — the " hydatid whizzing." In many cases exploratory puncture will be indicated, as in order to recognize or exclude echinococcus or abscess. (Regarding the con- dition when there is echinococcus, particularly of the effects, see Tumors of the Abdomen.) Moreover, it is necessary to compare the results of palpation, in the broad sense of the word, with the accom- panying appearances of other organs, which belong to the individual diseases of the liver. These may stand in a causal relation (constitu- tional syphilis, primary cancer of the stomach, etc.), or they may be results (ascites in cirrhosis of the liver or pressure from tumors, scars of the portal vein, rigors in abscess of the liver, etc.). The gall-bladder. If this is normal, it is only in cases of extreme emaciation that it can occasionally be felt. This is much sooner possible when it is abnormally full of fluid, as in biliary engorgement, hydrops vesicae fellece, suppuration, or when it is distended with gall- stones. In biliary engorgement and catarrhal icterus it is possible to diminish the gall-bladder by carefully compressing it, and expelling the contents into the ductus choledochus and the duodenum. When there are gall-stones, if the abdominal wall is thin, we sometimes get the distinct impression of a sac filled with angular stones rubbing against one another. A dense, rough tumor indicates carcinoma of the gall-bladder. PERCUSSION OF THE LIVER. Wherever the liver is in contact with the thoracic or abdominal wall, we, of course, have dulness, and this is an absolutely deadened EXAMINATION OF THE DIGESTIVE APPARATUS. 327 sound where the liver receives the whole of the percussion-stroke, and the stroke is not permitted to reach to an underlying air-containing organ, as the intestine or stomach. A relative dulness, with tympanitic associated sound, occurs when a thin layer of liver lies over the stomach or intestine, as is the case in the neighborhood of the lower border of the liver. To a certain extent it depends upon the strength Fig. 89. Percussion boundary of the liver in front (Weil). g h, the upper limits of the lungs; ef, the lower limits of the lungs; 6 d, the boun- dary between the lung and heart at the incisura cardiaca. The darkly-hatched surface represents the portions of the heart and liver that are in contact with the chest-wall; the light hatching, the so-called relative heart and liver deadness; m, spleen deadness; n, the average position of the lower border of the stomach. of the percussion-stroke whether we have a relative or an absolutely deadened sound (see p. 117) : the weaker the stroke, the sooner do we have absolute dulness. The varying thickness of the covering of the liver is confusing — consisting partly of ribs and partly of abdominal wall. Still more confusing for exact examination is it that the border of the arch of the ribs, at the most important point in the mammillary line, normally exactly corresponds with the lower border of the liver. 328 SPECIAL DIAGNOSIS. The difference in sound which is caused by this change in the covering alone obscures the exact examination of the liver at this point. The limits of the liver, so far as they are determined by percussion, are ascertained by gentle percussion at the right lower border of the lung, by the transition from the clear lung-sound (or relative liver- dulness) to the absolutely deadened sound. Thus, the upper boundary of the parietal part of the liver is easily found, with the exception of- a small portion, where the liver lies against the heart (see Fig. 87). Here we cannot determine the boundary by percussion, because the heart-dulness and liver-dulness cannot be distinguished. The lower border of the liver near the spine cannot be pointed out, because it joins the kidney (see Fig. 88), but everywhere else its sound could be very easily distinguished from the tympanitic sound of the stomach and intestine if its anterior part were not too sharp — that is, if the liver were not here too thin. For this reason, even with the most gentle percussion in the epigastric region, it is usually found too high. Often no distinct liver-dulness can be perceived in any portion of the epigastrium. Moreover, we must guard against being deceived by the dulness of one of the bellies of the rectus abdominis (lax abdominal wall). The relative liver-dulness lying above the absolute does not corre- spond to the anatomical size of the liver, which lies much further back than this, as is shown by a comparison of the anatomical figure with the boundary as determined by percussion. This is because the lung becomes thinner at its lower border ; moreover, it is only anteriorly and at the side that it is always distinctly present. It usually fails between the scapular line and the spine, owing to the thick wall and the diminished sharpness of the edge of the lung. Mode of procedure : We percuss strongly or lightly down a known vertical line on the thorax, for determining the beginning of relative liver-dulness, and thus fix the lung-liver boundary — that is, the transi- tion from the relative to the absolute liver-deadness. Then we percuss downward, through the extent of liver-dulness, until by the gentlest percussion, we get the entirely pure tympanitic sound. From this point we go again upward till we get the first indication of relative dulness. We determine the exact boundary lines by exclusion (see p. 117). EXAMINATION OF THE DIGESTIVE APPARATUS. 329 The average boundary-lines of the liver, as determined by percus- sion, are about as follows : The upper, the lung-liver boundary : Middle line, base of the ensi- form cartilage ; mammillary line, sixth rib ; middle axillary line, eighth rib ; scapular line, tenth rib. The heart-liver boundary cannot be determined by percussion, but it lies near the apex-beat. The lower, the liver-stomach (intestine) boundary : Left of the middle line, toward the half-moon-shaped space, ascending obliquely to about the sixth rib in the parasternal line ; middle line, not lower — often higher — than midway between xiphoid process and the umbili- cus ; mammillary line, at the bend of the ribs ; middle axillary line, the tenth rib ; scapular line, the eleventh rib. But from these there is frequently a considerable departure, even normally. Throughout, the lower boundary has been found much higher, this being caused by a fold of intestine lying over the liver and thus diminishing the extent to which it is parietal. This is par- ticularly the case with the ugly, but not pathological, form of the thorax where it is short and its lower aperture is quite wide ; also, in persons who have a full abdomen. In this w,ay the liver-dulness may sometimes be entirely wanting : at the upper boundary of the half- moon-shaped space we pass, in percussing, from lung-sound into tympanitic resonance. Extreme elevation of the liver-dulness, although very variable within normal limits, is not at all applicable in diagnosis. Mobility of the boundaries of the liver. In deep breathing, there is a more marked active displacement of the upper boundary (corre- sponding to the respiratory excursion of the border of the lung) than of the lower, which displacement is the expression of the movement of the dome of the diaphragm. As regards passive movement, we only notice that in the left-side position both boundaries move down- ward, the upper distinctly so (see Lungs) ; the lower, very little. Pathological Relations, — 1, The upper boundary of dulness is found higher. The cause of this can first of all be found in the pleural cavity : pleural exudation, tumors of the pleura, of the lungs, pneumonia; or in the chest wall: tumors, peripleuritis. Then, of course, it is not possible to distinguish the dulness of what lies above the liver from that of the liver itself, since two media that on per- 330 SPECIAL DIAGNOSIS. cussion give dulness cannot be distinguished from one another. If there is exudative pleuritis upon the right side, the diaphragm is deeper and the liver moves down, causing its lower boundary of dulness to be lower, and thus in this disease there may be an extensive dulness, reaching from high in the thorax to far below the border of the ribs — dulness of the exudation plus liver dulness. If the conditions just named are excluded, then we may have {a) Displacement of the liver upward, with high position of the diaphragm. Then, at the same time, the lower border of the liver is higher, and indeed the latter is displaced upward further than the former, because the liver, as it moves upward, in a sense turns on its axis — that is, the lower border turns up, so that it is to a less extent parietal — the square position of Frerichs. (For the conditions which displace the liver, see above.) (h) A tumor, of the convexity of the liver, as a new formation, an abscess, echinococcus, when the upper boundary of dulness pur- sues an irregular course, according to the form of the tumor ; or a subphrenic abscess. In these cases, the liver is usually displaced downward, often very markedly so ; hence, the lower boundary of the liver at the same time stands deeper. (c) A simultaneous general enlargement of the liver. This is rare, occurring only when the liver is very large. Here also the lower boundary of dulness is considerably deeper. It is often very difficult to distinguish, and then only by inspection (projection) and palpa- tion of the surfice and consistence of the liver, and other evidences of disease referred to under (6). 2. The upper boundary of dulness is found deeper. This occurs : (a) "With a simultaneous normal position of the lower boundary, in slight substantive, and in vicarious, emphysema. Although in this case the lung moves down into the complementary space, and thus covers the liver somewhat more than is normal, yet the dome of the diaphragm does not become deeper. {h) With simultaneous downward displacement of the lower boun- dary : low position of the diaphragm with the liver : marked emphy- sema with low position of the diaphragm ; j^neumothorax. We can have the same percussion result with considerable emphysema and en- largement of the liver. Finally, there may be low position of both boundaries resulting from the low position and enlargement of the EXAMINATION OF THE DIGESTIVE APPARATUS. 33 1 liver, as is a frequent occurrence in severe emphysema, because of the existing engorgement of the liver. When the liver is displaced downward it easily gives the impression of being enlarged without such being the fact, because it is often parietal for a larger area than is normal. Also, for this reason, the liver-dulness is higher than it is normally on the average ; especially in pneumothorax is it often distinct. 3. The behavior of the lower boundary when the upper is displaced has in general been already mentioned. It remains to be noticed that, when the liver is pushed down by a thoracic affection on the right side {pleurisy, pneumotliorax), it stands obliquely, that is, the right to be deeper than the left, hence the depressed lower boundary of dulness stands steeper than normal, from the right toward the left. On the other hand, when we have a pleurisy or pneumothorax upon the left side, or marked pericarditis exudativa, since the left end of the liver (loh. sinistra) is then alone pressed down, the lower line of dulness is found more horizontal. With a normal upper border, the lower boundary stands deep and reaches further into the half-moon-shaped space when the liver is en- larged; on the other hand, higher than normal, under some circum- stances even until the liver dulness completely disappears : (a) If the liver is smaller, as in cirrhosis, acute yellow atrophy, here occurring rapidly, {h) As happens much more frequently than (a), in case the liver, though perfectly sound, is less parietal than normal, or is not at all so, as in those who are on the whole well, in meteorism, ascites, entrance, of air into the peritoneum. In this way even an enlarged liver may elude examination. In yet two other rare cases is the liver dulness entirely wanting : in situs inversus viscerum and in cases of ''wandering liver." With the latter, sometimes a portion of the upper surface of the liver will be found in contact with the abdominal wall further down. Apparent low position of the lower border occurs when there is an airless mass below the liver, as with a full colon, or a large tumor of the colon, of the omentum, or of the stomach, although these are rare. The form of the lower border departs from the normal when there is unequal enlargement of the liver (see above) ; also sometimes in marked enlargement of the gall-bladder, seldom determined by per- 332 SPECIAL DIAGNOSIS. cussion. (For the different kinds of enlargement, see under Palpa- tion.) 4. Relative liver-dulness is diagnostically of little interest. It is relatively high, if the diaphragm rises steeply upward and inward from the thoracic wall, and very low, if the diaphragm goes oif per- pendicularly from the thoracic wall, as in severe emphysema, but especially in pneumothorax. All in all, percussion of the liver, when rightly performed and cor- rectly interpreted, is of very great value. But where palpation can be employed, as is usually the case whenever the inferior border of the liver is lower than normal, it must yield to the latter method of examination, which is more anatomical and hence more exact. If the border of the liver can be felt, then we note its course upon the body by the results of palpation and not of percussion, and proceed with the diagnosis in accordance with this position. Examination of the Spleen. Anatomy. — The spleen, a long, generally almost oval, organ, lies in the left hypochondrium, between the ninth and eleventh ribs, in such a way that its long diameter in the dorsal position of the body lies almost exactly behind and parallel to the tenth rib. Its posterior end lies about two centimetres from the tenth dorsal vertebra ; its anterior end, normally, scarcely reaches to a line drawn from the tip of the eleventh rib to the left sterno-clavicular articulation {linea costo-articularis), at any rate does not pass beyond it. The upper (anterior — upper ^) of the two borders of the spleen exhibits one or two notches. The spleen lies close to the under surface of the diaphragm, in the periphery of that portion Avhich rises sharply upward, and toward its inner lower end it covers a small portion of the upper part of the left kidney, also the colon and stomach. Topographically, with reference to the thorax, its location is as follows : Its upper third, during moderate respiration, is covered by the lung. The lower two-thirds are in con- > In what follows I designate the two borders of the spleen as " upper " and " lower," because from the topographical standpoint that always seems to me the most natural. We speak of an upper and lower border of all the ribs, even of the lower ones, which are oblique. I cannot understand why one of the two ends of the spleen should be called the " upper" and the other the " anterior," as is done by Weil. EXAMINATION OF THE DIGESTIVE APPARATUS. 833 tact with the thoracic wall, but it changes its relation somewhat with the position of the body by reason of the passive mobility of the border of the lung (which see). Its upper border follows the ninth rib, forms the outer boundary of the '-half-moon-shaped space," and Fig. 90. € B A Sc M C B A. Se M Position of the spleen. ("Weil.) 21, the middle line of the back; A, B, C,th.e axillary lines; >S'c, the scapular lines; abc d, spleen; a 6 c' c^, unusual rhomboidal form of the spleen ; efg, outer boundary of the kidney ; I be, the spleen-hmg and d h g, the spleen-kidney angle > n m, the lower border of the liver. stands at a sharp angle with the lower border of the lung (see figure), called the spleen-lung angle, whose apex, in the upright position, is about at the posterior axillary line, but when in the right-side position, in consequence of the movement downward of the lower border of the lung, it moves somewhat forward, even as far as the anterior axillary line. Its lower border follows the eleventh rib, and for the most part bounds the left kidney. The spleen is in parietal contact only in its lower two-thirds, but it cannot be reached by the finger except sometimes by turning the abdominal wall under the border of the ribs. 334 SPECIAL DIAGNOSIS. INSPECTION OF THE SPLEEN. In the normal condition, and even when greatly enlarged, inspec- tion of the spleen gives no result, A very considerable enlargement causes a projection of the left hypochondrium, and of the abdominal region obliquely inward and downward from it. When the abdominal wall is thin, the border of the enlarged organ or a circumscribed swelling on its parietal surface may be seen. Then if the upper end of the spleen has not left its place close to the diaphragm (see below), it usually plainly descends with deep inspiration. PALPATION OF THE SPLEEN. Palpation is very much the most important method of examination, because its results are much more reliable than is the case with per- cussion. Ordinarily, in order to employ palpation, it is necessary for the patient to assume what is called the diagonal position on the right side, that is to say, a position midway between the dorsal and the right- side position, and also for the reason that percussion can be practised very much better in this position, and because the unity of the position is useful for comparing the results of the two methods of examination. When the patient is very sick, it is better to palpate in the dorsal posi- tion. When the spleen is of very considerable size, this is also best (then, too, it is preferable for percussion). If it is difficult to find the spleen, then we try the right-side position, because this more fully relaxes the left side of the abdominal wall. If we have the patient take several deep inspirations, a slight swelling of the spleen can usually be made out, because we can feel the anterior end of the organ close to the border of the ribs, at about the tenth rib, where it comes in contact with the tip of the finger. Without further investi- gation, we cannot refer a simple increase of resistance at the edge of the ribs to the spleen ; but we must further seek to feel its border. The spleen can be felt : 1. In individual cases in health, when the abdominal wall is very lax ; also, sometimes, in persons with deformed chest (kypho-scoliosis). 2. If it is enlarged. It may be enlarged and yet retain its form. It is uniformly enlarged in certain acute infectious diseases, as in typhoid, exanthematous, recurrent, fever ; in scarlet fever, usually in EXAMINATION OF THE DIGESTIVE APPARATUS. 335 severe smallpox ; malaria, here relatively very large ; in erysipelas, here often very little enlarged ; in sepsis and pysemia ; sometimes in acute miliary tuberculosis ; in engorgement of the spleen, especially in cirrhosis of the liver ; in occlusion of the portal vein ; in general venous engorgement ; in amyloid disease of the spleen ; in leukaemia (greatest enlargement), and in splenic angemia ; sometimes, in infarc- tion of* the spleen (heart disease); and also in tubercular peritonitis. We must here also mention the apparent enlargement of the spleen where there are thick peritoneal deposits (perisplenitis). It may also be unequally enlarged by new formations, especially by carcinoma, and by echinococcus and abscess. 3. It may be felt if it is displaced, with low position of the dia- phragm (rare); the "wandering" spleen. In palpating we take notice of: Pain. Tenderness, probably always from the peritoneum, some- times occurs in acute infectious diseases, in suddenly developed engorge- ment, in infarction of spleen, new formations, abscesses. There may sometimes, in abscesses and infarction, be tenderness to pressure upon the ribs in the neighborhood of the spleen. Size. The largest tumors of the spleen, often reaching into the right side of the abdomen, occur in leukaemia. On the other hand, in the acute infectious diseases, we have moderate enlargement of the spleen, which does not come below the border of the ribs. In other diseases the splenic tumor varies very much in size. Pulsating splenic tumor has been observed now and then in cases of aortic insufficiency. Consistence. As a rule, the consistence increases with the size, and is more dense in chronic, than in acute, cases. Generally, the consistence is not a guide in diagnosis. Form., surface. It has already been mentioned in what diseases the spleen is uniformly, and in what unequally, enlarged. In diseases of the first group, we can almost always, and in the latter sometimes, feel distinctly the notches in the upper border, if the spleen projects far enough beyond the border of the ribs. In carcinoma, the surface shows hard, uneven tumors ; in echinococcus, they are round, tense, elastic. But in leukaemia, the surface is not always uniform, for it may sometimes exhibit flat elevations. Mobility. We have already mentioned the downward movement of the spleen with deep inspiration. I have seen cases of very great 336 SPECIAL DIAGNOSIS. enlargement of spleen where this did not take place, because the spleen had pushed the diaphragm high up on the left side (see Percus- sion), and hindered its contraction. Wandering spleen, having diminished respiratory movement, but passively movable, and sometimes even showing displacement down- ward with change of posture, occurs only in women. The spleen may wander astonishingly far from its place, even into the true pelvis, and it has been found in the- abdominal cavity entirely free from its attach- ments ; but usually there is only slight displacement. Tumors of this kind are recognized as wandering spleen by their form and by the notches. Often, it is at the same time enlarged. A spleen displaced by the low position of the diaphragm can seldom be felt. (See further regarding displacement, under Percussion of the Spleen.) Relation of the colon to the spleen. Enlarged and wandering spleen lies in front of the colon. We can best prove this by inflating the colon with air in connection with palpation and percussion. PERCUSSION OF THE SPLEEN. Percussion is limited to that portion of the spleen which is not covered by the lung (Weil). It is bounded above by the lung ; toward the front superiorly, we have the upper border, inferiorly, the anterior end, and a portion some distance behind (inferior border), against the stomach and intestine; further back, against the kidney. But this latter portion cannot be defined, there being dulness against dulness. When we can only percuss with the patient in one position, as with very sick patients, we do so in the right diagonal posture. But if we wish to be very exact, and the patient can bear it, it is best also to percuss in the upright posture. Let it be repeated, that palpation generally, even though the physician be skilful in per- cussion, gives a much more certain result. But percussion must never be omitted. When the spleen is very much enlarged, we may examine the patient in the dorsal position. The diagonal posture is only required to determine whether, and how much, the spleen pushes up the diaphragm. ' In both the diagonal and the upright posture, we begin by determining the lower border of the left lung. It is normally in the upright position : EXAMIXATIOy OF THE DIGESTIVE APPARATUS. 337 Fig. 91. mammillary line, sixth rib ; middle axillary line, eighth rib ; scapular line, tenth rib. In the diagonal position, it varies from the seventh to the eleventh rib. From here, if we percuss in the vertical line, over the border of the lung downward, and, in the diagonal position, about in the anterior or middle axillary line, below the border of the lung, Ave will meet dulness instead of the tympanitic sound of the half-moon- shaped space: spleen-dulness. The place at the border of the lung where the dulness is met with is the apex of the spleen-lung angle (see anatomy, p. 333). We now per- cuss vertically downward, through this angle beyond the deadened sound, till we come to a tympanitic (intestinal) resonance : the boundary line is the lower border of the spleen. Then we percuss from the half-moon-shaped space and from the abdomen, upon lines which cross what we suppose to be the arena of spleen-dulness, and thus ascertain where the tympanitic stomach or intestinal resonance changes to dulness. This marks the line of the spleen. If we mark these points, and connect them, we obtain the figure of the parietal portion of the spleen, which we can complete by determining the lower border of the spleen in the posterior axillary line, or in a vertical line between this and the scapular line. In the upright position, the conditions are altered in such a way that the border of the lungs, and with it the lung-spleen boundary, stands somewhat higher (see above), and hence we find the apex of the lung-spleen angle in the middle or posterior axillary line. As has already been said, the size of the spleen-dulness, with careful percussion and under favorable conditions (see below), cor- responds to the parietal part of the spleen. From this we must estimate the size of the spleen. In measuring it, we have only two points of departure : the height of the spleen-dulness in the vertical 22 Shape of the spleen-deadness. 338 SPECIAL DIAGNOSIS. line passing through the apex of the spleen-lung angle, and the rela- tion of the anterior end of the spleen to the linca costo-artieularis. The average in health has been found to be (Weil) : In the diagonal posture, the height of the spleen is 5.5 to 7 cm., the anterior end at most reachino; to the linea costo-articularis. In the upright position, the height is 4.5 to 6 cm., the anterior end under some circumstances passing a little beyond the linea "costo- articularis: -the spleen-lung angle more pointed — that is, the spleen is a little more horizontal. We are interested in the mobility of the spleen-dulness in deep inspiration only so far as it affects the boundary between the spleen and lung (see what has been said regarding active mobility of the border of the lung). Weil, in his work upon Topographical Percussion, has sufficiently explained why we must forego the determination of the portion of the spleen which is covered by the lung. In the first place, we percuss tolerably strongly. If in that way we obtain no result, we then percuss very lightly. With strong percussion over the spleen, we very seldom get resonance, also, with moderately strong, only rarely abso- lute deadness. Also, we must often be satisfied, by gentle percussion, with a relative dulness, associated with tympanitic accompaniment. Departures from what has been called the " average " in health : (a) The dulness of the spleen is only approximated as regards size or intensity: a very frequent occurrence when it is covered by intestine, or the spleen is thin and the intestines near it are distended by gas. (5) The area of spleen-dulness is larger, while its form is retained or is changed : this occurs when the stomach is overloaded with food, when there are fecal masses in the neiwhborino; colon, when there is corpulence (the greater omentum loaded with fat) : but, also, some- times without these conditions being present. We must guard against deception as respects the stomach and intestine by repeated examina- tions, especially with abstinence from food and after free purgation. When there is obesity, we ought not, on the whole, to draw any con- clusion from a large area of spleen-dulness. But, at any rate, we must never, by a single examination, diagnos- ticate a spleen-tumor from percussion alone. Pathological Relations. — As mentioned above, diminution of spleen-dulness is often met with in health. In sickness, it occurs from EXAMINATION OF THE DIGESTIVE APPARATUS. 339 overlapping of the spleen from above by the lung : this happens with emphysema of the lung, when the lung spreads into the comple- mentary space ; sinking down of the lower border of the spleen and its anterior end, as evidence of displacement downward by flattening of the diaphragm, but in emphysema this cannot be proved. There is always diminution of spleen-dulness (even to complete disappear- ance) when it is displaced upward, as in shrinking after pleurisy, contraction of the lung, high position of the diaphragm. Here, generally, there is no spleen-dulness at all, on account of the intestine lying over it, Enlargement of spleen-dulness. If we make out such a condition 'we ought to call to mind the sources of error mentioned above. We should never make the diagnosis of enlarged spleen from a single percussion, without the support afforded by palpation. We must notice whether the enlarged dulness shows the relations of the figure of the spleen ; if it does, then it is quite probable that the spleen is enlarged ; likewise, if the examination in the diagonal and the standing position shows a similar result, with change of dulness that distinctly corresponds with the changed position of the border of the lung and the spleen. Enlargement of the spleen is to be assumed when the vertical measurement of dulness is as much as 9 cm. or more ; also, if the area of dulness extends considerably beyond the linea costo-articularis ; and, lastly, if the dulness is very decided, with moderately strong percussion absolute. When there is considerable enlargement of the spleen, the area of dulness upward is larger, and, hence, the diaphragm, and with it the border of the lung, moves higher in the chest. More- over, in every upward enlargement of the spleen-dulness it is to be remembered that it may be merely apparent, being caused by pleuritic exudation, infiltration of the lungs, or pleural tumor. When there is a decided enlargement of the spleen, it considerably diminishes the half-moon-shaped space. If there is, simultaneously, tumor of spleen and liver, the space may be entirely deadened. AUSCULTATION OF THE SPLEEN. In rare cases, auscultation enables us to recognize peritoneal friction- sounds should there be inflammatory deposits upon the serous coat of the 340 SPECIAL DIAGNOSIS. spleen and the parietal portion of the peritoneum opposite to it, if the diaphragm is not paralyzed by the peritonitis or the spleen has not become adherent. Peritoneal friction-sound over the spleen (and over the liver) seems to me to have greater weight as evidence that the first of the two last-named conditions is wanting, than as the sign of peritonitis, for the latter usually appears to be plainer from other symptoms. It may easily happen that we find it difiicult to distin- guish whether we really have peritoneal, rather than pleuritic, friction- sound. Auscultating with the stethoscope enables us to localize the sound more exactly. We must also take into consideration the whole picture of the disease. Examination of the Pancreas, Omentum, Retro-peritoneal Glands. The pancreas is accessible for examination, and even to palpation, if it is the seat of new formation, as of carcinoma, especially of the caput pancreatis, and hence is larger and harder than normal : we have a roundish tumor in the right epigastrium which does not move during respiration, about midway between the point of the xiphoid cartilage and the umbilicus, hence, directly under the border of the liver ; or a somewhat longer tumor across the epigastrium. Unless there are characteristic associated symptoms (compression of the ductus choledochus and pancreaticus, biliary engorgement, and change in the character of the stools), the diagnosis of tumor of the pancreas can scarcely be made from such a tumor, which may also belong to the omentum, but especially to the retro-peritoneal glands. The omentum, also, is only perceptible when it is thickened by inflammation or neAv formations, or by both. It frequently shrinks up to a transverse band which lies close above the umbilicus, as in tuberculosis, but doubtless also in "simple" chronic peritonitis. Car- cinomatous knots in the omentum are best to be distinguished from similar deposits in the anterior wall of the stomach, by examining the latter, both when empty, and full, or inflated. Sometimes it is very difficult to distinguish them from carcinoma of the liver, especially if the omentum, from adhesion with the liver, moves with each respira- tion. Echinococcus of the omentum is quite rare. Enlargement of the retro-peritoneal glands generally occurs in EXAMINATION OF THE DIGESTIVE APPARATUS. 34I secondary carcinoma as firm, immovable bunches, which are located in the cavity of the abdomen, about on the level with the umbilicus ; but sometimes they reach even deeper. They may compress the side of the inferior vena cava or the iliac vein. This may easily be con- founded with aneurism of the aorta, especially if it is a round tumor and propagates pulsations, and it may also even communicate a hum- ming murmur of stenosis from the aorta. We must again call attention to the importance of always emptying the intestines and bladder in all cases of this character where the diagnosis is difiicult. This is not the place to explain the differential diagnosis of a large number of other affections of the abdomen, especially tumors of the uterus, ovaries ; also, pregnancy. We refer for these to works upon Gynecology and Pregnancy. , Examination of the Contents of the Stomach. In general we may obtain the contents of the stomach for examina- tion in two ways : when the patient vomits, or when, by emptying the stomach by means of an oesophageal catheter, we remove a portion of its contents. The catheter may be introduced for therapeutic purposes, or only for the purposes of diagnosis. The latter way of obtaining some of the contents of the stomach, it is readily seen, is the more exact for making a diagnosis, because we regulate the time for doing it by the object we have in view. First, with reference to the most important problem in the diagnosis of the contents of the stomach, namely, the examination of the stomach- digestion and the secretion of gastric juice, it is only necessary to empty the stomach to obtain the object required. At the same time, it is to be remembered that, in n^any cases, the examination of vomited matters or the fluid employed in rinsing out the stomach (especially in cases of poisoning) is of very great importance, and is, then, not to be overlooked. Artificial emptying of the stomach or removal of some of its contents for the purposes of diagnosis is, as has been said, the only method which enables us to form a reliable opinion regarding the gastric secretion and the process of digestion, for the reason just given, that such an opinion can usually only be formed when the contents of the 342 SPECIAL DIAGNOSIS. Stomach have been obtained in a pure state and at a definite time after partaking of a meal. Vomiting can make the artificial emptying of the stomach unnecessary only when it occurs at exactly the time desired, and when the material vomited does not contain bile and not too much mucus (see below). Induction of emesis is contra-indicated when there is a tendency to hemorrhage, and in poisoning, where we have reason to think the poisons, as acids and alkalies, have caused erosion of the oesophagus or stomach. Sounds, even soft ones, are to be employed with the greatest caution if there has ever been any hemorrhage of the stomach, and also when there is any suspicion of an ulcer of the stomach or of a carcinoma that is eating through the walls. Knowledge regarding the secretion of gastric juice and stomach- diges'tion is important really in thre^ directions, because, by means of it, certain diseases may be recognized early, before inspection, palpa- tion, etc., are of any value, or where these methods do not in any way give any result. And even where other methods of examination have led to a positive conclusion, the diagnosis is not only made still more definite by this knowledge, but likewise the effect of a disease of the stomach upon its functions is determined. Lastly, there is sometimes a flat contradiction between the severe complaints of the patient regarding the stomach and a perfectly normal gastric digestion. In this case, the examination of the contents of the stomach immediately furnishes an explanation, as in some forms of "nervous" dyspepsia. EXAMINATION OF THE PROCESS OF DIGESTION. Stomach- digestion and its Disturbances. 1. After partaking of a meal which contains albumen and starch (fat does not come under consideration, because it is not digested by the stomach), there first occurs, under the influence of the ptyalin of the saliva, the amylolytic period of digestion : the starch contained in the food taken gradually disappears, and dextrine takes its place (achroo- and erythro-dextrine) and there is a slight amount of grape- sugar ; any cane-sugar that has been taken is inverted, that is, is partly transformed into grape-sugar. These processes go on tolerably rapidly. Moreover, under the influence of microorganisms that excite fermenta- EXAMINATION OF THE DIGESTIVE APPARATUS. 343 tion, there occurs a partial lactic-acid fermentation of the grape-sugar, and hence lactic acid is formed (lactic-acid fermentation). This amylolytic period varies in length according to the size of the meal ; on the average, it lasts three-quarters of an hour. As a matter of course, it is entirely absent if only meat is eaten ; then, also, there is no lactic acid. Immediately after food is taken, the mucous membrane of the stomach begins to secrete muriatic acid and pepsin, and the stomach-juice mixes Avith the alkaline chyme. But at first the muriatic acid is in combi- nation, and we do not have free muriatic acid in any quantity until, on the average, one-half to three-quarters of an hour ; thus the amylo- lytic period is brought to a close, because the diastatic action of the saliva cannot go on in an acid solution. Instead, there begins the peptonizing action of the secretion of the stomach upon the albuminous bodies. The lactic acid disappears, and after the first hour none, or only a trace of it, can be detected. The stomach now contains an increasing amount of free muriatic acid, and this reaches its maximum, 0.2 per cent., or less, according to the size and character of the meal, from two to five hours after the time it was eaten. From now on there appear peptones and their precursors (syntonin and propeptone). Simultaneously with the free muriatic acid, the [milk-curdling ferment] rennet-ferment appears, under whose action the casein of the milk that has been taken is coagulated. The pepsin and rennet-ferment are not secreted as such by the mucous membrane of the stomach, but are formed by their zymo- gens \_d'i^v, ferment], propepsin and rennet-zymogen. Both, under the influence of the muriatic acid, become transformed into pepsin and renpet-ferment. The lactic acid, although in very much larger quantity, has this efi'ect upon the zymogens also. This second or muriatic-acid period of stomach-digestion, now shows the very important peculiarity that, during its course, under the influ- ence of the 0.2 per cent, of free muriatic acid, we have the antiseptic action of the gastric juice, by which the greater proportion of the microorganisms swallowed with the food and drink, particularly those that excite fermentation and putridity, as well as certain pathogenic ones, as the cholera bacillus, are destroyed. During the progress of stomach-digestion the food is mixed by peris- talsis, and partly by the aid of the ferments is comminuted and reduced 344 SPECIAL DIAGNOSIS. to a homogeneous mass. A small portion of the fluid resulting from digestion is absorbed ; but besides, at the pyloric end of the stomach, a continuous separation of the solid and fluid portions is going on, and the latter, during the whole period of digestion, passes little bj little into the duodenum. 2. About six hours after a mixed meal of moderate quantity (much sooner after a smaller one), the stomach has become entirely empty, and thereafter contains only small particles of food. In the interval until the next meal, in the great majority of healthy persons, it appears that the stomach contains a very scant amount of clear fluid, with a neutral reaction, but no muriatic acid or pepsin. The stomach- digestion of nurslings has as yet been very little studied. According to Leo, the fasting stomach of a nursling almost always contains free muriatic acid, while during digestion free muriatic acid cannot at all, or only after an hour, be demonstrated ; this is not because there is none secreted, but because it is neutralized by the milk. Leo always found rennet-ferment, excepting in one case where there was rennet-zymogen. After half an hour, the greater portion of the milk has passed into the intestine, and in one, or at most two hours, the stomach is empty. Leo also thinks that the peptonizing of the milk in the stomach is a subordinate process. He regards the stomach as really a milk-reservoir, and perhaps as ofiering a barrier to patho- genic microorganisms. 3. The chief points in regard to the effect of pathological disturb- ances of the gastric secretion, of the motions of the stomach upon digestion, and the sterilization of the food and its further transporta- tion into the intestine, are as follows: Diminished secretion of muriatic acid (subacidity, hypacidity) interferes with the digestion of albumen and the power of the stomach to prevent decomposition and fermentation. When the muriatic acid is increased (superacidity, hyperacidity), free acid is present earlier, and thus there is interference with the digestion of the starches, because this only goes on while the contents of the stomach have an alkaline reaction ; likewise, the albuminous bodies are either normally, or more rapidly, peptonized, but in some cases it is remarkable that they are more slowly peptonized. Diminution of the muriatic acid generally appears to go parallel with a diminution of the pepsin. On the other hand, this parallelism EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 345 is generally not present Avhen there is superaciditj ; with increase of the muriatic acid, there even appears to be an absence of pepsin. At least, this latter condition alone explains those cases where the pepto- nization of the albuminous bodies is prolonged, although the free acid is increased. Hence, with subacidity (inacidity) not only are the albuminous bodies imperfectly digested, but under the influence of the unrestrained development of micro5rganisms there occurs an abnormal decomposi- tion, and particularly of fermentation with formation of lactic acid in excess of the normal time and amount, as well as of other organic acids. This abnormal chemical activity in turn produces a paralysis of peristalsis and muscular tone. The removal of the food stops for this reason, and probably also because the pylorus does not readily allow material to pass into the duodenum which is in an abnormal chemical, and in part physical, condition. The food remains too long in the stomach, and hence the stomach-digestion is prolonged. Lastly, if the condition persists, there is ectasia or dilatation of the stomach. It is to be remarked that by the word dilatation alone is always meant permanent dilatation, in contradistinction from temporary dilatation, which occurs after every meal. Quite similar in its final results is the effect of a hindrance to the emptying of the stomach, as is particularly frequent with pyloric stenosis ; only here the disturbance is on the whole much more marked. In stenosis of the pylorus, the difficulty in expelling the food is at first overcome by an hypertrophy of the muscular coats of the stomach ; but gradually there becomes manifest a disproportion between the strength of the stomach and the narrowed passage. Part of the con- tents of the stomach remain behind at the time of the next meal, and so the stomach becomes more and more dilated. There is an accumu- lation of material (peptones, albuminates, muriatic and phosphoric acid salts) ; and the muriatic acid, though free, is yet so interfered with that it no longer exerts its peptonizing and antifermentative action. There is no further digestion, but in place of it the food accumulated in the stomach takes on fermentation, with formation of a great amount of lactic acid, butyric acid, acetic acid, and alcohol. Through this abnormal chemical action, peristalsis and the muscular tone are still more weakened : there results a true circidus vitiosus of the motor and chemical phenomena. 346 SPECIAL DIAGNOSIS. 4. The chief points in the symptomatology of a distended stomach are the following: Subacidity or inacidity may be recognized by the diminished per- centage of muriatic acid or its absence. Further, there are signs of abnormal fermentation, of which the most important is the unusual duration and amount of lactic acid. Digestion is usually prolonged: the stomach is not empty after seven hours ; it still contains un- changed particles of meat, discernible microscopically or even macro- scopically. If we institute experimental digestion with the gastric juice in an incubator (see below), we find that it is diminished, or that it has lost its power to digest albumen. Superacidity during digestion shows an increased amount of free muriatic acid : usually the free acid makes its appearance too early ; the amylolytic period is thus shortened, and there is unchanged starch (microscopically and chemically demonstrable). Albuminous digestion in the incubator may be quickened. Increased diflficulty in conveying the food from the stomach (especi- ally when due to stenosis of the pylorus) is connected with diminution or absence of free muriatic acid. Thus, the secretion of acid may be normal or even increased ; but the muriatic acid is loosely connected with the bulky remaining albuminates, peptones, and salts, and hence is without chemical or antiseptic action on the one hand, and, on the other, its presence is " concealed," or cannot be established by the ordi- nary reactions. The great amount of lactic acids (butyric and acetic acids) is shown by the amount of fermentation. The diminished digestion of all kinds of food shows this plainly. In the incubator the albumen is not digested. 5. A peculiar anomaly as respects the gastric secretion consists in the fact that even when the stomach is empty, muriatic acid, pepsin, and rennet-ferment, or propepsin and rennet-zymogen, are secreted (supersecretion, hypersecretion). A very considerable amount of this gastric secretion may be accumulated in the stomach ; and this is still more increased by the fact that, generally, the presence of an acid fluid in the stomach stimulates the secretion of saliva. The saliva swallowed is not, however^ sufficient to neutralize the acid fluid. Schreiber has recently found that, even in persons who are in per- fect health, there is a small quantity of acid gastric secretion in the fastiner stomach. This is in direct contradiction of the statements of EXAMINATION OF THE DIGESTIVE APPARATUS. 347 former authors. We will again enter (p. 355) upon the question of the gastric secretion in the fasting stomach. 3Iode of Procedure in Examining the Stomach-digestion. The action of the stomach is divided into the chemical eifect of its secretion and the assistance furnished by mechanically mixing the food and reducing it to small particles ; the passing- on of the digested or sterilized material, and the absorption of a portion of it. Com- pared with that which is passed along, the amount absorbed seems to be small. These processes imply, as has been shown above, a certain length of time, which, in health and when a meal of moderate size is eaten, takes place within tolerably definite limits. Thus, the examination of the action of the stomach is connected with the determination of the' duration of digestion, the examination of the chemical action during digestion, lastly, the relation of the onward movement and absorption. I. Duration of digestion. Since the duration of digestion very much depends upon the kind and size of the meal, in making the examination, it is indispensably necessary to arrange similar conditions artificially. This requirement will be met by Leube's experimental meal, consisting of a plate of water-gruel, an ordinary piece of beef- steak, and white bread. After partaking of this meal, the patient takes nothing until seven hours from the time it was eaten, when the stomach is to be emptied by means of an oesophageal catheter. When the digestion is normal, the stomach after this space of time is empty, or contains only a few particles of the remains of the food. The stomach is emptied or washed out by means of an oesophageal catheter and a siphon, or exceptionally by employing a stomach- pump. We employ a soft N^laton's oesophageal catheter of at least 0.6 cm. internal diameter, to which we attach a piece of rubber tubing, 1 m. to 1.20 m. in length, with a short piece of glass tubing inserted along its course ; on the other end of the tubing is a glass funnel. The catheter is introduced without a guide ; in short, like any other oesophageal sound (see p. 293). After it has been used several times, the patient learns to introduce it himself, which he does by a sort of swallowing motion. Care must be taken lest the sound goes clear down, as has more than once happened. 348 SPECIAL DIAGNOSIS. If the stomach is quite full, then immediately after the catheter is introduced its contents well up through it, even if the rubber tube and funnel have not been attached. If the stomach is only moder- ately full, then it is often simply necessary to press the patient in order to bring up the contents of the stomach through the catheter. If, in this way, we do not receive anything, then, if there is no reason to suspect an ulcer or a carcinoma that will bleed easily, we may carefully aspii'ate with a stomach-pump. If, even then, we do not get anything, we must wash out the stomach with a small, but measured, amount of water, so as to see whether there are still some remaining particles of food. For this purpose we fill the tube and a part of the funnel with lukewarm water, before connecting it with the catheter, and then we pour more water into the funnel, hold it high and allow the water to run into the stomach. Next, before it is quite empty, we lower the funnel quickly into a vessel standing ready upon the floor : the tubing and funnel act as a siphon, and suck out the contents of the stomach. By filling and emptying it several times, the stomach will generally be completely emptied. If, in this way, we cannot obtain sufficient siphon-action, we can increase the suction power of the apparatus by placing the funnel in a vessel of water, extending the rubber tube, and then lifting the funnel a little in the water. If the rinsings of the stomach after seven hours contain at most only a few remnants of food, in most cases the digestion is normal. At any rate, if it is tolerably certain that there is diminution of gas- tric juice, an injurious effect from emptying the stomach is entirely excluded. But it is possible that there is superacidity, and, as a matter of course, supersecretion. If this is the case, we repeat the experiment, except that the catheter is introduced one or two hours sooner. In this way we determine the duration of digestion. If, after seven hours, the stomach still contains considerable por- tions of food, then digestion is prolonged : subacidity, or there is inter- ference with the physiological emptying of the stomach : stenosis of the pylorus, diminished peristalsis, or dilatation. Digestion of a simple meal (see above) lasting longer than seven hours is, in health, only observed in menstruating women. II. The chemistry of digestion. We may again employ Leube's experimental meal for investigating the chemistry of digestion. Some- EXAMINATION OF THE DIGESTIVE APPARATUS. 349 times we may make use of what we obtain while determining the dura- tion of digestion — that is, if seven hours after the meal we find the stomach yet full. If it is empty, then we repeat the experimental meal, and make the trial five hours after it. If we then find it empty (which, normally, is not seldom the case), we go back to four hours. In such cases, at any rate, where there is free muriatic acid, we endeavor to examine the contents of the stomach at the height of the muriatic- acid digestion — that is, at the time when the muriatic acid has its chief value. This is usually about an hour before the close of the period of gastric digestion. Ewald has introduced an important simplification of this examina- tion. He gives a test-breakfast, consisting of a dry roll and luke- warm water or dilute tea, which are taken fasting. The period of digestion is thus so shortened that, one hour after, digestion has reached its highest point. In regard to the dispute as to which is preferable, the experimental meal or the experimental breakfast, we take the ground that the latter is decidedly to be preferred for settling the important points we are seeking, particularly for the practising physician, who is not able to control his patients, and hence must choose the experiment lasting one hour rather than the other, where he is obliged to be away from his fasting patient from four to six hours. But, on the other hand, we must, with others, emphasize the fact that the experimental breakfast makes too slight a demand upon the stomach to permitof a nice judgment as to what it can do. Hence, our experience leads us to believe that the experimental breakfast may mislead us in two diametrically opposite directions — in many cases, by the digestive power of the stomach seem- ing greater than it is ; or, in other cases, that it does not appear to be as strong as it really is, because i( is too little stimulated (in certain nervous dyspepsias, also in many cases of chronic catarrh, as alcoholic catarrh). The greater "cleanliness" of his experiment, as Ewald maintains, cannot be recognized as regulative ; after filtration, in all cases, we obtain after the experimental meal a perfectly clear fluid, which responds very well to the reactions presently to be described. Jaworski gives as the experimental meal the albumin of two boiled eggs with 100 gm. of water — a simplification which we do not think useful or necessary. It is an unnatural experiment, as the well-known instinctive disgust for food of pure albumin proves. 350 SPECIAL DIAGNOSIS. The following procedure is recommended for making the examina- tion : 1. We satisfy ourselves whether there is any bile, blood, or pus in the contents of the stomach (see Vomit). If there is not, then we filter a portion for further examination. 2. We carefully examine the residuum upon the filtering-paper with the naked eye. If an experimental meal has been given, then we observe how thoroughly the masses of meat have been macerated, especi- ally whether the maceration is uniform ; further, we notice whether there are any unchanged particles of bread. (Regarding certain things seen under the microscope, see Vomit.) 3. AYe test the reaction of the fluid-filtrate with litmus (paper or tincture). An acid reaction may be due to muriatic acid or organic acids, or both. 4. Then follows the qualitative examination for free muriatic acid and lactic acid. For testing for free muriatic acid we recommend the test with tropaolin-paper.^ W^e moisten the paper with a drop of the filtrate, then place the bit of paper in a watch-glass and heat it. If there is free HCl, the tropaolin-paper first becomes brown, then, as it dries, lilac color. Approximately equivalent is the test with a saturated alcoholic solution of 00-tropaolin, which has been mixed with a double quantity of the filtrate in a small porcelain dish, distributed by rinsing. After pouring off the surplus, it is to be slowly heated : free HCl yields a lilac-red reflection. Lactic acid gives no reaction, even when tolerably concentrated (0.6 per cent.). It is very distinct when the solution of HCl is pure — about 0.05 per cent. In the presence of albumin, peptones, phosphates, it is much less distinct. Still more certain and much moi;e distinct, while its distinctness is much less aff"ected by other substances, is the phloroglucin-vanillin test. The reagent consists of phloroglucin 2 parts, vanillin 1 part, to absolute alcohol 30 parts. Of this, one or two drops are placed in a shallow por- celain dish, with an equal amount of the filtrate, and carefully heated. Free HCl gives a deep red, or, if the quantity is small, a bright rosy-red deposit ; if there is no HCl, then the deposit is brown-red or brown. It is distinct — even to 0.05 per thousand. It is very 1 Filter-paper soaked with a saturated solution of 00-TropUolin. EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 351 nearly absolutely certain ; its only dra^wback is that the reaction takes place also in the presence of sulphuretted hydrogen (hence, after tainted eggs have been eaten). This test veiy much surpasses all others. It is sufficient to employ this only. Of the numerous other tests we only mention : The reaction "svith methyl-violet, which is applied as follows : two reagent-glasses are half-filled with a transparent solution of methyl-violet, and to this some of the filtrate is added. Free HCl colors methyl-violet blue. The reaction is not very distinct, nor is it very reliable; it can be imitated by table-salt, and it may be concealed by albuminate, pep- tone, etc. There are also to be named: congo-paper, blue ultramarine, and, lastly, resorcin, recently recommended by Boas (resorcin 5 parts, sugar 3 parts, dilute spirit to 100 parts). The examination for lactic acid is conducted in the way suggested by Uifelmann : to about 100 gm. of a 2-per-cent. solution of carbolic acid we add one to two drops of a solution of chloride of iron, when the mixture becomes steel-blue. To this we add some of the stomach- fluid. If lactic acid is present, the solution is discolored and becomes yellow or yellowish-green ; on the other hand, if there is only HCl, the solution becomes clear, like water. Butyric and acetic acids give it a more yellowish-red color ; moreover, they are recognized by their odor, at any rate after shaking up some of the stomach-fluid with ether and evaporating the ether. The test is a very delicate one, and shows 0.01 per thousand of lactic acid. Its certainty is somewhat detracted from by the fact that lactic-acid salts give the,same reaction. It is more important that alcohol, sugar, and acid salts cause the solution of chloride of iron and carbolic acid to assume a straw-yellow color. For this reason, in case there is no pronounced greenish-yellow, but a straw-yellow coloration, we must employ a more certain method : we simply agitate some of the filtrate with ether in a reagent-glass, pour oiF the ether, and then evaporate the residue over hot water, not a flame. We dissolve the deposit in water, and apply Uff"elmann"s reaction by the addition of a few drops of the reagent (Ewald). 5. The quantitative examination of the muriatic acid has a certain value in subacidity, but still greater when there is a suspicion of superacidity. Let it be once more remarked that the latter may be the case not only when the duration of the digestion of albuminous 352 SPECIAL DIAGNOSIS. material is diminished, but also when it is normal, or even when its duration is prolonged. Two methods may be employed, in both of ■which the supposed time of greatest amount of HCl is selected. Pus, blood, bile, a large amount of saliva must be excluded. Repeated examination is necessary. If the quantity of HCl exceeds 0.8 per cent., it may certainly be regarded as pathological. As much as 0.6 per cent, of free acid has been found. First method : The determination of the total acidity is made by neutralizing it with a normal solution of soda. Of course, this will be understood to have value only in case there are no organic acids present, or not an appreciable amount of them. It is treated with a 1 to 10 normal solution of soda and litmus or phenol-phtallein ; 1 c.c. of the 1 to 10 soda solution neutralizes 0.0365 HCl. Second method : As suggested by Giinzburg, we can employ the phloroglucin- vanillin reaction for an approximative quantitative de- termination of HCl, by remembering that the reaction still positively takes place in the presence of 0.05 per thousand of HCl. Hence we have to dilute the stomach-fluid with a definite quantity of distilled water so long as the reaction is produced sufficiently to be recognized. Since GUnzburg's reaction is not disturbed by lactic acid, the simul- taneous pi-esence of lactic acid does not interfere with this method. It is still very desirable that there should be an exact revisional proof of this method. 6. Examining the digestion in an incubator. The examination of the digestive power of the gastric juice is of especial value for demon- strating pepsin. At any rate, experience shows that when there is free muriatic acid, pepsin is usually present ; on the other hand, when muriatic acid is absent, no pepsin is present, for the reason that the mucous membrane of the stomach does not secrete pepsin itself, but secretes its zymogen, propepsin, and because muriatic acid has the exclusive, or at least the chief, power to form pepsin out of propepsin. For these reasons, it may suffice, in most cases, to examine for muri- atic acid alone. But the thorough examination is of the greatest value for arriving at a complete judgment. We test the digestive power of the gastric juice upon a piece of the white of a hard-boiled egg. A piece about a centimetre square and a millimetre thick placed in a reagent-glass full of normal stomach-fluid should be dissolved in about an hour. If the solution is delayed, or EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 353 does not take place at all, it proves that there is a deficiency in the normal amount of pepsin only when we are able to detennine that there is also a deficiency in muriatic acid. For this reason, it is best to conduct the examination simultaneously in two reagent glasses, to one of which a few drops of HCl have been added. The coagulating effect of the gastric juice — that is to say, of the rennet-ferment — upon the casein of milk is proved by the fact that, at the temperature of the body, neutralized stomach-filtrate with neutral (or amphoteric) milk is coagulated ; in fifteen to thirty minutes, if the rennet-ferment is present, there is coagulation of the casein. This test, it seems, can generally be omitted if it concerns nurslings, in whom it is of special interest : for it has been shown that when free HCl and pepsin are present, the rennet-ferment is never absent; even in most cases of absence of both the others, rennet-ferment indeed seems not to be met with, but rennet-zymogen, which requires muriatic acid in order to transform it into rennet-ferment. In order to prove the presence of rennet-zymogen in gastric juice which is deficient in HCl and rennet-ferment, we supply the deficiency by adding HCl and then allowing it to stand in an incubator for two hours, after which we apply the test for the ferment mentioned above. In atrophy of the mucous membrane of the stomach, there is entire absence of rennet-zymogen, as well as of HCl and pepsin. Of the somewhat difficult methods of examining the products of digestion we can here mention the two following : 1. The transforma- tion of the starches into erythro- and achroo-dextrin can be quali- tatively followed by means of dilute Lugol's solution (iod. 1 part, iodide of potash 2 parts, aq. dest. 200 parts); it colors starch blue; erythro- dextrin, purple-red; achroo-dextrin remains colorless or be- comes yellow. A mixture of starch and dextrin with the first drops of the iodine solution becomes colorless, but upon further addition it becomes red and then blue. 2. Peptone and propeptone in alkaline solution, upon the addition of a solution of sulphate of copper, give a wonderfully beautiful purple color ; albumin makes it blue- violet ; hence, on account of this simi- larity of colors, it is often extremely difficult to distinguish albumin from peptone, particularly if the stomach-fluid is turbid. III. The effort has been made in various ways to ascertain what part the movements of the stomach play in digestion. No method 23 354 SPECIAL DIAGNOSIS. that has thus far heen devised meets the requirement ; hence, we only mention them very briefly. The peculiarity of salol that it splits up into salicylic acid and phenol only in the intestine, whereupon the appearance of salicylic acid in the urine is easily proved, has been employed by Ewald to determine the rapidity of the passage of food from the stomach into the intestine. Salicylic acid is recognized in the urine after the addi- tion of chloride of iron by the violet reaction in the urine. In order to recognize the first traces, we must make the test upon an ethereal extract [of the urine. (Compare what is said later regarding the Urine after the Administration of Medicines.J]. Ewald found that in health the first positive reaction took place one-half to one hour after it had been taken ; when the process of transportation from the stomach had heen interrupted, it was later. However, the results of this procedure seem to be quite variable. The same thing must be said of the use of pills of iodide of potash coated with keratin, which very evidently are preferable, because we do not need to employ the urine in proving the absorption of the iodide, but we can make use of the saliva. But Stintzing has found that these pills are sometimes dissolved in the stomach. Finally, Klemperer has attempted a method, which, from a purely technical standpoint, is very exact, but is decidedly impracticable. He introduces into the empty stomach 100 grammes of olive oil, and, after a certain interval, washes the stomach out. From healthy stomachs he found that, in two hours, 70 to 80 grammes of the oil had been discharged into the intestine, while in cases of catarrh of the stomach about half, and in one case of atrophy a quarter, of that amount had in the same time disappeared from the stomach. This method is less objectionable, because the oil is sometimes not borne in the patient's stomach — it may even be rejected. But it is much more so because it does not suflSciently irritate the stomach. Lastly, the absorptive power of the stomach has been frequently the object of examination. Penzoldt gives 0.2 iodide of potassium in gelatin capsules, and then at once tests the saliva to see whether the capsule was close and free from iodide of potassium upon its outer surface. For this purpose we have the patient, moment by moment, spit upon a piece of filter-paper saturated with a solution of starch, upon which we place a trace of EXAMINATION OF THE DIGESTIVE APPARATUS. 355 fuming nitro-hydrochloric acid ; the appearance of the iodide in the saliva will be recognized by the red and blue coloration of the paper. In health, the iodide will make its appearance, if it has been taken upon an empty stomach or three hours after eating, in from six and a half to eleven minutes ; if directly after a meal has been eaten, after twenty to forty-five minutes. In cases of dilatation, if taken upon a fasting stomach, its earliest appearance is after fifteen to thirty minutes. It also seems to be delayed in carcinoma, chronic catarrh, and in fevers. The question is, whether we can draw a conclusion as to the absorption of the products of digestion from the behavior of the iodide. The examination of the fasting stomach has for its object the determination of the behavior of the gastric secretion after the com- pletion of stomach-digestion. Hence, it is conducted with reference to the diagnosis of a possible hypersecretion. Method. Recent investigations upon this subject show that it is very important to avoid making use of the secretion of the stomach which results from any mechanical irritation. Hence, we must be very cautious and proceed very rapidly. We recommend a Nelaton's sound, without an eye, but, instead, a number of fine openings at the end, which is to be introduced into the stomach some hours after Ave have washed it out in order to make sure that it was empty. Or, still better, we first determine the duration of digestion, then we allow the stomach to be quiet after the expiration of the last meal. Then a stomach- pump is "quickly introduced ; aspirate, withdraw the sound, and empty it into a vessel. Next we examine the fluid thus obtained as to its reaction, and, if acid, for muriatic acid ; further, as to its digesting qualities. For passing judgment upon the results of this procedure and its diagnostic significance, see the following pages. Finally, on account of its historical interest, we mention bere the method given by Leube, but supei'seded by his experimental digestion. He introduced ice-water into the empty stomach and then aspirated it, in order to obtain for examination the gastric secretion pure — that is, diluted with water. Results of the examination of stomach- digestion : their value. 1. If the examination of the duration of digestion shows that it is not prolonged, then, as a rule, the process of digestion is normal ; but 356 SPECIAL DIAGNOSIS. the period of digestion may be shortened, and this sometimes is the case when there is superacidity. If the period of digestion is pro- longed, this must be further investigated. 