COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64123103 RC71 .H97 Clinical methods; a RECAP Rohorf ffufrluson. M -^ //(J f / 7/ Ra in //. ?/ = t\ ^^ ffinlumhia Unturrattg in t\}t (EitQ 0f Hrui fork ©olbgf nf JpijgatrtanB unh ^urgFona IWrs ... C.^ .Gi-u^^'the.r.. CLINICAL METHODS A GUIDE TO THE PRACTICAL STUDY OF MEDICINE (L a- f I t ^ i^ J* e ',*'■ ■'■fp . ' \ \ > i BACTERIA (pp. 523-532). (After an Original Drawing by Richard Midr.) «, Bacillus diphtheria;. Long forms. 24 hours' growth; agar cult; .stained watery methyl blue ; x 1,000. ft', The same after 5 days' growth. Involuted forms. b, Bacillus tubercle in sputum, from case of phthisis, Stained Z. Neelsen ; X 1,000. c, Spirillum cholera?. 24 hours' growth ; agar cult ; stained fuchsine ; x 1,000. d, Pneumococcus (Fraenkel's) in sputum, from case of acute pneumonia. Stained Z. Neelsen, fuchsine ; decolorised in weak acetic acid ; x 1,000. c, Gonococci in gonorrhosal pus. Stained thionine blue ; x 1,000. [Byoutispiecc. CLWICAL METHODS A GUIDE TO THE PKACTICAL STUDY OF MEDICINE BY EOBEET HUTCHISON, M.D., M.R.C.P. DEJIONSTRATOR IN PHYSIOLOGY, LONDON HOSPITAL MEDICAL COLLEGE AND HAEEY EAINY, M.A., F.KC.P.EcL, F.R.S.E. UNIVERSITY TUTOR IN CLINICAL MEDICINE, ROYAL INFIRMARY, EDINBURGH WITH 137 ILLUSTRATIONS AND 8 COLOURED PLATES PHILADELPHIA LEA BUOTHERS & CO. 1- LjC H^7 PEEFACE The title " Clinical Methods " probably describes the scope of this book better than any other. It is not intended as a treatise upon medical diagnosis. On that subject there is already a sufficiency of good works in existence. It aims rather at describing those methods of clinical investigation by the proper application of which a correct diagnosis can alone be arrived at. To every student when he first begins work in a medical ward the question presents itself : How shall I investigate this case ? To that question the present work is intended to provide an answer. The first chapter deals, therefore, with the methods of case-taking in general, and includes a general scheme for the investigation of medical cases. The rest of the book is really an expansion of that scheme, each system being taken up separately, and the methods of investigating it described in detail. A special chapter has been devoted to the clinical methods of examining children, as these differ in many respects from those employed in the case of adults. Chapters have also been added on the ex- amination of Pathological Fluids and on Clinical Bacteriology, subjects which are daily growing in importance. The methods employed in the investiga- tion of surgical, gynaecological^ or obstetric cases do not fall within the scope of the work. No efibrt has been spared to make the book thoroughly up-to-date, and it is hoped, therefore, that it will be found useful by those practitioners who may wish to make themselves acquainted with the latest methods of clinical investigation. While the whole vi Clinical Methods. book has passed through the hands of both of us, yet each has made himself specially responsible for cer- tain parts. Thus Dr. Rainy has written Chapters II., IV., YI., and XIV., the sections on the electrical examination of muscles and nerves, on the parasites of the alimentary tract, and on the microscopal ex- amination of the urine. The rest of the work is from the pen of Dr. Hutchison. In order to avoid burdening the text, but few references have been given to authorities and original sources. We should like, however, to take this opportunity of acknowledging the help which we have received from various friends. Amongst these are Drs. Alex. Bruce, R. W. Philip, G. Lovell Gulland, and John Thomson, who have helped us with criticism and advice in the preparation of Chapters IV. and IX., VI., V. and XII. respectively. We have also to thank Dr. Patrick Manson, Dr. Byrom Bramwell, and Prof. Symington for the use of specimens and illustrations, and Drs. T. F. Milroy and J. Purves Stewart for assistance in the revision of proofs. To Dr. R. J. M. Buchanan we are specially indebted for jDreparing the drawings illustrating the microscopical examination of the blood. R. H. H. R. September, 1897. OOXTEXTS CHAPTER I. Case-taking ^ CHAPTER II. General Condition and Appearances .... 16 CHAPTER III. Alimentary System and Abdomen .... 42 CHAPTER IV. Circulatory System ^' CHAPTER Y. Clinical Examination of the Blood . . . .181 CHAPTER YI. Respiratory System 209 CHAPTER Yll. The Urine 267 CHAPTER YIII. The Skin ^'^^ CHAPTER IX. Nervous System ^^° CHAPTER X. Examination of the Eye, E.ar, Throat .an'D Nose . 451 viii Clinical Methods. CHAPTER XI. PAGE LocoMOTORY System . . . . , , ,481 CHAPTER XII. The Clinical Examination oe Children . . ,489 CHAPTER XIII. The Examination of Pathological Fluids. . . 502 CHAPTER XIV. Clinical Bacteriology . 512 APPENDIX . 534 INDEX .544 LIST OF PLATES. Bacteria Frontispiece Viscera of Thorax and Abdomen, as seen from the front ...... To face p. 61 Viscera of Thorax and Abdomen, as seen prom behind . . . . . . ,, ,, 65 Viscera, from the side „ „ 69 Cells of Normal [Blood. Cells from thej Blood in Spleno-myelogenous Leuc^mia. Cells from the Blood in Lymphocyth^mia ,, ,, 203 The Blood in Malaria » n 205 Motor Segmental' Functions of the Cervical Enlargement . . . . • • ?? )> 369 Motor Segmental Functions of the Lumbar Enlargement 5> ?> ^71 LIST OF ILLUSTRATIONS. -»<>•- PAOE Remittent fever (hectic). Case of phthisis .... 39 Intermittent fevers ......... 40 Crisis. Case of lobar pneumonia ...... 40 Lysis. Case of broncho-i^neumonia ..... 41 Scraping from a patch of thrush. Culture of saccharomyces albicans (monilia Candida) — the fungus of thrush . . 44 Enlargement of spleen ........ 69 Showing colon crossing a tumour of the kidney ... 73 Microscopical view of vomited matter ..... 83 Oxyuris vermicularis (nat. size) . . . . . .88 Oxyuris vermicularis (magnified) ...... 88 Ankylostoma duodenale (nat. size) . . .... 89 Ankylostoma duodenale (magnified) ..... 89 Trichocephalus dispar ........ 90 Cestoda 91 Ova of entozoa ......... 94 Amoebic dysentery 95 The heart in an infant ...... . . 103 Antero-posterior section of thorax near the left parasternal line 119 Superficial and deep dulness of normal heart and liver . . 122 Aortic aneurysm . . . . . . . . .124 Diagram to illustrate the effect of dilatation of the right and left sides of the heart respectively 125 Dilatation and hj'pertrophy of left side of heart . . . 126 Dilatation of right side of heart ...... 127 Pericardial effusion . 128 Displacement of heart upwards 129 Displacement of heart and liver in emphysema . . . 130 Displacement of heart in right-sided pleural effusion . . 131 Displacement of heart in left-sided i^leural effusion . . 132 Cardiac cycle .......... 135 Position of the cardiac valves and auscultatory ai'eas . . 137 Presvstolic mitral murmur 146 Cl I NIC a l Me thods . -IDroiiagatioii in front -propagation behind Mitral systolic murmur Mitral systolic murmur Aortic systolic murmur . Aortic diastolic murmur . Pulmonary systolic murmur Combined aortic and mitral sj-stolic mui'murs Bigeminal pulse Trigeminal pulse Noi'mal forms of pulse Low-tension pulse . High-tension pulse . Aortic stenosis Aortic incompetence Aortic incompetence ; compensation established Mitral incompetence .... Pulse in aneurysm Aortic atheroma (senile pulse) Pulsus bisferiens Dicrotic pulse ...... Haemocytometer pipette (Thoma-Zeiss) . Thoma-Zeiss counting-slide Microscopic view of Thoma-Zeiss countiu; divisions ...... Von Fleischl's hpemometer Filaria nocturna Embryos of filaria nocturna in blood Diagram showing method of making a blood of two slides . Si^ectra of hsemoglobin and its derivatives Cross section of rachitic chest Cross section of pigeon breast . Traube's space in pleuritic effusion Pleurisy, with effusion, seen from behind Pleurisy, with effusion, seen from the side Pleurisy, with effusion, seen from the front Physical signs at beginning, height and j)neumonia . . . . Physical signs at the various stages of pleurisy Elastic tissue from lung in sputum of a case of phthisis Bronchial cast from a case of plastic bronchitis film slide showing decline PAGE 147 148 150 151 152 153 159, 160 168 169 169 170 171 172 173 173 174 174 174 181 182 by means of List of Illustratioxs. XI putum t' ill sputum 2, Spectrum of urobilin masked by leucin Cursclimainrs spirals in s Charcot-Leyden crystals Ova of distoma pulmonal Actinomyces in sputum Aspergillus fumigatus Record of pneumonia 1, Spectrum of urol)ilin ; other ijigments . Urea nitrate . Gerrard's ureometer Pavy's api^aratus Deposit in acid urine Uric acid , Urate of soda . Oxalate of lime Ty rosin crystals ; cystin Stellar phosphates . Trij)le phosphates . Deposit in alkaline fermentation of urine, showing urate of ammonia, triple phosphates, and bacterium urese Renal eijithelium Eijithelial cells from the urinary passages Tube casts Tube casts ..... Hyaline and waxy tube casts . Ova of Bilharzia htematobium in urine Animal parasites of the skin . Vegetable parasites of the skin Outer aspect of right hemisphere, showing convolutions Outer aspect of left hemisphere, showing functional areas . Mesial aspect of right hemisphere, showing convolutions Mesial aspect of left hemisphere, showing functional areas . Diagram to show relative positions of the face, arm, and leg fibres in their course from cortex to crus . Diagram showing the course of the motor fibres from the cortex to tlie cord Upiper and lower nexu'ons of motor path Lateral view of the skin areas supplied by the second, third, and fourth cer%^cal segments . Sensory segmental functions of the spinal cord PAGE 261 261 262 262 263 266 270 286 288 316 329 330 331 331 332 333 334 335 336 337 338 339 340 345 352 355 358 359 359 360 361 362 363 368 369 Xll Cl I NIC a l Me tho ds. Scheme of a transverse section of the spinal cord, showing on the left side the positions of the various tracts, and on the right side the names of the diseases affecting each part Cutaneous nerve supply of upper limb ..... Cutaneous nerve supply of lower limb ..... Distribution of the sensory nerves of the head Showing the exact distribution of the sensory nerves of the fingers Showing the segmental sensory supply of the skin of the hand Schematic figure, showing the com'se of the ojitic fibres . Diagram showing the connections of the centres for contrac- tion of the pupils ........ Distribution of anaesthesia in complete paralysis of the fifth nerve ...... Motor points, face and neck . Motor points, back of arm Motor points, front of arm Motor points, front of thigh . Motor points, back of thigh and leg Motor jjoints, side of leg .... Bordier's method of recording the electrical muscle, in health .... Bordier's method of recording the electrical reactions of muscle, in a case of complete reaction of degeneration Normal tympanic membrane . Diagram of larynx ..... Posterior nares and surrounding parts . Position of viscera in child of five . Foulis' cells Cholesterin crystals .... Fatty needles and fatty crystals in degenerated cells Colony of actinomyces in jius, from a case of actinomycosis of the csecum ......... "Widal's pipette Hsemin crystals reactions of a 371 372 373 374 376 383 403 40(5 440 441 442 443 444 445 447 447 470 475 479 496 506 507 507 508 526 539 Clinical Methods. CHAPTER I. Case-taking. There can be no question of the value of accurate and systematic case-taking. It trains the beginner in habits of thoroughness and exactness at the bedside, and ensures that no point of importance in the case is missed. To the more experienced clinician the sys- tematic record of cases is of no less value. It orives to his experience a concrete embodiment, so that he can draw upon it at any future time by the comparison of new cases with old, and so enables him gradually to build up his clinical knowledge upon a sure foundation. When we come to the method to be pursued in taking a case, however, it is a question of '''• quot homines, tot sententice.^' Almost every clinical teacher has his own particular plan for investigating and recording a case. Nor is it of so much importance what particular method one adopts, provided he adheres to it. Every good method of case-taking should be both comprehensive and concise. It should be comprehensive, so as to be capable of being applied to every case and of covering all the points in it ; it should be concise, so as to pre- sent all the important features of a case in as small a compass as possible. The question of conciseness is of very great importance. Nothing is more annoying than to be obliged to wade through a mass of verbiage in order to get at the chief facts of a particular case. B 2 Case-taking, The student should practise the art of focussing a case in such a way as to present its leading features in a few sentences. For this object the writing of resumes of cases will be found a useful exercise. He should also avoid lengthy verbal descriptions as far as possible, especially where the facts admit of graphic repre- sentation. The outline diagrams now supplied by Messrs. Lewis, Danielsson, and others will be found useful aids in this respect. Physical signs can be filled in on them by means of conventional symbols. We have appended to this chapter a scheme of case-taking which meets all necessary requirements. At the same time, it must be used, like all such schemes, with some judgment and elasticity. All the points mentioned need not be minutely inquired into in each individual case. For example, if a patient is suffering from advanced cardiac disease, there is no use in writing a minute description of the state of liis teeth. Yet that is the kind of error into which be- ginners not infrequently fall. Of course, it demands some experience to enable one to say what are the points which it is of importance to inquire into in any particular case, and at first one may sometimes be at fault ; but the application of a little common- sense will ensure the avoidance of any gross blunders. The " taking " of any case consists of two parts — (1) The interros^atioii of the patient; (2) The physical examination. The object of the interrogation of the patient is to elicit information regarding his present illness and the state of his previous health and that of his family. The interrogation must be pursued with patience, the patient being allowed, as far as possible, to tell his story in his own words. Two good rules should be remembered — firstly, to avoid leading questions ; and, secondly, never to ask the same question twice. The use of leading questions is only occasionally allowable, Interrogation of Patient. 3 as, for instance, when one suspects that he has to do with a case of malingering, wlien one may get the patient to assert the existence of contradictory symp- toms, so confirming one's suspicions. It may also be necessary in dealing with patients who are stupid either by nature or as the result of disease. When one is trying to elicit what are known as " subjective symptoms," the use of leading questions may also be admissible. It is important to avoid asking the same question twice, because to do so looks careless, and conveys to the patient the impression of taking but a languid interest in his case. We may proceed now to go more into detail re- garding the questions which should be asked. In doing so, we shall consider first the questions which one has to put in every case — what one may call the general interrogation — and then we shall take up the questions which have to be put in examining cases of disease affecting the different systems or organs ; this may be called the si^ecial interrogation. 1. Oeneral interrog-ation. — Begin by ascer- taining the patient's name, age, occupation, and whether he is married or single. It is also of importance to note his exact postal address for purposes of future communication. Two important questions then follow — (1) Of what does he complain % (2) How long have the symptoms been present ? Having thus defined his complaint and its duration, proceed to ascertain the chief facts in his history. The most logical plan is to take \hefa7nily history first. It is usually suflBcient to inquire regarding the state of health or cause of death of the immediate relatives only — the parents, brothers and sisters, and, if the patient be married, of his own children, if he has any. These facts tell us whether he is predisposed by heredity to any particular disease. 4 Case-taking. One may then pass to his personal history. Here it is well to begin with what may be grouped together as the patient's environment, or surroundings and habits. This includes inquiry into [a) the exact nature of his occupation, and whether or not it exposes him to injurious influences ; (h) his home surroundings, their sanitary condition or otherwise ; (c) the amount of exercise he takes ; (d) the nature of his food, and the amount of his indulgence in such articles as alcohol, tea, and tobacco. Regarding alcohol, it is important to ascertain not merely how much — e.g. how many glasses of spirits per day — the patient takes, but how and when he consumes it — e.g. with or between meals. The kind of tobacco he smokes and the number of ounces consumed per week may require to be ascer- tained in some cases, (e) One should always ascertain, lastly, whether or not he has ever lived abroad, and, if so, in what part of the world. The information thus acquired enables one to add to the tendencies to disease which the patient has in- herited, those which he has acquired from his environ- ment and personal habits. One should take up next the question of the patient's previous health. Ascertain wiiat illnesses he has had, when he had them, their duration, and wdiether or not his recovery from them was complete. It is usually necessary to inquire directly as to whether or not the patient has ever had syphilis. It is not sufficient to ascertain that he has had a sore ; the question of secondary symptoms— e.p'. rash — must also be gone into. If the patient denies syphilis, it may be necessary to ask whether or not he has ever been exposed to the risk of it, and whether or not he has had any other venereal disease. In the case of female patients, information regarding venereal disease should, as far as possible, be obtained indirectly, direct interrogation on the subject being employed Interrogation of Patient. 5 only when a definite history is absolutely necessary for the elucidation of the case. The student need hardly be reminded that even under these circum- stances his questions should be put as delicately as possible. Having now ascertained the patient's inherited and acquired tendencies, and the seeds of disease which may have been sow^n in him by his previous illnesses, ^ye are ready to acquire information re- garding his present disorder. Ask how and when it began, whether suddenly or gradually; what was the first thing he noticed wrong; what has been the order of appearance of his symp- toms, and which are those that chiefly trouble him at the present time. Ascertain whether or not he has already been under treatment, and, if so, what has been done for him. This exhausts the general interrogation, and in- cludes the chief facts that have to be inquired into in every case. 2. The special iiiterrog:atio]i, to which we have already referred, must be modified according to the particular organ which is believed to be affected and the nature of the disease of which it is suspected to be the seat. It is here that the student has most diflS.culty. It is only by experience that one can tell what it is essential to ask in each individual case. In order to help the beginner, however, we have drawn up for his guidance a scheme of interrogation which he can pursue when he has reason to suppose that the patient's general symptoms point to an affection of any particular system or organ. Such a scheme is necessarily very far from complete, and may require to be supplemented in individual cases. Nor is one able in such a work as this to explain why such and such questions should be put in affections of this or that organ or system. The reasons for the questions 6 Case-taking. the student will find out for himself in due time. Our present object is merely to help him in the interroga- tion of his earlier cases, so that he may not miss any important facts. The questions are to a consider- able extent concerned with eliciting what are some- times spoken of as " subjective symptoms" — i.e. the morbid sensations experienced by a patient as the result of the disease of some organ or system. In making the notes, these, along with the other replies, should be entered under the special system to which they refer. 1. Alimentary syisteiii and abdomen. (a) Symptoms point to an affection of the stomach. Inquire regarding — Ajypetite. — Is it excessive, diminished, or capricious F Does it increase on eating ? Does he suffer from thirst ? Meals. — Arrangement of these ; the nature of the food. Does he eat between meals ? Sensations referred t" stomaoh. — Their nature, and where exactly they are felt. ITieir relation to the taking of food ; are they produced or relieved by it ? How long after food do they come on ? Are they specially influenced by different kinds of food ? Vomiting. — Frequency and time of ; by day or by night ; in the morning or in the evening. Its relation to food ; is it only after food, or does it occur at other times ? Its relation to pain ; does it relieve pain or not ? Does patient strain and retch much, or does the vomited matter come up quite easily ? General characters of vomited matter. — Its amount and colour. Is there ever " coffee-grounds " vomiting ; is it ever sour and frothy ? Eructations. — Presence or absence ; have they any taste ? Flatulence. — Presence or absence ; after food only or between meals ? Relation to particular articles of food. Does it tend to escape downwards or upwards ? State of the bowels.* — How often are they opened? Any special characters of the motions. * While the methods of gynecological examination are beyond the scope of this book, yet it must not be forgotten that it is frequently necessary in piu-ely medical cases to inquire regarding the menstrual function. The cases in which such inquiry may be Inter ROG AT/OX of Patient. 7 id) Symptoms point to an affection of the intes- tines. Inquire regarding — Diarrhfva. — Its frequency and its relation to meals or to special articles of food. Character of the motions. Has he ever passed .any blood or slime ? Is there any straining during defaK-ation r Is there any flatulence ': Constipation. — "What is his usual habit r are the bowels opened regularly, and if so, how often r How long since the last motion r Has he ever noticed any grooA-ing or flattening of the motions? Does the constipation alternate with diar- rhcea r Has he any griping pain r Has he had any vomiting r Pain. — Character; persistent or intermittent. Where is it felt worst ? Is it relieved or aggravated by pressure ? (c) Symptoms point to an affection of the liver — e.g. patient is jaundiced, or lias pain in region of liver. Inquire regarding — Pain. — Its site. Has he ever any attacks of very severe pain, coming on suddenly and lasting for a few hours ? If so, did the pain radiate, and in what direction ? Was there vomit- ing with it r Was he yellow at all after it subsided r Has he ever pain in the tip of the shoulder "r Does he suffer from piles r Does he ever vomit blood ? Has he noticed any change in the colour of the urine or faeces ? Does his skin itch at all (if he is jaundiced) ? Inquire also required are too diverse to be enumerated here. It need hardly be said that the necessary questions should not be abruptly X)ut to the patient, but shoulcl be delicately led up to. Having inquired regarding the regularity of the bowels, one may ask if the patient is "regular in her own health," or "regular in her unwell times."' It will be remembered that in a majority of cases menstruation recurs every tw^enty-eight days, but the intervals may be longer or shorter according to the patient's habit. If menstruation has ceased, one must inquire how long it has been absent. Normally the cessation of menstruation, or menopause, should not occiir till about the forty-fifth year. It is also necessary to inquire whether the patient is losing more or less blood than usual. This is specially indicated in cases of an?emia. If the menstrual flow lasts for less than two or more than eight days, it is to be regarded as abnormal. The presence or absence of pain at the j)eriod is also a poiut of some importance. The age at which menstruation began, and the occurrence or not of intermenstrual leucoiThcta (" white discharge ") must sometimes be inquired into. 8 Case-taking. regarding his digestion on the lines of the interrogation already laid down for affections of the stomach. 2. The symptoms point to an affection of the circulatory system. Inquire regarding — h. family lihtory of gout, rheumatism, angina, apoplexy, or heart disease, A personal history of rheumatic fever, St. Vitus* dance, scarlatina, or diphtheria. (If a child, ask also about sore throats and " growing pains "). The following subjective sensations : — Dyspnoea. — Has he to sit up in bed, or can he sleep lying- down ? When does it come on ? Frcecordial pain or distress ; its exact site and character ; does it radiate or not ? If so, in what dii^ection ? Palpitation : its relation to meals, and to exertion. Does the heart give an occasional thump now and then ? Sleep, good or bad ; does he di-eam ? Giddiness, is it ever present, and when ? Ask also for signs indicative of general venous distension — e.g. do the feet ever swell ? Has he any cough ? What is the state of the digestion ? Does his nose ever bleed ? 3. The symptoms and appearances point to an affection of the blood. Inquire regarding — Family history of bleeders. Has he had any loss of blood ? Has he bleeding piles ? (If a woman — is menstruation ex- cessive or diminished?) What is the state of the bowels ? Any possibility of lead poisoning or malaria ? Such subjective sensations as breathlessness on exertion ; headache ; giddiness. Do the feet ever swell ? 4. The symptoms point to an affection of the respiratory org'ans. Inquire regarding — Family history of bronchitis, asthma, phthisis, or " scro- fula." The patient's occupation ; does it expose him to the inhalation of irritating fumes or particles ? Has he ever had large glands in the neck ? Does he sweat at night ? Is he getting thinner ? Co'uyh. — Its character and frequency ; when is it worst ? Does it pain him or not ? Does he ever vomit with it ? lExjyectoration. — Its amount and general characters ; yellow or not ? Ever blood in it ? If so, is it only after severe coughing ? Is the blood bright and frothy or dark in colour ? Interrogation of Patient. 9 Pcbiih in chest. — Is it aggravated by taking a brcith!-' Constant or not ? Where seated ? Di/sjmoea. — "\\Tien is it felt ': If spasmodic, ask him to describe an attack. 5. The symptoms })oint to an atFection of the Kid- neys — e.g. general dropsy — or iiriiiary passages — e.g. pain in micturition. Inquire regarding — Family history of Bright's disease, gout, or apoplexy. Personal history of scarlatina, syphilis, lead-poisoning, pro- longed suppurations, gravel or gout, and previous renal disease. Has he any pain in the lumbar region ? Ever any attacks of acute pain shooting down into the groin ? The following remote symptoms : — Headache, vomiting, drowsiness, paralysis or fits, dimness of sight, dyspnoea. Does the face ever look puJffy in the morning P What is the state of the bowels ? Inquire regarding micturition as follows : — Urine. — Is it altered in amount P Has he to rise in the night to pass it ? Is it altered in colour ? Is it clear or turbid when passed? Ever any blood in it r If so, at what period of micturition is it present ? Is there any increased frequency of micturition ? Is the increase by day or by night r Is there any pain during mictuiition ? is it before, during, or after the act ? What is its character, and where is it felt ? Is it aggravated by movement ? 6. In sliiii diseases. Inquire carefully into the patient's personal habits as regards diet, clothing, and washing. Ask if he has been taking any drugs recently. It may be necessary to inquire carefully regarding syphilis. Does the eruption itch ? If so, when is the itching worst ? Did the eruption appear all at once or in crops r (Family history of gout ; previous history of rheuma- tism, anaemia, etc.) 7. The symptoms point to an affection of the nervous system. Inquire regarding — A family history of mental disease, St. Vitus' dance, paralysis, or fits. I o Ca S£- ta king, » The nature of the patient's work ; is he exposed to any poisons — e.g. lead, mercury, arsenic, naphtha, etc. Syphilis and alcohol should be inquired about with special care. In cerebral cases it is often very important to inquire re- garding- discharge from the ear. Should he complain of fits, the following questions should be asked : — Age at first fit ? Any assigned cause ? Describe the first fit. When did the second occur ? What has been shortest and longest interval between the fits ? Are they more or less frequent now ? Do they occur in sleep or not ? Has he any premonition or aura ? Is the onset sudden or gradual ? Are convulsions present ? Are they uni- or bi-lateral ? Where do they begin ? Does he bite his tongue, micturate, or deftecate during the fit ? Is restraint necessary during the fit in order to prevent him from hurting himself ? How does it end — sponta- neously, oris it induced ? Are there any after- symptoms, such as sleep, headache, or automatism ? If he complains oi paralysis, inquire regarding — Symptoms of heart disease, or chronic renal disease {see Circulatory and Urinary Systems). Had he any premonitory symptoms before the onset ? Has he any headache or vomit- ing ? Where is the headache situated ? Has he any giddiness or difiiculty in walking ? (The method of eliciting other sub- jective symptoms of nervous disease is considered along with the investigation of the cranial nerves). 8. The symptoms point to an affection of the bones or joints. Inquire specially, in the family history, for tubercular disease, rheumatism, gout, or syphilis, and in the personal history for tubercular disease, previous manifestations of gout or rheumatism, for syphilis or gonorrhoea, and for any remote or recent injury (and in a woman for leucorrhoea or post-partum trouble). If there be pain referred to a bone, ask whether it is worse during the day or during the night. If the pain be in a joint, ask whether it is constantly present or only when the joint is moved. Are there any starting pains at night ? Is the pain affected by weather? Does the pain shift from one joint to another ? If the patient be a young cliild, the following special questions should be put to the mother : — How many other children are there ? Any dead, and of Physical Examination. ii what ? Where does patient come in the family \ Has there been any miscarriages ? If so, when ? Health of father's and mother's family ? Was this a full-time child ? Was the labour normal / Was the child breast-fed ; if so, how long ? If not, how was it fed ? "SMiat food does it get now ? Had it any rash after birth, or any snuffles ? When did it begin to get its teeth and to walk / AVhat previous illnesses has it had ? (Inquire especially about the acute specific fevers.) If the child is suffering from cough, inquii-e specially whether it has ever whooped, when the cough is worst, and whether the child is ever sick after it. The interrogation of the patient being completed, one proceeds to — 2. The physical examiiiatioii. One investigates first of all, in every case, the patient's general state. This includes the general condition of his nutrition, the presence of any ob- viously morbid appearances, and the other points considered in detail in Chap. II. One proceeds after that to the investigation of each system by itself. What system should be taken up first ? As regards this, there are two possible methods. One may either take up the systems in one and the same order in every case, beginning, say, with the Alimentary, or one may examine first the system which is most affected. The latter is, on the whole, the better plan, provided always that one is able to tell which system it really is which is most diseased. The advantage of this method is that it gives most prominence to the most important part of the physical examination. Whichever plan the student elects to adopt, he may now proceed to the physical examination of the different systems in accordance with the instructions laid down in the following chapters, the results being noted in the order given in the scheme below. Only one more point regarding case-taking remains to be emphasised, and that is the importance of noting negative as well as positive facts. It is often quite 12 Case-taking. as essential, for example, to state that such a symptom as dyspnoea is absent as to record the fact of its presence. This is a point the importance of which is apt not to be fully appreciated by the beginner. In conclusion, it need hardly be said that the examination should be carried out as gently as possible, all unnecessary exposure, exhaustion, or chilling of the patient being carefully avoided. If the patient is suffering from severe or acute disease, it may be advisable to postpone all physical examin- ation other than that which is absolutely necessary to the diagnosis of his condition, or for guidance in treatment. It should also be borne in mind that when a patient is much exhausted, or suffering from serious disease of the lungs or heart, very dangerous and even fatal results may ensue if he be thoughtlessly made to sit up in bed in order to Lave his chest examined. CASE-TAKING SCHEME. 1. INTEREOGATION. Name. Age. Occupation. Married or single. Address. Date of coining under observation. Complaint. Duration. Family history. — Inquire regarding parents, brothers and sisters, and patient's own children. Note state of their health, or the cause of their death, with age at which they died. Personal history. Environment. — Nature of work and its surroundings. Hygienic conditions at home ; habits as to exercise, food, tea, alcohol, and tobacco. Previous illnesses or accidents (if any), with their time of occurrence, duration, and results. Present illness.— Time and mode of its origin, the order in which symptoms appeared, and the chief symptoms which trouble patient now ; treatment (if any) already employed. CASE-TAKI^G Scheme. 13 2. PHYSICAL EXAMINATION. 1. Present state. General condition. — General state of consciousness and intelligence. Decubitus (if in bed), or attitude and gait (if up). General state of development and nutrition. Expression of face ; presence or absence of pallor, jaundice, cyanosis, dropsy, or trophic changes. Presence or absence of any si^ecial characters of the hands (p. 29). Glandular enlargements. Character of the respiration, and the presence or absence of cough. Take the temperature. 2. Aliuieiitary system. Subjective symptoms (see special interrogation). Examine the mouth (including the teeth, gums, and tongue), fhepliarynx, and fauces (pp. 42-46), and the cesojyJtagus (with use of sound if necessary) (p. 47). General inspection, palpation and percussion of the abdo- men (pp. 51-60). Stomach. — Palpation and Percussion (pp. 60-64). Exami- nation of gastric contents (test breakfast) or vomit. Intestines. — Investigation of (p. 74). Eectal examination if necessary (p. 75). Examination of faeces (p. 84). Liver and Gall Bladder. — Examination of by palpation and percussion (pp. 64-68). Spleen. — Examination of (p. 69). 3. Circulatory system. Hea/rt. — Subjective Symptoms (see special interrogation). Inspection and palpation of pnecordia, noting position and character of apex beat, presence or absence of epigastric pul- sation or prascordial thrills, or of pulsation in the neck or at the base of heart. Percussion of Heart (p. 117). {a) Upper border ] (J) Right border > superficial, deep. \c) Left border ) Auscultation of Heart (p. 132). {a) At apex and a little internal to it. (b) Tricuspid area at lovrer end of sternum. (c) Aortic area. {d) Pulmonary area and a little outside it. [e) Between base and apex (third and fourth left costal cartilages.) (/) Veins and arteries of neck. If a bruit is heard, note : — - - 14 Case-taking. {a) Its time. {h) Its character (musical, harsh, etc.). (e) Its point of maximum intensity. \d) Its direction of propagation. Pulse. — Describe its rate and its rhythm. Compare the force of successive beats. Ascertain the state of the vessel waUs. Note the blood pressure during and between the beats. Observe the amplitude of the pulse waves. Analyse a complete beat of the pulse regarding rise, maintenance, and fall of pres- sure, and determine the presence or absence of secondary waves. 4. The blood. Estimate the red and white corpuscles (pp. 181-188). Esti- mate the hgemoglobin (pp. 189-192). Examine the blood microscopically, making films if necessary (pp. 193-208). 5. Respiratory system. . ,-*- Subjective symptoms (see special interrogation). V','^J-n6 v) Count the respirations and describe their character. U Inspection of chest, noting its shape, power of expansion, etc. (p. 213). Mensuration of the two sides of the chest. Palpation of chest (expansion and vocal fremitus) (p. 223). Percussion of lungs anteriorly, laterally, and posteriorly (p. 229). Auscultation of lungs in same order (p. 240), noting — {a) Type of breath sounds. (&) Character of vocal resonance. {o) Presence or absence of accompaniments. Sputum. — Note its naked eye and microscopic characters (p. 256). 6. Urinary system. Palpate the Kidmeys (p. 72). Examine the ?7rme. — Physically (p. 267), chemically (p. 278), microscopically (p. 329), making a note in every case of the following points — Quantity in twenty-four hours, colour, specific gravity, reaction, odour, general character of deposit. Amount of urea. Presence or absence of albumin, blood, sugar, and bile. Microscopic characters of deposit. 7. Skin. General colour ; presence or absence of pigmentation or eruption ; nature of " primary lesion " in eruption and of " secondary lesions," if present (pp. 347-357). Case-taking Scheme. 15 Palpate the skin ; dryness, smoothness, thickness, elasticity. Character of subcutaneous tissues. 8. Nervous system. Inquire regarding suhjective Bymptoms (see special interro- gation). Investigate state of — (1) Intellectual functions (intelligence, memory, sleep, coma, delirium, speech, etc.) (Chap. IX,). (2) Cranial nerve functions (testing them in order) (p. 3S7). (3) Motor functions (noting presence or absence of paralysis, or of abnormal muscular movements, and state of muscular nutrition) (pp. 378-386). (4) Sensory functions (including condition of sensibility to touch, weight, temperatui-e, and pain, and the muscle sense) (pp. 427-431) ; presence or absence of abnormal sensations (p. 431). (5) Eeflex functions — Superficial reflexes (p. 431). Deep „ (p. 434). Organic ,, (p. 439). (6) Electrical reactions of muscles and nerves (if necessary) (p. 440). 9. The eye. Appearances seen on ordinary inspection of lids, conjunctiva, cornea, etc. (p. 451). Use oblique illumination and ophthalmoscopy, noting state of media, refraction, and characters of fundus (pp. 454-464). N.B. — The fundus of the eye should be reported, on in all cases of nervous disease. The Ea,r. — Examine pinna, meatus, and membrane (using speculum and inflation if necessary) (p. 468). The Tliroat, nose, and larynx. — Examine larynx (laryngoscopy) and anterior and posterior nares (posterior rhinoscopy) (pp. 472-480), noting any abnormalities. 10. L f— 1 o =4-1 Pi o H O) w -§ H ^ ^ ew O -U C^ (In ^ a O m Pico &t ft M 03 03 S o p — Ed 'iH H^ :3 Ph 60 g o3 I p Cl) d !i el d s M o "o ■o ^^ cp be d M liver. f livei cludin rfi be of lobe c ach in O 1— ( Oi '■^ -J §3 a P^^l^ ^ o^ ^ f-l r^ --J JH o3 b>. '5 <'S p Ph (U =f-l ■t:^ o !■? ^ O) . 2; © CM 03 ^ fl 'O (D O ^ S O «> S ^ a s & (4 o p •is » 1— t o =w » o o 03 >^ 1— 1 M (^ H «f-l IS o 2 -^^ P^ o rt © a pi c3 g © 2 M o oo o o a bn © a Ti =4-1 rt O © 4J o !i 02 (t! -< P4 w S M © p:5 r^i General Examination. 51 T]ie umbilicus is \\ in. to \\ in. above the level of the bi-iliac line, and lies opposite the upper part of the 4th lumbar vertebra. The aorta bifurcates about |- in. below and slightly to the left of the umbilicus, the iliac arteries running in a line drawn from that point to the middle of Poupart's ligament. The cceliac axis arises at a point 4^- in. to 5 in. above the umbilicus, and the renal arteries about an inch lower than the coeliac axis. General Examination of Abdomen. The patient should be lying on his back in a good light. The abdomen is exposed by turning down all the bedclothes except the inner sheet. The night- shirt should then be drawn up, and, lastly, the sheet folded down a little above the level of the pubes. These details are of especial importance in the case of female patients. Before beginning the examination of the abdomen, make sure that the bladder is empty. If necessary, a catheter must be passed. Inspection of abdomen. — Look first at the general contour of the abdomen. Is it of normal fulness, is it swollen or protuberant, or is it sunken or retracted % If there is any bulging, note if it be general or local. General fulness, it has been epi- grammatically remarked by Dr. Wyllie, may be due to "fat, fluid, or flatus." If one were to venture to improve upon this, it would be to say, ' ' fat, fluid, gas, or growth^'' as new growths are a not unfrequent cause of general abdominal tumidity. The mode of distinguishing these conditions will be considered when we come to ascites. In general bulging it should be noted whether the distension is most marked in the antero-posterior or in the transverse diameter. If the bulging be merely local, observe in which 52 The Abdomen. zone it is situated. Is it above or below the level of the umbilicus, and in which of the abdominal regions is it most marked % Lastly, note if there is any movement to be seen in the swelling, either along with or independently of respiration. Puli!»at)ioii in the epig^astric re$^ioii is a phenomenon which may be noticed on abdominal inspection^ apart from any bulging in that region. The causes of it are (1) distension of the right ventricle (see p. 106) ; (2) venous pulsation of the liver ; (3) aortic pulsation. The last is a condition which is very frequently observed in nervous subjects, especially women. The cause of it is obscure. It may be distinguished from right ventricle pulsation by being situated somewhat to the left of the middle line, by the fact that it can usually be traced down- wards towards the bifurcation of the aorta, and by its being not quite synchronous with the apex beat, but somewhat delayed. (4) Transmitted pulsation from a tumour overlying the aorta. (5) Aneurysmal. This iS; perhaps, the least common cause of epigastric pulsation. The pulsation in this case is expansile, a fact which can best be elicited by placing the narrow ends of two stethoscopes one on each side of the swelling, and observing if the other ends move apart at each impulse. The movements of the abdominal wallis should be studied. Normally, they bulge during inspiration, and fall in again during expiration. In paralysis of the diaphragm the reverse holds true ; sometimes the paralysis is unilateral, in which case one side of the abdomen will move naturally. Ces- sation of movement of the abdominal walls is a valuable sign of peritonitis. Sometimes peristaltic waves are visible through the abdominal wall. This is especially apt to be the case in chronic intestinal obstruction. The coils of Inspection. 53 intestine above the constricted part then stand out prominently. From this a definite " pattern " of abdominal tumidity results, depending on the site of the obstruction. If, for example, there be a constric- tion at the ileo-c?ecal valve, the distended coils of small intestine may often be observed standing out in the centre of the abdomen one above the other, so as to form a "ladder pattern." On the other hand, if the obstruction be low down, say in the sigmoid flexure, the pattern of tumidity is one in which the periphery of the abdomen is chiefl.y affected. A dilated stomach may also stand out as a prominent tumour in which peristaltic waves are visible. The direction of such waves should always be noted. If absent, they can often be elicited by flicking the surface with a wet towel, or by merely sharply tapping it with the finger. Peristaltic waves in the stomach run from left to right ; those in a distended transverse colon from right to left. This may sometimes be of diagnostic value. Attention should next be paid to the surface ot the abdomen. In great distension the surface is smooth and glossy. Striae (white lines in the epidermis) should be looked for ; they indicate former distension. Note any distension of the surface veins, and endeavour to ascertain in what direction the blood in them is flowing. In obstruction of the inferior vena cava, the inferior epigastric veins are full from the establishment of a collateral circulation. In such cases also a large lateral vein can be seen running up about the mid-axillary line, and thus establishing a communication with the tribu- taries of the superior vena cava. In portal obstruc- tion a number of distended veins may often be seen radiating out from the umbilicus. To this appear- ance the term " caput medusae " has been applied. It is due to establishment of a connection between 54 The Abdomen. tlie portal and parietal veins by means of the round ligament. Pigmentation of the abdominal wall is sometimes important. Along the middle line it forms the linea nigra — one of the signs of pregnancy. Note the appearance of the umhilicus. Is it de- pressed, level with the surface, or bulging ? Is there any excoriation around it ? Lastly, one should never omit to look at the usual sites for any evidence of hernia. Palpation of the abdomen. — The patient should be on his back, with the knees drawn up, and the shoulders a little raised. He should be told to keep the mouth open and to breathe quietly, or his attention may be diverted l)y conver- sation. The hand of the physician must be warm. Ordinary palpation should be performed with one hand only. In order to gain the confidence of the patient's abdominal muscles, the hand should be allowed to rest for a moment on the surface of the abdomen before palpation is actually commenced. Each I'egion should be palpated systematically. Poking with the finger tips should be avoided, the best movement being a gentle one from the metacarpo- phalangeal joints. During expiration the receding abdominal wall should be followed by the fingers, and a gentle rotatory motion of tlie finger tips may then be carried out. It often enables one to feel the deeper structures better than one can do by simple pressure. In examining the lateral regions of the abdomen, bimanual palpation is often of service. The physician should sit or kneel by the bedside. One hand is placed posteriorly in the interspace between the last rib and the crest of the ilium. The other is placed over the abdominal wall in front. The posterior wall is then pushed up against the hand in front, so that any structure lying between the two hands can be distinctly felt. The secret of the method consists Palpation. 55 in keeping the front hand as still as possible. This procedure is of special value in the examination of the kidneys. The first thing to notice in palpation of the abdo- men is the degree of resistance experienced. Normally the abdomen has an elastic or doughy feeling only to be learnt by practice. In disease the resistance may be increased. It should be observed whether this increase is general or local. General peritonitis pro- duces a great increase in the resistance from a reflex contraction of the muscles of the abdominal wall. Local increase in resistance is very frequently due to localised peritonitis, and is often of great diagnostic value. Palpation of the normal abdomen is painless. If tenderness is elicited, its exact extent and point of maximum intensity should be noted. Anything of the nature of a tumour should be carefully felt for. In doing this, confusion is apt to be brought about by the recti. The thickening produced by parts of these may easily simulate a tumour. If this source of fallacy be suspected, try if the fingers can be got under the edge of the muscle, and feel if it thickens as the patient raises himself in bed. If it be decided that a tumour is really present, one has first to determine whether it is situated inside the abdomen or in the abdominal wall. Try, there- fore, to move the abdominal wall from side to side over the tumour. If the growth be intra-abdominal, this can usually be done without difficulty, unless it has contracted adhesions to the parietal peritoneum. Try also to grasp the tumour and to make the fingers meet, as it were, under it. This can' usually be accomplished in the case of tumours situated wholly in the abdominal wall. Supposing the tumour to be intra-abdominal, the first question to be settled is — Where is it growing from? and, especially, is it coming up out of the 56 The Abdomen. pelvis, or is it truly abdominal % To decide this the edge of the hand should be pushed back about an inch below the umbilicus, and in the direction of the prominence of the sacrum. One can then feel whether the tumour is passing down into the pelvis or not. The size and shape of the tumour should next be noted, and the nature of its surface — whether smooth or nodular. The presence or absence of fluc- tuation should then be investigated. The mobility of a tumour is a very important point to determine. The directions in which it can be moved should be noted, and whether it is influenced by respiration. The latter is a point of special value. Tumours connected with the liver and spleen move freely with respiration. Tumours of "the kidney may be slightly movable ; those con- nected with the other abdominal organs do not move with respiration at all unless they have contracted adhesions. In palpating the abdomen, the existence of splash- ing or gurgling at any points should be looked for. Splashing is often found over a dilated stomach, but is only of diagnostic value if it can be elicited some hours after the swallowing of food. Gurgling is pro- duced by the passage of gas and fluid through con- stricted parts of the alimentary tract. It may thus be felt at the pylorus, especially if stenosed, or over strictures of the intestines. Finally, the umbilicus should be examined. In malignant disease of the liver the umbilicus often becomes early infiltrated, and this sign has proved of great diagnostic value. The infiltration can often be recognised by its producing a " mooring " of the umbilicus — just as a scirrhus of the mamma does of the nipple. In conclusion, we have to remark that in obscure cases of abdominal disease palpation in the knee- Percussion. 57 elbow position, and under an anaesthetic, should never be omitted. Percussion of abdomen. Percussion should be carried out in the same manner as will be described for the chest. We would point out, however, that in abdominal percus- sion the " flicking " method is extremely serviceable in detecting slight degrees of dulness — e.y. in making out the lower edge of the liver. In carrying out this method the fore finger of the left hand is placed firmly on the abdomen, with the palmar aspect uppermost, and is then sharply " flicked " with the middle finger of the right hand. Percussion of the normal abdomen yields a resonant note throughout, except in the regions of liver and splenic dulness. The ])ercussion pitch of the hollow viscera depends on two chief factors — ■ («) The depth of the air space. (6) The tension of the containing wall. As these two factors are of almost equal import- ance, and as each of them varies greatly in the same viscus at different times, the reader will readily understand that it is a mistake to dogmatise about the relative pitch of the note yielded by the various hollow viscera. Other things being equal, however, the smaller air-space of the small intestine will yield a higher pitched note than the larger air-space of the colon. The presence of free gas in the peritoneal cavity causes the normal liver and spleen dulness to disappear. If any abnormal dulness be detected, the chief point to be determined regarding it is whether it is constant in position or shifts with alterations in the position of the patient. This will be more fully dis- cussed when we come to speak of ascites. Hydatid cysts yield on percussion a special kind of vibration called the " hydatid thrill " (fremissement 58 The Abdomen, hydatique). To elicit it three fingers should be placed over the cyst and the middle one firmly percussed, the percussing finger being allowed to rest for a moment after each stroke. An " after-thrill " will then be experienced in the two adjacent fingers. It should be added that the sign is absent in about half the cases of hydatid cyst. Auscultation of abdomen. Auscultation is not of much service in the exami- nation of the abdomen. It is best to carry it out by means of a binaural stethoscope. In the region of the stomach one may listen for swallowing sounds, bub- bling and splashing (to be described later), or for abnormal conduction of heart sounds. Elsewhere one may hear friction sounds — from the presence of lymph on the surface of the peritoneum. One may listen over aneurysms to detect a bruit, and over suspected enlargement of the uterus for the presence of foetal heart sounds. The latter are best heard (in normal presentations) at a point midway between the umbilicus and the left anterior superior spine. The examination of the abdomen by the combined auscultation-percussion method will be referred to later. In cases of general abdominal swelling measure- ment should never be omitted, as it affords a valuable index of the progress of the case. The circumference may be taken at the level of the umbilicus or at the point of maximum distension. The examination of cases which are believed to have fluid in the peritoneal cavity or ascites calls for special consideration. In cases in which the fluid is sufficient to cause general distension, the conditions for which one is apt to mistake it, are, as we have seen, fat in the abdomen and abdominal wall, gas in the intestines or free in the peritoneum, and new growths. Fluid gives, of course, a dull note A use UL TA TION. 5 Q on percussion. The dulness is not always absolute, however, owing to the transmitted resonance of sub- jacent bowel. When the fluid is free and not suffi- cient to fill the whole abdomen, its upper limit is more or less horizontal, but may show irregularities owing to the fluid running up into " bays " between coils of bowel. Free fluid is also distinguished by the fact that it shifts its position with that of the patient. If he be turned over on his side and time given for the intestines to float up, it will be found that the uppermost flank is now resonant, while the height of the dulness on the lower side has risen. If the fluid be very small in amount, it is a good plan to turn the patient on his hands and knees. A dull area then appears around the umbilicus from accumu- lation of fluid there. The " transmitted thrill " is another important physical sign of fluid in the peritoneum. It is elicited by placing one hand over the lumbar region of one side, the patient being on his back, while the opposite lumbar region is sharply tapped with the fingers of the other hand. A distinct impact will be felt to pass from one hand to the other. As a not dissimilar impulse is apt to be transmitted through the abdo- minal wall, especially if fat, it is always well to get an assistant to place the edge of his hand firmly in the middle line of the abdomen while percussion is being made. This damps down any vibrations trans- mitted by the wall. Where the amount of fiuid is large, the vibrations are visible as well as palpable. On the whole we consider that the results of simple percussion afford the most trustworthy evidence of the presence of ascites. Fati^ to be distinguished by taking the abdominal wall between the hands and pinching it up. Gas is distinguished by the results of percussion. Of new 6o The Abdomen. growths, ovarian tumour is, perhaps, most liable to be mistaken for ascites. An ovarian tumour, how- ever, causes an antero-posterior bulging of the ab- domen, while in ascites the bulging is mainly lateral. In ovarian tumours, also, the dulness is central and does not change with the position of the patient; in ascites the chief dulness is in the flanks, and it shifts, as we have seen, when the patient is moved. Lastly, in ascites the umbilicus is flat or bulges out, while in ovarian tumours it is drawn upwards. SECTION III. One may now pass to the examination of the viscera contained in the abdomen, beginning with the stomach. The Stomach. Special anatomy (Plates L, 11. ). The stomach is situated in the left hypochondriac and the epigastric regions. Its cardiac orifice lies behind the seventh left costal cartilage, one inch from the sternum and four inches from the surface. The pyloric orifice is surprisingly close to it, being about three fingers' breadths below the base of the xiphis- terum and one finger's breadth to the right of the middle line. It passes considerably farther to the right, however, when the organ is distended. It is usually under cover of the liver. About two-thirds of the stomach is under cover of the ribs, the fundus reaching, in ordinary circumstances, as far up as the fifth rib in the mammary line. It is, therefore, somewhat behind and above the apex of the heart. Only a small part of the body of the stomach and of the pyloric region is in contact with the anterior abdominal wall. The exact position of the great cur- vature varies. Under normal conditions it should never be lower than the level of the iwibilicus. / j3RQCii PLATE I.— VISCERA OF THORAX AND ABDOMEN, AS SEEN FROM THE FRONT. Scale : 1 = 5-6. (After LuscJiTca.) {To face p. 61. The Stomach. 6t The physical oxannnation of the stomach is chiefly concerned ^vith the determination of its size. It is by no means easy to be sure of the exact dimen- sions of the stomach, owing in part to its position, in part to the fact that the amount of gas contained in it varies greatly from time to time. The fact that it is in direct contact with the transverse colon, which yields a very similar note, also adds to the confusion. Recourse is frequently had to inflation of the stomach with gas in order to overcome some of these difficulties. Inflation may be carried out in two ways : — (1) Make the patient swallow a small teaspoonful of tartaric acid in solution and immediately afterwards a similar quantity of bicarbonate of soda. The evolu- tion of carbonic acid gas which follows distends tlie organ. The patient must be told to refrain^ if he can, from eructation. (2) Pass a stomach-tube which has a glass mouth- piece. Then distend the stomach either by blowing down the tube or by fitting on to it a rubber ball spray -producer, and so pumping in air. Inflation should never be practised if there has been any recent bleeding from the stomach or if one has reason to suspect the existence of a gastric ulcer. It should also be avoided in feeble subjects and in those in whom the heart is in any way embarrassed. Inspection of the stomacti region is included in the general examination of the abdomen. If dilated the organ may possibly be seen standing out even before inflation. It may form a tumour in any part of the abdomen except the upper portion of the epigastric region. If it be dislocated downwards, the outline of the lesser curvature may be visible. Peri- staltic movements of the stomach wall have already been referred to (p. 53). Palpation of the stoniaoh.— Note if there be 62 The Stomach. any tenderness felt on palpating the stomach and define its point of greatest intensity. Examine for tumours. The commonest of these is a pyloric new growth. Tumours of this region are characterised by their great mobility. They may be felt in, or pushed into, any region of the abdomen. Lastly, try for splashing. To make out this, sit at the left side of the patient with one hand over the left lower ribs behind ; with the other placed over the front of the stomach make short, sudden, dipping movements. If "splashing" be elicited it will be partly heard and partly felt. Distinct splashing elicited three hours after a meal, especially if it can be made out below the level of the umbilicus, is very suggestive of a dilated stomach. Percussion of tlie stomach. — Three bound- aries of the stomach can be made out by percussion : (1) Between stomach and lung; (2) between stomach and liver ; (3) between stomach and colon. The last is that which it is most important to determine, and should be examined first. It is by no means always easy to define the lower border of the stomach exactly. This is because the transverse colon may give an almost identical note with it. Use light percussion. The "flicking" method succeeds very well here. Begin low down near the pubes and percuss upwards just to the left of the middle line. The lower border of the stomach should be reached about a finger's breadth above the umbilicus. The limit between the lower edge of the lung and the upper part of the stomach is made out in a similar way. It is best to percuss from stomach to lung. The usual line of demarcation between the two runs in a slightly arched manner from the sixth costal cart- ilage in the parasternal line to the ninth in the mid-axillary line. The area of stomach resonance Percussion. 63 wliicli is bounded above by this line and l^y tlio anterior edge of the spleen, and below by the left costal margin, is called Traube's space. It covers that portion of the stomach which is in direct contact with the chest-wall. We have seen that the fundus of the stomach extends above this under cover of the lung as high as the fifth rib in the nipple line. It cannot, however, be satisfactorily percussed out. The demarcation between the stomach and liver is made out by percussing lightly from the stomach towards the liver margin. It is not of much im- portance. We would repeat that for the diagnosis of dilated stomach the position of the great curvature is of most importance. If this be found to be below the umbilicus, while the lesser curvature is in its normal position, then the existence of dilatation is certain. It is con- firmed if the stomach note extends much across the middle line towards the right. The position of the stomach-lung and stomach- liver boundaries depends as much upon the condition of the lung and liver as upon the stomach itself. Thus in fibroid contraction of the lung more of the stomach is exposed than is normal, and its area is therefore apparently increased. Cirrhosis of the liver may produce a similar apparent extension of stomach area. On the other hand, effusions into the pleura or enlargements of the liver cover up the stomach, and cause a diminution in its area of resonance. Hence in the former condition Traube's space is much diminished (see p. 233). The possi- bility of a dislocation of the whole organ downwards must never be lost sight of. In such a case the outline of the lesser curvature may often be seen standing prominently out, especially when the organ is inflated. If the distance between the greater and lesser curvature is more than 10 cm., dilatation exists. 64 TiiR Stomach. Tiie coiiibiiiecl pereiisf^ioii— aiif^ciiltatioii iiietlioci often gives valuable aid in mapping out the stomach. To carry it out proceed as follows : — Place the end of a wooden stethoscope over the stomach, either somewhere in Traube's area, or, better, in the angle between the xiphoid cartilage and the left costal margin. Then percuss lightly near the stethoscope. A characteristic note is heard. Then, still keeping the stethoscope in the same situation, start percussing near the pubes, and percuss ujD towards the umbilicus until a note similar to that first heard is made out again. That indicates that the edge of the stomach has been passed. One can now, by percussing in different directions, make out the limits of the organ all round. The method depends on the fact that the aerial vibrations set up under the percussing finger resound all through the organ, and therefore reach the stethoscope placed over any part of it. Previous inflation of the organ is not required. Be careful not to use too strong a percussion stroke, or vibration may be set up in adjoining viscera. Auscultation of the stomaeli area may detect peritoneal friction over it, or the crackling due to the bursting of fermentation bubbles in the interior. Heart sounds and murmurs are sometimes heard loudly over the stomach as over a resonating chamber. The deglutition sounds are of no diagnostic value. The chemical investiofation of the stomach is considered in, Section lY. (p. 76). The Liver. Special anatomy (Plates I., II., III.), — The liver lies chiefly in the right hypochondrium. Its left lobe extends across the epigastric region, but does not pass more than two inches to the left of the sternum. J8R0DII PLATE 1 1. -VISCERA OF THORAX AND ABDOMEN, AS SEEN FROM BEHIND. Scale : 1 = 5-6. (After LuschM.) [To face p. 65 The Liver. 65 Above, the liver reaches almost to the nipple ; below it extends to the costal margin. The lower border passes obliquely upwards from the ninth right to the eighth left costal cartilages, crossing the middle line somewhat above the mid point between the base of the xiphoid and the umbilicus. The gall bladder is situated just internally to the ninth right costal cartilage and immediately to the outer side of the right rectus muscle. IiispcctioiB of the liver is of little value. Any visible swelling, fulness, or pulsation should be noted. The edge of the liver can sometimes be seen when the organ is enlarged. It forms a sharp line which moves up and down with respiration. Palpation of liver.— The lower edge should first be felt for. In order to do this, place the hand flatly on the abdomen, with its edge towards the costal margin and just to the outer side of the rectus muscle, the reason for going so far out being to avoid the upper septum of the rectus sheath, which is apt to be mistaken for the lower edge of the liver. Tlien depress the edge of the hand slightly so as to push up a fold of skin, and ask the patient to take a long breath. If the edge of the liver is palpable, it will be felt to ride over the edge of the hand. Trial, of course, must be made at different levels before it is decided that the edge cannot be felt. The edge of the liver cannot, or can only very rarely, be felt in health. It moves down from two-fifths to three-fifths of an inch with inspiration. The character of the edge should also be noted — whether it is smooth or irregular, thickened or sharp. If in doubt whether what is felt be really the liver edge, feel for the fissure for the gall bladder, and, towards the middle line, for that produced by the round ligament. The surface of the liver in the epigastrium should 66 The Liver. then be felt in the usual way. Any tenderness should be noted, and whether it is localised or seneral. The character of the surface should be made out. Is it smooth, as in waxy disease, or nodular, as in carcinoma 1 In the latter condition the centres of the nodules will often be found to be umbilicated. Care must be taken not to con- found little irregularities which are frequently present in the upper parts of the recti with irregu- larities on the surface of the liver. Liver friction (due to perihepatitis) can sometimes be felt. It is usually best made out over the posterior surface of the organ between the vertebrae and the mid- axillary line. Heaving pulsation of the whole organ can best be appreciated by placing one hand over the lower right ribs behind and the other over the organ in front. Percussion of the livei*.— The following table shows the normal percussion limits of the liver (Fig. 20) :- Mamillary Mid-.\xil- Scapular line. lary line. line. Deep A 4th space. 7th space. 9th space. diilness. Blend Upper J with limit. heart Superficial dulness. ^ dulness. j 6th rib. Sth rib. 10th rib. Hand's Costal mar- Blends with Lower limit. brealood in the vomit the guaiac test is not satisfactory. It is better to take up some of the brown deposit with a pipette, to place it in a porcelain capsule, and add a pinch of powdered chlo- rate of potash and a few drops of strong hydrochloric acid. Heat till dissolved. Cool and add a few drops of ferrocyanide of potash solution. A blue colour indicates that blood is present. The reaction is due to the iron contained in the blood pigment. If the patient has been taking iron the test is, of course, inapplicable. In such a case some of the deposit should be digested with caustic potash, filtered, and the solution examined for the spectrum of alkaline hsematin, or the deposit may be subjected to Teich- mann's test (Appendix, 19). To confirm the test, add to the alkaline hsematin solution a few drops of sulphide of ammonium, which converts it into hsemochromogen. The spectrum of the latter is identified by its possessing two bands, one, narrow and dark, in the yellow between D and E, the other, broader and less dark, at the junction of the yellow and green between the lines E and b (Fig. 63). 3. Microscopic examination (Fig. 8). — Take up some of the deposit which adheres to the muslin, spread it out on a slide, and examine either directly or in a drop of salt solution. Various particles derived from the food may be recognised. Muscle fibres by their transverse striae. Starch granules by their concentric lines and the fact that a drop of very dilute iodine solution turns them blue. Elastic fibres by their double contour and bold curves. Fatty 2^aQ'ticles by their high refractility. Various vegetable parasites may be present. The most important are the sarcina ventriculi Microscopic Cha racters. 83 (a large micrococcus) and the yeast fuiig'i. The former can h^ recognised ]:)y their forming small cubical packets of cells resembling miniature bales of wool ; the latter consist of round or oval cells in chains or clusters. They are usually about the size of white blood corpuscles. The addition of a little very dilute iodine solution Fig. S. — Microscopical view of vomited matter. n, vegetal lie cells ; h. epithelial cells ; c, starch granule ; d, oil glolmle ; e, muscle ' fibre; /, sarcina ventriculi ; g, torula. to the vomited matter may render the detection of sarcinse more easy. The iodine stains them a deep mahogany brown. Permanent preparations of these fungi may be made by spreading out some of the deposit in a thin layer on a cover glass and drying over a flame. The best stain for sarcinse is an extremely dilute — almost transparent — solution of gentian violet. Stain for a minute or two. Bismarck brown also gives good results ; stain very briefly. For yeasts use a 2 per cent, solution of methylen blue, and stain for half a 84 Examination of Falces, minute. Wash in water in both cases, dry between filter papers, and mount in balsam. SECTION VI.— EXAMINATION OF F^CES. 1. Naked eye. The following points should be attended to : — {«) Amount of the daily stools ; (b) Their colour ; (c) Their odour ; (c/) Their consistence and form ; (e) The presence of any abnormal ingredients. As regards amoimt, it is usually sufficient to state whether the stools are copious or scanty. The average daily amount of f?eces in health is 120-1 80 grms. (about 4 ozs.). The colour of normal faeces is partly due to urobilin, partly to chlorophyll and other pigments. The presence of unaltered bile pigment is always abnormal, and may be due to increased rapidity of peristalsis. Black stools may be produced by the administration of iron, bismuth, or manganese. In haemorrhage high up in the intestine the altered blood makes the stools dark, tarry-looking, and very offensive. The blackness due to blood may be dis- tinguished from that produced by drugs by mixing part of the stool with twice its volume of water and allowing it to stand in a glass jar. If blood be present the water becomes reddish ; under other conditions it remains dark or greenish. Pallor of the stools may be due to an obstruction to the entrance of bile into the intestine, as in jaun- dice, or to extreme dilution of the stool, as in cholera. The odoiir of the faeces is due to the presence of indol and skatol. The absence of bile seems to favour putrefaction, hence the stools in jaundice are often very offensive. Cholera stools, on the other Naked-Eye Characters. 85 hand, contain ^'ery little organic matter, and are almost free from odour. In fermentative processes in the intestine the stools may have a sour smell. The form and consistence of the stools is of importance. In obstinate constipation the stools may be much drier and harder than normal, and e\en friable. In all forms of diarrhoea they are more fluid than normal, and may even be watery. Slimy stools are due to the presence of an excess of mucus. It is important to note whether the stools are formed or fluid. If formed, any abnormality in the shape should be noted. The stools of constipation have often the form of round balls, frequently coated with mucus. In obstruction in the large intestine the stools may be ribbon-like. If ascites is present, the pressure of the fluid on the bowel often leads to flattening of the feeces. The presence of a rectal polypus may produce a groove or furrow along the fsecal mass. In order to facilitate the detection of abnormal ingredients, the stool should be placed on a fine sieve, and a large quantity of water added. The whole is then shaken and stirred up till the soluble parts are all washed away. The residue is then examined. Gall stones are easily recognised. It is important to note whether they are facetted or not, for if they are, then the stones are multiple. Particles of un- digested food, fruit stones, foreign bodies, concretions — e.g. those produced by magnesia — and parasites should all be looked for. The full consideration of the parasites which may be found in the stools is undertaken later. We would only mention here that one has often to search stools for the head of a tapeworm. The best method of procedure in sugh a case is to add to the stool a 86 Examination of Fmces. considerable quantity of water containing a little carbolic acid, and to shake the mixture gently for a few moments. It is then allowed to stand for about ten minutes. The parasite sinks to the bottom, the supernatant fluid is poured off", and more water added till the residue is nearly colourless. The parasite will then be readily found. The head is only about as large as that of a large pin, and the neck about as thick as a stout thread. Special terms are applied in clinical medicine to some particular varieties of stool. The hilious stool is well illustrated in the typical stool of typhoid fever. Its characters are described in the term of " pea soup " stool, usually applied to it. Watery stools are found in all cases of colliquative diarrhoea, and after the administration of hydragogue cathartics. To the watery stools of cholera the special name of rice-water stools is applied. Such a stool is colourless, devoid of odour, alkaline in reac- tion, and contains a number of small flocculi, consist- ing of shreds of epithelium and particles of mucus. The name is applied to it from its resemblance to the water in which rice has been boiled. Purulent^ or pus-containing, stools are found in severe dysentery or intestinal ulceration, or in cases where an abscess has found its way into the intestine. Slimy stools are due to the presence of an excess of mucus, and point to an affection of the large bowel. The mucus may envelop the fa;cal masses, or may be intimately mixed with them. Bloody stools vary in appearance according to the site of the haemorrhage. If the latter takes place high up, the stools look like tar, as has been already mentioned. In an ordinary intus- susception the stools may look like red currant jelly, In those rare cases in which the intussusception occurs in the jejunum the appearance of the material passed per anum has been compared to Microscopic Characters. 87 that of a melted strawberry ice. If the h?eiiiorrhage be from the large intestine, the blood is less intimately mixed with the fgecal matter, and may even be of a bright colour. In haemorrhage from the rectum or anus it may merely streak the fsecal masses. 2. Microscopic examination of faeces. If the stool is solid, a small particle of it should be picked up with forceps, placed on a slide, and mixed with a little salt solution. If the stool is liquid, a portion of the deposit should be removed with a pipette and placed on the slide without salt solution. A cover glass is put on in either case, and the specimen examined directly. Should it be desirable to use any stain, a little very dilute watery eosin is to be recommended for the purpose. One may find (1) particles of food — as already described in the vomit; (2) cells — red blood cor- puscles, intestinal epithelial cells, pus corpuscles, or leucocytes ; (3) crystals ■ — e.g. triple phosphates, phosphate of lime, cholesterin, fatty and hjematoidin crystals. Xone of these has any pathological sig- nificance. (4) Parasites and bacteria may also be found. The latter are considered in Chapter XI V. ; the former demand a more detailed description here. The parasites which occur in the intestinal tract include worms and protozoa. The worms belong either to the nematoda or to the flat worms, the latter group containing the cestoda, which are fairly common, and the flukes, which, in Europe at least, are by no means ordinarily found in man. (A) Nematoda. 1. Perhaps the commonest of all internal parasites is the small threadworm, Oxyuris vermiculariSf whose presence is associated with considerable itching about the anus. It inhabits the large intestines, caecum and vermiform appendix, and specimens can often be seen wriggling about in the recently-passed motions of Examination of Keces. their host. To the naked eye they look Hke small white threads, from a half to one centimetre in length. Under the microscope the female maybe distinguished Fig. 9. — Oxyuris vermicularis. 1, male; 2, female. Nat. size. {After Payne.) large uterus by the filled with ova, and the pointed posterior end, whence its name is de- rived (Figs. 9, 10, 15, A). 2 A§cai'ij§ luin- brjcoides has a general resemblance to an earth- worm. It measures, as a rule, from six to eight inches, and sometimes considerably exceeds this length. Not infre- quently its presence in children is associated with nervous disorders. The ova, which can oc- casionally be found in the dejecta, have brown- ish yellow granular con- tents, and in many cases mt Fig. 10.— Oxyuris verniiculari.s. a, young female ; b, male ; c, mature female. Magnified. {After Payne.) Nematoda. 89 Fig. 11.— Ankylostoma duodenale. the shell is surrounded by an irregular albuminous sheath (Fig. 15, B). 3. Ascaris iiiy!i»tax, a closely- allied worm, is sometimes parasitic in children ; the infection is got from a, male size. ; 6, female. Nat. {.After Payne.) cats. 4. Ankylost- oma duodenale is a parasite whose presence is fraught with much greater risk to the host than that of those already mentioned, as it causes profound anaemia by drawing blood from the wall of the bowel. It lives for the most part in the upper part of the jejunum, and its existence there is rendered probable, when, in an infested district, severe anaemia, other- wise inexplicable, sets in. The diag- nosis is clinched by the discovery of ova in the motions. They exhibit a segmented yolk, enclosed in a thin shell, and are sufficiently numerous to be readily detected. The adult worm, which is rarely seen before therapeutic agents have been em- ployed, is about half an inch long, and the mouth is provided with four claw- like teeth. The male is distinouished by its lobed caudal bursa (Figs. 11, 12). 5. Triclioceplialus dispar is, perhaps^ a commoner parasite than might be suspected ; its presence does not seem to cause any very Fig. 12. — Ankylo- stoma duodenale. «, female; b, male. Magnified, c, nat. size. (,Bristowe.^ 90 Examination of Fmces. serious inconvenience. The length of the worm is under two inches, its colour is white, the anterior portion is much narrower than the posterior, and is buried in the mucosa of the csecum. The ova are very character- istic, and when present, are readily recognised (Figs. 13, 15, c). 6. Trichina spiralis occurs in Fig. 13.— Trichocephaiiis dispar. the alimentary a, female : &, male. Nat. size. (^After Payne.) -i • , i canal, m the sexu- ally mature state. The striped muscles are the habitat of the embryonic form, and when much affected they may become shortened. This is well seen in the biceps, where the contraction induces a very typical flexion of the forearm. 'J.'he adult male measures 1*5 mm. in length; the female, which is viviparous, is about twice as long. (B) Cestoda. Many different kinds of tapeworm have been found as parasites in man, but those of most importance are Taenia solium, T. mediocanellata, and T. echin- ococcus. Taenia cucumerina is also occasionally found in children. Besides its occurrence in the fully developed state, T. solium may be present in the tissues, in the form of a cysticercus ; T. mediocanel- lata is almost never found in this condition in man ; whilst T. echinococcus always occurs in the cystic stage, and has never been found in the mature con- dition in the human intestinal tract (Fig. 14). The presence of an adult tapeworm in the bowel is generally revealed by the passage of ripe proglot- tides in the stools, and after the administration of anthelmintics the head may be detected by the methods previously described. Cestoda. 91 1. Tsviiia solium (Figs. 14, «, a, 15, d). The mature Avorm measures 2 or 3 yards in length ; a ripe proglottis is about 10 mm. long, and 6 mm. l3road, with Fig. 14. — Cestoda. a. head of TiBuia solium, x 10 ; a', mature segment of do., nat. size : h. Lead of T. sagiuata, x 10; V, mature segment of do., nat. size ; c, head of Bothrio- cephaluslatus, x 10; c'. mature segments of do., nat. size; d, head of T. cucu- merina, x lo ; rf', mature segment of do., nat. size ; e, T. echinococcus, x 10 ; e', do, nat. size ; /, hydatid scolex (invaginated), x 250 ; e weaker than usual. Decided shortening or weakness of the first sound, still more its disappearance, indicates cardiac failure. In acute febrile disease this change may occur rapidly, and should always be looked for; the left side of the heart generally yields first. {h) The first sound may be louder than usual. It is then said to be aceeutuated. In simple dilatation the sound is often slightly accentu- ated and very clear, sharp, and short, as a large volume of blood is projected against the valve cur- tains, and the sound easily penetrates the thin ven- tricular wall to the observer's ear. In hyiyertrophy the sound is accentuated but dull, prolonged, and thudding, as the vibrations produced by the unusually 140 Circulatory System. forcible closure of the valve have to pass through the thickened heart walls, and the muscular element of the sound is specially prominent. (c) If the {Second sound is more distinct in the mitral or tricuspid areas than the first, we have either to do with a weakened first sound or an accentu- ated second ; whilst if the first sound is louder than the second in the aortic and pulmonary areas, the first sound is accentuated. {d) The relative loudness of the second sound in the aortic and pulmonary areas varies some- what, and is a good deal influenced by the patient's age. The pulmonary sound is rather more accentu- ated than the aortic in youth ; in old age the reverse is the case ^ when the subject is in good health. Accentuation of the second sound means that the valve where the accentuated sound is pro- duced is closed with unusual force. The force of closure depends on the momentum of the column of blood that effects it, and the momentum depends equally on the mass of moving blood and on the velocity of its recoil against the valve. In the aorta the mass of blood is increased when the vessel is dilated near its origin ; the velocity of recoil when, in consequence of contracted arterioles or other obstruction to the outflow of blood, the arterial blood pressure is increased. When the aortic accentuation is due to the former cause, the sound often assumes a peculiar resonance suggestive of the echo produced when a cork is drawn from an empty bottle. Over the pulmonary artery an accentuation of the second sound generally indicates increased blood-pressure in the pulmonary circulation, due either to disease of the lungs or of the left side of tlie heart. In jjneumopericardium the sounds are singularly clear and resonant, in pericardial effusion they are faint * Cf. Beneke : "Die Altersdisposition, " plate 1. A USCUL TA TION. 1 4 1 and muffled, hi 'pnPAimothorax tliey arc in many instances accentuated and clear, wliilst when there are cavities in the lung near one of the valve areas, the sound arising in that area may be reinforced by the cavity acting as a resonator. 2. Under certain conditions the first or the second sounds may be doubled. Various explanations have been offered to account for the reduplication. The simplest is that which assumes that when such a doubling occurs, the valves, either cuspid or semi- lunar as the case may be, close sooner on one side of the heart than on the other ; the reason being in the case of the mitral and tricuspid, asynchronism of systole of the respective ventricles, and in the case of the aortic and pulmonary valves some variation of the normal relations of blood pressure in the aorta and pulmonary arteries, since an increase in pressure will accelerate the closure of the valve which is subjected to it. This view is probably correct in some but not in all cases. Clinically, reduplication of the first sound occurs under very various con- ditions, the most important variety being known as the "bruit de galop,^' where the rhythm at the apex shows the accent on the second element of the triplet ^ — ^. In some cases the appearance of this " bruit de galop " is of very unfavourable import."^ Reduplication of the second sound in- dicates, in a large proportion of the instances in which it is heard, an increase of pressure in the pul- monary circulation. It occurs, therefore, in certain lung diseases and in diseases of the left side of the heart, being very characteristic of mitral stenosis, in which disease it is heard in a large proportion of the cases. It should^ however, be mentioned that many observers do not consider that the reduplication in * Of. Fraentzel, " Yorlesungen uber die Kiankheiten des Herzens,'" Part I., p, 56. 142 Circulatory System. mitral stenosis is due to early closure of the pulmonary valves."^ Alterations in the rhytliiii of the sounds deserve attention.! The usual rhythm is that of triple time in music, with the accent on the first beat in the mitral and tricuspid areas, and on the second in the aortic and pulmonary, whilst the third beat is silent. This is slightly modified by the fact that a quickly- acting heart gains time chiefly in the period of ven- tricular diastole, but the relation of the sounds is less modified by this than the phases of the cycle are. When, however, the vitality of the heart has been seriously impaired by long- continued high blood tension, such as is seen in chronic nephritis, and especially if fever or some such cause assists in weaken- ing the myocardium, the sounds become almost equidistant, the period of ventricular systole being unduly lengthened. This deliberate ^J«7if/'^tZ?t7>i-Z^A;e sequence of the sounds should always be regarded with considerable anxiety, as it points — unless, indeed, the patient is being overdosed with digitalis — to serious involve- ment of the cardiac muscle. Exactly the opposite effect is produced on the rhythm when systole is rapidly accomplished, or when, from great weakness, the ventricle fails to efiect a complete emptying of itself, and the systole becomes abortive. 3. Adventitious sounds are sometimes endo- cardial in origin, at others exocardial. Those which are endocardial are called miirmurs. They are due to disease either of, or close to, the valve where they occur, when they are often known as organic ; or to some alteration in the state of the blood, which, by * Vide infra, p. 147. t For fuller information, consult Broadbent's "The Pulse," p. 63. A use UL TA TION. 1 43 .-ilU'ctiiig its viscosity on the one hand and the nutrition of the tissues of tlie heart and vessels on tlie other, produces the conditions necessary for the de\elopnient of a murmur. The physical explanation of niurninrs is by no means simple, the following are some of the factors concerned in their production : — 1. The viscosity of the blood ; 2. The velocity of the blood-stream ; 3. The passage of the stream from a narrower into a wider channel. The third condition is equally well produced when a narrowed oritice leads to a normal cavity beyond it, or when a normal orifice opens into a dilated cavity. Endocardial nnirmiirs always have a definite relatio7i to the events occurriny in the course of tlie cardiac cycle, their time and import varying with their point of origin. In the so-called "organic" cases, where the valves or their surroundings are iuiplicated, a murmur may either result from obstruction to the onward flow of the blood, or from leakage backwards through a closed but incompetent valve. The former are known as obstructive murmurs, the latter as regurgitant. In examining a murmur the following points must be noted : — 1. Its time of occurrence ; 2. Its point of maximum intensity ; 3. Its direction of selective propagation beyond the ]n-a?cordial area ; 4. Its character. The time of its occurrence is noted with reference to the sounds of the heart, and these by comparison with the time of occurrence of the apex beat. The maximum loudness of a murmur which has been produced at a given valve usually 144 ClRCULATORV SVSTEM. occurs at the point where the valve sound would be best heard in health. To this rule, however, there are some exceptions. Experience shows that valvular murmurs are not equally well heard at all points of the chest wall which are equidistant from the point of their greatest inten- sity, but that each is much more distinctly audible at a distance in some directions than in others ; this fact is expressed by saying that such murmurs have directions of selective propag^ation.