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CLINICAL MANUAL 
 
 FOE. THE 
 
 STUDY OF MEDICAL CASES. 
 
 EDITED BY 
 
 JAMES FINLAYSOlSr, M.D., 
 
 PHYSICIAN AND LECTUEER ON CLINICAL MEDICINE IN THE GLASGOW WESTERN INFIEMAET ; 
 
 PHYSICIAN TO THE GLASGOW HOSPITAL FOR SICK CHILDREN ; PRESIDENT OF THE 
 
 GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY ; HONORARY LIBRARIAN 
 
 TO THE FACULTY OF PHYSICIANS AND SURGEONS, GLASGOW, ETC. 
 
 SECOND EDITION, KEVISED AND ENLAEGED. 
 
 WITH ONE HUNDRED AND FIFTY-EIGHT ILLUSTRATIONS. 
 
 PHILADELPHIA: 
 
 LEA BROTHERS & CO. 
 
 1886. 
 
I'lIILADELMIIA : 
 D O II N A N, P R I N T E It, 
 
 N. W. cor .Seventh and Arch Strcota. 
 
LIST OF CONTRIBUTORS AND THEIR SUBJECTS. 
 
 W. T. GAIKDNEE, M.D., LL.D., Professor of the Practice of 
 Physic in the University of Glasgow ; Physician to the Glasgow 
 Western Infirmary; Physician in Ordinary to H. M. the Queen, 
 in Scotland, etc. 
 
 On The Physiognomy or Disease. 
 
 JAMES PINLAYSON, M.D., Physician and Lecturer on Clinical 
 Medicine in the Glasgow Western Infirmary; Physician to the 
 Glasgow Hospital for Sick Children, etc. 
 
 On Case-taking, Family History, etc. 
 
 On Symptoms of Disorder in the yarious Systems. 
 
 (Except in so far as specified below.) 
 
 ALEXANDEK KOBEKTSOISr, M.D., Physician to the Glasgow 
 Royal Infirmary and to the City of Glasgow Parochial Asylum. 
 
 On Insanity. 
 
 JOSEPH COATS, M.D., Assistant Physician, Pathologist, and 
 Lecturer on Pathology in the Glasgow Western Infirmary. 
 
 On The Examination oe the Fauces, Larynx, and Nares. 
 
 WILLIAM STEPHENSON, M.D., Eegius Professor of Midwifery 
 in the University of Aberdeen. 
 
 On Disorders of the Female Organs. 
 
 SAMSON GEMMELL, M.D., Professor of the Practice of Physic 
 in Anderson's College, Glasgow ; Physician to the Glasgow 
 Hospital for Sick Children ; Physician to the Dispensary of the 
 Glasgow Western Infirmary. 
 
 On The Physical Examination of the Chest and Abdomen. 
 
PREFACE TO SECOND EDITION. 
 
 Considerable delay has occurred in the issue of this 
 edition, as the pressure on his time, from some other work, 
 prevented the Editor from undertaking, at an earlier period, 
 that thoroug;h revision of his Clinical Manual which a new 
 edition of a book of this kind necessarily demands after 
 the lapse of a few years. Every portion has been revised 
 by the original contributors and by the Editor himself: such 
 additions and alterations have been made as seemed desir- 
 able. Large sections, here and there, have been entirely 
 re-written, and the number of illustrations increased from 85 
 to 160. These changes have led to an increase in the size 
 of the book : althouo;h in a sense this is to be resetted, it 
 could scarcely be avoided. 
 
 The plan of the book remains unchanged. It is designed 
 to afford such assistance as students, actually working at 
 Clinical Medicine, might seem to require. It is hoped that 
 it may continue to be useful to them in their clinical work, 
 even after they have completed their course at the schools. 
 
 The manner of using this Manual will depend on the 
 subjects brought up before the student in the course of clin- 
 ical instruction, and on the way it is employed by those 
 teachers who may recommend it as helping to lighten their 
 labors in the details of clinical teaching. In the absence of 
 any such guidance, the student is recommended to read the 
 first three chapters : from these he will learn the scope of 
 the work, and he will then be able to select for himself, with 
 
VI PREFACE. 
 
 the aid of the Index, such portions of the Manual for con- 
 secutive reading or for special reference and consultation as 
 his requirements from time to time seem to demand. It 
 will be seen at a glance that this book does not aim at sup- 
 plying any short and easy road to medical diagnosis : its 
 object is to guide the student to a careful examination of 
 the symptoms in his patient, and to supply information as to 
 the methods and results of clinical investigation. To inter- 
 pret these aright reference must often be made to various 
 systematic treatises : some bibliographical notes are appended 
 to the chapters to aid the student in this important part of 
 his inquiry. 
 
 The Editor has to acknowledge much assistance obtained 
 from many friends versed in special departments of medicine : 
 he would be only too glad to enumerate their names were it 
 not that this might imply a greater responsibility than it 
 seems fair to impose on them for their kindly help. 
 
 Dr. John Wilson has supplied some additional drawings 
 for this edition : these, along with all the others, are acknowl- 
 edged in the list of illustrations. 
 
 To two of his former hospital assistants — Dr. Malcolm 
 MacMurrich and Dr. Robert Stevenson Thomson — the 
 Editor's thanks are due for their aid in revising the sheets: 
 the Index for this edition has been prepared by Dr. Mac- 
 Murrich. J. F. 
 
 351 Bath Crescent, 
 
 Glasgow, September, 1886. 
 
CONTENTS. 
 
 CHAPTEE I. 
 
 PAGE 
 
 The Physiognomy of Disease 13 
 
 CHAPTEE II. 
 
 Examination^ and Reporting of Medical Cases . . 52 
 
 CHAPTER III. 
 
 Temperatuee — Pulse — General Signs of Pyrexia . . 74 
 
 CHAPTER ly. 
 Skin — Hair — Nails — Glands — Joints — Bones . . . 109 
 
 CHAPTER Y. 
 
 Examination of the Organs of Special Sense : Testing 
 
 OF Cranial ISTerves 159 
 
 CHAPTER YI. 
 
 Symptoms of Disorder in the Neeyous System . . 208 
 
 CHAPTER YII. 
 Electrical Instruments in Diagnosis .... 269 
 
 CHAPTER YIII. 
 Insanity 296 
 
 CHAPTER IX. 
 
 Disorders of the Respiratory and Circulatory Systems. 333 
 
 CHAPTER X. 
 
 Examination of the Fauces, Larynx, and Nares . - 374 
 
Vlll CONTENTS. 
 
 CHAPTEK XI. 
 
 PAGE 
 
 Disorders of the Digestive System 396 
 
 CHAPTEK XII. 
 Jaundice and Dropsy , 425 
 
 CHAPTER XIII. 
 
 Examination of the Urine and Significance of Urinary 
 
 Symptoms 447 
 
 CHAPTER XIV. 
 Symptoms Connected with the Male Generative Organs. 506 
 
 CHAPTER XV. 
 
 Disorders of the Female Organs and their Relations 
 
 TO the General Health 509 
 
 CHAPTER XVI. 
 
 The Physical Examination of the Chest and Abdomen. 537 
 
 Index . . 641 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 1. Unusually high temperature just before death : great exacer- 
 
 bation with a rigor . 79 
 
 2. Yery low temperature in rectum just before death . . 79 
 
 3. Diagram of daily range of temperature in phthisis and tuber- 
 
 culosis .......... 80 
 
 4. Diurnal range of hectic fever in child ..... 81 
 
 5. Diurnal range of hectic fever in adult ..... 82 
 
 6. Temperature in acute tuberculosis ..... 82 
 
 7. Temperature in quotidian ague . . .... 83 
 
 8. Temperature in tertian ague ...... 84 
 
 9. Temperature in relapsing fever (Wunderlich) ... 85 
 
 10. Temperature in smallpox (Wunderlich) .... 85 
 
 11. Temperature in measles (Wunderlich) ..... 87 
 
 12. Eise of temperature in enteric fever ..... 88 
 
 13. Crisis in pneumonia (Wunderlich) ..... 89 
 
 14. Lysis in broncho-pneumonia (Wunderlich) .... 89 
 
 15. Eemitting lysis in enteric fever ...... 90 
 
 16. Collapse of temperature from hemorrhage in enteric fever . 91 
 
 17. Collapse of temperature simulating an improvement . . 91 
 
 18. Temperature in case of enteric fever with two relapses 
 
 (Dr. Forrest) . 92, 93 
 
 19. Temperature, pulse, and respiration in pneumonia . . 98 
 
 20. Temperature and pulse in cerebral meningitis ... 99 
 
 21. Tracings of pulse and respiration in health (Foster) . . 101 
 
 22. Influence of respiration on pulse (Dr. Gemmell) . . . 102 
 
 23. The itch insect. Drawn by Dr. John Wilson . . .120 
 
 24. Pediculis pubis. Drawn by Dr. John Wilson . . . 123 
 
 25. Hair with favus. Drawn by Dr. John Wilson . . . 125 
 
 26. Favus crust. Drawn by Dr. John Wilson .... 126 
 
 27. Hair with favus (Bazin) 127 
 
 28. Hair with ringworm (Bazin) ....... 127 
 
 29. Downy hairs in ringworm. Drawn by Dr. John Wilson . 128 
 
 30. Hairs with ringworm. Drawn by Dr. John Wilson . . 129 
 81. Parasite in pityriasis versicolor (M'Call Anderson) . , 141 
 
 32. Pupilometer (after Nettleship) 171 
 
 33. ^sthesiometer 197 
 
LIST OF ILLUSTEATIONS. 
 
 IIG. 
 
 34. Dyanamometer ......... 
 
 35. Tracings of ankle clonus in both legs . . . . . 
 3G. Diagrams representing the frequency of fits in status epi- 
 
 lepticus .......... 
 
 37. Crucifixion attitude, hystero-epilepsy (Bourneville et Reg- 
 nard) 
 Galvanic battery . 
 
 38. 
 39. 
 40. 
 41. 
 
 PAGE 
 
 212 
 221 
 
 244 
 
 247 
 270 
 271 
 272 
 278 
 286 
 346 
 356 
 361 
 
 Faradic battery 
 Magneto-electric battery 
 Induction coil 
 42-47. Ziemssen's motor points (Ziemssen) . . . 281- 
 
 48. Cheyne-Stokes respiration (Dr. M'Yail) 
 
 49. Fibrinous cast of bronchi. Drawn by Dr. John Wilson 
 
 50. Elastic fibres from sputum. Drawn by Dr." John Wilson 
 
 51. 52. Potaiii's, Melangeur's, and Zeiss's slide for counting cor- 
 
 puscles 367, 368 
 
 53. Leuksemic blood. Drawn by Dr. John Wilson . . . 371 
 
 54. Laryngeal mirror in position (Morell Mackenzie) . . 383 
 
 55. Laryngeal image in normal state (Morell Mackenzie) . . 386 
 
 56. Laryngeal phthisis (Morell Mackenzie) .... 389 
 
 57. 58. Paralysis of vocal coids (Morell Mackenzie) . . . 393 
 
 59. Parasite in thrush (Ch. Pvobin) 398 
 
 60. Sarcinse ventriculi (Otto Funke) 406 
 
 61. Oxyurides (Davaine) ........ 415 
 
 62. Oxyurides magnified (Leuckart) ...... 415 
 
 63-65. Tffinire (Leuckart) . . . . • . . .416 
 
 66. Head of tjcnia solium (Cobbold) 417 
 
 67. Head of taenia mediocanellata. Drawn by Dr. Jdhn Wilson. 417 
 
 68. Syphilitic teeth (Mr. Jonathan Hutchinson) . . . 421 
 
 69. Crystals of tyrosine (Roberts) 431 
 
 70. Percussion-dulness in ascites ...... 436 
 
 71. Position of ovarian tumors (Bright) ..... 438 
 
 72. Human echinococci (Davaine) ...... 444 
 
 73. Crystals of cholesterine (Otto Funke) 445 
 
 74. Blood corpuscles in urine (Roberts) 471 
 
 74*. Spectro.scopic bands of blood ...... 472 
 
 75. Pus corpuscles in urine (Roberts) ...... 477 
 
 76. Hyaline tube casts (Roberts) 480 
 
 77. Epithelial tube casts (Roberts) 481 
 
 78. Fatty tube casts (Roberts) 482 
 
 79. Renal epithelium (Roberts) 483 
 
LIST OF ILLUSTRATION'S. 
 
 XI 
 
 the 
 
 hypo- 
 
 FIG. 
 
 80. Epithelium from bladder, ureter, and pelvis of kidney 
 
 (Koberts) 
 
 8L Vaginal epithelium in urine (Eoberts) 
 
 82. Spermatozoa (Roberts) .... 
 
 83. Vibriones in urine (Roberts) 
 
 84. Bacteria in freshly voided urine (Roberts) . 
 
 85. Mould fungus in urine (Roberts) 
 
 86. Yeast or sugar fungus (Roberts) . 
 
 87. Extraneous matters in urine (Roberts)* 
 
 88. Various forms of uric acid crystals 
 
 89. Hedge-hog crystals of urate of soda (Roberts) 
 
 90. Amorphous urates (Roberts) 
 
 91. Ammonio-magnesian phosphates 
 
 92. Crystallized phosphate of lime . 
 
 93. Oxalate of lime, crystals .... 
 
 94. Cystine (Roberts) . . . . 
 
 95. Apjohn's apparatus for estimation of urea by 
 
 bromide of sodium solution (Roberts) . 
 
 96. Transverse section of healthy adult chest (Gee) 
 
 97. Pigeon-breast (Gee) ..... 
 
 98. Rickety chest (Gee) ... . . . 
 
 99. Bilateral enlargement of emphysema (Gee) 
 
 100. Unilateral retraction of chest (Gee) . 
 
 101. Pneumograph of Marey (M'Kendrick) 
 101*. Position of thoracic organs (Luschka) 
 
 102. Area of normal percussion-dulness of heart, 
 
 spleen (modified from Weil) . 
 
 103. Increased cardiac dulness from hypertrophy 
 
 104. Percussion-dulness in pericardial effusion (Gairdner) 
 
 105. Displacement of heart and liver from pneumothorax 
 
 (Weil) . 
 
 106. Displacement of heart and liver from pleuritic effusion 
 
 107. Diagrammatic representation of a cardiac revolution 
 
 (Sharpey) 
 
 108. Auricular-systolic murmur (Gairdner) .... 
 
 109. Ventricular-systolic murmur (Gairdner) .... 
 
 110. Ventricular-diastolic murmur (Gairdner) .... 
 
 111. Auricular - systolic and ventricular - systolic murmurs 
 
 (Gairdner) ......... 
 
 112. Ventricular-systolic and ventricular-diastolic murmurs 
 
 Gairdner) . . 
 
 liver 
 
 and 
 
 484 
 485 
 485 
 
 486 
 486 
 
 487 
 
 489 
 490 
 491 
 491 
 492 
 493 
 494 
 495 
 
 502 
 538 
 539 
 639 
 540 
 541 
 545 
 558 
 
 563 
 
 568 
 569 
 
 570 
 571 
 
 576 
 
 578 
 578 
 579 
 
 579 
 
 580 
 
Xll LIST OF ILLUSTEATIONS. 
 
 FIG. PAGE 
 
 113. Auricular-systolic, ventricular-systolic, and ventricular- 
 
 diastolic murmurs combined (Gairdner) . . . 580 
 
 114. Areas of cardiac murmurs (Gairdner) .... 582 
 
 115. Marey's sphygmograph ....... 591 
 
 116. Dudgeon's sphygmograph ....... 593 
 
 117. Pond's sphygmograph ....... 594 
 
 118. Events in a normal sphygmogram ..... 595 
 119 Healthy pus 595 
 
 120. Anacrotic pulse-curves (Landois) ..... 596 
 
 121. Pulse-curves under increasing pressure (Landois) . . 596 
 
 122. Pulse of high tension in Bright's disease .... 597 
 
 123. Dicrotous pulse . 598 
 
 124. 125. Full dicrotism 598 
 
 126, 127. Hyperdicrotous pulse 599 
 
 128. Monocrotic pulse (Riegel) 599 
 
 129. Pulsus bigeminus ........ 600 
 
 130. Pulsus trigeminus ........ 600 
 
 131. Regular irregularity in pulse (Gairdner) .... 601 
 
 132. Pulsus paradoxus (Kussmaul) ...... 602 
 
 133. Senile pulse 603 
 
 134. Pulse in aortic stenosis ....... 603 
 
 135,136. Pulse of aortic regurgitation ..... 604 
 
 137. Pulse in mitral stenosis ....... 605 
 
 138. Pulse irregular in force and rhythm in milral regurgitation. 606 
 
 139. Irregular pulse in mitral regurgitation .... 606 
 
 140. 141. Venous pulse-tracings (Friedreich) . . . 606, 607 
 142-145. Radial pulse-tracings in aneurism . . . 607, G08 
 146, 147. Marey's cardiograph (M'Kendrick) . . . 608,609 
 
 148. Marey's cardiographic tracing (M'Kendrick) . . . 609 
 
 149. Cardiographic tracing (Galabin) ..... 610 
 
 150. Simultaneous tracings by Marey of action of auricle and 
 
 ventricle (M'Kendrick) 611 
 
 151. Sinuiltaneous tracings by pneumograph, sphygmograph, 
 
 and cardiograph (M'Kendrick) . . . . .611 
 
 152. Cardiogram in mitral stenosis (Galabin) .... 612 
 
 153. Cardiogram in aortic regurgitation (Galabin) . . . 612 
 
 154. Anatomical regions of the abdoincn ..... 613 
 
 155. Abdominal viscera, anterior aspect (Marshall) . . , 614 
 
 156. Abdominal and thoracic viscera, posterior asj)ect (Luschka) 620 
 
 157. Displacement of cardiac and hepatic dulness in emphysema 
 
 (Weil) 623 
 
 158. Various degrees of enlargement of the spleen (Weil) . 628 
 
CLINICAL MANUAL FOR THE STUDY OF 
 MEDICAL CASES. 
 
 CHAPTER I. 
 
 THE PHYSIOGNOMY OF DISEASE. 
 
 In examining for medical purposes a patient affected with 
 some bodily disease, it is of importance for the inquirer to 
 have before his mind from the first the nature and the scope 
 of the inquiry proposed, and not to be misled by any of the 
 merely conventional phrases or forms of thought under which 
 plausible fallacies and rash generalizatioDs are so prone to hide 
 themselves. This remark applies with peculiar force to the 
 investigation of the more external or physiognomic characters 
 of diseases, because it is in dealing with these that the phy- 
 sician is under the strongest temptations to appear wise at all 
 hazards, and thus to formulate his knowledge (or his igno- 
 rance) under terms which may or may not be correct as regards 
 the individual case before him, but of which he would find 
 the exact definition extremely difficult or impossible. Thus, 
 it is very easy in a particular case to pronounce the patient 
 " of a phthisical aspect," or " of a gouty habit," or "strumous," 
 or of a rheumatic or other "diathesis," or to say that he has a 
 well-marked " malignant," or " cancerous cachexy ;" and any 
 one of these expressions may, in the particular case, indicate 
 something that is really true, while, nevertheless, the expres- 
 sion itself is altogether objectionable, and devoid both of real 
 accuracy and scientific value. What the clinical observer has 
 to do is not to grasp at a hasty generalization, but to note 
 details of positive fact, and out of these to evolve the elements 
 of a sure diagnosis. The statement that the patient has some 
 peculiar and specific constitutional morbid tendency or bias is 
 not, in any case, the statement of a fact, but of an opinion, 
 and sometimes of a very insecure and fanciful opinion. Such 
 a statement, therefore, should never be found among the pre- 
 
 2 
 
14 THE PHYSIOGNOMY OF DISEASE. 
 
 liminaries ; iH'obably, indeed, rarely even in the more advanced 
 stages, of a hospital report ; inasmuch as even when true in 
 fact, it is an inference based upon many, and much simpler, 
 facts which ought to have been separately noted. The same 
 principle holds, perhaps still more strongly, as regards the 
 so-called " temperaments " — sanguine, bilious, nervous, etc., 
 and all their more complex varieties. Without discussing 
 here at all the amount of truth, or of reality, underlying these 
 expressions, it may be certainly affirmed that their relation to 
 particular diseases is almost wholly illusory ; and therefore 
 the statements in which the elements of a diagnosis, so to 
 speak, are concerned, should be as sim2:>le and precise as pos- 
 sible, and should certainly not involve any general doctrine or 
 theory of the disease and of its causes.^ 
 
 Nevertheless, it is quite true that diseases, considered as 
 disturbances of the physiological course of a healthy life, are 
 often marked by incidents which leave indelible traces not 
 only in the history, but on the physical structure of the body ; 
 and it is the study of these, properly speaking, which ajffords 
 to the well-informed physician almost the whole basis of objec- 
 tive fact out of which a morbid tendency, or diathesis, can be 
 inferred with a fair amount of probability. In other words, 
 diathesis, as a study of facts, in an individual case, is an 
 inference either from previous facts in the history indicating 
 deranged i)liysiological function, or from manifest structural 
 changes, the result of these; Avhereby we are enabled to estab- 
 lish, but only as a presumption founded with more or less 
 probability on the evidence, the existence of a tendency to sim- 
 ilar changes, or changes of some allied order, in the future. 
 In other words, the proof of diathesis is essentially the proof 
 of disease; but, it may well be, disease in its earliest manifes- 
 tatitms and least notable forms. 
 
 There is a whole group of diseases, for example, which affect 
 
 1 The admiralile lectures of Mr. Jonathan Hutchinson — "The Pedigree of Disease," 
 London, 1884 — ])ul)li.slii;d since this paragraph was issued in the first edition of the pres- 
 ent work, do not app(;ar to tlie avithor essentially to modify anything herein set forth, 
 hut rather to confirm the methods of procedure ahove insisted on. (See especially the 
 remarks on temperament and diathesis at pp. 22, 23, 29.) The position taken hy this dis- 
 tingui.shc^d investigator may he indicated hy two very hrief extracts, as follows : "We 
 may perhaps define the term lemjyerament as applicahle to the sum of the physical ])ecu- 
 liarities of an individual, exclusive of all definite tendencies to disease. . , . If there 
 he a distinct jnoclivity, we must then use a stronger term, and speak of dialhesis.^^ 
 "Temperament — the original vital endowment of the individ\ial — is iinquestionahly a 
 real force, ami one which we would most gladly recognize and estimate if we could. The 
 Bcei)ticism which I have been expressing applies not to the reality of the thing, liut to 
 our ability to discriminate it" (p. '.H)). The whole work, in fact, although perhaps not 
 Huitable for beginm-rs, may be commended to advanccil students as a commentary on 
 lh(! rules ami methods of diagnosis recommended in this chapter. 
 
DIATHESIS — SENILE DECAY. 15 
 
 the human body chiefly or exclusively during its period of 
 growth, whether of early infancy or of adolescence ; and another 
 group, the first approaches of which are usually observed only 
 along with, or succeeding, the physiological signs of senile 
 decay. As regards the latter group, it may be said with truth 
 that physiology and pathology are inextricably intermingled. 
 A too early arxus senilis, the premature development of " crow's 
 feet " at the outer margins of the eyelids, wrinkles in the skin 
 of the face, diminished sensibility of the retina, or early presby- 
 opia; still more, the well-known changes in the arteries, twist- 
 ing or rigidity of the radials, etc ; falling or grayness of the 
 hair, diminution or loss of sexual activity, and cessation of the 
 catamenia in women ; all of these (and yet perhaps none of them 
 singly and unsupported by the others) may be appealed to as 
 evidence of a liability to diseases of the senile group generally ; 
 and, if further corroborated by slight manifestations of actual 
 disease, or of organic changes the result of disease, may form 
 considerable elements in the diagnosis of a diathesis, as, for 
 example, a tendency to hemorrhagic apoplexy. Or, again, 
 certain transverse markings upon the teeth (quite distinct 
 in character from those to be afterward noticed as syphilitic) ; 
 curvatures, or other alterations in the form of the long bones, 
 and a certain well-known conformation of the thorax, may 
 indicate with the utmost precision disorders proper to the 
 period of the first or of the second dentition, when rickety 
 distortion, with or without bronchitis and other severe but 
 not permanent conditions of disease interfering with the free 
 ex^Dansion of the lungs, may have left an impress upon the 
 bony skeleton. So, too, it may be remarked that the presence 
 or absence of traces of past disease of the bones and joints, or 
 of glandular enlargements and cicatrices in the neck, or of 
 spinal disease, may, together with a certain conformation of 
 chest, or indeed of the body generally, form part of a chain 
 of circumstantial evidence, as it were, tending to prove, or to 
 disprove, a liability to tubercular disease of the lungs. But 
 what has chiefly to be rooted out of the mind of the ill- 
 informed, or imperfectly trained, clinical student is the impres- 
 sion that such conclusions are to be safely reached through 
 mere phrases appealing largely to the imagination without 
 minute and careful study of details. The popular, and to a 
 certain extent the half-educated, medical mind is always look- 
 ing for a pathognomonic sign, or a broad, striking, easy, gen- 
 eralization from a few facts ; whereas it is only by ripened 
 experience that we come to know gradually the real value of 
 
16 THE PHYSIOGNOMY OF DISEASE. 
 
 common and obvious, still more, of uncommon and not obvious, 
 facts when seen in comb inatio7i, so as to form conjointly a basis 
 for large inferences. Such a diagnosis, however, is often the 
 result of the careful study of the physio(/nomic characteristics 
 of individual patients. 
 
 In beginning the study of this subject, it is impossible to 
 overlook the importance of the weight and size of the body as 
 a test of its physiological condition. Many diseases, perhaps 
 indeed all diseases attended by fever, and many or most of the 
 organic diseases of the viscera, whether febrile or not, are 
 characteristically marked by a loss of weight, which often bears 
 some sort of relation to the progress of the disease, especially in 
 cases that end fatally. This tendency is the physical expression 
 of a derangement of the entire textural nutrition of the body, 
 one which, as a rule, becomes apparent externally, in the first 
 instance, through the gradual wasting of the stores of fatty 
 material in the subcutaneous layers and in the interstices of 
 the muscles, omenta, orbits, etc. ; but which really carries as 
 an ultimate result the wasting of every texture in the body — 
 the bones, the fibrous tissues, and the nervous centres being 
 (according to Chossat) the last to become appreciably altered 
 in weight ; the brain, indeed, almost inappreciably, even in an 
 animal starved to death. But in morbid inanition fas opposed 
 to this physiological kind) there is usually not only deficient, 
 but altered, tissue-formation ; so much so, that while fat dis- 
 appears from all the usual situations in which it is normally 
 stored up, fatty or oleo-albuminous molecules are formed in 
 the microscopic elements of the Avasting textures generally, and 
 chemical products, also, of decomposition of the nitrogenous 
 tissues are found in excess in the blood, muscles, and glandular 
 viscera. And this may take place (as in diabetes mellitus), 
 when large quantities of actual nutritious matter of various 
 kinds are passing through the organs of assimilation, and are 
 even digested and assimilated, up to a certain point, with pre- 
 ternatural activity. In such cases it has been said, with a 
 certain amount of truth, that the body becomes autophagous, or 
 self-devouring ; the muscles feed upon the integumentary 
 tissues, the brain and nerves upon the muscles ; the new nourish- 
 ment conveyed into the system, if any, being wasted and 
 rapidly excreted, along with the effete matter of the wasting 
 tissues. This state of morbid emaciation is most easily recog- 
 nized in the living patient by gradual loss of weight, as well 
 as by the external characters of shrinking and shrivelling of 
 the soft tissues, in the order indicated above as a general rule. 
 
DIVERSITIES IN RELATIVE WEIGHT. 17 
 
 But loss of weight, as a personal and individual fact, can be 
 exactly established only by repeated weighings of the same 
 patient at intervals ; and in hospital wards this ought to be 
 done on admission, and afterward every week or two, so as to 
 obtain an accurate view of the progress of the case. In private 
 practice, among men of the well-to-do classes, it is quite 
 common, nowadays, to find that the habitual or physiological 
 weight of the individual, and even the amount of variation in 
 it in the midst of apparent good health, are well enough known 
 to patients themselves, from actual weighings more or less fre- 
 quently repeated ; and by availing ourselves of these spon- 
 taneously provided data Ave are often able to form a tolerably 
 clear conception of the morbid changes present at the time of 
 first seeing the patient. But in other cases no such data exist ; 
 and the " personal equation," so to speak, of weight has to be 
 adjusted for the individual from more general statements, or 
 from actual observations founded on averages. But this is by 
 no means easy ; for the limits of variation in weight consistent 
 with health, even in the same individual, have yet to be deter- 
 mined ; and the extreme limits of difference in a number of 
 individuals of like stature are notoriously so wude, even under 
 strictly physiological conditions, as to render all averages in- 
 applicable to the extremes. A vast series of observations by 
 Dr. Hutchinson has, for many years past, been commonly ap- 
 pealed to as affording the nearest approximation attainable to 
 the common English standard of relative height and weight ; 
 while a corresponding American standard has been furnished 
 in the reports of the Surgeon-General at Washington. The 
 Greek ideal of robust manhood in the well-known statue of 
 the (so-called) " Dying Gladiator " has been made the basis of 
 a mathematical calculation, by the late Dr. William Robertson, 
 of Edinburgh, by which the statue, reduced to the proportions 
 of a human figure, has been rendered (as it were) into exact 
 terms of weight corresponding with every successive inch and 
 half-inch of stature over five feet ; the normal elements of the 
 human body in fixed proportions being taken as substituted 
 for the marble. But all such calculations are, owing to the 
 reasons stated above, of only a limited value to the clinical 
 observer as furnishing a standa,rd of health. It appears, 
 indeed, from more extended and recent anthropometric re- 
 searches, that not only do the nationalities and races examined 
 differ in their mean proportions, but that sex and age, 
 social position and occupation, each in its degree, exercises a 
 disturbing influence on the general or standard proportion, 
 
 2* 
 
18 THE PHYSIOGNOMY OF DISEASE. 
 
 which is capable of being expressed in figures ; so that among 
 boys (say) of 15, girls of the same age, men of 20, artisans, 
 gentlemen ; probably also for all manner of varying occupa- 
 tions, certainly for English, Scotch, and Irishmen under like 
 conditions, and (by inference) for all the many diversified 
 races entering into the composition of these, a different standard 
 of weight would have to be established as corresponding with 
 every degree of stature existing in each of these categories.^ 
 The almost infinite diversities which are thus shown to be con- 
 cealed under a general average must necessarily lead to caution 
 in the practical, or clinical, application of any of these 
 formulas, without due consideration of the almost unknown 
 limits of the diversities which in any individual instance may 
 be consistent even with ideal good health ; and practical ex- 
 perience teaches that a very considerable latitude is to be 
 allowed in this respect, on either side of the mean. Perhaps 
 the following condensed summary may be adoi)ted as an ap- 
 proximation to the ordinary working rule applicable to most 
 adult men -? 
 
 A man of 5 feet should weigh from 8 to 9 stones. ' ■ - '■ i "4 ) 
 " 5 ft. 3 ins. " 9 " 10 " ^ ^ 
 
 " 5 ft. 6 ins. " 10 " 11 " 
 
 " 5 ft. 9 ins. " 11 " 12 '' 
 
 " G ft. " 12 " 14 " 
 
 In applying these or any other relative numbers to an indi- 
 vidual case it will be well to ascertain, as far as possible, the 
 life-history of the actual 2:>atient in respect of height and weight 
 proportion, if not in exact figures, at least in such terms as 
 may be conventionally well enough understood for practical 
 purposes. Supposing, for example, that the patient is a well- 
 grown man, verging toward the " sere and yellow leaf," and 
 in advancing age evidently tending to accumulate fat in the 
 abdominal wall and elsewhere — Was he always "stout" (in 
 the sense of his present condition), or was he, as a youth, 
 " thin," or " slender," or " wiry," or " a light weight ? " All 
 of these are expressions w^ell understood by most men as con- 
 
 1 One of the Tidilf^s (VI.) given in tlie Appendix to tliis chapter aijpearis to demou- 
 Htrato from numerical data, that the food of infants under a year old lias a most marked 
 influence on their condition and bodily weight, and possibly even on their stature. 
 
 - The data in the text are purposely given so as not to imi)ly too close or too absolute 
 an ai)i)roximation to an ideal standard, lait to funnuliite what may be easily retained in 
 the memory f(jr every-day use. At the end of this chapter will lie found a n\imber of 
 more ajfparently ]»recise calculations (including those of Dr. JIutchinson above men- 
 tioned) ; the differences among these being significant of the latitude that must be 
 allowed in an individual case, as well as some of the more calculable elemcuts in the 
 variations above referred to. 
 
CORPULENCE. 19 
 
 veying easily appreciable relations of bodily conformation, 
 and the last of them might even lead to more exact statements 
 tending to determine the precise time of life when the sense of 
 an increasing burden of flesh became manifest as a subjective 
 fact. In the growing period of the body it is quite common 
 to say of persons of slender habit, that they '*' shot up very 
 fast" — i. e., that the increase in height did not carry corre- 
 sponding breadth along with it in boyhood ; and this expres- 
 sion, or something like it, is often used by mothers as indicat- 
 ing a fear or misgiving that the phthisical tendency, either as 
 a diathesis, or even as an actual disease, may have existed or 
 been manifested at an early period of life. " Wiry," again, is 
 generally open to a different interpretation ; it corresponds in 
 a man, to what in a woman would be called (but not, of 
 course, by herself or her friends) " scraggy " or " raw-boned ; " 
 viz., a physical conformation in which bone and muscle pre- 
 dominate, and the whole organization indicates a robust and 
 active rather than a graceful or refined personal presence ; 
 but, nevertheless, a bodily organization perfectly sound in 
 essentials and eminently fit, from its very hardness and angu- 
 larity, to do rough work in the battle of life. " Thin," or 
 " slender," in a man, perhaj^s conveys the trace of an impu- 
 tation of physical inferiority ; or, on the other hand, these ex- 
 pressions may be perfectly indifferent as regards previous 
 health or disease. The physical opposites of these bodily 
 states, within the limits of health, are usually conveyed by 
 the expressions " lusty," or " stout," or " in good condition," 
 and a little good-humored allusion, half in joke, will often 
 elicit most important facts for the physician ; indeed, begin- 
 ners would do well to study the facetious vocabulary of Prince 
 Hal, as applied to that great impersonation of vigorous and 
 humorous rotundity — Falstaff, in the pages of Shakespeare.^ 
 In women, and especially in those who have still reason to be 
 careful about appearances, it is necessary to take care not to 
 give offence by a too abrupt or coarsely worded question ; but 
 with a little tact there is no real difficulty in getting at the 
 facts in a round-about way, and even without using the sickly 
 French slang of " embonpoint," which is supposed by some to 
 
 1 "King Hem-y IV.," Part I. — The converse of the character of that lusty knight, 
 who might be supposed to he the original of the proverb, "Laugh and grow fat," will 
 be found in Ctesar's remark on Cassius as a probable conspirator, and "dangerous," on 
 account of his "lean and hungry look," his much thought and reading; his keen 
 penetration "quite through the deeds of men ; " and his contempt of personal gratifica- 
 tion and amusement. A perfect type of what would be styled in old medical language 
 the "bilious," or rather "atrabilious," or "melancholic temperament."— See "Julius 
 Caesar," Act I., Scene 2. 
 
20 THE PHYSIOGNOMY OF DISEASE. 
 
 be specially polite language as applied to ladies of a somewhat 
 too large and substantial physique. But in all these inquiries 
 and observations it is to be remarked that the experience of 
 years, and the critical appreciation of the human form under 
 a great variety of conditions, normal and abnormal, give to 
 the physician in many cases a power akin to that of the artist, 
 incommunicable by words ; an instinct of divination, so to 
 speak, by which the true character and the history of the 
 organism may be read in the external features and physical 
 characteristics; and this, not only as to health and disease, 
 but as to all the leading elements of character.^ 
 
 There is one remark that will not perhaps quite readily 
 occur to the superficial observer, but which is, nevertheless, of 
 the widest possible application to the subject of body-Aveight, 
 and of the greatest significance in respect to the physiognomy 
 of disease. It is natural, perhaps inevitable, to think of great 
 and small body-weight as being really opposed or contrasted 
 conditions, just as we think of giants and dwarfs as opposed 
 or contrasted in respect of stature and general bulk. But 
 this is a false, or at least a misleading analogy ; for while a 
 son of Anak may be in every way as healthy and as well pro- 
 portioned as a General Tom Thumb, it is impossible to look 
 upon excessive any more than defective body-weight, per se, 
 as a mere question of big or little. Up to a certain point, in- 
 deed, and within the limits of strict physiological health, the 
 increase of bulk may be a mere question of degree ; e. g., a 
 man of medium stature may be 140 pounds in weight, or he 
 may be 180, or even, perhaps, 200 pounds ; if the projjortion 
 of all the more important or essential bodily parts is fairly 
 preserved — e. g., of the muscles and ligaments to the bones, of 
 the viscera of the chest and abdomen to the external struct- 
 ure, and of the cavities to the viscera — there will not be neces- 
 sarily, at least, any appreciable impairment of function, or 
 any disease. But the tendency of extremes in both directions 
 is very apt to be toward impaired function, and, therefore, 
 toward actual or proximate structural disease. And in the 
 case of excessive corpulence, still more than that of excessive 
 emaciation, it may be said that the morbid tendency, once im- 
 
 ' It is, however, liere especially, because of the almost infinite complexity of the 
 Iihciioineiia which have to l»o considorerl, tliat the tjreatest scope is found for errors or 
 iriia^iiiatioris arising from the (h^sin; to formulate prematurely the mere impressions of 
 ail in<lividual, without due regard to th<! " jiersonal eiiuation : " as in the case of a recent 
 American nx^dical author of sotne distinction, who boldly denounces the "!\Iadonnadi 
 San Sisto" at Dresden as a tyjie of ftunale heauty which Uaphacd W(juld by no means 
 have committed to canvas hati he been familiar with the much more perfect models 
 quite commonly to bo found in American cities ! 
 
ATKOPHY. 21 
 
 planted, is apt to be progressive ; the functions and structures 
 that are oppressed by the abnormal growth of fatty tissue 
 being thereby permanently, though very gradually, altered, 
 so that most of the tissues visibly degenerate, and what seems 
 at first sight to be a hypertrophy of the bodily frame be- 
 comes, in a most genuine and physiological sense, a true 
 atrophy of some of the most important and vital parts of it. 
 Thus, fatty atrophy of the heart, of the secreting cells of the 
 liver and kidney, and of other important organs and parts, is 
 extremely common in cases of excessive corpulence ; and the 
 blood itself, there is strong reason to think, undergoes in such 
 cases a kind of relative atrophy, both its amount and its 
 nutritious quality being more or less impaired. Hence the 
 old and probably correct observation derived from the days 
 of large bloodlettings, that stout subjects (in the sense of 
 corpulent^ do not bear loss of blood nearly so well as those of 
 more slender bodily constitution. It is also notorious that 
 such subjects often succumb much more readily to fevers and 
 other exhausting diseases than those of " wiry " frame, or 
 even those who, from defectively slender development, may 
 have appeared to be of a much inferior physique. It is not 
 at all clear, therefore, that any amount of external fat beyond 
 a fair average is, physiologically speaking, advantageous to 
 the possessor. And it is just at the period of life when the 
 first traces of senile decay begin, that the embarrassment 
 caused by an excess of rotundity is most apt to tell upon the 
 constitution. Generally speaking, a moderate accumulation 
 of fat up to the age of forty, or even forty-five, is wholesome 
 rather than otherwise ; and if associated with a broad chest, 
 well-developed and active muscles, an energetic character, and 
 a healthy respiration and circulation, will tend to long life, 
 even if the digestion should be, as often happens, rather feeble. 
 But increase of fat to a notable degree beyond the middle 
 term of life is always to be regarded with suspicion, as imply- 
 ing a probability of vital and dynamic conditions of nutrition 
 tending to precipitate the process of senile decay. And 
 anything like marked obesity j^ersisting to, or increasing at, 
 the age- of sixty is a manifest invasion of the prerogatives of 
 that age which has been characterized as that of the " lean 
 and slippered pantaloon." On the whole, it may reasonably 
 be doubted w^hether the " spare " constitution of body, if it be 
 free from, or escape, the risks incidental to actual disease in 
 childhood and adolescence, is not in reality more favorable to 
 long life than any considerable amount of fat. There are no 
 
22 THE PHYSIOGNOMY OF DISEASE. 
 
 statistics on the subject ; but the medical observation of man- 
 kind in general shows that, as in Pharaoh's dream, it often 
 happens that '' the ill-favored and lean-fleshed kine did eat up 
 the well-favored and fat kine." And the spontaneous and 
 instinctive expression of the late Mr. Banting as to his exces- 
 sive fatty envelope, viewing it, as he did, as a " parasite " 
 destructive both to health and comfort, is not so far removed 
 from truth as are many poj^ular estimates of this condition 
 of body. 
 
 Thus it comes to be to a certain extent recognizably true, in 
 a practical and clinical sense, that overweight and nnderweirjht 
 constitute the physiognomic associations of certain forms of 
 bodily disease rather than others, and therefore are assumed 
 as indicating tendencies to particular diseases, or diatheses ; as 
 when we infer (rightly or wrongly) a phthisical taint from a 
 very spare habit of body, or a tendency to fatty degeneration, 
 or to cardiac disease, or to apoplexy, from the opposite. 
 Speaking generally, hoAvever, all such judgments ought to be 
 controlled by numerous other observations of detail (some of 
 which will be discussed further on) before they can be ac- 
 counted as moderately secure, or indeed as anything better 
 than mere guesses at truth. There are innumerable instances 
 of apoplexy, for examjile, and of allied diseases of the nervous 
 system, in habits quite the reverse of corpulent or plethoric ; 
 and instances could easily be adduced even of such notably 
 emaciating diseases as tubercular consumption, scrofula, and 
 diabetes, in persons apparently, or originally, quite the reverse 
 of emaciated. But still it holds as a general observation that 
 in a group of chronic diseases too numerous to mention here, 
 but including all those attended by hectic fever, emaciation is 
 the rule ; while in another group, including most of the cardiac 
 and vascular diseases, and many of the senile degenerations, 
 it is rather, on the whole, the exception ; while, as has been 
 already indicated, corpulence, per se, may not only become a 
 disease, but may lay the foundation of many others.^ 
 
 The ideal of a sound and ])erfectly organized bodily struc- 
 ture at the various ages of life has been so beautifully pre- 
 sented to us in the masterpieces of ancient and modern 
 sculpture, that every medical student or physician who desires 
 to keep his eye and mind in training would do well to spend 
 an hour now and then in a gallery of casts or marbles, and to 
 
 * See on the queHtiun of ovtuwoiglits iind iinderweiphts considered in relation to insur- 
 ance of 11 ves — Medical InvoHtigations in Life Insnrance ; United States Life Insurance 
 Company, 1873. 
 
TEMPEKAMENTS. 23 
 
 compare the perfect forms coming from the chisel of Phidias 
 or Praxiteles, Thorwaldsen, or Canova, with those habitually 
 seen in the hospital or consulting-room. He will then come 
 to appreciate by his senses what is simply a j)hysiological and, 
 indeed, a physical fact, that there is an ideal relation of size 
 and form as between every separate part of the human body ; 
 and that every outward and inward structure contributes an 
 exactly balanced proportion to the whole visible result. The 
 study of this proportion, as affected by disease, and as modified 
 by action and suffering, constitutes the physiognomy of disease. 
 The ancient doctrine of the temperaments, briefly alluded to 
 in the commencement of this chapter, was an attempt to show 
 forth in language founded on the prevailing humoral patho- 
 logy the conception, that every detail in the external physical 
 appearance of a man's body stands related to the whole of his 
 hereditary, and in a measure also his acquired, bodily and 
 mental characteristics. As a general principle this needs not 
 to be disputed ; and some of the attempts in modern times to 
 pour the new wine of physiology and pathology into these old 
 bottles have been distinguished by great ingenuity, although 
 not in accordance with the methods of investigation which it 
 is the object of this chapter to set forth for the young and 
 unskilled observer. It may be sufficient to refer in general 
 terms to the excellent article, " Temperament^" by the late 
 eminent anthropologist, Dr. J. C. Prichard,^ for a general state- 
 ment of the subject, and to several other works mentioned at 
 the end of this chapter, as well as that of Mr. Hutchinson, 
 alluded to above (p. 14). What can be attempted here is 
 merely to set forth those facts which a really exact observation 
 absolutely demands to be noted in reference to well-marked 
 varieties of morbid conformation, Avithout giving way to any 
 doubtful hypothesis or individual opinion as to the facts. For 
 many most interesting illustrations of idiosyncrasy and dia- 
 thesis, and of the relation of diseases to climate, food, etc., as 
 influencing the bodily organization, and sometimes even the 
 visible structure of the body, Mr. Hutchinson's book may be 
 referred to with confidence. No one in the present day has 
 brought such large and varied stores of clinical and patho- 
 logical experience to bear upon these subjects, in their relation 
 to the higher philosophy of medicine. But in an elementary 
 treatise like the present a simple reference to these valuable 
 researches is all that is either possible or expedient. What 
 
 1 Cyclopjedia of Practical Medicine, by Drs. Forbes, Tweedie, and Gonolly, vol. iv. 
 p. 159. London, 1835. 
 
24 THE PHYSIOGNOMY OF DISEASE. 
 
 follows here may be regarded as belonging to the common- 
 places of medical experience, but on that account all the more 
 valuable to the beginner, inasmuch as these facts of common 
 experience are precisely those which are of daily application 
 to the routine of clinical work. 
 
 In spare habits, or when there is a reasonable suspicion, a 
 priori, of phthisical atrophy, the following points require to 
 be observed, especially in early adult life. The presence of 
 "clubbing" of the finger-ends, or of undue curvature of the 
 nails ; the red line on the gums, said to be more or less char- 
 acteristic of tubercular disease ; the peculiar momentary start- 
 ing and elevation of the skin j^roduced by a tap of the finger 
 point over the costal cartilages, and described as " myoidema;" 
 any undue, and especially any unilateral, flattening below the 
 clavicles, or deformity elsewhere of the chest, and any in- 
 equality, or want of symmetry, in the respiratory movements ; 
 any rapid and too easy flushing of the face, and especially that 
 limited flush of the cheek with pallid complexion generally, 
 which denotes fever in an exhausted constitution; any or all 
 of these may in particular cases be valuable indications of truly 
 morbid emaciation.^ In infants and children, sometimes also 
 in adults, it is not uncommon to observe emaciated limbs and 
 face, with an enlarged abdomen (almost always a sign of grave, 
 often tubercular disease). And in very young infants the 
 presence of emaciation generally, with a retracted abdomen, 
 and a large head, the anterior fontanelle (if still open) being 
 protruded instead of depressed, is a combination of signs of 
 
 1 These sulyects are referred to in detail under the sections on the "Xails" (Chapter 
 IV.), "General Signs of Pyrexia" (Cliapter III.), "Gums" (Chapter XI.), and in tliose 
 dealing with tlie "Physical Examination of the Chest" (Chapter XVI. Part 1). Myoi- 
 d<!ma is tlie name first appli<!d by Dr. Lawson Tait (Dublin Journal of Medical Science, 
 vol. Hi. p. 31G) to a jdienonienon observed long ago by Drs. Graves and Stokes (Dublin 
 Hospital Reports, v(d. v. ]>. 70), as probably characteristic in some degree of phthisical 
 emaciation, and as being found most frequently "in incipient phthisis over the seat of 
 the irritation" — i.e., on the side first affected and in the sui)ra-clavicular region. Ac- 
 cording to Dr. Tait, the sign attends especially the softening stage of tubercle. "After 
 each stroke of the ends of the fingers" (say the first discoverers of this sign) "a number 
 of little tumors appeared, answering exactly to the number and situation of the points of 
 the fingers, when they had struck the integuments of the chest. These having continued 
 visible for a few moments, subsided, but could be again made to appear on repeating the 
 percussion." [My observations, in very numerous instances, lead me to concur with the 
 original rlcscrijition here given more closely than with the details of fact and of procedure 
 ill Dr. Lawson Tait's paper. In i)arti(ular, I have fimnd that the "little tumors" of 
 Drs. Graves and Stokes, which are undoubtedly tlie more im|)ortant part of myoidema, 
 are produced more easily, and with far less risk of fallacy, when the percussion is made, 
 not over a voluntary muscle at all, but over the anterior co.stal cartilages. The name 
 th<'r(!fore seems, in a certain sense, a misnomer, if it is intended thereby to suggest that 
 the iiintraction of the fibrilbe of voluntary muscle has anything to do with tlie more dis- 
 tinctive iihenomeiia. The " little tumors" are (juite evidently due to a temporary con- 
 traction of muscular fibres in the skin itself, similar in kind to those of the dartos on 
 pinching the scrotum. I believe the jduuiomenon, thus iuterjireted, to have some, but 
 by no means a pathognomonic, significance. — W. T. G.] 
 
ANEMIA. 25 
 
 the gravest import, as tending to reveal disease of the meninges 
 of the brain, even should the symptoms otherwise be obscure 
 or wanting ; still more, if these indications are accompanied 
 by peculiarities of expression, or abnormal movements of the 
 eyes (strabismus, nystagmus) or of the pupils ; or by the 
 phenomenon described by Trousseau as the " tache cerebrale," 
 and considered by him to denote fever with a cerebral or 
 meningeal lesion/ 
 
 A condition frequently, but not necessarily, associated with 
 the phthisical or morbidly emaciated habit, is ancemia; a 
 term which has been variously defined, but which may be 
 taken as corresponding in general not so much with diminu- 
 tion in the absolute quantity of the blood as with depreciation 
 of its quality : a lower specific gravity of the serum, a more or 
 less considerable fall in the proportion of the blood-corpuscles, 
 and of course of the coloring matter. Physiognomically con- 
 sidered, anaemia is recognized chiefly or exclusively by this last 
 character ; and the most marked examples of it are those in 
 which emaciation, though perhaps present more or less, is not 
 extreme. If, indeed, the blood is simply reduced in quantity 
 as a part of the general emaciation, but remains not greatly out 
 of proportion to the other tissues (as in many cases of phthisical 
 emaciation), the characters of ansemia will not be at all strik- 
 ingly present. The lips will remain well colored, and the 
 mucous membrane may even be morbidly congested in such 
 a condition. But when, along with only a moderate reduction 
 in the amount of the solid soft tissues, and without any circum- 
 stance tending to the local determination of blood, there is a 
 great reduction in the quality of the latter, the consequences as 
 regards the appearance of the patient are very striking. There 
 is, in the first place, an extremely pallid hue of the whole sur- 
 face, and especially of the face ; lips not quite so pale as the 
 rest of the countenance, but entirely devoid of their natural 
 rosy hue ; the conjunctivae of the eyelids similarly pale ; the 
 ocular conjunctivae bluish, from the shining through of the 
 choroid ; and all these characteristics brought out the more 
 remarkably in dark complexions, inasmuch as the tints wdiich 
 depend not on blood but on pigment may be unchanged. Thus 
 the skin may be as nearly as pale as that of a corpse, and yet 
 
 1 On drawing the back of the nail or the blunt end of a pencil along the skin, we find, 
 in the healthy subject, that a momentary whiteness of the part is followed after a time 
 by a distinct red streak. But in certain states this redness is much more easily produced, 
 and is likewise very much more intense and persistent ; it is to this excessive redness that 
 the term tache cerebrale is applied, from its being frequently observed in cases of acute 
 meningitis. Biit it is now quite certain that it may be found equally in cases of enteric 
 fever, and in many other diseased conditions. 
 
 3 
 
26 THE PHYSIOGKOMY OF DISEASE. 
 
 there may be dark circles fchloasma) round the eyes or on the 
 brow ; or the natural diffused pigment of the whole surface 
 may be so exaggerated as to give to certain parts of it almost 
 the appearance of the skin of a negro or mulatto (the so-called 
 " bronzed skin " or "Addison's disease "). But in cases of 
 anaemia, pure and simple, there is usually no special pigmentary 
 change, and the whole external characteristics suggest merely 
 an unduly watery or much impoverished blood. The skin is 
 cool, and the tongue may be clean, though extremely pale ; 
 there is often a little puffiness of the eyelids and dropsical 
 swelling of the ankles ; it may be (as in Bright's disease) even 
 general dropsy of the entire subcutaneous tissues. The mus- 
 cles are flabby rather than much reduced in bulk ; the expres- 
 sion is that of great languor, but not of suffering or of anxiety ; 
 if the texture of the skin is fine and delicate, the blue veins 
 may be seen below the surface, but reduced very much in 
 volume as compared with the normal ; and in the veins of the 
 neck there is found the well-known humming of the " anaemic 
 murmur," or " bruit de diable." A special variety of this 
 state of pure anaemia is chlorosis, in which greatly disordered 
 or absolutely arrested menstruation in young girls is attended 
 by all the circumstances above noted, often with a very remark- 
 ably green tint of the complexion (as the name implies). In 
 all these cases the blood, tested accurately by instruments 
 devised for the purpose, shows a reduction in the amount of 
 coloring matter, or of corpuscles, equal to one-third, one-half, 
 or even more ; and in this way a physiognomic sign, which 
 formerly could only be stated in general terms, can now be 
 reduced to most accurate expression, and made subservient to 
 exact observation as to the progress of disease or the results 
 of treatment. (See Chapter IX.) 
 
 When this anaemic condition is recognized, we must never 
 rest satisfied in the investigation of the case till we have done 
 our best to ascertain the probable cause. We inquire for the 
 history of any hemorrhages or any of the less obvious forms 
 of loss of blood described elsewhere (Chapter IX.). A similar 
 deterioration may result from the chronic influence of the 
 malarial fevers, for example, or from the recent occurrence of 
 some acute illness from which the patient's system has not 
 fully recovered. But too often such anaemia is only symptom- 
 atic of the serious inroads of tubercular, syphilitic, malignant, 
 or renal disease, and the investigation of the urine is so impor- 
 tant in all apparently causeless forms of anaemia that it must 
 never be neglected. Present or past suppuration of a chronic 
 
COLLAPSE. 27 
 
 character may likewise be responsible for the deterioration of 
 the blood ; the extreme pallor and the wax-like appearance of 
 patients suffering from the lardaceous (waxy or amyloid) 
 degeneration of the viscera usually arise from such prolonged 
 suppurations, but this disorder may also' be due to less obvious 
 causes. The examination of the blood frequently guides to 
 the diagnosis of leukaemia and to the investigation of the 
 spleen ; or the general enlargement of the lymphatic glands 
 may suggest the presence of Hodgkin's disease as the cause of 
 the persistent ansemia. But after eliminating all these causes 
 of the deterioration, we may still find ourselves in the presence 
 of a simple progressive 2}e7micious amemia, the origin and 
 pathology of which still remain obscure, while the tendency 
 to death is very marked. 
 
 The converse of ansemia, in medical language still current, 
 is 2^lethora ; a condition which has had a great deal to answer 
 for in medical pathology and treatment. But plethora, con- 
 sidered merely as a morbid excess of blood, can hardly be said 
 to hold its place among recognized pathological states at the 
 present day ; fulness of blood, in other words, can scarcely be 
 considered morbid, unless there is some other pathological 
 change either as regards its quality or its distribution. The 
 condition to which the name plethoric is usually applied is one 
 in which there is stagnation of blood in the smaller veins of 
 the surface, giving to it, especially in the face and nose, the 
 rubicund and " port-winey " appearance suggestive of the days 
 when two bottles of that luscious stimulant were regarded as a 
 moderate allowance for a gentleman at an after-dinner sitting. 
 This peculiarity of countenance, as well as the plethoric and 
 well-fed condition generally, when occurring in persons (es- 
 pecially males) past the middle term of life, particularly if 
 associated with hereditary predisposition or with known habits 
 of self-indulgence, has been regarded as among the notes of 
 the gouty habit or diathesis, and also, along with a short and 
 thick neck, as among the predispositions to apoplexy. 
 
 There is a very remarkable condition of the blood and of 
 the containing vessels, in one of its aspects allied to ansemia, 
 in another to plethora — that, namely, which, attended with 
 coldness of the surface and rapid depression of the powers of 
 life, corresponds with the so-called " collapse " or " algide " 
 stage of Asiatic cholera. In so far as this condition can be 
 here dealt with, it may be regarded as one in which a highly 
 concentrated blood encounters resistance in being driven 
 through the capillaries ; the great mass of the blood, there- 
 
28 THE PHYSIOGNOMY OF DISEASE. 
 
 fore, tending to accumulate in the venous system, and producing 
 congestion, and even ecchymosis, by rupture of the smaller 
 veins. It has been shown by chemical analysis that the blood 
 in this condition has lost a considerable proportion of its 
 water and albumen, owing to the enormously rapid and 
 cojoious discharges from the intestinal canal ; but the blood- 
 corpuscles remain, for the most part, in the vessels. There is, 
 therefore, a strange combination of shrivelling of most of the 
 textures of the body from loss of fluid, and persistence of 
 blood-color, altered, however, in the direction of lividity by 
 deficient aeration. A person in this state has the skin, 
 especially in the face and extremities, of quite cadaverous 
 coldness, and oflen has the whole attitude and expression of 
 a corpse ; the ends of the fingers are shrivelled, the features 
 thin and j^inched, the nose and all the extremities livid in a 
 high degree ; the conjunctivse are bloodshot and ecchymosed ; 
 the eyes sunk in the orbits ; the tongue and breath cold ; the 
 respiration and circulation almost inappreciable ; but there is 
 no disappearance of the external fat, nor any true emaciation ; 
 the breasts, accordingly, in w^omen, and the abdomen in cor- 
 pulent men, remain well clothed with integument even after 
 death. A condition more or less allied to this is seen in some 
 cases of very acute peritonitis, tending rapidly to death, as in 
 perforation of the boAvels, which, like cholera, may cause death 
 by collapse in a few hours, though, of course, without the 
 excessive evacuations above referred to. 
 
 The traditional description of the so-called fades Hlppo- 
 cratica is not very far removed in some of its details from the 
 state of acute collapse as above described, and has been so 
 often formulated in one shape or other by compilers, as con- 
 veying the elements of a fatal prognosis, that it may be well 
 to transcribe the words from the original source : " a sharp 
 nose, hollow eyes, collajjscd temples ; the ears cold, contracted, 
 and their lobes turned out; the skin about the forehead rough, 
 distended, and parched ; the color of the whole face green, 
 black, livid, or lead-colored." But the reader will do well to 
 consult the other physiognomic details in Sec. 2-4 of the 
 Prognostics of Hipj)ocrates (Dr. Adams's translation, vol. i. 
 p. 236) for numerous vivid and picturesque touches which are 
 now among the commonplaces of medical observation. And 
 the description of the phthisical body by Aretseus is equally 
 deserving of perusal, as a sample of accurate appreciation of 
 detailed facts emanating from remote antiquity. The most 
 important facts of the description referred to are as follows, 
 
ARET^US ON PHTHISIS. 29 
 
 but the whole chapter in the excellent translation of Dr. 
 Adams well merits perusal : 
 
 " Voice hoarse ; neck slightly bent, tender, not flexible, somewhat 
 extended ; fingers slender, but joints thick ; of the bones alone the 
 figure remains, for the fleshy parts are wasted ; the nails of the fingers 
 crooked, their pulps are shrivelled and flat, for, owing to the loss of 
 flesh, they retain neither their tension nor rotundity ; and owing to 
 the same cause, the nails are bent, namely, because it is the compact 
 flesh at their points which is intended as a support to them ; and the 
 tension thereof is like that of the solids. Nose sharp, slender ; cheeks 
 prominent and red; eyes hollow, brilliant, and glittering; swollen, 
 pale, or livid in the countenance; the slender parts of the jaws rest 
 on the teeth, as if smiling ; otherwise of a cadaverous aspect. So 
 also in all other respects ; slender, without flesh ; the muscles of the 
 arms imperceptible ; not a vestige of the mammge, the nipples only to 
 be seen; one may not only count the ribs themselves, but also easily 
 trace them to their terminations ; for even the articulations at the 
 vertebrae are quite visible ; and their connections with the sternum 
 are also manifest ; the intercostal spaces are hollow and rhomboidal, 
 agreeably to the configuration of the bone; hypochondriac region 
 lank and retracted ; the abdomen and flanks contiguous to the spine. 
 Joints clearly developed, prominent, devoid of flesh, so also with the 
 tibia, ischium, and humerus ; the spine of the vertebra, formerly hol- 
 low, now protrudes, the muscles on either side being wasted ; the 
 whole shoulder-blades apparent like the wings of birds. If in these 
 cases disorder of the bowels supervene, they are in a hopeless state. 
 But, if a favorable change takes place, symptoms the opposite of those 
 fatal ones occur." — Aretceus.^ Causes and Syiwptoms of Chronic Dis- 
 eases^ Book I., Chapter YIII., On Phthisis. 
 
 In association with the various atrophic and ansemic states 
 above referred to, we have to consider the physiognomic im- 
 port of another much-abused word, around which, as around 
 the words " diathesis " and " temperament," a great deal of 
 very obscure pathology has been made to revolve. Cachexia, 
 in its original and etymological sense (K.aK6~ and ^f<r), means 
 any bad or defective habit of body — habitus depravatus — usu- 
 ally the result, not the cause, of disease. The term " habit " 
 here implies, of course, chronicity ; and the word cachexia is, 
 accordingly, one consecrated by usage to the definition of 
 states characterized by chronic lesions of nutrition, as ojoposed 
 to the fevers and acute diseases. In the systematic nosologies 
 — Cullen's for example — ^the caehexice form an order including 
 all chronic diseases of nutrition which are not strictly local, 
 and not obviously associated wdth fever. Hence cancers, 
 dropsies, rickety afifections of the bones in childhood, and, 
 above all, the various types of glandular, articular, pulmo- 
 nary, cutaneous diseases, known either as scrofulous or tuber- 
 s' 
 
30 THE PHYSIOGNOMY OF DISEASE. 
 
 cular, are commonly enumerated among the cachexies ; and 
 more modern authors add gout, rheumatism, scurvy, and 
 syphilis to the list. But the use of the thermometer tends 
 very much to break down the distinction between the febrile 
 and the non-febrile diseases — between ihepy7^exice and cachexice; 
 and in some of the latter — e. g., in tubercular diseases and in 
 syphilis — the febrile element, though spread over longer periods 
 of time, and, therefore, less intense as a rule, is quite as really, 
 if not invariably, associated with many of the nutritive 
 changes as in the pyrexiae commonly so called. It cannot, 
 therefore, be admitted that there is anything in the essential 
 nature of a cachexia to differentiate it pathologically from a 
 fever, or from an acute disease like pneumonia. There is, it 
 is true, the element of time, implied in the long duration and 
 very gradual evolution of the disease ; but the relation of the 
 local changes to the constitutional disease is, in the cachexia 
 as in the fever, a matter of inference from the study of the 
 whole of the phenomena ; and it is impossible to admit, a jwiori, 
 that a specific, and latent, constitutional taint always precedes 
 and determines the local affection. The safe rule of physiog- 
 nomic diagnosis here is, to make the discovery of a cachexia 
 (as of a diathesis) an inference from individual facts actually 
 observed and verified in the particular case ; not a general 
 formula such as is often implied under the terms scrofulous, 
 strumous, syphilitic, gouty, or cancerous cachexia. It may 
 be easily admitted, indeed, that these cachectic states actually 
 exist in connection with the diseases named ; but what is not 
 so easily admitted is the proof of the cachexia apart from all 
 positive manifestations of actual disease of the special kind 
 implied in its name. 
 
 The following brief indications, however, may be noted as 
 regards particular types of cachexia. In the scrofulous or 
 strumous variety, as also in a certain proportion of cases of 
 tuberculosis in the adult, there may be found evidences of de- 
 fective nutrition, or emaciation, extending back to childhood, 
 and modifying the entire form of the skeleton, as well as the 
 integument. A slender form, and a narrow or deformed chest 
 may be accompanied by the cicatrices of glandular abscesses, 
 or of sinuses connected with the bones ; a delicate, pale skin, 
 or one marked by traces of eruptions on the scalp or elsewhere ; 
 often with retarded ]uiberty, and imperfectly developed organs 
 of sex ; fiabby mus(;les, attenuated bones, and relatively large 
 (sometimes ankylosed or actively diseased) joints. The upper 
 part of the abdomen may be increased in bulk, from waxy 
 
CANCEROUS CACHEXIA. ' 31 
 
 enlargement of the liver ; or the whole abdomen, from disease 
 of the peritoneum or mesenteric glands. The upj^er lip may 
 be tumid, from often-repeated catarrhs, commencing with 
 coryza, in the earliest years of life ; all actual disease of this 
 kind having been long in abeyance. The eyes may have 
 suffered in infancy or early youth from ulcerations and obscura- 
 tions of the cornea, or from repeated chronic conjunctivitis and 
 " ophthalmia tarsi," leading to thickening and granular con- 
 ditions of the eyelids, or ^^ermanent injury to all or any of 
 these structures, or of the hair-bulbs of the eyelids ; the ears 
 may have been affected by discharges, mucous, or mucopuru- 
 lent, indicating inflammation, either external to the membrana 
 tympani, or in the tympanic cavity, and, in the latter case, 
 possibly involving destruction of the membrana tympani, or of 
 the ossicula auditus, or of the labyrinth and pars joetrosa of the 
 temporal bone ; and thus, imperfection of sight and of hearing 
 may tell a tale of comj^licated changes, conveying, by impli- 
 cation, the note of a scrofulous diathesis. Such patients are 
 commonly more or less ansemic, and are often (sometimes 
 periodically) subject to febricula (hectic). 
 
 In the gouty habit there is frequently no cachexia, properly 
 speaking, at all appreciable until the middle term of life is 
 reached, or past. There may, on the contrary, be all the indi- 
 cations of strong vitality, robust conformation, and great 
 bodily and mental activity. At a certain period of life, how- 
 ever (prematurely or not), the ordinary signs of ageing occur ; 
 and along with these (and with the cessation of the catamenia 
 in women) come an increase of obesity, or the plethoric de- 
 velopment of the facial veins (described above), eruptions on 
 the skin, varicose veins in the lower extremities, manifestly 
 diminished energy, and sometimes oppression of breathing. 
 Preceding or succeeding these signs may occur the special de- 
 formities due to the local deposits of uric acid in the joints of 
 the toes and fingers, or (as Dr. Garrod has remarked) in the 
 lobes of the ears. The peripheral arteries often present at this 
 stage well-marked senile degeneration. There are, however, 
 not a few exceptions to these remarks : and the gouty habit 
 may even concur Avith, or follow, the scrofulous cachexia, as 
 age advances. 
 
 It is doubtful whether any very definite cachexia can be 
 said to accompany cancerous disease, apart from the local 
 developments of it in the organs, and their consequences. But 
 in the majority of cases of gastric, hepatic, omental, or uterine 
 cancer, and in not a few mammary and other external can- 
 
32 THE PHYSIOGNOMY OF DISEASE. 
 
 cerous growths, there are either extreme emaciation aud 
 anaemia, or persistence of the external fat with flabby integu- 
 ments, and a peculiar sallow, pale complexion ; the expression 
 of the countenance at the same time indicating habitual sufler- 
 ing and great despondency of mind. 
 
 Dropsical cachexia is most frequently associated with Bright's 
 disease of the kidney. It is marked by great pallor, a languid 
 expression without suffering, unless from difficulty of breath- 
 ing ; often puffiness of the face and eyelids ; absence of fever, 
 and an almost perfectly dry, cool skin, sometimes of fine, semi- 
 transparent texture, at other times locally thickened and even 
 wrinkled or furrowed from the effects of former long-continued 
 dropsical effusions, especially in the lower extremities, scrotum, 
 and loins. 
 
 It does not appear at all clear (notwithstanding the well- 
 known description by Dr. Todd of the "rheumatic dia- 
 thesis"), that either in acute or chronic rheumatism there is 
 any definable cachexia or physiognomic peculiarity of bodily 
 conformation, apart from the more obvious history and conse- 
 quences of the disease. 
 
 In rickets, there is a precursory or incubative stage of im- 
 paired general health or cachexia (according to Sir William 
 Jenner, Medical Times and Gazette, 1860, vol. i.), extending 
 usually from the fourth to the twelfth month of the infant's 
 life. More or less emaciation takes place, and the movements 
 indicate languor and peevishness or moroseness, perhaps with 
 hot skin and a degree of low febrile irritation. By and by, it 
 is observed that the natural impulse of healthy children to 
 play about does not exist ; the child prefers to lie still, and 
 refuses to be amused ; the superficial veins become large, and 
 the jugular veins especially are much dilated; the hair con- 
 tinues thin upon the scalp, and the fontanelle remains widely 
 open. Intercurrent diseases of the chest may occur even at 
 this stage, and may considerably modify the progress of the 
 rickety cachexia ; but three truly physiognomic characters 
 are specially noted by Jenner, as appertaining to, and distinc- 
 tive of, rickets, even in advance of the characteristic deformi- 
 ties of the skeleton, which are often not easily observed until 
 the little patient begins to walk. The fird is, profuse perspi- 
 ration of the head and up[)er part of the body, especially 
 during sleep, with large and full veins of the scalp and some- 
 times undue pulsation of the carotids. The second of these 
 early syin[)toins is an intolerance of covering at night; the 
 child insisting on kicking the bedclothes off, and lying with 
 
KICKETS. 38 
 
 naked limbs, so as to be " always catching cold," according to 
 the mother, who tries in vain to keep the infant properly pro- 
 tected. The tldrd characteristic symptom is positive suffering 
 when touched, or even when approached, by strangers, ob- 
 viously from general tenderness, both of the surface and of 
 the muscles and bones ; an exaggeration of the state above 
 described as existing at the very earliest stage of this cachexia. 
 " A child in health," says Sir William Jenner, " delights in 
 movements of every kind. It joys to exercise every muscle. 
 Strip a child of a few months old, and see how it throws its 
 limbs in every direction ; it will raise its head from the place 
 where it lies, coil itself round, and gras]3ing a foot with both 
 hands thrust it into its mouth as far as possible, as though the 
 great object of its existence at that moment was to turn itself 
 inside out. The child, suffering severely from the general 
 cachexia Avhich precedes and accompanies the progressive 
 stages of the bone-disease in rickets, ceases its gambols ; it lies 
 with outstretched limbs as quietly as possible, for voluntary 
 movements produce pain." The consequence of all this suf- 
 fering, after a short period, is further permanently imprinted 
 on the physiognomy in an aspect not only of languor, but of 
 premature sadness and sedateness, as of age, the effect of 
 which is increased by the inability of the muscles to support 
 the spinal column ; this, accordingly, becomes curved forward 
 in the cervical region, and backward in the dorsal. The 
 bones of the cranial (especially the occipital) are soft and 
 thin (craniotabes of Elsasser), yielding in some cases to 
 pressure like cardboard ; and the form of the skull is altered, 
 flattened behind or at the vertex, and protuberant in front. 
 There is enlargement of the ends of the long bones ; the ribs 
 are " very soft, so that there is great recession of each rib 
 wdiere it joins the costal cartilage at each inspiration." It is 
 easy to see in this description of the signs of a " cachexia " a 
 very real and present disease, the source of all the deformi- 
 ties and permanent alterations in rickets, to which we have 
 already alluded as being themselves, in after-life, physiog- 
 nomic evidence of disturbed health and function during the 
 period of childhood. 
 
 The Syphilitic cachexia is so plainly a part of the actual 
 disease, defined and demarcated by the well-known succession 
 of the various stages and external and internal lesions, that it 
 seems unnecessary here to treat of it in detail, as the evidence 
 of its presence is dealt with under special sections in connection 
 with the throat, the skin, the bones, the joints, etc. But in 
 
34 THE PHYSIOGNOMY OF DISEASE. 
 
 long-standing cases of syphilis its deep influence on the system 
 is often manifested, not merely by an appearance of bad health 
 and general delicacy, but also by a dingy, sallow, and some- 
 what discolored appearance of the skin of the face ; this may 
 impart to such patients something of the physiognomic aspect 
 of malignant disease already referred to. 
 
 In all bodily conditions involving fever, whether classed 
 among the specific fevers or not, there are certain physiog- 
 nomic characteristics which ought to be constantly present 
 to the mind of the physician, not only as throwing light on 
 the diagnosis, but often also on the prognosis and treatment. 
 Thus, in the earliest periods there are the somewhat collapsed 
 appearance, the pallor, the shivering, and cutis anserlna which 
 belong to the cold stage. At a later, but still early, period, 
 the face is flushed, the expression is that either of languor or 
 of pain, according as there is or is not a local disease ; very 
 often the attitude indicates restlessness, as when the patient is 
 found overnight or in the early morning with the bedclothes 
 tossed and disordered, and the body more or less exposed. In 
 this stage the skin may be dry or moist, or it may be dry on 
 the exposed parts and moist under the clothes, or vice versa} 
 In certain fevers, as in the rheumatic and pysemic kinds, 
 moisture of surface and often 2:)rofuse sweating predominate 
 throughout ; in others, as in scarlet fever and most of the 
 eruptive fevers, a dry hot skin is more characteristic of the 
 early stages up to the height of the fever. In phthisis, and 
 in most of the fevers accompanying organic disease, sweats of 
 considerable intensity alternate with hot and dry skin, often 
 repeatedly in the course of twenty-four hours (hectic fever). 
 In fevers which accompany diseases gravely affecting the 
 respiration, as in pneumonia and broncho-pneumonia, the flush 
 on the cheeks has a peculiar duskiness or lividity ; this is very 
 notably the case, also, in acute tuberculosis. In some cases of 
 pyiemia, as well as in acute pulmonary affections not pysemic 
 in origin, a yellowish color of the integument, sometimes 
 amounting to jaundice, may take place without any evidence 
 that the liver is directly involved in the disease; and in acute 
 and febrile diseases of the liver itself (abscess, etc.) the com- 
 bination of the febrile physiognomy with jaundice is more 
 
 1 A remarkable contrast to those irregularities nf the eiitaneous traiisi)irati(>n in fevers 
 is to Ik; fo\iii(l in most cases of diabetes ni(!llitiis, in wliidi, with great emaciation and 
 disorder of nutrition and of the urinary excretion, the surface often remains throughout 
 harsiily dry and cool, the natural perspiration, even under severe exertion, being sus- 
 pended. Generally speaking, a dry skin which does not very easily jierspire, and main- 
 tains an ctiuable temperature, is tiie sign of a "wiry" frame and of good health. Cor- 
 pulent persons, on the other hand, perspire easily. 
 
FEVER. 35 
 
 easily explained. Fevers depending on septic poisoning of 
 the blood are recognized by the peculiar odor, as of putrefac- 
 tion, which exhales from the body even at an early stage, 
 before the cadaveric odor or the symptoms of approaching 
 death have appeared; such cases may have a traumatic origin, 
 or they may occur spontaneously, as in some instances of en- 
 teric fever, of erysipelas, of dysentery, and of septic poisoning 
 from infection. Fevers depending on abscess, or upon profuse 
 suppuration in connection with mucous or serous surfaces, are 
 often very specially characterized by the tendency to intense 
 and repeated shiverings, which can be compared only to the 
 commencing stage of the ague-fit. A like disposition to rigors 
 sometimes follows the passing of a catheter or bougie into the 
 bladder, and this without any appreciable injury done to the 
 mucous membrane. All these phenomena may be fairly in- 
 cluded in the range of physiognomic diagnosis ; the more pre- 
 cise appreciation of temperature through the thermometer will 
 come under consideration hereafter (see Chapter III.). In all 
 fevers which continue for more than a brief period, the tongue 
 becomes more or less coated with a white or yellow fur ; in the 
 hectic of phthisis, however, and in some cases of enteric fever 
 and of mild intermittent, the tongue remains surprisingly clean 
 and natural. As the fever advances the fur increases, the 
 papillae enlarge and become congested; the dorsum of the 
 tongue becomes dry, usually first in the neighborhood of the 
 raphe. At a still more advanced stage the tongue becomes 
 dry all over, brown, and roasted-looking, while incrustations 
 0/ brown epithelial debris (sordes) gather upon the teeth, 
 alveoli, and lips ; this condition is specially characteristic of 
 typhus and similar fevers, typhoid pneumonia, and generally 
 speaking of the more severe continued fevers from the middle 
 of the second week onward ; it yields very gradually after the 
 crisis, the fur being throw^n ofi" sometimes in patches, sometimes 
 more evenly, and the natural moisture returning (see, also, 
 Chapter XL). At the stage indicated by the phenomena just 
 described, there has usually been more or less of mental dis- 
 turbance, and the whole attitude and manner of the patient, 
 as well as his words, indicate a wandering mind and semi- 
 unconsciousness, or even an advance into coma, with great 
 and increasing w^eakness ; the posture being in the more ex- 
 treme cases absolutely prostrate on the back, with the mouth 
 more or less open, the eyes half closed, and sometimes a film 
 of dried mucus and lachrymal secretion on the conjunctivae; 
 the pupils being often contracted so as to resemble pinholes, 
 
36 THE PHYSIOGNOMY OF DISEASE. 
 
 and insensible to light. When associated with profuse sweat- . 
 ing, or, even apart from this, with cold extremities (the febrile 
 heat remaining in the central parts of the body), the prognosis 
 is as bad as it can well be in any fever. A very unfavorable 
 sign is a starting or twitching movement of the tendons of the 
 wrist (subsultus tendlnum), and tremor of the muscles gener- 
 ally; still more unfavorable, if possible, are the movements 
 of the hands described by Hippocrates, and reproduced by 
 countless authorities with more or less conscious imitation for 
 more tlian 2000 years under the name of Garpliologia, floccitatio, 
 etc. : " When in acute fevers, pneumonia, phrenitis (acute de- 
 lirium), or headache, the hands are waved before the face, 
 hunting through empty space as if gathering bits of straw, 
 picking the nap from the coverlet, or tearing chaff from the 
 wall — all such symptoms are bad and deadly."^ The peculiar 
 deadliness of such symptoms, it may be remarked, depends 
 upon the fact of their indicating at once two apparently con- 
 trasted states of the nervous centres and especially of the 
 basal ganglia and mcsencephale, if not also of the medulla 
 oblongata, viz., restlessness, with greatly lowered, if not lost, 
 sensibility to external impressions ; unconsciousness, with dis- 
 turbed excitomotor activity, and almost always with entire 
 absence of real sleep (coma vigil); the movements are abso- 
 lutely automatic, and yet they are continuous, being excited 
 by some purely physical irritation of the motor centres arising 
 apart altogether from consciousness, and acting feebly through 
 the efferent nerves upon those groups of muscles especially 
 which, in the normal condition, exhil)it the most highly differ- 
 entiated and exquisitely combined movements under the influ- 
 ence of the will. To the same order of phenomena belong 
 the constant mutterings (typJioniania or typhoid'^' delirium) ; 
 the wordless, and sometimes even voiceless, movements of 
 articulation (innssitatio) observed in the later stages of many 
 severe fevers, conveying to the mind of the observer merely 
 
 1 Prognoslifs, IV ; yVflaniH^H tniiislatini), vol. i. p. 2.'58. 
 
 - It hIiouIiI ])(•■ ]iarti(-Mlnrl.y iciiiark(!(l, as nocc^ssary for the reconciliation of old and new 
 tcrniH, tliat tin; word " typlioid " is not used \u'.ri' in tlu; H])('cial and limited sense given 
 to it liy lionis an<l the Krent^h school of the ju'esent centnry, as a designation of enteric 
 fever, but in that larger and more g(!neral meaning which it had from at least the time 
 of Galen, of tyj)hMH-liUe {TV(pog f/fJof). Typhns and most of its derivatives, including 
 t.yitliomania, are Hippocratic words, used in a figurative sense, from TJyof, smoke, as 
 indicating the ntiipor whldi attinds the graver kinds of ft^ver ; and, in the case of typho- 
 matiia, the condiii:at inn of stupur wilh ri'sllos delirium — exactly tlie fuTi<'tional cnntrast 
 referred to ab<ive. Tin' ('(ymological facts are interesting, ius sliuwing how, even in the 
 HKjrtt remote period to whiih llie liteiatuic of medicine extemls, clinical iihenomena 
 whi<rh only receive their jdiysiological interitietation from modern science were, n(;ver- 
 tlielesH, sometimes very exactly notcid. 
 
DISEASES OF THE CHEST. 37 
 
 the idea of unrest, without the faintest suggestion of meaning, 
 or even of consciousness. (Compare sections on " Delirium" 
 and " Sleeplessness," at the end of Chapter VI.) 
 
 The specialties of physiognomic diagnosis bearing on dis- 
 eases of the chest are so interwoven with the subjects to be 
 discussed at length in Chapter IX. of this work (" Dyspnoea," 
 " Orthopncea," etc.) that a few preliminary remarks here are 
 all that seem to be required in order to preserve the continuity 
 of the present chapter. It is impossible to define with pre- 
 cision, in many cases, what is of cardiac and what is of pulmo- 
 nary origin, in any particular combination of physiognomic 
 peculiarities ; because, in point of fact, cardiac lesions almost 
 always bring pulmonary diseases in their train ; and it is also 
 the case that certain pulmonary derangements are quite sure 
 to be followed, after a time, by cardiac diseases both func- 
 tional and organic, which form their necessary and logical 
 supplement. The intimate association of the functions of 
 respiration and circulation in health is the evident cause of 
 their usual, and even necessary, association in disease. One 
 brief statement will, it is hoped, make this perfectly clear, 
 even to the merest tyro in medical observation. The chem- 
 ical changes in the blood which constitute the ultimate act 
 of resj)iration, may be intercepted equally — (1) by a cause 
 mechanically hindering the access of air to the blood ; or (2) 
 by one which obstructs the flow of the blood generally 
 through the capillaries of the lungs, and thus prevents the 
 access of the blood in circulation to the oxygen which awaits 
 it in the pulmonary air vesicles. The familiar example of 
 asphyxia, or suffocation, is the typical illustration of the 
 first, and obstruction of the pulmonary artery by a large 
 embolus, or thrombus, of the second mode of detriment to 
 the function of respiration ; and in both of these cases we 
 have, among other things, the rapid development of cya- 
 nosis, or lividity, as the index of the functional lesion. But 
 it is only in cases in which the change is rapid and complete, 
 from unimpaired to nearly abolished, or very greatly im- 
 paired, function that cyanosis can be relied upon as indicating 
 accurately the nature and extent of the detriment. As a 
 matter of fact and of daily observation, very grave destruc- 
 tive diseases of the lungs, and also of the heart, may exist 
 altogether without cyanosis; and cyanosis may exist, as a 
 chronic condition, with far less than could have been ex- 
 pected of respiratory difficulty and apparent effort. Hence 
 it becomes necessary to qualify the first, or, a priori, appre- 
 
 4 
 
S8 THE PHYSIOGNOMY OF DISEASE. 
 
 heusion of the physiological facts above referred to by many 
 details of diagnosis resulting from clinical observation ; and, 
 although it is j^erhaps true that there is in nature (hypo- 
 thetically at least) a typically cardiac, and a typically pul- 
 monic, physiognomy known to the highly skilled observer in 
 certain forms and aspects of diseases of the heart and lungs 
 respectively, it is impossible to state the details of these in 
 such a way as to cover the whole ground of diagnosis in 
 these two departments. In advanced pulmonary emphysema 
 and asthmatic bronchitis, for instance, there is commonly a 
 cyanotic countenance, the apparent lividity being greater or 
 less according to the greater or less amount of blood per- 
 meating, or detained in, the smaller vessels. In severe and 
 acute pneumonia, cyanosis is associated with the febrile flush 
 so characteristic of a disease where the temperature frequently 
 rises in a few hours to 104° F. or 105° F., or even higher in 
 some cases. But in very many chronic pulmonary diseases 
 more destructive and fatal than these, and in many cases also 
 of these diseases themselves, cyanosis is either absent or not 
 notably present ; because the absolute reduction in the mass 
 of the blood, and especially of its red corpuscles, permits of 
 such an amount of aeration, even with a damaged lung, as to 
 exempt the patient under ordinary circumstances from this 
 particular manifestation of a disturbed respiration. 
 
 In many cardiac diseases, and also in such affections of the 
 respiratory system as are characterized by difliculties of 
 breathing amounting to an agony, the patient remains almost 
 constantly in the semi-erect, or even in the erect posture 
 owing to the difficulty or impossibility of lying down with 
 comfort. To this condition the name of orthopnoea {op66g^ erect) 
 is applied ; to be distinguished from dys])noea ((H'a-, difficult ; 
 TTVfw, I breathe), in resjiect that the latter is, essentially, a 
 mere subjective sensation of breathlessness, whereas the former 
 is a quite special kind of difficulty, marked by a character- 
 istic attitude, and therefore coming clearly within the range 
 of physiognomic diagnosis. But even in dyspnoea not thus 
 charactej'ized, there may be differences of detail directly in- 
 dicated in the physiognomy. Thus, the breathing may be 
 simply accelerated, as in simple uncomplicated pneumonia, 
 and in some cases of j)leurisy ; or laborious, as in most cases 
 of severe bronchitis and asthma, and almost all of obstructive 
 laryngitis, or of pressure from without upon the air-passages. 
 Or, the breathing may be at once slow, and labored or noisy, 
 as in apoplectic coma; or simply slow, and with diminished 
 
DISORDEKED RESPIRATION. 39 
 
 extent of movement (shallow), as in the painless extinction of 
 chronic exhausting disease ; or slow and sighing, at intervals, 
 as in many states of disordered innervation ; or it may present 
 the more developed form of this, or what has been called the 
 " Cheyne-Stokes breathing " (to be discussed in a subsequent 
 chapter), when a succession of gasping and rapid acts of res- 
 piration alternates with a period of apparent failure of the 
 impulse to breathe (apnoea), the frequency and the depth of 
 the successive inspirations diminishing till breathing appears 
 to be about to cease altogether.-^ All of these characters of 
 the respiratory movements are thus far typical, that they 
 indicate, not perhaps the particular disease under which the 
 patient is suffering, but the whole bearing of the morbid 
 phenomena, wherever they may take origin, upon the function 
 of respiration; the further examination of which in detail, 
 including the physical diagnosis of heart, lungs, etc., may or 
 may not give the key to what would otherwise be an inde- 
 terminate position. 
 
 In some cases, perhaps, of grave and complicated disorder 
 of the respiration, but still more characteristically in certain 
 extreme forms of disease of the heart (which may or may not 
 be attended by dyspnoea properly so-called), there is a very 
 peculiar restless and often sleepless form of anguish, which 
 communicates itself, in an all but indescribable way, to the 
 whole attitude and manner of the patient. This may amount 
 to positive pain, or it may not ; the peculiar note of its exist- 
 ence, however, is the evident dread of something immediately 
 impending, a feeling which in the most severe cases prints 
 itself upon the countenance, and is further revealed by the 
 uneasy, agonized shiftings of position, and the utter disability 
 for the repose of quiet, natural sleep. Patients in this con- 
 dition will pass whole nights in a state of restless agitation 
 (pervigilium) without delirium, but with a constant dread of 
 falling asleep ; or they will yield to long-continued fatigue, by 
 falling into short, uneasy snatches of sleep, broken by sudden 
 starts and alarmed awakenings, and with an almost expressed 
 sense of the instant danger they ever seem to experience that 
 a very deep sleep might at any time become, or pass into, " the 
 sleep that knows no waking." All this makes up (when 
 
 1 What has been provisionally termed " nreemic dyspnoea" is a phenomenon fai" too 
 much involved in questions of rather doubtful pathology to be more than merely alluded 
 to in this place ; nevertheless, the ingenious researches of Cuffer, though still uncon- 
 firmed, may be mentioned as probably of importance in this connection. "Eecherches 
 cliniques et experimentales sur les alterations du sang dans I'uremie et sur la pathogenie 
 des accidents uremiques." Pai'is, 1878. 
 
40 THE PHYSIOGNOMY OF DISEASE. 
 
 watched carefully with a skilled and observant eye) a physiog- 
 nomy which is usually sufficiently distinctive of what may be 
 in general terms described as cardiac suffering; and when 
 this is enhanced and rendered definite, or its locality clearly 
 indicated by pain, and especially by very severe and paroxys- 
 mal pain following a certain course, and bearing a certain 
 relation to bodily exertion, etc. (as will be afterward described 
 in detail), it constitutes the phenomenon, or symptom, or dis- 
 ease, which has been termed *' angina pectoris," and is known 
 to be frequently associated with sudden death. But here the 
 physiognomic characters above mentioned may present them- 
 selves apart from positive pain ; or, again, the latter may be 
 extreme, in the absence of the former. But patients may 
 conceal, or misrepresent, their internal sensations, while the 
 functional distress they suffer is clearly manifested through 
 its outward tokens in the countenance, manner, etc. ; the study 
 of the truly physiognomic traits briefly indicated above is, 
 therefore, of great advantage to the physician, in his diagnosis 
 of such cases. 
 
 In all diseases of the nervous system it is of paramount im- 
 portance to observe the attitude and bearing of the patient, 
 his manner of answering questions, of putting out his tongue, 
 of speaking, eating, handling familiar objects, walking, etc. 
 There should be no hurry in making these observations; some- 
 times the abnormal facts can be taken in at a glance, as it 
 were ; at other times the disease may elude observation alto- 
 gether, until brought into full view by some particular 
 abnormal act. This applies in a very special sense to dis- 
 orders supposed to be of the mind, which have often a very 
 distinct physiognomic expression, while in other cases they 
 require to be sought out through tedious processes of detail, 
 amid many difficulties and possible fallacies, or even as under- 
 lying positive deception. In all disorders attended with, 
 paralysis, tremor, or convulsion, there will be at some time or 
 other visible phenomena aflecting one or other of the modes 
 of ordinary activity above enumerated ; or there may be de- 
 ficient power of evacuating or of retaining the excretions of 
 the bowels and bladder. A slight tremor of the lips, and a 
 hesitating utterance, as if the lips and tongue had no grip (so 
 to speak) over the consonants, will, along with a peculiarity 
 in the gait, an unusual stillness in the muscles of expression, 
 and a slight disparity of the pupils, reveal with almost abso- 
 lute certainty an early stage of one of the most hopeless of 
 diseases — general paralysis of the insane. A similar but 
 
NERVOUS DISEASES. 41 
 
 more complete absence of facial expression, without any of 
 the other characters just mentioned (unless it be a flaw in the 
 articulation absolutely limited to the labial consonants), will 
 give the key to a more rare, but far less dangerous disorder — 
 double or bilateral paralysis of the portio dura: while a one- 
 sided action of the face and brow, with a permanently open 
 or half-open eye on the side of the paralysis, and a twist of 
 the mouth toward the opposite side, will show forth the much 
 more common, and equally isolated, paralysis of the portio 
 dura on one side only. An open mouth, dribbling saliva, an 
 awkwardly moving or nearly motionless tongue, with very 
 indistinct articulation, will reveal the labio-glosso-laryngeal 
 paralysis of Trousseau and Duchenne, the bulbar paralysis 
 (so called from the seat of the lesion in the pons Varolii) of 
 other authors. The trailing walk of the hemiplegic patient, 
 in which the weight of the body is supported on one limb, 
 while the other (the paralyzed) limb is either dragged on the 
 ground, or lifted by a movement of circumduction proceeding 
 from the pelvis, and favored by a hitch of the whole body, 
 are signs which can be noted at once, along with the motion- 
 less, sometimes rigid, hand and arm of the same side, semi- 
 flexed, and with the fingers bent into the palm. The slow, 
 shuffling, and evidently enfeebled gait of the true paraplegic, 
 arising from sheer deficiency of muscular energy ; the con- 
 trolled and, as it were, leaden movements of spastic paralysis, 
 when the feet are lifted with difficulty, clinging to the floor, 
 and tending in progression to fall foul of each other, but still 
 obviously moved deliberately, and without any loss of coordi- 
 nation ; and, contrasted with both of these, the incoordinate, 
 erratic, stumbling, and staggering gait of locomotor ataxy, 
 with its evident loss of balancing power ; all of these types 
 are equally characteristic, almost at first sight, and easily dis- 
 tinguishable from the limping of hij)-joint or other articular 
 disease, and from the reeling, serpentine, plainly bewildered 
 course of the man tending homeward after a debauch, and 
 ready at any time to lie down in the dirt, to save the trouble 
 of further picking his way. More difficult to distinguish 
 from the latter are some forms of apoplexy or of cerebellar 
 disease, of the diagnosis of which, however, it is impossible to 
 treat in this chapter. The wrist-drop of lead paralysis, the 
 irregular manipulations of writer's cramp and other periph- 
 eral nervous disorders of the fingers, must also be omitted 
 here, though essentially of the nature of really physiognomic 
 diagnosis. The peculiar jerkings and general " insanity of 
 
 4* 
 
42 THE PHYSIOGNOMY OF DISEASE. 
 
 the muscles " which characterize chorea must also be dismissed 
 with a reference to special articles aud treatises ; as also the 
 whole subject of tremor, paralysis agitans, and spinal scle- 
 rosis.^ 
 
 Eeverting to the disorders which seem to have more relation 
 to the mental functions, it may be affirmed with truth that 
 almost every distinct type of insane aberration has its peculiar 
 physiognomy ; from the extravagant and excited gestures, 
 shouts, and destructive violence of the maniac, to the mutter- 
 ing and moaning of the victim of pure melancholia, nursing 
 his secret sorrow alone; or the mindless, speechless, slouching, 
 purely animal characteristics of the extreme demented patient, 
 pushed about almost like a chattel by his keeper, without 
 spontaneity, and only capable of being excited into a tem- 
 porary sense of apparent enjoyment by the sight of food, or 
 of tobacco, or perhaps, in some instances, by objects of sexual 
 desire. And within these divisions lie almost endless varieties 
 — e. g., the hysterical maniac, incoherent, extravagant in speech, 
 laughing and weeping by turns, erotic and shameless in her 
 behavior at times, and with lucid intervals, it may be, of long 
 duration ; the harmless and good-humored, half-demented crea- 
 ture, pleased with every slight attention, easily amused, and 
 always busy with some mechanical or artistic occupation — 
 knitting, or drawing, or writing long snatches of nonsense in 
 verse, or playing the fiddle ; the suspicious monomaniac, who 
 follows you with his eye at every turn, grumbles and mutters 
 audibly his suspicions, and would no doubt at times lay violent 
 hands on you if permitted ; the egotist, who adopts the manner 
 and stvle of the Emperor of India, or the Queen of Sheba, or 
 of more sacred characters than these, or, it may be, of the 
 Creator of the Universe ! Each of these insanities tends to 
 ])roduce, as it Avere, a physiognomy for itself; the whole phys- 
 i(;al habit becomes so moulded upon the prevalent delusion, 
 that it may almost be said that a glance at the patient and 
 his surroundings gives some considerable insight into the 
 s[)ccial character of his mental unsoundness. Still more 
 curious, because more inexplicable, are the physiognomical 
 individualities that lie within the apparently narrow bounds 
 of idiocy and imbecility. There is the congenital idiot, often 
 dwarfish in body and infantile in expression and habits, sexually 
 undeveloped, with a /\-shaped palate, and one or more appa- 
 
 1 These sulijects are discussed in special sections of Chapters V., VI., and VIII. Con- 
 sult the index for the names of the various diseases and sj'niptoms referred to. See in 
 particular the sections on "Speech," " Walking aud Balancing," "Twitchiugs," etc. 
 
INFANCY. 48 
 
 rently accidental bodily deformities, living the life almost of 
 .an infant : the cretin of the Alpine valleys, goitrous and other- 
 wise physically deformed ; the epileptic idiot ; the hydrocephalic 
 idiot ; the microcephalic idiot ; the paralytic idiot. Of all 
 these, and of other varieties, the physical and physiognomic 
 characters have been admirably described by Dr. Ireland in 
 his well-known work on Idiocy. (For further details, see, 
 also, Chapter VIII. on "Insanity," in this manual.) 
 
 As, in the insane and the imbecile, physiognomic diagnosis 
 assumes a special importance from their inability, in many 
 instances, to give a coherent account of themselves, so it may 
 be said that in infancy and early childhood the physiognomy of 
 disease constitutes by far the most important aspect of diag- 
 nosis considered as a whole, unless in the case of positive 
 physical signs directly bearing on the state of the internal 
 organs. If a healthy infant of from four to six months is 
 carefully studied from the medical and physiological point of 
 view, it will be found, of course, to have increased consider- 
 ably both in stature and weight since its birth f but in ad- 
 dition to the mere growth and increase of bulk, a skilled eye 
 and touch will easily determine the fact that the muscular 
 structures of the limbs have acquired much greater firmness, 
 plumpness of outline, and with these more apparent spontaneity 
 and definiteness, so to speak, of physiological activity. The 
 cause of this change is partly the constant exercise of the 
 muscles themselves, and partly the rapid development of the 
 nervous centres presiding over the muscular movements. As 
 yet, the movements are mostly automatic ; there are few, if 
 any, purpose-like acts of prehension with the hands, for instance, 
 until nearly six months old, although an object conveyed into 
 the grasp is held, just as the nipple is held when placed be- 
 tween the lips. There is, however, a constant activity of the 
 limbs, both u^^per and lower ; and a gradual education of all 
 the voluntary muscles, including those of expression and 
 voice, to the function afterward to be performed under the 
 influence of the intelligent will. The child is obviously a 
 sentient and emotional being, and one of the half-conscious 
 impulses which guide its movements when awake is the posi- 
 tive delight which it experiences in giving to every individual 
 voluntary muscle, down even to the smallest of those which 
 move the toes and fingers, a fair share of daily and hourly 
 exercise. Watch an infant, four, or six, or eight months old, 
 
 1 See Tables VI. and VII. at tlae end of this chapter. 
 
44 THE PHYSIOGKOMY OF DISEASE. 
 
 crowing with the mere physical enjoyment of perpetual mo- 
 tion, kicking its arras and legs about as it is removed from its 
 bath, and lies naked in its nurse's arms, and you will be com- 
 pelled to recognize the force of this healthy, but apparently, 
 as yet, unintelligent instinct. It is the same instinct as, in the 
 more developed system of the kitten at a like or yet earlier 
 age, leads it to chase its own tail, and to do a thousand pranks 
 that seem aimless, but are in fact surely guided toward a defi- 
 nite end in the evolution both of the bodily and the mental 
 faculties, viz., the instinct of play} Next to the yet more 
 absolutely necessary, and therefore earlier displayed, instinct 
 of suction, this is the faculty that, more and earlier than any 
 other, rules the life and determines the physiognomy of the 
 infant. We have seen, in the graphic words of Sir William 
 Jenner, how this power of spontaneous and wdiolesome bodily 
 movement is disturbed in the rickety cachexia. It might be 
 added that in almost every serious disease of early infancy 
 and childhood it is possible, by studying carefully the relation 
 of the spontaneous movements to each other, and to the atti- 
 tude and expression of the child, its cries, smiles, inarticulate 
 noises, its color, state of general nutrition, behavior in sleep 
 and in waking, to arrive at a reasonable and often perfectly 
 just conclusion as to the general nature and locality of the 
 disease. If there is paralysis in any limb ; if the spine or any 
 individual joint is weak or pained ; if the breathing is ob- 
 structed ; if the abdomen is pained and tender, or distended ; 
 if the bony skeleton is too yielding, and does not afford the 
 requisite support, or affords it only with pain ; in each case 
 there is a typical departure from the normal attitudes and 
 modes of activity, as displayed in the waking moments ; or 
 from the happy, quiet, sleeping existence of the healthy infant. 
 Of course, it is absolutely necessary that the survey should be, 
 as far as possible, complete and deliberate ; do not, therefore, 
 confine the observation to the face, or be satisfied Avith feeling 
 the pulse, and looking at a bundle of clothes. Note the color 
 of the cheeks, the heat of the skin all over the body, the pres- 
 ence (especially in sleep) of twitchings, startings, sudden 
 catchings of the breath, or breathing with effort and with im- 
 perfect expansion of the chest ; observe the descent of the 
 diaphragm, the elevation of the ribs on both sides, the state 
 of the abdominal wall and its contents, the state of the fonta- 
 
 ' Dr. John Strachan has discussed tlie j)li.vsi()l()gical and educational aspects of this 
 Bubji'ot in an ailniirable little treatise — "What is IMaj'?" Edinburgh, 1877; a work 
 which may bo recommended to the perusal of every student and practitioner of medicine. 
 
INFANTILE DISOKDEKS. 45 
 
 nelle, the size of the head as compared with the body, and 
 any abnormal flattening of the vertex or projection of either 
 frontal region ; the fulness of the veins of the head and neck, 
 the presence or absence of local or undue perspirations ; ob- 
 serve if the eyes are completely closed, as in healthy sleep, or 
 half closed, as in some febrile and cerebral diseases ; if the 
 child buries its head in the pillow, or has the hair worn away, 
 as it were, on some parts of the head, or has the neck twisted 
 backward, and stiff; or, at a more advanced age, if he grinds 
 the teeth, or picks the nose habitually; if the nostrils are 
 dilated in inspiration, and if there is any noise in the larynx, 
 or in the chest ; if the surface shows any eruptions, the mouth 
 and anus any mucous patches or condylomata, or other evi- 
 dence of syphilitic disease; if the muscles are flabby, or well 
 nourished; if the abdomen is retracted, or tumid and resistant, 
 or soft, natural, and easily manipulated. All or most of these 
 observations can be made even in a sleeping child without 
 disturbing it too much ; but, of course, it will be best to take 
 them in the order most convenient for this end. The pulse 
 and respiration should also be numbered, if possible, during 
 sleep. Other observations, as on the mouth, gums, teeth, 
 tongue, throat, nostrils, ears, as also all detailed physical ex- 
 plorations, should be postponed until all the information that 
 can be procured during sleep and waking from these physiog- 
 nomic data has been carefully gathered and noted, and until 
 some questions as to previous history have been put. 
 
 Most of the inferences to be drawn from the preceding ob- 
 servations will be commented on in other parts of this book. 
 We may here, therefore, fitly close our chapter on the physi- 
 ognomy of disease. 
 
46 
 
 APPENDIX TO CHAPTER I. 
 
 APPENDIX. 
 
 TABLE I. — RELATION OF HEIGHT AND WEIGHT IN HEALTHY 
 MEN, ACCORDING TO VARIOUS AUTHORITIES. 
 
 
 
 
 
 
 
 Dr. Robertson ; 
 
 
 
 
 Hutchinson 
 
 ; Common 
 
 American 
 
 calculated 
 
 
 IleiKlit. 
 
 English Standard. 
 
 
 Insurance. 
 
 according to 
 
 Height. 
 
 
 
 
 
 
 Standard. 
 
 Greek Model. 
 
 
 5 ft. 
 5 " 
 
 1 in 
 
 8 st 8 
 
 (120 lb 
 
 ) 
 ) 
 
 120 lbs 
 
 
 61 ins. 
 
 2 " 
 
 9 " 
 
 (126 ' 
 
 (133 ' 
 
 125 " 
 
 
 62 •* 
 
 5 " 
 
 3 " 
 
 9 •' 7 
 
 130 " 
 
 125 lbs. 
 
 63 " 
 
 5 " 
 
 4 " 
 
 9 " 13 
 
 (139 ' 
 
 
 135 " 
 
 131 " 
 
 64 " 
 
 5 " 
 
 5 " 
 
 10 " 2 
 
 (142 ' 
 
 ) 
 
 140 " 
 
 137 " 
 
 65 " 
 
 5 " 
 
 6 " 
 
 10 " 5 
 
 (145 ' 
 
 ) 
 
 143 " 
 
 144 " 
 
 66 " 
 
 5 " 
 
 7 " 
 
 10 " 8 
 
 (148 ' 
 
 ) 
 
 145 " 
 
 150 " 
 
 67 " 
 
 5 " 
 
 8 " 
 
 11 " 1 
 
 (155 ' 
 
 ) 
 
 148 " 
 
 157 " 
 
 68 " 
 
 5 " 
 
 9 " 
 
 11 " 8 
 
 (102 ' 
 
 ) 
 
 155 " 
 
 164 " 
 
 69 " 
 
 5 " 
 
 10 " 
 
 12 " 1 
 
 (169 ' 
 
 ) 
 
 100 " 
 
 172 " 
 
 70 " 
 
 5 " 
 
 11 " 
 
 12 " 6 
 
 (174 ' 
 
 ) 
 
 165 " 
 
 179 " 
 
 71 " 
 
 6 " 
 
 " 
 
 1 " 
 
 2 " 
 
 3 " 
 
 4 " 
 
 
 
 
 170 " 
 175 " 
 180 " 
 185 " 
 
 187 " 
 195 " 
 203 " 
 211 " 
 219 " 
 
 72 '« 
 
 " 
 
 
 
 73 " 
 
 6 " 
 
 
 
 74 " 
 
 6 " 
 
 
 
 75 " 
 
 6 " 
 
 
 
 76 " 
 
 
 
 
 
 
 Hutchinson's figures are found in his celebrated paper on "Respiration," in the 
 .Medico- Chirurgical Tianmctiowf, vol. xxix., London, 1846; and in his article "Thorax," 
 in Todd's Oijdopiedia of Anatomy and Physiologij, London, 1849-52. 
 
 The American stamlard i.s given in the Medical Investigations of the United States 
 Life Insurance Company. 
 
 Dr. Wm. Robertson's calculations are referred to in the text ; they were made for the 
 Scottish Widow's Fund ; his talde is somewhat abbreviated here. 
 
APPENDIX TO CHAPTER I. 
 
 47 
 
 TABLE II. — MEAN HEIGHT AND WEIGHT, FROM 10 TO 30 
 
 YEARS. 
 
 Public school boys, naval and military cadets, medical and university 
 students: most favored classes in England. (7709 observations.) 
 
 ABSTRACT FROM ROBERTS'S ANTHROPOMETRY. 
 
 Age last birthday. 
 
 Mean height, with- 
 out shoes. 
 
 Mean weight, 
 including clothes 
 = 9 lbs. 
 
 10 years .... 
 
 53 inches. 
 
 67 
 
 lbs. 
 
 11 " 
 
 
 
 
 
 54.50 
 
 
 73 
 
 
 12 " 
 
 
 
 
 
 56.50 
 
 
 80 
 
 
 13 
 
 
 
 
 
 58.50 
 
 
 88 
 
 
 14 " 
 
 
 
 
 
 61.00 
 
 
 98 
 
 
 15 
 
 
 
 
 
 63.50 
 
 
 110 
 
 
 16 
 
 
 
 
 
 66.50 
 
 
 126 
 
 
 17 
 
 
 
 
 
 68.00 
 
 
 140 
 
 
 18 
 
 
 
 
 
 68.50 
 
 
 146 
 
 
 19 
 
 
 
 
 
 68.75 
 
 
 148 
 
 
 20 
 
 
 
 
 
 69.00 
 
 
 150 
 
 
 21 
 
 
 
 
 
 
 
 152 
 
 
 25-30 " 
 
 
 
 
 
 69 00 
 
 a 
 
 154 
 
 
 TABLE III. — MEAN HEIGHT AND WEIGHT OF 10,904 GIRLS 
 IN THE UNITED STATES OF AMERICA. 
 
 (Including 3681 American, 3623 Irish, 585 German, and 1397 mixed 
 English, Irish, and American parentage.) Dr. Bowditch. 
 
 
 ABSTRACT 
 
 FROM ROBERTS'S ANTHROPOMETRY 
 
 
 
 Age last birthday. 
 
 Height without 
 shoes. 
 
 We 
 
 ight, including 
 clothes. 
 
 5 
 
 years 
 
 41.0 inches. 
 
 
 40 lbs. 
 
 6 
 
 
 
 
 
 
 43.5 
 
 
 
 44 
 
 
 7 
 
 
 
 
 
 
 45.5 
 
 
 
 48 
 
 
 8 
 
 
 
 
 
 
 47.5 
 
 
 
 52 
 
 
 9 
 
 
 
 
 
 
 49.5 
 
 
 
 56 
 
 
 10 
 
 
 
 
 
 
 51.5 
 
 
 
 60 
 
 
 11 
 
 
 
 
 
 
 53 5 
 
 
 
 66 
 
 
 12 
 
 
 
 
 
 
 56.0 
 
 
 
 76 
 
 
 18 
 
 
 
 
 
 
 58.0 
 
 
 
 88 
 
 
 14 
 
 
 
 
 
 
 60.0 
 
 
 
 96 
 
 
 15 
 
 
 
 
 
 
 610 
 
 
 
 104 
 
 
 16 
 
 
 
 
 
 
 61.5 
 
 
 
 110 
 
 
 17 
 
 
 
 
 
 
 62.0 
 
 
 
 112 
 
 
 18 
 
 
 
 
 
 
 62.0 
 
 
 
 114 
 
 
48 
 
 APPENDIX TO CHAPTER I. 
 
 TABLE IV. — MEAN PIEIGHT AND WEIGHT OF BOYS AND MEN 
 BETWEEN 4 AND 50 YEARS. 
 
 English artisan class. (13,931 observations.) 
 
 ABSTRACT FROM ROBERTS 'S ANTHROPOMETRY. 
 
 Age last birthday. 
 
 
 
 Height without 
 shoes. 
 
 Weight, including 
 
 clothes 
 
 = 7 and 10 lbs. 
 
 4 years .... 
 
 38.50 inches. 
 
 44 Ib.s. 
 
 5 " 
 
 
 
 
 
 41.00 " 
 
 50 " - 
 
 6 " 
 
 
 
 
 
 43.00 " 
 
 54 " 
 
 7 " 
 
 
 
 
 
 45.00 " 
 
 57 " 
 
 8 
 
 
 
 
 
 47.00 " 
 
 59 " 
 
 9 
 
 
 
 
 
 49.00 " 
 
 62 " 
 
 10 
 
 
 
 
 
 50.50 " 
 
 66 " 
 
 11 " 
 
 
 
 
 
 51 50 " 
 
 70 " 
 
 12 
 
 
 
 
 
 53.50 " 
 
 74 "' 
 
 13 
 
 
 
 
 
 55.50 " 
 
 78 " 
 
 14 
 
 
 
 
 
 58.00 " 
 
 84 " 
 
 15 
 
 
 
 
 
 60.50 " 
 
 94 " 
 
 16 
 
 
 
 
 
 63.00 " 
 
 1C6 " 
 
 17 
 
 
 
 
 
 64.50 " 
 
 116 " 
 
 18 
 
 
 
 
 
 65.50 " 
 
 122 " 
 
 19 " 
 
 
 
 
 
 66 00 " 
 
 128 " 
 
 20 
 
 
 
 
 
 66.25 " 
 
 132 " 
 
 21 
 
 
 
 
 
 
 
 22 
 
 
 
 
 
 66.50 '' 
 
 136 " 
 
 23-30 " 
 
 
 
 
 
 66.50 " 
 
 138 " 
 
 23-50 " 
 
 
 
 
 
 66.50 " 
 
 140 " 
 
APPENDIX TO CHAPTER I. 
 
 49 
 
 TABLE V. HEIGHT AND WEIGHT OF BOYS BETWEEN 
 
 13 AND 20 YEARS. 
 
 (3695 boys in telegraph service in England.) 
 
 ABSTRACT FROM ROBERTS'S ANTHROPOMETRY. 
 
 Average weight in pounds, without coat, hat, and shoes. 
 
 
 
 
 Age at last Birthday 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Average 
 in lbs. 
 
 Height 
 
 Height. 
 
 
 
 
 
 
 
 
 in 
 
 
 13 
 
 14 
 
 15 
 
 16 
 
 17 
 
 18 
 
 19 
 
 
 inches. 
 
 
 lbs. 
 
 lbs. 
 
 lbs. 
 
 lbs. 
 
 lbs. 
 
 lbs. 
 
 lbs. 
 
 
 
 4 ft. 3 in. 
 
 62 
 
 
 ... 
 
 
 
 
 
 62.0 
 
 51 
 
 4 " 4 " 
 
 73 
 
 70 
 
 • • . 
 
 67 
 
 
 ... 
 
 
 
 70.0 
 
 52 
 
 4 " 5 " 
 
 72 
 
 69 
 
 
 
 
 
 
 
 70.5 
 
 53 
 
 4 " 6 " 
 
 74 
 
 74 
 
 74 
 
 67 
 
 . , , 
 
 
 
 
 72.2 
 
 54 
 
 4 u 7 u 
 
 75 
 
 76 
 
 77 
 
 76 
 
 ... 
 
 76 
 
 
 
 76.0 
 
 55 
 
 4 " 8 " 
 
 78 
 
 80 
 
 78 
 
 87 
 
 81 
 
 
 
 
 80.8 
 
 56 
 
 4 " 9 " 
 
 82 
 
 83 
 
 83 
 
 86 
 
 
 
 
 
 83.5 
 
 57 
 
 4 " 10 " 
 
 86 
 
 86 
 
 87 
 
 88 
 
 94 
 
 • • • 
 
 
 
 88.2 
 
 58 
 
 4 " 11 " 
 
 87 
 
 89 
 
 91 
 
 98 
 
 93 
 
 91 
 
 
 
 90.7 
 
 59 
 
 5 " 
 
 90 
 
 93 
 
 92 
 
 96 
 
 101 
 
 109 
 
 
 
 970 
 
 60 
 
 5 " 1 " 
 
 96 
 
 98 
 
 99 
 
 101 
 
 106 
 
 102 
 
 IK 
 
 ) 103.0 
 
 61 
 
 5 " 2 " 
 
 96 
 
 101 
 
 104 
 
 106 
 
 109 
 
 111 
 
 11? 
 
 ; 105.7 
 
 62 
 
 5 " 3 " i 
 
 103 
 
 108 
 
 108 
 
 110 
 
 115 
 
 117 
 
 11/ 
 
 • 111.1 
 
 63 
 
 5 " 4 " 
 
 111 
 
 112 
 
 115 
 
 115 
 
 116 
 
 115 
 
 12t 
 
 ) 115.0 
 
 64 
 
 6 " 5 " 
 
 
 107 
 
 117 
 
 115 
 
 120 
 
 127 
 
 121 
 
 118.0 
 
 65 
 
 5 " 6 " 
 
 
 119 
 
 117 
 
 122 
 
 126 
 
 126 
 
 13C 
 
 ) 123.3 
 
 66 
 
 5 " 7 " 
 
 
 123 
 
 120 
 
 125 
 
 132 
 
 129 
 
 13^ 
 
 5 128.0 
 
 67 
 
 5 " 8 " 
 
 
 
 131 
 
 126 
 
 131 
 
 142 
 
 U4 
 
 t 134.8 
 
 68 
 
 5 " 9 " 
 
 
 129 
 
 142 
 
 132 
 
 138 
 
 144 
 
 14C 
 
 ) 189.4 
 
 69 
 
 5 " 10 " 
 
 1 ••• 
 
 
 136 
 
 144 
 
 147 
 
 161 
 
 13' 
 
 ' 143.0 
 
 70 
 
 5 " 11 " 
 
 
 ... 
 
 ... 
 
 
 149 
 
 129 
 
 15t 
 
 ) 142.6 
 
 71 
 
 This table shows not only the average weight and average height of boys, but also the 
 variation of weight in boys of the same height, according to age. For example, there is 
 a steady progression with age at the height of 5 feet 2 inches, boys of 13 being only 
 96 lbs., and those of 19 being 113 lbs. — a range of 8 or 9 lbs. above and below the mean 
 of 105.7. 
 
60 
 
 APPENDIX TO CHAPTER I 
 
 TABLE VI. — WEIGHT AND LENGTH OF INFANTS ACCORDING 
 TO THEIR AGE AND THE CHARACTER OF THEIR NOURISH- 
 MENT. 
 
 (Russow : from Gerhardt's Handbuch der Kinderkrankheiten.) 
 Class I. — Children of average age and upward. 
 
 
 Weight in Grammes. 
 
 Length in Centi- 
 metres. 
 
 Nourishment. 
 
 
 a 
 
 OQ 
 CO o 
 
 a 
 
 05 O 
 
 a 
 
 00 
 (M o 
 
 ^a 
 
 to 
 in >> 
 
 coS 
 
 a 
 
 ^a 
 
 Breast milk .... 
 
 Breast milk, with some 
 cow's milk and 
 starchy food . . . 
 
 3594 
 3525 
 
 5701 
 5310 
 
 7072 
 6317 
 
 8401 
 7916 
 
 9930 
 
 8480 
 
 51 
 49 
 
 67 
 64 
 
 73 
 69 
 
 Class II —Children under the average weight. 
 
 Breast milk .... 
 
 3027 
 
 4225 
 
 5775 
 
 6490 
 
 7910 
 
 49 
 
 59 
 
 69 
 
 Breast milk, with cow's 
 
 
 
 
 
 
 
 
 
 milk and starch}^ food 
 
 2928 
 
 4143 
 
 5598 
 
 5932 
 
 6823 
 
 'v 
 
 
 
 Cow's milk and starchy 
 
 
 
 
 
 
 [43 
 
 55 
 
 63 
 
 food exclusively . . 
 
 2900 
 
 4089 
 
 4744 
 
 5254 
 
 6128 
 
 J 
 
 
 
 The original figures are here given as indicating the relative variations very clearly. 
 For those not quite familiar with the metric system the following figures will serve as a 
 guide : lOCH) grammes, or 1 kilogramme = 2.2 lbs. avoirdupois (nearly) ; and 10 lbs. = 
 4536 grammes ; 1 centimetre = 0.3937 inch ; 50 centimetres = 19.685 inches. 
 
 The artificial feeding here referred to concerned the poorer classes of society. Rela- 
 tively better results might )>e obtained from more careful and scientific substitutes. 
 
 TABLE VII. — HEIGHT AND WEIGHT OF OLDER CHILDREN 
 ACCORDING TO AGE AND ACCORDING TO NOURISHMENT IN 
 INFANCY. (Russow.) 
 
 Nourishment in first year of 
 
 Weight in Kilogrammes. 
 
 Length in Centimetres. 
 
 life. 
 
 12 mos. 
 
 9.93 
 7.43 
 
 4 years. 
 
 8 years. 
 
 12 mos. 
 
 4 years. 
 
 8 years. 
 
 Breast milk 
 
 Artificial food .... 
 
 14.2 
 12.0 
 
 20.7 
 18.3 
 
 73 
 
 66 
 
 93 
 
 87 
 
 116 
 113 
 
BIBLIOGRAPHY. 51 
 
 Bibliography. 
 
 For consultation, by those v/ho may wish to follow out the medical 
 literature of this subject, the following authorities may be referred to, 
 with a caution, however, in the case of some of them, sufficiently in- 
 dicated in the opening paragraphs of this chapter: Galen on the 
 temperaments, especially in his treatise De Temperamentis (irepl 
 apdoeuv) ; and elsewhere in many places, for which see the general in- 
 dex, Kiihn's edition, vol. xx. p. 588. For a more brief resume, see 
 Paulus JEgineta, translated by Adams, vol. i. pp. 84-87. — Lavater, 
 L'Art de Connaitre les Hommes par la Physionomie, Paris, 1806-7. 
 — Baumgaertner, Physiognomice Pathologica, with Atlas in folio, 
 Stuttgart, 1839. — Sir Charles Bell, Essays on the Anatomy and 
 Philosophy of Expression, London, 1824; sixth edition, 1872. — Lay- 
 cock, lectures in Medical Times and Gazette, 1862, vol. i. — Corfe, 
 Medical Times and Gazette, 1867, vol. i. — Southe}^, in his lectures 
 on "Individual Hygiene," deals with the temperaments and sub- 
 jects allied thereto. Lancet, 1878, vol. i. — Wilks, in a paper on 
 "Nature of Disease," has an interesting section on temperaments, 
 Guy's Hospital Keports for 1869. — Duchenne, Mecanisme de la 
 physionomie humaine, ou analyse electro-physiologiqne de I'expres- 
 sion des passions — Atlas, 2e edition, Paris, 1876. — Bourne ville et 
 Eegnard, Iconographie photographique de la Salpetriere, 3 vols., 
 Paris, 1876-81. — Fothergill, Physiological Factor in Disease, Lon- 
 don, 1883, Chap. 2. — Jonathan Hutchinson, The Pedigree of Dis- 
 ease, London, 1884. — Charles Darwin, The Expression of the 
 Emotions in Man and Animals, London, 1872; and The Variation 
 of Plants and Animals under Domestication, 2 vols., London, 1868, 
 Although these works of a consummate naturalist are not specially 
 occupied with disease or its expression, they contain a mass of sug- 
 gestive thought bearing on the subject. — Mahomed and Galton, in 
 Guy's Hospital Keports for 1881, began an attempt to represent 
 the physiognomy of disease by the ingenious method of " composite 
 photographs ; " their paper deals with phthisis, but is chiefly inter- 
 esting as illustrating the method pursued. — C. Roberts, Manual of 
 Anthropometry, London, 1878, may be referred to for details of 
 growth and weight. — Gerhardt's Handbuch der Kinderkrank- 
 heiten (an article by Yierordt), Bd. I., Tubingen, 1881, gives full 
 details of the growth of infants. — Statistics Medical and Anthropo- 
 logical of the Provost Marshal General's Bureau, 2 vols., Washing- 
 ton, 1875. — Quetelet, Anthropometric, Bruxelles, 1871. 
 
CHAPTER II. 
 
 EXAMINATION AND EEPORTING OF MEDICAL CASES. 
 
 Case-taking. 
 
 In examining cases brought under his notice, a physician 
 is guided by the circumstances in which he finds the patient, 
 and by his knowledge and experience of the condition with 
 which he has to deal, and so, Avhile one case is approached in 
 one way, another is dealt with in quite a different manner. 
 No one method can actually be applied to all cases ; indeed, 
 no one method could possibly be the best if used indiscrimi- 
 nately. When a patient is gasping for breath and scarcely 
 able to speak, we must reserve our questions for a few impor- 
 tant points. When a patient is delirious, muddled, or obvi- 
 ously unreliable, it is vain to try to procure from him a 
 connected statement of his history and his sensations. If 
 actually insensible, or in a fit, we dare not delay our examina- 
 tion of his condition, so far as this can be ascertained, simply 
 because we might prefer to await the arrival of information 
 as to the previous history or the mode of attack ; such delay 
 (even apart from all practical questions of treatment) might 
 deprive us of the only opportunity of ascertaining the nature 
 of the ailment. Nor would a physician exj)lore the family 
 history of a person with scabies in the same way in which he 
 would investigate this part of a phthisical case ; his questions 
 directed to the patient with scabies on this matter Avould 
 probably be limited to a few pointed inquiries to ascertain 
 the infectious character of the eruption, from its presence in 
 other members of the family. 
 
 Usually we begin by incpiiring, more or less fully, what the 
 patient feels to be wrong ; this serves to direct the first part 
 of our physical exploration of the organs, and the mischief 
 detected there often sends us back to inquire into the exact 
 way in which the illness began, into the previous health, and 
 the family history ; certain points thus ascertained may de- 
 
CASE-TAKING. 53 
 
 mand a renewed examination of the organs, or the exploration 
 of other parts. 
 
 In urgent cases we seize upon the severest symptoms, the 
 dyspnoea or pain, for example, and try to get the greatest 
 information attainable at the least cost to the patient, sparing 
 him as much as possible the fatigue of questioning or of 
 physical examination, according as the one or the other causes 
 the greatest annoyance or danger, filling up the gaps as well 
 as possible from the information supplied by the attendants. 
 
 When there are obvious features of capital importance, 
 such as jaundice, febrile eruptions, bronzing of the skin, j)ul- 
 sating tumor in the neck, serious hemorrhages, profound anae- 
 mia, and the like, we often begin with these facts, and having 
 ascertained their origin, proceed in our inquiries to the other 
 parts of the case and its earlier history. 
 
 AVhen the illness is obscure, a more systematic examination 
 of all the organs and functions of the body, and an equally 
 careful inquiry into the personal and family history of the 
 patient may be required to unravel the difficulties. 
 
 In reporting cases, likewise, very different methods are pur- 
 sued by the same physician, according to the varying peculi- 
 arities and the different points of interest and importance in 
 each case, and also according to the special object he has in 
 view in making the record, whether for the purpose of treat- 
 ment, of clinical teaching, or scientific research. 
 
 The student in the medical wards, however, is not placed 
 in exactly the same position. The cases assigned to him for 
 reporting are usually selected by those in charge of the 
 patients, and they seldom fail to warn the student when pro- 
 longed physical examinations would be dangerous, or when 
 special parts of the investigation must be omitted or passed 
 over slightly. To the student, therefore, a more uniform plan 
 can be recommended, and it is the more useful to him, as 
 without some method to guide him he is apt to omit noticing 
 various important features of the ailment. This may arise 
 from forgetfulness, or from there being so many points which 
 have to be investigated ; but the student is likewise apt to 
 omit important parts of the inquiry from supposing that the 
 indications of disease found by him in one part are sufficient 
 to account for the whole illness ; having found, for example, 
 the presence of albumen in the urine, and other evidence of 
 renal disease, the beginner may never think of examining the 
 heart, and may pass over a distinct loss of vision without 
 
 5* 
 
54 EXAMINATION OF MEDICAL CASES. 
 
 remark, supposing it to be due to a mere accidental coinci- 
 dence. 
 
 It is in the examination of the actual state of the patient 
 (status prsesens) that the student chiefly requires the assist- 
 ance of some method in his investigation of the various 
 symptoms and physical signs. Many clinical teachers have 
 forms drawn up to guide their students in the reporting of 
 cases in their wards. As furnishing a memorandum, to re- 
 fresh the memory, such forms are useful for beginners, but 
 the slavish following of any such form is to be avoided. 
 
 The examination of patients demands a review of the man- 
 ner in which the various functions of the body are performed. 
 It is usual to divide the manifestations of disorder into two 
 classes— the " subjective " and the " objective." The " sub- 
 jective" comprises those of which the patient himself is con- 
 scious and for a knowledge of which we have to rely on his 
 statements. The " objective " includes those of whose exist- 
 ence the examiner has evidence from his own senses. The 
 subjective manifestations of disease are those spoken of by 
 many writers as " symptoms," the objective being named 
 " signs," or sometimes *' physical signs." Some authorities, 
 however, do not draw this distinction between " symptoms " 
 and " signs ; " they use the word " symptom " as including 
 both forms of evidence, and so they divide " symptoms," in 
 their diagnosis, into (a) "subjective" and (b) "objective." 
 It is well to keep clearly in view the distinction implied above, 
 whichever meaning may be attached to the word "symptom," 
 the more restricted meaning of which seems best for ordinary 
 use. This distinction is, as a rule, clear and definite enough. 
 A pain is a " symptom " (subjective) ; a bulging in the chest, 
 to which it may be due, is a " sign " (objective) : giddiness is 
 a "symptom" (subjective); the staggering resulting from it 
 is a " sign " (objective). Frequently, how'ever, we find that 
 no very accurate distinction is possible ; coughing is both a 
 subjective and objective manifestation of disease, and so is 
 vomiting ; bad forms of aneurismal pulsation may constitute 
 the leading complaint of the patient, and may be perceived 
 equally by him and by the i)liysician. Breathlessness is really 
 a sense of the want of breath on the part of the patient, and 
 so is purely " subjective ; " but in its extreme forms at least it 
 is so obvious to any onlooker that it might be classed as 
 " objective." Technically and strictly, the sense of breath- 
 lessness and its attendant distress are " subjective ; " the rapid 
 breathing, the effort in inspiration, or the posture assumed by 
 
SIGNS AND SYMPTOMS. 55 
 
 the patient during this breathlessness, may be classed as 
 " objective." 
 
 A preliminary division which is found convenient is to 
 separate the " external " from the " internal " part of the 
 examination, and it is safer always to begin with the external 
 portion, as otherwise it is apt to be neglected. It can usually 
 be dismissed rapidly, although there are some cases where this 
 constitutes the main part of the examination. 
 
 Unxler the external portion may be included those obvious 
 features which go to form the '' physiognomy of disease," or 
 refer to peculiarities in the conformation of the patient. The 
 temperature of the body, although really an internal phe- 
 nomenon, is usually judged of by the feeling of the skin, or 
 by the application of a thermometer to the axilla ; it is thus 
 included under this department. The conformation, weight, 
 and muscular development, the apparent age as compared 
 with the real age, the expression and complexion of the face, 
 the presence of dropsy, the posture, and the like, come in here. 
 An examination of the skin for eruptions, discolorations, scars, 
 or tumors of any kind, and a survey of the limbs and joints, 
 for any signs of disease, likewise fall to this portion of the 
 investigation. Such facts as glandular enlargements may be 
 stated in this connection. 
 
 The internal examination deals Avith the functions of the 
 various physiological systems, and on the whole the best 
 method is to take up these systems one by one, stating 
 whether they seem to be normal or in what points they 
 deviate from healthy action. 
 
 It is usually well, as recommended by the late Professor 
 Sanders, to combine the anatomical with the physiological 
 method, and to deal with the circulatory and res])iratory 
 systems in sequence, as they both have their great central 
 organs in the chest : and in the same way to keep in sequence 
 the digestive and the genito-urinary systems as their central . 
 organs are in the abdomen. 
 
 We begin with the system which seems from the history 
 or from the general aspect of the case to be the one most 
 essentially affected, and we also, of course, consider it in much 
 fuller detail. Hospital cases are usually so far prepared for 
 the student by the previous record of the temperature and 
 the preservation of the urine and expectoration for his in- 
 spection. 
 
 " If we find orthopnoea, general anasarca, and distended 
 jugular veins, we begin with the circulatory system. 
 
56 EXAMINATION OF MEDICAL CASES. 
 
 " If we find iDurulent expectoration, emaciation, and clubbed 
 finger-ends, we begin with the respiratory system. 
 
 " If we find albuminous urine and pale puffy countenance, 
 we begin with the urinary system. 
 
 " If we find jaundice and protuberant abdomen, we begin 
 with the digestive system. 
 
 " If we find paralysis or convulsive twitches, we begin with 
 the nervous system, and so forth." (Sir William Koberts.) 
 
 These anatomical and physiological divisions could never, 
 however, preserve us from making serious omissions in our 
 reports, unless each detail in each system were investigated 
 with an absurd and, indeed, a reprehensible completeness. 
 The manifestations of disorder in the various systems often 
 appear in the most unexpected quarters. These points can 
 only be learned by a varied experience of morbid conditions, 
 such as the beginner cannot be expected to possess. The de- 
 tailed description of the symptoms dealt with in the various 
 chapters of this book are intended to supply, to some extent, 
 from the experience of others, the want thus felt by a beginner, 
 so that Avhen he comes upon any of these symptoms he may 
 know how to pursue the investigation in its various ramifica- 
 tions, and to estimate to some extent the bearing of the facts 
 on the diagnosis. 
 
 As an indication of the points to be investigated under each 
 heading, and the order in which the inquiry may be taken up, 
 the following tabular statement is appended. It is slightly 
 modified, for the present purpose, from the form used by 
 Professor Leech, of Owen's College, Manchester : 
 
 NAME — SEX — AGE — ADDRESS — OCCUPATION — DATE OF 
 ADMISSION — PHYSICIAN — REPORTER OF CASE. 
 
 Preliminary inspection and inquiries tending to elicit general char- 
 acter and duration of symptoms : definite inquiry as to what has 
 brought the j^atient to seek medical assistance. 
 
 Previous History: 
 
 1. Social. 
 
 2. Previous health. 
 
 3. Present illness. 
 
 4. Family history. 
 
 Present State : 
 
 1. External surface. 
 
 2. Nervous system. 
 
 3. Special organs. 
 
 4. Circulatory system. 
 
 5. Kespiratory system. 
 T). Digestive S3^stem. 
 
 7. Genito-urinary system. 
 
DETAILS OF EXAMINATION. 57 
 
 Treatment. 
 Progress of Case. 
 
 Diagnosis. 
 
 Prognosis. 
 
 Previous History. 
 
 1. Social. — Particulars concerning residence, coldness, dampness, 
 
 salubrity — prevalence of special diseases — changes of residence 
 — residence abroad. 
 
 Occupation — peculiarities of occupation, as exposure to heat, 
 cold, lead, noxious gases, dust, etc. — changes in occupation — 
 service in army. 
 
 Pood and clothing — excess or defect, etc. — stimulants, character 
 and amount— tobacco — drugs. 
 
 General or special habits and mode of life. 
 
 If married, date of marriage — issue — stillborn children — mis- 
 carriages and times at.vfhich they have occurred. 
 
 2. Previous health. — Nature and character of previous illness (ail- 
 
 ments of infancy in special cases) — previous admissions into 
 hospital — indications of gout, rheumatism, syphilis (gonor- 
 rhoea, sore throat, rashes, symptoms of infantile syphilis, if 
 necessary) — cough — haemoptysis. 
 
 Sexual disorders — catamenia — leucorrhoea. 
 
 Inquire specially for hemorrhages or discharges, if there be 
 anaemia. 
 
 Previous general nutrition and weight. 
 
 3. History of present attack. — Mode of onset — antecedent occur- 
 
 rences — course of symptoms — treatment before admission. 
 
 4. Fatnily history. 
 
 Pather, sisters, ") Ages, health; or age at time of death 
 
 Mother, brothers, j and the cause of death. 
 
 In special cases, grandparents and uncles and aunts. 
 
 Diseases in other relatives, especially consumption and scrofulous 
 disease, insanity, rheumatism, and heart disease, gout, cancer 
 or malignant disease : specify whether relative affected was on 
 side of father or mother. 
 
 Present State. 
 
 1. External surface. — Posture — temperature — general appearance — 
 form of head — face, color and expression of — worn, languid, 
 sallow, excited, stupid, livid in any part, flushed, anaemic — 
 wrinkles — nostrils — lips — arcus senilis — conjunctivae — pupils — 
 eyelids — eyeballs — ears. 
 
 Relation of appearance to age. Nutrition — well nourished, stout, 
 spare or emaciated, weight, height. 
 
 Peculiarities of external configuration, tumors, swellings, deform- 
 ities, form of joints. 
 
 Skin — oedema, face, body, ankles, etc. Perspiration — face, head, 
 body — odor, if any — cutis anserina — roughness — softness — 
 cicatrices — rashes (maculae, stains, erythema, wheals, papules, 
 vesicles, pustules, scaliness, tubercles), ulcers — discoloratiuns 
 and superficial vessels. 
 
58 EXAMINATION OF MEDICAL CASES. 
 
 Hair on head, body. Nails curving — clubbing of fingers — onychia 
 
 — structural alterations. 
 Glands — superficial, back of neck, along sterno-mastoid, in axilla, 
 
 groin, parotid. 
 
 2. Nervous system. — Intelligence — mental peculiarities — emotional 
 
 indications — hysteria — coma — delirium — vertigo — headache, its 
 nature and locality — sleep — dreams. 
 
 Rigors — lassitude — pains in back — tenderness on pressure along 
 spine — effect of application of hot sponge. 
 
 Paralysis of muscles — face, bod}-, and extremities — hemiplegia, 
 paraplegia, monoplegia. 
 
 Want of coordination — muscular sense — nutrition of individual 
 muscles — electric reaction. 
 
 Rigidity — tonic or clonic spasms — tremor — choreic movements — 
 character of convulsions or fits — ^reflexes, superficial and deep 
 — excitabilitj'. 
 
 Alterations of sensation — ansesthesia (in relation to touch, tem- 
 perature, and weight) — analgesia — h3'per8esthesia — hyperal- 
 gesia Pricking — formication — coldness — sense of constriction 
 — neuralgic and other pains. Note exact seat of pain — recur- 
 rency, constancy, intermittence, and whether altered by move- 
 ment or rest. 
 
 "Walking — various methods, staggering, etc. Difficulties and 
 modes of speech, aphasia, etc. Tendons. Joints — character of 
 changes in joints — special joints affected — surface temperature 
 — redness — pain — tenderness — stiff'ness — deposits round joints — 
 deformities — presence of fluid. 
 
 3. Special organs. — Eye and vision — acuteness of sight, field of 
 
 vision, diplopia, hemiopia, musc;c and flashes of light, colored 
 spectra, phot()])hobia, color-blindness — peculiarities of conjunc- 
 tival discoloration or arcus senilis, if present — minute exami- 
 nation of movements of eyeballs — nystagmus — ophthalmoscopic 
 examination. 
 
 Ear and hearing — deafness, undue acuteness of hearing — tinnitus. 
 
 Condition of meatus, discharges from it — membrana tympani — 
 mastoid process. 
 
 The nose and smell — appreciation of odors, of irritants — perver- 
 sion of smell — dryness of nostrils, discharges, fetor — examina- 
 tion of nasal cavities. 
 
 Taste — acuteness, bluntness, or abolition of taste as tested with 
 bitters, salines, etc. 
 
 4. Circulatory systeyn. — Palpitation — cardiac pain, dyspnoea or 
 
 anguish — pulse, frequency, irregularity, or intermittence, large 
 
 or small, hard or soft, and compressible — sphygmographic 
 
 tracing. 
 Inspection — Cardiac region, general appearance — locality, 
 
 strength, and area of impulse. 
 
 Root^of neck — venous fulness and pulsation, arterial pulsation. 
 
 General surface Make special investigations as to any pecu- 
 liarity noted on external examination, such as lividity — pul- 
 sation, enlargement of veins, etc. 
 
DETAILS OF EXAMINATION. 59 
 
 Percussion. Map out cardiac dulness — percuss over and outside 
 sternum. 
 
 Palpation. Peel for apex beat, thrill at apex and base. 
 
 Auscultation — listen with stethoscope, between third cartilages, 
 at apex, over ensiform cartilage, at aortic and pulmonary carti- 
 lages, etc. Note character of sounds — accent — strength — re- 
 duplication. Murmurs, their ihythm and conduction. Exami- 
 nation of blood. 
 
 5. Respiratory system. — Number of respirations and their character, 
 
 easy, labored — dyspnoea, inspiratory, expiratory — orthopncea — 
 result of exertion. Pain in chest — cough — character of sputa 
 (microscopic examination if necessary) — nasal cavities — voice — 
 examination of larynx — physical examination of chest. 
 
 Inspection — form, depressions or bulgings, local or general — con- 
 dition of spaces — movements, character, and amount — note 
 whether breathing is abdominal or thoracic — condition of ex- 
 trinsic muscles of respiration. 
 
 Percussion — dulness — increased resonance — tubular note — 
 cracked-pot sound, etc. — describe exact locality of altered 
 sounds. Note amount of resistance. 
 
 Palpation — fremitus, etc. 
 
 Auscultation — changes in character of inspiratory and expiratory 
 sounds or their rhythm. New sounds — rhonchi — friction 
 sounds, etc. — conduction of heart sounds — vocal resonance — 
 bronchophony — ^egophony, pectoriloquy — whispering pectorilo- 
 quy — splashing sounds — metallic tinkling. 
 
 6. Digestive system. — Lips — teeth — gums — mouth — tongue, mode of 
 
 protrusion, moist, dry, tremulous, clean, pale, coated, raw, 
 fissured, tooth-marked — fauces and jiharynx — deglutition — 
 thirst — appetite — pain or discomfort after eating — acidit}' — 
 flatulence — time after food at which they appear — hiccough — 
 amount, frequency, and characteristics of vomiting, nature of 
 vomit (microscopic examination if necessary). 
 
 Condition of abdominal walls — results of percussion and palpa- 
 tion — presence of fluid or of solid tumors, or of ascites — 
 nature of fluid, if removed — abdominal pain or tenderness — 
 colic — condition of rectum, piles, hemorrhage — frequency of 
 defecation, difficulties — character of motions, abnormal constit- 
 uents, worms, blood, pus, etc. 
 
 Size of liver as determined by percussion and palpation — measure- 
 ment at epigastrium and in nipple line — feel of surface, hard, 
 nodulated — tenderness — splenic dulness, enlargement, if an}' — 
 condition of lurabar regions. Hypogastric region — iliac region 
 — hernise. 
 
 7. Oenito-urinary system,. — Frequency of micturition — difficulty, 
 
 pain, its character and locality. 
 Urine — quantity in 24 hours in fluid-ounces ; color, reaction, 
 speciflc gravity, clearness or turbidity, presence and amount of 
 albumen and sugar — amount of chlorides — percentage of urea 
 in 24 hours' urine in special cases. 
 
60 EXAMINATION OF MEDICAL CASES. 
 
 Deposits — their general appearance. Microscopic examination — 
 ascertain presence or absence of epithelium, pus, blood, casts of 
 the uriniferous tubes — their character, number, and variety — 
 fatty particles, renal cells, amorphous lithates or phosphates, 
 crystals of uric acid, oxalate of lime, triple phosphates, etc. 
 
 Male — scrotum — testes — gonorrhoea — stricture — syphilis. 
 
 Female — menstruation, when established ; natural, excessive in 
 quantity, too frequent, accompanied with much pain — leucor- 
 rhoea — ascertain if there be any enlargement of uterus by per- 
 cussion and palpation externally. An examination per 
 vaginam, with specujum and with uterine sound, may be neces- 
 sary. Note condition of breasts, and state if pregnancy known 
 to exist. 
 
 The Personal History. 
 
 The history of the illness under observation should, as a rule 
 be taken separately from the record of the general previous 
 health of the patient. We begin by seeking to know what 
 symptom, or combination of symptoms, or what circumstance 
 has brought the patient into the hospital, or made him seek 
 medical advice. The points regarded by the person himself 
 as important are thus obtained, and should always be recorded 
 at the beginning of our reports, even although they may not 
 seem to us the most essential features of the illness. The 
 subsequent course of the case has often much light thrown 
 upon it by this record of these indications, for the patient may 
 feel tlie importance of certain things which may be over- 
 shadowed in our minds by considerations based on our theo- 
 retical views. 
 
 Taking these leading comj^laints as our basis, we try to dis- 
 cover the date at which they appeared, the order and sequence 
 of the symptoms, and the relative severity of the different 
 parts of the iUness at different times, and particularly the date 
 at which the disease laid the person aside from work and 
 confined him to the house, or to his bed, as the case may be. 
 Having traced the date and origin of the present complaints, 
 w^e seek to ascertain if they arose in the midst of health, or if 
 they sprang out of some previous illness or general derange- 
 ment. If it appears that the patient regards the present 
 ailment as definitely originating from some other illness, or if 
 from the known facts of disease this relationship seems prob- 
 able to ourselves, we begin our history of the present illness 
 with an account of the earlier one out of which it has seemed 
 to spring. But if the present illness cannot be well defined 
 by a date of previous health, or if the history is entangled in 
 a long story of former disease or general delicacy, it usually 
 
HISTORY OF THE PATIENT. 61 
 
 conduces to simplicity to begin by taking the history of the 
 present aggravation of the condition separately, and then to 
 include the former part of the illness in the account of the 
 previous health of the patient. For example, if we find that 
 dyspnoea, dropsy, etc., constitute the chief complaints of the 
 patient, if these have existed for two or three months, and 
 seem to date from a second attack of rheumatic fever, six 
 months ago, we may begin with this second attack of rheuma- 
 tism ; we trace the sequence of events from it, and reserve a 
 detailed account of the first rheumatic attack, and any former 
 illness, for the other part of the case which deals with the 
 previous history of the patient. But if we find a serious 
 haemoptysis, or a violent pain in the chest, or severe headache 
 and vomiting to form the obvious and urgent comj^laint of a 
 patient on admission, we deal first with the origin and course 
 of these, even although it may be certain that the patient has 
 long been the victim of chronic lung disease. Having traced 
 the history of these urgent features of his complaint, we can 
 go back and try to unravel the tangled web of chronic ill 
 health in all its various manifestations. 
 
 In the case of children, and especially of young children, we 
 may often save time by ascertaining from the mother the point 
 in the child's age up to which he was regarded as healthy. 
 We may note in passing whether the child was suckled, or 
 how he was fed, when he was weaned, when dentition began, 
 and when he was able to walk. From this period of health 
 we trace all the illnesses onward, up to the present, even 
 although there may not be much connection between them. 
 If, again, the child has been delicate from birth, or troubled 
 with many recurring illnesses from the beginning, it is equally 
 important to procure a connected history of all these, so as to 
 judge of the child's prospects in the present attack of whatever 
 kind this may be. 
 
 In procuring the history of an illness from the patients or 
 their friends, we should try to get the facts as known or 
 observed by themselves, rather than mere names or theoretical 
 conceptions, such as "inflammation," " brain fever," and the 
 like. Calling an illness "rheumatism," for example, may 
 tend to mislead us in the history of cases which really depend 
 on spinal meningitis or locomotor ataxy. We must try to 
 learn from the patient or his friends, in such a case, what 
 evidence there was of the so-called rheumatic attack, whether 
 it confined the patient to bed, whether it was associated with 
 distinct swelling of the joints, wdiere the pain was localized, 
 
 6 
 
62 EXAMINATION OF MEDICAL CASES. 
 
 whether there was feverishness, and so forth. The story of 
 any so-called inflammation of the chest or lung must likewise 
 be recorded, with such additional information as can be ob- 
 tained, and in such cases the duration as well as the symptoms 
 should be stated; this may tend to confirm or to throw doubt 
 on the name given. Sometimes, however, when the name of 
 the disease is given with some precision, and stated on the 
 authority of some medical man, or in connection with some 
 hospital, we may accept the name of the disease, adding in our 
 notes the authority on which we do so. 
 
 In following up the sequence of symptoms we also aim at 
 representing in our report the facts of the illness as actually 
 exi)erienced and complained of by the patient, apart from all 
 theoretical views; some j^atients are very fond of importing 
 these into their narrative. The reality or severity of certain 
 symptoms may often be usefully indicated by stating special 
 facts ; for example, in a case of swelling of the belly, that the 
 skirts had to be widened, or that the trowsers could not be 
 buttoned ; or in a case of weakness, that the person could not 
 walk across the floor without assistance ; or in the case of pain, 
 that the patient could get no sleep, or that he screamed out, 
 or fainted in connection with it. Details like these guide our 
 estimate of the value of the history as derived from the patient. 
 We must, likewise, make use of our own knowledge to check 
 the patient's history, particularly in putting sj^ecial questions 
 to make sure of the real facts when the account seems im- 
 probable or incredible. We may also, after getting the history 
 from the jiatient, inquire as to whether certain sym2)toms were 
 not present, as he may have forgotten them, but we must, if 
 possible, avoid j^utting ideas into our patients' miuds; leading- 
 questions must be sparingly used, or at least reserved for the 
 end of the interrogation, and in particular to bring out nega- 
 tive points in the case with clearness and precision. 
 
 The history of the previous health should be, in part, of a 
 general kind, such as patients can readily supply ; the dates 
 and durations of previous illnesses should, as a rule, be speci- 
 fied, as well as the names of the diseases ; the general state of 
 the strength, especially as regards the ability to work, and the 
 date of any deterioration in this respect must likewise be 
 noted. But in addition to this general sketch we must often 
 put special questions as to special points, which the patient 
 might otherwise overlook. Thus, in cases of heart disease, we 
 always inquire about rheumatism ; the indications of this, 
 especially in childhood, are often so slight that they might 
 
SOCIAL HISTOKY: HABITS. 63 
 
 easily be missed without some special inquiry. In cases of 
 spinal paralysis, aneurism, and some other affections, we must 
 inquire for any strain or injury, and we note its date and the 
 exact manner in which it happened. We must often, indeed, 
 go back upon the history of our patients, especially as regards 
 this earlier portion of it, after the examination of the case in 
 various ways has guided us so far to the diagnosis. Some- 
 times, moreover, as described in the section on ", Family His- 
 tory" (see p. 68), we must search about in aur questions for 
 diseases allied to the one suspected to exist, using popular 
 names likely to be known by the patient or his friends. 
 
 The inquiry as to previous venereal diseases is often impor- 
 tant, but must be approached with delicacy particularly in the 
 case of women, and especially when dealing with those Avho 
 are young and apparently respectable. We may often gain 
 some information as to syphilis in an indirect way, by inquir- 
 ing for a history of sore throat, skin eruptions, nodes, noc- 
 turnal pains, and falling out of the hair ; or, in the case of 
 those who have had children, whether any of these were born 
 dead, whether there had been any miscarriages, whether the 
 children born alive had eruptions on their buttocks, snuffles, 
 or the like. We can seldom place much reliance on the mere 
 denial of syphilis, and it should be remembered that men 
 frequently refuse to admit having had syphilis, although they 
 confess readily enough to having had gonorrhoea frequently : 
 it is apparently the question of constitutional taint and not of 
 morality which determines such denials : with tact in ap- 
 proaching the subject we can often obtain the history and 
 date of infection. The history of gonorrhcea is important in 
 certain arthritic affections, and particularly in cases of uri- 
 nary irritation, as when stricture follows it, the bladder and 
 kidneys are often involved. Syphilis has to be considered in 
 the history of a multitude of diseases — skin diseases, nervous 
 affections of various kinds, disease of the liver, amyloid degen- 
 eration of the liver and kidneys, aneurism, and other forms of 
 disease of the bloodvessels, laryngeal ulceration, etc. 
 
 Social History: Habits. — Certain points not of a purely 
 medical character are usually inquired into, in addition to 
 the bare facts as to age, occupation, residence, marriage, etc., 
 wdiich are taken in all cases for the routine purpoi^es of the 
 hospital records ; special points must often be searched out. 
 
 The age often suggests a comparison between the alleged 
 and the apparent age of the patient. 
 
 The occupation may have to be scrutinized as to the special 
 
64 EXAMINATION OF MEDICAL CASES. 
 
 peculiarities of the employment, and the exposure to evil 
 influences known to beset certain trades ; former occupations 
 sometimes explain certain ailments, and this is important in 
 connection with those who have been discharged from the 
 army and are now engaged in other pursuits. 
 
 Occupations which are apt to injure the health or to favor the devel- 
 opment of disease can onl}- he roughly indicated here. Soldiers and 
 sailors are specially liable to aneurism. Hammermen and others 
 using their arms violently, are frequently the victims of aortic valvu- 
 lar disease, apparently owing to the strain on the great vessels. Publi- 
 cans and others having to do with the manufacture and sale of alcohol 
 are liable to disease of the liver, kidneys, and nervous system: this 
 arises partly from the injurious influence of the vapors, particularly in 
 badly ventilated places where they may work, hut chiefly from the 
 constant exposure to temptations to excess which many cannot resist. 
 Some of those employed as commercial travellers are exposed to similar 
 dangers. Butchers have been supposed to be injuriously influenced 
 by their business, and have been regarded as specially liable to apo- 
 plectic attacks. Coal miners are subjected to the influences of cold 
 and damp in their work, which often implies constrained postures, and 
 so they are found to be liable to sciatica and other more distinct forms 
 of rheumatic disease. Agricultural laborers, fishermen, and others 
 much exposed are also liable to chronic rheumatism. The inhalation 
 of dust in various forms often gives rise to disease of the lungs, and 
 this is specially the case when the ventilation is bad. On this account 
 miners suflfer from a special form of lung disease from the coal dust 
 and the soot resulting from blasting, etc. Knife-grinders, stone- 
 masons, and potters are all liable to peculiar forms of pulmonary con- 
 sumption. Some factory workers owe their liability to lung disease 
 partly to dust and partly to confinement in close rooms. Those whose 
 work is among horses and cattle may more readily contract glanders, 
 farcy, and other animal poisons ; the}' are also more exposed to anthrax 
 or malignant pustule : but workers in hides, horsehair, etc, are also 
 affected at times b}' this formidable disease. The influence of metallic 
 jjoisons is shown in those who work with mercury in " silverizing " 
 mirrors. Those who make white lead are specially subject to the inju- 
 rious influence of this metal ; but painters, glass-workers, potters, and 
 at times plumbers, dyers, and others brought habitually into contact 
 with lead are frequently affected. It should be borne in mind, how- 
 ever, that lead poisoning is often due to contamination of the water 
 supply and other articles of food and drink quite apart from the occu- 
 pation of those aflected. Sedentary or studious occupations are apt to 
 be specially injurious to adolescents of both sexes, and the effect is 
 often intensified by this change in their occupation coinciding with a 
 change of residence to a large town and living in lodgings for the first 
 time. In such cases the appetite and dige^^tion are apt to fail, and any 
 tendency to lung disease is readily developed. Sedentary occupations 
 in older people favor indigestion, liver disorders, piles, etc. Girls 
 exposed to prolonged standing, as in serving at counters, or to con- 
 tinuous exertion with their feet in working sewing machines, often 
 suffer in their general health and in their pelvic organs. Firemen on 
 
USE OF ALCOHOLIC STIMULANTS. 65 
 
 board of steamers are apt to have disorders of the kidneys, no doubt 
 from the profuse sweating to which they are exposed. Bright's disease 
 seems liable to occur in those exposed by their occupation to habitual 
 cold and wet. Mental strain, so notable in some forms of com.mercial 
 activity, is likewise supposed to lead to Bright's disease ; of course, 
 the same influence at business, literary work, or school may lead to 
 various disorders and diseases of the brain. On the other hand, the 
 want of due work and occupation for body and mind is apt to favor 
 hysteria, hypochondriasis, and a multitude of nervous disorders. 
 
 The residence may raise questions as to the healthiness of 
 the locality, its freedom from certain diseases and its exposure 
 to others; the accommodation in the particular house may 
 also have to be investigated, as regards its cubic space, its 
 water supply, drainage, etc. ; former residences, exposure to 
 malarious influences, to tropical climates, etc., have often to 
 be inquired for, and the results must in many cases be recorded 
 even when they are negative. 
 
 The kind of food habitually used often supplies very impor- 
 tant light as to certain diseases ; the use of tea in excess, 
 especially if to the exclusion of milk, vegetables, potatoes, etc., 
 often explains scorbutic, nervous, and dyspeptic disorders. 
 The excessive use of tobacco is suggested in cases of cardiac 
 palpitation or pseudo-angina pectoris, dyspepsia, dimness of 
 vision, quasi-paralytic disorders, and other forms of nervous 
 disturbance. The use of alcoholic stimulants must be inquired 
 into in cases of liver disease, and so-called " bilious attacks," 
 renal affections, dyspeptic complaints, convulsive attacks, par- 
 ticularly when affecting male adults, and in all diseases char- 
 acterized by delirium, with or without much fever ; the history 
 of any previous intemperance often explains the high delirium 
 present in acute illnesses, and has great importance in the 
 prognosis and the treatment. The form of alcohol used, 
 whether wine, beer, or spirits, is sometimes a matter of impor- 
 tance ; even the exact variety of spirit used is sometimes a 
 point of interest ; the use of undiluted spirits on an empty 
 stomach seems to be very specially injurious ; we must like- 
 wise ascertain whether a somew^hat excessive use of alcohol 
 was of daily occurrence, or whether the excess was only during 
 an occasional outbreak in the course of wrecks or months. 
 
 The regular use of other stimulants or sedatives, especially 
 opium, chloral, ether, and chloroform, must sometimes be in- 
 quired into. 
 
 The fact of marriage, its date, and the number of children 
 born alive and dead must also be recorded, particularly in the 
 case of w^omen, and in their case the number and date of mis- 
 
 6* 
 
6^ EXAMINATION" OF MEDICAL CASES. 
 
 carriages or abortions should also be noted in some part of the 
 report. 
 
 The practice of masturbation is to be inquired for with 
 great caution, as we must avoid suggesting the idea of evil to 
 those whose minds are free from any such notions ; but in 
 certain cases of epileptic seizures, in certain forms of cardiac 
 palpitation in boys, and in some cases of nervous prostration 
 and spermatorrhoea the questions must be put with clearness 
 in the interest of the patients, for their warning, quite as 
 much as for the benefit of the diagnosis. Excessive venereal 
 indulgence, whether within the marriage state or not, is often 
 responsible for nervous disorders, spinal paralysis, locomotor 
 ataxy, and other less definite forms of disease. These effects 
 are more common in the male than in the female. 
 
 Family History. 
 
 The importance of family history in throwing light on the 
 tendency to special diseases is well shown in life insurance 
 studies. This inquiry embraces a note of the age of the pa- 
 rents and of the brothers and sisters of the patient, and of 
 their state of health, if alive ; of the ages at which any such 
 relatives may have died, the nature of the illnesses they have 
 had, and the diseases which caused their death. Inquiries as 
 to other relatives are occasionally important, especially when 
 the number of brothers and sisters is small, or the information 
 regarding them obscure ; the grandparents, and the uncles 
 and aunts of the patient, on both sides, are the most important 
 in this respect. In going beyond these to half-brothers or sis- 
 ters, to nephews and nieces, to cousins, or even to the children 
 of the patient, we necessarily introduce complications from 
 marriage ; these, however, may sometimes be allowed for in 
 summing up the inquiry. 
 
 Now all this information can seldom be obtained with any 
 feeling of accuracy, and in hospital practice the deficiencies 
 are so enormous as to discourage the student, and perhaps to 
 give him an erroneous view of the value of this branch of the 
 inquiry. We should begin by getting the bare facts as to the 
 size of the fiimily, the ages of those living, and the diseases 
 and ages of those who have died. In some cases, where we 
 can interrogate the mothers of children, with suspected syphilis 
 for example, we should also try to obtain the number and 
 dates of the miscarriages and stillbirths, ascertaining whether 
 these occurred before or after the birth of the child under 
 
FAMILY HISTORY. 67 
 
 consideration. The further prosecution of the inquiry must 
 turn upon the facts thus elicited, and upon the other facts 
 discovered in the investigation of the illness. Hence we often 
 revert to the family history at the end of the inquiry, to bring 
 out information on special points as to the health or history of 
 the living or the dead. When the causes of death alleged 
 are doubtful or unsatisfactory, Ave may sometimes judge for 
 ourselves from the facts of the illness supplied by our inform- 
 ants. In particular, we must receive with great reserve the 
 deaths set down to "teething," "change of life," "childbirth," 
 " cold," " inflammation," etc. Many deaths are set down to 
 childbirth or change of life, although really due to phthisis. 
 Consumption often leads to disorders of the menstruation, or 
 its suppression at an early age ; and childbirth is frequently 
 followed by a very rapid progress of the same disease which 
 may not, up to this point, have been clearly recognized, or at 
 least admitted. Regard should be had to the age at which 
 such a death occurred, how long the confinement had been 
 survived, how long the weakness had lasted, and whether it 
 was associated with cough, spitting of blood, or other suspicious 
 symptoms. In these doubtful cases, inquiry as to the collateral 
 branches of the family is important — e. g., if a patient's mother 
 is reported to have died from a cause in doubt we may search 
 with advantage into the history of the maternal uncles and 
 aunts. " Inflammation of the lung" and " pleurisy" must be 
 scrutinized in the same way, especially if other deaths occurred 
 from phthisis or pulmonary affections in the same family ; if 
 either pleurisy or pneumonia proved fatal after a prolonged 
 illness, we may suspect that these were allied to phthisis, or 
 that some such tendency existed in the constitution of the 
 victim. The name of " bronchitis" also covers many deaths 
 from phthisis : the age of the subject, the duration of the ill- 
 ness, and the occurrence of lividity, dropsy, etc., may some- 
 times guide us. "Worm fever," "intermittent fever," "the 
 dregs of the measles," and some other terms of this kind are 
 often merely popular names for tubercular disease. Sudden 
 deaths ascribed to apoplexy are to be investigated as to whether 
 the death was almost instantaneous or whether the illness 
 lasted at least some hours ; in the former case cardiac or 
 aneurismal disease is more probable than apoplexy ; apoplectic 
 attacks in early manhood, with one-sided paralysis, are to be 
 suspected as due to syphilitic, cardiac, or renal disease. In 
 fact, the name of the disease must be regarded, unless sub- 
 stantiated by good evidence, as of only little account ; all the 
 
68 EXAMINATION OF MEDICAL CASES. 
 
 knowledge we possess of the nature of diseases and their rela- 
 tive frequency at particular ages, and in particular countries, 
 must l)e brought to bear on the scrutiny, and some familiarity 
 with the names of diseases in common use among the poor is 
 also of much value in hospital inquiries. 
 
 In inquiring into the illnesses which the members of a 
 family may have had, it is desirable to suggest various dis- 
 eases allied to the one known or suspected to exist in the 
 patient, using for this purpose various names, so as to meet the 
 limited knowledge of our informants, and also to refresh their 
 memories. Thus in regard to scrofulous diseases, we ask for 
 swollen glands or " waxen kernels," or runnings in the neck, 
 disease of the spine and other bones, bad joints, white swell- 
 ings or " incomes," as they are termed in Scotland, chronic 
 ulceration of the intestines, and chronic peritonitis, disease of 
 the glands of the bowels, water in the head, consumption of 
 the lungs, or decline, or weakness of the chest with spitting 
 of blood, and so on ; we may in this way get at the facts when 
 a more general question fails. It is wise also in most cases to 
 avoid disagreeable Avords, such as scrofula, in the first instance 
 at least, as many people are so annoyed at the suggestion of 
 such affections being supposed to exist in their family that 
 they are shy of giving any detailed information. In inquir- 
 ing for a family history of cancer we should likewise be chary 
 of mentioning this dreaded name, at least if our patient's dis- 
 ease is only of doubtful malignancy, trying rather to get our 
 informants to volunteer statements on the subject, and search- 
 ing for the information wanted under the names of growths, 
 tumors in the breast or elsewhere, disease of the liver, stomach, 
 or womb, with wasting, jaundice, dropsy, floodings, etc. 
 
 We must further bear in mind, in these inquiries, the varia- 
 tions of allied diseases which appear in different members of 
 the family, and in different generations ; by asking for such 
 by name we often refresh the memory of our informants. 
 Heart disease, rheumatism, chorea, psoriasis, and some other 
 cutaneous affections, perhaps also renal concretions, and em- 
 physematous bronchitis, appear to replace each other in 
 different members of the sanie family. Thus, a patient may 
 be said to have inherited heart disease from his having in- 
 herited rheumatism, leading, as it so often does, to an ^affection 
 of the heart ; but another member of the same family may 
 have had heart disease transmitted to him Avithout any overt 
 rheumatism in his own history. The neurotic group includes 
 the various forms of neuralgia, hypochondriasis, hysteria, in- 
 
FAMILY HISTORY. 69 
 
 sanity, epilepsy, and chorea ; apoplexy and hemiplegia are 
 included by some fperphaps doubtfully) in this group, their 
 hereditary character seems rather to be associated with vas- 
 cular disorders. Not unfrequently the patient seems to inherit 
 an unstable nervous system, predisposing to all sorts of 
 nervous disturbance rather than leading to any one form of 
 disease. Certain rare forms of paralysis, as wasting palsy 
 and pseudo-hypertrophic muscular paralysis, tend to occur in 
 various members of the same family. Sometimes a disease 
 occurs in various members of a family without any inherit- 
 ance being traceable {e.g., so-called "hereditary ataxy" or 
 "Friedreich's disease")- Gout, disease of the liver, con- 
 tracted kidney, renal calculus or gravel, and angina pectoris 
 form another allied group. These have also some affinity 
 with the disorders connected with arterial degenerations, and 
 so may lead to aneurismal disease or to apoplectic attacks. 
 Certain forms of glycosuria, particularly in those who are 
 somewhat stout and beyond middle life, tend to occur in 
 patients of this class. Syphilis, which has, of course, marked 
 hereditary characters, assumes such a multitude of forms as to 
 preclude enumeration, but the tendency is for such syphilitic 
 diseases to die out in the course of time from early death or 
 sterility. Abortions, stillbirths, early deaths in infancy asso- 
 ciated with cutaneous eruptions on the buttocks, snuffles, and 
 wasting, are important in many family histories ; nervous 
 deafness, opacities of the cornea, notched teeth, epilepsy and 
 imbecility are occasional manifestations of the same disorder 
 in those children in the family who survive ; in adult subjects 
 who have acquired syphilis we must either put the question of 
 infection directly or investigate their symptoms and condition 
 when the question of syphilis is important in the family his- 
 tory we are studying. The group of scrofulous and tuber- 
 cular diseases has been already referred to. Diabetes has 
 often a distinct hereditary origin, and at times it is also mixed 
 up with a family history of tubercular tendencies. 
 
 Although family history is chiefly useful in determining 
 the tendency to certain chronic and constitutional affections, 
 or to premature decay of the individual, or of certain of his 
 organs, we find, likewise, a tendency in some families to acute 
 diseases — enteric fever, for example, and even to certain de- 
 grees of severity or to special complications — as intestinal 
 hemorrhage — and this may guide us at times, especially in 
 prognosis. In diphtheria also we have an illustration of an 
 acute infectious disease affecting special families in various 
 
70 
 
 EXAMINATION OF MEDICAL CASES. 
 
 branches and at various times and places to a striking extent. 
 Such cases are very instructive, in view of the recent doctrine 
 of phthisis being due to a specific organism — so far resem- 
 bling the organisms of the infectious fevers — and in view of 
 the admittedly hereditary character of this complaint. 
 
 It is sometimes quite evident from which of the parents a 
 patient has acquired his morbid tendency, and in some insur- 
 ance reports information is sought as to whether the proposer 
 resembles the male or the female side of the house in his gen- 
 eral conformation, so as to judge of his j^redisposition to 
 diseases which may exist on the one side and not on the other. 
 No doubt there is some guidance to be obtained here when 
 the whole facts are well known to the physician himself, but 
 otherwise he cannot- place much reliance on mere statements. 
 Sometimes two perfectly distinct forms of disease are found in 
 the same family, the father contributing one tendency and the 
 mother the other. 
 
 TRANSMISSION OF TWO FORMS OF DISEASE. 
 
 Family history of a youns^ l^dy, a3t. twenty-five years, affected with 
 a second attack of acute rheumatism, complicated with pericarditis 
 and aortic valvular disease ; distortion of the joints supervened. 
 
 Father. 
 
 Has had rheumatic fever; 
 his brother has "rheu- 
 matic ffOUt." 
 
 Mother. 
 
 Healthy ; but two of her sis- 
 ters and one of her brothers 
 died of consumption. 
 
 Family. 
 
 Eldest brother ; two attacks of rheumatic fever, with pericarditis 
 both times; died of affection of heart and lungs. Another 
 brother; slight rheumatism in knees, but no heart affection. 
 Eldest sister; pains in knees and shoulders, but no serious ill- 
 ness. 
 
 Other five brothers and sisters ; none of them rheumatic, but some of 
 them affected or threatened, more or less distinctly, with con- 
 sumption. 
 
 The healthy condition of one parent may indeed tend to 
 neutralize the morl)id proclivities acquired from the other; 
 and, on the other hand, similar morbid tendencies in the 
 families of both parents seem to tell with special severity on 
 their offspring. It is probably in this way that the injurious 
 influences of consanguineous marriages come out. In remote 
 islands with but few families, for example, repeated inter- 
 marriages seem to favor imbecility in the children ; and deaf- 
 
FAMILY HISTORY. 71 
 
 mutism has at times, likewise, appeared to be due to similar 
 causes. In other cases, however, two or more deaf-mutes may 
 be born into a family without any such cause or without any 
 hereditary history being known. 
 
 The question as to which parent is the more potent in 
 transmitting morbid tendencies cannot as yet be answered 
 satisfactorily. In the case of consumption it would seem, 
 from insurance statistics, that a consumptive mother is more 
 likely to transmit this disease than a consumptive father ; and 
 when we have the history of a consumptive mother and of 
 one brother or sister being affected, this fact is usually re- 
 garded as adding greatly to tlie risk. Probably in other 
 diseases the transmission by the mother is more potent also, 
 and in the case of the "hemorrhagic diathesis" the disease is 
 almost invariably transmitted through the female line : this is 
 all the more curious inasmuch as the mothers, and indeed all 
 their sex, almost invariably escape. This disease affords an 
 illustration of hereditary transmission without either of the 
 parents being affected; but one or other of the maternal 
 uncles may be "bleeders," as they are called — even, however, 
 when they marry and have children their children are not 
 affected. 
 
 TRANSMISSION TO MALES IN FEMALE LINE. 
 
 Family history, showing the occurrence of the hemorrhagic diathe- 
 sis in three successive generations. Transmission in the female line 
 of descent, but only males affected. 
 
 1st G-ENERATlOlSr. 
 
 A maternal granduncle (the brother of maternal grandmother) was a 
 bleeder ; he died set. 30 ; was married, but had no family. 
 
 2d Generation. • 
 
 A. maternal uncle was a bleeder ; he died aet. 26; he had one male 
 
 child, but he was not affected. 
 
 This man had numerous cousins, and two out of his three maternal 
 aunts had bleeders in their families — three in all. No bleeders in the 
 families of his five maternal uncles. 
 
 3d Generation. 
 
 The patient, a boy, a3t. 8, and his brother, who died fet. 5, were both 
 
 bleeders. Other two brothers and three sisters not affected. 
 
 Two male cousins bleeders, the children of a maternal aunt; one 
 
 female child in the same family not affected. In another large family 
 
 of cousins, males and females, by another maternal aunt, none affected. 
 
72 EXAMIKATION OF MEDICAL CASES. 
 
 More misleading still are the facts of atavism ; in this case 
 the whole of the generation of which the parents are members 
 escape, but inquiry into the history of the grandparents or the 
 granduncles or aunts of the patient may reveal a strong family 
 predisposition to special diseases. 
 
 ATAVISM — TRANSMISSION OF PHTHISICAL DISEASE. 
 
 Family history, showing a marked tendency to consumption, derived 
 apparently from the grandparents, without involving the intermediate 
 generation. 
 
 1st Generation. 
 
 Paternal grandfather, died of " decline in bowels," set. 62. 
 Paternal granduncle, died of consumption, aet. 30. 
 Paternal granduncle, died of consumption, set. 50. 
 Paternal grandmother, died of " liver complaint and decline." 
 
 2d Generation. 
 
 Father, always healthy, killed by accident, set. 62. 
 Paternal uncle, healthy, killed by accident, set. 18. 
 Paternal uncle, living and well, set. 66. 
 Paternal aunt, died, three weeks ill, "sore leg," set. 50. 
 Mother, no consumption traceable in her family, living and very 
 healthy, set. 72. 
 
 3d Generation. 
 
 Patient and four of his sisters all died of pulmonary phthisis, ages 
 from 23 to 45 years. A brother died of a " rack or strain," followed 
 by purging and vomiting, set. 23. 
 
 Six other brothers and sisters living and well, ages from 27 to 52 years. 
 Of these several have families ; one cousin died of consumption, 
 set. 20, in one family ; in another, two cousins died of " water in the 
 head," and one died of "overgrowth with swelling of the belly." 
 
 A point in the family history to which special importance 
 is attached by som^ authorities concerns the time of appear- 
 ance of the disease in the j^arents as compared with the time 
 of the birth of the child. In the case of syphilis it is obvious 
 that if the child were born before the parent contracted the 
 disease there could be no transmission. It seems that even in 
 the case of gout, and some other hereditary constitutional 
 diseases, the children born after the pronounced appearance 
 of the disease in the parent are more prone to the affection 
 than those born before that period. 
 
 Even after allowing for all these sources of difficulty in 
 interi)reting the family history, we must remember that the 
 members of the family who might have been affected, if they 
 had lived, may have been cut off by accident, or ])y what we 
 
FAMILY HISTOKY. 73 
 
 might call accidental diseases, such as fevers and some other 
 acute diseases; or we may encounter the difficulty of the dis- 
 eases in question usually appearing at ages beyond those avail- 
 able in the study of our patient's history. A large family, 
 with all the living members grown uj) to middle or advanced 
 life, should show pretty clearly the tendency of their family 
 constitution, but even then cancer, for example, is so notoriously 
 disposed to appear at the later periods of life that it may still 
 be absent from the family history at the time we are in search of 
 it. A child may die of cancer supposed to be quite unknown in 
 the family till j^erhaps his parent dies of the same disease many 
 years later. This defect might be supposed likely to be supple- 
 mented by the history of the uncles and aunts, or of the grand- 
 parents or the granduncles and aunts of our patient ; but there 
 is first of all the enormous difficulty of getting information so 
 extensive and so precise, and even then, unless the numbers be 
 large in such families, we may readily miss the evidence of a 
 family taint. In tubercular disease, likewise, especially in 
 children, the family tendency may not have had time to 
 manifest itself in the other members at the date of our inquiry. 
 The number and ages of those living come in here to enable 
 us to guess, as it were, at the j)robabilities of such a tendency 
 having had time and opportunity to manifest itself, if really 
 present. A deceptive apj)earance of soundness in the family 
 history may sometimes arise from there being no account of 
 deaths or illnesses connected with the suspected disease, when 
 really from smallness in the number of the family, or from 
 deaths due to fevers and other accidental diseases, no oppor- 
 tunity was allowed for the morbid tendency to show itself. 
 Such a family history, although not "bad," is not "good;" it 
 is defective in its evidence. In a larger family, again, a stray 
 death may have occurred from phthisis or rheumatism, due, 
 perhaps to exceptional exposure or unfortunate modes of life, 
 although no great tendency to such disease existed in the 
 family. We must, therefore, consider all these points in trying 
 to form a sound judgment. 
 
CHAPTER III. 
 
 TEMPERATUKE— PULSE— GENEEAL SIGNS OF 
 PYKEXIA. 
 
 Temperature. 
 
 An increased heat of the body is one of the oldest and most 
 widely recognized signs of fever. It may be estimated roughly 
 by applying the hand, or j^erhaps the back of the hand, to the 
 surface of the patient's body, selecting some of the sheltered 
 parts, such as the axilla, the groin, and especially the abdo- 
 men. It must be borne in mind that a certain coldness of the 
 extremities and of the exposed parts often coexists with a great 
 elevation of the temperature in the interior of the body, and 
 even in the axilla or groin. The variable temperature of the 
 observer's hand, moreover, must be remembered as a fruitful 
 source of fallacy, so that when we aim at accuracy in deter- 
 mining the degree of pyrexia, as febrile heat is often called, or 
 at certainty in pronouncing its absence, we must have recourse 
 to the thermometer. 
 
 Clinical thermometers should be sensitive, and should have 
 the bulb of such a size and shajDe as to be adapted for introduc- 
 tion into various parts of the body. The graduation should 
 be on the stem itself. Accuracy in the instrument is, of course, 
 desirable in all cases, and is especially important if any startling 
 deviation from the usual range of temperature happens to be 
 discovered. Certificates of accuracy, or of the amount of error 
 in the scale, may be obtained by sending the instruments to be 
 tested at Kew Observatory. It is important to have the 
 observations made, if possible, with the same instrument, in 
 the case of a given patient ; in this way, although there may 
 be some slight error in the instrument, the changes in the 
 patient's temperature, noted from time to time, are really but 
 little affected by such errors ; the variatiotis in a patient's tem- 
 perature, from time to time, are usually more im})ortant in the 
 case than the absolute height of the reading within half a 
 degree on either side. If the self-registering maximum ther- 
 mometer be used, care must be taken to shake down the index 
 
TEMPERATUEE. 75 
 
 below the probable temperature of the patient, before it is 
 applied ; if an instrument without any registering index be used, 
 care must be taken to read it in situ, as, of course, the mercury 
 falls whenever the instrument is removed from the body. In 
 applying the thermometer to the axilla, the following points 
 must be attended to : if there be much sweat, the skin should 
 first be wiped dry ; the bulb should be introduced deeply into 
 the axilla, under its anterior or pectoral fold, with the point 
 directed slightly upward, and the arm must be kept close 
 against the thorax ; it is sometimes a good plan to make the 
 patient keep the arm in position by means of his other hand, 
 or by lying slightly on the arm during the observation ; strong 
 muscular effort on the part of the patient in holding his arm 
 by the side is apt to cause a hollow in the axilla, and so to 
 remove the soft parts from the bulb of the thermometer. We 
 may, indeed, require some one to hold the instrument in posi- 
 tion if the patient has not strength or intelligence enough to 
 keep the arm closely applied ; care must be taken that no 
 folds of the underclothing interpose between the bulb and the 
 skin; it should also be seen that the instrument does not slip 
 down or project behind and beyond the axilla. The thermometer 
 must be left in position till the mercury maintains the same level 
 for two or three minutes. The time required for an accurate 
 measurement of the temperature in the axilla depends on this 
 cavity requiring to be kept closed long enough for it to reach 
 its maximum heat, as this may have been reduced by exposure 
 to the air ; it is clear^ therefore, that a very different length of 
 time may be required in different observations ; the only accu- 
 rate method is to see that the maximum is really attained, as 
 judged by the stationary position of the mercury ; a stationary 
 position for two or three minutes is found to be sufficiently 
 accurate for ordinary clinical purposes. The routine method 
 of keeping a thermometer in the axilla for five minutes only, 
 and then entering the reading, cannot be too strongly con- 
 demned as often extremely fallacious ; and yet this method of 
 observation is sometimes resorted to in order to prove the 
 efficacy of antipyretic treatment by iced compresses applied to 
 the chest ! When self-registering instruments are to be used 
 by unskilled persons, who cannot be trusted to read the index, 
 fifteen minutes may be named as a proper time for the applica- 
 tion of the instrument. If the arm be kept closely applied to 
 the side for fifteen or twenty minutes, immediately before the 
 thermometer is introduced into the axilla, the necessary time 
 for the actual observation may be shortened. Heating the 
 
76 TEMPEEATURE. 
 
 bulb of the instrument beforehand, to a temperature near the 
 blood-heat, is desirable if the weather be cold or the bulb be 
 large, but it does not materially lessen the time required for 
 the observation, as this depends on the state of the axilla much 
 more than on the coldness of the instrument. 
 
 If the mouth be used for testing the temperature, the bulb 
 should be placed under the tongue and the lij^s kept shut, the 
 breathing being performed through the nostrils. The mouth 
 resembles the axilla in being sometimes open to the air and 
 sometimes shut, and similar remarks apply to it as to the axilla. 
 The mouth may often be used with advantage for testing 
 rapidly the temperature, in an approximate manner, in dis- 
 pensary or private practice, as the clothes do not require to be 
 removed for the purpose. Care must be taken that nothing 
 very cold (as ice) has recently been in the mouth when the 
 temperature is being tried in this place; very hot liquids 
 recently taken are also apt to affect the readings here. 
 
 The rectum gives results more accurately and rapidly than 
 either of the preceding, and it is sometimes preferable, especi- 
 ally in the case of children, where axillary measurements are 
 often irksome, tedious, and unsatisfactory. The bulb is oiled, 
 and introduced two inches within the bowel, and held steadily 
 till the maximum is reached ; this always occurs in two, three, 
 or four minutes, because w^e have not to contend here against 
 the cooling influence of the air, as in the case of the axilla and 
 mouth. If very young, the child may be placed Avith advant- 
 age on his left side, in the nurse's lap, with his face to her 
 right breast. The objections to the rectum (apart from the 
 annoyance and exposure involved) are the possible compres- 
 sion of the bulb by the muscles of the bowel Avhich may force 
 the mercury mechanically up the stem of the instrument ; the 
 chance of the bulb being inserted into hard feces and so pre- 
 vented from being in contact with the bowel ; and the possi- 
 bility of its being affected by the descent of fluid feces from a 
 higher and warmer level : in any of these cases the tempera- 
 ture of the rectum itself, which is what we desire, may really 
 be missed. The temperature of the rectum as compared with 
 the axilla may be quoted roughly at three-quarters of a degree 
 Fahr., or nearly one-half degree Centigrade higher than that 
 of the axilla. 
 
 The var/iiui yields accurate and rapid results with the ther- 
 mometer, but is only seldom to be recommended for clinical 
 observations ; the temperature in cases of labor, uterine dis- 
 eases, etc., may sometimes be thus tested with advantage. 
 
DAILY VARIATIONS. 77 
 
 The urme sometimes affords rapid and useful information, 
 if it be passed directly on to the bulb of the instrument; or it 
 may be passed into a vessel slightly heated, and the tempera- 
 tare immediately taken with a sensitive registering thermom- 
 eter. 
 
 The time of the day at which the temperature is taken should 
 be noted, or at least clearly understood. The human temper- 
 ature has a daily range, during health, of nearly two or three 
 degrees of Fahrenheit's scale (say a degree or a degree and a 
 half Centigrade), taking the extremes in both directions reached 
 during the 24 hours, and putting the mean at 98.6° F. or 37° 
 C. : the range is more amj^le in cliildren than in older persons ; 
 the temperature rises in the early morning hours, attains a 
 maximum in the afternoon, and falls so as to be at its minimum 
 an hour or two after midnight. In fevers, likewise, there is a 
 daily range, although the temperature is persistently above 
 the normal : the minimum occurs usually some time about 4 
 A.M. ; the daily ascent varies somewhat, beginning usually 
 earlier in the day in severe than in mild cases, but as a rule it 
 is distinctly manifest about mid-day or toward the afternoon : 
 the maximum may be expected most frequently about 8 p.m., 
 or sometimes an hour or two earlier. In hectic fever, and 
 toward the convalescence in enteric fever, the morning tem- 
 perature is often nearly normal, although the afternoon and 
 evening readings may be very high. (See Figs. 3, 4, and 5.) 
 Sometimes, hoAvever, the type is " inverted," the temperature 
 being low at the hours at which in ordinary cases it is high, 
 so that it is high in the morning and low in the evening. The 
 importance of having the observations made at the same hours, 
 so as to have them fairly comparable with each other, becomes 
 thus very apparent, as otherwise we might mistake the diurnal 
 variation for a real aggravation or diminution of the fever. 
 This likewise shows the danger of relying on one observation 
 (especially in the morning or forenoon) as proving the absence 
 of pyrexia. Frequently repeated observations in the course 
 of the day reveal some curious and important facts in the 
 history of the temperature. This sometimes dips down to the 
 normal, or even below the normal, for a few hours in the midst 
 of a raging fever, or shortly before the crises is reached : or 
 equally short exacerbations may be detected. In hospital 
 practice only three, or four, or six observations in the day are 
 usually taken, even in febrile cases, so as to avoid fatiguing or 
 annoying the patients ; and in private practice, unless there 
 are skilled nurses or intelligent friends to be entrusted with 
 
 7* 
 
78 
 
 TEMPERATURE. 
 
 the observations, only one or two records can usually be ob- 
 tained : the best hours in such cases are about 9 or 10 a.m., 
 and 7 or 8 p. m. If frequent observations are to be made, the 
 best hours are about 3, 6, and 9 a.m., 12 noon, 3, 6, 9, and 12 
 p. M. ; and special readings should also be made in connection 
 with rigors, convulsions, or other unusual occurrences and 
 also in testing the effect of remedies, or of any special anti- 
 pyretic treatment. 
 
 Normal and abnormal temperatures may be classified as 
 follows : 
 
 Fahr. 1 Very low or collapse tem- 
 / peratures. 
 Subnormal temperatures. 
 Normal temperature. 
 
 Slightly above normal, or 
 sub-febrile temperatures. 
 
 "(Moderately febrile temper- 
 j atures. 
 
 I Highly febrile temperatures. 
 
 Hyper-pyretic temperatures 
 
 Such a table enables us, on reading the thermometer, to 
 affirm the absence, the presence, or approximately the degree 
 of pyrexia in a patient at a given time ; but this really sup- 
 plies but little information. The temperature may be normal 
 and yet the patient may be dying, or may even be in the 
 midst of a dangerous fever, which will manifest itself in the 
 course of an hour or two as a burning heat. We often, how- 
 ever, detect by the thermometer the presence of pyrexia when 
 we have but little expectation of doing so, judging from the 
 patient's pulse, skin, or general aspect ; or when, as in a rigor, 
 or in cholera, and some other conditions, from the coldness of 
 the surface and extremities, an inexperienced person would 
 think a febrile heat impossible. Very high or very low tem- 
 peratures may also, as a rule, be regarded as evidencing, in 
 themselves, a dangerous condition. Hyper-pyretic tempera- 
 tures occur as serious complications in acute articular rheuma- 
 tism, chorea, enteric fever, and some other diseases, associated 
 usually with great cerebral disturbance. Very high tem- 
 peratures, lasting but a short time just before death, are not 
 uncommon in various diseases. (See Fig. 1.) Very low tem- 
 peratures, however, are equally or even more common just at 
 
 Below 
 
 / 35° Cent. 
 
 \36 " 
 
 = 
 
 95° ] 
 96.8 
 
 About 
 
 36J 
 
 i( 
 
 = 
 
 97.7 
 
 Normal 37 
 
 
 = 
 
 98.6 
 
 About 
 
 f37^ 
 \ 38 
 (.38^ 
 
 
 = 
 
 99.5 
 100.4 
 101.3 
 
 About 
 
 r39 
 139^ 
 
 
 — 
 
 102.2 
 103.1 
 
 About 
 
 r4o 
 
 t40J 
 
 
 = 
 
 104 
 104.9 
 
 Above 
 
 41 
 
 
 = 
 
 105 8 
 
COLLAPSE TEMPERATUEES. 
 
 79 
 
 the end. (See Fig. 2.) Collapse temperatures, as judged by 
 the heat in the axilla, are sometimes due to a surface depres- 
 sion ; the axilla under such circumstances does not give such 
 a close approximation as usual to the temperature of the 
 
 Fig. 1 
 
 FEBRUARY 
 
 PLJERPEF^yaJL J_, L 
 Hi llT="iDAY!AFtER 
 
 (dufeF{Y?)^Rk^iipqLAS 
 
 Fig. 2. 
 
 MAY OUNEI C 
 
 29 30 31 I I 
 
 
 
 ^\ 
 
 - 
 
 1 
 
 I T EfJiP. t 
 I IN R ECtU ML o o" 
 
 Unusually high temperature just before death ; 
 great exacerbation with a rigor. 
 
 Very low temperature in 
 rectum just before death. 
 
 blood : in such conditions if we wish to know whether the 
 internal heat is really lowered we must apply the thermom- 
 eter to the rectum or vagina ; but the internal temperature 
 may also be much depressed in collapse. (See comparison of 
 terminal temperatures in Fig. 17.) The thermometer only 
 supplies information as to pyrexia at the given time ; its indi- 
 cations, therefore, must be interpreted with due caution, and 
 in view of other symptoms and of the known facts of disease. 
 The period'wity of the temperature is one of the most inter- 
 esting and important points to be considered. It has already 
 been pointed out in connection with the time of day for taking 
 observations that even in health, or after convalescence is 
 
80 
 
 TEMPEKATUKE. 
 
 established, constant oscillations are going on. An illustra- 
 tion of these small variations may be seen in the diagram 
 showing the relapses in enteric fever ; for a whole month the 
 temperature was normal, but slight variations, seldom exceed- 
 ing one degree F., habitually occurred. (Fig. 18, tempera- 
 ture during September.) 
 
 In febrile diseases also the rise of the temperature from 
 morning to night is usually well marked — the whole range 
 being, of course, maintained at a higher level. (See the 
 febrile stage in enteric fever, Fig. 18 ; relapsing fever, Fig. 9; 
 pneumonia. Fig. 14 ; and other diagrams.) 
 
 In hectic fever we have not unfrequently the morning and 
 even the forenoon temperatures nearly normal, while at night 
 
 Fig. 3. 
 
 9 10 II 12 13 14 15 16 17 18 19 20 21 ZZ 23] 
 
 io5°-H-H 
 
 ... -- jiiinimiHMiivHiHi 
 
 siiiiiiiiiiinnii 
 
 1 
 
 nniiAHiuifiiiiinwi^^^^^ 
 
 Diagram showing the daily range of temperature in a boy six years old affected with 
 phthisis and tuberculosis ; observations were made in the rectum six times in the 
 twenty-four hours, and the maximum and minimum temperatures have been recorded 
 on the diagram; the minimum always occurred in the morning, usually about 6 A. m., 
 and the maximum always in the afternoon, sometimes as earlj' as 2, usually about 4 
 or 6, and occasionally somewhat later. 
 
 The pulse varied from 136 to 148, and the respirations from 44 to 60. 
 
 a high degree of fever is reached. When the fever falls, but 
 does not completely intermit or disappear at some part of the 
 day, it is termed " remittent ; " this form of pyrexia is very 
 common in phthisis and tubercular diseases ; it is also often 
 found in some stages of prolonged suppuration. The remis- 
 sions of hectic fever are well shown in the diagram, the 
 highest of the temperatures noted in the evening and the 
 
HECTIC FEVER 
 
 81 
 
 lowest in the morning having been selected in drawing up 
 the chart on page 80. (See Fig. 3 ; compare also the daily 
 oscillations at the termination of enteric fever, as shown in 
 Fig. 15.) 
 
 When this diurnal variation in hectic fever is studied more 
 closely, the temperature is found to rise with considerable 
 regularity at certain parts of the day, usually about midday 
 or in the early hours of the afternoon. This rise is often 
 very sudden — an elevation of three or four degrees F. may 
 be attained within three or four hours, or even less, so that 
 the temperature may pass from the normal level to a high 
 fever height within that time. This daily periodicity, with a 
 
 Fig. 4. 
 
 Diurnal range of hectic fever in a phthisical child, 
 every two hours in rectum. 
 
 Temperatures 
 
 daily or quotidian paroxysm, is well shown in two diagrams 
 from cases of phthisis. In the one (Fig. 4) the temperatures 
 are those of a child taken every two hours in the rectum; in 
 the other the temperatures were those of an adult taken every 
 four hours in the axilla. (Fig. 5.) 
 
 In other forms of tubercular disease the type of hectic fever 
 may be departed from, and in acute miliary tuberculosis, in 
 particular, we not unfrequently have an approach to the type 
 of a more or less severe continued fever, as shown in the chart 
 from a case of this disease in a child. (Fig. 6.) 
 
 The daily paroxysm constitutes the peculiarity and supplies 
 
82 
 
 TEMPEKATURE 
 Fig. 5. 
 
 HECTC FflVEf 
 PHTHISIS. 
 
 ioo°444- 
 
 Diurnal range of the temperature in hectic fever. 
 
 Fig. 6. 
 
 Temperatures in a case of acute miliary tuberculosis in a boy, showing the type of a 
 continued fever. Tulse 130-160 ; respiration 40 to 60 and 70. 
 
 the name of that form of ague or intermittent fever termed 
 quotidian. The regularity of the paroxysms as to time, the 
 rapidity of the ascent and descent, and the completeness of 
 the intermission, are shown in the accompanying temperature 
 chart. (Fig. 7.) 
 
QUOTIDIAN AGUE. 
 
 83 
 
 The periodicity of intermittents is not, however, necessarily 
 of the daily type. One day may be omitted ; or, in other 
 words, the intermission may last a full day : in this way the 
 
 
 
 Fig. 7. 
 
 
 ^ 
 
 ■ 
 
 - 
 
 C. 1881. 13^" Y 
 
 ■'■ r- 1 
 
 uhI 
 
 15'" 
 
 i J 1 
 
 Y 16' 
 
 c. 
 
 ■:4l 
 
 .140 
 
 .39 
 
 106- 
 
 i ; 
 
 105- 
 
 : Q 
 
 1 
 
 fffHWWMP 
 Hlnnili 
 
 MMI 
 
 Htm 
 mni 
 iHim 
 
 illHI 
 
 wmii 
 
 IBflHI 
 
 ■mi 
 
 ■MU 
 
 wmm 
 wmm 
 nriiiiii 
 umm 
 mull 
 ■mm 
 
 HI^IIH 
 nHKH 
 
 103: 
 
 ,102: r 
 
 101: -H — 
 loo; - ^ 
 
 99- 
 
 9a — 
 
 i 
 
 Daily paroxysms in intermitteut fever : quotidian ague : temperature in axilla. 
 
 attack occurring on one day is followed by another, not on the 
 second, but on the third day ; hence the name " tertian " is 
 applied to this form of ague. (See Fig. 8.) 
 
 A further variation of the paroxysm in intermittents is when 
 the fever occurs not on the third but on the fourth day — there 
 being two days of an intermission — so that the name " quar- 
 tan " is applied. 
 
 This return of the fever, after it had apparently gone quite 
 away, sometimes assumes a different periodicity. We may 
 have a whole w^eek free from fever, and the patient may seem 
 so well that if the regularity of the disease were not so well 
 known, we could scarcely believe in the return of the whole 
 train of symptoms on the thirteenth or fourteenth day. This 
 peculiarity furnishes the distinctive name of " relapsing 
 fever." This remarkable disease, called also "famine 
 fever," has appeared in this country on several occasions in 
 the form of an epidemic. The sudden collapse or fall of the 
 temperature, the almost equally sudden rise at the relapse, 
 
84 
 
 TEMPERATURE. 
 
 and the week's intermission, are shown plainly in the diagram. 
 
 The periodicity of febrile diseases is shown in the duration 
 of the pyrexial period as well as in that of the apyretic in- 
 
 FiG. 8. 
 
 l04Trj 
 
 13- 
 
 ' ' 1 
 
 14-"- 
 
 ! 1 1 1 1 1 1 n 
 
 15 _• 1 16 _- 
 
 
 i ' 
 
 il' 
 
 Dniyii 
 
 ■Mi 1 lUl i- 
 
 "^ 
 
 IIWIIIII 
 
 Hllllllll 
 
 IHHHIi 
 
 ! 
 
 4— i- 
 
 i 1 1 ! 
 
 i liii ■ 
 
 Mi- 
 
 1 J.- 
 
 1 ■ 
 
 ■■■■■■mi 
 
 ■■■■■■■■■H 
 
 ■■■■■■■HI ■HI 
 
 HI 
 
 ■■■■■■■■ 1 
 
 ■^■■■■■■S 
 
 ■■■■■■■HI! 
 
 
 1 
 
 ij 
 
 il Alii ri.i 
 
 ii 
 
 i 
 
 
 Hunn 
 
 iMiii^'^nHi 
 
 lUHiBiiin 
 
 i : 
 
 1 
 
 1 
 
 i : ; 
 
 ! 
 
 ' 1 
 
 IIHUIIUIIIIIIIIIIIIIIIIIIIlll 
 
 H 
 
 1 i ■ 'I 
 
 1 i i 
 
 +4^4r-'^ 
 
 • ■ \ \ 
 
 i ' 
 
 f ■■ 
 
 I'tv 
 
 ■■\i\ i\i 
 
 ; -i 
 
 
 IfiBBBHIH^ 
 
 ■■■■—r^Miw 
 
 ■H 
 
 ■■■■■■■■1 
 
 I'jai^nBnn 
 
 am^Kam'JBn 
 
 11 
 
 
 II i ^ 
 
 ^^LL^ 
 
 1 i/ ! 1 ' 
 1-/ i 
 
 1 
 
 1. 
 
 iJEtoytnr 
 
 hp i $lfei I pt rtt^PL^tir^iRL. DURiNt ATTACKS 
 
 Intermittent fever : tertian ague : temperature in axilla. 
 
 terval. The paroxysm in a simple quotidian intermittent can 
 only, of course, last a part of a day : the same may be said of 
 simple forms of the tertian and other varieties also ; but in 
 bad forms the intermissions become incomplete, and the 
 pyrexia assumes the remitting type, or even merges into a 
 continued fever. 
 
 In relapsing fever the duration of the pyrexia is just as 
 definite as that of the interval, althougli in both a little varia- 
 tion occurs. The first attack usually lasts five to seven days, 
 and the relapse three or four — the interval between them 
 varying also from about six to eight days. 
 
 In smallpox the primary fever undergoes on the third day 
 a material reduction, or it may be, in the modified variety, a 
 complete subsidence, coincidently with the appearance of the 
 eruption. (See Fig. 10.) In lobar pneumonia the pyrexia 
 terminates with as much abruptness as in the infectious fevers ; 
 the date of the crisis, however, may vary from the third to 
 the tenth or twelfth day. Very definite as to duration is the 
 
ENTEKIC FEVEK. 
 Fig. 9. 
 
 85 
 
 Temperature in relapsing fever (Wunderlicli). 
 
 pyrexia of typhus fever, which may be stated as about a fort- 
 night, with a margin of variation of a day or two on either 
 side. In the case of enteric fever the period of pyrexia is 
 much more variable, some cases terminating favorably in ten 
 
 Fig. 10. 
 
 F C I I I 2 I 3 
 
 105-a 41 
 
 ■■■■III 
 ■■■■■II 
 
 ■■■■■■■■i^ianarj 
 
 Temperature in modified smallpox or varioloid (Wunderlich). The rapid subsidence 
 of the temperature occurs on the third day, with the appearance of the eriiption. 
 
86 TEMPERATURE. 
 
 or twelve days, most of them attaining the usual period of 
 about three weeks, and some even going on, Avithout intermis- 
 sion, for five or six weeks. (Compare duration of attacks in 
 Fig. 18.) Even this fever, however, cannot go on indefinitely ; 
 a fever course in this disease prolonged beyond five or six 
 weeks can usually be found to depend on complications, or 
 perhaps on relapses. Tliese are, no doubt, sometimes difiicult 
 to detect or. to prove in particular cases, although the general 
 statement given above may be accepted. The subject of re- 
 crudescences and relapses, however, falls to be considered in 
 another section of this chapter. 
 
 The ab.sence of any recognizable 'periodicity hi the pyrexia con- 
 stitutes a feature of pysemic fever which has some value in 
 diagnosis. In this disease we may have paroxysms occurring 
 daily, or sometimes twice or thrice in a day. These frequently 
 coincide with the occurrence of severe rigors. No definite 
 relationship to days or hours can be made out in such cases, 
 the temperature running up and down in the most erratic 
 manner, and we are sometimes afforded, on this account, 
 grounds for suspecting the presence of this formidable dis- 
 ease. 
 
 Another variety of the absence of periodicity in the tem- 
 perature (at least as to duration) is found in those cases where 
 the fever course appears to be going on indefinitely for many 
 weeks or months. In whatever way such cases may have 
 begun, we must, under such circumstances, carefully consider 
 the probability of having to do with some form of tubercular 
 disease, or, it may be, with chronic suppuration. 
 
 The manner of rise in the temperature and the duration of 
 the jyyrexia, with regard to the date of the illness, are often 
 most valuable for diagnosis. Some diseases are remarkable 
 for the rapidity with which the temperature rises. Most of 
 the short fevers or febriculse, as they are called, begin sud- 
 denly, and rapidly attain their maximum. Amongst these 
 are the surgical febriculse (immediately after operations), and 
 the feverish attacks, associated with obscure and often tran- 
 sient disturbances of the general health, due to disorders of 
 the digestive organs, especially in childhood. The following 
 likewise usually show a rapid development of pyrexia : Suppu- 
 rations, and most of the diseases ushered in with severe rigors, 
 ague (Figs. 7 and 8), tonsillitis, acute nephritis, scarlatina, 
 smallpox (Fig. 10), pneumonia (Fig. 13), pleurisy, peritonitis, 
 meningitis of the convexity, relapsing fever (Fig. 9), erysipelas, 
 pyiemia, parotitis. All of these may have very high tempera- 
 
ENTEEIC FEVER. 87 
 
 ture on the first day of the illness. Occasionally in malignant 
 cases of smallpox and scarlet fever the disease proves fatal so 
 early that the system is overwhelmed with the poison and 
 never shows any febrile heat. Measles sometimes almost 
 reaches its maximum temperature on the first day of the fever, 
 although a marked fall usually intervenes between this and 
 the maximum temperature reached on the fourth or fifth day 
 with the full development of the rash (Fig. 11). A great and 
 
 Fig. 11. 
 
 Temperature iu measles (Wunderlich). Fall of temjjerature after the first clay's fever. 
 Great rise on the fourth day, with the appearance of rash. Maximiun ou fifth day, with 
 full development of the rash. 
 
 sudden elevation of the temperature is so common in the dis- 
 eases named above that they should always be thought of in 
 doubtful cases. 
 
 Other diseases are rather characterized by a more gradual 
 and progressive elevation of the temperature ; this is especially 
 observed in enteric fever (Fig. 12), although exceptional cases 
 of this disease occur in which the pyrexia attains its maximum 
 at what seems to be the very beginning of the illness. But 
 in enteric fever, as a rule, the manner of rise is such that 
 during the first three or four days every day marks an ad- 
 vance on the previous one, the morning temperature falling 
 from the elevation of the previous night, but being in excess 
 of that of the previous morning. In typhus fever the ad- 
 vance of the temperature is somewhat more sudden than in 
 enteric, but iu it, likewise, several days usually elapse before 
 the maximum, or any very high point is reached. In articular 
 rheumatism, affecting several joints, in catarrhal pneumonia, 
 
88 
 
 TEMPEKATURE. 
 
 in acute tuberculosis, and phthisical affections, the ascent of 
 the temperature is usually spread over several days. 
 
 Fig. 12. 
 
 Gi'adual risu of tempeiatuio at the beginning of enteric fever. 
 
 The duration of the pyrexia often assists the diagnosis. The 
 complete and continued subsidence of the temperature, within 
 a week, may serve to exclude typhus and enteric fevers ; its 
 prolongation for twelve or fourteen days, without any febrile 
 rash or any evidence of local inflammatory mischief, may 
 sometimes guide us to the diagnosis of enteric fever (see Fig. 
 18 for first fifteen days); or its persistence may, in a chest 
 complaint, lead us to the diagnosis of phthisis (see Fig. 3), or 
 empyema. The duration of the pyrexia is also controlled by 
 the periodicity discussed in a previous section. 
 
 The decline of the tem2')erature, both as regards its date and 
 maimer, is of the utmost importance in prognosis and some- 
 times in diagnosis. The favorable termination of a febrile 
 disease, by a rapid fall of the temperature to the normal or 
 subnormal level, constitutes a crisis. This fall may amount 
 to three or four degrees or more in twelve to thirty-six hours. 
 This method of termination is common in pneumonia (lobar), 
 relapsing fever, typhus, smallpox, tonsillitis, facial erysipelas, 
 and febricuhe of various kinds. Its suddenness is represented 
 in the diagrams of ague (Figs. 7 and 8); of pneumonia (Figs. 
 13 and 19); and of relapsing fever (Fig. 9). In smallpox a 
 critical fall of the temperature occurs with the appearance of 
 the rash on the third day (see Fig. 10), although in severe 
 cases it may rise again. It occurs, however, in a modified and 
 less abrupt manner in measles and sometimes in enteric fever. 
 (See Figs. 11 and IG.) The suddenness of the crisis varies 
 
DECLINE OF THE TEMPERATURE, 
 
 89 
 
 much in different diseases and even in different cases ; in many- 
 cases of typhus a gradual diminution, extending over three or 
 four days, is sometimes so distinct as to make the crisis in this 
 disease much less pronounced than is usually taught, and to 
 assimilate it rather to a lysis ; frequently, however, the critical 
 fall of the temperature is very marked. 
 
 Lysis is the term applied to a more gradual diminution of 
 the fever, spread over several days ; this may usually be ob- 
 served in scarlatina and broncho-pneumonia, occasionally in 
 pleurisy and pericarditis, and also in acute rheumatism. The 
 
 Fig. 13. 
 
 Fig. 14. 
 
 Crisis. 
 Temperature in lobar pneumonia (Wunderlich). 
 Sudden crisis on eighth day ; pseudo-crisis on 
 fourth day. 
 