2. Free muriatic acid, which belongs to the time when normal digestion is at its height, may be completely wanting (inacidity, anacidity). This almost uniformly occurs when there is complete destruction (corrosion) of the mucous membrane of the stomach, when it is atrophied, or has undergone amyloid degeneration. Further, inacidity is almost always present in carcinoma ventriculi with dilata- tion, more rarely, although also very frequently, in all other kinds of dilatation. Of these we must mention especially that which occurs with chronic gastric catarrh. The dilatation produced by the scar of an ulcer (at the pylorus), or accompanying an ulcer, is associated with diminution or absence of free HCl. Subacidity, or even inacidity, is further observed in severe anaemia of all kinds and with fever, and, lastly, in certain cases of nervous dyspepsia. Accompanying this condition is the more or less markedly increased formation of lactic acids (butyric, acetic acids, alcohol) — a sign of abnormal fermentation. In very severe cases it may result in fetid decomposition of the contents of the stomach. Moreover, for an unusual length of time or continuously, there may be undigested masses or fine particles of meat. For reasons that are readily understood, the behavior of the stomach in cases of phthisis has been very much studied; the results vary in a very remarkable degree. The general conclusion from these examinations seems to be that in cases of severe phthisis with con- tinued fever, very often no free HCl, sometimes even no rennet- zymogen, is found, but that free muriatic acid is also sometimes wanting in remittent fever. At any rate, the examination of the stomach- digestion in phthisis for prognostic and therapeutic reasons is to be recommended in every single case. 3. Increased amount of HCl at the height of digestion, shortening of the time (normal maximum of one hour) during which lactic acid is present, are signs of superacidity. Thus the period of digestion is shortened, or normal, or sometimes even prolonged. As evidence of disturbed amylolysis, we have unchanged starch during the whole period of digestion. EXAMINATION OF THE DIGESTIVE APPARATUS. 357 Superacidity is present in the majority of cases of ulcer, also in certain nervous dyspepsias (gastroxynsis, pyrosis hydrochlorica), lastly in acute and sometimes in chronic gastric catarrh. It is also observed in the forms of insanity accompanied with depression, 4. It has been shown by recent investigations (Schreiber, and par- ticularly E. Pick), regarding the significance of the presence of acid- secretion of the stomach, that a positive conclusion from the examina- tion can only be drawn with caution, because the irritation of the sound seems to stimulate the stomach to pour out its secretion very rapidly. We can only diagnosticate supersecretion (hypersecretion), when by a rapid, careful procedure at least about 200 c. c. of acid gastric secretion are obtained, Superseci'etion occurs in the gastric crisis of tabes and certain neuroses, as hysteria and nervousness. It is sometimes also observed with ulcus ventrioidi, in individual cases of carcinoma, and in acute aind chronic catarrh. Emptying the stomach for therapeutic purposes, or washing it out, must be undertaken, in the first place, in cases of recent acute poisoning, and frequently for the purpose of diagnosis. This is the case in almost all cases of poisoning, where the poison has been swallowed. But it must be remembered that in poisoning with substances that are corro- sive, as acids and alkalies, on account of the danger of perforation of the oesophagus or stomach, the sound must be used with the greatest caution, or even not at all. The detection of the kind of poison in the contents of the stomach belongs to toxicology. Some poisons entirely escape detection. What has been said above regarding the examination of the con- tents of the stomach, explains the therapeutic use of washing out the stomach when it is diseased, in that it can be employed for observing the course of the disturbance of digestion in diseases of the stomach. For instance, it is evident from what has been said that it is not without value occasionally to institute a daily washing out of the stomach, in case it is diseased, to determine whether it contains lactic acid many hours after the last meal was taken. Also, frequent micro- scopical examination of the sediment of the rinsings of the stomach (in sarcina ventriculi, etc, see Vomit) is of undoubted value. 358 SPECIAL DIAGNOSIS. Vomiting, and the Examination of what is Vomited. The act of vomiting consists of one or several strong forcible contrac- tions which occur simultaneously in the oblique abdominal muscles and the diaphragm. In this way the stomach is compressed, and, by the simultaneous opening of the cardiac orifice, its contents escape upward. Otherwise the stomach takes no active part in expelling the food. From the not infrequent presence of bile in the last portions that are vomited toward the end of a severe effort at vomiting, it is evident that the pylorus also sometimes does not entirely close. In this connection we do not include the vomiting, or rather the expulsion of food from dilated parts of the oesophagus when there is stenosis or diverticula. (See Examination of the (Esophagus.) Vomiting may occur in a great variety of ways, and in diseases which differ greatly in character. We suppose that the so-called vomiting- centre is situated in the oblongata. This may be stimulated from the periphery, chiefly through the sensory portion of the vagus, and so give rise to reflex vomiting. Moreover, it may be stimulated directly or by impressions from other portions of the brain (central vomiting). Children generally vomit easier than adults. There are also indi- vidual differences. Clinically, we distinguish : 1. Vomiting occasioned by reflex influences from the stomach. It occurs in all diseases of the stomach, but also in irritation of the mucous membrane of the stomach by different poisons, certain emetics, etc., and also by overloading the stomach. 2. Reflex vomiting caused by other abdominal organs, as from the female sexual apparatus in menstruation, pregnancy, diseases of the sexual apparatus ; from inflammation of the peritoneum ; also, in renal and biliary colic, etc. Likewise, vomiting may be caused by irritation or tickling of the fauces. Probably here also belongs vomiting which occurs at the end of a severe fit of coughing, as in whooping-cough and phthisis. 3. Central vomiting. It may result from irritation of the brain of various kinds : as different evident diseases of the brain, especially tumors ; in the different forms of meningitis ; in neuroses, particularly hysteria ; and from uraemia. Vomiting occurs also in the beginning of certain acute infectious diseases, as pneumonia, scarlet fever, small- pox, erysipelas. EXAMINATION OF THE DIGESTIVE APPARATUS. 359 Vomiting is almost always accompanied by certain other phenomena: previous malaise, often severe sweating, quickening of the pulse ; exhaustion, with the feeling of relief, but also evidences of collapse. In diseases of the brain, it sometimes occurs without any preliminary indisposition, even quite suddenly and unexpectedly. As regards the time when the vomiting begins, in diseases of the stomach, it often (not always) follows eating. Also in peritonitis, vomit- ing is often excited by the taking of food ; but here also it takes place quite independently of this. The vomitus matuiinus of drunkards, as a rule, regularly occurs early in the morning, when the stomach is empty. Also in certain nervous dyspepsias there are apt to be attacks of vomiting when the stomach is empty. When there is severe vomit- ing without phenomena of stomach or other abdominal disturbances, we must take into consideration the other conditions named above — acute infectious diseases, disease of the brain, uraemia, hysteria — according to the circumstances. The frequency of vomiting is extraordinarily variable, and is of little moment in diagnosis ; only that it might be mentioned that in very marked dilatation of the stomach, from pyloric stenosis, vomiting occurs remarkably infrequently, but in most cases tolerably regularly, at intervals of several days (but then very profusely). There may be eructation in all the conditions in which vomiting occurs. It is observed, especially, in slight and severe diseases of the stomach of all kinds. The odor of the eructation corresponds to that of the contents of the stomach, as a matter of course. (See under Odor of -the Vomit.) In individual cases, combustible gases have been observed (marsh gas, and probably also other gases). There occur with nervous persons very distressing and entirely odorless eructa- tions. The Vomit. When we examine the vomit, we notice the quantity, the macro- scopical and microscopical appearance, the odor, and the reaction. The chemical examination can probably occasionally enable us to judge of the character of the stomach-digestion. This is especially the case in those diseases which we cannot include in a methodical investigation, as, particularly, inclination to hemorrhage, etc. (See above.) Of course, we must consider the relation of the vomiting to 360 SPECIAL DIAGNOSIS. the time of the last meal, and what this meal consisted of. The points of view are to be taken from what has been said above regard- ing experimental digestion. Where there are macroscopical appear- ances of blood and coloring matter of bile, we must farther apply the chemical tests for these substances. The qnantiti/ vomited. Here we must consider the time and fre- quency of the vomiting, as well as the amount of food taken. When there is vomiting from an empty stomach, there is usually only a little mucus, seldom much mucus or saliva that has been swallowed (i'0»uYms matutinus potatorum), or more or less pure gastric juice (hypersecre- tion). In acute infectious diseases, diseases of the brain, urjemia, sometimes scai'cely anything at all is vomited. A vomiting which seems to result from the ingestion of food, but the amount of which considerably exceeds the quantity of food and drink last taken, is an almost mathematically sure proof of dilatation of the stomach. Here the contents of the stomach may accumulate for a number of days and then be thrown off en masse, to the amount of several litres. The macroscopical appearance. This will naturally depend very much upon the food taken. It was mentioned above, Avhen speaking of the experiments with digestion, that under some circumstances we can form a conclusion regarding digestion by the comminution of the food. Some foods, as coffee, cocoa, red wine, huckleberries, etc., markedly color the vomit, and may sometimes give rise to mistake, if it is superficially examined, by causing one to think that there has been hsematemesis (the laity being not infrequently thus deceived, and hence we must be very careful in accepting the anamnesis). When preparations of iron have been taken, the vomit is black ; but it is also sometimes black in acute lead-poisoning. Apart from the food, we can, from some prominent constituents (when the contents of the stomach are abnormal), make certain important distinctions in what is vomited, as well as in the sputum. Watery, watery-mucous, mucous vomit. The first and the second named may ordinarily have two very different meanings. In both cases we have a somewhat turbid fluid, resembling saliva or fluid mucus, which is vomited from a fasting stomach. It has an alkaline reaction, and usually indicates chronic gastric catarrh. The fluid consists of mucus from the mucous membrane of the stomach, and of EXAMINATION OF THE DIGESTIVE APPARATUS. 361 saliva that has been swallowed. In this way the frequently men- tioned "water-brash" of drunkards [vomitus matutinus potatorum) especially manifests itself in the early morning, immediately after rising. Also such vomiting occurs (rare) in nervous dyspepsia. If the fluid smells sour, and has an acid reaction, and if it shows the muriatic acid reaction and power of digestion, then we have gastric juice secreted by the empty stomach : hypersecretion. This gastric juice is often over-acid — hypersecretion with hyperacidity (over 0.3 per cent.). This occurs in certain kinds of nervous dyspepsia (gas- troxynsis, gastroxia ; also hysteria ; tabes), but also in dyspepsia fol- lowing healed ulcer, and acute and chronic gastric catarrh. In these cases the quantity vomited may amount to several hundred grammes. A special form of watery-mucous vomit is peculiar to Asiatic cholera. In this disease there is often vomited a great quantity of alkaline, stale-smelling fluid, like rice-water (very like the stools of cholera) (which see). The small flocks, like rice, are mucous flocks. It is not possible to separate mucous from watery-mucous vomit. Sometimes a great quantity of mucus is observed in chronic catarrh of the stomach. Vomiting of bile. As previously mentioned, bile may be mixed with every vomit, and this is especially apt to be the case in very severe efforts at vomiting, so that toward the end almost pure bile is ejected. The vomit looks yellowish-green or green, and smells decidedly bilious. It exhibits the reaction of the coloring matter of the bile. (See Urine.) A grass-green bilious vomit, occurring with tolerable uniformity, with every act of vomiting whether violent or not, is a not unimpor- tant peculiarity of peritonitis, and of marked obstruction of the bowels. Bloody vomit, vomiting of blood (hgematemesis). Blood from the nose, throat, and oesophagus may become mixed with the vomit in the act of vomiting. Small quantities, in streaks, are usually of no sig- nificance. Large hemorrhages from the oesophagus, as in varices of the lower portion of the oesophagus, and in cirrhosis of the liver, usually after it has run down into the stomach, cause severe haemate- mesis. Also blood from the nose, and even from the lungs, may reach the stomach and be vomited up (see p. 170). We must be careful not to confound such an occurrence with hemorrhage of the 362 SPECIAL DIAGNOSIS. stomach. In doubtful cases the anamnesis is of less value than the examination of the stomach, nose, and lungs. (See p. 170 for further particulars regarding the distinction of hemorrhage of the lungs from that of the stomach.) Small points of blood and streaks in the vomit, moreover, even if they come from the stomach, according to our experience, are generally without significance ; that they are from the stomach is proved by the presence, not infrequently, of bloody suffusion of the mucous mem- brane of the stomach at the autopsy. Streaks of blood frequently recurring, whose soui'ce the autopsy proves to be the stomach, are not at all uncommon in cirrhosis of the liver. Bloody vomit, from hemorrhage of the stomach, takes place in ulcer of the stomach, carcinoma ventriculi, portal engorgement from cir- rhosis of the liver, closure of the portal vein (rare in general venous stasis), in severe lesions of the mucous membrane of the stomach by corrosive poisons, also in general hemorrhagic diathesis (see cutaneous hemorrhages), in yellow fever, meloena neonatorum ; in the last-named cases there usually occurs simultaneous hemorrhage of the bowels. Very decided, and sometimes fatal, hsematemesis is chiefly peculiar to ulcus ventriculi (also meljena). In carcinoma we notice very fre- quently repeated, but always moderate, hemorrhages. Moreover, in all these conditions the vomiting of blood may be entirely wanting, either because there is no escape of blood into the stomach, or because the blood is not vomited. When we suspect hemorrhage of the stomach, which is not vomited, we are to examine the stools (which see). Sometimes, in ulcer of the stomach, the patient becomes suddenly pale, may collapse, or may even die from a hemorrhage of the stomach, Avithout there being any vomiting of blood. In order to observe exactly an ulceration of the stomach, it is particularly necessary to observe uninterruptedly the stools. Pure blood is seldom vomited, unless there is a great quantity of it, or it is vomited directly after or during the hemorrhage. Moreover, it is never of so clear an arterial color as in hemorrhage of the lungs. The blood is almost always more or less changed by the gastric juice : it is very dark, black -brown, and has an acid reaction. If it has been in the stomach for some time, as is quite often the case in carcinoma with dilatation, because the hemorrhages are usually small and there EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 353 are long pauses bet-^veen the hemorrhages, under the influence of the acids, bj the breaking-up of the red corpuscles and the hsemoglobin, and the appearance of hsematin, it becomes coffee-brown and also of the consistence of coffee-grounds. Then, in case it is abundant, it is easy, "with some experience, to recognize it ; yet it is easy to confound it with other substances, as coffee, cocoa, etc. (See above.) For this reason, and because we cannot here employ the microscope, it is preferable, in this case, always to make a special test of the blood. Testing the blood: 1. A'ery correctly, the hjemin test is generally employed, because it is certain and distinct. The following is the best way to make it : Some of the coffee-grounds material is filtered ; a Fig. 92. ^^ ■ ^ Crystals of hsemin. Zeiss's apochromatic lens ZSTo. 8, eye-piece Xo. S, camera lucida. ilagnified about 300 diameters. little of this is to be evaporated in a watch-glass. Scrape off some of the dried material, mix it with a trace of finely-pulverized salt, place the dried mixture upon an object-glass, cover it with a glass cover, and allow one or two drops of glacial acetic acid to flow under it ; then the acetic acid is again evaporated very slowly, and, after it is thor- oughly dry, one or two drops of distilled water are allowed to flow under to dissolve any crystals of salt that may be present. Under the microscope, there can be seen crystals of haemin (hydrochlorate of hsematinj in coffee-brown or reddish-brown crystals in rhombic plates, which must be considerably magnified, as the crystals are very small. 364 SPECIAL DIAGNOSIS. The following method (an adaptation to the vomit of Heller's test for blood-coloring material in the urine, which see) leads to a result more quickly : We place some of the filtered stomach-fluid in a reagent-glass, with a like quantity of normal urine, make it strongly alkaline with liquor potassae, and heat it. The urine-phosphates are precipitated and carr}^ with them the coloring-material of the blood, and when blood is present, we have a cloudy, flocculent, reddish-brown deposit. Vomiting of pus. Pus, as a macroscopically visible constituent of the vomit, is somewhat unusual, and is only observed in isolated cases of phlegmonous gastritis or of abscess of a neighboring organ, breaking into the stomach. Probably it can then only be observed when it pours into the stomach in such quantities and so quickly thajt it makes the contents of the stomach alkaline, for only thus will it avoid immediate digestion. Regarding separate white corpuscles, see below. Fecal vomiting (miserere, ileus). In this condition, either there are considerable quantities vomited which do not look distinctly feculent, probably coming rather from the stomach or the upper portion of the small intestine, and the fecal addition is betrayed by its odor, or there are distinctly fecal masses, even balls of excrement. This kind of vomit occurs in severe diffuse peritonitis and in serious occlusion of the bowels (see Inspection and Palpation of the Abdomen). It indicates an extremely serious and, in most cases, fatal condition ; yet it does not by any means have the absolutely fatal significance which was formerly ascribed to it. As visible admixtures which can be seen with the naked eye, are still to be mentioned: Round worms, which come from the small intestine, probably brought into the stomach by the first efforts at vomiting, and are afterward seen in the material vomited up. It is a startling appear- ance, but in itself has no significance. Also : Membranous rags of echinococcus, in case one should break into the stomach from the liver or spleen. In these cases, the microscope sometimes shows the scolices and hooks of the parasite (see illustration, p. 183). Moreover, in individual cases, there are found in the vomit, also, oxyuris, anchylostomen, trichinae (see these under Stool). Microscopical examination. This is of very little independent EXAMINATION OF THE DIGESTIVE APPARATUS. 365 value in determining the processes of digestion. In vomiting which takes place during digestion, we, of course, expect to find portions of food in very varying condition, according to the time the vomiting occurs. Starch-grains in considerable quantity, for the time when the amylolytic digestive period ought to be past, indicate incomplete amylolysis, as is almost always produced by hyperacidity (in conse- quence of the too early appearance of free muriatic acid). Mucous corpuscles are found in watery and mucous vomit ; epithe- lium, from the mouth, throat, oesophagus, also sometimes from the stomach, is observed ; unchanged red blood-corpuscles are very rare ; in hemorrhage of the stomach, the microscope generally is useless, because the red blood-corpuscles are broken up. Also, it is rare to find white blood-corpuscles that are well-preserved. Vomited material (Jaksch). ce, Muscular fibre; 6, white blood-corpuselej c,d,c", flat and cylindrical epithelium j d, starch-corpuscles j e, fat-globules; /, sarcina ven- triculi ; g, yeast-ferment; h, i, cocci and bacilli (those near h were once found by Jaksch in a case of ileus, hence arising from the intestine); k, fat-needles> connective tissue; I, vegetable cells. Sarcina ventriculi (schizomycetes) and torula cerevisiae (germinating fungus) are not entirely without value, as indications that the stomach retains its contents for a long time, as, especially, in dilatation. 366 SPECIAL DIAGNOSIS. Of the two fungi, the sarcina is the more important. If it is not macerated or deformed by pressure with the covering-glass, it is generally easily recognized, when strongly magnified, by its peculiar resemblance to a ball wrapped with a string crossing at right-angles. It is stained a reddish-brown by a weak solution of iodine, or iodide of potassium. TorulfB of different kinds and sizes (the latter very much like a small white blood-corpuscle, generally smaller) are easily distinguished as small bodies strung along together, sharply defined, which refract the light and are egg- or elliptical-shaped. Isolated ones are observed in the contents of the stomach with normal digestion. When the quantity is considerable, it shows that it has been a long time in the stomach, whose contents have undergone alcoholic fermentation. Other different kinds of bacilli and cocci, which have only recently been carefully studied, are found in the vomit, but as yet they have no diagnostic value. Also, there are found in the vomit aphth?e (probably originating in the oesophagus, see above) and favus, achorion Schonleinii. Reaction of the vomit. This is usually acid from muriatic or organic acids (see above, under Digestion). It may be alkaline when a considerable quantity of blood is vomited, as in Avater-brash, the watery vomit of Asiatic cholera ; also, rarely, in cadaverous vomiting, as in ulcerating cancer of the stomach, and in the vomiting of kidney- disease (see below, under Odor). Moreover, oesophagus-vomiting manifests itself by being always alkaline (see under Examination of the QGsophagus). Odor of the vomit. In many respects this is very important. Thus, particularly the presence of sebacic acid is recognized with great certainty by its characteristic pungent odor. The odor is very important in many poisons, as with phosphorus (odor of garlic), bitter almonds, or nitro-benzole (odor of bitter almonds), ammonia, carbolic acid, etc. There is fecal odor with ileus, cadaveric odor in ulcerating car- cinoma, also in fresh hemorrhage of the stomach. The odor is ammoniacal in nephritic patients, especially when there is uraemia. It is thought to result from the separation of urea by the mucous membrane of the stomach, by the urea in the stomach changing into carbonate of ammonia. EXAMINATION OF THE DIGESTIVE APPARATUS. 3g7 Examination of the feces. As in examining the contents of the stomach, the inquiring physician must pursue his task from two points of view : On the one hand, he is to draw a conclusion from the character of the intestinal discharges as to the intestinal digestion, and any pos- sible disturbances of it from the abnormal chemical changes, and also an opinion regarding the present disease. On the other hand, he is to form a diagnosis directly from the occurrence of certain products of disease, or even of substances generated by disease, as intestinal parasites or microorganisms found in the stools. Unfortunately an explanation from the point of view first mentioned is difficult for sev- eral reasons : first, because we have to do with the last step of an extremely complicated process, and then, in many respects, we do not sufficiently understand this process itself, or its pathological variations. With reference to the other point, and especially regarding organic exciting causes of disease, we have only a few sure principles, part of which are old, and jDart have only recently been acquired. We have next to consider : The intestinal discharges, with reference to their frequency and their possible, usually subjective, accompanying symptoms. The more particular examination of the stools : quantity, consist- ence, or form, color, odor. In addition, there are the admixtures which are visible by the naked eye, and those to be seen only by the aid of the microscope. As yet, it is not possible to form an estimate of the intestinal diges- tion by the character of the intestinal fluid. It is well known that sometimes (especially by evacuating the fasting stomach) there enters into the stomach a fluid mixed with bile which is to be regarded as a mixture of pancreatic and intestinal fluids, since with an alkaline reac- tion it digests albumin, starch is changed into dextrine and maltose, and fat is split up. But this occasional occurrence has not yet been employed for consecutive examinations. Boas recently, after carefully rinsing out the stomach with soda and having it tightly squeezed, has endeavored, by employing an oesophageal sound, to obtain the intestinal juice. But his results have not yet been completely published ; hence it is not possible to form an opinion as to what assistance his method will be for the purposes of diagnosis. 368 SPECIAL DIAGNOSIS. Intestinal discharges. In health their frequency varies individu- ally very much. Ordinarily, at all ages, excepting nursing children who have three or four movements a day, there is one stool in twenty- four hours ; but many persons regularly have a movement twice in the twenty-four hours, wdiile others only have one in two or three days, or even at longer intervals, without experiencing any inconveni- ence [or disorder]. But in scarcely any other way do physiology and pathology so much encroach upon each other's limits as with reference to the frequency of the intestinal discharges, for sometimes a move- ment even once in two days may be troublesome, and the physiological habitual constipation, in many cases, cannot in any way be distin- guished from the pathological condition. Constipation, or, better, pathological constipation, is called obstipa- tion ; the expression obstruction (severe obstruction) is often inten- tionally used for constipation in a serious sense. The opposite to this condition is looseness, diarrhoea. The frequency of the discharges is directly connected with the quantity of food taken ; hence a person who is fasting is always constipated. This point must often be thought of. The character of the food, too, has an influence upon the frequency of the discharges, and upon the passage of food through the intestinal canal. (See under "quantity.") Thus rapid peristalsis causes diarrhoea, slow peristalsis, obstipation. Hence, any mechanical obstruction in the alimentary canal brings on constipation. Diarrhoea is the most important sign of intestinal catarrh. This is brought about by errors of diet, by cold, by infectious causes, as the intestinal catarrh of typhus, dysenteric inflammation of the large intestine, and also many intestinal catarrhs which were formerly referred to the cause first mentioned. In this condition, the stools are always thin (see the second section below and Consistence of the Stools) ; their frequency may be increased, even to occurring hourly, or yet oftener. Moreover, medicines or poisons may increase the peristalsis alone, or intestinal catarrh, and thus result in diarrhoea. In all these cases the increased peristalsis increases the fluidity of the intestinal contents, even causing eff"usion from the intestinal wall into the intestinal cavity (cholera), until we have the condition of diar- rhoea. (See below.) EXAMIXATION OF THE DIGESTIVE APPARATUS. 359 Obstipation may be a disease which is relatively harmless, although very troublesome, becoming habitual. But it is of much greater diag- nostic significance, however, as an early sign of peritonitis from paralysis of the intestine. Of still greater importance is severe ob- struction in all forms of stenosis of the intestine, as fecal accumulation, particularly in the caecum ; strangulation, invagination, intussuscep- tion of the intestine : new formations, scars in the intestinal wall, compressing tumors external to the intestine ; constrictions, bends produced by peritoneal exudations. In many cases of chronic intes- tinal occlusion, as in chronic peritonitis, constipation alternates with diarrhoea. But the condition of obstipation or diarrhcea is still more affected by a possible increased or diminished abstraction of fluid from the intestinal contents ; the more fluid there is, the quicker it passes through the bowel. Now, if the intestinal contents part with much fluid when there is slow peristalsis, as a result of prolonged retention, they become dry and hard, hence are carried forward with difficulty. If the peristalsis is quicker, the contrary exists. The efiect of slow or quick peristalsis is felt in the transit [of the intestinal contents], caus- ing either obstipation or diarrhoea. The severest diarrhcea occurs in cholera Asiatica, because in this disease there is great effusion of fluid from the intestinal wall into the lumen of the intestine. 1 . It is to be understood that an ordinary constipation and severe obstruction are to be sharply distinguished from each other, for a quite ordinary obstipation may be very obstinate. Here the decision is made by considering other phenomena, as vomiting, pain, and par- ticularly by examining the abdomen. This can never be omitted in any sudden attack of obstipation, special attention being given to the hernial orifices and the caecum. 2. Persons who eat little or nothinof, whom manv things either strangle (stenosis of the oesophagus), or cause vomiting, as in diseases of the stomach, but especially pyloric stenosis, in which case there is infrequent but considerable vomiting at a time, cannot have frequent stools; hence they must be obstipated. Such cases are easily over- looked, particularly if the patients complain a good deal of obsti- pation. 24 370 SPECIAL DIAGNOSIS. The special peculiarities which precede the examination of the bowels are of diagnostic importance : Pain with the movements. There will be pain at the anus or at the lower portion of the abdomen in all kinds of inflammatory affec- tions of the anus, the rectum, or their neighborhood. We have severest pain when the lower portion of the rectum is compressed by a large inflammatory (purulent) exudation, especially in the exudation of peri- and para-metritis ; also in fissure of the anus and abscesses from peri-proctitis (see Surgery). Likewise, in carcinomatous, syphilitic, gonorrhoeal stenosis of the rectum, but also in the usually harmless hemorrhoids, the pain at stool is characteristic. Sometimes in all these conditions, and particularly in all inflammations of the large intestine, but most pronounced in dysentery, there is usually painful straining at stool, and pain after it — tenesmus. Whenever there is pain at stool there must be a careful inspection of the anus and pal- pation of the rectum. Involuntary discharges of the bowels, incontinentia alvi, are most frequently dependent upon the cloudiness of intelligence which ac- companies any severe disease ; but they may result from paralysis, particularly in diseases of the spinal cord. If the stools are thin, then incontinence occurs with less loss of intelligence than if they are firm. Slight incontinence manifests itself sometimes by the fact that the patient must hasten to go to stool as soon as he has the impulse. Incontinentia is opposed to reteiitio alvi as regards its neurotic origin. (See Examination of the Nervous System.) Physical and chemical peculiarities of the feces. Assuming an unobstructed passage, the amount of the stools is determined by the quantity and quality of the food taken. In the latter respect it depends upon how much of the food is digested and taken up ; hence, all vegetable foods make copious stools. Also, the quantity of the stools is increased in diarrhoea, because too Httle of the fluid portion of the intestinal contents is taken up. The greatest increase occurs in cholera, from the eff'usion of quantities of fluid into the intestine. Enormous quantities of firm, solid stools may be passed after pro- longed obstipation or serious obstruction. We may form an estimate from the amount of the stools, or of their weight, of the resorption of food, if we know how much of resorbable EXAMINATION OF THE DIGESTIVE APPARATUS. gjl substances the food taken contains, and if we can decide that a par- ticular stool comes from the food taken within the period of observa- tion, by the admixture of substances which give a distinctive color. However, we neglect the addition made to the feces during digestion from the digestive juices. On the one side, there is a too rapid move- ment of the food along the alimentary canal, and, on the other, dis- turbance of the resorption of the food. We learn from the recent investigations of F. Miiller, that in mild enteritis and in mild amyloid degeneration only the fat, but in severe cases of disease of the mucous membrane all the nutritive material, is poorly resorbed ; further, that a deficiency of pancreatic juice makes no special disturbance; defi- ciency of bile and tuberculosis of the lymphatic glands disturb the absorption of fat (see below) ; finally, that absorption is only slightly disturbed by accumulation in the intestinal canal. Co7is{stence, or form. Normally, the stool is firm or mushy. The fact has already been stated, and the reason given, why in diarrhoea the stool is more or less thin, or like thin soup. The stool may really be watery, as in cholera Asiatica, but also in all severe acute cases of enteritis, also in dysentery. The dried fecal balls which are passed with or after obstipation are very hard. The form of firm feces does not have any independent value. Especially the stool which is like the stool of sheep (small, hard balls, about the size of a cherry) is not characteristic of stenosis of the rectum, because it also occurs in ordinary constipation. Band-like flat scybala rather indicates stenosis, more especially compression of the rectum antero-posteriorly. Here may be mentioned the arrangement in layers of the thin and the mushy stools which not infrequently are met with. In these the firm portions settle so that the upper part of the stool consists of a clear watery layer. This is the kind of stool we have in typhus, but we also have it in other thin stools, and it is very commonly a result of the admixture of urine. Odor of the stools. The variations from the normal fecal odor not infrequently have distinct diagnostic value. In nursing children a slightly sour odor is normal. The alcohol-stool is offensive, but does not always really have a foul odor. An odor like sebacic acid (with acid reaction* from acid fermentation) is peculiar to the slight forms of infantile diarrhoea. A 372 SPECIAL DIAGNOSIS. decidedly foul smell (putrid albumin, alkaline fermentation) belongs to severe forms of this disease. The stools of cholera and dysentery often smell flat, like semen (cadaverin, Brieger). Cadaverous, foul, stinking stools characterize gangrenous dysentery, carcinomatous or syphilitic ulceration of the rectum. When blood or pus is mixed with the stool in considerable quantities the fecal odor may be masked and replaced by a mild, stale odor. Often the stool is ammoniacal, from admixture with urine which has decomposed. Reaction of the stools. Only in children, particularly nurslings (in whom it is noi'mally slightly acid) is the reaction diagnostic, and gives important indications for treatment. Decided acid reaction is observed in acid fermentation in the intestinal canal ; alkaline reac- tion in alkaline fermentation with putrid albumin. In both condi- tions there is intestinal catarrh. Color, constituents, admixtures of the stools, so far as they can be recognized by the naked eye. The normal color of the stools varies from bright- to blackish-brown. It is in part due to the addition of bile (that is, products of decomposition of the coloring matter of the bile, particularly hydrobilirubin), and partly to the food. By the latter, the stool may be unusually colored, as by huckleberries, which color it black, and may be confounded with blood. In the normal stool, portions of food can be recognized with the naked eye, if things* that cannot be digested — like cherry-stones, particles of wood, etc. — have been swallowed. We also see grape- seeds, the skin of many kinds of fruit, etc. Large fibres of con- nective-tissue, undigested portions of grains, mushrooms, etc., may sometimes be met with in the stools, if the patient has eaten rapidly or has swallowed his food in quantities. With the naked eye, we can see fibres and pieces of undigested substances, the old designa- tion for which was lientery, like portions of muscle, flocks of casein, in the stools of children ; sometimes somewhat friable, perhaps slimy ; or even portions of starch. All of these indicate disturbance of digestion in the small intestine, or also in the stomach, as is seen in intestinal catarrh, or catarrh of the stomach, or in the dyspepsia of fever, with increased peristalsis. In the rare condition of communication between the stomach and colon (perforating ulcer of the stomach), Ave find the coarsest admix- ture of digestible portions of food in the stool. EXAMINATION OF THE DIGESTIVE APPARATUS. 373 Occasionally, extraordinary forms of remains of vegetables (orange- like, etc.) have given rise to mistake. With children, hystei'ical persons, and imbeciles, we must be prepared for all sorts of pre- posterous foreign bodies in the stools. The stools of nurslings and of adults who ILve upon milk illustrate the appearance of the stool "when colored only by bile-pigment. Firm stools are generally darker than thin ones, because more concentrated. In severe diarrhoea, but especially in cholera, dysentery, also severe enteritis, after the first evacuations have swept out the intestinal con- tents, the stools always become brighter, afterward grayish-white and watery, or, in dysentery, colored by blood, etc. When there is diminished flow of bile into the intestine, as occurs in hepatogenous icterus, the stools are lighter. If the bile is cut off, they are grayish-white, clayey, and faintly glistening. This is due not alone to the want of the transformation of the bile-pigment, but also, it would seem, chiefly to the large amount of fat in the so-called alcoholic stools. The increased amount of fat, in turn, shows dimin- ished digestion of the fat, due to the deficiency of bile. We designate as bilious stools those which contain the coloring- matter of the bile unchanged. A quick passage of the contents of the intestine, and profuse diarrhoea, always bring about this kind of stool. We see it most frequently in acute intestinal catarrh, especi- ally in children ; perhaps there is here also an increased effusion of bile. The bilious stool is bright-yellow, green-yellow, or green, and has the reaction of the coloring-matter of the bile. We filter it, and treat the filtrate as we do when testing for bile in the urine (which see). Mucous stool. When mucus can be distinctly recognized in the evacuations of the bowels, it always indicates catarrh of the mucous membrane of the intestine, and hence something pathological ; though in many cases the disturbance in the intestines may be regarded as without significance. There are unnoticeable transitions from the normal secretion of mucus by the intestine to a decided stimulation by chemical or mechanical irritation, even to a true enteritis. Nothnagel considers that small, visible particles of mucus interspersed in firm stools, belong to a normal condition. Larger masses of mucus, in the form of more or less thick shreds, always indicate with greater probability a catarrh of the large intestine. 374 SPECIAL DIAGNOSIS. Certain small, roundish particles of mucus, like sago granules, must usually come from this portion of the intestine. Catarrh of the large intestine then can be definitely diagnosed from the stools, if firm fecal balls are passed which are covered with mucus. Sometimes we find spread over the scybala a layer of thick, tough mucus. An abundant admixture of mucus in thin stools occurs, especially in acute intestinal catarrh, if the large intestine is also affected, and in catarrhal dysentery. We designate as intestinal infarction cylindrical tubes which consist entirely of mucus (or partly of fibrine), and which form casts of the large intestine. In rare cases they occur in chronic catarrh of the large intestine, and are usually passed with great pain (mucous colic). If there are fine and equal portions of mucus in solid fecal balls, we then think of catarrh of the small intestine. But, also, mucus occurring in thin stools may have its origin in the small intestine. Then it is usually finely divided, and is soft. In cholera Asiatica (also in cholera morbus) the stools are watery, and contain particles of mucus which look like boiled rice (rice-water stools). Nothnagel utters a warning against regarding all small, slimy-look- ing particles in the stools as mucus. They may come from the food. The chemical reaction determines in a doubtful case. Watery stools. To these we have already referred repeatedly. They occur in severe acute intestinal catarrh, in dysentery, and in cholera Asiatica, and express profuse diarrhoea, by which the intestinal contents are completely expelled. Even bile, or its transition products, are not usually found in watery stools. Fatty stool. This is usually recognized by its slightly glistening, and its greasy look. When there is much fat, the stools are clayey- looking, or whitish, even when the bile is not cut off from the intes- tine. When the stool contains considerable fat, moreover, it has the peculiarity of becoming softer and more glistening with the eleva- tion of the temperature of the body. For further regarding fatty stool and its occurrence, see under Microscopical Examination. Bloody stool. This has an extremely variable appearance, dependent upon the more or less change in the blood, and whether it is not at all, or is intimately, mixed with the feces. When firm scybala are covered over with blood, it indicates hemor- rhage of the rectum, or large intestine. If the blood does not look EXAMINATION OF THE DIGESTIVE APPARATUS. 375 at all changed, it is from the rectum or anus. When there is an admixture of blood with thin stools, if the blood retains its color, and is not intimately mixed with feces, mucus, or pus, it points with tolerable certainty to the large intestine or anus. However, there may be intimate mixture of blood even in hemorrhage from the large intestine, and in watery stools, as in meat-juice stools in dysentery, and in severe catarrh of the large intestine in children. Hemorrhage of the large intestine occurs most frequently with hemorrhoids in the lower portion of the rectum, carcinomatous ulcera- tion, again chiefly from the rectum, and in other ulcerations of the large intestine of any kind, as in dysentery. When the blood is intimately mixed with the feces, it indicates hemorrhage from the small intestine or from the stomach. Besides, in this case the blood is usually more or less changed, brownish-red, even deep-black, the color of tar, from breaking up of the red corpuscles and of haemoglobin (formation of sulphate of iron ?). The degree of change which the blood undergoes depends upon the length of time it has been in the intestinal canal, and the way in which it is mixed with the feces. There is the least change, the blood sometimes remaining red, with preservation of the red corpuscles, when a large quantity of blood from the lower part of the ileum passes quickly into the colon, because of existing diarrhoea. This happens with the profuse hemorrhage of the bowels in typhus abdominalis. Blood which comes from the stomach, duodenum (in ulcer of the stomach, ulcus duodenale) becomes as black as tar before it is evacu- ated, because of its slow transit and the usual absence of diarrhoea. Moreover, with gastric hemorrhage, the blood may appear in the stool like coffee-grounds (see above, p. 363). In most cases, in order to prove the existence of blood, it does not suffice merely to examine with the naked eye. Then we employ the microscope to make out the red blood-corpuscles, and if they are broken up, then it is necessary to test for hsemin. (See above, p. 363.) 1, We have already repeatedly spoken of the importance of giving continued attention to the stools whenever there is a suspicion of hemorrhage in the alimentary canal. This obtains particularly with ulcer of the stomach or duodenum. 2. It is evident that any blood which reaches the stomach, having its origin in the oesophagus, or coming from farther up and being swallowed, 376 SPECIAL DIAGNOSIS. may appear in the stools (see examination of the nose, expectoration, oesophagus). Purulent stools. A considerable quantity of pure pus is not so very rare, happening as a sign of a rupture somewhere of a collection of pus (generally of a parametric exudation) into the intestines, especially the rectum. Therefore, whenever there is a febrile affection of the abdomen, where the formation of the pus is either made out, or at least is thought to be possible, we ought always, but especially if there has been a sudden decline of the fever, carefully to examine the stools as well as the urine (which see). Moreover, dysenteric, catarrhal, syphilitic, and carcinomatous, ulcera- tions of the large intestine produce some, or possibly considerable, accumulation of pus, according to their extent ; likewise, periproctitic abscesses. Gall-stones, enteroliths. The former come either from the gall- bladder or the intrahepatic gall-passages (intrahepatic stones, much smaller than the others, rare) through the ductus choledochus, and, as they come into the intestine, often produce severe colic and jaundice. Whenever there is abdominal colic, particularly if it is connected with jaundice, and generally whenever there is jaundice, we must look out for gall-stones in the stools. In rare cases, if there is suppuration of the gall-bladder, they come from the gall-bladder, there being adhesion with the colon, into which they break, and thus directly reach the intestine. When we are looking for gall-stones the stool must be passed through a sieve. If it is formed or mushy, it must be broken up by pouring a stream of water upou it. The gall-stones are generally very easily recognized by their shining appearance, smooth surface, and many angled (facets) form. Small, especially intrahepatic, stones may not have facets, and be more crumbling. They consist chiefly of cholesterin, and also contain coloring matter of the bile. Enteroliths are rare. They usually come from the vermiform appendix, and their centre commonly consists of solid, undigested portions of food, as a cherry-stone, around which have been deposited some lime or magnesium salts. Portions of tissue from the intestinal canal. In very rare cases, when there is invagination of the intestine, the whole of the portion that is turned in sloughs off, the intestine forming new adhesions, EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 377 and thus life is preserved. This entire piece may appear in the stool. Shreds of mucous membrane from the large intestine in. dysentery, portions of tissue of carcinoma, or other new formations, m-ay appear in the stools. Animal parasites. In what follows it will be shown that some of the animal parasites that exist in the human alimentary canal have no pathological significance ; others, on the other hand, are very important factors as excitors of disease. The examination for these latter or for their eggs cannot be made too frequently, or too carefully. An examination of the stools for parasites must be undertaken not alone when there are complaints or symptoms which directly indicate intestinal parasites, or in general when there are evidences of intes- tinal catarrh, but in anv case of ansemia, when there is anv o-eneral nervous depression, in certain other phenomena of the nervous system (see works upon pathology), if the cause of the particular complaint does not appear to be clear. The cases are numberless where, after long fruitless search elsewhere, the discovery of a joint of a tape- worm, for instance, leads to the correct apprehension and treatment of the patient. In order not to separate what belongs together, we collect here all that is to be said regarding the occurrence of intestinal animal para- sites and their eggs in the stools, whether in the examination we employ the naked eye, the simple or the compound microscope. Tape-iuorm (cestodes). Its habitat is exclusively the small intes- tine. It gives rise to very great pathological disturbances (intestinal catarrh,, anaemia, nervous manifestations of varying severity). It consists of a very small head and neck, and a ribbon of flat joints (proglottides), several meters long, which constantly push off at the end of the worm, and grow again from above. It clings to the wall of CO o the intestine by its head. It can be recognized by a single joint, which can easily be seen with the naked eye, or by the presence of eggs in the stools (micro- scopical examination). 1. Tcenia solium. This is 2 or -3 meters long. Its head is the size of the head of a pin, glistening gray : the rest of the worm is white, or yellowish-white. Upon the head are four pigmented suck- ing cups (to be seen with a simple microscope), which surround a crown of chitin hooks, " crown of hooks." The ripe proglottides — 378 SPECIAL DIAGNOSIS. that is, those on the lower end of the worm — are about 10 nam. long, 5 or 6 mm. broad, and are like gourd-seeds (but are smaller). From the peculiarity of these ripe joints, which are continuously thrown off and passed with the stool, we are able to make the differential diagnosis Fig. 95. Fig. 96. Fig. 94. — Taenia solium, head enlarged. (Heller.) Fig. 95. — Taenia solium. Rif)e joint, magnified 6 times. (Hellee.) Fig. 96. — Egg of taenia solium. (Heller.) between this and the other tape-worms. The joints show a longitu- dinal canal (the uterus), from which, toward both sides, as many as a dozen branches go off which ramify like the branches of a tree. The eggs of T. solium (which require the use of a moderate micro- scopic power in order to find them, stronger to examine them care- fully) are round, and, if they are ripe, have very thick shells (which show radiating lines, and which, with a little pressure upon the cov- ering glass, break into hard pieces. In the finely granular contents we often see a few chitin hooks. 2. The Tcenia mediocaneUata, seu snginata, grows to 4 or 5 meters. The head is somewhat larger than that of the solium, is also more strongly pigmented. It has no crown of hooks, but four sucking cups, which are much stronger than those of the solium. On the whole, the rest of the worm, as respects its individual joints, is fatter and thicker than the first-named. The ripe proglottides are passed, not only by the stool, but Avander independently from the anus, having strong, very energetic, independent movements. They are distin- guished from the T. solium in that the uterus gives off more and finer branches on each side, which divide dichotomouslv. EXAMINATION OF THE DIGESTIVE APPARATUS. 379 The egg of the T. mediocanellata looks extremely like that of the T. solium., except that on the average it is soniewhat larger. Fig. 97. Fig. 98. Fig. 1 Fig. 97.— Taenia mediocanellata. Head darkly pigmented. (Heller.) Fig. 98. — Tffinia mediocanellata. Eipe joint, magnified 6 times. (Heller.) Fig. 99. — Egg of taenia mediocanellata. (Heller. j 3. Bothriocephalus lata (sinus head) is found in Germany, only in the neighborhood of the North and East Seas, of Lake Geneva, and in Northwestern Russia [Sweden, Poland, Belgium, Holland. Fig. 100. Fig. 101. Fig. 102. Fig. 103. Fig. 100. — Head of bothriocephalus latus. (Heller.) Fig. 101.— Ripe joint of bothriocephalus latus enlarged six times. (Heller.) Fig. 102. — Egg of bothriocephalus latus. (Hellkr.) Fig. 10.3.— Egg of bothriocephalus latus, with developed embryo. (Leuckart.) " Low-lying damp regions near the borders of seas and lakes are those in which it is most often abundant."] It is the largest of the tape- 380 SPECIAL DIAGNOSIS. worms, and reaches to 7 or 8 meters in length. Its head is elongated, and has two narrow, long-drawn out sucking cups. The illustration shows its form and the shape of the uterus. The ripe joints are not given oif singly, but a large piece of the worm is always passed at one time, and then, after a long interval, another ; most frequently in the spring and fall. For this reason we here refer to the finding of the eggs (which are always present in the stools). They are oval (see Fig 102), and much larger than those of two other kinds of tape-worm. The shell is bright brown, relatively thin, and, on one end of the oval, has an opening which is closed with a cover of exactly the same kind. The contents of the egg are granular. As has recently become known, the bothriocephalus gives rise to severe anaemia, with changes in the blood like those in severe per- nicious anaemia ; for this reason, and because there are no joints thrown off, this tape-worm is very easily overlooked for a long time. 4. Tcenia cucume7'ina, 5-20 cm. long, 2 mm. wide; the head is somewhat long, and has sixty hooks; the last joints are reddish, and have the form of pumpkin seed. Six to fifteen of the eggs lie together in the so-called cocoon. It occurs in dogs, cats, and not infrequently in men, especially children (Leuckart). Its pathological significance is not known. (See Fig. 104.) Fig. ] 04. Tasnia cucumerina (Birch-Hirschfeld). a, joint, natural size ,• b, enlarged 12 times; c, cocoon, enlarged 290 times. Hound worms — Ascaris lumbricoides. This is easily recognized from its likeness to the common earth-worm. Its habitat is the small intestine. Very frequently it gives rise to little or no complaint, but it sometimes, and especially in children, causes very uncomfortable phenomena of all sorts, particularly of the nervous system. Occa- sionally, when there is severe vomiting [and sometimes when there EXAMINATION OF THE DIGESTIVE APPARATUS. 381 has not been any vomiting at all], it gets into the stomach and is then vomited. ^Moreover, it may crawl into the ductus choledochus, and thus cause obstinate jaundice. These worms appear in the stools ; and sometimes, in sleep, they will crawl out of the anus. They are said sometimes to come out of the mouth and nose while the person is sleeping. The fresh eggs of the ascaris lumbricoides have a verv peculiar appearance, since its chitin capsule is covered with an uneven, as it were, humped albuminous envelope. (See Fig. 105.) Fig. 105. Fig. 108. Fig. 105. — Ascaris lumbricoides (Jaksch). a, -worm natural size; b, head; c, egg. Fig. 106. — Oxyuris vermicularis. Xatural size. 1, female; 2^ males. Fig. 107. — Egg of oxyuris vermicularis (enlarged). Fig. 108. — Oxyuris vermicularis, enlarged, a, ripe, but unimpregnated female; b, male ; c, female containing eggs. 382 SPECIA L DIA GSOSIS. Oxyuris vermicularis is a small, white worm (Fig. 106) found particularly in the large intestine. It may wander from the anus into the vagina. It has very slight pathological significance. It appears in the stools, and also it is not infrequently found by itself in the neighborhood of the anus. When first passed, it has usually very lively peculiar movements. The eggs are commonly unsymmetrical. (See Fig. 107.) Anchylostoma duodenale, very like the last in form, but often longer, even twice as long ; usually inhabits the upper part of the small intestine, especially the duodenum. Formerly it was only observed in other countries [discovered by Dubini in 1838, in northern Italy], more recently also in Switzerland ■ first during the building of the St. Gothard tunnel), and finally it was noticed among brickmakers. Because it continually sucks blood from the wall of the intestine, it causes severe, sometimes fatal, anaemia (anchylostomiasis, formerly '•Egyptian-chlorosis," Griesinger). It is difficult to discover the worms in the stools unless some vermifuge is used, but, on the other hand, the tolerably characteristic eggs are always present. They are as large as, or perhaps a little larger than, those of Fig. 109. i a Anchylostoma duodenale (J AKSCH). a, male: h, female, natural size ; c, male; d, female, slightly magnified; e, head; /, egg. the oxyuris. They have a thick covering, and contain two or more segmentation globules. By allowing the stool to stand for several EXAMiyATION OF THE DIGESTIVE APPARATUS. 383 days in a "warm place, Ave can see the embryos develop in the eggs. In this very serious disease the stools often contain blood. Besides the intestinal parasites already mentioned, there are the following, part of which are pathologically unimportant, and others are very rare : Tricocephalus dispar. Its habitat is the colon, especially the c^cum. It is of no importance. Both the worms and eggs are highly characteristic in form. (See Figs. 110 and 111.) FiG.no Ftg. in. Fig. 110. — Triehoceohalus dispar, natural size. (Hellee.) Fig. 111. — Egg of trichocephalus dispar, moderately enlarged. TricJiina spiralis. It very rarely occurs in the intestine, but some- times in the first stage of the trichinosis, the stomach-stage, with intestinal phenomena, it is found in the stools. Since the early recog- nition of trichinosis is of the greatest importance, in a suspicious case the stool is to be examined with the greatest care, best after the adminis- tration of an aperient. The appearance of the intestinal trichina is shown in Fig. 112. It is only one- third as long as the oxyuris, and hence cannot be seen with the naked eye. Distoma hepaticum and D. lanceolatum, two rare, but pathologi- cally important, parasites, which inhabit the gall-passages of the liver, sometimes make themselves known by their eggs, which, passing out into the intestine with the bile, appear in the stools. The egg of the D. hepaticum is much larger than the other parasites previously men- tioned, about three times as large as those of ascaris lumb. The egg of the D. lanceolatum is somewhat smaller than that of the oxyuris. For its other characteristics see Fig. 114. Infusoria of very great variety of species are found in the stools of all kinds of diarrhoea: in acute and chronic intestinal catarrh, in 384 SPECIAL DIAGXOSIS. typhoid fever, in tuberculosis of the intestine. Immediately after the evacuation of the bowels they manifest very active movement. Their pathological and diagnostic significance are both negative. Fig. 112. Fig. 113. Fig. 112. — Adult intestinal trichina, human. Male, female, and two embryos slightly magnified. (Biech-Hirschfeld.) Fig. 113. — Trichina (Jaksch.) a, male; b, female intestinal trichina; c, muscle trichina. Fig. 114. — Egg of distoma hepaticum and distoma lanceolatum. (Heller.) EXAMINATION OF THE DIGESTIVE APPARATUS. 385 Microscopic examination of the feces. Thin, or thin-mushy stools, are examined without making any addition to them. To thick, mushy, or solid stools, about a half per cent, of solution of salt is added ; and the solid portions must, of course, be broken up. Somewhat of a selec- FiG. 1]5. SirP''' Monads from the feces (Jaksch). a, tricomonas intestinalis; h, cercomonas intes. j c, Amceba coli ; d, paramsecium coli ; e, living monads ; /', dead monads. tion must be made from the different portions of the stool, according to the object of the examination. In what follows are presented the details. The amplification also varies with the object of the exami- FiG. 116. Microscopical constituents of the stools (partly from Jaksch). a, vegetable fragments ; b, muscular fibres; c, white blood-corpuscles; d, saccharomyces j e, microorganisms; J, crystals of triple phosphate ; g, fatty acid crystals. nation. In general, we employ the dry method. When looking for parasites (which have already been described), it is better, on the other hand, to make use of a tolerably strong amplification. 25 386 SPECIAL DIAGNOSIS. 1. Undigested portions of food. These may be found in every stool, and in varying quantities, according to the kind of food eaten. We mostly meet with coverings of vegetable cells, elastic fibres, etc. 2. Portions of digested food. Although these, if visible with the naked eye, indicate disturbed digestion in the small intestine, yet microscopical particles of these substances are seen in small quantities in normal stool, as well as small portions of muscular fibre, with the transverse striations, shreds of connective tissue, starch granules, and fat. But considerable quantities of the substances named always indicate disturbed digestion either in the small intestine or the stomach, and hence have the same significance as the occurrence of larger pieces, which can be seen without being magnified. When the microscopical particles are colored a bright yellow, as we commonly see small por- tions, particularly of muscular tissue, but sometimes almost all the solid portions of the stools, it shows that there is unchanged bile in the stool, and catarrh of the small intestine. Fat, in the shape of polygonal glassy lumps, of needle-shaped crystals, and also in the form of drops, is a very frequent constituent of the stools. The glassy lumps occur very frequently in health, and are often colored yellow or yellowish-red. They are recognized as fat, fatty acids, or soap, by their transformation upon the addition of sulphuric acid, and, when warmed, into drops of fat (Miiller). Drops of fat occur in the stools with milk-diet (hence, particularly in those of children), when taking cod-liver oil, likewise castor-oil, and, if there is intestinal catarrh, then in very considerable amount. The needles of fat have pathological significance. They sometimes occur singly, and, again, in bundles and druses. They are changed by simply warming them, or by the addition of acid and then warm- ing, into drops of fat, and this takes place whether they consist of fatty acids or (lime-) soap. When there are great numbers of fat-needles, it is a pathological sign of disturbance of the resorption of fat, as may result from shutting off of the bile from the intestine, from any form of enteritis, of tuberculosis, amyloid degeneration of the intestine, and, lastly, fiom disease of the mesenteric glands. The increase of the fat in the stool is not, as was formerly assumed, characteristic of a want of pancreatic juice (disease of the pancreas, EXAMINATION OF THE DIGESTIVE APPARATUS. 387 closure of the ductus Wirtungianus). As a matter of fact, the absence of pancreatic juice does not seem to hinder the resorption of fat (Miiller). Detritus. The amount of detritus in the stools is very great, because Ave cannot determine separately the amount of kernels, husks, etc. 3. Additions to the stools from the alimentary canal. A micro- scopical quantity of mucus occurs in the stools of persons in health. Small glassy lumps of mucus may also be present, which come from the cells of plants. Usually the examination with the naked eye is sufficient to determine whether there is a pathological admixture of mucus. It is necessary only to mention that a firm stool, abundantly inter- spersed with small light lumps of mucus, is observed with intestinal catarrh (Nothnagel). In these cases, we can generally discover the mucus, if we carefully examine, without any artificial aid. Epithelium. Some cylindrical cells, often mucous metamorphosis, are a frequent occuiTcnce, If the quantity is large, it indicates intestinal catarrh. Very abundant cylindrical epithelium occurs in chronic catarrh of the large intestine, especially in mucous colic, in this case caused by mucous " infarction." It has already been men- tioned that regular shreds of mucous membrane are found in the stools, also portions of tissue. Red and white blood-corpuseles. These are present in quantiti.es in fresh bloody, and in purulent, stools. When seen but once, they do not huve significance. 4. Crystals. Except the fat crystals mentioned above, there are almost no crystals which are brought into requisition for the purposes of diagnosis. Crystals of ammoniaco-magnesian phosphate (see these under the examination of the urine), no doubt, occur in the stools in enteritis and abdominal typhus. But they may also be found in any other stools, if they are not kept separate from the urine and stand for a long time. Lime-salts of all kinds, partly with inorganic, partly with organic, acids, in the form of wedges, dumb-bells, needles, etc., sometimes colored an intense yellow by the bile in the stool, have no diagnostic import. Charcot's crystals, in appearance and probably also chemically 388 SPECIAL DIAGNOSIS. entirely agreeing with the Charcot-Lejden crystals of asthma, are observed in rare cases of dysentery, typhus abdominalis, intestinal tuberculosis, anchylostomiasis. 5. Vegetable parasites. We may divide the large number of vegetable microorganisms which we find in the stools, from the stand- point of clinical diagnosis, into two classes : (a) Those which, primarily, for clinical diagnosis are only of sub- ordinate significance, because we do not know that they have any definite connection with any diseases. Here, also, we class those which are indirectly harmful — that is, they cause abnormal decom- position of the intestinal contents. This class is extremely numerous, and great numbers of one kind or another are present in every stool. The knowledge of the different kinds has recently been greatly extended by the important labors of Xothnagel, Bienstock, Escherich, and others. But the point has not yet been reached which makes them as available, for clinical diagnosis, as the other peculiarities of the stools. For this reason we will treat of them only very briefly here. Of the fungus-spores we have (very rarely) that of thrush in children who are suffering from thrush in the mouth. Germi- nating fungus, and, indeed, the different kinds of torula cerevisise (see Fig. 116, d), occasionally occur in all stools, especially in the milk-stools of children. In intestinal dyspepsia with acid fer- mentation they are generally more abundant than in normal diges- tion. But the schizomycetes belong to the numberless micro- organisms which are seen in every microscopical preparation of the stools, whether normal or pathological. Of chief importance are the micrococci and bacilli. A very large part of these are colored yellow or brownish with iodine and iodide of potassium ; others are colored by the same reagent blue or violet (Xothnagel). These latter, according to Jaksch, are increased in intestinal catarrh. "We are already able to conclude that the knowledge of these intestinal bacteria furnish diagnostic indications of anomalies in intestinal digestion, and that . the different kinds of bacilli possess extraordinary biological peculiarities. Some require for their rapid development a neutral or slightly alkaline reaction, while others an acid reaction, of the intestinal contents ; some are aerobiotic, others EXAMINATION OF THE DIGESTIVE APPARATUS. 