^ The character of the murmur also helps to de- cide a doubtful case. Obstructive murmurs are apt to be rough ; regurgitant to be soft and blowing. The pitch and general quality of murmurs vary greatly ; some have quite a distinct musical character, others are harsh and sawing. The loudness of a murmur has no relation to the amount of damage which causes it. A very loud murmur is often far less serious than one so soft as to be nearly inaudible. Murmurs due to disease of extra-uterine origin are very much oftener found to proceed from the valves of the left side of the heart than from those of the right, and in adult life murmurs at the tricuspid and pulmonary areas, due to morbid processes arising in these valves, are rare. The following is a short epitome of the chief murmurs which may be heard at the various valves : the diagrams illustrate the position of the more common ones in the cardiac cycle. I. — mitral murmurs. These may be either obstructive or regurgitant (Fig. 33). * The complete explanation of the selective propagation of many murmurs is still unknown. In most cases, however, the following factors greatly influence the direction in which the murmur is conducted : — (1) The varying conductivity of the different structures in the chest wall, and between the chest wall and the heart ; (2) the direction of the vibrating blood-stream ; (3) the position of the chamber of the heart or of the vessel in which the valve lies. Auscultation. 145 {a) Obiiitriirtive murmurs occur during ventri- cular diastole, and are invariably of organic origin. They sometimes follow immediately on the second sound when they are known simply as " diastolic.''^ At other times the murmur is separated from the second sound by a brief interval, but terminates before the occurrence of the first sound, it is then called '•'■ mid- diastolic " ; in yet other instances the murmur only Mitral. III JIII HIIlii, Syst.ilic O'cguroitant) Presystolic (obstructive) Diastolic luitrul Diastolic and iiresystolic mitral Presystolic and systolic (double) Rare forms of mitral obstructive murmurs Fig. 33. begins with the advent of auricular contraction, when it is designated an '■'' auriculo-systolic,''^ or, more often, a " presystolic " murmur. In each case the murmur is due to the onward rush of the blood through the de- formed or narrowed mitral valve into the wider cavity of the left ventricle. During the earlier part of diastole this is effected by the aspiration of the relax- ing ventricle, which is ordinarily strongest near the beginning of diastole — at the end of the period the con- tracting auricle is the main agent in producing the flow. Sometimes an early diastolic murmur is followed by a moment of silence, w^hich is then succeeded by a pre- systolic murmur.* Best heard at the apex, or some- * The term " post-diastolic " as applied to certain of these mur- murs is very misleading. They are all diastolic in time, though, as has been stated, some are separated from the second sound by a pause. K 146 ClR CULATORY S YS TEM. times rather nearer the sternum, they have no direc- tion of selective propagation ; they are harsh and rough in character, more particularly when of the presystolic variety, and very often are associated with a distinct Fig. 34. — Presystolic initial inurnmr. thrill. In the majority of cases the second sound is reduplicated so that the murmur and accompanying sounds may be phonetically represented by "rriip ti-ti" ; or, where the heart's action is rapid and the murmur occupies a considerable portion of the diastolic [)eriod, by "ti-ti rriip." Occasionally the presystolic murmur is accompanied by a mitral obstructive murmur oc- curring at the beginning of diastole, when the pho- netic representation would become ' ' 7-rup ti tiff rriip ti tiff" or, if the murmur occur a shade later in diastole, by "rr up titi iff, rrup titi iff." Auscultation. M7 The exact significance of the reduplication of the second soiin din mitral obstruction is a matter of dubiety. At present many observers deny that the second ele- ment of the reduplication is produced at the semilunar Fig. 35. — Mitral systolic iminuur— proiiagatiou in front. valves, and the fact that it is better heard at the apex than at the base supports their contention. No other very satisfactory explanation is, however, available to account for the sound, which some consider to be a short murmur (Fig. 34). {b) Regurgitant iiiuriniirs occur during ven- tricular systole and may be either organic, or simply due to dilatation. They begin with the apex beat and replace more or less completely the first sound in the mitral area. Their point of maximum in- tensity is at the apex, their direction of selective 148 CiRCULA TOR y System. propagation is outward towards the axilla and angle of the left scapula, and they are generally soft and blowing in character. Slight mitral systolic murmurs, especially those due to dilatation of the ventricle and mitral orifice and not to disease of the valve curtains, vgis/ Fig. 36. —Mitral systolic muiiuur — propagation behind, frequently lack any selective propagation backwards. It is possible that some basal h^emic murmurs may be due to mitral regurgitation when the left ventricle is dilated {see p. 153) (Figs. 35, 36). II. — Aortic iiiuriiiiirs (Fig. 37). {a) Obstructive iiiuriiiiirs occur during ven- tricular systole, they are due either to obstruction of the ostium aortse from valve disease or to aortic dila- tation beyond a normally-sized ostium. They are rough in character ; have their area of greatest loud- Auscultation. 149 ness at the second riofht costal cartilacje near the sternum ; are propagated with the blood-stream into the arteries ; and may, in most instances, be readily heard over the carotids — sometimes at a much greater distance (Fig. 38). (h) Rrgiirgitaiit miiriniir^ occur during ven- tricular diastole ; they begin with the closure of the semilunar valves, and replace in part or completely [I (iilislriirtive) A LORTir. iLn J ,1k lllii,. I)i (reij astolic urgit(ivt) Sypri lie riiid dhi^rulir ((toiihlf) Fig. T, the normal second sound in the affected region. They are sometimes heard best in the aortic ai'ea; not infre- quently, however, they are as distinctly audible over the left half of the sternum, at the level of the third rib and interspace. Their direction of selective pro- pagation is towards the lower end of the sternum, though occasionally they are almost equally well heard near the apex ; their character is less harsh than that of systolic aortic murmurs. Their intensity is greatest at first, and gradually diminishes during the diastolic period. Marked regurgitation leads to auscultatory phenomena in the arteries (see p. 155) (Fig. 39). In many instances one finds that a double iniiriiiur is present at the aortic orifice, the systolic element of which is not caused by real stenosis of the ostium, but l»y roughening and deformation of the valve segments, the diastolic murmur being due to the backward leakage through the misshapen cusps. This double murmur often possesses a very distinctive " sawing " character. III. — Tricuspid inuruiurs are comparatively rare. 150 Circulatory System. (a) Obstructive iniiriiiiii's resemble those of the mitral valve, but have their maximum inten- sity at the lower end of the sternum. They have no selective propagation. (h) Reg-iirg^itaiit miiriiiiirs have a similar Fig. 38. — Aortic systolic murmur. character to mitral regurgitant murmui'S, are best heard in the tricuspid area, and are associated with the venous pulse, q.v. (p. 175). The}^ are usually a sequel to disease of the left side of the heart, after compensation has failed. IV. — Pulmonary uiiiruiurs (Fig. 40) are best heard in the pulmonary area, have no direction of selective propagation, are usually systolic, though occasionally they are well heard as higli as the first rib, and are rarely due in extra-uterine life to disease of the valve, but are most often caused by A use UL TA TION. I 5 I dilatation of the artery be3'^ond tlie valve ring. They are very well heard in many cases of exophthalmic goitre. ■'^ A diastolic pulmonary murmur is excessively rare. In a large number of cases more tliaii one Fig. 39. — Aortic diastolic murmur. iiiuriniir is present during the cardiac cycle. When they occur at different epochs, it is easy to study each separately ; when two or more occur together, each will be found to possess its own position of maximum loudness, its characteristic direction of selective pro- pagation, and its ])eculiar quality of sound (Fig. 41). Each lesion, moreover, will produce more or less definite effects on the general circulation, and by obser^'ing these by the other methods at our disposal, a diagnosis * In these cases there is often an aortic svstolic murmur also. 152 ClR C UL A TORY SyS TEM. can usually be arrived at. It must be recollected that during the last few days of life, when the diseased heart is acting feebly, serious lesions are often un- accompanied by any murmur, the force of the Fig. 40. — Pulmonary systolic murmur. blood-stream being too weak to produce any vibration. A patent forainen ovale may give rise to a murmur at the base of the heart, dependent on difference of pressure in the right and left auricle ; a murmur usually rather harsh in character, systolic in time, and with its maximum intensity at the level of the second left costal cartilage and first interspace, a short distance outwards from the sternum, is some- times caused by the ductus arteriosus remaining unclosed. Auscultation. 153 H^MIC BRUITS. Ill aiiseiuia several murmurs are frequently heard over the heart and vessels. One, which is of specially common occurrence, is audible in the second Fig. 41. — Combined aortic and mitral systolic murmurs. left intercostal space over or just external to the pul- monary area. Various theories have been advanced to account for it. The chief of these are — 1. Naiiiiyii's theory, where it is held that the sound is due to reguro-itation th rough the mitral valve into the left auricle, and that it reaches the ear by way of the auricular appendix, which for various reasons — includino- the fact that tlie anterior border of the left lung is often rather retracted in anaemia — approaches the chest wall more closely than under other conditions. Naunyn and others have pointed 154 Circulatory System. out that the murmur attains its maximum intensity not over the puhnonary artery, as is found in un- doubted cases of puhnonary systoHc murmurs, but farther to the left ; and the writer's observations confirm this statement in a preponderating majority of cases. 2. Russell's theory. — This theory assumes that the left auricle is dilated and tilled with blood at un- usually high pressure, and that it therefore presses sufficiently firmly against the pulmonary artery to produce a constriction. The hypothesis is unsup- ported by any cogent facts, and is inconsistent with a sound view of the mechanics of the circulation. 3. Many writers regard the murmur as clue to slig^lit dilatation of the pulmonary artery be- yond the valve ring, and to a less viscous condition of the blood, which would accentuate the vibrations set up by such a dilatation. 4. Sansom-^ holds that the vibrations which cause the murmur arise in the conus arteriosus, and perhaps also in the semilunar valves themselves, and are due to a fibrillary tremor of the over-strained muscular fibres which are found in these regions. The first and third of the above theories have at present the greatest number of supporters. Hsemic murmurs are also heard at times in the mitral, and much less frequently in the tricuspid and aortic areas, the last being particularly uncommon. In all cases such murmurs are systolic in time. A continuous humming sound is often audible over the veins at the root of the neck in chlorosis. It is known as the hruit de diahle, and is caused, in part at least, by an alteration in the calibre of the internal jugular vein as it passes through the cervical fascia. In order to hear the bruit de diable clearly, the * " Diagnosis of Diseases of the Heart," p. 28-5. A use UL TA TION. I 5 5 stethoscope must he held very lightly, so as to exert no pressure, over the clavicular head of the sterno- luastoid muscle. Not seldom one may also hear the sound perfectl}'^ distiiictl}^ when the stethoscope is placed on the sternoclavicular articulation, by wliich mano3u^'re all possibility of creating a factitious bruit by pressure is avoided. Uremic murmurs may arise in the larg'ei* arteries, and are present independently of the pressure of the stethoscope, and it seems probable that an important, if not the chief, factor in their production is a disturbance of the vasomotor mechanism of the vessels."^ There are, moreover, other sounds which may become audible in the arteries, and which are the result of changes in the pressure of the blood-stream. The most notable instance of this is found where relaxed arteries are so rapidly distended by a large blood- wave that their walls are thrown into vibration by the sudden strain, and a sound is produced which corresponds with the advent of the pulse-wave. In cases of aortic regurgitation, where these conditions are most fully developed, we have also a second sound which occurs at the instant when the pressure once more falls off. This double sound, when heard in the femoral, is very characteristic of aortic regurgitation. Pressure produced by an ill-applied stethoscope often converts these sounds into murmurs. A murmur in the subclavian artery as it crosses the apex of the lung may be caused iDy pulmonary disease. When there is an aneiirysmal dilatation of the aorta, murmurs may or may not be present, or ■* A valuable contribution to our knowledge of the pli3*sical causes wliicli lead to the production of hgemic bruits is to be found in Thoma's " Textbook of General Pathology " (English edition, vol. i., p. 271). 156 Circulatory System. the aortic second sound may be accentuated over the sac ; but no definite rule holds for such cases. When an aneurysm opens into another large vessel — such, for example, as the superior vena cava — the murmurs produced may be very loud, and are heard in unusual situations. Exocardial i§oiinci§ may be due either to peri- cardial friction or to a localised pleurisy near the heart. When pericardial friction occurs over an area uncovered by lung, it has a singulavl37" superficial character, and thus can often enough be readil}^ recognised. Unlike the murmurs already described, pericardial friction does not correspond definitely with the events of the cardiac cycle. It is generally more distinct in systole than in diastole, but tends to exhibit a to-and- f ro character, the first element occurring during systole and the second during diastole, but not necessarily commencing at the beginning of either phase. Some- times the sound occupies the latter part of systole and the early part of diastole without exhibiting any pause between its first and second elements ; sometimes it remains audible during the whole of the cardiac cycle. Further, its position of greatest intensity does not correspond with any of the areas in which valvular murmurs are best heard, and it is not propagated to a distance, but remains confined within narrow limits. Its position may be observed to vary from day to day. As a rule, it appears first near the l)ase of the heart on the left side, but when the condition has become general, it is best heard near the left nipple, and is sometimes associated with a distant thrill. The in- tensity is often considerably modified by the attitude of the patient. When the inflammatory process in- volves the auricle as well as the ventricle, the to-and- fro rub may be replaced by a triple friction sound. A use UL TA rioN. 157 In pericarditis, the heart's action is apt to become tumultuous, and when fluid is poured out, the cardiac sounds become faint and distant. When air and fluid are present in tlie pericardial sac — an event of very rare occurrence — a cliiiriiiiis: or "water- wheel" sotiiid can be heard on aus- cultation. To distinguish between the rub of pericarditis and that of pleurisy over a neighbouring portion of lung, the patient should be instructed to hold his breath. Pericardial friction is unchanged by this, but if it be of pleural origin, it will either be much reduced in intensity or will wholly cease. On the other hand, deep respiration will increase the pleural sound, but will not influence the pericardial. The possible co-existence of both pleuritic and pericardial friction must not be overlooked. SECTION VI.— THE PULSE. The examination of the pulse gives us direct information regarding two things, namely, the con- dition of the vessel walls and the amount and variations of pressure of the contained blood. By intelligent observation of these facts we can obtain very valuable information regarding the state of the heart and circulation, as w^ell as the general state of the patient. When any observation is to be made on the pulse, the patient should be lying on his back, or at least sitting ; and, except for special purposes, should not have been making any eflfort for some little time previous to the examination. The pulse is most readily felt when the patient's forearm is pronated. In cases of aortic regurgitation the peculiar character of the pulse {vide infra, p. 170) is more distinctly brought out when the patient's arm is elevated. To feel the pulse place three fingers of the right 158 Circulatory System. hand on tlie patient's radial artery at the wrist. It is immaterial Avhether the observer's index finger be nearest the elbow or the hand of the patient, but for beginners it is best to select the same position in all cases. If it is made a habit to examine both radials in every case, errors in diagnosis, such as failing to detect the presence of aortic aneurysm, or an abnormal position of the vessel, w^ill frequently Idc avoided. When the artery is beneath the finger, the follow- ing observatioiis should be systematically made : — 1. Rate of pulse ; 2. Rhythm of pulse ; 3. Equality or inequality in force of successive beats ; 4. The condition of the vessel wall and the size of the vessel ; 5. The amount of movement during passage of a pulse-wave ; 6. The blood pressure in the vessel during the beat (maximum pressure); 7. The blood pressure between the beats (mini- mum pressure); 8. The general character of the pulse as regards rise, maintenance, and fall of pressure, and the pre- sence or absence of secondary waves. The first three observations depend on the action of the heart, the fourth on the vessel, the remainder on both heart and vessel, the latter being the dominant factor in most cases. The rate of the j)ulse is given as so many beats per minute. It is well not to begin counting imme- diately the finger is laid on the pulse, as the agitation of the patient often accelerates it at first. After waiting till it resumes its normal rate, count the beats for one minute, and record the result. The beat at which the observation commences should not be counted. Pulse. 159 The successive be,!ts of the pulse may recur at equal or une(j[ual intervals, giving a reg'iilai' or irre^ilar liiytliiii. In the latter case, the beats may occur in symmetrical groups, some of the simpler of which have received special names : thus if there be two beats and a pause, recurring in regular sequence, we obtain the pulsus higeminus (Fig. 4:2), three beats and a pause give the pulsus trifjeminus (Fig. 43). In other cases no such symmetry occurs. Besides the Fig. 42. — Bigeminal puLso. (From a tracing lent hy Dr. Byrorn Braniwell, "Student's Guide to Examination of the Pulse." varying interval that may occur between consecutive beats, the beats themselves may be unequal in force. Some beats may be weaker, and the weaker beats may eventually become imperceptible — we thus arrive at pulses which may be classed under the previous heading (irregular pulses) ; this is especially true of the symmetrical types. The fourth observation is directed to ascertain the state of the vessel. Two points should be noted : first, the size (calibre) of the vessel ; secondly, the condition of its walls. To determine the calibre, empty the vessel of blood by firm pressure, and endeavour to gauge its breadth in the flattened state. Should this be impracticable, allow the blood to return below the linger, and note the size of the cvlindrical tube. When the vessel is i6o Circulatory System. contracted the calibre is siiial], when the muscular coat is fully relaxed it is distinctly larger. Be careful to ascertain that the radial artery is really under observation ; in a certain proportion of cases it winds round to the back at an unusually high level, whilst the superficialis volse continues to run in the usual site of the larger vessel. One may thus be led into error, if the abnormal distribution is not recognised. To discover the state of the walls, flatten the vessel and cause the skin of the patient's wrist to Fig. 43. — Trigeminal pulse. slip up and down over it. In health the vessel wall can rarely be felt unless the arm is thin. In disease one may feel general or local thickening, calcification, tortuosity, or irregular dilatations. These changes must be discounted when an attempt is made to estimate the blood pressure in the vessel. Having observed the state of the vessel, one pro- ceeds to apply just sufficient pressure to flatten it between the beats. When this is done the increased blood pressure that is present during the beat will cause the blood vessel to resume its cylindrical shape ; and further, inasmuch as the vessel wall is elastic, will stretch it until the internal stress is balanced by the strained wall. This observation enables us to estimate the ampli- tude of moveoieiit of the vessel wall during the passage of the pulse-wave. As the elastic stretching of the vessel is never great, the mo\'ement chiefly Pulse. i6i depends on the resumption by the flattened artery of its cylindrical shape, and the amount of such move- ment is consequently greater the more dilated the vessel is. The force of the heart's action also exercises a certain influence on the amount of move- ment, although to a much less degiee than the re- laxation or contraction of the coats of the artery. This proceeding is often described as " observing the expatision " of the pulse. The next point is the determination of the inaxiinuni blood pressure, which, of course, occurs during the beat. In this case three fingers must be placed on the artery, so that it may be com- pressed both above and below the point where the pulse is being felt. Place the finger next the wrist firmly on the vessel to prevent any pulse from the ulnar artery reaching the middle finger through the palmar arch ; let the middle finger rest on the vessel with such pressure as will render the pulse most distinct, and then gradually compress the artery above this point with the remaining finger, noting the pressure em- ployed when the pulse ceases to be felt by the middle finger. This pressure, being just sufficient to pre- vent the blood from lifting the finger during the beat, corresponds to the maximum blood pressure. Only careful practice on a large number of healthy and diseased pulses will enable the student to de- termine whether in a given case the requisite pres- sure is normal, excessive, or diminished.* The importance of cutting off" recurrent pulsation through the palmar arch must never be overlooked. * A new form of sphygmometer for the clinical estimation of blood pressure has been introduced by Leonard Hill and Barnard. The instrument is simple in construction, easy of application, and gives results which are found, when tested experimentally, to be perfectly accurate. It is supplied, along with full directions, by Hicks, Hatton Garden, London, E.C. 1 62 Circulatory System. It is most likely to occur in cases where, owing to vascular dilatation, the blood pressure is unusually low, and thus if neglected would lead to serious error, as the middle finger would continue to feel the pulse even when the upper finger exerted great pressure. As a natural consequence the observer would greatly over-estimate the maximum blood pressui-e in the vessel. It is worth noting that this recurrent pulse is frequently present in chlorosis. It is rather more difficult to estimate the mininiiiiii blood pressure. One thing may be remembered — namely, that in cases where the maximum pressure is low the minimum must be still lower ; this rule must not, however, be extended into an assertion that a high maximum will necessarily involve a high minimum pressure. To test for the minimum pressure, one may attempt to roll the vessel from side to side under the fingers between the beats. When the pressure is low, one cannot feel the vessel at all ; if it is high it may feel as hard as a piece of whipcord. Of course, one must be careful not to be misled by thickening of the wall of the artery. Another method which gives good results, and which may be more easily appreciated by many, is to feel the pulse first with light, then with moderate, and finally with considerable pressure of the fingers on the artery. A pulse of low tension {i.e. with a low minimum pressure) is best felt in the first case, for the light pressure is sufficient to flatten the vessel between the beats, whilst it allows the artery to resume its cylindrical shape without much resistance during the beat, and is thus favourable to the development of the greatest possible amplitude of movement ; whilst on the contrary, where the tension is high considerable pressure is required to flatten the vessel between the beats. But one obtains the FULSE. 163 greatest amplitude of movement precisely when the vessel is thus flattened, and so in a high-tension pulse the more firmly one presses the more forcible does the pulse appear to grow. A normal pulse, lying as it does between these extremes, is best developed when moderate pressure is applied. When all tliese points have been determined, one should conclude by studying the general cha- racter of the piilse-beat. This is divided into three periods : first, the period during which the blood pressure is rising ; secondly, the period at which the blood pressure continues near its maxi- mum ; and lastly, the period during which the blood pressure once more falls off. The amount of movement having been already observed, one tries to estimate the rapidity of the rise of pressure, describing the rise as abrupt, rapid, moderate, or slow. In cases where it is abrupt it will be found that the pulse is of low tension; where it is slow the pulse is either one of high tension or an aneurysm is present. The latter con- dition may cause the rise to be excessively gradual. It is only in aneurysm that the rise of pressure may be as gradual as the subsequent fall. As regards the period at which the pressure remains near its maximum, the point to be ob- served is whether the pressure is well sustained, or whether, on the other hand, it has no sooner attained its hiijhest value than it begins to fall off again with rapidity. In the third period, one observes whether the fall of pressure is swift or gradual. During the fall, instead of a continuous decrease, there may be oscillations of pressure, which, in marked cases, are quite perceptible to the finger as distinct impacts foUowingj the primary stroke of the pulse. Of these 164 Circulatory System. the most noteworthy is that known as the dicrotic wave. It is best marked in pulses of low tension (provided there is not aortic regurgitation) and is most readily felt when the finger is very lightly ap- plied to the vessel. Where not readily perceived it is often accentuated by occluding the vessel on the distal side by the lower finger whilst the middle and upper ones remain lightly applied. The secondary wave which the finger detects with the next greatest frequency is the tidal or pre- dicrotic wave. It occurs in certain pulses of high tension where the blood escapes slowly from the con- tracting ventricle, and is very characteristically present in aortic stenosis. In opposition to the dicrotic wave, it is best felt when considerable pressure is applied to the artery, and thus there is no difficulty in dis- criminating between the two. Besides these, in pulses of high tension, there are frequent fluctuations of pn^ssure at a period subse- quent to that in which the dicrotic wave occurs. These can sometimes be detected by the fingers, but it requires much practice to recognise them. They are visible enough in good sphygmographic tracings. The typical pulse of a healthy adult man should be described in some such terms as the following : — The rate is seventy per minute. The beats are regular in rhythm and equal in force. The expansion is moderate in amount. The vessel is not tortuous, its walls are not rigid or thickened, and between the beats it is just possible to feel it. It is of medium size. Tension. — The passage of the pulse-wave can be arrested by moderately firm pressure, and the beat is best felt when a medium degree of pressure is applied. Cbaracter. — The rise of pressure is neither The Sphygmograph. 165 abrupt nor very gradual, it is fairly well sustained, and its fall is gradual, but not very tardy. No conspicuous oscillations of pressure are discernible during the time of subsidence. SECTION VII. — THE USE OF THE " SPHYGMOGRAPH. For permanent record, and also to aid in the ana- lysis of details, it is important to employ a sphygmo- graph as well as to feel the pulse in all cases where the state of the heart and vessels is an important factor. Numerous types of sphygmograph are now in use, but only Marey's and Dudgeon's will be described here, as they are most frequently employed. In Marey's spliyg:niog^rapli the pad which rests on the artery acts on a long lever the farther end of which traces the pulse curve on smoked paper, that is held in a frame driven by clockwork. In Dudg^eoii's the same result is obtained by connect- ing two shorter levers in such a manner as to magnify the movement of the pad fifty times. The end of the lever in Marey's instrument describes the arc of a circle ; in Dudgeon's, owing to the mechanical device employed, the style moves backv/ards and forwards in a straight line. The following description of the method of using each will aid the student in applying them : — I. Marey's instrument : The patient should sit or lie down. Place the arm support on a table of suitable height beside the patient. Loosen any tight garments about the patient's arm, which must be bared to above the elbow. Place the arm supine on the support, with the back of the wrist at the highest part. Semiflex the fingers. Mark the line of the radial on the skin, and draw a cross line where the pad of the sphygmograph is to rest. Wind the clockwork and adjust the paper on the instru- 1 66 'Circulatory System. ment.* Place the pad of the sphygmograph very accurately in position, with the lever pointing up the arm towards the elbow, and fix the instrument in its place by non-elastic. bands. Adjust the pressure of the pad, by means of the screw or milled head, until the lever affords the maximum range of move- ment. Adjust the level of the style, after re-coupling it with the pad, so that the movement of the lever takes place opposite the smoked paper, and see that the style is in contact with, but does not press too heavily on the latter. Before varnishing the trace, note patient's name, date (and time of day), whether right or left radial, pulse rate, respiration, and ap- proximate pressure employed.! Ordinary quick-drying negative varnish, as used by photographers, is em- ployed to fix the trace, the paper being dipped into a jar of varnish, or laid, trace upwards, in a saucer containing some. II. Dudgeon's instrument is used as follows : — 1. Wind up the clockwork. 2. Insert one end of the smoked paper (smoked side uppermost) on the righthand side of the in- strument between the roller and small wheels. 3. Make the patient hold out either hand open, and in an easy position, palm upwards, the fingers pointing towards you, and tell him not to move the wrist or fingers. 4. Ascertain and mark the precise spot where the radial artery beats at the wrist. 5. Slip the band, the free end of which has been drawn through the clamp, over the patient's hand. 6. Adjust the pressure of the spring. * The paper is best smoked over a small piece of burning cam- phor, which may, if necessary, be moistened with a drop of alcohol. f The nominal pressure as given by the index on the screw is not even approximately correct, but if the same instrument is always used the results are comparable to some extent. The Sphvgmograph. 167 7. Place the pad on the artery, the clockwork case being nearest the elbow. 8. Retain the instrument in place with the right hand ; tighten the band sutficiently with the left, and clamp by means of the screw with the right hand. When the band is correctly tightened, the needle will oscillate over the paper. If the tightness is nearly but not quite correct, bend the hand backw^ards at the wrist to increase the tension, or forwards to diminish it. 9. Set the paper in motion by releasing the catch that controls the clockwork. 10. Let the paper run through unassisted, and catch it in your hand as it passes from the instrument. Generally the patient's hand must be supported whilst the tracing is taken. 11. Stop the clockwork as soon as the paper has passed. In a pulse tracing rise of blood pressure will be represented by an upstroke, and fall by a downstroke. Bearing this in mind the student will readily understand the main outlines of a healthy pulse tracing. The pressure rises fairly rapidly ; therefore the upstroke, when the paper is driven forward at the usual speed, is nearly, but not quite perpendicular. The percussion wave is quickly followed by what is known as the tidal (or pre-dicrotic) wave ; these are not separately distinguishable by the finger in health, the sphygmograph, however, indicates their existence by a notch at the beginning of the downstroke. Thereafter the pressure begins to fall ofl*, but, at the moment when the aortic valves close, the decrease of pressure is arrested, and a positive (dicrotic) wave is propagated into the vessels : this condition is recorded by a small break in the descent of the downstroke of the tracing. The foot of the notch immediately before the dicrotic upstroke indicates the time when 1 68 Circulatory System. the aortic valves close. After this rise the line again curves downwards, often exhibiting slight secondary- oscillations, until a new upstroke marks the arrival of Fig. 44.— Normal forms of pulse. (Mahomed.) the next pulse-wave. Ordinarily the blood pressure takes much longer to fall than to rise, hence the downstroke is much less vertical than the upstroke (Fig. 44). The Sphygmograph. 169 In healtli a pulse tracing taken with suitable pressure, has a sharp apex, a small tidal wave, and a Fig. 45.— Low-tension pulse moderately distinct dicrotic wave. A rounded apex, in most cases, means either excessive pressure of the Fig. -16.— High-tension pulse. spring or bad application of the instrument (see however p. 171). The upstroke is longer and steeper than usual, when the ventricle discharges a larger volume of 170 ClRC ULA TOR y SVS TEM. blood than normal into the arteries, and when the arterioles are dilated (low tension) (Fig. 45). The upstroke is shorter and less steep when the heart acts feebly or when the aortic ostium is stenosed, so that less blood than usual is delivered in a given time, and also when the blood |>ressure is high and undue opposition is thereby offered to the outflow from the heart (Fig. 46). In conditions where the minimum blood pressure Fig. 47.— Aortic stenosis. is low, the dicrotic wave is well marked ; where it is high, the dicrotic wave is small, and secondary oscillations are present. The following conditions give characteristic tracings : — 1. Aortic stenosis. Small amplitude, sloping upstroke, tidal wave well developed, and often higher than primary apex (Fig. 47). 2. Aortic iiicompeteiice. Great amplitude, abrupt upstroke, rapid fall, little or no dicrotic wave. This is known as the water-hammer, collapsing, or Corrigan pulse (Figs. 48, 49). 3. Mitral disease. Small amplitude, moderately steep upstroke, secondary waves rather slight, successive beats unequal and irregular, especially The Sphygmograph. 171 when failure of heart is threatening to set in. In mitral stenosis the vascular tension tends to be higher than in mitral incompetence (Fig. 50). 4. Aiieiirysiii of the ascendino- or transverse aorta generally aftects the pulse in the implicated radial, where the impulse is delayed, whilst the rise Fig. 48. — Aortic incompetence. is gradual, the amplitude less, and the apex rounder than in the unaffected radial (Fig. 51). 5. Arterial atheroma of the great vessels by abolishing the modifying effect of their elasticity, renders the tracing similar to one taken from the pressure curve of the left ventricle. This is known as the senile pulse (Fig. 52). Aortic atheroma com- bined with a moderate degree of incompetence, gives 172 Circulatory System. a pulse which is like that of atheroma, but with sharper apex. Several types of pulse have received special names, of these the following are amongst the more important : — 1. Piilsuis bisferiens. The tidal wave is felt separately from the primary impact. The tracing is characteristic (Fig. 53). 2. Pulsus dicroticiis. The i dicrotic wave is exaggerated (see I p. 164) (Fig. 54). 3. Pulsus celer. The pres- ; sure is ill sustained, the up and I down strokes are therefore abrupt. I* 4. Pulsus tardus. The pres- \ sure is well sustained, the tracing \ is less abrupt. This is sometimes ; described as a " long " pulse. \ 5. Pulsus bigfeminus. There \ are two beats and a pause. The \ two beats may be alike, or they > may differ in force (Fig. 42). ' 6. Pulsus trigeminus. ' Three beats and a pause (Fig. 43). j' 7. Pulsus paradoxus. The pulse becomes smaller or disappears at the end of inspiration, when the patient breathes deeply. It occurs in pericardial adhesion. 8. The pulse is described as "n'iry" when the vessels are contracted and the heart beat rapid and moderately strong. This may occur in peritonitis. When the heart gets weak, whilst the The Sphvgmograph. 173 Fig. 50. — Mitral incompetence Left side. Right side. Fig. 51. — Pulse in aneurysm. otlier conditions continue, the pulse grows "thready," but at the same time the blood pressure generally begins to diminish. 9. The pulse is said to be *' running " when the vessels are relaxed, and the heart's action is weak and fairly rapid. Circulatory System. Fig. 52. — Aortic atheroma (senile pulse). Fig.^53. — Pulsus^bisferiens. Fig. 54.— Dicrotic pulse. The Venous Pulse. 175 SECTION VIIL— THE VENOUS PULSE. In a considerable number of cases where the cir- cuhition of blood through the right side of the heart is interfered with, either from valvular disease or from increased blood pressure in the pulmonary circulation, the embarrassment manifests itself by distention or pulsation in the veins. From their size, nearness to the heart, and comparatively superficial situation, the veins of the neck offer special facilities for the study of these phenomena. Wliilst inspecting the root of the neck, the observer has already had an opportunity of noting these appearances where they exist, but the several varieties and deojrees of disturbance in the venous circulation must now be more completely distin- guished. A mere flicker of pulsation at the root of the neck when the patient is recumbent, is common enough even in perfect health, and must not, in the absence of further evidence, be regarded as indicating any disease of the heart. When, however, the pulsa- tion passes farther up, the case is entirely altered. Two points must then be noted — first, whether there is actual regurgitation, or merely retarded emptying of a full vein during the beat of the heart ; and second, the exact moment at which the pulsation occurs with reference to the apex beat. Sometimes there is no difficulty in distinguishing between regurgitation and simple uiidiilatioo in the vein. In bad cases of tricuspid incompetence, a mere glance at the patient will at once reveal the nature of the pheno- menon. Where the conditions are less urgent, and the distinction is less readily determined, a simple plan is to empty the vein from below upwards by running the finger along it, and then keeping its upper extremity closed by the pressure of the finger, so that no blood can enter it from the periphery. 176 Circulatory System. In cases of simple undulation, the vessel either remains empty and collapsed, or at most re-fills very gradually, as small collateral branches discharge their contents into it. Where, however, there is true pulsation, the valves at the root of the neck have ceased to be competent. As a consequence of this, coupled with the overloaded state of the right heart, a backward wave of blood is forced into the vein, which re-fills from below with a series of bounds corresponding to the beats of the heart, and after three or four pulsations is again distended and pulsating as vigorously as ever, although the ob- server's finger continues to maintain the peripheral closure. Regarding the time of occurrence of the venous pulse a great divergence of opinion has existed. Recent observations * lead to the following conclu- sions :— A large wave is, in typical cases, driven back during auricular systole ; a short time after it has obtained its highest pressure, and when it is just beginning to fall off it is reinforced by the shock which the carotid pulse imparts to all the adjacent structures. Thereafter the pressure again falls, and often reaches its minimum during the earlier part of ventricular systole, when the obstacles to the entrance of blood into the auricle seem to be less marked. The pressure again rises near the end of ventricular systole, the exact time of this second rise depending, on the one hand, on the amount of tricuspid leakage — or in some cases perhaps of mere backward yielding of the tricuspid curtains without leakage — and on the other, on the activity of the auricle \ it then falls off somewhat during ventricular diastole to rise once more at the commencement of the next cardiac cycle with auricular systole. These conditions may be * James Mackenzie, "Pulsations in the Veins." Joum. of Pathology and Bacteriology, vol. I., p. 53. The Venous Pulse. 177 traced in relation to the events of the cardiac cycle, when the sequence will resemble that of the accom- panying diagram, where the upper tracing represents the movement of the recording lever of a suitably adjusted tambour applied to the pulsating vein, whilst the lower part indicates the events in the cardiac cycle, which correspond to the various parts of the curve so obtained (Fig. 55). The details of individual tracings differ greatly in some one part of the curve, in others another being specially emphasised. For details the original paper must be consulted. In certain circumstances a venous pulse of totally different origin may be present. This is known as the centripetal venous pulse, and is due either to great dilatation of the arterioles, so that the arterial pulse passes through the capillaries and is visible even in the veins, or to an aneurysmal varix, whereby direct communication occurs between an artery and vein, and the pulse-wave of the artery reaches the vein by this channel. The observer can have no great difficulty in recognising the nature of such centripetal pulsation. M 178 Circulatory System. SECTION IX.— SYMPTOMS OF THE PRIN- CIPAL DISEASES OF THE HEART. 1. Valvular diseases. — (a) Aortic iiicompe- fence. The patient complains of attacks of giddi- ness, is often pale, and his arteries pulsate. Capillary pulsation may be observed. The apex beat is dis- placed downwards and outwards, and has a heaving character. The left border of the heart is farther out than usual. A murmur accompanies the second sound, as has been elsewhere described, and the pulse exhibits a "water-hammer" character. (6) Aortic stenosis. Here the apex beat is rather weak, and the displacement less notable than in the last condition. The arteries are small, and the tension of the pulse, before compensation is destroyed, is somewhat high. Vertigo or fainting fits are not uncommon. The murmur is described on p. 148. The aortic second sound is very weak. (c) Mitral incompetence. This condition is often associated with dyspnoea, which is the first symptom of which the patient may complain. The face is apt to be cyanotic. The apex beat is of moderate strength, and is frequently displaced out- wards. On auscultation, in addition to the character- istic murmur, one finds marked accentuation of the second sound in the pulmonary area. {d) Mitral stenosis. Here the stress falls chiefly on the left auricle and right side of the heart. The apex beat is therefore only slightly displaced out- wards, and is not unduly vehement. The murmur is very frequently accompanied by a thrill, and in many cases the second sound as heard at the apex is re- duplicated. The pulse is at first not notably affected, but gradually becomes irregular and feeble as com- pensation fails. (/?) Tricuspid incompetence, which is usually Heart Diseases. 179 secondary to mitral disease, is associated with dilata- tion of the right auricle, and consequently with outward displacement of the right border of the heart, with venous and hepatic pulsation, and with dropsy. The murmur has already been described ; the second sound in the pulaionary area is weak. The patient usually suffers from very decided dyspncea. 2. Idiopalliic lieart diseases lead at first to hypertrophy and dilatation of the ventricles, sub- sequently to fatty changes in the myocardium. The physical signs will obviously vary with the stage of the disease, and are frequently somewhat hard to interpret. Like all other forms of heart disease, they terminate in failure of compensation, with its accom- paniments of dyspnoea, urinary deficiency, dropsy, and cyanosis. 3. Pericarditis is characterised by jDain in the chest, more or less fever, and by friction of a to-and- fro character when eflusion is scanty. When more fluid has been poured out, the area of dulness is triangular and oversteps the second left interspace. The apex beat is internal to the left limit of duluess, and may be weak or quite unable to be felt. The pulse may be greatly affected, and it is by this disease that the " pulsus paradoxus " is produced. 4. Intratlioracic aneurysm of the aorta leads in some cases to a tumour at the upper part of the chest, which is dull on percussion, and in which expansile pulsation can often be observed. It may also affect the character and synchronism of the pulses at the two wrists. The auscultatory phenomena are very variable. It produces numerous symptoms by involvement of different structures upon which it comes to press as it enlarges. 5. Cardiac Asthma. This condition is charac- terised by attacks of severe dyspncea, often lasting for several hours on end. The patient is so breathless i8o Circulatory System. that he requires to sit up, and may have to call the accessory respiratory muscles into violent exercise. It is distinguished from bronchial asthma by the state of the heart, which is generally dilated, and whose apex beat is weak. The pulse also is small, rapid, and irregular, and the dyspnoea is not of the pure expira- tory type which characterises asthma of respiratory origin. i i8i CHAPTER V. Clinical Examination of the Blood. Eiiiinieratiou of red blood corpuscles.— This may be done by means of either a Thoma-Zeiss or a Cowers' hsemocytometer.* The former is the simpler and more accurate instrument. We shall describe it first. 1. Thoma-Zeiss lisemocyto- metei*. — The instrument consists of a mixing pipette (Fig. 56) suitably graduated and a counting slide. Cleanse the lobe of the patient's ear with soap and water, dry it, and rub it a little between the finger and thumb in the drying, so as to render it hypersemic. Make a puncture on the lower border of the lobe by means of the lancet-shaped needle supplied with the instrument. The needle should be inserted with a rather sudden stab — not too slowly — and the blood must flow freely. On no account must the blood be squeezed out, as it is theii always diluted by lymph squeezed out of the tissues. Slowly suck up blood by means of the pipette till either the mark 0.5 or 1 is reached. If one should u * A new form of hsemocytometer has beeu introduced by Dr. George Oliver, but the authors have had no experience of its use. V It is supplied, along with full directions, by pjo- 55, Hjeniocy- the Tintometer Company, Limited, 6, Far- tometer pipette ringdon Avenue, London, E.G. (Thoma-Zeiss). 1 82 The Blood. happen to go a little beyond the 05 mark, the column of blood should be gently blown down to the proper point. If blood has been sucked past the mark 1, it has reached the mixing chamber, and the process must be begun over again. Having charged the pipette, wipe the end of it on a clean cloth, and plunge it at once into the diluting fluid (Appendix, 17), which should be standing ready in a small, wide-necked bottle with the stopper out. Suck up the diluting fluid as far as the mark 101. Whilst doing so, the pipette should be gently rotated so as to start the mixing. Seize the pipette firmly :^^;^^g| n^;^ — TfL i I «$^1 'W/'///////y//////////, /'/^y /////', Fig. 57.— Thoma-Zeiss Counting Slide, s, slide ; m, platform ; c, wall of trench. by its ends between the forefinger and thumb, and shake thoroughly for about one minute. This pro- duces a thorough mixing of the blood with the fluid. It must be remembered that the column of diluting fluid which occupies the capillary part of the pipette does not enter into the mixture. Hence, if blood is sucked up to 0*5, the dilution produced is in the proportion of 1 in 200, whereas if blood is taken up to the mark 1, the dilution is only 1 in 100. The former degree of dilution is to be preferred in most cases. The finger should now be removed from the pipette, and the diluting fluid in the capillary tube blown out. After a few drops of the diluted blood have been shaken out, a small drop is transferred to the counting slide (Fig. 57). The latter consists of a small platform (m) bounded by a trench which is surrounded by a glass slab (c). On the surface of the platform microscopic squares are ruled, each having an area of -^^ square millimetre. Special cover glasses, carefully ground, are supplied, which rest Counting the Red Corpuscles. 183 upou the glass slab, a space being left between the under-surface of the cover and the surface of the plat- form, which space is exactly y^ millimeter in depth. The drop of diluted blood should be placed in the centre of the platform, and should be of such a size that when the cover glass is placed in position the drop is flattened out so as to cover most of the surface of the platform, but yet without any of it flowing over the edge into the trench. It requires a little experience to enable one to take just the proper size of drop. It is important that the cover glass should lie quite flat upon the glass slab. This can best be achieved by previously washing both it and the slab with caustic potash, so as to remove all grease, and then rubbing them with soft chamois leather. The cover must be lowered into position by means of a needle. One recognises that the cover glass is lying properly by the appearance of concentric colour (Newtonian) rings betv/een it and the slab. The rings should be visible when the cover is simply lying on the slab Avithout any pressure being exerted. The rings are best seen by looking horizontally along the surface of the cover. If they are not visible at first gentle pressure on the cover glass often brings them out. Unless the rings are seen, one cannot be sure that the space between the cover and the platform is exactly -^ millimetre in depth. Having placed the drop in position, and the rings being visible, one should set the preparation aside for five minutes or so, to enable the corpuscles to settle. It should then be examined with the low power to see whether any air bubbles or foreign bodies are present, and whether the corpuscles are distributed with fair uniformity throughout the field, after which the high power is used for counting. The little squares will be seen to be marked oflf into sets of sixteen by double ruling (Fig. 58). Should the lines marking off the squares be 1 84 The Blood. t ? f 1 . I 1 ■ \ I — -■ *o°o° °° »: * • ,* •' 'o ' K ° % *° » \% • o oo OO oO*o O « O 00 * * O ** o o « o O O oo o '^ o • o » ~ ^ o" ^ 1^ ^ O O ° , 'O O J " o ~rj — 5"^'^ Z 7'g~ , o o ^"0 o „ * ■«■■ ^1^ OB^ -^—Mi—S— ^a ° ^' -' — IH-i 1 — 4^^ — I — ■■ ! 1 t - — \ Fig. 58. — Microscopic View of Thoma- Zeiss countins-slide showing divisions. only dimly seen, it may be necessary to intensify them. This is best done by rubbing the surface of the plat- form with a little finely powdered graphite — e.g. the scrapings from a very soft lead pencil — and then , polishing it with soft chamois leather. For enumeration of the red cells, at least three sets of sixteen squares should be counted. The squares in each set should be gone over systematic- ally in horizontal rows of four at a time. Of the corpuscles which lie wpon the lines bounding the row only those on the upper and on the left hand lines should be counted. Calculation. — Count the corpuscles in each of the four horizontal rows from above downwards. The total is the number of corpuscles in sixteen squares. Count in this way three sets of sixteen, and divide the total by forty-eight, which gives the average of cor[)Uscles in one square. But the dimensions of this square are ^^^ X yV ^^ toVo cubic millimetre. Therefore, if there be x corpuscles in this dimension, there will be 4,000 x in 1 cram. But the blood was diluted 200 (or 100) times. Therefore, in 1 cmm. of blood there will be 4,000 a; x 200 (or 100) cor- puscles. Suppose, for example, that one finds a total of 288 corpuscles in the forty-eight squares. This gives an average of six corpuscles per square, or 6 X 4,000 — i.e. 24,000 per cmm. of diluted blood, or 4,800,000 per cmm. of pure blood, if the dilution was one in two hundred. k Counting the Red Corpuscles. 185 The constant error in the Thoma-Zeiss instrument is less than 1 per cent, of the total result. The variable error depends upon the number of corpuscles counted. By counting 200 corpuscles, it amounts to 5 per cent, of the total; by counting 5,000 it amounts to only 1 per cent. To count the whole 256 squares takes about half an hour. This usually means counting 1,200-1,500 corpuscles. The co-efficient of error is then about 2 per cent. 2. Oowers' haeiiiocytoniefer. The instrument consists of a capillary tube graduated for 5 cmm., and a pipette graduated for 995 cmm., a mixing vessel and stirrer, and a counting- slide. Take up 995 cmm. of diluting fluid (Appendix, 17) in the pipette and. transfer it to the mixing vessel. Suck up 5 cmm. of blood in the capillary tube and gently blow it into the above quantity of fluid. Mix the two very thoroughly by rotating the stirrer between the finger and thumb. The blood is now diluted in the proportion of 1 in 200. Transfer a drop of the mixture to the centre of the ruled area on the counting-slide, cover, and fix the cover glass with the clips. The ruled area is divided into squares of -^^ mm. square, and the space between the sur- face of a square and the under surface of the cover glass is \ mm. in depth. Count the corpuscles in ten squares. The result multiplied by 10,000 is the number of red cells in a cubic millimetre of undi- luted blood. The normal number of red corpuscles is 5,000,000 per cmm. In some full-blooded adults this number may be exceeded. In females, even in health, it is usually rather smaller (about 4,500,000). The blood of newly born children sometimes contains more than 5,000,000, and that number is also sur- passed in cases of prolonged cyanosis. 1 86 The Blood. The number is reduced in all forms of anaemia. In chlorosis, however, the number of corpuscles may be normal or nearly so. Eniimeration of JLcucocyte^s. A special pipette is supplied for this purpose with the Thoma-Zeiss instrument. It is used in precisely the same manner as the red-corpuscle pipette, but permits of a lesser degree of dilution of the blood. The best diluting fluid to employ is 0*3 per cent, solution of acetic acid to which enough of a watery solution of methyl green has been added to give the mixture a decided green colour. The advantage of this mixture is that it dissolves all the red cells while it stains the nuclei of the white. One can thus easily count the whites, and at the same time note the relative numbers of the uni- and multi-partite nucleated varieties. It is important that a large drop of blood should be allowed to exude before one begins to fill the pipette. The blood should be sucked up to the mark 0-5_, the end of the pipette wiped, and diluting fluid taken up to the mark 101. Owing to the relatively large calibre of the pipette, the blood is apt to run out of it. It is well, thei-efore, to keep the pipette in a horizontal position as soon as one has filled it with blood. The blood and the fluid are mixed as already described. This produces a dilution of 1 in 20. A drop is then placed on the counting-slide with the same precautions that were observed in the case of the red cells. In this case the whole sixteen sets of sixteen squares should be counted, or 256 squares in all. Instead of going over the squares in rows of four, a whole set of sixteen can easily be counted at one time. A movable stage greatly facilitates the enumeration. One should note on a piece of paper the number CoUNriNG THE LEUCOCYTES. 1 87 of leucocytes witli multipartite and with rounded nuclei respectively in each set of sixteen squares. In this way one gets the proportion of each variety present, and by adding them together the total number of white corpuscles is obtained. The calculation is made in the same way as that of the red corpuscles, it being borne in mind that each of the 256 squares counted represents ^oVo cmm, of diluted blood, and that the dilution is much less than in the enumera- tion of the reds (1 in 10, or 1 in 20). For example, if there be twenty-five leucocytes in the 256 squares, this represents an average of -^-^-^ per square, or 2-^x 4,000 per cmm. of diluted blood, or 7,182 per cmm. of pure blood if the dilution is 1 in 10. This is about the normal number. In leucocythaemia, where a very large excess of leucocytes is present, one can easily count the red and the white cells in the same drop. For this purpose a 3 per cent, solution of common salt just coloured with gentian violet is to be preferred for diluting the blood. This stains the nuclei of the whites, and at the same time preserves the reds. The dilution and calculation are the same as for the red cells. In most cases, however, it is not easy to make an accurate estimation of the leucocytes by means of an ordinary hasmocytometer such as that of Gowers. Should its use be unavoidable, it will be found that the easiest way to pick out the white corpuscles from the mass of reds which tends to conceal them is to raise the microscope a little and then focus slowly down upon the field. The white corpuscles, being highly refractile^ come into view first as little bright spots, and can thus be more easily enumerated. If Gowers' instrument is used, one must count the leu- cocytes in fifty squares, and multiply the result by 2,000. This gives the number of leucocytes in 1 cmm. of pure blood. 1 88 The Blood. The liiiniber of leucocytes in normal blood is about 7,000 per cmm., or 1 to 700 reds. The number varies, however, within considerable limits even in health. The normal proportion of leucocytes with divided nuclei to those with rounded nuclei is about 2 to 1. A 'physiological leucocytosis, in which the small cells with rounded nuclei (lymphocytes) are both absolutely and relatively increased, occurs in infancy, during pregnancy, and after meals. In the patlio- logical leucocytosis, met with in fevers and other conditions, the increase affects chiefly the cells with multipartite nuclei, and these may come to be ten or more times as numerous as the others. The condition of the leucocytes in leucocythoimia will be referred to later. After use, the diluting pipettes should be thoroughly cleaned. A little trouble in this is repaid by saving of time and annoyance when next they come to be used. They should be washed out (1) with distilled water, (2) with absolute alcohol, and (3) with ether. A stream of air should then be blown through till one is sure that the glass ball in the chamber moves freely without tending to adhere to the sides. To save time in these manipulations, the rubber tube may be taken off and the fluid blown out through the wide end of the pipette. Coagulated blood may be removed from the capillary tube by means of a horse-hair. If the blood adheres firmly to the pipette, it may be removed by repeated rinsing with strong alkali or acid, or it may even require to be digested away with pepsin. Estimation of Blood Platelets. For this purpose the use of a pipette is not to be recommended, as the platelets adhere to its wall. One also requires to employ a diluting fluid of a certain degree of viscidity, otherwise the platelets are Estimation of Platelets. 189 apt to run into groups. The best method of pro- cedure is as follows : — ■ Place upon a slide a drop of a mixture of equal parts of glycerine which has been saturated with dahlia and 2 per cent, salt solution. The use of the dahlia is to stain the platelets. Touch the drop of blood with this mixture and cover. Count with -J^ lens in a succession of fields, (1) the platelets, (2) the red corpuscles. Continue until 400 of the latter have been enumerated, and estimate the proportion of platelets to red corpuscles. Normally this should be as 1 : 8^. By then making an estimation of the reds in the ordinary way, one arrives at the number of platelets per cmm. Normally this is about 640,000. Variations in their number are not yet of any known clinical significance. Two precautions are necessary in making the above estimation : (1) To avoid squeezing the blood out of the puncture, and (2) to reject any preparation in which the platelets are found to have run together into clumps. The estimation of the amount of hsemo- gClohin in the blood may be accomplished by means of either v. Fleischl's hsemometer or Gowers' hsemo- globinometer.* Von Fleischl's haemometer. — (Fig. 59). The instrument consists of a stage, resembling that of a microscope, with an aperture in the centre. Into this aperture there fits a short cylinder (g) with a glass floor. The cylinder is divided into two compart- ments (a and (X ) by a vertical partition. Below the stage there is a frame carrying a wedge-shaped piece of coloured glass (k), which lies opposite the bottom * Dr. George Oliver has also invented a new form of hsemo- globinometer which gives very accurate results and is not difficult to use. It is supplied, along with full directions, by the Tintometer Co. {vide footnote, p, 181). 1 90 The Blood. of one half of the cylinder and can be moved with a screw so that any thickness of the wedge can be brought below the cylinder. Light from a lamp (daylight will not do) is reflected into the bottom of the cylinder by means of a white disc (s). A small Fig. 59. — "Von Fleischl's Hsemonieter. a', compartment above tinted wedge ; a, compartment for blood ; Ky wedge turned by T; P, scale ; G, cylinder ; M, indicator ; S, disc ; B, screw for adjusting scale. capillary tube attached to a wire is supplied with the instrument. Method of use. Fill one compartment (a) about a quarter full of distilled water. See that the capillary tube is quite clean and dry. To ensure this one may, if necessary, pass through it a threaded needle, the thread being soaked in alcohol. Prick the lobe of the ear and insert one end of the tube sideways into the drop of blood. The tube fills itself and must then be Estimation of Hemoglobin. 191 wiped on the outside so that no blood adheres to it. Plunge the tube into the compartment containing dis- tilled water and shake it about by means of the wire handle till all the blood is washed out. If necessary, one may aid this by forcing water through the tube from a dropping pipette. The mixing of the blood ^Yith. the distilled water may be completed with the aid of the wire handle of the tube, care being taken that no blood is allowed to lurk in the corners. One now fills up the rest of this compartment and the whole of the other with distilled water from a dropper. All daylight is now excluded, and then, looking down upon the cylinder, one turns the screw until a sufficient thickness of the coloured wedge has been brought under the other half of the cylinder to match exactly the tint of the blood. One then reads the figure on the scale (p)^ and this gives the percentage of hgemoglobin. The instrument is so constructed that when the screw is opposite the mark 100 a sufficient thickness of the coloured wedge has been introduced to match exactly the colour produced in the other half of the cylinder by the amount of blood which the capillary tube takes up, provided the blood contains a normal amount of haemoglobin. To facilitate accurate matching of the two halves of the cylinder, the following precautions are necessary (Cabot) : — 1. — Use very little light. The less the percentage of haemoglobin the less light one should use. 2. Look at the two halves of the cylinder through a tube made of a roll of black paper. 3. Do not sit opposite the light as one does when using a microscope, but sit at one side of the instru- ment The light from the two halves of the cylinder then falls on the right and left halves of the retina, not on its upper and lower parts, the sensitiveness of which to colours is unequal. 4. Use one eye and only look for a very few 192 The Blood. seconds at a time, since the colour sense soon gets fatigued. 5. Move the screw with short quick turns, not gradually. Sudden changes in tint are more easily appreciated than those brought about gradually. Oouers' hsemoglobinonieter. — Place a couple of drops or so of distilled water in the little graduated test tube supplied with the instrument. Get a large drop of blood from the ear, and fill the pipette with it up to the mark. Then dip the end of the pip- ette into the distilled water in the tube and gently blow out the contained blood. Mix and go on adding water drop by drop, comparing the colour from time to time with that of the standard tube. The latter is filled with prepared blood, and represents the colour of blood which contains a normal amount of haemoglobin when diluted in the proportions effected by the instru- ment. The comparison should be made both by trans- mitted light, care being taken to hold both tubes level with the eye, and also by reflected light, the tubes being held side by side against a sheet of paper. Good daylight is indispensable. Stop adding water when the tint in the two is the same, and read off the level at which the mixture stands in the graduated tube. If this be at (say) 60, then the blood contains 60 per cent, of haemoglobin. We are inclined to think that Gowers' instrument is rather over-standardised. In many healthy people the proportion of haemoglobin falls short of 100 per cent, when measured by it. In a few adults, however, the amount rises even above this, and it must also be re- membered that the amount of haemoglobin in the blood at birth is very high — frequently above 100 per cent. In all forms of anaemia the percentage is dimin- ished, notably in chlorosis. One can also state the percentage of haemoglobin in terms of the amount contained in each corpuscle. Thus, Microscopical Examination. 193 if the number of red cells be 20 per cent, of the normal and the ha3moglobin 10 per cent., then the h{\3moglobin value of each corpuscle is \% or \ normal, Tlie importance of this method of expressing the facts is seen when one recollects that the total amount of haemoglobin in the blood may be diminished while the amount in each corpuscle is really above the normal. This happens in some forms of ansemia. The last point to be remembered in making all blood estimations is that, as far as possible, all observa- tions on the same individual should be carried out under the same conditions as regards time of day, taking of food, etc. This is important, as it is found that the composition of the blood is temporarily altered by the taking of food, or by the occurrence of profuse sweating, diarrhoea, etc. Microscopical Examination of Blood. Blood may be examined (1) fresh, (2) fixed but unstained, (3) stained. 1. Blood examined fresh. — A drop of blood is transferred from the ear to a slide, covered, and examined at once. In the case of normal blood, the red corpuscles will be observed to arrange themselves in rouleaux as one watches, clear spaces being left between in which the white cells and little clumps of aggregated platelets may be seen. Any abnormality in the shape of the red cells or in the formation of rouleaux should be noted. It can also be seen whether any large excess of white corpuscles is present. The presence of abnormal elements should be noted. Amongst these are abnormal varieties of white cells, although these are more easily recognised in stained specimens. The best method of staining preparations of fresh blood is to dilute the drop with an equal quantity of N T94 The Blood. \ per cent, salt solution to which a little methyl violet has been added. This stains the nuclei of the leucocytes and the blood plates. It also brings out nucleated red corpuscles if these are present. Sometimes particles of pigment can be noticed Fig. 00. — Filaria nocturna ; x 160. {After Patrick Manson.) amongst the corpuscles. This is the condition known as nialaiieeiiiia. It is found occasionally in chronic malaria. The spirilliiiii of relapsing fever can be recognised by this method, and also the lllariae «>aiig'uJiii!s> lioiiiiiiis. The latter can be seen, with a low power, moving about among the red cells. Microscopical Examination. 195 They average about -/-.- in. in length, and are about as broad as a red blood corpuscle (Figs. 60, 61). They remain alive for a surprisingly long time even at ordinary temperatures, especially if the prepara- tion is kept from drying by being sealed with a little vaseline. The following is the method recommended by Manson as best suited for their demonstration : — Fig. 61. — Embryos of filaria noctuiua in Llood ; x 50. (From an origina m icrophotograph. ) Spread out a thick drop of blood on a slide by means of a needle, and allow it to dry. It may then be preserved indefinitely. When the parasites are to be demonstrated, immerse the slide in a solution of one drop of saturated alcoholic fuchsin in 1 oz. of water. Stain in this for one or two hours. If, on examining the film, it is found that the blood is very deeply stained, one must decolorise by 196 The Blood. means of dilute acetic acid (four drops of acetic acid to 1 oz. of water). The specimen may Ije examined either wet or dry, and with or without a cover. On searching it with a low power, the filarise will be recognised by their being very deeply stained. The preparation is apt to fade after a few days. A more rapid result is obtained by staining the film for half a minute in a 2 per cent, solution of methylen blue. It is then decolorised a little with dilute acetic acid as above described, and examined with a low power while wet. If a permanent prepara- tion is desired, the film is allowed to dry and a drop of balsam and a cover glass applied. 2. Blood cells fixed but unstained. — This is the best method for studying changes of shape and size in the cells ; 2 per cent, osmic acid is the most useful fixative. Place a drop of it on the finger or lobe of the ear, and prick the skin through it. The blood is fixed as soon as it exudes, and the mixed drop may be examined immediately. The addition of a little methyl green to the osmic acid helps to bring out the nuclei of the leuco- cytes. Permanent preparations may be obtained by running in a drop of glycerine under the cover glass. This method shows very well the blood plates and the size and shape of the red corpuscles. Nor- mally, of course, the latter are all disc-shaped and practically uniform in size. In some diseased con- ditions, however, this ceases to hold good. Thus there may be a number of red corpuscles present which are decidedly smaller than normal (microcytes), whilst others, again, may be considerably above the average size (megalocytes). Or the red corpuscles may be distorted — spindle-shaped, indented, budded, etc. This is known as 'poikilocytosis. It is apt to Microscopical Examination, 197 occur in some forms of anaemia, especially in per- nicious antemia. 3. £xaiiiiiiattoii of blood in liliii<^. — Films may be made either on slides or on cover glasses. The former have the advantage of being more easily manipulated. To make a good film, it is important that the slides or covers should Ije free from grease. Slides should Ije washed in ammonia, rinsed in ether, and then rubbed with a clean silk handkerchief or piece of old cotton. Cover slips should be immersed for a few hours in strong- nitric acid, washed in w^ater, and then in alcohol and ether. Simple boiling wdth soap and water is also an efficient means of cleaning them. They should be preserved in alcohol to which a little ammonia has been added, and when wanted should be rubbed wnth a piece of clean silk. Ho\*^ to make films.— (1) On cover slips. Prepare several clean cover slips — preferably square ones — and prop them up in a row so that they can be easily grasped by their edges. Prick the ear. Touch the apex of the drop of blood with the centre of a cover slip, care being taken not to touch the skin. Drop another cover slip on the top of the drop of blood in such a way that the corners of the two cover slips do not coincide but are placed diagonally to one another. This makes it more easy to grasp them separately. The drop of blood spreads out at once into a film, and w^henever it has spread slide the cover slips apart without squeezing them, (2) On slides. Tw^o slides are takeu, one of which should have a smooth ground edge at least at one end. The majority of the better variety of microscope slides do quite well. A small drop of blood is transferred to the surface of the other slide at a distance of about i in. from one end. The smooth edsje of the other slide is then used 198 The Blood. to spread out the drop by pushing it over the latter like a plane (Fig. 62). In this way a long thin film is spread out on the sui-face of the slide. Only one film is obtained at a time by this method, but it is much larger than those which are made on cover glasses. We are indebted to Dr. Patrick Manson for the OP or BLOOD -^ riLM OF BLOOD SLIDE Fig. 62.— Diagram showing metliod of making a blood film by means of two slides. description of a very simple and rapid method of making films upon slides : — Take a piece of gutta- percha tissue about 2 in. long and 1 in. broad. Fold it slightly along its long axis so that one side becomes somewhat convex, the other concave. Pass one end of the convex surface lightly across the top of the drop of blood and immediately lay it flat on the slide near one end. Wait for a moment till the blood has had time to spread itself out between the slide and the gutta-percha tissue, then draw the latter lightly along the surface of the slide. A thin film of blood is thus spread out. A large series of very good films can be prepared by this method in a few minutes, the gutta-percha tissue being reapplied to the drop of blood after every second film has been made. Fixation of the film. — (1) By drying. Cover Microscopical Examination. 199 glass films may be allowed to dry in the air. Waving the slip about hastens the process. They should then be stained for half a minute in a saturated solution of methylen blue in absolute alcohol, washed in water to remove superfluous stain, allowed to dry, and mounted in balsam. This method does fairly well for rouofh clinical examination. To oet better results, one may use Ehrlicli's fixation method. The dried slide or cover glass films are placed in an oven, which is slowly heated up to 115° 0. This takes about half an hour. They are left at this tem- perature for ten minutes^ and the flame is then extinguished. After another ten minutes they are removed, and are now ready for staining. AVe have found that mereh" leaving the films overnight in an ordinary paraffin oven gives almost equally good results and is less troublesome. The dried films may be kept away from dust till a batch has been col- lected ; these are then placed in a box in the oven and left overnight. Very good results can also be obtained by heating the films on a strip of metal at a temperature of 100' C. for a quarter of an hour. One proceeds thus : — A strip of clean metal, preferably copper, about 1 ft. long and 3 in. broad, and supported on a tripod, is heated in its centre by means of a Bunsen or spirit lamp. When the centre has attained a fairly constant degree of heat, one deposits drops of water in succession from near the centre outwards. The point at which a drop j'ust boils is of approximately the right temperature. The films are then laid on the metal at that spot, face downwards, and left for a quarter of an hour. They are then allowed to cool, and are ready for staining. (2) By corrosive sublimo.te. — One requires a saturated solution of corrosive sublimate in normal salt solution. Be sure that the solution is saturated ^6o The Blood, at the boiling point, so that crystals separate out on cooling. The films are placed in this while still moist. Cover glass films are floated on the surface of the solution. Slide films are best placed standing back to back in a wide-necked bottle filled with it. Leave the films for at least half an hour (longer does no harm). Wash them thoroughly in normal salt solution, and then in successive strengths of alcohol to which a little salt has been added. (For clinical work washing in alcohol may be omitted.) The removal of the corrosive is facilitated by adding* a drop or two of iodine to the 50 per cent, alcohol. The films are then ready for staining. (3) The following method has been described by Gulland as very simple and trustworthy. Films are made in the usual way. They are placed at once in a mixture of the following composition : — Saturated solution of eosin in absolute alcohol ... ... ... ... 25 cc. Pure ether ... ... ... ... 25 cc. - Solution of corrosive sublimate in absolute alcohol (2 grms. in 10 cc.) 5 drops. Some of this fluid is placed in a flat dish and the cover slips are floated on it, wet side downwards ; 5 cc. to 10 cc. is suflicient for four cover glasses. Films on slides may be plunged into a wide- necked bottle containing the mixture. The same quantity of the fixing solution may be used several times if it be covered up so as to prevent evapora- tion. Fixation will be complete in three minutes, but it will do no harm to leave the films in the solution for twenty-four hours. Pick out the cover glasses with forceps, and wash them thoroughly in a small basin of water, waving them to and fro. Stain for one minute in a satui-ated watery solution of methylen blue. Wash again. Dehydrate rapidly Microscopical Examination. 201 with absolute alcohol. Clear in xylol, and mount in xylol balsam. Red corpuscles are stained pink, all nuclei deep blue, the blood-plates a fainter blue. The bodies of the leucocytes are in various shades of pink, the eosinophile and basophile granules being well brought out. Organisms are also well stained. Pus, sputum, etc., may also be examined by the above method, but the fixation time for these should be longer. How to §taiii tlie liliii!!i. One must employ a " nuclear stain " to pick out the nuclei, and some " contrast stain " to stain the protoplasm. It must be remembered also that the granules contained in the protoplasm of the different varieties of leucocytes stain in various ways. Some have an afl&nity for " acid," and others for "basic," dyes. An " acid dye " is a salt the acid part of which has staining power. In the case of a " basic dye," it is to the base that the staining power of the compound is due. The most commonly used acid dyes areeosin, rubin — i.e. acidfuchsin — and aurantia j good examples of basic dyes are found in methylen blue, gentian violet, and safranin. The following combinations of stains will be found to give very good results for all ordinary purposes : — 1. Methylen blue and eosin. — Stain the film for a quarter of a minute in moderately strong watery eosin, or for ten minutes in eosin and glycerine. Wash in water. Stain for two or three minutes in LofHer's methylen blue (Appendix, 22), wash in water, dry and mount in balsam, or dehydrate with absolute alcohol, clear in xylol, and mount in balsam. All nuclei are stained blue by this method. The red blood corpuscles are pink. All oxyphil e cells stain strongly pink. 2. Ehrliclis triple stain of aurantia, acid fuchsin, and methyl green (Appendix, 25). Stain for one to 2 02 The Blood. five minutes in a strong solution. Wash, allow to dry, mount in balsam. Nuclei are stained a greenish blue ; oxyphile granules are red. The so-called neutrophiles are purple. Basophile granules are unstained. 3. Hcematoxylin and eosin. Stain for half a minute in Delafield's hsematoxylin. Wash in distilled water and then in a bowl of water to which a pinch of lithia carbonate, or carbonate of soda, has been added. Then place in saturated watery eosin for ten seconds. Wash, dry, mount in balsam. All nuclei are stained bine, red corpuscles pink, and eosinophile cells are well brought out. If cover slip films are used they should be floated face downwards on the stain. Slide films may be plunged into a wide-necked bottle containing the stain, and left there the requisite time. The bottle should be deep enough to admit the entire slide, and a glass cover may then be placed on the top. Examination of the tilm. In a good film the corpuscles should be spread out evenly, no rouleaux being seen. Even with the low power the white cells can be recognised by their stained nuclei, and some idea can be gained of their relative numbers. For the minute examination of the white cells a high power, and preferably an immersion lens, is requisite. It must first of all be remembered that the following are the varieties of leucocytes found in normal blood (Plate IV., Fig. 1), with their relative proportions : — 1. Leucocytes with multipartite nucleus and very fine oxyphile granules ... ... 60-75% 2. Leucocytes, with round or branched nucleus and coarse oxyphile granules ... 2-4% 3. Small leucocytes with rounded nucleus and no granules (lymphocytes) ... 20-30% I'll.. 1. CELLS L»i-' NUUMAL JJLOOD. a. Fiiiely-grauular (iosiiioiiliilc; leucocyte. '/. Coar.sely-graiiular cosiiiopliilr' Idicocyte. c. Lyiriphocyte. (.1. Hyaline leucocyte, witli line auioi'iihous points of Ijasoithile substance. e. Finely-granular basopliile leucocyte- /. Rod Ijlood corpuscle. Fro. 2.— CELLS FROM THE BLOOD IX SPLFXO-MVELOGEXOUS LEUCyEillA. «. Myelocyte ; a', with mixed granulation ; a" , Avlth double nuclei ; a'", mye- locyte undergoing mi- tosis. h. Normal coarsely-granular cosinojjliile leucocyte. c. Normal finely - granular eosinoijliile leucocyte ; c\ non-granular. d. Atyjiical coarsely-granular eosinopliile leucocyte. l K. Lyijiphocyte, with fine baso- pldJe amorphous points. /■ Xoi'inal finely - granulai' basophile leucocyte. (J. Atypical liasojihile myelo- cyte. h. Nucleated red blood cor- Ijuscle ; fi, undergoing mitosis. /. Hyaline leucocyte, with fine basophile amorplions points. Fig. 8.— CELLS FROM THE liU)U\} IX LVMPHOCYTH^MIA. ^-=^ - " (X. Lyinphocyte, with fine basopliile amorphous ])Oints. /;. Hyaline leucocyte, with basophile amorjihous points. '/. Atypical basophile leucocytes. e. N^orinal finely-granular liasophiie leucocyte. /. X^ornial finely-granular eosinophile leucocyte. (J. Xormal coarsely-granular eosino- idiile leucocyte. h. Xormal red blood corpuscle. /. Xucleated red blood corpuscle. PLATE IV. (From an. Original Dividing liij Jjr. Jlabert J. M. JJadaiiMn.) [To face p. 20.3. Microscopical Examination. 203 4, Large leucocytes with rotinded nucleus and no granules ("hyaline" corpuscles).,. ... ... ... ... 6°/^ 5. Leucocytes with lobed nuclei and small basophile granules ... ... ... l-^V^ The alterations which occur in the relative pro- portions of these in leucocytosis have been mentioned above (p. 188). In the lyini:>liatic (or lymphocytic) form of leiicocytliceiiiia an enormous increase occurs in the number of the lymphocytes (Plate IV., Fig. 3). In the spleno-myelogenous form of the disease the coarsely oxyphile (eosinophile) cells are both rela- tively and absolutely increased, and in addition one meets with abnormal cells, probably derived from the bone-marrow, and known as myelocytes (Plate IV., Fig. 2). These are of a large size, and contain one excentrically-placed nucleus, which stains rather faintly. They contain small granules, but it is doubtful whether these are oxyphile or neutrophile. The myelocytes may amount to 50 per cent, of all the corpuscles present. In lyrtvpliadenoma the ordinary leucocytes with multipartite nucleus are slightly increased. The coarsely oxyphile cells are not at all increased, and there are no abnormal cells present. In examining blood films one sometimes encoun- ters nucleated red corpuscles. These are normal constituents of the blood for the first few days after birth, and are present abnormally in all extreme cases of diminution of the red cells, notably in leuco- cytluemia and pernicious anaemia. They can be distinguished from lymphocytes (for wdiich at the first glance they are apt to be mistaken) (1) by the more homogeneous staining of the nucleus ', (2) by the presence round the nucleus of a much wider rim of protoplasm than a lymphocyte possesses, which 204 The Blood. stains very much more deeply than that of a lympho- cyte, and with high powers one can often see a clear space between the nucleus and the surrounding rim of protoplasm ; (3) by the fact that the contour of a nucleated red corpuscle is smooth, while that of a lymphocyte is usually more or less irregular {see Plate IV., Figs. 2, 3). It should be remembered that nucleated red corpuscles are often much larger than the ordinary kind. Parasites in the blood. — We have already described the way to look for filarise in the blood (p. 195). Of this parasite there are several species which are the embryos of corresponding parental forms. The embryos live free in the blood ; the parental forms are found in the tissues and lymphatics. In one species the embryos are present in the blood during the night only {F. nocturna), in another only by day {^F. diurna). In yet another form (i^. perstans) they are always present. The blood in suspected cases should therefore be examined both during the day and during the night. For the diagnosis of the different species special works must be consulted, but the chief points to attend to are : (1) The time when the parasites are present in the blood ; (2) the nature of their movements ; (3) whether or not they possess a sheath ; (4) the shape and character of their extremities. To recognise the parasite of malaria, proceed as follows : — Prepare some perfectly clean and very thin cover slips, and remove all traces of grease in the manner already described (p. 197). Cleanse the skin of the tinger-tip or ear with soap and water and then with alcohol and ether. Make a small 2yrick in the skin. Wipe away the first drop of blood, leaving a perfectly dry surface, so that subsequent drops will not run. Fig. 1. tiffif '^•^ Fig. 2. Fig. 3. Fig. 4. Fig. 5. PLATE v.— THE BLOOD IN MALAEIA. Showing dilTeront forms and stages of development of the parasite. {AJter 'Thayer and Ilcwctson.) Fig. 1.— The parasite of tertian fever. Fig. 2. —The X)arasite of quartan fever. Fig. 3.— The parasite of festivo-autuninal fever. Fig. 4. — Creseentic and oval bodies. Fig. 5. — Flagellated forms. [Tofare2->. 205. Microscopical Examination. ^ 205 Squeeze out a tiny dro[) about the size of a large piu's head. Touch the apex of this drop with the centre of a cover glass, and immediately drop it, face downwards, on a perfectly clean slide. Make several such preparations, and reject all those in which rou- leaux are present. It is absolutely essential that the red corpuscles should lie flat. Examine with a J^ immersion lens and rather feeble illumination. Look in the red corpuscles for the presence of small black specks, often rod-like and showing slow move- ments of translation (Plate V., Figs. 1, 2). These are surrounded by clear areas. One may also see in the centre of some of the red cells clear amoeboid areas which show no pigment (Plate Y., Figs. 1, 2). Rosette forms may also be visible (Plate Y., Fig. 2). These forms of the parasite are always present in cases of malaria which have not had quinine. Other varie- ties are only met with in some chronic cases. Of these there are two chief forms : (1) The crescentic, (2) the flagellated (Plate Y., Figs. 4 and 5). These are easily recognised. The crescentic bodies are highly refractile, rather longer than a red blood corpuscle and about 2 ^n in diameter. Particles of pigment may be recognised in the parasite and also in some of the ordinary leucocytes. The examination of blood for the malarial parasite demands some care. Manson says that one must devote half an hour to the examination of a slide before pronouncing on the absence of parasites in it. The quartan form of the parasite (Plate Y., Fig. 2) is distinguished from the tertian (1) by being smaller in size, (2) by its pigment granules being darker, (3) by its showing fewer segmenting forms. If it be desired to stain the parasite, one should use for the purpose a concentrated solution of methylen blue in 06 per cent, salt solution. A tiny drop of this is placed on the skin, and the puncture made 2o6 ^ The Blood. through it. The mixed drop is then examined as above. The parasite stains blue, while the red cells remain uncoloured. "^ To get 'permanent preparations proceed as fol- lows : — Stain a fixed film for two seconds with very dilute eosin (0"5 cc. concentrated alcoholic eosin to 500 cc. water), wash, pour on some Loffler's solution (Appendix, 22), diluted one in four of water. Wash this off after a few seconds, allow the film to dry, and mount in balsam. The parasite is stained blue and the red cells pink. The examination of the blood for bacteria is considered in Chapter XIV. Carbonic oxide in the blood. — In cases of suspected carbonic oxide poisoning, the presence of the gas may be detected by spectroscopic examination. Some blood is obtained by the application of a cup- ping-glass and is freel}"^ diluted with distilled water. The solution has a cherry-red colour. Place some of it in a thin flat glass tube, and examine with a hand spectrum. Direct the spectrum, as in all such examina- tions, towards a white cloud and not towards the sun. Two bands (Fig. 63) are seen (bands of carbonic oxide haemoglobin) occupying very much the position of the oxyhsemoglobin bands. They are distinguished from the latter by the fact that addition of a few drops of sulphide of ammonium produces no alteration in them. Various methods have been proposed for the clinical estimation of the specific gravity of the blood. The simplest is the following : — A mixture is made of chloroform and benzol in such proportions that the specific gravity of the fluid, as taken with a sensitive urinometer, is 1,060. Some of this is placed in a tall glass vessel, and a drop * Patrick Manson has described a special method by which the flagellated form of the parasite can be successfully stained {Brit. Med. Journal, 1897, vol. ii., p. 68). Chart of Specfra. 