 Lysis. 
 Temperature in broncho-pneu- 
 monia (Wunderlicli). Gradual fall 
 extending over four days. 
 
 defervescence in the two forms of pneumonia is usually strongly 
 contrasted ; in lobar or croupous pneumonia we have a sudden 
 crisis ; in catarrhal or broncho-pneumonia we have usually a 
 lysis. (See Figs. 13 and 14.) Sometimes the lysis assumes a 
 remitting character, the morning temperatures falling gradually 
 or suddenly, and the evening temperatures preserving for some 
 days nearly their former elevation. This is not uncommon in 
 enteric fever. (See Fig. 15 ; compare, also, the gradual de- 
 scent of the temperature in the three attacks shown in the 
 diagram of enteric fever. Fig. 18.) 
 
 Certain fallacies beset the estimation of the value of a fall of 
 temperature. It is very often found that a high, febrile tem- 
 perature undergoes a great diminution on the day after admis- 
 
 8^ 
 
90 
 
 TEMPEEATUKE. 
 
 sion to the hospital ; this seems often to be really due to an 
 unusual elevation on the day of admission, arising from the 
 disturbance of moving the patient, etc., so that little weight 
 is attached to the temperatures of the first day's residence in 
 
 Fig. 15. 
 
 Eemittiug lysis in euteric fever. 
 
 hospital. Occasionally a pseudo-crisis, as it is called, occurs a 
 day or two before the real crisis, the temperature, after being 
 low for a few hours, mounting up again to its former height ; 
 this pseudo-crisis affords no guarantee of a subsequent genuine 
 crisis. (See Fig. 13.) Collapse temperatures may stimulate a 
 crisis, although really indicative of serious complications, as 
 in the intestinal hemorrhage of enteric fever, where the cause 
 of the fall may not always at first be quite apparent, (See 
 Fig. 16.) The fatal termination of some cases of febrile dis- 
 ease is often associated with a marked fall in the temperature, 
 and occasionally this occurs under such circumstances as to 
 simulate an improvement. (See Fig. 17 ; compare also Figs. 
 2 and 6.) Collapse temperatures may occasionally be detected 
 for a few hours in the midst of a raging fever, or just before 
 the terminal exacerbation of a febrile disease, whether it be 
 favorable or fatal. Sometimes the decline of temperature in 
 a tubercular subject is connected with the supervention of 
 cerebral complications. (See Fig. 20.) 
 
 Hecrudeseenees ; relapses; complications. A reascent of the 
 temperature, after a more or less complete subsidence, may be 
 
RELAPSES. 
 Fig. 16. 
 
 91 
 
 ; DA 
 
 i 
 
 Y OF ILLNESS 
 . 9 10 ri 12 13 
 
 14 
 cent! 
 
 
 
 
 
 
 
 : i i 
 
 iT TT 
 
 1 
 
 — p - 
 
 1 
 1 
 
 
 ' 
 
 iJ 
 
 i .; 
 
 
 
 
 Al 
 
 
 HH 
 
 in 
 
 1 
 
 
 
 n'lii 
 
 103° J 
 
 :.- '1 
 
 
 -^ 
 
 V 
 
 i\ 
 
 •■> fl 
 
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 Collapse of the temperature iu enteric fever, due to iutestiual hemorrhage on the 
 eleventh day — an accident which usually occurs later in the illness. The crisis in this 
 case was unusually sudden. 
 
 Fig. 17. 
 
 Collapse of the temperature simulating an improvement. The relatively excessive 
 depression of the axillary, as compared with the vaginal, temperatures was noted during 
 the collapse, both sets being taken with great care. A diminution of the difference 
 occurred with the rallying of the temperature. 
 
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KELAPSES IN ENTERIC FEVER. 
 
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94 TEMPEKATUKE. 
 
 due, as already explained, to the peculiar periodicity of the 
 disease. In other cases, however, we find it to be due to a 
 " recrudescence " of the fever. By this term is meant a reascent 
 of the temperature after a defervescence which from its extent 
 or its duration cannot be i*egarded as complete. Such exacer- 
 bations often depend on the extension of the mischief; for 
 example, from new portions of the lung being involved in 
 pneumonia, or to advancing intestinal ulcerations in enteric 
 fever. Such recrudescences are distinguished from " relapses :" 
 the latter only occur after a definite period of complete apy- 
 rexia. Theoretically the distinction made is that in recrudes- 
 dences we have merely the extension or aggravation of mis- 
 chief already existing : in relapses we have new mischief ab 
 initio. 
 
 Enteric fever is particularly liable to both, and in this dis- 
 ease we would expect to find new or recent deposits in the 
 intestinal glands at the date of a relapse. No doubt if these 
 fresh deposits in a relapse occur before the subsidence of the 
 first febrile attack, we may have an overlapping of the first 
 febrile period by the second : in this way a relapse might 
 appear to afifect the temperature after the manner of a recru- 
 descence ; and in such a case nothing but a careful post- 
 mortem examination, if the illness proved fatal, could settle 
 the distinction. True relapses in enteric fever occur after an 
 interval of a few days perfectly free from pyrexia, and when 
 the patient appears in other respects to be recovering ; usually 
 this interval is about a week or less, but ten or twelve days 
 are not uncommon. A diagram is here given showing a very 
 prolonged period of intermission — a full month — between the 
 first and the second attack. This length of interval is very 
 exceptional, but the evidence of its reality is complete; if the 
 temperature had not been taken so carefully during the pro- 
 longed interval it might have been plausibly contended that a 
 relapse had occurred during this month of such a slight nature 
 as to have escaped recognition, and this is a thing which 
 should be remembered as quite likely to occur. Between the 
 first and the second relapse, in this same case, the apyretic 
 period was of the usual duration of eight or ten days. (See 
 Fig. 18.) The rise of the temperature at the beginning of a 
 relapse in enteric fever is much more sudden than in the same 
 stage of the first attack. (See Fig. 18 ; c()in[)are temperatures 
 at the beginning of August with those at the beginning of 
 October and November; compare also Fig. 12.) 
 
 The reascent of the temperature may be due to complications. 
 
SURFACE THERMOMETERS. 95 
 
 These may occur at any stage of an illness or after con- 
 valescence is established. In any case, whatever may be the 
 usual mode of onset of the disease under other circumstances, 
 the rise of temperature with the complication is usually abrupt. 
 Complications may also, by their presence, delay a crisis, as is 
 often seen in bronchitis complicating typhus, and in this way 
 prolong the illness ; or the complication may impress a remit- 
 ting character on the fever, as is seen in the hectic fever of 
 phthisis, sometimes developed in a case of pneumonia or 
 pleurisy in a tubercular subject. The temperature of con- 
 valescents, however, it must be remembered, is very unstable, 
 and there is often a serious-looking disturbance of the temper- 
 ature in them from very slight causes (indigestion, constipa- 
 tion, fatigue, excitement, etc.), which would not thus affect the 
 healthy. For this very reason, temperature observations in 
 this stage are highly important, as affording the best evidence 
 of continued safety or the first alarm of threatened danger. 
 
 From what has been said, it will be seen that the temper- 
 ature, although of the utmost importance in diagnosis and 
 prognosis, must not be regarded too exclusively, or aj^art from 
 the other facts of the case and the general state of the patient. 
 The natural course of the temperature in the various diseases, 
 as ascertained by experience, must be kept in mind ; a degree 
 of elevation or a special behavior of the temperature may 
 have a very serious significance in one disease and very little 
 in another. The comparison of the temperature with the pulse 
 often serves to correct our views of each, and although they 
 usually rise and fall together (see Fig. 19), certain deviations 
 occasionally or habitually occur in special diseases, or in 
 certain stages of such affections, which are of the greatest 
 significance ; (for example, at the beginning and the end of 
 enteric fever, and toward the end of tubercular meningitis ; 
 see Fig. 20). 
 
 Surface Thermometers. 
 
 In the precedino; sections the ordinary clinical thermometer is sup- 
 posed to be applied in such a way as to give us an approximation to 
 the heat of the blood. Surface thermometers are used to give an 
 estimate of local or surface temperatures. They are made with broad 
 or spiral bulbs so as to expose a large surface to the part tested, and 
 these bulbs are enclosed in small cavities, ingeniously made, so as to 
 lessen the loss of heat when applied. They are sometimes sold in 
 pairs, so that two parts, or two sides of the body, may be tested simul- 
 taneously. Hitherto their use has not been very extensive, nor have 
 the results so far obtained been very important. They enable us, 
 however, to record in figures diflferences in local temperature which 
 
96 PULSE. 
 
 may be appreciable in other ways, as in cases of obstructed arteries in 
 limbs, atrophic infantile paralysis, local inflammation or hyperaemia, 
 etc. The difficulty in using them depends on the length of time 
 required to heat up the air chamber containing the bulbs of mercury: 
 on the variation in the results obtained, within similar periods of time, 
 according as the instrument is pressed more or less firmly on the part 
 if the thermometer is tied : on the heat of the hands of the observer 
 complicating the result, if the instruments are held by him; and 
 apparently also on a prolonged application, carried to the extent of 
 obtaining a stationary condition of the mercury, ceasing to afford a 
 true surface temperature, and yielding rather an approximation to the 
 internal heat, from the part being so long covered over by the instru- 
 ment. It seems best to use a pair of instruments (carefully compared), 
 so as to have the applications simultaneous, if dift'erential observations 
 are required ; otherwise the loss of time and the altered conditions of 
 heat render the results obtained by the transference of the same instru- 
 ment from one part to another very uncertain. In applying them 
 they should be held in an exactly similar manner, and pressed with as 
 nearly as possible equal firmness. Moreover, the readings from minute 
 to minute during the rise of the mercury should be noted in each 
 instrument, as the difference in rapidity of the rise appears to indicate 
 the surface temperature in a more striking manner than the figures 
 ultimately attained. In checking the results by a second application, 
 the instruments may be changed so as to be applied to different sides. 
 
 The Pulse 
 
 affords such valuable indications for the determination of the 
 febrile state, and for estimating the general strength of the 
 patient, that the noting of it is a matter of routine in all 
 cases. Apart from fever, however, there are other important 
 points to be attended to in noting the pulse, and to prevent 
 repetition these also will be considered here. 
 
 T he frequency of the pulse is not difficult to estimate; the 
 pulsations in the artery, the radial by preference, are counted 
 for a quarter or for half a minute, with the aid of a watch 
 furnished with a seconds dial, and the number per minute is 
 thus calculated. For delicate inquiries, the pulse should be 
 counted for a whole minute, or even for two consecutive 
 minutes, the number being halved of course in stating the 
 result. Other points also must be attended to when accuracy 
 is desired. The normal rate of tlie pulse varies with age, and 
 also in different individuals (according to temperament) ; in 
 the adult it is usually stated as being about 72, but it is some- 
 times higher and often much lower : it is more rapid in child- 
 hood, and in infancy is often about 100, apart from disease. 
 In the same individual the pulse varies with position, both in 
 health and disease, the rate being higher when the patient is 
 
PULSE-EATE. 97 
 
 standing than sitting, and higher while sitting than lying 
 down : any movement or exertion tends to increase the rate, 
 and mental excitement is particularly apt in some people to 
 make it rise very high. Hence, in estimating the pulse or its 
 changes from day to day, in such a delicate inquiry, for ex- 
 am23le, as the estimation of an incipient defervescence, care 
 must be taken to have results really comparable, and not to 
 compare the rate of the pulse while the patient is sitting up 
 in bed with that obtained on a previous day while he was 
 lying still. The influence of meals is also very great, the 
 pulse rising considerably after a full meal, and especially after 
 the use of stimulants in the healthy state ; in febrile diseases, 
 however, the effect of stimulants is often to reduce the pulse- 
 rate when their influence is beneficial. Apparently the habitual 
 use of spirits for years tends to keep up a persistently high 
 pulse-rate natural to the individual, quite apart from any 
 febrile disease or any special excess. The time of day has a 
 certain influence in the normal state, even apart from food 
 and exercise ; the pulse-rate, like the temperature, is lower 
 during the midnight hours, and rises in the early morning, 
 but the exact time of these changes varies ; they are usually 
 later if occurring in febrile diseases than in the normal state. 
 Sleep has a tendency to reduce the pulse-rate. Considerable 
 tact is often required to secure a fair estimate of the pulse; 
 in some cases we obtain the best chance at the beginning of 
 our visit, counting the pulse before the patient is disturbed in 
 any way by speaking or moving ; or perhaps, especially in 
 children, during the quietness of sleep. With some patients, 
 again, the approach of a stranger sets up the pulse to such 
 a height that we must wait till it has subsided. The lowest 
 rate we can obtain is the most reliable index in judging the 
 degree of fever. A fit of coughing, or the exertion of moving 
 or sitting up for the purpose of auscultation, etc., often com- 
 pletely spoils the value of the pulse-rate as a gauge of pyrexia. 
 It is in such cases that temperature observations come in as a 
 valuable check (see " Temperature "), and these often assure us 
 that the rapidity of the pulse is due to excitement, general 
 weakness, or irritability of the heart, apart from fever. As a 
 rule, the pulse and temperature in febrile cases are elevated or 
 depressed, and rise and fall together (see Fig. 19) ; but strik- 
 ing diflerences occur in certain cases. The pulse is often but 
 
 little elevated in the beo-innino; of enteric fever, at a time when 
 
 ... 
 the temperature is very high ; while after the recovery has 
 
 begun, the pulse may be rapid from weakness, although the 
 
 9 
 
98 
 
 PULSE 
 
 fever temj^erature has completely fallen. And in some 
 patients, Avith febrile or inflammatory disease, the pulse is 
 
 Fig. 19. 
 
 Crisis in lobar pneumonia: tlie diagram shows the sudden improvement in 
 temperature, pulse, and respiiation ahiiost simultaneously. 
 
 often quite normal in rate, although the temperature is per- 
 sistently high. On the other hand, in incipient phthisis, we 
 
SLOWNESS OF THE PULSE, 
 
 99 
 
 may have a constant elevation of the pulse with but little 
 change in the temperature. In cerebral cases, also, the rela- 
 tionship of the pulse-rate to the temperature is subject to 
 
 Fig. 20. 
 
 JAN 1879 
 20 
 
 :temp. puuse 
 ^L0_4;.l 4-Di lii 
 
 Jj.ojiJili-b 
 
 M I I I I : I 
 
 Subsidence of a high temperature frum phthisis on the supervention of tubercular 
 meningitis : the time when cerebral symptoms occurred is indicated by delirium noted 
 on the chart. The pulse, which fell at first with the temperature, ran up toward death, 
 although the temperature remained comparatively low. 
 
 special variations ; the terminal stage of tubercular meningitis 
 is often characterized by a high pulse and a comparatively 
 low temperature. (See Fig. 20.) 
 
 The ratio of the pulse-rate to the frequency of the respira- 
 tion, is sometimes of value as an index of the existence or 
 supervention of respiratory disease; for although a little 
 acceleration of the respiration is natural in the febrile state, 
 any great disturbance of the ratio usually points to such 
 complications. (See " Respiration," Chapter IX.) 
 
 Sloimiess of tJie pulse has been just referred to as an excep- 
 tional occurrence in the febrile state in the sense of there not 
 being the usual acceleration. We sometimes find, however, 
 an absolute reduction in the pulse-rate in certain diseases ; 40 
 to 50 beats are not uncommon, and we may have 30, 20, or 
 even less. These low numbers are sometimes due to the efiect 
 of digitalis used medicinally. In fatty degeneration of the 
 muscular fibres of the heart a very low pulse-rate is an im- 
 
100 PULSE. 
 
 portant sign of this condition. Occasionally in epileptics the 
 pulse is very slow ; and in various brain diseases, particularly 
 when there is pressure or effusion, the pulse-rate falls ; this 
 fall, however, may be followed by a terminal exacerbation. 
 (See Fig. 20.) 
 
 The force or strength of the pulse often guides our prognosis, 
 and directs us in the treatment, especially as regards stimu- 
 lants. It is not easily estimated by the beginner ; it requires 
 experience and the watching of cases (especially febrile cases), 
 from day to day, for the education of the fingers. Some- 
 times the radial pulse gives a fallacious idea of Weakness, 
 from the vessel being of unusually small size Oiigh division 
 or other abnormality). Pressure on the arm from the patient's 
 position in lying on it, or some accidental tightness of the 
 dress, may also interfere with the radial pulse. Moreover, 
 the radial arteries on the two sides are often of very different 
 size, and so we find that errors sometimes arise from our de- 
 tecting a difference due merely to an accidental change in the 
 method of observation — the other arm having, perhaps, been 
 taken instead of the one usually felt. In doubtful cases the 
 radial, brachial, or other arteries on both sides should be ex- 
 amined, and the heart's sounds should be listened to. When 
 the pulse is really very weak, the first sound of the heart is 
 usually diminished and sometimes almost suppressed, the 
 second sound remaining distinct. Differences in the strength 
 of the two radial or other pulses are often of value in diag- 
 nosis, particularly in cases of aneurism of the arch of the 
 aorta, giving rise to more or less obstruction of certain 
 branches. Sometimes the two pulses are not perfectly syn- 
 chronous from similar causes. Occasionally, also, the dimi- 
 nution or obliteration of an arterial pulse serves to indicate 
 the occurrence of embolism, but care must be taken to see 
 that these differences are not due to unusual distribution of 
 the vessels. A survey of the arteries should be made, both 
 wdth the finger and eye, when judging of the force of the 
 pulse, and the examination sliould not be limited merely to 
 tlie part of the radial artery at the wrist; by extending our 
 observation we may detect any undue rigidity, twisting, or 
 unevenness of the vessels. Sometimes other arteries must be 
 examined to satisfy ourselves (m this subject ; the temporals 
 and the branches of the thyroid axis are selected for the 
 purpose of testing the smaller vessels, the brachials and the 
 femorals as a sample of the larger. 
 
 TJie hardness of the pulse-heat must be distinguished from 
 
EIIYTHM OF THE PULSE. 101 
 
 the hardness due to the state of the arterial walls just referred 
 to. The walls may not be rigid and yet the pulse may feel 
 like a cord. This is an indication of high arterial tension, 
 and is often noticeable in various forms of Bright's disease, 
 and particularly in cases of the contracted kidney. 
 
 The rhythm of the pulse is in health j^erfectly regular, so 
 that any deviation from this should be noted. Sometimes 
 there is a distinct intermission, a loss of a beat at regular or 
 irregular periods, but there may be such a loss in the radial 
 pulse without any corresponding intermission in the heart's 
 sounds or action ; there may thus be a marked difference in the 
 pulse-rate as counted at the wrist and at the heart, the strength 
 of the cardiac contraction being unable to produce a proper 
 beat at the wrist : such abortive beats, may sometimes, however, 
 be recognized by sphygmographic tracings. (See "Sphyg- 
 mograph," Chapter XVI., under "Irregularity.") Or the 
 irregularity may consist of two or three hurried beats followed 
 
 Fig. 21. 
 
 This diagram, from Foster's Physiology, shows the influence of the respiration on the 
 pulse in a healthy subject. The upper tracing is the pulse. The lower curve gives the 
 movements of the chest wall. During inspiration the pulse-waves diminish in height 
 and become more dicrotic, while during respiration the height of the pulse-waves is in- 
 creased, while their form tends more toward that of a pulse-wave with a raised arterial 
 pressure. This diagram shows one form of the eflect of the respiration on the pulse, hut 
 this effect varies considerably in different experiments and under different conditions. 
 (Foster.) 
 
 by a succession of slower ones, or we may have the occasional 
 occurrence of one or two weak or almost suppressed beats. 
 Sometimes the pulse-beats vary greatly in strength through- 
 
 9^ 
 
102 PULSE. 
 
 out a given minute, without any intermission or marked 
 change in the rhythm. This change in the strength and 
 character of the pulse can be made out in certain cases to be 
 associated with the respiratory movements, or with the occur- 
 
 FiG. 22. 
 
 This sijbyymographic tracing was taken by Dr. Gemmell from a case of nra'mic coma 
 with stertorous breathing. The variations shown coincide with the respiratory move- 
 ments. I corresponds with inspiration and E with expiration. ^ 
 
 rence of convulsions, or some other visible phenomena. (See 
 Figs. 21 and 22 for illustrations of this in healthy and dis- 
 eased states.) 
 
 The significance of irregularity of the pulse is most varied. 
 It sometimes affords one of the first indications to brain mis- 
 chief, especially in children, or of incipient pericarditis. It 
 is very common in various forms of heart disease, at all ages, 
 especially in mitral disease, fatty heart, and the degenerations 
 incident to old age. Apart from these, however, it is often 
 due to functional disturbances, esjoecially such as are asso- 
 ciated with indigestion, flatulence, excessive smoking, etc. It 
 is likewise developed, not unfrequently, through nervous agi- 
 tation, in certain persons, just as acceleration of the heart's 
 action or fluttering is produced in others from thesame cause; 
 concentration of the attention on the intermission is apt in 
 such cases to increase the irregularity, or the frequency of the 
 intermission. Some persons, apart from any medical knowl- 
 edge, have an obscure sensation of the intermission, which 
 causes a start or a shock. A more serious form of disturbance 
 occurs in the intermittent pulse of typhus fever and other 
 grave diseases ; this is almost always a sign of danger from 
 failure of the heart, but here also exceptional cases occur, of 
 less grave import, due to the peculiarities of the individual, 
 or to his habitual liability to this disturbance. An intermis- 
 sion in the pulse sometimes marks the beginning of the epi- 
 leptic fit. In states of debility, during convalescence from 
 serious diseases, and in the case of children after enteric fever, 
 for example, intermission of the pulse is sometimes associated 
 with unusual slowness, and is specially noticeable at night. 
 
SYMPTOMS OF FEBEILE STATE. 103 
 
 This does not imply any real danger, and, indeed, in children 
 who are practically healthy intermission of the pulse may 
 often be detected during their natural sleep. 
 
 Dicrotous jndse. — Somewhat allied to the rhythm is the 
 curious double beat in the pulse sometimes felt in febrile 
 cases. It is not uncommon in the convalescence from typhus 
 fever. This is best felt by applying the tips of the fingers 
 very lightly over the vessel, avoiding any such pressure as 
 would extinguish the weak second beat. The sphygmograph 
 brings out this dicrotism very clearly. Another form of 
 double beat, with the beats more distinct and more closely 
 together, has been named the "pulsus bigeminus." These 
 peculiarities are best discussed in connection with the sphyg- 
 mograph. (See Chapter XVI.). 
 
 The pulse of unfilled arteries, characterized by a sudden fill- 
 ing up of the artery followed by a very sudden collapse of 
 the vessel under the finger, often enables us to suspect, or 
 sometimes even definitely to recognize, incompetency of the 
 aortic valves, on feeling a patient's pulse. The peculiarity is 
 brought out in a more striking way by raising the patient's 
 arm vertically while feeling the radial pulse ; visible pulsation 
 throughout the arteries and especially in the neck is usually 
 very marked. This is also spoken of as the " water hammer " 
 pulse from its sudden slapping or jerking character; "the 
 pulse of aortic regurgitation " from its cause ; and " Cor- 
 rigan's pulse " from its describer. It also occurs in thoracic 
 aneurism. 
 
 (For capillary and venous pidse, see Chapter XVI.) 
 
 A thrill in the pidse can often be felt in certain cases of 
 cardiac disease (mitral and aortic valvular disease), and this 
 may come out in the sphygmographic tracing. 
 
 The sphygmograph gives important aid in the study of the 
 pulse. Its indications have a certain value in diagnosis, but 
 in addition to this a little practice with it has great educa- 
 tional value to the student in enabling him to recognize by 
 his fingers many of the peculiarities of the pulse which it 
 records. It seems best, however, to discuss it in connection 
 with the physical diagnosis of the heart, of which it forms an 
 important part. (See Chapter XVI.) 
 
 General or Constitutional Indications of the 
 Febrile State. 
 
 In addition to an increased temperature and a rapid pulse, 
 there are certain general signs of fever which are of great 
 
104 SYMPTOMS OF FEBEILE STATE. 
 
 value. Flushing of the face is common in fever, but care is 
 required to prevent mistakes in judging of this, as the color 
 of the cheeks varies much in different persons, and such an 
 accident as lying on the cheek often produces a local flush, 
 apart from fever; in such cases the thermometer is an invalu- 
 able guide. Sweating is habitual in rheumatic and enteric 
 fever, and in the disturbances of the puerperal state, and is 
 common in certain stages of most febrile diseases ; the total 
 absence of sweat, giving the sense of a dry j^ungent heat to 
 the hand as applied to the skin, is an important fact in the 
 height of fevers, pneumonia, etc. The critical sweats after 
 the height of the fever in ague is passed, or during the crisis 
 of relapsing fever, are only extreme illustrations of the com- 
 mon combination of sweating with the subsidence of a febrile 
 temperature. The sweating is sometimes of daily occurrence, 
 as in the night or early morning sweatings of phthisis, coin- 
 ciding with the diurnal variation of the temperature ; it is 
 also often cold and clammy, and in such cases it may be asso- 
 ciated with bad dreams ; this combination is common in cases 
 of deep-seated suppurations, disease of the bones, etc. The 
 profuse sweatings of py^emic affections may also be referred 
 to here. The influence of remedies in favoring or checking 
 sweating, the nature and amount of the clothing and the 
 softness of the bed are details to be kept in view in judging of 
 special cases. Great liability to sweating on but slight exer- 
 tion is a common indication of weakness quite apart from the 
 febrile state. Sweating is sometimes local, as of the head in 
 rickets ; or of one side of the body, in certain affections of 
 the sympathetic nerve, sometimes apart from any other obvious 
 disease, and sometimes connected Avith aneurismal or other 
 tumors in the chest or neck ; the influence of nervous emotion 
 in the production of sweating is proverbial. Headache and 
 pain in the hack are very common in nearly all the acute 
 speciffc fevers at their beginning, and one or other is usually 
 present, more or less, in all febrile states. Pain in the back 
 is very specially pronounced in cases of smallpox. (Of course, 
 these pains are often due to quite different causes, see Chap- 
 ter VI.) Unequal distribution of heat, a feeling of heat in the 
 head and of cold in the extremities, a l)urning heat in the 
 hands or the feet, a sensation as of cold water trickling down 
 the back, a feeling of chilliness increased on any exposure to 
 a slight draught of cold air, and actual shiverings in all de- 
 grees of their severity are exceedingly common in the begin- 
 ning of febrile diseases, especially before the patient has taken 
 
IMPAIKED DIGESTION. 105 
 
 to bed ; these sensations often lead him to hang about the fire- 
 place, complaining of cold, although his temperature may be 
 very high ; they tend to disaj)pear Avhen, by proper heating 
 and clothing in bed, the temperature of the various parts of 
 the body becomes more equalized. Young children seldom 
 have distinct shiverings. While shiverings are common at 
 the beginning of all acute inflammatory and febrile diseases, 
 they are especially frequent and repeated in ague, in serious 
 suppurations, in renal inflammation, paroxysmal hsematinuria, 
 and renal colic, in cases of gall-stones, in puerperal fever, and 
 in embolism and pyaemia. The passage of instruments into 
 the bladder often determines a violent rigor with febrile dis- 
 turbance. Rigors also occur occasionally in connection with 
 sudden defervescence. Many of the sensations just referred 
 to, and even actual shiverings, may occur a^^art from fever 
 altogether in nervous subjects ; the thermometer is here, again, 
 invaluable. The digestive functions are almost always im- 
 paired in febrile diseases, and especially at the onset of the 
 specific fevers : vomiting is very common in them, and is some- 
 times very severe and persistent (smallpox, scarlatina, relaps- 
 ing fever, and occasionally enteric fever) ; in other cases 
 sickness or nausea is all that is complained of. The appetite 
 is almost always impaired, and often completely supj^ressed. 
 The bowels are usually disordered ; the febrile state tends, as 
 a rule, to produce constipation, but occasionally diarrhoea is 
 seen to result from the action of the specific poison (as in the 
 beginning of malignant scarlatina), and sometimes there is a 
 special connection between the diarrhoea and the febrile dis- 
 ease (as in ulceration of the bowels in enteric fever, in the 
 inflammatory diarrhoea of infants, and in tubercular and dys- 
 enteric ulcerations) ; at times, however, the looseness of the 
 bowels seems related to the pyrexia as such, and ceases with 
 it : or it may be due to the concurrent impairment of the 
 digestive functions and their inability to deal with the food 
 forced on the patient in his febrile state. The state of the 
 tongue is usually a good index of the constitutional disturbance 
 produced by the fever, so far as the digestive organs are con- 
 cerned fsee " Tongue," Chapter XL). Thirst is almost always 
 present in the febrile state, especially at the beginning of the 
 illness, and notwithstanding the large amount of fluid swal- 
 lowed, the urine is usually scanty and high-colored. Muscular 
 prostration is present in all severe cases of fever, and is often 
 very marked even at the very beginning of some of the speci- 
 fic fevers. Delirium is usually associated, in very varying 
 
106 SYMPTOMS OF FEBEILE STATE. 
 
 degrees however, with high ranges of pyrexia from whatever 
 cause ; the degree of it, and the date at which it appears, as 
 well as its character, vary much in different diseases. Con- 
 vulsions sometimes take the place, as it were, of delirium, 
 especially in young children, and often mark the beginning 
 of acute inflammatory or febrile diseases in them. A degree 
 of bronchial catarrh is not uncommon in nearly all serious 
 febrile states, and is a special feature in some. Cutaneous 
 eruptions are characteristic of certain febrile diseases (see 
 "Febrile Rashes," p. 137): various symptoms referred to 
 above are dealt with more fully elsewhere ( see Index). 
 
 The Clinical Significance of the Febrile State is very great, 
 and this remark applies both to the presence and absence 
 of this state in a given case. It has already been explained 
 how the" febrile state is to be judged of; the possibility of 
 our observation occurring in an apyretic interval must be 
 remembered before we arrive at a negative conclusion. Some- 
 times the fact of fever (i. e., pyrexia) is all that can be made 
 out ; but without denying the existence of the old " simple 
 continued fever," we are seldom justified in resting satisfied 
 till we either have referred the pyrexia (1) to one of the specific 
 fevers ("typhus, scarlatina, ague, pertussis, etc.), or have as- 
 certained that it is symptomatic (2) of some special inflamma- 
 tion (pneumonia, pleurisy, abscess, rheumatism, etc.), or at 
 least (8) of some disease known to be associated with febrile 
 disturbance (phthisis, tuberculosis, syphilis, septicsemia, etc.). 
 
 (1) Specific Fevers and Rashes. — In determining the ques- 
 tion of fever, attention must be directed to the presence or 
 absence of the *' rashes" found in most of the specific fevers 
 (see p. 130). These must be carefully searched for in their 
 favorite situations, and the date of the illness must be consid- 
 ered particularly as to whether there has been time for the 
 appearance of the rash. As the exact date of the illness is 
 often obscure, and as the day on which a febrile rash appears 
 deviates occasionally from the average, some little allowance 
 must often be made for such variations before arriving at a 
 decision. The occasional absence of the rash, in nearly every 
 fever usually characterized by an eruption, must also be re- 
 membered. Other circumstances often render the existence of 
 such fevers very probalile, or indeed certain, even when no 
 rash has appeared. In examining for a febrile rash, other 
 cutaneous eruptions (not of this class) may be detected, and 
 it must be considered whether the eruption discovered is of 
 the kind and of the extent to account for, or to be in harmony 
 
SIGXIFICAKCE OF PYEEXIA. 107 
 
 with, the febrile movement. Some " skiu diseases," as they 
 are called, are associated with much fever, others with little 
 or none. The possibility of an eruption from the use of medi- 
 cines, and the influence of certain articles of diet must be kept 
 in view (see "Eruj)tions from Medicine and Food," p. 124). 
 Moreover, when there is high pyrexia, a certain congestion of 
 the skin, especially in the dependent parts, sometimes simu- 
 lates a scarlet rash. Eruptions indicative, so far, of certain 
 diseases, although they cannot be called specific, are some- 
 times found in the febrile state^such as herpes labialis in 
 pneumonia, or miliary vesicles in enteric aud childbed fever, 
 rheumatism, etc. Occasionally a rash is found in diseases not 
 usually characterized in this way — thus we may have a rash 
 in diphtheria and relapsing fever, and in the early or pre- 
 eruptive stage of smallpox and enteric fever. 
 
 (2) Inflammations. — When no specific rash exists, and no 
 distinct history of contagion is suggested, search must be made 
 for signs of inflammation, and although the case may be ad- 
 mitted to a medical ward, the possibility of superficial inflam- 
 mations or abscesses, periostitis, otitis, parotitis, and other 
 glandular inflammations, must never be forgotten, esjDecially 
 in the case of children or those unable to express their sensa- 
 tions. Tonsillitis, quinsy, pharyngeal abscess, scarlatina, and 
 diphtheritic sore throat must specially be remembered in this 
 connection. Pain and its situation usually guide us to these 
 and similar inflammations, and also to articular or muscular 
 rheumatism. Regarding internal inflammations, the impor- 
 tance of examining the chest cannot be overrated, as we often 
 find there the explanation of the febrile disturbance. This 
 must never be neglected. Inflammations of other internal 
 organs usually indicate their existence by pain over the parts, 
 or by changes in the excretions, or by other alterations in the 
 functions, such as paralysis, delirium, etc. A systematic 
 search must be made into the state of all the important 
 organs before arriving at a negative conclusion. 
 
 Shiverings are common in various febrile diseases, especi- 
 ally at the beginning; but when severe and recurring, the 
 idea of suppuration somewhere is suggested, or the presence of 
 stones in the kidney or gall-bladder, or perhaps embolism and 
 pysemia. Such suppurations may be in parts beyond the 
 reach of our diagnosis, but search must be made for tender 
 regions in the principal organs, and also in the joints, and for 
 pus in the excretions. 
 
 (3) A miscellaneous grouj:) of diseases having certain rela- 
 
108 SYMPTOMS OF FEBRILE STATE. 
 
 tionships with the specific fevers and inflammations, but not 
 definitely belonging to either, still remains. It is impossible 
 to enumerate them, but traces of their presence will usually 
 be found on systematic examination of the patient. Care 
 must be taken not to conclude at once that the febrile state is 
 due solely or chiefly to the inflammation which we may thus 
 detect by our examination. For example, bronchitis is an 
 habitual accompaniment of typhus, and pheumonia is common 
 in many fevers. Inflammation or congestion of the kidneys 
 (with albuminuria) is a frequent complication in many com- 
 plaints. It is often diflicult to know whether we have to do 
 with a primary, a secondary, or a mere coincident inflamma- 
 tion ; the date of the illness, and the known characters of the 
 disease, often assist us, and the want of correspondence be- 
 tween the apparently slight extent or severity of the inflam- 
 mation and the intensity of the fever, sometimes leads us to 
 suspect that there is somethiug behind the local inflamma- 
 tion. 
 
 The temperature in disease is now discussed more or less fully in all 
 systematic works on medicine, and also in treatises on special diseases. 
 — Wunderlich, Medical Thermometry, translated for the New Syden- 
 ham Society, London, 1871 : this work contains a mass of informa- 
 tion as to the general behavior of the temperature, and details and 
 references bearing on special diseases also — Miirchison, The Con- 
 tinued Fevers of Great Britain, 3d edition, by Dr. Cayley, London, 
 1884. — The pulse is discussed fully in many v, orks on physiology, see 
 especially Landois, Text-book of Human Physiology : translated with 
 additions by Dr. Wm. Stirling, 2 vols., London, 1885. — Byrom Bram- 
 well, Student's Guide to the Examination of the Pulse and the Use of 
 the Sphygmograph, 2d edition, Edinburgh, 1883. — See also Chapter 
 XVI. of this manual, where further information and references regard- 
 ing the sphygmograph may be found. 
 
CHAPTER IV. 
 
 SKIN— HAIE— NAILS— GLANDS— JOINTS— BONES. 
 
 Cutaneous Eruptions. 
 
 Eruptions on the skin are sometimes brought prominently 
 under our notice as the chief part of the patient's complaint, 
 or, at least, are so obvious that they caimot be overlooked ; 
 but in other cases we have to search carefully for an eruption 
 of which the patient may be unconscious, or which he may 
 regard as quite trivial and accidental. Most of the cutaneous 
 eruptions serve to indicate the presence of some more or less 
 serious poison in the blood, or of some constitutional affection 
 or tendency to disease. Thus the eruptive fevers present on 
 the skin the evidence of a general disturbance of the whole 
 system. The occurrence of an early or late syphilitic erup- 
 tion likewise reveals a constitutional affection, and the same 
 may be said of scrofulous, and perhaps also at times, of can- 
 cerous diseases of the skin. The pigmentations of pregnancy 
 and Addison's disease, the blotches in scurvy and j^urpura, 
 and the influence of certain medicines in producing eruptions 
 of various kinds, all indicate the same thing. Eczema and 
 psoriasis, from their symmetrical distribution, their tendency 
 to recur, and their association wdth certain other diseases in 
 the patient himself, or in his family, can usually be shown to 
 be much more than mere local diseases. Even parasitic affec- 
 tions of the skin often owe their rapid development and per- 
 sistency to the general state of the health : the vegetable j^ara- 
 sites do not seem to find a suitable nidus in j)erfectly healthy 
 subjects. 
 
 We must, therefore, always direct our attention to these 
 two great points in the study of cutaneous eruptions — the 
 local condition and the general state. The general derange- 
 ment may manifest itself by changes of which the skin affec- 
 tion is but one out of many ; or the cutaneous disease may be 
 the sole manifestation, or, at least, the chief evidence, of the 
 general disorder. On the other hand, affections of the skin 
 arising from local causes, or, as more frequently hapjoens, 
 aggravated by local influences, may give rise to a general 
 disturbance of the whole system. 
 
 10 
 
110 CUTANEOUS ERUPTIONS. 
 
 For the classification of skin eruptions the most satisfactory 
 and the most solid system would be one based on their causa- 
 tion, rather than on their special forms. Hitherto this has 
 only been possible to a slight extent, as the causes of many 
 eruptions are unknown, and the causes of others are not uni- 
 form, or, perhaps, are complex and indirect. The real cause 
 of eruptions must be kept in view, however, so far as this is 
 possible. It is of the utmost importance, for example, to 
 know whether an eruption is due to iodide of potassium, to 
 sraall2:)0x, to syphilis, or to scabies ; any system which would 
 group together such diverse affections as " papular " or " pus- 
 tular," even although they may all present papules or pus- 
 tules, tends only to mislead. And further, any grouping of 
 skin eruptions based merely on the elementary lesion is ren- 
 dered impossible for any useful purpose, when we find scabies, 
 for example, presenting at different times, or even in diflferent 
 parts at the same time, such diverse lesions as papules, vesi- 
 cles, and pustules ; or when we find eczema at one time pap- 
 ular, at another vesicular, at another pustular, and at another 
 somewhat scaly ; or when we find syphilis assuming nearly 
 every variety of form. 
 
 Still, as the causes of eruptions are often unknown, and 
 cannot even be suspected by the inexperienced, we avail our- 
 selves of the obvious distinctions afforded by the peculiarities 
 of the lesion; and when nothing more can be done, the student 
 may at least describe the nature of the lesion, the exteut and 
 distribution of the eruption, and the general and local symp- 
 toms associated with it. 
 
 The Elementary Lesions, indeed, formed the basis on 
 which Willan and Bateman's classification was built; and, 
 although now discarded, like most of the old nosological 
 systems, the facts on which it rested are of great value and 
 are still constantly referred to ; being themselves pioneers in 
 dermatology their groupings form a guide to the beginner, 
 and so they will be indicated here more fully than might 
 seem proper from the standpoint of our present ideas of classi- 
 fication. 
 
 Erythema is a simple redness of the skin due to hyperiiemia, 
 fading readily on pressure, and not extending to the cellular 
 tissue: there is often oedema, and in one form of disease bear- 
 ing this name the lesion is deeper. (See " E. nodosum," p. 
 113.) 
 
 Wheals (pomphi) are well represented by the red and white 
 elevated patches produced by the sting of a nettle, or the bite 
 
ELEMENTARY LESIONS. HI 
 
 of a bug, or even of a flea ; they are usually rapidly formed 
 and quite evanescent: in slight forms the white portions may 
 not appear ; in severer forms they may be complicated with 
 actual blisters. Their presence is usually associated with itch- 
 ing, burning, or tingling sensations. 
 
 Papuke are pimples of various sizes and forms ; they are 
 circumscribed and solid, but may be very different in their 
 constitution. 
 
 Vesiculce and bullce differ from each other in size, the former 
 being small blisters and the latter large ones. They may be 
 simple, or they may have divisions so as to be compound. 
 They may present perfectly clear fluid under the epidermis, 
 or they may contain inflammatory products to a variable 
 extent, so as to present all degrees of turbidity — the separate 
 vesicles passing through these various stages ; they may be 
 associated with all degrees of redness of the adjacent skin, or 
 they may be free from this comjilication. Vesicles usually 
 occur in clusters, the grouping and position of which are 
 important in the diagnosis. They may pass on to suppuration, 
 forming pustules, or their contents may dry up, forming crusts. 
 Several vesicles may coalesce, forming large blisters or " blebs." 
 The contents of bullae may be sanious and slight ulcerations 
 may be left on the separation of the crusts. 
 
 Pustuke may result from the fluid in the vesicles becoming 
 purulent or from the suppuration of a papule — this may arise 
 from irritation or other inflammatory action ; the pus is often 
 formed so rapidly that it may seem to exist from the begin- 
 ning. There is often an inflammatory areola at their base, 
 and this is a point insisted on by some in their classification. 
 When the contents dry up they form crusts or scabs. These 
 are often of a brownish color from the admixture of blood. 
 
 Squamce or sccdes and pityrmsis. Scales must be distin- 
 guished from thin crusts resulting from dried secretion. 
 Squamse are true scales, without moisture, from the beginning. 
 When the desquamation is very minute the term pityriasis is 
 used. Unfortunately, however, a disease of rare occurrence, 
 " pityriasis rubra," is so named, although characterized by the 
 shedding of large scales or flakes. 
 
 Tuhercida are little lumps, too large to be classed as pimples 
 or differing from them in other respects. They have only an 
 etymological connection with the tubercle recognized in the 
 pathology of internal affections. They include various cuta- 
 neous and mucous growths of perfectly dissimilar kind. 
 
 Hemorrhages. Maeulce or stains of the skin are sometimes 
 
112 CUTANEOUS ERUPTIONS. 
 
 hemorrhagic ; or they may be parasitic ; chemical agents and 
 various constitutional disorders j)i'oduce pigmentary deposits. 
 (See p. 140.) 
 
 Secondary Changes may result from or be present along 
 with various forms of elementary lesion. 
 
 Desquamation, although often occurring independently (see 
 " Squamae "), may form the terminal stage of an erythema, or 
 some inflammatory process by Avhich the epidermis has suffered. 
 
 Crusting is one of the most important secondary changes. 
 Very thin crusts may resemble scales, but careful examina- 
 tion usually shows them to be largely composed of dried secre- 
 tions (in ichthyosis, however, the scales are epithelial). The 
 discharge may be very slight, and may proceed from a sur- 
 face not ulcerated, or it may proceed from an ulcer. When 
 the crusts are dark, this usually points to the presence of a 
 sanious fluid retained in them, and this occurs frequently in 
 syphilis. Lupus and syphilis differ in their tendency to scab- 
 bing — the ulcers in the former usually scabbing slightly, those 
 of the latter often scabbing freely. 
 
 Limpet-shaped crusts are almost diagnostic of syphilis 
 (rupia). Cup-shaped crusts occur chiefly in the head, com- 
 posed of the parasitic growth termed favus ; they are light 
 yellow in color, and rather brittle. (See pp. 126, 127.) 
 
 Ulcerations are secondary changes which must be examined 
 and described in reference to their edges, etc., and any atten- 
 dant constitutional disturbance, as in surgical practice. 
 
 Swelling and infiltration of the skin, the results of the in- 
 flammatory process, are very important points in the diag- 
 nosis of eczema and of erysipelas. They give, in addition to 
 the swelling, a feeling of undue hardness and resistance to the 
 skin. 
 
 Hardness of the skin constitutes the leading feature of sclero- 
 derma adultorum. The skin feels hard, as if bound down, 
 and it is often cold to the touch ; the comparison has been 
 made to the touching a frozen corpse ; the hardness may be 
 pretty general or it may occur in bands. A circumscribed 
 variety in patches of circular form and pale color, resembling 
 disks of ivory, is described by some under the name of mor- 
 phoea. The form of scleroderma in newborn infants affects 
 the cellular tissue also. It is associated with oedema and with 
 depression of the temperature. In myxoedema the skin feels 
 dry and parchment-like, but the suggestion conveyed is usu- 
 ally that of a drojisy ; it will be referred to under that sec- 
 tion. 
 
ELEMENTARY LESIONS. 113 
 
 Excoriations, fissures, scars, and atropine lesions are frequently 
 very suggestive, and must be recorded. The glossy skin re- 
 sulting from lesions of the nerves may be mentioned in this 
 connection, and the disfigurations described by Alibert as 
 keloid (or cheloid) resembling hypertrophied scars. 
 
 ELEMENTAKY LESIONS IN SPECIAL DISEASES. 
 
 (Will AN and Bateman). 
 
 Exanthemata: Erythema, Wheals. — Willan and Bateman 
 had an order named " exanthemata " — the word signifying an efflores- 
 cence : this included two of the febrile eruptions rubeola and scarla- 
 tina, and also roseola, urticaria, purpura, and erythema. The erup- 
 tions of the specific fevers are now separated from other forms of skin 
 disease and put into a group by themselves. Purpura is now placed 
 in the class of hemorrhages. 
 
 Erythema may be symptomatic of adjacent inflammation or due to 
 mechanical or chemical irritants; but it also occurs idiopathically, 
 and some forms occupy an intermediate position. Thus E. intertrigo 
 is due to the fretting of ff>lds of skin against each other, often aggra- 
 vated by the decomposition or fermentation of the secretions. E. 
 Iseve arises from the pressure of dropsical fluid in a part. E. gangrse- 
 nosum may result from pressure, as in an ordinary bedsore, but it may 
 likewise be caused by grave trophic lesions in the nervous system. 
 E. fugax is usually due to digestive disorder. E. nodosum differs 
 somewhat from other forms in presenting nodular exudations as well 
 as redness: these are usually situated over the tibia ; they are often 
 painful and tender: they appear to be frequently manifestations of 
 the rheumatic constitution. The name erythema as a special disease 
 was formerly applied to many cases of the slighter forms of erysipelas. 
 Roseola, or " rose rash," is now usually regarded as an erythema, from 
 which it need not be separated. 
 
 Wheals constitute the characteristic sign of urticaria or "nettle- 
 rash," both in its acute and chronic forms. This disease is often pro- 
 duced by special articles of diet in certain individuals, as shell-fish, 
 etc. (see p. 124), or at least appears due to errors in digestion, and at 
 times to nervous disturbance. The local irritation of parasites and 
 exposure to the heat of furnaces may also set up this condition. " Fac- 
 titious urticaria" is the name used for the variety produced in certain 
 persons by mechanical irritation : this may be of such a character 
 that the name firmly traced with a pointed instrument, on almost any 
 part of the skin, comes out distinctly in wheals ; these white letters 
 may remain for many minutes. This susceptibility may be lost by 
 the individual in the course of time. 
 
 PAPULiE. — Willan and Bateman included under this heading 
 strophulus, lichen, and prurigo. The term strophulus is now sup- 
 pressed by many authorities: it is a somewhat vague term applied to 
 eruptions occurring in infants, loosely ascribed to teething, and termed 
 popularly "red gum," " white gum," or " hives." It is not always 
 papular, and seems often to be connected with the sudoriparous appa- 
 
 10* 
 
114 CUTANEOUS ERUPTIONS. 
 
 ratus. When not papular it should be classed with the erytheraata : 
 when papular it need not be separated from lichen. This disease, 
 again, is regarded by many as a form of eczema, in which the exuda- 
 tion takes the form of papules, and so they prefer to name it eczema 
 papulosum or E. lichenoides. Some who admit this, still recognize 
 forms of lichen under the names of L. ruber and L. planus. Prurigo 
 is still much disputed. A special disease described by Hebra under 
 this name is rare in this country; but papular eruptions, with the 
 enlarged papillre irritated and abraded by scratching, are common 
 enough : it is better to call this a " pruriginous eruption " to prevent 
 confusion, and if taken in this sense such an eruption is a valuable in- 
 dication of itching, past or present, and so we find it in scabies, 
 phthiriasis, and urticaria. 
 
 Vesicul.e and Bullae — Under the former, Willan and Bateman 
 included varicella, vaccinia, herpes, rupia, miliaria, eczema, and 
 aphtha: under the latter, erysipelas, pemphigus, and pompholyx. 
 Our present ideas lead us to separate the specific fevers from ordinary 
 skin disease (see p. 130), and so varicella and vaccinia may be re- 
 moved : erysipelas in its slight forms was spoken of as erythema : in 
 its bad forms it was so often complicated by blisters that it came under 
 the heading of vesiculse : it has, however, really more affinity with 
 the eruptive fevers (see p. 139). Aphthae are now spoken of only or 
 chiefly in connection with little blisters in the mouth and tongue (see 
 Chapter XI., " Tongue "). Miliary vesicles are discussed at page 139. 
 
 Herpes consists of an eruption of small vesicles arranged in groups 
 on an inflamed base : these run their course, and are not usually suc- 
 ceeded by fresh groups of vesicles : there is generally a feeling of ten- 
 sion and burning ; occasionally neuralgic pains precede or follow the 
 eruption. "Herpes labialis " is common in ordinary colds : it also 
 appears in many cases of pneumonia, and in some forms of urinary 
 irritation and disease. " Herpes prseputialis " appears on the prepuce 
 and a similar eruption may appear on the glans also. " Herpes zos- 
 ter " (shingles, zona) usually girdles the trunk unilaterally, limited 
 pretty strictly by the middle line, both before and behind, but it may 
 affect the thigh, the face, or the arm, following very accurately the 
 cour.>e of certain nerves. It is not infectious, and rarely occurs a 
 second time in a patient. 
 
 Eczetna is now generally made to include several forms of skin dis- 
 ease which were formerly separated from each other. It is an inflam- 
 matory disease with exudation and infiltration of the skin, associated 
 with a sense of burning or itching, and it tends to the formation of 
 crusts. In the ordinary form there are vesicles (eczema vesiculosum) 
 exuding a clear fluid, which has the property of stiffening linen ; an 
 excoriated, red, and inflamed surface usually remains exposed ; the 
 discharge may dry very rapidly into crusts which ma}' be so thin as 
 to resemble scales. In some cases the moist discharge, if present at 
 all, may almost have escaped attention, redness and scaliness of the 
 skin being the chief features (eczema erythematosum and eczema 
 squamosum). In other cases the plastic exudation may remain below 
 the surface, giving rise to little papules — the lichen of older authors, 
 but termed eczema papulosum or lichenoides by some. Or the exu- 
 dation, either from obvious irritation, or from debility in the subjects, 
 may become purulent, or the secretion of pus may be abundant from 
 
ELEMEXTARY LESIONS. 115 
 
 the beginning : this, which was formerly called impetigo, is now often 
 named " eczema pustulosum," or " eczema impetiginodes." Eczema 
 is also named from the parts affected, as " E. aurium," etc. ; also from 
 obvious secondary changes " E. fissum," (>r from the cause, as " E. in- 
 tertrigo " from friction. 
 
 Rupia; see " Ecthyma " under the "Pustulas," for although it may 
 begin as a vesicle with clear fluid, the contents soon become bloody 
 or purulent. The limpet-lil^e crusts in this disease are diagnostic of 
 syphilis. 
 
 Pe7nphigus is characterized by large blisters, or bullae, varying from 
 the size of a pea to that of an egg, with different degrees of inflamma- 
 tion at their base, and followed sometimes by ulceration. Occasion- 
 ally large thin crusts or scales are formed (" P. foliaceus "), 
 
 Pompholyx is now merely a synonym for pemphigus. 
 
 PusTULiE. — It must be remembered that vesicles readily become 
 pustules, and so some diseases may appear to come under both head- 
 ings. Willan and Bateman included under " pustulee," variola, por- 
 rigo, impetigo, scabies, ecthyma. Vai^iola being a specific febrile dis- 
 ease is discussed elsewhere (p. 133). Porrigo was a general term 
 applied to " scald heads," where the hair was matted together with 
 crusts and scabs, arising from inflammation set up, usually in weak 
 subjects and especially in children, and sometimes due to or associated 
 with the irritation of pediculi. Prom what has been said it will ap- 
 pear that this is a pustular eczema. Another form is due to the para- 
 sitic disease, favus, aflfecting the head (see page 127). 
 
 Impetigo is merged by many into eczema, the terms E. pustulosum, 
 impetiginosum or impetiginodes being applied to it. Some retain the 
 name impetigo for scattered, sejoarate, pustules without much inflam- 
 mation at their base. A form of this disease named I. contagiosa is 
 interesting as being both infectious as regards others, and inoculable 
 in new places in the patient himself. Ecthyma is a name applied, 
 somewhat variously, to large pustules not a2:gregated together, and 
 each one surrounded by an inflamed base. They are said to occur in 
 debilitated subjects apart from syphilis ; but when very distinct they 
 are not unfrequently of this nature, and when they dry up they form 
 the limpet-shell crusts of rupia. Occasionally the pustule of a so- 
 called " ecthyma " is merely due to scabies. 
 
 Scabies is classed arbitrarily under " pustulte ;" it presents, however, 
 likewise papular and vesicular lesions. Occasionally no distinct erup- 
 tion apart from scratching can be spen, especially if the hands are 
 often in water from the occupation of the patient. It is parasitic, and 
 is now removed to this class. The itch insect or " acarus scabiei " is 
 found at the end of the little furrows characteristic of this disease, 
 and can sometimes be picked out with a needle from this situation for 
 microscopic examination. (See Fig. 23.) These furrows are seen as 
 small white lines, about a quarter of an inch in length at most, chiefly 
 at the sides of the fingers near the clefts; they are usually tortuous ; 
 they are sometimes inflamed, often interrupted by dots, or by vesicles, 
 and are very apt to be destroyed in their appearance by scratching. 
 The presence of the insects sets up violent itching; this leads to 
 scratching and the appearance of a " pruriginous eruption," or to the 
 development of large pustules (so-called ecthyma), or it may be to 
 
116 CUTANEOUS ERUPTIONS. 
 
 eczema. The distribution of the eruption is ver}^ important in the 
 diagnosis (see p. 119). 
 
 Squama. — This class included, according to Willan and Bateman, 
 Pityriasis, Psoriasis, Lepra, and Ichth3'osis. 
 
 Piify^-iasis, or desquamation, occurs after erythema, febrile rashes, 
 and various other affections of the skin, but it is not usual to speak of 
 it under this technical name when it forms only a stage in a disease. 
 "Pityriasis versicolor" is parasitic, and is not properly a squamous 
 disease, although minute scales are sometimes shed. (See Fig. 31.) 
 "Pityriasis rubra acuta" is a rare disease characterized by great 
 redness of the skin and the shedding of large true scales, without 
 moisture and without much infiltration of the skin. 
 
 Psoriasis and lepra (alphos) are now classed as one disease; the 
 name " lepra" (used by some for true leprosy) was formerly applied 
 to the patches of psoriasis, in which it spread at the circumference 
 (psoriasis circinata) while the centre was healing; the form of a ring 
 was thus assumed. This is a true scaly disease, without moist secre- 
 tions, the scales are white and often glittering, somewhat imbricated 
 and very adherent ; the}' appear on dusky red patches, which are 
 slightly elevated; all degrees of density in the arrangement of scales 
 are found. All parts of the body may be affected ; the extensor sur- 
 faces of the elbows and knees seldom escape in an abundant eruption 
 of simple psoriasis. When it appears on the palms of the hands, or 
 on the soles of the feet alone, it is very often syphilitic. A form of 
 psoriasis, resembling the shape of rupia crusts, has been named "P. 
 rupioides." 
 
 Ichthyosis. When the skin is dry, harsh, and wrinkled, with thin 
 scales loose at their edges, the term " xeroderma" is sometimes used. 
 When the scales are thicker, more abundant, and mingled with seba- 
 ceous matter, the name " ichthyosis " is applied. It is a chronic dis- 
 ease dating from childhood. 
 
 TuBERCULA. — The diseases grouped by the old writers under this 
 heading have but little in common. They were Phyma (boil). Ver- 
 ruca (wart), Molloscum, Vitiligo, Acne, Sycosis, Lupus, Elephantiasis, 
 Framboesia. 
 
 Acne is an inflammatory disease of the sebaceous glands character- 
 ized by pimples or pustules, often arising from " comedones " — small 
 white pimples with a central black speck. "Acne rosacea " affects the 
 nose chiefly ; there are much redness and hypertrophy of the skin with 
 more or less acne. The cutan(ious surface presents dilated vessels ; 
 although often associated with intemperance it frequently exists apart 
 from this. Sycosis, as now recognized, is distinguished as parasitic or 
 non-parasitic; the latter form affects the hair follicles, chiefly on the 
 beard and face, giving rise to pustules, papules, and crusts. The para- 
 sitic form affects the same parts, but the mischief is due to the same 
 kind of parasite as occurs in ringworm. (See Figs. 28-30.) 
 
 Lupus is an inflammation and ulceration of the skin occurring in 
 scrofulous subjects, and characterized by the presence of new forma- 
 tion. When slight and superficial, without ulceration, it is called 
 " lupus erythematodes." When the deposit forms little swellings, 
 without ulceration, " lupus non exedens " is the term applied ; when 
 ulcerations and cicatrices are present, it is called "lupus exedens;" 
 
CLASSIFICATION". 117 
 
 even in the other form, however, subcutaneous cicatricial marks may 
 be traced. 
 
 MoUusciun is a term applied to soft tumors of the skin, one variety 
 is fibrous, " fibrt)ma molluscum ; " another variety, not exceeding a 
 pea in size, is epithelial, "molluscum epitheliale; " this latter is the 
 contagious variety. 
 
 Elephantiasis is a name applied to two quite different diseases ; ele- 
 phantiasis Arabum is a chronic hypertrophic disease of the skin and 
 subcutaneous connective tissue characterized by enlargement and de- 
 formity of the part affected, accompanied by lymphangitis, swelling, 
 oedema, thickening, induration, pigmentation, and papillary' growth ; 
 elephantiasis Grsecorum (or true leprosy) is an endemic, chronic, malig- 
 nant, constitutional disease, characterized by alterations in the cuta- 
 neous, nerve, and bone structures, resulting in ansesthesia, ulceration, 
 necrosis, general atrophy, and deformity. (Duhring.) True leprosy 
 occurs in the form of masses of infiltration and tubercles (tubercular 
 form), in smooth patches (macular form), and in patches with anaes- 
 thesia (anaesthetic form) ; these forms may occur separately or in com- 
 bination. Framhcesia or yaws is a disease of the West Indies char- 
 acterized among other things by papules or tubercles of the skin; it 
 need only be mentioned here. Vitiligo is an affection of the pigmen- 
 tation, and will be referred to under that heading (p. 142.) 
 
 A satisfactory classification of skin diseases might be attain- 
 able if the causes were more fully known. As yet, this 
 method is only very partially available. By it the eruptive 
 fevers are separated from other skin affections ; and, indeed, 
 in the following table they have been removed altogether. 
 The parasitic diseases of the skin are likewise separated from 
 others, as they form a natural group by themselves. In the 
 absence of the etiological method the anatomical site of the 
 disease and the nature of the pathological process, so far as it 
 can be known, seem to form the best basis. The table here 
 given is from Dr. Duhring's work on Diseases of the Skin, 
 third edition, Philadelphia, 1882. It is essentially Hebra's 
 classification. 
 
 Class I. — Anomalt^ Secretionis — Disorders of Secretion. 
 
 Sebaceous 
 
 Seborrhcea, Comedo, Milium, Sebaceous Cyst • • ^ i rl 
 
 Hyperidrosis, Anidrosis, Bromidrosis, Chromidro- \ o i. -i ^^ 
 sis, Sudamen J ° 
 
 Class II. — HYPERiEMi^ — Hyperemias. 
 Erythema Simplex, Erythema Intertrigo . . . Erythematous. 
 
118 CUTANEOUS EEUPTIONS. 
 
 Class III. — Exsudationes — Inflammations. 
 Erythema multiforme, Erythema Nodosum, Urti- ) -n, ,v . ^ 
 
 can a 
 
 f Erythematous, 
 
 ^, j vesicular, 
 
 Eczema -,' i ' 
 
 I papular, 
 
 [ squamous. 
 
 Herpes, Herpes Zoster, Herpes Iris, Miliaria . . Vesicular. 
 
 Pemphigus Bullous. 
 
 Lichen Ruber, Prurigo, Lichen Scrofulosus . . Papular. 
 
 Acne, Acne Rosacea, Sycosis Non-parasitica, Im- \ p j. i 
 petigo. Impetigo Contagiosa, Ecthyma . . . / 
 
 Psoriasis, Pityriasis Rubra Squamous. 
 
 Furunculus, Anthrax Phlegmonous. 
 
 {Erythematous, 
 vesicular, 
 bullous, etc. 
 
 Class IV. — H^morrhagi^e — Hemorrhages. 
 Purpura Corium, etc. 
 
 Class V. — Hypertrophic — Hypertrophies. 
 Lentigo, Chloasma, Ntevus Pigmentosus . . . Pigment. 
 Molluscum Epitheliale, Callositas, Clavus, Cornu, \ Epidermis, 
 
 Verruca, Ichthyosis, Keratosis Pilaris . . . . j papillae. 
 
 Scleroderma, Morphoea, Sclerema Neonatorum, ") ^ ,ri.i,.i 
 
 Elephantiasis Arabum, Dermatolysis .... J 
 
 Hypertrophy of the Hair Hair. 
 
 Hypertrophy of the Nail Nail. 
 
 Class VI. — Atrophic — Atrophies. 
 
 Albinism, Vitiligo, Canities Pigment. 
 
 Atrophia Cutis, Atrophia Senilis, Striae et Macula3 ) ^ . 
 
 iL , 1 • V v^orium. 
 
 Atrophica^ j 
 
 Alopecia, Alopecia Areata, Atrophy of the Hair . Hair. 
 
 Atrophy of the Nail Nail. 
 
 Class VII. — Neoplasmata — New Growths. 
 Keloid, Molluscum Fibrosum, Xanthoma . . . V 
 
 Connective 
 tissue. 
 
 Rhinoscleroma, Lupus Erythematosus, Lupus ^ 
 
 Vulgaris, Scrofuloderma, Lepra, Syphiloderma, > Cellular. 
 
 Carcinoma, Sarcoma J 
 
 Na3vus Vasculosus, Telangiectasis Bloodvessels. 
 
 Lymphangioma Lymphatics. 
 
 Neuroma Nerves. 
 
DISTKIBUTION OF ERUPTIONS. 119 
 
 Class YIII. — Neuroses — Neuroses. 
 
 Hyperaesthesia, Dermatalgia, Pruritus .... Hypersesthesia. 
 Anaesthesia Anaesthesia. 
 
 Class IX. — Parasite — Parasites. 
 
 Tinea Favosa ] 
 
 Tinea Tricbophytina. — T. Circinata, T. Ton- ( -y- ^^ -u-i 
 
 surans, T. Sycosis [" ° 
 
 Tinea Versicolor J 
 
 Scabies, Pediculosis Capitis, Pediculosis Corporis, \ a • -i 
 Pediculosis Pubis . j 
 
 [Eruptive Fevers. See p. 130.] 
 
 Distribution of Eruptions. — In examining a cutaneous erwp- 
 tion, it is a great advantage to see the surface of the Avhole 
 body, or as much of it as j)0ssible. Special abundance of the 
 eruption on certain parts, or the s]3ecial exemption of others, 
 affords at times considerable assistance in the diagnosis. We 
 can in this way also detect the symmetrical character of many 
 eruptions, or the essentially local disposition of others — as 
 when the hand or forearms are affected by some irritant en- 
 countered in a trade, or when the eruption is limited to the 
 legs and caused by stockings with aniline or arsenical dyes. 
 Some eruptions, again, follow the course of certain nerves, and 
 in zona we have usually a pretty strict limitation to one-half 
 of the body, the eruption stopj^ing at the middle line both 
 before and behind when the trunk is involved. But in addi- 
 tion to this general view of the surface, special regions must 
 be examined for special eruptions. Of the febrile rashes, 
 some show first on the face (variola and morbilli), but most 
 of them appear first on the trunk, so that we must search the 
 chest, abdomen, and back, and we should also examine the 
 arms at the anterior aspect of the elbows, etc., where the skin 
 is delicate. We look at the extensor surfaces of the elbows 
 and knees particularly in psoriasis ; at the chest and back in 
 syj^hilis ; at the clefts of the fingers in scabies, to see if any 
 little furrows are present with acari at their extremities (see 
 Fig. 23) ; and also at the inside of the thighs, the external 
 genital organs, the mammae, the wrists, ankles, and umbilicus 
 in this affection; the face is almost always exempted. We 
 examine specially the chest, armpits, and between the shoulders 
 for phthiriasis ; over the chest for pityriasis versicolor ; on 
 
120 
 
 CUTANEOUS ERUPTIONS. 
 
 the head for ringworm and faviis : over the shins for erythema 
 nodosum ; on the face and shoulders for acne ; on the cheeks, 
 nose, and ears for lupus, etc. 
 
 Fig. 23. 
 
 The itch insect, Acarus scabiei. Female ; ventral aspect. (Drawn by Pr. John Wilson.) 
 
 The constitutional disturbance and the general symptoms 
 associated with cutaneous eruptions must be carefully inquired 
 into. Pyrexia, headache, and perhaps delirium, pain in the 
 back, sickness, vomiting, or shiverings ; and pain, burning, 
 tingling, and itching in the parts affected are the most im- 
 portant. Intense pyrexia often precedes the appearan<5e of 
 the rash in the eruptive fevers and erysipelas, and (as men- 
 tioned in the chapter on "Pyrexia"), the skin ought to be care- 
 fully examined by good daylight, if possible, for any appear- 
 ance of a rash. The inspection of the skin for a febrile rash 
 should, in the first instance, be made at such a distance (two 
 to three feet) that the general appearance of the surface can 
 be seen, rather tlian any minute alterations in the skin ; these 
 may be subsequently examined if necessary. Pain in the 
 
ITCHING. 121 
 
 back and vomiting are especially suggestive of smallpox ; in- 
 tense headache of typhus ; sore throat and vomiting of scar- 
 latina ; coryza and bronchial catarrh of measles ; shiverings 
 may occur in the early stage of any of these, and also in 
 erysipelas. But even in those forms of eruptions, more usu- 
 ally called diseases of the skin, there may be much constitu- 
 tional disturbance, with considerable pyrexia and some gastric 
 disorder, as in eczema and urticaria. The intensity of the 
 general symptoms bears a much more distinct relation to the 
 extent of the cutaneous affection in these cases than in the 
 eruptive fevers. Severe neuralgic pains sometimes precede, 
 sometimes follow, the eruption of herpes zoster. Considerable 
 pain is often experienced in eczema, but in such a case the 
 cause is apparent. 
 
 Itching is an important fact in cutaneous disease. It is 
 seldom very troublesome in the eruptive fevers, although often 
 present to some extent in measles, smallpox, and chickenpox. 
 It is seldom marked in syphilitic eruptions, so that its absence 
 counts for something in the diagnosis. In urticaria, psoriasis, 
 and eczema, itching is often very troublesome. In parasitic 
 diseases it is a very prominent feature, especially in scabies 
 and phthiriasis. The existence of itching can usually be 
 recognized by the presence of a " pruriginous eruption " due 
 to scratching, and the marks of the nails often tell the same 
 story ; this irritation alters the appearance of an eruption very 
 materially, chiefly by causing inflammation. Itching, however, 
 may exist without any eruption. In some of these cases, this 
 may be due to a nervous affection of the skin, as in " pruritus 
 senilis," the itchiness varying much at particular times. Pruri- 
 tus, es|)ecially at the intestinal and genito-urinary orifices, may 
 be symptomatic of pregnancy, or of disease of the womb, stone 
 in the bladder, diabetes, piles, or other affections of the rec- 
 tum. In many cases, especially (although not exclusively) in 
 children, itching at the anus is due to the presence of thread 
 worms ; in them it is often associated with itching at the nose 
 also, as manifested by picking at the nostrils. But this pick- 
 ing occurs also in diarrhoea and other forms of intestinal 
 irritation. 
 
 Itching is occasionally present to a troublesome extent in 
 jaundice; it is not unfrequently produced by the internal use 
 of opium and morphia in all their forms. Some persons are 
 especially liable to this inconvenience from the use of opium. 
 An itching of the eyelids is one of the indications of the action 
 of arsenic. 
 
 11 
 
122 CUTANEOUS ERUPTIONS. 
 
 Causes of Cutaneous Eruptions. Infection, Medicine, 
 Food. — In inquiring as to the cause of eruptions, we may as- 
 certain the patient's ideas on the subject, or we may interrogate 
 him as to special points in connection with special forms of 
 disease. 
 
 Injection. — In the group of eruptive fevers we inquire for 
 any similar illnesses in the same family or neighborhood. 
 Some assistance is at times obtained by learning that the 
 patient has formerly had certain sj)ecific fevers, as a second 
 attack in some of these is but rarely met with. (See p. 131.) 
 In suspected erysipelas, we inquire for exposure to this disease 
 in surgical wards, or otherwise ; and for any contact with puer- 
 peral fever or pyaemia, especially if our patients are predis- 
 posed to infection by recent delivery, open sores, etc. In 
 children, and especially in hospital practice, where infection 
 may be present, wounds or oj)en sores predispose to the occur- 
 rence of scarlatina, which may be mistaken for erythema or 
 erysipelas. 
 
 In syphilitic eruptions Ave may inquire for the history of the 
 original infection in the patient. Sometimes we inquire as to 
 the husband in the case of a suspicious eruption in a married 
 woman ; of course, in doing so care and discretion must be 
 exercised. Or in the case of congenital syphilis we may have 
 to search for the evidence of infection in the parents, and in 
 the brothers and sisters ; in this last variety, the occurrence of 
 abortions before the birth of the patient is often an important 
 indication of syphilis. But in addition to cases of this kind, 
 we can sometimes trace the infection of a patient from second- 
 ary or congenital syphilis. A nurse's arm may be infected 
 from the sores on an infant's anus, or the nipple from the sores 
 on the child's mouth, or vice versa. (See " Syphilitic Eruptions," 
 
 In impetigo contagiosa the patient may inoculate one part 
 from another by means of scratching, or may communicate 
 the disease to another person. The occupation is im})ortant 
 in connection with cases of suspected glanders, malignant 
 pustule, etc. 
 
 In parasitic diseases we often gain considerable assistance 
 from the knowledge of their having spread by infection. 
 Thus, if two persons sleep in the same bed, scabies in the 
 one is almost certain to be communicated to the other. This 
 disease is also communicated by infected bedclothes, apart 
 from any direct contact with patients so affected. In ringworm 
 the affection often spreads from the use of ths same hair- 
 
INFECTION". 
 
 123 
 
 brushes, although the patients may not otherwise be much 
 associated : ringworm of the body may appear in those who 
 are attending on children whose heads are affected. In favus 
 the contagion may be derived from some pet animal as well as 
 from a patient. The pediculus pubis is sometimes found in 
 persons of good position from their consorting with prostitutes. 
 Its presence usually gives rise to great itching and irritation 
 of the parts, but does not always do so. This parasite may 
 affect other portions of the body as well as the pubes ; it is 
 found in the axilla, and also on the eyelashes or eyebrows, 
 particularly in the children of the poor : the ova may be found 
 at the roots of the hairs, presenting a definitely roundish con- 
 tour on examination with a hand lens, and so distinguishable 
 from small scabs or crusts which they closely resemble. On 
 pulling out a few hairs they can be examined microscopically 
 on a slide. (See Fig. 24.) The itch insects, and pediculi cor- 
 poris and their ova often continue to act on the patient through 
 the medium of the underclothing and the bedclothes, even 
 after those on the skin have been got rid of. Indeed, the clothes 
 of the patient are the special habitat of the pediculi referred 
 to, which are on this account sometimes named " pediculi vesti- 
 mentorum :" they often lurk in the seams, where they also 
 deposit their ova, and so escape destruction. Certain varieties 
 
 Fig. 24. 
 
 Pediculus pubis, or crab louse, with ova adhering to the hair. 
 (Drawn by Dr. John Wilson.) 
 
 of the same parasitic disease must be borne in mind while 
 searching for the history of infection — thus we have ringworm 
 of the head, of the body, and of the beard. 
 
 Many cutaneous diseases have been found to be associated 
 with and presumably due to specific microorganisms. The 
 
124 CUTANEOUS EKUPTIONS. 
 
 bacillus of tubercle and of lepro'sy and the microbes of the 
 eruptive fevers, erpsipelas, and syphilis may be mentioned; 
 but the subject is too complicated, and in some phases of it 
 too uncertain, to demand more as yet than a mere reference 
 to it in such a book as this. 
 
 Certain medicines and articles of diet are apt to produce 
 cutaneous eruptions. Shell-fish, preserved salmon, cucumbers, 
 walnuts, game, sausages, pickles, spices, even strawberries, and 
 various other articles produce at times an eruption of urticaria 
 or erythema. Some persons, indeed, are particularly liable to 
 this effect from special articles, so that it is almost certain to 
 follow their use ; in others, the effect is less constant. These 
 eruptions sometimes simulate the specific fevers ; the absence 
 of consitutional disturbance in proportion to the rash, and the 
 absence of the special features of the specific fever simulated 
 may sometimes guide us in the discrimination. Of medicines, 
 iodide and bromide of potassium, belladonna and atropine, 
 quinine, salicylic acid and its salts, chloral, sulphur, arsenic, 
 tar, and copaiba may be named as all producing at times 
 cutaneous eruptions ; and the application of carbolic acid as a 
 dressing sometimes determines an eruption of erythema which 
 may simulate scarlet fever. 
 
 Iodide and bromide of potassium produce pimples (acne), which 
 appear chiefl}^ on the face and shoulders ; occasionall\' the eruption is 
 more distinctly pustular, and has even been mistaken for smallpox. 
 The eiuption is sometimes hemorrhascic. The affection of the mucous 
 membrane of the nose and eyes, and the swelling of the glands be- 
 hind the jaws, sometimes guide us in the recognition of iodism. 
 
 Belladonna and atropine produce at times a distinct erythema 
 somewhat resembling that of scarlatina; a certain similarity to the 
 eruption of measles is found in some cases. This rash may result 
 from the internal use of the drug (usually in full doses), or from the 
 action of external applications in the form of plasters, especially if 
 excoriations exist on the skin. Dryness of the fauces and more or less 
 dilatation of the pupils are usually present to assist in the recognition 
 of this eruption. 
 
 Quinine sometimes gives rise toa very pronounced red efflorescence; 
 this effect is not common, and depends on an idiosyncrasy in the 
 patients affected. 
 
 Chloral often produces a congestion of the skin, and this may as- 
 sume the character in certain cases of patches of redness like scarlatina 
 or urticaria. 
 
 Salicylic acid and the salicylates also determine patches of erythema 
 and blotches of ecchymosis, which are liable to be further complicated 
 by the effects of profuse sweating 
 
 Antipyrin, thallin, and some other of the newer antipyretics, pro- 
 duce red rashes at times. 
 
EEUPTIONS FEOM MEDICINES. 
 
 125 
 
 Opium also seems at times to give rise to patches of redness in the 
 skin. 
 
 Arsenic produces, although but rarely, an eruption somewhat re- 
 sembling eczema, or at least a prominence of the papillae with conges- 
 tion of the skin. In certain cases herpes zoster has appeared to be 
 due to the use of arsenic, and pityriasis rubra has also been known to 
 supervene in connection with its administration. Puffiness and itch- 
 ing of the eyelids, sickness or pains in the bowels, and whiteness of 
 the tongue assist in the recognition of arsenical influence. Local 
 irritation from arsenic may manifest itself by ulcerations of the part 
 affected. 
 
 Sulphur and tar are said to produce at times an eruption resembling 
 a badly developed eczema, and large doses of turpentine may produce 
 an erythema. 
 
 Copaiba gives rise in some cases to urticaria of the usual kind, but 
 
 Fig. 25. 
 
 
 fMVf/pilfiWf^ 
 
 \ ' 
 
 
 i' / "11 
 
 Wli 
 
 imm 
 
 O O 
 
 " 
 
 O Oo 
 
 O O 
 
 o O 
 
 3 
 
 ^ O 00 '^ 
 
 Root of hair affected with favus, showing the spores : 250 diameters. 
 (DraM^n by Dr. John Wilson.) See p. 127. 
 
 11* 
 
126 
 
 CUTANEOUS ERUPTIONS. 
 
 the white parts of the wheals may be absent, so that the rash is only 
 red ; at times this eruption closely simulates measles in its general 
 appearance, but it does not specially affect the face, and is not asso- 
 ciated with catarrh. Copaiba is so much used in the treatment of 
 gonorrhoea that when we see an eruption associated with this disease 
 we should always suspect the action of this drug. Cubebs has also 
 been known to produce a similar rash. 
 
 Nitrate of silver administered internally for some time may cause a 
 dark discoloration of the skin aflfecting the parts exposed to the light. 
 
 In addition to the above, a great many remedies produce eruptions 
 from their local action if applied to the skin. 
 
 Affections of the Hair: Examination of Vegetable 
 Parasites. — Absence of the hair is termed "alopecia." This 
 
 Fig. 26. 
 
 Portion of favus crust, showing the mycelium, with septate cellular tubes, moniliforiu 
 rows of cells, and free spores : 250 diameters. (Drawn ))y Dr. .John Wilson.) 
 
 is sometimes, althoiigli very rarely, almost universal, affecting 
 the face and head, tlie piibes, eyebrows, and even the minute 
 hairs in every part of the body (alopecia universalis). The 
 baldness of advancing years, and premature baldness, which 
 is often hereditary, need only be mentioned. The loss of the 
 
AFFECTIONS OF THE HAIR. 
 
 127 
 
 hair in syphilis, and after fevers and erysipelas, is usually 
 only temporary, but sometimes a partial baldness becomes 
 permanent in this way. Limited patches of baldness on the 
 scalp, and more rarely of the beard, assuming a circular form, 
 or at least with circular margins, are termed " alopecia areata;" 
 in this affection the hair is quite absent in the fully developed 
 affection, the skin being quite smooth and even glossy. It is 
 supposed by some to be due to a parasite (Microsporon 
 Audouini), but it is regarded now by most authorities as a 
 neurosis. In ringworm and favus the hairs are not quite 
 absent, the bald patches present some stunted hairs. In favus 
 the hairs are found, in a typical case, to pierce a cup-shaped 
 yellow crust near its centre ; this sulphur-colored crust fre- 
 quently has a mouse-like odor ; patches of red, irritable, 
 shining skin may be found where the hair follicles have been 
 destroyed. The parasite in favus is named Achorion Schdnleinii. 
 In ringworm the hairs resemble stubble, being dry and 
 withered or sometimes half broken ; the brittle hairs break 
 
 Fig. 27. 
 
 
 I 
 
 Fig. 28. 
 
 vmffMK 
 
 
 Portion of hair from a case of faviis — Tinea favosa 
 — showing spores of vegetable parasitic growth — 
 Achoroin SchUnleinii. (Reduced from Bazin.) 
 
 Portion of hair from a case ot 
 ringM'orm, showing vegetable 
 parasitic growths (with sporules 
 infiltrating hair, and a fragment 
 of a tubular growth) — the Tri- 
 cJiopliyton tonsurans. (Reduced 
 from Baziu.) 
 
 off short ; there is often white dust at their bases, and the skin 
 between them j^resents an appearance like that of a plucked 
 
128 
 
 CUTANEOUS ERUPTIONS 
 
 fowl. The parasite in riDgworm is named Tinea trichophytina 
 or Tricophyton tonsurans. 
 
 In examining hairs, scales, crusts, etc., for vegetable para- 
 sites certain precautions should be used. A diseased hair- 
 should, of course, be selected, if possible, for the examination ; 
 we judge by its stunted, brittle appearance, and by its loose- 
 ness on extraction. In examining scales, too much of them 
 may render the specimen rather opaque ; the scales and even 
 the hairs may have to be dissected by needles to expose the 
 j^arasitic growths. Digestion in a solution of caustic potash 
 renders the specimen more transparent. In certain cases it is 
 desirable to get rid of the fat about the hair or the scales, as 
 the small oil globules simulate vegetable spores. To remove 
 these, sulphuric ether may be used, either before the applica- 
 tion of the potash or after it, the specimen being dried from 
 the one before the other is applied. 
 
 In examining for vegetable parasites, we search for sj)ores 
 
 Fro. 20. 
 
 Downy hairs found in ringworm after treatment by blistering. The upper hair shows 
 the point sijlit into filaments by the action of the parasite; the lower shows the shaft 
 split up in the same way : 250 diametei's. (Drawn by Dr. John Wilson.) 
 
 (conidia) ; these are small globular bodies, usually arranged 
 in groups or clusters, or in rows ; when rows of these exist they 
 may give off branches (sporidia). Branching tubes, often of 
 a very fine thread-like structure, constitute the " mycelium " 
 or " thallus " of these vegetable growths ; they vary much in 
 diameter, and often interlace in the most intricate manner. 
 These growths are not destroyed by caustic potash, alcohol, 
 ether, or chloroform ; in doubtful cases, where fat, blood, or 
 pus may simulate spores, these reagents may be absolutely 
 
RINGWORM 
 Fig. 30. 
 
 129 
 
 ^\Sm8i^ 
 
 o ooRo 
 
 Hairs from a case of Tinea ton.'nirans, or ringworm, showing the parasite - Tinea trivo- 
 phytina. One of the hairs shows the brittle character often found in this disease. Free 
 spores are Feen lying loose as well as in the substance of the hair: 300 diameters. 
 (Drawn by Dr. John Wilson.) 
 
130 CUTANEOUS ERUPTIONS. 
 
 necessary for the discrimination. Foreign bodies containing 
 vegetable fibres may sometimes simulate mycelium, but care 
 in selecting the specimen and the absence of branching usually 
 prevent error. The various jieculiarities in the parasitic 
 growths and in the hairs may be seen in the drawings of 
 favus and ringworm. (See Figs. 25 to 30, with the descrij)- 
 tive notes.) 
 
 Febrile Rashes. 
 
 Certain specific febrile diseases are characterized by the 
 appearance of a cutaneous eruption. They are typhus, enteric, 
 and scarlet fever, measles, smallpox, and cliickenpox ; ery- 
 sipelas may also be included in this list for our present pur- 
 pose. In addition to these, cutaneous eruptions, of a varied 
 and uncertain character, are occasionally seen in relapsing 
 fever, in diphtheria, and in cerebro-spinal meningitis ; some 
 have alleged the occasional presence of an eruption in pneu- 
 monia and acute tuberculosis, but this must still be reckoned 
 doubtful. In all of these diseases the eruption is preceded by 
 constitutional disturbance and the general signs of fever, 
 especially by pyrexia, shiverings, sickness, and vomiting, 
 headache, pain in the back, and general malaise, delirium, 
 and great nervous disturbance : convulsions may be met with 
 in children. Certain of these symptoms are more pronounced 
 in some fevers than in others, and several of them may be 
 almost absent in a given case. In addition to those which 
 may be regarded as more or less common to all, special symp- 
 toms are found in special fevers : as the sore throat of scar- 
 latina and diphtheria, the bronchial catarrh and coryza of 
 measles, and the diarrhoea of enteric fever. The history of 
 infection or the presumption of immunity in the individual 
 from previous attacks of special fevers sometimes guides our 
 diagnosis. The date at which the rash appears, or its absence 
 at a given time, constitutes an important element in the dif- 
 ferential diagnosis. But in considering the following dates 
 some allowance must be made for uncertainty in fixing the 
 correct date of the illness ; for a slight variation from the 
 average date of the eruption ; and also for the occasional 
 delay of the eruption quite beyond its usual term, or even for 
 its non-appearance, its suppression, or its fugitive character 
 (especially in malignant scarlatina). 
 
 Sul)jcet to these qualifications, which are indicated more 
 
INCUBATION" OF FEVERS. 131 
 
 fully in the remarks on the eruj^tious in detail, the following 
 dates may be given : 
 
 Date of Appearance of the Febrile Rashes after 
 THE First Signs of Illness. 
 
 Scarlatina rash appears on the first or second day. 
 
 Smallpox appears on the third day. 
 
 Measles appears on the fourth day. 
 
 Typhus appears on the fifth day. 
 
 Enteric fever appears on the seventh day or later. 
 
 Chickenpox usually shows itself within the first day after the con- 
 stitutional disturbance, but this is often so slight as not to be clearly 
 marked. 
 
 German measles (red measles, rotheln, roseola, rosalia, etc.) may 
 appear on the second, third, or fourth day, or the rash may be amongst 
 the ver}^ first symptoms recognized. 
 
 Erysipelas varies considerably as to the date of its appearance on 
 the skin, but may usually be detected on the day after shiverings or 
 other febrile disturbances have appeared. Occasionally, however, the 
 rash is delayed or suppressed, or appears only as fugitive patches 
 which readily escape notice, just as happens in certain cases of scar- 
 latina. 
 
 PERIOD OF INCUBATION. 
 
 This is not always uniform, and in many cases cannot be determined 
 with accuracy, as the infection may linger in the clothing or other 
 materials (fomites), for some time after the more obvious exposure of 
 the person to the disease. 
 
 Scarlatina: incubation period varies from a few hours to eight or 
 ten days ; apparent prolongation for a longer period (which is not 
 unusual) can often be explained more naturally on the supposition 
 of infection through clothing and the like. 
 Sm,all2iox : thirteen or fourteen days. 
 Varicella, or chickenpox : ten to fourteen days. 
 
 Measles: usually about a fortnight; said to be seven days when 
 inoculated from nasal mucus ; variation in extreme from seven to 
 twenty-one days. 
 German 'measles (Rotheln) : varies from seven to fourteen days. 
 Typhus fever : varies from a single day to nearly three weeks ; usually 
 
 about seven to fourteen days. 
 Enteric fever : about two or three weeks. 
 Erysipelas : period very uncertain ; probably short, as a rule. 
 
 LIABILITY TO SECOND ATTACKS. 
 
 Scarlatina: an indubitable second attack very rare, but not un- 
 known ; dubious illnesses erroneously called scarlet fever may 
 account for most of the so-called second attacks. 
 
 Varicella, or chickenpox : a second attack extremely rare. 
 
 Typhus fever : a second attack extremely rare, but not unknown ; 
 the common confusion between typhus and typhoid (enteric) fever 
 must be remembered in judging of the history of patients. 
 
182 CUTANEOUS ERUPTIONS. 
 
 SynaUpo.v : a second attack by no means rare ; errors in ttie diagnosis 
 from other forms of pustular eruptions are quite possible. Traces 
 of former attacks are usualU^ visible. 
 
 Measles: a second attack, as alleged, is very common ; possibly this 
 may arise from there being two forms of measles with quite dis- 
 tinct powers of infection (see " Rotheln" or " German measles "). 
 
 Eiiteric fever : one attack does not seem to afford much if any pro- 
 tection from a second (relapses are also very common). 
 
 E7'ysipelas : one attack seems rather to predispose to a second than 
 to afford exemption. 
 
 The scarlatina rash, when well developed, presents a bright 
 uniform redness very similar to that of a boiled lobster. In 
 the early stage a multitude of minute red points can often be 
 recognized, but these soon coalesce and present a uniform 
 redness. The rash usually appears first on the chest, abdo- 
 men, neck, or back. It sometimes conies out first on the legs. 
 It disappears on pressure — pressure with the fingers, or strokes 
 with the nails leaving white marks. In the progress of the 
 rash it extends from the trunk to the arms and legs, and 
 frequently can be seen to have, as it were, fresh developments, 
 fading in one part while extending to others, and varying in 
 brightness at different times. Toward the end of the first 
 week it usually begins to fade, and disappears as a rule before 
 the tenth or twelfth day. After the rash fades desquamation 
 begins, and this is usually in proportion to the severity of 
 the rash. (Desquamation, arthritic pains, and albuminous 
 urine often point to the scarlatinal nature of a rash previously 
 reo-arded as triflino:.) At times the scarlatina rash is so faint 
 and evanescent as to elude recognition. Examination by 
 good daylight is very important in such cases. In malignant 
 forms the rash is sometimes very dusky or almost petechial ; in 
 other cases it is patchy and shifting in its appearance. In the 
 puerperal form the rash may not be noticeable, or may only 
 be traceable as slight patches on the hands or elsewhere. 
 
 The rashes most likely to be mistaken for scarlatina are 
 the belladonna rash, the eruption of urticaria when the white 
 parts of the wheals are absent, and some forms of erythema. 
 This last disease has probably been the real affection in some 
 ])atients said to have been repeatedly attacked by scarlatina. 
 In young infants a transient erythema or roseola sometimes 
 simulates scarlatina ; its repetition and the absence of sore 
 throat serve to distinguish it. The bright redness and the 
 copious desquamation in "Pityriasis rubra acuta" have some- 
 times been mistiikcn for scarlet fever. In "German measles," 
 the rash often resem])les scarlatina so closely that it cannot 
 
SMALLPOX. 133 
 
 be discriminated in the later stage of the eruption. In all 
 cases of doubtful rash, the character of the tongue, and especi- 
 ally the presence of sore throat, with patches on the tonsils 
 or ulcerations, constitute most important guides ; indeed, ivhen 
 the rash is copious we must have great hesitation in admitting 
 its scarlatinal nature if there be no sore throat. Constitutional 
 disturbance and j)yrexia are present in all degrees in scarla- 
 tina, and sometimes are so slight as to evade our recognition. 
 Subsequent desquamation or peeling of the skin about the 
 fingers or elsewhere, and the occurrence of albuminuria about 
 the tenth to the twentieth day, often clear up the nature of 
 a doubtful rash. A previous attack of scarlatina is not an 
 absolute protection from this disease, but it is rare to find 
 clear evidence of a second attack. There is great variety in 
 the predisposition to take scarlet fever. A person may have 
 been exposed to the disease, even in the same bed, and escape 
 the infection, but may be attacked on much slighter exposure 
 later on. 
 
 An eruption of roseola, resembling, to some extent, that of 
 scarlatina, sometimes appears before the smallpox rash comes 
 out. It is likewise found after vaccination, and revaccina- 
 tion. A similar redness is noticed occasionally in enteric 
 fever in its early stage, and in connection with relapses. 
 (Roseola exanthematica.) 
 
 The smallpox eruption (variola) appears as a rule on the 
 third day, but sometimes on the second, fourth, or fifth. In 
 serious cases it appears early, as a rule. The stage of incuba- 
 tion is usually a fortnight. Occasionally a " roseola " precedes 
 the true smallpox eruption, giving rise to the idea of scarla- 
 tina. The appearance of the smallj)ox rash is usually associ- 
 ated with a distinct, and often Avith a very great diminution 
 of the previous febrile disturbance (see Fig. 10;, unless, in- 
 deed, in the graver forms, where the decline may be scarcely 
 noticeable. The eruption appears first on the face and neck 
 in most cases, but sometimes on the palate, the wrists, or the 
 trunk ; it spreads to the other parts in a day or two. At the 
 beginning the eruption consists of red papules : these can be 
 felt to be hard, like small shot embedded under the skin. 
 The pimples in the course of a day or two become vesicular, 
 but the contents rapidly become purulent, and an area of in- 
 flammation (areola) appears around the pustules ; consider- 
 able swelling and itching of the skin usually accompany a 
 severe eruption. When the pustules run into one another 
 they are called " confluent," when they remain quite separate 
 
 12 
 
134 CUTANEOUS ERUPTIONS. 
 
 the term " discrete " is applied. A depression in the centre of 
 the pustule usually becomes apparent soon after it is formed, 
 but this " umbilication," as it is called, does not always occur, 
 and sometimes it becomes effaced. Each pustule is multi- 
 locular. The " maturation " of the pustule occurs about the 
 ninth day. As the pustules shrink scabs are formed, and 
 when these separate dark colored stains remain for a time. 
 Depressed marks or " pits " are left in proportion to the sever- 
 ity of the case. The smallpox papules may often be felt in 
 the roof of the mouth, the soft palate, and the tongue ; the 
 eruption occurs, also, in other parts of the mucous surface. 
 In severe cases hemorrhages are seen under the skin as well 
 as inside the pustules. Hemorrhages from the mucous mem- 
 branes and a few papules may be the only visible manifesta- 
 tion of hemorrhagic smallj)Ox. 
 
 In smallpox modified by vaccination (varioloid), the erup- 
 tion is usually less abundant and is not often confluent. The 
 constitutional disturbance may be considerable or but slight. 
 The eruption may closely resemble that of unmodified small- 
 pox, or it may consist simply of a few abortive pimples with- 
 out any proper vesication or pustulation. Vaccination and 
 re-vaccination lessen the chance of contracting smalljjox very 
 materially. (For diagnosis see below.) 
 
 Chickenjwx (varicella) resembles smallpox in many respects, 
 but it is essentially vesicular, although it may be j^ustular 
 where irritated ; the hard nodular papules are usually absent. 
 The eruj^tion has no sj^ecial preference for the face, but rather 
 for the shoulders, back, and hairy scalp. The vesicles are 
 preceded by an eruption of red spots, but slightly elevated : 
 the lesion is altogether much more superficial than in small- 
 pox and there are no dissepiments in the vesicles. The erup- 
 tion usually appears within twenty-four hours of the preceding 
 disturbance, if there has been any, but as a rule this is slight. 
 A succession of separate crops of the eruption can often be 
 recognized from their being present in different stages. It is 
 an infectious disease, but usually attacks children only. It is 
 not prevented by vaccination, and does not protect the patient 
 from smallpox. 
 
 The chief difficulties in the diagnosis of smalljwx arise in the 
 slighter forms, occurring in vaccinated persons, as the few 
 })imples which appear may be regarded as trivial, especially 
 if the patient be subject to acne. In some forms of measles a 
 certain resemblance to smallpox arises from the si)Ots in the 
 early stage being unusually hard, or from the dusky hue and 
 
GERMAN MEASLES EASH. 135 
 
 hemorrhagic tendency of the rash. In some forms of small- 
 pox also, the rash resembles measles from a transient efflores- 
 cence forming a basis for a subsequent papular eruption. The 
 presence or absence of the shot-like papules peculiar to small- 
 pox and the subsequent course usually guide us aright. A 
 pustular eruption in syphilis sometimes resembles smallpox 
 very closely, especially when it appears after great general 
 disturbance. An eruption from iodide of potassium, usually 
 papular but sometimes pustular, occasionally simulates small- 
 pox. The presence of the loculi and the umbilication in 
 smallpox pustules are often useful in guiding us. 
 
 Chickenpox, although usually differentiated easily enough 
 from smallpox, is sometimes quite undistinguishable from the 
 modified form of the disease, at least in isolated cases. 
 
 The measles eruption (rubeola, morbilli) appears usually 
 on the fourth day, and corresponds with an exacerbation of 
 the prodromal fever. (See Fig. 11.) It appears almost 
 always on the face first. It consists of elevated red spots or 
 patches, which tend to assume a circular or crescentic outline. 
 At first the skin between the spots is not red, but it usually 
 becomes so in some parts, and the elevated patches often coa- 
 lesce. The eruption spreads from the face to the trunk, and 
 from the trunk to the limbs. It may be three or four days 
 before the rash attains its maximum extent, and it may be 
 fading in some parts as others become affected. The rash 
 fades on pressure in ordinary cases, but in grave forms the 
 eruption may be dusky and even petechial. Considerable 
 swelling of the skin of the face is usually obvious in measles. 
 The coincident phenomena generally guide us aright in the 
 early stage or in doubtful cases ; running at the nose and 
 eyes, sneezing, cough, and bronchitic rales are very common. 
 In cases with a receding or undeveloped rash we have, at 
 times, grave nervous disturbance. 
 
 The eruptions most likely to be confounded with measles 
 are copaiba rash, typhus, roseola, and hemorrhagic smallpox 
 in the early stage. 
 
 The German measles rash (rubeola notha, roseola, rotheln, 
 rosalia) resembles at times measles and at times scarlatina, or 
 it may begin with a resemblance to measles and become very 
 like scarlatina. It does not show such a preference for the 
 face as measles, and the crescentic character is less marked. 
 The rash may be very abundant with but a moderate tempera- 
 ture (102^ or 103° F.). It usually appears about the same 
 time after the beginning of the febrile disturbance as a scar- 
 
186 CUTANEOUS EKUPTIONS. 
 
 latina rash, but may be somewhat later. There may be slight 
 sore throat, but seldom any distinct patches or ulceration. 
 There may be slight bronchial catarrh. The symptoms, like 
 the rash, present a combination of the peculiarities of scarla- 
 tina and measles, but the whole disease is usually mild and of 
 short duration, and the rash disappears in three or four days. 
 The disease is communicated by a special infection, evidently 
 different from that of either scarlatina or measles, and a pre- 
 vious attack of one or both of these diseases does not protect 
 the patient from German measles. It is probable that this 
 disease is often involved in the not uncommon reports of chil- 
 dren having had measles twice. This form of eruption is 
 sometimes confused with a copious typhus rash, as well as 
 with scarlatina and measles. It also resembles the copaiba 
 rash. 
 
 The typhis rash appears from the fourth to the seventh day, 
 usually about the fifth day from the first signs of acute illness. 
 The rash is but rarely absent in typhus fever, except in mild 
 attacks in young patients, and its extent and depth bear a dis- 
 tinct relation to the severity of the case. It is, however, very 
 apt to be overlooked by the inexperienced, owing to its delicate 
 tint, to its brief duration in some cases, or to the absence of 
 good daylight for the examination. Sometimes the inexperi- 
 enced look too closely into the skin, and so fail to see the 
 mottled rash, which becomes more evident when looked at 
 from a little distance. A dirty condition of the skin, and the 
 presence of flea-bites, also render the recognition of a typhus 
 rash more difficult. Flea-bites, indeed, present a considerable 
 resemblance to typhus spots in certain stages, but the central 
 minute dark dot or bite can often be recognized; flea-bites 
 also are generally aggregated on covered parts of the body, 
 typhus spots are often seen on the back of the hands. Before 
 the rash appears in a definite form there is frequently a con- 
 gestion or redness of the skin, well shown on pressing with the 
 fingers, especially over the back, the chest, and the belly. 
 This condition is associated with suflfusion of the eyes, and a 
 dingy complexion. 
 
 There are two elements in the typhus rash, which, however, 
 are not always both present — these are definite spots and a 
 more general m(^ttling. The spots, when seen immediately after 
 their appearance, are usually red, perhai)S slightly elevated, 
 and they disap))car on pressure. They vary in size up to 
 about a quarter of an inch in diameter, and are irregular in 
 their form. In a day or so they become dirty looking, and 
 
ENTERIC FEVER ERUPTION. 137 
 
 cease to disappear on pressure. Fresh spots may appear dur- 
 ing the first two or three days of the eruption, but these are 
 sujieradded to the first ones, which remain. The spots ulti- 
 mately become bluish or reddish-brown in color, and distinct 
 petechise or subcutaneous hemorrhages are not unfrequently 
 developed in the typhus spots. In addition to the distinct 
 spots just described, we usually have soon after they appear a 
 general mottling of the skin, as if there were a "subcuticular" 
 eruption of minute spots. This, indeed, may be the only 
 eruption visible in certain cases, especially in the mild forms. 
 This mottling requires a good light for its observation, and 
 the chest and abdomen should be well bared for the examina- 
 tion ; pressure of the fingers is useful in ascertaining the pres- 
 ence of this rash. The term " mulberry rash " has been used 
 as descriptive of the general appearance of the typhus erup- 
 tion. The parts on which the eruption first appears are the 
 trunk, more especially on the front, the parts about the front 
 of the shoulders, and sometimes even the arms and hands. 
 The legs, and particularly the face, are less affected, but when 
 the rash is copious the distribution may be very general. The 
 rash persists for about a week after its appearance, fading 
 somewhat as improvement begins, or becoming blue, dark, or 
 petechial as death approaches, and the spots continue to be 
 visible on the dead body if the rash has existed for some 
 time. 
 
 A second attack of genuine typhus is very rare, but owing 
 to the frequent confusion of enteric fever, and perhaps pneu- 
 monia, with this disease, the mere fact of a former attack 
 being alleged cannot be much relied on, but special inquiries 
 as to the place in which the illness occurred, and as to its 
 symptoms, may clear up the doubts. 
 
 The eruptions most likely to be confused with typhus by 
 the inexperienced are those of measles, German measles, and 
 flea-bites. A rash somewhat resembling that of typhus ap- 
 pears occasionally in relapsing fever. A much more common 
 error, however, consists in overlooking the presence of the 
 rash altogether. 
 
 The enteric fever eruption is almost never very obtrusive, and 
 so it is seldom noticed by the public; as a rule, it requires to 
 be carefully looked for. It appears chiefly on the trunk, and 
 especially on the abdomen, but an examination of the back 
 sometimes discloses the only spots visible. The eruption con- 
 sists of small circular rose-colored papules (lenticular spots) 
 jiot exceeding one-eighth of an inch in diameter; they are 
 
138 CUTANEOUS ERUPTIONS. 
 
 slightly but distinctly elevated ; they fade, or almost dis- 
 appear on gentle pressure, and they fade in this Avay so long 
 as they last, differing in this respect from the typhus spots. 
 The number of these spots in a case of enteric fever varies 
 exceedingly ; in some cases only two or three such papules 
 can be found on a careful search of the whole body, and in 
 others there may be twenty or thirty on the abdomen. The 
 abundance of the eruption bears no relation to the severity of 
 the case. Some cases present only one or two spots, although 
 carefully examined every day, and not very unfrequently no 
 eruption can be found at all. The spots appear in successive 
 crops, each crop lasting about four or five days before disap- 
 pearing. This feature of a succession of rose spots is most 
 important in the diagnosis. It can be demonstrated by mark- 
 ing with ink all the spots visible to-day, say with a circle, 
 those which appear to-morrow with a triangle, and those which 
 appear next with a square ; by the time these last appear, the 
 first marks will be found empty or containing only the merest 
 trace of a spot. This eruption seldom appears before the 
 seventh day of the fever, but its appearance is often much 
 later. Fresh eruptions may continue to appear until con- 
 valescence is fairly established, and they may appear during 
 a relapse, even although none were present in the first attack. 
 
 In addition to those rose-colored lenticular spots, very deli- 
 cate blue patches (taches bleuatres) have been described in 
 this fever as appearing on the abdomen, and an eruption of 
 sudainina is regarded by some as very characteristic of this 
 disease, but these last are found in various other affections. 
 (See "Sudamina," p. 139.) 
 
 The chief sources of fallacy in connection with the erup- 
 tion of enteric fever are: (1) An imperfect examination of 
 the trunk of the body. (2) Mistaking the presence of acci- 
 dental pimples for true " rose spots ; " the marking and subse- 
 quent observation of these bring out their difference. (3) 
 Typhus spots when freshly out sometimes resemble "rose 
 spots," as they fade on pressure at this time, but become per- 
 sistent after a day or two. There is no mottling between the 
 enteric rose spots. (4) An abundant eruption of " rose spots " 
 has sometimes been confounded with a typhus rash. 
 
 (Enteric fever is contagious, no doubt, chiefly through the 
 intestinal excretions ; it fre(iuently afl^ects various inmates of 
 a house about the same time, and arises very often from bad 
 drains or leaking soil pipes and contaminated water supply. 
 This may operate in poisoning milk, which seems to be a very 
 
EEYSIPELAS. 139 
 
 suitable vehicle for the propagation of the poison. A pre- 
 vious attack does not seem to afford much, if any, protection 
 from a second. Inquiry into these matters may aid the diag- 
 nosis.) 
 
 Sudamina or miliary vesicles are minute accumulations of 
 the secretion from the sweat ducts, arising from obstruction to 
 their openings. They vary in size, but are seldom larger 
 than a pin-head. They can be felt as giving a roughness to 
 the surface and can be seen in good light as glittering points. 
 Their contents are usually clear ; occasionally there is evi- 
 dence of inflammatory action in their contents being opaque 
 and their bases inflamed. This latter condition has been 
 separated from sudamina by some, and named " miliaria." 
 
 Sudamina are found in various diseases characterized by 
 much sweating, and have no specific significance, although 
 formerly they Avere regarded in this light. They are common 
 in enteric fever, acute rheumatism, phthisis, and after child- 
 birth. 
 
 Erysipelas is characterized by redness of the skin, the in- 
 flammation has a deeper seat than in erythema, and there is 
 usually very considerable swelling and elevation of the aflfected 
 part. The redness is usually pretty sharply defined by a line 
 bounding the part aflected, and it extends, as a rule, in a 
 continuous way from one part to another. Vesication is not 
 uncommon in erysipelas if severe, and even the deeper subcu- 
 taneous tissue may be involved in the more serious forms 
 (phlegmonous erysipelas) which are met with in surgical prac- 
 tice. Erysipelas often extends from wounds or sores, especially 
 when it arises from infection ; but it may be idiopathic, and it 
 seems at times to arise from direct exposure of the part to 
 cold. In medical i^ractice it is usually found attacking the 
 head and face, causing much swelling of the loose tissues 
 about the eyes and nose. Or it may attack a limb, or begin- 
 ning in one leg it may spread up the thigh, and crossing over 
 come down the other leg. It .occurs in newly born children, 
 spreading sometimes from an unhealthy umbilicus, but it may 
 appear in older children also, apart from any open sore. It 
 may attack puerperal women, who are specially liable to such 
 infection, and in some cases of undoubted erysipelas no rash 
 may be visible ; these attacks are usually called puerperal 
 fever. Sometimes in grave forms of erysipelas the patches of 
 redness are irregular and fleeting, readily esca2:)ing notice. In 
 connection with extreme dropsy of the legs, whether the skin 
 
140 CUTANEOUS EKUPTIONS. 
 
 gives way or is punctured, and sometimes aj^art from any 
 oozing, erysipelas often forms a grave complication. 
 
 Staining, Pigmentation, and Discoloration of 
 THE Skin. 
 
 Subcutaneous hemorrhages are recognized by their being 
 unaffected on pressure. When small, the words " petechife " 
 or " ecchymoses " are used : when large, the term " vibices " 
 is sometimes applied. These hemorrhages are found in typhus 
 fever, in smallpox, in purpura, in scurvy, in diseases of the 
 liver and sj^leen, and in the terminal stage of dropsy and 
 other exhausting diseases. We must examine for any history 
 of hemorrhage from the nose, gums, or bowels, in cases of 
 .purpura or of the hemorrhagic diathesis ; and we may some- 
 times find submucous hemorrhages in the mouth. Purpura 
 also occurs in connection with rheumatic affections of the 
 joints. In sus^^ected scurvy we inquire for a history of de- 
 privation of vegetables and milk ; this may readily occur in 
 laborers who often live on tea and bacon and bread. The 
 presence of spongy gums and fetid breath, and the existence 
 of pain and hardness near the hemorrhagic patches, especially 
 in the calf, usually guide us aright. In disease of the liver, 
 leukaemia, etc., the spots of hemorrhage seem to be due to a 
 depraved state of the blood. In typhus fever, smallpox, and 
 measles, subcutaneous hemorrhage is an indication of the 
 gravity of the attack. (See, also, Chapter IX., " Hemor- 
 rhages.") 
 
 Port-ioine stains, ncevi, moles, etc., need only be mentioned 
 here. Tlieir existence since childhood and their general 
 appearance usually prevent any misconception. 
 
 Discoloration of the skin sometimes results from external 
 agencies, as the application of iodine or nitrate of silver. 
 Frequently repeated poulticing and blistering may likewise 
 give rise to a dark mottling or pigmentation of the skin. 
 On the legs, especially of old people, but also in some others, 
 we often find considerable darkening and mottling from the 
 patients sitting much with their legs near the fire. 
 
 Of medicines administered internally, nitrate of silver may 
 be mentioned as giving rise to a dark l)luish discoloration of 
 those parts of the skin exposed to the liglit. This is a rare 
 accident nowadays, but with such an alteration in color, especi- 
 ally in one subject to epileptic fits, we must inquire whether 
 this remedy had been used. 
 
PITYEIASIS VERSICOLOR. 
 
 141 
 
 The yellow tinge of jaundice is described elsewhere, and 
 some of the conditions most likely to be confounded with it 
 are there referred to. (See Chapter XII.) Associated some- 
 times with jaundice, but also occurring independently of it, 
 we have at times localized yellow patches, chiefly about the 
 eyelids, but sometimes elsewhere (xanthelasma) ; occasionally 
 the yellow discolorations are associated with distinct firm 
 tumors of small size occurring in various parts (xanthoma). 
 
 Chlorosis, syphilis, malarial fevers, and cancers may all pro- 
 duce an unhealthy color and complexion. In phthisis, also, 
 we sometimes see considerable pigmentation about the cheek- 
 bones, and around the orbits. 
 
 Great exposure to the air and weather, associated with un- 
 cleanliness, gives rise to a darkening of the skin with brownish 
 spots and freckles, and sometimes a more general and uniform 
 discoloration (vagabondismus). Sailors and others exposed 
 to tropical climates have frequently a swarthy look, and the 
 influence of race must not be forgotten. 
 
 In pityriasis versicolor there are defined patches of brownish 
 discoloration, with minute scales, situated usually on the chest 
 
 Fig. 31. 
 
 Microspor on furfur, the vegetable parasite of pityriasis versicolor. 
 Drawn by Dr. John Wilson. (Dr. M' Call Anderson.) 
 
 or at least on the trunk ; the parasitic nature of this eruption 
 can be demonstrated by scraping ofl" a few scales, digesting in 
 liquor potassse, and examining by the microscope. The branch- 
 ing growths of the parasite and the aggregation of spores in 
 bunches are shown in the diagram (Fig. 31;. 
 
142 CUTANEOUS ERUPTION'S. 
 
 Pregnancy is very often characterized by considerable pig- 
 mentation. It is chiefly marked around the nipple, about the 
 linea alba, and on the face. In uterine tumors, and in other 
 forms of uterine disease, there are often distinct brownish 
 patches on the face, chiefly on the brow, but other parts may 
 also be aflected (chloasma uterinum). 
 
 In Addison's disease, the pigmentation affects chiefly the 
 face, the exposed part of the neck, the backs of the hands, the 
 axillary and umbilical regions, the genitals, and the inner 
 aspect of the thighs. This discoloration, described as " bronzed 
 skin," resembles the tint of a mulatto, but in some parts the 
 discoloration is darker or almost black. In many cases, con- 
 siderable assistance is experienced by finding brownish stains 
 or black streaks on the buccal mucous membrane and on the 
 tongue and the nipples, although these also may occur in other 
 conditions. The constitutional symptoms associated with the 
 pigmentation in Addison's disease are those of asthenia rather 
 than of emaciation, combined wdth great feebleness of the mus- 
 cles, including the heart itself. Pains in the back and vomit- 
 ing are not uncommon. The disease is often complicated with 
 pulmonary phthisis, or disease of the vertebrae, but the diag- 
 nosis can be most safely arrived at when the prostration and 
 discoloration seem otherwise inexplicable. It is commonest 
 in young male adults ; greater care is required in the diag- 
 nosis in the case of women, and especially if there be any 
 uterine irregularity. The presence of hepatic or renal disease 
 ought also to make us more guarded in our diagnosis in cases 
 of bronzing. 
 
 White patches of skin may result from cicatrices of all 
 kinds. White streaks are seen in connection with atrophic 
 lesions of the skin, which may be associated with evidence of 
 atrophy or defective formation elsewhere. White vertical 
 lines on the abdominal walls are found habitually in women 
 who have borne children ; they sometimes guide us in forming 
 an opinion as to this fact. They arise from previous disten- 
 tion : similar streaks are found in persons of both sexes and 
 in children, in connection with former dropsical swellings of 
 the belly. White patches from simple absence of pigment in 
 the skin are named vitiligo or leucoderma : around the margin 
 of the w'hite patch there is an increase or deepening of the 
 natural color of the skin. Absence of pigment in the skiiii, 
 ]\a,{r, and choroid constitutes albinism. 
 
SYPHILITIC ERUPTIOKS. 143 
 
 Syphilitic Eruptions. 
 
 Syphilitic eruptions assume nearly every variety of appear- 
 ance found in disease of the skin. It is of more importance 
 to recognize an eruj^tion as syphilitic than to define its special 
 form. 
 
 The following points for such a discrimination are given by 
 Dr. Tilbury Fox : 1. Previous syphilitic infection, as evidenced 
 by the history, by cicatrices of the primary sores, etc. 2. The 
 symmetry of syphilitic eruptions. 8. Their so-called " copper 
 color ; " dull red at first, becoming reddish yellow-brown. 
 4. A tendency to circular form of the patches. 5. The scales 
 when present are very light and small. 6. The crusts are 
 thick, greenish, or black, and adhere firmly ; vesicles are flat, 
 and do not rujoture readily ; ulceration is common, the surface 
 ashy gray, and the edges sharp. 7. Pain and itching in the 
 parts are not usually troublesome. 8, Polymorphism ; papules, 
 pustules, and tubercles coexist in the same subject, or one 
 form of eruption gradually assumes the character of another. 
 
 As to the different periods of syphilitic eruptions he gives 
 the following chart : 
 
 1st period — Syphilitic fever, with transient hypersemia of 
 the skin, giving rise to roseola, etc. (about the same time 
 as the sore throat — a few weeks after infection). 
 2d period — Hyj^ersemia and infiltration about the seba- 
 ceous glands — syphilitic acne. 
 
 Hypersemia and deposit in the hair follicles, syphilitic 
 
 lichen. 
 In the derma — papular, and tubercular, squa- 
 mous and pustular syphilis. 
 About the nerves — syphilitic herpes and pem- 
 phigus. 
 3d period — Characterized by changes in preexisting syphi- 
 litic formations which lead to syphilitic ulceration, exos- 
 tosis, etc. 
 
 In congenital syphilis we look for mucous tubercles at the 
 anus or mouth, red patches or pustules on the buttocks, ankles, 
 or hands, subacute onychia, fissures at the lips ; a history of 
 " snuffles " at birth, and the presence of notched teeth or of 
 old keratitis or nervous deafness, are important. 
 
144 NAILS — GLANDS. 
 
 Affections of the Nails. 
 
 Affections of the nails sometimes serve to indicate constitu- 
 tional disorders ; there are also, of course, local affections of 
 the parts. 
 
 Carving of the nails is observed along with a clubbed shape 
 of the finger-ends, in cases of phthisis ; sometimes the curv- 
 ing exists without any of the clubbing referred to. This 
 deformity is not limited to phthisis, but is found in various 
 chronic states tending to atrophy. It may be found in cardiac 
 and aneurismal disease, and in the latter is sometimes on one 
 side only. 
 
 Atrophy of the nails, shown by much curving, yellowish- 
 brown discoloration, cracking, etc., may result from lesions of 
 the nerves, or from disease of the spinal cord, and are found 
 at times even in hemiplegia. Cases are reported of shedding 
 of the toe-nails repeatedly in locomotor ataxy. 
 
 Transverse white marks, or thinned portions in the nails, are 
 sometimes clearly seen after serious illnesses, such as fevers, 
 and we may occasionally avail ourselves of them in checking 
 the history or the dates supplied by a patient. A mark of 
 this kind half way up the nail may be reckoned as indicating 
 an illness three or four months previously. 
 
 The nails are sometimes shed in pityriasis rubra, and in 
 severe eczema affecting their neighborhood. In psoriasis and 
 pityriasis rubra, the nails are often affected, becoming dingy, 
 thickened, curved, grooved, and dirty looking. 
 
 Onychia, inflammation of the matrix of the nail with sup- 
 puration beneath it, and loosening of its attachments, is occa- 
 sionally due to syphilitic disease. Strumous disease may also 
 determine inflammation of the nails. Parasitic diseases some- 
 times affect the nails (favus and ringworm). 
 
 GiANDULAR Affections. 
 
 Affections of the lymphatic glands afford many indications 
 of general constitutional states. They are often, however, 
 merely dependent on local irritation. Thus a sore on the foot 
 or leg, perhaps of a trivial nature, may by the strain of walk- 
 ing give rise to enlargement and tenderness in the femoral 
 glands ; the anatomical relationship of the lymphatics serves 
 to indicate the connection of these with the leg, instead of 
 the genital organs as might at first be supposed. In the neck, 
 also, the jwsterior cervical glands may be enlarged from the 
 
GLANDULAE AFFECTIONS. 145 
 
 irritation of an eczema of the scalp, past or present, and not 
 as the result of constitutional syphilis. A chain of small 
 hard glands in this situation, however, constitutes an impor- 
 tant indication of eonstitutional syphilis, in the absence of any- 
 superficial cause for their enlargement. The inguinal glands 
 are often enlarged, and sometimes proceed to suppuration, 
 from the irritation of a gonorrhoea, or of a soft chancre on 
 the penis; indeed, the history of suppurating buboes and the 
 presence of cicatrices in the groin are to be regarded as evi- 
 dence of some local irritation in the genital organs, rather 
 than a proof of constitutional syphilis ; this may, however, 
 coexist with the other. The typical form of glandular en- 
 largement in the groin due to constitutional syphilis, consists 
 rather in the presence of a group of moderately enlarged, 
 painless, and movable or rolling glands, which proceed to 
 suppuration only in exceptional cases. 
 
 Enlargement of the glands elsewhere may be due to syphi- 
 lis in the exceptional case of a primary sore being contracted 
 in some unusual situation ; a general affection of the whole 
 glandular system is also found at times in constitutional 
 syj^hilis. 
 
 Enlargement of the glands serves as a valuable indication 
 of an affection of the system in certain forms of cancer or 
 epithelioma ; malignant tumors of the breast affect the axillary 
 glands, malignant growths in the throat affect the cervical 
 glands, and so on. Even deep-seated diseases may reveal 
 themselves by such glandular affections, as in the case of 
 malignant growths at the base of the skull involving the 
 glands in the neck, and cancer of the abdominal organs affect- 
 ing some part of the lymphatic system within our reach. 
 
 Enlargement of the anterior cervical glands is due in the 
 immense majority of cases to a scrofulous tendency in the 
 patient, and their presence, or the evidences of their former 
 existence, from the scars and cicatrices left, frequently serve 
 to indicate this constitutional taint. They may, however, be 
 due to some of the other causes referred to in this section. 
 These scrofulous glands sometimes remain chronically en- 
 larged, although free from 2^ain. In persons of a weak con- 
 stitution, the lymphatic glands are sometimes enlarged from 
 exj^osure to cold and other comparatively slight causes which 
 would not affect a robust person. Scrofulous glands may 
 occasionally be felt through the abdominal walls in cases of 
 tabes mesenterica, but owing to the swelling and tension of 
 
 13 
 
146 GLANDULAR AFFECTIONS. 
 
 the belly so frequently present in such cases, very often we 
 cannot detect glandular swellings, even of large size. 
 
 A generalized enlargement of the lymphatic glands is so 
 often associated with Leukcemia, that it is well to examine the 
 blood microscopically when they are thus affected. The rela- 
 tive proportion of white blood corpuscles to the red corpuscles 
 varies greatly even in health, and it is often considerably in- 
 creased in ansemia and also in cancerous affections, but when 
 the proportion, as estimated carefully in various fields of the 
 microscope, amounts to 1 in 20 or 1 in 10, the case may be 
 regarded as one of leukaemia; the proportion is often higher, 
 and the white corpuscles may even equal the red in number. 
 (" See Examination of the Blood," Chapter IX.) In such cases 
 we must see if there is any enlargement of the spleen. Leu- 
 kaemia may exist with enlargement of the lymphatics alone 
 (lymphatic leukaemia), or with enlargement of the spleen 
 alone (splenic leukaemia), or both forms of enlargement may 
 be present. General enlargement of the lymphatic glands 
 may exist without leukaemia, although dependent on some 
 grave constitutional afiection; the name "Hodgkin's disease" 
 is sometimes applied to this special variety, although it is 
 applied by others in a more general sense to cases of various 
 kinds with lymphatic enlargements (lymphadenoma). In 
 such cases there is sometimes a complication from the jDres- 
 ence of a mediastinal or abdominal tumor (lymphoma) of a 
 similar nature ; these may give rise to exudations, and so the 
 case may be mistaken for a pleurisy or peritonitis occurring 
 in a scrofulous subject. 
 
 Enlargement of the cervical glands is of habitual occurrence 
 in scarlet fever ; it sometimes appears very early in the disease, 
 before the other symj^toms have been developed, but usually 
 comes on about the second or third day of the illness, or even 
 later. It is specially marked in the grave forms with serious 
 affection of the throat ; in young children, the enlarged glands 
 may appear like a collar surrounding the neck, this is always 
 a very serious indication. Glandular affections in connection 
 with ulceration of the throat, appearing late in the course of 
 the fever, are always of special gravity. In scarlatina, these 
 glands often suppurate and lead to extensive sloughing. 
 
 Glandular enlargements in the neck, especially about the 
 angle of the jaw, are sometimes found in diphtheria and other 
 forms of sore tliroat and tonsillitis, but they seldom attain the 
 size or extent common in scarlet fever. 
 
 Parotitis. — Inflammation and suppuration of the parotid 
 
JOINTS. 147 
 
 may be due to scarlet fever, from the general invasion of the 
 glands in this region. Parotitis is a sequela of typhus which 
 is not uncommon. It is but rarely seen in relapsing and other 
 fevers or in erysipelas. 
 
 Parotitis may also occur as a special affection, due to 
 some specific infection (mumps). It is very liable to spread 
 in schools; the period of incubation is about a fortnight. 
 This disease attacks children chiefly, but not exclusively, and 
 especially between five and fifteen years of age. Sometimes 
 it is unilateral but usually double. There is considerable pain, 
 especially on moving the jaws, and a certain amount of fever 
 and constitutional disturbance is common. This form of paro- 
 titis seldom proceeds to suppuration, but it sometimes sets up 
 a purulent otitis. Occasionally affections of the breast or tes- 
 ticle, by metastasis, have been observed. 
 
 An affection of the parotid, differing from mumps, associated 
 with marked swelling and even suppuration, may depend on 
 the implication of the lymphatic glands in its vicinity rather 
 than on inflammation of the parotid itself. 
 
 The salivary glands when much swollen or affected with 
 calculi usually come under the notice of surgeons. 
 
 Plague, Glanders, etc. — Acute glandular swelling (buboes) 
 in the axilla, groin, and neck are found as a rule in the 
 plague, associated often with carbuncles and other evidence of 
 serious disturbance, but this disease is not now prevalent in 
 Europe. 
 
 Glandular swellings are likewise found in connection with 
 glanders and farcy, occurring in men infected from horses, 
 asses, and mules ; sometimes pustular eruptions and discharges 
 from the nose likewise appear. 
 
 The Joints. 
 
 The joints should be examined in all cases in which they 
 seem painful. When, from the presence of fever or any other 
 cause, we suspect the existence of acute rheumatism, gout, or 
 pyaemia, we must make a careful search in the joints for any 
 swelling or tenderness. In syphilis, also, the history of pain in 
 the joints is often important. The presence of chronic disease 
 of the joints, or the evidence of past mischief in them, may 
 often throw light on the scrofulous, rheumatic, or gouty ten- 
 dencies of a patient ; the evidence of old disease in the joints, 
 or former suppuration, may serve to explain the existence of 
 lardaceous disease of the viscera. Local disease of the joints 
 
148 JOINTS. 
 
 comes for the most part under the care of the surgeon ; the 
 discrimination of the various lesions from one another, and 
 from hysterical affections, which occasionally assume this form, 
 must be sought in surgical works. 
 
 On the border-line between medicine and surgery is the form 
 of disease popularly called ''rheumatic gout,'' but more correctly 
 named ''rheumatoid arthritis," or " chronic rheumatic arthritis ;'' 
 this is characterized by more or less pain, but especially by 
 enlargement of the ends of the bones, and deformity or 
 "nodosity of the joints;" the parts involved are often twisted 
 out of their position. The knuckles are perhaps the parts most 
 frequently involved in the early stage, but all the joints of 
 the limbs, and even the articulations of the jaw, may be more 
 or less affected. A certain crackling sensation is often ex- 
 perienced by placing one hand over the joints while moving or 
 manipulating them with the other. Although essentially a 
 chronic disease, the patient may have acute or subacute attacks 
 superadded ; we then find redness, swelling with effusion, and 
 tenderness ; in some cases there may be a considerable resem- 
 blance to gout. Enlargement of the ends of the bones always 
 implies an old-standing affection; osseous deposits may like- 
 wise exist in the adjoining ligamentous tissues, and may even 
 be found lying loose in the joints. The general health is 
 usually deteriorated, and the articular mischief often dates 
 from some debilitating or exhausting illness. 
 
 Enlargement of the ends of the bones, and other osseous 
 growths and deformities resulting from spontaneous fractures, 
 are met with occasionally in cases of locomotor ataxy ; or the 
 cartilages may become eroded, giving rise to crackling sounds 
 on manipulation, and even to spontaneous dislocation ; the 
 large joints are those chiefly affected in this disease. Chalky 
 deposits in the joints sometimes simulate the deformity of 
 rheumatoid arthritis, and some doubt may remain in certain 
 cases till the deposits are exposed by ulceration. Enlargement 
 of the ends of the bones, with the appearance of " double 
 joints," occurs in children as one of the characteristics of 
 rickets. (See " Bones.") 
 
 In acute articular rheumatism (rheumatic fever) pain in the 
 joints is usually an early symptom, although there may be high 
 fever for a day or two before this becomes pronounced. When 
 the pains are present in various joints we can seldom mistake 
 the nature of the illness. But when the joints of the spine seem 
 the only parts affected, we may indeed be in doubt, as pain of 
 this kind often arises from serious disease of the bones, or from 
 
EHEUMATIC AFFECTIONS. 149 
 
 certain affections of the spinal cord, or of its membranes. For 
 this reason any case of rheumatism, with acute symptoms, 
 involving the back chiefly, without any swelling of the joints 
 in the limbs, must always be scrutinized carefully during its 
 progress, as many mistakes arise from applying the name 
 " rheumatism " to such an illness ; pain in the limbs, with 
 great tenderness on handling them, may be present in the 
 spinal affections referred to, and this tends further to simulate 
 rheumatism ; more rarely, cerebral meningitis may be char- 
 acterized by hyperaesthesia in this way, and cerebro-spinal 
 meningitis usually presents this symptom. When the patient is 
 known to have had articular rheumatism, the case is so far 
 simplified ; a rheumatic attack may be confined chiefly to the 
 back, but it usually involves other joints also during some part 
 of its course. 
 
 Acute rheumatism usually produces very marked swelling, 
 with considerable effusion into the joints, and along with this 
 there is often redness of the skin, and almost always great 
 pain, especially on disturbing their position in any way, so 
 that the patient becomes very helpless, and dreads the least 
 shaking of his bed. The mischief in the joints appears very 
 suddenly ; it is sometimes very fleeting, shifting about from 
 one limb or one set of joints to another, or from one side of the 
 body to the other. Rela|)ses are very common in this disease, 
 and one attack seems to predispose to another. We inquire 
 in cases of this kind for the history of any previous attacks, of 
 any exposure to cold and wet, and also for any hereditary 
 tendency to rheumatism. We must always make a careful 
 search for the evidence of cardiac mischief, this may exist 
 apart from any thoracic symptoms ; there is, however, usually 
 more or less pain in the chest when pericarditis is present. 
 The temperature of the patient is a very important symj)tom 
 in rheumatism ; a strict watch must be kept on it if it seems 
 to be rising very high. With such elevations we may have 
 alarming delirium, coma, or other cerebral symptoms, although 
 the articular pains may be but slight or may even have 
 greatly diminished. Sweating is habitual in acute rheuma- 
 tism, and the urine is usually high-colored and loaded with 
 urates. 
 
 In children, the joint affection in rheumatism is often so 
 slight and fleeting, that the disease is apt to be overlooked, 
 or attributed to "growing pains." In such cases swelling and 
 pain about the feet are often the most marked features : in 
 older subjects pains in the heels, of an obscure but severe 
 
 13* 
 
150 JOINTS. 
 
 character, seem often to be essentially rheumatic in nature. 
 These slight attacks in children may be complicated with 
 endocarditis or pericarditis, and may lay the foundation of 
 permanent cardiac disease. 
 
 Chronic forms of rlieumatism are found in elderly people, 
 apart, it may be, from any previous acute attacks. This affec- 
 tion is characterized by pain and stiffness of the joints, and 
 the muscles and tendinous structures are also more or less 
 involved. In other cases we have the complication of rheu- 
 matic arthritis. 
 
 Quasi-rheumatic affections of the joints occur in scarlatina and 
 relapsing fever. In the former the articular affection occurs 
 usually after the first violence of the fever is over, and often 
 coincides with the period of albuminuria and cutaneous desqua- 
 mation. There is not usually much swelling in the joints, but 
 the pain is sometimes very considerable. (For more serious 
 articular affections in scarlatina, see " Pyaemic affections of the 
 joints," p. 152.) 
 
 In relapsing fever, pains in the joints occur at the begin- 
 ning of the febrile attack, and often add materially to the 
 general suffering. They may also return with the relapse. 
 The presence of high fever and of articular pains in this dis- 
 ease simulates acute rheumatism- very closely, but the epi- 
 demic character of relapsing fever, and its complete absence 
 for years together in this country, prevent any very frequent 
 errors in this respect. Here, also, the joints are but little 
 swollen as compared with the usual form of rheumatism. 
 Arthritic pains and swelling occur in connection with purpura 
 (see p. 153), and also with the hemorrhagic diathesis (see 
 Chapter IX., "Hemorrhages"). 
 
 Gonorrhoeal rheumatism (gonorrhoeal synovitis) is compara- 
 tively a rare affection. It must not be supposed to include 
 all the cases of chronic articular pains in patients w'ho have 
 had at some time a gonorrhoeal discharge. Gonorrhojal rheu- 
 matism arises during the period of the urethral discharge. It 
 is rare, but not unknown, in the female sex. It usually attacks 
 the knee-joint, but it may involve various joints in succession, 
 and even the synovial sheaths of the tendons. Its appearance 
 may be marked by a diminution in tlie discliarge. It tends 
 to recur with a subsequent gonoirhocal infection, or even with 
 other forms of urethral irritation, or it may linger as a more 
 clironic affection associated with a gleety discharge, or even 
 after this has disappeared ; recurring disease is apt to lead to 
 serious destruction, or to stiffness of tlie joint ; although the 
 
GOUT. 151 
 
 health suffers seriously, the patients seldom die of the disease. 
 Occasionally this gonorrhoeal rheumatism is associated with 
 ophthalmia at its commencement, and with iritis in its later 
 stages. As a rare occurrence we may have true pysemic syno- 
 vitis from gonorrhoea, with its usual gravity. 
 
 Gout manifests itself by pain and swelling in the joints, asso- 
 ciated with more or less general disturbance ; and it appears 
 both in acute and chronic forms. Gout has a special tendency 
 to affect the ball of the great toe, especially in the first attack, 
 but almost any joint may be involved ; previous injury renders 
 a joint particularly liable to the gouty inflammation, and this 
 may determine the site of the seizure. The joint becomes ex- 
 ceedingly painful in an acute attack, especially if it be the 
 first ; there are usually great swelling, redness or lividity, and 
 tension ; the veins are usually much swollen, and after the 
 tension subsides, oedema of the part remains, and the skin 
 desquamates. The paroxysms of pain have a marked tendency 
 to nocturnal exacerbations. The fever is usually much less 
 than in rheumatism, and its intensity seems more distinctly 
 related to the local inflammation. General disturbance, and 
 especially gastric disorder, characterized by acidity, may be 
 regarded as usual, and cramps in the muscles are not uncom- 
 mon. Alarming symptoms referable to the stomach, heart, 
 or nervous system sometimes occur in connection with gouty 
 attacks, or with a recession of the articular affection. The 
 fleeting and erratic forms of attack common in rheumatism 
 are not found in gout. 
 
 The personal and family history are very important in the 
 diagnosis of gout in doubtful cases. Gout is rare in Scot- 
 land, except among the upper classes, although not uncom- 
 mon amongst workingmen and hospital patients in London. 
 It is more common in men than in women, and seldom appears 
 till the patient is about forty years of age. The influence of 
 heredity is very strongly marked, and this may determine an 
 attack in those who are very careful in their living. The 
 habits of the patient as to excess in eating and drinking are, 
 however, very important ; the use of malt liquors and wines 
 predisposes to gout much more strongly than even a free use 
 of spirits. Excess in the use of animal food is likewise potent 
 in producing gout. The connection of lead-poisoning with 
 gout seems also to be so frequent, in London at least, as to 
 assist in the diagnosis. The occurrence of renal aflfections in 
 gout is likewise common, and should be inquired into, and the 
 state of the heart and arteries should likewise be investigated. 
 
152 JOINTS. 
 
 The test of the gouty condition by finding crystals of uric 
 acid in the serum of the blood is important. Dr. Garrod 
 recommends two drachms of the serum of the blood to be 
 placed in a flat glass dish and set aside to evaporate slowly ; it 
 is first acidulated slightly with acetic acid, and a fine linen 
 fibre is introduced into it ; when the fluid has been reduced 
 to the consistency of a jelly, this fibre is found crusted over 
 with crystals of uric acid if the blood be derived from gouty 
 patients, but there are no crystals from the blood of those free 
 from this taint. 
 
 Chronic forms of gout become developed from repetitions 
 of the acute affection. In gout the tendency is for the recur- 
 rences to be more and more frequent, with less distinct causes 
 for each attack. The joints are also apt to become permanently 
 changed, particularly from the deposit of chalky masses in 
 their structures. These are called " chalk-stones " (or toj^hi — 
 i. e., concretions) ; they consist chiefly of urate of soda along 
 with animal matter ; their composition may be determined as 
 in the case of urinary calculi. Sometimes these concretions 
 give rise to small abscesses, and in this way become exposed. 
 They are found in various joints. Before they become visible 
 the diagnosis of these hard masses in the joints may be doubt- 
 ful, as they may simulate some enlargement of the ends of 
 the bones. Assistance is afforded at times by finding similar 
 small concretions in the ear, especially in the helix, varying 
 in appearance from the minutest possible vesicle beneath the 
 skin to a bead-like nodule resembling a pearl. 
 
 The constitutional symptoms in chronic gout vary consid- 
 erably ; dyspeptic disorders form the leading feature in such 
 cases. 
 
 Pyoimie affections of the joints occur in many cases of pyaemia 
 as they arise in surgical practice. With these we have no 
 concern here. Affections of this kind occur after childbirth, 
 sometimes at a considerable time after delivery, associated it 
 may be with evidence of suppuration elsewhere (pelvie abscess, 
 phlebitis, pyceynia, etc.). Essentially the same kind of articular 
 mischief occurs also sometimes in scarlatina. This puerperal 
 and scarlatinal form of pysemic arthritis is limited to one joint 
 in some cases, but in others various joints are affected. Such 
 illnesses, although always serious, are not necessarily fatal. 
 Pysjemic disease of the joints sometimes occurs also after cer- 
 tain forms of pneumonia, with typhoid symptoms, and after 
 enteric and some other fevers. When suppuration is known 
 to be going on in a case, we must always regard articular 
 
BONES. 153 
 
 pains with great suspicion ; gonorrhoea has been known to 
 give rise to true pyaemia, and gonorrhoea! rheumatism is 
 regarded by some as a mild form of this disease. 
 
 Pysemia, with affection of the joints, sometimes occurs in 
 an idiopathic form, as it may be called — that is, without any 
 obvious cause. In such cases the symptoms may resemble 
 those of enteric fever, although shive rings are usually present 
 in a more loronounced form. In obscure cases it is well to 
 examine the various joints as to swelling, redness, and tender- 
 ness to pressure. 
 
 Pysemic joints are usually painful, but sometimes the pain 
 is not well marked ; tenderness is very generally present even 
 in such cases. The pysemic affection has but little of the 
 fleeting or shifting character of acute rheumatism, but we 
 may see, even in fatal cases, the implications of certain joints 
 followed by their recovery, and it may be the supervention of 
 mischief in others. Actual pointing of a pysemic joint may 
 take place. 
 
 Articular ijains with subcutaneous hemorrhages occur both in 
 purpura and scurvy. There is a disease, " peliosis or pur|)ura 
 rheumatica," in which fresh developments of articular pains 
 and of hemorrhagic spots appear together, and there may be 
 hemorrhages elsewhere as well; it is regarded by some as a 
 mere coincidence of purpura with a rheumatic attack. In 
 scurvy the articular pains and stiffness of joints, due to the 
 fibrinous effusions found in this disease, are often so perma- 
 nent as to lead to the idea of rheumatic instead of scorbutic 
 disease. Affections of the joints are also found in the hemor- 
 rhagic diathesis. (See Chapter IX., " Hemorrhages.") 
 
 Syphilitic affections of the joints occur in a slight form in 
 what is termed the secondary stage. But the more severe and 
 persistent pains occur later, among the tertiary symptoms, 
 when nodes, etc., become developed. These pains usually 
 affect several joints, and especially involve the larger ones ; 
 they have a very marked tendency to nocturnal exacerbations, 
 and the ^^ains are often evidently present in the bones as well 
 as the joints. Other evidences of syphilis usually coexist with 
 these pains when they are severe. This manifestation of 
 syphilis has some value in judging of the history of a doubtful 
 case. 
 
 Bones. 
 
 Affections of the bones come so much more under the notice 
 of surgeons that we must refer to surgical treatises for in- 
 
154 BONES. 
 
 formation on this subject ; only a few points of special impor- 
 tance to the physician claim attention here. 
 
 Co7igenital malforraations of the skull and spinal column 
 (encephalocele and spina bifida), with protrusion of the 
 brain and spinal cord, or of the membranes, are often impor- 
 tant as furnishing the exj^lanation of convulsive or paralytic 
 symptoms. 
 
 Affections of the skull are met with in rickets, hydroceph- 
 alus, and syphilis whether this is congenital or acquired. The 
 enlarged head of rickets may be mistaken for the slighter 
 forms of hydrocephalus ; the head, however, has more of a 
 square shape in rickets, more of a globular form in hydro- 
 cephalus ; the top of the head is usually flatter in rickets ; 
 and although the sutures and fontanelles are often unduly 
 wide in both, we can sometimes trace the thickened edges of the 
 rickety bones forming distinct ridges where the sutures are. 
 In both diseases the small face often contrasts with the en- 
 larged head, but this is usually more striking in hydroceph- 
 alus ; in this disease also the eyes appear strikingly prominent 
 from the balls being directed downward, and from the expos- 
 ure of a large portion of the upper part of the white sclerotic. 
 
 Great thinning of the bones of the skull (craniotabes) is 
 found as an early symptom in rickets and also in congenital 
 syphilis. By searching with the finger over the occipital and 
 adjoining portion of the parietal bone, in particular, little 
 patches about the size of the point of the finger may be de- 
 tected so soft and thin as to feel like membrane. On the 
 other hand, thickenings of the bone may be encountered in 
 congenital syphilis, when it involves the skull, so that four 
 bony eminences may surround the fontanelle. (Parrot.) 
 Syphilitic aflfections of the skull in the adult, with nodes or 
 with suppuration and necrosis (corona veneris), are well 
 known to surgeons ; they may likewise point the physician to 
 mischief within the cranium, giving rise to nervous lesions. 
 
 Old depressions or painful cicatrices have to be searched 
 for and considered in certain cases of epilepsy. 
 
 The examination of the head by auscultation and percus- 
 sion will be mentioned in the study of nervous symptoms in 
 Chapter VI. 
 
 Periostitis, Necrosis, Ostitis, Caries. — These arc usually re- 
 garded as purely surgical, but they may have many close 
 relationships with internal disease. Syphilitic periostitis and 
 nodes aflfecting the skull have been already alluded to, but it 
 is often important to search on the tibia for evidence of old 
 
ENLARGEMENT OP THE BONES. 155 
 
 lesions of this class in suspected syphilis. Present or past 
 periostitis, necrosis, and caries may throw light on the consti- 
 tutional tendency of the patient, or of his relatives, and may 
 point to certain pulmonary or cerebral disorders being in all 
 probability tubercular ; or such affections may give the clew 
 to the diagnosis of lardaceous disease of the kidney, liver, 
 spleen, and intestines. All such affections of the bones are 
 usually so obvious, and are almost always attended with so 
 much pain, that they can scarcely be overlooked. Occasion- 
 ally, however, in young subjects, acute periostitis and " necro- 
 sial fever " may simulate a general disorder, and may be 
 readily mistaken for typhoid or some other fever, at least for 
 a time ; the diagnosis may become further complicated by its 
 giving rise to pysemic pericarditis, pleurisy, etc. In connec- 
 tion with periostitis it may here be stated that necrosis some- 
 times occurs as a sequela of enteric fever. Deep-seated pains 
 in the bones, with marked nocturnal exacerbations, may afford 
 indications of syphilitic disease. 
 
 Enlargement of the epiphyseal extremities of the hones is a 
 notable symptom in rickets ; it occurs chiefly in the wrists and 
 ankles, but it shows itself also in "beading" at the junction 
 of the ribs with the costal cartilages ("rachitic rosary"). 
 These rickety enlargements may sometimes be confused with 
 the swellings due to congenital syphilis found at the epiphyses 
 also ; but while both are affections of infancy, the syphilitic 
 lesion is common under six months, while rickety changes in 
 the bones are seldom pronounced till some months later. In 
 syphilitic affections involving the arms the child may appear 
 to be paralyzed from this cause, and this "pseudo-paralysis" 
 may assist the differential diagnosis. These deposits may sup- 
 purate but they seldom open into the joints. Although the 
 ends of the bones are the common sites of the syphilitic lesion, 
 they sometimes lead to local enlargements in the shafts, and 
 when they involve the phalanges we have the variety termed 
 " dactylitis syphilitica." 
 
 In the form of disease termed " acute rickets " the enlarge- 
 ments are very rapidly developed, and present more pain than 
 the mere tenderness of ordinary rickets. This form of disease 
 has been shown by Dr. Barlow to depend on acute hemor- 
 rhagic lesions due to scurvy or to some tendency allied thereto. 
 It may coexist with true rickets, but it may occur without 
 any manifestation of this disease. 
 
 Enlargement of the ends of the bones due to rheumatism 
 has been discussed under " Joints." (See p. 147.) 
 
156 BONES. 
 
 Distortion of the long bones is found to a notable extent in 
 rickets. In the ribs it leads to the occurrence of various 
 forms of "pigeon breast;" this deformity will be referred to 
 and its meaning discussed in Chapter XVI. In the lower limbs 
 it is seldom present to any striking extent, unless the child 
 has begun to walk, or at least to stand, and so the Avorst cases 
 of rickets, early developed, do not show much deformity of 
 the legs. The distortion resulting is best ujiderstood if we 
 imagine all the natural curves and twists of the long bones 
 intensified to a greater or less degree ; sometimes this is enor- 
 mous ; but the bones may be twisted, from accidental causes, 
 in quite difierent directions from the normal curves. The 
 bones of the upper extremity are also often distinctly curved, 
 particularly in those patients who have been too badly affected 
 with rickets to allow of their standing or attempting to walk. 
 In such cases the little patient sitting in bed, and moving him- 
 self from side to side with his arms, produces a curving of the 
 bones there from the weight of his body falling upon them 
 instead of on the legs. The clavicles are often so sharply 
 bent as to suggest the idea of a fracture. Softening of the 
 bones in adults (mollities ossium) is chiefly of importance 
 from its distorting the spine and pelvis of women during the 
 childbearing period. It is associated with obscure pains, and 
 from the distortion the woman's stature may be diminished to 
 the extent of two or three inches. Although much commoner 
 in women it occasionally affects men, and the ribs and sternum 
 may be implicated as well as the bones of the limbs, pelvis, 
 and spine. 
 
 Distortions of the spine must be studied as to whether they 
 are permanent, or whether they disappear on taking the weight 
 off the vertebral column. We also ascertain whether they are 
 lateral (skoliosis) ; angular, with projection backward of the 
 spinous processes (kyphosis) ; or if there is a general bulging 
 backward of the dorsal and lumbar regions, with slight pro- 
 jection forward of the cervical portion, such as arises from 
 general weakness or softness of the bones, as in rickets ; or if 
 there is a "saddleback" appearance, with projection forward 
 of the lumbar and lower dorsal region, and backward of the 
 upper dorsal and cervical portion of the spine. The lateral 
 distortion is found chiefly in girls of poor physique ; but such 
 deformities, even when extreme, do not give rise to paralysis. 
 Lateral curvatures also result from pleurisy with retraction of 
 one side of the chest, especially when this occurs in childhood ; 
 and any inequality in the lower limbs, or arrest in growth, such 
 
BIBLIOGRAPHY. 157 
 
 as occurs in infantile paralysis, tcDcIs to produce this deformity. 
 Angular curvature is found in caries of the vertebrae (Pott's 
 disease), and is often associated with abscess in various parts, 
 with severe neuralgic pains, and with paralysis. The deformity 
 named lordosis or "saddleback," occurs at times as an inde- 
 pendent affection, but is chiefly interesting to physicians as 
 one of the leading peculiarities of pseudo-hypertrophic muscular 
 paralysis. 
 
 "With regard to skin diseases the following works may be consulted : 
 Hebra and Kaposi, On Diseases of the Skin, translated for the New 
 Sydenham Society, 5 vols., London, 1866-80. — Sir Erasmus Wilson, 
 Lectures on Dermatology, 4 vols., London, 1871-78. — M'Qall Ander- 
 son, On the Treatment of Skin Diseases, with an Analysis of 11,000 
 Consecutive Cases, London, 1872 ; also his treatise on special skin dis- 
 eases. — Neumann, Text-book of Skin Diseases, translated by Dr. Ful- 
 lar, London, 1871. — Tilbury Fox, Skin Diseases, 3d edition, London, 
 1873, — Duhring, Practical Treatise on Diseases of the Skin, 3d edition, 
 Philadelphia, 1882. — Y. Ziemssen, Handbook of Diseases of the Skin, 
 by various contributors. New York, 1885. 
 
 Por illustrations of skin disease, see Sir Erasmus Wilson, Portraits 
 of Diseases of the Skin, London, 1848-55. — Hebra and Elfinger, Atlas 
 der Hautkrankheiten, Wien, 1856-76. — Atlas of Portraits of Diseases 
 of the Skin, New Sydenham Society, London, 1861-84. — Tilbury Fox, 
 Atlas of Skin Diseases (based on Willan and Bateman's Delineations), 
 London, 1877. 
 
 For febrile eruptions — Murchison, Treatise on the Continued Fevers, 
 3d edition, London, 1884; this contains colored illustrations of the 
 eruptions in typhus and enteric fevers. — Murchison, "Observations 
 on the Period of Incubation of Scarlet Fever and some other diseases" 
 (Trans. Clinical Society, vol. xi.), London, 1878. — Peynolds's System 
 of Medicine, vol. i., London, 1866; and other systematic works on 
 medicine. — Treatises on diseases of children also contain much that is 
 important here, such as West, Lectures on the Diseases of Infancy and 
 Childhood, 7th edition, London, 1884. — Eustace Smith, Practical 
 Treatise on Diseases of Children, London, 1884. 
 
 The nails and hair are discussed in works on skin diseases. 
 
 The glandular diseases are treated of in surgical works ; also in works 
 on medicine in connection with leuksemia, Hodgkin's disease, etc. ; 
 e. ^f., G-owers, "Splenic Leucocyth^mia, and Hodgkin's Disease," in 
 Eeynolds's System of Medicine, vol. v., London, 1879. — Hodgkin's 
 paper appeared in Med. Chir. Trans., vol. xvii., London, 1832. — Ben- 
 nett, Leucocythfemia, Edinburgh, 1852. 
 
 For joint affections — Carrod, on "Gout, Rheumatic Arthritis, and 
 Eheumatism," in Reynolds's System, vol. i. — R. Adams, Treatise on 
 Rheumatic Gout, with Atlas, 2d edition, London, 1873. — For joint 
 affection in ataxy, see Charcot, Lectures on Diseases of the Nervous 
 System, translated for New Sydenham Society, 2 vols., London, 
 1877-81. — Transactions of Clinical Society, vol. xviii., London, 1885. 
 
 For diseases of bones, surgical works must be consulted, or special 
 treatises, such as Macnamara, Clinical Lectures on Diseases of Bone, 
 
 14 
 
158 BIBLIOGRAPHY. 
 
 London, 1878. — See also articles on rickets and syphilis in works on 
 diseases of childhood, especially Koger, Recherches Cliniques sur les 
 Maladies de I'Enfance, tome ii. (Syphilis), Paris, 1883. — Parrot (and 
 others), Transactions of the International Medical Congress, vol. iv. 
 p. 35, London, 1831. — Taylor (R. W.), Syphilitic Lesions of the Os- 
 seous System in Infants and Young Children, New York, 1875. — 
 Barlow, "Cases of Acute Rickets," Med. Chir. Trans., vol. Ixvi., 
 London, 1883. — Lees and Barlow, "Relationship of Craniotabes to 
 Rickets and Congenital Syphilis," Pathol. Trans., vol. xxxii., London, 
 1881. 
 
CHAPTER Y. 
 
 EXAMINATION OF THE ORGANS OF SPECIAL SENSE: 
 TESTING OF CRANIAL NERVES. 
 
 An examination of the organs of special sense is often called 
 for in the study of nervous symptoms. The investigation here, 
 as elsewhere, resolves itself into an objective and subjective 
 division. Under the " objective" we include those indications 
 of disease obvious to the observer, or at least capable of dem- 
 onstration by some reliable test. Under the "subjective" we 
 have various symptoms for the existence of which we have to 
 rely more completely on the mere statements of the patient, 
 although these also may be susceptible of some scrutiny. As 
 the two sets of symptoms often pass into each other, no separ- 
 ation of them will be made in this chapter. 
 
 The Eye. 
 
 The examination of the eye affords indications of the greatest 
 variety and importance. No allusion will be made here to 
 diseases of the eye itself, unless in so far as these bear on 
 general diagnosis, or unless they might lead to confusion or 
 error. 
 
 The yellotu discoloration of the conjunctiva is discussed else- 
 where in connection with jaundice. For the various points 
 bearing on the diagnosis of jaundice, and on the color of the 
 sclerotic, see " Jaundice," Chapter XII. 
 
 Opacities of the cornea, traces of old iritis, and the like, are 
 sometimes useful as indicating, along with notched teeth and 
 other signs, certain constitutional affections, especially syphilis 
 and scrofula. Acute iritis may supervene in syphilitic, rheu- 
 matic, or gouty cases while under observation. The cornea 
 may become opaque or may ulcerate from lesions of the fifth 
 nerve, or it may suffer in this way from exposure due to 
 paralysis of the seventh nerve. 
 
 The arciis senilis consists of an opaque ring or segment of a 
 ring, in the cornea at its junction Avith the sclerotic. It usually 
 exists in both eyes, when present at all, but it may be present 
 
160 OEGANS OF SPECIAL SENSE. 
 
 to an unequal extent. It occurs habitually in persons over 60. 
 When present in younger subjects (35 to 50) it is to be regarded 
 as a sign of early degeneration of the tissues ; it is very often 
 associated with atheroma, gout, renal disease, and cardio-vas- 
 cular changes. The complete ring round the cornea is re- 
 garded by some as less suggestive of degenerative processes 
 than the segment to which the word "arcus" more properly 
 refers. It would seem that strain on the eyes such as may 
 arise from much microscopic work favors the early develop- 
 ment of this change in the cornea. 
 
 Suffusion of the eyes, with injection of the conjunctiva and 
 lachrymation, is often due to local inflammation ; but we also 
 find it at the beginning of certain fevers, especially measles 
 and typhus. It may likewise constitute one of the early signs 
 of meningeal and cerebral diseases. It is often associated with 
 photophobia. 
 
 Photophobia, or intolerance of light, is common to many 
 diseases of the eye (phlyctenular ophthalmia, keratitis, iritis, 
 and retinitis). It is also found in certain stages of meningitis, 
 cerebral tumors, typhus, measles, etc. It is common in many 
 varieties of headaches and especially in migraine. In nervous 
 subjects it may exist apart from any serious changes in the 
 eyeball, there being thus a hyper&esthesia of the retina. 
 
 Protrusion of the whole eyehall (exophthalmos) may indicate 
 abscess of the orbit, thrombosis of the cavernous sinus, or 
 tumor somewhere behind the eyeball ; in such cases it is 
 usually unilateral. When it affects both eyes, and when asso- 
 ciated with enlargement of the thyroid, and rapidity of the 
 heart's action, it constitutes an important element in the diag- 
 nosis of exophthalmic goitre. Occasionally the protrusion is- 
 much greater on one side than the other in this disease, and 
 in rare cases it may be unilateral ; when the patient looks 
 down, the upper part of the sclerotic is unduly visible, from 
 the upper eyelid not following the eyeball in its downward 
 look, and this feature aflTords us some guidance even when the 
 exophthalmos is slight, or, it may be, still absent on one side. 
 
 Complete paralysis of the ocular muscles, or of the third 
 nerve, may lead to a slight protrusion of the eyeball, from the 
 removal of the backward tension of these muscles. Consider- 
 able variation exists normally in the prominence of the eye- 
 balls. 
 
 Inability to clo^e the eyelids properly (lagophthalmos) is very 
 common, but not invariable, in peripheral paralysis of the 
 facial nerve. (See "seventh nerve," p. 203.) It is uncommon, 
 
SQUINTING OR STRABISMUS. 161 
 
 although not unknown, in the paralysis of the face of ordinary 
 hemiplegia from cerebral causes. Exposure of the eyeball may 
 lead to irritation of the conjunctiva or cornea. From implica- 
 tion of Horner's muscle the tears often run down the cheek. 
 
 Ptosis, or droop of the iipj^er eyelid, is a sign of paralysis of 
 one of the branches of the third nerve. Sometimes, however, 
 it is not paralytic, being obviously due to some mechanical 
 impediment to the action of the muscles or eyelids themselves. 
 When paralytic, ptosis may exist alone, or be combined with 
 other evidences of a lesion of the third nerve, or of intracra- 
 nial disease. 
 
 The movements of the eyelids, according to Dr. Gowers, are 
 associated with, and to some extent due to, the movements of 
 the eyeballs. In its downward movement, the eyeball com- 
 municates a mechanical depression to the lower lid. In the 
 case of the upper lid, the levator palpebrse is made to act or 
 relax, by an " associated movement," with the concurrent 
 action or relaxation of the superior rectus animated by the 
 same nerve. Hence, in paralysis of the inferior rectus we may 
 have an apparent paralysis of the eyelids when the patient tries 
 to look down, from the want of the relaxation of the levator 
 palpebrse usually associated with the contraction of the inferior 
 rectus. We may also have in a case of ptosis, due to cere- 
 bral disease, an upward movement of the upper lid when the 
 patient exerts his superior rectus in looking up, although there 
 may be no voluntary power over the levator palpebrse apart 
 from this associated movement. 
 
 Squinting, or Strabismus — Paralysis of the Ocular 
 Muscles — Diplopia. — In examining for strabismus we get 
 the patient to direct his vision with both eyes open, to a point 
 placed exactly opposite him in the middle line. The ob- 
 server's finger held in such a position suits quite well. This 
 is tried at various distances, both near and remote, and we 
 notice whether the centre of the cornea coincides with the 
 centre of the palpebral fissure. If a deviation occurs (primary 
 deviation), we should notice w^hether this comes into more 
 prominence when near or when distant objects are looked at ; 
 we also observe whether the eyeball is turned inward (internal 
 or convergent strabismus), or whether it is turned outward 
 (external or divergent strabismus) ; we can usually say at 
 once which of the two eyes is the one whose axis of vision is 
 directed to the object, and which is the one which deviates. 
 Sometimes, however, the patient can "fix"' the object with 
 either eye indifferently, and so either the one or the other may 
 
 14* 
 
162 OKGANS OF SPECIAL SENSE. 
 
 deviate (" alternate squint "). When the same eye is always 
 used to " fix " the object there is usually a distinct difference 
 in the acuteness of the vision on the two sides — the better eye 
 being, of course, selected by the patient for this purpose. If 
 now we get the patient to "fix" the object with the less per- 
 fect eye, by interposing the hand before the sound one, or by 
 placing a piece of dimmed glass in front of it, we may then 
 find that the sound eye (which was quite straight in the former 
 experiment) deviates inward or outward, just as the other did. 
 In many cases this "secondary deviation," as it is called, can 
 be ascertained, by a scale placed below the eyelid, to be 
 exactly equal to the primary deviation : this is the common 
 case when the squint depends on hypermetropia and myopia 
 apart from any paralysis of the ocular muscles (" concomitant 
 squint ") ; in paralytic squint, on the other hand, the second- 
 ary deviation is often more extreme than the primary, and 
 this sometimes constitutes an important indication of ocular 
 paralysis. A deviation, however, which originated in a paral- 
 ysis in a hypermetropic or myopic patient, may be perpetuated 
 as a concomitant squint after the paralysis has passed away ; 
 and in rare cases, from the persistence of a non-paralytic 
 squint, and the stretching of the fibres of the muscle, w^e may 
 find a want of proper movement from simple muscular weak- 
 ness aport from any paralysis of nervous origin. 
 
 In cases o^ " concoynitant squinV there is no impairment of 
 the movement of the eyeballs ; this can be shown by testing 
 the eyes sej)arately — only one being open at a time, and the 
 object looked at being carried up and down, and to the extreme 
 right and left ; the free mobility of each eye in all directions 
 may then be ascertained. Strabismus having these peculiari- 
 ties is due to a want of proper adjustment in the action of the 
 muscles, or to a certain shortening of one or other of them ; 
 such a squint depends, in the great majority of cases, on errors 
 in the refraction of the eye, convergent squint being associated 
 with hypermetropia, and divergent squint with myopia; in a 
 few cases, however, this relationship may be reversed. These 
 errors in refraction are in many cases hereditary, so that a 
 tendency to squinting is often inherited. In such cases of 
 strabismus, binocular or stereoscopic vision is usually sacri- 
 ficed at an early period in the case, and so the patient is not 
 troubled with dii)lopia. Specks on the cornea, and other 
 defects in the vision, often seem to determine tlie occurrence 
 of squinting and the suppression of the vision in the weaker 
 eye. Patients with hypermetropia and myopia may also have 
 
DIPLOPIA BINOCULARIS. 163 
 
 squinting very readily induced by various acute illnesses of a 
 general nature ; this squint may be temporary or permanent. 
 It may thus simulate a cerebral disturbance under certain 
 circumstances. 
 
 In paralytic squint the movement of the eyeball is impaired 
 in certain directions, so that it cannot be moved outward or 
 inward beyond the middle line, as the case may be ; the sound 
 muscle may also overbalance the paralyzed one, so that, for 
 example, in paralysis of the external rectus we have often an 
 internal squint, and in paralysis of the internal rectus an 
 external squint. Before concluding that there is ocular 
 paralysis, we must see that no merely mechanical impediment 
 exists to hinder the movements. In paralytic squint the " sec- 
 ondary deviation," already described, is often greater than the 
 primary, and when the vision is directed toward the paralyzed 
 muscle, or, more strictly, in the direction of its action, this is 
 often very extreme. Thus, if a person with paralysis of the 
 right external rectus be tested as to his affected eye (the vision 
 of the other being obstructed with a dimmed glass), and if he 
 be directed to look at an object on his extreme right, the ner- 
 vous energy is directed to the right external rectus and to the 
 left internal rectus, so as to execute this conjoint movement ; 
 as the paralyzed muscle does not respond properly, a still fur- 
 ther force is directed to these muscles, and thus the internal 
 rectus of the sound eye is led to contract excessively, quite 
 beyond anything that is required, and so produces a marked 
 " secondary deviation ;" its pupil may, indeed, be buried within 
 the palpebral fissure. 
 
 Diplopia hinocularis is common in paralytic squint ; indeed, 
 diplopia may constitute the only evidence of a slight paralysis 
 of an ocular muscle; for when this "paresis" (as a slight loss 
 of power is called) is not too great, there may be no discern- 
 ible diminution of the movements of the eyeball. Diplopia is 
 usually complained of by patients when it is present to any 
 marked extent, but the " false image " is often extremely faint, 
 and the separation of the two images is sometimes slight, or 
 only developed in certain directions of the vision. Moreover, 
 it is important to determine the relation of the two images to 
 the respective eyes, and so a careful test is often demanded. 
 A candle in a dark room, placed at different heights, and in 
 different positions to the right or left of the patient, may be 
 used. It is well also to have a piece of red glass to place 
 before one of the eyes, so as to allow of the identification of 
 each image by its color. If the vision of one eye is less per- 
 
164 ORGANS OF SPECIAL SENSE. 
 
 feet than that of the other, we place the colored glass before 
 the sound eye, so as to render the defective image relatively 
 plainer. Indeed, this method may reveal a diplopia which 
 would otherwise escape the patient's attention. The faulty 
 image is usually recognized, apart from this contrivance, by a 
 certain dimness, or obscurity as compared with the other ; the 
 false image may be placed at the side of the other ; or above 
 or below it ; or there may be an obliquity in its position ; at 
 times, also, one of the images has a different projection in 
 space, appearing nearer to the patient than the other ; these 
 differences depend on the affection being due to paralysis of 
 the superior, inferior, external, or internal recti muscles, or of 
 the superior or inferior oblique, or to various combinations of 
 these lesions. 
 
 With regard to the lateral displacement of the false image, 
 we must ascertain whether the diplopia is " crossed " or " di- 
 rect." If, from the shadowy character of the " false image," 
 or by alternate closing of the eyes, or better still by the assist- 
 ance of the colored glass the image to the right be found to be 
 that which is seen with the right eye, then Ave call the diplopia 
 " direct " or " homonymous." If with the same test we find 
 that the image identified with the right eye is seen to the left, 
 then we call it " crossed." " Crossed " diplopia occurs in 
 paralytic divergent squint, or when there is a tendency to di- 
 vergence of the axes of the two eyes from paresis of the in- 
 ternal recti ; " direct " diplopia occurs when there is conver- 
 gence or a tendency thereto. 
 
 The images may also be superimposed, the one above the 
 other, and this is usually associated with a certain obliquity 
 in the position of the image seen by the paralyzed eye ; this 
 may be slightly " crossed " or not in different cases. (See 
 p. 166.) 
 
 In order to facilitate the investigation of these varieties of 
 paralysis the following details are submitted in a tabular 
 form : 
 
 FUNCTIONS OF OCULAR MUSCLES. 
 
 Rectus superior elevates the axis of vision and slightly inverts the 
 
 Uf)per part of the vertical meridian of the eye. 
 Obliquus inferior^ elevates the axis of vision and slightly- everts the 
 
 upper part of the vertical meridian of the eye. 
 
 1 The rectus superior aud the obliquus inferior are tlius required jointly for a pure 
 elevation. 
 
OCULAE PARALYSIS — DIPLOPIA. 165 
 
 Eectus inferior depresses the axis of vision and slightly inverts the 
 
 lower part of the vertical meridian of the eye. 
 Obliquus superior^ depresses the axis of vision and slightly everts the 
 
 lower part of the vertical meridian of the eye. 
 Kectus internus inverts the axis of vision. 
 Rectus externus everts the axis of vision. 
 
 OBLIQUE MOVEMENTS. 
 
 Elevation with adduction. Eectus superior and internus with ob- 
 liquus inferior. 
 
 Depression with adduction. Rectus inferior and internus with ob- 
 liquus superior. 
 
 Elevation with abduction. Rectus superior and externus with ob- 
 liquus inferior. 
 
 Depression with abduction. Rectus inferior and externus with ob- 
 liquus superior. 
 
 Hence we find that the position of the eye or of the pupil 
 varies according to the special muscle paralyzed, when the 
 paralysis is of such a degree as to give rise to deviation. 
 Moreover, as this deviation depends on the activity of the 
 sound muscles quite as much as on the weakness of the para- 
 lyzed one, the results are not always uniform, as we may have 
 to deal with a complex paralysis. In the following tabular 
 statement only one muscle is presumed to be afiected, the rest 
 being sound. 
 
 RESULTS OF PARALYSIS OF SPECIAL OCULAR MUSCLES WHEN 
 THE OTHERS ARE SOUND. 
 
 Paralysis of rectus superior: inability to raise eyeball properly above 
 horizontal level ; pupil may diverge somewhat downward, and a 
 little outward (from action of the rectus inferior and the obliqui). 
 
 Paralysis of rectus inferior: inability to lower eyeball properly below 
 horizontal level; pupil may diverge somewhat upward, and a 
 little outward (from action of the rectus superior and the ob- 
 liqui). 
 
 Paralysis of rectus externus: inability to turn eyeball properly out- 
 ward ; pupil diverges inward (from action of rectus internus). 
 
 Paralysis of rectus internus : inability to turn eyeball properly in- 
 ward; pupil diverges outward (from action of rectus externus). 
 
 Paralysis of obliquus superior : but little alteration in movements of 
 eyeball ; slight deviation of cornea upward and inward, or simply 
 upward. 
 
 Paralysis of obliquus inferior; but little alteration in movements of 
 the eyeball; slight deviation of the cornea downward and in- 
 ward. (Paralysis of the sphincter of the iris, giving rise to a 
 
 1 The rectus inferior and the obliquiis superior are thus required jointly for a pure 
 depression. 
 
166 OKGANS OF SPECIAL SENSE. 
 
 moderate dilatation of the pupil, and to paralysis of the accommo- 
 dation, often accompanies this form of paralysis ; this depends on 
 the branch to the lenticular ganglion being given off from that 
 branch of the third nerve which goes to the inferior oblique 
 muscle. Occasionally, however, the lenticular branch arises from 
 the sixth nerve.) 
 
 DIPLOPIA IN OCULAR PARALYSIS. 
 
 Diplopia is specially, or perhaps only, develoj^ed when the 
 axis of vision is turned in the direction in which the action of 
 the paralyzed muscle should be called into play: thus, upward 
 when the elevators are paralyzed, downward when the depres- 
 sors are involved, and outward or inward in the case of the 
 exterual and internal recti. Certain actions, as climbing or 
 descending a ladder, may thus bring a diplopia into trouble- 
 some prominence ; on the other hand, a certain position of the 
 head is often assumed by the patient so as to prevent the ten- 
 dency to diplopia. In testing, we require therefore to use 
 various positions for the object. 
 
 As already explained (p. 164), the diplopia is " crossed " 
 when from paralysis or weakness there is divergence of the 
 visual axes or even a tendency thereto, and for similar reasons 
 w^e have " direct " diplopia when the tendency is toward con- 
 vergence. The action of the superior and inferior recti as 
 tending to turn the axis of vision somewhat inward, when 
 their correctors are paralyzed, and of the two obliqui as tend- 
 ing to evert it when the counter-balancing muscles are para- 
 lyzed, must also be remembered. (See p. 165.) 
 
 HOMONYMOUS AND CROSSED DIPLOPIA. 
 
 External rectus paralyzed: diplopia is not "crossed;" images on 
 same level ; displacement increased by moving the object out- 
 ward. 
 
 Internal rectiis paralyzed: diplopia is "crossed;" images on same 
 level ; displacement increased by moving the object toward the 
 sound side. 
 
 Superior rectus paralyzed : diplopia vertical and "crossed;" image 
 seen by faulty eye above the other, and somewhat obliquely, 
 chiefly when vision is directed upward. 
 
 Inferior rectus f»aralyzed : diplopia vertical and " crossed ; " image 
 seen by faulty eye below the other, and somewhat obliquely, 
 chiefly when vision is directed downward. 
 
 Superior oblique paralyzed: diplopia vertical and not "crossed;" 
 image seen by faulty eye below the other, and somewhat ob- 
 liquely, chiefly when vision is directed downward. 
 
 Inferior oblique paralyzed : diplopia vertical and not " crossed ; " 
 image seen by faulty eye above the other, and somewhat ob- 
 liquely, chiefly when vision is directed upward. 
 
SIGKIFICANCE OF SQUIKTIKG. 167 
 
 Listinctive efforts to combat the diplopia are often observed in 
 patients, as the presence of the " false image " gives rise to a 
 feeling of distress, and is apt to lead to error and confusion in 
 estimating the position of objects. The most natural and in- 
 telligible counteracting movement is the closing of the affected 
 eye, and so at first sight it may seem that the patient has 
 ptosis : the drooping of the uj^per lid, however, is readily seen 
 to be due not to paralysis of the levator, but to a voluntary 
 action or even to a spasmodic contraction of the sphincter. 
 
 Again, the diplopia is developed, in a case of paralysis of 
 the abducens, because the patient cannot direct the eyeball 
 outward, and the diplopia becomes marked in proportion as 
 the object looked at calls for tbis action. But although the 
 patient cannot turn the eye outward he can rotate the head in 
 this direction, and by maintaining the head in such a position 
 as to supplement the action of the weak muscle he can often 
 minimize the troublesome diplopia. These habitual devia- 
 tions of the head become in this way suggestive of special 
 forms of ocular paralysis. 
 
 POSITIONS OF THE HEAD IN OCULAR PARALYSIS. 
 
 In paralysis of the sixth nerve the face is turned toward the paralyzed 
 side. 
 
 In paralysis of the fourth nerve the face is directed downward and 
 toward the shoulder of the paralyzed side. 
 
 In paralysis of the third nerve the face is turned habitually toward the 
 shoulder of the sound side to combat the weakness of the internal 
 rectus. Special positions of the head upward or downward may 
 be required in ascending or descending, owing to the elevators and 
 depressors being likewise paralyzed, Sometimes, from the presence 
 of ptosis also, no effort is required to avoid the diplopia, as the 
 vision exists then only on the sound side. 
 
 The Clinical Significance of Squint, Ocular Paralysis, and 
 Diplopia. — When a squint is not of paralytic origin it has not 
 much significance to the physician, but on this very account it 
 is important that he should be able to distinguish such cases. 
 Occasionally a squint originates in a paralysis, although this 
 may have passed quite away ; in such a case it has some sig- 
 nificance in the history. But it must also be remembered that 
 in subjects predisposed to strabismus by optical defects, a con- 
 comitant squint may originate in connection wdth any acute 
 illness quite apart from paralysis. 
 
 When a squint is due to paralysis of the third, fourth, or 
 sixth nerves (see pp. 202, 203) it has great significance. As a 
 
168 OEGANS OF SPECIAL SENSE. 
 
 rule, these nerves are affected by lesions at the base of the brain, 
 or the base of the skull, so that some interference with the 
 nerve itself in its course is indicated, rather than a lesion at its 
 deep origin ; the lesion is thus on the same side as the paralyzed 
 muscle. Hence these nerves are specially involved in cases of 
 cerebral tumor and basal meningitis ; they are all very fre- 
 quently paralyzed from syphilitic disease within the skull. 
 When one of these nerves is involved, the other cranial nerves 
 must also be examined, as combinations of paralysis of the 
 sixth nerve with patclies of anaesthesia in the region of the fifth, 
 for example, are even more suggestive of syphilitic lesions. 
 Paralysis of the fourth nerve is usually due to syphilis. Paral- 
 ysis ot' these three nerves, however, and especially of the third, 
 may often be classified with the so-called "rheumatic" paral- 
 ysis — that is, they seem to be induced by cold. 
 
 Paralysis of the third nerve, Avlien complete, includes droop 
 of the upper eyelid (j^tosis), paralysis of all the muscles of the 
 eyeball except the external rectus and the superior oblique, 
 dilatation of the pupil, and some defect in the power of accom- 
 modation. This paralysis of most of the muscles leads to great 
 deficiency in the mobility of the eye, as already explained, and 
 the I3upil is directed outward and somewhat downward. The 
 paralysis of the sphincter of the iris should be specially studied 
 in connection with the signs of paralysis of the inferior oblique 
 muscle (occasionally, however, the supply to the iris comes 
 from the sixth nerve). The dilatation of the pupil in paralysis 
 of the third nerve is only moderate in degree ; it can be 
 rendered much more extreme by the use of atropine. Ex- 
 treme dilatation of the pupil, therefore, may suggest some 
 irritation of the sympathetic, when there is no question of the 
 use of atropine or other mydriatics. The various branches of 
 the third nerve may be paralyzed separately, so that we may 
 have ptosis alone, or external deviation alone, or dilatation of 
 the pupil, or paralysis of the accommodation, or various com- 
 ])inations up to the most complete paralysis of the nerve. 
 
 Diplopia (double vision with both eyes open) may be asso- 
 ciated .with a paralytic s<iuint, or it may furnish the only 
 evidence of paresis in the ocular muscles which may not be 
 extreme enough to lead to squinting. While diplopia is ex- 
 tremely common in paralytic scjuint, it is extremely rare in the 
 ordinary forms of squinting associated with optical defects ; 
 indeed, even in ocular paralysis the diplopia may cease when 
 the squinting becomes very pronounced and the afiection 
 chronic. The special forms of diplopia and their bearing on 
 
OCULAR VERTIGO. 169 
 
 the diagnosis of paralysis iu special muscles have already 
 been referred to (p. 166). 
 
 Diplopia is sometimes complained of by adults at the very 
 beginning of cerebral meningitis, probably from the inflamma- 
 tion leading to a slight paralysis of the nerves. It is also pro- 
 duced in some persons by much less serious disturbances: 
 derangements of the digestive organs, for example, may bring 
 on diplopia and the somewhat allied symptom of vertigo. In 
 certain cases of alcoholic intoxication there is a want of due 
 adjustment in the complex movements of the eyeballs leading 
 to double vision ; a similar condition is found in the early 
 stages of locomotor ataxy arising from want of coordination, 
 apart from squinting or any profound, or at least permanent, 
 paralysis of the ocular muscles ; this must be distinguished 
 from the paralysis and squinting of a more permanent nature 
 found in the later stages. 
 
 Diplopia and strabismus, even when due to disturbance of 
 the brain, are both particularly apt to occur in those whose 
 eyes are not normal in their refraction. 
 
 Diplopia monoGularis can be__readily distinguished from the 
 diplopia just referred to, as this double vision occurs while 
 using a single eye. This is comparatively a rare symptom, 
 and is almost invariably due to some error in the eyeball itself. 
 Irregularities of the crystalline lens or cornea and the presence 
 of artificial pupils are the recognized causes of this affection. 
 Spasmodic affections of the accommodation, hysteria, mental 
 disorders, and cerebral tumors have, however, been alleged as 
 occasional causes of the disorder. 
 
 Erroneous Projection, Ocular Vertigo. — An erroneous estimate 
 of the position of objects is common in cases of paralysis of the 
 ocular muscles, so that a person (say) whose right external 
 rectus is affected, when asked to strike an object placed on his 
 right, or to walk toward such an object, is often found to aim 
 at a point too far to the right ; this probably arises from the 
 mind being conscious of an unduly great energy being directed 
 to the paralyzed muscle in the vain endeavor to get it to act ; 
 it appears probable that the position of objects is estimated 
 from this " out-going current," as it is termed. This erroneous 
 estimate of the position of objects in certain directions leads to 
 constant confusion from the changes which occur in the 
 apparent position of objects as the person walks along or even 
 moves his eyes; hence arises the "monocular vertigo" which 
 occurs in cases of paralysis of the third nerve, for example, if 
 the sound eye be closed and the drooping lid be held up as the 
 
 15 
 
170 ORGANS OF SPECIAL SENSE. 
 
 patient walks along. A somewhat analogous confusion and 
 vertigo may result from binocular diplopia, or from conditions 
 bordering on this state ; the patient often places his head in 
 such a position as to lessen the disj^lacement of the images or 
 closes the affected eye altogether. In paralysis of the ocular 
 muscles the closing of the sound eye does not abolish this 
 monocular vertigo. An erroneous estimate of the position of 
 objects, or of the j)osition of the false image in diplopia, from 
 an apparent forward displacement, is found to occur in certain 
 cases of ocular paralysis, particularly when the fourth nerve 
 and the superior oblique muscle are involved. 
 
 Pupils. Equality or Inequality. — Normally the pupils are 
 equal ; they dilate considerably in the dark and contract when 
 exposed to light. Occasionally, however, the pupils are un- 
 equal congenitally, and the response to light diminished in the 
 eye whose pupil is already contracted (congenital myosis). In 
 examining such cases we should do so while they are shaded 
 from any bright light. Inequality of the pupils is occasionally 
 found in some persons (congenitally?) along with other indica- 
 tions of an affection of the sympathetic, such as unilateral 
 sweatings. Old iritis sometimes accounts for the contraction 
 and immobility of the pupil observed; this can usually be 
 made out by detecting traces of exudation, or some irregularity 
 in the outline of the iris, especially on dilatation with atropine, 
 or the exudation may be seen on the capsule of the lens on 
 ophthalmoscopic examination. As iridectomy is now so com- 
 mon, the student must learn to recognize an artificial pupil. 
 The possibility of an eyewash containing belladonna, atropine, 
 cocaine, or some other mydriatic being used must never be for- 
 gotten in the inquiry ; occasionally a little belladonna gets into 
 an eye quite accidentally. The action of belladonna in dilating, 
 or of Calabar bean in contracting, an abnormal looking pupil, 
 affords assistance in the study of this abnormality in special 
 cases. This has been recommended as a test in distinguishing 
 paralytic from spasmodic changes in the pupils ; the distinction 
 betw^een spasm and paralysis, although, it should be kept in 
 view, has not yet been sufficiently clearly differentiated. 
 
 Apart from these circumstances, inequality of the pupils is 
 always a fact of great importance as indicating — (1) in cases 
 of dilatation— some lesion of the third nerve, the significance 
 of which must be estimated by considering whether the other 
 branches of this nerve are involved. Irritation of the sym- 
 pathetic (as distinguished from paralysis) has likewise been sup- 
 posed to lead to dilatation of the pupil. In cases of this kind 
 we must search for evidence of disturbance of the sympathetic, 
 
ALTERATIONS IN THE SIZE OF PUPILS, 
 
 171 
 
 Fig. 32. 
 
 Imm. 
 
 2i 
 
 3? 
 
 42 
 
 and we must see if any of the cranial nerves are affected. (2) 
 Abnormal contraction, that is, the absence of any consider- 
 able dilatation when shaded from the light, may 
 be due to some affection of the sympathetic in 
 the neck, or of the cervical spinal cord (spinal 
 myosis ; idiopathic affection or wounds of, or 
 pressure on, the sympathetic in the neck from 
 tumors, especially from aneurisms) ; it is also 
 common in general paralysis of the insane. (3) 
 The inequality may be due to some unilateral 
 lesion of the brain, or perhaps to unequal jires- 
 sure of fluid on the two sides of the brain in 
 cases of injury or effusion. Even when due to 
 serious disease the inequality does not always 
 preserve the same degree, and, indeed, is not 
 always persistent. 
 
 Alterations in the size of both pujnls are likewise 
 important. The absolute size of the pupils may 
 be measured by applying the holes of a catheter 
 gauge over the pupil, taking them in succession 
 till one is found to agree. Or the diameter in 
 millimetres may be pretty accurately estimated 
 by the eye on comparison with a series of black 
 spots. Such a scale is included in IN'ettleship's 
 pocket case of tests for the eye ; the sizes selected 
 by him are those reproduced here ; in his scale the 
 black spots are printed on tinted paper to resem- 
 ble so far the background of the iris. On hold- 
 ing this series of spots by the side of the pupil, the 
 eye can usually read off the size with confidence. 
 (See Fig. 32.) A statement of the size in figures is 
 much more satisfactory than descriptive or figur- 
 ative words such as " pinhole pupils," etc. The 
 normal size varies from about three and a half 
 millimetres to seven and a half millimetres ac- 
 cording to exposure to light, the iufluence of age, 
 etc. Sometimes the pupils are unduly dilated or 
 contracted, and sometimes they fail to respond to 
 the light in the usual way. Contraction of the 
 pupils may be produced by the use of opium, 
 and this affords a valuable means of diagnosis in 
 cases of suspected opium poisoning, and also in Pupiiometer. 
 estimating the effect which opium, as a medicine, The figures ex- 
 may have had on the system. Belladonna and !LT,T,^JnH 
 
 J.' !•• 1- n TIT ®*®^ ^^ milli- 
 
 atropme, aammistered internally or absorbed metres. 
 
 5f 
 
 10 
 
172 ORGANS OF SPECIAL SENSE. 
 
 through the skin or mucous surfaces, as well as applied to the 
 eye and brow, produce well-marked dilatation of the pupil ; 
 if applied to one eye they act only on one side. Calabar 
 bean, applied to the eye or given internally, causes well- 
 marked contraction. Atropine and Calabar bean seem to have 
 a special and direct stimulating influence on the radiating 
 and circular fibres of the iris, respectively, in addition to any 
 paralyzing effect on the nervous supply. Alcohol and chlo- 
 roform likewise affect the pupil, but in rather an uncertain 
 way, due in j^art, perhaps, to their dose, and to their varying 
 effect on the system ; other agents also have -at times an action 
 on the pupil. In profound alcoholic coma the pupil becomes 
 contracted when the patient is left undisturbed ; on shaking or 
 trying to rouse him, the pupils dilate, without other signs of 
 consciousness showing themselves, and after five or ten minutes 
 slowly return to their contracted state. (Mace wen.) A some- 
 what similar reaction, with more rapid return to the contracted 
 state, is sometimes seen in apoplexy. In cerebral diseases the 
 pupils are often unduly coutracted or dilated, but it is scarcely 
 possible, in the present state of our knowledge, to lay down any 
 general doctrine on the subject. In simple serous effusion, in 
 meningitis with effusion, and in many cases of apoplexy, the 
 pupils are dilated, and this is usually reckoned among the " pres- 
 sure signs." In not a few cases of apoplexy, however, the pupils 
 are contracted, and this is seen in some of the worst and most 
 rapidly fatal forms of hemorrhage (in the pons). In epileptic 
 fits the pupils are often contracted during the fit and dilated 
 after it. The student must content himself with noting the 
 state of the pupils, reserving the significance of the sign for 
 further consideration and study in view of the whole facts. 
 In cases of total blindness of both eyes the pupils are perma- 
 nently dilated, unless, indeed, there be adhesion of the iris. In 
 typhus fever, especially in the stage of delirium, the puj)ils 
 are usually contracted; in enteric fever, on the other hand, 
 the pupils rather dilated. In the uriemic poisoning of renal 
 disease the pupils are only moderately contracted as a rule. 
 During natural sleep the pupils are contracted ; this can often 
 be seen by gently raising the eyelids ; the pupil then dilates 
 as the person awakes, and if the light be bright it immediately 
 contracts again under this stimulus. Under moderate doses 
 of chloral the behavior is the same as in natural sleep. 
 
 Keflex dilatation of the pupil may be produced in the 
 healthy subject by pinching the skin, especially near the eye, 
 and this test is applied in studying the other pupillary re- 
 
SENSITIVENESS OF PUPIL TO LIGHT. 178 
 
 flexes — response to light, and the contraction during the act 
 of convergence and accommodation, Under the influence of 
 great pain the pupils often dilate, and likewise under various 
 states of emotional excitement. Habitual dilatation of the 
 puj^ils is sometimes noticeable in boys addicted to masturba- 
 tion. Just before death the pupils almost always become 
 dilated, even if they have been contracted before (say from 
 opium) ; soon after death, however, they undergo contraction 
 to a varying extent. 
 
 Rhythmical alternations in the size of the pupils can often be 
 seen in " Cheyne-Stokes respiration." The pupil contracts 
 during the period of apnoea, so as to resemble the state found 
 during sleep ; with the first few breaths of the ascending series 
 the pupil begins to dilate, to contract again as the respiration 
 stops. Sometimes a rhythmical contraction and dilatation 
 can be seen with every respiratory act during the full deep 
 breaths of the " Cheyne-Stokes respiration : " similar alterna- 
 tions with each breath have been noticed during the stertorous 
 breathing of coma ; the pupil dilates with the inspiration and 
 contracts with the expiration. 
 
 The sensitiveness of the iJiqnls to light should be tested by 
 first covering the eyes with the eyelids and fingers, and then 
 opening them suddenly ; or by keeping the lids open and 
 shading the eyes from the light and suddenly exposing them 
 again ; the degree and rapidity of dilatation and contraction 
 may be thus observed. Light from a taper or candle often 
 suits better than daylight, as its direction is more under con- 
 trol, or the light from an ophthalmoscope may be suddenly 
 directed upon them. This test is sometimes applied to dis- 
 cover the sensitiveness of the retina in those who are uncon- 
 scious or unable to express themselves. In such cases we may 
 have contraction of the iris in a blind eye through the influ- 
 ence of light on the other, if it be sensitive, and there may be 
 likewise a sympathetic dilatation; hence it is better to test 
 the eyes separately. For similar reasons a dilated pupil on 
 one side may, by admitting more light, lead to an excessive 
 contraction of the other. The amount of variation on expos- 
 ure to light is usually greater in young persons, and when the 
 pupils are naturally large. The sensitiveness of the pupil to 
 light is often much diminished in apoplexy, and also when 
 there is eflusion of any kind on the brain. In some cases of 
 meningitis the pupil is affected by light, but instead of con- 
 tracting it, oscillates — i. e., varies between contraction and 
 dilatation in a curious way. (Tremulousness of the iris itself, 
 
 15* 
 
174 ORGANS OF SPECIAL SENSE. 
 
 backward and forward with a wave-like motion, arises from 
 undue fluidity of the vitreous, probably combined with rup- 
 ture of some portion of the ligament of the lens, and is only 
 of oplithalmic interest.) When the pupils are much dilated 
 or contracted from the influence of drugs, or from paralysis, 
 or from congenital peculiarity, they are not readily afiected 
 by light. 
 
 Contraction of the pupil during the act of accommodation and 
 convergence is a normal occurrence. Occasionally it is found 
 that pupils which do not respond to light may contract during 
 accommodation for near objects. This is found chiefly in 
 cases of locomotor ataxy, and this reaction of the pupils is 
 named, from its discoverer, the " Argyll Robertson pupil " or 
 symptom. The pupils in such cases are usually small. The 
 influence of stimulation of the skin may be tried as a com- 
 parison. 
 
 The accommodatio7i of the eyes for distinct vision of near 
 objects becomes defective with age (about forty-flve or fifty 
 years of age) ; this " presbyopia," as it is called, is probably 
 due, in part at least, to changes in the lens itself; such defects 
 become more pronounced and occur at an earlier age in those 
 who are hypermetropic, and so require to use their accommo- 
 dation even for distant vision. The accommodation may be 
 defective from some nervous lesions, or when the third nerve 
 is paralyzed, and diphtheritic paralysis of the accommodation 
 is not uncommon. The size of the pupil is not always aflfected 
 when the accommodation is paralyzed, although both are very 
 often involved together. When the vision is defective from 
 this cause convex glasses (+ 12 or 3 D.) should correct it 
 fully, provided the person's refraction is normal (emmetro- 
 pia). Atropine, cocaine, etc., paralyze the accommodation 
 pro tempore. 
 
 Ophthalmoplegia externa : Ophthalmoplegia interna. — These 
 names are applied to paralytic affections involving the muscles 
 of the eye. The external form implicates the levator palpebrse 
 and all the muscles attached to the exterior of the eyaball. It 
 is usually bilateral, but may affect the two sides with unequal 
 severity. The pupils may be more or less implicated, and 
 there may be loss of vision and atrophy of the optic nerve. 
 It has been ascribed to syphilis and rheumatism. The internal 
 form implicates the muscles which effect the movements of 
 the pupils and the power of accommodation. It is supposed 
 to be due to an affection of the lenticular ganglion, and can 
 
MUSCJE OR MOTES. 175 
 
 sometimes be ascribed to syphilis. Details as to the special 
 muscles implicated will be foand in the preceding sections. 
 
 Strain on the eyes, a sense of fatigue readily induced, and a 
 great tendency to confusion of the lines and words in a book, 
 after reading for a few minutes, constitute the indications of 
 " asthenopia." This strain may be prolonged or intensified to 
 a great extent, and may give rise to headache of such a char- 
 acter as to suggest cerebral mischief. This excessive strain 
 may be due to some specially exacting form of work arising in 
 connection with the constant and extreme demands made on 
 the power of the accommodation or of the convergence ; some- 
 times, indeed, the combination of different and unnatural 
 degrees of accommodation and convergence may produce this 
 strain, particularly in those who use glasses. These excessive 
 demands arise in connection with optical defects of the eye — 
 hypermetropia, myopia, astigmatism — in the last the varying 
 demands are incessant and most exacting ; these defects are 
 often complicated with weakness or " insufficiency " of the 
 internal recti muscles. The headaches arising from the strain 
 thus produced, although at first induced directly by taxing 
 the eyes, may continue in a more permanent form, so as to give 
 little or no suggestion of an ocular origin of the disorder. 
 Some of the defects cause a constant strain on the eyes, which 
 cannot be relieved by any amount of apparent rest. 
 
 MusccB or motes are to be distinguished according as they 
 are fixed or floating. Muscse volitantes — motes floating about 
 in the field of vision —may be seen by any healthy eye, and in 
 such cases they are due to minute opacities normally existing 
 in the vitreous. They may be demonstrated by looking at a 
 light through a minute hole in a blackened card ; in this 
 way the shadows of the opaque objects are projected on the 
 retina. Motes like strings of beads, and also motes darting in 
 various directions, may be seen at times apart from disease, 
 especially on looking at dazzling white objects ; these latter 
 are essentially subjective and appear to be due to disturb- 
 ances in. the circulation. Muscse are usually more obtrusive 
 in myopic eyes, and in conditions of weakness and irritability 
 of the retina from whatever cause. Motes from normal opaci- 
 ties must be distinguished from floating specks due to abnormal 
 opacities in the vitreous ; the latter are generally visible with 
 the ophthalmoscope. Fixed muscse — fixed black spots or 
 bands — are due to opacities in the substance of the retina. 
 Opacities in the lens are revealed by ophthalmoscopic illumi- 
 nations as black bands or streaks, but they are not perceived 
 
176 ORGANS OF SPECIAL SENSE. 
 
 by the j^atient as such, unless by some such device as the 
 experiment with the blackened card, just described. 
 
 Flashes of light (photopsia) are produced by irritation of the 
 retina, or of the optic nerve in any part of its course from the 
 brain. Even gentle pressure on the eyeball gives rise to cir- 
 cles of light or j^hosphenes, and blows produce more violent 
 flashes in the same way ; such sensations are frequent in 
 incipient disease of the optic nerve. Flashes of light are like- 
 wise often complained of by those whose cerebral arteries are 
 rigid, and in whom disturbances of the circulation in the optic 
 nerve, or in the cerebral centres connected with it, may be 
 presumed to exist ; they are recognized as amongst the pro- 
 dromata of apoplectic and other cerebral seizures. 
 
 Colored spectra (chromopsia) are of somewhat similar nature ; 
 they have been known to usher in epileptic fits. Yellow vision 
 (exanthopsia) is observed in certain cases of jaundice, but it is 
 rare, at least in a highly marked form ; it is occasionally pro- 
 duced by santoniue administered internally ; this predomi- 
 nance of yellow renders the recognition of red difficult. 
 
 Convulsive movements of the ocular and palpebral muscles may 
 occur as independent functional affections of the eye ; they 
 then come more properly under the notice of ophthalmic sur- 
 geons, but they sometimes serve to indicate cerebral mischief. 
 Spasm of the orbicularis palpebrarum (blepharospasm) occurs 
 in cases of intolerance of light, or from other forms of reflex 
 irritation, and is often associated with hypermetropia ; but 
 twitchings and remittent spasms of this muscle may, if severe, 
 be due to central causes, resembling thus certain forms of 
 convulsive w-ry neck, twitchings of the trapezius, etc. 
 
 Nystagmus (convulsive rhythmical movement of the eye- 
 ball) occurring as a simple ocular affection, and dating from 
 early life, need not be noticed here. The movements are 
 usually lateral, rarely vertical : sometimes they have more of 
 a rotatory character. They are often of but limited extent, 
 and of extreme rapidity ; frequently they require close obser- 
 vation to detect tlieir presence. Nystagmus seems also to be 
 developed in connection with particular occupations, as in 
 coal-miners and some others. It is also, however, met with as 
 a symptom of definite disease of the nervous centres : it some- 
 times appears in one eye only, but usually in both. The 
 movements can often be seen at the beginning of fits, and are 
 then regarded as part of the convulsion. Sometimes they are 
 associated witli a peculiar deviation of the eyes, both eyes 
 being directed as if the patient were trying to look fixedly 
 
CONJUGATE DEVIATION OF EYES. 177 
 
 toward the back of Ms shoulder (coDJiigate or lateral devia- 
 tion of the eyes) ; associated with this there is often, if not 
 usually, a turning of the head also in the same direction. 
 The significance of this combination will be referred to in 
 connection with these other symptoms. Frequently the oscil- 
 lations of nystagmus can only be detected when the patient 
 looks steadily in a given direction to the extreme left or right, 
 and in such cases there is sometimes associated w^ith it an 
 appreciable paresis of the muscle called thus into play — e. g., 
 of the right external rectus when the nystagmus appears on 
 looking steadily toward the extreme right. On the other 
 hand, there is sometimes in nystagmus a point at which the 
 eyeballs rest when the vision is directed there ; this is espe- 
 cially seen in miners' nystagmus. In cases of cerebrospinal 
 sclerosis nystagmus is an imj)ortant symptom ; it is sometimes 
 present to a glaring extent, but sometimes it requires to be 
 searched for by directing the vision steadily to special j^oints. 
 Conjugate or lateral deviation of the eyes differs from squint 
 inasmuch as the two eyes have their axes of vision parallel, 
 although both are deviated from the middle line. With this 
 we have often a rotation of the head at the same time ; the 
 j^atient has then the appearance of regarding fixedly some- 
 thiug over his shoulder, for almost always the eyes look in the 
 same direction as that to which the head is turned. The 
 deviation of the eyes, however, may occur apart from any 
 rotation of the head. 
 
 This curious symptom is found in connection with the occurrence of 
 convulsions and also at the onset of certain hemiplegia attacks. In 
 the former, the symptom appears to he itself due to convulsion or spasm 
 of the particular combination of muscles (on both sides of the body) by 
 which the movements are executed. At other times it appears that the 
 movements are performed by the sound muscles, which contract strongly 
 owing to the balancing action of their antagonists being suddenly lost 
 from paralj'sis. The symptom points strongly to a gross lesion of the 
 brain on one side, although it has been noted in idiopathic epilepsy also. 
 The side to which the deviation takes place varies apparently with the 
 cause ; the following is the doctrine which has been formulated : 
 
 [a) If associated with convulsions it may be presumed that the devia- 
 tion is due to spasjn ; hence it should be toward the convulsed side 
 when the convulsion is unilateral and so presumably due to a lesion on 
 the opposite side of the brain ; the patient will thus look away from the 
 side of the brain on which the lesion ma}^ be presumed to exist, (1) pro- 
 vided such lesion is in the hemispheres or peduncles : (2) in lesions of the 
 tnesocephaloyi, however, the direction is reversed, and the patient then 
 looks away from his convulsed limbs if the convulsions are unilateral. 
 
178 orga:n"s of special sense. 
 
 In this convulsive form the muscles of the neck are more rigid than in 
 the paralytic, the head is replaced with more difficulty, and if conscious 
 the patient may even complain of pain on moving it back. 
 
 (b) In the paralytic form of the lateral deviation, the symptom is 
 found in connection with somewhat sudden apoplectic attacks; (1) if 
 the eyes are turned away from the paralyzed limbs the lesion is supposed 
 to be in the hemisphei^e ; (2) if they look toward the paralyzed limbs 
 the lesion is supposed to be in the mesocephalon. In this paralytic form 
 the rotation is attended with less rigidity of the neck, and the head 
 can be restored to its natural position without much trouble, and with- 
 out indications of pain if the patient is conscious. 
 
 The distinction between conjugate deviation of the eyes and strabis- 
 mus is usually perfectly clear, but occasionally we have a combination 
 of these conditions, in a somewhat imperfect form, in cases of paralysis 
 of the sixth nerve. When this lesion exists alone, and is due to an 
 affection of the nerve trunk, we have of course a convergent squint, at 
 least in certain directions of the vision. But when the mischief is due 
 to a lesion at the origin of the nerve in the fourth ventricle (" nuclear 
 paralysis"), we certainly sometimes have a conjugate deviation of 
 paralytic origin, both the eyes being directed away from the external 
 rectus implicated. This arises from the external rectus of one side 
 acting habitually in harmony with the internal rectus of the other, 
 probably in virtue of some crossing of the fibres from the nucleus of 
 the sixth nerve on the one side, to the nucleus of the third nerve on the 
 other; such an arrangement would, of course, facilitate the synergic 
 action in the lateral movement of the eyeballs in the normal state. On 
 this view we have the internal rectus of one side animated, in part, by 
 a nervous supply from the origin of the sixth on the other. If then 
 we have a nuclear paralysis of the sixth nerve on the right side, for 
 example, we will have not only paralysis of the right external rectus 
 but weakness of the left internal rectus ; and so instead of an internal 
 squint of the right eye (or deviation of this eye to the left), we have 
 conjugate deviation of both eyes toward the left side. 
 
 The aeuteness of vision affords indications as to the state of 
 the optic nerve, but of course the vision may be interfered 
 Avith by many k)cal causes which have no special significance 
 to the physician (opacity of the media, closed pupil, separation 
 of the retina, etc.) : moreover, the advance of age lessens and 
 abolishes the power of accommodation (presbyopia), and there 
 may also be a paralysis of the accommodation from nervous 
 lesions or the action of drugs. Optical defects (hypermetropia, 
 myopia, and astigmatism) often produce imperfect vision, and 
 so may simulate an impairment of the optic nerve. These 
 subjects must be studied in detail at the eye infirmaries, but 
 with a few precautions the use of Snellen's test-types^ affords 
 a valuable means of testing the vision ; the different numbers 
 
 1 Test-t.v'iios for \\u\ Dctcniiiiiiitioii of tlie Aciitencss of Vision, by H. Snellen, M.D. 
 Fourth edition. Williams and Norgate, 18G8. Also, Optotypi ad A'isum Determinanduni, 
 Editio quinta. Motrico Systeniate, 1875. 
 
VISUAL ACUTENESS. 179 
 
 of his scale can be read fluently by an average eye at the 
 corresponding number of feet^ or metres (No. 1^ at a foot and 
 a half, No. 20 at 20 feet; or 0.5 at half a metre, etc.) ; lines 
 and spots are given which may be counted by those who are 
 unable to spell the Roman capitals. In using the types both 
 high and low numbers should be used at corresponding dis- 
 tances. The difference between the nearest and furthest 
 points at which the smaller types can be read indicates the 
 range of the accommodation ; but a full examination demands 
 in certain cases the use of lenses also. 
 
 The degree of hypermetropia is estimated by the strongest 
 convex glass with which the person can read No. 20 at 20 
 feet, or the corresponding types at 6 metres ; this represents 
 the " manifest hypermetropia." But wlien the accommodation 
 is completely paralyzed by the repeated application of atropine, 
 especially in young subjects, a stronger lens may be required, 
 this addition being the index of the " latent hypermetropia." 
 In the case of myopia the tveakest concave glass sufficient to 
 render No. 20 visible at 20 feet (or the corresponding types at 6 
 metres) is reckoned the measure of the myopia. When such 
 lenses improve the vision without rendering it perfect, astig- 
 matism should be tested for ; some circular arrangement w^ith 
 radiating lines may be used, or the dial of a clock, to see if all 
 the figures on the circle and the hands in the various positions 
 are perfectly straight and equally distinct. When by suitable 
 glasses the person can read No. 20 at 20 feet (or at 6 metres 
 in the other scale), we reckon the vision good, the presump- 
 tion being that any defects are merely due to optical causes. 
 In many such cases, how^ever, the correction is not absolutely 
 satisfactory, especially in myopia. 
 
 It must be remembered that there may be a marked affection of 
 the optic nerve although the person may be able to read the smallest 
 types quite satisfactorily. 
 
 Defect of visual acuteness is often spoken of as " amblyopia" 
 and complete blindness from nervous causes as " amaurosis." 
 We often find these due to grave lesions of the retina or of 
 the nervous centres, and it is on this account that the examin- 
 ation is so important to the physician as furnishing evidence 
 of Bright's disease of the retina, cerebral tumor, or meningitis. 
 But dimness of vision may arise from other causes of some- 
 what less serious nature, as in anaemia from loss of blood, 
 
 1 Parisian feet, which are slightly longer than English ; proportion, 46-49. 
 In the fifth edition the metrical system is followed, beginning at U 5, 0.6, and so on in 
 fractions of a metre. 
 
180 ORGANS OF SPECIAL SENSE. 
 
 prolonged discharges as in leucorrlia3a, and protracted suck- 
 ling : even suddenly assuming the erect posture in cases of 
 debility and feeble circulation from whatever cause, may 
 bring on dimuess of vision. In other cases the dimness of 
 vision may be due rather to weakness in the muscular appa- 
 ratus of the eyes which regulates the convergence and accom- 
 modation, and these may be weak from general causes as 
 well as from the local strain on the eyes already referred 
 to (p. 175). 
 
 The field of vision should be estimated in certain cases, as it 
 is often of great importance in medical practice ; it is found to 
 be much diminished in some affections of the optic nerve, 
 due to cerebral as well as to more local causes. Each eye 
 should be tested separately ; the line of vision of the patient 
 is to be directed steadily forward, to meet the gaze of the 
 observer's eye seated immediately opposite him, and the ob- 
 server's finger or some luminous object in his hand should 
 then be carried to the extreme left and right, and above and 
 below, till the limit is reached at which it is visible while 
 the eye is kept looking straight forward. In this way the 
 observer can watch whether the patient's vision is kept steadily 
 fixed ; at the same time he can compare the extent of the field 
 of vision in his own right eye with that of the j)atient's left 
 (and vice versa) — using his own eye as an approximate standard. 
 Ophthalmic surgeons have more accurate methods of measuring 
 and reducing to a scale the field of vision by means of a 
 perimeter, but the above method is a ready means of forming 
 a fair general estimate. The field of vision is sometimes con- 
 tracted almost equally in all directions, but the defect is 
 usually in particular directions, such, for example, as the 
 upper and inner half. 
 
 Local defects in the field of vision may be detected in 
 connection with localized lesions in the retina, and of course 
 these are more troublesome to the patient when they happen 
 to be central. In the absence of a visible lesion in the retina 
 a central amblyopia may be due to a latent choroiditis or to 
 some serious lesion of the optic nerve ; it has appeared fre- 
 quently to be due to poisoning by tobacco, or perhaps alcohol, 
 and in a few instances to a hereditary defect. 
 