389 anaerobiotic ; and while some have the power to transform starch into sugar, others cause the decomposition of albumin. {b) Pathogenic fungi. These we are able to isolate, and from them diagnosticate the disease they cause, as the tubercle-bacillus in the sputum. Here, also, belong the pathogenic schizomycetes. These are : Koch's cholera bacillus, the bacilli of typhus and tubercle. Cholera bacilli (comma bacilli) are the pathognomonic sign of Asiatic cholera. They are short, more or less crooked rods, which are sometimes connected one to another in such a way as to form " spirals," like a screw. The curve may be very slight, even want- ing: or marked, even semicircular. In general, they are shorter, but thicker, than the bacilli of tubercle. Fig. T17. Fig. 118. Comma bacillus, pure culture (prepared by Prof. Gartner). Zeiss's immersion lens one-twelfth, eye-piece No. 2, camera lucida. Magnified aboht 600 times. // ..-'-tt 11: 1- 1/ I i' Cholera dejections upon a damp sheet. (Two days old.) a, S-form bacilli, 600 : 1. (Koch.) Habitat : mode of preparation. They are particularly found in the free mucous floccules of rice-water stools, also very abundantly upon the linen soiled by the dejections, and, indeed, here after two or three days, provided the linen has been kept moist. A mucous floccule (or a drop of the stools), or some of the deposit on the linen, is placed upon a covering-glass. First dry it in the air, then pass it 390 SPECIAL DIAGNOSIS. two or three times through the flame of a spirit-lamp, and stain it ■with methylene-blue or fuchsin by warming it one to five minutes. These bacilli have been found, we may say, constantly in the stools of Asiatic cholera by a great many other examiners besides Koch, and they are found in no other stools. They must, therefore, diagnostically be of pathognomonic value to even those who doubt Koch's teachings concerning their pathogenic character. Covering-glass preparation of a mucous floccule in Asiatic cholera. Zeiss's homogeneous immersion one-twelfth, eye-piece No. 2, drawn by a camera lucida. Magnified about 650 diameters. But since the morphological peculiarities of the cholera bacillus in the microscopical preparation do not furnish an absolutely certain recognition, and, on the other hand, since there is no specific reaction (as with the tubercle-bacillus), in order to determine an isolated case, it is indispensably necessary to establish a pure culture. (See, regarding this, the works upon bacteriology.) Comma bacilli are also, in individual cases, found in the vomit of Asiatic cholera. Morphologically, but not biologically, they are like Tinkler and Prior's spirals of cholera 7iostras, which possibly stand in the same relation to this latter disease that the comma bacillus does to Asiatic EXAMINATION OF THE DIGESTIVE APPARATUS. 39I cholera. They are positively distinguished from the bacilli of Asiatic cholera by pure culture. A bacillus which is morphologically like the comma bacillus occurs in tooth-mucus (Lewis and Miller), and just such an one, also, in old cheese (cheese- spirals, Deneke). Biologically, they differ from Koch's comma bacillus and from each other. Typhus bacillus. These bacilli are regularly found in typhus abdominalis, in the diseased portion of intestine, in the mesenteric glands, the spleen and liver, in the kidneys, and also frequently in the blood (which see). They have also frequently been found in the Fig. 120. Fig. 121. v Spirillum (Finkler and Prior), 700 : 1. Typhus bacillus in pure culture. Zeiss's (Flugge.) homogeneous immersion lens one-twelfth, eye-piece No. 2, drawn with camera lucida. Magnified about 650 times. stools of typhus. But since they are distinguished (just at the end they are rounded ; are about as long as the tubercle bacillus, but are much thicker — about one-third as thick as long) both by their form and by a specific color-reaction from the other bacilli which occur in the stools, their microscopical proof is extremely uncertain ; pure cultures are here much more necessary for the positive determination. The typhus bacillus is best stained with methylene-blue in a dry preparation upon the glass cover. Tubercle bacillus. These are frequently found in tuberculous ulcers of the intestine. It is not yet sufficiently established whether they are always present, chiefly because not infrequently tubercular ulcers of the intestines do not have any symptoms, and particularly do not cause diarrhoea ; and so, often enough, the firm stools are not examined for bacilli. On the other hand, in phthisical patients, the tubercle bacillus is sometimes observed in the stools without there being any intestinal tuberculosis. They come from swallowing tuberculous sputum. CHAPTER YII. EXAMINATION OF THE URINARY APPARATUS. This comprises the examination of the urinary organs themselves and the examination of the urine. Indeed, in very many cases, the latter examination only is made, or it forms the chief part, whether in its relation as being the secretion of the kidneys, or whether it be in reference to admixtures or alterations of the urine, which occur in the course of its transit through the urinary passages. The local examination of the urinary organs is now not often required, but if it is, tlie result of the examination generally confirms the diagnosis. This direct examination, therefore, ought never to be neglected. Moreover, where the kidneys themselves are diseased there come into consideration certain resulting phenomena in the different organs of the body. Examination of the Kidneys. Anatomy. The kidneys, about 10 to 12 cm. long, about 5 cm. broad, of well- known form — lie upon the two sides of the spinal column, upon the anterior surfiice of the quadratus lumborum muscle and tlie lumbar portion of the diaphragm, and reach from the level of the twelfth dorsal vertebra to the level of the second or third lumbar vertebra. The lower portions diverge somewhat downward, and hence lie with their lower ends somewhat further fi'om the median line of the body (about three fingers' breadth) than the upper ends (about two fingers' breadth). The right kidney is a little lower down than the left. The upper half of both kidneys is covered by the eleventh and twelfth ribs, the extreme upper portion also by the complementary pleural sinus (see Fig. 122); hence, the lower border of the lungs does not extend as low down as the kidneys. It is very important to note that the outer border of both kidneys corresponds tolerably exactly (392) EXAMINATION OF THE URINARY APPARATUS. 393 Tvith the outer border of the thick fleshy layer of the sacro-spinalis muscle. The left kidney at its upper end, rather by its suprarenal capsule, is in contact with the spleen ; the right kidney, with the under surface of the liver. Both organs encroach upon the upper end of the kidney of their respective sides, like the tiles of a roof (see Fig. 122). The figure also furnishes information regarding the so-called spleen-kidney and liver-kidney angle. Fig. 122. Anatomical situationof the kidneys. (Weil.) a, rf, borders of the lungs; c, e, limits of the pleural sacs; /, angle between the spleen and kidney; ^r, angle between the liver and kidney. The superior surface of each kidney is covered by the parietal peritoneum, and in front of it lies the ascending or descending colon. The anterior inner border of the right kidney is not far from the ductus choledochus and the duodenum. In the rare condition known as horseshoe-kidney, the lower ends of 394 SPECIAL DIAGNOSIS. the two kidneys are connected by a transverse band consisting of kidney-parenchyma. This transverse portion passes, like a bridge, across the aorta and the spine, about on a level with the second lumbar vertebra. Local Examination of the Kidneys. In every respect its result is almost negative. The normal kidney, of course, cannot be inspected. In remarkably exceptional cases we may, by employing bimanual palpation, Avith the legs drawn well up (one hand being placed behind in the lumbar region and the other pressing deeply in front), get some information, provided the abdominal covering is very unusually lax and thin, and the stomach is empty. Of late, percussion of the kidneys has very rightly come more and more into discredit. It must be perfectly evident to every one that it is impossible to point out the normal kidneys, or even moderately enlarged ones, if he remembers that the kidney is less voluminous than the spleen; that, moreover, it lies much less favorably ; and, besides, if he takes into consideration how often the normal spleen is with difficulty, or cannot at all, be made out. The kidney is unfavorably located for percussion, because the sacro-spinalis muscle (of considerable mass) lies over it, but especially for the reason that its lateral border almost exactly corresponds with the convex border of the kidney. So we cannot with certainty determine whether the kidney lies under the muscle, nor where its limits are. Individual exceptional cases, where very thin or atrophic sacro- spinalis muscles permit of percussion of the kidneys, may nevertheless occur, as the cases mentioned above, where the normal kidneys can be felt. But we cannot consider the result of percussion of the kidneys as of great value. Pathological Conditions of the Kidneys. Inspection. The kidney can only be inspected when it is very much enlarged, or enlarged and displaced. Tumors of the kidney may make their appearance in the lumbar region, in the side, and in the lateral anterior portion of the abdomen, near the border of the ribs. According to their nature, they are smooth, roundish, irregular, EXAMINATION OF THE URINARY APPARATUS. 395 or uneven (see Palpation). They do not move with respiration. Their appearance may strikingly vary, but not necessarily so, with the changes of position of the body (the dorsal position, lying down). If the tumor is very large, then it generally presses the colon, ascending or descending, toward the anterior abdominal wall, and then the colon, according to the amount of its distention, may lie up against the abdominal wall (see Palpation). If the kidney is the seat of a tumor, it very often departs from its place high up against the diaphragm, and becomes the so-called wandering kidney. In this case it is much easier seen from in front. A normal kidney wandering so much as to be visible, is a curiosity (Bartels). A roundish, symmetrical swelling, located in the dorsum in the region of the kidney, or somewhat sidewise from it, points to purulent perinephritis. Sometimes it extends upward in the abdominal cavity, from the diaphragm being pushed up. Often there is oedema of the skin at the spot (deep formation of pus, see p. 52), or there may be inflammatory redness. Moreover, abscess, due to the congestion accompanying caries of the spine, may break here. Also, large peri- nephritic abscesses have been seen as tumors above the border of Poupart's ligament in the iliac region. Palpation. This is most important in the local examination of the kidneys. We employ it in the dorsal position with the knees well drawn up, but sometimes also in the abdominal position. In both cases, we always first examine bimanually, one hand being upon the region of the kidney and the other upon the abdomen. Tenderness upon pressure occurs : sometimes in acute, almost never in chronic, nephritis ; also in tumor of the hidney, stone in the pelvis of the kidney, in case it excites inflammation ; in inflammatory hydronephrosis, and in perinephritis (here there is often very great sensibility). When the kidney is enlarged from engorgement, amyloid disease, or nephritis (large white kidney), it is never perceptible to palpation except it leave its place (wandering kidney), or we have one of the exceptional cases in which even a kidney of normal size and location can be felt (see above, Local Examination of the Kidney). Very large new formations, as carcinoma, sarcoma, hydro- and pyo-nephro- sis, echinococcus, and perinephritis, only are palpable. The tumor 396 SPECIAL DIAGNOSIS. can be felt in one side of the lumbar region, or at one side of the anterior abdominal region. With new formations it is usually uneven ; in hydronephrosis, smoothly round, more or less tense, under some circumstances fluctuation can be distinctly made out. Echinococcus is usually smooth and tensely elastic ; it may show hydatid buzzing (see above, p. 326). It is important to remember that tumor of the kidney is only very rarely movable upon pressure (for if it descends, then we have a wandering kidney). We have never seen a case where one moved with respiration ; but it seems that in some cases there is this move- ment. At any rate, the absence of respiratory movement points to the kidney, and especially against the spleen or a tumor fixed to the liver. In a considerable number of cases it will be found that the ascend- ing and descending colon is in front of the kidney-tumor and pressed by it against the abdominal wall. In these cases, this fact has great value for dififerential diagnosis. In other cases, the tumor will be found lying exactly in the median line, and then it is of significance for differential diagnosis, especially from ovarian tumor. The location of the colon, moreover, is usually only made out with certainty when it can be felt, and particularly when it contains air. It is, therefore, advisable to inflate it (see p. 311). Wandering kidney; movable kidney. By this we understand downward dislocation of the kidney, whether much or little. Almost always only one is dislocated, and this is usually the right one. In these cases the kidney is commonly of normal size, but it may be enlarged, and this is most frequently due to hydronephrosis caused by the bending of the ureter, or also because it is the seat of a new formation. It is generally very easy to recognize a kidney that is very much out of place, but when it is still high up, near the liver or the spleen, it is often very difiiciilt to do so. The diagnosis is based upon the bean-shaped form of the kidney, eventually, upon its being of the appropriate size, and upon its mobility by pressure, which is almost never wanting; also, sometimes, with the changes of position of the body. Not infrequently the kidney can be perfectly replaced. In some cases dyspeptic symptoms, even dilatation of the stomach, also jaundice from engorgement, have been observed when the right EXAMINATION OF THE URINARY APPARATUS. 397 kidney was displaced (from compression of the duodenum or of the ductus choledochus). Those cases are rarities where the pulse can be felt in the renal artery. Percussion. We employ percussion to establish the existence of tumors of the kidney which give a deadened sound, on account of their solidity ; but they are almost always clearly made out by palpation. Its value in determining dislocation of the kidney was formerly very much over-rated. It was thought that we were able to prove one-sided dislocation of the kidney, because, when the patient was lying upon the abdomen, the resonance of the two sides in the neighborhood of the kidneys was found to be different : clearer upon the side of th« wandering kidney, in contrast with the absolute dulness of the normal side. In our opinion, even in the most favorable cases, such a con- dition cannot be employed for deciding the diagnosis. But, on the other hand, percussion may be of the greatest value, either to determine the relation of a tumor in one side of the abdomen to the colon, or to determine the course of the colon over a tumor of the kidney (see above). In such a case, distending the colon with air is of the greatest assistance. Further, it might possibly occur that a considerable enlargement of the kidney could be made probable (never certain) by an area of dulness upon the back, extending from the region of the kidneys toward the side. Diagnosis of tumor of the kidney. The positive evidence of tumor of the kidney has just been spoken of. We may have to make a dif- ferential diagnosis between a right kidney which is not very much displaced downward and a distended gall-bladder, or an echinococcus located upon the lower surface of the liver. If there is respiratory mobility, this speaks against it being the kidney, but if the tumor can be replaced, even so that it may even disappear, then it speaks for it being the kidney. Both wandering kidney and a pedunculated echi- nococcus may be easily movable upon pressure. It may often be impossible to determine exactly the form of a tumor situated close under the liver. A wandering left kidney is distinguished from a wandering spleen by the form, which is made out by percussing the neighbor- hood of the region of the spleen : in wandering spleen, we may find notches ; if it is the kidney, we may feel the pulse at the hilus. We distmguish tumor of the left kidney from tumor of the spleen by the 398 SPECIAL DIAGNOSIS. form and relation to the colon. Sometimes respiratory mobility decides in favor of the spleen ; but with this it may also be wanting ; while notches on the upper border of the tumor may speak with prob- ability for the spleen, yet in one case, where they could be very dis- tinctly felt, they led us to a false diagnosis ; it was found to be a carcinoma of tlie kidney. We know of one case where a movable tumor of the left side of the abdomen was, by a recognized master of percussion, pronounced a wandering kidney on account of the tympanitic resonance in the region of the left kidney. It was operated upon ; it proved to be a wandering spleen. It was extirpated with permanently favorable result. Examination of the Ureters and Bladder. Simon, by introducing the hand into the rectum, has repeatedly felt of the ureters (see works upon Surgery). Recently Ilager- Kaltenbach and Sanger have proposed, in the case of women, to palpate them per vaginam. We can feel their lower ends where they come down on either side of the neck of the uterus and enter the lower side of the bladder. With some practice often even a normal ureter, but still more one that is thickened, can be felt in the lateral and anterior fornix vagince and the anterior vaginal wall close to the middle line. In this way it is not difficult to recognize thickening or tenderness of one or both kidneys. Both occur in cystopyelitis and in tubercu- losis of the urinary apparatus ; thickening and distention may some- times be observed also in pyelitis calcidosa (renal calculus). The bladder lies behind the symphysis pubis, when ordinarily dis- tended, it rises above it, but only when it is excessively full, as in paralysis of the bladder, spasm of the sphincter, stone in the bladder, stricture of the urethra, does it swell so much as to be noticed (rarely) by inspection ; but especially by palpation and percussion, as a roundish tumor, which, of course, is dull in sound. In men it can also be felt from the rectum. We are able to decide with certainty whether a tumor in the hypogastrium is a distended bladder or not by drawing off the urine with a catheter. It may be confounded with a pregnant uterus, and also with other swellings. Always before undertaking an examination of the abdomen, we must see that the bladder is empty, partly to avoid confounding the distended bladder EXAMINATION OF THE URINARY APPARATUS. 399 with something else, and partly because, if the bladder is full, it inter- feres with the examination of the abdomen. Anomalies located in the wall of the bladder can usually be felt best when the bladder is full. The external examination is made per v'aginam, per rectum, and sometimes bimanually. Surgery and gynecology teach the complicated methods of examining the bladder and ureters. With reference to the examination of the male urethra, tve refer to the lectures and hand-books upon Surgery. Examination of the Urine. Under normal conditions and when free from admixture, the urine, as it issues from the orifice of the urethra, exhibits the renal secretion in a state of purity, since, in its transit through the urinary passages, it receives scarcely any additions from the mucous membrane that are worth mentioning ; and further, since, at the time of its discharge from the body, and for some time after, its physical and chemical conditions are the same as at the moment of secretion. In a number of pathological conditions, also, the urine is the pure and unaltered secretion of the kidneys ; while, in a second series of diseases, it is changed by its exit from the body, and, indeed, by admixtures from the urinary passages, or by decomposition of its constituents in the bladder. To the first series belong the anomalies of the secretion itself; to the second, the diseases of the urinary passages. In women the urine may be contaminated by admixture of material from the vagina or uterus, and of these the most frequent and impor- tant is the menstrual fluid. In order to avoid this contamination, we are sometimes obliged to draw off the urine with the catheter. It is usually contaminated by fecal material only from carelessness of the patient or of the attendant. But sometimes it results from commu- nication of the intestine with the urinary passages, as of the rectum with the bladder or with the vagina. Recent investigations by Lustgarten and Mannaberg show that the former assumption that the urine is normally free from bacteria must be given up. The urine of healthy persons contains a number of micro5rganisms which have their origin in the urethra. The most important are a large streptococcus, a diplococcus which resembles the gonococcus, also like that in epithelium, but, of course, it is not found 400 SPECIAL DIAGNOSIS. in pus-corpuscles, and lastly, a bacillus which morphologically and in its color-reactions agrees with the tubercle bacillus, and which probably is the smegma bacillus, which also occurs in the preputial sac. This latter may give occasion for the erroneous supposition that there is tuberculosis. But that it has its origin in the urethra is shown by the fact that it is observed even when the preputial sac has been most carefully cleaned previous to urination, though it is only found in individual cases, while in cases of tuberculosis it is always abundantly found in the urine. Sometimes inoculation must decide (see Appen- dix). We may avoid the urethral bacillus by drawing the urine with a catheter, but then also, sometimes, possible tubercle bacilli from the prostate or genital apparatus may be found in the urine. In case of disease of one kidney or pelvis of the kidney, the question may arise as to what part of the urine passed is from the right, and what from the left, kidney. If one kidney fxils, the other acts vicari- ously. In tuberculosis of the urinary passage and in pyelitis, it may happen that for a time one ureter is stopped ; the urine comes only from the other kidney, and it may be quite normal. Then, suddenly, the character of the urine will change, showing considerable white blood-corpuscles, seed-like particles, tubercle bacilli, or calculi, and blood. The quantity of urine is, for the time being, increased ; for the closed side has again opened. In certain diseases of the urinary apparatus, the manner of passing the urine shows characteristic peculiarities ; but in many of the conditions under consideration, the urine is passed in a perfectly normal way. Painful strangury, frequent urination, a feeling of burning in the urethra while passing the urine, may result from the urine being much concentrated, such as is passed when there is engorgement of the kidneys, and in the majority of cases of acute nephritis. Very pronounced tenesmus of the bladder — that is, painful urgency, ex- tremely frequent, very painful urination, in which only a small quantity of urine is passed at a time — indicates cystitis. We must mention here, further, retention and incontinence of urine, nocturnal enuresis (regarding these, see under Examination of the Nervous System). In regard to the mode of procedure in examining the urine, let it be here remarked, in the first place, that we should take care that the urine is received in vessels that are perfectly clean — if possible, in EXAMINATION OF THE URINARY APPARATUS. 401 glass vessels ; and, also, that for judging of certain general character- istics, it is necessary to examine the mixed urine passed during twenty-four hours,, or that passed during the day and during the night, separately. For certain examinations it is necessary to separate, in the most careful way, the urine passed each twenty-four hours. In the warm season of the year, the urine ought to be examined as soon as possible after it is passed. In order to examine the sediment, the upper portion of the urine is to be carefully poured off, and the re- maining cloudy portion is put into a conical glass, in which it is allowed to stand till the sediment is deposited ; then we take up a few drops from the bottom of the glass with a pipette. When there is unconsciousness or difficulty in passing the urine, we must employ the catheter. The artificial emptying of the bladder, for the purposes of examination, must never be omitted in any case of unconsciousness. We briefly describe the characteristics of the normal urine. (A) Normal Urine. 1. Amount. In twenty- four hours, with healthy persons, it amounts on the average to about 1500 grms. But its variations within physi- ological limits are very considerable, since every increase in the amount'of water taken increases the amount of the urine, and every increase in the amount of water disposed of in other ways diminishes the urine. In the latter respect, in health we have to consider the loss of water by respiration and by perspiration, from heat and from active bodily exertion. It is superfluous in the cases just referred to to specify the maximal and minimal figures for the amount of the urine; only when those conditions are wanting, must a departure from the average quantity of urine given above cause us to think of a pathological condition. Within the twenty-four hours, the least urine is passed at night, or in the early morning, very much the greater portion being passed during the course of the day. Usually, the amount of urine passed increases about an hour after taking fluid. Emotional excitement, especially anxiety, sometimes temporarily increases the secretion of urine. 2. Color; transparency. In health, the color is usually dark straw- color to reddish-yellow. Generally, the greater the amount of urine 26 402 SPECIAL DIAGNOSIS. the clearer it is. In this respect as well as in the quantity, with phjsiologicallv exceptional cases, it shows marked variations from the average : from being almost as clear as water, after a great amount of fluid has been drunk, to a decidedly dark reddish-yellow (concentrated urine), after severe sweating. The coloring-materials which give the normal color to the urine are not yet all exactly known. The most important pigment seems to be urobilin ; moreover, indican interests the clinician. Both coloring-materials may, in disease, be pathologi- cally increased. (See Pathological Colors of the Urine.) Urine freshly passed is, in health, always perfectly clear and transparent ; but in these respects it may change some time after it has been passed. {a) In almost all normal urine, after standing a short time, there is formed a slight cloud of mucus. This is from the urinary passages, chiefly from the bladder. {h) It not infrequently happens, with healthy persons, that the urine, if somewhat concentrated, is cloudy when it becomes cool from the separation of the uric-acid salts. Gradually, the salts sink down and form a sediment of clear brick-dust red or flesh- color (associated coloring-matter of the urine, brick-dust sediment, lateritious sedi- ment). It has the pecvJiarity — by which it is likewise recognized — that it is again immediately dissolved as soon as the urine is tvarmed. After a long march in the heat, this sediment occurs very regularly, because the urine is then concentrated ; but it also is observed in urine that is not so very dark, if it is allowed to stand in a cool place. (See further regarding the Urinary Sediments, p. 428.) (c) Urine that stands exposed for a long time, both clear and dark, likewise sometimes becomes cloudy, because it undergoes ammoniacal fennentation. The urea is changed into carbonate of ammonia, which makes the urine alkaline, whence there is a deposit of phos- phates (ammonio-magnesian phosphates or triple-phosphates, also phosphate of lime). Urate of ammonia also is fonned and deposited. These separations and numerous bacteria render the urine cloudy and gradually form a whitish sediment. In hot weather this ammoniacal fermentation takes place within a few hours after the urine is passed ; in a cool place, it does not begin before 36 to 48 hours, or not at all. For a more particular account of the condition when there is ammo- niacal fermentation of the urine, see p. 413. EXAMINATION OF THE URINARY APPARATUS. 403 3. Specific gravity. In health it usually varies between 1015 and 1020. It depends upon the amount of solids held in solution by the urine, hence, on the one hand, upon the absolute quantity of the solids, and, on the other, of the amount of the watery portion of the urine, or the quantity of the urine. The abundant urine which follows drinking a great amount of water is always of low specific gravity, and, therefore, clear. A scanty urine, from the loss of water in other ways, is always of high specific gravity, and hence is dark. Then, also, in health the specific gravity, under some circumstances, temporarily oversteps very considerably the figures given above, from as low as 1003 to as high as 1025, or even higher. In the absence of "physiological causes," these figures are always of pathological significance. Mode of procedure : We measure the specific gravity of the urine by means of an areometer graduated for taking the specific gravity of the urine (that is, from 1000 to about 1040, " urometer"). We take a portion of the urine which we wish to weigh (generally a mixture of that which has been passed during the previous twenty-four hours) and pour it into a not too narrow cylindrical glass until the column of urine is longer than the urometer. With filter-paper or a pipette, we remove any air-bubbles from the surface, and then introduce into it a perfectly clean and dry urometer ; wait until it has become quiet, and then observe the figure that stands opposite the lower border of the meniscus of the fluid. None of the simple medical instruments is so often useless as the urometer. ' We should never use one until its accuracy has been tested. It is always desirable to have a urometer upon which is given the temperature for which its scale is arranged ; not that we must always have the urine at this temperature, but because the absence of this requisition from the instrument shows very certainly that it has been prepared without care. 4. Reaction: In general, this is always acid, chiefly from the presence of acid urates and phosphates. The degree of acidity varies individually ; moreover, it is a constant quantity in every individual case of health, and when the food is approximately alike. But in the twenty-four hours the reaction varies considerably, so as to be even alkaline, and yet physiological. The variations proceed in such a way that, after every meal consisting of a mixed diet, the 404 SPECIAL DIAGNOSIS. acidity declines until, after about two hours, it becomes alkalescent — but this quickly passes so as to give place again to an acid reaction (Gorges). These variations have been referred by many to the loss by the body of acids and alkalies in stomach and intestinal digestion. Hence it is assumed that the separation of HCl in the stomach in- creases the alkalescence of the blood, and hence the urine becomes less acid, or alkaline. But, according to recent investigations by Noorden, this increased alkalinity of the blood does not exist. By a graphic representation of the reaction of the urine during twenty-four hours we obtain the so-called " acid-curve." This, with some healthy persons, and under like conditions (as to time and quality of food), is tolerably constant, but with other healthy persons it varies consider- ably. Sometimes the reaction of the urine is amphoteric — that is, it colors red litmus blue, and at the same time colors blue litmus red. The neutral or alkaline urine of health at the time of passing is usually clear. But it quickly becomes cloudy from the withdrawal of the phosphates, which gradually form a sediment. The cloudiness does not disappear upon the application of heat, but becomes more marked : on the other hand, the urine again becomes clear upon adding acetic acid, which dissolves the phosphates. 5. Odor. The normal aromatic odor of urine is well known ; it is changed by certain foods. Most frequent and most striking is the stench of urine after eating asparagus ; garlic gives its odor to the urine. During alkaline fermentation we may have the development of ammonia, which gives its known pungent odor. 6. Sediments. With reference to the cloudiness, the urate sediment of the acid, and the phosphatic sediment of the alkaline urine, have been mentioned on p. 402. (Regarding the microscopical condition of the sediment, see p. 430.) Whenever there is a sediment it is not unimportant to remember that different things may have been mixed Avith the urine after it was passed ; see above, p. 390. 7. The portions in solution. The constituents of normal urine, which, from our present knowledge, are of importance to the clinician, besides the coloring materials, are the following : urea, uric acid, kreatinin, oxalic acid, chloride of sodium, sulphates, phosphates, carbonates. EXAMINATION OF THE URINARY APPARATUS. 405 Urea < COxttt^ > passed in twenty-four hours amounts in the adult to about 30 grammes (men somewhat more, women somewhat less). However, the amount of urea varies within wide limits : it is dependent upon the amount of albuminous material in the food taken, and, on the other hand, it is almost independent of the amount of muscular exertion. Uric acid, like urea, is a product of the metabolism of albu- min ; in man the quantity is much smaller than the former, being in proportion to the urea about as 1 : 45 ; but it is to be remarked that great variations take place, chiefly under the influence of the food ; and this in such a way that albuminous food increases the acidity of the urine. Hence, with reference to clinical diagnosis, the uric acid as well as the kreatinin is chiefly of interest, because they may place difficulties in the way in examining the urine for sugar, in that they sometimes simulate the reaction of sugar. Sometimes, on the other hand, they hinder the reaction of sugar (see under Mellituria). Qhloride of sodium, the most important of the inorganic con- stituents, in health corresponds in amount with tolerable exactness to the amount of salt in the food taken. On the average, it usually is proportioned to the urea as 1 : 2 to 1 : 3. Exceptionally, in health, there is found in the urine : Albumin, the so-called physiological albumin. There is still great difference of opinion regarding this subject ; while it is doubted by some, others maintain (Senator, recently Posner) that traces of albu- min exist in the urine in every healthy person. It occurs in very small quantity (about one per cent.) after severe exertion or hearty eating. The urine of the newly-born not infrequently contains some albumin. Sugar (grape sugar) is observed in individual cases in very small quantities. After partaking freely of cane sugar, this may appear in the urine. Bile acids are likewise observed in very small quantities in normal urine. Fat is recognizable generally only in microscopical drops (or only in ether extract), and is found when the food has contained a great abundance of fat, as of cod- liver oil. 406 SPECIAL DIAGNOSIS. (B) Pathological Urine, Anomalies in the quantity. Increased amount (polyuria) is observed : 1. In a watery condition of the blood, in the different forms of anaemia or hydraemia. The increase here is never very great : 2000 grammes or less ; there may be no increase, and if the heart is weak (see below) it may even be diminished. 2. In the different forms of contracted kidney, and this in conse- quence of the accompanying hypertrophy of the left ventricle, which causes increased pressure in the whole arterial system, and thus also in the renal arteries (here even to 3500 grammes or more). Here the chief cause of the polyuria is the increased arterial pressure from the increased action of the heart (see below). 3. In diabetes. Both diabetes insipidus and mellitus (mellituria) manifest themselves by the increase, often an enormous amount of urine: 4000 to 10,000 grammes, and more. Sometimes in diabetes mellitus there is only a moderate polyuria, or, for a time, in this dis- ease there is even complete absence of polyuria (diabetes decipiens). (See under Specific Gravity and Sugar in the Urine.) 4. As a necessary consequence of abnormal thirst, polydipsia, as it is sometimes particularly observed in hysteria. In this connection we must further mention the quite temporary polyuria which sometimes occurs in nervous persons after great mental excitement. Finally, there is the polyuria which occupies a place by itself, resulting from an obstruction somewhere in the urinary pas- sages, where the urine is held back, and then the passage again becomes free (see under Obstruction). Finally, we must briefly refer to some drinks which temporarily increase the amount of the urine, as coffee, beer, and wine, which increase the quantity of urine more than the amount of water repre- sented. Likewise there are to be mentioned certain articles of diet which have the same effect, partly in that they increase the blood- pressure by affecting the action of the heart, partly in that they stim- ulate the secreting action of the kidneys. In the above pathological conditions, where we do not have a removal from the organism of water that has accumulated there, then the polyuria must be made up, of course, by imbibing an increased EXAMINATION OF THE URINARY APPARATUS. 407 amount of drink (polydipsia). "Whether we have the increased thirst from increased loss of water, or whether the polyuria is the result of the polydipsia, is not entirely clear, especially in many cases of dia- betes insipidus. In diabetes mellitus the polyuria is probably only a purely secondary result of the polydipsia, which, in turn, is to be regarded as the consequence of the glukaemia (Cohnheim). Diminution in the amount of urine, under some circumstances even to the extent of not passing any (anuria), occurs : From diminution in the secretion of urine : 1. In the loss of water in other ways : in severe sweating (see, also, Normal Urine); in any kind of severe diarrhoea, particularly in Asiatic cholera, Avhere for days together there is continuous anuria. .Thus, also, during the formation of a pleuritic or peritoneal exuda- tion, where fever is to be taken into account as a cause (see below). 2. In fever, and largely in consequence of the loss of water in other ways ; by increased perspiration and the greater loss of water by the lungs. 3. By reduced blood- pressure resulting from the diminished work of the heart ; hence, in diseases of the heart-muscle : incompensation in valvular disease, in weakening of the hypertrophic heart of con- tracted kidney, in emphysema, in all the diseases, frequently men- tioned, which harmfully affect the action of the heart. In these conditions the amount of the urine is the chief means of forming a judgment of the course of the disease, and furnishes the indications for treatment. 4. In acute nephritis, subacute and chronic nephritis, except con- tracted kidney (regarding which see also under 3). In these diseases, also, the amount of the urine is a symptom which indicates the severity of the case. In acute nephritis there not infrequently is, for a time, anuria. 5. From suppression of urinary secretion due to nervous causes, especially in a still indistinct reflex way in trauma, as from operations affecting the abdomen. Also, there may be a less quantity of urine from difficulty in mic- turition ; from a very narrow stricture of the urethra (surgery) ; from retention in the bladder ; from obstruction in the ureters. In regard to the latter, when one kidney is cut off. the other generally vicari- ously performs tlie work of both ; but there may also be anuria when 408 SPECIAL DIAGNOSIS. one ureter is closed, as from stone in the kidney, and this, in fact, from a kind of reflex suppression in the other kidney (see Shock). The great zeal in using the catheter in recent times has given us as a result, among other things, the knowledge of the fact that in health with every urination the bladder is completely emptied, even to a few drops. If a certain amount of urine remains in the bladder (residual urine) there is a pathological cause for it. This may be a purely mechanical hindrance to the emptying of the bladder, as stricture, hypertrophy of the prostate, urinary calculi ; or it may result from the mechanical hindrance, atony of the bladder ; or there mav be primary nervous paresis of the detrusor, as occurs in tabes and in all diseases of the lumbar cord. The amount of residual urine is said to be tolerably constant ; it is measured by having the patient pass his urine, and then use the catheter immediately afterward. Color and transparency of the urine in disease. Primarily, the color varies according to the degree of concentration, in the same way as in normal urine ; and as in health, so also in general in disease, it stands in a certain relation to the amount of the urine : the greater the amount, the clearer the urine. But, like the variations of quan- tity from the average, the changes in the color of the urine are also much more sio-nificant in disease than is the case in normal urine. The scale of colors of the urine passes from the almost colorless to the straw-yellow, reddish, red-brown, even brown-black. It is not neces- sary to have a very exact determination of the color of the urine by comparing it with those of a table of colors, as was proposed by Vogel, because it could only have a value in determining the degree of con- centration, and generally for this the specific gravity is much more exact (see). Patients with cirrhosis (without icterus, which see) sometimes pass urine that, in proportion to its amount, is very dark. Antemic (chlorotic) persons, on the other hand, often pass remarkably clear urine. In fever the urine is relatively dark — reddish or brownish-red (see below. Urobilin). In diabetes mellitus there is a peculiarity in the very striking con- tradiction between the clear color and great amount of the urine on the one side, and its high specific gravity upon the other, which is of diagnostic impoi'tance. EXAMIXATIOX OF THE URINARY APPARATUS. 409 As special pigments of the urine, the following are to be men- tioned : 1. Color due to the increase in the normal pigments. Two of these come into consideration here : Indican, occurring in increased amount, may sometimes give to the urine a bluish or bluish-black color, if it has been decomposed in the urinary passages and changed into indigo-blne ; but very often we do not recognize that the urine contains more indican, because indigo has not yet been formed. Hence, when there is a suspicion of indican, or if we wish to make use of its possible presence for the purposes of diagnosis, even when the urine appears to be perfectly normal, we must examine it with reference to this substance. When urine containing indican has been standing for some hours, it can generally be recognized by the bluish shimmer of the residuum, from the drops of urine from the upper part of the urine-glass sprinkled and spread out as thin as possible, and sometimes, also, by a bluish film upon the surface of the urine. Besides, all of the urine is some- times blackish-blue, and this is most markedly the case when the urine putrefies (for its chemical reaction, see below), Indican urine — that is, increase of the indican — occurs : when there is accumulation of the intestinal contents, especially of the con- tents of the small intestine, hence in occlusion of the intestine from any cause, as peritonitis or obstinate obstipation; likewise, in all forms of severe cachexia, as well as in Asiatic cholera ; lastly, in ndividual cases in health. Urobilin, if it exist in considerable quantity in the urine, colors it a decided red or brownish-red. The foam of the urine sometimes looks yellowish-red or yellowish-brown. While there is only a small quantity of it in health, it is abundant in febrile diseases and Avhere there is at any time resorption of large effusions of blood. When there is a marked separation of it which continues for some time, a brownish discoloration of the skin is observed in the so-called urobilin-icterus, though there is still dispute as to its nature. Proof of the increase of indican : The following reaction establishes the presence of indican in increased amount, because it does not operate in the presence of the small quantity found in normal urine. We mix equal parts of urine and fuming nitro-muriatic acid in a 410 SPECIAL DIAGNOSIS. reagent glass ; into this we drop two to three, or at most four, drops of a concentrated solution of chlorinated potash ; immediately, or after a few seconds, there is formed just beneath the surface a blue-black cloud — indigo-blue. By stirring the solution of potash in the urine we obtain, according to the quantity of indigo formed, a more or less dark coloration of the whole fluid. If, then, we add a few drops of chloroform and agitate (not shake) the reagent-glass several times, we have the blue color at the bottom from the settlino; of the chloroform (it becomes green if too much of the solution of chlorinated potash has been added, from the further oxidation of the indigo-blue). Tests for urobilin. 1. Spectroscopic : Absorption bands in green- blue, between Frauenhofer's lines b and F (sometimes it is necessary to dilute the urine with water, in order to be able to make the exami- nation). 2. Chemically : We add ammonia to the reddish urine in the reagent-glass. If there is much urobilin there, it gradually becomes a clear green ; it is then filtered ; and, sometimes, upon the addition of a few drops of a watery solution of chloride of zinc, there appears the rose-red-greenish fluorescence that is peculiar to urobilin. 2. Discoloration of the urine from the presence of the coloring- matter of the blood, of the bile. That of the blood colors the urine variously according to the amount that is mixed with the urine, also whether it is fresh or has been changed, and according to the original color (concentration) of the urine : flesh-red or blood-red with green- ish shimmer with the light passing through it, corresponding to the dichrotic behavior of the blood ; or an untransparent brown, even blackish. Frequently the bloody color* is easily recognized ; but, generally, the reaction-test for blood coloring-matter is necessary (see Coloring Matter of the Blood). Coloring-matter of blood occurs in the urine : 1. In hsematuria, and this in the sediment. It is circumstantially described in the section on Admixture of Blood Avith the Urine. 2. In haemoglobinuria. In this condition the haemoglobin is found entirely dissolved or in granular lumps, but no red blood-corpuscles, or very few, are found in the urine. This results from hsemoglobingemia (see p. 271), and this condition may arise from very diSerent causes : from poisons (chlorate of potash, mineral acids, arsenical solutions, pyrogallic acid, naphthol, poison of the edible mushroom, Jielvella escuhata ; after transfusion of animal blood, as of lamb's blood) ; in infectious diseases EXAMINATION OF THE URINARY APPARATUS. 4II (as scarlet fever, abdominal typhus, malaria, syphilis) ; after extensive burns ; lastly, we have to mention a form of h hemoglobinuria which occurs as an independent disease — paroxysmal hsemoglobinuria. Coloring matter of the bile exists in the urine in icterus (icteric urine). Such urine is most frequently a beer-brown, sometimes brown- green, or even black. If the urine of icterus, as is very seldom the case, is very thin, then it may have a golden- reddish tone. The foam that forms when it is shaken is then highly characteristic : from clear to dark yellow, green-yellow, even brownish. (Regarding the chemical tests for bile coloring-matter, and more particularly regard- ing its presence and that of the bile acids in the urine, see section on Coloring Matter of the Bile.) 3. Staining of the urine from medicines. It is very important to recognize these changes in color, so that one may be on the guard against deception by confounding them with the coloring matter of the bile and the blood. The chrysophanic acid contained in rhubarb and senna passes off by the urine. It colors the urine slightly, making it at most a little brownish, if it is normally acid ; but if it is alkaline, or is made so, then it becomes a purplish-red. After taking logwood, alkaline urine also becomes reddish or violet. Santonin colors the urine yellow or greenish-yellow, with a yellow foam ; upon the addition of an alkali the color changes to red. Picric acid makes the urine yellow, but there is no change in color after changing the reaction. Carbolic acid, naphthalin, creasote, and other preparations of tar, as well as the infusion of the leaves of uvse ursi (arbutin) produce a greenish or greenish-black color of urine. Brownish or blackish discoloration of the urine after standing for some time in the air is observed in patients with melanotic tumors, because the pigment which forms the coloring matter of the blood in those tumors passes off by the urine. A similar behavior of the urine is found in the presence of an abnormal amount of pyrocatechin, an extremely rare occurrence. Transparency. A loss of transparency by turbidness may take place even in normal urine when it has been allowed to stand (see above). Urine that is turbid when passed is always pathological. This is the case, first of all, in nephritis, in consequence of the forma- 412 SPECIAL DIAGNOSIS. tion of organic constituents ; in all diseases of the urinary passages, for the same reason (here particularly on account of mucus) ; but especially in severe cystitis, because the urine in this condition is alkaline when it is passed (alkaline fermentation in the bladder), and hence, besides the organic constituents, contains a deposit of phos- phates. Admixture of blood and pus always makes the urine turbid to some extent. The most striking, and, at the same time, the rarest kind of turbidness is that caused by fat in the urine, chyluria. Here the urine is milky, as if mixed with pus (galacturia) from the emulsi- fied fat ; or it contains large drops of fat or fat-bubbles swimming upon its surface (lipuria). By shaking the urine up with ether it becomes clear. But when it is allowed to stand, part of the fat settles as a sediment, and part forms a cream-like layer on top. (See further regarding Chyluria.) The specific gravity of the urine in disease may vary from a little over 1000 to over 1060 (in diabetes mellitus). Apart from certain special admixtures (we mean particularly sugar, which increases the specific gravity without changing its color, and the special pig- mentary admixtures, which, on the other hand, darken the color without essentially adding to the specific gravity), almost always in disease, as in health, a scanty, dark urine has a high specific gravity ; an abundant, clear urine, a low specific gravity. According to Hseser and Neubauer, from the specific gravity we can obtain an approxima- tion to the amount of solid constituents of the urine by multiplying the last two figures of the specific gravity by 2.33. This product represents the quantity of solid constituents in 1000 grammes of the urine. If we have 1200 grammes of urine with a specific gravity of 1021, then 1000 grammes of this contains 21 X 2 33 = 48.93 grammes of solids, and the whole amount = 58.7 grammes. But not much has been said regarding the change of material upon which it chiefly depends, because the different solid constituents of the urine have very different specific gravity, particularly urea, which, as compared with chloride of sodium is as 2 to 3. Hence, we can never draw defi- nite conclusions from the specific gravity alone, and even where we can exactly determine the solids, as by examining the various material changes, the quantitative determination of the urea or of the nitrogen is indispensably necessary. EXAMINATION OF THE URINARY APPARATUS. 413 The chief value in the determination of the specific gravity with reference to diagnosis consists in the following : 1. High specific gravity with clear and abundant urine points to diabetes mellitus. We may even say that a specific gravity of 1040 and over, the urine being clear, can only be caused by sugar, and hence is pathognomonic of diabetes. 2. Repeated or continued examination of the urine in general engorgement is of value, because this, as well as the quantity of the urine, measures the labor of the heart. It is not unimportant to know further : 3. A low specific gravity, when there is a small amount of urine which is often high colored, occurs in nephritis from diminished excre- tion of urea, also in severe diarrhoea and vomiting. Reaction of urine in disease. For the reasons previously given (under Reaction of the Normal Urine) the reaction of the urine is reliable only a short time after it has been passed. Neutral or alkaline reaction of the urine is met with in sickness : 1. Under the same conditions that make it neutral or alkaline in health. 2. When there is resorption of transudates and exudation in the cavities of the body, also from large effusions of blood, especially in the pleura and peritoneum. 3. With dilatation of the stomach, and particularly if the contents of the stomach must frequently be brought up, either by vomiting or artificially. The reason given is that the blood and the organism lose their acidity because free HCl is not again resorbed (?) (See above, under Reaction of the Normal Urine.) 4. Considerable admixture of blood or pus. In the cases of alka- line urine previously mentioned the urine is clear, or is turbid from the deposit of phosphate ; it contains no bacteria, or only a few. 5. With alkaline fermentation of the urine in the bladder. This accompanies severe forms of cystitis. Here the urine is turbid, because of the presence of pus-corpuscles, abundant bacteria, deposit of triple-phosphates, urate of ammonia, carbonate and phosphate of lime and magnesia. Sometimes it has a peculiar, urinous smell, and is pungent from the free ammonia. By this latter a strip of red litmus- paper, just held free over the fluid, is colored blue. Further regarding the formed constituents of'simple alkaline urine, 414 SPECIAL DIAGNOSIS. and that which has been the subject of alkaline fermentation, see under Sediment. The acidity of the urine may be determined by a simple, but really not very accurate, method : Prepare a lO-per-cent. solution of caustic soda (1 of soda to 9 of distilled water), and pour this from a burette into the urine until a piece of very sensitive litmus becomes blue. 1 c.cm. of the soda solution corresponds to 0.0063 of oxalic acid. Works upon analysis of the urine teach the more exact methods. Pathological odor of the urine. Here we must mention as worthy of recognition the pathological departures from the odor of normal urine. A urinous, more or less pungent, ammoniacal odor, in cases of severe cystitis, shows ammoniacal fermentation in the urine that is passed. Then there is the feculent odor when the urine is mixed with feces, whether the admixture takes place after the urine is passed (see Contamination, p. 399), or whether it has taken place from com- munication between the bladder and the intestine, with discharge into the bladder. The most notable, and at the same time diagnostically important, odor of the urine is the fruity (apple-odor), or like chloroform. The substance which has this peculiar odor seems to be acetone (Fetters) [compare what is said later regarding Acetone]. The urine which has this odor, upon the addition of chloride of iron, sometimes gives a burgundy-red reaction (" chloride-of-iron reaction," Gerhardt), which shows the presence of acetic acid (see further below). Usually the odor of apples is more noticeable in the breath of the patient even than in the urine, and it may be noticed in the breath alone. The apple-odor is observed in individual cases of diabetes mellitus. It especially occurs in diabetic coma or as the precursor of this con- dition, but it also exists, and, indeed, often for a long time, without the occurrence of coma. Unusual odors may be imparted to the urine by medicines : after taking turpentine, violet odor; after cubebs and copaiva, the aromatic odor of these drugs. Foul, albuminous urine, but especially urine that contains pus, develops, as the result of certain organisms, sulphuretted hydrogen : hydrothionic urine. Sometimes this fermentation, with the develop- ment of sulphuretted hydrogen, seems to take place in the bladder (cystitis). On the other hand, if the urine, when first passed, is EXAMINATION OF THE URINARY APPARATUS. 415 clear, and upon being promptly examined is found to contain sul- phuretted hydrogen, it is probable that there has been resorption of Srig into the blood or into the bladder from the intestine, or from a depot of pus in the neighborhood of the bladder ; under which cir- cumstances the general symptoms of poisoning have recently been observed. Urinary sediments. We are to call to mind the sediments, pre- viously mentioned, which may occur in normal urine. On the other hand, these same sediments may sometimes be observed as patho- logical signs, as is shown in what follows : All formed constituents which separate when the urine is allowed to stand are reckoned as "sediments," whether they can be recog- nized with the naked eye or only under the microscope, or whether they are organized or are really "deposits." As previously men- tioned, in order to examine the sediment it is desirable carefully to pour oiF from the vessel containing the urine the upper part ; the lower turbid or already settled portion is to be put into a glass with a pointed bottom, and again allowed to settle. Then follows the examination with the naked eye and with the microscope. For the latter, we take up some of the sediment with a pipette by introducing it [closed by one finger upon the upper end] to the bottom of the pointed glass, when it is to be opened again for a moment, then it is withdrawn and carefully wiped oflF, and a drop of its contents allowed to flow upon an object-glass. [An object-glass with a depression in the centre making a shallow cell is very convenient, since a larger drop can be examined at each time.] Upon this we place a glass cover, and examine it with a magnifying power of about 400 diameters. If the sediment is very scanty, we are to focus the microscope so as first to examine the edge of the covering-glass. It may happen that the sediment is so scanty that we cannot see anything at the bottom of the glass with the naked eye, but by carefully removing a drop from the bottom of the glass and placing it under the microscope we may possibly make out formed constituents, as a few casts (contracted kidney). It is necessary to color the urinary preparations only when examining for certain microorganisms (see below). 416 SPECIAL DIAOyOSIS. Sediments of organic bodies, or direct products of these. Mucus. Physiologically this exists only in small quantities. It is increased in all diseases of the urinary passages, but especially in cystitis, and also in fever. Some mucous forms are characteristic : In the form of minute roundish floccules, the size of a millet-seed or the head of a pin, they are tolerably characteristic of mild cystitis. Under the microscope they show white blood-corpuscles lying closely to one another, and they are apparently conglomerations of white corpuscles. In the form of threads, one to two centimetres long — gonorrhoeal threads — sometimes more purely mucous in character, and, again, containing abundant pus-corpuscles : they occur in chronic gonorrhoea or as the residuum of a past attack. Finally, we find microscopical mucous threads, cylindroid (see Fig. 123, p, 417), which may be confounded by the inexperienced with the so-called urine-casts. The origin and diagnostic significance of these is not clear. They are found in nephritis by the side of the casts, in cystitis, but also in health. They will be distinguished from the urinary casts by their usually being of considerable length, their mucus-thread texture, their very varying thickness (as fine as threads, especially at the end), and their tape-like appearance. Chemical proof of mucus in solution : The addition of acetic acid makes a flocculent precipitate, which is not again dissolved by an excess of acid, nor is it again dissolved by heat, as is the case with a precipitate of urates produced by acetic acid. In women mistakes may arise from the admixture of vaginal mucus with the urine. Blood, or red blood-corpuscles. The appearance of the urine varies very remarkably in hematuria. Sometimes there is a considerable blood-red sediment, not infrequently partly congealed ; again, only a fine deposit of red blood-corpuscles spread out evenly ; and lastly, sometimes, a more brown-red, clear, or dark -brownish sediment. The red blood-corpuscles may be so scanty as to escape detection with the naked eye. This distinction pertains to the amount of the blood and its having been for a longer or shorter time in the urine — that is, with reference to the location of the hemorrhage, (Regarding the color of the urine, see p. 401,) EXAMINATION OF THE URINARY APPARATUS. 417 Fig. 123. Scematuria occurs : (a) In diseases of the kidneys — that is to say, in acute and chronic hemorrhagic nephritis, in embolic hemorrhagic infarction of the kidney (valvular disease of the heart), in septic hemorrhage of the kidneys (acute en- docarditis), in marked engorgement of the kidney, with new formations, and, lastly, in injuries to the kidney. (b) In certain diseases of the urinary passages, and also of the pelvis of the kidney (nephrolithiasis, tumors), of the bladder (severe cystitis, tumors, stone), of the urethra (gonorrhoea with parasites of the urinary canal ; see below). Moreover, hsematuria has symptoma- tic significance for recognizing diseases of other kinds. Thus it occurs in scor- butus, morbus Werlhofii, haemophile, and, lastly, in the rare hemorrhages of the kidney or urinary tract that are due to leukaemia. From the appearance of the sediment and the way it is passed, a conclusion with reference to the location of the hemorrhage and the kind of disease will be made from the following points of view : A small amount of blood, or, at least a not too abundant quantity of blood, uniformly mixed with the urine, the color of the blood being retained, or, more frequently, changed into a brownish color, points to a hemorrhage of the kid- ney. That this is its source can be more certainly proved by the microscope showing blood-casts (see below). Where there is renal hemorrhage, the blood-corpuscles are always more or less discolored, as rings or shadows. Cells and casts, if present, are stained brown by the coloring-matter of the blood. A brown color of the sediment 27 Cylmdroids(seep. 416). (Jaksch.) 418 SPECIAL DIAGXOSIS. and of the urine indicates acute hemorrhagic nephritis. The sudden occurrence of bloody urine, with valvular disease of the heart, points to renal infarction. Individual red blood-corpuscles occur in very concentrated urine in renal engorgement. In hemorrhage of the pelvis of the kidney, especially that caused by stone, the urine usually alternates between being bloody and free from blood, and this, either because there are temporary hemorrhages or because the ureter of the diseased side is for the time being stopped, and then the urine that is passed only comes from the sound side. The blood may for a time escape very freely; in rare cases it may be passed in the form of vermiform coagula (casts of the ureter), which give great pain as they are passed. Cystic hemorrhages, especially in villous tumors, may be so free as to be fatal. The urine is not intimately mixed with blood, especially if the patient lies quietly in bed ; at first there is little or no blood at each urination ; but then, again, pure blood is sometimes passed. On the other hand, in hemorrhage from the urethra, blood comes only at the beginning of the urination. Here, sometimes, there is an escape of blood between the urinations. Works upon surgery treat more at length of hemorrhages of the bladder and urethra. Microscopical examination. In every respect this is the most valuable method for recognizing haematuria, especially from the following points of view: 1. Because the separate red blood-corpuscles can be discovered where neither the fluid portion of the urine nor the sediment shows the color of blood, and where, also, the fluid portion does not show the reaction of the blood-pigment (see below). 2. Because it alone establishes the diflferential diagnosis between hema- turia and hasmoglobinuria. 3. Because, from the condition of the red blood-corpuscles, from the presence of possible blood-casts (see Casts), we can sometimes determine that there is renal hemorrhage. In hjematuria we find more or less abundance of red corpuscles. In decided hemorrhage, especially from the lower portion of the urinary tract, these are only slightly changed. If retained for some time in the urine, and particularly if they are scanty, as in renal hemorrhage, they are smaller, have granular contents, or are more or less markedly discolored. If they are very pale, then we have the so-called rings. If there are no red blood-corpuscles in a urine that is bloody and certainly contains haemoglobin (see Examination of the EXAMINATION OF THE URINARY APPARATUS. 419 dissolved portion), or if they are very scanty in a urine that contains a good deal of haemoglobin, then we have heemoglobinuria (which see). Besides red blood-corpuscles, we frequently find in the sediment, according to the disease present, still other formed constituents : in cystitis, first of all, white blood-corpuscles, phosphate crystals ; in nephritis, casts and white blood-corpuscles. A considerable amount of blood in the urine makes it somewhat albuminous. With women, we must remember the possibility of being deceived by the menstrual blood. Hcemoglohin. In hsemoglobin there is usually a brown or brown- black sediment, which consists of brown flakes and fine granular detritus. A few red blood-corpuscles are likewise found. If casts and epithelium are present, they are often colored brown. Ptts, or white blood- corpuscles. It is rare that a considerable amount of pus is passed by the urethra. It happens if a neighboring depot of pus breaks into the urinary canal : in perinephritic abscess with discharge into the pelvis of the kidney, but particularly in ab- scesses of all kinds in the neighborhood of the bladder. Here the discharge of pus takes place suddenly, and after a short time the urine becomes normal again. But the discharge of pus into the urinary passage may continue for some time, or it may indicate cystitis. Sediments of pus or white blood-corpuscles are more frequent, being caused by inflammation of the mucous membrane of the urinary tract, or by nephritis. In the latter case they are less abundant than in the former. The sediment is yellow to white, in nephritis; in catarrhal cystitis it is sometimes very like phosphatic sediment (which see). In inflammation of the urinary tract, generally the sediment becomes a peculiar compact jelly, from mucus; in alkaline urine, it is due to the mucous swelling of the white blood-corpuscles (see above); in nephritis, it is quite spongy. The microscopical examination shows the white blood-corpuscles more or less changed according to their amount, the length of time they have been in the urine, and the reaction of the latter. In alka- line urine they are very clear and much swollen. Of the diseases of the kidneys, acute hemorrhagic nephritis, and sometimes the sub- 420 SPECIAL DIAGXOSIS. chronic (chronic parenchymatous) nephritis, show a relatively abundant amount of pus-corpuscles. To a slight degree, pus makes the urine albuminous ; a considerable amount of albumin in the urine is always due to renal albuminuria. When the quantity of albumin in the urine is slight, the question may arise whether we have nephritis, either as a separate disease or as a complication of cystitis or pyelitis. This can only be answered by the infallible sign of nephritis — that is, casts in the urine. Fat-drops. The fat accompanying chyluria may, as was previously mentioned, exist in the urine as a sediment, but also as a cream-like or swimming layer, or in the form of large drops. We must remember that it may be due to impurities, as the use of an oiled catheter. The microscope shows minute particles of fat or large drops, which markedly refract the light. In the first case the fatty character of the sediment may be most quickly recognized by the grease-spot formed upon paper by the sediment. We may also shake it up with ether, and then allow the ether to escape by evaporation. The occurrence of fat-drops free and attached to casts, adipose white blood-corpuscles, is very important in diagnosing large white kidney. epithelium. We find in the urine the epithelium of the urinary passages and the epithelium of the renal urinary channels [urinary tubules]. In addition, in women we have very frequently, but espe- cially when there is leucorrhcea. flat epithelium from the vulva. The cells of epithelium in transition are everywhere very similar. But renal epithelium is usually easily recognized as such. While in normal urine only individual flat epithelial, and some- times, caudate cells occur, we meet a large quantity of the three species of cells named in inflammation of the urinary passages. Usually, they are well preserved. It is misleading to form a conclu- sion from the kind of cells as to the location of the inflammation (especially whether of the pelvis of the kidney or of the bladder). The vulva being excluded, a large quantity of flat epithelium points to the bladder. Abundant caudate, but especially overlapping, " tile- like." roundish cells with large nuclei, were formerly often regarded as characteristic of inflammation of the pelvis of the kidney ; but more recently this view has come into discredit. EXAMIXATIOX OF THE UHiyARr APPARATUS. 