207 Red Orang e Yellow Green Blue Violet "I B C VII. VIII. Fig. 63.— Spectra of hfemoglobiu and its derivatives. I., oxvhsEniogloTjin ; II., reduced haemoglobin ; HI., carbonic oxide baenioglobin; IV., methairaoslobin (in acid solutiont; V., acid-b«raatin ; VI., alkali- li;ematin ; VII., haeniochromogen ; VIII., Laematoporphyrin (in acid soliuion) ; IX., liKiuatoporphyrin (in alkaline soluiionj. of blood added to it from a hsemocytometer pipette. If the drop remains suspended without either rising to the surface or sinking to the Itottom, the spe- cific gravity of the blood is the same as that of 2o8 The Blood. the mixture. If the drop floats, add benzol out of a burette, stirring well with a glass rod, until the drop remains suspended. If it sinks, add chloroform till a similar result is attained. Then take the specific gravity of the mixture with a urinometer, and the result will give the specific gravity of the blood. The normal specific gravity of blood is about 1,060. Variations are not of much clinical value. The specific gravity is always in proportion to the amount of haemoglobin — a low specific gravity means little haemooflobin. The ratio is so constant that one can tell the percentage of haemoglobin by taking the specific gravity. The clinical estimation of the albalinity of the 1>lood can only be accomplished by the use of rather elaborate methods, the results yielded by which are not of sufficient importance to justify their description in a work such as this.* The coagulability of the hlood can be esti- mated with a fair degree of accuracy by means of Wright's coagulometer.t The instrument consists of a series of fine tubes of equal calibre which are kept at a uniform temperature by being placed in a jacket surrounding a tin of water. Blood is drawn into each of the tubes at definite intervals, and, after the lapse of varying periods of time, one blows down the tubes in succession. If the blood can no longer be blown out, coagulation has occurred. The interval between the filling of the tube and the occurrence of coagulation is known as the " coagulation time." At a temperature of 18 "5° C, the coagulation time of a healthy individual is about four minutes. * For a discussion of the methods enii^loyed in the clinical estimation of the alkalinity of the blood and the results which they have 3delded, see a paper by one of the authors (Dr. Hutchi- son) in the Lancet, March 7th, 1896. t The instrument is supplied, along with full directions for use, by Dean, 73, Hatton Garden, London, E.G. 209 CHAPTER Y. Respiratory System. SECTION I.— ANATOMY. (Plates L, II., Iir.) The following anatomical facts must be boi-ne in mind when the lungs are examined : — 1. Borders of tlie Iniig^s. Rig-lit lung'. — The anterior border passes for- wards, downwards, and towards the middle line from the apex, which lies at the level of the neck of the first rib. Behind the sternum, at the level of the second rib, it has nearly reached the middle line, and passes directly downwards to the level of the junction of the sixth costal cartilage with the sternum, where it turns rather abruptly to the right to pass outwards as the lower border. The lower border meets the right para- sternal line at the level of the upper border of the sixth rib, the mammary line also at the level of the sixth rib, the axillary lines at the seventh and eighth ribs, the scapular line at the tenth rib, and at the side of the vertebral column reaches as far as the tenth interspace or eleventh rib. Left lung. — From the apex to the level of the fourth costal cartilage the anterior border passes in a direction which corresponds with that of the right lung. At this point it bends rather suddenly out- wards, thereby lea^^ng part of the anterior surface of the heart exposed, and passes in an arched line outwards and downwards to reach the sixth rib a little external to the parasternal line. From this point the lower border passes backwards along a line o 2IO Respiratory System. corresponding to, but a little lower than, that of the lower border of the right lung. The lower borders of both lungs are convex towards the abdomen. In forced respiration they may vary in level to the extent of two or even three inches, according to the phase of the respiratory cycle. In quiet respiration the differ- ence between the extremes is only about 1 cm. 2. LiObeis of the Uiiig^i^. It is often important to know the limits of the individual lobes of the lungs. This may be done by drawing a line from the second dorsal spine to the sixth rib in the mammary line ; this corresponds to the upper border of the lower lobe. A second line, drawn forwards on the right side from the centre of this line to meet the sternum at the level of the fourth costal cartilage, will mark the boundary between the upper and middle lobes. Obviously, therefore, the greater part- of each lung, as seen from behind, is composed of the lower lobe, only the apex belonging to the upper lobe ; whilst the middle and upper lobes on the right side, and the upper lobe on the left, occupy most of the area in front. In the axillary regions^ parts of all the lobes are accessible. The bifurcation of the trachea corresponds in front with the lower part of the manubrium sterni ; behind with the disc between the fourth and fifth dorsal vertebrae. The reflected pleural sacs reach decidedly lower than the inferior borders of the lungs, whoselimits they overstep for about two inches in the mammary, nearly four inches in the mid-axillary, and one and a-half inches in the scapular lines. The sinus thus formed lies on the left side above the resonant stomach cavity, and therefore, should it become distended with fluid, as in cases of hydrothorax, a dull area will be discovered at a part where the healthy percussion Anatomy. 211 note is tympanitic. The anterior i-eflection of the left pleura below the fourth rib is considerably nearer the middle line than the anterior border of the left lung ; « hence in emphysema, when the lung presses forward into this available space, the area of absolute cardiac dulness is greatly encroached upon. With reference to the correspondence of points in front and at the back, Quain gives the following- relations as existing during expiration : — " The upper margin of the sternum is on a level with the disc between the second and third dorsal vertebrae ; the junction of the manubrium and body- is opposite the fifth dorsal vertebra; and the xiphi- sternal articulation generally corresponds to the lower part of the ninth dorsal vetebra." The scapula is a useful landmark posteriorly. Its upper angle, when the arms hang by the side, is generally on a level with the disc between the first and second dorsal vertebrae, the root of the spine with that between the third and fourth dorsal vertebrae, and its lower angle with the body of the eighth dorsal vertebra. In reference to the ribs, the upper angle of the scapula just covers the second rib ; the lower angle reaches as low as the seventh interspace or eighth rib. The twelfth rib cannot always be felt. It is not safe, therefore, to count the ribs from below upwards. For convenience in description, the thoi'ax is mapped out into regions, as follows : — icb) T'liree central regions anteriorly. Suprasternal^ from the cricoid to the upper border of the manubrium. Superior sternal, from the upper border of the manubrium to the level of the third chondrosternal articulation. Inferior sternal, from third chondrosternal articulation to lower end of sternum. 212 Respiratory System. These three regions are bounded laterally by the lateral sternal lines and their upward con- tinuations."^ (6) Five aiifero-lateral regions on each side. Sujyradavicular bounded above by an oblique line from the side of the cricoid to the outer end of the clavicle, below by the clavicle. Clavicular, composed of the area occupied by the clavicle. Infraclavicular^ bounded above by the clavicle, below by a horizontal line at the level of the third chondrosternal articulation. Maimiiary, from the lower edge of the infraclavicular area to the level of the sixth chondrosternal junction. Inframammary , below that level. These regions extend outwards to the anterior axillary line. (c) Two lateral areas on either side. . .,7 [ meeting each other Axillary \ . j_i i i ^ xi T r -n {at the level or the imra-axillarii \ • ,^ ^^ •^ ' sixth rib. {(1) Four reg^ioiis at the hack on either side of the spine. Suprasca,pular. Scapular, subdivided into supra- and infra- spin ous. Infrascajndar, and Interscapular. — The position of the dorsal regions is sufficiently defined by their names. * Sometimes the sternal regions are classified as "episternal" and "xiphisternal." I.VSPECriON. 213 SECTION IT.— INSPECTION. Inspection determines : — (A) Form of chest. («) Healthy. {b) Symmetrical chests with features indicating pro- clivity to disease. {c) Symmetrical chests with features indicating past disease. [d) Symmetrical chests with features indicating pre- sent disease. ie) Unilateral changes. (/) Local changes. (B.) Movements o£ chest. [a) Respiratory. (1) Kate. (2) Rhythm. (3) Type. I The alar chest. i The flat chest. [ The rachitic chest. ' The pigeon breast. ( Harrison's sulcus. I The barrel- shaped chest. I Bilateral retraction. I Enlargement. ( Diminution. / Bulging. 1 Retraction. \ Funnel-shaped depres- \ sion. (4) Character [see Chapter II. ). also j' Amount of expansion. \ Unilateral fixation. I Local lagging. I Local indrawing and ( bulging. {b) Xon-respiratory. Pulsations (Chapter IV.). (A) The sliape of the tliorax depends partly on the curvature and obliquity of the ribs, partly on the curves of the spinal column. The curvature of the sternum results from the relations of these factors in each case. When tlie ribs are normally curved, the more horizontally they lie, the more nearly does a cross section of the chest approach the form of a circle, the wider are the intercostal spaces, and the more obtuse does the subcostal angle become ; whilst on the contrary, increasing obliquity of the ribs leads to 214 Respiratory System. narrowing of the intercostal splices, to increasing ellip- ticity of the cross section of the chest, the major axis lying transversely and the minor axis in an antero- posterior direction, and at the same time the subcostal angle becomes more acute. In a healthy male the angle is about 70°, in the female about 75°, The variations may amount to 10° above or below these averages. When there is lateral curvature of the spine^the chest is rendered asymmetrical ; when the spine is unduly concave forward, other changes are produced which will be dealt with subsequently. The ideal healthy chest will conform to the following description : It is bilaterally symmetrical, its contours are smooth, it has no deep hollows, and at most shows only a slight recession below the clavicles. In cross section it is an ellipse, broader from side to side than from front to back in the proportion of about 7 to 5 ; and its general shape is ellipsoidal, with the longest axis vertical. In children the cross section is much more nearly circular. The sternum, which is convex from above down- wards when viewed from the front, lies at the bottom of a shallow groove known as the sternal furrow, formed by the pectoral muscles of each side. The junction of the manubrium with the body of the sternum exhibits a slight angular projection (angulus Ludovici), sometimes visible, almost always palpable. The sternal furrow ends below, at the level of the seventh costal cartilage, in the infrasternal depression (or scrobiculus cordis). A slight hollow below the clavicle marks the separation between the divisions of the pectoralis major ; it should not be deep, and ought only to be distinct when the muscle is made to contract. A second hollow, which is mucb more distinct, separates the pectoralis from the deltoid. This fossa lies farther from the middle line, and is The Normal Chest. 215 known as the infra-clavicular (or Morenheim's) fossa. It becomes very marked in many cases of phthisis. The shape in the mammary regions depends greatly on the degree of development of tlie mammary gland and on the amount of subcutaneous fat. In the adult male the nipple is usually situated about 4 in, from the middle line, in the fourth intercostal space. In actual practice it is very rare to find a chest which is perfectly symmetrical. Generally the right side is rather more capacious than the left, and the spinal column almost always has a slight degree of lateral curvature. In inspection of the chest the examiner must never be content with viewing it from one aspect only. He should tirst look at it from the front, then from the side, thereafter from the back, and finally he should look over the shoulders from behind and above, so as to see the profile of a horizon- tal section of the thorax. The last method is very useful in detecting lack of symmetry or unequal expansion on the two sides. The neck, especially as regards the manner in which it is set on the chest, and the epigastrium should be inspected at the same time as the thorax. Deviations from the normal form may either affect the whole of the thorax or localised parts of it. The abiioriiial shapes of the chest as a whole may be grouped in three classes, according as they indicate merely a proclivity to lung disease, a history of former disease, or the existence of present disease. The first class contains the alar and flat chests ; the second the rickety chest, the pigeon breast, and the chest with Harrison's sulcus ; the third includes the barrel-shaped chest and the hollow or retracted chest. In these groups the changes affect both sides of the thorax, and so the symmetry remains undisturbed. 2l6 ReSPIR a TORY SVS TEM. In other instances the morbid conditions at work may lead to unilateral changes in the shape of the chest, one side having its volume either increased or dimi- nished, and being otherwise deformed. Lastly, the chest may exhibit local deviations from the normal form, due generally to local disease. I. Syninietrical chests with features iudicatiug^ proclivity to luiig^ diseases (" Phthinoicl '^ Chests) The two forms which belong to this class are the alar and the flat chest. I. The alar chest is one where the vertebral borders of the scapulae project unduly, and the shoulders droop. The cause of this appearance is to be found in the obliquity of the ribs, which makes the projection of their curves and angles in the horizontal plane more sharp, leads to a long and rather shallow thorax, and is associated with a long neck and prominent throat. 2. The flat chest is due to a loss of the forward con- vexity of the costal cartilages, which become more or less straight. As a result, the sternum is less distant from the vertebral column than usual. The flat chest is often, but not always, associated with the alar form. II. Syiniiietrical chests Avith features iudicatiiig past diseases (and not seldom pre- disposing to pulmonary disease). This group contains a number of forms, but only a few need be considered here. 1. The rachitic chest. — In rachitis the bones are less rigid than usual, and so are more readily Fig. 64. —Cross section of rach- itic chest. (Gee.) The dotted line represents the normal outline for the same age. A BNOR MA L ChES TS. 217 deformed by any applied force. From the nature of the disease the part that yiehls most readily is where the bone and cartilage meet, and therefore, when any cause prevents the free access of air to the luugs during inspiration, this part bends inwards before the pressure of the external air. A vertical groove is thus formed in this region, and persists even after the cause which first led to its production has dis- appeared. The section of a rachitic chest is shown in the accompanying woodcut, where the depressions situated at a little distance from either side of the sternum are easily recognised. AYhen the rachitic condition is severe the line of least resistance becomes so weak that no unusual obstruction to inspiration is necessary in order to produce the grooves ; the slightly lower air pressure ^\'ithin the thorax, which is necessarily present during in- spii'ation, being sufficient to lead to its formation (Fig. 64). 2. The pigeon breast. — ^Here in consequence of some obstruction (often quite trivial) to inspiration at a time of life when the ribs are soft, they become straightened in front of their angles ; where, owing to their smaller degree of curvature, they are most readily deformed by ex- ternal pressure. The re- sult is that the sternum becomes unduly prominent and projects beyond the plane of the front of the abdomen, so that there is a sharp angle at its lower end. At the same time the cross section of the chest ceases to be elliptical, and approaches a triangular form, the angles being Fig. 65. — Cross section of pigeon breast, {(ite.) The dotted line represents the normal outline. 2i8 Respiratory System. situated at the sternum in front, and at the costal angles behind (Fig. 65). 3. Harrison's sulcus. — This is a transverse constriction which, beginning at the level of the xiphisternum, passes outwards and slightly down- wards. It seldom reaches as far as the midaxillary line. This deformity is due to the same cause as the last, but either the obstruction has been slighter, or the bones have been more fully hardened. The depression is therefore limited to the most yielding part of the chest, and this corresponds to the region where the cavity is widest. Lower down than the sulcus, the liver and other abdominal viscera had supported the chest wall and so prevented it from being drawn inwards ; whilst higher up, the greater curvature of the ribs had enabled them to withstand the external pressure. The three deformities just described are frequently found together in one individual, and cases of pigeon breast almost invariably exhibit a well-marked Harrison's sulcus. III. Symmetrical chests with features indicating^ present domino-thoracic, the female as tUoracico-abdominal, or almost purely thoracic. The presence of pain or dyspnoea should should always be inquired for, and its exact nature noted. \See Chap. II.] 4. Kegarding " movement " during respiration, the points to be noted are its amount, whether it is expansive in character, and whether it is similar on the two sides and over corresponding areas. Amount of movement and expansion are by no means interchangeable terms; in emphysema the Palpation. 223 chest may move considerably, but there is little ex- pansion. In comparing the two sides it will often be found that deficient or absent movement betokens pleurisy with effusion, or non-expansion of the lung from con- solidation or rigidity of its structure, Local tlelicieiicy in expansion is frequently a very important indication of phthisis, or it may be due to lobar pneumonia, the former especially at the apices, the latter at the apex or base according to the situation of the disease. Sometimes one part of the chest wall lags behind the rest during inspiration Any such lagging is im- portant as suggestive of disease. The existence of any indrawing- of the chest wall or of the inter- spaces during inspiration, or of any bulging^ during expiration, must be noted. Both may occur physio- logically, in which case the conditions are present over the whole chest, and are not very conspicuous, or they may result from pathological conditions, when they sometimes affect the whole thorax, at other times one side, and yet at others only appear locally. Examples of inspiratory indrawing are found in ob- struction of the larynx (general), or in blocking of some of the smaller bronchi (local). One of the best instances of localised expiratory bulging is seen at the apices of the lungs in advanced emphysema. SECTION III.— PALPATION. Palpation determines : — A. Form of chest [confirms or modifies th.e results of inspection, q.v.^ B. Movements of chest. a, Respiratory \yide also inspection], J, Pulsations [Chap. IV.]. 2 24 Respiratory System. / Palpable pleuritic friction. C. Vibrations P^lP''^^^^ ^■^^^'- ,. I ( increased. \ Vocal fremitus I diminished. ( absent. D. Tenderness, E. Fluctuation. F. Resistance of chest wall to compression. Inspection of the thorax should go hand in hand with palpation and mensuration. In this way the observations made by the eye are confirmed and extended, in some respects greater accuracy is attained, and various facts which the eye cannot discover are elicited. Palpation takes note firstly of the form and move- ments of the thorax ; secondly, of vibrations or tremors wliich are communicated to the hand ; and thirdly, of the behaviour under pressure of any pain of which the patient complains. Under the first head inspection is supplemented ; under the second one learns something of the accompaniments — e.g. friction, or rhonchi — which interrupt the smoothness of the respiratory movement, and also of vocal fremitus, which serves to indicate the condition of the con- ducting media. The third enables one to detect the cause of many thoracic pains. Before making a systematic examination, it is well to lay the hand on any part of the chest which presents an obvious swelling, or where the patient complains of pain. In doing so the observer should remember to look at the jDatient's face rather than at the part under examination, as he thus most quickly learns whether he is causing any avoidable suffering. Pain may be due to inflammatory conditions in the chest wall, to intercostal neuralgia, where, as a rule, specially painful spots can be discovered corresponding to the points where the branches of the affected nerves emerge through the fascia ; to intercostal myalgia. Palpation. 2-^5 where the pain is aggravated by pincliing the afTected muscle, or to pleurisy. In the case of the latter, pressure may considerably increase the pain by bring- ing the opposed surfaces of the inflamed pleura more firmly into contact. At the same time the nature of any swelling should be investigated. The hand will also supplement the information derived from inspec- tion with regard to prominence of the intercostal spaces, and may occasionally detect fluctuation in them when there is pleuritic effusion. Fluctuation also occurs, and is much more distinct when an ab- scess has formed in the chest wall. Such an abscess may be due to disease of the bones or soft parts forming the parietes of the thorax, or to pus which has broken through from the pleural cavity {empyema necessitatis). In the latter case the pus may often be driven back by gentle pressure, to reappear when the patient coughs. When these preliminary observations have been completed, the observer should direct his attention to the form of the thorax. Here the hand is best aided by mechanical appliances, such as the cyrto- meter and by simple measurements. Tracings and measurements should be taken at the periods of full expiration and inspiration. In a well-formed adult male the girth of the chest at the level of the nipples should be 34 inches at the end of expiration, and should measure at least two inches more when a deep inspiration has been taken. Height, age, and build of course greatly modify these measurements, and insurance returns indicate that different races vary very considerably in chest girth. It is generally far more important to ascertain the increase of girth between inspiration and expiration, both full and ordinary, than to determine the exact circumference of the chest at either phase. If the shape of a cross section of the chest is p 2 26 Respiratory System. re(]^uired, a tolerably efficient cyrtometer can be improvised by connecting two pieces of flattened composition gas-pi])e, each about two feet long, by a hinge of elastic tube. The hinge should be placed over the spine, and the metal pipe moulded to the surface of the chest. It can then be opened at the hinge and closed again over a piece of paper, to which the outline should be transferred if a per- manent record is desiied.* There is no difficulty in applying the same simple instrument, so as to obtain the outline of the chest in other planes than the hori- zontal. Thus by placing the hinge above the shoulder the two pieces of pipe may be carried down the parasternal line in front and in a corresponding line behind, whilst, by sharply bending their lower ends outwards^ they may be made to cross each other in the axillary line and the point of intersection marked. The instrument is then opened at the hinge and re- adjusted over the paper so as to yield the desired tracing. The nature of the respiratory moveiueiits must next be studied. It is important to make certain that the two sides of the chest move to approximately the same extent. This is done by fixing the finger-tips of either hand at the patient's sides, and making the radial borders of the thumbs meet in the middle line in front of the chest. The hands being kept rigid, the patient is directed to take a full inspiration, when the distance of departure of the thumbs from the middle line indicates the extent of expansion of either half of the chest. Sometimes one-half of the thorax lags behind the other ; this is readily detected by the hands no longer moving synchronously, * Various more elaborate instruments have been devised, but, though ingenious, they are cumbrous, and consequent!}' not of great clinical use. The best of them is Dr. Graham Brown's l)erigraph. Palpation. 227 Tlie movements at the apices may be similarly observed. In this case the physician stands behind the patient, and fixing his thumbs on the vertebrae, lets his fingers lie over the right and left lung apices reaching towards the clavicles whilst the patient breathes deeply. Thereafter one hand should be placed on front of the chest, and the other on the epigastrium. In health, as the chest expands, the epigastrium is also raised to a greater or less degree. If the epigastrium fall in with each expan- sion of the chest, there is reason to suspect paralysis or llaccidity of the diaphragm. Fixation of the diaphragm with immobility of the epigastrium during respiration is generally due to abdominal disease {see p. 52.) Vibrations may be detected by palpation. For this purpose the palm of the hand should be applied iiat on the chest, and since the sensitiveness of the two hands is often unequal, the same one should be employed on both sides. In addition to the 'S'ibra- tions already referred to in the chapter on the heart, fremi tus .may be due to pleural f rjctioii, to catarrhal changes in the mucosa of the bronchi leading to local constrictions, or to fluid in the bronchi or in pul- monary cavities. After the presence or absence of these forms of fremitus has been determined, the observer should study the vocal fremitus, or vibrations which the voice communicates to the chest wall. These are conducted from the larynx by the trachea and bronchi to the smaller tubes within the lungs, and thence through the lung tissue to the surface. Anything which afl^ects the conducting power of the air-passages, or lung tissue, or the interposition of additional materials through which the vibration must pass to reach the palpating hand, will obviously affect the intensity of the fremitus. To test the vocal fremitus^ the patient is told to 2 28 Respiratory System. repeat "one, one, one," or " ninety-nine," in a clear voice. The hand placed on the thorax detects distinct vibration whilst this is done, and it must be deter- mined whether the vibrations in corresponding areas on the two sides of the chest are approximately equal in intensity — not, however, forgetting that where the heart encroaches on the left lung the fremitus is necessarily much diminished — and also whether they correspond to what former experience has led the observer to recognise as normal for the region under examination, for a similar chest and like pitch and loudness of voice. Vocal fremitus is increased when the voice is of a deep pitch, when the chest wall is rigid and often when it is thin, as also when the lung is consolidated, or contains a cavity near its surface. Since the right bronchus is wider and shorter than the left, whilst the septum separating the two bronchi occupies a position to the left of the centre of the trachea, the laryngeal sounds pass more freely along the right than they do along the left bronchus, and therefore the vocal fremitus is normally somewhat greater over the right lung than over the left. Vocal fremitus is diminished when the pitch of the voice is high, when the chest wall is thick, and especially when there is much thickening of the pleura. It is greatly diminished, or totally absent, when the lung is separated from the chest wall by pleuritic effusion. The cause in this case is not that fluid is a bad conductor of sound or of vibra- tion — the reverse is the case — but because the relaxed lung itself fails to convey the vocal fremitus, and so the vibrations never reach the fluid. In young persons and in female subjects the vocal resonance is different both in character and intensity from that which occurs in male adults. The differences are due to the different conformation and degree of rigidity of Percussion. 229 the thorax, and to the distinctiv'e pitcli and quality of the voice in each instance. The resistance of the chest to compression is best estimated by placing the hand over the sternum whilst the patient is lying down, and attempting to i)ress it backwards towards the vertebral column. The rigidity naturally in- creases with advancing age, but observations also indicate that in certain diseases {e.g. in phthisis and in emphysema) the rigidity often becomes greater than usual. Where this is so the prognosis is rendered less favourable, as free expansion of the lunof is hindered. SECTION IV.— PERCUSSION. Percussion determines : — A. The boundaries of the lungs [topographical percussion]. B. The resonance of the lungs. («) Normal variations in different parts. [b] Abnormal alterations. ! Increase [hyper-resonance]. Bimimition, in varying degrees from slight impairment to absolute dulness. ( liigh-pitched. 2. Qualitative : — Tympanitic | medium-pitched. ( low-pitched. Skodaic. Boxy. Cracked- Pot. Bell sound (coin percussion.) Amphoric. But little need be added here to what has been already stated in a previous chapter regarding the theory of percussion. It must be recollected that it is a most difficult task to give even a partial explana- tion of the phenomena observed from the standpoint of physics, and in practice it is rarely necessary to appeal to theory, as a long experience has enabled 230 Respiratory System, physicians to attacli certain meanings, more or less empirically, to v^arious })ercussion phenomena. It may, however, help the student to appreciate the various sounds when he hears tliem, if a few of the main factors in their causation are recapitulated. Firstly, we have to consider the materials whicli produce the sound. . These are the pleximeter, the chest wall beneath it, and the subjacent viscus so far as it comes within the range of action of the percus- sion stroke. The pleximeter sound, by the choice of a suitable material, may either be rendered insignifi- cant, or, in consequence of its special qualities, immaterial in its effect on the resonance. The chest wall yields a sound varying with the part struck, and depending for its quality on whether sternum, clavicles, ribs, or soft parts, underlie the pleximeter. The sound due to the wall is, however, quite subordinate to that of the organ lying beneath when the latter contains air, and when the percussion stroke is firm enough. The character of the sound produced varies quantitatively and qualitatively, the quanti- tative variations depending on the force of the blow delivered, and on the capacity of the part struck to resound to the blow. The Quality of the sound depends on the particular vibrations which are elicited, and on the selective reinforcement of some of them by the resonance of the origans involved. When the air in a cavity of sufficient size and appropriate shape is set into vibrations whicli are not modified by excessive tension of the containing walls of the space, the sound heard has a tympanitic character, but when the cavity is subdivided into a number of small loculi by numerous septa, more or less tense, a characteristic resonance, no longer tympanitic, is produced. Such conditions prevail in the healthy Percussion. 231 lung, and the observer must learn by assiduous prac- tice to recognise its distinctive quality. In general terms, this pulmonary resonance may be said to be low in pitch and clear in character. In percussion over the lung we endeavour to as- certain three sets of facts ; firstly, the position of the apices and lower borders of the lungs, and also of that portion of the anterior border of the left lung, which lies over the heart ; secondly, the state of the lungs in regard to the quantity of air contained in their various parts, and the tension of their elastic frame- work ; and, thirdly, whether they are unusually remote from the surface of the chest, the separation being due to thickened parietes, or fluid or gas in the pleural cavity. The apices and borders. Owing to the slope of the surface of the neck, resonance can usually be observed in health for one and a half to two inches above the level of the clavicle. The apices are either equally high above the clavicles, or the right may reach a shade higher than the left, if the right is a little lower than the left, or the left decidedly lower than the right, there is a probability of past or present disease in the lung whose apex fails to attain the normal limits. Should both apices be very low in level, there may be disease of both lungs. When the examination is made the patient must look straight before him, not turning the head to the side away from the examiner, as this alters the tension of the muscles over the lung. The percussion stroke should be moderately strong, and care should be taken that it is delivered quite per- pendicularly to the surface. The lowor toorder of the rig^ht lung: lies over the liver, and is thin, therefore its exact situation is best made out by light percussion. Posteriorly, how- ever, the muffling due to the thick muscles and fat of 232 Respiratory System. tlie back makes it necessaiy to percuss more firmly. When the i)atient is obese, very heavy percussion with several lingers may be necessary in order to penetrate the parietes, and bring the lung tissue within the sphere of influence of the blow. In quiet respiration the lower border is found to lie in the mammary line at the sixth rib, in the midaxillary line at the eighth rib, in the scapular line at the tenth rib, and nearer the vertebral column, as low as the tenth space. On the left side the lower border overlaps the stomach, and so the transition is not from lung resonance to dulness, but to tympanitic stomach resonance. Posteriorly, however, the splenic dulness and the dulness of the various solid structures which lie below the lung near the spine are interposed, so that the conditions resemble those found on the right. The position of the lower border corresponds pretty closely with that on the right side ; it may, however, be found a trifle farther down. In old people the lower borders of both lungs extend beyond these limits, in children they do not reach them by about a rib's distance lower and higher respectively. The anterior border of the left lung: emerges from behind the sternum at the level of the fourth costal cartilage, and forms the upper and left limits of the area of superficial cardiac dulness. The limits described are exceeded in very deep inspiration, and in diseases such as emphysema, where the volume of the air- containing lung is increased. In pneumothorax the lower border of resonance is often considerably below the limits assigned, and the character of the sound is different (p. 237). The limits are not attained when the lungs are shrunken or consolidated, when increased abdominal pressure interferes with the normal level of the PERCCrSS/OA^. 233 diapliragiu, or when there is effusion in the cavity of tlie pleura. Tn this case, should the etfusion he left-sided, instead of passing in the anterior axillary line from lung resonance to tympanitic stomach resonance, a hand of dulness will be found between Fig. 66. — Ti-aube's space in pleuritic eflfusion. a, portion rendeied dull ; b, portion remaining resonant. the two resonant areas ; and since the lower limit of the pleural sac reaches nearly four inches * lower at this point than the inferior border of the lung, the dulness will pass downwards to a lower level than the normal lung resonance does, and Traube's area (p. 63) will be encroached npon (Fig. 66). In * In the cadaveric condition Luschka cnves it as 10 cm. 234 Respiratory System. consolidation of the lung, on the contrary, this area will not be diminished. Having outlined the lungs, the character of the percussion sound over their various parts must be studied. Beginning in front, the examiner should tap lightly on the most prominent point of each cla- vicle — being careful to ascertain that the points ex- amined correspond exactly with each other — and should observe the quality of the sound, and particularly determine whether under like conditions of percus- sion the effects on either side are identical. There- after the other corresponding areas on either side should be carefully compared, many points being systematically percussed in each area. The presence of the heart will obviously interfere, in certain parts of the left side, with the development of a sound re- sembling that on the corresponding point on the right. When the front has been fully examined, the observer should percuss in both axillary and infra- axillary regions — the patient meanwhile holding his hands joined above his head; lastly, the various areas posteriorly should be worked out ; the patient, if able to sit up, being instructed to fold his arms and bend slightly forwards. It is most essential at all parts of this exami- nation that the patient's attitude be a comfortable one, so as to avoid any unilateral strain on his muscles, and that his arms and shoulders should be placed symmetrically. The head must not be inclined to either side. If any of the regions are unusually hollowed so that the finger cannot be readily adapted to them, a small cork will be found to make a good pillar plexinieter (p. 116). Should the patient's chest be unsymmetrical {e,.g. from spinal curvature), the observer must not expect equal resonance on the two sides. Per c u SSI on. 235 III ;t healthy individual the resonance in the various regions will exhibit the following character- istics : — Apices. — Clear, not very intense as the vibrating mass is small, and tending to have a slight tympanitic quality added as the trachea is approached. Clavicular reg^ioiis Sternal end. Clear, moderately intense, with tympanitic element due to trachea. Centre. Clear, more intense than in supra- clavicular or outer clavicular regions. Devoid of tympanicity. Outer end, as centre, but less intense. Infra-clavicular rcg:ion§. — Clear and intense. Slightly tympanitic near sternum. Mainniary regions. — Here there is naturally a difference between the two sides ; on the right, the lung is encroached on in the lower part of this area by the liver ; on the left, the heart occupies a good deal of the space, and the stomach note is elicited through the thin lung at the lower part. In general, however, the pulmonary resonance is clear and fairly intense, except where the neighbouring organs come within the range of vibration. The chest wall here is thicker from the presence both of the pectoral muscles and the mammary gland, and the sounds elicited are consequently more muffled. In the infra-ananiniary regions the sounds are greatly influenced by the neighbourhood of the liver, the colon, and the stomach. The lung-sound, however, is clear, though not intense, the thin layer of lung becoming rapidly emptier of resonance as its lower border is approached. In the axillary regions the sound is intense and clear, diminishing however in intensity at the lower part of each lateral area. Posteriorly, the great masses of muscle which clothe the back muffle the resonance and make it feebler ; and therefore tinner percussion, often with 236 ReSPIR a tor V Si '5 TE M. several fingers, is requiied. The scapular region is most muffled, tlie infra-scapular least so. The inter- scapular and supra-scapular regions are intermediate in quality. In disease, the resonance may be affected (1) quan- titatively and (2) qualitatively. Resonance is increased in emphysema (slightly), but at the same time the pitch is raised Fig. 67.— Pleurisy, with effusion, seeu from beliiucl. (Case].) Fig. 68.- Pleurisy, with effusion, seen from the side. (Case 2.) by the greater tension of the chest wall, and this in some cases not only prevents the increased re- sonance from being observed, but almost suggests dulness. When the lung tissue is relaxed, but still contains air, the effect of the septa which subdivide the air columns is for the most part abolished, and the sound becomes distinctly tympanitic. At the same time, the resonance is increased in intensity. This is some- times called Skoclaic resonance, and occurs above Percussion. 237 the level of a pleural ettusion, or in the upper [)ortion of a lung whose lower lobe is affected hy pneumonic consolidation. When air has found its way into the pleural cavity, the sound is as a rule intensely tympanitic, unless the air be under considerable pres- sure. A characteristic form of high-pitched tym- panitic resonance may be heard, in pneumothorax, by percussion over the front of the chest with a couple of coins ; one being used as a plessor and the other as a plexiraeter, whilst the ob- server listens at the back of the patient. Jn very marked cases the sound is soft and musical, and has been com- pared to the chiming of a distant church bell ; in cases that are less pronounced it approximates rather to the stroke of a hammer on an anvil when heard a long way off. Cavities in the lung, or the presence of large or me- dium bronchi within range of the percussion stroke, like- wise cause the sound to become tympanitic. A tympanitic sound, which may closely resemble that caused by the presence of a vomica, is heard when the portion of lung which lies between the trachea or primary bronchi and the surface becomes consoli- dated. This sound is sometimes called " Williams's tracheal resonance," and is most frequently discovered in the first or second intercostal spaces near the sternum. It is by no means an uncommon phenomenon. Resonance is cliniinislied in cases where the Fig 69. — Pleurisy, with effusion, seen from the front. (Case 1.) 238 Respiratory System. pleura is thickened, or where there is consolidation of the lung, either of a whole lobe, as occu?\s in pneu- monia, or of small patches, as in early phthisis. In the latter instance a particular strength of percussion stroke will in each case be found to develop the dulness to the best advantage, according to the size of the solid patch and its distance from the surface. When fluid is present, as in hydrothorax or pleurisy with effusion, the dulness is absolute, and an unusual sense of resistance is ex])erienced by the pleximeter tinger. In pleurisy with effusion the upper limit of the fluid generally follows a curved line, as is shown in the accompanying figures (Figs. 67, 68, 69). In the case of patches of solid lung substance, the airless j)ortion is often surrounded by a shell of tissue in which the septa are relaxed. The result of per- cussion over this composite arrangement is to produce a sound whose resonance is less intense and emptier than the healthy lung would yield, whilst what is left of it assumes a subtympanitic quality. The effect is described as a boxy or wooden sound. Several peculiar sounds which are produced by percussion in pathological conditions remain to be noted. 4Jracked-|>ot sound. — This is due to a sudden expulsion of air through a constricted orifice It occurs in cases where percussion is practised over a cavity which communicates with a bronchus of moderate size, and is most distinct when the mouth is opened. It has a hissing character, combined with a chinking sound like that produced by shaking coins together. It is also heard in certain cases of thoracic fistula, and occasionally in pneumothorax, as well as in the relaxed lung above the level of fluid in })leurisy, and near the consolidated area in pneumonia. If healthy children are percussed whilst they are crying, a cracked-pot sound is often produced. Percussion. 239 Aiii|>liori€ resonance. — This phenomenon is clue to the selective reinforcement of certain vibrations by a large cavity ; by this means the overtones are accentuated and die out more slowly. The following alterations in percussion sounds may be observed under certain pathological con- ditions ; their explanation is for the most part simple from a physical standpoint. (a) Tympanitic resonance, when due to the presence of a pulmonary cavity which communicates with a bronchus, is raised in pitch when the patient opens his mouth. This is sometimes called Wintrieli's phenomenon. {b) The pitch of the percussion sound over a cavity varies with the position of the patient. The most obvious explanation is that, if the cavity be partly filled with fluid, this varies in position and so alters the shape of the cavity when the patient changes his attitude. Other factors, however, often enter into the interpretation of this change, which has been called Oerliardt's phenomenon. (c) The resonance over a cavity becomes higher in pitch during inspiration, and lower during expira- tion. The phenomenon depends on the tension of the cavity, and is called Friedreich's pheno- menon. (d) In pneumothorax the metallic resonance is higher in pitch when the patient is lying dow^n than when he sits up. This is referred to as Biermei^'s phenomenon. In certain conditions of malnutrition the muscles on the front of the thorax are unduly irritable. In these circumstances a light tap over the sternum pro- duces fibrillary contractions at some distance off, in the pectoral muscles: This phenomenon often occurs in phthisis. 240 Respir a tor y Svs tem. SECTION v.— AUSCULTATION. Auscultation determines : — ■ A. Character of respiratory sounds. l' Normal. Fue.ile. Harsh. Jerky or cog-wheel. Feeble or absent. With prolonged expiratory murmur. '^ I Low-pitched (cavernous). I. .S { Medium-pitched. ^ ( High-pitched (tubular). Amphoric i Low-pitched, (with an echoing < Medium-pitched, quality added) ( High-pitched, (c) Indeterminate or broncho-vesicular breathing. B. Vocal resonance. I Slight. Increase < Marked, Bronchophony. ( Extreme, Pectoriloquy. Slight. Decrease \ Marked. Entire absence. («) Vesicular breathing , (rustling in character) {h) Bronchial breath- ing (guttural [ch] or aspirate [ha] in character) ir. {a) Quantitative changes I Aegophony. \ Amphoric resonance. Mcdii [b') Qualitative changes C. Accompaniments. p , ^ ( Sibilant or high-pitched. iWn ' ''h'\ I -^Isdl^'^'Ti -pitched. ^ ^ ^/ ( Sonorous or low-pitched. («) Rales ^ fIiesotu(Jit(-aietal\ic)'\ /Fine. Moist(Cre- J or consonant pitations) | Non-resonant or y toneless ) \ Coarse. [b) Friction sounds. — Fine, medium, coarse. [c] Splashing sounds. — (Hippocratic succussion). In auscultation three observations must be made at each point examined : First, the cliaracter of the breath sounds j second, the character of the vocal A use UL TA TION. 2 4 I resonance; and third, the presence or absence of other sounds. In ord(!r to make these observations with facility, the examiner should attend to the attitude of the patient, which must be as symmetrical and uncon- strained as circumstances will permit. This is easily attained when the patient can sit up ; but if he is unable to do this he should be rolled round first to one side and then to the other, in order that the back, and especially the bases of the lungs, may be thor- oughly examined. The student must remember that in serious cases great injury may be done to a patient by too prolonged an examination. Care must be taken, especially when an ordinary single stethoscope is used, that the chest-piece is accurately applied, and that no undue pressure is exerted. The patient must be directed to breathe through the nose, regularly and fairly deepl}', but not noisily. There are two typical varieties of breath sound, both of which are audible in health at certain parts of the chest, and these must be carefully studied. The first is known as vesicular breathing, the second as bronchial. The former is heard over healthy lung tissue, the latter over the trachea and main bronchi. In vesicular breathing:, which can be heard typically in the axillary and infrascapular regions of a healthy individual, the following facts will be noted : — The inspiratory sound is fairly intense, and is audible during the whole of the act. The pitch is low and the quality is characteristic, being some- what rustling. It is this quality which is specially described as vesicular. The expiratory sound follows that of inspiration without a distinct pause — ^unless, as not infrequently happens, the patient holds his breath for a second at the end of inspiration — it is less intense than the Q 242 Respiratory System. inspiratory sound, is lower in pitch, and lacks tlie vesicular quality, being more of a simple Ijlowing sound. It only remains audible during the earlier part of the expiratory phase, and under normal con- ditions the inspiratory sound is heard for at least thrice as long a time as the expiratory. To learn to recognise bronchial breathing, the student should listen over the trachea, though he must not expect to hear so intense a type of bronchial respiration when he subsequently examines a diseased lung. The inspiration sound is moderately intense. It becomes inaudible shortly before the end of in- spiration. Its pitch is much higher than that of vesicular breathing, and the quality is blowing or hollow, with a guttural or aspirate intonation. The expiration sound is generally more intense than the inspiratory ; the pitch is often higher ; the duration extends through the greater part of expira- tion, being as long as, or even longer than, the inspiratory sound, from which it is divided by the silent period that marks the end of inspiration. In quality it exactly resembles the inspiratory sound, being aspirate or guttural in character. This quality is sometimes described as " tubular," but the same name is also applied to one of the varieties of bronchial breathing, and so is better avoided. The principal variations which can be detected in vesicular breathing' are as follows : — 1. Puerile. — The sounds are harsher than in the adult, but have a similar duration. 2. Harsh, with prolongation of expiration, the character, however, remaining vesicular. This fre- quently indicates loss of elasticity of lung tissue; hence it often occurs in early phthisis, but may occur in bronchitis. A use UL TA TION. 1^% 3. Jerky, iiitorriiptod, or '" <*oj;:\vIiita1ioii$, are pro- duced either in the alveoli or in the bronchioles and bronchi. They produce on the ear a sound like the bursting of smaller or larger air- bubbles, and indicate the presence of fluid secretion in the air cells or tubes. They are classitied as fine, medium, and coarse or bubblino^.^ Fine erepitataoiis are caused by the opening up of collapsed alveoli whose walls have been agglu- tinated by the exudation of a little fluid secretion. This at first causes them to adhere, but, as the air pressure gradually increases during the movement of inspiration, the adhesion at last gives way suddenly, and allows air to enter. The separation of the walls is accompanied by a cracking sound, which can be imitated by separating the moistened forefinger and thumb near the ear. When this condition occurs in a number of alveoli, the combined eflect is to produce the sound of fine crepitation. It occurs onlyf near the end of inspiration, as is to be anticipated from its mode of production, and indicates the presence of exudation in the alveoli of the affected part of the lung. Fine crepitations are veiy characteristically present during the first stage of pneumonia, and in acute con- gestion from any cause ; they also occur in early miliary tuberculosis. After atelectasis they are occasionally heard, and in oedema of the lung they occur in asso- ciation with bubbling rales which are caused by the simultaneous presence of fluid in the bronchi. Meclitiiii crepitations occur chiefly in the smaller bronchi, and are audible at the end of in- spiration and the beginning of expiration. They are caused by the air bubbling through fluid secretion * The term " crepitation " is sometimes restricted to the first variety, the others being called fine and coarse bubbling rales. t Rarely a few sounds closeh' resembling fine crepitations are heard during expiration. 250 Respiratory System. which has been poured out into the hunen of the bronchi. Coarse bubbling crepitations occur in the larger divisions of the bronchi, and may be heard at almost any phase of respiration ; they may be quite continuous in their occurrence. Coarse crepitations may also originate in pulmonary cavities. Sometimes the rales are 11011-resoiiaDit or toneless. In this case they occur, as a rule, in spongy lung tissue ; but in other cases they are quite resonant, and convey an impression to the ear of being all possessed of a definite pitch. There are only two conditions in which resonant rales occur — either consolidation exists, or there is a cavity of sufficient size to act as a resonator for rales which ire produced either in itself or in a neighbouring bronchus. The highest degrees of resonance are known as metallic and tinkling^ consonances. Here the rales have a very distinct high pitch, and give the impression of a shower of drops falling into a metallic vessel, which reverberates the sound of their fall. This is associated with amphoric breathing, and, like it, suggests either a large cavity or pneumothorax. The position where rales are heard greatly influ- ences the importance to be attached to their presence. If heard at the apex, they at once suggest phthisis; whilst medium and coartie crepitation at the bases may be due merely to a transient exudation which will rapidly disappear again. When the patient has been breathing quietly for some hours, and especially if he has been lying in bed, a few crepitations, even if heard at the apex, may be due to temporary causes, though they should always be regarded with a degree of suspicion. The commonest accompaniment arising in the pleural cavity is a friction -sound characteristic of Auscultation: 251 pleurisy :it the stage wliere exudation is not abundant enough to separate the inflamed and roughened sur- faces. It possesses a creaking or rubbing character, often quite characteristic ; but sometimes, when less well marked, rather hard to distinguish from a rale. The friction sound may be fine, medium, or coarse. In some instances it is palpable, but, since coarse rales may be so too, this does not serve to distinguish them. The chief features of difference are that friction sounds occur during that part of inspiration when the roughened surfaces are rubbing against each other, to reappear at a corresponding period of expiration. They are, moreover, unchanged after the patient has coughed, whilst rales may alter under these conditions because of changes in the disposition of the secretion which causes them. The fact that friction is sometimes more localised than crepitation may also be of service. Sometimes friction is markedly intensified by increas- ing the pressure with which the stethoscope is applied. This acts by causing the roughened surfaces to rub against each other more firmly. Pressure does not affect the intensity of rales. The situation of the doubtful sound, or the presence of pain, or some point in the history of the case, may assist the observer in arriving at the diagnosis. It must never be forgotten that the presence of one form of accompaniment does not exclude the others. Any two or all three may be found co- existing in one case. When pleuritic friction is developed along the anterior edge of the left lung, and especially when that part of it which is in rela- tion to the apical segment of the heart is affected, the friction sounds often assume the rhythm of the heart-beat rather than that of the respiratory move- ments. Hence the sound is liable to be mistaken for pericardial friction. To distinguish between this so-called pJew-Q'perimrdial friction and that of true 252 Respiratory System. pericarditis will rarely be very difficult if it is recol- lected that the former, depending as it does on the apposition of two roughened patches of pleura, is only heard during those phases of respiration when the patches are in contact. Hence a deep inspiration, by removing one of them from the other may prevent the production of the sound, whilst in other cases holding the breath, or emptying the lungs as com- pletely as possible may lead to a like result. In short, pleuro-pericardial friction is much more dependent than true pericardial friction on the movements of respiration. Hippocratic succussioii is the name given to a splashing sound which can be heard when a patient who has both gas and fluid (usually pus) in the pleural cavity is shaken or moves suddenly. SECTION VI.— SYMPTOMS OF THE PRIN- CIPAL PULMONARY DISEASES. 1. Acute bronchitis. — The patient complains ,of pain behind the sternum, of some breathlessness, and of troublesome cough. The sputum is at first mucous and scanty, but subsequently becomes muco- purulent and abundant. The physical signs are, by percussion, resonance normal ; by auscultation, breath sounds vesicular, and accompanied by sonorous and sibilant rhonchi, the latter being especially prominent when the smaller tubes are implicated. The vocal resonance is unaltered. 2. Chronic bronchitis, — The symptoms re- semble those of acute bronchitis, but pain is less, and dvspnoea is more marked. The sputum is abundant and mucopurulent. Coarse crepitations are usually abundant. 3. t^niphysenia. — The patient suffers from breathlessness, and is often somewhat cyanosed. He Symptoms of Pulmonary Diseases. 253 generally has a good deal of cough and some expec- toration. Tlie chest is barrel-sliaped, and its expan- sion during inspiration is insufficient. On percussion there is hyper-resonance, sometimes a trace of tym- panicity. The borders of the lungs encroach on sui'rounding organs, and the area of superficial cardiac dulness may he greatly lessened. Auscultation reveals prolongation of expiration and diminution of vocal resonance. ■t. Phtliisis. — The earliest signs of the disease are often loss of weight and appetite, cough, and tendency to sweating during the night. At a later stage one finds severe cough, especially in the morning, sometimes hemoptysis, increased rate of respiration, diarrhcea, hectic fever, and the other symptoms of an acute inflammatory disease. Inspection reveals in many cases a phthinoid chest with local retraction and defective movement. By palpation one detects increased vocal fremitus ; by percussion, localised dulness, especially above or below the clavicle, and sometimes the physical signs of a cavity are apparent. By auscultation one finds that expiration is prolonged, or that the breathing is bronchial in character. The breath sounds are accompanied by crepitations, most of which are of medium size. The sputum contains tubercle bacilli, and often also elastic tissue. 5. LrOtoar pueumooia is recognised by its sudden onset with rigors, cough, and pain in the side, associated with fever which remains continu- ously high. The face is flushed, the breathing rapid, and the sputum, which is not copious, is rust- coloured and excessively tenacious. The microscope reveals the presence of pneumococci. The physical signs vary with the stage of the disea-se. First stage : Percussion-sound rather tympanitic but slightly dull, fine crepitations present. Second stage : Absolute dul- ness on percussion, high-pitched bronchial breathing, 254 ReSPJR a TORY S} 'S TEM. increased vocal resonance and fremitus. Third stage \ Gradual diminution of dulness, disappearance of bronchial breathing, presence of medium and some fine crepitations. Vocal resonance and fremitus return to normal (Fig. 70). 6. Chronic interistitial piiciinionia. — The patient complains of some breathlessness on exertion, and of cough with rather copious nmcopurulent expectoration. The sputum may be fetid, or, when the disease is a pneumonokoniosis, may contain characteristic elements. The physical signs are a •_/i Oilixf^' ,.., Marked i'eci/PesonsacB |r.<:<-«fr:?l/<,«" Ca/Zed BronaJTophan/ Fig. 70. — Physical signs at beginning, height and decline of a pneumonia. i^AfUr Wyllie.) gradually developed flattening over the affected region, where also expansion is absent, or defective and delayed ; die shoulder of the diseased side droops. On percussion there is a dull area surrounded by one where the resonance is boxy, and the heart is drawn over by the contracted lung. Auscultation reveals feeble or bronchial breathing, and a few crepitations and rhonchi. The vocal resonance and fremitus are exaggerated. 7. Pleurisy is characterised by the presence of fever, pain in the side, restrained but rapid breathing, and suppressed dry cough. In early stages friction is Syj/PTOMs OF Pulmonary Diseases. 255 aiidil)le, whilst ;iftor etfusion lias occurred one nnds absolute dulness in the affected area, with some tym- panitic resonance above the fluid. Breath sounds and vocal resonajice are diminished or absent in the dull area. Above it the breathing may be somewhat bronchial and accompanied by fine crepitations. En massive effusions the neighbouring organs are dis- placed (Fig. 71). 8. Paieuiiiotliorax. — The patient complains of sudden pain and breathlessness. The affected side is distended and immobile, or lags behind the other. ///7e /^r/ct/o/i Coarse /^r/'ct/im Fig. 71.— Physical signs at the various stages of pleurisy. (After Wyllie.) On ])ercussion there is a loud, deep resonance more or less tympanitic, and by coin-percussion a characteristic ringing sound is elicited. The breath sounds and vocal resonance are absent, or, if a bronchus com- municates with the pneumothorax, are replaced by amphoric breathing and resonance, whilst if fluid is present one may hear metallic tinkling and elicit Hippocratic succussion. The surrounding viscera are displaced. 9. Haeniorrliagic infarction of the lung occurs in the course of valvular heart disease, and is characterised by the sudden onset of pain, associated with blood-stained expectoration. If the infarct is near an accessible portion of the surface of the lung, 256 Respir a tor y Svs tem. one Cciii often discover a patch of dulness, with altered breath sounds and crepitations. 10. AstBiuiii may usually be regarded as a symp- tom rather than a disease. Cardiac asthma has already been described, and asthmatic conditions may likewise arise from polypi or other sources of reflex nasal irritation, or from disease of the stomach or kidneys. The form known as bronchial or " spas- modic " asthma results mainly from spasm of the muscles of the smaller bronchi. In it the patient is found sitting up or leaning forward with the hands fixed on some object in order to give additional pur- chase to the accessory muscles of respiration. The face is flushed and the vessels are turgid. Expiration is prolonged and laboured, and the lungs are too full of air. Percussion yields a somewhat hyper-resonant sound. Auscultation reveals at first musical rales and wheezing sounds, with marked prolongation of expiration. After secretion has been established, deeper rhonchi become audible. The sputum, which is scanty, contains small lumps, in which Cursch- mann's spirals and Char cot-Ley den crystals are found. SECTION VII.— THE SPUTUM. The characters of the cough have already been treated of in a previous chapter (Chap. II.). It remains to add a few notes on the appearance and examination of the sputum in different diseases.. The following are the principal points to be observed by the naked eye : — 1. Quantity ; 2. Consistency ; 3. Whether homogeneous or in layers of different apj)earance ; 4. Whether frothy or airless ; 5. Colour and transparency ; 6. Odour. The Sputum. 257 The above qualities depend on the character of the material which is coughed up. The main varieties are mucous sputum, serous sputum, fibrinous spu- tum, purulent sputum, and Ijlood. In many instances transition types between them are observed. Mucous sputum is characteristically present in early bronchitis. It is clear, tough, and stick}^ As a rule, the amount is not great. At a later stage of bronchitis the mucus is mixed with pus cells. The sputum is then less tough, more copious, and has a greenish yellow colour. Muco-purulent sputum occurs in many diseases of the lung. In phthisis with ca^dty formation one often finds small ragged lumps of muco-pus, sur- rounded by mucus, which are heavier than the other constituents since they are airless. They therefore sink to the bottom and become more or less flat and buttonlike. This constitutes the "nummular" sputum of phthisis. If there be a fair amount of serous or watery fluid mixed with such sputum it gradually settles into three layers, the lowest being purulent, the next serous, and the uppermost com- posed of frothy mucus. Sputum composed of pus alone usually proceeds from an abscess which has ruptured into the lung or air-passages. Serous sputum occurs apart from mucous expectoration as a thin watery fluid, generally blood- stained. It indicates cedema of the lung. Pulmonary cedema without extravasation of blood yields a white frothy sputum like soapy water. Blood may be coughed up alone, or the sputum may be more or less bloodstained. It must be dis- tinguished from blood brought into the mouth from epistaxis, gastric luemorrhage, or bleeding from varicose veins in the walls of the oesophagus. Its brighter colour and its frothy appearance often make R 258 Respiratory System. the discrimination perfectly simple. When it comes from the lungs its presence may result either from pulmonary or cardiac disease, or from aneurysm. Several diseases cause a characteristic colora- tion of the sputum. Thus, in pneumonia it is rusty and so viscid that it often will not fall out of an inverted spittoon ; it is bright yellow or g^reen when a liver abscess has ruptured into the lung, and the latter colour also appears in some cases of pneumonia. Sometimes when an amoebic hepatic abscess has discharged by the lung, the sputum has the appearance of auchovy sauce. Black spu- tum is common with coal miners, whilst red-streaked sputum is suggestive of phthisis. Pruue-juice sputum occurs when blood lingers in a lung which has become oedematous. Thus it is found in cases of chronic pneumonia that are going on to disintegra- tion of the lung tissue. Red-currant-jelly sputum is said to be characteristic of malignant disease in the lung. It has also been found in hysteria. The quantity of sputum coughed up in twenty- four hours is important ; and still more so whether large quantities are rapidly got rid of at considerable intervals or whether it comes away in small amounts and frequently. Occasionally small casts of bronchi are to be found in the sputum, but the examination for formed elements is best conducted with the aid of a microscope. The odour of the sputum is seldom very characteristic. Ordinarily it has a " stale " smell, but in cases of gangrene of the lungs, of fetid bron- chitis, and of bronchiectasis it may develop an exceedingly penetrating putrid odour. An unpleasant odour may also be acquired during its transit through the mouth. microscopic examination of sputum. — Generally it is well first to examine an unstained and The Sputum. 259 fresh specimen, and thereafter to use special methods for the recognition of bacteria. To select a suitable piece, place the sputum in a Hat glass vessel, which can be laid on either a white or a black backi^round as is found convenient. Mixed with the amorphous mucous exudation which forms the basis of the sputum may be seen various organised and crystal- line substances, of which the following are the principal groups : — I. Cellular structures. — (1) Pus corpuscles in various stages of granular degeneration and with several nuclei. (2) Epithelium from mouth, air-passages, and alveoli. The latter may contaiii pigment which has reached them from the air, or they may exhibit a very characteristic iron-containing pigment, which is un- usually abundant in cases of heart disease with pul- monary congestion, and indicates brown induration of the lung. This pigment yields the hsemosiderin reaction on the addition of hydrochloric acid and potassium ferro-cyanide. (.3) Salivary corpuscles are picked up by the sputum on its passage through the mouth. (4) Red blood corpuscles. — A few are of no importance. Large numbers occur in haemoptysis. (0) Eosiuophile cells occur in asthma, and are often associated with Charcot-Leyden crystals. They are large and contain numerous fine granules wbich stain with eosin. II. Elastic fibres indicate destruction of lung tissue, whether from phthisis, gangrene, or abscess. In gangrene only a few fibres escape the destructive process. They are found in the small tough lumps of the sputum, and are best demonstrated by a rapid heating with an equal quantity of 10 per cent, solution of caustic soda, which liquefies the other elements more quickly than these fibres. After 26o Respiratory System. boiling, a gelatinous mass is left, to which a con- mm':- ., i'^y'^ -^, ..... .,-^ .^.. ^ - Fig. 72.— Elastic tissue from lung in sputum of a case of phthisis. X 300. siderable quantity of water should be added and the mixture left in a conical glass till the elastic fibres settle to the bottom. Thus they may be isolated, and in well marked cases exhibit the alve- olar arrangement of the lung tissue. Too prolonged an expo- sure to the caustic will lead to the solu- tion of the elastic fibres as well as of the other constituents (Fig. 72). III. Fibrin caists, often large enough to attract the unaided eye, are still Fig. 73. — Bioncliial cast from a case of ■plastic bronchitis. Natural size. The Sputum. 261 more frequently visible under a low power of the microscope (Fig. 73). IV. Ciirsclmiaiiii's spirals are found in the sputum of asthmatic patients. Some of the sputum 'm^^- Fig. 74.— Cursehmaun's spirals in sputum, x 200 and natural size. should be spread out on a piece of glass on a black sui-face. The spirals look like little sago grains. When unrolled, they appear as convoluted threads which may be quite an inch in length. ,, .^5^^,^ IJnder the microscope ■; ;P ^ they show a central •;;.-.. core, round which a K:^^^^^'- sheath of tough mucus, with a large number of ',---^ ^^ small round cellular elements in it, is coiled (Fig. 74). Fig. 75.— Charcot-Leyden crystals. x350. V. Crystals.— (1) In asthma, fine colourless crystals wdth sharp ex- tremities are often found. They are often associated 262 ReSPIRA tor Y SyS 7 EM. Fig. 76. — Ova of Distoma pulmonale in sputum. High power. Fig. 77 —Actinomyces in sputum. The Sputum. 263 with the spirals already described, and are known as Cliarcot - Leydeii crystals. They are probably phospliates of an organic base (Fig. 75). (2) Fatty acid crystals are needle-shaped, and generally occur in clusters. (3) C'liolesteriii occurs in rhomboidal plates, which generally have a small notch in one corner. They occur in old purulent sputum from pulmonary cavities, but their presence is uncommon. (4) Hppiiiatoidiii crystals occur where there has been an old hpemorrhage in cases of abscess and empyema. They have a characteristic brown-yellow colour, and appear as needles, rhombi, and plates. (5) L.eiiciii and tyrosiii may be found on rare occasions in pus from old perforated empyemata. VI. Parasites. — These belong both to the animal and vegetable kingdoms. Of animal parasites, ecliinococci are the most important. The presence of booklets, and still oftener of fragments of the lam- inated ectocyst, are the usual indications of their existence (see p. 93). In China and other parts of Eastern Asia Distoma pulmonale is frequently found. Its presence causes sharp attacks of haemo- ptysis, which may be mis- taken for the haemoptysis of phthisis. Microscopic scrutiny of the sputum, however, generally reveals characteristic ova (Fig. 76). The vegetable parasites are fairly numerous. Be- sides bacteria, which are considered in a separate chapter, and amongst which the most important are tubercle bacilli, pneumococci, and Pfeiffer's bacillus, Fig. 7S. - Aspei'gillus fumigatus. 264 Respiratory System. some of the higher fungi are also found, the most important being actinomyces and aspergilliis fiuiiigatus (Figs. 77, 78). APPENDIX TO CHAPTER VI. On Graphic Methods of Eecordixg the Coxditions Observed in the Heart and Lungs. 1. Full-size outlines of the heart. The position of the nipples, and the outlines of the clavicles, ribs, and sternum, should be carefully traced on the chest -with a dermatograph pencil, and the same should be done for the outlines of relative and absolute dulness of the heart and liver. These tracings should then be gone over rapidly with a small paint brush dijDped in sweet almond oil, and a sheet of tissue paper pressed down upon the patient's chest. The oil will leave a mark on the paper, which can be more strongly traced by a pencil after the paper has been removed. An alternative method is to photograph the chest wdth the lines drawn in. This has the convenience of pre- serving the record in a less bulky form. A scale of inches should in this case be laid across the patient's epigastrium to permit of absolute measurements being taken from the photograph. 2. The use of symbols on outline charts. («) The heart. — The presence and position of murmurs are easily indicated by shading. Their intensity is roughly represented by the heaviness of the shading. Examples of this method are seen ia Figs. 34, 35, and 39. When two syn- chronous murmurs are present, and one wishes to show where the first, after becoming fainter, gives place to the second, which grows increasingl)'- loud as the stethoscope is carried along the line joining their areas of maximum intensity, one makes use of the musical signs of diminuendo and crescendo, ^ and ^. The situation of pericardial friction is indicated bj' a zigzag line, wv%w^. When the apex beat does not reach the edge of the deep cardiac dulness, its situation is shown by a small cross. X . (h) The lung's. — The position of any dull area is in- dicated by shading. If, following the suggestion of Prof. Sahli, one represents superficial dulness in blue chalk and deep in red, one can not only make the record clearer, but can Graphic Records of Physical Signs. 265 also superpose on the same chart auscultatory phenomena in black symbols without clogging it. The auscultatory phe- nomena are well represented by the following symbols.* 1. Types of breathing : — • [a) Vesicular. A A A Puerile. Normal Feeble. Ailult. o None. /\ Inter- rupted. A Harsh, with expiration prolonged. [b] Transition \ " Bronchovesicular " Type. \ or indeterminate, {c) Bronchial. {(l) Amphoric. //\ Tubular or High-pitched. Medium- pitched. Low- pitched. 00 High- pitched. C?0 O^ Medium- pitched. Low- pitched. 2. Accompaniments : — (a) Friction. AAAA AVWW AnAw^v/ / TO Fine. Medium. c Coarse. (b) Dry rales. (c) Moist rales : — Consonating. Non-consonating. /// Sibilant rhonchi. /// Medium- pitched rhonchi. Fine. Medium. /// Sonorous rhonchi. o o Coarse. If the accompaniments occur during inspiration, the letter i is prefixed to the symbol ; if during expiration, e. * Mostly after Dr. Wyllie. 266 R ESP IRA TOR Y SVS TRM, Vocal resonance is indicated by the letters V.R., followed t»y + 1, + 2, + 3, if it is slightly, moderatel)', or greatly in- creased; or — 1, — 2, — 3, if it is proportionately diminished. Fig. 79. — Record of pneumonia. Other physical signs are best indicated by various letters of the alphabet. The accompanying figure (Fig, 79) illustrates the application of these symbols to a case of pneumonia. 267 CHAPTER VII. The Urine. The nietliod of interrogating a patient whose symptoms point to an affection of the urinary system has ah^eacly been described (p. 9), and the physical examination of the kidneys has been con- sidered along with that of the other abdominal organs (p. 72). In this chapter we propose to take up the examin- ation of the renal secretion. Collection of Samples. Owing to the variations in the composition of the urine at different times of the day, the sample examined should, if possible, be taken from the total urine of the twenty-four hours. If only one sample can be obtained it should be that which is passed about three hours after taking a meal, as abnormal ingre- dients are then more likely to be present. The sample should be poured into a tall conical glass, covered, and allowed to stand for some hours in a cool place. Any suspended matters soon settle to the bottom of the glass, and the examination of the sample may then be proceeded with. This should be conducted (1) physically, (2) chemically, (3) microscopically. SECTION L— PHYSICAL EXAMINATION OF THE URINE. Attention should be paid to the following points : (rt) Quantity, (6) colour, (c) consistence, {d) odour, (e) density, (/) naked-eye characters of the deposit. 1. Quantity. The amount of urine passed 268 The Urine. during the day should be measured separately from that passed during the night. The sum of the two gives the total for twenty-four hours. The bladder should be emptied at a fixed hour — say 8.30 a.m., and the product discarded. All the urine passed during the day is carefully collected, and the bladder emptied again at 8.30 p.m., the product being added to the day's secretion. This is the amount of the '■'■day urine.'''' The bladder is again emptied at 8.30 next morning, and the product added to that which has been passed during the night. The total quantity is the " night firiiie." This added to the day urine gives the total for twenty-four hours. It is often difficult to collect all the urine that is passed, some being lost with the motions. This is especially the case with children, female patients, and those who pass their evacuations involuntarily. Where great accuracy is required, recourse must be had to the catheter. A healthy adult male passes on an average 50 ozs. (1450 cc.) of urine in twenty-four hours ; women a few ounces less. The existing tables which represent the amount of urine secreted by children are by no means trustworthy, the quantities being probably too high. The following may be taken as representing approxi- mately the average secretion at various ages. It is constructed from data furnished to us by Dr. Still as the result of his observations at the Hospital for Sick Children, London. Below two years of age Between two and three years . . . „ three and four ., „ four and five ,, At six years ,, eight years ... „ twelve ,, ... 4- -6 ozs. daily. 6- -8 8- -9 , 9- -10 12 16 20 Quantity. 269 Above this the quantity gradually approximates to the adult standard. The most noteworthy point about these figures is the comparative smallness of the amount of urine secreted by children. One may say roughly that between the ages of two and twelve the number of ounces of urine passed per day is equal to twice the age of the child in years. Normally, very much more urine is secreted during the day than during the night. The normal proportion of day urine to night urine is :: 100 : 25-60. Approximation of the night quantity to that of the day is always abnormal, and is especi- ally apt to occur in chronic renal disease, of which, indeed, it may constitute one of the earliest signs. Thus the proportion of day to night urine may become :: 100: 100 or even 200. The solids are increased in proportion to the water. An increased secretion of urine occurs physiologi- cally after increased consumption of food or drink, and after exposure to cold. Conversely, one finds the secretion diminished when little food or drink has been taken, and after exposure to heat — especially if followed by sweating. A i^atkological increase in the urine occurs in diseases associated with an increased arterial pressure — e.g. granular kidneys — also in both forms of diabetes, during the absorption of exudates and in some neurotic conditions — e.g. hysteria. Abnormal diminu- tion of urine is found where the arterial pressure is lowered or the intravenous pressure in the kidney increased — e.g. in advanced mitral disease; also in all fevers and in cerebral irritation — e.g. concussion. (&) Colour of the urine. Normal urine is said to have the colour of amber or pale sherry. The exact tint fluctuates widely even in health, depending upon the degree of dilution and upon the reaction. An acid urine is always 270 The Urine. darker than one which is alkahne, even when they are equally concentrated. The nature of the pigment to which normal urine owes its colour is not fully understood. It is not urobilin, that pigment only occurring in very small quantity in the urine under normal conditions. In febrile and some other diseases, however, a large quantity of urobilin may appear in the urine. The latter has then a warm orange colour, and usually shows a dull pink tint at the apex of a conical glass. If examined spectroscopically in a thin layer the urobilin band will be seen in the green between h and F (Fig. 80). Such a urine is often dichroic — E h GREEN Fig. 80. 1, Spectrara of Urobilin. 2, Spectrmn of Urobilin masked by other pigments. looking red by transmitted and green by reflected light. The presence of excess of urobilin may be con- firmed by rendering the urine strongly alkaline with ammonia, filtering, and adding to the filtrate a few drops of a 10 per cent, solution of chloride of zinc. If excess of urobilin is present, the solution becomes fluorescent. The following are the chief varieties of alteration in colour of the urine, with their causes : — Colour. 271 Pallor. — This is present whenever a large excess of urine is being secreted. It may also occur from an absolute diminution in the amount of urinary- pigment. This is the case in diabetes ; a diabetic urine is pale even when concentrated. Orange-coloured or reddish brown. — After the administration of rhubarb, senna and chrysophanic acid. Distinguished from blood by the fact that addition of a mineral acid causes the urine to become yellow, while an alkali turns it dark red. Some bilious urines are also of an orange tint (p. 31 9). Dark hrown. — This may be due to methsemo- globin, which is found in haemorrhage into the kidneys, and in paroxysmal hsemoglobinuria. The spectroscope shows a band in the red in addition to two bands very near those of oxyhaemoglobin (p. 207). Red. — From blood (see p. 304). Port wine coloured. — Due to the presence of hsematoporphyrin (see p. 306). Broivnish black. — This maybe due to the presence of melanin, which is sometimes excreted in the urine in cases of extensive melanotic sarcoma wherever situated. Such a urine usually darkens on standing, and may even become quite black. It does not reduce cupric oxide in alkaline solution. On addition of ferric chloride the urine yields a brownish turbidity, or even a black precipitate which is soluble in excess. Greenish black. — From the presence of aromatic compounds (hydroquinone, etc.) after the administra- tion of carbolic acid, guaiacol, salol, resorcin, naphtha- line, etc. Greenish or yellowish green. — From the presence of bile (see p. 319). The adminivstration of santonin is also followed by a yellowish green colour, but on adding an alkali the urine becomes dark red. Yellowish and milky. — From the presence of pus 272 The Urine. (see p. 322) or of fat. The fat may form an emulsion as in chyluria, or it may be present in the form of droplets which float on the surface of the urine (lipuria); the latter condition sometimes occurs in advanced fatty disease of the kidney. The presence of fat in the urine can always be shown by the addition of a little caustic soda and ether. On shaking up the mixture the fat is dissolved out, and is left behind on evaporation of the ether. Bluish or greenish blue. — This occurs when the urine contains a large excess of indigo- forming substances — e.g. in some cases of typhus. It is especially seen after putrefaction has occurred. The urine may be opalescent from the presence of various substances in suspension. If the opalescence persists after filtration, it is due to the presence of bacteria. A slight opalescence which causes the urine to look smoky is produced by the presence of small quantities of blood (see p. 304). Alcaptonuria. — This is a condition in which the urine is natural-looking when passed, but when exposed to the air it becomes gradually darker from the surface downwards ; ultimately it may be dark brown or black. It is due to the presence in the urine of dioxyphenyl acetic acid. It may occur spontaneously in quite healthy persons. The addition of an alkali causes the urine to become dark at once. Such urines reduce alkaline solution of cupric oxide. Urines containing melanin also become darker on exposure to the air owing to oxidation of the pigment, but they do not reduce cupric oxide. Carbolic acid urine also becomes darker on exposure to air owing to the oxidation of the hydro- quinone which it contains into pigments not yet fully investigated. CONSJSTEXCE AND OdOUR. 273 In alkcaline urines an iriclesceiit pellicle frequently appears on the surface. When the urine has cooled this can be skimmed off like a thin brittle film. It is composed of phosphate of lime. The idea formerly entertained that such a pellicle occurs especially in the urine of pregnancy is groundless. (c) Consistence of urine. — In health the urine is quite watery in consistence. If much sugar or bile is present it is less mobile, and in the presence of bile or of much albumin the froth which forms on shaking is more persistent than is usual. Alkaline urine containing pus may be quite ropy. A special alteration in consistence occurs in the condition known as Fibrinuria. When this is present the urine is reddish yellow when passed, but soon sets into a jelly which contracts somewhat on standing. If only little fibrin is present the whole urine may not coagulate, but a sticky sediment forms at the bottom of the vessel. Fibrinuria is due to the entrance of blood plasma into the urinary tract. It occurs as a very rare symptom of villous growth in the bladder, and sometimes also after the administration of cantharides. The fibrin may be recognised as such by washing it and then placing in 1 per cent. HCl. It swells up, but is not dissolved unless pepsin be also added. {d) Odour. — N^ormal urine has a characteristic " aromatic " odour. When the urine has stood for some time the odour becomes ammoniacal. In cases where there is an abnormal communication between some part of the urinary tract and the intestine the odour may become f secal. In acetonuria the odour is fruity. After the administration of turpentine the urine has an odour like violets. Cubebs, santonin, and some other drugs also impart to it their peculiar smells. In diabetes the odour has been compared to that of new-mown hay. s 274 The Urine. {e) Density. — Clinically the specific gravity of urine is always taken with the instrument known as a iiriiionieter. An ordinary urinometer is graduated for a temperature of 15° C, and will record variations in specific gravity from 1000 up to 1060. How to use the urinometer.— The urine should be allowed to cool, and sliould be placed in a tall jar, wide enough to allow the urinometer to float freely without touching the sides. All bubbles must be removed ,from the surface by means of bibulous paper. The urinometer should be wiped clean and placed floating in the centre of the jar. The eye is then placed level with the surface of the urine and the division of the scale to which the latter reaches read off". Care must be taken to read the level of the true surface of the urine, not the edge of the rim which heaps itself up around the shaft of the urinometer. If only a small specimen of the urine is obtainable it may be necessary either to use "specific gravity beads," or else to add water to it in order to get enough fluid to float the urinometer. The specific gravity found is then multiplied by the necessary figure according to the degree of dilution. Normal urine has a specific gravity varying from 1015 to 1025. In children it is usually somewhat higher than in adults. If very concentrated the specific gravity may rise to 1035 even in health. In normal urine the specific gravity is in direct proportion to the amount of urea present. An abundant urine of loiv specific gravity is suggestive either of diabetes insipidus, or of chronic renal disease. An abundant urine of high specific gravity is characteristic of diabetes mellitus. In the latter condition the specific gravity may reach 1075 ; in most cases, however, it is between 1040 and 1045. In diabetes insipidus, on the other hand, the Characters of Deposit. 