 Hemiopia. — When the defect is limited to one-half of the 
 field of vision the affection is named hemiopia or hemianopsia, 
 and patients may complain that they see only one-half of an 
 object. It is rare for an up])er or under half to be involved ; 
 sometimes a less segment than a half is im2)licated. It is 
 
COLOK-BLINDKESS. 181 
 
 usually a lateral half which is lost, and the defect is named 
 according to the unseen j^ortion; thus if the half of the object 
 to the patient's right be unseen with the right eye we term this 
 " temporal hemiopia," or perhaps better " temporal hemianop- 
 sia" of that eye. The defect in the retina is, of course, in the 
 opposite or nasal half to bring about this result, the temporal 
 half being sound ; the etymological accuracy of the term 
 "temporal hemiopia" is, therefore, not interfered with; in 
 speaking of a defect, however, perhaps "hemianopsia" is a 
 more suitable word. One eye only may be involved, but both 
 eyes are usually affected simultaneously ; the most common 
 combination is temporal hemianopsia of one side and nasal of 
 the other (homonymous.) When two nasal halves or two 
 temporal halves are involved simultaneously the resulting 
 defect is, of course, much less obvious to the patient ; it may, 
 indeed, readily escape his notice — the deficiency in the half 
 of the field of vision in the one eye being supj^lemented by 
 the sound half of the other associated with it in binocular 
 vision. 
 
 Occasionally hemiopia is combined with hemiansesthesia, 
 the patient's vision is defective on the side with which he 
 would try to look on his affected limbs. Sometimes hemiopia 
 is found in hemicrania (migraine) and passes off with the 
 other symptoms of this functional disturbance. When due 
 to actual lesions, we usually find it associated with tumor 
 or hemorrhage. The optic nerve, the optic commissure, or 
 optic tract, in some part of its course, are usually the struc- 
 tures implicated, but sometimes the mischief appears to exist 
 in some deeper cerebral centre. The curious limitation of the 
 defect to one lateral half of the retina depends no doubt in 
 most cases on the decussation of the fibres at the commissure; 
 but the occurrence of some decussation at the cerebral centre 
 for vision would almost seem necessary to explain the impli- 
 cation of both eyes in some of the cases of unilateral cerebral 
 lesion. 
 
 If a tumor is in the front of the chiasma, we can under- 
 stand that the two inner halves of the retina would be involved, 
 while implication of one optic tract would give us the common 
 combination of an outer and inner half of each retina ; thus a 
 lesion of the left optic tract would affect the left half of each 
 retina giving thus right homonymous lateral hemianopsia. 
 
 Color-blindness (achromatopsia) is not uncommon as a con- 
 genital or even as a hereditary defect. Red and its com- 
 pounds and green are the colors most commonly concerned. 
 
 16 
 
182 ORGANS OF SPECIAL SENSE. 
 
 No special significance can, as yet, be attached to this defect. 
 A degree of color-blindness, however, is often found in con- 
 nection with blind spots in the central part of the retina, and 
 so it should be investigated in cases of optic neuritis and 
 atrophy, and in the study of tobacco poisoning with central 
 amblyopia. We may, however, have a scotoma for a particular 
 color without any loss of the general visual acuteness. Color 
 blindness likewise complicates hemiansesthesia. The field of 
 vision for the various colors is not equally extensive in the 
 normal state, and in certain nervous affections it is notably 
 curtailed for certain colors. The field of vision for colors 
 may be tested in the same way as the general field of vision — 
 various colored objects of suitable size being substituted for 
 the white luminous object. Dyscluvmatopsia is the term ap- 
 plied when there is difficulty in distinguishing colors without 
 absolute color-blindness. 
 
 For testing the color sense the most generally convenient 
 plan is to supply the patient with a large number of skeins 
 of colored wools of various shades ; we then give him a good, 
 bright sample of red and of green, in particular, and ask 
 him rapidly to sort all the shades of red into one lot and of 
 green into another. He should be placed in a good light, but 
 he should not be allowed to scrutinize the skeins too closely. 
 In supplying the samples a variety of shades must be used, 
 and especially pinks, rose colors, pale greens, stone, gray, 
 slate, and drab colors, as these arc the most generally con- 
 fused ; the larger the number of shades sorted correctly the 
 clearer is the evidence of a correct color sense. Other colors 
 may also be given or the whole bundle with all the colors may 
 be given for him to classify according to their colors. 
 
 Hemeralopia, called also " night blindness," consists in the 
 inability to see proi)erly toward evening, as the daylight de- 
 clines. It is found in soldiers and others who have been ex- 
 posed to dazzling lights. It has no special significance to the 
 physician. This symptom is found also in the affection known 
 as retinitis pigmentosa. (Hemeralopia is employed by some 
 in exactly the o])posite sense, the term nyctalopia being then 
 used for night l)lindncss.) 
 
 Ophtlialmoscojyic examinations are useful (1) in discovering 
 whether the loss of vision, which may be detected, is due to 
 other than nervous lesions; (2) in distinguishing various 
 affections of the retina and optic nerve from each other ; and 
 further, (3j marked changes of much diagnostic significance 
 are sometimes discovered when there is no affection of the 
 
OPHTHALMOSCOPIC EXAMINATION. 183 
 
 visioa as tested by types. The use of the ophthahnoscope 
 must be learned practically in the dark rooms of our eye 
 infirmaries, and no description of the instruments or the 
 methods of using them would be here of much use. The 
 methods by the erect and inverted images are both used for 
 medical cases, but for the more delicate examination of the 
 nervous and vascular changes the direct method is preferable. 
 The student should aim at making himself familiar with both 
 methods, and should, by examining many eyes, apart from any 
 cerebral affections, learn to distinguish the varieties in the 
 size, shape, and appearance presented by the optic nerve, 
 whether congenital or acquired, and in particular the changes 
 in the fundus so often associated with hypermetropia and 
 myopia. He should also learn, if possible, to estimate the 
 degree of hypermetropia or myopia and the presence of 
 astigmatism, by means of the 023hthalmoscope, as in many 
 cases in medical practice no other method is available. 
 
 The following are the points specially to be attended to in using the 
 ophthalmoscope in medical cases: The shape of the optic disk should 
 be noted ; if both disks are oval in the same direction, instead of be- 
 ing circular, optical defects (astigmatism) should be tested for, before 
 concluding that there is a real change. We also ascertain the pres- 
 ence or absence of the congenital cup^ or any excess of cupping (as in 
 glaucoma) ; or any filling up of the cup ; these points can be made out 
 by observing the course of the vessels and by estimating the focal 
 depth. The course of the bloodvessels over the disk must be scruti- 
 nized ; in particular, let it be noted whether the arteries appear to 
 project forward on the disk, or to curve over its edge from its swollen 
 state (" choked disk," oedematous papilla). 
 
 The size and appearance of the large arteries should be noted : 
 whether they seem diminished in calibre, and whether they appear 
 glistening and as if affected with sclerosis, or accompanied with whitish 
 streaks. These streaks are found associated both with intraocular 
 and with cerebral disturbances ; in the former (hypermetropia) the 
 acuteness of vision is not diminished, but in cerebral cases giving rise 
 to this condition of the arteries, the vision is almost always affected ; 
 streaks over the centre of the vessels do not indicate serious changes, 
 and are due probably to mere reflection of the light The vessels may 
 be abolished by emholisyn or thrombosis of the retinal artery or of one 
 of its branches ; this accident is characterized by sudden blindness; 
 at first there is a whitish patch of exudation with a red spot, marking 
 the position of the macula ; this exudation disappears, and the color 
 returns in a few days, but the vessels soon become obliterated, and 
 the blindness is parmanent. The veins should be noted as to the pres- 
 ence of enlargement or tortuosity, and as to whether they seem spe- 
 cially dark and congested where they dip into the tissue of the nerve. 
 The size and color of the disk are very important; attention must be 
 directed to see if it is unduly pale or of a bluish or greenish tinge, and 
 
184 OEGANS OF SPECIAL SENSE. 
 
 the distribution of pigment around its margin, if any be present, 
 must be noted. The disk is often pinker than normal, shading off so 
 gradually into the color of the retina as scarcely to be distinguished 
 from it (neuritis) ; or the edges may be veiled by exudation. On the 
 other hand, the disk may be unduly pale, with a deficiency of the 
 minute vessels distributed to its substance (white atrophy, sclerosis). 
 The disk itself may be normal or pale, even although the large ves- 
 sels in front of it are increased in number. The size of the disk may 
 remain normal although the condition known as white atrophy is 
 highly marked, but the nerve may be shrunken as a whole or in par- 
 ticular parts (atrophy with loss of substance, or contraction). Traces 
 of exudation^ either in patches or in the course of the vessels, are 
 sometimes found associated with a general pink and prominent aspect 
 of the disk, which assumes a woolly appearance ("choked disk"). 
 The bloodvessels should also be examined in their course, particularly 
 as to \hQ 'presence of hemorrhages ] these should be noted as to whether 
 they seem true clots, or whether the vessels seem to terminate in 
 branching-like spots involved in patches of white exudation ; mere 
 dark spots from a sudden bend must be distinguished from hemor- 
 rhages. "When reddish spots without any true clot are found, miliary 
 aneurism ma}'^ sometimes be suspected, particularly at bifurcations 
 of vessels. Large exudations forming irregular patches, partly on 
 the nerve and partly beyond it, or connected by streaks with the disk, 
 obscuring the vessels and associated with loss of vision, are to be sus- 
 pected as syphilitic. Whitish j^early spots of exudation in the neighbor- 
 hood of the macula lutea are common in Bright's disease of the 
 kidney, and large patches, with smaller glittering spots elsewhere, 
 are also found in this affection; somewhat similar patches are seen 
 occasionally in diabetes and some other affections. Shining miliary 
 tubercles are occasionally seen in the choroid in cases of tuberculosis 
 and tubercular meningitis. 
 
 S'lyiiificance of Ophthalmoscopic Appearances in Medical Diag- 
 nosis. — Optic neuritis and optic atrophy are the two most im- 
 portant conditions discovered in the fundus in the examination 
 of medical cases. Optic neuritis regarded as an affection of 
 the nerve in its course cannot be differentiated clinically from 
 inflanmiation of the " papilla," as its termination within the 
 eye is called. To inflammation of this part the word " papil- 
 litis " is more specially applied by some. Atrophy is often 
 preceded by optic neuritis occurring in connection with cere- 
 bral tumors and inflammations, and in such cases the disk is 
 usually ragged or ill-defined at certain parts ; in simple white 
 atrophy, on the other hand, the disk is sharply defined, but 
 this form of atrophy is less characteristic of definite cerebral 
 affections, being found in a variety of conditions. Great 
 changes in the fundus are observed from time to time in the 
 progress of cerebral cases involving the optic nerve and retina ; 
 hemorrhages appear and disappear, or give place to patches 
 
CHOKED DISK. 185 
 
 of exudation. These sometimes become absorbed, or they 
 may increase in number and size. The tendency is for all 
 these inflammatory processes, including even oedema of the 
 papilla, to terminate in atrophy of the nerve. 
 
 In attempting to explain the changes in the fundus of the 
 eye, as bearing on medical diagnosis, we must be content with 
 comparatively obscure indications, as the subject has not been 
 sufliciently long under competent observation to lay down 
 general laws safely. The exudations described as character- 
 istic of syj^hilis, or of Bright's disease, and miliary tubercles, 
 aneurisms, or embolisms (when they can be definitely recog- 
 nized as such) are sufficiently suggestive of their significance. 
 In addition to the exudations already described, hemorrhagic 
 spots are likewise found in Bright's disease, and the detection 
 of such always demands an examination of the urine; not 
 unfrequently cases of Bright's disease come first under notice 
 from a failure of vision due to these changes. (Edema of 
 the retina likewise occurs in renal dropsy, and its aggravation 
 or subsidence may account for the great changes in the state 
 of the vision which sometimes occur within short intervals. 
 Hemorrhages are found likewise to complicate many inflam- 
 matory processes in the optic nerve and retina whether these 
 arise from cerebral or more local affections. They likewise 
 occur in pernicious anaemia, leuksemia, diabetes, and in cer- 
 tain cases of heart disease. In endeavoring to understand the 
 ophthalmoscopic appearances found in connection with cere- 
 bral tuQiors and inflammations, the following different theories 
 may be borne in mind, as they have been advanced to explain 
 the swollen and inflamed state of the optic nerve known as 
 the "choked disk." 1. An interruption to the return of the 
 blood from the eye, due to pressure on the cerebral veins by a 
 tumor, may give rise to congestion and slight fulness of the 
 optic nerve, and there may then be induced a secondary in- 
 crease of this congestion, from strangulation, as it were, of 
 the vessels of the congested and swollen nerve by its own in- 
 expansible sheath. This view is now abandoned by many ; 
 the results of constriction are supposed to arise from direct 
 pressure of the inflammatory exudations on the veins. 2. 
 Or, the swelling, congestion, and oedema of the disk may arise 
 from pressure in the subvaginal space, either from the pres- 
 ence of exudation originating there, or from the pressure of 
 fluid forced along the sheath of the optic nerve from the sub- 
 arachnoid space. 3. An extension of the inflammatory pro- 
 cess from the brain or cerebellum, or the membranes, down 
 
 16* 
 
186 ORGANS OF SPECIAL SENSE. 
 
 the course of the optic nerve, may give rise to a " neuritis de- 
 scendens." This explanation applies specially to cases of 
 meningitis and no doubt also to many cerebral tumors. 4. 
 Vascular changes, resulting in congestion of the optic disk, 
 may be due to disturbances of the circulation, brought about 
 through an indirect influence of the cerebral tumor, or other 
 mischief, on the vasomotor or sympathetic system, apart from 
 any merely mechanical effect, or from any continuity of in- 
 flamed tissues. 
 
 Optic neuritis or atrophy due to cerebral causes is usually 
 double, although the changes in one eye are often more ad- 
 vanced than in the other; if only one eye be affected, a lesion 
 on the opposite side of the brain may be presumed. Localiza- 
 tion of the disease from ophthalmosco2:)ic signs is scarcely 
 possible, but the comparativ^e frequency of blindness and 
 affections of the optic nerve in tumors of the cerebellum is 
 Avell established. The mere size of the tumor seems to have 
 no relationship to the ocular symptoms. Unilateral ojitic 
 atrophy (white) is not unfrequent in locomotor ataxy. 
 
 The Ear. 
 
 Tests of Hearing. Nervous Deafness. — The sense of hearing 
 is usually tested by means of a watch applied to or held near 
 one ear while the other is closed by the finger. We begin by 
 applying the watch closely enough for it to be distinctly 
 heard, and we gradually remove it, in a straight line from the 
 ear, till the sound is lost ; and by measuring this distance we 
 have a means of comparison between the two ears, and also a 
 rough gauge of the absolute acuteness of hearing. The ex- 
 pression in figures may be made thus : if an average ear can 
 hear a given watch at forty inches, and if the patient can only 
 hear it at ten inches with the right ear, but at forty with the 
 
 left, we Mrite R. = - : L. = : if only audible on contact, 
 
 C 
 
 we may say ^ . In other cases, low speech, or notes of differ- 
 ent pitch, at varying distances, or loud sounds, are sometimes 
 tried to test the power of hearing. Some persons hear a 
 watch badly, and conversation pretty well ; in others, again, 
 this is reversed. 
 
 The degree in which sound is conducted through the bones^ 
 when a sounding body is applied directly to the head, some. 
 
EXAMINATION OF THE EAR. 187 
 
 times yields valuable information, especially in discriminating 
 deafness due to disease in the nervous structures of the ear, 
 from that due to disease in the conducting apparatus (external 
 and middle ear). When the hearing is normal, "bone con- 
 duction " of sound is weaker than " air conduction," which is, 
 of course, the ordinary medium of hearing, (a) In the nor- 
 mal state, if a vibrating tuning-fork be held in contact with 
 the mastoid process till the note has completely died away, and 
 then quickly transferred to a point near to, but not touching 
 the orifice of the ear, the sound will be heard for several 
 seconds longer — " Rinne's experiment, positive result." (6) 
 In some cases of deafness the sound of the tuning-fork is not 
 heard when held opposite the ear after it has ceased to be 
 audible as applied to the mastoid process — " Rinne's experi- 
 ment, negative result." 
 
 In cases of deafness with a " negative result " it is held by 
 Lucae that the disease causing the deafness is in the conduct- 
 ing structures of the ear: if, on the other hand, a "positive 
 result " is obtained, the disease is assumed to be in the nervous 
 apparatus. These deductions from the results of Rinne's 
 experiment are not to be relied on in all cases, according to 
 Politzer and Barr. A more reliable test consists in applying 
 a large vibrating tuning-fork (C) to the middle line of the head 
 (forehead, vertex, or teeth), and ascertaining if it is perceived 
 by the patient princij^ally or exclusively on the side on which 
 he is deaf: or in the event of both eyes being afl:ected, if it is 
 heard more loudly on the deafer side (Weber's test). In either 
 of these cases, it may be assumed, with great probability, that 
 the disease causing the deafness is in the conducting structures : 
 if an opposite result is obtained by this test, a lesion of the 
 nervous structures of the ear may be inferred. The watch is 
 also used in testing " bone conduction." When in a case of 
 marked deafness the tick of the watch applied to the temple 
 or forehead is heard in the deaf ear more loudly than in the 
 hearing ear, or more loudly than if applied to the orifice of 
 the ear, the nervous structures are probably unimpaired. It 
 seems, how^ever, that an opj^osite result does not, in every 
 case, justify us in assuming disease of the nervous structures. 
 
 EXAMINATION OF THE EAR. 
 
 "When, by means of the watch test, or otherwise, we are satisfied of 
 an impaired state of the hearing, we must examine the organs to see 
 if any impediment can be found, such as a plug of wax, or any growth 
 
188 ORGANS OF SPECIAL SENSE. 
 
 or tumor in the meatus, or any obstruction in the passage of the Eus- 
 tachian tubes. The ear is ilhiminated by reflecting light from a con- 
 cave mirror through a speculum which straightens and slightly dilates 
 the external meatus. Daylight is much the best, but a lamp may be 
 required when this is defective. If wax be found on such an exami- 
 nation, the hearing should be tested after its removal by syringing, as 
 it does not follow that the wax was the sole or the chief cause of the 
 deafness complained of. Inquiry should likewise be made as to the 
 existence, at any period, of discharges of any kind from the ears (pus, 
 blood, or watery fluid), and in such cases the likelihood of perforation, 
 or even of almost complete destruction of the membrana tympani,must 
 be considered. Fracture of the base of the skull must also be remem- 
 bered in this connection. This perforation may demand a careful exami- 
 nation of the ear by means of the speculum, as just described, but some- 
 times it can be demonstrated by causing the patient to force air into 
 his ear by blowing his nose while the nostrils are tightly compressed 
 (Valsalva's method). In many cases of perforation of the membrane, 
 we may, in this way, hear a loud hissing or whistling sound due to the 
 air rushing through the perforation. This same experiment likewise 
 enables us to discover if the Eustachian tube is patent; for when the 
 tympanum is in its natural state we may thus hear, by means of the 
 aurist's diagnostic tube (or even a stethoscope applied to the external 
 ear), a sharp click from the compression of the air in the cavity during 
 the blowing of the nose as described. This method is not available in 
 children, or in those adults who cannot be made to do the experiment 
 properly. Politzer's bag, with its tube introduced into the nostril, is 
 often useful in such cases, as the air can be thus blown through the 
 Eustachian tube during the act of svvalhjwing, when no obstruction is 
 present. In other cases, again, the proper investigation requires the 
 air to be actually blown into the Eustachian tube by an ear-catheter 
 introduced into it, but such manipulations are only to be attempted by 
 those specially trained in aural surgery. In examining the Eustachian 
 tubes attention should be directed to the condition of the pharynx, 
 tonsils, and posterior nares, as many aural diseases begin in these situ- 
 ations. A proper examination of the orifices of the Eustachian tubes 
 may demand the use of rhinoscop3\ (See Chapter X.) 
 
 In the examination of the ear by the speculum and reflected 
 light, we aim at discovering the condition of the walls of the 
 meatus, the appearance of the membrana tympani, whether it 
 is ruptured, or whether distinct alterations exist in the curva- 
 ture of the membrane — such as bulging toward the meatus or 
 the contrary — whether there is any abnormality in the reflec- 
 tion of the light from the membrane, and whether there is 
 undue vascularity in the neighborhood of the handle of the 
 malleus or elsewhere. An exploration of the state of the 
 petrous bone, in cases of suppuration, can sometimes be made 
 by means of the probe, although this is a dangerous instru- 
 ment in such situaticms. All these changes point to disease 
 of the meatus and middle ear, and they indicate mechanical 
 
NOISES IN THE EAK. 189 
 
 causes for the deafness, and so may remove it from the realm 
 of the physician. But suppuration in the tympanum, etc., 
 may throw a light of the utmost value on certain cerebral or 
 pysemic symptoms in a case. Abscess of the brain and menin- 
 gitis occasionally depend on some previous suppuration in the 
 ear, and this may have extended upward from the throat, as 
 in certain cases of scarlatina. Puffiness over the mastoid pro- 
 cess, generally with present or past otorrhoea, is somedmes 
 found in connection with suppuration going on in the mastoid 
 cells, and this suppuration may be associated with a train of 
 symptoms indicative of septic poisoning or other serious mis- 
 chief, to which it may supply the only clew. Facial paralysis 
 is not unfrequently due to disease of the middle ear, especially 
 when this is of a suppurative character. When a degree of 
 deafness exists, and its cause cannot be referred to any impedi- 
 ment in the passages of the ear, we may infer a lesion of the 
 auditory nerve in some part of its course ; the test by bone 
 conduction may greatly assist us, and an examination of the 
 other cranial nerves may throw some light on the nature and 
 position of the lesion ; the presence of subjective symptoms 
 must likewise be considered in this connection. The occupa- 
 tion of the patient, and his relation in this respect to noises, 
 the previous history of blows on the head, of attacks of giddi- 
 ness, or of noises in the ears, and the family history as to deaf- 
 ness, hereditary syphilis, etc., should all be inquired into. 
 Scarlatina, typhus, and typhoid fever are often complicated 
 with deafness during the acute illness, and this occurs occa- 
 sionally as a sequela : in the first-named disease the mischief 
 is usually in the conducting structures of the ear, in the others 
 the deafness is almost always nervous. 
 
 Noises in the ear (tinnitus aurium) are often complained 
 of: they are generally associated with some degree of deafness, 
 more rarely with no defect in hearing. The noises vary in 
 degree from very slight sounds, heard only when everything 
 around is perfectly still, up to noises so distressing as scarcely 
 to be bearable. The sounds are described in the most varied 
 manner as ringing, humming, hissing, buzzing, whiffing, etc. 
 Sometimes there are two or more dijQferent kinds of sound in 
 the one ear. They are often traceable to some mechanical 
 cause, giving rise to pressure on the labyrinth, either directly 
 or indirectly. Thus wax pressing on the membrana tympani, 
 or obstructions in the Eustachian tube altering the pressure 
 of the air in the tympanum, can sometimes be shown (by the 
 effect of their removal) to have been the cause of tinnitus. 
 
190 OKGANS OF SPECIAL SENSE. 
 
 It should be remembered, however, that apparently similar 
 obstructions may exist without producing this symptom. In 
 cases of deafness, brought on by blows on the head, tinnitus is 
 often present. In many cases the noises in the ear seem to be 
 due to actual mischief in the labyrinth itself, and especially 
 to pressure of the stapes on the foramen ovale ; such pressure 
 may arise from disease of the external, middle, or internal 
 ear. A lesion of the labyrinth is especially probable in those 
 cases where the noises are associated with great deafness, and 
 with sudden and violent attacks of giddiness, and a tendency 
 for the patient to turn or to fall to one side (Meniere's disease. 
 (See p. 290.) Occasionally the noises in the ear appear (like 
 certain forms of deafness) to be purely nervous, coming and 
 going irregularly, or especially produced or aggravated in 
 connection with mental annoyance and over-fatigue ; or devel- 
 oped, like certain forms of weak sight, by prolonged lactation, 
 etc. Noises in the ear have, in certain cases, their explana- 
 tion in disturbances existing in the brain itself, or in its circu- 
 lation ; like flashes of light, they form part of the prodromata 
 of apoplectic attacks. In certain cases of acute diseases 
 (typhus), and in some nervous complaints, the hearing is 
 abnormally acute, so that very slight sounds, otherwise likely 
 to escape notice, seem to be painfully loud, although in other 
 stages of typhus and enteric fever deafness is often present. 
 Quinine in full doses often produces more or less noise or 
 ringing in the ears ; great differences exist as to the suscepti- 
 bility of patients in respect of quinine. Salicine and salicylic 
 acid may also give rise to the same symptom. Sometimes the 
 noise or singing in the ears is due, in all probability, to the 
 patients hearing sounds actually produced in their own blood- 
 vessels, and these can sometimes be stopped for the time by 
 pressure on the carotids. Possibly they sometimes hear sounds 
 produced by the circulation of the blood in the rigid arteries 
 at the base of the brain in cases of atheroma. 
 
 A whiffing sound, as if close at the ear, corresponding with 
 the arterial pulsations, is often complained of by persons af- 
 fected with some disorder of the heart's action (usually of a 
 functional character), and associated with a sense of throbbing 
 throughout the arteries; this sound distresses them chiefly 
 while lying on the left side, and, indeed, often renders this 
 posture in bed impossible. 
 
THE XOSE. 191 
 
 The Nose. 
 
 The sense of smell is tested by applying a phial charged 
 with very distinct odors to the nostril ; one nostril should be 
 tested at a time, the other being compressed, and the mouth 
 also should be kept shut. If the smell be not appreciated in 
 this way, the mouth may be kept open while the scent is being 
 sniffed up, or strongly flavored materials may be given to be 
 tasted or applied in such a way as to allow the odor to ascend 
 by the posterior nares. The odor may be blown into the 
 mouth and the person directed to breathe out through his 
 nose. The patient may likewise be questioned regarding his 
 recognition of flavors in his food or drink, as it has been 
 clearly ascertained that much of what w^e discern by the 
 mouth is really due to the sense of smell, and that those who 
 are affected simply with a loss of smell from nervous lesion 
 (anosmia), are incapable of discriminating the flavor of many 
 articles of diet (wines, coffee, cheese); such persons frequently 
 tell us that both smell and taste are nearly gone, and may 
 complain more of the loss of taste, as they call it, than of the 
 loss of smell. 
 
 Certain fallacies beset our investigation of this sense. 
 1. The presence of strongly pungent vapors or solids (ammo- 
 nia, snuff, etc.) may be recoguized by those destitute of smell, 
 from the action of these irritants on the branches of the fifth 
 nerve ; such things, therefore, must be avoided as tests ; assa- 
 foetida, musk, lemon, camphor, etc., are suitable for this pur- 
 pose. 2. Smell may seem lost from some imperfection in the 
 nasal cavity apart from any nervous lesion; thickening of the 
 mucous membrane from a common cold, or more serious alter- 
 ations in the hard or soft parts, as well as distinct growths, 
 are frequent sources of imperfection in the sense of smell ; in 
 such cases smells may possibly still be appreciated (especially 
 as flavors) by way of the posterior nares ; in other cases the 
 nasal affection may have actually imi^aired the terminal 
 branches of the olfactory nerve in the mucous membrane. 
 3. In facial paralysis, probably from some difficulty in direct- 
 ing the odorous current forcibly to the olfactory tract, in sniffl- 
 ing it up, there is sometimes an imperfect sense of smell in the 
 paralyzed nostril, without any real defect in the first nerve. 
 A dryness of the nostril may likewise cause a defect in smell, 
 — the tears flowing down the cheek, instead of into the nasal 
 duct in certain cases of facial paralysis. Disorders of the fifth 
 
192 ORGANS OF SPECIAL SENSE. 
 
 nerve may also produce changes in the state of the mucous 
 membrane, and so impair the acuteness of smell. 
 
 Loss of smell, as a single lesion, is sometimes met with in 
 connection with injuries to the head; but in the case of cere- 
 bral tumors and the like, other nerves are usually involved, 
 and not the first nerve alone. When anosmia is associated 
 with hemianciesthesia, from cerebral causes, the two are on the 
 same side — that is, on the opposite side from the presumed 
 lesion in the brain. On the other hand, when anosmia is asso- 
 ciated with aphasia and gross lesions of the temporo-sphenoidal 
 lobe, the olfactory nerve is implicated on the same side as the 
 cerebral lesion. 
 
 Perversions of smell and the associated perversions of taste, 
 as distinguished from a pure loss of these senses, are almost 
 entirely limited to cases of insanity, or other serious affections 
 of the brain and nervous centres, including hysteria. Such 
 perversions are, no doubt, intimately associated with the 
 delusions from which the insane sometimes suffer when they 
 imagine that they are themselves fetid and putrefying, or that 
 they are asked to eat filth, or that attempts are made to 
 poison their food. The occurrence of " a bad smell" consti- 
 tutes sometimes the aura ushering in an epileptic fit. Occa- 
 sionally a patient is conscious of a bad smell, really present in 
 his case, say from gangrene of lung or fetid eructations in 
 dyspepsia, Avhen the attendants may have a difficulty in recog- 
 nizing its presence, because of its only coming occasionally 
 with certain coughs or eructations. The use of certain medi- 
 cines, as phosphorus and some metallic salts, may likewise 
 l^roduce at times disagreeable sensations in the organs of smell 
 and taste. The use of bismuth may give rise (probably from 
 the presence of an impurity) to an odor of garlic in the brea-th 
 which may be perceived by the patient and also more com- 
 monly by the attendants. 
 
 Chronic discharge from the nose is sometimes simply 
 catarrhal, but it is usually fetid (ozsena), and often depends 
 on disease of the bones wdiich can be detected by the probe. 
 Such a discharge in children from one nostril only is always 
 suggestive of the presence of a foreign body in the nose. 
 Fetor from the nose may be distinguished from fetor due to 
 gangrene of lung, or from that of sore throat, disordered 
 stomach, carious teeth, etc., by testing the breath while the 
 mouth and the nostrils are closed alternately. 
 
 "Kunning from the nose" is one of the features of coryza 
 or catarrh of the nasal passages and sinuses connected with 
 
THE SENSE OF TASTE. 193 
 
 them ; it is a leading feature of a " cold in the head," and also 
 forms a prominent symptom in the invasion of measles. The 
 obstruction to the breathing through the nose observed in 
 infancy, and known as "snuffles," is usually due to syphilis. 
 
 The Sense of Taste. 
 
 The sense of taste is not easily tested in a satisfactory 
 manner. The difficulties are the following: Some so-called 
 tastes are really appreciated by the olfactory nerve, while 
 acrid substances may perhaps be recognized by the nerves of 
 common sensation. Loss of taste from nervous causes (ageustia) 
 is very often unilateral, and when a sapid substance is applied 
 to one side of the tongue as a test, it is apt to pass over quickly 
 to the other side, or to the soft palate, when the tongue is 
 taken in. To avoid this, the substance may be applied to the 
 tongue while it is kept protruded, but it is found that even in 
 the normal state it is not easy to recognize various tastes under 
 such conditions. The sense of taste proper seems to reside in 
 the tongue and soft palate chiefly, but the movements of the 
 tongue against the hard palate and lips, and the intimate 
 admixture of the substance with the secretions of the mouth, 
 seem to be almost essential for the proper appreciation of 
 tastes. A further difficulty arises from the different parts of 
 the tongue having very different degrees, and even kinds of 
 sensation. The best way is to try strong solutions of a sweet 
 and of a bitter substance, as these are pure sapids (sugar and 
 picric acid, e. g.) and to rub them with the finger or with a 
 piece of lint, or a brush, very freely and firmly on to various 
 parts of one side of the tongue while it is j^rotruded, and to 
 ask the patient to indicate by a movement of the head whether 
 and when he recognizes the taste before he takes in his tongue. 
 If we suspect a defect on one side, we can sometimes demon- 
 strate it more clearly by applying the test solution to the 
 affected side, and while it is still unrecognized, we may touch 
 the other side of the tongue with the same substance before 
 it is taken in ; we may thus find that the patient at once indi- 
 cates his recognition of the test fluid on the sound side by a 
 sign or a contortion of his face. Care must be taken to have 
 the patient's mouth thoroughly washed out before any new 
 substance is tried, as also to have the brushes or other agents 
 used in applying the test thoroughly cleansed, and it is well to 
 begin with the milder tastes, as the strong bitter substances 
 linger a long time in the mouth and complicate further trials. 
 
 17 
 
194 OECxANS OF SPECIAL SENSE. 
 
 In addition to sweet and bitter, acid and salt substances 
 should be tried. Acids without smell must be selected for 
 such trials, such as citric or tartaric acid. The galvanic test 
 may be applied by meaus of small electrodes, at the end of 
 fine wires fastened on a handle, but insulated from each other, 
 and connected with a few cells of a constant current battery. 
 This may be used to define the area of the gustatory sense in 
 the tongue, as w'ell as to ascertain its presence. Along with 
 the tests by sapids, the tongue should also be tried as to its 
 tactile sense by the compasses (see pp. 196-199); loss of taste 
 ^vith perfect tactile sensation, and loss of tactile sense with 
 perfect taste, are both occasionally found, as well as loss of 
 both ; we must also, of course, pursue the examination by 
 testing the other cranial nerves, etc. The significance of a 
 lesion of taste, when ascertained, is rendered somewhat ob- 
 scure by the curious differences of opinion as to the nerves of 
 taste and their real origin. The glosso-pharyngeal, for special 
 sense at the back part of the tongue, is generally recognized ; 
 Dr. Gowers, however, thinks that this nerve has really nothing 
 to do with taste, although fibres from the fifth nerve may be 
 distributed along with its terminal branches, and so give rise 
 to this idea. The lingual branch of the fifth nerve is admitted 
 by all to supply common sensation to the tongue, and most 
 authorities consider it to be concerned more or less also in the 
 special gustatory sense; the chorda tympani nerve, however, 
 which joins it from the seventh, is now regarded as the nerve 
 of special sense for the anterior part of the tongue, and it 
 seems quite certain that it has to do with the sense of taste. 
 But admitting this as proved, it is not quite certain that the 
 portio dura of the seventh pair really contains in itself sensory 
 fibres ; some, indeed, allege that the sensory fibres in the chorda 
 tympani come froui the " pars intermedia" of the seventh pair, 
 or from some junction with the fifth nerve in ways which are 
 not always uniform. It is conceivable, moreover, that the 
 lingual and chorda tympani may affect the sense of taste by 
 an indirect action on the glands and papillse. We may regard 
 it as certain that taste maybe afiected in eases presenting 
 evidence of a lesion in the glosso-pharyngeal nerve; that it 
 may be afiected, or preserved, in cases presenting definite dis- 
 orders of the fifth nerve, including among these anaesthesia of 
 the tongue; and that it is often afiected in cases presenting 
 the well known features of paralysis of the portio dura of the 
 seventh pair, arising from disease of the ear and other 
 peripheral causes. The variation as to the presence of the 
 
SENSIBILITY OF THE SKIN AND MUSCLES. 195 
 
 affection of taste in cases of facial paralysis depends probably 
 on the exact locality at which the lesion of the seventh nerve 
 exists; when this paralysis is due to a cerebral lesion, the 
 taste does not appear to be affected. 
 
 The taste may also be affected in various ways in general 
 diseases, such as insanity and hysteria, and the perversions of 
 taste, like those of smell, referred to under that sense, may be 
 mixed up with the delusions and hallucinations of the insane. 
 In various forms of digestive disorder the patients often com- 
 plain of having "a bad taste" in the mouth. Local causes 
 affecting the tongue, such as dryness in febrile disease, foul 
 coating in dyspepsia, stomatitis, and the like, naturally impair 
 the sense of taste. 
 
 Sensibility of the Skin and Muscles. 
 
 The skin has various forms of sensibility which are, so far, 
 capable of differentiation, and as these are variously affected in 
 disease, different tests come to be applied. In carrying out 
 any of the following tests in cases of nervous disease, a certain 
 sloivness in the trans^nission of the sensations may be noticed, or 
 there may be a second and different kind of sensation trans- 
 mitted after the first impression. 
 
 Common Sensation. Analgesia. — The most marked differ- 
 ences in disease are presented by the tactile sense and the 
 sense of pain : what would be felt in health as extremely pain- 
 ful may be felt distinctly enough, but quite without pain : in 
 such cases even the slightest touch may be perceived as acutely 
 as in health. 
 
 The sense of pain belongs to the group of " common sensa- 
 tions," as distinguished from more specialized sensations, and 
 may here be taken as their type. Itching, burning, and other 
 conditions bordering on pain are included in this group : but 
 pleasurable sensations come also under this category. The 
 sensation of electrization of the skin comes under it, and as 
 the current from an induction apparatus can be regulated to 
 produce the slightest perceptible effect, or the most painful 
 sensations, it is reckoned the best test. The electrodes of a 
 faradic battery are applied close together to the part, by pre- 
 ference in the form of a fine wire brush ; the minimum strength 
 which can be perceived is noted as well as the maximum 
 strength which can be borne without a sense of pain. We 
 may find that the patient perceives the application of a strong 
 current in the affected area, as if the brush were touching 
 
196 OKGANS OF SPECIAL SENSE 
 
 him, with, however, no sense of ^^ain, but at once cries out 
 when the brush is taken beyond the boundary of the affected 
 j^art. In the same way a needle thrust through the skin and 
 twisted about may be perceived by the patient, but without 
 pain, apparently much in the same way as any one might feel 
 the same process applied to the sleeve of his coat. This loss 
 of the sense of pain, with preservation of the tactile sense, is 
 termed analgesia. 
 
 The sense of temperature seems also to be so far distinct from 
 other forms of cutaneous sensibility. It is best tested by 
 means of hot and cold water, in two similar test tubes, applied 
 to the skin. The patient is then asked to say which of the 
 tubes is the hotter. By varying the temperature of the water 
 an exact estimate of the delicacy of this sense can be arrived 
 at. A hot and cold spoon serves the purpose of a rough test. 
 At times temperatures may be felt as painful although they 
 are not extreme. This indicates a hypersesthesia or excessive 
 sensibility: allied to this is the tenderness experienced in some 
 forms of spinal inflammation on applying a hot sponge to cer- 
 tain of the vertebrae. 
 
 The tactile sense is very unequally distributed over the 
 cutaneous and mucous surfaces, some parts being very much 
 more sensitive than others. Defects in the acuteness of this 
 sense are often complained of in particular parts, and so it 
 becomes important not only to verify the existence of this 
 amesthesia, but also to define with some accuracy its degree 
 and its distribution. Various methods are pursued. The 
 patient may be touched lightly with the finger or a feather in 
 A^arious parts, and he should be asked, while his eyes are shut, 
 whether and at what part he is touched, the observations 
 being, of course, varied by an occasional blank experiment. 
 A source of confusion consists in the transmission of vibrations 
 mechanically from the region of one nerve distribution to that 
 of another ; so that in a finger whose supply is wholly lost a 
 rubbing sensation may be felt by contiguity, much in the same 
 way as one can feel something rubbing the surface of his 
 glove and can even define the direction of the movement. 
 It is found that in aniestliesia the precision of localizing the 
 sense of impact is much diminished. If the defect be very 
 slight the patient may be tried with the most delicate impres- 
 sions possi))le, such as result from touching of a hair ; if, on 
 the other hand, the sense be very duU, the point of a })in, or 
 the pinching of the skin, may be used to produce a distinct 
 impression, and by the patient's answers, or the expression of 
 
TESTS IN ANESTHESIA. 
 
 197 
 
 his face, we may be able to define the area of impaired sensa- 
 tion. In conducting such experiments it should be noticed if 
 the perception of the impact is distinctly delayed, as this indi- 
 cates a bluntness in the sense. Other methods of testing the 
 sensation consist in trying if the patient can recognize by the 
 hand, and with his eyes shut, different textures of cloth, flannel 
 from cotton, for example, or if he can say whether a carpet, 
 or a rough or smooth substance, is interposed between his bare 
 foot and the floor, care being taken that there is no great dif- 
 ference in the temperature of these objects. The lifting of 
 minute objects by the hand, the discrimination of coins, and 
 the manipulation of worsted or cotton yarn in sewing or knit- 
 ting, often enable us to judge of the degree of tactile sense 
 remaining with considerable certainty ; blindfolding the 
 patients often brings out very prominently the loss of tactile 
 sense, as we may see them groping about with their hands for 
 objects which are already actually touching their fingers. 
 These mothods, or at least some of them, are applicable to 
 various ages and various grades of intelligence, but a greater 
 precision is sometimes obtainable by means of compasses or an 
 " sesthesiometer," as it is sometimes called. (See Fig. 33.) 
 
 Fig. 33. 
 
 4 5 6 7 
 
 iiiliiiiliiiiliiriliiiiliiii'ii!iiiiiilniil|iiiliiiiiMii 
 
 9 15 51 I 
 
 ,ImmI,„I„„I.,„I 
 
 "5 6 ', 7 ', S S ^ 33 /^i 
 
 lMM.:.li:|liM:lMMllillli.r|.inl:i.lw,n'.ui.Jjl I 
 
 Two forms of ajsthesiometer, half actual size. The figures indicate centimetres : the 
 second instrument is adapted for greater separation of the points. 
 
 It is found that in anaesthesia the sense of locality as regards 
 the part touched varies much, and a patient can often say 
 with certainty that he is touched and yet be very vague as to 
 the locality. This forms the basis of the test (Weber's). A 
 person with a very dulled sense could tell if touched simul- 
 taneously on the knee and the foot ; but even a healthy sub- 
 ject becomes confused if the two localities touched are suffi- 
 ciently approximated. The essence of the test, therefore, 
 
198 OKGANS OF SPECIAL SENSE. 
 
 consists in discovering the smallest distance at which the two 
 points of a pair of compasses, simultaneously and lightly 
 applied to the surface, can be recognized by the skin touched 
 as two separate objects. The points should be blunted in 
 some way (except, perhaps, in the case of the finger-tips and 
 other sensitive parts) ; sealing wax or ivory points serve this 
 purpose, or the points themselves may be rubbed down. The 
 patient should first be infoi'med, with his eyes open, as to the 
 process of testing to be attempted, a few trials being made to 
 let him know the object aimed at. The eyes should then be 
 shut, or the vision obstructed in some way, and the compasses, 
 widely opened, applied so as to give a distinct impression of 
 two separate points : the points should then be gradually ap- 
 proximated till they are felt as if they made only one impact, 
 or till the answers become confused and unreliable, in which 
 case we may revert after a time to the same part to see if the 
 same result is obtained. During this gradual approximation 
 of the points of the compasses, an occasional variation by the 
 impact of only one limb of the compasses should be intro- 
 duced, so as to make sure that the patient is not answering at 
 random. 
 
 The following directions should be attended to : 1. The two 
 points must be put down simultaneously and with equal pres- 
 sure, otherwise the succession of the impacts leads of itself to 
 the inference of two points. 2. The part of the patient under 
 observation should be kept quite unmoved and steady : patients 
 instinctively, when in doubt, tend to move the fingers or hand 
 to satisfy themselves when asked whether two points are ap- 
 plied, as they get in this way also a succession of impressions. 
 3. The two points should be always kept in the same relative 
 direction in making estimates of the delicacy of sensation in 
 the same limb — i. e.,we must keep always either in the axis of 
 the limb or always transversely to it. 4. The points should 
 be kept stationary, or if moved along allowance must be made 
 for the variation of the sensibility thus introduced, especially 
 if we a})proach more sensitive areas. With every care the 
 results are often unsatisfactory and confusing. In fact, con- 
 siderable intelligence is required in the patients to secure reli- 
 able results, and they often seem so stupid or careless or 
 fatigued that the results appear a mass of confusion. Possibly 
 at times the disease itself helps the confusion by leading a 
 patient to feel one point as if it were two or more (poli/aMhesia). 
 
 The following list may serve as an indication of the normal 
 sensitiveness of different parts, but it cannot be regarded as 
 
WEBER S TEST, 
 
 199 
 
 absolute : a comparison of the sensation on the two sides of 
 the body indicates changes in a more reliable manner when 
 the lesion is unilateral. (Selected from Weber's table.) 
 
 DISTANCES AT WHICH TW^O POINTS CAN BE RECOGNIZED AS 
 SUCH IN THE NORMAL STATE. 
 
 line. 
 
 lines. 
 
 line. 
 
 Point of the tongue . I 
 Dorsum and edge of 
 
 tongue 4 
 
 Palmar surface of third 
 
 phalanx 1 
 
 Palmar surface of sec- 
 ond phalanx ... 2 lines. 
 Palmar surface of meta- 
 carpus 3 
 
 Skin of cheek .... 3 
 
 Tip of the nose ... 3 
 
 Lower part of forehead 10 
 
 Neck under jaw ... 15 
 
 Skin beneath occiput . 24 
 
 Sternum 20 
 
 Ked surface of lips . . 2 lines. 
 Lips where covered with 
 
 skin 4 " 
 
 Dorsal surface of third 
 
 phalanx 8 " 
 
 Dorsal surface of first 
 
 phalanx 7 " 
 
 Dorsum of hand at 
 
 knuckles 8 " 
 
 Middle of thigh ... 30 " 
 
 Over patella .... 16 " 
 
 Dorsum of foot near toes 18 " 
 
 Penis 18 " 
 
 Upper dorsal vertebrae .24 " 
 
 Middle dorsal vertebrae . 30 " 
 
 The area of diminished sensation, or of complete anaesthesia, 
 often enables us to refer the defect to a single nerve, or to a 
 special branch of a nerve.^ The extent of the area of anaes- 
 thesia, and its level in the trunk, may enable us to define the 
 locality of the lesion in the spinal cord to which it is due. 
 Anaesthesia is, indeed, very often due to spinal lesious, but is 
 sometimes found in more general diseases — after diphtheria, 
 for example (in the skin as well as in the fauces), in hysteria, 
 and occasionally in other affections clearly of a functional 
 character. In cases of ovarian irritation certain limited areas 
 of anaesthesia can sometimes be made out : occasionally the 
 ansesthesia in such cases extends to one side of the body (hemi- 
 ansesthesia) : such unilateral ansesthesia is found also in some 
 cases of cerebral lesions (posterior part of internal capsule), 
 associated with paralysis of the same j)arts. In locomotor 
 ataxy anaesthesia of the feet and legs is very common. (Com- 
 pare section on "Paralysis with Ansesthesia," p. 210.) Anaes- 
 thesia is frequently caused by pressure on the nerves, as by 
 tight bandages, splints, crutches, etc., or by more serious 
 forms of pressure arising from malignant tumors, aneurisms, 
 abscesses, etc. 
 
 1 In studying this distributiou, Flower's Diagrams of the Nerves, 3d ed., Lend , 1880 ; 
 and Heiherg's Atlas of the Cutaneous Nerve Supply : Bailliere, Tindall & Cox, Lond., 
 1885, may be consulted with advantage. 
 
200 ORGANS OF SPECIAL SENSE 
 
 The trophic effects of nervous lesions must be noted, wheu 
 present, as important facts in cases of anaesthesia : ulcerations 
 of the cornea in the case of the fifth, glazing of the skin, 
 wasting of the nails, grayness of the hair, and the like, are to 
 be named in this connection. Amesthesia can occasionally be 
 shown to exist in an area affected with neuralgia, and a certain 
 degree of anaesthesia — a dulled perception of tactile impres- 
 sions — is habitually present in cases of so-called hypersesthesia 
 in Avhich slight irritations of the skin produce jminful im- 
 pressions. In serious lesions of nerves from injury, there is 
 sometimes a deep-seated burning pain to which the name 
 " causalgia " is api)lied. 
 
 Diminution of the sensation in the mucous membranes can 
 be ascertained by touching the parts, tickling the fauces, etc. ; 
 diminished sensitiveness of the fauces, epiglottis, etc., some- 
 times determines the occurrence of choking or of pulmonary 
 affections, especially in the insane. The tongue has already 
 been referred to. 
 
 The sense of jivessure differs from the sense of touch and the 
 sense of weight. It is tested by applying a series of coins or 
 Aveights on the part to be tried : this must be firmly supported 
 and care must be taken to avoid complications from the sense 
 of temperature by introducing some non-conducting substance 
 next the skin. 
 
 Muscular Sensibility. Sense of Weight. — Tlie " muscular 
 sense" is a name applied by some to the faculty we possess of 
 judging of weight. This faculty is often very defective in 
 locomotor ataxy, and has been supposed to account for the 
 incoordination of the movements found in this disease. In the 
 case of the upper limbs various w^eights, of as nearly as pos- 
 sible the same bulk, may be given as tests while the patient's 
 eyes are closed, and it can then be seen how far he is able to 
 discriminate them by his muscular sense. For light objects, 
 coins answer adnurably — a sovereign and a shilling, for ex- 
 ample. In testing the lower limbs the patient may be placed 
 on a high seat, with his feet quite off the ground, or one les^ 
 may be swung over the other, and various weights, enclosed 
 in a bag, or attached by any other convenient arrangement, 
 may be suspended on the foot, and the power he has of esti- 
 mating weights may thus be gauged. 
 
 In health there is a distinct consciousness of muscular con- 
 traction when it is excited by the faradic current : the sensi- 
 bility of muscle is tested in this way. Probably connected 
 with the muscular sense, and the consciousness of the outgoing 
 
ANESTHESIA AND P AR JESTHE SI A . 201 
 
 current from the brain to the muscles, is the notion we have of 
 the position in which our limbs happen to be at a given time. 
 The conception of this is often quite erroneous in patients 
 whose tactile sense seems good. The patient's eyes being 
 bandaged, the limbs are placed or held in various positions, 
 and the interrogation made. 
 
 Diminution and perversion of the cutaneous sensibility as com- 
 Ijlained oj by the jyatients may take a great variety of forms. 
 
 AncBsthesia is described by patients as a " numbness " or 
 " deadness " of the affected parts, or occasionally as if thickened 
 skin, leather. India-rubber, or even air cushions were inter- 
 posed between their feet, or other affected parts, and the 
 objects touched. These sensations may be regarded as due to 
 pure defects. Associated with anaesthesia, there m.ay be in 
 the same part " hypercesthesia " — that is to say, painful sensa- 
 tions from irritations which in the normal state would scarcely 
 be noticed : thus a light touch affecting, perhaps, only the 
 hairs of the skin, or a slight current of air, may be felt by 
 such patients as acutely painful ; but as there is in hyperses- 
 thesia no real increase of delicacy in touch, but almost always 
 a diminution, the term " hyperalgesia " might be more fitly 
 employed, while this, and all forms of disordered sensation, 
 might be classified under the general name of the parcesthesice. 
 The feeling of "pins and needles" in a limb is often com- 
 plained of in paralysis ; the feeling is somewhat similar to that 
 experienced by everyone at times when by accident undue 
 pressure is made on certain parts of a limb, as on the arm by 
 lying on it, etc. Allied to this tingling is the feeling as if 
 small insects were crawling over the body {''formication''')', 
 other creeping feelings, and sensations as if the hairs of the 
 body were standing on end {horripilation, goose-skin), are 
 complained of in various nervous affections, and also in febrile 
 disturbances. Feelings of flushing, both local and general, 
 and of coldness, or of cold water trickling down a part, are 
 often experienced in nervous affections, especially hysteria 
 and hypochondriasis, as well as in certain febrile states. (See 
 " Pyrexia," p. 103.) Coldness of the limbs is often bitterly 
 complained of in paralysis, although the parts may seem only 
 slightly colder than natural. The girdle sensation, sl feeling 
 of constriction of the trunk, as if the clothes were too tightly 
 fastened round the body, or as if a cord were tightly com- 
 pressing it, is often present in spinal affections. Some of the 
 above perverted sensations pass into, or are associated with 
 actual pain in various parts. 
 
202 OKGANS OF SPECIAL SENSE. 
 
 Testing of the Cranial Nerves. 
 
 In many cases of paralysis the critical examination of the 
 cranial nerves may enable us not only to pronounce on the 
 cerebral nature of the illness, but even to localize the lesion in 
 some part of the brain. In certain cerebral affections, more- 
 over, it occasionally happens that only one or two nerves are 
 paralyzed, and these may escape attention unless we test the 
 nerves systematically : variations in the paralysis likewise 
 occur from time to time, in certain cases of cerebral or cranial 
 tumors, and even a more transient paralysis of these nerves is 
 sometimes seen in cerebral abscess. 
 
 First nerve — olfactory — supplies the sense of smell. (See 
 p. 191.) 
 
 Second nerve — Optic — the nerve of vision. (See p. 178.) 
 
 Third nerve — Motor oculi — supplies directly, or through 
 the lenticular ganglion, the sphincter muscle of the iris, the 
 ciliary muscle regulating the accommodation, the levator pal- 
 pebra3, and all the muscles of the eyeball except the superior 
 oblique and external rectus. These muscles should be tested 
 separately. (See pp. 161-174.) 
 
 Fourth nerve — Patheticus, Trochlearis — supplies the supe- 
 rior oblique muscle of the eye. (See pp. 165, 166.) 
 
 Fifth nerve — Trifacial, Trigeminal — is partly motor, but 
 much the larger part is purely sensory. The ynotor branches 
 are derived from the small root of the nerve. These motor 
 branches are all given off from the inferior maxillary portion. 
 They are distributed chiefly to the muscles of mastication, 
 viz, the temporal, masseter, and internal and external ptery- 
 goids ; the mylo-hyoid, and the anterior belly of the digastric, 
 likewise, are supplied from this source. The power of closing 
 the jaw perfectly, and of moving it laterally, affords evidence 
 of the soundness of these branches. The buccinator muscle 
 Avas formerly supposed to be supplied by the fifth, but it is now 
 recognized tliat the buccal branch of this nerve is sensory, and 
 that the motor supply comes from the seventh. The motor 
 branches from Meckel's ganglion going to the palate and 
 uvula are supposed to be derived from the seventh nerve. 
 
 The sensory branches supply common tactile sensation to the 
 skin of the face from the forehead to the chin, to the mucous 
 surfaces of the mouth, tongue, palate, and uvula; the conjunc- 
 tiva, the mucous membrane of nose and the teeth, are all 
 supplied from this source. In addition, the lingual or gusta- 
 tory branch supplies probably some portion of the special 
 
SEVEKTH NERVE. 203 
 
 sense of the tougue (apart even from the fibres of the chorda 
 tympani nerve mechanically united with it). The fifth nerve 
 has, however, very important functions connected with the 
 nutrition of the eyeball, of the hairs, and other parts to which 
 it is supplied. When affected as far back as the Gasserian 
 ganglion, sloughing of the cornea, and other trophic changes 
 have been observed. The tests applied in judging of the sen- 
 sory branches of this nerve are by means of the compasses for 
 the common tactile sense of the skin, tongue, and lips ; by 
 tickling the palate or uvula for the production of reflex action, 
 acting on one side only at a time ; by test solutions for the 
 special sense of the tongue (see *' Taste," ]). 193) ; and by 
 examination of the clearness of the cornea, the color of the 
 eyebrows, the amount and character of the secretions of the 
 nostrils, etc., for any trophic changes in affections of this 
 nerve. Pain or neuralgia in the situations enumerated above 
 may be referred to this nerve. 
 
 Sixth nerve — Abducens oculi — supplies only the external 
 rectus of the eye. Deficiency in the power to move the eye- 
 ball outward is the sign of paralysis of this nerve, but care 
 must be taken to ascertain that the eyeball is not fixed from 
 inflammation, abscess, or tumor of the orbit. In slighter 
 forms, diplopia may be the only evidence of this paralysis, 
 while in severer forms there may be internal strabismus. 
 (See pp. 161, 169.) 
 
 Seventh nerve (portio dura) — Facial — This nerve is essen- 
 tially motor, but some communicating branches are still 
 involved in doubt as to their exact function. The muscles 
 directly supplied include all the great muscles of expression, 
 and in judging of their healthy or paralyzed condition, it is 
 desirable to get the patient to laugh, to whistle, or to simulate 
 expressions of surprise, etc. These muscles include those of 
 the external ear, the occipito-frontalis, corrugator supercilii, 
 orbicularis palpebrarum, the muscles of the nose, cheek, upper 
 and lower lips, the orbicularis oris, buccinator, stylo-hyoid, 
 part of the platysma, and the posterior belly of the digastric. 
 In addition to these, the facial sends a branch to JMeckel's 
 ganglion — the large superficial petrosal nerve — and it is prob- 
 ably from this source that the motor supply of the azygos 
 uvulae and the levator palati is derived. The facial, moreover, 
 sends a branch — the chorda tympani — to join the lingual or 
 gustatory of the fifth ; and it is now generally agreed that the 
 chorda tympani supplies the sense of taste in the anterior part 
 
204 ORGANS OF SPECIAL SENSE. 
 
 of the tongue. (See " Taste," p. 194.) The facial also sup- 
 plies the intrinsic muscles of the tongue (lingualis). 
 
 In examining cases of paralysis of the portio dura, attention 
 should be specially directed to the occipito-frontalis and the 
 orbicularis palpebrarum : these are usually paralyzed to a 
 marked extent in lesions affecting the trunk of the nerve. 
 The eye often remains uncovered and waters readily, or even 
 becomes seriously affected from exposure. In slighter forms 
 of paralysis of the orbicularis the inability to close the eyelids 
 may only become obvious when the patient is asked to shut 
 each eye separately. These muscles often escape in large part 
 in the facial paralysis due to general cerebral causes (hemi- 
 plegia). The mouth is usually also badly affected in lesions 
 in the trunk of the seventh, so that the patient cannot whistle, 
 and from paralysis of the orbicularis oris the saliva may 
 escape : from the flabby state of the buccinator, the food often 
 accumulates helplessly between the cheek and the teeth. All 
 these symptoms are usually much more marked in cases of 
 paralysis from peripheral causes than in those from central 
 affections. Deviation of the uvula or unilateral paralysis of 
 the palate sometimes leads to a diagnosis of a lesion behind the 
 origin of the petrosal branch in the tympanum (the nervus 
 petrosus superhcialis major arises at the intumescentia gangli- 
 formis). The palate hangs loosely on the paralyzed side, and 
 its reflex movements are lessened : it may also be drawn to 
 the sound side. The uvula sometimes deviates to the para- 
 lyzed side, sometimes to the sound side. It is not always quite 
 even in the healthy state, and this probably accounts for its 
 being off the middle line in some of the cases of paralysis 
 reported ; but its deviation to the paralyzed side has been 
 attributed by some to the unopposed action of the pharyngo- 
 palatine muscle. Paralysis of the seventh nerve may affect 
 the movements of the tip of the tongue, especially tlie pointing 
 of it or the moving of the tip in various directions when pro- 
 truded. It is also quite certain that some loss of taste occa- 
 sionally exists in the anterior part of the tongue in peripheral 
 paralysis of the facial nerve. The hearing should be tested 
 carefully in paralysis of the portio dura. 
 
 The passage of the facial nerve through bony canals renders 
 it very liable to injurious pressure from inflamnuitory exuda- 
 tions, especially of the rheumatic and syphilitic type ; in 
 young subjects the nerve is occasionally unprotected by bone 
 in the tympanic cavity, and so inflammatory processes there 
 
EIGHTH NEKVE. 205 
 
 also may lead to tempoi-aiy compression, even when no destruc- 
 tive lesion in the bone has been produced. 
 
 Facial paralysis sometimes exists on both sides (bilateral or 
 double facial paralysis). In such cases the face is symmetrical 
 but expressionless. It may arise from a combination of light 
 and left aural disease, or from accidental combinations of other 
 peripheral forms of facial paralysis. It is most commonly, 
 however, due to disease in the pons Varolii or medulla oblon- 
 gata, and constitutes in this way a feature of progressive bulbar 
 paralysis. (Glosso-labio-laryngeal paralysis.) 
 
 Seventh nerve (portio mollis; — Auditory. This nerve sup- 
 plies the sense of hearing : it has been also supposed to be 
 concerned in the estimate we form of our position in space, 
 and so in the power of maintaining our equilibrium. Disor- 
 ders in it show themselves by deafness, noises in the ear, and 
 it may be vertigo. (See p. 190.) 
 
 Eighth nerve — glosso-pharyngeal — is almost purely sen- 
 sory : it supplies sensation to the tonsils and pharynx, and 
 so is greatly concerned in the reflex actions of swallowing : it 
 supplies the back part and the sides of the tongue with special 
 sensation, and is distributed to the circum vallate papillae. It 
 supplies the mucous membrane of the tympanum and Eusta- 
 chian tube with sensory fibres. It may be tested by attempt- 
 ing to produce reflex actions, by tickling the pharynx, and by 
 test solutions, especially bitter fluids, applied to the back of 
 the tongue. (See "Taste," page 193.) 
 
 Eighth nerve — spinal accessory. The portion of the nerve 
 which arises from the medulla oblongata (bulbar portion) 
 seems to be distinct in function from that arising; from 
 the spinal cord. Both roots are purely motor. The fibres 
 from the bulbar portion enter the branch comm.unicating with 
 the pneumogastric, and are distributed to the muscles of the 
 pharynx and larynx (through the superior and recurrent 
 laryngeal nerves). The fibres derived from the spinal portion 
 of the nerve are distributed to the sterno-mastoid and trape- 
 zius muscles. Disorder of the roots of the spinal accessory 
 nerve may, therefore, give rise to laryngeal and pharyngeal 
 disorders, or to convulsive or other affections of the trapezius 
 or sterno-mastoid. 
 
 Laryngeal disorders may also arise from affections of the 
 recurrent laryngeal nerve, due to aneurismal or other tumors 
 in the chest. Glosso-labio-laryngeal paralysis is probably 
 associated with, and in part due to, an affection of this nerve. 
 
 18 
 
206 OKGANS OF SPECIAL SENSE. 
 
 Eighth nerve — pueuniogastric. This nerve has such a 
 wide distribution, such important connections with other 
 nerves, especially the sympathetic, and still remains in so 
 much obscurity as to certain of its functions, that no attempt 
 need here be made to detail its sphere of operation. The 
 student may remember, in the present connection, that it sup- 
 plies the mucous membrane of the pharynx and larynx, and 
 also the muscles of both, although, as mentioned in the pre- 
 ceding section, this motor portion is derived probably from 
 the spinal accessory. The thyroid gland also derives its 
 supply from the pneumogastric ; and the heart, lungs, oesoph- 
 agus, stomach, bowels, liver, and spleen all receive important 
 nervous filaments, either directly from this nerve, or from the 
 cardiac, pulmonary, and other plexuses to which it gives 
 branches. Aphonia, dysphagia, vomiting, constipation, pal- 
 pitation, intermittent pulse, hepatic disorder, glycosuria, dia- 
 betes, and respiratory disorders and distress, may all at times 
 be referred, directly or indirectly, and with more or less prob- 
 ability, to an affection of this nerve in some part of its course. 
 
 Ninth nerve — hypoglossal — is purely motor. It supplies 
 all the depressor muscles of the hyoid bone, receiving some 
 important fibres from the second and third cervical nerves 
 through the communicans noni. 'J'he genio-hyoid and the 
 omo-hyoid are also sujDplied from the same source. It also 
 supplies the (extrinsic) muscles which act on the tongue, 
 and it even gives a few terminal fibres to its intrinsic muscles 
 (lingualis). This nerve, therefore, is concerned in deglutition 
 and in the movements of the tongue. Paralysis of this nerve 
 on one side leads to protrusion of the tongue toward the para- 
 lyzed side, from the unop2:)osed action of the sound genio-hyo- 
 glossus. If extreme, as in cases of injury, the paralyzed side 
 is flabby and falls into wrinkles, but there is no loss of tactile 
 or gustatory sense. The tongue is usually deviated to one 
 side from affection of this nerve in hemiplegia ; in glosso- 
 labio-laryngeal (bulbar) paralysis the ninth nerves are clearly 
 involved. 
 
 The subjects comprised under this chapter are discussed in many of 
 the Works on nervous diseases referred to in the next chapter, such as 
 — lvo!-s, Tiie Di-eases of ilie Nervous Syt-tem, 2d edit , 2 vols., Lon- 
 don, 1883. — Gower?, Diagnosis of Diseases of the Jirain, London, 1885. 
 — Physiological works may also be consulted — e. g., Landois, Text- 
 book of Human Physiology, translated by Dr. Stirling, 2 vols,, Lon- 
 don, 1885; and Austin Flint, Jr., The Physiology of Man, 5 vols., 
 New York, 18G8-74; the tifih volume deals with the special senses. — 
 Anatomical works are also useful for reference, especially such works 
 
BIBLIOGRAPHY. 207 
 
 as — Flower, Diao^rams of the Nerves, 3d edit., London, 1880. — Hei- 
 berg's, Atlas of the Cutaneous jSTerve-supply of the Human Body, 
 translated by W. W. Wagstaffe, London, 1885. — Eiidinger, Anatomie 
 der Menschiichen Gehirn-Net-ven, 2d edit., Stuttgart, 1870. 
 
 Eye. — In addition to general treatises on ophthalmic medicine, the 
 student is referred to the following: Eobin (Albert), Des Troubles 
 Oculaires dans les Maladies de I'Encephale, Paris, 1880. — Gowers, 
 JNIanual and Atlas of Medical Ophthalmoscopy, 2d edit., London, 
 1882. — Panas, Lemons sur le Strabisme, les Paralysies Oculaires, le 
 Nystagmus, le Blepharospasme, etc., Paris, 1873. — Wecker et Jager, 
 Traite des Maladies du fond de I'QEil, et Atlas d'Ophthalmoscopie, 
 Paris, 1870. — Buuchut, Atlas d'Ophthalmoscopie et de Cerebroscopie, 
 Paris, 1876. 
 
 Ear. — Politzer, Text-book of the Diseases of the Ear and adjacent 
 Organs, translated by Dr. Cassell-, London, 1883 — Barr, Manual of 
 Diseases of the Ear, Glasgow, 1884. — Macnaughton Jones, Atlas of 
 Diseases of the Membrana Tympani, London, 1878. — Hinton, Atlas 
 of Disease.5 of the Ear, London, 1874. — Woakes, On Deafness, Giddi- 
 ness, and Noises of the Head, London, 1879. 
 
 Nose. — In addition to general surgical treatise', special treatises on 
 diseases of the throat and of the ear deal with this region — e.g.^ 
 Prosser James, Laryngoscopy and Rhinoscopy: the Diagnosis and 
 Treatment of Diseases of the Throat and Nose, 4th edit., London, 
 1885. — Mackenzie (Morell), Manual of Disea=es of the Throat and 
 Nose, 2 vols., London, 1884. — Woake.=i, Post-Nasal Catarrh and Dis- 
 eases of tbe Nose, London, 1884. — Ogle (W.), Anosmia: or. Cases 
 Illustrating the Phvsiology and Pathology of the Sense of Smell, 
 Medico-Chirurgical Transactions, vol. liii., London, 1870. 
 
CHAPTER VI. 
 
 SYMPTOMS OF DISORDEK IN THE NERVOUS SYSTEM. 
 
 Various symptoms of disorder in the nervous system have 
 been already dealt with in the chapter on the " Organs of 
 Special Sense and the Cranial Nerves" (Chapter V.) : and in 
 two subsequent chapters special branches of the subject will be 
 taken up in connection with the employment' of "Electrical 
 Instruments in Diagnosis" (Chapter VII.): and the "Study 
 of Insanity " (Chapter VIIL)- These sections must, therefore, 
 be referred to as supplementing the present chajDter. 
 
 Paralysis. 
 
 Paralysis is usually understood to mean a loss or diminution 
 of motor power: occasionallv the term is applied to sensory as 
 well as motor nerves, in which case some loss of function is 
 signified. 
 
 The distribution of the paralysis is one of the first points to 
 be investigated. " Hemiplegia " is the name given to a paral- 
 ysis of one lateral half of the body, especially of one arm, one 
 leg, and one half of the face ; the paralysis of the face is usu- 
 ally on the same side as that of the limbs ; when it is on the 
 opposite side it is termed " alternate hemiplegia," or " crossed 
 paralysis." "Paraplegia" technically denotes a paralysis of 
 the lower part of the body ; the legs and the lower part of the 
 trunk, including at times the bladder and rectum, are the 
 parts affected. " Monoplegia " is a term applied to paralysis 
 of one limb. 
 
 Paralysis is sometimes limited to the lower limbs or even to 
 the parts below the knee, to the hands, arms, and shoulders, 
 or to the forearms (especially in cases of infantile paralysis, 
 wasting palsy, lead ])()isoning, and traumatic paralysis). 
 Paralysis of the face often exists without any affection of the 
 limbs; it is usually one-sided, but occasionally double. 
 
 Beyond these obvious distinctions we must be on the watch 
 for more definite anatomical and physiological variations in the 
 distribution of the paralysis; thus we have aflfections of single 
 
PARALYSIS. 209 
 
 nerves (as the sixth), or of special divisions of a nerve, as in 
 the case of the third cranial nerve (see pp. 160-174), or of the 
 miisciilo-spiral nerve and the like. Or we may have special 
 muscles or groups of muscles paralyzed, as in the case of the 
 deltoid, and the muscles of the thumb in muscular atrophy ; 
 and of the extensors of the forearm, with the immunitv of the, 
 supinator longus, in lead j^aralysis. Again, the distribution 
 of the paralysis may affect special processes, as in paralysis of 
 deglutition, articulation, respiration, etc., — various nerves and 
 muscles being implicated together. 
 
 The delicate exercise and coordination of the movements 
 required in the complex use of the vocal organs, of the hand 
 in writing, and of the feet and legs in walking, may be greatly 
 impaired in cases where paralysis, in its ordinary sense of 
 want of motor power, can scarcely be affirmed. Such a con- 
 dition is observed in the early stages of locomotor ataxy, gen- 
 eral paralysis of the insane, writer's cramp, shaking palsy, 
 and some other affections. 
 
 The state of the patient as to intelligence, and his general 
 mental and emotional condition, are to be noticed particularly 
 in the examination; they are likewise to be considei^d in con- 
 nection with the previous history of such paralytic attacks. 
 This inquiry is of special weight in cases of hemiplegia, of 
 paralysis of the cranial nerves, of shaking palsy, and of gen- 
 eral paralysis of the insane. It is evident, also, that we must 
 ascertain how far the mental condition of our patient can be 
 relied on before we submit him to tests, the value of which 
 turns largely on his intelligent cooperation. We seek to 
 know if any period of unconsciousness occurred in connection 
 with the paralysis, and at what stage of the illness it super- 
 vened ; what warning was given of the attack by headache, 
 sickness, giddiness, or the like; what was the depth of the 
 unconsciousness and the period of its duration; whether it Avas 
 associated with convulsions, and of what kind these were ; 
 whether the unconsciousness has passed away or still continues 
 to any extent. (For observing paralysis in unconscious states, 
 see "Fits: Sudden Paralysis," p. 251.) We have often to 
 inquire, moreover, whether the intelligence was affected in any 
 degree, before the paralytic attack, or during its onset, or only 
 after its continuance for some time. We must test the intelli- 
 gence, by questioning the patient on subjects with which he is 
 known to have been familiar, or we may have to take the 
 opinion of his friends on this point. 
 
 18* 
 
210 SYMPTOMS OF NERVOUS DISORDERS. 
 
 Associated with more or less diminution of the intelligence, 
 and occasionally without any indication of weakness in this 
 respect, we observe in some forms of paralysis an excessive 
 mobiHty of the emotional nature, manifesting itself in some 
 patients by weeping, and in others by laughing without any 
 adequate cause ; in some there are alternations of both condi- 
 tions. In general paralysis of the insane we often have in the 
 patient inflated ideas of his general importance, and even of 
 his strength ; in cerebro-spinal sclerosis there is usually a 
 striking placidity of mind and general hopefulness as to his 
 condition, but this peculiarity does not go much beyond this 
 limit. Irritability of the temper, and very great changes in 
 the moral character, not unfrequently date from j)aralytic 
 attacks. 
 
 The sensations of the skin are often affected — sometimes 
 impaired and sometimes perverted. (For "Anaesthesia and 
 Perverted Sensations," see pp. 195-201.) AVhen sensation is 
 intact, this should be mentioned. When an affection of the 
 sensibility can be determined, this should be defined as to its 
 distribution, and compared with the distribution of the paral- 
 ysis; in some regions, as in the case of the abdomen, we are 
 able to form a more accurate notion of the level of a spinal 
 lesion by considering the range of the anaesthesia than by 
 merely considering the range of the paralysis. When this 
 affection is limited to one lateral half of the body, it is termed 
 " hemi-ansesthesia ; " this is comparatively a rare occurrence 
 in hemiplegia, at least in a glaring form ; when due to cere- 
 bral disease, it is supposed to point to a lesion in the posterior 
 part of the internal capsule. It may exist quite apart from 
 paralysis, and frequently there is no gross lesion at all in such 
 cases, the symptom changing from side to side. It is then re- 
 garded as hysterical ; it is often associated with hemiopia. 
 (See pp. 180 and 199.) 
 
 The limitation of anaesthesia to the area supplied by a par- 
 ticular nerve, as in the case of the fifth nerve, is of great 
 diagnostic value; this may concur with paralysis of the mus- 
 cles of mastication supi)lied by the same nerve. Similar com- 
 binations of anaesthesia and paralysis, in the regions supplied 
 by special nerves, nerve trunks, or plexuses, may be seen in 
 various affections, especially in traumatic cases, and, as al- 
 ready mentioned, in serious lesions of the cord. In estimating 
 the site of the lesion in the cord, a comparison of the distribu- 
 tion of the anaesthesia with the spinal origin of the nerves 
 
CONDITION" OF LIMBS AND MUSCLES. 211 
 
 implicated, can be readily made by the use of Flower's dia- 
 grams of the nerves.^ 
 
 Paralysis often exists to a marked extent without anaes- 
 thesia, or with little alteration as regards sensation. In ordi- 
 nary hemiplegia, well marked anaesthesia is rare. Even in 
 many cases of paraplegia the anaesthesia is slight, and the 
 same may be said of lead palsy. In infantile paralysis the 
 sensation is almost invariably preserved. 
 
 Pain a7id paralysis 2iYe sometimes combined. In such cases 
 we must first ascertain, if possible, whether the apparent 
 paralysis may not really be due to the pain. In severe neu- 
 ralgia of the face, or of a limb, or in pain from diseased joints 
 and the like, the parts cannot be moved on account of the 
 commanding nature of the pain ; in cases of muscular pain, 
 as in a common stiff neck, the absence of motion is no doubt 
 due chiefly to this ; in certain forms of what is termed " rheu- 
 matic paralysis," however, the inability to move the part 
 affected seems to be partly owing to this pain and partly to a 
 rheumatic affection of the nerves or their sheaths impairing 
 their function. When the pain in paralysis is not of this 
 character, we ascertain if the skin and muscles of the affected 
 limb are tender on pressure, or if the pains come in severe 
 darts of momentary duration, or if they are associated with 
 cramps, permanent contractions, or startings of the limbs. 
 Thus cerebral meningitis is often associated at its commence- 
 ment with a generalized " hyperaesthesia," and this is like- 
 wise noticeable in some cases of hemiplegia; spinal meningitis, 
 by its attendant pains, may simulate rheumatism ; lesions of 
 the cord may give rise to pains resembling sciatica and other 
 forms of neuralgia or rheumatism in the limbs ; " electric " or 
 " toothache-like " pains in the legs are habitual in locomotor 
 ataxy ; the pain at the beginning of infantile paralysis may 
 be such as to give rise to a suspicion of hip-joint disease ; 
 pains of various degrees of intensity occur likewise in wasting 
 palsy. 
 
 The condition of the paralyzed limbs a7id muscles must be 
 ascertained. Diminution in bulk, firmness, and temperature 
 are often found even in recent cases of the atrophic paralysis 
 of infants, and in old cases of various forms of paralysis. 
 Occasionally a relative increase of temperature can be made 
 out in the paralyzed limbs in the early stage of hemiplegia, 
 
 1 For the more elaborate deterininatiou of the " Functional relations of the motor 
 roots of the brachial and lumbo-sacral plexuses," see Ferrier, Proceedings of the Eoyal 
 Society, vols, xxxii. and xxxv., London, 1861 and 1883. 
 
212 
 
 SYMPTOMS OF NERVOUS DISORDERS, 
 
 but a slight difference in the opposite direction is much com- 
 moner later on. The muscles are to be examined as to their 
 bulk; we look to see whether they are apparently larger than 
 normal, as in pseudo-hypertrophic muscular paralysis where 
 the bulk of muscle contrasts Avith the feebleness of the limbs. 
 More often they are smaller and softer than natural, but in 
 judging of this we must allow for the changes brought about 
 by disuse from any cause ; wasting is specially noticeable in 
 cases of mechanical injury of the nerves, in wasting palsy, 
 infantile paralysis, and certain other forms of spinal paralysis. 
 Small fragments of muscle have been sometimes removed by 
 Duchenne's emporte-piece histologigiie to ascertain whether the 
 muscular fibres have undergone fatty degeneration, or have 
 been replaced by fibrous tissue. AVe also examine the mus- 
 cles as to the power remaining in them ; the dynamometer 
 is sometimes useful in recording the force, especially as a test 
 of im])rovement or deterioration in this respect ; considerable 
 variations occur with the dynamometer from a varying degree 
 of tact in using it. The commonly used dynamometer is only 
 available for the hands (see Fig. 34) ; more elaboi-ate instru- 
 ments for testing the legs and other parts are also occasionally 
 
 Fig. 84. 
 
 Dynamometer, a-b is a powerful spriug ; c-d is the scale indicating the pressure 
 
 in kilogrammes. 
 
 employed. Grasping the fingers of the observer, pushing the 
 foot against his hand, raising the arm or leg into certain posi- 
 tions, and holding out weights, etc., may be mentioned as 
 rough tests of the muscular power. Coarse trials of mere 
 strength like these may fail to reveal defects in the more deli- 
 cate exercise and adjustment of the muscles required in using 
 tools, in writing, sewing, etc., and the influence of anaesthesia 
 is often very potent in leading to difficulties in such opera- 
 tions ; it may of itself readily simulate a paralysis of the 
 
TKOPHIC LESIOKS IN PAEALYSIS. 213 
 
 movements. Unsteadiness and spasm may come into play 
 likewise to spoil the muscular movements. (See pp. 215, 223, 
 253.) 
 
 The electric exploration of muscles is of considerable value ; 
 this is dealt with in a special section. (See electrical instru- 
 ments, Chapter VII.) The so-called muscular sense is also 
 dealt with in another place. (See Chapter V., p. 200.) 
 
 The condition of the muscles as to permanent contraction, 
 remittent spasm, movements, and tremors must be considered 
 in cases of paralysis. Rigidity of the paralyzed limbs should 
 be inquired into as to whether it appeared at the beginning of 
 the paralysis, or not till afterward. In some cases, with the 
 onset of the hemiplegia, there is an " initial rigidity ; " or in a 
 few days an " early rigidity ; " or in the course of months a 
 " late rigidity ;"and when from long continuance of this the 
 tendons and joints are fixed we have a " structural rigidity." 
 The early forms of rigidity no doubt depend on the irrita- 
 tive nature of the lesion very often in the cortex of the brain 
 or its membranes and on the changes set up there ; the late 
 rigidity usuall}'- depends on descending sclerosis, involving the 
 antero-lateral columns, resulting from the primary lesion. In 
 testing the condition we try whether we can stretch out the 
 rigid limbs, and whether this causes pain ; also whether any 
 involuntary movements exist in the contracted member, 
 whether the contraction is associated with tonic spasm of the 
 muscles, and whether this spasm, if present, ever gives way to 
 relaxation. 
 
 Trophic lesions in paralysis are not uncommon. The tem- 
 perature of the paralyzed limb is often a little lower than 
 usual ; but an excessive coldness, soon developed after the 
 attack, constitutes a leading feature of infantile paralysis. In 
 this disease, however, the limb becomes rapidly soft and 
 wasted, and not unfrequently it is found after a time to have 
 grown less than its neighbor even in length. 
 
 The formation of bedsores is one of the most serious of the 
 trophic lesions. Paralyzed patients are, of course, from their 
 helplessness in movement, specially liable to the formation of 
 bedsores in the same way as other patients long confined to 
 one position; and this tendency is much aggravated when, as 
 often happens, there is the irritation from the involuntary 
 evacuation of urine and feces to contend with. In certain 
 cases of paralysis from acute myelitis we sometimes find large 
 "bedsores" produced in the course of three or four days, evi- 
 dently due not to pressure, but to diminished vitality in the 
 
214 SYMPTOMS OF NEKVOUS DISOEDEES. 
 
 part. For although such a sore is spoken of as " acute decu- 
 bitus," we sometimes find it on such a part of the body as to 
 put the influence of injurious pressure, or even of the irrita- 
 tion of urine, quite out of the question, say, for example, on 
 the anterior part of the thigh. No doubt the sores are usu- 
 ally in such parts as to allow of great aggravation of the 
 mischief from pressure and irritation. 
 
 The first appearance is redness, then little vesicles or one 
 large blister, and then a gangrenous sore, unless, as seldom 
 happens, the blisters shrivel up and dry without further mis- 
 chief. The whole process may occur with the most astonishing 
 rapidity, and when it goes on to a serious extent it may lead 
 to secondary febrile disturbance. 
 
 Although bedsores of this description are much commoner 
 in spinal than cerebral cases, similar trophic lesions can be 
 seen at times in hemiplegic attacks ; when in such cases the 
 sore appears on the buttock, rather than the sacrum, and only 
 affects the paralyzed side, we have a strong suggestion of its 
 dependence on loss of innervation. 
 
 The implication of the joints described by Charcot, and of 
 the skin, nails, and cornea, have been already described. (See 
 pp. 148 and 159.) 
 
 Involuntary movements in paralyzed limbs must be noted 
 when present. In chorea the erratic movements are often 
 complicated with a certain degree of paralysis. Both the 
 movements and the paralysis are usually more pronounced on 
 one side than on the other. Occasionally the chorea is limited 
 to one side (hemichorea), and the paralytic complication, 
 when present, usually attacks the side chiefly affected with the 
 twitchings. This paralysis generally follows the chorea, some- 
 times precedes it. Of a somewhat similar nature is the trans- 
 ient hemiplegia which sometimes follows epileptic convulsions 
 (epileptic hemiplegia). 
 
 Unilateral convulsions sometimes usher in a hemiplegia; 
 sometimes such convulsions occur or recur in the course of the 
 paralysis. Such convulsions may take place without loss of 
 consciousness, and may be limited to a paralyzed arm or leg. 
 
 Paralyzed limbs sometimes move involuntarily in connection 
 with automatic actions, particularly the arm in the act of 
 yawning. Movements of the legs, quite involuntarily, are 
 common in paraplegia ; where the spinal cord is seriously de- 
 stroyed, these may be very marked and even violent ; they are 
 often produced by very slight irritations acting in a reflex 
 manner ; occasionally the exciting cause is plain enough, as 
 
SHAKING OF THE PARALYZED LIMBS. 215 
 
 when the irritation is from exposure to cold air, or from 
 rubbing of the bedclothes in turning them down, etc. ; but 
 sometimes the cause is not apparent ; the urinary passages and 
 the bowels are no doubt at times the seat of such hidden irri- 
 tations. 
 
 Choreic movements sometimes become developed in para- 
 lyzed limbs in hemiplegia (post-hemiplegic chorea) ; these 
 differ from Dr. Hammond's " athetosis," as in this latter affec- 
 tion there is no history of preexisting hemiplegia, although a 
 certain loss of power may coexist with it. A minute fibrillary 
 quivering under the skin is observed sometimes in cases of 
 muscular atrophy ; similar quivering is noticeable in the 
 tongue and lips in general paralysis, delirium tremens, and 
 some other affections. 
 
 A degree of irregular muscular movement or tremor is seen 
 in certain forms and stages of cerebral and cerebellar disease, 
 locomotor ataxy, cerebro-spinal sclerosis, and general paraly- 
 sis ; some of these peculiarities will be noticed in the section 
 on unsteadiness in balancing the body, and in walking ; such 
 complex efforts bring out the deficiency in a marked manner. 
 (Seep. 222.) It must not be forgotten that simple weakness 
 renders the limbs unsteady as well as feeble, and various 
 febrile states intensify the trembling as well as the weakness 
 (^delirium tremens, typhus, etc.). 
 
 Shaking of the jmralyzed limbs is not uncommon in hemi- 
 plegia — tremulous vibrations differing from choreic movements 
 in being somewhat rhythmical in their character and much 
 more limited in their extent ; this general shaking of the 
 whole limb resembles that which may occur after unwonted 
 muscular efforts. We may have this shaking developed with- 
 out any preceding hemiplegia or paralysis, although when 
 established it amounts to a virtual paralysis, and is named 
 " paralysis agitans," or " shaking j)alsy." Such shaking is 
 often unilateral ; sometimes it affects only one limb ; some- 
 times the head is notably affected with similar shaking or nod- 
 ding movements. It should be noted whether the tremor is 
 only brought on during muscular exertions, or whether it per- 
 sists during repose. Along with this shaking we often observe 
 emotional disturbances, and sometimes that peculiar gait 
 termed " festination," in which the patient has to hurry on to 
 keep himself from tumbling forward, always " in pursuit of 
 his cSntre of gravity," as has been said. Such affections are 
 most common in the aged, or those past middle life ; but a 
 similar affection, due to cerebro-spinal sclerosis, is sometimes 
 
216 SYMPTOMS OF NEKVOUS DISORDERS. 
 
 seen in younger persons, often associated with shaking of the 
 head and with nystagmus. The twitchings of special muscular 
 fibres in cases of facial paralysis which have practically re- 
 covered, may be mentioned here. These twitchings occur in 
 certain cases quite apart from electrical treatment although 
 this is sometimes blamed for them. 
 
 " Nodding convulsions," with nodding, bending, rotating, 
 or bowing of the head or of the body, constitute a rare dis- 
 ease observed in young children ; it is described also under 
 the names of " eclampsia nutans," and " salaam convulsions." 
 
 Somewhat intermediate between chorea-like movements and 
 shaking palsy are the tremors seen in mercurial paralysis, and 
 some other forms of metallic poisoning. The occupation of 
 the patients, and the existence of salivation, etc., assist us in 
 the diagnosis. 
 
 Reflex action has already been referred to as accounting for 
 certain involuntary movements in paralyzed limbs ; but we 
 often produce these deliberately, for purposes of diagnosis. 
 When reflex movement is preserved we infer that the loop of 
 nervous connection to and from the spinal cord is intact — the 
 sensory or afferent nerves, the part of the spinal cord con- 
 cerned, and the efferent or motor nerves. It is evident that 
 serious disease in any part of this loop may interfere with the 
 reflex action. In particular, the practical integrity of the 
 gray matter of the cord, at a given level, may be thus inferred, 
 although serious disease may exist above or below this point. 
 Indeed, the reflexes are often increased when serious lesions in 
 the cord exist above the level of this loop, probably because 
 the influence from the controlling centres in the spinal cord 
 and also in the brain are thereby cut off"; owing to the absence 
 of cerebral control somewhat similar results may follow from 
 disease in the brain itself. The presence of normal, dimin- 
 ished, or excessive reflex action aflTords thus an important 
 index of the state of the nervous centres. Information as to 
 the integrity of the afferent and efferent nerves may also be 
 gathered, as we may find by this test that they can transmit 
 nervous impulses although sensation and voluntary movement 
 may be both quite lost. When the reflexes are preserved the 
 nutrition of the muscles and their response to electricity are 
 usually but little impaired. In the study of the reflexes a 
 comparison of the two sides of the body affords important in- 
 dications, particularly as the amount of reflex moveflaent 
 varies much in individual cases even in health. 
 
SUPERFICIAL REFLEXES. 217 
 
 Superficial Reflexes — The most familiar illustration of these 
 is the plantar reflex — the movement obtained in the toes on 
 tickling the soles of the feet. This may often be obtained in 
 profound paralysis, involving the motion and sensation alike, 
 aud the movements may occur without the patient's conscious- 
 ness. In health, a strong will can inhibit these reflex move- 
 ments ; but when the influence of the brain is cut off", by a 
 grave lesion of the cord higher up, the part is given over 
 completely to the reflex impulse. We can often trace varia- 
 tions in the movements according to the varying intensity of 
 the stimulus. Thus a slight tickling may make the toes only 
 move ; stronger impressions by scratching and pricking may 
 make the foot and leg jerk up ; these stimuli when of a more 
 violent character may cause the thigh to be pulled up to the 
 belly ; or may even excite movements in the leg of the oppo- 
 site side. By grasping the first metatarsal bone firmly between 
 the finger and thumb, this reflex movement can often be well 
 felt, say in cases of paralysis from Pott's disease of the spine ; 
 the interval between the impression and the movement, and 
 the comparative slowness of the action contrast well with the 
 sudden movements produced voluntarily. Very occasionally 
 movements may be produced in the same way in a paralyzed 
 arm, in cases of hemiplegia due to brain disease. The reflex 
 movements of the palate have been already referred to in 
 connection with the testing of the cranial nerves. (See p. 
 204. j 
 
 The superficial reflexes have been specially studied by Dr. 
 Gowers, who has formulated the following indications to be 
 drawn from them. In beginning the study of these reflexes, 
 the student would do well to try them first in some young 
 subject, free from nervous disease, as they can then be seen to 
 perfection. In older subjects the reactions are not usually so 
 striking, or some of them may even be absent aj)art from any 
 nervous disease. 
 
 Plantar reflex: stroking the sole of the foot causes movements of 
 the toes : the part of the cord concerned is the lower part of the lum- 
 bar enlargement. 
 
 Gluteal reflex: firm, sadden stroking with the finger of the skin 
 over the buttock, gives rise, sometimes, to reflex coiitraction of the 
 glutei ; the part of the cord concerned is at the origin of the fourth or 
 fifth lumbar nerve. 
 
 Cremanteric reflex: stimulation of the skin at the inner aspect of 
 one thigh, causes retraction of the testicle on the same side : both are 
 often pulled up by more violent irritation : sometimes, however, this 
 
 19 
 
218 SYMPTOMS OF NERVOUS DISORDERS. 
 
 reflex is absent : the part of the cord concerned is at the origin of the 
 first and second lumbar nerves. 
 
 Abdominal reflex: sharp, sudden stroking of the abdominal wall 
 from the lower margin of the ribs downward, about the line of the nip- 
 ple, gives rise to contraction of the muscles in the region of the umbili- 
 cus : the part of the cord concerned is at the origin of the eighth to 
 twelfth dorsal nerves. 
 
 Epigastric reflex : a firm, downward stroke on the ribs in the infra- 
 axillary region, gives rise to a dimpling in the epigastrium : the part 
 of the cord concerned is at the origin of the fourth to the sixth or 
 seventh dorsal nerves. 
 
 Scapular reflex : irritation of the interscapular region gives rise to 
 contraction of the scapular muscles, and especially the posterior fold 
 of axilla: the part of the cord concerned is at the origin' of the two 
 or three lower cervical and two or three upper dorsal nerves. 
 
 Dorsal and lumbar reflexes : the erector t^pinoB muscles may be stim- 
 ulated, at various levels, by irritation of the skin along their edges. 
 These serve to corroborate the other reflexes. 
 
 "Deep Reflexes."" — This name is applied to the responses 
 obtained on striking tendons or muscles under certain con- 
 ditions of tension: the name may also be extended to the 
 rhythmical clonic contractions induced by forcing the feet into 
 certain positions. The exact physiological nature of these 
 so-called reflexes is still disputed, but it seems generally agreed 
 that the normal reaction requires the integrity of the nervous 
 looj) to and from the spine as in true reflexes. These deep 
 reflexes may be diminished or abolished in disease, or, on the 
 other hand, they may be unduly increased. 
 
 Curious changes in the reactions are found temporarily in 
 connection with chloroform narcosis, the peculiar condition of 
 the nervous system existing after epileptic fits, and at the 
 very onset of hemiplegic attacks : in the following remarks 
 the more permanent and common conditions only will be dealt 
 with. 
 
 The knee-jerk is perhaps the best name for the forward jerk 
 obtained on striking the patellar tendon (called also " patellar 
 tendon reflex," and the " knee phenomenon"). The best way 
 is to make the patient cross the one leg over the other, allow- 
 ing it to hang in an easy position : or if there is any difiiculty 
 from obesity, stiffiiess, or otherwise, he may be placed on a 
 high stool, or table, with his legs dangling over the edge : or 
 the hand or the arm of the observer may be passed under the 
 knee to be examined, so as to elevate it from the ground and 
 to support it fully while the patient is seated on an ordinary 
 chair. These positions give a moderate amount of stretching 
 of the quadriceps extensor muscle, and allow of ready move- 
 
INCREASE OF THE KNEE-JEKK. 219 
 
 ment of the limb. The region of the tendon, just below the 
 patella, is then sharply struck with the points of the fingers, 
 or with the ulnar edge of the hand ; when there is any diffi- 
 culty in getting the response it is well to bare the knee, taking 
 care that the clothing, if turned up, does not interfere with the 
 free movement of the limb, and then to strike the tendon in 
 the place indicated, or to direct a stroke on it with a percus- 
 sion hammer. The foot and leg in the normal state are then 
 jerked forward instantly. The amount and readiness of the 
 response varies in different subjects, even in health; it is 
 seldom completely absent, although at times it requires a little 
 care to bring it out, especially in securing free suspension of 
 the limb and in directing the tap to the proper spot : it is 
 also sometimes desirable to direct the patient's attention to 
 some muscular effort with his hands by pulling or pressing, so 
 as ta allow the experiment on his knee to escape any perturb- 
 ing influence from his watching it. When the patient is con- 
 fined to bed the knee may be supported by lifting and steady- 
 ing it by means of the hand placed behind it : or the patella 
 may be pressed as far down as possible while the leg lies 
 extended on the bed, and while the muscle is thus stretched, 
 the finger holding the patella is suddenly struck so as to tend 
 to depress the patella further, when an upward jerk of the 
 patella as it is drawn up by the muscle can be seen or felt by 
 the observer. 
 
 The absence or diminution of the knee-jerk is almost constant 
 in locomotor ataxy, even in the early stages : very exception- 
 ally a regular case of the disease is found with this reflex pre- 
 served.. In the so-called " hereditary ataxy " (Friedreich's 
 disease) the knee-jerk is usually exaggerated instead of being 
 diminished. Other forms of paralytic disease may also be 
 characterized by this absence. Of course, when the lower 
 portion of the cord presents destructive lesions no response 
 can be obtained, but it may also be absent in less grave forms 
 of disease, as in alcoholic paraplegia, diphtheritic paralysis, 
 infantile paralysis, and other forms of poliomyelitis anterior, 
 and wasting palsy, involving the legs and thighs ; in pseudo- 
 hypertrophic muscular paralysis it is also usually absent, and 
 in some general diseases it may also be lost : thus in diabetes 
 raellitus it is frequently absent, or, at least, very faintly 
 marked. 
 
 Increase of the knee-jerk is an equally important symptom in 
 certain diseases : when it is extreme the slightest tap with a 
 finger suffices to make the leg jurnp forward, and a rapid sue- 
 
220 SYMPTOMS OF NEKVOUS DISOKDEKS. 
 
 cession of light taps may be found to keep the leg stretched 
 out during their continuance. This increase in the knee-jerk 
 is found to be associated most often with sclerosis of the lateral 
 columns of the cord — whether this is primary or secondary. 
 In the secondary forms, the degeneration may be due to a 
 lesion in the brain cutting off the due motor impulses, and so 
 we find lateral sclerosis and increased knee-jerk in the late 
 rigidity of hemiplegia on the paralyzed side only. Or mis- 
 chief in the cord (as in Pott's curvature) may lead to degen- 
 eration in those columns below the site of the lesion : this 
 usually affects both halves of the cord, and so the sclerosis, 
 and the increased knee-jerk are on both sides. In dissemi- 
 nated sclerosis also, probably from implication of the lateral 
 columns, the knee-jerk is usually intensified. 
 
 In all these forms of disease there is apt to be, in bad cases 
 at least, more or less of the spastic condition : when spaam is 
 well marked, increased knee-jerk is usually also present. 
 
 Increase of the knee-jerk is often associated with "ankle 
 clonus." 
 
 Ankle clonus is brought out in patients who present this 
 " foot phenomenon," as it is also called, by pressing the foot 
 upward at the ball of the toes, toward the tibia. It is best 
 to have the knee only very slightly bent, whether the patient 
 is sitting or lying. The upward pressure should be sudden 
 and forcible, and it ought to be continued for some seconds, 
 even if no trembling occurs at first. While the gastrocnemius 
 is thus stretched, a sudden stroke on the. tendo Achillis often 
 helps to determine the clonic contractions. These are rhyth- 
 mical in character, and their uniform rate, 6 to 10 in a second, 
 can be shown by a recording apparatus. They are quite 
 beyond the control of the patient, unless indeed by changing 
 the position of the foot or leg. 
 
 Ankle clonus, unlike the knee jerk, is not developed in the 
 normal condition ; its affinities are with the exaggerated not 
 the normal knee-jerk. No doubt both in healthy and dis- 
 eased subjects a slight tremor, as if the clonus were about to 
 begin, is often found for a second or two, but no continuous 
 rhythmical movements occur. In healthy subjects they may 
 sometimes be induced by sitting far forward on the edge of a 
 chair, resting the foot on the ball of the toes, and beginning 
 voluntarily a movement of the leg as if dandling a baby on 
 the knee ; after a time these movements may be continued 
 automatically with the foot in this position. A somewhat 
 similar plan often succeeds in j)roducing the rhythmical 
 
ANKLE CLONUS. 
 
 221 
 
 clonus in paralysis ; the patient is seated on a chair pretty 
 well forward, with his feet on the ground, resting on the toes, 
 a little behind the vertical line of his knees ; the ^^ressure 
 upward is thus made by the floor opposing the weight of the 
 foot instead of by the hand of the observer as in the other 
 plan. When thus placed the rhythmical movements often 
 begin at once, but the toes are apt to slip forward, so stopping 
 the clonus ; it is well, therefore, for the observer to place his 
 own foot or some heavy object in front of the patient's toes. 
 Frequently, however, the clonus does not start at once when 
 the patient is so placed, but does so after a little interval ; a 
 sharp tap downward on the knee or a stroke on the tendo 
 A chillis may suffice to set it up at once and it may then go 
 on for many minutes. 
 
 When thus established, both legs can often be made to go 
 at the same time and at the same rate. (See Fig. 35.) But 
 
 Fig. 35. 
 
 Simultaneous tracing of the foot or ankle clonus in both legs. 
 
 it seems as if the movements in the two legs were not syn- 
 chronous ; indeed they appear to the eye rather to alternate 
 with each other in their elevation and depression — so far like 
 the alternate action of the legs in walking — this is not brought 
 out in the tracing here given, probably because the rate of 
 revolution of the recording cylinder was not rapid enough, 
 and the adjustment of the levers not quite perfect. In many 
 cases the clonus thus set up invades the muscles higher up, 
 and we may have a simultaneous clonic rhythmical contrac- 
 tion of the adductors of the thigh, the whole limb becoming 
 thus violently agitated. The association of ankle clonus with 
 the more extreme forms of exaggerated knee-jerk is very 
 
 19* 
 
222 . SYMPTOMS OF NEKVOUS DISOEDERS. 
 
 close, and its clinical significance is much the same, pointing 
 often to the occurrence of sclerosis of the lateral columns. 
 Sometimes, however, the descending changes have not ap- 
 parently had time to go this length, the lesion in the cord 
 only cutting off, so far, the inhibitory action of centres in the 
 brain or perhaps in the cord itself Certainly ankle clonus 
 may be found in a case of Pott's disease, with a spastic state 
 of the muscles, which may be recovered from, the cord, there- 
 fore, being presumably free from profound changes in the 
 lateral columns of the kind referred to. Its occurrence in 
 connection with chloroform narcosis and epileptic fits also 
 points to its arising apart from permanent organic changes. 
 It also occurs sometimes in chronic rheumatic cases, and even 
 in the debility and disease resulting from an attack of fever. 
 
 It is disputed whether it ever occurs in cases of pure hys- 
 terical paralysis ; certainly its presence in suspected cases of 
 this kind should make us all the more careful in our exami- 
 nation before forming such a diagnosis. 
 
 Occasionally ankle clonus can be obtained in cases not 
 characterized by an increased knee-jerk especially in dis- 
 seminated sclerosis. 
 
 Increased reflex in the tendons of the arm and ivrist. Front 
 tap contraction. These evidences of " myotatic irritability," 
 as it has been called, can often be obtained in the same kind 
 of cases as furnish increased kuee-jerk. Tapping the muscles 
 and tendons in the arm and wrist, particularl}' in cases with 
 rigidity, leads to marked contractions. 
 
 If the leg be held out, and the foot slightly bent upward, 
 a tap on the muscles on the front may lead to a more or less 
 distinct contraction of the muscles in the calf. 
 
 Walking and balancing in ^jara/y/.sts. The power of bal- 
 ancing the body varies much in different forms of paralysis ; 
 it is sometimes very deficient in cases Avhere the loss of mus- 
 cular power is but slight. This want of power in balancing 
 often comes out when the patient tries to walk. In children 
 the complaint of inability to walk is sometimes made when the 
 real defect is in the intelligence (idiocy). Lateness of walking 
 in children often arises from the constitutional affection known 
 as rickets, apart from any true paralysis. 
 
 The manner of walking must always be scrutinized in cases 
 of paralysis. In hemiplegia the paralyzed leg is often swung 
 from the trunk, and the toe of the paralyzed leg may drag or 
 scrape as it goes along, so that it makes a mark, for example, 
 on a gravel Avalk. AVheii infantile j^aralysis affects one of the 
 
SPASMODIC GAIT. 223 
 
 lower limbs, the chief deficiency is almost invariably below 
 the knee, and when the loss of power is not extreme the foot 
 during walking is swung round or " thrown," as the parents 
 say, in a very characteristic manner. In paraplegia the feet 
 may almost be said to be trailed along when the paralysis is 
 considerable ; when one leg is worse than the other this trail- 
 ing often serves to distinguish it. In less severe cases the 
 feet and legs are lifted with an obvious effort. The hurrying 
 gait known as " festination," already referred to, may exist in 
 all degrees from a slight hurrying and a slight difficulty in 
 stopping, up to the most extreme running and staggering 
 forward to an extent that is quite alarming. At other times 
 there is the appearance of hurrying with very small steps ; 
 these small steps, with the feet scarcely raised at all from the 
 ground, are often met with in serious forms of brain disease, 
 usually in the aged. 
 
 The element of spasm is an important one in the gait of the 
 patient. When the adductors of the thigh are in a state of 
 spasm the legs cross each other in such an active manner as 
 to render progression almost impossible. When the muscles 
 of the calf are affected the patient walks on his toes, and he 
 may be jerked upward as he moves with something like a hop 
 (high action). Sometimes an upward jerk with each step, 
 although associated with walking on the toes, is due to voluntary 
 rather than spasmodic action, the patient trying thus to keep 
 from tripping with his toes. In some cases the spasm is only 
 induced at the beginning of a muscular effort. (See p. 225.) 
 In many cases of sclerosis with a spastic condition of the 
 muscles the shaking of the feet, as in incipient ankle clonus, 
 can be noticed, as the toes are brought down to or are just 
 leaving the ground. The distortions from paralysis of special 
 groups of muscles assume the various forms of talipes — 
 varus, valgus, and calcaneus. 
 
 Staggering in a most extreme form is often found in disease 
 of the cerebellum, so that the patient in a bad case cannot 
 make a few steps forward without staggering to the one side. 
 Similar deviation to the one side is one of the symptoms in 
 Meniere's disease. The influence of ocular paralysis and 
 vertigo in causing staggering must also be remembered. (See 
 pp. 169, 190, 257.) Patients affected with staggering are apt 
 to be suspected of intemperance. 
 
 In locomotor ataxy and in general paralysis of the insane 
 there is frequently very marked unsteadiness in walking and 
 standing, but special tests require to be applied in some cases 
 
224 SYMPTOMS OF XERVOUS DISORDERS. 
 
 to bring this out. We ask the patient to walk along a given 
 line ; the seam of a carpet or a plank of the floor answers for 
 this purpose. Or we ask him to put his feet together and to 
 stand still ; or we ask him to stand on one foot and then on 
 the other. In ordinary paraplegia when the patient gets fairly 
 into the erect position he can often stand very firmly ; any 
 deficiency in this respect usually arises from the knees giving 
 way from muscular Aveakness, and with care in adjusting him- 
 self such a person can even stand on a single foot. In loco- 
 motor ataxy this power is remarkably diminished. A patient 
 who can walk fairly is unable to stand steadily, he cannot get 
 a " grip of the ground," he says, and requires to spread out his 
 feet and to keep a strict watch ^vith his eyes on the ground. 
 This relationship of the sight to the power of balancing must 
 be specially considered in cases of suspected ataxy. It comes 
 out to its greatest extent when the patient puts his feet close 
 together and tries to balance himself with his eyes shut ; a 
 good method of testing, especially with the view of tracing 
 any improvement or deterioration, is to count the number of 
 seconds during which such a patient can thus remain : care 
 must be taken to have assistance at hand, not only to prevent 
 actual accidents, but also to give the patient a feeling of security 
 in submitting to the test. A further indication of the im- 
 portance of the eyesight in balancing comes out in the event 
 of the patient having to walk in the dark, or as haj^pens in 
 certain cases, in the event of blindness coming on ; we may 
 also apply the test by seeing how he can walk while looking up 
 toward the ceiling instead of at his feet : interesting experi- 
 ments may also be made by blindfolding the patient and seeing 
 what he can do in rising from the ground, walking, etc. 
 Another test, combining some of these, consists in trying if 
 the patient can walk backward. The least hold of anything 
 often assists w^onderfully in steadying the patient in this con- 
 dition, the hand, like the eye, coming to the assistance of the 
 lower limbs. A striking peculiarity in the walking of such 
 patients consists in the way in which they very often raise 
 their feet much higher than is requisite, and stamp them down 
 with unnecessary force. All these peculiarities seem to depend 
 in part on the diminished sensibility of the skin of the feet, 
 but chiefly on a want of the delicate adjustments of the force 
 in the various muscles required for a particular eflbrt. A 
 further test is supplied by the act of turning right round 
 while walking back and forward. Deficiency in this respect 
 appears in many cases of general paralysis also. 
 
DIFFICULTY OF SPEECH. 225 
 
 Various defects in walking appear in connection with other 
 affections as well as paralysis proper. The most important of 
 these is disease of the joints and especially of the hip-joint, so 
 that we have often to scrutinize the symptoms, measure the 
 limb, and test for localized pain by pressure and percussion, 
 before coming to a decision. In children, particularly from 
 there being often but little pain, the distinction between hip- 
 joint disease and infantile paralysis is sometimes very difficult 
 to establish, and a similar difficulty arises when it happens that 
 the pains in the early stage of infantile paralysis resemble 
 those of hip-joint disease; the measurement of the limb, the 
 examination of the joint, the temperature of the paralyzed leg, 
 the electrical reaction and the nutrition of the muscles, with 
 the history of the case must guide the diagnosis. Abscesses 
 of various kinds, involving the psoas and iliacus, and some 
 rheumatic affections of the muscles, may give rise to difficulties 
 in walking bearing some resemblance to paralysis. In addi- 
 tion to these, confusion may arise from affections of the joints 
 of the chronic rheumatic type, with enlargement of the ends 
 of the bones or even at times partial dislocation and more or 
 less grating on movement. Such affections may simulate 
 paralysis from impairing the movements, but somewhat similar 
 disorders in the joints arise in some cases of locomotor ataxy 
 and other forms of disease in the cord. (Charcot.) 
 
 Rising from the sitting or reeumbent posture affords often a 
 valuable means of testing the strength or of observing the 
 weakness of certain groups of muscles. The remarkable way 
 in which a child with pseudo-hypertrophic muscular paralysis 
 turns round to his knees and then helps himself up with his 
 hands on his thighs, so long as his power is equal even to this, 
 is almost pathognomonic. In muscular atrophy also the 
 special weakness can often be thus seen. A difficulty in 
 rising from a seat constitutes a leading feature of the para- 
 lytic disease described by Thomsen : in this aflection any call 
 on the voluntary muscles for action, after a period of rest, is 
 attended with the development of spasm and rigidity in various 
 parts of the body lasting for some little time ; the difficulty in 
 rising is only a part of the disorder, although from the previous 
 rest in the sitting posture this is one of the notable features of 
 the disorder ; it is said to date from childhood and to be dis- 
 tinctly hereditary. 
 
 Difficulties as to speech require very special study in cases of 
 paralysis. A patient may be unable to speak or to answer a 
 question because of unconsciousness or impaired intelligence 
 
226 SYMPTOMS OF NERVOUS DISORDERS. 
 
 (idiocy or dementia of any kind) ; congenital or other defects 
 in the hearing and in the vocal organs need only be mentioned. 
 AVhen the inability arises from such causes, the general aspect 
 of the patient and the previous history usually guide us aright. 
 In other cases, the loss of articulate speech is associated with 
 such obvious paralysis of the tongue, lips, and palate, that we 
 can very safely refer the loss of speech, or the defective utter- 
 ance to this cause. In such cases we must test the motor 
 power of these parts in various ways. (See seventh, eighth, 
 and ninth nerves, pp. 203-206.) A further assistance is given 
 in this matter by ascertaining which are the most imperfect 
 sounds ; the pronunciation of the labials in particular is often 
 affected from paralysis of the lips, and a nasal tone may be 
 communicated to the voice from paralysis of the palate. 
 
 Certain defects remain wdiich cannot be explained at all in 
 this way, and there are others which are only partially in- 
 telligible on such a view. When for exam^^le a patient cannot 
 speak, or can use only one or two simple w'ords to express him- 
 self, and is yet able to repeat lists of words, or even sentences 
 dictated to him, it becomes clear that the defect is not due to 
 any want in the muscular and nervous mechanism of the 
 organs. This is equally clear in those cases where the patient's 
 difficulty occurs only or chiefly with the names of objects and 
 persons. To the affections of speech indicated in this para- 
 graph the term "aphasia" is applied. 
 
 Aphasia must be studied and described as to its various 
 forms. The patient can sometimes express himself quite cor- 
 rectly in writing, although unable to speak ; to this rare condi- 
 tion the term "aphemia" is applied by some. He appears 
 sometimes to understand words addressed to him perfectly, 
 although unable to speak, or at least to go beyond a word or 
 two. In other cases words addressed to him may seem to con- 
 vey no meaning at all. This condition must be tested by 
 asking the patient to do certain things, carefully avoiding any 
 suggestive gestures in making the request, or in particular 
 asking him to do something absurd, or at least very unusual. 
 He may be able to say certain words or parts of sentences 
 while stumbling almost exclusively at names; he may know 
 when the right name for the object or person is supplied to 
 him, or he may supply wrong names, although conscious that 
 they are wrong, and quite clear as to what he really means. 
 A patient who can scarcely say " yes " or " no " correctly may 
 be able to repeat words and short sentences after they are 
 dictated to him although unable to originate them ; or even 
 
APHASIA. 227 
 
 to recite familiar j)assages, such as the Lord's Prayer, pieces 
 of poetry, etc., especially when these are started for him. 
 Aphasic patients have usually one or two words, especially 
 " yes " or " no ; " when they have only one of these its affirm- 
 ative or negative meaning may be clearly expressed by the 
 patient through variations in the tone or gesture. They have 
 often certain phrases and expressions which are brought out in 
 a parrot-like manner, although at times they are deceptive 
 from fitting admirably as answers {,e.g. "I cannot tell"). 
 Exclamations of anger, surprise, etc., and oaths are sometimes 
 given utterance to at odd times by those quite unable to speak 
 unless thus surprised into such emotional expressions. Aphasic 
 patients can often sing or hum tunes, although unable to use 
 words or only to use a few ; w^hile singing, a freer use of words 
 is often noticeable. Writing is an important test to be applied 
 to aphasic patients. A few can express themselves in writing 
 quite well although they cannot speak. When from paralysis 
 of the right arm the patient cannot write, movable letters may 
 be tried. Various degrees of ability are seen in aphasia in 
 this respect, but anything like perfect use of writing is very 
 rare. A strange medley of words, or stray words and confused 
 combinations of strokes and syllables, are often shown by 
 aphasics with obvious self-satisfaction : or in slight cases, only 
 an occasional wrong word is found, and these errors may be 
 intelligible in view of the similarity in sound, or some other 
 explanation may be found from the context : or as in the 
 speech of aphasics portions of words may be transposed and 
 part of one word put on to another. Some, however, can 
 write words to dictation who cannot originate a written sen- 
 tence. Many can write words and long sentences from a copy 
 supplied to them. Some can copy from printed characters into 
 ordinary writing ; others can only copy as if by pure imita- 
 tion. Some can identify their own names or the names of 
 friends in a long list, whether in written or printed characters, 
 although they do not know the individual letters ; the general 
 appearance of the familiar word probably guides them. Many 
 aphasics appear to read books with interest — although j^rob- 
 ably gaining no idea from the process ; we must test them as 
 to their knowledge of what they seem to be reading. A 
 patient with complete loss of speech not having even the 
 power of saying " yes " or " no " was found to be able to un- 
 derstand a paragraph in a newspaper and could write down 
 one or two simple words correctly when questioned on its con- 
 tents. Persistent aphasia may exist along with but little 
 
228 SYMPTOMS OF NERVOUS DISORDERS 
 
 diminution of high mental j^ower, but the intelligence is 
 usually seriously impaired, even more than might appear on 
 a preliminary investigation. 
 
 These details indicate the points to be noted in connection 
 with the study of the varying gradations of the affection in 
 aphasic patients ; such a note of the actual state is better than 
 applying mere names to characterize the kind of aphasia, as 
 these usually imply artificial distinctions and theoretical con- 
 siderations not fully justified by the facts. A most important 
 distinction, however, is between sensory and motor aphasia. 
 In the former the patient may be found to be quite unable to 
 understand words or names of objects repeated again and again 
 in his hearing (word-deafness); or what is more common, he 
 may be quite unable to recognize words or names of objects 
 written or printed bef)re him (word-blindness). Occasionally, 
 a patient unable to repeat a word or name when pronounced, 
 can at once do so when he sees it in written or printed char- 
 acters ; it is very common to find an aphasic able to repeat a 
 word when pronounced to him although unable to do so when 
 shown the same word or the object referred to. In sensory 
 aphasia there is often no hemiplegia. 
 
 In motor aphasia the understanding of spoken language 
 may be perfect, and even at times the power of reading may 
 be preserved almost intact, and yet the loss of language for ex- 
 pressing the simplest ideas may be extreme or indeed complete. 
 
 The clinical fact most frequently associated with aphasia is 
 right hemiplegia, in rare cases there is left hemiplegia ; in the 
 latter event we should inquire if the patient is left-handed. 
 Unilateral convulsions and other evidences of cerebral disturb- 
 ance are not uncommon. The cerebral lesion which most often 
 leads to aphasia is embolism of the left middle cerebral artery 
 and the softening and destruction of portions of the brain 
 structure supplied by this vessel; of course, thrombosis may 
 lead to the same result. The suddenness and extent of the 
 cerebral lesion seem to play an important part in determining 
 the occurrence of this symptom ; the lesion is usually found 
 to implicate the posterior part of the third frontal convolution 
 on the left side or at least the parts in its immediate vicinity, 
 such as the lower part of the ascending frontal convolution ; 
 when, however, the aphasia is of the sensory variety — word- 
 blindness and word-deafness — the angular gyrus and the 
 first left temporo-sphenoidal convolution are supposed to be 
 involved. When aphasia exists without distinct hemiplegia, 
 it may still be clear from other symptoms that it is con- 
 
BLADDER AND EECTUM. _ 229 
 
 nected with cerebral disease. Aphasia occurs sometimes in 
 chorea in a marked manner, and much oftener in a slight form ; 
 such attacks of chorea usually present some degree of paralysis, 
 and of slight or transient dementia. Aphasia without any 
 history of paralysis of any kind is most commonly observed 
 after severe illnesses — after enteric fever, for example, in chil- 
 dren ; it is usually only temporary in such cases. 
 
 The jioxmr of writing is often affected in paralysis ; the 
 importance of testing this has already been referred to in con- 
 nection with aphasia ; the difficulty of finding words, and the 
 confusion of speech are often admirably reflected in the writing 
 when the affection is slight. This concerns the j)ower to form 
 words and sentences, but even the mechanical part of the hand- 
 writing may afford useful indications. In paralysis agitans, in 
 general paralysis, in chorea, in cerebrospinal sclerosis, and in 
 the forms of locomotor ataxy affecting the arms, the unsteadi- 
 ness is shown in the writing ; even when one cannot observe 
 this distinctly, there is sometimes clear proof of a departure 
 from the usual character of the writing. This affection of the 
 writing varies considerably at different times, and is apt to be 
 made W'Orse by having the attention of onlookers directed to 
 the writer. When there is anaesthesia of the fingers, or 
 paralysis of the muscles of the hand and thumb, the writing- 
 is also apt to be affected, as the patient cannot guide the pen 
 properly. 
 
 Different from all these is the peculiar spasm which seizes 
 the fingers in " writer's cramp ;" when the patient begins to 
 use the pen, the movements soon get to be beyond control, 
 and the pen cannot even be held. In less severe forms the 
 spasm only appears after a certain amount of writing has been 
 done, and the difference in the character of the w^riting at the 
 end from the beginning can be readily noticed. When there 
 is any form of aflTection of the writing it is well to preserve 
 specimens, containing the date, for comparison subsequently. 
 
 In cases of insanity it is often well to test the patient by 
 getting him to express his ideas in writing, for another reason, 
 as he becomes more apt to wander into extravagant ideas when 
 the restraining influence of an incredulous listener is removed. 
 
 Paralysis of the Bladder and Rectum is an imi3ortant 
 fact in cases of paralysis, and always constitutes a grave com- 
 plication. This paralysis may show itself either by w^ant of 
 power in retaining the excretions till a suitable opj^ortunity 
 occurs (incontinence, paralysis of sphiucters), or by a want of 
 power in expelling the contents (constipation, retention of 
 
 20 
 
230 SYMPTOMS OF NERVOUS DISORDERS. 
 
 urine). It does not occur in hysterical paraplegia in a 
 persistent form, although occasional retention of urine is often 
 present in hysterical subjects. This form of paralysis is, 
 likewise, almost unknown in infantile paralysis. But before 
 considering paralysis, properly so called, reference may be 
 made to conditions which simulate j^aralysis of these parts. 
 Tlie presence of coma or unconsciousness, from any cause, 
 often leads to untimely intestinal and urinary evacuations, 
 quite apart from any other defect. Similar causes may lead 
 to retention of the urine; this is common in the unconscious- 
 ness found in serious febrile derangements, but also occurs in 
 cases of paralysis of the nervous centres. Retention of urine 
 is common in connection with injury of the parts, and after 
 operations in the neighborhood of these organs; severe or 
 instrumental labor, operations for piles, etc., may be named 
 as common causes. Such retention may indeed be due to an 
 inhibitory form of paralysis : very probably owing to the pain 
 in the neighborhood of the bladder we may have retention 
 in cases of ^peritonitis. Ketention of the urine in connection 
 with stricture or enlarged prostate, although no doubt partly 
 due to nervous spasm, really depends upon distinct mechanical 
 impediments. 
 
 The frequency of fistulous communications between the 
 bladder and vagina in giving rise to dribbling away of the 
 urine must always be remembered; occasionally the aperture 
 is minute and sometimes it is situated within the uterus, 
 instead of the vagina, requiring special investigation or the 
 injection of fluids for its recognition. Dribbling away of the 
 urine may be due to disease of the bladder, such as cystitis, 
 arising from calculus or other causes ; it may also result from 
 the organ having been habitually, or on some special occasion, 
 over-distended so as to injure the muscular and nervous struc- 
 tures. Involuntary evacuation of feces, apart from injury of 
 the parts, may also result from great fluidity and frequency 
 of the motions, from profound debility of the patient, or from 
 great mental apathy ; it is owing to this that such involuntary 
 evacuations are always to be regarded as grave symptoms, 
 especially in acute disease ; they may also arise from anaesthesia 
 of the anal aperture, so that clue warning is not transmitted. 
 Such motions occur also in idiotic persons. A form of local 
 paralysis of the rectum, leading to retention of feces, is found 
 in cases of constipation where the bowel has been habitually 
 or enormously distended. The condition of irritability or 
 spasm of the organs may lead to discharge of the contents 
 
BLADDEK AND KECTUM. 231 
 
 beyond the patient's control. Dysentery, and other diseases 
 characterized by tenesmus, cystitis, calculous disease of the 
 bladder and kidney, etc., may act in this way, apart from any 
 paralysis. (See " Disorders of defecation and urination," 
 Cha^Dters XI. and XIII.) 
 
 Spasmodic discharge of the urine, however, also occurs in 
 spinal paralysis, — the bladder contracting on its contents with 
 great force, and without much warning, and the patient being 
 quite unable to restrain or delay the ^^rocess. A somewhat 
 similar suddenness and violence of contraction may also occur 
 in the bowel, by which the patient is apt to be " taken short," 
 as he says. Irregular action in this way sometimes occurs in 
 locomotor ataxy as part, apparently, of the general incoordi- 
 nation ; it may alternate with a sluggish action of the bladder. 
 
 Wetting the bed in the early hours of night is often com- 
 plained of in the case of children (enuresis, nycturia). This 
 seems also to be usually due to some form of spasmodic action, 
 as it tends to occur soon after going to sleep, and long before 
 the bladder can be much distended ; indeed, it often occurs 
 only during the early hours of sleep, and not at all later on, 
 although there is then much more distention ; during the day 
 there is no trouble with the bladder in such cases. This ail- 
 ment usually persists in the children affected for a considerable 
 time, and seems due to some nervous defect ; occasionally it is 
 associated with and apparently due to phimosis. Wetting 
 the bed occurs also in chorea. It sometimes affords an early 
 indication of the occurrence of epileptic fits happening during 
 the night, which might otherwise be overlooked. After enteric 
 fever, and perhaps some other acute illnesses, this defect is 
 occasionally noticed as a passing fact, in cases where there had 
 been no trouble with the bladder durino; the heig-ht of the 
 fever. It occurs especially in little girls, and seems part of 
 the general weakness, both mental and physical, often found 
 after this fever. 
 
 Paralysis of the bladder may show itself by retention, or by 
 incontinence, or by spasmodic discharge of urine, in the same 
 case : beginning as retention, incontinence may follow ; or be- 
 ginning with an irregular spasmodic action of the bladder, re- 
 tention or incontinence may supervene. 
 
 Retention of urine is often associated with a kind of incon- 
 tinence, only the overflow dribbling away, the retention may 
 thus be overlooked altogether. More rarely a permanently 
 distended bladder discharges portions of its contents in such 
 natural quantities and at such intervals as to make the idea 
 
232 SYMPTOMS OF NERVOUS DISORDERS. 
 
 of retention seem very improbable. In old cases of stricture 
 retention of urine to a slight extent, after the act of micturi- 
 tion, is quite a common occurrence. 
 
 Paralysis of the bladder is found in many cases of hemi- 
 plegia (luring its early stage, but it usually passes away as the 
 patient partially recovers. Sometimes, however, it is perma- 
 nent, and this is more likely to happen if the bladder has been 
 neglected and allowed to be over-distended during the period 
 of unconsciousness. Paralysis of the bladder is very common 
 as part of the paralysis due to spinal lesions in the lower dor- 
 sal or lumbar regions, and in such cases it is more apt to be 
 permanent. In whatever way the urinary affection begins, it 
 tends to the form characterized by incontinence ; disease of 
 the bladder itself (cystitis) is also often present, produced 
 partly, perhaps, by distention or by the use of instruments, 
 favored by the alkaline urine often secreted in spinal paral- 
 ysis, and by the ammoniacal decomposition which is so apt to 
 work its way upward in such cases even when no instruments 
 have been passed into the bladder. 
 
 A reflex paraplegia, originating from disease of the genito- 
 urinary organs, is alleged to occur sometimes, and in any case, 
 of the combination of the two sets of symptoms, we should try 
 to ascertain the exact sequence of events ; serious disease of 
 the bladder occurring distinctly before the paralysis of the 
 limbs points in this direction, but an incipient paralysis may 
 manifest itself by urinary disturbance as an early feature ; 
 sometimes, indeed, an affection of the bladder remains the only 
 evidence of paralysis for a long time. 
 
 Paralysis of the bowels usually manifests itself chiefly as a 
 more or less obstinate constipation ; this can be overcome, as a 
 rule, by medicines, but occasionally it is so extreme as to sug- 
 gest some serious obstruction, especially when from any cause 
 vomiting supervenes. The paralysis may also affect the 
 sphincters, leading to incontinence of feces, as already men- 
 tioned. 
 
 The Clinical Significance of Paralysis in the various 
 forms in which it appears has been alluded to occasionally in 
 connection with special symptoms ; the subject is so complex 
 that reference nnist be made to the text-books under such 
 headings as hemiplegia, paraplegia, diseases of the brain, 
 spinal cord, etc. 
 
 Hemiplerjia almost invariably implies a cerebral lesion ; a few oases 
 of spinal hemiplegia, however, have been recorded. When the face 
 is involved in the hemiplegia, the diagnosis of some cerebral lesion 
 
SIGNIFICANCE OF PAEALYSIS. 233 
 
 may be made with confidence, and the lesion is always on the side of 
 the brain opposite to that on which the limbs are paral3'zed. The 
 causes of the lesion must be searched for ; we examine the state of the 
 arteries for indications of rigidity, of the cornea for appearances of the 
 arcus senilis, and of the heart for evidence of hypertrophy. "When 
 these exist in a hemiplegic patient not very much advanced in j^ears, 
 they strongly suggest a hemorrhagic lesion, and if tlie paralysis has 
 been complicated by the occurrence of a fit of unconsciousness, with 
 lividity and stertor, this may almost be regarded as certain. These 
 remarks apply whether there is any evidence of chronic disease of the 
 kidney or not ; but the existence of such disease renders a hemorrhagic 
 lesion in such a case even more probable. When there is valvular 
 disease of the heart (with or without evidence of hypertrophy), we 
 must keep in view the possibility of embolism ; such attacks are usu- 
 ally sudden, and may or may not be attended with unconsciousness ; 
 embolism is, on the whole, commoner in the middle cerebral artery of 
 the left side than in any other part of the brain, and this is a frequent 
 cause of aphasia. Occasionally an embolism determines a profuse 
 hemorrhage indirectly, through its first leading to the formation of a 
 small aneurism at the bifurcation of the artery plugged by the clot. 
 
 The cerebral lesion in hemiplegia may be of the nature of softening ; 
 this may be a consequence of embolism, but may also arise from other 
 forms of disease in the vessels (atheroma, thrombosis). Syphilitic 
 lesions sometimes give warning of their presence, before the develop- 
 ment of hemiplegia, not only by headache, but also by affections of 
 single cranial nerves (third, fourth, fifth, sixth, and seventh in par- 
 ticular) ; these are sometimes recovered from, other nerves again be- 
 coming involved ; syphilitic lesions often determine convulsions, oc- 
 curring sometimes in connection with the beginning of the paralysis, 
 sometimes before, and sometimes after it. Occasionally hemiplegia 
 and paraplegia exist in the same subject from syphilitic lesions affect- 
 ing bo.th the brain and spinal cord; the indications of a multiple 
 nervous lesion — one not easily explained by the simple growth of a 
 tumor or the mere extension of the diseased condition — should always, 
 in a young adult, suggest the question of syphilis. The existence of 
 syphilitic nodes, iritis, retinitis, etc., must be inquired for, and the 
 history of primary sores can sometimes be obtained m clearly syphi- 
 litic cases, although there may have been no appearance of secondary 
 symptoms ; in nervous cases the date of such infection is often very 
 remote. 
 
 Cerebral tumor often causes paralysis of special cranial nerves before 
 hemiplegia appears, or quite apart from it ; in these cases the ophthal- 
 moscopic appearances are specially important, as optic neuritis is very 
 common in tumor; the comparative frequency of chronic tubercle of 
 the brain and its membranes must be remembered in the case of chil- 
 dren. Cerebral abscess may produce variable states of coma, and a 
 shifting paralysis of various cranial nerves ; it is sometimes indicated 
 by the occurrence of shiverings and special sources of purulent infec- 
 tion can often be traced (from suppuration of the tympanum, from 
 disease of the bones, from scarlatinal sore throat, etc.). Tumor and 
 cerebral abscess ar6 both apt to give rise to convulsions as well as to 
 hemiplegia. Hemiplegia occasionally complicates pregnancy, passing 
 
 20* 
 
28i SYMPTOMS OF NEKVOUS DISORDEKS. 
 
 away, it may be, soon after delivery : the urine is almost always albu- 
 minous in such cases, but their pathology still remains obscure. 
 
 In the puerperal state hemiplegia and aphasia sometimes result from 
 embolism and thrombosis. Transient hemiplegia may follow a uni- 
 lateral convulsion, and a more permanent hemiplegia is not uncommon 
 in long-standing epilepsy, especially when this chiefly involves one 
 side of the body. Cases of double hemiplegia with a spastic state of 
 the muscles can sometimes be traced back to early life or even to birth. 
 
 Parajylegia may always be regarded as due to disease of the spinal 
 cord or its membranes : even in the case of " reflex paralysis," as it is 
 called, from irritation of the genito-urinary organs, there is probably 
 always some lesion of the cord. In hysterical paralysis, however, which 
 often assumes the paraplegic form, we cannot speak so definitely, and 
 in some varieties of it, where it passes away rapidly and completely, 
 we may be almost sure that no serious lesion exists. When the para- 
 plegic patient complains of great pain in the limbs, as well as in the 
 back, we suspect the membranes to be aflfected (spinal meningitis, 
 whether primary or secondary) ; when reflex action is abolished and 
 faradic contractility is rapidly lost, we infer destruction of some part 
 of the cord itself, or of the cells in the anterior cornua, or of the motor 
 roots ; when reflex actions are greatly exaggerated, we infer the exist- 
 ence of a limited lesion in some parts of the cord. (See p. 217.) As 
 to etiology, we must inquire for any history of strain as well as more 
 obvious injuries to the column ; such accidents often set up, in course 
 of time, meningitis, or disease of the cord itself. Caries of the verte- 
 brae is a common cause of paraplegia. This may not always manifest 
 itself by distortion of the spine, even in cases which have gone on to 
 the formation of psoas abscess. The influence of sexual excesses, in 
 married life as well as otherwise, accounts for various forms of para- 
 plegia proper, as well as locomotor ataxy. Sexual desire and power 
 are usually diminished in cases of disease of the cord ; occasionally, 
 in early stages and certain forms of locomotor ataxy, an ingreased 
 sexual capacity exists. S37philitic lesions of the cord must be judged 
 of on the same principles as those of the brain. It is generally agreed 
 that syphilis is a common cause of locomotor ataxy. 
 
 Monoplegia — paralysis of one limb — is due to many diff'erent causes. 
 Infantile paralysis, lead poisoning, wasting palsy, and traumatic lesions 
 are the commonest; sometimes the injuries are not of a very glaring 
 character, as in cases of paralysis of the arm, due to lying on it while 
 asleep, and especially during intoxication or after great fatigue. Occa- 
 sionally the injury to the nerve arises within — some tumor orpressure 
 or destructive process affecting the functions of the nerve in its course. 
 Occasionally, paralysis of an arm or a leg may result from cortical 
 lesions in the brain, without any other obvious signs of central disease. 
 
 Infantile paralysis is no doubt essentially a spinal paralysis, the 
 lesion, however, involves the anterior cornua alone or chiefly (polio- 
 myelitis anterior) ; this localization accounts for the aflfection being 
 almost invariably purely motor in character, for the coldness and great 
 trophic changes, and for the limitation of the paralysis, in many of the 
 cases, to one leg only, or to one arm. Not unfrequently, indeed, two 
 or more limbs, or even the whole four limbs, may be attacked during 
 the early period, the illness being characterized by pain and febrile 
 disturbance} but the paralysis becomes, as a rule, more limited, and 
 
SIGXIFIOANCE OF PARALYSIS. 235 
 
 frequently settles down to one limb, or to one group of muscles. The 
 rapid loss of the faradic contractility of the muscles, and their response 
 to weak currents from a constant battery for a considerable time, are 
 points of diagnostic value. An essentially similar form of paralysis 
 occurs sometimes, but only rarely, in the adult from a similar lesion, 
 and occasionally a form of the same disease, without any sudden begin- 
 ning, can be recognized (poliomyelitis anterior chronica adultorum). 
 
 In wasting palsy the muscles are usually affected bilaterally, but 
 one side is often in advance of the other: the muscles of the thumb 
 and hand, the muscles of the feet, and the deltoids, are amongst those 
 most frequently affected in the early stage, but nearly every group, 
 including the respiratory series, may ultimateh^ become involved. 
 The muscles usually respond to faradic electricity pretty well, con- 
 sidering their loss in bulk. 
 
 Lead Palsy. — Paralysis of Vie extensors of the forearms, and more 
 rarely of the legs, is frequently found in lead poisoning, the other 
 muscles being intact : the sensation is sometimes affected, but not often 
 to a marked extent. Traumatic paralysis from injury to the musculo- 
 spiral nerve may simulate this; the history leaves no doubt in such 
 cases, but in those forms supposed to be due to lying on the arm or to 
 exposure to cold (so-called rheumatic), there may be, in patients ex- 
 posed to lead, a certain difficulty. The immunity of the supinator 
 longus in lead paralysis is important : it is tested by getting the 
 patient to put his forearm in a position of half-flexion and half-prona- 
 tion, and while he tries to retain it in this attitude, the observer pro- 
 ceeds forcibly to extend it ; if the supinator longus be active it can be 
 seen and felt resisting this extension (Duchienne). The diminution or 
 abolition of the faradic contractility of the muscles in lead paralysis 
 is an important fact, as this is almost always preserved in rheumatic 
 affections of recent origin. The presence of a blue line at the free 
 margin of the gums, the history of colic, and the occupation or sur- 
 roundings of the patient are points to be scrutinized. 
 
 Alcoholic paralysis occurs in those much addicted to constant over- 
 indulgence in alcohol. It affects the lower extremities much more 
 frequently than the upper. It is often preceded by pains about the 
 joints, and sometimes several slight paralytic conditions of a passing 
 nature, occur before the more serious form sets in. Even when the 
 paralysis is so distinct as to prevent walking, the loss of power is not 
 by any means absolute : ataxic forms have also been described. "With 
 the paralysis there is osdema of the feet, especially when they are 
 allowed to hang down. The knee jerk is diminished, and often com- 
 pletely abolished. Perversions of the sensation, with "hyperesthesia " 
 and diminution of the tactile sense, sometimes occur. Mental dis- 
 orders may be associated with this condition, and the writer has 
 observed, in particular, great loss of memory, affecting certain subjects 
 only, with clear recollection of many others, in some cases of this dis- 
 ease. 
 
 When the alcoholic paralysis involves the upper limbs, a certain 
 resemblance to lead palsy is observed, as the loss of power specially 
 implicates the extensors, and the electrical reactions are somewhat 
 similar in the two conditions. Muscular atrophy may occur as a com- 
 plication. 
 
 Diphtheritic paralysis chiefly affects the palate, but it may also 
 
236 SYMPTOMS OF NERVOUS DISORDERS. 
 
 imj)licate the artns and legs, and frequently it abolishes the power of 
 accommodation in the eye. Sometimes there is anesthesia, which 
 may, indeed, be more prominent than the motor paralysis. It seems 
 to depend on the poison of diphtheria affecting the nervous system, 
 rather than on gross structural lesions: it usually passes away in the 
 course of a month or two. 
 
 Paralysis after fevers likewise occurs. Smallpox, enteric fever, and 
 typhu?, are all followed at times by paralysis, sometimes of a wide dis- 
 tribution, sometimes limited to a single limb. Some of these pass 
 away completely under treatment, but others are permanent. In scar- 
 latina hemiplegia, complicated sometimes with aphasia, has been 
 observed ; such seizures are due, no doubt, to some gross cerebral 
 lesion, probably the result of thrombosis. In whooping-cough hem- 
 orrhagic lesions in the brain, associated with paralysis, have been 
 recorded as rarities. 
 
 In unsteadiness in walking we must subject the patients to the tests 
 enumerated in the section on this subject (see pp. 222-225), and we 
 must direct our attention to their power of speaking distinctly, to the 
 presence of any of the delusions characteristic of general paralysis, 
 and to any history of insanity in the family, (See Chapter VIII.) 
 
 Paralysis of the face may be due to central or peripheral causes. 
 (See p. 203.) 
 
 Paralysis of the j)oXate is most ofien due to diphtheria and to bulbar 
 paralysis. (See pp. 203, 205, 235.) 
 
 Paralysis of the speech occurs in many cases of right-sided hemi- 
 plegia, in bulbar paralysis, in general paralysis of the insane, and in 
 affections of the ninth and seventh nerves, (See Sections at pp. 225- 
 229.) 
 
 Neuralgia. 
 
 Neuralgia, pain in a nerve, requires to be considered as to 
 the exact nerves or branches concerned ; the ^vhole of a plexus 
 of nerves, the cervical, brachial, lumbar, or sacral, may be 
 involved. The point of chief importance in considering neu- 
 ralgia is to see to avoid labelling a pain as neuralgic when 
 there is some other very definite disease merely involving the 
 nerve in a secondary manner. 
 
 In neuralgia there is, as a rule, little or no fever ; the pain 
 follows the course of certain nerves in a definite manner ; al- 
 though it may, at times, radiate not only to other branches of 
 the same nerve, or to its fellow on the opposite side, but even 
 to branches of completely different nerves. It is usually, if 
 not always, distinctly intermittent, disappearing more or less 
 completely at times ; it is sometimes, especially in the facial 
 form, distinctly periodic — coming very regularly at the same 
 hour every day. There are often special tender spots corre- 
 sponding to the points where the nerve is superficial or passes 
 through openings in the bones or fascia. There is no inflam- 
 
NEURALGIA. 237 
 
 mation, tumor, or other disease present to account for the 
 pain ; aucl further, certain nerves have a special predisposition 
 to such painful affections. The fifth nerve, the sciatic nerve, 
 the intercostal nerves, and the brachial, lumbar, and sacral 
 plexuses are those commonly involved. The viscera may also 
 be affected. 
 
 Although the absence of any obvious cause for the pain is 
 an important diagnostic point, it is quite possible that a true 
 neuralgia may be set up by the irritation, for example, of a 
 decaying tooth, of a wounded nerve, or from a twist or strain, 
 from prolonged pressure, an irritating scar, etc. The influ- 
 ence of cold and damp is also potent ; this may cooperate with 
 some of the causes just named, as in the case of miners lying 
 for a long time with their legs in a constrained position in a 
 damp part of the workings. Apart from these, which may 
 set wp what seems to be a true neuralgia, we may have pains 
 of a reflex character ; in cases of irritation of the stomach, 
 bowels, ureter, uterus, etc., we often have pains in the head 
 and limbs, which disappear when the irritation passes off. The 
 pain caused by a neuroma or a neuritis, may here be men- 
 tioned ; there is usually very marked local tenderness in such 
 cases. 
 
 In addition to local causes, we must have regard to the 
 general condition, as this is very important in neuralgia. 
 Ansemia in particular is very often responsible for this affec- 
 tion, and various debilitating agencies likewise lead up to it. 
 Ague is an occasional cause of supraorbital neuralgia. The 
 hysterical tendency frequently manifests itself as a neuralgia 
 in various parts, sometimes of a fixed, sometimes of a shifting 
 character. The neurotic constitution, transmitted by inherit- 
 ance, may manifest itself as a neuralgia in some members of 
 the family. Rheumatism may affect the trunk or the sheath 
 of a nerve, and so give rise to rheumatic neuralgia. Syphilis 
 may operate in a similar way, or it may simulate neuralgia 
 from the effects of syphilitic tumors in the brain or spinal 
 cord. Sciatica is sometimes seen in the course of gonorrhoeal 
 rheumatism. Chronic alcoholism may give rise to hyper- 
 sesthesia and neuralgia of the lower limbs, simulating at times 
 locomotor ataxy ; narcotics sometimes produce similar effects 
 from long habitual abuse. 
 
 The greatest care is required in the diagnosis of neuralgia, 
 as numerous blunders are committed in ascribing pains to 
 neuralgia and rheumatism which are of quite a different char- 
 acter. Lumbago, especially in its slighter forms, must be 
 
238 SYMPTOMS OF NEEVOUS DISOKDEES. 
 
 accepted as merely a provisional diagnosis till the kidneys, the 
 urine, and perhaps the uterus and rectum have been exam- 
 ined. Pains in the front of the thigh or along the sciatic 
 nerve, and neuralgic pains in the arms and legs generally, may 
 really be due to serious disease of the bones and joints of the 
 spinal column, the cord, or its membranes; or to abscess, 
 aneurism, and malignant tumors in the abdomen or thorax ; 
 intercostal neurlgia can seldom be safely affirmed without re- 
 peated examination of the heart and lungs ; and an apparent 
 
 neuralp-ia of the fifth nerve may prove to be due to cerebral 
 
 ' ' ' 111? 
 
 tumor or nicipient mennigitis, or to some tumor at the base oi 
 
 the skull, or to some less deep-seated disease in the bones of 
 
 the face. 
 
 The influence of neuralgia on the bloodvessels and nutri- 
 tion is sometimes apparent in the congested state of the affected 
 part, in lachrymation and discharge from the nose, and in 
 the change of color produced in the hair near the aflTected 
 part. An eruption of herpes zoster sometimes accompanies 
 neuralgia, and in old subjects such eruptions are often followed 
 by violent and persistent neuralgia. 
 
 In Bright's disease of the kidney we sometimes have very 
 severe and intractable forms of neuralgia. 
 
 In neuralgia the parts are usually kept preternatu rally still, 
 and in the facial form a species of tonic spasm may sometimes 
 be noticed ; at other times there are twitchings of the muscles. 
 (See convulsive tic, p. 249.) 
 
 For some points in connection with paralysis, locomotor 
 ataxy, and neuralgia, see p. 210 ; for aniesthesia and neural- 
 gia, see p. 200. 
 
 Fits of Various Kinds. 
 
 The nature of the seizures commonly called "fits" varies 
 so much, and their character is often so obscure, especially to 
 the inexperienced, that a somewhat more general view of such 
 attacks will be given here than is usual in systematic descrip- 
 tions. This is the more necessary, as the student has fre- 
 quently to discover from the descriptions given by the patient, 
 or his friends, the true nature of a so-called " fit " before he 
 can estimate its significance in the previous history. 
 
 We have then to remember, amongst the possibilities — 
 fainting fits ; fits of dyspnoea, associated, perhaps, with iingina 
 pectoris, or other forms of cardiac anguish and thoracic pain, 
 leading to more or less obscuration of the intelligence in cer- 
 
FITS OF VARIOUS KINDS. 239 
 
 tain cases ; fits with convulsive twitcliings of the face or limbs, 
 general, unilateral, or local, with or without unconsciousness 
 (epileptiform type) ; fits associated with, or followed by paral- 
 ysis, especially hemiplegia, with or without loss of conscious- 
 ness ; fits with lividity of the face, unconsciousness, and ster- 
 torous breathing (apoplectic) ; fits with simple unconsciousness, 
 without paralysis or convulsion (coma); fits without absolute 
 loss of consciousness, but with agitation, screaming, crying, 
 sobbing, laughing, biting of lips, and occasionally with an ap- 
 proach to convulsions or to coma (hysterical or hysteroid) ; or 
 similar emotional symptoms associated with distinct convul- 
 sions, sometimes tonic, sometimes clonic (hystero-epilepsy) ; 
 fits with plastic rigidity of the limbs, which are retained in the 
 positions in which they are placed, usually associated with 
 some alteration of the consciousness (cataleptic) ; fits with tonic 
 spasm of the jaw, or of the muscles of the trunk and limbs 
 (trismus and tetanus) ; fits with inversion of the hands and 
 feet, or especially of the thumbs, as a principal part of a tran- 
 sient convulsion, or persisting in a comparatively uncompli- 
 cated manner for hours or days (carpo-pedal). 
 
 In addition to these, attacks of giddiness, of speechlessness, 
 of cramps, of laryngeal obstruction or " crowing," and many 
 others, are sometimes spoken of as " fits," but are usually 
 qualified as to their nature by the patients themselves. Some 
 of these need only be named, as their nature becomes apparent 
 when a little attention is directed to them, either by question- 
 ing or observation. Some of them, indeed, chiefly demand 
 attention because of their occurrence under peculiar circum- 
 stances, simulating those fits of a nervous nature with wdiich 
 we are chiefly concerned here. Thus a severe attack of tho- 
 racic pain or cardiac anguish may lead to much tossing about, 
 with inability to speak, and may ultimately induce fainting 
 and unconsciousness, so that we may be led to think of some 
 convulsive disorder from cerebral causes ; or fits of giddiness 
 from various causes may lead to falling down and unconscious- 
 ness for a time ; or a fit of " crowing " may be complicated 
 with, or pass into, a distinct convulsion. 
 
 Fainting Fits {Syncojoe). — We inquire as to the presence of 
 any of the common causes which induce such attacks, nervous 
 shocks, arising from fear, grief, excitement, or pain ; the sight 
 of blood, the loss of blood, the want of food and rest, especially 
 with prolonged anxiety ; exposure to the close atmosphere of 
 crowded or overheated rooms ; the existence of pregnancy ; 
 profuse or painful menstruation, etc. Certain persons, more- 
 
240 SYMPTOMS OF NERVOUS DISORDERS. 
 
 over, are known to be much more prone to faint than others. 
 The hemorrhage which leads to the fainting may be concealed 
 from view at least for a time. The sudden removal of fluid 
 accumulations in the abdomen, or even the passing of a cath- 
 eter and the emptying of a distended bladder may cause syn- 
 cope. Profuse discharges from the bowels frequently do the 
 same. In debilitated conditions the sudden assumption of the 
 upright posture may cause faintness or actual swooning, and 
 in certain forms of weak heart, and especially in fatty degen- 
 eration, such attacks are liable to occur without any very 
 obvious cause. In fainting fits the patient has usually some 
 warning of the attack, and the observers may notice a pre- 
 liminary pallor, or sighing and yaAvning, or a dreamy expres- 
 sion of countenance ; even when these are not present in a 
 pronounced form, the patient has often a sense of swimming, 
 or of faintness, etc., so that in the exent of his falling he is to 
 some extent saved by its gradual character and by those in- 
 stinctive movements of self-preservation which partial con- 
 sciousness permits ; the element of suddenness often serves to 
 distinguish the epileptic fit from a swoon, even when it is so 
 slight as to be otherwise liable to misinterpretation. The 
 combination of hysterical tendencies in their less pronounced 
 forms, with fainting fi's or swoons, may give rise to consider- 
 able confusion. In a simple fainting flt the pulse is feeble, 
 the respiration diminished in extent, and the face pale ; con- 
 sciousness is abolished, but not usually so absolutely as in cases 
 of coma. No twitchings occur except, perhaps, as the patient 
 wakes u]), and no paralysis precedes or follows the fit. 
 
 Convulsion fits are usually obvious enough, and can scarcely 
 escape recognition when the whole phenomena are before us ; 
 the difficulties arise from our sometimes seeing only the latter 
 part of an attack, or from the convulsive part being so slight 
 as to evade recognition. In epilepsy, Avhich furnishes the type 
 of such fits, we have usually a premonitory sensation, vision, 
 or internal feeling of some kind (aura); a sudden pallor of 
 the face ; a scream ; complete unconsciousness ; a sudden fall, 
 so that the patient often hurts himself; a series of convulsive 
 movements, affecting the eyes, face, head, neck, trunk, and 
 limbs in the general convulsion. Sometimes the convulsion is 
 unilateral, either throughout or at the beginning of the attack, 
 sometimes the twitching is limited to a single limb, or to the 
 facial muscles on one side. AVhen the convulsion is severe 
 and general, the face becomes blue from the respiratory mus- 
 cles being involved ; the patient frequently foams at the 
 
FITS OF VAEIOUS KINDS. 241 
 
 mouth, and the froth is often bloody from the tongue having 
 been bitten in the convulsive movements of the tongue and 
 jaws, or from the intense congestion of the throat resulting 
 from the fit; the convulsion consists of a series of rapid mus- 
 cular contractions or twitchings (clonic), although certain 
 groups of muscles may remain for a time firmly contracted 
 and rigid (tonic) ; the whole body may be wTiggled about in 
 the violence of the attack. After a few minutes, in ordinary 
 epileptic seizures, the convulsions cease, the lividity begins to 
 disappear, a period of deep unconsciousness with stertorous 
 breathing supervenes, and this merges gradually into a quiet 
 sleep which may be prolonged for some time even after a short 
 interval of restored consciousness. After the fit the patient 
 seems well, although perhaps complaining of a headache, and 
 of a feeling of confusion for a short time, and he may subse- 
 quently feel sore and stiflT from the violence of the muscular 
 movements. There is no paralysis, or if there be hemiplegia 
 it is usually very slight and quite transient (ej)ileptic hemi- 
 plegia). After the fit there is sometimes great excitement, 
 and very erratic conduct with or without violence, and there 
 may be the execution of elaborate automatic actions indicat- 
 ing a deliberate purpose, although quite apart from the con- 
 trolling consciousness of the individual. 
 
 Such are the features of the typical epileptic fit (grand mal) ; 
 when convulsive attacks, from any cause, approximate to this 
 type, they are called " epileptiform " or " epileptoid ; " but 
 nearly every one of the individual features enumerated may 
 be absent, or at least so slight as to escape notice. In partic- 
 ular, there may be no obvious convulsions, a sudden pallor 
 and loss of consciousness being all (petit mal). Allied to this 
 are the so-called " inward fits " of infants, in which we have 
 turning up of the eyes, with apparent unconsciousness, and a 
 momentary rigidity in certain cases. There may, on the other 
 hand, be preservation of consciousness, along with unilateral 
 or localized convulsions ; further, the convulsive part of the 
 attack may be over before the patient comes under notice, so 
 that the condition observed resembles simple coma, especially 
 if there be no evidence of struggling, disordered bed-clothes, 
 wetting of the bed, bloody foam, etc. The existence of injury 
 from a fall occurring in connection with a fit rather favors the 
 idea of an epileptic attack or convulsion fit of some kind, as 
 unconsciousness is seldom so suddenly lost in other fits as to 
 prevent some eflfort at preservation ; in some circumstances the 
 marks of injury must make us consider whether the injury, by 
 
 . 21 
 
242 SYMPTOMS OF NERVOUS DISORDERS. 
 
 damaging the uervous structures, may not have determined 
 the convulsive seizure. In apoplectic attacks convulsions 
 occasionally supervene, and in hysteria the discrimination of 
 it from epilepsy is sometimes impossible ; indeed a complex 
 condition of hystero-epilepsy is now recognized. (See p. 247.) 
 
 The presence or absence of the various features referred to 
 as characterizing a typical attack must be noted. If possible, 
 we should notice or ascertain how the convulsion begins, 
 whether with rotation of the head to the shoulder and conju- 
 gate deviation of the eyes, with nystagmus, with twitchings of 
 the cheek and lips, or with convulsion of the fingers, feet, etc 
 Occasionally the convulsion is limited to one side, or even to 
 one limb or one cheek (Jacksonian epilepsy) ; in such cases we 
 must make sure which side is affected, and if consciousness be 
 not lost we may learn from the patient something of his sen- 
 sations in the affected part, where they began, and how they 
 extended. In cases v/ith unilateral convulsion, Ave must try 
 to ascertain whether there w-as paralysis of the affected side 
 before the fits, or wdiether it appeared after the convulsion, 
 whether it was transient or whether it persisted for some time. 
 AYhen unconsciousness is not present at the very beginning of 
 a fit, it is important to discover the time at which it appeared, 
 especially in connection with convulsions or sensations spread- 
 ing up the limbs. It is not always easy to be sure of the pres- 
 ervation of consciousness in a fit; Avhen unable to answer 
 questions we must trust to the appearance of intelligence of 
 the patient when we speak to him, and to his power of after- 
 ward describing what bapj)ened during the fit, w'ho assisted 
 him, etc. 
 
 If the fits recur, we should estimate not only their duration 
 but also the length of the intervals ; we should likewise notice 
 whether the muscles become quite relaxed during the intermis- 
 sions, or whether there remain some tonic spasms ; any appear- 
 ance of an exciting cause must be noted in these recurrences ; 
 the determination of the convulsive attacks by some irritation 
 is an important feature in strychnia poisoning. 
 
 In connection with such convulsion fits we nmst ascertain 
 whether the patient has had any attacks before, and at what 
 age they began ; epilepsy in its ordinary form usually mani- 
 fests itself in childhood, or appears about puberty. Any his- 
 tory or evidence of cerebral disease must likewise be searched 
 for ; particularly acute or chronic hydrocephalus, cerebral 
 tumors, abscesses, etc. In children we must remember that 
 various forms of ap2)arently slight irritation may cause con- 
 
FITS OF VAKIOUS KINDS. 243 
 
 vulsions ; disorders of the stomach from improper food, and 
 diarrhoea are frequent causes of convulsions. In the atrophic 
 and anaemic condition resulting from these or similar causes, 
 we may have convulsions and other symptoms simulating to 
 some extent the course of meningitis ; but the history, the diar- 
 rhoea, and the collapsed fontanelle serve to guide the diagnosis 
 of this spurious hydrocephalus (hydrencephaloid). The irri- 
 tation of the gums and mouth during the period of dentition, 
 the presence of worms in the intestines, and indeed anything 
 which tends to produce pain and feverishness, may give rise, 
 in predisposed subjects, to general convulsions. Children with 
 rickets and laryngismus stridulus are frequently subject to 
 general convulsions. Acute illnesses (fevers, inflammations 
 of the lungs, and meningitis) sometimes begin, especially in 
 children, with a fit of this kind, and whooping cough is par- 
 ticularly apt to be thus complicated in its course ; in hydro- 
 cephalus acutus, convulsions commonly supervene at some 
 stage of the illness. In the course of scarlatina, convulsions 
 may be due to the supervention of renal disease. Various 
 poisons are well known to give rise to convulsions. In adults, 
 when there is no history of typical epilepsy, we must consider 
 whether the fits may be due to intemperance and chronic alco- 
 holism, or to syphilis or to Bright's disease. A sudden out- 
 burst of convulsions may be the form in which patients so 
 affected may first be laid up. Other forms of cerebral tumor, 
 as well as the syphilitic, may, however, declare themselves in 
 this way. Eenal disease may likewise surj^rise a patient thus 
 w^ho has scarcely ever regarded himself as ill ; but usually 
 there has been some history of dropsy, of recent scarlatina, 
 incipient blindness, or some indication of serious disease. The 
 urinary examination is important in such cases ; but we must 
 remember that convulsion fits, from any cause, are often asso- 
 ciated with temporary albuminuria ; the quantity and specific 
 gravity of the urine, and the microscopic examination, by 
 revealing fatty .casts and epithelium, may here guide us in 
 recognizing a chronic form of the disease. 
 
 Cerebral embolism and thrombosis, certain forms of apo- 
 plexy, and senile degenerative changes in the brain, and the"" 
 congestive attacks in "general paralysis," sometimes reveal 
 themselves by convulsions. 
 
 In women during pregnancy and the puerperal state we are 
 apt to have convulsions, depending apparently on irritation, 
 from distention or otherwise, of the uterus, and on the presence 
 of albumen in the urine with all the disorder of the system 
 
244 
 
 SYMPTOMS OF NERVOUS DISORDERS. 
 
 which this implies. Other forms of irritation propagated from 
 the sexual organs may likewise be mentioned, as causing con- 
 vulsions ; and in particular the premature or unnatural excite- 
 ment produced by masturbation ; ordinary sexual intercourse 
 may determine the occurrence of a fit in those predisposed to 
 such attacks. 
 
 Fig. 36 A. 
 
 FEBRUARY - MARCH 
 
 ,21 22 23 24 Z5 26 27 28 1 2 3 4 5 6 7 8 9 10 
 
 Fig. 36 B. 
 
 These two diagrams represent the daily number of convulsion fits in a child who had 
 two great paroxysms, the one in March and the other in the following July. The nniii- 
 bers in the column on the left indicate the fits noted in the twenty-four hours. 
 
 Repetition of Convulsions — Status Epilepticus. — It frequently happens 
 that one convulsion is followed by another after the lapse of a few min- 
 utes or a few hours : this applies to the regular epilepsy and to all the 
 forms of disease already mentioned as giving rise to convulsions of this 
 type. In this way a patient may be for a few hours almost continu- 
 ously in fits with short periods of consciousness between them, or with 
 
HYSTERICAL FITS. 245 
 
 periods of coma between the convulsions. Sometimes, however, the 
 condition is even more prolonged: for many hours we may have 
 almost incessant convulsions, the number being exceedingly great and 
 the intervals between them very short. This is called the " epileptic 
 state,'"' and it may persist for a day or two. Sometimes there is a 
 gradual working up to this state by a marked increase in the number 
 of fits before they become so constant, and in the diagrams here given 
 of two such attacks in the same child it will be seen that the ascent of 
 the curve indicating their daily number, and the acme of the paroxysm 
 was somewhat similar : in the one attack the maximum number of fits 
 was 180, and in the other 155 in the twenty-four hours. (See Figs. 
 36 A and B.) 
 
 This condition is always one fraught with danger to life : the gravity 
 becomes all the greater when very considerable elevations of tempera- 
 ture are also present, as is often the case. There is also danger to the 
 intellectual faculties, and in point of fact the "status epileplicus " is 
 much more commonly met with in asylums than in other forms of 
 practice. 
 
 Hysterical jits assume sucli a variety of forms that only the 
 leading features, or rather the common ones, can be noticed. 
 As a rule, consciousness is not abolished, although there may 
 be changes in this respect, and unconsciousness may be simu- 
 lated ; occasionally, indeed, consciousness may seem to be 
 really suppressed. This test, therefore, although important, is 
 by no means absolute ; on the other hand, the preservation of 
 consciousness in local and unusual forms of epilepsy must also 
 be remembered. The emotional disturbance in hysteria is 
 perhaps the most important feature ; it is practically confined 
 to the female sex ; the rising of a ball in the throat (globus), 
 sobbing, sighing, laughing, crying, and even screaming are 
 quite common. Along with these manifestations there may be 
 tossing about and great agitation, with quivering, twitching, 
 tonic spasm of the muscles, and biting of the lips, so that the 
 movements may bear a certain resemblance to those of epi- 
 leptic convulsions; but we can usually detect a certain purpo- 
 sive character in the movements, such as clutching at the 
 attendants, and we can sometimes see th'at they are to some 
 extent under the control of the will, if the patient be firmly 
 dealt with. 
 
 In other cases the movements only amount to a general 
 shaking of the body or limbs, or to quivering of the facial 
 muscles when the patient is doing her best to control herself. 
 Swoonings and brief periods of simple unconsciousness con- 
 stitute at times the only manifestations of hysteria. There is 
 often in this condition great tenseness of the abdominal mus- 
 cles and great tenderness on touching the skin. At other 
 
 21* 
 
246 SYMPTOMS OF NERVOUS DISORDERS. 
 
 times the muscular spasm may give rise to the appearance of 
 general distention of the abdomen or to a localized tumor — 
 both subsiding under chloroform. Or the muscular spasm in 
 the limbs may be more permanent, remaining as a " contrac- 
 ture," with or without paralysis, and lasting for days or 
 months, or even years. 
 
 The determining causes of such seizures often supply impor- 
 tant information ; quarrels, disappointments in love, excite- 
 ment, grief, vexation, etc., may be named as among the more 
 obvious of these. Disturbance of the sexual organs and 
 functions (disordered menstruation, amenorrhoea, change of 
 life, etc.) are likewise important. In debility from long-con- 
 tinued and exhausting diseases hysterical tendencies may show 
 themselves in patients who had hitherto been able to control 
 such manifestations, so that these attacks may form one of 
 the features of grave disease or of impending death. It is 
 well to remember also that cerebral affections sometimes give 
 rise to symptoms having much resemblance to hysteria ; there 
 may be the quivering eyelids when we try to open them ; the 
 obedience to commands sharply given after a period in which 
 the patient seemed unable to comply ; the refusal of food 
 overcome perhaps by the use of the stomach tube ; and even 
 the emotional excitement and self-consciousness so suggestive 
 of hysteria. In all cases involving the least doubt, great care 
 must be taken in forming or at least in acting on any judg- 
 ment of the case as hysterical. 
 
 Plastic rigidity, as found in catalepsy, is closely allied to 
 hysterical fits ; in a slight form it may, indeed, be noticed 
 occasionally during such seizures. In its most typical mani- 
 festations the limbs and also -the neck and trunk may be re- 
 tained even in the most unnatural positions in which they 
 are placed, or in which they may happen to be when the fit 
 occurs. The arms, for example, may be moulded into various 
 attitudes, and kept in positions not easily maintained even by 
 a muscular man, or the head may be bent back and fixed in 
 such a position that the patient remains resting on the back of 
 her head with the body arched, as occurs in certain cases of 
 tetanus. Such a fit may last for a considerable time, or there 
 may be a succession of such fits, with intervals of a natural 
 condition. In grave forms of such seizures the consciousness 
 is obviously involved, but in slighter cases it is preserved, and 
 the patient may be able to obey commands when stirred up, 
 the movements being then very automatic — every step or 
 every movement requiring the fresh energy of a new imperious 
 
HYSTEKO- EPILEPSY. 
 
 247 
 
 order for its performance. Like hysteria, catalepsy may be 
 said to be almost confined to the female sex. 
 
 Hystero-epilepsy combines some of the peculiarities of the 
 hysterical and epileptic seizures. It is almost limited to the 
 female sex. The attacks come on suddenly and present at 
 times great violence ; the movements have often more of a 
 purposive character than in epilepsy. One of the commonest 
 and most striking is the " crucifixion attitude " as described by 
 Charcot. The head is suddenly thrown back, the spine curved, 
 the feet extended, and the patient may rest on the occiput 
 and heels for a time ; the arms are also thrown back, some- 
 what above the level of the shoulders, the hands clenched, and 
 the thumbs turned in. The illustration here given (Fig. 37), 
 
 Fig. 37. 
 
 The crucifixion attitude in the hystero-epilepsy of Charcot. (Bourneville et Eegnard.) 
 
 obtained from Charcot's Clinque, gives a good idea of the 
 position. To this tonic spasm there may succeed clonic con- 
 vulsions of various types ; a tendency to rhythmical muscular 
 movements is one of the most striking features. Great men- 
 tal or emotional excitement may be associated wdth or may 
 follow the attacks, but the remarkable attitudes indicating 
 various passions, as described by Charcot, seldom occur in this 
 country. 
 
 r 
 
248 SYMPTOMS OF NERVOUS DISORDERS. 
 
 In the intervals the patients may be found to present 
 various sensory disturbances — hypersesthesia of the ovarian 
 region, and hemianeesthesia with color-blindness sometimes ap- 
 pearing suddenly or changing from side to side. Slight irri- 
 tation of the sensitive ovary may determine a fit, or firm 
 pressure may cause it to cease ; the influence of magnets and 
 metals likewise produces remarkable changes, but all these 
 occurrences are probably dependent in large part on the atti- 
 tude of expectation on the part of the patient. 
 
 Local convulnons have already been referred to as some- 
 times replacing general convulsions in an epileptic fit (" Jack- 
 sonian epilepsy " ), but the spasms which affect the hands and 
 feet of children must be specially mentioned (carpo-j^edal 
 spasms). The hands and feet are bent in, the wrists are 
 slightly flexed, and the thumbs are drawn across the palms. 
 This form of spasm is common in infantile convulsions from 
 any cause.; it sometimes precedes general convulsions, the 
 spasm in the hands coming or going frequently, or being pre- 
 served continuously for some time before the general attack 
 comes on, and remaining after the general convulsions cease. 
 In more favorable cases the nervous aflfection may never get 
 any further than this local spasm. This affection is often asso- 
 ciated with a swollen appearance of the dorsum of the feet 
 and hands, arising in cases of protracted innmtile diarrhoea. 
 Along with this carpo-pedal spasm there may be some tonic 
 contraction of the muscles of the back and at the nape of the 
 neck. Consciousness is not usually lost in this condition. 
 
 This state is closely connected with the occurrence of gen- 
 eral convulsions, of which it is to be regarded as a warning ; 
 but a less serious form of spasm in these situations is described 
 under the name of tetany ; the thumbs are the parts most fre- 
 quently affected, but the feet may also be involved ; the hand 
 and fingers are often contracted into a cone-like shape ; in a 
 more severe form the muscles of the trunk and of the jaw may 
 become affected, but the rigidity does not begin in the last 
 named situation as in tetanus. The contraction is not usually 
 very painful, but pain may be caused if an attempt be made 
 to overcome the spasm. It usually varies in intensity from 
 time to time, even when a degree of it remains persistently 
 for days. It has a special tendency to recur after intervals of 
 apparently j)erfect recovery ; according to Trousseau transient 
 spasms may be induced in these intervals by pressure on the 
 nerve trunks. The excitability of the muscles to electrical 
 stimulation is increased. Although most common in children, 
 
LOCAL SPASMS. 249 
 
 it affects adults occasionally, especially women during lacta- 
 tion ; its frequency appears to be related to climatic influences, 
 and it has been supposed to be connected with rheumatism. 
 
 Spasms or cramps in the legs are common in many persons ; 
 they often occur suddenly during the night, without any 
 obvious cause, but their frequent dependence on gastric dis- 
 orders, acidity, etc., is quite certain. Such cramps are very 
 painful while they last. A more general form of the same 
 thing sometimes presents a resemblance to the severer forms 
 of " tetany " as just described. In addition to gastric dis- 
 order, we must mention diarrhoea and cholera as giving rise 
 to painful cramps ; they are also common in connection with 
 childbirth. Spasms in the limbs also occur, as already men- 
 tioned, in connection with cerebral and spinal disease. (See 
 p. 213.) 
 
 Local s])asms in the region of the face and neck likewise de- 
 mand attention. Such spasms may be tonic — the contraction 
 of the muscle being steady and sustained — or they may be 
 clonic and twitching in character. Slight tonic contraction of 
 certain facial muscles is found at times in connection with 
 severe neuralgia ; the person's face assumes a fixed appear- 
 ance, as if he were acting a part {histrionic spasm). Similar 
 spasms usually, however, more limited to isolated muscles, 
 sometimes remain after an attack of facial paralysis. Twitch- 
 ings of the face may be the only manifestations of an epileptic 
 fit, and unilateral facial twitchings of the face and neck may 
 constitute the only or chief manifestation of a cerebral lesion. 
 
 Sometimes the patient is liable to frequent repetitions of 
 twitchings of the face (convulsive tic) ; these attacks are not 
 usually painful, but they may be associated with a painful 
 affection of the fifth nerve. Twitchings of the orbicularis 
 palpebrarum have been already referred to. (See " Eye," p. 
 176.) 
 
 Permanent contraction of the muscles of the neck, espe- 
 cially of the sterno-mastoid, gives rise to a form of wry-neck. 
 This is, perhaps, usually congenital, and resembles clubfoot 
 so far. Occasionally, how^ever, it appears about puberty, or 
 even later, especially in females, and is generally classified 
 then as hysterical. In such cases it may persist for years. 
 Deviations of the head may arise from rheumatic affections of 
 the muscles of the neck, or from the influence of cold, giving 
 rise to the common form of "stiff'-neck" of a passing char- 
 acter. A similar deviation may result from painful glandular 
 enlargements in the neck. Caries of the vertebrae may lead 
 
250 SYMPTOMS OF NERVOUS DISORDERS. 
 
 to a lurching over of the head to one side, and disease of the 
 occipito-atlantoid, or axoidal articulations, usually gives rise 
 ta a very peculiar fixity of the muscles of the neck, wliich be- 
 come affected in this Avay simply to preserve the patient from 
 the pain due to the least movement of the head. Deviations 
 of the head associated with ocu'ar paralysis have been already 
 referred to (p. 167). 
 
 Twitching of the sterno-mastoid on one side, or of the 
 trapezius, constitutes a most troublesome nervous affection, 
 which sometimes assumes great violence and prevents sleep. 
 These movements are under the influence of the spinal acces- 
 sory nerve, as shown by the effect (usually temporary) of its 
 section, they are obviously of centric origin, and depend prob- 
 ably on disease at the root of this nerve. This convulsive 
 wry-neck may persist for years in a violent form, or it may 
 assume a troublesome severity only occasionally. The influ- 
 ence of emotional excitement is often very marked, sometimes 
 in the way of greatly intensifying the movements, sometimes 
 in inhibiting them altogether. 
 
 Bilateral convulsion of the muscles acting on the head is 
 found in the nodding convulsions of children, which sometimes 
 proceed to a bending of the whole trunk (eclampsia nutans, 
 salaam convulsions). Such an affection may be symptomatic 
 of cerebral tubercle, although it also occurs as a more inde- 
 pendent disease. (See also p. 216.) 
 
 Tonic spasm affecting the jaw (trismus) is usually the earliest 
 manifestation of tetanus and of stryclnia poisoning, and so 
 must be watched for during the administration of this medi- 
 cine. Tetanus affects the muscles of the back and abdomen 
 as well as the limbs. When the back is affected, so as to be 
 curved backw^ard, the form is named " opisthotonos ; " when 
 the abdominal muscles are so much involved as to cause a 
 bending forward, " emprosthotonos " is the name employed; 
 " pleurosthotonos " is applied to similar lateral deviations. 
 Tetanus comes under the notice of surgeons in connection with 
 injuries, but it occurs also idiopathically, sometimes from ex- 
 posure to cold and wet. The distinctions of tetanus from 
 strychnia poisoning must be sought for in detail in the text- 
 books ; but the tendency to remissions and to exacerbations 
 brought alwut by irritations of various kinds, constitutes one 
 of the features of poisoning. The early affection of the jaw 
 in tetanus and strychnia poisoning forms a marked contrast 
 with the late develo])ment of this symptom in the severe forms 
 of " tetany " already alluded tq. 
 
SUDDEK PARALYSIS. 251 
 
 Spasms of deglutition on attempting to swallow, form one of 
 the features of hydrojjhobia. Spasmodic stricture of the oesopha- 
 gus is rare but not unknown. Spasms of the glottis as they 
 occur in cases of pertussis, laryngismus stridulus, laryngeal 
 disease, and thoracic tumor are referred to in the section on 
 dyspnoea, etc. (Chapter IX.). 
 
 Sudden paralysis is sometimes spoken of as a "fit" or 
 " stroke." In connection with the occurrence of this we must 
 observe, or try to ascertain, whether the paralysis came on 
 suddenly in its maximum extent, or in a series of successive 
 invasions, or whether the advance was marked by temporary 
 or partial recoveries. The exact manner in which the paraly- 
 sis occurs should be ascertained, so that we may judge of the 
 rapidity of the attack, and of the parts involved, aud by such 
 inquiries we are often able to ascertain the presence or absence 
 of consciousness during the seizure. Tendencies to giddiness, 
 flashes of light, noises in the ears, and unusual disposition to 
 sleep, may be inquired about ; the friends of a patient can 
 often give important information on these points if the patient 
 himself be unable to do so. If there be unconsciousness we 
 should try to ascertain at what period it supervened, if it did 
 not form the initial symptom, whether it obviously deepened 
 or lightened after it aj)peared, whether it was associated with 
 stertorous breathing, and whether the face was flushed or livid 
 at the beginning of the fit, or, on the contrary, pale and 
 bloodless. The occurrence of convulsions or twitchings at the 
 onset or in the course of the attack should be inquired for ; in 
 unilateral convulsions a paralysis of the aflected side may last 
 for a few hours or even for a day or two after the fits. 
 
 When a patient is deeply unconscious it is not easy to de- 
 termine- the presence of paralysis ; but a certain twist in the 
 features, and a difference at the angles of the mouth, often 
 serve to reveal a one-sided paralysis. On lifting or moving 
 the limbs we may be able to discover a distinct difference in 
 the flaccidity of the two sides, and we are often able to ob- 
 serve that any restless movements of the patient are confined 
 to the limbs of the one side. Attention must be directed in 
 the further examination to the state of the heart and blood- 
 vessels (rigid arteries, hypertrophy or valvular disease of the 
 heart, etc.), to the state of the kidneys, and to the previous 
 history of any former attacks. The immediately preceding 
 events are also important, exposure to the sun, the possibility 
 of injury to the head, the presence of excitement, the facts as 
 
252 SYMPTOMS OF NERVOUS DISORDERS. 
 
 to eating and drinking, etc. (See section on " Paralysis," pp. 
 208-209.) 
 
 Com.a has already been referred to as a frequent accompani- 
 ment of paralysis and convulsion. Unconsciousness likewise 
 occurs in simple fainting fits, and forms one of the less com- 
 mon manifestations of hysterical attacks, and of the rare 
 conditions known as catalepsy, mesmeric trance, etc. 
 
 But coma may exist apart from such complications. As 
 explained under the section on convulsion and sudden paraly- 
 sis, it is not always easy to say whether the comatose state has 
 been complicated by these ; indications for the discrimination 
 are given under these headings, but with regard to paralysis 
 we have often to wait till the coma passes away before we can 
 judge: with regard to convulsions we may remain in doubt 
 unless there be a repetition of them. Moreover, even in a fit, 
 essentially of an epileptic character, the convulsive part may 
 be absent, as already remarked. 
 
 . Many diseases terminate in coma lasting for some time be- 
 fore death, and coma forms a frequent episode in febrile dis- 
 eases which are attended with delirium. In such cases we 
 have usually a series of symptoms leading up to the comatose 
 condition, jDreparing us, as it were, for its occurrence. 
 
 When occurring suddenly, apart from any manifestations 
 of nervous disturbance, or when developed rapidly, even in 
 the midst of nervous symptoms, it calls for consideration 
 under, the present section. The most striking form of this 
 sudden coma occurs in renal disease, the nervous complication 
 taking the form of ursemic coma instead of convulsion. It 
 may supervene without warning, and after lasting for a 
 variable period of hours or days, it may pass off" suddenly 
 and completely without leaving any apparent effects. We 
 must in such cases test the urine with care; it may be worth 
 while even to draw ofi" some with a catheter for the purpose. 
 We should also, if possible, ascertain to what extent urine 
 had been passed for some days before the fit, — whether it was 
 deficient in quantity or quality. We inquire also for any 
 history of dropsy, or other evidence of renal disease, dimness 
 of vision, or the like. In renal coma the pupils are usually 
 moderately contracted, or at least not dilated ; and the tem- 
 perature is not elevated; it may even be low. The test for 
 ammonia in the breath, by means of its action on the fumes 
 of a drop or two of strong hydrochloric acid i)laced on a glass 
 rod, is not very satisfactory; adaptations of Nessler's test 
 solution have likewise been tried, but not with nnich success. 
 
CHOEEA. 253 
 
 Very different in most respects from this is the coma found 
 at the violent onset of scarlet fever, measles, and some other 
 specific fevers. The coma in such cases attacks children 
 especially, after a short period of delirium and excitement, in 
 the midst usually of a high fever. In such cases the diagnosis 
 is often enveloped in much obscurity, owing to the absence or 
 suppression of the rash, and the true nature of the attack may 
 only appear on the subsequent occurrence of some fever in 
 other inmates of the house. 
 
 The whole group of poisons classed as narcotics produce 
 coma or unconsciousness. Of these, the most important is 
 opium. This may cause coma in certain cases when adminis- 
 tered even in medicinal doses, especially in renal disease, and 
 in some forms of cerebral disorder. Extreme contraction of 
 the pupils is an important indication of opium poisoning, al- 
 though found in other forms of coma due to cerebral disease. 
 (See p. 171.) Chloroform, chloral, and alcohol must also be 
 remembered; the diagnosis of unconsciousness from alcohol 
 as distinguished from cerebral disease is often difficult; the 
 smell of the breath is imj)ortant, but sometimes misleading, 
 as those who feel ill may have resorted to the use of spirits on 
 that account just before the seizure. 
 
 In nearly all cerebral diseases coma plays an important 
 part; it may be associated with convulsions and paralysis, or 
 it may occur alone. It is often due to pressure on the brain 
 from depressed fracture and from hemorrhage, so that in trau- 
 matic cases the coma comes on after the injury in a gradual 
 manner. Or the pressure may arise from fluid in the ven- 
 tricles, from meningitis, or from cerebral or meningeal hemor- 
 rhage. Tumors, abscesses, thrombosis, and other forms of 
 disease in the brain, often give rise to disturbances manifesting 
 themselves in coma w^hich may be transient, although the cause 
 may be permanent. 
 
 Twitching or Choreic Movements. 
 
 Twitchings or clonic spasms have been mentioned in con- 
 nection with paralysis (p. 214), but' they also occur inde- 
 pendently in the form of disease termed chorea. The move- 
 ments are erratic, and are specially developed when the patient 
 attempts to perform definite actions, such as raising a spoonful 
 of fluid to the mouth, — the limbs refusing to obey accurately 
 the impulse of the will. Even while sitting quietly, twitch- 
 ings in the face and limbs occur, and these are aggravated on 
 
 22 
 
254 SYMPTOMS OF NERVOUS DISORDERS. 
 
 attention being directed to the patient. Grimaces, from 
 twitchings of the mouth and eyes, are the commonest forms of 
 the early manifestations of this affection. A good test in 
 chorea consists in getting the patient to hold out a stethoscope 
 at arm's length on the palm of the hand, to pick up a pin 
 Avith one hand and j^ut it into the other, or to keep the arms 
 steadily at the side while standing or walking, or to keep the 
 tongue protruded for a little time. The restless tossings in 
 bad cases are so extreme that the patient can scarcely be kept 
 in bed or prevented from hurting herself by the movements. 
 Speech and even deglutition are affected in the more serious 
 forms. One side is often much more involved than the other, 
 and sometimes is affected alone (hemi-chorea). Complications 
 with paralysis have been already referred to (p. 214). A 
 slight weakness of mind and flightiness are common in chorea, 
 and may often be traced even after the twitchings have ceased ; 
 sometimes the defect is very pronounced, associated with 
 speechlessness, incontinence of urine, and other alarming 
 symptoms, but it very rarely leaves any permanent disorder 
 of the mind. 
 
 Chorea is most common in children of about seven to twelve 
 years of age, especially in girls, but it also occurs about pu- 
 berty, and during pregnancy, sometimes in those previously 
 affected. There is, indeed, a special tendency to relapses or 
 recurrences of this disease; these are most often developed in 
 the winter or spring months. We must have regard to the 
 general state of the children, particularly as to anaemia and 
 constipation. The disease is to some extent hereditary, or at 
 least included in a general family tendency to rheumatic and 
 cardiac affections, which seem to have some affinity with 
 chorea. Not unfrequently we find chorea following cardiac 
 disease due to rheumatism, but occasionally the chorea com- 
 plicates the acute stage of rheumatism, it sometimes precedes 
 it, and often occurs independently of it. The heart must be 
 examined in choreic patients; systolic bruits are not uncom- 
 mon, but many of these pass aw^ay, and are evidently not due 
 to valvular disease; some may be hseniic in their origin, and 
 some due to disturbed muscular action in the heart itself. 
 Scarlatina has also a tendency to develop chorea. Many facts 
 point to the connection of chorea with cerebral embolism and 
 thrombosis. The determining cause is often supposed to be 
 some fright, but this has probably been much exaggerated by 
 the public, the child being easily frightened because of the 
 illness beginning. When high fever exists with chorea, the 
 
DELIRIUM. 255 
 
 case assumes a more serious aspect ; sometimes the pyrexia is 
 due to endocarditis or rheumatic complications. 
 
 Local forms of chorea seem to belong to a different form of 
 disease. (See " Local Spasms," pp. 176 and 249.) Sudden 
 twitchings affecting the whole body, or certain portions, with 
 lightning-like suddenness are described under the name of 
 " electric chorea ;" this disease has little affinity with ordinary 
 chorea, being more allied to hysterical affections or "spinal 
 irritation." 
 
 Delirium. 
 
 Delirium is always a sign of nervous disturbance, but it may 
 arise merely from a general affection of the whole economy 
 operating on the nervous system. In high fever from any 
 cause and in long protracted febrile states with much debility 
 delirium is extremely common, so that a certain disturbance 
 of this kind is habitual just before the fatal termination of an 
 illness. The slighter forms of febrile delirium show^ them- 
 selves when the patient is half asleep, or before he is properly 
 awake ; the talking, as if in sleep, is continued probably in 
 connection wdth the previous dreams, even when the patient 
 awakes so as to speak or to answer the attendants. In the 
 slighter forms of this "wandering" or "wavering" the patient 
 catches himself up very quickly, and knows that he has intro- 
 duced the confusion of his dreams into his conversation. In 
 deeper forms of delirium the patient fails to recognize any 
 error, and may go on speaking, or contending, or struggling 
 with the attendants, as if they w^ere the enemies conjured up 
 in his dreams. Although the jDatient fails to recognize those 
 around, a certain recognition may remain, and may suggest 
 resemblances or reminiscences from an association of ideas 
 which we can som.etimes trace. In yet deeper forms of de- 
 lirium the external world is less recognized, and the j)atient 
 shouts, screams, or sings, quite irrespective of what the at- 
 tendants do or say. In these last two forms the patient has 
 often a tendency to rise up and get out of bed, probably with 
 the notion of escaping from something disagreeable. Another 
 form of delirium is characterized by low muttering, or by the 
 movement of the lips without much sound, varied at times by 
 a few louder words, but without, as a rule, any great excite- 
 ment or disturbance. Picking at the bed-clothes, drawing out 
 imaginary threads, and waving motions with the arms, are 
 not uncommon in this state. (Compare p. 36.) 
 
 All these forms of delirium are common in the specific fevers 
 
256 SYMPTOMS OF NERVOUS DISORDERS. 
 
 and in severe inflammations, very specially in typhus fever and 
 severe scarlatina, in inflammation of the lungs, and in men- 
 ingitis. In pneumonia its onset is sometimes very sudden and 
 so unexpected as to be liable to lead to accidents or to raise 
 the suspicion of insanity. The influence of intemperate habits, 
 or of the habitual use of stimulants, is very j^otent in causing 
 or increasing the delirium of fevers and inflammations, and a 
 mobile nervous system and great mental activity likewise tend 
 in the same direction. Some of these forms of delirium are 
 found in various forms of injury to the skull and disease of 
 the brain, in intoxication from alcohol and chloroform, and in 
 the poisoned state of the system known as ursemia. It occa- 
 sionally haj^pens that delirium breaks out violently after the 
 crisis of a febrile illness, having up to that time been but 
 slight in character. This can sometimes be explained by the 
 previous intemperance of the patient, but oftener perhaps by 
 aniemia of the brain resulting from a prolonged fever, or by 
 the circulation of eflfete matters in the system, poisoning the 
 nervous centres, as in ursemia. 
 
 Delirium differing considerably from the foregoing is com- 
 mon in delirium tremens. In this disease the patient is affected 
 with delusions and illusions, and is often very suspicious. He 
 is usually full of business of some kind in his delirium, driving 
 horses, hurrying off" to the station, etc., and seems to see various 
 objects distinctly, to Avhicli he calls attention ; he addresses 
 strangers as well-known friends, with whom he has had appoint- 
 ments, and gives long accounts of circumstances and trans- 
 actions which are essentially imaginary, although mixed up 
 with actual facts and correct names. Sleeplessness and trem- 
 bling are usually present. The patients often are terrified 
 by the vision of mice and rats, and even more dreadful forms 
 supposed to resemble demons. The delirium here referred to, 
 although due to the chronic use of alcohol, is, of course, quite 
 distinct from the forms of mental disturbance from recent 
 excesses. The illusions produced by certain other poisons or 
 medicines, especially hyoscyamus, may be mentioned here. 
 Belladonna also gives rise to delirium and excitement, and 
 opium and chloral in doses inadequate to procure quietness 
 for the patient often produce or intensify the excitement. 
 Salicylic acid and its compounds sometimes produce maniacal 
 delirium. 
 
 When delirium is mixed up with unmanageable conduct 
 and violence, we speak of it as mania or maniacal delirium. 
 It may be merely an exaggeration of the delirium already 
 
VEKTIGO. 267 
 
 described as symj^tomatic of fevers or of inflammations, etc., 
 but it may arise apart from these as one of the forms of 
 insanity. It apjDcars likewise, occasionally, after epileptic fits, 
 or even in cases essentially of this nature, in which no proper 
 fit is observed (epileptic mania). Mania likewise appears 
 after childbirth in various forms (puerperal mania), sometimes 
 with its usual violence and excitement ; there is often a ten- 
 dency to deeds of violence, not only as regards the patient 
 herself, but more especially as regards her infant. In its 
 further progress it may settle down to a melancholy w^hich 
 may indeed be its leading characteristic from the beginning, 
 and if much prolonged it is apt to tend to dementia. (Com- 
 pare the sections on epileptic, puerperal, and other forms of 
 mania, etc., in Chapter VIII.) 
 
 Vertigo. 
 
 Vertigo, or giddiness, and a sense of swimming, or of un- 
 dulating motion, must be considered as to whether the sensa- 
 tion is felt by the person within himself, or w^hether external 
 objects seem to wdiirl or move. We may try the effect of 
 closing the eyes as a test of this. Both forms may occur 
 separately, or they may be combined. A further point of 
 distinction is w'hether the person is perfectly conscious of the 
 fallacious character of his sensations, preserving his power of 
 reasoning correctly, or whether with the vertigo his whole 
 mind becomes confused. The usual character of the motions 
 experienced is that of whirling round either slowly or quickly ; 
 but sometimes the movements seem even more strange, articles 
 appearing to be piled up on the top of each other, or even 
 turned upside down. In slighter forms there is only the sense 
 of heaving up and doW'U, or from side to side, as if on board 
 ship, or on a suspension bridge which sways under our feet. 
 Physical conditions of this kind may indeed give rise to vertigo 
 lasting for a longer or shorter time, and rapid rotation and 
 swinging are w^ell known as determining vertigo in those 
 unaccustomed to these motions. 
 
 Vertigo appears not unfrequently in connection with slight 
 derangements of the stomach and liver, and may be associated 
 with other evidence of digestive disorders. It may thus appear 
 after alcoholic excesses as well as during the stage of intoxica- 
 tion. The use of tobacco by those unaccustomed to it, or 
 habitual excess in others, may likewise occasion vertigo. 
 Nervous excitement in many forms, anger, fear, and the pres- 
 
 22* 
 
258 SYMPTOMS OF NERVOUS DISORDERS. 
 
 ence of unaccustomed surroundings, give rise to sensations of 
 this kind, when, as we say, the person does not know " whether 
 he is on his head or his feet," 
 
 A form of stomachal vertigo, of great suddenness and severity, 
 may be recognized in certain cases where there is not much 
 evidence of gastric disorder, the name being derived from the 
 obvious effect of treatment directed to this organ, especially by 
 the use of alkalies, tonics, and nourishing diet. The vertigo 
 in such cases is often very violent, rendering progression quite 
 impossible, and not prevented by closure of the eyes. With 
 this there may be associated the idea of a yawning abyss at 
 the feet, but the patient is usually able to argue correctly as 
 to these illusions. Persons Avho have had such attacks are 
 liable to their repetition. (^Vertigo a stomacho Iceso. Trousseau.) 
 
 Vertigo, associated with deafness or noises in the ears, forms 
 a leading feature of " Meniere's disease," arising from affections 
 of the labyrinth or semicircular canals ; but similar results 
 may follow from pressure on the labyrinthine fluid from various 
 causes. (Vertigo ah aure Icesa. See "Ear," i). 189.) 
 
 A form of vertigo which is liable to be misinterpreted is 
 that which is due to weakness or paresis of the ocular muscles, 
 occurring especially in persons with an abnormal state of the 
 refraction of the eyes. Such paresis, which may not give 
 rise to any obvious squint, although there may be diplopia, 
 is apt to produce some apparent deviation of the objects looked 
 at, and it gives rise to erroneous impressions of the position 
 of objects from the unusual force exercised in adjusting the 
 eyes. Vertigo due to such causes ceases when the eyes are 
 closed, or when the one affected with paralysis is shut. (See 
 p. 169.) 
 
 Vertigo from cerebral congestion, or in connection with an 
 impending apoplectic attack, usually appears with pain in the 
 head, sickness or nausea, and other cerebral symptoms. Such 
 vertigo may be rendered worse by a full meal, or by dyspeptic 
 disorders, so that we must not set down this symptom exclu- 
 sively to the stomach on that account. In a person over fifty 
 affected with vertigo, especially if somewhat persistent although 
 not very violent, we must be on our guard against apoplectic 
 attacks, particularly if numbness in one side, or other indica- 
 tions of brain disease, are likewise present. Attacks of vertigo 
 in an extreme form are often present in cases of cerebral 
 tumor, and perhaps more particularly of cerebellar disease. 
 The vertigo inay, in some cases, account for the staggering 
 found in such cases, but is not always associated with it. This 
 
SLEEP AND SLEEPLESSNESS. 259 
 
 vertigo may lead the patient to think he is falling off the bed 
 when he is lying safely enough, and it may exist in cases 
 where blindness has occurred and where ocular causes are 
 thus excluded. Vertigo likewise constitutes a "warning" in 
 some cases of epilepsy, or may be the chief part of an attack 
 (epileptic vertigo). 
 
 Disturbance of the cerebral circulation is probably a very 
 common cause of vertigo, even when this is brought about by 
 reflex irritation from the stomach. Such disturbances may 
 also arise in feeble persons, or after fevers, etc., on suddenly 
 raising the head. A certain approach to this vertigo is com- 
 mon on getting up for the first time after a long illness with 
 confinement to the recumbent posture, or on going out to the 
 street for the first time. Vertigo is likewise a common incident 
 in cases of loss of blood in large 'quantity at one time or in small 
 quantities for a long period, and for similar reasons Ave find it in 
 profuse or chronic diarrhoea, or it may appear after these, in 
 the event of the patient rising or sitting up. Allied to vertigo 
 from anaemia due to hemorrhage, is the giddiness observed 
 from more chronic deteriorating causes, overwork, deficient 
 food, prolonged lactation, menorrhagia, leucorrhoea, etc. Occa- 
 sionally vertigo results from an apparently opposite cause — the 
 stopping of some habitual discharge. 
 
 The onset of the specific fevers and acute inflammations is 
 often characterized by vertigo, and the state of the system 
 known as uraemia may likewise give rise to this symptom. The 
 influence of alcohol and other poisons may be compared with 
 these poisoned states. 
 
 Sleep axd Sleeplessness. 
 
 Various disorders in the patient's sleep must be inquired for 
 and noted when present. There may be sleeplessness, or undue 
 tendency to sleep, or the sleep obtained may be disturbed or 
 troubled. 
 
 ^Sleeplessness may be due to accidental disturbances, such as 
 change of residence and unusual surroundings, or removal to 
 hospital, and the like. Again, it may be due to anxiety or 
 unnatural excitement and activity of the mind before with- 
 drawing to rest, and many other similar disturbances ; these 
 operate much more powerfully on some people than on others. 
 Pain is a fruitful cause of w^ant of sleep ; this pain may be 
 connected with the disease under which a patient labors, or 
 it may be, as it were, accidental — from an attack of tooth- 
 
260 SYMPTOMS OF NERVOUS DISORDERS. 
 
 ache, etc. Dyspnoea and orthopnoea may interfere with sleep, 
 owing to the inability of the jjatient to lie clown or to keep in 
 one position. Patients with serious cardiac and renal disease 
 affected in this way can only obtain brief snatches of sleep, 
 and may be seen nodding off continually into momentary 
 slumbers, as they sit up or lean their heads forward ; it may 
 be added of some of these patients that as they are never 
 properly asleep, so they are seldom thoroughly awake : they 
 sometimes awake with such feelings of alarm that they are 
 anxious to avoid sleep. (See p. 89 ; see also Chapter IX.) 
 
 Highly febrile states are usually adverse to natural sleep : 
 this arises partly from the attendant restlessness and irrita- 
 bility which, instead of getting less with the approach of night, 
 tend rather to increase ; the presence of sweating, and the dis- 
 comfort associated with it when profuse, are apt to aggravate 
 such a condition. In these cases the patient, worn out with 
 restless tossing about during the night, may obtain some sleep 
 about four or five in the morning, as the daily remission of the 
 fever becomes established. High fever and delirium combined 
 are very adverse to sleep, and may prevent any sleep for many 
 successive days and nights. The diseases in which this is most 
 marked are pneumonia, typhus, and delirium tremens, but it 
 occurs in a multitude of other diseases. Patients who are 
 intemperate in the use of stimulants, and those also whose 
 minds are usually very actively employed, either from their 
 natural disj)osition or from the character of their occupa- 
 tions, are apt to suffer most from this complication in such 
 diseases. 
 
 Mania, melancholia, and various forms of mental disorder, 
 even in its slighter manifestations, are often associated with, 
 and sometimes preceded by, marked insomnia : it often seems 
 to the patient's friends as if the mental derangement were due 
 to want of sleep. Those affected in this way may have two or 
 three hours' sleep in the course of the night, but it is almost 
 invariably during the very first part of the night that they 
 sleep, after which they lie awake, and rise up in the morning 
 in the very depth of their misery. This contrasts with the 
 sleeplessness arising from worry and anxiety which often keep 
 the victims awake for some hours, but allow them to sleep as 
 the morning wears on. When sleep is procured by narcotics 
 in cases of insanity, the patient often awakes from a long sleep 
 as wretched as if he had lain awake, or even more so. The 
 period of misery after a sleepless morning is a favorite time 
 for suicidal tendencies to manifest themselves. 
 
DISTUEBANCE OF THE SLEEP. 261 
 
 Sleeplessness is often an early indication of an impending 
 attack of delirium tremens and one of the most persistent 
 symptoms daring its continuance. Chronic sleeplessness may 
 sometimes be attributed to the abuse of alcohol; in such cases, 
 as. in regular insanity, the person may sleep in the early part of 
 the night, remaining awake after two or three in the morning. 
 The habitual use of opium, of chloroform inhalations, and of 
 chloral, begun perhaps to procure rest, is very often responsible 
 for the persistence of an aggravated form of utter sleeplessness 
 which large doses of these drugs may be quite unable to over- 
 come, although the want of them may intensify for the time 
 the patient's misery. A somewhat similar form of sleepless- 
 ness, however, may be found in hysterical patients and others 
 troubled with "nervousness" in various forms quite apart 
 from the use of such drugs or of alcohol. 
 
 Disturbance of the sleep by a rapid succession of ideas, or by 
 a whirl of incongruous or disagreeable visions, is frequent in 
 the slighter forms of delirium, and it also occurs sometimes in 
 those whose brains are overtaxed. Such sleep may leave the 
 person with a feeling as if he had been more busily employed 
 than while awake, and does not afford any sense of rest. 
 Effects of this kind are sometimes produced by the medicinal 
 use of opium and other sedatives, especially when administered 
 in unsuitable cases or in too small doses. Dreams of terror 
 which overtake the patient whenever he goes off to sleep, and 
 from which he awakes bathed in cold sweat, are common in 
 deep-seated suppurations, disease of the bones, and other 
 serious affections associated with hectic fever. These dreams 
 are sometimes so terrible that the patient struggles against the 
 approach of sleep. Less alarming or at least less persistent 
 forms of this disorder are found in " nightmare " produced 
 usually by a meal still undigested of which the person had 
 partaken shortly before sleeping. Slighter forms of this dis- 
 turbed rest are very common in various dyspeptic disorders, 
 and also in functional derangements of the liver. 
 
 The "night terrors" which cause children to waken up and 
 scream in a scared manner, quite unconscious apparently of 
 the presence of their parents or attendants, depend probably 
 on the vividness of their dreams, which are not dispelled by 
 the sight of well-known faces. 
 
 Somnambulism or night-walking, in its milder forms, is not 
 uncommon in children as a very occasional event, but it con- 
 tinues to occur frequently in some even till adult life is reached ; 
 
262 SYMPTOMS OF NERVOUS DISORDERS. 
 
 it is commoner in females than in males, and indicates a sensi- 
 tive or overwrouglit nervous system. 
 
 Undue tendency to sleep is sometimes met with, especially in 
 children, as an early indication of the action of the specific 
 fevers, scarlatina and enteric fever in particular. _ It is an im- 
 portant symptom in various head affections, in the later stage 
 of meningitis for example, and in other forms of disease char- 
 acterized by pressure on the brain. In adults with a tendency 
 to apoplectic attacks, undue sleepiness and an invincible dis- 
 position to go to sleep, especially after meals, supply important 
 warnings of an impending attack. 
 
 Great tendency to sleep is likewise a feature to be watched 
 for carefully in renal disease, as it frequently indicates the 
 approach of urasmic poisoning, and may be the jjrecursor of 
 convulsions or other serious accidents ; in this condition and 
 also in brain disease small doses of opium may produce 
 alarming effects. 
 
 A certain tendency to undue sleepiness occurs in some cases 
 of ansemia, from various causes ; a form of this, occurring in 
 children, sometimes simulates hydrocephalus (spurious hydro- 
 cephalus, hydrencephaloid). This form of disease is usually 
 associated with diarrhoea ; convulsions may supervene and 
 perplex the diagnosis even more. The flattened fontanelle, 
 the previous diarrhoea, and the pallid complexion are impor- 
 tant points in the recognition of this condition. 
 
 Exposure in cold air determines a tendency to sleep and 
 aggravates the danger arising from the drowsiness induced by 
 drunkenness. When sleepiness becomes extreme, so that the 
 patient can scarcely be roused, we approach the condition 
 termed coma. (See p. 252.) 
 
 Headache. 
 
 In studying cases of headache we must try to separate all 
 the more superficial pains and forms of disease, such as neu- 
 ralgia and toothache, and also the pains due to rheumatic 
 affections of the face or head, glandular and other swellings 
 in the neck, and affections of the bones. Sources of pain of a 
 deep-seated character exist in inflammation of the jaw, or of 
 the roots of the teeth, and in inflammations of the tympanum, 
 of the iris, of the eyeball, orbit, etc. In the case of those able 
 to express their sensations we are often guided aright by their 
 description of the locality of the pain, but when we have not 
 this assistance we are apt to be at a loss in cases of this kind. 
 
HEADACHE. 2^56 
 
 Careful testing by pressing, and if need be by probing, the 
 individual teeth and gums, trying the various spots where the 
 nerves are superficial for the tenderness so common in neu- 
 ralgia, pressure in the vicinity of the ear, an examination of 
 the eye, and moving the head in various directions — all these 
 may often guide us in our search for the cause of the pain. 
 
 Quite distinct from these various pains, headache is found 
 in the early stage of many fevers and serious inflammations ; 
 when delirium comes on, the headache disappears. Headaches 
 also occur very frequently in cases of digestive disorder, in 
 various nervous affections, especially in hemicrania or "sick 
 headache," and in many serious lesions of the brain and its 
 membranes ; headache likewise occurs from overwork and 
 prolonged mental strain, in the poisoned state of the system 
 known as uraemia, and in anaemia from prolonged suckling, 
 leucorrhoea, or other exhausting disorders. The effect of strain 
 on the eyes, from excessive use or more particularly from 
 errors in their refraction, must likewise be remembered as 
 a frequent cause of headache. (See p. 175.) 
 
 In the investigation of headache, the presence or absence of pyrexia 
 is most important; when this is ascertained to be really absent by 
 means of careful and repeated thermometrical observations, we may 
 eliminate at once the group of the fevers and many of the internal 
 inflammations. 
 
 The association of headache with sickness and vomiting, is very fre- 
 quently observed in the most diverse forms of the affection. 
 
 In febrile diseases the two symptoms go together, both being pro- 
 duced by the same cause, although often the whole illness is, at first, 
 ascribed to digestive disorder ; the furred state of the tongue may favor 
 this error. In such cases the headache is usually general. 
 
 Sometimes it is quite plain that errors in eating and drinking have 
 determined a gastric catarrh or a disorder of the liver : this often leads 
 to severe headache, which tends .to be chiefly frontal, or it may also 
 involve the back of the eyes. 
 
 In other cases, of nervous 07^igin, the headache may seem to deter- 
 mine the vomiting: in brain disorders, vomiting often supervenes 
 without any obvious gastric cause, or even without any relationship 
 to the taking of food, and perhaps with no disorder of the tongue, at 
 least at the first ; as the case goes on, especially if due to inflammation 
 of the membranes, the tongue may become extremely foul. In the 
 unilateral headache of tnigraine the nervous disturbance often shows 
 itself at first in disorders of vision, as in spectra of various kinds, and 
 then in pain on the side of the head opposite to the affected eye. Patients 
 with this disorder are liable to recurrences of the headaches : some- 
 times the pain varies from side to side' in dift'erent attacks, but usually 
 it shows a preference for the right or the left. After the headache has 
 increased in severity for a few hours, violent sickness, retching, and 
 vomiting, supervene ; the patient cannot raise the head without much 
 
264 SYMPTOMS OF NERVOUS DISORDERS. 
 
 aggravation of the suflfering; this is also increased by exposure to 
 light. After lasting for some hours, or for a whole day, or even two 
 days, the nervous disturbance passes oft". This " sick headache " is 
 often due to heredity ; other more ordinary forms of headache, par- 
 ticularly in hysterical subjects, seem also to be part of the neurotic 
 inheritance — part of the peculiar liability to nervous disorder which 
 may assume many forms, and give a troublesome persistency to this 
 symptom. Headache, with vomiting and giddiness, may indicate 
 grave disorders in the bloodvessels and circulation of the brain, with a 
 tendency to apoplectic attacks: in such cases the headache is often 
 occipital, sometimes vertical. 
 
 Headache, with some sickness and giddiness, may also arise from 
 sympathetic disturbance reflected from the digestive organs, or due to 
 irritation of an ovarian and uterine character (with dysmenorrhoea, 
 etc.) ; the sexual organs in the male may, in the same way, be responsi- 
 ble for headaches of this type. The age of the patient, the state of 
 the arteries, and the other circumstances of the case may guide us in 
 the discrimination of these from cerebral cases. Headaches due to 
 congestion of the brain are usually made worse by any approach to 
 stooping, and the patient may often be seen to keep his head as high 
 as possible ; in addition to active congestion, such as may be associated 
 with apoplectic tendencies, headaches may be due to passive congestion,, 
 as from heart disease, etc. 
 
 The headaches of exhaustion may be due to overtaxing the nervous 
 energy by study, prolonged anxiety, or fatigue, especially when con- 
 joined with unfavorable surroundings. Headaches often arise from 
 ancemia xoith imperfect nutrition of the brain tissue from want of suit- 
 able nourishment or inability to digest such food as may be taken ; 
 similar impoverishment may be brought about by long-continued losses 
 of blood from the bowel or womb, and by prolonged discharges of any 
 kind, by overlactation, or other similar drains on the system. 
 
 The influences of impure air, as from overcrowded rooms in school 
 or workshop, imperfect bedroom accommodation, or the contamina- 
 tion of sewer gas, may greatly aggravate many forms of headache, or 
 they may of themselves give rise to such disorders. Not unfrequently 
 various combinations of these influences are at work, as in the case of 
 children with a naturally eager temperament, badly nourished at home, 
 overtaxed with studies, and exposed to impure air in the school. 
 