421 Rentil epithelia occur in considerable numbers only in affections of the kidney, and especially in nephritis. If their form is well pre- served, they are recognized "without diiEculty as polygonal or round- cornered cells of peculiarly sharp contour, with large oval nuclei and a decidedly gi-anular, often yellowish-looking, protoplasm. They are small — not larger than white blood-corpuscles, sometimes smaller. In acute hemorrhagic nephritis they are often coarsely granular, brownish in color; in the large white (butter) kidney, but sometimes also in the first disease, we not infrequently see them in all stages of fatty degeneration. Fig. 124, |S)3 Epithelium from the urine, a, h, epithelium from the bladder, from the pelvis of the kidney ; c, caudate epithelium (pelvis of the kidney ?) ; d, renal epithelium, partly changed into fat. Regarding cylindrical epithelium, see under Casts. Shreds of tissue. Shreds of connective-tissue and " caseous crumbs " are found in tuberculosis of the urinary apparatus. Particles of carcinomatous tissue are separated in carcinoma, but are more frequently found in carcinoma villosum of the bladder. Only particles which distinctly show the structure of carcinomatous tissue are of importance here. Single, or, also, several pretended " cancer-cells " lying close to one another have no diagnostic value. Spermatozoa. After every discharge of semen these are seen in the urine. Hence, they are not unimportant for detecting masturba- tion. They also occur in spermatorrhoea. Lastly, sometimes they are found after epileptic attacks ; also, now and then with severe diseases of all kinds, as in typhus patients. Casts. The so-called urinary casts (Henle, 1842) are incontestably the most important form-elements in pathological urine. They are 422 SPECIAL DIAGNOSIS. found with renal albuminuria. Aside from quite individual excep- tional cases, they occur without simultaneous albuminuria only in one condition : hepatogenous icterus. Here they have no diagnostic interest further than that, from their occurrence, we may suspect the presence of bile-acids in the urine. They are intensely stained with the bile-pigment. We concern ourselves only with the occurrence of casts with albu- minuria. By their presence these not only permit a conclusion that there is a disease of the kidneys which causes albuminuria, but, by their quantity and character, also enable us to diagnose the exact nature of the disease. Regarding their numbers the casts are scanty, and then usually hyaline (see beloAv), in engorgement of the kidneys, in fever, in physiological albuminuria ; and, lastly, they are tem- porarily present in contracted and amyloid kidney. There is often here a sediment which is scarcely, or not at all, visible. In making a preparation we must, with the greatest care, take a few drops from the bottom of the urine-glass and examine the p'reparation with great thoroughness. It is advantageous, but not indispensable, to stain any casts that may be present by the addition of a little gentian- violet solution placed upon the edge of the covering-glass. The casts are very abundant in acute, and frequently also in chronic, nephritis. In these diseases they may form the principal portion of a tolerably abundant sediment. Variation in the quantity of the casts is to be observed in all the diseases named. Sometimes it seems as if, after a period of stagna- tion, the casts are passed in greater abundance. This is not very rare in amyloid nephritis, also in acute attacks of nephritis. In size and form the casts vary greatly. We will speak further regarding this. As to their nature, we distinguish the following kinds of casts : Hyaline casts. These are of great variety as to length and breadth ; sometimes not so broad as a white blood-corpuscle (thin hyaline casts), and, again, five or six times as broad (thick or medium casts). In length they may be as much as one millimetre. They are homogeneous and clear as water, with a very fine outline, hence often very difficult to see ; the ends look as if broken off, rounded, or even clubbed (for aggregation of substances within them, see below). They occur in company with other forms in all diseases of the kidney. EXAMINATION OF THE URINARY APPARATUS. 423 Exclusively hyaline casts occur most frequently in contracted and amyloid kidney, also in fever and with [renal] engorgement. A special kind of hyaline casts are the waxy, so named from their smooth form and usually yellowish color. Sometimes they show the amyloid reaction with iodine and iodide of potassium — brown, then violet with sulphuric acid. We cannot form a conclusion from them as to the nature of the disease of the kidney ; certainly they -pia. 126. are not pathognomonic of amy- loid kidney. | : z;! Additions to the hyaline, and i; ,,:\ also to the waxy, casts fre- quently occur in the form of red and white blood-corpuscles, renal epithelium, crystals, gran- ular masses, which, in turn, may show urates, phosphates, Fig. 125. Hyaline casts (narrow and tolerably broad ones). Waxy casts. (Jaksch.) 5, a cast containing crystals of oxalate of lipie. albuminous or fat granules, and, lastly, bacteria. Among these additions those of special significance are red blood-corpuscles, as in hemorrhagic nephritis, possibly adipose renal epithelia, white blood- corpuscles (granular spheres), and free fat-granules. These adipose elements, if abundant, are important for the diagnosis of large white or fatty kidney. In some cases of pyelonephritis we have seen hyaline casts which 424 SPECIAL DIAGNOSIS. were split like a pair of trousers. These might possibly have their origin in collective tubes (?). Casts that are coarse or finely granular are generally hyaline, with additions to their contents, as above. But, especially in acute nephritis, conglomerate casts of albumin in lumps and granules also occur ; sometimes stained or mixed with h^ematoidin. Blood casts are conglomerations of red blood-corpuscles held together by coagulation. They are important as indisputable signs of renal hsematuria. EpitheJial casts are either hyaline casts with the addition of renal epithelium (recognized by their sharp outline and distinct large nuclei), or they are true epithelial tubes. In both cases they have the same significance — the free desquamation of renal epithelium, especially as it occurs with acute hemorrhagic nephritis. Fig. 127. Fig. 128. Fig. 129. W 1 Fig. 127. — Granular casts. (Jaksch.) Fig. 128. — Eed blood-corpuscles, partly as " rings '' and casts of red blood-corpuscles. (ElCHHORST.) Fig. 129. — Epithelial cast. (Jaksch.) Casts of lumps of haemoglobin in hgemoglobinuria, urate-casts in the newly born (uric acid infarction in connection with ammonio-uric acid), and casts of bacteria in pyaemia (?) are very rare occurrences. We may confound casts with cylindroids (see p. 416), also with threads of linen or other adventitious materials in the urine. Practice in examining and cleanliness guard one from mistake Animal parasites. Echinococcus. Shreds from echinococcus bladders, scolices, are met with in the urine if an echinococcus of the kidney or from the neighborhood of the urinary apparatus breaks into EXAMIXATION OF THE URINARr APPARATUS. 425 the urinary passage. The passing of urine is often attended with severe pain, especially by attacks of colic during its transit through the ureters. They may be preceded by anuria from obstruction of the urethra, obstruction of one ureter, and " reflex " suppression of secretion upon the sound side (or reflex spasm of the sphincter vesicEe). Distoma hoEmatohium, an exotic from ■ Egypt, located in the roots of the portal vein, also particularly in the plexus vesicalis, causes hsematuria. The eggs of the parasite make their appearance in the urine. Strongylus gigas located in the pelvis of the kidney causes pyuria and hsematuria. Filaria sanguinis, an exotic from East India, Japan, China, and Australia, located in the large lymph- vessels, among other things causes engorgement of the lymph-vessels of the bladder : chyluria (and likewise galacturia, see) and hsematuria (peach-red urine). Besides, the urine contains embryo filaria, round worms of delicate structure, lying in a fine sheath, with lively motion. Its width is about that of a red blood-corpuscle ; its length, two to three millimetres. Oxyuris vermicularis, trichoma vaginalis (an infusorium), and, in one case under my observation, the larva of the fly family, musca vomitoria (I) may become mixed with the urine from the vagina. Vegetable parasites and fungi. Normal fresh urine, free from im- purities, is not entirely free from fungi (see p. 399). A number of bacilli and cocci colonize in urine that has been standing for some time, of which those of special interest are the ones which cause alkaline fermentation, changing the urea into carbonate of ammonia (see p. 402). The micrococci and bacilli of alkaline fermentation, and, with them, the signs of this fermentation — alkaline urine, crystals of triple- phosphate and carbonate of ammonia (see beloAv) — however, occur in fresh urine in severe cystitis, particularly as the result of the use of a catheter that is unclean, in cases of weak or paralyzed bladder; but this is no doubt also caused by paralysis of the bladder alone, and the spontaneous entrance of fungus germs through the urethra. The fungi produce cystitis by the fermentation they set up, and this, in turn, favors the development of the fungi. If these schizomycetes are very numerous they may form the greater part of the ^undant 426 SPECIAL DIAGNOSIS. sediment. Under the microscope we see chiefly the chain-coccus (micrococcus urene, micrococcus ure?e liquifaciens) and bacilli (chiefly bacillus urete, Leube), not so long, but thicker than the bacillus tuberculosis; all these forms of fungi being in the most lively motion. It is the presence of these fungi that distinguishes simple alkaline urine (see p. 413) from urine that is alkaline from fermentation. Tubercle bacilli in the urine are an absolutely sure sign of ulcer- ating uro-genital tuberculosis. But in this disease, especially when there is tuberculosis of the pelvis of the kidney or of the kidney of only one side, the ureter of that side is temporarily or permanently stopped. In regard to the occurrence of single bacilli having the form and the color-reaction of tubercle bacilli, compare what has been said regarding smegma bacilli, p. 400. If tubercle bacilli appear at all in the urine, they are generally abundant, not infrequently even Fig. 130. 9 Pure culture of tubercle bacilli ia the urine in tuberculosis of the genito-urinary apparatus. Zeiss's homogeneous immersion one-twelfth ej-e-piece No. 4. Drawn with a camera lucida. Magnified about 1100. Author's observation. in masses and with an arrangement which reminds one of a pure culture. Fig. 130 exhibits an excessive development of this kind (personal observation). In purulent urinary sediment they can be demonstrated just as distinctly as in the sputum. If there is decided anaemia, wasting, and continued fever, as well as in cases of long- continued gleet, every purulent urinary sediment should be examined for tubercle bacillus. EXAMINATION OF THE URINARY APPARATUS. 427 Gonococci (Neiser) occur in the pus of recent gonorrhoea in clusters, in epithelial cells, and in pus-cells. The latter circumstance is char- acteristic of gonococci, and distinguishes them from other bacteria which resemble them. Gonococci are chiefly met with as diplococci, and since the individual coccus seems to be divided into two by a bright transverse band, it often makes the so-called roll-form. In gleet and in persons who have formerly had gleet, but have for years Fig. 131. Gonococci in the pus from the urethra. Zeiss's homogeneous immersion one-twelfth, eye-piece No. 2. Drawn with a camera lueida. Magnified about 650. been free from any symptoms, we find a diplococcus which resembles the gonococcus. But by recent investigations it has been discovered that even in the urethral secretion of persons in health, who have never had gonorrhoea, there occurs a diplococcus, free as well as enclosed in epithelia (although, of course, not in pus-corpuscles). This diplococcus has a form very much like the gonococcus (Lust- garten and Mannaberg). The gonococcus is to be stained with gentian-violet or methylene-blue, or fuchsin, and then rinsed in water. Pathogenic fungi which circulate in the blood are, in individual cases, found in the urine : thus, tubercle bacilli in acute miliary tuberculosis, equinia, erysipelas cocci in erysipelatous nephritis (Fehleisen), spirillum recurrens in complicating hemorrhage of the kidney (Kannenberg), pus-micrococci in pyaemia and endocarditis (Weichselbaum). Also, casts of micrococci are described in septic processes (Litten and others). Lastly, in cases of acute nephritis, bacteria have recently been found in the urine and in the kidney, which have been regarded by different authors as the specific excitants of the nephritis. These cases are too much isolated to permit us to form a definite conclusion as yet. 428 SPECIAL DIAGNOSIS. A small form of sarcina is found rarely in alkaline fermentation in the urine. It, as well as the other fungi named, is regarded as the cause of the transformation of the urea. Leptothrix buccalis occurs as a foreign substance, as from the preputial sac (Huber). The occurrence of the yeast fungus, saceharomyces, in urine con- taining sugar is not unimportant. Here it causes acid fermentation. In urine that does not contain sugar, some yeast-cells are found occa- sionally, but they do not increase. Inorganic Sediments. These consist of materials which are ordinarily found in the urine in a state of solution, but which, for various reasons, are absent, chiefly because the urine is very much concentrated, or because its reaction has changed. These bodies show the forms of more or less pure crystals ; they may be crystalline, or amorphous, but neverthe- less often have a peculiar symmetrical form. Here we really consider the finer urinary sediments ; urinary calculi, vehich belong to surgery, will be mentioned at the end and only very briefly. {a) The more frequent inorganic sediments. From acid urine there are deposited: Uric acid, uric acid salts (sodium, lime), oxalate of lime. From the faintly acid, neutral (amphoteric), alkaline urine there are deposited : Ammonio-magnesian phosphates, phosphate of lime, carbonate of lime, urate of ammonia, and sometimes uric acid. All these substances may occasionally be deposited from healthy urine (see p. 402). Uric acid. As is stated above, we find this as a deposit not only in acid, but sometimes in neutral and alkaline, urine. It can often be recognized with the naked eye in the form of yellowish-red, glittering granules, which are located upon the side of the urine-glass, or in the form of a yellowish-red powder at the bottom of the glass. Uric acid deposited from the urine always has this yellowish-red color, while the chemically pure uric acid is colorless. Under the microscope it shows the greatest variety of crystal forms and crys- talline figures (see Fig. 132). The basis form is the rhomboidal plate. But this is rare. More frequently we have derivatives of EXAMIXATIOX OF THE URINARY APPARATUS. 429 this, the so-called "whetstone " (with a cross or in druses), "barrel- shaped,'^ also peculiar bundles of prisms, lastly, amorphous lumps and clubs with separate, shining, smooth surfaces — all easily recognized by their distinct color. We may artificially produce a separation of uric acid deposit by adding to the urine some concentrated solution of salt and allowing it to stand for twenty-four hours. Ordinarily, chemical reaction is not necessary. Fig. 132. Fig. 133. Uric acid and uric acid salts. (Funke.) Oxalate of lime. (Laache.) The occurrence of uric-acid crystals in the urine only shows that uric acid is not exactly wanting in the urine, and nothing more. It is said that the frequent separation of amorphous forms indicates urinary calculi (Ultzmann). Urate of soda and lime. When concentrated urine cools there is often a very abundant sediment, colored a flesh-red by the urinary pigment, "brick-dust sediment," or sedimentum lateritium. When cooled to zero, C, we can obtain it from any urine. It will be most easily recognized by the fact that it immediately completely dissolves when the urine is warmed (not boiled, because then there is a phos- phatic cloudiness, and also coagulation of albumin, if present). Under the microscope the urates of soda and of lime are seen as very fine grains. They incline to settle upon the casts, and especially upon mucus threads. Uric-acid crystals form about half an hour after the addition of some muriatic acid. From concentrated urine the lateritious sediment is deposited at 430 SPECIAL DIAGNOSIS. the ordinary temperature of the room, especially in engorgement of the kidneys, in attacks of diarrhoea, in fever, and also in health (see p, 402), We should never conclude from its presence that there is increased separation of uric acid. We can only determine this by ascertaining the amount of uric acid and urate separated in twenty- four hours. Oxalate of lime. Single crystals of this may appear in any urine that has been standing for some time. The crystals are almost always tolerably small, sometimes minute regular octahedra, which are con- spicuous by their perfect form and strong refraction of light (envelope- form). They are rarely hour-glass- and dumb-bell-shaped. The crystals are insoluble in water, and are thus distinguished from chloride of sodium. Fig. 134. Fig. 135. Triple-phosphates; urate of ammonia. (Laache.) Phosphate of lime. (Laache.) These crystals occur in the urine in great abundance after eating certain fruits and vegetables, as apples, pears, cauliflower, and the different kinds of sorrel; and also in diabetes mellitus, catarrhal icterus, hypochondria. Moreover, we cannot conclude, without further evidence than the mere occurrence of a somewhat large amount of these crystals, that there is increased separation of oxalic acid (oxaluria). The disease described by English physicians (and Can- tan i) as oxaluria does not seem to be a unity. This oxaluria occurs in cachexia (tuberculosis, cancer). EXAMIXATIOX OF THE URIXARY APPARATUS. 431 Ammoniaco-magnesian jjlio^pliate (triple-pliosphate) is found in urine that is simply alkaline and that is undergoing alkaline fermenta- tion. Sometimes it forms the principal portion of the whitish sedi- ment. The basis form is the rhombic prism ; it is well formed in the '•coffin-lid crystals," often also of various other forms, and is then more difficult to recognize. The triple-phosphates are all perfectly colorless, and soluble in acetic acid, thus contrasting with oxalate of lime. PhospJioric acid as a basic salt occurs in amorphous grains in alkaline fermentation of the urine. It is soluble in acetic acid, but not by heat. As a neutral salt it occurs in simple alkaline urine in the form of long wedges or knife-blades. These disappear in alkaline fermentation. Fig. 136. G.li^ Fig. 137. 'Wm^ "/■r ^:>^" :r 1 :-my.i. ... ^*« c- K--i.*'^l-- ' • V '. ': -'"^ ■ : . " '" y, .'-i '^ m ■" ■-.'; ^ ^M ■ .'cO ^H ' "^^ t "- j:- ^hBb ' ■■ ■' . r jS|^H ^ ^^3^^^l ^^^1 ^bI^^^I iH.B^^^^fl^^^l^H BiM^^^^M Carbonate of lime. CLaacrb.) Leuein and tyrosin. TLaache.) Carbonate of lime, in the form of spherules or crossed drum-sticks, seldom occurs in alkahne urine. ["In highly alkaline urine, in which the alkalescence is caused by carbonate of ammonia set free by decomposition of urea, carbonate of lime occurs in small quantity, but in an amorphous form. This is the only form in which I have yet seen carbonate of lime in human ui'ine."" — Beale.] It is dissolved bv the addition of muriatic acid, with effervescence. The so-called phosphaturia is a condition in which phosphates and carbonates are precipitated before or immediately after the urine is passed. But there is no increase in the phosphoric acid. The 432 SPECIAL DIAGNOSIS precipitation is probably produced by the alkalinity of the urine. Phosphaturia occurs in neurasthenia, hypochondria, chronic articular rheumatism. Urate of ammonia accompanies triple-phosphate in alkaline fer- mentation. The characteristic form is that of the thorn-apple (grayish-yellow or brownish opaque balls, from which fine needles project). When muriatic acid is added, there develop under the coverinor-orlass uric-acid crystals. (b) More rare inorganic sediments. Haematoidin is exceptionally found in the forms of needles and plates mentioned before (p. 180). Sometimes we see white blood-corpuscles Avhich contain haematoidin needles, which project through the cell-membrane. Leuein and tyrosin (see Fig. 137). The characteristic forms of these substances, which almost always appear together, are sometimes found in the sediment, more often only when we have evaporated the urine in a water-bath to the consistence of syrup, or until we slowly boil down a drop of urine upon an object-glass until it is almost dry. Leuein appears in the form of faintly shining spheres, which some- times, if they are large, show radiating lines and concentric rings. Tyrosin crystallizes in very fine needles, Avhich commonly form druses and bundles. Leuein and tyrosin are products of the decomposition of albumin. They do not occur in normal urine. Diseases in which they are found and for which they may have diagnostic value, are acute yellow atrophy of the liver and acute poisoning by phosphorus. They are also seen in variola and typhus, as well as in pernicious anaemia (Laache). Cystin sometimes occurs in the urine in health. Large quantities of cystin in the urine may cause the formation of cystin-calculi and excite cystitis, and are thus a pathological condition in themselves. According to recent investigations (Baumann, Brieger) there seems to be a connection between the occurrence of ptomaines and cystin in the urine. Brieger assumes that by the presence of certain ptomaines in the intestinal canal (hence, in mycotic enteritis) the cystin forms a combination with the ptomaines in the intestine, which overflows into the urine. There the compound decomposes, and cystin is again set free. Sometimes this does not take place, and so calculi are formed. The ptomaines, in turn, may cause inflammation, especially cystitis. EXAMIXATION OF THE VRIXARY APPARATUS. 433 « Cvstin, besides occurring in the urine in the form of calculi, is seen in the form of extremely thin, six-sided, and very perfectly formed colorless plates. (c) Concretions in the urine. We are interested only in the con- cretions that arise in the pelvis of the kidney, as in nephrolithiasis, pyelitis calculosa. Those that form in the bladder belong to surgery. The former are named, according to their size, renal sand, renal gravel, renal calculi. If- they attain a certain size, they cause severe attacks of pain in their transit through the urethra (renal calculi colic). Most frequently the concretions consist chiefly of uric acid and urates. They are then brown or brown -black, and tolerably smooth on the surface. Stones of oxalate of lime are densely hard and have a rough surface (mulberry calculi) ; they are dark brown. A combination of layers of uric acid and oxalate of lime is likewise met with. Phosphatic calculi are tolerably soft, but not infrequently they contain a kernel of the first-named substances (phosphate de- posited upon the stone from the alkaline urine of cystitis [excited by the original stone]. Finally, we must mention stones of cystin and (extremely rare) xanthin. All these stones, with the exception of the phosphatic calculi, are formed in acid urine. For the exact chemical examination of the concretions we refer to the text-books upon Urinary Analysis. Examination of the Urinary Constituents in Solution. 1. Anomalies in the quantity of the normal constituents. In dis- ease the normal constituents of the urine are variously increased or diminished. These quantitative variations, however, can only excep- tionally be made use of for the diagnosis of disease. But they are important for determining the change of material and the removal of material that can be carried off by the urine in various diseases. This requires throughout an exact quantitative analysis, for the different "approximative methods " have no value at all. We cannot here go into an explanation of the exact methods, but must refer to the hand- books upon urinary analysis. However, we mention briefly the most important anomalies which belong here. We have already mentioned the quantities of the normal constituents of the urine, p. 404. Urea. This is increased in fever, either absolutely, as in pneu- 28 434 SPECIAL DIAGNOSIS. monia, or relatively — that is, in relation to diminution in the amount of food taken. It is also increased in diabetes. We find it diminished in all forms of nephritis, but especially in uraemia ; in cachexia of all kinds, especially if there is dropsy ; and, lastly, sometimes in acute yellow atrophy of the liver. The very decided increase in the amount of excretion of urea which takes place immediately after the crisis in pneumonia is designated as post epicritical. It is probably con- nected with the increase in the amount of water secreted by the kidney. Sehrwald has recently {Munchen med. Wochenschrift, 1888, No. 46) devised a simplification of Knop-Hiifner's method of determining the amount of urea, which seems to us to be very practical and rela- tively exact. We have not yet had an opportunity to test thoroughly the method. At least, we recommend that it be tried. Urie acid is usually increased in fever parallel with the urea. Besides, it is increased in leukaemia and pernicious antemia (with the first, often very markedly), also in all diseases which affect the inter- change of gases in the lungs ; and, lastly, with the uric-acid or gouty diathesis, apart from attacks of gout, during which it is often dimin- ished. The total amount of nitrogenous material in the urine, the most important for determining the metamorphosis of tissues, approximately agrees with the amount estimated from the urea, because the uric acid, kreatinin, and xanthin bodies are insignificant in amount com- pared with the urea. Besides, the most practicable method for the quantitative determination of the urea (Liebigs) is really a determina- tion of the total amount of nitrogen, expressed as urea (C. Yoit, Salkowski, and Leube). When determining both nitrogen and urea, of course, it must be done apart from any possible albumin — that is to say, the latter must first be removed. Chloride of sodium is pathologically increased during the resorp- tion of transudations and exudations, and also in intermittent fever, from the destruction of red blood-corpuscles (Kast). It is diminished in fever, nephritis, and in many cachectic conditions. [In pneumo- nia, during the st*ge of exudation and until resolution begins, the chlorides are diminished or disappear from the urine. While the dis- appearance of the chlorides from the urine is not characteristic of EXAMINATION OF THE URINARY APPARATUS. 435 this disease alone, it shows that exudation is still going on, or that resolution has not yet commenced.] Sulphuric acid interests us chiefly with reference to the associated ethylsulphuric acid (phenol-, indoxyl-sulphuric acids). It is found with increased separation of indican and carbolic acid. Regarding the former, see p. 409. The latter occurs with the internal and external use of carbolic acid. It has been found that the phosphates are diminished in rhachitis, also in acute yellow atrophy of the liver. In nephritis they are not infrequently diminished. 2. Abnormal constituents. Albumin. Except in the rare cases of physiological albuminuria already mentioned, any separation of albumin in the urine is pathological. This is always so if it con- tinues. The albuminous substances, which in the conditions reckoned as albuminuria in the narrow sense can be separated, are serum- albumin and serum-globulin. Their amount varies from a trace to one-half per cent. — very exceptionally more. Generally, it remains below one-half per cent. The secretion of hemialbuminose is very rare, and thus far has not been found to have special diagnostic sig- nificance. Of late, we are not accustomed to regard peptonuria as albuminuria. It will be considered at the close of this chapter. Albuminuria occurs : 1. As true renal albuminuria, in all forms of acute and chronic nephritis, in amyloid kidney, in engorgement of the kidneys ; in hydrsemic conditions of the blood, as anaemia, leuksemia ; in fever, and in acute poisoning ; in these two cases, especially in the latter, there occur, besides all the transitions to nephritis ; lastly, after epi- leptic attacks, apoplexy (transitory albuminuria). Besides, there has recently been discovered a peculiar form of albuminuria which is distinguished from other forms by the absence of all pathological signs in the urine, especially of cylinders : cyclic albuminuria. See, regarding this, p. 437. 2. Further, albumin in solution in the urine may also pass over into the urinary passages when blood and pus are mingled with the urine in the bladder. The amount of albumin, however, is always small. Qualitative tests for albumin. We select a few from the great number of tests for albumin, which have the tolerably uniform approval 436 SPECIAL DIAGNOSIS. of authors (see, regarding them, Penzoldt's Old and New Urinary Tests), and which, according to our experience, have the preference. The preliminary condition is that the urine be not contaminated, as by menses or leucorrhoea, and that it be clear. The latter is the more necessary in proportion as the amount of the albumin is small. In order to be able to discover it when only a very little is present, it is necessary to filter the urine until it is perfectly clear. (a) Addition of acetic acid and ferro-cyanide of potassium. By the acetic acid the urine is rendered distinctly acid, and then the cold urine is mixed with a few drops of a watery solution of potas. ferro- cyanide. Even with a very small amount of albumin, very fine floccules are formed, often almost milky cloudiness, though when there is only a very small quantity of albumin it is somewhat delayed. This very certain and distinct test is strongly recommended for use at the house of the physician. (b) Boiling and the addition of nitric acid. If the urine is neutral or alkaline, acetic acid must be added to it to render it acid before boiling. If there is cloudiness, it can only be due to one of two causes : albumin or phosphates. To determine which of these it is, we add about ten drops of nitric acid, when the phosphatic deposit is immediately dissolved ; but if the deposit is of albumin, it is made more distinct. When the albumin is somewhat abundant, the deposit can be immediately recognized by its floccular appearance. The test is a sharp one, showing even 0.005 to 0.01 per cent, of albumin, and, being tolerably certain, is in general to be recommended. (c) Picric-acid test. We add to the urine a few drops of a con- centrated watery solution of picric acid : if it immediately becomes cloudy, it shows albumin ; but cloudiness appearing later shows nothing (Johnson, Penzoldt). It is a certain and sharp test, not less to be recommended than the others. As portable tests for albumin, we can proportionally recommend the following as best : (d) Geisler's albumin test-papers.^ These consist of a piece of filter-paper saturated with a concentrated solution of citric acid, and of another saturated with a three-per-cent. solution of iodide of potas- sium added to a twelve or fifteen-per-cent. solution of corrosive subli- [1 They may be obtained of Parke, Davis & Co., and other manufacturing chemists.] EXAMINATION OF THE URINARY APPARATUS. 437 mate. We first put one of the strips of the first into the urine — if very alkaline, more than one — then one of the second papers, and shake it. Cloudiness due to albumin appears pretty promptly. Pep- tone is also precipitated, which, in many cases, can cause deception (see Peptonuria). In concentrated urine, urates are also precipitated, but these can afterward be dissolved by heat. Deception from the solution of particles of paper making a cloudiness is not possible, if it is carefully examined. As a preliminary test at the sick-bed, this method is to be recommended. But we ought not to be satisfied with its result, and should always afterward employ one of the tests pre- viously mentioned. If we examine the urine a number of times in twenty-four hours, and find that there is a periodic presence and absence of albumin, we designate this condition as cyclic albuminuria.^ It never occurs after rest at night ; the albumin is generally separated after exertion. In case this condition is suspected, we are to examine the urine several times during the day, and especially toward evening, also directly after rising in the morning. Klemperer has made a very clear demonstration of the course of the separation of the albumin. He places about five c.cm. of the urine, passed at different times during the day, in a series of reagent- glasses, and then boils them with the addition of nitric acid The height of the deposit in the glasses, as they are arranged in a row, may be regarded as a direct delineation of the " albumin curve." Quantitative test for albumin. Here, as in all quantitative de- terminations, the urine of exactly twenty-four hours must be mixed, and a portion from this mixture examined. The urine for exactly twenty-four hours can be obtained if we have the patient urinate early, say shortly before seven o'clock, and then keep all the urine that is passed till the next morning at exactly the same hour, passing his urine again at seven o'clock. It is possible to make an exact quantitative determination only by completely separating the albumin from a measured quantity of urine. Filter, wash the residue upon the filter-paper, dry, and weigh it. (For particulars regarding these processes, see text-books upon Urinary [I In the British Medical Journal, January 31, 1891, p. 218, Dr. Herringham gives a valuable and careful study of a case of Cyclical Albuminuria which was under his care at the West London Hospital. — Teanslator.] 438 SPECIAL DIAGNOSIS. Fig. 138. Analysis.) This examination can only be conducted in a laboratory. There is no mode of procedure which is more simple, nor one that is so nearly exact as this. The polarizing method is only applicable ■when there is a considerable amount of albumin. A substitute for the exact quantitative determination is quite com- monly found by endeavoring to estimate the amount of deposit which results from the qualitative determination, especially by the boiling nitric-acid test : we wait a long time — till it settles in the reagent- glass — and then we speak of one-half, one-quarter, or the whole being albumin, by comparing the volume of albu- min that can be seen with the whole amount of urine in the reagent-glass. It may be assumed that one-half the volume of albumin, if the reagent-glass has stood for one hour, corresponds to about 0,2 to 0.6. This estimate is extremely unreliable, being chiefly dependent upon the size and thickness of the flakes of albumin. But, if we always employ the same test for albumin, it is certainly not valueless forjudging of the variations in the separa- tion of albumin in the course of disease. More exact is the method with Esbach's albuminometer, although it acts upon the same principle, and so is only approximative. What exactness it has depends in reality upon the employment always of the same reagents, mix- ing them with an equal amount of urine, and always allowing the same time for the deposit of the precipitate. The albuminometer — a graduated thick reagent-glass — is filled with urine to the mark U, from there to R with the reagent. This reagent consists of 10 grammes of picric acid and 20 grammes of citric acid to 1000 of distilled water. ^ The glass is then closed with a rubber cork, turned upside down ten times, and allowed to stand undis- turbed for twenty-four hours, best in a special stand. After this period of time we notice at what mark of the scale on the glass the albuminous deposit stands. The marks each give one-tenth per cent, of albumin. As the scale only goes as far as 0.7 per cent., urine that Esbach's Albuminom- eter. 1 The exact amounts of both acids (chemically pure and dry) are to be dissolved in 1000 grammes of water, made hot, and, after cooling, any deficit in the amount of fluid is to be made up by the addition of water to 1000 grammes. EXAMINATION OF THE URINARY APPARATUS. 439 is strongly albuminous must be diluted in a definite way before the test. We must avoid producing air-bubbles, because these cause the precipitate, or a part of it, to swim, and for this reason we are not to shake the glass. If there are air-bubbles, they must be removed with a pipette. In most cases the method is tolerably exact (an error of one-tenth to two-tenths of albumin), but in individual cases, and often without any recognizable cause, the pi^ecipitate does not sink down as well as it usually does. Nevertheless, it is to be recommended as an improve- ment upon the simple, rough " volumetric " estimate. [The apparatus is not at all expensive. It can be obtained in New York of Eimer & Amend.] Rare forms of albumin. PejJtone (von Jaksch, Maixner, and others). This never occurs in healthy urine. Pathologically, it occurs sometimes in ordinary albuminuria, and, again, independently — peptonuria. It occurs in a great number of very different condi- tions : in large abscesses, in emphysema, sometimes in pneumonia ; likewise in acute rheumatism, scorbutus, phosphorus-poisoning ; also, in carcinoma ventriculi, in puerperal fever, in typhus abdominalis, etc. Hence, this very remarkable substance has no value for diagnosis. Its determination, even qualitative (biuret reaction), is, for various reasons, difficult, Hemialhumose (hemialbuaiinose, propeptone) very rarely exists in the urine (albumosuria). There must arise a suspicion of these albuminous bodies, which, according to the latest researches, show a mixture of four albuminous substances (Kuhne, K., and Chittenden), if there is a precipitate in the urine after it has been subjected to the boiling and nitric-acid test. For demonstrative tests, see the text- books upon the subject. Hitherto this substance has had no diag- nostic significance. Kahler has recently observed hemialhumose in multiple primary lympho-sarcoma of the spinal cord. Fibrin occurs in the urine in hsematuria, in deep-seated inflamma- tion of the urinary passages, in tuberculosis, in poisoning with can- tharides, and in chyluria. It is recognized by the fact that it coagulates spontaneously in the urine, although sometimes only after the urine has stood for some time. The coagula are then to be further examined. 440 SPECIAL DIAGNOSIS, In this place are to be mentioned two phenomena that occur in those diseases of the kidney that stand in close relation to albumin- uria : dropsy and uraemia. The dropsy of kidney disease manifests itself, very frequently, first in the skin of the face, especially at the eyelids. With contracted kidney the oedema is very fugitive, often changing its place ; in a large number of cases, it is entii'ely wanting during the entire course of the disease. With large white kidney it is more decided and stable ; there is often a very soft, doughy oedema. In this respect acute nephritis varies very much. In all forms of Bright's disease, from its association with heart-weakness, a new factor may come into play for the development or increase of the oedema and effusion into the cavities of the body (dropsy of engorgement). With reference to the cause of the dropsy in kidney-disease, no doubt the most important element is the diminished elimination of water by the kidneys. This retention of water often, especially if excessive, has the effect that even a slight, perhaps a scarcely notice- able, dropsy of the skin and subcutaneous tissue considerably disturbs the excretion of water by perspiration. At any rate, it is certain that the dropsy of kidney-disease is, in many cases, not explained by the retention of water ; but neither is Cohnheim's hypothesis, that the walls of the vessels are abnormally pervious, at all generally accepted. This whole matter is still an open question. Uraemia is an association of nervous manifestations which, at least in the majority of cases, is dependent upon the retention in the blood of urinary products (especially uric acid). In individual cases of "uraemic" manifestations, however, this explanation is not correct, and the nature of such cases is not yet clear (oedema of the brain (?), Traube ; sometimes anatomical changes in the brain (?), Striimpell, etc.). We coincide with Striimpell's view, that ursemia is a multi- farious condition — a number of conditions, which by their presence and their phenomena seem to belong together, are in reality different. Slight urtemic symptoms may last, with slight changes, for weeks, even months, as somnolence, restlessness, headache, malaise, vomiting, dyspnoea (ursemic asthma), indications of Cheyne-Stokes respiration, slight transitory disturbances of vision. The more severe symptoms are : decided cloudiness of intelligence, even to coma or delirium ; maniacal conditions ; convulsions, from single convulsive movements EXAMIXATION OF THE URINARY APPARATUS. 441 to pronounced epileptic attacks ; and temporary amaurosis. There may be slowness of the pulse, with acceleration later, and fever. In individual cases there occur evident symptoms of cerebral congestion : convulsions, pargesthesia, paralysis of an arm or of one side of the body, and aphasic manifestations. Mucin. It has already been mentioned when this appears in the urine. When the mucin is dissolved, its presence can be established by the addition of acetic acid : it forms a flocculent, thready pre- cipitate in cold urine, which is not again dissolved by an excess of acetic acid. Coloring-matter of the blood. The occurrence of this body has also been previously mentioned (p. 410). Here we have to refer to testing for haemoglobin, or heematin in solution. First, it must be mentioned that, of course, the urine shows the presence of albumin in both hsematuria and hsemoglobinuria. The amount of albumin is always small, provided there is no albuminuria besides. Blood-pigment will be shown to be present by the following pro- cedures : {a) Heller s test. A portion of urine is made decidedly alkaline with caustic potash, and boiled in a reagent-glass : the phosphates are precipitated as very delicate floccules, which look like mucus, and slowly sink to the bottom. They accompany the blood-pigment, and hence look brown or red-yellow. When the urine is concentrated, we dilute it, after boiling, by filling the reagent-glass with water, because the color of the floccules is easily concealed. Urine that is poor in phosphates, as in nephritis, gives no phosphatic deposit. Such urine must be mixed with some that has the normal amount of phosphates, before making the test. The color described as belonging to the phosphatic deposit occurs nowhere else, except with urine containing chrysophanic acid, but this latter is recognized by its change in color after the reaction. This test is very simple, certain, and, with clear urine, is tolerably distinct. (h) Reaction with tincture of guaiac. The reagent consists of tinct. guaiac, ol. terebinth, ozonisat., aa 10 parts. A small portion of this, placed in a reagent-glass, is carefully covered with urine : when the coloring-matter of the blood is present, there is, besides the dirty white deposit of resin, an indigo-blue ring. When shaken up, the 442 SPECIAL DIAGNOSIS. whole contents of the glass become a non-transparent bright blue. The test is a very distinct one. (c) Test for hcemin. This is made with a large drop of urine or urinary sediment, exactly in the same way as has been described already (p. 363) for finding it in the material vomited. The test is more distinct than the preceding, particularly if we boil it down in a porcelain dish and then apply the reaction. (d) Spectroscopic examination. This gives the absorption-bands of methsemoglobin, namely, in yellow, green, and red. Of course, this is an extremely distinct test. Bile-pigments and Bile-acids. G-mellins test for hile-pigments. We pour a small quantity of nitric acid into a reagent-glass and add to it one or two drops of fuming nitric acid, forming a trace of an admixture of nitrous acid. To this mixture we very cautiously add a layer of urine, by permitting it to flow from a pipette, down the side of the glass held obliquely. When the bile-pigment is abundant, if the fluids are kept carefully distinct, there is a ring of green (blue), violet, and red. The first named constitutes the test. There is no reaction when there is only a small amount of bile-pigment. RosenhacJi s modification is decidedly more distinct. Filter some urine, not too little (about 200 c.cm.), through a medium-sized filter, and pour upon this the mixture of nitric and nitrous acids. The colored rings form upon the filtrate. Still sharper is Gmellin's test, if, after acidulating the urine with acetic acid, we shake it up Avith chloroform, pour ofi" the urine, and then with the chloroform, colored yellow by the bile-pigment, make a layer with the nitric-acid mixture. Penzoldt recommends a filtrate prepared as in the Gmellin-Rosen- bach test (allowing a good deal of urine to flow through), over which acetic acid is poured, and this is allowed to flow into a broad glass vessel, so as to have it in a shallow, but broad, layer. The acetic acid becomes yellow-green, gradually becomes green (quicker, if it is warmed), even bluish-green, Penzoldt declares that this test is very distinct. Pettenkofers test for bile-acids: glycocholic, taurocholic, and EXAMINATION OF THE URINARY APPARATUS. 443 cholal acids. This test is based upon the fact that the addition of a weak solution of cane-sugar (1 to 500) and a trace of concentrated sulphuric acid to urine causes a violet- red color. We must be care- ful not to have the resulting elevation of temperature too high, at most not higher than about 50° C. For various reasons this last reaction is uncertain. Its result is reliable only when the bile-acids, if present, have been isolated. At any rate, the bile-acids have only a slight diagnostic value : a trace sometimes occurs in normal urine, while we find in undoubted cases of jaundice due to engorgement of bile, often none, or only a trace, because frequently in the transmission it becomes broken up in the blood. Hence, we cannot account for the absence of the bile-acids in the urine in cases of icterus by the assumption that it is not an hepatogenous icterus. On the other hand, an abundance of bile-acids in the urine proves that the jaundice is due to engorgement of bile. Moreover, it is clear that if we wish to explain "hepatogenous" icterus by the idea of engorgement of bile in the liver, logically, we must assume an increase of the bile-acids in this jaundice also. As a matter of fact, this is found to be the case in toxic " hemato-hepato- genous'' icterus (arseniuretted hydrogen, toluylendiamin, Stadelmann). Gfr ape- sugar. Pathologically, grape-sugar occurs in the urine : 1. In diabetes mellitus, usually in considerable quantity — as much as two to five per cent, (minimum one-half, maximum ten per cent.). The urine is increased in amount, is bright and clear, of higher specific gravity, as has already been mentioned. 2. As glycosuria (Frerichs), usually in small quantity. It is almost always temporary after poisoning with carbonic oxide, curare, amyl nitrite, turpentine ; sometimes with mercury, morphia, chloral, prussic acid, sulphuric acid, alcohol ; again, in acute infectious dis- eases (typhus, scarlet fever, diphtheria, etc. ; in diseases of the oblongata (but here it is more lasting) ; and from other neurotic causes, as excessive mental exertion, neuralgia, injuries to the central nervous system, concussion of the brain, etc. ; also, after epileptic convulsions and apoplexia cerebri. It is to be remarked that the urine is always to be examined for sugar when it has a decidedly high specific gravity ; but particularly if it is clear and abundant, and, at the same time, has a high specific gravity. 444 SPECIAL DIAGNOSIS. Qualitative test for sugar. Bismuth test (with Nylander's modifi- cation). For this purpose, we employ Nylander's reagent : 2 parts basic nitrate of bismuth and 4 parts soda tartrate, to 100 parts of an 8-per-cent. solution of caustic soda. Of this we take 1 part to 10 of urine, and boil them together. After a few minutes, if there is only a little sugar — sometimes only after it has cooled — it becomes black from the reduction of the contents of the reagent-glass with the formation of the oxide of bismuth, if the urine contains as much as one per cent, of sugar. It is evident that this is a very distinct test. It is only uncertain when there is albumin in the urine (arising from the black sulphuret of bismuth) ; here it had better not be employed. Trommers test. To a given quantity of urine we add about one- third as much liq. potassae, and to this, drop by drop, of a 10-per-cent. solution of the sulphate of copper, as long as it is held in solution by mixing ; then it is heated. A precipitate of yellowish-red hydrated cupric suboxide, which may appear even before the fluid has been boiled, shows the presence of sugar with the greatest probability. The yellow color of the liquid, or a precipitate that takes place later, may be caused by a very small amount of sugar, but also by uric acid and creatinin. Thus, the test is uncertain when the quantity of sugar is small ; hence, in brief, it is not a sharp one. Phenyl-hydracin test (von Jaksch). About two grains of muriate of phenyl-hydracin and three of acetate of soda are put into a reagent- glass which is filled half-full of water. After heating, the glass is to be filled with the urine to be tested. It is allowed to stand for fifteen or twenty minutes in boiling- water, then it is put into a beaker- glass filled with cold water. When there is a large amount of sugar, there is formed a macroscopically visible deposit. With a small amount of sugar, after standing, there is a deposit, which can be seen with the microscope, of yellow needles, single and in druses — phenyl- glucosazon. Yellow plates and brown balls prove nothing. Albumin that may be present must previously be removed by boiling the urine. Jaksch urges this test because it is a very exact one. Its difficulty consists in this, that the needles of phenyl-glucosazon are sometimes not alike clearly characteristic in distinction from the yellow plates, etc., which prove nothing, these latter not being crystallizable in alcohol. Nevertheless, the test seems to be a very sharp one. EXAMINATION OF THE URINARY APPARATUS. 445 Of the other very numerous tests for sugar we only mention the following : Moore's liq. potassce and boiling test, which causes urine that con- tains sugar to become brown — not a very certain and sharp test ; and the test with diazo-benzol-sulphuric acid and potash, recommended by Penzoldt. One test, of great importance and highly recommended on account of its absolute certainty, is somewhat troublesome : Fermentation test. This rests upon the peculiarity that yeast has of separating sugar into alcohol and carbonic acid (succinic acid, etc.). The test may be made in a simple way, as follows : Three perfectly clean reagent-glasses are filled about two-thirds full of mercury. The first is then to be filled with some of the urine to be tested and a little yeast ; the second is to be filled with normal urine and some yeast ; the third with a thin, watery solution of sugar and yeast. It is well to add to each a drop of a solution of tartaric acid. All three tubes are now placed upside down in a tray of mercury, by covering the opening with the thumb as we invert them. The second tube should not show any development of carbonic acid, but if it should do so the yeast was not perfectly free from sugar, and the experiment must be repeated with yeast that is perfectly pure. The third glass should show the development of carbonic acid, otherwise the yeast has become inactive. The first tube shows carbonic acid or not, according to the state of the urine under examination in respect to its containing sugar. The development of carbonic acid is recognized by the existence of gas in the upper part of the inverted tube. Its presence is made certain by its being absorbed when potash-lye is introduced into the tube. Fermentation-tubes are very helpful in employing the fermentation test (see Salkowski-Leube, Penzoldt). Quantitative determination of sugar. This is indispensable, if a case of diabetes is to be carefully observed, particularly for deter- mining its severity, its course, especially the effect of treatment. From the qualitative examination we cannot draw satisfactory con- clusions as to the amount of sugar, except by a comparison of the specific gravity of the urine with its quantity. We make use of the urine that is passed in exactly twenty-four hours. 446 SPECIAL DIAGyOSIS. 1. Estimating it tcith Fehlinc/s solution (after Salkowski-Leube). The Drinciple is that in Trommer's test, the oxide of copper in an alkaline solution of grape-sugar is reduced to a lower state of oxida- tion : five parts of anhydrous grape-sugar will reduce 34,639 parts of pure sulphate of copper to oxydul. The problem is to determine how much of a specimen of urine is necessary to reduce a certain amount of sulphate of copper. Solution I. 34,639 grammes of pure sulphate of copper are, by warming, dissolved in about 100 grammes of water, and the solution is then diluted to 500 c.c. It is to be set away well corked. Solution II. 173 parts of tartrate of soda and 100 parts of officinal solution of caustic soda of the specific gravity of 1034, dissolved in water to 500 parts. This is to be kept in a well-stoppered bottle ; but it must not be allowed to become too stale. Mode of procedure: Equal parts of I. and II. are mixed together. The mixture (Fehling's solution) must not, when boiled, separate any oxydul 10 c.c. of the mixture and 40 c.c. of water are placed in a deep porcelain saucer. Thoroughly mixing the urine of twenty -four hours, we take a portion of this and dilute it with 9 parts of water (urine 1, water 9), and with this we fill a burette. The mixture in the saucer is brought to the boiling-point, and into this the urine in the burette is allowed to flow : there occurs a separation of oxydul and oxydul-hydrate, and the blue color of Fehling's solution disap- pears. The instant when the fluid (if we incline the saucer) first loses its color, shows the completion of the reduction. We allow the amount of urine necessary to complete the reduction to flow from the burette. Calculation : Since 0.05 gramme of grape-sugar reduces 10 c.c. of Fehling's solution, therefore the quantity of the mixture which has escaped from the burette contained 0.05 gramme of grape-sugar We represent that quantity of the mixture by "^," then the mixture in 0.05 X 100 5 the burette contains = - per cent, of suo;ar. And, since the mixture of urine was diluted tenfold, the urine itself contains = — per cent, sugar — that is, 5 times the amount diluted, divided by the quantity of the mixture in the burette that was used. EXAMIXATIOX OF THE UHIXARF APPARATUS. 4^.7 The dilution of the urine is to be varied according to the amount of sugar it contains. 2. Determinijig the sugar hy circumpolmHzation. This depends upon tLe property of sugar to turn the plane of polarization to the right. Recently, the method has come somewhat into discredit, or it has been shown to be exact only when we exclude oxybutyric acid and any levulose that may be present (which, according to Kulz, some- times occurs in severe forms of diabetes). Regarding complicated methods (complete fermentation, etc.), see hand-books upon Urinary Analysis. We do not give a description of the method by polarization, as a description of its use always accompanies the different apparatus sold. (We recommend particularly the simple apparatus made by Zeiss.) Other soluble constituents of the urine. Levulose sometimes occurs in the urine, in addition to grape-sugar, in cases of diabetes mellitus. It gives' the chemical reaction of the latter, and for this reason it cannot, without complicated methods, be recognized, chiefly on account of a striking difference between the quantitative determination by Fehling's solution, on the one side, and thq polarizing apparatus on the other. Levulose turns it to the left : but we must be on guard with reference to oxybutyric acid. Lactose, occurring in puerperal patients, inosite in diabetes in- sipidus, albumin, can only be demonstrated in the urine when they are isolated. Lipuria, as has been already mentioned, occurs in chyluria. It has, in one instance (Ebstein), been found in pyonephrosis; small quantities of fat occur, with large white kidney (see Sediments), in poisoning by phosphorus, and in diabetes mellitus, but also in health after taking very much fat, as cod-liver oil. The proof is by shaking it up with ether. Lapaciduria (fugitive fatty acids in the urine) has recently been much studied, but thus far, from the standpoint of diagnosis, without significance Diaceturia, resulting from glacial acetic acid in the urine (Jaksch), never occurs under physiological conditions. It is observed (always with a simultaneous abundance of acetone, see below) in diabetes, and especially in the severe forms, which then sometimes end in coma ; and in fever, especially with children ; also, according to Jaksch, as an independent disease, likewise particularly in children. Diaceturia 448 SPECIAL DIAGNOSIS. is generally, especially if it occurs in adults, associated with severe symptoms, particularly nervous, which are to be regarded as signs of auto-intoxication [poisoning] ; hence, it may result in deep coma and be the direct precursor of death. As to its significance when it occurs in children, Jaksch, by recent investigations, arrives at the supposition that the convulsions which so frequently occur with them in acute diseases are explained by diaceturia. Proof. Some solution of chloride of iron is slowly added to the urine ; sometimes there occurs a precipitate of phosphates, which must be removed by filtration ; then more iron chloride must be added. If glacial acetic acid is present, the urine becomes a Bordeaux-red. Then the test must be repeated with urine that has been boiled. Further, a poition of urine must be mixed with sulphuric acid, ex- tracted with ether and repeated with the extract ; lastly, it must be examined for acetone (see below). Diaceturia is present if, in the presence of the chloride- of-iron reaction of the fresh urine, 1, the boiled urine shows no, or only a slight, chloride -of-iron reaction ; 2, if the ether extract shows a chloride-of-iron reaction which fades in the course of twenty-four hours at the longest ; 3, if acetone is present at the same time (Jaksch). Acetonuria, in contradistinction from the preceding, is, it seems, in most cases a phenomenon without significance. It occurs in health (a trace), in fever, in diabetes, with inanition, but also without these in carcinoma, in psychoses. There also seems to be an auto-intoxication [poisoning] with acetone (v. Jaksch), which accompanies symptoms of cerebral irritation (also epileptic convulsions), states of depression. The cases hitherto observed have ended in recovery. Thus, an abundance of acetone is found in the urine, but no glacial acetic acid (see above). The exact proof is complicated. Several methods have been given, which, if one wishes to be certain, it is best to employ simultaneously : 1. Distil the urine with some phosphoric acid. Several cubic centi- metres of this distillate are mixed with a few drops of solution of iodine and iodide of potassium ; an immediate precipitate of iodoform- crystals proves acetone (Lieben). 2. We add to the urine some freshly-prepared oxide of mercury, obtained by mixing an alcoholic solution of potash with chloride of mercury. Filter it, and cover the filtrate Avith sulphate of ammonium : a black ring of sulphate of mer- cury shows acetone (Reynolds). EXAMINATION OF THE URINARY APPARATUS. 4-j[,9 Acetone is a product of normal decomposition of albumin. If this body is abundant in the urine it indicates an increased decomposition of albumin. It is worthy of note that acetic acid easily breaks up into acetone and carbonic acid, and that acetic acid, in turn, is a product of oxidation of /3-oxybutyric acid. This acid is found in diabetic coma, as it seems, exceptionally in very large quantities in the urine (Stadelmann, Minkiwsky) ; and it becomes more and more probable that it, in union with other fatty acids, must be regarded as the cause of diabetic coma, as the pupils of Naunyn, mentioned above, have for years maintained. Hence, in diabetic coma we have to deal with an acid-intoxication of the organism, in which it is to be assumed that the given acids only as acids are poisonous — that is, by the withdrawal of alkalies from the blood. In close relation with the withdrawal of the acids stands (according to Hallervorden, Stadelmann) the separation of a substance with which the organism, as long as possible, attempts to neutralize the pernicious acids : the separation of ammonia in the urine. We cannot go into the subject here, for the reason that the quantitative deter- mination of ammonia does not come within the province of this work. [The Translator adds here a summary of Stadelmann's observations upon "Diabetic Coma," as given in the American Journal of the Medical Sciences, taken from Deutseh. med. Wochenschrift, 1889, No. 46 : " 1. Diabetic coma, apart from accidental coma due to other causes, occurs only in the case of diabetic patients whose urine contains oxybutyric acids. " 2. Almost equivalent in value with the recognition of oxybutyric acid is the determination of the amount of ammonia in the urine ; while it is also far easier of performance. " 3. Diabetic patients with an excretion of ammonia of more than one and one-tenth grammes per day, are in danger of becoming severe cases of the disease. " 4. Patients excreting two, four, six, and more grammes of am- monia daily, need constant watching by the physician, and are in constant danger of passing into diabetic coma. " 5. If the determination of the presence of oxybutyric acid, or the estimation of the amount of ammonia, cannot be carried out, at least the chloride-of-iron test should be made. If this gives a more positive 29 450 SPECIAL DIAGNOSIS. reaction, oxybutvric acid is present in the urine, and the cases answer to the statements made in the third and fourth conclusions. The converse of this, however, is not always true, for there are cases of diabetes with oxybutvric acid in the urine, and even suffering from diabetic coma, the urine of which does not give the chloride-of-iron reaction/'"] Regarding the occurrence of the two compounds of sulphuric acid or of the products of their decomposition (here also belong indican, which has been previously mentioned, indoxylsulphuric acid), also of ptomaines, ferments (especially pepsin), see the various special works upon these subjects. The Urine as Affected hy Medicines. The determination as to whether a medicine has been taken or not may often be of diagnostic importance. A number of medicines may be directly detected in the urine ; to those not easily, or not at all, demonstrable to a slight extent, according to Penzoldts recommenda- tion of a particular case, we can add one easily demonstrable. If we find in the urine the reaction of demonstrable medicines that have been given, then we can naturally assume that any other which was mixed with it has been taken. Iodide of potassium. Add a couple of drops of red fuming nitric acid and about one-quarter as much chloroform as there is of urine ; shake it; the chloroform gradually settles down, colored reddish- violet. Bromine. The same method ; chloroform colors it brown-yellow. Salicylic acid. The urine is made a blue-violet by the chloride of iron (not Burgundy-red, see Diaceturia). When the amount of sali- cylic acid is small, we shake up the urine (to which some sulphuric acid has been added) with ether and then apply the test. Rhubarb and senna, see p. 411. Carbolic acid, also naphthalin, resorcin, etc. Upon standing, the urine becomes olive-green to brown-black, even black (hydrochinon). Exact determination requires particular methods. Salol. Urine containing this, as well as carbolic acid, becomes green to black, and, at the same time, responds to the tests for sali- cylic acid. EXAMINATION OF THE URINARY APPARATUS. 45I Antifehrin. Add one-fourth volume of a concentrated solution of hydrochloric acid in a reagent-glass ; boil for a few minutes ; cool ; add a few c.c. of a three-per-cent. solution of carbolic acid and a drop of dilute solution of chromic acid. The mixture becomes red ; after the addition of ammonia up to an alkaline reaction, a beautiful blue. (After Miiller.) Antipyrin, thallin. Red coloration with chloride of iron ; more- over, thallin urine is green-brown. Works upon Chemical Analysis and Toxicology give further information. CHAPTER YIII. EXAMINATION OF THE NERVOUS SYSTEM. Anatomy; Normal and Pathological Physiology. Only a sketch of Avhat is most important can be given here. For further particulars, see the special text-books upon the subject. 1. THE CORTICO-MUSCULAR TRACT (THE PYRAMIDAL TRACT, FLECHSIG). It has its origin in the so-called psycho-motor centres of the cortical substance of the cerebrum. These lie in the motor-cortical Fig. 139. ^^obulus paracentralis Lateral view of the brain. (Combined from Ecker.) Gyri and lobuli marked with antique type, the sulci and fissures with italic type. (452) EXAMINATION OF THE NERVOUS SYSTEM. Fig. 140. 453 •If.spinaf Diagram of the motor tracts of the facial nerve and of the nerves of the extremities. (Edinger.) AtA,B, C, are indicated supposed local diseases. ^, lesion of the left side of the internal capsule, causing right hemiplegia on the right side; B, lesion of the left half of the pons, touches the pyramidal tract of the extremities of the right side and of the left facial, causing crossed paralysis ; C, shows the rare condition of uncrossed facial paralysis and paralysis of the extremities from lesion in the pons. 454 SPECIAL DIAGNOSIS. Fig. 141. region, which includes the anterior and posterior central convolutions and the lobus paracentralis of each hemisphere. It has been found that the centre for the lower portion of the face (the countenance, exclud- ing the forehead), and the tongue, is from the lower section of the anterior rather than the posterior central con- volution. The centre for the arm is in the middle portion of the anterior central convolution. The centre for the leg is in the lobus paracentralis and the upper section of both central convolutions. Thus, the centres of the cortex lie tolerably wide apart. The tracts course from there, and next converge in the corona radiata, in a fan-shape, to the internal capsule, where they lie close together in its anterior segment, hence between the lenticular nucleus and optic thalamus. They lie close behind a point midway between these [but do not connect with them]. From thence they go to the foot of the crus cerebri, passing about in the middle of it. In the pons, the pyramidal tracts are split up by transverse fibres. They unite again to form pyramids at the an- terior portion of the medulla ob- longata, and here the pyramidal tracts of the two sides lie very close together. [From the circumstance that they form the anterior pyramids of the medulla, they receive their name, " pyramidal tracts."] At the lower end of the medulla the right Diagram of the innervation of the muscles. (Partly from Edinoer.) The radiation of flie Py-tracts varies at different portions of ihe cortex (see p. 452). Py-H, pyramidal tract for the cervical spinal cord ; Py-L, pyramidal tract for the lumbar por- tion of the cord ; H, cervical cord ; L, lumbar cord; Py-V \b omitted. Notice that down to the lumbar por- tion of the cord Py-L passes in the lateral column. EXAMINATION OF THE NERVOUS SYSTEM. 