275 specific gravity may fall to nearly that of distilled water. The presence of albumin in the urine does, not materially affect its specific gravity. It should also be borne in mind that the urinometer is entirely unaffected by the presence of merely suspended substances. Esfiiiiatioii of tlic aiiioiiiit of solids.— This may be roughly done by multiplying the last two fi^gures of the specific gravity by 2*33. The result is the number of grammes of solids in 1 litre of the urine, or the number of grains of solids in 1,000 fluid grains of urine ; e.g. if the specific gravity of a urine is 1020, it contains 20 x 2*33 = 46-6 grammes of solids in every litre, or 4-6 percent. This multiplied by 4*375 gives grains per ounce — in this case 20*1. The average daily output of solids in the urine is about 60-70 grammes (2-2| oz.). The above mode of calculation is not applicable to urine containing abnormal ingredients, e.g. sugar or albumin. (/) ]\al£ed-eye characters of the deposit. — When normal urine has stood for some time there appears in it a deposit of " iniiciis." This forms a woolly -looking cloud which usually settles to the bottom of the glass, but, if the urine be of high specific gravity, may be in the middle of the glass or even at the top. It should be mentioned that this substance probably does not consist of true mucin. It has been described as a nucleo-albumin. This, however, is by no means certain, as the body has not been investigated with regard to the presence or absence of the different essential characters of the nucleo-albumin group. If traces of blood are present in the urine the cloud of " mucus " has often a brownish tint. The normal urinary ingredients which may sepa- rate out in the form of a deposit, visible to the 276 The Urine. naked eye, are — earthy phosphates, urates and free uric acid. Phosphates. — The phosphates of calcium and magnesium separate out if the urine is neutral or alkaline. They form a colourless deposit. It can be recognised by the fact that if a little of it be trans- ferred by a pipette to a test tube, and some dilute acetic acid added, the deposit dissolves. A deposit of pus is apt to be mistaken for one of phosphates. They may be distinguished b}^ moving the glass gently from side to side. It will then be found that a deposit of phosphates is more flocculent and less compact than one of pus, and the surface layers of it are easily detached on shaking, and float up ; this does not happen in the case of pus. Acetic acid also does not dissolve pus, while the addition of caustic alkali renders it ropy. If the urine be acid, however, and its reaction has not been tested, a deposit of pus cannot be distinguished with the naked eye from a deposit of phosphates. It should also be borne in mind that deposits of phosphates and pus often occur together. Urates. — The quadri-urates of sodium, potassium, and ammonium may form a deposit if the urine be concentrated or highly acid. They may appear, even in health, when the urine cools. Owing to their ajQBlnity for the urinary pigments the deposit is usually coloured, being commonly red, or like terra-cotta, form- ing what is known as the "torick- dust" deposit. If the urinary pigment be scanty, however, the deposit may be merely yellowish, or even colourless. Deposits of quadri-urates can alw^ays be recognised by the fact that they disappear rapidly on heating the urine. The heating ought to be accomplished gradually, because the urine might also contain albumin, which, if the urine were rapidly heated, might be coagulated before the deposit of urates had all had time to clear up, and thus confusion might arise. Acetic acid does Characters of Deposit. 277 not dissolve a deposit of urates. On the other hand strong mineral acids, such as nitric acid, dissolve the deposit at once with the production of effervescence. Acid urate of soda, is a rare deposit. It occurs in acid urines. It forms a yellowish, granular, sandy-looking sediment. It does not dissolve readily on heating. Acid iii'ate of auiiiioitia forms a very similar deposit, but it occurs in ammoniacal urines, and is therefore mixed up with a deposit of phosphates. Uric acid. — This may form a scanty deposit visible to the naked eye. The deposit occurs in the form of crystalline grains of a darkish brown colour, and is therefore known as the " cayeime-pepper deposit." When in doubt use the microscope. The sulphates practically never form urinary deposits. Oxalates do, but the deposit is always scanty, mixed up with the cloud of mucus, and not easy to recognise with the naked eye. We have already spoken of the occurrence of fibrin, and the other abnormal ingredients which may be deposited will be described in the section on the microscopical examination of the urine. We would warn the reader against the common mistake of supposing that a substance is necessarily being excreted in excess when it appears in the urine in the form of a deposit. This, of course, is not necessarily the case at all. Thus the occurrence of a " cayenne-pepper " deposit does not necessarily mean that the patient is excreting an excess of uric acid. It may merely be due to the fact that the conditions which normally cause the uric acid to be in solution have become modified. The urine may be abnormally acid, for example, or it may be deficient in colouring matter or in salts, all of which conditions tend to lessen the solubility of uric acid, and to favour its deposition in the form of crystals. Similarly in the 278 The Urine. case of a deposit of phosphates. That does not mean that more phosphoric acid is being ehminated, it merely indicates that the urine has become alkaline. SECTION II.— CHEMICAL EXAMINATION OF THE URINE. 1. Reaction. — This is taken with litmus paper. The urine is usually acid in reaction. This is not due to the presence of free acid, but to acid salts — chiefly the acid phosphate of sodium (NaHoPO^). Sometimes the reaction is blue to red litmus paper, and red to blue litmus paper. This amphoteric re- action is due to the presence of large quantities of the disodic phosphate (NaoHPO^) in addition to the acid salt. It has no clinical significance. The urine may be normally alkaline after meals. This is some- times known as the " alkaline tide^ It reaches its acme three hours after the taking of a meal. It is chiefly due to the disodic phosphate replacing the acid salt. Alkalinity of the urine may be due to ammonia. This can be detected by its smell, also by the fact that if the red litmus paper which has been turned blue be heated, the red colour is restored, owing to the ammonia being driven off. The degree of acidity of the urine cannot be measured by direct titration with a standard alkaline solution in the usual way, for the reason that none of the phosphates of sodium react neutral to tlie usual indicators. To those who might wish to make tJie estimation the method of Haussmann^ may be recom- mended, but it is too complicated for general use. In any case the exact quantitative estimation of the acidity of the urine is of no clinical service. For ordinary purposes, the intensity of the red colour produced in litmus paper is a sufficient indication of the degree of acidity. * " Verhand. d, 14ten Cong. f. inn. Med." Wiesbaden, 1896. Chlorides. 279 2. Exaiiiiiiatioii of the urine for its nor- mal non-nitrog^enous constituents. (1) Chlorides. — Chloride of sodium is the chief inorganic constituent of normal urine. Small quanti- ties of the potassium salt also occur. Qualitative test for their preseiice. — Filter the urine if not already clear. If albumin is present remove it by boiling. Add to ^ an inch of the urine in a test tube a few drops of nitric acid (be sure that the acid used is quite pure and free from HCl), and then as much of a 3 per cent, solution of nitrate of silver as there is of urine. If the normal amount of chlorides is present an abundant curdy jDrecipitate appears at once. If the chlorides are diminished, the solution merely becomes milky. If a mere trace of them is present, the solution is opalescent, and if they are altogether absent it remains quite clear. The use of the nitric acid is to prevent the precipi- tation of phosphate of silver. Quantitative estimation. — For ordinary clinical use ]?Iohr's method is to be recommended. One pro- ceeds as follows : — Place 10 cc. of the urine, freed if necessary from albumin, in a beaker, and mixed with 50 cc. of distilled water. Add three drops of a solution of neutral chromate of jDotassium (1 in 20) and a pinch of calcium carbonate. The use of the latter is to neutralise any free acid that may be present. Fill a burette with standard solution of nitrate of silver (Appendix, 9). Run the silver solution into the beaker, stirring all the time. A precipitate of chloride of silver falls out. Whenever the least trace of a pink colour appears stop. This can be best appre- ciated by allowing the precipitate to settle, which it very quickly does. If the sediment is in the least flesh-coloured, enough silver solution has been added. The appearance of the pink colour indicates that the 2 8o The Urine. silver has united with all the chlorides present and has begun to form chromate of silver with the potas- sium chromate. Calculation. — Onecc. should be deducted from the total number of cc. of silver nitrate used. The reason for this is that there exists in urine, besides chlorides, other substances with which the silver unites more readily than it does with the chromate. Roughly, the deduction of 1 cc. is sufficient to allow for these. Every remaining cc. of the solution used is equivalent to 10 milligrammes of sodium chloride. Suppose 11 cc. to have been used in all, deducting 1 cc. there is left 10 cc. This is equivalent to 100 mg. sodium chloride, which will be the quantity of chlorides in the amount (10 cc.) of urine used. If 1,500 cc. was the amount of urine, in twenty-four hours it will contain 15 grammes of sodium chloride. For the accurate estimation of small quantities of chlorides in the urine the method of Volhai'd should be employed, but for a description of it special works must be consulted. About 12 grammes represents the average daily excretion of chlorides in health. The chief cause of physiological variation is the nature of the diet. Pathologically, chlorides are found to be diminished in all febrile affections with the exception of malaria. In the latter disease the chlorides are increased during the febrile period, diminished in the apyrexial in- tervals. In acute croupous pneumonia, the chlorides are more markedly diminished than in any other fever. They may indeed disappear entirely. We reojard their behaviour as of great diac^nostic value. In no other disease, except, perhaps, typhus and rheu- matic fevers, does such a notable diminution occur. In the diagnosis of pneumonia from empyema and pleurisy the test is of special help. The chlorides are increased after the crisis in pneumonia, the increase, however, Phospha tes. 281 not usually manifesting itself till the third day after fever has ceased, and also in cases where the rapid absorption of a large exudation is taking place. (2) Phosphates. — Phosphoric acid occurs in the urine in two chief forms of combination. Combined with potassium, sodium, and ammonium, it forms the alkaline phosphates ; with calcium and magnesium the earthy phosphates. Three-fourths of the total phos- phoric acid is combined with the alkalies and only one-fourth with the earths. The alkaline phosphates being readily soluble never form a deposit. The earthy phosphates are insoluble in an alkaline medium, hence they are precipitated when the urine loses its acid reaction. This precipitation is aided by the action of heat. The heat probably acts by driving off carbonic acid. Hence if a urine, the reaction of which is not acid, be heated, a cloud of earthy phos- phates may appear. This is distinguished from albu- min by its ready disappearance on a4ding a few drops of acetic acid. Qualitative tests for lyhosphoric acid in urine. — Place half an inch of clear urine in a test tube. Add a few drops of a solution of uranium acetate or nitrate and a little sodium acetate solution (Appendix, 11). A somewhat greenish precipitate which does not disappear on adding acetic acid indicates the presence of phosphates. Quantitative estimation. — Fill a burette with standard solution of uranium nitrate (Appendix, 10). Measure 50 cc. of the urine to be examined into a porcelain dish or a medium-sized beaker. (If the urine is very concentrated, 20 cc. of it will be sufficient.) Add to the urine 5 cc. of an acetic acid solution of acetate of soda (Appendix, 11). If only 20 cc. urine were taken, add 2 cc. of the solution. Place on a Avhite porcelain slab about a dozen drops of a 10 per cent, solution of ferrocyanide of potash. Each 282 The Urine. drop should be about the size of a sixpence. They should be deposited in regular rows a short distance apart. Heat the urine on a water bath. If the latter is not obtainable use a tripod covered with wire gauze. The urine should be heated to a temperature just short of boiling. When heated, run in the uranium solution, stirring all the while. As a rule, 16 cc. may be run in right away. A precipitate of uranium phosphate falls down. Take out a small drop of the mixture with a glass rod and place it just touching one of the drops of ferrocyanide. If the least brown colour appears at the point of junction of the drops do not run in any more uranium solution, but heat the urine up again to just short of boiling, and try another drop. If still a faint brown tint appears, enough uranium solution has been added. The brown colour indicates that all the phosphoric acid present has united with the uranium, and the latter is beginning to form uranyl ferrocyanide. If the colour is dark brown, too much uranium has been added. One must then add 5 cc. more urine to the mixture, heat up, and cautiously run in more uranium solution. If no brown tint has appeared after run- ning in 16 cc. of the uranium, one must add more of it, but slowl}^, and not more than half a cc. at once, testing a small drop after each addition till the faint brown tint appears. If the urine has cooled at all while one is adding the uranium, never omit to heat it up again before deciding that the brown tint is really present. It is only at a temperature just short of boiling that all the phosphoric acid can be made to unite with the uranium. The use of the acetate of soda in the above process is to unite with the nitric acid liberated by the union of the uranium with the phosphoric acid. Calculation. — Suppose 20 cc. uranium solution has been required. The solution was made of such Sulphates. 283 a strength that each cc. = 5 milligrammes plios- j)horic anhydride ; 20 cc. are therefore equivalent to 0*1 gramne PoO-, and that is the amount in 50 cc. urine. If the patient is passing 1,500 cc. urine in twenty-four hours, his daily excretion of PoO^ will be 3 grms. Normally, 2-3 grms. of phosphoric anhydride are excreted daily. Physiological variations depend chiefly upon the food. The phosphates are often considerably diminished in renal disease, but not, apparently, out of proportion to the other solids of the urine. They are said to be increased in wasting diseases of the nervous system. Their behaviour in fever is inconstant. (3) Sulphates. — Sulphuric acid occurs in the urine in combination with sodium and potassium (inorganic sulphates), and with cresol, phenol, indol, skatol, pyrocatechin, etc. (organic sulphates). The former are ten times more abundant than the latter. Test for inorganic sulphates. — Add to 10 cc. urine a few drops of hydrochloric acid and one-third of its volume of 10 per cent, barium chloride solution. If the normal amount of sulphates is present, an opaque milkiness develops. If the precipitate is thick and creamy, the sulphates are in excess ; if a mere opalescence appears, they are diminished. About 2|^ grms. of sulphuric acid (SOg) are excreted daily. The exact determination of the total sulphates, and of the proportion of inorganic to organic, is a gravimetric process unsuited for ordinary clinical work. An approximate notion, however, of the proportion of organic sulphates present may be obtained by the following procedure : Add to the urine an equal volume of alkaline barium chloride solution (two parts of baryta water to one part of barium chloride 284 The Urine. solution). This precipitates the inorganic sulphates along with phosphates. Filter. Render the filtrate pretty strongly acid Avith hydrochloric acid, and heat almost to boiling. The organic sulphates are thus decomposed and thrown down in the inorganic form. Normally they should form merely a white cloud. If the precipitate is at all dense, the proportion of organic sulphate is in excess. The total sulphates are increased by an increase in the diet, and in fever. The amount of sulphuric acid excreted in organic combination is increased when a larger quantity than usual of the aromatic substances with which it is combined enters the circulation. This occurs when phenol and allied substances are given as drugs, or when the production of such substances in the body is increased, as it is whenever putrefactive processes are going on. Thus the amount of organic sulphates is increased in cases where putrid abscesses have formed, or where there is retention of the intestinal contents. (4) Oxalates. — Oxalic acid occurs in the urine, combined with calcium. The salt is usually kept in solution by the acid phosphate of sodium present in the urine. It is found as a precipitate, however, in about one urine out of every three. This is due to the absence of a sufficient amount of the phosphate of soda to keep it in solution. It does not necessarily mean that the excretion of oxalic acid is increased, although it is true that the more oxalic acid there is present, the greater is the tendency for it to be precipitated. About 0"017 grm. is the average amount of oxalic acid excreted daily. It is prob- ably all derived from the food. It is increased after the taking of certain vegetables, especially cabbage, tomatoes, and rhiibarb. The so-called "oxaluria" seems to be merely a variety of acid dyspepsia. Nitrogen. 285 3. Examination of the urine for its normal nitrog^enous constituents. Of the total amount of nitrogen in the urine — 84-87% is in the form of urea ; 2-5% ,, ,, ammonia compounds ; 1- 3% ,, ,, uric acid ; 7-10% „ „ "extractives" (including xanthin bases). Estimation of total nitrogen hy KjeldahVs method (modified). — Measure out 5 cc. of urine with a pipette and place it in a Kjeldahl's flask of about 150 cc. capacity, add to it 15 cc. of pure sulphuric acid and a crystal of pure sulphate of copper about the size of a split pea ; heat on net till the mixture is colourless or pale green ; this takes about half an hour or less ; violent boiling should be avoided. Allow to cool, then dilute with 50 cc. of distilled water, again allow to cool, transfer to a distillation flask of about 7uO cc. capacity, and add enough 23% solution of caus- tic soda to render the mixture almost neutral ; add also a pinch of talc to prevent bumping. When cool add more soda (till the fluid is deep blue in colour), and close at once with the stopper connected to the con- densing tube of the distillation apparatus ; measure into a flask 150 cc. of a decinormal solution of oxalic acid, and let the lower end of the condensing tube just dip below the surface of this solution, then boil the blue fluid. The nitrogen passes off' in the form of ammonia and is fixed by the oxalic acid. When the fluid which drops from the condenser has no longer an alkaline reaction, stop the process by removing the stopper from the flask. Care must be taken that at the end no alkali comes over from the flask contain- ing the strongly alkaline fluid, as is rather apt to occur should there be bumping. Titrate the 100 cc. of decinormal oxalic acid with a decinormal soda 286 The Urine. solution. Every cc. of soda less than a hundred used represents "0014 grm. of nitrogen. Example. — Suppose that on titrating the oxalic acid solution with decinormal soda the neutral point is reached when 60 cc. of the latter have been added, the remaining 40 cc. of the decinormal oxalic taken must therefore have been neutralised by tlie ammonia derived from the nitrogen in the 5 cc. of urine, there- fore the 5 cc. of urine contain '0014x40 grms. nitrogen, or -056 grm. If the total amount of urine passed in 24 hours be 1500 cc, this will contain 16 "8 grms. of nitrogen. About 15 '20 grms. of nitrogen are excreted daily in the urine of a healthy adult on ordinary diet. A knowledge of the quantity excreted in disease is not of much value unless one has some idea of the amount of nitrogen in the diet. It must be remembered also that normally 1-2 grms. of nitrogen appear in the faeces. Urea (Co(NH2)o). Qualitative test for. — Place a drop or two of the suspected fluid on a slide and add one drop of nitric acid, warm gently. On evaporation rhombic or hexagonal crystals of ni- trate of urea will be found if the latter body is present. (Fig. 81). _ Quantitative Estima- Pig. 81. — Urea nitrate. tlOTl. 1. From the sj^ecijic gravity. — An approximate estimation of the amount of urea may be made by dividing the last two figures of the specific gravity by 10 — e.g. if the specific gravity of a given urine be 1020 it contains (approximately) 2^ of urea, this only holds good in the absence of sugar, or much albumin, and if the patient be not very feverish. Urea. 287 2. From the amount of nitrogen given off on treating the urine ivith hyjjohromite of soda. This method depends upon the fact that urea is decomposed by hypobromite of soda according to the following equation — CO(NH,)o + 3NaBrO =: 3NaBr + No + 2HoO + COo. It is" found that under ordinary conditions 1 gramme of urea yields 371 cc. of nitrogen ; all that is necessary, therefore, is to remove the CO^ by means of an alkali (caustic soda), and to measure the remaining volume of gas and to calculate from it the amount of urea which was contained in the quantity of urine taken. The various forms of apparatus employed in carrying out the process differ chiefly in the method adopted for catching and measuring the nitrogen given ofif. One of the earliest and simplest consists in receiving the gas in an ordinary burette inverted in a large jar of water. The number of cc. of nitrogen given off multiplied by 056 = grms. of urea in 100 cc. urine, i.e. the percentage, and this multiplied by 4-375 = grains of urea in 1 oz. of urine. More commonly nowadays one makes use of one or other of the following special forms of apparatus : — (1) GerrardJs ureometer (Fig. 82). — This consists of a graduated glass cylinder closed at its upper end by a rubber stopper. Through the stopper there passes a T tube. One limb of this tube is closed by a clip or stopcock, the other is connected to a piece of rubber tubing. The other end of the rubber tubing terminates in a piece of glass tube, which is inserted into the rubber stopper of a wide-mouthed flask of about 6 oz. capacity. From the lower end of the graduated C5dinder another rubber tube passes to a short wide glass tube open at its upper end. The object of this tube is to act as a reservoir of water. It can be slipped up and down upon the cylinder by means of a metal ring. 288 The Urine. How to use the aiofaratus. — Place in the glass flask 25 cc. of hypobromite solution (Appendix, 12). An excess of hypobromite does no harm — one must merely be sure that enough is taken Fisf. 82. — Genard's ureometer. to decompose all the urea likely to be found in the urine. Measure 5 cc. of urine into the small glass tube provided for the purpose. If the urine contains albumin, the latter must be first removed. This is best done by taking a definite quantity of Urea. 289 urine — say, 50 cc— adding to it a drop or two of acetic acid, and boiling for a couple of minutes. Filter and make up to its original volume. The small tube containing the urine must now be lowei'ed into the flask. This is best done b}^ inserting the point of the little finger — not too tightly — into the mouth of the tube. The latter must then be propped up against the inner surface of the flask so as to prevent the hypobromite solution from mixing with the urine. The reservoir of the graduated cylinder must now be filled M'ith water. The stopper is then tightly inserted into the mouth of the flask. The clip or stopcock must now be opened, and the reservoir raised until the water inside the cylinder stands at the zero mark, and is level with that in the reservoir. The water must also be very low down in the latter, else there will be an overflow subsequently. Now close the stopcock and gently tilt the flask so as to allow the urine and hypobromite solution to mix. Great eflfervescence ensues, and the nitrogen liberated enters the cylinder and drives water out of it up into the reservoir. Wait for ten minutes to allow coolins; to take place. Then lower the reservoir until the water in it and the cylinder are again level, and read off the amount of gas in the latter. The cylinder is graduated in percentages of urea. To get the number of grains per ounce, multiply this by 4*375. In normal urine only 92 per cent, of the nitrogen of the urea is given off. If sugar be present, the yield is for some reason much larger, amounting to about 99 per cent. In Gerrard's instrument the scale is constructed for normal urine. In cases of diabetes, therefore, it is necessary to correct one's result by multiplying the flgure obtained by ff, i.e. by 0-93. (2) Ureometer of Dor emus. This is a very simple and cheap form of apparatus, devised by Dr. Chas. Doremus of New York, Modi- T 290 The Urine. fications of it are sold by Southall (Birmingham) and Cooper (London), It consists of a bent tube with a long limb closed at its upper end, and a short limb which expands into a wide bulb with an open mouth. In using the instrument it must first be filled with hypobromite solution. Hold the tube vertically, and pour in the solution just short of overflowing. Then gently incline the instrument so that the solu- tion fills the long limb as far as the mark near the bend, and no air bubbles are present. A little water should then be added to fill the rest of the bend and the lower part of the bulb. The instrument may now be fixed in its stand. One cc. of urine has next to be measured out with the pipette provided. This is where the difficulty in using the instrument comes in. In order to accom- plish it successfully, proceed as follows : — Slip the rubber nipple high up upon the pipette. Compress the nipple, and immerse the point of the pipette just below the surface of the urine. Then allow the nipple to expand fully. Urine will be drawn up beyond the mark. Now slide the nipple bodily down with the finger and thumb over the rimmed end of the pipette. This displaces the urine. Continue the displacement till the mark is reached. The pipette will now keep itself charged with exactly 1 cc. of urine. Wipe the outer surface of the pipette, and insinuate the end of it as far as it will go into the long limb of the apparatus. Now compress the nipple so as to squeeze out all the urine, and then withdraw the pipette, keeping up the compression until it is out of the liquid. In about a quarter of an hour the amount of nitrogen which has collected in the long limb may be read off". The instrument is provided with an English scale representing grains per ounce, and also with a metrical scale. The large divisions on the Uric Acid. 291 latter represent centigrams of urea per cc. of urine. The scale between is subdivided into tenths. Suppose the reading to be *025. This means -025 grm. of urea in 1 cc. of urine, and, multiplying by 100, = 2-5 per cent. If more than 3 per cent, of urea is present, the urine should be diluted with an equal volume of water, and the result multiplied by 2. Albumin, if present, should always be removed beforehand. About 450 grains (25-40 grms.) of urea are excreted daily in health. This is about 2 per cent., or 9 grains per ounce. It is increased when much food or water is taken. Also in fevers, in diabetes, and in poisoning by phosphorus or arsenic. It diminishes under diminished diet, in some severe diseases of the liver (because less is formed), and in some conditions of the kidney. ITric acid (C-H.N-O..) occurs in the urine in combination with alkalies. Being a dibasic acid, it forms two classes of salts, the normal urates (XaoU), and the acid urates (NaHU). In addition, it seems to form a third kind of combination in which one molecule of acid urate is united to one of uric acid, constituting what ma\' be called a quadri-urate (NaHUHoU). According to some observers, it is the latter form of combination which occurs in normal urine, and which is sometimes precipitated in the form of the common " brick dust '' deposit of urates or "lithates." Under certain conditions uric acid becomes free in the urine, and separates out as a crystalline deposit ("cayenne-pepper'"' deposit). Acid urates may also separate out in a crystalKne form. Both forms of separation, when occurring inside the urinary passages, lead to the disease known as "gravel ' or to stone fonnation. The microscopic characters of these deposits will be described in another section. The conditions which favour the separation of uric acid and acid urates are (1) the presence of a large 292 The Urine. amount of uric acid in the urine ; (2) a high degree of acidity ; (3) the presence of little salts, and of a small amount of pigment. Qualitative test for uric acid (murexide test). — Evaporate the suspected fluid to a small bulk. Place five drops of it in a porcelain basin, and add one drop of nitric acid. Evaporate very slowly, avoid- ing charring. When almost dry, add to the orange- coloured residue a small drop of ammonia. A pur- plish or rosy red colour appears at the edge of the drop, often better seen after gently heating. The action which takes place consists in the oxidation of the uric acid into alloxantine (CgHgN^Og) — the orange- coloured residue. On adding ammonia, purpurate of ammonia is formed (JSTHj^CgH^JSTgOg), and produces the purplish red colour. Quantitative estir)iation. — For clinical purposes this is best accomplished by the method proposed by Hopkins. It is based upon the insolubility of acid urate of ammonia in a saturated solution of ammonium chloride. By saturating a given quantity of urine with chloride of ammonium, all the uric acid separates out as acid urate of anmionium, which is collected ; the uric acid is then split off from it, and estimated either by weighing or by titration with permanganate of potash. Proceed as follows : — (1) Saturate 100 cc. of urine with powdered ammonium chloride. About 30 grms. will be re- quired. Saturation is complete whenever a few crystals remain undissolved after vigorous stirring at short intervals. Even if these should redissolve as the temperature of the mixture risps again after its initial depression, it does not matter. (2) Render alkaline by adding a little ammonia. (3) After standing for ten minutes, filter and wash precipitate several times with saturated solu- tion of ammonium suljohate. Uric Acid. 293 (4) Wash precipitate off filter with a jet of hot water, add a pinch of carbonate of soda, and heat till precipitate dissolves. (5) Add distilled water to 100 cc. (6) Add 20 cc. strong sulj^huric acid. (7) While hot, titrate with a J^ normal solution of potass, permanganate — i.e. 1"578 grm. per litre. (8) Stop whenever a j^ink colour lasting a few seconds has appeared. Subsequent disappearance of the colour is to be disregarded ; it is sufficient that it should be visible for a second or two after stirring. (9) Every cc. of the permanganate used =: '00375 grm, of uric acid. The presence of bile pigment interferes with the titration with permanganate. In that case the uric acid must be estimated by weighing, and for the details of the method we must refer the reader to the original paper.* The trouble in the above method is the washing with ammonium sulphate. This must be continued till all ammonium chloride is removed, but the solution is so dense that it passes very slowly through the filter paper. To obviate this difficulty^ Hopkins has described an abbreviation of the pro- cess which is accurate enough for clinical purposes. It is as follow^s : — (1) Saturate 20 cc. of urine with chloride of ammonium, and add ammonia, as above. (2) Place a plug of glass wool in the neck of a small funnel, and Avash it by filtering through it some saturated ammonium sulphate solution. (3) After the saturated urine has stood for ten minutes, filter it through the glass wool. (A little experience is necessary to enable one to pack the glass w^ool firmly enough to keep back the pre- cipitate, but yet not so tightly as to render filtration very slow.) * Journal of Pathology and Bacteriology, June, 1893. 294 The Urine. (4) Wash the precipitate with saturated sulphate of ammonium till no more chloride comes away. (5) Transfer plug and precipitate bodily to a flask. Add 20 cc. water and a small pinch of carbonate of soda. Heat till the urate dissolves. Cool under the tap, and add 4 cc. of strong sulphuric acid. (6) Titrate with J^j normal permanganate solution, as above. (This is best made by diluting some of the strong solution from time to time.) (7) Every cc. of the permanganate used = 0-0015 grm. uric acid. The presence of albumin does not affect these methods. If there be a deposit of uric acid or urates in the sample of urine, the whole should be thoroughly shaken up, the amount to be operated with measured off", and saturated as usual. Or a few drops of ammonia may be added and the urine warmed till the deposit dissolves. A deposit of phosphates may be neglected. From 0-4 to 0.7 grm. (7-10 grains) of uric acid is excreted daily. The amount is increased whenever a large destruction of nuclein is going on ; thus in leucocythsemia as much as 4 grms. may be excreted daily. It is also increased in acute fevers. It is diminished in chronic gout and after the administra- tion of quinine. We would again warn the reader against the common error of assuming that a deposit of urates or uric acid necessarily indicates an increased excretion of the latter. Xantliin bases. — Amongst the chief products of the disintegration of nuclein are uric acid and some basic bodies which may be termed the "nuclein" or xanthin bases. These substances differ from uric acid in being pretty strongly basic. Xanthin is the chief member of the group. It has the formula o X A NTH IN Bases. 295 CjH^N^Oo — i.e. one atom of oxygen less than in uric acid. The other members are hypoxanthin or sarkin (C-H^N^O), guanin (C5H5N-O), and adenin (C-H5N5-I-3H0O). These bases are sometimes spoken of along with uric acid under the term "alloxur bodies.' These alloxur bodies contain between them from 1-5 per cent, of the total nitrogen in the urine. A method has been de.scribed for estimating them,"^ but it is not adapted for ordin- ary clinical use, nor has its accuracy ))een fully established. The results Avhich it has yielded show that the amount of nitrogen eliminated in the form of uric acid is much more constant than that which appears in the form of xanthin bases. Usually a good deal more of the former is eliminated than of the latter, but the proportions vary greatly even in health, and may at times even be reversed. The xanthin bases are increased just as uric acid is in conditions associated with increased destruction of nuclein — e.g. in leucocyth^emia. A milk diet causes the bases to increase while the uric acid diminishes. There is no constancy in their behaviour in gout. The only other nitrogenous constituents of normal urine which call for mention are creatinin and hippuric acid. €r eat mill — C^H-NgO — is creatin minus water. It is one of the forms in which creatin is excreted, and most of it is derived from the creatin in flesh food. About 1 grm. of it is excreted daily. Variations are of no known clinical siofnificance. It is of some importance as being one of the constituents of normal urine, which is able to reduce cupric oxide. Hippuric acid — -CgHglSrO.. — occurs in the urine as hippurate of sodium. About ^ grm. of it is ex- creted daily. This amount is increased by the taking * Ztsch. f. Phys. Chemie, Bd. xx. Ki'iiger-TVulff. 296 The Urine. of benzoic acid as a drug, or of fruits — e.g. mulberries and cranberries — which contain aromatic acids. 4. Abnormal cliemical constituents of Mi'ine. I.— PROTEIDS. Any or all of the proteids of blood plasma — serum albumin, serum globulin, and fibrinogen — may occur in the urine. In addition, one meets with the compound proteids — mucin and nucleo- albumin, and with albumoses, both primary and secondary. It is doubtful whether true peptone ever occurs in the urine. It is true that two of these — mucin and nucleo-albumin — are to be regarded as normal urinary constituents, being added to the renal secretion as it passes along the urinary passages, but in health they are present in such small amount that they may be neglected. It is also true that any of the proteids mentioned above may occasionally find their way into the urine even in perfectly healthy persons. Into the possible causes of this, and into the distinction between " functional " and " organic " albuminurias, we do not propose to enter. Chemical examination of the urine can merely show the presence in the urine of a proteid ; it cannot tell us to what its presence is due. (1) ^erum albumin and serum g^lobulin in the urine. — These proteids may be found in the urine either together or separately. The former condition is the usual one, and constitutes what is ordinarily spoken of as "albuminuria." The relative proportion of each proteid varies greatly in different cases, but usually serum albumin is present in larger amount than serum globulin. The variations in their relative amounts have no clinical significance. In what follows the term " albumin " will be held to include also globulin, unless stated otherwise. Proteids in the Urine. 297 Tests for alhumin in the urine. — A great many reactions have been proposed for this purpose, and much has been written on the subject. The fact seems to be that while in the majority of cases the presence of albumin or globulin in the urine can be demonstrated with perfect certainty by the appli- cation of one or two simple tests, yet every now and then cases are met with in which some doubt exists. We believe that by carefully applying the four fol- lowing tests the presence of albumin and globulin can be cleaily shown even when present in very small amount. Before proceeding to apply any of the tests, it is a sine qud non that the urine should be ahso- lutely clear. It may therefore be necessary to filter it. If it be acid, this can be proceeded with at once ; should it be alkaline, enough acetic acid should first be added to render it faintly acid. It may be necessary to fi.lter more than once. Should the urine still not be clear, the turbidity is probably occasioned by the presence of bacteria. These can best be removed either by (1) simply shaking up the urine with powdered barium carbonate, and filtering, or (2) adding to the urine a little caustic soda till a pre- cipitate of earthy phosphates appears. This carries down with it all bacterial debris, and on filtering the urine will now be found to be clear. It should then be slightly acidified with acetic acid, and the following tests proceeded with : — 1. Boil an inch or so of the urine in a test tube. If it remains perfectly clear while the reaction is still acid, no albumin is present. Turbidity may be due to coagulated albumin or to the throwing down of earthy phosphates. Add a drop of nitric acid. Any turbidity which remains is due to the presence either of albumin or of nucleo- album in. 2. Heller^ s test. — Place a quarter of an inch of pure nitric acid in a test tube. With the aid of a 298 The Urine. pipette allow some of the urine to flow on to its surface. If after standing for half a minute no opaque white ring appears at the junction of the two fluids the urine may be regarded as free from albumin, for the test is capable of revealing the presence of •002 per cent. If a ring forms it may be due to albumin, nucleo-alljumin, or primary albumoses. A difluse haze at the upper part of the fluid may be due to mucin. In the case of albumoses the ring disappears on heating, and reappears on cooling. (The metliod of distino-uishino- nucleo-albumin and mucin will be considered later.) If the urine be very concentrated, nitrate of urea or acid urates may separate out, usually in the form of a cloud without sharp margins. This can at once be distinguished by the fact that previous dilution of the urine with twice its volume of normal salt solution prevents its appearance. The precipitate also disappears on heating, and shows small crystals on examination with the microscope. The presence of resinous bodies — e.g. balsams — in the urine may also cause the appearance of a white cloud, which, however, is at once dissolved on the addition to the urine of half its volume of alcohol (rectified spirit). It will often be noticed that a brownish red trans- parent ring appears at the junction of the nitric acid and the urine. It is due to the oxidation of the urinary indigogens and the production from them of pigments. It occurs, therefore, in urines which are rich in indigogens, and has, of course, nothing to do with albumin. Such urines will be more fully considered later. Eflfervescence on the addition of nitric acid may be due to decomposition of urea with the liberation of COc, and nitrogen. This only occurs if the nitric acid used contains some nitrous acid also. As a substitute for nitric acid in the above test, one can use', Spiegler^s s^ution, j It coilsists of — P ROTE IDS IN THE UrINE. 299 Perchloricle of mercury ... ... 4 parts Tartaric acid ... ... ... 2 ,, Glycerine ... ... ... 10 „ Water 100 „ It gives a distinct white ring if as little albumin as 1 in 350,000 is present. 3. Ferrocyanide of 'potash test. — Take 2 in. of urine in a test tube. Add 10 drops of a 5 per cent, solution of ferrocyanide of potash, and then render strongly acid witli acetic acid. If the urine remains clear, no albumin is present. Turbidity may be due to albumin, albumose, or nucleo-albumin. Albumose may be distinguished by the nitric acid test ; nucleo- albumin by the fact that it is precipitated by acetic acid alone without the aid of ferrocyanide. 4. Picric acid test.— iJJsQ a saturated solution of pure picric acid, without the addition of citric acid, as in Esbach's solution). Place 2 in. of the picric acid in a test tube. Allow the urine to drop into it from a pipette. If no cloud forms around the drops, the urine is albumin-free. A cloud may be due to albumin, albumoses, or peptone. The precipitate pro- duced by the higher albumoses and peptone disappears on heating. Quinine also gives a precipitate with picric acid which disappears on heating. It will be observed from what has been said above that it is comparatively easy to be sure of the absence of albumin — not so easy to be certain of its presence. The substance which is most apt to be mistaken for serum albumin in the urine is nucleo-albumin. We have already indicated some methods of distinguishing between the two, and shall return to the subject later when we consider " nucleo-albuminuria." Quantitative estimation of alhumin. — This can be done with sufficient accuracy for clinical purposes by means of Esbach's albuminimeter. The principle of the method consists in measuring the depth of the 300 The Urine. coagulum produced in the urine by the addition of picric acid. The instrument consists of a thick glass test tube, with graduations on it from up to 7. Method. — Filter the urine if not already clear, and if alkaline render slightly acid with acetic acid. If the specific gravity is 1010 or more, dilute the urine sufliciently to bring the density below that level (to 1008). This is important, and is often overlooked. Fill the tul)e with the urine up to the mark U. Pour in the reagent (Appendix, 13) up to the mark R. Close the tube with a rubber stopper, and gently invert it a few times to allow the fluids to mix. Set aside for twenty-four hours. At the end of that time read off the level of the surface of the pre- cipitate. The figures on the scale represent grammes of dried albumin per litre of urine. Divide by 10 to get the percentage, and multiply the result by 4-375 to get the amount of albumin in grains per ounce of urine. If the urine requires to be diluted, the result must, of course, be multiplied the requisite number of times. Yery small quantities of albumin cannot be esti- mated by Esbach's method, as the instrument does not record less than O'l per cent. If after the first trial the level of the precipitate is found to be above the mark 7, the urine must be diluted and a fresh estimation made. An excretion of 8 grms. of albumin daily represents an ordinary degree of albuminuria. This is equivalent to about ^ per cent. (2) Albiimosuria. — This is a more correct term than " peptonuria," which was formerly in use. It is very doubtful whether true peptone ever occurs in the urine at all. The clinical significance of the presence of albumoses in the urine is not yet finally determined. Recent investigations tend to show that they may occur in any " infective " disease — i.e. wherever dis- Proteids in the Urine. 301 integration of tissue is going on under the action of micro-organisms. Thus they are not uncommonly met with in the urine in pneumonia. They are most constant, however, in cases where a large collection of pus has formed in the body — e.g. in empyema or large abscess formation. They have also been found in considerable quantity in some cases of nephritis. The disease osteomalacia has long been stated to be accom- panied by the presence of albumoses in the urine. It is doubtful if the substance met with is really an albumose, and it is also doubtful whether the cases examined were all examples of true osteomalacia. Detection of alhunioses. — There are two classes of albumoses — primary and secondary — the latter stand- ing nearest to the peptones. From a clinical point of view the differentiation of the two is of no importance, but they differ somewhat in their chemical reactions, and this necessitates the application of different tests for their detection. We will assume first that the urine to be examined is free from albumin. Proceed as follows : — 1. Add to the urine (filtered and acidified if necessary) a few drops of a saturated solution of picric acid. A white cloud which disappears on heating indicates the presence of either albumoses or peptone. The presence of antipyrin, quinine, and certain resins in the urine is apt to give a similar reaction. 2. Apply Heller's test as already described (p. 297). A white cloud which disappears on heating and re- appears on cooling indicates the presence of primary albumoses. The cloud is situated towards the upper part of the tube — it does not form a sharp ring close to the nitric acid as is the case with albumin. The secondary albumoses do not give this reaction unless in the presence of an excess of salt. 3. Add to the urine an equal volume of a saturated 302 The Urine. solution of common salt, and then drop in acetic acid as long as a cloud forms. If this disappears on heat- ing and reappears on cooling albumoses are present. Both forms of albumose give this reaction. If the urine is already albuminous the albu- min should be removed before testing for albumose. To do this bring the urine to boiling point, add a drop or two of acetic acid, and boil for two minutes. Filter and test filtrate as above. The small quantity of albumose likely to be formed from the albumin during the boiling does not vitiate the result. If we wish to avoid the possibility of such a fallacy, we can add to the urine its own volume of 10 per cent, trichloracetic acid, rapidly bring to the boil, and filter hot. Test the filtrate, after cooling, for albumoses. If the presence of true peptone be suspected, the urine must be saturated while boiling with sulphate of ammonium and the filtrate tested for peptone by the ordinary reactions — the best being the occurrence of a white ring on pouring Spiegler's solution on to the surface of the liquid ; or, better, dialyse the urine for two hours and test the dialysate for peptone. No albumose passes through in that time. Very delicate reactions for the presence of albumoses and peptones in the urine have been described by Salkowski* and by Harris,! and may be referred to by those who are specially interested in the subject. We have had no personal experience of their use. (3) iVucleo-albiimmiiria and muciiiuria. — We have already mentioned that both a nucleo-albumin (or a substance very closely resembling one) and mucin occur normally in the urine, and it is probable that the so-called " mucus '- of the urine consists mainly of the former. In catarrhal conditions of the urinary passages, however, and esj^ecially of the bladder, an * Centralh.f. d. Med. Wissenschaften, No. 7, 1894. t American Journal of the Medical Sciences, May, 1896. Proteids in the Urine. 303 excess of true mucus may appear in the urine, and to this the term "iiiiiciiiiiria" has been applied. As long as the urine is acid mucin is insoluble and forms a deposit at the bottom of the vessel. Such a deposit may be distinguished from pus by the absence of pus cells on microscopical examination, and by the fact that on adding to it some caustic potash the solution is not decidedly ropy, as it is in the case of pus. If the urine is alkaline the mucin goes partially or entirely into solution. It may then be detected by adding to the urine a few drops of acetic acid. A white cloud insoluble in excess indicates mucin. This often suc- ceeds better if the urine be previously diluted with its own bulk of water, as the presence of a large quantity of salts tends to prevent the precipitation. Mucin gives no precipitate with ferrocyanide of potash and acetic acid, provided the former be added first. AVe have already said that micleo-albiiinimu'ia is very apt to be mistaken for ordinary albuminuria. The reason of this is- that nucleo-albumin gives most of the ordinary albumin reactions. Thus it gives a positive result with Heller's and with the ferrocyanide test. It may be distinguished by the fact that it is pre- cipitated on the addition of acetic acid or on saturation of the urine with sulphate of magnesium. It is rather more difficult to distinguish it from mucin. The latter is insoluble in excess of acetic acid, nucleo-albumin is soluble in large excess. This test, however, is not always quite satisfactory. Mucin does not give the ferrocyanide reaction if the acetic acid be added last ; nucleo-albumin does. Nucleo-albumin gives a sharp ring with Heller's test ; mucin only a diffuse haze. Nucleo-albumin yields, as a rule, no reducing substance on boiling with mineral acid, and its ash contains phosphorus; mucin yields a reducing substance, and its ash is phosphorus-free. The significance of nucleo- albuminuria has not yet been fully made out. It seems 304 The Urine. to occur not unfrequently in febrile diseases or in con- ditions associated with a destruction of the secreting cells of the kidney. "Fibrinuria" has already been described (p. 273). II.— BLOOD AND ITS DERIVATIVES. Blood may appear in the urine as a whole (hsematuria), or blood pigment may appear without corpuscles (hsemoglobinuria). These two conditions can only be diflferentiated by examining the deposit for blood cells. There is here one source of fallacy. In alkaline urines, especially if they have stood for some time, the red cells are apt to swell up and disappear. The urine should, therefore, be examined as fresh as possible. If a urine contains only a small amount of blood or blood pigment it has a peculiar opaque appearance, to which the term "smoky" is applied. Larger quantities of blood give to the urine a red appearance varying in intensity with the amount of blood present. The blood corpuscles are apt to settle to the bottom, producing a flocculent deposit, which is brown or red according to the amount of the blood and the degree of its alteration. The following tests depend upon the presence of blood pigment, and therefore give a positive reaction both in hfematuria and in hsemoglobinuria. (1) Heller's test. — Place 2 inches of the urine in a test tube and render it strongly alkaline with caustic soda. Boil. If blood pigment is present the deposit is brownish-red in colour while the super- natant fluid is bottle-green. The precipitate consists of earthy phosphates which have carried down with them hsematin derived from the blood pigment, and are therefore reddish in colour instead of being white or yellowish. If the urine be alkaline a few drops of calcium chloride Blood in the Urine. 305 solution should be added to form more earthy phosphates. If the \irine be very dark, as it may be, {e.g.) from the presence of bile, the supernatant fluid should be decanted off the precipitate and replaced by water. The test is suifficiently delicate to reveal the presence of 1 cc. of blood in 1 litre of urine. Fallacies. — If the patient is taking senna, santonin, or rhubarb the test may yield a positive result even although no blood is present. If the coloration is due to haemoglobin, however, the pre- cipitate yields the spectrum of alkaline hsematin (Fig. 63), and this excludes all possibility of fallacy. (2) Guaiac test. — Take 1 inch of urine in a test tube, add to it two drops of tincture of guaiac. A white precipitate forms, owing to partial precipi- tation of guaiac resin. Now add 1 inch of ozonic ether without shaking. If blood pigment is present a blue colour appears at the junction of the fluids. The blue colour is due to oxidation of the guaiac by oxygen derived from the ozonic ether, the blood pigment acting as the carrier. Ozonic ether is a solution of peroxide of hydrogen in sulphuric ether. Fallacies. — If iodides are present in the urine a blue colour is produced on applying the test. It is distinguished from that due to blood, (1) by the fact that it appears much more slowly, (2) by its appear- ing simultaneously all through the fluid, not at the junction of the ether and the urine. Pus gives a greenish-blue colour with guaiac alone. It disappears on heating. The presence of much saliva in the urine {e.g. from the patient spitting into it) is also a possible source of fallacy,^ as it gives the guaiac test. ]?Iethseiiiog:loI>iiiHrm. — Methsemoglobin may be formed from htemoglobin in any acid urine after it has stood for some time. Not unfrequently, how- ever, methsemoglobin is present in the urine when u 3o6 The Urine. passed. It lias been said to indicate that the haemorrhage has its origin in the kidney. The cha- racteristic smoky tint of the urine in hsematuria of renal origin is largely due to methaemoglobin. The pigment present in " paroxysmal hsemoglobinuria " consists largely of methsemoglobin. Spectroscopic examination is the only satisfactory test for methae- moglobin. The urine if very dark in colour should first be diluted, and it should always be filtered. It should then be examined in a layer 5 cm. thick— a small flat glass bottle does well enough. If methsemogiobin is present there will be a band visible in the red, in addition to two bands nearly in the position of those due to oxy haemo- globin (see Fig. 63). Hsematoporphyriiiiiria. — Haematoporphyrin (iron-free haematin) occurs normally in the urine in very small amount, and may be considerably increased without affecting its colour. When present in large quantities the urine has a dark port-wine colour. Such a urine does not give the guaiac reaction. If examined with the spectroscope in a thin layer it may possibly show the characteristic spectrum of so-called alkaline haematoporphyrin, that being the form met with even in acid urines. Often, however, no distinct spectrum can be obtained on direct examination of the urine. In such a case the pigment can be extracted by shaking up the urine with a little amylic alcohol or acetic ether, after the addition of a few drops of acetic acid. The extract so obtained shows the bands of alkaline haemato- porphyrin, viz : 4 bands, one at the junction of the red and yellow, a second in the yellow, a third in the green, and a fourth (the broadest) between the green and the blue (see Fig. 63). On adding a drop or two of hydrochloric acid the bands of acid haematoporphyrin are obtained, viz. 2 bands, one in Blood in the Urine. 307 the orange (narrow) and one at tlie junction of the yellow and green (broader). The latter is the characteristic band and consists really of two halves, a lighter half on the side next the narrow band and a very dark half on the side away from it. Hferaatoporphyrin sometimes appears in large amount in the urine of patients who are taking sulphonal, but much more commonly in females than in males. It is a sign of very grave signiticance, as such cases often terminate fatally. The excretion of port- wine-coloured urine by a patient who is taking sulphonal is always an indication for the immediate stopping of the drug and for the free administration of alkalies. Urine which contains blood or haemoglobin con- tains also, of course, some albumin, and it is often difficult to say whether the blood is sufficient to account for all the albumin present or whether true albuminuria exists as well. We have found that if human blood be added to normal urine in an amount sufficient to produce distinct smokiness, the quantity of albumin amounts to merely a trace. Even when the quantity added is sufficient to render the urine distinctly red, the amount of albumin as shown by Esbach's method is only \ per 1,000. Ill— SUGARS IN THE URINE. The only sugars which are of practical importance in the examination of the urine are glucose and lactose. It is possible that Isevulose may sometimes occur along with glucose. Cane sugar and maltose may conceivably appear in the urine if excessive quantities of either be ingested. The occurrence has been described of the special varieties of sugar known as the pentoses, but these are only very rarely present, and are not yet of much clinical importance. 3o8 T^HE Urine. Oliicose ill the iiriuo. — Glucose (dextrose or grape sugar), CgH^.^Og, is by far the commonest variety of sugar met with in the urine. The con- dition is spoken of generally as "glycosuria." This must be distinguished from " diabetes." Diabetes — or, more correctly, diabetes mellitus — is a disease of which glycosuria is the chief symptom, but every patient with glycosuria has not necessarily got diabetes. It has long been dis})uted whether or not traces of glucose occur in normal urine. Recent researches appear to have finally settled the question. Traces of glucose do occur in normal urine, but not in an amount capable of detection by the reagents usually employed. If, therefore, glucose be detected by any of the tests we are about to describe, its presence may be regarded as pathological. Tests for glucose in tlie urine. — A group of these tests depends upon the fact that glucose can become oxidised at the expense of certain metallic oxides, this oxidation occurring most easily at a temperature near boiling, and in the presence of free caustic alkali. Copper is the metal usually employed in the test. If one takes a solution of caustic soda and adds to it a few drops of a very dilute solu- tion of sulphate of copper, a blue precipitate forms. This is hydrated cupric oxide (CuO-HoO). If now one boils the blue precipitate it becomes black from the separation of cupric oxide (CuO). In the presence of certain substances, however — such, for example, as a tartrate^ — the cupric hydrate formed on the addition of the sulphate goes into solution instead of being precipitated. A deep blue fluid then results, which remains unaltered on boiling. If an oxidisable sub- stance such as glucose is present, however, the blue cupric hydrate is reduced on boiling to cuprous hydrate (CuoO'HgO), which is not capable of being held in solution, and accordingly appears as a yellow Sc'G.-i/^s i\ THE Urine. 309 precipitate, or it may be further dehydrated to cuprous oxide (CuoO), which is red. Now, ghicose is not merely capable of reducing cupric hydrate, but it is also one of the substances which, like the tar- trates, is capable of holding it in solution. Hence, if a solution of glucose be rendered alkaline with caustic soda, and a few drops of cupric sulphate solu- tion added, the cupric hydrate formed is dissolved and a blue solution results. On raising this to the boiling point the glucose reduces the cupric hydrate, and yellow cuprous hydrate or red cuprous oxide is precipitated. Such is a brief account of the chemistry of the copper test for sugar. The two chief methods of applying it are : — (1) Trommer's test. — Take 2 in. of the urine in a test tube, add -|- of its volume of caustic potash, and then drop in carefully some 1 per cent, solution of sulphate of copper, shaking after each addition. If any considerable quantity of glucose is present the cupric hydrate formed is at once dissolved, and a blue solution results. Continue to add sulphate of copper until a little cupric hydrate remains undis- solved. Boil the upper part of the fluid and it becomes yellow from separation of cuprous hydrate ; and on prolonged boiling this becomes red (CuoO). If more cupric hydrate has been formed than the amount of sugar present is capable of holding in solution, the excess yields black cupric oxide on boil- ing, which obscures the result. Hence the advantage of Fehlino-'s reao-ent in which solution of all the cupric hydrate is ensured by the addition of a tar- trate. The formula for the reasjent will be found in the Appendix (14). If even a small quantity of glucose is present, the reduction in Trommer's test begins before the boiling point is reached. Glucose is the only 3 TO The Urine. substance likely to be found in the urine which will do this. (2) Fehling's test. — As a preliminary to" carry- ing out the test, one must always make sure that the reagent is good. This is necessitated by the fact that Fehling's solution alters on keeping, with the result that on boiling it deposits a precipitate of cuprous oxide. The exact nature of the alteration is not fully understood. To test the Fehling's solu- tion add to it an equal volume of water, and boil for two minutes. If the solution remains clear, it is to be regarded as safe. Should a precipitate occur, a little more caustic soda should be added and the liquid filtered. It is then ready for use. Add to 1 in. of Fehling in a test tube a few drops of the urine (freed from albumin), and boil. If any con- siderable quantity of glucose is present, a yellow or red precipitate will appear. Should none be evident, add as much urine as there was Fehling, and boil for two minutes. Set aside. If after standing the solution still remains quite clear, there cannot be more than a mere trace of sugar present. " If the proportion of sugar," says Allen,* " be moderate- that is, under 0*8 per cent. — the precipitation of the yellow or red cuprous oxide does not take place immediately, but occurs as the liquid cools, the ap- pearance being somewhat peculiar. The liquid first loses its transparency, and passes from a clear bluish- green to an opaque light greenish colour. This green milky appearance is said to be very characteristic of dextrose, but it would be more correct to say that its appearance indicated the j^resence of some substance interfering with the normal reaction of sugar." Uric acid, creatinin, and many other sub- stances may act as such interfering agents. Their presence renders the indications of Fehling's test * "Chemistry of Urine," p. 61. SUGA/iS IN THE UrINE. 3II uncertain when only small quantities of sugar are present, Allen has accordingly proposed the follow- ing modification of Fehling's test by taking advantage of the fact that a sliglitly acid solution of cupric acetate will precipitate most of these " interfering " substances without affecting any form of sugar. He proceeds as follows : — Heat 7-8 cc. of the urine to boiling in a test tube, and, without removing any precipitate of albumin, add 5 cc. of the cupric sulphate solution used in preparing Fehling. Partially cool the liquid and add 1-2 cc. of a saturated solution of sodium acetate, con- taining enough acetic acid to give it a feebly acid reaction. Filter. To the filtrate add 5 cc. of the alkaline tartrate mixture used for Fehling, and boil for twenty seconds. If more than 0"2 per cent, sugar is present, cuprous oxide separates before the boiling point is reached. With smaller quantities precipita- tion takes jjlace during the cooling of the solution, which becomes greenish, opaque, and suddenly deposits cuprous oxide as a fine yellow precipitate. Certain iirecaidions and fallacies in the use of Fehling's test hav^e still to be mentioned. In the first place, the urine must be free from albumin. If necessary add a drop or two of acetic acid to the urine, boil and filter. Neutralise the filtrate with a little calcium carbonate. Fehling's test cannot be applied to strongly am- moniacal urine, as the free ammonia would prevent precipitation of cuprous oxide. In that case, Pavy's modification should be employed (p. 315). If the amount of glucose present be more than is required for reduction of all the cupric oxide, some of it is apt to be caramelised, especially on prolonged boiling. The whole liquid and precipitate then become of a dark brownish colour. The fallacies attendant upon the use of Fehling's 312 The Urine. test are due to the fact that other substances in the urine besides glucose can reduce cupric oxide. The chief of these are uric acid, creatinin and hippuric acid among the normal ingredients ; of the abnormal constituents, the chief are lactose, glycuronic and glycosuric acids, and the products of certain drugs — • e.g. chloral, chloroform, glycerine, benzoic acid, salicy- lates, carbolic acid, etc. ; " alcapton " urines also reduce Fehling. If the patient be taking no drugs, and if the urine be examined by Fehling's method as modified by Allen, the only substances likely to lead to error are glycuronic acid and lactose. If one is still in doubt, the following additional tests should be employed : — (3) Picric acid test. — Take 1 in. of urine in a test tube. Add \ in. of saturated solution of picric acid and a few drops of caustic potash ; heat. If sugar is present, the solution becomes of a very dark red colour, owing to the reduction of the picric to picraiilic acid. Fallacies. — (1) Normal urine causes some darken- ing of the fluid when the test is carried out as above. This is owing to the creatinin which it contains. The colour is not nearly so dark as that produced by sugar, and the solution always remains transparent when held up to the light. (2) If the picric acid is impure, it may darken spontaneously when heated with caustic potash. It is, therefore, well to test the picric acid employed before using it. (4) Phenyl hydrazine test. — Place in a test tube \ in. of powdered phenyl hydrazine hydro- chloride and I in. of powdered acetate of soda, and then half fill the test tube with the urine. Boil for two minutes without shaking. Set aside to cool, and examine the deposit after some hours. If sugar is present^ yellow needle-shaped crystals (phenyl glucosazon) will be found arranged in stars or fans. Sugars in the Urine. 313 The crystals are fairly long. Glycuronic acid and pentose also give crystals, but are very rarely present. The crystals yielded by lactose are also almost identical in appearance with those of glucose. The chief value of the test is a negative one. If no crystals are found, sugar is certainly absent. (5) Fermentation test. — This is really the only absolutely certain test for glucose, that being the only fermentable substance which is ever found in the urine. Neither lactose nor glycuronic acid — the two substances most liable to be mistaken for glucose — is fermentable. The following precautions must be observed in carrying out the test : — (1) The urine must be acid. Alkaline urine would putrefy ; there- fore render it acid, if necessary, by adding tartaric acid. (2) Boil the urine for ten minutes, so as to drive off any air it may contain. Use German yeast. Shake the urine up with a small piece of it, so as to form an emulsion free from lumps, then place the urine so prepared in a tube. Special fermenta- tion tubes are manufactured. If one of these be not obtainable, an ordinary test tube inverted in a bath of mercury will do. A Doremus (Soutliall's) ureometer tube does extremely well. The long limb of it should be filled with the urine completely, no air bubbles being left. Set aside the tube in a warm place, and examine after a few hours. If a distinct bubble has appeared at the top of the tube, the urine is fermentable, and contains at least ~q per cent, glucose. Care must be taken to ascertain that the yeast is active. It should be tested with a dilute solution of glucose. It is also well to have a control tube full of normal urine to which yeast has been added, as the yeast itself is apt to give off a little gas. If these precautions be observed, the test is absolutely trustworthy and extremely delicate. 314 The Urine. Quantitative estimation of sugar. (I) Fehling's iiiethod consists in titrating the urine with a known quantity of Fehhng's solution at boihng temperature, and observing when all the cupric acid has been reduced to cuprous oxide, as evidenced by the discharge of all the blue colour from the solution. As Fehling's is a standard solution, and as the exact quantity of glucose re- quired for the complete reduction of a given quantity of it is definitely known, it is easy to estimate the amount of glucose present from the quantity of urine used up in the titration. One proceeds as follows : — If ordinary diabetic urine is being examined, it should be diluted to the extent of 1 in 20 (5 cc. of urine to 95 cc. of water). Fill a burette with it. Measure 10 cc. of Fehling's solution into a flask or porcelain basin, and add 50 cc. of water. Boil the mixture. When boiling, run in the urine, stirring all the while. It is a little difficult to be sure of the exact moment when all the Fehling's solution has been reduced. The best way to tell is to remove the flame occasionally and tilt the basin, so that one looks through a layer of the fluid at the white edge of the basin instead of against the red background of cuprous oxide which has accumulated at the bottom. Another way is to filter a few drops of the fluid through a small filter paper, and examine the filtrate against a white surface. If there be any tinge of blue left, the filtrate must be returned to the basin and the titration continued. When complete reduc- tion has occurred, read ofl' the amount of urine used. Calculation : 10 cc. Fehling = 0-05 grm. glucose. Suppose 10 cc. of the diluted urine has been used, and 5,000 cc. to be the amount of urine passed in 24 hours ; then — a ' ^A X. 5,000 X 0-05 ^. Sugar m 24 hours = — — = 25 grms. Sc/GARS IN THE UrINE. 315 but the urine was diluted 1 in 20, .-. sugar in 24 hours = 25 x 20 =: 500 grms. To get the result in English measure, remember that — 10 cc. Fehling =: 0*77 grain sugar, 28-395 = cc. in 1 oz. Therefore — ounces of urine Grains su^ar in 24 h ours . » = T- X 0-77 X 28-3 in 24 hours number or cc. used, ounces in 24 hours %.e. = ~ X 21-8. number or cc. used The result must be multiplied according to the degree of dilution. (2) Pavy^s method is much more convenient for clinical purposes. It differs from that of Fehling in this — that a quantity of strong ammonia is added to the alkaline cupric tartrate solution. Ammonia is able to dissolve cuprous oxide, the solution being colourless. Hence when the solution is titrated at the boiling point with a solution containing glucose, the mixture gradually fades until every trace of blue has gone, and one is not confused by the throwing down of a red precipitate. Pa^-j^^'s solution has also the advantage of keeping indefinitely, and of being possessed of an originally deeper colour. The method of preparing it will be found in the Appendix (15). Method. — Fill a burette with diluted urine as before. The outflow from the burette should be regulated by a stopcock or screw. The end of the burette is connected with a tube passing through the stopper of a 150 cc. flask. Another hole in the stopper allows the passage of an exit tube for the escape of the fumes of ammonia (Fig. 84). Place in the flask 10 cc. of the solution, diluted with 20 cc. water. When the solution is boiling, run in the urine. It should be run in at the rate of 60-100 drops per 3i6 The Urine. minute. Not too fast, or the limit of reduction may be overstepped, and not too slowly, or all the ammonia may be driven off and some cuprous oxide thrown 83. — Pavy's Apparatus. down. When the blue colour has entirely faded, take a reading of the burette. The calculation is performed in the same way as for Fehling's method, but it must be remembered that 10 cc. of Pavy's solution is only = 0-005 grm. i.e. it is ten times less strong than Fehling's. glucose The following table saves the trouble of calculation Sl/gaj?s in the Urine. 317 TabJc shmvinct the Amount of Siipar expressed in Parts {hy weight) prr 1,000 (hii volume), e or re.^ ponding with cc, in lOths, required to Decolorise 10 Cf. of the Animoniatcd Cupric Test. cc to de- Parts per cc. to de- Parts per cc. to de- Parts per coloris'e. 1,000. colorise. 1,000. colorise. ] ,000. 10 5-000 5-7 •877 10-4 •480 •1 4-545 -8 •862 •5 •476 •2 4-166 ■9 -847 '6 •471 •3 3 846 6-0 -833 •7 •467 •4 3-571 -I -SI9 •s •462 "5 3-333 ••"> -806 •9 •458 ■<■( 3-1-25 -3 •793 WO -454 ' 1 2-041 ■4 -7S1 -1 •4.'i0 ■s 2-777 -5 769 -2 •446 •9 2-632 -6 -757 ! -3 -442 2 2-500 -7 •746 •4 •438 •1 2-380 -8 •735 •5 •434 "1 2-272 •9 •724 •6 •431 •3 2-173 7-0 •714 •7 •427 •4 2-083 -1 •704 •8 •423 •5 2-000 •2 •694 •9 •420 •6 1-923 -3 •684 12^0 •416 •7 1-851 -4 •675 •1 •413 •8 1-785 -5 •666 •2 •409 •9 1-724 •6 •657 •3 •406 3-0 1-G66 •7 •649 ■4 •403 •1 1-612 •8 •640 •5 •400 •2 1-562 -9 •632 •6 •396 •3 1.515 8-0 •625 •7 •393 •4 1-470 -1 •617 •8 •390 ■5 1-403 -2 •609 •9 •387 •6 1-388 •3 •602 13^0 •384 ■7 1-351 •4 •595 -1 •381 •s 1-316 •5 •588 •2 •378 •9 1-281 •6 •581 •3 •375 4-0 1-250 -( •574 ' '4 •373 •1 1-219 j -8 •568 1 •o •370 •2 1-190 -9 •561 •6 •367 ■3 1-162 1 9-0 •555 • ( •364 •4 1-136 -1 •549 •8 •362 •5 1-111 -2 •543 •9 •359 •tj 1-086 •3 •537 14-0 •357 •7 1063 •4 •531 •1 •354 •8 1-041 -5 •526 •2 •352 •0 1-020 •6 •520 •3 •349 50 1-000 -( •515 •4 •347 •1 •980 •8 •510 •5 •344 "2 •961 •9 -505 •6 •342 •3 -943 10-0 -500 •7 •340 •4 -925 ■1 -495 ■8 •337 •5 •909 •2 -490 •9 •335 •6 ■ -892 •3 -485 15 •© •338 3i8 The Urine. It gives the sugar in grammes per 1,000 cc. The same table may be used for Fehliug's method (pro- vided that 10 cc. of Fehling has been taken), the number of parts per 1,000 being always multiplied by 10, to allow for the greater strength of Fehling's. solution; e.g. if 10 cc. diluted urine is used in Pavy's method, reference to the table shows that this means 0*5 grm. sugar per 1,000 cc. ; by Fehling's method, it would be equivalent to 5 grm. per 1,000 cc. In each case the result must be multiplied by 20 if the urine has been diluted 1 in 20, and if it be desired to express the result in grains per ounce the amount per 1,000 cc. should be multiplied by 04 375. In both methods the urine must be freed from albumin (if necessary) by adding two drops of acetic acid, boiling, neutralising with calcium carbonate, filtering and making up to the original volume with water. In an ordinary case of diabetes, 3 litres or so. (about 5| pints) of urine will be passed daily, con- taining on an average 100 grms. of glucose (3-4 per cent.). Lactosiiritt. Lactose is sometimes found in appreciable quantity in the urine of women who are nursing. It reduces Fehling's solution, and gives yellow crystals of phenyl lactosazon with the phenyl hydrazin test, which are broader than those yielded by glucose, but it gives no reaction with the fermentation test. It may be estimated by titration with Fehling's solution^ it being remembered that the reducing power of lactose is to that of glucose as 10 is. to 7 ; i.e.\i 7 parts of glucose reduce a given quantity of Fehling, it will require 10 of lactose to eflect the same result. Pentosuria. — This is a condition only recently described. It consists in the presence in the urine of pentoses, i.e. carbohydrates containing only 5 atoms Bile in the Urine. 319 of carbon. They have the general formulre, C-Hj^jO^. The pentoses do not exist free in nature, but can be obtained easily by hydrolytic decomposition of complex carbohydrates belonging to the gum class, present in many fruits {e.g. cherries). They are dis- tinguished from the hexoses, such as glucose in not furnishing Isevulinic acid in decomposition with sul- phuric acid or HCl. With phloroglucin and HCl they give a cherry red reaction. They furnish osazones, are not fermentable and, on distillation with HCl, furfurol is given off. They are optically active, and reduce cupric oxide. They only occur very rarely in the urine, and their pathological significance is unknown. IV.— BILE IN THE URINE. Both bile pigment and bile acids may be present. Usually they occur together, but the pigment much more abundantly than the acids. The usual cause of the entrance of the bile constituents into the urine is some obstruction in the bile -passages. It was for- merly believed that bile pigment could be formed in the blood owing to a destruction of the normal blood pigment, and thence find its way into the urine, constituting the so-called "haematogenous" jaundice. This is now known to be an error. It is also very doubtful whether traces of the bile acids are really always present in the urine, as is the belief of some. As long as the urine is fresh, bilirubin is the form of bile pigment always found in it. After it has stood for some time, biliverdin is apt to be formed as the result of oxidation. Urine which contains bile is greenish or brownish- yellow in colour, and somewhat more viscid than normal, so that the froth which forms on the top after shaking is unusually permanent. Salol urine may closely resemble urine which contains bile, but 32 o The Urine. the froth in the latter case is also greenish ; in salol urine it is not. Tests for bile ptg^inent. GmelinHs test. — Place some of the urine in a conical glass, and run a little impure nitric acid down the side so as to form a layer at the bottom. Oxi- dation of the bile pigment occurs, the most highly oxidised product (choletelin) forming a yellowish red ring nearest the acid. Above this is a reddish ring, then violet (bilicyanin), and highest of all, green (bili- verdin). Of these rings the green is alone character- istic of bile, all the others may be yielded by urinary indigogens. The test, as thus carried out, is not very sensitive, and may fail even when 5 per cent, of bile is present. The sensitiveness of the reaction can be increased by repeatedly filtering the urine through an ordinary filter paper. The latter becomes im- pregnated with the bile pigment, and if a drop of impure nitric acid be placed upon it a play of colours can easily be seen. The following modification of it is much more delicate still, and should always be employed in doubtful cases. It will reveal the presence of 0*2 per cent, of bile. To 50 cc. urine add 5 cc. of 10 per cent, barium chloride solution and 5 cc. chloroform. Shake for several minutes. Set aside for ten minutes. The chloroform and precipitate of phosphates fall down, carrying with them any bile pigment. If there is still any of the precipitate sus- pended, move the jar gently to and fro for a little, when it will settle down. Now draw off the chloro- form and precipitate with a pipette ; if some urine is removed at the same time, no matter. Place in a flat dish, and set the latter over a basin of hot water till all the chloroform has evaporated. Allow to cool, and pour off any fluid from the precipitate. The latter Bile. 321 will he yellowish. Place impure nitric acid in drops here and there on the surface of the precipitate. If bile pigment is present, a play of colours appears round each drop. Tests for bile sicids. (1) rettenkofer^s Test. — Place some of the urine in a conical glass. Add three drops of syrup of cane sugar, and mix. Pour strong sulphuric acid down the side so as to form a layer at the bottom. Then shake gently, and slowly add more sulphuric acid. If bile acids are present a purplish red colour appears. This is often most easily to be detected in the froth which forms on the top of the liquid on shaking. The froth acquires a pink tinge if bile acids are present. The test depends on the formation of f urfuraldehyde from the sugar and acid ; this unites wdth the cholic acid of bile to form a purplish compound. The urine must be free from albumin in Pettenkofer's test. The above test very rarely succeeds well in urine. The followinoj delicate test has been proposed by Oliver as a substitute. It depends upon the power of bile acids to precipitate peptone in acid solution. The peptone solution is pre- pared as in the Appendix (16). Proceed as follows : — (2) Oliver's Test. — Filter the urine until quite clear, acidify it if necessary, and dilute it till the specific gravity is less than 1,008. Take 60 minims of the solution in a test tube and add to it 20 minims of the urine. If bile acids are present a decided milkiness appears at once, and is dense in proportion to the amount of acids. It may dis- appear on agitation, but reappears on adding more of the solution. The test is extremely delicate, and nothing as yet found in the urine interferes with it. 32 2 The Urine. V.^PUS IN THE URINE (PYURIA). The naked-eye characters of a urine which con- tains pus have already been described (p. 276). On chemical examination such a urine is, of course, always albuminous. It is often difficult to decide, just as it is in hsematuria, whether all the albumin is accounted for by the pus alone or whether there is true albuminuria in addition. Reinecke has proposed the following method for enabling one to form a conclusion in this matter. He shakes up the urine of twenty-four hours thoroughly, so as to diffuse the pus evenly through it. He then counts the pus cells present by means of a hsemo- cytometer, just as in the method for estimating the red blood corpuscles in the blood, only without previous dilution. He finds that 100,000 pus cells per cubic millimetre should correspond to 1 per cent, of albumin (Esbach). If there be more albumin than this with that number of corpuscles, then albuminuria is present in addition to pyuria. Obviously, the method can only afford approximate indications. More- over, it is inapplicable if the urine be ammoniacal, or if it contains much mucus. It should be added that if the number of pus cells exceeds 3,000 per cubic millimetre, the urine should be diluted with 1 per cent, salt solution prior to counting. Tests for pus. — As already mentioned, urines which contain pus give a green colour on the addition of guaiac, which, however, disappears upon heating. If liquor potasses be added to the deposit of pus, a ropy, gelatinous mass results. For the micro- scopical recognition of pus in the urine, see p. 338. Some Rarer Abnormal Constituents of Urine, 1. Urinary JiidJg'Og:ens. — We have seen (p. 283) that indol is excreted in the urine in the form of potassium indoxyl sulphate — the so-called *' indican." Indigogens. 323 Small quantities of potassium skatoxyl sulj)liate, derived from skatol, are also to be found in human urine. On oxidation these compounds yield coloured substances, indigo blue and indigo red. Hence they are spoken of as urinary indigogens. In order to detect their presence one oxidises them in one of the following ways : — (1) Remove albumin, if present, by boiling. Add to some of the urine in a test tube an equal quantity of hydrochloric and a few drops of nitric acid, and boil. Cool and shake up with a little chloroform. The chloroform dissolves out the products of oxidation and becomes of a violet tint from the mixture of indigo blue and indigo red, if excess of indigogens is present. The presence of iodides in the urine must be excluded before applying this test. (2) Remove albumin and add hydrochloric acid, as above. Then drop in slowly a freshly prepared dilute solution of bleaching powder (1 in 20), shaking all the time till the blue colour ceases to become deeper. The indigo blue may then be dissolved out with chloroform as above. The development of the blue colour does not proceed very rapidly, and one must be careful not to add too much bleaching powder, or oxidation will proceed too far, colourless compounds resulting. Traces of the indigogens are normally present in the urine. The reddish yellow transparent ring which appears above a layer of nitric acid when the latter is added to the urine is due to their partial oxidation. They are increased in all conditions associated with excessive putrefaction. Hence they are much in- creased whenever the intestinal contents are unduly retained — e.g. in chronic constipation and intestinal obstruction. They are also increased in some fevers. 2. Acetone. — Hydroxybutyric acid, aceto-acetic acid, and acetone may all occur in the urine. 324 The Urine. The relationship between the three may be seen from the following formulae : — i3-Hydroxy butyric acid = CH3 CH(OH)OHoCOOH. Aceto-acetic acid r= CH3 CO, CH.COOH, Acetone ... = CH3, CO, CH.. /3-Hydroxybutyric acid is formed first, probably by destruction of proteids ; it then becomes oxidised, yielding aceto-acetic acid. CH3CH(OH)CHoCOOH + = CHgCOCH^ COOH + H3O. The aceto-acetic acid is very easily decomposed into acetone and CO3. OHgCOCHgCOOH = CH3COCH3 + COo Only aceto-acetic acid and acetone require to be detected in the urine. Hydroxy butyric acid always occurs along with the first of these. Test for aceto-acetic acid. — The urine must be fresh and unboiled, as the acid readily decomposes. Take some urine in a test tube, drop in a solution of perchloride of iron, diluted until it is of a pale sherry colour, as long as a precipitate of phosphate of iron falls. Filter, and add to the filtrate another drop or two of the iron solution. The solution becomes claret coloured if aceto-acetic acid is present. On boiling the urine the colour disappears. Antipyrin, salicylates, carbolic acid, and some other drugs give a similar colour with perchloride of iron, but it is not affected by heat. Test for acetone. — Urine containing acetone has a peculiar fruity odour. It reduces Fehling's solution. The best test for its presence is based upon its ready conversion into iodoform : — CgHfiO + 4K0H + 31, = SKI + KC.HgOg + OHI3 (Iodoform) + 3 H2 O. To 1 in. of the urine add five drops of 10 per cent. Glycuronic Acid. 325 caustic soda or potasli. Heat gently. Then drop in a saturated solution of iodine in potassium iodide until the liquid has a yellowish brown colour. Then add a little more caustic potash or soda. Iodoform appears as a yellowish turbidity, which settles down into a crystalline precipitate. It may be recognised by its odour. Under the microscope it consists of hexagonal plates often gathered into stars. If only traces of acetone are present, it is better to distil the urine after the addition of a little phosphoric acid and test the distillate as above. Acetone and the substances from which it is derived are especially apt to appear in the urine in cases of diabetes, and are to be regarded as of grave import, their appearance being often followed or accompanied by the development of coma. They are also found in some fevers. 3. Olyciiroiiic acid. — (CgH^^QOy) is probably derived in the body from dextrose. Mere traces of it exist in combination in normal urine. It is very prone to form ethereal or glucosidal compounds if suitable substances are introduced into the circulation. Hence it appears in the urine in considerable quantity, in paired combination with aromatic substances, etc., after the administration of such drugs as chloral, benzoic acid, chloroform, morphia, etc. This circum- stance gave rise to the old belief that such drugs produce glycosuria ; in reality the substance which is excreted after their use is glycuronic acid, not glucose. Occasionally glycuronic acid occurs spontaneously in the urine. It is then very apt to be mistaken for glucose. The error is a serious one, for the patho- logical significance of glycuronic acid in the urine is much less grave than that of glucose, Glycuronic acid reduces Fehling's solution, and gives a yellow crystalline precipitate with the pheny Ih^ drazin test. 326 The Urine. It can be best distinguished from glucose in the following ways : — (1) It does not ferment with yeast. (2) Dissolve some jpure phloroglucin by the aid of heat in 5 cc. of fuming hydrochloric acid so that a slight excess of the substance remains undissolved. Cool and divide into two equal portions. To one add ^ cc. of normal urine ; to the other a similar quantity of the urine under examination after decolorising both with animal charcoal. Place both in a beaker of boiling water. In a few minutes the urine which contains glycuronic acid will show a red scum from which a bright red colour spreads throughout it. The normal urine remains unaltered. 4. Cystin (C3HgNS02)3 is sometimes found as a deposit in acid urines. It is recognised by its characteristic crystals {see Fig. 88). It is soluble in alkalies ; hence the deposit disappears when the urine putrefies, an odour of sulphuretted hydrogen being evolved. Its origin in the body is unknown. Its presence in the urine is not of much pathological importance except from its tendency to form calculi. Cystinuria is a hereditary disease running in some apparently healthy families, VI.