 Poisonous ma^^grs circulating in the system from imperfect elimina- 
 tion of urea in renal disease may give rise to the form of headache 
 known as ura3mic, and this may exist and may point to grave danger 
 without an}' very notable diminution in the urinary excretion. But 
 in Bright's disease we may have headaches from increased arterial ten- 
 sion, or from some of the forms of intractable neuralgia occasionally 
 found associated with it ; at other times, the headache of Bright's dis- 
 ease may be associated with hemorrhagic and other changes in the 
 retina, and so becomes closely allied to the headache of arterial degene- 
 ration, liable to result in apoplectic attacks. Prolonged constipation 
 may give rise to headache, possibly due in part to the undue retention 
 of eflfete matters in the bowel, and to that extent it comes within the 
 class of toxic headaches. Many poisons, including some taken as food, 
 drink, or medicine, may give rise to headaches of this class, particu- 
 larly when special idiosyncrasies are kept in view. 
 
PAIN" IK THE BACK. 265 
 
 In grave structural disease of the brain, of the base of the skull, and 
 of the membranes, we have a fruitful source of severe and persistent 
 headache; meningitis, affecting the hard and soft membranes, and 
 other forms of inflammatory disease, abscesses, tumors, hemorrhages, 
 embolisms, softenings, all give rise at times to this symptom. With 
 these may be classed the deep-seated and unbearable headache of syphi- 
 litic disease, sometimes due to ostitis or periostitis, and at other times 
 to disease of the brain itself: these pains frequently present a marked 
 tendency to nocturnal exacerbations. The headache of sunstroke may 
 also be referred to, although the nature or existence of structural lesion 
 may not be very clear : headache may not only occur at the beginning 
 of the sunstroke, but may persist for months or years afterward. In 
 all the cases enumerated above, we usually have more or less sickness 
 and vomiting, or at least nausea, when the pains are severe : excep- 
 tional cases, however, not unfrequently occur where the most intense 
 headache due to meningitis, for example, may not be complicated with 
 vomiting from first to last. 
 
 In the study of cases of headache, the detection of paralysis of cer- 
 tain cranial nerves, the examination of the organs of sense, the exist- 
 ence of vertigo, noises in the ear, or flashes of light, may help the 
 diagnosis. The occurrence of disorder in the cerebral functions, of 
 delirium, excitement, or insensibility ; or the supervention of local 
 paralysis, hemiplegia, or convulsions, frequently point to the cerebral 
 nature of the disease. 
 
 Pain in the Back. 
 
 This symptom, like headache, occurs at the beginning of 
 many of the specific fevers and some of the acute inflamma- 
 tions. It is very specially prominent in the case of smallpox. 
 In rheumatic affections pain in the back is sometimes a very 
 marked feature of the com|)laint, but other joints also usually 
 show some indication of pain and swelling. In disease of the 
 spinal cord, and more especially in spinal meningitis, there is 
 often pain in the back, although it may radiate in various 
 directions, giving rise to a general " hypersesthesia." Pain in 
 the neck, often associated with retraction, is a notable feature 
 in cerebro-spinal meningitis, although it occurs in cerebral 
 meningitis also. Pressure over the various vertebras, and the 
 effect of heat and cold to the spine, should be tried in such 
 cases. The sense of coostriction, as if by a cord, is likewise 
 common in spinal diseases. (See p. 201.) 
 
 Pain in the lumbar region is often designated " lumbago ; " 
 such an affection may be rheumatic, gouty, or neuralgic. 
 Many cases, however, carelessly set down as lumbago, are 
 often due to much more serious ailments, especially to disease 
 of the kidney, renal calculus, etc. Affections of the bladder 
 also sometimes give rise to pain in this situation. Pain in the 
 lumbar and sacral region is a very common feature in inflam- 
 
 23 
 
266 SYMPTOMS OF I^EKVOUS DISORDERS. 
 
 mations, flexions, and various affections of the womb, or other 
 disorders of the female organs. (See Chapter XV.) 
 
 Caries of the vertebrae, with or without incipient abscess, 
 and aneurism of the aorta are frequent sources of severe and 
 intractable pain of a most puzzling character, as the pain may 
 exist for a long time before definite evidence of their presence 
 can be ascertained : malignant tumors may also cause pain 
 for a long time before their presence can be recognized. Care- 
 ful search, however, should be made for indications of these 
 diseases, and the possibility of their presence must be remem- 
 bered in obscure cases. 
 
 Auscultation and Percussion of the Head. 
 
 Auscultation of the head has been practised chiefly in the 
 case of children. A systolic bruit may often be thus heard in 
 infancy : but it is now quite certain that its presence is of no 
 importance in the diagnosis of meningitis or hydrocephalus. 
 It seems, indeed, to be more frequent in rickets than in any 
 other condition, the unclosed fontanelle having probably more 
 to do with the phenomenon than anything else : anaemia, 
 however, has been supposed to be a determining influence 
 also. 
 
 The stethoscope may be applied lightly over the fontanelle 
 in this examination : or a towel or handkerchief may be ap- 
 plied to the infant's head and direct auscultation practised 
 without risk of hurting the child. The student must remem- 
 ber that respiratory sounds are transmitted sometimes very 
 loudly to the ear of the observer during such auscultation, as 
 well as various other adventitious sounds. 
 
 Percussion of the skull has been of late years practised with 
 some advantage. The point of the fiijger is made to strike 
 the skull somewhat sharply in various regions : symmetrical 
 spots are selected for the sake of comparison, and of course as 
 nearly as possible the same force must be used in making the 
 strokes. It is found that in some lesions of the brain, par- 
 ticularly in those of limited extent involving the cortex or 
 membranes, a very distinct area of tenderness can sometimes 
 be made out. This may guide the diagnosis, and in conjunc- 
 tion with localized motor or sensory disturbances may assist 
 us in defining the exact locality of the lesion : as already 
 stated, it may also afford us some indication of its superficial 
 character. 
 
 In the study of this method it is essential, especially in view 
 
BIBLIOGEAPHY. 267 
 
 of any proposed operations, that an accurate idea be formed 
 as to the position of the convolutions, and in particular of 
 those which concern the movements of the face and limbs. 
 Ordinary anatomical works, even when the convolutions are 
 delineated in relation to the sutures, afford only a vague guide 
 to the clinical inquirer, as the sutures are of course usually 
 quite hidden, and the variations in form of individual heads 
 are considerable. An important contribution to the definite 
 localization of the convolutions has been made by Dr. Robert 
 W. Reid, who gives detailed directions for the measurements 
 required on the living subject.^ 
 
 The practice of this method of ascertaining the presence of 
 tenderness on percussion has brought out certain alterations- 
 in the sounds thus produced. Dr. Wm. Macewen has called 
 the attention of the writer to this subject, and it seems quite 
 certain that in cases with considerable effusion in the ven- 
 tricles, usually with enlargement of the head, a peculiar quality 
 of percussion sound is obtained in the case, for example, of 
 children with cerebral tumors. The alteration is not always 
 equally marked on the two sides. How far these alterations 
 are due to distention of the cavities of the brain and thinning 
 of their walls, and how far to changes in the bones, cannot as 
 yet be formulated : the method seems, however, worthy of 
 notice here as a guide to its further study. 
 
 The list of works enumerated here should be supplemented by many 
 of those mentioned in last chapter on the or2:ans of sense and by some 
 of those which will be found at the end of Chapter VII. on electrical 
 instruments ; in particular, the great work of Duchenne, De Pelectrisa- 
 tion localisee, Seed., Paris, 1872: portions of this have been trans- 
 lated by Dr. Puore for the New Sydenham Society, London, 1883. 
 For books on insanity and general paralysis, see Chapter VIII. 
 
 Eoss (James), Treatise on the Diseases of the Nervous System, 2d ed,, 
 2 vols., London, 1883 : this edition is of special value, as it gives copi- 
 ous references to the literature of the subjects discussed : but the work 
 is also issued in an abridged form in one volume: Eoss, Handbook of 
 the Diseases of the Nervous Sj^stem, London, 1885. — Ziemssen's Cy- 
 clopedia, vols, xi.-xiv., London, 1876-78, contains a series of very 
 important articles ; for example, on " Diseases of the Peripheral Nerves 
 and of the Spinal Cord," by Erb, and on " Disturbances of the Speech," 
 by Kussmaul, etc. — Eeynolds's System of Medicine, vol. ii., 2d ed., 
 London, 1872, contains the articles on nervous disease. — Trousseau, 
 Clinical Medicine, vol, i., as issued by the New Sydenham Society, 
 London, 1868, contains his lectures on nervous diseases : these may be 
 
 1 " Obserrations on the relation of the principal fissures and convolutions of the cere- 
 brum to the outer surface of the scalp."— Lancet, September 27, 1884. One of his dia- 
 grams is reproduced in Dr. Stirling's translation of Landois's Physiology, vol. ii. 
 p. 934. 
 
268 SYMPTOMS OF NEKVOUS DISOKDERS. 
 
 recommended to the student as extremely interesting clinical descrip- 
 tions, although, of course, now somewhat antiquated in their path- 
 ology. — Quain's Dictionary of Medicine, London, 1882, may be con- 
 sulted for short articles, usually of much value, on special nervous 
 diseases. 
 
 In addition to the above cyclopedic works, the following deserve 
 special attention : Gowers (W. R.), Lectures on the Diagnosis of Dis- 
 eases of the Brain, London, 1885: The Diagnosis of Diseases of the 
 Spinal Gord, 4th ed., London, 1884 : Epilepsy and other Chronic Con- 
 vulsive Diseases, London, 1881: Pseudo- Hypertrophic Muscular 
 Paralysis, London, 1879: Medical Ophthalmoscopy, 2d ed., London, 
 1882 : A Manual of Diseases of the Nervous System is also announced 
 as in the press. — Charcot (J. M.), Lectures on Diseases of the Nervous 
 System, New Sydenham Society, 2 vols., London, 1877-81 : Lectures 
 on the Localization of Cerebral and Spinal Diseases, New Sydenham 
 Society, London, 1881 : Iconographie de la Salpetriere (Bourneville), 
 Paris, 1876-81. — Wilks (S.), Lectures on Diseases of the Nervous 
 System, 2d ed., London, 1883. — Hammond (W. A.), Treatise on Dis- 
 eases of the Nervous System, 7th ed., London, 1881. — Axenfeld (A.), 
 Traite des Nevroses, 2e ed. (augmentee par Huchard), Paris, 1883. — 
 Althaus (J.), On Sclerosis of the Spinal Cord, London, 1885. — Buz- 
 zard, Clinical Lectures on Diseases of the Nervous System, London, 
 1882. 
 
 For nervous diseases in childhood, special reference may be made 
 to Eilliet et Barthez, Traite Clinique et Pratique des Maladies des 
 Enfants, 3e ed. (par E. Barthez et A. Sanne), tome i., Paris, 1884. 
 — Gerhardt's Handbuch der Kinderkrankheiten, Bd. V., Tubingen, 
 1880. 
 
 For alcoholic paralysis, see Oettinger, Etude sur les Paralysies Al- 
 cooliques (These No. 183), Paris, 1885: also Broadbent, Medico- 
 Chirurgical Transactions, vol. xlix., London, 1884: Dreschfeld, 
 Brain, 1884 and 1886. — For other special forms of nervous disease and 
 some of the newer symptoms, references to the periodical literature 
 are required. 
 
CHAPTER VII. 
 
 ELECTEICAL INSTKUMENTS IN DIAGNOSES. 
 
 Three very different forms of electricity have to be recog- 
 nized in medicine : all three are used at times in treatment : 
 the student should therefore be familiar with the appearance 
 of the various kinds of electrical apparatus and with the 
 principles of their action. The word " electricity," and com- 
 pounds made up from it, must be kept as general terms includ- 
 ing all the varieties. 
 
 From the scope of the present work only the use of the 
 instruments in diagnosis will be considered : the subject is thus 
 much curtailed. 
 
 I. The Franklinic (or Static) form of electricity is de- 
 veloped by the ft'ictional excitation of plates or cylinders 
 of glass on appropriate cushions. By such instruments a 
 patient can be charged with positive or negative electricity if 
 properly insulated on a stool with glass legs, or some efficient 
 non-conductor ; sparks can then be drawn out or passed into 
 various parts of his body. Leyden jars can also be charged 
 in this way. Although furnishing the means used in the oldest 
 methods of electrical treatment, and although it- seems to be 
 coming again into more notice of late years for the treatment 
 of disease, this form of electricity has no recognized place in 
 the practice of diagnosis. It is, therefore, mentioned here 
 simply to avoid any confusion of ideas which might result 
 from its omission. 
 
 II. The galvanic form of electricity is also often spoken 
 of as Voltaic, and from its being excited by the juxtaposition 
 of dissimilar metals associated with chemical action it is 
 also sometimes named contact electricity. The arrangement 
 for producing this form of electricity consists of " a pair " 
 of dissimilar metals and some appropriate exciting material 
 contained in " a cell," the whole of this arrangement being 
 named " an element." These elements are of the most varied 
 character as regards the nature of the metals and as regards 
 the nature of the excitant, as well as its mode of application 
 to the metals by single or double cells ; there are also great 
 differences as regards the kind and degree of chemical action 
 
 23* 
 
270 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 which goes on, and also of course as regards the actual size of 
 the elements. The names and composition of some of the 
 common elements will be indicated hereafter. A number of 
 such elements, connected by suitable wires in series, constitutes 
 
 Galvanic battery supplying the "continuous current: " 20 elements (E) arranged in 
 series ; the terminal conducting wire leading up to the negative pole (N) is shown ; 
 there are other wires (F), at stated intervals going to the studs in the dial collector (M) 
 for making connection with the positive pole (P) A galvanometer (G) is included. 
 
 a " galvanic battery " (or Voltaic pile), and the electricity ob- 
 tained thereby is spoken of as the galvanic current, or very 
 often as " the primary battery," " the constant current," or 
 " the continuous current," — these names being designed to dis- 
 tinguish it from the next form of electricity. The strength of 
 such a bjittery depends on the nature of its elements and on 
 the number of these called into play — 10, 20, 40, etc., as the 
 case may be. (See Fig. 38.) 
 
 III. The faradic form of electricity is the name applied to 
 the induced currents obtained in a coil when this is excited 
 by the influence of a galvanic current or of a magnet more 
 or less suddenly brought into relationship with it or removed 
 
FARADIC ELECTRICITY. 271 
 
 from it. This arrangement of galvanic current (or magnet) 
 and coil is called an induction apparatus : as the currents are 
 only produced when the influence of the current or magnet 
 is begun or stopped, some form of interruption is esseritial, and 
 
 Fig. 39. 
 
 Faradic battery. Electro-magnetic form, supplying the "interrupted current:" 
 there are two elements (E and E') and two coils : the inner coil h, the outer H. (An 
 extra coil is shown at H', which can be substituted for the other, H.) 
 
 so the term interrupted current is often applied to it in 
 medicine. 
 
 Two varieties of instruments for producing this form of 
 electricity are named according to the way it is produced. 
 1. If the current is induced in the coil by the action of a 
 galvanic current which passing through it induces a current 
 in the coil, and at the same time magnetizes a piece of iron 
 inserted into the centre of the coil so as to intensify these in- 
 duced currents, we speak of this arrangement as an " electro- 
 magnetic battery." . (See Fig. 39.) 2. If the excitation is by 
 a magnet which, by mechanical action, is made alternately to 
 act, or cease to act, on the coil we speak of this as a " magneto- 
 electric machine:" the common cheap rotatory machines, 
 with fixed horseshoe magnets and a pair of bobbins or coils, 
 are familiar to all as being sold for medical purposes.' (See 
 Fig. 40.)^ The powerful " dynamo " now used so much for 
 electric lighting is a specimen of the same kind of apparatus. 
 
 The essential points in all faradic batteries are the presence 
 of a coil and arrangements for interruptions (even a magnet 
 is not essential, although required in all batteries for medical 
 
272 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 purposes to intensify the current induced in the coil). Accord- 
 ing as the current is from the inner or outer coil of such a 
 battery we speak of the " primary induced current " or the 
 
 Fig. 40. 
 
 Faradic battery, magneto-electric form. The fixed horseshoe magnets, the two bobbin- 
 lilve coils, and the arrangement for interruption by rotation are shown. 
 
 " secondary induced current : " or the current from the first or 
 second coil of an induction apparatus. 
 
 Galvanic Batteries. 
 
 For medical purposes, certain points in the construction of batteries 
 come to be important. For example, we cannot introduce cells with 
 fuming nitric acid into the chambers of the sick, and a certain degree 
 of portability in the battery is often essential in medical ap]>lications. 
 Constancy in the strength of the current is also important, but as the 
 applications at any one time are not usually very prolonged, this is of 
 less consequence. More important is it to have batteries which are 
 not very apt to go wrong, or, at least, which can be easily repaired. 
 A general concensus of opinion points to the "Leclanchd element" as 
 the most suitable, on the whole, for medical batteries ; there are no 
 corrosive fluids used, and but little di.eagreeable gas evolved ; the ad- 
 dition of a little water is usually all that is required for a long time 
 in attending to the cells, and the battery, although long disused, may 
 usually be found quite ready for action without preliminary prepara- 
 tion of any kind. 
 
 A battery consists of a group of elements joined together by connect- 
 ing wires, usually in series, so that the zinc plate of the one element 
 
GALVANIC BATTEKIES. 273 
 
 is connected with the carbon (or other equivalent) plate of the next ; 
 the terminal plates of the whole series are connected with two con- 
 ducting wires and handles for the application of the current, the posi- 
 tive and negative poles respectively. The current may be best conceived 
 of as starting from the zinc plate (or the one most easily acted on by 
 the exciting fluid), then passing through the fluid to the carbon, 
 platinum, silver, or copper plate (or the one less easily acted on), and 
 from this point through the wires, when (by means of some conductor) 
 the circuit is made complete by joining the terminal plates, and so 
 back to the zinc plate again to resume its circuit as before ; the same 
 circuit goes on through any number of elements which may Rearranged 
 in electrical connection. 
 
 The current is thus from the zinc to the carbon within the cell ; but 
 from the carbon to the zinc, through the conducting terminal wires, 
 outside of the cell or batter3^ Some confusion is apt to arise from 
 this distinction; the zinc plate being spoken of as the "positive 
 metal;" the copper, silver, platinum, or carbon being the "negative;" 
 whereas the terminal of the last zinc is the " negative pole," and the 
 terminal of the last copper, carbon, etc., is the "positive." To dis- 
 tinguish which is which in a given battery, we may look to see with 
 which of the metals the conducting wire or the terminal is connected, 
 if the mechanism is exposed to view ; sometimes, however, the arrange- 
 ment is hidden. "We may, of course, ascertain which is the positive 
 pole by means of a galvanometer. In the absence of this, the chemi- 
 cal reactions by which hydrogen and metals are liberated at the nega- 
 tive pole, and acids, etc., at the positive, may be readily applied. 
 Iodide of potassium solutions (with or without admixture of starch) 
 are usually at hand ; on dipping the two wires from a battery into 
 such a solution in a suitable dish, the iodine can be readily recognized, 
 if the circuit is complete, appearing at the positive pole, with its 
 peculiar color. The term anode is applied to the positive pole, or 
 sometimes the mark -|- is used ; the term kathode or cathode and the 
 sign — are used for the negative pole. 
 
 In some forms (Grove, Bunsen, Daniell) the two metals are enclosed 
 in separate cells, usually with diff'erent fluids ; the inner cell is made 
 of porous earthenware; this allows of a certain interchange of fluids, 
 and prevents the deposition of bells of hydrogen on the platinum, 
 carbon, or copper plates by an oxidizing process due to the fluid there. 
 When there is only one fluid for the two metals, the strength of the 
 current undergoes a rapid diminution during the period of its being 
 in action. A form of JBunsen's element has been devised by Stohrer 
 with only one exciting fluid, oxidation being obtained by the intro- 
 duction of chromic acid into the centre of the carbon cylinder. 
 
 The "collector," by which we can call into play a smaller or 
 larger number of the elements comprised in the battery, is often in 
 the form of a dial. The diagram {Fig. 38, N, F, and M) indicates 
 how a wire is carried up from the last zinc plate of the series to one 
 of the terminals for the conducting wire representing the negative 
 pole ; while a series of connecting wires are led up, at stated intervals, 
 to the studs marked with the numbers ; this stud can be brought into 
 electrical contact at the will of the operator, by means of a rotating 
 handle, with the terminal for the positive pole; many other devices 
 are resorted to for the same purpose. 
 
274 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 Electrical Units. — The power of a cell is estimated by the amount 
 of work it can do ; this can be ascertained in various ways (say by the 
 decomposition of water), and for the purposes of comparison units are 
 established The "electro-motive force" of a Daniell's cell newly 
 chartred (with sulphuric acid 1 to 11) may be regarded as very near 
 the British Association standard or unit of electro-motive force; this 
 unit is called a " volt." Some elements have an electro-motive force 
 more than such a Daniel), and others less ; this depends on the rela- 
 tionship to each other of the special metals used, and on the strength 
 of the exciting fluid even in cells of the same construction, but the 
 mere size of the elements does not aftect the amount of electro-motive 
 force or " potential" indicated in volts. The accompanying table may 
 be found useful as a guide in judging of the relative power of batteries 
 with different elements. 
 
 Resistance. — The strength of current obtainable from a battery, 
 however, depends not only on the number of " volts " thus at our dis- 
 posal, but on the resistance they have to encounter. This is of two 
 kinds — the resistance within the battery, and the resistance outside of 
 the battery. The resistance outside may again be divided, in connec- 
 tion with medical uses, into the resistance presented by the conducting 
 wires and handles, which is usually so slight as to be ignored, and the 
 resistance of the human body (or the part of the body) placed in the 
 circuit; this, although variable, is always very great (estimated at 
 1200 or 1500 ohms, or more by some authorities, even after careful 
 moistening of the skin). The resistance within the battery can be 
 measured by electricians by special methods which need not be ex- 
 plained here. All forms of resistance are expressed in units of resist- 
 ance termed Ohms. This is represented by a column of mercury of 
 definite dimensions, or, in practice, by a coil of wire of definite length 
 and thickness. 
 
 Ohm\s Laiv. — The strength of the current is represented by the num- 
 ber of "volts" or the electro-motive force, divided by the total 
 amount of resistance or "ohms." Or, if we use symbols, C^ Cur- 
 rent ; ^= Electro-motive force ; R = Kesistance ; we have, according 
 to Ohm's law, " the current is equal to the electro-motive force divided 
 by the resistance," 
 E 
 
 Unit of Quantity. — The unity of quantity, or the current produced 
 by a "volt" through an "ohm," is called an ampere (formerly a 
 Weber). 
 
 If the question of time be introduced along with the quantity, one 
 ampere in a second is called a coulomb. 
 
 Some confusion still exists from changes in the nomenclature as 
 regards the " weber," " ampere," and " coulomb." 
 
 Accessory Apparatus. 
 
 Oalvanometer. — The strength of the current may be measured with 
 considerable accuracy by means of galvanometers specially graduated 
 from standards for this purpose. (The ordinary "tangent galva- 
 nometer," often supplied with batteries, is useful as determining the 
 
VARIOUS GALVANIC ELEMENTS, 
 
 275 
 
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276 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 passage of a current — showing, therefore, the activity of the battery, 
 the soundness of the connections, and the direction of the current, but 
 in no sense indicating its strength.) In a "dead beatJ' galvanometer 
 the needle comes rapidly to a stationary point and so is to be preferred 
 in practice. 
 
 The division into the 1000th part of the unit is the " milliampere " 
 of de Watteville, and regarded by him as most convenient for medi- 
 cal purposes; 5, 10, 20 milliamperes are estimated as equivalent to 10, 
 30, or 80 Daniell's elements, if the conditions under which they are 
 used are similar, the resistance to be overcome being in the circuit. 
 
 Rheostat. — Resistance is measured by " ohms." An instrument fur 
 introducing resistance into the circuit is called a "rheostat." The 
 resistance may be graduated roughly by sliding up and down a metal 
 rod, through varying quantities of water or salt water contained 
 within a suitable tube, the bottom of the tube and the sliding rod 
 being both in electrical connection with the terminals of the battery 
 (water rheostat) ; more accuracy is obtained by using coils of wire of 
 detiriite length, etc., with known powers of resistance; more recently 
 plumbago has been utilized for this purpose. As the current strength 
 depends on the " electro-motive force divided by the resistance," it is 
 clear that the strength may be varied (1) by increasing or diminishing 
 the number of " volts " (or practically by varying the number of ele- 
 ments brought into play); or (2) by diminishing or increasing the 
 number of "ohms" of resistance by means of a rheostat interposed 
 in the circuit. We may in this way use the full strength of a large 
 battery (say of 80 or 100 elements), and vary the strength in the ap- 
 plication by using more or less resistance, the resulting current strength 
 or dose being measured by a suitable galvanometer. 
 
 The resistance of the parts of the human body to which the appli- 
 cations are made is so enormous, as compared with the resistance 
 within the batteries we use or in the conducting wires and handles, 
 that it assumes great importance in relation to the strength of current 
 required in medical work. The main part of the resistance is in the 
 skin itself; this is very greatly lessened by complete moistening with 
 simple water, and especially lukewarm ^alt water; but even when 
 this moistening is carefully done, the individual resistance in the body 
 of one patient may be found to vary much from that of another. 
 
 The Conductiag Wires or Rheophores. — The amount of resistance 
 presented by the conducting wires varies according to their length, 
 thickness, and composition. As it is desirable to eliminate sources of 
 confusion and make comparisons easier, Erb's standard patterns are to 
 be recommended. 
 
 The handles or electrodes require to be of various sizes for applica- 
 tions in different situations. VVe sometimes require tine-pointed 
 handles, and at other times large flat electrodes for application to the 
 sternum or back. Erb's standards are termed "fine" = ^ cent, in 
 diameter; "small" = lj to 2 cent.; "medium":=4 to 5 cent. ; 
 " large "^5 or 6 X 10 or 12 cent. It is a matter of great impor- 
 tance that some of our handles should be furnished with an interrupter 
 for making or breaking the circuit without any further trouble on our 
 part than pressing a spring; the reactions obtained only on opening 
 or closing the galvanic current can thus be critically watched. It is 
 necessary to have the electrodes covered with some material capable 
 
FARADIC BATTERIES. 277 
 
 of absorbing water, as this is required to favor the conduction through 
 the skin. 
 
 A co'm7nutator for stopping the current, and for suddenly reversing 
 it, should also be part of the apparatus in a battery for medical diag- 
 nosis. In this way the poles can be changed without shifting the 
 electrodes. 
 
 Faradic Batteries. 
 
 Of the two forms already mentioned, the one with a galvanic ele- 
 ment and the other with a fixed magnet, it may be said that the former 
 is much the more serviceable instrument, both for diagnosis and treat- 
 ment ; it simply requires to be started by the operator, and it permits 
 of much more precise regulation of the strength. The second forn:i, 
 unless driven by clockwork, requires some one to turn the handle, so 
 as to allow the operator to have his two hands free ; it is less under 
 his control, and the current is very apt to be variable and at times 
 disagreeably painful, from sudden accessions of strength; on the other 
 hand, such an instrument is less liable to be out of order if left unused 
 for long periods. 
 
 The current induced in the inner coil of an electro-magnetic appa- 
 ratus at the making or closing of the galvanic circuit is in the oppo- 
 site direction to that which comes from the galvanic element itself; 
 this current induced in the inner coil is called the " extra-current" by 
 physicists ; its strength on the making of the galvanic current is thus 
 diminished, so far, by the strength of the current from the element 
 itself which is in the opposite direction ; on the breaking of the circuit 
 there is no such deduction from the strength of the current thus in- 
 duced. Although in medical batteries it is called the primary current, 
 it must always be borne in mind that it is really a current induced in 
 the coil. The presence of induced currents in the inner coil gives 
 rise, by induction, to currents in the second or outer coil — alternately 
 in opposite directions — on their instantaneous occurrence and cessa- 
 tion ; the current from the second or outer coil is called the secondary 
 current. 
 
 The terminals from such induction coils transmit, therefore, cur- 
 rents in alternately opposite directions in rapid succession, and so we 
 might suppose that the original difference in the current from the 
 positive and negative poles of the element would be lost, and that no 
 distinction in the poles of an induction apparatus could exist. It 
 seems, however, that there is a difference ; this can be well shown by 
 reversing the poles of a powerful battery in connection with G-eissler's 
 vacuum tubes when the change of color at the poles becomes apparent. 
 The difference can even sometimes be felt in the physiological action 
 of the two poles on the muscles, by grasping in each hand the elec- 
 trodes of an induction apparatus. It is well, therefore, to preserve 
 the distinctive names of the poles, even in such batteries. Special 
 arrangements have been devised in medical batteries for obtaining 
 the induced current always in one direction ; in such batteries, of 
 course, the positive and negative poles are quite distinguishable. 
 (The uni-direction battery of Dr. Dixon Mann, made by Mottershead 
 & Co., Manchester. "1 
 
 24 
 
278 ELECTRICAL INSTRUMENTS IN" DIAGNOSIS. 
 
 The proper regulation of the strength of current in an induction 
 apparatus is a matter of the utmost consequence both in diagnosis and 
 treatment. The arrangement by sliding the coil along is one of the 
 best methods ; in proportion as the outer coil is brought near the mag- 
 net (in the centre of the inner coil) the currents in the outer coil are 
 intensified. (See Eig. 41.) Pushing in or drawing out the magnet 
 
 Fig. 41. 
 
 Induction coils, with sledge arrangement, for regulating the strength of current, and 
 a graduated scale : LeA'er (L) for giving single shocks. Such coils may be driven by a 
 bichromate or a Leclanche element. 
 
 or bar of iron within the inner coil increases or weakens the current 
 in both coils. Another method sometimes employed is by the appli- 
 cation of a copper cylinder surrounding the inner coil, the strength 
 being lessened as this cj-linder is drawn toward the magnet within 
 the inner coil. These sliding arrangements are usually graduated so 
 as to afford a rough gauge of the strength of the current employed at 
 a given time. The strength, however, depends also on the exact con- 
 dition in which the element or elements happen to be at the moment 
 of using the battery. 
 
 The rapidity of the interruptions is likewise important, and they 
 also affect, so far, the strength of the application ; they are controlled 
 by screws and springs. For diagnostic purposes arrangements for 
 obtaining single i^hocks are often of value: this can be done roughly 
 by interposing the finger against the movements of the hammer, but 
 special devices exist in some instruments for this purpose. (See Fig. 
 41, L.) 
 
 Of course, a rheostat may be used as in galvanic batteries for inter- 
 posing graduated resistance and so regulating the strength of the cur- 
 rent as ajjplied. As yet, no accurate estimate of the exact strength of 
 induction currents is available in medical batteries. Scientifically 
 "the capacity defined by the condition that a coulomb charges it to 
 the potential of a volt is called 2^ farads 
 
 The strength of an induction apparatus depends on the number and 
 strength of the elements by which it is excited: on the length and 
 fineness of the wire in the coils and on the size and construction of the 
 
OBJECT OF ELECTRIC TESTS. 279 
 
 bar of soft iron or wires magnetized within the inner coil. For diag- 
 nostic purposes a powerful instrument is desirable in case such may 
 be required. 
 
 Object of Electrical Tests. 
 
 We aim at ascertaining the condition of the nerves and 
 muscles in their relationship to electrical stimuli. It is the 
 peripheral nervous apparatus to which the tests are applied 
 and concerning which definite statements can be made ; but 
 we are enabled by inferences from these results, and from our 
 pathological knowledge, to judge at times of the condition of 
 the central portions of the nervous system also. 
 
 Sensory Nerves. — The nervous system may be explored as 
 to its sensory and motor integrity in transmitting electrical 
 stimuli. The sensory impression conveyed from the applica- 
 tion of the faradic current corresponds very well with what is 
 termed " common sensation," especially with painful impres- 
 sions, and the peculiar tingling produced by this excitation 
 may be perceived as affecting not merely the terminal nerves 
 if these are locally stimulated, but the terminal nerves dis- 
 tributed from the nerve thus excited. The method of testing 
 will be referred to presently. With the galvanic current, we 
 have, in addition to a true electrical stimulation of the sensory 
 fibres affected by the poles, an irritation from chemical action 
 in the skin going on under the electrodes. 
 
 Motor Nerves. — The great nerve trunks and plexuses may 
 be explored as to their power of transmitting motor impulses 
 on electrical stimulation, and we may be able thus to see the 
 muscles animated by the branches from such nerve trunks 
 contracting actively, or we may see certain muscles, supplied 
 by certain branches, remaining inactive, in the event, for ex- 
 ample, of an injury involving such branches. 
 
 Motor Points. — The muscles are found to be readily stimu- 
 lated by the excitation, with either current, at the point of 
 entrance of the nerve. These are the " motor points " studied 
 by Ziemssen and so important in the practical application of 
 electricity. A normal response thus obtained, shows the in- 
 tegrity of such terminal branches entering the muscle so far 
 at least as the transmission of electrical stimuli is concerned. 
 
 Muscles. — The muscular system, however, may be acted on 
 directly by galvanic stimuli — individual fibres being excited 
 by the application, even ajoart, apparently, from any nervous 
 influence. But the preservation of the nutrition and func- 
 tional activity of the muscle dejoends very much on the pre- 
 
280 ELECTEICAL INSTRUMENTS IN DIAGNOSIS. 
 
 servation of nervous connections, and so the presence or ab- 
 sence of muscular action, even in a case of injury to the 
 nerve, enables us to judge, so far, of the profoundness of the 
 disturbance thus brought about. Reactions can be obtained 
 in paralyzed muscles on the application of powerful galvanic 
 currents so long as the muscle is not hopelessly atrophied. 
 
 Central Nervous System. — The central nervous system is less 
 available for electric exploration, but certain lesions at the 
 anterior cornua, where the motor roots emerge, come practic- 
 ally to resemble lesions of the motor roots, or the motor fibres 
 of the nerves themselves. On the other hand, lesions in the 
 brain, although producing profound paralysis, leave the nerves 
 quite capable of transmitting electrical stimuli for a long time. 
 Hence the presence and absence of perturbations in the elec- 
 trical reactions may, at times, be used for inferring the exist- 
 ence or non-existence of a central lesion. 
 
 Method of Testing. 
 
 Polar Method. — In aj^plying tests for diagnostic purposes, we 
 try the two poles separately, and, as a rule, we begin with the 
 negative pole or kathode : this applies even to the use of faradic 
 batteries ; with them we use the secondary current. By means 
 of a commutator, the current, of course, can be reversed with- 
 out disturbing the position of the electrodes. The other pole 
 is applied by preference in the form of a flat electrode of large 
 size, duly moistened, and held firmly by the hand of the 
 patient, or by some other contrivance, over a mesial part of 
 the body, such as the sternum, the nape of the neck, or ab- 
 domen. The first two are generally preferred : over the 
 sternum the patient may hold the plate pretty equably him- 
 self: or by a little padding between it and his clothes it may 
 be properly adjusted and retained: or at the neck a knitted 
 worsted band affords the desirable elasticity, or other contriv- 
 ances may be resorted to. These situations are selected as 
 being indifferent or remote, and as being equal for both sides 
 of the body in comparative tests. 
 
 Nerves. — For testing the nerves of sensation we use for the 
 part to be tested an electrode in the form of a wire brush. 
 Erb has devised an electrode having a similar effect, from a 
 multitude of conducting points, without the mechanical irrita- 
 tion of the wire fibres in the brush. This form of application 
 requires, of course, no moistening of the skin. The faradic 
 current is usually employed for such purposes, and we measure 
 
METHOD OF TESTING. 
 
 281 
 
 by the sliding scales already mentioned the strength required 
 to cause a distinct sensation, however slight, and the strength 
 which gives rise to actually painful impressions. When the 
 
 Abductor minimi digiti, 
 
 Flexor brevis minimi digiti... 
 Opponens minimi digiti , 
 
 Lumbricales (2, 3, and 4).. 
 
 Fig. 42. 
 
 Branch of the median nerve 
 for the pronator teres 
 
 Palmaris longus 
 
 Flexor carpi ulnaris 
 
 Flexor sublimis digitorum 
 (middle and ring fingers).... 
 
 Ulnar nerve 
 
 Flexor sublimis digitorum 
 (index and little finger 
 
 Deep branch of ulnar nerve... 
 Palmaris brevis 
 
 Flexor carpi radialis. 
 Flexor profundus digitorum. 
 
 -Flexor sublimis digitorum. 
 
 . Flexor longi;s pollicis. 
 . Median nerve. 
 
 ^^ »---^^ Abductor pollicis. 
 
 , Opponens pollicis. 
 
 ^^^^i--..^- Flexor brevis pollicis. 
 
 -«■ 4 ^^^^^^fr— -^— Adductor pollicis. 
 
 7^^H^ft*— \ -.- Lumbricalis (1st). 
 
 Ziemssen's motor points. 
 
 two sides can be compared in unilateral disease, we have in 
 this method a pretty reliable basis for ascertaining the degree 
 of impairment. No absolute standard can, however, be laid 
 
 24* 
 
282 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 down, and the strength perceived as painful no doubt varies 
 much in individual cases even in health. 
 
 In applying such tests, with strong currents at least, mus- 
 cular contractions may be produced, and the patient may have 
 
 Fig. 43. 
 
 Supinator longus 
 
 Extensor carpi radialis longior. 
 
 Extensor carpi radialis brevior 
 
 Extensor communis digitorum. -| 
 
 Extensor indicis --. 
 
 Extensor indicis and extensor f 
 
 ossis metacarpi pollicis ( 
 
 Extensor ossis metacarpi pollicis 
 
 Extensor primi internodii pollicis. 
 Flexor longus pollicis 
 
 Dorsal interossei. 
 
 Extensor carpi ulnaris. 
 
 Extensor minimi digiti. 
 
 Extensor indicis. 
 
 Extensor secundi internodii pol- 
 licis. 
 
 _. Abductor minimi digiti. 
 
 Dorsal interosseus (4). 
 
 Ziemssen's motor points. 
 
 the sense of this contraction in the muscles in addition to the 
 sensation in the cutaneous nerves. This is termed electro- 
 muscular sensibility ; it varies considerably in degree in certain 
 cases. 
 
NERVES. 
 
 283 
 
 The motor nerves are tested with both galvanic and faradic 
 currents. The anode is applied, as before, in the form of a 
 large plate over the sternum or at the nape of neck. The 
 kathode is applied in the form of a " small " or " fine " elec- 
 trode, according to the size of the nerve explored. In this 
 case the electrodes must be thoroughly moistened by frequent 
 dipping : with the galvanic current warm salt water or weak 
 acid is preferred as greatly favoring the conduction : Avith the 
 faradic battery simple water is sufficient. Not only the elec- 
 
 FiG. 44. 
 
 Anterior crural nerve.. 
 Obturator nerve 
 
 Sartorius 
 
 Adductor longus 
 
 Branch of crural nerve to 
 quadriceps extensor cruris 
 
 Grureus 
 
 Branch of crural 
 vastus internus 
 
 Tensor fafsciaa femoris (branch 
 of superior gluteal nerve). 
 
 Tensor fasciae femoris (branch 
 of crural nerve). 
 
 -Kectus femoris. 
 
 Vastus externus. 
 
 Vastus externus. 
 
 Ziemssen's motor points. 
 
 trodes, but the skin also where they are applied, should be 
 well moistened or soaked. Any difference in this respect may 
 give rise to the appearance of a difference in the electrical 
 reactions when really there is none. The region of the nerve 
 trunk where it is most superficial is selected by preference, and 
 exactly symmetrical spots are selected for the comparison of 
 the two sides. When there is one side sound we have here, 
 of course, a standard in the individual himself, but when both 
 
284 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 sides are implicated in the disease we are driven to general 
 comparisons with other patients, or, better still, with other 
 nerves in the same patient : thus it is found that the peroneal, 
 the ulnar, the temporo facial, and the spinal accessory are 
 usually stimulated to action by a similar strength of current : 
 by comparing the strength required for the stimulation of one 
 of these with that required for another, we can say, even when 
 both sides are diseased, whether there is a notable departure 
 
 Fig. 45. 
 
 Inferior gluteal nerve for 
 
 gluteus maximus 
 Great sciatic nerve 
 Long head of biceps, 
 
 Short head of biceps 
 
 Adductor niagnus. 
 
 Seniitendinosus. 
 
 Semimembranosus. 
 
 Posterior tibial nerve ^; J 
 
 Peroneal nerve if « 
 
 Gastrocnemius (external 
 head) 
 
 Soleus 
 
 Gastrocnemius (intci'ual 
 head). 
 
 Ziemssen's motor points. 
 
 from the normal. It may hap2:>en as a rarity, even in health, 
 that there is a marked difference of excitability between the 
 two sides of the body, due to a difference in the resistance of 
 the structures, even after they have been fully and equally 
 soaked with water. The proof of this difference may be ob- 
 
THE MOTOR NERVES. 
 
 285 
 
 tained by means of the galvanometer, and so, if the faradic 
 battery gives such diversities, it may be necessary to test Avith 
 the galvanic battery and a galvanometer in the circuit before 
 definitely concluding that there is really such a difference. 
 
 Pig. 46. 
 
 Gastrocnemius (internal 
 head) 
 
 Soleus. 
 
 Flexor communis digi- 
 torum lon2;us 
 
 Posterior tibial nerve. 
 
 Abductor poUicis. 
 
 Ziemssen's motor points. 
 
 The difference of the reactions in this part of the investiga- 
 tion is one simply of degree ; it is estimated by the readiness 
 of response to the currents of various strengths, whether gal- 
 vanic or faradic. We must watch the contraction of the 
 muscles animated by the nerve in question. Sometimes the 
 observer is apt to be*misled by the action of other muscles, 
 animated by quite different nerves, from the indirect stimula- 
 
286 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 tion carried to them from a diffusion of the current. In 
 watching the muscular contraction we must have a good direct 
 light falling equally on both sides : we can usually secure this 
 best in the sitting posture. We note the minimum strength 
 of each current, faradic and galvanic, which excites contrac- 
 
 FiG. 47. 
 
 Peroneus longus. 
 Tibialis anticus... 
 
 Extensor lougus pol 
 licis 
 
 Branch of peroneal 
 nerve fur extensor 
 brevis digitorum 
 
 Dorsal interossei 
 
 ^^^ - Peroneal nerve, 
 
 -. Gastrocnemius (ex- 
 ternal head) . 
 ■- Soleus. 
 
 -• Extensor communis 
 \ligitorum longus. 
 
 ^^,„ Peroneus brevis. 
 
 Soleus. 
 
 Flexor longus pol- 
 
 :^^ licis. 
 
 Extensor brevis digi- 
 torum. 
 
 Abductor minimi 
 
 digiti. 
 
 /iemsscn's motor points. 
 
 tion : or we may find an absence of response with the highest 
 strengths of the faradic current, or it may be of both currents. 
 Occasionally in disease the nerves show an increased excit- 
 
COMPAEATIVE TESTS. 287 
 
 ability, but much more commonly there is a diminution or 
 abolition. 
 
 In using the faradic current the electrode may be applied 
 for a few seconds, or lifted and reapj^lied as may seem neces- 
 sary to assure ourselves of the muscular action ; or single 
 shocks may be passed by using the arrangement for this pur- 
 pose possessed by some batteries (see Fig. 41), or the finger 
 may be used to regulate the action of the vibrating hammer, 
 or interrupting handles or commutators may be used for 
 cutting off and joining the circuit. With the faradic current 
 during the continuance of its passage, the muscle contracts, 
 and, if prolonged, it becomes tetanized. 
 
 With the galvanic current the reaction of the muscles is 
 obtained (with ordinary strengths of battery at least) only 
 at the moment the current begins to pass and the moment it 
 ceases — i. e., at the " closure " or " makiug " of the circuit 
 and at the " opening " or " breaking " of it. This can be 
 readily felt on taking one electrode in one hand and dipping the 
 other into a basin with salt water containing the other elec- 
 trode ; at the moment of putting the hand in there is a shock 
 and muscular contraction, and also at the moment of with- 
 drawing it ; during a steady immersion of the hand there may 
 be a tingling sensation but no shock or muscular twitching. 
 This is a point of great importance both in diagnosis and 
 treatment. 
 
 The facility with which the shock occurs depends on various 
 circumstances : the strength of the current ; Avhich pole is 
 applied ; the suddenness with which the circuit is made or 
 broken; and this sudden change is, of course, intensified by 
 the previous passage of a current for a little time in the oppo- 
 site direction, so that sudden reversings of the current by a 
 commutator afford powerful stimuli. The importance of sud- 
 den closures and openings of the circuit calls for the use of 
 interrupting handles, so that the electrode duly moistened 
 may be firmly pressed over the spot, and then the circuit 
 closed or opened as desired. The firmness of pressure with 
 w^hich the electrode is applied to the skin influences the facility 
 of the conduction of the current very much, and so it follows 
 that the gradual application of pressure, or the sliding up of 
 the electrode cautiously from thick cuticle to the thinner skin 
 over the part tested lessens the suddenness with which the 
 change in the nerve is joroduced by the electrical stimulation, 
 and so lessens the readiness of the muscular response. In 
 applying or removing a soft sponge we have, of course, vary- 
 
288 ELECTRICAL INSTRUMENTS IN DIAGNOSIS. 
 
 iug degrees of this SLiddenness, aud this introduces confusion 
 in the comparison of our results ; with an electrode held on 
 firmly, and with the circuit closed or opened suddenly by 
 metal connections, we are afforded means for a fair comparison. 
 
 " Localized electrization " of the muscles is effected in tw'o 
 ways. In searching with an electrode over a limb, we find 
 certain "points of election" where the application at once 
 excites the contraction of a given muscle, or of a definite 
 portion of it in the event of its being a large one. These are 
 the " motor points " of Ziemssen, and have been shown to be 
 the entrance points of the nerves to the muscle. They can 
 be learned by a little practice on a limb, but considerable 
 guidance is afforded by the diagrams given by Ziemssen, some 
 of which are here reproduced. We avail ourselves of these 
 points in stimulating the muscles by the pole of either the 
 faradic or the galvanic battery. As before, we test with the 
 faradic current before the galvanic, and, as before, we use 
 the kathode or negative pole first. We note the minimum 
 strength with which the muscles can be excited, and, of course, 
 we notice which muscles or which group of muscles respond 
 to our stimulus and which do not. 
 
 With the galvanic current we proceed to ascertain w'hich 
 pole (" kathode" or " anode ") over a " motor point " gives a 
 muscular contraction with the least strength of current, and 
 whether this response occurs more readily with the " closing " 
 or the " opening " of the circuit. 
 
 In health the order is : 
 
 (1) The minimum strength of current gives with kathode, 
 
 on closing the circuit, a contraction. 
 '' (2) Applying more strength, we next get with anode, on 
 opening the circuit, a contraction. 
 
 (3) With about the same strength, with anode, on closing 
 l^ the circuit, a contraction. 
 
 (4) Lastly, on using a greater strength, with kathode, on 
 
 opening the circuit, a contraction. 
 
 By taking the initial letters of the important words of the 
 above, we have symbols which stand thus, as the order of 
 facility with which contractions are produced in health : 
 
 (1) K. C. C. = Kathodic closure contraction. 
 
 (2) A. 0. C. = Anodic opening contraction. 
 
 (3) A. C. C. ==: Anodic closure contraction. 
 
 (4) K. 0. C. = Kathodic opening contraction. 
 
QUALITATIVE CHANGES IN" REACTIONS. 289 
 
 By using very strong currents in healthy subjects we may 
 with (1) kathodic closure produce tetanus of the muscle; (2) 
 with kathodic opening a slight contraction ; (3) with anodic 
 closing, and (4) with anodic opening a stronger contraction. 
 In symbols this is expressed thus : (1) K. C. Te.\ (2^ K. 0. C. ; 
 (3) A. G. C; (4) A, 0. C 
 
 Sometimes we have phenomena produced both of a sensory 
 and motor character with duration of the current ; this is 
 expressed by the symbol D, Thus, K. D. Te. would indicate 
 the occurrence of tetanus in the muscle during the passage 
 of the current at the kathode.^ 
 
 Qualitative Changes in Reactions. — We may have in dis- 
 eased conditions alterations, in the electrical reactions, not 
 merely of a quantitative character — i. e., either excessive or 
 diminished for a given strength of current, but we may have 
 also qualitative alterations. The qualitative changes may 
 show themselves by presenting an altered series of reactions in 
 respect of the two poles and their occurrence at the oj^ening 
 or closing of the circuit; thus we may find the anodic closure 
 contraction as readily obtained as the kathodic closure con- 
 traction instead of requiring more battery power; it may 
 even be produced with a less strength of current than the 
 other. But further, we may have alterations in the manner of 
 the contraction ; the muscle may respond to the galvanic stim- 
 ulant, and may indeed act with a very low power of the 
 battery current, but instead of the normal sudden twitch the 
 contraction may be slow and long drawn, resembling some- 
 what the vermicular contraction of the organic muscles. 
 
 Reaction of Degeneration (B.D.) is an interesting and 
 important phenomenon. " It is characterized in the main by 
 
 1 The symbols used for electrical reactions were originallj^ introduced in Germany, 
 aad, unfortunately, there is some confusion when the initials of the English equivalents 
 are substituted for the initials of the German words. Even in English writings the 
 forms kathode and cathode are both used, and so we may have K. or C, or Kn. or Ca. 
 By using K. for kathode, we lessen the confusion from a repetition of G. for "closure" 
 and for "contraction " ^. or An. = anode ; K. or C. or Ka. or Ca. = kathode or cathode ; 
 C. = closure of the circuit (or making it) ; 0. = Opening of the circuit (or breaking it) ; 
 C. ^ contraction of a muscle; C and C'"=very marked and still more accentuated 
 contractions ; T. or Te. = tetanus of a muscle ; S. = sensation produced on stimulating 
 sensory nerves; D. ^Duration of the current, as opposed to mere closing and opening 
 of the curcuit. The musical symbols < > (crescendo and diminuendo) indicate increase 
 and diminution : they are used to express the increasing or diminishing loudness in the 
 sounds produced on electrical stimulation of the auditory nerve ; they are also used to 
 show the relationship of one reaction of muscle being greater than another (thus A. C. C. 
 > K. C. C. ^the anodic closure contraction becoming greater than the kathodic closure 
 contraction). B. D. = " Eeaction of Degeneration." The German symbols may be also 
 found at times even in English books, and they are repeated here from the last edition 
 of this manual: A. = anode ; Ea. ^kathode ; S. =schliessung or closing of the cir- 
 cuit ; O. = oeffnung or opening of the circuit ; Z. = zuckung, or contraction, or twitch- 
 ing ; Z.' = the accent indicates intensification ; z. = the small letter indicates a feeble 
 contraction ; Te.= tetanic contraction ; El. = klang or sound. 
 
 25 
 
290 ELECTRICAL INSTRUMENTS IN" DIAGNOSIS. 
 
 diminution and loss of the faradic and galvanic irritability of 
 the nerves, and the faradic irritability of the muscles, while 
 the galvanic irritability of the muscles persists, is sometimes 
 considerably increased, and is always changed qualitatively 
 in a definite manner." (Erb.) 
 
 Almost immediately after the lesion occurs which gives rise 
 to this reaction we have a sudden and usually very great 
 reduction of the muscular response both to the faradic and 
 galvanic current as aj^plied to the iierves ; often, indeed, within 
 a week or two weeks no response can be obtained. 
 
 The same result is found on trying to faradize the muscles ; 
 very often no i-esponse can be obtained at all ; sometimes there 
 may be very slight contractions with very strong currents. 
 But with the galvanie current applied to the muscles (although 
 a slight diminution may be noticed for the first week) we have 
 not only a response to currents of moderate intensity, but a 
 preternaturally ready reponse to very weak currents. Con- 
 currently we have alterations in the polar reactions, in 
 particular the anodic closure contraction being as readily 
 produced, or even more readily, than the kathodic closure 
 contraction ; and further, we have the slowness and long-drawn 
 character of the muscular contraction already noticed. We 
 have then (1) loss of faradic and galvanic excitability of the 
 nerves; (2) absence of faradic excitability in the muscles; 
 (3) increased galvanic excitability of the muscles (early in- 
 duced and lasting for a period of weeks at least) ; (4) diverg- 
 ence from the normal series of polar reactions with the galvanic 
 current, as regards the relative readiness with which contrac- 
 tions are excited ; (5) a slow or long-drawn contraction of the 
 muscle instead of the normal lightning-like twitch. 
 
 A partial form of the " reaction of degeneration " has also 
 been described by Erb ; the phenomena are less marked and 
 somewhat confusing ; in particular there may be a preservation 
 of the faradic excitability, combined with the peculiar changes 
 of polar reaction to the galvanic current already described, 
 and with the latter a slowness in the muscular contraction 
 perhaps only recognizable by a practised eye. The reaction 
 of degeneration may continue to be present after the muscles 
 concerned have recovered voluntary action, and occasionally 
 a reaction of degeneration may be detected (in lead paralysis) 
 before marked loss of power has appeared. The explanation 
 of the " reaction of degeneration " has not yet been fully made 
 out, but the preservation of galvanic contractility with the loss 
 of faradic contractility seems to depend on the extremely short 
 
SIGNIFICANCE OF ELECTRICAL REACTIONS. 291 
 
 duration of induction currents. From their extremely short 
 duration, the faradic currents, while potent for the stimulation 
 of healthy nerves, seem unable to act directly on muscle ; the 
 galvanic current can, however, stimulate muscles directly ; even 
 with this form, however, if the currents be interrupted Avith 
 great rapidity (say 50 in a second), we again find an absence 
 of muscular contraction under the conditions described as 
 furnishing the reaction of degeneration. Why the excitability 
 of the muscle should be absolutely increased in the early stage 
 of this reaction is not so clear ; probably the changes going on 
 in the muscle itself bring about this alteration. 
 
 Significance of Electrical Keactions. 
 
 The significance of electrical reactions as regards the sensory 
 nerves does not require special notice fsee p. 280), and the 
 subject of anaesthesia has been already discussed elsewhere 
 (pp. 195-201). Cases with actually increased excitability to 
 galvanic and faradic stimulation of nerve and muscle are few 
 in number, and probably have not always been actually present 
 even when reported. A few cases, however, Avith this reaction 
 seem to occur at times in the early stages of cerebral paralysis 
 and possibly in the incipient stages of some inflammatory 
 affections of the spinal cord also. This phase is usually of very 
 short duration. In tetany the increased excitability seems to 
 be well authenticated, and it has been alleged Avith less weight 
 of evidence in chorea. In all these cases there may be pre- 
 sumed to exist a transient stage of preternatural excitability 
 of the nervous centres. 
 
 The chief interest in this inquiry arises from the electrical 
 reactions aflfording indications of the state of nutrition of the 
 motor nerves and muscles. The results thus obtained have, 
 therefore, a certain relationship with the examination of the 
 muscles by the finger and eye. (See p. 211.) The electrical 
 reactions and the nutrition of the muscles are both dependent 
 on their nervous connection Avith the spinal cord through the 
 efferent nerves; hence Ave have here a certain relationship also 
 with the results obtained on testing the nervous loop concerned 
 in reflex actions. (See p. 216.) But the poAver of conducting 
 electrical stimuli and of transmitting A^oluntary impulses from 
 the nervous centres are not synonymous. In a nerve which 
 has been cut both functions are lost ; but in a nerve regenerated 
 there may be a restoration of voluntary poAver and yet no 
 transmission of electrical excitation. The student must also 
 
292 ELECTKICAL INSTKUMENTS IN DIAGNOSIS. 
 
 remember that there may be the most perfect response to 
 electrical stimuli for a long time in cases presenting hopeless 
 forms of paralysis from destructive lesions in the brain or 
 spinal cord. The following theoretical considerations may 
 help the student to follow the subject as at present understood. 
 So long as the nervous connections of the muscles with the 
 anterior horns of the gray matter of the cord remain perfect, 
 the electrical reactions are but little affected ; hence they may 
 be preserved for a very long period, for example, in cases of 
 paralysis from cerebral lesions, till disuse and the resulting 
 atrophy in nerve and muscle have brought about secondary 
 changes. In cases of hemiplegia, therefore, and in many 
 serious cerebral lesions we have the reactions but little affected. 
 
 In hysterical paralysis the electrical reactions are normal, 
 and of course the same is the case in patients wdio simulate 
 paralytic affections. But even in gross destructive lesions of 
 the gray matter of the spinal cord, the motor nerves above and 
 below the affected area may still preserve their connections 
 with the anterior horns unimpaired, and so the muscles ani- 
 mated by these nerves may, as in cerebral lesions, continue to 
 react normally till secondary changes, from disuse or from 
 spread of the disease in the cord, have been set up. (The 
 nerves, however, in direct connection with the destroyed area 
 in a spinal lesion w ill, of course, have their electrical reactions 
 implicated.) Again, extensive disease of the white columns of 
 the cord may exist without much disturbance of the electrical 
 reactions, inasmuch as these lesions often exist without much 
 tendency to implication of the anterior horns. Hence, even 
 in bad forms of locomotor ataxy and in spastic paralysis we 
 may have a good response to electrical stimuli. We must 
 remember, however, that some spinal affections, beginning else- 
 where, may extend their influence to the gray matter, and so 
 we may find changes in the electrical reactions developed in 
 time. 
 
 We can equally understand, in view of the relationship of 
 the nerves and muscles to the anterior cornua already sub- 
 mitted, why in sections, lacerations, or other serious injuries of 
 the nerve trunks the electrical reactions are affected. In such 
 injuries we have a rapid abolition of farado- and galvano-con- 
 tractility in the nerves, a com])lete loss of farado-contractility 
 in the muscles, and the rapid development of the " reaction of 
 degeneration," already described. (See p. 289.) But the injuries 
 may be less severe, although sufficient to cause paralysis, and 
 as these occur in all degrees, we may have various gradations, 
 
SIGNIFICANCE OF TESTS. 293 
 
 from complete loss of electrical reactions to almost complete 
 preservation of them. Thus in paralysis of the arm from 
 pressure during a heavy sleep, or from the use of crutches, the 
 muscles may respond perfectly ; in such cases the actual in- 
 jury to the structure of the nerve is no doubt usually trifling; 
 even then abolition of conductivity of the nerve higher up, on 
 stimulating the brachial plexus, has sometimes been made out. 
 
 Closely allied to traumatic paralysis is the paralysis of the 
 facial nerve from destructive ear disease involving the bones ; 
 and we have here similar electrical reactions. But Ave may 
 have a form of facial paralysis from a less severe injury, com- 
 parable to that produced by pressure, of which mention has 
 been made in the case of the arm ; but the serious character of 
 the pressure in the case of the facial nerve results from the 
 constricting influence of inflammatory products squeezing the 
 nerve against its bony canal, as in the rheumatic and syphilitic 
 affections of the facial nerve. As this injurious pressure may 
 have all degrees of intensity, we may have in slight cases 
 almost no alteration of the reactions, or in bad cases the 
 "reaction of degeneration," and other resemblances to the 
 phenomena presented by a divided nerve ; intermediate be- 
 tween these extremes we may have various degrees of di- 
 minished faradic excitability. It is clear, therefore, that 
 under certain circumstances the electrical reactions aid us in 
 prognosis, the slighter lesions as indicated by this test being 
 more quickly recovered from. In a few cases of facial paralysis 
 also the electrical reactions aid the diagnosis, in distinguishing 
 a peripheral from a central lesion of this nerve ; the bad 
 response to electrical stimuli may afford grounds for a rela- 
 tively good prognosis ; in cerebral forms of paralysis of this 
 nerve the faradic excitability is as usual preserved. 
 
 Morbid processes of various kinds and the destructive in- 
 roads of malignant tumors may of course destroy the trunk of 
 a nerve in any part of its course, and so give rise to electrical 
 reactions resembling those found in traumatic paralysis. But 
 diseased processes in the nervous system itself may produce 
 lesions practically equivalent to a traumatic injury, although 
 higher up than the mere nerve trunk. In infantile paralysis 
 we have a lesion in the anterior cornua of the spinal cord, 
 Avhich by its destructive influence on the large cells and tissues 
 there cuts off" the motor roots of the spinal nerves from the 
 connection which is so important for the nutrition of the mus- 
 cles : hence the rapid wasting in this disease ; hence also the 
 
 25* 
 
294 ELECTRICAL IlSrSTRUM ENTS IN DIAGNOSIS. 
 
 rapid change in electrical reaction. In this disease, as in bad 
 cases of facial paralysis, Ave get results similar to those found 
 in divided nerves, and the " reaction of degeneration " is very 
 common, at least in bad cases, and is rapidly developed. But 
 the wasting and the electrical changes do not affect the whole 
 limb indiscriminately: special groups of muscles are selected, 
 for reasons which are not clear, but in connection with which 
 Ferrier's investigations on the roots of the spinal nerves have 
 some bearing. (See foot-note, p. 211.) 
 
 In grave forms of myelitis affecting the gray matter of the 
 cord we can understand the great diminution of the electrical 
 reactions, and indeed there may be complete absence of con- 
 traction with either faradic or galvanic current. We must 
 remember, however, that in equally serious disease of the 
 spinal cord we may have good electrical reactions in connec- 
 tion with nerves not directly sprins;ing from the diseased area. 
 (See p. 292.) 
 
 In progressive muscular atrophy (although the lesion is 
 probably in the anterior liorns ) the electrical reactions are less 
 altered : we often have indeed a diminution in the response, 
 but this seems so far explicable by the diminished bulk of the 
 muscle ; later in the case, according to some, there may be a 
 partial " reaction of degeneration." Similar remarks apply 
 to bulbar paralysis. 
 
 It is not easy to understand the reaction of the nerves and 
 muscles in paralysis from lead poisoning, unless we assume 
 that the poison influences specially the roots of the spinal 
 nerves concerned. It is very common in such cases to have 
 great loss of farado-excitability or abolition of it altogether, 
 with the " reaction of degeneration " well marked. Here also, 
 as in facial paralysis, the different degrees of reaction are very 
 great, and for similar reasons the electrical reactions guide the 
 prognosis, the recovery being much quicker when the loss of 
 faradic excitability is slight. In rare cases alcoholic paralysis 
 simulates lead poisoning in the electrical reactions as well as 
 in affecting the extensors. 
 
 In pseudo-hypertrophic muscular paralysis the faradic ex- 
 citability is preserved till the case is far advanced and the 
 muscles much destroyed, but owing to the wasting being 
 greater than might be supposed, and owing to the resistance 
 from tlie excess of adventitious tissue, the reactions often 
 appear diminished, both as tested over tlie nerves and over 
 the muscles, but particularly in the latter case. 
 
BIBLIOGEAPHY. 295 
 
 The two great advocates of the galvanic and faradic forms of elec- 
 tricity respectively are Eemak and Duchenne. — Eemak, Galvano- 
 therapie der Nerven und Muskel- krankheiten, Berlin, 1858. — 
 Duchenne, D'electrisation localisee, 8e edition, Paris, 1872 : portions 
 of this great work have been translated by Dr. Poore for the New 
 Sydenham Society, London, 1883. 
 
 Students not familiar with electrical experiments would do well to 
 read and practise the experiments given in an admirable series of les- 
 sons by Dr. De Watteville, Practical Introduction to Medical Elec- 
 tricity, 2d edition, London, 1884. This book can also be recommended 
 for instructions in the diagnostic and therapeutic uses of electricit3^ — 
 Erb, Handbook of Electro-therapeutics, translated by Dr. Putzel, 
 London, 1883: important works bearing on this subject by Erb are 
 also available for English readers in the translation of Ziemssen's Cy- 
 clopedia. — A. Hughes Bennett, Practical Treatise on Electro-diag- 
 nosis, London, 1882. — Altha'us, Medical Electricity, 3d edition, Lon- 
 don, 1873. — Tibbits, How to use a Galvanic Battery, London, 1877 : 
 Dr. Tibbits has also translated a portion of Duchenne's work dealing 
 with instruments, and he has published a pamphlet on static elec- 
 tricity, London, 1886. — Beckensteiner, Etudes sur I'electricite, Lyon, 
 may be consulted especially as regards static electricity. — The works 
 of Meyer ; Onimus ; Kosenthal and Bernhardt ; and Beard and Kock- 
 well may also be mentioned. 
 
CHAPTER VIII. 
 
 INSANITY. 
 
 Before considering the forms of insanity, it is desirable 
 that the meaning of certain terms, which are of constant use 
 in describing mental disorders, should be clearly understood. 
 These are : 
 
 Illusions, Hallucinations, and Delusions. — Illusion and hallu- 
 cination have reference only to disordered perceptions. Both, 
 separately or together, may exist without insanity. In order 
 to the occurrence of an illusion a real impression must be pro- 
 duced on the sensorium ; but this impression appears in con- 
 sciousness as very different from the actual fact. The impres- 
 sion in most cases comes from without, and is transmitted 
 through one or other of the senses (by far the most frequently 
 through those of hearing and sight) ; but it may spring from 
 one of the internal organs. On the other hand, an hallucina- 
 tion arises when no imj^ression has been produced on any of 
 the senses, and it is equally independent of visceral sensations. 
 It is entirely a new creation due to an abnormal condition of 
 the sensorium itself The varying morbid states of this great 
 centre, or of these great centres of sensation, seem in the con- 
 sciousness of the individual to be impressions that have come 
 in natural course from the organs of special or general sensa- 
 tion. Briefly expressed, illusions are objective in relation to 
 the sensorium, whereas hallucinations are subjective. Thus, 
 if a human voice be heard by one when others hear only the 
 tolling of a bell, that is an illusion ; but should it be heard 
 when there is no sound of any kind, that is an hallucination : 
 and so with the other senses. It is sometimes diflicult to dis- 
 tinguish between these two forms of morbid perception, especi- 
 ally when they relate to general sensation. Whatever their 
 origin, should the patient's reason stiH enable him to discard 
 them as false and unsound, he is sane in relation to them ; 
 and this frecpiently happens with illusions, although seldom 
 with hallucinations. If he cannot be convinced of their un- 
 reliability he is very generally insane, but not always, as early 
 training, peculiar religious views, and other special circum- 
 stances may account for the apparent mental unsoundness. 
 
ILLUSIONS, HALLUCINATIONS, ETC. 297 
 
 Delusion, strictly regarded, pertains exclusively to tlie 
 highest mental functions, and has no direct connection with 
 sensation in any form. A man who asserts he is ten thousand 
 years old, or that he is the Almighty, labors, therefore, under 
 delusion proper. But though the term is occasionally em- 
 ployed in this restricted sense, to distinguish it from those 
 already described, it is also commonly used generically to in- 
 clude them all. It may thus be correctly applied to either 
 illusions or hallucinations, if they are the result of disease, and 
 are not corrected by reason. In a court of law, as a matter 
 of expediency, it is advisable to avoid the latter terms, and to 
 designate all morbid ideas of lunatics as " insane delusions ; " 
 the word delusion hy itself being often popularly used to de- 
 scribe a mere unfounded belief. 
 
 The chief forms of insanity, according to the best established 
 classification, are mania, melancholia, monomania, dementia, 
 and idiocy ; and besides, there are several important varieties 
 which will be briefly described. Jfa?i{a implies considerable 
 general excitement, which is usually accompanied by incoher- 
 ence of ideas, delusions, and violent conduct ; but there are 
 varieties of mania without incoherence or distinct delusions. 
 In melancliolia there is mental depression with delusion gener- 
 ally limited to one or to a small number of subjects. There 
 is also simple melancholy without delusion. In monomania 
 there is no depression, but generally exaltation or perversion 
 of feeling ; delusion is restricted to one or (much more com- 
 monly) to a small number of subjects, all of the same char- 
 acter; but the intellect, although often wonderfully clear and 
 acute in other directions, is not altogether free outside the 
 morbid circle. In dementia the powers of the mind, previously 
 of average vigor, are enfeebled or destroyed. In idiocy the 
 original mental development has fallen far short of the normal 
 standard, either through a congenital cause or one occurring 
 in early childhood. Imbecility is this state in a minor 
 degree. 
 
 Premonitory mental symjytoms almost always precede an 
 attack of any of the acquired forms of insanity. These are 
 to be looked for in disturbance of the emotional powers rather 
 than in an abnormal state of the intellect — the latter condi- 
 tion being subsequent to the former. There is usually a pre- 
 liminary period of depression, and this is often »een even where 
 the fully pronounced derangement is a state of excitement. 
 The patient has a vague feeling of discomfort, of mental 
 weariness and pain. There is unwonted irritability ; trifles 
 
298 INSANITY. 
 
 that would formerly be unheeded now fret and worry ; those 
 most loved and bound by the closest ties of kindred are re- 
 garded with suspicion, jealousy, and aversion ; a feeling of 
 baseless apprehension, and sometimes a painful anticipation of 
 insanity, are experienced : unusual vacillation of purpose 
 may be a feature ; and the sufferer, particularly in the pre- 
 monitory stage of melancholia, may likewise have a weariness 
 of the world, and a longing for death. Such feelings and 
 dispositions in various combinations form the foundation of 
 morbid sentiment on which delusion, in its varied forms, is 
 based. In some cases of mania, however, there is no pre- 
 liminary depression and the initiatory stage is one of gradually 
 increasing excitement. 
 
 Mania. — In acute mania the preliminary stage of depression 
 with iritability, should it exist at all, is not generally of long 
 duration. About the period when it is giving place to excite- 
 ment there is occasionally a general susceptibility of the 
 nervous system, characterized by exceeding sensitiveness to 
 sharp and loud noises, and to bright light, and also by a dis- 
 position to sudden and violent starting of the legs and even 
 the whole frame, especially when about to fall asleep. Some 
 people are, how'ever, subject to similar startings in a minor 
 degree from slight causes, such as derangement of the di- 
 gestive system, and many epileptics suffer from them in the 
 intervals between the fits. 
 
 The mental excitement may show itself very gradually, or 
 it may be quite sudden in its onset. The disorder of the in- 
 tellect occurs in degrees varying from scarcely noticeable 
 rambling in conversation to complete incoherence. Cases 
 which are characterized by mere exaltation without obvious 
 intellectual disturbance have been named simple mania. In 
 this condition patients generally act very foolishly, quite un- 
 like their former selves, although, at the same time, they are 
 very ready with a plausible excuse for their improprieties of 
 conduct, and it may be very difficult, and at first perhaps even 
 impossible to certify that they are insane. In the majority of 
 such cases, after an interval of weeks or months, the gradual 
 development of incoherence, wdth or without delusions, shows 
 that the intellect has become distinctly involved ; but some 
 undergo no material change, however ])rotracted their dura- 
 tion. The writer has had cases for years under his care, chiefly 
 elderly females, in which a meddlesome disposition that was 
 the source of nuich mischief both amongst fellow-patients and 
 attendants, a general forwardness and recklessness of conduct, 
 
ACUTE MANIA. 299 
 
 a slight and not very obvious rambling in conversation, and 
 an excitability of temper, were almost the sole evidences of 
 insanity. That this mental condition was, however, attribut- 
 able to disease was supported by the fact that in the most 
 marked of these cases there had been attacks of ordinary in- 
 sanity in early life, and that the excitable demonstrative mood 
 was not natural to the person, but had set in after a long incu- 
 bation of abnormal quietude and reticence. The mental 
 derangement in some patients corresponds very closely with 
 the " moral insanity " of the alienistic physician Prichard, to 
 be afterward noticed. 
 
 In ordinary acute mania illusions and hallucinations, par- 
 ticularly of sight, as well as delusions j^roper, are very common, 
 although, as already stated, mania may exist without any of 
 them. A distinguishing feature of the morbid ideas is their 
 evanescence ; they are not fixed, even though the same kind of 
 fancies may recur from time to time. Besides the intellectual 
 disturbance, there are general restlessness and impatience, a 
 hurry, a confusion, and an unusual disposition to action. 
 Some patients are in a happy, joyous mood; others are angry 
 and irritable ; not a few alternate between these states. The 
 conduct is often violent and disgusting : shouting, singing, 
 gesticulating, quarrelling and fighting, tearing clothes, smear- 
 ing the person and bedroom with feces, and other filthy actions. 
 Outrageous conduct is often first manifested during the night. 
 It is to be observed that both delusions and actions are 
 stamped by the character of the prevailing morbid emotion. 
 
 From the very commencement of the illness sleep is almost 
 always deficient in amount, and is occasionally absent alto- 
 gether ; or, what is more common, it is obtained for half an 
 hour or an hour, now and again, the patient awakening in no 
 respect improved. Terrifying dreams often disturb these brief 
 snatches of sleep. The appetite, although frequently con- 
 siderably impaired in the early stage of the disorder, is usually 
 good when it is fully developed, and, indeed, is sometimes 
 abnormally keen. But, notwithstanding the large quantities 
 of food consumed, nutrition is not well maintained, and many 
 patients distinctly fall off" in condition. The tongue is moist 
 and clean in many cases, but may be furred and yellow, in 
 which case the breath will probably also be unpleasant. The 
 bowels are generally confined, and the stools are apt to be 
 offensive, but occasionally a tendency to diarrhoea is seen. 
 Thirst is seldom present. The urine is commonly diminished 
 in quantity, increased in specific gravity, of acid reaction, with 
 
300 INSANITY. 
 
 an excess of pliospliaLes; but occasionally it is neutral or even 
 alkaline, and the amonnt may be normal. Excitement of the 
 sexual instinct, which is not rare, may show itself in mastur- 
 bation and indecent exposure of the person. Menstruation is 
 usually altogether or in a great measure suppressed. The 
 menses generally return coincidently with recovery, but their 
 appearance does not always herald the advent of convalescence ; 
 and, on the other hand, mental health may be restored while 
 they continue iu abeyance. In the majority, the skin is some- 
 what harsh and dry, but it is quite common to find it soft and 
 moist ; its secretions are often disagreeable in odor. An in- 
 crease of the evening temperature by about a degree F. is 
 common, and should the patient's exertions be violent there 
 may be a similar elevation at any time of the day while the 
 excessive muscular action lasts ; but, with these exceptions, it 
 does not ordinarily rise above the average of health. Ab- 
 normal heat of head, especially of the vertex, is often notice- 
 able. In a few cases there is excessive salivary secretion. 
 The pulse, as a general rule, is from eighty to ninety in fre- 
 quency, and of diminished volume ; but there are many ex- 
 ceptions, some being a few beats above and others below that 
 range. In the early stage the conjunctivae will sometimes be 
 found somewhat injected and yellowish, but this is not common 
 when the excitement is fully established ; the aspect is then 
 frequently bright and glistening. The expression of the 
 countenance as a whole is altered, and the change is occa- 
 sionally so great that relatives have a difficulty in recognizing 
 the sufferers. The mental exaltation, the incoherence, and 
 the delusions are reflected in the face : there may be the tense, 
 fierce look of a painful morbid idea, or the relaxed joyous 
 expression of the ecjually morbid but more happy thought, or 
 simply the absence of that due fixity or natural change of 
 feature which accompanies the thinking process in a state of 
 health. 
 
 Acute mania occurs occasionally in a more asthenic form 
 than that just described. The physical symptoms are indi- 
 cative of greater debility ; the pulse is weak and quick, the 
 ])upils wide, the face pale, and there is often distinct anaemia. 
 The psycliical distur])ance is also more uniformly high. In 
 short, this form holds a middle position between the sthenic 
 and the one next to be considered ; and there is a gradation 
 of cases connecting all three. 
 
 The variety now before us corresponds in some respects 
 with severe delirium, and is hence known as aeute delirious 
 
TRANSITOKY MANIA. 301 
 
 mania. The incohereuce in this state is complete; the patient 
 talks or shouts in fragmentary, disconnected sentences, and 
 the excitement is very high. There are no definite delusions, 
 the mental disorder being apparently too great for formulated 
 thought of any kind, but in some cases indications of transi- 
 tory hallucinations and illusions are observable in the midst 
 of the ravings. Such patients are generally violent and de- 
 structive and of dirty habits, but their acts differ from those 
 of ordinary acute mania in jDartaking more of blind fury, 
 Avith less distinct consciousness in the agents. The physical 
 symptoms are proportionately intensified. The pulse is gen- 
 erally very quick and weak, the conjunctivae are injected, and 
 the pu|)ils are often smaller than the normal, the skin is 
 parched and hot, the tongue is dry, tending to -brown, the 
 appetite usually is in abeyance, and there is very often a sick- 
 ening odor from the breath, a degree of thirst is common, and 
 there is an almost total absence of sleep. There is a high 
 mortality in this condition, but should the tendency to death 
 from exhaustion be overcome, the patients usually make ex- 
 cellent and speedy recoveries from their mental disorder. 
 Cases in which the pulse is not greatly accelerated and the 
 temperature is but little raised are the most hopeful ; the 
 opposite conditions are of evil omen. 
 
 Mania transitoria is a variety which, as its name implies, 
 passes away quickly — even in a few hours, or at longest in a 
 day or two. The symptoms are those of the most acute form 
 of sthenic mania. The seizure occurs suddenly, and is most 
 frequently met with as a result of mental shock or of intoxi- 
 cating liquor in persons who are of the "insane temperament" 
 — who, in their ordinary health, are excitable, nervous, odd 
 in their opinions, and peculiar in their general conduct — this 
 condition being usually the fruit of heredity. It is also apt to 
 show itself in individuals who have had sunstroke or whose 
 heads have been injured (possibly many years j^reviously), 
 after a slight excess in alcohol, or from a moral cause, such as 
 sudden and great provocation. When due to alcohol, this is 
 the " mania a potu," properly so called. 
 
 Chronic mania may be considered as established when — 
 the symptoms of the acute stage having somewhat subsided, 
 after some months' duration — the delusive ideas are more 
 definitely formed than at first, the incoherence is still consid- 
 erable, though somewhat less, and the excitement is not so 
 constant, but more paroxysmal in its character. At this 
 period, illusions and hallucinations, especially of hearing, are 
 
 26 
 
302 INSANITY. 
 
 commonly present ; but one or more of the other senses also 
 are frequently involved in the same patient. The bodily con- 
 dition is now generally good. This is the state of a large 
 proportion of the inmates of asylums. It may last for many 
 years in much the same form ; but, what is more common, by 
 slow degrees the mind becomes more and more enfeebled till 
 at length its powers are irretrievably lost in the ruin of com- 
 plete dementia. 
 
 MelancJiolia stands next in importance to mania as a 
 leading form of insanity. It is often met with as simple mel- 
 ancholy, without delusion or distinct intellectual derangement 
 of a positive kind. Yet in most cases neither the intellect nor 
 the will is free ; they are distinctly enfeebled. The sufferer 
 cannot duly concentrate his attention on any subject or reason 
 it out to a conclusion with his former ability. The emotional 
 distress is overpowering, and the whole course of thought is 
 swayed and broken by the strength of the morbid feeling. 
 Many are desponding and lethargic, do not interest themselves 
 in the ordinary affairs of life, shun society and seek to be 
 alone, nursing their gloomy thoughts. In others the mental 
 distress is more active, showing itself in restlessness and 
 agitation, Avringing of the hands, and in the unhappy, woe- 
 begone countenance. Although there is no definite delusion, 
 there are usually forebodings of evil, the future is all dark, no 
 ray of hope illumines their sojourn in this world, or perhaps 
 even the prospect beyond the grave. A disposition to suicide 
 occasionally arises, and this should always be borne in mind, 
 but it is not so common as in the more pronounced forms of 
 melancholia. There is derangement of the general health. 
 Anaemia is usual, with chilliness, particularly of the extrem- 
 ities ; the pulse is often slower than normal ; in women 
 leucorrhcea is common. The appetite is poor, and there is 
 sluggishness of the bowels, the colon more especially being 
 inactive and frequently loaded. In many cases an insufficient 
 amount of sleep is obtained, but -in some it is not deficient. 
 The patient's slumbers are often disturbed by hideous dreams, 
 and are not refreshing. There is not unfrequently a disposi- 
 tion to lie abed till the morning is far advanced, and it may 
 be only by a degree of constraint that the sufferer can be got 
 to rise and dress. Usually the morbid feeling is at its worst 
 in the morning, and as a rule there is some abatement as the 
 day advances. It is worthy of note that a sense of the ludi- 
 crous may exist along with this depressed emotional state. 
 
 Hypochondriasis passes into melancholia when the more or 
 
MELANCHOLIA. 303 
 
 less imaginary troubles that affect the patient amount to 
 actual delusion, out of which he cannot be reasoned. In illus- 
 tration of this, a patient complained for a long time of un- 
 easiness, and sometimes of severe pains in the abdomen, for 
 which there was no very obvious cause ; then she became 
 miserable, and declared that the devil himself was in her 
 belly. Her first condition could not be pronounced to be in- 
 sanity ; but wdien the delusion arose, the proof of it was clear. 
 In hypochondriasis the depression of feeling is seldom so great 
 as in melancholia, nor is it so completely beyond the patient's 
 control ; and, instead of a disposition to suicide, there is 
 usually fear of death, and apprehension that the unreal, but 
 not the less dreaded, troubles will prove fatal. 
 
 Acute melancholia may be suddenly caused by a severe 
 mental shock, but it is much more frequently preceded by a 
 long preliminary stage of depression. When the disorder is 
 fully developed, the unhappy feeling may attain to one of 
 despair. The wretched sufferer may utter loud lamentations, 
 tear his hair, strike his breast, and even make desperate at- 
 tempts at self-destruction. It is seldom, however, that the 
 condition is so bad as this ; but there are all degrees be- 
 tween simple melancholy and the state just described. The 
 attitude and the expression betoken the mental frame. In 
 some the arms hang heavily by the- side, the eyes are turned 
 downward toward one point, and are almost statue-like in the 
 fixity of their gaze, and the angles of the mouth are depressed ; 
 or, the morbid feeling being more acute, the hands are 
 clenched, the features are tense, and the sufferer moves about 
 in restless agitation. The latter variety is less common than 
 the former. Notwithstanding their misery, melancholies sel- 
 dom shed tears ; their sorrow is too deep for that. In most 
 cases they are decidedly worse in the morning, just after 
 awaking from sleep. Although in general sleep is broken 
 and much disturbed by unhappy dreams, it is by no means so 
 deficient in amount as is the case in acute mania. The pulse 
 is weak and not accelerated ; the skin is clammy and cold, 
 and the lips have a purplish tinge ; the tongue is apt to be 
 furred, and is sometimes indented at the edges ; the bowels 
 are generally constipated, and the breath offensive, and the 
 stools are occasionally deficient in bile. There is usually 
 amenorrhoea in women. Refusal of food is common, and may 
 arise from delusion, from suicidal intent, or from real derange- 
 ment of the digestive organs. Precordial anxiety is not un- 
 common ; and in some cases of intermittent melancholia the 
 
30i INSANITY. 
 
 paroxysm begins with this sensation, which seems to the pa- 
 tient to extend upward to the head, and then the gloom and 
 mental pain are experienced. In some cases — fortunately 
 rather rare — the physical symptoms correspond closely with 
 those of delirious mania, and as in it also the mortality is 
 high. 
 
 There is a form of melancholia known as melancholy with 
 stupor, or melancholia attonita. It has two varieties, depend- 
 ing on whether the element of stupor or that of profound 
 melancholy prevails. The symptoms are much alike in both. 
 The patients stand in the one position, or continue the same 
 motion, heedless of what passes around ; they require to be 
 fed, and often resist artificial feeding; and they are frequently 
 inattentive to tlie calls of nature. The circulation is languid, 
 and the skin is cold and bluish. The varieties are best dis- 
 tinguished by the aspect. In the melancholic the features 
 are tense, and the countenance, as a whole, betrays fear or 
 anguish so deep that the mental powers are overwhelmed ; 
 whereas, in the other, while a certain amount of depression is 
 evident, stupidity predominates in the expression. A general 
 resistive disposition is a marked feature in many cases, espe- 
 cially of the melancholic variety, any interference with the 
 patients, such as removing them from one seat to another, in- 
 ducing strenuous opposition on their part. Some exceptional 
 cases are characterized by the occurrence of epileptic or epi- 
 leptoid fits, but generally at long intervals. Convulsive seiz- 
 ures in which consciousness is preserved are more common ; 
 such motor phenomena are, however, amongst the rarer accom- 
 paniments of this form of disorder. In both varieties it often 
 happens that serious disease in other organs, particularly the 
 lungs, is insidiously progressing though manifesting very in- 
 distinct symptoms. 
 
 Acute melancholia, though often recovered from in a few 
 weeks or months, may become chronic, or the chronic form 
 may supervene on acute mania, in which case there is usually 
 more or less dementia along with it. Whatever its origin, 
 melancholia, if confirmed, has a tendency to pass into dementia, 
 though that frequently does not occur for many years. The 
 chronic forms are not unfrequently associated with disease 
 in one or other of the abdominal organs, on which they may 
 be partially dependent. The ordinary forms are incident to 
 middle or declining life, though it is not rare to meet with 
 them in young people. Melancholy with stupor, on the other 
 hand, is nuich more a disease of youth than of age. 
 
MONOMANIA. 80o 
 
 Monomania is generally used to signify partial insanity of 
 the intellect. The term is misleading if it be regarded as 
 meaning mental unsoundness on one subject, the judgment 
 and the emotional powers in other respects being absolutely 
 free. However limited the delusive idea, the natural tone of 
 the mind is always altered — elevated or depressed, expanded 
 or contracted — and there is also a morbid exaggeration of 
 self-feeling. At the same time cases are not rare where the 
 intellect is wonderfully sound and vigorous outside the sphere 
 of morbid ideas. Thus, two cousins, men about forty years 
 of age, came under notice at the same time, the one of whom 
 fancied that his penis was once, somehow, tampered with by 
 his fellow-workmen, and also that on several occasions, without 
 his consent, he had been acted on by electrical agents ; w^hilst 
 the other declared that he himself was " a little Christ." On 
 all other subjects they were apparently sensible, intelligent 
 men, with whom one might talk for hours withot discovering 
 their morbid fancies, unless one had a clew to them previously ; 
 but the unhealthy state of feeling above referred to was quite 
 obvious. The delusions of monomania are of endless variety. 
 They may be roughly grouped according to the prevailing 
 morbid sentiment, which, as has already been said, lies at the 
 root, and precedes formal delusion. One class, in which there 
 is exaltation of feeling, is characterized by morbid ideas re- 
 specting power, wealth, talents, personal appearance, etc. In 
 another class, suspicion being the prevailing sentiment, the 
 patient may probably imagine that there is a plot against his 
 life, that spies dog his footsteps, and that his food is drugged. 
 Prompted by such fancies, lunatics in a number of cases have 
 killed their imaginary persecutors. Hallucinations and illu- 
 sions, especially those of hearing, besides delusions proper, 
 are common. They are very important should they assume 
 the form of " voices " conveying commands to the patient, 
 and particularly should there be any disposition to obey. 
 This, as previously mentioned, is a frequent source of suicide 
 and homicide in the insane. 
 
 Monomania, especially when accompanied by hallucinations 
 of hearing, is an intractable form of insanity. Still, occa- 
 sional recoveries do take place after it has lasted for several 
 years. In most cases, as time passes — it inay be not till after 
 many years — additional delusions spring up, and the morbid 
 circle gradually widens till the intellect is entirely involved. 
 Then there is also incoherence, the mental degeneration having 
 passed into incurable dementia. The general bodily health 
 
 26* 
 
S06 INSANITY. 
 
 during this slowly progressive mental decay is usually very 
 good. 
 
 Dementia is usually the sequel to other forms of mental 
 disorder. Mania occasionally passes into it after a few 
 months, but this is not usual till a much longer time has 
 elapsed. Melancholia and partial intellectual insanity, as a 
 rule, reach dementia at a considerably later period than mania 
 does ; often not for many years. But chronic progressive 
 dementia may be primary, and arise independently of any 
 antecedent disorder of the mind. The condition ranges in 
 degree from slight enfeeblement, characterized by dulness of 
 apprehension, weakness of memory, and inability to follow out 
 a subject; or by general silliness of language and conduct; 
 to complete mental disorganization, in which the patients are 
 unable to comprehend the simplest questions, and require all 
 their wants to be attended to like an infant. In most cases, 
 however, even when the intellect is in this degraded state, 
 dements can take their food themselves. Many are grossly 
 indecent in their conduct and are dirty in their habits, and 
 some have an abominable disposition to eat their own feces 
 and drink their urine, though by careful watching and train- 
 ing they can usually be led to give up the practice. When 
 the psychical ruin is less complete, but still in cases where there 
 is great incoherence of thought, patients are quite able to 
 follow manual occupations, such as shoeraaking or tailoring, 
 to which they had been trained previous to their insanity. 
 The bodily health in this state is generally good, and there 
 may be marked obesity. 
 
 In secondary dementia there may usually be observed 
 traces of the particular form of derangement which prevailed 
 at the departure from mental health. Thus, in the epileptic 
 variety, irritability and a disposition to violence are marked 
 features ; in the general paralytic form there are the delusions 
 of grandeur; in that of monomania fragments of the original 
 delusions are often observable ; and when it results from 
 mania there are occasional bursts of excitement with incoher- 
 ence and fragmentary delusions, making it occasionally diffi- 
 cult to tell whether a particular case ought to be regarded as 
 chronic mania or dementia. The vestiges of the primary 
 mental disorder are not, however, traceable in the last stage, 
 except in epile])tic and paralytic varieties. 
 
 Senile dementia is particularly characterized by failure of 
 memory respecting recent events, while the long past is often 
 remembered with considerable accuracy. There is also more 
 
OTHER FORMS OF SENILE INSANITY. 307 
 
 or less incoherence of ideas. Sometimes there are delusions 
 which are seldom persistent, though while they last they may 
 incite to violence. Feebleness of purpose and facility of dis- 
 position are ordinary features. Cases are to be met with in 
 which there are occasional attacks of maniacal excitement, 
 lasting for a few days, and followed by depression and ex- 
 haustion. A tendency to indecency of conduct has been 
 manifested in a number of instances. In some cases there 
 are restless agitation and sleeplessness, or very insufficient sleep 
 at night. The physical signs of old age accompany this men- 
 tal condition. From various causes senility may appear long 
 before the usual period of life. 
 
 Other forms of Senile Insanity. — It would be a mistake, 
 however, to suppose that the other leading forms of mental 
 disease do not appear in the later periods of life. Thus, one 
 of the most common of these forms is a variety of mono- 
 mania, that, namely, of suspicion. Groundless jealousy of 
 near relatives, and aversion to them may be the earliest 
 marked symptoms ; but there are usually also other indications 
 of mental disturbance such as violent explosions of anger 
 from trifling causes, along with strange and extravagant con- 
 duct, quite at variance with the previous disposition of the 
 individual. Ere long, failing memory and other evidences of 
 general intellectual enfeeblement reveal the advancement of 
 the mental decay. Melancholia is not generally characterized 
 by the same fixity of feeling and consciousness in morbid 
 thought as when it presents itself before the development of 
 senile changes of structure. Thus it is not unusual for aged 
 melancholies to be very miserable and even suicidally dis- 
 posed at one time of the day, generally the morning, and 
 comparatively cheerful at night. Mania, again, though marked 
 by as much incoherency as in many of the forms already 
 described, is lacking in the vigorous demonstrations in word 
 and action which these forms usually present. It is not more 
 than might have been expected, that even abnormal processes 
 of thought should not have that acuteness and intensity which 
 we are accustomed to find in the earlier periods of life, while 
 yet the cerebral, equally with the other tissues, are free from 
 the degenerations incident to advancing years. 
 
 It is by no means unusual to have recovery from the senile 
 forms of insanity, save that of dementia, which may be re- 
 garded as a hopeless condition. For instance, the writer had 
 under his care a patient, eighty-three years of age, who made 
 
308 INSANITY. 
 
 an excellent recovery in about two months from a well-marked 
 attack of acute mania. 
 
 Organic dementia is the name given to a variety which occa- 
 sionally follows apoplectic seizures, either without paralysis, 
 or associated with hemiplegia or other obvious organic disease 
 of the brain. In the majority of hemiplegics, both old and 
 young, there is marked emotional Aveakness, manifested by a 
 tendency to weep immoderately to appearance, though it is 
 seldom that any tears are shed. Occasionally in the same 
 person there is an equal readiness to laugh, but the fit of 
 laughter generally ends in weeping of the form described. 
 The memory is also weak, and the judgment impaired. When 
 the paralysis is on the right side, and is accomj^anied by 
 aphasia, there is, as a rule, less indication of weakened feeling 
 than when it is on the left side. In very many cases of 
 organic dementia the patients are stupid, silly, and facile ; and 
 on the physical side, besides jmralysis, they suflfer from dis- 
 ease of the heart or kidneys and frequently of both organs. 
 But it is well to bear in mind that the mental derangement — 
 which is often largely maniacal in its symptoms — which some- 
 times follows an apoplectic seizure, occasionally improves 
 greatly, may indeed entirely pass away on the gradual subsid- 
 ence, or possibly complete removal, of the lesion within the 
 skull. 
 
 Acute or primary dementia is very different in its nature 
 from the varieties which have been described. Indeed, it has 
 so little real kinship with the other forms of dementia that in 
 some recent treatises on mental disease the name has been dis- 
 carded altogether, and stupor used in its place. There is, how- 
 ever, the very serious objection to the latter term that both in 
 the pojDular and medical mind it has been long associated Avith 
 a mental condition other than insanity. It has, therefore, been 
 thought better to retain the name with which it has been so 
 long associated and is still very generally known. Acute 
 dementia occurs in the young, more frequently in women 
 than in men, and is prone to affect those who are naturally 
 feeble-minded and excitable, more particularly if there be a 
 hereditary tendency to insanity. It is usually the result of a 
 severe mental shock, such as fright, unexpected bad news, etc. ; 
 and its occurrence is often quite sudden, or within a few days 
 after the shock has been sustained. The powers of the mind 
 are in almost complete abeyance, but they are not destroyed. 
 The patients stare vacantly when addressed, evidently not 
 understanding what is said to them. They perhaj^s make 
 
CIRCULAR i:t^SANITY. 60\) 
 
 grimaces, or perform actions automatically, but more com- 
 monly they remain in the same position, unless moved from it, 
 their arms hanging heavily by their sides, and their aspect 
 blank and stupid. They may become distinctly cataleptic, 
 though this is somewhat exceptional. Their circulation is 
 languid, the extremities and features being bluish, and their 
 general condition is soft and flabby. Nutrition is not well 
 maintained, and they occasionally become considerably emaci- 
 ated. They are often inattentive to the calls of nature. The 
 prognosis of this form is generally favorable, but the writer 
 has seen several cases, especially when the cause was fright, 
 Avhere the disorder became permanent. He has also observed 
 an attack of acute mania intervene between this state and 
 recovery. Usually, however, it gradually passes away, pari 
 passu, with the restoration of the general health. 
 
 It will be observed that acute dementia resembles somewhat 
 closely " melancholy with stupor." The two forms are distin- 
 guished chiefly by the facial expression ; in the latter — at 
 least in the more common variety — it is intent and fixed, 
 indicative of the profound mental concentration; whereas in 
 the former it is vacant and meaningless. In cases, however, 
 where the element of stupor predominates over the melan- 
 choly, the diagnosis is sometimes very difiicult. It occasionally 
 happens that the disorder begins as melancholia, and gradually 
 lapses into complete stupor. It will be observed, on reading 
 the next section, that there is also a close resemblance, or 
 rather identity, in many of the symptoms with those of 
 "Katatonia." In fact, the relationship of the three conditions 
 — acute dementia, katatonia, and melancholy with stupor — is 
 very close, and it is only in typical cases of the respective 
 forms that there is a well-pronounced difference between them. 
 
 Circular Insanity {Folie eirculaire) is a form in which 
 mania and melancholia alternate, sometimes with intervals of 
 a few days, or a week or two, of apparent sanit>^; usually the 
 cycle is completed in a month or six weeks. The alternating 
 condition often partakes more of dementia than of melancholia. 
 
 The contrast between the physical symptoms of the respec- 
 tive mental states is equally striking. Thus, so long as the 
 depression lasts the pulse is small and feeble, the skin is chilly 
 and dry, the bowels are sluggish, and the appetite is indiflerent, 
 though a sufficiency of food is generally taken ; while, on the 
 other hand, an exaggerated activity of all the bodily functions 
 is usual during the period of excitement. In the latter state 
 the temperature exceeds the standard of health, whereas in the 
 
310 INSANITY. 
 
 former it is below it. When the alternations are fully estab- 
 lished, this form of insanity is very frequently incurable. 
 
 Katatonia is the name which has recently been given to a 
 variety of circular insanity, in which physical phenomena of a 
 very varied kind occur. They are associated more particularly 
 with the depressed or melancholic stage of the disorder. The 
 most characteristic features are epileptic fits and cataleptic 
 states, which may coexist with stupor or profound melan- 
 cholia ; sometimes convulsive seizures are amongst the earliest 
 symptoms of the disorder. After weeks or months of this 
 mental and physical torpor the patient emerges from it, and 
 often passes into a condition of exaltation, or at least of excite- 
 ment, in which he assumes histrionic attitudes and, as has been 
 said, speaks and acts dramatically. Hallucinations of sight 
 and hearing are now manifested, and it would seem, at least 
 in some cases, that the mind was active during the preceding 
 stage : thus one patient who had been for months cataleptic, 
 afterward told the writer that in acting as he had done he was 
 obeying the commands of the Almighty. While the mental 
 depression lasts there are a sluggish circulation, coldness and 
 blueness of the surface, and occasionally oedema of the ex- 
 tremities ; defective sensation is also a prominent symptom, 
 and many patients are inattentive to the calls of nature. This 
 state gradually gives place to quickened but often irregular 
 action of the heart, and to improvement in the general tone of 
 the system, concurrently with which there is, as already indi- 
 cated, greater though abnormal activity of mental function. 
 From this condition there may be progressive and complete 
 recovery, or the patient may relapse into mental torpor and 
 catalepsy with or without convulsive seizures ; but before this 
 recurrence there is in many cases an intervening period, it may 
 be of almost full restoration to mental health, or, on the other 
 hand, of acute mania. The elements of the morbid cycle vary 
 greatly in different cases. 
 
 Partial Emotional Insanity. — In the disorders described 
 under monomania partial derangement of the intellect is the 
 most prominent feature. But insane feeling, usually fear or 
 apprehension, limited to certain positions or surroundings, 
 may be the chief expression of the psychical distiirbance. 
 One variety of this state is a dread of being alone in a wide 
 s]3ace — in the country, for instance, or in an open market 
 place. To this the name of agoraphobia has been applied. 
 The subject of it if alone, say in a public square, is seized 
 with intense dread, his heart palpitates violently, he becomes 
 
IMPULSIVE INSANITY. 311 
 
 giddy, chill perspiration bedews his face, the houses and other 
 objects seem to whirl round him, and, to prevent himself from 
 falling, he leans against the wall, or crouches to the pavement, 
 or clutches at a passer-by. Should any one take his arm and 
 lead him into a small apartment, these sensations quickly sub- 
 side and he feels quite well. 
 
 But the apprehension may be of quite an opposite kind, 
 namely of a confined or shut place, and this bears the name 
 of claustrophobia. The sufferers from it experience a distress 
 equal to that just described if in a closed room, at least when 
 alone, but are at once relieved when the windows and door 
 are opened. Some people have a morbid dread of society, 
 others of being alone ; the former has been designated anthro- 
 2)02)hobia, the latter inonophobia. To the intense fear which 
 some endure while a thunderstorm lasts, the name astrophobia 
 has been given. The latter varieties of emotional weakness 
 are perhaps scarcely to be regarded as distinct forms of mental 
 disorder. 
 
 More deserving of a place in this category is a morbid fear 
 of pollution, which is the prominent symptom in some cases. 
 Those suffering from it will refuse to shake hands with others, 
 or even to touch them lest they should acquire some con- 
 tagious disorder or be somehow contaminated by the contact. 
 On being reasoned with they may tacitly acquiesce in the 
 statement that there is no reasonable ground for their appre- 
 hension, but notwithstanding this admission, they will prob- 
 ably proceed to rub or wash their hand or other part which 
 may have been touched. This mental condition is called 
 mysophobia. The writer has met with an apprehension of an 
 opposite kind, where the dread of the patients was that they 
 themselves would defile others by their touch. In these latter 
 cases more particularly there is a tolerably clear basis of de- 
 lusion, as there is also in another of the " j^/io^ms" which has 
 still to be mentioned — that of syphilis ; and though grouped 
 together here on account of their distinctive features, they 
 might correctly be classed with other monomanias of the 
 intellect. 
 
 Impulsive Insanity. — A teudency to act under insane 
 impulses is a feature of the acute forms of mania and melan- 
 cholia, particularly the former. Besides this, however, there 
 are varieties in which this disposition is the chief, and occa- 
 sionally almost the only evidence of mental derangement. 
 Generally there is only one kind of impulse in the same patient, 
 but there may be more than one, and the one may alternate 
 
312 INSANITY. 
 
 with the other. The suicidal and the homicidal are the most 
 common and the most important, and bear the names of 
 suicidal and homicidal mania, although this last form is rare, 
 and recently its very existence has been questioned by some 
 authorities. 
 
 Similar morbid impulses to steal and to set fire to houses, 
 etc., are known respectively as kleptomania and pyromania. 
 But homicidal and other criminal acts are much more fre- 
 quently the results of deUisions, and more particularly of 
 " voices " that may seem to the victims to come from Heaven, 
 requiring implicit obedience from them, as a sacred duty. 
 
 The impulsive tendency is not unfrequently manifested in 
 persons respecting whom no suspicion of mental defect is enter- 
 tained by others, in prompting to break large sheets of glass, 
 to interrupt public speakers in their addresses, and to other 
 actions which the patients know full well to be wrong, and 
 struggle against with all their might, and fortunately almost 
 always successfully. In some who are troubled in this way 
 the writer has found other indications of derangement in the 
 nervous system — one which was much complained of being a 
 " springy " feeling in the feet, as if they were made of India- 
 rubber. This sensation was experienced every few steps in 
 walking, and when severe passed up to the head, producing a 
 giddy feeling. A nother troublesome symptom was involuntary 
 starting of the limbs in going to sleep. In all these patients 
 the cause appeared to be mental strain. But the enfeeblement 
 of will may be manifested by phenomena of a very different 
 kind. A case, for example, is recorded by Hammond, in 
 which the patient, an intelligent gentleman, would spend an 
 hour or two in determining whether he should take off his coat 
 or his shoes first in undressing for bed, and frequently he 
 \vould fail and require to summon assistance: his morning 
 experience was similar ; he would sit for half an hour with 
 his stockings in his hands, unable to determine which should 
 be put on first. French writers have named this disorder, 
 " folic du doute." In other cases similar difficulty has been 
 experienced about the raising of a glass of water to the head, 
 crossing a gap in a line of houses, and many other matters. 
 
 Moral Insanity. — Sometimes the moral powders of the 
 mind are afiected in a marked manner, wdiile the intellectual 
 are but little disturbed. This condition has been called moral 
 insanity. Those in whom it is seen have usually a strong 
 hereditary bias toward mental disorder, and may have pre- 
 viously sufiered from it in one of its more complete forms — 
 
COMMUNICATED INSANITY. 313 
 
 particularly mania. Pure cases of this variety are rare : still 
 they are met with occasionally. The symptoms are lying, 
 stealing, cheating, mischief-making of all kinds, and a dis- 
 position to violence — these being opposed to the patient's 
 former character. In one characteristic case, long under 
 observation, besides the state just described, there was further 
 evidence of morbid change in the brain in partial hemiplegia. 
 This designation — moral insanity — is objectionable, and should 
 be avoided by medical witnesses in courts of law ; if required 
 to define the condition, it is better to speak of " partial in- 
 sanity." 
 
 Communicated Insanity (Folie a deux, Folie communiquee). 
 — As indicated by the title, this variety of mental disease 
 arises from close association Avith an insane person. It occurs 
 most frequently in women. The writer recalls three cases of 
 sisters in each of which the insanity of one of them had ap- 
 parently this origin, the imposed and original forms being 
 identical or nearly so. In two of the cases there were hallu- 
 cinations of hearing and delusions of suspicion, in the third 
 the delusions were of an amatory kind. The sisters lived 
 apart by themselves, except in one instance, where they re- 
 sided with their brother and widowed mother. It has been 
 held that in such cases the one first affected, having more force 
 of character, either natural or acquired by disease, than the 
 other, impresses her morbid ideas on her companion, who 
 gradually assimilates them till they become part of her mental 
 constitution. This, though usually the order of development, 
 is not always so, as in one of the cases referred to the more 
 vigorous of the two was the last to succumb. Though the 
 communication is generally to only one individual, it may be . 
 to two and even more members of a family. In almost all 
 the recorded cases the suflTerers were closely related to each 
 other, so that in all probability there was a hereditary dispo- 
 sition to mental disease. In this connection it is worthy of 
 remark that it has not been clearly established that a larger 
 proportion of the attendants in lunatic asylums become insane 
 than of other classes of the community, though it is probably 
 somewhat higher. 
 
 The insane themselves do not often acquire each others' 
 delusions; instances of that kind are, however, of occasional 
 occurrence. Thus, there is at present a patient in the asylum 
 under the writer's charge, who for many years has entertained 
 the delusion that there is a peacock in her head. For some 
 months another jiatient of good general intelligence, who had 
 
 27 
 
314 INSANITY. 
 
 insane ideas about money, Avas much beside her at work. The 
 latter, while still adhering to her fancies respecting wealth, 
 was found to have adopted her comrade's peculiar craze and 
 even in. an exaggerated form, for she insists that not one but 
 two or three peacocks are in her brain. 
 
 Relation of Vat'ious Diseases and Functional Disorders to Insanity. — 
 In susceptible persons certain states of the system, both physiological 
 and pathological, are sometimes the immediate causes of insanity ; or 
 if in some cases they are not the sole agents, they so operate that 
 trifling, and of themselves altogether inadequate, irritations, mental 
 or physical, become cajiable of inducing derangement of. mind. Arising 
 in such systemic conditions, the forms of mental disorder acquire dis- 
 tinctive characters, which have given rise to special names indicating 
 the supposed causation. Thus there is an hysterical mania in which 
 the strange imaginations and peculiar deceptions characteristic of 
 hysteria are associated with excitement, slight incoherence, morbid 
 craving for sympathy, hallucinations and delusions, and erotic displays, 
 as well as generally with some of the physical symptoms of the disease, 
 such as the gktbus hystericus, hysterical convulsions, and inability, or 
 alleged inability, to pass urine. 
 
 At the establishment of the tnenstrual function^ excitement with 
 delusions and a disposition to impulsive violence may appear, consti- 
 tuting the " mania of puberty." This generally passes away in a few 
 days or weeks, and seldom continues after menstruation is regular. 
 At the same period of life, in both sexes, instead of ordinary acute 
 mania, that already described as simple mania, or, as it is sometimes 
 called, reasoning mania, may arise, but the form may be a moral per- 
 versity manifesting itself by a suddenly acquired disposition to lying, 
 cheating, stealing, and the like, — this state being the result of disease, 
 though very often not so considered. It is not unfrequently preceded 
 by marked mental depression, with distinct suicidal attempts. Hallu- 
 cinations of hearing and sight, and also delusions, spring up in the 
 course of the disease, but it may not be till after months or years 
 have passed, during which there may be nothing but the moral ob- 
 liquity and waywardness of conduct to indicate the i)resence of mental 
 aberration. It is to this form that the term hebephrenia has been 
 applied. It is much more likely to be of long duration than the 
 maniacal condition, and too often gradually involves the mind gener- 
 ally, passing ultimately into incurable insanity. 
 
 J3etween puberty and the full development of the body, mental dis- 
 order may arise from various causes. This period extends over a 
 number of years, but is shorter in women than in men, for the former 
 airive at maturity sooner than the latter. It is held by some authori- 
 ties that the derangement of mind which then occurs has special 
 characters owing to the activity of the processes of growth, especially 
 those related to the sexual functions; they have named it the insanit}'^ 
 of adolescence. Mania is the form that usually presents itself, and 
 the symptoms are, as a rule, acute, and marked by vigorous demon- 
 strations. Hallucinations relating to the generative organs, or at least 
 of an amative nature, are common, but further than this there is 
 nothing distinctive in the features. 
 
RELATIONSHIP TO VARIOUS DISEASES. 315 
 
 Disorder of the uterus and ovaries at any time during the years of 
 their functional activit}^, especially when there is amenorrhoea, is not 
 an uncommon cause of other varieties of insanity. The distinctive 
 delusions that spring: up then have often reference to these organs or 
 to their functions ; thus the sufferers may fancy that they give birth 
 to children, or that their persons are violated while asleep. Nympho- 
 mania may arise from the same source; the particular feature in it 
 being a disposition on the part of the patient to make indecent ad- 
 vances to the other sex, and even to make shameful exposure of the 
 pei-son. A distinction has been drawn between this state, which is 
 regarded as due to the general disturbance of the nervous system from 
 a peripheral irritation in the sexual organs, and that named eroto- 
 mania, in which the organs of generation are apparently health}'-, and 
 the morbid action is believed to be entirely in the brain. The mental 
 symptoms are really alike in both, though it has been held by some 
 that, as opposed to nymphomania, the language and conduct in eroto- 
 mania are pure, and do not greatly transgress propriety. In the male 
 sex a condition corresponding in the character of the acts and in the 
 general psj'chical features is known as satyi-iasis. It is, however, to 
 be borne in mind that delusions connected with the organs of genera- 
 tion in both sexes may exist with perfect propriety of conduct, and 
 also that amenorrhoea is a common symptom in insanity due to other 
 causes. 
 
 At the close of menstruation one of the many troubles that are apt 
 to arise is mental disorder. It occasionally assumes a maniacal char- 
 acter, but much more frequently the form is melancholia, with delu- 
 sions and a disposition to suicide. It has been named "climacteric 
 insanity." The symptoms are those of ordinarj' melancholia, a mor- 
 bid fear of having done something wrong or of impending evil, with 
 impulsive tendencies to homicide as well as to suicide, being somewhat 
 prominent features in many cases. It is rather an unfavorable form 
 of mental disease; still, recoveries are not rare. 
 
 It is thought by some that excessive venereal indulgence^ especially 
 in the newly married, may suffice to overthrow the mental powers in 
 susceptible persons, inducing what has been designated sexual mania; 
 but other direct causes probably always combine with it in the pro- 
 duction of the insanity, and there is nothing distinctive in the symp- 
 toms. 
 
 The vice of niasturho,tio7i, in both sexes, sometimes induces an in- 
 tractable form of mental derangement. Early symptoms springing 
 from the vile habit are an unwonted shyness and an evasive look, 
 irresolution of character, and a disposition to be alone. By-and-by 
 a general feeling of fear and suspicion of others arises, with sulkiness 
 of temper; then come hallucinations, such as that the victims arc 
 acted on through the walls by electricity, that their food is poisoned, 
 that they are tormented by evil spirits, etc. ; great religious fervor is 
 common, especially in women. There is, however, much variety in 
 the morbid phenomena. Thus the writer has met with cases in which 
 feelings of pride and self-consequence were well marked, with grandiose 
 delusions and an offensive forwardness of manner. In most cases the 
 intellect gradually becomes weak, and after an indefinite period the 
 unfortunate sink into dementia. General nervous symptoms, such as 
 palpitations and feeling of sinking at the heart, are usually associated 
 
316 INSANITY. 
 
 from the beginning with the psychical disturbance. Should the mas- 
 turbation be stopped before the intellect is much impaired, mental 
 health maj^ be restored ; but if once insanity has been distinctly estab- 
 lished, recovery is the exception, rather than the rule, as the vice is 
 then seldom mastered. 
 
 The influence exerted on the mind of women by the sexual S3^stem 
 is evinced in other ways than those mentioned. The majority of 
 women are more susceptible and impressible, and are sometimes very 
 irritable during the flow of the menses. During healthy jjregnancy, 
 also, cravings for extraordinary articles of diet are very common. 
 These are usually innocent enough, but not always, as when a woman, 
 overcome by the sight of the bi'awny arm of a baker who worked 
 opposite her dwelling, compelled her husband to offer him money to 
 allow her to take " one bite " out of it. 
 
 Mental disease occasionally appears during utero-gestation, and is 
 apparently dependent on it; this is known as the insanity of freg- 
 nancy. It is not common, and is more prone to occur at a late than an 
 early period of gestation. Though mania and monomania are both 
 met with, melancholia is the usual form, refusal of food, and a dispo- 
 sition to suicide being sometimes marked features. The majority of 
 such patients recover soon after delivery, but a large proportion con- 
 tinue insane. 
 
 In severe labor, during the passage of the head through the os inter- 
 num, and also through the vaginal orifice, it occasionally happens 
 that the patient fVills into a state of semi-conscious delirium, lasting 
 for a few minutes. The writer has seen a mild attack of mania arise 
 during severe labor resulting from contracted pelvis, which passed 
 away in two days after delivery. This is a rare event. 
 
 The most important of all this group of disorders is that which 
 occurs within two or three weeks after delivery, and bears the name 
 of puerperal mania. The fi^urth or fifth day is the most common 
 time for the appearance of the symptoms, though it may be at an 
 earlier as well as at a later period. Sometim.es the attack is very 
 sudden, but genprally for a day or two previously the patients are 
 unusually excitable, give little or no heed to their infants, sleep little 
 or none, complain of pain and a feeling of constriction in the head, 
 and have often ocular disorders, such as flashes of light and double 
 vision. They ramble in conversation, and talk more than in health; 
 imagine they see objects ; mistake the identit}' of peoj^le, and act fool- 
 ishly. The fjulse is also quick, and the skin may be hot. When the 
 insanity is fully developed, the symptoms, both physical and mental, 
 are all of an acute type, and the condition may even amotmt to de- 
 lirious mania ; but, fortunately, this is somewhat exceptional. It is a 
 feature of the psychical state that the language used is often filthy 
 and obscene. Aversion to husband and baby is a common, but by no 
 means a constant, symptom. Under the influence of this feeling, 
 mothers have in many instances destroyed their infants. Cases are 
 also met with, beginning within a week after childbirth, in which"the 
 condition would be more correctly designated acute melancholia than 
 acute mania, Early in the disease, as a rule, both the lochial dis- 
 charge and the mammary secretion are arrested; but in mild cases 
 the latter, and even both, may continue to flow, though in reduced 
 quantity. Occasionally the urine is found to be albuminous. It is 
 
RELATIONSHIP TO VARIOUS DISEASES. 317 
 
 well to remember that there is also sometimes metritis or endometritis, 
 as these are apt to be overlooked through the greater prominence of the 
 mental symptoms. First confinements are more liable to be followed 
 by mania than subsequent ones; but it is not uncommon for a woman 
 to have an attack after several successive births. Good recoveries, as 
 a rule, are made after the first two, or even three, seizuies; but should 
 there be any more, the mind generally becomes permanenth' weakened. 
 Although the maniacal is by far the most frequent form of mental 
 derangement, melancholia occurs occasionally. 
 
 There is yet another important variety connected with the puerperal 
 state — the insanity of lactation. It occurs after some months' nurs- 
 ing, or immediately after the weaning of the infant, and is largely 
 due to the drain, through the mammary glands, having proved too 
 much for a feeble or susceptible frame. As might be expected, 
 the patients are weak, and usually anremic. Melancholia is the 
 type of disorder that is most frequently developed, but other forms 
 are occasionally seen. In this variety, also, a disposition to destroy 
 the infant is not uncommon ; besides this, a tendency to suicide is 
 sometimes manifested. Exophthalmic goitre and functional cardiac 
 murmur have been noticed in a few cases, particularly where the men- 
 tal derangement presented maniacal features. The prospect of re- 
 covery from this, as from the preceding variety of puerperal insanity, 
 is very good, at least from first attacks ; a small percentage, however, 
 lapse into incurable insanity. 
 
 Alcoholic Insanity. — As alreud}^ stated, "transitory mania" may be 
 at least directly induced by alcohol ; but besides this and the much 
 more common disease, delirium tremens (see p. 256), there are other 
 disorders resulting from the same powerful agent, which have yet to 
 be noticed. (1) Habits of intoxication, along with the ordinary 
 symptoms of chronic alcoholism, often induce a state of mind char- 
 acterized by gloomy suspicion and hallucinations of hearing. This 
 condition has prompted to homicide as well as to suicide in a number 
 of cases. (2) Excesses in alcohol may cause mania or melancholia of 
 an ordinary acute kind, except that the delusions partake of the de- 
 lirium tremens character, and that the attacks themselves are of 
 shorter duration. Though cases of this kind are occasionally seen, 
 they must be regarded as rare. (3) Progressive dementia, accom- 
 panied by a form of general paralysis, is a rather common result of 
 prolonged drunken habits. It not unfrequently occurs in women who 
 have been long addicted to secret tippling. The symptoms closely re- 
 semble those of ordinary general paralysis, and in some cases the dis- 
 orders can scarcely be distinguished from each other. The diagnosis 
 will be considered in connection with general paralysis. (4) There 
 remains the condition known as dipsomania or oinomania. The crav- 
 ing for drink in this state is insatiable, and no consideration whatever 
 deters the victim from seeking its gratification. Three varieties have 
 been distinguished — the acute, the chronic, and the periodic. The 
 acute, which is rare, has been noticed after hemorrhage in the puer- 
 peral state, in recovery from fevers, after excessive venereal indulg- 
 ence, and in some forms of dyspepsia. It often passes away in a few 
 days, and shows no disposition to return. The chronic is the form 
 that exists in the habitual drunkard. In him the craving for alcoholic 
 stimulants is constant, and is often strongest in the morning. He ex- 
 
 27* 
 
318 INSANITY. 
 
 periences a sensation of sinking at the stomach, with a feeling of 
 mental depression amounting even to misery when not under their in- 
 fluence. Great moral depravity is generally a marked feature of 
 character; and the writer has observed that in women this is usually 
 associated with much pretence or show of religion. The periodic 
 variety is not common. It occurs in paroxysms of exceeding severity, 
 ordinarily with intervals of some months between them. All these 
 varieties, but particularly the last one, are not unfrequently the out- 
 come of the " insane temperament." 
 
 The poison of syphilis in the constitution may give rise to different 
 forms of associated disorder of the brain and mind. Thus, after a pro- 
 dromal period of irritability, slowness of mental action, and occasional 
 confusion of ideas, accompanied by shooting pains in the limbs and 
 numbness of the head, there may be one or more convulsive fits, fol- 
 lowed by mania or melancholia ; or instead of either of these forms of 
 mental derangement, the symptoms mentioned may be succeeded by a 
 hysterical condition which rapidly declines into dementia more or less 
 complete. Sometimes the premonitory stage is succeeded by a state 
 which bears considerable likeness to general paralysis. There may 
 even be grandiose delusions likewise, though tliis is not common. 
 The defects in articulation and the paresis of the voluntary muscles 
 generally are very similar in both cases. In the syphilitic form we 
 find both greater rapidity and irregularity in the progress of the symp- 
 toms. The sensory phenomena are likewise much more marked, such 
 as pains in the limbs, numbness, and formication ; and these, as well 
 as the motor symptoms, are more apt to be unilateral at an early stage 
 of the disease. The retinse are less frequently affected : and should 
 there be inequality of the pupils, it will probably be found that some 
 of the ocular muscles are also paralyzed. The convulsive seizures are 
 more disposed to be partial, both as regards the implication of con- 
 sciousness and the muscles involved, than in the case of geneial paral- 
 ysis, and the attacks are also more frequently followed by paralysis 
 of the convulsed members ; this may or may not be persistent. The 
 evidences of constitutional syphilis in nodes, enlarged glands, cutane- 
 ous eruptions, etc., with a histor}^ of contagion, will of course materi- 
 ally aid the diagnosis. It is to be observed that insanity, as well as 
 other forms of disease in the central nervous system due to syphilis, is 
 most apt to occur in cases where the secondary symptoms have been 
 slight or at least not marked. It does not follow from this that the 
 sufferers from constitutional syphilis, with pronounced external symp- 
 toms, have an immunitj^ from mental disease. The writer may men- 
 tion, in illustration of the contrary, that he has had cases both of 
 mania and dementia under his care, in which there was necrosis of 
 the bones of the skull and of the nasal cartilages, the latter conditions 
 at least being dependent on the action of the sypl)ilitic poison. 
 
 Besides a real there is also a spurious syphilitic insanity, which bears 
 the name of syphilophobia. The distinctive feature of this disorder is 
 an intense fear in the mind of the sufferer that syphilis has been 
 acquired, every trifling papule being regaided as convincing evidence 
 of its presence. In other respects the mental state is that of acute or 
 chronic melancholia. It is most frequently met with in persons of 
 high moral tone who have once or twice fallen into irregularity of 
 conduct. 
 
RELATIONSHIP TO VARIOUS DISEASES. 319 
 
 Epileptic Insanity. — When epilepsy has continued for some years it 
 induces mental defect, and this may occur much sooner if the fits are 
 frequent, but if they are at long intervals the mind may remain un- 
 affected. In some cases the petit fnal would appear to exert a more 
 baneful influence on the mental powers than the full convulsive seiz- 
 ure ; but this, though asserted by some, is not always the case, as the 
 writer has seen patients subject to the latter form in whom dementia 
 rapidly supervened, and others who had suffered from epileptic vertigo 
 for years, at short intervals, and still . retained considerable mental 
 vigor. Irritability of temper and weakness of memory are the first 
 indications of the mind being involved, but in course of time all its 
 powers are implicated, and ultimately the wreck is complete. But 
 instead of a uniform, progressive degeneration, it often happens that, 
 after a single seizure or a number in succession, an acute maniacal 
 attack occurs, in which there is generally manifested a disposition to 
 violence, and occasionally also to suicide in the same patient. Mur- 
 ders have been committed by epileptics while in this condition. Hal- 
 lucinations and delusions are usual in the course of paroxysms, and 
 some patients manifest marked religious feeling at these times more 
 particularly. The mania may pass away in a few minutes or in an 
 hour or two, and in any case seldom lasts longer than four or five 
 days, though it is apt to return on the recurrence of the fits. The last 
 feature, however, is very irregular, and, in illustration, the writer 
 may allude to a patient under his care who had an attack of epileptic 
 mania about five years ago, and has ccmtinued free from it since, 
 while there has been no abatement of the convulsive seizures. Though 
 the mental disorder generally follows the convulsions, it occasionally 
 precedes them, and in some cases would seem to take their place, the 
 entire paroxysm being apparently mental. In some instances epilep- 
 tics fall into an automatic state without having had a convulsive 
 attack, and then perform actions which, though usually irregular and 
 destructive, may be definite and correct in themselves, but only wrong 
 as to time or place, — the patients being quite unconscious, and in- 
 credulous when told of their conduct on their recovery. This state is 
 generally very brief, lasting only for seconds or minutes, but it may 
 continue for half an hour, seldom longer. 
 
 The poison of rhewnatisin and gout in the system may induce mental 
 disorder which sometimes amounts to insanity. Such attacks are 
 often of a metastatic character, the joint affection being in abeyance 
 during the continuance of the mania, which is the usual form of de- 
 rangement in these circumstances. The attack commonly passes away 
 within three or four vv^eeks. A similar event may occur in the course 
 of asthma. For example, a person who had been a martyr to the 
 spasmodic form of the disease for nearly twenty years, rather suddenly 
 became maniacal ; the asthma then entirely disappeared, and did not 
 trouble her during the six weeks that the insanity lasted; but when 
 the latter subsided, the asthma returned in all its former oppressive- 
 ness. The writer has also seen \X\e jioison of lead induce an attack of 
 maniacal delirium, which continued for a few days in one case, and 
 for a month in another ; there were also convulsions in the former 
 case, but none in the latter; the characteristic blue lines on the gums 
 were present in both. 
 
 The feeling of sinking and general discomfort experienced by those 
 
320 INSANITY. 
 
 habituated to the use of opium, in whatever form and way it be taken, 
 when ihey are not under its influence, occasionally attains to such a 
 degree of intensity that the condition may even amount to insanity. 
 The unfortunate sufferers who have arrived at this stage, after the 
 effect of the drug has died awa}^, are wretched, miserable, and may 
 even be suicidally disposed. The writer has known it necessary to 
 commit such a one to an asylum : but this is quite exceptional. 
 
 Phthisical Insanity. — In the later stages of phthisis pulmonalis 
 mania is occasionally developed. The symptoms are generally very 
 acute, even attaining the severity of those of delirious mania: the 
 attack often terminates in fatal exhaustion. In an early stage of the 
 same disease, or of general tuberculosis, Dr. Clouston has pointed out 
 that a morbid mental condition of a different character is sometimes 
 present. It is characterized by unfounded suspicion and irritability, 
 with occassional bursts of excitement or fits of depression. This mental 
 state is, however, not so common as an opposite one in tubercular dis- 
 ease of the lungs, in v;hich the patients are sanguine and unduly 
 hopeful, even when their illness is going on to a fatal issue. But the 
 psychical condition in the latter case is not insanity. 
 
 The excitability which is an ordinary symptom of Graves's or Base- 
 dow's disease (exoj)hthalmic goitre), may increase and be accompanied 
 by incoherence and violence, so that mania is established. The attack 
 commonly subsides in a few days. 
 
 One of the characteristics of the peculiar widely diffused disease of 
 the tissues, to which Dr. Ord has given the name of myxoedema, is a 
 dulness of perception and a general torpor of the mental faculties. 
 Dr. Savage has described cases in which there were also present delu- 
 sions of suspicion, but the number hitherto observed is too small to 
 warrant the conclusion that these may be regarded as typical of the 
 insanity that has this origin. 
 
 Tape-tvortn in the intestinal canal may induce mania through the 
 action of the peripheral irritation on the brain, just as it occasionally 
 gives rise to epilepsy. 
 
 Blows or falls on the head are not unfrequently followed by insanity. 
 The form varies: mania and dementia are both met with, as also a 
 combination of the two. The condition is hopeful or otherwise ac- 
 cording to the amount of injury sustained by the brain. 
 
 When distinct insanity is produced by sunstroke^ or follows typhus 
 fever or other of the exaniheynaia ^ although mania may be the primary 
 character, dementia generally soon ensues; or the insanity may be of 
 this form from the first. Tiie prognosis in these cases is generally un- 
 favorable. But tliis is to be distinguished from a condition of mental 
 excitement of moderate severity, accompanied by hallucinations of 
 hearing and sight, which occasionally arises somewhat suddenl}' in an 
 advanced stage of these diseases, and also in pneumonia, but usually 
 passes away in a day or two, or even sooner. This has been lately 
 described as a form of insanity; but observation of such cases would 
 rather lead the writer to designate it as an acute form of delirium, 
 symptomatic of the associated disease, though not always of a state of 
 collapse, as was believed by Dr. II. Weber, who first directed atten- 
 tion to this vaiiety of mental disorder. 
 
 The catalogue of physical diseases or causes, on which insanity may 
 be more or less dependent, has not yet been exhausted. In fact, it 
 
GENERA]. FARALYSIS. 321 
 
 would seem that a morbid condition of any organ, in persons of weak, 
 susceptible nervous systems, may so disturb the functions of the brain 
 that mental derangement may be the result. Thus it has been devel- 
 oped in connection with cardiac, intestinal, hepatic, and vesical dis- 
 eases. There is little uniformity in the symptoms of the insanity 
 which arises in this way; and it would rather appear that the char- 
 acter of the mental disturbance is more dependent on the general con- 
 dition of the system as to strength or weakness, and on the nature of 
 the hereditary bias, which so commonly exists, than on the. special 
 organ whose morbid state may have been the exciting cause of the 
 cerebro-mental disorder. At the same time it may be said generally 
 that disease in the abdominal organs, and especially in the liver, is 
 more apt to be associated with melancholia than in any other form. 
 It has been alleged that when disease of the heart and unsoundness of 
 mind both exist in the same person, melancholia is the form most 
 commonly found with mitral lesions, and mania with aortic disease; 
 but the uniformity of these associations is not established. In con- 
 sidering the concurrence of disease in these organs with insanity it is 
 always to be borne in mind that this may be altogether accidental, or 
 that their morbid state may be due to that impaired nutrition of the 
 central nervous system on which the insanity itself depends. 
 
 General paralysis, also called " general paresis," and some- 
 times "paralytic dementia," is a very important and a very 
 fatal form of insanity. It is peculiarly a disease of middle life, 
 seldom occurring under thirty or above sixty years of age. It 
 is at least four times more common among men than among 
 women. Its ordinary duration is from two to three years; 
 but it may terminate fatally in six months, or be protracted 
 for six years or longer. When the disease is developed, in 
 nine cases out of ten there is exaltation of feeling, though this 
 is occasionally preceded by a brief period of depression ; and 
 in a few exceptional cases there is melancholy feeling through- 
 out its whole course. After the brief preliminary stage of 
 depression has passed away, if it existed at all, the patient 
 becomes restless and flighty in his manner, and impatient of 
 control. He spends his money foolishly, and launches forth 
 into wild speculations. Then the characteristic delusions 
 arise. He asserts he is ^vorth millions of money, is as strong 
 as Samson, and is king of the universe ; any or all of these or 
 similar extravagant notions may be entertained. Even in this 
 stage, the defective memory and the inability to follow out any 
 subject of thought, reveal the enfeeblement of intellect ; and 
 emotional ^veakness may also be evident in the aspect, and the 
 tendency to bursts of passion if in any way opposed. At this 
 period there is also sometimes a disposition to indulge to 
 excess in alcohol, and to be indecent in conduct before the 
 
322 INSANITY. 
 
 opposite sex ; occasionally a proclivity to steal is manifested. 
 The delusions usually persist to near the fatal close, or at least 
 so long as advancing defect in articulation permits of their 
 being recognized ; but even they would seem sometimes to be 
 involved in the utter wreck of mind in the final stage. In the 
 earlier period of the disease, maniacal excitement, with de- 
 structive tendencies, is very common ; and it occasionally 
 happens that a maniacal attack occurs at the very onset. In 
 some rare cases expansive delirium yields to hyj^ochondriacal 
 feeling, and in others, equally rare, the disorder assumes the 
 circular type. 
 
 Indications of the paralysis appear in most cases shortly 
 after the onset of the psychical disturbance ; but it is to be 
 observed that at first the condition is ataxic rather than dis- 
 tinctly paralytic. The two sets of symptoms frequently, how- 
 ever, occur simultaneously, and the ataxic may even precede 
 the mental disorder. These indications are first noticeable in 
 tremor of the upper lip, especially when the zygomatici and 
 the elevators of the lips are in action. Certain movements of 
 the tongue are likewise not performed with their natural pre- 
 cision. The patient has thus difficulty in articulating words 
 ill which there are several labials or liquids — tolerable, Feb- 
 ruary, constitutional — for example. The defect seems a 
 thickness or slight stuttering, like that of a person in the first 
 stage of drunkenness ; and it may only be observable at this 
 period when the patient is under emotion. It is not usually 
 till after some weeks or even months have elapsed that the 
 muscles of the lower extremities are involved. Then there is 
 observable at first a peculiar cautiousness of gait, with slight 
 uncertainty and unsteadiness, most distinct when about to 
 turn after walking a few paces. The arms are often late of 
 being much implicated, but ultimately they do not escape. 
 As the disease progresses, the articulation becomes more and 
 more indistinct, the tongue while being put out is projected in 
 a jerky manner, and a fibrillar movement is observed in its 
 substance. Similar tremulous, irregular contractions occur in 
 the muscles around the mouth when called into action. All 
 the muscles of the face are involved, and a characteristic 
 hebetude of expression is acquired. Though both sides are 
 generally affected ])retty equally, the paralysis occasionally 
 is more pronounced in tlie muscles of the one side than the 
 other. AVhen the disease is far advanced, the muscles of 
 deglutition and respiration participate in the increasing ruin, 
 and it is not seldom that death occurs from choking by a mor- 
 
GENERAL PARALYSIS. 323 
 
 sel of ordinary food. In most cases after it has reached its 
 middle stage, epileptiform seizures and attacks of cerebral con- 
 gestion occur occasionally : but though more common at this 
 and the later periods, the convulsive attacks are not confined 
 to any stage; they may occur at the commencement of the 
 disease. Instead of involving the whole body, as is usual, the 
 seizures may be partial, resembling those of syphilitic origin. 
 The pupils are very generally unequal : in some they are 
 minutely contracted ; in exceptional cases they are normal. 
 There is often hypersemia of the retina in the early stage, 
 and neuro-retinitis, quickly passing into atrophy, when the 
 distinctive symptoms of the disease are obvious : but there 
 are many exceptions to this rule. Loss of the sense of smell 
 has been stated to occur early in the disease, but according to 
 the writer's observation this is certainly not a uniform symp- 
 tom. Auditory hallucinations are occasionally observed, par- 
 ticularly when the disease is of syphilitic origin. Defect in 
 cutaneous sensibility is not very marked at first, but later its 
 existence is clear ; local hypersesthesia may coexist with it. 
 The muscular sense is also impaired ; and electric contractility 
 suffers at an advanced period. AYhen the disease is distinctly 
 progressing, the evening temperature is often from 2^ to 4° F. 
 above the normal. Convulsions and cerebral congestion are 
 marked by a still greater increase of heat. " Hsematoma auris" 
 not unfrequently occurs along with the more acute symptoms. 
 In a few cases, during the course of the disease, there are re- 
 markable remissions, extending over a number of months, and 
 these may be so complete that a cure may be supposed to have 
 been eflfected ; but unfortunately, with scarcely an exception, 
 there is a relapse, leading ultimately to a fatal issue. The 
 progress of the disease is slower in women than in men. 
 
 In private practice general paralysis is very often over- 
 looked in its early stage. In a few exceptional cases the 
 diagnosis is difiicult, but in the great majority, when the 
 symptoms are looked at together — for no one by itself is 
 pathognomonic — it is easy, and a mistake should not occur. 
 The following are the leading symptoms, mentioned in their 
 order of importance : Diificulty in articulating certain words, 
 and tremor of the u]3per lip ; emotional weakness with exalta- 
 tion (it may be necessary to contradict the patient before 
 these are properly manifested) ; grandiose delusions ; general 
 feebleness of judgment and memory; unsteadiness of gait; 
 inequality of pupils ; hy perse mia of retina, followed by atrophy 
 of optic disk. Sometimes the intense self-feeling, as well as 
 
324 INSANITY. 
 
 the exaltation, come out most distinctly in writing, and it may 
 therefore be advisable to ask the patient to write his views on 
 any subject in which he may seem to be particularly interested. 
 It will also be noticed that in many cases there is an omission 
 of syllables or words, or a repetition of them. 
 
 The disease for which it is most apt to be mistaken is a 
 form of paralytic dementia due to long-continued excesses in 
 alcohol ; and certainly it is occasionally very difficult to dis- 
 tinguish between them. This is not surprising when it is 
 remembered that habits of drunkenness are sometimes asso- 
 ciated with over-indulgence in venery in the production of 
 real general paralysis. The distinguishing features of the 
 alcoholic variety are: Stupidity with depression of feeling, 
 rather than emotional exaltation with intellectual weakness 
 and extravagant delusions ; belief in present or past halluci- 
 nations of the alcoholic type; no inequality or other abnormnal 
 state of pupils; defects in articulation partaking of a drawl 
 as well as of a stutter ; absence of retinal change except con- 
 gestion at first, wdiich rapidly subsides ; the wdiole aspect one 
 of obtuseness rather than of exaltation combined with feeble- 
 ness. Still, cases do occur now^ and again where the paralytic 
 and mental symptoms are very much alike in both forms, and 
 there may be nothing but a history of habitual drunkenness, 
 and of a former attack or attacks of delirium tremens, with 
 normal state of the pupils and only slight congestion of the 
 fundus of the eye, on which to base a rather doubtful diagnosis 
 of alcoholic dementia. 
 
 Monomania occasionally bears a degree of resemblance to 
 general paralysis in its early stage. The delusions may be 
 equally extravagant in both, but in the former there is less 
 variability in their character ; the memory is good, the judg- 
 ment in other respects may not be obviously impaired, and 
 altogether there is greater mental vigor. Besides, the ataxy 
 or paresis of the muscles of articulation, emotional weakness, 
 etc., are not present. 
 
 Locomotor ataxy in its ordinary form can scarcely be mis- 
 taken for the disease under consideration. But the patholog- 
 ical changes in the cord found in ataxy would seem occasionally 
 to extend to the medulla oblongata and higher parts of the 
 brain, inducing defective articulation and mental disorder. 
 In the ataxy of general paralysis the knee-jerk is usually 
 present. Delusions of grandeur are not a common feature of 
 insanity arising thus. 
 
 It will suffice merely to mention that the mental and 
 
IDIOCY. 825 
 
 physical degradation, which are often found in epilepsy of long 
 standing, occasionally bears a general resemblance to a some- 
 what advanced stage of general paralysis, in which, as already 
 stated, epileptiform seizures are common ; an inquiry into the 
 history, besides a study of the symptoms, should at once 
 establish the diagnosis. 
 
 Idiocy. — Idiots, considered pathologically, have been ar- 
 ranged by Dr. Ireland into ten different groups ; but looked 
 at broadly and generally, in relation to their symptoms, they 
 may be divided into two great classes — the apathetic and the 
 agitated — between Avhich there is every grade. Individuals 
 of the lower types of the first class have often awkward, 
 clumsy, and ill-proportioned bodies and coarse features ; lips 
 thick and everted ; teeth irregular and decayed ; gums swollen ; 
 ears ill-formed and large. Their heads are in general of good 
 size, and are sometimes larger than the average ; but they 
 are misshapen and not unfrequently flattened in the occipital 
 region. Mentally they are often gloomy, generally passive, 
 but sometimes passionate and dangerous. The agitated class 
 are quick and flighty, and run about laughing, crying, and 
 gesticulating. They are subject to bursts of passion, and are 
 often 23ugnacious. They have in general abnormally small 
 but well-formed heads. In both classes attention and percep- 
 tion are exceedingly feeble ; there is little memory and less 
 judgment; and the will is imperfect — their acts being usually 
 the results of impulses originating in their sensations. Occa- 
 sionally there is an exceptional development of a particular 
 faculty or talent, most frequently that of music. Speech is 
 very defective, and many cannot articulate at all ; squint is 
 common ; and a large proportion, especially where the con- 
 dition • is congenital, have what has been called the saddle- 
 shaped palate — that is, a palate whose arch is considerably 
 higher thaii the normal. A large proportion have a tendency 
 to be of dirty habits, and occasionally the sexual appetite is 
 very strongly developed. 
 
 Idiots, as well as imbeciles, and particularly the latter, may 
 have attacks of melancholia, or monomania, but most fre- 
 quently of mania. The acquired disorder may pass away, 
 leaving the patient much as before the seizure, or it may 
 continue to some extent, modifying the original condition. 
 
 Dr. Ireland holds that even in early infancy idiocy may be 
 recognized by the slowness or awkwardness of the child's 
 motions. He says : " If laid fiat ujDon his face, he will sink 
 upon the floor, whereas a normal child of a few months will 
 
 28 
 
826 INSANITY. 
 
 try to right itself, or cry for assistance." In the writer's 
 experience, however, this is not a reliable test in all cases. 
 When a little older, the wandering, unsettled eye, the inability 
 to fix the attention, the slowness and inaptitude to learn, and 
 the general vacancy of expression, reveal the mental defect. 
 The state of the palatal arch, when present, is a valuable aid 
 to diagnosis. 
 
 The Diagnosis of Insmiity from Delirium. — It is first of all 
 to be noticed that in certain cases there is no real difierence 
 between insanity and delirium ; thus mania, occurring in the 
 course of pneumonia or in an advanced stage of phthisis 
 pulmonalis, is sometimes simply delirium of an acute type. 
 However, cases in which the two states approximate so 
 closely are not very common, and in general the distinction 
 is quite obvious, being marked by definite characters. (Com- 
 pare p. 255.) 
 
 Delirium is very generally preceded for some days by other 
 and more characteristic symptoms of the disease on which 
 itself is dependent. Should that be inflammation of the 
 lungs or brain or other leading organ ; or severe injury of 
 extremities or other parts, inducing inflammation ; or one of 
 the specific fevers, or smallpox, or other animal poison in the 
 system ; ordinary symptoms of the particular morbid state 
 will usually have been manifest before the mental disturbance 
 appears. The character of the delirium in the first instance, 
 and also often throughout its entire course, is in most cases 
 quiet rambling or incoherence, and these symptoms are most 
 aj^t to show themselves at night, especially when the patient 
 is drowsy, and no one is addressing him. Associated with it 
 there are also frequently hallucinations, particularly of vision. 
 Occasionally, however, the excitement is greater, arid the 
 patient can with difliculty be controlled. Should it spring up 
 after injury in one of drunken habits, we have often much 
 excitement and violence, along with fear and hallucinations. 
 This state frequently partakes more of ephemeral mania than 
 of ordinary delirium tremens. But though delirium is usually 
 a late event in the disease of which it is symptomatic, occa- 
 sionally, and particularly in children, it occurs early in its 
 course ; in that case, however, it is accompanied by a tempera- 
 ture markedly elevated, and by other acute febrile symptoms. 
 
 The physical symptoms that accompany delirium are com- 
 monly high temperature, very quick pulse, furred dry tongue, 
 parched skin, injected conjunctivae, scanty high colored urine, 
 etc. — in fact, such as indicate the febrile state. These, it will 
 
MODE OF EXAMIIS^ATION. 327 
 
 be observed, do not correspond with the condition in the most 
 common form of acnte mania, where the febrile action is 
 slight, if there be any at all. In establishing the diagnosis 
 no symptom is so reliable as the temperature. Indeed, the 
 determination of this jooint may be regarded as of so much 
 importance that it might be laid down, as a rule, that in any 
 case where the temj)erature is distinctly above the normal, as 
 ascertained by the thermometer, or even by the hand, if the 
 thermometer cannot be used, the examination should not be 
 regarded as complete until it be ascertained if inflammatory 
 action in one of the leading organs, or one of the continued 
 fevers, does not occasion the mental disturbance. In delirious 
 mania, how^ever, there is often elevated temperature with other 
 febrile indications, but they are seldom so marked as in ordi- 
 nary delirium. Further, in this form of mania the excitement, 
 as a rule, is higher and more constant than in delirium, con- 
 tinuing without the least remission, or with snatches of sleep 
 of not more than half an hour or an hour in duration, for 
 days and nights together ; whereas the excitement and inco- 
 herence of delirium generally vary considerably in their 
 intensity, being often worse at night than during the day. 
 
 Much aid in the formation of the diagnosis wall be obtained 
 by the observation of the special symptoms of local disease, 
 should these be present. It is probably most frequently in re- 
 lation to the early stage of acute meningitis that doubt arises. 
 In it there are generally injection of the eye and flushing of 
 the face, intolerance of light and sound, considerable head- 
 ache, vomiting, contracted pujDils, pain and spasmodic move- 
 ments in the extremities, and high temperature ; and as the 
 disease progresses, squinting, general convulsions, dilated 
 pupils, etc. 
 
 It will be sufficient to mention that typhus fever has been 
 mistaken for mania ; the high temperature, parched skin, 
 ferretty eyes, and eruption, with the history, should make the 
 diagnosis clear. 
 
 From the observations that have been made, it will be under- 
 stood that the diagnosis of delirium from the varieties of mania 
 which it at all resembles, rests much more on the history of 
 the illness and on indications of existing acute physical disease 
 than on any very marked difference between the mental symp- 
 toms in the two conditions. 
 
 Mere drunkenness has been mistaken for insanity even by 
 medical men. A little inquiry into the case, and the observa- 
 
328 INSANITY. 
 
 tion of tlie too familiar symptoms of intoxication should pre- 
 vent such an error. 
 
 The mode of examining a person supposed to he insane is a matter 
 of considerable importance. There is generally little diflficulty where 
 ordinary mania or melancholia are concerned, at all events when 
 they are fully developed ; it is experienced most frequently in the 
 varieties of partial insanity. In some cases even the introduction 
 to the supposed lunatic is no easy matter. No general rule of pro- 
 cedure can possibly be laid down, as this must vary according to the 
 social status, the habits, the mental peculiarities, and many other cir- 
 cumstances. The frank bluntness of address that might suit a laborer 
 would scarcely be acceptable to an educated gentleman. The writer's 
 practice is generally — not in all cases — to drop the title of " Dr." and to 
 be introduced as " Mr." It has seemed sometimes that the announce- 
 ment of the medical title has at once aroused a feeling of suspicion and 
 hostility, and rendered the inquiry very difiicult. A few easy general 
 observations may suffice to establish agreeable relations between the 
 physician and the patient before the professional nature of the visit is 
 revealed. This in the great majority of cases it would be unwise to try 
 to conceal, as most patients would at once resent any attempt at decep- 
 tion. It will often, then, be advisable to state quietly to the patient 
 that you are a physician ; that you understand from his relatives that 
 he has been somewhat out of sorts lately ; that possibly it might be only 
 supposition on their part, but it would allay their anxiety if he would 
 kindly answer a few questions respecting his health. This being con- 
 ceded, it will be well in the first instance to make some medical in- 
 quiries of an ordinary kind and then to extend the investigation to the 
 special senses, particularly those of hearing and sight. Cautiously ask 
 respecting noises in the ear, and if they resemble whispers or loud 
 voices, and what they say ; and in relation to the eyes, if motes or other 
 unusual objects be seen, if they assume special forms, and if so, what 
 they are like. Then lead the conversation on to matters relating to 
 home and family, business prospects, religious views, etc. Of course, 
 the particular line of inquiry will frequently be guided by information 
 previously obtained from relatives and friends, though this in some 
 cases is incorrect and in others is defective. It occasionally happens 
 that near relatives who are constantly beside the patient are quite un- 
 aware of the existence of dangerous delusions. In most cases the general 
 bearing and expression of countenance indicate the nature of the morbid 
 ideas ; and, especially where the history is imperfect, this guide will 
 save an immense amount of trouble by at once suggesting the kind of 
 questions best fitted to draw them out. The psychological physician 
 should be skilled in y)hysiognomy. Many useful hints in prosecuting 
 the investigation are also frequently obtained by the observati<m of 
 peculiarities of dress, oddities about the room, and sundry other things. 
 
 But perhaps at the very commencement of the interview the patient 
 indignantly resents the idea that he is ill at all. Then the most judi- 
 cious plan will sometimes be to sympathize with his indignation ; to ask 
 what could have made the relatives suppose that his health was im- 
 paired ; and to inquire if it could be due to any plot or conspiracy, and 
 if so, what may be the motive. This may bring out delusions of sus- 
 I)icion, which are common incases where difficulty in the examination 
 
FAMILY HISTOEY. 329 
 
 is experienced. Occasionally a lunatic who is very reticent in con- 
 versation will express his views more freely in writing, and in this 
 way the existence of delusions may be ascertained. 
 
 These observations illustrate the general method of procedure ; they 
 cannot do more, as the investigation in each case ought to be based on 
 the features which are peculiar to it. It need only be further remarked 
 that, should the patient be melancholic, the inquiry ought always, if 
 possible, to demonstrate the presence of a disposition to suicide when 
 it exists, as it so often does in this condition. Generally the point may 
 be determined by indirect questions, but occasionally it is necessary to 
 ask the patient plainly- if he is weary of life and contemplates self- 
 destruction. 
 
 Family History. — As insanity is a highly hereditary dis- 
 ease, it is important to inquire respecting its existence in the 
 family to which the patient belongs. But the inquiry should 
 not be restricted to mental disorder, as it is now well established 
 that, in the descent from one generation to another, various 
 neurotic affections — such as epilepsy, chorea, hysteria, a dis- 
 position to habitual drunkenness, particularly in its paroxysmal 
 form, etc. — are mutually interchangeable. (Compare p. Q^.^ 
 Thus it is common for an epileptic patient to beget an idiotic 
 or imbecile child ; or conversely, the offspring of an imbecile 
 father or mother, or of one who has been insane, or is of the 
 insane temperament, may be epileptic or idiotic. The prog- 
 nosis of the mental illness would be more serious if a strong 
 hereditary taint were present ; not that the prospect of recovery 
 from an attack of insanity, which otherwise might be curable, 
 Avould thereby be much, if at all diminished ; for this is 
 scarcely less frequent than where no such taint is in the 
 constitution. There would, hoAvever, as an expression of the 
 ancestral defect, be a greater tendency for the type of disease 
 to be more grave from the beginning — showing itself, for 
 instance, at first as a slight deviation from the normal standard, 
 and then gradually merging into incurable insanity. As a 
 further illustration of the constitutional vice, it is worthy of 
 note that in patients who have recovered from one or more 
 attacks, recurrence is particularly to be dreaded. Idiocy and 
 imbecility are often transmitted from parent to child, though, 
 as already mentioned, the morbid tendency may be transmuted 
 into another neurosis in the descent. Consanguineous mar- 
 riages, and particularly those of cousins-german, yield, it is 
 generally, and the writer thinks correctly, believed, a larger 
 proportion of idiots or infants with some mental defect than 
 when no such relationship exists ; but this conclusion is not 
 yet determined with certainty. It seems, however, well es- 
 
 28^ 
 
330 INSANITY. 
 
 tablished that if in this class of marriages there be a decided 
 neurotic taint in the family to which the parents belong, the 
 husband and wife both inheriting it, the defect Avill probably 
 be intensified in the children. The establishment of puberty 
 is very trying to the mental stability of those in whom a 
 marked hereditary tendency exists, especially to women ; so 
 also are pregnancy and childbirth. Experience shows that, as 
 a rule, the hereditary tendency is more prone to be transmitted 
 from father to son than from father to daughter, and from 
 mother to daughter than from mother to son. It is to be 
 borne in mind that the existence of insanity in the family is 
 often denied by the relatives. The inquiry is a delicate one, 
 and should be carried out with consideration for the feelings 
 of those concerned. 
 
 Question of Asylum Treatment. — If the medical examiner 
 be satisfied that his patient is insane, he Avill next require to 
 consider what advice he should give to the friends — whether 
 he should recommend immediate removal to an asylum, or a 
 trial of treatment at home, or, at all events, elsewhere than 
 in such an institution ; the matter is one of great practical 
 importance, and is at the same time one sometimes very diffi- 
 cult to determine. Many considerations besides those of a 
 medical character must be weighed in seeking to arrive at a 
 correct conclusion. Thus it will be obvious that if the patient 
 be wealthy, and have kind, judicious relatives, and if his house 
 be in a retired situation and have private ground attached, it 
 will not be necessary to insist on so early removal to an asylum 
 as if he be a laborer liviug in a small house in a crowded 
 neighborhood ; for in the former case the patient already 
 possesses, or can readily procure, most of the advantages 
 which an asylum presents, but which the poorer man can have 
 nowhere else. But though these points ought to form an 
 important element in the judgment, the main grounds will 
 rest in the character of the disorder itself The indications 
 derived from it, however, can only be stated in a general 
 way. Should the insanity, though characterized by a con- 
 siderable amount of excitement, be quite sudden in its onset, 
 without distinct premonitory symptoms, the attack often 
 passes away quickly ; a sudden seizure should then, other cir- 
 cumstances not being unfiivorable, dispose to a trial of home 
 treatment. More particularly, the following forms are fre- 
 quently of short duration, namely, those that result from 
 alcohol, with the exception of the paralytic dementia produced 
 by that agent ; the milder attacks of mania that are apt to 
 
BIBLIOGEAPHY. 331 
 
 occur about the establishment of puberty in both sexes, especi- 
 ally in the female ; the so-called metastatic forms occurring in 
 rheumatic and gouty constitutions ; the slighter seizures after 
 childbirth and through over-lactation, though there is consider- 
 able uncertainty respecting both of them : in all these cases the 
 medical attendant would be justified in advising that the effects 
 of medicinal agents and other measures at home should be 
 tested in the first instance. Patients suffering from mild types 
 of melancholia are also frequently treated under the care of 
 relatives ; but the physician must never forget the tendency to 
 suicide in such cases. Attacks of epileptic insanity likewise 
 generally soon pass away, but then they not unfrequently recur 
 in connection with fresh seizures; and, indeed, the mental 
 state, even at its best, of epileptics who have reached this stage 
 of their disease is commonly such that the asylum is the most 
 suitable place for them. On the other hand, insanity of slow 
 development, which has gradually attained a considerable de- 
 gree of intensity, is not likely to be of short duration ; typical 
 general paralysis is an unmanageable as well as an incurable 
 form ; and varieties which present suicidal or homicidal features, 
 or both, are dangerous ; all these should be consigned to an 
 asylum at once. Further, with respect to the class in which this 
 extreme measure may have been at first delayed, should there 
 be no improvement, and particularly should there be rather an 
 aggravation of the symptoms after ten days or a fortnight of 
 treatment at home, it will then in most cases be the wisest 
 course to recommend removal to an asylum. 
 
 The following manuals maybe consulted by the student: Bland- 
 ford, Insanity and its Treatment, 3d edition, London, 1884. — Clouston 
 (T. S ), Clinical Lectures on Mental Diseases, London, 1883. — Savage 
 (G-. H,), Insanity and Allied ISTeuroses, London, 1884. — Sankey (W. 
 H. O.), Lectures on Mental Diseases, 2d edition, London, 1884. — 
 Spitzka, Insanity: its classification, diagnosis, and treatment, New 
 York, 1883. 
 
 Those who wish to consult larger, and in some respects more com- 
 prehensive treatises, are referred to Bucknill and Tuke, Psychological 
 Medicine, 4th edition, London, 1884. — Maudsley (H.), The Pathology 
 of Mind, London, 1879. — Hammond (W. A.), Treatise on Insanity 
 in its Medical Eelations, London, 1883. 
 
 Some may wish to consult the writings of Pinel and his pupil 
 Esquirol, who reformed asylum treatment in France, and laid the 
 foundations of modern psychiatry: Pinel, Traite sur I'alienation 
 mentale, ou la manie, Paris, 1801. — Esquirol, Des maladies mentales, 
 Paris, 1838. 
 
 Special treatises: Ireland, Idiocy and Imbecility, London, 1877. — 
 Mickle, General Paralysis of the Insane, London, 1880. — Magnan, 
 
832 INSANITY. 
 
 On Alcoholism: the various forms of alcoholic delirium and their 
 treatment, translated by Dr. Greenfield, London, 1876. — Charcot, 
 Lectures on Diseases of the Nervous System (Hysteria), translated 
 for New Sydenham Society, 2 vols., London, 1877-8L — Lasecjue, 
 Folic a deux (and other monographs). Etudes, tome i., Paris, 1884. 
 — Brierre de Boismont, Des hallucinations, Paris, 1802. — Robertson 
 (Alex ), Unilateral Hallucinations, Trans. Intern. Congress, vol. iii., 
 London, 1881. — Hammond, Mysophobia (and other monographs), 
 Neurological Contributions, New York, 1879-81. 
 
CHAPTER IX. 
 
 DISORDERS OF THE RESPIRATORY AND 
 CIRCULATORY SYSTEMS. 
 
 Dyspncea, difficulty in breathing, want of breath, pain in 
 the chest, palpitation of the heart, cardiac spasm and anguish, 
 a sense of impending suffocation, and all forms of rapid, 
 labored, or obstructed breathing, require to be considered in 
 one clinical group, as they frequently become inextricably 
 mixed up together. They depend on the most diverse causes. 
 Amongst these may be named nervous or spasmodic asthma; 
 inflammatory affections of the larynx, trachea, lungs, bronchi, 
 pleura, and pericardium ; destructive lesions of the lung and 
 perforation of the pleura ^yith pneumothorax ; inflammations 
 or abscesses about the fauces, larynx, or oesophagus ; various 
 forms of cardiac disease ; aneurism al and other thoracic 
 tumors ; thrombosis and embolism of the pulmonary artery ; 
 dropsy of the abdomen and of the pleura and pericardium ; 
 nearly all abdominal swellings and tumors when bulky ; 
 sometimes abdominal tumors which are not very large also 
 give rise to dyspnoea, as in the case of the gravid uterus in the 
 early stage of certain pregnancies ; spasm of the glottis as an 
 isolated affection (^laryngismus stridulus), as well as an inci- 
 dent in other diseases ; ursemic poisoning and other forms of 
 defective renal activity ; certain varieties of ansemia, chlorosis, 
 and hysteria ; and at times grave nervous affections involving 
 the respiratory centres, nerves, and muscles. 
 
 Dyspxcea, Palpitation, Thoracic Pain, etc. 
 
 The subject of dyspnoea must be approached in various 
 ways. 
 
 1. By trying to discover from the patient the character of 
 his distress, and the causes of its aggravation on moving or 
 breathing deeply for example, as noticed by himself. 
 
 2. By observing the number of respirations in a minute, 
 the appearance of laborious breathiug, the evidence of any 
 stitch or sharp cutting pain, of acute suffering, or of mortal 
 terror as depicted on his countenance : by noticing any ap- 
 
334 EESPIRATION AND CIRCULATION. 
 
 pearance of cyanosis and lividity, or of pallor in the face ; 
 and by scrutinizing the sounds, whether crowing, hoarse, 
 wheezing, gurgling, or choking, emitted during respiration. 
 We must, likewise, notice the attitude assumed by the patient 
 during an attack, and the character of the cough and expec- 
 toration when these are present. (See pp. 338, 348, 353.) 
 Paroxysms of coughing from any cause may of themselves 
 produce considerable dyspnoea, and frequently aggravate it 
 Avhen they are severe. 
 
 3. By an appreciation, whenever this is possible, of the pre- 
 vious facts or history of the case ; particularly as to any 
 known disease in the heart, or the thoracic aorta, the lungs, 
 pleura, or pericardium, or anything likely to lead to perfora- 
 tion of the pleura (phthisis, abscess, etc.) : any rheumatic attack 
 likely to give rise to pericarditis or endocarditis ; anything 
 predisposing to thrombosis or embolism in the pulmonary 
 artery (the puerperal state, venous thrombi, and dilated 
 heart) ; any condition predisposing to rapid dropsy, especially 
 into the pleura, pericardium, or pulmonary tissue (scarlatinal 
 nephritis in particular ) ; any known tendency to angina 
 pectoris or spasmodic asthma in the individual or in his 
 family ; and any preliminary symptoms of diphtheria, croup, 
 or laryngitis. 
 
 4. By a careful physical examination of the thoracic and 
 other organs. By this we can often detect whether the air is 
 prevented from entering the lungs by tumor, pressure, or 
 spasm in the upper portions and larger divisions of the respira- 
 tory tract, or by the presence of fluid or air in the pleura, 
 or by oedema and exudation into the small bronchi and 
 air- vesicles, or by other forms of pulmonary or pleuritic 
 disease. We can often also detect evidences of heart disease, 
 pericarditis, or effusion, even although the distressed state of 
 the patient is not favorable for a careful examination of the 
 chest ; dropsical accumulations or tumors in the abdomen 
 pressing on the heart and lungs can be readily observed, and 
 the state of the urine may throw much light on the case. An 
 examination of the neck for any aneurism, tumor, or abscess, 
 and of the throat for any abscess of the tonsils, or for one 
 bulging behind the pharynx, for diphtheritic patches in the 
 fauces, or for tendernciss over the larynx, is of great impor- 
 tance. Laryngosc()j)ic examination can seldom be practised 
 in the height of an attack, but even then an examination by 
 the finger may sometimes supply important information (see 
 Chapter X.) : on the partial subsidence of the attack we may 
 
DYSPNCEA. 335 
 
 find evidence of thickening and ulceration of the cords, or 
 tumors, oedema, or abscess, in this situation, giving rise to 
 mechanical obstruction or recurring spasm ; or we may find 
 paralysis of one of the cords indicating rather the origin of 
 the attacks in some irritation of the lar3'ngeal nerves lower 
 down. (Many of these subjects are dealt with in other sec- 
 tions of this book, as will be seen on consulting the index.) 
 
 The number of respirations per minute afibrds an important 
 indication of dysj)noea. The normal rate may be stated as 
 about 18 to 20 per minute in the male adult while awake, but 
 variations of from 12 to 24 are not uncommon. In children, 
 and also in women, the rate is somewhat more rapid. Like 
 the pulse, it is much affected by different postures, and by 
 sleep, agitation, exertion, sjieaking, coughing, and swallowing. 
 The resj)iration is also apt to be deranged in its rhythm when 
 the attention is directed to it, so that we must try to count its 
 rate without the patient's noticing it. This may be done very 
 well while taking the pulse, by continuing to hold the patient's 
 wrist, Avhile we watch the movements of the chest unknown to 
 the patient, and count them for half a minute; or, if these are 
 not very visible, we may lay the hand or a finger very lightly, 
 and as if by accident, on the chest wall, under the clavicle in 
 the female, and below the xiphoid in the male ; in other cases 
 we can count best by listening to the breathing, or by watching 
 the movements of the bed-clothes. In critical estimations of 
 the rate of breathing we w^atch for a quiet period, or take some 
 opportunity of noting the number w^hile the patient is sleep- 
 ing, or at least before he is disturbed by speaking, coughing, 
 moving, or crying ; or we may require to let a little time 
 elapse for the subsidence of these disturbances if they have 
 already occurred. 
 
 In febrile states, from w^hatever cause, the respiration is 
 often quickened, the increase keeping a certain proportion to 
 that of the pulse ; the ratio in health is 1 respiration to about 
 4 or 4.5 beats of the pulse, and so long as something like this 
 ratio is maintained, the increase may be ascribed simply to the 
 febrile disturbance affecting the system. When the rapidity 
 of the respiration exceeds this proportion, we infer the exist- 
 ence of some respiratory disorder. An attack of bronchitis, 
 for example, may reveal itself in this way in the course of 
 typhus. Tbe resj)iration is accelerated in almost every variety 
 of disease of the respiratory organs, in acute or subacute forms, 
 and this constitutes one of the features of nearly every kind 
 of dyspnoea. The number is often 40 or 50, it sometimes rises 
 
336 RESPIRATION AND CIRCULATION. 
 
 to 60 or 80 per minute, and may almost equal the pulse-rate 
 (1 respiration to 1.25 pulse-beat). 
 
 The respiration is somewhat rapid and easily accelerated in 
 certain non-febrile states, even apart from any special respira- 
 tory complication ; the debility after fever, and certain anaemic 
 conditions, may be mentioned amongst these. In rickets, 
 the rapid breathing seems to be due in part to the general 
 state, and in part to the great liability of rickety children to 
 pulmonary collapse. 
 
 The appearance of labor in breathing is of great importance.^ 
 There may be very ra2:>id breathing without any great effort or 
 labor, but the least additional strain may show at once that 
 the breathing is being carried on at the extreme limit of the 
 patient's power ; any exertion, such as sitting up in bed, or 
 speaking, or indeed anything which demands additional eifort, 
 brings out the patient's weakness in this respect ; he says a 
 word or two and stops to recover breath, and then resumes. 
 A striking illustration of the same thing is found in infantile 
 dyspnoea ; the child's whole energy is required for breathing, 
 and so after a momentary attempt at sucking, or after one or 
 two such attempts, he refuses the breast, altjiough obviously 
 anxious to drink, and no doubt very thirsty; this refusal is 
 an important clinical fact in the pneumonia and suffocative 
 bronchitis of children. In uncomplicated pneumonia and some 
 other diseases characterized by rapid breathing, no great effort 
 is visible ; the state of matters is very different in cases where 
 an obstruction exists to the entrance of air through the glottis, 
 trachea, or bronchi — whether this arises directly from organic 
 obstruction or from nervous spasm. Hence in laryngeal 
 obstructions and spasms from any cause, in croup, in spasmodic 
 asthma, and in bronchitis and emphysema, the efforts at 
 breathing often assume the most extraordinary intensity ; the 
 thoracic movements and the action of the accessory muscles 
 of respiration may be exaggerated, the muscles of the neck 
 stand out with great distinctness, the patient sits up or even 
 stands, and sometimes clutches at objects with his hands, so 
 as to give the muscles greater purchase. We have here a 
 typical picture of inspiratory dyspnoea. The excessive action 
 of the dilator narium is often a valuable index of this labori- 
 ous breathing, especially in the case of children affected with 
 pneumonia and bronchitis. 
 
 Similar results likewise happen when, instead of obstruction 
 
 1 See also reiiiarks under "Nervous Dyspmea," p. 347. Compare also j). 37. 
 
EXPIEATORY DYSPNCEA 337 
 
 to the passage of the air, a large j^tH't of the breathing surface 
 is suddenly cut off in other ways, as by the perforation of the 
 pleura and the consequent collapse of the lung from pneumo- 
 thorax, or by sudden effusion of fluid into the pleura, or even 
 by sudden oedema, hemorrhagic condensation, or congestion of 
 the lungs. Again, a similar result may be brought about by 
 sudden blocking of the pulmonary artery — although the air 
 may enter both lungs freely, the pulmonary function is, of 
 course, arrested or impaired by such an obstruction. This 
 element of sudden7iess is of great importance in leading to 
 dyspnoea, for if the breathing surface be cut off gradually, the 
 "respiration and the system may have time to adapt themselves 
 to the altered conditions ; hence there may be extensive throm- 
 bosis of the pulmonary artery without any alarming dyspnoea, 
 until perhaps a fatal displacement of some clot takes place ; 
 even pneumothorax may exist without the patient's being able 
 to fix the probable date of its occurrence — the collapsed lung 
 having, perhaps, been long practically useless from some pre- 
 vious extensive disease ; the whole of one side and part of the 
 other may be full of fluid, while the patient has scarcely been 
 conscious of breathlessness, owing to the very gradual increase 
 of the effusion. This element of suddenness exists, of course, 
 in all the spasmodic forms of laryngeal and bronchial obstruc- 
 tion. A further point of importance in connection with 
 dyspnoea is the exact situation at which the mechanical im- 
 pediment exists; a slight oedema of the glottis may cause 
 suffocation, and an exudation in the trachea or large bronchi 
 gives rise to the most distressing dyspnoea from the large re- 
 spiratory area involved. 
 
 But the patient with obvious dyspnoea may experience or 
 manifest no difficulty in inspiration : his difiiculty as felt by 
 himself may be the emptying of his chest of the air. This 
 expiratory dyspncea as it is called may be attended by prolonged 
 wheezing sounds with the expiratory act. This form of 
 dyspnoea occurs in pulmonary vesicular emphysema and spas- 
 modic asthma. 
 
 The following are the common causes of dyspnoea, arising, 
 directly or indirectly, in a mechanical manner : Inflammations 
 of the larynx, oedema and spasm of the glottis, foreign bodies 
 in the larynx or trachea ; diphtheritic or croupy membranes in 
 the larynx, trachea, or bronchi ; tumors and abscesses either 
 of the larynx itself or pressing on it or on the trachea from 
 without (especially aneurisms, cancers, retropharyngeal ab- 
 scess) ; aneurisms, glands, or other tumors in the chest press- 
 
 29 
 
338 RESPIE.ATION AND CIECULATION. 
 
 ing on or irritating the recurrent laryngeal nerves ; spasmodic 
 or nervous asthma ; inflammatory disease of the lungs, bronchi, 
 and pleurse ; dropsical exudations into the pulmonary tissue 
 or into the pleura; pneumothorax; extensive consolidation, 
 collapse, or emphysema of the lung; extensive excavation from 
 tubercular disease, bronchiectasis, gangrene, or abscess ; em- 
 bolism and thrombosis of the pulmonary artery ; and pressure 
 on the chest from below, from abdominal distention or tumors 
 of any kind. (Compare next section.) 
 
 Cardiac dyspncea, or cardiac asthma, as it is sometimes 
 called, may be explained in certain cases, or to some extent, 
 on mechanical principles. For example, a somewhat mov- 
 able thrombus in the right side of the. heart, at the tricuspid 
 orifice, may play a similar part to that of a plug in the pul- 
 monary artery, and ordinary forms of incompetency of the 
 valves or of obstruction at the orifices may, if extreme, retard 
 the circulation through the lungs, and so impair their function. 
 Again, the lungs may be involved through the heart — pul- 
 monary infarctions, bronchitis, congestion or oedema of the 
 lung, and pleuritic effusion, may all have a cardiac origin, 
 and be the result of mechanical impediments from plugs, 
 diseased valves, etc. The great dyspnoea from exertion in 
 heart disease may often be traced to increased strain on the 
 circulation bringing into prominence mechanical defects too 
 slight to be at other times of any great importance. But 
 cardiac dyspnoea is often too extreme or too spasmodic and 
 transitory to be readily explained on such mechanical grounds. 
 Clinically, we must accept as a fact the frequent occurrence 
 of the most extreme forms of cardiac and aneurismal dys- 
 pnoea, apart from any of the mechanical explanations or 
 structural changes just suggested ; the idea of some nervous 
 cause is often forced on the mind. 
 
 Orthopiio&a — the assumption of the upright posture for the 
 purpose of getting breath — is one of the great features of 
 cardiac dyspnoea. But in cases with effusion into the pleurse, 
 and even in oedema or congestion of the lung and bad bron- 
 chitis, the patient sometimes has a considerable tendency to 
 sit up for breath. When, however, this symptom is strongly 
 marked, we must always suspect the cardiac origin of the ill- 
 ness, or the presence of some cardiac complication ; and this 
 suspicion gains in strength if little or no pulmonary mischief 
 be detected on examination. Thoracic aneurism is to be 
 classed with cardiac disease in this respect. Affections of the 
 pericardium, and adhesions of this membrane, likewise give 
 
CAUSES INCEEASING DTSPNCEA. 339 
 
 rise frequently to orthopnoea, although simple rheumatic peri- 
 carditis even in an extreme form may exist without this 
 symptom. All forms of cardiac disease — those involving the 
 size of the heart, the tissue of the walls, the orifices, and the 
 valvular structures — may give rise to orthopnoea. The cardiac 
 element in the dyspnoea may, therefore, be a secondary or 
 additional complication, appearing in the course of pulmonary 
 emphysema, disease of the kidney, and other affections which 
 tend to implicate the heart ; and this cardiac complication 
 may give rise to paroxysmal exacerbations in the midst of a 
 chronic state of dyspnoea of moderate severity. 
 
 Occasionally the orthopnoea is so constant and so extreme 
 that the patient cannot even lean back for a moment without 
 the feeling of impending suffocation, and he can only get a 
 little sleep while sitting up and leaning forward, with the 
 head resting on his knees or hands, or on a table before him. 
 Some patients, indeed, resolutely refuse to go to bed, and may 
 sit in a chair for weeks and months together, without once 
 even attempting to lie down. These extremely persistent 
 forms of orthopnoea are usually associated with considerable 
 dropsy. 
 
 The explanation of orthopnoea is plain enough when there 
 is any considerable oedema of the lung, dropsy, or pleuritic 
 effusion, as the recumbent posture tends in such cases to 
 hamper the movements of the heart and lungs from the gravi- 
 tation of the fluid. Further, the erect posture no doubt gives 
 the respiratory muscles much better purchase in their play ; 
 but the extremely marked influence of posture observed in 
 not a few cardiac cases cannot be reasonably explained in 
 any such way, and appears to depend on some nervous cause. 
 
 Great increase of the dyspno&a on hurrying or climhing is 
 closely related to orthopnoea in many respects. While found 
 to some extent in nearly every form of disease which impairs 
 the respiratory function, it is, like orthopnoea, specially 
 marked in cardiac affections of all kinds. A patient who is 
 able to walk fairly enough and at a moderately good pace on 
 a level road, may at once show signs of dyspnoea if there be 
 a continuous, although gentle ascent, or if a few steps have 
 to be mounted briskly ; hurrying and mental or emotional 
 excitement operate in the same way ; all of these influences 
 often operate together against a patient in hurrying to a high- 
 level railway station, and not unfrequently he first finds out 
 his weak point under such circumstances. 
 
 Amongst other causes which operate in causing dyspnoea 
 
340 KESPIRATION AND CIRCULATION. 
 
 under similar circumstances may be mentioned all forms of 
 disease impairing the functions of the lungs ; conditions of 
 debility, anaemia, etc., from whatever cause ; disease of the 
 kidneys, dropsy, obesity, pregnancy ; and the changes incident 
 to advancing age. 
 
 The importance of this feature in the diagnosis of cardiac 
 disease is so great that we sometimes set our i^atients to go up 
 one or two stairs, or even to run a few yards, when we are 
 doubtful of there being any affection of the heart, so that we 
 may judge of the state of their respiration at the end of such 
 an exjDeriraent. 
 
 Paljntation is one of the accompaniments of the various 
 cardiac symptoms just described ; sometimes it forms the most 
 prominent feature of such complaints, but it may exist quite 
 apart from any organic affection of the heart. 
 
 When due to cardiac disease it has a tendency to very 
 marked exacerbations in connection with exertion and excite- 
 ment, so that when the palpitation occurs frequently, or 
 chiefly, apart from these influences, and when it is not readily 
 induced by running, or by climbing hills or stairs, we have 
 good reason to hope that it is not due to organic disease. 
 
 The palpitation of cardiac disease is frequently associated 
 with an undue heaving impulse, and there is usually clear 
 evidence of enlargement or of valvular disease, on a physical 
 examination of the chest. The right ventricle frequently 
 becomes distended or displaced, so as to give rise to a painful 
 sense of oppression and tenderness from the existence of pulsa- 
 tion in the epigastrium. The palpitation from aneurisnuil 
 disease in the chest must be considered along with that of 
 cardiac disease, and the investigations in both cases are con- 
 ducted by similar methods ; the palpitation and pulsations of 
 aneurismal tumors must be carefully studied as to the site of 
 their maximum intensity and diffusion. (See Chapter XVI., 
 Part 2, *' The Physical Examination of the Heart.") 
 
 Incipient inflammation of the pericardium and endocardium 
 may readily give rise to this symptom, and palpitation of the 
 heart may also be determined by pressure on or displacement 
 of the heart resulting from pneumothorax, pleuritic effusion, 
 etc. 
 
 But, apart from these organic affections, palpitation is very 
 common in dyspepsia, and particularly in cases with nuich 
 flatulent distention of the stomach. In such cases, especially 
 when complicated with hysterical tendencies, palpitation may 
 attain its most extreme degrees ; and in these forms it fre- 
 
PAIN IN THE CHEST. 341 
 
 quently proves most troublesome when the patient is lying 
 still in bed. The palpitation of dyspepsia is often complicated 
 with intermission or irregularity in the heart's action, which, 
 by exciting and alarming the patient is apt to increase the 
 palpitation still further. 
 
 Palpitation is one of the leading symptoms of exophthalmic 
 goitre : it is then associated with prominence of the eyeballs, 
 and a certain fulness or enlargement of the thyroid gland ; 
 frequently there is also organic disease of the heart. 
 
 Palpitation of the heart is likewise found in cases of anaemia 
 and general debility : loss of blood from bleeding piles and 
 uterine discharges, for example, may give rise to symptoms 
 sometimes erroneously construed as cardiac. Palpitation and 
 epigastric pulsation in boys sometimes owe their origin to the 
 practice of masturbation or other forms of disorder of this 
 class. 
 
 Throbbing of the abdominal aorta is not uncommon in de- 
 bilitated and nervous patients, and it may thus simulate 
 aneurism in this situation, but a careful examination of the 
 vessel reveals a general pulsation of the aorta without any 
 enlargement or any true tumor of the artery. Throbbing of 
 the arteries in the body generally may likewise be felt by 
 patients; this may arise from a relaxed state of their ves- 
 sels, apart from any very serious affection, although such 
 generalized pulsation likewise occurs in cases of aortic incom- 
 petency. 
 
 Pain in the chest exists in a great many cases of dyspnoea, 
 and sometimes constitutes the leading feature and cause of 
 the respiratory distress ; this is especially marked in cases of 
 pleurisy and pericarditis during the stage of friction ; the 
 movements of the chest are actually hampered by the pain 
 induced by the movements. Similar distress is sometimes 
 occasioned by pleurodynia. The detection of friction sounds 
 over the heart and lungs in such cases explains their nature. 
 The pain or distress in dyspnoea may, on the other hand, arise 
 simply from the extremely urgent need for breath which the 
 patient experiences ; when carried beyond a certain point, 
 this becomes exquisitely painful. It is intensified by any co- 
 incident overdistention of the right ventricle or by palpitation 
 or tumultuous action of the heart, or by irregularities or im- 
 perfections in the contraction. These irregularities are often 
 quite discernible by the patient, and may depend not merely 
 on affections of the organ itself, but on pressure on it or dis- 
 placement of it in connection with pleuritic exudations, 
 
 29* 
 
842 KESPIKATION AND CIRCULATION. 
 
 pneumothorax, thoracic and abdominal tumors, excessive 
 dropsy, or even distention of the stomach and bowels in cases 
 of flatulence. Many cases, of course, have a complex origin, 
 as when the pain of a perforation in the pleura and the in- 
 cipient pleuritis thus induced are complicated with the ex- 
 tremely painful dyspnoea resulting from the sudden suppres- 
 sion of a lung, and from the pressure on the heart and liver 
 due to displacement of the mediastinum and diaphragm. 
 The combination of cardiac, pericardial, or aneurismal pains 
 with pleuritic stitch, and the association of these with the 
 most extreme forms of dyspnoea resulting therefrom, and from 
 oedema or consolidation of the lung, with extreme dropsy, 
 give rise to a complex distress which we have too often to 
 witness. 
 
 A certain simulation of some of these alarming states may 
 arise in connection with flatulence ; this may be associated 
 with pain in the neighborhood of the heart, with great palpi- 
 tation, and, especially, in hysterical cases, with dyspnoea and 
 a sense of choking. Gouty, neuralgic, and intercostal pains, 
 and various sensations referable to uterine irritation, may also 
 occasionally simulate the attacks just mentioned, or even those 
 included in the next paragraph. 
 
 Angina pectoris is a name reserved for pain obviously of 
 cardiac origin and of a very special and alarming character ; 
 all forms of cardiac anguish, although not presenting the 
 features of this complaint in its most typical form, have a cer- 
 tain resemblance to this peculiar suffering. " The subjects of 
 angina pectoris report that it is a suffering as sharp as any- 
 thing that can be conceived in the nature of pain, and that it 
 includes, moreover, something which is beyond the nature of 
 pain, a sense of dying." (Latham.) Others speak of a feel- 
 ing of " constriction " of the thorax, of its being an inward 
 pain, or of its resemblance in some way to suffocation. But 
 the most typical angina may occur without the least impedi- 
 ment to the respiration, and the patient may feel that he can 
 breathe quite freely. The pain is not always centred in the 
 cardiac region, but it always tends to the left side of the chest. 
 The most constant of all the features of true angina is an in- 
 describable dread of immediate death, or perhaps, as has been 
 said, " a sense of dissolution, not a fear of it." In the case of 
 those who cannot express their feelings accurately, or who do 
 not care to do so openly, we can sometimes detect in their 
 countenances the evidence of a mortal terror. Along with 
 the above there is often a transient pallor of the face, and 
 
LIVIDITY OF FACE. 343 
 
 likewise an associated pain shooting down the left arm, or 
 darting across, as it were, from the heart to the elbow, or there 
 may be numbness and tingling of the arm, spreading even to 
 special fingers. 
 
 The most typical forms of angina pectoris may exist with- 
 out any lesion recognizable during life ; the dissections in fatal 
 cases often show merely certain changes in the structure of the 
 walls, especially fatty degeneration of the fibres, and atheroma 
 of the coronary arteries ; nearly every variety of disease in 
 the heart or aorta may, at times, be found associated with this 
 symptom and apparently giving rise to it : we may likewise 
 say that indications of angina-like attacks may frequently be 
 traced as forming an element in the complicated sufferings of 
 heart disease. 
 
 The cliaracter of the noise heard during the breathless attack 
 often guides us. The presence of snoring, or of very rough 
 and loud-sounding respiration, is fouud in cases of tracheal 
 obstruction (croup, diphtheria) ; the variation in the sound 
 often suggests a gradually diminishing aperture for the pass- 
 age of the air, resulting in a half-choked croak or squeak. 
 Something of the same kind of breathing may sometimes be 
 heard where an abscess behind the pharynx, or even in the ton- 
 sils, causes much dyspnoea. When the obstruction consists in 
 a spasmodic closure of the glottis the sound is more crowing 
 or stridulous (pertussis, laryngismus stridulus, irritation from 
 foreign bodies, ulceration or tumor in the larynx, or pressure 
 on the laryngeal nerves, etc.). If the constriction be further 
 down in the trachea and larger bronchi, whether spasmodic or 
 mechanical, the breathing may have more of a wheezing or 
 whistling sound : if there be much fluid secretion there, gurg- 
 ling sounds may be loudly heard. But some of the most 
 severe forms of dyspnoea and gasping respiration may exist 
 without noisy respiration, as in embolism of the pulmonary 
 artery, pneumothorax, and rapid effiision into the pleura or 
 pericardium. In cardiac and aneurismal dyspnoea, the pres- 
 ence of noisy respiration will depend on the nature of the pul- 
 monary or laryngeal complications. 
 
 Lividity or duskiness of the face (cyanosis) is a feature in 
 dyspnoea requiring careful attention ; in extreme forms a 
 similar condition can sometimes be recognized also in the fin- 
 gers, nails, and other parts. All diseases or accidents inter- 
 fering with the entrance of air to the lungs, or with the effi- 
 ciency of the respiratory function, may produce cyanosis. A 
 tinge of lividity can often be detected along with the febrile 
 
344 EESPIRATION AND CIRCULATION. 
 
 flush of pneumonia, of phthisis, and of acute tuberculosis, 
 especially if these diseases be extensive. A certain degree of 
 it is habitual in all serious forms of acute bronchitis ; in this 
 latter complaint, in children, the blue color of the face is an 
 indication of considerable gravity. In attacks of bronchitis 
 supervening on extensive emphysema, lividity is habitual, and 
 often excessive. In extreme pleuritic effusion, likewise, liv- 
 idity indicates the gravity of the condition. In extensive ex- 
 cavation or destruction of the lung, and also in pneumo- 
 thorax, lividity is often very marked. In cardiac disease of 
 nearly every form lividity is apt to appear, imparting a dusky 
 flush to the cheeks from chronic passive congestion : this may 
 be so habitual as to lead to changes in the tissues (induration 
 and even inflammation). If the cardiac disease involves the 
 tricuspid valve, more extreme lividity may take place. In 
 malformations of the heart, and defects permitting the direct 
 passage of blood from the right to the left side, extreme liv- 
 idity usually exists ; in infancy this may often be seen to 
 come on during crying, or at certain times only, owing, prob- 
 ably, to the varying efliciency with which the foetal orifices 
 are closed. The term " morbus cseruleus " is applied to this 
 condition. The most extreme cyanosis, however, may exist 
 from such congenital causes without the least dyspnoea. 
 Amongst other causes of lividity, not specially referred to in 
 the above, may be mentioned cholera during the stage of col- 
 lapse, and the inhalation of gases not adapted for respiration 
 (nitrous oxide, chloroform vapor, carbonic acid, etc.). 
 
 Altered rhythm of the breathing; Cheyne-Stokes breathing; 
 nervous and renal dyspnwa. — Alterations in the rhythm of the 
 respirations sometimes occur. In health the breathing, al- 
 though very regular on the whole, frequently presents an 
 occasional inspiration of greater depth than usual, a fact of 
 which we frequently avail ourselves in the auscultation of 
 young children. But very marked alterations in the respira- 
 tory rhythm are found in certain cases of cardiac disease 
 (especially dilated and fatty heart), and sometimes in cerebral 
 affections, or even in certain fevers where cerebral symptoms 
 supervene. The breathing referred to is sometimes named 
 "suspirious" or "sighing," and in slight forms may consist of 
 a few quick gasps, or deep sighing inspirations, followed by a 
 period of slow and shallow respiration, or by a very temporary 
 suspension of the process. This form of breathing may be 
 associated with attacks of "angina sine dolore" (Gairdner), 
 as manifested by the look of anguish and general distress de- 
 
CHEYNE-STOKES BREATHING. 345 
 
 picted on the countenance of cardiac patients, without, it may- 
 be, any very definite ^Dain. This suspirious respiration is often 
 23resent, likewise, in very A'^ariable degrees, in some cases of 
 cerebral disease, and also in the course of fevers where cere- 
 bral symptoms have arisen. In its most marked character it 
 is spoken of as the Cheyne-Stokes respiration. " It consists in 
 the occurrence of a series of inspirations increasin^^^ to a max- 
 imum, and then declining in force and length until a state of 
 apparent apnoea is established. In this condition the patient 
 may remain for such a length of time as to make his attendants 
 believe that he is dead, when a low inspiratiou, followed by 
 one more decided, marks the commencement of a new ascend- 
 ing and then descending series of inspirations." (Stokes.) 
 This extreme form is met with in connection Avith various 
 forms of cardiac disease— not merely in fatty degeneration, to 
 which it was at one time specially ascribed. It also occurs 
 in aneurismal disease, and in cases of scabrous aorta without 
 aneurismal dilatation ; very frequently the association is with 
 renal disease and ursemic poisoning, but in such cases there is 
 very often some cardiac complication also. In some cases of 
 tubercular meningitis " Cheyne-Stokes respiration" may be 
 found in perfection ; the distinction drawn by some between 
 the cerebral variety and that of cardiac origin seems untenable ; 
 the difference is rather in the degree of approximation to the 
 type described, all gradations being found at times in both, 
 although the rhythm is no doubt less " regular in its irregu- 
 larity" in the so-called "cerebral breathing" of brain disease. 
 
 The change is usually more gradual in its character in the 
 descending than in the ascending series of respiratory move- 
 ments. In the period of apnoea we can often trace a slight or 
 usually abortive effort at respiration. All these points are 
 well illustrated in the tracings appended. ^Fig. 48.) The 
 last of tlie series shows that even in the period of profound 
 apnoea the patient, when urged to do so, can execute spas- 
 modic, irregular, and imperfect respiratory movements. 
 
 During the period of apnoea the patient's consciousness, or 
 at least his intelligence, seems often to be partially and some- 
 times more completely obscured; the cessation of respiration 
 is sometimes preceded by very slight moaning sounds, more 
 slight than, but still having some resemblance to, the sounds 
 often heard as a cardiac patient, distressed for want of sleep, 
 drops off for a few seconds into an uneasy slumber. During 
 the period of apnoea the puj)il usually becomes contracted, as 
 in sleep, and dilates with the first or second of the deep inspira- 
 
346 RESPIRATION AND CIRCULATION, 
 
 Pl«. 48. 
 
 1 
 
 I 
 
 o 
 
 I— I 
 H 
 <I 
 
 m 
 
 m 
 
 i-H 
 
 o 
 
 H 
 m 
 
 w 
 
 
 1 
 i 
 
 Exact cojjy of portions of tracings taken by Dr. M'Yail, by means of his "spirograph," 
 from a case of Cheyne-Stokes respiration. 
 
NERVOUS DYSPNCEA. 347 
 
 tions of the ascending series. Sometimes rhythmical alterna- 
 tions in the pupil are also noticed with each individual breath 
 — the pupil contracting with the expiration, and dilating with 
 the inspiration. (See p. 173.) 
 
 Labored respiration constitutes a common feature in cere- 
 bral apoplexy, dating sometimes from the very beginning of 
 the attack, in the severe forms associated with deej) uncon- 
 sciousness and stertor. It may appear in the course of a day 
 or two in cases wdiich begin in a less alarming way, although 
 advancing toward death. This disturbance of the respiration 
 is probably due in part to the direct affection of the pneumo- 
 gastric and other nerves ; when developed later in the case, 
 the respiration becomes involved from the unconscious and 
 paralyzed condition of the patient favoring an affection of the 
 lung itself. In the unconscious period after convulsion fits, 
 the same state of the breathing may be present. 
 
 Nervous Dyspnoea. — Nervous disturbance has been already 
 alluded to as complicating various forms of dyspnoea. Thus, 
 in diphtheria or croup, the mechanical obstruction is often 
 gravely aggravated by nervous spasm, and this forms a com- 
 plication in the alarming but usually transient attacks of 
 catarrhal laryngitis ; the irritation of foreign bodies in the 
 larynx or trachea, and the pressure of aneurismal and other 
 tumors in the chest often determines serious, or it may be fatal, 
 spasms of the glottis. Even in cardiac cases the breathlessness 
 seems at times to be at least in part of nervous origin. 
 
 In spasmodic asthma the sudden onset of dyspnoea in the 
 midst of practically good health, the rapid development of the 
 most extreme respiratory distress, the rapid and very com- 
 plete way in which this may pass off, and the almost magical 
 subsidence of the attacks, at times, under the influence of 
 agents acting on the nervous system, all point to the nervous 
 origin of the complaint : this has been plausibly ascribed to 
 a spasm of the small bronchial tubes. The patients make 
 extreme and at times frantic efforts to breathe ; the chest is 
 soon distended to its utmost capacity, so that further inspira- 
 tory efforts, although very visible in the labored action of the 
 accessory muscles of respiration, can make but little extra 
 expansion ; indeed, the real difficulty seems rather to be in 
 emptying the chest of the air already in it, and the prolonged 
 wheezing with the expiration is usually much more marked 
 than the similar sounds with inspiration. Hence this form of 
 breathlessness is often classified as an " expiratory dysjmoea." 
 As expectoration becomes established the spasm relaxes, and 
 
348 RESPIRATION" AND CIRCULATION. 
 
 the attack may pass off as quickly as it came ; or the inhala- 
 tion of medicated fumes, dense enough almost to choke the 
 attendants, may bring instantaneous relief to the asthmatic. 
 
 In other cases the determining influence in an asthmatic 
 attack acting, no doubt, partly through the nervous system, 
 seems to be from pollen, hay, or special forms of dust (such 
 as ipecacuanha) which are obnoxious to special individuals. 
 
 Nervous dyspnoea, however, may occur in a marked form 
 apart from any gross nervous lesion, and without any evi- 
 dence of the respiratory or circulatory organs being diseased. 
 Such attacks are found almost exclusively in women and are 
 usually complicated with hysteria. Allied to this is the dysp- 
 noea sometimes found in the earlier months of pregnancy, 
 where no sufiicient explanation of it can be afforded by the 
 mere distention ; indeed it may pass off' as the abdomen be- 
 comes larger. 
 
 Renal dyspncea may show itself as an early symptom of 
 kidney disease, ajDpearing readily on exertion ; but a more ex- 
 treme form of breathlessness, resembling an asthmatic attack, 
 appears sometimes in affections of the kidney apart from 
 oedema, cardiac complications, or other recognizable influ- 
 ences. 
 
 Before any negative conclusion can be arrived at warrant- 
 ing the diagnosis of nervous or renal dysj^noea, and before any 
 diagnosis of one form of dyspnoea to the exclusion of others 
 can be safely made, the most careful exploration of the res- 
 piratory and circulatory organs must be undertaken, and the 
 features of the whole case must be viewed from various aspects 
 and even perhaps watched for some time in its various phases. 
 (See " Introductory Remarks," p. 338.) 
 
 Cough. 
 
 Cough is a leading symptom in many diseases ; it sometimes 
 constitutes the chief complaint of the patient, but in other 
 cases we have to inquire very particularly as to its presence. 
 In all cases of dyspnoea and thoracic disease the indications 
 afforded by its absence, or by its special characteristics when 
 it is present, must be regarded as most important. Occasion- 
 ally it is so slight, and the patient has become so much accus- 
 tomed to it, that it is only when attention is specially directed 
 to it that its existence is noticed ; in such cases those who live 
 wdth the patient can often give us more reliable information 
 than the patient himself. Such slight forms of cough, occur- 
 
COUGH. 349 
 
 ring chiefly in the morning, often constitute one of the early 
 symptoms of phthisis. Although a very constant indication 
 of jDulmonary affections, cough is occasionally absent even in 
 serious and advanced disease of the lungs, so that mere ab- 
 sence of this symptom is no security for the soundness of these 
 organs. Vie must also remember that pleurisy even with ex- 
 tensive effusion frequently occurs without this symptom. 
 
 In the investigation of cough we inquire if it seems dry or 
 moist and what kind of expectoration, if any, is brought up ; 
 if the cough is loud and clanging, with barking or brassy 
 sound ; or if it is associated with hoarseness, or imperfection 
 in the closure of the glottis ; if there is a sense of constant 
 irritation with the cough, or if the act of coughing seems to 
 clear away some obstruction ; if it comes in paroxysms, or if it 
 is more persistent and regular in its occurrence ; if it comes 
 on at particular times, as on going to bed at night or getting 
 up in the morning, or on passing into a colder atmosphere, or 
 on exertion, or on speaking ; if it is set up by any special pos- 
 ture, as by lying on the back, or on the one side as compared 
 with the other, or with the head low ; if it is habitual in win- 
 ter, disappearing or getting much less in summer time ; if it is 
 associated with retching, or terminated by an act of vomiting ; 
 and if there is stridulous or crowing inspiration associated with 
 it. The duration of the cough, the site and character of the 
 attendant pain, if any, the presence of dyspnoea, the special 
 character of the sputum, and the examination of the chest, 
 constitute important points in the inquiry. 
 
 The presence of cough always suggests the existence of some 
 kind of disease in the respiratory tract, but we know that a 
 cough may be induced, apart from this, in a reflex manner. 
 Thus aneurismal or glandular tumors in the mediastinum may 
 produce spasmodic or paroxysmal attacks of coughing from 
 pressure on the nerves ; syringing the ears has been known to 
 produce coughing, and probably certain forms of aural disease 
 may likewise do so ; in hysterical attacks, and in pregnancy, 
 cough may be set up apart from any disease of the air passages ; 
 and certain forms of gastric irritation may likewise produce a 
 reflex cough. But " stomach coughs " and any other forms of 
 reflex cough are not to be too readily accepted ; the most 
 careful and repeated examination of the chest must first be 
 made in all such cases. 
 
 In i^ertussis (whooping-cough) the violent cough is the chief 
 fact ; there is usually, however, more or less bronchial catarrh 
 also, the signs of which can generally be found in the lungs, 
 
 30 
 
350 RESPIRATION" AND CIRCULATION". 
 
 especially if we listen just before a paroxysm of coughing. 
 This disease is rare above the age of puberty ; it is infectious, 
 and one attack usually protects the j^atient from a second, but 
 a relapse after an interval of freedom for some weeks or 
 months is not uncommon. These j^oints are often important 
 in the diagnosis. In the early stage the paroxysm of coughing 
 is characterized by a rapid succession of expiratory acts, with- 
 out much pause between them, so that the child's face rapidly 
 becomes red ; this peculiar cough coming in j^aroxysms may 
 often be recognized as whooping-cough by an experienced ear 
 even before the "whoop" becomes developed. This "whoop" 
 is a long-drawn crowing sound, due to the inspiratory act 
 which follows the violent series of coughs ; this peculiar sound 
 is produced by the passage of the air through a glottis 23artially 
 closed by spasm. This sound may be loud and resounding, or 
 it may be somewhat choked and scarcely audible or at times 
 quite suppressed, through excess of the spasm. The child's 
 face, by its blueness, or blackness, indicates the gravity of the 
 last variety of fits ("dumb kinks"). To the violent parox- 
 ysmal acts of coughing the name " kinks " is applied by some 
 mothers, the term "whooping" being reserved for the inspira- 
 tory " crowing." Certain cases pass through their course with- 
 out a single paroxysm of " crowing " being heard, but this is 
 quite exceptional. The paroxysm of whooping-cough is often 
 terminated by vomiting, the contents of the stomach coming 
 away freely ; in many cases there is much glairy and sticky 
 phlegm also, and this may be all that is brought up. The fits 
 of coughing sometimes produce bleeding from the nose, ears, 
 and eyes ; great suffusion and much swelling of the eyes and 
 face are common ; and as a rarity, subcutaneous emphysema 
 may be developed from rupture of the air vesicles through 
 stress of coughing. All degrees of feverishness and prostra- 
 tion are found in whooping-cough, but these are usually present 
 to a serious extent only in those cases associated with much 
 catarrh, with diarrhoea, or other complications. In the slighter 
 forms of the disease during the intervals of the paroxysms the 
 child seems often perfectly well. In the diagnosis, the presence 
 of an ulcer on the frenum linguie is sometimes of considerable 
 value ; it appears in about one-half of the cases soon after the 
 paroxysmal cough has been fully developed. It only occurs 
 in those children who have incisor teeth in the lower jaw, and 
 it seems to have a purely mechanical origin. This ulcer dis- 
 appears with the diminution of the cough. The paroxysmal 
 cough of pertussis, and also the ulcer, may both disaj^pear 
 
LARYNGEAL COUGH. 351 
 
 with the advent of serious complications rpneumonia, convul- 
 sions, etc.) and may reappear after these have passed away. 
 
 A crowing inspiration, somewhat resembling that of per- 
 tussis, is found in young children in the disease known as 
 laryngismus stridulus; it is due, as in whooping-cough, to 
 spasm of the glottis, but there is not necessarily or usually any 
 special cough in laryngismus. This " child crowing " affects 
 rickety children in particular, and is frequently associated 
 with attacks of general convulsions. 
 
 Another disease associated with paroxysmal cough and 
 crowing is that known as bronchial phthisis, due to tubercular 
 affections of the bronchial glands. This may bear a very close 
 resemblance to pertussis. The history of a former attack of 
 whooping-cough, or the absence of any evidence of infection 
 received or transmitted, and the chronicity of the complaint 
 frequently assist in the discrimination of this disease. 
 
 In measles and influenza the disease although of a general 
 nature, falls specially on the organs of respiration, and mani- 
 fests itself by cough among other symptoms. A certain degree 
 of pulmonary catarrh or congestion, with more or less cough, is 
 present in enteric fever and many other febrile diseases. 
 
 Irritation of the throat or glottis may set up a cough in a 
 mechanical way. Thus the passage of fluids or solids toward 
 the larynx may produce violent coughing, which tends to per- 
 sist for some time, even after the source of irritation is re- 
 moved. Greedy sucking on the part of a thirsty infant, the 
 trickling down of fluids from the posterior nares fpost-nasal 
 catarrh, etc.), and the presence of an elongated uvula may be 
 mentioned under this heading. Certain irritating gases, such 
 as chlorine and sulphurous acid, if inhaled, likewise produce 
 violent paroxysms of coughing in healthy persons. In those 
 rendered specially susceptible, from disease in the larynx or 
 bronchi, the passage from a hot to a cold atmosphere, or the 
 reverse, may set up violent fits of coughing. 
 
 A laryngeal eough is often loud, clanging, and very fre- 
 quent and irritating ; it may also be hoarse and imperfect. 
 Ulceration and thickening of the mucous membrane in the 
 larynx may give rise to both forms; the ulceration is often 
 associated with tubercular or syphilitic disease. Tumors, 
 oedema, abscesses, etc., operate in the same way. Direct pres- 
 sure on the trachea by an aneurismal or malignant tumor 
 may give rise to a croupy quality of the cough, usually associ- 
 ated with stridulous respiration. A laryngeal cough may, 
 however, arise indirectly from the pressure of a tumor on the 
 
852 KESPIRATION AND CIRCULATION. 
 
 recurrent laryngeal nerve. With this we may have evidence 
 of laryngeal spasm, or of paralysis, or both. In paralytic 
 affections of the larynx the cough, like the voice, is usually 
 hoarse. All forms of laryngeal irritation are apt to give rise to 
 spasm of the glottis. This often imparts a stridulous char- 
 acter to the inspiratory acts associated with the cough. In 
 laryngeal ulceration streaks of blood are common in the 
 sputum, but the expectoration is seldom profuse. An examin- 
 ation of the larynx by the laryngoscope (see Chapter X.) ; of 
 the chest, for any signs of tubercular disease, aneurism, or 
 thoracic tumor ; and an inquiry as to the presence of consti- 
 tutional syphilis, are all very important points in such cases. 
 A barking, brassy cough is common in croup, and also in 
 diphtheria involving the larynx and trachea. Along with this 
 quality of the cough we have noisy breathing, which can 
 usually be recognized at once as due to obstruction in the 
 upper part of the air-joassages. An examination of the fauces 
 may reveal the white patches of diphtheritic exudation, the 
 extension of which to the larynx has caused the obstruction, 
 but in many cases of undoubted laryngeal dij^htheria there may 
 be no visible affection of the fauces. When the disease begins 
 in the trachea there is usually a period of illness for a day or 
 tAvo days, associated with high fever, prior to the appearance 
 of any alarming obstruction to the breathing. Very sudden 
 attacks of hoarse, croupy cough, coming on in the night, and 
 subsiding quickly on the use of warm baths, emetics, etc., are 
 usually due to a form of laryngitis. (To this and also to 
 laryngismus stridulus, the name " false crouj) " is sometimes 
 applied.) Croup and laryngeal diphtheria cannot be separated 
 clinically ; a case of so-called croup, in its most typical form, 
 may occur amidst, or may give rise to, undoubted diphtheria. 
 Occasionally threads of membrane, or even hollow casts, are 
 expectorated or coughed up in these affections. 
 
 Foreign bodies of the most diverse kinds sometimes pass into 
 the trachea or into one of the bronchi: in the act of entering 
 violent and paroxysmal cough is set up, but as this may 
 gradually subside much doubt may remain as to whether the 
 foreign body was swallowed, or whether it actually passed 
 down into the trachea. In the latter case the cough usually 
 continues to recur in paroxysms of varying intensity, and 
 severe or fatal spasm of the glottis may supervene. In cases 
 of this kind, assuming a chronic form, the cough may simulate 
 that of advancing phthisis ; and emaciation, sweating, and 
 feverishness may all add to the resemblance ; subsequent dila- 
 
EXPECTOKATION. 853 
 
 tation of the bronchi, the formation of cavity, and the secretion 
 of pus may add further to the difficulties : when this takes 
 place the fetor of the pus expectorated is often a striking 
 feature. The discrimination may be impossible ; but when 
 the history clearly points to the accident in swallowing as the 
 date of the appearance of the cough, when the family history 
 is good, and the physical signs of phthisLs equivocal in any way, 
 the sputum fetid and destitute of the tubercle bacilli, the 
 possibility of this form of disease, and the question of surgical 
 exploration or interference must be considered. 
 
 In all varieties of bronchial and pulmonary disease cough is 
 almost always present, sometimes in slight forms, sometimes 
 in suffocative paroxysms of great severity. In the pneumonia 
 of children, however, it is seldom present in the early stage, 
 and in exceptional cases in adults it may be absent or at least 
 trifling for several days after the acute signs of illness have 
 appeared. In pericarditis cough is often a troublesome symp- 
 tom ; it has sometimes a hoarse quality. In pleurisy, apart 
 from complications, there is sometimes an entire absence of 
 cough ; but pleurisy frequently accompanies pneumonia and 
 phthisis; when cough coexists with pleurisy, it is often ex- 
 tremely painful — the pain being referred to the site of the 
 pleuritic inflammation. In like manner, pain with the cough 
 occurs notably in pericarditis and peritonitis, and also in 
 rheumatic affections of the thoracic muscles. In bronchitis 
 the pain associated with the cough is usually substernal A 
 violent or very fi-equent cough often excites muscular pains, as 
 the result of strain, all over the chest and abdomen ; and it may, 
 likewise, occasion distressing pain in the head. The character 
 of the expectoration, the physical examination of the chest, 
 and the previous history must be relied on in seeking to 
 ascertain the cause of cough in pulmonary disease. It must be 
 remembered that cardiac, aneurismal, or renal affections may 
 constitute the primary disease of which the pulmonary mis- 
 chief is but a manifestation or complication, and that some 
 general diseases, notably pertussis, influenza, measles, and 
 enteric fever may be the real cause of the pulmonary disorder 
 and its attendant cough. 
 