455 and left pyramidal tracts interlace, so that very much the larger part of the fibres go to form the lateral column of the opposite side of the spinal cord (lateral pyramidal tract). Only a small part of the fibres [of the external aspect of the pyramids], without crossing to the opposite side, pass to the anterior column of the spinal cord [forming the columns of Tiirck]. (Anterior pyramidal tracts, Pi/- V.) At diiferent levels of the cord, from the lateral pyramidal tracts, fibres continually pass to the ganglion cell-groups of the same side, and from these ganglion cells arise the anterior roots of the [nerves of the] spinal cord. These unite with the posterior, and form with them the mixed peripheral nerves. In these the motor tracts pass to the muscles. The tracts for the motor cranial nerves separate in the pons and oblongata successively from the pyramidal tracts, decussate, and enter the anterior horn ganglia arising from the ganglion cells, quite analogous to the gray nuclei of the pons and oblongata, at the floor of the fourth ventricle. From these arise the motor cerebral nerves. Fig. 142. ^^WM •w w ■^ nwmmwm::^ I wr. M.w. Location of the nuclei of the cranial nerves. ("Edinger.) The oblongata and pons are represented as transparent. The nuclei of sensation are red, the motor are black. The centres of the cortex are those of voluntary motion ; the centres of the anterior horns simply convey these to the peripheral nerves. Moreover, they are the reflex spinal centres, in that they receive sensible irritation from the posterior roots of the spinal cord 456 SPECIAL DIAGNOSIS. (see below) and transpose them into motor stimuli, which they convey to the anterior roots. But both central apparatuses also have trophic influences — that is, they preside over the nutrition of a certain section of the cortico- muscular tract. The cortical centres preside over the nutrition of the fibres until they enter the ganglia of the anterior horn. These latter control the nutrition of the peripheral nerve-fibres and of the muscles. Paralysis is produced by any lesion (local disease : hemorrhage, softening, inflammation, tumor) at any point in the cortico muscular tract which disturbs the central ganglia or interrupts the course of the tract. According to the location of the lesion, this paralysis shows difierent characteristics ; and these may primarily be studied from three points of view : 1. If the lesion is located in the cortex, or afiects the tracts above the point of decussation, then the paralysis is upon the opposite side of the body ; on the contrary, lesion below the decussation produces paralysis of the same side. If located in the pons, it may happen, for example, that besides the pyramidal tract, which as yet has not decussated, it affects the fibres of the facial, which have already crossed over (see above), it then causes paralysis of the opposite side of the body and of the same side of the face, hence these two cross each other — hemiplegia cruciata sen alterans. 2. If the lesion affects a cortical centre, or a point in the pyramidal tract in the brain, the pons, the oblongata, the spinal cord above the point of entrance of the particular tract into ganglia of the anterior horn (or the analogous gray nuclei of the oblongata or of the pons), then, because the trophical influence of the cortical centre from above ceases at that point, the aff"ected tract degenerates just up to the cor- responding cells of the anterior horn, while these and the peripheral nerves and the muscles do not degenerate. This degreneration of the pyramidal tract does not in itself cause any further clinical phe- nomena. On the other hand, if the lesion is in the anterior horn, or downward from there in the motor tract, there is degeneration downward of the nerves and muscles supplied by the portion Avhich is the seat of the lesion. In the latter case, we have the clinical evi- dences of degeneration (rapid diminution in volume, diminution or loss of electrical reaction, and other signs of degeneration, see below). EXAMINATION OF THE NERVOUS SYSTEM. 457 3. Since the centres and tracts in the different sections in some instances lie wide apart and in others close together, a certain extent of lesion, according to its location, will cause a paralysis widely different in its extent : (a) A lesion of* considerable extent located in the cortex, or in the corona radiata, just under it, generally affects the centre for one-half of the countenance, or an ai'm, or a leg (monoplegia). (b) If located in the internal capsule, then the lesion need not be so very large in order to produce a paralysis of the whole of the opposite side of the body — hemiplegia. This points to the crus cerebri. (c) If the lesion is in the cord, where the motor organs and all the other nervous organs of the body lie close together, it easily causes paralysis of both sides : thus, lesion of the dorsal portion of the cord produces paralysis of both lower extremities, or paraplegia inferior ; lesion of the cervical portion of the cord sometimes causes paralysis of both arms and both legs, or only the former — paraplegia superior seu brachialis. To the above statements we may add still another : (d) If the lesion is in the pons and oblongata, it may easily affect to a considerable degree the centres that are very essential to life, as the respiratory-centre, vagus-centre for the heart, and death may soon follow. Often, if there is hemorrhage or softening, it may take place immediately. A local disease at the base of the brain injures the cranial nerves which go off from that point. If it is located in the anterior cranial fossa, the olfactory nerve will be affected ; if in the middle cranial fossa, it may cause disease of the opticus, oculomotorius, trochlearis, abducens, sometimes also the olfactorius ; if in the posterior fossa, the trochlearis, abducens, facialis, acusticus, glosso- pharyngeus, vagus, accessorius, come under consideration. The disease may be bilateral. See the illustration, Avhich shows how the different nerves come together at the base of the skull. From simultaneous injury to the crus cerebri, pons, and oblongata, the pyramidal tracts may become affected, and paralysis of the extremi- ties results. In basilar affections, this is generally less marked than is the paralysis of the cranial nerves. 458 SPECIAL DIAGXOSIS. The foregoing contains only tlie introduction to the points of diagnosis in these directions. We must refer for particulars to the Fir.. 143. Points of exit of the cranial nerves from the skull (Hexle.) The Roman figures indicate the cranial nerves; Vi,V2, V^, first, second, and third branches of the tri- geminus : V-, Gasserian ganglion. chnical text-books. We refer here to text-books upon clinical medi- cine, and pax'ticularly to the second edition of Edinger's book on the EXAMINATION OF THE NERVOUS SYSTEM. 459 Structure of the Central Organs of the Nervous System, the second edition of which has just appeared. 2. THE SENSITIVE OR CENTRIPETAL TRACTS, The tract of the sensibility of the skin of the trunk and of the extremities passes from the sensitive terminal fibres of the skin in the mixed nerves, then into the posterior root to the cord. From there it, for the most part, enters the posterior horn (it is doubtful whether a small portion may not enter the lateral column) ; it decussates soon after its entrance into the cord — how, we do not know. Above the cord we do not know the behavior of this tract till it reaches the tegumentum cruris cerebri, into which it passes. Then it enters the inner capsule behind the pyramidal tract — that is, in the posterior third of the posterior peduncle. Beyond this, we do not exactly know its course. The tract of deep sensibility (usually called the muscular sense) probably has the same course as that we have just described. Most probably it ends in the motor cortical zone of the central convolutions and the lobus paracen trails. An important centripetal, but not in the strict sense a sensitive, tract, are the columns of GoU, which likewise arise from the posterior roots, which, moreover, only from the upper part of the dorsal portion of the cord, and above that point, form a compact bundle in the median portion of the posterior column. We know nothing positive of their function. Also, the lateral column of the tract of the cere- bellum is centripetal, which, in the upper portion of the cord, springing from the columns of Clarke, goes into the cerebrum. Its function, also, is not entirely clear ; probably it is of service in preserving equilibrium. Severe lesions, or complete interruption of the tract of sensibility of the skin in the peripheral nerves, or in the cord, or in the internal capsule, cause total ansesthesia of the skin. If the lesion is not severe, there is diminution of the sense of touch or a partial loss of sensibility — a partial paralysis of sensibility, as the sense of pain — and this latter is frequent, especially in disease of the spinal cord. Ansesthesia from local disease of the internal capsule, or of the spinal cord, manifests itself upon the opposite side. 460 SPECIA L DTA GNOSIS. 3. CENTRES AND TRACTS OF THE SPECIAL SENSES. (a) Sight. This tract passes from the retina in the eye to the chiasm. Here occurs a peculiar partial decussation (semi- decussation), which is reproduced in Fig. 144 : the optic nerve-fibres belonging to the outer half of the retina do not cross, those belonging to the inner half do. Then it passes in the optic tract to the anterior corpus quadrigeminum, and from there in the posterior third of the posterior limb of the internal capsule entering into relation with the pulvinar of the optic thalamus and the corpus geniculum ext., and then spreads out obliquely backward and upward in the cortex of the occipital lobe. The most important points in relation to this nerve are the following : Fig. 144. Diagram of the optic nerve-fibres in the chiasm. 1. That pathological processes at the base of the brain, and lesions in the posterior end of the inner capsule (causing a simultaneous hemi- ansesthesia), of the pulvinar of the optic thalamus, or of the occipital lobe, produce disturbances of vision. 2. That every complete destruction of the cortical centres in the occipital lobes, as well as of the tract from there to the chiasm, cuts off the impressions of sight from the outer half of the retina of the same side and the inner half of the opposite side, thus from synony- mous halves of the two retinae. Thus, hemiopia and hemianopsia are produced (see under Eye). (b) Hearing. The acoustic nerve passes, together with the facial, EXAMINATION OF THE NERVOUS SYSTEM. 461 to the oblongata, to the acoustic ganglion, in regard to which we cannot here enter into further detail. In its central course it comes into relation with the cerebrum, and then appears, probably, in the most posterior, sensitive portion of the internal capsule, whence it spreads out in the cortex of the temporal lobe (see Word-deafness). (c) Smell. Of the olfactory nerve perhaps nothing more is to be said than that its centripetal tract seems to pass through the posterior portion of the internal capsule. The sense of taste is located [chiefly] in the glosso-pharyngeus nerve, distributed to the palate and the pos- terioi? third of the tongue, by which nerve it is conveyed to the oblongata. The course for the anterior two-thirds, however, is com- plicated : as the chorda tympani, it first passes in the lingual nerve, but leaves this and goes to the facial, leaves this again at the genicu- late ganglion, and probably extends, as the greater superficial petrosal nerve. Vidian, and the spheno-palatine ganglion, to the trigeminus (second branch), going toward the centre with this. We again meet the fibres of taste in the posterior portion of the inner capsule. It is very important to note the participation of the sense of taste at the anterior portion of the tongue in peripheral paralysis of the facial, and also (according to Erb and others) in disease of the tri- geminus situated high up, as well as in lesions of the posterior portion of the inner capsule (hemiaesthesia). Until we come to the symptomatology, we delay speaking of all other points regarding localization of the brain, especially regarding aphasia and the phenomena associated with it, and regarding the oi'igin of certain forms of convulsions, of vertigo, coordination, etc. 4. EEMARKS UPOX THE VESSELS SUPPLYING THE BRAIN. The brain is supplied with blood from the two internal carotids and from the vertebral artery. The right and left vertebral unite at the basilar surface of the pons to form the basilar artery ; this, again, divides at a point corresponding to the anterior inferior border of the pons into the two posterior cerebral arteries, which, by the posterior communicating arteries, form a connection with the carotids (the circle of Willis). Besides the ophthalmic and the posterior communicating, the carotid gives ofi" the anterior communicating, which, with its opposite fellow, completes the circle of Willis. There also arises from 462 SPECIAL DIAGNOSIS. the carotid the middle cerebral, the [largest, and] most important vessel of the brain. Of these vessels the greatest interest attaches to those which supply the pons and medulla, and the most important part of the cortex and the internal capsule. The pons and medulla are chiefly supplied by the basilar and vertebrals. The branches of these are terminal arteries — that is, they do not anastomose with each other, or with other branches in their neighborhood. Hence, thrombosis or emboli of such branches, or, for instance, of a part of the basilar, immediately produces arrest of func- tion, and, besides, unless the stoppage is again removed, produces anoemic necrosis of the affected portion of the pons or medulla. The region of next importance is that supplied by the middle cerebral artery (the artery of the fissure of Sylvius). This, as well as the regions of the cerebrum supplied by each of the two other arteries supplying portions of the cerebrum, divides distinctly into two parts, which do not anastomose with each other, into an inner and a cortical portion. The inner region, supplied by the middle cerebral artery and its branches, embraces the internal capsule, with the exception of its posterior section (sensory tract), the lenticular nucleus, the greater part of the caudate nucleus, and a part of the optic thalamus. This internal region of the middle cerebral artery (artery of the fossa of Sylvius) is sharply distinguished from the neighboring regions of the other arteries of the brain : there are no anastomoses ; hence, con- tinuous occlusion of this vessel at its root must inevitably result in softening of the above-named central portion of the brain. The cortical region of the middle cerebral artery extends over the third frontal convolution, the anterior central convolution (with the excep- tion of the upper portion, which belongs to the anterior cerebral artery), the posterior central convolution, the superior and inferior parietal lobes, the whole region in the neighborhood of the fissure of Sylvius, lastly, the second and third temporal convolutions. This cortical portion of the artery of the fossa of Sylvius seems to anasto- mose, in individual instances, with the neighboring cortical regions in a great variety of ways ; for this reason, occlusion of the artery in only a part of the cases results in softening of this cortical portion of the brain. The optic centre of the occipital lobe, the corpora quadrigemina, EXAMINATION OF THE NERVOUS SYSTEM. 453 and the posterior portion of the internal capsule are supplied by the posterior cerebral artery. The prominence of the middle cerebral artery consists not only in the fact that it supplies the most important portion of the cerebrum, but also because it is within this region that both hemorrhages and emboli most frequently occur. These two disturbances chiefly affect the internal region of the artery — the hemorrhages, probably, because the pressure is highest in the branches that go directly off from its root, or that here is felt most strongly the rapid changes in the power of the heart; but emboli much more frequently disturb the inner territory than the cortical, because, as was mentioned before, there are no anastomoses in the former region, while in the cortical there are. In the relation of the left carotid to the aorta (going off at a very acute angle) seems to lie the explanation as to why emboli are much more frequent in the left middle cerebral artery than in the right. Symptomatology and Methods of Examination. examination of the seat of disease. We learn from the physiological properties of the nervous system that when affected by disease there is little or nothing to be seen at the seat of the disease, while the symptoms are manifest at other por- tions of the body often quite distant from it. Besides, the brain and spinal cord are almost entirely removed from the possibility of being examined, on account of their bony casements. Lastly, very often a local disease of the nervous system, although it causes pronounced phenomena, is locally very indistinct. For all these reasons, the local examination of the nervous system, in a number of its diseases, is quite subordinate. Still, we place its consideration first, because in a systematic examination it belongs there, and because the expression of our opinion cannot at all affect the value which it, nevertheless, in many respects possesses. The S?:ull. — The majority of the diseases of the brain and its coverings run their course without any manifest effect upon the skull ; indeed, there is no disease of that organ in which it may not more or less frequently happen that alterations in the skull were entirely wanting. If there are such alterations in a portion of the cases, 464 SPECIAL DIAGNOSIS. they are secondary in their nature, dependent upon disease on the inner surface ; in other, more rare cases, the alterations of the skull are the cause of the disease of the brain. As methods of examination, Ave mention inspection, palpation, and measuring or tracing the shape of the cranium upon paper. The Size of the Cranium. — Generally this is determined by the circumference of the head over the glabella and the occipital protu- berance, and by estimating the relation between the brain-case proper and the face. This latter can be measured simply by the eye. In the newly born the circumference of the head is 39 to 40 cm. (accord- ing to others somewhat less). In the course of the first year it increases to about 45 cm., and from then to the beginning of the twelfth year to 50 cm. ; in adults it amounts to about 55 cm. (in women it is generally somewhat less than in men). Marked enlargement of the cranium, macrocephalus (to 80 cm. and more in circumference), occurs with hydrocephalus, if the fontanelles have not yet closed. Then the frontal bones particularly project; the countenance is proportionally too small, the eyes are directed down- ward, the expression is often peculiarly staring ; the fontanelles are very large and remain open for a long time ; the cranial bones are thin. Hydrocephalus which occurs later, when the skull has already closed, causes little or no enlargement of the head. Moreover, a somewhat considerable macrocephalus is peculiar to the rhachitic skull, and is here dependent upon thickening of the bones of the skull. But it is generally somewhat angular (caput quadratum). There is no notable recession of the bones of the face as in the former; the bones give the impression of being dense, only the occipital bone is sometimes very thin, even as paper, sometimes upon pressure crackling like parchment (be careful !). Here, too, the fontanelles remain open abnormally long — sometimes into the third year. The distinction from hydrocephalus is made in the first place by an examination of the nervous system, which in this disease is almost always injuriously affected (as respects its psychic, intel- lectual, and motor functions), Avhile in rhachitis it is normal ; also the evidences of rhachitis are to be sought at other points (the infe- rior maxilla, the thorax, the bones of the extremities). Moreover, we may have a combination of hydrocephalus and rhachitit thickening of the cranium. EXAMIXATIOX OF THE yERVOUS SYSTEM. 4^5 Abnormally small skull, microcephalus, is naturally connected Tvith abnormally small brain, thus necessarily with idiocy (see). Form of the Skull. — Departures from the typical form. Here belong dolichocephalus, brachycephalus, and other forms of head which are often met with without any pathological condition of the brain, but also in congenital malformation of the brain, as in idiots. Asym- metry of the skull likewise occurs with this condition, but also not infrequently with persons who are perfectly healthy and intelligent. We discover the asymmetry of the skull by viewing it from above or by tracing it upon paper : measuring the sagittal and the large trans- verse diameters of the cranium with the calipers, and making an outline with a strip of lead as was described upon page 163, in the examination of the form of the thorax. Circumscribed projections and depressions have much greater path- ological significance, the latter, however, very frequently not with reference to disease of the brain but as signs of a general disease. Projections occur in disease of the cranial walls and of the dura mater, ^ and these are chiefly syphilitic gummata, carcinoma, and sarcoma. Sinking-in, depressions, impressions, may be traumatic. If there is defect of the bony wall the defect may feel like a fontanelle. Soft and slightly depressed [or depressible] round spots are sometimes present in carcinoma of the cranial vault. Very important, lastly, are scar-like, round depressions over which the scalp is adherent, and which often contain an actual scar: these occur as the result of healed syphilitic gummata or deep ulcerations. All these appearances, but especially the traumatic and syphilitic depressions, are of the greatest diagnostic importance. When the skull is thickly covered with hair they may be easily overlooked, if we do not examine it with the greatest care by feeling all points. In making the examination of the cranium, it is of the greatest importance that we should have a clear conception of the location of the brain and its different parts with reference to its bony casement. We cannot here go into particulars, but attention is called to Fig. 14-5, from which we especially learn the relation of the so-called motor cortical regions of the temporal and occipital lobes to the cranium. 1 The knowledge and significance of tumors of the cranium caused by meningocele and cephalocele are taught in works upon surgery. 30 466 SPECIAL DIAGNOSIS. The most important point is that the motor cortical region lies just in front of a vertical line drawn through the external orifice of the auditory canal. Fig. 145. Explanation of the topographical relation between the surface of the brain and the skull, c, fissure of Rolando; iTC and Y C, posterior and anterior central convolu- tion; S, S, S, fossa of Sylvius; P, P, upper and lower parietal lobes; 0, occipital lobe; C6, cerebellum ; T, temporal lobe ; i^. Frontal lobe. (Strumpell from Ecker.) Sensibility of the Cranium to Pressure. — This is ascertained by pressure with the finger or by gentle stroke with the tip of the finger or the percussion hammer. General sensibility to pressure occurs in nervousness, especially nervous pain in the head. We also sometimes meet Avith circumscribed sensibility to pressure in nervous- ness, also in hysteria ; but sometimes the latter corresponds with a circumscribed meningitis, as this may be caused chiefly by tumors, abscess of the brain, etc. If there are other signs of a disease of this character present, then its topical diagnosis may be aided by palpation and percussion ; by itself its results must be received with caution. Regarding the significance of dilatation of the veins of the skuU, see page 260. EXAMIXATIOX OF THE NERVOUS SYSTEM. 467 Suppuration of the ear and nose (the latter seldom) plays an im- portant part as causes of meningitis and abscess of the brain. THE SPIXAL COLUMN. Form. The significance of the expressions scoliosis, kyphosis (lateral and posterior curvature of the spine) and kyphoscoliosis have already been referred to on page 88. Lordosis is an abnormal cur- vature forward. If these curvatures are obtuse-angled, none of them have a deleterious effect upon the spinal cord, or at least only excep- tionally. Acute-angled kyphosis (gibbous), as is usually caused by caries of the vertebrae, also by fracture of a vertebra, is of much greater importance, [causing] compression of the cord. It is to be remarked that in order to recognize slight lateral curvature it is desirable to mark the spines of the vertebrne, without moving the skin, with a blue crayon, and then to observe carefully the line that is thus formed. Any weakness or paralysis of the muscles of the spine on one or both sides may lead to secondary curvature of the spine, espe- cially to scoliosis and lordosis ; see still further regarding this under Function of the Muscles. Diminished mobility of the spinal column, if it occurs with respect to the whole length in persons of mature years, is often not patho- logical. Complete general stiffness occurs, also, in arthritis deformans. If the stiffness is limited to a certain portion, while the rest of the vertebrae have free motion, this is of pathological significance (almost always due to caries, and here we sometimes have stiffness without curvature of the spine). Forcible bending is then generally painful. The spinal column is abnormally mobile when there is weakness or paralysis of its extensor or flexor muscles in young persons. This is especially marked in juvenile muscular atrophy, often in connection with habitual curvature. Sensitiveness of the vertebral column to ijressure (especially of the spines of the vertebrae) may have a great variety of significance. There may be palpable disease, especially caries, but also tumors of the vertebrae, of the spinal meninges, spinal meningitis, or tabes ; but it may likewise occur with spinal irritation (particularly in the neck and between the shoulder-blades), as well as in hysteria, and here it may be excessive. We discover this sensibility by strong pressure. 468 SPECIAL DIAGNOSIS. or by striking the spines of the vertebrte. Often, but by no means always, there is at the same time painful sensibility when a hot sponge or the cathode of the galvanic current is passed over it. Here, also, belongs the rigidity of the neck in meningitis, particu- larly basilar — an important sign of this disease ; also, the rigidity of the whole spinal column in spinal meningitis. With the former, by the contraction of the cervical extensors of the head, the latter is often bent back to a marked degree, " boring into the pillow." Backward bending of the vertebral column — opisthotonus — likewise occurs with attacks of tetanus ; with epileptic, and especially hys- terical, convulsions. With the latter, as the " arc de cercle," there are sometimes incredible distortions. The anatomical relation of the cord to the spinal column is as follows : the cervical enlargement of the cord corresponds about with the third cervical or the first dorsal spine, the lumbar enlargement about on the level with the ninth dorsal to the first lumbar vertebral spine; the conus terminalis begins at the first or second lumbar vertebra. THE PERIPHERAL NERVES AND THEIR SURROUNDINGS. The nerves, as the seat of disease, come into consideration in all peripheral paralyses and in neuralgias (also among others, in reflex epilepsy). In order directly to examine a nerve-trunk, an exact knowledge of its course is necessary, and also of the organs that surround it, from which an injurious effect upon the nerve may proceed. By the examination of a nerve we learn its anatomical condition : any possible symmetrical thickening, with neuritis or perineuritis, unequal thickening or tumors in the nerve, with neurofibroma, neuroma ; also any possible sensibility to pressure, as occurs with neuritis along the whole length of the diseased nerve, although this may be entirely absent. Finally, here belong the sensitive points in neuralgias (see below). Moreover, a special examination must be made of certain points, which, from any cause whatsoever, may easily be the starting-point of a disease of a peripheral nei've. These are : (a) those points where a nerve is especially exposed to traumatism, because it lies near the EXAMINATIOX OF THE XERVOUS SYSTEM. 469 surface of the body (especially if it at the same time lies oyer a bone). These situations essentially coincide, in part, ivith the electro-motor points to be mentioned later. Severe injuries, deep punctures, etc., of course, may destroy a nerye at any point. They are : (5) neigh- borhoods "where a nerve may be exposed to injury from other organs. Here belongs compression by development of callus about the seat of fracture, especially of the bones of the extremities ; also com- pression and sometimes inflammatory irritation from glandular tumors (axilla, neck, etc.), aneurism, hernia (crural nerve) ; lesion of the facial nerve caused by caries of the petrous portion [of the temporal bone], etc. Indeed, in case of lesion of a peripheral nerve we are frequently able to find the seat of the disease in this sense ; but in every sincjle case it must be looked for. An extremely instructive case from the standpoint of diagnosis of the locus morbi vras observed by Erb, which was reported by the author. It was a case of ulnar neuritis resulting from exposure of the ulnar nerve from the fracture of the internal condyle of the humerus. The author has recently seen a similar case : both internal condyles of the humerus projected; the sulcus ulnaris was broad and shallow. In the first case there was a unilateral, in the second a bilateral, ulnar neuritis resulting from frequent injury to the nerve at its exposed point. EXAMIXATIOX OF THE COXDITIOX OF THE MIXD. In this section, which touches upon a territory foreign to this work, — the mental state — we must, of course, limit ourselves to a brief mention of what is necessary in making a medical examination. 3Iode of examination. An attentive observation of the behavior of the patient in bed, the expression of his countenance, his position, the reaction to external impressions, give many disclosures regarding the faculty of perception, and of his sensibility [or well-being]. By engaging the patient in conversation (taking the anamnesis, page 18), we are able to discover more regarding these points, and to judge of the intellectual activity : memory, imagination, possible delusions, the ability to think logically. In testing the memory, we take notice of the recollection of things that are long past, as well as of more recent events, or of what has taken place during the present illness. The 470 SPECIAL DIAGNOSIS. test of the power of thought and of the imagination is made by more or less simple arithmetical problems and by questions which are suit- able to the social position and the occupation of the patient. We observe the great diflFerence which various degrees of education pro- duce in patients affected with the same disease, and we also take into consideration the age of the patient. We observe any possible diminution or increase of action, both instinctive, as the taking of food, or sexual indulgences, and of actions with conscious purpose. This expresses in general terms the course of the examination. To be sure, we shall very frequently be obliged, in order to recognize the first traces of a mental disorder, to take into consideration whether the patient has changed in his nature or behavior. Thus, for example, if a person becomes suddenly forgetful, careless, and disorderly, this will have quite a different significance than if he had always from his youth been so. Of course, in regard to these things we must chiefly rely upon the statements of his relatives. In what follows is given the explanation of the terms that have been adopted in the medical clinic, and the phenomena that accom- pany the several conditions : Disturbances of consciousness are designated, according to their severity, as : stupor, also somnolence (sleepiness, lethargy, from which the patient can easily be awakened) ; sopor, in which the patient can only be awakened by decided appeals to his senses ; coma, or complete loss of consciousness, in which the patient cannot be awakened in any way. The slightest degree of obtunded conscious- ness manifests itself in the scarcely noticeable trouble which it costs the patient to collect himself in order to answer a question, or by his indifference with respect to being sick — a subjective sense of well- being. Further, there is an indication given by the sensibility to pain, and the arbitrary or involuntary voidance of the stools and urine. In this respect, the sensibility to pain often does not coincide with the other manifestations of consciousness. Disturbance of consciousness occurs : in acute infectious diseases ; especially in typhoid fever (see more below), where the early mani- festation of dulness has diagnostic value; but it may accompany any infectious disease, and may pass into deep coma; in acute poisoning of various kinds, especially from narcotics ; as ur£emic, diabetic, carci- nomatous coma ; as epileptic, apoplectic coma ; in meningitis ; in the EXAMIXATIOX OF THE XERVOUS SYSTEM. 47I most varying diseases of the brain, especially in tumors of the brain and its meninges. In the different forms of meningitis, however, consciousness may be retained for a remarkably long time. In tumors of the brain there is often for a long time a slight obscuration. It occurs also in injuries and concussion of the cranium; in large hemor- rhages; in all chronic cachexia at the end of life, at any rate in the last moments. A patient "svho is in deep coma when he comes under the eye of the physician always causes great difficulty in diagnosis, the greatest when he can make no inquiry in regard to the patient. Systematic examination of the whole body is to be made: of the cranium for wounds; of the heart and vessels; for evidences of apoplexy, menin- gitis ; for signs of poisoning ; of the urine, which is to be drawn with the catheter (for sugar, reaction for chloride of iron, for albumin, casts; for certain poisons or as evidence of certain poisons, hemo- globin) ; lastly, of the stomach by evacuation (poisons). Special Phexomexa of Obtuxded Coxsciousxess. — Delirium, that is, talk and gesticulations arising fi-om delusions. It may follow any disturbance of consciousness, but it occurs especially frequently with acute infectious diseases ; with severe cachexia, often as the end of life approaches ; finally, as delirium tremens seu potatorum, in chronic alcoholic poisoning. The latter manifests itself by talkative- ness, restlessness, rapid alternations between passion and great anxiety, fear, hallucinations of sight (small black animals, especially mice, etc.), loss of sensibility to pain and cold ; besides alcoholic trembling (see). The expression "muttering delirium " is used to designate a low murmuring with profound disturbance of consciousness. It is always a serious indication of great weakness and occurs particularly with typhoid fever. Hysterical delirium forms a transition to the true psychoses, which cannot be treated here. Spasms, vomiting, see below. Loss of consciousness, which quickly passes off, occurs as " syn- cope," " dizziness." This may be very benign, as in anaemia and chlorosis, nervousness, great excitement, or severe pain. But it may have a serious significance in elderly people as precursors of apoplexy, or as slight epileptic attacks (petit mal) ; lastly, it occurs in all possible chronic diseases of the brain, but especially in progres- 472 SPECIAL DIAGNOSIS. sive paralysis. All of these conditions must be thought of when attacks of dizziness occur frequently in the same individual. Dizziness, vertigo. In many respects this is to be looked upon as a slight, temporary loss of consciousness, or connected Avith it (see above). But it only indicates a disturbance of the sense of equilibrium and occurs as such most purely as a swimming of the eyes in diplopia (see Eves) from deception regarding the location of objects in space and regarding the level of the floor. It also occurs in affections of the ear (vertigo ab aure laesa) ; in tumors of the brain, especially of the vermiform process of the cerebellum ; in multiple sclerosis ; with diseases of the stomach (vertigo a stomacho Igeso) ; in anaemia, and in cerebral neurasthenia. Pathological depreciation of the power of the mind to perform its functions is designated as imbecility. It occurs in all gradations from moderate diminution in the perceptive faculties, to a complete animal condition. Congenital imbecility is designated idio'-y, when accompanied with certain physical manifestations as cretinism. As an acquired condition it occurs as dementia senilis, also in organic diseases of the brain, especially tumors, apoplexy, multiple sclerosis ; but also, as a temporary condition in convalescence from severe dis- eases, there is a slight imbecility. Imbecility with delusions of great- ness is a tolerably characteristic sign of progressive paralysis. Of disturbances of volitional impulses are to be mentioned : abulia (hypochondria, drunkenness, indulgence in morphia) ; loss of desire for food : anorexia ; certain forms of pathological excesses : boulimia (a morbidly great and unnatural appetite for eating all sorts of .things), nymphomania and satyriasis (abnormal sexual desires). Disturbances of Sensibility. 1. sensitiveness to peripheral irritation. The determination of the sensibility which a patient has for irrita- tions applied from the periphery (by the physician) is made difficult by the fact that the estimation of them must rest with the patient, who is the subject of the experiment. Subjective sensibility, especially to pain, without doubt varies with individuals: with "torpid" persons EXAMINATION OF THE NERVOUS SYSTEM. 473 and with the aged it is depreciated. Moreover, in a varying degree, it is diminished with persons who are unconscious to the point of entire loss of sensation. Further, it will be influenced, when the irri- tation is slight, by the attentiveness of the person examined. The report of what is discovered in such examinations depends wholly upon the sincerity and good-will of the patient. We must always think of the possibility of simulation and concealment, and the absence of favorable intention. Very little weight must be given to the statements of the patient as to his capacity to feel. The most brief examination is best, as securing the most exact answers, for we very often meet with erroneous conceptions of the condition of the sensibility of the skin. Whenever we are testing the sensibility, it is advisable to prevent the patient from seeing what we are doing. If the disease is uni- lateral, it is desirable to make use of this circumstance to compare the diseased with the healthy side. How we are to guard against decep- tion by simulation, see below. Finally, it is most emphatically recommended that the individual should employ the utmost similarity possible in the methods of making his examinations ; for only in this way is it possible con- stantly to sharpen his own judgment. Moreover, every record of an examination should contain a statement of how the result was ob- tained. Passing over the higher senses, the sensibility to peripheral irrita- tion is divided into (a) the sensibility of the skin, (h) the so-called deep sensibility. {a) Sensibility of the skin. This again is divided into a number of qualities whose relation to each other and distinction one from the other is not yet entirely clear. We avoid any discussion of dis- puted points, and treat the qualities from' the standpoint of clinical interest. 1. The sense of touch, sensibility to contact. We test this by gently touching the skin with the tip of the finger, the patient keeping his eyes closed, and whenever he feels the touch saying "now" ; it is better if he will also say " on the hand," or on the gi-ven finger, etc. Thus we approximately test the sense of locality (see below). And it is also recommended, in order to shorten the examination, to test the 474 SPECIAL DIAGNOSIS. latter immeeliately more exactly by having the patient designate with the tip of the finger the spot that is touched. If he is able to do this then his sense of touch and of locality is normal ; if he cannot, there may be several reasons for his inability, as disturbance of the sense of touch and of locality, sometimes of the muscular sense (see below). Then we must endeavor to separate the sense of touch from the sense of locality. In many cases of slight disturbance the patient is able to feel the contact, but it is duller and different from what it is in normal places. Then we often obtain more exact information if we touch him with rough and soft materials;, and the like. In other cases this procedure is unnecessary. 2. The local sense, the power of localization, is tested by having the patient tell exactly where he has been touched. A healthy per- son can tell this with different degrees of accuracy, according to the portion of the body which is touched. This about corresponds with the distances on the body which the related sense of space has been found to give. (See below.) Testing the sense of space (only required when from any reasons the sensibility must be tested with the greatest exactness) is best done with Sieveking's gesthesiometer : by means of two sliding points we are able to measure the shortest distance at which the two points can be recognized as two separate objects. In health the minimal dis- tance, on the average, is as follows : At the tip of the finger In the palm of the hand On the back of the hand The forearm and the leg The back . The upper arm and thigh 2.5 to 5 mm. 8 to 12 " 31 about 40 " 40 to 70 " about 75 " Analogous, although in its results not wholly corresponding to those of the above-mentioned method, is that of testing the sensation of movements (Leube) : it relates to the power to distinguish points and the shortest lines that can be drawn upon the skin. 3. TVie sense of pressure residing in the skin is tested by the ability of the patient to determine the smallest differences between weights EXAMINATION OF THE NERVOUS SYSTEM. 475 placed upon the skin. The limb must lie firmly, so that the muscular sense (see) is excluded. It is best to take blocks of wood of the same size (instead of metal), but made of different weight by being loaded with lead. The healthy person perceives differences of weight which are equal to about 2^0- to -^^ of the absolute weight of the bodies employed. Partial paralysis of the sense of pressux-e is frequently observed, especially in tabes. 4. The serise of warmth and cold. This is most quickly and simply tested by breathing and blowing upon the skin. Healthy persons distinguish the first from the second perfectly Avell. This method, however, is entirely unsatisfactory, because the finer disturb- ances of the sense of cold and heat are not revealed by it. Somewhat more exact is the test made by means of two test-tubes filled with water at different temperatures. AVe must select a difference of tem- perature which we ourselves distinctly recognize, as, for instance, by passing the hand over them. If, with one of these methods, we find a disturbance of one of the two temperature-senses, then we can more exactly determine the degree of this disturbance by employing tem- peratures which vary still more ; hence, very low or very high (ice, hot water). At the same time we can thus determine the temperature at which cold- or heat-pain begins. A finer test of the sense of heat is made by the aid of the thermaes- thesiometer- We recommend Nothnagel's — two cylindrical wooden vessels, with metal bottoms, into each of which is dipped a thermom- eter to test the temperature of the water that is poured into them. In a very imperfect way we may make a substitute for this thermses- thesiometer by using two reagent glasses half filled with water. In these are placed thermometers surrounded by pledgets of wadding. The temperature of the glasses is varied by dipping them into vessels of cold or hot water. The thermsesthesiometer enables us to deter- mine exactly the fineness of the sensibility to heat and cold. The normal fineness of the sensibility to heat differs with the absolute height of the temperature which we select. The temperatures between 27° C. and 33° C. are most delicately distinguished. Here the recognizable differences in health average 0.5° C, except over the legs, where the number may be somewhat larger, and on the back, where it is about 1° C. On the cheeks it is about 0.25° C. 476 SPECIAL DIAGNOSIS. Fig. 14r,. 5. Sensibility to i^ain} We recommend to test exclusively by pinching a fold of skin between two fingers, because in this way, with some pi'actice — it depends very much upon the size of the fold of skin tliat is taken, and it is recommended always to press the rounded portion of the skin — we can best attain some uniformity in regard to the amount of irritation employed each time. (Regarding pain caused by faradization, see below.) With patients who are unconscious it very often happens that the sensibility to pain is the only quality of sensation that is accessible to examination. When there is very decided uncon- sciousness we are made aware of it by the possible distortion of the counte- nance on account of pain or even a withdrawing of an extremity (not to be confounded with reflex of the skin, see below). 6. Electric sensibility. By the galvanic as well as the faradic current we can develop an objectively- visible as well as subjectively- painful sensibility of the skin. We confine ourselves to the descrip- tion of the farado- cutaneous sensibility. It is best obtained by employing Erb's electrode for testing farado- cutaneous sensibility (made by Stohrer, in Leipzig), which is a cable of insulated copper wires cut at right angles with its axis. We mount this electrode upon the cathode of the opening current of a Dubois's induction-coil (the other electrode may stand anywhere upon the body), and notice the distance of rotation when the point of the skin under examination becomes sensitive (minimum of sensation), and also where it stands when pain is produced. Then, besides, we are to test the galvanic resistance at each point tested (see under Elec- trical Examination for Motility), in order to have an approximate guide as to how strong a current, furnished by Dubois's apparatus, is Erb's electrode fortesting the sen- sibility of the skin, a, tube of hard rubber; h. free surface of the elec- trode. (Erb.) 1 Corresponding with the mode of procedure in making an examination, this is included here, although it properly belongs with common sensation (which see). EXAMiyATIOX OF THE XERVOUS SYSTEM. 477 exhausted by the resistance of the body (or of the skin) at the indi- vidual points ; hence, how much of it is used up each time in produc- ing the irritation of the skin. The following table gives the average figures of health as found by Erb, but vre remark that the figures change according to the strength and construction of the induction apparatus employed, and also that the deviation of the needle (for testing the galvanic resistance) was attached to an old galvanometer without absolute divisions. For both of these reasons the relation of the figures from each other, rather than the absolute variation of the needle indicated bv them, is of value : Points of resistance. Cheeks . ilinimum. 200-220 Pain. 130 Deviation of the needle with 8 elements ; con- duction resistance 150. 26° Neck 180-200 120 22° Upper arm . Forearm 200 190 120 115 21° 18° Back of the hand . 175 110 15° Tip of the finger . Abdomen 125 190 90 120 2° 20° Thigh . Lower leg Back of the foot . 180 170 175 115 no no 21° 19° 10° Sole of the foot 110 80 5° The method is further liable to error, regarding which we cannot speak here. Farado-cutaneous sensibility does not go entirely parallel with any other quality of sensibility. Most frequently, but not always, the sensations of pain produced by pinching, and the minimal sensations of pain produced by the faradic current, correspond with each other (this is especially the case in tabes). The method has not yet been sufficiently studied to be of independent diagnostic significance, and particularly to have a value for special diagnosis. Its application is chiefly to be recommended in unilateral slight disturbance of sensi- bility, from the possibility of making a comparison with the sound side, which cannot be quite certainly established when there is normal irritability of the skin. (Regarding stereognosis, see p. 481.) Now, if by testing the sensibility we find it diminished, we speak of Jiypcesthesia, often incorrectly spoken of as anaesthesia. If none is found — that is, if the strong or maximal irritation employed, which 478 SPECIAL DIAGNOSIS. is always to be stated as accurately as possible, meets with no response — then we speak of loss of sensibility, or anaesthesia. Heightened sensibility is hypercesthesia, or sensibility to variations of temperature and to pain. In many cases, especially in diseases of the peripheral nerves, the sensibility is equally altered in all its qualities ; in others, and especially in diseases of the spinal cord, in cerebral anaesthesia, and not infrequently in hysteria, there exists a partial paralysis of sensibility. Of this, the most frequent form is the diminution or absence of sensibility to pain — analgesia. When sensibility is slowly conducted (^^ delayed sensibility "), it is recognized by requiring the patient, with his eyes closed, to call out " now " the instant he has a sensation. Sometimes, the pause can be measured by seconds (ten seconds, and more). This phenomenon is most frequently observed with reference to pain, as in tabes and in peripheral paralysis. If we take hold of the skin, to pinch it, the patient will often call out "now" twice, because he felt the touch, and then, later, the pinch: there is double sensibility. For this reason, it is best to take up the skin first, without pressing it, and then suddenly to pinch it. Gradual increase of the sensibility to pain, when inflicted, so that just at the moment of being pinched it is inconsiderable, and, later, the pain increases markedly, appears by its phenomena and occurrence to be related to delayed communication of the pain. Perverse sensibility to changes of temperature (Striimpell) consists in cold being experienced as heat. According to our recent views of the complete opposition of the sensibility to heat and the sensibility to cold, this disturbance is not, as yet, explicable. Yet it has an analogy in those rare anomalies of sensibility where a gentle touch is felt as cold. After- sensibility (Naunyn) is a term used to describe a pain that, when first inflicted, immediately subsides, but for some time after returns, and, indeed, with increase of intensity. Polyoesthesia (Fischer) : when one point of the sesthesiometer is placed upon the surface, it feels as if there were two. Allochiria (Obersteiner) : when the right extremity is touched, it is referred to the left, and vice versa, as in tabes, myelitis, hysteria, multiple sclerosis. Local manifestations of disturbed sensibility. Of course, these EXAMINATION OF THE NERVOUS SYSTEM. 479 are to be determined as accurately as possible. This is very easily done when the disturbance of sensibility is sharply bounded ; how- ever, not infrequently the region of disturbed sensibility of the skin passes very gradually and indistinctly into the normal portion. Total anaesthesia is a curiosity. Unilateral ansesthesia, or hemianoesthesia, not passing beyond the middle line of the body, sometimes affecting the head, trunk, and extremities (including the mucous membrane), in a similar way, occurs with certain deposits in the internal capsule (in the posterior third of its posterior limb), and in hysteria. In the latter, and (it is said) also in the first case, there is simultaneously exact unilateral disturbance of all the higher senses. Par anaesthesia is ansesthesia of both lower or both upper limbs. A zone of dis- turbed sensibility, a territory of any extent, may exist in all imagin- able parts of the body. If it is small, it may easily be overlooked, unless the search for it is very carefully made ; this is particularly apt to be the case in the extremities. Here, especially (but also on the trunk), we must carefully determine whether the ansesthesia cor- responds with the region of distribution of a cutaneous nerve or of a mixed nerve-trunk (see p. 484), or whether it is not confined to such a territory — that is, '' diffuse " or " washed out." In the first case it would indicate an isolated disease of that particular nerve. Anses- thesia (analgesia) affecting an extremity which is limited to the por- tion distributed about a joint (say, as far as the wrist, or up as far as the elbow-joint, etc.), has been met with in certain functional neuroses, especially of the so-called hystero-traumatic neuroses of the French. It may.happen — indeed, it very frequently does — that an ansesthetic territory does not really comprise the limits of a nerve of the ex- tremities, but the inner half of it is wanting. Thus, in a radial paralysis, there may be an anaesthetic zone (easily overlooked) con- fined to a small part of the dorsal side of the forearm. This results, either because the nerve is not interrupted throughout its whole trans- verse section, or because we have that very puzzling phenomenon, the "vicarious" participation of a neighboring nerve. (h) Deep Sensibility. This is divided into the less important categories of the dynamic sense, the sensation of spasm of the muscles, and the important 480 SPECIAL DIAGNOSIS. so-called muscular sense, which is a generic name for a series of sensations. Dynamic sense is the capacity to recognize the weight or the difference of weight between different bodies which one lifts. It may be exactly tested only with the upper extremities, and even here it is not wholly separable from the pressure- sense of the skin. Different weights are placed in a cloth-sling pulled over the hand on to the wrist. A healthy person will recognize differences of one-tenth. Sensation of spasm is the unpleasant sensation or pain which is experienced in very strong contraction of the muscles, as in cramp in the calf of the leg, or strong faradic muscular stimulus with ansesthesia of the skin. Muscular sense. By this we understand the ability to recognize, with the eyes closed, the position a limb is in (conception of location), and the active and passive motions of a limb. It is due to the sensi- bility of the muscles, joints, and their ligaments, by the feeling of varying tension of the skin in flexion and extension of a joint, by the impressions of touch which come from portions of skin being in con- tact, as in the axilla and elsewhere. We test the sensation of location and of motion in the arm (with the eyes closed), in persons with uni- lateral disease very simply : we place the diseased arm in different positions, and have the patient with the sound hand take hold of the wrist of the diseased arm. The same method may be employed in unilateral disease of the leg. Besides, it is well, when there is disease of the legs and bilateral affection of the arms, to have the patient describe the positions in which they are placed or the passive motions of the joint that are made. We can also have the patient describe and represent numbers in the air with his hands. Romberg's symptom. The patient places his feet close together, and as soon as he closes his eyes he begins to reel, sometimes he may fall down. The phenomenon is dependent upon anaesthesia of the soles of the feet and disturbance of the muscular sense of the legs, which is no doubt increased by the existing ataxia (which see), because in this condition the motions to correct the swinging are too violent ; this is especially characteristic of tabes dorsalis. [But something of this symptom may be present in health, owing to the lack of vision to correct incipient lateral movements. This may be made clear by closing the eyes and then attempting to stand on one foot.] EXAMINATION OF THE NERVOUS SYSTEM. 481 A finer test of the muscular sense may be made by placing before the patient a table with numbered squares like a chess-board, each square measuring about 10 cm. on a side, and having him point them out with the eyes open until he has them all in his head, and then with closed eyes to touch them with the hand ; or, on the other hand, the patient moves his hand about the squares and names the fields as he comes to them. With the legs, the same test may be made with cubes measuring 10 cm. on a side, placed one on top of another and then side by side. This test, however, requires a certain degree of intelligence on the part of the patient. Conception of space (" finding one's position in space ") can be tested by placing substances of different thicknesses between his thumb and forefinger to ascertain the smallest perceptible differences of thickness. In testing the conceptions of active motions, we see that it is very much disturbed in paralysis, ataxia, and chorea ; regarding these, see below. The Knowledge of Form (Stereognosis). "We recognize the form of bodies partly by the sensibility of the skin and partly by deep sensibility. The former is employed more for very small bodies (which we are able to grasp with the hand ; here, indeed, the hand is the chief means), the latter more for large substances. Thus far only the recognition of small bodies has been sought, especially in an exact way by Hoffmann. To make this test he selected a ball, half-ball, segment of a ball, a cone, a three-cornered pyramid, a regular octahedron, and a dodec- ahedron — all of a size for the hand to grasp. He chiefly tested the hand of persons in health and sick people as regards their ability to recognize these bodies (to which popular names were given). Hoffmann and others have found that the recognition of small bodies was principally made by the skin and sense of space and of pressure of the skin, and to a less degree by the sense of motion in the joints and the power of determining the location in space. Also, that the active to-and-fro motion of the body in the hand, for a dif- ferent reason, comes into consideration : if the active motion is want- ing, then the stereognosis is hindered, but not abolished. Formerly the examination of stereognosis did not have an inde- 31 482 SPECIAL DIAGNOSIS. pendent value ; testing the separate qualities of sensation is superior to it. According to our experience, the most important result of Hoffmann's examination is the knowledge that the separate factors of stereognosis may very perfectly act one for another when there are pathological disturbances. 2. SENSIBLE PHENOMENA OF IRRITATION AND PAIN FROM PRESSURE UPON NERVES. 1. Parcesthesia. This occurs as a subjective sensation of touch, like fur, creeping of ants, creeping of insects, falling asleep; also as a subjective sensa- tion of pain, as a fine stinging or pricking, and also a severe pain ; lastly, as a subjective sensation of cold and heat or painful burning. The so-called feeling of constriction, which occurs most frequently upon the trunk in the region of the thoracic vertebra, especially in tabes, but also in local disease of the spinal cord and its meninges, belongs here. Generally it is a sensation of tension, but it also occurs in all stages of transition to genuine neuralgic pains, when it is deeply located (see Neuralgia). 2. Spontaneous Pain. Headache (cephalalgia). This, according to the manner of its occurrence as well as its significance, may be extremely varied in its character. Its chief forms are : (a) Headache produced by palpable disease of the meninges in the different forms of meningitis; in all those diseases of the cranium and the brain which accompany meningitis. If the affection is circum- scribed, the headache may likewise be so, and it then sometimes indicates the location of the disease; but, also, often enough in this case it is not located. Related with this are the nocturnal headaches of syphilis. (h) The headache of neurasthenia is quite various in its onset. Sometimes it appears as a painful pressure in the head, sometimes as extremely severe pain ; again it is diffuse, then localized, especially at the crown of the head. There is the hysterical headache, not infre- quently circumscribed at the crown (clavus hystericus). EXAMINATION OF THE NERVOUS SYSTEM. 483 (c) Migraine. This is generally an unilateral headache occurring with pauses of extremely varied duration, with disturbances of the stomach, scintillations (see the eye), tinnitus aurium, dilatation or contraction of the pupil of the affected side, accompanied with other pains. The condition is idiopathic or symptornatic, especially in tabes, tumors of the brain, also sometimes in diseases of the nose, etc. {d) Neuralgia in the head, see below. (el Toxic headache occurs particularly in chronic poisoning with lead, mercury, alcohol, nicotine. Here, also, belongs the headache of uraemia. (/) There is a headache which occurs in the beginning and during the course of acute infectious diseases, especially intense and long continued in typhoid fever. (^) Anaemic headache ; headache with gastric dyspepsia ; abdominal diseases of all kinds, especially diseases of the female sexual organs. (Ji) The so-called habitual headache. Often there is an hereditary disposition to headache, which occurs with exertion, excitement, bodily disturbance, as catching cold, etc., and the disposition generally lasts during the gi'eater part of one's life. Pain in the spine may concern the vertebrae, as in chronic rheuma- tism, arthritis deformans, caries ; the spinal "muscles, as in muscular rheumatism ; the spinal cord or its meninges, especially in meningitis and in tabes with tumors. But it occurs very frequently, and is especially torturing, in neurasthenia and spinal irritation. (See, also, what was previously said regarding the vertebrge.) Neurulgia. This is generally a severe paroxysmal pain occurring in the region of one or more distinct nerves. It may be idiopathic or result from catching cold, but it may also be symptomatic, with the greatest variety of significance. The principal varieties of neu- ralgia are those produced by mechanical irritation (pressure of a tumor, aneurism, periostitis, etc.) ; sequela of inflammation of the affected nerve ; neuralgia dependent upon infectious or toxic influences (malaria, syphilis, lead, mercury, nicotine, etc.) ; or accompanying constitutional diseases, as diabetes, gout, phthisis. In every neuralgia, we are to keep in mind the whole course of the affected nerve, and consider where and how it may be injured, and how such a local injury may directly or indirectly be discovered. Of special importance are the neuralgic, lightning, lancinating 484 SPECIAL DIAGNOSIS. pains, in the initial stage of tabes dorsalis. They occur very much more frequently in the lower extremities and the trunk in the region of the intercostal nerves, and nowadays are not infrequently con- founded with rheumatism. Also in the beginning of multiple neuritis there are neuralgic pains, although generally of moderate intensity. We have previously mentioned the pain produced by pressure upon the head and upon the vertebrae. The peripheral nerve are sensitive to pressure in neuritis whenever this is accompanied by actual inflam- matory phenomena in the nerve, or there is perineuritis. Very fre- quently there is especially pronounced tenderness of the nerve during an attack of neuralgia, but also often, although to a slighter degree, in the intervals. This tenderness is very great at certain points of the nerves, "especially where the nerve can be pressed against the bone (Valleix's points) [points douloureux]. Tenderness and spontaneous pain in the joints, without anatomical changes, and generally very changeable in severity, are characteristic of articular neuralgia. ■ 3. DISTRIBUTION OF THE SENSORY CUTANEOUS NERVES. It is recommended that the accompanying figures [Figs. 147 and 148] be studied, in connection with which we will draw attention to a few points which seem to us to be especially important. 1. The nerves of the head. It is to be noticed that the nerve Vi also supplies the conjunctiva and a portion of the raucous membrane of the nose ; further, that when it is paralyzed, we observe severe inflammation and ulceration of the eye (ophthalmia neuroparalytica), which, until recently, were regarded by most persons as arising from lesions, as by dust, etc., which were not warded off because they had not been seen. The author inclines to the old view that the disturb- ance of nutrition forms the starting-point of the trouble. Nerve F'2 supplies the mucous membrane of the superior maxilla, a part of the gums and of the nose, the upper teeth, and the chorda [tympani] ; hence sometimes there is disturbance of the taste at the anterior por- tion [two-thirds] of the tongue. Nerve V^ supplies a portion of the tongue and the mucous membrane of the cheek, and presides over the secretion of saliva. It contains motor fibres, of which the most im- EXAMIXATTOX OF THE XERVOUS SrSTEM. 485 portant are those distributed to the muscles of mastication (masseter, temporalis, pterygoideus ext. et int.) 2. Nerves of the neck and trunh. These do not require any fur- ther explanation. 3. Nerves of the shoulder, arm, and hand. Here we are especially to note the smallness of the cutaneous filaments of the radial nerve that supply the dorsal side of the forearm. Anaesthesia here may Fig. 147. Fig. 148. Figs. 147 and 148. Distribution of the cutaneous sensitive nerves upon the head (Seeligmueller). oma, omi, "S. occipit. niaj. and minor (from the N. cervical, II. and III.); am, N. auricular, magn. (from X. cervic. III.); cs, iN". cervical, superfic. (from If, cervic. III.); V-^, first branch of the fifth (.so, N. supraorbit. ; st 'S., supratrochl. ; it,'S. infratrochl. ; e, K. ethmoid ; I, 'S. lachrymal) ; V2, second branch of the fifth {sm, N. subcutan. malae seu zygomaticus) : T'3, third branch of fifth (a;!, If. auriculo-tempor.j b, N. buccinator. ; w, K. mental) ; B, posterior branches of the cervical nerves. easily be overlooked. It is to be remarked, also, that the distribution of the cutaneous nerves to the fingers, and also to the hand, is sub- ject to some changes, so that slight variations from the arrangement usually described ought not to lead to mistake. Lastly, very often on examination of a peripheral paralysis it is found that the extension of the sensory disturbance lags behind that of the motor. The phenomenon is largely explained by a vicarious participation of neigh- boring cutaneous nerves in a portion of the territory affected (not- 486 SPECIAL DIAGNOSIS. Fig. 149. Distribution of the cutaneous nerves to the shoulder, arm, and hand (Henle). The region of the N. radial is represented by the unbroken hatched line, that of the X. ulnaris by the broken hatched lines, a, anterior, b, posterior surface ; sc, Nn. supra- scapular (plexus cervicalis); ax, chief branch of X. axillar; cps, cpi, Nn. cutanei post, sup. and inf. (from N. radialis) ; ra, terminal branches of N. radial ; cm, cl, Nn. cutanei medius (also to the plexus) and lateralis (chiefly to the X. medianus) ; cp, N. cutan. palmar., X. rad.; and, X. cutan. medialis; me, X. medianus; u, X. ulnaris; epu, N. cutan. pahn. ulnaris. withstandino; the many investia^ations recrardinoj its existence, this idea of vicarious action has not yet been as clearly explained as is desirable). EXAMINA'PION OF THE NERVOUS SYSTEM. 487 Fig. 150. Distribution of the cutaneous nerves of the lower extremity. (Henle.) ii, IST. ileo- inguinal (plex. lumb.j ; li, N". lumbo-inguinal (to the genito-crural. plex. lumbal.) ; se, N. spermat. ext. (to thegcnito-crural.) ; cp, K. cutan. post. (plex. ischiad.) ; cl, N. cutan. lateral, (plex. lumb.)