— EHRLICH'S DIAZO REACTION IN URINE. We shall first describe this test, and then state its significance. The reaction depends upon the fact that if sulphanilic acid (amido-sulpho-benzol) be acted upon by nitrous acid, diazo-sulpho-benzol is formed, which unites with certain aromatic compounds occasionally present in the urine to form aniline colours. Two solutions are necessary : (A) A saturated solution of sulphanilic acid in 5 per cent, hydrochloric acid ; (B) a \ per cent, solution of sodium nitrite. Both sojutioiis should be as fresh as possible, Drugs in the Urine. 327 Add to some urine in a test tube an equal quantity of A ; then add three drops of B, and shake till a froth forms. Render alkaline with ammonia. If the liquid becomes of a port wine colour while the froth is also red, the reaction is positive. The test has the following significance : — (1) If the urine of a supposed typhoid in the second or third week fails to give the reaction, the diagnosis is probably wrong. In very mild cases, however, the reaction may be absent. (2) The reaction is present in measles, but not in German measles (rotheln). It is thus of value in distinguishing between the two. (3) It is very constantly present in tubercular disease which is advancing rapidly. VII.— DRUGS IN THE URINE. Aiitipyrin. — After its use the urine may be red and dichroic, leading to the suspicion that blood is present. On adding a little dilute perchloride of iron a purplish red colour develops, which persists on boiling. Urines containing antipyrin produce a partial reduction of Fehling's solution on boiling. Carbolic acid (see also section on Colour of Urine, p. 269). — The best test for it is to add a little bromine water. The appearance of a whitish precipitate (tribromophenol) indicates the presence of phenol. Ciiloral, cliloroform, etc., lead to the appear- ance of glycuronic acid (p. 325). Bromides. — Add a little hydrochloric acid and a few drops of a weak solution of bleaching powder. Shake with chloroform, and the latter becomes brownish i-ed from the solution of the free bromine. Iodides. — Acidify the urine with a little pure nitric acid, and shake up with chloroform. The latter becomes of a rose-red colour. Iron. — Add a few drops of nitric acid. Boil, cool, 328 The Urine. •^ ^ ^ o O i— ( o m t < o W Q S — © • o OS c3 P3 a. S o '-J §2 -1 o s -5 — ~ ■5; — i^ ;: ce S 'S ^ ;:: « 5 ^ " a '^ s^ o O o 1 S :s 3 ^ s ^ a ^ --t? ■ 0:25 :S as 1: .s OS CI CO =4H Ji o o o - n '% o O CO 5tt O 1:3 PI o w o na -'S< c -H ia s t:3 >. ^ gs ^_ _f^ cS =H " CO d § s PQ 03 3 03 --J O w XI o Microscopical Exam in a tion. 329 and add a little 10 per cent, ferrocyanide of potash. A precipitate of Prussian blue forms if iron is present. Rhubarb and isaiitoiiiii have been referred to under tJie colour of the urine (p. 271). Salicylates and salol appear in the urine as salicyluric acid. Such a urine gives a bluish violet colour on the addition of a little perchloride of iron ; it also partially reduces Fehling's solution. Taiiitiu gives a bluish black colour with per- chloride of iron. SEOTIO^N" III. MICROSCOPICAL EXAMINATION OF URINARY DEPOSITS. 1. — Unorgaulsecl deposits. — The first group of urinary deposits includes the various salts and crystalline substances that are found in urine, either when freshly voided, or more often when it has stood ^F^ l&lr '&^^^^ ^t ^'^A^ ^^^' '§kM^ yr # -«L> Fig. 84. — Deposit in acid urine. for some time. The following occur in acid urine (Fig. 84). (1) Uric acid. — This appears under a variety of foims, and, unless the urine is almost devoid of colouring matter, assumes a reddish brown colour in consequence of its absorbing a considerable amount of i)igment. To the naked eye the appearance 330 The Urine. resembles that of a shower of grains of cayenne pepper collected at the bottom of the specimen. Under the microscope the crystals are either rhombic prisms or some modification of that form. Often the more obtuse angles are rounded off and the edges Fig. 85. — Uric acid. (Finlayson after Funlce.) continued in curved lines, so that pointed oval shapes result. Numerous crystals may be joined together to produce rosettes and other composite forms. Some of the more common are represented in the accom- panying figure (Fig. 85). (2) Urate of soda, occurs rather frequently in the urine of recently born infants, when it produces a yellow stain on the napkin. In adults it is found very seldom. The appearance presented under the microscope is that of spheres, either solitary or in clusters, having a more or less crystalline structure, and possessing numerous spines radiating from their surface (Fig. 86). Microscopical Examination. 331 (3) Amorphous urates. — These are quadri- urates of potassium, sodium, and ammonium. Tliey have a considerable affinity for the urinary pigments, and hence are generally more or less pink or brick- coloured. In very pale urines they are colourless, and resemble rather closely a deposit of phosphates. Microscopically they con- sist of small granular par- ticles, arranged in moss- like clumps. On heating a urine from which they have separated out, they will be found to re- dissolve before the boiling point has been reached. Uric acid and urate of soda can be preserved in Canada balsam — the water being got rid of by Fig. 86.— Urate of soda. {AfUr Roberts.) Fig. 87.— Oxalate of lime. (After Finlayson.) drop passing them through alcohol, then letting a dry on the slide, and adding balsam in xyloL (4) llippiiric acid a|)pears in human urine ghiefly after the administration of benzoic acid or its 332 The Urine. salts. It occurs as colourless four-sided prisms, inso- luble in hydrochloric acid but soluble in ammonia. (5) Oxalate of lime. — This deposit is rarely abundant. The small colourless crystals lying on the top of the mucous deposit that settles at the bottom of the urine glass give the impression of an undu- lating snowy surface. They also adhere to irregu- larities on the surface of the glass, producing the appearance of scratches. Two forms are found under Fig. 88. — a, tyrosin crystals ; ?>, cystin ; c, leucin. the microscope. The first, which is by far the commoner, consists of small octahedral crystals. When, as is generally the case, they are slightly flattened along one axis, they appear like squares crossed by two diagonal lines, or like long octahedra, according as the short axis lies in or perpendicular to the line of sight. The other form in which oxalates occur is that of minute dumb-bells or oval biscuit- shaped discs. Some writers consider that this form is not really due to oxalate but to carbonate of lime ; yet, though carbonates frequently enough assume this shape, there can be little doubt that under certain Microscopical Examina tion. 333 eoiiditioiifs oxalates do so too. For permanent speci- mens octahedral oxalates are best mounted in glycerine jell}", dumb-bell oxalates in balsam (Fig. 87). (6) Cystiii is a rare deposit in human urine, but when it occurs the precipitate is often copious, and is not unlike a sediment of fawn-coloured quadri-urate. The addition of a few drops of acetic acid to a urine containing cystin in solution determines its precipi- tation. From urine it is deposited as hexagonal — stellar phosphates. {After Finlayson.) tablets, soluble in ammonia and re-crystallising when the ammonia evaporates as hexagons or prisms (Fig. 88, b). (7) Xaiitliiii is of extremely rare occurrence ; the crystals are said to be similar to " whetstone " crystals of uric acid, but are soluble in ammonia, in warm hydrochloric acid, and in nitric acid. (8) Tyrosiaa is generally found associated with leucin, but occurs independently also. It forms colourless sheaves of fine needle-like crystals. A similar appearance may be presented by several other deposits ; therefore, if there be any doubt as to the 334 The Urine. nature of the sediment, a chemical analysis may be necessary (Fig, '^%., a). (9) Leiiciii occurs in nrine as yellow spherical masses without obvious crystalline structure. Leucin and tyrosin occur together in acute yellow atrophy of the liver (Fig. 88, c). In alkaline urine the following occur : — (1) Phosphates. — These may either be salts of Fig. 90. — Triple phosphates. {After Finlayson.) phosphoric acid and calcium, or of phosphoric acid with ammonium and magnesium. (a) Phosphate of lime is found either in an amor- phous or a crystalline form, the latter being also known as stellar phosphate (Fig. 89). Amorphous phosphate of lime occurs in small white granules, as a deposit at the bottom of alkaline urine. To the naked eye the sediment is white and tiocculent ; unlike urates, it has no affinity for urinary pigment. The deposit is increased on heating. Stellar phosphates are rather uncommon. They consist of colourless plasmatic crystals, which occur either singly or more often in radiating clusters. They are found in very faintly acid as well as in neutral MiCR OS CO PIC A L EXA MINA TION. 335 and alkaline urine. Roberts is inclined to regard the presence of this deposit in abundance as an accompaniment of some grave disorder. (6) Ammonium magnesium, or "triple " phos- phate, is deposited in ammoniacal states of the urine. To the naked eye the sediment appears very white, and when the crystals are large they may be visible as bright points. Sometimes the deposit also clings to the sides of the glass and forms a film on the sur- face of the urine. The crystals are in- complete, triangular, colourless prisms, which may offer considerable variations in appearance, according to their length and degree of perfection. Fig. 91. -Deposit in alkaline fermenta- Often they are described tlon of urine, showing urate of ,,^ .p ,5, ,, n^ auimonia, triple phosphates, and as " knife-rest or " COitin- bacterium ure^e. lid " crystals. If the am- moniacal change is well marked, and still more if ex- cess of ammonia is added to healthy urine, the deposit takes the form of feathery stars, and is then known as a precipitate of "feathery" phosphates (Fig. 90). It is difficult to preserve these crystals perma- nently, but they keep fairly well in a solution of ammonium chloride. (2) Urate of auiuiouia occurs in alkaline urine, and is very commonly present in cases of cys- titis. Microscopically it occurs in small spherical masses which are practically indistinguishable in many instances from those of urate of soda, except that they are generally darker and more opaque, and, 33^ The Urine. unlike the soda salt, are associated with crystals of triple phosphate. The si)heres may have smooth surfaces, or they may be beset with innumerable spiny processes (Fig. 91). (3) Carbonates generally occur in human urine Fig. 92. -Renal epithelium. {After PmUHs.) a, normal ; b, disintegrated ; c, fatty. as granular particles, which dissolve in acetic acid with evolution of COo. As phosphates give off no gas on solution in acetic acid, it is quite easy to distinguish between them. On rare occasions in human urine, and commonly in horse's urine, car- bonate of lime appears in the form of dumb-bells or of spheres with a radiating crystalline structure. (4) Cholesteriii has occasionally been found in the urine ; it occurs in characteristic thin, rhom- boidal, colourless plates, with a notch at one of the corners (see Fig. 133). Microscopical Examination. 337 mmm§ mi ■)iiKil Fig. 93. — Epithelial cells from tlie uriuarj'- passages. (From Sahli's " Klinische Untersuchungs-Methoden," after Bizzozero.) a, cells of the deepest layer ; b, long cells of the second layer ; c, " tailed" cells ; d. flat cells of superficial layer; e, r'.sr, cells of superflcial layer in surface view, with nuclei and indentations ; h, i, k, I, epithelium from bladder, altered by action of urine ; m, cells from male urethra. Other sediments, such as indigo, lime and mag- nesia soap crystals, and haematoidin have been observed, but are of little importance. w 338 The Urine. 2. — Orjfaiiised depoisits. (1) Red blo»d corpuscles are present in cases of haematuria, but under certain conditions are rapidly disintegrated, and should therefore be ex- amined for in recently voided urine. According Fig. 94, — Tube casts. (After'iRoberts.) a, epithelial ; b, granular to the density of the urine they appear fairly normal, or swollen, or shrunken and crenated. (2) Leucocytes a^nd pus corpuscles occur where there is irritation and suppuration of the urinary tract. According to the length of time which has elapsed, the cells may be indistinguish- able from ordinary leucocytes, or they may be very granular and fatty. The addition of acetic acid clears up the cell body and brings two or three nuclei iiito view. Where pus is present, examine carefully Microscopical Examination. 339 for pathogenic micro])es, especially for gonococei and tubercle bacilli, (3) In cases of cliyluria the urine contains nucleated granular corpuscles similar to leucocytes, and very finely divided fatty material which appears Fig. 95.— Tube easts. (^After Roberts.) a fatty casts ; b, c, blood casts ; d, free fatty molecules. simply granular under the microscope. A few red blood corpuscles are often present. The urine and blood should be carefully examined for the presence of filariae, particularly if the patient comes from a district where these parasites exist. In lipiiria, the fat may occur in larger globules which refract light strongly, and which are sometimes free in the fluid, at other times enclosed in cells or tube casts. It must not be forgotten that fatty matter may 340 The Urine. reach the urine unintentionally from an oiled catheter, or may be added purposely in the form of milk by a patient who wishes to deceive the physician. (4) Epithelium from various parts of the urinary tract may be found in the urine. The following varieties are readily recognised : — {a) Renal epithelium,. This is polygonal, nucleated, Fig. 96.— Hyaline (a) and waxy (6) tube casts. (J/fer Boherts.) and rather larger than a leucocyte. It may present fatty degeneration, or be more or less disintegrated (Fig. 92). (6) Epithelium from the bladder and urhiary passages presents various appearances, according to whether it is derived from the more superficial or deeper layers. Formerly, tailed cells were thought to indicate implication of the pelvis of the kidney ; Microscopical Examination. -i^^i this is, however, inaccurate. They may equally well iDroceed from the deeper layers of the bladder epithelium, as may be seen from the accompanying diagram (Fig. 93). (c) Vaginal epithelium is very commonly present in the urine of women. It is squamous, and the large cells appear sometimes singly, at other times in groups. (.5) Spermatozoa occur at times in the urine, where their characteristic appearance makes it easy to recognise them. (6) Prostatic threads are found when there is chronic inflammation of the prostate, especially after gonorrhoea. They consist of mucus, and are mostly voided with the first portions of the urine. They are much larger than tube casts, being visible readily enough to the naked eye as they float in the urine or on its surface. (7) Tube casts (Figs. 94, 95, 96).— The follow- ing classification, which is more satisfactory than those usually adopted, is given by Prof. Senator, of Berlin.* There are three main groups of tube casts : — 1. Casts wholly or mostly composed of cellular structures. 2. Granular casts. 3. Amorphous casts, having a homogeneous struc- ture, and occasionally striated on the surface. Group 1. Cellular. — The cells may be epithelial or composed of red blood corpuscles or leucocytes. {a) Epithelial. The casts may be completely covered with epithelial cells, as though the whole epithelium had scaled off a tubule, or the cells may have been separately detached and subsequently moulded. The cells may or may not show a nucleus, and they may appear fresh, or affected by granular or fatty degeneration. * " Die Erkrankungen der Nieren," in Nothnagel's " Specielle Pathologie unci Therapie," vol. xix. 342 The Urine. (b) The red blood corpuscle casts exhibit a surface thickly covered with the minute round corpuscles. (c) Leucocytes rarely form casts by themselves, but are pretty often found adhering to the surface of other casts. Group 2. Oraiiiilar. — The granules are some- times coarse, at other times fine. They are sometimes fatty, at other times they result from granular degen- eration of protoplasm. They represent in some in- stances the relics of broken-down epithelium, in other cases they result from a granular change occurring in old amorphous tube casts. Group 3. Amorphoiis. — This group contains two varieties, the hyaline and the waxy. (a) Hyaline tube casts are pale, transparent, and homogeneous. Occasionally the surface is striated. They may be almost invisible, but are rendered more prominent by the addition of iodine solution. Their origin has l)een variously accounted for. Senator believes that in the vast majority of cases they are derived from epithelium which has undergone hyaline degeneration, or has yielded a secretion that is coagulable. (b) Waxy casts are broader and more highly re- fractile than hyaline. Often they are more or less fissured. Possibly they may be formed from other casts which have remained long in the urinary tu- bules; they are not symptomatic of waxy disease of the kidney. Sometimes tliey give the amyloid reaction with iodine and sulphuric acid, and with methyl violet. Transition forms between the various groups are not uncommon ; often, for instance, a cast is partly epithelial and partly hyaline. A tube cast frequently picks up adventitious elements from the urine, and thus comes to contain bacteria, or crystals such as oxalate of lime. In length, tube casts are very variable ; occasionally Microscopical Examination. 343 tliey approach a millimetre in length. One end may be spirally twisted or in rare cases bifurcated. Form- erly tube casts were called "fibrin cylinders," but now it is proved that fibrin rarely or never enters into their composition, the only exception being that in the case of red blood corpuscle casts the blood discs may be bound together by a little fibrin. Structures called cylindroicls have been described by Thomas and others. They resemble extremely long and narrow tube casts, but are usually considerably flattened. Very various estimates have been formed of their significance, some observers regarding their presence as quite immaterial, others looking on them with considerable suspicion as being nearly related, both in origin and clinical import, to tube casts. Senator inclines to the latter view. Not to be confounded either with tube casts or cylindroids are the small strings of mucus which occasionally are present in a urinary sediment. Small clumps of micrococci and short so-called "prostatic threads " are also liable to be misinterpreted by an inexperienced observer. When there is reasonable cause for doubt, the addition of acetic acid or some other reagent will often make the discrimination perfectly simple. It is frequently difficult to preserve tube casts permanently for microscopic examination. The two methods which the writers have found most serviceable are : — (a) Collect some of the sediment containing the casts, wash rapidly in water, and drop into a conical glass containing picrocarmine stain. When the sedi- ment has collected at the foot of the glass, which will have occurred in twelve hours or so, wash the deposit once more in water, and drop it into a small quantity of Farrant's medium in a conical glass. It will gradu- ally sink in this, and after a day or two samples can be removed from the foot of the fluid, and permanently 344 The Urine. mounted in some of the fluid from which they have been withdrawn. (6) Harris proposes the following method : Let urine stand for twelve hours, then remove deposit, and place in a pipette whose upper end is closed by a rubber stopper. The pipette should contain the following preservative fluid : — Pot. acetate ... ... ... 60 grms. Chloroform ... ... 10 cc. Distilled water ... ... ... 1,000 cc. When the sediment has sunk through the fluid it may be transferred to a slide along with a drop of the preservative, and permanently sealed there. Specimens keep fairly well. The use of a centrifuge is of great value for secur- ing tube casts in perfectly fresh urine, and for washing them rapidly in water prior to preserving them. (8) Tumours of the bladder, especially when villous, may often be detected by the presence of fragiiieiits of the growth in the urine. These show a core of connective tissue with its blood-vessels, coated with several layers of nucleated epithelial cells. In can- cerous tumours, though their debris is commonly enough present^ yet nothing at all so characteristic is to be seen as is found in the papillomata. (9) Elastic fibres are often present in cases of ulceration of the bladder. They may be detected either without special treatment, or after the use of caustic soda, as was described in Chapter VI. on the " Respiratory System," after a preliminary filtration of the yet acid urine to remove the phosphates, which would otherwise be precipitated copiously when an alkali was added. The parasites that infest the urinary tract are in temperate climates neither numerous nor common. Senator"^ enumerates the following : — Echinococcus, * Loc. cit.. p. 420, ct scq. MiCR O SCO PIC A L EXA MINA TION. 345 cysticerciis cellulosse, eustrongjlus gigas, distoma (oi' Bilharzia) lia?matobiuin, filaria sanguinis liominis, nephropliages sanguinarius (a menilDer of the arthro- pod a related to the acari), rhabditis (sp. ?), and certain psorosperms. Several of these are of such extreme rarity as to be of no practical importance ; echino- coccus, cysticercus, and filaria having been described Fig. i^tT.— Ova of Bilharzia haematobium in urine. {After Roberts.) a, X 5i» in mucus ; b, x lOij in urine freshly voided. elsewhere,"^ distoma h^matobium alone needs to be referred to in this chapter. D. hcematohium. The ova measure 0*12 mm. by 0'04 mm. A spine projects at one pole or at a little dis- tance from it. In urine the spine is usually situated at the pole ; the form with a lateral spine predominates in ova obtained from the rectum (Fig. 97). The adult male Bilharzia is thicker and shorter than the female, and is provided on the ventral sur- face with a gynsephoric canal. The female is cylin- drical and wormlike. The male measures 12 mm., the female about 16 mm., in length. Their habitat is in the blood-vessels of the portal system and in the * Pp. 92 and 204. 346 The Urine. venous plexuses of the bladder and rectum. The ova escape from the blood-vessels into the tissues of the body. Those which reach the rectum and bladder are discharged, and enable a diagnosis to be made. The parasite is very common in Egypt, where nearly a fourth part of the native population are supposed to suffer from it. After the urine has been voided for some time, it becomes contaminated by numerous non-pathogenic fungi and infusoria ; but several pathogenic bacteria occur in the urinary tract, and in cases of doubt should always be sought for. The chief of these are the gonococcus, the tubercle bacillus, which must not be mistaken for the morphologically similar smegma bacillus, and the bacillus coli communis. In cases of cystitis a great variety of bacteria may occur. Actinomyces, though rarely present in the kidney, has been found there. ForeJg-n toodies often occur in urine which has been set aside for examination. Besides hairs, feathers, moth-wing scales, cotton, woollen, and silk fibres, starch grains derived from dusting powders — and readily recognised by their turning blue on the addition of a little dilute tincture of iodine — and, more confusing than any of these, pinewood dust swept from the floor — one occasionally finds fragments of the contents of dermoid tumours or abscesses that have opened into the bladder or ureter. Small shreds of striped muscle may in rare instances be voided with the urine, and are derived, in some cases at least, from a sloughing psoas abscess. It may happen also that the patient has been sick, and sputum or vomited matter may be more or less abundantly mixed with the urine. If these sources of contamination are forgotten, there is a risk of very erroneous interpretations being given of not a few urinary deposits. 347 CHAPTER YIII. The Skin. For the examination of the skin and its appendages the patient should be stripped as completely as cir- cumstances permit and placed in a good light. One should first note the colour of the skin as a whole. In anaemia the skin is pale; in chlorosis it has a greenish tint ; in pernicious anaemia it is lemon yellow. In order to distinguish the yellowness of per- nicious anaemia from jaundice, look at the conjunctiva. The best way to do that is to place one hand on the patient's forehead, ask him to look at the ground, and then raise the upper eyelid with the thumb. In jaun- dice the conjunctiva is seen to be yellow where it covers the sclerotic ; in anaemia it is white. In judging of the degree of anasmia, one should be guided more by the colour of the mucous membranes than by that of the skin itself. The conjunctiva lining the lower eyelid is most usually taken as an index. It is easily seen by getting the patient to look up while one depresses the lower lid with one finger. Instead of being pale, the skin may be abnormally red or flushed. The flushing may be general or local. Its exact extent should always be noted, and whether or not it fades on pressure. The best way of telling whether any redness of the skin fades on pressure or not is to place a lens on the skin and press it down. It will then be seen whether or not the skin becomes pale under the lens. The term tache c^r6brale is applied to the red flush which appears in some cases of intracranial disease when the skin is stimulated. To elicit its 348 The Skin. presence, di^aw the finger nail firmly across the patient's forehead. A red line soon develops along the track of the nail, and persists for some time. It is due to a disordered vasomotor supply, but is found in other conditions besides those of cerebral irritation, and is therefore not of much diagnostic value. Rarer alterations in colour of the skin are those due to the taking of nitrate of silver and those which occur in Addison's disease. The former constitutes what is known as argyria. It consists in a leaden grey hue of the whole skin, which is unaffected by pressure. The pigmentation of Addison's disease consists in a bronzing, which appears first on parts in contact with the air, and next on those which are ex- posed to pressure. It is made up of small brownish spots, which fade off' at their margins into healthy skin. The lips and buccal mucous membrane should always be examined in cases of supposed bronzing. In Addison's disease they often exhibit marks of pig- mentation of a dark bluish -black colour, which have been compared to the stains produced by sucking a pen. Having noted any alteration in the colour of the skin, one should look for the presence of any erup- tion. If any such be observed, the patient should be questioned about it on the lines laid down on p. 9. The exact situation and extent of the eruption should be noted, and whether it is symmetrical or confined to one side only. These general facts having been noted, one should pass to a description of the minute characters of the eruption. In order to do this, it must be borne in mind that every cutaneous eruption consists of a ** primary lesion, " to which secondary lesions may or may not be superadded. The following is a description of the different primary lesions which may be met with. (1) macules or spots. — Any abnormal change in Lesions. 349 the colour of the skin confined to a limited area. Always note whether or not they fade on pressure. (2) Papules. — Solid projections above the sur- face, which are not larger than a pea. The term tubercle is applied to any solid projection from the skin which is larger than a pea but not larger than a cherry. Anything larger than that is called a tumour. Always note whether the top of a papule is rounded, pointed, or flattened. As regards the base, observe whether it infiltrates the skin widely or not. (3) Vesicles. — Elevations of the horny layer of the epidermis by transparent or milky fluid which are not larger than a pea. If larger than that they should be described as bullae or blebs. Always note whether or not there is an area of redness around the base of a vesicle. (4) Pustules. — Small elevations of the skin containing pus. Always observe whether there is much infiltration around them or not. (5) Wheals. — Slightly elevated portions of skin, the centre of which is paler than the periphery. Having stated which of these primary lesions it is that composes the eruption, one should next note whether the lesions are isolated (discrete), or whether they run together. It must also be remembered that an eruption may be made up of more than one kind of primary lesion. Thus papules may be mingled with pustules, or pustules with vesicles, and so on. Next look for secondary lesions. These are either produced mechanically or are the result of changes which take place in the primary lesion in the course of its growth or decline. The commonest secondary lesions of mechanical production are excoriations due to scratching and fissures (rhagades) — deep cracks going down to or through the coriumj and produced by the stretching of the 35° The Skin. skin after it has become inelastic owing to infiltration. Fissures are often very painful. The following are the secondary lesions produced by changes in those which are ]5rimary. (1) Desquamation. — If the primary lesion be a dry one (macules or papules), a mere scaling off of epidermic cells occurs, and the eruption is then said to be " scaly.'' In moist lesions (vesicles, pustules, bullae) the epidermic cells become glued together by the dried fluid, and a scab or crust forms. The scab may be serous, purulent, hsemorrhagic, or sebaceous, accord- ing to the nature of the contents of the primary lesion. (2) InliUratJoii may occur around the primary lesions leading to the production of a leathery feeling in the skin. This is usually the result of prolonged chronic inflammation. (3) Pigmentation may occur around the prim- ary lesions. This is also usually due to prolonged inflammation. (4) Ulceration. — Due to breaking down of the primary lesions and destruction of a part of the true skin. The points to note in describing an ulcer are (1) the nature of the floor of the ulcer and the granula- tions covering it; (2) the character of the edge — smooth, raised, undermined, etc. ; (3) the discharge ■ — is it serous, purulent, watery, fetid, etc. 1 (4) the character of the surrounding skin, whether indurated, pigmented, etc. (5) Scar formation.^This only occurs where the true skin has been involved, i.e. wliere there has been an ulcer. Describe the scar, noting especially whether it be thin or thick, freely movable or ad- herent to the deeper tissues, pale or livid, pitted or not, surrounded by a zone of pigmentation or not. Palpation. 351 Proceed now to the palpation of the skin. Pass the hand gently over it, pinching it up between the forefinger and thumb, and note the following points : — Is it smooth or rough, thin or thick, dry or moist % If there be any visible sweating, note whether it is general or local ; whether it is attended or not by any flushing of the skin ; and whether the sweat has any particular odour. The elasticity of the skin should be investigated. If a fold of healthy skin is pinched up it immediately flattens itself out again when released. Sometimes, however, it only does so very slowly, remaining for a considerable time in a creased condition. This indicates a diminished elasticity. It occurs not infrequently in debilitated and in old persons. The condition of the subcwtaiieous tissue should also be investigated. It may be infiltrated with fluid (oedema), with solid material (as in myxoedoma), or with air (subcutaneous or surgical emphysema). The presence of oedema is usually recognised by the fact that if the skin be pressed with the finger, especially over a hard body such as a bone, a pit is left which persists for some little time. It must be borne in mind, however, that this is not an invariable guide. In some cases of oedema no pitting can be produced. This is specially apt to be the case where the oedema is one of very long standing. The best place to look for slight degrees of oedema in cai'diac disease is behmd the malleoli of the tibia and fibula. In chronic renal disease oedema can often be earliest detected below the conjunctiva. This subconjunctival oedema is seen by pushing up the lower lid over the sclerotic. A little drop of fluid resembling a tear is then squeezed up underneath the conjunctiva over the sclerotic. Subcutaneous emphysema gives rise on Fig. 98.— Animal parasites of skin. .^f^"* X 17-OIAM. a, (lea; h, Pediculus capitis^ ; h', ovum of ditto, with eml)ryo ("nit"); c P corporis; f/, P. pubis; e, Acarus scabiei (female, male, ovum, larva); /! Demodex folliculorum. Parasitic Diseases. jDv) palpation to a crackling sensation, wliich has been compared to that which is experienced in handling a bag of feathers. J^Iicroscopic exainiiiation of the skin and its appendages is confined to the diagnosis of some parasitic diseases, of which the following are the chief (Fig. 98) :— (1) Scabies or itcli. — This is due to the acarus scabiei. The female acarus is larger than the male, and forms burrows in the skin in which the eggs are deposited. These burrows should be looked for betsveen the fingers and on the inner aspects of the wrists. They are recognised with the naked eye as little short dark lines terminating in a sort of shining spot of skin. The eggs He in the dark line ; the insect in the shining spot. It may be picked out by means of a flat surgical needle passed along the black line to the clear spot. The use of a lens aids the operation, and permits of the recogni- tion of the insect. The latter may be placed on a slide under the microscope for more minute inspection (Fig. 98, e). (2) Pediculosis. — Three varieties of pediculus occur. Pediculus capitis on the head, P. corporis on the trunk, P. pubis on the pubic and axillary hairs. The eggs or "nits " of the P. capitis are stuck on to the hairs (Fig. 98, b' ). From their position on the hairs one can judge of the duration of the con- dition, for they are fixed on at first near the root of the hair, and are then carried up with the latter in its gi'owth. The higher up the nits are, therefore, the longer have pediculi been present. The P. corporis should be looked for in the seams of the clothes, especially where the latter come into close contact with the skin^e.^. over the shoulders. The microscopic characters of the pediculi are shown in Fig. 98, and require no verbal description. X 354 The Skin. It will be noticed that the P. corporis is the longest and narrowest of the three, the P. pubis is shoj'test and broadest, and the P. capitis is between the two in size. The P. pubis is also distinguished from the others by being yellowish-brown in colour. P. capitis and P. corporis are both greyish in colour, though the latter varies considerably with the colour of the skin of its host. The shape of the thorax and abdomen forms a distinguishing character between P. capitis and P. corporis (Fig. 98, 6, c, d). (3) Ring- worm.— Recent investigation by Sabour- aud and others has shown that two distinct classes of parasite are capable of producing the appearances which are included under the name " ringworm." One of these is not a trichophyton. It goes by the name of imc7'osporon Audouini, and is the cause of the commonest and most contagious and intract- able form of the disease. Its operations are chiefly confined to the scalp, but 90 per cent, of all cases of ringworm in that situation are due to its presence. The other parasite belongs to the trichophyton family, but it is probable that there are several varieties of it. It is the commonest producer of ringworm of the beard and skin (tinea circinata), but only occurs in about 10 per cent, of the cases of ringworm of the scalp. It succumbs much more readily under treatment than does the microsporon. The trichophyton is characterised microscopically by having fairly large spores, which are arranged in chains, and the joints of its mycelium are placed at regular intervals. The microsporon has small spores, which are scattered irregularly, and the joints of its mycelium are at unequal intervals (Fig. 99). A useful method of detecting hairs which are affected by ringworm consists in dabbing over the diseased patch with a piece of wool soaked in chloroform. On evaporation of the latter, the Parasitic Diseases. 355 afiected liaiis are Avhitened, and louk as if cuxered witli Iiuar frost. Tliey can thus readily be dis- tinguished from healthy liairs of the same size by the aid of a lens. Hairs affected by favus are not similarly whitened by chloroform. Microscopic examination. — If one is dealing with a j^atch of ringwoiTQ of the skin, it is sufficient to scrape off some of the scales with a blunt penknife, to place them in a drop of 10 per cent, liquor potassse, and cover. The mycelium of the fungus will be recognised as branching, refractile threads, amid whicli the spores are scattered in groups or rows. Fig. 99.— Vegetable parasites of tlie skin. a, Favus {Achorion Schonleivii), sliowiufr the parasite and an affected liair ; b. Ringworm (Micro^poron Audoiiini), showing low- and liigh-power viow of affected hairs ; c, Pityriasis versicolor, showing theniicrosporon furfur, x 800. 356 The Skin. If a hair be similarly examined, it will be found to be broken up and full of spores (Fig. 99, h). No mycelium can be seen. For diagnostic purposes, it suffices to wash the hair in ether and then to soak it for 15 minutes in liquor potassse. The spores will be seen in the substance of the hair and in its sheath. Fatty particles are the only thing likely to be mistaken f jr them. A drop of ether will dissolve fat particles but leaves the spores unaffected. Liquor potassse, how- ever, causes the spores to swell. Its use should therefore be avoided if one wishes to distinguish the two varieties of fungus. For that purpose staining is of great help. It should be carried out as follows : — (1) Remove an affected hair by means of a broad- pointed pair of forceps. (2) If very greasy, wash it for a few seconds in ether or benzol. (3) Steep the hair for an hour in a mixture of 10 parts of a 5% alcoholic solution of gentian violet and 30 of aniline water (Appendix, 24). (4) Dry the hair between blotting-paper, and steep in Gram's solution. This fixes the stain for 5-10 minutes. (5) Dry again, and then soak for 10 minutes in pure aniline to which enough iodine has been added to give it a distinctly brown colour. This decolorises. (6) Wash in pure aniline for a few seconds, then in xylol, and mount in balsam. On examination with the high power the two varieties of fungus can be differentiated by the characters already described. It should be noted that the difference in size of the spores of the two varieties is really not very great, after all. The arrangement of the spores and the character of the mycelium are the points to which attention should be directed. 4. Favus. — This is produced by the achorion Parasitic Diseases. 357 ScLonlemii, which consists of a long branching myce- lium with rather large spores arranged in rows or groups. If a favus crust and the accompanying hair be examined in caustic potash, the hair is seen to differ from one affected by ringworm in being full of mycelium. One can often see air bubbles being chased out of the mycelium as the liquor potassae finds its way in. The medulla of the hair is absent. The hair may be stained by the method described above. The long, wavy, branching mycelium will be easily seen, and a few rather large spores in rows or in grotips (Fig. 99, «). 5. Tiuea versicolor. — This is produced by the microsporon furfur. A scraping should be examined in caustic potash. The fungus shows a refractile mycelium which interlaces freely and includes bunches of round spores in its meshes (Fig. 99, c). The spores may be stained with saffranin, differentiated by weak acetic acid, and the mycelium counterstained with raethylen blue. 6. Deniodex follieuloniiii (Fig. 98, /) is a minute acarus about y-^^ in. in length, which is some- times found in the sebaceous contents of comedones. It has a disproportionately large abdomen marked with transverse rings, which give it at first sight the appearance of a minute worm. It possesses a suctorial proboscis and styliform jaws, and from the thoracic portion of the body four pairs of stunted legs project. It is simply a parasite lining in sebaceous matter, and is of no pathological importance. 358 CHAPTER IX. Nervous System. SECTION I.— ANATOMY AND PHYSIOLOGY OE THE NERYOUS SYSTEM. Much recent knowledge regarding the structure and mechanism of the central nervous system is still too unsettled to admit of being used at the bedside ; but if the student wishes to investigate a case of nervous disease intelligently he must first have a clear grasp of some well-established facts in the anatomy and physiology of the brain and spinal cord. A few paragraphs devoted to these subjects will therefore not be out of place. (1) Anatomy and physiology of the motor and sensory paths. — The student will remember that the motor area of the brain is situated round the fissure of Rolando, the leg centre being highest up, the arm centre next to it and the centres for the face, lips F B ONTA t Fig. 100.— Outer aspect of Right Hi'iuispliore, .showing coiivolution.s. Anatomy of Brain. 359 and tongue l>eiiig lowest. Stated more exactly, it may 1)6 said that the movements of the lower limlj are presirled over by the upper ends of the ascending Fig. 101. — Outer aspect of Left Hemisphere, showing functional areas. frontal and ascending parietal and the posterior end of the marginal convolution ; the movements of the V. OBT Fig. 102.— Mesial aspect of Right Hemisphere, showing convolutions. upper limb by the middle third of the ascending frontal convolution, the posterior end of the superior frontal, the middle third of the ascending parietal 36o Nervous System. (for the hand and wrist), and part of the marginal convolution lying posteriorly to the part which supplies the head. The head, neck, and face are supplied by Fig. 103.— Mesial aspect of Left Hemispliere, showing functional areas. the lower part of the ascending frontal and by the posterior extremities of the middle and inferior frontal convolutions. Also by a small part of the anterior extremity of the marginal convolution. The trunk muscles are supplied by that part of the marginal convolution which lies bet\'i een the centres of supply for the leg and arm (Figs. 100, 101, 102, 103). The motor fibres start from the pyramidal cells in the above convolutions and pass in the white matter of the hemispheres to the internal capsule {i.e. the knee-shaped band of white matter which is bounded on its outer side by the lenticular nucleus and on its inner side by the optic thalamus and caudate nucleus). The motor fibres occupy the anterior two-thirds of the posterior limb of the internal capsule, the fibres for the face being farthest forward, those for the leg farthest back, the fibres for the arm being between (-Fig. 104). It is in the internal capsule that haemorrhage most The Mo tor Pa th. 361 fiequeiitly occurs, and owing to the close approxima- tion of all the fibres at this point, a comparatively small lesion is aVjle to produce a widespread result. Fig. 104. — Diagram to show relative positions of the face, arm, and leg fibres in their course from coitos to eras. Tlie section through the cortex ami crus is vertical ; through the internal capsule it is hori- zontal ; * indicates the elbow of the internal capsule. /, face ; «, arm ; \. leg fltires. From the internal capsule the motor jB.bres descend to the crus cerebri occupying the middle third of its anterior aspect. As they descend in the crus tho fibres for the leg are to the outer side, the fibres for the face are nearest the middle line, and those for the ami are between the two. Entering the pons, the fibres are no longer quite on the surface but are covered by a layer of transversely placed fi.bres. In the upper part of the medulla they form a well-marked bundle, the anterior pyramid, lying quite on the surface. At tlie lower part of the medulla the greater numl>er of the fibres cross to tlie opposite side, forming what 362 Ner vo us Sys tem. is known as the " decussation of the j^yramids" and run down in the crossed pyramidal tract of the cord to end at diflferent levels in the grey matter of the anterior cornu (Fig. 105). The motor impulses are here transferred to the cells of the anterior cornu and ^ conveyed by their fibres y^ ^^(y, to the anterior roots, and thence to the motor nerves and muscles. The small number of fibres which do not decussate in the medulla are continued down in the anterior or direct pyramidal tract, and end in the anterior cornu of grey matter. Some of them also de- scend in the crossed pyramidal tract of the same side. It must also be re- Fig. 105. — Diagram showing the membered that a small course ofthe motor fibres from the number of motor fibres cortex to the cord. j j c c, corpsus callosuni ; c n, caudate ^lo not deCUSSate at all, leus ; I R, Island of Reil; C ?, "l-mf c^r\A in +Vifi ar»f(=>rinv istrum, * Site of facial decussa- ^^^ ^^^ 1" ^^® antenoi cornu of the same side. This, perhaps, explains the fact that after a unilateral central lesion the knee jerk on the same side may be exaggerated as well as that of the opposite leg. In thus tracing the course of a motor impulse, we have spoken of nerve cells and nerve fibies. It would be better, however, to discard these names in favour of the more recent terminology, which describes a nerve cell, its dendritic processes, and the fibre con- nected with it (axis cylinder process) as a '^ neuron/' Thus, anatomically, the motor impulses are conveyed Vil Nerue C.F nucleus Glaus tion ; c p T, crossed pyramidal tract DPT, direct pyramidal tract. The Motor Path. 363 by means of two neurons. One of these is tlie pyra- midal cell in the cerebral cortex and the motor fil)re arising from it {i.e. its axis cylinder process) and end- ing in the anterior cornu. The other is the anterior cornual cell, and the fibre arising from it and ending in the muscle. There is apparently no direct ana- tomical continuity between these two neurons, but the nerve impulse is able to pass from the one to the other by contact (Fig. 106). This conception has also the advantage of making clearer some well-known physiological and patho- logical facts. Thus it can easily be understood that if one part of a neuron be injured the health of the Tvhole neuron suffers. If, for example, what one may call the body of the upper neuron [i.e. the cortical cell) be injured, the axis cylinder process of the neuron [i.e. the motor fibre) is also affected, and ultimately undergoes the process spoken of as degeneration. Conversely, if a motor c: Fii^. 106. — Upper and Lower Neurons of Motor patli. c c, cerebral cell; s c, spinal cell; s, sensory fibre ; 31, muscle. 364 Nek vo us Sys tem. fibre be cut across — say, in the spinal cord — the health of the cortical nerve cell, of which it is a process, becomes secondarily impaired. We have spoken of the motor path as consisting of an upper neuron (the cortical cell and its motor fibre) and a lower neuron (the anterior cornual cell and its motor fibre). It must be realised that these are not entirely independent of one another. On the contrary, tlie upper neuron seems to exercise a sort of restraining influence on the lower which checks the outflow of nerve energy which is constantly proceeding from the lower neuron to the muscles, and which produces the " tone " of the latter. The result of this is, that if the upper neuron suffers damage in any of its parts, the restraint on the lower neuron is diminished, the tone of the muscles is raised, and, as a consequence, what are known as the "tendon reflexes" of the muscles become exaggerated {see p. 434). Tlie influence which the lower neurons exert on muscles in maintaining their tone is sometimes spoken of as a " trophic " influence. Thus, if the lower neuron be injured in any part {e.g. if there be inflammation of the grey matter of the anterior corn 11, or if a motor nerve be cut across) the corresponding muscle fibres lose their " tone," they become flabby and atrophied, and are then said to be " degenerated." The course of the sensory fibres has not yet been definitely made out. The fibres for touch and muscular sense seem to run in the posterior columns, those for temperature and pain in the grey matter around the central canal (Ferrier) or in the antero- lateral tract (Gowers). The fibres of the posterior columns end in the nucleus gracilis and nucleus cuneatus of the medulla. Up to this point the neurons concerned have been the cells of the posterior root ganglia, which are therefore said to be " trophic " for the s( nsory fibres from the periphery up to the medulla. The Spinal Cord. 365 Tliere a new set of neurons begins with the cells of the nucleus gracilis and nucleus cuneatus. The fibres arising from these cross to the opposite side in the lo^ver pait of tlie medulla, forming the decussation of the tillet, that being apparently the main sensory crossing. They then pass up to tlie tegmentum, and the majority en 1 in the thalamus. The remainder, however, appear to pass up through the posterior part of the posterior limb of the internal capsule to find their termination in the cerebral cortex. The central convolutions, and especially the gyrus fornicatus, seem to be the parts of the cortex chiefly concerned in the appreciation of sensory impressions, but it is probable that the sense of touch is located in the Rolandic area as well. The muscular sense seems to be located in the deeper layers of the motor cortex. The course of the fibres and the position of the centres for the special senses are described under the section dealing with the cranial nerves. The speech centres and their connections are described at p. 382. (2) The spioal cord. The cord extends as far down as the interspace between the first and second lumbar spines; the membranes are continued down as far as the body of the second sacral vertebra. The cervical enlargement reaches to the seventh cervical spine. Its largest part is opposite the disc between the fifth and sixth cervical vertebrae. The lunibar enlargement lies opposite the three lowest dorsal spines, its widest part corresponding to the body of the twelfth dorsal vertebra. Physiologically tlie cord is to be regarded as made up of a series of superimposed segments, from eacli of which a pair oi nerve roots arises. To enable us to localise focal lesions of the cord it is necessary to be acquainted with the functions of each segment, and therefore with the area of supply of the pair of nerve C. I. JI. Til. IV. V, VI. VII. VIII. 1). I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. L. I. II. III. IV. V. S.I. II. III. IV. OUIOIN FllOAf COIID. (1) ,4 s regards bodies. Between atlas and occiput. Oiiiiuh-ile axifi. Oiiposite axis. Oiiposite Srd eerv, vert. Opposite -4111 cerv, vert. Opposite .ith cerv. vert. Opposite 6tli cerv. vert. Opposite 7th cerv. vert. Opposite disc Ije- tween 7tb cerv. and 1st dorsal. Opposite disc be- tween 1st and 2udD. Opposite disc be- tween 2nd and 3rd D. Opposite disc be- tween Srd and 4th D. Opposite lower border 4th D. Opposite lower border 5th D. Oiiposite body of 6th D. Opposite body of 7th D. Opposite body of 8th D. Opposite liody of 9th D. Opposite body of 10th D. Opposite ))0dy of 11th D. Opposite body of 12th D. Opposite body of 12th D. Oppo.'-ite body of 12th D. Opposite disc be- tween 12th D. and 1st L. Opposite Tiody of 1st L. Opposite body of 1st L. (2) As regards spines. A hove arch of atlas. Opiiosite arch of atlas. Opiiosite siiiiie of axis. Oiiposite interval between 2nd and ."Jrd spines. Opposite spine of Srd cerv. Opposite spine of 4th cerv. Opposite spine of 5th cerv. Opposite spine of 6th cerv. Opposite spine of 6th cerv. Opposite spine of 7th cerv. Opposite spine of 1st D. Opposite spine of 2nd D. Opposite spine of Srd D. Opposite spine of 4th D. Opposite spine of 5th D. Opposite spine of 6th D. Opposite spine of 7th D. Opposite spine of Hth D. Opposite spine of 9th D. Opi)osite spine of loth I). Opposite spine of nth D. (Opposite spine of 12th D. POT XT OP KXIT. Between atlas and occiput. Above axis. Aliovc .^rd cerv. Above 4th cerv. AV)ove 5tli cerv. Above 6th cerv. Above 7th cerv. Above Ist dorsal. Between island 2nd. Between 2nd and .3rd. Between Srd and 4th. Between 4th and 5th. Between Between Between Between Between loth. Between nth. Between 12th. Between 1st L. /Between L. . Between L. Between L. Between L. Between \ 1st S. 5th and 6th. 6th and 7th. 7th and 8tb. 8th and 9th. "Jth and 10th and nth and 12th D. and 1st and 2nd 2nd and Srd Srd and 4th 4th and 5th 5th L. and f)p]>ositc spine of 1st L. Between 1st and 2nd R. Between 2nd and Srd S. Between .Srd and 4ih S. Between 4th and 5th k S. C. I. Jl. 111. IV. VJ. Vll. VIII. D. I. II. IJI. IV. y. Vf. VII. V^III. IX. X. XI. XII. L. I. II. III. IV. V. .S. I. II. III. IV. V. WU.sci.ics. Slonio iiia.st(>icl.| 'l'r;i])i'y,ius. Sc.Hlciii. llotalors of Ucud. Diapliragin. Diaiibragin, supra ami infra spiua- tiis, deltoid, biceps, supinator loiigus, coraco-bracbialis, rbom- boids. Deltoid, biceps, sup. longus and brevis, coraco-ljracblalis, rbom- boids, bracbialis-aiiticus, teres minor, pectoraJis (clavic-bead), serratu.s magnus. Biceps, l)racliialis anticus, pector- alis (clavic-head), serratusmag- nus, triceps, extensors of wrist and fingers, pronat )rs. Triceps, extensors of wrist and fingers, pronators, flexors of wrist, subscapularis, pector- alis (costal bead), latissimus dorsi, teres major. Flexors of wrist and fingers, small muscles of band. Extensors of tbunib, muscles of tbenar and bypotbenar emin- ences. ' Muscles of back and abdomen. Muscles of abdomen. Ilio-psoas, sartorius, quadriceps, adductors. Quadriceps, internal rotators and abductors of hip. Abductors and adductors of hip. tibialis anticus, hamstrings. External rotators of hip, anterior tiliial muscles, extensors of toes, calf muscles and glutei, ham- strings. .Glutei, calf muscles, peronei, small ) muscles of foot. I Perineal muscles, bladder and rec- / turn. , Back of bead, angle of j-iw to vertex, neck. Nock, upper shoul- der, u|iper ]iari of chest. Back of shoulder and arm, outer side of arm and forearm. Narrow strip on front and back of arm and forearm, outer half of hand. Inner side and l)ack of arm and forearm, middle of hand. Part of arm&fo rearm, inner half of hand. Inner side of arm and forearm down to waist, ItKKI.KXKS. /Skin of chest and abdo]ue.n in bands cor r e- sponding to dis- tribution of N spinal nerves. Skin over groin and front of scrotum. Outer side of thigh. Front and inner side of thigh. Inner and outer side of thigh and leg to ankle. Back of Dhigh (ex- cept in distribu- tion of 1st and 3rd sacral), outer side of leg and foot. strip on back of thigh and leg, sole of foot. Skin over sacrum, perineum, gen- itals (posterior surface!, rectum, and vagina. Supinator. jerk, l)iceps jerk. Elbow jerk, wrist jerk. Epigastric (4th to 7th). Abdominal (8th to ) inh). Cremasteric. Knee jerk. Gluteal. Plantar, ankle > jerk, and ankle clonus. Rectal / vesical. and 368 Ner vo us Svs tem. roots arising from it. Tlie table on pp. 366 and 367 shows (1) The points of origin of the nerve roots from the cord as regards both tne bodies and the spines of the vertebrae. This enables one to localise on the sur- face of the body the position of each spinal segment. (2) The points of emergence of the nerve roots from the spinal canal ; and (3) The motor, sensory, and reflex functions of each pair of roots, and, therefore, of each segment. Plates VI. and VII. exhibit in a diagrammatic form the motor functions of the cervical and lumbar segments ; the sensory functions are shown in Figs. 107 and 108. Fig. 107. - Lateral view -of the skin areas supplied by tlie second, third, and fourth cervical segments. 5TERN0MAST01D S C ALEN 1 NECK MUSCLES C 2and37"'''^'^ PE21US (dovjn to 6^" dorsal) -^ o 4 T. '^. ^ T^RES MINOR '^ ^6- ^> //) C0RAC0BRACHI/\LI5^'C> '^. 'oy ^ <. ^A DE|P SHOULDER MUSCLES \ e %. '^>. r Vi ^^ ^ 'V?, V / ELBOW JERK ^•-v^ IWRrST JERK ^-o. V I P^TO RALIS MAJOR <^/ '^J* ^A> ^f/^ "^ (/ -«, /U ^ OF HIP. PLATE VII.— MOTOR SEGMENTAL FUNCTIONS OF THE LUMBAR ENLARGEMENT. [To face p. 371. The Spinal Cord. 371 The peripheral distribution of the chief sensory nerves is sulficiently indicated in Figs. 110, 111, and 112. The exact distribution of the sensory nerves Fig. 109. — Sclieme of a transverse section of the spinal cord, slio^^lng on the left side the positions of the various tracts, and on the right side the' names of the diseases affecting each part. 1, Descending flbres of fillet in lateral ground bundle ; 2, Schultze's descending tract in postero-external tract ; 3 Septomarginal tract of Bruce and Muir in postero-intemal tract. Besides tue names given on the diagram, the follow- ing synonyms should be noted :—Poscero-internal tract = Fasciculus gracilis = Column of GoU ; Postero-external tract = Fasciculus cuneatus = Column of Burdach ; Marginal zone = Lissauer"s tract; "Comma" tract = Ascending antero-lateral tract = tract of Gowers. (This must not be con- fused with Schultze's descending tract, to which the term comma tract is also sometimes applied.) of the fingers is shown in Fig. 113, and should be compared with the segmental sensory distribution represented in Fig. 114. Vascular supply of the brain and spinal 372 Nervous System. —r^ 4l 7 Fig. 110. — Cutaneous nerve supply of upper limb. Anterior aspect : 1, cervical plexus ; 2, circumflex ; 3, ext. cut. of muse, spiral ; 4, ext. cutaneous ; 5, mediau ; 6, ulnar ; 7, int. cutaneoiis ; 8, nerve of Wrisberg ; Posterior aspect : 1, cervical plexus; 2, circumflex ; S, int. cut. of muse, spiral; 4, intercosto-hunieral ; 5, nerve of Wrisberg; 6, int. cutaneous; 7, ext. cut. of muse, spiral ; 8, ext. cutaneous; 9, ulnar ; 10, radial. \2 ! ?,. 8 10 i / o / i"\ 8 Fig. 111.— Cutaneous nerve supply of lower limb. Anterior aspect: 1, ilio-inguinal ; 2, genito-cvural ; 3, ext. cutaneous; 4, middle cutaneous ; 5, internal cutaneous ; 6, patellar plexus ; 7. brauclies of external popliteal; S, incernal saphenous; 9, musculo-cutaneotis ; 10, external sa- phenous; 11. anterior tibial. Posterior aspect: 1, -', 3, small sciatic; 4, ex- ternal cutaneous ; 5, internal cutaneous; 6, internal saphenous; 7, branches of external popliteal; 8, short saphenous ; 9. posterior tilnal ; 10, internal saphenous ; 11, internal plantar ; li', external plantar. 374 Nervous System. cord. — The brain is supplied by the internal carotid and vertebral arteries. Owing to the position of origin of the left common carotid, an embolus can enter it more easily than it can the artery of the opposite side. Embolic lesions are therefore more Great occipital — -/— Small occipital (cervical plexus) Great auricular (cervical plexus) 5th, supra-orbital branch 5th. auriculo temporal branch i [ — -J-Sth. infra-orbital branch Fis;. 112.- — -) 5th. inferior dental branch Superficial cervical (cervical plexus) -Distribution of the sensory nerves of the head. Compare witli it the segmental distribution as shown in Fig. lOS. frequent in the left than in the right cerebral hemi- sphere. The two vei'tetoi'al arteries unite at the lower border of the pons to form the basilar, which runs up the middle of the anterior surface of the pons, and ends by di\dding into the two posterior cerebrals. It gives off lateral branches which run out transversely over the pons, and vertical branches which pass into its substance. The latter not infrequently become thrombosed. The posterior cerebrals supply the occipital lobes, the lower part of the tenqjorosphenoidal lobes, with the uncinate gyrus, the inner part of the crus Blood Supply of Brain. 375 and the corpora quadrigeraina, and tlie posterior part of the posterior limb of the internal capsule. Block- ing of one of these arteries will therefore involve the visual centi'e and the sensory fibres. The basilar artery supplies the upper surface of Fig. 113. — Showing the exact distribution of the sensory nerves of the fingers. E, radial ; m, median ; u, ulnar. the cerebellum ; the vertebrals supply its lower surface. The iiiteriial carotid oives off the anterior cerebral artery, which curves round the anterior end. of the corpus callosum, and is chiefly distributed to the inner surface of the cerebral hemisphere as far 376 Ner vo us Sys tem. back as the })arieto-occipital fissure. It also sup[)lies the superior frontal convolution. The internal carotid is practically continued on to the brain as the middle cerebral, which lies in the p^ Sylvian fissure. An embolus which has found its way into the internal carotid, therefore, usually ends in the middle cerebral or one of its branches. The middle cerebral gives off cortical hrancltes^ which supply the nio^or area of the upper part of the temporosphenoidal lobe. These branches anastomose Blood Supply of Brain. 377 freely wifcli those of adjoining arteries, hence blocking of one of them may be largely compensated for by the establishment of a collateral circulation. It also gives off central branches, which run more or less vertically upwards, penetrating into the brain sub- stance and supplying the basal ganglia. There are two chief groups of these central arteries — an anterior group called the lenticulo-striate, and a posterior group, the lenticido-optic. These arteries are very commonly the seat of miliary aneurysms, and as the lenticulo-striate are more directly exposed to the force of the wave of arterial blood, they are more frequently ruptured than are the lenticulo-optic. These central arteries do not anastomose with one another. They are, therefore, to be regarded as end- arteries. Hence it is that a lesion of one of them is much less likely to be compensated than is a lesion of a cortical branch. The venous blood from the brain is poured into the venous sinuses. Owing to the slow current in these, thrombosis readily occurs in them. The blood from the interior of the lateral ventricles is chiefly returned by the veins of Galen, which end in the straight sinus. Owing to their long course, these veins are frequently exposed to pressure by tumours, etc. This is apt to lead to increased exudation of fluid into the lateral ventricles. The arteries which supply the spinal cord have a long and tortuous course. This renders them liable to thrombosis, but makes embolism of them almost impossible. The lower end of the cord is far removed from the point of origin of the vessels which supply it. Hence it is, perhaps, that this part is more liable to suffer damage from nutritional changes than are the higher regions. The student mav now pass to the method of 3 7 8 Ner vo us Sys tem. examining a patient with nervous disease as described in the subsequent sections. We would recommend him to begin by ascertaining the state of the intellectual faculties of the patient, including speech (Section II.). He should then rapidly test the condition of the cranial nerves in their order. How this is to be done is described in Section III. (p. 387). By proceeding thus, valuable information is gained at the outset, which may guide one in his subsequent in- vestigations. The motor, sensory, and reflex functions should then be examined in order, following the methods described in Sections IV. (p. 418), Y. (p. 427), YI. (p. 431). Lastly, the electrical reactions of the muscles and nerves should be tested in those cases in which it may seem necessary (Section YII., p. 440). SECTION II.— INTELLECTUAL FUNCTIONS. It is important to arrive at some idea of the patient's intellectual state early in the taking of a nervous case, as it affords indications that are of help in the subsequent investigation of his symptoms. For example^ if one finds that his memory is deficient one attaches only a limited value to the account that he gives of the onset of his illness or the state of his previous health. Or if one discovers that he is coma- tose, or unable to understand speech, it is evident that one cannot expect to make much of any attempt to investigate the state of his sensory functions. This section will, therefore, be devoted to methods of investigating a patient's mental condition, including the functions concerned in producing and interpreting speech. The first thing to be determined is whether we are dealing with a riglit-liaiided or a left-liaiicled patient. The importance of this depends upon the fact that right-handed people are left-brained, and vice versa. Ask the patient, if a male, which hand he Intellectual Functions. 379 uses to throw a stone or to pull a cork : if a female, which haud is employed in comljing the hair. It is of comparatively little use to ask which hand he writes with, as all children are taught to write with the right hand. The state of the iiieiiiory next calls for in- vestigation. It may be tested by asking the patient what day of the week it is, what he ate at breakfast, and so on."^ Inquire as to his sleep, and whether or not he is troubled with dreams. Note whether or not he is more emotional than is normal. An abnormal emotional state is evidenced by the patient's bursting into laughter or into tears on very slight provocation, or by his giving way easily to fits of anger. In the course of taking his case, one will already have arrived at a general notion of the degree of the patient's intelligence. Sometimes it is necessary to ascertain whether he is the subject of Iialliicinatioiis or delusions. A hallucination consists essentially in an imaginary or a misinterpreted sense impression. A delusion is purely intellectual. It is an erroneous idea which would be incredible to the patient's equals, and which is unshaken by facts. If the patient says he hears voices when no one is present, or if he sees a tree and believes it to be a man, he is the subject of a hallucination — in the former case auditory, in the latter visual. If he declares that he is the Emperor of Russia, he is the victim of a delusion. The existence of hallucinations and delusions is often difficult to ascertain. Sometimes they are discovered by chance ; in other cases they can be elicited by skilful question- ing : often they are reported by the friends. Delirium or coma may be present ; in such * It is important to distinguish between («) the memory of recent events and [h) the memory of older occurrences. Both should be tested in eveiy case. 3^0 N'er vo us S\ 's tem. a case the investigation of the intellectual faculties already described is futile. Lastly, one should inquire whether or not the patient is the subject of fits. If he be so, a full history of the attacks should be obtained, following the scheme of interrogation given on p. 10. Should the observer be fortunate enough to see the patient during a fit, the following are the points to which he should specially devote attention : — (1) The nature of the movements. — Are they general, or confined to one limb or part of a limb ? Where do they begin] Are the convulsions tonic or clonic] Is there any struggling, arching of the back, or attitudinising ] Are the abdominal muscles involved or not ] (2) Is there any involuntary evacuation of the bladder or rectum ] (3) The state of the eyes. — Is the conjunctival reflex present, or is it abolished 1 Do the pupils react to light ] Is there any inco-ordinate movement of the eyeballs 1 One should next proceed to the investigation of the speech functions.'^ Supposing that the patient is able to speak, one should note whether there is any peculiarity in his articulation. The following are the chief abnorm- alities which may be present : — (1) Stammering:.— This requires no special description. (2) Lialling*, or baby speech. Ask the patient to read something aloud. If he lalls, one will recognise that all the difficult consonants are dropped ; he speaks like a baby, and, if a child, may perhaps make use of words of his own invention. P, B, and M, * In our description of the methods of clinically investigating the sjieech functions we have followed very closely the teaching of Dr. AVyllie {;vide his valuable work on the "Disorders of Speech "). Speech Functions. 381 T, D, and N, are the easiest consonants ; K, G, S, Sh, and Ch, are more difficult ; C and L are the most difficult of all. Thus, such a patient has no diffi- culty in saying "papa," "mamma"; but if asked to say " British constitution," he will probably pronounce it " Bitte tontitu." (3) Scanning: or staccato speech. — The patient speaks slowly and deliberately, syllable by syllable, as if scanning a line of poetry. Ask him to say "artillery." He will pronounce it "ar-til-ler-y." This is the kind of speech found in cases of multiple cerebro-spinal sclerosis. (4) Slurring- speech. — The syllables are slurred together as in a state of intoxication. Thus, "British constitution " becomes " Brizh conshishushon." This kind of speech is met with very typically in general paralysis of the insane. (.5) Syllable-stwnibling-. — In this condition the patient misplaces some of the letters in a word, and reiterates some particular syllables. Thus "West Eegister Street" becomes "West Eegigistrerer Street." If the patient's defect consists not in any per- version of articulation, but in an inability to produce speech at all, or to understand it when spoken or when written, then his condition is described as one of aphasia. In order to understand the method of investigating a case of aphasia, it must be remembered that for purposes of speech we hav^e (1) a producing mechanism. This consists of two parts — one concerned in the pro- duction of spoken speech, the other in the production of written speech. (2) A receiving mechanism. ^ This also consists of two parts — one for the reception of spoken speech, the other for t^he reception of written speech. 382 Ner vo us Sys tej\i. We may thus classify cases of aphasia as follows : — [ Aphomia (loss of power 1. Lesions of productive mechanism 1 of talking). (motor aphasia). \ Agraphia (loss of power ( of writing), „ -r • J! i- \, • i Auditory (word deaf- 2. Lesions 01 receptive mechanism \ -^ ness'i (sensory aphasia). \ ^.^^^^ (word blindness). It must be borne in mind, however, that it is the exception to meet with a case of aphasia of a pure type. Thus, a patient may have both aphemia and also word-deafness. He may be unable to read as well as unable to write, and so on. The cortical centres for the production and re- ception of speech are situated in the left cerebral hemisphere in right-handed persons, in the right hemisphere in the case of those who are left- handed. Hence the importance of ascertaining early in the investigation of a nervous case whether the patient is right- or left-handed. The centre for sj)oken speech occupies the posterior extremity of the third frontal convolution (Broca's convolution), and the lower end of the ascending frontal and probably also of the ascending parietal convolution. The centre for the production of written speech is believed to be in the posterior end of the second frontal convolution. References to Fig. 115. c, cuneus ; c c, posterior extremity of corpus callosnni; F ."5, Broca's convolution (speech centre); T 1, suuerior teniporo sphenuidai, or Wernicke's, convolu- tion (auditory word centi'C) ; 1 and l',left and right optic radiations; 2, fibres connectin?,' Teft angular gyrus with left cuneus and through the corpus callosum (ii' and 2") with the right cuneus; a lesion at x cuts these fil ires as well as the optic radiation, and therefore causes right lateral homonymous hemianopsia— word blindness— but no agraphia ; 3, fibres connecting angular gyrus with Wernicke's convolution. The straight black line (4) represents the connection between Broca's and Wernicke s convolutions ; the l^lack line bifurcating in front i5) represents the connections of the angular gj'rus with the motor region of the left (5') and right (5") hemispheres. Speech Functions. 383 \Q.Qyr, Fig. 115. — Sch ematic figure, showing the course of the optic fibres. (From Wyllie, after Bejerine.) [For references see foot of i>. 382.] 384 Nervous System. The centie for the reception of spoken speech is in the posterior half of the superior teiiiporo-sphen- oidal convolution, and that for the reception of written speech (visual speech centi-e) in the angular gyrus. The visual speech centre is connected by special fibres with the primary visual centre in each occipital lobe. Hence, a lesion in the left occipital lobe does not produce word-blindness unless it be so situated as to cut od also the fibres which connect the visual centre in the light occipital lobe with the left angular gyrus (Fig. 115). For practical purposes it is best to proceed with the investigation of any case of aphasia in the fol- lowing order : — I. ISpoken speech. 1. How is it received and interpreted 1 — Find out, firstly, whether the patient's hearing is good. If so ask him to put out his tongue, shut his eyes, etc. If he does so, test him as to his understanding of nouns by asking him to touch his nose, ear, chin, forehead, etc., in turn. Then test his verbs by asking him to smile, to whistle, etc. If the patient responds satisfactorily to these questions, he has evi- dently no difficulty in interpreting the meaning of words heard — i.e. there is no ivord-deafyiess. 2. How is it j)roduce I. ? (1) If the patient can only use a few words, make a note of what these are. If he repeats any word or phrase again and again ("recurring- iitteraiice"), note what it is. (2) If he has a considerable vocabulary, make a note (rt) of any examples of lalling, slurring, etc., as described on pp. 380 and 381. This affords an indi- cation of his j)oiver of articulation. Test him with such words and ])hrases as "British constitution," " West Register Street,'' " Biblical criticism," "artillery." Speech Functions, 385 {b) Show liini common ol)jects — a knife, a pen, a matchbox, etc. — and ask him to name them or, if he is dumb, to indicate with his fincjers the number of sylhibles in the name of each. If he is unable to fulfil these tests, he has evidently got some forget- f ulness of words (aiiiiie§>ia. verbalis). Sometimes the patient has a general idea of the word he wants to use, but forgets exactly how to pronounce it. He omits some syllables, or substitutes others for them, so that the listener may hardly be able to make out what word it is he wishes to use. This has been termed by Wyllie '■'■ articulative amnesia.'^ (c) If he makes mistakes in his use of words, calling the knife a pen, or vice versa, he is suffering from paraphasia. In that case, one should note whether or not the patient shows that he is aware of his error by trying to correct himself, or whether he goes on talking gibberish. 3. Hoiv is it repeated or echoed i — ^Ask him to repeat words after you. If he is word-deaf, try to make clear your request by the aid of pantomime, repeating the word or phrase over and over again. If he is able to repeat what you say, endeavour to find out whether or not he understands what he is saying. 11. l^%^i*itfeii speech. 1. How is it received or interpreted] — ^ Ascertain whether or not his sight is good. If so, write on a piece of paper such questions or commands as. How old are you ? Put out your tongue, etc. If he does not respond satisfactorily, there is evidently some word-blindness present — i.e. the patient has visual aphasia, 2. Hoiv is it iwodiiced J — Ask him to write his name, (This can often be done when all other power of writing is lost.) If he is able to do so, ask him z 386 Nervous System. some simple question — e.g. How many do two and two make 1 — and got him to write a reply. If he has word-deafness, put your question in writing. If his right hand is paralysed, make him write or print with his left. If he writes pretty well, get him to write an account of his illness, and note whether he makes use of the wrong word at times (paragraphia), or whether there is repeated use of any particular word. 3, Can he write to dictation or copy 1 — Try, using some simple book. If he succeeds, endeavour to ascer- tain whether or not he understands the meaning of what he writes. III. Plieiiomeiia associated avUIi speech. 1 . Does he understand 'pantomime ? Does he nod his head for " yes," shake it for " no," and can he indicate numbers with his fingers'? Loss of gesture language is termed ainiiiiia. Mistakes in the use of gestures — e.g. nodding for " no," or shaking the head for " yes " — is termed paramiiiiia. 2. Does he understand symbols — e.g. numerals ? Thus, one may write down — - 2 2 2 2 2 2 4 5 6 and ask him to point out which is right. If he can read music, test him with musical notes. 3. Can he recognise common objects ? — Place beside him a pencil, a coin, and a match. Ask him to strike a light, or to write something down. If he is unable to select the proper article for the purpose, he is suffering from mind -blindness. Inability to recognise his friends is another proof of the same condition. Olfactory Nerve. 387 SECTION III.— CRANIAL NEUVE FCTNOTIONS. In this section we propose to give a brief resume of the essential points in the anatomy of each cranial nerve, to indicate its functions, and, in some cases, the chief symptoms which result from its paralysis, and then to describe the method in which one inves- tigates the state of the nerve at the bedside. First ov olfactory iierve. Anatomy. — The nerve fibres which arise from the olfactory bulb are distributed to the Scbneiderian membrane, at the upper part of the nasal fossaa. The cortical centre for smell is believed to lie in the uncinate gyrus. The exact course of the fibres between the cortex and the bulb is unknown, but it is probable that some of them do not decussate. Test. — Have three small bottles containing some oil of cloves, some oil of peppermint, and some tincture of asafoetida. Apply these to each nostril separately, and ask the patient if he recognises them. In test- ing, avoid the use of such irritating substances as ammonia, for these act, partly at least, through the fifth nerve. The sense of smell may be abolished. This is known as anosmia. Before concluding that the nerve is at fault, take care to exclude local changes in the nose itself — e.g. catarrh. Parosmia is the name applied to a condition in which the sense of smell is perverted, so that, for instance, offensive substances seem to have a pleasant odour, and vice versd. Inquire also regarding hallucinations of smell. These sometimes constitute the aura of an epileptic fit. Second or optic nerve. Anatomy. — From the retina, which is the end-organ of the sense of sight, the fibres of the optic nerve pass back to the optic chiasma. Here the fibres from the inner half of each 388 Nervous System. retina decussate, whilst those from the outer half remain on the same side. Each optic tract, therefore, consists of fihres from the outer half of the retina on the same side and the inner lialf of the retina on the opposite side. Each tract passes back to the corpora quadrigomina, thence the fibres pass to the external geniculate body of the same side, then reach the posterior limb of the internal capsule, on leaving which they spread out in the optic radiation to the cortex around the calcarine lissure. This, therefore, constitutes the primary visual centre, and represents the opposite half of the field of vision, the left halt' of the held of vision being repre- sented in the cortex of the right hemisphere, and rice versa. From the primary visual centre fibres pass to the angular and supramarginal gyri of the same side, and these constitute a higher visual centre. In this higher centre word images would appear to be stored, and in it also both ej-es would seem to be represented, but the field of the opposite eye to a much greater extent than that on the same side (Fig. 115), Test. — In testing the optic nerve, one lias to investigate three functions : (1) Acuity of vision; (2) extent of field of vision ; (3) colour sense. We shall consider the methods of testing these seriatim. Certain preliminaries must always be attended to. One of these is to see that any error of refraction in the patient's eyes is first corrected, and that there is no opacity of his media ; another is to take care to examine each eye separately. 1. Acuity of vision. — If this be very much di- minished, it may be doubtful whether the patient is able to tell light from darkness. To investigate this, place the patient in a darkened room opposite to a lamp, alternately cover and uncover his eye, oi-, what is perhaps a better plan, concentrate the light upon his eye by means of a mirror or lens, and ask him to say when it is light and when dark. In lesser degrees of impairment, ask the patient to count fingers. This is done by placing him witli his back to the light while the observer, standing- facing the patient, holds up a varying numV)er of fingers of one hand, and asks .the patient to say Optic Nerve. 389 how many there are. The test should be applied at varying distances. For the detection of slight degrees of impairment of visual acuity Snellen's types will be found useful. These consist of letters of different sizes, each of which should be capable of being read at a definite distance — the largest at 60 metres, the smallest at 6. In using the types, the patient is placed with his back to the light, while the types are placed level with the eye at a distance of 6 metres (about 20 ft.). He is then asked to read the letters from above downwards. For the purpose of recording the result, the following symbols are employed : — V = visual acuity. d = distance of eye from type (i.e. 6 metres.) D = ,, at which type should be capable of being read. Suppose that at 6 metres the patient is able to read the smallest type — that is to say, that which should be readable at 6 metres off. Then his visual d {i.e. 6 metres) acuity (V) =: ^Fr~r- 1- 1 ^^ or normal. •^ ^ ' JJ (^.e. metres) But if at that distance he can only read the largest size of type — that which one should be able to read at 60 metres — then Y = -— 60. The term amblyopia (literally "blunt-eyed- ness ") is often used to mean defective vision without any visible change in the fundus oculi, or with signs of mere optic atrophy. By crossed amblyopia one means dimness of vision in one eye, there being a lesion in the opposite half of the brain. It occurs, for instance, not infrequently in hysterical hemi- anaesthesia on the same side as the loss of sensation. Tne term amaurosis (literally " darkness") used to signify complete blindness with a similar absence of 390 Nervous System. visible change. It must be confessed, however, that these terms are used very vaguely, and as far as possible they should be avoided. 2. Extent of field of vision. — For ordinary clinical purposes the extent of the field of vision can be tested with sufficient accuracy in the following way : — Seat yourself opposite to the patient and at a distance of about half a yard from him. If his right eye is to be tested, ask him to place his hand upon his left, and to look steadily at your own left eye. Look steadily yourself at the patient's right eye, your own right being closed, and hold up your left hand in a plane midway between his face and your own, and at first at almost full arm's length off. Keep moving the fingers of the hand, and bring it nearer until you can just yourself " with the tail of your eye " catch the movement of the fingers. Then ask the patient whether he sees them, telling him mean- while to be sure not to take his own eye off yours. If he fails to see the fingers, keep bringing the hand nearer until he sees them. Test the field in this fashion in every direction — upwards, downwards, to right, and to left, using the extent of your own field always for purposes of comparison. For more accurate delimitation of the field of vision, an instrument termed the perimeter is used. For a description of it special works on ophthalmology must be consulted. Changes in the field of vision. — It may be con- tracted all round its periphery. This is spoken of as " concentric diminution " of the field of vision. It occurs in hysteria, optic atrophy, and various aft'ec- tions of the retina. Sometimes the loss of vision is confined to the centre of the field. This is spoken of as a central scotoma or as central amblyopia. It is frequently Optic Nerve. 391 due to toxic causes — e.g. excess in tobacco or alcohol — causing a chronic reti'obulbar neuritis, and is then generally bilateral. Sometimes it is due to local disease of the choroid or of the retina in the neigh- bourhood of the macula. In that case it may afiect only one eye. The term Iieiiiiaiiopsia (also written hemi- aiiopia and hemiopia) means loss of sight in one-half of the field of vision in both eyes from causes other than disease in the retina. Right lateral hemi- anopsia means abolition of the right half of the field of vision ; left lateral hemianopsia, abolition of the left half. These forms of hemianopsia are also spoken of as " homonymous.^^ " Sujoe^'ior " and " inferior " hemianojjsia mean loss of the upper and lower halves of the visual field respectively. They are rarer than the lateral variety, and are sometimes spoken of as " altitudinal " hemianopsia . Temporal hemianopsia means loss of vision in the temporal or outer halves of both fields, and is due, therefore, to loss of visual power in the nasal half of each retina. It can only be produced by a lesion either just before or just behind the optic chiasma, involving those fibres of the optic nerves which have decussated, and is accordingly very rare. Nasal hemianopsia signifies a loss of the nasal or inner half of each field, and indicates a diminution of visual power in the temporal side of each retina. It can only be produced by a bilateral lesion con- lined to the uncrossed optic fibres on each side of the chiasma. It only occurs with excessive raritj^. Temporal and nasal hemianopsia are somebimes spoken of as heteronymous y in contradistinction to the homonymous variety. 3. CJoloiii' sense. — This is tested by means of Holmgren's wools. Throw all the skeins together on 362 Ner vo us Svs tem. a table in good daylight, keeping the test skein separate. Explain to the patient that he is to match the colour, not to name it, and that he is to select all those skeins which are like it, whether they are of a darker or lighter shade or not. Show him first a pure pale green skein, and ask him to match it. If he does so correctly, his colour vision is normal. If, on the other hand, he selects one of the " con- fusion colours," (grey, straw colour, etc.) he is to be regarded as colour-blind. Total colour-blindness is rare. Eed-green blindness is the commonest form. Yellow-blue Vjlindness is not nearly so conmiou. If the patient is totally colour- blind he confuses with the test skein all those of equal brightness, no matter what their tint may be. If red-green blindness is suspected, show him a purple skein and he will select blue as a match for it — indicating that he fails to see the red element in the purple. If he be blue blind he will select red or orange. Colour field. — In a normal eye the field for blue is largest, then comes yellow, then red, and lastly green. Concentric diminution of the colour field occurs in hysterical amblyopia. In some toxic con- ditions, especially tobacco poisoning, one finds a central scotoma for colour. Its existence can easily be determined by placing the patient with his back to the light, and then holding up about 2 feet in front of him a square of black pasteboard in the centre of which is a small white spot. Ask him to look steadily at the white spot, and while he does so suddenly place about 2 inches to the outer side of the spot a black strip of cardboard, near the end of which a red or green wafer has been fixed. If a central colour sco- toma is present, the patient will not see the red, or green spot whilst he is looking at the white one. If, on the other hand, the coloured spot be placed to the Third^ Fourth^ and Sixth Nerves. 393 inner side of the ^vhite spot, he lias usually no diffi- culty in seeing it. Colour-blindness, of course, inter- feres with the use of the test in some cases. The exact extent of the field for each colour is best test-ed by means of the perimeter. Subjective visual seusatious mav be pre- sent. Amongst the commonest of these for which one ma}^ have to inquire is the occurrence of what are known as muscc*^ volitantes — little specks or moats seen floating before the eyes, especially on looking at a white surface or up to the sky. They are not in- frequent in antemic and debilitated persons. In migraine peculiar zig-zag lines, known as " fortifica- tion fiirures," are often seen at the beginning of the attack, and in the investigation of such a case should always be inquired for. The teruL teicTiopaia is also applied to the condition. Hallucinations of sight occur in some cases, notaljly in delirium tremens ] they may also form part of the aura in epilepsy. Third, fouitli, and i^ixtli nerves. — It is con- venient to take these together, as conjointly they serve to innervate the muscles which move the eye- baU. Anatomy. — The fibres of these nerves take their origia from a series of nuclei which begin in the floor of the aqueduct of Sylvius below the anterior corpora quadrigeniina, and extend down as far as the eminentia teres in the floor of the fourth ventricle. The nucleus for the third nerve is highest up. Its most anterior cells supply the ciliary muscle and iris, those for the ocular muscles being farther back. Behind that comes the nucleus of the fourth, and most posteriorly of all that of the sixth. The third nerve emerges on the inner aspect of the crus, and is therefore apt to be involved in lesions implicating that part of the brain. The foui'th pair emerge on the anterior part of the roof of the fourth ventricle. They are peculiar in that they are the only cranial nerves which decussate between their nuclei and their point of emergence. The sixth emerges between the medulla and pons, and runs forward beneath the latter for a considerable distance before 394 -^-^^ '^<^ ^^ -^ ^^ TEM. leaving tlie slcull. This long course renders it particulculy liable to the effects of pressure. Fiiiiclioiis. — The sixth nerve supplies the ex- ternal rectus, the fourth supplies the superior oblique. All the other ocular muscles, along with the sphincter pupillte, the muscle of accommodation, and the levator palpebrse superioris, are supplied by the third. Symptoiiis of paralysis. — SixtJi nerve. Ina- bility to move the eye outwards and diplopia on look- ing in that direction. Possibly internal squint. In nuclear lesions there is also loss of the power of con- jugate deviation in the direction of the affected muscle. Fourth nerve. — Impaired power of downward movement ; possibly upward and inward squint ; and diplopia on looking down. Third nerve. — Ptosis ; the eye can only be moved outwards and a little downwards and inwards ; loss of accommodation ; pupil of medium size and unable to contract ; loss of power of accommodation. Paralyses of the third nerve are not infrequently partial — only one or a few of these functions being lost. Thus the levator palpebrte superioris is often alone atfected, producing ptosis, while the other muscles retain their normal power. In order to estimate the degree of ptosis, one must eliminate the action of the occipito-frontalis. This is done by pushing down upon the latter muscle so that the eyebrows are kept level, and then asking the patient to look up. The amount to which the lids are raised indicates the strength of the levator. Any retraction of tlie upper lid, from over- action of the levator, is to be noted by observing the relation of the edge of the lid to the upper margin of the cornea when the patient is looking straight forward. How to test tliese nerves. — • As will be gathered from the above resume, the signs of a lesion Squint. 