 Expectoration. 
 
 The expectoration of hospital patients is usually preserved 
 for inspection as a matter of routine. Earthenware spittoons 
 are generally employed, but glass dishes have the advantage of 
 
 30* 
 
354 RESPIKATION AND CIRCULATION. 
 
 showing the character of the expectoration somewhat better, 
 especially if it is abundant. In jorivate practice we have to 
 give special directions for the preservation of the sputa when 
 this is a matter of importance, as in pneumonia and cases of 
 hsemoptysis. Little vessels, such as soap dishes, or articles of 
 a similar size, are generally at hand in the bedroom, and can 
 be used for this purpose. When the quantity is large, we have 
 sometimes to pour the contents slowly from one vessel to 
 another, so as to judge of their character and admixture; or 
 by emptying them on to a blackened plate we may be able to 
 pick out little pieces for more critical examination. While 
 thus emptying the contents, we are able to notice any fetor, 
 or the peculiar odor of gangrene, if either be present. The 
 sputum can often be best examined by floating some of it in 
 water and teasing it out : small casts of minute tubules may 
 thus be found. (For microscopic examination, see p. 359.) 
 
 We describe the expectoration as to its quantity in the 
 twenty-four hours ; as to its composition, whether mucous, 
 purulent, mucopurulent, watery, serous, or bloody , as to its 
 consistence, whether thick or thin, composed of separate and 
 defined sputa, or more homogeneous; Avhether tenacious, viscid, 
 fluid, or frothy. The frothiness may show itself as large air 
 bubbles, or these may be so minute and so much mixed with 
 the mucus as to require close examination. Various impurities 
 are often mixed up with the expectoration — as blood from the 
 gums, matters from the nose or stomach, pieces of food from 
 the mouth, and accidental particles carried in from the air. 
 Coloring materials suggestive of blood may be derived from 
 the brown crust of bread, from wine, from tobacco-juice, and 
 the coloring of sweetmeats. 
 
 In health a little mucus is expectorated, and in disease the 
 sputum may consist chiefly of mucus. In smoky towns this 
 is very apt to be of a dark color from the presence of floating 
 soot ; and in the case of miners, from similar causes, the ex- 
 pectoration is usually black. Occasionally the black color is 
 derived from disintegration of the pulmonary pigment in 
 cases with breaking up of the lungs, even in those who had 
 long given up this kind of work. 
 
 Frothy mucm, sometimes rather watery, is often expectorated 
 in acute bronchitis and oedema of the lung. Minute aeration 
 of the sputa is often found in the tenacious mucus expectorated 
 in pneumonia, but this is usually rusty or distinctly bloody. 
 (Seep. 357.) 
 
 Parulent sputa cannot be absolutely separated from mucous 
 
MEMBEANOUS SHKEDS. 355 
 
 sputa, as the two conditions merge into each other, and an in- 
 termediate condition is often named " mucopurulent." These 
 forms of expectoration must also be described as to their 
 frothiness, consistence, color, etc. The sputa may consist of 
 almost pure pus ; and when these spread out so as to form flat 
 masses resembling the shape of pieces of money, they are 
 called " nummular ; " when they retain a spherical form they 
 are termed " globular ; " such sputa are usually dense and 
 tend to sink in water. Both of these forms are commonly 
 seen in cases of advanced phthisis, but nummular sputa may 
 often be found in chronic bronchitis also. Purulent expec- 
 toration is common in all chronic forms of catarrh affecting 
 the respiratory tract. Very profuse expectoration of pus, 
 usually of a fetid character, may proceed from dilated bron- 
 chi (bronchiectasis). The influence of foreign bodies in 
 causing excavation and profuse discharge of fetid pus must 
 also be remembered. A sudden profuse expectoration of pus, 
 or the sudden increase of it, may depend on the bursting of a 
 tubercular vomica or of an intrapulmonary abscess, or it may 
 be due to the opening of a collection of pus in the pleura 
 into a bronchus, or to the opening of a hepatic abscess through 
 the diaphragm ; or, more rarely, to the bursting of some 
 abscess in the mediastinum or elsewhere. When an empyema 
 bursts in this way the pus expectorated is usually rather fluid, 
 and it may come up in large quantities. The signs of pyo- 
 pneumothorax usually become developed after such an acci- 
 dent, but this is not always the case. The pus from a pul- 
 monary abscess may or may not be fetid ; possibly it may 
 have a gangrenous odor ; its quantity on any one day although 
 large is not excessive (say 12-18 oz.), and the microscope may 
 reveal shreds of lung tissue in great abundance, and in some 
 cases blood crystals are also present ; such abscesses are some- 
 times due to embolism of the pulmonary artery. Hepatic 
 abscess usually declares its presence by symptoms and facts 
 pointing to the liver before it gets the length of perforating 
 the lung. 
 
 Membranous shreds from the larynx and trachea are some- 
 times expectorated in croup and diphtheria, and fibrinous casts 
 of the bronchi may occur in connection with plastic or fibrin- 
 ous bronchitis. The dichotomous divisions are well shown in 
 the drawing here given, which is a full-size copy of the speci- 
 men (Fig. 49.) Small casts of the minute tubes are some- 
 times found on floating out the sputum in water, or on 
 
356 
 
 RESPIRATION AND CIRCULATION, 
 
 microscopic examination. Spirals from the alveoli have been 
 described by Curschmann as microscopic objects. 
 
 Little cheesy masses sometimes come from pits in the tonsils ; 
 but these, and also calcareous masses, may be expectorated in 
 
 Fig. 49. 
 
 Fibrinous cast of bronchi ; drawn full size, but the cast was slightly shrunken by 
 keeping. (Dr. John Wilson.) 
 
 cases of old standing phthisis. They sometimes come from 
 bronchial glands which have ulcerated into the tubes. Shreds 
 of hydatids may be brought up in connection with the bursting 
 of hydatid cysts of the lung and even of the liver. (See 
 Fig. 72, Chapter XII.) 
 
 The expectoration of blood (haemoptysis) is always a most 
 important fact. Care must be taken to avoid errors from the 
 presence of coloring matter accidentally mixed with the 
 sputum ; the microscope may here be called in to discriminate 
 the red blood-corpuscles. But even when we are sure of the 
 presence of blood, this may j^ossibly come from spongy gums, 
 
HEMOPTYSIS. 357 
 
 as many gums bleed very readily, especially if they are 
 sucked ; or the blood may come from the nose, trickling down 
 the posterior nares, even when none appears from the nostrils ; 
 or the blood may come from ulcerations, etc., in the throat or 
 in the larynx. The mention of these sources may serve to 
 direct our attention in scrutinizing the source of the bleeding; 
 examination by the laryngosco23e is often important in this 
 inquiry. Or, again, especially in profuse bleeding, there may 
 be a question as to whether it may not come from the stomach. 
 (See " Hsematemesis.") Blood from the lungs is usually 
 more florid and more frothy than that brought up from the 
 stomach ; the latter is usually dark and acid, and may be 
 mixed up with partially digested food. The term " vomiting " 
 of blood, as used popularly, signifies the bringing up of any 
 large quantity of blood, whether from the lungs or stomach. 
 Even Avhen it comes from the lungs, the action resembles very 
 much that of vomiting. Difiiculties in the diagnosis may 
 arise from blood from the lungs being in part swallowed 
 before it is vomited up agaiu. The continuance of blood- 
 stained sputa for some hours at least after a profuse discharge 
 of blood from the lungs usually affords guidance in doubtful 
 cases of haemoptysis. 
 
 When the blood really comes from the lungs, whether it be 
 in large or small quantity, it is always a serious fact. The 
 least grave form, perhaps, is the presence of slight streaks in 
 the expectoration in connection with violent fits of coughing, 
 or during an attack of moderately acute bronchitis. 
 
 The rusty sputa found in pneumonia owe their color to 
 blood ; in some cases the presence of blood is very pronounced 
 in this disease. The rusty color is produced by the very 
 intimate admixture of blood with the mucus, and this secre- 
 tion is usually very tenacious, as can be shoAvn by turning the 
 vessel upside down ; minute air-bubbles may often be seen in 
 this expectoration. This rusty expectoration is very important 
 in the diagnosis of pneumonia from pleurisy and other affec- 
 tions, although it is occasionally absent — notably in the case of 
 children, and also usually in the 23neumonic consolidations of 
 typhus. Very bloody expectoration in pneumonic attacks, and 
 the long-continued presence of blood in the sputa in such cases 
 are always calculated to give rise to fears of phthisical disease. 
 
 Closely allied to the rusty spit of pneumonia, although 
 often more distinctly bloody and more largely aerated, is that 
 of valvular heart disease, or that which is found in minute 
 aneurismal hemorrhages into the trachea, or that of pulmo- 
 
358 KESPIRATION AND CIRCULATION. 
 
 nary infarctions due to embolism of the pulmonary artery. 
 This last form arises in cases of heart disease, and also in dis- 
 eases characterized by a tendency to venous thrombosis 
 (phlegmasia dolens, childbirth, etc.). The coexistence of 
 pleuritic friction with evidence of pulmonary consolidation 
 and haemoptysis has often been noticed in cases of this kind. 
 
 An intimate admixture of blood with the sputum may give 
 rise to a darker color, somewhat resembling prune juice ; this 
 occurs in cases where the blood lingers longer in the pulmonary 
 tissues ; it is found in cases of chronic pneumonia going pn to 
 destruction of the lung, and also in certain cases of aneurismal 
 hemorrhage, where the openings are so minute as to leak only 
 to a slight extent. In the destruction of the lung from gan- 
 grene there may be admixture of blood with the gray, greenish 
 gangrenous expectoration, seldom to any very great extent ; 
 gangrene of the lung in children seems to be more frequently 
 characterized by haemoptysis. 
 
 A form of bloody spit, somewhat resembling the appearance 
 of red currant jelly, is sometimes seen and is regarded as char- 
 acteristic of malignant growths in the lungs. 
 
 Hemorrhage from the lungs may occur as part of a general 
 hemorrhagic tendency as in purpura and hemorrhagic small- 
 pox ; the exact appearance of the blood will vary according to 
 the extent and situa,tion of the special bleeding. In certain 
 cases of irregular or suppressed menstruation the discharge is 
 said to find its escape occasionally from the lungs. This idea 
 of " vicarious menstruation " must always, however, be regarded 
 with the gravest suspicion, especially in young subjects, as 
 suppressed menstruation and haemoptysis afford strong grounds 
 for suspecting pulmonary phthisis; this doubt can only be set 
 aside by careful watching over a lengthened period. 
 
 Large hemorrhages from the lungs occur in phthisis both in 
 its earliest and its latest stages ; in cardiac affections, especially 
 in disease of the mitral orifice and valve ; and in cases of 
 thoracic aneurism bursting into the trachea or bronchi. With 
 regard to phthisis the profuse hemorrhage in the early stage 
 is not always easily explained ; it may occur while as yet 
 there are no physical signs of consolidation, and sometimes 
 there is even an absence of the physical signs we would expect 
 from the presence of blood in the air vesicles : usually, how- 
 ever, some moist rides can be heard. (A slight haemoptysis 
 frequently repeated is much commoner, of course, in phtliisis 
 than these alarming attacks.) Large hemorrhages in the late 
 stages of phthisis are usually due to the giving way of some 
 
EXAMINATION OF SPUTUM. 359 
 
 considerable artery, destroyed probably in the course of the 
 ulcerative process. Sometimes these hemorrhages are due to 
 the rupture of aneurisms of the pulmonary artery ; such 
 aneurisms form on the walls of old phthisical cavities, and 
 frequently give rise to smart hemorrhages, or to constant 
 staining of the sputa for some time before the fatal hsemoptysis 
 occurs. 
 
 Haemoptysis may, as a rule, be ascribed to heart disease 
 when valvular disease is discovered, apart from any signs of 
 aortic aneurism. The large hemorrhages from rupture of 
 aortic aneurism are usually almost immediately fatal, but the 
 patient may rally for a time. Such hemorrhage is generally 
 preceded by slighter forms of bleeding, but sometimes a pro- 
 fuse haemoptysis is the first indication of aneurismal disease. 
 
 Microscopic Examination of the Sputum has assumed of late years 
 a special importance in the diagnosis of phthisis from the detection 
 of microorganisms. Tuherclehacilli are found in the sputum in a very 
 large proportion of phthisical cases if adequate search be made by com- 
 petent observers ; as they may occur early in the case, when physical 
 signs are indistinct, absent, or perhaps doubtful in character, their 
 diagnostic importance is sometimes very great, inasmuch as they seem 
 never to be found in the sputum of non-tubercular patients, even 
 although they may be lying beside phthisical cases. Their abundance 
 is, however, subject to great variation ; one preparation from a given 
 sample of sputum may contain many bacilli and another, from the same 
 specimen, few or none ; they are usually most abundant in the dense 
 purulent portions ; they may vary in the samples as collected in the 
 morning or during the day, being usually most abundant in the former ; 
 they may also vary much from day to day in the same case, no doubt 
 from the variations going on in the process of destruction in the lung. 
 On these accounts the individual specimen of sputum ought to have 
 several preparations made from it ; examinations of the morning spu- 
 tum, on several separate days, ought also to be made before the least 
 weight can be attached to negative results ; even then the importance 
 attached to iho, absence of bacilli is but slight, although in experienced 
 hands negative results acquire value by their repetition. On the other 
 hand, the detection of bacilli even once is of great importance, although 
 here also repetition of the test is desirable, especially if the bacilli are 
 few, in case of any error in observation. 
 
 The methods of detecting these organisms are now taught in the 
 pathological laboratories, and it is desirable that some experience should 
 be gained in this way befure the method is applied to diagnosis. In 
 the case of the tubercle bacilli the appearances alone are not sufficient, 
 but along with the staining reactions they are regarded as conclusive 
 apart from cultivation experiments. 
 
 Method of Ehrlich and Oibbes. — A double staining is used — fuchsine 
 and methylene blue. A minute portion selected from a dense part of 
 the morning sputum is placed on a cover glass and spread out very thin, 
 say by rubbing it with another cover glass. This is then dried either 
 
360 RESPIRATION" AND CIRCULATION". 
 
 by exposure to the air for a time, or by passing it lightly over the flame 
 of a spirit-lamp. The glass with the dried lilm is now immersed or 
 floated in the solution of fuchsine ;^ this may be put into a watch-glass, 
 and separate glasses should be used for each specimen ; the film of spu- 
 tum should, of course, be directed down if the glass is floated on the 
 solution ; it should be left in contact with the coloring matter for half 
 an hour. This process stains all the microorganisms of a reddish color. 
 The next process is to remove the color from them all except the tubercle 
 bacillus; this is done by dipping the glass with the stained film into 
 dilute nitric acid (1 of strong nitric acid to 2 of water ; some use these 
 more dilute) : washing in this for a few seconds removes the color : 
 the acid is then washed off by means of distilled water. Methylene 
 blue staining is next applied by dipping the glass for a few minutes 
 into a saturated solution of this coloring matter; this colors all the 
 organisms and matters blue except the tubercle bacilli : these may thus 
 be found as minute rods colored red in the midst of blue surroundings. 
 
 For the examination a high power of the microscope is required, 300 
 or 400 diameters. An Abbe's condenser is useful ; by it colored par- 
 ticles only are brought into prominence, and so the search is much 
 facilitated. Sometimes minute fatty crystals may resemble the bacilli 
 in color, but seldom very closely in form ; any other organisms which 
 retain the red stain diflfer in their general appearance. 
 
 The numbers found \ ary enormously, but little stress can be laid on 
 this variation. The occurrence of very large numbers of bacilli in 
 specimen after specimen, as examined on several occasions, seems to 
 warrant a grave prognosis, and their very scanty or unfrequent occur- 
 rence may, more doubtfully', be held as a favorable indication, with the 
 reserve already expressed regarding the natural tendency to variation 
 in this respect. 
 
 Other sjoecific organisms have been described, as the " pneumococci," 
 and the micrococci of diphtheria, but as yet this part of the subject is 
 too doubtful to be of use in regular clinical work, although deserving 
 of investigation. 
 
 Fungous growths are often met with in sputum : they have as yet no 
 special importance in diagnosis ; but it is important to be familiar with 
 them to prevent mistaking them for elastic fibres. Bacteria of ordinary 
 putrefaction are also found in sputum. 
 
 Parasites. — Booklets and other traces of hydatid cysts may be found 
 in the sputum. 
 
 Epithelium: Spirals^ etc. — The microscopic examination reveals pus 
 and other forms of inflammatory corpuscles, but these have seldom 
 much importance in the diagnosis. Abundant epithelial cells, when 
 of columnar form, indicate implication of the tubes, whereas squamous 
 epithelium has but little significance. Spiral bands of minute size are 
 described by Curschmann as occurring in asthmatic cases ; they have 
 been supposed to point to inflammation of the alveoli. Casts of the 
 minute tubules can sometimes be recognized microscopically. 
 
 Crystalline forms in the sputum are found in connection with hemor- 
 rhagic affections ; blood crystals may thus occur in infarctions and 
 
 ^ 5 c.cm. of aniline oil ; 100 com. of diatilled water ; filter this, and add 11 c.cm. of a 
 saturated alcoholic solution of fuchsine. 
 
LUKG TISSUE IN SPUTUM. 
 
 361 
 
 abscesses. "Charcot's crystals" are of pointed octahedral shape and 
 destitute of color; their significance is still obscure. 
 
 Cholesterine is rarely present in sputum : it occurs in connection 
 with old accumulations of blood in the langs, and has been known also 
 to come from a communication with old pleuritic effusions containing 
 similar crystals. 
 
 Fatty acids are developed in the fetid accumulations occurring in 
 bronchiectasis. Leucin and tyrosin have also been noted. 
 
 Cancerous growths may occasionally be traced in the sputum, par- 
 ticularly in cases where the larynx is involved. 
 
 Lung tissue : Elastic fibres. — Of great importance in the microscopic 
 examination is the detection of lung tissue or elastic fibres. When the 
 shape of the pulmonary alveoli in these fragments can be recognized, 
 we infer with certainty some destructive lesion in the lung, but not 
 necessarily of the phthisical type. When fragments of yellow elastic 
 fibrous tissue are found these come most commonly from the lung, but 
 they may also come from the larynx. Abscess of the lung, from pul- 
 monary infarction, may give rise to a purulent expectoration very rich 
 in lung tissue, and a single microscopic field may contain many frag- 
 ments of lung tissue in such cases. Elastic fibres from the lung may 
 also be found in the sputum from cases of bronchiectasis, but the com- 
 monest cause of their presence is ordinary phthisis. When the lung 
 tissue is abundant in the sputum, a little of it, placed on a slide, is all 
 that is required for the examination ; those skilled in the process may 
 be able to pick out little fragments likely to contain pulmonary fibres, 
 but the crowd of pus cells greatly impedes the examination. A few 
 drops of caustic soda solution applied to the specimen may clear the 
 field and facilitate the search. 
 
 Fig. 50. 
 
 Elastic fibres of lung tissue obtained from sputa after digestion in caustic soda. 
 (Drawn by Dr. John Wilson.) 
 
 Another method, recommended by Dr. Fenwick, consists in lique- 
 fying the pus by means of caustic soda. A solution containing about 
 twenty grains to the ounce is added in equal volume to the expecto- 
 rated matter brought up during a night ; this is cautiously boiled in a 
 
 31 
 
362 RESPIRATION AND CIRCULATION. 
 
 flask or flat dish, so as to allow of eflScient stirring and mixing ; the 
 mixture is just boiled, and if still not sufficiently liquefied, a little 
 more of the solution should be added. Prolonged boiling and too 
 much alkali lend to dissolve the fibrous tissue searched for, and so 
 must be avoided. The liquefied mixture is placed in a cylindrical 
 glass vessel, and after it settles, a few drops of the sediment may be 
 examined with the microscope, or a portion of the liquefied material 
 may be placed in a similar vessel, and three or four volumes of water 
 added to it so as to assist the precipitation of the pulmonary fragments. 
 
 In examining the sediment, a few drops should be lifted by means 
 of a dipping tube (not drawn to a point), and these should be placed 
 on a large slide or shallow cell ; the layer of fluid must, however, be 
 very thin. A low power should be used — an inch or half-inch objective 
 — and if any group of fibres resembling the arrangement of the pul- 
 monary cells can be seen, higher powers may be used to resolve their 
 structure. Separate yellow elastic fibres can often be recognized, with 
 their typical curling at the ends. The pieces vary much in size; 
 sometimes only a few loose fibres can be found. (See Fig. 50.) 
 
 Several things tend to confuse the beginner in this inquiry. Por- 
 tions of vegetable tissue, from the food or from accidental admixture, 
 are often found, as they resist, of course, the caustic action of the 
 soda ; their cellular structure sometimes misleads. More misleading 
 still is the appearance of certain vegetable growths ; but their branch- 
 ing and interlacing fibres usually guard us from error. A good plan 
 for the beginner is to secure some pus from a phthisical cavity, at a 
 post-mortem inspection, and by subjecting this to microscopic exam- 
 ination after digestion in soda, and also without any such preparation, 
 he becomes familiar with the appearances searched for, apart from 
 most of the structures which tend to confuse. 
 
 Fluids Removed from the Chest by Tapping. 
 
 These have considerable significance in the diagnosis and prognosis 
 of certain cases. The most important point is, whether the fluid is 
 purulent or serous. This can usually be judged of pretty accurately 
 by the eye, on the first few drachms being seen in the tube. Occasion- 
 ally a pretty clear fluid becomes almost solid after its removal ; more 
 commonly a certain amount of coagulation, varying much in extent, 
 can be recognized, but frequently almost no trace of coagulation is 
 perceptible. The highly coagulable fluid indicates the presence of a 
 certain intensity of the inflammatory process. 
 
 Admixture with blood renders the fluid less clear, and in many 
 cases forms a transition stage toward purulent transformation not 
 always easy of recognition. In such cases we may find a slight de- 
 posit of cells resembling pus, with blood above it. 
 
 Slight admixture with blood is sometimes ascribed to the puncture 
 of the chest wall, but is usually due to the bloody character of the 
 fluid itself. Sometimes after repeated tappings, the reddish color 
 changes to a more chocolate tint. 
 
 Very bloody fluid is always suggestive of a bad type of pleuritic 
 exudation. Most of such cases prove to be due to malignant disease. 
 Sometimes, however, the bloody fluid arises from tubercular disease of 
 the pleura. 
 
HEMORKHAaES. 363 
 
 Purulent fluid suggests, of course, a very difi'erent diagnosis and 
 prognosis from clear serous fluid. The most important distinction in 
 purulent fluids is between those which are fetid and those which are not. 
 
 In the further examination of the fluid removed, especially when 
 clear, we note the reaction, the specific gravity, and whether it is, as 
 is usually the case, loaded with albumen. The microscopic examina- 
 tion often reveals blood, leucocytes, or pus corpuscles ; these may be 
 fatty; compound granular corpuscles are also common. Sometimes 
 we find cells suggestive of cancerous growths. Occasionally crystals 
 of cholesterine or blood crystals may he found in the case of old 
 efifusions. Hooklets or other indications of parasitic cysts are some- 
 times present, although such cases are rare in this country. (See 
 Fig. 72.) 
 
 Hemorrhages. 
 
 In the investigation of a case of anaemia, and in conducting 
 certain parts of other inquiries, we have sometimes to ask 
 about the occurrence of any serious loss of blood. Such 
 losses may be serious from their immediate severity, or from 
 their long continuance. It is often necessary to enumerate to 
 the patient the various forms of hemorrhage Avhen making 
 the inquiry at him, as otherwise we may fail in ascertaining 
 the facts. Thus we inquire, for any excessive bleeding occur- 
 ring from the surface, from wounds, ulcers, leech bites, etc. 
 In the case of women, we ask about any losses of blood in 
 connection with abortions, or with childbirth ; and for any 
 other hemorrhages from the womb (menorrhagia, metror- 
 rhagia). Spitting or vomiting of blood, whether from the 
 lungs or stomach (hsemoptysis and hsematemesis), and bleed- 
 ing from the nose (epistaxis), or from the gums, can scarcely 
 be overlooked. Passing blood from the bowels, and the bleed- 
 ing from piles, should be inquired for separately, to prevent 
 mistakes, and the change of color in the blood, giving rise to 
 dark or tarry motions (melsena), should be exj^lained to the 
 patient. Blood in the urine (^hsematuria) is usually recognized 
 as such by the patient, if very profuse and long continued, but 
 smaller quantities may escape notice ; subcutaneous hemor- 
 rhages or blotches, and purple spots may also be inquired for. 
 
 Most of these forms of bleeding are discussed under their 
 special sections, but bleeding from the nose (epistaxis) requires 
 some special notice here. Like other forms of bleeding, it 
 may be due to general causes, such as purpura, etc. (see p. 
 140), this form of hemorrhage being but one of the manifes- 
 tations. 
 
 Epistaxis also occurs in connection Avith severe headache, 
 arising either from functional disturbance or from cerebral 
 
364 RESPIKATION AND CIECULATION. 
 
 disease. The hemorrhage is followed sometimes by consider- 
 able relief; it may be brought on in some persons very readily 
 by excitement and heated rooms. In children a bleeding 
 from the nose often oocurs without obvious cause and without 
 any serious significance. It is not uncommon in the early 
 stage of enteric fever, and it also forms an early symptom in 
 certain cases of cardiac, splenic, and hepatic disease of various 
 kinds. It occurs sometimes also in renal affections. Bleeding 
 at the nose often arises in direct connection with the violent 
 paroxysms of whooping cough, and it may be associated in 
 this disease with bleeding from the eyes and ears. Sometimes, 
 although rarely, this bleeding from the nose is so readily ex- 
 cited by the fits of coughing, and is so excessive, that we must 
 suppose some peculiarity in the system at the time, especially 
 as this proclivity, after lasting for a while, may pass away, 
 although the fits of coughing continue, or even become more 
 violent. Bleeding from the nose may be from one nostril 
 only, or from both. In many cases the blood goes back to 
 the throat, and it may be 'swallowed or brought up according 
 to the strength or the position of the patient. Slight bleeding 
 from the nose is often due to picking the nostril. This occurs 
 in children chiefly, and is suggestive of gastro-intestinal irri- 
 tation from worms, diarrhoea, etc. 
 
 Amongst the general causes of hemorrhage, applying to many 
 or most of the forms, may be mentioned purpura hsemor- 
 rhagica, the hemorrhagic diathesis, and hemorrhagic small- 
 pox. Bleeding at the nose often arises in enteric fever, 
 probably from general causes; intestinal hemorrhage is mostly 
 due to the local affection in this disease. In relapsing fever, 
 menorrhagia and post-partum hemorrhage are common ; and 
 floodings after abortions or parturition are sometimes most 
 alarming in typhus fever and smallpox. Scurvy resembles 
 purpura in predisposing strongly to hemorrhage from the 
 gums and other mucous surfaces, and also from the ulcers 
 which arise in its course. 
 
 The hemorrhagic diathesis (haemophilia) nmst also be men- 
 tioned here. The bleedings connected with this state may be 
 spontaneous — apart from an}'- obvious injury — l)ut more com- 
 monly they arise from slight wounds, knocks, or pricks ; leech 
 bites are peculiarly apt to be intractable. Affections of the 
 joints sometimes appear in 3'oung subjects in connection with 
 this state. The joint affections seem sometimes to be due to 
 injury, probably from effused blood. 
 
 The hemorrhages from chronic hepatic, cardiac, and renal 
 
EXAMINATION OF THE BLOOD. 365 
 
 disease are usually determined by local conditions — cardiac 
 disease giving rise especially to haemoptysis, hepatic disease to 
 gastric, intestinal, or hemorrhoidal bleeding, and renal disease 
 to hsematuria — but a general influence can also be traced in 
 all, from their tendency to be associated with smal] subcutane- 
 ous hemorrhages and epistaxis. Hemorrhage under the con- 
 junctiva occurs at times in renal disease, and retinal hemor- 
 rhage is a well-known complication. Cerebral hemorrhage is 
 likewise common in renal disease, especially when associated 
 with cardiac hypertrophy. 
 
 In the forms of splenic enlargement due to malarial fevers 
 and other causes, in the different varieties of leukaemia and 
 lymphatic disease, and in pernicious anaemia, epistaxis and 
 subcutaneous hemorrhages also occur. 
 
 Examination of the Blood. 
 
 Apart from the superficial examination of the blood lost in 
 hemorrhages of various kinds, much might be hoped from an 
 elaborate chemical and microscopic investigation of samples 
 of the blood in different forms of disease. Hitherto compara- 
 tively little has been made of this form of inquiry, but indica- 
 tions of its growing importance are not wanting. With regard 
 to the chemical department of this subject there are two great 
 difficulties. We have to face all the complications of one of 
 the most difficult departments of organic analysis, while but 
 few physicians in actual practice, if, indeed, there be any, are 
 adequately prepared suddenly to undertake such investiga- 
 tions when an important occasion happens to arise. The 
 works of Hoppe-Seyler may be referred to for the best instruc- 
 tions in this branch of chemistry. But further, we are con- 
 fronted with the practical difficulty of obtaining samples of 
 blood at such times and in such quantities as chemical analysis 
 demands : the abandonment of venesection as a common form 
 of treatment renders this scarcely possible. While this prac- 
 tice was common, attention was much directed to the presence 
 or absence of the " buffy coat " in the blood withdrawn, an 
 appearance so usual in inflammatory diseases that its presence 
 was relied on, in doubtful cases, as an indication of the exist- 
 ence of inflammation. 
 
 Occasionally, even now, we try to procure small quantities 
 of blood for experimental or diagnostic purposes, as described 
 in the section on gouty joints where Garrod's method of de- 
 tecting uric acid is dealt with in detail (p. 152j. 
 
 31* 
 
S66 RESPIRATION AND CIRCULATION. 
 
 Minute quantities of blood for microscopic and other similar 
 examinations are always obtainable, Avitliout detriment to the 
 treatment, of whatever kind this may be : fortunately it is in 
 this direction that the most distinct advances have recently 
 been made in the examination of the blood for the purposes of 
 diagnosis. 
 
 The richness of the blood in hcemoglobin may be estimated in 
 various ways. One of the simplest is by Dr. Gowers's hsemo- 
 globinometer. A definite quantity of blood is diluted with 
 water in a graduated tube till it comes to the standard furnished 
 by another tube colored for this purpose. This standard is so 
 arranged that normal blood should bear dilution up to 100 
 volumes. A capillary pipette is used to measure 20 cubic 
 millimetres of blood drawn from the finger by the prick of a 
 small lancet : the wound should furnish enough of blood with- 
 out any squeezing being required. The blood is blown into 
 the empty tube, or rather into a few drops of water placed at 
 the bottom of the tube to prevent coagulation, and then shaken 
 up quickly with the water : water is then cautiously added by 
 means of a suitable pipette : this is done with occasional shak- 
 ing till the eye recognizes that the standard tint has been 
 reached. This should be judged of by holding both tubes up 
 to the light and also by looking down on them as placed 
 against a w^hite object. If we find 100 degrees of dilution 
 are required, we reckon it to have the normal or average 
 color: if 110 are required, we reckon it 10 per cent, richer 
 than the average : if 50 degrees of dilution suffice to bring the 
 blood to the standard tint, it has only one half of the normal 
 color : or it may fall to 20 degrees, indicating, of course, only 
 20 per cent, of color. 
 
 The richness of the blood in corpuscles might be supposed to 
 be deducible from the color test, inasmuch as the red corpus- 
 cles supply the color. If, indeed, the red corpuscles are re- 
 duced by a half, we may be sure that the color test for the 
 haemoglobin will also give a great reduction. But it is found 
 in disease that the red corpuscles may approximate to their 
 usual number, and yet that the color of the blood is gravely 
 deteriorated. Or, with a notable diminution in the number 
 of corpuscles in a given volume of blood, there may be a still 
 more notable diminution of the color or haemoglobin. In such 
 cases the inference is plain — each individual corpuscle is itself 
 deficient in coloring matter. 
 
 In some forms of anaemia the corpuscular richness is much 
 more notably diminished than in others : in chlorosis, for ex- 
 
HEMACYTOMETER 
 
 367 
 
 ample, we may have a great diminution of haemoglobin as 
 shown by the color test, and but little reduction of the number 
 of corpuscles. In pernicious ansemia we may have enormous 
 reductions of the corpuscles, which sometimes only amount to 
 about one-tenth of their normal number, and in this disease 
 we may also find evidence of deficient haemoglobin for each 
 corpuscle. 
 
 Various instruments have been devised for counting the actual num- 
 ber of corpuscles in a given volume of blood. They are all somewhat 
 similar. A capillary pipette is required for measuring a minute quan- 
 tity of blood, and we require arrangements for diluting with a given 
 volume of fluid : we select a 10 per cent, solution of sulphate of soda 
 or some such fluid which will not destroy the corpuscles. The diagram 
 (Fig. 51) shows "Potain's melangeur " graduated to give 100 dilu- 
 tions when the blood is sucked up to 1 and the fluid drawn up to 101 
 
 Fig. 51. 
 
 Potain's melangeur and Zeiss' slide for counting the blood corpuscles. 
 
 as marked below and above the bulb respectively : the bulb contains a 
 glass bead to facilitate the shaking up and mixing. This is reckoned 
 the best method of diluting and mixing, whichever instrument may be 
 used for the counting. The figure here given (Fig. 51) shows the slide 
 made for this purpose by Zeiss, of Jena. It consists of a cell -^-^ of a 
 millimetre in depth, and it is ruled with a great number of squares 
 each of which is ^^ of a square millimetre. These small squares are 
 arranged within a large square (containing sixteen of the small squares) 
 ruled off with three lines so as to guide the eye in counting the cor- 
 puscles, as otherwise the strain on the eye is apt to be too great. (See 
 Fig. 52.) 
 
 If, then, a small drop of the properly diluted blood be placed in the 
 centre of the cell, the edges of which are, of course, properly ground, 
 and if a perfectly flat cover glass supplied for the purpose be now ap- 
 plied, we have the means of counting the corpuscles in a given volume 
 of blood ; for we know the depth of the cell, Jg- of a millimetre, and 
 we know the superficies of the square, ^i^- of a millimetre, and we 
 
 know the dilution of the blood, 
 
 1 
 
 100' 
 
 Of course we require to count 
 
368 
 
 KESPIRATION AND CIRCULATION. 
 
 the corpuscles in a considerable number of squares in order to secure 
 a fair average, 32 or 48 of the small squares, that is, 2 or 3 of the large 
 ones. Having done so, we calculate what is the mean number for 4 
 small squares, and that gives the number in ji^ of a square millimetre. 
 We multiply, therefore, by 100 for this, and by 10 for the depth of 
 
 Pig. 52. 
 
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 Zeiss's slide, as seen under the microscope, with a drop of diluted blood. The series of 
 sixteen small squares is ruled off" by three close lines to give one large square : several of 
 these squares are contained in the slide. (Drawn by Dr. John Wilson.) 
 
 the cell ; and again by 100 for the dilution of the blood ; thus in Fig. 
 52 the mean number of corpuscles in 4 little squares is about 44 : 
 
 44 X 100 X 10 X 100 = 4,400,000 corpuscles 
 
 in one cubic millimetre of blood. 
 
 In order to estimate the significance of this figure, we require to 
 know the numbers obtained in average healthy persons: these are 
 estimated at about 5,000,000 for men, and about 4,500,000 for women, 
 per cubic millimetre. In cases of disease a reduction to 2,000,000 or 
 
WHITE COEPUSCLES. 369 
 
 3,000,000 is not uncommon : occasionally the figure is under 1 ,000,000, 
 and in pernicious anaemia may sink to 500,000. 
 
 It is evident that in such methods the sources of error are numer- 
 ous : the rulinor of the squares may not be accurate, the dilution may 
 be faulty, or the cover may not give a perfectly flat level, and so the 
 estimated depth may be wrong, or the squares which we happen to 
 count may not supply a fair average. The last source of error may 
 be diminished by counting numerous squares or taking different drops, 
 and the chances of error in seme other parts of the process may be les- 
 sened by repeating the experiment. The most probable source of 
 error which remains izi this instrument after such precautions is with 
 regard to the exact depth of the layer examined, as this depends not 
 merely on the exactness with which the cell is made to such a minute 
 depth, but also on the perfect flatness of the cover as applied to the 
 edges of the cell. To secure greater preci-ion in this respect, special 
 arrangements have been introduced in the new form of instrument 
 devised by Malassez. 
 
 It must be remembered that a considerable range of error of obser- 
 vation must be allowed for, even when every precaution is taken in 
 such measurements, and that the standard for the healthy is also a 
 mere approximation. 
 
 White Coiyuscles. — The presence of an excessively large pro- 
 portion of colorless corpuscles in a drop of blood drawn from 
 a patient constitutes the condition now known as leukcemia. 
 This condition in its most striking form is usually associated 
 with evidence of changes in the spleen or in the lymphatic 
 glands of the patient or in both. (" Splenic and Lymphatic 
 Leukaemia:" see also p. 146.) But the number of the white 
 relatively to the red corpuscles varies greatly in different 
 persons, within the limits of health : in various diseases the 
 proportion is likewise seriously disturbed, so that much care 
 is required in formulating a diagnosis based on an apparent 
 increase of the white corpuscles ; in anaemic conditions and in 
 cancerous affections, in particular, the white corpuscles are 
 often increased. In preparing a specimen for microscopic 
 examination we usually prick the skin of the finger suddenly 
 by means of a needle, and occasionally it is better to produce 
 congestion of the finger beforehand by the moderate compres- 
 sion of a ligature. We place the drop of blood on a perfectly 
 clean slide and apply a cover-glass, taking care to avoid the 
 soiling of the glasses by any exhalations from the skin of the 
 patient or of the observer, and also avoiding any pressure 
 likely to damage the corpuscles. The drop of blood, indeed, 
 may with advantage be received on the under surface of the 
 cover glass, held with a pair of forceps, and the cover-glass 
 may then be slipped very gently down on to the microscopic 
 
370 RESPIRATION AND CIRCULATION 
 
 slide : we aim at having just enough blood to fill the space 
 between the two. The red corpuscles usually tend to run into 
 Toideaux, and the white bloodvessels may generally be easily 
 recognized from the difference of their shape, their somewhat 
 larger size, and their want of color : their granular appearance 
 also favors their recognition. The actual number of white 
 blood-corpuscles visible in tho, field may then be counted, and 
 in noting the result we should name the power of the micro- 
 scope, specifying the number or the focal distance of the objec- 
 tive and the maker of the instrument ; or we may attempt to 
 estimate the proportion of the white to the red corpuscles by 
 counting both in a given part of the field, noting 1-40, 1-20, 
 1-10, or 1-2, etc., as the case may be. An extremely well- 
 marked case is represented in the figure, which is an accurate 
 reproduction of an actual microscopic field. (See Fig. 53.) 
 We should always estimate several different microscopic 
 " fields " before arriving at an opinion, and it is very desirable 
 also to have more than one specimen of blood to avoid acci- 
 dental fallacies. The figures named above indicate the results 
 frequently obtained in cases of disease : the normal proportion 
 of the white to the red corpuscles is very much less, and great 
 variations occur in connection with the time of food taking. 
 (Estimates from 1-300 to 1-1200.) 
 
 Such methods of enumeration, how^ever, are confessedly 
 rough, and very subject to accidental variations. A more 
 accurate determination demands the actual counting of the 
 corpuscles of both kinds in a quantity of blood of known 
 volume. By means of the hseraacytometer this can be done 
 if we use diluting fluids which allow the difference in size 
 betw^een the corpuscles to be recognized. 
 
 The size of the corpuscles is a point of interest. This can be 
 measured by using an objective of high power and an eye- 
 piece micrometer with divisions of known value. Normal red 
 corpuscles are about 11 or 8 /^ (micro-millimetres) in diameter 
 (a micro-millimetre—// — is y^jViFtl^ P^i't of a millimeter — 0.001 
 mm.). In anaemia tlie size of the corpuscles is often increased, 
 say to 10 or 11 /^, and in other diseases alterations have also 
 been observed. 
 
 The great proportion of the white corpuscles are, as a rule, 
 larger than the red (about 12 //), but when measured or even 
 scrutinized closely, they are found to vary much in size, say 
 from 4 to 13 /^. Their great variation in size is often seen in 
 the blood taken from cases of leukaemia, some cases being char- 
 acterized by abundance of the smaller size, some showing the 
 
LIVING ORGAKISMS. 
 
 371 
 
 larger size, and some both large and small : this combination 
 is brought out in the drawing (Fig. 53), where large and small 
 white corpuscles may be seen lying side by side. 
 
 Fig. 53. 
 
 Drop of blood from a case of splenic and lymphatic leuksemia. There is great excess 
 of the white corpuscles ; these are seen to be of various sizes. (Drawn from an actual 
 "field" by Dr. John Wilson.) 
 
 Apart from micrometric investigation the size of the white 
 corpuscles may be estimated by the eye in comparison with 
 the red. In noting cases of leukaemia some indication as to 
 the relative abundance of large or small corpuscles should 
 be made, although the significance of this is not as yet very 
 definite. 
 
 Very small corpuscles, more highly colored than the usual 
 red corpuscles, and of globular shape, have been found in cases 
 
372 RESPIRATION AND CIRCULATION. 
 
 of pernicious anaemia : they are specially described and figured 
 by Eiclihorst. 
 
 Very small granular masses of protoj)lasm, sometimes irreg- 
 ular in shape, but sometimes spherical, are often found in the 
 field ; these, no doubt, sometimes arise from mechanical injury 
 to the white corpuscles, resulting from pressure. In some cases 
 they may be due to disintegration from other causes of the 
 white corj^uscles, or of Bizzozero's corpuscles. 
 
 Bizzozero's corpuscles, or " blood plates," are about half the 
 size of red corpuscles (say 3 y") ; they are colorless, biconcave 
 disks. Their significance is not yet settled, either as found in 
 health or disease. 
 
 Living Organisms. — Another branch of the microscopic 
 investigation of the blood has recently opened ujd a most 
 interesting and important department of pathology. The ex- 
 istence of living organisms in the blood has now been estab- 
 lished in several diseases. The earliest discovered and perhaps 
 the best studied organism of this class is that found in the 
 disease known under the names of malignant pustule, splenic 
 fever, anthrax, charbon, and other synonyms : the organism is 
 found in the human subject and in various animals affected 
 with the disease. This organism is a short, straight, motion- 
 less rod, about as long as the breadth of a blood corpuscle ; 
 it is named the Bacillus anthracis, and has been shown by 
 experiment to be definitely related to the activity of the virus. 
 (This bacterium resembles a very common and harmless one 
 found in infusions of hay, etc., named the Baeillus subtilas, 
 but this latter is endowed with motion.) 
 
 In relapsing fever organisms of another class are found in 
 the blood during the paroxysm of the fever, and also in the 
 relapse, but not in the apyretic interval. They consist of 
 minute spiral fibrils of the most extreme tenuity, and the 
 length is from two to six times the breadth of a blood cor- 
 puscle. They are named Spirilla (or by Cohn, Spirochcete 
 Obermeieri) ; the spirals assume the various forms in their 
 combinations. 
 
 The Filar ia sanguinis hominis (Lewis) may also be men- 
 tioned : It is found in the blood (and the urine) of persons 
 affected with a certain form of chyluria, but as yet only in 
 hot countries. It is about the breadth of a blood corpuscle, 
 and about yg-^h of an inch in length, and exhibits active 
 wriggling movements. It should be searched for in the blood 
 during the hours of repose at night. 
 
 This subject is one of growing importance, but as yet it 
 
BIBLIOGRAPHY. 373 
 
 concerns experimental pathology more directly than regular 
 clinical work. 
 
 Most of the subjects dealt with in this chapter are discussed pretty 
 fully in all systematic works on the practice of medicine, and on 
 diseases of children, or in special treatises on diseases of the chest and 
 of the throat ; for references to these last, see bibliographies ap- 
 pended to Chapter XYI. and Chapter X. 
 
 "With reference to particular portions of this chapter, see Biot. 
 Etude clinique et experimentale sur la respiration de Cheyne-Stokes, 
 Paris, 1878. — Hunter Mackenzie, Practical Treatise on the Sputum, 
 Edinburgh, 1886. — Bizzozero et Firket, Manuel de microscopie 
 clinique, microscopie legale, chimie clinique, technique bacterio- 
 scopique, deuxieme edition franjaise, Paris, 1885. — Klein, Micro- 
 organisms, 3d ed., London, 1886. — Woodhead and Hare, Pathological 
 Mycology, Edinburgh, 1886. — Bennet, Leucocythsemia, Edin., 1852. 
 Wickham Legg, Treatise on Haemophilia, sometimes called the 
 hereditary hemorrhagic diathesis, London, 1872. — Mrs. Ernest Hart, 
 " Micrometric numeration of the blood corpuscles and the estimation 
 of the hgemoglobin," Quart. Journal of Microscopic Science, vol. 
 xxi., Lond., 1881. — Hayem (G), Recherches sur I'anatomie normale 
 et pathologique du sang, Paris ; also Legons sur les modifications du 
 sang, Paris, 1882. — Manson, The filaria sanguinis hominis, Lond., 
 1883. — Eichhorst, Die progressive pernizidse Anamie, Leipzig, 1878. 
 
 32 
 
CHAPTER X. 
 
 EXAMINATION OF THE FAUCES, LAKYNX, AND 
 
 NAEES. 
 
 The Fauces and Pharynx. 
 
 In order to investigate the fauces and the parts in that 
 neighborhood, it is necessary to bring the patient opposite a 
 window or a lamp so arranged that the light will pass through 
 the mouth to its posterior parts. The large laryngeal reflector 
 may be used for the purpose of directing the light as required. 
 If the patient be now made to open his mouth and take a 
 deep breath, it will often happen that the fauces are at once 
 visible. Frequently, however, the tongue interferes with the 
 view; in its posterior parts, especially, it often mounts up, 
 and lying in contact with the soft palate, completely fills up 
 the back part of the mouth. It is sometimes a little diflicult 
 to dispose of the tongue, but by varying the procedure accord- 
 ing to circumstances the difficulties may generally be over- 
 come. It is sometimes sufficient to ask the patient to say 
 " Ah," which causes the dorsum of the tongue to be depressed. 
 Very often it is necessary to press down the tongue, and this 
 may sometimes be done with the finger of the observer, but 
 as a rule it is best performed with a spatula or the handle of 
 a spoon. The best form of tongue depressor is a flat metal 
 plate slightly curved, so as to give a hollow surface, fitted to 
 adapt itself to the dorsum of the tongue. It is an advantage 
 that the plate should have an oval aperture near its extremity, 
 because the surface of the tongue will project through this, 
 and by catching on the edges of the aperture prevent the 
 instrument slipping. There is also an instrument which acts 
 as a gag and speculum as well as a tongue-depressor. It con- 
 sists of a wide tube attached to the plate which depresses the 
 tongue. The wide tube occupies the anterior i)art of the 
 mouth, and as the teeth rest on its upper and lower surfaces, 
 the mouth is held wide open, and the passage is clear for 
 vision. This instrument is self-adjusting. The spatula, in 
 whatever form it may be, should be pushed well back before 
 
FAUCES. 375 
 
 being brought to bear on the tongue, and should then be 
 pressed firmly dowmvard and forward. 
 
 When the tongue is thoroughly depressed, a full view is 
 obtained of the uvula hanging down and tremulous in the 
 middle line ; the soft palate arching to either side of the 
 uvula, and dividing into two pillars, which appear as slight 
 projections, one in front of the other ; the tonsils which lie 
 between the pillars of the fauces and in the normal state do 
 not project beyond them ; and lastly, the pharynx, whose 
 posterior wall is seen behind the uvula and soft palate. It is 
 often possible by moving the spatula from one side of the 
 tongue to the other, to expose the pillars of the fauces and 
 the tonsils more fully than by keeping it in the middle line. 
 
 Besides the parts visible by simple inspection, it is to be re- 
 membered that the inferior and superior parts of the pharynx 
 are concealed from view, being above or below the level of the 
 mouth. The wall of the pharynx in its inferior j^art is attached 
 laterally to the thyrtnd and cricoid cartilages of the larynx, 
 and a space or pouch is left on either side between larynx and 
 lateral wall of pharynx, the pharyngo-laryngeal sinus, in 
 which foreign bodies sometimes lodge. In order to explore 
 this the laryngeal mirror should be used, or the finger may be 
 made to reach it through the open mouth. The superior part 
 of the pharynx, that corresponding with the posterior nares, 
 may also be explored by the finger or the laryngeal mirror. 
 The finger can be passed upward behind the soft jDalate, and 
 the roof of the pharynx as well as the openings of the pos- 
 terior nares and Eustachian tubes felt. 
 
 In order to appreciate the changes which occur in the fauces, 
 it will be necessary to familiarize one's self with the normal 
 appearances. But this being premised, the principal points to 
 be observed are these : The state of the uvula, whether it be 
 unusually thick, or long, or (what generally goes along with 
 these) unduly motionless ; whether it be altered in color, in 
 the way of bright red or dark red, the former usually indi- 
 cating a more acute and the latter a more chronic inflamma- 
 tion. Is there any exudation or ulceration on the uvula? 
 Then as to the fauces j^roper : Is the mucous membrane cover- 
 ing these parts thickened, or reddened, or ulcerated, or the 
 seat of an exudation? Is there any enlargement or other 
 change visible in the tonsils or their neighborhood? The 
 condition of the mucous membrane of the posterior wall of 
 the pharynx, as seen between the two posterior pillars of the 
 fauces, is of great importance as it is often the seat of disease. 
 
376 EXAMINATION OF THEOAT. 
 
 A systematic examination of each part with a direct view to 
 determining the facts in regard to these various conditions will 
 be of great consequence. 
 
 Morbid Appearances in the Fauces. — We have now to give 
 some indication of the conditions actually met with in certain 
 of the commoner diseases. The commonest of all is catarrh, 
 in which, as a general rule, fauces, pharynx, and tonsils all 
 take some part. 
 
 In acute catarrh we find the whole soft palate of a red color, 
 wdth considerable swelling, especially of the uvula. The 
 uvula is both longer and thicker than usual. The swelling 
 shows itself most in the uvula because, on account of the 
 looseness of its tissue and its freedom from adhesion to parts 
 around, the inflammatory exudation has more room to accu- 
 mulate here, and the uvula may become quite plump and 
 bulky. The pharynx is also seen to be red, and in certain 
 stages of the disease it may be found covered with a mucous 
 or mucopurulent secretion. The tonsils are for the most part 
 swollen, and they project toward the middle line. 
 
 Chronic catarrh of the fauces and pharynx may supervene 
 on repeated acute attacks, but it has in most cases an inde- 
 pendent origin. There are two forms of this disease generally 
 recognized, the one designated relaxed throat and the other 
 granular pharyngitis. In the former, there may be little visi- 
 ble alteration in the parts, even when the patient makes con- 
 siderable complaint of fulness and stiffness in the throat. 
 But in other cases there is swelling of the fauces generally, 
 but especially of the uvula, which hangs down unduly and is 
 not raised in the normal fashion by tickling it. The parts are 
 unduly red, and varicose veins may be visible. The elongated 
 uvula, by irritating the back of the tongue, the pharynx and 
 even the epiglottis, sometimes gives rise to troublesome cough- 
 ing. In granular pharyngitis, the mucous membrane of the 
 pharynx is seen to be beset with little elevations about the 
 size of millet seeds. As the disease advances these get more 
 numerous and give to the pharynx a reticulated or generally 
 granular appearance. This condition frequently extends to 
 fauces, nares, and larynx, and as it is frequently due to over- 
 straining of the voice by public speakers the designation 
 clergyman^ s sore throat is used in many cases. There is seldom 
 any ulceration in either form of chronic catarrh, and if ulcers 
 be present they are very superficial. 
 
 Acute Tonsillitis — Quinsy. — In this condition we have an 
 acute phlegmonous inflammation usually centring in the 
 
SCAELET FEVEE. 877 
 
 neighborhood of the tonsil, but extending to neighboring 
 parts of the fauces and soft palate. It is to be remembered 
 that in catarrh we have an inflammation of the mucous 
 membrane simply, whereas here the submucous tissue and 
 deeper j^arts are involved. The disease is usually unilateral, 
 at least to begin with. The tonsil is enlarged, projecting 
 toward the middle line as a bulky rounded swelling. As the 
 inflammation increases and extends there are great redness and 
 swelling of the j^illars of the fauces and the soft palate, fre- 
 quently passing on to suppuration. The abscess usually 
 points at the anterior border of the tonsil, but may do so near 
 the posterior wall of the pharynx. Cases have occurred in 
 which the pus burrowing among the tissues has pointed exter- 
 nally near the angle of the jaw. The swelling in quinsy is 
 generally visible externally, and as there is difliculty in swal- 
 lowing and even in moving the jaw, as well as a peculiar 
 muflled condition of the voice as if a bulky object had stuck 
 in the throat, the disease is usually easy of recognition. It is 
 often difiicult, however, to arrive at a complete knowledge of 
 the extent and principal seat of the inflammation on account 
 of the swelling and the difficulty in opening the mouth. The 
 local condition must often be inferred from exploration with 
 the finger, assisted by the finger of the other hand outside. 
 Fluctuation may be sometimes detected by placing one finger 
 below and behind the ramus of the jaw, and the other in con- 
 tact with the inflamed part. (Stoerk.) 
 
 Enlarged Tonsils. — This is a very common condition espe- 
 cially in children, due, apparently, to prolonged chronic 
 inflammation. The disease is usually bilateral, but is fre- 
 quently more advanced on one side. The swollen organs 
 project on either side of the fauces as rounded irregular masses, 
 sometimes meeting each other in the middle line. The ob- 
 struction in the fauces causes a peculiar thickness of the 
 voice, and when extreme may seriously interfere with respira- 
 tion, for the enlarged glands project toward the pharynx and 
 posterior nares as well as at the fauces. The interference 
 with respiration may be so serious as to cause malformation 
 of the chest, from the exaggerated respiratory eflbrts acting 
 on the yielding chest wall of the child. The so-called " pigeon- 
 breast" is said to arise frequently in this way. A certain 
 amount of deafness is often a concomitant symptom. 
 
 Scarlet Fever. — The condition of the fauces is that of an 
 acute inflammation, and the appearances presented are very 
 like those in acute catarrh. The uvula, palate, tonsils, and 
 
 32* 
 
378 EXAMINATION OF THROAT. 
 
 pharynx are generally, even in the mildest cases, red and 
 swollen. The red and swollen mucous membrane is often 
 covered with a layer of tenacious mucus, and in the more 
 severe cases the tonsils may be so much swollen as almost to 
 obstruct the fauces. All these processes are acute, developed 
 in the course of a few hours. In the more severe cases there 
 is more than a simple catarrhal inflammation. Instead of a 
 layer of mucus on the surface, there appear specks and patches 
 of a gray color, which seem to be adliering, although they 
 can generally be removed without breach of surface. Along 
 Avith this catarrh, as in simple catarrhal inflammation, suj)er- 
 ficial ulcers may form, which are not to be mistaken for the 
 patches about to be mentioned as occurring in diphtheria. 
 But sometimes there is actual sloughing of parts of the 
 mucous membrane, and the sloughs coming away leave deeper 
 irregular ulcers. This sloughing is, however, only met with 
 in exceptionally severe cases, and scarcely in the earlier 
 periods. It is to be remembered that the condition seen in 
 the throat may extend to parts which are invisible, especially 
 to the posterior nares. Important elements in the diagnosis 
 of the scarlet fever throat will be supplied, of course, by the 
 state of the tongue, the rash on the skin, and the other indi- 
 cations of the specific fever. 
 
 Dijyhtheria. — We have here also an acute inflammation of 
 the same parts, but the appearances presented are very dif- 
 ferent. The mucous membrane here is red and swollen, but 
 the attention is very particularly called to the existence of a 
 peculiar exudation on the surface. Instead of the tenacious 
 mucus, there appear on, or one might almost say, in the mucous 
 membrane of the fauces, specks and patches of a white color. 
 These are mostly met with on the uvula and palate, but they 
 are often seen on the surface of the tonsils and pharynx, and 
 even in various parts of the mouth. The patches are at first 
 white, but they soon get darker in color from dirt and blood. 
 This white material really involves the mucous membrane as 
 well as appearing on its surface, and the consequence is 
 shnighing of the superficial layers of mucous membrane. 
 The sloughs and exudations separate and fall oflf, hanging 
 from the surfiice as shreddy, ragged masses. It should be 
 remembered that the inflammation does not usually confine 
 itself to the parts seen, but often extends down into the pharynx 
 and larynx, and upward into tlie posterior nares. 
 
 It is very hnportant to be able to distinguish the exudation 
 of diphtheria from conditions of a different nature, and to 
 
SYPHILIS. 379 
 
 judge from the frequency with which simple diseases of the 
 throat are called diphtheria, the distinction does not seem to 
 be very easy. The exudation covering the parts in simple 
 acute catarrh may be mistaken for that of diphtheria. All 
 kinds of ulcers may be mistaken for diphtheritic patches, 
 especially as they may be coated with a whitish secretion. 
 Ulcers are met with in ordinary catarrhal inflammations, and 
 these are most frequently seated on the soft palate, the tonsils, 
 or the pharynx. Ulcers also occur in scarlet fever, and there 
 they have similar seats. In smallpox, too, we may have ulcers 
 and other evidences of acute inflammation in these regions, 
 but the eruption on the skin will prevent any mistake being 
 made. It should be remembered that the diphtheritic patch 
 is an exudation on and in the mucous membrane, and is, there- 
 fore, raised above the surface, whereas an ulcer, of whatever 
 kind, is depressed below it, although, of course, this depression 
 may be masked by the joresence of secretions on its surface. 
 There is a form of disease which resembles the exudation of 
 diphtheria more closely than any other, but which can hardly 
 be mistaken for it, and that is the condition found in the mouth 
 and known as thrush or muguet. These patches often extend 
 to the fauces, pharynx, and even further, and as the peculiar 
 white appearance in due to an excess of epithelium united into 
 a membrane by the thread of a fungus, the patch may have a 
 superficial resemblance to that of diphtheria. But the exist- 
 ence of these patches on difierent parts of the mouth, and their 
 characters on close inspection, as well as the general symptoms, 
 ought to prevent any such mistake. The microscopic exami- 
 nation may also assist us, by revealing the presence of a vege- 
 table parasitic growth. (See Fig. 59.) 
 
 Syphilis. — The fauces are affected in a considerable propor- 
 tion of cases in the secondary stage of syphilis, the conditions 
 here coinciding with the eruptions of the skin, and partaking 
 somewhat of their nature. We have an erythematous con- 
 dition resembling a similar catarrh, but with the redness 
 more defined in area and in the form of patches with some- 
 what abrupt edges. In a considerable number of cases there 
 are mucous j^atches visible, chiefly on the pillars of the fauces 
 and soft palate. These form small, slightly raised areas, gen- 
 erally round or elliptical in shape, and mostly symmetrical. 
 In the later periods of syphilis extensive ulceration is the char- 
 acteristic phenomenon. As pauses occur in the process from 
 the effects of treatment or otherwise, cicatrization nearly always 
 accompanies the ulceration. The adhesion and cicatrization 
 
380 EXAMINATION OF THKOAT. 
 
 of opposed ulcerated surfaces and the contraction of the 
 cicatricial tissue often bring about very serious deformities, 
 amounting sometimes to marked stenosis of the fauces. 
 
 The ulcers which form are usually situated on the soft 
 palate or uvula, but may attack the pharynx. They gener- 
 ally cause considerable destruction of the mucous membrane, 
 and in this way it is not uncommon to meet with cases in 
 which the soft palate and the uvula are eaten away in great 
 part. The loss of the soft palate will cause the person to have 
 a peculiar nasal voice, and his pronunciation of certain letters 
 will be imperfect, because he is unable to close the nares 
 during phonation. 
 
 Almost the only disease likely to be confused with syphilis 
 is cancerous disease with ulceration. If it be remembered that 
 in syphilis there is always some other indication of specific 
 disease, mistakes will generally be avoided. 
 
 Retropharyngeal Abscess. — It is necessary to bear in mind 
 that abscesses occasionally form behind the pharynx, between 
 it and the bodies of the vertebrae — retro- or post-pharyngeal 
 abscesses. These abscesses, which mostly occur in children, 
 sometimes originate in caries of the vertebrae, but various 
 other causes have been assigned for their formation, such as 
 direct injury to the pharynx from swallowing hot water or 
 from the impaction of fish-bones. In many cases the cause is 
 obscure, and the abscess is said to have an idiopathic origiu. 
 It is occasionally met with as a sequela of fever. The chief 
 symptoms are pain, difliculty in swallowing and in breathing, 
 usually with distinct swelling of the neck, which is frequently 
 more apparent on one side than the other. The abscess may 
 actually point in the neck, although it usually does so inter- 
 nally. If the finger be inserted in such cases, through the 
 mouth, a tense swelling will be found behind the uvula and 
 soft palate, bulging these forward and greatly obstructing the 
 passage. The swelling may also be visible on depressing the 
 tongue, but sometimes the mouth cannot be fully opened, or 
 the abscess is too low to be visible. As the abscess increases, 
 it may form a very serious cause of obstruction to the respira- 
 tion and deglutition. 
 
 The elucidation of many of the matters above referred to 
 may often be facilitated by the use of the finger. The state of 
 the tonsils, for instance, or the consistence of any swelling can 
 be thus explored ; while, at the same time, information is 
 gained as to the state of sensitiveness of the parts. It is often 
 useful to assist the internal exploration by using the other 
 
THE LARYNX. 381 
 
 hand outside, so as to place the tissues between the finger 
 inside and that outside. 
 
 The Larynx. 
 
 Laryngoscojoy. — The examination of the larynx is not a difficult 
 process, but one which requires a certain amount of practice, patience, 
 and tact. Before detailing the various steps in the |)rocedure, it may 
 be well to refer to certain matters connected with light and instru- 
 ments. As daylight can seldom be had sufficiently concentrated, it is 
 necessary to be provided with a lamp of some kind, and as it is im- 
 portant that the light should be near the level of the patient's mouth, 
 the lamp must be capable of being raised and lowered. It is also well, 
 where possible, to surround the flame "vvith an opaque tube open only 
 at one side, because this enables one to have the room dark, and the 
 apparent intensity of the illumination is thereby increased. It is ad- 
 vantageous, where possible, to use some kind of light concentrator, 
 which usually takes the form of a metal tube, at one side of which 
 there is a strong convex lens. This may be adapted to a gas-bracket, 
 or to a lamp, or it may be in the form of a movable apparatus appli- 
 cable to any form of illumination. Useful adaptations have been 
 devised by Dr. Morell Mackenzie. In choosing a lamp, one with a 
 round flame is preferable, as there is always a non-luminous portion 
 in a flat flame, whether of gas or lamp. 
 
 We require, in the next place, some apparatus for concentrating the 
 light on the patient's fauces. It is not well, as a rule, to do this by the 
 direct light of the lamp ; a concave mirror having a rather long focus 
 is the most convenient arrangement. In order that the hands may be 
 free, it is requisite to have this mirror fixed to the head, which is done 
 either by a strap passing round the head, or b}^ a spectacle frame. The 
 present writer has been in the habit of using the latter, and finds, 
 among other advantages, that the ease with which it can be put ofi" or 
 on renders it very convenient. Whichever method of fixing be used, 
 the reflector should be worn over one eye, in such a position that the 
 eye which is covered by it can look through the hole which should 
 always exist in the centre of the reflector. (It is not sufficient to have 
 clear glass in the centre, but the reflector should be actually perfo- 
 rated.) The reflector should be placed over the eye nearest to the lamp, 
 and in such a position that, while this eye is protected from the light 
 of the lamp, the shadow of the reflector, projecting a little to the other 
 side of the ridge of the nose, will screen the other eye from the glare 
 of the lamp. If, for instance, the lamp be placed to the right of the 
 observer, then the reflector will be placed over his right eye. The right 
 eye, while protected from the lamp, will be able to look through the 
 aperture at the patient, and the left eye will be shaded by the edge of 
 the reflector, but will be free in other directions. 
 
 Of late years the electric light has been adapted for laryngoscopic 
 purposes. The most convenient form is that in which a small Swan's 
 lamp, with a system of convex lenses in front of it, is fixed on the fore- 
 head by an elastic band. As the source of light is at the forehead of 
 the observer, the eyes are not exposed to the glare, and the hands are 
 not likely to obstruct the rays of light. This method of illumination 
 
382 EXAMINATION OF THROAT. 
 
 is exceedingly satisfactory, more particularly as it preserves the natural 
 color of the parts. 
 
 The laryngeal mirror is a small mirror, preferably round in shape, 
 mounted on a stem, and intended to be placed in the fauces of the 
 patient, so as to catch the light and direct it down to the larj'nx, and 
 at the same time reflect the image of the larynx toward the eyes of 
 the observer. The observer should be provided with mirrors of differ- 
 ent sizes, and he should see that the stem passes off directly from the 
 border of the mirror, there being serious objections to the arrangement 
 by which the wire forming the stem is carried a certain distance out 
 from the mirror before being turned down to form the stem. 
 
 We may now turn to the procedure in the actual examination of the 
 patient. In order to appreciate the difficulties of this process and to 
 understand the mechanism, it is strongly to be recommended that the 
 student will begin by practising on himself. A short paragraph on 
 auto-laryngoscopy will be added to this description. For an ordinary 
 examination the patient and observer should be seated on two chairs 
 facing each other. The lamp may be conveniently placed to the 
 patient's left ; it ought to be about the level of his ear, and as near his 
 head as may be convenient. The observer, with the reflector over his 
 right eye, moves the reflector till the bright light falls on the patient's 
 face. He then asks the patient to open his mouth, and observes that 
 the head is so placed that the rays of light can find free access to the 
 fauces. Frequently the head is bent to one side or the other, and this 
 should be rectified. The patient should also be made to sit straight 
 up, the tendenc}^ to lean the shoulders backward being prevented, and 
 with the head inclined slightly backward. Before proceeding further, 
 all these points should be noted, and a full illumination of the mouth 
 obtained. At this stage it will often be impossible to see the fauces, 
 because the tongue obstructs the view, and it is necessary in the next 
 place to get it disposed of. It is not sufiicient here to depress the 
 tongue with a spatula, because when the laryngeal mirror is introduced, 
 the back part of the tongue will probably be raised, and spatula and 
 dorsum pushed against the mirror. It is most convenient to ask the 
 patient to put out his tongue as far as he can, and to catch it with the 
 finger and thumb of the left hand, a napkin being used for purposes 
 of cleanliness, and also to prevent the organ slipping from the grasp. 
 The protruded tongue should simply be taken hold of; it should not 
 be dragged forward, all that is wanted being to prevent it slipping back 
 and the dorsum mounting up against the soft palate. The tongue 
 being thus secured, a full view of the fauces should be obtained, and 
 it is well to be sure of this view before proceeding further. 
 
 The next procedure is the introduction of the laryngeal mirror. It 
 should be slightly heated before being introduced, otherwise the breath 
 condensing on it dims the surface. It is best heated by placing it over 
 the lamp, and it should be held with the surface of the mirror down- 
 ward so that this surface can be seen. The vapor produced in the 
 combustion of the lamp at first condenses on the surface, but as the 
 temperature rises the vapor is cleared away, and the mirror resumes its 
 brightness. When this has occurred it is read}' for introduction ; but 
 before introduction the back of it should be applied to the skin, say of 
 the left hand, to see that it is not too hot. The patient will see you 
 apply it to your own skin, and will not dread that he is going to have 
 
LARYKGOvSCOPE. 
 
 883 
 
 his throat burned. It should not be applied to the skin of the face, as, 
 on account of the thinness of the epidermis, there are risks in exam- 
 ining syphilitic patients. The tongue being held by the left hand, and 
 
 Fig. 54. 
 
 Diagram showing larjnigeal mirror iu position, ami tlie angles of incidence and re- 
 flexion. A, laryngeal mirror, pushing back uvula, but not touching wall of pharynx. 
 C, left vocal cord. B, mirror introduced through wound in trachea after tracheotomy — 
 infra-glottic laryngoscopy. (Morell Mackenzie.) 
 
384 EXAMINATION OF THROAT. 
 
 the fauces continuously illuminated, the heated mirror is now to be 
 introduced into the mouth, and in doing this the right hand will be 
 kept to the left of the middle line, and slightly below the level of the 
 patient's mouth, so as not to come between the lamp and the eyes of 
 the observer. Fig. 54 shows the position to be aimed at for the laryn- 
 geal mirror, and indicates the paths of the rays of light passing to and 
 from the larynx and reflected by the mirror. The mirror is passed 
 backward, keeping its surface parallel with the tongue, and taking care 
 not to touch any of the structures in the mouth with it. It is so in- 
 troduced that the stem lies in the left half of the mouth, coming out 
 near the left angle. The mirror is kept in the middle line, and is 
 pressed against the uvula and soft palate, which it pushes backward 
 and upward toward the posterior nares, but without touching the 
 posterior wall of the pharj-nx. (See Fig. 54.) The instrument should 
 be held delicately, but steadily, in the hand. Any tremulousness has 
 the effect of tickling the fauces, and is apt to bring on reflex eflForts at 
 vomiting, which necessitate the withdrawal of the mirror. Just as 
 the mirror is being placed, the patient should be asked to say "ah," 
 and the instrument should be pushed home while he is doing this. 
 The effect of pronouncing this vowel is that the mouth is at once fully 
 opened, and the uvula drawn up somewhat. 
 
 The first object to come into view is the back of the tongue with its 
 large circumvallate papillae. Then the tip of the epiglottis will be 
 seen, and it is probable that for some time the beginner will see little 
 more. By carefully adjusting the mirror, however, and by asking the 
 patient to say " aA," the movements of the laryngeal structures will 
 by and by attract the eye and suggest such changes in the position of 
 the observer and of the mirror as to bring the interior of the larynx 
 itself into view. As a general rule, the mobile arytenoid cartilages 
 will come first into view immediately behind the epiglottis. By in- 
 clining the mirror more downward, the vocal cords may be exposed as 
 two pearly-white bands extending from the arytenoids forward as if 
 into the base of the epiglottis. The great diflBculty in the way of 
 obtaining a full view of the vocal cords is the epiglottis, which often 
 hangs down so that only the arytenoid cartilages, and sometimes not 
 even they, can be seen behind it. Something may be done to raise the 
 epiglottis by having the tongue well protruded, the glosso-epiglottic 
 ligaments pulling the epiglottis upward. A great deal may also be 
 done by asking the patient to say " a " (as in hate)^ for the pronuncia- 
 tion of this vowel causes the base of the tongue to be brought forward. 
 It is difficult to say "a " with the tongue protruded, but an approach 
 to it will be made, and in the effort the epiglottis will be raised. It 
 is generally possible by this means to get a view of the cords even to 
 their anterior extremities. But sometimes even this fails, and it is 
 necessary to use a further method. The epiglottis is most fully raised 
 in enunciating the vowel " e" (as in ?ne), but with the mouth open 
 and the tongue held out, it is impossible even to attempt to say " e." 
 If the patient beasUed, however, to say "aA," "e" (as in saying aye 
 slowly and prolonging the e), the mere attempt to pass from the one 
 vowel to the other will result in the pulling up of the epiglottis. This 
 will generally be successful in the worst cases, but it is, of course, only 
 a glimj)se that one gets while the actual phonation is in progress. 
 Next to the difl&culty with the epiglottis, the most serious obstacle 
 
LARYNGOSCOPE. 385 
 
 to lar^'ngeal examination is the tendency to retch which many patients 
 present when the mirror is phaced in the fauces. There are very great 
 individual differences in this respect, and the difficulty can only be 
 overcome by patience. In order to avoid it, the two principal precau- 
 tions are to introduce the mirror with a firm hand and to avoid touch- 
 ing the pharynx or tongue with it. It is sometimes necessar}' to ask 
 the patient to tickle his fauces frequently with a feather, in order to 
 accustom them to the contact, and after a few days they generally get 
 sufficiently non-sensitive. When the straining efforts set in, it is 
 necessary to withdraw the mirror, as the pharynx contracts and com- 
 pletely closes the view. If the fauces are very exceptionally sensitive, 
 the best plan is to cause the patient to suck ice for about ten minutes 
 before the examination. The introduction of cocaine has enabled us 
 to overcome most of these difficulties. If the fauces be painted with 
 a four or five per cent, solution, an examination may be freely made 
 in about twenty minutes. 
 
 Auto-laryngoscopy may be practised in various ways. A very simple 
 plan is that of Dr. Foulis, in which a globe filled with water is 
 used to condense the light, and a little piece of looking-glass is placed 
 above this condensor to enable the image to be seen. The globe may 
 be had in a glass-blower's, and is of the kind used by jewellers to con- 
 centrate light on their work. It is mounted in a simple way on a 
 candlestick, and placed in front of the light. The observer sits in 
 front of it, allows the light to fall on his fauces, introduces the mirror 
 after heating it, and observes the image in the piece of looking-glass 
 above the condensor. Another simple method is for the observer to 
 seat himself wilh the lamp in the same relation to himself as it would 
 be to a patient. Then in front of him are fixed the ordinary laryngeal 
 reflector held in some kind of stem, and side by side with it a small 
 toilet mirror or hand-glass. The light coming from the lamp is re- 
 flected on the fauces just as in the case of a patient, and the image is 
 seen in the mirror or hand-glass. A very ingenious method is that of 
 Dr. George Johnson, and perhaps it is the best, as it needs no special 
 apparatus. The observer sits down in front of an ordinar}' looking- 
 glass, which has a lamp placed at one side. He puts on the ordinary 
 reflector, and so manipulates it that he illuminates his fauces, as seen 
 in the looking-glass, as if it were the fauces of a patient, and when 
 this has been done, introduces the laryngeal mirror into his own fauces 
 as before. The objection to this method is that the image being twice 
 reflected is not very clear, but it approaches much more closely to the 
 examination of a patient than either of the others. If the looking- 
 glass be a thoroughly good one, and its surface well cleaned, this method 
 presents little difficulty. 
 
 Palpation often affords considerable assistance in the investigation 
 of the larynx. By external examination one may detect painful spots 
 in the larynx. During vocalization the fremitus is readily felt by the 
 finger placed near the thyroid cartilage, and by this means we may 
 judge of the strength of the vibrations of the vocal cords. In some 
 cases of unilateral paralysis of the muscles of the larynx the absence 
 of fremitus on one side has been detected and the paralysis diagnosed 
 without laryngoscopic examination. 
 
 The index finger may also be used to explore the interior of the 
 larynx, and this method is often very useful where laryngoscopy is 
 
 33 
 
386 EXAMINATION OF THROAT. 
 
 difficult or not available. The patient should be placed on a chair 
 with the head inclined backward, and the tongue fully protruded. It 
 will often be best to hold the tongue out with the left hand protected 
 by a cloth, while the right hand is usedfor the examination. The 
 index finger is now to be introduced at the left angle of the patient's 
 naouth, and directed backward along the hard palate till the tip of the 
 finger reaches the uvula. It is then to be bent into the form of a hook 
 and suddenly passed downward, hooking round the epiglottis into the 
 interior of the larynx. Any roughness or thickening of the epiglottis 
 can thus be distinguished and also an\" swelling of the ary-epiglottic 
 folds. It is sometimes advisable in this examination to keep the 
 mouth open by a piece of cork inserted between the teeth. 
 
 It is impossible here fully to describe the appearances pre- 
 sented by the normal larynx ; these should be made familiar 
 by practice; but ^ve must refer to the principal points which 
 ought to be taken j^articular notice of. These are illustrated 
 in Fig. 55, and may be followed by reference to the figure. 
 The laryDsreal mirror reveals the mucous membrane over the 
 
 com 
 
 The laryngeal image during quiet insijiration. ge, glosso-epiglottic folds, u, upper 
 surface ; I, lip, and c, cushion of epiglottis ; v, ventricle of larj'nx ; ae, ary-epiglottic fold ; 
 cW, cartilage of Wrisberg ; cS, capitulum Santorini ; re, vocal cord ; vh, ventricular 
 band ; pv, processus vocalis; cr, cricoid cartilage ; t, tracheal rings. (Morell Mackenzie.) 
 
 movable arytenoid cartilages at the back of the larynx. The 
 general contour of these cartilages as well as the appearance 
 of the mucous membrane should be noticed. Then the ary- 
 epiglottic folds which form the lateral borders of the upper 
 opening of the larynx, can be seen passing obliquely backward 
 from the epiglottis. At the bottom of the larynx the true 
 cords attract attention, appearing as flat pearly-white bands 
 which are very mobile, and during vocalization come close 
 together. Above the vocal cords and parallel with them, but 
 separated by a space, are the ventricular bands which are 
 often called the " false cords." They are folds of mucous mem- 
 brane running in a direction from before backward. Between 
 
LAEYNX. 387 
 
 each band and the corresponding vocal cord we can generally 
 see a slit ; this is the opening of the ventricle of the larynx, a 
 shallow pouch, nothing of which is seen except the slit-like 
 opening. 
 
 Morbid Appearances in the Larynx' — The student having 
 made himself familiar with the normal appearances of the 
 larynx, will be prepared to attempt the investigation of 
 morbid states. A Jaryngoscopic investigation will be under- 
 taken whenever anything directs special attention to the throat. 
 If there is any change in the voice, any hoarseness, or even a 
 slight variation from the usual tone as appreciated by the 
 patient's friends ; if there is any pain or uneasiness either 
 spontaneous or occasioned by speaking or swallowing, or on 
 handling the larynx ; if there is a cough which is not accounted 
 for by the state of the lungs, and which may have its origin in 
 the larynx ; in all these cases an examination of the lar^Tix 
 will be called for and should be undertaken. In most diseases 
 the pharynx and even the fauces are affected in common with 
 the larynx, the structures being virtually continuous. It will 
 not be possible to do more than indicate very briefly the ap- 
 pearances presented in certain of the more common diseases 
 of the larynx. 
 
 Alterations in color are of great importance in the larynx. 
 The mucous membrane of the larynx generally has a bright 
 red color, that of the epiglottis being much paler than the 
 rest, while the vocal cords have a white tendinous appearance. 
 Ansemia of the larynx is most manifest in the epiglottis as it 
 is normally less injected than other parts. Hypersemia is often 
 peculiarly visible in the vocal cords, which may lose their white 
 color ancl become strikingly injected. With this there is an 
 abnormal redness of the mucous membrane generally which 
 may precede that of the cords. It is to be remembered that 
 nearly all the alterations in the larynx manifest themselves in 
 differences of color, because the laryngeal image mostly gives 
 a flat picture without the due perspective, and even ulcers are 
 chiefly recognized by the alteration in color and brightness. 
 
 Acute catarrh manifests itself chiefly in an excessive injec- 
 tion of the mucous membrane generally, with some swelling. 
 The swelling is not usually considerable, but in some cases it 
 amounts to a distinct inflammatory oedema. (^See " CEdema 
 glottidis.") As there is considerable exudation on the surface, 
 mingled with desquamated epithelium, the parts have often an 
 excoriated appearance, which may be very manifest in the 
 vocal cords. 
 
388 EXAMINATION OF THROAT 
 
 Chronic catarrh attracts the attention of the patient by 
 alterations in the sensations and in the voice, generally also 
 by a certain amount of expectoration, which may, however, be 
 small. On laryngoscopic examination it may require care to 
 detect anything abnormal, as the changes, in the early stages 
 at least, generally consist in alterations in color. The mucous 
 membrane is unduly red, but the color is less vivid than in 
 acute catarrh. In older cases the dull red may merge toward 
 gray. The redness sometimes extends to the vocal cords, but 
 it does so for the most part unequally. The mucous membrane 
 as a whole is not usually much thickened, but there are often 
 localized thickenings. The vocal cords may present an irreg- 
 ular granular appearance from limited thickenings, and there 
 may be undue prominence of the ventricular bands or the 
 mucous membrane between the arytenoid cartilages. These 
 thickenings will cause a certain rigidity of the structures and 
 thus interfere with vocalization. Considerable hypertrophy 
 of the mucous membrane is, however, rare in chronic catarrh, 
 although some cases have been described. The mucous mem- 
 brane occasionally presents erosions or superficial ulcers, but 
 there is rarely any deep ulceration. 
 
 Tuberculosis of the larynx (phthisis laryngea). — In the 
 diagnosis of this disease we are to remember that we have to 
 do with a condition characterized by infiltration of the mucous 
 membrane similar to that in inflammation, but with a peculiar 
 tendency to breaking down of the infiltrated structures so as 
 to form ulcers, which have no inclination to healing. It is 
 characteristic of the process, also, that it usually attacks, to 
 begin with, limited portions of the larynx ; the epiglottis, the 
 ary-epiglottic ligaments, the vocal cords ; and it is very often 
 unilateral. The process in this way diflTers from an inflam- 
 matory one in its distribution, but it also differs in the absence 
 of redness and in the great tendency to ulceration. If it begin 
 in the epiglottis or ary-epiglottic folds, we have, in the first 
 place, swelling of the parts, without I'edness. The swelling of 
 the ary-epiglottic folds is often very marked in the early 
 stages and it may be unilateral or bilateral. The swelling 
 of the mucous membrane may persist for some time without 
 ulceration, a fact that it is well to remember, as a case may 
 readily be mistaken for one of simple catarrh. Ulceration 
 occurs in the regular course, and is the most characteristic 
 phenomenon of the disease. The ulcers are at first small and 
 scattered, but they usually through time enlarge and coalesce, 
 and, although at first superficial, they may cause, by degrees, 
 
INFLAMMATION OF THE CAKTILAGES. 389 
 
 considerable destruction, especially of the epiglottis (see Fig. 
 56). One vocal cord is often attacked by ulceration, or both. 
 These ulcers almost never show any tendency to healing, so 
 
 Tig. 56. 
 
 Laryngeal phthisis, showing destruction of a large portion of the epiglottis and 
 general iilceration. (Morell Mackenzie.) 
 
 that cicatrices are not met with, this being in striking contrast 
 with what is observed in syphilis. The ulceration and swell- 
 ing go on side by side, and there is sometimes such a degree 
 of localized swelling from infiltration of the mucous membrane 
 as to produce a resemblance to a tumor. This is especially 
 the case in the vocal cords, where, particularly at the anterior 
 extremities, there may be, along with ulceration, considerable 
 projection of the granulations. 
 
 Syj^hiUs in the larynx presents similar characters to those 
 observed in the fauces. We may have a catarrh not distin- 
 guishable in its appearances from ordinary catarrhs. Occa- 
 sionally condylomata or mucous patches occur and may be 
 seen as definite tumors on the cords or elsewhere, or as flat 
 prominences. Syphilitic ulceration is not very common, but 
 sometimes it is very extensive, and being accompanied by 
 cicatrization and contraction it may produce the most serious 
 destruction and distortion of the parts. 
 
 Inflammation of the cartilages of the larynx or rather of 
 their perichondrium may be at the basis of a chronic laryn- 
 geal catarrh, or even of an acute catarrh. The disease usually 
 goes on to the formation of abscess and frequently necrosis of 
 the cartilage. Pain of a dull character, difficulty of swallow- 
 ing, and external swelling, mostly accompany the process. 
 
 In croup and diphtheria we are seldom called on to examine 
 the larynx, as the disease is generally obvious on other grounds ; 
 but if we are, the white exudation coating the mucous mem- 
 brane will be visible. Here the exudation is not involved in 
 the mucous membrane, as it is in the mouth and fauces, but 
 lies on its surface, and comes away without ulceration. 
 
 33* 
 
390 EXAMINATION" OF THROAT. 
 
 (Edema glottidis must also be referred to in this place. This 
 is a condition which may supervene on any acute inflammation 
 of the larynx. It is met with, but not commonly, in acute 
 catarrh. It occurs in the laryngitis induced by the pustular 
 eruption cl smallpox which often spreads to the larynx. It 
 may be the c«^nsequence of syphilitic or tubercular disease, 
 and sometimes supervenes on inflammation of the cartilages, 
 or it may be a concomitant of erysipelas. The fluid accumu- 
 lates in the submucous tissue of the larynx, the oedema being 
 generally the consequence of an acute inflammation of the 
 mucous membrane. Just as in oedema of the skin the fluid 
 accumulates most where the subcutaneous tissue is loose, so 
 here the oedema is greatest where the submucous tissue is 
 loose. The mucous membrane of the larynx is mostly bound 
 down pretty firmly to the subjacent structures, it is loose over 
 the epiglottis, but especially in the ary-epiglottic folds. Ac- 
 cumulating there, the fluid swells up the mucous membrane ; 
 the epiglottis is often very prominent, and the ary-epiglottic 
 folds form prominent rounded tumors. It is these latter which 
 obstruct the larynx, and it is generally easy to reach and incise 
 them with the aid of the laryngeal mirror. The vocal cords 
 are not affected at all. 
 
 Groivths are not uncommon in the larynx, and they are often 
 situated on the vocal cords. If this be the case they alter the 
 voice, usually making it hoarse. If the growth be on the cords 
 it is easily seen, elsewhere it is not so distinct, especially if it 
 be small. Most of these tumors are simple in their nature ; 
 but sometimes sarcomata or cancers attack the larynx, especi- 
 ally the latter. Cancers are mostly epithelial here, and are 
 characterized by the warty, ulcerated appearance which they 
 present. 
 
 Paralysis of the Vocal Cords. — The movements of the vocal 
 cords are governed by muscles, whose actions may be divided 
 into three. In the state of Vest, the glottis assumes a position 
 intermediate between closure and the widest degree of openness 
 — a position usually designated the cadaveric position, because 
 it is that presented after death. From this position it may be 
 moved by the adductors which close the glottis and render the 
 production of the voice possible, or by the abductors which 
 widen the glottis and allow of freer passage of air. In ad- 
 dition to these there are muscles 'which regulate the tension of 
 the cords, and so produce variations in the pitch and certain 
 characters of the voice. When the laryngeal mirror is intro- 
 duced in a person with a normal larynx, there is usually visi- 
 
BILATEEAL PAEALYSIS. 391 
 
 ble a variety of delicate movements of the arytenoid cartilages 
 and vocal cords, the parts being seldom at rest and usually 
 varying with the movements of respiration. In quiet respira- 
 tion they do not diverge much from the cadaveric position ; 
 but in deep inspiration they diverge widely, being drawn 
 asunder by the abductors, returning during expiration. In 
 vocalization they are brought closely together by means of the 
 adductors. In coughing there is a closure of the glottis and a 
 sudden opening of it. If the patient cannot speak above a 
 whisper, or if there be a peculiar tone in the voice or cough, 
 while the vocal cords present their normal appearance, then 
 there must be some degree of paralysis, which may be unilateral 
 or bilateral. There may be aphonia from general or respira- 
 tory weakness, which hardly warrants the name of paralysis. 
 
 Bilateral paralysis will occur usually as the result of some 
 lesion of the central nervous system, but there are cases where 
 the stems of both pneumogastrics or recurrents have been 
 interfered with. The simplest form is where the loss of voice 
 is due to hysteria or fright. In such cases the laryngoscope 
 shows free movement of the cords during respiration, but the 
 edges do not come together closely in vocalization. In cough- 
 ing, however, there is complete closure of the glottis, showing 
 that there is no true muscular paralysis, and it often happens 
 that, while the laryngoscope is in position, the patient recovers 
 her voice on being suddenly asked to repeat certain words. A 
 true paralysis of the muscles of the larynx generally occurs in 
 the later stages of bulbar paralysis and progressive muscular 
 atrophy, being associated with paralysis of the tongue. The 
 laryngoscope shows defective mobility of the laryngeal struc- 
 tures, in respiration, coughing, and speaking. Diphtheria is 
 also sometimes followed by paralysis of the larynx, which is 
 often associated with paralysis of the muscles of the fauces and 
 may be inconsiderable as compared with the latter. 
 
 A number of cases have been published in which a bilateral 
 paralysis of the abductors of the cords (the posterior crico- 
 arytenoid muscles ) has been asserted. It appears that both 
 in unilateral and bilateral paralysis the abductors are usually 
 earlier affected than the adductors, and they may be alone 
 paralyzed. In this case the unopposed adductors produce a 
 progressive narrowing of the glottis and increasing laryngeal 
 obstruction. At first the obstruction may be paroxysmal and 
 resemble spasm of the glottis, but it afterward becomes more 
 or less persistent, and regularly increases in degree. There 
 may even be spasm where one laryngeal nerve is interfered with 
 
392 EXAMIXATION OF THROAT. 
 
 by aneurism (Johnson, Sclmitzler), this pointing to reflex 
 paralysis of the abductors or stimulation of the adductors. 
 
 Unilateral paralysis is of more frequent occuri*ence, and is 
 due to interference on one side "with the nerves supplying the 
 larynx. These nerves are the sujDerior laryngeal and the 
 recurrent laryngeal. The former supplies very few muscles, 
 the crico-thyroid, and more doubtfully the muscles which de- 
 press the epiglottis during deglutition. It also supplies sensory 
 fibres to the upper part of the larynx : when its stem is inter- 
 fered with there is defective sensation and paralysis of the 
 muscles which act on the epiglottis during deglutition. Inter- 
 ference with the stem of this nerve is so rare that it requires 
 no further consideration. The inferior or recurrent laryngeal 
 nei've is by no means unfrequently interfered with, especially 
 by aneurisms of the aorta which are liable to stretch the nerve 
 on the left side. The right recurrent nerve, curving round 
 the subclavian artery comes very near the apex of the lung, 
 and it is said to be frequently affected in phthisis pulmonalis, 
 the pleurisy Avhich is incident to this disease extending and 
 setting up inflammation in the nerve, but the frequency of this 
 occurrence has probably been exaggerated. Paralysis of the 
 recurrent may also be due to enlargement of the thyroid from 
 goitre or cancer, to cancer of the oesophagus, to tumors in the 
 mediastinum ; or these conditions, as well as aneurism, may 
 give rise to bilateral paralysis, although this is rare. The 
 regular unilateral paralysis may be complete or incomplete. 
 It is to be remembered that the muscles of the larynx consist 
 mainly of the adductors which close the glottis and the abduc- 
 tors which open it. During normal inspiration, the abductors 
 open the glottis widely ; during phonation the adductors close 
 it. If tliere be complete paralysis of the one recurrent (usually 
 the left) then the glottis, being acted on by neither set of mus- 
 cles, remains half open, in the position which it assumes in the 
 dead body (the cadaveric position). The arytenoid cartilage 
 and the cord remain motionless both in inspiration and phona- 
 tion (see Figs. 57 and 58), while the cord of the other side 
 moves freely. During phonation, the sound cord comes for- 
 ward to the middle line or projects beyond it, and maybe 
 carried so much beyond the middle line as to meet the para- 
 lyzed one, the cartilages partly overlapping, particularly when 
 a high note is sounded. When the paralysis is incomplete 
 there is diminished movement of the glottis. The paralysis is 
 sometimes incomplete in respect that it affects certain muscles 
 more than others ; and it appears, for some unknown reason, 
 
INVESTIGATION OF THE NARES, 
 
 393 
 
 that the fibres of the nerve which sai^ply the abductors are 
 more frequently paralyzed than those which supply the adduc- 
 
 FiG. 57. 
 
 Fig. 58. 
 
 Paralysis of left recurrent, nerve. 
 Image during inspiration — the left cord 
 in the cadaveric position. (Morell Mac- 
 kenzie.) 
 
 Paralysis of left recurrent nerve. 
 Image during phonation— left cord in 
 cadaveric position. (Morell Mackenzie.) 
 
 tors. As a result, the adductors act continually without oppo- 
 sition and retain the cord of the affected side in the position 
 of phonation. In that case the two cords will go closely 
 together during phonation, but the affected one will not retire 
 during inspiration. 
 
 The voice and cough are often greatly altered in these 
 various affections of the muscles. Most characteristic is the 
 loud clanging cough met with in many cases of aneurism. As 
 the glottis closes imperfectly the patient uses very forcible ex- 
 pirations in his coughing, and there is a great rush of air 
 through the glottis. As the unaffected cord is rendered tense 
 a loud tone is produced, but it is of an impure character, 
 giving the peculiar clang to the cough. As the cord on the 
 affected side does not retire in inspiration, but retains the 
 cadaveric position, or may even be in the position of phonation, 
 there is always a certain obstruction, during inspiration, which 
 gives rise to a strid ulcus sound. The voice is sometimes re- 
 duced to a whisper, but more frequently it has a peculiar clang- 
 ing sound, being very imperfectly under the command of the 
 patient, sometimes suddenly assuming the falsetto character. 
 
 Spasm of the glottis or laryngismus stridulus, which is com- 
 paratively frequent in children and may complicate bronchitis, 
 whooping cough, etc., scarcely calls for special notice here. 
 The condition seldom admits of observation with the laryn- 
 goscope, and is sufficiently indicated by the difficulty of respi- 
 ration aud the stridulous sound which accompanies it. A 
 more or less permanent stridor may occur in obstruction of 
 the glottis by tumors or swellings in the larynx ; and it is to 
 be borne in mind that in cases where there is already con- 
 
394 EXAMINATION OF THROAT. 
 
 siderable obstruction, it not uncommonly happens that spasm 
 comes on and renders the obstruction complete, sometimes with 
 fatal results, if tracheotomy be not resorted to. 
 
 Investigation of the Nakes. 
 
 Rhinoscopy consists in the inspection of the nares ; this may 
 be done by inserting a mirror behind the uvula, with its surface 
 so placed as to reflect the image from the posterior nares. 
 The mirror must be a small one, not more than five-eighths of 
 an inch in breadth, and it should be bent so that its surface is 
 at right angles with the stem. It is generally necessary also 
 to use a tongue spatula, which should be introduced further 
 back than usual. The patient sits with his head erect, or 
 slightly bent forward, and the light of the lamp is to be 
 reflected ou the fauces exactly as in laryngoscopy. The tongue 
 having been depressed with a finger or a spatula, the mirror, 
 after being heated, is introduced into the back of the throat, 
 and placed so that its surface forms with the horizon an angle 
 of 130 degrees. The mirror may be conveniently introduced 
 first on one side of the uvula and then on the other, so that 
 an image may be obtained of the two posterior nares sej^ar- 
 ately. The uvula often obstructs the view, and so does the 
 soft palate, if the distance between the anterior pillars of the 
 fauces and the wall of the pharynx be too short. A hook has 
 been devised for raising the uvula, but it is in most cases of 
 doubtful utility. The image obtained is at first rather difficult 
 to understand, and especially so, as it is impossible to get a 
 full view of the posterior nares at once, and it must be taken 
 l^iecemeal. The most prominent appearance is the middle 
 turbinated bone ; below it is the inferior, and above it, some- 
 what in the distance, the superior. The septum is also to be 
 seen; and, by moving the mirror, the trumpet-shaped ex- 
 tremities of the Eustachian tubes. It must be confessed that 
 the examination is often unsatisfactory ; and those who desire 
 to follow it out more fully should consult some of the special 
 works, such as that of Morell Mackenzie. 
 
 The anterior nares may be examined by causing the patient 
 to bend his head far back, and then directing the light by 
 means of the reflector into the nostrils. The nostrils may be 
 dilated with a blunt probe, or other means. A spatula has 
 been devised for dilating the nostrils, and so exposing the 
 anterior nares. 
 
 Khinoscopy will be called for when the existence of a 
 
BIBLIOGRAPHY. 395 
 
 chronic discharge from the nares, or a persistent obstruction, 
 directs special attention to these parts. Sometimes, also, the 
 condition of the openings of the Eustachian tubes in deafness 
 may be discovered by means of rhinoscopy. When a view of 
 the nares is obtained it may be possible to observe any undue 
 redness, or thickening of the mucous membrane, the existence 
 of ulcers, the proximate source of discharges, etc. The ex- 
 istence and exact seat of polypi, which frequently obstruct the 
 passage, may also be discovered by this means. 
 
 The most complete English work on these subjects is Morell 
 Mackenzie's Manual of Diseases of the Throat and Nose, 2 vols., 
 London, 1880-84 : this author has also written the article on the 
 larynx in Reynolds's System of Medicine, vol. iii., and monographs 
 on several departments of the subject. — Lennox Browne has a general 
 work entitled The Throat and its Diseases, London, 1878, which is 
 illustrated by^^numerous colored lithoEjraphs. This author has also 
 published in conjunction with Emil Behnke two works chiefly con- 
 nected with singing, namely, Voice, Song, and Speech, London, 1884, 
 and The Child's Voice, London, 1885. Behnke has also a book on 
 the mechanism of the human voice. — There are several important 
 works by J. Solis Cohen, of Philadelphia. — Prosser James has a small 
 work on the laryngoscope, while Sir G. Duncan Gibb's book, which led 
 the way among works of this description, retains a permanent value. 
 
 The laryngoscope as a practical instrument was worked out by 
 Czermak, whose original work on the subject bears date March, 1858. 
 Many attempts, more or less successful, had been made to illuminate 
 and examine the larynx, an account of which will be found in Morell 
 Mackenzie's manual ; but it was not till Czermak took the matter in 
 hand, with the laryngeal mirror devised by Signor Garcia, that the 
 laryngoscope, as we now know it, came into existence. 
 
 The principal systematic works in German are those of Stoerk, 
 Tobold, and Tiirck, and the article on the " Larynx " in Ziemssen's 
 Encyclopaedia. — -In French, the works of Mandl, and Eauvel are the 
 chief. — A work by Gottstein on diseases of the larvnx has been trans- 
 lated by M'Bride, Edin., 1885. 
 
 There are numerous works on special departments of the subjects 
 such as tumors and paralysis of the vocal cords. On the former, the 
 works of Butlin, On Malignant Disease of the Larynx, London, 1883 , 
 Bruns, Die Laryngotomie, Berlin, 1878; and Morell Mackenzie's 
 manual may be named. In the last mentioned a full literature of the 
 subject is given. 
 
 Paralysis of the cords is very fully treated in Mackenzie's manual 
 and Stoerk's Klinik, Stuttgart, 1880. — Paralysis of the abductors is 
 specially discussed by Semon in two articles in the Clinical Society's 
 Transaction, vols. xi. and xii , London, 1878 and 1879. — The subject 
 of paralysis in general is also discussed in the Transactions of the 
 International Medical Congress, vol. iii., London, 1881. 
 
 Seech, Diseases of the Mouth, Throat, and Nose, translated by Dr. 
 Blaikie, Edin., 1886. — Baber, Guide to the Examination of the Nose, 
 London, 1886. 
 
CHAPTER XI. 
 
 DISOEDERS OF THE DIGESTIVE SYSTEM. 
 
 The digestive orgaDs are often deranged in a great many 
 diseases of a general nature, as well as in local affections of 
 these organs themselves ; an inquiry into their state becomes 
 thus an important j)art in nearly every case as a matter of 
 diagnosis ; but, perhaps, the prognosis and treatment depend 
 even more particularly on this investigation. Fevers and 
 inflammations of nearly every kind aftect the digestive func- 
 tions, more or less seriously, and many cerebral and other 
 nervous disorders likewise do so ; general constitutional dis- 
 eases, anaemia, Addison's disease, leukaemia, etc., also disturb 
 them more or less profoundly. Affections of the kidney, ute- 
 rine disorders, and pregnancy, frequently declare themselves 
 first by vomiting. Diseases of the oesophagus, stomach, bowels, 
 liver, pancreas, peritoneum, and mesenteric glands, necessarily 
 derange the digestive functions; affections of the digestive 
 organs may be primary, or they may be due to mischief in 
 contiguous parts (aneurisms, abdominal tumors, etc.). 
 
 This complexity in the etiology of digestive disorders neces- 
 sitates a very careful investigation of the different groups of 
 symptoms ; each particular disorder has often to be scruti- 
 nized in respect of the duration, the proximate cause, and the 
 relative date of the symptom in question. 
 
 The appetite is usually more or less impaired (anorexia) in 
 all serious diseases, especially in those with high fever or other 
 acute symptoms, and in those which involve the digestive 
 organs in a direct manner. We should ascertain the habitual 
 character of the appetite in health ; we also inquire whether 
 there is any remaining desire for particular kinds of food, and 
 what these are, whether the appetite is capricious as to special 
 kinds of food or abnormal articles, or at particular times ; 
 whether the loss of appetite is associated with nausea or loath- 
 ing of food ; and whether actual sickness and vomiting occur 
 on attempting to overcome this repugnance. Many influences 
 not usually thought of as diseases are often at work in causing 
 impaired appetite : grief or anxiety, and depression of spirits, 
 want of variety in the food or of company at meal-times, want 
 
THE STATE UF THE TONGUE. 397 
 
 of fresh air and exercise, and the use of certain drugs, includ- 
 ing opium, chloral, and alcohol (even in medicinal doses), are 
 often responsible for the absence of appetite complained of by 
 our patieuts. 
 
 In some forms of nervous disease there is an inordinate appe- 
 tite (boulimiaj arising from a sense of want or emptiness, very 
 soon even after a meal : certain forms of indigestion are like- 
 wise characterized by a sense of spurious hunger. In diabetes 
 also the appetite is sometimes excessive. In certain states of 
 bodily and mental disorder an unnatural appetite (pica) for 
 the most extraordinary articles may sometimes be noticed ; 
 this may be found at times in chlorosis, pregnancy, and insanity. 
 (Compare Chapter VIII., p. 316.) 
 
 Thirst is a very frequent complaint in all diseases associated 
 with much pyrexia ; in such cases, notwithstanding the quan- 
 tity of fluid consumed, the urine is usually scanty. In several 
 forms of stomachic derangement, also, the presence of thirst is 
 a frequent symptom, and in such cases the urine may be abun- 
 dant, although otherwise normal. When from any cause 
 vomiting is excessive there is apt to be great thirst superin- 
 duced. In certain forms of Bright's disease, and very notably 
 in diabetes, the complaint of thirst often directs our attention 
 to the examination of the urine, and in such cases a large con- 
 sumption of fluid is usually found to be associated with fre- 
 quent micturition and the passing of a large quantity of urine ; 
 the further examination brings out abnormalities in the spe- 
 cific gravity, and usually, also, as regards the presence of 
 albumen or sugar. Particular articles of diet (salt fish, etc.) 
 often cause temporary thirst, and the use or abuse of alcohol 
 is frequently followed by more or less thirst and dryness of the 
 throat, especially in the morning. Some medicines — opium, 
 and more es|)ecially belladonna — are apt to cause dryness in 
 the mouth and throat with a sense of thirst. 
 
 The State of the Tongue. 
 
 This affords valuable indications respecting the digestive 
 functions, especially when the disorder is due to the influence 
 of constitutional disturbance from febrile or inflammatory dis- 
 ease. Indeed, the progress of a febrile attack can often be 
 traced both in its increase and decline by corresponding 
 changes in the state of the tongue. Many poiuts bearing 
 upon the tongue have been already discussed in connection 
 with taste and nervous disturbance (pp. 193, 225.) 
 
 34 
 
398 DISORDEKS OF THE DIGESTIVE SYSTEM. 
 
 The 'presence of a fur or coating on the tongue should be 
 described as to its extent, whether the edges and tip are 
 clean, and as to the color and thickness of the fur, which is 
 sometimes very dense. Different from the ordinary coatings 
 of digestive disorder are the white soft patches of muguet 
 (parasitic stomatitis or aphthae, popularly known as " thrush," 
 " frog," etc.) : these are often seen in children, especially in 
 those who are fed artificially ; but they may likewise occur in 
 others, and even in adults suffering from chronic diarrhoea and 
 exhausting diseases approaching a termination ; these white 
 spots and patches are found, also, on the mucous membrane of 
 the cheek and throat ; they are due to the presence of a vege- 
 table parasite (o'idium albicans, see Fig. 59), which may be 
 
 Fig. 59. 
 
 O'idium albicans, the vegetable parasite of muguet or thi-ush. 
 
 (Reduced from Ch. Robin.) 
 
 seen with the microscope, after removing such spots with the 
 point of a knife, and digesting them in liquor potassse. (For 
 distinction from white diphtheritic patches, see Chai^ter X., 
 p. 378.) Very much rarer than this is is the presence of black- 
 ness in the tongue, associated with hypertrophy of the filiform 
 papillse and the presence of microorganisms differing from the 
 ordinary lej^tothrix buccalis. The dark streaks on the mucous 
 membrane of the tongue, cheek, and lips observed in Addi- 
 son's disease, are local manifestations of a general pigmen- 
 tation. 
 
 The dryness of the toncjue is the next point to be considered. 
 This may be tested by applying the tip of the finger to it as 
 well as by looking at it. The dryness may exist either with or 
 without coating. In advancing typhus, pneumonia, surgical 
 
THE STATE OF THE TONGUE. 399 
 
 fever, etc., we often find the tongue becoming dry, brown, and 
 hard, so as to be not unlike roasted leather. Along with this 
 we often see sordes on the gums and teeth : this dirty-looking 
 matter consists of epithelial debris, fragments of food, and 
 parasitic growths all mixed uj) together. In less severe or 
 receding forms of the same condition, the dorsum may be 
 dry, and the edges and tip somewhat moist. But the tongue 
 may be dry in whole, or in part, without much, if any, fur, in 
 which case it has a red glazed appearance ; or, if some parts 
 are less dry than others, we may see streaks here and there, 
 and perhaps small patches of fur on the dorsum : this state is 
 not unfrequently complicated with hacks or cracks, often very 
 painful : a similar condition frequently can be traced further 
 back in the fauces. 
 
 The red raw tongue is seen in certain febrile states (espe- 
 cially enteric and scarlet fevers) ; this may succeed the in- 
 tensely furred condition already referred to ; the whole of the 
 thick coating sometimes disappears with great quickness, 
 leaving a very red moist surface exposed. This sudden des- 
 quamation is scarcely so favorable as a more gradual cleaning. 
 This red raw tongue, in such a case, may become dry and 
 glazed in the further progress of the fever. 
 
 The " strcavberry tongue " is characterized by great distinct- 
 ness of the papillae, associated with considerable redness, and 
 not unfrequently with thick white fur in adjacent parts. This 
 strawberry tongue is common in scarlet fever, not usually at 
 the very beginning, but after some days' continuance of the 
 fever. An appearance closely resembling it may also be 
 found in cases of simple digestive disorder. 
 
 Enlargement of the circumvallate papillce, at the back of the 
 tongue, is not uncommon in cases characterized by various 
 dyspeptic symptoms, and often associated with a pitted con- 
 dition of the tonsils. 
 
 Little blisters on the tongue (aphthae), and various degrees of 
 ulceration, supply the evidence of the different forms or de- 
 grees of stomatitis (vesicular, ulcerative, gangrenous) : these 
 are often associated with salivation, fetor, and iliuch febrile 
 disturbance. 
 
 A swollen, sodden appearance of the tongue with very dis- 
 tinct indentations on the edges, corresponding to the teeth, is 
 often found in dyspepsia of various kinds, including those con- 
 nected vnth the free use of alcohol. Swelling of the tongue 
 occurs in salivation by mercury ; the rest of the mouth par- 
 ticipates in this action ; the mucous membrane of the cheek 
 
400 DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 opposite the teeth should also be examined ; there is usually 
 a well-marked " mercurial fetor." Iodide of potassium also 
 causes at times swelling and salivation. Glossitis (from these 
 or other causes) may lead to swelling so great that the tongue 
 cannot be kept within the mouth. 
 
 Swellings under the tongue (ranula) and hardness, nodula- 
 tiou, or patches, from syphilis and cancer, belong rather to 
 surgery than medicine. Occasionally salivary calculi give 
 rise to much swelling and pain in this situation. 
 
 Nearly all of these last-named alterations, associated w^ith 
 swelling or enlargement of the tongue, may lead to difficulties 
 in speaking and swallowing; they sometimes render eating or 
 drinking painful or impossible. 
 
 Paleness of the tongue from amemia, lividity in cyanosis, 
 coldness in cholera or collapse, and patches of ecchymosis in 
 purpura, are further points of an obvious character which 
 should be noted when present. 
 
 In examining the tongue we frequently detect a foulness in 
 the breath. This is often due to sore throat, rotten teeth, de- 
 composing particles of food or blood in the mouth or nose, 
 oziena, and gangrene of the lung ; by closing the nose and 
 mouth alternately, holding the breath, exploring the teeth and 
 nostrils, etc., we can sometimes make out these sources of 
 fetor. It may, however, arise also from disorder of the 
 stomach due to grave febrile disorders, to prolonged constipa- 
 tion or intestinal obstruction, to errors in diet, to particular 
 forms of dyspepsia with fetid eructations, or to the chronic 
 and baneful influence of alcohol, opium, and chloral. Some 
 medicines impart a disagreeable smell to the breath, and 
 among these the garlic odor of bismuth may be mentioned, as 
 it is apt to be overlooked owing to the absence of smell in the 
 medicine itself; it is not always present during the use of this 
 drug, and seems due to the occasional presence of tellurium in 
 certain parcels as an impurity. Various drugs likewise affect 
 the breath from their volatility. 
 
 Vomiting. 
 
 Vomiting should be considered in respect of what appears 
 to be its immediate cause ; we inquire as to whether it is con- 
 nected with anything taken into the system,.as food, drink, and 
 medicine; or into the lungs by direct inhalation, or in connec- 
 tion with emanations of various kinds ; or by absorption 
 through the skin, or through cuts and abrasions; the possi- 
 
voMiTiNa. 401 
 
 bility of poisoning, intentional or accidental, or in connection 
 with tlie occupation and habitation of the patient, must not 
 be forgotten. The presence or absence of ^^yrexia often guides 
 us in deciding as to the vomiting being symptomatic of the 
 poisoning of the specific fevers. We inquire, further, whether 
 the vomiting is associated with the j)osition of the patient, in- 
 duced, for example, on moving or on rising from bed ; whether 
 it only comes on at particular times, as in the morning, or in 
 connection with fits of coughing ; whether it is associated with, 
 or preceded by, sickness, nausea, or pain in the stomach and 
 liver, or connected with jaundice, or with disorders of the 
 bowels. Vomiting is likewise frequently associated with head- 
 ache, pain in the back, fever, paralysis, convulsions, insensi- 
 bility, dropsy, disease of the urinary organs, and disorders of 
 the menstruation. We must inquire in certain cases whether 
 there has been an exposure to the sun, any injury to the head 
 or belly, any surgical operation, or any other obvious fact of 
 this kind in the previous history of the patient. 
 
 When due to ingesta, the vomiting may be immediate, or it 
 may not occur for many hours ; some assistance may be derived 
 from the known tendency of the patient to vomit readily, or 
 after certain articles. In such cases when the vomiting is not 
 immediate, there is usually some period of sickness, of cold- 
 ness, faintness, or giddiness just before the vomiting occurs, 
 and there is often a history of some previous derangement of 
 the primce vice, perhaps with furred tongue, constipation, etc. 
 AVhen sickness and vomiting are due to these last-named causes 
 there is usually great and permanent relief from the emptying 
 of the stomach, but sometimes improper food and certain 
 medicines (antimony, chloroform, opium, etc.) set up a more 
 prolonged vomiting, due probably to some changes being in- 
 duced by them in the digestive organs (gastritis, jaundice, intes- 
 tinal catarrh, dysentery, etc.), as evidenced by the other 
 symptoms of these complaints. Allied to these is the vomiting 
 induced by the use of rich food in excess, or the morning sick- 
 ness so common in those who drink alcohol regularly and 
 freely, although perhaps never to the extent of causing obvious 
 intoxication, or in those who are addicted to the frequent use 
 of sedatives. The vomiting in alcoholic cases may be due to 
 a practice long continued and not to any one act which we can 
 name : these attacks are often called " bilious " by the patient, 
 and ascribed by him to anxiety in business, vexation, etc. 
 
 When the stomach has been upset from any cause, many 
 things irritate it which would not otherwise do so ; when even 
 
 34* 
 
402 DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 a little cold water is almost immediately rejected, we have 
 evidence of very great irritability of the stomach. 
 
 The influence of the recumbent position in helping to ward 
 off sickness and vomiting, applies to nearly every variety of 
 the disorder ; but in some cases, including cerebral affections, 
 the effect of change in j)osition is very great; in uterine flexions 
 and in pregnancy, the erect position often determines vomiting 
 at once, and this is no doubt one of the reasons why the sick- 
 ness is chiefly marked in the morning in many of these cases. 
 In cases of vomiting due to abdominal abscesses, peritonitis, 
 and general debility, the influence of position, and the impor- 
 tance of perfect rest after swallowing anything are often very 
 marked. The sickness caused by the rolling of a vessel at sea, 
 by rapid rotation, by driving with the back to the horses, etc., 
 may be mentioned in this connection, although such sickness 
 is probably caused in some way through changes in the cere- 
 bral circulation. 
 
 The pains and discomforts associated with vomiting are very 
 variable. In fevers and inflammator}^ diseases the vomiting 
 is usually accompanied with more or less headache, and often 
 with pain in the back, and a feeling of soreness in the limbs, 
 or with general malaise. But in addition to this there is often 
 pain in the chest, over the liver or gall-bladder, the bowels, 
 kidneys, bladder, ovaries, uterus, testicles, etc., according to 
 the special organs attacked. 
 
 Pain in the stomach itself should be inquired into as to 
 whether it appears immediately after a meal (as is common in 
 gastric ulcer), or only after the process of digestion has actu- 
 ally been going on (dyspepsia) ; whether the pain is associated 
 with much wind in the stomach, and whether it is relieved by 
 eructations, or by the act of vomiting. This relief is often 
 very marked in cases of dyspepsia and of dilatation of the 
 stomach. The sense of sickness or nausea usually precedes 
 vomiting from most causes, but not unfrequently it is absent 
 in the vomiting due to cerebral disease, and occasionally in 
 that of renal disease, so that " causeless vomiting " should 
 always be considered from this point of view. Apart from 
 serious cerebral lesions, morning sickness is not uncommon in 
 those whose brains are overtaxed to a serious extent. Vomit- 
 ing without any very obvious cause is also found in Addison's 
 disease, pernicious annemia, and other constitutional disorders. 
 
 In cerebral disease violent headache often accompanies the 
 vomitinir, and headache is very often associated with the sick- 
 ness and vomiting due to indigestion. The combination of 
 
CEREBRAL VOMITING. 403 
 
 headache and vomiting, both in extreme forms, is seen in the 
 nervous affection known as "sick headache" (migraine), but 
 in this case the headache is usually unilateral (hemicrania), 
 and the duration of the attack, in an acute form, varies from 
 a few hours to one or at most two days. While pain in the 
 back and vomiting are common in all febrile affections, such 
 a pain with very marked tenderness in the spine may some- 
 times denote a spinal meningitis, or some other form of inflam- 
 matory mischief in the cord. Violent paroxysms of profuse 
 vomiting may form the leading feature of the " gastric crises " 
 occurring in locomotor ataxy. 
 
 Disorder of the bowels frequently indicates the cause of the 
 vomiting with which it is associated. Vomiting is often severe 
 at the beginning of summer diarrhoea, especially in children, 
 and it is common also in cholera and dysentery ; it sometimes 
 accompanies the act of defecation. Severe vomiting and diar- 
 rhoea sometimes occur in the various forms of peritonitis. This 
 combination is also found at the beginning of certain cases of 
 malignant scarlatina and measles. Vomiting is likewise com- 
 mon in cases of prolonged constipation, whether from general 
 disorder of the digestive organs, or from serious obstructions 
 with the attendant inflammation, due to hernia, internal stran- 
 gulation, invagination, etc. Examination of the hernial re- 
 gions, of the state of the abdomen, of the character of the 
 vomited matters, and of the stools, if any, should never be 
 neglected. 
 
 Vomiting is also a leading symptom in the various forms of 
 local and general peritonitis, often associated with constipation 
 and flatulent distention of bowels. 
 
 Irritation of the fauces, produced by choking, or by an in- 
 fant's sucking too greedily, or perhaps by an elongated uvula, 
 or by coughing, very often produces vomiting. Various forms 
 of cough, especially when associated with profuse expectora- 
 tion, are apt to excite vomiting. The paroxysms of whooping 
 cough are often terminated by an act of vomiting. It may be 
 noticed in passing that severe vomiting and retching may set 
 up a form of coughing and hawking which may seem again to 
 induce further vomiting. 
 
 Menstrual irregularities, uterine flexions, pelvic inflamma- 
 tions, and other forms of uterine and ovarian disease, are 
 frequently responsible for severe and persistent vomiting with 
 great sickness. Any history of suppression of the menses, 
 within the childbearing period of life, associated with this 
 symptom, should lead us to consider the question of pregnancy. 
 
404 DISORDEKS OF THE DIGESTIVE SYSTEM. 
 
 In the vomiting due to renal disease Ave usually have im- 
 portant assistance from the state of the urine. Not a few 
 cases of so-called " biliousness " with sickness and vomiting 
 are found to be due to this form of disease. Vomiting occurs 
 at times in all forms of kidney affections, but the j^assage of 
 renal calculi, and the poisoned state of the system known as 
 ursemia, may be named as conditions specially likely to give 
 rise to it. The occurrence of vomiting in connection with a 
 great diminution of the urine in renal disease is always of 
 very serious import in this respect. The vomiting and other 
 alarming symptoms observed in retrocedent gout may likewise 
 be mentioned in this connection. 
 
 Vomiting is an habitual accompaniment of the paroxysmal 
 and excruciating pains in the hepatic region due to the passage 
 of gall-stones ; it usually precedes the jaundice due to this 
 cause. A certain amount of vomiting, indeed, is a common 
 precursor of jaundice from whatever cause, although it is 
 occasionally quite absent. (See " Jaundice," Chapter XII.) 
 
 The quantity of matter ejected, and the sensation of sour- 
 ness, burning, bitterness, fetor, etc., experienced during the 
 act are of importance in judging of the size of the stomach 
 and of the changes which the contents of the stomach have 
 been undergoing. (See " Vomited Matters," infra.) 
 
 Q^sojihageal vomiting differs from ordinary gastric vomit- 
 ing in the relatively small quantity which comes up, and in 
 the absence of effort and straining during the act. It bears 
 some resemblance to the sudden emptying of an India-rubber 
 hose on removing it from a large water tap. It occurs in cases 
 of stricture of the oesophagus, especially when there is dilata- 
 tion of its cardiac extremity. This is almost always a malig- 
 nant disease, but it may also arise from injuries (burns and 
 caustic liquors). 
 
 Vomited Matters. — These should always be preserved for inspection, 
 esf)ecially in cases of suspected poisoning, and when the vomiting is of 
 an obscure character. 
 
 The quantity vomited at a time is often important, as it helps to re- 
 veal the size of the stomach, and to indicate the extent to which the 
 meals, of several days it may be, are retained. Excessively large 
 quantities are ejected in cases of dilatation of the stomach due to 
 cancer of the pylorus, or other forms of stricture. These excessive 
 quantities are often only ejected at intervals of two or three days, and 
 the disproportion between the amount swallowed on a given day and 
 the amount vomited, may serve to indicate the retention of several 
 days' food. The relatively large quantity vomited in certain cases 
 after the swallowing of a small amount of bland fluid, serves usually 
 
VOMITED MATTERS. 405 
 
 to reveal somewhat serious congestion, if not erosion or ulceration, of 
 the stomach. The " coffee grounds" vomiting in such cases is due 
 probably to the exudation of blood, whose character has become 
 altered by the juices of the stomach. (See " Black Vomited Matter.") 
 
 The obvious character of the vojnited matters often explains an attack 
 of vomiting, as when we find unripe fruit, undigested pie-crust, and 
 similar articles brought up by a sick child, or when we find alcoholic 
 liquors vomited by a drunken man. The degree of digestion undergone 
 by the ejected matters may be important, as indicating the length of 
 time the food has been retained. The curdled milk vomited by infants 
 does not necessarily imply an undue acidity of the stomach, but the 
 excessive tenacity or solidity of the curd may indicate that the par- 
 ticular milk given cannot be digested. 
 
 Occasionally a recent meal is retained while former meals which 
 have been so far digested are ejected, owing probably to their being 
 more fluid. The character of the matter vomited, as experienced by 
 the patient, especially as to sourness, bitterness, fetor, etc., is some- 
 times of value ; the smell and reaction can be ascertained by ourselves. 
 The conjunction of great acidity in the vomited matters with alkalinity 
 of the urine has often been noticed. 
 
 The smell is valuable as assisting our recognition of the nature of 
 the matters vomited. It is further of great importance when the 
 odor can be recognized as distinctly fecal. Occasionally various forms 
 of decomposition simulate this odor ; but when it is quite unequivocal 
 it indicates some form of obstruction or strangulation of the bowel, 
 or some fistulous communication of a lower part with a higher part 
 of the intestine, or with the stomach itself. The yeasty or frothy 
 appearance of the vomited matters indicates that fermentation has 
 been going on in the contents of the stomach. This is often asso- 
 ciated with the odor peculiar to this process, so that the smell of the 
 vomited matter and of the patient's breath resembles that of an old 
 beer or porter barrel. Torulfe and sarcinse should be searched for in 
 such cases. (See " Microscopic Examination," p. 406.) 
 
 Blood in large quantity can be generally recognized as such (hsema- 
 temesis). It is usually darker and less frothy than that brought up 
 from the lungs. Large hemorrhages from the stomach are commoner 
 in simple gastric ulcer than in cancer, although they occur in both. 
 They likewise occur in connection with portal congestion due to cir- 
 rhosis of the liver. Occasionally large quantities of blood are vomited 
 from the opening of an aneurism into the oesophagus ; such an acci- 
 dent is usually rapidly fatal. Blood in small quantities, causing 
 florid streaks amongst ,the mucus and vomited matters, is not un- 
 common in any very violent attacks of vomiting if long continued. 
 Such streaks are specially apt to appear in cases associated with con- 
 gestion and catarrh of the stomach from diseases of the liver or other 
 causes. Dark fluids^ resembling " cofi"ee grounds " or " sooty fluids," 
 are almost always composed of altered blood acted on by the digestive 
 juices. They are found frequently in cancer of the stomach, in 
 gastric ulcer, in congestion of the stomach, in liver disease, and in 
 peritonitis ; their occurrence toward the end of a prolonged labor may 
 likewise be mentioned here as a somewhat serious symptom. 
 
 Bile in the vomited matters is often complained of when the 
 presence of the altered blood just referred to is really meant. Bile is 
 
406 DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 to be recoo;nized as a greenish or yellowish viscid fluid ; it is usually 
 yellow at first but green in the later stages of protracted vomiting : it 
 may be vomited up in any case where the retching and straining are 
 prolonged, after the stomach has been emptied of its contents. 
 
 Pus is rarely vomited from the stomach, although very frequently, 
 brought up from the lungs. Occasionally submucous suppuration of 
 the stomach, stricture of the oesophagus, or of the cardiac orifice of the 
 stomach, and the opening of an abscess into the stomach, may give 
 rise to this symptom. 
 
 The appea?^ance of wo7'ms and of shreds of hydatids is important : 
 the round worm (ascaris lumbricoides) is the only one commonly 
 met with in such a way. It is occasionally vomited by children 
 during illnesses of various kinds not directly related to the presence of 
 worms. 
 
 The microscojnc exammatioji of the vomited '>natters reveals muscular 
 fibres, starch granules, oil globules, and shreds of vegetable tissue, 
 according to the diet of the patient. Crystals of margarine, etc., are 
 also often seen. Blood, pus, etc., may be recognized, if their structure 
 be not destroyed by the digestive fluids. " Cancer cells " can seldom 
 or never be recognized as such with any degree of certainty. The 
 growth known as Torula ce7^evisice, or the yeast plant, is often found 
 in fermenting matter from the stomach. (See Fig. 86, Chapter XII.) 
 Sarcince should likewise be searched for when there is fermentation, 
 or in cases of accumulation of the contents of the stomach. (See 
 Fig. 60.) They are found in many cases of dilatation of this organ, 
 
 Fig. 60. 
 
 Sarcinie venlriculi, with stiuch granules, and oil globules, from voniitod matters. 
 
 (OttoFunke.) 
 
 from whatever cause, in ulcer and cancer of the stomach without 
 dilatation, and in certain cases of gastric catarrh. Their presence or 
 absence cannot be relied on in the diff'erential diagnosis of these 
 affections. These are little square structures resembling wool-packs, 
 from which they take their name. When found in the stomach or 
 its contents they are called Sarcince venijHculi, but similar structures 
 have been found in the urine (see Chapter XIII.), and in various 
 other fluids cf the body. Digestion of the vomited matter in liquor 
 potassae brings out the appearance of the sarcinae somewhat more 
 distinctly. 
 
FLATULENCE AND HICCUP. 407 
 
 For the appearance of booklets, etc., from hydatids, see Fig. 72. 
 Casts of the gastric follicles have been described by Dr. Fen wick 
 as occurring in vomited matters. 
 
 Enmctations and regurgitation of food or fluids are to be con- 
 sidered as to the time at which they occur with regard to 
 meals. A slight amount of regurgitation of milk, after suck- 
 ing, is quite natural in infants. In adults, regurgitation may- 
 occur during the process of digestion ; in such cases it is 
 usually accompanied with pain and excessive acidity (" heart- 
 burn "). There may be a rising of fluid into the mouth, how- 
 ever, without acidity ; indeed, the fluid which thus ascends 
 from the stomach or oesophagus may be quite bland or even 
 alkaline ; such " w^aterbrash " (pyrosis) is always an indica- 
 tion of digestive disorder, and occasionally of serious lesions of 
 the stomach. Apart from the ascent of actual fluid from the 
 stomach, the patient may be conscious of excessive acidity, 
 and the gas belched up may be recognized as very sour. At 
 times the eructations have the sharp smell of rancid butter 
 (butyric acid fermentationj ; at other times there is the smell 
 of sulphuretted hydrogen ; sometimes the gas is inodorous, 
 and, as a rarity, it has been found inflammable. Occasion- 
 ally oesophageal vomiting resembles regurgitation from its 
 occurring just after attempting to take food, although this has 
 not really entered the stomach. 
 
 Flatulence and Hiccup. 
 
 Flatulence manifests itself by distention in the region of the 
 stomach and bowels, causing often a certain amount of pain 
 and discomfort in these situations, relieved to some extent by 
 the passage of wind from the mouth or from the anus. 
 Rumbling noises and colicky pains often attend the passage of 
 wind along the intestinal tract. But, in addition to these 
 more obvious symptoms, wind in the stomach often gives rise 
 to pain between the shoulders, or about the heart, to giddi- 
 ness, faintness for a minute or two, palpitations of the heart, 
 etc. 
 
 The period in the process of digestion at which the flatulence 
 begins to appear should be ascertained, as also the influence 
 which certain articles have in determining the flatulence (vege- 
 tables, saccharine, starchy and fatty foods, tea, tobacco, alcohol, 
 etc.). The peculiar fermentation which leads to the produc- 
 tion of gas may be often guessed at by the description which 
 
408 DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 the patient gives of the taste and smell of the eructations, or 
 perhaps it may be judged of by the observer. The lactic 
 acid, the butyric acid, and the alcoholic fermentations are the 
 commonest. The gas is sometimes quite inodorous, and it 
 occasionally appears so soon after the taking of food that it 
 can scarcely have had time to result from fermentation. At 
 other times a dilated stomach with visible peristaltic move- 
 ment may be filled with fermenting matters, and the gas 
 brought up may have a beery smell. 
 
 The repeated passage of wind from the bowel in cases of in- 
 testinal obstruction serves to show that the obstruction is not 
 absolute. The suppression of the passage of wind leads in 
 cases of this class to excessive tympanitic distention of the ab- 
 domen, esjDecially if the seat of obstruction be low down, so as 
 to lead to distention of the colon. 
 
 In addition to intestinal obstruction, the accumulation of 
 wind in the bowels is commonly observed in peritonitis, both 
 acute and chronic (puerperal, traumatic, and tubercular, as 
 well as other forms ^ In enteric fever, a certain degree of 
 this " tympanites " is habitual, and in adynamic states in this 
 and other diseases it often assumes alarming characters. In 
 disease of the liver, and in ascites resulting from that or other 
 causes, such flatulent distention is most distressing and often 
 seems to the patient the essence of the disease. In rickets, 
 and in some forms of infantile disease characterized by diges- 
 tive derangement, distention of the bowels is so habitual as to 
 lead to a permanent enlargement of the belly, sometimes simu- 
 lating more serious disease. 
 
 In cardiac disease the digestive functions are often impaired, 
 probably from passive congestion, and distressing flatulence in 
 the stomach from this or from nervous causes may be the 
 result : this fact is all the more important as flatulence very 
 often gives rise to symptoms simulating heart disease, such as 
 fluttering, irregularity, oppression, and breathlessness, and so 
 these symptoms may be misinterpreted. Flatulence in the 
 stomach and bowels is one of the commonest features in cases 
 of hysteria. A sensation compared to the ascent of a ball of 
 wind to the throat, producing a sense of impending suffoca- 
 tion, is often described by hysterical patients (globus hys- 
 tericus). 
 
 Hiccup is common as aj)pearing readily in certain persons 
 after eating or drinking ; when of short duration it is seldom 
 of much importance. Protracted duration of hiccup is always 
 a serious symptom, especially in fevers or other illnesses with 
 
STATE OF THE BOWELS. 409 
 
 much nervous prostration, in diseases of the liver and kidneys, 
 and in cases of intestinal obstruction. 
 
 State of the Bowels — Abdominal Pain. 
 
 The state of the boivels requires to be noted in most cases. 
 In healthy subjects the bowels act about once in the twenty- 
 four hours : certain persons have two motions in the day, or a 
 motion only once in two days, without any real departure 
 from health. In children the motions are, as a rule, more 
 frequent than in adults, and in young infants three or four 
 motions in the twenty-four hours may be regarded as normal. 
 In judging of the frequency or infrequency of the motions, as an 
 index of disease, we must have regard to the quantity and 
 quality of the food used, and the amount of muscular exercise. 
 Scanty food, or the use of food that can be nearly all absorbed 
 without residue, and the absence of active exercise, tend to 
 produce scanty and infrequent motions. Constipation, pro- 
 longed beyond three or four days, must be regarded as an ab- 
 normal state : occasionally, however, there is an interval of 
 nearly a week between the motions in persons who reckon this 
 their natural condition. The frequency of the motions should 
 be stated, if possible, as to the actual number of stools in the 
 twenty-four hours : occasionally, it is important to know 
 whether the frequency is less during night, and then the 
 number of stools by day and by night may be given sepa- 
 rately. Sometimes two or three motions occur so close together 
 as to make it almost fair to reckon them one motion, particu- 
 larly if no frequency exists at other parts of the day. The 
 influence of certain meals may often be seen in determining 
 several motions at particular times, as immediately on begin- 
 ning breakfast, although there may be no disturbance after- 
 ward. In children the relation to taking food is often so 
 marked as to give rise to the erroneous idea of the milk just 
 swallowed having passed at once through the bowels. The 
 influence of movement and exertion may sometimes be traced 
 in the same way ; the relative frequency of the stools at par- 
 ticular times, and under particular circumstances, has often to 
 be specially noted, in order to give us a true idea of the state 
 of the case. 
 
 The consistency of the motions is the next point of impor- 
 tance ; it has a distinct bearing on the question of frequency, 
 but this subject naturally falls to the section on the character 
 of the stools (p. 413). 
 
 35 
 
410 DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 The degree of force or straining during defecation, the pres- 
 ence of pain in the bowels (see next section), the force with 
 which the motions are expelled, the passage of wind with the 
 motions, and the presence of faintness or sickness before, during, 
 or after defecation, are all points which should be inquired 
 into, particularly in cases of diarrhoea and constipation, and 
 of 23artial obstruction of the bow^el. Straining is of two kinds : 
 the one where dry, hard feces have to be forced onward by 
 great muscular effort, or where mechanical obstruction in the 
 bowel, in any part of its course, leads the patient to feel as if 
 this were required ; the other form consists of a feeling as if 
 something more were just about to pass at the anus, even when 
 nothing or only a little bloody slime may be present : this last 
 variety is termed " tenesmus." 
 
 When motions are passed in bed and without notice, it 
 should be ascertained whether this arises from unconsciousness, 
 from defective sensibility in the parts, from paralysis of the 
 si^hincters, from great fluidity of the motions, from spasmodic 
 or irregular action of the bowel, from inability of the patient 
 arising from pain or paralysis to effect the necessary move- 
 ments, from idiocy or defective intelligence, from indifference, 
 or, in children, from shyness or want of training. The inten- 
 tional or wilful soiling of the bed, so as to mislead or to secure 
 attention, should also be remembered as an occasional occur- 
 rence. (Com^oare p. 229.) 
 
 Pain in the Abdomen and Bowel. — Pain in the region of 
 the bowels is of such importance that we must try to dis- 
 criminate the different forms, and, as we cannot say at once 
 whether the pain is in the bowels themselves, or in adjacent 
 organs, we must consider them together. 
 
 Abdominal tenderness may be general or local, and all 
 degrees of tenderness to the touch are met with. Generalized 
 tenderness is found in peritonitis, sometimes to an extreme 
 degree, so that the least touch, or even the pressure of the bed- 
 clothes is painful ; the most extensive peritonitis, however, 
 may exist with but little tenderness ; and in certain puerperal 
 cases, and in the chronic forms of peritonitis the tenderness is 
 often extremely sliglit, or even altogether absent. Apart from 
 wounds and other injuries, surgical operations, and childbirth, 
 we find acute peritonitis to arise most frequently, perhaps, 
 from perforation of the stomach and bowels, in the course of 
 gastric and intestinal ulcers, enteric fever, and affections of 
 the caecum and vermiform appendix. Abscesses and accumu- 
 lations of various kinds may, by rupture, produce the same 
 
COLIC. -ill 
 
 effect (hepatic and renal abscess, severe intestinal obstruction, 
 hydatids, ovarian cysts, vertebral abscess, rupture of gall- 
 bladder, ulceration of gall-duct). Tubercular deposits, although 
 commonly associated with chronic peritonitis, sometimes set up 
 an acute attack. The previous history, the mode of onset, and 
 the other concurrent symptoms must here guide the diagnosis. 
 
 Sometimes, however, peritonitis arises without any obvious 
 cause (so-called idiopathic). Certain cases of rheumatism 
 affecting the abdominal walls are not easily separable from 
 peritonitis, as tenderness, fever, and vomiting may all be 
 present. In many cases of hysteria there is extreme sensi- 
 tiveness and shrinking on touching the abdomen : the absence 
 of pyrexia in such cases usually serves to negative the idea of 
 acute inflammation. 
 
 Localized tenderness, from circumscribed peritonitis, is found 
 particularly over the caecum (perityphlitis), and in the neigh- 
 borhood of the uterus (perimetritis, pelvi-peritonitis, etc.). Oc- 
 casionally a localized peritonitis, particularly over the liver, 
 is found associated with Bright's disease, syphilis, and other 
 depraved states ; and a localized peritonitis is said to be some- 
 times produced by embolic lesions in the spleen. A peri- 
 tonitis beginning as a localized or circumscribed affection may 
 suddenly become general. 
 
 Localized tenderness, however, may likewise be due to 
 various affections of the abdominal organs themselves apart 
 from peritonitis : we aim at determining the site of the ten- 
 derness in relation to the organs, and at discovering any alter- 
 ations in the size, position, shape, or density of the viscera in 
 question. (Congestion and cancer of the liver, cancer, inflam- 
 mation, or ulceration of the stomach, dilatation of the gall- 
 bladder, calculous affections of the liver and kidneys, inflam- 
 mations, dilatations, and displacements of the kidneys, disease 
 of the suprarenal capsules, inflammations of the ovaries, 
 uterus, or bladder, and aortic or other forms of abdominal 
 aneurisms, may be mentioned in this connection.) 
 
 Colic — spasmodic and painful contraction of the bowel^ 
 often produces pain quite as great as that of peritonitis : the 
 parts, however, are seldom very tender ; pressure, indeed, may 
 relieve the pain : the temperature, moreover, is usually nat- 
 ural. In severe persistent colic, associated with constipation, 
 the question of lead poisoning should be considered. In an 
 attack of abdominal pain, Avith constipation and vomiting, 
 even when no local tenderness or tumor is complained of, the 
 hernial regions should be carefully examined, at least, in 
 
412 DISORDEES OF THE DIGESTIVE SYSTEM. 
 
 patients of whose history we are ignorant, and the question of 
 hernia, internal strangulation, invagination, etc., must be 
 considered before resorting to energetic cathartics. 
 
 Abdominal pains, apart from any evidence of peritonitis, 
 intestinal obstruction, or inflammations of the viscera, some- 
 times occur in such a form as to lead to the diagnosis of 
 abdominal neuralgia, but this must always be accepted with 
 the greatest reserve. Affections of the mesenteric glands 
 (tubercular and malignant) are often associated with severe 
 pain of obscure origin, and old adhesions of the intestines may 
 give rise to pain appearing at particular times in connection 
 probably with the varying position of the bowel, without any 
 recent inflammation. Neuralgic pains referred to the region 
 of the groin are often due to uterine disorders. In chronic 
 peritonitis the pain varies much in severity ; there may be 
 extensive disease of this kind without any remarkable pain or 
 tenderness having ever been noticed by the patient ; variations 
 in the severity of the pains in such cases depend probably, in 
 part, on the dragging of adhesions, as just described, occurring 
 particularly in connection with vomiting, with the movements 
 of the bowels, distention of the intestines, etc. ; fresh attacks 
 of acute inflammation, supervening in chronic peritonitis, may 
 sometimes be recognized by the pains being associated with a 
 special local tenderness, and with an elevation of the general 
 temperature. 
 
 Abscesses and tumors, especially aneurisms of the aorta, and 
 malignant disease of the abdominal organs, or affections of the 
 bones, often cause severe abdominal pains during the early 
 stages at which their existence cannot be recognized by the 
 most careful physical examination. 
 
 Pains associated with defecation are of various kinds. When 
 there is only slight pain just before the bowels act, passing 
 away soon after the motion, it is of but little consequence : 
 this is very common, especially in all forms of looseness of the 
 bowels, and in connection with the action of many purgatives. 
 When the pains are more severe, of a griping character, and 
 fre(|uently recuriing, considerable importance is to be attached 
 to them. Looseness of the bowels with such pains often pro- 
 ceeds from the irritation set up by improper or undigested 
 food, fruit, etc.; in dysenteric diarrhoea and dysentery, the 
 pains accompanying defecation are, as a rule, of a more strain- 
 ing character, and the sense of the bowel not being properly 
 relieved is usually very marked (tenesmus). 
 
 Painful defecation, with constii)ation, is commonly due to 
 
APPEARANCE OF MOTIONS. 413 
 
 the size and hardness of the fecal masses being such as to give 
 rise to pain from this alone ; the masses are sometimes so hard 
 or so large, and the rectum so much paralyzed, that even 
 painful forcing with the abdominal muscles fails to dislodge 
 the feces, and they have to be softened by enemata, or even 
 scooped out mechanically. AYith hard masses of this descrip- 
 tion any tender parts of the rectum and anus are apt to be 
 rendered exquisitely painful. Inflamed piles, fissures of the 
 anus, prolapse of the rectum, fistula, and various forms of 
 stricture, inflammation, ulceration, or excoriation of the parts 
 may be mentioned as common causes of exquisitely painful 
 defecation ; a careful examination of the parts is often neces- 
 sary to avoid serious mistakes. 
 
 Appearance of Motions. — The motions should be examined as to 
 several points ; the most important of these will now be considered. 
 
 Consistency: we ascertain whether the motions are "formed" — that 
 is, possess the cylindrical shape of the bowel; the diameter of the 
 pieces of fecal matter is of importance in the diagnosis of stricture of 
 the lower bowel, as in certain cases they are found to be very narrow, 
 or perhaps flattened and ribband-like. Somewhat globular masses of 
 various sizes, usually hard and dry (scybala), are often found in cases 
 of constipation ; such pieces have lost much of the moisture and gas 
 naturally contained in feces, from their being long retained in the 
 pouches of the large bowel. Feces long retained often fail to float in 
 water, on account of this loss of gas. If the motion be not " formed," 
 it should be described as to whether it has the consistence of a thick 
 or a thin pultaceous mass, or whether it is chiefly fluid, with a few 
 solid masses interspersed. Fluid motions are often described as resem- 
 bling "pea soup" (enteric fever); "rice water" (cholera); or the 
 " scrapings of meat " (dysentery) ; etc. 
 
 The color of the motio7is is sometimes described simply by the terms ■ 
 dark, light, green, black, etc. Occasionally it is indicated by refer- 
 ence to the cause of the color; thus we speak of much bile or little 
 bile being present. The natural color of the motions is derived from 
 the biliary coloring matter; whitish or "clay-like " motions are found 
 when there is an absence or a diminution of bile. 
 
 Blood — Melcena. — Black tnotions from altered blood are found when 
 blood is mixed with the motions in such proportions and at such parts 
 of the digestive tract as to be acted on by the gastric and intestinal 
 secretions, as in gastric and intestinal ulceration, and some forms of 
 hemorrhage from portal obstruction. When the hemorrhage is large, 
 from whatever cause this may arise, the blood preserves much more 
 of its usual color. When the bleeding is from piles, fistula, polypus, 
 and cancer of the rectum, or from other lesions of the lower bowel, 
 the blood in the motions usually retains its typical appearance as 
 blood, with more or less of a florid color. 
 
 Black motions are not at once to be presumed to derive their color 
 from altered blood, as various medicines render the motions dark, 
 particularly iron, bismuth, and charcoal, and, to a less extent, lead, 
 
 35^ 
 
414 DISOKDEES OF TPIE DIGESTIVE SYSTEM, 
 
 copper, tannic acid, logwood, and some others ; as logwood stains 
 babies' napkins, attention is sometimes called to this peculiarity. 
 Mercurial purgatives often render the motions darker, but this is 
 partly owing, no doubt, to their being thus rendered more bilious. 
 Motions with what looks like unmixed and unaltered bile (a greenish, 
 yellowish, glairy fluid) are occasionally seen. 
 
 Green ^notions are common in infantile diarrhoea ; they may persist 
 for a considerable time after the diarrhoea has been checked ; motions 
 passed with a yellow color sometimes change their appearance, so that 
 napkins with yellow motions originally may be green after the lapse 
 of some hours when produced by the nurse for inspection. Some- 
 times the motions are almost white, r\ot unlike boiled bread and milk. 
 In children the motions often present a white cw'dy appearance and 
 possess a sourish smell, and not unfrequently undigested masses of 
 curdled milk are found mixed up with the feculent matter. 
 
 Mucus is passed in large quantity in some cases of invagination of 
 the bowel — large quantities of glairy, clear, gum-like material coming 
 away with little or no fecal matter. Such mucus may be colored with 
 a little blood, or associated with large quantities of it. Mucus, usu- 
 ally of a less transparent kind, is found more or less in cases of dys- 
 entery, and in such cases a little bloody mucus may constitute the 
 whole of a motion, voided with a feeling of great urgency, and passed 
 with much pain and straining. Other forms of mucous discharge, 
 consisting of more opaque yellowish flakes and shreds, are passed in 
 cases of catarrh of the bowel, and considerable casts of parts of the 
 intestinal tract are voided in certain cases of so-called "mucous dis- 
 ease." 
 
 Shreds of mucus are often spoken of by patients as "skins," and 
 are sometimes confounded by them with portions of disintegrated 
 worms. 
 
 Pus in the motions may proceed from various aff'ections of the lower 
 bowel just named in connection with bleeding from the same situation 
 (see p. 413), and some admixture of pus is common in dysenteric 
 motions and in the aftection referred to as intestinal catarrh. Inflam- 
 mations of the csecum sometimes .lesult in the discharge of pus from 
 the bowels. 
 
 Various abscesses open into the bowel, and may thus give a whitish 
 coating to the feces, or furnish a considerable quantity of pus. Of 
 these the most common are pelvic abscesses, connected with child- 
 birth, or aff'ections of the womb ; but abscesses arising from the kidney 
 and other organs in the abdomen, and even psoas abscesses, occasion- 
 ally burst into the bowel. Abscess of the prostate usually opens in 
 this way. Sometimes a cancerous tumor breaking down presents 
 something like a purulent deposit in the feces. Portions of bowel 
 which have sloughed may also be voided with the motions, usually, 
 however, in a gangrenous or disintegrated state. This occurs in cer- 
 tain cases of recovery from invagination of the bowel. 
 
 Worms are usually seen quite readily if the motions are examined 
 at all, at least in the case of round worms (ascaris iumbricoides), and 
 tapeworms (tcenice of various kinds). Thread worms {oxyurides) , 
 however, require to be looked for more closely as they are small. 
 Their movements, when expelled alive, assist in their recognition. 
 (See Figs. 61 and 62.) The mere statement of patients as to the pres- 
 
APPEAKANCE OF MOTIONS. 
 
 415 
 
 ence of worms should be received with caution ; they must he made 
 to describe the appearances seen, and, if possible, fragments of tape- 
 worms should be brought for examination, and directions should be 
 given for the narrow parts to be specially looked for and preserved for 
 scrutiny, to see if the head of the parasite is included in the mass. 
 
 Fig. 62. 
 A B 
 
 Fig. 61, 
 
 Oxyurides vermiculares. Female, natural 
 size. (After Davaine.) 
 
 Oxyurides vermiculares, magnified five times. 
 A. Male ; B. Female. (Leuckart.) 
 
 The different kinds of tcenia may be recognized by the appearance 
 of the head, and by the microscopic examination of the proglottides 
 with regard to the arrangement of the passages in the uterus, with 
 the ova, etc. For this purpose one or two of the large segments are 
 placed on a microscopic slide to dry (after immersion in strong spirit) 
 so as to be rendered transparent. The tcenia solium and the tcenia 
 medio caneUata are the only tapeworms common in this country. (See 
 Figs. 63-67.) Bothriocephalus latus is another variety of tapeworm, 
 characterized by the presence of two deep depressions — one on each 
 side of the head — instead of the suckers as in those figured here. 
 
 Round worms resemble earth-worms in general appearance, although 
 paler in color. The female worm is usually about the length of the 
 page of this book, and the male is considerably smaller (400 mm. and 
 250 mm. respectively as a maximum). When dry, however, they 
 shrivel up to some extent. 
 
 Portions of hydatids are sometimes expelled with the motions. Any 
 little cysts resembling these should be preserved for further examina- 
 tion. (See Fig. 72, Chapter XII.) 
 
 Fatty m^atter is occasionally found in the motions in large quantity ; 
 it has been noticed in certain cases of disease of the pancreas. Smaller 
 quantities of oily material may be passed from the inability of the 
 patient to digest or absorb the fat in the food or the oil administered 
 as medicine. 
 
 Gall-stones must be searched for in the way described elsewhere 
 (see " Jaundice," p. 427) when the discovery of them is important. 
 We must accept the statement of patients as to passing gall-stones 
 with great reserve, unless they can be produced, or unless they have 
 
416 DISORDEKS OF THE DIGESTIVE SYSTEM 
 
 Fig. 63. 
 
 Fig. 64. 
 
 TsBTiia mediocanellata, Datiiral size, 
 showing the differeut size and shape of 
 the segments in the various parts. (The 
 tsenia solium resembles this in general 
 appearance ; for distinctions see Figs. 01- 
 67.) (Leuckart.) 
 
 m 
 
 ■J? 
 
 .?^s 
 
 Proglottides of the 
 isenia solium, magni- 
 fied twice, showing ar- 
 rangement of the 
 uterus. (Leuckart.) 
 
 Fig. 65. 
 
 Proglottis of tienia 
 viediocanellata, magni- 
 fied, showing the ar- 
 rangement of the 
 uterus (Leuckart.) 
 
CONSTIPATION AND DIARRHOEA. 
 
 417 
 
 been found in the way described, as hardened feces and intestinal con- 
 cretions are sometimes mistaken for them. 
 
 Fig. 66. 
 
 Head of tsenia solium, armed with 
 a circle of booklets, showing two of 
 the foi;r suckers. (Dr. Cobbold.) 
 
 Head of txnia mediocanellata (not 
 armed with booklets , showing two of 
 the four suckers. (Drawn by Dr. 
 John "Wilson.) 
 
 Bones, coins, artificial teeth, and various otber things, swallowed by 
 accident, are often found in the motions after very variable periods, 
 extending sometimes to several months, after the accident. Such 
 articles are often more or less corroded by the digestive fluids ; any 
 animal matters in the article are usually greatly diminished in bulk, 
 or even quite absent. The metallic parts acted on may have caused 
 discoloration of the motions during the period the article was re- 
 tained. 
 
 The smell of the stools is sometimes particularly oflfensive, and special 
 odors can sometimes be recognized as peculiar to certain conditions, 
 but they are not easily described. Amongst the most offensive are 
 dysenteric motions, and the motions in certain forms and stages of 
 enteric fever. In the diarrhoea of children the milk sometimes under- 
 goes a peculiarly offensive decomposition, controlled in certain cases 
 by the previous boiling of the milk. In jaundice also the motions are 
 often very disgusting, and in some cases of gastric and biliary derange- 
 ment. Sourness can often be recognized as characterizing the motions 
 of children, and such motions are often distinctly curdy. The odor 
 of sulphuretted hydrogen, present in natural feces to a variable extent 
 according to the nature of the food, is extremely marked during the 
 internal use of sulphur and some of its compounds. Other medicines 
 may also communicate their special odor to the stools. 
 
 The cliniGal significance of constipation and diarrhoea varies 
 extremely. Slight indications have been inserted in enumer- 
 
418 DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 ating the different symptoms, and the following hints are now 
 added. 
 
 Constipation is extremely common in its slighter forms, in 
 connection with disorders of digestion, especially such as pro- 
 ceed from nervous causes, worry of business, irregularity in 
 habits, etc. But similar causes lead in some subjects to diar- 
 rhoea. Alternations of constipation and diarrhoea are common 
 in certain forms of gastro-intestinal disorder, and are met with 
 even in dysentery and enteric fever. Occasionally also the 
 constipation usual in cancerous obstruction of the rectum is 
 varied by an intercurrent profuse diarrhoea. A constipated 
 state of the bowels is habitual at the beginning of many febrile 
 disorders. Pretty obstinate constipation is so frequent at the 
 beginning of meningitis as to afford an important indication 
 of its onset. Occasionally a preexisting diarrhoea is replaced 
 by constipation on the supervention of meningitis. Constipa- 
 tion when protracted, especially when associated with vomit- 
 ing or hiccup, and abdominal pain and swelling, should always 
 dictate the necessity of examining for hernial strangulation, 
 even in the less usual situations, or for considering the ques- 
 tion of internal obstruction in its various forms, or of invagi- 
 nation of the bowel. The occurrence of visible peristalsis, and 
 loud rumbling or gurgling noises, indicate mechanical obstruc- 
 tion : in such cases an examination of the rectum by the finger 
 is usually called for in the diagnosis. Chronic peritonitis 
 sometimes leads to similar symptoms. Paralysis of spinal 
 origin occasionally gives rise to constipation of such an obsti- 
 nate character as to suggest the idea of obstruction. 
 
 Diarrhoea attends certain febrile states, apart from any 
 specific intestinal affection, being induced in some way by the 
 pyrexial state, or the ])oisoned condition of the blood, and per- 
 haps by the inability of the patient to digest the food taken 
 in, especially if overfed with rich animal soups. Even in 
 healthy subjects, indigestible or undigested food gives rise to 
 looseness of the bowels, usually associated with griping pains. 
 Poisonous substances often produce severe diarrhoea. In addi- 
 tion to the well-known cathartics and the irritant poisons, cer- 
 tain forms of shell-fish and the flesh of animals in certain states 
 of decomposition may be mentioned, and special changes from 
 the preparation of the food, occurring at times in sausages, 
 pies, etc. The influence of impure water, the leaking of sew- 
 age pipes, the emanations from foul drains, and the climatic 
 and other influences which lead to dysentery may be men- 
 tioned in this connection. Cholera in its epidemic form, and 
 
THE TEETH AND GUMS. 419 
 
 in the less severe forms known as British or autumnal cholera, 
 and cholera infantum, may likewise be referj-ed to in this 
 group. The scarlatinal poison sometimes manifests its early- 
 presence by a violent diarrhoea, especially in malignant cases; 
 measles also is liable to this complication. The spontaneous 
 looseness seen in certain stages of uraemia and in puerperal 
 fever may be referred to a similar cause. Enteric fever (with 
 its intestinal lesion) presents an intermediate form between 
 the foregoing and those cases of diarrhoea which owe their 
 origin to local causes, as tubercular, catarrhal, or dysenteric 
 ulceration of the bowels. Peritonitis frequently gives rise to 
 severe forms of diarrhoea ; but in many other cases there is 
 constipatiou. 
 
 The presence or absence of the various concomitant symp- 
 toms, and the results of the physical exploration of the ab- 
 domen, must be relied on for the differentiation of these forms. 
 
 The Teeth axd Gums. 
 
 An examination of the teeth affords evidence in many cases 
 of certain constitutional states, as well as of various local 
 sources of disturbance. The number of teeth differs in the 
 first and the second dentition. The age of young persons can 
 sometimes be estimated from the state of the dental develop- 
 ment. 
 
 FORMULA OF THE MILK TEETH. 
 
 M, C, I, C, M, ] . 
 
 — — - — ^20 in all. 
 
 M, C, I, C, M, J 
 
 The order of their appearance varies somewhat. As a rule, the 
 lower central incisors appear first, then the upper central incisors, and 
 then the lower lateral incisors. The following may be given as the 
 usual order and date of their appearance : 
 
 Central incisors, about the 7th month. 
 Lateral incisors, " 9th " 
 
 First molars, " 15th " 
 
 Canines, " ISth " 
 
 Second molars, " 24th " 
 
 The order, however, is sometimes different ; the date of the 
 appearance is sometimes earlier, and often much later than 
 appears above. The process goes on by little starts, with dis- 
 tinct intervals or pauses between. 
 
 Disorders of Dentition. — Lateness in dentition often arises 
 from the constitutional derangement known as rickets ; the dis- 
 
420 DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 turbances of digestion, and of the general health, arising from 
 this cause, are often ascribed erroneously to the ills of teething. 
 But although the first teeth have appeared at the usual time 
 the rickety state may really exist, and from this cause, or from 
 the occurrence of attacks of illness, the normal progress of the 
 dentition may be arrested or delayed for a time. Precocious 
 cutting of the early teeth is often followed by delays in the 
 subsequent ones. 
 
 During the process of teething the infant has usually a great 
 increase in the amount of the saliva. Various disturbances of 
 the health, especially diarrhoea, cutaneous eruptions, and con- 
 vulsions, are ascribed by the public to this process, particularly 
 when the dentition is delayed or irregular in its course ; but 
 these illnesses are often due to disorders produced by the use 
 of artificial food which is frequently begun at the teething 
 time ; or they may be due to rickets or to some other vice in 
 the constitution of the infant. The advance of the teeth is 
 characterized at times by great tenderness over the gums ; in 
 other cases the rubbing or squeezing of the gums seems to 
 afford relief or satisfaction. The prominence of the gum over 
 an advancing tooth often gives quite a fallacious idea of its 
 nearness to the surface. Such appearances may come and go 
 more than once before the tooth comes through. We can 
 seldom safely predict the speedy cutting of a tooth unless the 
 sharp edge be felt just under the gum. Any unusual heat of 
 the mouth, any increase in the salivation, and any little ulcera- 
 tions of the gums should be noticed in connection with the 
 teething process. 
 
 In bad forms of rickets and syphilis the teeth may never 
 appear at all, and in other cases the milk teeth often rot 
 away or drop out prematurely. This loss also happens occa- 
 sionally in other cases, from gastric disorders. Various medi- 
 cines are sometimes blamed for destroying the teeth (mercury, 
 iron). 
 
 The second dentition begins with the appearance of the 
 first permanent molars; this precedes the shedding of the 
 twenty milk teeth, which begin then to fall out in succession. 
 
 FORMULA OF THE PERMANENT TEETH. 
 M3 B^ Q, I, Ci \\ ^\, 
 
 M3 13, C, I, Ci B, M, 
 
 32 in all. 
 
MALFORMATIOK OF PERMANENT TEETH. 421 
 
 The order in which they make their appearance may be thus stated : 
 
 Anterior molars, at the 7th year. 
 
 Central incisors, " 8th " 
 
 Lateral incisors, " 9th " 
 
 Anterior bicuspids, " 10th " 
 
 Posterior bicuspids, " 11th " 
 
 Canines, " 12th " 
 
 Second molars, " 12th to 14th year. 
 
 Third molars, " 18th to 25th " 
 
 The eruption of the permanent teeth seldom gives rise to 
 much local or constitutional disturbance, except in the case of 
 the " wisdom teeth ; " considerable pain and swelling some- 
 times appear in connection with the cutting of the last molars, 
 in the lower jaw in particular. 
 
 The shape and appearance of the teeth sometimes afford im- 
 portant indications. Transverse grooves and slight pitting on 
 their surface are supposed by some to indicate a scrofulous 
 constitution, or at least the occurrence of some previous 
 derangement in the health. 
 
 The notched teeth described by Hutchinson afford important 
 evidence of congenital syphilis. They often occur in those 
 affected with syphilitic keratitis or with nervous deafness and 
 other manifestations of the inherited disease. The deformity 
 affects the upper central incisors most frequently p^nd most 
 distinctly, although the other incisors and the canines may 
 also be affected. The upper central incisors, in a typical 
 case, are dwarfed both in their length and breadth ; the 
 atrophy affects the middle lobe, giving rise to a central notch 
 at its edge ; sometimes from this notch there may be traced a 
 shallow groove both before and behind. These changes are 
 
 Fig. 68. 
 
 Notched teetli. Malformation of permaueut teeth fuunci in hereditary syphilis. 
 (Mr. Jonathan Hutchinson.) 
 
 not always present in hereditary syphilis ; they are only of 
 value as signs in the case of the permanent teeth. After a 
 time the depth of the notch may be lessened through the 
 weariug down of the edge, but the deformity can usually be 
 detected even then. (See Fig. 68.) 
 
 36 
 
422 DISOKDERS OF THE DIGESTIVE ORGANS. 
 
 Caries of the teeth occurs from causes not fully known, but 
 the lingering of acescent fluids about the teeth, arising from 
 the decomposition of particles of food in the mouth, seems to 
 favor this destruction. Caries is frequent in cases of chronic 
 dyspepsia. This affection of the teeth sometimes accounts for 
 the fetor of the breath which may be noticed ; this might be 
 erroneously ascribed to disorder of the stomach, etc. The 
 condition of the teeth has important bearings, likewise, on 
 the diagnosis of facial neuralgia, pains in the ears, affections 
 of the eyes, etc. ; the pain sometimes radiates from the teeth, 
 not only all over the face, but even down to the neck. For 
 a proper examination of the teeth in this respect the assistance 
 of the dentist is often essential, but in the absence of this we 
 may learn something from detecting some special tooth, ob- 
 viously rotten, or with an exposed pulp, which gives rise to 
 sharp pain on ^ pressing it or probing it. In a diffused facial 
 neuralgia, from any cause, we must remember that the teeth 
 also may participate in the general suffering, so that we must 
 search for a local and specialized tenderness of one or two 
 teeth in particular. Neuralgia seems sometimes to be set up 
 by the extraction of a tooth — the pain being recognized by 
 the patient as different from that of the previous caries. 
 
 The rottenness or the absence of the teeth may throw im- 
 portant light on dyspeptic disorders, or even on the imperfect 
 nutrition of a patient. Defects in the teeth often seriously pre- 
 vent the due trituration of the food necessary for its proper 
 digestion and assimilation. 
 
 Falling out of the teeth occurs in connection with mercurial 
 salivation, and also in connection with scurvy. The earliest 
 signs of these affections, however, appear in the gums. The 
 teeth also fall out in certain cases of destructive ulceration 
 involving the gums (noma). The milk teeth often rot and fall 
 out prematurely in rickets and syphilis. 
 
 Grinding the teeth is almost habitual in certain children, and 
 it readily occurs in others when the stomach and digestion are 
 out of order. Its presence, therefore, is not to be ascribed at 
 once to the irritation of worms, although this is a prevalent 
 popular opinion. No doubt, however, it is frequently jiresent 
 in such cases. In smallpox and some other febrile diseases in 
 childhood grinding of the teeth is an unfavorable indication. 
 Although commonest in childhood this symptom is not un- 
 known in adults. 
 
 The gums are often spongy and their edges ragged and 
 irregular in those whose teeth are bad and neglected, and 
 
INFLAMMATION OF GUMS. 423 
 
 when the tartar is very abundant. When these causes of 
 irritation exist the indications from the gums are not so 
 valuable. 
 
 Sivelling of the gums, with slight tenderness, constitutes one 
 of the earliest indications of the action of mercury. The 
 special fetor of the breath due to mercury and the occurrence 
 of salivation also help the diagnosis. This influence is pro- 
 duced whatever may be the way in which the metal enters the 
 system. Some other metallic poisons cause something of the 
 same kind, but in a much less degree. 
 
 The blue or blackish line involving the gums, just beyond the 
 teeth, affords, when it is pronounced, a valuable indication of 
 lead poisoning. When it is present we must inquire for the 
 history of colic, and the other signs of poisoning, and ascertain 
 if any exposure to the deleterious influence of lead has arisen 
 in connection with the water supply or the occupation of the 
 patient. 
 
 A red line on the gums is regarded by some as an indication 
 of a phthisical constitution : although often present, no great 
 reliance can be placed on its indications. 
 
 Very spongy gums, with submucous hemorrhages, are com- 
 mon in scurvy ; bleeding readily arises from slight irritation 
 of the parts, and fetor of the breath is also usually present. 
 Slight forms of scurvy are not uncommon among laborers who 
 carry their food to their work, and live on tea, bread and 
 bacon, etc. Subcutaneous hemorrhages, etc., must be looked 
 for. Purj)ura likewise affects the gums, but they are seldom 
 so spongy as in scurvy, and hemorrhages sometimes arise there ; 
 these may prove serious from their persistence and the diffi- 
 culty of stopping the bleeding. 
 
 Inflammation of the gums may form part of a general affec- 
 tion of the mouth, already described (vesicular, ulcerative, and 
 gangrenous stomatitis; seep. 399). The local inflammation 
 or swelling known as " gum-boil " arises from inflammation 
 around the root of the tooth affected (periodontitis) : the tooth 
 is often felt to be tender, and sometimes to be elevated, as it 
 were, from the socket. The local disturbance, as manifested 
 by swelling, and the general inflammatory reaction are often 
 extreme : when by accident the swelling is not considerable 
 the first indication of the cause of the violent symptoms may 
 be the appearance of pus by the side of the tooth. With in- 
 flammation of the gums from any cause more or less saliva- 
 tion is frequent. 
 
 The presence of sordes on the gums and teeth in fevers, of 
 
424 DISORDERS OF THE DIGESTIVE ORGANS. 
 
 the white patches of muguet, and the discoloration of Addi- 
 son's disease, have been noticed elsewhere. (See pp. 142, 397, 
 398.) Pallor of the gums affords a valuable indication of 
 ansemia. 
 
 General treatises on medicine and special works on diseases of child- 
 hood deal with many of the subjects referred to in this chapter. For 
 details as to disorders of the rectum, anus, etc., reference must be 
 made to surgical works. See also references in Chapter XII. on 
 " Jaundice," and Chapter XVI., part 3, on the " Examination of the 
 Abdomen." — Wilson Fox, Diseases of the Stomach, 3d edition, 
 London, 1872. — Pavy (F. W.), Practical Treatise on the Function of 
 Digestion ; its Disorders and their Treatment, 2d edition, London, 
 1869. — Habershon (S. O.), On the Diseases of the Stomach; the 
 Varieties of Dyspepsia, their Diagnosis and Treatment, 3d edition, 
 London, 1879: also Pathological and Practical Observations on 
 Diseases of the Abdomen, 3d edition, London, 1878. — Chambers (T. 
 K.), The Indigestions, London, 1867. — Germain See, Des dyspepsies 
 gastro-intestinales, Paris, 1881. — Brinton (Wm.), Intestinal Obstruc- 
 tion, London, 1867. — Treves, Intestinal Obstfuction, London, 1884. 
 
 Cobbold (T. S.), Entozoa, London, 1864: and Supplement, London, 
 1869. — Davaine (C), Traite des entozoaires, et des maladies vermin- 
 euses de I'homme et des animaux domestiques, 2e edition, Paris, 1877. 
 — Leuckart (R.), Die Parasiten des Menschen, 2te Aufi., Leipzig, 
 1879-81 : a translation of this work by W. E. Hoyle is published, 
 Edinburgh, 1886. — Kiichenmeister und Zurn, Die Parasiten des 
 Menschen, 2te Aufl., Leipzig, 1880-82. 
 
 Coles, The Teeth, London, 1872. — Garretson (J. E.), System of Oral 
 Surgery, Philadelphia, 1873.— Wedl, The Pathology of the Teeth ; 
 translated by Boardman and Hitchcock, Philadelphia, 1873. — Cole- 
 man, Mani'.al of Dental Surgery and Pathology, London, 1881. — Mr. 
 Jonathan Hutchinson's description of syphilitic teeth occurs in his 
 Clinical Memoirs on certain Diseases of the Eye and Ear consequent 
 on Inherited Syphilis, London, 1863. 
 
CHAPTER XII. 
 
 JAUNDECE AXD DROPSY. 
 
 It is convenient to consider these affections together, as both 
 are frequently due to disease of the liver, and it is not un- 
 common to find both in the same patient. It must be re- 
 membered, however, that dropsy arises from various causes, 
 and may depend on diseases which have no connection with 
 jaundice or with any form of hepatic disease. 
 
 Jaundice. 
 
 When jaundice is well marked there can be no mistake 
 about its presence. The yellowness of the skin and ocular 
 conjunctiva, and the discoloration of the urine with bile, 
 present a striking and easily recognized group of symptoms. 
 Discoloration of the skin, somewhat resembling jaundice, is 
 found in certain cases of anaemia, in chlorosis, in Addison's 
 disease, a.:d in the chloasma associated with fibroid tumors 
 and other affections of the womb. Exposure to the sun and 
 weather may produce in certain complexions a tinge re- 
 sembling jaundice, and the serious disturbances of the general 
 health induced by intermittent fevers, by the presence of 
 malignant disease, and by syphilis, all resemble at times, the 
 cutaneous discoloration of jaundice. All these may usually 
 be seen to differ from the jaundiced tint on a critical examina- 
 tion ; and in nearly all these affections the whiteness of the 
 conjunctivae, which often indeed shine out with a pe&rly 
 brightness, removes the cases at once from this category. 
 The conjunctiva, however, sometimes presents a dingy yellow 
 color, apart from jaundice, this being due to the presence of 
 yellow subconjunctival fat, and this complication presents a 
 serious difficulty in determining the presence or absence of a 
 shght discoloration ; but when the color is due to this cause it 
 usually occurs in patches at special parts, and is not so evenly 
 diffused as in jaundice. 
 
 The urine comes to our aid in such doubtful cases, for it^ 
 very readily assumes the jaundiced color. The method of 
 testing for bile pigment is described in the section on urinary 
 
 36* 
 
426 JAUNDICE AND DKOPSY. 
 
 examinations. (See Chapter XIII.) No great reliance can be 
 placed on the reports of patients regarding bile in the urine, 
 as they often mistake bloody or concentrated urine for bilious 
 discoloration, and the internal use of santonin or rhubarb may 
 produce a pretty close resemblance to bilious urine. The 
 urine shows- the presence of jaundice earlier than anything 
 else, but it likewise is the first to lose the color, if the attack 
 be passing off, so that the urine may be free from bile although 
 the conjunctivae still remain really tinged with it. By watch- 
 ing the skin, the conjunctivae, and the urine, in different stages 
 of the suspected jaundice, Ave are seldom left in much doubt. 
 The urine in jaundice is often turbid from mucus, or it may 
 deposit urates : even when it does not give distinct reactions 
 on testing for albumen the sediment often contains abundance 
 of colored tube-casts. 
 
 The appearance of the stools renders much assistance in the- 
 study of jaundice, for while everything else is discolored, the 
 motions are often free from bile, presenting a paler appearance 
 than natural. This is often best described by the word 
 " clayey," But we may also have marked jaundice with much 
 bile in the feces. The pale color of the feces may thus, in 
 doubtful cases, assist the diagnosis of jaundice, but their bilious 
 color does not count for much as negativing the idea of jaun- 
 dice. The motions in jaundice are usually costive, and if long 
 retained in the bowel the feces are often highly offensive, from 
 decomposition going on within. The bile acts normally both 
 as a purgative and an antiseptic. 
 
 Obstructive and Non-obstructive Jaundice. — The 
 presence or absence of bile in the motions affords an important 
 aid in classifying the cases according as they are, or are not, 
 due to or associated with obstruction of the common bile-duct. 
 If such obstruction be the cause of the jaundice, the motions 
 are pale in proportion to the depth of the jaundice : we find, 
 as a rule, that in cases due to obstruction the jaundice is much 
 deeper than where no obstruction exists. 
 
 The obstruction may be due to something within the duct 
 itself: thus thickening of the mucous membrane in the walls, 
 or any excess of mucus, may readily give rise to the form 
 called " catarrhal : " gall-stones may block up the channel, or 
 the ducts themselves may be the seat of a malignant growth. 
 Ulcers, cicatrices, foreign bodies, and even worms have been 
 known to interfere with the opeliing of the duct into the duo- 
 denum, and catarrh or inflammation of the mucous membrane 
 of the duodenum mav likewise cause obstruction from the 
 
PEESENCE OR ABSENCE OF PAIN. 427 
 
 swelling implicating the orifice of the duct or from the extru- 
 sion upward of the catarrhal process. 
 
 But the obstruction may he due to pressure from ivlthout, by 
 a tumor (usually malignant) in the pancreas or duodenum ; 
 or by waxy, cancerous, or scrofulous glands at the fissure of 
 the liver; or, a tumor connected with the liver itself may, 
 from its position, compress the duct, as in the case of a can- 
 cerous nodule, an abscess, an aneurism, or a hydatid cyst ; 
 or again, an inflammatory exudation (perihepatitis) may by 
 its contraction constrict the duct. Abdominal tumors con- 
 nected with the kidney, ovaries, etc., may compress the bile- 
 duct and give rise to jaundice. The pregnant uterus, or fecal 
 accumulations in the bowels may likewise do so ; and hardened 
 scybala have been mistaken for cancerous nodules in cases of 
 jaundice due to such a cause. 
 
 In discriminating these causes we have regard to the size 
 and form of the liver, the presence and character of the pain 
 (if any), and the special symptoms of the various afifections 
 named, in their relation to the date of the appearance of the 
 jaundice. In cancer the liver is usually enlarged, often 
 nodular, more or less painful, and tender to the touch. The 
 occurrence of jaundice is due to the accidental position, as it 
 w^ere, of the cancerous mass, and so it may be an early or a 
 late symptom, and indeed it is often absent in hepatic cancer. 
 Malignant disease elsewhere is, of course, a strong presump- 
 tion in favor of the cancerous origin of jaundice. The j)er- 
 sistence or variability of the jaundice is important ; jaundice 
 due to the pressure of a cancerous nodule on the duct never 
 disappears after it is established ; the history of previous 
 attacks of jaundice, therefore, which have passed off", predis- 
 poses one in favor of a less serious view of the case ; but we 
 must remember that in rare cases the previous attacks may 
 have been of quite a different nature from the existing jaun- 
 dice — thus gall-stones and cancer may exist in the same case. 
 
 The CGinbination of intense jaundice and ivhite stools with 
 abdominal droj)sy at the same time may be regarded as 
 pointing to an obstruction of the duct and of the portal vein 
 by the same cause, which in such a case must be something 
 outside of both, usually a cancerous mass. Jaundice, usually 
 slighter in character, may exist along with dropsy due to 
 cirrhosis of the liver ; the jaundice in such cases is not only 
 usually slight, but bile is not completely absent from the 
 stools, unless, indeed, there be a complication from a concur- 
 rent catarrh of the ducts giving rise to obstruction ; a diminu- 
 
428 JAUKDICE ANl; DROPSY 
 
 lion of the bile in the feces may, however, be found resulting 
 from the atrophy of the cells in the liver. When there is 
 dropsy with a congested liver, from alcohol for example, the 
 motions may be highly bilious. 
 
 The presence or absence of ]xiin is an important point in 
 the study of jaundice. Pain is usually, but not always, more 
 or less present in cancer ; even in catarrhal jaundice, with 
 perhaps some congestion of the liver, there is some pain and 
 discomfort in the hepatic region. In the passage of gall- 
 stones the pain reaches a maximum ; it is very violent, par- 
 oxysmal, and often associated Avith great sickness. Such 
 paroxysms of pain may occur several times during the attack 
 of jaundice, as well as for a day or two before it appears. 
 Occasionally the jaundice is permanent, the gall-stone being 
 permanently impacted in the common bile-duct. Attacks of 
 pain and jaundice due to the passage of gall-stones are apt to 
 be repeated after an interval of months or years. We must 
 remember that it is possible to have an attack of biliary colic 
 without jaundice, from the gall-stone escaping quickly, or from 
 its only affecting the cystic duct. The detection of gall-stones 
 in the motions settles the diagnosis. In doubtful cases, where 
 there is a suspicion of cancer, these must be carefully sought 
 for. Although dried gall-stones float in water, they do not 
 come to the surface on adding water to the feces and break- 
 ing up the solid masses as is sometimes supposed. To detect 
 them we must pass all the motions through some form of 
 sieve, or through a muslin filter after pounding them suffi- 
 ciently with a stick, and the offensiveness of the process may 
 be lessened by adding previously some disinfectant, such as 
 Burnett's or Condy's fluid. If there is any doubt as to the 
 object found being a gall-stone, a portion of it may be pounded 
 and dissolved in sulphuric ether or boiling alcohol, from which 
 crystals of cholesterine are deposited. (See Fig. 73.) 
 
 Rigors occurring in jaundice point to distention of the bile- 
 ducts from the obstruction of gall-stones; or to the presence 
 of abscess of the liver ; or perhaps to the existence of pysemia, 
 of which the jaundice may be a symptom. Hemorrhages 
 from the stomach and bowels, and subcutaneous blotches occur 
 in old and severe forms of jaundice, and are due probably to 
 deterioration of the blood in cases of obstruction, or to blood- 
 poisoning or portal obstruction, in those serious cases where 
 there is no obstruction of the ducts in any form. Hemor- 
 rhages from the umbilicus occur in some grave forms of infan- 
 tile jaundice. (See p. 432.) In addition to the symptoms 
 
JAUNDICE WITHOUT OBSTRUCTION. 429 
 
 already noticed, itcliiness of the skin, yellow vision, cutaneous 
 eruptions, xanthelasma, slowness of pulse, a lowered tempera- 
 ture and impaired nutrition, are occasionally very noticeable. 
 Sometimes jaundice appears without anything else to attract 
 attention, not even squeamishness or impaired appetite. 
 Popularly, jaundice is often ascribed to a feeling of disgust 
 produced by disagreeable sights and smells, but probably in 
 such cases the incipient jaundice really makes the persom 
 more suscej^tible than usual. 
 
 Jaundice without obstruction of the ducts is still somewhat of 
 a puzzle both clinically and pathologically. Clinically the 
 proof of bile in the stools is at times rendered doubtful by 
 our knowledge that in some cases of this class there is a 
 tendency to hemorrhage, and small quantities of blood, by 
 imparting a dark color to the feces, may simulate an admix- 
 ture with bile ; some cases might thus be erroneously regarded 
 during life as free from obstruction of the ducts owing to this 
 misinterpretation of the color of the stools. Even pathologi- 
 cally the case may be misinterpreted. It is now known that 
 very slightly increased resistance to the flow of bile through 
 the ducts may lead to a practical obstruction and a tendency 
 to reabsorption of the bile, but these slight impediments may 
 be easily overcome mechanically by the pressure of the path- 
 ologist on squeezing the gall bladder ; it is even possible that 
 accidental pressure in the handling of the organs, before 
 examining the orifice of the duct, might be sufficient to force 
 on the bile into the duodenum although little or none could 
 pass during life. 
 
 There is, however, a pretty general agreement that jaundice 
 may occur, and does often occur, without obstruction. The 
 relationship of such cases to changes in the blood has often 
 been suggested and is no doubt full of significance. One 
 interesting variety of this relationship is the coincidence of 
 hsemoglobinuria with non-obstructive jaundice. We have 
 here evidence of destructive processes going on in the red 
 blood-corpuscles leading to their disintegration, so that they 
 are no longer recognizable in the urine as corpuscles, although 
 their hsemoglobin is present in abundance. In grave forms 
 of the so-called " pernicious ansemia," we have at times a true 
 jaundice or bile pigmentation, quite distinguishable from the 
 mere sallow tint of the face so common in this and various 
 other forms of anaemia. In such cases of pernicious ansemia 
 we have profound alterations in the blood with tendencies to 
 hemorrhages and other indications of grave disorder. 
 
430 JAUNDICE AND DEOPSY. 
 
 Hseraoglobinuria and jaundice of the non-obstructive variety 
 may both be induced by poisons, and they may be both found 
 together in the same case at the same time, as the result of 
 poisoning of the system in bad malarial fevers, for example. 
 As a great clinical group we may, therefore, class various 
 poisons together as active agents in producing non-obstructive 
 jaundice. Phosphorus, antimony, and arsenic, may be named 
 as well-known poisons giving rise to jaundice. More doubt- 
 fully, perhaps, chloroform and ether may be admitted as 
 occasionally doing the same. Next, we have snake-bites, 
 whose influence in causing jaundice rapidly, Avithout obstruc- 
 tion, has long been known. This animal poison forms an 
 interesting link between the ordinary poisons and the poisons 
 of the specific fevers. Thus, in relapsing fever, in typhus, 
 occasionally in scarlatina, and notably in yellow fever, we 
 may have jaundice. The so-called " epidemic jaundice" im- 
 plies by its name a relationship to the infectious diseases. 
 But we may have this form of jaundice complicating acute 
 lobar jDueumonia also, a form of disease which has such 
 numerous points of resemblance to the fevers that many are 
 disposed to class it with them. In pneumonia complicated 
 with jaundice it has often been stated that the right lung is 
 specially involved, but this is by no means invariably the 
 case, and even when it is the one implicated, the disease may 
 involve the upper lobe, so that mere contiguity of the in- 
 flammatory process to the liver has evidently but little to do 
 with the jaundice. In acute yellow atrophy of the liver 
 jaundice is a leading symptom ; the relationship of this dis- 
 ease on the one hand to phosphorus poisoning, and on the 
 other to the acute specific fevers, seems to bring it into the 
 same great group ; the student must remember, however, that 
 the female sex and the pregnant or puerperal condition, are 
 also closely connected with the etiology of this remarkable 
 disease. In these cases the jaundice is not usually very in- 
 tense, but it is persistent ; there are febrile symptoms and 
 often great nervous disturbance, the liver is usually dimin- 
 ished in bulk, but this cannot always be clearly proved by 
 percussion during life. The detection of crystals of tyrosine 
 in the urine sometimes aids the diagnosis ; these may be found 
 in the sediment of the urine as passed ; but more commonly 
 some ])re]iminary evaporation or concentration is required. 
 (See Fig. 69.;) 
 
 In advanced cirrhosis for chronic atrophy) of the liver, 
 jaundice with bile in the motions may occur : in such cases we 
 
DROPSY. 431 
 
 may have nervous symptoms and other evidences of a jDoisoning 
 of the system. Pysemic infection is another cause of non- 
 
 FiG. 69. 
 
 Crystals of tyrosine deposited spontaneously in the urine, from a case of acute yellow 
 atrophy of the liyer. (Roberts.) 
 
 obstructive jaundice readily classed with the group of poisonous 
 influences. 
 
 Another factor in the causation of jaundice is nervous dis- 
 turbance : occasionally anxiety has determined a sudden jaun- 
 dice, and the influence of the nervous system on secretion is 
 well established. 
 
 A further group of cases of jaundice without obstruction of 
 the ducts seems to dej^end on the increased secretion of bile, 
 say in cases of congestion of the liver ; or on diminished ac- 
 tivity in the processes of oxygenation, etc., by which the bile 
 is used up in the system ; or on the diminished elimination of 
 it, the result of prolonged habitual constipation. 
 
 In the study of such cases the detection of biliary acids in 
 the urine was at one time regarded as a point of great impor- 
 tance : no reliable test for these acids can be conveniently 
 applied to the urine in clinical work, and as yet the impor- 
 tance of this branch of the inquiry is not great. 
 
 Cases of jaundice essentially or originally without obstruc- 
 tion may readily become complicated or associated with catar- 
 rhal processes leading to obstruction of the ducts and absence 
 of bile from the stools. Again, even in cases due to influences 
 operating on the blood, we may have jaundice without obstruc- 
 
432 JAUNDICE AND DROPSY. 
 
 tion aggravated by an obstructive jaundice due to an impedi- 
 ment to the flow of bile from increased viscidity, this being 
 brought about by changes in the blood from which it is secreted. 
 The discussion of such subjects belongs, however, to pathology 
 rather than clinical medicine. 
 
 Ill infancy we have often a spurious jaundice due to mere 
 discoloration of the skin, for a few days after birth, without 
 any affection of the conjunctivae : pressure of the fingers on the 
 skin, by removing the congestion for the time, may help us in 
 recognizing the pure or the yellow tint underlying the colora- 
 tion referred to. A true jaundice occurs not unfrequently 
 from catarrh of the ducts, and sometimes from imperfect oxi- 
 dation of the blood, especially in the unfavorable surroundings 
 of a badly ventilated lying-in hospital. A very serious form 
 of jaundice occurs in infancy associated with an unhealthy 
 state of the umbilicus (phlebitis, peritonitis, pyaemia). Jaun- 
 dice is occasionally dependent on a congenital defect of the 
 bile-ducts : this malformation, although rare, has been known 
 to occur in several members of the same family, and has been 
 supposed to be possibly due to intrauterine syphilitic perihepa- 
 titis : this defect is sometimes associated Avith fatal hemor- 
 rhages from the umbilicus and other parts : the jaundice 
 appears within a few days of birth, and, even if otherwise 
 uncomplicated, leads to atrophy and death within a few 
 months at the furthest. 
 
 Dropsy. 
 
 Dropsy must be studied in respect of its severity, its extent 
 and distribution, the mode of its onset, and the evidence, if 
 any, of coexisting diseases, especially of disorders of the blood, 
 of disease of the heart, liver, kidneys, spleen, and ovaries, or 
 of the presence of any swellings or tumors in the abdomen or 
 chest. 
 
 Anasarca and GEdema. — When general dropsy of the 
 whole body (general anasarca) appears somewhat suddenly, 
 the common cause is renal disease (nephritis). In such cases, 
 if the attack be not too sudden and extreme, the swelling is 
 usually first noticed in the face in the morning, the patient 
 feeling his eyelids stiff and heavy, and his friends noticing a 
 degree of puffiness in the cheeks and around the orbits: this 
 often disappears after moving about for a time, the swelling 
 appearing iu the feet and ankles at night: this in its turn dis- 
 appears with rest in the horizontal posture — the fluid gravi- 
 
LOCAL DROPSY. 433 
 
 tating according to the position of the patient. To detect 
 oedema in the subcutaneous cellular tissue we press firmly and 
 steadily with the point of the finger and observe if a " pitting " 
 or dej^ression remains. We select, in slight cases, some part 
 with the resistant bone beneath to bring out this pitting more 
 easily. In extreme dropsy the loose areolar tissues of the eye- 
 lids, penis, and scrotum or vulva, become speedily distended. 
 The testing of the urine usually shows such a case to be of 
 renal origin ; pain in the loins, sickness or vomiting, headache, 
 and more or less shivering are common in acute cases. An 
 extreme pallor of the complexion is often a notable feature in 
 this form of disease. Severe renal dropsy has been known 
 to exist without albuminuria, but this is rare ; the previous 
 history of scarlet fever, etc., may assist the diagnosis in such 
 a case. 
 
 CEdema of the feet, and even of the face, closely resembling 
 renal dropsy, is found at times to be due to ansemia, the altered 
 condition of the blood predisposing to these exudations. The 
 urine should be carefully tested more than once in such cases 
 before deciding on the absence of kidney disease, as albumen 
 is temporarily absent from the urine in certain renal cases, 
 especially before breakfast. QEdema from alterations in the 
 blood occurs in connection with chloro-ansemia, and also with 
 the disorders incident to the " change of life." But the im- 
 poverishment of the blood from fevers, profuse hemorrhage, 
 severe diarrhoea, etc., may also lead to oedema, especially as in 
 such cases the organs of circulation are also usually enfeebled. 
 Chronic disease of the liver seems also at times to lead to more 
 or less general oedema of the anaemic type, no doubt from 
 changes in the blood : such forms of oedema may precede by a 
 long time the occurrence of the abdominal form of dropsy 
 more commonly due to liver disease. 
 
 CEdema beginning at the feet, and gradually invading the 
 legs, but keeping strictly to the lower limbs, or at least to the 
 lower part of the body, is usually due to some mechanical 
 imj)ediment to the circulation, either in the limbs, in the ab- 
 dominal vessels, or in the heart itself. Varicose veins, venous 
 thrombi, aneurisms, tumors, or anything pressing on the veins 
 of the limb, tumors in the pelvis, abdominal tumors generally 
 (including pregnancy), glandular enlargements (scrofulous or 
 malignant) in the neighborhood of the vena cava, and similar 
 obstructions, may all act in this way. Nearly all the forms of 
 cardiac disease lead to some impediment to the circulation, so 
 that, sooner or later, oedema of the feet is apt to appear, especi- 
 
 37 
 
434 JAUNDICE AXD DROPSY. 
 
 ally when the nutrition of the muscLilar fibres begins to fail 
 (valvular disease, enlarged, weak, and fatty hearts When 
 such dropsy works its way up to the abdomen, the increasing 
 pressure on the renal veins is apt to set up congestion of the 
 kidneys, and this complication may cause the dropsy to assume 
 the character of general anasarca. Allied to this oedema from 
 mechanical impediment or feeble circulation is the swelling of 
 the feet so often seen in the case of old people, and in many 
 exhausting diseases, especially before death. Chronic renal 
 disease, however, may also give rise to dropsy limited for a 
 long time to the lower limbs. 
 
 Oedema of the upper p>art of the body may be but part of a 
 general dropsy, specially appearing in the dependent parts of 
 the trunk, or in either arm, according to the accident of 
 position : careful observation and inquiry as to the posture of 
 the patient immediately prior to our visit may explain the 
 variations in such cases. Oedema limited to the chest, arms, 
 neck, or face, points to some mechanical obstruction to the 
 circulation within the chest, giving rise probably to pressure 
 on the veins. Tumors in the mediastinum, especially aneu- 
 risms, cancers, and glandular swellings (lymphadenoma), 
 must be remembered in this connection. Obstructions in the 
 lungs, as in bad forms of emphysema, with engorgement of 
 the right side of the heart and the veins of the neck, may also 
 determine a swollen state of the face. For similar reasons 
 violent paroxysms of coughing, especially in pertussis, may 
 lead to swelling of the face resembling oedema. The discrimi- 
 nation of these causes must be sought for by physical signs 
 and the other symptoms. 
 
 Localized dropsical swellings are usually due to local influ- 
 ences. The effect of posture has already been referred to, as 
 well as the position of a tumor pressing on special veins. In 
 addition to these, the existence of venous thrombosis is a fruit- 
 ful source of such dropsies, and this may readily concur with 
 depraved states of the blood and feeble or disordered circula- 
 tion giving rise to a more general oedema likewise. 
 
 Another form of oedema found in young children, affecting 
 chiefly the dorsum of the hands and feet, but occasionally extend- 
 ing to the legs also differs from that usually seen in adults in 
 that it does not pit on pressure; the swelling is firm and the 
 skin drawn tightly over it. This condition is met with in 
 various wasting diseases, chiefly chronic diarrhoea, and in con- 
 nection with carpo-pedal spasms : it always serves to indicate 
 a serious derangement of the strength, but is not necessarily 
 
FLUID IN THE PE KIT ONEU M . 435 
 
 of fatal import : it is seldom or never associated with albumi- 
 nuria, and seems to belong rather to the class of ansemic drop- 
 sies. Allied to this state, with, however, greater hardness 
 and tightness of the skin, is the condition described by Under- 
 Avood as " hide-bound," and by the French writers as " sde- 
 rhne,^^ or " induration of the cellular tissue," often associated 
 with great depression of the strength, and a lowering of the 
 general temperature. 
 
 Myxoedema, a name applied to oedema of mucus- or jelly-like 
 consistence, may closely resemble renal dropsy, particularly 
 as the face is usually very pallid as well as dry and bloated. 
 The swelling, however, shows little tendency to gravitate to 
 the lower parts, and it is too firm and resilient to pit on pres- 
 sure. The swelling extends to all parts of the body and often 
 affects the sides of the neck above the clavicles, in a notable 
 manner. The features become coarse and the hands " spade- 
 like." The thyroid is sometimes much diminished in size. 
 With the advance of the disease the mental operations become 
 very slow, the whole aspect torpid, and the temj^er rather 
 sullen. Toward the end of the case a regular oedema may 
 supervene on the other swelling. The diagnosis turns on the 
 absence of albumen from the urine, on the occurrence of this 
 disease in adult women, and on the progressive changes in the 
 direction already indicated. 
 
 Abdominal JDropsy is of three kinds : fluid in the cellular 
 tissue of the abdominal walls ; fluid within the peritoneal 
 cavity ; fluid withiu some cyst in the abdomen, usually of the 
 ovary, but occasionally of the kidney, liver, or other parts. 
 
 (Edema of the abdominal parietes is sometimes so consider- 
 able as to suggest the presence of fluid in the peritoneum, with 
 which indeed it is often associated. It may be due to the 
 causes producing general dropsy, as already detailed, but when 
 it seems unduly great in this situation there is usually some 
 local obstruction to the return of blood from the veins of this 
 region. This oedema is discriminated from ascites by the test 
 of " pitting," and in applpng the pressure we avail ourselves 
 of the tissues over the lower ribs, or over the ilium and 
 sacrum, when the parietes in front yield so much as to make 
 the demonstration difficult. This oedema changes somewhat 
 with position, not immediately, as in the case of fluid freely 
 movable in the peritoneum, but only after the lapse of some 
 time. 
 
 Fluid in the peritoneum — ascites — may be of inflammatory- 
 origin (peritonitis with effiision, including tubercular, or even 
 
436 
 
 JAUNDICE AND DKOPSY. 
 
 cancerous peritonitis) ; or it may be purely dropsical in its 
 nature (hyclro-peritoneum). In the former case, the fluid is 
 sometimes partially retained in the meshes of the inflamma- 
 tory exudations, or hemmed in by adhesions, so that it does 
 not move freely with changes in the position of the patient ; 
 but, as a rule, all cases with much fluid in the peritoneum can 
 be tested in this way, and the level of the fluid, seeking the 
 most dependent parts, can be marked out by percussion. The 
 
 Fig. 70. 
 
 The shadiug indicates the position of the percussion-chdness in a case of ascites, while the 
 patient is lying on the hack, the fluid falling to the low levels in the flanks, and the 
 umhilical region remaining clear. 
 
 intestines, unless bound down by adhesions, float up toward 
 the umbilicus when the patient lies on his back, giving a reso- 
 nant note on percussion there ; but if the fluid accumulation 
 be great, even this region may be dull, only a small area in 
 the epigastrium yielding a clear sound. In the flanks and 
 hypogastric region, there is often a fulness or bulging, and the 
 percussion note is dull when the patient lies on the back, from 
 the presence of the fluid there, as these regions are then the 
 lowest; but if this level be marked, and the patient be turned 
 quite round, first to the right side and then to the left, the area 
 of dulncss will be found to change completely if it be due to 
 fluid freely movable in the peritoneum — first the one flank 
 and then the other becoming resonant, and the dulness shifting 
 at the same time to the parts formerly clear. Certain difiicul- 
 ties beset this test. Occasionally, as already stated, the fluid 
 and the bowels may be hampered in their movements, and so 
 the changes may be less definite. Moreover, when the amount 
 
TEST FOR A.SCITES. 437 
 
 of fluid is small, we may be unable to distiuguish the dulness 
 in the flanks in the midst of the resonance from the over- 
 distention of the abdominal wall due to the accumulation of 
 gas in the intestines, which is so common in abdominal dropsy. 
 OEdemaof the integuments often interposes an insurmountable 
 barrier to the detection of slight ascites. Sometimes by press- 
 ing away the oedema from a portion of the flank, or by getting 
 the patient to lie for a long time on one side, we may be able 
 to get quit of this complication and ascertain the state of the 
 deeper parts. The condition of the abdominal viscera, a loaded 
 colon, an enlarged liver or spleen ; the presence of a tumor, of 
 the gravid uterus, of an ovarian, an omental, or some other 
 cyst, may all give an area of less movable dulness, and impair 
 in this way the value of the test by change of posture : most 
 of these complications usually exist only, or chiefly, on one 
 side, and by dij^ping the hand down through the peritoneal 
 fluid we can occasionally ascertain the presence of a tumor, 
 and so make allowance for it. 
 
 When the quantity of fluid in the peritoneum is small, we 
 can sometimes recognize its presence best by placing the patient 
 on his elbows and knees : the umbilical region, quite resonant 
 during examination in the recumbent posture, may then be 
 found to give a dull note in this altered position, while the 
 flanks formerly dull now become resonant on percussion. 
 
 Another test for ascites is the detection of fluctuation. The 
 flat hand is placed on the side of the abdomen, and with the 
 fingers of the other a sharp tap is directed perpendicularly to 
 the abdominal walls on the other side, when a distinct wave is 
 often both seen and felt. This sign varies much in distinctness 
 in different cases. It is scarcely available except in pretty 
 considerable dropsy. When the umbilical ring is protruded, 
 as is usually the case in extreme ascites, this fluctuation is often 
 well felt by placing the finger there. This sign of fluctuation 
 may be obtained in the various forms of fluid accumulation in 
 the abdomen, and is not limited to ascites. Even the presence 
 of much fat in the belly may give us a certain degree of fluc- 
 tuation, very likely from its almost fluid condition at the tem- 
 perature of the body. An attempt is sometimes made to 
 intercept the wave from this cause by getting some one to 
 press the abdominal wall with the edge of the hand during 
 the application of the test, as this is sometimes found to arrest 
 the wave-like movement transmitted through fat in the abdom- 
 inal walls. Again, when there is great flatulent distention of 
 the intestines, with tense abdominal walls, as in many cases of 
 
 37* 
 
438 
 
 JAUNDICE AND DROPSY. 
 
 rickets, a feeling closely resembling fluctuation is sometimes 
 transmitted by the air-filled viscera, without the presence of 
 any fluid at all. Of course, the test by j^ercussion comes here 
 to our aid (it may be said, however, in passing that if the bowel 
 be greatly distended with air it may give a dull note : this 
 happens occasionally in intestinal strangulation). A greatly 
 distended bladder sometimes simulates peritoneal fluid, so 
 that it is often wise to empty the bladder by the catheter 
 before deciding finally on the nature of the fluid accumulation 
 or resorting to paracentesis : in the case of women, a long flex- 
 ible catheter should be used, as a silver female catheter might 
 not pass through the elongated neck of the bladder. The 
 mere fact of a patient having recently passed urine, does not 
 always remove the necessity of using the catheter in doubtful 
 cases. 
 
 Cystic drojjsy of the ovaries and other forms of cystic disease 
 often resemble ascites, and they occasionally exist along with 
 it. Ovarian dropsy, in its early stages at least, usually affects 
 
 Pig. 71. 
 
 Position of an ovarian tumor of the right side, in various stages of enlargement. The 
 shading indicates the percussion-dulness in ovarian dropsy of moderate extent: tho umbilical 
 region is dull, from the presence of fluid, and the flanks remain clear. The outer circle 
 shows a further extent to which the dulness may reach in ovarian dropsy. (Bright.) 
 
 one side more than the other, and so the distention is not 
 always symmetrical. It leaves, as a rule, one or both of the 
 flanks clear on percussion, and gives a dull note in front, 
 different thus from the disposition of the dulness in ascites. 
 The umbilical ring may be flattened but is seldom protruded, 
 unless there be ascites also. The effect of change of position 
 
CAUSES OF ASCITES. 439 
 
 on the percussion-dulness is scarcely appreciable in ovarian 
 dropsy, or, at least, it is much less than in ascites. Percussion 
 of the lumbar regions, while the patient rests on her arms and 
 knees, sometimes assists the diagnosis by revealing dulness over 
 the diseased ovary behind. 
 
 Other cystic diseases are discriminated from ascites in a 
 manner similar to that mentioned in connection with ovarian 
 dropsy — chiefly by their position and by the fluid not being 
 freely movable. Dilated kidney (hydronephrosis, pyoneph- 
 rosis), cystic disease of the kidney, and parasitic cysts (hyda- 
 tids) of the liver and of various abdominal organs, including 
 the omentum, are the chief forms of encysted accumulation in 
 the abdomen. Occasionally very soft cancers simulate abdom- 
 inal dropsy, and colloid material by its escape into the abdom- 
 inal cavity sometimes gives rise to a semifluid accumulation 
 there : large fatty tumors in the abdomen have also been 
 known to simulate fluid. 
 
 Causes of Ascites. — The first point is to ascertain whether 
 the ascites is the only fluid accumulation present in the patient, 
 or if it forms but a part of a more general dropsy. We some- 
 times require to trace the development of the dropsy in dif- 
 ferent parts as to their relative dates : thus a case may have 
 begun as a pure abdominal dropsy subsequently becoming 
 complicated with dropsy of the feet. When existing alone, or 
 out of proportion to the dropsy elsewhere, ascites may depend 
 on inflammatory exudations from the peritoneum, or on 
 mechanical obstruction to the portal or mesenteric veins. 
 When associated with general dropsy, ascites may simply 
 form a part of a more general affection ; an examination of 
 the heart and of the urine will assist the diagnosis. When 
 the dropsy is almost exclusively abdominal we consider the 
 following causes : 
 
 1. Peritonitis with considerable effusion is almost always 
 chronic or subacute. The tenderness which we are in the 
 habit of looking for in inflammation of the peritoneum, is 
 often very slight, or, indeed, absent, if there be much effli- 
 sion : cases of this class are usually due to tubercular, or, it 
 may be, cancerous affections of the peritoneum : in the latter, 
 the exudations may be due in part to the compression of veins 
 by the cancerous nodules, and in part to the inflammation set 
 up: this inflammatory element may account for the partial 
 subsidence of a dropsy in obviously malignant affections. By 
 applying the hand over the abdomen in the umbilical region, 
 and by wriggling it about in various directions and with vary- 
 
440 JAUNDICE AND DROPSY. 
 
 iiig pressure, we can, at times, perceive a grating or crackling 
 sensation, from the rubbing together of rough surfaces, or 
 from the presence of fluid in the meshes of the inflammatory 
 exudations : a similar sense of friction may be conveyed to the 
 hand or the ear applied to the abdominal wall during a pro- 
 longed act of inspiration : care must be taken not to confound 
 this with the noises occurring within the intestines themselves. 
 When such friction can be made out in a case, it points clearly 
 to inflammatory mischief or complication. Occasionally peri- 
 toneal friction can be felt or heard over the liver, and is devel- 
 oped in cases of abdominal dropsy, especially in the terminal 
 stages of renal disease. 
 
 As chronic peritonitis with efliision is usually tubercular, 
 considerable assistance may often be derived from a consid- 
 eration of the age, family history, and general aspect of the 
 patient, from the presence of evening pyrexia, and from the 
 concurrence of other symptoms and signs of tubercular disease 
 — glandular masses in the abdomen (tabes mesenterica), ulcer- 
 ation of the bowel, pulmonary phthisis, pleuritic efl^usion, etc. 
 Cancer is usually associated with but little disturbance of the 
 temperature, but rapidly developed cancer in the peritoneum 
 and elsewhere may run a febrile course. 
 
 2. Tahes mesenterica is a cause of ascites in children which 
 must never be forgotten ; but it is not so common as is often 
 supposed ; tubercular peritonitis often resembles this form of 
 disease, and the large belly of rickets is even at times con- 
 founded with this very serious disease. Tabes mesenterica is 
 rare under four or five years of age. The dropsy in tabes is 
 usually purely abdominal ; any other, if present, can generally 
 be made out to be quite secondary : the distention of the 
 abdominal veins is an important sign of this form of dropsy in 
 the young, but somewhat similar distention is seen in malig- 
 nant growths in the abdomen, as these likewise obstruct the 
 venous circulation. Occasionally a mass of large mesenteric 
 glands can be felt through the abdominal walls. The general 
 symptoms of wasting disease, and the occurrence of evening 
 elevations of the temperature, the presence of pulmonary 
 phthisis, the existence of abdominal pains, of capricious appe- 
 tite, of occasional disturbance of the bowels, and the history 
 of any tendency to tubercular disease in the family, must all 
 be carefully considered in doubtful cases. This glandular 
 disease may be associated with tubercular peritonitis. 
 
 3. Portal Ohdradioii. — Disease of the liver causes ascites 
 from its aflecting the portal vein, either in its main trunk, or 
 
CAUSES OF ASCITES. 441 
 
 in its ramifications in the hepatic structure. Various diseases 
 of the liver, as well as affections of other organs in its neigh- 
 borhood, may thus give rise to ascites ; indeed, anything which 
 obstructs the portal circulation tends to give rise to abdom- 
 inal dropsy. The two common affections of the liver thus 
 associated with dropsy are cirrhosis or atrophy of the liver, 
 and cancer. The former, when extensive, leads to the oblite- 
 ration of so many minute branches of the portal vein, that it 
 can scarcely fail to give rise, in time, to dropsy ; but in cancer 
 much depends on the accidental position of the malignant 
 nodule, as to whether it hapj)ens to press on or destroy the 
 portal vein or its branches. Along with cancer of the liver, 
 we must consider cancerous growths in the pancreas, glands, 
 and other parts in the neighborhood of the vena portse, as 
 these can seldom be separated clinically from hepatic affec- 
 tions. Perihepatitis (by compression of the portal vein from 
 the contraction of the lymph effused in its neighborhood) like- 
 wise causes ascites ; and occasionally enlarged glands in the 
 fissure of the liver complicate amyloid disease as well as cancer, 
 and so give rise in this way to ascites. Hydatid cysts, ab- 
 scesses, and any tumors or swellings in the liver may likewise, 
 from their particular positions, give rise to ascites. Prolonged 
 congestion of the liver — whether of a mechanical nature, as 
 seen in long-standing cases of heart-disease, or resulting from 
 the pernicious influence of alcoholic stimulants — is apt to lead 
 to induration of its tissue, and obstruction of the portal circu- 
 lation, and so gives rise to peritoneal dropsy. Thrombosis of 
 the portal vein sometimes produces a rapidly increasing ascites, 
 and this cause should be considered when the dropsy suddenly 
 assumes an alarming form, threatening asj^hyxia from its bulk : 
 it is usually due to preexistent disease of the liver, or other 
 organs concerned in the portal system, but it occasionally arises 
 here, as elsewhere, from a very depraved state of the blood. 
 