^ cr, N. cruralis (plex. lumbal.); obt, N". obturator, (plex. lumb.); sa, N. saphen. (plex. lumbal.); cpe, IST. commuu. peron. (F. peron. tibial.); cti, N. commun. tibial.; per', per", 'N peronsei ram. superflc. et prof.; cpm, N. cutan. post, med. fplex. ischiad.); cpp, N. cut. plant, propr. (N. tib.); plm,pU, N. plantar, medial. et lateral. (N. tib.). Paralysis of the brachial plexus at Erb's point (see Electrical Ex- amination) sometimes causes anaesthesia in the region of the median nerve. Paralysis from compression of the radial [musculo-spiral] at 488 SPECIAL DIAGNOSIS. the point -where it passes around [the humerus] causes sensory disturb- ance only at the hand (see Electrical Examination), because the pos- terior cutaneous nerves [internal, supplying the posterior and internal aspects of the arm as far as the elbow ; and external, arising from the nerve on the outer border of the arm, is distributed to the back of the forearm] are given off above the point of circumflexion. On the other hand, compression of the radial in the axilla (crutch-paralysis) often causes anaesthesia of the forearm. 4. Nerves of the lower extremities. (See the accompanying figure— Fig. 150.) Disturbances of Motility. In this connection we consider not alone the disturbances of mus- cular action in the strict sense, but also the manifestations as respects tonus and the nutrition of the muscles, the coordination of their actions, their electrical and mechanical irritability, and their reflex manifestations. 1. PARALYSIS. By paralysis of a voluntary muscle, Ave understand a condition in which, by the action of the will, it can only to a diminished extent, or cannot at all, be made to contract. If there is complete absence of voluntary contraction, we call the condition |>ara/?/6-«s ; if the power of voluntary contraction is only diminished, it is called paresis. Paralysis is the result of some anomaly of the muscular nervous system or of its motor terminal apparatus. The loss of motion due to stiffness of the joint has nothing to do with paralysis. Such inability to move a joint is especially frequent in the extremities, and may lead the inexperienced into error. If there is simultaneous stiflfness of the joint and paralysis, it may be extremely difficult to determine the existence of the latter. Diminu- tion of power of motion caused by pain has nothing to do with paralysis when there is only a want of self-control on the part of the patient. However, very severe pain may cause a local restriction of movement, which is, in fact, to be considered as a paralysis. Phenomena of paralysis; methods of examination. Paralysis is recognized by the complete absence of the power of motion in the sense of action of the affected muscles, and, as regards the muscle EXAMIXATTOX OF THE NERVOUS SYSTEM. 439 itself, by the absence of contraction that can be seen or felt. An extensive paralysis, if it causes the muscles to be lax (see below), pro- duces a characteristic atonic behavior of the affected limb : if we take it up and then let go, it falls down — an important symptom of loss of consciousness. As regards those muscles, and there are many such, whose failure does not in a very noticeable degree affect the motion of a limb, because their actions are replaced by others, we recognize the paralysis by observing and feeling the muscles during active movements of the joint which would likely call them into action ; amono- such belongs the supinator longus. Paresis is recognized by the diminu- tion of ''native vigor" when resistance is called for; and also, sup- posing the joint to be free and an absence of tension on the part of the antagonizing muscles, by diminished freedom and rapidity of motion. Again, we sometimes resort to an attentive examination and careful feeling of the body of the muscle. On the other hand, we may be deceived by the statement of the patient that he has a feeling of lassitude, etc. Extent of tlie paralysis. Paralysis of one-half of the body, with or without paralysis of the corresponding side of the face, is called hemiplegia. Paralysis of one side of the face, of an arm, a leg, is called monoplegia facialis, brachialis, cruralis. AVe also speak of monoplegia brachio-facialis. Paraplegia inferior is paralysis of both legs ; paraplegia superior, of both arms. Hemiplegia cruciata signifies paralysis of the arm of one side and the leg of the opposite side; hemiplegia alternans, or likewise cruciata, paralysis of an extremity of one side and of the facial or oculomotorius of the other side. The extent of the paralysis is an extremely important aid in diagnosis, as follows from the anatomical remarks made at the opening of this section. For anatomical diagnosis, see further below. 2. DISTURBANCE OP THE NTTRITIOX AXD TOXE OF THE MUSCLES. Nutrition shows manifest differences that are very striking, and of the highest diagnostic importance. It is determined by the volume of the muscle and by its electrical behavior (see Electrical Examina- tion). More or less symmetrical diminution in the volume of the muscles of a portion of the limb is designated as diffuse atrophy ; when it affects a single muscle, as circumscribed atrophy. A corresponding 490 SPECIAL DIAGNOSIS. increase in the volume is called Itypertrophy or pseudo-hypertrophy (see below). The existence of atrophy, and its extent, are determined by inspection and palpation ; if possible, also, by measuring. When- ever one side alone is affected, we are always to compare it with the healthy side. Requiring the patient to make active motion, by which the muscle under examination is made to contract, or which causes contraction in the surrounding muscles, often makes the impression much clearer. We can easily combine testing of the strength with the examination of the state of nutrition. The volume of an extremity is measured with the tape-measure while the limb is extended at rest (both arms and both legs are to be in exactly the same position), and it is best done at certain points of election. We measure the upper arm at the point of its greatest circum- ference ; the forearm, 2 to 3 cm. below the lower margin of the inner condyle of the humerus ; the thigh, 15 cm. above the upper edge of the patella ; the calf of the leg, at its greatest circumference. Thus, in measuring the forearm and the thigh, we must first fix the point where we are going to take the measure, and mark it with a blue pencil. Atrophy is divided into the following varieties, which are to be very sharply distinguished from each other : (a) Atrophy of inactivity. This consists of a diminution in the volume of the muscles, which is very slight and which very slowly develops in the course of months of inactivity. Almost without ex- ception, it supervenes in cases of paralysis, and also in any long- continued inaction of the muscles, as in surgical diseases which require the limb to be kept at rest. In this form of atrophy, as will be shown later, the electrical sensibility of the muscles is qualitatively unchanged. (b) Degenerative atrophy, with the so-called atrophic paralysis. This quickly leads to a high degree of atrophy of the affected muscles, and to a qualitative change in their electrical sensibility — the reaction of degeneration (see below). This degenerative atrophy only occurs if the centre which presides over the nutrition of the muscle, hence that portion of the gray matter of the anterior horn corresponding to the affected muscle, is disturbed or is separated from the muscle; therefore, in all primary and secondary diseases of the anterior horns, EXAMIXATIOX OF THE XERVOUS SYSTEM. 49I in local separations or interruptions of the connection with the anterior roots or peripheral nerves, in peripheral neuritis. Here belong : poliomyelitis acuta, subacuta, chronica ; progressive muscular atrophy of spinal origin ; amyotrophic lateral sclerosis ; all processes within and of the spinal cord which destroy the gray sub- stance (tumors, hemorrhages, softening) ; compression of the anterior roots and the peripheral nerves ; traumatic complete separation, severe contusion ; pressure-necrosis of these ; and all forms of acute and slow degeneration or degenerative neuritis. Also, it will be understood (see above, p. 456) that the motor nerves below the seat of the lesion, as far as the muscle, atrophy; see also Electrical Examination. On the other hand, degenerative atrophy is wanting in all paralyses which are due to a disease of a motor tract above the anterior horn ganglia — that is, in the pyramidal tract of the spinal cord, of the brain, in the cortex of the brain. Therefore, in these cases, we only have the atrophy of inactivity. ^Moreover, degenerative atrophy is wanting in paralyses of myopathic origin (see below) and in functional paralyses. Nevertheless, degenerative atrophy in many diseases occurs in such a way as to cause great clinical difficulties : the rapid (developing within fourteen days) diminution in the volume of a muscle, of course, can only occur when the whole of the affected muscle, or a large compact portion of it is suddenly, at an approximately definite time, completely paralyzed by disease of the anterior horn or of a peripheral nerve (poliomyelitis acuta, section of a nerve, rheumatic facial paral- ysis, etc.). A disease developing slowly, in the course of weeks and months, causes slowly progressive atrophy, at first disseminated in the separate muscular fibres, only gradually becoming general. There are also difficulties in determinino- the reaction of degeneration in such slowly extending degenerative atrophy (see below). We have the greatest difficulty in making out degenerative atrophy when the dis- ease is a disseminated one, in which bundles of muscular fibre that are still normal are distributed everywhere between diseased bundles. (Regarding this, see further under Electrical Examination.) It is to be remarked that all cachexias cause general atrophy, as well as atrophy of the muscles. But it is worthy of still further note that, under the influence of a general atrophy, the paralyzed muscles 492 SPECIAL DIAGNOSIS. Fig. 151. often become excessively atrophied, even when the atrophy is not a degenerative one. In cases of myelitis transversa and simple atrophy of inactivity of the legs, when there comes to be a general, atrophy, we have often seen the legs become extremely atrophied, quite out of proportion to the volume of the arms. But there is no reaction of degenera- tion, and this fact furnishes diagnostic assistance. It is often extremely difficult for the beginner to form a conception of the behavior of the anterior gray col- umns when there is disease of a trans- verse section of the spinal cord, and to answer the question in connection with it, what sort of paralysis will result from such disease. For this reason two examples are presented : In a severe contusion of the promi- nence of the neck (fracture of a cervical vertebra, for instance) it may happen that the whole section of the anterior gray columns, which inner- vates the arms, is disturbed, and that simultaneously the pyramidal-tract fibres for the muscles of both legs are unbroken (at II in the figure) : there follows a degenerative atrophic par- alysis of the arms and a non-atrophic, " simple " (spastic, see under Tonus) paralysis of the legs. The pyramidal- tract fibres of the latter degenerate as far as the lumbar portion of the cord (as far as X), but the degeneration stops here : the anterior horn ganglia remain normal, and hence the periph- eral nerve and muscle also. A myelitis transversa of the dorsal portion of the cord interrupts the pyramidal tracts to the legs : these become simply (spastically) Schema of the innervation of the muscles (partly from Edinger). The radiation of the Py-tracts varies at different portions of the cortex (see p. 454). EXAMINATION OF THE NERVOUS SYSTEM. 493 paralyzed; a myelitis transversa of the lumbar portion of the cord disturbs the anterior horn ganglia of the legs : these are affected with atrophic paralysis. {e) Primary myopatliic atrophy. This is a disease of the muscle, the nervous system being intact. It manifests itself by the fact that, in this disease, the muscle gives less response, corresponding to a simple diminution in its volume : or, if it becomes completely shrunken, there is complete paralysis ; and further, by the fact that the electrical examination, as a rule, does not exhibit any trace of the reaction of degeneration. This kind of atrophic paralysis occurs in two quite dissimilar forms : (a) In muscular dystrophia (Erb), the myopathic form of progres- sive muscular atrophy (here often combined with hypertrophy or pseudo-hypertrophy) (see below). (6) In severe chronic diseases of the joints. The parallelism between atrophy and paralysis mentioned above is, moreover, generally present also in degenerative-atrophic paralyses, provided they develop gradually (subacute and chronic). A distinct disunion of atrophy and paralysis occurs only in acute degenerative- atrophic paralysis (poliomyelitis acuta, injury, etc., of the nerve, acute degenerative neuritis) : here the paralysis develops more or less rapidly, but atrophy only becomes manifest in the course of weeks. Charcot has recently discovered, in certain hystero-traumatic paralyses, a functional paralysis with more marked atrophy, but without the reaction of degeneration. But the atrophy here is not so decided as degenerative atrophy, being rather between this and the atrophy of inactivity. In very exceptional cases, when there is disease of the cerebrum, particularly of its cortex, there has been found a considerable mus- cular atrophy, which appears early, sometimes even before the occur- rence of paralysis, without the reaction of degeneration. In indi- vidual cases of this character, contractures were completely wanting, and tendon-reflex was not increased. Genuine hypertrophy of muscles occurs in Thomsen's disease [general myopathic spasm] ; also sometimes in individual muscles, especially the gastrocnemius muscle, in dystrophia musculorum ; here, also, belongs the muscular hypertrophy which develops in the sound leg when one is paralyzed (as in long-standing infantile paralysis). 494 SPECIAL DIAGNOSIS. Genuine hypertrophy is recognized by the increased volume, great hardness, and especially by the increased vigor of the muscle. Pseudo-hypertrophy, on the other hand, shows increased volume, but diminished power. This occurs in dystrophia musculorum much oftener than genuine hypertrophy, but it may be developed from the latter. Tonus of paralyzed muscles, active spasm, rigidity of muscles. An increased tonus of the muscles that are paralyzed (rigidity, active spasm) is a characteristic, though sometimes absent, sign of those paralyses which are of cerebral or spinal origin above the anterior horn. This tonus may be so slight that the examiner will only notice it as a slightly increased resistance during passive motion. But it may also be so strong that even when perfectly at rest a muscle is as hard as a board, and that motion of a joint, in which the muscle would be extended (that is in which the muscle would act as an antagonizer), is entirely impossible. Thus spasm of the quadriceps prevents bending of the knee, not only passive, but also active bend- ing, which, probably, if the flexing muscles were intact or were only paretic, would take place (spastic pseudo-paralysis). Patients also, even in slight degrees of rigidity, experience great difficulty in making active motions. That these spasms are not due to permanent ana- tomical changes in the muscles, only to muscular contraction, is proved by the fact that they are sometimes subject to striking change. If the paralyzed muscles are spastic to a high degree, often for a long time there does not develop any atrophy of inactivity. Paralyses due to affections of the cortex of the brain usually manifest themselves by very early spasms. In hysteria, also, very decidedly active spasms occur. (Regarding increased tendon reflex as an attendant phenomenon of spasms, see p. 497.) Atonic paralysis. This is characterized by diminution or loss of muscular tonus, in consequence of which there is abnormal passive mobility of the joints. This laxness is present in recent paralyses, in which the atrophic, acutely degenerative condition has not yet devel- oped (''atonic atrophic paralysis"). It is also found in cases of chronic and long-standing degenerative paralysis (see also under Contractures). Cerebral paralyses, as hemiplegia, in rare cases, may also manifest decided atony. There is a tolerably marked laxness of the muscle, ■without paralysis, in tabes. EXAMINATION OF THE NERVOUS SYSTEM. 495 Contractures. In long-continued paralyses, both degenerative and simple, there develops in the paralyzed limbs a constant anatomical shortening of individual muscles, and, indeed, just the muscles that are chiefly spastic often shorten in spastic paralysis, but not always. On the other hand, in degenerative paralysis, it is more the antago- nizers of the paralyzed muscles, or those of the paralyzed muscles that are strongest. Thus, from the moment of paralysis, the prevailing position, the posture of the affected limb, gives the first indication of the development of contracture. These contractures do not change. The motions of the limb that oppose the contracture, and the stretch- ing of the affected muscles caused by this motion, are very painful. 3. THE REFLEXES. 1. Skin Reflex. By this we understand the quickly passing contractions of the muscles which are caused by an irritation applied to the skin. The stimulation of the skin usually recommended is tickling or stroking it with the blunt end of a pencil or the handle of the percussion hammer. It is well from the beginning to aim at a certain symmetry in the methods we employ ; only in certain cases, especially if there is diminution of the reflex, we may endeavor to call it forth by prick- ing with a needle or touching it with a piece of ice. The skin reflexes about to be mentioned in detail are, even in health, very different in different individuals (the cremaster reflex relatively varies least) ; but upon the two halves of the body they are always alike. Therefore, where there are unilateral anomalies of it, the most cer- tain results of trial of the skin reflex are obtained by a comparison with the sound side. If we have like results upon both sides of the body, then it has only a doubtful diagnostic value. We are not to confound with skin reflexes those motions that are voluntarily made. With some practice they are readily distinguished. In the face and the upper extremities, the skin reflexes are of no importance ; on the other hand, the three reflexes upon the legs and abdomen are of especial diagnostic significance : (a) The reflex of the sole of the foot. This is produced by irri- tating; the skin of the sole of the foot, and in health consists either in a dorsal flexion of the toes or of the whole foot, or even in motion of 496 SPECIAL DIAGNOSIS. the hip-joint and knee. Pathologically, the reflex may be absent (weakened on one side and increased upon the other). It may be increased with reference to the amount of the contraction, with refer- ence to its extent, as in simultaneous contraction of the other leg, motion of the pelvis or of the whole body, for instance, as shorter opisthotonus ; or it may occur slowly, or only after repeated and con- tinued application, or summation of a strong irritation. It would be influenced in its form by the tonus of the muscles of the legs : in spasm of the extensor, for instance, often, instead of a single motion of flexion, there occurs repeated trembling. {h) The cremaster reflex in men consists of a prompt upward motion of the testicle from the contraction of the cremaster which follows irri- tation upon the inner surface of the thigh. It is not to be confounded with the indolent contraction of the tunica dartos of the scrotum, which follows somewhat later. Sometimes the cremaster reflex is extended to the muscles of the abdomen, causing the backward draw- ing-in of the abdomen. ((?) Abdominal reflex. This is a contraction of the muscles of the abdomen [chiefly the rectus] from irritation of the skin of one side of the abdomen [stroking downward from the edge of the ribsj, which is recognized by an unilateral or a bilateral drawing-in of the abdo- men ; when the irritation is weak, by a slight displacement of the navel toward the side irritated. The figure explains the mechanism of the skin reflex : the sensible irritation proceeding from the skin is conveyed by the motor fibres to the anterior horn ; but the anterior horn itself is influenced by the reflex retarding fibres which pass in the pyramidal tract. It is clear that the skin reflex must be lost by an interruption of the reflex arc at any point, or by the unsusceptibility of the skin, or by myopathic paralysis ; that it must be increased with any increased excitability of the anterior horn, or removal of the restraining reflex from the brain, also in hyperaesthesia of the skin. Recently, an increase of the abdominal reflex upon one side has been observed in intercostal neu- ralgia (Seeligmiiller). We have not mentioned a number of other skin reflexes, since they are not important : for pupillary reflex, the reflex closure of the lids, see under Examination of the Eye. Of the reflexes of the mucous membrane, the choking reflex when the mucous membrane of the pharynx is tickled has diagnostic sig- EXAMIXATIOX OF THE yERVOUS SYSTEM. 497 nificance : its absence is a frequent occurrence in hysteria (anaesthesia of the mucous membrane), also in bulbar paralysis (nuclear paralysis). Of verv much greater diagnostic importance are the 2. Tendon Reflexes (^periosteal, fascial reflex). These reflexes are likewise short contractions. They are produced by taps upon the tendons of muscles, upon the bones and fascia, also by sudden tension of a tendon by a quick passive movement (in which, however, the muscle itself is also stretched), Both the short move- ment of the limb and the momentary hardening of the muscle may be made an object of examination. In order to develop the tendon reflex it is necessary to have the limb perfectly relaxed, and it is well, also, to divert the attention of the patient. Fig. 152 Diagram of the course of the cutaneous and tendon reflexes. S, skin : M, muscle; V, anterior horn ; Hi, posterior horn ; .?, the tract of the tendon reflexes ; h, the tract of the cutaneous reflexes. Whenever it is possible, a comparison is to be made between the right and left limbs, but even where this cannot be done, as when the disturbance is bilateral, or the two sides are disturbed in a similar way, the greatest importance can be attached to the result of the test, because here the individual variations are not prominent, as they are 32 498 SPECIAL DIAGNOSIS. in the reflexes of the skin ; hence the tendon reflexes are much more important aids in diagnosis than the skin reflexes. Tendon and skin reflexes may be confounded. In a doubtful case, this can be avoided by comparing irritation of the skin alone at the given points, by means of pinching, pricking a fold of skin, or by direct mechanical muscular irritation (see beloAV, Biceps-tendon Re- flex); lastly, as in the skin reflexes, by having the patient take part in the examination by making voluntary contractions ; these take place later, and, hence, can only deceive the inexperienced. We may be very easily misled into supposing that there is an absence of tendon reflex, if the muscles under examination are not perfectly relaxed. We enumerate the tendon reflexes according to their importance: {a) Patellar reflex (Erb ; knee-phenomenon, Westphal), consists in a contraction of the quadriceps. It is caused by striking with a percussion hammer, with the tips of the semi-flexed fingers, or with the rim of the ear-plate of a stethoscope, upon the patellar tendon. Often we must carefully seek the most susceptible point. Sometimes we may first make the test with the leg covered ; but if the result is in any way doubtful, then the knee must be uncovered. Whenever a very exact examination is to be made, the latter must always be done. In order to get the muscles completely relaxed, we must select certain positions : a favorable position is to have the limb extended at rest, with the feet resting upon the floor ; another position is with the leg crossed over the other in the sitting position ; a third is to have the patient sit upon a table with the legs hanging down ; with the patient in bed, we pass the hand under [the thigh just above] the knee and gently lift it up. As a means of inducing patients to relax the limb, they are to be diverted by conversation, or they may be directed to close the fist as tightly as possible, or sometimes we may have them grasp the left hand of the examiner or press the hand of someone else. Not only active contraction, but possibly also increased tonus of the quadriceps, disturbs the exhibition of the reflex. Even a patho- logically increased patellar reflex may thus be hindered by spasm, which must be carefully guarded against. Hence, as far as is pos- sible, we must prevent any active spasm by the position (particularly EXAMINATION OF THE NERVOUS SYSTEM. 499 by a cautious passive motion) of the knee-joint. It may also be inter- fered with by deformity and stiffness of the joint. With very rare exceptions, the patellar tendon reflex is always present in health, and both sides are equally strong. The author cannot forbear saying that he regards as impracticable the designation " Westphal's sign" for the absence of patellar reflex — notwithstanding his very high regard for the meritorious investigator, who is deserving of the honor — because this designation could easily be confounded with the opposite (as, that Westphal's sign meant patellar reflex). (b) Tendo-AcMllis reflex and foot-phenomenon. Striking upon the tendo Achillis, and often only on a very limited portion of it, in health, generally causes a reflex contraction of the gastrocnemius (and soleus) with slight plantar flexion of the foot. In doing it, it is best to lift up the foot by taking the malleoli with the left hand (the foot of course being bare). By foot-phenomenon we designate the contraction of the same muscles if there is a continuous contraction, a passive dorsal flexion of the foot, often best excited by a quick passive motion (stretching the tendons, also the muscles) ; a reaction then takes place in a series of rhythmical contractions of the plantar flexors, or a long series of contractions : foot clonus, foot-phenomena, dorsal clonus. This latter phenomenon is not really a pure tendon-reflex, rather in part it is dependent upon direct irritation of the muscles as a result of stretching. But it has exactly the same diagnostic significance as increased tendon-reflex, for it does not at all occur in health, or, at most, only temporarily, as when one is very tired. (c) Tendon reflex of the upper extremities. Here they do not have the same diagnostic importance [as those under (a) and (5)], particularly because they are very often absent in health. Striking the flexor tendons at the wrist-joint, the biceps at the bend of the elbow, the triceps tendon close above the olecranon, generally causes a slight reflex contraction ; in the two latter Ave must be careful not to strike the muscle itself. (See Mechanical Irritation.) (d) Periosteal and fascial reflexes are elicited by striking the latter and the bones — the tibia: patellar reflex; bones at the wrist-joint: biceps, even pectoralis reflex. We not infrequently observe them in health, but very particularly when there is increased tendon reflex. 500 SPECIAL DIAGNOSIS. Not wholly unimportant, also, are the bone reflexes which are manifest in the muscles of the face from blows upon the knee — upon the nose; they are absent in bulbar paralysis, and are present in paralysis of the facial tract above the bulb. The mechanism of the tendon reflex is made clear by Fig. 152, p. 497. We see that for its production it is necessary to preserve the integrity of the reflex arc : {a) tendons ; {h) sensitive (that is, centri- petal) nerve ; {c) posterior root ; {d) anterior horn ; {e) motor nerve ; lastly, (/) muscle. But we take note of the influence upon these of restraining fibres in the pyramidal tract, which may be cut ofi", and also may possibly be temporarily irritated. Interruption of the pyramidal tract (which is manifest by its secondary degeneration as far as the anterior horn) or cutting oft' of the pyramidal tract by primary degeneration, causes increase, therefore, of tendon reflex, as in cerebral paralyses, spinal paralyses from disease of the pyramidal tract, in myelitis transversa, amyotrophic lateral sclerosis, spastic spinal paralysis ; but also increased irritability of the spinal cord itself, as in strychnia poisoning, tetanus, lyssa, neuroses, and particularly sometimes in hysteria. On the other hand, the tendon reflexes are diminished or are lost : in disease of the anterior horns, of the periph- eral nerves, of the posterior roots or their connection with the anterior horns (poliomyelitis, spinal progressive muscular atrophy ; any disease of the peripheral nerves; tabes dorsalis — here diagnostically very im- portant ; myelitis, tumors, hemorrhages, if in certain locations — that is, if they disturb the gray substance for the arm or leg). It follows from what precedes that the increase, and also in many respects the diminution, of the tendon reflexes, goes parallel with in- creased or diminished tonus of the muscles. And, in fact, tonus seems to be genetically related to tendon reflexes. In this sense it is also of interest that the predominant reflexes at the arm are the flexors, at the leg the extensor of the knee, the plantar flexor tendo-Achillis reflex for the foot, and that exactly corresponding with a recent spastic paralysis of the arm, we are apt to have flexor spasm of the arm and extensor spasm of the leg at the knee and ankle. Westphal's view [p. 499] that the "tendon reflexes" are not reflexes, but that they are always, when elicited by the prescribed methods of testing, due to the direct irritation of the muscles by stretching and concussion, is to be regarded, especially as respects EXAMINATION OF THE NERVOUS SYSTEM. 501 patellar reflex, as definitely refuted. Nevertheless, we must still agree that the ordinary method of examination for the foot-phe- nomenon in this respect is not free from objection (as has been urged by others also, as Jendrassik) : the brusque dorsal flexion of the foot must necessarily stretch the gastrocnemius — here it may be due to the eifect of stretching of the muscle added to that of the tendon. Mixture of tendon reflex and direct muscular irritation from stretch- ing the muscle probably also occurs in executing " brusque passive motion " of the limb (very quickly bending it, and extending the knee- joint, etc.), which is very strongly to be recommended for determining a slight degree of increased tonus of the muscles. 4. ELECTRICAL EXAMINATION OF THE NERVES AND MUSCLES.^ Regarding the Physies, and the Instruments Employed. For the electrical examination we employ the secondary or induc- tion current of the faradic battery and the constant current of a gal- vanic battery. We graduate the strength of the faradic current by the extent to which we withdraw the outer coil from the inner, which is reckoned by centimetres and millimetres from the point where one coil is completely enclosed by the other, or the distance between the coils X cm. ; the strength of the galvanic current is changed by im- mersing a difierent number of elements, sometimes more delicately by a rheostat. [The galvanic batteries now made in the United States and England usually have a rheostat as a part of the outfit. It is much better to use it, for two reasons : all the cells of the battery are drawn from alike, since all can be thrown into the current at the beginning of each sitting ; the gradations in the strength of the current are made without shock to the patient.] The current is conveyed to the body by an electrode, previously moistened with warm [preferably salt] water. In making the examination, one of these is always the indifi'erent one — that is to say, it merely serves to close the current that is flowing through the body; the other is the " difi"erentiating " or examining one. The first must be as large as possible, in order to spread out the current 1 Of course it is not necessary here to go into particulars. Hence we refer the reader to special works, particularly to Erb's classical presentation in his Electro-Therapy. 502 SPECIAL DIAGNOSIS. over as large a surface as possible at the point where there is much the greatest resistance, namely, at the skin. The resistance is inversely proportional to the cross-section. Usually, the indifferent electrode is placed upon the sternum. For examining nerves and small muscles, the examining electrode must be quite small, in order to convey the current as closely as possible to the structures, which all lie near the skin ; we cannot examine those lying deeper. For this reason, in making the faradic examination, it is best to select the so-called "fine" electrode of Erb (see Fig. 153). But in em- ploying the galvanic current, such a small electrode would so concen- trate the current by its small cross-section that its passage through the skin would be too irritating, and hence we must select for this Fine" electrode of Erb (natural size). current one somewhat larger. The size of the electrode is, as already said, of important influence upon the intensity of the current in its transit through the skin and a short distance beyond it, hence, also, in that to the stimulating nerves. It is likewise not unimportant, for it is very desirable to know, at least approximately (why, see below), with how strong a current we touch the nerves beneath the skin. For this reason, and in order that the conditions under which the examinations, conducted by different persons, may be as nearly as possible alike, it is strongly recommended to employ a so-called " normal electrode." Unfortunately, we have several, of which we consider only the following : one devised by Erb, of 10 sq.cm. diameter (either square, 3.3 cm. on a side, or round with a diameter of 3.5 cm.) ; and one by Stintzing, round and somewhat convex, 3 sq.cm. in cross-section and 2 cm. in diameter. With every record of an examination there should always be a statement of the size of the electrode employed. We have no absolute measure for the total strength of the faradic current in making examinations. Here we note the distance of the coils, but this, according to the construction and power of the EXAMINATION OF THE NERVOUS SYSTEM. 503 apparatus, may indicate different strengths of current ; nevertheless, this has value for comparison where the examinations are made each time with the same apparatus (see below). For the galvanic current we have an absolute measure : the milliampere (M.-A.), = -jTmn — y. — • (See text-books upon Physics.) To ascertain the number of milli- amperes used, we employ a so-called absolute galvanometer. The total strength of current as given by the galvanometer is then divided by the transverse section of the examining electrode in such a way that, for example, with a total strength of 2.5 M.-A. and an electrode of 2.5 12 sq.cm. transverse-section to a sq.cm , a current of y^ M.-A. is given off (N. B., to a sq.cm. of the skin); the density of the current in the nerves examined is not exactly proportional to that in the skin (see below). Hence, this fraction has no exact value as such — rather only as a brief expression of the two figures which we have to consider. If we employ a normal electrode, then we can note : Norm, electrode 2 5 Erb (10 sq.cm.) 2.5 M.-A., or ^ M.-A. (N. el. Erb). This comparison of the total strength of the current with the absolute measure is nowadays indispensable ; it has, it is true, only a value which is, in a certain sense, circumscribed. A difficulty which at present is tolerably successfully overcome, consists in the fact that the conducting resistance of the skin, for various reasons, declines, and with it, although only in a slight degree, the strength of the current increases, while the electrodes rest upon the body, and hence, also, from the moment when the galvanometer is switched-in to the instant when the needle comes to rest. This space of time in the new galvanometers (especially Edelmann's horizontal galvano- meter, but also with the instruments of Bottcher-Stohrer and Hirsch- mann), by appropriate checks, is satisfactorily shortened. Stintzing is to be credited with very exact examinations regarding these points. A much more considerable difficulty, and one which probably will never be entirely overcome, consists in the fact that we cannot con- centrate our current upon the nerve (muscle) to be examined, because it lies in tissue which itself is a good conductor, and that from the total strength of the current and the cross-section of the conductor of 504 SPECIAL DIAGNOSIS. the current into the skin we can only approximately determine the current which enters the nerve (muscle) itself. For this, there are two chief reasons : first, because the situation of the nerve with reference to the skin varies with each individual (layer of fat, anatomical peculiarities) ; and because, from the situation of the nerve, the frac- tion of the current which enters it is intrinsically changed. (Even the quality of the contractions caused by the current will be influenced by the relation of the nerve to the skin. — Erb.) Further, since the nerve offers a quite considerably stronger resistance to the current if it enters it at a [right] angle to its axis, than if it flows along its axis, the angle at which the current enters the nerve will consider- ably affect the strength of the current ; and we cannot accurately measure this angle in the case of all nerves. There follows from the foregoing, first of all, the practical point that, in spite of our ability to measure the strength of the total current, we are taught to bear in mind the individual peculiarities of the nerves (muscles) to be examined, in their relation to the skin, in interpreting the results of the examination, so as to supply, as far as possible, the want of exactness in our calculation; and it follows, further, that it is superfluous, and even a source of error (because it withdraws our attention from the more important points of view), if we strive after exactness in electrical examination by the fineness of the apparatus, especially of the galvanometer — an exactness which, let it be said once for all, the examination cannot have. Of what use is it exactly to determine the strength of the total current to within one-tenth of a M.-A., when we do not exactly know how much of the total sti'ength the real objects of our examination — the nerves — receive ? JIow to distinguish the poles quiekly. In the faradic current the poles come but little into consideration, namely, only so far as to know that the cathode (negative pole) of the opening current of the secondary coil has a stronger irritating effect than the anode. In the galvanic current, the poles are widely different, and hence it is important to distinguish them quickly upon the apparatus. The simplest way is to employ a very mild current, and then to place the two electrodes upon the cheeks ; upon the side of the anode we experience a peculiar indefinable taste upon the tongue and the mucous membrane of the cheek of that side ; or we place the wires EXAMIXATIOX OF THE XEEVOUS SYSTEM. 505 of both poles about 1 cm. apart upon a piece of -wet blue litmus paper : the anode colors it red. By a current- changer we are able to reverse the poles — that is, to quickly make the anode the cathode, and vice versa. Methods' of Examixatiox axd their Physiological Results upox the llyixg humax body. As a foundation to what is here to be spoken of, we refer most urgently to the text-books upon physiology or upon electro-ther- apeutics, especially to what is taught regarding electrotonus and the laws of contraction (Pfliiger). Unfortunately, we cannot enter upon these subjects here; only remarking that the results of the ex- amination upon uninjured animals and men diifer from the physio- logical results, and for physiological reasons, which cannot here be explained. [The student is referred to Landois and Stirling's -P/?j/- siology, section 336, for an excellent presentation of Electrotonus — law of contraction.] The electrical examination consists of an irritation of a nerve (indi- rect irritation) as well as of the muscle (direct irritation), one of which, indeed, takes place with both kinds of current, and in observing the eflFect of the irritation, as it is manifest by muscular contraction. Thus, we have to make use of an indirect faradic and galvanic and a direct faradic and galvanic examination. As previously stated, the extent of the irritation is always a matter of uncertainty to us (dis- tance of the coils ; total strength of the galvanic current in M.-A.). We draw our conclusions from the results of the examination : (a) From the degree of excitability of the nerve (muscle), by deter- mining with what strength of current there follows the first, small- est, just noticeable, or minimal contraction ; or also by determining the extent of irritation which is necessary with the galvanic examina- tiop to cause a tetanic contraction. The minimal contraction is observed at the muscle, or by the movement of the joint. The com- prehension of these minimal contractions (still more of galvanic teta- nus — see below) by the individual examiner is, to a certain extent. variable, and a source of inexactness. (5) With reference to the quality of the reaction in the direct irri- 506 SPECIAL DIAGNOSIS. tation of the muscle with the galvanic current, that is, the character of its contractions and its " law of contraction" (see below). Since the electrical currents only stimulate by sudden oscillations in the current (except it be very strong), the faradic current, because it consists of a great number of opposing currents of short duration, causes a tetanic contraction proceeding from the nerve as well as from the muscle itself, which continues while the electrode remains with the current closed ; the galvanic current, on the other hand, indirect as well as direct, produces its effect only at the instant of its entrance : contraction from closing the current, and at the instant of its exit : contraction from opening the current. But while with the nerve exposed (Pfliiger) at the cathode [represented hereafter by Ca] (negative pole), only the closing of the current, and at the anode [represented hereafter by An], only the opening of the current occa- sions a contraction, we find that with the nerves and muscles of the living man there is another law of contraction (explained in works upon electro-therapy). Greneral Methods., and Explanation of the TermB Ennployed in Galvanic Examinations. The indifferent electrode stands upon the sternum, the examining electrode (normal electrode) upon the nerve (muscle). With the current-changer we close the current so that the examining electrode is the cathode — that is, we make the " cathodal closure " CaS [S = Schliesung, closure] ; there results a contraction, C, thus it is CaSC ; then we open the current, thus making a cathodal opening, CaO: sometimes there is CaOC ; then we reverse and close the current, so that the examining electrode becomes the anode, An, making AnS : we sometimes have AnSC, then likewise at the end AnOC. With a very strong current we have upon CaS, and with the current remaining closed, a tetanic contraction : CaSTe. Latvs of normal contraction with galvanic stimulation : 1. Nerve : (a) Weak current : feeble CaSC, CaO : negative, AnS : AnO : " EXAMINATION OF THE NERVOUS SYSTEM. 507 (b) Stronger current : strong CaSC, CaO : negative, AnSC, AnOC. (c) Very strong current : CaSTe, feeble CaOC (not always), strong AnSC, strong AnOC. That is, with a weak current there is only CaSC, with a strong one also AnSC, and about at the same time AnOC, with very strong, CaSTe, and sometimes CaOC. The contractions are, all of them, short, lightning-like. 2. Muscle, irritated at a place where there is no nerve, or, at least, irritated as little as possible (at a distance from the " motor point," the place where the nerve enters, see below) : Moderate current : CaSC, Only a little stronger : AnSC. The contractions of opening the current are subordinate, often entirely wanting. The contractions mentioned as occurring at the closure are, indeed, short, but yet not so lightning-like as those from an exposed nerve. Method of Examination in Detail. Normal Condition, Preliminary remarks. In examining individual nerves and muscles we must strive most earnestly to employ exactly similar methods. In the first place, in examining nerves, we should use Erb's fine electrode for the faradic current, and either Erb's or Stintzing's normal elec- trode for the galvanic current. With the galvanic current, especially, we should always make about the same pressure upon the electrode, increasing the pressure only when there is a very firm layer of fat (in order, in this way, to equalize, to some extent, the effect of the fat layer). We are always to examine homonymous parts together, that is the right, then the left radial, the right, then the left median, or, when the disease is unilateral, the nerve (muscle) of the sound side always first. 508 SPECIAL DIAGNOSIS. 1. Points of Stimulation, In what follows we give the points of stimulation of the nerves and the so-called motor points of the muscles (studied by Duchenne, Ziemssen, Erb — the illustrations from Erb's Electro-Therapeutics)^ which chiefly correspond to the points where the nerves enter the muscles, and hence are essentially also the nerve-points. In exam- ining the muscles themselves we place the electrode upon the fleshy part of the muscle, avoiding, as far as possible, both of these related points. Fig. 154. M. frontalis. L'pper branch of facial. M. comig. supercil. M. orbic. palpebr. Muscles of the j nose. 1 M. zygomatic!. M. orbicul. oris. - Middle branch cf facial. M. masseter. M. levator nienti. M. quadr. menti. M. triang. menti. N. hypogloss. Lower branch of facial. >I. platysma myoid. Muscles of the root I o'f tongue. ( M. omohyoideus. N. thoracic, anter. (M. pector.) Kegion of central convolution. Region of the third frontal convolution. M. temporalis. Upper branch of facial in front of ear. N. facialis (Stamra). N. auricul. post. Middle branch of facial. Lower br. of facial. M. splenius. M. sterno-cleidci- mastoideua. N. accessorius. M. levator auguli scapul. M. cucullaris. N. dors, scapulae. N. axillaris. N. thoracic, long. (M. serratus antic. maj.) N. phrenicus. Supraclavicular Plexus point. (Erb's point. brachialis. M. deltoid., biceps, brachial, intern, and Bupinat. long.) Points of Electrical Irritation upon the Head and Neck. (Erb.) The points most distinct in the figure correspond to the chief places for applying the stimulation. In the faradic examination, we seek EXAMINATION OF THE NERVOUS SYSTEM. 509 carefully in the course of the nerve for these most excitable points (that is, of course, for those places where they lie nearest the skin). Remarks regarding Fig. 154 : We observe particularly the upper, Fig. 155. II. triceps (caput longuni) M. triceps (caput intern.) J^erv. ulnaris { M. flexor cirpi ulnaris M. fies. digitor. comniun profand. M. flex, digitor. sublim. (digiti U et III) SI. flex, digit, snbl, (digit, indicia et minimi) Nerv. -ulnaris M. palmaris brev. M. abductor digiti min. M. flexor digit, min M. opponens digit, min Mi. lumbricales M. deltoidesa Nerv. musealo- eufaneus II. biceps bracbii M. bracli. intetnus / Iferv. medianua snpinator longns pronator teres flex, carpi radialia flex, digitor. Eublim. flex. polJicis longus medianits abductor poUic. brev. opponens pollicis -flex. poll. brev. adductor pollic. brev. Points of Electrical Irritation upon the Arm. (Erb.) 510 SPECIAL DIAGNOSIS. middle, and lower facial (the three most distinct points upon the face). At the brachial plexus we notice Erb's point [the supra-clavicular point]. Fin. 156. M, tlelloideus M. extensor digit, comniuiits [ M. extensor indicia M. abductor pollic. long. M, extensor poUic. Lrev, M. inteross. dorsal. I et II N. raJialis M. brachial, intern. - M. supinator long. M. radial, ezt. long. M. radial, ext. brer. M. 'triceps (caput longam) I M. triceps (caput extern. M. ulnar, extern. M. supinat. bier. M. extens. digiti minima SI. extens. indicis I M. extens. poll. Ipng, AI. abduct, digit, min. M. inteross. dorsal. lU et IV. Points of Electrical Irritation upon the Arm. (Erb.) 2. Examination. The tongue and soft palate will be best directly irritated with an electrode that is isolated as far as to the end (which may be done by EXAMINATION OF THE NERVOUS SYSTEM. 511 simply winding it with adhesive plaster). A strong galvanic current should never be used upon the head. Remarks regarding Figs. 155 and 156 : We examine the arm in the position of moderate flexion and slight pronation, but the muscles are to be relaxed (hence, the arm must rest upon something). The radial nerve lies deep, especially if the muscles are well developed. We can generally follow with the finger the ulnar nerve upward from the sulcus of the internal condyle of the humerus. Remarks upon Figs. 157, 158, 159 (pp. 511-514) : It is very diflScult to stimulate the ischiatic nerve. It can only be done by Fig. 157. N. cruralis M. adductor maguns M. addnct. longvs M< tensor fasciae latae M. sartorios ^ a 41 .■;/ u M. quadriceps feraoris if II. rectus femorls vastus ezternus H. vastus internus Points of Electrical Irritation upon the Upper Part of the Thigh. (Erb.) pressing the electrode in deeply and employing a strong current. We can easily find the peroneus nerve, if we feel for the head of the fibula and go inward and upward from this. Upon the back, since the nerves almost nowhere lie sufficiently 512 SPECIAL DIAGNOSIS. near the surface to permit of the indirect examination, we have to do almost exclusively with direct muscular irritation. It is superfluous to make more exact statements regarding the simple topographical relations. We demonstrate this upon a single nerve-muscle, and for this we take the radial. We always begin with the faradic current, and this for good reasons, which have recently been made more strong (relations of the "resistance to conduction "' — Stintzing), which we cannot enter upon here. (a) Faradic Examination. (a) Nerve. The indifferent electrode is placed upon the sternum, the examining electrode (the fine one of Erb), held as a pen in Avriting, is placed upon the radial nerve [musculo-spiral], where it turns around the humerus at the middle of the arm : here tolerably deep pressure is necessary. The induction-coil is to be pulled out till the minimal contraction is produced, and the distance to which it is removed is read off and noted. Thus will we feel for the nerve with the elec- trode: the minimal contraction takes place at the instant we pass over the nerve. Next, there is to be determined the " conductive resistance" at that particular spot: we employ the galvanic current; we apply a well-moistened normal electrode; a definite number of elements of the battery is inserted ; we read off and note down the figures of the galvanometer in M.-A. The galvanometer is to be read when the electrode has been upon the nerve for just thirty seconds. It is necessary, in our opinion, to determine the "conductive re- sistance " exactly in the manner described by Erb. The fluctuations in the conductive resistance, and with it (in an opposite sense) the strength of the total current, are in fact, during the examination, very slight, and can ordinarily, as has been shown most accurately by Stintzing, be neglected. But, in some cases, it happens that at the point of examination the skin is very tender, or abnormally dense ; in which case, of course, with the same separation of the coils of the same apparatus, we have relatively a stronger or relatively a weaker current ; and we obtain a minimal contraction with a large, or with only a very slight, conductive resistance. This result we would EXAMINATION OF THE NERVOUS SYSTEM. 513 refer to an increased or diminished irritability of tlie nerve if we had not ascertained by the galvanic determination of the "con- ductive resistance " that the skin was the cause of the variation. Extremely instructive examples illustrating this point are given by Erb in his Electro- Therapeutics. Fig, 158. Nerv. isehiadicus M. ticeps fern. (cap. long.) M. biceps fern. (cap. brev.) N. peroneus M, gastrocnem. (cap. extern.) M. soleus U. flexor ballucis longus •leus niasimus adductor inuguus emitendinosus M. semimembranosus -V. tibialis H. gastrocnAm, (cap. int.) M. soleus M. flexor digitor. comm. longas Points of Electrical Irritation upon the Back of the Lower Extremity. (Erb.) In other words : v/henever we are making an electrical examina- tion, we must know what strength of total current we are employing. Since we are not able to determine this directly with reference to the 33 514 SPECIAL DIAGNOSIS. faradic current, "we must endeavor to form an opinion of the total strength of the faradic current (with a certain definite separation of the coils) by bearing in mind the total strength of the galvanic current which is caused by a certain number of elements (always the same). M. tibial, antic II. eztens. digit, comm. long. M. peroneus brevis • M. extensor hallneis long. 11 i. interossei dorsalgs Fig. 159. Jferv. peroneus M. gastrocneni. extern. U. peroneos longas :. solens M. flexoi. kallacia long. U. eztens. digit, comm. brovis M. abductcir digiti min. Points of Electrical Irritation upon the Leg. (Erb.) If we examine at the same time a number of nerves, we first de- termine the minimal contraction for all, and then the conductive resistance ; and, after we have examined the nerves, we can at once make the faradic examination of the muscles. It is always well to follow the faradic examination with the galvanic, and in this way, with a good deal of practice, we can form an opinion regarding the relation of the conductive resistance at the different points of stimulation of the nerves, and can make a counter judgment regarding the faradic result by a comparison of the number of ele- EXAMINATION OF THE NERVOUS SYSTEM. 515 ments used each time, and the absolute strength of current that is obtained. But, then, there must always be given in the record of the galvanic examination both the number of elements and the strength of the current in M.-A. V^e wish that the direction given above, that the galvanometer should be read when the electrodes have been in place just thirty seconds, could be carried out in all efforts at electro-diagnosis, because otherwise the marked increase of the current at the beginning, just after the electrodes have been applied, could easily occasion great inequalities. (,5) Muscles supplied by the radial \jnusculo-spiraT\ nerve. We use a somewhat larger electrode, stimulate the fleshy part of the individual muscles, and, lastly, determine the minimal contraction; the determination of the conductive resistance is not necessary. Under some circumstances, there comes into consideration the quality of the muscular contraction in indirect and direct faradic stimulation. (See under Reaction of Degeneration.) (h) Galvanic Examination. {a) N'erve. Place the indifferent electrode upon the sternum and the examining electrode (with somewhat strong pressure) upon the radial [musculo-spiral] nerve where it passes around the humerus ; close the cathode three times ; if the result is negative, increase the number of elements : acjain close the cathode three times, and so on until the minimal contraction is found. Then switch-in the galvanom- eter and read off the strength of the total current. (Galvanometers that have a very good arrangement for damping the vibration of the needle can remain switched-in during the examination.) Now determine the minimal AnSC in the same way (but it may be omitted). Usually we may be satisfied with this. The next point of interest would be the determination of CaSTe. (Regarding varia- tions in the quality of the reaction, see under Reaction of Degenera- tion.) (,5) Muscles of the radial. We proceed as in the case of the nerves, but sometimes we may place the indifferent electrode upon the wrist, dorsal side, etc. It is always necessary to determine the minimal CaSC and minimal AnSC ; but before all, the most exact observance 516 SPECIAL DIAGNOSIS. of the character of the contraction (see under Reaction of Degenera- tion), -whether it is " lightning-like " or " slow," and in this direction ■we not only observe the minimal contraction, but also whether it is a stronger, or a strong, contraction. Summarized, the scheme of examination would be as follows : (a) Faradic examination : (a) nerve (,J) muscle ih) Galvanic examination : («) nerve ((?) muscle. 3. What to Observe in Determining the Electrical Reaction. We examine in two main directions : (a) the quantitative excita- bility, or degree of excitability of the nerves and muscles ; (b) the qualitative excitability of the muscles under galvanic stimulation. {a) Quantitative excitability. Its diminution in the most marked degree, namely, loss of excitability, is easily recognized. To the record is always to be added : ''lost when the coils of the induction apparatus were separated to a distance x, or for a current of X M.-A." On the other hand, it is diflBcult to define the limits be- tween the normal and pathological in simple diminished or increased excitability, particularly of the nerves. We can take different ways to arrive at a conclusion in this regard : (a) We compare the two halves of the body — very much the most certain way, but of course only applicable in cases of unilateral disease. Normally, the difference between the two halves of the body is very slight. The maximal differences for the nerves and with the galvanic current, according to Stintzing (58 healthy persons ; Stintzing's normal electrode of 3 sq.cm.), are : Ram. frontal. X. VII 0.7 M.-A. X. radialis 1.1 M.-A. N. accessorius 0.15 " | X. peroneus 0.5 " X. medius 0.6 " j X. tibialis 1.1 " X.ulnaris 2" above the olecranon 0.6 " | For faradic excitability the difference for the two sides of the body, at least for the four pairs of nerves that come especially into consider- ation, rami frontal, (facial.), N. accessorius, ulnaris, peroneus (see below) is, according to Erb, scarcely ever greater than 10 mm. separa- tion of the coils of his Dubois induction apparatus ; according to EXAMINATION OF THE NERVOUS SYSTEM. 517 Stintzing the maximal difference of all the pairs of the body that are accessible for examination is 15 mm. A difference which approaches this maximal difference must lead one to think of a pathological condition ; a difference that is materially greater is certainly pathological. But whenever a difference is found, we must always consider whether the two homonymous nerves are situated exactly alike (malformation of the bones, etc., see above). (/5) We are to observe the relation which exists between the irri- tability of the N. frontalis (facialis), accessorius, ulnaris (at the elbow), peroneus : according to Erb's method. These nerves, but especially the ulnaris and peroneus, show only slight differences in health, as the following table, taken from Erb's Handbook, shows : Faradic Current. 1. Healthy person, mechanic, age thirty-eight years. N. frontalis N. accessorius N. ulnaris . , N. peroneus . Distance of coils in mm., minimal contractions. r. 165 172 159 160 1. 166 177 158 163 Variation of galvanom. (old one), 10 elements. 18<= 16= 7° 1. 19° 15° 2. Healthy person, laborer, age twenty-four years. Distance of coils in mm., minimal contraction. Variations of galvanometer (old one), 10 elements. N. frontalis .... N. accessorius . . . N. ulnaris N. peroneus .... r. 195 187 135 180 1.192 182 185 180 r. 17° 10° 6° 5° 1.17° 9° 10° 5° Gralvanic Current. Healthy men, thirty-eight to twenty-four years of age. (Normal electrode, 10 sq.cm.) N. frontalis ]Sr. accessorius N. ulnaris . . N. peroneus . Occurrence of the first CaSE. r. 1.4 M. 0.5 ' 0.4 ' 1.5 ' 1. 1.2 M.-A. 0.5 " 0.4 " 1.5 " Occurrence of the first CaSTe. , 8.0 M.-A. 4.0 •' 6.0 " 7.0 " 8.0 M.-A. 4.0 " 5.5 " 7.0 " 518 SPECIAL DIAGNOSIS, By studying these tables we ascertain from them the relation be- tween these four pairs of nerves as to the extent of their irritability, and it is possible to recognize with greater certainty a bilateral varia- tion, especially of the ulnar or peronous nerves. ij) Lastly, Stintzing has given us in a very exact way the " limits of value " for the irritability of nerves ascertained in the case of fifty- eight healthy persons (Edelmann's galvanometer, normal electrode 3 sq.cm.). But these figures are only of value for Stintzing's normal electrode : R. front. N. fac. . . . 0.9— 2.0M.-A. N. ulnaris . 0.2—0.9 M.-A R. zygomat. N. fac. . . 0.8—2.0 " 2" above the olecr. R. ment. N. fac. . . . . 0.5—1.4 " N. radialis . 0.9—2.7 " N. accessorius . . . . 0.1—0.44 " N. peroneus .... . 0.2—2.0 " N. medianus . . . . . 0.3—1.5 " N. tibialis . 0.4—2.5 " In individual cases, however, Stintzing has found still smaller or larger figures. These extreme values are exceptions, possibly, of a pathological nature. Except in the reaction of degeneration, the quantitative irri- tability of the muscles very often goes quite parallel with that of the nerves. We can endeavor to determine this by estimating it. For its relation to the reaction of degeneration, see under the latter heading. (5) Qualitative irritability/ of muscles from galvanic stimulation. Although, with respect to the nerves in general, we are only interested in the strength of current required to produce the first occurrence of CaSC and CaSTe, since the law of contraction of the nerves is that normally the character is almost always lightning-like, in the direct galvanic stimulation of the muscles, two important variations come into consideration : the character of the contraction (whether lightning- like or slow, vermiform, wave-like), and further, the law of contraction, and particularly the relation between CaSQ and AnSC. But the first point of view is much the more important. There are two classes of pathological galvanic muscular reactions : 1, the reaction of degeneration (EaR), the exclusive attribute of de-, generative-atrophic paralysis ; 2, the myotonic reaction, which occurs solely in Thomsen's disease. EXAMINATION OF THE NERVOUS SYSTEM. 519 1. The Reaction of Degeneration (JSaB). (a) Complete EaR. The electrical examination gives the following results : Faradic : 1 = 0, that is, irritability (I) lost, : I = 0, that is, irritability lost. nerves : muscles Galvanic : nerves : muscles : 1 = 0, that is, lost, : slow, tonic, vermiform contractions : the quantitative irritability, about normal, or increased or diminished ; AnSC occurs with a less strong current than the CaSC, and with a less strength of current from which both take place, AnSC is greater than CaSC : AnSC > CaSC. Faradic : nerves : muscles Galvanic : nerves : muscles {h) Partial EaR. diminution of I, ; diminution of I ; diminution of I, EaR as above. For more ready comprehension we add here two curves from Kast, which graphically exhibit the normal muscular reaction and the EaR. Fig. 160. „ ■ :» A i J^ Ka An. ' Ka An Ka An J ^-^ — Kcb : An J ^ — Ka An Ka An Diagrammatic representation of the normal galvanic muscular reaction. Healthy young girl. Stimulation of the muscles in the region of theperoneus. 33 cells. Ka = CaSC ,• An = AnSC. (After Kast.) 520 SPECIAL DIAGNOSIS. Fig. If.l. Diagrammatic representation of the reaction of degeneration (EaRV (After Kast ) Case of poliomyelitis anter. chronic. Same muscles as above. 40 cells. Contractions tardy, AnSC > KaSC. Course of EaR. EaR is the pathognomonic sign of those changes which take place in muscle, or motor nerves and muscle, Avhen they cease to stand under the peculiar trophic influence of their anterior horn ganglia — those alterations we designate as degenera- tion of the nerves and muscles. This degeneration can be most beau- tifully studied by the electrical phenomena if a nerve trunk is, at some place, suddenly interrupted throughout its whole transverse section. Whenever there is such an interruption there is manifest a complete separation of the portion of the nerve of the muscles located peripherally from the anterior horn, which must inev'-tably lead, not only to paralysis, but also degeneration of the portions cut off, and with it EaR. But now the case can either proceed so far that there is a permanent interruption at the injured spot, which results in com- plete atrophy of the nerves and muscular fibres, or, after a time, the conduction at this place may be restored ; and in the latter case there is a return of the tissues of the nerves and muscles to the normal con- dition — that is, there is regeneration of them. Now, according as the degeneration of the nerve (muscle) results in atrophy {i.e., transfor- mation into connective tissue), or again regenerates and returns to its normal condition, the EaR shows a definite result as such, and also in its temporary behavior with reference to the ability to use the muscles. This result of EaR may, of course, be made use of in drawing a conclusion as to the condition of the nerves and muscles. Erb has investigated these facts in regard to rheumatic facial paral- ysis, and by experimental examinations, in a classical manner. He has given representations for the course of rheumatic facial paralysis, which we here insert. Fig. 162 gives a representation of complete EaR with reference to motility, and faradic and galvanic irritability of the nerves and muscles; EXAMINATION OF THE NERVOUS SYSTEM. 521 and over it are given the designations of the simultaneous histological changes. The line of galvanic muscular irritability is wavy so long as the qualitative changes (slowness of contraction and preponderance of AnSC) continued. 1. Paralysis loith relative early return of motility. The first trace of motility appears at a time when there is still complete EaR. One week later the faradic and galvanic irritability of the nerves reappears ; Degeneration of nerves. Fig. 162. Atrophy, etc. of muscular fibres. Regeneration. Cirrhosis 10. 11. 24. Weeks. Complete EaR with reference to motion. Faradic and galvanic stimulation of the nerves and muscles. Paralysis with early return of motility. (Erb.) hence there now is partial EaR ; three weeks later, the slowness of the contractions begins to disappear. Diminished irritability of the nerves and motility continues a still longer time. '2. Paralysis with later return of motility. Temporarily the condition is like that in Fig. 162. Here, also, there is for some Fig. egeneration of Atrophy, etc., nerves. of muscles. 16.3. Cirrhosis. Regeneration. . ' ' 1. 2. .5. 6. 10. 15. 20. 25. 30. 35. 40 45. 50. 55. Weeks Motility Paralysis with later return of motility. (Eeb.) 522 SPECIAL DIAGNOSIS. time a partial EaR. All the evidences of regeneration return again later. 3. Permanent paralysis. Motility, irritability of the nerves, and faradic muscular irritability do not return. The galvanic muscular Degeneration of nerves. FlO. 164. Atrophy ; nuclear proliferation ; cirrhosis Total atrophy. 1. 3. 10. 20. 30. 40. 50. GO. 70. 80. 90. 100. Weeks. Jlutility Irremediable paralysis. (Eeb.) irritability in the course of some months becomes inl ; the contractions, so long as they are still possible, are slow. Xerve? Fio. 165. Deftenerative .itrophy of muscular fibres, r Regeneration. 0. Weeks. Motility. Paralysis in which there is only partial EaR. (Ekb.) 4. Paralysis in wldcli there is only partial EaR. The faradic and galvanic irritability of the nerves and faradic irritability di- minishes only to a slight degree. Motility returns again quite early. EXAMIXATIOX OF THE NERVOUS SYSTEM. 