395 involving any of these nerves may be : (1) The pres- ence of a squint ; (2) defective power of movement of the eye ; (3) the presence of diplopia. Of these signs the last is really the most trustworthy of all, for paralysis of the muscles supplied by the nerve may be 80 slight as to lead to no appieciable squint and to no visible defect in mobility. We shall consider the question of squint first. 1. By squint or strabisiiiiis is meant a want of parallelism in the two visual axes. It may be due either to paralysis of a muscle or to over-action — ■ i.e. spasm — of its opponent. The former constitutes paralytic strabisniiis, the other brings about what is called " concomitant " (or simsmodic) strabis- nitis. The first point, therefore, to be decided about any squint is this — Is it paralytic or is it concomitant ^ The chief points of distinction between the two are these : — {a) Spasmodic squint is always present ; on asking the patient to look straight forward, which is the position of rest of all the ocular muscles, the squint is seen at once. Paralytic strabismus, on the other hand, may only be visible when the patient happens to look in a direction requiring the action of the paralysed muscle. (6) In spasmodic strabismus the affected eye follows the sound eye equally in all its movements. It is for this reason that it is termed "concomitant." The visual axes are not parallel even in the position of rest, and the defect of parallelism remains the same in whatever direction the patient turns his eyes. In paralytic squint the visual axes may appear parallel in the position of rest, but even if they do not, the Avant of parallelism becomes more and more evident the farther the patient tries to turn his eyes in the direction of action of the paralysed muscle. 396 Ner vo us Sys tem. (c) Diplopia is usually present in paralytic squints, absent in those which are spasmodic. The commonest form of concomitant squint is the internal strabismus which occurs in children, and is associated with hypermetropia. 2. Defective power ol" iiiovenieiit of the eye.— In order to elicit this symptom, place the patient with his back to the light ; stand in front of him, and, holding up one finger, ask him to follow its movements with his eyes. It will easily be noticed whether or not a squint is brought out in either eye when he attempts to do so. The examination may be repeated on each eye separately, its mobility being tested in each direction. The power of convergence of the eyes should always be tested in addition to the mobility of each eye separately. In order to do this, hold up your finger directly in front of the patient at a distance of about 18 in. from the tip of his nose. Tell him to keep looking at the finger, which is then gradually brought nearer to the nose. Note to what extent convergence occurs, and whether it is well maintained ■ — i.e. whether the eyes remain directed towards each other or whether they diverge again after their first convergence. In some cases the defective mobility is so slight as to elude detection. This is especially apt to be the case in paralysis of the oblique muscles. In such a case one falls back upon the diplopia as an indication of the ajffected muscle. 3. Diplopia. — In order to elicit this symptom, hold your finger straight up in front of the patient, and ask him how many there are. Then repeat the question with the finger held at each side of the visual field, then high up, and then low down. Make sure that the patient's head is not moved during the investigation. If in each position he sees one finger Diplopia. 397 only, there is no diplopia. If at any part of the field two fingers are seen — one distinct, the other some- wliat hazy — one may be sure that diplopia is present. In that case one has next to ascertain (1) whicli is the affected eye ; (2) which is the afiected muscle in that eye. In order to determine these points, proceed as follows : — Place over one of the patient's eyes a red glass — preferably over the stronger eye, if he has better vision in one than the other. Then hold up in front of him a tall lighted candle. Move it about until he sees two candles — a red and a yellow. One of these is the true image — i.e. that of the sound eye ; the other is the false image — i.e. that of the affected eye. Which is which ? In order to answer this question the following rule is given : — The affected eye is that in the direction of the image of tvhich the diplopia increases. The application of this rule will be made plain by an example. Suppose the red glass is opposite the patient's left eye, and the patient says that the red image is to the right of the yellow. On moving the candle farther to the right the distance between the images increases — i.e. the diplopia becomes greater — that is to say, it becomes greater on moving the candle in the direction of the red image. But that is the image belonging to the left eye ; therefore, apply- ing the rule, the left eye is the one that is affected. The affected eye having been thus discovered, one wishes to know which is the affected muscle. To help one in this a second rule has been given : — The paralysed muscle is that lohich would have turned the eye in the position and direction oj the false image. In the above example one found that the left eye was the one afiected, and that its image was to the 398 Ner fo us Sy^s tem. right of tho true image. Applying the above rule, one asks, Which muscle moves the left eye to the right] and the reply is, The internal rectus. The left internal rectus, therefore, is the affected muscle. When, as in this case, the false image is on the opposite side to the affected eye, the diplopia is said to be ^^ crossecV ; when the false image is on the same side as the affected eye, the diplopia is said to be " direct.^'' Paralysis of an internal rectus always ]3roduces a crossed diplopia ; paralysis of an external rectus a direct diplopia. The detection of the affected muscle in cases of ver- tical diplopia is somewhat more dif- ficult than in cases where the diplopia is lateral. The same rules, however, ap- ply. Suppose, again, that the red glass is over the left eye, and that two images are seen, one above the other, the yellow being higher up. On looking upwards the distance between the images becomes greater ; therefore, according to the first rule, the right eye is the one affected. Which is the paralysed muscle ? In order to apply the second rule, one must remember the action of each muscle, and, from the position of the false image as described by the patient, deduce which muscle it is which would have turned the eye in that position and direction. This will be the muscle affected, Werner's diagrams (Figs. 116, 117) facilitate the recollection of this Fig. 116. Diplopia. 399 greatly. The continuous lines on the diagrams re- present the positions of the true images, the dotted lines those of the false images. Thus in paralysis of the left inferior rectus the false image is at a lower level than the true, it is to the right side of the true image (crossed diplopia), and its upper end is inclined towards the true image (Fig. 116). In paralysis of the left inferior oblique the false image is higher up than the true image and to its left side (direct diplopia), and its upper end is inclined away from the true image (Fig. 117). To return, then, to our supposed case. One had proved that the right eye was the one affected, and that its imao-e was higher up than the true imao;e. The paralysis must therefore affect either the right superior rectus or the right inferior oblique. Ask the patient whether the upper end of the false image is inclined towards or away from the true, and whether it is to the right or the left of the latter. Supposing he says that the false image (yellow candle) is to the left of the true, and with iis upper end inclined away from the latter. Then, one knows at once, by referring to the diagram (Fig. 116), that the right superior rectus is the muscle affected. If, in the above example, the patient is unable to state clearly whether the false image is to the right Left ! V HiCfUt Sap. 051.1 ^Su/j.OU Fig. 117. 400 Nervous System. or left of the true, and what is the exact nature of its inclination, one can have recourse to another method. Ask in which direction the difference in height of the two images increases. If towards the temple, the rectus is the affected muscle. If towards the nose, it is the oblique. In applying the above tests it is more convenient to move the patient's head in order to change tlie direction of his eyes than to move the candle. Thus if one turns the head to the left and asks him to look at the candle, the eyes are turned to the right. Thus moving the head to the left comes to the same thing as moving the candle to the right, and vice versd. To lower the eyes, hold the head back ; to elevate the eyes, depress the chin. These movements are effected by the observer, who places himself at the patient's side, the lighted candle being placed on a table some distance off. The position of tlie patient's liea<1 is also of considerable help in detecting tlie paralysed muscle. He tries, by turning his head, to give to the affected eye the position in which it should be placed by the paralysed muscle. Thus, if the face is turned to the left, it indicates a paralysis of the left external rectus or right internal rectus, and vice versd. If it be directed upwards, an elevator is paralysed ; if downwards^ a depressor. If the head is inclined to the left shoulder, it indicates pai^alysis of the superior rectus or oblique of the right eye, or of the inferior rectus or oblique of the left eye. If the inclination of the head is towards the right shoulder, it indicates paralysis of the superior rectus or oblique of the left eye, or of the inferior rectus or oblique of the right eye. Abnormal movements of the eye. Involuntary clonic contractions of the muscles of the eyeball not infrequently occur. The movements IVys ta gm us. 401 are usually symmetrical, occurring equally in both eyes. To these movements the term nystagmus is applied. If the external or internal recti are affected, lateral nystagmus results. Vertical nystagmus is due to an atfection of the superior or inferior recti, and rotary nystagiiius to an involvement of the oVjlique muscles. Lateral nystagmus is the commonest variety. In examining for nystagmus, ask the patient to look straight in front of liim, and observe whether the eyes remain steady. Then ask him to look to his extreme right, then to the left, and then upwards and downwards. Nystagmic movements are frequently onl}^ to be observed when the eyes are turned as far as possible in one of these directions. Such an occurrence is indicative of paresis of the muscles which turn the eyes in that particular direction. If both eyes are kept persistently turned in one direction, the condition is spoken of as conjiig-ate deviation of the eyes. It is usually either to the right or to the left. Conjugate deviation of the eyes may Vje brought about either by a lesion which produces paratysis oi- by one which causes irritation or spasm. In the former case the eyes (and usually, also, the head) are turned towards the side of the lesion, pro- vided the latter be in the cerebral hemisphere. The patient, in fact, is said " to look towards his lesion." An irritative lesion in a similar situation causes the deviation to be towards the healthy side. If, how- ever, the lesion have its seat in the pons, these rules are just reversed, the deviation being towards the sound side in a paralytic lesion, and towards the affected side in one which is irritative. examination of the pupils. — This important part of the investigation of a nervous case may be conveniently considered at this stage. The following points must be noted about the pupils in every case : — A A 402 Nervous System. 1. ISize. — Compare the size of the two pupils, first in a bright light and then in a dim light. Note whether the pupils are large or small, and whether any irregularity is present. It must be remembered that the size of the pupil in health is subject to great variations. As a rule, the pupils are larger in dark eyes than in light. A much dilated pupil is often a sign of nervous exhaustion or instability. Slight inequality of the pupils may also be present in perfectly healthy subjects. We are inclined to think that in such cases the left pupil is usually the larger. If one pupil is larger than the other, the question arises : Which is the normal % This question is not always very easily answered, but, as a rule, the pupil which exhibits the least mobility is to be regarded as the abnormal one. 2. Shape. — Note whether the pupil is circular in outline, as it should be, or whetlier its contour is irregular. Such irregularities may be due to adhesion of the iris to the lens {see p. 454). Irregularity in shape of the pupil is often an early symptom in general paralysis of the insane. ^. Mobility. {a) Reaction to lig^ht. — This is a reflex action. The stimulus is produced by the action of light on the retina, and travels along the optic nerve and optic tract to the corpora quadrigemina, and thence by communicating tibres (Meynert's fibres) to the centre for the third nerve. The motor impulse passes from that centre by means of the fibres of the third nerve to the sphincter pupillae muscle (Fig. 118). Test. — Examine each e3^e separately. Place the patient opposite a bright Hght, and cover the eye with the hand. Leave it covered for about half a minute, then withdraw the hand and watch the pupil. It should contract almost immediately, then The Pupils. 403 dilate again a little, and, after undergoing slight oscillations, settle down to its normal size. The test may also be carried out by concentrating light upon the pupil by means of a mirror or lens, just as one does in testing the light perception. Owing to the decussation of some of the fibres of the optic nerves at the chiasma, light acting upon one eye affects the centre for pupil contraction of the other eye as well as that on its own side. It is probable that fibres pass directly between the centres for the two third nerves which aid in bringing about this result. As a consequence, one finds tliat if light be shut off from one eye both pupils dilate, and if bright light be made to enter one eye both pupils contract. This is known as the c o 11 s <^ 11 s II a I reaction of the pupils. It should be tested by keep- ing one eye in the shade while light is thrown into the other. The effect on the jjupil of the shaded eye is then observed. Lesions of the optic nerve or optic tract interfere with this reflex. ITeriiiclse's hemiopic pupil reaction may Fig. lis. — Diagram showing the connections of the centres for contraction of the pupils. (Svsanzy.) 3 >.', 3 X, centre; 1, connection between nuclei of 3rd nerves; 2, Meynert's fibres; Q, corpora quadrigemina ; c, chiasma ; o, optic nerve ; p. pupil contracting fibres of 3rd ; l, seat of lesion ; arrows shijw path of impiUse in lesion of right tract at l. 404 Nervous System. be mentioned here. Hemianopia, as we have seen, may be due to a lesion of the optic tract between the chiasma and the corpora quadrigemina, or it may be produced by destruction of the optic fibres between the corpora quadrigemina and the occipital cortex, or it may be due to lesions in the cortical visual centres themselves. If the lesion be in front of the corpora quadrigemina — i.e. in front of the pupil centre — -the light reflex is lost ; whereas, if it be at any point behind that the contraction of the pupil to light is retained. It is uj)on this fact that Wernicke's reaction is based. In carrying out the test the light must, of course, be concentrated on the blind halves of the retinse. Proceed as follows : Place the patient in a dark room with a light beside his head. Hold a large plane mirror in the left hand, and by means of it illuminate both pupils and observe their size. Then take an ordinary ophthalmoscopic mirror in the right hand and direct a strong beam of light on to the blind side of the retinse. If the lesion be in front of the corpora quadrigemina no contraction of the pupils should result, if behind that they become smaller. (6) Reaction to accoiiiiiiodation. As is well known, the pupils become smaller on accommodating for a near object. It is really more correct to speak of reaction to convergence., as it is found that it is the convergence of the eyes, not the mere effort of accommodation, which causes the pupil to become smaller. Te6^^.— Hold up one finger close to the patient's nose. Ask him to look away at a distant object. Then suddenly tell him to look at your finger. As the eyes converge to accomplish this the pupils should become decidedly smaller. If the patient is unable to see, the test may still be carried out by getting him to hold up his own The Pupils. 405 iinger ahout ca foot in front of liis face and then asking him to direct his eyes to it. If the pupil reacts to accommodation but iiot t(» light, it is probal)le that there is a lesion either of the optic or of Meynert's fibres. If it reacts neither to light nor to accommodation, it is probable that there is a lesion either of the pupil centre or of tlie fibres of the third nerve. Argyll-Robei'tsoii piipil.^ — This is the term applied to the condition of ptipil tisually observed in locomotor ataxy. It reacts, to accommodation but not to light. It is probably due to a lesion in Meynert's fibres (Fig. 118) — i.e. the fibres of communication between the corpora quadrigemina and the ptipil centre. (c) Cilio - f^piiial reflex. — Dilatation of the pupil can often be observed to follow irritation of the skin of the neck either by pinching or by the action of a Faradic current. It is due to stimulation of the pupil-dilating fibres in the cervical sympathetic (p. 417), and is abolished in lesions of that nerve, Abiioriiial iiioveiiieiits of the pupil* Tlie term " liippiis " is applied to the alternate contraction and dilatation of the pupil which can sometimes be observed going on rhvthmicallv {see p. 454). ' ^ ■ Fifth nerve. Anatomy. — 1. The seilSOry I'OOt takes origin iu a large nucleus in the pons, situated in the floor of the fourth ventricle and lying external to the motor nucleus, and partly also from the "ascending" root, which begins as low down as the second cer^^cal segment. It emerges at the side of the pons, and, immediately beyond the Gasserian ganglion, separates into its thi'ee divisions.* The fii'«;t, or ophlhaliuic, division supphes the eyeball, conjunctiva (except that of the lower lid) and lachrymal gland, the mesial part of the skin of the nose as far as the tip, the upper eyelids, the forehead, and the scalp as far as the vertex. 4o6 Nervous System. Paralysis of this division results in loss of sensi- bility in the area of skin and mucous membrane supplied, and in trophic changes in the eyeball (if the lesions involve the Gasserian ganglion). The conjunc- tival reflex is abolished. The second or superior maxillary division supplies the cheek, the front of the temple, the lower eyelid and its conjunctiva, the side of the nose, the upper lip, the upper teeth, the lining- membrane of the nose, the upper part of the pharynx, the roof of the mouth, the soft palate, and the tonsils. Paralysis of it leads to abolition of sensibility in the above area, and loss of the palate reflex. The third or inferior maxillary division is joined by the motor root. It suj)plies sensation to the lower part of the face, the lower lip, the side of the head, the ear, the tongue, and the lower teeth. It supplies also the salivary glands and, through the motor division, the mus- cles of mastication, the tensor tympani, and, also perhaps, the tensor palati, although many be- lieve that this mus- cle is innervated spinal the Fig. 119. — Distribution of aiiftsthesia in comxilete paralysis of the fifth nerve. by cessory root. origin ac- Wlotor This takes n a small nucleus lying internally to the chief sensory nucleus, and partly also from the descending root, which arises in nerve cells scattered around the aqueduct of Sylvius. It emerges at the side of the pons, just in front of the sensory division, passes underneath the Gasserian ganglion, and joins the inferior maxillary division, to which it gives its motor fibres. Fifth Nerve. 407 Paralysis of the whole fifth nerve leads to loss of sensation in the areas of skin and mucous membrane above mentioned, and to defective power of chewing. (Fig. 119.) Trophic lesions may be present, and the salivary, buccal, and lachrymal secretions much diminished, and the sense of taste abolished. One curious result of the sensory paralysis is that the patient, when drinking, imagines that the cup is broken, as he only feels it on one side of his mouth. How to test the fifth nerve. 1. motor fiiiietioiis. — Ask the patient to clench his teeth while the observer keeps his hands on the temporal and then on the masseter muscles. These should stand out with equal prominence on each side. If there be paralysis on one side, the muscles on that side will fail to become prominent. On opening the mouth the jaw deviates towards the paralysed side, being pushed over by the healthy external pterygoid muscles. The condition of the tensor tympani muscle cannot be satisfactorily examined except by noting whether there is any difficulty in hearing notes of a particular pitch — i.e. a diminution in the " field of hearing." 2. Sensory functions. — The common sensi- bility o! the area supplied is tested in the usual way (p. 42;;). Taste. — In suspected lesions of the fifth nerve the sense of taste should always be examined. It seems probable that all the taste fibres eventually reach the brain in the fifth nerve. The taste fibres from the anteiior two-thirds of the tongue pass from the lingual nerve to the chorda tympani, thence to the facial, thence by the great superficial petrosal to Meckel's ganglion, and thence to the second division of the fifth. The taste fibres from the posterior third of the tongue enter the glossopharyngeal nerve, leave it in 4o8 Nervous System. the nerve of Jacobsoii, reach the tympanic plexus, and thence by the small superficial petrosal and otic ganglia arrive at the third division of the fifth. Once the taste fibres have entered the brain their exact course becomes doubtful. There is no doubt that they reach the posterior part of the internal capsule, and by that time they have already decus- sated. It is probable that they end in the tip of the temporosphenoidal lobe. How to test the sense of taste. — Have some sugar, some quinine, and some salt, all in powder. Ask the patient to put out his tongue and to keep it out until the conclusion of the test. Place some sugar on the tongue, rub it gently in, and ask him, " Is that salt % " If taste is normal he will shake his head. In this way all the substances are tried, first on the anterior part of the tongue and then at the back. A weak galvanic current is also a useful test. It should produce a sort of metallic taste. Loss of taste may, of course, arise from lesions of the taste fibres in any part of their course above stated. In addition to loss of taste, one should always ask the patient whether he has any abnormal taste sensations. Seventh nerve. Anatomy. — The course of the fibres of this nerve from the cortical centre to the nucleus has alreadj' been described (p. 360). The nucleus is situated in the pons external to that of the sixth nerve. The fibres which are destined to supply the orbicularis palpebrarum, however, possibly proceed from the nucleus of the third, and those for the obicularis oris from that of the twelfth nerve. On leaving the nucleus the fibres wind round the nucleus of the sixth, and finally emerge along with the eighth nerve, between the olive and restiform bodies. The nerve lies in close contact with the eighth, so that a lesion of the one at this part can hardly avoid injuring the other, and' enters the internal auditory meatus along with Seventh Nerve, 409 it. During its course in the aqufduct of Fallopius it gives off a branch to the Stapedius muscle, and is joined b}' the chorda tympani, which contains taste fibres from the anterior two-thirds of the tongue. In this part of its course the nerve is exposed to the effects of pressure, owing to its being en- closed in a bony tube. It emerges at a point opposite the junction of the anterior border of the jnastoid with the ear, and spreads out on the side of the face to supply its muscles. In this part of its course it seems to be peculiarly liable to the effects of exposure to cold. Fiinctioii«i. — The seventh is a purely motor nerve. It supplies all the muscles of the face and scalp, except the levator palpebree superioris. It also supplies the platysma. Effects of paralysis. — These are usually at once seen on looking at the patient. The affected side of the face has lost its expression. The naso- labial fold is less pronounced than on the other side. The furrows of the brow are smoothed out, the eye is more widely open than the other, and the mouth is somewhat drawn to the healthy side. The patient is unable to whistle, and food is apt to collect between his teeth and his gums. How to test tlie seventh nerve. (1) Ask the patient to shut his eyes as tightly as ever he can. Note that the affected eye is either not closed at all — in which case the eyeball rolls upwards to make up for the failure of the lid to descend — or, if the eye is closed, the eyelashes are not so far rolled in as on the healthy side. Try also forcibly to open the eyes while the patient attempts to keep them closed. If the orbicularis is acting normally, it should be almost impossiljle to open the eye against the patient's wish. If the muscle be partially paralysed, however, the exertion of very little force may sutlice to open it. The effort made in screwing the eyes tightly shut causes the corners of the uiouth to be drawn upwards. In paralysis of the lower part of the face the corner 4IO Nervous System. on the affected side is either not drawn up at all, or at all events not so much as on the healthy side. (2) Ask the patient to whistle. He is unable to do so. (3) Ask him to smile or to show his upper teeth. The mouth is then drawn to the healthy side. Sig^ns of paralysis of the facial nerve \i\ different parts of its course- Paralysis of the seventh nerve produces different symptoms according as the lesion is situated above the nucleus or either at the nucleus or below it. The former constitutes what is known as cerebral or supra- nuclear facial paralysis, the latter produces peripheral or infranuclear paralysis. The chief difference between the two forms is that in supranuclear paralysis the lower part of the face is chiefly affected; in peripheral paralysis both the upper and lower parts are equally involved. The probable explanation of this is that the two or- bicularis palpebrarum muscles are so often required to act together that each is supplied from both sides of the brain, and consequently a unilateral lesion oidy partially cuts off the nerve impulses to one side. We have already described what is meant by " crossed paralysis,'^ and the part which the facial plays in it. Infranuclear facial paralysis may be pro- duced by a lesion of the nucleus itself, of the nerve trunk inside the aqueduct, or of the nerve trunk either after its emergence from the aqueduct or before it has entered it. A lesion inside the aqueduct — unless it be towards the outer end of the latter — involves the fibres of the chorda tympani, and therefore produces a paralysis of taste sensation in the anterior two-thirds of the tongue. A lesion in any of the other situations produces a typical complete facial paralysis (Bell's paralysis). Eighth Nerve. 411 A lesion of the nerve before it has entered the aqueduct can be distinguished from a lesion below the stylo -mastoid foramen by the fact that in the former condition the Stapedius muscle is paralysed (causing excessive sensitiveness to loud sounds or " hyperacusis ") while in the latter it escapes. Never omit, therefore, in a case of facial paralysis to inquire regarding the patient's sensitiveness to loud sounds. The practical deduction from these facts is that in examining a case of facial paralysis one should never omit to investigate the taste sensibility of the anterior part of the tongue. Abnormal facial niovemeiitis. — The muscles supplied by the facial nerve are frequently affected by spasmodic movements. These may involve all the facial muscles or groups of them only. The spasm may be of either the clonic or tonic variety (p. 425). The nature of the movements if present, their extent, and the muscles affected by them should always be carefully noted. Eig:litli IVerve (auditory). Anatomy. — This nerve consists of two sets of fibres. One set supplies the cochlea, and subserves the function of hearing ; the other part supplies the vestibule and semicircular canal, and is the nerve of equilibration. The auditory fibres arise from a nucleus which is mesially placed in the floor of the fourth ventricle. They emerge dorsally to the restiform body forming the dorsal root of the eighth nerve. The fibres for equilibration take origin in a nucleus placed laterally to the other, and emerge on the ventral aspect of the restiform body forming the ventral root of the eighth nerve. The two roots join, and the fibres run together to the bottom of the internal auditory meatus, where they separate, to be distributed to the different parts of the inner ear. The cortical centre for hearing is in the first and second temporosphenoidal convolutions of the opposite hemisphere. The exact course of the fibres between the nucleus and the cortex is unknown. The cortical centre for the fibres of equilibration is probably situated in the cerebellum, but as to that nothing is definitely known. 41-2 Nervous System. Test, (a) Hearing:. — Before testing a patient's power of hearing it is well to exclude the presence of wax in the ear {see p. 469). This being disposed of, one can test the hearing power b}^ means of a watch. Stand behind the patient and ask him to shut his eyes. Begin outside the probable range of hearing jDOwer and bring the watch gradually nearer the ear, asking the patient to speak whenever he hears the tick. One requires, of course, to know at what distance the tick should be audible by a healthy ear. It is well to test each ear separately, one being closed whilst the other is being examined. If impairment of hearing be detected, one must next try to ascertain whether it is really due to disease of the auditory nerve or merely to some affection of the middle ear. In order to settle this point, the timing: forlt test may be employed. Strike a tuning fork and place the end of it against the centre of the patient's forehead. If the deafness discover-ed by the watch is due to an affection of the middle ear, the patient will hear the tuning fork louder on that side than on the healthy one. On the other hand, if the deafness is due to disease of the auditory nerve the tuning fork will only be heard on the healthy side. The test may also be carried out by means of the watch. In affections of the nerve, the watch is not heard even when pressed against the ear ; in disease of the middle ear, it is heard even more loudly than when similarly applied to the healthy side. The explanation of these facts is not yet clearly made out, nor are they invariably trustworthy. They hold good, however, for a majority of cases. Other points in favour of the deafness being due to the nerve and not to the middle ear are, (a) if the hearing is better in a quiet place, (b) if conversation is heai-d better than the watch, (e) if inflation of the middle ear renders the li earing worse. Eighth N'erve. 413 Abnormal auditory isciisatioii!^. — The patient may complain of " ringing in the ears " or tinnitus. The precise character of the sound varies in dillerent cases. It may be of a humming, buzzing, hammering, or whistling character. The presence or absence of this symptom should always be inquired for, and Avhether it is constantly present or in what circumstances it comes on. Hyper^esthesia of the auditory nerve (liyper- actisis), by which even slight sounds are heard with painful intensity, sometimes occurs, especially in hysteria and in lesions of the facial nerve above or in the aqueduct owing to paralysis of the stapedius muscle. Hallucinations of sound may also be present, the patient fanc^dng that he hears voices, bells, etc. The presence of these points to an affection of the cerebral cortex. (6) .Equilibration. — This sense cannot be con- veniently tested clinically. Disorders of it produce vertigo. The patient will describe this as giddiness or dizziness. In order to constitute true vertigo, external objects should seem to move round him. Ask if this is so, and, if it is, in what direction the objects seem to move. Ask also whether the vertigo ever causes him to fall to the ground. Vertigo may be due to paralysis of one of the ocular muscles, to an aifection of the ear or auditory nerve, to loss of muscular or common sensibility especially in the lower extremities, or to an affection of the stomach. When a patient complains of vertigo as his chief symptom one should therefore examine carefully for squint, for disease of the outer and middle ear, and for signs of disease of the eighth nerve. One should also investigate the condition of muscular and common sensibility and inquire for symptoms pointing to gastric disturbance. 414 Nervous System. The ninth (glosi^opharyiig^eal), tenth (vag^us), and eleventh (spinal accessory) nerves. Anatomy. — J'hese arise in order from above downwards from, an elongated nucleus in the floor of the fourth ventricle. The ninth has also an ascending root, beginning as low down as the fourth cervical segment. They emerge by several roots along the lateral aspect of the medulla, beginning above in the groove between the olive and restiform bodies. The spinal part of the eleventh emerges from the lateral column of the cord, beginning as low as the sixth cervical nerve; it passes up through the foramen magnum to join the medullary (accessory) part, and emerges with it through the jugular foramen. After its emergence the two divisions of it again part company, the medullary or accessory portion joining the vagus. Fnnctions. The ninth (glossopharyngeal) is sensory for the posterior third of the tongue and for the mucous membrane of the pliar3^nx. It is motor for the middle constrictor of the pharynx and for the stylo- pharyngeus. It contains in part of its course the taste fibres for the posterior part of the tongue {see p. 407). Ho^v to test the glossopharyngeal. — The ninth nerve is rarely paralysed alone. Paralysis of it can only be diagnosed by examining its sensory func- tions. Examine the power of taste in the posterior part of the tongue (p. 408). Loss of it may mean paralysis of the trunk of the glosso-pharyngeal nerve. In root affections of the nerve taste is not implicated, as the taste fibres enter the brain by the fifth. Tickle the back of the pharynx, and note if the reflex is present. The tenth (vagus) is motor for the soft palate (with the exception, perhaps, of the tensor palati), pharynx, and larynx. It must be stated, however, that many authorities believe that the palate is Tenth Nerve. 415 supplied by the f?pinal accessory. It is also sensory and motor for the respiratory passages, the heart, and (through the sympathetic ganglia) for most of the abdominal ^'iscera. The fibres for the soft palate take origin in the nucleus ambiguus, emerge in the lower roots of the vagus, reach the pharyngeal plexus^ and thence pass to the muscles of the palate. The motor fibres for the larynx, the viscero-motor, and the cardio- inhibitory fibres are really derived from the medullary or accessory part of the spinal accessory, which, as we have mentioned (p. 41 4j, joins the vagus just after emerging from the skull. How to test tlie vagvs. — Paralysis of the vagus is chiefly evidenced in its palatine and laryn- geal branches. {a) The palate. — Ask the patient whether he is troubled with the regurgitation of fluids through his nose when he tries to swallow. This is a common occurrence in total paralysis of the soft palate, owing to defective elevation of it during swallowing. For a similar reason the patient is unable to pronounce words which require complete closure of the naso- pharynx. Thus " egg '^ becomes "eng,"' "rub" becomes "rum,' and so on. In unilateral paralysis these symptoms are not observed. For direct examination of the soft palate place the patient facing the light with his mouth open, and in- troduce a tongue depressor. The position of the uvula is quite unreliable as a guide to the state of the soft palate. Deviation of it is not uncommon even in health. One must watch the movements of the palate during phonation. Ask the patient, therefore, to say " Ah " and observe whether both sides of the palate arch upwards; in health a sort of depression appears in the centre of the palate when the patient says " Ah." If one side is paralysed that side will remain 4i6 Nervous System. flat and immobile, and the median raphe will be pulled towards the other side. In bilateral paralysis the whole palate remains motionless. (6) The larynx. — The superior laryngeal branch of the vagus is sensory for the larynx al>ove the level of the true cords, and is motor for the cricothyroid muscle. Unilateral paralysis of the nerve does not produce any symptoms. Bilateral paralysis causes the vocal cords to be relaxed. The voice is therefore hoarse and deep, and the utterance of high notes im- possible. The recurrent laryngeal branch supplies sensation to the larynx below the level of the cords, and motor fibres to all the laryngeal muscles except the crico- thyroid. Paralysis of it leads to appearances which are recognised by the laryngoscope and are described at p. 477. The eleventli. — The accessory part of this nerve gives to the vagus its motor fibres for the larynx. Lesions of the accessory part, therefore, before its junction with the vagus may give rise to laryngeal paralysis. The rest of the nerve dips below the sterno- mastoid muscle about one inch below the tip of the mastoid process, and emerges from underneath that muscle again at about the middle of its posterior border. It supplies the sternomastoid and upper part of the trapezius. Lesions of it, therefore, lead to paralysis of these muscles. How to test the spinal accessory. — Paralysis of the upper part of the trapezius is evinced by asking the patient to shrug his shoulders while the observer offers passive resistance by press- ing on the shoulders from behind. Paralysis of the sternomastoid causes difficulty in rotation of the head towards the opposite side. The twelftli or hypoglossal nerve. Anatomy. — The twelfth nerve arises from a.nucleus in the Twelfth Nerve. 417 lower part of the floor of the fourth ventricle, close to the middle line. It emerg-cs between the anterior pyramid and the olive. It is a purely motor nerve, supplying the tongue and the depressors of the hyoid bone. Its cortical centre is in the lower part of the ascending frontal convolution. Test. — Ask the patient to put out his tongue as far as possible. If the hypoglossal Ije paralysed the tongue, instead of being protruded straight, is pushed over to the paralysed side. Be careful not to mistake an apparent deviation of the tongue, really due to the mouth being twisted to one side, for a real deviation of it. Such an apparent deviation occurs in facial para- lysis. Ask him also to move his tongue from side to side, and to lick each cheek with it; observe whether he can do so freely. Note whether there is any wasting of the tongue and whether there be any tremor or fibril- lary twitching in it. The presence of wasting indi- cates that the lesion is either nuclear or infranuclear. Paralysis of the cervical sympathetic may be conveniently considered here. A complete descrip- tion of the functions and distribution of the nerve, however, is not necessary in such a work as this. For purposes of diagnosis the fibres supplied to the eyeball are alone of importance. These take origin in the an- terior part of the floor of the aqueduct of Sylvius, pass down the cervical cord to a centre in the lower cervical and upper dorsal regions (ciliospinal centre), from which the fibres emerge in the last cervical and first dorsal nerve roots and pass to the sympathetic cord by the rami communicantes. From the cervical sympathetic cord the fibres pass along the internal carotid to the cavernous plexus, and thence md the ophthalmic division of the fifth to the eyeball. They convey the impulses which cause dilatation of the pupil, and supply also the muscle of Miiller. Para- lysis of the cervical sympathetic is recognised by the following signs : — Some recession of the eyeball, so that the eye looks smaller than its fellow ; slight B B 4i8 Nervous System. drooping of the upper lid ; contraction of the pupil with absence of dilatation on shading the eye, or on in- stillation of cocaine ; abolition of the ciliospinal reflex. SECTION IV.— MOTOR FUNCTIONS. In investigating the motor functions of a patient, one has to satisfy himself on four separate points. (1) Is there any muscular paralysis or weakness] (2) Can the patient co-ordinate his actions norm- (3) What is the state of nutrition of his muscles ] (4) Is there any abnormal muscular movement present ? (I.) Investig^atioii of motor power. — The first thing to be noted as regards the patient's volun- tary power is whether or not he is capable of per- forming gross muscular movements. Can he walk % Can lie sit up in bed ? Can he move each of his limbs as a whole ? These main points having been determined, it may be necessary to investigate the principal muscles and groups of muscles separately. The general rule for one's guidance in this investi- gation is to ask the patient to throw into action the particular muscle or group of muscles which one wishes to test, whilst the observer offers to that action a greater or less degree of passive resistance. The following is the method of procedure for the chief muscles which one wishes to test : — 1. Upper limb. Flexors of fingers. — Ask the patient to squeeze your hand. If a record of the power of grasp be desired, which can be compared with the result yielded in similar circumstances on another occasion, one should make use of the dynamometer. Inter ossei and lumhricales. — Paralysis of these muscles gives rise in cases of some standing to a Muscles of Upper Limb. 419 peculiai' positiuu of tlie liaiid known as *' main en g:i'ille " or claw-liand. The above-mentioned muscles produce Hexion of the first phalanges on the metacai-pals and extension of the other two phalanges. Paralysis of them produces, by over-action of their opponents, over-extension of the first phalanges and flexion of the other two. The fingers are also slightly separated from one another. Claw-hand occurs in some cases of progressive muscular atrophy and, in a partial form, in paralysis of the ulnar nerve. Claw-foot is an analogous condition. Opponens pjoUicis. — Ask the patient to touch the tip of his little finger with the point of his thumb. Adductor of thumh. — Ask the patient to grasp a book between the forefinger and thumb. Flexors of lorist. — The hand being held with the palm upwards, ask him to bring the points of his fingers towards the front of the forearm. Extensors of icrisf. — The hand being held with the palm downwards, the observer grasps the patient's wT-ist and asks him to bend the hand up backwards as far as possible. If he is unable to produce dorsi- flexion of the wrist some weakness or paralysis of the extensors is present. Slight weakness of the extensors of the wrist mav be elicited by asking the patient to grasp something firmly in his hand. If the extensors are weak the wrist becomes flexed as he does so. owing to the flexor muscles getting the better of the extensors. Weakness or paralysis of the extensors of the wrist leads to the condition known as WTist-drop. Supinator longus. — Place the arm midway between the prone and supine positions : then ask the patient to bend up the forearm whilst the observer ofiers opposition to the act by grasping the hand. If the muscle be healthy, it will be seen and felt to stand out prominently at its upper part. 420 Nervous System. Biceps. — The patient's elbow being held against his side, ask hira to bend "up the forearm while op])Osition is offered by grasping the hand or wrist. If the biceps is healthy it will be observed to stand out prominently as it contracts. The Triceps is tested by asking the patient to straighten out his forearm whilst the observer endea- vours to keej:* it flexed by means of passive resistance. Deltoid. — Ask the patient to lift his arms straight out at right angles to the trunk. In paralysis of the deltoid he is unable to do so. Pectorals. — Ask the patient to stretch his arms out in front of him, and then to clap his hands while the observer endeavours to hold them apart. Note whether both heads of the muscle are thrown into contraction or not. Serratus magnus. — Ask the patient to push against resistance. In a healthy condition of the muscle its various digitations will be seen to stand out in contraction, whilst the scapula will remain in close ap])osition to the chest wall. If the muscle is para- lysed, the posterior border and inferior angle of the scapula will come to project more or less when the patient pushes. Latissimus dor si. — Ask the patient to clasp his hands behind his back while the observer, standing behind the patient, offers passive resistance to the downward and backward movement. 2. Trunk muscles. Weakness of the muscles of the abdomen is in- dicated by the patient being unable to raise himself in bed without the aid of his arms. To test the erector spince and muscles of the back, make the patient lie on his face and try to raise his head from the bed by extending the neck and back. If the back muscles are healthy, they will be seen to stand out prominently during this effort. Muscles of Lower Limb. 421 The method of detecting paralysis of the dm- 'pliragm lias already been described (p. 227). The trapezius is tested in its upper part by asking the patient to shrug his shoulders while tlie observer tries to press them down from behind. In its lower part it can be tested by asking him to approximate the shoulder blades. 3. The head muscles. — For the methods of detecting weakness or paralysis in the muscles of the liead, the reader is referred to the section dealing with the investigation of the Cranial ]N^eiwes (p. 387). 4. The loAver liiub. The muscles of the foot are tested on the same lines as the corresponding muscles of the hand — passive resistance being offered to their action in each case. Extensors of hnee. — Bend up the patient's knee, and then, pressing with your hand on the sole of his foot, ask him to try to straighten it out again. Flexors of knee. — Turn the patient on his face, and then ask him to bend up the knee whilst the observer endeavours to hold it down by pressing upon the back of the ankle. Extensors of thigh. — The knee being extended, lift the patient's foot otf the bed, and ask him to depress it against resistance. If the extensors of the hip are paralysed he will be unable to do so. Flexors of thigh. — The knee being extended, ask the patient to raise his leg off the bed. The adductors of the thigh are tested b}' abducting the limb, and then asking the patient to bring it back to the middle line while passive opposition is offered to the act. In a similar way the abductors are tested by bringing the limb across the middle line, and then asking the patient to move it outwards again. Rotators of the thigh. — Turn the patient on his face, and bend the knee to a right angle. Then 42 2 Nervous System. ask him to roll the leg outwards or inwards whilst passive resistance is offered by grasping the foot. If, on carrying out any of these tests a muscle or group of muscles is found to have only a feeble power of contraction, paresis of it is said to be present. If no contraction be elicited at all the condition is one of paralysis. The term hemiplegia is applied to a condition in which there is paralysis of one side of the face and of the arm and leg on the same side. If the paralysis of the arm and leg be on one side, and that of the face on the other, the condition is one of crossed paralysis. The term paraplegia is applied to a paralysis of the lower part of the body ; the term monoplegia to a paralysis of one arm (which is therefore characterised as a brachial monoplegia), one leg {crural monoplegia), or one side of the face {facial monoplegia). The detection of paralysis — and still more of paresis — in a patient who is comatose is often a very difficult matter. It is to be observed, however, that even in such a patient one can usually detect a greater degree of limpness in the paralysed limb. If the arm, for example, be raised from the patient's side and allowed to drop, it falls, if it be paralysed, just as if it did not belong to the patient ; the sound arm also falls, but not in such an utterly limp fashion. The distinction, however, is often by no means easy. II. Investigation of muscnlar co-ordina- tion. By muscular co-ordination is meant the co-opera- tion of separate muscles, or groups of muscles, in order to accomplish a definite act. If such co-operation be absent or imperfect, the performance of certain acts becomes difficult or impossible, and the condition is then said to be one of inco-ordination. The term ataxia or ataxy has a similar meaning. Muscular Co-ordination. 423 The co-ordination or harmonious action of groups of muscles is the product of various factors, amongst the chief of which are sight, the muscular sense, the contractility and elasticity of the muscles, and in the case of some acts, at least, cutaneous sensibility. If inco- ordination be present, it is not easy to say which of these factors is at fault. ISTor is this neces- sary, the fact of in co-ordination being all that one wishes to ascertain. It is usual, however, to eliminate the sense of sight, as the help it affords the patient is so great that it might prevent slight degrees of inco- ordination from being detected. The eyes should therefore be bandaged. How to test co-ordination. 1. In the ui^i^ev limhs. The eyes being bandaged, ask the patient to touch the point of his nose first with one forefinger and then with the other. Or ask him to bring the points of the two forefingers together. If he is able to do these things successfully, without making random shots, no inco-ordination is present. Another good test of co-ordination in the upper limb is to ask the patient to thread a needle. In that case, of course, the eyes must be left uncovered. 2. In the lower limhs. If the patient is able to walk, a good test for co- ordination in the lower limbs consists in asking him to walk along a straight line — e.g. a crack between two boards of the floor, or the edge of a carpet. If inco- ordination is present he will soon deviate to one side or the other. If he cannot walk, proceed as follows : The eyes being covered, ask the patient, as he lies in bed, to touch the dorsum of one foot with the great toe of the other. Another method is to leave the eyes open and then to ask him to follow with his toe one's forefinger, with 424 Nervous System. which one describes circles in tlie air. If he is able to describe the circles accurately his power of coi ordination is good. A special test for co-ordination in the lower limbs is to make the patient stand with his heels together and his eyes shut, and to notice whether he stands steadily or sways about. The inability to do this, which exists in locomotor ataxy, is known as Rom- l>erg's !syiiiptoiu. It is due in part usually to the absence of sensation in the soles of the feet, but is found even when sensation is unimpaired. III. The state of nutrition of the muscles. — This is gauged roughly by pinching the muscles, and noting whether they are firm, as in health, or wasted and flabby. In the disease known as pseudo-hypertrophic paralysis some of the muscles are abnormally firm and large. This is especially apt to be the case with the calf muscles and the infraspinati. Such hypertrophy must not be mis- taken for a mere increased muscular development. It is due to an overgrowth of the interstitial tissue of the muscle at the expense of the muscle fibres, and is really a sign of disease. The finer indications regarding muscular nutrition which are afforded by the use of electrical stimulation are de- scribed in the section on the Electrical Examination of Muscles and ;^^^erves (p. 440). IV. Abnormal muscular movements.— These consist of involuntary muscular contractions of various sorts. The first thing to note is whether the move- ments are w^idespread or localised. If they are confined to one part of the body, note the joints at which the movements occur, and the muscles or groups of muscles involved. The term spasm is often applied to any exaggerated and in- voluntary muscular contraction. The contraction may either be continuous, in which case it is said to be Abnormal Muscular Movements. 425 it tonic," or there may be a series of sliort contrac- tions with complete or partial relaxation of the muscle in the intervals ; in that case they are spoken of as " clonic." The term contractnre or rigidity is usually applied to that continuous spasm of groups of muscles often observed in cases of paralysis due to cerebral lesions. It is doubtful, however, whether this is a true muscular contraction. Tetanic spasm is observed in its completest form in tetanus, strychnine poisoning, hydrophobia, and some forms of hysterical fits. It may lead to a bend- ing of the whole body backwards {opisthotonos) or sidewards (j)leitrosthotonos) or forwards {emprostho- tonos). The term tetany is applied to a peculiar form of tonic spasm affecting the hands and feet. The fingers are pressed together, flexed at the metarcarpo-phalan- geal joints, but extended at their phalangeal articula- tions. The thumb is tucked in under cover of the fingers. The hand therefore assumes a conical shape, and is sometimes said to be in the "obstetric position," that being the position in which the accoucheur holds his hand when introducing it into the vagina. The wrist is also flexed. In the foot one finds marked flexion of the toes and anterior part of the foot, some- times also of the ankle. Tetany is chiefly a disease of infancy, but is sometimes met with in adults who have dilatation of the stomach. Clonic spasms are of various degrees of severity. If very widespread they are spoken of as convul- sions, and are seen typically in epilepsy. If con- vulsions be present, study their onset, noting whether the contractions appear in all the affected muscles simultaneously, or whether one group of muscles is first attected, the spasm spreading to other groups' by degrees. If the latter be the mode of invasion, it 426 Nervous System. indicates a suread of the irritation alonsf the sur- face of the cortex cerebri, and occurs typically in Jacksonian epilepsy. The mildest variety of clonic muscular contraction is termed tremor. Tremor may be either jine or coarse. Fine tremor is usually more easily felt than seen. It occurs in exophthalmic goitre and in some forms of metallic poisoning. All forms of tremor are most easily seen by increasing the leverage at which the affected muscles act. Thus tremor of the upper limbs is often brought out by getting the patient to extend his arms in front of him. In describing tremor, always note whether it is constantly present or whether it is affected in any way by voluntary muscular action. Ask the patient to lift a glass of water to his lips, and note whether the tremor is increased thereby (as it is, for example, in cases of disseminated sclerosis), or whether it is diminished or altogether abolished. Tremor which only comes on when the patient attempts to use the affected muscles is sometimes described as " intention " tremor. Clonic contraction of individual fibres or bundles of fibres in a muscle is termed fibrillary twitching^. It is seen in many cases of progressive muscular atrophy, and indicates an abnormal state of nutrition in the spinal cells connected with the affected fibres. The term choreic is ajiplied to involuntary movements of a purpose-like character occurring in individual muscles or groups of muscles. Such move- ments are seen most typically in chorea minor or St. Vitus's dance. They consist of abrupt involun- tary twitchings or contractions which cause the patient (usually a child) to seem fidgety and un- settled. They are increased by mental agitation, but are often diminished by voluntary muscular effort. If the movements are limited to one side of the body the term hemichorea is applied. Sexso/^v Fu.yctions. 427 Choreic movements, if slight, can be elicited in two ways. Firstly, one may ask tlie patient to hold both hands straight up above the head ; or, secondly, one may ask the patient to spread out his hands, palms downwards, on the extended hands of the observer. In the former case it may be observed that the patient is unable to hold up his hands steadily for any length of time ; in the latter one may notice that little twitchy movements soon become evident in the patient's fingers. If the patient is able to write at all, one may get him to scrawl his name with the affected hand, and keep the result for purposes of comparison later. In this way one is able to gauge any increase or diminution in the choreic movements. The last point to be noted regarding any abnormal muscular movement is whether or not it persists during sleep. The term athetosis is used to describe a slow muscular contraction Avhich leads to continuous and deliberate twisting movements, specially affecting the hands and feet. SECTION v.— SENSORY FUNCTIONS. In investigating the sensory functions of a patient, we have to test the acuteness of the followino- forms of sensibility : — (1) Common sensibility. This includes the powers of appreciating touch and pressure. (2) Sensibility to pain. (3) The temperature sense. (4) The muscular sense. In addition, one has to note the presence or absence of any abnormal sensations. At the outset it is well to explain to the patient the nature of the tests to be performed, so as to secure, as far as possible, his intelligent co-operation. The 428 Nervous System. eyes should then be bandaged, and the different forms of sensibility tested as follows : — 1. Commoii iseii!sil>jlity. (a) Touch. — The point of the finger or, preferably, the feather end of a quill pen may be used as a stimulus. For carefully mapping out areas of altered sensibility a small cone of cotton wool is best. It is so light that the element of pressure is entirely eliminated. A fine camel-hair brush also answers the purpose very well. Tell the patient to say "Now" whenever he feels a touch. Compare corresponding points on opposite sides of the body, and employ every now and then a negative test, asking the patient if he feels you touch him, in order to prevent his making random replies. Ask him also to localise the stimulus by pointing to the exact position of the spot touched. This is im- portant, as a patient may be able to feel the stimulus and yet not be able to localise it. Sensibility to touch may be altered in various ways. (1) It may be entirely abolished. This constitutes aueesthesia. If the abolition affects the whole of one side of the body, it is termed hemiancesthesia. If the existence of anaesthesia be discovered, one must at once proceed to mark out its exact extent and boundaries, (2) It may be exaggerated, so that what should in health be felt as a mere touch produces a painful impression resembling pricking or burning. This constitutes liypersestliesia. If hypersesthesia be discovered, its extent should be carefully mapped out. Hjrpersesthetic spots are sometimes met with, especially in hysterical patients. The commonest sites for these are over the brim of the pelvis, in the infra- mammary region, along the vertebral column, and on the scalp. Pressure on such spots may sometimes induce hysterical fits. If that occurs, the spots are spoken of as " hysterogenetic." (3) Sensation may be a})preciated well enough, but there may be great Sejvsorv Functions. 429 delay in its conduction, an appreciable interval occur- ring between the application of the stimulus and the response of the patient. This delayed coii- duclioii exists not infrequently in cases of alcoholic neuritis and locomotor ataxy. (4) The stimulus may be badly localised, the patient believing, for example, that the outer side of a limb was touched when the stimulus was really applied to its inner aspect. Some- times a touch on one side of the body is referred to a corresponding point on the opposite side. This is termed alloclieiria. (5) Pressure. — This is tested by supporting the limb or part to be tested in such a way as to eliminate any muscular action on the part of the patient, and then laying different weights on the surface, and asking the patient which feels heavier. Different coins of the same size — e.g. sovereign and farthing — answer the purpose well enough. 2. Sensibility to pain. The point of a quill pen may be used as a stimulus. The point of a pin or needle has the disadvantage of being so fine that it may miss the nerve endings. The application of a faradic current is also an excellent method of testing sensibility to pain. It enables one to gauge degrees of sensibility by noting what strength of current is required to cause pain, and then com- paring the result with the corresponding area on the opposite side. Absence of the sense of pain is termed anal- g^esia ; an exaggerated sensibility to pain, so that a miild stimulus produces an unusual degree of suffering, is termed hyperalgesia. 3. Temperature sense. — Use test tubes of hot and cold water. Touch the part to be investigated with each in turn, and ask the patient whether it feels hot or cold. Note whether he calls hot " cold " or cold "hot," or whether he does both. 43° Nervous System. It should be noted that the different forms of sensibility already mentioned inay require to be tested on the accessible mucous membranes as well as on the skin surfaces. The sensibility of some viscera is also of importance. Thus the absence of pain on squeezing the testicle may be an early sign of locomotor ataxy. 4. Muscular sense. — This demands the in- vestigation of two separate points. {a) The patient's power of estimating weights. (p) His power of appreciating the position of his limbs. ici) Sense of weig^ht. — Place in the patient's hand substances which resemble one another as far as possible in every respect except as regards weight. Metal balls covered with leather, some being solid and others hollow, are often used for the purpose. In their absence one may use two match boxes, one full, the other empty, or some other extemporised device. A solid ball and a hollow one may be placed one in the patient's right hand and the other in his left, and he is then asked to state which is the heavier; or one hand may be tested at a time, the balls being lifted one immediately after the other. If the leg is being investigated, the weights should be placed in a handkerchief and slung round the patient's ankle. (6) Sense of position. — The patient's eyes being carefully shut, take hold of one of his limbs and move it about in various directions through the air, finally leaving it in some definite position, say semi- flexed and slightly elevated; then ask him to put the corresponding limb in a similar position. If there be no paralysis of the latter and yet the patient is unable to imitate with it the position of the other, then there is reason to believe that the sense of position is impaired. In testing a patient's sense of position in this Reflex Functions, 431 manner, be careful not to allow the part tested to touch any other skin surface ; otherwise, the patient will be able to appreciate its position by the informa- tion derived from his ordinary sense of touch.* Are tliere any abnormal sensations pre- sent I — These are termed paraestliesise, and con- sist in various sensations experienced by the patient in the absence of any outward stimulus. The com- monest of these are a feeling of " needles and pins," of numbness, of heats or chills, of pressure or tight- ness (a good examj)le of the latter being the "girdle pain " of locomotor ataxy), of itching — sometimes termed "pruritus" — or a feeling as if insects were crawling over the body (formication). The term anra is applied to the curious par- aestliesise which frequently precede an epileptic fit and serve as a warning of its approach. SECTION VL— REFLEX FUNCTIONS. There are three classes of reflexes which one has to test. (1) The superficial reflexes ; (2) The deep or tendon reflexes ; (3) The organic reflexes. We shall consider these separately. 1. The snperficial reflexes. In these the simplest form of reflex action is concerned. On stimu- lation of a certain part of skin or mucous membrane contraction of certain muscles results. The path of the impulse is by the sensory nerve fibres to the grey * A very delicate test for defective muscular sense (and therefore for inco-ordination) in the upper limbs consists in shutting the patient's eyes and then making him hold his arms straight out in front of him with the fingers in a horizontal row. After a moment or two, if the muscular sense be defective, the fingers cease to remain in an even line. Some will rise a little, others fall, or even become twisted in below the rest. 432 Nervous System. matter of the cord or a sensory centre in the brain, thence by motor nerve fibres to the muscle. A lesion in any part of this path causes the reflex to disappear. Thus anaesthesia of the skin, disease of the sensory fibres or posterior nerve roots, changes in the grey matter of the cord, lesions of the motor nerve fibres or of the fibres of the muscles, may all cause abolition of the superficial reflexes. In addition to this, it must be borne in mind that the reflex excitability of some individuals is normally very much o-reater than that of others, and this makes it difficult for one to estimate the value of slight alterations in the reflexes unless the lesion is unilateral, in which case the healthy side can be taken as a standard of comparison. The investiga- tion of the superficial reflexes is of more value as affording information regarding the health or other- wise of the reflex arc concerned than as a guide to the presence or absence of disease elsewhere. In hemiplegia the superficial reflexes are usually di- minished on the healthy side. Exaggeration of both knee jerks along with diminution of the plantar re- flexes is a combination characteristic of many cases of functional paraplegia. The chief superficial reflexes of spinal origin, their nature, the mode of obtaining them, and the level of the cord concerned in their production is given in the table on p. 433. The following superficial reflexes are dependent on cranial nerves : — (1) Coiijiiiictival. — Elicited by touching the conjunctiva, resulting in contraction of the orbicularis palpebrarum. The nerves concerned are the fifth (sensory) and the seventh (motor). (2) Pupil reflexes. — {See pp. 402 and 454). (3) Palate reflex. — Elevation of the palate on touching the mucous membrane covering it. The Reflex Functions. 433 fl ~ r r -- -^ 'd x 7- X Q '•-■ ^ '^ '^ H C I 5 r -f -§ 3 Si '£ "3 — — •^ CJ & 3 ^ Z o Q 3 O j3 = ^•^ 3 o a-i 3, ^^ 3 ^ -t^ o -u o X '^ o -^ ~ ::; x X X X S ac 'a o 1 |_ 3 — "^ '3 -*J 2 "II ?li •^ 3 ~ = ~ s s Ti :C ^ iC t: ic ^ S: ^ sc > ^ = = — ^ X 3 'T" w 3 ^ !3 © TA 3 '■'■ ^ z tC X 3 "^ ft2 '^ ^^ -^ ^ s H — — o - •—1 <:^ , , ai o X s -| •r X 5 6^ D I IS O a, ^ X O ^ i! O at J « 2 c tf A d 1- g X 6C^ .5-2 1 s Is > o o ♦* -4J — ^ 5 \\ ~ 1. J '^ g.S i- '-' "" ^ ~~ ^ o o * * eg -^^ -u o .-» o 5 3 "TV -^"53 a 2 ,o «-t 3 -rJ ^ c .S=: ^ «*-• o ^J u_ C « j^ .2 >< 'o ^ "o 3 __ t; "x z x i; S3 '^ ^ « X _^ "x ~ ~ r — :; »4 o be ^.1 i c r^ c « 'n C ^r c o h tl CO -»3 ->^ —3 ~^ X X X X X X i< . K * * ' iJ b ■ ^ , PS S 1 ■? ' h i* ^^ "2 ■ 1— t -5 c3 S 3: \ 3 S ~ • ~ S* o ;ih o o <; ,— a; I Si o c c 434 Nervous System. nerves concerned are the glossopharyngeal and the vagus (or spinal accessory ?). 2. Deep or tendon reflexes. — If a muscle be put upon the stretch and its tendon be then sharply struck, the muscle immediately contracts. This is spoken of as a deep or tendon reflex. It is very doubtful, however, whether one is correct in speaking of it as a reflex at all. It would seem that the con- traction of the muscle follows too rapidly on the blow upon the tendon to permit of there being time for a reflex arc being traversed. What really happens is probably this. The stretching of the muscle reflexly increases its " tone." When the tone is thus raised any mechanical stimulus, in this case the blow upon the tendon, by suddenly increasing the tension of the muscle, excites in it a direct contraction. The only point where a reflex act really comes in, therefore, is in the preliminary raising of the muscle tone. Without this increase of tone, how- ever, the subsequent direct contraction would be impossible. We have already indicated (p. 363) that the ''tone" of a muscle is dependent upon the cells in the anterior cornua of the spinal cord — i.e. the lower neurons. When the control of the upper neurons over the lower is cut off", the latter produce an increased " tone " in the muscles, with the result that the tendon reflexes are more easily excited than normal. In other words, their reflexes are increased or exaggerated. Exaggeration of tendon reflexes, therefore, is characteristic of lesions affecting the upper neurons — i.e. the cerebral cortex, or the fibres passing from it to the anterior horns of the cord. A similar exaggeration may be brought about by any- thing which stimulates the lower neurons, thus making them more able to resist the controlling influence of the upper. Strychnine and the toxin Reflex Functions. 435 of tetanus are able to do this, and therefore produce an increase of the tendon reflexes. On the other hand, anything which impairs the activity of the lower neuron will cause a diminution in the tone of the muscles, and will thus make the tendon reflexes correspondingly difficult to elicit. Diminution or abolition of the tendon reflexes is therefore characteristic of lesions affecting the lower or spinal neuron. Of course, any disease of the muscle fibres themselves, or of the sensory fibres which proceed from the muscle to the spinal cord, and along which the stimulus travels when the muscle is first stretched, which stimulus causes the reflex increase of tone, will also cause a diminution of the tendon reflexes by preventing the necessary increase of tone from taking place. Hence it is that in locomotor ataxy, in which the posterior roots are nmch involved, the deep reflexes are absent. There is only one point more to be referred to, and it is rather a confusing one. In a lesion — e.g. a fracture dislocation — which produced complete trans- verse destruction of the cord at any level, one might expect that, owing to the cerebral influence being cut ofi*, all the deep reflexes below that level would be exaggerated. This, however, is not the case. The reflexes in that condition are (as a rule) totally abolished. The explanation of this apparent anomaly is still a little doubtful. It has been supposed by some that it is to be attributed to the cutting off" of a cerebellar influence which descends to the cells of the anterior cornua, and, so to speak, energises them, so that they are able to maintain the tone of the muscles. It must be admitted, however, that experi- mental evidence is totally opposed to this conclusion, as lesions of the cerebellum are followed by exaggera- tion and not by abolition of the deep reflexes. The knee jerk or patellar tendon reflex is 436 ^ERVOus System. the best known of the deep reflexes. It consists in a contraction of the quadriceps extensor when the patellar tendon is tapped. The spinal segments con- cerned are the second and third lumbar. HoiD to elicit the knee jerk. — If the patient is able to sit up, get him to sit on a chair or on the edge of the bed and cross one knee over the other. If he is unable to effect the latter, pass your wrist under the knee to be tested, resting your hand on the opposite knee and allowing the patient's leg to swing suspended, as it were, on the back of your wrist. If he cannot sit up, bend the knee up a little as he lies on his back and support it by allow- ing it to rest on your hand or the back of your wrist. The result of this disposition of the limb is slightly to stretch the quadriceps extensor, and so refiexly to increase its tone. The next thing to do is to try to divert the patient's attention. This may be done by asking him to " let the leg hang as if it did not belong to him," or by engaging him in conversation. The patellar tendon must then be struck a sharp blow midway between the patella and its insertion. The edge of the hand may be used for the purpose, or the edge of a thin book, or the ear piece of a stethoscope, especially if it be sur- rounded by a rim of solid indiarubber. A percussion hammer is also a good instrument for the purpose. Immediately after the blow the foot will be ob- served to be jerked up from the sudden contraction of the muscle. The briskness of the knee jerk varies greatly in different individuals. In health, however, it is hardly ever entirely absent. Sometimes one is unable to elicit it without having recourse to what is known as *' reinforceiiieiit " of the knee jerk. This consists in asking the patient to make some strong voluntary muscular effort with the upper limbs. One may ask Reflex Functions. 437 him, for example, to hook the fingers of the two hands together and then to pull them against one another as hard as possible. Whilst he is doing so one tries to elicit the knee jerk, and one usually gets it more readily than under ordinary conditions. How reinforcement acts it is a little ditficult to say. According to some, it is by increasing the general muscular tone throughout the body ; according to others, it acts by diminishing the inhibitory cerebral control. The following tendon reflexes are similar in nature to the knee jerk, but — probably owing to mechanical difficulties in producing adequate stretching of the muscle — are not usually so easy to obtain in health, and may indeed be entirely absent. Ankle jerk. — ^Grasp the dorsum of the foot with one hand and hold up the leg with it. Slightly dorsiflex the foot so as to put the tendo Achillis OQ the stretch, then with the other hand sharply flick the latter on its under surface. A sharp con- traction of the calf muscles results. Adductor jerk is produced by abducting the thigh and tapping the tendon of the adductor magnus. Contraction of the adductors results. Sometimes in patients who have very exaggerated reflexes one finds that on tapping the patellar tendon a sudden contraction occurs in the adductor muscles of the opposite thigh. This is termed the " crossed adductor jerk." Its explaaation is still rather obscure, but it is apparently a truly reflex pheno- menon. Triceps or elbow jerk. — Flex the elbow to more than a right angle, then tap just above the olecranon. The triceps contracts. The reflex depends upon the sixth cervical segment. Supinator jerk. — Produced by tapping the supinator tendon just above its insertion into the 43 8 Nervous System. styloid process of the radius. The fifth cervical is the cord segment concerned. liVrist jerk is produced by letting the hand hang down, and then striking the extensor tendons just above the wrist. The hand is jerked up. This reflex depends upon the sixth cervical segment. Jaw jerk. — Ask the patient to open his mouth, but not too widely. Place one finger firmly on his chin and then tap it suddenly with the other hand as in percussion. A contraction of the muscles that close the jaw results. This jerk is never present in health. The motor nucleus of the fifth nerve is the centre involved. The term "clonus" is applied to the following tendon reflexes : — Ankle clonus. — To elicit this phenomenon, bend the patient's knee slightly and support it with one hand, grasp the fore part of the foot with the other hand, and suddenly dorsiflex the foot. The sudden strain put upon the calf muscles causes them to con- tract. The pressure of the hand upon the sole of the foot is meanwhile continued and when the contraction ceases causes the calf muscles again to become tense, and so produces another contraction in the latter. In this way a whole series of contractions — i.e. a clonus — results. The relative tendency to the development of ankle clonus on the two sides is best estimated by slowly dorsiflexing the foot and observing the exact point at which the movements first begin. The less the degree of dorsiflexion required to produce the clonus the greater is the tendency to the development of the latter. Ankle clonus is nearly always a sign of disease. The spinal segments concerned in it are the first to the third sacral. Knee clonus. — In cases where the knee jerk is Organic Reflexes. 439 exaggerated, one can sometimes elicit a knee clonus by extending the patient's leg and then suddenly pushing down the patella towards the foot. If the pressure on the latter be continued, a series of clonic contractions of the quadriceps can often be produced. 3. Organic reflexes. — This term includes such processes as respiration, deglutition, micturition, and defsecation. They depend upon complex muscular movements excited either by stimulation of mucous membranes or, in the case of respiration, of a centre in the medulla. One should always ascertain from the patient whether he has any difficulty in swallowing, noting specially whether there is any regurgitation of food through the nose. The function of deg-liitition does not usually require to be specially tested beyond the examination necessary to exclude the existence of an obstruction (p. 47). Defsccatioii. — The patient should be questioned as to any difficulty in the act, and as to the presence or absence of tenesmus. Note also the occurrence or not of incontinence of faeces. The reflex action of the anal sphincter may be tested by introducing the oiled finger into the anus, and noting whether contraction of the sphincter occurs with normal force, whether it be weak or altogether inactive, or whether there is any spasm excited. The activity of the anal sphincter reflex may also be tested by pricking the skin in the neighbourhood of the anus. Under normal conditions a brisk con- traction of the sphincter should immediately be visible. Mieturitioii. — The patient should be questioned as to difficulty or pain in the act {see p. 9). One should then note whether there is either retention of urine or incontinence of it. If there be incon- tinence, ascertain by the use of the catheter whether it be due to the overflow from a distended bladder or 440 Nervous System. whether it be a reflex incontinence — i.e. whether the bladder merely fills up and then empties itself completely by reflex action. The centres for the bladder and rectum are HL frontalis Vppir Iraneh o/faeial il. corrag. superoil. M, orbic. palpelir. ITasal muscles | M. zygomatici M. orbioul. oris •[ Ifiddle branch qf facial H. masseter M. levator mentl M. qnadr. meuti 2i. triang. menti Hypoglossal n. Lover braiuh of facial 'il. platysma myoid. nyoid muscles | IkL omohyoideus Ant. thoracic n. (i&L pectoral.) Region of central conTolutiona Region of 3rd frontal conr. and island of Reil (centre fair speech) M. temporalis Upper branch of facial in front of the ear Facia/ n. (trunk) Post, auricular n, ifiddle branch of facial Loicer branch (if facial M. splenias 51 sternocleido- mastoideu3 Spinal accessory ru. il. levator anguli scapuJ. 51. cucuUaria Dorsalis scapuice Axillary n. Zong thoracic n. (IL Eerrat.aut.maj.) fhrenien. Supraclavicular point. Brachial plexvtt (Erb's point. M. deltoi.l., biceps, brachialis intern, and supin. long.) Fig. 120. — Motor points, face and neck. situated in the fourth and fifth sacral segments of the cord. SECTION YIL— ELECTRICAL EXAMINA- TION OF MUSCLES AND NERVES. 1. Apparatus. — For the purposes of diagnosis as distinguished from therapeutics electricity is applied in three forms : First as the continuous current, second Electrical Ex a mina tion. 441 ff. fleltoia. (lunder part) Fadiat Kerv M. bracliial. intern. M. supinator long. M. radial, est. long, AI, radial, est. brev. 11. extensor digit, communis M. extensor indicis M. abductor pollic. long. M. esteusor pollic, brcT. H. intcross. doisol. I etn. M. triceps (caput longum) M. triceps (caput extern.) M. ulnar, extern. M. supinat. brev. M. extens. digiti minim, M. extens, indicis I M, extens. poll. long. M. abduct, digit, min. 1 M. inteross. dorsaU j IILetlY. Fig. 121.— Motor points, back of arm. as tlie faradic current, third by using the discharge through Crookes's tubes, with high vacua and suitable internal arrangements, for the purposes of skiagraphy by the X rays described by Prof. Rontgen. The 442 Nervous System. 11. triceps (long Lead) VL triceps (inner head) "Ulnar n, | M. flexor carpi nlnaris IL flex, digitor. commun, profund. M, flex, digitor. snbUm. (digiti II. et IIL) M. flex, digit, subl. (digit, iudicis et minimi) Ulnar n. Jll. palmaris brev. M. abductor digiti Tiiin. M. flexor digit, min. 2L opponeus digit, rniu. 21m. lombricoles -I M. deltoid, (anterior half) Mvxulo- euXaneous n, ]^ biceps brachii M.brach. intemas I Median n, M. Enpinator longns M. pronator teres M. flex, carpi radialls U. flex, digitor. sublim. M. flex, pollicis longua Median n. II. abductor pollic. brcT. M. opponens pollicis H. flex. poll. brcv. ill. adductor pollic. brev. Fig. 122. — Motor points, front of arm. Elect RICA l Ex a mina tion. 443 details of this last application are beyond the scope of the j)resent work. The continuous current must be of sufficient intensity to overcome the resistance of the body and yet have enough strength left to stimulate the nerves Crural n. M . arUuctor maguus SI. adduct. longas M, vastus intemus j M. teflsor fasciae lata»- JL sartorins if. quaiiriceps femoris (commou point) IL rectus femoris vastus extemus Fig. 123.— Motor points, front of thigh. and muscles. It must therefore have an available electromotive force of over 40 volts. A battery of thirty-two Leclanche dry cells is ample for ordinary use, as its electromotive force is decidedly higher than this to start with and will continue so for a considerable time if properly cared for and neither left too long absolutely idle nor employed to yield very 444 Nervous System. heavy currents which would speedily exhaust the small cells. Where the continuous current from an electric light installation is available it may be used, when precautions are taken for the safety of the patient by the employment of shunts to reduce the voltage to a suitable figure. Whether battery or light installation with regulat- ing board be used, it is of great importance to have Udalic n. TEL Weeps, fern. (cap. long.) U. biceps fern. (cap. brev.) Peroneal n. SL.gastrocnem. (cap. extern.) M. soleus 2f..flexor hallacis longos - M. glutens masimns M. adductor magnna M. semitendlDosns M. senumeoibranQsaa Tibial n. M. gastrocnem. (cap. int.) M. soleus M. flexor digitor. conmo. longu3 TiHal n. Fig. 124.— Motor points, back of thigh and leg. Electrical Examination. 445 efficient accessory apparatus in the way of current re- versers, galvanometers, connecting wires, and electrodes. The galvanometers should give readings in milliamperes, not in unmeaning graduations, as too often is the case in those supplied with medical batteries. For the faradic current the best form of appar- atus is an induction coil of the sledge pattern with a HL tibial, antic. 34. cxtens. digft. comm. long. M. peroneus breris IL extensor lialluois long. Hnuinteiossei dotsales j Peroneal n. M. gastrocneni. eztenu M. peroneus longtts M. soleus 21. flcxoz hallncis long; M. extens. digit, comm. "breTis 2L abductor digiti mfp. Fig. 125. — Motor points, side of leg. secondary coil of wire which should not be very fine, as very thin wire on the secondary coil produces too great an effect on the sensory, and too little on the motor nerves for most diagnostic purposes. To drive 446 Nervous System. the coil one or two dry Leclanch^ cells are sufficient. It is often convenient to be able to pass from the con- tinuous to the faradic current and vice versd without changing the connections leading to the patient. This can be effected by a suitable switch. One large flat electrode should be procured, and several small ones, va.rying in size from a small spher- ical bulb to a disc of metal with a surface of about 60 or 100 square centimetres. These should be covered with washleather, which can be renewed at frequent intervals, and should be made to screw into a holder with a button by means of which the observer can interrupt the current. 2. Electrodiag-iiosis. (Figs. 120-125). Beg^in with the faradic current.* It stimu- lates the nerves directly, the muscles only indirectly through their nerve supply. Examine systematically each nerve trunk in the area under consideration, and the motor point of every muscle supplied by each of these nerves. The motor points correspond for the most part with the points of entry of the motor nerves into the muscles which they supply, and are shown in Figs. 120-125. The observer should try the current upon himself before applying it to the patient, both to reassure the latter and to compare the effects it pro- duces on himself with those elicited in the patient. A small electrode — either the button electrode or the disc of 10 to 20 square centimetres, according to circumstances — should be used for the part under ex- amination, whilst the other (or " indifferent ") electrode should be a larger plate placed either on the abdomen or between the shoulders. The electrodes and the skin where the tests are applied should be well soaked with a solution of common salt in warm water, but care * Children, however, are more apt to resent the use of the faradic current than that of the galvanic, hence in their case it is often better to reverse the usual sequence. Elec trodia gnosis. 447 ^L T i Tit J^ — 1 /• ^ /^ ' ..-^ ■% << /" r - /- / i' y / / / rr / mA. S JO <3 ^ Fig. 126. — Bordier's method of recording the electiieal reactions of a muscle, in health. must be taken to avoid the presence of any crystals of undissolved salt on the skin. Note the intensity of the miniinuin current which produces contraction at each point, and compare the effects of a similar current on the corre- sponding point on the other side of the body. The inten- sity of the cur- rent is recorded in terms of the distance of the secondary from the primary coil; battery power, rate of interruption, and other adjustments being assumed to remain constant. When the faradic current has been employed, pass to the g-alvanic. Use the electrodes in exactly the same manner as for the faradic examination, and remember that when a small electrode is used, the nerves and muscles that lie super ticially be- neath it, and are therefore closer to it, are chiefly stimulated, since response to the stimulus depends on current density. Begin with a weak current, and gradually increase its strength till the muscle responds by a slight contraction. nf — t; A y' ^ r- *^t A: * ** * M i°H ,' .M * > / r r^' y ^x V ' -.^ ^A, |< X x' / / i x .^ y X / / X t r O^.a. '5 10 IS 2<| Fig. 127. — Bordier's method of recording the electrical reactionspf a muscle, in a case of complete reaction of degeneration. 448 Nervous System. At each point employ first the cathode"^ and then the anode, and observe whetiier contraction occurs most readily when the circuit is completed or when it is interrupted. Record the strength of the current as indicated by the milliamperameter and compare it with that which produces similar effects at the cor- responding point on the other side. In liea,ltli the cathodal closing contraction is the first to appear ; in other words, the muscle responds more readily when the pole applied to it is the cathode, and when the electric circuit is completed; a decidedly stronger current is required to elicit the anodal closing and opening contractions, and the cathodal opening contraction appears last of all. This sequence may be represented by the formula C.C.C. > A.U.C. > A.O.C. > C.O.C., or by the follow- ing expansion of it : — Weak current CC.C. — — — Medium current C.C.C' A.C.C. — — Fairly strong current C.C.C." A.C.C A.O.C. — Yery" strong current C.C. Tetanus A.C.C." A.O.C C.O.C. When a graphic representation is desired, the results may be recorded on a chart, as shown in Figs. 126 and 127. The contractions in health are abrupt and sharp. Except when the current is very strong, contractions only occur when the circuit is made or broken, not during the passage of a uniform current. In disease the response to electrical stimulation may be altered either quantitatively or qualitatively. By " quantitative alterations " one understands that a given current produces a greater or less con- traction than it could were the nerves and muscles in a normal state. " Qualitative alterations " involve either or both of two changes— namely, first * The cathode or negative electi'ode is attached to the zinc rod in the cell, the anode or positive electrode to the copper or carbon. Electrodiagnosis. 