 In investigating these causes of ascites, we try to discover 
 the size of the liver and any peculiarity in its form : the evi- 
 dence of other results of portal obstruction and the history 
 of any causes likely to give rise to such diseases must also be 
 searched out. 
 
 In cirrhosis, the whole organ is usually small, sometimes, 
 indeed, keeping quite within the margin of the ribs ; occasion- 
 ally, however, it is not diminished in size, and perhaps in the 
 early stage it may even be unduly large. The surface of the 
 cirrhotic liver is often uneven, with little " hob-nail " projec- 
 tions, seldom exceeding a pea in size ; these can be felt in some 
 
442 JAUNDICE AND DROPSY. 
 
 cases on moving the hand from side to side over the organ, or 
 dipping the fingers down over its edge ; not unfrequently there 
 are certain irregularities in the tendinous walls of the abdo- 
 men, which are apt to mislead us in such examinations. The 
 nodules in cirrhosis are smaller than those usually found in 
 cancer. The spleen is generally enlarged in cirrhosis of the 
 liver, but this can seldom be made out if there be much fluid 
 in the abdomen. Jaundice, in an extreme form, is rare in cir- 
 rhosis, but the patients have often a dingy or earthy com- 
 plexion, with dark rings at the orbits ; if jaundice be present 
 at all it is slight, and the bile is not quite absent from the 
 stools, unless, indeed, there be coincident catarrh of the ducts, 
 or some other similar complication. 
 
 In obstruction of the portal vein the branches going to its 
 formation are more or less involved, and so, in addition to 
 exudations into the peritoneum, there is a tendency to disturb- 
 ance of the stomach and bowels, especially vomiting of blood, 
 passing of blood by the bowels, the existence of hemorrhoids, 
 the occurrence of tarry motions, and an enlargement of the 
 spleen. The habitual presence of a sediment of very red 
 lithates in the urine, obvious imperfections in the nutrition, 
 and the previous history of spirit drinking, are further points 
 to be inquired for. Drinkiug of undiluted spirits is the com- 
 mon cause of cirrhosis of the liver, but it occurs at times 
 quite apart from this habit, and has even been seen in young 
 children. Bleeding from the nose and subcutaneous hemor- 
 rhages are also occasional symptoms in cirrhosis of the liver. 
 
 In cancer of the liver, the whole organ is usually enlarged, 
 but sometimes only one part appears affected : the surface 
 often presents very distinct nodules of the size of a marble or 
 even larger, with at times, a central cup-like depression : these 
 nodules are usually painful, or, at least, tender on pressure, 
 but cancer of the liver sometimes runs a painless course. This 
 affection of the liver is generally secondary to cancer some- 
 where else — if judged from the pathological standpoint; but 
 clinically, it is often impossible to get evidence of any other 
 organ having been affected, and even when the liver is involved 
 secondarily, the primary cancer may be in the gall-bladder, 
 the bile-ducts, or other parts intimately related to the liver. 
 Careful search, however, should be made for evidence of cancer 
 in the stomacli, rectum, or elsewhere, and the glandular regions 
 should be explored for any swellings. Hereditary tendencies 
 to malignant disease are sometimes traceable in the family 
 history, but tli^y are no doubt often missed, even when really 
 
EXAMINATION OF FLUIDS REMOVED. 443 
 
 present. Jaundice, like dropsy, is not a constant sign of hepatic 
 cancer, but when deej^ persistent jaundice, with pale stools, 
 coexists with ascites, it adds great probability to the diagnosis 
 of a cancerous mass compressing both the bile-ducts and the 
 portal vein. The combination of jaundice and ascites, how- 
 ever, is also found in cirrhosis of the liver. (See p. 427.) 
 
 An excessively enlarged spleen is sometimes the only obvious 
 cause of abdominal dropsy. 
 
 The examination of the abdomen as to the presence of 
 tumors, or even as to the size of the liver and spleen, is often 
 extremely imperfect, owing to the distention of the j)arts by 
 fluid accumulation ; by dipping the fingers suddenly down 
 through the fluid or by varying the position of the patient, 
 we may discover an enlargement of the liver or spleen, which 
 might otherwise escape notice. When, however, paracentesis 
 has been resorted to, an opportunity is afforded, immediately 
 after the operation, of exploring the parts, owing to the great 
 flaccidity of the abdomen ; the spleen can often be thus felt, 
 and nodulation of the liver then discovered ; cancerous masses 
 in the omentum, peritoneum, or mesenteric glands, can often be 
 easily felt at this time, although, perhaps, in no other way. 
 
 • 
 
 The excanination of the fluid remaved by tapping may help the diag- 
 nosis, but reference must be made to special treatises for full details 
 regarding these various fluids and their characters. The occurrence 
 of blood in the fluids removed, especially by aspiration, is often noticed 
 toward the end of the operation, very likely from the withdrawal of 
 the support afforded by the fluid to the vessels within : the presence of 
 blood probably favors the coagulation of the fluid removed. Coagula- 
 tion of the fluid, when very considerable, suggests the presence of 
 inflammatory processes ; slight coagula, sometimes blocking the canula, 
 may occur in all forms of ascites, but as they form no part of the char- 
 acteristics of ovarian fluids, this ma}' aid the diagnosis. Chylous fluids 
 with a milky appearance are occasionally met with : some implication 
 of the thoracic duct may explain this. Occasionally the fluids removed, 
 particularly after tappings which have not done well, may indicate 
 purulent admixture. The fluid in simple dropsy is usually clear, with 
 a specific gravity of about 1.012-1.015 ; it contains, as a rule, but little 
 blood, although highly albuminous ; bloody serum has, however, been 
 observed in the dropsy due to portal obstruction. Ascitic fluids vary 
 much in specific gravity (1.012-1.035), and also in the quantity of albu- 
 men which they contain. In cases of cancer the fluid may be of the 
 same character as that of simple dropsy, even when the disease involves 
 the peritoneum, but in cancerous cases blood is a more frequent con- 
 stituent. A71 hydatid cyst — unless contaminated with eff"used blood 
 and the products of inflammation — yields a clear fluid of low specific 
 gravity, about 1.007-1 009, without albumen or urea, and wi'h abund- 
 ance of chloride of sodium. Moreover, echinococci or booklets may 
 
444 
 
 JAUNDICE AND DROPSY. 
 
 usually be found on microscopic examination. (See Fig. 72.) Urine 
 may be recognized by its odor sometimes, or by its yielding crystals 
 of nitrate of urea on the addition of nitric acid, after concentration or 
 extraction with alcohol. Urea may be found in the dropsical exuda- 
 tions of the abdomen due to renal disease, but when it occurs in a cystic 
 
 Human ecliinococci. A, a group of echinococci, still adhering to the germinal mem- 
 brane Vy their pedicles, magnified 40 times; B, an echinococcus magnified 107 times; 
 the head is invaginated in the caudal vesicle ; a pedicle is attached to it. C, the same 
 compressed ; the head contracted, the suckers and the hooks are seen in the interior. D 
 echinococcus magnified 107 times; the head is protruded from the caudal vesicle. E, 
 crown of hooks magnified 350 times. (Davaine.) 
 
 accumulation, the kidney or the bladder must be thought of. Urine 
 from a dilated kidney (hydronephrosis) is usually of a very low specific 
 gravit}' ; it may contain a trace of albumen. The possibility of com- 
 plex flaicU from the rupture of cysts, the cfTusion of blood, and the pro- 
 ducts of inflammation must be remembered: dark chocolate-colored 
 fluids with shreds, etc. ; coming away on tapping are usually due to 
 such causes. 
 
 In ovarian cysts we have, as a rule, somewhat dark-colored fluids, 
 sometimes slightly, sometimes extremely ropy or even gelatinous. In 
 such cases we occasionally see glittering specks with the naked eye, 
 shown by the microscope to be scales of cholesterine. (See Fig. 73.) 
 These are commonly found in encysted fluids, but their presence has 
 been recorded in chronic inflammatory peritoneal effusions also: they 
 assist but do not settle the differential diagnosis of ovarian from peri- 
 toneal dropsy. Ovarian fluids may, however, present a close resem- 
 blance to peritoneal exudations ; they are often clear and sometimes 
 of low specific gravity. The specific gravity of ovarian fluids varies 
 from 1.003-1.045. In parovarian cysts the fluid is, as a rule, clear, of 
 very low specific gravity, and with little or no albumen : occasionally, 
 however, such cysts may also have dark, ropy fluid. The detection 
 of " paralburaen " in abdominal fluids has been alleged as diagnostic 
 
MICROSCOPIC EXAMINATION OF FLUIDS. 445 
 
 of an ovarian origin, but this substance has now been found in other 
 forms of disease. " Paralbumen " is not precipitated by heat, although 
 the fluid may become turbid. The action of dilute acetic acid assists 
 
 Fig. 73. 
 
 Crystals of cholesterine. (Otto Funke.) 
 
 its recognition; like mucin, paralbumen is precipitated by this 
 reagent, or at least a turbidity is produced, but the turbidity due to 
 mucin is not dissipated by excess of the acid, or by the addition of 
 a strong solution of chloride of sodium, while the turbidity in the 
 case of paralbumen is dissolved by both of these reagents. Paral- 
 bumen is precipitated by alcohol : so is a substance named " metal- 
 bumen," but this latter again is not precipitated by ferrocj^anide of 
 potassium and acetic acid as paralbumen is. Some confusion exists as 
 to the reaction of " paralbumen : " indeed, the various forms of albu- 
 men do not seem as yet sufficiently well demarcated. Another test 
 often applied is to boil the fluid, and, after obtaining a coagulum, to 
 add strong acetic acid, which redissolves the precipitate from ovarian 
 fluids, or renders it gelatinous after it is shaken up. 
 
 Mixtures of ordinary albumen and of these altered forms no doubt 
 frequently occur, and tend to confuse the results of the tests. 
 
 The microscoipic examination of ovarian fluids may reveal choles- 
 terine cr3^stals as already mentioned, and various cellular structures, pus, 
 blood, epithelial cells, and compound granular masses. Besides these 
 Dr. Drysdale describes a granular cell regarded by him as peculiar to 
 ovarian fluids. It resembles a pus cell, but varies in size : acetic acid 
 does not remove the granular appearance; with ether the granules 
 become more transparent, but the cell is not otherwise altered. Ab- 
 solute reliance cannot be placed on these cells as settling the diagnosis. 
 Groups of pear-shaped cells have also been described as occurring in 
 fluids due to malignant disease of the ovaries or peritoneum. 
 
 Murchison, Diseases of the Liver, Jaundice, and Abdominal Dropsy, 
 3d edition, by Brunton and Fayrer, London, 1885. — Frerichs, Diseases 
 of the Liver, translated by Dr. Murchison for New Sydenham 
 
 38 
 
446 JAUNDICE AND DROPSY. 
 
 Society, 2 vols., London, 1858-61. — Wickham Legg, On the Bile, 
 Jaundice, and Bilious Diseases, London, 1880: this work contains a 
 mass of historical information, copious references, and a full account 
 of acute yellow atrophy of the Liver. — MacMunn, The Spectroscope 
 in Medicine, London, 1880. — Habershon, Diseases of the Abdomen, 
 3d. ed., London, 1878. 
 
 Spencer Wells, Diagnosis and Surgical Treatment of Abdominal 
 Tumors, London, 1885. — Lawson Tait, Pathology and Treatment of 
 Diseases of the Ovaries, Birmingham, 1883. — Bright, On Abdominal 
 Tumors and Intumescence, New Sydenham Society, London, 1859. 
 — There are many other books on ovarian tumors ; reference may 
 also be made to the treatise on diseases of women mentioned in 
 Chapter XV. — For general dropsy, see Basham, The Significance of 
 Dropsy as a Symptom in Kenal, Cardiac and Pulmonary Disease, 3d 
 edition, London, 1866. 
 
 Various works referred to in Chapter XIII. on urinary disorders, 
 and in Chapter XVI. on the physical examination of the chest and 
 abdomen, may also be consulted. 
 
CHAPTER XIII. 
 
 EXAMINATION OF THE UKINE, AND SIGNIFICANCE 
 OF UEINARY SYMPTOMS. 
 
 The urine is usually examined to some extent in all 
 hospital cases on admission as a matter of routine. The 
 nature of any further examination is determined by the 
 character of the case. In private practice the examination 
 of the urine is called for on the detection of any suspicious 
 symptoms likely to be associated with urinary disturbances ; 
 and the beginner will do well to examine it in all cases where 
 the diagnosis remains doubtful. Patients also frequently com- 
 plain of changes in the character of their urine ; these will 
 be referred to in describing the naked-eye appearance. 
 
 The Touiine examination of the urine embraces its reaction, its 
 specific gravity, its color, and other naked-eye appearances ; 
 also a determination of the presence or absence of albumen, 
 and of the character of any sediment, microscopically and 
 otherwise. These points should be noted in all hospital cases 
 on admission, even if the results seem purely negative in their 
 indications, as they may be of much value in the subsequent 
 development of the case. The nature of the further investi- 
 gations depends to some extent on the results of this examina- 
 tion. Thus, if the specific gravity be high, especially in a 
 pale urine, sugar must be tested for and the quantity of urine 
 ascertained. If the specific gravity be low and the color pale, 
 a measurement of the quantity passed ia the twenty-four hours 
 will be important. In cases with albuminuria some notion of 
 the cjuantity of the urine is usually desirable to guide not 
 only the diagnosis, but also the prognosis and treatment ; 
 sometimes exact measurements of the quantity of the urine 
 are of the utmost value. Special circumstances in the case 
 determine the further investigations. Thus the propriety of 
 a quantitative estimation of the chlorides in febrile cases, of 
 the urea in a variety of diseases, of the presence of biliary 
 and other pigmentary matters, etc., must be determined by 
 the general clinical features of the case. 
 
 The samjjles to he selected for testiiu/ de])ei'id to some extent 
 on the points specially aimed at in the inquiry. For the re- 
 
448 URINE AND URINARY SYMPTOMS. 
 
 action, the sample should be recently passed, and if alkaline 
 the relation of the specimen to meal times must be considered. 
 For the specific gravity the whole quantity passed in the 
 twenty-four hours should be tested, or a sample taken from it. 
 In examining for crystals or tube-casts, the sample should be 
 allowed to settle quietly and completely for several hours. In 
 suspected albuminuria we may have to examine samples 
 passed at different periods of the day, as in slight cases the 
 albumen is often absent in the urine passed before breakfast, 
 and appears in considerable quantity after going about a little, 
 or after breakfast or dinner. The urine passed in the early 
 morning gives the fairest sample of the secretion, apart from 
 the influence of special meals. In private practice it is a 
 good plan to try to procure two separate samples passed, the 
 one in the morning and the other at night. In hospital, the 
 early morning samples may be ordered to be kept in the first 
 instance, and the whole quantity or special samples subse- 
 quently ordered, as occasion seems to require. Too much 
 care cannot be taken in securing the purity of the samples, 
 both as regards the cleanness of the vessels into which the 
 urine is originally passed, and of the urine glasses and bottles 
 in which the samples are preserved. Dirty vessels promote 
 speedy putrefaction, and give rise very readily to ammoniacal 
 odor, and to the development of vibriones. The presence of 
 syrups and the like, in imperfectly washed bottles used for 
 the samples, may give rise to serious mistakes. In hospital 
 practice another danger arises from the samples being con- 
 taminated with tube-casts and crystals from the urine of 
 neighboring jmtients, who may have been using the same 
 vessels. 
 
 In some cases of purulent and bloody urine, it is desirable 
 to have the sample passed into two glasses, so as to examine 
 the first and second portions separately, as this sometimes 
 brings out certain peculiarities in various forms of urinary 
 disease. 
 
 Quantify. — This varies in health according to the bulk of 
 the patient, the quantity of his food and drink, and the 
 amount of his excretions by the skin, bowels, etc. It may be 
 roughly estimated at from 30 to 50 or 60 fluid oz. in the 
 twenty-four hours. In disease the modifying influences re- 
 ferred to have also some play. In particular, a profuse dis- 
 charge from the bowels or skin naturally lessens the urine. 
 The quantity of the urine should always be considered in its 
 relationship with the specific gravity, as this sometimes enables 
 
QUANTITY OF URINE. 449 
 
 us to understand and estimate the value of the changes which 
 occur. Thus in a urine diminished by diarrhoea the specific 
 gravity may rise ; in a urine increased from great quantities 
 of fluid being imbibed the specific gravity may falL There 
 is often a difficulty in preserving the whole urine passed by a 
 patient, j)artly from forgetfulness or indifference on his part, 
 especially if he be well enough to go about, and partly from 
 the great tendency the urine has to be 23assed at stool and 
 so lost. By getting the patient to pass water before going to 
 stool this loss may often be prevented, and in male patients a 
 wide-mouthed bottle can easily be used simultaneously. Some- 
 times, however, the loss is inevitable, both from this cause (as 
 in diarrhoea) and from the urine dribbling away, or from its 
 being passed unconsciously and without warning. 
 
 Suppression of urine, or even any great diminution in its 
 amount, is always a serious fact in disease ; but the report is 
 sometimes given that there is suppression of urine when really 
 it is retained in the bladder. When the quantity of the urine 
 is as low as 10 or 20 oz. in the twenty-four hours, it must be 
 regarded as small ; it sometimes, however, falls to a few 
 drachms only. Diminution or suppression of urine is liable 
 to occur in acute nephritis and in the terminal stages of vari- 
 ous forms of Bright's disease. In cases with much fever, and 
 in those with copious vomiting, the urine is diminished. From 
 nervous causes it may also be greatly reduced, as in hysterical 
 ischuria; a secretion of copious urine is, however, a much 
 commoner feature after a paroxysm of hysteria. 
 
 When above 60 oz. it is decidedly increased, if such figures 
 be maintained for several successive days; but we must re- 
 member that the amount oscillates from day to day in health 
 and also in disease. Increased secretion of urine (polyuria) 
 is found in certain stages of lardaceous disease of the kidney, 
 and in granular contraction of the kidney, where the amounts 
 often reach or exceed 100 oz. In diabetes the quantities are 
 seldom much under 100, and often go up to 300 or 400 oz. 
 or more. It is well (owing to the confusion arising from 
 various measures in this country) to have the urine measured 
 in fluid-ounces, or, if the quantities be large, in imperial pints 
 of 20 fluid oz. 
 
 When the quantities passed are moderate, they may some- 
 times be preserved with advantage for our inspection in large 
 glasses graduated in ounces, and in this way the quantity can 
 be read oflf and the specific gravity of the whole can be readily 
 taken. 
 
 33* 
 
450 UEINE AND UEINAEY SYMPTOMS. 
 
 Specific Gravity. — This is usually taken by means of the 
 urinometer which is introduced into the sample, in a urine 
 glass, and the level of the fluid on the stem gives the reading, 
 as calculated for a temperature of 60° F., pure water being 
 1000. The level of the general surface of the urine should be 
 taken and not that of the drop which runs up the stem : it 
 should be seen that the instrument floats freely and does not 
 adhere to the sides or the bottom of the glass. As a rule, we 
 need not be very particular as to the temperature being 
 exactly 60° F., but we must not take the specific gravity when 
 the urine is newdy passed and so much hotter than this tempe- 
 rature, as this might lead to an error of three or four degrees of 
 specific gravity. The stem of the hydrometer should be long, 
 so as to give accurate readings more easily, and as these in- 
 struments are often wrong in their graduation some test of 
 their accuracy is desirable, by comparing them with a standard 
 or by the use of the balance. When the quantity is too small 
 to allow of the instrument's floating freely, a narrower vessel, 
 or some means of displacing the fluid, may enable us to man- 
 age our purpose. The specific gravity bottle is of course avail- 
 able in the case of the sample being very small, or of greater 
 accuracy being desired, and specific gravity " beads " are 
 sometimes useful for small sam]^les. An ingenious method of 
 obtaining the specific gravity from one bead, by a process of 
 dilution, has been devised by Dr. Oliver.^ 
 
 In testing a series of urines, the hydrometer should, of course, 
 be dried to prevent contamination of one specimen by another. 
 As already stated, the specific gravity of the sample noted 
 should be that of the twenty-four hours' quantity, or, if not, 
 allowance must be made for a possible deviation : in many 
 cases the specific gravity of samples passed at different hours 
 of the same day varies enormously. The specific gravity must, 
 as already stated, be considered in relation with the quantity 
 passed ; the normal is usually quoted from 1.015-1.025. High 
 specific gravities (above 1.025) are found in diabetes (from 
 sugar); in urines with a concentration of the normal ingre- 
 dients from febrile or other diseases, or from a limited con- 
 sumption of fluid; in the scanty urine of acute renal dropsy ; 
 and in rare cases, from an enormous quantity of albumen 
 being held in solution. Low specific gravities (below 1.015) 
 occur in nearly all cases (except diabetes mellitus) where the 
 quantity is large; especially in diabetes insipidus; in cases of 
 
 1 The apparatus may be obtained from Wilson & Son, Harrogate. 
 
THE REACTION OF URINE. 451 
 
 lardaceous disease of the kidney, with a harge secretion of 
 urine ; and in general in all chronic cases of Bright's disease. 
 Temporary depression of the specific gravity is met with after 
 large imbibition of fluids, in hysterical affections associated 
 with a profuse flow of urine, and also in the gush of water 
 escaping from a hydronephrosis, and in rare cases, even in the 
 small quantities which succeed in passing the mechanical im- 
 pediment if both ureters be obstructed : the specific gravity 
 difierentiates scanty urine in the last-named cases from that 
 passed in acute nephritis, where the specific gravity is always 
 high in proportion to the degree of suppression. 
 
 By doubling the last two figures of the specific gravity, we 
 obtain a rough estimate of the number of grains of solids per 
 1000 (Trapp's formula). Or by multiplying the number of 
 ounces of urine passed in a day by the last two figures of the 
 specific gravity, we obtain an approximation (rather in excess) 
 to the total number of grains of solids thus excreted : in health 
 we may say 50 oz. of sp. gr. 1.020^=1000 grains (50X20) for 
 an average man. 
 
 The reaction of urine is tested with blue and red litmus 
 paper, or with delicate test-paper which becomes red or blue 
 with acid or alkali respectively. Normally the urine is acid ; 
 but even in health it may, occasionally, be neutral or slightly 
 alkaline at certain parts of the day, and especially after food 
 containing many alkaline salts. The acidity may be unusu- 
 ally great (as in lithiasis) : the degree can be determined by 
 the alkalimeter. In certain depressed states of the general 
 health, in some cases of abundant acid vomiting, in some forms 
 of spinal paralysis, and in long-standing disease of the bladder 
 with retention or incontinence, the urine is habitually alka- 
 line, and the reaction has thus a certain value in diagnosis. 
 Normal urine often becomes more acid for some hours after 
 being passed (urinary acid fermentation) ; but all urines which 
 are allowed to stand long enough decompose and become alka- 
 line, from the conversion of the urea into ammonia, so that we 
 must see to have the samples fresh. Alkalinity from ammonia 
 (volatile alkali) may be discriminated from that due to soda 
 or potash (fixed alkali), by exposing or gently heating the 
 test-paper which has been turned blue by the urine, as the 
 volatile alkali is in this way driven off", and the red color 
 returns. The reaction of urine is of value in the recognition 
 of urinary deposits : a bulky deposit Avhich forms soon after 
 the urine is passed may usually be pronounced to consist of 
 uric acid or its salts (urates), if the reaction be acid ; if, on 
 
452 URINE AKD URINARY SYMPTOMS. 
 
 the other hand, such a deposit concurs with an alkaline or 
 even a neutral reaction, the probability is that it is phosphatic 
 (the addition of an alkali to normal urine precipitates the 
 phosphates). The persistence of pus in urine of acid reaction 
 points to a renal origin, pus from the bladder, if persistent, 
 usually renders the urine alkaline and ammoniacal. Care 
 must be taken to have the samples fresh in such cases, as urine 
 with much pus, from any cause, rapidly decomposes. Alka- 
 linity of the urine is sometimes a point aimed at in treatment 
 by the administration of potash or other alkaline medicines 
 (rheumatism, lithiasis, gout) : the reaction must be determined 
 hj frequent testing in such cases, as the urine rendered alkaline 
 by remedies readily becomes acid unless the doses are frequent 
 and sufficiently strong. On the other hand, medicines seem 
 to have little chemical power in rendering an alkaline urine 
 acid. Benzoic and carbonic acids, however, seem to have some 
 influence in this respect. 
 
 The obvious characteristics of urine are of importance not 
 only as regards the samples we examine ourselves, but also 
 as regards the description of alterations complained of by 
 patients. Both of these will be considered here. Normal 
 urine has a pale yellow tint, is clear when passed, but deposits, 
 on standing, a faint cloud of mucus, which forms only a slight 
 sediment. This mucus is sometimes more abundant than 
 natural, as in slight catarrh of the bladder, and this excess 
 may pass gradually into a deposit of muco-pus. When the 
 cloud is absent, this usually implies some excess in the quan- 
 tity of the urine, which has thus washed away or diluted the 
 mucus. 
 
 The color and clearness of urine vary much. Tables of 
 colors have been devised by Vogel to assist the naming of the 
 variations ; he makes nine gradations ; pale yellow, bright 
 yellow, yellow ; reddish-yellow, yellowish-red, red ; brownish- 
 red, reddish-brown, brownish-black. If the urine be turbid, it 
 should be ascertained, if possible, if it were so when passed, 
 or if it only became so afterward. Turbidity, when freshly 
 passed, may depend on decomposition going on within the 
 bladder, or on excess of vesical mucus, or on the presence of 
 renal epithelium and shreds, pus, blood, semen, and prostatic 
 secretions, bile, uric acid, urate of soda (hedge-hog crystals), 
 phosphates, cliyle, or sarcinse. When the urine is clear on being 
 passed and afterwards becomes turbid, this is usually due to 
 the precipitation of urates or of phosphates, or to decomposition, 
 or saccharine fermentation. When the sediment has completely 
 
OBVIOUS CHARACTEEISTICS OF URINE. 453 
 
 fallen, sometimes the supernatant fluid is perfectly clear ; some- 
 times it remains slightly turbid from some remaining admixture 
 of the sedimentary matter. 
 
 Patients frequently complain of the urine being Mffli colored 
 and scanty; this often arises from simple concentration of the 
 secretion in febrile diseases, apart from any special renal affec- 
 tion, but it also occurs in acute nephritis. Urine i.(jliite like 
 milk is often spoken of in the case of children, and this character 
 is usually due to the presence of white urates or colorless uric 
 acid crystals. In adults, if the urine be milky when passed, this 
 is. usually due in their case to the presence of earthy phosphates 
 (arising, perhaps, from a transient alkalinity of the urine after 
 dinner), unless persistent this is of little importance ; or the 
 turbidity may be due to decomposition and the formation of 
 ammonio-magnesian phosphates : or to the presence of pus, 
 which is always of more or less serious significance ; in rare 
 cases it may be due to chyle, to spermatic fluid or sarcinse. 
 When the patient describes the urine as ^'turning thick," this 
 is almost always due to a deposit of urates on the cooling of 
 the urine, and is seldom of much consecjuence. When the 
 urine is spoken of as '"'' resemhling porter," the presence of bile 
 in some quantity is usually indicated, but blood may also give 
 such a color. When described as turbid arid smoky when 
 passed, this may be due to a slight and intimate admixture 
 with blood ; a blood-red color in a more pronounced form de- 
 pends on a quantity of florid blood being passed ; clots may also 
 come away either of a florid color or of a darker hue, or even 
 of a chocolate appearance. Very red urine, having something 
 of the bloody tint, is sometimes due to excessively red urates, 
 especially as found in certain hepatic cases. Very j:) ale urine 
 is found usually when the quantity is habitually excessive, as 
 in diabetes, and in certain forms of chronic diseases of the 
 kidney ; or it may also concur with a temporary increase in the 
 quantity, from free imbibition of fluids, or in connection with 
 hysterical or nervous attacks in both sexes. Anaemia may also 
 be responsible for the paleness of the urine. Black urine is 
 sometimes passed by those using carbolic acid or creasote, 
 either externally or internally ; more frequently this black 
 color only appears after the urine has been kept for a time ; 
 the addition of a minute quantity of strong vitriol funpurified) 
 frequently brings out a greenish color in such cases, but this 
 test is rather uncertain. A dark red or almost black color is 
 sometimes found in the urine in cases of melanosis. Indigo- 
 blue has occasionallv beeu found in urine after it has beeij 
 
454 URINE AND URINARY SYMPTOMS. 
 
 standing for a time and has become alkaline. Bad odor in 
 the urine when j^assed depends, as a rule, on decomposition 
 occurring within the bladder, or on the escape of an abscess 
 into it, and is significant of cystitis, etc. Certain vegetables 
 impart a strong odor to the urine, and the smell of many- 
 articles used in the food or drink may be recognized in the 
 urine. In oxaluria a certain resemblance to the odor of 
 sweetbrier may sometimes be recognized, and during the 
 administration of turpentine there is sometimes a smell as if 
 from sweet violets, but this cannot be said to be unpleasant. 
 Gas coming wdth the urine suggests some communication -of 
 the urinary passages with the bowels. Shreds and fibrous 
 masses may be passed in cases of chronic inflammation of the 
 bladder, or they may come from an inflamed and dilated kid- 
 ney (])yelo-nephritis). Gritty matter or gravel may also be 
 complained of as coming wdth the urine and irritating the 
 urethra : this will usually be found on examination to be due 
 to uric acid, or, more rarely, to other forms of calculous con- 
 cretions. Urinary sediments usually demand chemical tests or 
 microscopic examination for their discrimination. (See pp. 
 470-496.) Crystals of uric acid can often be seen by the 
 naked eye, or with a simple lens, resembling cayenne pepper 
 grains, falling to the. bottom of the glass, or adhering to its 
 sides, or to shreds of mucus. Glittering, colorless prisms of 
 ammonio-magnesian phosphate can also sometimes be thus 
 seen floating as a scum on the surface of the urine, or resting 
 on the mucous sediment, or adhering to the sides of the glass. 
 A very delicate white jDowdery sediment covering the top of 
 the cloud of mucus, and resembling, as has been said, fine 
 powder dusted over a wig ("powdered wig deposit"), can 
 sometimes be recognized with tolerable certainty as due to 
 oxalate of lime crystals ; occasionally, in alkaline urines, mi- 
 nute phosphatic crystals simulate this appearance, but, as a 
 rule, the latter are more glittering than the former ; deposits 
 of cystine in acid urines may resemble oxalates very closely. 
 Fawn-colored, pink, or reddish amorphous precipitates, formed 
 as the urine cools, can usually be recognized at once by the 
 naked eye as composed of urates (urate of ammonia, potash, 
 and soda) ; when the deposit is whitish, there is more difliculty ; 
 white urates, or even uric acid, earthy phosphates, and pus, 
 may be scarcely distinguishable* from each other by the naked 
 eye. A glairy ivhitish or yelloivish material, floating on the 
 surface of the urine, or difliised through it, is often seen when 
 the sample is contaminated with leucorrhceal discharges. Urine 
 
SUGAR IN URINE. 455 
 
 with a whitish turbidity forming a coagidum on standing is 
 mixed with chyle. 
 
 Sugar in Urine. 
 
 Sugar should be tested for in any complete examination of 
 the urine, and esj^ecially in all cases in which diabetes is sus- 
 pected ; when the quantity of urine is excessive, or the specific 
 gravity unusually high (above 1.030) ; when there is excessive 
 thirst ; when great loss of strength or of flesh has occurred 
 without obvious cause ; when eruptions of boils or itching at 
 the urinary orifices are troublesome ; and when any of the 
 other symptoms of diabetes may present themselves. It should 
 also be remembered that in certain cases of cerebral disease, 
 with or without distinct paralysis, and particularly in some 
 cases of cerebral tumor, sugar appears in the urine. When 
 examining for sugar, albumen should also be tested for, not 
 only because its presence is a serious complication in diabetes, 
 but also because the presence of albumen may interfere with 
 the certainty of the reactions for sugar by the copper test ; in 
 such cases the albumen should be separated by heating, with 
 the addition of a little acid, and subsequent filtration. Boiling 
 the albuminous urine with crystals of sulphate of soda is like- 
 wise said to yield a fluid suitable for the application of the 
 copper test. 
 
 6'o/9p$r Test — Trommer's Test. — This is based on the power 
 which diabetic sugar has of reducing copper salts from the 
 cupric to the cuprous state under certain conditions. A few 
 drops of a strong solution of sulphate of copper are mixed 
 with a little urine in a test tube, liquor potassae is then cau- 
 tiously added, just enough to dissolve th^e precipitate which it 
 throws down in the first instance ; the mixture is boiled, and 
 if sugar is present, a red precipitate of the cuprous oxide falls 
 down. Errors are frequently made in applying this test from 
 not using the proper quantities or proportions of copper and 
 potash with the urine. 
 
 Fehling's test solution^ obviates some of these difficulties. A 
 portion of the test fluid is first boiled in a test tube^ we notice 
 
 1 Fehling''s Solution. — Sulphate of coi)per, 903^ grains; neutral tartrate of potash, 364 
 grains : solution of caustic soda (of sp. gr. 1.12) 4 fluid-ounces. Add water to make up 
 exactly to 6 fluid-ounces. 200 grains by measure are reduced by 1 grain of grape sugar. 
 (Or, 40 grammes of sulphate of copper in crystals ; 160 grammes neutral tartrate of 
 potash ; 750 grammes caustic soda sp. gr. 1.12 ; add water up to 1154.5 cubic centimetres. 
 Of this 10 cubic centimetres correspond to 0.05 gramme of grape sugar, j The copper 
 may be dissolved in one-half of the water and the potash with the soda in the other 
 half, both carefully stoppered, and equal volumes mixed when required ; in this way 
 the test-fluid may be preserved from decomposing, which it readily does, especially if 
 exposed to air and light. 
 
456 URINE AND URINARY SYMPTOMS. 
 
 if it remains uncliaiiged in color ^as it is apt to become altered 
 by keeping) ; if unatfected, one or two drops of the suspected 
 urine are added ; if diabetic sugar be present in any quantity, 
 the color at once changes, and a yellowish or reddish j)i'ecipi- 
 tate comes down. If this does not happen, a little more urine 
 should be added (but always so as to be less than the volume 
 of the test-fluid in the tube), and the whole should again be 
 boiled and allowed to cool ; if no yellow or red precij^itate of 
 the cuprous oxide comes down it may be pronounced free of 
 sugar. 
 
 Caxdion. — Prolonged boiling must be avoided, as reduction 
 may occur in this way apart from sugar. Boiling the urine 
 before adding the test-fluid is also apt to lead to reduction of 
 the copper even if there be no sugar. Adding too much urine 
 is also to be avoided, as a great excess of non-saccharine urine 
 may reduce the copper. The test-fluid must be in good con- 
 dition — capable of resisting boiling without being changed ; in 
 delicate inquiries, it is desirable to add an equal bulk, or more, 
 of pure water to the boiling test-fluid, to boil again, and to 
 allow the whole to cool slowly so as to have complete security 
 of the perfect condition of the copper solution before proceed- 
 ing to test. 
 
 The quantity of sugar may also be determined by the copper test. 
 Fehling's solution is made of such a strength that 200 grains (by 
 measure) are completely reduced b}^ one grain of diabetic sugar. Of 
 course, great accuracy in weighing and measuring the ingredients is 
 required for quantitative analysis. This quantity of the test-fluid is 
 boiled in a porcelain capsule or a glass flask, and a quantity of pure 
 water, equal to one or two volumes of the test-fluid, is poured in also. 
 The saccharine urine is diluted with pure water, in the proportion of 
 1 volume of urine to 9 of water, if tlie sugar happens to be abundant; 
 or in a less proportion (or without dilution) if the sugar is scanty. The 
 diluted urine is introduced into a burette, graduated to grains, and is 
 then gradually added to the boiling copper solution till tlie blue color 
 is quite discharged. In order to judge of this a minute or two must 
 be allowed for the red precipitate to fall, otherwise it obscures an}' 
 slight blueness which may remain in the supernatant fluid. When 
 the precipitate falls, by holding up the flask to daylight, or against a 
 white object, or by looking down through the fluid to tlie white sides 
 of the porcelain dish, if this be used, any remnant of blue color is 
 readily detected. If this can be recognized the mixture is again 
 brought to the boiling point, and a few drops of the diluted urine are 
 again added. Too much time must not he allowed to elapse in wait- 
 ing for the red precipitate to fall, as after standing f )r a length of time 
 the cuprous oxide is changed and redissolved, and the blue color is 
 reproduced. The number of grains of urine consumed in the experi- 
 ment is then read oflf, and this represents the quantity which contains 
 
feeling's and pavy's solution. 457 
 
 one grain of sugar ; it is then a matter of calculation how many grains 
 of sugar are contained in the ounce of urine (437j grs. in an ounce 
 avoirdupois). Allowance, of course, is made in the calculation for the 
 degree of dilution employed. If the total quantity of urine passed in 
 the day be known, the total quantity of sugar excreted can then be 
 readily calculated. Similar calculations can be made in grammes and 
 the proportion calculated in percentages. 
 
 PavT/'s a7nmoniated soltdion of cajy-per Jor quantitative analysis has 
 some advantages over Tehling's solution. Its composition is cupric 
 sulphate, 4.158 grammes ; potassic sodic tartrate (Rochelle salt), 20.400 
 grammes; potash (caustic), 20.400 grammes ; strong ammonia (sp.gr. 
 0.880), 300 c. cm. ; water to 1 litre. (Or in English weights, cupric sul- 
 phate, 36^ grains; Rochelle salt, 178 grains; caustic potash, 178 
 grains; strong ammonia (sp. gr. 0.880), 6 fl. oz ; water to 1 pint.) 
 The potassic sodic tartrate and the potash are dissolved in a portion 
 of the water and the cupric sulphate with the aid of heat in another 
 portion ; the solution of cupric sulphate is poured into the mixture of 
 potassic sodic tartrate and potash, and when cold the ammonia is 
 added; finally, water is added to bring up to the bulk specified. 10 
 c. cm. of the above solution are reduced by (and so equivalent to) 0.005 
 gramme of glucose or diabetic sugar. 
 
 The advantage of this solution is that the ammonia holds the 
 cuprous oxide in solution, and so the fluid is decolorized when the 
 cupric salt is completely reduced ; whereas, in Fehling's solution the 
 red precipitate mingling with the remnant of blue color in the test-fluid 
 renders it more difiicult to estimate the complete reduction. 10 c. cm. 
 are measured, placed in a glass flask, and diluted with two volumes 
 of pure water; the diluted urine is then added, just as in the process 
 with Fehling's solution. The only special precaution is to avoid dis- 
 sipation of the ammonia which would result from prolonged boiling 
 or even from undue slowness in the process of testing. The dissipa- 
 tion is further lessened by passing the point of the buretta through a 
 cork fitting the mouth of the flask, another opening being, of course, 
 provided for the escape of the steam. As the diluted urine is run into 
 the flask containing the boiling solution the change in color can be 
 watched, and when the blue fluid has become as colorless as water we 
 conclude that the reduction is complete, and a calculation can then be 
 made as in the other process. (A simple apparatus for this purpose 
 is made by Cooper, 58 Oxford Street, London ; the method is fully 
 described by Dr. Pavy, in the Lancet for March 1, 1884, and he there 
 gives a table to facilitate the calculations.) Dr. Pavy has devised 
 pellets for the copper test and definite quantities of his solution in her- 
 metically sealed tubes, but these, although convenient, do not keep 
 perfectly for indefinite periods of time. 
 
 Fei^mentation Test. — Occasionally there are uncertainties in the 
 results of the copper test, when, for example, the reduction of the 
 copper is slight in extent or doubtful in character, and when the urine 
 is rich in uric acid. It is then important to decide as to the presence 
 of sugar by fermentation ; sugar is the only substance known which 
 ferments with yeast and liberates carbonic acid gas. A small tube may 
 be nearly filled with the suspected urine, a little yeast is then added, 
 and the whole inverted over mercury in a cup ; the apparatus is then 
 put in a warm place and allowed some time to ferment. If sugar be 
 
 39 
 
458 URINE AND URINARY SYMPTOMS. 
 
 present, in other than very minute quantity, gas accumulates in the 
 tube, and this can be shown to be carbonic acid by testing it, say with 
 lime-water. It is well to conduct a blank experiment with simple 
 water and the yeast at the same time, as a security against the gas 
 being formed in any other way. 
 
 ToriUa Test. — The detection of torulte (see Fig. 86) occasionally 
 assists in the diagnosis of saccharine urine, or directs attention to its 
 examination by chemical reagents. 
 
 The quantitative test by fermentation, as described by Sir William 
 Roberts, of Manchester, consists in determining the specific gravity of 
 the urine before and after complete fermentation. A small lump of 
 German yeast (the size of a walnut) is added to four ounces of urine, 
 the specific gravit}^ of which has first been carefully taken and noted ; 
 this is placed in a wide-mouthed bottle (12 ounces), corked, but with 
 an opening cut in the cork so as to allow the carbonic acid to escape ; 
 it is then placed in a moderately warm situation, and in the course of 
 twenty-four hours, or when the fermentation is completed, it is allowed 
 to cool, and its specific gravity is again taken at the same temperature 
 as before the fermentation was begun. The loss in the specific gravity 
 indicates the quantity of sugar fermented out. The specific gravity is 
 reduced partly by the loss of the sugar formerly held in solution, and 
 partly, perhaps, by some of the light alcohol thus generated remaining 
 in the mixture. To avoid any fallacy from a difference in the tempera- 
 ture of the fluid at the two separate observations on the specific gravity, 
 it is desirable to have a duplicate sample of the original urine, without 
 yeast, in a 4 ounce bottle, firmly corked, and kept beside the other 
 throughout, so as to compare the specific gravity of the two specimens 
 after the fermentation is over. It has been found, empirically, that 
 one degree of specific gravity lost by fermentation, corresponds with 
 one grain of sugar per fluid-ounce of urine. 
 
 Esthnation of the quantity of sugar from direct observation of the 
 specific gravity of the urine is, at best, a rough method, as complica- 
 tions arise from the presence, in varying proportions, of the normal 
 solid ingredients of the urine. This source of difficulty is relatively 
 greater when the total quantity of the saccharine urine passed daily is 
 not excessive. A specific gravity which is not excessive cannot, of 
 course, coincide with a high proportion of sugar per ounce; this, 
 indeed, follows from the method of quantitative determination by fer- 
 mentation, as it has just been stated that the degrees of specific gravity 
 lost in this process indicate an equal number of grains per ounce; if 
 the specific gravity is only 1.030 the number of grains is likely to be 
 under 30, usually considerably under 30, for the ordinary ingredients 
 (urea and salts) of the urine imply of themselves a fair S|)ecific gravity 
 (say 1.010 or 1.015), unless indeed the urine is very dilute. A high 
 specific gravity (say 1.045 to 1.050) with a ver\' large quantity of urine 
 (several quarts) may be safely taken as evidence ot a high proportion 
 of sugar in cases of diabetes. 
 
 Moore's test for sugar ivith liquor potassoi is a favorite method, on 
 account of its easy application. Equal volumes of urine and liquor 
 potassaj are boiled together, when a dark brown color results in cases 
 of diabetes. This is not a test suitable for small quantities of sugar, 
 and it is subject to fallacies, especially from the presence of lead in 
 the reagent, as this may arise from the glass of the bottles used. This 
 
VARIOUS TESTS FOR SUGAR. 459 
 
 test is often of use in confirming our opinions in the absence of more 
 reliable appliances. 
 
 Bismuth Test for Sugar. — A solution of carbonate of soda is pre- 
 pared in the proportion of one part of the crystals to three parts of 
 water. This solution is mixed with a little of the suspected urine in 
 equal volumes, and a pinch of the basic nitrate (or even the subnitrate) 
 of bismuth is then added, and the whule boiled; if sugar be present 
 the bismuth becomes grajnsh or blackish from the formation of the 
 suboxide or of metallic bismuth. The test is a delicate one, but is not 
 available for quantitative analysis. When the urine tested is not very 
 watery it is, of course, relatively rich in phosphates, and these are 
 liable to be precipitated by the soda solution giving rise to a white 
 deposit which conceals the blackness of the reduced bismuth. In such 
 urines a preliminary separation of the phosphates, b}" boiling the urine 
 with the alkaline mixture and filtering or decanting before the addi- 
 tion of the bismuth, may obviate this difficulty. 
 
 Picric Acid Test. — In applying this test for determining the presence 
 of sugar we mix an equal volume of urine and of a saturated solution 
 of picric acid, we then add a few drops of liquor potassse and boil ; i'f 
 sugar is present a deep red-brown color is produced. Inasmuch as 
 many high-colored urines take on a more or less deep color, apart from 
 sugar, when treated in this way, this does not seem a good qualitative 
 test, as the presence of sugar turns on the degree of redness produced. 
 
 For quantitative purposes the method seems more reliable, as the 
 exact depth of color can be measured by a process of dilution when 
 definite quantities of the urine and of the reagents are boiled and 
 mixed in tubes of definite diameter and compared with a standard 
 colored solution in a similar tube. Dr. Geo. Johnson has devised an 
 apparatus by which quick results of sufficient accuracy can be obtained. 
 It is convenient to use his graduated tubes which may be obtained from 
 E. Cetti, 36 Brooke Street, Holborn, London, E. C. : full instructions 
 are given with the instrument, or they may be found in a little book 
 by Dr. G-eo. Johnson, On Testing for Albumen and Sugar, London, 
 Smith, Elder & Co., 1884. 
 
 Test-papers for Sugar. — Dr. Oliver has elaborated a system of testing 
 by papers to enable the reagents to be easily carried and to avoid the 
 inconveniences resulting from decomposition in Fehling's solution. 
 
 The cicpric test-paper is a compound paper ; the one with tartrate of 
 cuprammonium, the other with carbonate of soda; these are combined 
 with a layer of rubber. The paper is boiled in sixty minims of soft 
 water, giving a transparent greenish fluid ; the papers are then removed 
 and the solution again boiled ; a drop of the diabetic urine now added 
 will reduce the copper, whitish streaks and a yellow color appearing; 
 this is hastened by further boiling. If, after such heating and further 
 addition of a drop or two of urine the solution remains transparent, 
 with its green color, we presume there is no distinct amount of sugar. 
 
 Indigo-carmine Test-papers. — These have been applied with great 
 ingenuity by Dr. Oliver, both to the qualitative and quantitative 
 determination of sugar; special papers are used for quantitative pur- 
 poses. The blue color is discharged by the reducing or deoxidizing 
 power of diabetic sugar. Many details and precautions must be ob- 
 served in using these tests, and as they are fully detailed in the in- 
 
460 UKINE AND UEINARY SYMPTO-MS. 
 
 structions supplied with the test-papers they need not be given here. 
 (Obtained from Wilson & Son, Harroijate.) 
 
 The polainscope is available botb for the qualitative and quantitative 
 analysis of sue^ar, provided tbe fluid be decolorized and freed from any- 
 other ingredients (such as albumen) which acton polarized light; but 
 the instruments as yet are rather troublesome and expensive, at least 
 in their accurate forms. 
 
 Albuminuria. 
 
 The tests for albumen chiefly relied on in clinical medicine 
 are two, and, as a rule, they should both be applied, at least 
 in all doubtful cases. They are (1) boiling, with the subse- 
 quent addition of a drop or two of acetic or nitric acid ; and 
 (2) the application of strong nitric acid to the cold urine. 
 Some other tests, in particular picric acid, in acid or acidu- 
 lated urines, may be recommended as good negative tests ; 
 that is to say, if they give no reaction, when properly applied, 
 the urine may be regarded as free from albumen, but if a 
 precipitate is obtained, this should be subjected to further 
 scrutiny. Various other agents precipitate albumen, and are 
 used for special inquiries — corrosive sublimate, ferrocyanide 
 of potassium with some acid superadded, acidulated brine, 
 mercuric iodide with citric acid, alcohol, ether, chloroform, 
 chromic acid, carbolic acid, tungstate of soda, metaphosphoric 
 acid, etc. Some of these have been introduced into clinical 
 medicine, and may, perhaps, be used occasionally with advan- 
 tage ; but the clinical significance of the precipitates obtained 
 from some of them remains still so doubtful that we fall 
 back with the more confidence on the two methods named 
 above, which have stood the test of long experience. It 
 should be seen to that suitable samples are examined before 
 pronouncing the absence of albuminuria. (See p. 447 ) 
 
 1. Test by heat. — The urine is heated in a test tube to the 
 boiling point, and one or two drops of acetic or of nitric 
 acid are then added. If albumen be present there is a tur- 
 bidity, or a precipitate, which does not dissolve on adding the 
 acid. If the amount of albumen be small, b}'' heating the 
 upper half of the fluid in the test tube we sometimes can demon- 
 strate the reaction more clearly by comparing the boiled and 
 the unboiled layer. The urine may be turbid to begin with ; 
 if this be from urates, they will dissolve on a slight applica- 
 tion of heat to the whole quantity in the tube (say 9^° F.) ; 
 the test is not interfered with by this. If the turbidity of 
 the urine cannot thus be got rid of, filtering may be resorted 
 
ALBUMINUEIA. 461 
 
 to. Occasionally a degree of turbidity from decomposition, ex- 
 cess of mucus, or similar causes, may remain, and this inter- 
 feres with the delicacy of the test for minute quantities of 
 albumen. 
 
 Apart fi'om this, which is only a slight imperfection, some 
 fallacies may mislead the student in ushig the heat test, (a) 
 Albumen may be present, but, being held in solution by 
 alkalies, it may not come down on heating ; hence the pro- 
 priety of trying the reaction before boiling, and the necessity 
 of adding acid after boiling, before deciding on the result.^ 
 (6) A precipitate may form on boiling, somewhat resembling 
 albumen, but really consisting of earthy phosphates ; such a 
 precipitate is soluble on adding a little acid, a precaution 
 w^hich should never be neglected in applying the heat test, 
 (c) If too much strong acid be added to the boiling urine in 
 testing the precipitate which forms, this may dissolve even 
 albumen; excess need not be risked; as the smallest amount 
 suffices to dissolve earthy phosphates. (d) Occasionally a 
 minute quantity of nitric acid in the sample of urine (remain- 
 ing over perhaps in badly washed test tubes) prevents the 
 precipitation of albumen on boiling, from the formation of a 
 soluble acid compound. Sometimes the addition of even a 
 little acetic acid to the urine before boiling may likewise 
 prevent the precipitation of albumen by heat, and so this 
 should be avoided unless guarded in the most scrupulous 
 manner ; even a great natural acidity of the urine itself has 
 been known to prevent the precipitation of albumen by heat. 
 The reaction of the urine for the correct application of the 
 test should be just slightly acid. Any acids used to secure 
 this must be applied with caution ; ^ in very rare cases alkalies 
 may have to be used to neutralize undue natural acidity. 
 
 2. Nitric acid added to the cold urine forms a test for albu- 
 
 1 Occasionally in acid urines a faint cloudiness in tne boiled portion is developed only 
 after acids have been added — not from albumen, for in acid urines this would show itself 
 on simple boiling, but apparently from the so-called mucin reaction, due to the acid, but 
 intensified by previous boiling. 
 
 - The addition of acetic acid before boiling has often been recommended, but it is 
 attended with danger unless gone about in the most precise manner, as any undue quan- 
 tity may dissolve the albumen. Sir William Eoborts recommends '6 drachms of urine to 
 have 1 drop of acetic acid B. P. added to it ; on boiling the upper portion of this fluid, 
 a slight opacity reveals the most minute quantity of albumen ; if the urine is alkaline 
 it is cautiously neutralized by acetic acid before the final drop is added to the 3 drachms. 
 There is reason to fear that even 1 drop of acetic acid to 3 drachms of certain urines 
 may prevent the precipitation of albumen ; and, on the other hand, a minute cloudiness 
 obtained in this waj' seems at times to be due to other causes than albumen. 
 
 Another way of applying the heat test is to acidulate the urine with acetic acid and 
 add one-sixth of its volume' of a saturated solution of sulphate of magnesia before 
 boiling. 
 
 The method recommended in the text is the one on which the writer places reliance. 
 
 39* 
 
462 UKINE AND UEINARY SYMPTOMS. 
 
 men of great value. The delicacy of this test in pale urines 
 of low specific gravity is quite marvellous. The strong nitric 
 acid may be added to a small quantity of urine in a test tube, 
 ten or twelve drops of the acid being allowed to trickle down 
 the side of the tube ; the test tube should be held obliquely 
 and raised gently, so as to avoid, if possible, much comming- 
 ling of the fluids. The acid falls to the bottom, and can 
 usually be recognized from its different color, or (on moving 
 the tube very gently) from its obviously different specific 
 gravity. Another way is to introduce some nitric acid first 
 into a tube, the lighter urine being then poured down very 
 slowly and cautiously, say by means of a pipette, so as to 
 float, without mixing much with the acid. AVith either 
 method albumen, if present in the urine, forms a cloud just 
 above the level of the acid ; or if the quantity be minute, a 
 ring of haziness appears at the junction of the two fluids. A 
 third way of applying this test is to introduce a little nitric 
 acid by a pipette (the outside of the pipette being wiped free 
 from acid) right down to the bottom of the urine in the test 
 tube. All these plans ("contact method") aim at getting 
 the action of the acid localized to a part of the urine without 
 being diffused through it. (A ring of red color merely, with- 
 out turbidity, at the junction of the fluids does not indicate 
 albumen. This is sometimes very marked, and when highly 
 developed on boiling the acid and urine together, constitutes 
 the " urohaematine" reaction supposed by Dr. Harley to be 
 due to the loss of blood, as it were, in a disguised form. A 
 ring of green color with nitric acid is found from bile pig- 
 ment.) 
 
 Certain fallacies and difficulties beset the nitric acid test 
 also : (a) If the quantity of albumen be minute, some time 
 may have to elapse before the haziness is developed. The 
 tube should be left at rest for a few minutes before pronounc- 
 ing that there is no haze of albumen. (6) Occasionally, on 
 adding nitric acid to the cold urine, a more or less dense pre- 
 cipitate occurs, not from albumen, but from urates. This 
 happens even Avhen the acid is applied as directed ; it is more 
 liable to cause confusion if the bad plan be followed of drop- 
 ping the acid into the urine, but this should be avoided. The 
 urates usually appear first near the surface of the urine, and 
 not at the junction of the urine with the acid, although it 
 often extends that length. A very gentle heat suffices to dis- 
 solve this 2:)recipitate of urates : this may be done by passing 
 
OTHER TESTS FOR ALBUMEN. 463 
 
 the tube two or three times through the flame of a spirit lamp 
 or by immersing the tube in warm water ; in applying heat 
 for this purpose we must avoid anything like a boiling tem- 
 perature, as albumen itself is dissolved if boiled with excess 
 of nitric acid in the tube. A further confirmation of such a 
 precipitate being due to urates may often be obtained by get- 
 ting a similar reaction on adding a drop or two of acetic acid 
 to another sample, as this acid does not precipitate albumen 
 in cold urine. (Occasionally, however, an albuminous prin- 
 ciple resembling caseine is thus precipitated by acetic acid.) 
 The microscope may sometimes also assist us. The precipi- 
 tate of amorphous urates may be recognized as such by the 
 microscope ; sometimes crystals of uric acid are also quickly 
 formed, (c) Occasionally the addition of nitric acid is fol- 
 lowed by the evolution of a multitude of air bells ; these are 
 usually plain enough and can be seen rising in the urine. 
 Sometimes the bells are so numerous and so minute, and re- 
 main so long in the vicinity of the layer of nitric acid, as to 
 resemble the haze of coagulated albumen. Close scrutiny, 
 and the lapse of a little time, which allows them to rise and 
 dissipate themselves, prevent any error from this cause, {d) 
 When the urine is turbid, the delicacy of the nitric acid test 
 is lost. Filtering may assist us in such a case, but besides 
 being troublesome it is apt to be imperfect in its efiect. When 
 the turbidity is due to urates (the commonest cause), by heat- 
 ing very gently, or adding a little warm water, a clear fluid 
 can be obtained on which to operate, and by keeping the tube 
 slightly warm (in warm water or in the warm hand), this 
 clearness may be maintained long enough for the satisfactory 
 application of the test, (e) A precipitate formed at the 
 bottom of the acid consisting of nitrate of urea seldom 
 presents any difiiculty as regards distinguishing it from albu- 
 men ; it is crystalline, readily soluble at a very gentle heat, 
 and usually it takes a long time to form, although it sometimes 
 appears in a few minutes when the urine is loaded with urea 
 and the temperature is low. (/) An opalescence from the 
 use of cubebs and copaiba is occasionally encountered. (^) 
 A haze from mucin, quite above the level of the acid, and 
 sometimes in the form of a ring, seldom leads to error. 
 
 A dilution of the nitric acid with five volumes of a saturated 
 solution of sulphate of magnesia lessens the corrosive proper- 
 ties of the acid, which are so objectionable, without impairing 
 seriously the delicacy of the test. 
 
464 URINE AND URINARY SYMPTOMS. 
 
 Other tests for albumen have been recommended, especially of late. 
 The most important of these will be noticed shortly. 
 
 Picric Acid. — A saturated solution in water (about six grains to the 
 ounce, is prepared. If this be dropped into an albuminous urine an 
 opacity forms around each drop ; this is readily dissipated on shaking, 
 but after the accumulation of a certain number of drops the opacity 
 becomes peisistent. If the urine is not distinctly acid the albumen may 
 fail to show an opacity till enough of the reagent has been added to 
 cause an acidity from the picric acid itself; but as this is a weak acid, 
 some other should be used — say citric acid or a little dilute acetic acid. 
 A more delicate plan, the "contact method," is to float some of the 
 picric acid solution on the surface of the urine, after acidulating with 
 citric acid ; this is readily done by a pipette, as the test solution is much 
 lighter than most urines. Albumen at once appears as an opacity at 
 the junction of the fluids. If the ui'ine is too light to permit of this 
 method, its specific gravity can be increased by adding to it some drops 
 of a satui'ated solution of citric acid or of a solution of common salt. 
 The fallacies which beset this test depend partly on the possible pre- 
 cipitation of urates on adding the necessary acid, and partly on other 
 substances besides albumen being precipitated by picric acid. In par- 
 ticular, alkaloids (of which the commonest and most important is 
 quinine) are precipitated by picric acid. Peptones are also precipitated 
 by picric acid, and they are occasionally found in urine. The precipi- 
 tate fi-om urates, alkaloids, and peptones are all dissolved on heating, 
 so that when a precipitate is obtained by picric acid it is essential to 
 proceed furtiier and tiy the effect of heat; if the precipitate remains 
 after heating, then we may presume that albumen is present; on the 
 other hand, if no precipitate occurs on adding picric acid to the cold 
 acidulated urine, we may presume that albumen is absent with as 
 much certainty as can be obtained from any one test. 
 
 The only remaining fallacy consists in the development of a distinct 
 but usually slight haze, particularly when the picric acid is used by 
 the "contact method;" this occurs in a great many urines which we 
 have every reason to believe to be free fiom albumen. The production 
 of this haze has been supposed to be due to mucin, but this is not cer- 
 tain. It is not due merely to the citric acid used in the test, although 
 this and other acids used in testing urine appear at times to develop 
 this reaction. Some authorities try the reaction with strong citric acid 
 alone, and if the picric acid alone gives more than this does, they infer 
 there must be something more than mucin to give rise to it. This con- 
 fusion, of course, only occurs in connection with the suspicion of very 
 minute quantities of albumen. 
 
 The fallacies in connection with the picric acid test may be sum- 
 marized : («) Alkalinity of the urine or inadequate quantity of the 
 picric acid may prevent the precipitation of the albumen ; citric acid 
 should be added and the picric acid used in excess, [b) Urates and 
 occasionally uric acid may be precipitated from the urine by the citric 
 acid or other acidulating agent or even by picric acid alone in rare 
 cases; this precipitate dissolves on heating, (c) Alkaloids in the urine 
 are precipitated by picric acid; quinine, if taken by the patient, even 
 in moderate doses, may give this precipitate; it is dissolved on heat- 
 ing, id) Peptones in the urine are precipitated by picric acid ; these 
 
TEST PAPERS FOR ALBUMEN. 465 
 
 are dissolved by heat, (e) Slight opacities may occur from the so- 
 called mucin reaction simulating minute quantities of albumen. 
 
 The ferrocy article of potassium test has long been known ; a few drops 
 of a solution of this salt, with a little acid, precipitate albumen. As 
 in other tests involving the addition of acid, we may have urates pre- 
 cipitated as well as albumen. Of late pellets have been used with 
 advantage in applying this test, as they are very portable. An acid 
 pellet and a ferrocyanide pellet (kept in separate bottles) are added to 
 the cold urine in a test tube or a wineglass. If no precipitate occurs, 
 we may presume that there is no albumen present. If a precipitate 
 forms, the application of heat or the addition of a little warm water 
 may serve to indicate the presence of urates which would be dissolved 
 by this. (Those recommended by Dr. Pavy may be obtained from 
 Cooper, 66 Oxford Street, London.) 
 
 Ferrocyanide test-papers have been devised by Dr. Oliver. A ferro- 
 cyanide paper and a citric acid paper are put into a narrow tube with 
 60 minims of pure water, and after a little gentle agitation to dissolve 
 the reagents, the papers may be removed. The urine is then dropped 
 into the test-fluid thus extemporized, and if albumen be present in such 
 quantity as to be readily recognized (in one minute) by the nitric acid 
 test, it will appear as an opacity before six drops have been added. 
 The addition may be carried up to thirty drops of the urine. This 
 method of dropping in the urine is alleged to overcome the fallacy 
 from the precipitation of urates. The delicacy and portability of these 
 test-papers are great recommendations. 
 
 The mercuric iodide test requires the addition of some acid, say nitric 
 acid. (The " potassio-mercuric iodide" solution consists of mercuric 
 chloride 2.70 srrammes ; potassium iodide 6.64 grammes ; distilled water 
 100 c.cm.) "When this is dropped into the acidulated urine, a whitish 
 precipitate appears if albumen be present. Precipitates also occur 
 from urates, from alkaloids, and from peptones, as in the picric acid 
 test, but these are dissolved on heating as described above. Traces of 
 opacity on using this test occur in a multitude of urines presumably 
 quite normal, so that some caution and the use of confirmatory tests 
 are imperatively demanded if a reaction is obtained. If no reaction 
 occurs, the negative evidence — as to the absence of albumen — is very 
 strong. 
 
 Mercuric test-papers are recommended by Dr. Oliver to be used in 
 the same way as the ferrocyanide papers. A mercuric iodide paper 
 and a citric acid paper are put into a narrow tube with 60 minims of 
 pure water and the reagents dissolved out by gentle shaking, after 
 which the papers may be removed. The urine is then added drop by 
 drop, and four drops suffice to produce an opacity if albumen be pres- 
 ent in quantity sufficient to be readily recognizable (in one minute) by 
 the nitric acid test. If no reaction occurs on adding twenty drops of 
 the urine, we may say there is no trace of albumen ; but if any pre- 
 cipitate forms, this must be tested by boiling it before we can say 
 albumen is present, as alkaloids and peptones are precipitated by this 
 reagent.^ 
 
 1 Dr. Oliver's test-papers, both for the qualitative and qnantitative determination of 
 albumen and sugar with the tube pipettes, and scales required, may be obtained from 
 "Wilson & Son, Harrogate, 
 
466 URINE AND URINARY SYMPTOMS. 
 
 The acidulated hrine ieM consists of a saturated solution of common 
 salt with one per cent, of strong hycli'ochloric acid. This is applied by 
 the "contact method" in the same way as nitric acid. It is a very 
 delicate test, but as it precipitates other things as well as albumen, it 
 has been abandoned by Sir William Roberts, who introduced it. 
 
 The quantity of albianen may be roughly estimated by judging of 
 the extent of the precipitate formed on boiling, especially after it has 
 been allowed to subside in the tube for a definite time (say twenty- 
 four hours: its amount may be thus estimated at a half, a fourth, an 
 eighth, etc. Sometimes the quantity is indicated by saying a "trace" 
 of albumen, or " slight," or " moderate," or " large " amounts, as the 
 case may be ; or that the urine is solidified on heating. Such indica- 
 tions are of clinical importance, but the estimate thus made has little 
 chemical value. The estimation by precipitation and weighing is so 
 troublesome as to be practically unavailable in clinical medicine. 
 
 The polariscope may also be used for determining the amount of 
 albumen in the absence of any other matter atfecting the ray of light. 
 This instrument is too costly in its good forms to be often available. 
 
 Dr. Oliver'' s test-papers (ferrocyanide of potassium, and mercuric 
 iodide) have been ingeniously adapted for giving approximate quanti- 
 tative results by means of estimating the degree of transparency or of 
 opacity resulting from the reagents. 
 
 Picric acid has also been employed, especially by Esbach, for deter- 
 mining the quantity of albumen. (Graduated tubes for this purpose 
 mav be obtained from Cetti, 36 Brooke Street, Holborn, London.) 
 
 The quantitative deter }ninatio7i of alhwnenby nitric acid, as proposed 
 by Sir William Roberts, is based on the fact that the reaction with this 
 test takes longer to show itself in proportion as the albuminous solution 
 is dilute. Indeed, in very slight degrees of albuminuria several minutes 
 are required to bring out the haze with nitric acid. The test consists 
 in diluting an albuminous urine to such an extent that the haze be- 
 comes perceptible in a definite time, when a definite quantity of urine 
 is treated with a definite quantity of nitric acid, in a tube of a definite 
 width. The quantity used is 5 cubic centimetres of the fluid in a test 
 tube |th of an inch (15 mm.) in its internal diameter; the nitric acid 
 is applied by a pi|>ette drawn to a point, holding 10 or 12 minims when 
 immersed to the depth of 2 inches ; the acid is discharged against the 
 side of the tube while it is held at an angle so as to prevent mixing of 
 the fluids, the dilution aimed at is such as to give rise to a haze ap- 
 pearing not sooner than 35 seconds and not later than 45 seconds. The 
 tube must be held up to the daylight and watched carefully with some 
 black object, such as a coat sleeve, in the vicinity. If the reaction 
 appears bef >re 30 seconds, more dilution is required ; if not till after 
 45 seconds, less dilution must be employed. A drachm mea^^ure for 
 the urine and a pint measure for the water serve the purpose of dilut- 
 ing, and these fluids must of course be well mixed. If higher dilutions 
 are required, the drachm of urine may first be mixed wilh one or two 
 volumes r)f water before the further dilutif)n in the pint measure is 
 begun. One or two rough experiments before beginning careful dilu- 
 tion may guide us as to the number of volumes with which we should 
 begin. INFost albuminous urines can stand at least one volume of water 
 being added, so as to give this reaction in the time named (35-45 
 seconds) I some may require as much as 200 or even 300 volumes of 
 
PEPTONES AND ALBUMEN IN URINE. 467 
 
 water to bring them to the necessary siate of dilution. • The slate of 
 dilution required for the reaction within the time named is termed 
 the " zero; " each volume of water required to be added is termed a 
 "degree" of this scale. The value of each degree was calculated by 
 the balance to be equivalent to 0.0034 per cent, of albumen (or 0.0148 
 gr. per fluid-ounce). If, then, a urine showed 250 degrees of albumen 
 we multiply by this fraction: thus 250x0.0034 = 0.85 per cent, of 
 albumen , if we wish to calculate the total loss of albumen per da}^, 
 we multiply the number of ounces passed by the 4872- gi'ains contained 
 in an avoirdupois ounce, multiply this again by 0.85 (as determined 
 above) and divide by 100 : this gives the answer in grains of dry 
 albumen. 
 
 In applying this method we must, of course, obtain a proper sample 
 of the whole urine passed in the twenty-four Jiours. 
 
 In addition to the estimation of the total albumen passed in a day 
 this method supplies by its varjing scale of degrees some definite 
 figures instead of vague expressions as to the abundance of albumen 
 in urine, as "20 degrees," "60 degrees," "100 degrees," "200 
 degrees," etc. (See Medico-Chirurgical Transactions, vol. lix. Lon- 
 don, 1876.) 
 
 Peptones and Modified Forms of Albumen in Urine. 
 
 The subject of the various albumiuous matters found in urine is 
 still very confused, and the detection of peptones there has added to 
 the confusion. Certain reagents seem to precipitate all the substances 
 of this class — as picric acid and mercuric iodide: on the other hand, 
 heat and nitric acid in the cold precipitate serum albumen and 
 globulin, detecting albumen in combination with acids and alkalies, 
 but leaving the others in solution. The ferrocj^anide of potassium 
 test does not precipitate peptones in urine. 
 
 (r^o^M^m held in solution in the urine by the salts is precipitated 
 when such a urine is dropped into a quantity of pure water, giving 
 rise to a milky or opalescent appearance. Paralbumen and metaL- 
 bumen have been already alluded to in connection with the fluids in 
 ovarian cysts. (See p. 444.) Hemialbutnose is partially coagulated 
 by heating but is redissolved on boiling, reappearing, however, as the 
 fluid cools : this seems to be the substance described by Dr. Bence 
 Jones as found in the urine in a case of osteomalacia : the precipitate 
 with nitric acid in the cold was dissolved on heating, and also reap- 
 peared on cooling. Peptones are thrown down by picric acid and 
 mercuric iodide, but the precipitate is dissolved on heating. By 
 separating the albumen by heat and filtration and then applying the 
 reagents which precipitaie peptones, and seeing if the application of 
 heat clears up the opacity resulting therefrom, we may discover pep- 
 tones if abundant. An accurate separation and testing of peptones is 
 too intricate a matter for ordinary clinical work. A test by means of 
 Fehling's solution is relied on by some, but seems rather uncertain. 
 On floating a solution of peptones on this fluid a rosy-red color is 
 produced at the junction. When urine is thus floated on Fehling's 
 solution we may find a zone of opacity at the junction from phosphates 
 (due to the alkaline solution), and above this the rosy tint is looked 
 
468 URINE AND URINARY SYMPTOMS. 
 
 for if peptones be present. It must be remembered, however, that 
 albuminous urines give a colored reaction with Fehling's solution 
 which is said to have more of the violet tint, but the distinction is not 
 alwa^^s plain, and if peptones and albumen happen to be both present 
 the result is confusing. Peptones have been found in urine along 
 with pus, and in some cases of suppuration going on elsewhere : they 
 seem also to have been met with in the urine of women after delivery, 
 in cases of pneumonia and pleurisy, of rheumatism with effusion, and 
 in some of the infectious fevers: they have also been supposed to 
 result from imperfect digestion and from derangement of the liver, 
 and it has been thought that peptonuria may sometimes precede a 
 regular albuminuria. As yet, definite information on these points 
 cannot be supplied. 
 
 The clinical significance of albuminuria is very variable ; it 
 is sometimes of the utmost importance in diagnosis, and at 
 other times of scarcely any account. 
 
 When due exclusively to the presence of blood, pus, etc. (as 
 revealed by the microscope), the clinical significance of the 
 albumen turns of course on the significance of these ingred- 
 ients, and must be considered under these headings. Some- 
 times, however, the amount of albumen seems out of propor- 
 tion to the amount of blood or pus contained in the sample : 
 in such cases the want of a convenient quantitative test for 
 albumen and blood is much felt, but an experienced eye can 
 usually judge pretty safely from comparing the variations in 
 the amount of albumen occurring with ditferent quantities of 
 pus or blood. Sometimes a notable variation in the amount 
 of blood and pus deposited in different samj^les. from the same 
 case, with but little change in the quantity of albumen pre- 
 cipitated on heating, leaves no doubt as to the presence of 
 albumen apart from, and in addition to, the blood and pus 
 which may be found. 
 
 Many acute febrile diseases often give rise to albuminuria 
 for short jDcriods, without the diagnosis or prognosis being 
 seriously affected thereby. In typhus and enteric fevers, 
 smallpox, scarlatina, diphtheria, and malignant sore throat, 
 erysipelas, pneumonia, pleurisy, pericarditis, acute rheumatism, 
 meningitis, acute tuberculosis, puerperal fever, and acute 
 suppurations of various kinds, albuminuria is often detected : 
 it has then its chief significance as one of the features of the 
 general disturl)ance ; there is, however, in certain cases even 
 then the beginning of a serious local affection. 
 
 After the priynary fever has subsided, notably in scarlatina, and 
 occasionally in smallpox, erysipelas, and enteric fever, albu- 
 minuria is observed as a recognized sequela. In the case of 
 
ACUTE OR CHRONIC RENAL DISEASE. 469 
 
 scarlatina, iudeed, it may be said to be of almost habitual 
 occurrence ; and when albuminuria appears in a member of a 
 family affected with this fever, or when conjoined in the indi- 
 vidual himself with desquamation of the cuticle, arthritic 
 pains, hydrothorax and other well-known sequelae of scarlatina, 
 it often enables us to recognize an attack of this disease in a 
 patient w^ho would not otherv\'ise have been known to be so 
 affected. 
 
 In 2yreg7ianGy and the pueiyeral state albuminuria is not in- 
 frequent, and although not necessarily of grave import, it is 
 always significant of possible dangers (convulsions during 
 labor, chronic renal disease, etc.). 
 
 Chronic chest complaints are often complicated with albu- 
 minuria, and this has great importance as regards prognosis 
 (chronic bronchitis, emphysema, |)lithisis, chronic pneumonia, 
 pleurisy or empyema, heart disease, aneurism, mediastinal 
 tumors, etc.). Sometimes in such cases, and especially in 
 heart disease, the albuminuria is only one of the indications of 
 a general venous congestion which may pass off quickly or 
 may linger for a long time ; sometimes it is indicative of a 
 nephritis favored by renal congestion ; sometimes, on the other 
 hand, the renal disease, of which albuminuria is the sign, may 
 be justly regarded as the primary fact, and the affection of the 
 heart or lungs as a complication. 
 
 In all drojDsies the presence or absence of albumen is im- 
 portant. Occasionally genuine renal dropsy exists without 
 albuminuria, but this is so rare as to make such a diagnosis 
 demand very special proof. Albuminuria, on the other hand, 
 may be regarded as presumptive evidence of a renal origin 
 for the dropsy, in whole or in part ; but the mischief in the 
 kidney may be dependent, as just explained, on general 
 venous obstruction clue to cardiac, hepatic, or ovarian disease, 
 or to dropsy of the peritoneum, or to any cause giving rise to 
 direct pressure on the renal veins. 
 
 In acute or chronic renal disease of all kinds, whether with 
 or without dropsy, the detection of albuminuria is of the 
 greatest value : concurrent evidence from the presence of 
 blood or of renal derivatives in the urine (tube-casts, epi- 
 thelium, etc.), from alterations in the specific gravity and the 
 quantity of the secretion, from local pain, and from the 
 general features of the case, may come in here to help the 
 diagnosis. 
 
 In nervous diseases the existence of albuminuria is of impor- 
 tance, but the nature of the connection in such cases is variable. 
 
 40 
 
170 URINE AND URINARY SYMPTOMS. 
 
 Sometimes the nervous affection is a tolerably direct manifesta- 
 ation of the renal disease, as in ur?emic convulsions, coma, 
 blindness, or delirium : sometimes the nervous affection is due 
 to organic changes associated with the renal disease, as in 
 hemiplegia due to cerebral hemorrhage associated with hyper- 
 trophy of the heart, rigid arteries, and disease of the kidney. 
 At other times albuminuria may be regarded as an effect of 
 the nervous disease, as in the temporary albuminuria due to an 
 epileptic or other convulsive fit, and the albuminuria pro- 
 duced by certain inflammations, tumors, and other lesions of 
 the brain. 
 
 In many clironic and constitutional affections we must watch 
 for albuminuria: phthisis, syphilis, scrofulous disease of the 
 joints and bones, and profuse suppurations generally, are often 
 associated with albuminuria due to lardaceous degeneration 
 of the kidneys. Cases of chronic indigestion and depressed 
 states of the health, with habitually alkaline urine, or with 
 persistent deposits of oxalate of lime, gouty attacks, and the 
 like, inust be particularly w^atched in respect of this symptom, 
 both because of the frequent complication of such cases with 
 albuminuria, and because symptoms of the class just indicated 
 are often the earliest manifestations of renal disegse. Other 
 chronic diseases, as diabetes, jaundice, cancer, exophthalmic 
 goitre, and lead poisoning, are often complicated with albu- 
 minuria. 
 
 Remedial agents, especially blisters, may give rise to a tran- 
 sient albuminuria, sometimes with, sometimes without, h?ema- 
 turia and strangury. 
 
 In the midst of so many possible sources of albumen in the 
 urine, we must fall back on the history and the general symp- 
 toms and features of the complaint to guide our diagnosis ; 
 and in particular, we must have regard to the persistence and 
 to the quantity of the albumen, and to other evidence of 
 derangements in the urine, as respects its quantity, its specific 
 gravity, its color, and the presence of tube casts, renal or other 
 epithelium, pus, blood, crystals, parasites, etc. 
 
 Blood in the Urine 
 
 is always to be regarded as important. Sometimes its appear- 
 ance is so far accidental : thus the possibility of the admixture 
 of menstrual blood with tlie urine, or of slight bleeding from 
 the use of the catheter, must be borne in mind ; the possible 
 existence of more serious injuries to the genito-urinary organs 
 
GUAIAC TEST FOR BLOOD, 
 
 471 
 
 must not be ignored, although these do not belong to purely 
 medical practice. 
 
 Blood in the urine can often be recognized by the eye from 
 its giving a dingy or smoky tint to the urine, especially when 
 the blood comes from the kidney and is intimately mixed with 
 it. Sometimes it has a darker hue, resembling chocolate. 
 All gradations of red or blood-color, with or without clots, 
 may be found, especially when the blood comes from the pelvis 
 of the kidney, the ureter, or bladder. When the blood is 
 present in any distinct quantity the existence of an albumi- 
 nous reaction may be calculated on with certainty, and the 
 presence of this may serve to confirm our suspicion of blood, 
 while the absence of albumen should make us suspect some 
 fallacy if the blood-tint - seems pronounced. Occasionally, 
 however, the appearance of a perfectly distinct blood-color 
 may coexist with the merest trace of albumen : indeed, it may 
 happen that a reduction in the amount of albumen coincides 
 with the appearance of blood in the urine in very distinct 
 quantity. The microscope assists the diagnosis of hsematuria 
 
 Fig. 74. 
 
 Blood corpuscles in iii ine. a, Slightly distended by imbibition ; h, Showing their bicon- 
 cave contour ; c, Shrivelled; d, Serrated. (Roberts.) 
 
 by determining the presence or absence of blood corpuscles, 
 and these may be seen in cases in which no albumen can be 
 detected by the tests. The red blood-corpuscles are recog- 
 
472 
 
 URINE AND URINARY SYMPTOMS. 
 
 nized by their size being smaller than that of pus, or mucus, 
 or white blood-corpuscles, and by their having the double 
 outline due to the biconcave character of the disks (Fig. 74, 
 b). It frequently happens, however, that the blood disks in 
 urine are swollen up, by the absorption of fluid, into a globular 
 
 Eed. 
 
 Fig. 74-. 
 Orange. Yellow. Green. 
 
 Blue. 
 
 No. 1 
 
 No. 2 
 
 No. 3 
 
 No. 4 
 
 No. 5 
 
 Tl 
 
 Reduced hjemofflobin. 
 
 Acid hfBinatiue. 
 
 Reduced haematine. 
 
 Diagram showing the position of the Fraunhofer lines in the solar spectrum (No. 1) ; and 
 the absorption bands of hfemoglobiu and ha)niatine (Nos. 2 to 5). 
 
 form, and this peculiarity is consequently lost ; occasionally 
 their edges are serrated from similar physical causes (Fig. 74, 
 a, d). A fallacy is not unfrequently presented by globular 
 vegetable s2:)ores simulating the microscopic appearance of red 
 blood-corpuscles. 
 
 A chemical test for blood (or hasmoglobin), by means of 
 guaiac, is often of value. Two or three drops of the urine are 
 placed in a test tube, a couple of drops of tincture of guaiac 
 are added, and a few drops of " ozonic ether " are then shaken 
 up with the whole. The ether dissolves the precipitated resin, 
 or goes to the surface and carries up with it a distinct bluish 
 color if blood be present. The peroxide of hydrogen in the 
 "ozonic ether" is very liable to undergo decomposition, and 
 so we must be sure of the activity of our reagents before 
 
HEMOGLOBIN. 473 
 
 deciding that there is no blood. In testing a urine it is also 
 necessary, when the quantity of blood is minute, to allow it to 
 settle, and to apply our test to a few drops lifted from the sedi- 
 ment by a pipette, as the corpuscles containiug the haemoglobin 
 fall to the bottom. This reaction can also be obtained at 
 times from minute traces of haemoglobin in the urine, in scar- 
 latinal dropsies, even before the albumen appears, as judged 
 by the ordinary tests (so-called " pre-albuminuric stage ") ; 
 or ^or some time after it disappears (" post-albaminuric 
 stage "). It w^ould appear, however, that this depends on the 
 great delicacy of the guaiac test, w^hen properly applied, 
 detecting blood in minute quantities which elude the ordinary 
 tests for albumen, unless special precautions are taken.^ This 
 test is sometimes applied by means of white bibulous paper 
 dipped in the urine, the guaiac and ozonic ether being subse- 
 quently applied to the paper when it has dried. If this method 
 be followed, the paper itself must first be tested wuth pure 
 water, as some papers give a misleading reaction ; high-colored 
 urine, from bile, may also mislead. 
 
 Another test for haemoglobin is supplied by the spectro- 
 scope. If a solution of oxy-hsemoglobin, presenting a layer of 
 suitable thickness, be interposed between the light and the slit 
 of the instrument, two dark absorption bands are found at the 
 yellow and green portion of the spectrum, between the D and 
 E lines, as shown at No. 2 in the diagram. The first is nar- 
 rower and more sharply defined at the edges than the second. 
 This is due to oxy-hsemoglobin, such as is found in blood taken 
 from the finger. If reducing agents be applied — e. g., a little 
 ammonium sulphide — the two bands are converted into one ; 
 the edges of this are not sharply defined, and it is nearly inter- 
 mediate, as to position, between the other two. (vSee ISTo. 3 in 
 the diagram.) If this reduced haemoglobin be now^ shaken up 
 in the tube with a quantity of air, the haemoglobin is again 
 oxidized and the two bands reappear, slowdy coalescing into one 
 again as the air bells rise to the surface and escape. This 
 beautiful reaction as described by Professor Stokes, of Cam- 
 bridge, is conclusive proof of haemoglobin. Occasionally in 
 bloody urine a third dark band is found in the red part of the 
 spectrum, in the position indicated in the diagram as that of 
 acid hsematine (No. 4). In such cases this band is regarded 
 as due to " met-hsemoglobin ;" its exact nature is obscure, but 
 
 1 See Dr. E,. Steyenson Thomson's paper on this subject, Med.-Chir. Trans., toI. Ixix., 
 Lond., 1886. 
 
 40* 
 
474 uiaxE AXD urinary symptoms. 
 
 probably it results from changes or decomposition in the other 
 form. In bloody urine this band in the red never occurs 
 alone ; it is always associated with the other two, so that the 
 appearances are as if No. 2 and No. 4 in the diagram were 
 conjoined. When the urine becomes alkaline from decompo- 
 sition the band in the red may disappear readily, and this is 
 apt to lead to contradictory statements on the part of different 
 observers. (No. 4, " Acid hsematine," and No. 5, " Reduced 
 hiematine," in the diagram are only obtained on the applica- 
 tion of suitable reagents to blood ; they do not occur apart 
 from this.) 
 
 These tests by guaiac and the spectroscope are of special 
 importance in cases of hcemocjlohinuria, which often appears 
 in paroxysmal forms (paroxysmal h^emoglobinuria), ushered 
 in by shiverings and associated with fever. In such cases the 
 urine appears to be bloody, but the most careful search may 
 fail to reveal any blood corpuscles, the haemoglobin having 
 been dissolved out and the corpuscles disintegrated. In such 
 cases the urine is loaded with albumen and the spectroscope 
 reveals the presence of haemoglobin, in the form of oxy-haemo- 
 globin, often associated with " meth?emoglobin," giving a 
 band in the red. In these cases (formerly called paroxysmal 
 ha^matinuria) we may have chocolate- colored masses in the 
 sediment, occasionally tube-casts are seen, and oxalates are 
 frequently present. The attacks may pass off in a few hours, 
 leaving the urine perfectly clear aud free from blood or albu- 
 men. They seem to be determined at times by the influence 
 of cold. Other forms of hfemoglobinuria occur in connection 
 with fevers and poisoning. 
 
 Clinical Significance of Hcematuria. — The appearance of 
 blood in the urine (apart from the accidental contaminations 
 from the vagina, etc., already referred to) points either to 
 some general disease attended with bleeding, as in the case of 
 purpura and scurvy, of haemophilia, hemorrhagic smallpox, 
 and malarial fever, or some forms of disease affecting the 
 bloodvessels generally ; or it may be due to the operation of 
 some poisonous agency acting specially on the kidneys — such 
 as cantharides, turpentine, creasote, and alcohol ; or to some 
 local affection of the urinary organs and passages themselves — 
 such as inflammation of the bladder or kidneys, cancer of 
 these organs, parasitic disease of the kidney, renal iubolism, 
 and calculus in the kidney or bladder ; occasionally it is due 
 to the extension or bursting of abscesses, cysts, etc., into some 
 
SPECIFIC GEAVITY OF URINE. 475 
 
 part of the urinary tract from adjacent structures, and especi- 
 ally from pelvic abscesses. 
 
 The further discrimination of such cases turns on the aspect 
 of the blood. If intimately mixed with the whole of the 
 urine, imparting a smoky tint to it, the blood is usually of 
 renal origin ; minute clots may come from this source, but 
 any considerable clots indicate a bleeding lower down. Some- 
 times, however, these may come from the pelvis of the kidney. 
 Florid blood and distinct clots point to the bladder, prostate, 
 or urethra. If the blood is passed specially with the last por- 
 tion of the urine, this usually indicates a vesical origin. If 
 the hsematuria is associated with excess of mucus or muco- 
 pus, we suspect the bladder ; the urine in such cases tends to 
 become alkaline. If the amount of pus varies much from 
 time to time, without roj^y mucus and with habitually acid 
 reaction, we often find the explanation in a kidney dilated 
 with pus intermittingly emptying itself. The reaction of the 
 urine, and the discovery of gravel, microscopic calculi, or crys- 
 tals, may guide us, although these may be irritating either the 
 kidney or the bladder. Parasites detected in the urine may 
 explain the hemorrhage. The kind of epithelium found along 
 with the blood is often of consequence, if v^^e can recognize it 
 as renal or vesical, or as coming from the pelvis of the kidney 
 or the ureter ; the so-called " cancer cells " are always to be 
 accepted with dubiety. The detection of tube-casts in a bloody 
 urine indicates that there is a renal element in the case, but it 
 is quite possible that even in such cases the bladder may be 
 responsible for most of the mischief, for the renal affection may 
 be secondary, as in disease working its way back from the urethra 
 and bladder. Again, if we can satisfy ourselves that there is 
 more albumen in the urine than can be accounted for by the 
 blood (or i^us) present, this also usually points to a renal affec- 
 tion. The quantity and specific gravity of the urine likewise 
 assist us in determining the presence of acute or chronic disease 
 of the secreting parts of the kidney. Of course, the general 
 symptoms of the case must be strictly inquired into, especially 
 as to pain and its site ; its area of distribution, whether over 
 the pubes, in the lumbar and sacral regions, in the thighs, the 
 region of the ureters, or in the penis and testicles ; the rela- 
 tionship of the pain to the act of micturition, to the times of 
 rest or exertion, or to any supposed cause of its develojDment, 
 must also be considered. Phthisis may gi7e the clew to the 
 bleeding associated with tubercular pyelitis, and the cachectic 
 appearance of the patient may suggest the idea of malignant 
 
476 URINE AND URINARY SYMPTOMS. 
 
 disease as the cause of the hemorrhage. A surgical examina- 
 tion of the urethra and prostate, and of the bladder for calculi 
 or growths, may be required to settle the questions here raised, 
 at least in cases of persistent or frequently recurring hsema- 
 turia, associated with painful micturition. The occurrence 
 of shiverings, the circumstances under which the hsematuria 
 appeared — whether after scarlatina, or in the course of chronic 
 or acute renal diseases, or associated with hemorrhages else- 
 where, after a fit of drinking, or in connection with the use of 
 special drugs, or after injuries to the parts, or associated with 
 gonorrhoea and stricture, or in connection with renal colic or 
 tumor, and tenderness in the loins — all these must be inquired 
 into ; their significance must be sought for in the description 
 of urinary diseases in special treatises, or in the text-books of 
 surgery as well as of medicine. 
 
 Pus IN THE Urine 
 
 occurs sometimes as a microscopic deposit only ; at other times 
 it appears in sufficient quantity to present a very distinct and 
 even a bulky sediment. In such cases it may often be recog- 
 nized by the naked eye, but it is apt to be confounded Avith 
 phosphatic deposits (and in point of fact it often exists along 
 with them) ; it may also be confused with white urates. 
 Liquor potassse, as a reagent, may assist in the discrimination ; 
 for urates are dissolved by this agent, phosphates are but little 
 affected, or are rendered more dense by it, while pus becomes 
 ropy or gelatinous on the addition of an equal bulk of liquor 
 potass8e to the purulent deposit : the impossibility of pouring 
 out such a mixture drop by drop is good evidence of this ropi- 
 ness. Sometimes the pus assumes this ropy character soon after 
 the urine is passed ; this is due to the development of ammonia, 
 which acts on pus in much the same way as liquor potassse 
 does ; sometimes the ropiness exists when the urine is passed, 
 from the ammoniacal decomposition going on within the 
 bladder itself. The microscope reveals the presence of pus 
 corpuscles ; these when seen may be further tested by the 
 addition of dilute acetic acid, which clears up the granular 
 contents and brings out the tripartite nucleus. (See Fig. 75.) 
 Other white cells are often found in urinary sediments which 
 can scarcely be distinguished from pus ; the white corpuscles 
 of the blood, mucus corpuscles, inflammatory corpuscles (leuco- 
 cytes), and even altered renal epithelium, all resemble pus so 
 closely as to be at times indistinguishable. 
 
PUS IX THE URINE. 
 
 477 
 
 Mucus corpuscles may be suspected when the mucous 
 appearance of the sediment is very marked ; renal epithelial 
 cells are usually larger than pus corpuscles ; the action of 
 acetic acid and of liquor potassse sometimes assists in various 
 doubtful cases. The reaction of purulent urine, when of renal 
 
 Tig. 75. 
 
 Pus-corpuscles. «, Without reagents, h, After the addition of acetic acid. (Roberts.) 
 
 origin, is usually distinctly acid (if tested immediately on 
 being passed), even in long-standing suppuration ; it is usually 
 alkaline and ammoniacal in long-standing suppuration from 
 the bladder. When of renal origin, the deposit of pus in the 
 urine glass is often very distinctly demarcated from the super- 
 natant fluid ; in vesical suppuration, whether from calculous 
 irritation or not, it is usually more diffused from being min- 
 gled with mucus ; in both cases it may be associated with 
 blood in various degrees and ways. In renal suppuration, the 
 blood when present usually lies as a distinct layer on the top) 
 of the pus ; in vesical cases, the blood is often more mixed up 
 with the mucus and pus. Sounding of the bladder is impera- 
 tively called for in ail doubtful cases with bladder symptoms. 
 The coexistence of mucus, of fibrous shreds, of crystals of 
 various kinds, and of epithelium from the kidney, ureter, 
 bladder, or urethra, is sometimes of great value in judging of 
 the origin of the pus. If much scaly epithelium from the 
 vagina be present, leucorrhoeal contamination should at once 
 be suspected, and the use of the catheter may be required to 
 overcome the difficulty of this admixture. Sometimes, in the 
 male, instructive hints may be gathered from the relative 
 abundance of pus in the first half of the urine as compared 
 
478 URINE AND URINARY SYMPTOMS. 
 
 with the second, during a single act of micturition ; any pus 
 in the urethra is naturally washed away with the first half of 
 the urine, while if the seat of suppuration be in the bladder, it 
 is rather more abundant in the second half, and may be more 
 contaminated with blood ; if from the kidney it is usually 
 equally diffused. In suppuration from a dilated kidney the 
 quantity of pus often varies in a remarkable way at different 
 acts of micturition, and some information may be gained by 
 procuring a series of samples in separate glasses. Albumen 
 can be made out by ajDpropriate tests in all cases of excessively 
 purulent urine — from the presence of albumen in the pus 
 itself; but when we can make out a greater amount of albu- 
 men than the pus can well account for, there is a strong case 
 for the renal origin of the complaint ; Ave may find, for exam- 
 ple, the same quantity of albumen present in various samples, 
 although the pus may vary greatly or may even present an 
 insignificant amount in certain specimens. Very marked 
 albumen with but a slight layer of purulent sediment would 
 imply that the pus cannot have furnished it. A deep layer 
 of pus with mere traces of albumen in the urine leads us to 
 infer that the urine itself is not albuminous. It is, however, 
 often very difficult, or even quite impossible, to get clear evi- 
 dence on these points, and when blood as well as pus is 
 present, the determination of an independent albuminuria, in 
 addition to these, becomes impossible. As already explained 
 in the case of hsematuria, the detection of tube-casts is of 
 great value in determining the presence of renal mischief of 
 some kind ; but these casts are found in cases of renal irrita- 
 tion from calculus and gravel as well as in Bright's disease 
 and the other destructive lesions of the kidney. A tumor in 
 the loins, when present, often indicates for us the source of 
 the pus in the urine (pyonephrosis) ; and the kind of crystals 
 found in the sediment may guide us to a diagnosis of the nature 
 of the concretion in case of calculous pyelitis, and of stone in 
 the bladder. 
 
 The clinical significance of pus in the urine (pyuria) re- 
 sembles somewhat that of hsematuria, and it is equally varied. 
 It may follow acute renal inflammation, and it often appears 
 in cases characterized by copious albuminuria and in cases of 
 Bright's disease following fevers and parturition. It occurs 
 also in renal embolism. As already indicated, the pus may 
 proceed from abscesses in the substance of the kidney, or from 
 suppuration of its ])elvis, due to calculus or to secondary 
 mischief working its way back from the bladder or urethra. 
 
EENAL TUBE CASTS 479 
 
 Perinephritic abscesses may have communications with the 
 kidney. Pelvic and other abscesses opening into the urinary 
 tract ; cystitis, whether of calculous or paralytic origin ; cancer 
 of the bladder ; inflammation and suppuration of the prostate ; 
 gonorrhoea and gleet, whether recent or of old standing, may 
 all give rise to purulent urine. Accidental contamination 
 from lochia! or leucorrhoeal discharges must also be remem- 
 bered as of frequent occurrence. 
 
 Renal Tube Casts 
 
 should ahvays be searched for in cases of albuminuria. They 
 are present in the great majority of cases in which the albumen 
 has a renal origin, but they are occasionally so scanty as to be 
 difficult of detection. The specimen of urine examined for 
 this purpose should have had time to settle thoroughly — for 
 several hours at least ; a conical bottom to receive the sedi- 
 ment is useful when the deposit is scanty ; the supernatant 
 fluid should be cautiously poured off in such a way as not to 
 disturb the deposit, or, if we have any further occasion for it, 
 some of the sediment may be removed from the bottom by the 
 pipette, and a drop placed on a slide with a cover glass may 
 be examined microscopically with a cjuarter-inch lens. Occa- 
 sionally the addition of a little acid to precipitate uric acid 
 crystals, or some other plan of carrying the scanty tube casts 
 mechanically down to the bottom, may facilitate the search. 
 When the reaction of the urine is alkaline, perhaps from the 
 administration of alkaline diuretics, the formation of casts 
 seems to be hindered in the tubes ; if alkaline from decompo- 
 sition, the delicate structure of the tube casts is readily dis- 
 solved and destroyed. When the casts are moderately abun- 
 dant, the only further precautions required are careful illumi- 
 nation and focussing. Many casts are so transparent as to be 
 almost invisible in a strong light, and a narrow diaphragm 
 and some shading, by moving the mirror, may be required to 
 aliow^ of their being caught by the eye. When scanty, a good 
 plan is to put several drops of the sediment in a shallow cell 
 with a cover glass, and examine wdth a low power (half-inch 
 objective) ; or to place a droj^ or two of the sediment on a 
 slide, spread it out (without a cover glass), and pass the whole 
 rapidly in review. If a doubtful structure is seen, requiring 
 a higher power, it can be placed quite in the centre of the 
 field, and the stronger lens brought down upon it ; or, as the 
 object glass is thus apt to dip in the fluid, an attempt may be 
 
480 
 
 URINE AND URINARY SYMPTOMS. 
 
 made to place a cover glass over the doubtful structure, and 
 after finding it as before with the low power, we may come 
 down upon it with a stronger lens to define its character. In 
 this way several drops of the sediment may be examined in 
 rapid succession, and tube casts detected which would other- 
 wise have escaped notice. By filling the pij^ette with the 
 sediment, and allowing it to settle, either by plugging the 
 upper opening or by leaving it to stand in the urine, we some- 
 times obtain a better specimen for microscopic examination 
 when the sediment is scanty and the tube casts few in number. 
 In other cases again, where the field is crowded with cells or 
 granules, dilution with a little water facilitates the search for 
 casts. If pipettes are used, care must be taken to have them 
 well cleaned ; owing to the uncertainty attending this cleans- 
 ing of narrow tubes, it is often better to pour off the urine 
 
 Fig. 76. 
 
 Hyaline, or waxy casts, a, From a case of chronic Bright's disease of eight months' 
 duration, b, From a case of chronic Bright's disease (large white kidney) c, From a 
 case of chronic Bright's disease (contracted kidney, with fattj"^ degeneration). 
 (Roberts.) 
 
 and examine a drop of the deposit placed directly on the slide. 
 Shreds of mucus, strings of the amorphous granules of urates, 
 and vegetable growths sometimes assume forms which simulate 
 tube casts. 
 
EPITHELIAL CASTS. 
 
 481 
 
 Tube casts are of very various sizes, both as regards length 
 and breadth. When of large diameter this should be noted, 
 as it is a poiut of some importance, as indicating a certain di- 
 latation of the renal tubules, or, as some suppose, a loss of the 
 epithelium. They may be (1) perfectly " hyaline " — i. e., clear, 
 transparent, and empty (see Fig. 76). (2) They may be 
 packed full of rows of renal epithelial cells — " epithelial 
 casts " (see Fig. 77, a). (3) The cells thus contained may be 
 quite fatty, with obvious oily globules within them, or such 
 globules may lie within the cast — "oily or fatty casts" (see 
 
 Fig. 77. 
 
 a, Epithelial casts, b, Opaque granular casts, from a case of acute Bright's disease. 
 
 (Roberts. J 
 
 Fig. 78, a). (4t) The fatty element may be in such a minute 
 state of division as to present only a dark granular appearance 
 — " granular casts " (see Fig. 77, 6). Various stages or grada- 
 tions of these four varieties are met with, sometimes even in 
 different parts of the same cast. In addition to these, (5) the 
 casts may contain blood corpuscles, and sometimes only the 
 coloring matter of the blood — " blood casts " (see Fig. 78, 6) ; 
 and in the same way (6) " pus casts " are sometimes seen. In 
 estimating the significance of these different kinds of casts too 
 much importance should not be attached to a single specimen ; 
 
 41 
 
482 
 
 URINE AKD URINARY SYMPTOMS. 
 
 the character of the majority of the casts should rather be 
 kept in view. 
 
 The clinieal significance of tube casts is sometimes consider- 
 able, not only in the differentiation of the various forms of 
 renal disease, but as indicating the actual existence of a renal 
 affection in cases involved in doubt. Thus, in bloody or 
 purulent urine (as explained under these headings), where 
 the origin of the blood or pus is obscure, the existence of tube 
 casts clearly points to a renal element in the case. In rare 
 cases this may be due to a complication perhaps not connected 
 directly with the presence of the blood or the pus itself. 
 Renal tube casts do not, however, imply the existence of 
 Bright's disease, as they may arise from the irritation of a 
 calculus; they are then sometimes found with blood and 
 crystals, but not necessarily with either. Tube casts are found 
 in jaundiced urine, quite apart from any serious renal affections, 
 
 Fig. 78. 
 
 a, Fatty casts, h and c, Blood casts, a, Free fatty molecules. (Rol)erts.) 
 
 and apart even from albuminuria. With regard to the dif- 
 ferent kinds of casts, we may say, in a rough way, that epi- 
 thelial casts and blood casts are found in the earliest stages of 
 an acute parenchymatous nephritis, but very soon thereafter 
 ■we obtain hyaline casts as the predominating type, and when 
 
EPITHELIUM. 
 
 483 
 
 the inflammatory process has gone on to produce fatty changes 
 in epithelium, these changes are reflected in the tube casts. 
 GranuLar casts are found in advanced cases of chronic disease 
 of the kidneys, both of the parenchymatous and interstitial 
 type. Hyaline casts occur both in recent and old cases of 
 these forms of nephritis, and are the usual casts found in 
 lardaceous disease of the kidney. Tube casts, as a rule, are 
 abundant in cases of acute parenchymatous nephritis, less 
 abundant in the more chronic forms, and usually scanty in the 
 lardaceous form of renal disease. The exact forms of albu- 
 minuria, of renal origin, in which tube casts are really absent, 
 cannot be strictly defined ; but when inflammatory changes 
 are absent, mere congestion probably gives rise to but few 
 casts (transient passive congestion, exophthalmic goitre, etc.). 
 
 Fig. 79. 
 
 
 
 Eenal epithelium, a, Natural appearance, b, Atrophied and disintegrated renal 
 cells, c, Eenal cells in a state of fatty degeneration. (Koherts.) 
 
 There is reason to believe that a tube cast may occasionally 
 be detected in urine which is practically normal. 
 
 Epithelium 
 
 of various kinds is often found in urinary sediments on micro- 
 scopic examination, and it is of great importance to determine 
 its character, and, if possible, its origin. Renal epithelium 
 
484 
 
 URINE AND URINARY SYMPTOMS. 
 
 lying loose is recognized as being somewhat globular, and it 
 can sometimes be compared with epithelium contained within 
 tube casts in the same microscopic field. (See Fig. 77, a.) 
 Occasionally it resembles pus corpuscles, and can scarcely be 
 discriminated from them. Its presence forms an important 
 element in the diagnosis of desquamative nephritis both acute 
 and chronic. It undergoes various changes, the cells appear- 
 ing atrophied, or granular, or distinctly fatty. Sometimes 
 
 Epitlielial cells from the l)ladcler, ureter, and pidvis of the kidneJ^ (Roberts.) 
 
 large granular corpuscles are found along with fatty epithelium ; 
 these corpuscles, indeed, proliably result from altered epithelial 
 cells. Changes of this kind in the epithelium shed from the 
 kidneys are very suggestive of the processes going on in these 
 organs. (See Fig. 79.) 
 
 Cells from the bladder often appear as groups of tessellated 
 epithelial cells of circular form; sometimes they are pyra- 
 midal. (See Fig. 80.) 
 
 Tailed epithelium is found in the ureter and pelvis of the 
 kidney, and sometimes the recognition of such is of value in 
 the diagnosis of calculous pyelitis. (See Fig. 80.) Large 
 scaly epithelium is often present as a contamination from the 
 vagina. (Sec Fig. 81.) 
 
SPERMATOZOA, 
 Tig. 81. 
 
 485 
 
 Vaginal epithelium in the urine. (Roherts 
 
 Spekmatozoa, Bacteria, Fungi, Sarcin^, Haiks, 
 Fibres, etc. 
 
 Spermatozoa are occasionally seen in varying numbers in 
 the urine. They appear in large numbers in the urine after 
 seminal emissions, whether physiological or morbid, and a few 
 
 Fig. 82. 
 
 Spermatozoa. (Eoberts.) 
 41^ 
 
486 
 
 URINE AND URINARY SYMPTOMS. 
 
 are often introduced into the urinary passages during straining 
 at stool, etc. When present habitually, they may afford evi- 
 dence of spermatorrhoea. (See Fig. 82.) 
 
 Bacteria, Vibrlones, Micrococci, etc. — When urine undergoes 
 putrefactive changes, vibriones (Fig. 83) and other organisms 
 
 Tig. 83. 
 
 Vibriones in urine. (Roberts.) 
 
 are found in it, of which the most important, so far as the 
 decomposition of the urea is concerned, seems to be the micro- 
 coccus urese. (See Fig. 84, 5.) 
 
 
 Fig. 84. 
 
 ^ "Iff 
 
 / I I • 
 
 Various kinds of bacteroid organisms found in freshly voided urine : a, Bacterium 
 termo ; 6, Micrococcus ureiii ; c and d, Other bacterial forms. (Roberts.) 
 
 But the urine may present bacteria when voided without 
 ordinary decomposition having actually begun in a distinct 
 form, but with an undue proclivity to this. In such cases the 
 urine may be slightly turbid when passed, and this turbidity 
 does not settle down on standing. In cases of men with stric- 
 
SARCINA IN URINE. 
 
 487 
 
 ture, where instruments have been passed, and in women with 
 leucorrhoeal discharges, such urine presents bacteria. (Fig. 
 84, a.) 
 
 Another group of cases presents bacteria in j^erfectly fresh 
 urine Avith an acid reaction which may, indeed, be maintained 
 for days. The urine in such cases may be at first opalescent 
 from the organisms, but these settle down as a sediment. 
 Various forms have been found, as shown in Fig. 84, c and d. 
 Chains or threads of micrococci have also been described by 
 Sir William Roberts as found in freshly voided urine. In 
 studying these cases of " bacteruria," the most scrupulous care 
 must be taken to avoid any possible chance of contamination 
 from imperfectly washed glasses, pipettes, etc. 
 
 Fungi, Mould, Torula. — In acid urines we may see mould 
 growing, and on microscopic examination we may find various 
 forms of fungi with branching growths and spherical spores. 
 These sometimes mislead the student, being mistaken, the 
 former for tube-casts and the latter for blood corpuscles. 
 The early or rapid development of torulae is common in 
 saccharine urine, giving rise to turbidity without putrefaction. 
 Hence, when torulee are abundant, we may be led to search 
 for sugar, but growths of this kind are found apart from this 
 cause. (Compare Figs. 85 and 86.) 
 
 Mould fungus. Sporules and thallus. (Roberts.) 
 
 Sarcince are only rarely found in urine. They arp smaller 
 and paler than those common in the stomach. (See Fig. 60.) 
 They give the urine a turbid appearance when passed, and 
 they settle as a sediment, leaving the urine clear. They are 
 
488 
 
 URINE AND URINARY SYMPTOMS. 
 
 usually associated with more or less distinct symptoms of 
 urinary irritation. 
 
 Foreign Matters. — Cotton, flax, fibres, straw, hairs, and 
 feathers are often present in minute fragments from floating 
 dust from the bedding, etc. Air-bells and oil globules (per- 
 haps from an oiled catheter or an oily bottle used for the 
 sample) often puzzle the beginner. (See Fig. 87.) 
 
 Crystalline and Amorphous Deposits. 
 
 Uric acid can frequently be recognized as a red sand in the 
 urinary deposits, lying at the very bottom and in the corners 
 of the glass, or sometimes adhering to the sides, or entangled 
 in the mucus. Although usually highly colored, the uric acid 
 crystals thrown down from pale urines may be almost color- 
 less. Uric acid itself is without color; it only attracts the 
 pigment of the urine. The forms presented by uric acid, crys- 
 tals are very variable, but they may mostly be reduced to 
 modifications of the rhomb. The plates of Dr. Beale give 
 excellent representations of the variations and forms of aggre- 
 
 FiG. 86. 
 
 Yeast or sugar fungus (toriila cerevisiaj). Sporules and threads of thallus, (Roberts.) 
 
 gation usually met with. The following names applied by 
 Sir William Roberts to the crystals may assist in their recog- 
 
EXTEANEOUS MATTERS FOUND IN URIXE. 489 
 
 nition : quadrangular and oval tablets, cubes, six-sided tablets, 
 lozenges and barrel-shaped figures, stars and spikes, and fan- 
 shaj^ed crystals. (Compare Fig. 88.) The presence of a high 
 
 Fig. 87. 
 
 Extraneous matters found in urine : a, Cotton fibres ; h, Flax fibres ; c, Hairs ; d, Air 
 bubbles ; e, Oil globules ; /, Wheat starch ; g. Potato starch ; Ti, Rice-starch gi-anules ; 
 1, Vegetable tissue ; Tc, Muscular tissue ; 1, Feathers. 
 
 color often leads us to suspect the nature of these crystals 
 when they might otherwise be puzzling, and the detection of 
 
490 
 
 URI^^E AND URINARY SYMPTOMS. 
 
 transition forms from well-known shapes often serves to con- 
 firm our conjectures. Uric acid is very insoluble in water, 
 and it does not disappear on beating tbe sediment — a distinc- 
 tion from tbe deposit of urates. Uric acid is not dissolved by 
 acetic acid ; tbis serves to discriminate colorless uric acid 
 from certain crystalline forms of pbospbate of lime. Uric 
 acid is soluble after a time in caustic alkalies, and alkalies 
 administered internally may exercise a solvent power. Uric 
 acid may be passed in the crystalline form from the bladder, 
 and the crystals may then be seen in the fresh urine as red 
 particles, or as causing a general turbidity ; they are, however, 
 more often only formed and deposited by the urine after stand- 
 ing for a time ; this being due partly to the cooling of the 
 urine and partly to its increasing acidity after it is passed, 
 from a natural acid fermentation. The crystals often increase 
 in size after a time. The addition of a drop or two of strong 
 acid to normal urine precipitates uric acid in crystals. Some- 
 
 Yarious forms uf uric acid cr5'stals, (Selected from Otto Funke's Physiological Atlas,) 
 
 times the precipitate thrown down by the addition of acid to 
 urine consists of a dense mass of amorphous urates which 
 may resolve itself by and by into uric acid crystals. A sedi- 
 ment of uric acid crystals, on being kept till it becomes alka- 
 line, may be converted into hedge-hog crystals of urate of soda. 
 
AMOKPHOUS URATES 
 
 491 
 
 The " murexide test " brings out a beautiful red color on 
 treating uric acid "with nitric acid and ammonia. 
 
 Urates or Uthates are salts of uric acid combined with am- 
 monia, potash, or soda, the exact composition being often very- 
 difficult of determination : these bases would seem to be fre- 
 quently mixed together. Such sediments in the urine are 
 extremely common. They are found in urines which are 
 clear when passed, but become turbid on cooling or after 
 standing for some hours. They are occasionally found in 
 the urine as j^assed, especially in the case of children who 
 pass milky-looking urine; in such cases this sediment, of urate 
 of soda, may be crystalline, presenting the form of globules, 
 either simple or furnished with hedge-hog projections. (See 
 Fig. 89.) 
 
 The common form, however, consists of granules oi amorphous 
 urates (see Fig. 90) ; these often form aggregations so as to 
 assume the shape of ropes or strings, presenting a superficial 
 resemblance to granular tube casts. The microscope cannot 
 ahvays discriminate amorphous urates from an amorphous 
 
 Fig. 90. 
 
 Fig. 89. 
 
 Hedge-hog crystals of urate of 
 soda, spontaneously deposited from 
 the "urine of a child. Eoberts.) 
 
 
 
 Amorphous urate deposit. (Koberts. 
 
 deposit of earthy phosphates, but the reaction usually settles 
 the point : urates are deposited on cooling from acid urines ; 
 phosphates are found with an alkaline or at least a neutral 
 reaction. The use of liquor potassse likcAvise assists, as also 
 the action of heat : both of these dissolve a sediment of urates, 
 but leave phosphates unaffected or may even render such a 
 
492 
 
 URINE AND URINARY SYMPTOMS. 
 
 sediment more dense. The sediments of urates are usually 
 fawn-colored, or pinkish, or even as red as blood. The 
 chemical causes of the precipitation may be considered as 
 connected with the cooling of the urine, with its concentration 
 (from febrile disorders or from scanty supply of fluid), and 
 also with the increasing acidity of the urine after it is passed. 
 Adding a little acid sometimes precipitates urates from a urine 
 in which they may be deposited spontaneously in the course 
 of a day or two. The internal administration of alkalies or 
 diluents often accounts for the disappearance of these sedi- 
 ments under observation. 
 
 The murexide test reveals the presence of uric acid in these 
 deposits. 
 
 Phosphates appear in two distinct forms, amorphous and 
 crystalline ; the crystalline phosphates are of t^vo classes, the 
 
 Ammonio-niagnesian (or "triple ") phosphates. (Selected to show various forms.) 
 
 crystallized phosphate of lime and the ammonio-magnesian (or 
 "triple") phosphate. The phosphatic deposits often form a 
 white sediment somewhat resembling pus. 
 
 The ammonio-magnesian {or triple) phosphate is the com- 
 monest variety, and it may appear in almost any urine which 
 is kept till it decomposes, as the urea thus supplies the ammo- 
 nia for these crystals. The crystals are usually prismatic. 
 They often form on the surftice, appearing as a glittering scum, 
 or the glittering prisms may be seen on the sides of the glass, 
 or entangled in the mucous or purulent sediment. The reac- 
 tion of such urine is usually alkaline, but it may be neutral or 
 faintly acid. Such crystals are sometimes to be seen in the 
 
OXALATE OF LIME. 
 
 493 
 
 urine as it is passed, especially associated with pus, and with an 
 ammoniacal odor, from the decomposition going on within 
 the bladder. The forms of the crystals, although essentially 
 prismatic, undergo various alterations, and sometimes they 
 assume a feathery api^earance. (See Fig. 91) 
 
 Crystallized phosphate of lime apj^ears usually as stars or 
 rods, or as fan-shaped crystals, destitute of color ; other forms 
 are also occasionally met with. The action of acetic acid is 
 useful in distinguishing them from uric acid crystals, when 
 the latter are colorless, as the phosphates are dissolved by this 
 acid and uric acid is not. (See Fig. 92. ) 
 
 Fig. 92. 
 
 Crj'stallized phosphate of lime. (Selected to show various forms.) 
 
 Ainorj)hous sediments of earthy phosphates are occasionally 
 met with in freshly passed urine, apart from disease, giving 
 the urine a slightly milky appearance ; this arises from an 
 accidental alkalinity of the secretion, due perhaps to the kind 
 of food or to some medicine taken immediately before. Boiling 
 the urine (as in testing for albumen) often precipitates the 
 earthy phosphates in alkaline or feebly acid urines, so that 
 the action of alkalies and heat on them is exactly the reverse 
 of what we find with urates. The sediment when unmixed 
 with other deposits is 'at once dissolved on the addition of 
 acetic acid. 
 
 Oxalate of lime deposits can sometimes be recognized 
 by the naked eye as causing a very fine powdery sediment 
 dusted, as it w^ere, over a delicate cloud of mucus ("powdered 
 w^ig" deposit). These sediments occur in acid urines and 
 
 42 
 
494 URINE AND URINARY SYMPTOMS. 
 
 disappear if tlie urine be rendered alkaline by medicines. 
 The crystals are octahedral in shape, but appear at times 
 in somewhat different forms (single or double pyramids). 
 Occasionally they are found in the form of a dumb-bell, or 
 ellipsoidal, or reniform crystals. (For the various forms see 
 Fig. 93.) 
 
 Oxalate of lime crystals are sometimes passed as such from 
 the bladder ( indeed the dumb-bell crystals are alleged to be 
 sometimes formed within the tubules of the kidney), but 
 oxalate of lime is usually crystallized out of the urine after 
 it has passed, and the dimensions of the crystals can often be 
 seen to be increased after a time ; dumb-bells may change into 
 octahedral crystals by keeping. Oxalate of lime is insoluble 
 in acetic acid ; this is at times useful in distinguishing some of 
 
 Oxalate of lime crystals. (Selected to show various forms.) 
 
 the unusual forms from phosphates. Aggregations of minute 
 crystals or microscopic calculi are sometimes formed of very 
 small dumb-bell or pyramidal crystals. 
 
 Other crydaUlne (leposits are occasionally found in urine. 
 Carbonate of lime occurs in little balls. Cystine is found in 
 hexagonal tablets : it is dissolved by ammonia, and this may 
 give on evaporation six-sided tablets or prismatic crystals. 
 (See Fig. 94.) It is a rare deposit, but it is important on ac- 
 count of its forming certain calculi. Tyrosine occurs in 
 needles. (See Fig. 69.) Cholesterine is a rare deposit, it 
 occurs in scales. (See Fig. 78.) Xanthine is also extremely 
 rare. 
 
 The clinical significance of aw oi^ho us and crystalline deposits 
 is not so great as that of pus, blood, and tube casts. 
 
OXALATE OF LIME, 
 
 495 
 
 Uric acid occurring habitually as a sediment, or even the 
 persistence of urates as a deposit, indicates a derangement in 
 the health, pointing to some error in the digestive or hepatic 
 functions, and having perhaps some relation to. the gouty 
 diathesis (Lithiasis, Lithsemia). Very red urates are so fre- 
 quently associated with liver disease as to be useful in direct- 
 ing attention to this organ. Uric acid is often found in cases 
 of Bright's disease in the acute stages. The occasional occur- 
 rence of urates on the cooling of the urine has no real im- 
 portance, and uric acid crystals may likewise appear, at a 
 time, without any special significance. It is the habitual or 
 excessive occurrence of these which is important. They some- 
 times appear at the crisis of fevers, etc. 
 
 Oxalate of lime, in like manner, when deposited habitually 
 
 Fig. 94. 
 
 Cystine. Hexagonal tablets and prisms from evaporated ammoniacal solution. 
 
 (Koberts ) 
 
 and excessively, and in urines of high specific gravity loaded 
 with urea, is often found associated with a train of nervous 
 and dyspeptic symptoms which have been grouped together 
 and named " oxaluria," and are supposed by some to indicate 
 an " oxalic acid diathesis." Oxalates are frequently present 
 in the urine in nervous affections of various kinds. It must 
 
496 URINE AND URIXARY SYMPTOMS. 
 
 be understood, however, that a few oxalates frequently appear 
 in the urine apart from any obvious derangement of the health, 
 and they occur habitually after eating rhubarb and some other 
 articles of diet. The uric acid and the oxalic acid diathesis 
 seem to have certain affinities ; the former is certainly heredi- 
 tary ; it seems to be interchangeable with the latter in some 
 members of the same family, and perhaps at different periods 
 of the same person's history. 
 
 As associated w ith signs and symptoms of renal or vesical 
 calculus and gravel, the appearance of either uric acid or ox- 
 alate of lime crystals is often of great importance in diagnosis 
 and in guiding the treatment. These crystals, when asso- 
 ciated with blood, tube casts, or pus, often point to the site 
 and nature of the illness. The hedge-hog crystals of urate of 
 soda may likewise be sources of renal, vesical, or urethral 
 irritation, and may give rise to calculus. 
 
 Crydallized phosphcde of lime has been supposed to indicate 
 the existence of serious organic disease attended with waste 
 of tissue (phthisis, diabetes, paralysis). It certainly is fre- 
 quently met with in serious nervous affections. 
 
 The triple phosphates (ammonio-magnesian phosphates) have 
 not much significance unless when detected in newdy voided 
 urine; they then indicate that a process of decomposition is 
 going on within the bladder ; they may likewise indicate the 
 nature of vesical concretions in process of formation. 
 
 Persistent deposits of the amorphous earthy phosphates being 
 associated with habitual alkalinity of the urine, are not un- 
 frequently the index of a depressed state of health ; they may 
 also tend to vesical concretions. A similar remark applies to 
 carbonate of lime. 
 
 Tyrosine crystals are occasionally found in typhus and other 
 fevers, and especially in cases of acute yellow atrophy of the 
 liver; the urine usually requires to be evaporated down to 
 obtain these crystals. (See p. 430.) The clinical significance 
 of cystine is not yet clearly made out ; it may form the nucleus 
 of a calculus. 
 
 Scheme of Systematic Qualitative Analysis of 
 Urinary Calculi (^Thudichum). 
 
 Powder the calculus. Heat a small portion of the powder to red- 
 ness on some platinum foil, and observe whether any residue is left 
 which will not burn off. 
 
 A. In case it leaves a fixed residue, take a small portion of the 
 original calculus, dissolve in concentrated nitric acid, evaporate to 
 
BILE IN URINE. 497 
 
 dryness on a water bath in a white porcelain evaporating dish ; dip a 
 glass rod into the strongest ammonia, and bring it near the residue in 
 the dish, and observe whether a pink color is produced or not. 
 (" Murexide test.") 
 
 I. A pink color is produced, proving that the calculus contains 
 uric acid ; observe whether a portion of the calculus melts on being 
 heated. 
 
 a. It melts — 
 
 (1) And communicates a strong j-ellow color to the flame of a 
 spirit lamp or Bunsen burner: sodium urate. 
 
 (2) And communicates a violet color to the flame, giving the 
 potassium spectrum : potassium urate. 
 
 h. It does not melt; dissolve the residue left after ignition in a 
 little dilute hydrochloric acid, add ammonia till alkaline, and then 
 ammonium carbonate solution. 
 
 (1) A white precipitate falls: calcium, urate. 
 
 (2) ISTo precipitate ; add some hydric sodic phosphate solution ; a 
 white crystalline precipitate falls : tnagnesium, urate. 
 
 II. No pink color is produced. Observe whether a portion of the 
 calculus melts on being heated strongly. 
 
 a. It melts (fusible calculus). Treat the residue with acetic acid; 
 it dissolves ; add to the solution ammonia in excess ; a white crystal- 
 line precipitate falls : ammonio-magnesium phosphate. In case the 
 melted residue is insoluble in acetic acid, treat with hydrochloric 
 acid ; it dissolves. Add to the solution ammonia ; a white precipitate 
 indicates calcium phosphate. 
 
 b. It does not melt; moisten the residue with water and test its 
 reaction with litmus paper; it is not alkaline. Treat with hydro- 
 chloric acid, it dissolves without effervescence. Add to the solution 
 ammonia in excess, white precipitate : calcium phosphate. Treat the 
 calculus with acetic acid ; it does not dissolve. Treat the residue 
 after heating with acetic acid, it dissolves with effervescence : calcium 
 oxalate. Treat the original calculus with acetic acid, it dissolves with 
 effervescence : calcium carbonate. 
 
 B. The calculus on being heated does not leave a fixed residue. 
 Treat a portion of the calculus with nitric acid, evaporate and expose 
 to ammonia vapor as before. (" Murexide test.") 
 
 I. A pink color is developed. 
 
 a. Mix a portion of the powdered calculus with a little lime and 
 moisten with a little water ; ammonia is evolved and a red litmus 
 paper suspended over the mass is turned blue : ammonium urate. 
 
 b. No ammonia : uric acid. 
 
 II. ISTo pink color is developed. 
 
 a. But the nitric acid solution turns yellow as it is evaporated, and 
 leaves a residue insoluble in potassium carbonate : xanthine. 
 
 b. The nitric acid solution turns dark brown and leaves a residue 
 soluble in ammonia : cystine. 
 
 Bile in Urine 
 
 can often be recognized by the eye when present in any quan- 
 tity. Moreover, when testing for albumen by nitric acid, the 
 
 42* 
 
498 URINE AND URINARY SYMPTOMS. 
 
 peculiar greenish reaction produced by bile usually attracts 
 attention ; indeed, bile in the urine may be tested for by using 
 nitric acid by the " contact method : " dilution of the nitric 
 acid with three volumes of water rather favors the distinct- 
 ness with which the green reaction is brought out. Another 
 way of applying this test with nitric acid consists in placing 
 a drop or two of urine and a drop or two of strong nitric acid 
 on adjacent parts of a white ])late, and allowing the one to 
 run into the other. The commingling of the fluids should be 
 closely watched in good daylight, when a beautiful play of 
 colors is observed — including brown, green, blue, violet, red, 
 and yellow. Or a little acid may be dropped into the midst 
 of some urine placed on a plate, or on a white sheet of note 
 paper, when a similar reaction occurs. 
 
 The iodine test is also useful ; it likewise develops a green 
 reaction. Two or three drops of the tincture of iodine of the 
 British Pharmacopa^ia cautiously floated on to the surface of 
 the bilious urine in a test tube, by means of a pipette, bring 
 out the green color. If the urine be very highly colored it 
 may be diluted with water beforehand. The tincture of iodine 
 may also be diluted with two volumes of rectified spirit, as 
 too much iodine impairs the distinctness of the green color. 
 These tests apply only to hlle pigment. Rhubarb, santonine, 
 and senna impart a color to the urine somewhat resembling 
 the tinge of bile; the addition of liquor potassse converts this 
 into a fine red color. 
 
 A test for the biliary acids has been introduced, but it does 
 not give reliable results as applied to a complex fluid like 
 the urine. Two drachms of urine are introduced into a test 
 tube, a small piece of loaf sugar is added, and a drachm of 
 strong sulphuric acid is poured gently down the side of the 
 glass ; if the biliary acids are present, a deep purple color is 
 produced at the line of junction ; a brown instead of a jxirple 
 color indicates their absence. (Pettenkofer's test.) This 
 test, however, has not been found of much clinical value. 
 
 Of late an acidulated antiseptic solution of artificial pep- 
 tones has been proposed by Dr. Oliver as a test for the bile 
 acids or bile salts. For the details and precautions to be 
 observed the reader is referred to Dr. Oliver's Avork. The 
 test has not as yet been long in use. 
 
 The clinical significance of bile in the urine corresponds with 
 that of jaundice. (See p. 425.) Its presence or absence 
 assists in the differentiation of discolorations of the skin or of 
 the conjunctiva due to other causes. It likewise seems occa- 
 
. THE ESTIMATION OF UKEA. 499 
 
 sionally to indicate an incipient jaundice before the tissues 
 generally are affected, and its disappearance from the urine 
 sometimes affords evidence that the attack is passing off, 
 although the jaundice elsewhere may still remain very visible. 
 The presence of bile pigment may serve to explain, so far, the 
 existence of tube casts in urine, as already noticed under the 
 heading of tube casts, or, at least, to give their presence a less 
 serious significance. (See p. 482.) 
 
 Chloeides 
 
 are always present abundantly in normal urine. They are 
 often diminished, or almost suppressed, in several febrile dis- 
 eases, especially in pneumonia. The quantity may be roughly 
 determined by adding a little of a strong solution of nitrate 
 of silver to the urine, a few drops of strong nitric acid having 
 been added previously. The denseness of the precipitate, or 
 its relative abundance when the sediment falls down, serves 
 to indicate the quantity ; a sample of normal urine, treated in 
 the same way, may be used as a basis of comparison. This 
 precipitate of the chloride of silver (insoluble in nitric acid) 
 is soluble in ammonia. Albumen, if present, must be separ- 
 ated before testing for chlorides, as it also is thrown down by 
 nitrate of silver. Of course, an accurate quantitative estima- 
 tion can be made by the usual chemical methods if desired. 
 
 The Estimation of Urea 
 
 contained in urine affords valuable data in certain physiologi- 
 cal and pathological inquiries. It has been made out, how- 
 ever, that the quantity of nitrogen eliminated by the urine 
 depends more on the quantity taken in as food than on any- 
 thing else, so that if we aim at scientific precision, an analy- 
 sis of the food taken is almost required to give value to the 
 quantitative analysis of the urea. Albumen, if present, 
 should be separated by boiling, before beginning the estima- 
 tion of the urea. The natural excretion of urea may be 
 quoted roughly at 500 grains per day for a male adult, or 3j 
 grains per pound weight of his body (33.18 grammes; or 
 0.5 gramme per 1 kilo, of body-weight). 
 
 The specific gravity of the urine (in the absence of sugar) 
 usually gives a fair indication of the quantity of urea being 
 excreted. Occasionally, by the rapid crystallization of nitrate 
 of urea, on the addition of nitric acid to the cold urine, we 
 
500 URINE AND URINARY SYMPTOM^. 
 
 have evidence of its presence in excess. For very accurate 
 results, probably the best plan is to determine the total nitro- 
 gen by the ordinary processes followed by chemists in an 
 ultimate organic analysis ; but this, of course, is not available 
 in clinical practice. 
 
 Two volumetric processes for the estimation of urea are 
 employed, both of which afford moderately accurate results. 
 
 lAebig's Method is based on the principle of the precipitability of 
 urea by mercuric nitrate, and further, on the circumstances that the 
 white precipitate thereby produced is not decomposed, and, therefore, 
 not turned yellow by carbonate of sodium. (This yellow color results 
 from the formation of oxide of mercury, or basic nitrate of mercury, 
 or carbonate of mercury.) It is necessary also to separate from the 
 urine, before operating on it, the phosphates and sulphates, so that the 
 urine requires first to be prepared by treating it with baryta-water 
 and a solution of nitrate of barium. A further preliminary proceed- 
 ing consists in determining the quantity of chloride of sodium present, 
 as the reaction does not occur till the whole of the chloride of sodium 
 is decomposed and converted into nitrate of sodium. This may be 
 estimated by noticing the amount of mercurial solution added from 
 the burette before the white precipitate begins to appear; or the 
 amount may be determined more accurately by precipitation with 
 silver. A further difficulty arises from the fact that this mercury 
 process is only accurate when the proportion of the urea in solution 
 amounts to two per cent., so that an allowance must be made in carry- 
 ing out the process when the results indicate that more or less than 
 this amount is actually present. 
 
 It is somewhat difficult to prepare accurately in its proper strength 
 the solution of mercuric nitrate; indeed, the most satisfactory way is 
 to dilute a solution of pure mercuric nitrate so as to correspond with a 
 definite quantity of urea when this has been ascertained by precipita- 
 tion from a pure solution of urea in water. The solution may also be 
 purchased fiom certain makers. (Griffin, Bunhill Row, London.) 
 
 Details of Liebig's Method. — (Dr. Michael Foster, Watts' Diction- 
 ary of Chemistry., "Urine," vol. v. p. 966. London, 1874.) ^^ Pre- 
 pared urine (if albumen be present it must be separated by boiling, 
 some urea will probably be lost). Two volumes of urine are mixed 
 with one volume of a ' baryta mixture ' (consisting of two volumes of 
 baryta-water to one volume of a solution of barium nitrate, both 
 saturated in the cold), and filtered. Urea, solution: 2 grammes of 
 pure urea are dissolved in water and the solution diluted to 100 c. c. 
 — Mercurial solution : a concentrated solution of pure mercuric nitrate 
 is diluted with four times its bulk of water. 10 c. c. of the urea solu- 
 tion are measured into a beaker, and the mercurial solution is slowly 
 added from a burette as long as any precipitation takes place; a drop 
 of the mixture is then let fall by a glass rod into a drop of a solution 
 of sodic carbonate (say about 20 grains to the ounce) placed in a watch 
 glass, or on a glass plate, over some black surface. If the precipitat 
 which occurs on the mingling of the two drops does not become in a 
 few seconds distinctly yellow, more of the mercurial solution must be 
 
VOLUMETKIC ESTIMATION OF UREA. 501 
 
 added to the mixture in the beaker and the trial made again. As 
 soon as a distinct yellow color appears (the shade being noticed by the 
 observer in order to guide him afterward), the trial drops are returned 
 into the beaker, and a little of the soda solution added until the mix- 
 ture is only faintly acid. A drop is then again to be tried with the 
 soda solution, and if the yellow color does not show itself, a small 
 quantity of the mercuriarsolution must still be added to the mixture 
 in the beaker and the trial made again. When the yellow color has 
 been thus obtained, the total quantity of mercurial solution used is 
 read off; it corresponds to 0.2 gramme urea. The mercurial solution 
 itself is then diluted according to these results, so that 20 c.c. of it 
 correspond, to 10 grammes of the urea solution — i. e., so that 10 c. c. 
 correspond to 0.1 gramme urea. It is well not to add, at once, the 
 whole of the water required, but to stop a little short of that and 
 titrate again, since practically the degree of dilution required is rather 
 less than that suggested bj^ calculation. 
 
 ^'Method. — Of' the pj^ejmred urine 15 c. c. (corresponding to 10 c. c. 
 of the original urine) are poured out into a beaker or flask, and the 
 mercurial solution is added until the yellow reaction, as described 
 above, is obtained; the mixture is also in the same way reduced in 
 acidity and trial made again. The quantity of mercurial solution 
 used will give the amountof urea in the 10 c. c. of urine. Unfortu- 
 nately the reaction is exact only for fluids containing 2 per cent, of 
 urea ; its appearance is permature when more, and is delayed when 
 less than that percentage is present. If the prepared urine contains 
 an excess of urea, double its volume of the mercurial solution will 
 have been used and yet no reaction set in. Hence if, on arriving at 
 this point, 1 c. c. of distilled water be added to the mixture for every 
 additional 2 c. c. of the mercurial solution employed, the proportion 
 of urea will be maintained at 2 per cent, and the final result will be 
 correct. Thus if, after the addition of . 80 c. c. of mercurial solution 
 to 15 c. c. of the prepared urine the reaction is not seen, 1 c. c. of dis- 
 tilled water is added and the process continued. Supposing the reac- 
 tion finally sets in when 10 c. c. more, or 40 c. c. in all, of the mer- 
 curial solution have been used, the 5 c. c of distilled water, which 
 have been also added, will bring up the original 15 c. c. of urine to 
 20 c. c. ; the 40 c. c. of mercurial solution will have been employed 
 on a fluid containing 2 per cent, of urea. 
 
 " If the prepared urine contains less than 2 per cent, of urea an ap- 
 proximate correction may be made by subtracting 0.1 c. c. from every 
 5 c. c. of the mercurial solution that is run short of the normal 30 c. c." 
 Thus, if with 15 c. c. of prepared urine the yellow color is struck on 
 using 20 c. c. of the mercurial solution, 0.2 c. c. (30 — 20 = 5 X 2) are 
 deducted, and, therefore, 19.8 c. c. taken as the correct result. A 
 further correction must be made for chloride of sodium, the presence 
 of which delays the reaction. "We may make an approximate cor- 
 rection by deducting from the quantity of mercurial solution employed 
 1.6 c. c. — 2.5 c. c, according to the"^quantity of chloride of sodium 
 present. Or we may first remove the chloride. To 15 c. c. of prepared 
 urine one or two drops of solution of neutral chromate of potash are 
 added, and a solution of nitrate of silver dropped in from a burette, 
 until the appearance of the red chromate of silver indicates that the 
 whole of the chloride has been thrown down : the mercurial solution 
 
502 
 
 URINE AND URINARY SYMPTOMS 
 
 can then beat once used without removing the silver precipitate. The 
 reduction in the percentage of urea by the addition of the silver solu- 
 tion must, of course, be taken into account. Or two portions of pre- 
 pared urine may be taken of 15 c. c. each. One is neutralized with 
 nitric acid, the mercurial solution added, and the point marked at 
 
 Fig. 95. 
 
 Apjohn's apparatus for the estimation of urea by the hypobromite of sodium solution. 
 
 which a permanent precipitate (a distinct cloud, not a mere opales- 
 ence) is produced. The other is titrated in the usual way. The 
 number of c. c. employed in the latter, minus those employed in the 
 former operation, will give the real quantity of urea. 
 
 " It must be remembered that other nitrogenous bodies, creatinine, 
 allantoin, etc., are precipitated by the mercurial solution in the same 
 way as urea." 
 
 Hypo-bromite of Sodium, Process for Ksiimating Urea. — Davy's 
 process (by hypo-chlorite of sodium) has been modified and adapted 
 for clinical purposes by Esbach, of Paris, Eussell and West, and 
 Apjohn. The process consists in estimating the quantity of nitrogen 
 given off" when a solution of urea is mixed with a hypo-bromite solu- 
 tion. This last-named solution is very readily changed b}' keeping, 
 and so must be made fresh. It is composed of 100 grammes of caustic 
 soda, 250 c. c. of water, and 25 c.c. of bromine, all shaken up together. 
 (Of course the soda solution can be kept and the bromine added in 
 proper proportion when wanted, so as to be used fresh.) The follow- 
 ing is the description of Apjohn's process [Chemical News, Jan. 22, 
 1875). Theinstruments are such as may be found in any laboratory; 
 they are : (1) A glass measuring tube of about a foot in length, drawn 
 out at the end, which will be uppermost when the tube is used, like a 
 Mohr's burette, and sub-divided into 30 parts of equal capacity, the 
 aggregate volume of which is 55 c. c. (2) A small wide-mouthed gas 
 bottle of about 60 c.c. capacity. (3) A short test tube of about 10 c. c. 
 capacity, of such a height that when introduced into the gas bottle it 
 
VOLUMETEIC ESTIMATION OF UKEA. 503 
 
 will stand within it in a slightly inclined position. (See Fig. 95.) 
 [Various other adaptations of this method, and special forms of appa- 
 ratus, are in use for clinical work.] 
 
 The following are the arrangements for combining the apparatus 
 and working an experiment: The graduated tube, held in a clamp 
 attached to a retort stand, is depressed into a glass cylinder nearly filled 
 with water until the zero mark, which is near the upper end, exactly 
 coincides with the surface of the water. Fifteen c. c. of the hypo- 
 bromite solution having been poured into the flask, the test-tube con- 
 taining the urine is introduced by means of forceps, care being taken 
 that none of its contents shall spill into the hypo-bromite. The flask 
 is now closed with a very accurately fitting India-rubber stopper, per- 
 forated with a hole, in which is inserted a short piece of glass tubing 
 open at both ends, and is then connected with the measuring tube by 
 means of a piece of elastic tubing. It is now inclined so as to allow 
 the urine to mix with the hypo-bromite. Effervescence at once com- 
 mences, and as it proceeds the measuring tube is gradually raised, so 
 as to relieve the disengaged nitrogen from the h3^drostatic pressure. 
 The flask is shaken a few times, and when the reaction is completely 
 over, the apparatus is left for a few minutes until it has acquired the 
 temperature of the room in which the experiment is performed. 
 Another exact levelling of the measuring tube is made, and the num- 
 ber of the division corresponding to the volume of the developed 
 nitrogen is read off". Fifty-five c.c. of the nitrogen correspond to 0.15 
 gramme of urea, so that a single division corresponds to 0.005 gramme 
 of urea. If, therefore, we use 5 c.c. of urine, each measure of the 
 nitrogen evolved will correspond to 0.1 per cent, of urea (or 0.44 grain 
 per fluid-ounce). 
 
 Variations occur, of course, in the measured gas from the effect of 
 changes in the temperature and barometric pressure, but the advocates 
 of this method allege that these are inconsiderable in ordinary clinical 
 work. Other nitrogenous principles are also included with the urea in 
 the estimation by this method. Albumen, if present, must be sepa- 
 rated beforehand. 
 
 Of course the total urine passed must be known, in order to esti- 
 mate the total amount of urea excreted. 
 
 CoMPLAI?^TS BY PaTIENTS REGARDING UrINARY 
 
 Symptoms, etc. 
 
 Patients sometimes call attention to alterations in the ap- 
 pearance of their urine, of which it is imj^ortant to be able to 
 form some judgment. In the section on the " Obvious Char- 
 acteristics of Urine " these have been considered. 
 
 Frequency and j^ctin in micturition are often complained of 
 by patients, either with or without the consciousness of some 
 connection between these symptoms and other urinary dis- 
 orders. The student of clinical medicine must never forget 
 that these are important symptoms of surgical as well as 
 medical diseases. Frequency of micturition may be due to 
 
504 URINE AND URINARY SYMPTOMS. 
 
 stricture of the urethra, and it is very common in elderly men 
 with enlarged prostate; in women it occurs in connection 
 with uterine irritation, and with displacements of the womb. 
 Increased frequency in micturition may be due simply to 
 irritability of the urinary organs, but it is also often of value 
 in calling attention to, or marking the date of, an actual in- 
 crease in the secretion of urine, as in diabetes, and in certain 
 forms of chronic renal disease. In the early stage of both of 
 these tlie patient may find that he has begun to get up at night 
 to pass water, and although he may attribute this to his being 
 thirsty, and to his drinking more water than usual, the thirst 
 and the increased urine may be due to the same cause. Fre- 
 quency and pain in micturition often occur in nephritis, 
 strangury, cystitis, and also from calculus in the kidney, ureter, 
 or bladder. Scalding or pain in making water is often com- 
 2)lained of in the febrile state ; this is associated Avith the 
 secretion of a highly acid and concentrated urine ; it is also 
 often due to gritty matter (gravel) in the urine : and to 
 irritation of the urethra from gonorrhoea. In women it is not 
 unfrequently due to small vascular growths at the orifice of 
 the meatus urinarius, and occasionally to prolapsus of the 
 urethra itself: these are very apt to escape attention, as their 
 situation makes it a matter of much delicacy to examine the 
 parts thoroughly. In male children the pain in micturition 
 may be due to the irritation of a phimosis. Fissure of the 
 anus, and other affections of the rectum, or disease in its 
 neighborhood, often give rise to pain in passing water. These 
 various causes may have to be considered and decided on by 
 an ocular, or surgical, or instrumental examination of the 
 meatus, the urethra, the bladder, the womb, or the rectum. 
 Not unfrequently the presence of blood in the urine, its color, 
 and the manner of its coming, whether diffused in the urine or 
 appearing as a few drops at the end of micturition, may assist 
 the diagnosis. The presence of pus likewise in the urine, and 
 the character and situation of the pain, are of great value in 
 the study of such cases. (See *' Blood and Pus," pp. 470 and 
 474.) Any supposed cause of the painful attack, such as 
 injuries, or special exertions from riding, jolting, etc., should 
 be carefully inquired into. (See also the section on ".Paralysis 
 of the Bladder," p. 229.) 
 
 Tlie following gonerul treatises may be referred to : Roberts (Sir 
 William), Practical Treatii^e on Urinary and llenal Disease, 4th edi- 
 tion, London, 1885. — Dickinson, Diseases of the Kidney and Urinary 
 
BIBLIOGRAPHY. 505 
 
 Derangements, Part I., Diabetes (1875); Part 11., Albuminuria 
 (1877) ; Part III., Mincellaneous Aifections of the Kidneys and 
 Urine (1885), London, 1875-85. — Ralfe, Diseases of the Kidneys and 
 Urinary Derangements, London, 1885. — Thompson (Sir Henry), 
 Clinical Lectures on Diseases of the Urinary Organs, 6ih edition, 
 London, 1882. — Morris, Surgical Diseases of the Kidney, London, 
 188G. — Gruyon et Baz}^, Atlas des Maladies des Voies Urinaires, Paris, 
 1886. 
 
 For urine testing, in addition to general treatises given above: 
 Thudichum, Treatise on the Pathology of the Urine, including a 
 Complete Guide to its Analysis, 2d edition, London, 1877. — Ealfe, 
 Clinical Chemistry, London, 1883. — Johnson (Geo.), Various Modes 
 of Testing for Albumen and Sugar in the Urine, London, 1884. — 
 Oliver (G.), Bedside Urine Testing, 3d edition, London, 1885. — 
 MacMunn, The Spectroscope in Medicine, London, 1880. — Neubauer 
 and Vogel, Guide to the Qualitative and Quantitative Analysis of the 
 Urine, translated for the New Sydenham Society, London, 1865; for 
 the recent views of these writers reference must be made to subsequent 
 editions in German (and in French translations) of this standard work. 
 — Salkowski und Leube, Die Lehre vom Harn, Berlin, 1882. — Puhl- 
 mann, Die Chemisch-j\Iicroscopische Untersuchung des Harns, 3te 
 Afl., Berlin, 1885 — Works on organic chemistry must also be con- 
 sulted for special purposes — e, g.^ Hoppe-Seyler, Physiologische 
 Chemie, Berlin, 1877-81. — Charles, Physiological and Pathological 
 Chemistry, London, 1884. 
 
 For illustrations of urinary deposits: Beale, Kidney Diseases, 
 Urinary Deposits, and Calculous Disorders, 3d edition, London, 
 1869; his Plates are also published separately, 2d edition, London, 
 1869. — Whittaker, The Students' Primer on the Urine (with etchings), 
 London, 1880. 
 
 Special treatises must also be referred to for particular diseases : 
 Pavy, Nature and Treatment of Diabetes, 2d edition, London, 1869. 
 — Frerichs, Ueber den Diabetes, Berlin, 1884. — Johnson (Geo.), 
 Lectures on Bright's Disease, London, 1873. — Grainger Stewart, 
 Practical Treatise on Bright's Diseases of the Kidney, 2d edition, 
 Edinburgh, 1871. — Monuenoux, Les Matieres grasses dans I'Urine, 2 
 vols., Paris, 1884; this work gives an elaborate account of chyluria 
 and other rare conditions. — Senator, Albuminuria in Health and 
 Disease, translated for New Sydenham Society, London, 1884. 
 
 The following great works have a permanent value : Bright, Ke- 
 ports of Medical Cases, vol. i., London, 1827. — Payer, Traite des 
 Maladies des Eeins (3 vols., with large folio Atlas), Paris, 1837-41. 
 
 43 
 
CHAPTER XIV. 
 
 SYMPTOMS CONNECTED WITH THE MALE 
 GENERATIVE ORGANS. 
 
 Disturbances of the generative organs in the male come, 
 for the most part, under the notice of surgeons, and reference 
 must be made to surgical treatises or to special works for de- 
 tails on this subject. Complaints, however, are sometimes 
 made to physicians also, concerning impaired or disordered 
 functions in these parts, and various nervous diseases arise 
 from sexual excesses and abuses. The chief complaints met 
 with in medical practice are connected with impotence, semi- 
 nal discharges, and masturbatiou. 
 
 Impotence supervenes in the course of paralysis, and is very 
 common in those forms of spinal paralysis which involve the 
 bladder and rectum. Its occurrence in such cases is not due 
 directly to sexual excesses, even although the paralysis on 
 which it depends may have been brought about in this way. 
 Premature impotence, however, apart from other paralysis, is 
 apt to arise at a comparatively early age in those who have 
 erred in this respect. In locomotor ataxy there is sometimes 
 an impairment of this function : it has been alleged that this 
 disease differs from other forms of spinal paralysis in this re- 
 spect, and that there may be even an excessive aptitude for 
 frequent indulgence : this, however, seems to have been greatly 
 overstated, although it may be an early symptom in a few 
 cases. Locomotor ataxy is well known to depend not unfre- 
 quently on sexual excess in the case of men. 
 
 Various debilitating diseases, diabetes for example, are 
 characterized by impotence as part, apparently, of the general 
 debility. This is much less marked, or notably absent, in 
 some other exhausting diseases, and especially in phthisis. 
 
 Impotence is sometimes imagined or dreaded by patients 
 without there being any good grounds for the opinion ; and 
 the idea sometimes seizes possession of the mind in such a form 
 as to constitute a species of insanity. Prolonged brooding on 
 such subjects, and the reading of quackish, or even of legiti- 
 mate, medical dissertations on the consequences of nuisturba- 
 tion, etc., are apt in certain minds to foster the delusion and 
 to upset the calmness of reason. If the organs seem sound 
 on examination, and if there continue to be indications of 
 
PEIAPISM MASTURBATION 507 
 
 functional activity in them, we can reassure our patients. 
 Points of importance in the character of the impotence, such 
 as the following, have sometimes to be determined in view of 
 the treatment : The absence of sexual desire ; more or less 
 anaesthesia of the glans penis ; imperfection or weakness in 
 the erection, from defect in the muscles concerned, or from 
 other causes ; premature emission. 
 
 Priapism (excessive or permanent erection) is an occasional 
 symptom in spinal paralysis (myelitis especially), but no indi- 
 cations of sjoecial value can be drawn from its presence. It 
 has been specially noted in cases of injury to the cervical and 
 lumbar regions of the spine. It has been reported to occur 
 at times in cerebral cases also. 
 
 Madurhation is credited with the production of an untold 
 number of ills, both bodily and mental. While the practice 
 is highly pernicious, especially if long continued and fre- 
 quently repeated, it is probable that its influence has been 
 overstated, especially in connection with the causation of in- 
 sanity, although, no doubt, it sometimes leads to mental dis- 
 order. (See p. 316.) The possibility of excessive, or uncon- 
 trollable masturbation, like excessive drunkenness, being 
 sometimes due to the insane tendency of the patient, instead 
 of the cause of the insanity, must be borne in mind. The 
 frequent practice of masturbation, however, may produce 
 various nervous diseases, just as we find that excessive sexual 
 indulgence, even in the married state, may do ; and the great 
 frequency of the opportunities presented to the masturbator 
 in gratifying his desire, accounts probably for part of the 
 special evils which arise in his case. Excess in venery, which 
 is often carried to an extreme by some who are newly married, 
 and occasionally continued by them to an unreasonable extent, 
 may give rise to palpitations, pulsation in the epigastrium, 
 debility, dilatation of the pupils, and nervousness in various 
 forms ; among the more serious forms of disorder, due to the 
 various forms of excess, may be named spinal paralysis, loco- 
 motor ataxy, and convulsions. Mental disorder is supposed 
 to arise at times from this cause. (See p. 315.) 
 
 It should be remembered, in presence of anomalous nervous 
 symptoms, that even very young children sometimes practise 
 masturbation, and this may arise from some mechanical irri- 
 tation in the parts, or from less obvious causes (such as 
 diabetes) connected with the organs. In boys, pulsation at 
 the epigastrium and dilatation of the pupils, a languid frame 
 of mind and other nervous disturbances may arise from this 
 cause. 
 
508 l;ISORDEES OF MALE GENITAL ORGANS. 
 
 Seminal discharges may likewise assume a greatly exagger- 
 ated importance in the minds of patients from the pernicious 
 influence of quack literature, or the reading of medical books. 
 The terrors held over their patients by quacks in connection 
 Avith this have a disastrous influence on many persons. A 
 certain frequency of these emissions is natural to young men 
 Avho lead a chaste life, and their frequency is often increased 
 by studious or sedentary habits, and the attendant dyspepsia 
 and constipation so common in such persons. A course of 
 prurient reading also favors this unnatural frequency. When 
 the emissions occur every night, or twice or thrice a week, the 
 condition is certainly unnatural (although not necessarily 
 alarming), and this is the more certain if the discharges occur 
 without the patient being aware of their coming away, or if 
 they occur during the day, or without any previous erection. 
 Patients sometimes complain very much of this symptom, and 
 allege the frequent passing of semen in their urine. This 
 does occur at times, but the milkiness and turbidity com- 
 plained of are not unfrequently due merely to phosphatic 
 deposits occurring in the alkaline urine within the bladder. 
 Chemical and microscopic tests can set such doubts at rest. 
 Another form of discharge comi^lained of consists of a little 
 clear glairy fluid, like white of egg frequently or constantly 
 exuding from the urethra. This is due to prostatic or some 
 other than the seminal secretion, and has not much signifi- 
 cance, although it is increased by the same influences Avhich 
 favor frequent seminal emissions. When from the account 
 given, or from the frequent or habitual presence of sperma- 
 tozoa in the urine, we are satisfied of the existence of a mor- 
 bid condition, we must inquire whether any unnatural excita- 
 tion of the parts has been caused by masturbation, a practice 
 which patients, as a rule, do not readily confess. The general 
 health and habits, the state of the stomach and bowels, and 
 the use of stimulating food or drink late at night must be in- 
 quired into. 
 
 This condition is often found to be associated with a most 
 distressed state of mind, want of energy, depression of spirits, 
 with perhaps actual weakness and incapacity for work ; the 
 patients seem often to foster the idea of their dreadful condi- 
 tion and refuse all hope and consolation. This state is often 
 associated with other abnormalities, particularly frequent 
 alkalinity of the urine, or the deposit of oxalates with a high 
 specific gravity of the urine ; it disappears with improved 
 health and active occupation. 
 
CHAPTER XV. 
 
 DISORDERS OF THE EEMALE ORGANS, AND THEIR 
 RELATIONS TO THE GENERAL HEALTH. 
 
 Menstruation and its Disorders. 
 
 Students often experience considerable difficulty at first 
 in conducting inquiries on these subjects. What are the points 
 regarding which information is to be elicited? How are the 
 questions to be put? The inquiry can always be conducted 
 Avith such refinement as will not offend any proper delicacy of 
 feeling ; on the other hand an unfavorable impression may 
 readily be conveyed to the mind of the j^atient by the form or 
 mode of putting a question. 
 
 In many cases a few general questions are all that is neces- 
 sary. In hospital practice, where the cases are fully recorded, 
 inquiries should always be made as to these functions ; but in 
 private practice it is well to abstain unless there is a clear 
 necessity. When the patients are young, inquiries should, 
 when possible, be made through the parents ; at all events the 
 subject should be introduced through them. 
 
 It is well to lead up to the subject, or to introduce it with 
 a special bearing upon the symptoms complained of. Thus 
 one question may introduce another. Having asked if the 
 bowels are " regular," there may next come, " And are you 
 regular in your own health ? " " Not too often or too much 
 at a time ? " Or if some special pain or deranged function is 
 complained of, the subject may be introduced by asking, " Do 
 you suffer in this way more at the times you are unwell than 
 between times ? " — and then follow the further questions. It 
 is well even at times to offer some such explanation as " Symp- 
 toms such as you have are often dependent upon derangements 
 of your own health." Women do not understand the term 
 "menstruation." It is known to them as their "courses" or 
 " periods." They speak of " changing " or " altering," of 
 "being poorly" or "unwell," of being "regular" or ''not 
 regular;" they wdll say "I have seen nothing for such or 
 such a time," or "My own has left me." 
 
 Normal Menstruation. — The functional activity of the 
 female generative organs is normally manifested by the 
 
 43^ 
 
510 DISORDERS OF THE FEMALE ORGANS. 
 
 periodic discharge of blood, which constitutes what is termed 
 menstruation. The points regarding which inquiry is to be 
 made, or, in other words, the evidence by which the healthy 
 performance of the function is to be determined are : (1) The 
 regularity of the return ; (2) the duration of the flow ; (3) 
 the quantity of the discharge ; and (4) the amount of local or 
 general disturbance which accompanies it. There is an aver- 
 age standard which is taken as the guide, but each case must 
 also be judged by the individual habit. 
 
 (1) The interval between the first day of menstruation and 
 its reappearance at the next period is generally reckoned as 
 twenty-eight days or four weeks. The time, however, is not 
 fixed or definite, but varies in different individuals, and even 
 in the same person. Normally it oscillates between certain 
 limits, Avhich may be taken as from twenty -five to thirty two 
 days ; and the average for one woman may be twenty-seven, 
 for another twentv-nine. (2) The duration of the discharge 
 likewise varies in different individuals— from two, or even one 
 day, to eight days. (3) Some lose but little blood, others a 
 considerable quantity. (4) Some suffer no inconvenience, 
 whilst others have considerable local pain. The individual 
 habit, therefore, must always be ascertained and taken as the 
 criterion of healthy function, rather than any general standard. 
 What in one person may be normal may in another be evi- 
 dence of excess or defect. 
 
 It is not sufficient to recive a simple affirmative reply to the 
 question, " Are you quite regular?" Many ^vomen will say 
 they are, when afterward they will be found to have excess 
 either in time or in quantity, or in both. It is necessary there- 
 fore to follow up by "Not oftener than you used to be? not 
 more at a time than you always had ? " Excess in duration 
 is readily noticed ; but there is one source of fallacy which 
 must be guarded against. A colored discharge may continue 
 for a week or more, yet the actual hemorrhage may have 
 lasted only four or five days : the continuance of the discharge 
 resulting from the retention or breaking down of small clots, 
 may lead the patient to believe she is still menstruating. In 
 such a case a change in color as well as quantity will indicate 
 the character ; from being free and bright-colored it will have 
 become scanty and of a chocolate color, or like coffee-grounds. 
 As to excess in quantity it must to a great extent be reckoned 
 by comparison with what the woman has been accustomed to. 
 What one person finds an ordinary amount may in another be 
 evidence of an injurious excess. A common way of estimat- 
 
DISOEDERS OF MENSTRUATION. 511 
 
 iiig the quantity is by the increased number of napkins the 
 patient requires in twenty-four hours. The flow also may at 
 times be so j^rofuse that the patient will say that napkins are 
 of little use. Large clots are also evidence of excess ; but 
 small shreddy clots are common even in healthy menstruation. 
 
 Various derangements of menstruation have received distinct 
 terms in medical nosology. Its non-ajDpearance at the usual 
 age, or its suppression after its establishment, is known as 
 amenorrhoea ; when accompanied by excessive pain it is termed 
 dysmenorrhoea ; when in excess, menorrhagia. It cannot, how- 
 ever, be too firmly impressed upon the mind that these terms 
 represent symptoms only, and not actual diseases ; and how- 
 ever useful for the purpose of study or description these 
 names may be, they do not represent any actual state which 
 will determine treatment. Amenorrhoea may in one case be 
 the result of bad health, and in another may be consistent 
 with a robust constitution. Menstruation may regularly recur, 
 and yet the constitution may be steadily becoming undermined 
 from the strain thrown upon it in the developmental processes 
 which are taking place. It must always be remembered that 
 menstruation is but j^art of the general process of the develop- 
 ment of reproductive life, and that the latter is not completed 
 when the menstrual discharge has once regularly been estab- 
 lished, but continues for some years ; in fact it may be con- 
 sidered incomplete in many cases until the twenty-second 
 year. Whatever, therefore, the nature of the prominent 
 symptom may be, the opinion to be formed and the treatment 
 to be adopted will be determined less by that symptom than 
 •by the constitutional character or habit of body of the patient, 
 and by the nature of the disturbance of the general functions. 
 
 Primitive ainenorrhcea (emansio mensium), where the flow 
 has never taken place. The inquiries should be made to elu- 
 cidate the following points : 
 
 (1) The age and general development. In this country 
 menstruation first shows itself from the thirteenth to the six- 
 teenth year. But age is not a sure criterion, the general de- 
 velopment of the body must be associated with it. (2 ) The 
 previous history. A severe illness about the age of puberty 
 may retard menstruation. (3) What is the condition of the 
 general health? Is it impaired? then the amenorrhoea is but 
 part of the deranged condition — the effect, not the cause. If 
 the health is good, and the patient is not suffering, and her 
 configuration is womanly, there remains the question of de- 
 fective development of the uterus (infantile uterus), or defec- 
 
512 DISORDERS OF THE FEMALE ORGANS. 
 
 tive formation of the generative organs (absence of ovaries, 
 or uterus, or vagina). The diagnosis in the latter case can 
 only be absolutely made by a physical examination — a re- 
 course, however, only to be had under very special circum- 
 stances. 
 
 Internal evidence of functional activity, without discharge, 
 is sometimes pi-esent in the periodical recurrence of lumbar 
 and pelvic pains, malaise, and headaches — symptoms known 
 as the menstrual mollmen. At times epistaxis or other hemor- 
 rhages may occur. The regular periodicity is the all-impor- 
 tant character of such symptoms. They are evidence of 
 ovarian activity, and the presence of these organs is all that 
 can be inferred from them. The absence of such symptoms, 
 however, is no evidence of want of these organs. The occur- 
 rence of these symptoms with increasing severity, and the 
 appearance of a tumor rising out of the pelvis, are diagnostic 
 of retained secretion (imperforate hymen or occlusion of os, 
 etc.). In all cases where the menstrual molimen has occurred 
 the abdomen should be examined for such a tumor. 
 
 Menstruation having appeared, is the health suffering from the 
 strain of the developmental process f — Amenorrhoea usually 
 causes much anxiety on the part of parents for the health of 
 their daughters, but when once menstruation has occurred it 
 is thought the danger is passed. AVe liave already observed, 
 however, that the strain of reproductive development con- 
 tinues for some years after this event, and the health may 
 suffer from this cause, especially under the influence of bodily 
 or mental overwork. The symptoms are very varied, and 
 often indefinite, and may affect the nervous or digestive sys- 
 tems, or the blood-making function. With each menstrual 
 period there is the return of the lassitude and inaptitude for 
 work, change in disposition, and headaches, or the derange- 
 ments of the alimentary canal, or the localized pains from 
 which many girls suffer. As the i)atient is " quite regular," 
 it is supposed " it will all come right," especially as at first the 
 system rallies between times, and she regains health. But 
 gradually, by the accumulation of small effects, she recovers 
 less and less till finally the symptoms are constant. Amcmia 
 and chlorosis arc very common between the seventeenth and 
 twentieth year. 
 
 The health may thus suffer notwithstanding perfect regu- 
 larity in tlic menstruation. Frequently, however, this function 
 is also deranged. The character of the derangement depends 
 to a large extent upon the constitutional temperament. In 
 
MENSTKUAL MOLIMEN. 513 
 
 the relaxed or strumous habit there is generally excess in 
 frequency or amount, with copious leucorrhoea; in others the 
 tendency is to scanty or irregular menstruation ; and in the 
 highly nervous temperament, or when there is a hereditary 
 history of gout, the ovarian pains, spinal irritation, or cerebral 
 suffering predominate. 
 
 Suppression of Menstruation or Secondary Amenorrhoea — The 
 inquiries should be guided by the following list of causes : 
 (1) Pregnancy (see signs of pregnancy, p. 521}. (2) Influ- 
 ences affecting the system at a catamenial period (cold, 
 mental emotions, and exanthematous diseases). (3) Consti- 
 tutional causes (after fevers and acute diseases, sedentary 
 and confined occupations, overwork or over-pressure in educa- 
 tion, change of residence, long-continued mental anxiety, 
 anaemia, chlorosis, continued drain on the system, tuberculosis). 
 (4) The menopause (see p. 516;. (5) Local causes (pelvic 
 inflammations, acquired uterine or vaginal atresia, imperfect 
 involution after abortions or delivery at full time ; more 
 rarely diseases of the ovaries and displacements of the uterus). 
 
 Menorrhagia is excess of the menstrual flow. Hemorrhage 
 from the uterus, not menstrual, is termed "Metrorrhagia ; " 
 but it is difficult at times to determine whether the discharge 
 is of the one nature or the other. The distinction is never- 
 theless important. The first point to determine is the char- 
 acter of the excess, compared Avith the ordinary standard and 
 the individual habit already referred to. The excess may be 
 in quantity, or in duration, or in frequency of return, or in 
 any two or all of these combined. Whatever the change, 
 maintenance of regular periodicity, both in duration and the 
 return, favors the idea of a truly menstrual nature, as distin- 
 guished from hemorrhage. 
 
 The special cause of the monorrhagia must be determined 
 by the previous history, the general constitutional condition, 
 and the local examination. (1) The previous history . Menor- 
 rhagia is frequent after abortions, or on the return of the 
 catamenia after nursing, especially when lactation has been 
 prolonged. It is common shortly after marriage ; at times 
 menstruation will then be suppressed for one or two periods 
 and return in excess — the first being supposed to be due to a 
 miscarriage. Change of residence or mode of life is at times 
 the cause. Profuse menstruation sometimes follows acute 
 fevers and pelvic inflammatory affections. (2j The general 
 condition. It may be caused by whatever impairs the general 
 health, such as sedentary occupations, and over-pressure in 
 
514 DISOKDERS OF THE FEMALE 0RGAN6. 
 
 work or education. In young girls, especially those of the 
 strumous, or so-called phlegmatic temperament, menorrhagia 
 is often present ; also, at all periods of life, from a sluggish 
 abdomen ; constipation, hepatic derangement, loaded urine, 
 a full plethoric habit of body, or rheumatic or gouty constitu- 
 tions are frequently associated with the affection. Altered 
 conditions of the blood, associated with Bright's disease, pur- 
 pura, and the like, give rise to menorrhagia ; but in simple 
 amemia it is necessary to determine by the history whether 
 the anaemia is the cause or the effect. (3) Local examination. 
 It is often a question whether in a given case a local examina- 
 tion is necessary or not. If the periodicity is well maintained, 
 a sufficient constitutional cause having been found, and no 
 other marked symptom of uterine disease existing, then it is 
 not necessary at first. But if treatment has already failed, 
 if the periodicity is not well observed, and if there has been 
 marked flooding or metrorrhagia rather than menorrhagia, 
 and if any other symptoms suggestive of organic changes or 
 of displacement are present, then an examination should be 
 insisted upon. The local conditions which may give rise to 
 menorrhagia or hemorrhage from the uterus include nearly 
 all uterine affections. The following list contains the more 
 common: Polypi and fibroid tumors, malignant diseases of 
 the uterus, endometritis with granulations, chronic inflamma- 
 tion and hypertrophy, retroversion and prolapsus, congestion 
 of the ovaries, retained products of conception. 
 
 Di/snienorrhoea. — A certain degree of pain and discomfort 
 is felt during a menstrual period by the majority of women, 
 but at times it becomes so severe as to compel them to seek 
 advice. Cases of this description may all be classed under 
 the heading dysmenorrhoea ; but it is evident that the term is 
 thus used in a very general sense, and is equivalent to men- 
 strual suflTering when it becomes more than ordinarily severe. 
 Many different conditions have in this way been associated 
 together, with the inevitable result of much confusion. No 
 other subject, perhaps, has given rise to a greater diversity of 
 opinion. " It is manifest that the most discordant view's exist 
 amongst the very highest authorities, and on almost every 
 point." Keeping clear of all disputed points, as regards 
 causation, the subject will be here presented from its clinical 
 aspects. 
 
 From the mass of cases of acute menstrual suffering, it is 
 possible to disassociate a large class presenting a well-marked 
 train of symptoms, to which the term dysmenorrhciea proper 
 
DYSMENORRHCEA. 515 
 
 may be applied. By some writers the name " spasmodic dys- 
 meiiorrhoea " has been used to designate this class, but it is 
 objectionable as implying a theory which may or may not be 
 true, and at least has been disputed. 
 
 In dysmenorrhoea proper (so-called " spasmodic ") there is 
 acute pain associated with the beginning of the period, coming 
 on very generally before the discharge makes its appearance, 
 or synchronously with it ; continuing for one or at most two 
 days, but often only for a few hours; leaving behind it un- 
 easiness and prostration probably for several days. The pain 
 is referred to the hypogastrium and sacral regions, sometimes 
 running dow^n the thighs. It unfits the patient for her duties, 
 generally compels her to lie down, but prevents her from lying 
 quietly, making her " roll about " and moan or cry out. 
 Often it gives rise to reflex symj^toms such as headaches, 
 retching, and vomiting. 
 
 The distinguishing features will thus be seen to be — (1) 
 The limitation of the pain to the beginning of the period. If 
 there is in a case acute sufiering after the second or third day, 
 it will generally be found to be different in character, more 
 continuous and steady, and less paroxysmal. It is probably 
 due to some condition superimposed upon the other, such as a 
 general neuralgic or hypersesthetic state. There are some 
 cases of dysmenorrhoea where there is no suffering till after 
 the first or second day ; the pain may then be paroxysmal, 
 but the cause is evidently different from that of dysmenorrhoea 
 proper. (2) The paroxysmal character with the inability to 
 lie quietly is distinctive from a pain of an inflammatory 
 nature which fixes the patient dowai, is aggravated by move- 
 ment, and may even prevent her breathing wdth freedom. (3) 
 The seat of pain, central and diffused equally all round, is 
 distinctive from some cases where the pain may be present 
 before the discharge and relieved by it, but where it is con- 
 fined to one side, or both sides, but distinctly lateral. Here 
 the ovaries are evidently the seat of suffering. 
 
 The typical form of dysmenorrhoea above described is now 
 fully recognized as associated with some condition of the in- 
 ternal OS uteri, which is always relieved temporarily, and in 
 many cases permanently, by dilatation. Whether this condi- 
 tion is one of increased sensitiveness, of spasm, or a congenital 
 or accpjired stricture giving rise to obstruction cannot be here 
 discussed. Whilst this form of dysmenorrhoea is frequently 
 to be found pure and simple, yet it is very liable to become 
 complicated with one or more of other elements, which of 
 
516 DISORDERS OF THE FEMALE ORGANS. 
 
 themselves may give rise to very acute menstrual suffering. 
 Two or more conditions are therefore often found to coexist, 
 and must be as far as possible differentiated. Of these condi- 
 tions the chief are — (1) A general state of nerve exhaustion, 
 or a neuralgic condition associated with anaemia, gout, or 
 rheumatism, (2) Pelvic inflammation — the uterus, the ovaries, 
 the Fallopian tubes, or the peri-uterine tissues. (3) Polypi or 
 tumors of the uterus or cervix. (4) Flexions of the uterus. 
 (5) The desquamation of the uterine mucous membrane in 
 shreds or casts (Membranous dysmenorrhoea). 
 
 " The Change of Life : " The Climacteric Period : 
 THE INIexopause. — By these terms is denoted the end of 
 reproductive life in the female, as indicated by the cessation 
 of menstruation. This period is marked by a predisposition 
 to both local and general derangements of health. It occurs 
 between the fortieth and fiftieth years. 
 
 Local Derangements. — The manner of the cessation of men- 
 struation varies. It may cease suddenly or gradually —the 
 intervals becoming longer and more irregular, and the quan- 
 tity variable. This period of irregularity is spoken of as " the 
 dodging time." Frequently the change is indicated by excess 
 of menstruation, both in quantity and frequency. The menor- 
 rhagia of this period should not be overlooked, but carefully 
 investigated, especially if continuing past the ordinary age. 
 Hemorrhage returning after a lengthened interval, and pre- 
 senting no definite periodicity, is always suspicious and calls 
 for an examination. 
 
 General Deranr/emeiits. — The nervous, vascular, and digest- 
 ive systems frequently suffer. One of the most common com- 
 plaints consists in flushings, chiefly of the head and face, and 
 sometimes felt over the whole bod^^ It is associated with a 
 hot, bursting feeling in the skin, and is often relieved by per- 
 spiration. A dryness of the skin, or want of ordinary 
 perspiration, is frequently associated with flushings. A pecu- 
 liar headache affecting the occipital region, and extending to 
 the neck, is often experienced. It has long been recognized 
 that there is at this age a special predisposition to mental 
 derangements. Ilheumatic and gouty affections may also 
 manifest themselves, although previously absent. The digest- 
 ive system tends to become sluggish and impaired. 
 
 Clinical Value of Special Pelvic Symptoms. 
 
 Leucorrhcea. — The mucous membrane and glands of the 
 genital tract secrete a fluid sufficient to keep the opposing 
 
WATEKY DISCHARGES. 517 
 
 surfaces moist, but under ordinary circumstances it is not 
 manifest externally. In unhealthy conditions it escapes ex- 
 ternally, constituting what is termed leucorrhoea, or popularly 
 " the whites." A physiological degree of leucorrhoea is often 
 present just before or after menstruation, and must not be 
 confounded with the pathological state. A considerable 
 amount of white discharge is met with at times during preg- 
 nancy. In young girls leucorrhoea is common, and is often 
 regarded as the cause of the weakness. It is really the effect, 
 and may be met with in debilitated constitutions, especially 
 the strumous and phthisical. The absence of any other uter- 
 ine symptom except amenorrhoea, or scanty and irregular 
 secretion, will point to the truly constitutional nature. Any 
 bad hygienic influences, and certain occupations, such as the 
 use of the sewing machine, may lead to this form of the affec- 
 tion. 
 
 Leucorrhoea is an almost constant attendant in all uterine 
 affections, but usually other symptoms are associated there- 
 with. In such cases a careful examination should be made 
 when possible, before treating in routine fashion the prominent 
 symptom. 
 
 The secretion may come from the uterus, the vagina, or from 
 both. In the former case it may be seen by means of the 
 speculum escaping from the os, clear and glairy, like the white 
 of egg, becoming thick and opaque in the vagina. The micro- 
 scope (which, however, is rarely necessary) will also detect the 
 source by the character of the epithelial cells — round or col- 
 umnar from the uterine cavity, and tessellated from the 
 vagina. The discharge may be purulent in character, but no 
 special inference can be derived from this condition ; the diag- 
 nosis must be based on other considerations. A mucous dis- 
 charge may be present, and even abundant, without tbe 
 patient's being conscious of it, either from inattention or from 
 its escaping only during micturition. 
 
 Children at all ages are liable to a so-called " infantile leu- 
 corrhoea," which, however, arises from the vulva only, and is 
 in no way related to the discharge found in adults. It is often 
 very obstinate, and is dependent upon a depraved constitu- 
 tional state. 
 
 Watery Discharges. — Associated with leucorrhoea or occur- 
 ring alone, the discharge may be watery in character, some- 
 times greenish in color, at others pink or tinged with blood. A 
 greenish watery discharge sometimes follows parturition, and 
 is associated with imperfect involution of the uterus. If there 
 
 44 
 
518 DISORDERS OF THE FEMALE ORGANS. 
 
 is any cause for suspecting pregnancy, it may be the rare affec- 
 tion termed hydrorrhoea gravidarum, or a symptom of the cystic 
 (hydatidiform) degeneration of the ovum. Several cases are 
 on record where watery discharges formed the sole symptom of 
 a uterine polypus ; more commonly such tumors are associated 
 with hemorrhages. In all cases the odor is sufficient to distin- 
 guish between a watery discharge and an involuntary escape 
 of the urine. Met with under other circumstances, and espe- 
 cially when pink or frequently bloody, the usual cause is 
 malignant disease. In sarcoma of the uterus, and when a 
 fibroid tumor is undergoing degenerative changes, copious 
 watery discharges sometimes occur. 
 
 Pain. — The significance of this symptom, apart from the 
 revelations of a local examination, must be determined by the 
 character of the pain, its exact seat, and the time of recurrence 
 or exacerbation, considered in connection with the apparent 
 cause. 
 
 (1 ) The character is very variable, dull and constant, sharp, 
 shooting, hot, throbbing, etc. One term frequently used is 
 " down bearing ; " as used in general it is utterly indefinite. 
 It is em^Dloyed for tlie feeling of fulness or distention ; or it 
 may be simply weight, or the sensation that something is 
 trying to press out at the " front passage." It is met with not 
 only in uterine affections, but also when the bladder alone is 
 irritable, or it mav arise from hemorrhoids. 
 
 (2) The exact seat of the pain must be noted — whether 
 limited to a spot or diffused over a limited area. Thus pain is 
 often described as in the side — this may be near the crest of 
 the ilium or in the inguinal region. Again, a pain in the 
 latter part may be general or indefinite, or a painful spot can 
 perhaps be exactly localized and covered with two fingers. By 
 careful localization affections of special nerves can be made 
 out. The pain of cancer of the uterus is frequently localized 
 immediately behind tlie piibes, gnawing or grinding in charac- 
 ter and marked by nocturnal exacerbations. Dorsal, lumbar, 
 and sacral pains have no special pathognomonic significance — 
 they are common to all pelvic affections. 
 
 (3) Any periodicity in the character of the pain must be 
 noted. It is often marked in neuralgic affections — coming on 
 at a fixed hour. Nocturnal exacerbations are often well 
 marked in malignant disease of the uterus, and are occasion- 
 ally met with in pelvic inflammations and abscesses. 
 
 (4) An important question to determine is whether pain is 
 menstrual in origin. If recurring only with the catamenial, 
 
PAIN. 519 
 
 lasting for a short time after, and disappearing till the next 
 period,- the question is simple enough. But a pain such as 
 backache may be constant and yet menstrual. In such a case 
 the history will show that at first the pain occurred only with 
 menstruation, but gradually increasing (by accumulation of 
 effects) had become permanent, though still subject to exacer- 
 bations at a monthly period. A menstrual pain may return 
 for a day exactly midway between two periods. 
 
 (5) Lastly, light may be thrown on the nature of the pain 
 by the conditions which set it up, or which cause relief or 
 aggravation. Is it affected by position ? Pains of an inflam- 
 matory nature, or due to malposition, are relieved by rest and 
 aggravated by the erect posture. Neuralgic pains are not so 
 influenced. The weary backache, induced by exercise or 
 fatigue, and relieved by rest, is often due to the accumulated 
 effect of the menstrual pain. Again, pain occurring when 
 one position is assumed for a time, but relieved by a change 
 of position, or by walking about, would point to blood stasis 
 — being due to temporary distention of the vessels of the part. 
 A pain w^hich is absent while walking but comes on while sit- 
 ting is often of this nature. 
 
 Is the pain affected by movement ? An inflammatory con- 
 dition is always so. If slight it may be elicited only by a jolt 
 or sudden movement. Neuralgic pains are not so influenced. 
 If muscular, it may only arise on movement of certain mus- 
 cles. It must be remembered that muscular action produces 
 pressure, and may elicit a neighboring inflammatory pain, as 
 in the action of the psoas muscle in the various positions of 
 the leg. 
 
 The pain may be associated with the act of micturition or 
 defecation. In pelvic peritonitis acute pain on micturition is 
 frequent, but there is other pain as well. If closely limited 
 in its relation, occurring with the act and lasting for some 
 time after, the cause is most likely to be in the bladder or 
 urethra (painful caruncle). Intermitting pains of short dura- 
 tion simulating the pains of labor, are met with where some- 
 thing is being expelled from the uterus — such as a blood clot, 
 retained mucous secretion, or dysmenorrhoeal membrane. A 
 sharp cutting pain felt at the anus with the act of defecation, 
 and lasting for some time after — simulating every character 
 of fissure in ano, but where no disease of the part can be de- 
 tected — has been found to be associated with a tender condition 
 of the ovary. 
 
520 DISOKDEES OF THE FEMALE ORGANS. 
 
 The Constitutional, or Bemote Derangements due to Pelvic 
 Affections. — From the endless variety of these it is evident 
 that only a few can be here enumerated, such as every student 
 should be aware of. 
 
 1. The digestive system. Want of appetite, sickness, and 
 nausea are frequent. A uterine origin would be indicated if 
 the sickness occurs on assuming the erect posture in the morn- 
 ing, or with exacerbations at the menstrual period, or if the 
 general symptoms show remissions with the pelvic symptoms. 
 Constipation is more frequently a cause or source of aggrava- 
 tion of pelvic disorder than the effect, except where pain on 
 defecation incites the patient to restrain the action. The 
 same may be said of sluggishness of the liver, associated with 
 high-colored or sedimentary urine. 
 
 2. The nervous and vascular systems. A pain limited to a 
 spot under the breast is a frequent complaint ; also pains in 
 the back, in the lumbar region, or even extending between 
 the shoulders — the parts may be sensitive to the touch. Tic 
 may likewise have a uterine origin, but in such cases it will 
 frequently have a clear association with the catamenial period ; 
 it occurs also with pregnancy. The headaches are not always 
 definite in character, they may be frontal, or occipital, or at 
 the vertex. At the change of life the occiput is the more 
 general seat. (See " Change of Life," p. 516.) Through the 
 nervous system, the heart and bloodvessels are frequently af- 
 fected (palpitation, flushings, and the like). A very common 
 effect, due to pelvic derangement, is coldness of the extremi- 
 ties, which again reacts in aggravating the pelvic pains. Epi- 
 leptic attacks may occur regularly with the menstrual periods. 
 Spinal irritation has sometimes a uterine origin, as also hysteria 
 and other mental derangements. 
 
 3. As a very special influence due to pelvic origin must be 
 noted the faintness and constant feeling of exluiustion, or loss 
 of energy, experienced by many suffering from even slight 
 uterine ailments. In some patients the influence exerted 
 through the pelvic nerves is very marked. Many patients 
 are exhausted and feel faint after each time the bowels are 
 moved. An injection will sometimes cause great prostration. 
 In the same manner inflammation of the cervix and lacera- 
 tions, the result of delivery, will frequently produce great 
 lassitude and ready fatigue. Hemorrhoids at times have a 
 similar effect. Retroversion of the uterus acts in a similar 
 numner, even Avhen there is no local tenderness. The patient's 
 expression frequently is that all energy or strength seems to go 
 
DIAGNOSIS OF PREGNANCY. 521 
 
 as soon as she gets up and begins to move about. Tonics are 
 useless in such cases, so long as the local condition .is unalle- 
 viated. The special pelvic symptoms may be very slight, at 
 other times they are severe and well marked. The grouping 
 of symptoms in such cases generally is follows : Some pelvic 
 suffering, gradually loss of strength and appetite, ready ex- 
 haustion, with sickness on assuming the erect position, and 
 steady loss of flesh from inability to take nourishment. 
 
 The Determination of the Relation bettveen Pelvic Derange- 
 ments and Remote or Constitutional Suffering. — Affections of 
 the pelvic organs are known to produce marked disturbances 
 in the function of remote organs ; and again, derangements of 
 other parts frequently produce changes in the uterine func- 
 tion. It is, therefore, highly important to decide the relation- 
 ship. In many cases it is evident enough. Thus, amenor- 
 rhoea in a phthisical patient may be regarded as a common 
 effect, not the cause, of the general disorder. When not so 
 clear, the order and succession of the symptoms must be care- 
 fully investigated. 
 
 When derangements of the stomach are of pelvic origin, 
 there are some special characters which may indicate the asso- 
 ciation—as when they partake of the characters met with in 
 pregnancy — as sickness, if chiefly on assuming the erect position 
 in the morning ; or if manifesting recurrence or exacerbations 
 at menstrual periods; or if coming and going with special 
 pelvic symptoms. The same holds good with many neuralgic 
 aflTections. Frequently, however, it may be found that w^iilst 
 due to pelvic irritation the derangement has become perma- 
 nent and persists, whilst the exciting cause is intermittent, or 
 may even have passed off* altogether. The " weary backache" 
 is often of this nature due to menstrual irritation, yet _ persis- 
 tent. The early history, however, will reveal the true nature. 
 
 The Diagnosis of Pregnancy. 
 
 Pregnancy, it must be remembered, may occur under cir- 
 cumstances where it might not be expected, as in very young 
 girls, or in women past the ordinary age of childbearing. 
 Pregnancy has been recorded in this country at the thirteenth 
 year, and as late as the fifty-fourth. Women who have stopped 
 having children for many years may again begin to bear when 
 nearing the change of life ; or a woman may be pregnant for 
 the first time after many years of married life. It is v.-^ry 
 common for mothers who are nursing to be again pregnant 
 
 44^ 
 
522 DISORDERS OF THE FEMALE ORGANS. 
 
 without menstruating, or without even being aware of their 
 condition. Again, a patient may have had amenorrhoea for 
 many months, or may always have been very irregular, and 
 yet become pregnant. Caution, therefore, is ever needful, and 
 more especially when the use of the uterine sound as a means 
 of diagnosis is contemplated. 
 
 In the latter half of pregnancy, when the uterine tumor is 
 perceptible above the pubes, when either the foetal movements 
 may be felt, or the auscultatory signs can be heard, and when, 
 in first pregnancies, the mammary signs are distinct, there 
 can be little difficulty in the diagnosis ; errors then arise from 
 careless examination. The suppression of menstruation with 
 the occurrence of an abdominal tumor should always necessi- 
 tate, in the medical practitioner's mind, the exclusion of preg- 
 nancy, by the positive evidence of a thorough examination. 
 
 In the earlier months the diagnosis is more difficult, and in 
 doubtful cases it should be deferred. The suspicion, tliough 
 felt, should only be expressed on positive evidence. The sud- 
 den arrest of menstruation, without apparent cause, in a 
 woman who has always been previously regular — associated 
 with morning sickness, and shooting pains or fulness in the 
 breasts — is often quite sufficient pret^umptive evidence of preg- 
 nancy. 
 
 Suppression of the catamenia, although one of the first symp- 
 toms, is equivocal in value. It merely opens ujd the question. 
 The suppression may be due to other causes. It is possible 
 also for a woman to menstruate once or perhaps twice after 
 conception ; but in such cases the amount of discharge is 
 markedly diminished. A discharge of blood may also occur 
 during pregnancy, and be repeated at intervals, without being 
 menstrual in its nature. 
 
 Morning Sickness alone is of little value ; it is variable in 
 its occurrence as to time and duration, is often absent, and 
 may arise from other conditions. 
 
 Chanr/es in the Mammw. — The breasts early sympathize with 
 the condition of the uterus, but they do so in other conditions 
 as well as in pregnancy. They increase in size, and become 
 sensitive with shooting pains. It is in first pregnancies that 
 the areolar signs are of most value, but even then they vary 
 greatly in different individuals ; and a deepening of the 
 color, with slight prominence of the nipple, may arise from 
 other conditions of the generative organs. It is in the third 
 month that the increased turgescence begins to alter the char- 
 acters. The nipple becomes more prominent, the areola in- 
 
VAGINAL EXAMINATION. 523 
 
 creases in size, and its color deepens, whilst the follicles on its 
 surface become more prominent. As pregnancy advances 
 these changes are more pronounced, and the surface assumes 
 a moistened appearance. After the fifth month there may 
 appear Avhat has been described by Montgomery as the 
 " secondary areola," immediately around the other, faint in 
 degree, as if the color had been washed out. 
 
 The Abdominal Tumor. — The abdomen is often perceptibly 
 enlarged before the uterine tumor can be felt externally, and 
 before the uterus rises above the os pubis. After the twelfth 
 week, sometimes earlier, the uterus can be defined above this 
 bone ; by the sixteenth it should reach midway between the 
 symphysis pubis and the umbilicus; and by the twentieth it 
 is as high as the latter point. It is not always central in 
 position, most frequently there is an inclination to the right. 
 Its uniform spheroidal shape, and moderately firm elastic resist- 
 ance, are of service in distinguishing between it and other 
 tumors, differing in these respects from the hard uterine 
 fibroid, or the more fluctuating ovarian cyst. Should the con- 
 sistence change under manipulation, the tumor becoming firmer, 
 it is almost certain to be uterine, though not necessarily due 
 to pregnancy. At times the uterus may be so lax before the 
 seventh month that there may be some difficulty in defining 
 the tumor, especially if the abdomen be full or tense. Mis- 
 takes are frequently made from this cause. 
 
 Vaginal Examination. — Displacements of the cervix in the 
 earlier months are described in books, but they are unimpor- 
 tant and not reliable. The cervix from an early period un- 
 dergoes softening of its tissues, beginning in the mucous coat, 
 and gradually invading all the tissues, till tow^ard the end of 
 pregnancy the cervix seems shortened. The vaginal portion 
 is really shorter, from the uterus being held high up, but the 
 cervical canal is not diminished in length till a few days be- 
 fore parturition. In pluriparse the os in the later months is 
 sufficiently patent to admit the point of the finger. The 
 vaginal mucous membrane early assumes a deep violet hue. 
 The uniform character of the uterine tumor and its consist- 
 ence, will generally distinguish pregnancy from other causes 
 of enlargement, but of special value is the peculiar soft glob- 
 ular feeling apparent all round the cervix ; imparted by the 
 lower part of the body of the uterus. By the bimanual 
 method, an enlargement of the uterus can be readily recog- 
 nized, and this supplies an important diagnostic sign in the 
 earlier months. 
 
524 DISORDEKS OF THE FEMALE ORGANS. 
 
 Foetal Movements. — By the mother these are usually felt, for 
 the first time, from the sixteenth to the eighteenth week ; this 
 is spoken of as " quickening." Somewhat later they may be 
 felt by the examining hand, and about the same time hallotte- 
 ment may also be made out ; this name is applied to the sensa- 
 tion experienced by the examiner, of the resistant body of the 
 foetus floating in a fluid ; this may be made to recede by a 
 sudden push imparted to it by the finger of the observer in- 
 troduced into the vagina, and applied to the anterior part of 
 the cervix uteri ; in a short time it is felt to settle down where 
 it was before. Women who are not pregnant, but have a 
 strong desire to have children, or are suffering from mental 
 ailments, frequently imagine that they feel the movements of 
 a child. 
 
 Auscultatory Signs. — The uterine souffle may be heard earlier 
 than the foetal heart's sounds, but it is not certainly diagnostic 
 of pregnancy ; it is, of course, synchronous with the mother's 
 pulse, but a similar sound is heard at times in fibroid tumors. 
 The usual time for the pulsations of the foetal heart to be 
 heard is the eighteenth week, but they have been detected 
 earlier. In listening for them before the seventh month, a 
 point in the mesial line somewhere between the pubes and 
 umbilicus, but nearer the former, is where the sounds are most 
 likely to be heard. After the seventh month they will be 
 found nfiost frequently about the middle of a line drawn from 
 the umbilicus to the superior spine of the ilium on the right 
 side or the left ; but the place must necessarily vary with the 
 position of the child. The rate varies from 130 to 160, and 
 the beats are of course not synchronous with the maternal 
 pulse. 
 
 Pelvic Examination. 
 
 A systematic examination should always begin by palpation of the 
 abdomen. The patient should lie on her back with the thighs drawn 
 up. She should be directed to avoid holding in her breath, and to try 
 to keep the belly lax. Involuntary contractions may at times be over- 
 come by making her talk, but in the finer degrees of palpation, the 
 sudden and frequent changes in the abdomen thus produced will be 
 found to interfere with the delicacy of the touch. The whole hand 
 should be placed flat on the abdomen, and gentle intermitting pressure 
 exercised by the tactile ends of the fingers. The degree of pressure is 
 gradually increased until the deeper structures are reached. Passing 
 the hand over the abdomen, each part in succession is examined. At 
 times it is advisable to employ both hands simullaneousl}-. The size, 
 shape, and consistence of the belly generally are thus recognized. Any 
 tenderness is elicited, and its site and degree are noted. The presence 
 
PELVIC EXAMINATION. 625 
 
 of tumors, hardness or fulness, in relation to the pelvis are also de- 
 tected. Their exact position, mobility, or fixity, their form and 
 consistence, whether solid, elastic, or fluctuating, are determined. 
 Percussion also is not to be neglected, and in the case of tumors aus- 
 cultation may be necessary. 
 
 Vaginal Exaynination. — Position of the patient. Three positions 
 are employed in gynecology. Each has its advantages and disadvan- 
 tages. (1) The side or ordinary obstetric position. This is the one 
 most generally preferred in this country, being more delicate and com- 
 fortable for the patient. It affords a fuller range to the examining 
 hand internally than the second position, and does not produce the 
 disturbance of the parts which occurs in the third. It is, however, 
 badly adapted for bimanual examination. 
 
 (2) The back position. Whilst the patient lies on her back with 
 the thighs drawn up, the examining hand is placed under the right 
 thigh. This is the proper position for the bimanual examination ; but 
 it does not afford the same facility as the first for thorough exploration 
 of the posterior cul-de-sac of the vagina, unless the pelvis be raised 
 and the thighs drawn up to a greater degree than is comfortable to 
 the patient. 
 
 (3) The semi-prone position. Here the anterior part of the left 
 shoulder rests on the bed, with the left arm drawn behind the body ; 
 the left leg is drawn slightly up, and the right fully flexed ; the body 
 is then turned prone till the right knee rests on the bed. The effect of 
 this position is that the influence of gravity is reversed in the pelvis, 
 the weight of the organs is directed into the abdomen. There is 
 thereby produced a marked suction power, whereby, on the introduc- 
 tion of the finger, air is drawn into the vagina, distending it to its 
 fullest capacity. The relations of the different parts are in this way 
 disturbed, so that this position is not a suitable one in which to begin 
 the examination. It is specially adapted for surgical operations, and 
 is necessary when using the duck-bill speculum. It is also a favorable 
 position when rectifying a retroverted uterus, or when endeavoring to 
 raise a tumor out of the pelvis. 
 
 It will thus be seen that the side position is to be preferred at the 
 beginning of an examination, but to employ the bimanual method, 
 the patient should be asked to turn upon her back. 
 
 Digital Examination. — One finger only should first be used; if the 
 parts are sufficiently lax, there is often an advantage in thereafter using 
 two fingers. The finger, well lubricated, is passed from the perineum 
 forwards between the labia ; the orifice of the vagina can then be 
 readily felt, and the finger passed within. In so doing, observation is 
 made of any degree of resistance, the presence of any abnormal swell- 
 ing or tumor, any undue sensitiveness, tenderness, or sharp pain. The 
 movement should be made slowly and gently ; and the importance of 
 recognizing any tenderness in the vulva or orifice of the vagina, lies 
 in the fact that the pain so elicited, if unobserved at first, may bo 
 erroneously attributed to parts higher up. Having entered the vagina, 
 the finger is passed along the posterior wall of the vagina, until the 
 cervix is found. Its position and direction are first to be regarded, 
 and the presence or absence of any abnormal condition in its neigh- 
 borhood. The normal and abnormal conditions will presently be de- 
 scribed. 
 
526 DISORDEKS OF THE FEMALE ORGANS. 
 
 Before completing the examination, it is always advisable to employ 
 the bimcnmal method. With a linger of the one hand in the vagina, 
 the other hand is placed on the abdomen, and pressure exerted in the 
 direction of the axis of the inlet. The internal finger may first be 
 placed in the anterior cul-de-sac, and if the uterus is lying forward it 
 can readily be brought between the hands. If lying backward, 
 nothing will be felt between the hands but the abdominal and vaginal 
 walls. The internal finger may likewise be placed on the cervix or 
 behind it, and the uterus raised or drawn towards the outer hand. 
 The size of the uterus, its position, and the presence and relations of 
 tumors or swellings, can in this way be determined with great accu- 
 rac}'. It is, however, only occasionally, and after some experience, that 
 the normal ovaries can be thus defined. (See p. 532.) 
 
 Rectal exploration is at times necessary, and has its advantages. It 
 may be adopted in virgins when a vaginal examination is not advis- 
 able. It permits of the finger reaching further back than by the 
 vagina, and in the case of tumors gives further knowledge as to size 
 and relation. 
 
 Sound and Speculum. — Having completed the examination by thQ 
 hands, it is necessary in some cases to obtain further information by 
 means of the uterine sound and the vaginal speculum.^ 
 
 Mode of Using the Sound. — Before using this instrument the possi- 
 bility of the patient's being pregnant must be negatived ; and it should 
 not be employed by the inexperienced when inflammation of the uterus 
 or surrounding tissue is present. The introduction of the instrument 
 must be guided by the information previously obtained by manual ex- 
 amination. The direction given to the point will be forwards and 
 backwards, according as the uterus is believed to be inclined in a cor- 
 responding direction. If a marked flexion has been felt it may be 
 necessary to increase the curve at the distal end of the sound. The 
 instrument should be held lightly by the foreflnger and thumb of one 
 hand, and its point guided to the os by the forefinger of the other. As 
 it enters the cervix, when the. uterus is in normal position, or ante- 
 verted, the stem will be near the under surface of the symphysis pubis. 
 The point must be given a forward direction, and this is accomplished 
 by drawing the hatidle backwards towards the perineum. When fully 
 introduced, it should rest on that structure. In retroversion, the mode 
 of proceeding is reversed. The distance the point has entered is recog- 
 nized by the finger in the vagina. The knot or swelling on the stem, 
 represents two and a half inches — the normal length of the uterus — 
 the grooves mark further lengths of an inch. No force must be used, 
 the instrument should glide in by the manipulation of the handle. If 
 resistance be felt, the in.^trument must be withdrawn slightly, or the 
 point moved about by rotating the stem on its long axis, care being 
 taken that the stem is not made to rotate on its point caught in a fold 
 of mucous membrane. 
 
 Diagnostic Uses of the Uterine Sound — 1. Constriction of the cervix 
 may be recognized if the lumen be too small to permit the probe to 
 pass (very rare) ; the narrowing from flexion is recognized by the seat 
 
 ^ It is at times further required to explore tlie interior of the uterus by dilating the 
 cervix by means of tents. Tliis, h(jwever, Jiever comes under the chai'ge of the student^ 
 and is, then^forc, not liere entered upon. 
 
PELVIC EXAMINATION. 527 
 
 of arrest, and by the special manoeuvi-e necessary to overcome it, such 
 as tilting the sound in a certain direction, or having to press the fundus 
 upwards. 
 
 2. The Length of the Cavity. — The normal length is two and a half 
 inches. It will be found elongatedin {a) recent delivery: the normal 
 size is not reached till the third or fourth week. In repeated exami- 
 nations a steadily diininishin«: length of the cavity is valuable evi- 
 dence of recent parturilion. Under various C(mditi()ns, the diminution 
 in the size of the uterus is arrested [.subhivoliction),hoih after delivery 
 at the full time and after abortions. Usually, in this condition, it will 
 be found three and a half inches, but may be considerably beyond this. 
 (6) In hypertrophy from chronic congestion, metritis, and malio^nant 
 disease of the body, it may measure three and a half inches, (c) From 
 uterine tumors. The amount of elongation is greatly dependent upon 
 their seat; if subperitoneal, the increase may be slight; as they ap- 
 proach the mucous surface the tendency is to leniJ:then the cavity. A 
 tumor of the fundus may give an apparent shortening, (d) The elon- 
 gation may exist in the cervix only; in the vaginal portion this may 
 arise from hypertrophic elongation of both lips. It may thus measure 
 four to five inches, and has been found as much as nine inches. The 
 portion above the vagina may al<o be elongated from dragging of the 
 uterus upwards by tumors, (e) The cavity is shortened^ from defective 
 development (infantile uterus); in partial inversion of the uterus; 
 from adhesions, in tumors ; in the atrofihic state in the aged ; in hyper- 
 involution, where the normal process has been in excess. 
 
 3. Displacements of the Uterus. — These are readily determined by 
 the direction in which the sound passes. 
 
 4. To Ascertain the Connection or Non-con7iection of Tumors with the 
 Uterus. — If the sound passes directly into the tumor it proves it to be 
 uterine. A large sub-involuted uterus may thus be distinguished from 
 other swellings. A swelling behind the cervix maj^ thus be deter- 
 mined to be the fundus, or something occupying Douglas's pouch. If 
 the sound does not pass directly into the tumor it may still be uterine, 
 or have uterine attachments. The point is to be decided by whether 
 the moving of the tumor conveys motion to the sound or vice versa. 
 The non-uterine nature will be further confirmed if, by aid of the sound, 
 the uterus and tumor can be partially separated from each other. 
 
 5. The sound is further of service^ in elevatiyig the fundus or drawing 
 it forward., so as to bring it within reach of the combined internal and 
 external manipulation, to determine more accurately the size of the 
 organ. 
 
 6. In the Diagnosis of Inversion of the Uterus frojn a Polypus Pro- 
 jecting through the Cervix. — In both cases a rounded tumor is felt pro- 
 truding from the os. In inversion the sound cannot be passed upwards, 
 as the cavity of the uterus is inverted and obliterated, whereas if the 
 case is one of polypus the sound will pass by its side into the uterine 
 cavity. 
 
 The Speculum. — Ferguson's tubular glass speculum is the best 
 adapted for general use. Of the bivalve form, that known as Cusco's 
 is now mostly preferred. A good window light is the best, and it 
 should be on a level with the bed. Where the light is bad the tubular 
 form of instrument has a decided superiority in illuminating power. 
 
528 DISOKDEKS OF THE FEMALE ORGANS. 
 
 Should artificial light be necessary, a shade should be devised to screen 
 the observer's eyes. 
 
 The lateral position of the patient should, if possible, be adopted. 
 It is less trying to hei-, and suflBcient in the majority of cases. At 
 times, however, with Ferguson's speculum, we may fail to gain a view 
 of the OS in the lateral position, when we may succeed in the dorsal. 
 The shoulders of the patient must not be on a higher level than the 
 buttocks. The dress should be carefully adjusted so as not to expose 
 any part of the thighs. 
 
 Having oiled the instrument, and holding it in the right hand, we 
 gentlv separate the labia with the fingers of the left. With them for 
 a guide, the instrument is presented at the orifice of the vagina; we 
 then press it backwards so as to depress the perineum, and with a slight 
 rotary action introduce it within the orifice. The direction is now to 
 be changed backwards, to make it glide over the perineum, not upwards 
 towards the uterus. When once fully introduced, the outward end 
 should be depressed well on the perineum, and if the cervix does not 
 present properly at the inner orifice its position may be altered by a 
 gentle rotary movement of the speculum. 
 
 When the bivalve speculum is used, care must be taken that it is 
 introduced fairly behind the cervix before the blades are expanded. 
 Tlie opening up of the blades must be done slowly and carefully, 
 watching the efl^"ect meanwhile. 
 
 The above forms are those in general use, and are serviceable for 
 inspection, or when topical applications to the uterus have to be made. 
 When any surgical procedure is necessary, the duckbill, or Sims's 
 speculum, ha? decided advantages. It necessitates an assistant to hold 
 it, but this drawback has been overcome by vario\is modifications. In 
 using it the position of the |iatient is of great importance. The semi- 
 prone position is necessary, so as to permit of the full distention of the 
 vagina by air. 
 
 Pelvic Diagnosis. 
 
 1. Normal Position and Relations. — To the examining finger 
 the vagina should feel soft, moist, elastic, and roomy, without 
 any fulness or hardness on one side "as compared with the 
 other. The cervix uteri is readily reached and the os felt, 
 lying at the end of the examining finger, when fully introduced. 
 The direction of* the cervix is downwards and backwards, 
 looking to the coccyx. Through the superior vaginal wall 
 the body of the uterus can frequently be felt freely mobile, 
 and by the bimanual method it can then be readily brought 
 between the two hands. But often it has a backward direction 
 and then the anterior cul-de-sac is felt empty. To the exam- 
 ining finger the cervix should feel freely mobile, and no fulness 
 or hardness should be felt at either side. By pressing upward, 
 the supravaginal portion of the cervix can be defined, and 
 a curve felt when there is any degree of flexion where it joins 
 the body of the uterus. Pressing back the perineum the 
 
PELVIC DIAGNOSIS. 529 
 
 fing-er should feel evervthino- soft and elastic behind the uterus 
 in the posterior fornix. The rectum, however, may contain 
 feces, but these can be readily detected by the peculiar con- 
 sistence and by the sense of pitting on pressure. 
 
 2. Displacements of ilie Uterus. — There can be no true dis- 
 placement without a change in the relative position and direc- 
 tion of the cervix. Bnt the position and direction of the 
 cervix alone give no certainty as to the position of the fundus, 
 as the uterus is often flexed upon itself. The bimanual method 
 and use of the sound are often required to confirm or correct 
 the impressions derived from digital examination. 
 
 (a) Anteversion is frequently a normal or congenital condi- 
 tion. The cervix looks more backward, the finger defines the 
 supravaginal portion running forward, and the body can be 
 felt freely movable through the superior wall. It can readily 
 be brought between the two hands, and the size, form, and 
 mobility decide it to be the uterus. 
 