523 Varieties of JEaR. (a) Partial EaR is necessarily accompanied with slowness of con- tractions (which are also indirect — Erb). Not only the contractions which occur with direct galvanic irritation of the muscles, but all contractions, including those, also, which occur with galvanic and faradic stimulation of the nerves and faradic stimulation of the mus- cles, are slow in their character. ["The faradic excitability of the paralyzed muscle undergoes a diminution corresponding to that of the nerve, but the galvanic excitability of the muscles manifests the quantitative and qualitative changes which are characteristic of the severer forms of the reaction of degeneration."] (5) The AnSC of the nerves is slow, the CaSC is not (Lowenfeld), or, the muscle has a slow faradic reaction, while the nerve does not respond at all (Stintzing) ; or," the muscle has a slow, the nerve a prompt faradic reaction, etc. Stintzing, with the greatest pains, has recently undertaken to bring order out of this confusion with remarkable, although with few, results. Probably it is well to allow the material to still further accumulate before we undertake to interpret it, diagnostically or pathologically. (c) Mixed Electrical Reaction. We thus designate those electrical reactions which occur when a muscle is partly degenerated and partly normal, and a corresponding portion of the nerves is also sound and another portion degenerated. Then we find a diminution, but never a loss, of faradic and galvanic excitability of the nerves and of faradic excitability of the muscles. But the direct galvanic muscular reaction causes the greatest diihculties: the contractions are not exactly short, not altogether slow, AnSC = CaSC, here and there also shorter : it is hard to discover its significance. All of this is not easy to understand, because normal contractions are mixed with EaR ; especially difficult is it, if, as is almost always the case, the excitability is lowered. The object is sometimes attained by making repeated, indeed, daily tests (when it seems that EaR often becomes more distinct), by thorough examination of every part of the mus- cular system with weak as well as with moderately strong currents, frequently changing the location of the indifferent electrode (which must always be done in such a way as to avoid exciting the nerves). A 524 SPECIAL DIAGNOSIS. single clearer manifestation of EaR in one muscle, or in a bundle of muscular fibres, will usually serve as an indication of the whole disease as degenerative atrophic paralysis. It is true that EaR has twice been found in myopathic muscular atrophy in single muscles (Schulte and Zimmerlin). We (with Erb) do not share the opinion of Wernicke that this mixture is the single cause of every case of partial EaR. 2. Myotonic Reaction (Erb). Myotonia congenita occurs in the very powerful (hypertrophic) muscles which always exist with this disease : they show increased irritability and continuance of the contraction with the faradic cur- rent ; with the galvanic test, likewise, there is increased irritability, but only contractions as the current is closed, and then extremely slow and continuing contractions with peculiar formation of furrows and depressions. Stable acting currents (the stimulating electrode placed not upon the muscle, but on the vasti, for instance, near the patella) produce rhythmical, wave-like contractions from the cathode toward the anode. The relation of EaR to the so-called mechanical EaR is not unim- portant. (See, regarding this, on p. 526.) 3. Diagnostic Value of the Electrical Condition. The reaction of degeneration (EaR) occurs: 1. In all paralyses produced by disease of the ganglion cells of the gray anterior columns of the spinal cord, or of the motor nerves of the bulb. 2. In all paralyses produced by disease of the anterior roots and of the periph- eral nerves, where the trophic influence of the anterior horn ganglia fails on account of the interruption of the conduction, peripherally, in the nerve and muscle. The reaction of degeneration (EaR), therefore, is closely connected with degenerative atrophy of the muscles. Thus, it occurs : in polio- myelitis acuta, chronica, spinal progressive muscular atrophy, amyo- trophic lateral sclerosis, lesions of a section of the gray anterior horns from hemorrhage, tumors, etc. ; bulbar paralysis ; in traumatic lesion of the peripheral nerves; in neuritis of all kinds; in "rheumatic" paralyses ; in primary multiple neuritis ; in toxic paralyses, and those that occur after infectious diseases. EXAMIXATIOX OF THE XERVOUS SYSTEM. 525 The presence of- EaR points directly in opposition to : cerebral paralysis, paralysis from lesion of the pyramidal tract in the spinal cord ; further, against myopathic paralysis ; lastly, against functional or hysterical paralysis. Of course, the EaR is to be regarded as contra-indicating the diseases last named, only with the reservation that there is no com- plication -with the conditions first named. Of this character we, with others, consider also the condition of EaR found by Schulte and Zimmerlin with myopathic progressive muscular atrophy [see previous page]. In harmony with the above principles, partial EaR has exactly the same significance as complete. It occurs : 1. In slight afi"ections (as slight forms of rheumatic facial paralysis, slight paralysis of the arm from pressure). 2. In atrophic paralysis, which only affects a portion of the bundles of the muscular fibres, it is disseminated (especially frequent in spinal progressive muscular atrophy, amyotrophic lateral sclerosis, multiple neuritis), and, hence, as a mixed reaction. (See above, p. 523.) When EaR is absent, sometimes it does not strictly show that there is no afiection of the anterior horns or of the peripheral nerves — that is to say, it does not do so if we have to do with a disseminated disease (see Mixed Reaction). EaR may be wanting when there is an existing peripheral paralysis, if it is very slight (very slight pressure-paralysis of the N. radialis, which heals in three to four weeks). EaR in muscles that are not paralyzed is seen by itself in lead- paralysis and traumatic paralyses. Lessened excitability, especially of nerves, without EaR, occurs chiefly in myopathic muscular atrophy (dystrophia muse, Erb), in muscular atrophy from disease of the joints, and in lesions of the spinal pyramidal tracts, especially if recent and very severe. More- over, it is observed with multiple neuritis, arsenic-paralysis, alcohol- paralysis, bulbar paralysis, amyotrophic lateral sclerosis, etc., and here it is probably to be counted as mixed reaction. An intermitting general paralysis at intervals of one to four weeks, which lasts for twenty-four hours, with complete or almost complete loss of all electrical reaction, has been observed by Westphal. Its nature is very problematical. 526 SPECIAL DIAGNOSIS. Increased excitability as manifested by early occurrence of CaSC and CaSTe, occurrence of AnOTe, is an extremely important sign of tetanus. Slight increase is observed in cerebral, spinal, recent neuritic paralyses, in progressive muscular atrophy of spinal origin (here a more considerable increase, and this in muscles that are still performing their function). The increase of galvanic excitability of the muscles with EaR, as well as of the faradic and galvanic irritability of the muscles with myotonic reaction, does not belong here. (For myotonic reaction, see above, p. 524.) 4. Mechanical Excitability of Muscles and Nerves. 1. Upon striking a muscle with a percussion-hammer, we see that a short contraction occurs, like a CaSC with a tolerably weak current. We find these contractions increased and usually quite decidedly slow in those muscles which show electrical EaR : " mechanical EaR." If distinctly present, this shows the same thing as the electrical EaR ; but, often enough, it either fails or is not distinct, while the electrical examination proves the existence of EaR. Increased mechanical excitability with energetic, but slowly de- clining and prolonged contractions (to as much as thirty seconds, Erb), are peculiar to myotonia congenita. [See p. 524.] For those who are experienced, mechanical excitability is not with- out its value as a preliminary starting-point. But it cannot be a substitute for the electrical test. 2. Idiomuscular contractions are transverse prominences which appear locally at the spot where the muscle is struck — thus far without any diagnostic significance. 3. Mechanical excitability of the nerves (striking upon the trunk of the nerve at the point of electrical stimulation) has individual diiferences. In many healthy persons mechanical irritation does not cause any contraction at all. The mechanical excitability of the nerves — but not of the muscles — is very much increased in tetanus (especially in the branches of the N. facialis). 4. Charcot has discovered that a peculiar form of over-excitability of the nerves and muscles is characteristic of the lethargic stage of hypnosis in very hysterical persons : pressure upon the nerve or muscle causes contracture. EXAMINATION OF THE NERVOUS SYSTEM. 597 We mention here, further, the peculiar and obscure phenomenon of paradoxical contractions (Westphal) : In passive dorsal flexion of the foot there occurs a tetanic contraction of the tibialis anticus which lasts from a few seconds to several minutes ; the tendon of the muscle becomes prominent, the foot — even when it is no longer held — remains dorsally flexed. It frequently occurs in connection with increased tendon reflex. 5. Coordination and Ataxia. In all motions there is necessarily a more or less complicated concurrent action of a number of muscles. For example, in order to seize anything with the hand, not only are a series of muscles of the arm, hand, and finger moved, but at the same time, or a minimum of time before, the scapula, as a fixed point for the arm, must be steadied ; moreover, from the free attitude of the body, the shifting of the centre of gravity, brought about by the motion of the arm, must be equallized by the contraction of the muscles of the trunk and legs, and the equilibrium must be maintained — a proceeding which, it is evident from what has just been said, cannot be sharply defined. Hence, in order that the hand may attain its object, and in order that it may attain it in the shortest way and with a steady motion, a very exactly defined number of muscles must contract at the right instant and with the finest adjustment of energy. This correct selection of muscles, and their regula- tion as to time and gradation of activity, is called coordination. It is acquired by practice by means of conscious and unconscious direc- tion of our motions ; and it is preserved by an oversight which is continually becoming less conscious and more unconscious, and which all our motions acquire. Children at first are ataxic in grasping things as well as in walk- ing. The acquired coordination in walking can be partly lost again from long-continued severe sickness. The processes for acquiring and for maintaining coordination are certainly very diversified. Coordination will be acquired by the cor- rections which will be suggested by sensible irritations of all kinds, caused by the motions that are made and conducted to the central organs : the eye sees, the ear (as of the violinist and others) hears — the motion itself or its efi"ects, the sensibility of the skin, the whole 528 SPECIAL DIAGNOSIS. totality of deep sensibility furnishes information — and the correc- tion depends upon the sense of power of the muscles, which gives unconscious information regarding the intensity of the work accom- plished each time by the muscle. In this acquisition of co5rdi- nation the conscious will participates in many ways : in maintaining coordination it recedes very extraordinarily, and gives place to an unconscious influence of the motions by centripetal influences. But, if necessary, it may at any moment take hold, and even with a con- trary effect to that intended, in that the unusual, new agent of the regulation of the will disturbs the coordination which went on suc- cessfully before unconsciously. A person says, " I will make it par- ticularly beautiful," and just at that instant he becomes awkward. This happens, not only with nervous and embarrassed people, but also with those who are very calm : under the control of the will, they suddenly perform a motion which has long been automatically made. NoAv there is scarcely any doubt as to the nature of the centripetal influences, but where and how they bring their influence to bear upon the motor tract is very far from being clear. Voluntary motions certainly proceed to a certain extent from regulation derived from the cortex (where the complex motions, like those for speech, must exist), but certainly still other portions of the brain, which prob- ably act as reflex centres, have an influence upon this regulation (thus especially the cerebellum for the motions of the trunk and legs) ; and lastly, no doubt the gray anterior horns have a part in 'directing the continuity of motion : they preside over the tonus of the muscles, the antagonizing tension constantly in action during activity, they are the seat of tendon and skin reflexes. That all these things have an influence upon the continuity of motion seems to us (as well as to many others) cannot be doubted. But, likewise, there is no doubt that the various centripetal influences upon coordination, to a very great extent, may act vicariously for one another : when there is the loss of the conscious skin and muscular sensibility, in the disappearance of centripetal stimulation, they call forth the muscular tonus, the more attentive regulation of the cor- tical innervation (with the assistance, for example, of the eyes) replaces the loss of constancy ; that, on the other hand — for instance, in the case of the blind — the exquisite superficial and deep sensibility (conscious as well as unconscious) must become prominent. But now, EXAMINATION OF THE NERVOUS SYSTEM. 529 if coordination can no longer be maintained, then with its disturb- ance there occurs ataxia. It is clear from the foregoing that ataxia may exist at the same time with perfectly normal vigor ; indeed, it has nothing whatever to do with native strength. Ataxia shows itself according to its degree only with delicate, or it may even with gross, functions. It usually occurs as an excess of innervation in the sense of directing motion, or as a want of restraint (tabes) .: swing of the legs in walking, putting the feet down as if stamping, or only a clumsy way of moving the feet when turn- ing around (as in closing the door of one's room) ; thus, on account of the uncertainty, the legs are spread out in standing and walking ; impossibility of describing a circle with the foot when lying in bed, inability to exactly place the heel upon the knee of the other leg ; when endeavoring to take hold of anything, the hand misses it, as in the effort to take hold of one's own nose, in executing with the hand the finer movements of all kinds. In other kinds of ataxia there are other kinds of uncertainty, without this character of missing the mark, or the ataxia of the legs and trunk manifests itself by reeling. The control of the eyes sometimes diminishes the ataxia, sometimes not ; the first is often the case in tabes. Most ataxic patients accord- ingly show a noticeable inward consciousness with every ordinary voluntary motion (as walking), quite in contrast with persons in health [see p. 480]. Ataxia occurs : (a) In cerebral affections, and particularly those of the cortex ; here with paresis, confined to a limb or one-half of the body ; with lesions of the vermiform process of the cerebellum, of the crura cerebelli, and of the pons and the corpus quadrigemina ; and lastly, in individual cases in ordinary hemiplegia, if there is slight spasm, [b) Especially in tabes, where ataxia is the most impor- tant symptom, sometimes after disease involving the whole thickness of the spinal cord, (c) Rarely, and generally to a slight degree, in diffuse peripheral neuritides. (d) Rarely as a highly developed dis- turbance after acute infectious diseases. On the contrary, traces of ataxia after long confinement to the bed, especially after acute dis- eases, are not at all rare. Coordination is then temporarily and only partly lost. For details regarding the different theories of ataxia, especially those in regard to tabes dorsalis, see the different special works. It is our 34 530 SPECIAL DJAGyOSIS. opinion that only one source of coordination has always been assumed, in a somewhat one-sided way, by the advocates of the several views. 6. Spasms of the Voluntary Muscles. We gather together under this designation all those pathological motions existing outside of the influence of the will, so we must go very much beyond the popular literal idea of "spasms." But this cannot very well be avoided unless we purposely wish to divide the subject very minutely. First, then, a few general remarks : Tonic spasms are those lasting some time — from minutes to days and weeks — and are symmetrical. Clonic spasms are contractions of short duration, followed by relaxation of the affected muscles. All, with the exception of some forms of trembling, are phenomena of irri- tation derived from the nervous system ; and, in fact, chiefly from the cortex, pyramidal tracts, the anterior horns of the spinal cord, some probably also from the peripheral nerves (also from the muscles themselves : paralysis agitans, contractions of fibrillae). The patho- logical irritation is probably generally a direct one, but certainly also partly reflex ; and, indeed, there is no doubt that the same kind of spasm may be caused by direct as well as reflex influences — as partial traumatic and reflex epilepsy. Many kinds of spasm consist of motions that are always similar — many combined from a few, and sometimes from a great many. Spasms are partly the intrinsic element of the given disease, the thing of which the disease consists ; partly they are a symptom ; and then again they may be a local sign, that is, they may point directly to the seat, or point of origin, of the disease. Often we must deter- mine other phenomena (as paralysis, etc.) for the purpose of dis- covering the point of origin. With certain spasms, especially those that are paroxysmal and general, the condition of self-consciousness at the time of the attack is of great diagnostic importance. Also we often have to consider the general mental condition, for many cases of convulsions lead us over into the territory of psychiatria. We now only mention the difierent kinds of spasm : Trembling (tremor) consists of unproductive motions, often only to be seen by close observation, rapidly following one another. We EXAMINATION OF THE NERVOUS SYSTEM. 53 1 recognize them partly by observing the limb when at rest, partly when the hand is stretched out, or is holding a glass of water, and also by the handwriting. Graphic representation shows that the different forms of tremor differ in the form, frequency, and rhythm of the contractions. Trembling is physiological with bodily exertion, and with mental excitement, and it is sometimes constant, even with persons in good health. Upon the borders of the normal stand the tremors of the aged, tremor senilis. Alcoholic tremor, especially of the extremities and tongue, occurs with the passing away of the effects of the indulgence, or when it is declining ; the tremor saturninus, the tremor which affects morphia- habitues when they abstain from it, that with morbus Basedowii (generally very fine, rapid movements, sometimes also coarser con- tractions), and the tremors of nervous individuals, are the finer kinds of tremors. The tremor of jyaralysis agitans (especially of the extremities, but also of the head) manifests itself by a symmetrical rhythm, by a very characteristic position of the hand and fingers (" pill-maker "). It ceases when voluntary motions are made, especially if vigorous, but sometimes even when writing. On the other hand, the intention tremor occurs only with voluntary motions, in that toward the end of the motion it becomes stronger ; it stops as soon as the patient is quiet. It is an important symptom of multiple sclerosis ; it occurs, however, as tremor mercurialis. In many cases it is difficult to distinguish it from ataxia (which see). Between "tremor" and "clonic spasms " it is not possible to draw a precise distinction. The designation shaking-spasm is used for the transition forms of both. The prominent transition forms of this kind of tremor are those shiverings which begin with fine tremors, becoming constantly coarser with cooling off, and with rapidly-rising fever ; with hysteria there are conditions that resemble tremor. Likewise is to be mentioned the quaking which occurs with marked active spasm of the legs, as especially takes place sometimes after mechanical irri- tation ; foot clonus, particularly, often shows these transition forms very beautifully. In the foresoino; we have not distinguished between the tremors of spasm and those of paralysis, because in regard to most kinds of tremors it is not yet clear to which of the two classes they belong. 532 SPECIAL DIAGNOSIS. For further points regarding this subject, see the several special works. Fibrillary contractions are contractions in individual coarse or fine bundles of muscular fibres which do not produce motion in the limb. In individual cases, however, we can observe a very diminutive motor eff"ect. They are easily recognized by observing the muscle. In health they are often excited (with great individual differences) by the cooling of the skin ; but they also occur with atrophic paralysis, and very abundantly, and hence are not without diagnostic value, in spinal progressive muscular atrophy. Clonic spasms rarely occur by themselves, but they more frequently accompany epileptic and other attacks of convulsions (see below). We sometimes observe them isolated in local affections of the cortex of the brain (see below, Partial Epilepsy) ; but also in other localized cerebral diseases, and in myelitis transversa, as single brusque bending motions of the legs, generally both legs together — probably of reflex origin. Tonic spasms, by themselves, occur most frequently in the form of active spasms (see above, p. 494), in lesions of the pyramidal tracts, and with hysteria. Moreover, they occur in tetanus, and in these forms : as masseter spasms in trismus ; this latter also by itself; as rigidity of the face, risus sardonicus ; extension of the vertebrae with rigidity of the neck and opisthotonus, and in spasms of the legs in the state of extension. Moreover, tonic spasm of the muscles occurs when first moving them after long rest, and as a prolonged condition after voluntary contractions in myotonia congenita ; also, occasionally, as bending and adduction spasms of the arm and hands in tetanus ; as the tonic form of writers' cramp, although seldom purely as such, generally with slight contractions mixed with tremor ; and in the first stage of epileptic attacks (see below). Epileptic spasms, in genuine epilepsy, generally pursue a typical course : after certain subjective warnings (aura), or without these, there is a sudden loss of consciousness, ushered in with a cry, and imme- diately the patient falls down. Then there is a short tonic spasm of all of the voluntary muscles (more especially of the extensors of the arms, legs, vertebrge, but the hands are closed and the thumb is grasped by the fingers) ; then there is clonic spasm, with frightful vigor, of all the muscles of the body, including the muscles of the eyes, tongue, etc. ; after a few minutes there follows, either gradually or EXAMINATION OF THE NERVOUS SYSTEM. 533 suddenly, a period of relaxation with continued loss of consciousness — post-epileptic coma. During the attack, the tongue is often bitten, involuntary discharges take place, and, from the interference with respiration, marked cyanosis often occurs. It is very important to make a diflFerential diagnosis between genuine epilepsy and symptomatic, which often very much resembles the former. The latter occurs in all manner of anatomical diseases of the brain (regarding partial epilepsy in disease of the cortex of the brain, see below), as traumatic and reflex epilepsy, as epileptiform spasms in uraemia, these latter also as eclampsia gravidarum. There occur in children, upon slight provocation, epileptiform or eclamptic attacks during dentition, from intestinal irritation from worms, in the beginning of acute infectious diseases, as scarlet fever, measles, pneumonia, and in the beginning stage of acute poliomyelitis and encephalitis. It is generally very difficult to form an opinion regarding spasms from the anamnesis. Here we must be very cautious in arriving at a diagnosis. Partial epilepsy (Jackson's or cortical). In this there are epilepti- form convulsions which are limited to an extremity or to the facial mus- cles of one side. They are an almost infallible sign of disease located in a corresponding part of the cortex of the brain, and also are connected with or followed by paresis, increased tendon reflex, and sometimes by disturbance of the sensibility of the affected limb (monoplegia). The convulsions may be unilateral or even general, but they manifest themselves as originally partial epileptic, by beginning in the affected limb. Hysterical convulsions (attacks of hystero-epilepsy) sometimes have a great likeness to epilepsy ; yet almost always the motions may be distinguished in that they are more wide-reaching [and tumultuous], and more than all by the fact that they partly manifest co5rdinated motions, or remind one of them. Motions such as we see made by a person senselessly furious, or an unruly child, are not at all infre- quent ; especial manifestations are fits of laughing, shouting, weeping, coughing. The most important mark of difference between hysterical and epileptic spasms, in doubtful cases, is that in the former there is almost never an entire loss of consciousness ; very often it remains quite 534 SPECIAL DIAGNOSIS. intact; and the absence of involuntary discharges (urine, stool, in males also of semen), as is not infrequent with genuine epilepsy ; lastly, the tongue is not bitten, and there is reaction of the pupil during the attack. Gross [severe] hysteria. The attack of hystero-epilepsy may pass into a second stage [" phase des grand mouvements " of the French] of contortions, and excessive movements — among others, especially that of the "arc de cercle " (head bent backward, boring into the pillow; the trunk bent as in opisthotonus) — ^which may last for hours, are characteristic manifestations ; then there may follow a third stage, which is either quiet or may be excited (delirium) — the stage of hal- lucinations and of emotional attitudes. The stages may occur singly. Besides what has already been described, it is important for diag- nosis that thei*e should be present hysterical signs (stigmates hys- t^riques), manifested by the patient in the form of sensory anaesthesia, especially a concentric limitation of the field of vision ; also, hemi- anaesthesia; hysterogenous zones — that is, hypersesthetic regions of the body (ovaries, testicles, circumscribed portions of the skin), the irritation of which by pressure sometimes causes an attack or is asso- ciated with one. Constrained positions and motions. To the former belong the drawing of the head or trunk to one side, so that the patient assumes the side position in bed (sometimes with the eyes fixed : deviation conjugee occurs with the other manifestations); to the latter belong the involuntary forward, backward, and movement in a circle (manegegang). Both phenomena indicate a lesion of the vermiform process ot the cerebellum or of the median crus cerebri. With the constrained motions, or the " codrdinated spasms," are also to be reckoned the gross motions previously mentioned under hysteria, as laughing, screaming, etc. Chorea minor. This is the designation given to the very rapid, lightning-like, entirely irregular muscular contractions, which, on the one hand, produce restlessness of the limbs and of the face ; and, on the other, disturb and divert the regular voluntary motions. They affect the head (face, tongue, masticating muscles) of the trunk, espe- cially of the shoulders and legs, and sometimes the glottis. They occur in all degrees of severity, from single weak jerks to the most extravagantly confused strong movements (folie musculaire). If the EXAMINATION OF THE NERVOUS SYSTEM 535 subject is embarrassed, especially if observed, frequently the contrac- tions are increased. During sleep (but there may be difficulty in getting to sleep), the convulsions entirely disappear, excepting in par- ticularly severe cases. Chorea minor is not often purely one-sided, or hemichorea. Hemi- chorea may occur either as the forerunner or as the result of hemi- plegia, when it indicates a lesion of the posterior section of the inner capsule or of the optic thalamus. Especially frequent are choreic or athetose motions (which see), with declining acute encephalitis in children (poliencephalitis, Striimpell) in the paralyzed limbs. Quite recently, Flechsig has found both internal segments of the lenticular nucleus diseased in several cases of severe general chorea with delirium. Athetosis [described by W. A. Hammond]. This designates pecu- liar, slow, and at the same time tolerably energetic motions, particu- larly of the hands, arms, shoulders, but also anywhere else. If the motions are somewhat quicker than, but resembling, those of chorea,, they then form a transition to the latter. Athetosis, as well as chorea, is a disease in itself; hemiathetosis is observed in the same cerebral locations as hemichorea (which see). In the cerebral paralyses of children it is more frequent than hemichorea. Associated movements are abnormal involuntary motions, which take place with the performance of voluntary motions by the contrac- tions of muscles in reorions which have nothino; to do with the motions desired. We find them especially in cerebral, but also in spinal, and even in peripheral, paralyses ; hence they cannot be made use of as an aid in diagnosis. Sometimes we see them in muscles of the same limb as that put in motion. Particularly frequent is a dorsal flexion of the foot when the leg is drawn up to the abdomen, as in hemiplegia, spastic spinal paralysis (Striimpell), or in unilateral affections, as synonymous associated movements of the sound side with those of the diseased side, or of the diseased side with the sound side. Catalepsy, cataleptic rigidity, flexibilitas cerea, is a peculiar in- crease of the tonus of the voluntary muscles, of such a character that the limbs not only offer only a very slight or feeble resistance in passive motion, but also remain in a given position, even when it is opposed to gravity, and this sometimes for an hour and more at a 636 SPECIAL- DIAGNOSIS. time. Catalepsy very rarely occurs in anatomical diseases, as tumors of the brain and meningitis ; more frequently in hysteria, especially in hypnosis, and in certain psychoses, as in melancholia attonita. 7. Voluntary Muscles.^ their Innervation, their Function, and the Diseases that Disturb Them. 1. Muscles of the eye (see Examination of the Eye). 2. Muscles of the face, supplied by the N. facialis : M. frontalis draws up the brow and causes wrinkles across the forehead. M. corrugator supercil. draws the skin of the forehead over the roots of the nose into folds. M. orbicularis palpebrarum closes the eyes. M. depressor nasi seu dilator narium dilates the nostrils. M. levator lab. super, (propr.) and M. levator anguli oris lift up the upper lip and the corner of the mouth. M, zygomaticus major raises up and draws out the angle of the mouth. M. buccinator makes the cheeks tense, holds open the pouch of the cheek when eating, prevents the distention of the cheeks when blowing or when whistling (to a slight extent supplied by the trigeminus ?). M. orbicularis closes the mouth; is the chief factor in whistling, pronouncing the consonants b, f, m, p, v, w, the vowels o, u (greatly assisted by the levator menti). Paralysis of the facial: The forehead is smooth and remains so upon the affected side when the effort is made to wrinkle it ; the eye remains open and cannot be closed (lagophthalmus) ; the naso-labial furrow is obliterated ; the angle of the mouth hangs down ; the mouth, and often also the tip of the nose, are drawn toward the sound side ; the effort to expose the teeth, as in cleansing the teeth, makes very plain the defective elevation of the upper lip and distortion of the mouth. When blowing, the affected cheek is distended ; on attempt- ing to whistle, the lips are drawn to the sound side ; if the paralysis is unilateral, the labials are generally, except in recent paralyses, pro- nounced distinctly ; if bilateral, they cannot be. (See further, Soft Palate, Hearing, Taste.) 3. Muscles of mastication, tongue, soft palate, pharynx. Mm. temporalis and masseter (N. trigeminus branch III.) draw up the lower EXAMINATION OF THE NERVOUS SYSTEM. 537 jaw and press the teeth together. Mm. pterygoidei effect the side- ways movement (rotation) of the lower jaw. Paralysis of these muscles will be recognized by the absence, upon one or both sides, of these motions; bilateral paralysis of the temporalis and masseter, by the dropping down of the lower jaw. Palpation below the zygoma detects possible paralysis and atrophy of the mas- seter ; above the zygoma, paralysis and atrophy of the temporalis by its laxity. We pass over the complicated arrangement of muscles which draw down the lower jaw, because their paralyses have not yet been suffi- ciently studied. The tongue is stretched out — that is, it is drawn forward by the two Mm. geniohyoglossi, which act somewhat convergently, and is drawn back chiefly by the two Mm. styloglossi ; M. hypoglossus principally draws it down. These, and the inner lingual muscles, produce the changes in the form of the tongue. Unilateral hypoglossal paralysis : When the tongue is protruded it deviates toward the paralyzed side, because the genioglossus of the sound side pushes it that way. Bilateral paralysis (generally atrophic) causes diminution of all the motions, even to their complete oblitera- tion ; difiiculty in mastication and swallowing ; and in the formation of the consonants c, d, g, k, 1, n, r, s, sch, x, z, and of the vowels i [e], e [a]. Unilateral paralysis produces all these disturbances to a slight degree, and they become less with habit. Atrophy, seldom unilateral, will be recognized by diminution in the volume, by wrinkles, and sensible thinness. The soft palate derives its principal innervation from the spheno- palatine ganglion (N. petrosus superfic. maj., and from the ganglion geniculi of the facial nerve. The fifth and the tenth and eleventh ganglia also take part). Examination: by inspection and phonation — i. g., by observing the voice and inspection, and by the swallowing of fluids. Unilateral paralysis of the soft palate in paralysis of the facial located high up, shows deviation of the uvula toward the healthy side and depression of the arch of the paralyzed soft palate, both more distinctly in phonation. In the passive state, the relaxed uvula may hang to one side, even when there is no paralysis. Sometimes the speech is nasal, and fluids may escape from the nose in attempting to 538 SPECIAL DIAGNOSIS. swallow. Both symptoms are' due to ineffectual closure between the nose and the mouth : pharyngeal space. In bilateral paralysis, espe- cially with bulbar paralysis and as diphtheritic paralysis, the soft palate hangs down without any power to contract ; and nasal utter- ance and the difficulty in swallowing are increased. Tlie phdryngeal muscles (N. X.-XI.), witli the aid of the tongue, accomplish the act of swallowing. When they are palsied, this act is disturbed, and, from the lack of vigor and promptness in passing the food along, it easily enters the larynx : thus, there is coughing in connection with swallowing. But if the patient is unconscious, or there is at the same time disturbance of the sensibility of the larynx (N. laryngeus super, vagi), there may be no cough. 4. Laryngeal muscles. The muscles supplied by the laryngeus super, vagi are : depressors of the epiglottis ; Mm. thyreoepiglott., aryepiglottici (paralysis : difficulty in swallowing), and the M. crico- thyreoides, tensors of the vocal cords by movement of the thyroid cartilage toward the cricoid cartilage (paralysis : hoarse voice). N. laryngeus inferior (recurrent branch of the N. X.-XI.) : Mm. cricoarytaenoid. postici dilate the glottis (bilateral paralysis: inspi- ratory dyspnoea, sometimes of the severest kind, with the voice unchanged or very slightly impure). Mm. thyreo-arytsenoidei are the most important tensors of the vocal cords (paralysis: loss of voice and hoarseness). Musculi arytaenoidei transversi et laterales : they narrow the pos- terior portion of the glottis (in isolated paralysis : the voice is very hoarse, as in catarrh, hysteria). Mm. crico-arytaBnoidei laterales : in connection with the preceding they narrow the glottis. Complete paralysis of the recurrent : {a) unilateral (compression by aortic aneurism, carcinoma of the oesophagus, mediastinal tumors ; bulbar paralysis) : voice hoarse, easily changing to the falsetto, or little or even not at all altered ; (h) bilateral (rare) : complete aphonia, inability to cough. (Regarding the laryngoscopic examination, see Appendix.) 5. Muscles of the throat and neck. M. sterno-cleido-mastoideus (N. XI.) draws the head and face toward the opposite side and looking upward; both together somewhat bend the neck and push the head forward : or, if the head is the fixed point, they lift up the sternum or the clavicles, as in emphysema. The test of their function and EXAMIXATIOX OF THE yERVOUS SYSTEM. 539 recognition of their paralysis and spasm is easy. When both are pai'alyzed, the neck, and with it the head, incline backward. The muscles that stretch, bend, twist the neck or the head (nervi cervical. I.-IV ), maintain the head in the upright position. If they are weak or paralyzed, it is impossible to hold the head up : it falls forward, if it is not exactly balanced. This happens, if the head is too heavy (hydrocephalus). Defective mobility of the head is more frequently caused by spasm or inflammation (stiflF-neck, caries of the cervical vertebrae), than by paralysis. 6. JIuscles of the trunk. Muscles that move the vertebrae (inner- vated by Nn. dorsales and lumbales). Lumbar extensors and extensors of the lower vertebrse : M. erector trunci (sacro-lumb. et longissim.) with bilateral action. Bending forward : the abdominal muscles. Bending of the lower vertebrae sideways : quadrati lumborum. Twisting the trunk : semispinalis and multifidus. Paralysis of the erector trunci : (a) bilateral : the body is bent backward (lordosis of the lumbar, kyphosis of the upper thoracic, vertebrae, in such a way that the latter overhangs the sacrum ; a plumb-line held from it falls behind the sacrum) ; the pelvis is tilted up, the knees are bent, {h) Unilateral : in standing, a scoliosis of the lower vertebrae is convex toward the diseased side; on the other hand, there is a compensatory scoliosis of the thoracic vertebrae. Paralysis of the abdominal muscles : marked lordosis of tte lumbar and lower thoracic vertebrae, compensatory kyphosis of the upper thoracic vertebrae, but these are exactly vertical over the sacrum. There is marked inclination of the pelvis. In paralysis of the extensors, it is impossible to place the bent trunk in an unsupported upright position ; it is accomplished by placing the hands upon the knees and thighs. If. in addition, there is paralysis of the glutei, especially of the gluteus maximus, then the patient can only rise from the floor by first getting down on " all fours," then push up with the hands from the floor, in order immedi- ately to put them upon the knees and thus further support the body : this is his way of standing up. In paralysis of the flexors, it is impossible to sit up from the dorsal position without assistance. Opisthotonus is produced by spasm of the extensors, emprosthotonus 540 SPECIAL DIAGNOSIS. by spasm of the flexors ; unilateral spasm of the extensors causes scoliosis, convex toward the diseased side. 7. Muscles of the thorax., diaphragm, and abdomen. Here belongs most of what has already been said upon p. 815". There we learn regarding the ordinary and the auxiliary muscles of inspiration and the auxiliary muscles of expiration. Paralysis of the diaphragm (phrenic nerve, chiefly from the fourth nerve of the [deep] cervical plexus) in perfect quiet, may be entirely compensated by the thoracic muscles of inspiration ; but otherwise every increased requirement for breath produces marked dyspnoea ; and this is exactly the case with respect to the vicarious action of the dia- phragm when there is defective thoracic breathing. It will be under- stood, then, that paralysis of the auxiliary muscles of respiration has only a bad outlook for the breathing when it comes to such a pass that they must be called upon (see p. 96). Tonic and clonic spasm of the thoracic muscles of inspiration in tetanus and epilepsy at once cause severe cyanosis; in the first disease it may be fatal ; also tonic spasm of the diaphragm interferes very much with breathing and may be dangerous to life. Clonic spasm of the diaphragm (singultus, hiccough), in a mild form, is not infre- quently seen ; if it continues for hours and days, as it sometimes does in abdominal and cerebral aff"ections, then from the disturbance of the rest, and severe pain along the line of insertion of the diaphragm, it may bring about a serious condition. By the contraction of the abdominal muscles the anterior abdominal wall is flattened, and thus the abdominal cavity is lessened ; by the simultaneous contraction of the diaphragm there arises " the abdominal pressure," which is important in defecation and emptying the bladder, and the expulsion of the child in labor. The role of the rectus and obliquus externus, as flexors of the vertebral column (when those of one side act alone, the trunk is bent laterally forward over on one side), has been already mentioned, as well as their function in active expi- ration. 8. 3Iuscles of the upper extremity. {a) Muscles which move the shoulder-blade or fix it : M. trapezius (N. accessorius for the most part) raises the shoulder-blades and draws them toward the middle line, both of these by the middle and posterior parts. The former chiefly lifts up the acromion, the latter the inner EXAMIXATIOX OF THE NERVOUS SYSTEM. 54I upper angle. With its anterior clavicular portion it inclines the head obliquely backward and at the same time lifts up the acromion. Paral- ysis of the trapezius permits the scapula to drop down, to be drawn away from the middle line, and at the same time to turn round so that its apex moves toward the spinal column (because the levator scapulae holds up the upper inner anglej. The shoulder sinks downward and forward ; there is difficulty in raising the upper arm, because the scapula is not so perfectly fixed, and shrugging of the shoulders is restricted. From what has been said the test of its function is easy. M. levator anguli scapulae (X, dorsalis scapulae from the cervical plexus) lifts up the scapula by its inner upper border, with the ten- dency to turn the right scapula in the direction of the hands of the clock, and the left in the opposite direction. Its paralysis can only be recognized when the trapezius is paralyzed at the same time, by the complete inability to lift the shoulder. Mm. rhomboideus major et minor (N, dorsalis scapulae) draw the shoulder-blades toward the spinal column, and thus lift them in the same way as the levator scapulae and turn them in such a way that the lower angle of the scapula is nearest the spinal column. They fix the scapulae, especially in backward motions of the arms and legs, and when lifting weights. Paralysis [of these muscles] moves the scapula, and particularly its lower angle, away from the spinal column. Moreover, it is difficult to detect paralysis of these muscles when the trapezii are normal. M. serratus anticus (N. thoracicus longus seu posterior, Henle, from the brachial plexus) turns the scapula in such a way that the lower angle moves outward, draws it somewhat away from the spinal column, and presses it against the thorax : it is an important fixation-muscle of the scapula when the arms are lifted. AVhen the scapula is fixed (by the rhomboidei) it is a muscle of inspiration. Paralysis of the serratus, in the condition of rest, causes a slight elevation and rotation of the scapula, so that the lower angle stands out a little from the thorax and is (slightly) drawn toward the spinal column. The arm can be lifted up to the horizontal sideways : this moves the inner border of the scapula close up to the vertebral column. It can only be raised higher by fixing the scapula in the same way as would be accomplished by the serratus. When the arm is moved forward, the inner border of the scapula stands out like a wing. 542 SPECIAL DIAGNOSIS. {b) Muscles of the trunk and of the scapula [attached] to the upper arm : M. dekoides (N. axillaris at the infraclavicular portion of the brachial plexus) ; the middle portion extends the arm outward from the body, the anterior portion raises it obliquely forward, the posterior por- tion obliquely backward. It raises it as far as the horizontal, beyond which, the arm being fixed by the deltoid against the scapula, it is raised by the rotation of the scapula. Paralysis is easily recognized : If the muscle is relaxed, there is subluxation of the humerus, par- ticularly if at the same time the supraspinatus is paralyzed ; if the deltoid is atrophied, the contour of the bones at the shoulder shows plainly. M. supraspinatus (N. suprascapularis from the supraclavicular por- tion of the brachial plexus) assists the deltoid in raising the arm out- ward toward the front, rolls it inward, it is also said to hold the head of the humerus in its socket when the arm is raised. Mm. infraspinatus (N. suprascapularis) and the teres minor (N. axillaris) roll the upper arm outward. M. subscapularis (N. subscapularis from the brachial plexus) is a rotator inward. Paralysis of a rotator allows the arm to rotate in the opposite course ; in testing, we first make passive rotation, and letting the arm fall, allow it actively to do the same thing, while we oppose the rotation. M. pectoralis major (N. thoracic, anti. of the brachial plexus) ad- ducts the upper arm ; when the arm is raised up, it moves it forward in the horizontal plane, draws the arm down when it is raised. Test: Have the upraised arm moved forward in a horizontal plane while we oflFer resistance. M. latissimus dorsi (N. thoracico-dorsalis from the brachial plexus) draws down the arm when it is raised up in exertion, [it depresses it] and draws it backward. When the arm hangs down it draws it back- ward and inward [toward the buttock]. Test : The arm is raised to the horizontal and the effort is made to lower it while the movement is opposed. The teres major materially assists the latissimus ; it is at the same time a rotator inward. Mm. coraco-brachialis (N. musculo-cutaneous of the median) and anconeus longus (cap. long, tricipitis ; N. radial.), when the arm is EXAMINATION OF THE NERVOUS SYSTEM. 543 drawn down by the latissimus and pectoralis, hold the head of the humerus up and firmly in its socket. (c) Muscles from the upper arm to the forearm : M. triceps (N. radialis) is an extensor of the forearm. M. brachialis internus (N. musculo-cutaneus) is a simple flexor. M. biceps (N. musculo-cutaneus) flexes and supinates. M. supinator longus (N. radialis) flexes and pronates. This is proved by having the moderately pronated forearm flexed while the movement is resisted. If it is healthy, it rises up like a hard roll on the outer side of the elbow-joint. We here next mention the pronators : the pronator teres (it is at the same time a flexor) and quadratus, both supplied by the median nerve. (d) Muscles which extend from the condyles of the humerus and the bones of the forearm to the hand and fingers, and the small mus- cles of the hand : The extensor carpi radialis longus and brevis (N. rad.) + extensor carpi ulnar. (N. rad.) are elevators of the hand. The flexor carpi radialis (N. median) + flexor carpi ulnaris (N. ulnar.) are volar flexors of the hand ; the palmaris longus (N. median.) assists in this action. The extensor carpi radialis longus -f- flexor carpi radialis adduct the hand in the direction of the radius. Extensor carpi ulnaris + flexor carpi ulnaris adduct the hand on the ulnar side. If the exten- sor carp. rad. long, acts alone, it raises the hand obliquely on the radial side, as the ext. carp. uln. does on the ulnar side. Paralysis of the extensors of the hand (or especially lead-paralysis, also sleep-paralysis of the N. radialis) allows the hand, when the fore- arm is pronated, to hang loosely down. Paralysis of the abductors and adductors and also paralysis of the extensores c. radial, long, and carpi ulnaris alone, produces oblique position of the hand [paralysis from the former giving a position opposite to that of the latter]. We test the individual movements by successively opposing them. M. extensor digitorum (communis indicator, exte. digiti Y.. all from the N. radial) extend the first phalanges. M. flexor digitor. comm. sublim. (N. median.) flexes the middle phalanges ; M. flexor digitor. comm. prof. (N. media, the two ulnar bellies from N. ulnar.) flexes the terminal phalanges. Mm. inteross. dors, -f- volares (N. ulnar.) and Mm. lumbricales (N. med. and ulnar.) 544 SPECIAL DIAGNOSIS. flex the first phalanx and at the same time extend the middle and terminal phalanges. Mm. inteross. dors, alone abduct (spread apart), volares alone adduct the (middle : third) finger. Movements of the thumb : extensor pollic. long. (N. rad.) is essen- tially an extensor of both phalanges ; extens. poll. brev. (N. rad.) is an extensor only of the first phalanx. Adductor poll. long. (N. rad.) abducts the metacarpus. Flexor poll. long. (N. med.) flexes the term- inal phalanx. At the thenar are the opposing muscles — Abductor poll, brevis, outer head of the flexor brevis, and the opponens poll, (all from the N. med.). Adductors: adductor pollicis and the inner deep head of the flex. brev. (both N. ulnar.) These two and the abductor brev. flex the first and extend the terminal phalanx. The adductor, flexor, and opponens act at the hypothenar, their names indicating their action. All are innervated by the N. ulnaris. Characteristic positions of the hand and fingers : 1. In paralysis of the ulnar there is the clawing, clutching hand, main en griffe : the first phalanges are extended, the middle and terminal ones flexed (paralysis of the interossei), the thumb hangs helpless over the hand (paralysis of the adductor) ; the fingers are easily spread out (action of the extensores digit.). Thus the interosseal spaces on the dorsum are deepened, likewise the groove between I. and II. metacarpal bones (atrophy of the adductor pollicis, deep head of the flexor brevis and inteross. dorsi I.). The hypothenar is atrophic. 2. In paralysis of the thenar (deep median paralysis) there is the ape-hand : the thumb does not stand out opposing, but is parallel with, the other fingers. Paralysis of the extensors of the hand causes apparent weakness of the long flexors of the fingers, because the origin and insertion of the flexors are brought near together by the flexion of the hand at the wrist. Hence, we must passively extend the wrist and then test the flexion of the fingers. For the same reason it is necessary, when there is paralysis of the long extensors of the fingers, to passively extend the first phalanx before testing the flexion of the middle and terminal phalanges. Exaynination. We observe the position of the hand for possible atrophy. Then we test extension, flexion, abduction and adduction at the wrist — sometimes all of these — by resisting these motions ; then the extension of the fingers; next the long flexors by "hooking" of EXAMINATION OF THE NERVOUS SYSTEM. 545 the fingers ; then let the patient make the separate motions of the interossei muscles ; flex the first phalanx with the middle and end phalanges extended ; then spread out and close the fingers ; test the muscles of the thenar and hypothenar by bringing the thumb and little finger into contact ; lastly, the examiner places his own index finger in the saddle between the thumb and the second metacarpus, while the patient makes simple adduction of the thumb, thus testing the power that is manifested. Pressure of the hand is a very prac- tical way of making a general test of the long flexors and the small muscles of the hand. For such paralyses as are not wholly diffuse, but rather confined to individual muscles or groups of muscles, peripheral and certain spinal paralyses, it has value only as a preliminary examination. For various reasons we consider the dynamometer as an unnecessary apparatus and one that does not accomplish its purpose. It cannot be sufficiently insisted upon that in order to establish the diagnosis exactly in the upper extremity, and particularly in the hand, beside a clear conception regarding the location and physiological action of the muscles, there must be a knowledge of their innervation. We observe, especially, how the ulnar and median are distributed in the small muscles of the hand. The former innervates the hypothenar, interossei, the two ulnar lumbricales, and the adductors of the thenar, adductor pollicis, and the deep head of the flexor brevis ; the latter, the remaining muscles. In the hand, the radial only supplies branches to the skin. 9. Muscles of the lower extremity. {a) Muscles from the pelvis to the thigh : M. ileo-psoas (N. crural from the lumbar plexus) flexes the hip- joint ; it is assisted (and in the sense of pure flexion) by the action of tensor fasciae latae ,(N. gluteus super, from ischiadic plexus). In paralysis of the psoas, or of this and the tensor fasciae, it is not pos- sible to flex the thigh either in walking or in bed ; paralysis of the tensor fasciae alone permits the pure psoas action to take place : flexion with rotation outward. M. gluteus max. (N. glut, inferior or plexus ischiad.) extends the thigh ; when the thigh is fixed, it brings the pelvis to the horizontal position, and thus the trunk to the vertical (into the upright from the stooping posture, standing upright, etc.). When it is paralyzed, there 35 546 SPECIAL DIAGNOSIS. is the peculiar kind of action in rising from the floor described on page 539, uith paralysis of the extensors of the trunk. M. gluteus medius (N. glut. sup. from the plexus ischiad.), abduc- tor ; M. gluteus minim, (same nerve) rotates the thigh inward. The three glutei are the most important supporters of the pelvis. M. pyriformis (plex. isckiad,), M. obturator, int. (N. ischiad,), M. gemelli (N. ischiad.), M. obturator exter. (N. obturat., plex. lumbal.), M. quadrat, femor. (N. ischiad.), are all, in reality, out-rotators. M. adductor long., brev.,magn., pectineus and gracilis (N. obturat., plex. lumb.), are, for the most part, adductors, at the same time partly flexors. The efl'ect of their paralysis is clear. (b) Muscles from the pelvis and the femur to the leg : M. quadriceps (N. crural.) extends the leg ; its long head, the rectus, arises from the pelvis (anter. infer, spine), and hence acts with more power when the thigh is in a position of extension with reference to the pelvis. In paresis of the quadriceps, the leg (or pos- sibly both legs) in walking are frequently set forward, flexed more markedly at the knee-joint (the leg during the forward movement of the limb hangs vertically down), and this is true also when it is set down quickly, so that there is a sort of snapping of the knee-joint into the position of extension. The examination is best made by endeavoring to flex the limb when it is actively extended. M. sartorius (N. crural.) is probably chiefly an inward rotator of the flexed leg. Mm. biceps fem., semitendinos., and semimembranos. (N. ischiad.) flex the knee-joint ; the first rotates the flexed leg outward, the second inward. If the limb is powerfully extended by the quadriceps, then these flexors, as well as the gluteus max., act : they place the pelvis in the horizontal position (important in walking). (e) Muscles from the leg (or the condyles of the femur) to the foot and toes : M. gastrocnemius, soleus, plantaris (N. tibial.) are extensors ; that is, are plantar flexors of the foot, and, at the same time, adductors of the extended foot. Mm. peroneus long, and brev. (N. peroneus) are extensors (chiefly the first) and adductors of the foot, lift up the outer border of the foot. In paralysis of the peronei muscles (by " peroneus-paralysis " we mean paralysis of the whole peroneus nerve : see below, under M. tibialis EXAMINATION OF THE NERVOUS SYSTEM. 547 antic.) ; the foot in extension, as well as flexion, stands in the position of adduction and the outer border of the foot is deeper ; the foot becomes flat. It is not easy to test the activity of the peronei : we must first show the patient the movements of abducting and lifting up the outer border of the foot by passive movements, and then have him repeat them ; besides, we have the patient extend the foot : in paralysis of the peroneus longus decided adduction then takes place. M. tibial, ant. (N. peroneus) flexes ; that is, dorsally flexes and adducts the foot ; M. extensor digit, comm. and extens. halluc. long. (N. peron.) flexes and adducts the foot, extends the toes. Paralysis of the dorsal flexors causes the point of the foot to drop when the foot is lifted from the floor. If the peronei are likewise paralyzed (pero- neal paralysis ; that is, paralysis of the peroneus nerve), then the foot is lax at the ankle-joint; the point of the foot hangs down, with inclination to adduction. In walking we observe that the foot, as it is raised from the floor, makes a peculiar shufiling motion inward, and it is set down in a fumbling manner. Persons with unilateral, isolated peroneal paralysis are always inclined to take a longer step with the disabled limb in order to obtain the sweeping motion required for the awkward placing of the foot upon the floor. M. tibial, postic. (N. tibial.) is an adductor. Mm. flexor digitor. comm. long, and brev. (N. tibial.) are flexors of the middle and terminal phalanges of the toes ; Mm. interossei externi interni (N. tib.) are flexors of the flrst. extensors of the middle and terminal phalanges — interossei externi. [The outer three muscles are abductors of the second, third, and fourth toes, respect- ively, while the first is an adductor of the second toe, and assists the plantar interossei.] Paralysis of the interossei causes a peculiar kind of claw-position exactly analogous to that of the fingers (see p. 544). M. extensor halluc, longus (N. peron.) extends the first phalanx of the great toe ; Mm. adductor, flexor brevis, abductor hallucis (N. tib.) act essentially in accordance with their names : they produce simul- taneously flexion of the first and extension of the terminal phalanx. Paralysis of the flexor of the great toe hinders one in walking, but especially in springing. 548 SPECIAL DIAGNOSIS. Disturbances of Speech (Lalopathy). I. Dysarthria and Anarthria. By these expressions we understand those disturbances of speech in which we see it altered in the same Avay as the activity of a joint is distributed as to its motility : by paresis, paralysis, trembling, spasm, and even ataxia of the vocal muscles. Unilateral paralysis of the muscles of speech occurs in unilateral affections of the pyramidal tract above the medulla oblongata, or of the cortical centre of the motor speech muscles ; likewise in peripheral paralysis of the hypoglossus and facial nerves. At first the speech is decidedly disturbed ; if these affections continue, there occurs a considerable improvement in the speech, as if it were re-acquired by practice. Bilateral paralyses generally occur from the bulbus of the oblongata (bulbar paralysis), and are then, if they are ganglion paralyses, degenerative-atrophic. It is rare to have bilateral speech paralysis from bilateral cortical or pyramidal lesion (pseudo-bulbar paralysis). We also rarely have a bilateral paralysis of the hypo- glossus or facial nerves of peripheral origin. For the muscles that produce speech and their innervation, see above, pp. 536 and 537. Depending upon which muscles are paralyzed, the disturbance of speech may vary with different letters, as mentioned at the above-named place. We recognize slight anarthritic disturb- ances of speech by requiring the patient to pronounce difficult words quickly, especially such as contain many consonants. Simultaneously with this disturbance of speech, the voice, from paralysis of the palate, is often nasal (or also a kind of " clod-voice "), or the voice has a monotone, or it is inclined to change to a falsetto. (Regarding swal- lowing, see p. 537.) Scanning speech : sounding like the speech of a rider of a horse that is trotting ; there are sharp changes of rhythm, unnatural pauses, sudden, " explosive," and then, again, snapping pronunciation of words. It is particularly characteristic of multiple sclerosis. Hysterical dumbness is a complete loss of speech and generally also of the voice, which occurs suddenly, and generally after an attack of hysteria, which lasts anywhere from days to years, and may suddenly disappear. The mobility of the tongue is normal. EXAMINATION OF THE NERVOUS SYSTEM. 549 II. Aphasio Disturbances, Disturbance of G-raphic Communication {of Mimicking, of Singing). In order to understand these conditions it is necessary to make some explanations regarding the acquisition and use of speech, of writing, etc. Speech and its related functions have their foundation in the culti- vated memory, which is acquired by much practice, and for the mother tongue in childhood. We acquire such a development of the memory : 1. For speech in the narrow sense, and it comprises: (a) Cultivation of acoustic memory, acquaintance with the sound of words by hearing letters, words, and sentences spoken by others. (h) Cultivation of the motor memory, the complex motions used in speaking words, by imitating what we hear, trying to produce the same by correcting what the organs of speech produce until we attain the desired degree of perfection, and we treasure up [in the memory] the complex motions which are required for accomplishing what is desired. 2. The memory for writing comprises the cultivation of the optic memory, the acquisition of writing, and the complex motor writing- motions — again by imitating what we see. Likewise, we develop the comprehension and reproduction of music, a very individual faculty ; of mimicry, and of gestures, varying according to the nationality. Simultaneously with speech, or always somewhat later than imita tion of what is heard, ideas develop — the concrete first; upon the foundation of the concrete, the abstract. Now, we suppose that the cultivation of the sound of words, and of their /orm, also the complex motions for speaking as well as writing them, these four to be accumulated each at its own place in the brain- cortex ; but that, presiding over all, yet not concentrated at one place, but as the result of innumerable functions, with numberless tracts connected with the cells of the brain-cortex, is the mind — i7itelli- gence. The representations of memory, and the complex motions (which are likewise representations of memory), can only functionate the nervous tissue — that is, can only be represented as tones, chords, a series of tones and chords of a violin. And in fact they can be innervated : 550 SPECIAL DIAGNOSIS. 1. From the representations of the sound of words : these come from the periphery through the sense of hearing. If we hear the mother tongue (or any other language which we know), from the con- ception, we inwardly pronounce the words. 2. From the written representation : from the periphery — that is, from the organ of sight, if we read in a known language ; and from the conception, if we inwardly represent to ourselves the printed or written word. 3. From the complex motions of speech : from the centre repre- senting the sound of words by virtue of the imitative instinct — repeti- tion ; and from the mental conceptions — independent utterance of thought. 4. From the complex motions of writing : from written words, by virtue of our imitative instinct — copying ; from mental conceptions — writing out the thought. But still, this is not all : the impulse to produce the complex motions of speech may come from the written or printed representation — we read aloud. On the other hand, the impulse to make the complex motions of writing may come from what is heard — we write from dic- tation. Further, while we are speaking or writing, there comes along the muscular sense an innervation (going in a centripetal direction) of the complex motions of speech or writing. We can make this clear if, with the eyes closed, we have someone else move our hand, as if writing a word : by this means, without other assistance, we can recog- nize simple words. In a still higher degree, also, in the active motions of writing and speaking the report of what is written or spoken — that is, the contractions of the muscles taking part in these acts, and the motions produced by them, go centripetally to the brain. The conceptions of musical notes seem to coordinate those of word- sounds, while the complex motions for producing speech and those which produce music (melody and rhythm) — that is, for singing — are co- ordinated with the larynx and mouth. The conceptions of musical sounds are intimately connected with those of word-sounds, and the com- plex motions required in singing are connected with those required in speaking. The intimateness of this association appears very distinctly in the fact that when a melody happens to come to mind we hum the words belonging to it; or, if the words come first, then we hum the EXAMINATION OF THE NERVOUS SYSTEM. 55I melody. Sometimes this humming is a purely automatic act, for both the text and the melody are articulated involuntarily together. But, again, sometimes the internal re-sounding folloAvs the articulation or act of listening, and from this internal impression the articulation is first produced. Now, to these innervations there belong tracts of communication. Those conducting from the periphery to the " sensory " centres, leading to the centres for conceptions of sound and writing, we under- stand very well — the acoustic and optic nerves. Further, there must exist very manifold combinations between the conception and the four different centres themselves [mentioned on p. 549], but it is very difficult to obtain an exact presentation of these combinations. For instance, Kussmaul supposes that the tract from the centre of ideas to that for the complex, motions of speech goes through the portion which takes note of the sound of the word ; hence he assumes no direct innervation of the centre of the complex motions of speech from that of ideas. Likewise, there is a dispute whether there is a direct communication from the written representation, or whether there is a communication with the centre for the complex motion of writing, etc., only through another centre. We will only bring forward one instance, for the sake of illustration. The following acts, done without understanding by persons in health as well as by sick persons — repeating, reading aloud, copying, or writing from dictation — make it plausible that direct communication exists between the sensory and motor centres, which, therefore, do not go through the centre for ideas. But there is no doubt that, in regard to this, there are very considerable individual differences, particularly dependent upon the degree of cultivation and the intelligence. Of course, we also understand the tracts which peripherally lead from the "motor speech- and writing-centres " — they go through the pyramidal tracts, the bulbar nucleus, to the individual motor nerves ; and, finally, we have a general presentation, at least, of the tracts which pass centripetally from the muscles and joints. These very different qualities, acquired by practice, may each singly or several together be lost. When the organ of hearing remains per- fectly intact, the innervation from the periphery of the conception of the sound of words — that is, the ability to understand the words of one's native tongue — may be lost : there is word-deafness [" inability to 552 SPECIAL DIAGNOSIS. understand spoken words, although they are heard as sounds, while printed or written words are understood" — Billings], loss of intellectual perception of sounds. Even when the muscles of speech are perfectly normal, the ability to employ language, to express one's ideas through the innervation which results in the complex motions necessary to make use of the appropriate word in the native language, may be lost : motor or ataxic aphasia (or, as Kussmaul designates it, " the purest form of ataxic aphasia "). The arm may be in perfect condition, and yet we may not be able to write ; or the eyes may be intact, and yet we cannot read — agraphia, alexia. But since the different capacities under consideration — the understanding and formation of words, the understanding and production of writing — are in a very manifold way connected with each other, these disturbances almost never occur singly, but as a complex of disturbances. The expressions — '■'■ acoustic amnesia^' for word-deafness, " t^/swaZ amnesia" for loss of intellectual perception of sounds — seem to us to be very useful, more so than the German designations formed upon a different principle. The only objection is that these expressions may be confounded with the idea of amnesia discussed later on (p. 554). The study of these things has proceeded from the observations of the disturbances of speech in the narrowest sense, that is, of speaking (Boilliaud, M. Dax, Broca). For this reason, and because all dis- turbances that come under consideration apply to speech in the broader sense (spoken and written speech, with reference to its comprehension and production), we class together, not at all incorrectly, all the conditions under consideration, by the designation of aphasia, aphasie disturbances. We only mention now those two manifestations which may be most sharply distmguished, while for all the details we refer to the special works (see, also, the "schema" of Lichtheim). 