449 the character of tlie contraction, instead of being abruf^t, becomes "sluggish"; and second, the cathodal closing contraction is less readily elicited than the anodal contractions. Such qualitati^'e changes depend on the separation of the nerve and muscle from their nutritive centre. After a brief period the separation induces degener- ation, and whilst the degeneration proceeds the nerve first fails to respond to electrical stimuli, and after a longer interval the muscle also becomes insusceptible. It is during the time that elapses between the insen- sitiveness of the nerve and of the muscle, that the most characteristic electrical changes are observed, and these are together known as "tlie reaction of degeiier- ation." They may be summarised as follows : — ■ T. Faradic current. — No response can be elicited, even when a very strong current is employed. The reason for this is that the Faradic stimulus, in con- sequence of its brief duration, acts only on the nerve, and since the degenerated nerve can no longer transmit stimuli to the muscle the latter remains ujiaffected. II. Galvanic current. (a) Quantitative change. — The muscular excitability is increased, contraction following the application of a weaker current than is necessary to produce it in health ("The irritability of weakness"). (h) Qualitative changes. — 1. The contraction is no longer sharp^ but "sluggish." 2. In most cases anodal closing contraction is elicited with a weaker current than cathodal closing con- traction. This phenomenon is less constant and less im- portant than the sluggish character of the contraction. The quantitative change depends partly on alterations in the nutrition of the muscle, and partly on the removal of inhihitory influences ; the qualitative changes are produced partly because the nerve no longer regulates the character of the contraction, and partly also as a result of changes in the muscle itseK. The foregoing description appKes to a fully D D 45© Nervous System. developed reaction of degeneration. This is not manifested till more than a week after the trophic influence has been cut off. The nerves, however, begin to lose their sensitiA^eness about three days after the injury, and gradually become less and less responsive. The muscles behave as do the nerves to Faradic stimulation ; to the galvanic current they at first exhibit diminished excitability. After eight or ten days the excitability again increases, and eventu- ally exceeds that found in health. At the same time as the increase appears, the sluggishness of contraction and the abnormal sensitiveness to anodal closure become manifest. When the cause which has led to the severance of the nerve and muscle from their trophic centre cannot be removed, the muscular response once more gradually diminishes, and after the lapse of a considerable period, which may extend to two years or even longer, disappears entirely. When the trophic influence is timeously re-established, the reactions of nerve and muscle progressively return to the normal. In such cases ordinary muscular power usually begins to return some days before the nerves show any response to electrical stimuli. It will be readily perceived that from the stand- point of diagnosis, electricity yields far more valuable information when the disease is situated in the lower motor neuron, thereby severing the nerve endings and muscles from their trophic centres, than when the morbid process occupies a more central position. Serious disorder may be present in the higher trophic realms without revealing itself by any change in the electrical reactions — at most there will only be a quantitative change whose detection is often diflicult and whose value is uncertain. In the sensory system electrodiagnosis is of less value, and is chiefly of service in cases where a hysterical element is present. 451 CHAPTER X. Examination of the Eye, Ear, Throat, and Nose, * SECTION I.— THE EYE. Note first any obvious peculiarity about the eye. Observe whether there is any undue prominence of one or both eyes. Prominence of the eyes occurs in exophthahnic goitre. It is associated in that disease with the presence of what is known as von Graefe's sign. Ask the patient to look down. If von Graefe's sign is present, the upper lid seems to lag behind the eyeball in its descent, so that a large part of the upper portion of the sclerotic becomes visible. In paralysis of the cervical sympathetic the eyeball recedes so as to look more sunken than normal. Note also whether the winking movements are increased or diminished in frequency. Infrequency of the movements constitutes Stellv:ag^s sign of ex- ophthalmic goitre. The occurrence of squint, ptosis, retraction of the upper lid and alterations in the pupil have already been considered. The presence of any inflamma- tion along the margins of the lids (marginal blepharitis) should always be noted. It is often an indication of a strumous constitution. Next turn your attention to the coiijwiictiva. It may be necessary to examine the conjunctiva lining the eyelids. In order to do this in the case of the lower lid it is sufficient to depress the latter * In this chapter only those methods of investigation are described that are required in ordinary medical cases. 45 2 Examination of Eye. firmly with the thumb. To expose the inner sur- face of the upper lid, place the right thumb at the upper part of the upper lid and push upwards, so as to make the eyelashes stand out prominently. Grasp the lashes between the forefinger and thumb of the other hand, and evert the lid by rotating it round the thumb of the right hand."^ Note the colour of the conjunctiva — -whether it is pale, injected, or jaun- diced. The method of detecting oedema of it has already been described. Look at the cornea. Note the presence of any ulceration or opacity of it. Small opacities are described as ^^ nebulce.''^ ; larger opacities are spoken of as " leticoinata.'' Try to make out whether the opacity is really on the surface of the cornea or deeper down in its substance. This can best be determined by looking along the surface of the cornea, as it were, and observing whether the light is reflected from it over the opaque spot, or whether it is dull. If the former be the case, the opacity is deep-seated ; if the latter, it is superficial. Such superficial opacities point to former strumous ulceration. Deep-seated opacities are often due to congenital syphilis. * The following simple method of everting the upper eyelid, so as to permit of an inspection of the conjunctiva, is described by Lang in his book on "The Methodical Examination of the Eye" : — • "Whilst the patient with head erect turns his eyes down and looks towards the ground, the observer, who stands in front, places the end of his left forefinger on the right upper lid just above the tarsus, and his thumb on the lower lid just below the tarsus. By moving the forefinger a little upwards the margin of the upper lid is tilted forwards away from the globe ; the thumb is now made to push the edge of the lower lid upwards into the space between the upper lid and the cornea. The lower lid thus acts the part of a wedge, and drives the upj)er lid forwards until its conjunctival surface is in contact with the thumb. AVhen the whole thickness of the upper lid is between the finger and the thumb, the lower lid is released and the free edge of the tarsus is pushed upwards and backwards by the thumb, whilst the forefinger presses its attached margin downwards and forwards ; in this way the lid is everted. The right hand is employed to evert the left lid." Tension of Eyeball. 453 The term arcus senilis is applied to a crescentic opacity which is sometimes observed towards the margin of the cornea. It usually appears at the upper part of the cornea first, and then gradually extends round. It occui s normally in old people, and is sometimes observed also in the eyes of younger persons who lla^ e sclerosed arterial walls and other signs of premature senility. True arcus senilis can be recognised by its leaving a small strip of clear cornea between the arc and the sclerotic ; a crescentic opacity extending inwards from the sclerotic, which is sometimes met with, leaves no such clear strip. If arcus senilis be observed its presence should always be noted. It is often of importance in medical cases to be able to say whether a patient is suflering from iritis or merely from conjunctivitis. In each case the eye looks red and injected, but the characters of the injection are different in the two conditions. They are contrasted in the foJ lowing table : — Ciliary Injection (Iritis). Colour, pink. Vessels, straight. Vessels eaimot be moved. » Conjimcti va I Injection . Colour, brick red. Vessels very tortuous. Vessels can be moved on sclerotic injection, greatest Injection greatest round on lids and in cul-de-sac, ] cornea, diminishes towards diminishes round cornea. j periphery. Pressure on lid leaves no j Pressure on lid leaves anaemia. ' temporary anaemic spot. In taking the case, note specially which of these sets of characters is present. The tension of the eyeball should next be tested. This is done by placing the two forefiingers on the upper part of the sclerotic outside the upper lid while the patient looks downwards, the other fingers resting; on his forehead. Then try for fluctuation. The normal tension must be learnt by practice, and any increase or diminution of it 454 Examination of Eye. noted. An increased tension contra-indicates the use of atropine. Having oljserved these different points, one should next proceed to what is termed oblique focal iBUasBBiiintioii of the eyeball. For this purpose it is best to have the patient in a dark room, a lamp being placed in front of him. By means of a convex lens — the ophthalmoscope lens does very well— the light is focussed on the surface of the eye. If necessary, one may hold another lens in the left hand, and so magnify the view. Study in this way the surface of the cornea. The nature of the opacities already referred to can now be observed more minutely. Look at the iris. The outline of the pupil, its contractility to light, the existence of synechise, and the presence or absence of hippus, can all be very well observed by this method. Note whether any opacity can be detected behind the pupil, and if so, try to estimate the depth at which it is situated. Then proceed to retinoscopy. Use for this purpose a plane or slightly concave mirror, with an aperture in the centre. An ordinary ophthalmoscope mirror does very well, but it is preferable to use one of larger size, say about two inches in diameter. The patient should be in a dark room with a light just above his head, and it is well to have his eyes atropised. Sit fully a yard from him, and ask him to look far away over the top of your head. Then throw the light into his eye by means of the mirror. In a normal eye a red reflection from the retina will be seen through the pupil. If there be any opacity of the refractile media, the red refl-ection will be obscured. In this way cataract may be detected. When commencing it usually takes the form of opaque bands passing in towards the centre of the pupil like the spokes of a wheel. Then tilt the mirror, Hrst upwards and downwards, then from side ASTIGMA TISM. 45 5 to side. As one does so, a black shadow is observed to Hit across the pupil. Watch the edge of this shadow, From the direction in which it moves in- formation is obtained as to the state of refraction of the eye. If the eye be emmetropic, or if it be hypermetropic, or has less than one dioptre of myopia, the edge of the shadow moves in the opposite direc- tion to that in which the mirror is tilted if it be concave, but in the same direction to that in which it is tilted if the mirror be plane. In myopia of more than one dioptre the edge of the shadow moves in the same direction as a concave mirror, but in the opposite direction to one which is plane. In a normal eye the shadow moves very rapidly, and has a straight and sharply-de6ned edge."^ The more abnormal the patient's refraction, the more slowly does the shadow move, and the more crescentic and the less well defined is its margin. If the edge of the shadow moves differently in opposite meridians, the eye is astig^matic. If one meridian is normal the astigmatism is simple, and may either be of the myopic or of the hypermetropic variety, according to the nature of the refraction in the abnormal meridian. If both meridians are abnormal, the error of refraction being the same in kind in each, but unequal in degree, cotiwound astig- matism is present. It may' also be either of the myopic or of the hypermetropic variety, according to the nature of the refraction. If one meridian is myopic, the other hypermetropic, the condition is one of mixed astigmatism. In regular astigmatism the directions of greatest and least refraction are at right angles to each other, and usually fall exactly in the vertical and horizontal * The edge of the shadow is, of course, straight only when the soiTixe of li^ht lias a straight edge. This is so in an Argand burner, but not in an electric lamp. 456 Examination of Eye. meridians, the meridian of greatest curvature being most frequently the vertical. Sometimes, howeA^'er, the directions of greatest and least refraction are in the oblique meridians. In irregular astigmatism the directions of greatest and least refraction are not at right angles. This occurs comparatively rarely. For the optical explanation of these facts, and for the more detailed description of their significance, the reader is referred to special works on ophthal- mology. We would only remark here that retinoscojDy affords the simplest and readiest method of arriving at an idea of the state of a patient's refraction."^ In examining many medical cases such information is well worth obtaining, as errors of refraction have been found to be the reflex cause of many nervous symptoms, e.g. of headache, vomiting, etc. The fundus oculi remains still to be examined, and for this one must have recourse to the use of the oplitlialiiioseope. Many patterns of this instru- ment are sold. The essential points are that there should be two mirrors — a larger one for use in the indirect method of examination, and a smaller angled one for direct examination of the fundus. It is also important to be able to bring a series of small lenses * Sometimes a patient comes before one wearing glasses, and it may be imj)ortant to know what the refraction of these is. In order to discover this, hold the ^lass in front of the eye and look at an object through it. Then move the glass from side to side, and watch the object. If the latter seems to move in the opposite direction to the glass, the latter is convex ; if in the same direction, it is concave. The strength of the glass maj^ be approximately determined by bringing the small lenses of the ophthalmoscope behind it until one finds that which abolishes the apparent movement of the object looked at. In order to tell whether the glass is spherical or cylindrical, look at a straight object, e.c/. a window bar, through the glass, and then slowly twist the latter round. If the glass is cylindrical, the object looked at will aijpear to take up an oblique i^osition. Patients who use cylindrical glasses are astigmatic. Oph tha l mo scop y. 45 7 of different refraction behind the eyehole in the mirror. We would add, also, that the ordinary glass lens sup])lied with the instrument is inconveniently small. It is mucli l^etter to have one of about two inches in diameter. This can easily be obtained at a slight additional cost, and, if necessary, can be carried sej^arately in a small bag of chamois leather. There are two methods of using the ophthalmo- scope — the indirect and the direct. "We shall describe the former first, 1. Indirect opiillialaiioscopy. — It is best to have the room darkened ; at any rate, bright sunlight should be excluded. If the patient is in bed this may be effected by placing an umbrella over him. The patient (if he is able) sits in a chair with his head slightly inclined forwards, and the observer in another, about two feet from that of the patient, and directly opposite to the latter. A light — an ordinary oil lamp, or, preferably, an Argand burner — is placed close to the patient and on a level with his left shoulder. The observer should sit rather obliquel}^, his left shoulder being turned well round towards the patient. The ophthalmoscope is held in the right hand, the larger mirror being opposite the eye-hole. If the observer is not emmetropic, he corrects his own error of refraction by means of the small lenses behind the mirror; light is then reflected into the patient's eye from the lamp. A red reflection from the retina should fill up the entire pupil unless there be any opacity of the media, as already mentioned. Xo details of the fundus should yet be visible. If any blood-vessels be seen, one can be sure that the patient's refraction is abnormal. If these seem to move in the same direction as the head of the observer, the patient is hypermetropic; if in the opposite direction, he is myopic. Having got the fundus fully illuminated, one proceeds to 45 8 Examination of Eye. interpose the convex lens of the ophthalmoscope. Hold it between the finger and thumb of the left hand, so that it rests opposite the joints between the first and second phalanges of the index. The finger should not be at all flexed. The fore-arm should be kept vertical, the hand drooping from the wrist, and the little finger supported on the patient's forehead. This is the position demanding the least muscular eftbrt, and therefore the least fatiguing to the observer. The ordinary ophthalmoscopic lens is of about + 15 dioptres strength, and therefore requires to be held about 2^ inches from the patient's eye."^ The exact point at which it should be held is arrived at by moving the lens backwards and forwards till a clear image is obtained. A larger image of the fundus can be obtained })y using a convex lens of about +10 D (4 inches focus) and magnifying the image by means of a -f 2 D lens placed behind the mirror. In many ways this is preferable to the ordinary method. Having got the fundus into focus, one wishes to look at three i)arts of it — (1) at the optic disc, (2) at the macular region, (3) at the periphery. In order to bring the disc into view, the patient must be made to turn his eye some- what inwards. If the left eye is being examined, ask him to look at the tip of your left ear ; if the right is being examined, ask him to look at the tip of the little *A lens of 1 dioptre (1 D) strength has a focal distance of 1 metre (40 inches); a lens of 2 D has a focal distance of 20 inches, and so on. To signify a convex lens the sign + is used, thus : + 2 D means a convex lens of 2 dioptres ; — 2 D means a coucave lens of 2 dioptres, A lens wliich is curved equally in every direction — i.e. which isjiart of a sphere— is called spherical. It may be either convex or concave. A concave spherical lens of one diojitre strength is indicated thus : — 1 D spher. A cylindrical lens is part of a cylinder, and is therefore curved in one direction only. The direction corresponding to the axis of the cjdinder is uncurved, and is spoken of as the axis of the lens. A convex cylindrical lens of one dioi^tre strength is written + 1 D cyl. Cylindrical lenses are required in astigmatism. Oph tha l mo scop y. 459 fiiiijer of the rii^^ht hand, wliich is stretclied out for tlie purpose beyond the handle of the ophthahnoscope. In order to see the macuhxr region ask the patient to bring the eye slowly back from the above position toM-ards the centre of your forehead. The macular reo;ion is reached at about two discs' breadth from the margin of the disc. Attempts to look straight at the macula in this way are sometimes baffled by the great contraction of the pupil which results, and by the reflection of light from the surface of the cornea. When this is the case it is better to ask the patient to look not straight at the forehead, but a little to one side. The observer must then move his head till a view of the macular region is obtained. The periphery of the fundus ls seen by asking the patient to look first to his extreme right and left, then up to tlie ceiling, then downwards. If, on gradually withdrawing the lens, the image of the fundus appears to become larger, there is myopia present. If it becomes smaller^ there is liypennetropia. If it alters in one direction and not in others, there is simple astigmatism ; if it alters in one direction more than others, the astigmatism is compound. If, on moving the lens from side to side, one part of the fundus seems to move over the rest ("parallactic movement"), that part is at a higher level than its surroundings. Thus, if the disc be excavated, its margin will appear to move over the deeper part. The examination of the fundus, and especially of its peripheral region, is greatly facilitated by a prelim- inary dilatation of the pupil. The best way of effect- ing this is to apply a 2% homatropine and cocaine ointment to the eye about half an hour before ex- amining it. The effect may be afterwards counteracted by instilling a drop of eserine solution (1%). 460 Examination of Eye. If the patient be unable to leave bed, indirect ophthalmoscopy may easily be carried out by the above method, provided he is able to be propped up. If that is impossible, place the lamp on the pillow above his head, and carry out the rest of the procedure as above. 2. Direct ophtiialmoscopy.— The patient is placed as before, but with the light a little behind and above the shoulder corresponding to the eye under examination. The observer sits quite close to the patient, so that his eye can be advanced to within two inches of that of the latter. In examining the left eye of the patient, use your own left eye, and for his right use your right. Tilt the patient's head and your own in opposite directions, so as to avoid breathing one another's breath. Arrange the ophthalmoscope with the small oblique mirror opposite the eye-hole, and its surface directed towards the light. The apex of the wedge formed by the tilt of the mirror should be directed towards the root of the observer's nose, when the instrument is held flat against his cheek. If there is difficulty in getting proper illumination of the fundus, move the source of light about until the bright red reflection is seen through the pupil. Ask the patient to look over your shoulder at a distant object, and try to relax your own accommodation entirely. This is the real point of difficulty in the direct method. As one is desirous of seeing clearly the fundus of the patient, and as that is so near, one almost instinctively accommodates his own eye for a near object. With practice, however, this difficulty can be overcome. It sometimes helps one to achieve the desired result if he tries to think in a dreamy way of some distant object, and to picture it to himself. If it is found impossible at first to relax one's accom- modation completely, it may be nullified by the use of a — 2-3 D lens behind the mirror. Ophthalmoscopy. 461 When the fun(Uis has been brought into clear focus, its diiferent regions must be systematically studied, just as in the use of the indirect method. In order to see the disc by the direct method, look back- wards and inwards obliquely into the eye, telling the patient meanwhile to look straight in front of him. In the case of a patient who is unable to rise from bed, the direct method may be applied in one of several ways. (1) The observer kneels beside the bed at right angles to the patient, the light being placed on the pillow at the opposite side of the head of the latter. (2) The observer places himself at the top of the bed, so as to look down, as it were, on the patient's eyes, the light being placed on the opposite side of the head from the eye to be examined. (3) If the patient be a child, place him across the bed, and kneel at the patient's head, the light being held at the opposite side from the eye under examination. The images furnished by the two methods of ophthalmoscopy differ. In the indirect method the image is inverted, so that what seems to be the upper part of the fundus is really the lower, and the inner (nasal) side appears to be the outer, and vice versa. The image, however, embraces a large part of the fundus at one time, so that one gets, as it were, a bird's eye view of it. This method is, therefore, well suited for ordinary diagnostic purposes in medical cases. The image obtained by the direct method is an upright image, and therefore the different parts of the fundus are seen in their proper positions. The image embraces only a small part of the fundus at one time, but gives a magnified view of it. It is, therefore, well suited for the minute study of patho- logical changes in the fundus. The image obtained by the modification of the 462 Examination of Eye. indirect method already described {i.e. by interposing a weak convex lens, and magnifying the image by a + 2 D lens behind the mirror) is intermediate between the images obtained by the ordinary indirect and by the direct method. It is an inverted image, pretty highly magnilied, and shows also a fairly large part of the fundus at one time. We have said that the optic disc, the macular region, and the periphery of the fundus must be studied in detail in each case. We may now pass to a consideration of the special points to be taken note of in each of these regions. 1. Note as regards the optic disc — id) Its sliaiie. Normally this is circular. Some- times it is oval. If there be astigmatism present, the disc will appear to be oval, although it is really circular. This apparent oval shape may be dis- tinguished from that which is real by moving the lens backwards and forwards. If the disc be really oval, it remains unaltered ; if it is only apparently oval, its shape will be found to vary with the position of the lens. (6) Its colour. The normal disc is of a rosy tint, but distinctly paler than the rest of the fundus. The nasal side is normally rather redder than the other. In atrophy of the optic nerve, the disc becomes very pale, and may even be dead white or greyish in tint. In active hypersemia of the disc its colour approaches in intensity to that of the rest of the fundus. Such active hyperpemia is often present in high degrees of hypermetropia. In passive hyper^emia of the disc the veins are alone affected (p. 464), and the general tint is not altered. (c) The presence or absence of a 'physiological jyit-, and its size. Do not mistake the pallor produced by a very large pit for the pallor of optic atrophy. Ophthalmoscopy. 463 (0?) The character of the vessels. The arteries are normally distinguished from the veins by the following characters : — They are only |-^ the breadth of the veins, and they are not so dark in colour. They have a broader, better defined, and more continuous light stripe along their centres Normally, the arteries do not pulsate. They may be observed to do so in cases of aortic re^uro-itation, and in increased intra-ocular tension. The veins some- times pulsate, even in normal eyes, either owing to the twisting of the arteries round them at points, or to high intra-ocular tension. (e) The edge of the disc. It should be clear and well defined — especially at its outer side. As the vessels run across it, they should not be observed to tumble over at all. This "tumbling over," if present, is best evinced by the sudden disappearance of the central light strijDe on the vessel. ( /") The surroundings of the disc. This part of the fundus should be carefully searched if one is on the outlook for the presence of haemorrhages or tubercles, as both of these are more often encountered in the immediate neighbourhood of the disc than at other parts of the fundus. Tubercles will be recognised as roundish, ill-defined, yellowish bodies, usually about half as large as the disc. Hcemorrhages occur as bright or dark-red blotches, with flame-like margins. 2. The inaciilar reg'ioii is situated, as we have said, about two discs' breadth from the outer edcre of the disc. It is recognised by being rather darker in colour than the rest of the fundus, by being very devoid of blood-vessels, and frequently by being sur- rounded with a halo of reflected light, producing a shot- silk appearance. The macula itself is in the centre of the region, and is rather pale in colour, and often glitters somewhat. 464 Examination of Eve. Changes in the macular region are important, in that they interfere more with vision than similar changes in any other part of the fundus. In cases of albuminuric retinitis, a circle of white s[)ots may often be observed arranged around the macula (p. 467). 3. Periphery. — Inspection of the periphery of the retina is important, as it is here that some changes — such, for example, as disseminated choroiditis and retinitis pigmentosa — -are most early to be detected. The following is a brief description of the chief changes met with, in the fundus, which are of im- portance from a medical point of view : — • Optic neuritis. — -In medical cases this is usually bilateral (double optic neuritis). It begins as a mere passive congestion of the disc, with slight oedema. At this stage the veins are fuller than normal; on indirect examination the edge of the disc seems clear enough, but on closer inspection by the direct method it is seen to be slightly fiulfy-looking. The change in the edge of the disc usually begins at its upper and lower margins. These parts should therefore always be most carefully inspected. As the process progresses, it passes into true neuritis or papillitis. The disc is now distinctly swollen. This is best recognised by the fact that, on direct examination, one requires (provided his accommodation is fully relaxed) the aid of a convex lens behind the mirror in order to bring the vessels on the disc clearly into focus. The veins are still larger than before, and distinctly tortuous. Pathological tortuosity of the veins occurs at right angles to the plane of the retina. Tortuosity in the same plane as the retina may be quite normal. Often the veins can be observed to tumble, as it were, over the edge of the swollen disc. The arteries are smaller than normal, and may be partly obscured by Ophthalmoscopy. 465 the presence of exudation. The edge of the disc is no longer clear, even on indirect examination, l^ut fa les off into the surrounding retina Small haemor- rhages may be observed on or near the disc. It is often important to decide whether the pajjil- litis is advancing or not. One ought not to form an opinion on this point unless he has already examined the discs on a previous occasion. The best criterion is the degree of swelling of the disc. In order to estimate this, use the direct method, and be sure that your own accommodation is thoroughly lelaxed. Notice first wl] ether the retina can be seen quite clearly without the aid of a lens. If the eye is emme- tropic, one ought to be able to do so. If the le- fraction is abnormal, place behind the mirror the lens which is required to bring the vessels on the retina clearly into focus. Then look at the vessels on the disc. Owing to the swelling of the latter, the vessels are nearer the observer's eye than they should be, and a + lens must therefore be brought behind the mirror in order to enable one to focus them clearly. The strength of the lens required is the gauge of the amount of swelling which is present in the disc. Suppose, for example, that one requires to use + 1 D in order to focus the retina clearly {i.e. the patient has 1 D of hypermetropia), but that in order to focus the vessels on the disc one requires to make use of a + 6 D, then there is obviously + 5 D of swelling. Roughly speaking, every 3 D =:= 1 millimetre of swel- ling. In this way, one can estimate the amount of swelling from day to day, and so determine wdiether the neuritis is advancing or receding. The above method, it is obvious, requires a considerable amount of practice, and it is absolutely essential for success that the observer should be able thoroughly to relax his own accommodation. Those who are unable thoroughly to relax their E E 466 Examination of Eye. accommodation may use the following method instead of the above : — Bring behind the mirror the weakest — or strongest + If^ns with which («) the vessels on the fundus can still be clearly defined; do the same for (6) the vessels on the top of the disc. Then = the height of the disc in millimetres. 3 "" Optic neuritis is present in most cases of cerebral tumour at some period of the disease. It occurs also in about 50 per cent, of cases of tubercular meningitis, although it is often late in making its appearance. It is very uncommon to meet with it in the simple basal meningitis of infants, and in ordinary acute menin- gitis. It is also infrequent in cerebral abscess, and is not met' with in cases of cerebral haemorrhage, or thrombosis. On the other hand, it is not infrequent in other than intracranial diseases, and especially in Bright's disease (most commonly in the form which is associated with cirrhosis of the kidney and thickening of the blood-vessels). It is also met with in lead poisonings and in some cases of anaemia. Optic atrophy. — We have already mentioned that the most striking change in the fundus in this con- dition is the pallor of the disc and the smallness of the arteries on it. The atrophy may be («) primary {e.g. in locomotor ataxy) — this is sometimes called simple atrophy ; or (6) it may be post-neuritic atrophy ; or (c) it may follow degenerative changes in the retina. It is not always easy to say from a mere inspection of the fundus which variety it is that one has to deal with, and the longer the process has gone on the more difficult does the diagnosis become. Look at the edges of the disc. If they are indistinct, especially if white streaks can be seen radiating out from them and passing along the vessels into the retina, then one can be pretty sure that the atrophy is not primary but is post-neuritic in origin. If the Changes in Fundus. 467 atrophy is secondary to changes in the retina the disc looks like a bit of dirty parchment, and pig- mentary changes will be seen in the retina. In atrophy without previous optic neuritis the thinning of the nei've fibres renders very visible the fibres of the lamina cribosa, and the disc acquires a "mottled" appearance. The presence of such mottling should always be carefully noted. Albuminuric retinitis. — • This condition of the fundus is met with in some cases of Bright's disease, especially in the very chronic forms. The changes consist in (1) the presence of optic neuritis with marked fulness of the veins ; (2) the occurrence of haemorrhages on or near the disc ; (3) the development of white shining spots around the disc at a distance of about three discs' breadth from it, and of similar but much smaller spots arranged in a stellate form around the macular region. Any one of these sets of changes may be present without the others. The presence of these changes should be looked for in every case of chronic renal disease. Tubercle of the choroid and hcemorrhages in the retina have already been mentioned, and their commonest sites pointed out. Tubercles may be looked for in cases of suspected acute miliary tuberculosis and tubercular meningitis. As they only appear very late in the affection, however, they are more of pathological interest than of diagnostic importance. Hetinal hsemorrhages may occur in any form of profound anaemia, but especially in pernicious anaemia and leucocythsemia. They also occur in purpura. Embolism of the central artery of the retina may occur in cases of endocarditis. The appearance of the fundus is characteristic. Look at the macular region especially. There is present at it a peculiar round cherry-red spot. The disc itself is pale and its 468 Examination of Ear. arteries are empty. The retina as a whole is some- what milky-looking from the presence of CEclema. Disseminated choroiditis. — This is often an im- portant sign of previous syphilis. The changes observed are the presence of small white patches of various shapes and sizes, and disturbance of the pig- ment around them. These can be recognised as being situated in the choroid by the fact that the retinal vessels pass over them. In congenital syphilitic choroi- ditis there is often a marked heaping up of pigment around the patches, which are mostly circular in shape. SECTION II.— THE EAR. Examine first the external ear. Note any pecu- liarity of shape, observe the presence of any tumour or swelling, or the existence of any skin eruption upon it. Observe whether there is any discharge from the meatus, and if so, make a note of its character and odour. Note also whether there is any redness, tenderness, or swelling over the mastoid. The meatus and membrane must next be inspected. Daylight is best for the purpose. Place the patient with the ear to be examined turned away from the light. Use a handled-mirror about three inches in diameter, of a focal distance of about six inches, and with a perforation in the centre. In order to catch the light properly the surface of the mirror should be turned slightly upwards. By this means the external auditory meatus can be inspected. Note the presence of any foreign body, of an ac- cumulation of wax, of any eczematous eruption or furuncles, or any other abnormality, as the presence of such may contra-indicate the use of the speculum. Various forms of aspergillus may grow in the external auditory meatus and set up. an Otitis. The colour of the inspissated discharge depends upon that of the aspergillus, being black where A. niger is the Aural Speculum. 469 fungus. The structure of the growth can be seen if some of the debris is mixed with a little liquor potassse and glycerine and examined under the microscope. In order to see the membrane, a speciiliim must Ije employed. A metal speculum is best, unless one is wishing to make use of caustic applications, in which case it is better to use a vulcanite instrument. Choose a size of speculum appropriate to the ear under examination, warm it slightly, and introduce it so that the long diameter of its smaller end is placed almost vertically, but with a slight inclination from above downwards and forwards. Take care not to introduce it too far — not beyond the cartilaginous part of the meatus. There is, of course, no use in attempting to dilate the osseous part. Having intro- duced the speculum, hold it in position by means of the forefinger and thumb of one hand, while the pinna is gi'asped between the ring and middle finger of the same hand, the mirror being held in the other. The pinna should be pulled gently upwards and back- w^ards, so as to straighten the meatus as much as possible. The mirror is held with its surface look- ing slightly upwards as before, and the membrane can then usually be seen on looking down the speculum. If the ^T.ew be obstructed by the presence of impacted wax, the latter should be removed by being first softened w4th warm almond or oKve oil or soda solution (two teaspoonfuls of the bicarbonate to the pint), and then syringed out. The student will find that it is not very easy at first to hold the speculum properly and at the same time to pull the pinna upwards and backwards. It is therefore better, if one can, to have the mirror attached to the forehead by means of a spectacle frame. This leaves both hands free to manipulate the ear and speculum, or to make applications by means of the probe, etc. 470 Examination of Ear. If an ear miiTor be not at hand, the large mirror of an ophthalmoscope can be made to serve the purpose. The lens of the ophthalmoscope can also be held close to the speculum, and so a magnihed view of the mem- brane is obtained. This is especially serviceable in examining the ears of children. The first membrane (Fig. 128) and translucency. A thing noticeable about the normal is its bluish-grey colour small white knuckle-like Fig. 128.— Normal tympanic membrane. Twice natural size. {After PoUtzer.) A, handle of malleus ; b, umbo ; c, short process of malleus ; d, posterior fold ; E, triangle of light ; f, merabrana flaccida ; G, long process of incus. prominence may be observed towards the middle of its upper part. That is the short process of the malleus. Passing downwards and backwards from it the long process of the malleus may be noticed, which ends in the umbo near the centre of the membrane. Passing forwards and back- wards from the short process of the malleus one notices the anterior and posterior folds of the mem- brane. A triangular light portion of the membrane usually catches the eye, the apex of which meets the lower end of the handle of the malleus at an obtuse angle which opens forwards. This blight spot is due to the reflection of light. Its presence may usually be accepted as a proof of a healthy state of the membrane. Immediately above the short process of the malleus a notch may be observed in Inflation. 471 the ring of bone wliich bounds the tympanic mem- brane. The part of the membrane which fills in this notch is called the membrana flaccida, or Shrapnell's membrane. It would be beyond the scope of this work to enter into a description of the various abnormal appearances which may be met with in the tympanic membrane. For the purpose of describing the situation of any abnormality which may be ob- served, it is customary to divide the membrane into an anterior part, which is in front of the handle of the malleus, and a posterior part, which lies behind it. Each of these is then divided by an imaginar}^ line drawn through the tip of the handle into a superior and an inferior portion. Four quadrants are thus obtained, and in making notes one should say that a perforation {e.g. ) is seen in the anterior superior quad- rant, and so on. Inflation of the middle ear. — It is some- times desirable to injlate the middle ear with air. This is best effected by aid of a Politzer's bag. The bag should have a piece of rubber tubing, about one inch and a half in length, attached to its nozzle. Give the patient a mouthful of water, and tell him to keep it in his mouth until he is told to swallow it. Introduce the rubber tubing into the lower part of one nostril, pinch firmly the other nostril and the upper part of the one into which the tubing has been introduced, and, holding the bag in the palm of the right hand, tell the patient to swallow. The moment you observe the larynx rising squeeze the bag firmly, and the air will enter the middle ear. To ensure the entry of the air into the ear, or to direct it into one ear only, the passage of the Enstaehian catheter may be necessary. Hold the instrument lightly near the broad end with the thumb and two finorers of the right hand. With the thumb of the other hand push the point of the 472 Examination of Throat. patient's nose gently upwards. Pass the end of the catheter into the nostril with the curve of the instrument looking downwards, and the handle somewhat lower than the point. Pass it backwai'ds along the floor of the inferior meatus, and as soon as the curved part has entered the nostril raise the handle of the instrument until it is level, and con- tinue to push it Imck wards until it comes in contact with the posterior wall of the pharynx. Then rotate the instrument till its point is directed towards the middle line, and withdraw it until the curve hooks against the posterior end of the nasal septum. Then rotate the instrument, so that the point sweeps downwards and then upwards and outwards, the handle being kept pressed towards the nasal septum, and stop when the ring of the instrument is directed towards the outer canthus of the eye of the same side. The point of the instrument can then usually be felt to be arrested by the cartilaginous rim of the tube. The nozzle of a Politzer's bag may then be introduced into the outer end of the instrument, and the inflation accomplished. If one end of a rubber tube, with an ear-piece at each extremity, be inserted into the ear of the patient, and the other end into that of the observer, the latter can hear the sound which the air makes as it impinges against the membrane. If a whistling sound be heard, it indicates the existence of a dry perfora- tion. A bubbling sound shows the presence of fluid. SECTION III.— THE THROAT. The methods of examining the fauces and the pharynx have already been considered (p. 45). In order to obtain a view of the larynx, one must have recourse to laryngoscopy. In performing laryngoscopy, the patient and observer should be seated opposite to one another in a darkened room, and about a foot Lar yngoscop y. 473 apart. A light should be placed a little to the right (or left) of the patient's head and on a level with his mouth. An ordinary lamp will serve, but it is better to have an Argand burner, and it is also an advantage to have the light fitted with a bull's-eye condenser. The observer adjusts the reflector to his head by means of a forehead band or spectacle frame. If the former be used, the two knobs on the band should go against the root of the nose. It is then rotated on its ball and socket joint until the hole in the centre is directly opposite the right eye. This is ascertained by closing the left eye and observing whether one has a clear view through the aperture. One can also arrange the reflector so that it is in the centre of the forehead, and one then looks under its lower edge. This requires a little practice, but his the advantage of allowino" one to make use of both eves. It is also of advantage in the former method to have the aperture in the centre of the reflector in the form of an elonfjated slit rather than of a round hole, as a better view is thus obtained. The observer should next manipulate the reflector with both hands until the lio;ht is directed on to the patient's mouth. He then selects a mirror, and warms it face downwards over the lamp until the moisture, which at first condenses on the surface, has all dried oS*. He should also touch his cheek with the back of the mirror before inserting it, in order to make sure that it is not too hot. Having warmed the mirror, he should hold it in such a way that it can be readily introduced and manipulated. On the whole it is more convenient to hold the mirror like a pen than in any other way. It should also be held rather short, so that the hand of the observer can be steadied by resting the little finger on the patient's cheek. The mirror being ready, the patient is told to crane out his neck a little, and to open his mouth and 474 Examination of Throat. put out his tongue. The observer then throws a clean dry cloth over the anteiior part of the latter, and grasps it firmly but gently between the forefinger and thumb of the left hand. It must be held firmly, but without any squeezing, and should then be, as it "were, rolled out, as if round an imaginary axis situated near the hyoid. This manoeuvre has the advantage of causing a better elevation of the epi- glottis, whilst it prevents any risk of injuring the tongue against the lower incisor teeth. Before intro- ducing the mirror make sure that the light from the reflector is concentrated on the back of the patient's throat. This having been ascertained, the mirror should next be introduced with its surface turned almost directly downwards, and passed rapidly back, care being taken to avoid touching either the tongue or the palate. The patient should be told to be sure to breathe regularly and through his nose. This serves to engross his attention. As the soft palate rises during an inspiration, the back of the mirror is placed gently against it, opposite the base of the uvula. The soft palate is then gently pushed upwards and backwards, and the handle of the instrument lowered or raised until the back of the epiglottis comes into view. The patient is then told to say " Eh," and that usually causes the vocal cords to become visible. If the reflex excitability of the patient's pharynx be very great, so that any attempt to introduce the mirror induces retching, the application of a 10 per cent, solution of cocaine previous to beginning the examination will be found of great assistance. It must be remembered also that one sometimes meets with a patient whose larynx baffles all attempts at inspection owing to the position and shape of the epiglottis. In studying the vieu^ obtained, the true cords usually first attract attention owing to their gleaming Lar yngoscop v. , , Fig, 129.— Diagram of larynx. right and left, respirat on ; 6 recuVrent ef^ nh^^^^^ = 5. abductor respiration : 8, recurrent rteht nVwi i^-fi ' P^i^iiation ; 7, recurrent, left, arytenoid, pWnS • ?o amenoM anfi t'hv^^^^^ phonation ; 9 Phonation ; 11, thyro-aVvteno?ds St ifr.Vi'iJT";?,'"^''^^ P§^^t and left in the mirr'or/le.ytie'ii\-I'leffhao^o°?sifve\^\Tgh^ ^'^ ^'^'^''^^ ««^° 476 Examination of Throat. white colour. They should move freely on phona- tion. Tracing them forwards, they are seen to con- verge and disappear behind the cushion of the epiglottis. Posteriorly they diverge and terminate in knob-like prominences, which are the apices of the arytenoid cartilages. Immediately internal to each of these is a smaller knob — the cartilage of Wrisberg. Passing backwards from each side of the epiglottis to the arytenoid cartilages are seen the ary-epiglottic folds. In favourable circumstances the observer can see down the trachea, and even as far as its bifurcation. This is facilitated by the observer placing himself at a lower level than the patient, and holding the mirror in such a way that its surface looks almost directly downwards. In observing any abnormal condition of the larynx, the chief points to be attended to are — - (1 ) The colour of the cords and mucous membrane; (2) The presence of any swelling or ulceration ; (3) The mobility of the vocal cords. 1. The normal colour of the vocal cords is a pearly white. In laryngitis they become red. Any increase or diminution in the redness of the laryngeal mucous membrane should be noted. In tubercular affections the mucous membrane is abnormally pale ; in syphi- litic conditions it is unusually red. 2. The position and character of the swelling should be noted. Tumefaction of tlie aryepiglottic folds and of the epiglottis should be looked for in sus- pected laryngeal phthisis. Tumours of various sorts on the true cords are occasionally met with. As re- gards ulcers, note their number, their position, and the character of their floor. Tubercular ulcers are usually multiple, and are met with very frequently on the interarytenoid fold. Syphilitic ulcers are usually single, and have a yellow sloughy floor. 3. Observe whether the cords come together Rhixoscopv. 477 normally on phonation and ujien widely duiing in- spiration. In adductor pai'aly!i»i!!» the affected cord fails to move inwards on phonation, or the cord makes a sudden Diovement inwards and then goes back, the position being unsustained (Fig. 129 — 2, 3). In abductor paralysis the cord looks normal on phonation, but fails to move outwards again on inspiration (Fig. 129 — 4, 5). In paralysis of both abductors and adductors (paralysis of the whole recurrent laryngeal nerve, or " recurrent paralysis ") the cord is fixed in the cadaveric position — i.e. midway between complete adduction and abduction. This is much more common on the left than on the right side, owing to the greater liability of the left recurrent laryngeal nerve to be pressed upon by aneurysms (Fig. 129 — G, 7, 8). Adductor paralysis is usually the result of func- tional disease. Abductor paralysis, on the other hand, is the forQi of paralysis characteristic of an organic lesion of the nervous systera. Bilateral adductor paralysis or paresis is the cause of the condition known as hysterical aphonia. If on phonation the cords come together incom- pletely, leaving an elliptical space between them, there is paralysis of the internal thyro- arytenoids present (Fig. 129 — ll). If the anterior two-thirds of the cords come together, but leave a triangular cleft beliind, the interarytenoid muscle is affected (Fig. 129 — 9). For further details regarding these forms ofparalysis special works must be consulted. SECTION lA^.— THE NOSE. Anterior rhinoscopy. — The position of the patient and of the observer, and the arrangement of the light aud reflector, are the same as for laryngoscopy. The anterior nares should first be inspected with- out the aid of a speculum. Tilt the tip of the nose 478 Examination of Nose. upwards with the finger, and note the presence of any eczematous or ulcerated condition of the mucous membrane or skin. Observe whether any dried secretion or blood can be seen. Look for any swell- ing, ulceration, or perforation of the cartilaginous part of the septum. Having noted tliese points, take a solid two-bladed speculum, warm, and introduce it. Hold it in position with the left hand, and gently screw the blades apart with the right. The first object to be observed is usually the anterior end of the inferior turbinated body. Note whether it is larger than normal or not. If it be enlarged, touch it with a probe so as to ascer- tain whether the enlargement be osseous or due to swelling of the mucous membrane merely. Then de- press the patient's chin somewhat so as to bring the inferior meatus into view ; then ask him to hold his head a little back so as to obtain a view of the middle meatus and middle turbinated body. The latter is considerably lighter in colour than the inferior turbin- ated. The superior meatus can never be seen, and the superior turbinated only very rarely. The presence of polypi should be specially looked for in these parts. Their recognition is facilitated by the use of the probe. Lastly, turn the patient's head a little, so that the septum can be inspected. Note any deviation of it, or the presence of any prominence or spine or the existence of any ulceration or perforation. Swelling of the inferior turbinated body sometimes obstructs the view of the rest of the nasal cavity. The application of a little 10 percent, cocaine on a pledget of wool will usually cause the swelling to disappear. Posterior rhinoscopy. — This is tlie only method of obtaining a view of the posterior nares. In carrying it out, the position of the observer, the patient, the reflector_, and the light should be the same as for laryngoscopy. The patient, however, should Rhinoscopy. 479 have the chin rather depressed, the neck not being craned out as in the examination of the hirynx. Select the smallest laryngeal mirror, warm it, and ask the patient to open his mouth. It is sometimes an advantage to have the shaft of the mirror bent back a little about 1^ in. above the reflecting surface. Introduce a right-angled tongue depressor, and hold Fig. 130. — Posterior nares and surrounding parts. 1, Beptuni : 2, middle turbinated hone ; 3, inferior turbinated bone ; 4, superior turbinated hone; 5, superior meatus; 6, middle meatus; ;, inferior meatus; 8. main passage of nostrils ; 9. vault of pharynx; 10, cushion of soft palate ; 11, posterior surface of uyula ; 12, ridge formed by levator palati ; 13, sal- pin go- pharyngeal fold; 14, salpingo-palatine fold; 15, Eustachian cushion ; 16; fossa of Rosenmuller ; ir, Eustachian orifice. down the tongue witlj the left hand. Take the mirror in the right hand, and pass it in with the surface looking upwards. Introduce it behind the soft palate, passing along between the uvula and the left anterior pillar of the fauces Then turn the mirror a little, so that its surface looks upwards and forwards. The posterior nares will then come into view, What one usually sees first is the posterior end of the nasal septum. It looks narrow, sharp, and pale in colour below, but expands a little and looks reddish above ; a slight cushion-like swellinij can also be often seen about the middle of it on each side (Fig. 130). On the outer wall the posterior end of the middle 480 Examination of Nose. tiirl)inated bone can usually be easily seen as a large bluisli-red swelling. Above it, one can st^e the supeiior meatus and the end of the superior turbinated bone ; below it is the middle meatus and the upper part of the inferior turbinate. Observe the presence of any increase in size of any of these objects. Note also the general character and colour of the mucous membrane, or whether any mucus or pus can be seen adhering to it. Next turn the mirror a little upwards and to one side, keeping it rather low down, and with its back against the tonsil, and look for the cushion of the opposite Eustachian tube, which can usually be made out. It forms a bright red rounded projection, bound- ing a depression Avhicli leads to the orifice of the Eustachian tube. Observe whether there is any secretion at the mouth of the latter, or any adenoid swelling of the mucous membrane. Lastly turn the surface of the mirror upwards, and examine the vault of the naso-pharynx, noting espe- cially the presence of any adenoid swelling oi- tumour in that region. Normally the roof should present an appearance not unlike that of the surface of the tonsil (Luschka's, or the pharyngeal tonsil). Posterior rhinoscopy is often very difficult to per- form. Tire difficulty may be due to there being very little room between the posterior wall of the pharynx and the soft palate. If this cannot be overcome by inducing the patient to breathe quietly through the nose, or to sniff, it may be necessary to introduce a palate retractor, but for a description of this process special works must be consulted. Even after the mirror is pi'operly introduced, it is not always easy to recognise what one sees. This is largely due to the fact that only a small portion is seen at one time, and the mirror has to be turned about till every part has been viewed separately. Experience can alone overcome these difficulties. CHAPTER XL LocoMOTORY System. (Bones^ Joints, Gait.) The locomotory system includes the muscles, bones, and joints. The examination of the Diuscles is most conveniently considered along with that of the nervous system (Chap. IX. ). There remain for consideration the bones and joints. £xaiuiiiatioii of the bones. — In the case of the long bones of the limbs, look (Ij at the condition of the shaft, (2) at the articular ends. As regards the shaft, note any distension or bend- ing of the bone and any signs of a former fracture. Tlien pass the hand along the bone, noting the presence of any tenderness or thickening of it. Thickening is most likely to be detected on the exposed surfaces of bones, e.g. over the anterior surface of the tibia and at the lower ends of the radius and ulna. Such thicken- ing often affords valuable evidence of old periostitis, especially of the syphilitic form. As regards the ends of the hones, note the pres- ence of any general enlargement, such as occurs in rickets, or of any nodulation at the margins, such as one finds in rheumatoid arthritis. In examining a joint, note first the points which can be m'ade out by simple inspection. Observe the posi- tion in which the patient keeps the joint ; note any alterations in its contour, such as local or general swell- ing, and the presence or absence of any redness. Then pass to palpation, noting whether or not there is any increase of local heat in the joint, whether it is tender to the touch, and whether one can make out the P F 482 Loco MO TORY System. presence of any fluctuation in the joint cavity. Then tiy to move the joint, observing the degree of mobility in each direction, and whether or not attempts at movement produce pain. If the joint is movable, note whether any sensation of grating is produced on movement. If the mobility is limited in one or every direction, try to form a conclusion as to the cause of the limitation, and especially whether it is due to changes in the components of the joint itself, e.g. con- traction of ligaments, or fibrous or bony anchylosis, or whether it is due to changes in the structures sur- rounding the joint, e.g. shortening of tendons. Next turn your attention to the synovial membrane. Try to make out whether there is any thickening or boggi- ness of it. Lastly examine the articular surfaces of the bones, moving the joint (if possible) so that the edges of the articular surfaces can be examined with the fingers. Note the existence of any irregularity or thickening of these, and the presence of any outgrowth or " lipping " of them. The vertebral eoluniii and iskiill demand special attention. Observe in the former the presence of any local projection of the vertebral spines. If such there be, state which are the vertebrse involved, and at which the projection is most prominent. In counting the vertebrae for this or any other purpose, one can take as landmarks either the spine of the vertebra prominens or the last rib, tracing the latter back to the twelfth dorsal vertebra. In many cases, liowever, the last rib cannot be distinctly felt. It is therefore rather untrustworthy as a guide. Note also the presence of any curvature of the spinal column as a whole, or of one part of it, distin- guishing carefully such general curvature from the local projections above referred to. The curvature may be in an anterior or a posterior Vertebral Column. 483 direction, or laterally. Anterior curvature is termed lordosis, and is commonest in the lumbar region. General posterior curvature is spoken of as kyj^hosis. It occurs most typically in the dorsal region in old persons, and must be distinguished from the localised angular curvature of spinal caries. Lateral curvature is termed scoliosis, and may be towards either the right or the left side. It is always accompanied by a rotation of the bodies of the vertebrae in such a way that the spines come to point towards the concavity of the curve. An absence of the normal curves of the spine may be an indication of commencing vertebral disease. Ask the patient to stoop down, and notice the degree of mobility of the vertebral column, and the occurrence of any pain during stooping, noting the exact site of the latter, if present. Then pass the hand down the vertebral column, and observe whether any tender spots can be made out. Such tender spots are not infrequently met with in hysteria and in cases of irritation of the posterior nerve roots. Their presence can often be more easily elicited by drawing a sponge wrung out of hot water down the vertebral column ; the patient complains of pain whenever the hyper aesthetic area is reached. To elicit more deep-seated tenderness of the vertebrae, it may be necessary to "punch " the spines gently with the fist from above downwards, observing the point at which the patient complains of pain and verifying the observation by repeating the process from below upwards. In studpng the skull, note first its size. For this purpose it may be necessary to take lueasiire- nients. This should be done in three directions : (1) Antero-posteriorly from the root of the nose to the external occipital protuberance; (2) circumfer- entially at the level of a line drawn horizontally 484 Loco MO TORY System. round tlie skull from the supra-orbital ridges in front to the external occipital protul^erance behind ; (3) coronally from one auditory meatus to the other. If the skull is abnormally small, the patient is micro- cephalic. This is frequent in some forms of idiocy. Abnormal enlargements of the skull occur in hydro- cephalus, in ostitis deformans, and in acromegaly. JSText observ^e the sliape of the skull. Is it of the dolichocephalic (long-headed), or the brachy- cephalic (bullet-headed) type ] Are the two sides of the head symmetrical ? Certain well-recognised types of abnormal skull are met with. In hydrocephalus, the skull tends to assume a globular form. The fore- head is overhanging and the eyes are pushed down so that the upper part of the sclerotic is exposed. The lateral aspects of the skull (above the ears) project outwards. If the patient is a child, as is usually the case, the fontanelle is wide and bulging, and often fluctuates very distinctly. The sutures may be opened up, and imperfectly ossified areas (craniotabes) may be detected in the bones. In 7'ickets the skull tends to be square or oblong and box-shaped. The frontal and parietal bones often show central thickening ("bossing"). The forehead, however, does not over- hang, nor are the eyes depressed, and although the fontanelle is usually widely open, it does not bulge as it does in hydrocephalus, nor are the sutures opened up. In congenital syphilis the forehead is vertical, the frontal eminences are often exaggerated, and the bridge of the nose is depressed. Having noted the general shape of the skull, ask the patient to open his mouth, so that one may see the hard palate. Observe its width and degree of arching. A high, much-arched, and narrow palate is often one of the minor signs of mental deficiency. Next proceed to the palpation of the skull. Note first the thickness of the scalp, and whether it Palpation of Skull. 485 moves freely, as it ought, upon the subjacent bone. Atrophy and adherence of the scalp are apt to be associated with skin diseases in this region, and are often a bar to successful treatment. Observe the presence or absence of inequalities in the bones, such as may indicate the site of former injury or fracture. If a swelling be detected, pay special at- tention to its margins, noting whether a hard rim can be made out, and whether or not the rim disappears on firm pressure steadily applied by the finger for a minute or two. In blood extravasations the rim disappears, in a depressed fracture it persists. I^ote also whether the swelling can Ije moved as a wljole upon the skull or not. If the patient be a child, note the condition of the fontanelles and sutures, and look for the presence of unossified areas in the bones (craniotabes). The best place to look for these is in the neighbourhood of the lambdoidal suture. They feel like little spots which are covered only by parch- ment. Observe the presence of any tender spots or areas on the skull. For this purpose it may be neces- sary to tap the skull gently all over with tlie fore- finger. If tenderness is detected, note carefully its maximum point. Such tender points are sometimes met with in inflammatory affections of the cranial bones or membranes, and in cases of superficially situated intracranial tumours, but they may also be present in neuralgic affections of the scalp. The Gait. The character of a patient's gait is often an important indication of the nature of the affection from which he is suffering. It is specially important in cases of nervous disease. In studying the gait, it is well, if possible, to have the legs fully exposed. For this purpose the patient should have on only a night-shii-t or dressing- 486 Loco MO TORY System. gown, which should be brought through between the legs from behind, and pinned up in front. The feet should be bare. The patient is then told to walk away from the observer, to turn round at a given point, and then to come towards him again. If it be desirable to obtain a permanent record of the patient's footprints, one can have recourse to photography. Put on the feet a pair of woollen socks, and dip them in rather thick whiting. Then ask the patient to walk along a smooth floor. The marks left by the feet can then be photographed. In studying the gait, the points to toe noted are : — [ 1 ) Can the patient walk at all ? This being decided, one has to ask on self — (2) Does he pursue a straight line, or does he tend to deviate to one side or the other, or to both alternately? To bring out this point, it is well to ask the patient to walk along a straight line — e.g. a crack in the floor. (3) Does he tend to fall, and, if so, in what direction? These questions being settled, the next point to be decided is whether the gait conforms to any of the Avell- recognised abnormal types. Before one tries to make up one's mind in this matter, however, it is well to be quite sure that the peculiarity in the patient's gait is not due to some surgical cause or to local disease of a joint — e.g. rheumatoid arthritis of the hip. For example, we have known the peculiar gait which is affected by patients with congenital double dislocation of the hip to be mistaken for the result of weakness of the muscles of the back, and treated by massage and electricity. A previous examination of the bones and joints will eliminate such sources of fallacy. The three chief types of abnormal gait due to nervous affections are : — 1. The spastic ; 2. The ataxic ; 3. The reeling. The Gait. 487 In taking a patient's case, it is usually sufficient to state that the gait belongs to one or other of these types, or is a combination of one or more of them. The chief peculiarities of each variety are as follows : — 1. The spastic may be described as a" sticky " gait. The patient has difficulty in bending his knees, and drags his feet along as if they were glued to the floor, the toes scraping the ground at each step. The foot is raised from the ground by tilting the pelvis, and the leg is then swung forwards, so that the foot tends to describe an arc. This gait is seen most characteristically in patients with lateral sclerosis of the cord. The lieiiiiple^ic g°ait is a unilateral form of the spastic type. 2. The ataxic maybe described as a "s^am;;m^" gait. The patient raises his feet very suddenly often abnormally high, and then jerks them forward, bringing them to the ground again with a stamp, and often heel first. He seems to exhibit, also, an indefiniteness of purpose in the place chosen to put down the foot, and the feet while in the air do not move in one plane, but are waved about, as it were, before being set down. By adopting a " broad base," the patient tries to counteract the unsteadying effects of his style of progression. This gait is best seen in cases of locomotor ataxy. 3. The reeliBig" gait may be described as a " drunken " gait, and, therefore, requires no further description. It will be observed that patients with this gait walk "on a broad base," the feet being planted widely apart. It is important to notice whether supporting the patient by his axillse abolishes the reeling tendency. In some cases of cerebellar disease, such support has been observed to abolish the patient's vertigo for the time during which he is supported. 488 LOCOMOTORY SySTEI\T. This gait occurs most typically in cases of cere- bellar lesion. It is, therefore, sometimes referred to as a "cerebellar gait." Some rarer varieties of abnormal gait may be briefly referred to. These are : — The "festinaiit gait." This is the form of gait met with in typical cases of paralysis agitans. The patient is bent forwards, and advances with rapid short shuffling steps, so that, as has been said, "he looks as if he were trying to catch his centie of gravity." In some cases, if one suddenly pulls the patient backwards, he begins to walk backwards, and is unable to stop himself, though he is leaning forwards all the time. This peculiar phenomenon is spoken of as " retrojndsion.^^ The waddling- or oscillating gait is like the gait of a duck. The body is usually tilted backwards, there being a degree of lordosis present; the feet are planted rather widely apart; and the body sways more or less from side to side as each step is taken. The heels and the toes tend to be brought down simul- taneously. The chief peculiarities of this gait are due to a difficulty in maintaining the centre of gravity of the body owing to weakness of the muscles of the back. It is met with in pseudohypertrophic paralysis. The tiig-li-stepping: or prancing gait is a device adopted by the patient to prevent his tripping from his toes catching the ground. It is, therefore, met with in cases where the toes tend to droop from weak- ness of the extensor muscles, e.g. in peri)")heral neuritis affecting the anterior tibial nerve. The name suf- ficiently describes its characters. 489 CHAPTER XII. The Clinical Examination of Children. The clinical examination of young children is a matter full of difficulty to the inexperienced. It has to be carried out, not merely without the hel}) of the patient, but often in spite of his strenuous opposition. In this cliapter we propose to point out the best methods of ascertaining the necessary facts, and also the chief points in which the child differs from the adult in a clinical sense. The history of the patient and his illness must, of course, in the case of young children, be ascertained from the mother or friends. The best §c;lieBiie of iuterrog^ation to employ will be found on p. 10. Whilst the history is being elicited opportunity may be taken to cultivate the friendship of the child or, at all events, to get him accustomed to one's presence. The history having been ascertained, one proceeds to an examination of the child. This requires gentleness and deliberation, combined with infinite patience and good temper. If one is at all hurried or rough, the child begins to cry at once, and the subsequent examination is rendered a thousandfold more difficult. We would emphasise the fact that it is almost im- possible to be really systematic in one's examination of children. Certain things must always be looked for, but no definite order can be observed in looking for them. One has to seize the opportunity of ascertain- ing a fact as it presents itself^ and a rigorous adherence to " systems " is often out of the question. In the first place, a number of points can be ascertained before the child is undressed. One can study the lacies of the 49 o Examination of Children. child, note its complexion, the colour of its lips, and whether or not the alee nasi are acting. One should also at this period of the examination count the respiration and pulse-rate ; it is very important to get these noted while the child is still undisturbed. The respirations can usually be counted by merely watching the movements of the child's abdomen, that being very much more affected by respiration in young children than the chest is. The normal rate of a newly-born child is 40 or so respirations per minute, by the second year they have fallen to 30 or so, at the fifth year they are about 25, and by fifteen they have sunk to 20. Much more important than the absolute number of respirations is the ratio of respiration to pulse. Normallv this should be as l:3ior4. The pulse is best counted by allowing the mother to hold the child's hand in hers ; the fingers of the physician are then quietly slipped over the mother's hand on to the child's wrist and the pulse counted. If the child has begun to cry, it is useless to take the pulse-rate, as it may be at least 20 beats above the normal rate. The pulse-rate at birth should be 130, by the second year it has reached 110, by the fifth 100, by the eighth 90, and by the twelfth 80 ; after this it gradually sinks to the normal adult rate. During sleep the pulse-rate always falls about 10-20 beats. As a matter of fact, the examination of the pulse in infancy is of comparatively little clinical value. It is of little use as an index of the vital powers, the fonta- nelle replacing it in that respect. The vessel being extremely small, the characters of the pulse-wave can hardly be ascertained ; irregularity by itself is of com- paratively little significance, being very common, even in healthy infants, and being almost the rule in sleep. A pulse which is continuously slow and irregular is, however, of great significance, General Examination. 491 These pveliminary facts having Ijeeii noted, the child should be stripped and })laced in a blanket on the knee of the mother or nurse ; examination must then be proceeded with by the usual methods of in- spection, j^alpation, auscultation, and percussion. In the clinical investigation of children it must be noted that the two former methods are of much the greatest assistance. It is well to begin l)y looking and feeling the child all over. One notes the general state of develop- ment and nutrition, the state of the skin, whether dry and fevered, or moist, and the presence or absence of any rash or skin eruptions, and whether or not the normal degree of elasticity is present. The shape of the chest and the degree of prominence of the abdomen should be noted, it being borne in mind that the rickety and pigeon-breasted types of chest are very common in diseased children, and that a rather protuberant abdomen is to be regarded as normal. The hand should then . be lightly passed over the head. The state of the anterior foiitaiieSle should first be investigated. The fontanelle closes normally between the fifteenth month and the second year. If it re- mains patent after the secoiid year, it is often a sign of disease — most usually of rickets. Too early closure of the fontanelle occurs in some forms of microcephaly and idiocy. The degree of tension of the fontanelle is of great importance. In health it pulsates distinctly, and is neither sunken nor unduly elevated. A depressed fontanelle is an important sign of exhaustion; a tense fontanelle indicates increased intracranial pressure. It must be borne in mind, of course, that the fontanelle is normally tense when the child is crying. The systolic bruit heard over the fontanelle is of no clinical importance. The shape of the head and of its bones 492 Examination of Children must be investigated. The development of ** bosses " (" Parrot's nodes ") on the frontal and parietal bones is a common occurrence in rickets, especially in syphilitic children. One should also look for evidence of craniotabes (in young babes) and of rheumatic nodules (in older children). The general shape of the head as a whole should always be noted ; it may be box-shaped as in rickets, globular in hydro- cephalus ; it may be abnormally small or large, or it may be asymmetrical. Passing from the head, one may examine the long" bones. In children, this is of extreme impoi-lance; many of the commonest and most serious diseases of infancy affect the bones more prominently than any other part of the body. Look for thickening or ten- derness along the shafts of the bones. This may be due to scurvy, to syphilitic or to suppurative j)eriostitis, or to tumours. Examine carefully the epiphyses. In rickets these become enlarged. This is most easily seen where the ribs join their cartilages, the thick- ening there forming a row of bead-like prominences ("rickety rosary"). It is also easily seen at the wrists. The frequency of inflammatory affections of the epiphyses should also be borne in mind. The presence or absence of ''rheiiBJiatic nodules" should also be noted. These are little fibrous bodies varying in size from that of a lai ge pin's head to a pea, or even bigger. They occur not in the periosteum, but in the deep fascia, where it covers superficial bones, and also in the sheaths of tendons. They should be looked for especially over the olecranon and patella. They are usually movable, but not tender. If found, they are pathognomonic of rheumatism. The vertebral column should always be examined for siorns of tubercular disease or curvature. At this point, if not earlier, the child's tem- perature should be taken. In young children the Palpation^ Auscultation^ Percussion. 493 thermometer should be inserted into the rectum, or l)hiced in tlie groin or axilla ; in older children it may be placed in the mouth. It should be remembered that the temperature in children is much more variable than in adults, and often goes up upon very little provocation. One must now proceed to the examination of the thorax and abdomen* The front of the chest and the abdomen may be examined together, and either after or before the posterior aspect of the chest. The order adopted should be, firstly, inspection and palpation, then auscultation, and, last of all, per- cussion. Percussion is left to the last, owing to the fact that it frequently makes the child cry. In palpation, be sure that the hand is Cjuite warm; this is even more important in examining the child than in the case of an adult. In auscultation one should use either the immediate method — the ear being applied to the skin directly (this is only applic- able in examining the back), or else one should use a binaural stethoscope. The latter enables one to follow slight movements on the part of tlie child better than one can with a wooden instrument. If the chest-piece of the stethoscope is made of metal, remember to warm it before applying it to the chest. There is only one point to be observed in the per- cussion of a child, and that is, that the stroke should be light. This is not merely in order to avoid frightening the little patient, but also to escape the confusion which is apt to arise from the excessive resonance of the child's chest. When the abdomen and front of the chest have been run over in this way, one should turn his atten- tion to the posterior aspect of the lungs. For the examination of these, the child should not be laid on his face, as that interferes with respiration, and causes the abdominal viscera to push up the diaphragm, 494 Examination of Children. but lie should be held against the mother's breast with bis head looking over her shoulder. In this way the wliole of the back of the chest can be gone over. Last, but by no means least, comes the examination of the nioiitli and throat. It is impossible to exaggerate the importance of systematically examin- ing the mouth and throat in all cases of illness in children. At the same time, it is just this pai't of the clinical examination in which we are most likely to meet with opposition; and for that reason it is let't to the last, as it may be necessary to employ coercion in order to get it carried out. Begin by looking at the tongue. Sometimes the child will put out its tongue when asked. In little babies gentle pressure on the chin will often cause the mouth to be opened, when a view of the tongue can be obtained. Or if a drop of milk or a little sugar be placed just outside the lip, the child will often put out its tongue in order to lick it off. In more refractory children it may be necessary to push the lower lip over the teeth, and then to press the lip down against the lower incisors. The child then opens its mouth in order to avoid having its lip cut. With very obstinate children one may be obliged to compress the nostrils until the mouth is opened to get breath. Once the child has been induced, either voluntarily or by aid of one of the above devices, to open its mouth, one should note the state of the buccal mucous membrane, remembering the frequency of thrush, stomatitis, and ulcerations in children. The number and character of the teeth should be observed (see also p. 42), and the finger should be run along the gum to feel for any teeth that may be about to come through. One must then proceed to an examination of the throat. The child should be wrapped in a towel to restrain the movements of Throat. 495 its arms. The mother or nurse sits down opposite a good light and takes the child on her lap. Another assistant steadies the child's head from behind. The child having then been induced or compelled to open its mouth, one introduces a small-sized tongue de- pressor and holds down the tongue, thus exposing the pharynx. The linger will often serve instead of an instrument, and has the advantage of friofhteninsf the child less. Look for any enlargement of the tonsils, for any redness of the mucous membrane, and especially for the presence of any membranous patches on it. Palpation of the pharynx must also be carried out in many cases. To do this one must stand behind the child, and when its mouth is open push in the cheek from one side between its molar teeth. This serves as a gag, and effectually prevents the child from attempting to bite. The forefinger is then passed to the back of the pharynx and up behind the soft palate. Note the presence of any adenoids, or any bulging into the posterior wall of the pharynx, which may be an indication of the presence of a retro pharyngeal abscess. AVe have now indicated the general routine method to be employed in examining a child, but there remain some special points which we have not yet taken up. These we shall consider briefly under the difTerent systems : — 1. General condition. — Special importance at- taches to the regular weighing of children. Altera- tions in weight from time to time are of much help in prognosis and treatment. It should be remem- bered that a healthy child should weigh at birth about 7 lbs. This should be doubled by the time the fifth month is reached, and trebled in the first year. By the sixth year it is again doubled, so that a healthy child of six should weigh about three 496 Examination of Children. stones. This is again doubled when the fourteenth year is reached. Measiireiueiit of the head is often of irnportance Pirr 131 —Position of viscera in child of five. (Ajter Symington, " Topo- °' graphical Anatomy of the ChiUl," Phate XII.) Two measurements are usually sufficient — a coronal measurement from one auditory meatus to the other, and a circumferential measurement at the level of the root of the nose and external occipital protuberance.* * The circumference of the head at nine months should be about 17 in. ; at twelve months, about 19 in. ; at seven years, 20-21 in. After three years of age a circumferential measurement of 19 in. is too small. Alimentary and Circulatory Systems. 497 2. Aliiiieiitary system. — Note that the liver is normally rather large in children, and usually reaches at least half an inch below the costal margin. Enlargement of the spleen is very frequent in infantile diseases. It is best made out by palpa- tion, the hand being passed across the child's abdomen from right to left. By depressing the finger tips opposite the eleventh interspace the edge of the spleen, if the organ is enlarged, may be felt as it descends during inspiration. Inspection of the stools should never be omitted. The healthy infant, on the breast or bottle only, has two or three stools daily. These should be of the colour and consistence of beaten-up eggs. Any alterations in frequency, colour or consistence, or the presence of worms, should be carefully noted. 3. Circulatory systean. — Note that the apex beat of the child is normally rather higher than in the adult. It is usually in the fourth space just out- side the mammary line (Fig. 131). It should also be observed that alterations in the general contour of the preecordia are much more frequent results of cardiac disease in children than in adults. As regards aiisciiltation, it should be remembered that the pulmonary second sound in the young child is normally rather louder than the aortic. The pul- monary second is accentuated if it be permanently louder than the first. The aortic second is accen- tuated if it be as loud as the pulmonary. Remember also that hsemic bruits are very rare in babies, while congenital bruits are relatively very frequent. We have already mentioned that the cardiac rhythm in the child is not infrequently irregular even in health. 4. The blood. — It is sometimes difficult to ^et a large enough drop of blood from the ear of a child. In that case, a piece of woollen thread shoald be G G 498 Examination of Children. twisted round the thumb — not too tightly — and the latter punctured with a triangular needle at the root of the nail. In very young children nucleated red blood corpuscles are normally present in the blood in small numbers. The leucocytes are more numerous in the child than in the adult; 12,000 per cnim. is not uncommon. The uni-nucleated leucocytes are relatively more abundant than in the adult. In newly-born babies the percentage of haemoglobin is often very high. 5. Kespiratory system, — A child uses its diaphragm much more than its intercostals in breathing. Hence the movements are chiefly abdominal, and there is little real chest expansion. Any indrawing of the lower interspaces on inspira- tion should always be looked for. It occurs wherever there is obstruction to the entrance of air {e.g. diph- theria), but may also be present where there is collapse of the lower parts of the lungs, and also in pneumonia. In " extra-auscultation " one should be on the outlook for any stridor, and for the existence of a short, grunting expiration. The latter is a frequent sign of severe respiratory disease. In the adult the normal cycle of respiration is, of course, inspiration, expiration, pause. In the child this is often reversed, so that one gets first a short expiration, succeeded by a longer inspiration, and then by a pause. This reversal is specially frequent in respiratory disease or embarrassment. The re- spiratory pauses are often very prolonged in the child, so that one has to wait a long time if one is auscultating before the next inspiration is heard. The normal breath sound in the child is, after the age of six months or so, puerile in type. Vocal resonance is often difficult to estimate. In babies one may make use of the cry as a producer of vocal resonance ; in older children one may ask them Respiratory and Urinary Systems. 499 their name, get them to count, etc. It should be remembered as a general rule that if the breath sounds are distinctly harsher on one side than the other, then the harsh side is probably the normal. Children's chests conduct sound very readily. Hence abnormal sounds, especially crepitations, are very apt to be heard on both sides, although they are really only being produced on one. The great frequency of collapse of part of the lung should be borne in mind in diagnosing pulmonary disease in infancy. In percussing the lungs in children one must, as already mentioned, use a very light stroke. One should also take care only to percuss when the chest has been filled by an inspiration, otherwise one may be led into thinking that there is dulness present. It should also be remembered that the chest-wall of a young child is so elastic that one can often obtain the "cracked-pot" sound on heavy percussion, even although the lung be perfectly healthy. This is especially apt to happen if the child is crying. 