 (b) Anteflexion. — -The cervix, owing to the flexion, may be 
 in its normal situation, or may even look forward. The curve 
 in the upper portion of the cervix and the body in front can 
 be readily felt. A small fibroid growth in the anterior wall 
 may give the same signs, but by the bimanual examination, 
 aided, if necessary, by the sound, the fundus, and the irregu- 
 larity in the anterior wall, can be defined. Inflammation of 
 the cellular tissue in front of the uterus may also simulate 
 anteflexion, but by the method just referred to, and by atten- 
 tion to any tenderness and impairment of mobility, a correct 
 diagnosis should not be difficult. 
 
 (c) Retroversion. — Here the cervix is displaced forward 
 and looks down the vagina, or it may be directed upward. 
 The supravaginal portion is felt through the posterior fornix 
 runniug backward with no angle of flexion. In extreme cases 
 the body can be felt. Biraanually nothing is felt in front. 
 
 (c?) Retroflexion and Retroversion. — The cervix is displaced 
 forward and lies in the axis of the vagiua. jSTothing is felt in 
 front, but posteriorly a firm rounded body can be defined 
 occupying Douglas's pouch. Usually the curve of flexion can 
 be made out. These signs may be simulated by a myoma in 
 the posterior wall of the uterus ; and by inflammatory de- 
 posits, or blood, in Douglas's pouch. (See also p. 527 and pp. 
 533-536.) The true condition may be decided by the biman- 
 ual method of examination and by the sound, but the diag- 
 nosis in these latter cases does not rest on physical signs alone, 
 the history must be associated therewith. 
 
 45' 
 
530 DISORDERS OF THE FEMALE ORGANS. 
 
 (e) Prolapsus of Uterus and Vagina. — In the minor degrees 
 of prolapse of the uterus, the conditions are those of retro- 
 version, Avith increased mobility, or rehaxed state of the 
 vagina. In severer forms, and when complete, it is associated 
 with prolapse of the anterior (cystocele) or posterior walls 
 (rectocele). The bulging outward of the walls and the rela- 
 tive position of the cervix readily indicate the condition of the 
 parts. When not wholly protruding, or after replacement, by 
 asking the patient to bear down forcibly the mode of prolajise 
 may be traced by the finger or watched by the eye. 
 
 Care in determining the exact position of the cervix and the 
 OS uteri will prevent mistakes being made as to the exact 
 relations of the structures. A tumor may, however, protrude 
 from the vagina with the os uteri in its centre, from hyper- 
 trophic elongation of the cervix ; but here the finger will pass 
 readily into the vagina all round the tumor, and the sound 
 w^ill be found to pass considerably beyond t-he normal length. 
 The absence of the os uteri and the history will readily difier- 
 entiate an inversion of the uterus or other tumor. 
 
 The uterus may be displaced forward so as to lie behind the 
 symphysis, or backward into the hollow of the sacrum, or 
 more or less to one side, but these changes are always associ- 
 ated with well-marked swellings or tumors, the cause of the 
 displacement. Infiammatory adhesions may also draw the 
 uterus out of place without the presence of swellings ; it w ill 
 then be towards the side where the mischief lies ; in the other 
 cases it is to the op])osite side. 
 
 Cervix Uteri. — In examining the condition of the vaginal 
 portion of the cervix, its size, form, and consistence, together 
 with the degree of patency of the os, have to be observed. It 
 is found smaller than normal in "infantile " uterus, and in 
 the atrophy of advanced years. It may, on the other hand, be 
 longer, in " conical cervix," and when hypertrophied. There 
 is a congenital peculiarity, with a small anterior and large 
 posterior li|), giving the appearance of a curve in the lower 
 portion of the cervix. The os uteri in nullipara) is small, cir- 
 cular or ovoid, in those who have borne children it is trans- 
 verse, often fissured generally more on one side than the other, 
 and slightly patent. The rare conditions of occlusion or ste- 
 nosis can be readily made out by means of the speculum and 
 sound. 
 
 The cervix should feel uniformly smooth and of equal con- 
 sistence, likened to the sensation on touching the point of the 
 nose. In pregnancy it is softened. In diseased conditions the 
 
PELVIC DIAGNOSIS. 531 
 
 parts (mostly around the os) will feel soft and velvety, or 
 hard, indurated, swollen, or nodulated. Small pea-like bodies 
 may be felt around the os, due to distended Nabothian folli- 
 cles, and small mucous polypi may also be found projecting 
 from the os. 
 
 The speculum is often required to ascertain the exact state 
 of the cervix, and to determine the origin of a vaginal dis- 
 charge. It should not be used in cases of well-marked cancer 
 of the cervix, and the practised " tactus " soon admits of its 
 being dispensed with in a number of other states for diagnostic 
 purposes merely. The conditions of the parts thus revealed 
 vary greatly, but are chiefly associated Avith chronic cervical 
 catarrh. In nulliparae the cervix may appear normal, but 
 issuing from it may be seen a clear, glairy, very tenacious, or 
 it may be a muco-purulent fluid. Frequently, however, the 
 os is surrounded by a red vascular ring, or small angry 
 patches. In multiparse the os is more patent, the edges are 
 everted, revealing tl>e red inflamed mucous membrane of the 
 canal (the old idea of ulceration). If lacerations exist the 
 ectropion is jDroportionately increased, and when extensiv^e 
 may present a widely gaping angry surface. At times the 
 inflamed area presents a granular appearance, and when the 
 subjacent glands are obstructed small prominent cysts form, 
 scattered about the os ("follicular erosion"). The surface 
 may also be covered by abundant granulations, with the 
 cervix swollen and enlarged from parenchymatous inflamma- 
 tion. When the ectropion is extensive and due to severe 
 laceration, the condition may be recognized by means of 
 tenacula inserted into both lips, drawing these in upon one 
 another the raw looking surface will generally disappear and 
 the natural form of the cervix be restored ; there may still, 
 how^ever, be some angry points on the vaginal surface proper. 
 True chancres, condylomata, and syphilitic ulceration are to 
 be met with on the cervix, but they are rare. The history 
 will materially aid in the diagnosis. 
 
 Malignant Diseases of the Cervix. — Epithelioma occurs in two 
 forms, a superficial ulceration excavating the cervix, wdth 
 little or no tendency to papillary sprouting ; and a papilloma 
 sprouting from the vaginal portion, and extending or pro- 
 jecting into the vagina, but with little or no tendency to 
 involve its walls (cauliflower excrescence). These forms pro- 
 duce at first very little hardening of the adjacent tissue, but 
 infiltration does occur to some extent where the disease is far 
 advanced. Medullary carcinoma is the more frequent form. 
 
532 DISOKDEKS OF THE FEMALE OKGANS. 
 
 The vaginal portion of the cervix becomes either uniformly 
 indurated and tumefied or several hard nodules are formed. 
 The tendency is to rapid infiltration of the surrounding tissues, 
 Avith ulceration and destruction of the parts forming the canal. 
 It is consequently seldom seen until these changes have oc- 
 curred. The cervix then presents to the finger a ring or cup 
 of dense indurated tissue filled with softened pulpy tissue 
 undergoing sloughing or ulcerative changes. The uterus is 
 at this stage fixed. The infiltration may be figlt extending 
 into tlie broad ligaments, or the induration may have extended 
 along the vaginal wall, involving the bladder or rectum, or 
 both. At times the vagina may be so blocked up that the 
 finger can be passed only a short way. 
 
 These characters are too pronounced to be readily mistaken, 
 but in the earlier stage of these diseases the diagnosis is often 
 very uncertain even to men of experience. When doubt is 
 felt a small portion of the tissue may be removed for micro- 
 scopic examination. A condition w^hich is liable to be mis- 
 taken for malignant disease is where the cervix is enlarged 
 and indurated from chronic inflammation. The diagnosis is 
 rendered more difficult when the os is patent, and ulcerations 
 or granulations are present. Many means have been sug- 
 gested to determine between the benign and malignant forms 
 of disease, but the microscope is the only reliable one. 
 
 The Ovary. — With the forefinger of the one hand in the 
 vagina or rectum, and pressing well down with the other from 
 above, it is just possible to define clearly the ovary. But in 
 many cases where the woman is healthy and in good condition, 
 with a moderate degree of fat in the abdominal w^all and pad- 
 ding the pelvis, one is as likely to fail, especially when the 
 ovary is normal. When, however, the organ is diseased, 
 enlarged, or firmer than normal, and when displaced, it can 
 generally be felt. Any adhesion or thickening of the parts 
 around it obscures the examination ; the isolated mobile round- 
 ness of the organ is lost in diffused or irregular hardness. The 
 usual situation is to the side of the vagina and posterior to 
 the cervix ; at times, but rarely, it is in front. Often it 
 will be found prolapsed, lying in the pouch of Douglas. The 
 size, consistence, and degree of tenderness must be noted. 
 The healthy ovary is sensitive to pressure ; when diseased it is 
 often acutely tender, the pain l)eing associated with a peculiar 
 sickening feeling. From inflammation the ovary may attain 
 the size of a large walnut or small hen's egg ; when larger it 
 is due to the formation of cysts ; the organ may then feel dis- 
 
PERIMETRITIS AND PARAMETRITIS. 533 
 
 tinctly elastic. Ovarian cysts, which occupy the pelvis but 
 do not extend into the abdomen, have to be differentiated from 
 cysts of the broad ligament, dilatation of the Fallopian tubes, 
 pelvic abscess, pregnancy and extrauterine ^^regnancy, pelvic 
 h^ematocele, intestinal prolapse in Douglas's pouch, retro- 
 flexed uterus. For the special diagnosis the systematic works 
 must be consulted. 
 
 Affections of the Vulva and Orifice of the Vagina. — These 
 parts are liable to many affections, common to the body gen- 
 erally, such as eruptions of the skin, simple, erysipelatous, and 
 syphilitic inflammation, abscesses, cysts, congenital malforma- 
 tions, etc., for an account of which the systematic works must 
 be consulted. Here those only can be referred to which are 
 likely to comj^licate a vaginal examination, or are required 
 to elucidate some special symptom. 1. Increasing sensitive- 
 ness or pain on making an examination, may arise from 
 inflammation of the vulva, vaginitis, fissure of the vaginal 
 orifice, small, highly vascular and sensitive points in the 
 mucous membrane, or a similar general condition around the 
 orifice. These conditions are associated with a strongly 
 spasmodic condition of the sphincter vaginae, and constitute 
 ■what has been termed " vaginismus. The sensitiveness may 
 also arise from a painful caruncle at the orifice of the 
 urethra, or from hemorrhoids. 2. Swelling or tumors of the 
 labia. We may have abscess, varicocele, thrombi, inflamma- 
 tion of the gland of Duverney or occlusion of its duct, 
 dermoid cysts, hernia through the canal of Nuck (bowel, 
 omentum, or ovary), and hypertrophy. 3. Pruritis. This is 
 a common accompaniment of many special affections, such 
 as various eruptions, and discharges ; but it often occurs 
 without any visible change in the parts. It may arise from 
 local or constitutional causes ; amongst these are pregnancy, 
 the menstrual period, rheumatic or gouty tendencies, diabetes, 
 oxaluria, cystitis or urinary calculi, cancer of the uterus, 
 pediculi, scabies, and oxyurides. It is met with at all ages, 
 and is frequent from senile changes. 
 
 Perimetritis and Parametritis. — Two forms of pelvic inflam- 
 mation are met with — perimetritis or pelvic peritonitis, and 
 parametritis or inflammation of the cellular tissue around 
 the uterus. Although they are pathologically distinct, and 
 do occur separately, yet practically they are often combined, 
 and attempts to lay down signs for their differentiation have 
 as yet signally failed ; the best authorities are by no means 
 
 45* 
 
534 DISORDEES OF THE FEMALE ORGANS. 
 
 agreed. Amongst the differences tabulated in several books 
 there is no one point to which exception may not be taken. 
 
 The earliest sign is fulness on one side as compared ^vitli 
 the other, or posteriorly, the feeling of resistance at the part 
 is increased, and in most cases there will be tenderness on 
 pressure. The feeling of resistance further increases and 
 passes into diminished mobility, hardness or induration, and 
 fixation. The hardness may be diffused, like a phlegmon, or 
 more defined, giving the sensation of a tumor. The situation 
 of the hardness or tumor varies. The whole roof of the 
 pelvis may be rendered firm or resisting, the uterus lying 
 embedded in the inflammatory products. More frequently 
 the swelling is limited to one side of the pelvis, displacing 
 the uterus to the other. The lateral swelling may be ex- 
 tensive, lining the pelvic wall, or limited to the base of the 
 broad ligament. In the latter case the fulness and hard- 
 ness will be felt immediately to one side of the uterus and 
 above the level of the vagina. Very often the inflammatory 
 products are immediately behind the uterus, lying in the 
 pouch of Douglas, displacing the uterus forward, and at times 
 partially encircling the cervix. In these cases the swelling 
 does not pass in front of the cervix, but at times the cellular 
 tissue between the uterus and bladder is inflamed by itself; 
 this, however, much rarer than the other situations. The 
 tissues in the immediate neighborhood of either ovary may be 
 separately involved The swelling will then be in the poste- 
 rior lateral quarter of the pelvis. At times the hardness may 
 not be reached by the -finger in the vagina but may be 
 recognizable from above or detected only by the combined 
 method. Although generally extensive and readily recog- 
 nized, yet it must be remembered that the inflammation may 
 also be very limited in extent and not always associated 
 with hardness ; a slight fulness, limited in area, but very 
 tender to pressure, may be the only sign. 
 
 When the finger receives the sensation of hardness and 
 fixation, the mind naturally attaches thereto the idea of thick- 
 ness, and if the area be considerable, with marked signs, the 
 interpretation is a solid tumor. This impression is further 
 confirmed if a similar sensation is imparted to the hand 
 above. Nevertheless no solid tumor may exist. An inflamed 
 and adherent peritoneum, such as Douglas's pouch, may feel 
 like a hard lump, and the matting together of the broad 
 ligament and intestines, may impart all the sensation of a 
 solid tumor. Pelvic inflammatory tumors of large extent are 
 
DIAGNOSIS OF INFLAMMATOKY TUMORS. 535 
 
 always of this nature, " the apparent volume is in accordance 
 with the extent of these adhesions." 
 
 The phlegmon may extend from the pelvis into the iliac 
 fossa ; or forward and upward on the abdominal wall above 
 Poupart's ligament, and rising upward as high even as the 
 umbilicus. In other cases the inflammation extends along 
 the psoas muscles and may reach as high as the kidney, or it 
 may have a separate origin in this region. From the pelvis 
 the inflammation may likewise pass to the inner side and front 
 of the thigh. 
 
 The diflferential diagnosis of inflammatory tumors from 
 others which may be confounded with them often rests on 
 other points than physical signs, and especially on the his- 
 tory. These cannot be dealt with at length here. Among 
 the more frequent of these other conditions are — 1. Pelvic 
 Hmmatoeele. The diagnosis is often difficult, and will rest 
 chiefly on the mode of onset, its association with signs of loss 
 of blood, and the course of disease. 2. Retroflexed and retro- 
 verted uterus, pregnant or non-pregnant. There is not the 
 same degree of hardness, and there is not in general the im- 
 mobility found in inflammation, but a retroverted uterus 
 may also be involved in a perimetritis. 3. A prolapsed and 
 enlarged ovary will be mobile unless it also is associated 
 with perimetritis. 4. Accumulation and imjjaction of feces. 
 The peculiar consistence and pitting on pressure, the frequent 
 absence of pain, and independent mobility of the uterus, 
 should guard against errors. 5. Fibroid tumors of t\vQ uterus. 
 Their close relation to the uterus and mobility, in many cases, 
 render their recognition easy ; but when large they may 
 become impacted, or there may be intercurrent attacks of 
 inflammation ; the question then becomes one of great diffi- 
 culty. Increased length of the cavity of the uterus, recog- 
 nized by the sound, would point to a uterine fibroid. 
 6. Prolapse of the bowel into Douglas's pouch. There may 
 be a true hernia of the bowel behind the uterus, pushing the 
 organ forward, and forming a well-defined fulness or tumor 
 behind. When not inflamed, it may be recognized by its 
 peculiar elastic resistance, with its repressibility upward and 
 ready return. When inflamed and adherent it presents a 
 hard tumor, the nature of which it may be impossible to 
 determine. 7. Finally, the possibility of cancer of the peri- 
 toneum, and more rarely tubercular deposit, must not be 
 overlooked. Their recognition is dependent upon other cc;n- 
 ditions than those recognized by the hand. 
 
536 DISOKDERS OF THE FEMALE ORGANS. 
 
 In conclusion, we would remark that the cultivation of the 
 habit of a careful and thorough exploration of the pelvis is 
 the only sure means of guarding the practitioner against error. 
 We frequently see the attendant contented with the diagnosis 
 of some easily recognized condition, such as retroversion of the 
 uterus, while he overlooks the true cause of the patient's suf- 
 fering — pelvic peritonitis ; or a pelvic cellulitis may remain 
 unrecognized because no hardness is felt per vaginam ; still 
 more frequently debility and general symptoms have been 
 attributed to the stomach, or to nursing, or to anaemia, when 
 there was a pelvic origin for all, although this remained un- 
 recognized, because the examination was too cursory, or per- 
 haps never thought of at all. 
 
 The followino^ general works may be referred to: Thorburn, Prac- 
 tical Treatise on the Diseases of Women, London, 1885. — Duncan, 
 (J. Matthews), Clinical Lectures on Diseases of Women, third edi- 
 tion, London, 1886. — West, Lectures on Diseases of Women, fourth 
 edition, with additions by Dr. Matthews Duncan, London, 1879. — 
 Barnes, Clinical History of the Medical and Surgical Diseases of 
 Women, second edition, London, 1878. — Graily Hewitt, Pathology, 
 Diagnosis, and Treatment of Diseases of Women, fourth edition, 
 London, 1882. — Simpson (Sir James), " Works," volume 3, contain- 
 ing Lectures on Diseases of Women, Edinburgh, 1872. — Schroder, 
 " Diseases of the Female Sexual Organs," in Ziemssen's Cyclopaedia, 
 vol. X., London, 1875. — Thomas (T. Gaillard), Practical Treatise on 
 the Diseases of Women, fifth edition, Philadelphia, 1880. — Emmet, 
 Principles and Practice of Gynecology, third edition, London, 1885. 
 — Courty, Practical Treatise on the Diseases of the Uterus, Ovaries, 
 and Fallopian Tubes, translated by Agnes Maclaren, M.D., London, 
 1882. 
 
 Manuals : Edis, Diseases of Women, second edition, London, 1882. 
 — Galabin, Students' Guide to the Diseases of Women, third edition, 
 London, 1883. — Hart and Barbour, Manual of Gynecology, Edin- 
 burgh, 1882. — Atthill, Lectures on Diseases Peculiar to Women, 
 seventh edition, Dublin, 1882. 
 
 The elaborate Handbuch der Frauenkrankheiten, 3 vols., Stuttgart, 
 1877-82, edited by Billroth, may be referred to as a cyclopaedic work 
 on this subject. 
 
 Of special works, the " Memoirs " of Bernutz and Goupil, translated 
 by the New Sydenham Society, London, 1866-67, may be mentioned 
 in connection with their researches on Pelvi-peritonitis. Sir Spencer 
 Wells, Diagnosis and Surgical Treatment of Abdominal Tumors, 
 London, 1885. — Lawson Tait, Pathology and Treatment of Diseases 
 of the Ovaries, fourth edition, Birmingham, 1883. — Peaslee, Ovarian 
 Tumors, New York, 1873. — Pean, Diagnostic et Traitement des 
 Tumeurs de TAbdomen et du Bassin, 2 vols., Paris, 1880-85. — Mont- 
 gomery, The Signs and Symptoms of Pregnancv. second edition, 
 London, 1856. — Skene, Diseases of the Bladder and Urethra in 
 Women, New York, 1878. 
 
CHAPTER XVI. 
 
 THE PHYSICAL EXAMINATION OF THE CHEST 
 AND ABDOMEN. 
 
 Part I. Physical Examination of the Lungs. 
 
 Regionally tlie chest is usually divided as follows : The 
 anterior regions are the clavicular, the supraclavicular, the 
 sub-clavicular, the mammary, the suprasternal (or the jugular 
 fossa), and the sternal (upper, middle, and lower). The lateral 
 regions are the axillary and the infra-axillary. The posterior 
 regions are the suprascapular, the scapjular (including the supra- 
 and infraspinous spaces), the inter scajjular, and the infrascap- 
 ular. Such words as " vertical," " above,'^ " below," etc., are 
 always to be understood in the anatomical sense, as if the 
 patient were standing erect. 
 
 No detailed description of these regions need be given, as 
 the names speak for themselves, and in all cases where great 
 exactitude is required, it is preferable to indicate the point to 
 be noted, not by simply naming or sub-dividing the region in 
 which it lies, but by taking some definite anatomical land- 
 marks, such as a rib, the midsternum, a vertebra, or the 
 clavicle, and giving exact measurements from these points. 
 For this purpose the observer should always be provided with 
 a measure of length, and it is well to have it doubly divided 
 according to English inches and eighth-parts of an inch, and 
 according to the French metric scale which, with decimal sub- 
 divisions, is almost universally used on the continent in all 
 medical observations. It is convenient also to have a scale of 
 inches, or of centimetres, marked on the upper surfl^ce of the 
 plexinieter, but care should be taken that the markings are 
 accurate from end to end. 
 
 The methods of investigation pursued in the physical exam- 
 ination of the lungs, are inspection, palpation, mensuration, 
 percussion, and auscultation. 
 
 INSPECTION. 
 
 This should be conducted, if possible, with the thorax quite 
 exposed, but for a variety of reasons it often happens that 
 
538 PHYSICAL EXAMINATION" OF THE CHEST. 
 
 only a partial view can be obtained. Then, if it is possible, the 
 patient should be placed in the sitting posture to enable the 
 observer to view the chest from all points, and especially from 
 above downward over the shoulders. The light should be 
 good and should fall directly on the chest ; the attitude should 
 be erect, yet unconstrained. Too long exposure of the chest 
 is to be avoided, and "shawls can be used to lessen the danger 
 of catching cold. The points to which attention is directed 
 in this survey are: (1) The shape of the chest. (2) The 
 movements of its walls. 
 
 The Shape of the Chest. — This can be estimated in a general 
 way by the eye ; but the circumferential shape is accurately 
 determined by the "cyrtometer," an instrument perfected by 
 Woillez ; and by it also the relation which the two halves of 
 the thorax bear to each other can be gauged. A very handy 
 form of cyrtometer can be improvised with two pieces of 
 ordinary composition gas-pipe, united by a piece of India- 
 rubber tubing as a joint. The joint is applied directly over 
 the spinous processes and held- firmly in position. The two 
 pieces of pipe are then brought round the sides and moulded 
 
 Fig. 96. - 
 
 Circumference = 89 centimetres. 
 
 Transverse section of healthy adult chest upon level of sterno-xipliuid 
 articulation. (Dr. Gee.) 
 
 accurately to all the inequalities in the chest wall. They are 
 crossed in front, the one above the other, and a mark should 
 
THE SHAPE OF THE CHEST 
 
 539 
 
 be made on them to indicate exactly the mesial line of the 
 sternum. The joint allows them to be removed without de- 
 stroying the "set;" the apparatus is adjusted on a sheet of 
 paper, and a tracing made with pencil or ink. The measure- 
 ment is usually made about an inch below the level of the 
 nipple, or at the sterno-xiphoid joint. 
 
 In the healthy child the typical chest is somewhat circular, 
 while in the adult it takes the form of an ellipse, the trans- 
 verse diameter exceeding the antero-posterior.^ (See Fig. 96. ) 
 
 The variations from the typical forms are considerable, and 
 are quite consistent, in many cases, with a healthy condition 
 
 Fig. 97. 
 
 Pig. 98. 
 
 Circumference = .57.5 centimetres. 
 Pigeon-breast. Tracing taken 
 from a child of seven years. 
 Dotted line indicates the natural 
 shape at same age. (Dr. Gee.) 
 
 Circumference =42.75 centimetres. 
 
 Ricketj' chest. Dotted line 
 indicates the shape of chest in 
 an infant about the same age. 
 (Dr. Gee.) 
 
 of the thoracic,organs — occupation, accident, and various con- 
 ditions inducing the changes. There are, however, two typical 
 
 1 The following table, given by Dr. Gee, illustrates the circumference, and the ratio 
 of the diameters to the circumference in healthy chests at different ages. All the 
 measurements are taken on a level with the sterno-xiphoid-joint. 
 
 
 Age. 
 
 Actual circumference . 
 
 Eatio of diameters to 
 circumference. 
 
 
 Antero-posterior. 
 
 Transverse. 
 
 3 months 
 
 • 
 
 14% inches (37.5 0.1 
 
 26 
 
 29 
 
 2 years 
 
 
 18 " (45.75 c) 
 
 26 
 
 32 
 
 34 " 
 
 
 29f " (75 c.) 
 
 26 
 
 35 
 
 48 " 
 
 
 35 " (89 c ) 
 
 27 
 
 31 
 
540 PHYSICAL EXAMINATION OF THE CHEST. 
 
 deviations from the normal which are tolerably constant in 
 their characters ; the one is the " pigeon-breast," and the other 
 the ".rickety chest." 
 
 In the pigeon-breast (see Fig. 97) the sides are flattened, and 
 the sternum is carried in advance like a keel. It occurs in 
 childhood, when the ribs are yielding and adapt themselves 
 readily to any shape, from diseases in which great strain is 
 thrown upon the king as in whooping cough, measles, etc., 
 and is especially liable to take place in a rachitic subject. 
 
 The deformity that results from riehets alone is a contrast to 
 this. (See Fig. 98.) In it a constriction occurs in the lateral 
 region, and there is not the same sharp projection of the 
 sternum, as in the pigeon-breast. The chest, in fact, becomes 
 somewhat quadrilateral. In rickets also there is usually more 
 or less enlargement of the sternal ends of the ribs, giving rise 
 
 Fig. 99. 
 
 Bilateral enlargement of eniphj'senia. 
 
 Inner- lino = enii)hyscmatoiis chest. 
 
 Outer line = a circle drawn to show how nearl3' the emphj'sematous 
 
 approaches the circular shape. 
 Dotted line = natural adult chest. 
 
 Actual meastirement in centimetres. 
 Circumference == natural 89. emphysematous 87.75. 
 Transverse . . = " 29.6 " 27.2-5. 
 
 Antero-posterior = " 22.25 " 25.4. 
 
 (Dr. Gee.) 
 
 to a series of little nodules or " beads," which may be seen as 
 well as felt, constituting the so-called "rachitic rosary." 
 
UNILATEEAL CHANGES 
 
 541 
 
 These deformities do not necessarily indicate disease of the 
 lungs, but are frequently associated with it. 
 
 The two sides of the chest are nearly symmetrical, the left, 
 however, being usually a little less in circumference than the 
 right. This symmetry is often impaired by local conditions 
 which may be quite unimportant. 
 
 Emphysematous Chest. — In well-marked emphysema there 
 is a reversion toward the infantile type, in respect of the 
 altered proportion of the antero-posterior to the transverse 
 diameter. (See the Table, p. 540, and Fig. 99.) The chest 
 becomes more cylindrical, or, as it is often called, "barrel- 
 shaped;" the sternum is more arched from above downward 
 than in the normal condition, and the costal cartilages, along 
 with the sternum, present also an excessive arching trans- 
 versely, so that the front of the bony case seems unnaturally 
 bulged forward, while the lower ribs are laterally compressed. 
 There is, however, this well-marked difference between the 
 emphysematous and most of the infantile deformities, that in 
 proj^ortion as the former take place after the bony and carti- 
 
 FiG. 100. 
 
 Unilateral retraction of chest ; consequent upon cirrhosis of left lung in a girl of 
 fourteen years. The figures indicate antero-posterior and transverse diameters, and 
 semi-circumferences of right and left half of chest. (Dr. Gee.) 
 
 laginous structures have been consolidated, the changes are 
 gradual and devoid of abruptness. We rarely or never find, 
 accordingly, the pigeon-breast, or the depressed and incurvated 
 
 46 
 
542 PHYSICAL EXAMINATION" OF THE CHEST. 
 
 ribs of the rickety infant among the emphysematous deformi- 
 ties of adult age. 
 
 Unilateral changes may also occur. There may be bulging 
 of one side from effusion of fluid or air into the pleural sac ; 
 tumors of the lung, such as cancer, have a similar effect, and 
 even in pneumonia, if it is extensive, there may be a slight 
 but decided increase on the affected side. Retraction of one 
 side may occur from cicatricial processes in the lung tissue, as 
 in phthisis or abscess, or from the lung not expanding after 
 the absorption of a pleural effusion of air or fluid. (See Fig. 
 100.) If the retraction is extreme, lateral curvature of the 
 spine is usually present, the convexity being directed toward 
 the sound lung, and curvatures of the spine from other causes 
 may, in like manner, give rise to distortion of the chest. 
 
 The sub-clavicular regions always demand the most careful 
 inspection, as a degree of flattening there often attends the 
 deposition of tubercle. 
 
 Local bulgings may occur in the chest wall, in the region 
 of the heart, from pericardial eff'usion or extreme dilatation or 
 hypertrophy of the organ itself; aneurisms or tumors in any 
 part of the cliest may give rise to similar deformities, and an 
 empyema when pointing does the same. 
 
 Movements of the Ched Walls. — In estimating these, the 
 student must keep before his mind the fact that in w^omen the 
 thorax moves more freely during respiration than in men ; 
 the type being more thoracic in the female and more abdo- 
 minal in the male. The movements should be observed first 
 in quiet respiration, and then the patient should be directed 
 to take one or two deep breaths, filling the chest slowly and 
 fully. Both inspection and palpation should be brought to 
 bear on the determination of the amount of movement. 
 
 The thoracic respiratory movement may be exaggerated and 
 this is especially the case when the descent of the diaphragm 
 is impeded, as from pregnancy, and tumors or other condi- 
 tions in the abdominal cavity. On the other hand, the 
 thoracic movement may be much restricted, and abdominal 
 respiration greatly exaggerated, as in cases where the respira- 
 tory forces of the chest are at fault (as in paralysis of the 
 muscles), and the whole work of respiration is thrown upon 
 the diaphragm. There may, however, only be a deficiency in 
 the expansion of the thorax as a whole, as in pronounced 
 emphysema ; or in the same disease the lower zone may be 
 sucked in by the action of the diaphragm, while the upper 
 half is forcibly raised by the scaleni and steruo-mastoid mus- 
 
PALPATION. 54 
 
 Q 
 
 cles, without, however, there being a corresponding amount of 
 expansion. In obstruction of the larynx and trachea (as in 
 cases of croup in chiklren) we find certain parts sucked in 
 during the violent efforts at inspiration ; in particular, the 
 lower portion of the sternum, the lateral regions of the chest 
 wall above the level of the liver, and the supraclavicular and 
 the suprasternal regions. In children the soft bones yield 
 readily to the atmospheric pressure which exerts this influence 
 owing to the air not entering the lung freely enough to balance 
 it within ; the amount of the recession becomes thus a gauge 
 of the severity of the case. 
 
 Movement may be in abeyance over one side or the other, 
 from extensive pleuritic efiusion and pneumothorax ; or from 
 retraction arising from non-expansion of the lung after old 
 pleuritic efliision ; or from chronic excavation or fibroid 
 shrinking of the lung. Or the restricted movement may 
 only exist at the base, the sound side and upper half of the 
 affected one being thrown into undue motion. Pneumonic 
 and other consolidations at the base and modern pleuritic 
 effusion give rise to this. The movements at the apices should 
 be critically observed, and here inspection and palpation are 
 very usefully combined. The observer stands behind the 
 patient with a thumb on either scapular spine, while the 
 tips of his fingers lie over the apices in front immediately 
 beneath the clavicles. The patient is then directed to inspire 
 fully and quietly, and by scrutinizing the complex movements 
 of the ribs and watching the rise and fall of the fingers, a 
 very accurate comparison of the expansion of the two sides 
 can be made. Deficient expansion at either apex is a very 
 important fact as indicating disease of the lung, usually 
 phthisical. 
 
 PALPATION. 
 
 This has already been referred to as a very important 
 adjunct to inspection in determining" the expansion of the 
 upper part of the chest {vide supra), and it will naturally 
 occur to the student to employ it in estimating more exactly 
 than by inspection alone, deficient or undue movement in 
 other parts of the thorax. Palpation will also determine 
 the condition of the intercostal spaces, which may be unduly 
 prominent, resistant, and wide, as in cases of effusion into the 
 pleura either of air or fluid, or in the region of the heart from 
 pericardial eflPusion ; or they may be diminished in size by the 
 approximation of the ribs, as in cases of collapse or shrinking 
 
5tt4 PHYSICAL EXAMINATION OF THE CHEST. 
 
 of the lung. Fluctuation or elasticity may sometimes be 
 detected in the intercostal spaces in cases of fluid effusion, and 
 in some instances pleuritic friction, the vibrations from 
 snoring rales in the lungs, and the grating sensation present 
 in some forms of emphysema may be realized. Specially 
 tender spots or regions may also be detected during palpation. 
 The condition of the vocal fremitus, the presence of pulsations 
 and thrills (cardiac or aneurismal), and of pleuritic or peri- 
 cardial friction fremitus may also be noted, but these will be 
 discussed under their respective heads. (See pp. 636, 640, 
 653, 674.) 
 
 MENSURATION. 
 
 If the circumference of the two sides is required, the 
 student should first mark in ink the tips of the spinous pro- 
 cesses, some of the vertebrae, and in a like manner the mesial 
 line of the sternum, taking the centre of the jugular notch 
 and of the xiphoid cartilage as guide?. The semi-circumfer- 
 ence is taken from these lines, the measurements being made 
 at exactly similar levels, the tape applied accurately and with 
 equal tightness to the chest wall, and the two observations 
 made either on inspiration or expiration, or on both. The 
 level most commonly selected for the measurements is about 
 two inches below the nipple in a line with the sterno-xiphoid 
 joint, the advantages of this situation being that it is quite 
 free from bulky muscles and below the scapulae. A favorite 
 method of measurement is by the double tape, which is simply 
 two tapes joined. Their line of junction is placed exactly 
 over the spinous processes, they are brought round on either 
 side, and the circumference of the two halves can be read off 
 at once and their relative degree of expansion noted. 
 
 In the average healthy chest the right side is usually found 
 to exceed the left in circumference by about three-fourths of 
 an inch. But the circumference of either side may be in- 
 creased from morbid conditions, as in cases of effusion of air 
 or fluid into the pleura or pericardium, in unilateral emphy- 
 sema, or in thoracic tumor. In oedema of the chest wall 
 also, if the patient lies habitually or for any length of time on 
 the one side, the fluid will gravitate so as to increase the cir- 
 cumference on that side. But the circumference may be 
 diminished from shrinking of the chest wall in collapse of the 
 lung, after pleural effusion or from retraction in phthisis. 
 Discrepancies may also arise from deformities of the walls or 
 
MENSURATION. 
 
 545 
 
 from curvature of the spine. (See shape of chest as gauged 
 by the cyrtometer, Fig. 100.) 
 
 The anteroposterior diameter of the chest maybe estimated 
 by the cyrtometer or by callipers, one blade being placed in 
 front and the other behind ; and the movements of respiration 
 
 Fig. 101. 
 
 Pneumograpli of Marey. /, very thin brass plate bearing a tambour, h, the alumi- 
 nium disk of which is connected with the upright h, the upper end of which moves on a 
 horizontal screw, g. The band c e d is placed round the body. During expansion of 
 the chest, tension occurs between c and d, which acts on the tambour by the bending of 
 the brass plate /, and the movement is communicated to a recording tambour by a. 
 (MacKendrick.) 
 
 may be accurately determined by the '^ chest measurer'' of 
 Dr. Sibson, or the stethometer of Dr. Quain, both of which 
 indicate on a dial the degree of expansion. The spirometer 
 of Dr. Hutchinson, which measures the quantity of air 
 breathed out, is used to determine the " vital capacity " of the 
 lungs ; while the stethograph of Ransome gives tracings of the 
 movements of the chest walls. Marey's pjneumograph is a very 
 handy and simple instrument for recording the movements of 
 the chest walls. (See Figs. 101 and 151 ; compare pp. 102 
 and 346.) All these instruments, however, are of much more 
 value in physiological than in clinical investigation. Dr. 
 Ransome's " chest rule " may also occasionally be used with 
 advantage to note accurately the area of any .percussion- 
 dulness, or the exact position of any pulsation, auscultatory 
 phenomenon, etc., which it may be necessary to record. 
 
 46* 
 
546 PHYSICAL EXAMINATION OF THE CHEST 
 
 PERCUSSION. 
 
 This may be performed without any instrument, the fingers 
 of the one hand acting as the " plessor," and those of the other 
 as the " pleximeter." But the ivory pleximeter of M. Piorry 
 may be used or the various modifications of it, and the stroke 
 may be dealt by Wintrich's hammer. This last is, as a rule, 
 only useful for purposes of demonstration to a large class or 
 to educe sounds which require a strong stroke — e. g., the 
 " cracked-pot sound," or to elicit the note in parts thickly 
 padded w^ith muscle as in the supra-spinous regions in the back. 
 When the pleximeter is used it should be firmly and closely 
 applied to the skin, the percussing stroke should be delivered 
 on its centre, and if the finger is used as the plessor, care 
 should be taken that the nail does not impinge upon the ivory. 
 But the fingers give the most delicate results, and in very 
 critical percussion they are indispensable, as they enable the 
 physician to estimate the degree of resistance to his stroke 
 with greater delicacy than by any other method. The finger 
 playing the part of the pleximeter should be applied firmly 
 and flatly to the chest wall, and the stroke should be as direct 
 and perpendicular as possible, wdth a well-controlled move- 
 ment from the "wrist and not from the elbow. Care should 
 be taken that no sound is generated by the contact of the nails. 
 Occasionally, " immediate " or direct percussion is employed, 
 the fingers striking the chest wall directly ; this is especially 
 useful in the clavicular region, the bone there acting as a kind 
 of pleximeter for the apex of the lung behind it. 
 
 In the back of the chest the lower limit of lung-percussion 
 is on a level with the tenth or eleventh dorsal spine. In front 
 on the right side it is bounded inferiorly by the upper border 
 of hepatic dulness — i. e., about an inch and a half below the 
 nipjDle, while on the left side it is bounded at the lower border 
 of the third rib by the cardiac dulness, and in the left lateral 
 region by the stomach and spleen. In the upper front, the 
 apices of the lungs project to some extent above the clavicles 
 into the supra-clavicular spaces. 
 
 The parts of the chest which should be most carefully per- 
 cussed are the apices both in front and behind, the inter- 
 scapular regions, the axillary regions, and the bases. Each 
 point on the one side should be carefully compared with a 
 similar point on the other, and in many instances also with 
 different parts on the same side. Every stroke should be 
 made to yield results, and no spot should be lingered over 
 
PERCUSSION. 547 
 
 separately and without comparison with others, as the ear is 
 apt to get confused. If dull percussion is detected, especially 
 in the lower part of the chest, it should be tested with the 
 patient in various attitudes, for pleuritic effusion, if free, will 
 be found, in some instances, to obey the law of fluid level, and 
 the area of dulness will vary with the position of the pati ent. 
 This is especially marked in cases of hydro-pneumothorax. 
 In percussing above the clavicle, care should be taken that the 
 stroke is directed away from the trachea. It is also well to 
 remember that in health the percussion note of the left apex, 
 especially in women, is often a little flatter than the right.^ 
 
 Over the healthy lung the percussion note is termed " clear, ^^ 
 and the junior student will do well to contrast it carefully 
 with the note obtained over the stomach, which is " tympanitic'^ 
 or drum-like, and that over the liver whicli is " dull.'" No 
 uniform standard can be set up for the pulmonary note in all 
 cases, as there are so many modifying circumstances. For in- 
 stance, if the chest walls are well covered with muscle or fat, 
 the pulmonary note may be very obscure, especially in the 
 back ; and in such cases it is only by a careful comparison of 
 all parts of the chest that a standard can be arrived at for the 
 individual patient. 
 
 The percussion note over the lungs may depart from the 
 normal in the direction either of hyper-resonance or of dulness. 
 If over one side of the chest a frankly tympanitic note is got, 
 pneumothorax should be suspected, and other signs will gen- 
 erally confirm the diagnosis. But a more localized and much 
 less pronounced tympanitic note may be obtained in many 
 instances at the apex of a lung from tubercular excavation if 
 near the surface ; or where there is consolidation of the lower 
 lobe as in pneumonia ; or where the lower lobe is compressed 
 by pleural effusion, especially if that effusion is advancing or 
 beginning to recede. In these cases, however, the tympanitic 
 quality is usually associated with some diminution of reson- 
 ance so that the note is so far dull.^ In emphysematous 
 conditions of the lungs the mass of the percussion sound is 
 
 1 The normal pulmonary percussion sound is possessed of the qualities of pitch and 
 intensity, the former depending upon the number of vibrations in a given time, the 
 latter upon the magnitude of these vibrations. It has, however, no distinct musical 
 quality, no "timbre;" it is a sound, not a tone; and so contrasts strongly with the 
 drum-like note educed from the air-fllled organs in the abdomen. The pitch of the per- 
 cussion sound depends chiefly upon the degree of tension of the thoracic parietes, 
 although to some extent also upon the degree of tension of the lung tissue itself. The 
 greater the tension the higher the pitch and vice versa. 
 
 2 Skoda was the first to call particular attention to this tympanitic quality of percus- 
 sion note in cases of pleural effusion, and hence by many French observers it is designated 
 "ferwii scodique.''^ 
 
548 PHYSICAL EXAMINATION OF THE CHEST. 
 
 increased or exaggerated, while at the same time it is lowered 
 in pitch. 
 
 1) Illness over the lungs may be due to changes in the organs 
 themselves, or in the pleurse. All forms of ^^ulmonary con- 
 densation lead to it, such as pneumonia, tubercular or can- 
 cerous disease, oedema, congestion, collapse, etc. The dulness 
 in such cases may affect any part of the lung, but in the great 
 majority of instances the bases are chiefly involved ; tubercular 
 consolidation, however, is a marked exception to this, the 
 apices being most frequently affected, the first hints of it being 
 often obtained by a change in the percussion note in the supra- 
 clavicular spaces. 
 
 Dulness depending on changes in the pleura may result from 
 thick layers of lymph or fluid effusion ; in the latter case, if it 
 is moderate and free, the dulness will gravitate to the base, but 
 if the effusion is large the whole side may yield an abso- 
 lutely dull note, and it may even cross the mesial line, and 
 reach above the clavicle. (See Fig. 106.) The dull note in 
 rare cases may depend on pneumothorax, where the air is 
 present in such quantity as to distend the pleural cavity to its 
 utmost ; if a little air is let off in such instances by a hollow 
 needle, a tympanitic note becomes developed. Thickening of 
 the pleura will diminish the pulmonary resonance, and in 
 collapse of the lung w^ith retraction of the side, the resonance 
 will, of course, be seriously impaired if not altogether lost.^ 
 
 But area of dull percussion may occur from other causes 
 than changes in the lungs or pleurae. Thus aneurisms or 
 dilatations of the aorta, glandular tumors, cancer, pericardial 
 effusion, or dilated or hypertrophied conditions of the heart 
 may encroach on the limits of lung-percussion. These areas 
 should be carefully mapped out, and other signs will usually 
 guide the diagnosis. The displacements of the heart are con- 
 sidered under the head of cardiac diagnosis. (See page 569.) 
 
 The c7'acked-pot sound (Bruit de pot fele) demands special 
 mention. It is a modification of the tympanitic, and can be 
 well imitated by striking the hands fokled across each other 
 over the knee. The best method to elicit it is by a strong 
 stroke, and this is one of the instances for the use of the per- 
 cussing hammer. The patient should keep his mouth open 
 
 1 In cases of niodenite pleural effusion where the fluid is free, the line of dull per- 
 cussion is not jx'rfectly horizontal, liut nxjre or less curved. Observers are by no means 
 agreed, however, as to the exact shape of the curved line ; and as Uio scope of this work 
 precludes detailed examination of the (piestion, the student is referred to Dr. Garland's 
 monograph upon "pneumo-dynamics," where he will find full details and an excellent 
 bibliography. 
 
AUSCULTATION. 549 
 
 and breathe quietly. In the adult this sign generally indi- 
 cates a cavity in the lungs, but it may be present in healthy 
 children, owing to the yielding nature of the chest walls. 
 Walshe says it is usually got over the chest of a crying infant 
 on expiration. If a patient, who develops this sign, inspires 
 deeply and then holds his breath during the percussion, the 
 cracked-pot sound will disappear. The quality is most marked 
 in expiration, and it is essential for the production of the 
 phenomenou that the cavity shall be in free communication 
 with the bronchus. 
 
 AUSCULTATION. 
 
 Auscultation of the lungs may be conducted either mediately 
 by the stethoscope, or immediately by the application of the 
 ear to the chest wall. The former is the method more com- 
 monly employed in this country, although in certain instances, 
 especially in the auscultation of children, who are easily 
 frightened by the sight or pressure of the stethoscope, the 
 direct method may be more advantageous. But even in chil- 
 dren the stethoscope is often essential for exact observation, 
 and Avith a little manoeuvre the fear of the instrument can 
 usually be overcome. In adults also it is often well to auscul- 
 tate the back of the chest " immediately," a thin soft towel or 
 handkerchief being interposed between the ear and the skin. 
 In selecting a stethoscope the student should see that it fits his 
 ear accurately. The form of the instrument is not of very 
 much consequence, and it may be made of metal, vulcanite, 
 or wood. The ear-piece should be large enough to cover the 
 whole concha — say from 2J to 2f inches in diameter, and 
 slightly concave to admit of the exact application of the ear. 
 The bell should be large enough to bridge over an intercostal 
 space — from an inch and a sixth to an inch and a quarter in 
 diameter. 
 
 The stethoscope should be applied directly to the chest 
 without the intervention of any clothing, and it is necessary 
 that it should be planted quite fairly, so that the whole of the 
 circumference of the bell may be in contact with the skin. 
 Moderate pressure with the head will keep it in position, but 
 care should be taken that undue pressure is not exerted, as it 
 not only causes pain, but may even impede respiration to some 
 extent. Beginners, as a rule, are apt to press far too heavily. 
 Care must be taken to obviate friction between any part of the 
 patient's dress and the stethoscope, or between the patient's 
 
550 PHYSICAL EXAMINATION OF THE CHEST. 
 
 dress and liis skin in the vicinity of the instrument. In 
 patients who have much hair developed on the chest, the 
 student must be careful that he does not mistake the friction 
 of the hair with the stethoscope, during the act of respiration, 
 for an intrathoracic sound. This fallacy may be avoided by 
 wetting or shaving the part, or 'having the bell of the stetho- 
 scope shod with a piece of India-rubber. The differential 
 stethoscope of Dr. Scott Alison may occasionally be employed 
 in the physical examination of the lungs, but it is of much 
 more importance in cardiac diagnosis, especially in determin- 
 ing the rhythm of murmurs. It consists simply of two stetho- 
 scopes, with flexible stems, leading separately to each ear, and 
 connected by a joint. The ear-pieces are small and fit into 
 the ears, while the flexible stems allow of the bells being placed 
 at a greater or less distance from each other according to the 
 desire of the auscultator. A new form of differential stetho- 
 scope has been introduced by Dr. Spencer, in which the sounds 
 from each tube are communicated to both ears. A binaural 
 stethoscope with a single bell is also frequently used, and is 
 said to intensify the sounds. 
 
 During auscultation both the patient and the observer 
 should be in an easy posture. The patient should lie quite 
 flat or sit unconstrainedly, all muscular effort being in abey- 
 ance, and the auscultator should avoid stooping or straining 
 too much over the patient. A very thorough examination 
 can also be made with the patient standing erect, a blanket or 
 shawl being cast over his shoulders to prevent any chill. The 
 examination should be carried out quietly and systematically, 
 the various regions of the chest being, as far as possible, 
 symmetrically examined and carefully contrasted. It is often 
 necessary also to contrast different parts on the same side. 
 The patient should be directed to breathe quietly or forcibly, 
 according as circumstances demand, and it is well in most 
 cases to listen under both conditions, always taking care, how- 
 ever, that quiet respiration is first selected. A fact of im- 
 portance is, that forced inspiration should not be performed 
 spasmodically, or with noise in the mouth or nose, but slowly 
 and quietly. A thorough examination of all parts of the 
 lung is necessary, but special attention should be ])aid to the 
 apex, both in front and behind, to the axillary region, to the 
 interscapular region, to the base behind, and to any region 
 where pain is coni})lained of. The student must be careful 
 not to confuse his ear by lingering too long over the same 
 spot ; it is much better to return to it. The examination 
 
BKEATH SOUNDS. 551 
 
 should be conducted with as little fatigue to the patient as pos- 
 sible, and with this end in view, as well as to avoid unnecessary- 
 repetition, each spot on the one side should be compared with 
 a corresponding point on the other : exact comj)arative results 
 are thus obtained. 
 
 The principal objects for which auscultation of the lungs is 
 practised are: 1, To ascertain the condition of the respiratory 
 murmur or breath sounds ; 2, To detect the presence of any 
 superadded abnormal sounds or rales ; o. To ascertain any 
 alteration in the resonance of the voice and cough, or in the 
 transmission of the heart's sounds. 
 
 BREATH SOUNDS. 
 
 To aseertain the condition of the breath sounds. In this as 
 in all other departments of physical diagnosis, the student 
 must be acquainted with the healthy phenomena before he can 
 hope to detect morbid changes. There are three facts then 
 with which he must make himself perfectly familiar in the 
 healthy chest, viz., the character of the breath sounds as heard 
 over the trachea, over a bronchial tube, and over the spongy 
 lung tissue. The breath sounds over the trachea are loud, 
 hollow, articulate, and the expiration and inspiration are equal 
 in length and intensity, but separated by a distinct interval. 
 Bronchial respiration is heard to greatest advantage near the 
 sterno-clavicular articulations or in the interscapular spaces 
 near the spine. It approximates in character to the tracheal, 
 but is mucli less pronounced. 
 
 The vesicidar or resjnratory murmur jproper is heard over the 
 spongy lung, and may be found in its most typical form in 
 the lower half of the back, two or three inches from the spine, 
 or in the lateral region. It is soft, breezy, and uniform ; and 
 although the inspiratory and expiratory sounds are the same 
 in quality they differ in degree and prolongation, the expira- 
 tory being less loud and only about one-third the length of 
 the inspiratory. The interval between the two acts is of very 
 short duration. It is to be remarked that the inspiratory 
 murmur is normally louder and harsher in children than in 
 adults (hence called puerile), that in old age it tends to 
 become feebler, and that it is usually more marked in men 
 than in women. It is also to be expected that in an emaciated 
 subject the respiratory murmur will be more audible than in 
 one with Avell-developed muscular and fatty tissues. Besides 
 these there are variations which cannot be accounted for on any 
 
552 PHYSICAL EXAMINATION OF THE CHEST. 
 
 physical principle, and may be regarded as individual pecu- 
 liarities, some men having an extremely feeble, or almost in- 
 appreciable respiratory murmur throughout the chest, while 
 others have respiration which may almost be described as 
 puerile, both conditions being quite compatible with an abso- 
 lutely normal state of the lungs and air passages. 
 
 The vesicular murmur may undergo various changes in disease. 
 It may become weakened or suppressed. Weakening of the 
 respiratory murmur may result from some obstruction, such 
 as pressure of an aneurism on a bronchus, or spasm of a 
 brcmchus ; or from some obstruction in the larynx and trachea 
 hindering the free admission of air into the pulmonary vesicles. 
 The pain of pleurisy, by impeding the free movements of the 
 chest, may lead to partial restriction of the respiratory mur- 
 mur. It may also result from pulmonary condensation, 
 collapse, or emphysema. Absolute suppression occurs in cases 
 of large effusion either of serum (hydrothorax), or of pus 
 (empyema), or of air (pneumothorax), into the pleural sac. 
 Jn certain cases of condensation and collapse of the lung, the 
 respiratory murmur may be quite suppressed or replaced by 
 some other form of respiration, such as the bronchial. 
 
 The respiratory murmur may be exaggerated, or .as it is 
 technically called puerile. This exaggeration specially affects 
 the inspiratory murmur. In children the normal respiratory 
 murmur is of this type, but in the adult its presence usually 
 indicates that although the part of the lung over which it is 
 heard may be healthy, some other part is suffering from 
 causes leading to suppression or diminution of the respiratory 
 murmur. It is heard at the apex of a lung, for instance, 
 when the lower part is compressed by pleuritic effusion, or 
 when the base is consolidated ; or if owing to any cause the 
 function of one lung is much crippled, the respiratory murmur 
 is often exaggerated on the other side. All these facts indi- 
 cate its compensatory nature. 
 
 Jerky, wavy, sighing, or cogged-ioheel respiration, is the term 
 applied to the respiratory murmur when it loses its continuous 
 character and gets broken up into parts, or into a series of 
 little waves. It is tlie inspiratory nuirmur almost exclusively 
 which is affected in this manner. It is not indicative of any 
 positive disease, but should always be regarded with suspicion, 
 especially if it is localized at the apex, as an early indication 
 of phthisis. In many instances in the vicinity of the heart 
 jerky respiratory murmur is obviously pulsatile, and due to 
 the cardiac action. 
 
BREATH SOUNDS 553 
 
 Prolongatio7i of the exjnratioii. It has already been stated 
 that normally the expiratory murmur is much shorter than 
 the inspiratory, but in many cases it becomes so lengthened 
 as to equal the inspiration, and in some instances even to ex- 
 ceed it. It is a frequent indication of the early stage of tuber- 
 cular deposition, and in such cases is usually associated with 
 a degree of harshness or exaggeration of the respiratory mur- 
 mur. In vesicular emphysema, owing to over-distention of 
 the air vesicles and consequent loss of elasticity in their walls, 
 this prolongation of the expiration is very marked, and is 
 associated with weakening of the inspiratory murmur. 
 
 But the respiratory murmur, besides these alterations in it, 
 may come to assume a totally different quality ; it is replaced, 
 in fact, by breathing of another type. The changes in quality 
 are indicated by the terms tracheal, bronchial or tubular, cav- 
 ernous, and amjjhoric. Some of these differ only in degree, 
 and all of them may be heard at different stages in a case of 
 phthisis going on to excavation, as well as in other affections 
 having a similar tendency. 
 
 Bronchial or tubular respiration, as has been already stated, 
 is heard in the healthy subject over the large bronchi, but in 
 certain forms of disease it is present over the spongy lung. It 
 occurs in consolidation and collapse. It is heard in pneu- 
 monia during the stage of hej^atization, in phthisis, and in 
 cancer of the lung. It is occasionally also heard in pleuritic 
 effusion : in cases with large effusion, where the lung is 
 squeezed to the upper and back part of the chest, bronchial 
 respiration is often heard in this situation. 
 
 Cavernous respiration has the same hollow and articulate 
 quality as that heard over the trachea, and if these characters 
 are present over a limited area and not in the immediate 
 vicinity of a bronchial tube, and especially if associated with 
 the metallic phenomena (to be afterwards described), the pro- 
 bability is that a cavity exists. All conditions that lead to 
 excavation in the lung tissue produce it, and among these 
 phthisis is by far the most frequent. Dilated bronchi may 
 also give rise to it. Amphoric respiration is just a more ex- 
 quisite degree of the cavernous, and can be w^ell imitated by 
 blowing across the mouth of a large empty jar. It is heard in 
 large intra-pulmonary cavities, and in cases of pneumothorax 
 where there is a communication betw^een the lung and the 
 pleural sac. Guttmann maintains, how^ever, that it is pro- 
 duced in pneumothorax only when the pulmonary fistula has 
 
 47 
 
554 PHYSICAL EXAMINATION" OF THE CHEST. 
 
 closed, and the lung is still capable of a certain amount of ex- 
 pansion. (See also p. 556.) 
 
 RALES. 
 
 The respiratory murmur may be accompanied or replaced 
 by other sounds called rales. These may be classified as — (1) 
 sonorous and sibilant ; (2) mucous or bubbling ; (3) crepitant. 
 Friction sound is not usually classified among the rales, but, 
 in many instances, it so closely resembles, or is so closely 
 simulated by, intra-pulmouary sounds, that it seems well to 
 treat of it in this connection. Various combinations of these 
 rales occur and must be named accordingly. 
 
 Sonorous and sibilant rales. These are dry and somewhat 
 musical ; they are caused probably by some obstruction to the 
 tide of air in the bronchial tubes. The sonorous or snoring 
 rales are of a grave pitch, loud, and usually accompany both 
 inspiration and expiration, but the pitch may vary in the two 
 acts. The sibilant (wheezing, whistling, cooing, etc.) are high 
 in pitch, but in other characters resemble the sonorous. These 
 rales are heard most typically in acute and chronic bronchitis, 
 and in spasmodic asthma. The two forms of rale are usually 
 associated ; they vary much from time to time, and may dis- 
 appear temporarily after a cough. 
 
 Bubblinf/ or mucous rale. This rale, in its typical form, un- 
 questionably gives the ear the impression of moisture, like the 
 bubbling of air through some viscid fluid. It often exists both 
 with inspiration and expiration, and varies greatly in its de- 
 gree, sometimes approaching to the characters of the crepitant 
 rale, and then called " sub-crepitant " by some authors, while 
 at other times it is large, coarse, and quite decidedly mucous. 
 It may, in severe cases, be present all over the lung, but, as a 
 rule, is most abundant at the base. It is common in bronchitis 
 where the secretion of mucus is abundant ; in oedematous 
 states of the lung owing to disease of the heart or kidneys; 
 and in certain fevers, such as typhus, owing to congestion. In 
 the stage of resolution in pneumonia the rale known as the 
 crepitus redux is essentially a mucous rale, and the clicking 
 rale of phthisis is also moist. This rale in phthisis is so sig- 
 nificant as to demand special mention. It is very distinctly 
 moist and clicking, often very scanty, limited in its area, 
 chiefly accompanying inspiration, sometimes only toward ter- 
 mination, and having a marked tendency to develop at the 
 
RALES. 555 
 
 apices. It is very significant of softening tubercle. The cav- 
 ernous rale may also be considered as a modification of the 
 mucous. It is present in cases of cavity from tubercular dis- 
 ease or dilated bronchi. It usually accompanies both expira- 
 tion and inspiration, is heard over a limited area, and if the 
 patient coughs it often has a splashing or gurgling quality, 
 each splash being followed by an aftertohe or echo. 
 
 Crepitant rale. This is a finer rale than the mucous, and 
 is not distinctly moist. It is heard in its typical form in the 
 first stage of pneumonia, prior to consolidation, when it con- 
 stitutes the jDneumonic crejntus. This is heard, as a rule, on 
 inspiration only, often just at the end of it, and consists of a 
 number of minute crackles. It can be well simulated by 
 rubbing a lock of hair between the fingers near the ear. The 
 rale is extinguished on the supervention of bronchial respira- 
 tion. Crepitant rale is also present in oedema of the lungs, 
 and acute capillary bronchitis, and certain forms of pleuritic 
 friction often closely resemble it. It merges by insensible 
 gradations into the sub -crepitant rale, or very fine moist or 
 mucous rale. 
 
 Friction sound is produced in the pleura, owing to the 
 roughened surfaces grating on each other, and in its most ex- 
 quisite form it is easy of recognition. It is distinctly rubbing 
 or grating, very superficial, and usually accompanies both ex- 
 piration and inspiration, but it may be with inspiration alone. 
 It is often quite appreciable by the hand of the observer 
 (pleural friction fremitus), and the patient even may be con- 
 scious himself of the grating in his chest. Its most frequent 
 seats are in the mammary region, in the lateral region in the 
 line of the axilla, or further round, near the inferior angle of 
 the scapula. It is often accompanied by an unchanged con- 
 dition of the respiratory murmur, but this may be somewhat 
 weakened or jerky ; forced inspiration and coughing do not 
 obliterate it ; indeed, forced inspiration is often required to 
 bring it out. In many cases its characters are not so pro- 
 nounced, and it is often mixed up with intra-pulmonary rales, 
 which tend further to obscure the diagnosis. In some cases 
 friction is caused in a roughened pleura by the cardiac action. 
 This is heard on the confines of the heart, and is distinctly 
 related to the cardiac action, as may be found by its continu- 
 ing when the patient suspends respiration. 
 
556 PHYSICAL EXAMINATION OF THE CHEST 
 
 METALLIC AND AMPHORIC PHENOMENA. 
 
 There is yet a certain group of auscultatory signs which 
 may be classed under the title of metallic phenomena. These 
 are metallic tinkling, amphoric echo, the bell sound, and Hip- 
 pocratic succussion. All these phenomena are very variable 
 in their degree and persistence, and they occur in different 
 combinations. 
 
 Metallic tinkUng is well described by Laennec as "a peculiar 
 sound, which bears a striking resemblance to that emitted by 
 a cup of metal, glass, or porcelain when gently struck with a 
 pin, or into which a grain of sand is dropped." It may be 
 heard with respiration, voice, or cough — most typically with 
 the last two. It is very significant of cavity, and may be 
 found in large pulmonary excavations when near the surface 
 of the lung, and also in pneumothorax. 
 
 Amjihorie echo. This term is applied when the voice, 
 cough, and breath sounds have an intensely hollow resonance, 
 and it can be well imitated by speaking, coughing, or breath- 
 ing into a large empty jar. It very frequently accompanies 
 metallic tinkling, or may be interchangeable with it. It is 
 only present when large masses of air are thrown into vibra- 
 tion, and occurs most frequently in pneumothorax, altliough 
 it may occasionally be heard in intra-pulmonary cavities of 
 large size. It may accompany respiration, voice, or cough, 
 but is usually most pronounced with the last two. 
 
 The bell sound may be elicited by percussing the chest with 
 two coins (half-crowns do very well), the one coin being used 
 as the })leximeter and the other as the plessor. If percussion 
 is made at the front of the chest the auscultator applies his ear 
 to the same side behind, and he may hear a clear ringing 
 sound. The same result may be obtained by a sharp fillip on 
 the chest wall : this can be practised by the auscultator him- 
 self while listening. This sign is almost exclusively confined 
 to pneumothorax. 
 
 Mippocratic succu.mon is produced when there is a mixture 
 of air and fluid in the pleural sac (hydro- or pyo-pneumo- 
 thorax). The best way to elicit it is for the auscultator to 
 apply his ear directly to the back or side of the chest and, 
 half embracing the patient, to give him a sudden shake. We 
 have often to vary the posture of the patient to bring this out, 
 and it is sometimes best heard while he is recumbent. The 
 sound heard is similar to what is got by shaking a cask which 
 contains air and fluid. 
 
VOCAL RESONANCE AND FREMITUS. 557 
 
 VOCAL RESONANCE ANT) FREMITUS. 
 
 The next j^oint in the examination of the lungs is to ascer- 
 tain any alteration in the vocal resonance or fremitus, or in 
 the transmission of the heart's sounds. 
 
 Vocal resonance is the term applied to the vibrations caused 
 by the voice of the patient transmitted through the chest to 
 the ear of the auscultator. It is best elicited by causing the 
 patient to say such words as " twenty-one," " twenty-two," 
 " twenty-three," in his natural voice. It is, as a rule, most 
 distinct in adult males, especially if the voice is grave in pitch, 
 but it is subject to such valuations, that in the absence of other 
 signs of disease little diagnostic importance can be attached to 
 it. It is well to recollect, also, that even in health it is louder 
 in most cases at the apex of the right lung than of the left. 
 Over the spongy lung the vocal resonance is simply an indis- 
 tinct buzzing, but if listened to over the trachea, it is found 
 to be loud and near the ear, every syllable is quite appreci- 
 able even when whispered. This is almost identical wdth pec- 
 toriloquy, in which the sounds appear to be transmitted directly 
 into the ear from the chest. Over the site of the larger 
 bronchi the voice possesses a less degree of distinctness and 
 intensity, and to this is aj)plied the term bronchophony. 
 
 In disease the vocal resonance, over the area of spongy 
 lung, may approximate to bronchophony or 'pectoriloquy. The 
 change in the direction of bronchophony depends chiefly on 
 consolidation, and is often present in pneumonia, phthisis, and 
 other condensations. Laennec believed pectoriloquy (but 
 only in that degree which he termed " perfect pectoriloquy ") 
 to be pathognomonic of cavity in the lung, and no doubt it is 
 a frequent associate of this condition, and a valuable fact in 
 conjunction with other signs, but it may also be heard in cases 
 of consolidation, such as those mentioned above. 
 
 ^gophony was the name applied by Laennec to a peculiar 
 modification of the vocal resonance which is high in pitch, 
 very tremulous, and closely resembles the bleating of a goat, 
 or the voice of Punch in the puppet show\ It is not often 
 found in perfection, but degrees of it are not uncommon, and 
 its most frequent site is near the inferior angle of the scapula. 
 Laennec thought it depended on the interposition of a thin 
 stratum of fluid between the layers of the pleura, but it is also 
 found in the course of pneumonia, and in inflammatory 
 thickening of the pleura. Its cause is stiil a matter of dispute. 
 
 Autop)hony is a term used to denote the resonance of the 
 
 47* 
 
558 PHYSICAL EXAMINATION OF THE CHEST 
 
 auscultator's voice if he speaks while he has his ear applied to 
 the patient's chest. He may hear the tones of his voice inten- 
 sified on the one side as compared with the other. This phe- 
 nomenon is heard more or less in most of the cases where 
 bronchophony is developed, but it is chiefly marked in cases 
 of large cavity, and especially in pneumothorax. . 
 
 Fig. 101*. 
 
 Position of thuracic organs (Luschka). Compare also Fig 150. The outlines of organs 
 partially invisible in the dissection are indicated by very fine dotted lines. 
 
 Reference letters:— r. au. = right auricle; a. o. = arch of aorta; v. i. = the two 
 innominate veins; v. c. = vena cava descendens; p. = pulmonary artery ; 1. au. = left 
 auricle ; 1. v. ^ left ventricle ; r. v. = right ventricle. 
 
 The vocal resonance may he absent in certain cases, and this 
 is an important fact if the resonance was known to have ex- 
 
EXAMINATION" OF THE NOEMAL HEAET. 559 
 
 isted previously ; or it may be absent only on one side or at 
 one part. This points to some obstacle to the transmission of 
 the sound, chiefly owing to fluid effusion or some obstruction 
 in the bronchial tubes. 
 
 For amphoric voice in pneumothorax, see page 556. 
 
 The vocal fremitus is closely allied to vocal resonance. It is 
 the sensation appreciated by the hand placed on the patient's 
 chest while he speaks. This is also subject to great variation, 
 consistent with perfect health, but it may be stated as a 
 general rule, that conditions leading to increase or diminution 
 of the vocal resonance apply to vocal fremitus. It is thus 
 generally increased in consolidation of the lung, and dimin- 
 ished in pleuritic eff'usion. 
 
 In certain diseased conditions of the lungs the heart's 
 sounds may be transmitted widely over the pulmonary area. 
 This is especially the case in all forms of consolidation, and 
 when this transmission is to the apices of the lungs, and 
 especially to the right, it is often significant of phthisical 
 consolidation. The heart's sounds may be altered in quality 
 owing to diseased coriditious in the lung, but these will be 
 noticed under the physical diagnosis of the heart. 
 
 Part II. Physical Examination of the Heart. 
 
 In the physical examination of the heart, the same methods 
 of investigation are employed as in the case of the lungs, viz., 
 insj^ection, jmlpation, 'percussion, and auscultation. The car- 
 diograph and sphygmograph yield also valuable information 
 as to the state of the heart in many instances. 
 
 It is of great importance for the beginner to practise fre- 
 quently the 
 
 EXAMINATION OF THE NORMAL HEART. 
 
 The first point of importance for the student to note is the 
 contour of the chest-iuall in front of, and inclosing the organ. 
 In the healthy chest the left is usually symmetrical with the 
 right side, but, as will afterward be seen, certain diseases may 
 cause alterations in respect of this symmetry, which may have 
 a diagnostic importance. Having inspected the precordial 
 region, and having noted the fact of any visible pulsation, 
 whether diff'used over the cardiac area, or limited to the apex- 
 region, the epigastrium, or other part of the chest, the next 
 point to determine, if possible, is the exact jjosition of the apex- 
 
560 PHYSICAL EXAMINATION OF THE HEART. 
 
 heat. In many cases this corresponds with a visible pulsation 
 which may have been noted in the preliminary survey, but 
 in not a few instances no such distinct pulsation is seen, and 
 careful search by palpation must be made for the apex. In 
 all cases, whether there is a visible apex-beat or not, the inter- 
 costal spaces in the precordial region should be separately 
 examined with the tips of the index and middle fingers, in 
 order to fix, if possible, the exact spot at which the apex, or 
 rather the most superficial part of the left ventricle, strikes 
 the chest-wall. The most favorable opportunity for this is 
 in expiration, when, by the recession of the lung, the heart 
 approaches most closely to the ribs ; but the state of expira- 
 tion must not be too long maintained. (See foot-note, p. 646.) 
 In the normal chest, in the recumbent posture, the apex- 
 beat is usually found in the fifth intercostal space, slightly 
 inside the vertical line of the nipple.^ It is to be remembered, 
 however, that the site of the nipple varies to some extent, even 
 in males, and in w^omen its position is ruled by the degree of 
 development and laxity of the mamma, and so its relation to 
 the apex-beat is by no means constant. The usual position 
 of the apex-beat is as above indicated ; but in not a few 
 instances, even in healthy subjects, no distinct impulse exists 
 while the patient is in dorsal decubitus, and only a compara- 
 tively feeble pulsation is felt in the fourth or fifth intercostal 
 space. In such a case the patient should be turned on his left 
 side well round on his face. This change in posture favors 
 the gravitation of the heart to the surface of the chest, and to 
 the left side, so that an apex-beat, almost imperceptible in the 
 recumbent position, may now become distinct. Under such 
 circumstances, allowance must be made for its being carried 
 more to the left, but the degree of this varies in diflferent sub- 
 jects, according to the laxity of the tissues which bind the 
 heart. A cardiac apex-beat inappreciable in the recumbent 
 posture may also be made apparent by causing the patient to 
 sit up and lean somewhat forward. Percussion may assist 
 in determining to some extent the site of the apex, as it is 
 usually found immediately inside the left border of the pre- 
 cordial dulness. But the student should also use the stetho- 
 scope in aid of palpation in determining this most important 
 fact, and it is specially useful where no tangible apex-beat 
 exists. For this purpose he should auscultate in the apex- 
 
 1 Or midway iK'tween tlie vertical line of the iiijiplo and tlie "parasternal line," which 
 is an imaginary line falling midway between the margin of the sternum and the nipple 
 line. 
 
EXAMINATION OF THE NOEMAL HEAET. 561 
 
 region till a spot is found, over which the first sound of the 
 heart has the most definite and superficial character, and this 
 may be assumed to be the point at which the wall of the left 
 ventricle comes nearest to the surface. 
 
 Having determined as nearly as possible the position of the 
 apex-beat, it should be marked (with ink or pencil), and the 
 next step is to appreciate thoroughly the nature of the impulse. 
 This can be done either with the tips of the fingers or the ball 
 of the thumb, the former, however, yielding the more definite 
 results. In healthy subjects, in whom a tangible apex-beat 
 exists, it is precise and definite, the area of visible impulse 
 not exceeding a square inch ; and in those in whom it is not 
 present in the recumbent posture, but is developed w^hen they 
 are laid over on the left side, it presents similar characters. 
 Changes in neighboring organs may have so altered the rela- 
 tions of the apex as to obscure its impulse in all positions, and 
 such a condition is to be noted, but it does not necessarily 
 indicate disease of the heart. A definite apex-beat may also 
 be wanting in healthy subjects from the fact that the impulse 
 is delivered against a rib instead of an intercostal space. 
 
 In the strictly healthy subject no considerable impulse 
 exists over the right ventricle, but a degree of this can be 
 educed by sudden exertion, and it may be discriminated from 
 the apex-beat. This impulse or heave is best appreciated by 
 the ball of the thumb or pulse of the hand placed over the 
 region of the right ventricle. It can also be well appreciated 
 by the direct application of the ear when the impulse is com- 
 municated to the head. The student should notice this im- 
 pulse carefully, as in some diseased conditions it is of much 
 diagnostic value. In widely diffused impulse the point fur- 
 thest to the left, giving a distinct and direct impulse, is to be 
 regarded as the most probable site of the apex, but it does not 
 necessarily follow in such cases that the apex of the left 
 ventricle produces any sensible and separate impact at all. 
 
 Percussion of the heart is the next step in the examination. 
 In women in whom the mamma is large and flabby it should 
 be drawn up or to one side while the percussion is being 
 followed out. The area of precordial dulness will vary some- 
 what according to the strength of the percussing stroke. If 
 the deep or relative percussion dulness is wanted, a compara- 
 tively strong stroke is necessary, and the percussion should be 
 made as far as possible during expiration, while the heart is 
 most uncovered. If, however, the superficial or absolute dul- 
 ness is required, the lightest possible stroke should be employed, 
 
562 PHYSICAL EXAMINATION OF THE HEAKT. 
 
 in order to determine accurately only that part of the heart 
 which is uncovered. 
 
 Even with light percussion, however, the portion of heart 
 uncovered by lung cannot be delimited with absolute accu- 
 racy, inasmuch as the layer of lung having become so thin 
 near its margin the pulmonary resonance is modified by the 
 solid organ beneath, which, although overlapped, diminishes 
 the resonance in the area controlled by the percussion stroke. 
 
 If the object is to estimate the size of the heart, the area of 
 percussion dulness is best mapped out by a stroke just suf- 
 ficient to bring out a perfectly distinct pulmonary note, and 
 the point where the first diminution in the resonance can be 
 detected should be marked as the boundary. DifiTerent 
 observers may mark out the cardiac dulness in a given case 
 with very different results as regards the mere marking, 
 although probably with little difference as regards the infer- 
 ences they draw concerning the size of the heart — each observer 
 having become familiar with his own method as applied to 
 normal as well as abnormal conditions. The student must 
 aim at establishing some such standard for himself whatever 
 may be the method he is taught. From practice on normal 
 hearts he will arrive at a standard of percussion-dulness from 
 which safe inferences may be drawn in cases of disease. 
 
 In the delimitation of the heart, it is best to begin percus- 
 sion over the pulmonary area in the immediate vicinity of the 
 organ and travel inward. Commencing then with the right 
 border, the student should appreciate thoroughly the clear 
 note over the right lung and then percuss through the middle 
 line, noting the point at which the clear pulmonary note 
 becomes modified. Having marked out the whole of the right 
 border in this manner he should proceed to the left, to which 
 the position of the apex-beat will afford a guide. To delimit 
 the upper border, percussion is to be made from the left infra- 
 clavicular region downward, The lower border of cardiac 
 dulness cannot, as a rule, be separated from that of the liver. 
 It is useful to indicate these limits of percussion-dulness by 
 marking them with ink or pencil. The right border of the 
 dulness as thus ascertained will be found usually to coincide 
 pretty exactly with the mesial line (although with very strong 
 percussion it may pass in the right of that line from one inch 
 and a half to two inches). The left border, as a rule, coin- 
 cides with a line about half an inch outside the apex-beat, and 
 so corresponding nearly with the vertical line of the nipple. 
 The upper margin of dulness is usually near the lower border 
 
PRECORDIAL DULXESS. 
 
 563 
 
 of the third rib, and it curves downward to join the left 
 margin. (See Fig. 102.) The transverse measurement of this 
 
 Fig. 102. 
 
 Area of normal percussion-dulness of heart, liver, and spleen. 
 (Slightly modified from Weil.) 
 
 area of normal percussion-dulness as described may be stated 
 approximately at from three to four inches in the adult male. 
 In women it is less, and it will vary according to the build and 
 stature of the subject. While performing the percussion atten- 
 tion should be given to the sense of resistance to the percussing 
 stroke, as the presence of increased resistance may assist the 
 diagnosis. In many instances, however, the delimitation of 
 
564 PHYSICAL EXAMINATION" OF THE HEART. 
 
 the cardiac dulness is interfered with by the occurrence of 
 consolidation in either king in close proximity to the heart, or 
 by the presence of fluid in the pleurae. 
 
 The sounds of the normal heart are discussed at p. 572. 
 
 CHANGES IN THE APEX-BEAT — ABNORMAL PULSATION. 
 
 The apex-beat may become inappreciable, or at least much 
 obscured. This is especially apt to occur in cases of copious 
 fluid eff'usion into the pericardium, or from bulging of the 
 anterior margins of the lung in emphysema. Again, if the 
 right ventricle is much dilated it pushes the left into the back- 
 ground and hinders it from reaching the surface, so that no 
 precise apex-beat is present.^ In extensive adhesion of the 
 pericardium also, there is often no distinct apex-impulse, 
 but rather a systolic retraction of one or two of the inter- 
 costal spaces in the vicinity of the apex-region, or it may 
 be of' the whole chest wall in children, in whom the ribs 
 are yielding ; at the same time the heart has often a jogging 
 or tumbling action. The absence or want of precision of 
 the apex-beat may thus indicate disease either of the heart 
 itself or of some of the neighboring organs. 
 
 The apex-imj)ulse may be exaggerated. This is generally the 
 case in hypertrophy of the left ventricle, in which also it is 
 usually displaced downward and to the left. All causes, 
 however, which produce overaction of the heart, as, for in- 
 stance, mental excitement or violent exertion, may lead to 
 temporary exaggeration of the apex-impulse. 
 
 The apex-beat is often displaced. It may be found displaced 
 downward and toward, the left, so as to be felt in the sixth, 
 seventh, or eighth intercostal space, several inches outside the 
 nipple line. Under such circumstances the impulse is usually 
 much increased in intensity, and so widespread as to be visible 
 in two or three intercostal spaces. This is usually found in 
 hypertrophy of the heart, involving the left ventricle chiefly. 
 
 1 Apart from diseased conilitions altogether, a very simple experiment which anyone 
 can make on himself, will demonstrate the etfect which a distended ri^ht ventricle has 
 on the apex-beat. When lyin^ in an easy position a finger is put on the apex-beat, and 
 its character carefully noted, while wit!i the other liand tlie jtulseof some of the arteries 
 is felt. Respiration is then simply suspended without any deej) i)reliminary inspiration. 
 As the sense of suffocation api>roachcs, the ajK-x-beat grows gradually more indistinct, 
 and may even disajipear, while the heave of the right ventricle becomes more marked. 
 The pulse, however, is not affected to any extent, except perhaps being a little smaller, 
 and this shows that the left ventricle is still contracting quite etticiently although the 
 apex-impul.se has become obscure ; owing to the repletion of the right ventricle, the left 
 is, as it were, thrown behind and cannot reach the chest wall. When respiration is re- 
 sumed the apex-beat becomes apparent at once. These conditions are quite independent 
 of the expansion of the lung, being equally appreciable in inspiration or expiration. 
 
CENTRE OF PULSATIONS. 565 
 
 The apex-beat may come to be displaced upward, owing to 
 pressure on the diaphragm from ascites, tympanites, and solid 
 or cystic tumors of the abdominal organs ; or it may be 
 dragged upward by a shrinking of the left lung, as in phthisis 
 with contracting cavities in the apex, or from retraction of 
 one side of the chest after the absorj^tion of an effusion. In 
 considerable jDcricardial effusion the apex-beat is apt to be 
 raised, and the same is said to occur in cases of adherent peri- 
 cardium. It may be found disjjlaced either to the rigid or left 
 by fluid or air in the pleurae (hydrothorax, empyema, or 
 j^neumothoraxj. The displacement is much greater when 
 the effusion is in the left pleural sac, and, if it is extreme, 
 the heart may be found beating under the right nipple. 
 This condition has been called dexiocardia. [See Fig. 106.) 
 The impulse, however, which is felt in such a case is not 
 from the apex of the left ventricle, but from some part of 
 the right. The heart may remain displaced even after the 
 effusion disappears, through the influence of adhesions. 
 
 Changes in the character of the apex-impulse are also to 
 be noted. It may become unduly strong and heaving in 
 hypertrophy, or weak in cases of dilatation and fatty degen- 
 eration. Its regularity, or the reverse, in rhythm and force, 
 must also be attended to. 
 
 Centimes of p)ulsation other than the apex-beat may become 
 developed in diseased conditions. In certain cases, coinci- 
 dently with a want of distinct apex-beat, there is an undue 
 development of the imjndse or heave over the right ventricle. 
 This is especially the case in hypertrophy and dilatation 
 of the right side of the heart. There is then appreciable 
 over the region of the right ventricle a diffused impulse 
 which is often propagated into the epigastrium, through the 
 left lobe of the liver, in the form of a wide-spread pulsation ; 
 and in certain cases of displacement of the heart, as, for 
 instance, downward and inward from emphysema, even a 
 more direct impulse may be felt there. As this epigastric 
 pidsation is always important, it should be sought for, not 
 only by placing the flat of the hand over the pit of the 
 stomach, but also by inserting the tij)s of the fingers under 
 the costal cartilages in the direction of the heart. This 
 epigastric pulsation from the action of the heart must be 
 distinguished from a pulsation communicated from the aorta, 
 which is felt under certain conditions in the same region. 
 The aortic pulsation can usually be traced along the vessel in 
 the abdomen (not merely as a pulsating tumor, as in aortic 
 
 48 
 
566 PHYSICAL EXAMINATION OF THE HEART. 
 
 aneurism there) : and, by careful attention to its rhythm, it 
 may be found to succeed the cardiac systole by a minute 
 interval of time. This " throbbing aorta " is a frequent fact 
 in anaemic or nervous conditions. (See p. 341.) Aneurism 
 of the abdominal aorta, or of some of its branches, may also 
 give rise to pulsation in the epigastrium, but the sense of 
 tumor and other signs will usually guide the diagnosis. In 
 certain instances of very free tricuspid regurgitation, pulsa- 
 tion, synchronous with the cardiac systole, is felt in the liver. 
 
 When the base of the heart is uncovered, owing to retrac- 
 tion of the edge of the left luug, as in phthisis pulraonalis, 
 the roots of the great vessels, and especially of the pulmouary 
 artery, as it is most superficial, are exposed, and as it usually 
 happens in such cases that the patient is much emaciated, a 
 pulsation which corresponds with the expansion of the pul- 
 monary artery can sometimes be felt and eveu seen. It is 
 situated about the second left intercostal space, near the mar- 
 gin of the sternum, is very restricted in its area, and, in addi- 
 tion to the implse, the finger is conscious of its being succeeded 
 by a snap and sudden recoil, coincident with the closure of 
 the sigmoid valves. In rare instances, pulsation from the 
 auricle exists in this situation, but the impulse in such a case 
 precedes the apex-beat, and is succeeded by no snap. Simulta- 
 neous tracings of the cardiac apex-beat and the abnormal 
 pulsation in such cases may be taken wdth the polygraph, and 
 will at once resolve any difficulties that may arise as to its 
 being due to auricle or pulmonary artery. The aorta is too 
 deeply seated to give any definite imj)ulse externally in the 
 normal conditions, but when aueurismal disease of its thoracic 
 portion exists a pulsation may be produced which can, as a 
 rule, be quite easily separated from that of the heart. 
 
 Pulsation in the vessels of the neck. The jugular fossa 
 should be explored by inserting the tips of the fingers down 
 behind the sternum, the patient being directed to bend the 
 head forward, so as to relax the tissues. Undue pulsation 
 sometimes associated with a sense of resistance or tumor there, 
 chiefly due to aneurism, or at least dilated aorta, is often met 
 with in this situation. The trachea may be found displaced 
 somewhat backward, or to either side in such cases. The 
 state of the jugular veins is also to be noted, pulsation in 
 them being a frequent associate of valvular disease of the 
 right side of the heart. Such pulsation, however, is not neces- 
 sarily a serious matter ; it merely indicates regurgitation of 
 blood back into the veins, the valves at the root of the neck 
 
PKECOKDIAL DULNESS. 567 
 
 being incompetent, perhaps from distention of the vessel. 
 This may occur in health, though usually only to a slight de- 
 gree and without any distention or other abnormal symptom ; 
 the impulse of the auricle (perhaps also of the right ventricle) 
 being transmitted directly through veins with congenitally 
 imperfect valves. In some instances, although there is no 
 actual pulsation in the vein, it receives a movement from the 
 artery lying underneath it, so as to simulate this: the way to 
 solve the difficulty is by pressing very lightly on the vein at 
 the root of the neck, and so occluding it, and if under these 
 circumstances the pulsation ceases, the inference is that the 
 action is in the vein, w^hile if it continues it is most probably 
 due to the heave of the carotid. The pulsation in the veins 
 of the neck can usually also be recognized as different in 
 character from a transmitted arterial impulse, being, as a rule, 
 much more wavy. Tracings can sometimes be taken of this 
 venous pulse in the neck ; their characters and interpretation 
 will be found elsew^here. Retraction of the veins of the neck 
 during the cardiac diastole should be looked for, as it is said 
 to occur sometimes in cases of adherent pericardium. 
 
 Undue pulsation in the arteries of the neck exists in exoph- 
 thalmic goitre ; in some cases of anaemic palpitation ; in 
 aneurism ; and in aortic insufficiency, where the visible pulsa- 
 tion is often a very marked feature. 
 
 CHANGES IN THE AREA OF PEECOEDIAL DULNESS. 
 
 The area of precordial dulness may be increased, diminished, 
 or displaced. Decrease in its area is generally due, not to 
 disease of the heart itself, but to changes in the lungs, and 
 especially to emphysema, in which the anterior margins of 
 the lung may become so distended as to mask the cardiac dul- 
 ness to a greater or less extent. (See Fig. 157.) In ema- 
 ciating diseases, however, the heart participates in the general 
 atrophy, and this may lead to some decrease in the precordial 
 dulness. 
 
 But increase in this area is much more frequent. If the in- 
 crease is toward the left side and downward, and coincides with a 
 strong and somewhat diffused apex-beat in the sixth or seventh 
 interspace, or much to the left of its normal site, it most likely 
 indicates hypertrophy of the left ventricle. If, on the other 
 hand, the dulness extends chiefly to the right, the presumption 
 is that the right ventricle is the seat of hypertrophy or dilata- 
 
568 PHYSICAL EXAMINATION OF THE HEART. 
 
 tion, and this may be corroborated by the occurrence of a 
 well-marked heaving action over the right ventricle, by an 
 ill-defined apex-beat, and by the presence of pulsation in the 
 epigastrium. If the dulness is increased pretty equally both 
 to right and left, while the upper margin maintains its normal 
 position, hypertrophy or dilatation of both cavities may be 
 suspected (see Fig. 103) ; but if with lateral extension there 
 
 Fia. 103. 
 
 Cardiac dulness increased from hypertrophy of both ventricles. 
 
 is a conical prolongation of the dulness up in the direction of 
 the first rib, there is ground for suspecting effusion into the 
 pericardium. (See Fig. 104.) In all these cases there may be 
 a degree of vaulting in the precordial region, but it is usually 
 most marked in pericardial effusion, in which the percussion 
 resistance is also greatly increased. Apparent increase in the 
 
PKECORDIAL DULNESS. 
 
 569 
 
 dulness may arise from tumors, aneurismal, cancerous, or 
 glandular, situated in the mediastinum ; or from effusions into 
 the pleurse; or even from limited consolidations of the lung 
 in the immediate vicinity of the heart. The diagnosis of 
 
 Fig. 104. 
 
 Percussiou duluess in pericardial effusion ; the lower and left margins left undefined, 
 owing to their having been inseparable from the dull percussion of the abdomen and of 
 the left pleura. (Gairdner.) 
 
 aneurism may be made from the fact that the abnormal area 
 of dull percussion is usually situated at the base of the heart, 
 often at the manubrium sterni ; it coincides in situation with 
 the aorta and is sometimes joined to the cardiac dulness by 
 only a narrow neck ; a pulsation separable from that of the 
 heart is often present over it, sometimes accompanied wdth 
 thrill ; the heart's sounds are also frequently changed in quality 
 over the dull area, and sometimes associated with murmur. 
 The diagnosis in the other conditions mentioned may be 
 assisted by the fact that the cardiac sounds are normal in 
 character, not coextensive with the dull area, and there is not 
 the heaving impulse that might be expected were the exten- 
 sion due to dilatation or hypertrophy of the h^art itself. The 
 subjective symptoms will also afford valuable means of diag- 
 nosis 
 
 Displacement of the area of cardiac dulness either to the 
 right or left may be due to pleural effusions of fluid or air, 
 the displacement being always more marked when the left 
 pleura is the seat of the disease. (See Figs. 105 and 106.) 
 
 48* 
 
570 PHYSICAL EXAMINATION OF THE HEART 
 
 Tumors in the thorax may displace the precordial diilness in 
 almost any direction. A certain amount of displacement of 
 
 Fig. 105. 
 
 Displacement of mediastinum, heart, and liver from pneumutborax of the right side. 
 
 (Weil.) 
 
 the cardiac dulness is of habitual occurrence in emphysema of 
 the lung, associated usually with some diminution of its extent 
 also. (See Fig. 157.) 
 
 CARDIAC TREMOR OR THRILL. 
 
 In the palpation of the heart there is sometimes conveyed 
 to the hand along with the impulse a sense of tremor or thrill 
 
CARDIAC TREMOR OR THRILL. 
 
 671 
 
 — " purring tremor." It is most frequently associated with 
 valvular disease either aortic or mitral, and is quite distinct 
 in its character from the sensation which is sometimes felt 
 over the precordial region in pericarditis (pericardial friction 
 
 Fig. 106. 
 
 Displacement of mediastinum, heart, and left lobe of liver from pleuritic effusion on 
 the left side : the shading indicates the extent of dull percussion. 
 
 fremitus), from the rubbing of the roughened pericardial sur- 
 faces on each other. This latter, when typical, has a harsh, 
 rubbing, grating character, and does not, as a rule, possess the 
 fixity as regards site and rhythm of endocardial thrills. The 
 most usual sites of tremor are the apex and the base. When 
 limited to the apex it is very characteristic of constriction or 
 roughening of the mitral orifice, provided it can be felt imme- 
 
572 PHYSICAL EXAMINATION OF THE HEART. 
 
 diately to precede the apex-beat. It coincides, in fact, with 
 a presystolic murmur. lu not a few instances, however, thrill 
 in the apex-region coincides with the ventricular systole, and 
 is due to regurgitation through the mitral orifice. When felt 
 at the base, thrill is usually associated with disease (chiefly 
 obstructive; of the aortic valves, but this is not invariably 
 the case, as tremor often depends on aneurism of the first part 
 of the aorta apart from any valvular lesion. Thrill is some- 
 times aj^preciable over the pulmonary artery also, especially 
 where congenital stenosis of its orifice exists. Other condi- 
 tions afterward to be indicated Avill guide the diagnosis in all 
 these cases. 
 
 SOUNDS OF THE HEART, NORMAL AND ABNORMAL. 
 
 In auscultating over the heart the student will recognize 
 two sounds which differ in character and in their sites of in- 
 tensity. They are called the first and the second sounds. 
 The first sound (systolic), which coincides with the ventricular 
 contraction and the apex-beat, and immediately precedes the 
 pulse in the neck, is dull, prolonged, and somewhat distant. 
 The second sound (diastolic) coincides with no impulse, is 
 shorter, clearer, sharper, and more defined, and agrees in point 
 of time with the closure of the sigmoid valves of the aorta 
 and pulmonary artery. The characters of the two have been 
 represented by the syllables " Lubb Tup'' The first is heard 
 with greatest intensity over the apex-region and the ventricu- 
 lar area generally, while the second predominates over the 
 base of the heart. Skoda indicates the intensity of the two 
 sounds as heard at the apex and base, by saying that at the 
 apex they form a trochee — lubb tup — and at the base an 
 iambus — lub tup. This is not, however, invariably true. In 
 a slowly acting heart there is usually no difficulty in distin- 
 guishing the two sounds from each other ; they are defined 
 not only by the characters above indicated, but also by the 
 fact that the interval between the first sound and the second 
 ("short pause") is much less than that between the second 
 and the first — the diastole or " long pause" of the heart, as it 
 is called, intervening. The following diagram (Fig. 107) in- 
 dicates approximately the relations which the various periods 
 in a complete cardiac revolution bear to each other. When, 
 however, the heart is acting rapidly the shortening of the time 
 is chiefly at the expense of the long pause, and then it may be 
 
 matter of difficulty to determine which is the first and which 
 
ALTEKATIONS IN HEART SOUNDS. 573 
 
 is the second sound ; and this is all the more likely if either 
 sound is so altered in character as to approximate to the other. 
 The double stethoscope, however, will, as a rule, resolve this 
 doubt, the one bell being placed over the apex and the other 
 over the base. The different areas of intensity will also serve 
 to differentiate the sounds. 
 
 Both sounds are complex, inasmuch as the first coincides 
 with the contraction of the two ventricles and the second with 
 the closure of the sigmoid valves of the aorta and pulmonary 
 artery. The part of the first sound due to the left ventricle is 
 heard with greatest distinctness in the apex-region, while that 
 from the right side of the heart is most intense over the right 
 ventricle near the sternum. The aortic element of the second 
 sound is best communicated to a point at the junction of the 
 second right costal cartilage with the sternum ; hence this 
 cartilage is often termed the " aortic cartilage." The pul- 
 monic second sound is best heard near the junction of the 
 third left costal cartilage with the sternum. In health, as a 
 rule, the sounds at the apex and aorta predominate to a slight 
 extent over those of the right side of the heart. Some assist- 
 ance is also obtained from considering the relative intensity, 
 in A^arious circumstances, of the sounds as heard over the 
 carotid and subclavian arteries, where the second sound may 
 usually be regarded as identical with that produced by the 
 closure of the aortic valves. But much care is necessary in 
 founding conclusions on the above data. 
 
 The sounds of the heart may become (1) altered in char- 
 acter; (2) reduplicated ; (3j associated with, or replaced by 
 murmurs. 
 
 1. Alterations in Character of the Heart's Sounds. — In many 
 exhausting diseases the sounds are apt to become feeble, and 
 in the later stages of certain fevers, notably typhus, the first 
 sound is especially weakened, and in extreme cases almost 
 suppressed, while the second may remain tolerably clear and 
 distinct. Fatty degeneration or infiltration of the muscular 
 fibre of the heart naturally leads to the same result. In dila- 
 tation also the first sound fails in intensity and duration, and 
 in some cases becomes clearer than normal, approaching the 
 quality of the second sound. 
 
 Hypertrophy of the heart is usually associated with modifi- 
 cation of both sounds. The first sound becomes didl, prolonged, 
 and sometimes even booming in character, and should this 
 change be most marked in the apex-region, the presumption 
 is that the left ventricle is hypertrophied, while if it is present 
 
574 PHYSICAL EXAMINATION OF THE HEART. 
 
 chiefly over the right ventricle it-iisually points to that cavity 
 as the seat of the change. In either case the second sound is 
 undulij accentuated, the alteration being recognizable as over 
 the aorta or pulmonary artery, according to the cause of it. 
 But the second sound may be accentuated and deepened in 
 tone from other causes than hypertrophy of the ventricles. 
 This may be present over the aortic cartilage in cases of high 
 arterial tension in the systemic circulation, or in dilatation or 
 aneurism of the arch of the aorta, or when the aorta has lost 
 its elasticity from degenerative changes. Under these circum- 
 stances, however, a certain amount of hypertrophy of the left 
 ventricle is, as a rule, also present. In all such cases the 
 deepened tone is usually transmitted into the vessels in the 
 neck. Over the pulmonary artery the second sound is accen- 
 tuated in conditions which present an obstacle to the free 
 passage of blood through the lungs. This change may be met 
 with in pneumonia ; and it is often a marked feature in cases 
 of obstruction or regurgitation at the mitral orifice, lesions 
 productive of increased tension in the pulmonary circulation, 
 with more or less hypertrophy of the right ventricle. In cer- 
 tain cases, as in retraction of the upper lobe of the left lung 
 from phthisis, the pulmonic second sound may appear to be 
 morbidly accentuated when in reality it is simply brought 
 nearer the ear from the artery having lost its covering of lung. 
 In most of these instances, however, pulsation, both visible 
 and tangible, is present over the artery, and the snap of the 
 closure of the valve is often communicated to the hand. These 
 conditions will help to guide the diagnosis. (See p. 566.) 
 
 AVhen large air-filled cavities are in close proximity to the 
 heart the sounds may take on a hollow, ringing, metallic 
 quality, of the nature of an echo. The first sound is most 
 frequently so affected, the causes being pneumo-pericardium, 
 large pulmonary cavities, pneumothorax, or an over-distended 
 stomach. 
 
 2. EedvpliGation of the hearths sounds arises from a want 
 of synchronous action in the valves on the two sides of the 
 organ, and so one or other sound is split up into its component 
 elements. Either sound may be reduplicated, the second, 
 however, being most frequently so, and there is then produced 
 a " galloping " or " cantering action " of the heart, indicated 
 by the syllables " rat-ta-tatJ' The clinical significance of this 
 fact is not always clear ; and it occurs at times in healthy 
 subjects. It will be suflticient for the student to note that, if 
 it is best heard anywhere over the ventricular area, it is prob- 
 
RHYTHM OF CARDIAC MURMURS. 575 
 
 ably the first sound which is resolved into its component ele- 
 ments, while, if over the base, it is the second. Any condition 
 which increases the tension either in the systemic or pulmonic 
 circulation may disturb the balance of the two sides, and so 
 predispose to reduplication. It is certainly a frequent fact in 
 cases of Bright's disease, especially in the chronic granular 
 form, although not infrequent also in the acute disorder ; in 
 these conditions increased tension in the systemic arteries is of 
 well-known occurrence. On the other hand, increased ten- 
 sion in the pulmonary circulation is a necessary result of ob- 
 structive disease at the mitral orifice, and reduplication of the 
 second sound is, therefore, often found in this affection ; so 
 frequent is it, indeed, that even in the absence of auriculo- 
 systolic murmur at the apex, it has been looked upon by some 
 authorities as strong presumptive evidence of mitral stenosis, 
 especially when the pulmonic second sound predominates over 
 the aortic. Even holding the breath for a long time may in- 
 duce reduj)lication in the healthy subject. The impediment 
 to regular and equable action presented by incipient pericar- 
 ditis may also give rise to a ''cantering action." Reduplica- 
 tion may be complete, with the two elements of the sound 
 quite distinct ; or incomplete, where there is no distinct inter- 
 val, the sound appearing only lengthened and slurred (" tur- 
 ruj) "). In some instances both sounds are reduplicated. 
 
 3. Cardiac Miirynurs. — The sounds of the heart may be 
 associated with, or replaced by, murmurs. These may be pro- 
 duced either within the heart (endo-cardial) or outside of the 
 heart (exo-cardial), and may present a great variety of acous- 
 tic characters (blowing, rasping, cooing, etc.). The two most 
 important facts to determine about them are (A) their rhythm, 
 and (B) their site, or area of distribution. As so many car- 
 diac murmurs are valvular in origin, it is on the v/hole a good 
 rule to try all murmurs which require detailed investigation 
 by the tests of the valvular murmurs before proceeding to 
 any other. 
 
 A. Rhytlim of Cardiac Murmurs. 
 
 What has to be considered under this head is the relation- 
 ship, in point of time, which the murmur bears to the different 
 physiological acts which constitute a complete cardiac revolu- 
 tion, viz., the contraction, dilatation, and rest of each of the 
 cavities. (See Fig. 107.) The murmur has to be defined as 
 occurring during this or that portion of the heart's action, or 
 
576 PHYSICAL EXAMINATION OF THE HEART. 
 
 during the pause which intervenes between the periods of 
 activity. To do this it is necessary to watch carefully its re- 
 
 FiG. 107. 
 
 Diagrammatic representation of the movements and soiinds of the heart. (After 
 Sharpey.) This diagram shows merely the general relations of the several events, and 
 does not represent exact measurements. 
 
 In a heart beating seventy-two times a minute, Foster estimates each entire cardiac 
 cycle as occupying aboiit 0.8 sec. ; of which 0.3 sec. represents the duration of the systole 
 of the ventricle, 0.4 sec. the diastole of both auricle and ventricle, or the "passive in- 
 terval," and 0.1 sec. the systole of the auricle. 
 
 Only one "pause" is marked here— sometimes called the "long pause:" some 
 writers describe a "short pause " also — indicated in the diagram by the small space be- 
 tween the first and the second sound. 
 
 lation to the sounds, to the impulse, and to all the other 
 appreciable phenomena which attend upon the action of the 
 heart. 
 
 Every valvular murmur has one of three relations to the 
 sounds of the heart (complex murmurs, with two or more 
 murmurs combined, will be considered later). 
 
 (1) The murmur 'precedes and runs up to the first sound, end- 
 ing at the moment of this sound, and of the beat of the apex. 
 In this case the murmur is synclironous with the contraction 
 of the auricles, and is called auricular-systolic,^ or by some 
 
 1 The terms here applied to murmurs, viz., "auricular-systolic" (A.S.), "ventri. 
 cular-sj'stolic " (V.S.), and " ventricular-diastolic" (V.D.), have become the habitual 
 nomenclature in the Glasgow School, and what is meant l)y calling a murmur, a thrill, 
 or other phenomenon, "A.S.," "VS.," or "V.D.," is that it coincides in point of 
 rhythm or time with one or other of the periods of the heart's action, -which is thus 
 
KHYTHM OF CAEDIAC MURMURS. 577 
 
 presystolic (from its jDreceding tlie systole of the ventricle). 
 The interpretation of such a murmur depends on its occurring 
 only ivhen blood is being expelled from an auricle, and when the 
 ventricle is still passive. With very rare exceptions such a 
 murmur depends upon constriction of, or obstruction at, the 
 auriculo- ventricular orifices, with consequent interruption to 
 the flow of blood out of the auricle during its contraction. It 
 is thus said to be a direct or onward murmur; it is usually 
 very rough in character and often accompanied by a thrill. 
 (See p. 569.) It is to be remarked also that the first sound 
 of the heart in such cases is often so abrupt as to lead the 
 student to mistake it for the second sound. 
 
 The auricular-systolic murmur may merely j)recede the first 
 sound — i. e., it may originate in the pause of the heart's action, 
 or it may be prolonged quite through the period of rest, being 
 in this case necessarily associated with a degree of the ven- 
 tricular-diastolic murmur presently to be described. (P. 578.) 
 This last-mentioned condition is to be accounted for, according 
 to Dr. Salter, on the supposition that the narrowing and 
 roughening of the mitral orifice are so great that even the 
 passive flow of blood from the auricle into the ventricle at 
 the commencement of the diastole is sufficient to generate a 
 " fluid vein."^ In opposition to this view, however, Dr. Hil- 
 ton Fagge argues that the auricle in extreme mitral stenosis 
 begins to contract earlier, and goes on contracting longer, than 
 in the healthy heart, and that the whole of the murmur is 
 thus due to the auricular systole. This view seems to be 
 established by the cardiographic tracings of Mahomed and 
 Galabin. The varieties of the mitral obstructive murmur are 
 represented in the diagram, (Fig. 108.) For the sake of 
 brevity it is sometimes named "A.S." (auricular-systolic). 
 
 (2) The murmur follows and runs off from the first sound, 
 ending somewhere between the first and the second, or close 
 to the second sound. In this case the murmur is synchronous 
 with the contraction of the ventricles, and may be called ven- 
 
 exactly expressed. (See TTig. 107.) The period of auricular systole has no definite place 
 assigned to it in any scheme prior to Dr. Gairdner's ; the old tei'm "presystolic," as 
 applied to a murmur, being vague, and giving no hint as to its coincidence with the 
 systole of the auricle. The terms can be applied to all kinds of murmurs, indicating as 
 they do simply tlie exact rhythm apart from any considerations of causation. 
 
 1 A " fluid vein " (" veine fluide " of Savart), with its sonorous vibrations, is generated 
 when blood passes with sufficient force into a part of the cii'culatory apparatus actually 
 or relatively dilated. This explanation of the causation of murmurs was originally 
 formulated by Gorrigan, as far back as 1^29, but of late years it has been put upon a 
 more accurate scientific basis by M. Ghauveau and other French observers. The theory 
 is generally accepted as explanatory of arterial and venous murmurs, but some exception 
 has beeu taken to its application to endocardial murmurs. 
 
 49 
 
578 PHYSICAL EXAMINATION OF THE HEAET. 
 
 tricular-systollc. A ventricular-systolic murmur, being coin- 
 cident with the emptying of the ventricles, must of course be 
 caused (if valvular in origin) by hlood flowing from the ventricle, 
 either in the natural ouAvard direction (over a roughened 
 
 Fig. 108. 
 
 (Gairduer.) 
 
 aortic orifice, for example), or backward, by regurgitation 
 through the auriculo-ventricular orifices. When due to ob- 
 struction at the arterial orifices it is said to be a direct or 
 onward murmur, but when caused by regurgitation through 
 the auriculo-ventricular valves, it is named indirect or back- 
 ward. It may be indicated diagrammatically, as in Fig. 109. 
 
 Fig. 109. 
 
 (Gairdner.) 
 
 "V. S." is the contracted designation for this murmur (ven- 
 tricular-systolic). 
 
 (8) The murmur follows and runs off from the second sound, 
 ending somewhere during the interval between the second 
 sound and the first. In this case the murmur is simultaneous 
 Avith the dilatation of the ventricles, and may be called ven- 
 tricular- diastolic. It may be represented as in Fig. 110. A 
 
VARIOUS MURMURS. 
 
 579 
 
 " ventricular-diastolic " murmur is coincident ivith the filling of 
 the ventricles by their rapid expansion-movement. It is always 
 due, therefore (if valvular), to blood entering a ventricle, 
 either from the auricle (as already explained, p. 577), or more 
 
 Fig. 110. 
 
 (Gairdner. 
 
 commonly, from the arterial orifice ; and in this last case, of 
 course, the semilunar valves must be deficient so as to admit 
 of the regurgitation. This is the "A^. D." (ventricular-dias- 
 tolic) murmur. 
 
 Various combinations of these different murmurs occur not 
 unfrequently, and this renders the diagnosis so much the 
 more perplexing. For instance, it is not unusual to have an 
 " auricular-systolic and a ventricular-systolic " (A. S. + V. S.) 
 murmur combined (as in Fig. Ill), and they may even appear 
 
 Fig. m. 
 
 Auricular-systolic and ventricular-systolic murmurs combined. (Gairdner.) 
 
 to be so combined as to constitute but one'murmur. Commonly, 
 however, the first sound can be detected in the middle of this 
 murmur, splitting it, as it were, into two. All that precedes 
 the sound is " auricular-systolic," and all that succeeds it is 
 
580 PHYSICAL EXAMINATION OF THE HEART. 
 
 " ventricidar-sjstolic." In like manner, a " ventricular-systolic^' 
 and a " ventricidar-diastolic " (V.S. + V.D.) murmur are very 
 frequently combined (in cases of aortic obstruction and regur- 
 gitation), but here the second sound intervenes and makes 
 tlie rhythm quite plain. (See Fig. 112.) The greatest degree 
 
 Fig. 112. 
 
 Ventricular-systolic and ventricular-diastolic mui-mnrs combined. (Gairdner.) 
 
 of difficulty arises when the sound is merged in the murmur, 
 as it frequently is, when an " auricular-systolic " and a " ven- 
 tricular-systolic " murmur are combined, but even in such a 
 case it is often found that the first part of the murmur is very 
 rough, and the second part has much more of a blowing 
 character. The murmur will often, in fact, abruptly change 
 its character about the moment of the apex-beat ; or we may 
 find that one element of the complex murmur is heard more 
 
 Fig 113. 
 
 Auricular-systolic, ventricular-systolic, and ventricular-diastolic murmurs combined. 
 
 (Gairdner.) 
 
 clearly at the apex, and the other at the base, or elsewhere. 
 A very complex association of murmurs is found when all the 
 periods of the heart's movements are accompanied by murmur, 
 extending even through the period of rest. This is repre- 
 sented in Fig. 113. (A.S. + V.S. -f V.D.) 
 
AREA OP CARDIAC MURMURS. 581 
 
 Various authorities (e. g., Walshe, Hayden, etc.) have yet 
 further differentiated murinurs as to their time or rhythm ; 
 and such terms as jjostsystolic, prediastolic, and jmddiastoliG are 
 frequently to be metivith. Postsystolic indicates that, the first 
 sound remaining intact, the murmur occupies the portion of 
 the short pause immediately following it. Prediastolic signifies 
 that the murmur is heard during the latter part of the short 
 pause, and runs up to and is closed by the second sound. 
 Postdiastolic usually indicates what has been already described 
 as an auricular-systolic murmur Tsee p. 576) ; but some 
 authorities (e. g., Hayden) attach a different signification to it, 
 implying that it immediately succeeds an unchanged second 
 sound, and is prolonged to a greater or less extent into the 
 pause, terminating, however, distinctly before the occurrence 
 of the first sound. 
 
 B. Area of Cardiac Murmurs. 
 
 Having determined the rhythm of a murmur, the next step 
 in the investigation is to fix, wdthin as narrow limits as possi- 
 ble, the place of its origin and the area of its diffusion. 
 
 The point at which a valvular murmur is produced being 
 one of the four orifices, it is commonly desirable to test all 
 murmurs on the supposition that they may be valvular. The 
 first branch of the inquiry as to the seat of origin of a murmur 
 is therefore commonly this : At ivhich of the four valvular orifices 
 is it produced f As there are four valvular orifices, so there 
 are four distinctive areas to which murmurs arising at these 
 orifices may be pro|)agated. T'hese have been determined by 
 the accumulated experience of physicians at the bedside, 
 checked by the results of post-mortem examinations. The 
 following rules will be found useful in recognizing these areas. 
 
 (1) Area of mitral murmurs. The area of mitral murmurs 
 corresponds generally with the apex of the left ventricle. To 
 find this area with precision it is necessary to have determined 
 all the points about the apex-beat insisted on in the earlier 
 part of the physical examination. If a murmur concurs in 
 position with the apex-beat, and if its area of diffusion is 
 round this point nearly in a circle (see Fig. 114, area marked 
 A) ; or even, and more especially, if the murmur is communi- 
 cated more intensely and immediately to the left than to the 
 right of the apex, as ascertained by the impulse, it is probably 
 of mitral origin. This propagation to the left of the apex-beat 
 is specially true of the regurgitant murmur, but the murmur 
 
 49* 
 
582 PHYSICAL EXAMINATION OF THE HEAKT. 
 
 Fig. 114. 
 
 Areas of cardiac murmurs (Gairdner for the areas ; and Luschka for the anatomy). 
 The outlines of organs, which are partially invisible in the dissection, are indicated by 
 very fine dotted lines ; while the areas of propagation of valvular murmurs, as described 
 in the text, have been roughly marked by additional much coarser and more visible 
 dotted lines — the character of the dots being different in each of the four areas. A 
 capital letter marks each area, viz.. A, the circle of mitral murmurs, corresponding 
 with the left apex ; B, the irregular space indicating the ordinary limits of diflusion of 
 aortic murmurs, corresponding mainly with the whole sternum, and extending into the 
 neck along the course of the artei ies ; C, the broad and somewhat diffused area occupied 
 by tricuspid murmurs, and corresponding generally with the right ventricle ; D, the 
 circumscribed circular area over which pulmonic murmurs are conmiouly heard loudest. 
 
 Reference letters: — r. au. = right auricle; a. o. = arch of aorta; v. i = the two 
 innominate veins ; v. c. = vena cava descendeus ; p. = pulmonary artery ; 1. au. = left 
 auricle; 1. v. = left ventricle; r. v. = right ventricle. 
 
 of mitral obstruction is often heard in its greatest intensity a 
 little to the inner side of the apex impulse. Mitral murmurs 
 
AKEA OF PULMONIC MURMURS. 583 
 
 are often heard over a very limited space in front of the 
 thorax ; they are mostly inaudible at the base of the heart ; 
 but, on the other hand, they are frequently conveyed with 
 great distinctness to the back of the chest, about the lower 
 angle of the left scapula. They are usually either " auricular- 
 systolic" or "ventricular-systolic," the former being some- 
 times associated with a " ventricular-diastolic " portion ; and 
 various combinations of these occur. 
 
 Naunyn has asserted that the murmur of mitral regurgita- 
 tion may have its seat of intensity, not in the apex region, as 
 above described, but in the second intersj^ace, an inch and a 
 half or more to the left of the edge of the sternum, and that 
 it is communicated to this point from the left auricle which 
 crops up on the outer side of the pulmonary artery. He at- 
 tributes this distribution of it to the better conduction of the 
 murmur along the course of the regurgitating blood, and to 
 the fact that, owing to its dilated condition, the left auricle, 
 and especially its aj)pendix, comes nearer to the surface. 
 Paul Niemeyer, Gerhardt, and Dr. George Balfour concur in 
 this opinion, but the question is still suh judice. Dr. George 
 Balfour, who is the most strenuous advocate of this doctrine 
 in this country, indicates that in ansemic and chlorotic condi- 
 tions many of the so-called hsemic murmurs, referred to the 
 area of the pulmonic valve, are in reality mitral regurgitant, 
 and their seat of intensity is as described above. He accounts 
 for them on the ground that *' the defective nutrition of the 
 cardiac muscle, depending on the depraved constitution of the 
 blood, has resulted in relaxation of the muscular tissue, and 
 dilatation of the ventricular cavity, this producing imperfect 
 closure of the mitral valve, and hence a mitral murmur." 
 
 ( 2) Area ofpulmo7iiG murmurs. Murmurs in the pulmonary 
 artery, or at the pulmonic valves, are carried to the ear 
 nearly over the seat of the valves, or over the upper part of 
 the right ventricle. The circle D in the diagram (Fig. 114), 
 indicates the most elevated position of the murmur, but it is 
 frequently heard more distinctly a little lower down. Its area 
 coincides in position with that of the greatest distinctness of 
 the pulmonic second sound as contradistinguished from the 
 aortic second sound. Frequently it coincides in position with 
 a certain tactile vibration or snap, as described above (see p. 
 566), accompanying the second sound. Pulmonic murmurs 
 are usually very superficial, and therefore often very distinct, 
 and apparently near the ear ; they are nevertheless limited in 
 their power of diffusion, being usually inaudible at the apex 
 
584 PHYSICAL EXAMINATION OF THE HEAKT. 
 
 and also along the sternum. They are never distinctly heard 
 in the neck nor in the course of the great vessels. They are 
 almost invariably " ventricular-systolic " in rhythm, but " ven- 
 tricular-diastolic" murmurs may occur. Pulmonic murmurs 
 are usually "functional" in character — i.e., independent of 
 organic disease of the valves; but it must not be forgotten 
 that cono;enital malformations mav exist at the orifice of the 
 vessel, and may give rise to murmur. Even under such cir- 
 cumstances, the rhythm is usually systolic. (Compare also 
 last paragraph.) 
 
 (3) Area of tricuspid murmurs. These murmurs are heard 
 over the right ventricle where it is uncovered by the lung — 
 i. e., at the lower part of the sternum, and over the whole space 
 between this and the seat of the mitral murmur. A tricuspid 
 murmur is usually very distinct and superficial in its char- 
 acter, little audible, however, above the third rib, and thus 
 distinguished both from the pulmonic, and still more from the 
 aortic murmur. Its area in ordinary circumstances is indi- 
 cated by the triangular space marked C. in Fig. 114, but in 
 cases of considerable hypertrophy and dilatation of the right 
 side of the heart, especially in connection with emphysema, 
 the murmur is heard loudest toward the xiphoid and along 
 the margin of the sixth or seventh left costal cartilage. The 
 rhythm is usually "ventricular-systolic," but in rare instances 
 it may be " auricular-systolic." 
 
 (4) Area of aortic murmurs. These murmurs are found not 
 only in great intensity over the base of the heart and the 
 manubrium sterni, which are so n6ar their site of production, 
 but frequently, and not less distinctly, along the whole line of 
 the sternum ; rather oftener than otherwise, the aortic regur- 
 gitant murmur (V.D.) is absolutely louder close to the xiphoid 
 than at many points nearer to its origin. It is sometimes well 
 transmitted to the apex region, and may even simulate a mitral 
 obstructive murmur in rare instances. The aortic murmur is 
 distinguished from all the other valvular murmurs by being 
 propagated into the arteries of the neck. This is especially 
 true of the obstructive murmur, which is usually transmitted 
 with considerable intensity ; the regurgitant, however, may be 
 very faint and almost inaudible there. The aortic murmur 
 has often a special distinctness over the sternal end of the 
 second right costal cartilage ("aortic cartilage"). It is the 
 most widely diffused of all the cardiac murmurs, and can 
 sometimes be traced to great distances along the spine, and 
 even into the extremities. The area marked B in Fig. 114 
 
ANJEMIO AND FUNCTIONAL MURMUES. 585 
 
 indicates the limits of distribution of the aortic murmur. 
 The murmur may be " ventricular-systolic " or " ventricular- 
 diastolic ; " a combination of the two is very frequent. 
 
 Pericardial murmurs are usually present with both sounds 
 of the heart, and when present with only one it is almost in- 
 variably the first. In certain cases pericardial friction may 
 have a triple rhythm from the fact that roughening has 
 occurred over the auricles as well as the ventricles ; the first 
 ])art of the murmur is presystolic, the second' systolic, and the 
 third diastolic. Pericardial murmurs are to be distinguished 
 in part by their special acoustic character of friction, grating, 
 creaking, or shuffling. In general terms they may be said to 
 be deficient in precision of rhythm, and especially in what 
 may be termed accentuation. They are liable to change both 
 in rhythm and position from time to time. They are more 
 considerably altered as to character and intensity by the posi- 
 tion of the patient than endocardial murmurs, and they are 
 also more considerably, and especially more essentially, altered 
 in their character by pressure with the stethoscope. They are 
 sometimes heard along the left margin of the heart or at the 
 apex, but on the whole they most frequently occur over the right 
 ventricle and at the mid-sternum, and are not carried into the 
 arteries of the neck, or in the direction of the xiphoid carti- 
 lage. They are sometimes associated with well-marked frem- 
 itus (pericardial friction fremitus). 
 
 Pericardial murmur may be simulated by friction sound 
 generated in the pleura at the borders of the heart. As a 
 rule, this friction obeys the respiratory rhythm and ceases 
 when the breath is held, but in some instances the friction, 
 though due to roughening of the pleura, is developed by the 
 cardiac movements. The distribution of the friction the ab- 
 sence of symptoms of cardiac derangement, and perhaps the 
 presence elsewhere of signs of pleurisy, may guide the diag- 
 nosis. 
 
 Murmurs due to aneurisms of the arch of the aorta, especially 
 of the ascending part, are with difficulty distinguished from 
 those of aortic valvular disease. Sometimes the distinction is 
 impossible, or can only be arrived at through the superadded 
 signs of aneurism. Such murmurs are usually ventricular- 
 systolic (V.S.) in rhythm, but a diastolic murmur may also 
 occur in the aneurismal sac, apart from any valvular lesion. 
 
 Ancemic and functional murmurs (so-called Jicemic), as heard 
 over the heart and great vessels, are always ventricular-systolic 
 (V.S.) in rhythm, and they almost always simulate aortic or 
 
586 PHYSICAL EXAMINATION OF THE HEAKT. 
 
 pulmonic murmurs as regards their area. In rarer instances, 
 however, they may be confined to the apex region. They are 
 to be distinguished from murmurs of organic origin chiefly by 
 the circumstances in which they occur, and by the absence of 
 symptoms of valvular disease. 
 
 A metallic echo of one or both cardiac sounds may simulate a 
 murmur and may be produced in an air-filled cavity in the 
 neighborhood of the heart (tubercular cavity in the lung, 
 pneumothorax, and distended stomach). It is distinguished by 
 its peculiar, hollow, ringing, or booming quality. Reduplica- 
 tion of a souud is apt in some cases to simulate a murmur, 
 especially when the reduplication is incomplete, but attention 
 to details will minimize this difficulty. 
 
 Murmurs in the arteries. In almost all the large arterial 
 trunks a murmur, ventricular-systolic (V.S.^j in rhythm, may 
 be evoked by pressure with the stethoscope. Apart from this 
 pressure, however, such a murmur is often present in the sub- 
 clavian arteries, more especially on the left side, and that 
 wathout any lesion at the aortic orifice. It may be present in 
 ansemic conditions, but is not uncommon in apparently healthy 
 subjects. If, however, there is a double murmur (V.S. and 
 V.D.) in the aortic area, the systolic portion is invariably 
 carried into the vessels of the neck wdth considerable intensity, 
 and in not a few instances the diastolic is propagated in a 
 similar direction, though very faintly. Murmurs are very 
 frequently present at the root of the pulmonary artery (see 
 p. 583), and may exist also in aneurismal affections of the 
 aorta. Duroziez pointed out that in certain diseased condi- 
 tions, especially in aortic insufficiency, pressure wdth the steth- 
 oscope educed not only a systolic but also a diastolic murmur 
 in the arteries, chiefly in the femorals, but it has also been 
 found apart from any disease of the vascular apparatus. 
 
 Murmurs in the veins may also be present, especially in 
 the large trunks at the root of the neck. They are loudest, 
 as a rule, on the right side. They are humming or musical 
 in quality, and are continuous; they are thus easily differ- 
 
 1 strictly speaking, and with reference to absolute accuracy indeed, the rhythm of an 
 arterial murmur cannot bo indicated in terms of cardiac derivation at all ; the exact 
 time of the arterial murmur produced by the contraction of the ventricles, and the 
 onward current in the vessels being l)y so much hder than the ventricular systole, as the 
 vessel is remote from the heart. A more strictly accurate nomenclature, therefore, 
 would be to call an arterial murmur, such as is hero indicated, arleriid-diasloUc — i. e., 
 coincident in time with the expansion, diastole, or pulse of the individual artery ex- 
 amined. In some cases the postponement of the arterial murmur to the cardiac impulse 
 is easily verified, and the above term is not ouly apposite and convenient, but of practical 
 importance. 
 
CAEDIAC VALYULAK MURMURS. 
 
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588 PHYSICAL EXAMINATION" OF THE HEART. 
 
 entiated from arterial murmurs in the same locality, which 
 intermit with the cardiac action. This venous hum (humming- 
 top sound or Bruit de diahle) is often associated with impover- 
 ished states of the blood (anaemia, chlorosis, etc.), hut does 
 not necessarily indicate organic disease. The position of the 
 patient is apt to influence both the intensity and quality of 
 these murmurs, the erect posture generally rendering them 
 louder and more musical ; inspiration has a similar eflect. 
 
 THORACIC ANEURISM. 
 
 Incidental allusions have been made in the preceding pages 
 to aneurism of the thoracic aorta and its branches, but it may 
 be well to indicate a little more in detail points to which 
 attention should be given in the investigation of this subject. 
 The position of an aneurism Avill vary according to the por- 
 tion of the vessel involved. It may impinge on the thoracic 
 wall in the immediate neighborhood of the heart, or at almost 
 any point in the thorax ; and aneurisms of the innominate 
 branch of the aorta may even reach high up into the neck. 
 A very frequent seat of thoracic aneurism is under the manu- 
 brium sterni. Aneurisms of the ascending arch are said to 
 pass chiefly to the right of the sternum, those of the transverse 
 arch lie, as a rule, under the manubrium, while those of the 
 descending arch tend to the left siHe. No fixed rules can be 
 laid down, however; in some instances the pressure signs and 
 symptoms may aid us in determining the portion involved. 
 
 Aneurism in the thorax often causes a local bulging of the 
 chest iva.ll, and when looked at in a cross light this bulging 
 may be seen to pulsate, while palpation at once detects the 
 heaving action. If the aneurism has by its pressure eroded 
 any portion of the bony structure it may present itself as a 
 distinct puls(ding tumor, the impulse being separable from 
 that of the heart, both by position and rhythm (the cardiac 
 impulse immediately preceding that of the aneurism), and if 
 the tumor is grasped at its periphery between the fingers, the 
 pulsation is found to be expansile or eccentric ; and this is a 
 very valuable diagnostic point from glandular tumors, can- 
 cerous growtiis, abscesses, etc., in the mediastinum, which may 
 simulate aneurism by having the heave of the aorta commu- 
 nicated to them. Occasionally the aneurism may yield a 
 double impulse, corresponding with the cardiac systole and 
 diastole ; the latter, or " impulse of arrest," as it is some- 
 times called, being generally slight when present at all. A 
 
THORACIC ANEURISM. 589 
 
 distinct thrill is also occasionally felt ; most frequently in 
 aneurisms near the heart. Along with these signs there may 
 be an area of dull jjerciission, which, according to the size and 
 position of the aneurism, may be sej)arable from the cardiac 
 dulness, joined to it by a more or less narrow neck, or quite 
 continuous wnth it. 
 
 In many instances, however, no distinct pulsating tumor is 
 present, although there may be an obscure heave, and the 
 only definite physical signs are an area of percussion-dulness, 
 more or less marked, in the track of the aorta, and certain 
 auscultatory phenomena to be mentioned immediately. Some- 
 times, indeed, even these signs are wanting or very obscure, 
 and the diagnosis may rest almost entirely on other signs and 
 symptoms, such as fixed pain, dysphagia, dyspnoea, laryngeal 
 paralysis, hsemoptysis, signs of pressure on nerves and veins, 
 displacements of the trachea, backward or to either side, 
 sense of fulness in the jugular fossa, changes in the pupils, 
 pulses, etc. (Compare also Chapter IX.j 
 
 The auscultatory signs may vary. In some instances, especi- 
 ally where the tumor involves the first part of the ascending 
 arch, murmurs following both sounds (V. S. and V, D.) may 
 be present, owing to implication of the aortic valves. But 
 independently of any such condition, murmurs may be found 
 in aneurisms in any part of the thorax, the rhythm being 
 usually " ventricular-systolic," or, more correctly, arterial- 
 diastolic, as it corresponds with the expansion of the artery. 
 In many instances, however, no murmur is present, but the 
 cardiac sounds as heard over the suspected area may have 
 undergone alteration. Both sounds may have become very 
 distinct, sometimes even more so than over the cardiac 
 region ; the second is especially apt to be accentuated, and 
 even to develop a different quality, becoming deepened in tone 
 or "booming," and this character is transmitted into the 
 vessels of the neck. This mere change in the second sound 
 would not warrant any diagnosis of aneurism, as there are 
 other conditions w^hich induce it. In the aneurismal condi- 
 tions it is sometimes wanting, but when present with symptoms 
 such as are indicated above, and accompanied by an area of 
 dull percussion in the line of the aorta, the preusmption of 
 aneurism becomes very strong. 
 
 Simple dilatation of the arch of the aorta may give rise to 
 varying degrees of percussion-dulness, chiefly in the region 
 of the manubrium sterni. There is, as a rule, no visible or 
 tangible impulse over this area ; but if the finger is inserted 
 
 50 
 
590 PHYSICAL EXAMINATION OF THE HEART. 
 
 iDto the jugular fossa, the dilated vessel may be easily felt, 
 and its impulse recognized. The second sound is usually 
 accentuated and booming, but pressure symptoms are, as a 
 rule, absent. 
 
 Signs of aneurism may present themselves in the back of 
 the thorax. Percussion-dulness of limited area, and close to 
 the left side of the spine, with changes in the cardiac sounds 
 and symptoms of pressure, as already indicated, have to be 
 chiefly relied on. Indeed, in many such cases physical exam- 
 ination may yield little information, and the diagnosis Avill 
 depend almost entirely on the other symptoms. 
 
 The conditions most likely to simulate aneurism are visible 
 and tangible pulsation from the pulmonary artery or left 
 auricle, about the second left intercostal space (for diagnosis 
 see p. 566) ; pulsating empyema and cancerous tumors. Pul- 
 sating empyema usually occupies the normal situation of the 
 heart, which is found displaced to the right, and communicates 
 its impulse to the fluid collection. There is, as a rule, a dis- 
 tinct history of a pleuritic attack, and it is unattended by 
 murmur, thrill, or alteration in the cardiac sounds. Pulsating 
 cancer may j^i'esent more difficulty, as it may be attended 
 by murmur, and give rise to all the pressure symptoms already 
 indicated. But careful palpation may detect that the pulsa- 
 tion is not so distinctly expansile as in aneurism, nor does the 
 centre of pulsation correspond to that of dulness. The glands 
 in the neighborhood that are accessible may be discovered 
 enlarged, the cachexia may be well marked, and the sounds 
 of the heart over the dull area, except in so far as attended by 
 murmur, do not present the alterations so often found in 
 aneurismal conditions. 
 
 PULSE^ — SPHYGMOGRAPH. 
 
 The sphygmograpJi is an instrument designed to enable the pulse to 
 register itself, and so afford a permanent record of its frequency^ its 
 regularity^ itsforce^ nnd^ above all^ of the characters of the pulse ivave. 
 
 Many forms of tbe instrument are now in use, but they are all con- 
 structed upon tbe principle of Marey's spbygmograph ; tbe essential 
 parts being a spring which rests upon tbe artery, and vibrates witb its 
 movements, and a lever to wbich these movements are transmitted, 
 and wbich records them in an amplified degree on a slip of paper 
 carried along by clockwork. Tbe sphygmographs chiefly in use in 
 this country are those of Marey, modified by Mahomed, of Dudgeon, 
 and of Pond. 
 
 Marey^s sphygmograph (Fig. 115) consists of a brass framework 
 
 1 Compare also section on the " Pulse," at p. 98. 
 
MAEEY S SPHYGMOGEAPH. 
 
 591 
 
 
692 PHYSICAL EXAMINATION OF THE HEART. 
 
 fitted with a steel spring, which rests upon the artery and communi- 
 cates its pulsations to the long lever (made of light wood and terminat- 
 ing in a style), which records them vertically upon a strip of blackened 
 paper or mica, carried along at a given rate — about four inches in ten 
 seconds — by the clockwork frame into which it is fitted. Mahomed 
 effected a most important improvement in Marey's instrument by 
 adapting to it means for the regulation of the pressure of the spring 
 upon the artery. This consists of an " eccentric." by depression of 
 which a definite degree of pressure can be brought to bear, and the 
 dial indicates the amount, from one to eighteen ounces troy, which is 
 applied. In order to give steadiness to the hand and arm, as well as 
 to afford means for fixing the instrument in position, a wrist-rest or 
 cushion is used, as indicated in the illustration. 
 
 The artery, for which Marey's instrument is specially adapted, is 
 the radial, and the point at which it is most advantageously applied 
 is just where the artery crosses the styloid process of the radius. The 
 advantages are that the vessel is here very superficial, and is sup- 
 ported on a firm flat surface. If possible, the patient should be in the 
 recumbent posture, as this generally assures the most tranquil state of 
 the circulation; and great care should be taken that the humeral 
 artery is subject to no pressure in any part of its course. The instru- 
 ment may also be applied while the patient is in the sitting posture, 
 his arm resting on a table in front of him. 
 
 The point where the radial artery is most salient should be carefully 
 sought for and marked with ink or pencil. The patient's wrist is then 
 laid in the "rest," and the button which the sphygmographic spring 
 carries at its free extremity is placed immediately over the artery. 
 The straps, which should be inelastic, are then fastened to retain the 
 instrument in its place, the fins:ers being held in a semi-flexed position. 
 If the spring is not accurately adjusted over the artery it may be 
 shifted about a little without undoing the fixings, but generally it is 
 preferable to appl}' the sphy£;mograph afresh. After the spring is in 
 position it is connected with the lever to see that it is working 
 properly before any attempt is made to register the tracing on paper. 
 The spring must be fairly placed on the arter}', as the least deviation 
 to the side may deforrei the tracing, and render it not only worthless, 
 but absolutely misleading. The pressure also must be carefully regu- 
 lated, a number of tracings with varying degrees of pressure being 
 taken, and the most perfect selected. The slips on which the tracings 
 are taken may be prepared in various ways. One of the most effective 
 is to pass them through the smoke of a camphor flame till they are 
 sufficiently coated to allow of the style or needle leaving its impress. 
 The smoke of a turpentine flame, or even of a candle, may also be 
 used. If the paper is too deeply smoked it is apt to retard the excur- 
 sion of the needle and so deform the tracing. The paper employed 
 should have a high glaze ; and after the tracings are taken the 
 patient's name, with the date and the pressure employed, may be 
 marked on them by means of a needle or other sharp point. They 
 are then rendered permanent by dipping them into photographers' 
 varnish, or a solution of one part of gum benzoin in five parts of 
 rectified spirits. Smoked mica may be used instead of paper; and in 
 the case of Marey's instrument the tracing may be taken with ink, 
 but the method detailed gives more delicate results. 
 
dudgeon's sphygmograph 
 
 593 
 
 DudgeoyVs sphygmograph (Fig. 116) is a very handy instrument. It 
 is much cheaper than the other varieties ; and as it requires no wrist- 
 rest, and is small and easily portable, it is capable of more extended 
 
 Fig. 116. 
 
 Dudgeou's sphygmograph. 
 
 use in practice than Marey's. It is especially designed for adaptation 
 to the radial. The needle writes upon the horizontal, and pressure, 
 ranging from one to five ounces, is applied by means of an " eccentric." 
 
 Pond's sphygmograph (Fig. 117), which can also be employed as a 
 cardiograph, is very easily adjusted and capable of wider application 
 to the circulatory system than the instruments already mentioned. 
 The pulsations of the artery are in it communicated through an India- 
 rubber diaphragm (or, in the latest modification, through a metal 
 button attached to a spiral spring), to a series of levers, terminating 
 in a needle, which writes upon the paper on the horizontal. The 
 instrument is attached to a frame into which the wrist may be laid, 
 but can be easily detached from this and applied by the hand, to 
 almost any superficial artery in the body. The pressure gauge is fitted 
 on the upright stem of the instrument, but cannot be regulated with 
 any degree of nicety. 
 
 In the hands of a capable observer all the instruments above de- 
 scribed give reliable results, and the tracings with which the text is 
 illustrated are selected from a series afforded by all three. Various 
 forms of " transmitting sphygmographs " have been devised, and they 
 are of special use in cases where simultaneous tracings of the pulse, 
 the cardiac apex-beat, and it may be the respiration are desired; but, 
 on the whole, the " polygraph " of Marey is the most satisfactory. 
 
 Events in a Nortnal Sphygmogram. — Each individual pulse wave in 
 a sphygmogram is made up of a series of " events " to which special 
 
 50* 
 
594 PHYSICAL EXAMINATION OF THE HEART. 
 
 names have been applied. Ths following may be taken as a reminder 
 of the more special points in relation to these various phenomena, but 
 the student vs'ill do well to consult recent physiological works for 
 fuller details. 
 
 Fig. 117. 
 
 Pond's sphygmograph. 
 
 The line from which the tracing starts is called the " respiratory^^ or 
 " base Ime," as it represents the point of residual tension in the vessel. 
 On the ventricular contraction taking place the sphygmographic lever 
 describes an ascent, more or less perpendicular, named the ^^ primary 
 or percussion loave," terminating in an apex (Fig. 118, a) more or less 
 acute. Then follows a slight descent, succeeded hy the ^' secondary," 
 ^^ tidal," or ^' predicrotic" wave (Fig. 118, 6), which is supposed to 
 indicate the true blood wave in the vessel.^ The notch (Fig. 118, e) 
 which succeeds the tidal wave is designated the ^'aortic" or ^'■dicrotic 
 
 1 The separation of the primary and tidal waves is by some believed to be, in niajiy 
 instances, at least, due to the inertia of the lever of the sphygniograpli, the velocity 
 •which it acquires on the sudden ventricular contraction carrying it a little too far, and 
 so leading to the seimratiun of the two waves. This may be so when the jirimary wave 
 isamjile, the ventricle delivering its charge sharply and suddenly, but there are many 
 instances where leverse conditions obtain, and yet the two waves are perfectly distinct. 
 
EVENTS IN A SPHYGMOGRAM. 
 
 595 
 
 notch^^'' and is coincident with the closure of the sigmoid valves, indi- 
 cating the termination of the ventricular systole. Then follows the 
 " dicrotic wave" (Fig. 118, c), caused, for the most part, at least, by 
 the recoil of the blood from the root of the aorta. The descent line, 
 broken it may be by one or more small waves (Fig. 118, d), then falls 
 gradually to the base line of the next pulsation. 
 
 Fig. 118. 
 
 "Events" in a normal sphygmogram : a, primary or percussion wave ; 6, secondary or 
 tidal wave ; e. aortic notch ; c, dicrotic wave ; d, fourth wave. 
 
 In a good tracing the apex is usually more or less pointed. Eounded 
 apices are to be regarded with distrust, as indicative of faulty adjust- 
 ment or incorrect pressure. In certain instances, however, as in well- 
 marked aortic stenosis (Fig. 134), a rounded apex is one of the most 
 distinctive features of the tracing. 
 
 The various events indicated in diagram in Fig. 118 are easily recog- 
 nizable in most healthy pulse tracings — e. g., Fig. 119, in which is reg- 
 istered, under three ounces pressure, a healthy pulse numbering 68. 
 
 A pulse of this character giving an unbroken ascent line is called 
 " katacrotic ; " but when the summit of the tracing is reached through 
 an ascent line broken by one or more shoulders or peaks (Fig. 120, 
 a a), the pulse is said to be " anacrotic." 
 
 Fig. 119. 
 
 Healthy pulse. Pressure, 3 oz. Pulse, 68. 
 
 In katacrotic tracings the distention of the artery is accomplished 
 so suddenly that it is equal to one elastic vibration, and the ascent line 
 is therefore unbroken ; but when the distention is effected more slowly 
 then the maximum pressure in the pulse wave occurs toward the end 
 of the ventricular systole, and the upstroke is broken by a more or less 
 well-defined notch — it is anacrotic. Anything which affords an ob- 
 
596 PHYSICAL EXAMINATION OF THE HEAKT. 
 
 stacle to the discharge of the blood from the ventricle may produce 
 this form of pulse. Hence it is seen in well-marked aortic stenosis 
 (Fig. 134) ; in cases where the arterial tension is very high ; or where 
 the vessels are atheromatous. 
 
 The characters of the pulse tracing^ however, will depend greatly upon 
 the pressure exerted upon the artery, and the utmost care is therefore 
 necessary in its regulation. As Mahomed truly observes, " the use of 
 incorrect pressure is perhaps the most common source of error in 
 sphygmography." A series of tracings should be made with varying 
 degrees of pressure, and those in which the individual events are most 
 distinctly indicated selected for preservation. Observation should be 
 
 Fig. 120. 
 
 "Anacrotic" pulse curves, from the radial artery : a, a, the anacrotic notches. 
 
 (Landois.) 
 
 made in each case, also, as to the amount of pressure requisite to oblite- 
 rate the pulse. In cases where the vessels are not atheromatous this 
 gives valuable information as to the energy of the cardiac contraction, 
 and the tension resident in the vessel. 
 
 The changes in the form and relation of the individual parts of the 
 pulse curve under varying pressure are well illustrated by the series of 
 radial tracings in !Fig. 121. When the pressure is small the dicrotic 
 wave is relatively less; the whole curve high. (Fig. 121, a.) With 
 a moderate pressure (6, 100, c. 200 grammes) the dicrotic wave is best 
 marked; the whole pulse wave somewhat lowered. On increasing 
 the pressure {d, 250, e, 450 grammes) the dicrotic wave diminishes, 
 the tracing loses in height, the time occupied by the ascent becomes 
 shorter, while the descent line lengthens. It is only when pressure 
 from 220 to 300 grammes is exercised that the vibrations [ee) preceding 
 the dicrotic wave appear. This will serve to show what an important 
 element pressure is, and how carefully it should be adjusted. 
 
 Fig. 121. 
 
 III! 
 
 Various forms of radial pulse curves obtained by gradually increasing the pressure 
 (a, b, c, d, e) : e e, predicrotic waves : B, dicrotic wave. (Landois.) 
 
ARTERIAL TENSION. 597 
 
 Arterial Tension. — The sphygmograph gives valuable evidence as 
 to the degree of tension in the arterial system ; indeed, the indications 
 afforded by it in respect of this, are among the most useful and reliable 
 in sphygmography. 
 
 In robust health the tension in the pulse may be very considerable 
 (see Fig. 119), but in certain morbid states it is apt to be much aug- 
 mented ; the blood pressure in the artery is abnormally great ; there is 
 what is termed high tension. Pulses of high tension may to the finger 
 be large or small — large, when with impeded capillary outflow the 
 blood is discharged into the arteries by a powerful ventricle ; small, 
 when the muscular coat of the vessels is in a state of tonic contraction. 
 In both instances the pulse wave is hard to obliterate by the finger; 
 but in the one case it is large and full, in the other small and wiry. 
 In the latter instance the pulse to the finger of a careless or inex- 
 perienced observer may give a very deceptive impression. 
 
 The graphic characters which indicate high tension are : (a) Pro- 
 minerice and sustension of the tidal wave ; [b) smallness of the dicrotic 
 wave ; (c) occurrence of the dicrotic wave high up in the diastolic li7ie, 
 which sinks gradually to the next upstroke. We may add to these 
 that the pressure requires to be considerable to obtain a good tracing. 
 
 Prominence of the tidal wave is a very valuable gauge of high ten- 
 sion when the vessels are not atheromatous. Indeed, when in a pulse 
 tracing any part of the tidal wave rises above a line drawn from the 
 apex to the aortic notch it indicates, as a rule, undue blood pressure. 
 It will not do, however, to rely upon this character of the tidal wave 
 alone. Other indications must corroborate it. This character of high 
 tension is due to difficulty of arterial outflow. The systole of the 
 ventricle is, therefore, prolonged, and what is believed to be the true 
 ventricular wave, viz , the tidal, is ample and sustained. 
 
 Such a form of tracing is well seen in Bright's disease, especially the 
 chronic form with cirrhotic kidney ; but it is often enough apparent in 
 acute and subacute attacks. (Fig. 122.) Indeed, it has been described 
 
 Fig. 122. 
 
 Pulse tracing from a subacute case of Bright's disease in a boy aged ten. Pulse, 56. 
 
 Pressure, 5 oz. 
 
 by Mahomed as a condition antecedent even to the establishment of ^ 
 albuminuria. In angina pectoris it is of the utmost consequence to 
 determine whether, during the attack, the arterial tension is high, as 
 it gives the key to the treatment. 
 
 Dicrotism. — In the febrile state, and in other conditions, as after 
 hemorrhage, where the arterial tension is low, the elasticity of the 
 vessels unimpaired, and the ventricular contractions short and sharp, 
 there is developed what is termed the "dicrotic" pulse; a fact often 
 
598 PHYSICAL EXAMINATION OF THE HEAKT. 
 
 enough appreciable by the finger. In it the tidal wave is no longer 
 ap-parent (the maximum blood pressure occurring early in the ventri- 
 cular systole), the aortic notch is lowered^ and the dicrotic wave tnuch 
 
 Fio. 123. 
 
 Dicrotous pulse. Pressure, 'ly^ oz. Pulse nite, 110. From a patieut aged 
 twenty-four, suffering from phthisis. 
 
 Fig 124. 
 
 Full dicrotism. Pressure, 1% o/. Pulse, 112. 
 
 increased. Various degrees of dicrotism are recognized. A pulse is 
 "dicrotous" when, with a very marked secondary wave, the aortic 
 notch does not reach the respiratory line. (Fig. 123.) 
 
 It is said to exhibit " full dicrotism " when the aortic notch reaches 
 the level of the respiratory line. (Figs. 124, 125.) 
 
 FiG. 125. 
 
 Full dicrotism. Pressure, 1 oz. Pulse rate, 110, From a case of acute rheumatism. 
 
 When the aortic notch falls below the respiratory line, the term 
 " hyper-dicrotous " is employed. (Figs. 126, 127.) 
 
 It will be apparent ihat the hyper-dicrotous character results from 
 the dicrotic wave being caught up, before it has spent itself, by the 
 next cardiac contraction; and should the pulse, under such circum- 
 stances, become very rapid, the dicrotic wave may be lost entirely, 
 and the pulse become " monocrotic." (Fig. 128.) 
 
DICKOTOUS PULSES. 
 
 599 
 
 Dicrotism is indicative of low tension, and its characters are best 
 developed under low pressure. It may be produced by slight causes in 
 persons of nervous temperament, but it is in febrile diseai=es that it 
 attains its most typical characters ; and the degree of dicrotism may 
 
 Fig. 126. 
 
 Hyper-dicrotons pulse. Pressure, 2 oz. Pulse, 120. 
 
 Fig. 127. 
 
 Hyper-dicrotous pulse. Pressure, 1% oz. Pulse rate, 130. 
 
 Fig. 128. 
 
 Monocrotic pulse. (After Eiegel.) 
 
 aid in the estimate of the gravity of a case, inasmuch as it affords a 
 key not only to the character of the cardiac action, but also to the 
 tone of the nervous sj-stem generally. It is thus also an important 
 guide for stimulation. The conditions which favor the production of 
 dicrotism are, sudden and sharp ventricular contraction, elasticity of 
 the vessels, low arterial tension, and free capillary outflow. 
 
 Intermittence and Irregularity of the Pulse. — The sphygmograph 
 gives ready indication of any irregularities either in rhythm or volume 
 
600 PHYSICAL EXAMINATION OF THE HEART. 
 
 of the pulse waves. It occasionally happens that without any altera- 
 tion in time every second pulse wave lacks volume. This is the con- 
 dition described bj' Traube as ^^ pulsus altertians." In other cases the 
 pulse is *' intermittent,'' the heart now and again enjoying a longer 
 repose than usual, and hence the regularity of the tracing is disturbed. 
 It is to be noted in such cases that the pulse wave following the pause 
 is invaiiably more ample. This form of intermission, which may be 
 regular or irregular in time, is not inconsistent with health, or, at least, 
 may depend upon temporary conditions, such as indigestion, or exces- 
 sive tobacco smoking. It is to be carefully distinguished from a form 
 of " false " intermission where the ventricular contraction fails to reach 
 the wrist, or is too feeble even to raise the aortic valves ; or where a 
 fatty and dilated ventricle relieves itself through a patent mitral orifice. 
 The systole in such cases is abortive, and has no arterial expression, a 
 fact of the utmost significance as indicative of degenerative changes 
 in the cardiac muscle. In every case of pulse intermission, therefore, 
 the pulse rate should be critically checked by auscultation over the 
 heart. 
 
 In some instances, the irregularities conform to certain types. They 
 may occur at fixed intervals, as, for instance, every two or three beats. 
 Illustrations of this are found in the ^^ pulsus bigeminus" (Fig. 129 
 
 Fig. 129. 
 
 "Pulsus bigeminus ;" convalescent from pneumonia. Pulse, 68 ; pressure, 2 oz. 
 
 and Fig. 131, Nos. 3, 5, 6), in which the pulse waves run in pairs, and 
 in the ^'pulsus ti^igeminus " (Fig. 130), in which they run in groups 
 of three. 
 
 Fig. 130. 
 
 "Pulsus trigeminus," J. B., aged sixty-five. Typical angina pectoris without apparent 
 valvular or aneurismal disease ; pressure, 3 oz. Died suddenly. 
 
 Various forms of irregularity, both of rhythm and volume, are illus- 
 trated in the series of tracings in Fig. 131, and it is to be remarked 
 in connection with this series, that the sphygmograph will detect pulse 
 waves inappreciable by the finger. In Nos. 6 and 7 it was found that 
 every second cardiac beat failed to reach the finger at the wrist, but 
 the sphygmograph reveals them clearly as distinct interruptions in the 
 long descent line. 
 
PULSE TRACINGS. 
 Fig 131. 
 
 601 
 
602 PHYSICAL EXAMINATION OF THE HEART. 
 
 Pulse tracings from a man, aged sixty, suffering from bronchitis ; no cardiac complaint, 
 and no phj-sical signs of valvular mischief or hypertrophj' of the heart (Gairdner, 
 Glasgow Medical Jounuil, vol. iv. p. 548.) 
 
 The sphygmographic observations extended over a fortnight. In the morning, for 
 minutes together, the pulse was often perfectly regular, then two or three irregular beats 
 occurred, and the regular rhythm again resumed. As the day advanced the irregularity 
 usually became greater. A study of the tracings affords means of observing the regular 
 gradation from the strictly normal pulse down to that in which the alternate feeble beats 
 are hardly appreciable, only the strong ones being distinctly rendered on the paper. 
 No. 1 gives the regular pulse, numbei'ing 72 Nos. 2, 3, and 4 give various degrees of 
 irregularity. No. 5 shows the most marked form of the rhythmic irregularity (pulsus 
 bigeminus), the feeble beats being quite marked and the dicrotism after each quite 
 appreciable. In No. 6 the alternate feeble beats are less strongly marked, and in No. 7 
 they might bo mistaken for the dicrotism of a normal pulse. The rate of pulsation, in 
 all cases when the rhythmic irregularity^ was so well developed as to be practically con- 
 stant over a minute or so, was about 40 when numbered at the wrist by the strong pulses 
 only, and 70 to <S0 when numbered according to the cardiac pulses. 
 
 Respiration souielimes material!}' modifies the pulse tracing. This 
 may be apparent even in healthy subjects, the tension falling during 
 inspiration and rising during expiration. (Fig. 21.) When the 
 breathing is deep and stertorous, as in apoplexy or uraemie coma, the 
 undulatory character of the iespir»tory line of the tracing may be well 
 marked. (Fig. 22.) 
 
 In exceptional cases during inspiration the pulse wave may be almost 
 totally suppressed, the ^'- pulsiis paradoxus ^^ of Kussmaul (Fig. 132), a 
 condition attributable to the compression of the great vessels by fibrous 
 bands passing between them and the thoracic wall, and these of cour.>;e 
 are put upon the stretch during the inspiratory act. It has been 
 observed, however, under other conditions. 
 
 Senile Pulse. — A very characteristic form of tracing is found in cases 
 where degenerative changes have occurred to a marked extent in the 
 
 Fig. 132. 
 
 "Pulsus paradoxus" (after Kussmaul). I, inspiration ; E, expiration. 
 
 arterial walls. It is spoken of as the "senile pulse," as the conditions 
 which give rise to it — e. g., atheroma and calcareous degeneration, are 
 common in later life. The tracing is, as a rule, ample, the tidal wave 
 well sustained — so much so, indeed, in certain cases as to overtop the 
 apex of the upstroke and atford ?.n anacrotic tracing, and the dicrotic 
 wave is little marked. (Fig. 133.) The degree to which these char- 
 acters are developed will, of course, depend to a large extent upon the 
 amount of rigidity and the consequent loss of elasticity. Low pressure, 
 as a rule, gives the most typical tracing, although the pressure requisite 
 
AORTIC REGURGITATION. 
 
 603 
 
 to obliterate the pulse is gi-eat, owing to the condition of the vessel 
 walls. In certain instances, however, it may be a pulse of high tension. 
 
 Fig. 133. 
 
 Senile pulse. Patient aged seventy-two ; arteries very rigid ; considerable hypertrophy 
 
 of left ventricle. 
 
 The sphygmograph gives characteristic tracings in certain well- 
 marked forms of cardiac valve disease, especially in cases where the 
 left ventricle is affected. 
 
 Aortic stenosis, pure and simple, is a comparatively rare condition, 
 but when well marked it gives a highly di-tmctive tracing. (Fig. 134.) 
 
 Fig. 134. 
 
 Aortic stenosis in a patient aged twenty-six. Pressure, o}4^ oz. Loud, rough systolic 
 murmur at aortic cartilage ; pulse small hut hard ; evidences of moderate ventricular 
 hypertrophy. 
 
 Here, owing to the obstruction at the root of the vessel, the primary 
 wave is impeded, and as the ventricle discharges its contents slowly 
 and deliberately the tidal wave is well sustained, overtops the primary 
 wave, and forms the rounded summit of the tracing. The pulse, in 
 fact, is anacrotic. In cases of extreme obstruction there may be no 
 differentiation of the primary and tidal waves, the two being fused into 
 a simple undulation. The degree to which the tidal wave is produced 
 may be taken as a gauge of the amount of obstruction ; and in cases 
 where there is regurgitation associated with the obstruction, in the ab- 
 sence of atheromatous conditions, the degree to which the tidal wave is 
 developed may be regarded as significant, to some extent, of the amount 
 of obstruction present. 
 
 Aortic regurgitation affords a striking contrast to the preceding 
 tracing. The pulse wave in this lesion is usually very ample, the pri- 
 mary wave vertical, well produced, and terminating in a sharp apex, 
 while in the diastolic part the aortic notch is low and the dicrotic 
 wave small, at least relatively so. The characters of the systolic part 
 of the tracing indicate that a powerful ventricle is discharging a large 
 quantity of blood into vessels in a state of low tension. Such charac- 
 
604 PHYSICAL EXAMINATION OF THE HEART. 
 
 ters are often met with in functional disturbances of the heart in ner- 
 vous people, so that they are by no means characteristic of aortic 
 incompetency. But the diastolic part of the tracing is very significant. 
 No sooner is the cardiac systole past than the blood tension falls sud- 
 denly from the regurgitation through the patent orifice, and hence the 
 
 Fig. 135. 
 
 Pulse of aortic regurgitation. Pressure, 2^ oz. 
 
 collapsing character of the tracing, and the diminution and low posi- 
 tion of the dicrotic wave, which, under normal conditions, is the ex- 
 pression of the recoil of the blood column from the aortic valves. In 
 cases where atheroma exists the tidal wave, as in Fig 135, may be 
 very apparent ; in some instances, indeed, the primary and tidal waves 
 form twin peaks. Even in the absence of atheroma, should consider- 
 able obstruction be associated with the regurgitation, the tidal wave 
 may be well developed, as the ventricle discharges its contents more 
 slowly ; but even apart from obstruction, temporary high tension from 
 the large quantity of blood thrown into the vessel may give a well- 
 sustained tidal wave. 
 
 Fig. 136 indicates the characters of very free regurgitation in a 
 young subject. The aortic notch is as low as the base line, the dicro- 
 
 FiG. 136. 
 
 Pulse of aortic regurgitation. Pressure, 2 oz 
 
 tic wave is very small, and the tracing thereafter very flat. It was 
 developed under low pressure, and when the pressure was increased 
 the dicrotism disappeared. Some approximation may be made to the 
 amount of regurgitation present by considering the degree to which 
 these characters are developed. 
 
 Capillary Pulse. — This seems to be the most fitting place to refer 
 to the capillary pulse, inasmuch as it is brought about by aortic in- 
 competency. It consists in the fact that pulse waves can be seen in 
 
MITEAL REGUEGITATION. 605 
 
 the superficial capillary vessels. It can be well demonstrated by rub- 
 bing the skin, say of the forehead, with the finger so as to produce a 
 capillary blush, which may be seen to flush and pale with the systole 
 and diastole of the heart. In certain rare instances the pulse waves 
 are transmitted quite through the capillaries into the peripheral veins, 
 as, for instance, on the dorsum of the hand, giving rise to the venous 
 pulse. 
 
 The capillary pulse is produced by a large quantity of blood being 
 propelled suddenly by a powerful ventricle into vessels in a state of 
 low tension, and it may be somewhat dilated. Hence it is most likely 
 to occur when with a slowly acting heart there is free regurgitation 
 through the valves of the aorta with ample compensatory hypertrophy. 
 When hypertrophy of the left ventricle fails and mitral regurgitation 
 ensues the capillary pulse disappears. 
 
 Mitral Stenosis. — Considerable diversity of opinion has been ex- 
 pressed as to the character of the pulse in obstructive lesions at the 
 mitral orifice. Some hold that the pulse, as a rule, is regular, though 
 small, and that it is only when the compensatory conditions fail that 
 irregularity takes place. The majority of observers, however, indicate 
 irregularity as a very frequent condition even in cases where, as yet, 
 no obvious cardiac embarrassment exists. Dr. Sansom, who has given 
 much attention to the sphygmographic characters of the pulse in mi- 
 tral stenosis, is very strongly of this opinion, stating (and in this he 
 coincides with Mahomed) " that a pulse tracing which shows irregu- 
 larity in the diastolic periods, sometimes missed pulsation, and, as 
 described by Dr. B. Foster, the occasional appearance of a small 
 abortive pulsation in the line of descent is very strong evidence of the 
 existence of mitral stenosis." The writer has found, however, that in 
 many cases of well-marked obstruction (at least so far as presystolic 
 thrill and murmur with accentuation of the second pulmonic sound in- 
 dicate such), while the patient is quiescent the pulse is regular. On 
 exertion, excitement, or the supervention of pyrexia or pulmonary 
 disorders, however, irregularities are readily induced. In advanced 
 cases, marked irregularity is the rule. The size of the tracing will 
 vary according to the quantity of blood delivered through the nar- 
 rowed orifice to the ventricle, and to the efficiency of the ventricular 
 contraction. Fig. 137 shows a tracing from a well-marked case in a 
 young subject. The pulse to the finger was small but regular. 
 
 Fig. 137. 
 
 Mitral stenosis, patient aged sixteen, pulse 100, pressure 3 oz., well marked auricular- 
 systolic murmur and thrill. 
 
 Mitral regurgitation g\'VQ?> no very distinctive sphygmographic char- 
 acters, but the irregularity both in rhythm and force so frequently 
 
 51* 
 
606 PHYSICAL EXAMINATION OF THE HEART. 
 
 met with in such cases is well portrayed in the accompanying sphygmo- 
 grams. In Fig. 138, the cardiac contractions are well sustained, but 
 
 Fig. 138. 
 
 Tracing from a case of mitral regurgitation, showing the pulse irregular in force and 
 
 rhythm. 
 
 present marked irregularities; while in Fig 139, the feeble, hurried, 
 irregular pulse, indicative of free regurgitation and a failing ventricle, 
 is well seen. 
 
 Fig. 139. 
 
 Mitral regurgitation, 1 oz. pressure, dropsy in feet, dyspnoea. 
 
 Venous Pulse. — Diseases of the right heart give no special characters 
 to the arterial pulse, unless it be a tendency to undulation of the res- 
 piratory line ; but tracings may be aflForded by the jugular or subclav- 
 ian veins in cases of tricuspid regurgitation. 
 
 Fig. 140. 
 
 Jugular pulse-tracing showing the presence of the auricular wave a. (After Friedreich.) 
 
 In Fig. 140, the wave "a" preceding the main wave is due to the 
 auricular contraction, and its proportions are indicative of the energy 
 of the systole of the auricle; when it becomes dilated and paralyzed. 
 
ANEURISMAL PULSE, 
 
 607 
 
 the wave " a" disappears as in Fig. 141. The wave " b " is due to the 
 contraction of the right ventricle, and the wave " c " in the descent 
 line is said by Dr. Gribson to be reflected from the interior of the heart, 
 
 Fig. 141. 
 
 Jugular pulse-tracing after paralysis of the auricle ; the auricular wave a in the 
 preceding figure is no longer present. (After Friedreich.) 
 
 in the same way as the dicrotic wave in the radial tracings of very free 
 aortic regurgitation, as was first pointed out by Naumann. 
 
 Aneurism of the arch of the aorta or of its main branches may 
 modify the radial pulse; but the modifications will depend upon a 
 great variety of circumstances, such as the site of the tumor, its size, 
 its shape, the character of its walls and contents, etc. A frequent 
 modification is inequality of the two radial pulses. (Figs. 142, 143, 
 144, and 145.) 
 
 Fig. 142. 
 
 Aneurism : right radial pulse. 
 
 Fig. 143. 
 
 Aneurism : left radial pulse. 
 
 Should the aneurism be situated on the arch of the aorta below the 
 origin of the innominate artery the two radial tracings may be quite 
 equal in all respects. If, however, the aneurism involves the innomi- 
 nate, the right radial will give indications of the retardation of the 
 
608 PHYSICAL EXAMINATION OF THE HEART. 
 
 pulse wave ; while if the aneurism is situated so as to involve the left 
 subclavian (as it did in Fig. 143) the left radial tracing will be modi- 
 
 FiG. 144. 
 
 Aneurism : right radial pulse. 3 oz. 
 
 Fig. 145. 
 
 Aneurism : left radial pulse. 3 oz. 
 
 fied to a greater or less extent. In Fig. 143, the sloping ascent, 
 rounded apex, and unbroken diastolic line give graphic illustration of 
 the great interference with the pulse wave on the affected side. 
 
 THE CARDIOGEAPH. 
 
 This is by no means such a reliable instrument as the sphygmograph, 
 and its employment, consequently, in clinical inquiry is much more 
 restricted. Several forms of cardiograph have been devised, but those 
 of Marey and Gralabin are, on the whole, the most satisfactory. 
 
 March's cardiograph is shown in Fig. 146; and the adjustment of 
 
 Fig. 146. 
 
 Section of the cardiograph of Marey for recording the movements of the heart of 
 man or of animals, a, India-rubber membrane ; b, vulcanite or ivory knob applied 
 over the apex of the heart, resting on a thin aluminium plate ; c, spiral, which may 
 be tightened or relaxed by turning the milled head, d, thus increasing or diminishing 
 the sensibility of the instrument; e, /, tube leading to the registering tambour, 
 (MacKendrick.) 
 
galabin's cardiograph. 
 
 609 
 
 the apparatus with a registering tambour is represented in Pig. 147. 
 It is thus seen to consist of two tambours. Any impulse communi- 
 cated to the first tambour, which is applied immediately over the 
 apex beat, is at once transmitted to the registering tambour which 
 controls the writing lever and thus records the tracing on the drum. 
 Fig. 148 presents a tracing taken after this fashion. 
 
 Arrangement of apparatus for recording movements of the heart by the cardiograph 
 of Marey. a, Cardiograph ; h, tube, commuuicating with c, recording tambour ; d, 
 clockwork, moving cylinder, e ; /, fine adjustment screw for bringing lever of register- 
 ing tambour on surface of cylinder at the proper time ; g, box, in which the whole 
 instrument may be packed. (MacKendrick.) 
 
 Galabin's cardiograph is a modification of the principle of Marey's 
 sphygmograph. It will be found figured and described in the 
 Medico-Chirurgical Transactions^ vol. Ivii. p. 359, and also m 
 Bramwell's Diseases of the Heart, p. 754. 
 
 Ttg. 148. 
 
 Tracings of the cardiac pulsations of a healthy man. (Marey.) The differences in 
 form between the first two pulsations and the last are due to respiratory influences. 
 o, diastole ; b, ventricular systole. (MacKendrick.) 
 
610 PHYSICAL EXAMINATION OF THE HEART. 
 
 Pond's sphygmograph in cases where the apex impulse is limited and 
 well marked can readily be used as a cardiograph. It is held in posi- 
 tion by the hand, and gives, on the whole, very fair results. 
 
 Fig. 149. 
 
 Normal cardiographic tracing after Galabiu. a represents the auricular contraction ; 
 from a to d indicates the sudden hardening of the ventricle ; d, e, /, shows the continued 
 systole; i- is the rebound after the emptying of the ventricles; and Hs the gradual 
 ascent from the influx of blood during the diastole. 
 
 In order to secure a good cardiogram the patient must be placed in 
 that position in which the cardiac apex beat is most definite. He 
 ma}^, therefore, require to sit up, or lean forward, or lie somewhat 
 over to the left side. The cardiogi-aph must be applied over the site 
 of maximum impulse; and, if possible, the tracing should be taken 
 during complete expiration, and while the breath is held. This 
 assures the nearest approximation of the heart to the chest wall, and 
 at the same time obviates respiratory undulations, and other modifi- 
 cations of the tracing. 
 
 Fig. 149 is a cardiogram after Galabin. 
 
 It is to be remembered, however, that in cases where the button of 
 the cardiograph is not applied exactly over the site of greatest apex 
 impulse — as when the heart beats behind a rib — the tracing is apt to 
 be inverted and must be read accordingly. In other instances the in- 
 version may not be complete and the interpretation of the tracing 
 becomes a matter of much difficulty. 
 
 Observers are by no means agreed as to the exact causation of the 
 various waves in a normal cardiogram ; but Fig. 150, with simultaneous 
 tracings from the right auricle, right ventricle, and apex beat, will 
 serve to some extent to show the relation of the various phenomena; 
 while Fig. 151, giving simultaneous tracings of the cardiac apex, 
 radial pulse, and the respiration, exhibits the relation in time of the 
 cardiac contraction to the pulse at the wrist; and serves also to show 
 the alterations in the cardiogram induced by the respiratory move- 
 ments. 
 
 The whole subject of cardiography is still too much in a state of 
 flux to permit of any very precise statements. No doubt it afifords 
 some valuable data as to the relative duration of the cardiac systole 
 and diastole ; as to the mode in which the ventricle is being filled during 
 
NORMAL CARDIOGRAMS, 
 Fig. 150. 
 
 611 
 
 Tracings obtained from the heart of a horse by Chauveau and Marey. The upper 
 tracing is from the right auricle, the middle from the right ventricle, and the lower 
 from the apex of the heart. The horizontal lines represent time, whilst the vertical 
 represent amount of pressure. The vertical dotted lines mark coincident points in the 
 three movements. The breadth of one of the small squares equals one-tenth of a 
 second, a b, a' & , a'' 5", auricular systole; cdef, c' d' e' f, c" d" e" f, ventricular 
 systole : similar waives in the other curves have different letters. (MacKendrick.) 
 
 Fig. 151. 
 
 Simultaneous tracings taken by the pneumograph B, cardiograph C, and sphygmo- 
 graph A at the radial artery. The ascent of the curve in B corresponds to expiration, 
 and the descent to inspiration. There are from fotir to five cardiac pulsations to each 
 complete respiratory movement. Observe also that the pulsation at the^wrist is a little 
 later than the corresponding cardiac pulsation— thus d, in upper line A corresponds to'c, 
 in lower line C. (MacKendrick.) 
 
612 PHYSICAL EXAMINATION OF THE HEAKT. 
 
 the diastole ; as to the condition of the mitral orifice, and the state of 
 the cardiac muscle generally ; but the results, on the whole, are too 
 conflicting to admit of generalization, and much careful experiment 
 will be required before anything like precise doctrine is attained. 
 Mitral obstruction and aortic regurgitations give two of the most 
 characteristic cardiograms. Fig. 152 (from Bramwell after Galabin) 
 
 Fig. 152. 
 
 Cardiogram from a case of mitral stenosis, a represents the auricular contraction : 
 for the other letters see Fig. 149. (Galabin.) 
 
 is from a case of mitral stenosis with loud harsh murmur extending 
 through the long pause, a indicates the probable commencement of 
 the auricular contraction, which is represented by a prolonged, ascend- 
 ing, serrated line, the visible expression of the long rough murmur. 
 This indicates the lengthened systole of the auricle necessary to drive 
 the blood through the narrowed mitral orifice. Many variations, 
 however, are found. 
 
 A tracing from a case of well-marked aortic regurgitation is seen 
 in Fig. 153 (from Bramwell after Galabin). It will be noticed that 
 
 Fig. 153. 
 
 Cardiogram from a case of aortic regurgitation. (Galabin.) 
 
 the summit of the tracing is here sustained, having two peaks, c?and 
 /, indicative of h^-pertrophy of the ventricle, while the filling of the 
 ventricle during diastole is indicated by the rapid ascent of the dias- 
 tolic line" k." 
 
 For further details as to the cardiograph and its revelations the 
 student is referred to the authorities indicated. 
 
PHYSICAL EXAMINATION" OF ABDOMEN. 613 
 
 Part III. Physical Examination of the Abdomen. 
 
 Anatomists have divided the abdomen into various regions 
 by lines drawn from certain fixed points, viz., two horizontal 
 lines passing across the body, the one at the lowest point of 
 the costal arch, and the other at the highest part of the iliac 
 crests ; two vertical lines are drawn, one on either side, from 
 the cartilage of the eighth rib to the middle of Poupart's liga- 
 ment. The central regions are the epigastric, the umbilical, 
 and the hypogastric, and on either side of these the right and 
 left hypochondriac, lumbar, and iliac. (See Fig. 154.) Some 
 clinical observers have devised other lines for these divisions, 
 but the difference in the regions is only slight. (See the dotted 
 lines in Bright's diagram, Fig. 71.) 
 
 Fig 154. 
 
 ^gPCHOnS EPlCASt. 
 
 1^ ^ 
 
 ^luMB»ll \ 
 
 ^ If f///.:i^ 'I ;^ 
 
 <?IMAO \ 
 
 r -" / ' ^-HHfH+Hfr;, - > j 
 
 The anatomical regions of the abdomen. 
 
 It is well to have a general notion of what organs occupy 
 these regions. In the riglii hypocliondrium lies the right lobe of 
 the liver ; in the epigadric region the body of the stomach, the 
 left lobe of the liver, and behind the stomach the pancreas ; in 
 the left hypochondrium the cardiac extremity of the stomach and 
 the spleen; in the umhilical region the transverse colon, the 
 mesentery, and part of the small intestine ; in the right lumbar 
 region the right kidney and the ascending colon ; in the left 
 lumbar region the left kidney and descending colon ; in the 
 
 52 
 
614 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 hypogastrium the small intestine and the bladder when dis- 
 tended ; in the left iliac region the sigmoid flexure ; and in the 
 rif/ht iliac region the " caput caecum coli." (See Fig. 155.) 
 
 The methods employed in the physical examination are sim- 
 ilar to those already indicated in the case of the chest — viz., 
 inspection, j^aljmtiou, percussion, mensuration, and auscultation. 
 The last of these is of very limited scope in the abdomen com- 
 pared with the chest, but all of them should be used so as to 
 check each other at every step of the inquiry. 
 
 Before commencing the examination the patient should, as a 
 rule, be laid on his back, with the shoulders a little raised, and 
 
 Fig. 155. 
 
 Abdominal viscera in situ. The omentuni has becu removed ; the costal arch has been 
 preserved. The capital letters are the initials of the structures on whicli they are placed : 
 L, lungs; D, diaphragm; R, ribs; S, spleen; B, bladder. (From Marshall's "Physio- 
 logical Diagrams.") 
 
 the thighs slightly flexed on the pelvis to relax the abdominal 
 muscles. He should be directed also to keep his mouth open, 
 and breathe quietly. 
 
INSPECTION. 615 
 
 INSPECTION. 
 
 The abdomen being well exposed, inspection will determine 
 its shape, the conditio.: of the superficial parts, the respiratory 
 movements, and any other movements or pulsations which 
 may exist. In healthy women and children the abdomen 
 protrudes more than in adult males, in whom, in the recum- 
 bent posture, it is often somewhat flattened. If the subject is 
 fat, the surface will be free from m^arked inequality ; but if 
 the parietes contain little fat, and the recti muscles are well 
 developed, they may stand out somewhat on either side of the 
 middle line. 
 
 General distention of the abdomen may result from accumula- 
 tion of gas in the intestines (see "Tympanites," p. 633), or 
 from fluid efl'usion into the peritoneum fsee "Ascites," p. 435), 
 or from ovarian tumors (see pp. 439, 634), or from combination 
 of these ; or the hidging may he local from tumor of some of the 
 solid organs, or from undue distention of some of the hollow 
 viscera, such as the stomach in stricture of the pylorus. On 
 the other hand the abdomen may become much retracted in cer- 
 tain cerebral aflections (tubercular meningitis), in chronic 
 lead poisoning, and in cases of obstruction high up in the ali- 
 mentary canal leading to inanition. The umbilicus occupies a 
 point about midway, as a rule, between the pubes and the 
 xiphoid, but is subject to a certain degree of variation, and in 
 very young children is nearer the pubes. In the strictly nor- 
 mal condition it is depressed, but it may bulge as in umbilical 
 protrusion, and in cases of ascites. During the later months 
 of pregnancy, also, it becomes prominent. The skin is nor- 
 mally somewhat darker round the umbilicus than on other 
 parts of the abdomen, forming what is called an "areola," and 
 this pic/mentation becomes more marked during the course of 
 pregnancy ; and in Addison's disease (see p. 142 ) it is a marked 
 feature— the whole surface, however, being unduly pigmented. 
 In women " a brown line" is occasionally seen extending from 
 the umbilicus to the pubes, and is by some reckoned a sign of 
 pregnancy ; but this is to be accepted with reservation ; it is 
 sometimes present even in males. In women who have borne 
 children the abdominal walls are often very flaccid, and in 
 some cases, after many pregnancies, become so thin as to give 
 the impression that there is little else than a layer of skin 
 covering the intestines. White lines (linese albicantes) or 
 " water lines " occur on the skin after the distention of preg- 
 
616 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 nancy, and after the absorption of large dropsical effusions. 
 Occasionally the superficial veins (epigastric and mammary) 
 are much enlarged and tortuous, or even varicose, this condi- 
 tion being generally associated with some obstruction to the 
 portal circulation, as in cirrhosis, or with some pressure on the 
 inferior veua cava by tumors. The abdominal parietes may 
 be dropsical, and pit on pressure. This oedema is always great- 
 est in the dependent parts, often accompanied by fluid eft'usion 
 into the cavity of the peritoneum, and usually associated with 
 dropsical effusion into the cellular tissue of other parts of the 
 body. The abdomen is frequently the seat of skin eruptions ; 
 some of the febrile rashes indeed, as enteric fever, have a 
 tendency to appear there first. All such rashes, of course, 
 should be noted and described if present. 
 
 The degree to wdiich the abdominal w^alls participate in the 
 respiratory movements should be observed. In quiet respira- 
 tion in males the abdominal movement is more marked than 
 the thoracic ; while in females the thoracic movement pre- 
 dominates. The type in the male is thus said to be " abdom- 
 inal," and in the female " thoracic." This abdominal move- 
 ment may be affected by various conditions. Anything which 
 causes distention of the abdomen, and impedes the descent of 
 the diaphragm, will necessarily restrict it ; all forms of ab- 
 dominal intumescence will have this effect. In women the 
 respiration is made more thoracic by the presence of preg- 
 nancy and ovarian or uterine tumors. But apart from such 
 causes, the abdominal movement may be greatly restricted by 
 voluntary effort, owing to the pain which it excites, as in peri- 
 tonitis, diaphragmatic pleurisy, or pericarditis. But this 
 abdominal respiratory movement may be exaggerated when 
 from any cause the thoracic movements are restricted, and 
 the chief work of the respiratory process is thrown upon the 
 diaphragm. This is the case in large pleural effusions, in ex- 
 tensive consolidations of the lung, and in emphysematous and 
 asthmatic conditions. 
 
 A degree oi pulsation is occasionally visible in the epigastric 
 region, and may be due to the heave communicated from the 
 aorta. It is most frequently seen in females, especially those 
 who are thin and of nervous temperament ; it must not be 
 confounded with the epigastric pulsation communicated from 
 the heart. (See p. 341.) But visible pulsation may exist in 
 the abdomen from aneurism of the aorta or any of its branches; 
 and cancerous or other tumors may simulate aneurism al con- 
 ditions from their lying over the vessel and having its impulse 
 
PALPATION. 617 
 
 communicated to them. All the methods of inquiry must be 
 brought to bear on the investigation of such cases. In certain 
 instances of extreme tricuspid incompetency an expansile pul- 
 sation may be quite perceptible in the liver, synchronous with 
 the ventricular contraction, and due to the transmission of the 
 pulsation through the inferior vena cava and hepatic veins. 
 In subjects in whom the stomach or intestines are much dis- 
 tended owing to any obstruction, peristaltic action may occa- 
 sionally be seen through the abdominal walls ; this may also 
 be visible in the extremely thinned condition of the integu- 
 ments already referred to. 
 
 PALPATION 
 
 is a method of investigation widely applicable in abdominal 
 diagnosis, and should be follow^ed out with much detail. The 
 hands of the examiner should not be cold, as this is apt to 
 cause the patient to shrink ; and the palpation should not be 
 conducted, at least in the first instance, in a jerky or spas- 
 modic manner with the tips of one or two fingers, but with 
 the whole palmar surface of them applied gently, but firmly. 
 As the results of this method of examination will be given in 
 detail under the various organs, only a few general facts need 
 be noted here. It will determine the state of the temperature 
 of the surface, the presence of flaccidity or rigidity of the 
 walls, of the condition of the abdominal rings, the degree of 
 resistance at different points, and whether parts are freely 
 movable. When associated with percussion it enables us to 
 detect fluid in the peritoneum. (See "Ascites," p. 435.) It 
 will reveal the fact of smoothness or irregularity of the ab- 
 dominal organs, will determine the presence and character of 
 pulsations, and sometimes even detect peritoneal friction. 
 This last-mentioned condition is got either by causing the 
 patient to breathe forcibly while the flat of the hand is laid 
 over the suspected organ, or it may be elicited by sliding the 
 abdominal w^all over the part. (See p. 439.) In the case of 
 abdominal tumors palpation will determine their characters, 
 and whether they are afifected by respiration or not ; tumors 
 closely associated with the movable organs lying beneath the 
 diaphragm being depressed and elevated in respiration. Pal- 
 pation may also determine the fact of pregnancy by noting 
 the movements of the foetus in the uterus, as well as enabling 
 us in certain cases where the abdominal walls are thin, or in 
 an extrauterine foetation, to recognize the head or other parts 
 
 52* 
 
618 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 of the child. It also elicits important information as to the 
 presence or absence of pain or tenderness. In certain condi- 
 tions pain is so acute as to forbid palpation. This is especi- 
 ally (but not invariably) the case in acute peritonitis, where 
 the pain is often so exquisite as to lead the patient to flex the 
 thighs upon the pelvis in order to relax the abdominal mus- 
 cles and protect the belly from the pressure of the bed-clothes. 
 On the other hand, acute pain when of the neuralgic or colicky 
 type is sometimes relieved by pressure. If tenderness on pres- 
 sure exists over a limited area in the epigastric region, it may 
 point to the presence of gastric ulcer ; and in inflamed or 
 suppurating conditions of any of the organs or structures in 
 the abdomen, pain on pressure is, as a rule, a marked feature. 
 
 PERCUSSION 
 
 is to be performed in the manner described in the section on 
 the physical diagnosis of the lungs. The note yielded by the 
 air-filled organs in the abdomen is " tympanitic," having a 
 distinct musical tone, and the quality of this note vaiies ac- 
 cording to the size and degree of distention of the organs. 
 The note obtained over the stomach is fuller and lower in 
 pitch than that over the colon ; the note over the colon bears 
 a similar relation to that over the small intestine. It is by 
 means of this change in quality that the different parts of the 
 intestine can be distinguished from each other, and the student 
 should study them in this light, contrasting the percussion 
 tone also wdth that obtained over a solid organ such as the 
 liver, w^hich is " dull," and that elicited from the lung, which 
 is termed ** clear." Auscultatory percussion is sometimes of 
 value in the delimitation of air-filled organs. (See p. 619.) 
 
 MENSURATION 
 
 is used to determine the circumference of the abdomen, the 
 tape being applied to the most prominent part, usually a little 
 above or below the umbilicus, or at some other definite point 
 such as the umbilicus itself. This gives a datum for future 
 measurements, and increase or decrease can readily be deter- 
 mined, care being taken that the tape is applied at the same 
 level and with the same tension. The distance of the umbili- 
 cus from the ensiform cartilage, the symphysis pubis, or the 
 iliac spines has occasionally to be noted. The areas of per- 
 cussion-dulness of the various organs, whether normal or ab- 
 
EXAMINATION OF ABDOMINAL ORGANS. 619 
 
 normal, should be accurately measured and stated ; the points 
 to be indicated should be measured from definite anatomical 
 landmarks such as the umbilicus, ensiform cartilage, iliac 
 spines, etc., and not vaguely referred to the regions in which 
 they lie. 
 
 AUSCULTATION 
 
 is of great value in abdominal diagnosis in the detection of 
 vascular sounds, whether connected with abnormal conditions 
 such as aneurism, uterine tumors, etc. (see pp. 635, 636), or 
 with normal conditions during pregnancy (the foetal heart, 
 uterine souffle, etc., see p. 524). It is also applicable in dila- 
 tation of the stomach in practising succussion ; the sounds in 
 the bowels are also of importance, particularly in cases of 
 intestinal obstruction. Auscultation is also useful occasionally 
 in the determination of peritoneal friction, particularly over 
 the liver. It may be used in the diagnosis of stone in the 
 bladder, the stethoscope being placed above the pubes, while 
 the stone is struck with the sound. 
 
 "Auscultatory percussion" is sometimes used to delimit air- 
 filled organs, such as the stomach. For this purpose the ob- 
 server places his stethoscope over the epigastrium while an 
 assistant percusses from the periphery, till a point is reached 
 at which the note is communicated with sudden and great 
 directness to the listener, and this may be marked as the limit 
 of the air-filled portion of the organ. The same method is 
 pursued all around the stomach, the patient's position being 
 altered to allow the fluid to change its place, and the area 
 occupied by the viscus can thus be mapped out with tolerable 
 exactitude, if the note of the colon does not approximate to 
 that of the stomach. It is absolutely necessary to shift the 
 patient from one side to the other in this examination, other- 
 wise only the level of the fluid contained in the stomach will 
 be ascertained. 
 
 EXAMINATION OF ABDOMINAL ORGANS. 
 
 The most convenient method of treating further of abdo- 
 minal diagnosis is to take up the principal organs in detail, 
 considering them first in their normal relations, and then 
 passing on to abnormal conditions. The student may find 
 assistance in understanding their position by reference to the 
 anatomical figures here given, and especially to the posterior 
 view of the viscera. (Figs. 155, 156.) 
 
620 PHYSICAL EXAMINATION OF ABDOMEN 
 
 Fia. 156. 
 
 Posterior Tiew of viscera. (Reduced by photography, from Luscbka.) 
 
EXAMINATION OF LIVEK, 
 
 621 
 
 1. Upper lobe of left lung. 
 2 Under lobe of left lung. 
 
 3. Interlobular fissure of left lung. 
 
 4. Upper lobe of right lung. 
 
 5. Under lobe of right lung. 
 
 6. Middle lobe of right lung. 
 
 7. Superior fissure of right lung. 
 
 8. Inferior fissure of right lung. 
 
 9. Stomach, represented in outline, more 
 
 vertical than usual. 
 
 10. The spleen at its ordinary distance from 
 
 the vertebrae, and in the course of the 
 9th, 10th, and 11th ribs ; its relation 
 to the left lung in expiration is 
 shown ; the left kidney, partly shown 
 in outline, appears through it. It 
 must not be forgotten that in this 
 view from behind the spleen appears 
 only after the removal of the dia- 
 phragm. 
 
 11. The left kidney in so far as not covered 
 
 by spleen (the covered part is indi- 
 cated in outline) ; the pelvis of the 
 
 kidney and commencement of the 
 ureter passing out from it are shown ; 
 kidney on the right side has been 
 removed to show deeper parts, but 
 its position is indicated in outline. 
 
 12. Superior horizontal portion of the duo- 
 
 denum. 
 
 13. Descending portion of duodenum. 
 
 14. Inferior horizontal part of duodenum. 
 
 15. The duodeno-jejunal flexure. 
 
 16. Liver. 
 
 17. Hepatic duct. 
 
 18. Cystic duct. 
 
 19. Common bile duct. 
 
 20. Head of pancreas ; the rest of its course 
 
 shown in outline. 
 
 21. Ascending colon. 
 
 22. Descending colon. 
 
 23. Posterior surface of descending colon 
 
 uncovered by peritoneum. 
 
 24. Knuckle of colon forming sigmoid 
 
 flexure, covered by left iliac bone. 
 
 25. Portion of the sigmoid flexure. 
 
 Liver. 
 
 In the section devoted to the physical examination of the 
 lun^s it was noticed that the pulmonary percussion was 
 bounded inferiorly all round the right side by the upper mar- 
 gin of hepatic dulness. In order to define this margin, the 
 percussion should be carried from the clear pulmonary area 
 down on to the dull liver, using a light stroke, and at a point 
 one inch and a half or two inches below the right nipple, a 
 change will be perceived in the note, as well as in the sense of 
 resistance, and this indicates the spot at which the lung ceases 
 to overlap the liver. This is the boundary of "absolute'' 
 dulness ; the deep or " relative " dulness, which indicates the 
 highest point to which the liver ascends under the diaphragm, 
 is at a considerably higher level than this, and is ascertained 
 by means of strong percussion performed during expiration. 
 The description here given will apply to superficial percussion 
 and to the absolute dulness. The upper border is followed 
 into the cardiac dulness in almost a straight line — there being, 
 however, a tendency for it to descend a little toward the inner 
 extremity, where it joins the precordial dulness on a level 
 with the base of the ensiform cartilage. It is then extended 
 in the lateral region and the back, and will be found to de- 
 scend somewhat as it nears the spine, usually at the tenth of 
 
622 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 eleventh dorsal vertebra. Having marked this upper limit of 
 percussion with ink or pencil, the lower margin will next 
 engage attention, the percussing stroke being carried up from 
 the tympanitic intestine. This lower margin in the right 
 mammary line will be found to coincide pretty exactly with 
 the margin of the ribs ; in the axillary line it corresponds to 
 about the tenth intercostal space, and it crosses the epigas- 
 trium at a level of about two inches below the xiphoid, and 
 joins the left margin of the cardiac dulness. (See Fig. 102.) 
 The left lobe of the organ can thus be felt in the epigastrium, 
 giving a sense of increased resistance ; but in health its lower 
 edge cannot, as a rule, be strictly defined by palpation. 
 
 The average extent of hepatic dulness, according to this mode 
 of percussion, in a healthy adult of medium size, is from 2|- to 
 8 inches in the mesial line of the sternum, 4 inches in the line 
 of the nipple, and 4^ or 5 inches in the axillary line. 
 
 It must be remembered that these limits, which presuppose 
 the recumbent posture, may alter to some extent on the 
 patient's assuming the erect attitude, and in certain conditions 
 of respiration. Thus, on deep inspiration the whole organ is 
 somewhat depressed, and its upper limit overlapped to a 
 greater extent by the lung; the student ought to study these 
 changes. In children, in whom the liver is naturally large, 
 the upper margin of dulness may approximate to the nipple, 
 and the lower descend somewhat beneath the costal arch ; and 
 there are various deformities of the chest, such as those induced 
 by rickets, emphysema, and tight lacing, whicli tend to throw 
 the organ to a greater or less extent from under the cover of 
 the ribs, and so simulate enlargement. Congenital malforma- 
 tions of the organ may also be present. 
 
 The demarcation of the lower edge of the liver should never 
 be considered as settled from a single examination, as there 
 are various conditions which temporarily affect it. Thus, if 
 the stomach and intestines are distended with gas, they may 
 conceal the lower edge, and the area of dulness may appear 
 diminished. Again, if the examination is made after a full 
 meal, the dull percussion from the stomach may mask the 
 lower edge of hepatic dulness; or there may be accumulation 
 of feces in the colon having a similar effect. In cases of 
 thickened omentum also, or where the recti muscles are very 
 rigid, or where there is dropsy of the abdominal wall or of the 
 peritoneum, the exact determination of the lower edge may 
 be very difficult or even impossible. 
 
 Large abdominal tumors, by their pressure upward, will 
 
ENLARGEMENT OF LIVER. 
 
 623 
 
 tend to push the liver further under the ribs, and so raise 
 both its upper and lower limits of percussion ; while pleural 
 effusions of air or fluid, marked emphj^sema of the lungs, 
 tumors in the chest, and enlargements of the heart, will depress 
 the organ into the abdomen. The diagnosis in such cases must 
 be guided by the history and other physical signs. 
 
 The size of the liver is liable to vary to some extent, even 
 in health, under the influence of diet ; but this is only tem- 
 porary. In all cases where the liver is permanently increased 
 in bulk, the enlargement is, as a rule, chiefly in the downw^ard 
 
 Fig. 157. 
 
 Displacement of cardiac and hepatic dulness in emphysema of the lungs. (Weil.) 
 
 direction — the liver projecting beyond the ribs, and palpation 
 becoming a valuable means of diagnosis. 
 
624 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 The student must be careful to distinguish enlargement 
 from displacement of the organ. The distinction in cases of 
 emphysema, tight lacing, and rickety or other deformities of 
 the chest, lies in the fact that in displacement the upper level 
 of hepatic dulness will be found to be lowered to a greater or 
 less extent according to the degree of projection from under 
 the ribs (see Fig. 157) ; whereas, in enlargement, the upper 
 limit of dulness maintains its position, and in some instances 
 is even on a higher level, approximating to the nipple. 
 
 When the displacement is due to right pleural effusion, the 
 distinction may be less easily drawn, as the upper border of 
 liver dulness is merged in that of the effusion ; but the history, 
 symptoms, and other physical signs will usually give the key 
 to the condition. In pericardial effusion, hypertrophy of the 
 heart, and left pleural effusion, the left lobe is the part chiefly 
 depressed, and, as the upper limit of the right is not much 
 aflected, there is not the same liability to fiiUacy as in pleural 
 effusion on the right side. (Compare Figs. 105 and 106.) 
 
 The enlargement of the liver may affect the ivhole organ uni- 
 formly, or it may be localized, and it may be moderate in extent, 
 or fill the whole abdomen. When the liver is uniformly en- 
 larged, the outline of the organ is not materially altered. The 
 percussion of its limits should be followed out, and palpation 
 should always be brought to test the lower margin ; in not a 
 few instances it will be found that the lower edge can be felt 
 to project to a quite decided extent beyond the limit of per- 
 cussion-dulness. This is especially so in cases of abdominal 
 dropsy, and, to detect the lower edge in such instances, it is 
 frequently necessary to pursue palpation by a different method 
 from that indicated in the commencement of this section. It 
 has to be done with the tii:>s of the fingers, suddenly and 
 strongly, in order to penetrate through the fluid to the liver. 
 It is often possible also in uniform enlargement, to map out 
 the notch of the liver, which will be found somewhat near the 
 mesial line of the abdomen. It may be appreciated not only 
 by palpation, but also as forming a small bay of clear percus- 
 sion encroaching on the line of dulness. In some instances, 
 also, where the fissure of the gall-bladder is well marked, it 
 can be detected, though with nothing like the frequency of 
 the notch. In ascites the percussion of the lower edge of the 
 liver cannot be depended on, and palpation has to be chiefly 
 used in the delimitation of it. In uniform enlargement the 
 upper limit of dull percussion approaches the nipple level ; 
 and when the increase in size is considerable, it is often pos- 
 
DENSITY AND SMOOTHNESS OF LIVER. 625 
 
 sible, by applying the one hand in front and the other in the 
 kimbar region behind, to grasp the organ and communicate a 
 sense of impact from the one hand to the other. 
 
 Density, Smoothness, or Irregularity. — The hepatic region in 
 cases of enlargement can often be seen distinctly bulged, and, 
 on applying the hand over the part that projects, the sense of 
 resistance and the fact of smoothness or irregularity of the 
 surface may be recognized. If the organ is smooth, uniformly 
 enlarged, dense and resistant, it is most probably either amy- 
 loid, fatty, or congested, or the seat of simple hypertrophy, as 
 in leuksemia ; the fatty liver is usually the softest of these ; 
 the amyloid is, as a rule, the most dense, and it is often asso- 
 ciated with enlargement of the spleen and with albuminuria. 
 If, on the contrary, the surface of the organ is irregular, nodules 
 of varying size existing on its surface, and in some instances 
 projecting beyond its lower edge, and especially if some of 
 these nodules can be felt to be depressed or umbilicated in the 
 centre, and if palpation elicits a degree of pain or tenderness, 
 then there is strong ground for the suspicion of cancerous 
 disease of the liver. If, however, the irregularities on the 
 surface are small, and associated with symptoms of obstruction 
 to the portal system, such as ascites, enlargement of spleen, 
 hemorrhage from the stomach or bowels, etc , then it may be 
 a case of cirrhosis, or " gin-drinker's liver," although this 
 disease is not, as a rule, attended by enlargement, but rather 
 by atrophy. Uniform enlargement is apt to occur in all cases 
 in which there is obstruction to the systemic circulation ; and 
 so in diseases of the heart, especially of the right side, it is 
 a very frequent fact, the constant congestion of the portal 
 system giving rise to it. This may also occur from persistent 
 dietetic excesses, and an enlargement from alcohol is very 
 common. 
 
 The enlargement may not be uniform, but only involve one 
 or other lobe. This is especially the case in hydatid disease 
 and tro2:)ical abscess. In both instances a distinct tumor often 
 exists, and if it lies near the surface, fluctuation, or at least a 
 sense of elasticity can be felt ; in the case of hydatid cysts 
 there is sometimes detected on percussion a sense of tremor 
 called " hydatid fremitus." This is elicited by laying three 
 fingers over the seat of greatest distention and percussing 
 strongly over the middle finger. The affections are differen- 
 tiated by the grave constitutional symptoms and local tender- 
 ness in the case of abscess, and the almost total immunity from 
 them in the case of hydatid disease. 
 
 53 
 
626 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 With or without enlargement of the liver there may be 
 present a projection of dull percussion and increased resistance 
 from its under surface. If this arises from the region of the 
 gall-bladder, if it conveys the sense of fluctuation or elasticity, 
 and is pyriform in shape and tender to pressure, it is most 
 probably the gall-bladder enlarged from obstruction to its 
 duct. In some instances gall-stones are also present in the sac, 
 and crepitation may be elicited sometimes from the rubbing 
 of these on each other, A history of hepatic colic, and per- 
 haps even the passage of gall-stones, may serve to throw light 
 on the case. (See Chapter XIL, p. 425.) 
 
 Dlmiiiutlon in the size oj the liver can never be so certainly 
 stated as enlargement, as the area of hepatic dulness is apt to 
 be much encroached on by emphysematous lungs or distended 
 intestine. But actual diminution in size often takes place. 
 This is especially the case in cirrhosis and other forms of 
 chronic atrophy and in acute yellow atrophy of the liver. 
 This latter condition is very rare, acute in its course, and asso- 
 ciated frequently with jaundice and with symptoms of great 
 vital depression ; the atrophy may become extreme. It occurs 
 chiefly in females, and pregnancy is a predisposing cause. In 
 cirrhosis the atrophy is not extreme, it is not acute in its 
 course, and there is often a history of spirit drinking. 
 
 The presence or absence of ^^ant or tenderness in diseases of 
 the liver must be investigated. Murchison makes this the 
 ground for his division of enlargements of the liver into 
 " painful " and " painless." Among the " painless " there are 
 the so-called amyloid liver, the fatty liver, hydatid tumor of 
 the liver, and simple hypertrophy. Among the "painful" 
 there are congestion, catarrh of the bile-duels, interstitial 
 hepatitis, pysemic abscess, tropical abscess, and cancer. He 
 also remarks that painless enlargements are characterized by 
 an absence of jaundice and ascites, and by a chronic course, 
 whereas in painful enlargements jaundice and ascites are com- 
 mon symptoms, and the progress is more rapid. 
 
 Spleen. 
 
 In the normal subject the spleen can be detected by per- 
 cussion only, as it lies quite under cover of the ribs in the 
 left hypochondrium, its C(mvex surface corresponding with 
 the ninth, tenth, and eleventh ribs. Prior to attempting its 
 delimitation, it is well to determine the percussion of a line 
 passing from the left axilla downward and inward to the 
 
ENLARGEMENT OF THE SPLEEN. 627 
 
 umbilicus. This line will necessarily be oblique, and if 
 required it may be curved to carry it outside the areas of 
 cardiac and hepatic dulness, both of which should be defined 
 before attempting- the percussion of the spleen. This line 
 will be found to be more or less resonant throughout ; in its 
 upper 23art pulmonary resonance is obtained, and then passing 
 across the stomach, colon, and small intestines, the differences 
 in the tympanitic note of these organs may be more or less 
 distinctly realized. The presence of such a resonant line 
 removes various sources of fallacy from pleuritic or peri- 
 cardial effusions, pulmonary condensations, enlargement of 
 the left lobe of the liver, fluid or solid accumulation in the 
 stomach, etc. Having determined this line, light percussion 
 should be made backward and downward from it toward 
 the splenic region, till a change in the note is discovered ; 
 the percussion should then be carried down from the axilla 
 on to the upper margin of spleen, or rather to the point 
 where the lung ceases to overlap the organ ; and percussing 
 upward from the tympanitic abdomen into the hypochon- 
 drium, the lower border will be found normally inside the 
 costal arch. The posterior margin, cannot be ascertained 
 with any degree of certainty. In the average subject this 
 area of dulness will measure from two to three inches in the 
 oblique diameter, but this dulness varies greatly even in 
 normal conditions, and slight increase or decrease in its size 
 can never be confidently stated. 
 
 Enlargement of the spleen is, as a rule, almost entirely 
 downward and forward, unless it is very firmly bound by 
 adhesions to the diaphragm. (See Fig. 158.) Considerable 
 enlargement may take place, and may be detected by per- 
 cussion alone, unaided by palpation, as the organ lies so 
 much inside the margin of the ribs as to admit of considerable 
 increase in bulk before it projects from under the costal arch. 
 Even in such cases, however, it is often possible by pressing 
 the finger-tips well up under the costal arch to make out a 
 sense of increased resistance or even of tumor, and the exam- 
 ination may be aided by making counter-pressure with the 
 other hand behind. In moderate enlargement percussion plays 
 the principal part in the diagnosis : when, however, the organ 
 passes below the ribs, palpation becomes of prime importance, 
 and with one hand in front and the other behind, the organ 
 can be grasped and tilted backward and forward. The en- 
 largement may be so great as to fill the whole left side of the 
 abdomen down even to the pubes, and the fact of its being a 
 
628 PHYSICAL EXAMINATION" OF ABDOMEN. 
 
 spleen may be somewhat obscure, but if the enlargement is 
 moderate there is usually little difficulty in determining the 
 organ involved. A tumor arising from the left hypochon- 
 drium, which is superficial and mobile, with rather blunt 
 edges, and with a notch in its anterior border, can hardly be 
 
 Fig. 158. 
 
 Various degrees of enlargement of the spleen. The lines indicative of splenic enlarge- 
 ment are copied exactly from Weil, but the percussion limits of the heart and liver have 
 been somewhat modified. 
 
 anything else than spleen. The most likely sources ot fallacy 
 are enlai'ged or floating kidney, and fecal accunmlations in 
 the splenic flexure of the colon. 
 
 There are certain conditions in which palpation can detect 
 
KIDNEYS. 629 
 
 the spleen when not enlarged but displaced. In certain 
 deformities of the chest, as in rickets, the spleen may be thrown 
 to a greater or less extent from under cover of the ribs, in the 
 same way as the liver. In like manner large pleural effusions 
 in the left side of the chest will depress the spleen and bring 
 it within reach of palpation. It is to be remembered, also, 
 that in very rare instances the spleen, owing to relaxation of 
 its ligaments, may be greatly displaced, constituting what is 
 known as " movable spleen." 
 
 In emphysematous states of the lungs, or great distention of 
 the intestines with gas, the splenic dulness may be much 
 encroached on and thus appear diminished. 
 
 Causes of Enlargement. — Enlarged spleen may arise from 
 passive congestion, as in obstruction to the portal system from 
 cirrhosis of the liver. It may originate also from active con- 
 gestion, especially in certain specific fevers such as enteric and 
 relapsing, and above all in ague ; the constantly recurring- 
 congestion in this last affection may lead ultimately to chronic 
 enlargement (" ague cake"). But the increase in volume may 
 be due to splenic leuksemia, in which case the diagnosis is 
 aided by the discovery of increase in the v/hite blood-corj)us- 
 cles; or it may be from amyloid disease, and here the liver 
 will most probably also be enlarged, and the urine will usually 
 be found to contain albumen from a similar condition in the 
 kidney. Colloid cancer, inflammation, and, in very rare cases, 
 abscess of the spleen ma}^ also lead to enlargement. Embolism 
 of the spleen may give rise to considerable enlargement, and 
 in such cases friction may sometimes be detected over the 
 organ in the early stage. In young children of rachitic habit 
 the organ is often considerably enlarged as well as displaced. 
 
 The Kidneys 
 
 lie so deep in the lumbar regions, and in such close proximity 
 to solid structures, that they often cannot be marked out by per- 
 cussion in the natural condition with anything like accuracy. 
 The patient should be laid flat on his face, with all the lumbar 
 muscles well relaxed ; the tympanitic note of the colon is 
 realized, and the percussion carried backward to the anterior 
 edge of the kidney. The upper edge is approached in a like 
 manner, and is usually situated on a level with the first or 
 second lumbar vertebra, and the anterior edge from three to 
 four inches from the spine. It is to be remembered, however, 
 that one or other kidney may be absent altogether, or atro- 
 
 53* 
 
630 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 phied from calculus, or may occupy some other position. 
 Slight degrees of enlargement cannot be determined by pal- 
 pation and percussion, especially if the patient is fat and the 
 abdominal walls resistant. In most cases, indeed, the physical 
 examination of the kidney is quite subordinate to the careful 
 examination of the urine. There are instances, however, in 
 wdiich positive results can be got. Thus in cystic disease of 
 the kidney, or hydro- or pyo-nephrosis, increased dull percus- 
 sion and sense of tumor, or at least resistance, can often be 
 made out. The way to detect this increased resistance, or 
 sense of weight in the flanks, is to lay the patient flat on his 
 back with the muscles quite relaxed ; a hand is then applied 
 to either lumbar region, and the one w^eighed against the 
 other, when, if the case is at all well marked, there will be 
 little difficulty in fixing on the heavier or more resistant. 
 Sometimes, also, there may be distinct bulging. Having 
 determined this, the aflfected flank is grasped between the two 
 hands, one in front and one behind, close to the spine, and 
 just below the ribs ; sometimes the enlarged kidney can thus 
 be felt, and the sense of impact made out on moving it from 
 the one hand to the other. In cases of cystic disease, or hydro- 
 or pyo-nephrosis, the organ may be greatly distended, dis- 
 tinctly fluctuant, or at least elastic, and it might be con- 
 founded with ovarian cyst, hydatid disease, or luml3ar abscess; 
 but its renal nature can usually be made out, and there may 
 be elements in the urine to guide the diagnosis. If the disease 
 arises from calculus in the ureter, there may be perhaps a 
 former history of a like tumor relieved by a sudden and large 
 discharge of urine; and symptoms of renal colic may have 
 preceded the formation of the tumor. In pyo-nephrosis, also, 
 it sometimes happens that there is a history of a similar large 
 discharge of pus, with subsidence of the tumor; or at least 
 variations in the quantity of pus excreted in the urine may 
 occur, and this may guide the diagnosis. The kidney may also 
 be enlarged from cancerous, sarcomatous, or hydatid disease. 
 Perinephritic abscess may simulate renal tumor, but can usu- 
 ally be distinguished on account of its affecting the psoas 
 muscle as indicated by flexion of the thigh on the pelvis. 
 
 The kidney may become displaced from relaxation of its 
 ligaments, this occurring chiefly on the right side, and speci- 
 ally in women. Floating kidney is not always easy of diag- 
 nosis, but if there is an abdominal tumor in the umbilical 
 region, smooth, ovoid, presenting the characters of the kidney, 
 freely movable, capable of being replaced into one or other 
 
EXAMINATION OF STOMACH. 631 
 
 renal region, tender to pressure, but unattended by serious 
 constitutional disturbance, although, perhaps, Avith occasional 
 attacks of severe pain, then the suspicion of floating kidney 
 should be entertained ; this is all the more likely if we can 
 determine by palliation an absence of the kidney in the 
 lumbar region. 
 