1. Word-deaf7icss (Kussmaul), sensor)/ aphasia (Wernicke). The two ideas are not wholly identical. Special works show this more at length. The patient hears every word, but it sounds to him as any healthy person hears a word that belongs to a language which is wholly strange to him. The mother tongue, so far as the under- standing of the hearer is concerned, has become a foreign, unknown tongue ; also, ability to repeat and to write from dictation is wanting. EXAMINATION OF THE NERVOUS SYSTEM. 553 But, again, sometimes the understanding of writing may fail (alexia), and with it the ability to read aloud (see p. 558). But, in opposition to this, the power of volitional writing and to copy written characters, and further, volitional speech, is preserved. Nevertheless, we generally observe a disturbance in this also : very often the wrong words are used, because words that are related by sense or sound are, from unrestrained association, pronounced and strung together {paraphasia) ; or, it may be distinctly noticed that the correct words are employed, but they are distorted by repetition of syllables, dropping of syllables, transposition of letters or syllables {literal aphasia, syllahle-stumbling). Moreover, both conditions some- times have relation Avith amnesia (" amnestic aphasia.,'' see p. 556). 2. Atactic aphasia (Broca's aphemia, Wernicke's motor aphasia) consists in this, that the patient is unable to communicate his thoughts by words: he cannot name objects presented to him, although he promptly shows that he recognizes what they are in that he knows how to use them correctly ; at the same time there is dim- inution of the power to voluntarily write, or to write down what is heard (or write from, dictation) : agraphia, with the exception of the ability to transcribe from copy, which is usually retained. Thus, in pure cases, there is perfect understanding of what is said and also of what is written, and hence there is neither word-blindness nor word- deafness. But in one respect the condition of most patients of this character is still somewhat obscure : with reference to the question whether they are able to produce the sound of the word mentally, to conceive of its sound, i.e., to mentally sound the word. According to Lichtheim, it is probable that in most or in all such cases this capacity has also been completely lost. But regarding this point it is very difficult to form ja positive opinion with respect to these patients. We cannot refrain from dwelling a little upon this question. (For farther regarding the examination of patients with aphasia, see below.) We must confess that, in these cases, we have found that the method employed by Lichtheim, though it is ingenious, is very uncertain. Lichtheim, in order to determine whether the word which designates the given object is mentally correctly sounded, requires the patient to tell how many syllables there are in the word, or to press the hand as many times as it contains syllables. It is assumed that when an object 554 SPECIAL diagnosis;. is presented to a patient there arises in his mind a conception of the sound. What designation does he think of? I hold up a knife before him — does he think "a pocket-knife" or "knife?" — a drink- ing-slass : ''a drinking-glass" or a "glass?" — "handkerchief" or a " sackcloth ?" I admit that there are substances about which there is no doubt, but one would be easily inclined to hold that the number of syllables was wrong, and yet the patient thought he had understood and had spoken correctly. Slighter forms of atactic aphasia manifest only a slight defect in the command of languacre : single words are omitted or single words are defectively pronounced: "doltor," "dolner," for doctor; "lit," for lip; I am "benter," for better, etc. — that is, there is a literal ataxia, syllable-stumbling. But often the patient dwells upon only a few words, or only one, or even a single syllable, which is constantly employed for everything, as was the case with a patient reported by Striimpell, and whom we have watched for years, who could only say, "bibi, bi-bi-bi-bi-bi." We also have cases of paraphasia. An atactic-aphasic patient who, before becoming aflFected, was a good singer, may lose the power of singing as well as of speaking, and yet the "ear" may be retained: he hears when he himself or some one else sings a false note But though the speech may be lost, he may still retain the power to sing the melody of a song, and then it may happen that with the melody he may automatically articulate the words to which it belongs, although he cannot articulate them without the melody. In connection with this the reader is referred to p. 550 for what was said regarding the connection between the complex mo- tions of speaking and singing. There is another disturbance which plays an important part in all forms of aphasia and which presents a special group of symptoms : it is amnesia, amnestic aphasia. The patient presents a perfect picture of a person who is endeavor- ing to speak a foreign language which he only slightly or very imper- fectly understands. An object is held up before him : he is not able to name it ; he repeats it without understanding it, or he remarks : "Yes, certainly, that is the word;" or he hits upon the correct word through association, as upon the number of fingers held up before him by counting — " One, two, three, four — correct : four." This amnesis manifests itself only with reference to certain kinds of words, as for EXAMINATION OF THE NERVOUS SYSTEM. 555 proper names, or chiefly for those representing the most concrete ideas (Kussmaul). Amnesia can be mixed with the different forms of aphasia ; the former may be very indistinct — even for a time, or continuously, may predominate over the aphasia ; but it also occurs in all possible conditions that do not at all belong here : senile dementia, disease of the brain of all kinds, in convalescence from any very severe illness, etc. With Lichtheim Ave do not count these cases as aphasia. Localization of the aphasic disturbances. The exact localization of the two important centres of the understanding and use of language is one of the greatest attainments of recent times. The centre for the complex motions employed in the formation of words, the motor speech-centre, is located in the left third frontal con- volution (Broca) ; lesion of this point causes atactic aphasia. The centre for the formation of sounds, the centre for acoustic recollec- tions, is located in the left anterior central convolution (Wernicke). The right hemisphere has nothing to do with speech, except when the left side is mutilated, when it contains these centres instead of the left. Further, it is extremely probable, though it cannot be regarded as certain, that the centre for the conception of writing is to be looked for in the optic portion of the cortex of the occipital lobe (both sides or only the left ?), and the motor centre for writing in the left second frontal convolution. Hence, all these centres could lie within the given motor and sen- sory portions of the cortex : what relation they sustain to these we do not exactly know. We may always conceive of them as groups of cells which are brought into connection by tracts especially "smoothed" by repetition — that is, tracts with peculiarly slight resistance. Mode of Procedure in Testing for Aphasic Disturbances. We look for any possible aphasic symptoms whenever there is disease of the brain, but especially with any patient who has had an attack of apoplexy, and particularly when there is right-sided hemiplegia. It is evident from the kind of patient that there is cloudiness of the intellect on the one hand, from the blunting of the sensorium, which. 556 SPECIAL DIAGNOSIS. on the other hand, very often interrupts the accompanying inability to think and amnesia. Those patients can only be exactly examined in Avhom the general effect of the injury has passed off; and the most interesting cases are those where, after the indirect collective symp- toms (see, respecting this, the last section of this chapter) have disappeared, an aphasic assemblage of symptoms remains behind as a unilateral disturbance. In the first place, we ascertain whether there is amnesia : if the patient can, we have him count, but further we test him by requiring him to name objects placed before him. If he fails to do this, we give him the name of the object and have him repeat it. If he can do so (either with or without apparent understanding), he is not atactic- aphasic, but amnesic. It is to be remarked that occasionally amnesia may simulate all : atactic aphasia, word-deafness, word-blindness, agraphia. We now proceed to test for possible word-deafness : by conver- sation, by requiring the patient to do something, as to touch his nose, or by directing him to take something in his hand — a knife, pocket- handkerchief, etc. We must be careful to avoid making any kind of gesture, also looking in the direction of the object named. Hereupon we look for signs of atactic aphasia : requiring him to speak and to repeat ; further for evidences of paraphasia, literal aphasia. If the patient is atactic-aphasic, then we must always make the effort to discover whether he has the internal sense of words (see above). After these things, we conclude the test by having him read (that is, read with understanding), read aloud, have him write, compose, write from dictation, copy. With persons who were formerly known to have had a musical ear, or could sing, it will be well to inquire whether they retain or have lost these powers, or, especially, what is the relation of the singing of the air and hearing the music to the understanding and speaking of the words that belong to it. The diagrams serve to display the mutual relations of the four cen- tres to each other and to the so-called " centre of perception." Many forms have been prepared, of which we mention those of Wernicke, Kussmaul, Charcot, Lichtheim. These diagrams are very useful for studying this subject (and we especially recommend Lichtheim's). They are a very excellent guide EXAMINATION OF THE NERVOUS SYSTEM. 557 for examination, for the clear understanding of the different functions, and as a stimulus to independent thought. But they do not exhibit the actual facts. As a rule, these can never be represented ; the individual differences are too great. Charcot rightly distinguishes persons as those in whom either the conception of sound or the con- ception of writing, or even the mechanical representation of speech or of writing, whichever may be predominant, serves as a guide for speech and writing (and likewise for understanding as well as the production of them). We assume that in speaking as well as writing Fig. 166. Lichtheim's diagram of aphasia. A, centre for conception of the formation of sound {a A, conducting tract); 0, centre for conception of written characters (o 0, conducting tract); M, centre for the motions of speech {Mm, the centrifugal motor tract) ; E, cen- tre for the motions of writing [Ee, the corresjjonding motor tract) ; B, centre for con- ception of ideas. The arrows indicate the direction of innervation. • the mental conception causes an innervation of the centre for sound first, and then this innervates the centre for the complex motions re- quired in producing the effect [of speech or writing] ; and further, that, when writing is seen, it must first innervate the centre for sound. Thus there results the understanding of the writing, and hence we can form a conception of what is the significance, to such a person, of the loss of the centre for the conception of sound : a lesion of the temporal lobe. Hence, in our opinion, if we add to Charcot's diagram the centre of cognitions, with its manifold relations, it is the most plausible : it includes all tracts that can possibly exist, and in most 558 SPECIAL DIAGNOSIS. cases of aphasia we must assume that in each individual, while in health, some of the tract's did not exist. Hence, it follows that, from the character of the disturbance, whose location we can know nothing of without an autopsy, much less locate simply from the symptoms, we must draw a conclusion regarding the tract from that one which the patient has made use of in health for the purposes of speech (in its widest sense) ; and further, from this we must ascertain what centres or tracts are now cut off. It is plain from this how difficult it often is to judge of these things in an individual case. First we give Lichtheim's and then Charcot's diagram. After Lichtheim's we add his brief summary of the possible disturbances and their phenomena. This summary does not by any means give an idea of Lichtheim's work upon aphasia. Attention is here urgently called to the special works, particularly to the classical writings of Charcot, Wernicke, Kussmaul, and their pupils, as Lichtheim. 1. Interruption in M, the centre for the conceptions of motion or the motor speech-centre (atactic aphasia). Lost : {a) volitional speech ; (h) ability to repeat ; (c) " to read aloud ; {d) *■' to write volitionally ; (e) " to write from dictation [e [in the figure], the internal conception of the word-sounds). Retained : (/) understanding of speech ; (^) " of writing ; (/i) ability to write from copy, 2. Interruption in A, the centre for the conceptions of the sounds of words (sensory aphasia). Lost : {a) understanding of speech ; (6) " of writing; («) ability to repeat after one ; (d) " to write from dictation ; (e) " to read aloud. Retained : (/) " to write volitionally ; {g) " to write from copy ; (Ji) " to speak volitionally. EXAMINATION OF THE NERVOUS SYSTEM. 559 3. Interruption of MA. Intact : (a) understanding of speech ; (b) " of writing ; (c) ability to write from copy. But there is (a) paraphasia ; (6) paragraphia (the same disturbance in voluntary writing) ; disturbance of the same kind in — (/) repeating after one ; [(/) reading aloud ; [h) writing from dictation. 4. Interruption of MB: modification of motor aphasia. Lost : (a) power of voluntary speech ; (5) " " writing; — as in atactic aphasia. But intact are not only — (c) understanding of speech ; (d) " of writing; (e) ability to write from copy ; But besides (/) " to repeat what is said; {g) " to write from dictation ; (Ji) " to read aloud. 5. Interruption of Mm : modification of motor aphasia. Lost : All speech ; everything else intact. 6. Interruption of A B. Lost : (a) understanding of speech ; {h) " of writing. Disturbed : {c) volitional speech : paraphasia. Retained: (tf) " writing; (e) ability to repeat what is said ; (/) " to read aloud; [g) " to write from dictation. 7. Interruption of J. a. Lost : (a) understanding of speech ; (h) ability to repeat what is said ; (c) " to write from dictation. Retained : {d) power of volitional speech ; {e) " " writing; 560 SPECIA L DIA G NOSIS. [/) understanding of Avriting ; [g) ability to read aloud ; (A) " to write from copy. We now introduce Charcot's diagram without further explanation. Apply Lichtheim's Case 1 to it : it will be seen that in those cases which show that representation of symptoms perfectly (Broca's aphasia), it must be assumed that M is diseased ; but further, that in Fig. 167. Charcot's diagram of aphasia. Drawu by Marie {Prog, med., 1888). The designa- tions are the same as in Lichtheim's diagram. The centres are represented as being in those centres of the cortex where they are to be looked for ; the light hatching around A and indicate the general acoustic and optical field in the cortex. Notice the double arrows upon all connecting lines between A, 0,E, M. Also notice the arrows pointing centripetally toward Mvi and Ee, where the stimulation going to M and E cause the motions of speech and writing. In our opinion there is to be added the centre for ideas, which should have a twofold connection with A, 0, E,M. health the connection had passed from E to A only through M ; and still further, that for arbitrary innervation of E it must have previously gone from M, or from A through M. EXAMIXATIOX OF THE yEEVOUS SYSTEM. 561 As an addendum, we add here a few remarks upon the diagnostic value of the character of the writing : (a) Writing is the expression of thought, and in so far as this is the case it is a very fine test for recognizing psychical disturbances of all kinds. (See the text-books upon Psychiatria.) (5) As was mentioned above, agraphia belongs to the group of aphasic symptoms, and, in fact, it occurs in those forms which are completely analogous to disturbances of speech in the narrow sense : as total, as partial agraphia, as paragraphia, or literal agraphia. Likewise, it was previously stated that a sharp distinction was to be made between volitional writing, writing from dictation, and copying. Also, the loss of the capacity to form strictly grammatical sentences. to make a correct sequence of words (agrammatismus, akataphasia)j shows itself in the writing also, or still better than, in speaking. («?) Motor disturbance of the right upper extremity manifests itself in many cases in a very characteristic way in the handwriting : the different kinds of trembling, ataxia, the different varieties of writers' cramp. It is also worthy of note that patients with paralysis agitans very frequently write naturally because, as is well known, their tremblintf ceases when makincr intentional motions. The value of the handwriting for diagnosis here consists chieflv in the fact that we may recognize early slight disturbances (the contour wavy) : ataxia manifested by the strokes going beyond bounds, especially by the imperfections of the large letters. In paralytic dementia the writing, as well as the speech, is ex- tremely copious. This shows the psychical disturbances : delirium with exaltation or dementia ; there is agrammatismus, akataphasia, paragraphia, especially literal paragraphia in an extraordinarily high degree; lastly, there may be motor disturbances of the upper ex- tremities, trembling, ataxia. Sexse Organs, The Eye. — In considerino- the relations of the diseases of the eve to internal diseases, those in connection with the diseases of the nervous system are of very much the greatest importance. We find the eyes, or the function of sight, sympathetically affected in diseases of the nervous system in a great variety of ways. We 36 562 SPECIAL DIAGNOSIS. observe disturbances -which exhibit the more or less direct results of disease of the nerves or of the brain. They are : paralyses (less frequently spasms) of the outer and inner muscles of the eye ; dis- turbances of the diiferent qualities of vision itself, from lesion of the sensory tract at any point from the optic nerve to the cortex ; neuritis optica (choked disk), which, on the other hand, m.iy itself cause dis- turbance of vision. Other conditions, which are coordinate to the diseases in which they occur, oppose these conditions. They are of extremely varied character. We mention, as examples : atrophy of the optic nerve in tabes dorsalis, multiple sclerosis, embolus of the central artery of the retina with simultaneous embolus of the fossa of Sylvius, syphilitic iritis or retinitis in syphilis of the brain. Likewise, the disturbances of the apparatus of vision, occurring with any other internal diseases, may be either coordinated conditions or sequent phenomena of those diseases. Of the former category we name as examples : choroidal tuberculosis in acute miliary tuberculosis, retinal hemorrhage in general hemorrhagic diathesis (sepsis, pernicious anaemia), the various manifestations of syphilis, etc. As a sequent phenomenon we have embolus of the retinal artery in endocarditis aortge or mitralis, possibly cataract with diabetes mellitus, etc. We give these instances in order to show in how great a variety of ways the disturbances of vision may occur as symptoms of other dis- eases. In what follows we cannot classify the subject-matter according to the points of view mentioned above. We rather proceed in accord- ance with the course of an examination of the eye. 1. Movements of the eye. — As is well known, these take place, in part at least, in a very complicated way, by the coordinate action of the muscles of the eye. Paralysis or spasm of the outer muscles of the eye causes a defective motion of the eye and disturbs its binocular motion, which we designate as strabismus. If the strabismus is due to spasm, it is present in all positions of the eye ; but if dependent upon paralysis, then it has a different relation. In slight paralysis (paresis) of a muscle, strabismus only occurs when a motion of the eye is made which is in a considerable degree dependent upon the co- operation of the muscle paralyzed ; on the other hand, in more marked paralysis, strabismus may be almost always present. It is only absent when the eyes are brought into a position which cor- responds with an especially marked relaxation of the paralyzed muscle. EXAMINATION OF THE NERVOUS SYSTEM. 563 In long-continued paralysis of one or more muscles of the eye, con- tracture of the antagonizing muscles also takes place ; in consequence of which condition, strabismus is always, or almost always, present. Lateral strabismus is designated as divergent or convergent, according as there is a divergence, or an abnormal convergence, of the axis of vision. The direct result of strabismus is double-vision, or diplopia. This results from the fact that, in fixing an object whose image only falls upon the macula of the normal eye, it falls, in the one whose muscle or muscles are paralyzed, to one side of the macula, and at varying distances from it, according to the degree of the strabismus and the distance of the fixed object from the eye. In consequence of the double image, the determination of the position of an object in space, and with it the judgment of the patient with reference to his own position, is disturbed. Hence, primarily there is difficulty in taking hold of objects and in walking; there is dizziness (vertigo of the eye), and this is most marked when there is diplopia in looking downward (paralysis of a rectus inferior, of an obliquus superior). But after long-continued strabismus double vision disappears, for the patient learns to voluntarily shut out the abnormal eye. If it happens to be a case where there is paralysis or spasm of the muscles of both eyes which efi'ect the conjugate motions of the eyes (as the rectus internus of the right and the rectus externus of the left eye), then we speak of paralysis of the conjugate muscles of the eyes (or spasm of these muscles) ; for the position of the eyeball we employ the designation conjugate deviation. Paralysis of all or of almost all of the muscles of an eye results in protrusion of the ball — exophthalmus paralyticus. Marked or total paralysis of the oculomotorius produces, beside the paralysis of the eye (see below), also ptosis (depression of the upper lid), dilatation of the pupil, paralysis of accommodation (paralysis of the levator palp, sup., of the sphincter of the iris, of the muscle of accommodation). Deviation of the eye in which the paralysis or spasm is located is termed the primary deviation. In cases of paralysis there occurs in the normal eye a so-called secondary deviation, if Ave have the patient cover the normal eye and then have him look with it at an object which has been fixed by the diseased one. (Upon this subject, see works upon the Eye.) 564 SPECIAL DIAGNOSIS. We employ our own individual judgment in determining a paralysis of the muscles of the eye, by controlling the position of the eye of the patient while he is looking at a distant object and from the accom- modation, also, especially by motions of the ball sideways, upward and downward ; moreover, we test the patient by having him look at objects in different directions, and then question him as to double vision and in what relation the objects stands to one another. Mode of procedure in determining double vision. We hold up a finger about a metre from the patient, move it up and down, to the right and then to the left, and hold the finger steadily in the position in which the patient has a double image, and then have that position described by him. Then we suddenly close one eye : the patient now declares which image has disappeared. In this way we determine to which eye each one of the double image belongs. Or, we take a lighted candle as the object of vision, and alternately cover an eye with a piece of colored glass, and then, of course, the image presented to this eye is colored. (For further regarding this subject see works upon the Eye.) In regard to the significance of double vision, it is first to be stated that when the balls diverge the images are crossed ; when there is abnormal convergence, they are on the same side (on the side of the convergence). All the rest follows from what will now be said where we collate the function of individual muscles of the eye and the effects of paralysis. M. rectus externus (N. abducens), rolls the eye outward. Its paralysis, according to its degree, produces convergent strabismus, which is manifest either in looking straight ahead, or in looking only toward the side whose external rectus is affected. The double vision is also upon that side. M. rectus internus (N. oculomot.), rolls the eye inward, antagoniz- ing the preceding. When it is paralyzed the in-rotation of the ball is imperfect ; there is divergent strabismus, crossed double vision. M. rectus super. (N. oculomot.), rolls the eye upward and at the same time a little inward. Rectus super. -\- obliq. infer, together cause upward motion of the ball. Paralysis of the rectus sup., limits the motion upward ; the abnormal eye stares downward and a little outward : there is double vision when looking upward ; the image of the paralyzed eye is superimposed upon that of the other. EXAMINATION OF THE NERVOUS SYSTEM. 565 M. rectus inferior (N. oculomot.), rolls the ball downward and slightly inward ; acting with the obliq. sup., there is simple down- ward motion. Paralysis of the rectus infer. : in looking down, the paralyzed eye does not move, but remains directed upward and a little outward ; there is double vision, with one image above the other, the lower being that of the abnormal eye. M. obliq. infer. (N. oculomot.), if it is paralyzed, in looking up- ward we have the action of the rectus sup. alone : the eye turns some- what inward. There is double vision upon the same side, one image is above the other or they are side by side, particularly in looking upward. M. obliq. super. (X. trochlearis), if this is paralyzed, then in look- ing down the rectus inferior acts alone, turning the eye somewhat inward. There is double vision upon the affected side, especially when looking downward. Some of these paralyses, if they occur singly, can be easily recog- nized, and this is especially true of those of the recti. But when several are combined, particularly if the obliqui are involved, there is often the greatest difficulty in making out the exact lesion. A com- bination which may occur frequently is a paralysis of all the muscles supplied by the oculomotorius, with which we may then also have the internal muscles of the eye involving the levator palp. sup. With this total paralysis of the oculomotorius the eye is rotated outward (the action of the abducens), there is som^ exophthalmia, the pupil is dilated and remains so in the presence of light, and there is absence of power of accommodation. By nystagmus, or oscillation of the eyeball, we understand very slight clonic jerking motions of the ball. They are generally conju- gate. If they take place in a horizontal direction, then we speak of horizontal nystagmus. It is often most distinct in fixing the eyeball, but particularly with marked rotation movements of the balls side- ways or in a vertical direction. The diagnostic significance of paralysis of the muscles of the eye varies very much : paralysis of several muscles of only one eye always points with considerable probability to the base of the brain, or to the orbital fissure and orbit, and this is particularly apt to be the case if, at the same time, there is evidence of a lesion of the optic nerve (dis- turbance of vision, unilateral choked disc). Progressive paralysis of 566 SPECIAL DIAGNOSIS. the muscles of both eyes, sometimes ending in total paralysis of these muscles, indicates a progressive nuclear paralysis (ophthalmoplegia externa). It is difficult to estimate the symptomatic value with refer- ence to the topical diagnosis of conjugate deviation. When it is present we should always first think of the possibility of a lesion of the posterior corpus quadrigeminum or its neighborhood ; but aside from this, conjugate deviation occurs with all kinds of local disease of the brain, especially if recent. Hence, if the deviation is due to paralysis, we infer that the line of vision is toward the same side, but if it is a conjugate spasm, the line of vision is toward the opposite side. In the latter case the head is very often drawn to that side. Paralysis of the oculomotorius of one side and of the extremities of the opposite side (crossed paralysis) points with great certainty to a lesion of the crus cerebri, and this corresponds with paralysis of the third nerve. We can immediately understand this fact if we recollect that the N. oculomotorius dexter passes to the right crus cerebri at its base — that is, it passes alongside of the pyramidal tract belonging to the left side of the body. 2. The pupils. — We do not concern ourselves with those changes of the pupil which belong wholly in the province of diseases of the eye (especially in connection with iritis). We are to consider the size, or the changes in the size, which result from certain circumstances. When the iris is normal, the size is regulated by the action of two antagonizing muscles : the sphincter pupillge (N. oculomotorius) and the dilator pupillae (N. sym- patheticus). (a) The size of the pupil. Contracted pupil, myosis, occurs in health during sleep, likewise in old age. Otherwise myosis is always a sign which must awaken suspicion, and indeed is especially frequent in tabes dorsalis (see below. Reflex rigid pupil) ; and, also, although more rarely, in progressive paralysis. The degree of the illumination also has a marked effect upon the size of the pupil (if from reflex action it is not rigid, see below under c). Hence, it is to be examined under moderate illumination. Dilatation of the pupil, mydriasis, occurs with marked disturbances of consciousness, severe pain (see below under c), with atrophy of the optic nerve, paralysis of the M. oculomotorius ; lastly, sometimes with tabes and progressive paralysis. EXAMIXATIOX OF THE XERrOUS SYSTEM. 567 Effect of poisons. Atropine, duboisin, cocaine, dilate the pupil ; eserine, pilocarpin, morphia, contract it. These effects upon the pupil are, in connection with other symptoms, employed for diagnosis in cases of poisoning with any of these substances. {h) Inequality of the pupils sometimes occurs with persons in health, also in people with unequal refraction in the two eyes (with myopia : mydriasis ; in hypermetropia : myosis) ; but, otherwise, inequality of the pupils is a suspicious symptom. It occurs in uni- lateral affections of the brain of all kinds (thus, especially with hsematoma of the dura), with unilateral paralysis of the oculomotorius, of the opticus (dilatation), and in tabes : besides, it frequently occurs in attacks of migraine (irritation, paralysis of the sympathetic of the affected side). (c) Reflex changes in the size of the pupil. The pupil contracts in the presence of light from the contraction of the sphincter (the reflex arc [composed as follows] : («) the optic nerve ; {h) optic tract ; (c) probably the anterior corpus quadrigeminum : [d) oculomotorius). The test is made either in a light room by covering the eye with the hand and then suddenly withdrawing it. or in a room with a dim light by quickly going to the light (more certain). In either case the patient must not employ any accommodation, hence must look at a distant object (see below, converging motion). It is best to test each eye singly by alternately closing one. Sometimes there is an indica- tion for testing the crossed (" consensual") reaction: we observe the changes in the pupil of the right eye, while we vary the light which enters the left, and vice versa. (Regarding hemiopic pupillary reaction, see below.) In old age the reaction of light is physiologically slow. Pain, as painful irritation of the skin (pinching, Faradic brush), dilates the pupil through the action of the dilator. The reaction is slower and less marked than from light. Absence of reaction is the term used for "reflex rigid pupil " (Erb), both "to light " and "to pain." This absence of both reactions often goes hand-in-hand, especially in tabes, where Erb in 8-i cases found 59 instances (= 84.5 per cent.) of absolutely rigid pupils, or (more rarely) very feeble reaction. At the same time there was always reflex rigidity with reference to pain ; and, further, in 37 cases (= 52 per cent.) simultaneous myosis. Reflex rigidity is less frequent in progressive paralysis ; but there rarely ever occurs any other abnor- 568 SPECIAL DIAGNOSIS. mality of the pupils (myosis, mydriasis, inequality, slow reaction of rigidity) in this condition. The reaction of light also fails in atrophy of the optic nerve, and in complete paralysis of the oculomotorius. But it does not fail in central blindness, hence not in cortical hemianopsia. Moreover, when testing in this case, the light from the side where the field of vision is defective must be brought nearer, so that it may only fall upon the half of the retina which is cut off from the centre (see p. 569). Reaction of light takes place in the diseased eye in unilateral optic atrophy when the normal eye is illuminated ; on the other hand, reaction of light is not retained in the diseased eye in unilateral com- plete paralysis of the oculomotorius, as is evident from the course of the reflex arc. [d) Contraction of the pupil in convergence of the eyes, or from accommodation, may not take place in paralysis of accommodation (this most frequently after acute diseases, particularly diphtheria), but it may also be retained. This contraction of the pupils during accommodation has its chief diacjnostic significance in the fact that it must be avoided when testing for the reaction to light or pain — that is, it is generally retained with reflex rigidity of the pupils. 3. Testing for the central sharpness of vision, the color-sense, and the field of vision. (a) We test the sharpness of vision by means of Snellen's plates, which contain test-letters of different sizes, the number of which is represented by the distance in metres at which a normal eye can read the type. After correcting any possible anomaly of refraction in either eye, they are placed at a distance at which it can read the test- letter X. The sharpness of vision is expressed by a fraction whose denominator is the number on the plate, and whose numerator is the distance at which it can be read. According to the above, in normal vision the denominator and numerator must be alike ; the fraction then is always equal to 1 (|, f , etc.) ; instead of this [the sharpness of vision represented by] SV. = f, in case the eye is diseased we have SV. = f, etc. (For particulars, see text-books on the Eye.) As a matter of course, if we discover a diminution in the sharpness of vision, before we conclude that it is due to a disease of the nervous system we must exclude any disease of the refractive apparatus. (Here, also, the reader is referred to special works upon the Eye.) EXAMINATION OF THE NERVOUS SYSTEM. 559 [h) Testing the field of vision, FV., the "peripheral sight." The most exact way to do this is to employ a perimeter. A substitute for this expensive instrument, which can be recommended to one who is not a specialist, is the field-of-vision chart, which has six straight lines intersecting each other at a point making angles of 45 degrees. Starting from the point of intersection, these lines are divided into centimetres. At the point of intersection a rod of definite length stands perpendicular to the chart (it is screwed into the chart) ; upon this upright is a hoop into which the person to be examined places his head. It is used in the same way as a perimeter. The normal size of the field of vision for three or four healthy persons, with a definite length of the upright, is placed upon the chart. (It will be shown that on the outer side the field of vision is endless, because the angle is less than 90 degrees to the direction of the line of siiiht — but of this no account is taken.) The pathological result is drawn upon a diagram which represents the chart and the normal field of vision on a smaller scale. We recognize very decided disturbances by steadily holding a finger about a half metre from and in front of the eye, and then moving the other hand, or a light held by it, in every direction in the field of vision. Of course, in this case, as in all others, we are to test each eye singly. The great difficulty is in having the patient hold the eye fixed immovably. Concentric narrowing of the field of vision rarely occurs in organic diseases of the brain. It oftener occurs with multiple sclerosis, usually from atrophy of the optic nerve (see below), more frequently in neuroses; and it is an especially important symptom in hysteria, "traumatic hysteria," but also in " railroad neurosis," which is closely related to this. With atrophy of the optic nerve there likewise occurs narrowing of the field of vision, which is concentric, more rarely in the form of a sector. Central scotoma occurs particularly in alcohol- and tobacco-amblyopia. The result of semi-decussation of the optic in the chiasm is the peculiar symptom known as homonymous hemianopsia — a defect in the field of vision, involving about half of it, upon the same side of the body in both eyes. Fig. 168 explains this condition : a complete interruption of the optic tract or of the path centrally from it, or, lastly, a total destruction of the sight-centre in the cortex of the 570 SPECIAL DIAGNOSIS. occipital lobe, from which there must result hemianopsia ; and, too, the centripetal conduction of the half of the retina corresponding to the side of the lesion will be interrupted, consequently the half of the field of vision opposite the lesion will be defective. Thus, homonymous hemianopsia indicates a lesion which aifects the tract of sight between Fig. 168. Schematic drawing for explaining the relation of the eyes to vision, and representing hemianopsia. The direction of vision of the two eyes BR is very nearly parallel (the eyes being fixed upon a distant object). Jl/, macula lutea; CA, cTiiasm ; J?;-, i?^, right and left cortical field of sight (occipital cortex). Xotice a kind of semi-decussation in the chiasm, the division of the fibres in the retinae, and the character of the images as they appear in the cortex. H, a local disease behind the chiasm ; it causes hemianopsia. The portion of the field of vision which disappears, and the cortical field which does not perceive the object, are hatched. The corresponding tracts are represented by a wavy line. the chiasm and the cortex. Without doubt, this tract also passes through the posterior portion of the posterior crus of the inner capsule, and with equal certainty is in relation with the anterior corpus quadri- geminum of the affected side, for from here also hemianopsia may arise, or, when there is lesion of the corpora quadrigemina of both sides, there is blindness. Lesion of a tract as far as to the affected corpus EXAMIXATIOX OF THE XEE VOL'S SYSTEM. ' 571 quadi'igeminum causes hemianopsic rigidity of pupil with respect to light (see above, Hemianoptic reaction of the pupils — Wernicke). Hemianopsia is sometimes made manifest by the patient not notic- ing when someone comes to . his bed from that side ; by his not being startled when a light is quickly brought near him from the affected side ; or, in writing, he does not see what he has written upon one side of a sheet of paper, etc. A bilateral dropping out of the nasal half of the retina, with bilat- eral temporal (hence, not homonymous) hemianopsia, may be caused by a tumor which is situated close in front of or behind the chiasm. In this case the two eyes in some degree may compensate, by mutual action, for the defect, though, of course, very imperfectly — for binocu- lar sight is no longer possible. There occur other difficulties whose description does not belong here. Subjective sensations of vision occur in severe diseases of the eyes of all kinds, but especially in anaemia (flimmering), with nervous sub- jects. Temporary partial amaurosis has great significance : a strong shining, generally pronounced unilateral subj ective sensation of light, which, in some of th-e cases, is markedly present in migraine {inigraine ophthalmique), sometimes, during the attack, passing into hemianopsia. ((?) The color-sense. The central perception of color is tested by means of skeins of woollen yarns of as pure colors as it is possible to obtain. The color-sense within the limits of the field of vision — in other words, the size of the field of vision for the individual colors — is ascertained in the same way as that of pure white (see above). It is not without importance (see text-books upon diseases of the Eye). (c?) The results of the ophthalmoscopic examination which are here of interest to us will be fotmd in the Appendix. The diagnostic value of the electrical reaction of the retina cannot be determined, hence we pass it over here. Heaeixg. — Functional test. We ascertain the distance at which a whisper can be heard (a healthy person in a closed room can catch it at a distance of about twenty-five metres). We also employ the tick of a watch, which has previously been tested upon healthy persons, to ascertain the distance at which it can be heard. As a matter of course each ear is to be examined separately, and the ear not being examined is to be closed. To this also extends the testing of the behavior of the conductivity of the bones : a normal person does not at all or 572 SPECIAL DIAGNOSIS. only barely hears a watch held near to the closed ear, but hears it distinctly when it is brought in contact vrith the skull in the neigh- borhood of the ear. Persons with disease of the outer ear-passage and of the middle ear are in the same condition as those with normal ears when more or less completely closed : at a distance they hear poorly or not at all, but by the conduction of the bones they can hear excellently well. On the other hand, Avhen the acoustic nerve or its terminations in the tympanic cavity are diseased (nervous deafness), hearinor at a distance and throuorh the bones are both alike diminished. The examination with the ear-mirror cannot be described here. It naturally comes into consideration for the differential diagnosis of nervous deafness and of affections of the middle ear or of the external ear passages. (Regarding this and its detailed use, see the text-books upon diseases of the Ear.) We call especial attention, from the funda- mental scientific points of view, to the important electrical examination of the acoustic nerve (Brenner) ; it is true that, in its diagnostic rela- tions, it has no independent significance. impart from the special aural point of view, the determination of a disease of the ear or of the sense of hearing is of importance for vari- ous reasons : (a) for recognizing constitutional affections (caries of the petrous bone in scrofula, tuberculosis, middle-ear catarrh in syphilis ; see p. 286) ; (h) for recognizing any other local disease of the cranium, or within the cranium (at its base), or of the brain, which injures the acoustic nerve or the central conduction of hearing ; lastly, with ref- erence to further resulting phenomena of a disease of the ear or the petrous bone, if they exist : purulent (sometimes, also, tuberculous) meningitis, abscess of the brain, and facial paralysis. It is further to be mentioned that, on the other hand, in a normal condition of the hearing apparatus a functional disturbance may be caused by a rheumatic facial paralysis, if it is located high up : from paralysis of the stapedius muscle, supplied by the facial, and predominant development of the tensor tympani, there may arise a morbid acuteness of hearing, especially for deep tones. Subjective sensibility of hearing (tingling, ringing, buzzing, roaring in the ear, etc.) occurs in anfemia, nervousness ; further, in diseases of this organ of any kind ; but, lastly, also in palpable nervous dis- eases. The latter are then generally affections of the acoustic nerve, EXAMINATION OF THE NERVOUS SYSTEM. 573 as compression or neuritis, or of its terminations in the labyrinth. Subjective auditory sensations, as signs of disease of the acoustic nucleus of the oblongata, or of the auditory tract in its central course, or of the auditory centre of the cortex in the temporal lobe, are very rare, if not unreliable. It is very worthy of note that tinnitus aurium may sometimes introduce an attack of migraine, apoplexy, or, as an aura, an epileptic attack. Tinnitus aurium may occasionally be combined with "dizziness (nervus vestibularis) ; this is much the most pronounced in Meniere's disease. Marked ringing in the ears may become the source of psychical disturbance. In order to make a diagnosis of word- deafness, or of sensory aphasia, it is, of course, necessary, as a preliminary condition, to determine whether the hearing is good. Lastly, attention must be especially called to the fact that a uni- lateral disturbance of the hearing may have entirely escaped the attention of the patient. Smell. — Testing its function. For this purpose we may employ camphor, petroleum; perfumed spirit, and, as disgusting material, asafoetida ; but not ammonia or acetic acid, because even a very slight amount of the vapor of these substances may irritate the trigeminus. We first test one side and then the other. We do not here describe the examination of the nose with the nasal speculum. Anosmia [loss of the sense of smell] of neuropathic origin is not very frequent. It occurs in processes in the anterior cranial fossa and the anterior portion of the brain which lead to compression of the olfactory, as from tumors, meningitis, hydrocephalus; and here it is also due to compression of the olfactory. Unilateral anosmia has been observed as an associated phenomenon of total hemiansesthesia in lesion of the posterior portion of the internal capsule — of course, on the side opposite to that diseased. But in exactly the same way we may have unilateral anosmia with hysterical hemiansesthesia. It is rare to have anosmia from lesion of the nerves passing off from the bulb in the ethmoid bone, when this bone is fractured. But it is always to be remembered that the most frequent cause of loss or diminution of the sense of smell is disease of the nasal mucous membrane. It is further to be noticed that in old age anosmia some- 574 SPECIAL DIAGNOSIS. times occurs without any notable pathological cause (atrophy of the olfactory ). In very isolated cases the disturbance is to be referred to paralysis of the trigeminus ; that is, to the dryness of the nasal mucous mem- brane due to the paralysis. Hyperosmia and osmic pamesthesia (parosmia) occur in hysteria and insanity, and as an aura in genuine epilepsy. Regarding the significance of the nose as a point of departure in disease within the cranium, compare further, pp. 358-9. Taste. — Testin tympanitic sound near, 130 cause of venous stasis, 262 694 INDEX. Tumors, cause of inspiraturv dyspnoea, 99 cerebral, slow pulse with, 237 conceal apex-beat, 201 glandular, cause of pressure on nerves, 469 in chest cavity, dyspnoea from, 95 in lungs, weak percussion o. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. HARE, M. D., Professor of Therapeutics, Jefterson Medical College; Attending Physician to St. Agnes Hospital. ]VtJ]MEKOU© ILLXJSTrtA.TIO>S. THIRD EDITION. Price, Cloth, $1.00. Interleayecl for Xotes . . . $1.25. Specimen of Illustrations. University Medical Magazine, October, 1888. — " Dr. Hare has admirably succeeded in gathering together a series of Questions which are clearly put and tersely answered." Pacific Medicaiyour}ial,OcXoheT, 1889. — " Hare's Phvsiology contains the essences of its subject. No better book has ever been produced, and every stu- dent would do well to possess a copy." Ti}iies and Register. Philadelphia, October 5, 1889. — " In the second edition of Hare's Physiolog)' all the more difficult points of the study of the nervous system have been elucidated. As the work now ap- pears, it cannot fail to merit the appreciation of the overworked student." yonrnal of the Avierican Association, November 23, 18S9. — " Hare's Physiology — an excellent work ; admirably illustrated ; well calculated to lighten the task of the overburdened undergraduate." 10 No. 2. ESSENTIALS OF SURGERY. CONTAINING, ALSO, Surgical Landmarks, Minor and Operative Surgery, and a Complete Description, together with full Illustration, of the Handkerchief and Roller Bandage. By EDWARD MARTII^^, A.M., M.D., Instructor in Operative Surgery and Lecturer on Minor Surgery, University of Pennsyl- vania ; Surgeon to tlie Out-Patients' Department of tlie Children's Hospital, and Surgical Register of the Philadelphia Hospital, etc, etc. PROFUSELY ILLUSTRATED. Fourth edition, considerably enlarg'ed by an Appendix containing: fnll directions and prescriptions for the preparation of the va- rious materials used in ANTISEPTIC SUR- GERY ; also, several hundred recipes cover- ing the medical treatment of surgical affec- tions. Price, m, $1.00. Interleaved for Notes, $1.25. Medical and Surgical Reporter, Februai-y, 1 889. — " Martin's Surgery contains all necessary essentials of modern surgery in a comparatively small space. Its style is interesting and its illuslrations admirable." University Medical Magazine, Januaiy, 1889. — " Dr. Martin has admirably succeeded in selecting and retaining just what is necessary for purposes of examination, and putting it in most excellent shape for reference and memorizing." Kansas City Medical Record. — " Martin's Surgery. — This admirable compend is well up in the most Specimen of Illustrations. advanced ideas of modern surgery." No. 3. ESSENTIALS OF ANATOMYT Including- the Anatomy of tlie VLscera. By chj^rl.es js. iVA-ivcRi: de, m:. r>.. 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 College, etc., etc. ONE HUNDRED and EIGHTY FINE WOODCUTS. THIRD EDITION, Enlarged by an Appendix containing' over Sixty Illustrations of the Os- teology of the Human Rody ; The whole based upon the last (eleventh) edition of GRAY'S AX ATOMY. Price, Cloth, $1.00. Interleaved for I^otes .... $1.25 American Practitioner and N^eivs, February 16, 1889. — " Nancrede's Anatomy. — For self-quiz- zing and keeping fresh in mind the knowledge of Anatomy gained at school, it would not be easy to speak of it in terms too favorable." Southern Califo7-nia P7-actitioner, January, 1889. — "Nancrede's Anatomy. — Very accurate and trustworthy." American Practitioner and News, Louisville, Kentucky. — " Nancrede's Anatomy. — -Truly such a book as no student can afford to be without." 11 Specimen of Illustrations. No. 4. Essentials of Medical Chemistry. ORGANIC AND INORGANIC. CONTAINING, ALSO, Questions on Medical Pinysics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By LAWRENCE WOLFF, M. D., Demonstrator of Chemistry, Jefferson Medical College ; Visiting Physician to German Hospital of Philadelphia; Member of Philadelphia College of Pharmacy, etc., etc. SIXTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1,25. Ciiichinati Medical N'e-ws, January, 1889. — " \A'olff's Chemistry. — A little work that can be carried in the pocket, for ready reference in solving difficult problems." St. Joseph's Medical Hei-ald, March, 1889. — " Dr. Wolff explains most simply the knotty and difficult points in chemistry, and the book is therefore well suited for use in medical schools." Medical and Surgical Reporter, November, 1889. — " We could -wish that more books like this would be written, in order that medical students might thus early become more interested in what is often a difficult and uninteresting branch of medical study." No. 5. ESSENTIALS OF OBSTETRICS By W. EASTERLY ASHTON, M.D., Obstetrician to the Philadelphia Hospital. NUMEROUS ILLUSTRATIONS. SIXTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Specimen of Illustrations. 12 Southern Practitio7ier, January 1890. — " Ashton's Obstetrics. — An excellent little volume containing correct and practical knowledge. An admirable compend, and the best condensation we have seen." Chicago Medical 7it?ies. — " Ash- ton's Obstetrics — Of extreme value to students, and an excellent little book to freshen up the memory of the practitioner." Medical and Surgical Repo7-ter, Januaiy 26, 1889. — " Ashton's Ob- stetrics. — A work thoroughly calcu- lated to be of service to students in preparing for examination." TVifw York Medical Abstract, April, 1890. — "Ashton's Obstetrics should be consulted by the medical student until he can answer every question at sight. The practitioner would also do well to glance at the book now and then, to prevent his knowledge from getting rusty." ]Vo. 6. Essentials of Pathology and Morbid Anatomy. BY C. E. ARMAND SEMPLE, B. A., M. B. Cantab., L. S. A., M. R. C. P., Lond., Physician to the North-eastern Hospital for Children, Hackney ; Professor of Vocal and Aural Physiology and Examiner in Acoustics at Trinity College, London, etc., etc. ILLUSTRATED. FOURTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. From the College and Clinical Record, September, 1889. — "A small work upon Pathology and Morbid Anatomy, that reduces such complex subjects to the ready comprehension of the student and practitioner, is a veiy acceptable addition to medical literature. All the more modern topics, such as Bacteria and Bacilli, and the most recent views as to Urinarj' Patholog}', find a place here, and in the hands of a writer and teacher skilled in the art of simplifying abstruse and difficult subjects for easy comprehension are rendered thoroughly in- telligible. Few physicians do more than refer to the more elaborate works for passing information at the time it is ab- solutely needed, but a book like this of Dr. Semple's can be taken up and perused continuously to the profit and instruc- tion of the reader." Indiana Medical yoiirnal, December, 1S89. — " Semple's Pathology and Morbid Anatomy. — An excellent compend of the subject from the points of view of Green and Payne." Cinciiinati Medical N'ews, November, 1889. — " Semple's Specimen of Illustrations. Pathology and Morbid Anatomy. — A valuable little volume — truly a miiltiim in pa7-voP No. 7. Essentials of 3Iateria Medica, Thera- peutics, and Prescription Writing. By HEXRY 3IOIIRIS, 31. D., Late Demonstrator, Jefferson Medical College; Fellow College of Physicians, Philadelphia; Co- Editor Biddle's Materia Medica; Visiting Physician to St. Joseph's Hospital, etc., etc. SECOND EDITION. FOURTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Medical and Surgical Reporter, October, 1889. — "Morris' Materia Medica and Therapeu- tic-. — One of the best compends in this series. Concise, pithy, and clear, well suited to the purpose for which it is prepared." Gaillards Medical Jojirnal, November, 1889. — " Morris' Materia Medica. — The ver)' es- sence of Materia Medica and Therapeutics boiled down and presented in a clear and readable style." Sanitaritun, New York, Januan,-, 1S90. — " Morris' Materia Medica. — A well-aiTanged quiz-book, comprising the most important recent remedies." Buffalo Medical and Surgical Jourtial, Januar}-, 1890. — "Morris' Materia Medica. — The subjects are treated in such a unique and attractive manner that they cannot fail to impress the mind and instruct in a lasting manner.'' 13 Nos. 8 and 9. Essentials of Practice of Medicine. By HENRY MORRIS, M. D., Author of " Essentials of Materia Medica," etc. With an Appendix on the Clinical and Microscopical Examination of Urine. ByLA\VRENCE V/OLFF, M.D., Author of " Essentials of Medical Chemistry," etc. COLORED (VOGEL) URINE SCALE AND NUMEROUS FINE ILLUSTRATIONS. js IE c; O 3Xr 33 i: ID I T.I O KT, Enlarged by some THREE HUNDRED Essential Formulae, se- lected from the writings of the most eminent author- ities of the Medical Profession. COLLECTED AND ARRANGED BY WILLIAM M. POWELL, M. D., Author of ''Essentials of Diseases of Children." Price, Cloth, $2.00. lledical Sheep, $2.S0. Southern Practitioner, Nashville, Tenn., January, 1891. " Morris' Practice of Medicine. — Of material aid to the advanced student in preparing for his degree, and to the young practitioner in diagnosing affections or selecting the proper remedy." The Medical World, Philadelphia, November, 1S90. " Morris' Practice of Medicine contains, in a concise yet readable form, a complete sum- mary of the medical practice of to-day." Indiana Medical Journal, Indianapolis, December, 1S90. " Morris' Practice of Medicine. — An admirable condensation of the essentials of practice in a very small space. Students will find it an excellent remembrancer." American Practitioner and News, Louisville, Kentucky, January, 1S91. " Morris' Practice of Medicine. — The teaching is sound, the presentation graphic, matter as full as might be desired, and the style attractive." Southern Medical Record, January, 1891. " Morris' Practice of Medicine is presented to the reader in the form of Questions and Answers, thereby calling attention to the most important leading facts, which is not only de- sirable, but indispensable to an acquaintance with the essentials of medicines. The book is all it pretends to be, and we cheerfully recommend it to medical students." 14 No. 10. ESSENTIALS OF GYNECOLOGY. By EDWIX B. CRAIGIN', M.D., Attending Gynecologist, Roosevelt Hospital, Out- patients' Department; Assistant Surgeon, New York Cancer Hospital, etc., etc. 58 FINE ILLUSTRATIONS. Price, Cloth . . $1.00. Interleaved for Xotes .... $1.25 Aledical and Surgical Reporter, April, 1890. — " Craigin's Essentials of Gynsecolog}'. — This is a most excellent addition to this series of question compends, and properly used will be of great as- sistance to the student in preparing for examina- tion. Dr. Craigin is to be congratulated upon having produced in compact form the Essentials of Gynecology. The style is concise, and at the same time the sentences are well rounded. This renders the book far more easy to read than most compends, and adds distinctly to its value." College and Clinical Record, April, 1890. — " Craigin's Gynsecology. — Students and practi- tioners, general or special, even derive informa- tion and benefit from the perusal and study of a carefully written work like this." Specimen of Illustrations. No. 11. Essentials of Diseases of the Stiii. By HENRY W. STELWAGON, M, D., Clinical Lecturer on Dermatolcigj- in the Jefferson Medical College, Philadelphia ; Physician to Phila- delphia Dispensary for Skin Diseases ; Chief of the skin Dispensary in the Hospital of Univer- sity of Pennsylvania ; Physician to Skin De- partment of the Howard Hospital; Lec- turer on Dermatolrgy in the^Voxcen■s Med- ical College, Philadelphia, etc., etc. 74 ILLUSTRATIONS, many of which are original. Price, Clutli, $1.00. Interleaved for Kotes, $1.25. New York Medical ycmrnal, May, 1890. Stehvagon's Diseases of the Skin.^ — We are indebted to Philadelphia for an- other excellent book on Dermatology. The little book now before us is well entitled " Essentials of Dermatology," and admirably answers the pur- pose for which it is written. The experience of the reviewer has taught him that just such a book is needed. ^Ye are pleased with the handsome ap- pearance of the book, with its clear tj-pe, good paper, and fine woodcuts." 15 Specimen of Illustrations. No. 13. Essentials of Minor Surgery, Band- aging, and Venereal Diseases, By EDWARD MARTIN, A. M., M. D., Author of " Essentials of Surgery, ' etc. 82 ILLUST7JATIONS, mostly specially prepared for this work. Pric^, Cloth, $1.00. Interleaved for Notes, $1.25. Medical News, Philadelphia, January lo, 1891. — " Martin's Minor Surgery, Bandaging, and Venereal Diseases. — The best condensa- tion of the subjects of which it treats yet placed before the profession. The chapter on Genito- urinary Diseases, though short, is sufficiently complete to make them thoroughly acquainted with the most advanced views on the sub- ject." Nashville Journal of Aledieine and Sur- gery, November, 1890. — "Martin's Minor Surgery, etc. should be in the hands of every student, and we shall personally recommend it to our students as the best text-book upon the subject." Phartnacevtical Era, Detroit, Michigan, December i, 1890. — "Martin's Minor Sur- gery, etc. — Especially acceptable to the gene- ral practitioner, who is often at a loss in cases of emergency as to the proper method of ap- plying a bandage to an injured member." Specimen of Illustrations. No. 13. Essentials of Legal Medicine, Toxi- cology, and Hygiene. By C. E. ARMAND SEMPLE, M.D., Author of " Essentials of Pathology and Morbid Anatomy." 130 ILI.ITSTRAT10XS. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Southern Practitioner, Nashville, May, 1890. — " Semple's Legal Medicine, etc. — At the present time, when the field of medical science, by reason of rapid progress, becomes so va^t, a book which contains the essentials of any liranch or de]iartment of it, in concise yet read- able form, must of necessity be of value. This little brochure, as its title indicates, covers a portion of medical science that is to a great extent too much neglected by the student, by rea- son of the vastness of the entire field and the voluminous amount of matter pertaining to what he deems more important departments. The leading points, the essentials, are here summed up systematically and clearly. Medical Brief, St. Louis, May, 1890. — " Semple's Legal Medicine, Toxicologv, and Hy- giene. — A fair sample of Saunders' valuable compends for the student and practitioner. It is handsomely printed and illustrated, and concise and clear iu its teachings." 16 jVo. 14. Essentials of Refraction and Dis- eases of the Eye. By EDWARD JACKSON, A. M„ M. D., Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine ; Member of the American Ophthalmological Society ; Fellow of the College of Physicians of Philadelphia; Fellow of the American Academy of Medicine, etc., etc. AND Essentials of Diseases of the Nose and Throat, By E. BALDWIN GLEASON, M. D., Assistant in the Nose and Throat Dispensary of the Hospital of the University of Penn- sylvania; Assistant in the Nose and Throat Department of the Union Dispensary; Member of the German Medical Society, Phila- delphia; Polyclinic Medical Society, etc., etc. TWO VOLUMES IN ONE. PROFUSELY ILLUSTRATED. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Specimen of Eye lllubtrations. Specimen of Throat Illustrations. University Medical Magazine, Phila- delphia, October, 1890, "Jackson and Gleason's Essentials of Diseases of the Eye, Nose, and Throat. — This, the latest of Saunder's Question Compends, deserves the same praise that has been accorded the earher numbers of the same series of manuals. The subjects have been handled with skill, and the student who acquires all that here lays before him will have much more than a foundation for future work." Pharmaceutical Era, Detroit, Michigan, October 1, 1890, "Jackson and Gleason's Diseases of the Eye, Nose, and Throat. — The subjects are handled in a logical and masterly manner. It is a valuable addition to the student's library, and will be re- ceived with favor." New York Medical Record, November 15, 1890. "Jackson and Gleason on Diseases of the Eye, Nose, and Throat. — A valuable book to the be- ginner in these branches, to the student, to the busy practitioner, and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers know what a student most needs." 17 No. 15. Essentials of Diseases of Children. By V/ILLIAM M. POWELL, M.D., Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania; Examining Physician to the Children's Seashore House for Invalid Children at Atlantic City, N.J. ; formerly Instructor in Physical Diagnosis in the Medical Department of the University of Pennsylvania, and Chief of the Medical Clinic of the Philadelphia Polyclinic. Price, Cloth, $1.00. Interleaved for Notes, $1.2S. American Practitioner and News, Louisville, Kentucky, December 20, 1890. " Powell's Diseases of Children. — This work is gotten up in the clear and attractive style that characterizes the Saunders' series. It contains in appropriate form the gist of all the best works in the department to which it relates." Southern Practitioner, Nashville, Tennessee, November, 1890. " Dr. Powell's little book is a marvel of condensation. Handsome binding, good paper, and clear type add to its attractiveness." Annals of Gynaecology, Philadelphia, December, 1890. "Powell's Diseases of Children. — The book contains a series of important questions and answers, which the student will find of great utility in the examination of children. No. 16. Essentials of Examination of Urine. By LAWRENCE WOLFF, M.D., Author of " Essentials of Medical Chemistry," etc. COLORED (VO&EL) UEINE SCALE AND NUMEROUS ILLUSTRATIONS. JPrice, Cloth, 75 cents. Specimen of Illustrations. University Medical Magazine, June, 1890. *' Wolff's Examination of the Urine. — A little work of decided value." Medical Record, New York, August 23, 1890. " Wolff's Examination of Urine. — A good manual for students, well written, and answers, categorically, many questions beginners are sure to ask." Memphis Medical Monthly, Memphis, Tennessee, June, 1890. ♦'Wolff's Examination of Urine. — The book is practical in character, comprehensive as is desirable, and a useful aid to the student in his studies." 18 No. 18. Essentials of Practice of Pharmacy. By LUCIUS E. SAYRE, Professor of Pharmacy and Materia Medica in the University of Kansas. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Albany Medical Annals, Albany, N. Y., November, 1890. " Sayre's Essentials of Pharmacy covers a great deal of ground in small compass. The matter is well digested and arranged. The research questions are a valuable feature of the book." American Doctor, Richmond, Va., January, 1891. " Sayre's Essentials of Pharmacy. — This very valuable little manual covers the ground in a most admirable manner. It contains practical pharmacy in a nutshell." National Drug Register, St. Louis, Mo., December 1, 1890. "Sayre's Essentials of Pharmacy. — The best quiz on pharmacy we have yet examined." IN PREPARATION. READY ABOUT SEPTEMBER 1, 1891. No. 17. ESSENTIALS OF DIAGNOSIS. No. 19. ESSENTIALS OF HYGIENE. By ROBERT P. ROBINS, M. D. No. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. BALL, M. D. No. 21. Essentials of Nervous Diseases and Insanity. By JOHN C. SHAW, M. D. No. 22. Essentials of Medical Physics. By FRED. J. BROCKWAY, M. D. No. 23. Essentials of Medical Electricity. By DAVID D. STEWART, M. D., AND EDWARDS, LAWRENCE, M. D. 19 Tlie Fiske Firncl Prize Essay Tor IJ^OO- THE SURGICAL TREATMENT OF WOUNDS I OBSTRUCTION of the INTESTINES. By EDWARD MARTIN, A. M., M. D., Surgeon to the Howard Hospital; Assistaiit Surgeon to the University Hospital. AND HOBART A. HARE, M. D, Professor of Therapeutics, Jefferson Medical College; Attending Physician to St. Agnes Hospital. ILLUSTRATED. PRICE, CLOTH, S2.00, NET. " In presenting this Essay upon the Surgical Treatment of Wounds and Obstruction of the Intestines to the Trustees of the Fiske Fund, it is proper to outline the scope of our work, and to slate briefly the facts and lines of original research upon which our conclusions are based. For over two years we have made experiments in the laboratory upon these subjects, and have carried out in every detail all the methods and modifications of operations that have been published or which have occurred to us in the course of our own studies. ... In addition to the original work involved in studyinsf so important a branch of surgery as the one l)efore us (and which will be found represented, grnphically, in part at least by a number of tracings), we have collected and placed before the reader what we believe to be the fullest statistics yet collected upon gunshot wounds of the abdomen." — Extract from Prepack. INDEX. •PAGE Announcement 1 American Text- Book of Surgeuy 2, 3 ViERoRDT AND StUART's MeDICAL DIAGNOSIS 4 Keating's New Unabridged Dictionary of Medicine 5 Saunders' Pocket Medical Lexicon 6 Nancrede's Anatomy and Manual of Dissection 7 De8chweixitz"s Diseases of the Eye 8 Oarrigues' Diseases of Women 8 NoRRis's Syllabus of Obstetrical Lectures 8 Saunders' Pocket Medical Formulary 9 Saunders' Series of Question Compends 10-19 Martin and Hare's Wounds and Obstruction of the Intestines 20 20