6. Urinary system. — It is difficult to collect the total quantity of urine passed by a child per diem. A rough table of the average quantity for each age will be found at p. 268. It will be observed that the totals are surprisingly low. The specific gravity, on the other hand, is relatively higher than in adults. Sugar is very rarely present in the urine of children. 7. IVei'voiis system. — Motor paralysis is to be made out by watching whether the child ever moves the suspected limb. One cannot estimate the paralysis as one does in adults by means of passive resistance. Remember that inability to walk is not necessarily a sign of paralysis of the legs. One must note whether the legs are moved when the child is sitting or lying. Thus a rickety child may not be able to walk, but moves his leg freely if one tickles the soles. A child with infantile paralysis 5QO Examination of Children. of the legs cannot move the limbs in any circum" stances. The knee jerks in little children are best elicited by placing the child's foot on one's hand as a stirrup, and then gently percussing the tendon. The latter lies rather to the outer side in the child, and is comparatively narrow, so that one may easily miss it. The superficial reflexes are usually more brisk in healthy children than in adults. Tlie exact local- isation of sensory paralysis is extremely difficult in children, but sensory lesions occur but rarely in infancy. In examining the eyes with the ophthalmoscope, the direct method is that which it is best to employ. The child may be examined while lying on its back, a lamp being held alongside the head, but at a some- what lower level. It may be necessary to hold open the lids, but as far as possible avoid touching the child at all. One must often be satisfied with mere fleeting glimpses of the disc. In testing light perception in little children, it is best to hold a candle in front of the eyes, and see if they attempt to follow its movements. One may also threaten the cornea by suddenly bringing the finger near it, and observing whether the child winks before the eye is touched. In examining the ears, one must remember the shortness of the auditory meatus in the child, and the great obliquity of the drum membrane. The magni- fication of the view by means of an ophthalmoscopic lens is a useful aid in these cases. It is often difficult to gauge the intellectual capacity of a young child. Early signs of idiocy are — inability to support the head, which often rolls about helplessly ; causeless screaming ; inability to notice things ; and backwardness in grasping. In older children we can inquire as to progress at Intellectual Capacity, 501 school, etc., or ask the patient questions. Get him to count, multiply, and so on. The position of the child in the school is a rough guide to the develop- ment of the intelligence. A normal child remains in the infant school until he is seven years of age, after which he enters the standards. The averao^e aije of the children in each standard is as follows : — Standard I. 7-8 years II. 8- 9 „ III. 9-10 „ lY. ... 10-11 „ Y. ... 11-12 „ YI. ... 12-13 „ YII. ... 13-14 „ A normal child should have begun to walk a little by the age of eighteen months. Talking begins at a variable time after this. The distinction drawn by West between children that are idiotic and those that are merely backward may also be of help in the investigation ; a backward child would be normal for a younger age ; an idiot would be abnormal at any age. 502 CHAPTER XIII. The Examination op Pathological Fluids. In this chapter we pi^opose to deal witli the method of examining fluids, which may be obtained from one of the body cavities or from abnormal growths, in order to obtain information which may be of help in diagnosis. The flnid is obtained by means of " exploratloii." An ordinary hypodermic needle may be employed, but special "exploring" needles — which are really merely large and strong hypodermics — are also sold. The needle should be of such calibre that it is capable of sucking up oil. If it is able to do that, it will be able to suck up any fluid likely to be met with in exploring. Before being used, the needle should be sterilised. This is best done by slipping it into a test tube, covering it with water or weak carbonate of soda solution, and boiling for three minutes. It should then be placed in boracic lotion. The use of strong carbolic lotion for sterilising exploring needles is to be avoided, as it produces a coagulation of albu- minous fluids, which may block the needle or cause the fluid to seem opalescent. The patient's skin should be cleansed with some 1 in 20 carbolic acid at the spot selected for puncture. As a rule, it is not necessary to employ any local anaesthetic. In very nervous patients a small spot of skin may be frozen by means of the ethyl chloride spray. It should be remembered, however, that the local reaction after freezing causes really more pain than the original puncture. The needle should be held short, with the forefinger of the operator resting on it near the Where to Puncture. 503 point. It should be introduced rapidly and steadily, but without any " stab." When the needle has been fully entered, the piston is withdrawn. Should no fluid be obtained, the needle is drawn slowly out- wards, whilst a negative pressure is maintained in the syringe. It may then be found that fluid is obtained nearer the surface. Where to Puncture. In the case of the pleural cavity, the puncture is best made in the 9th or 10th space midway between the posterior axillary and scapular lines, this being the point at which fluid which is lying free in the cavity is most likely to be obtained. In cases of localised dulness, one must be guided, of course, by circumstances. Usually, however, one selects that point where the dulness is most absolute and the breath sound faintest. Puncture of the peritoneal cavity may be per- formed either in the middle line through the linea alba, or laterally, about a point on a line with, but rather above, the anterior superior spine. The former position ensures that no large blood-vessel will be injured ; but by lateral puncture one is more certain of entering fluid, especially if the patient be turned over somewhat on to the side of operation. Before puncturing in the middle line be sure the bladder is empty, and never insert a needle at any point unless it yields a dull note on moderately heavy percussion. In puncturing the peri car diiiiii one should select a spot in the third, fourth or fifth interspace, at a distance of ^ in. to 1 in. from the left margin of the sternum, the exact spot dej)ending on the degree of distension of the sac. Litimbar puncture is a method now not in- frequently resorted to for ascertaining the character of the effusion in cases of increased exudation into 504 Pathological Fluids. the subdural space. It is most usually required in children. Au antitoxin needle is best for the pur- pose. The patient, preferably anaesthetised, should be on his right side, slightly bent forward, and lying over so that the spine is towards the operator. Trace the last rib back to the twelfth dorsal spine, and count down from this to the third lumbar. Put the left thumb on the third interspinous space, enter the needle \ in. to the right of it, and pass slightly in- wards and upwards for a depth of | in. to 1 in., depend- ing on the age of the patient. A syringe is not essential, but forms a useful handle to the needle. The fluid usually escapes in drops ; a continuous flow indicates increased pressure. Lateral movement of the needle should be avoided, as it may produce bleeding. The fluid should be collected in a sterilised test tube. Its characters and their significance will be referred to later. In the exploration of cysts, etc., one must be guided by local circumstances, the rule being to select for puncture that parb of the tumour which is nearest the surface, and where one is not likely to injure important structures. Examination op the Fluid. The fluid having been obtained, it should ])e transferred to a conical glass and allowed to settle. Note first its physical cliaracters. The chief of these are the colour, consistence, specific gravity, odour, and the appearance of the deposit (if any). As regards the colour of tlie fluid, one of the most important points to note is whether it is bloodstained or not. It must be borne in mind, however, that a small amount of blood is apt to get into the fluid in the process of exploring. Observe, also, whether the fluid is transparent, opaque, or opalescent. Opacity is usually due to the presence of cellular Chemical Investigation. 505 elements ; opalescence to fatty particles or large numbers of micro-organisms. Pathological fluids are usually of a more or less watery consistence. Viscidity usually indicates the presence of mucin. It should be carefully noted whether or not the consistence of the fluid alters on standing. Many pathological fluids clot after standing for some time. The clot consists of tibrin. The specific gravity is taken with a urinometer, the same precautions being used as in the case of urine (p. 274). Most fluids are devoid of odour; sometimes, however, they are extremely fetid. The amount and colour of the deposit should be noted. If red, it probably consists of red blood corpuscles ; if white, it may be made up of leucocytes, cancer cells, etc. For clieMiical investigation the fluid should first be filtered. In the examination of the filtrate the following points must be attended to : — (1) The reaction. This is almost invariably alka- line. Sometimes it is neutral. (2) The presence of sernm albumin and serum globulin. This is ascertained by means of the same tests as have already been described for the urine (p. 297). If these proteids are present in large amount, the fluid is coagulated on boiling, even although the reaction is alkaline. If proteids are scanty, the fluid sliould be first rendered slightly acid by means of dilute acetic acid. As in the case of the urine, nothing is gained by testing for albumin and globulin separately. Albii- moses and peptone are almost never found in the fluids under consideration. The quantitative estimation of albumin and globulin cannot be accurately carried out in ordinary clinical work. Approximate results may be obtained 5o6 Pa t ho logic a l Fl uids. by tlie use of Esbach's tulje. The fluid must first be 7ery freely diluted, so as to bring the specific gravity down to 1,008, and should then be rendered acid by means of acetic acid (see p. 300). (3) The presence of imiciii or iiiicleo-albiiniin Fig, 132.— Foulis' cells. is proved by the appearance of a precipitate on the addition of acetic acid. The method of distinguishing betvi^een the two has been already' indicated (p. 303). (4) Siig-ar should be tested for by rendering the MiCR OS CO PIC A L EXA MINA TION. 507 Fig. 133.— Cliolesterin crystals. fluid slightly acid, boiling, and filtering. The filtrate is then evaporated down to a small bulk, and the tests for glucose described at pp. 308-13 applied. (5) Urea is not often present, except in traces, in ordinary pathological fluids. In fluids derived from the urinary organs it may be more abun- dant, and should be tested for by removing all proteids by heat, evaporating the fil- trate to a small bulk, and then testing for urea as described on p. 286. Microscopic Examination of the Sediment. Some of the deposit is taken up with a pipette, and a drop of it placed on a slide, covered, and examined. If desired, films of it may be made in the same way as in the case of blood (p. 197). This succeeds fairly well if the deposit consists of cancer cells. One may recognise under the microscope (1) elements derived from the blood — al- tered red and white corpuscles. The recog- Fig. 134.— Fatty needles and crystals in degenerated cells. fatty 5o8 Pathological Fluids. nition of altered white corpuscles or pus cells is facilitated by mixing with a dro]) of the deposit a small quantity of a 1 per cent, solution of acetic acid to which a little methyl green has been added. The nuclei are then more easily re- cognised. (2) Epithelial cells of various sorts. The recognition of cancer j - - cells is of special impor- f n, tance. The addition of ^ ; '^rA a little picrocarmine or magenta facilitates the process. .Do not mis- take ordinary endothelial cells for them. Cancer cells should be large, numerous, and show grouping here and there. The cells met with in fluids derived from malig- ^^^ W> -'v:- • '■ • '^^^^^"^^^^ pus, from a case of actinomycosis of the csecum. x 300. nant ovarian cysts, or malignant peritonitis f ol- Fig. 135.— Colony of actinomyces in lowing SUch Cysts, are known as Foulis' cells (Fig. 132). They are large cells containing one or more nuclei about the size of a red blood corpuscle. They may have either a. smooth outline or may show little buds or pro- jections indicating rapid proliferation. (3) In fluids derived from hydatid cysts scolices and liooklels may be found (p. 93). (4) Crystals— e.(/. of chole- sterin (Fig. 133), or fatty acids (Fig. 134), fragments of muscular tissue, etc. — are sometimes met with. (5) The pus from cases of actinomycosis contains small seedlike nodules. If one of these is bruised between a slide and cover glass, and examined with the high power, it will be seen to consist of a central mass of detritus, radiating out from which are a Inflammatory Effusions. 509 number of club-shaped highly refractile bodies (Fig. 135). If there is any ditticulty in identifying the fungus, cover-slip preparations should be made, and stained by Gram's method (Appendix, 20). For other staining methods, see p. 533. (6) The detec- tion of the Aiiiopba dyseuterise in the pus of abscesses, especially in the liver, is often of great diagmostic value. The orcjanism is described at p. 95. If one fails to find it in pus removed by exploration or in that obtained when the abscess is first opened, one must not jump to the conclusion that it is not present in the abscess. It frequently does not appear in the discharge until three or four days after the abscess has been opened. This is probably to be explained by the fact that the habitat of the organism is in the wall of the abscess (Manson). General Characters of the Principal Fluids. 1, Inflaiiiuiatory aud dropsical effusions. Inflammatory effusions are often spoken of as exudates ; dropsical effusions as transudates. They present the same general appearances, being clear fluids of a vellowish ofreen colour, and containing much albumin and globulin. It is very difficult to tell a dropsical from an inflammatory fluid by chemical or other examination. It would appear that the amount of proteids in an effusion depends much more upon site than upon cause. Pleural fluids contain the highest percentage of proteids, peritoneal fluids rather less, and subcutaneous fluids very little. The fluid in cardiac dropsy is more highly albuminous than in dropsy of renal origin. From a diagnostic point of view all one can say is that a fluid with a specific gravity of more than 1,018, which contains more than 4 per cent, of albumin, is almost certainly inflammatory ^ while one with a 5IO Pathological Fluids. specific gravity of less than 1,01-^), and an albumin percentage of less than 2|-, is certainly dropsical. Between these limits one must be in doubt. Nor is the occurrence of coagulation in the fluid after tapping of much help. If the coagulation be very rapid and complete, the fluid is probably inflam- matory, but considerable coagula may form even in purely dropsical fluids after standing for some time. Variations in the specific gravity, etc., of fluids obtained by repeated tapping in the same case are of no prognostic value. A marked rise in specific gravity and amount of albumin may, however, indicate the supervention of inflammation. 2. Fluid obtained by lumbar puncture.— Ordinar}'- cerebro-spinal fluid is perfectly clear and colourless, resembling distilled water. It contains very little albumin {^-^ per cent.), and if evaporated to a small bulk or tested will be found to reduce Fehling's solution, owing, probably, to the presence of pyrocatecliin. This is the kind of fluid which is found in cases of cerebral tumour. In cases of meningitis the fluid is not clear, but turbid from the presence of cellular elements. The turbidity may be so slight that it is only noticed after shaking the fluid and holding it up to the light. It contains quite an appreciable amount of albumin, varying from \ per cent, in chronic cases up to 1 or 2 per cent, in those which are acute; and a small clot of fibrin usually appears in it after standing for some time. It does not usually contain any reducing substances. The bacteriological examination of the fluid is of special importance, and should be carried out as in Chapter XIY. 3. The chief characters of the other fluids likely to be met with on exploration are contained in the following table : — Table of Fluids. 511 rC ._:,.• CO 0! +j Si 03 a 3 s 2 »= =" Ha -1 T-H T 4^ -c; 03 o) oi '■" ^ c ■« ^ — 5 < 0^ j^3qSsS."S H . ■<) -n pa H pjto m si >> 2t ;3 .« ^ ? 03 _i -w CI, 5 "S .2 a-TJ^ie 03 5-^^ 0^ a Q^.^;:^'^ s "^ ^ j-jOcjO'CiojoiS < CO cite OJ *" -^ 1 So "o ^ c3 1 , «w -• Oj ■ ID J ^ ' D ' >S 1 c 'aj 5 '^ ^ ^i !-i ._ > m5 tn > »o 1 (M r-T > 03 0-5 Q i) oj ca T^ -4-* >3 >> o3 >a .2 .S i pa <; = a- 03 t3 03 a; .-. to 0) ;-i >5>> ri U X cS -r* • 1-4 •;-' 00 03 OT g S-l 5 -1-3 III' SJO 0) — 03 QBj -S ^ >j a c3 O) be P3 2 M 0; 03 0) >j CO CI CO ."2 C 03 c ° " S '0 1 i-T >> > 2 t< M 03 S>> +3 >3 c M ■0 >5 a:> Ph OQ OQ 5^2 CHAPTER XIV. Clinical Bacteriology. In order to make a complete bacteriological examina- tion, three methods of observation are necessary. These are microscopic study of the oi'ganisms, their cultivation on suitable media, and the effects produced by their inoculation into various animals. To obtain material, and to carry out the subsequent examination, the following instruments, all of which must be thoroughly sterilised immediately before use, are required : — 1. Pl£&tiniiiii needles, about 3 in. in length and sutficiently stout not to bend very readily, fused into glass handles. Some of these should have their ends curved into a small loop, others ought to have the last half centimetre bent at riglit angles to the rest of the wire, whilst a few should remain straight and have their free extremity somewhat flat- tened like a narrow spatula. 2. Small sterile pipettes. — For clinical use, ordinary vaccination tubes, carefully sterilised and then sealed off, are very serviceable. A few larger ones are also needed. 3. Swabs for collecting particles from false mem- branes. To make these, a piece of stiff copper wire, about 18 B.W.G. in thickness, should be em- ployed. A portion 7 in. long, should have a flat loop made at one end, round which a small piece of absorbent cotton wool must be firmly twisted. Wool must not be used that lias been rendered anti- septic with mercuric chloride or other disinfectant. A test tube about an inch shorter than the wire is Appa RA TUS. 513 then selected, and its mouth plugged with a stopper of cotton wool, through which the wire passes. There- after the tube with its contained swab is carefully sterilised by heat. Several such swabs should be taken to the patient, and, after having been used to collect the material which requires examination, can be replaced in their test tubes and brought back to the laboratory without fear of contamination. 4. A hj'poderinic syringe which can be steril- ised by boiling. One which the writers have found convenient is designed by Strauss and sold by Collin, of Paris. The plunger is made of elder pith, and by a simple adjustment can readily be fitted to the piston rod, and the other joints are also rendered secure by discs of the same substance. Boiling improves rather than injures the pith fittings, and when one has worn out a new disc can easily be cut with a penknife from a piece of fresh pith. In order to make a complete examination of the materials obtained by the above means a small laboratory is required. In it there should be ovens for sterilising the different pieces of appa- ratus by dry heat and by steam, and if cultures are to be made, an incubator must also be obtained. For many purposes, and especially for the detection of bacteria in urine and in serous effusions, a centrifuge is practically essential, whilst a Bunsen burner, capsules, watch glasses, forceps, slides, cover slips, a good microscope, stains and reagents, test tubes, beakers, flasks, funnels, and filter paper are also required. The capsules should be of porcelain, nickel, or platinum, and should be employed, wherever heat has to be applied to staining fluids, in place of watch glasses, which crack readily. Metal capsules should be scrupulously washed^ and then sterilised by heating to redness in a flame. Porcelain ones should also be H H 514 Cl I NIC a l Ba cteriol og y. sterilised by heat, and must not be used after tliey become cracked. Slides aii€l cover g-laisses — the latter must be thin, preferably No. 1 — must be washed with dilute nitric acid, afterwards with ammoniated water, and then with alcohol. Thereafter they may be kept in a covered vessel under alcohol until they are required. The most generally useful forceps for holding cover glasses are those known as Cornet's. In these the spring is so arranged that the cover glass is firmly held until released by pressure, and the blades are constructed so that the cover slip is in a horizontal position when the forceps is laid down. 'ihe stains which are most employed belong to the basic aniline dyes, and are either simple aqueous and alcoholic solutions, or contain a mordant, such as an alkali, carbolic acid, or aniline oil, which makes the bac- teria take up the stain better and retain it more firmly. Most of these dyes are so used that the preparation is first overstained and then the excess washed out by suitable reagents, when, owing to the greater tenacity with which bacteria cling to the colouring matter, they remain clearly visible after all else has become partially decolorised. A few stains, however, one of the most important of which is Bismarck brown, are employed differently , as their selective action is so marked from the very outset, and their tendency to overstain is so slight, that there is no need of securing differentiation by the more tedious method of over- staining and then washing out. Such stains generally act with fair rapidity. For most purposes the following stains suffice : — 1. Fuchsin ... ... saturated alcoholic solution. 2. Gentian violet . . . saturated alcoholic solution. 3. Methylen blue ... saturated watery solution. 4. Bismarck brown ... ... aqueous solution. Stains. 515 5. Loffler's stain ... ... \ 6. Ziehl-Neelsen's stain [for tubercle] ( see Appendix, 7. Carboltliionine ... ... C 20-23. 8. Gram's reagents ... ... ) 9. Ronx's stain [for diphtheria] (see p. 524). The stains must not be kept too long, must be fre- quently filtered, and should be examined from time to time for bacteria, which occasionally invade them — es- pecially when the solutions are aqueous — and unless detected may lead to serious mistakes. For mounting the specimens one may employ Far- rant's medium if the slide is not to be permanentl}" preserved, otherwise Canada balsam in xylol should be used. It is very important to remember that some stains make bacteria look larger than others do, and also that their apparent size is less when they are mounted in balsam than when the examination is made with a drop of water or with Farrant's medium. When cultures are desired, tubes containing nutrient gelatin, blood serum, agar-agar, and glycerine agar, and flasks of bouillon must be provided. These can occasionally be obtained from dealers, but are better prepared in a well equipped laboratory. The details of preparation are outside the scope of this text-book. The method of exaniiiiatioii which is most readily available in clinical work is the preparation of Alms on cover slips. The technique is as follows : — A cover slip, which must be thin enough to admit of the film being examined through it by an oil immersion lens, and which is thoroughly clean, is taken, and a very small drop of the fluid under examination is spread over it in a thin layer by a sterilised platinum needle. If the material is too solid, as may be the case when cheesy particles are being examined, a drop of distilled water must be added and intimately mixed with the niass before the cover slip is smeared with it. The excess of fluid is then allowed to evaporate by 5i6 Clinical Bacteriology. holding the preparation, fihn upwards, some height above a flame, and the dry film is " fixed " by passing it thrice through a Bunsen or spirit flame, film upwards, at such a rate that each transit occupies something less than a second. Thereafter, in order to make the background stain less deeply, it is immersed for one minute in a 1 per cent, aqueous solution of acetic acid. It is then quickly dried, and fixed in the forceps, film upwards. A test tube is taken and half filled with distilled water, and the selected stain, which should have been recently filtered, is added until the fluid is just trans- parent. Take up a few drops of the dilute stain with a pipette and apply it to the film. After the lapse of a couple of minutes wash the slip with water, dry it thoroughly, and mount in xylol balsam. The specimen must be examined with a high- power objective. In most instances an oil immersion lens of yV inch focus should be used, although in many cases a lower power, such as a Zeiss D objective, may be sufficiently strong for clinical purposes. The micro- scope should be provided with an Abbe condenser the diaphragm of which must be used fully opened, and the plane mirror employed to reflect the light. The inner tube of the microscope should be drawn out to the length for which the objective is constructed. Continental objectives mostly work to best advantage with a tube length of 160 mm. English objectives require a tube length of 10 inches. In using the oil immersion lens, a drop of prepared cedar oil is placed on the cover-glass, and the objective lowered by the hand or coarse adjustment until it touches the surface of the oil ; the focussing is then carefully performed with the fine adjustment. As the lens is delicate and the working distance small, great care must be taken not to bring the lens and cover glass into contact ; and when the observation is Inoculation of Tubes. 517 completed the cedar oil must be gently \idped from the surface of the objective with a piece of old silk. When a tube requires to be inoculated the follow- ing procedure should be adopted : — The tube containing the pathological fluid is held between the thumb and first finger of the left hand, so that the mouth with its stopper of cotton wool is on the palmar side. The tube to be inoculated is similarly held between the first and second fingers of the same hand, with the surface of the nutrient medium upwards. Both tubes should be held as horizontally as possible short of wetting the stoppers with the contents. A platinum needle is then taken in the right hand, thoroughly sterilised by heating to bright redness, and allowed to cool again. The stopper of the specimen tube is then withdrawn by the right hand and placed between the fourth and fifth fingers of the left hand, and finally the stopper of the nutrient tube is withdrawn and retained between the fingers of the right hand, care being taken that the stoppers are only held by their external ends. The needle is then dipped into the specimen, and the smallest trace of it is withdrawn and transferred to the surface of the nutrient medium, along which a streak is drawn. The tubes are at once re-stoppered, the needle again sterilised, and the culture placed in an incubator as soon as convenient. Where micro-organisms are very abundant in the specimen, several tubes should be successively in- oculated without recharging the needle. In this way, though the growth is excessive in the first, in the third or fourth the colonies are more scattered, and pure cultures may be separated out. A cheap metal pen rack is a convenient support on which to lay the needle after it has been sterilised, when a number of tubes are being dealt with. 5i8 Clinical Bacteriology. Special Methods. 1. Spiituni. — The sputa which are of the greatest importance bacteriologically, are those of pneunionia and of phthisis. In pneumonia the diplococci are most readily found when the disease is at its height. Select a rust-coloured portion of sputum, spread it in as thin a film as possible, dry, fix, and stain with the fuchsin solution employed for tubercle bacilli as recommended by Ziehl. Decolorise by means of warm water. Tf successful, the cocci will be darkly stained, and the surrounding capsule will appear in a fainter shade of red. In tubercular sputum much of the success depends on the choice of a suitable specimen. The sample should be chosen from the interior of one of the mucopurulent masses that are seen underneath the serous fluid portion. If the mass is so tenacious that a suitable piece will not adhere to the needle, spread the sputum in a shallow glass vessel and either pick out the part required with sterilised forceps or plunge a hot needle into the mass, when a portion will adhere to it ; care must be taken not to use the central charred mass. When the sputum comes from a phthisical cavity it may contain almost pure cultures of tubercle bacilli in its interior, though the outer surface of the mass is naturally contaminated during its passage through the mouth. To prevent confusion from spread of contamination, the sputum ought always to be examined as soon as possible after it has been expectorated. (Frontispiece, 6.) In cases of hsemoptysis the best specimens in which to seek for bacilli are often the small dark red clots that are coughed up a day or two after the attack has suljsided. In acute miliary tuberculosis without typical tubercular sputum, it may be almost impossible to demonstrate the presence of the bacilli. Sputum. 519 In difficult cases the sputum should be heated with caustic soda and water till a homogeneous fluid is produced. This is set aside for thirty-six hours in a conical test glass and the sediment examined, or the sedimentation may be more rapidly effected by a centrifuge. When a suitable specimen has been obtained, it should be spread very thinly and evenly on a cover glass, and allowed to dry in the air at the temperature of the room. When it is quite dry, it is taken in a forceps and passed several times rapidly through a smokeless flame, as has been already described, to coagulate the albuminous materials, and so fix the film to the glass. It should then be placed film downwards on the top of a little carbol-fuchsin stain contained in a capsule, and the fluid heated till steam rises. Generally, it is well to repeat the heating three or four times. Then wash in water and decolorise in a 20 per cent, solution of sulphuric acid until all the elements except the bacilli have parted with the stain. As a rule, this is accomplished in from one to three minutes. Wash once more in water, dr}^, and mount either in a drop of Farrant's medium if the specimen is not to be kept for any length of time, or in Canada balsam dissolved in xylol if a more permanent preparation is required. The specimen must be examined with a high power and good illumination ; by preference with an oil immersion lens and Abbe condenser — though for clinical work a lower power is often sufficient. Many workers prefer to counterstain with a watery solution of methylen blue for one minute. This has the advantage of revealing the other elements present in the sputum, and the disadvantage of making the detection of the tubercle bacilli rather more difficult. 2. Blood. — This ^may be readily examined by 5 2 o Clinic A l Ba cteriology. careful sterilisation and subsequent pricking of the finger-tip, so as to make a drop of blood exude with which to prepare films on cover glasses. Since it is often very difiicult to obtain complete disin- fection of the skin, an alternative method may be adopted, and blood aspirated from a vein in the arm by means of a syringe. This method has the ad- vantage of securing a larger quantity of blood, and should be employed when inoculations are to be undertaken. Puncture of the spleen has been advo- cated on the Continent, but it may lead to unpleasant symptoms."^ When the film of blood has been made on the cover glass, it must be well dried in warm air before it is passed througli the fiame, and thereafter should remain for some time, best for three or four hours, in an oven at a temperature of 120^ C. Before applying the stain a preliminary immersion in dilute acetic acid assists both in discharging the colour of the red blood corpuscles and in accentuating the different affinities of the bacteria and blood elements for the dye ; it must, however, be carefully washed off, and the last traces of it neutralised by ammonia vapour before staining is proceeded with. The stains which prove most useful are Gram's, Loffler's, or alcoholic fuchsin. When the stain is blue, watery eosin may be used as a counterstain to bring out the red blood corpuscles. 3. Urine may be examined, after careful disinfec- tion of the meatus, either by drawing off a sample from the bladder with a sterile catheter, or by making the patient pass water, and, after the first portion of the urine has cleansed the urethra, collecting the remainder. The centrifuge should be invariably used * Similarly some observers have punctured the. lungs, liver, and other organs to secure luicontaminated samples of the bacteria which they contained. Urine. 521 to secure a deposit without delay, and the latter then examined. One of the most important bacteria that may be found in the urine is the tubercle bacillus. The pus which is separated from the suspected urine is spread not too thinly on a cover glass, which is then manipulated in the manner already described for tubercular sputum. In cases where the sediment contains small purulent-looking lumps, these should be selected to smear on the cover glass. If the urine is loaded with urates they may be readily dispelled by adding warm water to the sediment, or by washing the film with warm water before staining. The bacilli when found frequently occur in clumps, whilst it may be necessary to examine six or more preparations before a clump is discovered. One of the chief sources of fallacy in examining for tubercle bacilli results from the presence of the smegma bacillus, which has very similar morpho- logical characteristics, and especially resists the de- colorising action of sulphuric and nitric acids. To distinguish them the cover slip should be immersed for ten minutes in a solution of hot caustic soda to which 5 per cent, of alcohol has been added. The specimen is thereafter washed with water and absolute alcohol. Tubercle bacilli thus treated still retain the stain when exposed to the action of mineral acids, whilst the smegma bacillus is decolorised. In cases of cystitis the most commonly found organisms are the bacterium coli, the gonococcus, and the tubercle bacillus. In some instances, especially in women or in persons on whom catheters have been passed, the ordinary staphylococci of suppuration are also present in large numbers. In urethritis resulting from gonorrhoeal infection the gonococcus is present, but is often associated with numerous other dijDlococci, wliich are not very 522 Clinical Bacteriology. readily distinguished from it. Since it is of import- ance medically as the cause of certain affections which resemble rheumatism, it is necessary to be able to recognise it. Films may be made in the ordinary way, stained lightly with watery solution of methylen blue, again washed and examined in water, or dried and permanently mounted. The organism will be described subsequently. 4. Pms and other fluid exudations are best obtained by aspiration from the cavity in which they lie with a sterile hypodermic syringe, after thorough disinfection of the skin where the needle is to be inserted. Amongst the most important of such exudations are those into the pleural cavities. These may either be serofibrinous or purulent. In nearly three-fourths of the cases of empyema which have been examined, the organisms that have been found are either pneumococci, staphylococci, or streptococci, and in the case of adults the last constitute fully half of the total. In children the pneumococcus preponderates. As regards prognosis, the presence of streptococci gives much the gravest outlook, and this agrees with the relatively favourable issue of the disease in children. 5. Specimens from false membranes are best obtained by removing a small portion with a swab or forceps. Care must be taken not to touch any other part of the patient's mouth with the swab. In cases of suspected diphtheria it often happens that so many organisms are present on the surface of the membrane that it is almost impossible to identify the bacillus of diphtheria amongst the other bacteiia which are associated with it. Under these conditions the piece of membrane should be washed in a flask with a little boiled water. After being agitated in this for a short time, the cocci, mucus, and other adventitious elements which have adhered to the Chief Bacteria. 523 surface become for the most part detached, and the specific organism can thereafter be obtained in a much purer condition by thrusting a platinum needle into the membrane after its removal from the flask, and inoculating several tubes successively without recharging. 6. Faeces. — The faeces are always rich in micro- organisms ; it is therefore of great importance to lift only a very minute fragment for examination, whether on the slide or by cultures. The following are the most important bacteria from the point of view of clinical examination : — I. — Bacilli. (a) Bacillus tuberculosis. — It is rather small and slender (2 to 5 \x in length). As seen in sputum it is not infrequently a little curved ; and often two bacilli are found lying end to end, making an obtuse angle with one another. The staining may be uniform, or there may be small clear spaces of an ovoid form which are disposed at intervals. It is best stained by Ziehl's method. (6) Pfeiffer's bacillus is a minute bacillus with rounded extremities ; the ends stain more deeply than the centre. It is not coloured by Gram's method, but can be demonstrated by Ziehl's stain. It is found in the sputum, and occasionally in the blood of patients suffering from influenza. (c) Bacillus diplittieriae (Klebs-Loffler). — This bacillus aA^erages about 3 \i in length, the long variety considerably more, and -6 or -7 /x in breadth. The ends are rounded and rather stouter than the centre, and stain more deeply ; frequently there is unequal staining of the protoplasm. (Froxtispiece, «, a!.) In most instances they are very readily coloured by 524 Clinical Bacteriology. Gram's method, but for demonstration the best stain is that suggested by Roux, which is as follows : — 1 per cent, aqueous solution of dahlia, 1 part. 1 per cent, aqueous solution of methyl green, 3 parts. Distilled water, till the fluid appears of a moderately deep blue colour. The procedure which should be adopted in cases where a patient's throat is to be examined for the bacillus of diphtheria, is as follows : Set the patient in a good light. Depress the tongue with the handle of a spoon ; then take a swab, pass it to the back of the mouth without touching the lips, gums, or tongue, and press it gently against the suspected patch on the tonsil. By rotating the swab a portion of the false membrane is entangled and brought away, and the specimen thus obtained is returned to the tube and taken to the laboratory. A cover-glass preparation may be made directly from it, but is likely to prove unsatisfactory, as many different organisms are so abundantly present that it is seldom possible to detect the Klebs-Loffler bacillus with certainty. To start cultures, a platinum needle, previously sterilised and allowed to cool, is charged from the false membrane, and four tubes are succes- sively inoculated from the needle, which is drawn in a streak along the surface of each without recharging. By far the most satisfactory medium is blood serum. Gelatin and glycerin-agar are untrustworthy, and should never be employed for diagnostic cultures of the diphtheria bacillus.* After inoculation the tubes are placed in an oven at 37° C. If the Klebs-Loffler bacillus is present, growth will often be manifest in * Failing blood serum, a medium composed of agar-agar pre- pared with ascitic, pleuritic, or hydrocele fluid, containing 2 per cent, of a 10 per cent, solution of caustic potash, with 5 per cent, glycerin, and 1 per cent, grape sugar, as recom- mended by Kanthack, may be tried. Bacillus of Diphtheria. 525 eighteen, and always in twenty-four hours, by which time the colonies in the third and fourth tubes will be as large as pinheads. In colour they are dull white, and ap[)ear distinctly denser in the centre when viewed by transmitted light. The colonies are circular, and spread rather rapidly. In the first and second tubes the characters are not so well seen, because the colonies are so numerous that they rapidly fuse and so lose their contours. Specimens obtained from the individual colonies must be microscopically examined, and pure cultures can be started from some of them by mixing them with a little bouillon, and reinoculating serum tubes with the product. In doubtful cases the diagnosis may be established only after inoculations have been performed. Occasionally, when the membrane is peculiarly rich in adventitious bacteria, it may be necessary to place it in a tlask with some boiled water and to treat it in the manner described above, before proceeding to inoculate the tubes. When information is sought regarding other bacteria which may also be present in the specimen, it is best to break up a small fragment in bouillon and inoculate various culture media with a drop of the fluid. In practice one finds that sometimes the mem- brane contains a preponderant proportion of Klebs- Loffler bacilli ; in many cases, however, other bacteria occur in large numbers along with it, streptococci being frequently present, particularly in severe cases. In other instances a form of diplococcus has been observed. In addition to the typical form of Klebs-Lofiier bacillus there is a stunted form which is shorter and more irregular in outline. One cannot, however, estimate with any certainty the toxicity of a . specimen from its morphological characters, nor, on the other hand, is one justified in considering that 526 Clinical Bacteriology. the bacillus is not a true diplitlieria bacillus because it happens to be devoid of virulence, although the intensity of its toxin will obviously influence the clinical history of the case from which it is derived. It is not therefore expedient to classify such non- virulent bacteria as "pseudo-diphtheritic," since experience has shown that the virulence of diphtheria bacilli may vary exceedingly even when they have sprung from a common source. The term "pseudo-diphtheritic bacillus " has also been applied to various bacteria whose morphology is almost identical with the true, but which, under the tests of culture and inoculation, are found to deviate more or less from the latter. Used in this sense the term is convenient, if not strictly accurate. {d) Bacillus of typhoid (Eberth). — This organism can be obtained in the spleen during the course of the disease, and from the blood in the rose- coloured spots. It also occurs in the urine if albuminous, and in the stools. It is mobile, and by suitable methods flagella can be demonstrated. The ends are rounded, the length 3 or 4 /i., the breadth about 1 /^. It does not stain by Gram's method, but is readily coloured by the ordinary aniline basic dyes. In arriving at an early diagnosis of typhoid fever l¥idal's test seems likely to take a very prominent position. It is based on the fact that after a certain Fig. 136. — Widal's pipette. Actual size. time has elapsed the blood serum of a typhoid patient acquires a power of interfering with the ordinary behaviour of the bacillus, and it is conducted as follows"^ : — * The method is taken from Sheridan Delepine's ijajjer in the British Medical Journal for April 17th, 1897, p. 967. Bacillus of Typhoid, 527 1. Apparatus* (a) A small lancet-shaped needle to obtain blood. This must be capable of ready sterilisation. (5) A sterile pipette to collect the blood and transmit it to the laboratory ; it must be wide enough to admit the loop (Fig. 136). (c) A platinum needle ending in a loop of 1mm. diameter. (This will lift about 2 mgms. of fluid.) (d) A sterilised slide and cover glass. (e) A tube of bouillon containing a culture of typhoid bacillus not more than twenty-four hours old. The tube must be free from clumps of bacilli, and the latter must exhibit active movements on micro- scopic examination. (y) A microscope capable of magnifying at least 250 diameters (preferably from 300 to 400 diameters) should be used, though even with lower powers a good deal may be made out. 2. Method. {a) Carefully sterilise the patient's finger, and obtain several drops of blood by a prick in the thin skin near the root of the nail. The blood is drawn into the pipette, which is then sealed off and taken to the laboratory. (6) Take nine loopfuls of the turbid bouillon and deposit them separately on the microscope slide,* then again sterilise the loop and let it cool. (c) Break off the sealed ends of the pipette, remove one loopful of blood serum, and deposit it also on the slide. This will contain some corpuscles, but their presence will not cause any inconvenience. id) Mix the serum as rapidly as possible with the bouillon, apply the cover glass, press it gently down * The best form of slide is one with a slightly depressed plat- form surrounded by a trench, somewhat like the slide of the Zeiss hfemocytometer (Fig. .57). Such slides can be obtained from any dealer in microscopic apparatus. 528 Clinical Bacteriology. to obtain a thin uniform film, and examine, pre- ferably with a magnification of 300 to 400 diameters. If the serum be taken from a patient wlio is not the subject of typhoid fever, the bacilli preserve their motility unimpaired, and continue to do so for days if the specimen be suitably preserved. Moreover, they are diffused with tolerable uniformity through the fluid, and show no distinct tendency to form clumps. If, however, the serum be taken from a patient after the first week of an attack of typhoid fever, or even on the third or fourth day of the illness, though in this case the phenomena will be less distinct, the following facts will be observed : — The motility of the bacilli is almost at once impaired, and after the lapse of a few minutes — two to five where the serum is fairly potent — their movements wholly cease. They also tend to become agglomerated into clumps, which in a typical case will have begun to form before the microscopic examination has been com- menced, and by the end of half an hour hardly any solitary bacilli will be found in the specimen. Even where the serum is weaker, as occurs in a certain proportion of cases of typhoid, the same changes eventually supervene, but they occur much more slowly. As a rule, however, impaired motility and a tendency to form clumps are distinctly visible within half an hour, and there are but few cases in which the observations need to be extended over two hours. A method similar in principle to the above has been adopted by Prof. Wright and Surgeon-Major Smith"^ in their investigations on the differential diagnosis of typhoid from Malta fever. They have further been able to prove that at least some of the Indian fevers are due to the same organism(micrococcus melitensis) that Bruce has shown to be the cause of Malta fever. * Lancet, March 6tli, 1897, p. 656. Bacilli. 529 It need hardly be remarked that to examine a specimen of the stools directly under the microscope, with the view of detecting Eberth's bacillus, is certain to fail in its aim. (e) Bacillus coli is a ciliated bacillus Avhich appears under a considerable variety of forms. It is important as the cause of some cases of cystitis and of intra-abdominal suppuration. Some of its forms resemble that of Eberth's bacillus, but can be distinguished by the fact that it produces fermenta- tion in lactose, in which process the medium becomes acid, as can be shown by the addition of litmus. (/) Bacillus cholerse (Koch) is a curved vibrio with a tiagellum at each end. It possesses very marked motility. The organism is much smaller than the bacillus of tuberculosis. Involution forms are rather common. It is readily coloured by basic aniline dyes, but is not stained by Gram's method. (Frontispiece, g.) The gelatin cultures, and the so-called cholera-red reaction in broth, "^ are very characteristic, and should be practised in case of doubt. In examining the stools of a suspected case, the organism will be found most abundantly present in the mucoid masses. A film should be made from one of these, and, after staining with dilute Ziehl's fluid, examined with an oil immersion lens. In cases where they are fairly numerous, and where their * The red reaction is due to a rdtrosoindol body. Many- bacteria produce indol in bouillon ; only two, the bacillus of cholera and the bacillus of Finkler, produce both indol and nitrites. The bacillus of cholera produces these substances in the course of a few hours in sufficient amount to give a distinct reaction, Finkler's bacillus only after three or four days' incubation. The addition of an acid capable of acting on the nitrites, and so liberating nitrous acid, is all that is necessary to i)roduce the red coloration ; and the best acid to use is pure hydrochloric, as it is less often con- taminated with traces of nitrous acid than are nitric aod many samples of sulphuric acid, which will frequently produce the red reaction not only with Finkler's and the cholera bacillus, but also with all other bacteria which produce indol, II 53© Clinical Bacteriology. disposition is not too much interfered with by the simultaneous existence of other organisms, they will be seen to lie in rows, end to end and all pointing in the same direction like fish in a stream. Equally characteristic is the appearance when a drop of the suspected stool is added to 2 cc. of a decidedly alkaline solution of 1 part of sodium chloride and 10 parts of peptone in 100 parts of water. After eight to twelve hours' incubation at a temperature of 37° 0. an abundant growth of the cholera bacillus will be found on the surface of the fluid, and from it plate cultures may be made. [g) Bacillus aiithracis. — This organism affects certain classes of persons, especially wool sorters. Its appearance varies considerably with the medium in which it is flourishing. When found in the blood it consists of straight rods fully as long as a red blood corpuscle ; often two or more are arranged end to end, either in a straight line or slightly inclined to each other. It stains readily and is coloured by Gram's method. (A) Spirillum Otoeruieieri. — These spirilla are the cause of relapsing fever. They can be obtained in the blood only during the period of the attack, and wholly disappear in the intervals. When examined fresh, they exhibit movements ; they can also be demonstrated in film preparations if stained with a basic aniline dye and the blood corpuscles counter- stained with cosine. The spirilla are from 20 to over 30 /i in length. {i) Tetauus, glanders, and numerous other rarer diseases are also due to bacilli, but cannot be further referred to here. II. — Micrococci. (1) Staphylococci. — These occur in small masses and are readily stained by ordinary aniline dyes and Micrococci. 531 by Gram's method. The individual cocci measure about 1 [I in diameter. The chief varieties are S. pyogenes aureus, S. pyogenes albus, S. citreus. (2) Streptococci. — This group contains a con- siderable number of pathogenic organisms. They occur in shorter or longer chains. {a) S. pyogenes. — Stains as the staphylococci. It produces a severe suppuration with a great tendency to indeterminate extension. (6) S. erysipelatosus is very closely related to the last, and certainly cannot be distinguished by cov^er-glass preparations or by culture methods. The chains contain from five or ten to as many as forty cocci. Many authorities regard it as only a virulent form of S. pyogenes. (3) PiieumococcHs (diplococcus pneumoniae, Frsenkel) . — These diplococci are the cause of croupous pneumonia, though they occur also in normal saliva. They are lancet-shaped and the points of the lancets are directed towards each other. The diplococcus is enclosed in a capsule which stains less deeply than the cocci themselves. Occasionally one capsule con- tains four cocci. They stain readily, and are coloured by Gram's method, which aids in distinguishing them from Fried lander's pneumo - bacillus, as the latter cannot be stained by it. (Frontispiece, d.) (4) Micrococcus tetrag-eniis. — This organism is found in the sputum which comes from phthisical, bronchiectatic and other cavities in the lungs. The cocci are about 1*5 \x in diameter, and occur in groups of four enclosed in a capsule. They are readily coloured by Gram's method and by basic aniline dyes. (5) Oonococciis. — This is a diplococcus, the two cocci of which lie very closely together and are thus difficult to distinguish. With high magnification they are seen to be kidney-shaped and have their concave sides facing one another. Sometimes the gonococci 532 Clinic A l Bacteriology. are found free ; at other times, and more character- istically, enclosed in pus corpuscles, in which they occur in groups. They are readily stained by aqueous solutions of basic aniline dyes. They are decolorised by Gram's method, which often aids in clinching the diagnosis in a doubtful case. Advantage may also be taken of the fact to secure a double stain, the cover glass being first treated by Gram's method and then counterstained with Vesuvine or Bismarck brown. Most of the other microbes then stain violet, the cellular elements are light brown, and gonococci are darker brown. (Frontispiece, e.) (6) Sarciiia ventriculi is described elsewhere (p. 82). III. — Actinomyces. The ray fungus (Figs. 77 and 135) has been placed in various groups of fungi by different observers. It has affinities with several classes, but is perhaps best associated in the meantime with a somewhat miscellaneous group under the heading " Fungi im- perfecti," as has been proposed by Winter.* It may be found in pus, sputum, faeces, urine, or in tissues removed by operation or after death. It occurs in the form of minute yellow granular masses, which are generally recognised without much diffi- culty under the microscope. The most expeditious method for its demonstration is to crush a small granule immersed in a drop of glycerine, between a micro- scopic slide and cover glass. Treated thus, one sees a radiating cluster of pear-shaped bodies, whilst in the centre of the mass the filaments of an interlaced mycelium may be observed. If a stained preparation * Rabenhorst. Kryptogamenflora. Bd. I. Die Pilze, bearb. von Dr. Georg Winter. The present tendency is to regard it as more closely related to the streptothrix section of bacteria than to any other group. A C TINOM YCES. 533 is wanted, a good method * is to desiccate a layer of pus on a cover glass, then to wash it with ether and immerse in a concentrated solution of caustic potash. From this it is transferred to a 5 per cent, solution of eosin in water, where it remains for a quarter of an hour. It is finally washed in a concentrated solution of acetate of potash and mounted in the same medium. The centre of the mass is stained a bright red, the clubs pale pink or yellow. The mycelial elements are well stained by Gram's method, and thionine blue also yields satisfactory preparations. * Lemiere and Bdcue. 534 APPENDIX. Weights and Measures. Eiig^lisli weig^lits and measures. 1 grain, gr. 1 ounce, oz. = 437*5 grains. 1 pound, lb. = 16 ouiices = 7,000 grains. 1 minim = 0-91146 grain. 1 fluid drachm = 60 minims. 1 fluid ounce = 8 fluid drachms. 1 pint = 20 fluid ounces. 1 gallon = 8 pints. Relation of Eng^lisli to metric system, 1 grain = 64-8 milligrammes. 1 ounce = 28-3 grammes. 1 lb. = 453 '6 grammes. 1 gramme = 15-432 grains. 1 kilo = 2 lb. 3 oz. 1 minim = 0-059 cc. 1 fluid drachm = 3-5 cc. 1 fluid ounce = 28-39 cc. 1 pint = 567-9 cc. 1 cc. = 16-9 minims. 1 litre = 35-2 fluid ounces. 1 inch = 2-54 cm. 1 foot = 30-48 cm. 1 yard = 91-44 cm. 1 cm. = 0-39 in. 1 metre = 39-37 in. 3. Conversions. To convert grammes per 100 cc. into grains per ounce, multiply by 4-375. Appendix : Temperature Scales. 535 To convert grammes into ounces avoirdupois, multiply by 10 and divide Ly 283. To convert litres into pints, multiply by 88 and divide by 50. To convert kilos into pounds, multiply by 1,000 and divide by 454. 4. Centigrade and Falirenlieit scales. To convert Fahrenheit into Centigrade, subtract 32, multiply the remainder by 5, and divide the result by 9. To convert Centigrade into Fahrenheit, multiply by 9, divide by 5, and add 32. The following table shows the relation of degrees Fahrenheit to Centigrade, as far as is likely to be required in clinical work : — Centigrade. Falireulieit. Centigrade. Falirenheil 110 ... .. 230 37 98-6 100 ... .. 212 36-5 97-7 95 ... .. 203 36 96-8 90 ... .. 194 35-5 95-9 85 ... .. 185 35 95-0 80 ... .. 176 34 93-2 75 ... .. 167 33 91-4 70 ... .. 158 32 89-6 65 ... .. 149 31 87 -8 60 ... .. 140 30 . . .. 86 55 ... .. 131 25 77 50 ... .. 122 20 68 45 ... .. 113 15 59 44 ... .. 111-2 10 50 43 ... .. 109-4 + 5 41 42 ... .. 107-6 32 41 ... .. 105-8 - 5 23 40-5 ... .. 104-9 -10 14 40 ... .. 104-0 -15 + 5 39-5 ... ... 103-1 ... 102-2 -20 -4 39 ... 0-54° ... = 1° 38-5 ... .. 101-3 1 ... = 1-8 38 ... .. 100-4 2 ... = 3-6 37-5 ... 99-5 2-5 ... = 4-5 53^ Clinical Methods. Solutions Required for Examination of Gastric Contents. 5. Phlorog:liicin and vanillin i^olution. Dissolve 2 grms. of phloroglucin and 1 grm. of vanillin in 30 cc. of absolute alcohol. Keep the solution in the dark, and use it economically, as the ingredients are costly. 6. Boas's resorcin reag^ent. Kesorcin ... ... .. 75 grs. White sugar ... ... ... 45 grs; Dilute spirit ... ... .... 3| oz. Dissolve. 7. Uffelmann's Reag^ent. Carbolic acid (1 in 20) ... 10 cc. Water ... . ... ... 20 cc. Mix. Add one or two drops of liq. ferri perchlor. An amethyst blue solution results. It should be pre- pared fresh each time, as it does not keep. Lactic acid turns it yellow. Hydrochloric acid simply discharges the blue colour. Acetic acid turns it somewhat brownish. 8. Congo red test papers. These are made by soaking bibulous paper in a solution of Congo red, of the strength of 1 deci- gramme to 100 cc. of water, or in a saturated alcoholic solution. They are allowed to dry, and are then ready for use. Solutions Required for Urinary Testing. 9. I^tandard nitrate of silver solntion. Dissolve 29-063 grms. of pure y?*5ef/ silver nitrate in distilled water, and till up to 1 litre. Keep in the dark. Appendix : Solutions. 537 10. Standarcl iiraiiiiiiii solution. Dissolve 35 orms. of uranium nitrate in 90 cc. of water to which has been added .^'O cc. of glacial acetic acid ; then fill up to 100 cc. 1 cc. = 5 mc(. P0O-. 11. Acetic solution of sodium acetate. Dissolve lOOgrms. of crystals of sodium acetate in some water; add 100 cc. of strong acetic acid, and dilute with water to 1 litre. 12. Hypobroniite solution. Dissolve 100 grms. of caustic soda in 250 cc. of water. Cool, then add 25 cc. of bromine. The solution is apt to undergo the following decompo- sition : — 3 NaBrO = 2 NaBr + NaBrOg. It is therefore better to prepare it as required by adding 2*5 cc. of bromine to 25 cc. of the caustic soda solution. 13. Esbacli's reagent. Dissolve 10 grms. of picric acid and 20 grms. of citric acid in about 900 cc. of boiling water; cool, and add water to 1 litre. 14. Feliling^'s solution. (a) Take 34-64 grms. of pure sulphate of copper which has been powdered and pressed between bibu- lous paper, dissolve in 200 cc. of warm distilled water, cool, and fill up to 500 cc. (6) Dissolve 180 grms. of crystallised Rochelle salt in 300 cc. of hot water, fi.lter, and add 70 grms. of pure caustic .soda, or 100 grms. of potash; cool; fill up to oOO cc. 53^ Clinical Methods. When required, mix equal voluQies of {a) and (6). Tbe result is an alkaline solution of potassic cupric tartrate, of which 1 cc. is exactly reduced by 5 mg. of pure glucose 15. Pavy's solution. Required — Cupric sulphate Rochelle salt ... 4*158 grms. (361 grs.). 20*4 grms. Caustic potash Strong ammonia ... (178 grs.). 20-4 grms. ... 300 cc. (Specific gravity Water to •880) (6 oz.). ... 1 litre. (Ipt.). Dissolve the Rochelle salt and potash in part of the water, and the sulphate of copper in another (with the aid of heat), pour the copper solution into that of the alkali and Rochelle salt, cool, add the ammonia, then fill up to 1 litre or 1 pt. Keeps indefinitely. 10 cc. = 5 mg. glucose. 16. Peptone solution for testing: for bile acids. Powdered peptone (Savory and Moore's) \ dr. Salicylic acid ... ... ... ... 4 grs. Acetic acid ... ... ... ... \ dr. Distilled water to . . ... ... 8 oz. Filter repeatedly until transparent. Solutions Required in the Examination of Blood. 17. Diluting fluid for liaeinocytoineter. Sulphate of soda ... ... 104 grs. Acetic acid ... ... ... 1 dr. Distilled water ... ... 6 oz. 18. Appendix: J Stains Hsiyciii's !»ioliitioii. Common salt ... 1 grm. Sulphate of soda 5 grms. Corrosive sublimate ... 0*5 grm, Distilled water • • • 200 cc. 539 19. Teicliiiiaiiii's test for blood (IisEiiiiti test). Take up some of the deposit to be examined in a pipette. Rub it up with a small amount of common salt, and evaporate a little of the mix- ture to dryness on a slide. Moisten the residue with glacial acetic acid, ^^^ ^ and put on a cover o-lass. Gently „ ^ n Fjo' 137 Hcemin heat this over a very small name for crystals.' Highly several minutes, avoiding boiling, magnified. Allow a little glacial acetic acid to run in from the side of the cover glass from time to time during the process. Allow to cool, and examine for hfemin crystals with a high power (Fig. 137). Some Stainixg Methods. 20. Oram's iiietliocl. The following solutions are required : — (1) A solution of gentian violet in aniline water. This is prepared as follows : — Place in a test tube 1 part of aniline oil and 20 of ordinary water. Shake these thoroughly to- gether, and filter. Preserve the filtrate (a) in a stoppered bottle in the dark. Prepare a saturated alcoholic solution of gentian violet and filter it (b). To 9 parts of {a) add 1 part of (6) and filter the mixture. The two solutions should only be mixed shortly before use ; after twenty-four hours the stain becomes less trustworthy. 54<5 Clinical Methods. (2) A solution of 1 grai. of iodine, and 2 grms. of iodide of potash in 300 cc. of distilled water. Float the cover slip, face downwards, in a capsule containing some of the stain. In the cold the film is usually stained in five minutes ; if the fluid is heated till steam rises, in about one minute. Wash the cover slip in water, then place it for half to one minute in solution 2. Here the film becomes black. It is then washed in alcohol or methylated spirit until it ceases to lose colour and becomes a pale grey. Wash in water. Dry between filter papers. Mount in xylol balsam. The following modification of Gram's method will be found simpler and more efl&cient. For aniline oil water substitute a 1 in 20 aqueous solution of phenol in the same proportions, and carry out the staining as detailed above. After treatment with the iodine solution, and washing with alcohol, transfer to clove oil, which increases the sharpness of the dif- ferentiation ; wash out the clove oil with alcohol, then transfer to water, employ a contrast stain if desired, wash again in water, dry, and mount in xylol balsam. Some bacteria retain this stain, especially tubercle, leprosy, diphtheria, tetanus, and anthrax amongst bacilli ; and streptococci, staphylococci, micrococcus tetragenus, and diplococcus pneumoniae (Frsenkel) amongst cocci ; but many are decolorised by the process, and are thereby distinguished from those already mentioned. 21. Ziehl-lVeeliseii stain. A. Fuchsin, 1 part | dissolve Absolute alcohol, 10 parts/ Add of 5 per cent, aqueous solution of phenol 100 parts. B. Twenty per cent, sulphuric acid. Appendix : Stains. 541 C. Watery solution of methylen blue. The solu- tion should be nearly saturated. The addition of a trace of ammonia increases the precision of the staining. Method. — Heat A till steam rises, then float cover glasses, film down, on it for three or four minutes, rinse in water, immerse in B till decolorised, wash in water, counterstain if desired in C for one minute or more, wash rapidly in water, dry, and mount in xylol balsam for permanent preparations, or Farrant's medium if not to be preserved. Sections require longer staining and must not be dried ; clove oil should not be used for clearing purposes, as it often decolorises the bacteria. 22. LiOffler's stain. (This should be freshly prepared.) Concentrated alcoholic solution of methylen blue ... ... ... 1 cc. Caustic potash in 00 -1 per cent. aqueous solution ... ... 3 cc. Specimens are stained in from five to thirty minutes. Excess of stain is discharged by rapid washing in water acidulated wdth acetic acid (2 drops of acid in a watch-glassful of water) and all traces of acid well washed out. The specimen is then dried and mounted. 23. Carbol thionine. (Prepared freshly.) Saturated solution of thionine in 50 per cent, alcohol ... ... 10 cc. 1 in 40 solution of phenol in water 100 cc. This stain is one of the best for film preparations. After staining, which is rapidly effected, wash the specimen in w^ater, then dry and mount. Sections should, after washing, be passed through alcohol containing a trace of ammonia, thereafter dehydrated 542 Clinical Methods. by absolute alcohol, cleared with xylol, and mounted in balsam. 24. Aniline water is made by shaking up 1 part of colourless aniline oil with 3 parts of distilled water in a bottle of dark glass. The excess of oil sinks to the bottom, and the supernatant aniline water is decanted and filtered, when it is ready for use. Both the aniline oil and the aniline water must be kept in bottles of dark glass. "^ 25. ElirlicU's triple stain. — This is also known by the misleading name of the " triacid " mixture. It contains the same ingredients as the Ehrlich-Biondi stain, but in somew^hat different proportions. The staining ingredients are : — Orange G. Acid fuchsin. Methyl green. These should always be obtained from Griibler & Co., of Leipsic, or from one of their agents. The in- gredients may be obtained in the form of a powder (the Ehrlich-Biondi or Ehrlich-Heidenhain powder), which one can then make up into the stain for oneself in the following portions : — Powder ... ... ... gr. xv. Absolute alcohol ... 1 cc. Distilled water ... ... 6 cc. Or one can make the stain up according to Ehrlich's directions, thus : — Saturated water solu. of Orange '-'Gr" 120-135 cc. ,, ,, acid fuchsin 80-165 cc. „ ,, Methyl green 125 cc. (These must have become thoroughly saturated by being allowed to stand for some days.) * It is now usual to substitute a 1 in 20 aqueous solution of phenol for aniline water. It is more readily prepared, keeps better, and its mordant action is quite as efficient. A PPENDIX : St A INS. 543 Mix these with thorough shaking and add, the shakinsr beine: continued : — Glycerin ... ... 100 cc. Absolute alcohol ... 200 cc. Distilled water .. . ... 300 cc. The mixture once made, should not be again shaken, but should be left to stand for some time to "ripen " and to allow of sedimentation. When it is used, the supernatant fluid should be drawn o^ by means of a pipette. The stain having been made in either of the above ways, should be used undiluted. Blood films stain in it in from one to five minuies, depending upon the particular blood under examination, the mode of its fixation, and also upon the specimen of stain used. The exact time required can therefore only be found out by experiment. IJSTDEX. Abdomen, Anatomy of, 49 Auscultation of, 68 Examination of, 51 Inspection of, 51 Measurement of, 58 Palpation of, 54 Percussion of, 57 Regions of, 49 Abdominal Muscles, Paralysis of, 420 Acetic Acid, Test for, 79 Acetone in the Urine, 323, 324 Albumin in the Urine, 296, 297, 299 Albumosuria, 300 Alcaptonuria, 272 Alimentary System, Questions to be asked in Disease of, 6, 7 Amblyopia, 389 Amimia, 386 Amnesia Verbalis, 385 Ansesthesia, 428 Analgesia, 429 Aneurysm, Murmurs in, 155 Percussion of, 123, 124 Pulse in, 171 Angulus Ludovici, 98, 214 Aniline Water, 542 Anosmia, 387 Aorta, Site of Bifurcation, 51 Situation of, 137 Aortic Aneurysm, Percussion of, 123, 124 Area, 138 Incompetence, 178 Pulsation, 112 Stenosis, 178 Apex-beat, Definition of, 101 Extent of, 103, 109 Palpation of, 109 • Site, 101 Aphasia, Definition of, 381 Appetite, 6 Arcus Senilis, 23, 453 Ai-tery, Middle Cerebral, 376 Posterior Cerebral, 374 • State of (in examining Pulse), 159 Vertebral, 374 Articulation, Tests for Power of, 384 Ascites, 58 Asthma, Signs of, 256 Astigmatism, 455 Ataxy, 422 Atheroma, Pulse in, 171 Athetosis, 427 Attitude, 16 Auditory Meatus, Examination of, 468 Nerve, 411 Aura, 431 Auscultation in Children, 493 Auscultatory Sounds, Mode of Re- cording, 265 Bacillus Anthracis, 530 Cholerae, 529 Coli, 529 Diplitheriae, 523 of Typhoid, 526 Tuberculosis, 523 Bacteria, Stains for, 514 Bacteriology, Clinical, 512 Battery, Medical, 443 Biermer's Phenomenon, 239 Bile Acids in Urine, Tests for, 321 in the Urine, 319 Pigment inUrine, Tests for, 320 Bilharzia Hsematobium, 345 Bilious Stools, 86 Bimanual Palpation, 54 Bladder, Centre for, 440 Blebs, Definition of, 349 Blepharitis, Marginal, 451 Blood, Alkalinity of, 208 Bacteriological Examination of, 519 Coagulability of, 208 Density of, 206 Examination of, 181, 497 Expectoration of, 257 Films, Examination of, 202 Fixation of, 198 How Made, 197 Staining of, 199, 201 Microscopic Examination of, 193 Platelets, Estimation of, IBS Index. 545 Blood, Pressure, Gauging of, 101 Questions to be asked in Afl'ec- tions of, 8 Specific Gravity of, 206 Bloody Stools, SO Boas's Resorcin Reagent, 7S, 530 Boils, 32 Bone Diseases, Questions Regard- ing, 10 Bones, Examination of, 481 of Children, Examination of, ' 492 i Brachycephaly, 484 ; Brain, Blo(Xl Vessels of, 374 I "Brassy Cougli," 35 I Breath, Character of, 46 Sounds, Absence of, 243 Graphic Record of, 265 in Children, 498 Broca's Convolution, 382 Bronchial Breathing, 242 Bronchitis, Acute, 252 Chronic, 252 Bronchophony, 246 Broncho-vesicular Breathing, 245 Bruit de Diable, 154 de Galop, 141 Bruits Vascular, 155 (iSee o.lsQ Murmurs) Bull«, Definition of, 349 Butyric Acid, Test for, 79 Calculi, Urinary Analysis of, 328 Cauccr Cells, 508 Capsules for Bacteriological Stain- ing, 513 Carbol-thiunine Stain, 541 Carbonates in the Urine, 336 Carbuncles, 32 Cardiac Asthma, 179 Cycle, 134 Dulness, 118 Diminution of, 128 Increase of, 123 Impulse (.See Apex-beat) Murmurs (.b'ee Murmurs) Sounds (See Heart Sounds) Thrills, 110 Valves, Sites of, 13(i Carotid Pulsation, 105, 113 Case-taking, Divisions of, 2 Method of, 1 Scheme, 12 Centigrade aud Fahrenheit Scales, 535 Cervical Enlargement, 365 Cestoda, 90 Chest, Expansion of, 226 Inspection, 99 J J Chest, Landmarks on, 93 Measurement, 225 Movements of, 220 * Palpation of, 223 Percussion of, 229 Regions of, 211 Shai)e of, 213 Children, Case-taking in Diseases of, 10 Clinical Examination of, 489 Children's Diseases, Special Ques- ti'ms in Cases of, 10 Cholera Stools, Examination of, 529 Stools in, 86 Cholesterin Crystals in Fluids, 508 in Sputum, 263 in Uiine, 336 Choreic Movements, 426 Choroid, Tubercle of, 467 Circulatorv System, Examination of, 97 Questions to be Asked in Disease of, 8 Collapse, 39 Colour-blindness, 392 Sense, 391 Coma, 379 Complexion, 27 Conjunctiva, Examination of, 451 Consonance, 250 Constipation, 6 Continued Fever, 39 Conversions, Table of, 534 Convulsions, 425 Co-ordiuation, Tests for, in Lower Limbs, 423 Upper Limbs, 423 Cornea, Examination of, 452 Cough, 8 Causes of, 34 Character of, 33 Cover-glasses for Bacteriological Work, 514 Cranial Xerves, Investigation of, 387 Craniotabes, 485 Cranium, Diseases Affecting, 25 Crepitations, Varieties of, 249 Crisis, 41 Cultures,Method of Inoculating, 517 Cyrtometer, 225, 226 Cysticercus, 90 Cystin, 326 Cysts, Exploration of, 504 "Death-rattle," 83 Decubitus, 16 Defsecation, 439 Delirium, 41, 379 546 Clixical Methods. Delusions, 370 Dentition, 42 Desquamation, 350 Diabetes, Amount. of Sugar ^lassed in, 318 Odour of Breath in, 4(5 Diabetic Coma, Urine in, 32.5 Diarrhoea, (5 Diastolic Pulsation, 105 Diathesis, 22 Diazo-reaetion in Urine, 320 Dicrotic Pulse, 172 Dicrotism, 164, 172 Dioptre, Definition of, 438 Diphtheria, 45 BaciUus of, 523 Diplopia, 396, 398 Doliclioceplialy, 484 Dropsical Fluids, Characters of, 509 Dropsy, Hydraimic and Passive, 28 Local, 29 Mode of Recognising, 29 Dysentei'ic Stools, 86 Dysentery, Amreba of, 95 Dysmenonhcpa, Attitude in, 19 Dyspnoea, 8, 33 Ear, External, Examination of, 468 Ears, Appearances of, in Disease, 25 Examination of, in Children, 500 Echoing, Power of, 385 Ehrlich's Triple Stain, 201. 542 Electrical Examination of Muscles, 440 Nerves, 440 Electrical Reactions of Muscles, 448 — Alterations in, 448 Electrodiaguosis, 446 Emaciation, 22 Emphysema, 252 Percussion Sound in, 236 Subcutaneous, 29, 351 Emprosthotonos, 425 Empyema, Pulsating, 106 Ejiigastric Region, 49, 50 Pulsation, 52, 106 Palpation of, 113 Epigastrium Systolic Depressioii, 107 Episternal Notch, Pulsation in, 105 Equilibration, 411, 413 Eustachian Catheter, Passage of, 471 Examinaticni, Physical, 11 Excoriations, 349 Expectoration, 8 Expiration, Prolongation of, 243 Exploration, 502 Expression, 22, 25, 26 Exudates, Bacteriological Examina- tion of, 522 • Characters of, 509 Eye, Abnormal Movements of, 400 — — Appearances of, in Disease, 23 Examination of, 451, 500 Muscles, Examination of, 395 Eyebrows, Arcliing of, 23 Eyelashes in Strumous Subjects, 23 Eyelids, Eversion of, 452 Eyes, Movements of, 396 Face, Abnormal INIuscular Move- ments in, 411 Facial Expression, 23 Nerve, Anatomy of, 408 Facies Hippocratica, 26 Pieces, Bacteriological Examination of, 523 Naked-eye Examination of, 84 Falirenheit and Centigrade Scales, 535 Family History, 3 Fauces, Examination of, 45 Favus, 356 Fehling's Solution, Composition of, 537 ■ • Test, 310, 311, 314 Fever, Course of, 41 Types of, 39 Fibrinuria, 273 Fifth Nerve, Anatomy of, 405 Motor Root of, 406 Sensory Functions of, 407 Filaria Sanguinis Hominis, 194 Films for Bacterioh)gical Examina- tion, 515 Finger Percussion, 116 Fingers, Changes in Disease, 30 Fits, Method of describing, 380 Questions regarding, 10 Flags, Use of, to mark Pulsations, 107 •Flatulence, 6 Fluids Obtained by Puncture, Phy- sical Examination of, 504 Pathological Examination of, 502 Foetal Heart Sounds, 58 Fontanelle, Anterior, 491 Forceps for Holding Slides, 514 Fourth Nerve, 393 Fremissement Hydatique, 57 Fremitus, Vocal, 227 Friedreich's Phenomenon, 239 Gait, 20 Studv of, 485 Types, 486, 487, 4SS JNDEX. 547 Gall-bladder, Examination of, OS Galvanometer, 445 Gastric Analysis, 70 Contents, Acidity of, 77 Gerhardt's Phenomenon, 239 Giddiness in Heart Disease, S Girth, how Measured, 21 Relation to Height and Weight, 21 Glasses, How to Tell the Refrac- tion of, 450 Glucose in the Urine, 30S Glycuronic Acid in Urine, 325 Gmelin's Test, 320 Gram's Method of Staining, 539 Grip, Strength of, 29 Gums, Examination of, 43 Gynecological Examination, 0, 7 Habits, Questions Regarding, 4 HEematoma Auris, 25 Hsematoporphyrin in Urine, 306 Htemin Test, 539 Ha;mocytometer, 181, 185. 189 Diluting Fluid for, 53S Haemoglobin, Estimation of, 181 Hfemoglobinometer, 192 Hsemoglobinuria, 306 Hgemometer, Von FleischVs, 189 Hallucinations, 379 Hands, Examination of, 29 Health, Questions Regarding, 4 Hearing, Tests for, 412 Heart, Anatomy of, 97 Aiiscultation of, 132, 497 Borders of, 119, 121 Dilatation of, 126 Diminished Dulness, 128 Diseases, Symptoms of, 178 Displacements of, 130 Graphic Record of Outline of, 264 Increased Dulness, 123 - — Outline of, 264 Percussion of, 117, 120 Sounds, 138, 139, 140, 141, 142 Hectic Flush, 25 Height and Weight, Relation be- tween, 21 Hemianeesthesia, 428 Hemianopsia, 391 Hemichorea, 426 Hemiplegia, 422 Herpes Labialis, 24 Hiccough, 35 Hippoeratic Facies, 26 Hippocratic Succussion, 252 Hippus, 405 History, Family, 3 History, Personal, 4 "Hot Sponge" Test, 483 Hutchinson's Teeth, 43 Hydatid Fluid, Composition of, 93 Thrill, 57, 92 Hydrocephalus, 484 Hydropericardium, Dull Area in, 124, 127 Hyperacusis, 413 Hyperpesthesia, 428 Hyperalgesia, 429 Hyperpyrexia, 38 Hypochondrial Regions, 49, 50 Hypodermic Syringe, Sterilisable, 513 Hypogastiic Region, 49, 50 Hysterical Cough, 35 Idiopathic Heart Diseases, 179 Iliac Regions, 49, 50 Image, Ophthalmoscopic, 461 Immersion Lens, Use of, 516 Indigogens in Urine, 298, 322 Induction Coil, 445 Inferior Vena Cava, Obstruction of, 53 Inflammatoiy Effusions, Characters of, 509 Influenza Bacillus, 523 luoculation of Tubes, 517 Intelligence in Children, Estima- tion of, 500 Intermittent Fever, 39 Internal Capsule, 360 Interossei, Paralysis of, 418 Interrogation of Patient, 2, 3, 5 Intestines, Examination of, 74 Percussion of, 57, 74 Questions to be Asked in Disease of, 7 Iris, Diseases and Movements of, 24 Itch, 353 Jaundice, 7, 27, 347 Jaw Jerk, 438 Joint Diseases, Questions Regard- ing, 10 Joints, Examination of, 481 Kiflney, Diagnosis, from Gall- bladder and Spleen, 73 Floating, 73 ■ Movable, 73 Palpation of, 72 Kidneys, Anatomy of, 72 Examination of, 72 Questions to be asked in Dis- ease of, 9 Knee Clonus, 438 i48 Clinical Methods. Knee Jerk, 435, 436, 500 Kyphosis, 219, 483 Lactic Acid, Test f(ir, 78 Lactose in Urine, 31S Lalling, 380 Laryngoscopj'', 472 Larynx, Movements of, 32 Nerve Supply of, 415, 416 Leading Questions, when Permis- sible, 3 Left-handedness, Detection of, 378 Lenses, 458 Leucin as a Urinary Deposit, 334 r>eucocytes. Enumeration of, 186 in the Urine, 338 Varieties of, 202 Leucocythfemia, 187, 203 Leucocytosis, 188 Leucomata, 452 Leucorrhoea, 7 Lips, Appearances of, in Disease, 24 Examination of, 42 Lipuria, 339 Liver, Anatomy of, 64 ■ Diminution of, 68 Displacement of, 68 Enlargement of, 68 Examination of, 64 Expansile Pulsation of, 113 in Children, 497 ■ Inspection of, 65 Palpation of, 65 Percussion of, Q'o • Pulsation of, ^*6 Questions to be asked in Dis- ease of, 7 Lobar Pneumonia, Physical Signs of, 254 Locomotory System, 481 Liiffler's Bacillus, 523 Stain, 541 Lordosis, 483 Lumbar Enlargement, 365 • Puncture, 503, 510 Eegions, 49, 50 Lungs, Anatomy of, 209 Apices of (Percussion), 231 Auscultation of, 240, 498 Bulging of Apices, 32 Percussion, 231, 232 • Questions to be asked in Dis- ease of, S Resonance, 236, 237 Lymphadenoma, Leucocytes in, 203 Lymphatic Glands, 31 Lysis, 41 Macular Region, Characters of, 463 Macule. Definition of, 348 Main en Griffe, 30, 419 Malaria, Parasite of, 201 Malta Fever, 528 Mammary Line, 99 Region, 212 Melansemia, 194 Memory, Investigation of, 379 Menstruation, 6 Micturition, 9, 439 Middle Ear, Inflation of, 471 Milk-Sugar in Urine, 318 Mind-blindness, 386 Mineral Acids, Test for, 78 Mitral Area, 138 Disease, Pulse in, 170 ■ Incompetence, 178 Murmurs, 144 Stenosis, 178 Monoi^legia, 422 Motor Area, 358 Functions, Investigation of,418 — - Path, Anatomy and Physiology of, 358 Points, 446 Mouth, Examination of, 42, 494 Movable Kidney, 73 Mucinuria, 302 Murmurs, Aortic, 14S, 149 Cardiac, 142, 143, 144 -Due to Malformations of Heart, 152 Graphic Record of, 264 Hsemic, 153 Mitral, 145, 147 Multiple, 151 Presystolic, 145 Pulmonary, 150 Tricuspid, 149 Vascular, 155 Muscles, Nutrition of, 424 Tone of, 364, 434 Muscular Sense, 365, 430 Nails, Changes in Disease, 30 Nebulte. 452 Neck, Diseased Conditions in, 31 Pulsation in, 112 Rigidity of, 32 Root of. Pulsation at, 112 Nematoda, 87 Neoplasms, Abdominal, 60 Nervous Case, Order of Examina- tion of a, 377 Diseases, Attitudes in, 19 System, 358 Questions in Disease of, 9 Nose, Appearances of, in Disease, 24 Examination of, 477 Index. 549 Nucleoalbumiiiuiin, 302 Nutrition, 20 Nystagmus, 401 (Edema, Detection of, 3ol Localised, 29 (Esophagus, Anatomy of, 47 Auscultation of, 4S Examination of, 47 Oil Immersion Lens, Use of, 516 Olfactory Nerve, 387 Ophthalmic Division of Fifth Nerve, 405 Ophthalmoscope, 456 Ophthalmoscopv, Direct, 460 in Children, 500 Indirect, 457 Opisthotonos, 425 Optic Atrophy, 466 Disc, Characters of, 462 Fibres, Course of, 387 Nerve, 387, 388 Neuritis, 464 • Radiation, 388 Orthopnoea, 18 Osteal Percussion Sounds, 114 Ovarian Tumours, 60 Pain a Cause of Special Attitude, 17 Expressions in, 26 in Abdomen, 6, 7 Sensibility to, 429 Palate, Examination of, 45 Hard, 484 Innervation of, 415 Reflex, 432 Soft, Innervation of, 415 Pallor, 27 Palpitation, 8 Pantomime, Power of Interpreting, 386 Papillitis, 464 Papule, Definition of, 349 Parsesthesia, 431 Paragraphia, 386 Paralysis, 10, 422, 499 Paralysis Agitans, Attitude in, 19 Paramimia, 386 Parai^hasia, 385 Paraplegia, 422 Paresis, 422 Parosmia, 387 PaiTOt's Nodes, 492 Pathological Fluids, 511 Pavey's Solution, 538 Pectoriloquy, 246 Pediculosis, 353 Pentosuria, 318 Pepsin, Test for, 79 Peptone in tlie Urine, 302 Solution, 538 Percussion, 113, 116, 117, 493 Finger, 116 Flicking, 57 Pericardial Effusion, 124, 127, 140 Friction, 156 Thrills, 111 Pericarditis, 179 Dull Area in, 124, 127 Sounds in, 156 Pericardium, Puncture of, 503 Perigraph, 226 Perihepatitis, '^^ Peristalsis, Visible, 53 Peritoneal Cavity, Puncture of, 503 Peritonitis, Attitude in, 18 Pertussis, 34, 35 Pettenkofer's Test, 321 Pharynx, Examination of, 45, 495 Phonendoscope, 133 Phosphates, Crystals of, 334 in the Urine, 276, 281 Phtliisis, Physical Signs of, 253 Pitceon Breast, 217 Plessor, 116 Pleural Cavity, Puncture of, 503 Friction, 250 Sacs, Line of Reflection of, 210 Thrills, 111 Pleurisy, Physical Signs of, 255 Pleurosthotonos, 425 Pleximeter, 116 Pneumonia, Chronic Interstitial, Physical Signs of, 254 Pneumo - pericardium. Heart Sounds in, 140 Pneumothorax, Heart Sounds in, 141 Phvsical Signs of, 255 Prsecordia, 98, 100, 101 Palpation of, 108 Precordial Distress, 8 Pulsation, 104, 111 Pressure, Sense of, 429 Proteids in Urine, 296 Pruritus, 431 Pulmonary Area, 138 Artery, Pulsation Over, 111 Cavity, a Cause of Special Attitude, 17 Pulsation, Diastolic. 105 Pulse, Amplitude of, 160 Blood Pressure in, 161 Dicrotlsm of, 164, 172 Examination of, 157 Force of, 159 in Children, 490 Rate of, 158 Rhvthm of, 159 550 Clinical Methods. Pulse, Tension of, lt32 Tidal Wave, 164 Tracings, Characters of, 165 Varieties of, 159, 170, 171, 172, 173, 174 Venous, 175 Pupil, Abnormal Movements of, 405 Argyll-Robertson, 405 Reflexes, 432 Use of Mydriatics for Dilata- tion of, 459 Pupils, Examination of, 401, 402 Mobility of, 24 Reaction of, to Accommoda- tion, 404 Purulent Stools, 86 Pus, Bacteriological Examination of, 522 Expectoration of, 257 in the Urine, 305, 822, 338 Pustule, Definition of, 349 Pyrexia, 39 Pyuria, 322 Quadriurates in Urine, 276 Quartan Fever, 40 Quotidian Intermittent Fever, 40 Rales, Classitt cation of, 248 Rectal Examination, 75 Rectum, Centre for, 440 Red Blood Corpuscles, Nucleated, 203 • Number of, 185 Reflex Functions of Nervous Sys- tem, 431, 434, 439 Regurgitation in Veins, 175 Relapsing Fever, Spirillum of, 530 Remittent Fever, 39 Renal Arteries, Site of, 51 Calculus, Attitude in, 19 Colic, Attitude in, 19 Resonance, ^Egophonic, 248 Amphoric, 239, 247 Boxy, 238 Cracked-pot, 238 Emptying of, 114 Factors in, 230 Full, 114 Muttled, 115 ■ of Lung, 114 Percussion, 113 Skodaic, 236 -— Tympanitic, 114 Vocal, 245 Respiration, Characters of, in Dis- ease, 32 Cheyne-Stokes, 221 Forms of Obstructed, 32 Respiration in Cliildren, 490 Movements in, 220 Rate of, 221 Rattling, 33 Rhythm of, 221 Type of, 222 Respiratory Diseases, Symptoms of, 252 Excursion, 244 System, Examination (jf, in Children, 498 Retinal Haemorrhages, 467 Retinoscopy, 454 Rheumatic Nodules, 492 Rhinoscopy, 477, 478 Rhonchi, Varieties of, 248 " Rice-water " Stools, 86 Rickets, Skull in, 484 Rigor, 38 Ringworm, 354 Sarcina Ventriculi, 82 Scabies, 353 Scabs, 350 Scapula, Position of, 211 Scoliosis, 483 Serobiculus Cordis, 214 Segmental Functions of Cord, Table of, 366 Sensibility to Pain, 429 Sensory Functions, Investigation of, 427 Path, Anatomy and Physiology of, 364 Seventh Nei-ve, 408 Sibili, 248 Sighing Respiration, 33 Sight, Centres for, 388 Sixth Nerve, 393 Skin, Colour of, 347 Diseases, Questions Regard- ing, 9 Elasticity of, 351 Eruptions, 28, 348 Examination of, 27, 347 Microscopic Examination, 353 Palpation of, 351 Skull, Bossing of, 492 Examination of, 483 Measurement of, 483 Palpation of, 484 Shape of, 484, 491 Sleep, 379 Slides, Cleaning of, 197 for Bacteriological Work, 514 Smell, Tests for, 387 "Smoky Urine," 304 Snellen's Types, 389 Spasm, 424 Index. 551 Spectra, Chart of, 207 Speech Centres, 382 Investigation of, 380 Sphygmograph, Use of, 165 Sphygmometer, 161 Spinal Accessory Xerve, 414, 416 Cnnl, Anatomy of, 365 Blood Supply of, 377 Tracts of, 369 Spleen, Anatomy of, 6;' Auscultation over, 72 Enlargement of, 72, 497 Inspection of, 69 Palpation of, 70 • • Percussion of, 71 Splenic Infarcts, 72 Sputum, S, 257, 258, 259 Bacteriological Examination of, 518 Crystals in, 261 Examinaion of, 256 Fibrin Casts in, 260 Parasites in, 263 Squint, 395 Stains for Blood, 2f)l for Bacteria, 514 Stammering, 380 Sternum, Sounding-board Action of, 118 Stethoscopes, Varieties of, 132 Stomach, Absorptive Power, SO Auscultation of, (54 Chemical Examination, 76 Contents, Acidity of, 77 Analysis of, 76 Dilated, 63 Dislocated, 63 Inflation of, 61 Insi^ection of, 61 Motor Power, 80 Palpation of, 61 Percussion of, 62 Tube, Method of Passing, 47 Stools, Character of, in Infants, 497 Strabismus, 395 Sugar, Detection of, in Pathological Fluids, 506 • in the Urine, 307, 314 Sulphates in the Urine, 283 Superficial Reflexes in Children, 500 Symbols, Use of, 2 Syphilis, 4 Congenital, Skull in, 484 Swabs for Bacteriological Work, 512 Swallowing, Auscultation of, 48 Tape Worms, 90 Taste, Nerves of, 407 Tests for, 408 Teeth, Examination of, 43, 494 Temperament, 22 Temperature, 3t), 37, 3S in Children, Taking the, 492 Sense, 429 Tendon Reflexes, 434 Tertian Fever, 40 Test Meal, 76 Tetany, 425 Thermometer, Use of, 36 Third Nerve, 393 Thorax (.See Cliest) Thrills, Cardiac, 110 in Bloodvessels, 113 in Carotids 113 Pericardial, 111 Pleural, 111 Thread Worm, 87 Throat, Examination of, 472, 494 Exanunation of, for Diphtheria Bacillus, 524 Thrush, 44 Thyroid Gland, 31 Tinnitus, 413 Tongue, Examination of, 44, 494 Mobility of, 417 Tonsils, Examination of, 45 Tophi, 25 Torticollis, 31 Torula, 82 Touch, Centre for, 365 How to Test Sense of, 428 Trachea, Bifurcation of, 210 Tracheal Tugging, 112 Transudates, Characters of, 509 Traube's Space, 63 Trematoda, 93 Tremor, 426 Tricuspid Area, 138 Trommers Test, 309 Trophic Changes in Hand, 29 Tubercle Bacillus, 518, 521, 523 Tubercular Sputum, Bacteriological Exan; illation of, 518 Tubes, Inoculation of, 517 Tumour, Definition of, 349 Tuning-fork Test, 412 Tympanic Membrane, 468 Tympanitic Percussion Sound, 237 Tympanic Resonance, 114 Typhoid, Bacillus of, 52o Fades, 27 Fever, Urine in, 327 Tyrosin as a Urinary Deposit, 333 Utfelmann's Reagent, 78, 536 Umbilical Region, 49, 50 Umbilicus, 51, 54, 56 Unemia, Odour of Breath in, 46 552 Clinical Methods. Urate of Ammonia as a Urinary Deposit, 335 of Soda, Crystals of, 330 Urates, 276 Amorphous, in Urinary De- posits, 331 Urea, Detection of, in Pathological Fluids, 507 Estimation of, 286 Ureometers, Forms of, 287 Uric Acid as a Urinary Deposit, 277 Conditions Favouring Separation of, 291 Microscopical Chara(;ters, 329 Salts of, 291 Test for, 292 Urinary Calculi, Analysis of, 328 Deposits, Microscopical Ex- amination of, 329 Naked Eye Characters of, 275 Indigogens, 322 Passages, Questions iu Disease of, 9 Urine, 267 Abnormal Constituents, 296 Bacteriological Examination of, 520 ■ — - Blood in, 304 Chlorides in, 279 Collection of Samples of, 267 Colour of, 269, 271, 272 • Consistence of, 273 " Day " and " Night," 268 Density of, 274 ■ Deposits in, 275 Diazo-reaction in, 326 Diminution of, 269 Drugs in, 327 Filtration of, 297 Incontinence of, 439, 440 Milkiness of, 271 ■ Mucus in, 275 Nitrogenous Constituents of, 285 ■ Odour of, 273 • Opalescence of, 272 Oxalates in, 284 Pallor of, 271 Pellicle on Surface of, 273 • Phosphates in, 281 • Physical Examination of, 267 Quantity of, 267, 268, 269 Questions Regarding, Reaction of, 278 Urine, Retention of, 439 Specific Gravity of, 274 Sugars in, 307 Sulphates in, 283 Xanthin Bases in, 294 Urinonietei-, Method of Using, 274 Urobilin, Spectrum of, in Urine, 270 Vagus, 414 Valve Areas, 137, 138 Valves of Heart, Situation of, 136 Vascular Bruits, 155 Veins, Distension of, on Surface of Chest, 108 Venereal Disease, 4 Venous Pulsation, 105 Pulse, 175 Regurgitation, 175 Undulation, 175 Vertebral Column, Examination of, 482 Vertigo, 413 Vesicle, Definition of, 349 Vesicular Breathing, 241 Visual Centres, 388 Vocal Fremitus, 227 Resonance in Children, 498 Observation of, 245 Voice, Characters in Disease, 36 Vomit, Examination of, 81 Microscopic Examination of, 82 Vegetable Parasites iu, 82 Vomiting, 6 Watery Stools, 86 Weight, Sense of, 430 Weights and Measures, Table of, 534 Wernicke's Hemiopic Pupil Re- action, 403 Whooping Cough, 34, 35 Widal's Typhoid Test, 526 Wintrich's Phenomenon, 239 Word-deafness, 384 Wright's Coagulometer, 208 Wrist Drop, 419 Wrist Jerk, 438 Writing, Power of, 385 Xanthin as a Urinary Deposit, 333 Yeast Fungi, 82 Yellowness of Skin, 27 Ziehl-Neelsen Method of Staining, 540 PniSTED BY CASSELL & COMPASY, LIMITED, LA BKLIiE SAUVAGE. LOSDOX, E.G. Date Due Tf/w 2 '3 U i ; - . 1 ■ *. ■ \\\^ 1 A 1949 JU»^ 1. J^ f) ^^7' ^3y