 Pancreas. 
 
 In the healthy condition, physical diagnosis fails to detect 
 the pancreas, or at least to give data of any importance; but 
 when it is the seat of disease (chiefly cancerous), and the 
 patient is emaciated, it may come to present a palpable tumor, 
 lying across the upper part of the abdomen, chiefly in the 
 epigastrium, very deep, and often receiving an impulse from 
 the aorta or superior mesenteric artery. It is likely to be 
 confounded wdth aneurism, but the pulsation may be deter- 
 mined to be not expansile, being simply a heave communi- 
 cated to the tumor from the vessel. It may also be confused 
 with other deep tumors, and in such cases the diagnosis can 
 only be inferential. Tumors in the stomach may also be mis- 
 taken for it, but these are usually more superficial, more 
 mobile, and often obey the respiratory movements of the 
 diaphragm. The appearance of fatty matters in the stools is 
 presumptive evidence of disease of the pancreas. Jaundice 
 may be present in some cases of disease of the head of the 
 pancreas from pressure on the bile-duct. 
 
 The Stomach 
 
 will be found usually to occupy the epigastric and part of the 
 left hypochondriac regions, but its position is subject to great 
 variation according to its state of distention and the condition 
 of surrounding organs, its mobility allowing of much displace- 
 ment. If the left lobe of the liver is enlarged, the stomach 
 may be depressed into the umbilical region ; and owing to 
 ascites, abdominal tumors, etc., it may be pushed up so as to 
 lie much under the cover of the ribs. In retraction of the left 
 lung in phthisis, it may be dragged up into the left lateral 
 region, and in extreme cases may be found high up in the 
 axillary region. 
 
 The stomach may become enormously distended. This 
 most frequently happens in stricture of the pylorus (simple or 
 malignant). The distended organ may fill almost the whole 
 abdomen, and even encroach to some extent on the chest, 
 
632 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 especially on the left side, bat the distention is, as a rule, dis- 
 tinctly related to the epigastric region. The peristaltic action 
 may occasionally be observed through the abdominal wall as 
 a slow vermicular movement from left to right ; it may some- 
 times be excited by friction in the epigastric region. The 
 examination of the vomited matters often aids also in deter- 
 mining the existence of dilatation (see p. 404); the stomach 
 tube may have to be used to ascertain the quantity and nature 
 of the contents. The j^ercussion note is highly tympanitic, 
 and the organ can generally be pretty accurately mapped out, 
 if the method of auscultatory percussion, already described 
 (see p. 619), is employed. As there is usually fluid as well as 
 air in the organ, change in position may alter the percussion 
 limits. Thus, if the patient is laid on his left side, the fluid 
 will gravitate into the " cul-de-sac." This fluid level should 
 be carefully determined and marked, and the patient laid on 
 his back or right side, when the previously dull area will 
 become tympanitic, and the dulness will shift to the dependent 
 portion. If the patient is placed on his hands and knees, the 
 dulness will be transferred to the front, and the lateral regions 
 will become clear. If the hands are placed on either side of 
 the distended organ, and the patient shaken, the wave will be 
 appreciated over an undue area and the fluid felt dashing 
 from one side to the other, the splashing sound being often 
 audible to the bystander ; while, if auscultation is employed, 
 Hippocratic succussion and its metallic phenomena are well 
 heard. If the quantity of fluid iu the stomach is considerable, 
 and the fingers are depressed suddenly and sharply into the 
 epigastric region, a sense of splashing on their passage into 
 fluid is frequently apparent. 
 
 As distended stomach often depends on obstruction at the 
 pylorus, palpation should be employed to find if any undue 
 hardness, resistance, or tumor exists in that region. The 
 pyloric orifice in such cases does not always maintain its 
 normal position ; it may be displaced to a great extent, but 
 will generally be found somewhat to the right of the mesial 
 line, and in the upper part of the abdomen. If cancerous 
 disease of the pylorus exists, pain on palpation is usually com- 
 plained of.. The stricture may depend, however, on fibrous 
 thickening or on cicatricial contraction resulting from old 
 ulceration. Distention of the stomach may also be due to 
 atony of the muscular coat. 
 
 The normal tympanitic note over the stomach may be re- 
 placed by dulness, quite absolute to superficial percussion. 
 
EXAMINATION OF INTESTINES. 633 
 
 but on a stronger stroke being employed a trace of the tympa- 
 nitic quality may still be found. Associated ^vith this there 
 is frequently distinct resistance and hardness on palpation, the 
 pressure at the same time causing pain. These conditions are 
 chiefly due to tumor of the body of the stomach, usually can- 
 cerous in its nature. Pain on pressure over the stomach, how- 
 ever limited in its area, and unassociated with dull percussion 
 or increased resistance, is often due to simple gastric ulcer. 
 The diagnosis must rest on the symptoms. 
 
 The Intestines 
 
 occupy the greater part of the abdomen. The small intestine 
 lies in the lower and front part of the cavity. The transverse 
 colon crosses the upper part of the umbilical region, and the 
 ascending and descending colon occupy the posterior parts of 
 the lumbar regions. The " caput caecum coli " lies in the 
 right, and the sigmoid flexure in the left, iliac regions, but the 
 latter is usually overlapped to some extent by the small intes- 
 tine. Over the intestine the note is tympanitic, but it varies 
 in its quality according to the size and state of distention of 
 the part. Normally the colon yields the deeper and fuller 
 note. Areas of local dulness may present themselves at any 
 part, depending on accumulation of feces or other substances 
 in the intestines, tumors of the intestine, or of the glands, or of 
 some of the other viscera in the abdomen ; or the whole area 
 of intestinal percussion may become more or less dull owing to 
 morbid deposits in the peritoneum or omentum (tubercular or 
 cancerous peritonitis), large tumors in the solid organs, efi^u- 
 sion of fluid into the peritoneum, etc. On the other hand the 
 intestines may become much inflated with gas, rendering the 
 abdomen large, prominent, and to percussion very tympanitic, 
 constituting what is known as " tympanites." This condition 
 arises in many instances from obstruction in some part of the 
 canal (intussusceptio, hernia, constriction from bands of lymph, 
 twists in the gut, inflammation in its walls, accumulation of 
 feces or foreign bodies, cicatrization of ulcers, strictures simple 
 or cancerous, etc.). In many cases, however, tympanites is 
 quite independent of obstruction, being found in acute peri- 
 tonitis, in hysterical patients, in cases of dyspepsia where the 
 digestive powers are feeble, in enteric fever, and in spinal 
 lesions where there is atony of the muscular fibre of the tube. 
 In certain very rare cases the tympanites may arise from the 
 accumulation of gas in the peritoneal cavity. 
 
684 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 In tympanites the abdomen is well projected in front, spher- 
 ical, everywhere unduly resonant (unless the distention is very 
 extreme, when it may become somewhat dull); the coils of 
 intestine may sometimes be defined through the abdominal 
 walls, and peristaltic action observed in them, if the walls of 
 the abdomen are very thin, or if, from mechanical obstruction, 
 there is hypertrophy of the muscular coat of the intestines. 
 If the distention depends on obstruction the degree and distri- 
 bution of the tympanites may to a certain extent guide the 
 observer to the seat of lesion. If it is low down (in the rec- 
 tum or sigmoid flexure) the distention will be found to occupy 
 not only the anterior parts of the abdomen but also the flanks, 
 the inflated colon bulging the lumbar regions. But the ob- 
 struction may exist at the ileo-c?ecal valve, and in such cases 
 the swelling will occupy chiefly the umbilical region and lower 
 parts of the abdomen, there being no great distention in the 
 lateral regions, and notably no bulging in the flanks. 
 
 Ascites 
 
 is often present in diseased conditions of the abdominal organs, 
 more especially of the liver ; but as this subject has been 
 already discussed elsewhere, the student is referred for the 
 details of the physical signs to Chapter XII., p. 435. 
 
 Ovarian Tumors and Cj/sts. 
 
 Cystic disease of the ovaries is very apt to be confounded 
 with ascites, especially if the cyst is unilocular, or has one or 
 two compartments developed out of all proportion to the others. 
 In most cases the history is an important guide. The growth 
 may have been first discovered as a small painless tumor in 
 one or other iliac region, having gradually extended across 
 the abdomen. The abdomen is well projected in front, and 
 not bulged in the flanks as in ascites, and the umbilicus is 
 rarely protruded. The percussion-dulness is in the anterior 
 part of the abdomen, as the cyst expands up in front of the 
 intestines and pushes them backward and upward. (Compare 
 Fig. 71.) 
 
 Tympanitic percussion is thus got in the flanks, and altera- 
 tions in the position of the patient do not change materially 
 the relations of the dull and tvmpanitic areas. This is evidence 
 that the fluid is not free. Fluctuation is common in ovarian 
 cysts,' but it may be vague, palpation giving merely the sense 
 
OVARIAN AND OTHER TUMORS. 635 
 
 of elasticity, and in some cases solid matter can be detected 
 at various joarts of the tumor. On vaginal examination the 
 uterus may be found normal in size, but high up in the pelvis, 
 and perhaps displaced forward. In some cases the finger in 
 the rectum can determine the relation of the tumor to the 
 ovary, or its immediate vicinity ; and examination with the 
 uterine sound fails to show any direct connection with the 
 womb. (Compare Chapter XII. and Chapter XV., pp. 437, 
 527.) 
 
 In many instances, however, ovarian cysts are accompanied 
 by fluid effusion into the peritoneum, the result usually of 
 the tumor or of rupture of the cyst ; and the diagnosis may 
 only be made clear by tapping, and examining the abdomen 
 in its lax state ; the character of the fluid removed may also 
 guide us (p. 443). 
 
 Other Abdominal Tumors. 
 
 An ovarian cyst may be simulated by solid tumors of the 
 ovaries or uterus, and even the gravid uterus has been mis- 
 taken for it. A careful examination by auscultation and 
 other^Yise will usually determine the diagnosis of pregnancy. 
 (See p. 521.) Solid uterine tumors may be distinguished by 
 their density, by their relations to the uterus, especially when 
 examined by the uterine sound, by the elongation of its cavity, 
 and an increase in its size and weight. There may be a feel- 
 ing of movement or contraction on palpation, and a soft 
 blowing sound may sometimes be heard on auscultation, syn- 
 chronous Avith the patient's pulse. The tendency to metror- 
 rhagia is likewise of great value in the diagnosis. (See pp. 
 513, 514, 523, 526, 527.J 
 
 A distended bladder might also be a source of confusion, but 
 its growing out of the pelvis, fairly in the middle line, and 
 being pyriform in shape, somewhat elastic, dull to percussion, 
 and often tender on pressure, would probably raise such 
 doubts as to lead to the introduction of a long flexible cathe- 
 ter, when the tumor will disappear. 
 
 Hydatid disease of the liver may enlarge so greatly as to fill 
 the whole abdomen, but the history of growth from the right 
 hypochondrium will often be quite clear, and the hydatid 
 fremitus may be present. Hydatid disease of the peritoneum 
 or omentum may present greater difficulty, and the diagnosis 
 from ascites or ovarian cyst may only be arrived at by tap- 
 ping and examination of the fluid; the presence of hydatids 
 
636 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 or hooklets determines the point at once. Even in the absence 
 of these the characters of the fluid may give quite sufficient 
 ground for the diagnosis. (See p. 443.) 
 
 Phantom tumor may present difficuhies in diagnosis. It 
 occurs almost exclusively in women, especially in those with 
 hysterical tendencies, and it may simulate almost any form of 
 abdominal enlargement ; but the fact of its liability to vary 
 in size and shape, the tension of the abdominal walls, and its 
 disappearance under the influence of chloroform, will clear up 
 the diagnosis. 
 
 Aneurism of the abdojuinal aorta is most common in the 
 epigastric and umbilical regions, and may be recognized as a 
 tumor placed in the length of the artery, lying in close appo- 
 sition to the spine, but rather to the left side, and giving to 
 the hand the sensation of expansile pulsation, in many cases 
 associated with thrill. On auscultation a murmur may be 
 heard coinciding with the expansion of the artery ; in rare 
 cases it may be double. Aneurism of any of the branches of 
 the abdominal aorta may exist, especially in the coeliac axis or 
 superior mesenteric artery. Pulsation of the abdominal aorta 
 attended by murmur may be present without aneurismal con- 
 ditions (see p. 341), but in such cases there is no impression 
 of a distinct pulsating tumor, or of a murmur limited to the 
 tumor as distinguished from one corresponding with the track 
 of the aorta. Aneurisms may be simulated by tumors lying 
 over the aorta, and having an imj)ulse communicated to them. 
 The diagnosis rests chiefly on the non-expansile character of 
 the pulsation, but in many cases it is uncertain. Pain is often 
 a marked feature in abdominal aneurism. It is usually felt 
 in the back, is constant in character, as a rule, but subject to 
 violent exacerbations, with extension of it down the limbs 
 from implication of the sacral and lumbar plexuses. Obscure 
 pain of this character, apart even from physical signs, should 
 always raise the question of aneurism. 
 
 Localities of Tumors. 
 
 Leaving out of consideration the general enlargements of 
 the abdomen due to ascites and tympanites, it may be well to 
 indicate briefly a few facts with regard to local enlargements 
 or tumors. A tumor being discovered in the abdomen, the 
 whole physical inquiry hinges on the question, What organ 
 or structure is it connected with? In such an inquiry it is of 
 prime importance to consider the regional divisions of the 
 
SITUATION OF ABDOMINAL TUMORS. 637 
 
 abdomen mentioned in the early part of this section, and the 
 organs contained in them. If the tumor is confined entirely 
 or chiefly to one of these regions, then the various organs 
 must be gone over in detail to see from which it springs. In 
 serious diseases, however, the abdominal organs may be greatly 
 displaced from their ordinary position. It will suffice for our 
 purpose to indicate what tumors are most frequent in the 
 varicose regions. 
 
 In the epigastric region the tumors most frequently met with 
 are cancerous growths in the pylorus or body of the stomach, 
 enlargements of the left lobe of the liver, tumors of the pan- 
 creas, and aneurisms of the aorta. It is to be remembered 
 that the left lobe of the liver may present itself as a tumor 
 without there being any enlargement of it, conditions in the 
 thoracic viscera having depressed the organ. The same re- 
 mark applies to the liver in the right hypochondrium and to 
 the spleen in the left. 
 
 The tumors met with in the umbilical region are aneurisms 
 of the aorta, or some of its branches, omental tumors, fecal 
 accumulations in the transverse colon, floating kidney, and at 
 times cancer of the intestine and enlarged mesenteric glands. 
 Fecal accumulations may occur even with a history of diar- 
 rhoea : through the abdominal wall they can be moulded to 
 some extent by steady pressure with the fingers, and may even 
 be displaced a little along the bowel. 
 
 Tumors originating in the hypogastric region are distended 
 bladder, the gravid uterus, tumors of the w^omb and its appen- 
 dages, and inflammatory swellings in the pelvis. 
 
 Those originating in the right hypochondrium are chiefly 
 from the right lobe of the liver or gall-bladder. 
 
 In the left hypochondrium, the spleen is the organ chiefly 
 aflfected, although fecal accumulations in the splenic flexure 
 of the colon may occur. 
 
 In the lumbar regions, tumors of the kidneys, perinephritic 
 abscess, lumbar abscess, and fecal accumulations are most 
 frequent. 
 
 In the iliac regions, ovarian cyst, pelvic abscess, disease of 
 the caecum or sigmoid flexure, enlarged glands, pelvic cellu- 
 litis or hematocele are found ; tumors connected with bones 
 may also appear in this situation. 
 
 It is rare, however, for tumors to occupy only the region 
 from which they spring. They often involve several regions ; 
 and it is only by a careful consideration of the history and 
 symptoms, along with the physical signs, that a diagnosis can 
 
 54 
 
638 PHYSICAL EXAMINATION OF ABDOMEN. 
 
 be arrived at. In not a few instances several organs may be 
 affected, and this renders the examination all the more perplex- 
 ing. In many cases the most critical exploration may fail to 
 resolve the doubts. 
 
 Percussion was emplo3'ed more or less in abdominal cases from early 
 times, but its first application to the chest was by Auenbrugger, In- 
 ventum novum ex percussione thoracis humani ut signo abstrusos 
 interni pectoris morbos detegendi, Vindobonae, 1761. Little atten- 
 tion was given to the method till Corvisart published his translation 
 of this work (1808), and Piorry took up the subject in a series of pub- 
 lications (De la percussion mediate, Paris, 1828) ; his latest and most 
 important is Traite de plessimetrisme et d'organographisme, Paris, 
 1866. 
 
 Auscultation as applied to the diagnosis of diseases of the heart and 
 lungs was unfolded in a great work by Laennec, Traite de I'ausculta- 
 tion mediate, Paris, 1819 ; a translation by Sir John Forbes was pub- 
 lished, od edition, London, 1829. 
 
 Another work on these subjects of historical importance Avas first 
 published in Vienna, 1839, viz., Skoda, Treatise on Auscultation and 
 Percussion; translated by W. O. Markham, London, 1853. 
 
 Physical Diagnosis. — The following also deserve special attention : 
 Gee, Auscultation and Percussion, 3d edition, London, 1883. — Gutt- 
 mann. Hand-book of Physical Diagnosis, translated by Dr. Alex. 
 Napier for New Sydenham Societ}^, London, 1879. — Flint (Austin), 
 Manual of Percussion and Auscultation, 3d edition, Philadelphia, 
 1883. — Loomis, Lessons in Physical Diagnosis, 3d edition. New York, 
 1872. — Weil, Handbuch und Atlas der topographischen Percussion, 
 2e Aufl., Leipzig, 1880. — Gerhardt, Lehrbuch der Auscultation und 
 Percussion, 3e Aufl., Tubingen, 1876. — Niemeyer (Paul). Grundriss 
 der Percussion und Auscultation, 2e Aufl., Erlangen, 1873. — Woillez, 
 Traite theorique et pratique de percussion et d'auscultation, Paris, 
 1879 — Eichhorst, Lehrbuch der physikalischen Untersuchungs- 
 methodeti innerer Krankheiten, Braunschweig, 1881. More general 
 works on Diagnosis also deal with this subject — e. g., Da Costa, Medi- 
 cal Diagnosis, 6th edition, Philadelphia, 1884 — Graham Brown, 
 ]\Iedical Diagnosis, 2d edition, Edinburgh, 1883. — In addition to 
 these, all works on the practice of medicine will be found to give in- 
 formation as to special diseases. 
 
 Lungs, in addition to the above. — Walshe, Practical Treatise on 
 Diseases of the Lungs, 4th edition, London, 1871. — Stokes (William), 
 Treatise on the Diagnosis and Treatment of Diseases of the Chest, 
 Part I., Diseases of the Lung and Windpipe, reissued by New Syden- 
 ham Society, London, 1882. — Waters, On Diseases of the Chest, 2d 
 edition, London, 1873. — Powell (R. Douglas), On Diseases of the 
 Lungs and Pleura, including Consumption, 3d edition, London, 1886. 
 
 Heart. — Walshe, Practical Treatise on the Diseases of the Heart 
 and Great Vessels, 4ih edition, London, 1873. — Balfour (Geo.), 
 Clinical Lectures on Diseases of the Heart and Aorta, 2d edition, 
 London, 1882. — Bramwell (Byrom), Diseases of the Heart and Tho- 
 racic Aorta, Edinburgh, 1884. — Hayden, Diseases of the Heart and 
 Aorta, Dublin, 1875: this elaborate book may be consulted for special 
 
WOKKS ON PHYSICAL DIAGNOSIS. 639 
 
 details. — Samsom, Lectures on the Physical Diagnosis of Diseases of 
 the Heart, London, 1876 : this book contains in small compass all 
 that is most important. — Yon Dusch, Lehrbuch der Herzkrankheiten, 
 Leipzig, 1868. — Friedreich, Krankheiten des Herzens, 2e Aufl., 
 Erlangen, 1867. — Peter, Traite clinique et pratique des maladies du 
 cceur, Paris, 1883. — The works of Hope, Stokes, and Latham, have a 
 permanent importance in the history of this subject, although in a 
 sense superseded. — The papers of Dr. Gairdner, which have been 
 freely used in this chapter, will be found in his Clinical Medicine, 
 Edinburgh, 1862, and the Glasgow Medical Journal for 1867. 
 
 Sjphygmogrojih and Caj^dio graph. — Marey, La circulation du sang, 
 Paris, 1881 : and his earlier work, Physiologic medicale de la circula- 
 tion du sang, Paris, 1881. — Lorain, Le Pouls, Paris, 1877. — Ozanam, 
 La circulation etle pouls, Paris, 1886. — Undgeon,The Sphygmograph, 
 London, 1882, — Bramwell (Byrora), The Students' Guide to the Ex- 
 amination of the Pulse and the Use of the Sphygmograph, 2d edition, 
 Edinburgh, 1883 — Mahomed, Medical Times and Gazette, 1872. — 
 Galabin, Medico-Chirurgical Transactions, vol. Iviii., London, 1875: 
 and Guy's Hospital Keports for 1875. — Works on Physiology may 
 also be consulted with advantage, especially those of Dr. Michael 
 Poster, 4th edition, London, 1883; and of Landois, translated by Dr. 
 Stirling, London, 1885. 
 
 Abdomen. — Biblioo;raphical references are given at the end of 
 Chapter XI, on "Disorders of the Digestive System;" of Chapter 
 XII. on "Jaundice and Dropsy;" of Chapter XIII, on the " Urine 
 and Urinary Symptoms ;" and of Chapter XY. on " Disorders of the 
 Female Organs." These will be found to comprise most of the sub- 
 jects dealt wnth in this section. Of course, the works enumerated 
 above on physical diagnosis should also be consulted. 
 
INDEX. 
 
 A.C.C. (electrical symbol), 288 
 A.O.C. (electrical symbol), 288 
 A. or An = Anode, 289 
 A.S. = Auricular-systolic, 576 
 Abdomen, disease of organs there 
 predisposing to melancholic in- 
 sanity, 321 ; distention with 
 wind, 408 ; pains and tenderness, 
 410; tumor from pregnancy, 
 623 ; dropsy of, 435 ; percussion- 
 dulness in ascites (Fig. 70), 436 ; 
 dulness in ovarian dropsy (Fig. 
 71), 438; cystic accumulations 
 in, 438; colloid material in ab- 
 domen, 439 ; examination of, 
 for tumors after tapping, 443 ; 
 physical examination of (chapter 
 
 xvi.), 613; works of reference Acne, 116, 118, 124; rosacea, 116, 
 
 on examination of abdomen, 
 639; regions (Fig. 154), 613; 
 contents of regions, 613 ; viscera 
 in situ (Fig. 155), 614; inspec- 
 tion, 615; distention and retrac- 
 tion, 615; pigmentation, 615 
 Avhite lines, 615; dropsy, 616 
 movement with respiration, 516 
 pulsation visible, 616 ; palpa 
 tion, 617; percussion, 618 
 mensuration, 618 ; auscultation 
 619; auscultatory percussion 
 619 ; abdominal organs (Fig 
 156), 620; liver, 621 ; spleen 
 626 ; kidnej^s, 629 ; pancreas 
 631; stomach, 631; intestines 
 633 ; tympanites, 633 ; ascites 
 634; ovarian tumors, 634; vari- 
 ous tumors, 635 ; localities of 
 tumors, 636 ; aneurism of aorta, 
 637 
 
 Abdominal reflex, 218 
 
 Abducens oculi, 203 
 
 Abortions, in case-taking, 63, 65, 
 122 
 
 Abscess, of brain, due to ear dis- 
 ease, 189 ; causing paralysis, 
 234; pelvic, 534; abscess, of 
 lung, liver, etc., see Lung, 
 Liver, etc. 
 
 Acarus scabiei (Fig. 23), 120 
 
 Accommodation of eye, range of, 
 179 ; defects with age, 174 ; 
 nervous lesions, diphtheria, 174; 
 strain on, 175; paralyzed, 174; 
 asthenopia, 175 
 
 Achorion Schonleinii (Figs. 25, 26, 
 27), 125, et seq. 
 
 Achromatopsia, 181 
 
 Acid fermentation of urine, 451 
 
 Acidity, in stomach, 407; of urine, 
 451 
 
 118 
 
 Acute decubitus, 214 
 
 Addison's disease, 26, 142 
 
 Adolescence, diseases of, 15 
 
 ^gophony, 557 
 
 ^sthesiorneter (Fig. 33), 197 
 
 Ageing, 15, 31 
 
 Ageustia or ageusia, 193 
 
 Agoraphobia, 310 
 
 Ague, diagrams of temperature in 
 (quotidian), 83, (tertian) 84; as 
 cause of neuralgia, 237 ; splenic 
 tumor in, 629 
 
 Air-bubbles in urine (Fig. 87, d)^ 
 489 
 
 Albinism, 118, 142 
 
 Albumen, see Albuminuria, Par- 
 albumen, JNIetalbumen, Pep- 
 tones, Hemi-albumose 
 
 Albuminuria, convulsions due to, 
 243 ; absence of, occasionally in 
 renal dropsy, 433 ; tests for al- 
 bumen, 460; heat test, 460; 
 nitric acid test, 461 ; picric acid 
 test, 464 ; ferrocyanide of potas- 
 
 54* 
 
642 
 
 INDEX. 
 
 sium test, 465 ; mercuric iodide 
 test, 465; brine test, 466 ; esti- 
 mation of quantity of albumen, 
 466; modified forms of albumen, 
 467; significance of albumi- 
 nuria, 468; due to pus, blood, 
 etc., 468, 470; in acute febrile 
 disease, 468; after scarlatina, 
 468; in pregnancy and puer- 
 peral state, 469 ; in chronic chest 
 disease, 469 ; in dropsies, 469 ; 
 in renal disease, 469 ; in nervous 
 diseases, 469 ; in chronic consti- 
 tutional diseases, 470; after 
 blisters, 470; presence and ab- 
 sence of tube- casts, 480 
 
 Alcohol, inquiry as to use of, in 
 case-taking, 65 ; diplopia in al- 
 coholic intoxication, 169 ; influ- 
 ence on pupil, 172; central 
 amblyopia from, 180 ; paralj^sis 
 from, 219, 235, knee-jerk in 
 paralysis, 235, resemblance of, to 
 lead palsy, 235, mental disorders 
 in alcoholic paralysis, 235 ; a 
 cause of neuralgia, 237 ; of con- 
 vulsions, 243 ; of vertigo, 257 ; 
 cause of insanity, 801 ; alcoholic 
 insanity, various forms, 317 ; 
 diagnosis of alcoholic from gen- 
 eral paralysis, 324 
 
 Algide stage of cholera, 27 
 
 Alkalinity of urine, 451 ; from 
 decomposition, 451 ; from medi- 
 cines, 452; volatile and fixed 
 alkali in urine, 451 
 
 Alopecia, 118, 126 
 
 Alphos, 116 
 
 Alternate squint, 161 ; alternate 
 paralysis, 208 
 
 Amaurosis, see Blindness, 179 
 
 Amblyopia, 179 
 
 Amenorrhoea and insanity, 315; 
 primitive, 584; secondary, 613 
 
 Ammonia in breath, test for, 252 
 
 Ampere, 274 
 
 Amphoric, breathing, 553; phe- 
 nomena, 556 ; echo, 556 
 
 Anacrotic pulse, 595 
 
 Anaemia, 25; with bronzing, 26 ; 
 venous murmur in, 26; causes 
 of, 26 ; progressive pernicious, 
 27, associated with jaundice, 
 
 429 ; a cause of vertigo, 258 ; of 
 sleepiness, 262 ; of headache, 
 264; of neuralgia, 237; blood 
 in, 26,366; dropsy from, 433; 
 cardiac murmurs from, 586 
 
 Anaesthesia, 119, 201 ; tests of, 196- 
 199; range of, 199; in diph- 
 theria, hysteria, and ataxy, 199 ; 
 hemianaesthesia, 199 ; with 
 trophic changes, 200 ; and neu- 
 ralgia, 200 ; feeling of anaes- 
 thesia, 201 ; and paralysis, 211 ; 
 distribution of, 210; hemianaes- 
 thesia, 210; in regions of special 
 nerves, 210; site of spinal lesion 
 in, 210; absence of, in lead and 
 infantile paralysis, 211 ; aflect- 
 ing writing, 229; electricity in, 
 280 
 
 Analgesia, 195 ; tests for, 196 
 
 Anasarca, 432 
 
 Aneurism, in retina, 183 ; of 
 cerebral vessels in hemiplegia, 
 233; causing laryngeal affec- 
 tion, 205, 343, 351, 392 ; causing 
 pain in the back, 265 ; a cause 
 of hemoptysis, 357-369 ; dul- 
 ness of, and pulsation in chest, 
 568, 588 ; murmurs due to, 585 ; 
 thoracic aneurism, 588; percus- 
 sion signs, 589; auscultation, 
 589 ; signs at back of thorax, 
 590; conditions simulating, 590 ; 
 pulse in, 607 ; of abdominal 
 aorta, 636 
 
 Angina pectoris, 40, 342 ; " angina 
 sine dolore," 344 
 
 Anidrosis, 117 
 
 Ankle clonus, 220; tracing of 
 (Fig. 35), 221; relations to knee- 
 jerk, 221 ; methods of obtaining, 
 220; clinical significance of, 
 222 ; apart from organic disease, 
 222 
 
 Anode, 273 
 
 Anorexia, 396 
 
 Anosmia, 192 
 
 Anteversion and anteflexion of 
 uterus, 529 
 
 Anthrax, 118 ; bacterium in blood, 
 372 
 
 Aorta, aneurism of, tracing of 
 pulse on two sides, 607 ; throb- 
 
INDEX. 
 
 643 
 
 bing of abdominal aorta, 341, 
 566 ; dulness and puliation from 
 thoracic aneurism, 568 ; tremor 
 in aneurism, 654; alteration of 
 heart's sounds in aortic disease, 
 574 ; aortic murmurs, area of, 
 584; murmurs due to aneurisms 
 of, 685; abdominal aneurisms 
 of, 636 
 
 Aortic cartilage, 573, 584 
 
 Aortic stenosis, pulse tracing, 603 
 
 Aortic regurgitation, pulse trac- 
 ing, 604 ; cardiographic tracing, 
 612; capillary pulse in, 605 
 
 Apex-beat of heart, normal, 559, 
 561; obscured, 564; effect of 
 respiration on, 563; exagger- 
 ated, 564 ; displaced, 564 ; dis- 
 tinction from heave of right 
 ventricle, 565 
 
 Aphasia, 226 ; with anosmia, 191 ; 
 varieties of, 227 ; sensory and 
 motor, 228 ; causes of, 228 ; 
 with, and without hemiplegia, 
 228 ; from embolism, 228 
 
 Aphemia, 226 
 
 Aphonia, see Voice, loss of. 
 
 Aphthae, 114; on tongue, 398, 399 
 
 Apjohn's method of urea analysis 
 (Fig. 95), 502 
 
 Apncea, apparent, 344 ; see As- 
 phyxia, and also various sections 
 under Dyspnoea 
 
 Apoplexy, see Sudden paralvsis, 
 251 ; threatenings of, 258, 261, 
 264 
 
 Appetite, impaired, inordinate, 
 perverted, 396 
 
 Arcus senilis, 15, 159 
 
 Area of cardiac murmurs, 575, 581 
 
 Areola, of nipple in pregnancy, 
 522; umbilical, 615 
 
 Aretseus on phthisical physiog- 
 nomy, 29 
 
 "Argyll Kobertson's pupil," 174 
 
 Arm, paralysis of, 293; pain in 
 left, 343 
 
 Arsenic, itching from, 121 ; rash 
 from, 125 
 
 Arterial degeneration, groups of 
 diseases allied to, 68 ; rigidity of 
 arteries, 100 ; tracing of pulse 
 in, 602 
 
 Arterial diastolic murmurs, 586 
 
 Arteries, survey of state of, 100 ; 
 rigidity, twisting, etc., 100; in- 
 creased arterial tension (tracing), 
 597 ; audible pulsation of, 190 
 
 Articulation, see Speech 
 
 Aryteno-epiglottidean folds in 
 larynx, 386, 387 
 
 Ascaris lumbricoides vomited,406; 
 in motions, 414 
 
 Ascites, 435 ; percussion-dulness 
 in (Fig. 70), 436; fluctuation in, 
 437 ; distinction from ovarian 
 dropsy, 438 ; causes of ascites, 
 439 ; peritonitis, 439 ; tabes mes- 
 enterica, 440 ; portal obstruc- 
 tion, cirrhosis, thrombosis, can- 
 cer, etc., 440-442 ; examination 
 of fluids, 443 
 
 Asphyxia, 37 ; see also various sec- 
 tions under Dyspnoea 
 
 Asthenopia, 175 
 
 Asthma, cause of insanity, 319 ; 
 cardiac, 338 ; spasmodic, 347 ; 
 see also various sections on 
 Dyspncea, 333 
 
 Astigmatism, 178, 179; cause of 
 strain on eyes, 175 
 
 Astraphobia, 311 
 
 Asylum treatment in insanity, 
 question of, 330 
 
 Atavism, 72 
 
 Ataxy, locomotor, affections of 
 joints in, 148 ; diplopia in, 169 ; 
 pupil in, 174; ansesthesia in, 
 200; senseof weight, 200 ; walk- 
 ing in, 41, 215, 228, 225; spas- 
 modic discharge of urine in, 
 231 ; influence of sexual excesses 
 in causing ataxy, 234 ; syphilis 
 a cause of, 234 ; distinction from 
 general paralysis, 324 ; gastric 
 crisis in, 403 ; hereditary ataxy, 
 see Friedreich's disease 
 
 Atheroma of cerebral vessels as a 
 cause of hemiplegia, 233 
 
 Athetosis (Hammond's), 215 
 
 Atrophy, of tissues, with hyper- 
 trophy, 21 ; phthisical, 23 ; of 
 skin, 118 ; of optic nerve, 184 ; 
 color-blindness in optic atrophy, 
 181 ; of parts with anaesthesia, 
 199 ; of muscles, 235 
 
644 
 
 INDEX. 
 
 Atropine, rash from, 124; influ- 
 ence on pupil, 169-172 
 
 Attitude in difficult breathing, 38 
 
 Auditory nerve, testing of, 186, 
 189, 205 
 
 Auraepileptica, 240 
 
 Aural speculum, examination, etc., 
 187 
 
 Auricle, visible pulsation of, in 
 chest, 649 
 
 Auricular-systolic murmur, 576 
 (Fig. 108), 578 
 
 Auscultation of the head, 266 ; of 
 pregnant uterus, 524; pulmo 
 nary, 549 ; breath sounds, natu- 
 ral and abnormal, 551 ; rales, 
 654; metallic and amphoric 
 signs, 556 ; vocal resonance, 
 557 ; of heart's sounds, 572, et 
 seq. ; murmurs, 575, et seq. ; of 
 aneurisms, 588; of abdomen, 
 618 
 
 Auscultatory percussion, 619 
 
 Auto-laryngoscopy, Toulis's me- 
 thod, 385; Johnson's, 385 
 
 Automatic actions in hemiplegia, 
 215; in epilepsy, 241, 319 
 
 Autophf\gy, 16 
 
 Autophonic resonance, 639 
 
 Axilla, how temperature taken in, 
 74 ; as compared with vagina in 
 collapse, 94 
 
 Bacillus anthracis, 372 ; bacillus 
 subtilis, 372; bacillus of tuber- 
 cle, and method of detecting, 
 359 
 
 Backache in fever, 104 ; various 
 causes of, 265; see Menstrua- 
 tion, Dysmenorrhoea, etc., and 
 other parts of chapter xv. 
 
 Bacteria in blood, 372; in urine 
 485, (Fig. 84) 486 
 
 Bacterium termo, 486 
 
 Bacteruria, 487 
 
 Balancing of body, unsteadiness 
 in, 215; testing of, 222; rela- 
 tionship of sight to balancing, 
 224 ; relationship to portio mol- 
 lis of 7th ])air, 205 
 
 Baldness, 133 
 
 Balfour (Dr. Geo.), on so-called 
 htemic murmurs, 583 
 
 Ballottement, 524 
 
 Barking cough, 352 
 
 Barlow (Dr.), on "acute rickets," 
 155 
 
 Barr, on hearing tests, 187 
 
 " Barrel-shaped " chest, 541 
 
 Basedow's disease, see Exophthal- 
 mic goitre 
 
 Bateman, Willan and, on skin dis- 
 eases, 110, 113 
 
 Batteries, various forms, 269 ; bat- 
 tery current, 270 
 
 " Beading " of ribs, 155, 540 
 
 " Bearing-down" pains, 518 
 
 Bedsores in paralysis, 2l3 ; sec- 
 ondary febrile disturbance from, 
 214 
 
 Belladonna, rash, 124; influence 
 on pupil, 170, 171 ; delirium 
 from, 256; thirst from, 397 
 
 Bell's paralysis, see Facial nerve, 
 203 
 
 Bell-sound in auscultation, 637 
 
 Bichromate cell, 275 
 
 Bigeminous pulse, 600 
 
 Bile, vomited, 405; in motions, 
 413,426; inspissated, see Gall- 
 stones; bile in urine, 497; bile- 
 pigment, 498 ; biliary acids, 498; 
 
 Bimanual method of pelvic exami- 
 nations, 526 
 
 Bismuth, cause of bad smell in 
 breath, 192, 400; test for sugar, 
 459 
 
 Bizzozero's corpuscles, 372 
 
 Black spit, 354 ; black vomit, 405 ; 
 black stools, 413 
 
 Bladder, paralysis of, 229 ; reflex 
 paralysis from disease of, 232 ; 
 backache from disease of, 265 ; 
 distention of, simulating ascites, 
 etc., 438; epithelium from, 484; 
 distention of, causing tumor, 
 725 
 
 Blebs, 111 
 
 Bleeding, from nose, etc., with 
 whooping cough, 350; from 
 various parts, see section on 
 Hajmorrhages, 363 
 
 Blepharospasm, 176 
 
 Blindness, 179 
 
 Blisters on skin, 111 ; cause of 
 albuminuria, 470 
 
INDEX. 
 
 645 
 
 Blood, in an?emia, 26; in cholera, 
 28; in leukaemia, 146; in gout, 
 test for uric acid, 152 ; blood 
 crystals, 360, 363 ; blood in spit, 
 356-359 ; vomiting of, from 
 lungs, 357 ; various forms of, 
 358, 359 ; blood in pleuritic ex- 
 udation, 362 ; losses of, 363 ; ex- 
 amination of blood, 365; buffy 
 coat of blood, 3G5 ; richness of, 
 in h8emoo:lobin, method of esti- 
 mating, 366 ; diversities in rela- 
 tive richness in hsemoglobin and 
 corpuscles, 366 ; method of 
 counting corpuscles, 367 ; in 
 leukaemia and anaemia, method 
 of examination by microscope, 
 369; relative estimation of white 
 corpuscles, 369 ; counting abso- 
 lute number, 370 ; method of 
 measuring size of corpuscles, 
 370 ; white corpuscles, variation 
 in size, 370 (Fig. 53), 371 ; frag- 
 ments of protoplasm in blood, 
 372; small colored cells in blood 
 and increased size of red cor- 
 puscles in anaemia, 371 ; per- 
 nicious anaemia, 372; living 
 organisms in blood, 372 ; bacil- 
 lus anthracis, spirilla of relap- 
 sing fever, filaria sanguinis, 
 372 ; vomiting of, from stomach, 
 405 ; from bowels, 413 ; passed 
 in urine, 470; blood corpuscles 
 in urine (Fig. 74), 471 ; guaiac 
 test for blood in urine, 472 ; spec- 
 troscopic bands (Fig. 74"), 472; 
 blood in urine without albu- 
 men, 473; blood-casts (renal), 
 481 ; resemblance of spores to 
 blood corpuscles, 487 ; works of 
 reference on, 373. See also 
 Hemorrhages 
 
 Blueness of face in dyspnoea, 343 
 
 Bodv-weight, 16 ; see Weight 
 
 Boil, 118 
 
 Bones, affections of, 153 ; in syphi 
 lis, 154; enlargement extremi- 
 ties of, 148, 155 ; distortion of 
 long bones, 156 ; works of refer- 
 ence on diseases of, 157 
 
 Bothriocephalus latus, 415 
 
 Boulimia, 397 
 
 Bowels, paralysis of, 229 ; obstruc- 
 tion of, simulated by paralysis, 
 232; disorder of, and vomiting, 
 403 ; flatulence, 407 ; state of 
 bowels, and pain in bowels, 409- 
 412 ; motions from, 418 ; signifi- 
 cance of constipation and diar- 
 rhoea, 417; physical examina- 
 tion of intestines, 633. See also 
 
 . Tympanites, Ascites, etc. 
 
 Brain, affected from ear, 189; signs 
 of disease from ophthalmoscope, 
 185 ; headache from diseases of, 
 265 ; abscess and tumor of, caus- 
 ing paralysis, 233 ; affections 
 causing sighing respiration, 344 ; 
 See also Cranial jSTerves, Hemi- 
 plegia, Convulsions, Aphasia, 
 Coma, etc. 
 
 Breast-pang, see Angina Pectoris 
 
 Breasts, see Mammae 
 
 Breath, coldness of, 28; foulness 
 of, 400 
 
 Breath-sounds, see Eespiratory 
 Murmur 
 
 Breathing, physiognomy of vari- 
 ous kinds of, 38 ; labor in, 336 ; 
 altered rhythm of, 344 ; sighing 
 or suspirious, 344; See chapter 
 ix. passhn 
 
 Bright's disease, arterial tension 
 (tracing), 597; lesions of retina 
 in, 184; a cause of headache, 
 264; thirst in, 397 ; convulsions 
 in, 243; albuminuria in, 469 
 
 Brine test for albumen, 466 
 
 Broad ligament, inflammation of, 
 534 
 
 Bromide of potassium, rash from, 
 124 
 
 Bromidrosis, 117 
 
 Bronchi, fibrinous cast of (Fig. 
 49), 356; foreign bodies in, 
 causing cough and simulating 
 phthisis, 352 ; dilatation of, from 
 same cause, 352 
 
 Bronchial breathing, 551, 553 
 
 Bronchial phthisis, 351 ; bronchial 
 glands affected, 351 
 
 Bronchiectasis, 355; elastic fibres 
 in sputum of, 361 
 
 Bronchitis, catarrh in fevers, 106; 
 lividity in, 343 
 
64.6 
 
 INDEX. 
 
 Bronchophony, 639 
 
 Bronzed skin, 26, 141 
 
 Bruit de diable, 26, 588 
 
 Bruit de pot fele, 548 ; (for cardiac, 
 
 arterial, and venous bruits, see 
 
 Murmurs) 
 " Bruit scodique," 647 
 Bubblinfjj rales, 554 
 Buccinator, paralysis of, 202, 204 
 Bulbar paralysis, progressive, 41, 
 
 205; loss of voice in, 205, 391 
 Bulimia, see Boulimia, 397 
 BulliB, 111, 114 
 Bunsen's battery, 273, 275 
 
 Cc. and ccm. = cubic centimetre 
 
 Cmm. = cubic millimetre 
 
 C. C/C/^ (electric symbols), 289 
 
 Cachexia, 29; cachexia and pyr- 
 exiae, 30; scrofulous or strumous, 
 30; gouty, 31; cancerous, 31; 
 dropsical, 32; rheumatic, 32; 
 rickety, 32; syphilitic, 33 
 
 Caerulean disease, 344 
 
 Calabar-bean, influence on pupil, 
 170, 172. 
 
 Calcareous masses in spit, 356 
 
 Calculi, biliary, see G-all-stones ; 
 urinary calculi, analysis of, 566 
 
 Caligraphy, see Writing 
 
 Callositas, 118 
 
 Cancer, cachexia in, 31; increase 
 of white corpuscles in blood, 369; 
 "cancer cells" in sputum, 360 ; 
 in pleuritic effusions, 365 ; in 
 vomited matter, 406; of liver, 
 cause of jaundice, 427; of dropsy, 
 441 ; cancer of womb, 531 (see 
 Carcinoma) 
 
 Canites, 118 
 
 " Cantering " action of heart, 574 
 
 Cantharides, a cause of bloody 
 urine and strangury, 474 
 
 Capillary pulse, 604 
 
 Carbolic acid, effect on urine, 
 453 
 
 Carbonate of lime in urine, 494 
 
 Carcinoma, 118; of cervix uteri, 
 531 
 
 " Cardiac suffering," physiognomy 
 of, 40; cardiac dyspnoea, 338, 
 339 ; cardiac asthma, 338 (see 
 Heart) 
 
 Cardiograph, 608; works of refer- 
 ence on, 639; Marey's (Figs. 
 146, 147), 608, 609; Galabin's, 
 609; Pond's sphygmograph, 610; 
 normal cardiogram after Marey 
 (Fig. 148), and after Galabin 
 (Fig. 149), 610 ; tracings of auri- 
 cular and ventricular contrac- 
 tion, and comparison with pulse 
 and respiration (Figs. 150, 151), 
 611 
 
 Cardiogram in mitral stenosis (Fig. 
 152) and aortic regurgitation 
 (Fig. 153), 612 
 
 Cardiograms (Tracings, 140-153), 
 606-612 
 
 Caries, 154; of teeth, 422 
 
 Carphologia, 36 
 
 Carpopedal spasm, 248; oedema of 
 hands and feet, with, 248, 435 
 
 Cartilages, laryngeal, inflamma- 
 tion of, 389 
 
 Caseine, precipitation of, from 
 urine by acetic acid, 463 
 
 Case-taking, 52 
 
 Casts, of larynx, trachea, bronchi, 
 and minute tubules, 360; ex- 
 pectorated, 355; of gastric folli- 
 cles, 407 ; of renal tubes, see 
 Tube-casts 
 
 Catalepsy, 247, 251 
 
 Catamenia, see Menstruation 
 
 Cataract, 176 
 
 Catarrh, bronchial, in fevers, 106, 
 351; post-nasal, causing cough, 
 351; of fauces, 876; of larynx, 
 387; catarrhal jaundice, 426 
 
 Catheter, shiverings from passing, 
 35 
 
 Cathode, 273 
 
 Cauliflower excrescence from ute- 
 rus, 531 
 
 Causalgia, 200 
 
 Cavernous, respiration, 553 ; phe- 
 nomena, 556 ; rale, 555 
 
 Cellulitis, pelvic, 533 
 
 Cerebellar disease, staggering in, 
 41, 223 
 
 Cerebral nerves (see Nerves, 159); 
 respiration, 345 
 
 Cerebro-spinal sclerosis, see Scler- 
 osis 
 
 Cervix, see Uterus 
 
INDEX. 
 
 647 
 
 Chalk-stones in gout. 31, 152 
 
 " Change of life,'' 516 ; oedema at, 
 
 433; msanily at, 315 
 Charbon, bacterium in blood, 372 
 Charcot, on hysteroepilepsy, 247 
 Charcot's crystals, 361 
 Cheek, paralysis of, 204 ; lividity 
 of, 343; induration from con- 
 gestion, 344 
 Cheesv masses in spit, 356 
 Cheloid, 113 
 
 Chest, physiognomy of diseases of, 
 37 ; pain in, 333, 341 ; examina- 
 tion of fluids removed by tap- 
 ping, 362 ; unilateral changes in 
 shape, 542 ; movements of 542 ; 
 palpation, 543; mensuration, 
 544; percussion, 546; ausculta- 
 . tion, (see Lungs, Heart); chest- 
 rule, 545 ; physical examination 
 of (chapter xvi.), 537 ; regions 
 of, 537 ; parasternal line, 560 ; 
 works of reference on, 638; in- 
 spection, 537; shape, 538; table 
 of circumferences and diameters, 
 539; tracings of healthy, "pigeon- 
 breast," rickety, emphysema- 
 tous, and distorted chests (Figs. 
 96-100), 538-541 
 Cheyne-Stokes respiration, 39, 345; 
 tracings of (Fig. 48), 346; sig- 
 nificance of, 345, 345 ; size of 
 pupil in, 173, 345 
 Chicken-pox, 114, 134 ; see Yari- 
 
 cella 
 Child-crowing, 351 
 Childhood, physiognomy of, 43 ; 
 disease in, 44; history of illnesses 
 in, 61 
 Chilliness, in fever, 104, 201 
 Chloasma, 118; chloasma uteri- 
 num, 142 
 Chloral rash, 124; influence of, 
 
 on pupils, 172 
 Chloride of silver cell, 275 
 Chlorides, in urine, 499 ; in fluid 
 
 from hydatid cysts, 443 
 Chloroform, influence on pupils, 
 172; ankle clonus in narcosis 
 from, 222 
 Chlorosis, 26 ; relation of hajmo- 
 globin and corpuscles of blood 
 in, 366 
 
 Choking, in general paralysis, 322; 
 
 sound of, in dyspnoea, 343 
 Cholera, collapse in, 27 ; blood in, 
 28; lividity in, 344; cholera 
 infantum, 419 
 Cholesterine in spit, 361 ; in pleu- 
 ritic effusions, 363 ; obtained 
 from gall-stones, 428; in ovarian 
 fluids (Fig. 73), 445; in urine, 
 494 
 Chorda tympani nerve, 194, 203 
 Chorea and paralysis, 214 ; hemi- 
 chorea, 214, 254: post-hemiple- 
 gic, 215 ; and aphasia, 229 ; 
 wetting the bed in, 231 ; choreic 
 twitching, 253 ; features of, 253; 
 local chorea, 255 
 Chromidrosis, 117 
 Chromopsia, 176 
 Chyluria, filaria in blood, 372 ; 
 
 coagulum in urine, 455 
 Ciliary muscle, see Accommoda- 
 tion 
 Circular insanity, 309 
 Circulatory system, in case-taking, 
 58 ; chapter ix. on disorders of, 
 333 ; works of reference on, 373; 
 see also pulse (chapter iii.) 
 Heart, Sphygmograph and Cardi- 
 ograph (chapter xvi.) 
 Circumvallate papillae, enlarged, 
 
 399 
 Cirrhosis, see Liver, Lung 
 Claustrophobia, 311 
 Clavus, 118 
 
 Clayey motions, 413, 426 
 Clergyman's sore throat, 316 
 Clicking rale, 554 
 Climacteric period, insanity at, 
 
 315 ; section on, 516 
 Climbing, cause of dyspnoea, 339 
 Clonic convulsions, 241 
 Coagulation of fluids removed by 
 
 tapping, 362, 443 
 Cocaine, use of, in laryngoscopy, 
 
 385 
 Coccyx, position of, 528 
 Coffee-grounds vomiting, 405 
 Cogged- wheel respiration, 552 
 Cohn, on " spirochtete Oberme- 
 
 ieri," 372 
 Coil, importance of, in batteries, 
 271 
 
648 
 
 INDEX. 
 
 Coldness, in collapse, 27 ; feelins^ 
 of, 104, 201 ; of limbs, 201; of 
 tongue, 400 
 
 Colic, 411; biliary, 428 
 
 Collapse, of cholera, 28 ; in peri- 
 tonitis and perforation of bowel, 
 27, collapse temperature, 27, ei 
 seq. 
 
 Collector in galvanic battery, 273 
 (Fig. 38), 270 
 
 Color, spectra with, 176 ; color- 
 blindness, 181 ; field of vision 
 for colors, 222 ; method of test- 
 ing color sense, 182 
 
 Color of urine, Vogel's table, 452 
 
 Coma, in fever's, 35; cojna vigil, 
 36 (see also Unconsciousness) ; 
 causes of coma, 252; complica- 
 tions with paralysis, convulsion, 
 and fever, 252 ; ursemic, 252 
 
 Comedones, 116, 117 
 
 Conjunctiva, yellowness of, 158; 
 suffusion and congestion of, 160, 
 426 ; hemorrhages in, 365 
 
 Communicans noni, 206 
 
 Commutator for reversing cur- 
 rents, 277 
 
 Compasses, test of tactile sense bj', 
 197 
 
 Complications, effect on tempera- 
 ture, 94 
 
 Concomitant squint, 162 
 
 Congenital cup, 183 
 
 Conical cervix, 530 
 
 Conidia, 128 
 
 Consciousness in fever, 36 ; in 
 paralysis, 209; in fits, 242; in 
 hysteria, 245; loss of, in paral- 
 ysis, 251 
 
 Constant current electricity, 270 
 
 Constipation, in fever, 105; as 
 sign of j)aralysis, 229, 332, 418 ; 
 various forms of, 408; signifi- 
 cance of, 418; cause of jaun- 
 dice, 431 
 
 Constriction, of body, feeling of, 
 201; of chest, 342 
 
 "Contact method" of testing 
 urine, 462 
 
 Contagion in cutaneous eruptions, 
 122 
 
 Continuous current (electricity), 
 270 
 
 Contraction of limbs, 213 
 
 Convalescents, temperature of, 94 
 
 Convergence of ej'es, strain on, 175 
 
 Convulsions, in fevers, 106 ; of 
 octilar muscles, 176; conjugate 
 deviation of eyes and head in, 
 177; of muscles of neclt, 205 
 unilateral and hemiplegic, 214 
 nodding convulsions, 216, 250 
 "salaam," 216; unilateral in 
 aphasia, 228 ; section on con- 
 vulsive fits, 240; epileptiform, 
 241; tonic and clonic, 241 ; uni- 
 lateral and local, 241, 242; in 
 apoplexy, 241 ; in hysteria, 241 ; 
 in rickets and laryngismus, 243, 
 351; in acute fevers, etc., 243; 
 in brain diseases, 243 ; from 
 worms, teething, stomach de- 
 rangement, etc., 243; in diar- 
 rhoea, 243; puerperal, 243; in 
 Bright's disease, 243 ; repetition 
 of, 244; local or partial, 248; 
 " Jacksonian," 248; carpo- 
 pedal, spasms in, 248 ; convul- 
 sive tic, 249 ; in insanity, 319 
 
 Cooing sounds in auscultation, 654 
 
 Copaiba, rash from, 125 
 
 " Copper color " in eruptions, 143 
 
 Co[)per test for sjgar, 455 
 
 Cord-like constriction of trunk, 
 201 
 
 Cords, vocal, 386; false cords in 
 larynx, 386 
 
 Cornea, opacities of, 159; ulcera- 
 tions with anossthesia, 200 
 
 Cornu, 118 
 
 Corona veneris, 154 
 
 Corpulence, 19, 20 
 
 Corpuscles, red and white, see 
 Blood 
 
 Cotton fibres in urine (Fig. 87, 
 a), 489 
 
 Cough, section on, 348; stomach 
 cough and reflex cough, 349; 
 imperfect closure of glottis in 
 some laryngeal couglis, 349, 392 ; 
 in whooping-cough, 349; par- 
 oxysmal, 349, 350 ; with vomit- 
 ing, 350; with bleeding from 
 nose, etc., 350; in bronchial 
 phthisis, 351 ; in measles and 
 influenza, 851 ; from irritation 
 
INDEX. 
 
 649 
 
 or disease of throat and larynx, 
 351 ; barking or brassy; 352 ; 
 hoarse croupy congh in croup 
 and diphtheria, 852 ; sometimes 
 hoarse in thoracic aneurism and 
 pericarditis, 351, 358 ; from for- 
 eign bodies in larynx, trachea, 
 or bronchi, 352 ; absence of, in 
 certain pulmonary aifections, 
 348, 353 ; pain with cough, 353 ; 
 alterations of, from laryngeal 
 affections, 392, 393 
 
 Coulomb, 274 
 
 Cracked-pot sound, 548 
 
 Cramp in limbs, 211, 213 ; writer's 
 229 ; in legs and limbs, 249 
 
 Cranial nerves, testing of (chapter 
 v.), 159, 202 (see Nerves) ; pa- 
 ralysis of, in squint, 167; affected 
 in syphilis, 233 
 
 Craniotabes, 33, 154 
 
 Cremasteric reflex, 217 
 
 Crepitus and crepitant rale, 555 
 
 Crisis, temperature in, 88, 89 ; dis- 
 eases characterized by sudden 
 crisis, 88 ; pseudo-crisis, 90 
 
 Crossed diplopia, 164; crossed pa- 
 ralysis, 208 
 
 Croup, 352; breathing in, 843; 
 nervous spasm in, 347; move- 
 ments of chest-wall in, 621 ; 
 false croup, 352 
 
 Crowing inspiration, 239, 343, 351 
 
 Crucifixion attitude (Fig. 37), 247 
 
 Crusting (in skin diseases), 112 ; 
 in sj'philis, 143 
 
 Crystals in sputum, 360 ; in pleu- 
 ritic effusions, 363 ; deposit of, 
 in urine, 488 
 
 Cup-shaped crusts, 112 
 
 Currents of various kinds from 
 batteries, 269, et seq. 
 
 Curschmann, on spirals in sputum, 
 356, 360 
 
 Curving of nails, 144 
 
 Cu SCO's speculum, 527 
 
 Cutaneous eruptions, 109 ; see also 
 Skin 
 
 Cutis anserina, 34 
 
 Cyanosis, see Lividity 
 
 Cylinders, renal, see Tube-casts 
 
 Cyrtometer, 538 ; tracings by, 539, 
 547 
 
 Cystine, 494 (Eig. 94), 495, 496 
 Cystitis in paraplegia, 232 
 Cysts, sebaceous, 117 ; fluid ac- 
 cumulations in abdomen, 437 ; 
 parasitic hydatids (Fig. 72), 444 
 
 D. (electrical symbol), 289 
 
 Dactylitis syphilitica, 155 
 
 Daltonism, see Color-blindness 
 
 Dani ell's battery, 273, 275 
 
 Deafness, 186 ; bone and air con- 
 duction in (Kinne's experiment), 
 187 ; noises in the ear with, and 
 giddiness with, 190 ; from en- 
 larged tonsils, 377 
 
 Death, temperature before, high 
 and low, 79 ; sense of dying in 
 angina, 342 
 
 Deep reflexes, 218 
 
 Defecation, painful, 412; strain- 
 ing, 410, 412 ; pain in, from 
 uterine disorder, 519 
 
 Degeneration, reaction of (elec- 
 tricity), 289 
 
 Deglutition, see 8th and 9th nerves, 
 205 ; spasms of, 251 ; affected in 
 general paralj'sis, 322 ; affected 
 from state of tongue, 400 
 
 Delirious mania, acute, 300 
 
 Delirium in fever, 35, 106 ; fea- 
 tures of, 255 ; and mania, 251 ; 
 in intemperance, 256 ; with 
 sleeplessness, 259 ; diagnosis of 
 insanity, and delirium, 326 
 
 Delirium tremens, 256 ; sleepless- 
 ness in, 261 
 
 Delusions, definition of, 296 
 
 Dementia, from alcohol, 317 (see 
 also Mania, Melancholia Mono- 
 mania) ; paralytic dementia, 821, 
 324 ; section on various forms, 
 306 ; senile, 306 ; organic, 808 ; 
 scute or primary, 308 ; resem- 
 blance to melancholy with stu- 
 por and " Katatonia," 309 
 
 Dentition, first, 419 ; disorders 
 of, 419 ; second, 420 
 
 Dermatalgia, 119 
 
 Dermatitis, 118 
 
 Dermatolysis, 118 
 
 Desquamation, 112; in scarlatina, 
 132 ; of epithelium from tongue, 
 399 
 
650 
 
 INDEX 
 
 Deviation, primary and secondary 
 in squint, 161 ; conjugate or 
 lateral deviation of eyes and 
 head, 177, 178; spastic and pa- 
 ralytic forms of, 177 ; clinical 
 significance of and localization 
 of lesion in, 177, 178; com- 
 bination of conjugate deviation 
 and squint, 178 ; of tongue, 206 
 
 Dexio-cardia, 565 
 
 Diabetes insipidus, 450 
 
 Diabetes mellitus (see Sugar in 
 urine), 455 ; knee-jerk in, 219 ; 
 thirst and appetite in, 397 ; 
 quantity of urine in, 449 
 
 Diagnosis, physical (chap, xvi), 537 
 
 Diaphragm in respiration, 542 
 
 Diarrlicea, 409 ; in fever, 105, 418 ; 
 significance of, 417 
 
 Diathesis, 14; Hutchinson on, 14; 
 gouty, physiognomy of, 27 ; 
 rheumatic, 32 ; insane (see Tem- 
 perament), 301 ; hemorrhagic, 
 364 ; oxalic and uric acid dia- 
 thesis, 495 
 
 Dicrotism in pulse, 597 
 
 Digestive system, in case-taking, 
 59 ; disturbance of, in fever, 
 105; diplopia in, 169; palpita- 
 tion in, 340; chapter xi. on dis- 
 <:»rders of, 396 ; works of reference 
 on, 424; appetite, 396; thirst, 
 397 ; tongue, 398 ; vomiting, 
 400; flatulence and hiccup, 407; 
 state of bowels and abdominal 
 pain, 409; worms, 414; appear- 
 ance of motions, 413 ; signifi- 
 cance of constipation and diar- 
 rhoea, 417 ; teeth and gums, 419 ; 
 jaundice and dropsv (chapter 
 xii.), 425 
 
 Diphtheria, glands in, 149 ; occa- 
 sional rash in, 130; paralysis 
 of accommodation from, 174; 
 anaesthesia from, 199, breathing 
 in, 343 ; nervous spasm in, 347 ; 
 laryngeal, causing cough, 352; 
 affection of throat, 378 ; distinc- 
 tion from muguet, 379 ; paral- 
 ysis of larynx and fauces in, 391 
 
 Diplopia binocularis, 161, 163; 
 relation of images in, 164 ; "di- 
 rect" or "homonymous" and 
 
 "crossed," 164; variations of 
 diplopia with paralysis of special 
 muscles (table), 165, 166 ; in- 
 stinctive efforts to combat dip- 
 lopia 167 ; clinical significance 
 of, 169; vertigo in, 169; erro- 
 neous projection of objects in, 
 170; diplopia monocularis, arti- 
 ficial pupil, etc., 169 
 
 Dipsomania, 317 
 
 Direct murmurs, 578 
 
 Discoloration of skin, various 
 causes, 140 et seq. 
 
 Disk, optic, choked disk, etc., see 
 Optic nerve 
 
 Diuresis, see Urine, quantity of 
 
 Diurnal range of temperature, 77, 
 80, 81 
 
 Dorsal reflex, 218 
 
 Double vision, see Diplopia 
 
 Douglas's pouch, inflammation 
 of 527, 529, 534, 535 ; prolapse 
 of bowel into 535 
 
 " Down-bearing " pain, 592 
 
 Dreams disturbed, 261 ; of terror, 
 261 ; in mania, 299 
 
 Dropsy, cachexia of, 32 ; chapter 
 xii. on dropsy, 425, 432; works 
 of reference on, 445 ; concur- 
 rence of jaundice and dropsj'^, 
 427 ; anasarca and oedema, 432 ; 
 " pitting" in, 433 ; renal dropsy, 
 occasionally without albuminu- 
 ria, 433 ; anaemic dropsy, 433 ; 
 oedema of feet, 433 ; oedema of 
 upper part of body, 434; of 
 hands and feet in children, 434 ; 
 localized dropsical swellit)gs, 
 434 ; myxoedema, 435 ; abdom- 
 inal dropsy, 435 ; of abdominal 
 parietes, 435; of peritonitis, 435 ; 
 ovarian dropsy and encysted 
 fluids, 438, 635; causes of as- 
 cites, 439; peritonitis with effu- 
 sion, 439; tabes mesenterica, 
 440; portal obstruction, 440; 
 from cirrhosis, 441 ; thrombosis 
 of portal vein, 442; in cancer, 
 
 442 ; from enlarged spleen, 443 ; 
 examination of dropsical fluids, 
 
 443 ; albuminuria in, 469 
 Drugs, habitual use of, in case- 
 taking, 65 
 
INDEX. 
 
 651 
 
 Drunkenness, and insanity, 317 ; 
 mistaken for insanity, 327 
 
 Drypdale's ovarian cells, 445 
 
 Duchenne, emporte-piece histo- 
 lo2;ique, 212 
 
 Duck-bill speculum, 528 
 
 Duc]£::eon's sphvgmograph (Fig. 
 116), 593 
 
 Duhring's classificatioii of skin 
 diseases, 117 
 
 Dulness, see Percussion 
 
 Dumb-bell crystals, 490, 494 
 
 Dumbness, see Speech 
 
 Duskiness of face, 34, 343 
 
 Dust, special kinds of, in asthmatic 
 attacks, 348 
 
 Duverney, glands of, 533 
 
 Dynamometer (Fig. 34), 212 
 
 Dyschromatopsia, 182 
 
 Dysmenorrhoea, 514 
 
 Dysphagia, see Deglutition, diffi- 
 culty in 
 
 Dyspnoea, physiognomy of various 
 kinds of, 38; "uremic," 38; 
 note; section on, 333; rapidity 
 of breathing, 335; laborious 
 breathing, 336 ; inspiratory and 
 expiratory dyspnoea, 336, 337, 
 347 ; suddenness of dyspnoea, 
 337 ; mechanical causes of dys- 
 pnoea, 337; cardiac dyspnoea, 
 338; orthopnoea, 338.; with hur- 
 rying, climbing, and excitement, 
 339 ; cause of thoracic pain, 
 341; with palpitation, 342; 
 noise emitted in, 343 ; lividity 
 in, 343 ; altered rhythm of 
 breathing, 344 ; nervous, hy- 
 sterical, and renal, 347, 348 ; in 
 pregnancy, 348 
 
 Ear, in case-taking, 58 ; bead-like 
 nodule in gout, 31, 152; works 
 of reference on ear, 206 ; exami- 
 nation of ear, 187 ; discharges 
 from, 188 ; suppuration from, as 
 cause of cerebral abscess, men- 
 ingitis, and pyemia, 189 ; noises 
 in, 188 (see also Tinnitus au- 
 rium) ; vertigo, 258 ; paralysis of 
 facial nerve from disease of (elec- 
 trical reactions), 293; hsemato- 
 ma auris in general paralysis, 323 
 
 Ecchymosis, 140; in tongue, 400 
 
 Echinococci (Fig. 72), 444 
 
 Echo, amphoric, 556 ; of heart's 
 sounds, 574, 586 
 
 Eclampsia, see Epileptiform con- 
 vulsions 
 
 Eclampsia nutans, 216, 250 
 
 Ecthyma, 115, 118 
 
 Eczema, 114, 118 
 
 Ehrlich and Gibbes's method of 
 detecting tubercle bacilli, 359 
 
 Eichhorst, on small colored cells 
 in blood in pernicious ansemia, 
 371 
 
 Eighth nerve, 205 
 
 Electric light for ]ar5aigoscope,381 
 
 Electricity and electrical instru- 
 ments, 269 ; franklinic, 269 ; gal- 
 vanic, 269; faradic, 270; 2:al- 
 vanic battery (Fig. 38), 270; 
 construction and requirements 
 of batteries for medical purposes, 
 272 ; electrical units, 274 ; struc- 
 ture and strength of various gal- 
 vanic elements, 275 ; resistance, 
 274; Ohm's law, 274; unit of 
 quantity, 274 ; accessory appa- 
 ratus, 274 ; faradic batteries, 
 277 (Figs. 39, 40), 271, 272; in- 
 duction coils (Fig. 41), 278 ; ob- 
 ject of electrical tests, 279; 
 Zeimssen's motor points with 
 figures, 279, et seq. ; polar me- 
 thods of testing, 280 ; testing 
 nerves of sensation 280; testing 
 motor nerves, 283 ; localized 
 electrization of muscles, 288 ; 
 reactions in health (formulae), 
 288, 289 ; qualitative changes in 
 reactions, 289 ; reaction of de- 
 generation, 289; significance of 
 electrical reactions, 291 ; electri- 
 cal symbols, 288 ; works of ref- 
 erence on, 295; delusions of in- 
 sane regarding electrical agents, 
 805 
 
 Electrodes, 276 
 
 Electro-magnetic battery, 271 
 
 Electro-motive force, 274 ; table 
 of, in various elements, 275 
 
 Electro-muscular sensibility, 282 
 
 Elements, galvanic, names, struc- 
 ture, and strength of, 275 
 
652 
 
 INDEX. 
 
 Elephantiasis, 117, 118 
 
 Elsasser, on cranio-tabes, 33 
 
 Emaciation, 16; a feature in 
 mania, 299 
 
 Embolism, of retina, 183 ; of cere- 
 bral arteries, causing hemi- 
 plegia, etc., 233 ; in chorea, 
 254; of pulmonary artery, a 
 cause of dyspncea, 337 ; a cause 
 of pulmonary abscess, 355 
 
 "Embonpoint,'' 19 
 
 Emesis, see Vomiting 
 
 Emmetropia, 174 
 
 Emotions, variations of, in paral- 
 ysis, 208, 209, 215 ; influence in 
 producing speech in aphasia, 
 227 ; disturbance in hysteria, 
 245 
 
 Emphysema, chest distorted, 541 ; 
 displacement of heart and liver 
 (Fig. 157), 624 
 
 Emporte-piece histologique (Du- 
 chenne), 212 
 
 Emprosthotonos, 250 
 
 Empyema, bursting into lung, 355 
 
 Encephalocele, 154 
 
 Endo-metritis, endo-cervicitis, see 
 Uterus 
 
 Enteric fever, rise of temperature 
 in (diagram), 88 ; remitting lysis 
 in (diagram), 90; collapse of 
 temperature in (diagram), 91 ; 
 relapses in temperatures of (dia- 
 grams), 92, 93 ; hemorrhages in, 
 413; period of incubation, 131 ; 
 liability to second attack, 131 ; 
 eruption, 137 ; sources of fallacy 
 in connection with eruption, 
 138; causes of, 138; pupils in, 
 172 ; tongue in, 399 
 
 Enuresis, 231 
 
 Epigastric region, and contents, 
 613; pulsation in 341,565, 616; 
 tumors in, 637 ; epigastric re- 
 flex, 218 
 
 Epiglottis, as seen in larynx, 386 
 
 Epilepsy, affections of skull in, 154; j 
 pupils in, 172 ; ankle clonus in, 
 222 ; wetting the bed in, 231 ; 
 description of typical attack, 
 241 ; hystero-epilepsy, 242, 247 ; 
 " epileptic state," 244 ; daily 
 number of fits (diagrams), 244; 
 
 " Jacksonian,^' 248 ; relation to 
 insanity and idiocy in family 
 history, 329; relation to men- 
 struation, 521 
 
 Epileptic hemiplegia, 214, 241 
 
 Epileptic mania, 241, 319, 331 
 
 Epileptiform convulsions, 241 ; in 
 syphilitic insanity and general 
 paresis, 318, 323 
 
 Epistaxis in whooping-cough, 350; 
 various causes of epistaxis, 364 
 
 Epithelial tube-casts, 480 (Fig. 
 77), 481 
 
 Epithelioma of cervix uteri, 531 
 
 Epithelium, in sputum, 360; renal, 
 resembling pus, 477, 484; vari- 
 ous kinds of epithelium in urine, 
 484; renal (Fig. 79), 483 ; epi- 
 thelium from bladder, ureter, 
 pelvis of kidney (Fis:. 80), 484 ; 
 tailed epithelium, 484; squam- 
 ous vaginal (Fig. 81), 485 ; from 
 uterus in leucorrhcea, 517 
 
 Erb, on reaction of degeneration 
 of muscles (electricity), 289 
 
 Erotomania, 315 
 
 Eructations, 409 
 
 Eruptions in fevers, 106 ; cutane- 
 ous, 109; distribution of, 119; 
 elementary lesions in, 110, 113 ; 
 secondary, 112; constitutional 
 disturbance in, 120; causes of, 
 122; febrile eruptions, 130; 
 syphilitic, 143 ; works of refer- 
 ence on, 157 
 
 Erysipelas, 114; period of incuba- 
 tion, 131; liability to second 
 attack, 131 ; eruption of, 139 ; 
 in infants, 139; in dropsy, 139 
 
 Erythema, 110, 113, 117 
 
 Eustachian tubes, examination of, 
 188, 395 
 
 Examination and reporting of 
 medical cases (chapter ii.), 52 
 
 Exanthemata, as a class (Willan), 
 113 
 
 Excitement, cause of dyspnoea, 
 339 
 
 Exophthalmos, 160; exophthalmic 
 goitre, 160; and insanity, 320; 
 palpitation in, 341 ; pulsation in 
 arteries of neck, 566 ; albumin- 
 uria in, 483 
 
INDEX. 
 
 653 
 
 Expectoration, section on, 353 ; 
 how collected and examined as 
 to quantity, color, smell, tenac- 
 ity, etc., 354; in health, 854; 
 black color, 354 ; frothy mucous, 
 354 ; purulent, 354 ; membra- 
 nous shreds, 355 ; fibrinous casts, 
 356 ; cheesy masses, 350 ; cal- 
 careous masses, 356 ; hydatids, 
 356; of blood, 356; rusty ex- 
 pectoration, 356 ; "prunejuice," 
 358; likered-eurrant jelly, 358 ; 
 microscopic examination of, 359; 
 tubercle bacilli in, and method 
 of detecting, 359 ; other organ- 
 isms, epithelium, spirals, etc., 
 360 ; crystals in, 360; lung tissue, 
 361 ; how to search for lung 
 tissue in, 361 
 
 Expiratory murmur, normal, 551 : 
 prolonged, 563 
 
 External division in case-taking, l Farad, 278 
 
 Facial nerve, testing of, 203 ; 
 paralysis of, action of two kinds 
 in electricity, 293 (see preceding 
 entries) 
 
 Facies Hippocratica, 28 
 
 Fagge (Dr. Hilton), on auricular 
 systolic murmurs, 577 
 
 Fainting fits, 240; in uterine dis- 
 orders, 520 
 
 Fall of temperature before death, 
 79 ; in crisis, 88 ; fallacies in 
 judging of, 87 
 
 False croup, 352; false cords in 
 larynx, 386 
 
 Family history, 57, 66 ; hints on 
 investigation of, 68; variations 
 of allied diseases in, 69; im- 
 portance of, in acute diseases, 
 69; influence of sex in, with 
 examples, 69, et seq. ; fallacies, 
 72, 78 ; in insanity, 329 
 
 55, 57 
 
 Extra current (electricity), 277 
 Eye, in case-taking, 58 ; examina- 
 tion of symptoms connected 
 with, 159 ; works of reference 
 on, 206; protrusion of eyeball, 
 159, 160 ; eyelids, inability to 
 close, 160; droop of, 161; asso- 
 ciated movements of eyelids and 
 eyeballs, and fallacies from this, 
 161 ; paralysis of ocular muscles, 
 161, 167 ; functions of muscles, 
 164; clinical significance of ocu- 
 lar paralysis, 167 , strain on eyes, 
 175 ; convulsive movements of 
 muscles, 176 ; conjugate devia- 
 tion of eyes, 177 ; optical defects 
 of, 178 ; ophthalmoscopic exami- 
 nation, 182; importance of eye- 
 sight in balancing and walking 
 in ataxy, 224 
 Eyelids, paralysis of, 41, 160, 
 168, 204 ; convulsive move- 
 ments, 176 
 
 Face, paralysis of, see Facial 
 nerve, 203 ; pallor of, in epilep- 
 sy, 240 ; local spasms of facial 
 muscles, 249 ; flushing and 
 lividity, 251, 343 ; muscles of, 
 in general paralysis, 322 
 
 Faradic current, 270; batteries, 
 277 (Figs. 39, 40), 271, 272; in 
 testing sensibility of muscles, 
 201, 282: testing nerves of sen- 
 sation, i^80; motor nerves, 283, 
 284; muscles, 287,288; difi'erent 
 action from galvanic, 279, 287 
 
 Farcy, affection of glands in, 147 
 
 Fatty acids, in spit, 361 ; in vom- 
 ited matter, 405 ; fatty matter 
 in motions, 415; fatty tube- 
 casts, 481 ; (Fig. 78, a), 482 
 
 Fauces, examination of (chapter 
 X.), 374; method of inspection, 
 344; morbid appearances in, 
 376 ; catarrh of, 376 ; scarlatina 
 aflPecting, 377 ; diphtheria afi"ect- 
 ing, 378 ; ulcers in, 379 ; phleg- 
 monous inflammation of, 377 ; 
 syphilis afi'ecting, 379; destruc- 
 tion of tissue and cicatrization, 
 379; irritation of, causing vomit- 
 
 ing, 403 
 
 Favus, 112, 119, 127 ; parasite in 
 Figs. 25, 26, 27), 125, et seq. ; of 
 nails, 144 
 
 Feathers in urine (Fig. 87, I), 489 
 
 Fecal voniiting, 405 
 
 Feces, retention and involuntary 
 evacuation of, 230 ; tumor from, 
 in pelvic examination, 535; ap- 
 
 55* 
 
654 
 
 INDEX. 
 
 pearance of (see Motions, 413 ; 
 state of bowels, 409) 
 
 Feet, swelling of, in infancy, 248 
 (see also Dropsy) ; inversion of 
 feet in infancy, 248 
 
 Fehling's copper test solution for 
 sugar, 455 
 
 Female organs, disorders of 
 (chapter xv.), 509 
 
 Fenwick (Dr.), on detection of 
 lung tissue in sputum, 361 
 
 Ferguson's speculum, 527 
 
 Fermentation in vomited matters, 
 405; in stomach, lactic, butyric, 
 and alcoholic, 408 ; acid fer- 
 mentation of urine, 451 ; test 
 for sugar m urine, 457 ; quanti- 
 tative, 458 ; torulte in saccharine 
 urine, 458; torula cerevisiae 
 (Fig. 86), 488 
 
 Ferrocj-anide of potassium test for 
 albumen, 465 
 
 Festination, 215, 223 
 
 Fetor from nose, 192 ; in expec- 
 toration, 354 
 
 Fever, physiognomy of, 34; hectic, 
 34; duskiness in, 34; jaundice 
 in, 35; putrefactive odor in, 35, 
 shiverings in, 35 ; general -ymp- 
 toms of febrile state, 103; clin- 
 ical significance of febrile state, 
 106 ; specific, points to be ob- 
 served in diagnosis of, 106; 
 rashes in, 130; period of incu- 
 bation in fevers, 131 ; liability 
 to second attacks of fevers, 131 ; 
 cause of delirium in, 255, 326; 
 cause of vertigo in early stage, 
 259 ; of headache, 263 ; of back- 
 ache, 104, 265: as a cause of 
 insanity, 320 : respiration quick- 
 ened in, 335; hemorrhages in 
 fevers, 364; jaundice in, 429; 
 albuminuria in, 469 
 
 Fibres, vellow elastic, in sputum, 
 361 " 
 
 Fibrinous casts in fibrinous bron- 
 chitis, croup, etc., 355 (Fig. 49), 
 356 
 
 Fifth nerve, in nose, 191 ; in 
 tongue, 194; testing of, 202 
 
 Filaria sanguinis hominis in 
 chyluria, etc., 372 
 
 First nerve, see Nose, 191, 202 
 
 Fissures in skin, 112 
 
 Fits, various kinds of, 238; faint- 
 ing fits, 239; convulsion fits, 
 240; hysterical tits, 245; plastic 
 rigidity, 246; " inward fits," 241 
 
 Flashes of light, 176 ; in paralysis, 
 251 
 
 Flatulence as a cause of palpita- 
 tion, 340, -109; of thoracic and 
 cardiac pain, 342; forms of, 
 407; simulating ascites, 438 
 
 Flavors, relation to smell, 191 
 
 Flax fibres in urine (Fig. 87, b), 
 489 
 
 Flea bites and typhus rash, 136 
 
 Floccitatio, 36 
 
 Flooding, 364 
 
 Fluctuation in ascites, 437 
 
 " Fluid vein," in cardiac mur- 
 murs, 577 
 
 Flushing, of face, 104; feeling of 
 flushing, 201 ; flushing and 
 lividity in paralysis, 251 ; at 
 change of life, 516 
 
 Foetus, movements of, 524 ; sounds 
 of heart, 524 
 
 Folie circulaire, 309 ; folie du 
 doute, 312; folie d deiix, folie 
 communiquee, 313 
 
 Follicular erosion of os uteri, 531 
 
 Fomites, 131 
 
 Fontanelle, state of, in flts, 243, 
 262 ; systolic bruit over, in 
 rickets, 266 
 
 Food, habitual character of (case- 
 taking), 65; articles of, as caus- 
 ing eruptions, 124 (see chapter 
 xi., p. 396, passim) 
 
 Formication, 201 
 
 Foster (Michael), on details of 
 urea analysis, 500 
 
 Foulis (Dr.), on auto-laryngo- 
 scopy, 385 
 
 Fourth nerve, 202 
 
 Fox (Tilbury), on syphilitic erup- 
 tions, 143 
 
 Frambo3sia, 117 
 
 Franklinic electricity, -269 
 
 Frauiihofer, lines (Fig. 74''^), 472 
 
 Fremitus, vocal, 559; hydatid 625 
 
 Frenum linguae, ulcer on, in per- 
 tussis, 350 
 
INDEX. 
 
 655 
 
 Friction, in abdomen, 440; in 
 
 chest, 555 
 Frictional electricity, 269 
 " Friedreich's disease," 69; knee- 
 
 jerlc in, 219 
 "Frog" or thrush, 398 
 Front tap contraction, 222 
 Frothy spit, 354 
 
 Functional cardiac murmurs, 586 
 Fungi in sputum, 360; in urine, 
 
 487 ; mould fungus in urine 
 
 (Fig. 85), 487; yeast or sugar 
 
 fungus (Fig. 86), 488 
 Furring of tongue, 398 
 Furunculus, 118 
 
 I 
 
 Gairdner, on cardiac murmurs, i 
 577, et seq. j 
 
 Gait, see Walking i 
 
 Galabin, cardiograph, 609 ; cardio- 
 gram (Fig. 149), 610 
 
 Galloping action of heart, 574 
 
 Gall stones in motions, 415, 428 ; 
 a cause of jaundice, 426 ; test of, 
 by obtaining cholesterine, 428 
 
 Galvanic battery (Fig. 38), 270; 
 construction of and require- 
 ments for medical purposes, 272; 
 structure and strength of vari- 
 ous galvanic elements, 275; 
 galvanic current, 269 ; action 
 of, on muscles, 279, 287 ; form- 
 ulae of, in health, 288, 289; 
 alterations in disease, 290; dif- 
 ferent action from faradic, on 
 muscles, 280, 287 
 
 Galvanometer, 276 
 
 Gangrene, odor of, in expectora- 
 tion, 355 ; haemoptysis with, 358 
 
 Garrod (Dr.) test for uric acid in 
 blood, 152 
 
 Gases, irrespirable, causing liv- 
 idity, etc., 344 ; irritating, caus- 
 ing cough, 351 
 
 Gasserian ganglion, paralysis in- 
 volving, 203 
 
 *' Gastric crises," 402 
 Gee (Dr.), on shape of chest, 538 
 General paralysis, see Paralysis 
 Genital organs in the male, dis- 
 turbances of (chapter xiv.), 506; 
 impotence, 506 ; excessive apti- 
 tude for venery, 506 ; priapism, 
 
 507 ; masturbation, 507 ; sem- 
 inal discharges, 508; genito- 
 urinary system in case-taking, 
 59 ; disorders of female genital 
 organs (chapter xv.), 509; works 
 of reference on, 536; menstrua- 
 tion and its disorders, 510 ; 
 amenorrhoea, 511 ; suppression 
 of menses, 513 ; menorrhagia, 
 513 ; dysmenorrhcea, 514 
 German measles, period of incu- 
 bation, 131 ; liability to second 
 attack, 131 ; rash, 135 
 Giddiness, see Yertigo 
 Gingivitis, see Inflammation of 
 
 gums, 423 
 Girdle sensation, 201 
 Glanders, aff"ection of glands in, 
 
 147 
 Glands, affections of, 144 ; works 
 of reference on, 157; bronchial 
 glands affected, 351 ; hemor- 
 rhages and lymphatic glandular 
 affections, 364; mesenteric, en- 
 larged, 440 
 Globular sputa, 355 
 Globulin in urine, 467 
 Globus hystericus, 245, 314, 408 
 Glossitis, 400 
 Glosso-labio-laryngeal paralysis, 
 
 41, 205, 206 
 Glosso-pharyngeal nerve, 194, 205 
 Glottis, spasm of, 239, 251, 343, 
 350; irritation and spasm of, 
 from laryngeal irritation, for- 
 eign bodies, etc., 347, 351, 3-52, 
 389, 390, 393; cedema of, 390; 
 closure from paralysis of abduc- 
 tors, 391 
 Gluteal reflex, 217 
 Glycosuria, see Sugar in urine, 455 
 Goitre, exophthalmic, 160, and 
 
 insanity, 320 
 Gonorrhoea, in case-taking, 63 ; 
 rheumatism in, 150; gonorrhceal 
 synovitis, 150; pyemia in, 150; 
 pain in micturition, 504 
 " Goose-skin," 34, 201 
 Gout, cachexia in, 31 ; group of 
 allied diseases, 69 ; affections of 
 joints, 151 ; heredity and habits, 
 influence of, 151 ; lead, influence 
 of, 151 ; uric acid in blood, test 
 
656 
 
 INDEX, 
 
 for, 152 ; chronic gout, 152 ; a 
 cause of insanity, 319 
 
 Gouty habit, physiognomy of, 
 27 
 
 Gowers (Dr.), on associated move- 
 ments of the eyelids and eye- 
 balls, 161 ; on the superficial 
 reflexes and their indications, 
 217 ; method of estimating ha3- 
 moglobin in blood, 36G 
 
 Grandeur, delusions of, in general 
 paralysis, 321 
 
 Grand inal, 241 
 
 Granular pharyngitis, 376 ; granu- 
 lar tube-casts (Fig. 77 6), 481 ; 
 gi-anular corpuscles in urine, 
 484 
 
 Gravel in urine, 454, 487, et seq. ; 
 pain from, 503 
 
 Graves (Dr.), on m3^oidema, 24 
 
 Graves's disease, see Exophthal- 
 mic goitre 
 
 Grimaces in chorea, 254 (see also 
 p. 249) 
 
 Grinding the teeth, 422 
 
 Grove's battery, 273, 275 
 
 " Growinii; pains," 149 
 
 Growth of infant, 43 
 
 Growths in larynx, 390 
 
 Guaiac test for blood or haemoglo- 
 bin, 472 
 
 Gumboil, 423 
 
 Gums, 422 ; swelling of, 423 ; 
 spongy, 423 ; blue and red line 
 on, 423; inflammation of, 423 ; 
 sondes on, 399, 423; white and 
 black patches, 423 
 
 Gustatory nerve, 194 
 
 Habit of body, 29; habits of pa- 
 tients, 63 
 
 " Habitus depravatus," 29 
 
 Hajmacytometer (Fig. 51), 367 
 
 Haematemesis, 357 
 
 Haematine, absorption bands of 
 (Fig. 74^^), 472 
 
 Ha3matinuria, 303 
 
 Htematocele, pelvic, 535 
 
 Hajmatoma auris in general paral- 
 ysis, 323 
 
 Ha^maturia, 471 ; guaiac test for, 
 472; spectroscope test, 473; clini- 
 cal significance of, 474 
 
 Hyemic murmurs, 586 
 
 Haemoglobin, determination of 
 quantity in blood, 366 ; guaiac 
 test for, 472 ; spectroscope test, 
 473 ; absorption bands of (Fig. 
 74*), 372 
 
 Haemoglobinoraeter (Dr. Gowers'), 
 366 
 
 Hsemoglobinuria, 474 ; with jaun- 
 dice, 429 
 
 Haemophilia, 364 
 
 Haemoptysis, 356 ; fallacies as to, 
 355 
 
 Hemorrhages, cutaneous, 111 ; in 
 smallpox, 134; in typhus in 
 skin, 136; subcutaneous, 140; 
 joint afl'cctions and hemor- 
 rhages, 153 ; in retina, 184 ; in 
 brain as cause of hemiplegia, 
 233 ; hemorrhage a cause of ver- 
 tigo, 259 ; from lungs, 357 ; sec- 
 tion on hemorrhages of various 
 kinds, 363 ; cause of, 364 ; from 
 hepatic, cardiac, and renal dis- 
 ease, 364 ; in splenic disease, 
 365; from stomach, 405; from 
 bowels, 413 ; from gums, 423 ; 
 in jaundice, 42S, 432 ; by way 
 of urine, 470 ; vicarious in amen- 
 orrhcea, 511 ; from womb, 513, 
 516 
 
 Hemorrhagic diathesis, 364 ; he- 
 redity in, 71 
 
 Haemorrhoids, bleeding from, 364 
 
 Hair, hypertrophy and atrophy of, 
 118; affections of 126; gray- 
 ness in anaesthesia, 200 ; gray- 
 ness in neuralgia, 288 ; hair in 
 urine (Fig. 87, c), 489 
 
 Hallucinations, definition of, 296 
 
 Hammond's athetosis, 215 
 
 Hands, waving motions of, in 
 fever, 36 ; inversion of, in con- 
 vulsion, 248; swelling of dor- 
 sum in infancy, 248, 434; "spade- 
 like," 435 
 
 Hardness of the skin, 112 
 
 Head, habitual deviations of, in 
 diplo[)ia, 167 ; auscultation and 
 percussion of, 266 ; blows or 
 falls, as cause of loss of hearing, 
 189; of smell, 192; of insanity, 
 320 
 
INDEX. 
 
 657 
 
 Headache in fever, 104 ; from 
 strain on eyes, 175 ; various 
 causes of, 262 et seq.; sick head- 
 ache, coincident symptoms, 263, 
 with vomiting and giddiness; 
 254, 402 ; from exhaustion and 
 impure air, 264 ; from renal dis- 
 ease and other toxic causes, 264 ; 
 from structural disease of brain, 
 265 ; from sunstroke, 265 ; epis- 
 taxis in, 363 
 
 Hearing, in case-taking, 58; test 
 of, 186 ; formulas for, 186 
 
 Heart, disease of, phvsiognomy of, 
 38, 39; allied to 'chorea, 2o4 ; 
 cause of paralvsis, 251 : palpita- 
 tion of, 333, 340, 407, 408 ; dys- 
 pnoea from heart disease, 338 ; 
 irregularity of action, 341 ; pain 
 in cardiac region, 342; lividity 
 in, 343; haemoptysis in, 357- 
 359 ; Cheyne-Stokes respiration 
 in heart disease, 344 ; congenital 
 defects causing lividity, 343 : 
 sounds of, in foetus, 524 ; reso- 
 nance of heart's sounds from dis- 
 ease of lung, 559 ; physical ex- 
 amination, 559; normal heart, 
 559; percussion of, 561 ; normal 
 percussion (Fig. 102), 563; 
 changes in apex-beat, 564; pul- 
 sation other than apex-beat, 565; 
 pulsation in vessels of neck, 566; 
 changes in precordial dulness, 
 567 ; increased dnlness from hy- 
 pertrophy (Fig. 103), 568; from 
 pericardial effusion (Fig. 104), 
 569; tremor or thrill with action, 
 570 ; di placement to right and 
 left (Figs. 105, 106), 570, 571 ; 
 displacem.ent in emphvsema 
 (Fig. 157), 623; sounds of heart, 
 572; phenomena in a cardiac 
 revolution (Fig. 107), 576; 
 sounds altered in character, 
 573 ; echo of, 574, 586 ; redupli- 
 cation of sounds, 574 ; cardiac 
 murmurs, 574-586. See Sphyo;- 
 mograph and Cardiograph, 590, 
 608. 
 
 Heartburn, 407 
 
 Heat of body, increase of, 74 ; see 
 also Temperature ; unequal dis- 
 
 tribution of heat, 104 ; sense of, 
 196 
 
 Hebephrenia, 314 
 
 Hebra's classification of skin dis- 
 eases, 117 
 
 Hectic fever, 34 ; diurnal range of 
 temperature (diagrams), 79-82 ; 
 inverted type, 77 
 
 "Hedge-hog" crystals (Fig. 89), 
 491 
 
 Height, relation to weight, Eobert- 
 son on, 17; diversities in, 17 
 (tables), 18, 46 ; diversities ac- 
 cording to age (tables), 47, 48, 
 49 ; increase in infancy, 43 
 (tables), 50 
 
 Hemeralopia, 182 
 
 Hemialbumose, 467 
 
 Hemiansesthesia, 199; hemiopia 
 in, 181 ; color blindness in, 182 ; 
 with anosmia, 191 ; in hystero- 
 epilepsy, 205 ; with and without 
 paralysis, 211 
 
 Hemianopsia, see Hemiopia 
 
 Hemichorea, 214, 254 
 
 Hemicrania, sec Migraine 
 
 Hemiopia, 180 ; varieties of, 181 ; 
 combined with hemiansesthesia, 
 181 ; in hemicrania (migraine), 
 181 ; localization of lesion in, 
 181 
 
 Hemiplegia, gait in, 41-222 ; de- 
 finition of, 208 ; alternate, 208 ; 
 epileptic, 2I4; chorea, 215; bed- 
 sores in, 214 ; unilateral convul- 
 sions in, 214; post-hemiplegic 
 chorea, 214 ; shaking of para- 
 lyzed, limbs in, 214; reflex move- 
 ments of arm in, 217 ; connec- 
 tion with aphasia, 228 ; clinical 
 significance of 232 ; causes of, 
 233 ; and paraplegia combined. 
 233 ; in pregnancy and puerpe- 
 ral state, 233 ; double, with 
 spasm, 234 ; electrical reactions, 
 292 ■ 
 
 Hereditary transmission of disease, 
 influence of sex in, with ex- 
 amples, 70, 71, 72; influence of 
 consanguineous marriages in, 
 72 ; atavism in, with example, 
 71, 72; see also family his- 
 tory 
 
658 
 
 INDEX. 
 
 Herpes, 114, 118 ; herpes zoster 
 and neuralgia, 238 ; herpes iris, 
 118 
 
 Hiccup, 407 
 
 "Hide-bound," 435 
 
 Hip-joint disease, effect on walk- 
 ing, 224; diagnosis of, from in- 
 fantile paralysis, 225 
 
 Hippocrates, on acute collapse 
 [fades Hippocr'atica), 28; on 
 Carphologia in fevers, 36 ; Hip- 
 poeratic succussion, 550 
 
 History, personal, GO; of illness, 
 57, 60, et seq.\ of previous health, 
 57, 62 ; social, 56, 63 ; of habits, 
 63; of occupations, 64; of health 
 in children, 61 ; family history, 
 57, 66 
 
 Histrionic spasm, 249 
 
 Hoarseness, 351, 353 ; an indica- 
 tion for laryngoscopy, 387 
 
 "Hob nail" liver, 441 
 
 Hodgkin's disease, 146 
 
 Homicidal insanity, 312 
 
 Homonj^mous diplopia, 164 
 
 Hooklets from hydatids in fluids 
 Fig. 72), 444 ; in sputum, 360 ; 
 in pleuritic effusions, 363 
 
 Hooping cough, see Whooping 
 cough 
 
 Horripilation, 34, 201 
 
 Humming-top sound in veins, 588 
 
 Hurrying, cause of dyspnoea, 339 
 
 Hutchinson, on temperament and 
 diathesis, 14, 23 ; on notched 
 teeth in hereditary syphilis, 421 
 
 Hyaline tube-easts (Fig. 76), 480 
 
 Hydatids in spit, 350, 360; vomited 
 406; in motions, 415; fluid re- 
 moved from, 443 ; microscopic 
 examination of (Fig. 72), 444; 
 fremitus in percussing liver, 625, 
 635 
 
 Hydrencephaloid, 243 ; sleepiness 
 "in, 262 
 
 Hydrocephalic idiot, 43 
 
 Hydrocephalus, 2^2 ; affections of 
 skull in, 154; sleepiness in, 
 262 
 
 Hydrometer for urine, 450 
 
 Hydronephrosis, fluid from, 443 ; 
 urine from, 451 ; renal tumor, 
 719 
 
 Hydro-peritoneum, 486 
 
 Hydrophobia, 251 
 
 Hydro-pneumo-thorax, 547, 556 
 
 Hydrorrhoea gravidarum, 592 
 
 Hyoscyamus, cause of spectral illu- 
 sions, 256 
 
 Hyperiesthesia, 119, 200, 201 ; in 
 meningitis, 211, 265 
 
 Hyperalgesia, 210 
 
 Hyper-dicrotism in pulse, 598 
 
 Hyperidrosis, 117 
 
 Hyper-involution of uterus, 527 
 
 Hypermetropia, 178; associated 
 with squint, 162 ; manifest and 
 latent, 179 ; cause of strain on 
 eyes, 175 
 
 Hyper-pyrexia, 78, 79; in rheu- 
 matism, 149; in chorea, 254 
 
 Hypertrophy of heart (Fig. Iu3), 
 568 ; sounds in, 573 
 
 Hypertrophy and atrophy, 21 ; ap- 
 parent hypertrophy of muscles, 
 211 
 
 Hypo-bromite of sodium for urea 
 analysis, 502 
 
 Hypochondriac regions, their situ- 
 ation and contents, 613 ; tumors 
 in, 637 
 
 Hypochondriasis, 302 
 
 Hypogastric region and contents, 
 613; tumors in, 637 
 
 Hypoglossal nerve, 206 
 
 Hysteria, anaesthesia in, 199; fits 
 in, with swooning, 240 ; convul- 
 sive fits, 240; hysterical para- 
 plegia, 234 ; electrical reactions 
 in, 292; hysterical fits, 245; 
 simulated by cerebral affections, 
 246; hysterical mania, 314; 
 dyspnoea in, 348; aphonia in, 
 391 ; flatulence in, 409 
 
 Hystero-epilepsy, 242, 247; cruci- 
 fixion attitude in (Fig. 37), 247 ; 
 Charcot on, 247 ; various sensory 
 disturbances in, 248 
 
 Ichthyosis, 116, 118 
 Icterus, sec Jaundice, 425 
 Idiocy, physiognomy of, 42 ; sec- 
 tion on idiocy, 325; hereditary, 
 329 
 Iliac regions, situation and con- 
 tents, 613 ; tumors in, 637 
 
INDEX. 
 
 659 
 
 Illusions, in delirium, 256 ; from 
 hyoscyamus, 256 ; definition of, 
 296 
 
 Images, " false images," see Di- 
 plopia 
 
 Imbecility, 306 
 
 Impetigo, 115, 118, 122 
 
 Impotence, 506 
 
 Impulsive insanity, 311 
 
 Incontinence of urine, 229-232 ; 
 with retention, 231 
 
 Incubation of infectious fevers, 
 131 
 
 Indecency, see Obscenity 
 
 Indigestion, see Digestive system 
 
 Indigo in urine, 453 
 
 Indigo-carmine test-paper for 
 sugar in urine, 459 
 
 Induced currents, 270, 277 ; in- 
 duction apparatus (Figs, 39, 40, 
 41), 271, 272, 278 ; primary, sec- 
 ondary, 271 
 
 Induration of cellular tissue, 435 
 
 Infancy, physiognomy of, disor- 
 ders of, 43 ; increase in stature 
 in, 43 ; weight and length in, ac- 
 cording to age and nourishment 
 (table), 60 ; history of illness in, 
 61 
 
 Infantile paralysis, see Paralysis 
 
 Infantile uterus, 511, 530 
 
 Infarctions, pulmonary, causing 
 haemoptysis, 358 
 
 Infection in cutaneous eruptions, 
 122 
 
 Infiltration of skin, 112 
 
 Inflammations as cause of pyrexia, 
 107 
 
 Influenza, catarrh and cough in, 
 351 
 
 Insanity, physiognomy of, 42 ; 
 chapter viii., on insanity, 296; 
 works of reference on, 331 ; chief 
 forms of insanity, 297 ; pre- 
 monitory mental symptoms, 297; 
 insane temperament, 301, 317 ; 
 relation of insanity to bodily 
 disorders, menstruation, sexual 
 organs, pregnancy, 314; of lac- 
 tation, 317 ; alcoholic insanity, 
 317 ; syphilitic, 317 ; epileptic, 
 319 ; phthisical, 320 ; impulsive, 
 312; moral, 312; partial, 313; 
 
 circular, 309 ; partial emotional 
 insanity, 310 ; monomania, 305 ; 
 general paral^'sis, 321 ; de- 
 mentia, 306 ; communicated in- 
 sanity, 313 ; idiocy, 325; diag- 
 nosis of delirium from insanity, 
 326 ; mode of examining an 
 insane person, 328 ; family his- 
 tory, 329 ; question of asylum 
 treatment, 330 
 
 Inspection of chest as to lungs, 537 ; 
 as to heart, 559 ; of abdomen, 
 614 
 
 Intemperance, in case-taking, 65 ; 
 cause of delirium, 256 ; cause of 
 insanity, 317 ; of mania, 301 ; 
 of general paralysis, 324 
 
 Intermission in pulse, 600 
 
 Internal division in case-taking, 
 55 
 
 Interrupted current, 270, 271 
 
 Intestines, physical examination 
 of, 633 ; see also Bowels 
 
 Involuntary movements in pa- 
 ra]3'sis, 214 
 
 Involution of uterus, 527 
 
 Iodide of potassium, rash from, 
 124 ; in distinguishing poles of 
 galvanic battery, 273 ; saliva- 
 tion from, 400 
 
 Iodine test for bile pigment in 
 urine, 498 
 
 Ireland (Dr.), on idiocy, 48, 325 
 
 Iris, paralysis of, 165, 168 (see also 
 Pupil) ; tremulous iris, 173 
 
 Iritis, 157, 170 
 
 Irregularity of pulse, 599 
 
 Itch insect (Fig. 23), 127 
 
 Itching in skin diseases 121 ; at 
 anus and urethra, 121 ; in jaun- 
 dice, 121, 428 ; from opium and 
 arsenic, 121 
 
 " Jacksonian epilepsy," 242, 248 
 Jaundice (chapter xii.), 425; 
 \ works of reference on, 445; 
 tests of and states resembling 
 jaundice, 425; urine in, 425; 
 tube-casts in urine of, 482 ; stools 
 in, 426 ; obstructive and non- 
 obstructive, 426 ; cause of ob- 
 struction of ducts, 426 ; pain 
 in, 428 ; rigors in, 428, ; hemor- 
 
660 
 
 INDEX. 
 
 rhages, 428, 432 ; non-obstruc- 
 tive jaundice, cause? of, 429- 
 431 ; with hoemo«:lobinuria and 
 pernicious anaemia, 430; jaun- 
 dice in infancy, 432; concur- 
 rence of jaundice and dropsy, 
 427, 443; epidemic, 430 
 
 Jaw, spasm of, 250 
 
 Jenner (Sir Wm.), on rickets, 32 
 
 Jerky respiration, 552 
 
 Johnson (Dr. George), on auto- 
 la ryngoscopy, 385 ; on testing 
 for sugar, 459 
 
 Jointf?, aflections of, 147 ; in loco- 
 motor ataxy, 148; "double 
 joints," 148 ; works of reference 
 on, 157 ; pains with subcutane- 
 ous hemorrhages, 153; effect of 
 walking on joint-disease, 225; 
 in hemorrhagic diathesis, 364 
 
 Jugular pulse, 607 
 
 "K.C.C.," "K.O.C," "Iv.C.Te.," 
 " K.D.Te. (electrical symbols), 
 289 
 
 Ka or K = Kathode, 273, 288 
 
 Katacrotic pulse, 595 
 
 Katatonia, 310 
 
 Keloid, 113, 118 
 
 Keratosis pilaris, 118 
 
 Kidney, affection of, in gout, 151 
 headache in diseases of, 265 
 diseases of, albuminuria in, 469 
 suppuration in pelvis (pyone- 
 phrosis), 478 ; physical exami- 
 nation of, 629 ; floating or 
 movable, 630 
 
 Kinks in coughing, 350 , *' dumb- 
 kinks," 350 
 
 Kl =Klang (electrical symbol)289 
 
 Kleptomania, 311 
 
 Knee-jerk, 218 ; methods of ob- 
 taining, 218 ; absence or dimi- 
 nution of, 219 ; clinical signifi- 
 cance, 219; increase of, 219; 
 knee-jerk in spastic conditions, 
 219 ; in alcoholic paralysis, 235 ; 
 in general paralysis, 324 
 
 Knee-fihenomenon, see Knee-jerk 
 
 Kyphosis, 156 
 
 Labia, tumors of, 533 
 Labio-ulosso-laryngeal paralysis, 
 41, 205, 206 
 
 Laborious breathing, 336, 347 
 
 Labor, insanity in, 316 
 
 Labyrinth, affections of, with tin- 
 nitus, and vertigo, 189 
 
 Lactation, insanity of, 317 
 
 Lagophthalmos, 160 
 
 Lamp for laryngoscope, 381 
 
 Laryngeal (labio-glosso-) paralysis, 
 4i, 205, 206 
 
 Larvngismus stridulus, 239, 251, 
 343,^351, 352 
 
 Laryngitis, 351, 352 
 
 Laryngoscope, method of using, 
 381 ; lamp for, 381 ; electric 
 light for, 381 ; mirrors, 382 ; 
 laryngeal mirror in position, 
 (Fig. 54), 383; auto-laryn2;o- 
 scopy, various methods, 385 ; 
 when to be used, 387 ; works of 
 reference on, 395 
 
 Larynx, nervous disorders of, 205, 
 239, 251 ; irritation and disease 
 of, causing cough, 351 : foreign 
 bodies in, 352 ; examination of 
 (chapter x), 374; method of 
 examining by laryngoscope, 
 381; by palpation, 385; appear- 
 ances normally, 386, 387 (Fig. 
 55), 386 ; examining b}' finger, 
 385 ; morbid appearances, 387 ; 
 alterations in color, 387 ; when 
 larynx must be examined, 387; 
 catarrh of larynx, acute and 
 chronic, 387 ; tuberculosis of, 
 388 ; syphilitic disease of, 389 ; 
 inflammation of cartilages, 389 ; 
 croup and diphtheria, 389; 03de- 
 ma glottidis, 390; growths in, 
 
 390 ; paralysis of cords, 390-393 
 (Figs. 357, 358), 9; laryngeal 
 affections of voice and cough, 
 
 391 ; aneurismal aflections of, 
 
 392 ; works of reference on , 395 ; 
 movements of chest wall in ob- 
 structions of, 542 
 
 Laughing, test by, in facial pa- 
 ralysis, 203 ; undue, in paralysis, 
 210; in hysteria, 245 
 
 Lead, influences of, in gout and 
 renal disease, 151 ; paralysis, 
 235; influence of electricity in 
 lead paralysis, 290, 294 , blue 
 line on gums, 423 ; a cause of 
 insanity, 319; of colic, 411 
 
IN.DES:. 
 
 661 
 
 Leclanche battery, 272-275 
 
 Lens, crystalline, opacities in, 175 
 
 Lenticular ganglion, aflfections of, 
 175 
 
 Lenticular spots, 137 ; lenticular 
 ganglion, See Third Nerve, Ac- 
 commodation, Pupil 
 
 Lentigo, 118 
 
 Lepra, 116, 118 
 
 Leprosy, 116 
 
 Leptotiirix buccalis, 398 
 
 Leucocytes in urine, 477 
 
 Leucocythffimia, see Leukaemia 
 
 Leucoderma, 142 
 
 Leucorrhoea, discharge in urine, 
 454 ; physiological, before and 
 after menstruation, 516 ; section 
 on leucorrhoea, 516 
 
 Leukaemia, glands in, 146; blood 
 in, 146 ; splenic and lymphatic, 
 146; hemorrhages, 364 ; exami- 
 nation of blood in, 369. See 
 also Spleen 
 
 Levator palpebrsR, paralysis of, 
 161, 168 
 
 Lewis (Filaria sanguinis hominis), 
 500 
 
 Lichen, 114, 118 
 
 Liebig's method of urea analysis, 
 500 
 
 Light, flashes of, 176 : intolerance 
 of, 160 
 
 "Light weight," 18 
 
 Limbs, paralysis of, 209 ; state of, 
 in paralysis, 211 ; contractions 
 and shaking of, in paralysis, 
 215 ; involuntary movements 
 in, 214 
 
 Lime, carbonate of, in urine, 494 ; 
 phosphate of (Fig. 92), 493; 
 oxalate of, 494 
 
 Limpet-shaped crusts, 112 
 
 Linese albicantes, 615 
 
 Lips, quivering of, 215, 322 (see 
 also Labio-glossal paralysis) ; 
 paralysis of, tested by labials, 
 226 
 
 Liquor potassse, test for sugar, 458 ; 
 for pus in urine, 476 
 
 Lithates, see Urates 
 
 Lithic acid, see Uric acid 
 
 Liver, abscess of, opening into 
 lung, 355 ; acute yellow atrophy 
 
 of, 430; congestion of, causing 
 jaundice, 431 ; cirrhosis, cancer, 
 etc., causing dropsy, 433, 441; 
 cirrhosis, 430, 441 ; hemorrhages 
 from disease of, 442 ; cancer of, 
 442 ; nodulation of, 441 ; size of, 
 441 ; visible pulsation in, 566, 
 616; physical examination of, 
 619; dulness, natural, enlarged, 
 diminished, displaced, 622-624 ; 
 density, smoothness, irregu- 
 larity, 625; notch of, 625; gall- 
 bladder, 626 ; local enlargement, 
 625; diminution, 626; pain and 
 tenderness, 626; hydatids of, 
 626, 635. See also Jaundice 
 
 Lividity of face in Facies Hippo- 
 cratica, 28 ; in paral3-sis, 251 
 
 Lividity, rapid development of, 
 37 ; significance of, in chest dis- 
 ease, and occasional absence, 38; 
 associated with febrile flush, 34, 
 38, 343; in dyspncea, 343; of 
 tongue, 400 
 
 Locality, sense of, in anaesthesia. 
 197 
 
 Locomotor ataxy, see Ataxy 
 
 Lordosis, 156 
 
 Lucae, on hearing tests, 187 
 
 Lumbago, 237 ; various causes of, 
 265 
 
 Lumbar regions, situation and 
 contents, 613; tumors in, 637; 
 lumbar reflex, 218 
 
 Lunatic, mode of examining, 328. 
 See Insanity 
 
 Lung, abscess of, 355 ; tissue of, 
 in'sputum, 355, (Fig. 50) 361; 
 hemorrhage from, 355-358; 
 physical examination of lungs, 
 537 ; inspection of chest, 537 ; 
 shape of chest, 538; movements 
 of chest walls, 542; palpation, 
 543 ; mensuration of chest, 544 ; 
 percussion, 546; auscultation, 
 549 ; breath-sounds and respira- 
 tory murmur, 551; rales, 554; 
 friction, 555 ; metallic or am- 
 phoric phenomena, 556; vocal 
 resonance and fremitus, 557 
 
 Lupus, 116, 118 
 
 " Lusty," 19 
 
 Lymphadenoma, Lymphoma, 146 
 
 66 
 
662 
 
 INDEX. 
 
 Lymphangioma, 118 
 
 Lymphatic gland-, see Glands 
 
 Lymphatic leukaemia, 146; ex- 
 amination of blood in, 309 (Fig. 
 53), 371 
 
 Lj'sis, 89; remitting in enteric 
 fever, 89 
 
 H == micro-millimetre, 370 
 
 Mm. = millimetre 
 
 Maeewen (Dr.), on pupil in alco- 
 holic coma, 172 ; percussion of 
 skull, 267 
 
 M'Vail (Dr.), tracing of Cheyne- 
 Stokes re>piration, 346 
 
 Maculae, 111; atrophica, 118 
 
 Magneto-electric batteries (Fig. 
 40), 272 
 
 Magnets m batteries, 271 
 
 Mahomed, sphygmograph, 592, 
 605 
 
 Malassez's instrument for number- 
 ing blood-corpuscles, 369 
 
 Male organs, disorders of (chapter 
 xiv.), 506 
 
 Malignant disease, cachexia, 31. 
 See also Cancer 
 
 Mammffi, changes during preg- 
 nancy, 522 
 
 Mania, maniacal delirium, 256 ; 
 epileptic, puerperal, 257, 316 ; 
 section on varieties of mania, 
 397 ; acute, 398 ; acute delirious 
 mania, 300; mania transitoria, 
 301; chronic mania, 301; sui- 
 cidal and homicidal mania, 312; 
 hysterical mania, 314; mania of 
 puberty, 314 ; diagnosis of, from 
 delirium, 326 
 
 Marey, sphygmograph (Fig. 11.5), 
 591; cardiograph (Fig. 146), 
 608; pneumograph (Fig. 101), 
 545 
 
 Margarine, crystals of, in vomited 
 matter, 406 
 
 Marie Davy element, 275 
 
 Marriage, in case-taking, 65 
 
 Mastication, muscles of, paralysis 
 of, 202 
 
 Mastoid cells, suppuration in, 
 189 
 
 Masturbation, case-taking, 68; 
 fctate of pupil in, 173; section 
 
 on, 507; cause of convulsions, 
 244; in insanity, 300, 315 
 
 Measles, diagram of temperature 
 in, 86; catarrh and cough in. 
 351 ; period of incubation, 131 ; 
 luibility to second attack, 131 ; 
 rash in, 135 
 
 Meatus urinarius, pain in, 504 ; 
 discharges from, 508 
 
 Meckel's ganglion, 202 
 
 Medicines, as causing cutaneous 
 eruptions, 124; as causing sali- 
 vation, 399 ; causing odors from 
 patients, 192, 400; causing black 
 stools, 413 ; coloring urine, 453, 
 498 
 
 Mediocanellata, see Taenia, 416 
 
 Medulla oblongata, affection of, 
 205 
 
 MehBna, 413 
 
 Melancholia, during lactation, 
 317; section on various forms, 
 302; simple melancholy, 302; 
 hypochondriasis, 302; acute 
 melancholia, 303; melancholy 
 with stupor, or melancholia at- 
 tonita, 304 
 
 Membranous shreds in croup and 
 diphtheria, 355 
 
 Meniere's disease, 190 
 
 Meningitis, tubercular, fall of 
 temperature in (diagram), 98; 
 hyperaesthesia in, 211 ; cause of 
 pain in back and neck, 265,' 
 Che3'ne-Stokes respiration in, 
 346; constipation in, 418; diag- 
 nosis from mania, 327 
 
 Menopause, 516 ; insanity at, 315 
 
 Menorrhagia, 513 
 
 Menses, see Menstruation, 507, et 
 seq. ; emansio mensium, 511 ; 
 suppressio mensium, 513 ; men- 
 strual molimen, 512; cessation 
 of, 516 
 
 Menstruation, disorders of, in 
 insanity, 300, 314 ; close of, and 
 insanity, 315; " vicarious " (by 
 lungs), 358; normal and abnor- 
 mal, 507-516; strain of, on 
 development of patient, 512 ; 
 excessive, 513; painful, 514; 
 cessation, 516 ; suppression in 
 pregnancy, 522 
 
INDEX. 
 
 663 
 
 Mensuration in examining chest, | 
 544; in abdomen, G18 
 
 Mentagra, see Sycosis 
 
 Mercurial tremors. 216 ; saliva- 
 tion, 400, 423 
 
 Mercuric iodide test for albumen, 
 465 
 
 Mesenteric disease causing dropsy, 
 440 ; large glands felt in, 440 
 
 Mesmeric trance, 252 
 
 Metalbumen, 444; in urine, 467 
 
 Metallic phenomena in ausculta- 
 tion, 556; tinkling, 556; echo 
 of heart's sounds, 686 
 
 Methaemoglobin, 474 
 
 Metrori hagia, 513 ; at change of 
 life, 516 ; in cancer, 514 
 
 Microcephalic idiot, 48 
 
 Micrococci in sputum, 360; in 
 urine, 486; micrococcus urese, 
 486 
 
 Micrometer, for counting blood- 
 corpuscles, 367 
 
 Microsporon Audouini, 127 
 
 Microsporon Furfur (Fig. 31), 141 
 
 Micturition, frequency and pain 
 in, 603; pain in, from uterine 
 disorder, 519 
 
 Migraine, 263, 459; hemiopia in, 
 181 
 
 Miliaria, 114, 118; miliary vesi- 
 cles, 139 
 
 Milium, 117 
 
 Milk-teeth, formula, 419 
 
 Miscarriages, in case-taking, 63, 
 65, 66 
 
 Mitral murmur, area of, 581 
 
 Mitral stenosis and regurgitation 
 pulse tracings, 605 ; cardio- 
 gr aphic tracings, 612 
 
 MoUities ossium, 156 
 
 Molluscum, 117, 118 
 
 Monocrotic pulse, 599 
 
 Monomania, 305 
 
 Monoplegia, 208, 234 
 
 Moore's test for sugar, 458 
 
 Moral perversit}' in mania of pu- 
 berty, 314; from alcohol, 317; 
 moral insanity, 312 
 
 Morbili, see Measles 
 " Morbus C^eruleus," 344 
 Morell Mackenzie (Dr.), lamp for 
 laryngoscope, 381 
 
 Morphoea, 112, 118 
 
 Motes, 175 
 
 Motions from bowels, frequency 
 of, 409 ; consistency, 409, 413 ; 
 force and straining in expulsion, 
 410; passed in bed, 410; ap- 
 pearance of, 413; consistency, 
 413; size of fecal masses, 413; 
 "formed," 413; "peasoup," 
 "rice-water," etc., 413; color 
 of, 413 ; clayey, 413, 426 ; black, 
 413 ; bloody, 413 ; green and. 
 white, 414 ; mucus in, 414 ; pus 
 in, 414; worms in motions 
 (figures of thread worms and 
 tape worms), 415 ; hydatids in, 
 415 ; fatty matter in, 415 ; gall- 
 stones in, 415.; bones, coins, 
 teeth, etc., 417; smell of, 417 
 
 Motor nerves, electrical testing of, 
 279, 283 
 
 Motor oculi nerve, testing of, 202 
 
 Motor points electrical, Ziemssen's, 
 279, 288 (Figs. 42-47), 281-286 
 
 Mottling in typhus, 137 
 
 Mould in urine (Fig. 85), 487 
 
 Mouth, temperature taken in, 76; 
 paralysis of, 204 
 
 Muco-purulent sputum, 355 
 
 Mucous patches in throat, 379 
 
 Mucous rales, 554 
 
 Mucus, in motions, 414; "mucus 
 disease," 414; in ui'ine, 452 
 
 Muguet, distinction from diphthe- 
 ria, 379; parasite of (Fig. 59), 
 398 
 
 Mulberry rash, 137 
 
 Mumps, "^147 
 
 Murchison (Dr.), on enlargements 
 of liver, 626 
 
 Murexide test for uric acid, 491, 
 497 
 
 Murmur, see Eespiratory murmur 
 
 Murmurs, cardiac, 575 ; rh^nhm 
 of, 575 ; nomenclature (note), 
 576 ; presystolic, 577 ; direct or 
 onward murmurs, 577, 578 ; in- 
 direct or backward, 578; auri- 
 cular-systolic (Fig. 108), 578; 
 ventricular-sj'stolic (Fig. 109), 
 678 ; ventricular-diastolic (Fig. 
 110), 579; combinations of mur- 
 murs (Figs. 111-113), 579, 580; 
 
664 
 
 INDEX. 
 
 postsystolic, prediasystolic, post- 
 diastolic, 581 ; areas of murmurs 
 (Fig. 114), 581-584; tabular 
 view of valvular murmurs, 587 
 
 Murmurs, arterial, 586 ; venous, 
 588; pericardial, 585; aneuris- 
 mal, 585; anaemic functional, 
 htemic, 586 
 
 Muscoe, fixed and floating, 175 
 
 Muscles, development of, in in- 
 fancy, 43 ; tenderness in rickets, 
 33; muscular prostration in 
 fever, 105; pain in, 211; pain- 
 ful cramps of, 211 ; state of, in pa- 
 ralysis, 211 ; apparently hyper- 
 trophied, 212; atrophy of, 212; 
 examination of fragments, 212, 
 567 ; methods of testing power 
 of muscles, with the defects 
 and fallacies, 213 ; contractions, 
 spasms, and tremors in paralysis, 
 213 ; involuntary movements in 
 paralysis, 214 ; fibrillar tremor 
 in, 215; plastic rigidity, 246; 
 muscular atrophic paralysis, 235; 
 action of electricity on, 279, 287 ; 
 localized electrization of, 288; 
 formulae for galvanic reaction of, 
 in health, 288, 289; alterations 
 of reactions in disease, 289-294 ; 
 difi'erent action of faradic and 
 galvanic current, 285, 287; dif- 
 ference in response to galvanic 
 and faradic currents in paralvsis, 
 289, 292, et seq. ; Erb's reaction 
 of degeneration, 289 ; absence 
 of response to electricity, 294; 
 fibres in urine (Fig. 87, "A;), 489. 
 See also Myoidema and Muscu- 
 lar sense 
 
 Muscular sense and sensibility, 
 200; electro-muscular sensi- 
 bility, 282 
 
 Mu.ssitatio, 36 
 
 Mycelium, 128 
 
 Myelitis, electrical reactions in, 
 294 
 
 Myoidema, 24 
 
 Myopia, 178,179; associated with 
 squint, 162; cause of strain on 
 eyes, 175 
 
 Myosis, spinal, 171 
 
 M;yeophobia, 311 
 
 Myxoedema, 112, 435; insanity 
 with, 320 
 
 Nabothian follicles, 531 
 
 Nffivus pigmentosus, 118; vascu- 
 losus, 118 
 
 JS'ails, affections of, curving, white 
 marks, shedding of, 144 ; para- 
 sites in, 144; atrophy of, 118, 
 144, 200; hypertrophy of, 118 
 
 Narcotics, as cause of coma, 253 
 
 Nares, fluids from, causing cough, 
 351 ; bleeding from, 363 ; ex- 
 amination of (chap. X.), 374; 
 method of examining, 394 
 
 ISTaunyn, on cardiac murmurs, 
 583 
 
 Neck, spasm of muscles, 206, 249 ; 
 convulsive twitchings of, 250; 
 wry-neck, 249 ; fixity of muscles 
 in atlantoid disease, 250 ; re- 
 traction and pain in, 265 
 
 Neck, pulsation in vessels, 566; 
 retraction in veins during car- 
 diac diastole, 567 ; murmur in 
 veins of, 586 
 
 Necrosis, 154; " necrosial fever," 
 155 
 
 Negative pole in galvanic battery, 
 how distinguished, 273 
 
 Nerves, cranial, testing of (chapter 
 v.), 159, 202; first, 191, 202; 
 secowtZ, 178, 202 ; third, im-llZ, 
 202-Joarth, 165, 166, 2Q2\ fifth, 
 193, 202; sixth, 161-169, 203; 
 seventh— facial, 194, 203, 293 ; 
 seventh — auditory, 186,189, 205; 
 eiqJith — glosso-pharyngeal, 193, 
 
 205 ; eighth — spinal accessory, 
 205; eighth — pneumogastric, 
 
 206 ; ninth, 206 ; nerves of sen- 
 sation, testing of (electricity), 
 280; motor nerves testing of, 
 283; reduction of muscular re- 
 sponse in electrical stimulation, 
 289 ; nutrition of, how tested, 
 291 ; electrical reactions in lesi- 
 ons of facial, in ear disease, and 
 in cerebral lesions, 292, 293 
 
 Nervous deafness, 186 
 
 Nervous diseases, physiognomy of, 
 
 40 ; group of allied diseases, 68 j 
 
 albuminuria in. 46{| 
 
INDEX. 
 
 665 
 
 Nervous system, in case-taking, 
 58; s3"mptoras of disorder in 
 (cliapter vi.), 208 ; works of 
 reference on, 206, 267; nervous 
 dyspnoea, 347 ; organs of special 
 sense, 159; cranial nerves, 202; 
 paralysis, 208; neuralgia, 236; 
 tits, 238 ; twitchings, 253 ; de- 
 lirium, 255 ; vertigo, 257 ; sleep, 
 259; headache, 262; pain in 
 back, 265 ; central nervous sys- 
 tem, electricalexploration of, 280 
 
 Nettle-rash, -ee Urticaria 
 
 Nettleship's pupilometer (Fig. 32), 
 171 
 
 Neuralgia in skin diseases, 121 ; 
 with paralysis, 200 ; with anaes- 
 thesia, 200, 210; in ataxy, 211 ; 
 pains in infantile paralysis, 211 ; 
 section on neuralgia, 236 ; reflex 
 pains simulating, 237; general 
 state in, 237 ; precautions in di- 
 agnosis of, 237, 238; influence 
 of, on bloodvessels and on nutri- 
 tion, 238 ; with herpes zoster, 
 238 ; tonic spasm and twitch- 
 ings in, 238, 249; in Bright's 
 disease, 238 ; from caries of 
 teeth, 422 
 
 Neuritis, 237 ; optic, 183 ; color 
 blindness in optic neuritis, 181 ; 
 optic neuritis descendens, 186 
 
 Neuroma, 118, 237 
 
 Night-blindness, 182 
 
 Nightmare, 261 
 
 Night-terror.--, 261 
 
 Night-walking, 261 
 
 Ninth nerve, 206 
 
 Nipples, see Mammte 
 
 Nitrate of silver, discoloration 
 from, 126, 140 
 
 Nitrate of urea, 463 
 
 Nitric acid test for albumen, 461 ; 
 quantitative, 466 
 
 Nitrogenous principles in urine, 
 estimation of, 499 
 
 Nodding in shaking palsy, 215; 
 nodding convulsions, 216, 250 
 
 Nodosity of joints, 148 
 
 Noises in ear, 189 
 
 Noma, 422 
 
 Nose, in case-taking, 58 ; exami- 
 nation of, 191 : running from. 
 
 192; fetor from, 192; works of 
 reference on, 207 
 
 Nose, picking of, 121, 364 ; action 
 of dilator narium, in dyspnoea, 
 336; bleeding fronn, in whoop- 
 ing-cough and other diseases, 
 350, 364 
 
 Nuck, canal of, 533 
 
 Numbness, 201 
 
 Nummular sputa, 355 
 
 Nutrition, indications of, from 
 electrical reactions, 291 
 
 Nyctalopia, 182 
 
 Nycturia, 231 
 
 Nymphomania, 315 
 
 Nystagmus, 176 
 
 0=CEff'nung, opening of circuit 
 (electricity], 289 
 
 Obesity, 21 " 
 
 Objective symptoms, 54 
 
 Oblique muscles of eye, 165, 166 
 
 Obliquity in objects seen, 165, 166 
 
 Obscenity in insanity, 300, 316, 
 321 
 
 Occupations predisposing to dis- 
 ease, in case-taking, 64 
 
 Ocuhir muscles, paralysis of, 161, 
 174; functions of (table), 164; 
 results of paralysis (table), 165 ; 
 positions of the head in paraly- 
 sis, 167 ; clinical significance of, 
 167; erroneous projection of ob- 
 jects in, 169 ; monocular vertigo 
 in, 169; convulsive movements 
 in, 176 ; asthenopia, 175; paraly- 
 sis in syphilitic insanity, 318 
 
 Ocular vertigo, 169 
 
 CEdema, of glottis, 390 (see also 
 Catarrh of larynx, 387) ; section 
 on oedema, 432; of feet, 433; 
 of upper part of body, 434; lo- 
 calized oedema, 434 ; of hands 
 and feet in infants, 248, 434 
 
 (Esophagus, spasms of, 251 ; oeso- 
 phageal vomiting, 404 
 
 Ohm's^law, 274 
 
 Oidium albicans (Fig. 59), 398 
 
 Oil in motions, 415; in tube- 
 casts (Fig. 78, a), 482 ; globules 
 in urine l^Fig. 87, e), 489 
 
 Oinomania, 317 
 
 Olfactory nerve, 202 
 
 56* 
 
666 
 
 INDEX. 
 
 Oliver (Dr.), method of finding sp. 
 gr. of urine, 450 ; tests for sugar, 
 459 ; for albumen, 465 ; biliary 
 acids, 498 
 
 Onward cardiac murmurs, 577, 
 578 
 
 Onychia, 144 
 
 Opacity of cornea, 159 
 
 Opaque granular tube-casts, 481 
 
 Ophthalmoplegia externa and in- 
 terna, 174 
 
 Ophthalmoscopic, examination of 
 eye, 182 ; significance of appear- 
 ance in diagnosis, 184 
 
 Opisthotonos, approach to this in 
 infantile spasms, 248 ; character 
 of, 250 
 
 Opium, rash, 125; influence on 
 pu})ils, 171 ; extreme effect in 
 renal disease in causing coma, 
 253, 262 ; a cause of insanity, 320 
 
 Optical defects of eye, 178 
 
 Optic nerve, field of, and vision in 
 aff'ections of, 180; ophihalmo- 
 sc<)f)ic examination, 182, ei seq ; 
 testing of, 202; atrophy in gen- 
 eral parah'sis, 323 
 
 Orbicularis palpcbiarum, 204 
 
 Organic dementia, 308 
 
 Organisms, living, in blood, 372 
 
 Orthopnoea, 39, 338 
 
 Os (uteri), see XTterus 
 
 Ostitis, 154 
 
 Otorrhoea, 189 
 
 Ovaries, anesthesia from irritation 
 of, 199; headache from ovarian 
 irritation, 264; hyperaisthesia 
 of, 248; dii-ease of, a cause of 
 insanity, 315; dropsy of, physi- 
 cal signs from percussion, etc. 
 (Fig. 71), 438,634; fluidremoved 
 from ovarian cysts, 444 ; from 
 parovarian cysts, 444 ; pear- 
 shaped cells in fluid from ma- 
 lignantdisease, 445 ; absence of, 
 causing amenorrhosa, 511 ; pains 
 in dysmenorrhoea, 515; exami- 
 nation of, 532; from vagina or 
 rectum, 532; pelvic ovarian tu- 
 mors, 533, 536 ; tumors and 
 cysts, 634 
 
 Over weight as indicating diathesis, 
 22 
 
 Ovula nabothi, 531 
 
 Oxalates in urinary sediments, 
 454, 494 (Fig. 93), 495 
 
 Oxaluria, 495 
 
 OxA'genation of blood, how inter- 
 cepted in disease, 37 
 
 Oxyurides vermiculares (Figs. 61, 
 62), 415 
 
 Ozena, 192 
 
 Ozonic ether with guaiac, test for 
 blood in urine, 472 
 
 Pain in heart disease, 39 ; noc- 
 turnal pains in bones, 155; loss 
 of sense of pain with preserva- 
 tion of tactile sense, 196 ; and 
 numbness in same parts, 200; 
 and paralysis in same parts, 211 ; . 
 muscular, 212 ; electric or tooth- 
 ache-like in ataxy, 211; in 
 limbs from spinal meningitis, 
 234; thoracic pain, 341, 343, 
 364; in left arm, 343; abdomi- 
 nal and in bowels, etc., 410; 
 from gall-stones, 428; in mic- 
 turition, 503; in pelvic region, 
 518; in back, see Menstruation, 
 Dysmenorrhcea, etc. 
 
 Pair, galvanic, 269 
 
 Palate, paralysis of, 202, 203; nasal 
 tone from paralysis of, 226 ; 
 arched in idiocy, 42, 325; catarrh 
 of, 376; diphtheritic affection, 
 378; destruction of, in svphilis, 
 379 
 
 Pallor of complexion in anremia, 
 25; in renal dropsy, 432; of 
 tongue, 400 
 
 Palpation, in examining larynx, 
 385; lungs, 543 ; in examining 
 heart, 559, 561 ; abdomen, 617 
 
 Palpebra, paralysis of elevator, 
 161, 168; of 'orbicularis, 161, 
 204; convulsive movements of, 
 176 
 
 Palpitation of heart, section on, 
 333, 340 ; sense of palpitation in 
 epigastrium, 340; various causes 
 of palpitation, 340, 341; in 
 uterine aftections, 521 
 
 Palsy, see Paralysis 
 
 Pancreas, examination of, 631 
 
 Papilla optic, see Optic nerve 
 
INDEX. 
 
 667 
 
 Papulse, 111, 113 
 
 Paraeentesi.'?, see Tapping 
 
 Paiiesihesia, 201 
 
 Paralbumen in ovarian fluids, 445; 
 in urine, 445 
 
 Paralysis, physiognomy of, 40; 
 spastic, 41, 233 ; paralysis of 
 ocular muscles, 161 ; of cranial 
 nerves, 202; investigation of 
 paral3^sis, 208 ; distribution of 
 paralysis, 208 ; " crossed " paral- 
 ysis, 208 ; of special limbs, mus- 
 cles, nerves, or functions, 208; 
 state of intelligence and emo- 
 tions in paralysis, 209; prodro- 
 mata and warnings of paralysis, 
 209; sensations of the skin in 
 paralysis, 210 ; pain and paral- 
 ysis, 211 ; rheumatic, 211 ; state 
 of muscles and limbs in paral- 
 ysis, 211 ; trophic lesions in, 213; 
 lowered temperature and rapid 
 wasting in, 213,234; bedsores 
 in, 213 ; secondary fever from 
 bedsores, 214; involuntary 
 movements in parah'sis, 214; 
 jiaralysis after epilepsy, 214; 
 choreic movements and shaking 
 in, 215; reflex actions in, 216; 
 shaking palsy, paralysis agitans, 
 215; walking aft'ected in paral- 
 ysis, 41, 222, 224; scrivener's 
 palsy or writer's cramp, 229 ; of 
 bladder and rectum, 229; of 
 sphincters, 229 ; clinical signifi- 
 cance of paralysis, 232; diph- 
 theritic, 174, 219, 235 ; of ex- 
 tensors of arms, 234 ; lead 
 paralysis, 235 ; affection or es- 
 cape of supinator longus, 235 ; 
 wasting palsy, 235 ; traumatic 
 paral3'sis, 235 ; alcoholic paral- 
 ysis, 235 ; mental disorders in 
 alcoholic paralysis, 235 ; paral- 
 ysis after fe\-ers, 236 ; delusions 
 in paralysis, 236 ; sudden paral- 
 ysis, 251 ; conjugate deviation 
 of eyes in sudden paralysis, 177; 
 tests by electricity, 291 ; paral- 
 ysis of vocal cords, 390 ; Facial 
 Paralysis, single and double, 
 41 ; tests of, 203 ; electrical re- 
 actions in, 292; double, 205; 
 
 Glosso-labio-larynqeal Pa- 
 ralysis, 41, 205,206; Infan- 
 tile Paralysis, walking in, 
 222; diagnosis from hip-joint 
 disease, 225; peculiarities of, 
 234; knee-jerk in, 219; elec- 
 tricity, 294 ; G-ENERAL Paral- 
 ysis OF THE Insane, 40, 321 ; 
 section on symptoms and diag- 
 nosis of, 321 ; inflated ideas in, 
 210, 322; librillar tremor in, 
 215; walking in, 41, 222,225, 
 diagnosis from syphilitic in- 
 sanity, 318; from alcoholic in- 
 sanity, 324 ; from monomania, 
 324 ; from locomotor ataxy, 324 
 
 Parametritis, 533 
 
 Paraplegia, gait in, 41, 222 ; defl- 
 nition of, 208; involuntary 
 movements of legs in, 214 ; al- 
 coholic paraplegia, knee-jerk in, 
 220; paralysis of bladder and 
 rectum in, 232 ; reflex, 232; and 
 hemiplegia combined, 233; S3'ph- 
 ilitic disease as cause of, 234 ; 
 causes of, 234 ; hysterical para- 
 plegia, 234 
 
 Parasites, of skin, 119; itch insect 
 (Fig. 23), 120; infection, 122; 
 pediculis pubis (Fig. 24), 123; 
 examination of, 126 ; of hair, 
 126; parasites of hair (Figs.) 
 125, et seq.\ parasite on tongue, 
 398 (see Bacteria in blood) ; and 
 also Worms and Echinococci 
 
 Parasternal line, 560 
 
 Paresis (slight paralysis), see 
 Paralysis ; general paresis (see 
 General paralysis) 
 
 Parotitis, 146 
 
 Parovarian cysts, fluid from, 444 
 
 Paroxysmal hemoglobinuria (hse- 
 matinuria), 474 
 
 Parrot, on syphilitic skull, 154 
 
 Patellar tendon reflex, see Knee- 
 jerk 
 
 Patheticus (nerve), 202 
 
 Pavy's copper test solution fur 
 sugar, 457 
 
 Pear-shaped cells in ovarian can- 
 cer, 445 
 
 Pectoriloquy, 557 
 
 Pediculosis, 119 
 
668 
 
 INDEX. 
 
 Pediculus pubis (Fig. 24), 123 
 
 Peliosis, 153 
 
 Pelvic cellulitis, 533 
 
 Pelvic inflammations, 533 
 
 Pelvi-peritonitis, 411 
 
 Pelvis, symptoms referred to, 516; 
 pain, 518; examination of, in- 
 teriorl}', 524 ; normal position 
 and relation of parts, 528; fulness, 
 hardness, etc., in, 534; differen- 
 tial diagnosis of tumors in, 535 
 
 Pemphigus, 115, 118 
 
 Penis, see chH))ler xiv., 50G 
 
 Peptones in urine, 467; signifi- 
 cance of, 467 
 
 Percussion, of the skull, 266 ; dul- 
 ness in ascites (Fig. 70), 436; 
 dulness from great distention of 
 
 , bowel, 438 ; dulness in ovarian 
 dropsy (Fig. 71), 438; pulmo- 
 nary, 546 ; immediate or direct 
 {.icrcussion, 546; clear, tympan- 
 itic, and dull, 547, 548 ; cracked- 
 pot sound, 548 ; signiticance of 
 dull-percussion, 546-548; area 
 of normal percussion of heart, 
 liver, and spleen (Fig. 1,02), 
 563 ; decrease of caidiac dul- 
 ness, 567 ; increase of same, 567; 
 displacement, 569 ; in thoracic 
 aneurism, 588 ; of abdomen, 618; 
 of liver, 621 (Fig. 157), 623; 
 auscultatory })ercussion, 619 
 
 Pericardium, effusion into (Fig. 
 104), 569; pericardial murmurs, 
 685 
 
 Perichondritis, laryngeal, 389 
 
 Perihepatitis, a cause of jaundice, 
 427 ; of dro|)Sy, 441 
 
 Perimetritis, 411, 533 
 
 Periodontitis, 423 
 
 Periostitis, 154 
 
 Peristalsis, visible, 418, 616 
 
 Peritoneum, pain and tenderness 
 in, 411; fluid in, 435; inflam- 
 mation, with effusion, 439 
 
 Peritonitis, 411, 439 
 
 Perityphlitis, 411 
 
 Pernicicjus aniemia, 27; small red 
 cells in blood, 371 
 
 Perspiration, in fevers, 34, 35; 
 absence of, in diabetes, 34; in 
 wiry and corpulent persons, 34 
 
 Pertussis, 349 
 
 Petechia, 137, 140 
 
 Petit mal, 241 
 
 Petrosal branch of Vidian nerve, 
 203, 204 
 
 Phantom tumor, 636 
 
 Pharynx, paralysis of, 205; catarrh 
 of, 376 ; granular pharyngitis, 
 376; syphilitic ulcers in, 379; 
 retro-pharyngeal abscess, 380 
 
 Phlegmasia dolens, haemoptysis 
 in, 358 
 
 Phlegmonous ervsipelas, 139 
 
 "Phobias," 310" 
 
 Phosphates, precipitation of, on 
 heating urine, fallacy from, 461 ; 
 with pus in urine, 476 ; deposits 
 in urine, 492, 495; "triple" 
 (Fig. 91), 492; phosphate of 
 lime crystals (Fig. 92), 493 
 
 Photophobia, 160 
 
 Photopsia, 176 
 
 Phthiriasis, 123 
 
 Phthisis, atrophy of, 24 ; physiog- 
 nomic signs of, 24; Aretaeus on, 
 29 ; heredity in, 70 ; atavism in, 
 72; temperatures in (diagrams), 
 80, 81, 82; collapse of tempera- 
 ture in (diagram), 91; super- 
 vention of meningitis on (dia- 
 gram of temperature), 98; 
 phthisical insanity, 320; bron- 
 chial phthisis, 351 ; simulated 
 by foreign bodies in bronchi, 
 352; haemoptysis in, 358; tu- 
 bercle bacilli and lung tissue in 
 sj)it of, 359 361 ; of larynx 
 (JFig. 56), 389; red line on gums, 
 423 
 
 Phimosis, causing wetting the 
 
 bed, 231 
 Physical diagnosis or physical 
 
 signs (chapter xvi.), 537 
 Physical examination of chest and 
 abdomen (chapter xvi.), 537; 
 of lungs, 537 ; of heart, 559 ; of 
 abdomen, 613 
 "Physical signs," 54 
 Physiognomy of disease, 13 (see 
 names of sjiecial diseases in in- 
 dex) ; references to works on, 51 
 Pica, 397 (also name of type some- 
 times used in testing vision) 
 
INDEX. 
 
 669 
 
 Picric acid test for sugar, 459 ; for 
 albumen, 463; fallacies in, 464 ; 
 quantity of albumen, 466 
 
 Pig-eon-breast, 156 (Fig. 97), 539; 
 from enlarged tonsils, 377 
 
 Pigmentation of skin, 140 
 
 Pimples, 111 
 
 '' Pins and needles," 201 
 
 Pitting in dropsy, 433 
 
 Pityriasis, 111, 116; pityriasis 
 rubra. 111, 116, 118 ; pityriasis 
 versicolor, 116, 141 
 
 Plague, glandular atfection in, 147 
 
 Plantar reflex in health and dis- 
 ease, 216, 217; C(nnpared with 
 voluntary movement, 217; in- 
 dication drawn from, 217 
 
 Plastic rigidity, 246 
 
 Play, instinct of, 44 
 
 Plessor, 546 
 
 Plethora, 27 
 
 Pleura, perforation of, as cause of 
 dyspnoea, 337 ; pleuritic stitch, 
 341 ; examination of fluids re- 
 moved by tapping, 362 ; afiec- 
 tions of, giving dulness on per- 
 cussion, 548 ; obscuring breath- 
 sounds, 551 ; eflfusions, displac- 
 ing heart, 571 
 
 Pleurosthotonus, 250 
 
 Pleximeter, 546 
 
 Pneumococci in sputum, 360 
 
 Pneumogastric nerve, 206 
 
 Pneumograph (Fig. 101), 545 
 
 Pneumonia, lobar and catarrhal, 
 temperature in (diagrams), 89; 
 lobar, crisis of (diagram of 
 temp., pulse, resp.), 97 ; pyemic 
 disease of joints in, 152 ; expec- 
 toration in, 357 ; jaundice in, 
 430. See also chap. xvi. 
 
 Pneumothorax, as cause of dysp- 
 noea, 336, 337; displacing heart 
 and mediastinum, 572 
 
 Poisons, causing jaundice, 430 
 
 Polar method (electricity), 280 
 
 Polariscope, test for sugar, 460 ; 
 for estimating quantity of albu- 
 men, 466 
 
 Poles in galvanic battery, how 
 distinguished, 273 
 
 Poliomyelitis, anterior, see In- 
 faritile paralysis 
 
 Politzer's bag for inflating ear, 
 188 ; on hearing tests, 186 
 
 Pollution, morbid fear of, 311 
 
 Polysesthesia, 198 
 
 Polvmorphism in skin diseases, 
 148 
 
 Pom phi, 110 
 
 Pompholyx, 115 
 
 Pond's sphvgmograph and cardio- 
 graph (Fig. 117), 594 
 
 Pons varolii ; pupils in hemor- 
 rhage into, 172 
 
 PorrigOj 115 
 
 Portal vein, obstruction of, caus- 
 ing dropsy, 441 
 
 Portio dura, testing of, 203; 
 double paralysis, 41, 204 
 
 Positive pole in galvanic battery, 
 how distinguished, 273 
 
 Postdiastolic and postsystolic mur- 
 murs, 581 
 
 Post-pharyngeal abscess, 380 
 
 Potain's melangeur for diluting 
 blood (Fig. 51), 367 
 
 Pott's disease, 157; reflexes in, 
 217; knee-jerk in, 219; ankle 
 clonus in, 220 
 
 Powdered-wig deposit in urine, 
 454 
 
 Prealbuminuric stage (nephritis), 
 471 
 
 Prediastolic murmur, 581 
 
 Pregnancy, hemiplegia in, 234; 
 convulsion? in, 213 ; insanity 
 during, 316; dyspnoea in, 348; 
 albuminuria in, 469; leucor- 
 rhoea during, 517 ; diagnosis of, 
 521 
 
 Presbyopia, 174, 178 
 
 Presystolic murmurs, 577 
 
 Priapism, 507 
 
 Prichard(Dr. J. C), on "Tem- 
 perament," 23 
 
 Primar}' battery- current, 270 
 
 Primary induced current, 271, 277 
 
 Proglottides of tape-worms (Figs. 
 64, 65), 416 
 
 Progressive locomotor ataxy and 
 progressive labio-glosso-laryn- 
 geal paralysis, see Ataxy and 
 Glosso-labial paralysis 
 
 Progressive muscular atrophv, 
 235, 294; loss of voice, 391 
 
670 
 
 INDEX. 
 
 Prolapsus of uterus and vagina, 
 
 530 
 Protoplasm, minute fragments in 
 
 blood, 372 
 "Prune-juice" expectoration, 
 
 358 
 Prurigo, 114, 118 ; pruriginous 
 
 eruption; 114, 115, 121 
 Pruritus, 119, 121; pruritus 
 
 vulvae, 533 
 Pseudo -hypertrophic muscular 
 paralysis, 212 ; distortion of 
 spine in, 149; electrical reac- 
 tions in, 294; lojs of knee-jerk 
 in, 219 ; rising from recumbent 
 posture in, 225 
 Pseudo- paralysis in infantile 
 
 sypiiilis, 155 
 Psoriasis, 116, 118 
 Ptosis, 161, 168 ; apparent, in 
 
 diplopia, 167 
 Puberty, mania of, 314 
 Puerile breathing, 551. 552 
 Puerperal state, convulsions in, 
 
 243; albuminuria in, 468 
 Puerperal fever and erysipelas, 
 connection between, 139; joint 
 affections in puerperal state, 
 152; puerperal mania, 316 
 Pulmonary artery, embolism and 
 thrombosis of, 37, 337, 358 ; 
 aneurism of, a cause of haemop- 
 tysis, 359; visible pulsation in, 
 566 ; area of murmurs connected 
 with, 583 
 Pulsation, audible, 190 ; visible 
 in arteries, 103 ; in epigastrium, 
 341, 565; in abdomen, 616; 
 from abdominal aorta, 341, 565 ; 
 from right ventricle, 565; at 
 base of heart, 566 ; from auricles 
 and pulmonary artery, 566 ; in 
 vessels of neck; 566 ; in thorax 
 from aneurism, 568, 588 ; pul- 
 sating tumor, 588, 590. See 
 also Apex-beat. 
 Pulse, works on, 108; frequency 
 of, 96; pulse-rate, 97 ; influence 
 of movement, food, and stimu- 
 lants on, 97; diurnal range of, 
 97 ; comparison with temper- 
 ature (diagrams), 98, 99; slow- 
 ness of, 99 ; strength of, 100 ; 
 
 ratio to respiration, 97 ; effect 
 of abnormal division of vessels 
 on, 100 ; different on two sides, 
 100; not synchronous on two 
 sides, 100; hardness of, 100; 
 rhythm of, 101 ; intermission. 
 and irregularity of, 101, 341, 
 600; significance of, 102 ; trac- 
 ing of 606; influence of respi- 
 ration on (diagrams), 101, 601 ; 
 dicrotous, 103; tracing of, 597; 
 hyper-dicrotous pulse, tracing 
 of, 598; pulse of unfilled arteries 
 (aortic regurgitation), 103 ; 
 thrill in pulse, 103; healthy 
 pulse (tracing), 595; aortic re- 
 gurgitation (tracing), 604 ; in- 
 equality on two sides (tracing), 
 607 ; senile rigid artery (trac- 
 ing), 603; pulse in Bright's 
 disease (tracing), 597 ; increased 
 tension, 597 ; sense of throbbing 
 in pulses, 341; katacrotic, 595; 
 anacrotic, 595; monocrotic, 599 ; 
 pulsus alternans, bigeminus, 
 and trigeminus, 600; pulsus 
 paradoxus, 602 ; in aortic sten- 
 osis, 603 ; mitral disease, 605 ; 
 venous pulse (tracing), 607; 
 capillary pulse, 605 (see Sphyg- 
 mograph, r..90) 
 
 Pulse-wave, parts of (tracing), 602 
 
 Pupilometer, Nettleship's (Fig. 
 32), 171 
 
 Pupils, contracted in fevers, 35 ; 
 dilatation of, 168; inequality 
 of, 170, 323 ; irregularity of, 
 170; variations in size of both, 
 dilatation and contraction, 170 ; 
 sensitiveness to light, 170, 173 ; 
 methods of estinuiting size of, 
 171; reflex dilatation of, 172; 
 rhythmical alternations in size 
 of,'l73,347; oscillation of, 173; 
 artificial, 170; contraction of, 
 during accommodation and con- 
 vergence, 174 ; "Argyll Kobert- 
 son pupil," 174 
 
 Purging, see Diarrhoea 
 
 Purpura, 113, 118, 140; purpura 
 rheumatica, 153 ; hemorrhages, 
 in, 358, 363 
 
 Purring tremor, 571 
 
INDEX. 
 
 671 
 
 Pus, in sputum, 355 ; profuse ex- 
 pectoration of, 355; in fluids 
 removed by tapping chest, 363 ; 
 vomited, 406; in motions, 414; 
 in the urine, 476 ; pus corpuscles 
 (Fig. 75), 477 ; lest of pus by 
 liquor potass^, 476 ; significance 
 of pus in urine, 478 
 
 Pus-casts, 481 
 
 Pustulffi, 111, 115; malignant 
 pustule, blood in, 372 
 
 Pyaemia, temperature in, 86 ; 
 joints affected, 152; idiopathic, 
 153 ; a cause of jaundice, 431 
 
 Pyelitis, 478 
 
 Pvonephrosis, 478; renal tumor 
 "in, 630 
 
 Pyo-pneumothorax, 556 
 
 Pyrexia, the class pyrexias, 30 
 general signs of pyrexia, 74, 103 
 rise and duration of, 86, et seq. 
 clinical significance of pvrexia, 
 106 
 
 Pyromania, 312 
 
 Pyrosis, 407 
 
 Pyuria, 476 ; significance of, 478 
 
 Quickening, 524 
 
 Quinine, rash from, 124; a cause 
 
 of tinnitus, 190 
 Quinsy, 376 
 
 R. D. = reaction of degeneration 
 (electricity), 289 
 
 "Pvachitic rosary," 165, 540 
 
 Eales, pulmonary, 554; sonorous 
 and sibilant, 554; bubbling or 
 mucous, 554 ; crepitant, 555 ; 
 friction rale, 555 
 
 Ranula, 400 
 
 Eashes, febrile, 106, 119, 130; date 
 of appearance of, 130 
 
 Paving, see Delirium and Mania 
 
 Reactions, qualitative changes in 
 (electricity), 289 ; reaction of de- 
 generation, 289 ; partial form of, 
 290; inleadparalysis, 290, 294; 
 significance of electrical reac- 
 tions, 291 ; general theory of, 
 292 ; in facial paralysis, 293 ; in 
 infantile paralysis, 293 ; in mye- 
 litis, 294; in progressive muscu- 
 
 lar atrophy, 294 ; in pseudo- 
 hypertrophic muscular paralysis, 
 294 
 Reaction of urine, 451 
 Recrudescence of fever, 90 
 Recti muscles of eye, 164, 165, 166 
 Rectum, temperature taken in, 76; 
 paralysis of, 229; pains in, 412; 
 abscesses opening into, 414; ex- 
 amination of pelvic organs per 
 rectum, 526 
 Recumbent posture, manner of 
 
 rising from, in disease, 224 
 Recurrent laryngeal nerve, paral- 
 ysis of, 392 J (Figs. 57, 58), 393 
 Red blood-corpuscles, see Blood 
 Reduplication of heart's sounds, 
 
 574 
 Reflex actions in paralysis, 214- 
 224 ; clinical significance of, 
 216 ; superficial reflexes and in- 
 dications drawn from them, 216, 
 217, 218 ; deep reflexes and clini- 
 cal significance of variations in 
 them, 218-222; reflexes in arm 
 and wrist, 222; reflex paralysis, 
 282 ; reflex actions in para- 
 plegia, 234 
 Regions, anatomical, of chest, 537 ; 
 
 of abdomen, 613 
 Regurgitation of food, 407 
 Reid (Dr. R. W.), on the localiza- 
 tion of cerebral convolutions, 
 267 
 Relapses, effect of, on temperature, 
 
 90 
 Relapsing fever, diagram of tem- 
 perature in, 85 ; occasional rash 
 in, 130, 137; affection of joints 
 in, 1-50 ; bacterium in blood, 372 
 Relaxed throat, 376 
 Religious fervor in insanity, 315 
 "Remittent" fever, diagram of, 
 
 80 
 Renal tube-cast and epithelium, 
 
 see Tube-casts and Epithelium 
 Reporting of medical cases, 62 
 Reproductive system, in case-tak- 
 ing, 59 (see chapters xiv. and 
 
 XV.) 
 
 Residence, importance of, in case- 
 taking, 66 
 Resistance in electricity, 274 
 
672 
 
 INDEX. 
 
 liesonance of voice in auscultation , 
 557 ; of observer's voice, 557 ; of 
 heart's sounds, 559 
 
 Respiration, physiognoniv of vari- 
 ous kinds of, 38 ; muscles of, in- 
 volved in general paralysis, 322 ; 
 number of respirations per min- 
 ute, 335; as indicative of dys- 
 pnoea, 335 ; accelerated in febrile 
 and non-febrile states, 335; sigh- 
 ing, suspirious, Cheyne-Stokes 
 respiration, 39, 344; tracing 
 (Fig. 48), 346 ; " cerebral " res- 
 piration in brain disease and 
 fevers, 345 ; laborious, 336, 347 ; 
 movements of, thoracic and ab- 
 dominal, 542 ; movements of ab- 
 domen and abdominal organs, 
 616 
 
 Respiratory murmur, variations in 
 health, 551 ; weakened, 552 ; ex- 
 aggerated or puerile, 552 ; jerky, 
 sighing, 552 ; prolonged expira- 
 tion, 553 ; bronchial or tubular, 
 553 ; cavernous, 553 
 
 Respiratory system, in case-taking, 
 59; chapter ix. on disorders of, 
 333 ; works of reference on, 373. 
 See also chapter xvi. parts 1 
 and 2 
 
 Retention of urine, 229, 230 ; with 
 incontinence, 231 
 
 Retina, ophthalmoscopic exami- 
 nation of, 183; hemorrhages, 
 exudations, etc., 184; hj^per- 
 sesthesia of, 160 ; hemorrhages 
 in, 364 
 
 Retinitis pigmentosa, 182 
 
 Retraction of one side of chest, 
 542; lateral curvature of the 
 spine from, 542; of abdomen, 
 615; of neck, 265 
 
 Retropharyngeal abscess, 380 
 
 Retroversion and retroflexion of 
 uterus, diagnosis of, 529 
 
 Rheophore, 276 
 
 Rheostat, 276 
 
 Rheumatic gout, rheumatoid ar- 
 thritis, rheumatic arthritis, 148 
 
 Rheumatism, diathesis of, 82; 
 group of allied diseases, 68; af- 
 fection of joints in, 147, acute 
 rheumatism, 148 ; chronic rheu- 
 
 matism, 150; quasi-rheumatic 
 aftections in scarlatina, 150, 152; 
 in relapsing fever, 150; gonor- 
 rhoeal rheumatism, 150; simu- 
 lated by spinal meningitis, 211 ; 
 as cause of neuralgia, 237; al- 
 lied to chorea, 254; cause of in- 
 sanity, 319 
 
 Rhinoscleroma, 118 
 
 Rhinoscopy in aural disease, 188; 
 method, 394 ; when called for, 
 894; works of reference on, 
 395 
 
 Rhythm of pulse, 101 ; of respira- 
 tion, 344; of respiratory mur- 
 mur, 553 ; of cardiac murmurs, 
 575, 586 
 
 Rickets, physiognomy of, 32 ; pre- 
 cursory symptoms, 82 ; Jenner 
 on, 33 ; cachexy in, 33 ; affec- 
 tions of skull in, 154 ; ends of 
 bones in, 155 ; " acute rickets," 
 155; distortion of long bones 
 in, 156 ; distortion of spine in, 
 156; lateness of walking in, 
 222 ; tendency to convulsions 
 and laryngismus stridulus, 248, 
 851 ; systolic bruit over fonta- 
 nelle in, 226 , respiration in, 836; 
 abdomen in, 408 ; teeth in, 419; 
 chest in (Fig. 98), 539 
 
 Rigidity, initial early and late, in 
 paralysis, 213 ; plastic rigidity, 
 246 
 
 Rigors, in fever, from passage of 
 catheter, etc. , 35, 105; in jaun- 
 dice, 428 
 
 Ringworm (see Tinea tricophy- 
 tina), 119, 127 ; of nails, 144 
 
 Rinne's experiment in ear disease, 
 187 
 
 Rise of temperature, manner of, 
 85, 86, 87; in relapses, 94 
 
 Roberts (Sir AVm.), on case-tak- 
 ing, 55, 56 ; on estimation of 
 suii'ar b}' fermentation, 458; on 
 estimation of albumen, by nitric 
 acid, 466 ; on bacteria in urine, 
 487 
 
 Robertson (Dr. Wm.),on relative 
 heiglit and weight, 17 
 
 Ronchi, see Rales 
 
 Rosalia, see German measles 
 
INDEX. 
 
 673 
 
 Eoseola, 113 ; exanlhematica, 133; 
 see also German measles, 132, 
 135 
 
 Rose-spots, 137 
 
 Rotiieln, see German measles 
 
 Round worms, 414 
 
 Rubeola notha, see Gorman mea- 
 sles ; rubeola, see Measles 
 
 Running, cause of dyspnoea, 339 
 
 Rupia, 112, 115 
 
 Russell and "West's solution of 
 
 Sclerosis, cerebro-spinal, nystag- 
 mus in. 177,216; mental state 
 in, 209; muscular tremor in, 
 211 ; gait in, 215; lateral scle- 
 rosis, rigidity in, 213 ; knee-jerk 
 in, 219; ankle clonus in, 220; 
 walking in sclerosis with spasm, 
 223 
 Scratching in skin eruptions, 121 
 Scrivener's palsy, see Writer's 
 cramp 
 
 hypobromite of sodium for urea i Scrofula (see also Struma), ca- 
 
 analysis, 502 
 Rusty spit of pneumonia, 357 ; ab- 
 sence of, 357 
 
 S = sensation (electricity), 289 
 
 S = Schliessung = closing of cir- 
 cuit (electricity), 289 
 
 Saddle-back, 156 
 
 Salaam convulsions, 215, 250 
 
 Salicylic acid rash, 124 
 
 Salivation 399, 423 
 
 Salt (common) test for albumen, 
 466 
 
 Salter (Dr.), on the A.S. and Y.D. i Sedatives, use of, case-taking, 65 ; 
 murmur, 577 i cause of sleeplessness, 261 
 
 Sand in urine, see Gravel, Urine, j Sediments in urine, 454 
 
 etc. j Semen, emissions of, 508 (see also 
 
 Sanders (Professor), on case-tak- ! Spermatozoa) 
 
 ing, 55 I Senile decay, 15; dementia, 306; 
 
 Santorini, cartilages of, in larynx, [ pulse (tracing), 600, 602 
 
 chexia of, 30 : group of diseases 
 
 allied to, 67; glands in, 145 
 Scrofuloderma, 118 
 Sculpture, and ideal proportions, 
 
 23 
 Scurvy, 140 ; joints pained in, 
 
 153 ; hemorrhages in, 364 ; gums 
 
 in, 423 
 Scybala, 413 
 Seborrhoea, 117 
 Second nerve, see Optic nerve 
 Secondary induced current, 273, 
 
 277 
 
 387 
 
 Sarcina yentriculi (Fig. 60), 406; 
 in urine, causing turbidity. 452 
 
 Sarcoma, 118 
 
 Satyriasis, 315 
 
 Scabies, 115; acarus scabiei (Fig. 
 23), 119 
 
 Scabs, see Crusts, 112 
 
 Scales, 111 
 
 Scapular reflex, 218 
 
 Scarlatina, rise of temperature in, 
 86 ; rash, 131 ; period of incu- 
 bation, 131 ; liability to second 
 attack, 131 ; glands in, 146 ; 
 joints in, 150, 152 ; cause of 
 chorea, 254; throat in, 377; 
 tongue in, 399 ; albuminuria in, 
 468 ; prealbuminuric and post- 
 albuminuric stage of, 473 
 
 Sclereme, 118, 435 
 
 Scleroderma, 112, 118 
 
 Sensation, common, 195; slowness 
 in transmission of, 195; tests 
 for, 196 ; diminution and per- 
 versions of, 201 ; affected in 
 paralysis, 210; in insanity, 296, 
 312; action of electricity on 
 neryes of, 279, 280 
 
 Sense, organs of, examination and 
 disorders of, 159 ; eye, 159 ; ear, 
 186; nose, 191; taste, 193; 
 touch, 196 ; sense of tempera- 
 ture, 196 ; sense of pressure, 
 200; muscular sense, 200 
 
 Sensibility of the skin and mus- 
 cles, 195, et seq. ; electro-mus- 
 cular sensibility, 282 
 
 Seventh nerve, in taste, 194; "pars 
 intermedia" of, 194; testing of, 
 203 ; portio mollis, 205 
 
 Sexual desire (see also Venereal 
 excesses, Masturbation, etc.), in 
 
 57 
 
674 
 
 IKDEX. 
 
 paralysis, 284, 507; sexual ex- 
 cesses in paralysis, 234, 507 ; in 
 mania, 300 
 
 Shaking in paralysis, 213, 215; 
 shaking-palsy, 215 
 
 Shingles, 114; with neuralgia, 288 
 
 Shiverings, in fever, 85, 104, 107 ; 
 from passage of catheter, 85, 
 105 ; absence of, in children, 
 105 ; various other causes of, 105 
 
 Sibilant rales, 554 
 
 Sickness, see Vomiting, 400 
 
 Sighing respiration, 344, 552 
 
 Sight, see Vision 
 
 Sight, imperfections of, indicating 
 scrofulous diathesis, 31 
 
 " Signs," in case-taking, 54 
 
 Sims's speculum, 528 
 
 Sitting posture, manner of rising 
 from, in disease, 225 
 
 Sixth nerve, 203 
 
 Size of body, 16 
 
 Skin, works of reference on, 157 ; 
 eruptions, 109 ; diseases of, 
 classification, 110; elementary 
 lesions of skin (Willan and 
 Bateman), 110; iii special dis- 
 eases, 113; secondary changes 
 in skin, 112; Hebra's classitica- 
 tion of skin diseases from Duh- 
 ring, 117 ; disorders of secretion, 
 hypertemias, inflammations, 
 heinorrhages, hypertrophies, 
 atrophies, new growths, neur- 
 oses, parasites, 117, 118, 119; 
 constitutional disturbance in 
 skin diseases, etc., 120; cause 
 of, 121 ; staining, pigmentation, 
 and discoloration, 140; syphi- 
 litic eruptions, 143; sensation 
 of skin, variations in, 195, et 
 seq.^ 210; glazing of skin in 
 anaesthesia, 200; perverted sen- 
 saticm, 201 
 
 Skoliosis, 156 
 
 Skull, congenital malformations 
 of, 154; affections of, 154; per- 
 cussion of, 266 ; tender aieas on , 
 266; percussion sounds, 267 
 
 Sleep, effect on pulse, 97 ; pupils 
 in, 172; tendency to, in paral- 
 ysis, 251 ; various disorders of, 
 259; disturbances of, 260; un- 
 
 due tendency to, 262 ; causes 
 of, 262 
 
 Sleepiness, undue, 262 
 
 Sleeplessness and delirium, 256; 
 in mania, 260, 299 
 
 Sleeplessness, 259 ; with fever and 
 delirium, 260; in mental dis- 
 ease, 260; from drugs, 260; in 
 intemperance, 261 
 
 " Slender," 18 
 
 Smallpox, modified, diagram of 
 temperature in, 85; rash, 188; 
 diagnosis, 134 ; period of incu- 
 bation, 131; liability to a second 
 attack, 131; hemorrhages in, 
 364 
 
 Smee's cell, 275 
 
 Smell, in case-taking, 58; sense 
 of, tests for, 191 ; loss of, from 
 thickening in nose, 191 ; from 
 facial paral3'sis, 191 ; loss of, 
 with hemiana3sthesia and apha- 
 sia, 192; perversions of, 192; 
 of vomited matter, 405; of mo- 
 tions, 417 
 
 Snellen's test types, 179 
 
 Snoring respiration in dyspnoea, 
 343. See Stertor in paralysis, 
 251 
 
 "Snuffles," 143, 193 
 
 Solar spectrum with absorption 
 bands from blood (Fig. 74), 472 
 
 Solium, see Ttcnia, 415 
 
 Somnambulism, 261 
 
 Sonorous rales, 554 
 
 Sooty fluids vomited, 405 
 
 Sordes on gums and teeth, 898 
 
 Sound, uterine, care in cases of 
 suspe> ted pregnancy, 522 ; use 
 of, 526 
 
 "Spade-like" hands, 435 
 
 Spare habit, 24 
 
 Sparks, electrization by, 269 
 
 Spasms, in limb, 213 ; spasm in 
 walking, 223; in writing, 229 ; 
 of bladder and rectum, 231 ; 
 carpo-pedal, 248; in legs and 
 limbs, 249; in region of face 
 and neck, 249 ; histrionic, 249; 
 tonic in various parts, 250 ; of 
 deglutition, 251 ; of glottis, 251, 
 850, 352; cardiac spasm, 842; 
 of vocal cords, 393 
 
INDEX. 
 
 675 
 
 Spatula for tongue depression, 374 
 
 Special organs in case-taking, 58 
 
 Specific gravity of dropsical fluids, 
 443; of urine, 450; high and 
 low specific gravity of urine, 
 450 ; specific gravit}^ beads, 450 ; 
 diflferential density, method of 
 estimating quantity of sugar, 
 458; estimate of solids in urine 
 from specific gravity, 451 
 
 Spectra, 176; spectral ' illusions, 
 256 
 
 Spectrosco])e, test for blood in 
 urine, 473 
 
 Spectrum, solar, and absorption 
 bands from blood (Fig. 74^), 
 472 
 
 Speculum, auris, 188; vaginal, 
 use of, 527 ; various forms of, 
 527 _ 
 
 Speech, aflPections of, in paralysis, 
 225 : in idiocy, 226 ; in deaf- 
 ness, 226; in general paralysis, 
 322 ; affection from state of 
 tongue, 400 
 
 Spermatorrhoea, 508 
 
 Spermatozoa in urine, 485 (Fig. 
 82) 
 
 Sphygmograra, events in, 593, 
 et seq. 
 
 SphygmiOgraph, use of, 590 ; works 
 of reference on, 639 ; Marey's 
 (Fig. 115), 591; Dudgeon's 
 (Fig. 116), 593; Pond's^Fig. 
 117), 594; Mahomed's regula- 
 tion of pressure, 592 ; applica- 
 tion, 592; events in normal 
 sphygmogram, 593 ; katacrotic 
 and anacrotic pulse, 595 ; varia- 
 tions with diverse pressure (Fig. 
 121), 596 ; arterial tension, 597 ; 
 dicrotism, 597; full dicrotism 
 and hyperdicrotism (Figs. 123- 
 127), *698, 599; monocrotic 
 pulse (Fig. 128), 599 ; intermit- 
 tence and irregularity, 599; 
 pulsus alternans, biijeminus, 
 and trisreminus (Figs. 129, 130), 
 600 ; influence of respiration on 
 pulse, 602; senile pulse and 
 rigid arteries, 602; pulsus para- 
 doxus (Fig. 132), 602 ; pulse in 
 aortic stenosis (Fig. 134), 603; 
 
 pulse in aortic regurgitation 
 (Figs. 135, 136), 604; pulse in 
 mitral stenosis and mitral re- 
 gurgitation (Figs. 137-139), 605, 
 606; venous pulse-tracings 
 (Figs. 140, 141), 606, 607; jug- 
 ular pulse, 607 ; unequal pulses 
 in aortic aneurism (Figs. 142- 
 145), 607,608 
 
 Spina bifida, 154 
 
 Spinal accessory nerve, 205 
 
 Spinal cord, disease, 234; causing 
 pain in back, 266 ; electrical re- 
 actions in the various diseases 
 of, 292, et seq. 
 
 Spine, congenital malformations 
 of, 154; distortions of, 156; dis- 
 tortion of chest from curvature 
 of, 542; hot .sponge causing 
 tenderness, 265 ; disease of, 
 causing paralysis, 234 ; spinal 
 meningitis, pain in limbs from, 
 234; pain in back, 265 
 
 Spirals in sputum, 355, 360 
 
 Spirilla in blood in relapsing fe- 
 ver, 372 
 
 Spirits, use of, case-taking, 65; a 
 cause of cirrhosis of liver, 442. 
 See also Stimulants 
 
 Spirochaete Obermeieri in relaps- 
 ing fever, 372 
 
 Spirometer, 545 
 
 Spit, see Expectoration, 353 
 
 Spitoons, 353 
 
 Splashing sound in auscultation, 
 556 
 
 Spleen, enlarged, causing dropsy, 
 443 ; phvsical examination of, 
 626; enlarged (Fig. 158), 628 
 
 Splenic fever, bacterium in blood, 
 372 
 
 Splenic leukaemia, 146; hemor- 
 rhages in, 365 ; examination of 
 blood in, 369 (Fig. 53), 371 ; 
 (see Spleen) 
 
 Spores, 128; sporidia, 128; in 
 mould (Fis:. 85), 487 ; in veast 
 (Fig. 86), 488 
 
 Sputum, section on, see Expector- 
 ation, 353 
 
 Squanife, 111, 116 
 
 Squint, 161 ; see Strabismus 
 
 Staggering, 41, 190, 223, 258 
 
676 
 
 INDEX. 
 
 Stains on skin, 111 
 
 Staining of skin, 140 
 
 Starch granules, in vomited mat- 
 ter (Fig. 60), 406 ; in urine 
 (Fig. 87), 489 
 
 Starlings of limbs, 298 
 
 Static electricity, 269 
 
 Stature, increase in infancy, 43, 50 
 
 Status epilepticus, 244; daily 
 number of fits in (diagrams), 
 244 
 
 Status praesens, 54, 57 
 
 Stealing, impulse to, 312 
 
 Stellar crystals, 493 
 
 Sterno-mastoid, nerve supply of, 
 204; twitching of, 205,249 
 
 Stertor in paralysis, 251 
 
 Stethograph, 545 
 
 Stethometer, 545 
 
 Stethoscope, use and forms of, 549; 
 differential, 550, 573 ; Spencer's, 
 550 
 
 Stimulants, habitual use of, im- 
 portance of, in case-taking, 65 ; 
 eft'ect of, on pulse, 97 ; cause of 
 delirium, 286; cause of sleep- 
 lessness, 261 
 
 Stitch, pleuritic, 341 
 
 Storck, on abscess in tonsil, 377 
 
 Stohrer's battery, 273 
 
 Stokes (Dr.), on myoidema, 24; 
 on Cheyne-Stokes respiration, 
 344 
 
 Stokes (Prof.), on haemoglobin 
 and oxyhaemoglobin, 473 
 
 Stomach, vertigo from, 257 (see 
 Vomiting, 400); pain in, 402; 
 dilatation of, 404, 406, 631 ; 
 casts of follicles in vomited 
 matter, 407 ; acidity of, 407 ; 
 flatulence in, 407 ; physical ex- 
 amination of, 619, 631 
 
 Stomatitis, parasitic, 398 ; vesicu- 
 lar, ulcerative, gangrenous, 399 
 
 Stools (see ]Motions, 413 ; and 
 State of Bowels, 409) 
 
 "Stout," 18 
 
 Strabismus, 161 ; convergent, di- 
 vergent, alternate, 162; conco- 
 mitant, 162; paralytic, and non- 
 paralytic, 162, 163; connection 
 with hypermetropia and myopia, 
 162 J clinical significance of, 167 
 
 Strachan (Dr.), on " play," 43 
 
 Strangury, medicines as causes of, 
 474 
 
 " Strawberry tongue," 399 
 
 Strength, tests of, in limbs, 212 
 
 Striae atrophicse, 118 
 
 Stricture, spasmodic, of oesoph- 
 agus, 250 
 
 Stridulous breathing, 343, 350, 
 351, 352 
 
 Strophulus, 113, 118 
 
 Struma, see also Scrofula, cachexia 
 of, 30 
 
 Strychnia poisoning, 250 
 
 Stupor, in fevers, 36 ; with melan- 
 choly, 304. See also Coma. 
 
 Stuttering in general paralysis, 
 243 
 
 Subinvolution of uterus, 527 
 
 Subjective symptoms, 54 
 
 Subsultus tendinum, 36 
 
 Succussion, Hippocratic, in aus- 
 cultation, 556 
 
 Sucking, refusal of breast by in- 
 fants in dyspnoea, 336 
 
 Sudamen, 117 
 
 Sudamina, in enteric fever, 138 ; 
 eruption of, 139 
 
 Sufl:ocation, 37; see al>o various 
 sections under Dyspnoea and 
 Cough 
 
 Suffusion of eyes, 160 
 
 Sugar in urine, 455; copper test 
 — Trommer's, 455; Fehling's 
 and Pavy's solution, 455, 457 ; 
 method of testing, 456; quanti- 
 tative determination by copper 
 test, 456; fermentation test, 
 457 ; torula test, 458 ; quanti- 
 tative test by fermentation, 458 ; 
 estimation by specific gravity, 
 459; Moor's test with liquor 
 potassae, 458 ; bismuth test, 459 ; 
 picric acid test, 459 ; test-papers, 
 459 ; polariscope, 460 
 
 Suicidal insanity, 312; impor- 
 tance of ascertaining suicidal 
 tendency, 329 
 
 Sulphur, rash from, 125 
 
 Sunstroke, cause of paralysis, 
 251 ; of headache, 265 ; of in- 
 sanity, 301, 320; cause of vom- 
 iting, 401 
 
INDEX. 
 
 677 
 
 Superficial reflexes, 217 
 Superinvolution of uterus, 527 
 Supinator lon£:;us, testing of, in 
 
 lead palsy, 235 
 Suppurations, temperature in, 80, 
 
 86 
 Suspirious respiration, 345 
 Swallowing, see Deglutition 
 Swan's lamp for laryngoscope, 
 
 381 
 Sweating, in rickets, 32 ; in fever, 
 
 34, 104; various forms and 
 
 causes of, 104; unilateral, 104 
 Swelling of skin, 112 
 Swimming, sense of, see Yertigo, 
 
 257 
 Sycosis, 116, 118 
 Symbols, electrical, 288 
 Sympathetic, afifeclions of, 168, 
 
 170 
 
 Tsenias, various forms (Figs. 63- 
 67), 416, 417 ; T. mediocanellata 
 (Fig. 63), 416; head of T. 
 solium and T. mediocanellata 
 (Figs. 66, 67), 417 ; proglottides 
 (Figs. 64, 65), 416 
 
 Tait (Dr. Lawson), on myoidema, 
 24 
 
 Talipes, from paralysis, 223 
 
 Tape- worms (Fig. 63), 416; a 
 cause of insanity, 320 
 
 Tapping, examination of fluids 
 removed from chest by, 362; 
 abdominal, importance of emp- 
 tying of bladder beforehand, 
 438; examination of fluids re- 
 moved b}- tapping, 443; exami- 
 nation of abdomen immediately 
 after tapping, 443 
 
 Tar, rash from, 125 
 
 "Symptoms," in case taking, 53, ' Taste, in case-taking, 58; testing 
 
 of, 193 ; smell and taste, 193 ; 
 galvanic test for area of, 194; 
 affections of, 194; clinical sig- 
 nificance of lesions of, 194 ; in 
 general diseases, 195 ; perver- 
 sions of, 192 ; seventh nerve, 
 204 
 Tea, habitual use of, in case-tak- 
 ing, 65 
 
 64 
 
 Synchronous, or non-synchronous 
 
 pulse, 100 
 Syncope, 239 
 Syphilis, cachexia of, 33 ; history 
 
 of, in case-taking, 63 ; syphilis 
 
 (skin), 122; eruptions, 143; 
 
 congenital, 143 ; glands in, 144; 
 
 bones and joints, 153; aftections 
 
 of skull in, 154 ; of tibia and Teeth, 419 ; formula of milk teeth, 
 
 other bones in, 154; of fauces 
 in, 379; of larynx, 389; as 
 cause of hemiplegia; 233; as 
 cause of neuralgia, 237 ; con- 
 vulsions in, 243; as cause of 
 headache, 265; and insanity, 
 318 ; diagnosis of syphilitic in- 
 
 419 ; disorders of first dentition, 
 419; second dentition, formula 
 of permanent teeth, 420 ; 
 notched (svphilitic) teeth (Fig. 
 68), 421 ; caries of, 422 ; falling 
 out^of, 422 ; grinding teeth, 422 ; 
 sordes on, 398 
 
 sanity from general paresis, 318 ; ■ Telangiectasis, 118 
 
 notched teeth, 421 
 
 Syphiloderma, 118 
 
 Syphilophobia, 311, 318 
 
 Systems, physiological, in case- 
 taking, 58, 59. See also under 
 Nervous systems, etc. 
 
 T. or Te. (electrical symbol), 289 
 Tabes mesenterica, causing dropsy, 
 
 440 
 Tache cerebrale, 25 
 Taches bleurates, 138 
 Tactile sense, tests of, and distribu- 
 
 tion of, 196-199 
 
 Temperament, Hutchinson on, 14, 
 23 ; Prichard on, 23 
 
 Temperaments, 14, 23; "insane 
 temperament," 300, 318 
 
 Temperature of body, 74 ; works 
 on, 108 ; time of day fur taking, 
 77, 78 ; normal and abnormal 
 temperatures, table of, 79 ; per- 
 iodicity of, 79, et seq. ; diurnal 
 range in hectic (phthisis), 80, 81, 
 82 ; in acute miliary tubercu- 
 losis, 82 ; in intermittent fever 
 (quotidian ague), 83, (tertian 
 ague), 84; in relapsing fever, 
 
 57* 
 
678 
 
 INDEX 
 
 85; in smallpox, 85; in lobar 
 pneumonia, 84 ; in typhus fever, 
 85; in enteric fever, 85, 94; 
 absence of periodicity in, 83 ; 
 manner of rise and duration of 
 elevation, 80 ; rapid rise of, in 
 certain diseases, 86 ; gradual, 
 87; decline of, date and man- 
 ner, 88; fall of, fallacies in 
 judging, 89; fall before death, 
 78, 90; in recrudescences, com- 
 I'lications, and relapses, 90, 94, 
 et seq. ; of convalescents, 95 ; 
 comparison with j)ulse, 95 (dia- 
 gram), 99; in enteric fever and 
 meningitis, 95, 99; very high 
 and very low temperature, 78 ; 
 hyperpyretic and collapse tem- 
 peratures, 78, 79 ; diagrams of, 
 79; sense of temperature, 196; 
 not much elevated in mania, 
 300, 327 
 
 Tendency, morbid, 14 
 
 Tendons, starting of, at wrist, 36 
 
 Tenesmus, 410, 412 
 
 Tension, arterial, 597 
 
 Terrors, night, 261 
 
 Tetanic contraction (electricity), 
 289 
 
 Tetanus, 250 
 
 Tetanv, 249 ; electrical reaction 
 in, 291 
 
 Thallus, 128 
 
 Thermometer, clinical, 74; direc- 
 tions for use of, 74, et seq. ; sur- 
 face, 95 
 
 "Thin," 18 
 
 Third nerve, paralj^sis of, 166, 168, 
 169, 170; testing of, 202 
 
 Thirst, 105, 397 
 
 Thomsen's paralytic disease, 225 
 
 Thomson (Dr. 11. Stevenson), on 
 prealbuminuric and postalbu- 
 minuric stages, 473 
 
 Thorax, see Che.'^t. 
 
 Thread worujs (Figs. 61, 62), 415 
 
 Thrill, vocal, 557; cardiac, 570; 
 aneurismal, 589 
 
 Throat, irritation and disease of, 
 causing cough, 351 ; catarrh of, 
 375,376; relaxed throat, 376; 
 clergyman's sore throat, 376 ; 
 in scarlatina, 377 ; in diphtheria, 
 
 378; ulceration in, 378; phleg- 
 monous inflammation, 376; 
 tonsillitis, 376 ; syphilitic affec- 
 tion of, 379 ; destruction of 
 tissue, 380 ; retropharyngeal 
 abscess, 380 ; books of reference 
 on, 381 
 
 Thrombosis of cerebral vessels in 
 hemiplegia, 233 ; and in chorea, 
 254; of portal vein, 441 
 
 Thrush, see Muguet. 
 
 Thudichum, on analysis of renal 
 calculi, 496 
 
 Thumbs, inversion of, 244 
 
 Thyroid, fulness of, 160 
 
 Tic (see Neuralgia of fifth nerve), 
 202, 237 ; convulsive tic, 249 
 
 Timbre, 547 
 
 Tinea favosa, 119, 125, 126, 127 
 (Figs. 25, 26, 27), et seq.] tri- 
 chophyLina (circinata, tonsu- 
 rans, svcosis), 119, 127, 128 
 (Figs. 28. 29, 30) ; versicolor, 119 
 
 Tingling, 201 
 
 Tinnitus aurium, 189; in paral- 
 ysis, 251 
 
 Tobacco, use of, importance of, in 
 case-taking, 65; defects in field 
 of vision from, 180 ; color blmd- 
 ness from, 182 ; vertigo from, 
 257 
 
 Tongue, in fever, 35 (see also 
 Taste, 193) ; tactile sense of, 
 194; temperature under, 76; 
 nervous supply of lingualis, 
 204 ; of extrinsic muscles of, 
 206; paralysis of, 208 ; quiver- 
 ing of, 215, 322 ; ulcer on fre- 
 num in pertussis, 350; tongue- 
 depressor, 374; state of, section 
 on, 397; inflammation of, 399; 
 hardness and nodulation, 399 ; 
 pallor, lividity, coldness, ecchy- 
 mosis, 400; fur or coating on, 
 398; white patches of muguet, 
 
 398 ; discoloration of, 398 ; dry- 
 ness, 398; cracks and hacks, 
 
 399 ; red raw tongue, 399 ; des- 
 quamation of epithelium, 399; 
 strawberry tongue, 399 ; en- 
 larged papilla?, 399; blisters, 
 aphthae on, 399 ; swollen aspect 
 of, 399 ; swellings under, 400 
 
INDEX. 
 
 679 
 
 Tonic convulsion, 240; spasms, 
 246-249 
 
 Tonsils, catarrh of, 376 ; tonsillitis; 
 376 ; chronic inflammation, 377; 
 enlarged tonsils, 377 ; a cause of 
 pigeon-breast and deafness, 377; 
 in scarlet fever, 377 
 
 Tophi, 152 
 
 Torticollis, see Wrj-neck 
 
 Torula cerevisia^ in vomited mat- 
 ters, 406 ; in diabetic urine, 483 
 
 Torula in urine (Fig. 86), 488 
 
 Touch, see Tactile sense, 196 
 
 Trachea, affections of, giving rise 
 to cough, 351, 352 ; foreign 
 bodies in, 352; movements of 
 chest-wall in obstruction of, 542 
 
 Tracheal respiration, 551, 553 
 
 Trades predisposing to disease, 64 
 
 Trance, mesmeric, 252 
 
 Transmission of disease, see Here- 
 ditary disease 
 
 Trapezius, nerve supply, 205; 
 twitching of, 250 
 
 Trapp's formula for estimating 
 solids in urine, 451 
 
 Tremors, in paralysis, 213, 215; in 
 delirium, 256 ; in general paral- 
 ysis, 581 ; cardiac tremor, purr- 
 ing tremor, 570 
 
 Trichophyton, tonsurans (Figs. 
 28, 30), 127, 129 
 
 Tricuspid murmur, area of, 584 
 
 Trifacial, 202 
 
 Trigeminal, 202 
 
 Trigeminous pulse, 600 
 
 Trismus, 249 
 
 Trochlearis (nerve), 202 
 
 Tronimer's test for sugar, 455 
 
 Trophic lesions in paralysis, 213 
 
 Trousseau, on the tache cerebrale, 
 25 
 
 Tube-casts (renal), significance of, 
 in bloody urine, 475 ; in puru- 
 lent urine, 478 ; how to examine 
 for, 479; various kinds of, 481; 
 hyaline, w'axy, epithelial, gran- 
 ular, fatty (Figs. 76-78), 480- 
 482; blood-casts, pus-casts, 481; 
 significance of tube-casts of vari- 
 ous kinds, 481 ; absence of casts 
 in some cases of albuminuria, 
 483 
 
 Tubercle bacilli, 359; method of 
 detecting, 359 
 
 Tubercles, in choroid, 184 
 
 Tubercula, 111, 116 
 
 Tubercular diseases, diagrams of 
 temperature in. 80, 81, 82 
 
 Tuberculosis of larynx, 388 
 
 Tubular respiration, 553 
 
 Tumors, of brain, cause of paral- 
 ysis, 233 ; abdominal, causing 
 dropsy, etc , 437, 443 ; in larynx, 
 390 (syphilitic in larynx, 389); 
 pulsating tumor, 588 ; localities 
 of abdominal tumors, 636. See 
 various organs, Liver, Spleen, 
 etc. 
 
 Tuning-fork, test of hearing, 186, 
 187 
 
 Twitchings of muscles of face and 
 neck, 249, 250 ; of orbicularis 
 ■ palpebrarum, 176 ; twitching or 
 choreic movements, 253 
 
 Tympanites, 408, 633 
 
 Tympanum, membrana, ruptured, 
 188; state of, 188; suppuration 
 in, 189 
 
 Types, in testing vision, 178 
 
 Typhoid, meaning of word, 36; 
 t3^phoid delirium, 36 (typhoid 
 fever, see Enteric) 
 
 Tyohomania, 36 
 
 Typhus fever, period of incuba- 
 tion, 131 ; liability to second at- 
 tack, 131 ; rash, 136 ; pupils in, 
 172; hemorrhages in, 364; as a 
 cause of insanity, 320 ; mistaken 
 for mania, 327 
 
 Tvrosine in urine, crystals of (Fig. 
 ^69), 430, 494, 496 
 
 Ulcer on frenum linguas in per- 
 tussis, 350; bleeding from ulcers, 
 364 
 
 Ulcerations (in skin), 112 ; of 
 throat in scarlatina, 378; in 
 throat, of various kinds, and 
 how distinguished from diph- 
 theria, 378 
 
 Umbilical region and contents, 
 613 ; tumors in, 636 
 
 Umbilicus, hemorrhage from, 
 428_, 432; protrusion of, 437; 
 position and color of, 615 
 
680 
 
 INDEX. 
 
 Unconsciousness in paralysis, 209, 
 251; in fits, 2-40 ; in hysteria, 
 245 ; causes of, 251. See also 
 Coma 
 
 Underweiojht, as indicating dia- 
 thesis, 21 
 
 Unilateral convulsions, 214; in 
 aphasia, 228. See also Hemi- 
 plegia 
 
 Unit in electricity, 274 
 
 Unsteadiness in paralysis, 215; 
 atfecting writing, 229 
 
 Uraemia, coma in, 252 ; tracing of 
 puLe in, 102; pupils in, 172; 
 convulsions, 243; sleepiness in, 
 262; danger of opium in, 202; 
 headache in, 264 
 
 Urates, of soda, in joint-, 152; 
 urates in urine, 454; precipita- 
 tion of urates by nitric acid — 
 fallacv, 462 ; deposits in urine, 
 490 (Figs. 89, 90), 491 
 
 Urea, detection of, in fluids re- 
 moved by tapping, 444 ; nitrate 
 of urea on adding nitric acid to 
 urine, 463 ; estimation of quan- 
 tity, 499 ; Leibig's method, 500; 
 method b}' hypobromite of soda 
 solution, 502 
 
 Ureter, epithelium from, 484 
 
 Urethra, pain in, 504, 519 ; dis- 
 charges from, 508 
 
 Uric acid in blood, 152 ; in urine 
 as gravel, 454; precipitation of, 
 b}^ nitric acid in urine, 403 ; de- 
 posits in urine, 487 (Fii^. 88), 
 490; murexide test for, 491,497 
 
 Urinary system, in case- taking, 
 59,60; chapter xiii., on urine 
 and urinary symptoms, 447. See 
 Urine for details 
 
 Urine, temperature taken of, 77 ; 
 retention and incontinence of, 
 from paralysis, 229-232 ; from 
 hysteria, 314; dribbling of, from 
 vesico-vaginal fistula, 230; pass- 
 ing urine in bed at night, 231 ; 
 animoniacal, in paraplegia, 232; 
 filaria sanguinis hominisin chy- 
 luria, 372; jaundiced, 426; de- 
 tection of, in abdominal fluids, 
 444; examination of urine and 
 urinary symptoms (chap, xiii,). 
 
 447 ; works of reference on, 504; 
 routine examination of, 447 ; 
 samples to be selected, 447 ; 
 quantity passed, 448 ; specific 
 gravity, 450 ; method of calcu- 
 lating amount of solids in, 451 ; 
 reaction, 451 ; acid fermentation 
 of, 451 ; alkalinity from decom- 
 position, 451 ; obvious character- 
 istics and naked eye appearances, 
 
 452 ; color, clearness, 452 ; white, 
 453; milky, 453; turning thick, 
 
 453 ; resembling porter, 453 ; 
 turbid and smoky, 453 ; blood 
 color, 453 ; very red, pale, and 
 black, 453; blue, 453; yellow, 
 498; bad smell, 454; gas with 
 urine, 454; shreds with, 454; 
 gravel and sediments, 454; 
 glair}' matter in leucorrhoea, 454; 
 coagulation from chyle, 455 ; 
 sugar in urine, 455 ; copper test, 
 Trommer's, 455 ; Fehling's and 
 Pavy's solution, 455, 457 ; quan- 
 tity of sugar by copper test, 456; 
 b}' fermentation test, 457 ; torula 
 test for sugar, 458 ; quantity es- 
 timated by fermentation, 458; 
 by sp. gr., 458 ; Moore's test for 
 sugar, 458 ; bismuth test for 
 sugar, 459 ; picric acid test, 459 ; 
 test-papers for sugar, 459 ; po- 
 lariscope, 460; albuminuria, 460; 
 tests for albumen, 460; test by 
 heat, 460 ; by nitric acid in cold, 
 461 ; other newer tests for albu- 
 men, 464; quantitative estima- 
 tion of albumen, 466 ; peptones 
 and modified forms of albumen, 
 467; significance of albumin- 
 uria, 468; blood in urine, 470; 
 blood corpuscles (Fig. 74), 471 ; 
 guaiac test for blood, 472 ; spec- 
 troscope test for blood, 473 ; 
 hemoglobinuria, 474; signifi- 
 cance of hiematuria, 474; pus in 
 urine, 476 ; pus corpuscles (Fig. 
 75), 477 ; liquor potassao test for 
 pus, 476 ; significance of pyuria; 
 478; renal tube-casts, 479 ; how 
 searched for, 479 ; various kinds 
 of, 480-482 (Figs. 76-78) ; sig- 
 nificance of casts, 482; epithe- 
 
INDEX. 
 
 681 
 
 Hum in urine, 483; renal vesical, 
 etc. (Figs. 79 and 80), 483, 484 ; 
 vao'inal epithelium (Fia;. 81), 
 485 ; spermatozoa (Fig. 82), 485; 
 mould (Fio;. 85), 487 ; vibriones 
 (Fig. 83), 480 ; bacteria in (Fig. 
 84), 486 ; fungi. 487 ; yeast fun- 
 gus (Fig. 86), 488 ; foreign mat- 
 ters in, 488, 489 (Fig. 87) ; crys- 
 talline, amorphous deposits, 488; 
 significance of these, 494 ; uric 
 acid deposits, 490 (Fig. 88), 
 494. 495 ; urates or lithates, 
 (Figs. 89, 90), 491 ; phosphates, 
 (Figs. 91, 92), 492, 493; ox- 
 alates (Fig. 93), 494; analysis 
 of calculi, 496 ; bile, 497 ; biliary 
 acids, 498; chlorides, 499; 
 estimation of urea, 499; com- 
 plaints as to urinary symptoms, 
 ^503 
 
 TJrinometer, 450 
 
 TJro-hsematine, 462 
 
 Urticaria, 113, 124 ; factitious, 
 113 
 
 Uterus, headache from irritation 
 of, 264 ; backache from irrita- 
 tion of, 265 ; disease of, a cause 
 of insanity, 315; defect of, a 
 cause of amenorrhoea, 511 ; 
 hemorrhage from, 513 ; disor- 
 ders of, causino- dj'smenorrhoea, 
 515; gravid, 522, 524; exami- 
 nations per vagin am, 524; points 
 attended to in examining, 529 ; 
 versions and flexions, 529, 535 ; 
 prolapsus, 530; state of cervix, 
 530; malignant diseases of cer- 
 vix, 531 ; displacements, 529 ; 
 use of sound, 526; constriction 
 of cervix, 526 ; depth of, 526 ; 
 connections of tumors, 527 ; sub- 
 involution, 527 ; hyperinvolu- 
 tion, 527; examination by spec- 
 ulum, 527 ; pelvic inflamma- 
 tions, perimetritis, etc., 533; 
 hsematocele, 535 ; fibroid tumors 
 of, 535. See also Menstruation, 
 Dvsmenorrbcea, etc. 
 
 Uvula, paralysis of, 202, 203, 204, 
 elongated, causing cough, 351 ; 
 examination of changes in. 375; 
 catarrh involving, 376 
 
 Y. D. ^ Ventricular-diastolic, 576 
 
 V.S. Ventricular-systolic, 576 
 
 Vaccinia, 114 
 
 Vagabondismus, 141 
 
 Vagina, temperature taken in, 76; 
 as compared with axilla in col- 
 lapse, 91 ; scaly epithelium 
 from, in urine (Fig. 81), 485; 
 prolapsus of, 630 ; affections of 
 orifice of, 523 
 
 Vaginal examinations, 525; in 
 pregnancy, 523; mode of, 525; 
 indications from, 528, et seq. 
 
 Vaginismus, 533 
 
 Valsalva's method of inflating ear, 
 188 
 
 Valvular murmurs, rhythm of, 
 575; area of, 581 ; tabular view 
 of, 587 
 
 Vapors, irritating, causing cough, 
 351 
 
 Varicella, 119, 134 ; period of in- 
 cubation, 131; liability to sec- 
 ond attack, 131 
 
 Variola, 115, 133 
 
 " Veinefluide," 577 
 
 Veins, murmurs in, 586 
 
 Vena portse, see Portal vein 
 
 Venereal disease, history of, inpa- 
 tients, 63 
 
 Venereal excesses (see also Sexual 
 desire, Masturbation, etc.), his- 
 tory of, in patient, 66 ; cause of 
 paralysis, 234, 506 ; and in- 
 sanity, 315 ; a cause of general 
 paralysis, 324 ; cause of impo- 
 tence, 501 
 
 Venous pube (Fig. 140), 606 
 
 Ventricle of larynx, 387 
 
 Ventricular-diastolic murmur, 579 
 
 Ventricular-systolic murmur, 578 
 
 Verruca, 118 
 
 Vertebrae, caries of, a cause of 
 paraplegia, 234 ; of pain in back, 
 265; abscess in front of, point- 
 ing in throat, 380 
 
 Vertigo, monocular, 170; in ocu- 
 lar paralysis, 169; in aural dis- 
 ease, 189 ; in paralysis, 251 ; va- 
 rieties and causes of vertigo, 
 257 ; stomachal, 257 ; warning 
 of paralysis, 258 
 
 Vesication in erysipelas, 139 
 
682 
 
 INDEX. 
 
 Vesiculffi, 111, 114 
 
 Vesicular murmur, see Eespira- 
 tory murmur 
 
 Vibices, 140 
 
 Tibriones in urine (Fig. 83), 486 
 
 Vicarious menstruation, 358 
 
 Vienna test for pus in urine (liquor 
 potassa?), 476 
 
 Viscera, thoracic, in siiu (Fig. 
 101*), 558, (Fig. 156) 620; ab- 
 dominal (Fig. l55), 614, (Fig. 
 156), 620 
 
 Vision, in case-taking, 40; acnte- 
 ness of, 178 ; defect of, 179 ; field 
 of vision, 180; local defects in 
 field of, 180; double, 168 ; erro- 
 i:eous estimate of position of 
 objects, 169 ; forward diplace- 
 ment of image, 170; confu- 
 sion of lines in reading, 175 
 motes, 175; bemiopia, 180 
 flashes of light and color, 176 
 color-blindness, 181 ; yellow vis- 
 ion, 176; dimness of, 180; im- 
 portance of sight in balancing in 
 ataxv, 224 
 
 Vitiligo, 117, 118, 142 
 
 Vitreous, opacities in, 175 
 
 Vocal cords, examination of, 384; 
 hvporsemia, of, 387; paralysis 
 of, 390; bilateral, 391 ; unilate- 
 ral, 392 ; spasm of, 393 ; bilate- 
 ral paralysis of abductors, 391 ; 
 larvn£ro>copic image in paralv- 
 sisof (Figs. 57, 58)', 393; vocal 
 resonance, 557 
 
 Vogel's table of colors of urine, 
 452 
 
 Voice, loss of, 206, 391 ; altera- 
 tions of, from enlarged tonsils, 
 377; from syphilis, 379; in 
 laryngeal disease, 391, 393 (see 
 also Speech, Hoarseness); reso- 
 nance and fremitus, 557 ; altera- 
 tions in, 557; absence of vocal 
 resonance, 558 
 
 "Voices" heard bv the insane, 
 305, 312 
 
 "Volt," 274 
 
 Voltaic battery or pile, 269 
 
 Vomiting, in fevers, 105; section 
 on, 400 ; character of vomited 
 matter, 404 ; of blood, 405 ; 
 
 fecal, 405 ; coftee-grounds, 405 ; 
 of bile, pus, worms, etc., 405, 
 406 ; microscopic examination 
 of vomited matters, 406 ; sar- 
 cinffi (Fig. 60), 406 ; fermenta- 
 tion, odor of, 405 ; various causes 
 of, 400; preliminary symptoms, 
 
 401 ; influence of posture on, 
 
 402 ; pains, etc., associated with, 
 402 ; pain in stomach with, 402: 
 " causeless," 263, 402 ; vomiting 
 and headache, 163, 402 ; pain in 
 back and vomiting, 403 ; dis- 
 order of bowels with vomiting, 
 408 ; from irritation of fauces, 
 403; with coughing, 403 ; from 
 uterine disorder and pregnancy, 
 264, 403 (see also chapter xv., 
 possu7i) ; from renal disease, 
 404 ; from biliary disorder, 404 ; 
 oesophageal, 404; vo-mited mat- 
 ters, 404 ; quantity vomited, 
 404 
 
 Vulva, affections of, 533 
 
 Walking, manner of, in general 
 paralysis, 40, 223, 322 ; in hemi- 
 plegia, 41, 222; in paraple2:ia, 
 41 ; in spastic paralysis, 41, 223 ; 
 in locomotor atax}", 41, 223 ; in 
 drunkenness, 41 ; in apoplexy 
 and cerebellar disease, 41, 215, 
 223 ; unsteadiness, tremor in, 
 215; hurrying forward, 215; 
 testing of, 215 ; detieiency from 
 idiocy, 222 ; lateness in rickets, 
 222 ; in various forms of paraly- 
 sis and ataxy, 222-225 ; relation 
 of sight to, 224; in joint dis- 
 eases, 225 
 
 Waiting of paralyzed limbs, 213, 
 234, 294 
 
 Water-brash, 407 
 
 Watery discharije from ears, 188 ; 
 from womb, 517 
 
 Wavy respiration, 552 
 
 AYax'in ear, 187 
 
 Waxv tube-casts (Fig. 76), 480 
 
 " AVeber," 274 
 
 Weber's test of sensation, 197 ; 
 cautions in applying, 198; table 
 of relative sensibility, 199; of 
 hearing, 187 
 
INDEX. 
 
 683 
 
 Weeping, in paralysis, 210' (see 
 Emotions) ; in hysteria, 2-i^o 
 
 Weight, sense of, 200 
 
 Weight of body, 16 ; loss of, 16 ; 
 variations from time to time, 17; 
 according to height, Eobertson 
 on, 17 ; diversities in, 17, 18 ; 
 (table), 18; excessive and de- 
 fective, 20 ; increase in infancy, 
 43 (tables) 50 
 
 Wetting the bed, 231 
 
 Wheals, 110, 113 
 
 Wheezing sounds in dyspnoea, 
 343 ; in auscultation, 554 
 
 Whirling, sense of, 257 
 
 Whisper, voice reduced to, 393 ; 
 whisper in auscultation, 557 
 
 Whistling sounds in dyspnoea, 343; 
 in auscultation, 551 
 
 White patches of skin, 142 
 
 White blood-corpuscles see Blood ; 
 white blood, see Leukaemia 
 
 White discharge (" Whites "), see 
 Leucorrhoea 
 
 Whooping-cough, 349; resem- 
 blance of bronchial phthisis to, 
 351 ; vomiting in, 350 
 
 Willan and Bateman, 110, 113 
 
 "Wiry," 18 
 
 Womb, see Uterus ; hemorrhages 
 from, see Metrorrhagia 
 
 Women, disorders peculiar to 
 (chapter xv.), 508 
 
 Word-blindness and word-deaf- 
 ness, 228 
 
 Worms, vomited, 406 ; in motions, 
 414 (Figs. 61-67) 
 
 Wrisberg, cartilages of, in larynx, 
 386 
 
 Wrist, spasm of, in infancy, 248 
 
 " Wrist-drop," 41, 235 
 
 Writer's cramp, 229 
 
 Writing, power of, in aphasia, 226; 
 tests by, in aphasia, 227 ; power 
 of writing affected in various 
 ways, 229 ; cramp in, 229 ; test 
 by, in insanity, 256, 324, 329 
 
 Wry-neck, 249 
 
 Xanthelasma, 141, 429 
 Xanthine, 494 
 Xanthoma, 118, 141 
 Xanthopsia, 176 
 Xeroderma, 116 
 
 Yawning, automatic movements 
 durin<r, in hemiplegia, 214 
 
 Yaws, 117 
 
 Yeast, see Torula cerevisise; 
 yeasty vomited matters, 405 ; 
 test for sugar by, 457 
 
 Yellowness of skin and eye, 425 
 
 Z=Zackung (electrical symbol), 
 289 
 
 Zeiss' slide for counting blood cor- 
 puscles (Figs. 51, 52), 367, 368 
 
 Ziemssen's motor points (electri- 
 city), 279, 288 (Figs. 42-47), 
 281, 286 
 
 Zona, 114 
 
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